Fatih Ermis

Preliminary evidence of a reduced serum level of fibroblast growth factor 19 in patients with biopsy-proven nonalcoholic fatty liver disease.

OBJECTIVES We sought to determine whether serum concentrations of fibroblast growth factor 19 (FGF19) - an ileum-derived enterokine which plays a role in the control of glucose and lipid homeostasis - are altered in patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD). DESIGN AND METHODS Serum levels of FGF19 were measured using enzyme-linked immunosorbent assay in 91 patients with biopsy-proven NAFLD and 74 controls. RESULTS FGF19 levels were significantly lower in patients with biopsy-proven NAFLD (median: 130pg/mL) than in controls (median: 210pg/mL, P<0.001). Serum FGF19 levels were significantly but modestly associated with hepatocyte ballooning scores in univariate analysis (r=-0.25, P<0.05) but not after adjustment for potential confounders (β=-0.18; t=1.78, P=0.08). CONCLUSIONS This pilot study suggests that serum FGF19 levels are decreased in patients with NAFLD but are not independently associated with liver histology findings.

Is portal hypertensive enteropathy an important additional cause of blood loss in portal hypertensive patients

Abstract Objective. Recently, mucosal changes of small bowel were defined by developing new imaging techniques including capsule endoscopy (CE) in portal hypertensive patients. However, the clinical impact of these changes is unknown. In this study, we aimed to determine the additional cause of blood loss in portal hypertensive patients. Material and methods. A total of 444 portal hypertensive patients, hospitalized in our clinic between 2005 and 2007, were evaluated. Patients with obscure bleeding were enrolled to this prospective case–control study. CE was performed in 21 patients who met inclusion criteria. Gastroscopy, colonoscopy and computerized tomography/small bowel enema were performed in all patients. Results. Fourteen cirrhotic and seven noncirrhotic portal hypertensive patients were enrolled to this study. Mean age of patients was 47.9 ± 15.6 years, and 13 of 21 were male. Small bowel varices were found in 7 patients (1 active bleeding) and other mucosal abnormalities in 10 patients (vascular ectasia, erosion and edema, 1 active bleeding). Although two of them were normal, jejunal malignant mass was found in two patients (1 active bleeding). Of 21 patients, 19 (90.5%) patients had portal hypertensive abnormalities (including varices). However, ileal varices rate was 57.1% (4 patients) in noncirrhotic portal hypertensive patients and 21.4% (3 patients) in cirrhotics. Conclusion. Ninety percent of patients had portal hypertensive abnormalities in small bowel and one-third of them had small bowel varices. Small bowel varices and vascular ectasia were the main causes of obscure bleeding in portal hypertensive patients.

Gastroesophageal reflux in asymptomatic obese subjects:An esophageal impedance-pH study

AIM To investigate the relationship between reflux and body mass index (BMI) in the asymptomatic obese population using the impedance-pH technique. METHODS Gastroesophageal reflux is frequent in the obese population. However, the relationship between acid reflux and BMI in asymptomatic obese people is unclear. Forty-six obese (BMI > 25 kg/m(2)) people were enrolled in this prospective study. We evaluated the demographic findings and 24-h impedance pH values of the whole group. Gas, acid (pH < 4), weak acid (pH = 4-7) and weak alkaline (pH ≥ 7) reflux parameters were analyzed. RESULTS The mean age of patients was 49.47 ± 12.24 years, and half of them were men. The mean BMI was 30.64 ± 3.95 kg/m(2) (25.14-45.58 kg/m(2)). BMI of 23 was over 30 kg/m(2). Seventeen patients had a comorbidity (hypertension, diabetes mellitus, or ischemic heart disease). Endoscopic examination revealed esophagitis in 13 of the 28 subjects (10 Grade A, 3 Grade B). The subjects were divided into two groups according to BMI (< 30 and > 30 kg/m(2)). Demographic and endoscopic findings, and impedance results were similar in these two groups. However, there was a positive correlation between BMI and total and supine pH < 4 episodes (P = 0.002, r = 0.414; P = 0.000, r = 0.542), pH < 4 reflux time (P = 0.015, r = 0.319; P = 0.003, r = 0.403), and DeMeester score (P = 0.012, r = 0.333). CONCLUSION Acid reflux is correlated with BMI in asymptomatic obese individuals.

Second-line levofloxacin-based triple therapy's efficiency for Helicobacter pylori eradication in patients with peptic ulcer.

