Burhan Özdil

G-308A TNF-α polymorphism is associated with an increased risk of hepatocellular carcinoma in the Turkish population: case-control study.

BACKGROUND Tumor necrosis factor-alpha (TNF-alpha) is a pro-inflammatory cytokine that may act as an endogenous tumor promoter. A genetic polymorphism of TNF-alpha gene at position -308 promoter region is involved in the regulation of expression level and has been found to be associated with susceptibility to various types of cancer. METHODS To determine the association of the TNF-alpha gene G-308A polymorphism on the risk of hepatocellular carcinoma (HCC) in a Turkish population, a hospital-based case-control study was designed consisting of 110 diagnosis subjects with hepatocellular carcinoma and 110 cancer-free control subjects matched on age, gender, smoking and alcohol status. The genotype frequency of this polymorphism was determined by using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay. RESULTS The distribution G-308A genotype was significantly associated with the risk of HCC (p<0.001, odds ratio [OR]=4.75, 95% confidence interval [CI]=2.25-9.82 for -308 AA/GA genotypes versus GG genotype). CONCLUSION We suggested that the presence of the high producer allele -308A in the TNF-alpha gene appears to be associated with an increased risk for the development of HCC in Turkish population.

Potential Benefits of Combined N‐Acetylcysteine and Ciprofloxacin Therapy in Partial Biliary Obstruction

This study investigates the potential benefits of antibiotics and N‐acetylcysteine (NAC), a mucolytic agent, in patients who are candidates for endoscopic retrograde cholangiopancreatography (ERCP) due to partial bile duct obstruction. In total, 102 patients who had choledocholithiasis and choledochal dilatations by abdominal ultrasonography were included in the study. The patients were divided into placebo and NAC therapy groups. Physiological saline (equal volume with NAC solution) and ciprofloxacin (2 × 200 mg/d intravenously) were administered to the placebo group, and NAC (1800 mg/d intravenously) and ciprofloxacin (2 × 200 mg/d intravenously) were administered to the NAC group. In both groups, treatment protocols were administered for 7 days before ERCP. Total and direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), C‐reactive protein (CRP), alkaline phosphatase (ALP), gamma‐glutamyl transpeptidase (GGT), white blood cell (WBC) count, and neutrophil percent (NE%) levels were measured before the 7‐day treatment protocol. The same measurements were also evaluated before ERCP. In the NAC group, the levels of ALP, GGT, WBC, CRP, and NE% decreased significantly (P < .001), whereas a significant decrease did not occur in the placebo group. The combined usage of NAC and ciprofloxacin can be an alternative therapeutic option until ERCP is performed in partial cholestatic patients.

Evaluation of nitrite/nitrate levels in relation to oxidative stress parameters in liver cirrhosis

BACKGROUND AND OBJECTIVE Nitric oxide and reactive oxygen species have been implicated in several pathophysiological events leading to fibrosis and cirrhosis. The aim of the present study was to investigate the possible contribution of peroxynitrite (formed by the interaction of nitric oxide and superoxide anion) in the pathophysiology of cirrhosis. METHODS Twenty-six cirrhotic patients classified as Child-Pugh A, and seven as Child-Pugh B, were included in the study, and nine healthy volunteers served as controls. Levels of nitrite/nitrate (NOx), thiobarbituric acid-reactive substances (TBARS), nitrotyrosine (peroxynitrite marker), superoxide dismutase (SOD), catalase (CAT) and glutathione (GSH) were measured in blood samples. RESULTS NOx, TBARS, CAT, SOD and GSH levels were higher in cirrhosis patients than in the controls (NOx: 0.17 ± 0.02, 0.95 ± 0.12, 1.3 ± 0.1; TBARS: 2.0 ± 0.05, 4.6 ± 0.3, 5 ± 0.3; CAT: 1.8 ± 0.1, 4 ± 0.3, 4.5 ± 0.4; SOD: 1.8 ± 0.2, 4.8 ± 0.5, 7 ± 0.4; and GSH: 1.3 ± 0.05, 3.6 ± 0.3, 4.5 ± 0.6 in controls, and Child-Pugh A and B patients, respectively). However, there were no differences in nitrotyrosine levels across these groups (controls: 11.4 ± 0.4; Child-Pugh A: 11.1 ± 0.4; Child-Pugh B: 11.9 ± 1.6). NOx levels showed significant and strongly positive correlations with TBARS, SOD, CAT and GSH levels. In contrast, no correlations were found between either NOx or TBARS and nitrotyrosine levels. CONCLUSION Nitric oxide and reactive oxygen species, but not peroxynitrite, are overproduced in patients with cirrhosis in spite of evidence of an increase in antioxidant defenses. This suggests that therapeutic measures aimed at attenuating oxidative stress as well as increasing antioxidant defenses may well benefit patients with cirrhosis.

