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Background: The Coronavirus-2019 disease (COVID-19) pandemic has markedly restricted endoscopic and clinical activities in gastroenterology (GI), with a negative impact on trainee education. We aimed to inve stigate how and to what extent has GI trainees in Turkey are affected by the current pandemic in terms of general, psychological, and educational status., Methods: We conducted a web-based survey sent electronically to 103 official GI trainees in Turkey from 37 centers. The 32-item survey included questions to capture demographic (5-questions), endoscopic (7-questions), personal protective equipment (PPE) (3-questions), psychological and general well-being (11-questions), and educational (6-questions) data., Results: Ninety-six (93.2%) trainees completed the survey, of which 56.3% (n = 54) reported a decrease in independently performed endoscopic procedures. Due to pandemic, 91.7% of standard diagnostic endoscopic procedures, 57.2% of standard therapeutic procedures, and 67.7% of advanced endoscopic procedures were decreased. Out of 96 respondents, we detected signs of anxiety in 88.5%, exposure concern in 92.7%, concerns for prolongation of training period in 49%, loss of concentration and interest in 47.9%, and burnout syndrome in 63.5%. Female gender (odds-ratio: 3.856, 95% confidence interval: 1.221-12.174, P = .021) was the only independently associated factor with pandemic-related anxiety., Conclusions: COVID-19 pandemic has led to high amounts of anxiety and non-negligible rates of burnout syndrome among GI trainees, with a significant reduction in endoscopic activities. More effort and novel strategies are required to deliver sufficient competence and general-psychological well-being to GI trainees.

Background: Large gastric phytobezoars are generally resistant to standard chemical or endoscopic treatments. We presented our experience of an alternative endoscopic method using a hand-made tool called a "hand-made bezoaratome" for the treatment of large gastric phytobezoars., Methods: Patients who consulted or who were diagnosed with gastric bezoars at an education and research hospital between January 2015 and December 2018 were prospectively included in the study. Patients with phytobezoars of 50 mm and larger were included in the study. Patients with trichobezoars, lactobezoars, pharmacobezoars, under 18 years of age, and pregnant women were excluded. A 0.25 mm diameter guidewire and a mechanical lithotripter sheath were used to prepare the "hand-made bezoaratome." After the first procedure, patients were advised to consume 2500 mL of Coca Cola® or the same amount of pineapple juice per day, until the next procedure. Endoscopic procedures were performed at 5-day intervals until complete reabsorption of the bezoar was achieved. Patients were followed up for 6 weeks., Results: The study group included 37 (21 males, mean age: 57.6 ± 12.5 years) patients. The median size of the phytobezoars was 71 mm (50-90). The median endoscopic procedure time was 853 s (380-1940 s). The success rate for endoscopic fragmentation was found to be 100%. No major complications occurred during the endoscopic procedures, but 1 patient (2.7%) required surgery for ileus due to an obstruction at the distal part of the jejunum, 61 h after the second endoscopic session. The overall success rate of the endoscopic treatment was 97.3%., Conclusion: Using a "hand-made bezoaratome" is effective and reliable for the endoscopic treatment of large gastric bezoars.

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.

Background/aims: Several studies recommend prompt laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. However, histopathological alterations in the gallbladder during this time interval and the role played by ERCP in causing these changes have not been sufficiently elucidated. To compare early period LCs with delayed LCs following common bile duct stone extraction via ERCP with regard to operation time, hospitalization period, conversion to open cholecystectomy rate, morbidity, mortality, and histopathological alterations in the gallbladder wall., Materials and Methods: A total of 85 patients were retrospectively divided into three groups: early period LC group (48-72 h; n=30), moderate period LC group (72 h-6 weeks; n=25), and delayed period LC group (6-8 weeks; n=30)., Results: The operation time was significantly shorter, and the total number of complication rates and hospital readmission was significantly less frequent in the early period LC group (p<0.05). Ultrasound showed a significantly thicker gallbladder wall (>3 mm) in the moderate and late period LC groups than in the early period LC group (p<0.001). Culture growth was significantly higher, and fibrosis/collagen deposition in the gallbladder wall with injury to the mucosal epithelium was significantly more frequently detected by histopathological examination in the moderate and late period LC groups than in the early period LC group (p<0.05)., Conclusion: Early period LC following stone extraction by ERCP is associated with shorter operation time, fewer fibrotic changes in the gallbladder, and lower risk for the development of complications. Therefore, LC can be performed safely in the early period after ERCP.

