Irfan Koruk

Drug- and herb-induced liver injury: a case series from a single center.

BACKGROUND/AIMS Drug-induced liver injury (DILI) is common worldwide and has a potentially fatal outcome. It accounts for more than half of the cases of acute liver failure in the United States. Herb-induced liver injury (HILI) is a less documented condition but a growing problem. We present here the clinical characteristics and outcome of patients with drug- and herb-induced liver injury from our center. MATERIALS AND METHODS In this 4-year retrospective study, 82 patients in whom there was a causal or highly probable relationship between herbal medicine or drug use and liver disease are presented. RESULTS The mean age of patients was 43.1±14.8 years; sexual distribution was 53 females and 29 males. The major cause of hepatotoxicity was drugs (87.8%), with herbal medicine accounting for 12.2%. The leading causative agents were nonsteroidal anti-inflammatory drugs (NSAIDs) (23.1%), followed by antibiotics (19.5%). The pattern of hepatotoxicity was hepatocellular in 35 patients (42.6%), mixed in 28 (34.1%), and cholestatic in 19 patients (23.1%). Teucrium polium (known popularly as felty germander), which is a traditionally used herbal medicine of the Labiatae family in our region, was the most common cause of herb-induced liver injury and responsible in 7 of 10 herbal hepatotoxic cases. Acute liver failure developed in 3 patients (two patients related with flurbiprofen and diclofenac and one patient due to an isoniazid-rifampicin combination). CONCLUSION Antibiotics and NSAIDs were the most common etiologic agents for drug-induced liver injury. Surprisingly, herbs follow these groups of drugs and must be questioned more carefully.

Ultrathin endoscopy for gastrointestinal strictures.

Background and Aim:  The assessment and treatment of advanced gastrointestinal (GI) strictures, which are defined as the inability to pass through the strictured segment with standard endoscopes, might require radiological work‐up, repeated endoscopies and surgery. The aim of the present study was to assess the role of ultrathin endoscopy (UTE) for the evaluation and treatment of advanced GI strictures.

Investigation of intercellular adhesion molecules (ICAMs) gene expressions in patients with Barrett's esophagus

The adhesion molecules play a major role in inflammation as well as in neoplastic diseases. The aim of this study is to evaluate the expressions of the adhesion molecules, intercellular adhesion molecule 1 (ICAM-1), ICAM-2, and ICAM-3, in Barrett’s esophagus, recognized as a premalign lesion for esophageal cancer and related to inflammation. Eighteen patients with Barrett’s esophagus according to endoscopy and 25 volunteers without Barrett’s esophagus disease were included in the study. Tissue samples were supplied by biopsy and used for both gene expression and immunohistochemical analysis. The significance of the differences between the two groups was assessed by Student’s t test. The ICAM-1 expression level was fivefold higher in the patient group compared with that of the control. There was an increase in the serum level of ICAM-1 in patients compared to that of the controls, but this increase was not significant. ICAM-2 levels were also increased in the patient group, but it was not significant. There was no difference between controls and patients in ICAM-3 levels. Significantly higher levels of ICAM-1 gene expression make us think that ICAM-1 may play an important role in Barrett’s esophagus. We think that more studies, with larger patient groups and preferably detailed histopathological and clinical evaluations, are needed to explain the severity of ICAM-1, ICAM-2, and ICAM-3 molecules in Barrett’s esophagus.

Endoscopic removal of fractured basket traction wire.

A62-years old female patient presented to another hospital with complaints of nausea, vomiting and upper right quadrant pain since one week, and abdominal ultrasonography revealed that intrahepatic bile ducts and the common bile duct were dilated. Magnetic resonance cholangiopancreatography was performed at the same hospital and a filling defect of 8.5 mm was noted at the mid level of common bile duct. The stone could not be removed with balloon during sphincterotomy with ERCP. A 7-french 10 cm plastic biliary stent was inserted into the common bile duct extending to the proximal of the stone, and the patient was referred to our clinic for impacted common bile duct stone. Patient was admitted to the ERCP education video conference system at our clinic as a live case presentation of difficult stone. The plastic stent was removed with snare during duodenoscopy. Cholangiography demonstrated filling defect at common bile duct suggestive of stone and relative stenosis at the distal of common bile duct. The stone could not be pulled to duodenum with stone removal basket. Mechanical lithotripsy was therefore tried; however the basket traction wire was fractured during mechanical lithotripsy. Trial of common bile duct dilatation with biliary dilatation balloon also proved unsuccessful. Proximal piece of the basket was held endoscopically with the biopsy forceps, and it was pulled to duodenum through the common bile duct by first forward then backward traction of the biopsy forceps (Figure 1). The ERCP process was terminated with the insertion of a 7-french 10 cm plastic biliary stent to the common bile duct.

