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Fasciola hepatica is a zoonotic liver fluke that can cause disease in humans. F. hepatica is known to cause bile duct inflammation and biliary obstruction, but is rarely reported as responsible for producing acute pancreatitis. We report two patients complaining of acute pancreatitis. Endoscopic retrograde cholangiopancreatography showed distinct features, and sphincterotomy allowed extraction of multiple parasites. A high index of suspicion, specific ultrasonographic findings and eosinophilia are very helpful in the diagnosis of the disease.

Ectopic opening of the common bile duct into the stomach is an extremely rare congenital anomaly of the biliary system. Thus far, only three similar cases have been reported in the literature, and none of them had accompanying gastric cancer. In this report, we present a case with ectopic opening of the common bile duct into the stomach, which is an extremely rare anomaly, associated with gastric cancer, and we discuss the possible relation between the direct flow of bile into the stomach through the ectopic bile duct and the development of gastric cancer.

Background/aims: Fascioliasis is an important zoonotic disease caused by Fasciola hepatica. This zoonosis may cause serious morbidity and a considerable financial burden. Knowledge about Fasciola hepatica and interest in this parasite have increased in Turkey recently. However, there have been few studies on the real prevalence of this condition in the country. Therefore, we aimed to determine the prevalence of fascioliasis and the role of family history of the condition in the transmission of the parasite in the province of Mersin., Methods: Taking account of their populations, 729 people without a family history of fascioliasis and 155 people with a family history of fascioliasis from the city of Mersin and randomly selected three towns were included into the study to obtain a sample that well represented the population of the province of Mersin. A questionnaire composed of items about consumption of green leafy vegetables, stock-breeding and clinical symptoms of the disease was used to collect data. Excretory/ secretory (ES)-ELISA was used to detect IgG antibodies to Fasciola hepatica. People seropositive for Fasciola hepatica underwent abdominal ultrasonography, physical examination, biochemistry, and stool tests for the detection of Fasciola hepatica eggs., Results: A total of 0.79% of the participants were seropositive for Fasciola hepatica. One point ninety-three percent of the individuals with a family history of fascioliasis and 0.55% of the individuals without a family history of fascioliasis were seropositive for Fasciola hepatica. Out of 7 individuals found to be seropositive for Fasciola hepatica, 5 were female, 2 were male, and 4 had a family history of fascioliasis. Five and 4 patients, respectively, had a history of consuming green leafy vegetables and 4 had a history of stock-breeding. The clinical evaluation revealed that 4 patients had at least one sign of fascioliasis. Three patients had signs of fascioliasis on ultrasonography and 1 had Fasciola hepatica egg in stool examination. There was no significant difference in seropositivity for Fasciola hepatica between the individuals with and without a family history of fascioliasis (x2: 0.077, p>0.05)., Conclusions: The prevalence of fascioliasis was hypoendemic in the province of Mersin. There were no significant differences in the Fasciola hepatica prevalence between the groups with and without family history of fascioliasis. However, studies with larger sample sizes may reveal a difference.

Behçet's disease, as initially described, is a triad of recurrent oral and genital ulcers and relapsing uveitis. Classified as a systemic vasculitis, it can involve both the arteries and veins of almost any organ. Intestinal Behçet's disease is characterized by deep ulcers, most commonly located in the ileoceal region, with tendency to bleeding and perforation at multiple sites. Here, we report a case of Behçet's disease presenting with lower gastrointestinal bleeding, mesenteric arterial thrombosis and duodenal perforation.

Background/aims: Successful colonoscopy depends on the insertion of the instrument to the cecum, a detailed examination, and minimal discomfort to the patient during the procedure. The aim of this study was to determine the effects of alverine citrate plus simethicone on the cecal intubation time, colonic spasm and bowel cleanliness., Methods: A prospective, randomized, controlled trial in a consecutive series of patients was conducted to compare alverine citrate as an antispasmodic agent for relaxation of spasm with elective colonoscopy. The drug used consisted of 60 mg alverine citrate plus 300 mg simethicone. Sodium phosphate soda and enema were recommended for bowel cleansing. During colonoscopy, spasticity, difficulty of the procedure, pain, and cleanliness of the colon were scored between 0-4. The time required to reach the cecum was recorded as minutes., Results: Of 165 total patients, 83 and 82 patients were randomized as the drug group (mean age: 51.85+/-13.47 years) and control group (mean age: 51.68+/-16.28 years), respectively. There was a statistically significant difference between the groups in the mean time to reach the cecum in favor of the drug group (7.48+/-3.45 minutes vs. 6.20+/-3.24 minutes; p=0.02). The time to reach the cecum prolonged with an increase in pain score and difficulty score (p=0.0001 and p=0.001, respectively)., Conclusions: Alverine citrate plus simethicone reduced the intubation time significantly by 19%, from 7.48 minutes to 6.20 minutes.

