Orhan Sezgin

Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation

Objective:  Some benign esophageal strictures are highly resistant to bougie dilation. The aim of this study was to determine whether intralesional steroid injection had additional benefit to Savary‐Gilliards bougie dilation therapy (SGBD).

Endoscopic Management of Biliary Obstruction Caused by Cavernous Transformation of the Portal Vein

BACKGROUND Symptomatic biliary obstruction caused by cavernous transformation of the portal vein is an extremely rare disorder for which there is no consensus as to optimal treatment. The results of endoscopic treatments in a small group of patients is reviewed. METHODS A total of 10 patients (5 men, 5 women; mean age 36.1 years, range 17-48 years) with severe biliary strictures were treated between 1995 and 2001. Biliary sphincterotomy was performed in all patients. Four patients also underwent balloon dilation, nasobiliary drainage, and stone or sludge extraction by using a balloon. All patients had stent insertion. OBSERVATIONS The mean duration of therapy was 3.3 years (range 1-7 years). There was no complication directly related to the endoscopic procedures except for hemobilia that occurred in one patient during stent removal. Cholangitis developed in 5 patients during the therapy period and was treated endoscopically. In 4 patients, significant improvement in the biliary stricture was observed and stents were removed in 3. These patients were followed without stent insertion for one year. CONCLUSIONS Endoscopic management of biliary stricture caused by cavernous transformation of the portal vein appears to be effective and safe.

Hepatobiliary fascioliasis: clinical and radiologic features and endoscopic management.

Fasciola hepatica is a zoonotic liver fluke that can cause disease in humans. Fascioliasis is an uncommon disease. We retrospectively analyzed 9 cases of fascioliasis and reviewed the relevant literature. A high index of suspicion and specific ultrasonographic findings are very helpful in the diagnosis of the disease. However, serological studies and endoscopic retrograde cholangiopancreatography confirm the diagnosis. The disease has 2 stages: hepatic stage and biliary stage. While several drugs are used during the hepatic stage, endoscopic retrograde cholangiopancreatography is particularly effective in the biliary stage.

Comparison of two different treatment protocols in Helicobacter pylori eradication.

Background: The prevalence of Helicobacter pylori (H pylori) in Turkey is high and eradication rates are low. As a result, alternative treatment strategies are required. Objectives: To evaluate the status of H pylori eradication in Turkey by comparing the results of this study to other studies reported in the literature. Methods: Two hundred and eighty-two patients diagnosed with H pylori were included in this study. Patients were randomized into two groups. The first group consisted of 138 patients receiving 30 mg lansoprazole bid, amoxicillin 1 g bid, and clarithromycin 500 mg bid for 14 days. The second group consisted of 144 patients who received lansoprazole 30 mg bid and amoxicillin 1 g bid for seven days, followed by metronidazole 500 mg bid, tetracycline 500 mg qid, and lansoprazole 30 mg bid for an additional seven days. Results: H pylori eradication rates in the first group were 53.6% according to intention-to-treat analysis, and 52.5% according to per protocol analysis. In the second group, eradication rates were 72.2% per intention-to-treat analysis and 77.6% as per protocol analysis. H pylori eradication rates in the second group were significantly higher than the first group (P = 0.001, P < 0.05), whereas the incidence of adverse events in the second group was significantly lower (P = 0.048, P < 0.05). Conclusion: This study found a significant difference in eradication rates between the traditional triple therapy and modified sequential therapy groups. As a result, modified sequential therapy shows promise as an alternative treatment.

Chronic pancreatitis and aortic pseudoaneurysm in Behçet's disease.

Behçets disease is a chronic, recurrent, systemic disease characterized by orogenital ulcers and oculocutaneous inflammatory lesions. Cardiovascular, pulmonary, neurological, articular, and GI involvement are common features, but pancreatic involvement is very rare. We present a case of Behçets disease with both chronic pancreatitis and abdominal aorta pseudoaneurysm.

A Pilot Study Evaluating Sequential Administration of a PPI–Amoxicillin Followed by a PPI–Metronidazole–Tetracycline in Turkey

Background:  There is no effective regimen for the eradication of Helicobacter pylori in our country. It may be due to the increasing prevalence of resistance to antibiotics used for the treatment of H. pylori. Recently, a study from Turkey has revealed that a new treatment scheme consisting of sequential administration of pantoprazole plus amoxicillin for 7 days followed by pantoprazole plus metronidazole, and tetracycline for the remaining 7 days was effective in the first‐line treatment of H. pylori. Therefore, we aimed to confirm efficacy of a new therapy scheme in the first‐line H. pylori eradication.

