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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. more...

Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic tool for many biliary diseases. Selective biliary cannulation is the first step of the treatment process. Needle knife fistulotomy (NKF) and conventional precut sphincterotomy (CPS) are widely used in difficult biliary cannulation. However, there are different results in their effectiveness and safety. This study aimed to compare both methods regarding cannulation success and adverse event profile.All eligible consecutive patients with naive papillae who underwent biliary ERCP by a single experienced endoscopist over a 3-year period were included retrospectively. The standard cannulation method with a guidewire-loaded sphincterotome was initially used for biliary cannulation in all patients. Cannulation was accepted as difficult in the case of failure of standard cannulation within 5 minutes or despite 5 attempts or insertion of the guidewire to the pancreatic duct 5 times. Three modalities in patients with difficult biliary cannulation were employed according to the structure and configuration of the papillae in addition to unintentional pancreatic cannulation: (1) NKF, (2) CPS, (3) Double guidewire technique or guidewire orientation/precut following pancreatic stenting. Latter was excluded to enable direct comparison between NKF and CPS groups.A total of 644 patients were recruited. Analyses were performed with 541 patients after the exclusion of 103 patients. Mean (SD) age was 60.4 (18.2) years, and 257 (47.5%) patients were male. While standard cannulation was successful in 366 (67.6%), difficult biliary cannulation was observed in 175 (32.4%) patients. NKF was performed in 101 (57.7%) patients, and cannulation success was 100% in the first ERCP session. In contrast, CPS was performed in 74 (42.3%) patients with a lower cannulation success rate (79.7%) than NKF ( P0.001). Post-ERCP pancreatitis rate was higher in CPS (9.5%) than NKF group (3.0%, P =0.063). Bleeding and cholangitis were similar in both groups.In patients with difficult biliary cannulation with appropriate papillary structure and configuration, NKF should be used as the first choice in experienced hands because of high biliary cannulation success and low Post-ERCP pancreatitis risk. more...

Background Endoscopic ampullectomy (EA) offers an insignificantly intrusive strategy for viably treating mucosal and occasionally submucosal lesions of the ampulla of Vater and encompassing periampullary area with high achievement and is more secure. The aim of this study was to present safety, efficacy, and outcomes of EA in the treatment of benign lesions of ampulla Vater performed by single experienced endoscopists in a high volume center. Methods This retrospective study was conducted in patients referred to our hospital (Turkey High Speciality Training and Research Hospital, Turkey) for endoscopic evaluation of ampullary benign lesions over an 8-year period (between October 2011 and September 2019). Success rate was defined as complete resection of lesions. Results Twenty-nine patients with a median age of 64 years were included. Twenty-five patients had lesions confined to the ampulla vateri (86.2%). Accordingly, 2 lesions had intraductal extension adenoma (IDA) (6.9%) and 2 were lateral spreading adenoma (6.9%). The median size of the lesion was 17.5 mm (10 to 36 mm). Nineteen lesions (65.5%) were resected en bloc and 10 lesions (34.5%) were resected in piecemeal manner. Complete resection was achieved in 21 of 23 patients with benign ampullary lesions. The procedure success rate was 91.3%. Complications occurred in 6 patients (20.6%) of these 3 had (10.3%) bleeding, 2 (6.8%) had pancreatitis, and 1 had (3.4%) perforation. Four patients (13.7%) had a recurrence. Conclusions Deep resection of the benign ampullary lesions increases the complete resection rate, cannulation rate of the pancreatic duct, and stenting rate of the pancreatic duct. EA is a safe and successful procedure in patients with benign lesions of ampulla vater. more...

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. more...

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. more...

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. more...

