Meltem Ergun

Increased Prevalence of Colorectal Polyp in Acromegaly Patients: A Case-Control Study

An increase in the prevalence of colorectal polyps and cancer is reported in patients with acromegaly. This trial is designed to determine whether there is an increase in the prevalence of colorectal polyps/cancer in Turkish acromegaly patients. Sixty-six patients, who were under follow-up with the diagnosis of acromegaly and underwent total colonoscopic examination, were enrolled in the study. Sixty-five age- and gender-matched patients with nonspecific complaints were selected as control. The mean age of acromegalic patients was 51.5 ± 12.8 years of whom 27 (40.9%) were females. In 20 (30.3%) of the patients with acromegaly a total of 65 colorectal polyps were detected. Forty-seven (72.3%) of the polyps were detected at the rectosigmoid region. In 8 (12.3%) of the 65 control patients a total of 17 polyps were found. There was a statistically significant difference between the groups (P = 0.018). At the logistic regression analysis we found that the risk for colon polyps increased 3.2-fold in the presence of acromegaly, irrespective of age and gender (OR: 3.191, 95% CI: 1.25–8.13). In conclusion, patients who were followed up with the diagnosis of acromegaly should be taken to the colonoscopic surveillance program and all polyps detected should be excised in order to protect them from colorectal cancer.

How does a biopsy of endoscopically normal terminal ileum contribute to the diagnosis? Which patients should undergo biopsy?

Background Terminal ileum endoscopy and biopsy are the diagnostic tools of diseases attacking the ileum. However, abnormal histological findings can be found in endoscopically normal terminal ileum. Objective This study was performed to evaluate the histopathological results of biopsies from endoscopically normal terminal ileum in order to determine pre-procedure clinical and laboratory factors predicting abnormal histopathological results, if any. Methods A total of 297 patients who underwent colonoscopy and terminal ileum biopsy and had normal terminal ileum or a few aphthous ulcers in the terminal ileum together with completely normal colon mucosa were included in the study. The patients were grouped into two arms as normal cases and cases with aphthous ulcers. Histopathological and pre-procedural laboratory results of patients were analyzed according to their indications. Results The terminal ileum was endoscopically normal in 200 patients, and 97 patients had aphthous ulcers. Chronic ileitis rate was present in 5.5% of those with endoscopically normal terminal ileum and in 39.2% of the patients with aphthous ulcers. In both groups, the highest rate of chronic ileitis was detected in the patients with known inflammatory bowel disease (IBD) (15.4 and 50%, respectively), anemia (9.5 and 43.5%, respectively), and in the patients having chronic diarrhea together with abdominal pain (7.7 and 44.8%, respectively). We found that the sensitivity of mean platelet volume for predicting chronic ileitis was 87% and the specificity was 45% at a cut-off value lower than 9.35 fl. Conclusion In anemia indication or chronic diarrhea together with abdominal pain, the frequency of aphthous ulcers detected by ileoscopy and the frequency of chronic ileitis detected histopathologically despite a normal-appearing ileum were elevated.Background Terminal ileum endoscopy and biopsy are the diagnostic tools of diseases attacking the ileum. However, abnormal histological findings can be found in endoscopically normal terminal ileum. Objective This study was performed to evaluate the histopathological results of biopsies from endoscopically normal terminal ileum in order to determine pre-procedure clinical and laboratory factors predicting abnormal histopathological results, if any. Methods A total of 297 patients who underwent colonoscopy and terminal ileum biopsy and had normal terminal ileum or a few aphthous ulcers in the terminal ileum together with completely normal colon mucosa were included in the study. The patients were grouped into two arms as normal cases and cases with aphthous ulcers. Histopathological and pre-procedural laboratory results of patients were analyzed according to their indications. Results The terminal ileum was endoscopically normal in 200 patients, and 97 patients had aphthous ulcers. Chronic ileitis rate was present in 5.5% of those with endoscopically normal terminal ileum and in 39.2% of the patients with aphthous ulcers. In both groups, the highest rate of chronic ileitis was detected in the patients with known inflammatory bowel disease (IBD) (15.4 and 50%, respectively), anemia (9.5 and 43.5%, respectively), and in the patients having chronic diarrhea together with abdominal pain (7.7 and 44.8%, respectively). We found that the sensitivity of mean platelet volume for predicting chronic ileitis was 87% and the specificity was 45% at a cut-off value lower than 9.35 fl. Conclusion In anemia indication or chronic diarrhea together with abdominal pain, the frequency of aphthous ulcers detected by ileoscopy and the frequency of chronic ileitis detected histopathologically despite a normal-appearing ileum were elevated.

