Mustafa Ihsan Uslan

Allopurinol-induced DRESS syndrome.

A 70-year-old man was admitted to our clinic with complaints of fever, jaundice, dyspnea, and generalized rash after 3 months of allopurinol treatment for gout. On physical examination, he was found to have fever (38.5°C), jaundice, and generalized maculopapular rash. Leukocytosis, eosinophilia, elevation of liver enzymes, and hyperbilirubinemia were detected in his blood analysis. Skin biopsy was consistent with drug-induced hypersensitivity. He was diagnosed as Drug Rash with Eosinophilia and Systemic Symptoms (DRESS). Allopurinol treatment was stopped and steroid treatment was launched. At day 24 of admission, the patient died because of multiple organ failure.

Eosinophilic Gastroenteritis: A Rare Case Report

Eosinophilic gastroenteritis (EGE) is a rare disease characterized by eosinophilic infiltration and peripheral eosinophilia. It can be seen anywhere in the gastrointestinal tract. It is diagnosed in the biopsies taken during endoscopic examination to the patients with abdominal pain and chronic diarrhea. A 40-year-old woman was admitted with abdominal pain and chronic diarrhea. She has not any disease, food, pollen, or drug allergy in her medical history. Leukocyte: 19,400/mm3 (neutrophil: 19.9%, eosinophil: 57.4%, lymphocyte: 16.5%), platelet: 281,000/ mm3, immunoglobulin E: 1721 IU/mL (normal range: 20–100 IU/mL) was counted in her blood examination. The duodenal biopsy was reported as EGE. We applied methylprednisolone 20 mg/day. With this treatment, the patients symptoms regressed. In this article we present a case of chronic diarrhea diagnosed EGE. The first step in diagnosing is suspecting EGE. It should be borne in mind in patients with chronic diarrhea.

Recanalization of complete anastomotic biliary obstruction after living donor related liver transplantation with a novel through‐the‐scope magnet

The magnetic compression anastomotic (MCA) method was introduced in 1998 by Yamanouchi et al. for the rescue treatment of bile duct obstructions. To date, it has been reported in a few cases and small case series. Herein we report the use of a novel magnet for the treatment of an anastomotic biliary obstruction after living donor related liver transplantation (LDLT), which was designed in through-the-scope (TTS) fashion in order to overcome the technical difficulties encountered during the use of previously defined magnets. The magnet is a novel nickel-coated, cylindrical neodymium-iron-boron earth magnet with a diameter of 2.4 mm and a length of 5 mm (OBF, Istanbul, Turkey). This diameter was chosen in order to advance the magnet through the endoscope inside a 10-Fr stent pusher and to insert it over tortuous strictures. A hole was drilled in the center of the magnet for advancing a 0.038-inch guide wire. Side holes were drilled to the distal side for the attachment of a retrieval loop (Fig. 1). A 63-year-old woman developed a biliary anastomotic stricture a year after LDLT. The stricture could not be traversed with a guide wire despite several endoscopic and percutaneous attempts. Therefore, we concluded that we should perform the MCA technique, and we obtained written informed consent from the patient. Initially, a 0.035-mm guide wire was inserted endoscopically, and the first magnet was advanced up to the site of the obstruction. Later, the external biliary drainage catheter was replaced with a 10-Fr sheath, and the second magnet was pushed percutaneously over the guide wire to the opposite site of the stricture (Fig. 2). The 2 magnets immediately began to attract each other and to compress the tissue between them. Recanalization of the obstruction was achieved on the third day (Fig. 3). The magnets were removed by a stent-retrieving forceps, which was inserted through the papilla after an additional 2 days for consolidation. The obstruction was dilated by an 8-mm dilation balloon, and 3 plastic biliary stents were inserted. Cholangiography revealed a marked improvement in the obstruction after 3 months. The larger diameter (4-5 mm) of the previously defined magnets led to some difficulties during the MCA procedure. Intubating the esophagus required the use of an overtube in some patients. Insertion through the endoscope required a snare for transport, which interfered with the endoscopic view at the same time. The difficulties encountered during the insertion through the papilla of Vater and the advancement up to the level of the obstruction were overcome by large balloon dilation and fully covered metal stent insertion. Additionally, the daughter magnet required a large (18-Fr) percutaneous access hole, which was a traumatic and time-consuming procedure. Figure. 1. TTS magnet with a 2.4-mm diameter and a 5-mm length.