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.

Background/aims: The American Society for Gastrointestinal Endoscopy (ASGE) endoscopic retrograde cholangiopancreatography (ERCP) grading system was proposed but has not been fully evaluated with prospective clinical studies. In this study, we aimed to evaluate the effectiveness of the ERCP difficulty grading system for predicting success and adverse event rates related to the procedure., Materials and Methods: A total of 1057 ERCP procedures performed on 752 patients were included in the present study. The complexity grades of the procedures were recorded according to the ASGE grading system. Specific complications of ERCP (pancreatitis, cholangitis, bleeding, and perforation) were also defined and graded., Results: The procedure difficulty was determined as 1st degree in 153 patients (14.4%), 2nd degree in 498 patients (47.1%), 3rd degree in 271 (25.6%), and 4th degree in 135 patients (12.7%). The success rate for the entire procedures was 88.4%. The success rate for 1st degree procedures was 99.3%, 97.2% for 2nd degree procedures, 86.7% for 3rd degree procedures, and 46.7% for 4th degree procedures (p<0.005). When the difficulty of the procedures increased from 1 to 4, the adverse event rates increased from 1.3% to 10.4%., Conclusion: The findings support the evidence that the difficulty degrees of ERCP procedures can help predict the success and complication rates of the procedure. Because of the increased rates of failure and complications in more difficult cases, the procedures should be performed by experienced endoscopists in advanced centers.

Background/aims: The aim of this study was to compare the utility of the revised Mayo risk model (rMRM) and Child-Pugh scores (CPSs) for predicting the prognosis of disease in patients with primary sclerosing cholangitis (PSC)., Materials and Methods: Patients were divided into 2 groups: Group I (37 patients; alive and not requiring liver transplantation) and Group II (8 patients; deceased or requiring liver transplantation). rMRM suggests the possible survival percentage over a 4-year period. Thus, rMRM scores and CPSs on the first visit were calculated from the data at the time of diagnosis for patients diagnosed with PSC <4 years ago. rMRM scores and CPSs of patients with >4 years of follow-up were calculated using data from the visit 4 years prior to their last follow-up., Results: Bivariate analyses showed that need for liver transplantation/mortality was correlated with either first visit CPS (r=0.481, p=0.001) or rMRM (r=0.452, p=0.002). Analysis of the area under the curve showed that both models performed similarly in terms of predicting the need for liver transplantation/mortality (rMRM: 0.780; CPS: 0.762; p=0.8). There was a significant difference in Kaplan-Meier survival rates between Group I and Group II for both risk models (rMRM: p<0.001; CPS: p<0.001) when the decisive event was death or need for liver transplantation., Conclusion: Both rMRM and CPSs are useful in risk assessment of patients with PSC. The ability to predict prognosis is similar for both risk models.

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.

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.

