Ibrahim Ertugrul

Mucocutaneous manifestations in inflammatory bowel disease

Background: The aim of this study was to evaluate the prevalence and features of the major cutaneous manifestations (erythema nodosum [EN] and pyoderma gangrenosum [PG]) and to determine the associations between cutaneous manifestations and other extraintestinal manifestations in patients with inflammatory bowel disease (IBD). Methods: The mucocutaneous manifestations of patients with IBD were studied between December 2002 and June 2007. All patients underwent a detailed whole body examination by a gastroenterologist and dermatologist. Results: In all, 352 patients were included in this study; 34 patients (9.3%) presented with at least 1 major cutaneous manifestation. The prevalence of EN (26 patients) and PG (8 patients) in IBD was 7.4% and 2.3%, respectively. EN was more common in Crohns disease (16/118) than ulcerative colitis (10/234) (P = 0.002). EN was found to be related to disease activity of the bowel (P = 0.026). The prevalence of arthritis was significantly higher in the IBD patients with EN (11/26) than in IBD patients without EN (53/326) (P = 0.006). Arthritis was more common in IBD patients with PG (7/8) than in IBD patients without PG (57/344) (P = 0.00). IBD patients with PG were significantly more likely to have uveitis (1/8) compared with IBD patients without PG (5/344) (P = 0.017). Conclusions: We found the prevalence of 2 important cutaneous manifestations to be 9.3% in IBD in Turkish patients. EN was found to be more common in Crohns disease and is associated with an active episode of bowel disease and peripheral arthritis. In addition, PG was connected with uveitis and peripheral arthritis. (Inflamm Bowel Dis 2009)

Report of 24 left-sided portal hypertension cases: a single-center prospective cohort study.

Our aim was to analyze patients diagnosed with left-sided portal hypertension prospectively and to document the complications at follow-up. Twenty-four patients with isolated splenic vein thrombosis (diagnosed by ultrasonography or angiography or intraoperatively) and/or isolated fundal varices (diagnosed by endoscopy or endosonography) were involved in this study. Demographics, clinical presentation, diagnostic and therapeutic procedures, and morbidity and mortality were recorded in their follow-up. There were 11 and 13 left-sided portal hypertension cases associated with pancreatic diseases and nonpancreatic disorders, respectively. Chronic abdominal pain and gastrointestinal bleeding were the two most common complaints. All patients except one had isolated esophageal (2 cases) or fundal (21 cases) varices. Thirteen patients had splenomegaly on ultrasonography. On Doppler sonography, the splenic vein could be evaluated in 21 of the 24 patients (9 and 6 had complete and partial occlusion, respectively, and 6 had patent blood flow). Urgent intervention with therapeutic endoscopy and splenectomy was performed for two patients each. Medical therapy was begun for three patients according to the underlying diseases. Three patients underwent elective surgery. Two patients were lost to follow-up after the first visit and the mean follow-up of the remaining 22 patients after diagnosis of left-sided portal hypertension was 20 months. Only one patient (with pancreas cancer) had gastrointestinal bleeding at follow-up. All patients with pancreas and gastric cancer died within 2–12 months. Left-sided portal hypertension has various etiologies. It may be difficult to diagnose this entity both endoscopically and radiologically. Treatment should be directed at the underlying diseases. Recurrent hemorrhage due to left-sided portal hypertension is not usual and the prognosis depends mainly on the underlying etiology.

Effects of esophageal varice eradication on portal hypertensive gastropathy and fundal varices: a retrospective and comparative study.

Esophageal varice eradication results in gastric hemodynamic changes. The aim of this study was to detect the influence of variceal eradication on portal hypertensive gastropathy (PHG) and fundal varices and to compare the results of two therapeutic methods (endoscopic variceal ligation and endoscopic sclerotherapy). A total of 114 consecutive patients with cirrhosis and portal hypertension who underwent elective endoscopic variceal ligation (EVL) (85 patients) or endoscopic sclerotherapy (EST) (29 patients) for obliteration of esophageal varices were selected for this study. Both groups were compared for PHG and fundal varice formation before and after eradication. Fifty-eight (68.2%) patients in the EVL and 18 (62.1%) patients in the EST group had PHG before esophageal varice eradication (P > 0.05). PHG grade after eradication of esophageal varices by both EVL and EST was significantly higher compared to pre-eradication. PHG grade and aggregation were similar in both groups. Thirty-seven patients (34 F1, 3 F2) in the EVL group and 13 patients (10 F1, 3 F2) in the EST group had fundal varices before variceal eradication (P > 0.05). Fundal varices were detected in 46 (35 F1, 11F2) and 19 (11F1, 8F2) patients in the EVL and EST groups after eradication, respectively. There was a statistically significant increment in occurrence of fundal varices after eradication with EVL and EST groups. There was no significant difference regarding fundal varice development after esophageal variceal eradication in both groups. After varical eradication, PHG was found in 57 (87.7%) and 39 (79.6%) patients with and without fundal varices, respectively (P > 0.05). Esophageal eradication with EVL and EST increases both the incidence and the severity of PHG and fundal varice formation. Both methods have comparable influences on PHG and fundal varices.

