Acute pancreatitis in Turkey: Results of a nationwide multicenter study

BACKGROUND

Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management.

METHODS

All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria.

RESULTS

The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically.

CONCLUSIONS

This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

Liver injury after SARS-CoV-2 vaccination: Features of immune-mediated hepatitis, role of corticosteroid therapy and outcome

BACKGROUND AND AIMS

A few case reports of autoimmune hepatitis-like liver injury have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We evaluated clinical features, treatment response and outcomes of liver injury following SARS-CoV-2 vaccination in a large case series.

APPROACH AND RESULTS

We collected data from cases in 18 countries. The type of liver injury was assessed with the R-value. The study population was categorized according to features of immune-mediated hepatitis (positive autoantibodies and elevated immunoglobulin G levels) and corticosteroid therapy for the liver injury. We identified 87 patients (63%, female), median age 48 (range: 18-79) years at presentation. Liver injury was diagnosed a median 15 (range: 3-65) days after vaccination. Fifty-one cases (59%) were attributed to the Pfizer-BioNTech (BNT162b2) vaccine, 20 (23%) cases to the Oxford-AstraZeneca (ChAdOX1 nCoV-19) vaccine and 16 (18%) cases to the Moderna (mRNA-1273) vaccine. The liver injury was predominantly hepatocellular (84%) and 57% of patients showed features of immune-mediated hepatitis. Corticosteroids were given to 46 (53%) patients, more often for grade 3-4 liver injury than for grade 1-2 liver injury (88.9% vs. 43.5%, p = 0.001) and more often for patients with than without immune-mediated hepatitis (71.1% vs. 38.2%, p = 0.003). All patients showed resolution of liver injury except for one man (1.1%) who developed liver failure and underwent liver transplantation. Steroid therapy was withdrawn during the observation period in 12 (26%) patients after complete biochemical resolution. None had a relapse during follow-up.

CONCLUSIONS

SARS-CoV-2 vaccination can be associated with liver injury. Corticosteroid therapy may be beneficial in those with immune-mediated features or severe hepatitis. Outcome was generally favorable, but vaccine-associated liver injury led to fulminant liver failure in one patient.

P-019 Semen analysis results are negatively affected in patients with vitiligo:a cross-sectional study

Study question

Does vitiligo affect the results of semen analysis?

Summary answer

Semen analysis results are negatively affected in patients with vitiligo.

What is known already

Vitiligo is a multifactorial disorder characterized by the loss of functional melanocytes, and both genetic and non-genetic factors play a pathogenic role.Male infertility is also a common problem, contributing to almost 50% of all infertility problems.It was reported that skin-derived cytokines triggered in diseases with inflammation in the skin negatively affect spermatogenesis and sperm viability.Although vitiligo is a common skin disorder, the pathogenesis remains unknown. It was shown that inflammation and oxidative stress was accepted as a trigger factor in melanocyte degeneration.It was emphasized that the increase in inflammation in the body might be indirectly related to male infertility.

Study design, size, duration

This cross-sectional study was conducted between January 2015 and January 2021 by retrospectively evaluating patients who underwent sperm analysis at an university hospital. All patients aged between 25-45 years who underwent semen analysis at the relevant dates were evaluated in terms of the study (N = 5167).76 patients with vitiligo and 71 healthy controls were included in our study. The diagnosis of vitiligo was made clinically and using Wood's lamp.

Participants/materials, setting, methods

The control group was selected from among age and BMI-matched patients who underwent semen analysis (n = 71).The parameters examined in the study were as follows: Characteristics of cases (age, BMI, family history), Disease features (duration of disease, clinical type, Koebner phenomenon, halo naevi)The level of hormones [follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroxine (FT4), thyroid-stimulating hormone (TSH), testosterone, prolactin], and blood glucose, Semen analysis (volume, sperm concentration, total motility, A + B motility, morphology).