Increased Plasma Levels of Asymmetric Dimethylarginine in Nonalcoholic Fatty Liver Disease: Relation With Insulin Resistance, Inflammation, and Liver Histology

Background and Aim Cardiovascular disease (CVD) is the most frequent cause of death in nonalcoholic fatty liver disease (NAFLD). Insulin resistance, hepatic dysfunction, and chronic inflammation are factors interacting in explaining the increased CVD incidence in NAFLD. We aimed to evaluate the effects of insulin resistance and inflammatory biomarkers on asymmetric dimethylarginine (ADMA) levels, a predictor of CVD. We also investigated relationship between these markers and histological findings in patients with NAFLD. Patients and Methods Plasma ADMA, high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), and homeostasis model assessment of insulin resistance (HOMA-IR) were measured in 70 patients with histologically verified NAFLD (53 with nonalcoholic steatohepatitis [NASH], 17 with non-NASH) and 12 controls. Results The HOMA-IR (5.3 [3.9] vs 1.9 [1], P < 0.001), hs-CRP (5.6 [4.2] vs 2.2 [2.3] mg/L, P < 0.001), ADMA (0.81 [0.25] vs 0.48 [0.24] μmol/L, P = 0.005), and IL-6 (4.1 [1.2] vs 1.0 [0.4] pg/mL, P < 0.001) levels were all found higher in the NAFLD group than the control group. The ADMA levels were significantly higher in patients with NAFLD independent from HOMA-IR and body composition (P = 0.02). The IL-6 and HOMA-IR levels of the NASH group were found significantly higher than those of the non-NASH group. The only determinant significantly correlated to ADMA was HOMA-IR. Conclusions Our data suggested that although ADMA levels are independently higher in NAFLD, the only determinant correlated to ADMA is HOMA-IR and not inflammatory biomarkers (hs-CRP, IL-6) or presence/absence of NASH.

Effect of Entecavir and Tenofovir Treatment on Noninvasive Fibrosis Scores: Which One Is Better?

Liver biopsy is the best method for detecting fibrosis grade of the liver in chronic hepatitis B. However, the invasiveness of liver biopsy complicates its routine use in follow-up of treatment. We planned to determine the usage of fibrosis predicting noninvasive scores in the follow-up of the treatment of patients with chronic hepatitis B treated with entecavir or tenofovir. Two hundred twenty-eight patients with hepatitis B with liver biopsy were included in the study. Fibrosis grade was determined by Ishak score. The laboratory data at months 0, 12, and 24 during treatment were collected and noninvasive fibrosis scores (aspartate aminotransferase to alanine aminotransferase ratio [AAR], aspartate aminotransferase to platelet ratio index [APRI], fibrosis index based on the 4 factors [FIB-4] and red cell distribution width to platelet ratio [RPR]) were calculated. Statistically significant increase in all scores and decrease in platelet count were observed as the fibrosis level increased. For differentiation of patients with fibrosis ≥grade 2, the highest sensitivity and specificity rates were shown by APRI score (sensitivity 67%, specificity 69%, and cutoff ≥0.5). FIB-4 was the most successful score for differentiation of patients with fibrosis ≥grade 3 (sensitivity 83%, specificity 74%, and cutoff ≥1.45). A significant decrease in all noninvasive fibrosis scores was observed at months 12 and 24 during treatment with both entecavir and tenofovir (P < 0.001). Among these, only the improvement in APRI score was found better in entecavir group with statistical significance (P < 0.05). APRI score was effective in demonstrating early-stage fibrosis. FIB-4, RPR, and platelet count were better in demonstrating advanced fibrosis. Although noninvasive scores cannot replace liver biopsy for diagnosis, they can be used for monitoring the response to treatment.

