Muhsin Kaya

Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients

AIM To identify the frequency of bacterial growth, the most commonly grown bacteria and their antibiotic susceptibility, and risk factors for bacterial colonization in bile collected from patients with different biliary diseases. METHODS This prospective study was conducted between April 2010 and August 2011. Patients with various biliary disorders were included. Bile was aspirated by placing a single-use, 5F, standard sphincterotome catheter into the bile duct before the injection of contrast agent during endoscopic retrograde cholangiopancreaticography (ERCP). Bile specimens were transported to the microbiology laboratory in blood culture bottles within an anaerobic transport system. Bacteria were cultured and identified according to the standard protocol used in our clinical microbiology laboratory. The susceptibilities of the organisms recovered were identified using antimicrobial disks, chosen according to the initial gram stain of the positive cultures. RESULTS Ninety-one patients (27% male, mean age 53.7 ± 17.5 years, range: 17-86 years) were included in the study. The main indication for ERCP was benign biliary disease in 79 patients and malignant disease in 12 patients. The bile culture was positive for bacterial growth in 46 out of 91 (50.5%) patients. The most frequently encountered organisms were Gram-negative bacteria including Escherichia coli (28.2%), Pseudomonas (17.3%) and Stenotrophomonas maltophilia (15.2%). There were no significant differences between patients with malignant and benign disease (58% vs 49%, P = 0.474), patients with acute cholangitis and without acute cholangitis (52.9% vs 50%, P = 0.827), patients who were empirically administered antibiotics before intervention and not administered (51.4% vs 60.7%, P = 0.384), with regard to the bacteriobilia. We observed a large covering spectrum or low resistance to meropenem, amikacin and imipenem. CONCLUSION We did not find a significant risk factor for bacteriobilia in patients with biliary obstruction. A bile sample for microbiological analysis may become a valuable diagnostic tool as it leads to more accurate selection of antibiotics for the treatment of cholangitis.

Use of Acoustic Radiation Force Impulse Elastography to Diagnose Acute Pancreatitis at Hospital Admission Comparison With Sonography and Computed Tomography

To compare the diagnostic success rate of acoustic radiation force impulse (ARFI) elastography with those of sonography and computed tomography (CT) for acute pancreatitis at hospital admission.

Differentiation of tuberculous peritonitis from peritonitis carcinomatosa without surgical intervention

Background/Aim: Ascites of tuberculous peritonitis (TBP) is an exudative type and may well be misdiagnosed as carcinomatous peritonitis, especially in the elderly. The aim of this study was to identify independent predictors that can differentiate TBP from peritonitis carcinomatosa without surgical intervention. Patients and Methods: This prospective cohort study was performed on 75 subjects in the following groups: TBP (n=27) (TBP group), ovarian cancer complicated with ascites (n=24) (Ov Ca group), and gastric cancer complicated with ascites (n=24) (Ga Ca group). The frequency of clinical symptoms, laboratory parameters, and serum tumor markers levels were compared. Results: In univariate analysis; fever, night sweats, and abdominal pain were significantly more frequent in the TBP group compared to those in the Ov Ca group (P < 0.001, P < 0.001, and P = 0.035, respectively) and the Ga Ca group (P < 0.001, P < 0.001, and P = 0.015, respectively). Serum CA 19-9 and carcino embryonic antigen (CEA) levels were significantly lower in the TBP and Ov Ca group compared to the Ga Ca group (P < 0.001 and P < 0.001, respectively). Elevated serum CA 125 level was found in all patients with TBP and Ov Ca and in 86.6% of patients with Ga Ca. In the multivariate analysis, presence of fever (P < 0.001), night sweats (P < 0.001), age under 40 years (P = 0.008), and normal serum CA 19-9 level (P = 0.044) were independent predictor of diagnosis of TBP. Conclusion: The presence of fever, elevated serum CA 125 level, normal serum CA 19-9, and CEA associated with lymphocyte predominant benign ascites may establish the diagnosis of TBP.

