Genetic Investigations in Turkish Idiopathic Pancreatitis Patients Show Unique Characteristics

BACKGROUND/AIMS

Pancreatitis is one of the leading causes of digestive system-related hospital admissions, and it has a genetic background in a considerable portion of the patients. In this study, we aimed to investigate the genetic risk factors of idiopathic pancreatitis in Turkish patients and the contribution of copy number variations to the pathogenesis.

MATERIALS AND METHODS

Idiopathic pancreatitis is defined as failure to detect risk factors despite comprehensive clinical assessments. Next-generation sequencing and multiple ligand-dependent probe amplification of PRSS1, SPINK1, CTRC, and CFTR were performed. For further genotype-phenotype correlations, patients were also questioned for the age of onset, family history, and pancreatic divisum.

RESULTS

A total of 68 idiopathic pancreatitis cases were enrolled. Variants with potential clinical significance of PRSS1 were identified in 13.4%, SPINK1 in 6.3%, CTRC in 4.7%, and CFTR in 26.5% of the patients. No copy number variants were seen in any of these genes. At least 7.4% of the participants had complex genetic etiology involving 2 genes.

CONCLUSIONS

At least 42.6% of the participants had a potential genetic risk factor. Five novel genetic variants were identified, and distinctive genetic risk factors of Turkish population were shown. The results showed that genetic etiology was frequent in pancreatitis and it was even more prominent in patients with early-onset disease. Considering that genetic risk factors may be informative for decisionmaking in the treatment options in addition to providing extensive prognostic value and familial genetic consultation; clinicians need to be more eager to offer genetic tests to pancreatitis patients.

Endoscopic retrograde cholangiography via a permanent access loop

BACKGROUND/AIMS

The aim of this study was to investigate the indications, technical and clinical success, and complications of the endoscopic retrograde cholangiography (ERC) via a permanent access loop (PAL).

MATERIALS AND METHODS

Twenty patients who underwent ERC through PAL between 2009 and 2017 were included in this study. The technical success was described as achieving access to the bile ducts through PAL and the clinical success was described as the clinical and laboratory improvement of the patients after the procedure.

RESULTS

The study was performed with 20 patients. The median follow-up duration was 24 months (3-96) and the median number of ERC sessions was 3.9 (1-10). The most common ERC indications through PAL were stones (40%) and cholangitis (30%). In 16 patients (75%), anastomotic or branched strictures were observed. The improvement of strictures via intermittent stenting and dilatation was observed in 6 patients, but no improvement was observed in 5 patients. The treatment of those 5 patients continues. In this study, the technical success was 100% and clinical success was 85%. While no mortality due to PAL-mediated ERC was observed, free wall perforation was seen in one patient who was referred to surgery.

CONCLUSION

PAL-mediated ERC procedure is a technique with high technical and clinical success and low complication rate in patients who require frequent percutaneous procedures and those with difficult access to the biliary tract.

Endoscopic papillectomy of benign ampullary lesions: Outcomes from a multicenter study

BACKGROUND/AIMS

Endoscopic papillectomy (EP) has emerged as an alternative to surgery in the management of ampullary lesions. The aim of this study is to evaluate feasibility, efficacy, safety, outcome, and impact of EP in the management of benign ampullary lesions.

MATERIALS AND METHODS

This is a multicenter, retrospective study of 44 patients who had EP of benign ampullary lesions.

RESULTS

Over the 11-year period, 44 (55.7%) of 79 patients underwent EP for benign ampullary lesions. Complete resection was achieved in 40 patients (91%). An underlying adenocarcinoma was the only risk factor for incomplete resection. Twenty-eight lesions (63.6%) were resected en-bloc and 16 lesions (36.4%) were resected in piecemeal fashion. Post-papillectomy histopathologic diagnoses were tubular adenoma in 14 patients (32%), invasive adenocarcinoma in 9 patients (20.5%), tubullovillous adenoma in 7 patients (16%), tubullovillous adenoma with carcinoma limited to the mucosal layer in 5 patients (11.3%), adenoma with high-grade dysplasia in 4 patients (9%), neuroendocrine tumor in 1 patient (2.3%), ganglioneuroma in 1 patient (2.3%), hamartomatous polyp in 1 patient (2.3%), adenofibroma in 1 patients (2.3%), and Brunner gland hyperplasia in 1 patient (2.3%). Seven (15.9%) procedure-related complications occurred: 3 (6.8%) bleeding, 2 (4.5%) pancreatitis, 1 (2.3%) abdominal pain, and 1 (2.3%) stent migration to the pancreatic duct. Seven patients (17%) had recurrence.

CONCLUSION

Endoscopic papillectomy is a safe and effective method and can be considered as a first-line approach in patients with benign ampullary lesions with intent for cure. It also allows for correct histological diagnosis and staging.

Extraordinarily Elevated Ca19-9 in Benign Conditions: A Case Report and Review of the Literature

Carbohydrate antigen CA19-9 is commonly used in the diagnosis of pancreatic and biliary malignancies. However, increases in its level in benign conditions such as acute cholangitis or pancreatitis have also been reported. A 79-year-old woman presented with cholangitis and a pancreatic pseudocyst while showing elevation of CA19-9 up to 35,500 U/mL. The patient was adequately treated and at two months’ follow-up the CA19-9 level had returned to normal.