Mean platelet volume is an important predictor of hepatitis C but not hepatitis B liver damage

Background: The mean platelet volume (MPV) is the most commonly used measure of platelet size and is a potential marker of platelet reactivity. In this study, we aimed to explore the relationship between hepatic histopathology in viral hepatitis and MPV levels, which are associated with platelet count and activity. Materials and Methods: We performed a retrospective case-control study of baseline histological and clinical parameters in chronic hepatitis B and C patients in our tertiary reference center between January 2005 and January 2011. Two hundred and five chronic hepatitis B patients and 133 chronic hepatitis C patients who underwent liver biopsy were included in the study. The patients were divided into two groups: Chronic hepatitis B and chronic hepatitis C and were additionally divided into groups of two according to histological activity index (HAI) and fibrosis scores obtained by liver biopsy results (according to the Ishak scoring system). The clinical characteristics of chronic viral hepatitis patients, including demographics, laboratory (especially MPV), and liver biopsy findings, were reviewed. Results: One hundred and forty-three patients were male (69.1%), and the mean age was 41.9 ± 12.75 with an age range of 18-71 years in hepatitis B patients. In the classification made according to HAI, 181 patients were in the low activity group (88.3%) and 24 in the high activity group (11.7%). In the evaluation made according to fibrosis score, 169 patients were found to have early fibrosis (82.4%) and 36 were found to have advanced fibrosis (17.6%). In patients with hepatitis B, there was no statistically significant difference in terms of their MPV values between the two groups, separated according to their degree of activity and fibrosis. Sixty-three patients were male (47.3%), and the mean age was 50.03 ± 12.75 with an age range of 19-75 years. In the classification made according to HAI, 109 patients were in low activity group (81.9%) and 24 in high activity group (18.1%). In the evaluation made according to fibrosis score, 101 patients were found to have early fibrosis (75.9%) and 32 have advanced fibrosis (24.1%). There was a statistically significant difference between the activity and fibrosis groups of the hepatitis C patients (P = 0.04 and P = 0.02, respectively). Conclusion: MPV values are more reliable in hepatitis C patients than hepatitis B for predicting the advanced damage in liver histology. This finding might be useful for the detection of early fibrosis and also starting early treatment, which is important in hepatitis C.

Treatment of Biliary Stricture After Live Donor Liver Transplantation With Combined Metal and Plastic Stent Insertion: A Feasibility and Safety Study

Background Fully covered self-expandable metal stents (Fc-SEMSs) have a challenging use in the treatment of anastomosis strictures after live donor liver transplantation (LDLT) because they can occlude secondary branch biliary ducts when placed above the biliary bifurcation. In this study, we evaluated the technical feasibility and safety of combining Fc-SEMSs with plastic stent(s) inserted to the secondary branch biliary ducts for the treatment of anastomosis stricture after LDLT. Methods The study group included 22 patients (12 men, aged 51±11 years) with anastomotic biliary stricture after LDLT. A Fc-SEMS, 8 to 10 mm in diameter, was inserted to the straight, dilated main duct and plastic stent(s) were inserted to the secondary branches to avoid their occlusion. Stents were left in place for 2 months and removed with a stent retrieving forceps. Technical feasibilities, including technical success, successful removal, and adverse events of this novel strategy, were evaluated. Results Fc-SEMSs were successfuly deployed and removed in all of the cases. Three (13.6%) patients had pain requiring intravenous analgesia and Fc-SEMS had to be removed because of unbearable pain in one of them. Three (13.6%) patients developed cholangitis due to occlusion of unrecognized secondary branch biliary ducts. Primary stricture resolution rate was achieved in 17 (89.5%) of 19 patients. Recurrence was observed in 3 (17.6%) patients after a mean follow-up duration of 154.3±52.6 (range, 104-304) days. Conclusions Combination of Fc-SEMS and plastic stent(s) is technically feasible and safe for the treatment of anastomotic biliary strictures after LDLT.

Endoscopic anterograde cholangiography in a patient with Bouveret’s syndrome

Bouveret’s syndrome is the gastric outlet obstruction following a cholecystoduodenal or choledochoduodenal fistula. Endoscopy is the mainstay of diagnosis, but a radiographic examination such as upper gastrointestinal contrast series and abdominal radiography can also contribute to the diagnosis (1). Radiographic features of gallstone ileus are the classical Rigler’s triad consisting of pneumobilia, a dilated small bowel, and an ectopic gallstone (2). Available treatment options are endoscopy, open surgery, and laparoscopy. Herein we report a patient with Bouveret’s Syndrome who was treated by endoscopy.

Sağ Kolon Yerleşimli Adenomlar: High-Grade Displazi veya İnvaziv Kanser için Risk Faktörü

