Şahin Çoban

Left-Sided Portal Hypertension

Left-sided portal hypertension is a rare clinical syndrome which may lead to bleeding from isolated gastric varices. Pancreatic disease is the most common etiology. Left-sided portal hypertension should be considered in the presence of gastrointestinal bleeding with normal liver function and unexplained splenomegaly. It may be difficult to diagnose this entity both endoscopically and radiologically. While splenectomy is the treatment of choice for cases complicated by variceal bleeding, there is no consensus on the treatment of asymptomatic patients. The prognosis of left-sided portal hypertension mainly depends on the underlying etiology.

Mean platelet volume as a fibrosis marker in patients with chronic hepatitis B

Introduction: Many noninvasive tests have been studied for the diagnosis and determining the liver fibrosis score (LFS). In this study, we aimed to research the correlation of mean platelet volume (MPV) and stage of liver fibrosis in patients with chronic hepatitis B (CHB). Patients and Methods: Fifty‐nine patients with CHB were enrolled retrospectively into the study. Age–sex matched 25 healthy subjects were used as control group. The following data were obtained from computerized patient registry database: HBV‐DNA level, hepatitis B e‐antigen seropositivity, liver enzymes and function tests, white blood cell count, platelet count, hemoglobin, histological activity index, LFS, and MPV. Patients were divided into two groups: patients without significant fibrosis (F0, F1, or F2) (Group 1) and patients with advanced fibrosis (F3, F4) (Group 2). Results: A statistically significant increase in MPV was seen in patients with CHB compared with healthy controls (8.49±0.84 fl vs.7.65±0.42 fl, P<0.001). Receiver operating characteristic curve analysis suggested that the optimum MPV level cut‐off points for CHB was 8.0 fl, with sensitivity, specificity, PPV, and NPV of 68, 76, 86, and 50%, respectively. MPV levels were significantly higher in Group 2 (8.91±0.94 fl, P: 0.009) compared with Group 1 (8.32±0.74 fl). ROC curve analysis suggested that the optimum MPV level cut‐off points for Group 2 was 8.45 fl, with sensitivity, specificity, positive and negative predictive value of 77, 59, 45, and 85%, respectively. Multivariable logistic regression model, which consisted of HAI, ALT, HBV‐DNA, platelet count, and MPV, was performed. We showed that MPV was independently associated with advanced fibrosis (P: 0.031). Conclusion: We suggest that MPV might help in the assessment of fibrosis in CHB. It should not be considered a stand‐alone test for this use owing to nonspecificity with other diseases. J. Clin. Lab. Anal. 25:162–165, 2011.

Long-term Efficacy and Safety of Lamivudine, Entecavir, and Tenofovir for Treatment of Hepatitis B Virus–Related Cirrhosis

BACKGROUND & AIMS Data are limited on the efficacy and safety of tenofovir and entecavir when given for more than 1 year to patients with hepatitis B-related cirrhosis. We investigated the long-term safety and efficacy of these antiviral drugs in patients with chronic hepatitis B virus (HBV) infection, with compensated or decompensated cirrhosis, and compared results with those from lamivudine. METHODS We performed a retrospective analysis of data from 227 adult patients with chronic HBV infection who were diagnosed with cirrhosis, beginning in 2005, at 18 centers throughout Turkey. There were 104 patients who had decompensated cirrhosis, and 197 patients were treatment naive before. Seventy-two patients received tenofovir (followed up for 21.4 ± 9.7 mo), 77 patients received entecavir (followed up for 24.0 ± 13.3 mo), and 74 patients received lamivudine (followed up for 36.5 ± 24.1 mo). We collected data on patient demographics and baseline characteristics. Laboratory test results, clinical outcomes, and drug-related adverse events were compared among groups. RESULTS Levels of HBV DNA less than 400 copies/mL were achieved in 91.5%, 92.5%, and 77% of patients receiving tenofovir, entecavir, or lamivudine, respectively. Levels of alanine aminotransferase normalized in 86.8%, 92.1%, and 71.8% of patients who received tenofovir, entecavir, and lamivudine, respectively. Child-Turcotte-Pugh scores increased among 8.5% of patients who received tenofovir, 15.6% who received entecavir, and 27.4% who received lamivudine. Frequencies of complications from cirrhosis, including hepatic encephalopathy, variceal bleeding, hepatocellular carcinoma, and mortality, were similar among groups. Lamivudine had to be changed to another drug for 32.4% of the patients. CONCLUSIONS Tenofovir and entecavir are effective and safe for long-term use in patients with compensated or decompensated cirrhosis from HBV infection.

Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and mean platelet volume as potential biomarkers for early detection and monitoring of colorectal adenocarcinoma.

Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe. The aim of the present study was to elucidate the efficiency of the neutrophil/lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the mean platelet volume (MPV) as tools for the preoperative diagnosis of CRC and their usefulness in the follow-up of CRC. A total of 144 CRC patients, as diagnosed by colonoscopy, and 143 age-matched and sex-matched healthy participants were included in the study. Medical records were used to compare preoperative and postoperative data including hemoglobin levels, platelet counts, MPV, NLR, and PLR. NLR, PLR, and MPV were significantly higher in CRC patients preoperatively, compared with healthy participants. Receiver-operating characteristic curve analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR, (AUC: 0.853, sensitivity: 70%, specificity: 90%) and 8.25 fl as the cutoff value for MPV (AUC: 0.717, sensitivity: 54%, specificity: 76%). Subgroup analysis showed that NLR, PLR, and MPV levels were also significantly higher in nonanemic CRC patients compared with the control group, which is of great theoretical and clinical value for the early detection of CRC. Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV. Our results suggest that NLR, PLR, and MPV may be used as easily available additional biomarkers for CRC in screening the general population, as well as in postoperative follow-up.

Non-invasive tests in prediction of liver fibrosis in chronic hepatitis B and comparison with post-antiviral treatment results.

BACKGROUND AND AIM The aim of this study was to assess and compare the performance of a series of non-invasive tests to detect fibrosis in patients with chronic hepatitis B (CHB). PATIENTS AND METHODS Seventy-six patients with CHB, whose blood samples were collected and biopsies were done on the same day, were included in this study. Pre-treatment calculations of aspartate aminotransferase to platelet ratio index (APRI), Forns index, FIB-4, S-index, Shanghai Liver Fibrosis Groups index (SLFG) and Hepascore(®) were done and relations with mild and advanced fibrosis and cirrhosis were assessed. Post-treatment values of APRI, Forns index, FIB-4, S-index with oral antiviral agents were also investigated. RESULTS APRI, S-index, SLFG, FIB-4, Forns index and Hepascore(®) had 0.669, 0.669, 0.739, 0.741, 0.753, 0.780; retrospectively Area Under the Receiver Operating Characteristic Curve (AUROC) for significant fibrosis. APRI, Forns index, S-index, FIB-4, SLFG, and Hepascore(®) had 0.681, 0.714, 0.715, 0.738, 0.747, 0.777 retrospectively AUROC for advanced fibrosis. APRI, SLFG, FIB-4, Forns index, S-index, and Hepascore(®) had 0.741, 0.742, 0.768, 0.779, 0.792, 0.824 retrospectively AUROC for cirrhosis. APRI, Forns index, FIB-4 and S-index were significantly lower in post-treatment group compared with pre-treatment group (P-values: <0.05, 0.001, 0.003, 0.018; respectively). CONCLUSION Hepascore(®) showed the best performance to predict significant fibrosis. Our study also suggests that the use of non-invasive test to predict fibrosis in patients with CHB may reduce the need for liver biopsy and may help to monitor the efficacy of treatment.

Atypical presentation of hepatocellular carcinoma: a mass on the left thoracic wall

BackgroundHepatocellular carcinoma is a common malignancy for which chronic hepatitis B infection has been defined as the most common etiologic factor. The most frequent metastatic sites are the lung, bone, lymphatics, and brain, respectively. Metastases to the chest wall have been reported only rarely.Case presentationWe report a patient with hepatocellular carcinoma who presented with an isolated metastatic mass on the left anterolateral chest wall in the axillary region.ConclusionsMetastasis of HCC should be included in the differential diagnosis of rapidly growing lesions in unusual localizations, particularly in patients with chronic liver disease even if a primary tumor can not be radiologically identified.

Significance of Serum Receptor-Binding Cancer Antigen (RCAS1) in Pancreatic Cancer and Benign Pancreatobiliary Diseases

Background/Aims: RCAS1 is a novel tumor marker, and there are no sufficient data about the utility of this antigen as a serum tumor marker and about its tumor specificity. We aimed at measuring the serum levels of RCAS1 in patients with pancreatic cancer and at determining its diagnostic efficacy. Methods: Sera collected from patients with pancreas adenocarcinomas (39 cases) and benign biliary and pancreatic diseases (19 cases) and from healthy volunteers (13 cases) were analyzed for RCAS1 and the results compared with CA19-9. The relation between serum RCAS1 and tumor stage was also evaluated. Results: The serum RCAS1 levels exceeded the normal limit in 92.3, 26.3, and 23.0% of the patients with pancreatic cancer and benign biliary and pancreatic diseases and healthy volunteers, respectively. RCAS1 had a specificity similar to that of CA19-9 in pancreatic cancer, whereas RCAS1 had a higher sensitivity (p < 0.05). Both tumor markers had similar predictive values of positive and negative tests for pancreatic cancer. The RCAS1 level was less influenced than the CA19-9 level by biliary stenoses. The median serum levels of RCAS1 increased, as the tumor stage increased. Conclusions: RCAS1 is a valuable serum marker for the diagnosis of pancreatic cancer. The RCAS1 and CA19-9 levels increase the diagnostic efficiency of each other in pancreatic cancer.

Mean platelet volume in the diagnosis and prognosis of Crimean-Congo hemorrhagic fever.

