Evrim Kahramanoglu Aksoy

Comparison of Helicobacter pylori Eradication Rates of 2-week Levofloxacin Containing Triple Therapy, Levofloxacin Containing Bismuth Quadruple Therapy and Standard Bismuth Quadruple Therapy as a First-line Regimen

Objective: The aim of this study was to compare the efficacy and safety of 2-week levofloxacin-containing triple therapy, levofloxacin-containing bismuth quadruple therapy, and standard bismuth-containing quadruple therapy as a first-line regimen for the eradication of Helicobacter pylori.Methods: A total of 329 patients with H. pylori infection were randomly divided into 3 groups to receive one of the following regimens: (a) levofloxacin-containing bismuth quadruple therapy, RBAL (rabeprazole 20 mg, b.i.d., bismuth subsalicylate 562 mg, b.i.d., amoxicillin 1 g, b.i.d, levofloxacin 500 mg, once daily), (b) standard bismuth quadruple therapy, RBMT (rabeprazole 20 mg, b.i.d, subsalicylate 562 mg, b.i.d., metronidazole 500 mg, t.i.d, tetracycline 500 mg, q.i.d), or (c) levofloxacin-containing triple therapy, RAL (rabeprazole 20 mg, b.i.d., amoxicillin 1 g, b.i.d, levofloxacin 500 mg, once daily). The primary outcome was the eradication rate in the intention-to-treat (ITT) and per protocol (PP) analysis. Results: The eradication rates of the above 3 groups using ITT analysis were RBAL 83.8%, RBMT 88.3%, and RAL 74.8% compared with 91.2, 92.5, and 79.2%, respectively, using PP analysis. The eradication rate using RBMT was significantly higher than that of RAL (p = 0.029 in ITT analysis and p = 0.017 in PP analysis). Several side effects occurred in 156 patients (54.1%) in the RBAL group, 215 (52.3%) in the RBMT group, and 56 (26.2%) in the RAL group (p > 0.05, RBAL vs. RBMT; p < 0.001, RBMT vs. RAL; p < 0.001, RBAL vs. RAL). Conclusion: All bismuth-containing quadruple therapies had acceptable eradication rates, but levofloxacin-containing triple therapy was not as good as quadruple therapies. Hence, quadruple therapies should be considered the preferred first-line therapy for H. pylori infections.

Atypical Presentation of Celiac Disease in an Elderly Adult: Celiac Crisis

ponemal antibody absorption, Treponema pallidum particle agglutination, or syphilis enzyme immunoassay) should always be performed when there is a suspicion of latent forms of syphilis. IV penicillin G is the first-line treatment for any manifestation of neurosyphilis. Ceftriaxone and doxycycline may be used for individuals allergic to beta-lactams (although caution should be exercised with ceftriaxone in persons with a history of life-threatening allergic reactions to betalactams). There is limited evidence of the effectiveness of treatment of psychiatric symptoms in paretic neurosyphilis with psychotropic medications, and the lowest possible dose is recommended. Success of therapy may be determined according to symptomatic improvement, normalization of CSF white cell counts, and a nonreactive CSF-VDRL. Although symptoms usually improve rapidly upon starting treatment in early neurosyphilis, the parenchymal late phases regularly result in lasting deficits. The woman’s memory improved but still placed her in the 12th percentile of the Mini-Mental State Examination (Table 1). Her Repeated Battery for Assessment of Neuropsychological Status (RBANs) score improved after treatment (Table 1). There is a possibility that her chronic alcohol abuse and family history of Alzheimer’s disease contributed to her memory loss as well.

Autoimmune hepatitis/primary biliary cirrhosis overlap syndrome developed in a patient with vitiligo and Hashimoto thyroiditis.