Main results and the role of chance

Seventy-six patients with vitiligo and 71 healthy controls were included in our study. The mean age was 30.29 ± 4.18 (range, 25-45) years. The mean age at onset was 23.66 ± 3.96 (range, 15-35) years, and the mean duration of disease was 6.36 ± 2.80 (range, 2-20) years in the vitiligo group. Sixty-seven (88.16%) patients had non-segmental vitiligo and nine (11.84%) had segmental vitiligo. Seven (9.21%) patients had a family history, three (3.95%) had Koebner phenomenon, and one (1.32%) patient had halo naevi.Free T4 levels were significantly lower in the vitiligo group than in the control group (P < 0.001) There were no significant differences between the groups regarding age, BMI, FSH, LH, TSH, testosterone, prolactin, and blood glucose levels. When we evaluated the semen analysis results, we found that sperm concentrations A+B motility and morphology were significantly higher in the controls than in the patients with vitiligo (P < 0.001,p<0.01,and P < 0.001) )There were no significant differences between the groups concerning volume and total motility. We divided patients with vitiligo into three groups according to their sperm concentrations.There were no significant differences between groups regarding age and BMI Free T4 levels were significantly higher in the control group than in the other groups. (p < 0.001).

Limitations, reasons for caution

The retrospective design of the study is an important limitation. Although the relationship between vitiligo and sperm parameters has been examined, the direction and cause of this relationship could not be determined due to the study design.

Wider implications of the findings

Inflammation and oxidative stress may affect sperm quality.One of the reasons for the more negative results in sperm analysis parameters in patients with vitiligo in our study might be due to increased inflammation level.Oxidative stress may be the trigger factor in the destruction of melanocytes as well as semen parameters.

Trial registration number

not applicable

The role of endobronchial and endoscopic ultrasound guided fine needle aspiration for mediastinal nodal staging of non-small-cell lung cancer

Introduction

Mediastinal and hilar nodal staging is one of the key points for differentiating treatment modalities in patients with non-small-cell lung cancer (NSCLC). The aim of the present study was to determinate the diagnostic yields of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and combined EBUS-TBNA and EUS-FNA modalities for nodal staging in potentially operable NSCLC patients.

Materials and Methods

Twenty consecutive patients were prospectively enrolled in the study between March 2014 and November 2015. All patients had a potentially operable NSCLC diagnosis before endosonographic procedures.

Result

Thirty lymph nodes were sampled by EBUS-TBNA and 17 lymph nodes were sampled by EUS-FNA in all 20 patients. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of F-18 fluorodeoxyglucose positron emission tomography with computed tomography (PET-CT), EBUS-TBNA, EUS-FNA and combined EBUS-TBNA and EUS-FNA were 100%, 33.3%, 64.7%, 100% and 70.0%; 81.8%, 100%, 100%, 81.8% and 90%; 81.8%, 100%, 100%, 75% and 88.2%; 90.9%, 100%, 100%, 90.0% and 95.0%, respectively.

Conclusions

The combined EBUS-TBNA and EUS-FNA technique is a successful procedure for nodal staging in potentially operable NSCLC patients.

Noninvasive assessment of liver damage in chronic hepatitis B

AIM: To evaluate the efficacy of the aspartate aminotransferase/platelet ratio index (APRI) and neutrophil-lymphocyte (N/L) ratio to predict liver damage in chronic hepatitis B (CHB).

METHODS: We analyzed 89 patients diagnosed with CHB by percutaneous liver biopsy and 43 healthy subjects. Liver biopsy materials were stained with hematoxylin-eosin and Masson’s trichrome. Patients’ fibrosis scores and histological activity index (HAI) were calculated according to the Ishak scoring system. Fibrosis score was recognized as follows: F0-1 No /early-stage fibrosis, F2-6 significant fibrosis, F0-4 non-cirrhotic and F5-6 cirrhotic. Significant liver fibrosis was defined as an Ishak score of ≥ 2. APRI and N/L ratio calculation was made by blood test results.

RESULTS: The hepatitis B and control group showed no difference in N/L ratios while there was a significant difference in terms of APRI scores (P < 0.001). Multiple logistic regression analysis revealed that the only independent predictive factor for liver fibrosis in CHB was platelet count. APRI score was significantly higher in cirrhotic patients than in non-cirrhotic patients. However, this significance was not confirmed by multiple logistic regression analysis. The optimum APRI score cut-off point to identify patients with cirrhosis was 1.01 with sensitivity, specificity, positive predictive value and negative predictive value of 62% (36%-86%), 74% (62%-83%), 29% (13%-49%) and 92% (82%-97%), respectively. In addition, correlation analyses revealed that N/L ratio has a negative and significant relationship with HAI (r = -0.218, P = 0.041).

CONCLUSION: N/L ratio was negatively correlated with HAI. APRI score may be useful to exclude cirrhosis in CHB patients.

