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Background The standard oesophago-gastro-duodenoscopy procedure is performed with a single endoscopist (SE). Nurse-assisted (NA) oesophago-gastro-duodenoscopies have not yet been studied. We aimed to evaluate the efficacy of an NA endoscopy compared to an SE endoscopy. Methods A prospective, single-center, randomized trial, in which 500 adult patients were divided into two groups. In the first group, patients underwent an endoscopy with an SE. In the second group, the endoscopy was performed with an NA. The ease of the procedure (scores 1–4; 1 difficult, 2 satisfactory, 3 easy, 4 very easy), evaluation of patient satisfaction (scores 1–4; 1 uncomfortable, 2 satisfactory, 3 comfortable, 4 very comfortable), total time of the procedure and vocal cord observation were determined as quality indicators. Results Mean patient satisfaction scores in groups 1 and 2 were 2.98 ± 0.79 and 3.11 ± 0.78, respectively (p = 0.043), with uncomfortable ratings in 5.2% vs 4%, satisfactory in 16.8% vs 13.2%, comfortable in 53.2% vs 50.4%, and very comfortable in 24.8% vs 32.4% of patients in groups 1 and 2, respectively. Retching rates during the procedure were 54.4% and 45.2% (p = 0.040) in groups 1 and 2, respectively. No differences were seen in vocal cord observation (54.4% vs 56.0%), total procedure time (2.35 ± 1.56 vs 2.41 ± 1.48 min) and easy score (3.26 ± 0.603 vs 3.25 ± 0.64) in groups 1 and 2 for the procedures. Very easy, easy, satisfactory, and difficult ratings were given by 33.6% vs 34.8%, 60.4% vs 56.4%, 4.8% vs 7.6% and 1.2% vs 1.2% of groups 1 and 2, respectively. Conclusions Compared with the conventional method, the assisted endoscopic technique provides more comfort and less gag reflex without increasing the processing time or difficulty of performing the procedure.

ÖZETİnflamatuvar barsak hastalıkları aktivasyon ve remisyon ile giden ve etiyolojisi bilinmeyen kronik intestinal hastalıklardır. Aktiviteyi belirlemek inflamatuvar barsak hastalığında tedavinin düzenlenmesi ve prognozu göstermesi açısından büyük önem taşır. Aktiviteyi belirlemek için halen ortak bir konsensüs oluşmamıştır. Reelin de nörolojik gelişim ve sinaptik plastisite önemli roller oynamaktadır. Reelinin şizofreni patogenezinde rolü bulunmaktadır.Araştırma Ankara Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Gastroenteroloji – İBH Polikliniği’nde gerçekleştirilmiştir. Takip ve tedavisi yapılan İBH vakası 194 hasta ve 30 sağlıklı kontrol dâhil edilmiştir. Hastaların verileri poliklinik dosya ve hastane bilgi işlem sisteminden elde edilmiştir. CH aktivite indeksi ile UC True Love aktivite indeksi kullanılmış ve serumda Reelin düzeyi çalışılmıştır. Çalışma retrospektif olup hastalara ek herhangi bir işlem uygulanmamıştır.Araştırmada da; Reelin düzeyleri ÜK total: 0,6216 +/- 1,0835 aktif:0,3846 +/- 0,4850 remisyon:0,4354 +/- 0,4354 idi. CD’da Reelin total:0,3993 +/-0,5101 aktif: 0,3675 +/- 0,5789 remisyon: 0,4354 +/- 0,5789 idi ve kontrol grubunda: 0,5576 +/- 0,6142 olarak saptandı. ÜK ve CH arasında serum Reelin düzeyi ile anlamlı fark saptanmamış, ÜK ve CH ile ayrı ayrı kontrol grubu ile olan karşılaştırma sonucu anlamlı fark bulunmamıştır. (p > 0,05). Bu bağlamda da görülmektedir ki, serum Reelin düzeyinin ÜK ve CH vakalarını etkileme düzeyi farklılık içermemektedir. Araştırma kapsamında, ÜK ve CH aktif ve kontrol grubu arasında istatistik bakımdan anlamlı bulunmamıştır (p > 0,05). ÜK reelin düzeyleri:0,6216 +/- 1,0835 (X2 = 0,109; p > 0,05) ve aktif ÜK reelin düzeyleri: 0,3846 +/- 0,4850 (X2 = 0,820; p > 0,05) tutulum görülen lokasyona göre anlamlı farklılık göstermemektedir.Gruplar bazında genel olarak değerlendirildiğinde de görülmektedir ki, Reelin düzeyleri tutulum görülen lokasyona göre anlamlı farklılık göstermemektedir (X2 = 1,007; p> 0,05). Sonuç olarak çalışmamız; Reelinin, İBH’da aktivasyon remisyon markerı olarak kullanılamayacağını ve ayrıca ÜK-Crohn arasında ayrıcı tanıda belirteç olmadığını göstermektedir, Background/Aim: Crohn's Disease (CD) and Ulcerative Colitis (UC) are grouped as Inflammatory Bowel Diseases (IBD). There are many similarities between these two diseases, and CD and UC cases cannot be separated at a rate varying between 5% and 10%. Reelin is an extracellular matrix protein first known for its vital role in neuronal migration. Studies in rodent small intestine suggested that reelin protects the organism from intestinal pathologies. In a 5-year retrospective case-control study, we aimed to detect the effectiveness of serum reelin level in patients with IBD in determining the severity and activation of the disease and compare healthy volunteers with patients in terms of inactivation and remission.Methods: The data of all 194 IBD patients diagnosed at Beyazit Training and Research Hospital between 2011-2015 were retrospectively reviewed. The patients were matched with 30 healthy volunteers. Risk factors were assessed by multivariate logistic regression analysis.Results: The serum reelin levels were similar between UC and CD patients, the control group, UC and CD groups (P=0.067), and those with active disease or disease in remission, and did not differ according to disease behavior or location of involvement. Conclusions: Our study shows that Reelin cannot be used as an activation/remission marker in IBD. In addition, it does not differentiate between UC and CD.

