İlhami Yüksel

Mean platelet volume as a fibrosis marker in patients with chronic hepatitis B

Introduction: Many noninvasive tests have been studied for the diagnosis and determining the liver fibrosis score (LFS). In this study, we aimed to research the correlation of mean platelet volume (MPV) and stage of liver fibrosis in patients with chronic hepatitis B (CHB). Patients and Methods: Fifty‐nine patients with CHB were enrolled retrospectively into the study. Age–sex matched 25 healthy subjects were used as control group. The following data were obtained from computerized patient registry database: HBV‐DNA level, hepatitis B e‐antigen seropositivity, liver enzymes and function tests, white blood cell count, platelet count, hemoglobin, histological activity index, LFS, and MPV. Patients were divided into two groups: patients without significant fibrosis (F0, F1, or F2) (Group 1) and patients with advanced fibrosis (F3, F4) (Group 2). Results: A statistically significant increase in MPV was seen in patients with CHB compared with healthy controls (8.49±0.84 fl vs.7.65±0.42 fl, P<0.001). Receiver operating characteristic curve analysis suggested that the optimum MPV level cut‐off points for CHB was 8.0 fl, with sensitivity, specificity, PPV, and NPV of 68, 76, 86, and 50%, respectively. MPV levels were significantly higher in Group 2 (8.91±0.94 fl, P: 0.009) compared with Group 1 (8.32±0.74 fl). ROC curve analysis suggested that the optimum MPV level cut‐off points for Group 2 was 8.45 fl, with sensitivity, specificity, positive and negative predictive value of 77, 59, 45, and 85%, respectively. Multivariable logistic regression model, which consisted of HAI, ALT, HBV‐DNA, platelet count, and MPV, was performed. We showed that MPV was independently associated with advanced fibrosis (P: 0.031). Conclusion: We suggest that MPV might help in the assessment of fibrosis in CHB. It should not be considered a stand‐alone test for this use owing to nonspecificity with other diseases. J. Clin. Lab. Anal. 25:162–165, 2011.

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)

Long-term Efficacy and Safety of Lamivudine, Entecavir, and Tenofovir for Treatment of Hepatitis B Virus–Related Cirrhosis

BACKGROUND & AIMS Data are limited on the efficacy and safety of tenofovir and entecavir when given for more than 1 year to patients with hepatitis B-related cirrhosis. We investigated the long-term safety and efficacy of these antiviral drugs in patients with chronic hepatitis B virus (HBV) infection, with compensated or decompensated cirrhosis, and compared results with those from lamivudine. METHODS We performed a retrospective analysis of data from 227 adult patients with chronic HBV infection who were diagnosed with cirrhosis, beginning in 2005, at 18 centers throughout Turkey. There were 104 patients who had decompensated cirrhosis, and 197 patients were treatment naive before. Seventy-two patients received tenofovir (followed up for 21.4 ± 9.7 mo), 77 patients received entecavir (followed up for 24.0 ± 13.3 mo), and 74 patients received lamivudine (followed up for 36.5 ± 24.1 mo). We collected data on patient demographics and baseline characteristics. Laboratory test results, clinical outcomes, and drug-related adverse events were compared among groups. RESULTS Levels of HBV DNA less than 400 copies/mL were achieved in 91.5%, 92.5%, and 77% of patients receiving tenofovir, entecavir, or lamivudine, respectively. Levels of alanine aminotransferase normalized in 86.8%, 92.1%, and 71.8% of patients who received tenofovir, entecavir, and lamivudine, respectively. Child-Turcotte-Pugh scores increased among 8.5% of patients who received tenofovir, 15.6% who received entecavir, and 27.4% who received lamivudine. Frequencies of complications from cirrhosis, including hepatic encephalopathy, variceal bleeding, hepatocellular carcinoma, and mortality, were similar among groups. Lamivudine had to be changed to another drug for 32.4% of the patients. CONCLUSIONS Tenofovir and entecavir are effective and safe for long-term use in patients with compensated or decompensated cirrhosis from HBV infection.

Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and mean platelet volume as potential biomarkers for early detection and monitoring of colorectal adenocarcinoma.

Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe. The aim of the present study was to elucidate the efficiency of the neutrophil/lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the mean platelet volume (MPV) as tools for the preoperative diagnosis of CRC and their usefulness in the follow-up of CRC. A total of 144 CRC patients, as diagnosed by colonoscopy, and 143 age-matched and sex-matched healthy participants were included in the study. Medical records were used to compare preoperative and postoperative data including hemoglobin levels, platelet counts, MPV, NLR, and PLR. NLR, PLR, and MPV were significantly higher in CRC patients preoperatively, compared with healthy participants. Receiver-operating characteristic curve analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR, (AUC: 0.853, sensitivity: 70%, specificity: 90%) and 8.25 fl as the cutoff value for MPV (AUC: 0.717, sensitivity: 54%, specificity: 76%). Subgroup analysis showed that NLR, PLR, and MPV levels were also significantly higher in nonanemic CRC patients compared with the control group, which is of great theoretical and clinical value for the early detection of CRC. Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV. Our results suggest that NLR, PLR, and MPV may be used as easily available additional biomarkers for CRC in screening the general population, as well as in postoperative follow-up.

Inlet patch: Associations with endoscopic findings in the upper gastrointestinal system

Objective. Ectopic gastric tissue in the esophagus (inlet patch) mostly presents in the upper part of the esophagus and is usually under-diagnosed because of its localization. Little is known about its pathogenesis and significance. The aim of this study was to investigate whether there is an association between ectopic gastric tissue development and endoscopic features of the upper gastrointestinal tract, especially in the esophagus. Material and methods. A total of 9437 endoscopic examinations were analyzed prospectively. Endoscopic features and histological examinations of inlet patch and stomach specimens were documented. Endoscopic findings in patients with inlet patch were compared with those in patients without inlet patch. Results. Inlet patch was present in 171 (1.8%) of all patients. Forty-three (25.1%) patients with inlet patch and 519 (5.6%) patients without inlet patch had esophagitis (p=0.000). Histologically proven Barretts esophagus was more frequent among patients with inlet patch than among patients without inlet patch (3.5% versus 0.5%, p=0.000). Prevalences of hiatal hernia in the two groups were similar. Open cardia was diagnosed more frequently in the inlet patch group than in the other group (24.5% versus 10.0%, p=0.000). Helicobacter pylori colonization was detected in only 11% of inlet patch specimens, whereas 58% of stomach specimens from the same patients contained H. pylori colonies. Conclusions. Patients with inlet patch seem to have predisposing factors for gastroesophageal reflux, and Barretts esophagus is found more frequently in those patients. H. pylori colonization is involved in ectopic gastric tissue less frequently than in gastric tissue.

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.

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.

EFFECTIVE TREATMENT WITH PINEAPPLE JUICE IN SMALL BOWEL OBSTRUCTION DUE TO PHYTOBEZOAR IN A GASTRECTOMIZED PATIENT

Dear Editor, Phytobezoars are the concretions of poorly digested fibers, fruit seeds, and pulpy fruits. Most phytobezoars remain silent and spontaneously resolve. However, the majority of the symptomatic patients previously reported presented with small bowel obstruction (SBO). Hypoacidity in the stomach and delayed gastric emptying in elderly people have both been attributed to the formation of phytobezoars. Therapy for phytobezoars is usually based on endoscopic fragmentation. In the literature, the consumption of pineapple juice (ananas comosus) is suggested as an effective method for dissolution of phytobezoars because the juice contains bromelain, a proteolytic enzyme. To date, this is the second case of an obstructing small bowel phytobezoar successfully treated with pineapple juice, even after an incomplete endoscopic treatment. A 70-year-old man was admitted to our hospital with a 6-day history of abdominal pain, nausea, and bilious vomiting. He had undergone a partial gastrectomy and gastroenterostomy 10 years previously. Physical examination revealed an abdominal distention without rebound pain and hypoactive bowel sounds. Laboratory tests were unremarkable except for mildly elevated blood urea. Esophagogastroduodenoscopic examination showed a bile-filled stomach, and after removing the bile fluid, it was noted that the stomach had been resected from its proximal part. The phytobezoar was found in approximately the 30–35th cm of the afferent loop. We attempted to fragmentize the soft edges of the phytobezoar with a snare and dormia basket. However, we could not remove the phytobezoar with endoscopy due to the hard central part. We could not pass the endoscope through the distal part, despite manipulations. With the suggestion of drinking pineapple juice, the patient was followed up on an outpatient basis. On the third day, the control esophagogastroduodenoscopic procedure revealed that both the afferent and efferent loops were free of any occlusive material. The patient reported seeing a dirty yellowish solid component in his stool on the second day. Afterwards, the patient became free of nausea and vomiting. Phytobezoars should be considered in the differential diagnosis of SBO, especially in patients with prior gastric surgery. By reducing gastric acid secretion, and gastric motility, the formation of phytobezoars is facilitated. By adding gastrojejunostomy, a larger and less digested fruit bolus may be deposited into the jejunum to form the nucleus of the phytobezoar. Because of their infrequency and late diagnosis, gastrointestinal bezoars can be treated after the occurrence of some complications, such as acute SBO, strangulation, ulceration, and bleeding. The first step in the management of phytobezoars leading to SBO is endoscopic fragmentation by snare, or dormia basket. In such a patient in whom ongoing water intake did not solve the underlying problem, the unsuccessful fragmentation of the endoscopic procedure resulted in mandatory pineapple juice consumption, because of its proteolytic features. In conclusion, a gastrectomized patient admitted with SBO should undergo an upper gastrointestinal endoscopic examination first, and examination should be continued with a phytobezoar in mind. In case of incomplete endoscopic fragmentation, we suggest patients drink pineapple juice daily, which could lead to the dissolution of the phytobezoar. Moreover, pineapple juice is a good option for avoiding reformation of the phytobezoar.