Endosonogragphic features of lesions suggesting gastricectopic pancreas: experience of a single tertiary center

BACKGROUND/AIM

We aimed to present the endoscopic ultrasound (EUS) features of gastric lesions suggesting gastric ectopic pancreas during upper gastrointestinal endoscopy that were diagnosed in our gastroenterology unit, which is a tertiary center for endoscopic procedures in Turkey.

MATERIALS AND METHODS

The data of patients who underwent upper gastrointestinal EUS in our center between April 2012 and July 2014 were retrospectively analyzed.

RESULTS

All of the lesions suggesting gastric ectopic pancreas were localized in the gastric antrum. Thirty-six of 44 lesions (81.1%) showed central dimpling. Lesion borders were shown to be definite in 10 (22.7%) lesions, whereas the borders of 34 lesions (77.3%) were indefinite. Thirty-nine lesions (88.6%) had heterogeneous and 5 lesions (11.4%) had homogeneous echo patterns; whereas 29 lesions (65.9%) were hypoechoic, 9 lesions (20.5%) were hyperechoic and 6 lesions (13.6%) had mixed echogenicity. Forty-two lesions (95.5%) were shown to affect only a single sonographic layer of the gastric wall.

CONCLUSION

EUS features of lesions that strongly suggest gastric ectopic pancreas endoscopically, without any histopathological evidence and without either endoscopic or surgical resection, are as follows: indefinite border appearance, minimal heterogeneous hypoisoechoic echo pattern, existence of anechoic duct-like structures inside the lesion, common localization in the submucosal layer, and existence of umbilication.

Management of suspected common bile duct stone: diagnostic yield of current guidelines

BACKGROUND

The American Society for Gastrointestinal Endoscopy (ASGE) has recently published a guideline for suspected CBDS with the intention of reducing unnecessary ERCP and thereby complications. The aim of this study was to assess the diagnostic efficacy of the ASGE guideline.

METHODS

Data of patients who underwent ERCP with suspected CBDS were analyzed retrospectively. Patients were classified into high, intermediate and low risk groups based on predictors that have been suggested by the ASGE. Very strong predictors of the presence of ductal stones included: CBDS on transabdominal ultrasonography (US), clinical ascending cholangitis or total bilirubin (TBIL) >4 mg/dL). Strong predictors included dilated CBD >6 mm on US with gallbladder in situ and TBIL level of 1.8-4.0 mg/dL whereas moderate predictor included abnormal liver biochemical test other than bilirubin, age more than 55 years and clinical findings of biliary pancreatitis.

RESULTS

Of 888 enrolled patients, 704 had CBDS demonstrated by ERCP and the remainder did not. All very strong and strong predictors were found to be significantly higher among patients who had CBDS. Detection of CBDS by ultrasonography and a dilated common biliary duct were observed to be independent risk factors associated with the existence of CBDS. The high risk group had a high (86.7%) positive predictive value (PPV), however, sensitivity and specificity were observed to be moderate (67.8% and 60.3% respectively). PPV was 67.9% in the intermediate risk group and the sensitivity and specificity were very low (31.9% and 42.3%).

DISCUSSION

The probability of CBDS was observed to be high in the intermediate and high risk groups. However due to low sensitivity and specificity values, the ASGE guideline needs additional or different predictors.

The Detection of Cholangiocarcinoma in Primary Sclerosing Cholangitis Patients: Single Center Experience

PURPOSE

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. Cholangiocarcinoma (CCA) is one of the feared complications of PSC. In our study, we aim to establish the success of brush cytology and CA 19-9 in putting the diagnosis of CCA.

METHODS

The data of 30 PSC patients was retrospectively screened whom had brush cytology performed due to dominant strictures. The definitive diagnosis was established by histopathological examination or via radiological/clinic follow-up for at least 12 months.

RESULTS

A total of four patients were excluded from the study. Twenty-six patients diagnosed with PSC, six of which were also diagnosed with CCA, were included in the study. The sensitivity and the specificity of the brush cytology in the diagnosis of CCA in PSC patients were 66.7 and 95%, respectively. CA 19-9 had high correlation with bilirubin level. The optimal level of CA 19-9 in the diagnosis of CCA was determined to be 138.5 U/ml. Superiority of Ramage scoring over CA 19-9 in the diagnosis of CCA in PSC patients was not established (sensitivity and specificity were 50%, 94.7% and 83.3%, 85%, respectively).

CONCLUSION

Brush cytology has moderate sensitivity in differentiating strictures in PSC patients. CA 19-9 has high sensitivity but bilirubin level can affect the CA 19-9. Therefore, advanced techniques and parameters are needed for detecting CCA in PSC patients.

Double balloon enteroscopy: A 7-year experience at a tertiary care Centre

BACKGROUND

Double Balloon Enteroscopy (DBE) provides the opportunity not only to investigate but also apply endoscopic therapeutic interventions for small intestinal disturbances. The aim of this study is to assess the indications, diagnosis, therapeutic interventions, complications and safety in clinical practise of DBE procedures that have been performed in our clinic.