Intermittent versus Continuous Pantoprazole Infusion in Peptic Ulcer Bleeding: A Prospective Randomized Study

Background and Aim: Rebleeding has remained the most important determinant of poor prognosis in peptic ulcer bleeding. Gastric acid plays an important role in the pathogenesis of rebleeding. We aimed to compare the efficiency of intermittent and continuous pantoprazole infusion treatment on peptic ulcer rebleeding after endoscopic therapy. Materials and Method: In this prospective study, patients with active peptic ulcer bleeding or non-bleeding visible vessel were treated initially with endoscopic therapy. They were randomized to receive intermittent or continuous intravenous pantoprazole treatment. Rebleeding rate, duration of hospital stay, need for total blood transfusion and need for urgent surgery were compared among both groups. Results: Rebleeding rate (6.1 vs. 8.3%), duration of hospital stay (4.17 vs. 4.41), need for total blood transfusion (2.18 vs. 2.59) and need for urgent surgery (4.1 vs. 4.2%) were similar in intermittent and continuous pantoprazole infusion therapy groups, respectively. There was no bleeding-related death in either group. Conclusion: In patients with peptic ulcer bleeding, intermittent and continuous pantoprazole infusion after successful endoscopic therapy have comparable outcomes in reducing rebleeding. Both have similar effects on hospital stay, need for blood transfusion and urgent surgery. Intermittent administration has application and cost advantages over continuous infusion.

An Unusual Complication of Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiography (ERCP) has a greater potential for procedure-related complications than other endoscopic procedures in the upper gastrointestinal tract (1). Extraluminal hemorrhagic complications after ERCP are relatively rare but potentially life threatening and, thus, should be identified and treated rapidly (2). In this report, we describe a very rare complication—subcapsular hepatic hematoma—resulting from a guide wire–associated injury that developed 2 days after ERCP. A 41-year-old man was admitted to our hospital with the complaints of new-onset (few hours) right upper quadrant pain. He was known to have hilar cholangiocarcinoma for the last 8 months and his last biliary stent had been replaced 2 days before as an out-patient in our ERCP unit. Physical examination revealed left upper quadrant tenderness and subfebrile fever (37.8◦C). Laboratory data were as follows: hemoglobin 12.1 g/dL, hematocrit 38%, MCV 93 fL, white blood cell count 13.5 × 109/L, platelet count 437 × 109/L. Serum biochemical tests were within normal limits other than alkaline phosphatase 2140 U/L (38–155 IU/L); γ -glutamyltransferase, 508 U/L (15–60 U/L); total bilirubin, 6.16 mg/dL (0.1– 2.0 mg/dL); and direct bilirubin, 4.74 mg/dL (0.1–0.8 mg/dL). Abdominal sonography revealed a 78× 41mm in diameter collection in the anterior part of the liver (Figure 1). There were 3 stents in the common bile duct and intrahepatic biliary ducts. Computerized tomography demonstrated the subcapsular hematoma. He was hospitalized and followed with palliative measurements including intravenous fluid replacement, antibiotics

Detection of an aortoenteric fistula in a patient with intermittent bleeding.

Background A 57-year-old male with an aortobifemoral bypass graft presented to a gastroenterology clinic with a 3-month history of intermittent hematemesis, melena and fever. The patient had received antibiotic therapy 2 months before for the same symptoms; however, following brief regression (∼3 weeks) the symptoms had returned.Investigations Physical examination; analysis of full blood count; measurement of erythrocyte sedimentation rate, C-reactive protein levels, liver enzymes, electrolytes, renal function, serum cholesterol and serum triglyceride; HIV serology; blood, sputum, urine and stool culture analysis; performance of esophagogastroduodenoscopy, colonoscopy, abdominal ultrasonography and multidetector CT scanning.Diagnosis Aortoenteric fistula with an inflammatory mass surrounding the aortobifemoral bypass graft.Management Laparotomy with removal of the aortobifemoral bypass graft, performance of an extra-anatomic right axillofemoral bypass graft and an extra-anatomic right-left femorofemoral bypass graft.

Thrombosis of the portal venous system: a prospective study.