The outcome of endoscopic treatment for the management of surgical end-to-side hepaticoduodenostomy (HD) has not been extensively studied. The aim of this study was to evaluate the results of endoscopic management of HD.The medical records of 17 patients with HD stenosis who were referred to the ERCP unit between August 2003 and June 2012 for endoscopic intervention were retrospectively analyzed.Fourteen patients presented with cholangitis, of whom, jaundice was the presenting complaint in 3 patients. Eight patients (47.1%) who had stents placed for a median of 2 (min, 1; max, 3) ERCP periods remained asymptomatic for a median stent-free period of 19.5 months (min, 7; max, 96 mo). Five patients (29.4%) who had stents placed for a median of 2 (min, 1; max, 5) ERCP periods presented with an episode of stone-related cholangitis for a mean of 41.8±28.9 months after stent removal. These 5 patients remained asymptomatic for a median of 9.5 months (min, 5; max, 40 mo) after endoscopic stone extraction. Three patients with HD (17.6%) were followed up with stents for 4 to 19 ERC periods. One HD patient (5.9%) who had cholangitis associated with secondary biliary cirrhosis died of cholangitis-related complications, despite the treatment with stents for 4 ERC periods.Endoscopic management is also a realistic treatment option for stenotic HD anastomosis, although success rates may vary. more...

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 more...

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 naive 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 naive 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. more...

Both complete transection and accidental ligation of the main bile duct because of a cholecystectomy are the injuries that are not amenable to endoscopic treatment and require an additional surgery. Leaks resulting from the severance of an aberrant bile duct may be treated endoscopically, although such injuries are difficult to be identified, thus resulting in treatment delays. Presented here are the details and follow-up results of 7 cases of patients with postcholecystectomy aberrant bile duct injuries, which were treated by endoscopic treatment. more...

Background: Thrombosis in the portal system causes a wide spectrum of clinical pictures. There are few published studies describing the clinical features and consequences of portal venous system thrombosis. We aimed to document presentations and outcomes in patients with thrombosis in the portal and/or splenic veins. Patients and Methods: The study included 95 patients who were diagnosed with portal venous system thrombosis in the period September 2001 to April 2006. Demographics, clinical presentation, diagnostic investigation, management, morbidity, and mortality were recorded in their follow-up. Results: Of the 95 patients with portal vein thrombosis (PVT), 35 had isolated PVT (IPVT), 27 had isolated splenic vein thrombosis (ISVT), and 33 had thrombosis in both the portal and splenic veins (PSVT). The mean follow-up periods after diagnosis of IPVT, ISVT, and PSVT were 36, 31, and 32 months, respectively. Abdominal pain and gastrointestinal bleeding were the most common symptoms at presentation in the IPVT and PSVT groups, whereas abdominal pain was the dominant symptom in the ISVT group. During the follow-up period, no bleeding was seen in 26 of the 35 (74%) patients with IPVT, in 23 of the 33 (70%) patients with PSVT, and in 24 of the 27 (89%) patients with ISVT. Biliopathy developed during follow-up in 11 of 35 patients with IPVT, in 1 of 27 with ISVT, and in 5 of 33 with PSVT. In the ISVT group, there were 11 deaths, and one each in the IPVT and PSVT groups. Conclusions: The etiology of PVT varies in portal and splenic veins. IPVT has a higher morbidity (bleeding and portal biliopathy), whereas ISVT that is not associated with an underlying malignancy has a favorable prognosis. more...

Stent migration occurs in about 5-10% of patients undergoing biliary stenting. The aim of this study was to analyze the risk factors for stent migration in patients with benign and malignant strictures.We retrospectively analyzed records of 524 biliary plastic stent placement procedures. Details noted included the cause and localization of stricture, characteristics and number of stents, direction of stent migration, presentation of patient with migrated stent, and the methods used for retrieval of migrated stents.Two hundred and four (38.9%) of the procedures were performed for benign biliary strictures (BBS) and 320 (61.1%) for malignant biliary strictures (MBS). Thirty-four patients had 45 migrated biliary stents. The rate of migration was 8.58% (proximal 4.58% and distal 4.00%). Migration frequency was higher in BBS compared with MBS (13.7% versus 5.3%, p=0.001). In BBS, the rate of stent migration was higher in cases with one (19.3%) and two stents (20.9%) when compared with cases with multiple stents (2.7%) (p=0.001; p=0.001, respectively). Migration occurred more frequently (10.9%) in cases with two stents when compared both to cases with one stent (3.0%) and those with multiple stents (0%) in MBS (p=0.008; p=0.020, respectively). In BBS, short stents migrated more frequently proximally (77%) and long stents more frequently distally (73%) (p=0.008). In BBS, migration in cases with proximal stricture occurred more frequently distally (76.9%), while in those with distal stricture, migration was more frequently proximal (73.3%) (p=0.008). All of the proximally migrated stents could be successfully retrieved endoscopically.The risk of stent migration is higher in BBS compared with in MBS. The cases with multiple stents had significantly lower stent migration. In BBS, long stent, proximal and postcholecystectomy strictures were associated with distal migration, while short stent, distal and non-postcholecystectomy strictures were associated with proximal migration. more...