Relationship between Serum Soluble Vascular Adhesion Protein-1 Level and Gastric Cancer Prognosis

Background: Vascular adhesion protein-1 (VAP-1) is a glycoprotein that mediates tissue-selective lymphocyte adhesion in a sialic acid-dependent manner. The prognostic importance of VAP-1 was determined in various human cancers. The aim of this study was to determine the relationship between VAP-1 and prognosis of gastric cancer. Materials and Methods: Serum of operable and metastatic gastric cancer patients was collected before treatment (surgery, radiotherapy, and/or chemotherapy). VAP-1 levels were measured by enzyme-linked immunosorbent assay. Results: A total of 86 gastric cancer patients (32 female, 54 male) were included in the study. Curative surgical treatment was performed in 54 (62.8%) patients. The mean serum VAP-1 level was 324.4 pg/ml and significantly higher in operable gastric cancer patients compared to metastatic gastric cancer patients (383.1 ± 173.5 vs. 225.2 ± 113.9 pg/ml; p < 0.001). When a cut-off value for VAP-1 of 218.8 pg/ml was determined by receiver operating characteristic (ROC) curves for presence of metastasis, sensitivity and specificity were 81.5 and 65.6%, respectively. Patients with decreased VAP-1 levels had a significantly poorer prognosis compared to patients with increased serum VAP-1 levels (median survival 8.2 vs. 23.5 months; p < 0.001). Multivariate analysis showed that VAP-1 is an independent prognostic factor of gastric cancer (odds ratio 2.3, 95% confidence interval 1.1-4.9; p = 0.032). Conclusion: A low serum VAP-1 level may be an indicator of poor prognosis in gastric cancer. This study demonstrated that low serum VAP-1 levels are associated with poor prognosis in gastric cancer patients.

The value of micro-ELISA test in the diagnosis of Fasciola hepatica infection.

OBJECTIVE In sero-diagnosis of parasitic infection, it is essential to inspect cross-reactivity between the target parasite and other parasites in order to assess diagnostic performance. The aim of this study was to determine the cut-off value of antibody titer for diagnosis of F. hepatica (FH) infection by using the micro-ELISA and diagnostic performance of this test. METHODS The study population consisted of the following groups: FH group (n=42), Echinococcus granulosus (EG) group (n=27) and control group (n=33). The micro-ELISA test for detection of anti-F. hepatica antibody was performed in all groups. RESULTS The test was positive in all patients with FH, in 3 out of 27 (11%) patients with EG and in none of the control group. Mean antibody titer was significantly higher in the FH group compared to the EG group (23.8 ± 0.9 DU vs. 5.7 ± 1.2 DU; p < 0.001) and compared to the control group (23.8 ± 0.9 DU vs. 2.4 ± 0.2 DU; p < 0.001). When we used 11,5 DU as a cut-off value for sero-diagnosis of FH, the positive predictive value was 93.3%, negative predictive value was 100%, sensitivity was 100%, and specificity was 95%. CONCLUSION Cross-reactions are an important issue in serological diagnosis of parasitic infections. The micro-ELISA test for FH antibody can not definitely discriminate fascioliasis from hydatid disease.

Increased bone mineral density in patients with non-alcoholic steatohepatitis.

AIM To determine the relationship between non-alcoholic steatohepatitis (NASH) and bone mineral density (BMD). METHODS A total of 38 patients (25 males) with a diagnosis of histologically proven NASH and 42 healthy controls (24 males) were enrolled in the study. Demographic features, clinical findings, complete blood count and routine biochemical analysis, as well as adrenal, thyroid and gonadal functions, were recorded. Additionally, intact parathormone, 25-OH-vitamin-D3, tumor necrosis factor-α, interleukin-6, interleukin-1, insulin-like growth factor-1 and insulin-like growth factor binding protein-3 levels were measured in both groups. Furthermore, lumbar spine and femoral neck BMD of both groups were measured by the dual-energy X-ray absorptiometry (DXA) method. RESULTS The mean age was 41 ± 12 years in the NASH group and 43 ± 11 years in the control group. Among demographic features, waist circumference was significantly larger in the NASH group compared to the control group (P < 0.019). Among laboratory parameters, serum triglyceride (P < 0.008), alanine transaminase (P < 0.0001), aspartate transaminase (P < 0.001), alkaline phosphatase (P < 0.016), gamma glutamyl transferase (P < 0.0001), ferritin (P < 0.001) and 25-OH-vitamin-D3 levels (P < 0.0001) were significantly higher in the NASH group compared to the control group. Lumbar BMD was significantly higher in the NASH group compared to the control group (1.057 ± 0.119 g/cm(2) vs 0.941 ± 0.133 g/cm(2); P < 0.001, respectively). In the NASH group, there was no significant relationship between BMD and fibrosis stage in liver biopsy. CONCLUSION NASH increases BMD and may be related to an elevated serum 25-OH-vitamin D3 level.