Evolution in the diagnosis and treatment of autoimmune pancreatitis: experience from a single tertiary care center

BACKGROUND

Autoimmune pancreatitis (AIP) is a recently characterized disease with specific clinical, radiographic, and histological features. These diagnostic features have been codified in the recently revised HISORt criteria. The aim of this study was to determine how the recognition and management of AIP has evolved at our center since the publication of the HISORt criteria in 2006.

METHODS

We conducted a historical cohort study consisting of patients with AIP based on the revised HISORt criteria seen at our tertiary care center since 1990. Cases were identified from pathology, laboratory, and pancreas clinic databases. The medical records were reviewed to ascertain demographic and clinical characteristics, radiologic and laboratory results, and patient outcomes. When available, prior images and pathology slides were retrospectively reviewed. The clinical outcomes of the patients were assessed following surgical or medical treatment, and compared based on the calendar year of presentation (before or after 2006).

RESULTS

Forty-seven cases were identified based on the revised HISORt criteria. Of these, 22 were evaluated before and 25 after January 1, 2006. In the early cohort, the diagnosis was frequently missed, including 15 patients that underwent surgical resections. None from the early cohort had a serum IgG4 drawn or mention of possible AIP in the imaging reports. When histology was obtained, the surgical pathologist did not perform IgG4 or Movat stain to allow a histological diagnosis of AIP. Several patients developed diabetes (n=3), calcific pancreatitis with exocrine insufficiency (n=3), proximal biliary strictures (n=7), and pancreatic cancer (n=1) during follow-up. In contrast, patients in the late cohort were less likely to undergo a surgical resection that the early cohort (36% vs. 68%, p=0.042). They were more likely to have a serum IgG4 drawn (80% vs. 0%) and to undergo a corticosteroid trial (44% vs. 0%, p=0.0003). 10/11 patients (92%) who underwent corticosteroid trials had resolution of their symptoms and improvement in structural abnormalities on imaging.

CONCLUSION

A growing multidisciplinary awareness of AIP has led to improved diagnostic evaluation, prompter diagnosis, fewer surgical resections, and more frequent corticosteroid trials.

Neutrophil-lymphocyte ratio as a predictor of disease severity in ulcerative colitis

BACKGROUND

Blood neutrophil-to-lymphocyte (N/L) ratio is an indicator of the overall inflammatory status of the body, and an alteration in N/L ratio may be found in ulcerative colitis (UC) patients. The aims of this study were to investigate the utility of N/L ratio as a simple and readily available predictor for clinical disease activity in UC.

METHODS

Twenty-six patients and 28 healthy controls were enrolled in the study. The neutrophil and lymphocyte counts were recorded, and the N/L ratio was calculated from these parameters. The extent of disease classified according to the Montreal classification, clinical disease activity was evaluated using a modified Truelove-Witts severity index, and endoscopic disease activities were classified according to Schroder et al.

RESULTS

The serum N/L ratios of active patients were significantly higher than those of inactive UC and controls (P < 0.001). The optimum N/L ratio cut-off point for active UC was 2.47. There was no significant difference between inflammation parameters, disease extension, and disease activity.

CONCLUSION

Our results demonstrate that N/L ratio is higher in patients with active UC compared with controls and UC patients in remission and a cut-off value of 2.47 can be used to identify patients with active ulcerative colitis.

Mean platelet volume in biopsy-proven non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as the most common cause of chronic liver disease worldwide. It has been shown that NAFLD has a strong association with metabolic syndrome and its component like insulin resistance (IR). Cardiovascular disease has a relation with NAFLD. Platelet volume is an indicator of platelet function and activation. Mean platelet volume (MPV) has been reported as a risk factor for atherothrombosis. In our study, we aimed to investigate the relation of MPV with NAFLD and IR in the NAFLD patients. A total of 54 patients with histologically proven NAFLD and 41 healthy age-matched control subject were enrolled in this study. The NAFLD subjects were divided into two subgroups: 42 patients in the insulin resistant group (median age 39.5, females 22 [52%]) and 12 patients in the insulin sensitive group (median age 38, females 5 [41.7%]). MPV were significantly higher in the NAFLD group in univariate analysis (p < 0.05). In the NAFLD patients, we did not find any relation between steatosis grade, lobular inflammation, hepatocellular ballooning, NAFLD activity score and fibrosis with MPV value. Among the insulin resistant and sensitive groups in the NAFLD patients MPV values were similar. The results of this study showed that MPV, an indicator of platelet activation, increased in biopsy proven NAFLD patients but MPV is not correlated with the increase of IR in NAFLD patients. MPV is not related with inflammation and steatosis degree, hepatocellular ballooning and fibrosis in NAFLD patients.