Non-invasive methods are being developed to evaluate liver fibrosis. In this study, we aimed to evaluate the diagnostic performance of rheumatoid factor (RF) to predict liver fibrosis in chronic hepatitis B (CHB). A total of 235 non-arthritic, treatment-naive patients with hepatitis B virus (HBV) were enrolled in this study. The RF level was analyzed concurrently with HBV-DNA and routine biochemical tests. The liver biopsies were scored by using the Knodell modified histology activity index (HAI) and the Ishak fibrosis score. Mean age, ALT, AST, ALP, GGT, INR, and HBV-DNA levels were significantly higher, and mean albumin and platelet levels were significantly lower in the RF positive group than the RF negative group. Liver biopsy was performed in 112 (47.66%) patients, and the RF positivity rate was 18 (15.38%) in the infection subgroup and 73 (61.86%) in the hepatitis subgroup. Along with the RF positivity rate, the fibrosis and HAI scores were also increased. A high fibrosis score is associated with a high RF positivity rate. In the current study, we found that there was a significant positive correlation between RF and liver fibrosis stage in patients with CHB. The RF that is easily obtained with low cost may be considered as an alternative biomarker for predicting liver fibrosis in CHB.

Aim: Understanding immunopathogenesis of hepatitis-B virus (HBV) infection is pivotal in the management of complications. The aim of the study is to investigate the association of IgG4 levels with the liver fibrosis. Methods: Histological evaluation of the liver biopsy and laboratory analyses including IgG4 were performed. Results: A total of 130 patients fulfilling the criteria for a diagnosis of HBV infection were enrolled in the study. Of these patients, 14 had HBeAg positive and 116 had HBeAg negative HBV infection. In HBeAg-positive patients serum IgG4 levels were significantly higher than HBeAg-negative patients (p = 0.038). Conclusion: There is an association of IgG4 level and higher rates of viral replication and enhanced infectivity.

Background The comparative efficacy and safety of infliximab (IFX) and adalimumab (ADA) have shown variable results in biologic-naïve patients with Crohn’s disease (CD). Thus, long-term comparisons between IFX and ADA with or without immunomodulator therapies are still needed. The purpose of this study was to evaluate the long-term clinical effectiveness and safety profile of IFX compared to ADA in biologic-naïve patients with CD. Methods Data of all adult CD patients treated with IFX or ADA as their first biologic agent was collected retrospectively between December 2007 and February 2021. We compared CD-related hospitalization, CD-related major abdominal surgery, steroid use and serious infections leading to treatment cessation. Results Out of 224 biologic-naïve patients with CD, 101 started IFX first (median age at onset: 38.12 years, 61.4% male) and 123 started ADA first (median age at onset: 30.2 years, 64.2% male). Median disease duration was 6.94 years (IQR: 3.82–12.17) and 6.91 years (IQR: 3.94–10.95) for IFX and ADA, respectively, of whom 33% and 37.4% had active smokers, 10.9% and 13.4% had family history of inflammatory bowel disease (IBD) 22.8% and 19.5% had perianal disease, 43.6% and 43.9 had prior major abdominal surgery and 52.6% and 49.6% had extraintestinal manifestations. There were no significant differences between the two groups with respect to the age at onset of tumor necrosis factor antagonist, gender, smoking status, family history of IBD, perianal disease, prior major abdominal surgery, extraintestinal manifestations, prior immunomodulator (Thiopurine or Methotrexate) or steroid usage, all laboratory test results and Crohn’s Disease Activity Index (CDAI) score at baseline (p>0.05). Overall, the median follow-up time was 2.81 and 3.55 years after starting the first IFX and ADA group, respectively. There were no significant differences in the rate of steroid use (4% IFX vs. 10.6% ADA p=0.109), CD-related hospitalization (13.9% IFX vs. 22.8% ADA p=0.127), CD-related major abdominal surgery (9.9% IFX vs. 13% ADA p=0.608) and serious infections leading to treatment cessation (1% IFX vs 0.8% ADA p>0.999) between IFX and ADA. These outcomes were similar in patients treated with IFX or ADA monotherapy or in combination with an immunomodulator. Conclusion In this retrospective observational tertiary referral center study, we observed that there was no significant difference in long-term effectiveness and safety of infliximab and adalimumab in biologic-naïve patients with CD.

