Nevin Akcaer Ozturk

The prevalence of occult hepatitis B virus infection in type 2 diabetes mellitus patients.

Aim The prevalence of occult hepatitis B virus (HBV) infection is relatively frequent among patients with immune suppression. The impairment of the immune system is well demonstrated in diabetics. We aimed to investigate the prevalence of occult HBV infection among hepatitis B core antibody (HbcAb)± hepatitis B surface antibody (anti-HBs) positive type 2 diabetes mellitus patients. Materials and Methods The study involved 100 HBcAb±anti-HBs type 2 diabetes mellitus patients and 100 age and sex matched, HBcAb±anti-HBs healthy blood donors. Exclusion criteria were positive serology for HBsAg, hepatitis C virus or HIV, diagnosis of malignancy or earlier organ transplantation history, use of immunosuppressive therapy. All patients were questioned about their past medical history and were tested for serum alanine aminotransferase and HBV DNA level. Results The diabetic patients did not differ significantly from healthy controls in terms of sex and age. HBV DNA was detected in 11% of the diabetic patients (1×102–5×103 copies/ml) and in 3% of the controls (4×103–1×105 copies/ml). The difference between groups was statistically significant (P<0.05). The history of blood transfusion, surgery, and vaccination for HBV and alcohol use were similar in both groups (P>0.05). The serum alanine aminotransferase levels in diabetic patients were close to those of controls (26.2±16.4 IU/l vs. 23.9±9.7 IU/l; P>0.05). Conclusion These data suggest that the prevalence of occult HBV infection is higher in diabetics compared with healthy controls and this may contribute to the increased prevalence of primary hepatocellular carcinoma in diabetics.

Clarithromycin resistance and efficacy of clarithromycin-containing triple eradication therapy for Helicobacter pylori infection in type 2 diabetes mellitus patients.

Background: Antimicrobial resistance in Helicobacter pylori infection is an important factor leading to failure of therapy. The aim of this study was to determine the eradication rate of H pylori in type 2 diabetes mellitus and to assess the effect of clarithromycin resistance on H pylori eradication. Method: Fifty-six consecutive patients with type 2 diabetes mellitus and 58 age- and sex-matched control patients were included in the study. H pylori infection was assessed by a rapid urease test and histopathological examination of biopsy specimens. Biopsies were also taken for antibiotic susceptibility testing. All enrolled patients were treated with triple therapy consisting of clarithromycin, amoxicillin, and pantoprazole for 14 days. C-13 urea breath test was performed 6 weeks after completing the triple therapy to assess eradication and associated point mutations using real-time polymerase chain reaction (PCR). Results: H pylori was eradicated in 42.9% of diabetic patients and 79.3% of control patients, (P < 0.05). In type 2 diabetes mellitus patients, clarithromycin resistance was 64.3% (36/56), while in the control group, clarithromycin resistance was 35.7% (20/58) (P < 0.05). H pylori was eradicated in 14 (70%) of the 20 clarithromycin-susceptible diabetic patients and in only 10 (27.8%) of the 36 clarithromycin-resistant diabetic patients. Conclusion: The H pylori eradication rate was significantly lower and clarithromycin resistance was significantly higher in type 2 diabetics. Alternative and new treatment protocols and antibiotic susceptibility testing are needed to achieve successful eradication rates.

Efficacy and safety of sodium phosphate for colon cleansing in type 2 diabetes mellitus.

Objectives: The need for colonoscopy is common among diabetic patients. However, there are no standards per se for bowel preparation in patients with type 2 diabetes. In this study, we evaluated the efficacy, safety, and tolerability of sodium phosphate (NaP), and the quality of bowel cleansing in relation to glycemic control and late complications. Methods: A total of 50 consecutive type 2 diabetic patients and 50 non-diabetic patients underwent bowel preparation by NaP. Fasting blood glucose, sodium (Na), potassium (K), calcium (Ca), phosphorus (P), magnesium, and creatinine levels were measured on the procedure day. Patients were given a tolerability questionnaire regarding symptoms. Results: With regard to bowel preparation quality, optimal bowel cleansing was achieved in 35 (70%) diabetic and 47 (94%) non-diabetic patients (P = 0.002). Abdominal pain or discomfort during and an hour after the procedure was similar in both groups (P >0.05). The changes in Na, K, Ca, P and creatinine levels after NaP use did not reach statistical significance between the groups (P >0.05). In the diabetic patients, there was a significant correlation between the quality of bowel cleansing and mean age, duration of diabetes mellitus, level of hemoglobin A1c (HbA1c), fasting blood glucose level, and diabetic late complications (P <0.05). Conclusion: These data suggest that NaP is safe and tolerable in diabetic patients, but the quality of bowel cleansing is worse than in non-diabetic patients. These observations support the concept that the quality of bowel cleansing in those with type 2 diabetes is closely related to the duration and regulation of the disease and the presence of late complications.