A huge solitary fibrous tumor localized in the pancreas: a young women

CONTEXT

Solitary fibrous tumor is an uncommon spindle cell tumor which were first described in 1931 at pleura; it should be seen rarely in extra-pleural localization.

CASE REPORT

We report the ninth case of pancreatic solitary fibrous tumor in a 24-year-old woman who presented with mild epigastric pain radiating to the back and chronic constipation. Imaging studies confirmed a solitary mass in the epigastric region that begins from posterior of stomach, fills little curvature and extends to pelvis, invades vascular structures by encircling them and extends to retroperitoneal regions that was considered as it may have mesenchymal origin. The patient underwent an enucleation of the mass which was diagnosed as solitary fibrous tumor, supported by immunohistochemical studies showing positivity for CD34, vimentin and SMA.

CONCLUSION

There is limited data regarding biological behavior of solitary fibrous tumors with extra-pleural localization, because they are rare tumors. They are generally asymptomatic and slow growing tumors and it is difficult to distinguish them from other mesenchymal tumors. These issues as well as the prior nine cases are discussed.

Effects of testosterone gel treatment in hypogonadal men with liver cirrhosis

INTRODUCTION

Hypogonadism characterized by low serum testosterone level, loss of libido, small testes, impotence and gynecomastia is a common clinical situation in male patients with advanced chronic liver disease. The aim of the study was to assess the efficacy and safety of testosterone replacement on muscle strength, bone mineral density (BMD), body composition and gynecomastia in hypogonadal men with liver cirrhosis.

METHODS

Sixteen hypogonadal male cirrhotic patients were included and twelve completed the study. Abdominal USG and/or MRI were performed to exclude hepatocellular cancer. Testogel 50mg/day was administered for 6 months. Liver enzymes, hormone profiles and muscle strength were evaluated monthly. Body composition parameters, BMD and gynecomastia were evaluated before and after 6 months.

RESULTS

Serum free testosterone level was higher (20.13 ± 10.06 pmol/L; 57.26 ± 39.56 pmol/L, P=0.002) after treatment. Testosterone replacement resulted in an increase in muscle strength (34.03 ± 7.24 kg; 39.18 ± 5.99 kg, P<0.001), the subscapular site subcutaneous fat tissue (P=0.012) and the sum of the four regions (P=0.04). Subareolar breast tissue was lower (28.83 ± 17.18 mm; 15.00 ± 6.74 mm, P=0.007) after treatment. No significant adverse effects were detected.

DISCUSSION

Testosterone gel 50mg/day raises free testosterone to values below supraphysiological levels in cirrhotic men. Transdermal testosterone replacement improves muscle strength, ameliorates gynecomastia, alters body fat distribution and causes upper body adiposity in hypogonadal men with cirrhosis. Application of testosterone gel, which undergoes no hepatic first-pass metabolism, seems as a safe and well-tolerated agent in liver cirrhosis as compared to other anabolic steroids, which may be associated with various adverse events.

Epinephrine plus argon plasma or heater probe coagulation in ulcer bleeding

AIM: To compare the effectiveness of argon plasma coagulation (APC) and heater probe coagulation (HPC) in non-variceal upper gastrointestinal bleeding.

METHODS: Eighty-five (18 female, 67 male) patients admitted for acute gastrointestinal bleeding due to gastric or duodenal ulcer were included in the study. Upper endoscopy was performed and HPC or APC were chosen randomly to stop the bleeding. Initial hemostasis and rebleeding rates were primary and secondary end-points of the study.

RESULTS: Initial hemostasis was achieved in 97.7% (42/43) and 81% (36/42) of the APC and HPC groups, respectively (P < 0.05). Rebleeding rates were 2.4% (1/42) and 8.3% (3/36) in the APC and HPC groups, respectively, at 4 wk (P > 0.05).

CONCLUSION: APC is an effective hemostatic method in bleeding peptic ulcers. Larger multicenter trials are necessary to confirm these results.

