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Efficacy and Safety of Saccharomyces boulardii in the 14-day Triple Anti-Helicobacter pylori Therapy: A Prospective Randomized Placebo-Controlled Double-Blind Study

Background:  Recent studies indicate a potential role of Saccharomyces boulardii in the prevention of Helicobacter pylori treatment‐related side‐effects and also in improvement of eradication rate. Our aim is to investigate the efficacy and safety of S. boulardii in the prevention of side‐effects related to H. pylori eradication. The secondary aim of the study was to define the effect of S. boulardii on the eradication success of anti‐H. pylori therapy.

EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial

BACKGROUND Factors affecting diagnostic accuracy and comparison of patients in the follow-up period for negative outcomes are not thoroughly investigated in a randomized trial. OBJECTIVE Our purpose was to compare diagnostic accuracy, complications, and number of interventions. DESIGN Prospective, unicentric, single-blind, randomized study. SETTING Single tertiary referral university hospital. PATIENTS One hundred twenty patients with intermediate risk for common bile duct (CBD) stones were randomized to either an EUS-first, endoscopic retrograde cholangiography (ERC)-second (n = 60) versus an ERC-only (n = 60) procedure. INTERVENTIONS EUS, ERC, sphincterotomy, and balloon sweeping of CBD when needed. MAIN OUTCOME MEASUREMENTS Sensitivity of EUS versus ERC, factors affecting diagnostic capability, complications, total number of endoscopic procedures. RESULTS The sensitivity and specificity of ERC were 75% (95% CI, 42%-93%) and 100% (95% CI, 95%-100%), respectively. The sensitivity and specificity of EUS were 91% (95% CI, 59%-99%) and 100% (95% CI, 95%-100%), respectively. EUS is more sensitive than ERC in detecting stones smaller than 4 mm (90% vs 23%, P < .01). Although not significant, there was a trend for an increased number of endoscopic procedures in the ERC group compared with the EUS group (98 vs 83). The post-ERC pancreatitis rate was 6 in 120 (5%) in all study patients, and the post-ERC pancreatitis rate in patients with an undilated CBD was 5 of 53 (9.43%). The independent factors for post-ERC pancreatitis are undilated CBD (risk ratio [RR] 6.320; 95% CI, 1.703-11.524, P = .009), allocation into the ERC group (RR 2.107; 95% CI, 1.330-3.339, P = .02), female sex (RR 1.803; 95% CI, 1.155-2.813, P = .03), and age less than 40 years (RR 1.888; 95% CI, 1.245-2.863, P = .01). Kaplan-Meier analysis revealed higher rate of negative outcome in the ERC group than in the EUS group (P = .049, log-rank test). CONCLUSION The EUS-first approach is not associated with further risk for subsequent endoscopic procedures. Patients with an undilated CBD should be investigated by the EUS-first approach to prevent post-ERC pancreatitis.

Heparin and Insulin in the Treatment of Hypertriglyceridemia-Induced Severe Acute Pancreatitis

Heparin and insulin stimulate lipoprotein lipase activity. Therefore, they reduce serum triglyceride levels. However, heparin and insulins efficacy in treatment of hypertriglyceridemia-induced acute pancreatitis is not well established. We report a patient in whom heparin and insulin were used successfully.

Hepatic steatosis has no impact on the outcome of treatment in patients with chronic hepatitis B infection.

Background Hepatic steatosis, as a predictive factor in treatment outcome, was not investigated in chronic hepatitis B (CHB). The aim of this retrospective analysis is to determine possible relationships between hepatic steatosis and treatment response in patients with CHB. Methods One hundred forty patients with CHB [42 hepatitis B e antigen (HBeAg)-positive, 98 HBeAg-negative] were analyzed. Seventy-eight patients (55.7%) received pegylated interferon α 2a 180 μg/wk subcutaneously and 62 patients (44.3%) received pegylated interferon α 2a 180 μg/wk plus lamivudine 100 mg/d combination therapy. Results The presence of steatosis was associated with increased body mass index and hyperlipidemia. The sustained virologic response (SVR) rates in HBeAg-negative patients were 36.2% and 31.5% in patients with and without steatosis, respectively (P>0.05). The SVR rates in HBeAg-positive patients were 39.6% and 33.3% in patients with and without steatosis, respectively (P>0.05). The prevalence of hepatic steatosis did not significantly affect the outcome of treatments in both groups. In pegylated interferon monotherapy group (group 1), SVR was 18/78 (23%) and in the pegylated interferon plus lamivudine combination group (group 2) SVR was 16/62 (26%), (P>0.05, NS). The independent factors affecting the treatment outcome were higher baseline alanine aminotransferase level and lower baseline viral load. Conclusions The prevalence of steatosis is a common finding in CHB infection; however, it is not associated with viral load and treatment outcome.

