Burçak Kayhan

Case Report: Hepatic Hydrothorax in the Absence of Ascites (Report of Two Cases and Review of the Mechanism)

Hepatic hydrothorax is de® ned as the presence of signi® cant pleural effusion in a cirrhotic patient without primary pulmonary or cardiac disease (1). Pleural effusions, as a whole, are rarely due to cirrhosis of the liver with or without ascites. Among 436 patients with signi® cant pleural effusions, hepatic cirrhosis was established to be cause in only 2% (2). Although unusual, pleural effusion associated with hepatic cirrhosis and ascites is a well-described entity. It has been noted in varying frequencies, and a reasonable estimate would appear to be 4 ± 10% among all cases of liver cirrhosis (3). Clinical ascites is almost always evident, and the pleural ̄ uid is located either bilaterally or more commonly isolated to the right side. Postulated mechanisms for the development of pleural effusions in patients with hepatic cirrhosis and without pulmonary or cardiac disease include: (1) hypoalbu minemia and decreased oncotic pressure (4), (2) leakage of the plasma from the hypertensive azygos vein subsequent to the formation of collateral anastomoses between the portal and azygos system (1), (3) lymphatic leak from the thoracic duct (5), (4) passage of ascitic ̄ uid to the pleural space by way of lymphatic channels in the diaphragm (6, 7), and (5) transfer of peritoneal ̄ uid directly via defects in the diaphragm (8). The most likely explanatio n for hepatic hydrothorax appears to be that ascitic ̄ uid passes through congenital or acquired fenestrations in the diaphragm directly into the pleural space. A oneway valve mechanism is created, and a pressure gradient-directed, unidirectional ̄ ow of ̄ uid occurs through these defects into the pleural cavity (3). The description of hepatic hydrothorax in the absence of ascites is very rare (3, 9). Such pleural effusions in the absence or eventual disappearan ce of ascites may create diagnostic problems. The two cases presented in this paper, together with the review of previous reports in the literature, are discussed with emphasis to the possible mechanisms of this unusual entity. It is suggested that hepatic hydrothorax in the absence of ascites is a rare but natural variant of the more common occurrence of pleural effusions encountered in cirrhotic patients with ascites. A complicated peritonopleural ̄ uid traf® c may evolve at some stage of the disease, personal predisposing factors accounting for the rarity and diversity of this interesting clinical picture.

Prevalence of silent celiac disease in patients with dyspepsia

Celiac disease (CD) has become more common than in the past, although it frequently remains undetected for long periods of time. One reason for this is failure by health care professionals to recognize the variable clinical manifestations of CD and to perform the appropriate tests to make the diagnosis. Although dyspepsia may be part of a clinical spectrum in CD patients, there are scarce data about its prevalence in silent CD. We aimed to determine the prevalence of CD in otherwise healthy dyspeptic patients by means of serologic screening followed by endoscopic biopsies if appropriate. Anti-endomysium antibody assay was positive in 3 of 196 patients. All 3 were female, ages ranged from 19–52 years (mean ± SD age, 36±16 years). Duodenal biopsies were compatible with CD in all, whereas abnormal endoscopic findings were noted in 2. Therefore, a 1.5% prevalence of CD was observed in this study group. The odds ratio for CD was 2.57 (95% confidence interval) in comparison with the general population. CD should be kept in mind as a cause of dyspepsia during clinical activities. The association between these 2 conditions is, at most, weak, but a gluten-free diet may still bring symptomatic relief for dyspeptic symptoms in CD. During endoscopic examination for dyspepsia, if indicated, endoscopists should carefully inspect the duodenum for CD findings. Although routine serologic screening can not be recommended, it may be appropriate for the patients with refractory dyspepsia, especially females.

Analysis of peripheral blood lymphocyte phenotypes and Th1/Th2 cytokines profile in the systemic immune responses of Helicobacter pylori infected individuals

H. pylori elicits specific humoral and cellular immune responses in the mucosal immune system. However, the type and extent of T lymphocyte response in the systemic immune system is not clear for H. pylori positive patients. In this study, peripheral blood T lymphocyte phenotypes and serum Th1/Th2 based cytokines of 32 H. pylori positive patients were analyzed and compared to those of healthy controls. While αβ TCR+ lymphocytes and their phenotype analysis were not significantly different to those of healthy controls, the percentage of pan γδ TCR+ lymphocytes was up to 2.4 times greater in the H. pylori positive group then in healthy controls. Furthermore, significant increases in IL‐10 concentrations in serum samples of H. pylori patients indicated that their immune systems had switched toward a Th2 type immune response. The correlation between phenotype and type of T cell response in the peripheral blood during H. pylori infection is discussed.