Relationship between liver injury and serum cytokeratin 18 levels in asymptomatic hepatitis B virus carriers and in patients with chronic hepatitis B infection

BACKGROUND AND STUDY AIMS Apoptosis represents a well-known mechanism of cell death involved in most chronic liver injuries. Our aim was to investigate the serum fragment level of cytokeratin 18 (CK18), M30, in asymptomatic hepatitis B virus (HBV) carriers and patients with chronic hepatitis B (CHB) and to evaluate the relationship between serum M30 levels and the severity of hepatic injury. PATIENTS AND METHODS Asymptomatic HBV carriers (n=169), patients with CHB (n=100), and healthy control subjects (n=43) were enrolled in the study. Serum CK18 (M30) levels were analysed in all subjects. Liver biopsy for histopathological assessment was performed in asymptomatic HBV carriers and in patients with CHB infection. RESULTS Serum CK18 (M30) levels were significantly higher in asymptomatic HBV carriers (198.77±77.62U/L) than in healthy control subjects (146.92±40.18U/L). Patients with CHB (283.02±147.45U/L) had significantly higher CK18 (M30) levels than asymptomatic HBV carriers (p=0.001). The diagnostic efficacy of CK18 (M30) levels in distinguishing patients with HBeAg-negative CHB from asymptomatic HBV carriers was found to be moderate (c-statistics: 0.695), and the diagnostic cut-off value of CK18 (M30) was 262U/L (specificity: 85%, sensitivity: 48%, positive likelihood ratio: 3.35, and negative likelihood ratio: 0.60). There was a positive correlation between serum CK18 (M30) levels and histological activity index scores in asymptomatic HBV carriers and patients with CHB. CONCLUSIONS Serum CK18 (M30) levels may be a valuable indicator in distinguishing asymptomatic HBV carriers from patients with HBeAg-negative CHB when considered together with ALT and HBV-DNA levels.

Investigation of the Esophageal Rho-kinase Expression in Patients with Barrett’s Esophagus

Abstract The mechanisms responsible for the malignant transformation in Barrett’s esophagus (BE) are still poorly understood. The authors have evaluated the role of Rho-kinase (ROCK1 and ROCK2) expressions in patients with BE. All patients underwent upper gastrointestinal system endoscopy, which was confirmed histologically. Real-time PCR revealed no marked change in gene expressions of ROCK1 and ROCK2 at mRNA levels in BE when compared to controls. Immunohistochemical and western blot analyses showed no change in ROCK1 and ROCK2 protein expressions in BE. This study demonstrates that Rho-kinase gene and protein expressions are not modified in BE.

Varis dışı üst gastrointestinal sistem kanamasında endoskopik tedavinin başarısı ve tekrar kanama oranları

Background and Aims: Upper gastrointestinal system bleeding is an important and sometimes mortal situation. For endoscopic treatment of non-variceal upper gastrointestinal bleeding, some methods, such as injection treatment, thermal coagulation, argon plasma coagulation, and endoscopic clipping, can be used. In this study, we evaluated the relation between the endoscopic treatment modality for upper gastrointestinal bleeding and the re-bleeding rates. Materials and Methods: Patients who underwent gastrointestinal endoscopy for bleeding over a one-year period were included in the study. Results: We performed upper gastrointestinal endoscopy in a total of 5451 patients, and endoscopy was performed for upper gastrointestinal bleeding in 305 of them. In 68 of 305 patients (22.2%), there was active non-variceal bleeding. Among those patients, 38 of 68 (55.8%) had duodenal ulcer, 23 (33.8%) gastric ulcer, and 7 (10.2%) erosive gastrobulbopathy. Twenty-eight of 38 duodenal ulcer patients (73.6%) and 13 of 23 gastric ulcer patients (56.5%) had only injection treatment. Ten patients in each group (duodenal/gastric ulcer; 26.3% and 43.4%, respectively) received combined endoscopic therapy (injection treatment + thermal coagulation or injection treatment + argon plasma coagulation). In the monotherapy group, re-bleeding occurred in 4 of 28 duodenal ulcer patients (14.2%) and in 1 of 13 gastric ulcer patients (7.6%). In the combined therapy group, there was no re-bleeding in duodenal ulcer patients, but re-bleeding occurred in 2 of 10 patients (20%) with gastric ulcer. Conclusions:We believe that combined endoscopic therapy for upper gastrointestinal bleeding is more effective than monotherapy, especially in duodenal ulcer.