Bismuth-based first-line therapy for Helicobacter pylori eradication in type 2 diabetes mellitus patients.

Background/Aim: The primary aim of this study was to assess the efficacy of a bismuth-based quadruple regimen as first-line therapy for Helicobacter pylori (HP) eradication in diabetes mellitus (DM) patients. The secondary aim was to study the effect of HP eradication on dyspeptic symptoms in DM patients. Method: Eighty-nine consecutive type 2 DM and 48 non-diabetic age- and sex-matched patients were enrolled in this study. Diabetic patients were randomized to receive either pantoprazole (40 mg b.i.d.), clarithromycin (500 mg b.i.d.), and amoxicillin (1 g b.i.d., PCA-DM group) for 14 days, or pantoprazole (40 mg b.i.d.), bismuth citrate (400 mg b.i.d.), tetracycline (500 mg q.i.d.), and metronidazole (500 mg b.i.d., PBTM-DM group) for 14 days as the eradication regimen. All non-diabetic patients were treated by quadruple therapy (PBTM-non-DM group) for 14 days. We used the validated Leeds Dyspepsia Questionnaire (LDQ) to assess dyspeptic symptoms at baseline and 6 weeks after the end of treatment. Results: The HP eradication rates with intention-to-treat (ITT) and per-protocol (PP) analyses were 51% (for both) in the PCA-DM group; 81 and 85% in the PBTM-DM group, and 85 and 87% in the PBTM-non-DM group. The eradication rates are not different between the PBTM-DM and PBTM-non-DM groups (p > 0.05). The eradication rate was significantly lower in the PCA-DM group with both ITT and PP analysis than in the PBTM-DM and PBTM-non-DM groups (p < 0.05). LDQ score was 4.53 ± 7.7 in DM patients with successful eradication and 14.68 ± 5.9 in DM patients without successful eradication (p < 0.05). Conclusion: The bismuth-based quadruple eradication regimen as first-line therapy is safe, tolerable and achieves a high cure rate in patients with DM, and successful eradication may be beneficial on dyspeptic symptoms.

Efficacy of Two Different Helicobacter pylori Eradication Regimens in Patients With Type 2 Diabetes and the Effect of Helicobacter pylori Eradication on Dyspeptic Symptoms in Patients With Diabetes: A Randomized Controlled Study

Background:The eradication rate of Helicobacter pylori with a standard triple regimen has been reported as being lower in patients with type 2 diabetes mellitus (DM) than in those without DM. The aim of this study was to evaluate the efficacy and tolerability of 2 different H. pylori eradication regimens in patients with type 2 DM. Methods:Ninety-eight consecutive type 2 DM and 116 nondiabetic age- and sex-matched patients were enrolled in this study. Patients were randomized to receive either pantoprazole, clarithromycin, and amoxicillin (PCA) for 14 days or ranitidine-bismuth citrate, clarithromycin, and amoxicillin (RCA) for 14 days as the eradication regimen. H. pylori eradication was assessed using C14-urea breath test 6 weeks after the end of therapy. Results:The H. pylori eradication rate with PCA regimen in patients with DM with both intention-to-treat (ITT) and per protocol (PP) analysis was 24/49 (48.9% and 62.9%) and in non-DM patients was 44/58 (75.9% and 86.7%) with ITT and 44/57 (77.2% and 88.2%) with PP analysis (P < 0.05). The H. pylori eradication rates with RCA regimen in patients with DM were 22/49 (45.9% and 59.8%) with ITT and 22/48 (45.8% and 59.9%) with PP analysis and in nonDM patients were 44/58 (75.9% and 86.7%) with ITT and 44/56 (78.6% and 89.3%) with PP analysis. Conclusions:These data suggest that the eradication rate of H. pylori with PCA or RCA treatment is lower in patients with type 2 diabetes than in nondiabetics and that successful eradication could decrease dyspeptic symptoms.