Background/aims: Infection in the bile tract is a major cause of bacteremia and is related to high morbidity and mortality. We examined the changes in bacteria types and antibiotic susceptibility in bile cultures and simultaneous blood cultures taken from patients who applied for endoscopic retrograde cholangio pancreatography (ERCP)/percutaneous transhepatic cholangiography (PTC) for different bile duct diseases in recent years., Materials and Methods: Bacteria types that reproduce in bile and blood cultures from patients who applied for ERCP/PTC between the years of 2007 and 2012 in our clinic were examined. All patients were evaluated together, and in addition, the periods between 2007 and 2009 (Group 1) and between 2010 and 2012 (Group 2) were compared., Results: In total, 550 patients applied to this study. There were 266 patients in Group 1 and 284 in Group 2. Reproduction occurred in 77.6% of bile cultures. In the order of frequency, these cultures consisted of Escherichia coli (32.8%), Enterococcus spp. (26.2%), and Pseudomonas aeruginosa (11%). Enterococcus spp. were determined to be higher in Group 2 than Group 1 (p<0.016). Resistance to quinolones was found in 74.1% of patients, to ampicillin in 73.2%, and to cephalosporins in an average of 61%. Vancomycin was the most susceptible antibiotic (93.4%) to gram-positives. Resistance to piperacillin-tazobactam and amikacin was higher in Group 2 than Group 1 (p=0.001 and p=0.003, respectively)., Conclusion: The most frequently reproducing bacteria in the bile cultures evaluated in our hospital were Escherichia coli and Enterococcus spp. Although it was thought that the antibiotics given empirically were effective against these bacteria, there was resistancerate of 75% in our study. We determined that the first- and second-step treatment protocols must be updated.

Background/aims: Endoscopic retrograde cholangiopancreatography has become the standard treatment for common bile duct stones worldwide. 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 naive papilla (n=1850) who underwent endoscopic retrograde cholangiopancreatography during a study period of 2 years were prospectively evaluated. Among them, 757 patients with common bile duct stones were included in the study. Following successful cannulation, the patients who needed either more than one episode for stone extraction or mechanical lithotripsy, extracorporeal shock wave lithotripsy or 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 in 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. 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 in multivariate analysis., Conclusion: Endoscopic retrograde cholangiopancreatography is a very effective method for the treatment of common bile duct stones. Besides strictures 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.

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.

Background/aims: Early repeat endoscopic retrograde cholangiopancreatography may be required due to various conditions in patients who underwent planned endoscopic retrograde cholangiopancreatography. We aimed to assess the factors leading to early repeat endoscopic retrograde cholangiopancreatography and to determine the patients who need closer follow-up., Materials and Methods: A total of 691 patients with a mean age of 60.3±16.4 years who had naive papilla on endoscopic retrograde cholangiopancreatography were involved in the study. The patients who required repeat endoscopic retrograde cholangiopancreatography were identified. Presentations, predictive factors, treatment modalities, and outcomes of the patients were investigated., Results: Early repeat endoscopic retrograde cholangiopancreatography was needed in 19 (2.7%) patients. The most common presentation was cholangitis in 10 (52.6%) and unresolved jaundice in 4 (21.1%). Multivariate analysis identified biliary stricture (p=0.024), stricture at the hilus (p=0.005) and unilateral drainage in the presence of hilar stricture (p=0.017) as the independent risk factors for early repeat endoscopic retrograde cholangiopancreatography. Stent migration or dysfunction was the most common underlying cause. Therapeutic interventions were nasobiliary drainage in 13, stent exchange in 4 and stone removal in 2. Additionally, percutaneous drainage in 4 patients, drainage of abscess in 2 patients and percutaneous drainage of gallbladder in 1 patient were performed. Three patients died due to their underlying illness., Conclusions: Unilateral stenting especially in hilar strictures is a predictive factor for early repeat endoscopic retrograde cholangiopancreatography with high mortality. These patients should be under close follow-up.

A 45-year-old woman with the diagnosis of primary sclerosing cholangitis and ulcerative colitis admitted with the complaints of pruritus and jaundice. Endoscopic retrograde cholangiography revealed entirely narrow, irregular common bile duct and common hepatic duct and unusual cystic dilations in the common hepatic duct and left hepatic duct. Balloon dilation of the common bile duct was performed, and a 10 F double pigtail stent was inserted into the cyst. Three months after the endoscopic retrograde cholangiography, cystic dilatations had completely resolved. Primary sclerosing cholangitis may present with cystic dilatations upto a level that it may resemble Caroli disease.