Background Crohn’s disease (CD) and Familial Mediterranean fever (FMF) are both inflammatory disorders characterised by recurrent abdominal pain and fever attacks. Mutations of Mediterranean (MEFV) gene appear to be associated with stricturing behaviour and extraintestinal manifestations of CD. Further clinical studies regarding progression of CD in coexistence with FMF is still required. The aim of this study was to evaluate the influence of concomitant FMF in CD patients on the course of the CD in FMF endemic area. Methods Total 210 adult patients who had diagnosed with CD with or without FMF between November 2006 and April 2019 were respectively examined. FMF diagnoses were based on Tel-Hashomer criteria. The Montreal classification was used to define location and behaviour of CD. CD patients were divided into two groups FMF positive and FMF negative. Severity of CD was assessed by the need for hospitalisation related to CD, whether biological therapy was received and/or whether surgery was undergone due to CD. All demographic features, MEFV mutations, location/behaviour of disease, and extraintestinal manifestations were analysed retrospectively. Results In the present study, 8 (3.8%) of the total 210 CD patients have concomitant FMF. Mean follow-up time in CD-FMF was 59.55 months and CD-non-FMF was 60.98 months. CD patients with or without FMF showed similar demographic features including age, sex, smoking behaviour, disease location, behaviour, and treatment regimen in maintenance of the remission. Regarding extraintestinal manifestations, only peripheral arthritis was found significantly higher in CD-FMF patients (n = 3, 37.5%) compared CD-non-FMF patients (n = 21, 10.4%). In the CD-FMF patients, a result of MEFV mutation gene analysis was found in medical records 6 patients. Of those, 2 had homozygote MEFV mutation, 2 had heterozygote MEFV mutation and 2 without any MEFV mutations. In CD-FMF group, percentage of patients on biological therapy (n = 4, 50%) was significantly higher than CD-non FMF group (n = 24, 11.9%) (p = 0.012). Steroid dependence and hospitalisation in CD-FMF (n = 3, 37.5% and n = 5, 62.5%) group were relatively higher than CD-non-FMF (n = 83, 41.1%) group, but not statistically significant. The percentage of CD-FMF patients who underwent intestinal surgery (n = 1, 12.5%) was similar to that of CD-non-FMF (n = 33, 16.3%). Conclusion In the current study, the prevalence of FMF in CD patients was detected 3.8% in FMF endemic area. The group of patients on biological therapy in CD-FMF patients was significantly higher than CD-non-FMF patients. Frequency of hospitalisation in CD-FMF patients was relatively higher than CD-non-FMF patients. Our findings indicate that concomitant FMF in CD patients may have a negative effect on the course of CD.

BACKGROUND Crohn's disease (CD) is characterised by chronic gastrointestinal inflammation with relapsing-remitting behaviour and often requires endoscopic and/or radiologic assessment. OBJECTIVE The objective of this study was to compare the diagnostic accuracy of intestinal ultrasound (IUS) and magnetic resonance enterography (MRE) for the assessment of disease activity in CD using a simple endoscopic score for CD as a reference standard. PATIENTS AND METHODS A prospective observational study was carried out in 71 consecutive adult patients with known CD, attending our tertiary inflammatory bowel disease clinic, between November 2014 and July 2016. Ileocolonoscopy, IUS and MRE were performed within 1 month prospectively. The simple endoscopic score-CD 0-2 was accepted as remission. RESULTS The sensitivity of IUS and MRE for detecting endoscopic activity was found similar with regard to bowel wall thickening and mesenteric fibrofatty proliferation (P>0.05). The overall accuracy for detecting mural lesions was similar between IUS and MRE. When mural lesions were analysed, the sensitivity of MRE in detecting the loss of wall stratification and stenosis was significantly higher than IUS (P

Pantoprazole is a proton pump inhibitor that is commonly used in the treatment of peptic ulcer disease (PUD) and metabolized by cytochrome P450 (CYP) enzymes CYP2C19 and CYP3A4. Pantoprazole is a substrate for multi-drug resistance protein 1 (MDR1). Single nucleotide polymorphisms (SNPs) in CYP2C19, CYP3A4 and MDR1 affect enzyme activity or gene expression of proteins and may alter plasma pantoprazole concentrations and treatment success in PUD. In this study, we aimed to investigate the association between genetic polymorphisms in CYP2C19, CYP3A4 and MDR1 and pharmacokinetics of pantoprazole and therapeutic outcome in patients with either Helicobacter pylori-associated [H.P.(+)]-PUD or [H.P.(+)]-gastritis. The plasma pantoprazole concentrations were determined by using an HPLC method at the third hour after a 40-mg tablet of pantoprazole administration in 194 newly diagnosed patients with either [H.P.(+)]-PUD or [H.P.(+)]-gastritis. Genotyping was performed by using PCR-RFLP and DNA sequencing. Among patients appearing for follow-up examination (n = 105), the eradication rate for H. pylori was 82.8% (n = 87). The median pantoprazole plasma concentrations in poor metabolizers (PM), rapid metabolizers (RM) and ultrarapid metabolizers (URM) were 2.07, 1.69 and 1.28 μg/ml, respectively (p = 0.04). CYP3A4*1G and *22 polymorphisms did not affect plasma pantoprazole concentrations and H. pylori eradication rate. The MDR1 genetic polymorphisms did not affect plasma pantoprazole concentrations. MDR1 3435CC-2677GG-1236CC haplotype carriers had lower H. pylori eradication rate (60%) than the remaining subjects (84.9%) while the difference was not statistically significant (p = 0.07). In conclusion, while CYP2C19 genetic polymorphisms significantly affected plasma pantoprazole concentrations, polymorphisms of CYP2C19, CYP3A4 and MDR1 did not affect H. pylori eradication rates.

Background/aims To evaluate the effectiveness of tenofovir in patients with chronic hepatitis B infection in a real life setting. Materials and methods We performed a retrospective analysis of data from 164 patients with chronic hepatitis B who were treated with Tenofovir. Eighty-six patients (52.4%) were naive. Seventy-seven (46.9%) patients were previously treated with anti-viral drugs, including standard interferon (n=4), pegylated (PEG) interferon (n=14), standard interferon together with lamivudine (n=13), lamivudine alone (n=41), adefovir (n=2), lamivudine together with adefovir (n=1), and entecavir (n=2). Six patients (3.7%) had liver cirrhosis before treatment of tenofovir. Results The patients who have hepatitis B viral DNA>104 copy/mL with chronic hepatitis B infection were included in the treatment of Tenofovir. Average follow up time was 30.31±14.33 months. HBV DNA negativity and alanine aminotransferase (ALT) normalization were 86.5% and 71.3%, respectively, at the last visit. Hepatitis B e-Antigen (HBeAg) seroconversion occurred in 11 (19.6%) out of 164 patients. During the follow-up period, 4 (2.4%) patients developed liver cirrhosis and in 5 (3%) patients hepatocellular carcinoma (HCC) occurred out of 164 patients. HBsAg seroconversion occurred in one patient (0.6%). Conclusion Tenofovir can be used safely and successfully in those patients that were naive, experienced with immune modulators and/or antivirals, HBeAg-positive, and HBeAg-negative patients.

