Burhan Sahin

Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation

Objective:  Some benign esophageal strictures are highly resistant to bougie dilation. The aim of this study was to determine whether intralesional steroid injection had additional benefit to Savary‐Gilliards bougie dilation therapy (SGBD).

Endoscopic ultrasonography in the evaluation of dilated common bile duct

Abdominal ultrasonography (US) is the procedure of first choice in the evaluation of a dilated common bile duct (CBD). Dilated bile ducts and the level of obstruction can be reliably demonstrated with US, but the cause can be determined in only two thirds of patients. The aim of this prospective study was to assess the value of endoscopic ultrasonography (EUS) in detecting the cause of CBD dilatation in patients in whom US could not demonstrate the cause of dilation or in whom US revealed equivocal results. This 13-month study included the evaluation of 985 patients. Ninety consecutive patients found to have an enlarged CBD (diameter, ≥7 mm) of unexplained origin during US examination were included in this study. All patients were evaluated by EUS. Final diagnosis was determined by endoscopic retrograde cholangiopancreatography with or without sphincterotomy (n = 72) and surgical exploration (n = 17). The following diagnoses were made by EUS: choledocholithiasis in 40 patients, benign distal stricture in 8, choledochal cyst in 2, and ova of Ascaris in 1. The dilatation of CBD was found by EUS examination to be caused by a tumor in 13 cases. These included tumor of the papilla of the Vater in six patients, distal cholangiocarcinoma in five, and pancreatic head cancer in two. Endoscopic ultrasonography provided an accurate explanation for CBD dilatation in 70 of the 76 patients (92%). We conclude that the diagnostic strategy for cholestasis should include US as a first choice. When the diagnosis of biliary obstruction remains probable, EUS should be carried out. Endoscopic retrograde cholangiopancreatography with sphincterotomy should be reserved for therapeutic use rather than diagnostic.

Hepatobiliary fascioliasis: clinical and radiologic features and endoscopic management.

Fasciola hepatica is a zoonotic liver fluke that can cause disease in humans. Fascioliasis is an uncommon disease. We retrospectively analyzed 9 cases of fascioliasis and reviewed the relevant literature. A high index of suspicion and specific ultrasonographic findings are very helpful in the diagnosis of the disease. However, serological studies and endoscopic retrograde cholangiopancreatography confirm the diagnosis. The disease has 2 stages: hepatic stage and biliary stage. While several drugs are used during the hepatic stage, endoscopic retrograde cholangiopancreatography is particularly effective in the biliary stage.

Continuous active state of coagulation system in patients with nonthrombotic inflammatory bowel disease.

This study was planned for searching possible changes of the total coagulation and fibrinolysis system in inflammatory bowel disease (IBD) in order to obtain some clues for explaining the relation between IBD and hypercoagulability. A total of 24 patients with ulcerative colitis, 12 patients with Crohn disease, and 20 healthy controls were studied. Platelets; prothrombin time (PT); partial thromboplastin time (PTT); fibrinogen; d-dimer; fibrinogen degradation products; protein C; protein S; antithrombin; thrombin time; von Willebrand factor; coagulation factors V, VII, VIII, IX, XI, and XIII; plasminogen; antiplasmin; tissue plasminogen activator; plasminogen activator inhibitor 1; and prothrombin fragments 1 + 2 were studied. Most of the procoagulants (platelets, fibrinogen, von Willebrand factor, coagulation factor IX, and plasminogen activator inhibitor 1) were found increased together with decreases in some anticoagulants (protein S and antithrombin) in IBD. Also the activation markers of coagulation (d-dimer, fibrinogen degradation products, and prothrombin fragments 1 + 2) were all increased. The parameters of the total coagulation–fibrinolysis system were increased in IBD, regardless of the form and the activity of the disease.

Evaluation of intrapulmonary vascular dilatations with high-resolution computed thorax tomography in patients with hepatopulmonary syndrome.