Efficacy of calcium dobesilate in treating acute attacks of hemorrhoidal disease

PURPOSE: A randomized, double-blind, controlled study was conducted to investigate the efficacy of oral calcium dobesilate therapy in treating acute attacks of internal hemorrhoids. METHODS: Twenty-nine well-documented adult patients with first- or second-degree internal hemorrhoids were treated with calcium dobesilate for two weeks, while 16 patients received only a high-fiber diet to serve as control. Both symptoms and anoscopic inflammation were scored on a scale from 0 to 2 before (T0) and two weeks after treatment (T2). RESULTS: A success rate of 86.21 percent with cessation of bleeding plus lack of severe anitis anoscopically at two weeks were achieved with calcium dobesilate. The pretreatment symptom score of 2 fell significantly to 0.45±0.13, and the pretreatment anitis score of 1.69±0.09 fell to 0.55±0.12 at T2 (P=0.0001 for both comparisons). The symptom and anoscopic inflammation scores obtained with calcium dobesilate treatment were also significantly better than those with diet only (P=0.0017 andP=0.0013, respectively). CONCLUSION: Together with recommendations about diet and bowel discipline, oral calcium dobesilate treatment provides an efficient, fast, and safe symptomatic relief from acute symptoms of hemorrhoidal disease. This symptomatic healing is associated with a significant improvement in the anoscopically observed inflammation.

Peroxisome proliferators-activated alpha agonist treatment ameliorates hepatic damage in rats with obstructive jaundice: an experimental study

BackgroundPeroxisome proliferators-activated receptor alpha (PPARα) activation modulates cholesterol metabolism and suppresses bile acid synthesis. This study aims to evaluate the effect of short-term administration of fenofibrate, a PPARα agonist, on proinflammatory cytokines, apoptosis, and hepatocellular damage in cholestasis.MethodsForty male Wistar rats were randomly divided into four groups: I = sham operated, II = bile duct ligation (BDL), III = BDL + vehicle (gum Arabic), IV = BDL + fenofibrate (100 mg/kg/day). All rats were sacrificed on 7th day after obtaining blood samples and liver tissue. Total bilirubin, aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP), gamma-glutamyl transferase, (GGT), tumor necrosis factor alpha (TNF-α), interleukin 1 beta (IL-1 β), and total bile acid (TBA) in serum, and liver damage scores; portal inflammation, necrosis, bile duct number, in liver tissue were evaluated. Apoptosis in liver was also assessed by immunohistochemical staining.ResultsFenofibrate administration significantly reduced serum total bilirubin, AST, ALT, ALP, and GGT, TNF-α, IL-1 β levels, and TBA (P < 0.01). Hepatic portal inflammation, hepatic necrosis, number of the bile ducts and apoptosis in rats with BDL were more prominent than the sham-operated animals (P < 0.01). PPARα induction improved all histopathologic parameters (P < 0.01), except for the number of the bile duct, which was markedly increased by fenofibrate therapy (P < 0.01).ConclusionShort-term administration of fenofibrate to the BDL rats exerts beneficial effects on hepatocellular damage and apoptosis.

Identification of Helicobacter species by 16S rDNA PCR and sequence analysis in human liver samples from patients with various etiologies of benign liver diseases

Background/Aims Several reports indicated an increased prevalence of the Helicobacter species in hepatocellular cancer tissue and in liver samples infected with hepatitis viruses. The frequency of Helicobacter spp. in benign liver diseases was, however, not thoroughly investigated. Methods Seventy-five consecutive patients with suspected liver disease were enrolled. The indications were hepatitis B virus (n=30), C virus (n=8), B and C dual infection (n=1), nonalcoholic steatohepatitis (n=27), autoimmune hepatitis (n=3), primary biliary cirrhosis (n=1) and idiopathic elevation of liver enzymes (n=5). PCR detection of 16S recombinant RNA gene of Helicobacter spp. was performed on liver samples. PCR products of positive samples were further identified by DNA sequencing. The patients also had upper gastrointestinal endoscopy and gastric biopsy for the detection of H. pylori using histopathology and PCR. Results Helicobacter spp. DNA was detected in two out of 75 liver biopsy samples (2.6%), which were typed as H. pylori by DNA sequencing. One of these patients had chronic hepatitis C infection (man, 51 years old) and the other had nonalcoholic steatohepatitis (woman, 44 years old). Fifty-two out of 75 of the patients (69.3%) had H. pylori infection in their stomachs. Conclusion We have found that H. pylori infection is much less prevalent in benign liver diseases. The presence of H. pylori in nonalcoholic steatohepatitis (NASH) patients is a novel finding and this finding should be confirmed in a larger series.