Is increased colon subepithelial collagen layer thickness in diabetic patients related to collagenous colitis? An immunohistochemical study

In this study, we evaluated immunohistochemically whether increased thickness of the colon subepithelial collagen layer in diabetic patients relates to collagenous colitis. A total of 100 patients (25 in each group) were included in this study. There were diabetic patients with chronic diarrhea in the first group, diabetic patients without chronic diarrhea in the second group, non-diabetic patients with chronic diarrhea in the third group, and control patients in the fourth group. The endoscopic biopsy specimens were obtained from the rectum, sigmoid colon, and descending colon. The thickness of the subepithelial collagen layer was measured using the ocular micrometer method. The immunohistochemical staining was performed with type 1 collagen and fibronectin antibody. The thickness of the colon subepithelial collagen layer in diabetic patients with or without diarrhea was significantly greater than that in control patients. This thickened subepithelial collagen layer in diabetic patients was stained with fibronectin antibody, but not with type 1 collagen antibody in the immunohistochemical study. These immunohistochemical staining characteristics were not similar to those in collagenous colitis, but were similar to those in normal subjects. Increased colon subepithelial collagen layer thickness in diabetic patients does not relate to collagenous colitis.

Ameliorative effects of bombesin and neurotensin on trinitrobenzene sulphonic acid-induced colitis, oxidative damage and apoptosis in rats

AIM: To investigate the effects of bombesin (BBS) and neurotensin (NTS) on apoptosis and colitis in an ulcerative colitis model.

METHODS: In this study, a total of 50 rats were divided equally into 5 groups. In the control group, no colitis induction or drug administration was performed. Colitis was induced in all other groups. Following the induction of colitis, BBS, NTS or both were applied to three groups of rats. The remaining group (colitis group) received no treatment. On the 11th d after induction of colitis and drug treatment, blood samples were collected for TNF-α and IL-6 level studies. Malondialdehyde (MDA), carbonyl, myeloperoxidase (MPO) and caspase-3 activities, as well as histopathological findings, evaluated in colonic tissues.

RESULTS: According to the macroscopic and microscopic findings, the study groups treated with BBS, NTS and BBS + NTS showed significantly lower damage and inflammation compared with the colitis group (macroscopic score, 2.1 ± 0.87, 3.7 ± 0.94 and 2.1 ± 0.87 vs 7.3 ± 0.94; microscopic score, 2.0 ± 0.66, 3.3 ± 0.82 and 1.8 ± 0.63 vs 5.2 ± 0.78, P < 0.01). TNF-α and IL-6 levels were increased significantly in all groups compared with the control group. These increases were significantly smaller in the BBS, NTS and BBS + NTS groups compared with the colitis group (TNF-α levels, 169.69 ± 53.56, 245.86 ± 64.85 and 175.54 ± 42.19 vs 556.44 ± 49.82; IL-6 levels, 443.30 ± 53.99, 612.80 ± 70.39 and 396.80 ± 78.43 vs 1505.90 ± 222.23, P < 0.05). The colonic MPO and MDA levels were significantly lower in control, BBS, NTS and BBS + NTS groups than in the colitis group (MPO levels, 24.36 ± 8.10, 40.51 ± 8.67 and 25.83 ± 6.43 vs 161.47 ± 38.24; MDA levels, 4.70 ± 1.41, 6.55 ± 1.12 and 4.51 ± 0.54 vs 15.60 ± 1.88, P < 0.05). Carbonyl content and caspase-3 levels were higher in the colitis and NTS groups than in control, BBS and BBS + NTS groups (carbonyl levels, 553.99 ± 59.58 and 336.26 ± 35.72 vs 209.76 ± 30.92, 219.76 ± 25.77 and 220.34 ± 36.95; caspase-3 levels, 451.70 ± 68.27 and 216.20 ± 28.17 vs 28.60 ± 6.46, 170.50 ± 32.37 and 166.50 ± 30.95, P < 0.05).

CONCLUSION: The results of this study suggest BBS and NTS, through their anti-inflammatory actions, support the maintenance of colonic integrity and merit consideration as potential agents for ameliorating colonic inflammation.

Crohn's disease complicated by granulomatous interstitial nephritis, choroidal neovascularization, and central retinal vein occlusion

Extraintestinal manifestations of Crohn's disease are common. Granulomas may occur in different tissues in Crohn's disease, although kidney granulomas are extremely rare. Although ocular complications of Crohn's disease are infrequent, most ocular manifestations include iritis, uveitis, episcleritis, scleritis, and conjunctivitis. Central retinal vein occlusion has been reported in a few patients with Crohn's disease. The choroidal neovascularization is related to inflammatory disorders such as panuveitis, sarcoidosis. We report a patient with Crohn's disease complicated by granulomatous interstitial nephritis, choroidal neovascularization, and central retinal vein occlusion.