Current Diagnosis and Management of Gastrojejunocolic Fistula.

We herein report the case of a 51-year-old man with gastrojejunocolic fistula. It is one of the late severe complications of gastrectomy and gastrojejunostomy and is considered to be induced by a stomal ulcer due to inadequate resection of the stomach and incompleteness of vagotomy. The main clinical presentation of this condition is chronic abdominal pain, weight loss, diarrhea, gastrointestinal bleeding and fecal vomiting. The diagnostic workup should include barium enema, gastroscopy and sometimes colonoscopy and abdominal tomography for excluding and ruling out the possibility of malignant extraluminal disease. The historical approach of the treatment of this rare entity was 2–3-phased operations which included colostomy. However today, medical management has recently been recommended as the first-line therapy, with parenteral and enteral support treatments. The preferred surgical approach is single-stage gastrocolic resection and anastomosis and this has been favored to minimize mortality.

New Method Alternative to Surgery for Ingrown Nail: Angle Correction Technique

Ingrown nail is a disorder that affects mostly young adults (73% in patients aged 12–30), but it can be seen at any age. In general, the great toe is most commonly affected, but it may affect other toes as well. Although the etiology is not clearly known, genetic predisposition, inappropriate nail cutting, and wearing the wrong shoes facilitate the occurrence of ingrown nails. Its symptoms vary from mild discomfort to severe pain. Redness, inflammation, and abscess may develop occasionally in the great toe. It may lead to amputations or life-threatening infections in patients with diabetes. Sometimes pain itself leads to significant loss of man power. Because it develops intradermally, it may cause unpleasant foot odor due to debris and fat deposition between the skin and the nail. It may also lead to a nonesthetic appearance in the toenail. Different treatment modalities have been developed, including removal of the nail plate, orthonyxia, Emmert procedure, wedge resection, Zadik’s procedure, lateral approach, and ablation of the nail matrix using phenol or sodium hydroxide. Of these methods, surgical procedures are most commonly used, but in recent years, laser and thermal procedures are also being used. Medical and conservative treatments are mostly preferred for the treatment of infections. For all these treatment methods, the success rate of the treatment is low, and recurrence is frequent. The surgical procedures that aim at matrix removal may cause some problems, particularly in women regarding esthetic concerns. In this report, the clinical data and outcome results of eight patients treated using a procedure called ‘‘angle correction technique’’ are presented.

Massive lower gastrointestinal hemorrhage secondary to rectal hemorrhoids in elderly patients receiving anticoagulant therapy: case series.

Hemorrhages secondary to hemorrhoids are common but they are usually occult or oozing type with low amounts. Acute massive rectal hemorrhage is usually originated from upper GI (UGI) bleeding [1]. However, lower GI bleeding (LGI) may occasionally cause massive bleeding. In elderly patients, generally the reasons of colonic hemorrhage are diverticulum (17–40%), arteriovenous malformations (2–30%), colitis (9–21%), colonic neoplasms (11–14%), post-polypectomy, and anorectal pathologies (4–10%) [2]. Colonoscopy is the most important diagnostic tool for determining the focus of bleeding [3]. Generally massive LGI hemorrhage secondary to hemorrhoids has been reported in the literature as case presentations after surgical hemorrhoidectomy and rubber band ligation. Massive hemorrhoidal bleeding without any intervention has not been reported [4]. Case Reports

Atherosclerosis and acetylsalicylic acid are independent risk factors for hemorrhage in patients with gastric or duodenal ulcer

