Sedef Kuran

Factors Predicting Outcome of Balloon Dilatation in Achalasia

Background Balloon dilatation of the lower esophageal sphincter (LES) is one of the effective nonsurgical treatment options in the management of achalasia. We aimed to determine the long-term results of graded balloon dilatation and the factors predicting outcome. Patients Patients followed for more than 12xa0months between January 1995 to March 2005, without history of endoscopic or surgical therapy before the study, were included (nxa0=xa0111, mean age 46.3xa0±xa016.9xa0years; follow-up period 46.3 [12–150] months). Patients were evaluated by barium swallow contrast studies, upper endoscopy, and esophageal manometry. Pneumatic dilatation was performed with the use of polyethylene balloon system. Patient outcome was evaluated according to manometric studies and Van Trappen staging as determined following face-to-face interviews with the patients. Results We determined clinical response rates of 98%, 85.7%, and 75% at months 24, 48, and 60. According to receiver-operating characteristics (ROC) analysis, age ≤37.5xa0years, LES pressure (LESP)xa0≥30.5xa0mmHg, LESP after first balloon dilatation ≥17.5xa0mmHg, and balloon number >2 were found to negatively affect treatment response. Young age and higher esophageal body pressure at admission were determined to be negative predictive factors (Pxa0=xa00.038, relative risk (RR) 2.6, 95% confidence interval [CI] 1.05–6.4 and Pxa0=xa00.05, RR 1.069, 95% CI 0.99–1.14, respectively). Conclusion Balloon dilatation is an effective treatment of achalasia. Young age, higher esophageal body pressure, and high LESP after first balloon dilatation are negative predictive factors. Patients with young age requiring more than two balloon dilatations are likely to be unresponsive to the treatment.

Early Decision for Precut Sphincterotomy: Is It a Risky Preference?

The aim of this prospective study was to evaluate the results and the complications at a tertiary referral center which frequently uses precutting techniques for biliary cannulation. Four hundred seventy patients with naive papilla for whom biliary intervention was planned were included in the study. If the selective cannulation was not achieved after a few trials, precutting sphincterotomy was performed. The results were evaluated for the frequency, success, and complication rates of precutting. Precutting was performed on 238 (50.6%; 117 male, 121 female; mean age, 58.5±16.2 years) of 470 patients. Total success rate of endoscopic retrograde cholangiopancreatography (ERCP) was 99.2% (236/238). The rate of complications in patients with versus without precutting was 7 (2.9%) versus 3 (1.3%) for pancreatitis, 2 (0.8%) versus 1 (0.4%) for perforation, and 7 (2.9%) versus 3 (1.3%) for bleeding. The differences between the rates were not significant. Early precutting can be preferable in prolonged cannulation trials of therapeutic ERCP.

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

BackgroundAnomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.MethodsThe data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.ResultsA total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).ConclusionThe opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

Moxifloxacine Plus Amoxicillin and Ranitidine Bismuth Citrate or Esomeprazole Triple Therapies for Helicobacter pylori Infection

Up to 20% of patients, or even more, will fail to obtain eradication after a standard triple therapy. The aim of this study is to evaluate the efficacy of moxifloxacine-containing regimens in the first-line treatment of Helicobacter pylori. One hundred and twenty H. pylori-positive patients were randomized into four groups to receive one of the following 14-day treatments: ranitidine bismuth citrate (RBC) 400xa0mg b.d. plus amoxicillin 1xa0g b.d. and clarithromycin 500xa0mg b.d. (RAC group, nxa0=xa030); RBC 400xa0mg b.d. plus moxifloxacine 400xa0mg o.d. and amoxicillin 1,000xa0mg b.d. (RAM group, nxa0=xa030); esomeprazole 40xa0mg b.d. plus amoxicillin 1,000xa0mg b.d. plus clarithromycin 500xa0mg b.d. (EAC group, nxa0=xa030); and esomeprazole 40xa0mg b.d. plus amoxicillin 1,000xa0mg b.d. plus moxifloxacine 400xa0mg o.d. (EAM group, nxa0=xa030). Eradication was assessed by 13C urea breath test 8xa0weeks after therapy. Per-protocol and intention-to-treat eradication was achieved in 23 out of 30 patients (76.7%, 95% confidence interval [CI]: 61–92) in the RAC group, in 20 patients (66.7%, 95% CI: 49–84) in the RAM group, in 16 patients in the EAM group (53.3%, 95% CI: 34–71), and in 19 patients in the EAC group (63.3%, 95% CI: 54–72). Mild or moderate side-effects were significantly more common in the EAM group (70%) compared to the RAC (36.6%), RAM (43.3%), and EAC (56.6%) groups (Pxa0=xa00.03). From our results, we conclude that moxifloxacine-containing triple therapies have neither eradication nor compliance advantages over standard triple therapies. Further studies with new antibiotic associations are needed for the better eradication of H. pylori in developing regions of the world.