In hepatitis B virus (HBV)-related liver cirrhosis, patients with HBV replication show a higher mortality rate than those without. We aimed to investigate the long-term effects of lamivudine on HBV DNA suppression, Child-Pugh score, and survival in patients with hepatitis Be antigen (HBeAg)-negative liver cirrhosis.Sixty-eight patients (51 male, 17 female) diagnosed with HBV-positive liver cirrhosis, who were monitored by the hepatology and liver transplantation outpatient clinics of our hospital between June 1999 and May 2007, were included in the study. Lamivudine (100 mg/day) was administered orally. Follow-up visits were scheduled monthly during the first 3 months, and every 3 months thereafter. Complete blood count, haemostasis, biochemistry (aspartate aminotransferase [AST], alanine aminotransferase [ALT], amylase, urea, creatinine, total bilirubin, direct bilirubin, total protein, albumin), and alpha-foetoprotein were recorded every 3 months. HBV DNA levels, abdominal ultrasound and the Child-Pugh score were evaluated every 6 months.Sixty-eight patients (mean age, 52.05+/-12.6 years) were monitored for 49.51+/-18.51 months. Basal ALT, HBV DNA levels and Child-Pugh scores were 103.9+/-73.9 IU/ml, 4133+/-121,94 IU/ml, and 7.6+/-2.4, respectively. The ALT normalisation was 59.7% during the first year, 68.2% during the second year and 44.4% during the fifth year. There was a significant decrease in Child-Pugh scores in the first 3 follow-up years when compared with the baseline score (P0.05). During the treatment, HBV DNA positivity and YMDD mutations were determined in 20 of 68 (29.4%) patients at 46+/-17.9 months. Nine patients (13.2%) developed hepatocellular carcinoma at 44.8+/-21.5 months. Thirteen patients (19.1%) died during the treatment due to liver failure or variceal bleeding.Lamivudine is beneficial in patients with HBeAg-negative liver cirrhosis in terms of improvement in liver function and enhancement of survival and quality of life. An HBV DNA suppressive effect and improvement in Child-Pugh score were seen especially in the first years. It is important to be aware of YMDD mutation early, as addition of new antivirals is necessary to overcome unwanted results of the mutation. more...

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 1 st degree in 153 patients (14.4%), 2 nd degree in 498 patients (47.1%), 3 rd degree in 271 (25.6%), and 4 th degree in 135 patients (12.7%). The success rate for the entire procedures was 88.4%. The success rate for 1 st -degree procedures was 99.3%, 97.2% for 2 nd -degree procedures, 86.7% for 3 rd -degree procedures, and 46.7% for 4 th -degree procedures (p more...

Purpose There are no reports comparing the results of conservative/nonsurgical management with the addition of fully covered self-expandable metallic stents (FCSEMS) with the conservative approach in endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal retroperitoneal (type II) perforations. The aim of this study was to evaluate whether the addition of FCSEMS to conventional treatment provides further benefits in the course of type II perforations. Methods A total of 7471 ERCP with sphincterotomy performed between 2007 and 2014 were evaluated, and a total of 25 type II perforations (0.33%) were identified. About 20 patients who were detected during ERCP and biliary cannulation was accomplished were included in the study. Patients were divided into 2 groups: the conservative treatment group (10 patients) and the FCSEMS group (10 patients). Groups were compared for clinical findings, results of serial white blood cell (WBC) counts, the length of hospital stay, the need for surgery, and death, retrospectively. Results Five patients in the conservative treatment group and none of the patients in the FCSEMS group had pain requiring narcotic and/or nonsteroidal anti-inflammatory analgesics during the follow-up period (P=0.005). On post-ERCP day 1, in the conservative and the FCSEMS groups, mean WBC counts were 13,218±4410×10 and 8714±3270×10, respectively (P=0.029). The perforation-related length of hospital stay was 15.77±5.21 days in the conservative group and 11.7±3.19 days in the FCSEMS group (P=0.053). Excluding the patient with severe pancreatitis in the conservative group, there were no deaths or need for surgery. Conclusions Compared with conservative treatment alone, the addition of FCSEMS provides further benefits in terms of a painless course, lower WBC counts, and a short hospital stay. FCSEMS can be used as an additional treatment modality in type II perforation. more...