Background/aims: Helicobacter pylori infection has a high prevalence and is considered an important health problem in Turkey. Unfortunately, an effective treatment has not yet been found for the eradication of Helicobacter pylori infection, at least in our country. Standard therapies recommended for the eradication of Helicobacter pylori have failed in the province of Mersin, Turkey. The rate of eradication with the standard triple treatment was only 45% in the province of Mersin. It may be that Helicobacter pylori has become resistant to antibiotics. Therefore, we aimed to determine the rate of resistance to clarithromycin in the province of Mersin., Methods: The study included 92 patients presenting with dyspepsia to the Gastroenterology Clinic of Mersin University Medical School and undergoing endoscopy. We obtained gastric biopsy specimens and investigated whether Helicobacter pylori was present and resistant to clarithromycin. We used polymerase chain reaction-restriction fragment length polymorphism to determine A2143G and A2144G mutations and resistance to clarithromycin., Results: Out of 92 specimens, 37 (40.2%) had Helicobacter pylori DNA. Out of 37 specimens with Helicobacter pylori DNA, 15 (40.5%) had point mutations. Eleven specimens (29.7%) had mutations on nucleotide 2144 and 4 specimens (10.8%) had mutations on 2143., Conclusions: Taking account of the failure of the treatment regimens used to eradicate Helicobacter pylori infection in the province of Mersin, the high rate of point mutations determined in this study was not surprising and the rate of resistance to clarithromycin was an important indicator for the failure in the eradication of Helicobacter pylori infection.

Background/aims: To determine the relation between undiagnosed celiac disease and dyspepsia in the community., Methods: Patients presenting to the gastroenterology outpatient clinic of Mersin University Hospital, aged between 18 and 70 years and with no malignancy, malabsorption, chronic diarrhea, inflammatory bowel disease, diabetes mellitus, heart failure or renal failure, were asked to complete a questionnaire for functional bowel disease (based on Rome II criteria for irritable bowel syndrome and dyspepsia). The patients diagnosed with dyspepsia based on Rome II criteria formed the dyspepsia group and those with gastrointestinal complaints other than dyspepsia and irritable bowel syndrome formed the control group. Serum tissue transglutaminase antibody (anti-tTG) was determined in all patients. The patients with anti-tTG levels of >20U/ml underwent endoscopic duodenal biopsy., Results: The study included a total of 137 patients, of whom 69 (50.4%) were assigned into the dyspepsia group and 68 (49.6%) into the control group. Of 137 patients, 24 (17.5%) had an anti-tTG level of > or =20U/ml: 14 in the dyspepsia group (20.3%) and 10 in the control group (14.7%), with no significant difference between the groups (p=0.39). Of the 24 patients positive for anti-tTG, 15 (64.5%) underwent endoscopy, and of these 15 patients, 8 (53.3%) had endoscopic duodenal biopsy. Biopsy revealed that of the 4 patients in the dyspepsia group, 3 (75%) had Marsh type 0 histology (IEL<40, normal crypt) and 1 (25%) had Marsh type 3a histology. Of the 4 patients in the control group, 3 (75%) had Marsh type 0 histology and 1 (25%) had Marsh type 3a histology. Histopathological examinations showed celiac disease in 2 out of the 8 patients (25%) positive for anti-tTG who underwent biopsy. Intention to treat analyses revealed that 1 of 69 patients in the dyspepsia group (1.44%) and 1 of 68 patients in the control group (1.47%) had celiac disease., Conclusions: Celiac disease in this patient population had a high prevalence. Further studies with larger sample sizes are needed to confirm the relation between dyspepsia and celiac disease.

Background/aims: The aim of this study was to determine the causes and risk factors of acute upper gastrointestinal bleeding, a frequently encountered medical emergency, and to determine any relation in its frequency according to month or season., Methods: We evaluated the records of 336 patients who presented to our hospital with acute upper gastrointestinal bleeding between October 2001 and June 2005. Three hundred and sixteen patients had endoscopy within 12-24 hours of admission. Causes of bleeding, risk factors, drug usage and admission dates were documented, any relations with season or month of occurrence were determined and statistical analyses were made., Results: Two hundred and thirty-seven patients were male (70.5%) and 99 patients female (29.5%), with an average age of 57.7 years. The most frequent endoscopic findings were peptic ulcer (48.2%) and esophageal (or gastric) variceal bleeding (22%) in all seasons and months except September. Non-steroidal anti-inflammatory drugs (NSAIDs) were the most common risk factor (44.3%) and the risk of acute gastrointestinal bleedings was high in all seasons and months except October. March (14%) and spring (33.6%) were the month/season when bleeding was the most frequent. There was a gradual increase in the number of patients admitted with bleeding from autumn to spring. Furthermore, NSAID usage, which was the most frequent risk factor, showed a monthly fluctuation similar to the fluctuation in the total number of bleeding patients., Conclusion: In the province of Mersin, Turkey, the most common cause of acute upper gastrointestinal bleeding is peptic ulcer, and NSAID usage is the most frequent etiological risk factor. Although statistically insignificant, there were seasonal and monthly fluctuations in upper gastrointestinal bleedings in Mersin, where the Mediterranean climate is predominant. Bleeding was the most frequent in March and spring and the least frequent in September and autumn. Bleedings showed a seasonal fluctuation similar to that of NSAID usage, which was the most frequent risk factor. Therefore, if unnecessary NSAID usage can be prevented, it may be possible to protect most people against this emergency condition, which can be lethal, in all months and seasons.

