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Background/aims: Endoscopic ultrasonography-guided gastrojejunostomy is a minimally invasive method for the management of gastric outlet obstruction. Conventionally, a lumen-apposing metal stent (LAMS) is used to create an anastomosis. However, LAMS is expensive and not widely available. In this report, we described a tubular fully covered self-expandable metallic stent (T-FCSEMS) for this purpose., Methods: Twenty-one patients (15 men [71.4%]; median age, 66 years; range, 40-87 years) were included in this study. A total of 19 malignant (12 pancreatic, 6 gastric, and 1 metastatic rectal cancer) and 2 benign cases were observed. The proximal jejunum was punctured with a 19 G needle. The stomach and jejunum walls were dilated with a 6 F cystotome, and a 20×80 mm polytetrafluoroethylene T-FCSEMS (Hilzo) was deployed. Oral feeding was initiated after 12 to 18 hours and solid foods after 48 hours., Results: The median procedure time was 33 minutes (range, 23-55 minutes). After two weeks, 19 patients tolerated oral feeding. In patients with malignancy, the median survival time was 118 days (range, 41-194 days). No serious complications or deaths occurred. All patients with malignancy tolerated oral food intake until they expired., Conclusion: T-FCSEMS is safe and effective. This stent should be considered as an alternative to LAMS for gastric outlet obstruction.

Percutaneous Endoscopic Gastrostomy (PEG) is a simple and effective method of enteral nutrition in many patients who cannot take oral food. The accidental dislodgement of the PEG tube after the maturation of the gastro-cutaneous fistula (stoma) is called late dislodgement. If it is not detected early, the stoma lumen gets narrower; and does not permit the passage of the replacement tube. In this case, the commonly followed method is to continue enteral nutrition by opening a new gastro-cutaneous fistula after the complete closing of the original stoma. Here, we present a stoma-saving bougie dilatation method in 3 cases with severely narrowed stomas after late accidental dislodgement of the PEG tube.

Objective: The aim of this study was to optimize the currently used direct spectrophotometric serum prolidase enzyme activity (SPEA) assay method and compare its diagnostic accuracy with current precipitation and direct spectrophotometric assay methods, AST-to-ALT ratio, age platelet index, AST-to-platelet ratio index, cirrhosis discriminate score, Doha score, FIB-4, FibroQ, fibrosis index, Goteborg University Cirrhosis Index , King's score, and Pohl score for distinguishing Ishak F0 from F1-F3 in patients with chronic hepatitis B (CHB) infection., Methods: Liver biopsy results from 112 patients were included in this study., Results: The SPEA values were 529 (292-794) U/L, 671 (486-927) U/L, and 1077 (867-1399) U/L with the precipitation, current, and optimized direct spectrophotometric assay methods, respectively. According to multivariate logistic regression analysis optimized direct spectrophotometric SPEA was the only statistically significant parameter to predict the early stages of liver fibrosis., Conclusions: Optimized direct spectrophotometric SPEA assay method could be used to distinguish early stages of liver fibrosis in patients with CHB infection instead of the currently used spectrophotometric SPEA assay methods and other evaluated liver fibrosis indexes., (© The Author(s) 2023. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Groove pancreatitis (GP) is a rare form of chronic pancreatitis that is less common and is now gaining awareness with multimodal imaging modalities. Our aim is to analyze the mid-long term outcomes of patients diagnosed with GP with different treatment approaches., Methods: A computerized search from electronic patient record database between May 2013 and June 2019 with the keywords 'groove', 'paraduodenal' was applied. The clinical, radiological and pathological data of 25 patients diagnosed with GP were obtained., Results: In the GP patient group, the median age was 55 (25-87) and 80% was male. Alcohol and tobacco abuse was 40% among GP patients. The most common symptoms were upper abdominal pain (84%) and nausea-vomiting (40%), respectively. Gastric outlet obstruction was observed in 4 (16%) patients. CT and EUS imaging were performed to majority of cases (96% and 92 %, respectively). EUS-FNA was done in 14 of 25 (56%) patients. It was reported as atypia, adenocarcinoma and benign in 2 (8%), 2 (8%) and 10 (40%) patients, respectively. EUS-FNA was helpful to diagnose two pancreatic head adenoCA whose preliminary radiological evaluation was GP. The mean follow-up period was 29 (3-71) months. Conservative approach was the predominantly preferred treatment (%56). Apart from conservative approach, treatment strategies included biliary stenting, sphincterotomy, wirsung stenting via ERCP, cholecystectomy etc. Considering all treatment modalities, symptoms improved in 12 (48%) patients and progressed with recurrent pancreatitis attacks in 7 (28%) patients., Conclusion: Because GP is a less well-known form of pancreatitis, it presents several challenges for clinicians in diagnosis and treatment. This form, which can mimic pancreatic malignancy in particular, must be differentiated from carcinoma. EUS(±FNA) is a useful diagnostic tool complementary to imaging. Although the conservative approach remains the first choice in most patients, the clinician should consider invasive endoscopic procedures and surgical options in special cases when necessary.