Plasma viscosity changes in patients with liver cirrhosis.

Objectives: Plasma viscosity (PV) is a major determinant of capillary blood flow through the microcirculation, which, if impaired, can result in potentially important clinical sequelae. The objectives of this study were to investigate the alterations of PV values in different stages of cirrhosis, and to determine if any change in PV correlates with Child score or Model for End-Stage Liver Disease (MELD) score or has any prognostic significance. Method: The study included 92 patients with cirrhosis and 28 healthy volunteers. Upper endoscopic and ultrasonographic examinations of the patients were obtained. Serum biochemistry fibrinogen, complete blood count, C-reactive protein (CRP), and lipid profile were performed. PV was determined using a rotational viscosimeter. Results: PV decreased with the progression in Child scores (Child A: 1.46 ± 0.20 mPa-s, Child B: 1.33 ± 0.21 mPa-s, Child C: 1.12 ± 0.15 mPa-s), (P < 0.001). A similar change was detected between the MELD score and PV (P < 0.001). There was a positive correlation between the total protein, albumin and plasma viscosity in the control group, but a similar relationship was not found in cirrhotic patients. History of hepatic encephalopathy (30 of 92 patients) was independently associated with decreased PV (P = 0.003). Conclusion: We observed that increasing Child and MELD scores were significantly associated with lower PV levels irrespective of biochemical and hematologic values. These observations support the concept that hemorheologic changes in cirrhotic patients might be either the cause or the result of a pathophysiological process, and it may not be easy to distinguish between these two possibilities.

The role of ascitic fluid viscosity in the differential diagnosis of ascites.

BACKGROUND Ascites is defined as the pathological accumulation of fluid in the peritoneal cavity. It is the most common complication of cirrhosis, which is also the most common cause of ascites. Viscosity is a measure of the resistance of a fluid to deform under shear stress. Plasma viscosity is influenced by the concentration of plasma proteins and lipoproteins, with the major contribution from fibrinogen. To our knowledge, the viscosity of ascitic fluid has not yet been studied. OBJECTIVE To evaluate the role of ascitic fluid viscosity in discriminating between ascites due to portal hypertension-related and nonportal hypertension-related causes, and to compare results with the serum-ascites albumin gradient (SAAG). METHODS The present study involved 142 patients with ascites presenting with diverse medical problems. Serum total protein, albumin, glucose, lactate dehydrogenase (LDH) levels and complete blood count were obtained for all subjects. Paracentesis was performed routinely on admission and all ascitic fluid samples were evaluated by manual cell count with differential, ascitic fluid culture and biochemistry (total protein, albumin, glucose and LDH). Cultures of ascitic fluid were performed at bedside in all patients using blood culture bottles. Ascitic fluid viscosity was measured in a commercially available cone and plate viscometer. RESULTS Of the 142 patients studied, 34 (24%) had an SAAG of 11 gL or less, whereas 108 (76%) had an SAAG of greater than 11 gL. Sex and mean age did not differ significantly between the two groups (P>0.05). Serum total protein, albumin, glucose, LDH levels, leukocyte count, ascitic fluid glucose levels and ascitic fluid leukocyte counts were similar in both groups, with no statistically significant relationship detected (P>0.05). However, the mean (+/-SD) ascitic fluid total protein (0.0172+/-0.1104 gL versus 0.043+/-0.011 gL), albumin (0.0104+/-0.0064 gL versus 0.0276+/-0.0069 gL) and LDH (102.76+/-80.95 UL versus 885.71+/-199.93 UL) were found to be higher in patients with an SAAG of 11 gL or less than in those with an SAAG of greater than 11 gL (P<0.001). The mean ascitic fluid viscosities were 0.86+/-0.12 centipoise (cP) and 1.22+/-0.25 cP in patients with an SAAG greater than 11 gL and an SAAG of 11 gL or less, respectively (P<0.001). Although ascitic fluid infection was detected in 35 patients (24.6%) (19 patients with spontaneous bacterial peritonitis, seven patients with culture-negative neutrocytic ascites, three patients with monobacterial non-neutrocytic bacterascites and six patients with secondary bacterial peritonitis), no significant effect on ascitic fluid viscosity was detected. Multiple linear regression analysis revealed that ascitic fluid total protein, albumin and LDH levels were independent predictors of ascitic fluid viscosity (P<0.001). The sensitivity, specificity, and positive and negative predictive values of ascitic fluid viscosity for the discrimination between ascites due to portal hypertension-related and nonportal hypertension-related causes according to the SAAG were determined by receiver operating characteristic analysis. Regarding the cut-off value of 1.03 cP, ascitic fluid viscosity measurement had a high sensitivity, specificity (98% and 80%, respectively), and positive and negative predictive value (79% and 94%, respectively) for the etiological discrimination of ascites. CONCLUSION The measurement of ascitic fluid viscosity correlates significantly with SAAG values. In view of its simplicity, low cost, small sample volume requirement and allowance for measurement in previously frozen samples, measurement of ascites viscosity could be useful for the accurate and rapid classification of ascites.