Background/aims: It is known that ulcerative proctitis might show extension, but in practice, patients with proctitis are not considered as important with regard to regular follow-up and treatment. The aim of this study was to evaluate the extension of ulcerative colitis cases limited to the rectum and compare them with the patients with rectosigmoid and left colonic ulcerative colitis for their features, risk factors influencing the extension and natural course of the disease., Methods: The study involved 193 (62 rectal, 49 rectosigmoid and 82 left-sided) ulcerative colitis patients., Results: Fourteen percent of the patients showed extension to at least one proximal segment in 3.9±2.9 (range: 0.8-12) years. The extension was found as 16.1% in proctitis, 12.2% in rectosigmoiditis and 13.4% in left-sided colitis groups. Extension was found 2.79-fold (95% confidence interval: 1.1-7.1) higher in patients with chronic active disease. Further, the patients with amoebic attacks, those under steroid treatment and those without treatment showed higher risk for extension., Conclusions: Patients with proctitis, like the patients presenting with more extensive colitis, should be offered regular treatment and follow-up.

Background/aims: The aim of this study was to evaluate the efficacy, effects on survival and complications of self-expandable metal stent applications in patients with malignant gastroduodenal obstruction., Methods: Twenty-five patients undergoing metal stent insertion due to malignant gastroduodenal obstruction between February 2005 and July 2009 were included in the present study. In all patients, self-expandable metal stent 22 mm in diameter was inserted under scopic guidance. The patients were evaluated regarding age, gender, etiology, efficacy of stent insertion, complications, and duration of patency of the stent., Results: Of the 25 patients included in the study, 15 were female and 10 were male. Their mean age was 65.9 years (57-81 years). The most common etiological causes were duodenal tumor (n=10, 40%) and pancreatic tumor (n=8, 32%). Duodenal stent was inserted successfully in all patients. In 4 patients, percutaneous biliary metal stent was inserted at the same time due to concomitant obstructive jaundice. No mortality occurred during the procedure. A second stent was inserted in 4 patients due to stent migration. The patients were followed for a mean of 92 days (7 to 258 days) after the procedure. The stents remained clinically patent in all patients during the follow-up period until death., Conclusions: Insertion of duodenal metal stent is an effective and safe therapeutic approach in the palliative treatment of malignant gastric outlet obstruction.

Background/aims: Macroscopic appearance of the gallbladder is an important factor in laparoscopic cholecystectomy. The aim of this study was to evaluate surgical outcomes in patients with scleroatrophic gallbladders who underwent laparoscopic cholecystectomy., Methods: From 2002-2007, 295 patients were found to have a scleroatrophic gallbladder during laparoscopic cholecystectomy. The investigated variables included gender, age, body mass index, preoperative ultrasound evidence of gallbladder wall thickening, number of gallstones, diameter of common bile duct, preoperative endoscopic retrograde cholangiopancreatography, surgeon's experience, gallbladder adhesion score, drain use, conversion rate, operative time, intraoperative and postoperative complications, mortality, and length of hospital stay., Results: Most of the patients were male (56.3%). Overall mean age was 55.50±13.75 years. Mean body mass index was 27.91±4.43 kg/m2. Based on preoperative ultrasound findings, thickened gallbladder wall was present in 30.8% of patients, dilated common bile duct in 30.2% and multiple gallstones in 83.1%. Preoperative endoscopic retrograde cholangiopancreatography was performed in 32.5% of patients. High-grade adhesions (≥III) were encountered in 68.1% of patients. The conversion rate was 23.1%. The overall intraoperative complication rate was 31.5%. Drains were used in 63.7% of patients. Mean operative time was 65.2±32.6 minutes. The rate of postoperative complications was 9.5%. Median hospital stay was 1 day (range: 1-31 days). Mortality occurred in 3 patients (1.0%)., Conclusions: This study demonstrates that scleroatrophic gallbladders present more difficulties during laparoscopic cholecystectomy and are associated with a higher conversion rate. Therefore, it is highly important that patients whose preoperative imaging studies suggest a scleroatrophic gallbladder be referred to an experienced center for hepato-biliary surgery.