Objectives: First-line standard eradication efficacy with lansoprazole, amoxicillin and clarithromycin regressed over 10 years. The aim of this study was to evaluate the efficacy and tolerability of a levofloxacin-based regimen in patients with peptic ulcer after failure of the standard first-line H.pylori eradication therapy in a country with a high rate of infection. Methods: A total of 91 peptic ulcer patients who were diagnosed H.pylori positive proven by rapid urease test and histology between November 2005 to March 2008 were given lansoprazole 30 mg bid, amoxicillin 1 g bid and clarithromycin 500 mg bid (LAC) for 14 days. After three months from the first line eradication treatment omeprazole 20 mg bid, levofloxacin 500 mg bid, amoxicillin 1 g bid (OLA) 7 day treatment regimen was recommended as a second-line therapy for 37 patients who failed at first-line standard triple therapy. Results: Eradication rates for LAC regimen were found to be 57.14% (52/91) for intention to treat and 58.42% (52/89) for per protocol analysis. Eradication rates for OLA regimen were found to be 37.83% (14/37) for ITT and 41.17% (14/34) for PP analysis. Conclusion: OLA regimen eradication rate was successful only in 40% of patients who failed in the first-line eradication. New eradication treatment strategies must be performed, at least in Turkey.

Etiological factors of duodenal and gastric ulcers.

BACKGROUND/AIMS We aimed to determine the etiology of patients with duodenal and gastric ulcers. METHODS 140 patients diagnosed with peptic ulcer between April 2002-2009 were enrolled in this prospective study. Two biopsy specimens were collected from the antrum and corpus for histology and one for rapid urease testing, and stool samples were analyzed for Helicobacter pylori antigen. Serum calcium and gastrin levels were also analyzed. RESULTS 82 (58%) patients were male, with a median age of 47.70±15.03 years (range: 16-92). The ulcer was located in the duodenum in 96 patients, stomach in 40, and both duodenum and stomach in 4. The rates of patients positive for Helicobacter pylori antigen in stool, positive in urease testing and positive for Helicobacter pylori presence in antral and corpus samples were 48%, 52%, 67%, and 60%, respectively. 107 (76%) patients were positive for Helicobacter pylori in one of the test methods. 64 (46%) patients had a history of nonsteroidal antiinflammatory drug use within the last month. Mean levels of calcium and gastrin were 9.29±0.40 (7.90-10.20) and 73.96±89.88 (12.86-562.50), respectively. Gastrin level was correlated to inflammatory activity (p<0.05). 19 (13.6%) of the patients were negative for Helicobacter pylori, nonsteroidal anti- inflammatory drug use and hypersecretory illness, and were classified as idiopathic. CONCLUSIONS The most common cause of duodenal and gastric ulcer was Helicobacter pylori, and it was responsible for three-fourths of the cases. About half of the patients had a history of nonsteroidal antiinflammatory drug use, and nonsteroidal antiinflammatory drug and Helicobacter pylori were both responsible for the ulcer in three-fourths of these patients. In about one-tenth of the patients, nonsteroidal antiinflammatory drug use was the cause of ulcer alone, and about one-tenth of the ulcers were classified as idiopathic.

Effect of proton pump inhibitor (PPI) treatment in obstructive sleep apnea syndrome: an esophageal impedance-pHmetry study.

BACKGROUND/AIMS There is an increasing interest for a link between gastroesophageal reflux (GER) and obstructive sleep apnea syndrome (OSAS). There is no study in the literature which examines the relationship between OSAS and esophageal functions in adults with impedance. We first evaluated the role of reflux in OSAS with simultaneous polysomnography and impedance-pHmetry and then investigated whether the effect of proton pump inhibitor (PPI) treatment changes in these parameters. METHODOLOGY Twenty two OSAS patients who had applied to sleep laboratory between September 2007 and May 2008 were consecutively enrolled to the study. Twenty four hours esophageal impedance study was performed during polysomnographic recording. At least 50% of all apneas in patients must proceed with a reflux event in 2 minute intervals in order to be considered reflux related apnea patient. RESULTS Pathologic reflux episodes were determined in 20 patients (8 were weakly acidic, 12 were acidic). Reflux dependent apnea was found in 6 patients. There was endoscopically esophagitis in all reflux related apnea patients. There was a negative correlation between initial mean SaO2 and gas reflux events at night (p=0.004, r =-0.588) and mixed reflux events at night (p=0.02, r=0.493). There was a statistically significant regression of AHI (apnea hypopnea index) after 3-months PPI treatment (p=0.012). CONCLUSIONS Reflux may trigger apnea in some of the OSAS patients. Therefore, each OSAS patient must be inquired about esophageal and extraesophageal symptoms of reflux.

Folic Acid and vitamin B12 supplementation improves coronary flow reserve in elderly subjects with vitamin B12 deficiency.