Atrial Electromechanical Properties in Coeliac Disease

BACKGROUND Coeliac disease (CD) is an autoimmune and inflammatory disorder of the small intestine. There is reasonable evidence linking inflammation to the initiation and continuation of atrial fibrillation (AF) in inflammatory conditions. Atrial electro-mechanic delay (EMD) was suggested as an early marker of AF in previous studies. The objectives of this study were to evaluate atrial electromechanical properties measured by tissue Doppler imaging and simultaneous electrocardiography (ECG) tracing in patients with CD. METHODS Thirty-nine patients with coeliac disease (CD), and 26 healthy volunteers, matched for age and sex, were enrolled in the study. Atrial electromechanical properties were measured by using transthoracic echocardiography and surface ECG. Interatrial electro-mechanic delay (EMD), left intraatrial EMD, right intratrial EMD were calculated. RESULTS There was no difference between CD patients and healthy volunteers in terms of basal characteristics. Patients with CD had significantly prolonged left and right intraatrial EMDs, and interatrial EMD compared to healthy controls (p= 0.03, p= 0.02, p<0.0001, respectively). Interatrial EMD was positively correlated with age, disease duration, anti-gliadin IgG, anti-endomysium and disease status. In multiple linear regression, interatrial EMD was independently associated with disease duration, anti-endomysium and disease status after adjusting for age and sex. CONCLUSIONS In the present study, atrial EMDs were found significantly higher in patients with CD compared with healthy individuals. Measurement of atrial EMD parameters might be used to predict the risk of development of AF in patients with CD.

Unusual cause of acute gastrointestinal bleeding: gastric pyogenic granuloma.

Pyogenic granuloma (PG) is a benign, polypoid type of lobular capillary hemangioma that presents as a polypoid red mass. The lesion is found most commonly on the skin and in the oral cavity. It is extremely rare in the alimentary tract, other than in the oral cavity. Here, we report a case of PG identified in the stomach associated with acute bleeding. A 64-year-old man was admitted to our emergency room with a complaint of hematemesis and melena. Physical examination revealed no remarkable abnormalities other than conjunctival paleness.At the time of admission his laboratory findings were as follows: hemoglobin 10 g/dL, hematocrit 28.5%. An upper gastrointestinal endoscopy revealed a pedunculated reddish lesion approximately 8 mm in diameter with an irregular surface in the cardia of the stomach. Blood was leaking from the surface of the lesion (Fig. 1). The lesion was resected using a polypectomy snare. Histological examination of the resected specimen revealed many capillaries of various sizes, lined with plump endothelial cells, accompanied by acute and chronic inflammatory infiltrates. The endothelial cells proved to be immunohistochemically positive for CD34 (Fig. 2).The histological features were consistent with those of a PG. No bleeding was noted following endoscopic resection of the lesion. Anemia was resolved by treating with iron. PG is an acquired benign tumor arising from the blood vessels of the skin or mucosa, polypoid form of capillary hemangioma.To date, a few cases of PG of the digestive tract have been reported, particularly in the colon, ileum, and esophagus. Only two cases have been described in the stomach. To our knowledge, this is the second case report of gastric PG presenting with acute gastrointestinal bleeding. In conclusion, PG should be considered in the differential diagnosis of acute gastrointestinal bleeding.