MATERIAL-METHODS

The data of patients who had undergone DBE procedure in our clinic between October 2007 and December 2014 were retrospectively investigated. All features including indications, findings, histopathological results, applied interventions and complications due to procedure were noted.

RESULTS

A total of 297 patients, 160 (53,9%) male and 137 (46,1%) female were enrolled in the study. Total number of procedures for these 297 patients were 372 [256 (68,8%) oral and 116 (31,2%) anal]. Mean age of the patients was 46,9 (14-94) years. The most common indications were; obscure gastrointestinal (GI) bleeding (28,3%), iron deficiency anaemia (17,5% ) and abnormal findings in a prior imaging study (13,8%), respectively. The rate of new diagnosis with DBE was 11.8%, where the rate for confirmation of a possible diagnosis was 16.2%, rate of endoscopic treatment with definite diagnosis was 11%, rate for ruling out possible diagnosis or showing normal findings was 34.7% and rate for insufficient or unsuccessful procedures was 26.3%. Ulcers, inflammation and erosions (13%), polyposis syndromes (9.8%) and vascular pathologies (7.4%) were the most common endoscopic findings.

CONCLUSION

Our study shows that DBE has high efficacy for diagnosis and ability to perform treatment of small intestinal disturbances with safety.

An unusual cause of recurrent pancreatitis: A gastric duplication cyst with an accessory pancreatic lobe

Congenital anomalies of pancreas and its ductal drainage are uncommon but in general surgically correctable causes of recurrent pancreatitis. A gastric duplication cyst communicated with an accessory pancreatic lobe is an extremely rare cause of recurrent pancreatitis, but an early and accurate diagnosis of this anomaly is important because suitable surgical treatment may lead to a satisfactory outcome. Herein, we presented multidetector computed tomography and magnetic resonance imaging findings of a gastric duplication cyst communicating with an accessory pancreatic lobe via an aberrant duct in a 29-year-old woman with recurrent acute pancreatitis and also reviewed other similar cases reported in the literature.

Comparison of Propofol, Propofol-Remifentanil, and Propofol-Fentanyl Administrations with Each Other Used for the Sedation of Patients to Undergo ERCP

INTRODUCTION

Using single anesthetic agent in endoscopic retrograde cholangiopancreatography (ERCP) may lead to inadequate analgesia and sedation. To achieve the adequate analgesia and sedation the single anesthetic agent doses must be increased which causes undesirable side effects. For avoiding high doses of single anesthetic agent nowadays combination with sedative agents is mostly a choice for analgesia and sedation for ERCP.

AIM

The aim of this study is to investigate the effects of propofol alone, propofol + remifentanil, and propofol + fentanyl combinations on the total dose of propofol to be administered during ERCP and on the pain scores after the process.

MATERIALS AND METHOD

This randomized study was performed with 90 patients (ASA I-II-III) ranging between 18 and 70 years of age who underwent sedation/analgesia for elective ERCP. The patients were administered only propofol (1.5 mg/kg) in Group Ι, remifentanil (0.05 μg/kg) + propofol (1.5 mg/kg) combination in Group II, and fentanyl (1 μg/kg) + propofol (1.5 mg/kg) combination in Group III. All the patients' sedation levels were assessed with the Ramsey Sedation Scale (RSS). Their recovery was assessed with the Aldrete and Numerical Rating Scale Score (NRS) at 10 min intervals.

RESULTS

The total doses of propofol administered to the patients in the three groups in this study were as follows: 375 mg in Group I, 150 mg in Group II, and 245 mg in Group III.

CONCLUSION

It was observed that, in the patients undergoing ERCP, administration of propofol in combination with an opioid provided effective and reliable sedation, reduced the total dose of propofol, increased the practitioner satisfaction, decreased the pain level, and provided hemodynamic stability compared to the administration of propofol alone.

Effects of enteral nutritional support on malnourished patients with inflammatory bowel disease by subjective global assessment

BACKGROUND/AIMS

To investigate the prevalence of malnutrition in patients with inflammatory bowel disease (IBD) by subjective global assessment (SGA) and the effects of oral nutritional support on the clinical parameters, consumption of energy, macronutrients and fiber intake in the Study and Control groups, prospectively.

MATERIALS AND METHODS

A total of 38 (28 Male; 10 Female) hospitalized patients with moderate or severe IBD (13 with Crohn's disease (CD); 25 with Ulcerative colitis (UC)) were included. At stage 1, the disease severity, clinical symptoms and, signs, food consumption and nutritional status by using subjective global assessment (SGA) were recorded. At stage 2, the patients were blindly randomized into a Study Group and Controls. In the Study Group, a standard enteral product was added into the regulated hospital diets, but for the Controls, deficits were regulated by only hospital diets for 3 weeks. the independent variables were the group, the disease and its activity, age, Body body mass index (BMI), weight loss history, the hospitalization period; the dependent variables were SGA, bowel movements, change in nutritional status, disease severity, clinical findings, and also consumption of macronutrients.