Background/aims: Combination of a proton pump inhibitor, amoxicillin, and clarithromycin, which have been recommended as a primary treatment for Helicobacter pylori (H. pylori) infection, provides eradication in approximately 50% of cases of H. pylori infection in Turkey. There is no effective eradication regimen for H. pylori in our country. We aimed to compare bismuth- based triple and quadruple treatments for eradication of H. pylori., Methods: Eighty-two patients were enrolled into the study between October 2002 and August 2003. The patients were randomly assigned into two groups. One group received ranitidine bismuth citrate 2x400 mg, metronidazole 3x500 mg and tetracycline 2x1000 mg for 14 days (RMT group) and the other group pantoprazole 2x40 mg, bismuth subcitrate 4x300mg, amoxicillin 2x1000 mg and clarithromycin 2x500 mg for 14 days (PBAC group). The eradication was assessed four weeks after completion of the treatment, and the patients underwent endoscopy and were asked whether there were changes in their symptoms. When H. pylori was negative on both histological examination and urease test, the disease was considered eradicated., Results: H. pylori was eradicated in 26 of 42 patients in the RMT group (61.9%) and in 22 of 40 patients in the PBAC group (55%). In total, eradication was achieved in 48 out of 82 patients (58.5%). There was no significant difference in eradication between the groups., Conclusion: Neither regimen (RMT or PBAC) was effective in eradicating H. pylori infection in our area. Further investigations are needed.

Background/aims: Helicobacter pylori is the most common infectious disease all over the world. Ten to twenty percent of the patients remain infected despite treatment with proton pump inhibitors (PPIs), amoxicillin and clarithromycin. We compared PPI, bismuth, tetracycline and metronidazole with ranitidine bismuth citrate, tetracycline and metronidazole in cases resistant to PPIs-based triple therapies., Methods: The study included 52 patients who underwent a triple therapy with PPI, clarithromycin and amoxicillin for 14 days between September 2001 and December 2002, and were found to be resistant to the therapy. They were randomized to take ranitidine bismuth citrate (Rb) 400 mg twice a day, tetracycline (T) 1 g twice a day and metronidazole (M) 500 mg three times a day for 14 days (RbTM), or ranitidine bismuth citrate (Rb) 400 mg twice a day for 14 days and azithromycin (A) 500 mg once a day for 7 days (RbA). Four weeks after the treatment, endoscopies were repeated, and patients were assessed with respect to changes in symptoms. When H. pylori was negative on histological analysis and urease test, eradication was achieved., Results: A total of 52 patients, 32 females and 20 males with a mean age of 49+/-12 years, were included in the study. Eradication was achieved in 15 (28%) out of 52 patients in total. There was a significant difference between RbA and RbTM groups (p=0.01). In fact, H. pylori was eradicated in 3 (12%) out of 25 patients in the RbA group, whereas it was eradicated in 12 (44.4%) out of 27 patients in the RbTM group. Symptom scores significantly improved in both groups after the treatment, though there was not a significant difference between the groups (p=0.705)., Conclusions: Triple therapy including azithromycin does not seem to be a good choice in cases resistant to the first line therapies; however, a similarly lower rate of eradication was achieved with the quadruple therapy proposed. Therefore, different treatment schemes should be applied in resistant patients, and further studies are needed as well.

Dydrogesterone, similar to women's natural progesterone, has been used in a wide range of gynecological conditions. Despite its widespread use, dydrogesterone-induced hepatotoxicity and dydrogesterone-induced hemolytic anemia have, to the best of our knowledge, never been reported previously. We describe a case of hepatitis and warm antibody hemolytic anemia due to dydrogesterone.

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.

Sickle cell anemia is a disease caused by production of abnormal hemoglobin, which binds with other abnormal hemoglobin molecules within the red blood cell to cause rigid deformation of the cell. This deformation impairs the ability of the cell to pass through small vascular channels. Sludging and congestion of vascular beds may result, followed by tissue ischemia and infarction. Liver injury can be caused by the adherence of deformed or hemolyzed erythrocytes to hepatic vascular endothelium. Adhesion of large numbers of hemolyzed red blood cells to hepatic macrophages, or occlusion of hepatic sinusoids by fragmented red cells, can also result in injury of the liver. Chronic intrahepatic cholestasis is an uncommon complication in patients with sickle cell disease. The findings in this case suggest that therapeutic erythrocyte apheresis may benefit patients who have unusual complications of sickle cell disease, such as chronic intrahepatic cholestasis in the liver.