Background Thrombosis in the portal system causes a wide spectrum of clinical pictures. There are few published studies describing the clinical features and consequences of portal venous system thrombosis. We aimed to document presentations and outcomes in patients with thrombosis in the portal and/or splenic veins. Patients and Methods The study included 95 patients who were diagnosed with portal venous system thrombosis in the period September 2001 to April 2006. Demographics, clinical presentation, diagnostic investigation, management, morbidity, and mortality were recorded in their follow-up. Results Of the 95 patients with portal vein thrombosis (PVT), 35 had isolated PVT (IPVT), 27 had isolated splenic vein thrombosis (ISVT), and 33 had thrombosis in both the portal and splenic veins (PSVT). The mean follow-up periods after diagnosis of IPVT, ISVT, and PSVT were 36, 31, and 32 months, respectively. Abdominal pain and gastrointestinal bleeding were the most common symptoms at presentation in the IPVT and PSVT groups, whereas abdominal pain was the dominant symptom in the ISVT group. During the follow-up period, no bleeding was seen in 26 of the 35 (74%) patients with IPVT, in 23 of the 33 (70%) patients with PSVT, and in 24 of the 27 (89%) patients with ISVT. Biliopathy developed during follow-up in 11 of 35 patients with IPVT, in 1 of 27 with ISVT, and in 5 of 33 with PSVT. In the ISVT group, there were 11 deaths, and one each in the IPVT and PSVT groups. Conclusions The etiology of PVT varies in portal and splenic veins. IPVT has a higher morbidity (bleeding and portal biliopathy), whereas ISVT that is not associated with an underlying malignancy has a favorable prognosis.

Recurrent Pancreatitis in a Patient with Autosomal-Dominant Polycystic Kidney Disease

Autosomal-dominant polycystic kidney disease is an inherited disorder characterized by multiple cysts in kidneys and other organs. A 63-year-old man was evaluated for the etiology of recurrent pancreatitis and chronic renal failure. Multiple cysts of kidneys, liver, and pancreas and pancreas divisum was diagnosed. Pancreatitis should be included in the differential diagnosis of abdominal pain in patients with ADPKD. Pancreas divisum may be a predisposing factor for acute pancreatitis in these patients.

Conscious sedation during endoscopic retrograde cholangiopancreatography : midazolam or midazolam plus meperidine?

Background and objective No consensus exists for the safest and most effective agent and for optimal drug doses for sedation during endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy of midazolam with that of midazolam+meperidine, which provided comfort for the patient during ERCP. Materials and methods The patients were randomized to sedation with midazolam only (2.87±0.67 mg) (n=48, median age 55.54±14.66, 21 women, 27 men) or midazolam (1.82±0.71 mg) with meperidine (42.81±14.61 mg) (n= 48, median age 55.48±2.57, 20 women, 28 men). Procedure-related parameters and the efficacy of sedation as assessed by the endoscopist and the patients were compared. Results Prior endoscopic history, preprocedure anxiety scores, age, sex, baseline vital signs and type of interventions were similar in both groups. Sedation level, duration of procedure and recovery time were comparable in both groups. Sedation quality assessment scale was significantly higher in the midazolam with meperidine group. Degree of pain sensed during the procedure was significantly lower in the midazolam with meperidine group. Midazolam with meperidine group had better patient satisfaction. Twenty-four hours after the procedure, the degree of amnesia between both sedation groups was similar. The number of patients unwilling to repeat the procedure was distinctly higher in midazolam group. Development of hypoxia and arrythmia in the midazolam and midazolam with meperidine groups were comparable. Two patients in the midazolam group developed paradoxical agitation. Conclusions Conscious sedation for ERCP can be successfully and safely achieved by using either only midazolam or a low dose of midazolam with meperidine. Adding of meperidine to midazolam resulted in better patient and endoscopist comfort.

Intestinal obstruction in celiac disease: case report.

Celiac disease (CD), also known as gluten-sensitive enteropathy, is a disease characterized by malabsorption resulting from inflammatory injury to the mucosa of the small intestine after the ingestion of gluten, a protein found in wheat and wheat products (1). The clinical manifestations of CD vary tremendously from patient to patient and it may be associated with serious complications, such as intestinal obstruction. This rare complication results from mechanical blockage or pseudo-obstruction (2, 3). Gastrointestinal system motility disorders in patients with CD seem to facilitate intestinal obstruction (4). Two CD patients presenting with intestinal obstruction have been described. Strictures were found to be responsible in the first patient, and no etiology could be elucidated in the other one. Drawing attention to these rare complications, we discuss the diagnostic and therapeutic approach in the light of the relevant literature.