Introduction: Crimean–Congo hemorrhagic fever (CCHF) is a viral tick-borne zoonosis, which is a severe illness, causing hemorrhages in humans. Mean platelet volume (MPV) is used as a surrogate marker of platelet function and has been shown to be a sign of inflammation. The objective of the present study is to examine the association between MPV and CCHF. We also aimed to investigate the association between MPV and coagulopathy markers in the mortality rates and prognosis of patients with CCHF. Patients and Methods: Ninety-three patients with CCHF were enrolled retrospectively into the study and 15 of them were excluded according to the exclusion criteria. Twenty-five healthy individuals were included as a control group which was age and gender matched with CCHF patients. We compared the levels of MPV between the patient and the control groups. We also compared the coagulopathy markers of fatal CCHF patients (n = 9) with nonfatal cases (n = 69). Results: Platelet counts were significantly lower in the CCHF group. Levels of international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT) were significantly higher in CCHF group (P < .001, <.001, <.001, respectively). A statistically significant increase in MPV was observed in patients with CCHF compared with healthy controls (8.63 ± 1.23 fL vs 7.65 ± 0.42 fL, P < .001). Receiver–operating characteristic curve analysis suggested that the optimum MPV level cutoff points for patients with CCHF was 8.15 fL, with a sensitivity and specificity of 65% and 88%, respectively. The MPV levels were not significantly different between group 2 (nonsurvivor) and group 1 (survivor). However, platelet count, d-dimer, INR, PT, and aPTT were also positively correlated with the mortality rates (P = .008, <.001, <.001, <.001, and <.001, respectively). Multivariable logistic regression model showed an independent correlation between MPV and mortality rate (P < .001). Conclusion: In conclusion, MPV may be a beneficial marker in the diagnosis of CCHF, especially in cases with thrombocytopenia, the MPV levels are high. We also conclude that MPV may independently predict the prognosis of patients with CCHF.

Probable Sulbactam/Ampicillin–Associated Prolonged Cholestasis

OBJECTIVE To present a single case of sulbactam/ampicillin–induced chronic cholestasis and a literature review of antibiotic-associated chronic cholestasis. CASE SUMMARY A 74-year-old man with Hodgkins disease in remission developed severe and prolonged cholestasis after treatment with sulbactam/ampicillin 750 mg twice daily for 7 days. All other etiologies, including Hodgkins disease, were appropriately ruled out and the cholestasis was ascribed to sulbactam/ampicillin treatment. The patient improved gradually and became asymptomatic 7 months after the last dose of sulbactam/ampicillin. According to the Naranjo probability scale, sulbactam/ampicillin was the probable cause of the cholestasis. DISCUSSION Ampicillin, a semisynthetic penicillin, has rarely been associated with hepatic injury when used alone. Hepatocellular and acute cholestatic injury due to ampicillin have been described. Cholestasis secondary to sulbactam/ampicillin use has not been previously reported. CONCLUSIONS Sulbactam/ampicillin, one of the most widely used antibiotics, may cause chronic cholestatic hepatitis. Clinicians should be aware of this adverse affect and consider it during diagnostic workup of liver injury.

Clinical Trial: Transcutaneous Interferential Electrical Stimulation in Individuals with Irritable Bowel Syndrome – A Prospective Double-Blind Randomized Study

Background: The exact etiology of irritable bowel syndrome (IBS) remains unclear. Curative treatment is not available and current treatment modalities are mainly directed against the predominant symptoms. There are a few studies reporting the beneficial effects of transcutaneous electrical stimulation in patients with chronic constipation, gastroparesis, and functional dyspepsia. Aim: To investigate whether transcutaneous electrical stimulation is an effective procedure in IBS patients. Methods: IBS patients were randomly placed in vacuum interferential current (IFC) and placebo groups. Both treatments consisted of 12 sessions administered over 4 weeks. Symptoms due to IBS were documented via questionnaires, including the IBS Global Assessment of Improvement Scale, numeric rating scales, visual analogue scale, and IBS Quality of Life Scale at the beginning of, end of, and 1 month after the treatment. Results: Patients in the therapy (29 cases) and placebo (29 cases) groups were homogeneous with respect to demographic data and gastrointestinal system symptoms. When compared to the beginning scores, severity of abdominal discomfort, bloating, and abdominal distension and rumbling improved significantly in either interference or placebo groups at both the end of treatment and 1 month after treatment. In the IFC group, severity of symptoms continued to decrease significantly at 1 month after treatment when compared to scores at just the end of treatment, whereas in the placebo group severity of these symptoms did not change significantly on numeric severity scales. Also, the visual analogue scale of the first month after treatment continued to decrease significantly when compared to the level at the end of treatment in the IFC group. Total quality score increased significantly in the IFC group. Conclusions: Vacuum IFC therapy can significantly improve symptoms and quality of life in patients with IBS. It may represent a novel treatment modality for drug-refractory IBS patients.