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. 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). 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. 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. more...

Interleukin 33 (IL-33) is a cytokine belonging to the IL-1 superfamily. Soluble ST2 (sST2) binds to IL-33 and by functioning as trap receptor inhibits signal sending to Th2 via transmembrane ST2. Because Th2-type cytokines play an important role in fibrosis, the aim of this study is to determine whether sST2 can be used as a marker of fibrosis in chronic hepatitis B (CHB) patients or not. The study included 19 healthy controls, 54 patients with CHB, and 14 patients with cirrhosis because of CHB. The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the 4 factors (FIB-4) scores also calculated, and correlations between liver biopsies, sST2 levels, and these scores were analyzed in CHB and cirrhosis patients. The sST2 levels in patients with CHB were significantly higher than those in the control group subjects (median: 1133 pg/mL vs 762.5 pg/mL, respectively [P = 0.035]). In CHB patients, the METAVIR fibrosis score (stages from 0 to 4) showed a moderate correlation with serum sST2 level (r = 0.396, P = 0.004) and a weak correlation with FIB-4 score (r = 0.359, P = 0.008), but no correlation with APRI score (r = 0.253, P = 0.06). The under the curve value of serum sST2 was 0.68, and its prediction of significant fibrosis (METAVIR score ≥2) in values >674 pg/mL had a sensitivity of 91.7% and specificity of 40% (P = 0.009). According to multiple logistic regression analysis, only METAVIR fibrosis stage was found to be an independent predictor of serum sST2 elevation in CHB patients (P = 0.04). The sST2 level can be used for differentiating significant fibrosis from mild fibrosis in CHB patients. However, the efficacy of this marker should be verified by larger studies in the future. more...

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. 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. 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). 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. more...

Endoscopic treatment is effective in the treatment of patients with bile duct injury after cholecystectomy. We aimed to investigate the long-term results of endoscopic treatment, factors predicting the recurrence of the stricture, and to determine the optimal endoscopic treatment. The study was a retrospective cohort analysis and conducted at a tertiary referral center in patients with major bile duct injury (Strasberg E1–4 and E5 patients with main bile duct injury). Patients with minor injury (Luschka and cystic duct leakage), complete transection, and isolated aberrant bile duct injuries were excluded. The study group included 156 patients. The median follow-up period after stent removal was 6.5 years (range 1–16.5). Recurrence was seen in 18 patients (11 %) after a median duration of 9 months (range 2–96). Multivariate regression analysis revealed that the most important factors predicting the success of endoscopic treatment were: Rome type of treatment (inserting increasing number of stents every 3–4 months) (odds ratio 23.8, 95 % CI 1.46–390.7, p = 0.026) instead of Amsterdam-type treatment (replacing two 10F biliary stents every 3–4 months) and dilation of the stricture diameter to at least 76 % of the common bile duct diameter at the end of stent treatment (odds ratio 25.9, 95 % CI 2.46–272.7, p = 0.007). Endoscopic treatment is an effective method in the treatment of patients with bile duct stricture after cholecystectomy. Inserting multiple stents as much as possible without leaving a scar in the bile ducts should be aimed. more...

Endoscopically placed bile duct stents are commonly used to relieve obstruction in patients with benign or malignant biliary disease. These stents may become dislodged and migrate in about 5–10% of patients. Distally migrated stents can be managed expectantly, allowing the foreign body to pass through the rectum. However, proximal migration of biliary stents usually necessitates endoscopic stent removal. We present a case of a proximally migrated stent that was extracted successfully with intrastent balloon inflation during endoscopic retrograde cholangiopancreatography (ERCP). more...