Bile reflux index after therapeutic biliary procedures

BackgroundTherapeutic biliary procedures disrupt the function of the sphincter of Oddi. Patients are potential bile refluxers. The aim of this study was to assess how these procedures affect the histology-based bile reflux index (BRI), which can be used to reflect duodenogastric reflux (DGR).MethodsGastric antrum and corpus biopsies were collected from 131 subjects (56 men, 75 women; mean age, 55.9 ± 15.6 years). Group 1 (Biliary group-BG; n = 66) had undergone endoscopic sphincterotomy, endoscopic stenting, or choledochoduodenostomy for benign pathology; Group 2 (n = 20) had undergone cholecystectomy alone; and Group 3 (n = 6) Billroth II gastroenterostomy. Group 4 (no cholecystectomy; n = 39) had upper endoscopy with normal findings and served as controls. BRI > 14 indicated DGR (BRI [+]). To eliminate confounding effects of Helicobacter pylori (Hp) infection, comparisons were made according to Hp colonization.ResultsFifty-nine subjects (45%) were Hp (+). The frequencies of BRI (+) status in antrum and corpus specimens from Hp (-) BG patients were 74.3% and 71.4%, respectively (85.7% for both antrum and corpus for choledochoduodenostomy). Corresponding results were 60% and 60% for Group 2, 100% (only corpus) for Group 3, and 57.1% and 38.1% for controls (BG, Group 2, and Group 3 vs controls – p > 0.05 antrum, p < 0.05 corpus). Fifty-four BG patients had previously undergone cholecystectomy. Excluding those, the rates of BRI (+) in Hp (-) BG patients were 75% antrum and 62.5% corpus (p > 0.05 for both vs. Group 2).ConclusionPatients who had undergone biliary procedures showed similar bile-related histological changes in both corpus and antrum biopsies, but the changes seen in controls were more prominent in the antrum than corpus. Therapeutic biliary procedures increase the rate of BRI (+) especially in the case of choledochoduodenostomy. Therapeutic biliary procedures without cholecystectomy also increase the rate of BRI (+) similar to that observed in patients with cholecystectomy.

Autoantibody Profile in Systemic Sclerosis as a Marker for Esophageal and Other Organ Involvement in Turkish Populations

Systemic sclerosis (SSc) is a connective tissue disorder of unknown etiology characterized by fibrosis and vascular obliteration in the skin, gastrointestinal tract, lungs, and heart. Our aim was to investigate the autoantibody profile in patients with esophageal involvement of SSc and to describe the relationship between the autoantibody profile and organ involvement in SSc. We studied 47 SSc patients, all with esophageal involvement shown on esophageal manometry. The patients were separated into three groups based on the absence or presence of ANA, Scl70, and ACA. In this study ANA and Scl70 were present more frequently than ACA in patients with esophageal involvement of SSc. Pulmonary involvement and heart involvement were seen more in Scl70-positive and ACA-positive patients, respectively. We conclude that in patients with SSc, closer follow-up with autoantibody profile may enable early diagnosis of specific organ involvement and treatment of debilitating symptoms, with avoidance of potential life-threatening complications.

Biliocutaneous fistula following alveolar hydatid disease surgery treated successfully with percutaneous cyanoacrylate.

An 11-year-old boy was admitted to our hospital with a 2-year history of abdominal distension. A computed tomographic scan demonstrated ascites and multiple cysts of varying diameters in the liver, with the largest measuring 10 × 10 cm (Figure 1). Radiologic appearance was thought to be consistent with alveolar hydatid disease, and ascites was determined to be caused by hepatic vein obstruction by the cysts. Cystotomy and drainage operation was performed and 2 biliary openings into the cyst cavity discovered during the operation were sutured. During the follow-up period, biliary leakage was noted from the abdominal drainage catheter, and endoscopic retrograde cholangiopancreatography (ERCP) was performed 15 days after operation. Leakage from right peripheral intrahepatic duct to cyst cavity was seen, and nasobiliary catheter was placed after endoscopic sphincterotomy (Figure 2). At the third week of nasobiliary drainage, the amount of drainage from the abdominal catheter was unchanged, so the nasobiliary catheter was removed and stent insertion to the common bile duct was performed. Because there was still no decrease in biliary drainage from the abdominal catheter 1 month after stent insertion, we decided to close the fistula tract using cyanoacrylate. Cyanoacrylate and lipiodol combination (0.5 + 0.7 mL) was injected into cyst cavity at the entrance of the drainage catheter, and the catheter was removed (Figure 3). Cutaneous fistula tract was closed with cyanoacrylate. No leakage into cyst cavity during ERCP was observed, and it was decided to follow the patient without stent.