Cure rates obtained with five different Helicobacter pylori eradication protocols in patients with duodenal ulcer: a prospective, open-label randomized study in a primary care setting in Turkey

Abstract Background: Helicobacter pylori is the main causative agent in peptic ulcer disease. Duodenal ulcer disease is a chronic, recurring condition, and the risk of recurrence and complications does not diminish over time unless H pylori is eradicated. Several treatment protocols exist to eradicate H pylori , but their efficacy and costs vary. Because of regional variations in bacterial resistance and in treatment costs, primary care physicians must use the most appropriate protocol for their own region and population. Objective: The primary aim of this study was to compare the cure rates obtained with 5 different H pylori eradication protocols in H pylori —positive duodenal ulcer patients in Turkey. A secondary objective was to determine the accuracy of the duodenal ulcer diagnoses made by primary care physicans relying on information from physical examination and medical history alone. Methods: In a primary care setting, 2 family physicians, 5 general physicians (medical school graduates), 1 general surgeon, and 1 internal medicine specialist identified 265 symptomatic duodenal ulcer patients using medical history and physical examination results. These patients were referred to an open-access endoscopy unit for upper gastrointestinal endoscopy. Patients who had an endoscopically confirmed duodenal ulcer and who tested positive for H pylori were randomly assigned to receive 1 of 5 H pylori eradication treatments: (1) omeprazole/amoxicillin/clarithromycin; (2) lansoprazole/amoxicillin/clarithromycin; (3) omeprazole/ornidazole/amoxicillin; (4) lansoprazole/amoxicillin/clarithromycin/ornidazole, or (5) ranitidine bismuth citrate/amoxicillin/metronidazole. Follow-up endoscopies and biopsies were performed 6 weeks and 6 months after the end of treatment. Results: Of the 265 patients suspected to have duodenal ulcers based on medical history and physical examination findings, 181 (68.3%) had endoscopically confirmed duodenal ulcers. At both 6 weeks and 6 months after treatment, eradication rate were not significantly different between treatment groups in the intent-to-treat or per-protocol analyses. There was no significant difference in tolerability between the 5 regimens. Conclusions: Our results confirm the high accuracy of the duodenal ulcer diagnoses and endoscopy referrals made by primary care physicians based on physical examination and medical history of the patient. Primary care physicians should play an important role in treatment decisions regarding H pylori eradication. The 5 treatments studied are similar with respect to H pylori eradication rates. If the cost of treatment is an important consideration, the less expensive omeprazole/ornidazole/amoxicillin triple regimen may be a good choice for eradicating H pylori . In cases of resistant H pylori infection, the lansoprazole/amoxicillin/clarithromycin/ornidazole quadruple therapy appears to be the best choice for a second-line treatment if reliable culture and resistance testing are not available. Depending on regional variables, each nation needs to develop its own guidelines for the eradication of H pylori .

Comparison of the efficacy of the somatostatin analogue SMS 201-995 and electromagnetic fields in cerulein-induced pancreatitis in rats

Abstract Background: Despite known protocols, acute pancreatitis still has mortality rates of 10% and morbidity rates of 30%, and research continues into alternative therapeutic models for preventing both the inflammation and the complications of pancreatitis. Objective: This study was undertaken to investigate the effect of electromagnetic field therapy in acute pancreatitis and to compare the effect of electromagnetic fields with that of the somatostatin analogue SMS 201-995 in the treatment of cerulein-induced acute pancreatitis in rats. Methods: Male Wistar rats were divided into 4 equal groups. In group I, cerulein administration was followed by electromagnetic field therapy; group II received only cerulein. In group III (the control group), saline administration was followed by electromagnetic field therapy. In group IV, cerulein administration was followed by SMS 201-995 administration. After the procedure, serum amylase activity was determined for all rats and the pancreas of each rat was assessed histopathologically based on a scoring system in which 0=no change and 7=maximum change. A score ≥3 indicates cerulein-induced pancreatitis. Significance was set at P Results: Each group contained 12 rats. Statistically significant differences in pathologic pancreatitis scores were noted between groups I and II ( P P Conclusions: Electromagnetic field therapy appears to be as effective as somatostatin therapy in cerulein-induced acute pancreatitis in this study. It can thus be considered an alternative to somatostatin therapy in the treatment of acute pancreatitis in rats.