RESULTS

Prevalance of malnutrition (SGA-B or SGA-C) for all the patients was 92.1% at the beginning and 71.1% at the end of study. Improvements in disease activity score for the patients with UC were statistically significant in both the Study Group and the Controls (p=0.006 for the Study Group and p=0.001 for the Controls, respectively). Macronutrients, total and water soluble fiber consumption levels improved, with statistically significant differences for all the groups.

CONCLUSION

The prevalence of malnutrition is a major problem in patients with IBD. Not only the regulation of hospital food, but also enteral nutritional support, improved their levels of malnutrition, as well as their energy, macronutrients, and fiber consumption, and SGA is an easy method for nutritional monitoring.

[Evaluation of treatment results among patients with acute gastrointestinal bleeding due to Dieulafoy's lesion admitted to the emergency department]

BACKGROUND

Dieulafoy lesions (DL) are a rare cause of gastrointestinal bleeding (GIB), characterized by exteriorization of a large pulsatile arterial vessel through a minimal mucosal tear surrounded by normal mucosa. In the present study, we aimed to review the clinical experience with DL in our center, primarily focusing on clinical features and endoscopic therapeutic preferences according to clinical outcomes.

METHODS

Data from patients with upper GIB were admitted to the Turkiye Yuksek Ihtisas Training and Research Hospital gastrointestinal endoscopy unit between 2007 and 2011 and were reviewed for DL. Detailed clinical and endoscopic data were abstracted and collected.

RESULTS

Twenty-seven patients were identified with DL. Their ages ranged from 24 to 85 years (median age 70). Fifteen patients were male and twelve were female. Most of the DL occurred in the stomach and were most commonly localized in fundus (59.2%), followed by corpus (29.6%) and antrum (11.2%). The most common initial endoscopic therapeutic approaches were the application of hemoclips with (33.3%) or without adrenalin (40%) injection.

CONCLUSION

Our study revealed that DL occurred in relatively older patients with a male dominance. Primary hemostasis with endoscopic intervention is safe, successful and cost-effective.

Retraction of the main papilla toward the biliary system in patients with primary sclerosing cholangitis

BACKGROUND/AIMS

Retraction of the main papilla toward the biliary system was observed in 70% of patients with primary sclerosing cholangitis (PSC). However, this observation was confounded by the fact that all of the patients with this finding had a prior history of sphincterotomy. The aim of the present study was to observe whether main papillary retraction can be seen in patients with naïve papillae and accompanies the progression of the disease.

MATERIALS AND METHODS

The study was conducted in a single tertiary reference center and included 4 patients with PSC.

RESULTS

Main papillary retraction was seen to emerge with progression of PSC after an initial presentation with intra and extrahepatic involvement in 2 patients and after progression from intrahepatic to extrahepatic bile ducts in 1 patient. Main papillary retraction was seen in 2 patients with naïve papillae and could be detected by magnetic resonance cholangiography in 1 patient.

CONCLUSION

Retraction of the main papilla can be seen in patients with PSC regardless of prior sphincterotomy history.

Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis?

BACKGROUND

Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients.

METHODS

The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1).

RESULTS

Group 1 included 15 patients (six women, nine men, mean age: 62.2 ± 12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6 ± 16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p = 0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis.

CONCLUSIONS

Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.

Factors affecting the success of endoscopic treatment of sphincterotomy bleeding

BACKGROUND AND AIM

Endoscopic methods are effective in the control of endoscopic sphincterotomy (ES) bleeding. Initial failure or recurrent bleeding may develop in some patients, which may require angiographic or surgical interventions. We aimed to determine the factors leading to failure of endoscopic treatment methods.

METHODS

Forty-six patients (1.37%) had endoscopic and/or clinically significant bleeding among a total of 3354 ESs (2998 primary, 356 re-ES) performed within 3 years. Forty-one patients (21 immediate, 20 late onset bleeding) underwent endoscopic treatment. Nineteen patients were treated initially by epinephrine injection and 22 with heat probe. The relation between demographic, laboratory parameters, presence of comorbidity, cholangitis, coagulopathy, and juxtapapillary diverticula, pre-cutting, type of ES, time and pattern of bleeding, treatment modality, the success and relapse of endoscopic treatment were evaluated.

RESULTS

The first method was successful in the treatment of bleeding in 18 patients with heat probe and epinephrine injection, each. Presence of cholangitis, coagulopathy and increased international normalized ratio (INR) levels were found to determine the success of first treatment method. Bleeding could be stopped in all of the patients either with initially preferred or combined methods. Five patients developed recurrent bleeding. Presence of cholangitis, coagulopathy, increased INR levels, low thrombocyte counts and performance of precutting were factors predicting recurrence. Both of the treatment methods were 100% effective in patients without coagulopathy and none of the patients developed recurrent bleeding.

CONCLUSIONS

Treatment of ES bleeding in patients with high risks such as coagulopathy require new effective methods. Patients with coagulopathy must be carefully followed for the development of recurrent bleeding.

