Sinan Akay

Macrophage migration inhibitory factor expression and MIF gene -173 G/C polymorphism in nonalcoholic fatty liver disease.

Aim To investigate the macrophage migration inhibitory factor (MIF) expression and −173 G/C polymorphism of the MIF gene in nonalcoholic fatty liver disease (NAFLD). Method Ninety-one patients with diagnosis of NAFLD and 104 healthy controls were included in the study. MIF −173 G/C polymorphism was detected using the PCR–restriction fragment length polymorphism based method. NAFLD was stratified as nonalcoholic steatohepatitis (NASH), probable NASH and steatosis, respectively in groups 1, 2 and 3, according to NAFLD Activity Score. MIF expression was detected by immunohistochemistry staining. Results Mean age of the patients was 50.1±9.6 years, and 54 of them were male. Serum alanine aminotransferase and aspartate aminotransferase were 50/83, 42/63 and 31/32, respectively in groups 1, 2 and 3, (P<0.05). Both the MIF expression of hepatocytes and mononuclear cells were more prominent in groups 1 and 2 than group 3. There was no correlation between MIF expression of hepatocytes and fibrosis stage. However, MIF expression of mononuclear cells significantly increased according to fibrosis stage (P<0.05, R : 0.2). There was no significant correlation between MIF genotype and MIF expression in the liver. Conclusion MIF expression is significantly increased especially by mononuclear cells in liver tissue of patients with NASH secondary to inflammation. Thus, it should be considered as a consequence not a causal factor.

The efficacy of ranitidine bismuth citrate, amoxicillin and doxycycline or tetracycline regimens as a first line treatment for Helicobacter pylori eradication.

BACKGROUND The eradication rates of Helicobacter pylori (H. pylori) clearly decreased with standard PPI-based triple therapies. AIM To assess the efficacy of two different triple therapies consisting of ranitidine bismuth citrate-amoxicillin-doxycycline and ranitidine bismuth citrate-amoxicillin-tetracycline combinations as a first line treatment option. METHODS One hundred and fifteen consecutive dyspeptic patients in whom H. pylori infection was diagnosed for the first time were enrolled in this study. The patients were randomized into two groups. Group 1 (n=57) was assigned to receive a 14-day triple therapy consisting of ranitidine bismuth citrate 400 mg (b.i.d.), amoxicillin 1 g (b.i.d) and doxycycline 100 mg (b.i.d.). Group 2 (n=58) was assigned to receive a 14-day triple therapy consisting of ranitidine bismuth citrate 400 mg (b.i.d.), amoxicillin 1 g (b.i.d.) and tetracycline 500 mg (q.i.d.). RESULTS The eradication was achieved in 45.7% (21/46) and 40.8% (20/49) of the patients in group 1 and group 2, according to per protocol analysis. The intention-to-treat eradication rates were 36.8% (21/57) and 34.5% (20/58) in group 1 and group 2, respectively. CONCLUSIONS Two-week therapy with neither ranitidine bismuth citrate-amoxicillin-doxycycline nor ranitidine bismuth citrate-amoxicillin-tetracycline is adequately effective for H. pylori eradication as a first line therapy.

Use of activated protein C has no avail in the early phase of acute pancreatitis

OBJECTIVES Sepsis and acute pancreatitis have similar pathogenetic mechanisms that have been implicated in the progression of multiple organ failure. Drotrecogin alfa, an analogue of endogenous protein C, reduces mortality in clinical sepsis. Our objective was to evaluate the early therapeutic effects of activated protein C (APC) in a rat model of acute necrotizing pancreatitis. SUBJECTS AND METHOD Acute necrotizing pancreatitis was induced by intraductal injection of 5% Na taurocholate. Hourly bolus injections of saline or recombinant human APC (drotrecogin alfa) was commenced via femoral venous catheter four hours after the induction of acute pancreatitis. The experiment was terminated nine hours after pancreatitis induction. Animals in group one (n=20) had a sham operation while animals in group two (n=20) received saline and animals in group three (n=20) received drotrecogin alfa boluses after acute pancreatitis induction. Pancreatic tissue for histopathologic scores and myeloperoxidase, glutathione reductase, glutathione peroxidase, and catalase activities were collected, and blood for serum amylase, urea, creatinine, and interleukin-6 measurements was withdrawn. RESULTS Serum amylase activity was significantly lower in the APC treated group than the untreated group (17,435+/-432 U/L vs. 27,426+/-118 U/L, respectively). While the serum interleukin-6 concentration in the APC untreated group was significantly lower than the treated group (970+/-323 pg/mL vs. 330+/-368 pg/mL, respectively). CONCLUSION In the early phase of acute pancreatitis, drotrecogin alfa treatment did not result in a significant improvement in oxidative and inflammatory parameters or renal functions.