The significance of duodenal white spots

We read with great interest the article by Biyikoglu et al. describing the probable etiologies of duodenal scattered white spots (SWS) in a total of 107 patients who underwent upper endoscopy. Interestingly, they attributed this finding to a specific pathology in all cases. A total of 39 (36.4%) patients had intestinal lymphangiectasia (IL), 15 (14%) patients had giardiasis (G) and 30 (28.1%) patients had chronic nonspecific duodenitis (CD). Moreover, two with IL were also found to have G, 20 patients had both IL and CD and one had both G and CD. They concluded that a biopsy should be taken for differential diagnosis whenever SWS is seen on a routine upper endoscopy.

Treatment of Esophageal Strictures with Savary-Guilliard Bougies

Objective: Esophageal strictures may be caused by benign or malign disorders. Benign strictures are peptic stricture, Schatzki’s ring, esophageal web, and caustic ingestion, post-radiotherapy or post-surgical strictures. Dilatation with Savary-Guilliard bougies (SGD) is the most common endoscopic treatment of choice. In this study, we aimed to investigate the effectiveness of dilatation with Savary-Guilliard Bougies (SGB). Methods: We retrospectively analyzed the cases treated with SGD in Ankara Numune Education and Research Hospital between October 2005 and June 2011. All the demographic and clinical datas were recorded as well as endoscopic dilatation count and complications. Results: 73 patients (33(45.2%) males and 40 (54.8%) females) involved in the study. Mean age was 55,6±15,7(18-90) years old. A total of 536 dilatations of 73 patients performed in 169 sessions. Mean sessions of SGD 2,3±2.9(1-21) and dilatation counts were 7.4±9.4(1-65). The most seen etiologies were esophageal web (n=14, 19.2%), post-radiotherapy (n=14, 19.2%), anastomotic strictures (n=11, 15.1%) ingestion of corrosive substances (n=9, 12.3%) and malign strictures (n=8, 11%). The most seen benign causes and session counts were compared. Strictures secondary to radiotherapy and ingestion of caustic substances were the most common conditions treated with SGD. A single session was sufficient in strictures caused by esophageal web. No major complications such as perforation, major bleeding or sepsis were observed. Conclusion: SGD for the treatment of esophageal benign strictures is a safe, cheap, easily performed method without need for fluoroscopy. While treatment of esophageal web is usually treated with a single session, repeated endoscopic dilation sessions are required for the strictures caused by radiotherapy and corrosive ingestion.

Polypoid angiodysplasia: an unusual cause of lower gastrointestinal bleeding

Angiodysplasia is one of the most leading causes of lower gastrointestinal bleeding in elderly patients. Polypoid angiodysplasia is extremely rare; however, in the literature, a few cases have been reported as single polypoid lesion from Eastern countries. The lesions in our case were multiple polypoid, octopus-like, and were associated with diverticula. We managed to remove the polypoid angiodysplasia using snare polypectomy. This is the first reported case of multiple polypoid angiodysplasia associated with diverticula.RésuméL’angiodysplasie est l’une des causes principales de l’hémorragie gastro-intestinale basse chez les patients âgés. L’angiodysplasie sous forme de polype est extrêmement rare; cependant, dans la littérature, certains cas sous forme de polype simple ont été signalés en provenance des pays orientaux. Les lésions dans nos cas étaient multiples, sous forme de polype, ayant une apparence de pieuvre, et cela était lié au diverticule. Nous avons réussi à éliminer l’angiodysplasie sous forme de polype dans un piège à polypectomie. Ceci est le premier compte rendu démontrant que plusieurs angiodysplasies sous forme de polype lié au diverticule existaient.