An endoscopic or radiologic percutaneous approach may be an initial minimally invasive method for treating biliary strictures after living donor liver transplantation; however, cannulation of biliary strictures is sometimes difficult due to the presence of a sharp or twisted angle within the stricture or a complete stricture. When an angulated or twisted biliary stricture interrupts passage of a guidewire over the stricture, it is difficult to replace the percutaneous biliary drainage catheter with inside stents by endoscopic retrograde cholangiopancreatography. The rendezvous technique can be used to overcome this difficulty. In addition to the classical rendezvous method, in cases with complete transection of the common bile duct a modified technique involving the insertion of a snare into the subhepatic space has been successfully performed. Herein, we report a modified rendezvous technique in the duodenal bulb as an extraordinary location for a patient with duct-to-duct anastomotic complete stricture after liver transplantation. more...

Girifl ve Amac: Safra kanal› tafllar›n›n tedavisinde endoskopik retrograd kolanjiopankreatografi standard tedavi haline gelmifl- tir. Bu hastalarda endoskopik retrograd kolanjiopankreatografinin teknik guclu¤unu araflt›ran kucuk hasta gruplar› ile yap›lm›fl az say›da cal›flma vard›r. Bu cal›flmada biz bu faktorleri genifl bir hasta grubunda araflt›rmay› amaclad›k. Gerec ve Yontem: ‹ki y›ll›k bir sure icerisinde endoskopik retrograd kolanjiopankreatografi yap›lan tum naive hastalar (n=1850) prospektif olarak deer- lendirildi. Tafl c›kartmak icin birden fazla endoskopik retrograd kolanjiopankreatografi seans›, mekanik litotripsi, ekstra flok dal- ga litotripsi gerektiren yada endoskopik olarak c›kar›lamay›p cerrahiye giden hastalar zor tafl› olan hastalar olarak kabul edildi. Yafl, cinsiyet, labaratuvar parametreler, endoskopik ve kolanjiografik bulgular kay›t edildi. Zor icin prediktif faktorler univariate ve multivariate analizlerle araflt›r›ld›. Bulgular: Cal›flma grubu oralama 60±16 yafl›nda (4-96) 432 kad›n 325 erkek hastadan olufltu. 757 hastan›n 654'unde (%86.4) kolay tafl, 103'unde (%13.6) zor tafl var idi. Hastalar›n %98.1'inde endoskopik tafl c›karma ifllemi baflar›l› idi. Tafl›n otesinde darl›k olmas› (OR: 8.248), kucuk ortak safra kanal›/tafl cap› oran› (OR: 0.348), tafl cap› (OR: 1.187), tafl›n impakte olmas› (OR: 1.117) ve yuksek bilirubin deerleri (OR: 1.1) zor tafl icin multivariate analizde ba¤›ms›z belir- leyici faktorler olarak tespit edildi. Sonuc: Ortak safra kanal› tafllar› tedavisinde endoskopik retrograd kolanjiopankreatografi cok etkili bir yontemdir. Tafl›n ilerisinde darl›k olmas›n›n yan›nda kucuk safra kanal›/tafl cap› oran›, tafl cap›, impakte tafl ve yuksek bilirubin deerleri zor tafl icin onemli belirteclerdir. 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 techni- cal difficulty of endoscopic retrograde cholangiopancreatography in these patients. In this study, we aimed to investigate these fac- tors in a large group of patients. Materials and Methods: All patients with naive papilla (n=1850) who underwent endoscopic ret- rograde 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 ye- ars (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 effec- tive method for the treatment of common bile duct stones. Besides strictures distal to the stone, smaller common bile duct/stone di- ameter ratio, stone diameter, impacted stone, and higher bilirubin levels are significant predictors of difficult stone. more...

Herein we presented a male patient with esophageal stricture due to lichen planus successfully treated with repeated injections of intralesional triamcinolone and review the current literature on esophageal lichen planus with special emphasis on its treatment. more...

A 41-year-old man was admitted to the hospital with a three-day history of dysuria and right flank pain. Physical examination revealed tenderness at the right costo-vertebral angle.

