Mehmet Ibis

Mean platelet volume as an indicator of disease severity in patients with acute pancreatitis.

AIM Acute pancreatitis (AP) constitutes a systemic inflammatory process which is often accompanied by thrombosis and bleeding disorders. The role of platelets in the pathophysiology of the disease has not been elucidated yet. Mean platelet volume (MPV) is an index of platelet activation and reported to be influenced by inflammation. The objective of the present study is to assess whether platelet volume would be useful in predicting disease severity in AP. Additionally possible relationship of MPV with clinical and radiologic parameters in conjunction with other inflammatory markers during AP was also investigated. PATIENTS AND METHODS A total of 144 AP patients (male/female: 87/57), and 40 healthy subjects (male/female: 23/17) were enrolled in this study. Mean platelet volume and inflammatory parameters were measured for all study participants. Modified Glasgow Prognostic Score (mGPS) and the computerized tomography severity index (CTSI) were used as to predict the disease severity in AP patients. RESULTS A statistically significant decrease in MPV levels was observed in AP patients (8.06 ± 0.71 fL) compared with healthy controls (8.63 ± 0.62 fL) (P<0.001). According to the mGPS, overall accuracy of MPV in determining severe AP was 72.7% with a sensitivity, specificity, NPV and PPV of 70.6%, 73.9%, 81.9%, and 60 respectively (AUC: 0.762). Overall accuracy of MPV in predicting disease severity according to CTSI was not superior compared with other inflammation markers. CONCLUSION The present study demonstrated that MPV is decreased in AP. Assessment of MPV with other inflammatory markers may provide additional information about disease severity in AP.

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.

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.

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.

Serum adenosine deaminase levels in pancreatic diseases.

Background: Adenosine deaminase (ADA) is found in most tissues including the pancreas. Its role in inflammation and malignancy has been studied experimentally. To date, serum ADA levels in pancreatic diseases have not been studied before. Aim: To assess the levels of ADA in patients with pancreatitis and cancer of the pancreas. Methodology: Serum levels of ADA were investigated in 14 cases with acute pancreatitis (mean age 46 years; male/female 5/9), 38 with chronic pancreatitis (mean age 46 years; male/female 25/13), 21 with cancer of the pancreas (mean age 67 years; male/female 11/10), and 21 healthy controls (mean age 40 years; male/female 11/10). The ADA levels were also compared among patients with pancreatic cancer with regard to tumor size and localization and the presence of metastases. Correlation analysis between ADA and CA 19.9 was also performed. Results: Serum ADA levels were 12.66 (9.54–20.72), 12.51 (8.88–26.64), 15.36 (10.20–21.05) and 9.39 (6.58–11.84) U/l in patients with acute pancreatitis, chronic pancreatitis, pancreatic cancer, and healthy controls, respectively. Serum ADA levels were significantly higher in acute and chronic pancreatitis, and pancreatic cancer patients compared to the control group (p < 0.05). Pancreatic cancer patients had significantly higher serum ADA levels when compared with acute and chronic pancreatitis cases (p < 0.05). The serum ADA levels were comparable according to tumor size and location and the presence of metastases. There was a linear correlation between serum ADA and CA 19-9 levels (p = 0.027, r = 0.552). Conclusions: Our data suggest that the ADA enzyme may play a role in inflammatory diseases of the pancreas. Serum ADA levels increase in pancreatic disorders especially in pancreatic cancer. It may be a serum marker for the diagnosis of pancreatic cancer.

