Yucel Ustundag

MRCP vs ERCP in the evaluation of biliary pathologies: Review of current literature

OBJECTIVE:  Recently developed magnetic resonance (MR) techniques permit fast and correct imaging of the entire biliary tree with a high spatial resolution. The aim of this study was to compare the diagnostic potential of one of these new MR sequences in magnetic resonance cholangiopancreatography (MRCP) procedure and endoscopic retrograde cholangiopancreatography (ERCP) with review of current literatures.

The effect of Helicobacter pylori on insulin resistance.

Helicobacter pylori causes a lifelong infection in the stomach after exposure. H. pylorihas been shown to be associated with peptic ulcer and gastric cancer development. Moreover, it is held responsible for some other nongastric diseases. Among them, coronary heart disease attracts much debate. Many studies have demonstrated a close relationship between insulin resistance and atherosclerosis. Chronic inflammation and alterations in counter-regulatory hormones are deemed responsible for the etiology of insulin resistance. We aimed to examine the effect of H. pylori on insulin resistance. Sixty-three patients were enrolled in the study. Patients were divided into two groups according to H. pylori presence. HOMA-IR (homeostasis model assessment of insulin resistance) level was used to assess insülin resistance. Thirty-six patients were H. pylori positive and 27 were H. pylori negative. There was no difference between the two groups with regard to age, gender, or body mass index. HOMA-IR level was 1.73± 1.1 in the H. pylori-negative group, whereas it was 2.56 ± 1.54 in the H. pylori-positive group (P < 0.05). This study provides the first direct evidence for an association between chronic H. pylori infection and insulin resistance.

The effects of peritoneal dialysis and hemodialysis on serum tumor necrosis factor-alpha, interleukin-6, interleukin-10 and C-reactive-protein levels.

BACKGROUND: Markers of an acute phase reaction, such as C-reactive protein (CRP) or tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL)-6, are predictive for cardiovascular morbidity and mortality in normal subjects and in chronic renal failure patients. In this study, we aimed to investigate serum TNF-alpha, IL-6, IL-10 and CRP levels in continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) patients. MATERIALS AND METHODS: Serum levels of TNF-alpha, IL-6, IL-10 and CRP levels were measured in 30 patients who were just diagnosed with end-stage renal failure and treated, with 16 CAPD (nine female, seven male) and 14 HD (eight female, six male) patients, before CAPD or HD treatment and after 3 months from the beginning of CAPD or HD in patients with no clinical signs of infection. The control groups were 20 healthy persons of similar age and sex. Serum levels of TNF-alpha, IL-6, IL-10 and CRP were measured by enzyme-linked immunosorbent assay in stable CAPD and HD patients and in healthy persons. RESULTS: The mean serum levels of TNF-alpha, IL-6, IL-10 and CRP showed no significant differences between the CAPD and HD patients for the beginning values and the third month of treatment. However, serum TNF-alpha, IL-6, IL-10 and CRP levels were higher than the control group in the CAPD and HD patients regarding the beginning values and the third month of treatment (p < 0.001). CONCLUSIONS: CAPD and HD of the renal replacement therapy have no effects on serum CRP and cytokines.

Analysis of glomerular filtration rate, serum cystatin C levels, and renal resistive index values in cirrhosis patients

Abstract Background: The aim of this study was to evaluate the relation of glomerular filtration rate (GFR) to serum cystatin C levels, renal resistive index (RRI), serum creatinine and creatinine clearance in patients with different stages of cirrhosis. Methods: The study sample was 25 cirrhotic patients (10 females and 15 males; mean age 57.3±2.04 years), 10 in the compensated stage without ascites and 15 in the decompensated stage with new-onset ascites. None had azotemia nor were on diuretic treatment. The control group comprised 25 healthy adults (11 female and 14 men; mean age 56.56±1.91 years). Serum cystatin C, RRI, serum creatinine and creatinine clearance were measured. GFR was determined by technetium99m-diethylene triamine pentaacetic acid renal scintigraphy. Results: Cirrhosis cases had lower mean scintigraphic GFR than controls (64.5±4.03 vs. 87.96±4.16 mL/min, p<0.05). Serum cystatin C and RRI were significantly higher in the cirrhotic group compared to controls (1.16±0.09 mg/L and 0.68±0.01 vs. 0.86±0.03 mg/L and 0.64±0.01, respectively; p<0.05). Subgroup comparative analysis showed that only two parameters, scintigraphic GFR and serum cystatin C, were significantly different between compensated and decompensated cirrhotics (75.62±4.9 mL/min and 0.89±0.07 mg/L vs. 57.23±5.14 mL/min and 1.34±0.13mg/L, respectively; p<0.05). Scintigraphic GFR showed significant correlation with cystatin C, but not with serum creatinine or creatinine clearance (r=–0.877, p<0.05) in decompensated patients. No correlation was observed between scintigraphic GFR and RRI or between serum cystatin C and RRI in all subjects. A receiver operator characteristics curve showed that cystatin C at a cutoff value of 1.01 mg/L can significantly differentiate patients with GFR <70 mL/min with 80% sensitivity and 80% specificity. Conclusions: Serum cystatin C, but not serum creatinine or RRI measurement, correlates with GFR in each stage of liver failure and has a significant diagnostic advantage in detecting lower GFR in such cases. Clin Chem Lab Med 2007;45:890–4.