The long-term effects of lamivudine treatment in patients with HBeAg-negative liver cirrhosis

IntroductionIn hepatitis B virus (HBV)-related liver cirrhosis, patients with HBV replication show a higher mortality rate than those without. We aimed to investigate the long-term effects of lamivudine on HBV DNA suppression, Child-Pugh score, and survival in patients with hepatitis Be antigen (HBeAg)-negative liver cirrhosis.MethodsSixty-eight patients (51 male, 17 female) diagnosed with HBV-positive liver cirrhosis, who were monitored by the hepatology and liver transplantation outpatient clinics of our hospital between June 1999 and May 2007, were included in the study. Lamivudine (100 mg/day) was administered orally. Follow-up visits were scheduled monthly during the first 3 months, and every 3 months thereafter. Complete blood count, haemostasis, biochemistry (aspartate aminotransferase [AST], alanine aminotransferase [ALT], amylase, urea, creatinine, total bilirubin, direct bilirubin, total protein, albumin), and alpha-foetoprotein were recorded every 3 months. HBV DNA levels, abdominal ultrasound and the Child-Pugh score were evaluated every 6 months.ResultsSixty-eight patients (mean age, 52.05±12.6 years) were monitored for 49.51±18.51 months. Basal ALT, HBV DNA levels and Child-Pugh scores were 103.9±73.9 IU/ml, 4133±121,94 IU/ml, and 7.6±2.4, respectively. The ALT normalisation was 59.7% during the first year, 68.2% during the second year and 44.4% during the fifth year. There was a significant decrease in Child-Pugh scores in the first 3 follow-up years when compared with the baseline score (P<0.05). During the treatment, HBV DNA positivity and YMDD mutations were determined in 20 of 68 (29.4%) patients at 46±17.9 months. Nine patients (13.2%) developed hepatocellular carcinoma at 44.8±21.5 months. Thirteen patients (19.1%) died during the treatment due to liver failure or variceal bleeding.ConclusionLamivudine is beneficial in patients with HBeAg-negative liver cirrhosis in terms of improvement in liver function and enhancement of survival and quality of life. An HBV DNA suppressive effect and improvement in Child-Pugh score were seen especially in the first years. It is important to be aware of YMDD mutation early, as addition of new antivirals is necessary to overcome unwanted results of the mutation.

Intrahepatic Plastic Stent Entrapment Due to Guide Wire Stripping

During endoscopic retrograde cholangiopancreatography (ERCP) of a 56-year-old female patient on the periodic stent exchange program due to benign biliary stricture treatment, it was realized that the guide wire could not be pulled out after insertion of a 7-F biliary stent in the right intrahepatic duct. There was a thickening and deformity at the distal tip of the guide wire during scopic control and it was thought that the knotting of the guide wire prevented the guide wire from being pulled off (Fig. 1). The only solution of the problem was to extract the stent together with guide wire and so we used a Soehendra stent retriever (Wilson Cook Medical, Winston-Salem, NC) over the guide wire. The procedure was completed without extraction of the endoscope; multiple stent insertions were performed. The problem was not knotting of the tip, but the material (PTFE) which covers the tip of guide wire was stripped and metallic wire under the cover cut the proximal end of the Amsterdam-type plastic stent and embedded in it (Fig. 2). It was thought that the possible reason of the problem was the wearing of the guide wire due to reuse. The Soehandra stent retriever is used for stent replacement [1], extraction of proximally migrated stents [2], and dilatation of benign [3] and malign [4] biliary strictures. We did not find any case in the literature describing the stripping

A practical way of inserting a second guide wire in patients with biliary stricture: use of stent pusher.

To the Editor: Endoscopists interested in endoscopic retrograde cholangiopancreatography frequently encounter the problem of biliary strictures. The etiologies of strictures can be malignant or benign (e.g., postoperative). The procedure performed on these patients is stent insertion. Metallic or plastic stent insertion can be performed according to the etiology and the localization of the stricture. A guide wire needs to be placed above the biliary stricture for stent insertion. Biliary stent insertion is performed after this procedure (frequently after biliary dilatation).