Clostridium difficile infection frequency in patients with nosocomial infections or using antibiotics

BACKGROUND/AIMS

Clostridium difficile is the most common cause of nosocomial infectious diarrhea. The frequency of colonization in hospitalized patients varies between 10 and 43%.

METHODOLOGY

Clostridium difficile common antigen was investigated in stool samples of 50 patients who developed nosocomial diarrhea (group 1), 65 outpatients who attended the clinic after development of diarrhea during antibiotic use (group 2), 18 patients with active chronic inflammatory bowel disease (group 3), and 30 control patients were studied. The Latex agglutination test and the toxin A was performed to investigate the presence of the Clostridium difficile common antigen in stool samples. The possible predisposing factors for nosocomial infection were analyzed.

RESULTS

Clostridium difficile common antigen was found positive in 27.7% and 14% of group 2 and group 1, respectively while negative in stools of patients with inflammatory bowel disease. Asymptomatic fecal Clostridium difficile carriage in healthy volunteers was 3.3%. The antibiotic that induced diarrhea the most was clindamycin in group 1, and ampicillin-sulbactam in group 2. Enema was found to be the most important risk factor for C. difficile in hospitalized patients.

CONCLUSIONS

The Clostridium difficile common antigen was detected more frequently in antibiotic-associated diarrhea patients than in nosocomial diarrhea patients. Clostridium difficile-associated diarrhea was also more frequent in immunosuppressive patients with uremia and diabetes mellitus.

Pyoderma gangrenosum and exacerbation of psoriasis resulting from pegylated interferon alpha and ribavirin treatment of chronic hepatitis C

Interferon therapy is the cornerstone of chronic hepatitis C treatment. Side effects of interferon include possible triggering or exacerbation of immune diseases in consequence of immunomodulatory effects. We describe the unique case, in which pyoderma gangrenosum and exacerbation of psoriasis were developed 8 weeks after pegylated interferon alpha 2a and ribavirin therapy in a 45-year-old woman. The therapy had to be stopped on account of pyoderma gangrenosum and exacerbation of psoriasis in spite of a biochemical response to the therapy for hepatitis C. The evolution was favorable after stopping treatment. Therefore, we propose this would suggest a possible autoimmune mechanism for the development of pyoderma gangrenosum and exacerbation of psoriasis with pegylated interferon therapy. A susceptible patient, who has an autoimmune disease before interferon therapy, had to be informed that interferons may induce de novo or exacerbate existing immune diseases by immunomodulatory actions. To the best of our knowledge, this is the first case report of pyoderma gangrenosum and psoriasis that resulted from pegylated interferon alpha 2a and ribavirin treatment of chronic hepatitis C.

Rectal carcinoid tumor with bone marrow and osteoblastic bone metastasis: a case report

Rectal carcinoids comprise 12.6% of all carcinoid tumors and represent the third largest group of the gut carcinoids. A 64-year-old woman was diagnosed as high-grade neuroendocrine carcinoma. She had liver, bone, and bone marrow metastasis. Carcinoid syndrome was diagnosed due to diarrhea, nausea, vomiting, tachycardia, and high level of 24-hour urinary 5-hydroxyindoleacetic acid (160 mg/24 hours). No response was obtained by octreotide treatment. Rectal carcinoid tumors usually show favorable prognosis; however, poorly differentiated tumors might have unusually aggressive behavior and resistance to treatment. Bone marrow involvement might be a poor prognostic factor in carcinoid tumor as has been the case in many other tumors.

Serum paraoxonase 1 activity and malondialdehyde levels in patients with ulcerative colitis

This study was designed to evaluate the oxidative and antioxidative status in patients with ulcerative colitis by detecting antioxidant enzyme paraoxonase 1 activity together with the level of a well-known marker of oxidative stress, malondialdehyde. Serum paraoxonase 1 activity and malondialdehyde levels were analysed in 30 patients with ulcerative colitis and 30 controls using a spectrophotometric method; correlation analysis was made between these variables. Serum malondialdehyde levels were higher in the ulcerative colitis group (median: 2.5, range: 0.5-9.4 nmol ml(-1)) than among the controls (median:1.1, range: 0.5-2.3 nmol ml(-1); p < 0.001) whereas paraoxonase 1 activities were lower in the ulcerative colitis group (median: 158.4, range: 61.6-264.1 U l(-1)) than in the control group (median: 233.3, range: 114.4-431.0 U l(-1); p < 0.001). There was no correlation between serum malondialdehyde level, paraoxonase 1 activity and disease activity. (1) Increased reactive oxygen metabolites levels in ulcerative colitis may result in a pro-oxidation environment, which in turn could result in decreased antioxidant paraoxonase 1 activity and increased malondialdehyde levels, (2) increased cytokines may be a possible cause of decreased paraoxonase 1 activity and (3) decreased serum paraoxonase 1 activity may be a part of an inflammatory response.