References 1 Arai M, Yokosuka O, Fujiwara K, Kojima H, Kanda T, Hirasawa H, Saisho H. Fulminant hepatic failure associated with benzbromarone treatment: a case report. J Gastroenterol Hepatol 2002; 17:625–626. 2 Gehenot M, Horsmans Y, Rahier J, Geubel AP. Subfulminant hepatitis requiring liver transplantation after benzarone administration. J Hepatol 1994; 20:842. 3 Hautekeete ML, Henrion J, Naegels S, DeNeve A, Adler M, Deprez C, et al. Severe hepatotoxicity related to benzarone: a report of three cases with two fatalities. Liver 1995; 15:25–29. 4 Russmann S, Lauterburg B. Life-threatening adverse effects of pharmacologic antihyperuricemic therapy. Ther Umsch 2004; 61:575–577. 5 Van der Klauw MM, Houtman PM, Stricker BH, Spoelstra P. Hepatic injury caused by benzbromarone. J Hepatol 1994; 20:376–379. 6 Wagayama H, Shiraki K, Sugimoto K, Fujikawa K, Shimizu A, Takase K, et al. Fatal fulminant hepatic failure associated with benzbromarone. J Hepatol 2000; 32:874. 7 Aithal GP, Watkins PB, Andrade RJ, Larrey D, Molokhia M, Takikawa H, et al. Case definition and phenotype standardization in drug-induced liver injury. Clin Pharmacol Ther 2011; 89:806–815. 8 AMK: Acifugan recall. Pharm Ztg. 2003: 15http://www.pharmazeutischezeitung.de/index.php?id = 28679 [Accessed on 8 October 2012]. 9 Lee MH, Graham GG, Williams KM, Day RO. A benefit-risk assessment of benzbromarone in the treatment of gout. Was its withdrawal from the market in the best interest of patients? Drug Saf 2008; 31:643–665. 10 Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965; 58:295–300. 11 Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30:239–245.

An unusual neurological complication in a patient with ulcerative colitis

A 60-year-old female was admitted to our clinic with fever, headache, weakness, and confusion. Her past medical history was unremarkable other than ulcerative colitis (UC), and she received 4 g/day mesalamine, 100 mg/day azathioprine, and 25 mg/day prednisolone on admission. Because of UC activation 1 month previously, azathioprine and prednisolone were initiated at initial doses of 50 and 40 mg/day, respectively. The prednisolone dose was decreased by 5 mg weekly, whereas the azathioprine dose was increased to 100 mg in the second week. Physical examination revealed that her body temperature was 38.4°C. She had right hemiparesis, neck stiffness, and confusion. Laboratory test results were as follows: hemoglobin level, 10.9 g/ dL (11.7–15.5 g/dL); white blood cell (WBC) count, 2×103/μL (4.1–11.2×103/μL); platelet count, 125×103/ μL (159–388×103/μL); neutrophil count, 1.7×103/μL (1.8–6.4×103/μL), and C-reactive protein level, 15.8 mg/ dL (0–0.3 mg/dL). Liver enzyme and creatinine levels were normal. Magnetic resonance imaging (MRI) findings of the patient were consistent with meningitis. Lumbar puncture was performed, and cell count of the cerebrospinal fluid (CSF) was 600/mm3 WBCs, with 40% neutrophil and abundant erythrocytes. Gram-positive rods were detected in the Gram stain of CSF. Meropenem plus ampicillin was administered to the patient for a central nervous system (CNS) infection. Azathioprine was discontinued, and the prednisolone dose was gradually reduced (5 mg/1–4 day) because of the infection. The control cranial MRI in the second week revealed a left thalamo-mesencephalic abscess (Figure 1). Listeria monocytogenes (LM) was identified in the CSF culture. Meropenem was switched to gentamicin, and gentamicin plus ampicillin was continued for 1 month. The patient clinically improved, and the control cranial MRI in the sixth week showed a marked improvement of the abscess (Figure 2). She was discharged from the hospital with continuing treatment of 4 g/day mesalamine for UC. Turk J Gastroenterol 2017; 28: 137-9

A rare cause of severe gastrointestinal bleeding in a thrombocytopenic patient with acute myeloid leukemia.

A 24-year-old female who had been diagnosed with acute myeloid leukemia (AML) 1 month prior was admitted to our clinic with acute-onset substernal chest pain, hematemesis, and melena. She had completed her second cycle of chemotherapy (Cytosine arabinoside/ idarubicin.) 2 weeks ago. Apart from AML, her past medical history was unremarkable. Her physical examination was normal, except for melena in her digital rectal examination. Laboratory test results were as follows: hemoglobin level: 7.7 g/dL (11.7–15.5 g/dL), white blood cell count: 0.2×109/L (4.1×109–11.2×109/L), platelet count: 14×109/L (159×109–388×109/L), creatinine level: 0.62 mg/dL (0.5–0.9 mg/dL), alanine transaminase level: 19 U/L (0–33 U/L), aspartate transaminase level: 25 U/L (0–31 U/L), and international normalized ratio: 0.9 (0.8–1.2). Her hemoglobin level decreased in repeated measurements, leading to the development of tachycardia and hypotension. Upper gastrointestinal endoscopy was performed after red blood cell and platelet transfusions. Endoscopy showed a double lumen in the middle portion of the esophagus separated by a mucosal bridge that was coated with a hematoma (Figure 1).