Symptomatic Multichannel Pylorus as a Complication of Previous Peptic Ulcer Surgery

The multichannelled pylorus is a rare form of gastroduodenal fistula consisting of a fistulous communications between the gastric antrum and the duodenal bulb adjacent to the pylorus. It is commonly diagnosed endoscopically or with barium swallow studies since the clinical presentation is no different from other peptic disorders. A 52-year-old man presented with recurrent episodes of epigastric discomfort, pain, and nausea for several months. He had undergone truncal vagotomy and pyloroplasty operation for medically refractory duodenal ulcer disease 13 years ago. The remainder of his history was unremarkable and he had not taken any nonsteroidal antiinflammatory drugs (NSAIDs), steroids, or any other medications. The patient’s physical examination was unremarkable except for mild epigastric tenderness. Laboratory evaluation for complete blood count, serum calcium, electrolytes, glucose, and liver function tests were within normal limits. Endoscopic examination with Pentax EG 2940 revealed erythematous gastritis and an unexpected finding of the presence of a large and a small opening on each side of the pylorus. The access to the duodenal bulb from the antrum with endoscope was possible through naive pylorus and the larger opening but not with the smaller. Biopsy forceps were inserted through the smaller opening and its tip visualized in the duodenal bulb through the pylorus (Fig. 1). Biopsies from antrum and the corpus of the stomach were taken and histological examination demonstrated chronic gastritis with atrophy and Helicobacter pylori. Barium contrast radiography revealed two fistulous connections between antrum and the duodenal bulb apart from the normal pyloric opening (Fig. 2). The patient was treated with proton pump inhibitor and ursodeoxycholic acid and has been asymptomatic for 6 months. The multichannelled pylorus, usually double, is a rare abnormality consisting of multiple communications between the stomach and the duodenal bulb with a reported prevalence of 0.06–0.4%. As for other peptic disorders it is more common in males with a male to female ratio of approximately 2:1 [1]. It is hypothesized that the perforation and later reepithelization of an ulcer located in the antrum through the muscular layers to the duodenal bulb results in formation of gastroduodenal fistula. However, some cases have been reported as a congenital anomaly. The first congenital double pylorus case was described in 1971 [2] and the suggested pathogenesis was error of canalization. The normal histology of channels with the absence of an ulcer and endoscopic findings allow differentiation from acquired form. Patients usually have symptoms of peptic ulcer however some cases may be asymptomatic [3]. Even if some cases have experienced relief of symptoms concurrent with fistula formation and resultant improvement of gastric emptying, some patients may have persistent symptoms. The majority of patients can be managed medically, although 20% of patients with refractory symptoms may require surgical interventions. The successful treatment of double pylorus with a biliary sphincterotomy has also been reported [4]. Our patient’s history of truncal vagotomy and Jaboulay-type gastroduodenostomy, and the absence of data about the presence of H. S. Gokturk (&) M. Demir N. A. Ozturk E. Karagulle E. Yildirim U. Yilmaz Faculty of Medicine, Department of Gastroenterology, Baskent University, saray caddesi hoca cihan mahallesi, Konya 42090, Turkey e-mail: savasgokturk@yahoo.com