Goals: We aimed to determine the role of thorax high-resolution computed tomography (HRCT) in demonstrating the pulmonary vasodilatation in patients with hepatopulmonary syndrome (HPS). Background: Traditionally, the presence of intrapulmonary vascular dilatations can be detected by using one of the three diagnostic modalities: contrast-enhanced echocardiography, technetium 99 m-labeled macroaggregated albumin scan, and pulmonary angiography. Study: The study group included 10 patients with HPS (Group 1), 12 patients with normoxemic cirrhosis (Group 2), and 12 healthy controls (Group 3). All of the subjects underwent conventional and HRCT of thorax. The diameters of pulmonary trunk, main pulmonary arteries, and right lower lobe basal segmental arteries were measured. The ratios of right lower lobe basal segmental pulmonary artery to bronchus diameter were calculated. Results: The mean diameters of the main pulmonary trunk, right and left main pulmonary arteries were not different between the groups. Mean diameters of right lower lobe basal segmental pulmonary arteries were significantly higher in Group 1 compared with Group 2 (P = 0.01) and Group 3 (P = 0.002). Mean right lower lobe basal segmental pulmonary artery to bronchus ratios were significantly higher in Group 1 compared with Group 2 (P = 0.03) and Group 3 (P < 0.001). Group 2 had significantly higher pulmonary artery to bronchus ratios than Group 3 (P < 0.001). Conclusions: Thorax HRCT may be helpful in the diagnosis of HPS by demonstrating the dilated peripheral pulmonary vessels or increased pulmonary artery to bronchus ratios in patients with liver disease and hypoxemia.

Staging laparoscopy for gastric cancer.

Surgical resection remains the only potentially curative treatment of patients with gastric cancer. Evaluation of surgery and other treatments depends on accurate staging of the disease. The objective of the study was to compare staging laparoscopy with ultrasonography, endoscopic ultrasound, computed tomography, and histology for serosal infiltration, lymph node metastasis, peritoneal seeding, and hepatic metastasis. Diagnostic laparoscopy was carried out in 48 patients. Prelaparoscopic staging in all cases included upper gastrointestinal endoscopy and biopsies followed by endosonography, ultrasound, and computed tomography. Preoperative combined examination using CT and laparoscopy was superior when compared with each modality alone or the combinations of the other tests. The present study showed that preoperative evaluation of patients with laparoscopy is superior to all other diagnostic tests. We also found that laparoscopy and computed tomography were better in accurately assessing the serosal infiltration, peritoneal seeding, and hepatic metastases, which thus allows the surgeon to choose more effective treatment modality.

Chronic pancreatitis and aortic pseudoaneurysm in Behçet's disease.

Behçets disease is a chronic, recurrent, systemic disease characterized by orogenital ulcers and oculocutaneous inflammatory lesions. Cardiovascular, pulmonary, neurological, articular, and GI involvement are common features, but pancreatic involvement is very rare. We present a case of Behçets disease with both chronic pancreatitis and abdominal aorta pseudoaneurysm.

Colorectal cancer localization in young patients : Should we expand the screening program?

We sought to investigate the frequency and distribution of colorectal cancer (CRC) in patients by age and to evaluate whether there is a difference between young (<40 years of age) and older patients (≥40 years of age) with regard to cancer localizations. From a total of 5165 colonoscopies, 314 (6.0%) cases were identified to have colorectal carcinoma. Forty-one (13%) of 314 CRC patients were young, with a mean age of 31.1±5.7 years. When cancer localizations were compared with reference to age, it was seen that CRCs in young patients were mostly localized at the right colon, versus at the left colon and rectum (P=013) in patients >40 years of age. Tumor localizations in colon cancer patients change with age. In our study, young patients tended to have right-sided colon tumors, but those in patients >40 years of age were frequently localized at the left colon and rectum.

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

BackgroundAnomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.MethodsThe data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.ResultsA total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).ConclusionThe opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

Endoscopic management of a duodenal duplication cyst associated with biliary obstruction in an adult.

Duodenal duplication cysts are distinctly uncommon and most often present in infancy or early childhood. The clinical presentation is generally duodenal obstruction, hemorrhage, or pancreatitis. Duodenal duplication cysts rarely cause biliary obstruction in adults. So far, duodenal duplication cysts have been almost exclusively treated by surgical intervention. This report describes both endoscopic diagnosis and treatment of a large periampullary duodenal duplication cyst associated with biliary obstruction in an adult patient.