Liver biopsy : Is the pain for real or is it only the fear of it?

Although percutaneous liver biopsy (PLB) has very low mortality and morbidity rates, it often is considered painful and frightening by the patients. This study was designed to grade the intensity of pain expected before the procedure and experienced during the procedure, and whether there is any correlation between pain and the emotional state of the patient. A total of 118 consecutive patients (aged 19–68 (mean, 44) years), who were undergoing PLB for the first time, were included in the study. Visual Analogue Scale (VAS) was used before the procedure, after the procedure to grade the degree of pain expected, and the degree of the pain experienced respectively. All the patients were evaluated by a questionnaire for their personality and emotional situation by using the Minnesota Multiphasic Personality Inventory Somatization Sub-scale (MMPI-SS). Mean VAS score for expected pain before the procedure was 60±20 and for the pain experienced during the procedure was 22±16 (P < 0.0001). Although the expected pain scores of female patients were significantly higher than males (66±22 vs. 55±17; P=0.003), there was no difference between female and male patients in the experienced pain scores. The procedure of PLB is expected to be more painful than it really is by the patients, especially by females. Calming the patients by informing them about the procedure and their diseases will probably diminish the expected pain.

Reabsorption of ascites and the factors that affect this process in cirrhosis.

Ascites is one of the main features of liver decompensation in cirrhosis, and it is considered to be a dynamic process. In this study, we aimed to (1) measure the reabsorption rate of ascites; (2) evaluate whether these findings were related to features of ascites, hemodynamics, and serum measurements; and (3) examine morphologic changes in the diaphragm of cirrhotic patients. In all, 42 cirrhotic patients with ascites were enrolled in the study to comprise our study group. Using the dextran 70 test, patient ascites volumes and reabsorption rates were measured. Biopsies from the peritoneal side of the diaphragm were also processed for scanning electron microscopy and lymphatic immunohistochemical studies from the cirrhotic patients and control cadavers. The mean ascites reabsorption rate was 4.5 +/- 4.5 (0.18-14.6) mL/min, which correlated significantly with the calculated ascites volume (r = 0.75, P < 0.001). The mean ascites viscosity was 1.07 +/- 0.07 (0.99-1.17) centipoise, which demonstrated a high degree of negative correlation with the ascites reabsorption rate (r = -0.77, P < 0.001). Patients with a history of spontaneous bacterial peritonitis had significantly lesser ascites reabsorption rates than patients without this particular history. The size of lymphatic stomata in scanning electron microscopy depictions was increased, and lymphatic lacunae were dilated in immunohistochemical studies in the cirrhotic patients with ascites. However, these findings were not uniform in every cirrhotic patient with ascites. The volume and viscosity of ascites seem to influence its reabsorption rate. Additionally, previous episodes of spontaneous bacterial peritonitis may be responsible for the decreased ascites reabsorption rates observed in certain patient populations.

Improving the standard sequential treatment of Helicobacter pylori with either extended treatment or by adding bismuth

BACKGROUND AND STUDY AIMS Standard sequential treatment for Helicobacter pylori (H. pylori) eradication has less success because of increasing clarithromycin resistance. Extended treatment and bismuth containing regimens were, therefore, investigated. PATIENTS AND METHODS Consecutive H. pylori-positive patients with dyspepsia were randomly allocated to one of the three sequential regimens: The first group was given lansoprazole 30mg b.i.d. plus amoxicillin 1g b.i.d. for the first 5days, followed by lansoprazole 30mg b.i.d., clarithromycin 500mg b.i.d., and metronidazole 500mg t.i.d. for the second 5days (standard sequential, SS). The second group was given the same regimen but for 7+7days instead of 5+5days (extended sequential, ES). In the third group, colloidal bismuth 600mg b.i.d. was added to the second regimen for 14days (extended sequential+bismuth subcitrate, ES+B). Urea breath test or histology was performed before enrolment and 6weeks after the end of treatment to detect H. pylori. RESULTS A total of 280 patients were included in the study. Per-protocol eradication rates were 62% (56/90), 72% (56/78), and 75% (54/72) in patients who received SS, ES, and ES+B regimens, respectively. Moreover, intention-to-treat eradication rates were 53% (56/104), 62% (56/90) and 62% (54/86), respectively. The differences in eradication rates between the groups were not statistically significant. CONCLUSION Although prolonging of the sequential treatment to 14days may be considered, addition of bismuth to the regimen is of no avail.