Dieulafoy’s lesion (DL) is a relatively uncommon medical condition characterized by a large tortuous arteriole in the submucosa of any part of gastrointestinal (GI) tract wall that bleeds via erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole. Compared with other endoscopic hemostatic techniques, clipping alone for DL is limited. The aim of the present case series study is to identify common clinical and endoscopic features, rates of occurrence, to review the outcome of endoscopic management of upper GI tract DL, and to illustrate the use and the efficiency of endoclips in maintaining the GI bleeding due to DL. This case series was conducted at Department of Gastroenterology, Diskapi Yildirim Beyazit Educational and Research Hospital. The patients who were admitted to the emergency department of Diskapi Yildirim Beyazit Educational and Research Hospital underwent gastrointestinal system (GIS) endoscopy between 2008 and 2013 and were assessed retrospectively. Five cases of GI bleeding related to DL were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated. The median number of endoscopic hemoclips application in first endoscopy was 4 (2–9). Rebleeding developed in all patients who had hemoclips applied. Re-endoscopy was performed in three of these patients, which controlled the bleeding. Two patients were transferred to surgery. Combination of endoscopic injection and mechanical therapies seems a suitable method for maintaining upper GIS bleeding due to DL. Also, further studies are needed to better define the best endoscopic approach for the treatment of DL.

Background: Mannose binding lectin (MBL) is believed to be an important component of the innate immune response. MBL may be an important non-invasive predictor for progression of hepatitis B virus infection. In this study, we examined whether there is a relationship between MBL levels and progression of hepatitis B virus infection. Methods: In this cross-sectional study, fifty patients with chronic hepatitis B and 21healthy control subjects were included. They were classified into three groups: Active hepatitis B, inactive hepatitis B and healthy control groups. The association between MBL level with the stage of fibrosis and histological activity index (HAI) was found in patients with active chronic hepatitis B. Results: The mean ± SD of MBL level was as 2875.3 ± 2040.03 ng/ml in active HBV patients, 2463.9 ± 1915.4 ng / ml in inactive HBV patients, and 1865.04 ± 265.6 ng/ml in healthy controls (P: 0.344). MBL was not significantly correlated with HAI and the stage of fibrosis (r: -0.30, P: 0.876 and r: 0.077, P: 0.687, respectively). Conclusion: In our study, we could not find any significant association between MBL levels and progression of HBV infection; which is not in line with the hypothesis that MBL may be beneficial as a non-invasive predictor of the survival of patients with hepatitis B virus infection.

The quality of colon cleansing and the tolerance of patients to the procedure are two major determinants of the quality of a colonoscopy. Many bowel-cleansing regimens are known, but there is no ideal regimen. Alverine citrate (Relaxyl, Spasmonal) is a spasmolytic agent that has been shown to affect responses of mechanoreceptors of the intestine to both mechanical and chemical stimuli. Patients who underwent colonoscopies at four centers were randomly assigned two different bowel-cleansing procedures. The bowel-cleansing methods were oral sodium phosphate (NaP) (Group I) and oral NaP plus alverine citrate (Group II). Patients were randomized into one of these regimens. The quality of colon cleansing was assessed by an endoscopist with an empirical, clinically meaningful 3-point scale. Both groups were similar with respect to age, gender, and pre- and postcolonoscopic diagnosis. In Group I, 76 patients (47 women and 29 men; aged 39.53 ± 7.87 years) and in Group II, 71 patients (41 women and 30 men; aged 39.78 ± 8.27 years) were included in the study. In Groups I and II, 37 (48.7%) and 41 (57.7%) patients had perfect bowel cleansing, respectively. The overall colon cleansing in the group with NaP plus alverine citrate was comparable with that in the NaP group. The tolerability of patients to the colonoscopy in the two groups was also similar. Based on the present data, adding oral alverine citrate to NaP does not increase either the quality of bowel cleansing or the tolerance of patients to the procedure.

Background: The aim of this study was to evaluate the prevalence and features of the major cutaneous manifestations (erythema nodosum [EN] and pyoderma gangrenosum [PG]) and to determine the associations between cutaneous manifestations and other extraintestinal manifestations in patients with inflammatory bowel disease (IBD). Methods: The mucocutaneous manifestations of patients with IBD were studied between December 2002 and June 2007. All patients underwent a detailed whole body examination by a gastroenterologist and dermatologist. Results: In all, 352 patients were included in this study; 34 patients (9.3%) presented with at least 1 major cutaneous manifestation. The prevalence of EN (26 patients) and PG (8 patients) in IBD was 7.4% and 2.3%, respectively. EN was more common in Crohn's disease (16/118) than ulcerative colitis (10/234) (P = 0.002). EN was found to be related to disease activity of the bowel (P = 0.026). The prevalence of arthritis was significantly higher in the IBD patients with EN (11/26) than in IBD patients without EN (53/326) (P = 0.006). Arthritis was more common in IBD patients with PG (7/8) than in IBD patients without PG (57/344) (P = 0.00). IBD patients with PG were significantly more likely to have uveitis (1/8) compared with IBD patients without PG (5/344) (P = 0.017). Conclusions: We found the prevalence of 2 important cutaneous manifestations to be 9.3% in IBD in Turkish patients. EN was found to be more common in Crohn's disease and is associated with an active episode of bowel disease and peripheral arthritis. In addition, PG was connected with uveitis and peripheral arthritis. (Inflamm Bowel Dis 2009)