The importance of acoustic radiation force impulse (ARFI) elastography in the diagnosis and clinical course of acute pancreatitis

BACKGROUND/AIMS Acute pancreatitis (AP) is characterized by acute inflammation of the pancreas and it has a highly variable clinical course. The aim of our study was to evaluate the value of acoustic radiation force impulse (ARFI) elastography in the diagnosis and clinical course of AP. MATERIALS AND METHODS Consecutive patients with a diagnosis of AP (patients group) and healthy subject (control group) were prospectively enrolled to the study. Demographic features and clinical, laboratory, and radiological data were recorded. Virtual Touch Tissue Quantification (VTQ) was used to implement ARFI elastography. The tissue elasticity is proportional to the square of the wave velocity (SWV). RESULTS A total of 108 patients (age, 57±1.8 y) and 79 healthy subjects (age, 53.6±1.81 y) were included in the study. There were 100 (92.5%) edematous and 8 (7.4%) necrotizing AP. The mean SWV was significantly higher in the patient group than in the control group (2.43±0.08 vs. 1.27±0.025 m/s, p < 0.001). There was not significant difference between patient and control group regarding age and gender. SWV cutoff value of 1.63 m/s was associated with 100% sensitivity and 98% specificity for the diagnosis of AP. There was not significant difference between patients with and without complications and patients with edematous and necrotizing AP regarding mean SWV value. There was also not significant correlation between mean SWV value and age, mean length of hospital stay, and mean amylase level. CONCLUSION ARFI elastography may be a feasible method for the diagnosis of AP, but it has no value for the prediction of clinical course of AP.

The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia

Introduction Liver involvement is common in hematological malignancies, but the incidence and pattern of liver injury vary among the different types. The aims of our study were to determine the incidence and clinical course of acute hepatitis and the important factors for its development in patients with leukemia after chemotherapy. Materials and methods All patients with the diagnosis of leukemia who were treated at the Department of Hematology between January 2008 and January 2013 were included in the study. A detailed medical history, clinical and laboratory findings, treatment modalities, complications, and clinical course were recorded retrospectively. Results A total of 124 patients (64 females) with the diagnosis of leukemia were included in the study. The mean age was 45.2 years (16-89 years) and mean follow-up time was 29.7 months (0.25-192 months). A total of 43 (34.6%) patients had acute hepatitis after chemotherapy. Pattern of liver injury was hepatocellular in 31 patients, cholestasis in 2, and mix in 10 patients. Age (p = 0.001), hepatitis B surface antigen (HBsAg, p = 0.007), acute leukemia (p < 0.001), positive blood culture (p = 0.004), the amount of transfused red blood cell (p = 0.001), and amount of transfused platelets (p = 0.002) were significantly different under univariate analysis between the acute hepatitis group and the nonacute hepatitis group. Under multivariate analysis, only acute lymphoblastic leukemia (ALL) was identified as independent predictive factor for development of acute hepatitis after starting chemotherapy. Conclusion Acute and self-limited hepatitis develops in the substantial proportion of patients with leukemia. The most important factor for development of acute hepatitis is the type of leukemia. How to cite this article: Kaya M, Akdogan R, Uçmak F, Ayyildiz MO, Karakus A, Kaplan MA. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepato-Gastroenterol 2018;8(1):31-37.

Güneydoğu Anadolu Bölgesindeki Üçüncü Basamak Gastroenteroloji Kliniğinin Toksik Hepatit Deneyimi