A Pilot Study: Longer Duration of Posttransplant Hepatitis C Virus Therapy May Increase the Sustained Response Rate

BACKGROUND Although end of treatment virological responses are similar in posttransplant patients with recurrent chronic hepatitis C virus infection and nontransplant patients, the sustained virological response rate is lower in the posttransplant setting. We investigated the efficacy of a longer duration (3 years) of therapy. METHODS Thirteen patients with biopsy-proven recurrent hepatitis C were included in the study. In the first year of therapy, all patients were treated with a standard regimen of interferon alpha 2b 3MU 3 times in a week plus ribavirin (800 to 1000 mg/d). After the availability of pegylated interferon, patients were converted to pegylated interferon (1.5 microg/kg body weight). Hepatitis C virus RNA was evaluated at months 3, 6, 9, 12, 24, 36, and 42. If hepatitis C virus RNA was negative at month 12, the patients continued treatment for 36 months. RESULTS Hepatitis C virus RNA was negative in six patients at 12 months, including two who became hepatitis C virus RNA negative after 3 months; two, after 6 months; and two, after 12 months of therapy. Those six continued treatment completing 3 years of treatment with a sustained virological response. Four of those six patients with sustained virological response required colony-stimulating factors during treatment. CONCLUSION Although the hepatitis C virus RNA status of patients at 12 weeks is a good marker to predict a sustained virological response in the nontransplant setting, it is not valid in posttransplant patients. A prolonged duration of therapy for patients who are viral responders at 12 months may prevent recurrence and increase the sustained virological response rate.

İntestinal Behçet hastalığı

Behcets disease is known as a vasculitic pathology with a usually systemic course. It is described as intestinal Behcets disease in the presence of gastrointestinal system involvement, such as intestinal ulcers, hemorrhage or perforation. Prevalence of intestinal Behcets disease is very rare in Turkish patients and accounts for less than 1% of the patients. It may mimic inflammatory bowel disease or present as massive hemorrhage. Intestinal ulcers are mostly seen in the terminal ileum and cecum and may be complicated with perforation. Herein, we report two cases with intestinal Behcets disease, one of which was diagnosed as Behcets disease while under investigation for the etiology of intestinal disease.

Patients with Ectopic Papilla of Vater, Bulbar Stenosis and Choledocholithiasis: A New Syndrome?

Patients with Ectopic Papilla of Vater, Bulbar Stenosis and Choledocholithiasis: A New Syndrome? Galip Ersoz, Omer Ozutemiz, Sinan Akay, Oktay Tekesin Introduction: Ectopic localization of papilla of Vater and/or stenosis at duodenal bulb may cause challenges in the cannulation of papilla and the endoscopic treatment of the biliary diseases. Twelve patients with biliary stones, stenosis and deformity at the duodenal bulb, and papilla ectopically located at duodenal bulb or junction of the first and second parts of the duodenum; and their endoscopic management are presented here. Patients All of the patients were male, median age was 46 (35-52). In eight (%67) of the patients, there were accompanying stones in the gall bladder. One of the patients was diagnosed as secondary biliary cirrhosis. In none of the patients, there were symptoms related to duodenal stenosis. In 9 (%75) of the 12 patients the duodenoscope could not be advanced beyond the bulbus into descending duodenum because of the mechanical obstruction and deformity. The stenotic parts in the bulbus were dilated with TTS balloons with diameters ranging from12 to18 mm. Thus, ectopic papillae could be reached in all of the cases. Papilla could not be cannulated in one patient (%8) and in the remaining 11 cases, biliary stones ranging from 6 to 14 mm were detected with cholangiography. Since the site of the sphincterotomy and distal common bile duct (CBD) indentation could not be evaluated, papillary orifice and distal CBD were dilated with balloons starting from a 4 mm diameter and increasing the diameter of the balloons stepwise to 4 to 15 mm. In 6 (%50) of the patients, the stones could be extracted in the same endoscopy session with the cholangiography. In 3 (%25) of the patients, stones could be extracted in a second session and in the remaining 3 (%25), the endoscopic treatment for the biliary stones had failed. In one of the patients, after dilatation of CBD with a 12 mm balloon, retroperitoneal perforation in the intrapancreatic segment of the CBD occured and he was operated. No other major complication occured. Conclusion The shared features which may constitute a new syndrome of the presented cases are 1) male gender 2) ectopic location of the papilla 3) deformity and stenosis in the bulbus 4) presence of stones in the CBD. Bile duct stones can be treated with endoscopic balloon dilatation of distal CBD and papilla, bearing in mind that a serious complication such as perforation might be encountered.