Background: Cancer antigen 125 (CA‐125) is a tumor marker used for the diagnosis and monitoring of ovarian carcinoma. It can also be elevated in endometriosis, inflammations, and in nongynecological malignancies. Up to date, serum CA‐125 levels in inflammatory bowel diseases (IBD) have not been studied before. Aim: To assess the levels of CA‐125 in patients with ulcerative colitis (UC) and Crohn's disease (CD). Methods: Serum levels of CA‐125 were investigated in 68 cases with UC (male/female: 47/21), 32 CD (male/female: 21/11), and 31 healthy controls (male/female: 16/15). Levels of CA‐125 were also compared among UC patients according to lesion location, severity, and activity of CD. Results: Serum CA‐125 levels were 17.29±24.50 U/ml, 15.56±20.74 U/ml, and 8.85±2.62 U/ml in patients with UC, CD, and healthy controls, respectively. Serum CA‐125 levels were significantly higher in UC compared to control group (P=0.001). Serum CA‐125 levels were higher in CD patients compared to control group but there was no significance (P=0.087). Serum CA‐125 levels were higher in pancolitis compared to distal type and left‐sided UC. Conclusions: Our data suggest that serum CA‐125 levels may be increased in patients with IBDs. J. Clin. Lab. Anal. 23:244–248, 2009. © 2009 Wiley‐Liss, Inc.

A 62-year-old woman was evaluated for iron deficiency anemia. She had no history of any medications, trauma, smoking, or alcohol consumption. On physical examination, the patient had a pale appearance, and tenderness in the epigastric region but no rigidity or rebound. Upper gastrointestinal endoscopy revealed the majority of the stomach and duodenal bulb to be normal. However, a well-hidden, red-colored, ulcerated lesion (diameter 2cm) was observed. The lesion was located mainly on the posterior side of the duodenal bulb, partly occupying the duodenal bulb, and extended to the descending duodenum (●" Fig.1 and●" Video 1). The appearance and size of the lesion suggested a gastrointestinal stromal tumor (GIST), and it was therefore removed surgically. Histopathological examination of the resected tissue confirmed GIST. The patient was discharged 3 days after the surgery, and was doing well at follow-up. GISTs are the most common submucosal tumors of the gastrointestinal tract, representing 1%–3% of gastrointestinal malignancies. About 50%–60% of GISTs occur in the stomach, and about 20%–30% are malignant [1]. The duodenum is an uncommon location. Diagnosis of duodenal GIST is sometimes difficult, especially those arising in the posterior duodenal bulb. As peristalsis allows a better view of the duodenal bulb mucosa, observation of this area for a while during endoscopic examination is a feasiblemethodofdetecting hidden lesions.

A 51-year-old woman with an 8-month history of recurrent episodes of abdominal pain, mild bloody diarrhea, andweight loss (6kg in 3 months) was referred to our unit for evaluation of suspected Crohn’s disease. She had carried a diagnosis of type 1 neurofibromatosis for 30 years. Physical examination revealed multiple cafe-au-lait spots and multiple cutaneous neurofibromas. Her abdomen was mildly tender in the lower abdomen with no detectable palpable mass. Laboratory test results were as follows: hemoglobin level 9.6g/dL, sedimentation rate 40mm/h, C-reactive protein 23mg/dL. Other biochemical tests were unremarkable. A colonoscopy revealed a normal-appearing colon and an edematous terminal ileum with a 1-cm pedunculated polyp covered by exudate (●" Fig.1). A magnetic resonance enterography showed thickening of the jejunum and terminal ileum, and a pedunculated polyp, about 1cm in diameter, located in the terminal ileum (●" Fig. 2). An oral double-balloon enteroscopy showed multiple, raspberry-like, 3–5mm, sessile polyps, which were covered by faint exudates located in the proximal jejunum (●" Fig.3). Biopsies of the polyps in the jejunum and ileum revealed intestinal ganglioneuromatosis. Type 1 neurofibromatosis, also known as von Recklinghausen disease, may affect the gastrointestinal tract in 25% of patients in whom intestinal neurofibromas, gastrointestinal stromal tumors, or ganglioneuromatosis can be detected [1,2]. Intestinal ganglioneuromatosis is a rare neoplastic condition characterized by proliferation of nerve ganglion cells, nerve fibers, and supporting cells of the enteric nervous system. It occurs in three forms: as an isolated polyp, as multiple polyps (ganglioneuromatous polyposis), and as diffuse involvement of the bowel wall (diffuse intestinal ganglioneuromatosis) [1]. The disease may affect any part of the gastrointestinal tract. The most common symptoms are abdominal pain, change in bowel habit, diarrhea, and gastrointestinal bleeding, which resemble Crohn’s disease.