Serum levels of tumor necrosis factor-α, interleukin-6 and interleukin-8 are not increased in dyspeptic patients with Helicobacter pylori-associated gastritis

INTRODUCTION: Helicobacter pylori (H. pylori) is a non-invasive microorganism causing intense gastric mucosal inflammatory and immune reaction. H. pylori-induced gastric mucosal cytokine overproduction has been clearly documented previously. The stomach has a large surface area and continuous spill-over of locally produced cytokines into the blood stream is a possibility. There are few and conflicting data on circulatory proinflammatory cytokine levels in patients with H. pylori infection. MATERIALS AND METHODS: Forty-two dyspeptic patients were enrolled into the study. The presence of H. pylori infection was diagnosed with antral histopathologic examination. After overnight fasting; serum samples were obtained from each patient to determine circulating interleukin (IL)-6, IL-8 and tumor necrosis factor-alpha (TNF-alpha) levels. RESULTS: H. pylori was shown in 30 cases using Giemsa stain in antral histopathologic evaluation. Twelve cases were negative for H. pylori staining. Both the age and sex distribution had an insignificant difference in both H pylori-positive and H. pylori-negative groups. The mean circulatory levels of IL-6, IL-8 and TNF-a in both groups were not different. The situation was same in respect to the serum levels of these cytokines and the degree of inflammation, H. pylori density and activation scores according to Sydney classification. CONCLUSION: We could not show elevated circulatory levels of IL-6, IL-8 and TNF-alpha in H. pylori-infected cases. We believe that H. pylori-related cytokine activation become concentrated on gastric mucosa and this pathogen-induced local inflammatory cascade does not cause changes in circulatory levels of these cytokines. Moreover, there is no correlation between the levels of serum cytokines and Sydney parameters.

Factors Associated With Response to Therapy and Outcome of Patients With Primary Biliary Cirrhosis With Features of Autoimmune Hepatitis

BACKGROUND & AIMS For patients with primary biliary cirrhosis (PBC) with features of autoimmune hepatitis (AIH), treatment with ursodeoxycholic acid (UDCA) alone or in combination with immunosuppression is controversial. Little is known about the factors associated with initial response to therapy or outcome. We performed a retrospective analysis of treatment strategies and factors associated with outcomes of patients with PBC-AIH. METHODS We analyzed data from 88 patients who were diagnosed with PBC-AIH according to Paris criteria, from 7 centers in 5 countries. First-line therapies included UDCA alone (n = 30) or a combination of UDCA and immunosuppression (n = 58). RESULTS Of patients who received UDCA alone as the first-line therapy, 37% did not respond to treatment. Severe interface hepatitis was independently associated with lack of response to treatment (P = .024; odds ratio, 0.05; 95% confidence interval, 0.004-0.68). The combination of UDCA and immunosuppression was effective in 73% of patients who had not been previously treated or had not responded to UDCA. The presence of advanced fibrosis was associated with lack of response to the combination of UDCA and immunosuppression (P = .003; odds ratio, 0.13; 95% confidence interval, 0.03-0.48). Second-line immunosuppressive agents (cyclosporine, tacrolimus, and mycophenolate mofetil) led to biochemical remission in 54% of patients who did not respond to initial immunosuppression. Liver transplants were given to 4 patients with PBC-AIH. Five patients died during follow-up (3 from liver-related causes). CONCLUSIONS In a retrospective study of a large cohort of patients with PBC-AIH, UDCA alone did not produce a biochemical response in most patients with severe interface hepatitis; these patients require additional therapy with immunosuppression. Second-line immunosuppressive agents are effective in controlling disease activity in patients who do not respond to conventional immunosuppression.