Mitral and tricuspid annular velocities determined by Doppler tissue imaging in hypopituitary, growth hormone-deficient patients

BACKGROUND

The aim of this study is to determine systolic and diastolic velocity profiles of the left and right ventricles by tissue Doppler imaging (TDI) and to reveal the associations between TDI parameters and early atherosclerotic changes in adult hypopituitary patients with GH deficiency.

PATIENTS AND METHODS

The study group is composed of 16 hypopituitary, GH-deficient patients and 13 healthy controls. All patients had been receiving adequate substitution therapy other than GH at stable doses for at least 6 months. Conventional Doppler echocardiography and TDI of the mitral and tricuspid annulus were performed. Intima-media thickness (IMT) of the common carotid artery was calculated.

RESULTS

IMT was significantly higher in the hypopituitary group compared with controls (0.83 +/- 0.25 vs. 0.51 +/- 0.14 mm, p < 0.001). Hypopituitary patients had significantly lower peak early diastolic (Em) mitral annular velocity (11.2 +/- 3.0 vs. 13.9 +/- 2.8 cm/s, p < 0.05). Multiple regression analysis revealed that age was the only independent variable significantly associated with Em and IMT in the patients.

CONCLUSION

Diastolic abnormalities on TDI of the mitral annulus and early atherosclerotic changes occur concurrently in asymptomatic hypopituitary patients with GH deficiency. Aging may have a more deleterious effect on ventricular function and atherogenesis in this group of patients.

An uncommon lesion: gastric xanthelasma

Although the clinical significance of gastric xanthelasmas is unclear, they are important lesions because they may be confused with malignant lesions. The etiopathogenesis is also unclear, but chronic gastritis, Helicobacter pylori (H. pylori) infection, diabetes mellitus and hyperlipidemia have been implicated. Xanthelasma is more frequent in women and its incidence increases with age. The lesions are frequently located in the stomach, and less frequently in the esophagus, duodenum and the colon. The lesions have a yellowish-white appearance, are between 0.5 and 10 mm in size and can be single or multiple. Xanthelasmas were found to be associated with chronic gastritis, gastrointestinal anastomoses, intestinal metaplasia, and H. pylori infection. These lesions are predisposing conditions for gastric cancer. Therefore, endoscopic biopsy is mandatory and careful follow-up is required. In this paper, four patients who attended hospital with abdominal pain and dyspepsia and by chance were found to have xanthelasmas on endoscopic examination are presented, and gastric xanthelasmas are discussed.

Importance of anticoagulant proteins in chronic liver diseases

BACKGROUND/AIMS

This study was conducted to elucidate the importance of anticoagulant proteins in chronic liver disease and their possible role as markers in determining the severity of the liver disease.

METHODS

This study was conducted on 35 patients with cirrhosis, 15 patients with chronic active hepatitis and 10 healthy controls. Coagulation inhibitor proteins such as protein C, protein S and antithrombin, as well as D-dimer level and thrombin time, which reflect fibrin degradation products, were measured. Cirrhotic patients were categorized as Child A, B and C and chronic active hepatitis patients as mild or moderate activity according to the modified Knodell histopathologic classification. The parameters were compared between patient groups and healthy controls.

RESULTS

In comparison with controls, the cirrhotics had significantly decreased protein C, protein S, antithrombin levels and increased D-dimer levels. The Child B and Child C patients differed significantly with respect to protein C and antithrombin levels only. In the chronic active hepatitis patients, protein S, protein C and fibrinogen were within normal limits, whereas antithrombin was low.

CONCLUSIONS

In chronic active hepatitis, the antithrombin level may be used as an early marker of hepatocellular damage. In cirrhotics, protein C and antithrombin may be useful for assessment of hepatocellular damage, whereas D-dimer may be important for the transition to decompensation.

The prevalence of unrecognized adult celiac disease in Central Anatolia

BACKGROUND

The aim of this study is to assess the prevalence of unrecognized adult celiac disease in Central Anatolia of Turkey and establish if prevalence figures are similar to other reports in the international literature.