Amac: Toksik hepatit bircok ilac ve bitkisel urunun alinmasiyla ortaya cikan klinik tablodur. Cok sayida ilac degisik mekanizmalarla toksik hepatite neden olmaktadir. Hastaligin gorulme sikligi ve sebepleri bolgesel farkliliklar gosterebilmektedir. Calismadaki amacimiz klinigimize basvuran toksik hepatitli olgularin demografik, klinik ve laboratuar ozelliklerini sunmaktir. Yontemler: Agustos 2014-Haziran 2016 tarihleri arasinda klinigimize anormal karaciger fonksiyon testleri nedeniyle yatirilan, klinik ve laboratuar degerlendirme sonrasi TH tanisi konulan hastalar alindi. Hastalarin demografik ozellikleri, toksik hepatitin muhtemel etiyolojisi, klinik ozellikleri, biyokimya ve tam kan degerleri, klinik seyirleri kaydedildi. Bulgular: Calismaya yas ortalamasi 41.4±16.8 olan 56 (34 kadin) hasta alindi. Hastalarin 31 (%55.6)’inde ilaclar, 11 (%20.4)’inde bitkisel maddeler, 6 (%9,3)’inda narkotik madde ve 8 (%14,8)’inde bitkisel madde, ilac ve narkotik kullanimina bagli toksik hepatit gelistigi saptandi. Ilaclar icinde en cok antibiyotik (birinci sirada amoksisilin+ klavulanik asit) ve non-steroid anti inflamatuvar ilac (birinci sirada diklofenak sodyum) kullanimi hikayesi saptandi. Bitkisel madde kullanimi olan hastalarda en sik meryem otu, lavanta cayi ve atom cayi kullanim hikayesi mevcuttu. Narkotik madde olarak en sik ekstazi (5 hasta) kullanimi saptandi. Otuz yas alti (RR:1.545, p<0.001) ve erkek cinsiyet (RR:11.0, p=0.013) narkotik madde kullanimi icin risk faktoru olarak saptandi. Sonuc: Bolgemizde ilac ve bitkisel madde kullanimina bagli gelisen TH anormal karaciger fonksiyon testlerinin onemli bir sebebi olarak dikkate alinmalidir. Ozellikle genc erkeklerde narkotik kullanimi toksik hepatit etiyolojisinde onemli yer tutmaktadir.

An Adult Choledochocele Case Presented with Acute Pancreatitis: Treatment by Endoscopic Sphincterotomy and Cyst Unroofing

To the Editor: Choledochocele is a cystic dilatation of the intraduodenal portion of the common bile duct that can protrude into the duodenum. Although often classified as type III biliary cyst, choledochocele has distinctive demographic and anatomic features, and is associated with a lower risk of malignancy as compared to other types of choledochal cysts. Patients with this condition present with biliary colic, cholangitis, or pancreatitis.1,2 Until recently, transduodenal cyst excision with or without sphincterotomy had been the treatment of choice.3 At present, however, endoscopic sphincterotomy and cyst unroofing have become the treatment of choice.4 We present a case of choledochocele associated with acute pancreatitis that was treated with endoscopic sphincterotomy and cyst unroofing. A 38-year-old woman with a 24-hour history of severe abdominal pain, nausea, and vomiting was admitted to our clinic. On physical examination, mild upper abdominal tenderness was observed. On admission, her amylase level was 3,262 IU/L (reference range, 25 to 125) and her C-reactive protein level was 64 mg/dL (reference range, 0 to 0.8). Transabdominal ultrasonography and magnetic resonance cholangiopancreatography (MRCP) revealed a dilated main pancreatic duct, mild peripancreatic fluid collection, and a cystic lesion 4 cm in diameter that was localized to the second portion of the duodenum. Furthermore, MRCP revealed that the cyst had the same intensity as the biliary tract and that the cyst communicated with the main pancreatic duct and common bile ducts (Fig. 1). Duodenoscopy revealed a soft and pedicular mass covered with normal duodenal mucosa, approximately 4×3×3 cm in size, in the medial wall of the duodenum. Cholangiography revealed an intraduodenal cyst communicating with the common bile duct and main pancreatic duct (Fig. 2). The patient had no other symptoms during the 6-month follow-up. Fig. 1 A magnetic resonance cholangiopancreatography image showing that the cyst had the same intensity as the biliary tract and that the cyst communicated with the main pancreatic duct and common bile duct. Fig. 2 An endoscopic retrograde cholangiopancreatography image showing communication between the cystic dilatation of the intraduodenal common bile duct (white arrow) and the pancreatic duct (black arrow). In conclusion, choledochocele should be considered as a differential diagnosis of duodenal cystic lesion. Endoscopic unroofing may be considered as a simple and safe treatment option for choledochocele.