Spontan dalak infarkt› siroz ve portal hipertansiyonda nadiren gorulmektedir. Klinik gorunumu akut kar›n ar›s›n› taklit edebi- lir. Bu durumun tan›s› klinik bulgular ve dala¤›n goruntulenmesi ile konur. Son y›llarda, ultrasonografi ve bilgisayarl› tomogra- fi dalak enfarkt› tan›s› icin popularite kazanm›flt›r. Cok say›da olguda infarkt bolgeseldir ve tedavi counlukla konservatiftir. Biz burada siroza bal› portal hipertansiyon ve ayn› zamanda komorbiditeleri bulunan yafll› sirotik bir olguda nadir gorulen spontan dalak infarkt›n› bildiriyoruz. 72 yafl›nda sirozu olan kad›n hasta, iki gundur devam eden kar›n sol ust kadran ar›s› nedeni ile baflvurdu. Ozgecmiflinde kriptojenik siroz, konjestif kalp yetmezlii, kronik obstruktif akcier hastal›¤› ve hipertansiyon oykusu var- d›. Fizik muayenesinde palpasyonla splenomegali vard›. Bat›n ultrasonografisinde splenomegali ve dalak orta bolumde subkapsu- ler alandan hilusa doru uzanan 62x35 mm cap›nda lobule konturlu hipoekoik alan izlendi. Bat›n tomografisinde dalakta 64x58 mm cap›nda subkapsuler hipodens lezyon goruldu. Doppler ultrasonografide dalak hilusundan lateral zona doru uzanan kama fleklinde heterojen hipoekoik avaskuler alan saptand›. Olgumuzda bilgisayarl› tomografi ve Doppler ultrason ile dalak infarkt› ta- n›s› kondu. Hastam›zda altta yatan hastal›klar›n konservatif tedavisi yap›ld›. Spontan dalak enfarkt› sol ust kadran ar›s› ile bafl- vuran ve komorbiditeleri bulunan sirozlu hastalarda goz onunde bulundurulmal›d›r. Anahtar kelimeler: Dalak infarkt›, siroz, portal hipertansiyon Spontaneous splenic infarction has been seen rarely in cirrhosis and portal hypertension. The clinical presentation can mimic other causes of acute abdominal pain. The diagnosis of the condition is based on clinical findings and splenic imaging. In recent years, ultrasonography and computed tomographic scan have gained in popularity for the diagnosis of splenic infarction. Most reported cases are of focal infarction, and treatment is mostly conservative. Herein, we describe a rare case of spontaneous splenic infarction in an elderly cirrhotic patient with portal hypertension who also had comorbidities. A 72-year-old female previously diagnosed with cirrhosis was admitted for left upper quadrant abdominal pain for two days. Her medical history included cryptogenic cirrhosis, congestive heart failure, chronic obstructive pulmonary disease, and hypertension. Physical examination on admission revealed a palpable splenomegaly. Abdominal ultrasonography revealed splenomegaly and a hypoechoic area with lobulated contours mea- suring 62x35 mm extending from the subcapsular area to the hilus in the middle section of the spleen. Abdominal computed tomo- graphic showed a subcapsular hypodense lesion of the spleen measuring 64x58 mm. Doppler ultrasound revealed a wedge-shaped heterogeneous hypoechoic avascular area extending from the central zone to the lateral zone of the spleen. In our case, diagnosis of splenic infarction was made by computed tomographic and Doppler ultrasonography. Our patient received conservative treatment for the underlying diseases. Spontaneous splenic infarction must be kept in mind in cirrhotic patients with underlying comorbidi- ties presenting with left upper quadrant pain.

Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe. The aim of the present study was to elucidate the efficiency of the neutrophil/lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the mean platelet volume (MPV) as tools for the preoperative diagnosis of CRC and their usefulness in the follow-up of CRC. A total of 144 CRC patients, as diagnosed by colonoscopy, and 143 age-matched and sex-matched healthy participants were included in the study. Medical records were used to compare preoperative and postoperative data including hemoglobin levels, platelet counts, MPV, NLR, and PLR. NLR, PLR, and MPV were significantly higher in CRC patients preoperatively, compared with healthy participants. Receiver-operating characteristic curve analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR, (AUC: 0.853, sensitivity: 70%, specificity: 90%) and 8.25 fl as the cutoff value for MPV (AUC: 0.717, sensitivity: 54%, specificity: 76%). Subgroup analysis showed that NLR, PLR, and MPV levels were also significantly higher in nonanemic CRC patients compared with the control group, which is of great theoretical and clinical value for the early detection of CRC. Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV. Our results suggest that NLR, PLR, and MPV may be used as easily available additional biomarkers for CRC in screening the general population, as well as in postoperative follow-up.

Liver biopsy is the gold standard for assessment of fibrosis in patients with hepatitis B. However, it has some disadvantages, including inter-observer and intra-observer variability in biopsy interpretation and specimen variation. A standard biopsy specimen represents only about 0.0002 % of the whole liver. It has been shown that two biopsy samples collected during a procedure have significant influence on the diagnostic performance of interpretation in patients with hepatitis C or non-alcoholic steatohepatitis. Therefore, we aimed to assess the influence of collecting two liver biopsy samples during a single procedure for staging and grading chronic hepatitis B.27 patients were included in the study. The median age of the patients was 43.51 ± 11.69. Fifteen patients were female, 12 patients were male. In the biopsy procedure, two samples of liver lobes were obtained. Grade and stage scores were compared between the two samples. Fibrosis staging and grading were assessed according to the Ishak scoring system.Numbers of portal tract and biopsy size were equal in the two samples. There was a significant difference between the samples in terms of histological activity index (p value = 0.04). However, the difference was not enough to distinguish the mild and moderate stages. On the other hand, no significant difference in fibrosis staging between the two samples was found.With this relatively small size of patients, in this study, we showed that a proper liver biopsy size is sufficient to predict treatment decisions in chronic hepatitis B patients. However, further studies are needed to show the association of sampling variability in patients with hepatitis B.

Adenosine deaminase (ADA) is found in most tissues including lymphoid cells and lymph nodes. It is a marker of T lymphocyte activation. The role of type 1 and type 2 T helper cells in appendicitis has been investigated experimentally. Serum ADA levels in acute appendicitis have not previously been studied.To assess the serum levels of ADA in patients with acute appendicitis.Serum levels of ADA were investigated in 30 cases with acute appendicitis (mean age 26 years; male/female 17/13) and 21 healthy controls (mean age 40 years; male/female 11/10). Levels of ADA were compared in patients with acute appendicitis and healthy controls. Correlation analysis between ADA and other inflammatory markers (C-reactive protein (CRP), high-sensitivity CRP, erythrocyte sedimentation rate and white blood cell count) was also performed.Mean (SD) serum ADA levels were significantly higher in those with acute appendicitis than in the control group (13.41 (3.56) U/l vs 9.39 (1.22) U/l; p0.001). There was no correlation between ADA and the other inflammatory markers investigated.Although serum levels of ADA do not correlate with other known inflammatory markers, its serum level is increased in acute appendicitis and it has a higher positive predictive value.