Diagnostic Validity of Serum Macrophage Inhibitor Cytokine and Tissue Polypeptide-Specific Antigen in Pancreatobiliary Diseases

Background and Aim: Macrophage inhibitory cytokine (MIC-1) and tissue polypeptide-specific antigen (TPS) are novel markers for several inflammatory and malignant disorders, and there are no sufficient data about the utility of these antigens as serum tumor markers. We aimed at measuring the serum levels of MIC-1 and TPS in patients with benign and malignant pancreatobiliary diseases and at determining their diagnostic efficacy. Patients and Methods: Sera collected from patients with pancreatic adenocarcinomas (56 cases), periampullary carcinomas other than pancreatic carcinomas (15 cases), benign pancreatic diseases (31 cases), benign biliary diseases (15 cases) and healthy volunteers (33 cases) were analyzed for MIC-1 and TPS and the results were compared with CA 19-9. Results: Serum MIC-1 levels increased more significantly in patients with pancreatic carcinomas than in patients with benign pancreatobiliary diseases and healthy controls (p < 0.05). MIC-1 has a similar sensitivity (81%) but a lower specificity (73 vs. 97%) than CA 19-9 in patients with pancreatic carcinomas. Serum TPS was comparable among patients with malignant and benign pancreatobiliary diseases, and healthy controls. Conclusion: MIC-1 is a valuable tumor marker for the diagnosis of pancreatic cancer. It has a good correlation with CA 19-9. TPS has no diagnostic importance to differentiate pancreatobiliary diseases.

Ankaferd blood stopper for gastrointestinal bleeding.

We have read with great interest the article by Karakaya et al. focusing on a new hemostatic agent, Ankaferd Blood Stopper (ABS) [1]. We, herein, would like to share our experience regarding ABS in the setting of gastrointestinal (GI) bleedings [2–6]. ABS has been approved as a medicinal product for the management of open cutaneous, external postsurgical, and dental bleedings in Turkey. We have presented a retrospective small case series regarding the topical application of ABS for controlling spontaneous or postbiopsy bleeding from gastrointestinal cancers [2]. The endoscopic use of this agent in the context of bleeding GI tumors is interesting and of potential clinical relevance given the apparent immediate hemostatic response, simplicity of application (topical spray), and apparent lack of adverse effects [2, 3]. Regarding the exact mechanism of action of ABS, we believe that dual action is in fact involved in the hemostatic process. Besides the initial network, preliminary study has demonstrated antiangiogenic properties of the product, measured as microvessel density [4]. ABS was also found to be effective for chronic and serious GI bleeding [5, 6]. It is worth mentioning that topical application of ABS is not expected to be of benefit when used on its own for spurting arterial bleeds due to the forceful nature of the bleeding, although its use as an adjuvant to other modalities (endoclip, heater

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

Can red cell distribution width help to discriminate benign from malignant biliary obstruction? A retrospective single center analysis.

BACKGROUND/AIMS Differentiation of benign obstructive jaundice from malignant obstructive jaundice still remains difficult, despite improvements in diagnostic modalities. The aim of this study is to evaluate the usefulness of red cell distribution width (RDW) in differentiating benign and malignant causes of obstructive jaundice. METHODOLOGY One hundred and ninety four consecutive patients (101 malignant, 93 benign) with a history of obstructive jaundice were reviewed in the period between January 2008 and August 2009. Definition of biliary strictures was suggested by cholangiographic features and supported by brush cytology, fine needle aspiration (FNA) and the presence of mass or metastases by imaging and/or clinical followup. Patients were divided into two groups, benign and malignant, based on the discharge diagnosis. RESULTS The receiver operating characteristic analysis showed that a RDW of 14.8% was the best cut-off value for predicting a malignant biliary stricture with a sensitivity of 72% and a specificity of 69% (AUC=0.755, 95% CI=0.649-0.810). RDW was increased (>14.8%) in 31.6% of benign cases and 68.4% of malignancies. Depressed RDW levels (<14.8%) were found in 72.9% of benign cases and 27.1% of malignancies, which was statistically significant (p<0.001). CONCLUSIONS Our results show that RDW is useful in the differentiation of benign from malignant causes of biliary obstruction when using an optimized cut-off value. In patients in whom biliary obstruction is suspected, an elevated RDW value may be a reliable additional predictor for differentiating the underlying etiology of biliary obstruction.