First Week HCV RNA Level Under the Pegylated Interferon and Ribavirin Treatment Predicts Sustained Virological Response.

This study was planned to investigate whether the decrease in the hepatitis C virus (HCV) RNA levels at the first week of combined pegylated interferon and ribavirin treatment of naive genotype 1 patients with HCV was predicting sustained virologic response (SVR). Fifty-two patients were enrolled into the study. HCV RNA levels were measured at the baseline, first, fourth, and 12th weeks of treatment. Thirty-four patients achieved SVR, which basal, first week, and fourth week HCV RNA levels were log 5.57, log 3.65, and log 1.92, respectively. Eighteen patients could not achieve SVR, which basal, first week, and fourth week HCV RNA levels were log 6.22, log 5.45, and log 3.84, respectively (P < 0.05). Patients were distributed in 2 groups according to the amount of decrease in HCV RNA levels at the first week as less or more than 1.5 log. There were 20 patients with ≥1.5 log decrease in the HCV RNA levels at the first week. They were named as patients with very rapid virologic response (VRVR). All patients (100%) with VRVR were achieved SVR. In only 14 (44%) of the 32 patients without VRVR, SVR was achieved. In 16 (84%) of the 19 patients with rapid virologic response and 33 (79%) of the 42 patients with early virologic response, SVR was achieved. A ≥1.5 log decrease (VRVR) in HCV RNA levels of patients with HCV at the first week of combined pegylated interferon and ribavirin treatment predicts SVR very strongly.

First case of T-cell/histiocyte-rich-large B-cell lymphoma presenting with duodenal obstruction.

Gastrointestinal tract is the most common site of extranodal non-Hodgkin’s lymphoma. Small bowel involvement accounts for 2030% of all gastrointestinal lymphomas. Among all intestinal lymphomas, the ileum is the most common involved area, with duodenal involvement only accounting for a small proportion. The most frequent histological type is diffuse large B-cell lymphoma (DLBCL). T-cell/ histiocyte-rich-large B-cell lymphoma (TCHRBCL) is an uncommon morphologic variant of B-cell lymphoma. Duodenal involvement of TCHRBCL has not been reported previously. We hereby report this first case of TCHRBCL of the duodenum. (Published: 16 December 2013) Citation: Libyan J Med 2013, 8 : 22955 - http://dx.doi.org/10.3402/ljm.v8i0.22955

Zor taşlarda zor bir metod: Mekanik litotripsi, Şişli Etfal Hastanesi deneyimi

Giris ve Amac:Endoskopik sfinkterotomi, balon ve basket kateterler yardimiyla koledok taslarinin %85-90’i temizlenebilmektedir. Buyuk taslarda, impakte taslarda, cok sayida tasi olan hastalarda standart tedavi ile basari guctur. Zor taslar icin kullanilan metodlardan biri de mekanik litotripsi yontemidir. Biz de klinigimizde mekanik litotripsi yonteminin etkinligi ve guvenilirligini retrospektif olarak incelemeyi amacladik. Gerec ve Yontem: Calismaya Agustos 2011 ile Agustos 2014 arasinda Şisli Hamidiye Etfal Egitim ve Arastirma Hastanesi Gastroenteroloji Endoskopi unitesinde mekanik litotripsi yapilmis olan 18 hasta alindi. Hastalarin demografik ozellikleri, laboratuvar degerleri, hastalara yapilan islemler, islem sonrasi klinik seyir ve islem komplikasyonlari retrospektif olarak degerlendirildi. Bulgular:Mekanik litoripsi islemi 22-68 yas arasi 18 hastaya (11’i kadin) uygulanmistir. Hastalarin 16’sinda endoskopik sfinkterotomi yapilmis, balonla koledok temizlenmis, basket kateterle tas parcalanmaya calisilirken basket kateter koledokta sikismis ve mekanik litotripsi islemine gecilmistir. 2 hastada ise koseli ve buyuk taslar bilindiginden direkt olarak through the scope mekanik litotriptor ile taslar kirilmistir. Skop disindan mekanik litotripsi yapilan hastalarin 15’unde (%83) litotripsi islemi basariyla gerceklestirilirken, 2 hastada baskette kirilma meydana gelmistir. Bir hastada ise mekanik litotripsiyi takiben ozofagus alt ucta perforasyon saptanmistir. Endoskopik retrograd kolanjiopankreatikografi islemi, mekanik litotripsi ve anesteziye bagli mortalite gorulmemistir. Sonuc:Mekanik litotripsi, papilladan cikmayacak kadar buyuk taslarin kirilarak kucultulmesi amaciyla planli veya basketle koledok taslarinin temizlenmesi esnasinda, basketin koledok icinde sikismasi nedeniyle plansiz ve zorunlu olarak tasi kirmak maksadiyla kullanilir. Zor, deneyim gerektiren, literaturde basari orani %70-80 olarak bildirilen bir is-lemdir. Bizim olgularimizda da %83 tedavi basarisi etkin bir metod oldugunu gostermekte ancak riskleri de beraberinde getirmektedir.