The values of C-reactive protein (CRP) can prove useful in determining disease progress. Because of synthesis by the liver, production of CRP in response to inflammation may be attenuated in patients with liver dysfunction. This may result in differences interpreting CRP levels in patient with portal and non-portal hypertension ascites. The aim of the present study is to assess discriminant value of serum and ascitic fluid CRP, which is easily accessible and inexpensive laboratory marker of inflammation, concentrations for diagnosis of underlying cause of ascites. This prospective study was conducted at Diskapi Yildirim Beyazit Educational and Research Hospital Department of Gastroenterology. Patients with ascites were further divided into two subgroups based on underlying cause of ascites: Group 1, patient with ascites due to portal hypertensive etiology (high-gradient ascites); Group 2, patient with ascites due to non-portal hypertensive etiology (low-gradient ascites). A total of 91 patients fulfilling the criteria for a diagnosis of ascites were enrolled in the study. Of these patients, 50 had proven (Group 1) ascites due to portal hypertensive etiology (high-gradient ascites) and 41 had clinical (Group 2) ascites due to non-portal hypertensive etiology (low-gradient ascites). Mean baseline serum and ascites levels of CRP were significantly higher in Group 2 compared to those in Group 1 (p = 0.021, p =

We read the study of Cheng et al. [1] with great interest and congratulate the authors on this excellent piece of work. The authors found that intravenous albumin transfusion strategy has beneficial effects in patients with gastrointestinal bleeding and hypoalbuminemia. In patients with advanced hypoalbuminemia and ascites, hypervolemia occurs as a result of a decrease in effective circulating volume (ECV), profound hypoalbuminemia and activation of the renin–angiotensin–aldosterone system [2]. The ensuing loss of blood due to acute upper gastrointestinal bleeding will tend to cause a further reduction of ECV. This situation will cause systemic vasoconstriction, renal blood flow and a decrease of the granular filtration fraction, as well as renal water reabsorption by over-activation of the renin–angiotensin–aldosterone system. Also, more aggressive transfusion therapy without colloid oncotic pressure extenders will be locked in a vicious cycle of hypervolemia and ascites, and increased risk of adverse events [3]. For these reasons, we agree with Dr. Cheng and colleagues that intravenous albumin transfusion strategy should be the main arm of therapy for management of advanced hypoalbuminemia.

WOS: 000313112900020, PubMed ID: 23063679, BACKGROUND & AIMS: Data are limited on the efficacy and safety of tenofovir and entecavir when given for more than 1 year to patients with hepatitis B-related cirrhosis. We investigated the long-term safety and efficacy of these antiviral drugs in patients with chronic hepatitis B virus (HBV) infection, with compensated or decompensated cirrhosis, and compared results with those from lamivudine. METHODS: We performed a retrospective analysis of data from 227 adult patients with chronic HBV infection who were diagnosed with cirrhosis, beginning in 2005, at 18 centers throughout Turkey. There were 104 patients who had decompensated cirrhosis, and 197 patients were treatment naive before. Seventy-two patients received tenofovir (followed up for 21.4 +/- 9.7 mo), 77 patients received entecavir (followed up for 24.0 +/- 13.3 mo), and 74 patients received lamivudine (followed up for 36.5 +/- 24.1 mo). We collected data on patient demographics and baseline characteristics. Laboratory test results, clinical outcomes, and drug-related adverse events were compared among groups. RESULTS: Levels of HBV DNA less than 400 copies/mL were achieved in 91.5%, 92.5%, and 77% of patients receiving tenofovir, entecavir, or lamivudine, respectively. Levels of alanine aminotransferase normalized in 86.8%, 92.1%, and 71.8% of patients who received tenofovir, entecavir, and lamivudine, respectively. Child-Turcotte-Pugh scores increased among 8.5% of patients who received tenofovir, 15.6% who received entecavir, and 27.4% who received lamivudine. Frequencies of complications from cirrhosis, including hepatic encephalopathy, variceal bleeding, hepatocellular carcinoma, and mortality, were similar among groups. Lamivudine had to be changed to another drug for 32.4% of the patients. CONCLUSIONS: Tenofovir and entecavir are effective and safe for long-term use in patients with compensated or decompensated cirrhosis from HBV infection.

Biliary microhamartomas, also known as bile duct hamartomas and von Meyenburg complexes, are benign neoplasms containing cystic dilated bile ducts embedded in fibrous stroma. They develop in hepatobiliary system, do not generally give clinical outcomes, and are detected incidentally. However, they can rarely show malignant transformation. Our aim was to report the contribution of computed tomography, routine magnetic resonance imaging, and magnetic resonance cholangiopancreatography in the diagnosis of biliary microhamartomas in a 61-year-old woman.

Introduction: Many noninvasive tests have been studied for the diagnosis and determining the liver fibrosis score (LFS). In this study, we aimed to research the correlation of mean platelet volume (MPV) and stage of liver fibrosis in patients with chronic hepatitis B (CHB). Patients and Methods: Fifty-nine patients with CHB were enrolled retrospectively into the study. Age–sex matched 25 healthy subjects were used as control group. The following data were obtained from computerized patient registry database: HBV-DNA level, hepatitis B e-antigen seropositivity, liver enzymes and function tests, white blood cell count, platelet count, hemoglobin, histological activity index, LFS, and MPV. Patients were divided into two groups: patients without significant fibrosis (F0, F1, or F2) (Group 1) and patients with advanced fibrosis (F3, F4) (Group 2). Results: A statistically significant increase in MPV was seen in patients with CHB compared with healthy controls (8.49±0.84 fl vs.7.65±0.42 fl, P