Amac: Bu calismanin amaci high-grade displazi (HGD) ve invaziv kanser ( “ilerlemis patoloji (IP)” olarak tanimlanmistir) ile iliskili multipl hasta ve adenom karakterlerini degerlendirmektir. Materyal ve Metod: Toplam 6250 islem sonunda 894 hastada 1379 (% 22.06) polip mevcuttur. Biz patoloji sonuclarina ulasabildigimiz 914 polipi degerlendirmeye aldik. Bulgular: 914 polipte toplam 699 adenom tespit edildi. A total of 699 adenomas were detected from 914 polyps. Sag kolon yerlesimli poliplerde sola gore daha yuksek oranda IP ozellikleri bulundu (% 18.5 vs % 7.1 p: 0.002). Lojistik regresyon analizi sonucunda; erkek cinsiyet, 2 cm’e esit ya da buyuk boyut, villoz histoloji ve non-dimunitif gorunum adenomlardaki IP ozellikleri icin bagimsiz risk faktorleri olarak bulundu. Sonuc: Calismamizda, diger calismalara benzer olarak, erkek cinsiyet, 2 cm’e esit ya da buyuk boyut, villoz histoloji ve non-dimunitif gorunum adenomlardaki IP ozellikleri icin bagimsiz risk faktorleri olarak bulundu. Fakat diger bircok calismanin aksine biz sag kolon yerlesimli poliplerde sol taraf yerlesimli poliplere gore daha yuksek oranda IP ozellikleri bulduk.The long QT syndrome (LQTS) is characterized with arrhythmic attacks, repeating syncopes,seizures, and ventricular arrhythmias leading to sudden death. Arrhythmias with a potential ofmortal course develop due to elongation of ventricular repolarization, either acquired or inborn.Herein the present paper, a case of congenital LQTS, admitted after a sudden cardiac arrest andtotally recovered with implantable cardiac defibrillator (ICD), was focused on

Electrocardiographic changes in patients with acute pancreatitis

Background and Aims: Multiple organ system dysfunctions especially cardiovascular manifestations are frequently seen in severe acute pancreatitis (AP). The aim of this study was to investigate the frequency and type of electrocardiographic (ECG) abnormalities present in patients with AP. Materials and Methods: Patients with AP admitted to our hospital, the National Tertiary Referral Center, from January 2009 to December 2010 were included in the study. The diagnosis of AP was made by acute abdominal pain and tenderness, elevated serum enzymes and typical findings detected by abdominal ultrasonography and/or contrast-enhanced computed tomography. A 12-lead derivation ECG was recorded, and serum electrolytes were performed on admission in all cases. ECG abnormalities were recorded. ECG findings were summarized in terms of frequencies, means, and standard deviations. Results: A total of 64 AP cases 19 males (29, 7%), 45 females (70, 3%) were included into the study. Among patients included in the study, 42 (65.7%) were biliary, 20 (31.2%) were idiopathic, and 2 (3.1%) were drug-related. There were 42 (65.6%) patients with one or more serum electrolyte disturbances. 56.3% of the patients with AP had normal sinus rhythm, 43.7% had changes in ECG; and the T-wave negativity was the most frequent ECG abnormality. Twenty-five (89.2%) of the 28 patients with ECG abnormalities had one or more electrolyte abnormalities. Conclusion: The study results suggested that ECG changes may be observed frequently in patients with AP, and more attention should be paid to the cardiac patients with electrolyte imbalance.

'Graves' disease: A rare cause of cholestasis

Rarely, intrahepatic cholestasis may occur during the course of Graves′ disease. It is important to rule out other causes of intrahepatic cholestasis for diagnosis. In this article, we present a case of intrahepatic cholestasis due to Graves′ disease in a 52-year-old male patient with jaundice, pruritus, and weight loss.

Right-Sided Adenomas of the Colon: A Risk Factor For High-Grade Dysplasia or Invasive Cancer

Amac: Bu calismanin amaci high-grade displazi (HGD) ve invaziv kanser ( “ilerlemis patoloji (IP)” olarak tanimlanmistir) ile iliskili multipl hasta ve adenom karakterlerini degerlendirmektir. Materyal ve Metod: Toplam 6250 islem sonunda 894 hastada 1379 (% 22.06) polip mevcuttur. Biz patoloji sonuclarina ulasabildigimiz 914 polipi degerlendirmeye aldik. Bulgular: 914 polipte toplam 699 adenom tespit edildi. A total of 699 adenomas were detected from 914 polyps. Sag kolon yerlesimli poliplerde sola gore daha yuksek oranda IP ozellikleri bulundu (% 18.5 vs % 7.1 p: 0.002). Lojistik regresyon analizi sonucunda; erkek cinsiyet, 2 cm’e esit ya da buyuk boyut, villoz histoloji ve non-dimunitif gorunum adenomlardaki IP ozellikleri icin bagimsiz risk faktorleri olarak bulundu. Sonuc: Calismamizda, diger calismalara benzer olarak, erkek cinsiyet, 2 cm’e esit ya da buyuk boyut, villoz histoloji ve non-dimunitif gorunum adenomlardaki IP ozellikleri icin bagimsiz risk faktorleri olarak bulundu. Fakat diger bircok calismanin aksine biz sag kolon yerlesimli poliplerde sol taraf yerlesimli poliplere gore daha yuksek oranda IP ozellikleri bulduk.The long QT syndrome (LQTS) is characterized with arrhythmic attacks, repeating syncopes,seizures, and ventricular arrhythmias leading to sudden death. Arrhythmias with a potential ofmortal course develop due to elongation of ventricular repolarization, either acquired or inborn.Herein the present paper, a case of congenital LQTS, admitted after a sudden cardiac arrest andtotally recovered with implantable cardiac defibrillator (ICD), was focused on