Major predictors for difficult common bile duct stone

BACKGROUND/AIMS

Endoscopic retrograde cholangiopancreatography has become the standard treatment for common bile duct stones worldwide. However, there are only a few reports with small number of patients concerning the factors that contribute to the technical difficulty of endoscopic retrograde cholangiopancreatography in these patients. In this study we aimed to investigate these factors in a large group of patients.

MATERIALS AND METHODS

All patients with a naıïve papilla (n=1850) who underwent endoscopic retrograde cholangiopancreatography during a study period of 2 years were prospectively evaluated. Of these, 757 patients with common bile duct stones were included in the study. Following successful cannulation, patients who needed either more than one episode for stone extraction or mechanical lithotripsy, extracorporeal shock wave lithotripsy, or patients in whom stone extraction could not be achieved endoscopically and underwent surgery were regarded as having "difficult stones". Age, sex, laboratory parameters, endoscopic and cholangiographic findings were recorded in all patients. Predictive factors for difficult stones were investigated using univariate and multivariate analysis.

RESULTS

The study group consisted of 432 women and 325 men with a mean age of 60±16 years (range, 4-96). Of the total 757 patients, 654 (86.4%) had easy and 103 (13.6%) had difficult stones. Endoscopic stone extraction was successful in 98.1% of patients. A stricture distal to the stone (OR: 8.248), smaller common bile duct/stone diameter ratio (OR: 0,348), stone diameter (OR: 1,187) stone impaction (OR: 1,117) and higher bilirubin levels (OR: 1,1) were found to be independent predictors of difficult stone extraction on multivariate analysis.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is a very effective method for the treatment of common bile duct stones. Presence of a stricture distal to the stone, smaller common bile duct/stone diameter ratio, stone diameter, impacted stone, and higher bilirubin levels are significant predictors of difficult stone.

Endoscopic closure of gastrointestinal defects with an over-the-scope clip device. A case series and review of the literature

BACKGROUND

The over-the-scope clip (OTSC) is a novel endoscopic tool used in the non surgical treatment of gastrointestinal perforations, fistula, and anastomotic leaks.

AIMS

The aim of the present study was to evaluate the therapeutic efficacy of this new endoscopic device on anastomotic postsurgical leak and fistulas or GI perforation in a tertiary referral center.

PATIENTS AND METHODS

The study group consisted of nine patients (three female, six male, age: 22-65 years). The indications were anastomotic leak in five patients, fistula in three patients, and perforation in one patient. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used. All of the patients were treated with only one OTSC. None of the patients underwent additional endoscopic treatments.

RESULTS

The median size of the defects were 15 mm (range 5-20 mm). OTSC was favourable in five of nine patients (three with leak, and one with fistula and perforation, each). OTSC could not be deployed or partially closed the defect in the remaining four patients because of fibrosis at the edges of the defect. Excluding the case with perforation, the median time elapsed between the diagnosis and the placement of OTSC was 35 days (range: 20-80) in the successful group and 70 days (range: 38-94) in the unsuccessful group. There were no complications due to the OTSC application or the applicator cap.

CONCLUSIONS

OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy is lower in cases with fistulas mainly due to associated fibrosis at the borders.

Additional biliary cannulation methods in patients with juxtapapillary duodenal diverticula

BACKGROUND AND AIMS

Juxtapapillary diverticula (JPD) can increase the difficulty of biliary cannulation. A number of additional methods have been defined in case of failed cannulation attempt by standard technique. We aimed to investigate the more commonly preferred and practical additional methods among them.

METHODS

A total of 1,205 endoscopic retrograde cholangiopancreatographies (ERCP) performed during a study period of 14 months were prospectively entered into a database. Of these, 222 (18 %) had JPD (123 women, 99 men, mean age 69 years) and 983 had no diverticula (523 women, 460 men, mean age 57 years). Additional cannulation methods used in patients with JPD were recorded. Biliary cannulation time, total procedure time, use of pre-cut papillotomy, and therapeutic success of ERCP were compared between the groups as well.

RESULTS

Biliary cannulation was performed by standard technique in 210 patients with JPD (94.5 %). Cannulation was achieved by placement of a guidewire into the pancreatic duct in 6 (2.7 %) and use of two devices in one channel in 2 (0.9 %) patients. There was no significant difference between the total procedure time and therapeutic success of ERCP between the groups. Cannulation time was significantly longer in patients with JPD. Pre-cut papillotomy was performed less in patients with JPD.

CONCLUSION

Presence of JPD does not decrease the therapeutic success of ERCP. Placement of a guidewire in the pancreatic duct or use of two-devices-in-one-channel are practical, successful, safe, and preferred methods which can be used in patients with failed cannulation by standard technique.

A new approach to gastrointestinal fistula closure: endoloop and clips technique using double endoscope

Several endoscopic techniques have been described for closure of gastrointestinal fistulas. Herein, we describe a case of iatrogenic gastric fistula successfully treated with a new approach by simultaneous insertion of two endoscopes and using the endoloop and endoclips technique.

What to do if a transesophageal echocardiography probe buckled in esophagus?