Nazobiliyer drenaj halen etkin ve güvenilir bir yöntemdir: Şişli Etfal Hastanesi deneyimi

Background and Aims: Nasobiliary drainage is an established mode of treatment for acute suppurative cholangitis, bile leakage and biliary fistula. We retrospectively analyzed the safety and efficacy of nasobiliary drainage placement for biliary drainage in patients with acute cholangitis. Materials and Methods: Between January 2011 and December 2012, nasobiliary drainage was performed in 22 patients at Şisli Etfal Training and Education Hospital. The clinical characteristics, laboratory results, clinical outcomes, and complications were analyzed retrospectively. Results:Nasobiliary drainage was performed in 22 patients (11 female), and the mean age was 54,3±24,4 years (range, 12-84). Acute suppurative cholangitis (n=11), hydatid cyst with biliary communication (n=4), postoperative biliary leak (n=3), external biliary leakage (n=2), and hemobilia (n=2) were the main indications of nasobiliary drainage. The catheter was removed in 8,4±6,2 days, and time elapsed to normalization of total serum bilirubin levels was 4±0,6 days. There were no endoscopic retrograde cholangiopancreatography -related complications. Although it is not a comfortable treatment modality, there were no instances of displacement or kinking of the nasobiliary drainage.Conclusions: Biliary drainage by nasobiliary drainage is a safe and effective treatment in patients with severe cholangitis, postoperative bile leakage and bile fistula.

İndetermine koledok darlıklarında fırça sitolojisinin değeri: Şişli Etfal deneyimi

Backgaround and Aims:Endoscopic retrograde cholangio pancreatogaphy guided bile duct cytology for the diagnosis of indeterminate bile duct strictures is commonly used. The aim of this study was to define sensitivity, specificity, and positive and negative predictive values of endoscopic retrograde cholangio pancreatogaphy brush cytology from indeterminate biliary strictures. Materials and Methods:We retrospectively analyzed diagnostic yield of brush cytology in indeterminate biliary strictures in our single center, between January 2013 and April 2014. Demographic data, endoscopic retrograde cholangio pancreatogaphy reports, pathology reports, post-endoscopic retrograde cholangio pancreatogaphy operation, percutaneous biopsy results, the course of the disease and survival of the patientswere recorded. Results:Cytologic examination of thirty seven samples were done in 35 patients. The mean age of patients was 63.7±12 years. There were 19 females and 16 males. Three patients had adenocarcinoma, one high grade dysplasia and one low grade dysplasia, which were detected at cytological evaluation. Twenty samples were reported as normal with sufficient material; 3 were reported as insufficient material; and 9 were reported as indeterminate. The diagnosis of malignancy was confirmed with other methods in 4 patients. Follow-up data was obtained in 13 of 18 malignancy negative patients. Ten of the 13 patients were detected negative for malignancy and 3 were diagnosed malignant with additional examinations. Also, 3 out of 12 patients whose cytological results were insufficient or indeterminate were diagnosed malignant after additional examinations; the remaining 9 patients were found negative for malignancy. In accuracy analysis, the sensitivity of brush cytology was calculated as 57.1%, specificity 100%, positive predictive value 100% and negative predictive value 76.9%. Conclusion:In cases with indeterminate biliary strictures, positive predictive value of brush cytology was high but negative cytology results do not exclude malignancy. Cases with high suspicion of malignancy must be evaluated with additional examinations