Low efficacy rate of moxifloxacin-containing Helicobacter pylori eradication treatment: in an observational study in a Turkish population.

Background:  Standard triple therapy for Helicobacter pylori has an eradication rate of about 50% in Turkey. It may be due to an increased resistance of H. pylori to antibiotics. Therefore, we aimed to investigate the effectiveness of a new second‐generation fluoroquinolone, moxifloxacin‐containing triple therapy in H. pylori eradication.

Endoscopic management of a duodenal duplication cyst associated with biliary obstruction in an adult.

Duodenal duplication cysts are distinctly uncommon and most often present in infancy or early childhood. The clinical presentation is generally duodenal obstruction, hemorrhage, or pancreatitis. Duodenal duplication cysts rarely cause biliary obstruction in adults. So far, duodenal duplication cysts have been almost exclusively treated by surgical intervention. This report describes both endoscopic diagnosis and treatment of a large periampullary duodenal duplication cyst associated with biliary obstruction in an adult patient.

Valsartan-Induced Hepatotoxicity in a HBs-Ag-Positive Patient

TO THE EDITOR: Hepatotoxicity caused by angiotensin II receptor blockers is a very rare disorder. We report the first case with acute hepatic injury associated with valsartan, which is an antihypertensive agent. A 52-yr-old hypertensive woman was admitted to our hospital with complaints of weakness, nausea, jaundice, and right subcostal abdominal pain. Her past medical history was unremarkable except for primary hypertension and hepatitis B surface antigen (HBs-Ag) positivity. She had been followed as a HBs-Ag carrier for 4 yr without clinical and laboratory symptoms and signs of acute or chronic liver disease in our hospital. She had been treated for primary hypertension by valsartan for 1 month. There was no other medication. The patient had manifested pruritic erytematous skin changes 1 wk before this admission. After this complaint, moderate nausea, jaundice, and right subcostal abdominal pain developed. On admission, her physical examination revealed no abnormality except for painful mild hepatomegaly. Laboratory findings were as follows: complete blood count was normal and eosinophilia was present. Her total and direct bilirubin levels were 3.2 mg/dl and 2.8 mg/dl, respectively, on admission, and peaked 7.8 and 6.9, respectively on the 7th day of admission. Liver enzymes peaked at the 6th day as follows: ALT 780 U/L, AST 1292 U/L, -glutamyl transferase 945 U/L, and liver-specific ALP 1840 U/L. Serological tests for hepatitis virus were negative (anti-hepatitis A virus IgM, anti-hepatitis B core IgM and IgG, hepatitis B virus DNA by polymerase chain reaction, hepatitis C virus antibody hepatitis C virus RNA by polymerase chain reaction, anti-Epstein-Barr virus IgM, and anti-cytomegalovirus IgM and IgG), except for HBs-Ag positivity. Markers for toxoplasmosis, herpes simplex virus, and HIV were all negative. International Normalized Ratio (INR) and PT were mildly elevated. Hepatobiliary ultrasonography revealed mild hepatomegaly. Liver biopsy was considered, but the patient refused. Valsartan therapy was discontinued at once. Hepatic failure and related complications were not seen. The complaints of the patient were resolved within 2 wk under conservative management. Liver enzymes and bilirubin levels decreased rapidly within 2 wk and returned to normal limits within 3 months. She has been followed for 6 months asymptomatically. As far as we know, this is the first case of valsartanassociated hepatotoxicity in a patient with HBs-Ag positivity. There is just one case report of valsartan-associated hepatic injury from Spain (1). There are not a lot of cases of angiotensin II receptor antagonists associated hepatotoxicity, and in this case, presumably this association is a hypersensitivity reaction together with pruritic skin changes. Valsartan is eliminated mainly by hepatic clearance. Headache, dizziness, and fatigue were the most common adverse events in placebocontrolled studies; the incidence of these adverse events was not significantly different between placebo and valsartan recipients (2). Rash and angioedema have been reported with angiotensin II receptor antagonists very rarely (3). Drug-induced hepatic injury associated with losartan was reviewed by Tabak et al. (4). The importance of HBs-Ag positivity in this hepatotoxicity remains unknown, and the physicians who recommended these agents should be careful about this complication.

Acute Upper Gastrointestinal Bleeding Due to Metastatic Lung Cancer: An Unusual Case

There have been several published reports on metastatic lesions in the stomach, but the number of cases have been limited due to the low frequency of the condition. Metastatic lesions in the stomach are usually asymptomatic. A 55-year-old man with known metastatic lung adenocancer exhibited epigastric pain, hematemesis, and melena. A bleeding, ulcerated gastric metastasis was found and treated with endoscopic therapy and omeprazole.