A 65-year-old man was consulted because of buckling of transesophageal echocardiography (TEE) probe in the esophagus. A forward-viewing endoscope was inserted to the esophagus alongside the TEE probe. TEE probe was pushed to the stomach while the retroflexed tip portion was pushed by the endoscope in order to prevent retroflexion. The TEE probe was advanced into the stomach by this method where the buckled part was unfolded and then withdrawn. Cardiologists performing TEE and the referred gastroenterologists could perform such a method of solution in case of buckling of TEE probe in the esophagus.

Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

Background

Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis.

Methods

Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented.

Results

EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued.

Conclusions

The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.

Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is more complicated in patients with Billroth II gastroenterostomy (B II GE) especially in those associated with Braun anastomosis (BA). The aim of the present study was to review experience of ERCP in patients with B II GE.

METHODS

The records of patients with B II GE who had undergone an ERCP within the last 2.5 years were retrospectively evaluated.

RESULTS

Fifty-two patients with simple B II GE and seven with additional BA underwent ERCP within this period. The probability of common bile duct cannulation and success of endoscopic treatment was 43/52 (83%) and 2/7 (29%) in the respective groups. The reasons for failure were long afferent loop in patients with BA; for the nine patients with B II GE the reasons for failure were tumoral infiltration at the orifice of afferent loop in one patient, peripapillary tumoral invasion in two patients, failure of entrance to the afferent loop due to angulation in two patients, and long afferent loop in the remaining four patients. Overall, perforation developed in 10.2% (6/59 of the patients. Two of these patients died (2/59, 3.4%) and one (1/59, 1.7%) had concomitant pancreatitis.

CONCLUSIONS

Although ERCP is successful in a large proportion of patients with B II GE, it carries significant risks such as perforation. ERCP must be performed by experienced endoscopists at institutions that have suitable facilities to manage endoscopy-related complications.

An endoscopic finding in patients with primary sclerosing cholangitis: retraction of the main duodenal papilla into the duodenum wall

BACKGROUND

The diagnosis of primary sclerosing cholangitis (PSC) is reached by typical cholangiographic findings and liver biopsy. The characteristic cholangiographic abnormalities consist of multifocal strictures and dilatations in the intrahepatic and/or extrahepatic bile ducts. Patients may develop cirrhosis and portal hypertension. Endoscopy may reveal esophageal/gastric varices and portal hypertensive gastropathy.

OBJECTIVE

To define a novel endoscopic finding in patients with PSC.

DESIGN

Case series.

SETTING

Single tertiary referral center in Turkey.

PATIENTS

Ten patients with PSC, 16 with liver cirrhosis, and 10 with PSC-like cholangiogram.

INTERVENTIONS

Inspection of papilla with duodenoscope and ERCP.

MAIN OUTCOME MEASUREMENTS

Retraction of papilla into the duodenum wall.

RESULTS

Ten patients with PSC (8 male, 2 female, mean age 38 y) underwent ERCP at our institution. Retraction of papilla into the duodenum wall was observed in 7 patients (70%). The mean time elapsed between the retraction of the papilla and onset of PSC was 5.1 years (range 2-7 y). In patients with retraction of the papilla, both of the intrahepatic and extrahepatic bile ducts were involved; however, only the intrahepatic bile ducts were involved in patients with no retraction of papilla. Of 7 patients with retraction of papilla, 5 had a history of sphincterotomy procedure 5.4 years previously (range 5-6 y). Two patients had native papilla. None of the patients had end stage liver disease. Retraction of papilla was observed in none of the 16 patients with cirrhosis of the liver and in 10 with PSC-like cholangiogram.

LIMITATIONS

Only observational; absence of surgical and/or pathologic evidence.

CONCLUSIONS

Papilla may be embedded in the duodenum wall in some patients with PSC. Extrahepatic involvement seems to be necessary for the occurrence of this finding.

Secondary prophylaxis of esophageal variceal treatment: Endoscopic sclerotherapy, band ligation and combined therapy--long-term results

BACKGROUND/AIMS

To evaluate the long-term results of endoscopic sclerotherapy and endoscopic band ligation in secondary prophylaxis on variceal eradication and to evaluate the effectiveness of endoscopic sclerotherapy and endoscopic band ligation combination in resistant cases.

METHODS

The results of the patients who underwent endoscopic sclerotherapy (n=47 31M/16F, 49.9+/-16.1 years) and endoscopic band ligation (n=72 56M/16F, 46.6+/-14.1 years) were compared. The results of patients whose varices could not be eradicated who were treated with endoscopic band ligation and combined endoscopic sclerotherapy (combined group, n=62 49M/13F, 48.8+/-12.7 years) are also given. Patients were evaluated for portal hypertension etiology, Child score, fundal varices-portal hypertensive gastropathy presence according to first and last endoscopic findings, varices eradication, rebleeding, recurrence and complication rates.