Bile leaks are a major cause of mortality and morbidity after liver resections. We prospectively evaluated the safety and efficacy of endoscopic treatment of biliary fistulas developing after liver resections in 15 patients. Fistulas developed after extended right hepatectomy in 4, extended left hepatectomy in 8, and segmentectomy in 3 patients. Median time interval between surgery and endoscopic intervention was 10 days (range, 7 to 35 d). Endoscopic sphincterotomy followed by a nasobiliary drain insertion was the initial treatment. If the fistula persisted after 2 weeks, nasobiliary drain was replaced by a plastic stent. The effect of output (low in 10 and high in 5 patients) and the origin of fistula (stump in 10 and resection surface of the liver in 5 patients) on the time for closure were evaluated. Bile leakage ceased by only nasobiliary drainage catheter placement in 11 patients (73.3%). Plastic stents were inserted in 4 patients. There was a significant correlation between the output of bile leakage and the time needed for fistula closure. Endoscopic treatment methods are effective in patients with bile leaks due to liver resections. more...

Summary 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. more...

Summary Background and objective Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin have antiaggregant properties and patients with pancreaticobiliary disease commonly use these drugs. We prospectively investigated whether aspirin and NSAIDs are associated with endoscopic sphincterotomy related hemorrhage. Methods Three hundred and eight patients who underwent sphincterotomy were sequentially recruited into this prospective case-control study. Pre-endoscopic assessment included a complete blood count, coagulation studies and a detailed drug history after sphincterotomy patients were followed up for bleeding. Cases and controls were compared for patient and procedure-related risk factors of post-endoscopic sphincterotomy bleeding. Results Hemorrhage occured in 74 (24%) patients. Eight (2.6%) were clinically significant and five (1.6%) were severe. Amongst cases with hemorrhage, 17.6% were on NSAIDs and 14.9% on aspirin; 27.4% of controls took NSAIDs, and 9.8% aspirin ( P > 0.05). Aspirin use in patients with significant (12.5%) or severe hemorrhage (20%) was not different from the controls ( P > 0.05) and none of them had NSAIDs prior to sphincterotomy. Based on univariate analysis, coagulopathy and comorbidity were risk factors for significant post-sphincterotomy hemorrhage and coagulopathy was the only independent parameter (odds ratio = 22.72, 95% CI [4.25; 125]). Conclusion Aspirin and NSAIDs do not increase the risk of post-sphincterotomy hemorrhage and they can be safely used before the procedure. more...

Background and Aim: Rebleeding has remained the most important determinant of poor prognosis in peptic ulcer bleeding. Gastric acid plays an important role in the pathogenesis of rebleeding. We aimed to compare the efficiency of intermittent and continuous pantoprazole infusion treatment on peptic ulcer rebleeding after endoscopic therapy. Materials and Method: In this prospective study, patients with active peptic ulcer bleeding or non-bleeding visible vessel were treated initially with endoscopic therapy. They were randomized to receive intermittent or continuous intravenous pantoprazole treatment. Rebleeding rate, duration of hospital stay, need for total blood transfusion and need for urgent surgery were compared among both groups. Results: Rebleeding rate (6.1 vs. 8.3%), duration of hospital stay (4.17 vs. 4.41), need for total blood transfusion (2.18 vs. 2.59) and need for urgent surgery (4.1 vs. 4.2%) were similar in intermittent and continuous pantoprazole infusion therapy groups, respectively. There was no bleeding-related death in either group. Conclusion: In patients with peptic ulcer bleeding, intermittent and continuous pantoprazole infusion after successful endoscopic therapy have comparable outcomes in reducing rebleeding. Both have similar effects on hospital stay, need for blood transfusion and urgent surgery. Intermittent administration has application and cost advantages over continuous infusion. more...