METHODS

Subjects were randomly selected from patients at the time of blood sampling because of a routine examination or suspicion of some disorder other than celiac diseases and were screened with anti-tissue transglutaminase IgA and serum IgA measurements. Duodenal biopsies were taken from the patients who were found positive for anti-tissue transglutaminase IgA and had low IgA levels.

RESULTS

A total of 906 subjects between 20 and 59 years of age were included. Small bowel biopsies were performed for 55 of the 906 participants. Fifty-two of 55 participants taken biopsies had anti-tissue transglutaminase IgA levels greater than 15 IU/mL and 3 of them had low IgA levels. Celiac disease was diagnosed as 9 of 906 (0.99%). The majority of the patients with celiac disease had nonspecific gastrointestinal symptoms. There was no correlation between the titers of anti-tissue transglutaminase IgA and the severity of histopathologic findings.

CONCLUSIONS

In this study, we found that unrecognized adult celiac disease in Central Anatolia affects approximately 1% of the population, and the major constellation of symptoms are nonspecific gastrointestinal related. Serologic data are not adequate for a definite diagnosis, but the anti-tissue transglutaminase IgA test has high diagnostic value and may be used as screening tool. Confirmation with intestinal biopsy is required for a definite diagnosis.

Subclinical alveolar involvement in ulcerative colitis

BACKGROUND

Although pulmonary dysfunction has been described in patients with ulcerative colitis (UC), the pathogenesis remains unclear. Our aim was to study alveolar epithelial damage using technetium-99m diethylene triamine penta acetic acid (Tc-99m DTPA) aerosol scintigraphy in patients with UC but without respiratory symptoms.

METHODS

We enrolled 32 patients (18 women and 14 men; mean age, 36.4 +/- 11.6 yr) with active UC, 10 patients with inactive UC (6 women and 4 men; mean age, 43.4 +/- 11.8 yr), and 31 healthy controls (24 women and 7 men; mean age, 40 +/- 10 yr). Tc-99m DTPA aerosol scintigraphy was performed on all patients and controls. The relationship between alveolar epithelial permeability and the activity, localization, and duration of the disease was studied.

RESULTS

There was a significant difference between alveolar epithelial permeability results in patients with active UC and those of the controls (P < 0.001). The same correlation was also found between the patients with inactive UC and the control group (P < 0.001). There was no correlation between Tc-99m DTPA alveolar scintigraphic test results and the stage of activity, localization, and duration of the disease.

CONCLUSIONS

A latent pulmonary involvement may exist in patients with active and inactive UC. The alveolar involvement may be the earliest pulmonary damage, and a DTPA clearance test may show the early changes in pulmonary epithelial permeability that precedes clinical symptoms. Increased alveolar epithelial permeability is an extraintestinal manifestation in patients with UC and is not related to the activity of the colitis.

Determination of oxidative protein and lipid damage in adult hypopituitary patients with GH deficiency

The aim of this study is to determine oxidative protein and lipid damage in adult hypopituitary GH-deficient patients. Eighteen hypopituitary GH-deficient--otherwise healthy-adults on conventional replacement therapy other than GH (9 male, 9 female, age 41.8 +/- 16.4 yr) and 18 healthy subjects (6 male, 12 female, age 40.3 +/- 16.2 yr) participated in the study. Plasma products of oxidative protein damage [protein carbonyl (PCO) and nitrotyrozine (NT)], plasma oxidized LDL (oxLDL), plasma product of oxidative lipid damage [lipid hydroperoxide (LHP)] and antioxidant status of the plasma [total thiol (T-SH)] were measured. Body fat percentage, total and LDL-cholesterol concentrations were significantly higher in the hypopituitary group. Plasma PCO, NT, LHP and T-SH concentrations did not differ significantly between patients and controls. OxLDL concentration was significantly higher in the hypopituitary patients (62.4 +/- 17.8 vs 43.1 +/- 11.3 U/l, p = 0.001). In the patients, oxLDL correlated significantly with the duration of hypopituitarism (r = 0.6323, p = 0.01). In the controls, oxLDL correlated significantly with blood pressure, total and VLDL-cholesterol concentrations. Increased oxLDL concentration may indicate increased oxidative stress within the vascular compartment and may contribute to the proatherogenic state in GH-deficient hypopituitary patients independent from conventional risk factors.