A CASE WITH SEVERE ACUTE COLITIS FOLLOWING COLONOSCOPY

VOLUME 40 | NUMBER 5 | SEPTEMBER/OCTOBER 2017 Case A 60-year-old female patient was admitted to our clinic with dyspepsia for 6 months and a weight loss of 8 kg. Her medical history was unremarkable other than hypersensitivity to perfumes and detergents. Her physical examination and laboratory findings, including complete blood count, liver enzymes, creatinine, C-reactive protein, international normalized ratio, and thyroid-stimulating hormone, were normal. Endoscopy of the patient showed signs consistent with mild gastritis, and colonoscopy revealed a diminutive polyp and a single diverticulum in the right colon. Rectum and sigmoid colon were normal. A proton pump inhibitor was initiated for gastritis, and the patient was discharged from the hospital. She was readmitted to the clinic with abdominal pain, diarrhea, and hematochezia that started 3 hours after colonoscopy. Stool microscopy findings were negative for pathogenic microbiological agents. The gastrointestinal tract A CASE WITH SEVERE ACUTE COLITIS FOLLOWING COLONOSCOPY

ILEUS DUE TO EXTENSIVE AIR INSUFFLATION WITH ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used procedure for diagnosis and particularly for treatment of biliary tract and pancreatic disorders ( Baron, et al., 2006 ). The procedure-related complication rate may be as high as 5.4%–23% and the mortality rate is about 0.1%–1% ( Christensen, Matzen, Schulze, & Rosenberg, 2004 ). Biliary and intestinal perforation, pancreatitis, hemorrhage, and cholangitis are the most common complications. Intestinal obstruction following large biliary stone extraction has been reported rarely. Peritonitis secondary to perforation and acute pancreatitis may also be complicated with ileus. Here, we report an unusual case of nonobstructive ileus after ERCP procedure without those underlying etiologies. ILEUS DUE TO EXTENSIVE AIR INSUFFLATION WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Cirrhosis Related to Hepatic Sarcoidosis in Older Adults

empyema following head injury in an elderly patient: A case report and literature review. J Neurol Surg Rep 2015;76:e79–e82. 5. Choi CH, Moon BG, Kang H et al. A case of infected subdural hematoma. J Korean Neurosurg Soc 2003;34:271–273. 6. Chhiber SS, Nizami FA, Kumar A et al. Chronic subdural hematoma with contralateral subdural empyema. EC Neurol 2015;2:29–32. 7. Yamasaki F, Kodama Y, Hotta T et al. A case of infected subdural hematoma complicating chronic subdural hematoma in a healthy adult man (Japanese). No To Shinkei 1997;49:81–84. 8. Wortzman DJ, Tucker WS, Finlayson DM et al. Subdural empyema with a negative C.T. scan: A case report. Can J Neurol Sci 1980;7:67–69. 9. Leys D, Destee A, Petit H et al. Management of subdural intracranial empyemas should not always require surgery. J Neurol Neurosurg Psychiatry 1986;49:635–639. 10. Mauser HW, Ravijst RAP, van Gjin J et al. Nonsurgical treatment of subdural empyema: Case report. J Neurosurg 1985;63:128–130.

Image of the month: A Red Ball at the Base of the Cecum.

A 60-year-old woman with a history of tonsillar squamous cell carcinoma status after surgical resection (9 months previously) underwent an esophagogastroduodenoscopy for melena and anemia. An ulcerated gastric mass was seen endoscopically at the insertion site of a previously placed percutaneous endoscopic gastrostomy tube, which had been removed 3 months prior (left and center). Biopsies of the mass confirmed a diagnosis of metastatic squamous cell carcinoma that was clearly seen on a follow-up positron emission tomography–computed tomography scan (right).

An Unusual Cause of Gastrointestinal Bleeding in a Patient with Enteral Feeding

ABSTRACT Abbreviations: NG: Nasogastric; PEG: Percutaneous gastrostomy. How to cite this article: Öztürk Ö, Aksoy EK, Dadakci YC, Basar Ö. An Unusual Cause of Gastrointestinal Bleeding in a Patient with Enteral Feeding. Euroasian J Hepato-Gastroenterol 2014;4(2):119.