Background/aims: Macroscopic appearance of the gallbladder is an important factor in laparoscopic cholecystectomy. The aim of this study was to evaluate surgical outcomes in patients with scleroatrophic gallbladders who underwent laparoscopic cholecystectomy., Methods: From 2002-2007, 295 patients were found to have a scleroatrophic gallbladder during laparoscopic cholecystectomy. Investigated variables included gender, age, body mass index, preoperative ultrasound evidence of gallbladder wall thickening, number of gallstones, diameter of common bile duct, preoperative endoscopic retrograde cholangiopancreatography, surgeon's experience, gallbladder adhesion score, drain use, conversion rate, operative time, intraoperative and postoperative complications, mortality, and length of hospital stay., Results: Most of the patients were male (56.3%). Overall mean age was 55.50 ± 13.75 years. Mean body mass index was 27.91 ± 4.43 kg/m2. Based on preoperative ultrasound findings, thickened gallbladder wall was present in 30.8% of patients, dilated common bile duct in 30.2%, and multiple gallstones in 83.1%. Preoperative endoscopic retrograde cholangiopancreatography was performed in 32.5% of patients. High-grade adhesions (≥ III) were encountered in 68.1% of patients. The conversion rate was 23.1%. The overall intraoperative complication rate was 31.5%. Drains were used in 63.7% of patients. Mean operative time was 65.2 ± 32.6 minutes. The rate of postoperative complications was 9.5%. Median hospital stay was 1 day (range: 1-31 days). Mortality occurred in three patients (1.0%)., Conclusions: This study demonstrates that scleroatrophic gallbladders present more difficulties for laparoscopic cholecystectomy and are associated with a higher conversion rate. Therefore, it is highly important that patients whose preoperative imaging studies suggest a scleroatrophic gallbladder be referred to an experienced center for hepato-biliary surgery.

Atypical presentations of tuberculosis might cause difficulties in diagnosis, especially in developing countries. Primary hepatobiliary tuberculosis is a rare condition and the diagnosis of this condition necessitates a high index of suspicion. In this report, we present a case with obstructive jaundice, dilated intrahepatic bile ducts and lymphadenopathies in the porta hepatis. Endoscopic retrograde cholangiopancreaticography showed irregularities, strictures and dilatations both in the intra- and extrahepatic bile ducts resembling sclerosing cholangitis. The liver biopsy showed caseous granulomatous hepatitis and Langhans giant cells compatible with tuberculosis, and a lymph node biopsy obtained from the left cervical region demonstrated caseating confluent granulomas with abundant acid-fast bacilli. The present case shows that primary hepatobiliary tuberculosis may mimic primary sclerosing cholangitis and should be considered in the differential diagnosis of patients with sclerosing cholangitis-like changes on endoscopic retrograde cholangiopancreaticography.

Bile duct injury is a serious complication of laparoscopic cholecystectomy. We report a case of spontaneous hepaticoduodenal fistula following bile duct injury. Initially, Roux-en-Y hepaticojejunostomy had been planned for the patient, but as the patient did not show any symptoms or findings of biliary obstruction, we preferred a non-operative management. The fistula allowed adequate biliary drainage, and the patient has been followed regularly by the outpatient clinic with good clinical results for approximately five years.