This Case Study discusses a 57-year-old male diagnosed with an aortoenteric fistula secondary to aortic graft surgery. The case highlights the importance of performing multidetector CT as soon as possible in patients who are suspected to have this condition so a quick diagnosis can be made. Background A 57-year-old male with an aortobifemoral bypass graft presented to a gastroenterology clinic with a 3-month history of intermittent hematemesis, melena and fever. The patient had received antibiotic therapy 2 months before for the same symptoms; however, following brief regression (∼3 weeks) the symptoms had returned. Investigations Physical examination; analysis of full blood count; measurement of erythrocyte sedimentation rate, C-reactive protein levels, liver enzymes, electrolytes, renal function, serum cholesterol and serum triglyceride; HIV serology; blood, sputum, urine and stool culture analysis; performance of esophagogastroduodenoscopy, colonoscopy, abdominal ultrasonography and multidetector CT scanning. Diagnosis Aortoenteric fistula with an inflammatory mass surrounding the aortobifemoral bypass graft. Management Laparotomy with removal of the aortobifemoral bypass graft, performance of an extra-anatomic right axillofemoral bypass graft and an extra-anatomic right-left femorofemoral bypass graft. more...

To evaluate the efficacy of amantadine plus interferon-alpha and ribavirin in non-responder patients with chronic hepatitis C.Twenty-six non-responder patients received the regimen of IFN-alpha-2a at a dose of 6 million units three times a week, 1 000-1 200 mg of ribavirin daily, and 200 mg of amantadine daily in divided doses over 48 wk. After the end of treatment, at the 72nd wk, a sustained viral response rate was determined.An early (after 12 wk of therapy) response was seen in 34.6% (9/26) of patients. Response rate at the 24th wk was 42.3% (11/26). End of treatment response (ETR) was 53.8% (14/26). Sustained viral response (SVR) was 42.3% (11/26). There was a statistically significant difference between 0 and 12 wk (P = 0.04), 0 and 24 wk (P = 0.01), 0 and 48 wk (P = 0.00), and 0 and 72 wk (P = 0.001). No patient had severe adverse effects during the treatment.Combination regimen of interferon-alpha, ribavirin and amantadine can enhance sustained viral response on IFN-alpha and ribavirin non-responder patients with HCV. Triple therapy with amantadine should be evaluated in further studies. more...

Esophageal varice eradication results in gastric hemodynamic changes. The aim of this study was to detect the influence of variceal eradication on portal hypertensive gastropathy (PHG) and fundal varices and to compare the results of two therapeutic methods (endoscopic variceal ligation and endoscopic sclerotherapy). A total of 114 consecutive patients with cirrhosis and portal hypertension who underwent elective endoscopic variceal ligation (EVL) (85 patients) or endoscopic sclerotherapy (EST) (29 patients) for obliteration of esophageal varices were selected for this study. Both groups were compared for PHG and fundal varice formation before and after eradication. Fifty-eight (68.2%) patients in the EVL and 18 (62.1%) patients in the EST group had PHG before esophageal varice eradication (P0.05). PHG grade after eradication of esophageal varices by both EVL and EST was significantly higher compared to pre-eradication. PHG grade and aggregation were similar in both groups. Thirty-seven patients (34 F(1), 3 F(2)) in the EVL group and 13 patients (10 F(1), 3 F(2)) in the EST group had fundal varices before variceal eradication (P0.05). Fundal varices were detected in 46 (35 F(1), 11F(2)) and 19 (11F(1), 8F(2)) patients in the EVL and EST groups after eradication, respectively. There was a statistically significant increment in occurrence of fundal varices after eradication with EVL and EST groups. There was no significant difference regarding fundal varice development after esophageal variceal eradication in both groups. After varical eradication, PHG was found in 57 (87.7%) and 39 (79.6%) patients with and without fundal varices, respectively (P0.05). Esophageal eradication with EVL and EST increases both the incidence and the severity of PHG and fundal varice formation. Both methods have comparable influences on PHG and fundal varices. more...

Hemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. Pancreatitis are the most common cause of HP. Here, we report the case of a 48-year-old male with HP due to alcohol-induced chronic pancreatitis. Superior mesenteric angiography showed an inferior pancreaticoduodenal artery pseudoaneurysm. The patient underwent coil embolization for treatment of his pseudoaneurysm. Endoscopic retrograde cholangiopancreatography and pancreatic stents replacement was performed for pancreatic pseudocyst drainage. In patients with HP, angiographic and endoscopic combined treatment can protect from the risks of surgery. more...