BACKGROUND AND AIMS Major cardiovascular risk factors including hyperhomocysteinemia are frequently associated with decreased coronary flow reserve (CFR), an important physiological parameter of the coronary circulation. This study was designed to determine whether folate (5 mg) and vitamin B12 (500 μg) supplementation in elderly patients with vitamin B12 deficiency improved CFR, while reducing homocysteine levels. METHODS Forty-four patients aged >65 years showing serum vitamin B12 concentrations <180 mg/dL were randomized to take either oral folate (5 mg) plus vitamin B12 (500 μg) supplementation (n = 24) or placebo (n = 20) for 8 weeks. The study course consisted of two visits: visit 1 (pretreatment) included the baseline assessment of laboratory profile and CFR values with trans-thoracic Doppler echocardiography. Visit 2 was scheduled 8 weeks later to repeat CFR and laboratory tests after therapy. RESULTS In the treatment arm, oral supplementation with folate and vitamin B12 significantly improved total cholesterol, serum folate, serum vitamin B12, homocysteine, and insulin resistance. At 8 weeks, the treatment group had a significant increase from baseline in CFR values (baseline: 1.7 ± 0.2; postttreatment: 2.1 ± 0.2, p <0.001) that was not seen in the placebo group (baseline: 1.6 ± 0.2; posttreatment: 1.6 ± 0.2; P = ns). CONCLUSIONS In this study of elderly subjects with vitamin B12 deficiency, supplementation with folate and vitamin B12 was associated with a significant improvement in CFR values.

Durability of Sustained Virologic Response in Chronic Hepatitis C

Background/Aims The aim of this study is to investigate the rate of sustained virologic response (SVR) in chronic hepatitis C patients receiving antiviral treatment. Methods The files of patients with chronic hepatitis C treated with interferon±ribavirin between 1995 and 2009 were reviewed retrospectively. Six months after the end of treatment, patients with negative hepatitis C virus (HCV)-RNA (<50 IU/mL, as determined by the polymerase chain reaction method) were enrolled in the study. Results The mean age of 196 patients (89 males) was 46.13±11.10 years (range, 17 to 73 years). In biopsies, the mean stage was 1.50±0.94; histological activity index was 7.18±2.43. In total, 139 patients received pegylated interferon (IFN)+ribavirin, 21 patients received classical IFN+ribavirin, and 36 patients received IFN alone. The HCV genotypes of 138 patients were checked: 77.5% were genotype 1b, and 22.5% were other genotypes. After achievement of SVR, the median follow-up period was 33.5 months (range, 6 to 112 months), and in this period relapse was only detected in two patients (1.02%) at 18 and 48 months after treatment. Conclusions In total, 98.9% of patients with SVR in chronic hepatitis C demonstrated truly durable responses over the long-term follow-up period of 3 years; relapsed patients had intermittent or low-grade viremia.

Crimean-Congo hemorrhagic fever presenting with gastrointestinal manifestations: two cases.

Crimean-Congo hemorrhagic fever virus (CCHFV) is a viral hemorrhagic fever of the Nairovirus group that belongs to the Bunyaviridae family. Crimean-Congo hemorrhagic fever (CCHF) is a severe infectious disease with a mortality rate as high as 5%, and it is characterized by fever and bleeding. CCHF first emerged in Turkey in 2002, and the prevalence of the disease has been found to be increased (1). In fact, it is transmitted by tick bites, but people could be infected by direct contact with infected patient or animal blood and tissue. There have been reported fatal case reports about health workers who were infected from patients (2). These cases are usually different diagnosed patients rather than CCHF in other departments or in the emergency room. In this paper, we present two different case reports who applied to the emergency room with hematemesis and jaundice. After follow-up, they were diagnosed with CCHF.

Does Cholecystectomy Increase the Esophageal Alkaline Reflux? Evaluation by Impedance-pH Technique.

Background/Aims The aim of this study is to investigate the reflux patterns in patients with galbladder stone and the change of reflux patterns after cholecystectomy in such patients. Methods Fourteen patients with cholecystolithiasis and a control group including 10 healthy control subjects were enrolled in this prospective study. Demographical findings, reflux symptom score scale and 24-hour impedance pH values of the 14 cholecystolithiasis cases and the control group were evaluated. The impedance pH study was repeated 3 months after cholecystectomy. Results Age, gender, and BMI were not different between the two groups. Total and supine weakly alkaline reflux time (%) (1.0 vs 22.5, P = 0.028; 201.85 vs 9.65, P = 0.012), the longest episodes of total, upright and supine weakly alkaline reflux mediums (11 vs 2, P = 0.025; 8.5 vs 1.0, P = 0.035; 3 vs 0, P = 0.027), total and supine weakly alkaline reflux time in minutes (287.35 vs 75.10, P = 0.022; 62.5 vs 1.4, P = 0.017), the number of alkaline reflux episodes (162.5 vs 72.5, P = 0.022) were decreased with statistical significance. No statistically significant difference was found in the comparison of symptoms between the subjects in the control group and the patients with cholecystolithiasis, in preoperative, postoperative and postcholecystectomy status. Conclusions Significant reflux symptoms did not occur after cholecystectomy. Post cholecystectomy weakly alkaline reflux was decreased, but it was determined that acid reflux increased after cholecystectomy by impedance pH-metry in the study group.