Background/aims: Cholangitis is one of the most morbid complications of endoscopic biliary drainage and among the commonest causes of endoscopic retrograde cholangiopancreatography-related death. The aim of this prospective study was to investigate the risk factors for the development of cholangitis after endoscopic retrograde cholangiopancreatography in a tertiary referral center., Methods: The study involved 503 consecutive patients with naive papilla who underwent endoscopic retrograde cholangiopancreatography. We included the cholangitis occurring within 72 hours after endoscopic retrograde cholangiopancreatography for all patients undergoing the procedure. All patients received antibiotic prophylaxis before endoscopic retrograde cholangiopancreatography. Factors including age, gender, presentation, nature of the papilla, therapeutic procedures, and the diagnosis were analyzed to predict post-endoscopic retrograde cholangiopancreatography cholangitis., Results: Median age was 61.2 +/- 14.8 years and there were 274 (54.5%) women and 229 (45.5%) men. Seventeen (3.3%) patients (9 F, 8 M) developed cholangitis after endoscopic retrograde cholangiopancreatography. The risk of post-endoscopic retrograde cholangiopancreatography cholangitis development was most probable in patients with hilar cholangiocarcinoma. Post-endoscopic retrograde cholangiopancreatography cholangitis risk was significantly higher in patients with biliary dilatation and biliary stent insertion, and without periampullary diverticula (odds ratio, OR: 4.8, 4.4, 1.2, respectively). Total procedure duration was significantly prolonged and common bile duct diameter was significantly increased in patients who had cholangitis. Five patients (3 F, 2 M; 0.9%) died because of post-endoscopic retrograde cholangiopancreatography complicated sepsis., Conclusions: Increased common bile duct diameter, biliary dilatation, biliary stent insertion, prolonged total procedure time, and hilar cholangiocarcinoma have higher post-endoscopic retrograde cholangiopancreatography cholangitis risk. Moreover, the presence of periampullary diverticula was found to decrease cholangitis risk.

Inferior mesenteric arteriovenous fistula is rare and may be congenital or acquired. Two serious manifestations may occur in the course of the disease: portal hypertension and bowel ischemia. The diagnosis is generally established by conventional angiography. In this report, we present a case with multiple inferior mesenteric arteriovenous fistulas, considered idiopathic due to no known cause related to the etiology, and associated ischemic colitis, which were clearly demonstrated by multidetector computed tomographic angiography. We also review the available literature.

Vascular manifestations of Behçet's disease include venous and arterial occlusions, arterial aneurysm and pseudo-aneurysm formation. The main problem of the surgical treatment of vascular lesions in Behçet's disease is the high incidence of complications such as recurrent aneurysms, thrombosis and fistulization to the adjacent organs. Here we present a case of Behçet's disease with multiple complications after aortic reconstructive surgery, including perigraft infection, abscess distal to the graft, occlusion of arteries of the lower extremities, aortoenteric fistula and distal anastomotic site aneurysm rupture.

Background/aims: Inappropriate down regulation of an activated immune system is considered as the main pathogenetic mechanism in inflammatory bowel disease. Migration of circulating cells to a diseased intestine is considered as an important factor in the pathogenesis of inflammatory bowel disease. We aimed to evaluate some features of circulating immune cells in inflammatory bowel disease., Methods: Twenty-two control, 29 Crohn's disease and 17 ulcerative colitis patients were studied. CD2, CD3, CD4, CD8, CD11b, CD11c, CD25, CD45RA, CD45RO, CD54 and HLA DR on the surface of peripheral blood lymphocytes and CD11b, CD11c, CD45RA and CD45RO on the phagocytes were researched with two-color immunofluorescence flow cytometry., Results: The percentages of CD2+ and CD4+ lymphocytes were found significantly reduced in ulcerative colitis. CD3+ and CD8+ lymphocytes in inflammatory bowel disease were higher than in controls. CD45RA+ lymphocytes were found significantly decreased in ulcerative colitis and active Crohn's disease. CD45RO+ lymphocytes and CD45RO+, CD11b+ and CD11c+ phagocytes were significantly increased in Crohn's disease., Conclusions: We demonstrated that there were significant differences between ulcerative colitis and Crohn's disease in the expression of some important surface markers on the peripheral blood immune cells. It seems that circulating CD11b-CD11c and CD45RA-CD45RO expressing phagocytes are important in inflammatory bowel disease and may be useful in distinguishing Crohn's disease from ulcerative colitis. These findings may give us some clues about the immunopathogenesis of inflammatory bowel disease.