The Relationship between the MEFV Genotype, Clinical Features, and Cytokine-Inflammatory Activities in Patients with Familial Mediterranean Fever

Familial Mediterranean Fever (FMF) is an autosomal recessive disease characterized by periodic attacks of fever and polyserositis. The effects of the MEFV genotype differences on clinical picture and inflammatory activity have not been well documented. The aim of this study was to investigate levels of conventional inflammation markers, procalcitonin, interleukin levels, TNF-alpha, and C5a levels in patients with FMF who had different MEFV genotypes and compare them with those of healthy subjects. The study consisted of 41 patients with FMF (F/M: 23/18), and 31 healthy subjects (F/M: 18/13). Tests were performed during the attack-free period. White-blood cell count, CRP and IL-8 levels were higher in patients with FMF than in healthy subjects (p < 0.05) and also higher in M680I carriers than in the patients with M694V allele carriers. However, ESR, fibrinogen, procalcitonin, IL-6, C5a, TNF-alpha, and IgD levels were not significantly different between patients and healthy subjects (p > 0.05). Arthralgia or arthritis was significantly higher in M694V carriers than in non-M694V carriers (p < 0.05). It is concluded that the clinical features and inflammatory-cytokine activities were higher in patients with FMF during the attack-free period than in healthy subjects, and the different genotype might be related to different clinical pictures.

Case Report: Hepatic Hydrothorax in the Absence of Ascites (Report of Two Cases and Review of the Mechanism)

Hepatic hydrothorax is de® ned as the presence of signi® cant pleural effusion in a cirrhotic patient without primary pulmonary or cardiac disease (1). Pleural effusions, as a whole, are rarely due to cirrhosis of the liver with or without ascites. Among 436 patients with signi® cant pleural effusions, hepatic cirrhosis was established to be cause in only 2% (2). Although unusual, pleural effusion associated with hepatic cirrhosis and ascites is a well-described entity. It has been noted in varying frequencies, and a reasonable estimate would appear to be 4 ± 10% among all cases of liver cirrhosis (3). Clinical ascites is almost always evident, and the pleural ̄ uid is located either bilaterally or more commonly isolated to the right side. Postulated mechanisms for the development of pleural effusions in patients with hepatic cirrhosis and without pulmonary or cardiac disease include: (1) hypoalbu minemia and decreased oncotic pressure (4), (2) leakage of the plasma from the hypertensive azygos vein subsequent to the formation of collateral anastomoses between the portal and azygos system (1), (3) lymphatic leak from the thoracic duct (5), (4) passage of ascitic ̄ uid to the pleural space by way of lymphatic channels in the diaphragm (6, 7), and (5) transfer of peritoneal ̄ uid directly via defects in the diaphragm (8). The most likely explanatio n for hepatic hydrothorax appears to be that ascitic ̄ uid passes through congenital or acquired fenestrations in the diaphragm directly into the pleural space. A oneway valve mechanism is created, and a pressure gradient-directed, unidirectional ̄ ow of ̄ uid occurs through these defects into the pleural cavity (3). The description of hepatic hydrothorax in the absence of ascites is very rare (3, 9). Such pleural effusions in the absence or eventual disappearan ce of ascites may create diagnostic problems. The two cases presented in this paper, together with the review of previous reports in the literature, are discussed with emphasis to the possible mechanisms of this unusual entity. It is suggested that hepatic hydrothorax in the absence of ascites is a rare but natural variant of the more common occurrence of pleural effusions encountered in cirrhotic patients with ascites. A complicated peritonopleural ̄ uid traf® c may evolve at some stage of the disease, personal predisposing factors accounting for the rarity and diversity of this interesting clinical picture.

The rare presentations of a large polyp and an esophageal carcinoma in heterotropic gastric mucosa: a case series

BackgroundHeterotopic gastric mucosa (HGM) is commonly seen in the upper esophagus during endoscopyand is generally considered a benign disease. A hyperplastic polyp and an adenocarcinoma arising in heterotopic gastric mucosa are quite rare occurences.Case presentationsWe present two cases: The first is a patient who suffered from dysphagia because of a large hyperplastic polyp that arose from HGM; the polyp was excised endoscopically. Secondly, we report a rare case of adenocarcinoma arising in HGM of the cervical esophagus.ConclusionMorphologic changes or malignant transformation can develop in the inlet patch. Therefore, gastroenterologists should be aware of the possibility of HGM just distal to the upper esophageal sphincter.