RESULTS

181 patients were followed for 35.2+/- 25.6 (6-123) months. Varices eradication and recurrence rates were 93.6% and 44.7% for endoscopic sclerotherapy, and 90.3% and 47.2% for endoscopic band ligation (p>0.05). The number of sessions for eradication were 6.6+/-4.0 and 2.5+/-1.6 for endoscopic sclerotherapy and endoscopic band ligation groups, respectively (p<0.05). Rebleeding rates were 16.3% for endoscopic sclerotherapy and 6.1% for endoscopic band ligation (p>0.05). In the combined group, although the rebleeding rate was 34.4%, which was as expected significantly higher than that of endoscopic sclerotherapy and endoscopic band ligation, variceal eradication and the recurrence rates were 82.3% and 50.0%, similar to endoscopic sclerotherapy and endoscopic band ligation, and the number of sessions for eradication was 6.8+/-3.5.

CONCLUSIONS

Endoscopic band ligation is the most suitable method for varices eradication, but there is a group of patients resistant to endoscopic band ligation. In this patient group, the addition of endoscopic sclerotherapy to endoscopic band ligation was a suitable and effective technique in order to achieve variceal eradication.

Crohn's and Behçet's disease association presenting with superior vena cava thrombosis

A 21-year-old male patient with a 6-year history of Crohn's disease presented with shoulder pain and edema in the neck and bilateral supraclavicular fossa. Color Doppler ultrasonography and computed tomography scan revealed bilateral thrombosis of the external jugular veins, brachiocephalic veins, and superior vena cava. Other etiologies were appropriately ruled out and the thrombosis was initially attributed to Crohn's disease. In the follow-up, the patient developed recurrent, painful orogenital ulcers and acne vulgaris-like skin eruptions. HLA tissue typing was HLA B-51. The diagnosis of Crohn's disease associated with Behçet's disease was made. Although there are several case reports describing such an association, a Medline research revealed that this was the first presentation of such an association with thrombosis. Thrombosis in unusual sites may reflect the uncommon association of Crohn's disease with hypercoagulable conditions such as Behçet's disease.

Treatment of biliary leakages after cholecystectomy and importance of stricture development in the main bile duct injury

BACKGROUND/AIMS

Endoscopic treatment of biliary leakages after cholecystectomy, though widely accepted, has some restrictions. The efficacy and safety of endoscopic treatments in this patient group are evaluated in this study, and the problem of biliary stricture development in time after biliary ductal injuries is also emphasized.

METHODS

Seventy-four patients (20 male, 54 female, mean age 50.9+/-21 years) referred for ERCP between 1992-2002 were included in the study. Minor leakages (cystic duct leaks, accessory bile duct leaks) were managed by nasobiliary drainage +/- endoscopic sphincterotomy; major leakages were managed by nasobiliary drainage +/- endoscopic sphincterotomy +/- stenting.

RESULTS

Twenty-seven patients with cystic duct leaks and 6 patients with accessory bile duct leaks were successfully treated with nasobiliary drainage. Endoscopic treatment could not be performed on patients with total bile duct obstruction (7 patients) and aberrant bile duct injury (7 patients). All leakages from main bile ducts were closed (27 patients). Six of 27 patients had strictures at the beginning and they were treated by stenting. Twenty-one patients had no strictures at the beginning. Eight of 21 were treated by stenting and only 1 of them developed biliary stricture. Seven of 13 patients who had been treated by nasobiliary drainage developed biliary strictures. There were no mortalities due to procedure.

CONCLUSIONS

ERCP is an effective and safe method for diagnosis and management of bile leakages after cholecystectomy. Stricture development in the main bile duct leakages was an important complication.

Endoscopic treatment of primary sclerosing cholangitis

BACKGROUND/AIMS

Dominant stricture of an extrahepatic bile duct is responsible for symptoms and an exacerbation of cholestasis in 15-20% of patients with primary sclerosing cholangitis. The aim of this study was to evaluate the efficacy and safety of endoscopic treatment in this selected patient group.

METHODS

Retrospectively, we evaluated 16 patients who were treated endoscopically due to elevation of serum biochemical liver tests and symptoms which were attributable to dominant bile duct strictures during the period 1990 to 2003. Symptoms and biochemical liver tests were compared before and after treatment.

RESULTS

Sixteen patients underwent a total of 58 therapeutic endoscopic retrograde cholangiopancreatographies (ERCP). Sixteen endoscopic sphincterotomies, 15 balloon dilatations, 6 bougie dilatations, 3 stone/sludge extractions and 8 stentings were performed. Endoscopic therapy was technically successful in all patients (100%). Biochemical liver tests were significantly improved when compared with pretreatment values (p<0.001). Patients have been followed-up without stents except for the patients who had cholangiocarcinoma and cirrhosis at the beginning. Procedure-related early complications occurred in 8.6% of therapeutic endoscopic biliary procedures. There was no mortality due to endoscopic treatment. Two patients whose stents were changed every two to three months had cholangitis due to stenting during 13 stent periods. Four patients whose stents were changed in seven to 10 days developed suppurative cholangitis (total 6 stent periods).

CONCLUSIONS

Endoscopic therapy of symptomatic dominant strictures in primary sclerosing cholangitis is safe and effective. The cholangitis seen in long-term stenting seems to be solved by short-term stenting.

Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions

BACKGROUND/AIMS

The aim of this study was to evaluate the accuracy of endoscopic ultrasonography (EUS) and consistency of the EUS findings with histopathologic examination.