Background/aims: The aim of this study was to report our experience of hepatolithiasis, diagnosed in 55 patients between June 1995 and March 2003., Methods: Fifty-five patients who underwent endoscopic retrograde cholangiopancreatography for hepatolithiasis between June 1995 and March 2003 at our institution were evaluated. Diagnosis of hepatolithiasis was based on cholangiography, ultrasonography and computed tomography. Patients with hepatolithiasis were classified according to Tsunoda classification., Results: Fifty-five patients with hepatolithiasis (22 female, 33 male; mean age: 48.2 +/-14.9, range: 22-83) were included in this study. The major causes of hepatolithiasis were previous bilio-digestive surgery and Caroli disease, with rates of 49% and 14.5%, respectively. While 37 of 55 patients (67.3%) presented with only intrahepatic lithiasis, 18 patients (32.7%) had intrahepatic lithiasis associated with common bile duct (16/18, 29%) or gallbladder (2/18, 3.6%) stones. According to Tsunoda classification, 4 patients were classified as type I, 32 type II, 9 type III and 10 type IV. Patients with types I and II had significantly better stone clearance rates in comparison to those with types III and IV (p<0.05). Complete eradication of stones in the patients with proximal strictures was significantly lower than in the patients with distal strictures (p<0.01). While complete clearance of stones was achieved in 22 cases (40%), incomplete clearance was achieved in 17 cases (30.9%) with endoscopic retrograde cholangiopancreatography . Mean number of endoscopic retrograde cholangiopancreatography procedures for clearance of stones was 4 (ranges: 1-9)., Conclusion: The etiology of hepatolithiasis in our patients is similar to that observed in Western populations and endoscopic approach appears to be an effective alternative to surgery.

Background/aim: Biliary stents have been used for benign or malignant biliary strictures, preoperative biliary drainage, resolution of biliary or pancreatic leaks, and dissolution treatment of non-extractable bile duct stones since 1979, and should be replaced at 3-6 month intervals. The aim of this cross-sectional pioneer study was to identify the microorganisms in occluded bile duct stents and to determine incidence and diagnosis of multidrug resistance of the isolated microorganisms in stents and in blood cultures., Methods: Fifty-one patients (14F, 37M, mean age: 58.2+/-11.6 yr) with cholangitis due to occluded stents were studied consecutively and prospectively after stent replacement was done. Independent variables were age, gender, underlying disease, duration of disease, size, length and period of stents, and blood biochemistry. Dependent variables were microorganisms isolated from the stent content and blood of the patients and the results of antibiogram tests., Results: Primary disease was malignant in 25 (49.0%), stent size was 7F in 30 (58.8%), and stent length was 11 cm in 11 (21.6%) and 15 cm in 12 (23.5%) of the patients. The mean period after the 1st stent application was 207.0+/-111.3 days and the last stent duration was 111.0+/-64.0 days. Isolated microorganisms from stents and blood, respectively, were Escherichia coli (E. coli) (43.4%, 20.8%), Klebsiella spp. (17.1%, 17.0%), Pseudomonas aeruginosa (P. aeruginosa) (13.2%, 18.9%) and Enterococcus spp. (10.5%, 17.0%). Isolated microorganisms showed multidrug resistance at high percentages (81.6% for stent, 81.1% for blood). ALT, AST, ALP, and direct bilirubin levels showed statistically significant differences between the benign and malignant groups., Conclusion: All bile duct stents are contaminated by microorganisms, of which a high majority has multidrug resistance, and they frequently cause biliary sepsis. Biliary sepsis can be prevented by changing the stents periodically and by using proper antibiotic prophylaxis.

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.

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.