Kaposi's sarcoma (KS) is an unusual malignant vascular tumor principally affecting the skin of the lower extremities. It has four clinical varieties: classic, endemic, epidemic and iatrogenic.1 The latter is described mostly in organ transplant recipients receiving high-dose and/or long-term (9 to 23 months) immunosuppressive treatment.2 In addition, KS has been shown as a rare complication in inflammatory bowel diseases (IBD) that should be related to immunosuppression.3 Oral corticosteroids and immunomodulatory drugs, such as azathioprine (AZA) and 6-mercaptopurine (6-MP) are effective in Crohn's disease, however their use is limited …

Ornidazole is generally well tolerated antibiotic which is synthetic derivative of nitroimidazole. Serious side effects are very rarely encountered. The most common side effects are metallic taste, nausea, vomiting, abdominal pain and diarrhea.1 Even though it has been presented that ornidazole has side effects (for example neurotoxicity, glossitis and stomatitis). Hepatotoxicity related to this drug has been rarely reported. Before, this phenomenon was described with the three cases by Tabak, et al.2 Herein, we presented a case of recurrent prolonged hepatotoxicity associated with ornidazole. A 45-years-old female patient was admitted to our outpatient clinic with nausea, vomiting, loss of appetite, jaundice and abdominal pain. Her past medical history revealed vaginitis treated with two days course of oral ornidazole 500 mg twice daily. She also mentioned about ornidazole associated hepatitis following use of the drug a year ago. Meanwhile, elevated liver enzymes after ornidazole treatment in that period were as follows: ALT 720 U/l, AST 690 U/l, alkaline phosphatase 161 U/l, GGT 102 U/l, total bilirubin 8.2 mg/dl, direct bilirubin 4.0 mg/dl. On admission, physical examination revealed scleral jaundice and tenderness in the right upper quadrant. Laboratory examination revealed the following: ALT 397 U/l, AST 333 U/l, GGT 68, total bilirubin 1, 94 mg/dl. Alkaline phosphatase, albumin and prothrombin time were normal. She did not consume alcohol. She did not take herbal products and concomitant medication. She had not travelled any region of the world. Laboratory tests were normal for autoimmune hepatitis, thyroid tests, haemochromatosis or Wilson's disease. Viral markers for A-E were negative. Antinuclear antibody was negative. Hepatobiliary ultrasound revealed no evidence of extrahepatic obstruction, biliary ductal disease, hepatic parenchymal abnormalities, or cholelithiasis. These findings suggested hepatocellular type liver injury related with ornidazole. After ceasing the drug, transaminase and bilirubin levels returned to normal range after two months. We didn’t perform percutaneous liver biopsy because of liver function tests decreased to normal range and the patient didn’t accept. Besides she had a history of ornidazole induced hepatotoxicity. Ornidazole induced liver injury may be cytolytic, cholestatic, and/or mixed. In this report, we described a patient recurrent hepatitis due to ornidazole. Interestingly, hepatotoxicity due to ornidazole was appeared early as compared with previous cases.3 In conclusion, ornidazole which is frequently used nitroimidazole derivative may cause recurrent hepatitis. Physicians and patients should be awareness of hepatotoxicity due to ornidazole. Early recognition and withdrawal of the drug may prevent further damage.

Musculoskeletal disorders are well-defined extra-intestinal manifestations of inflammatory bowel diseases (IBD). There is little data regarding the frequencies of IBD and extra-intestinal manifestations from Central and East Europe and Middle Eastern countries. To determine the prevalence of peripheral arthritis in IBD and to document the relationship to other extra-intestinal manifestations. Enrolled in the study were 357 patients who were diagnosed with IBD from December 2002 through January 2008. All of the patients underwent a detailed whole-body examination by a gastroenterologist and rheumatologist. IBD-related peripheral arthritis (IBDPA) was found in 66 (18.5%) of the 357 patients (28.3% Crohn’s disease, 13.5% ulcerative colitis; p = 0.001 χ = 11.62). IBDPA was more frequent in female patients (60.6 vs. 39.4%, p = 0.000, χ = 11.12). In eight (12.1%) cases, IBDPA occurred before the onset of IBD. Acute self-limiting episodes, recurrences of the attacks, and persistent symptoms of arthritis were present in 40 (60.6%), 26 (39.3%), and 29 (45.7%) patients, respectively. Arthritis was symmetrical in 33 (50%) cases. Knees (65.2%) and ankles (62.1%) were the most commonly affected joints. Erythema nodosum and pyoderma gangrenosum were more common among patients with IBDPA than patients without it (p = 0.001, χ = 10.49, and p = 0.000 χ = 25.77, respectively). IBDPA is a frequent extra-intestinal complication of IBD. Those of female gender and the presence of Crohn’s disease, erythema nodosum and pyoderma gangrenosum have a higher risk to develop IBDPA.

Colorectal carcinoma, primarily a disease of adulthood, accounts for 0.2% of malignancies in adolescents and has very rarely been reported in childhood. Herein, we report a 15-year-old boy who presented with rectal bleeding, lower abdominal pain, and diarrhea. His physical examination revealed tender abdomen with hepatomegaly. A hard mass was palpated by digital rectal examination. Histologic examination revealed a mucinous rectal adenocarcinoma. He died 4 months after diagnosis. This case highlights the need for awareness of colorectal carcinomas and their invasive nature in the differential diagnosis of rectal bleeding and diarrhea in adolescents.

Hirschsprung disease (HD) is characterized by aganglionosis, which mainly occurs in the rectum and distal sigmoid colon. Typical HD is seldom diagnosed in adulthood, and segmental involvement is very rare. A 37-year-old man suffered from refractory constipation for 20 years. He could only defecate once a week and frequently needed an enema for defecation. A barium enema showed an annular stenotic segment of the rectosigmoid colon of 8 cm in length, which started 10 cm above anal circulation and showed dilated colon above the stenotic segment. The distal rectum was normal. The narrowed segment of the rectum was resected. At one-year follow up, the patient had normal defecation without laxatives.