Small colorectal liver metastases: Detection with SPIO-enhanced MRI in comparison with gadobenate dimeglumine-enhanced MRI and CT imaging

The aim of this prospective study was to compare the diagnostic role of superparamagnetic iron oxide (SPIO)-enhanced liver magnetic resonance imaging (MRI) versus gadobenate dimeglumine (GbD)-enhanced MRI and computed tomography (CT) investigations for detection of small (less than 1cm) colorectal liver metastases (LMs) of colorectal cancer. Seventy-eight LMs in 16 patients were evaluated with dynamic CT imaging, GbD-enhanced dynamic MR imaging and SPIO-enhanced MR imaging. Two radiologists were reviewed the LMs separately. Agreement between the readers and three algorithms was analyzed. Differences between the lesion detection ratios of the methods were analyzed by two proportion z test. Sensitivity values of each modality were also calculated. Interobserver agreement values with kappa analysis were found to be the best for three modalities and kappa values were 0.866, 0.843, and 1.0 respectively. For all 78 LMs, SPIO-enhanced MRI detected all lesions (100% sensitivity). This sensitivity value was higher than GbD-enhanced MRI, and there was a significant difference (p < 0.05). GbD-enhanced MRI depicted 71 lesions and this modality could not detected 7 lesions (91% sensitivity). This modality had moderate sensitivity, and this value is greater than CT imaging, so there was a significant difference also (p < 0.05). Dynamic triphasic CT imaging detected 64 (R1) and 65 (R2) LMs. This modality had the lowest sensitivity (R1: 0.82, R2: 0.83 respectively). Only SPIO-enhanced MRI was able to detect all LMs less than 1cm. LMs were the best detected with SPIO-enhanced MRI. We recommend SPIO-enhanced MRI to be the primary alternative modality especially for diagnosis of small colorectal LMs.

Eosinophil infiltration, gastric juice and serum eosinophil cationic protein levels in Helicobacter pylori-associated chronic gastritis and gastric ulcer.

INTRODUCTION: Helicobacter pylori is one of the main causes of gastroduodenal diseases, such as chronic gastritis and peptic ulcer. It has been shown that eosinophils increase in the stomach in H. pylori infection. Eosinophilic cationic protein (ECP) is a cytotoxic molecule secreted by the activated eosinophils. However, there are no sufficient data about the role of ECP in H. pylori infection and its effect on ulcer development. In this study we investigated the gastric eosinophilic infiltration, gastric juice and serum ECP levels in patients with chronic gastritis and gastric ulcer associated with H. pylori. MATERIALS AND METHODS: Forty-four H. pylori-positive and 20 H. pylori-negative patients who underwent upper gastrointestinal system endoscopy after admitting with dyspeptic complaints were enrolled in the study. Twenty-one of the H. pylori-positive patients had gastric ulcer while 23 patients had none. During endoscopy, multiple gastric biopsies and juices were taken. In gastric biopsies, H. pylori and eosinophilic infiltration were assessed. Additionally, gastric juice and serum ECP levels were measured. RESULTS: Eosinophil infiltration, gastric juice ECP levels, and gastric juice/serum ECP ratios in the H. pylori-positive group were greater than in the H. pylori-negative group (p < 0.01). There was no statistically significant difference regarding serum ECP levels between the two groups (p > 0.05). When H. pylori-positive patients were compared with regard to gastric ulcer presence, however, there was no significant difference in gastric eosinophil infiltration, gastric juice ECP levels, serum ECP levels, and gastric juice/serum ECP ratios (p > 0.05). CONCLUSION: The results of this study suggest that eosinophils and eosinophil-released ECP may contribute to inflammatory changes seen in chronic gastritis, whereas there is no proof that they play a role in ulcer development.

Acute dystonia during pegylated interferon alpha therapy in a case with chronic hepatitis B infection

Interferon (IFN) is the most widely prescribed drug of choice for chronic hepatitis B infection, which is a common health problem in our country. Therapy with IFN-alpha may be associated with a number of neuropsychiatric symptoms, such as Parkinsonism, akathisia, seizure, and depressive disorders. In this case report, we present clinical and laboratory findings of a case with chronic hepatitis B that developed acute dystonia soon after the first dose of pegylated interferon alpha. As far as we know, this is the first report in English literature indicating such an adverse effect of pegylated interferon alpha.

Abdominal Castleman Disease with Mixed Histopathology in a Patient with Iron Deficiency Anemia, Growth Retardation and Peliosis Hepatis

In Castleman disease, also known as giant lymph node hyperplasia, lesions are usually located in the chest. Peliosis hepatis is the presence of multiple blood-filled cysts in the liver. The combination of these two disorders in one patient is rare, with only three cases reported to date. We report the case of a 21-year-old man who presented with growth retardation and iron deficiency anemia. Work-up revealed hepatomegaly and multiple conglomerated giant lymph nodes near the splenic hilum. Once the mass was surgically removed, the patients anemia rapidly resolved and he showed catch-up growth. The lymphoid tissue exhibited mixed histologic type, so the patient was diagnosed with both hyaline vascular type and plasma cell type Castleman disease. A liver biopsy obtained at surgery showed sinusoidal dilatation and blood-filled cysts, indicating peliosis hepatis. This is the fourth documented case of peliosis hepatis associated with Castleman disease. In addition to describing the case features, we discuss the possible pathogenesis of peliosis hepatis in the setting of Castleman disease.