Background/aims: Perinuclear antineutrophil cytoplasmic autoantibody is a marker for ulcerative colitis, and anti-Saccharomyces cerevisiae antibody is known to be associated with Crohn's disease. The purpose of this study was to search the value of detecting perinuclear antineutrophil cytoplasmic autoantibody and anti-Saccharomyces cerevisiae antibody for the diagnosis of Turkish inflammatory bowel disease patients., Methods: Serum samples were obtained from 80 patients with ulcerative colitis, 61 patients with Crohn's disease and 40 healthy controls. Determination of both anti-Saccharomyces cerevisiae antibody and antineutrophil cytoplasmic autoantibody was performed with the standardized enzyme-linked immunosorbent assay., Results: In cases with ulcerative colitis, 65% tested seropositive for antineutrophil cytoplasmic autoantibody, whereas the controls showed 2.5% positivity. In cases with Crohn's disease, 63.9% tested seropositive for anti-Saccharomyces cerevisiae antibody, whereas the controls showed 2.5% seropositivity. The combination of a positive anti-Saccharomyces cerevisiae antibody test and a negative antineutrophil cytoplasmic autoantibody yielded a sensitivity and specificity of 32.0% and 97.5%, respectively. The combination of a positive perinuclear antineutrophil cytoplasmic autoantibody and a negative anti-Saccharomyces cerevisiae antibody test yielded a sensitivity and specificity of 44.2% and 97.5%, respectively., Conclusions: Both serologic tests may aid in the differential diagnosis of inflammatory bowel disease.

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.

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.

Background/aims: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation., Methods: Twenty-one liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. These patients received regular follow-up and detailed clinical assessment of at least 24 months., Results: Twenty-one eligible patients were followed up for a mean of 44.45 months (range 33.5-64 months). The mean number of sessions required to obtain eradication was 3.57+/-1.99 (range 1-8). Esophageal varices could be obliterated within 11.57+/-6.8 weeks (range 3-30). The percentage of variceal recurrence during follow-up was 57.14% (12/21) after endoscopic variceal ligation. Recurrence were observed in a mean of 34 months (median 29 months). Rebleeding from esophageal varices appeared in four patients (19.04%). The appearance rates of portal hypertensive gastropathy and fundal gastric varices after varice obliteration were found to be 45.45% (5/11) and 25% (3/12), respectively., Conclusions: Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.

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.

Background/aims: The value of serum tumor markers carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) in the differential diagnosis of obstructive biliary disease is dubious. We aimed to define their usefulness prospectively., Methods: Thirty-seven consecutive patients (12 female, 25 male, median age: 54, range: 19-83 years) who were referred for endoscopic retrograde cholanugiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) examination for obstructive jaundice were included (all with dilatation of biliary tree in ultrasonography or computerised tomography). Bile was obtained through the nasobiliary or external drainage catheter, placed with ERCP or PTC, respectively. Serum samples were taken from all patients at the time of acquisition of bile. Serum and bile samples were stored at -50 oC until they were tested. CA19-9 and CEA levels were measured with chemiluminescent enzyme immunoassay methods in serum and bile samples by using immulite GI-MA and CEA commercial kits, respectively (DPC(r), Los Angeles)., Results: In 22 patients with malignant disease, serum CEA levels were 38.6+/-115.8 ng/ml and CA19-9 were 386.9+/-409.7 U/ml, while in 15 patients with benign disease the serum CEA levels were 1.8+/-1.6 ng/ml and CA19-9 were 128.9+/-302.2 U/ml. The difference for both values was significant (p<0.05). In malignant disease bile CEA and CA19-9 levels were 160.8+/-457.8 ng/ml, 14000.9+/-19798 U/ml respectively, while in benign disease the corresponding levels were 21.08+/-48.6 ng/ml for CEA and 14818.9+/-24665.7 U/ml for CA19-9. The differences were not significant in this case (p>0.05)., Conclusion: It was concluded that serum CA19-9 levels are increased both in malignant and benign obstructive biliary diseases, albeit more significantly in the former. However, increase in serum CEA is mostly restricted to malignant diseases. Measurement of these markers in bile is of no value.

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.