OBJECTIVE Risk factors for hemorrhage due to gastric and/or duodenal ulcer in patients diagnosed by upper gastrointestinal (GI) endoscopy were investigated in the present study. METHODS Medical records of 350 patients (226 males, 124 females) diagnosed as duodenal or gastric ulcers by GI endoscopy in the gastroenterology clinic were scanned retrospectively. Upper GI hemorrhage was detected in 92 patients by upper endoscopic examination. The medical history of non-steroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA) usage and the presence of coronary artery disease (CAD) were investigated in all patients with or without hemorrhage. Results were evaluated by Chi-square test and logistic regression analysis. RESULTS The mean age of the patients was 50.4 ± 15.7 years (range: 25 to 82 years). Hemorrhage due to gastric or duodenal ulcer was identified in 92 patients (26%). Mean age was 64.6 ± 11.4 years in patients with hemorrhage and 45.7 ± 13.9 years in patients without hemorrhage. ASA usage was more common than NSAID in patients with ulcer hemorrhage (NSAID usage n=35 (40%); ASA usage n=51 (60%); p=0.035). Hemorrhage was reported in 20% of the females and in 28% of the males who have ulcer (p=0.055). Risk factors for hemorrhage were CAD (OR:24.75, 95% CI=1.6-96.7, p=0.001), ASA usage (OR:9.76, 95% CI=2.1-37.5, p=0.021), NSAID usage (OR: 4.72, 95%CI=1.1-16.5, p=0.032), age (OR: 11.59, 95% CI= 2.7-12.1, p=0.001), and male gender (OR: 2.56, 95% CI= 0.8, 9.6, p=0.052). CONCLUSION Advanced age, atherosclerosis, male gender and NSAID administration (particularly aspirin) are the major risk factors of upper GI hemorrhage in patients with gastric and/or duodenal ulcer.

New therapeutic option with N-acetylcysteine for primary sclerosing cholangitis: two case reports.

Primary sclerosing cholangitis is a progressive, cholestatic hepatic disease of unknown etiology. It is characterized by progressive inflammation, destruction, and fibrosis of the intrahepatic and extrahepatic bile ducts. Several medical therapies have been tried such as penicilamin, colchicine, methatraxate, cyclosporine, tacrolimus, and ursodeoxycholic acid. Treatment with mucolytic agents in excessively high viscosity conditions appears to have an important role. N-acetylcysteine (NAC), as a mucolytic agent, may fascilitate the drainage in partial obstructions by decreasing the mucous viscosity. We suggest that NAC and ursodeoxycholic acid have markedly positive effects on the clinical course of cholangitis and cholestasis when used together by affecting bile viscosity. Here, we present two cases treated with NAC. NAC capsul therapies at 800 mg/day were administered to two patients with primary sclerosing cholangitis. Clinical and laboratory parameters of patients saw significant improvement.

An Alternative Method for Percutaneous Treatment Of Hydatid Cysts: PAI Technique.

OBJECTIVE Surgery is still the first choice in complicated cystic echinococcosis. However, percutaneous methods have performed increasingly in recent years. The Puncture, Aspiration, Injection, Reaspiration (PAIR) technique is mostly the preferred percutaneous method. The Puncture, Aspiration, Injection (PAI) technique is the new modified method, which is differentiated from PAIR technique by its applicability to all types of hydatid cysts (types 1-5) and unperforming of reaspiration. METHODS The 52 hydatid cysts were prospectively examined in the study. Thirty-four of them were Types I and II, 13 of them were Type III, and 5 of them were Types IV and V. The technique was performed using the 20 G Chiba needle under the guidance of ultrasonography. Maximum cyst contents were aspirated immediately after the puncture to reduce the intracystic pressure. After confirming that aspirated liquid does not contain bile and that cyst has no cystobiliary connection, 95% alcohol was injected into the cavity, safely. Reaspiration of alcohol was not performed. RESULTS The cyst sizes were reduced after PAI on ultrasonographic evaluations in all cases. The liquid component disappeared and the cyst got solid characteristic three months after the procedure. CONCLUSION All hydatid cyst types can be treated safely and effectively with PAI technique without considering dimensions and whether.

Recurrent hypersplenism caused by giant accessory spleen due to portal hypertension after splenectomia.

Splenectomy is one of the primary choices of treatment in immune thrombocytopenic purpura. However, the disease may relapse despite splenectomy. One of the leading causes of relapse is the presence of accessory spleen, which may become enlarged significantly with underlying pathologies such as presence of portal hypertension. The accessory spleen, which will inevitably enlarge in time, may grow significantly within a short period of time in the presence of portal hypertension and may thus be misdiagnosed as a tumoral mass. Presence of ectopic spleen should be borne in mind in patients diagnosed with immune thrombocytopenic purpura with relapsing hypersplenism following splenectomy. This article discusses a patient developing portal hypertension secondary to chronic liver disease and presenting with a significantly enlarged accessory spleen as well as hypersplenism findings.