METHODS

EUS was performed in 90 patients with upper gastrointestinal tract submucosal tumors, followed in Turkiye Yuksek Ihtisas Hospital, Gastroenterology Clinic. Histopathological diagnosis and EUS findings of 25 of 90 patients were compared.

RESULTS

48.9% of the lesions were found to have arisen from muscularis propria, 33.3% from submucosa, 6.6% from mucosa and 10% from muscularis mucosae, and 1.2% from serosa of the 90 patients. In 25 patients histopathologic confirmation was done. 24% of 25 patients were leiomyoma, 20% polyp, 12% lipoma and the remainder were teratoma, carcinoid tumor, adenocarcinoma, polyp and leiomyosarcoma. EUS was successful in detecting all tumors. EUS diagnosis was consistent with histopathogical diagnosis in all patients with EUS findings as leiomyosarcoma (n=2) and polyp (n=6), in 46.2% of patients with EUS findings as leiomyoma, and in 50% of those with lipoma.

CONCLUSIONS

EUS is an accurate means of evaluating and diagnosing submuocal lesions of the gastrointestinal tract.

Hepatobiliary fascioliasis: clinical and radiologic features and endoscopic management

Fasciola hepatica is a zoonotic liver fluke that can cause disease in humans. Fascioliasis is an uncommon disease. We retrospectively analyzed 9 cases of fascioliasis and reviewed the relevant literature. A high index of suspicion and specific ultrasonographic findings are very helpful in the diagnosis of the disease. However, serological studies and endoscopic retrograde cholangiopancreatography confirm the diagnosis. The disease has 2 stages: hepatic stage and biliary stage. While several drugs are used during the hepatic stage, endoscopic retrograde cholangiopancreatography is particularly effective in the biliary stage.

Pattern of gastrointestinal and psychosomatic symptoms across the menstrual cycle in women with inflammatory bowel disease

BACKGROUND/AIMS

The purpose of this study was to determine the frequency of defecation, gastrointestinal (GI) and non-GI symptoms among women with ulcerative colitis (UC) (n=38) and Crohn's disease (CD) (n=21), and to compare the results with those from healthy women (n=38) across the menstrual cycle.

METHODS

Women were followed for three menstrual cycles with a symptom diary consisting of frequency of defecation, and GI and non-GI symptoms. One point was allowed for each symptom in the same phases of three cycles, and total scores for GI and non-GI symptoms were obtained.

RESULTS

Frequency of defecation was found to be higher during menstruation in controls and in remitting UC and CD. GI symptom scores were higher in all three phases in patients with CD. These decreased in the postmenstrual phase in controls, and in patients with UC and remitting CD. In all three cycles, non-GI symptom scores were higher in patients with CD. These symptoms decreased during the postmenstrual period in all three groups. The activation of UC and CD did not affect the non-GI symptom score in the same menstrual cycle. Patients on mesalamine had less GI and non-GI complaints than those on sulfasalazine in all phases. There was no correlation between GI and non-GI symptom scores during all menstrual phases.

CONCLUSION

Cyclic pattern present in healthy women persisted in patients with UC and CD. Disease activity and the drug used may modify the severity of the symptoms.

The course of colonic disease in ulcerative colitis patients with primary sclerosing cholangitis

BACKGROUND/AIMS

Although there are many studies reporting that colonic dysplasia and cancer develop more frequently in ulcerative colitis patients with ulcerative colitis with primary sclerosing cholangitis, there are insufficient data on the course of the colonic disease. In this study, the course of the colonic disease in ulcerative colitis patients with primary sclerosing cholangitis was investigated.

METHODS

Data obtained from ten patients with total colitis and accompanying primary sclerosing cholangitis (three females, seven males, mean age: 44.5+/-10.0 years) were compared with data obtained from 64 patients with pancolitis but without primary sclerosing cholangitis (27 females, 37 males; mean age: 42.3+/-17.1 years).

RESULTS

The follow-up period was 6.4+/-6.2 years in patients without primary sclerosing cholangitis, 12.7+/-6.2 years in total and 5.1+/-4.0 years (after development of the condition) in patients with primary sclerosing cholangitis (p<0.01). The number of disease attacks (3.7 attacks/yr vs. 0.5 attacks/yr), duration of the active disease (12.9+/-8.0 months vs. 0,3+/-1.0 months), the number of patients in whom corticosteroids were used (47 patients vs. one patient), the number of patients hospitalized (50 patients vs. one patient) and duration of hospitalization (1.2+/-0.8 months vs. 0,1+/-03 months) were higher in patients with than without primary sclerosing cholangitis (after development of the condition) (p<0.001). There was no significant difference in data obtained from patients with and without primary sclerosing cholangitis before development of the disease.

CONCLUSIONS

Colonic disease subsides when primary sclerosing cholangitis develops. The higher frequency of colonic dysplasia and cancer seen in patients with primary sclerosing cholangitis can be explained by the fact that most of them have a longer duration of total colitis and fewer need total colectomy. Even though it does not seem to cause clinical problems, the colonic disease should not be ignored in these patients.