Background: There are studies reporting that the location of intraductal papillary mucinous neoplasia (IPMN) predicts malignancy. Therefore, we evaluated the cyst location's relationship with malignancy, and the possibility of using cyst size and location to distinguish between non-main duct (non-MD)-IPMNs, mucinous cystic neoplasia (MCN), and cystic pancreatic ductal adenocarcinoma (PDAC)., Methods: We performed a retrospective analysis of data from 122 patients with a definite cyto-histological diagnosis of non-MDIPMNs, LR-MCNs, and cystic PDACs via endoscopic ultrasound fine-needle aspiration between October 2011 and October 2020. We grouped the cyst locations as head, uncinate, neck (HUN), and corpus or tail (CT). On histology, low-grade dysplasia and intermediategrade dysplasia were considered low risk (LR), whereas high-grade dysplasia and invasive carcinoma were considered high risk (HR)., Results: Of the 122 patients (61 (50%) women, median age 61.5 years (range 19-85), there were 34 (27.9%) LR-non-MD-IPMNs, 33 (27%) HR-non-MD-IPMNs, 19 (15.6%) LR-MCNs, and 36 (29.5%) cystic PDACs. We found no significant difference between LRand HR-non-MD-IPMN locations (P = .803). Low-risk non-MD-IPMNs were significantly smaller than HR-non-MD-IPMNs (P < .001), LR-MCNs (P = .002), and cystic PDACs (P < .001). The area under the receiver operating characteristic curve (AUROC) was 0.819 (95% CI: 0.716-0.902; P < .0001), and demonstrated a cyst size cut-off <2.2 cm to differentiate LR cysts, while cysts <1.6 cm had a negative predictive value (NPV) of 100% in non-MD-IPMNs., Conclusion: Cyst location is not predictive of malignancy in non-MD-IPMNs. Low-risk non-MD-IPMNs were smaller than HR-non MDIPMNs, LR-MCNs, and cystic PDACs. The cyst size cut-off was 2.2 cm; however, <1.6 cm had a 100% NPV differentiating LR- from HR-non-MD-IPMNs.

Background: Mucinous pancreatic cystic lesions (PCLs) express different mucin (MUC) types according to their histomorphologic types. High cystic fluid viscosity may help in the detection of mucinous PCLs. We hypothesized that high cystic fluid viscosity may be suggestive of a certain MUC type in mucinous PCLs., Methods: Prespecified MUC types (MUC1, MUC2, MUC4, MUC5AC, and MUC6) were evaluated in 18 definitively diagnosed mucinous PCLs with sufficient tissue material and prediagnostic cyst fluid viscosity evaluation-string sign (SS)-test. We evaluated the agreement of MUC expression with positive SS test results. Later, we compared cystic fluid carcinoembryonic antigen (CEA) between the prespecified MUC expressing and nonexpressing cyst types., Results: A total of 18 mucinous PCL patients, 11 females, with mean age ± SD (59.7 ± 13.3) were included. Almost all malignant mucinous PCLs expressed MUC1 (71.4%) (P = .023). We found no significant agreement between the prespecified MUC types and positive SS, except MUC4 which had mild agreement. Also, no significant relation was found between cystic fluid CEA levels and MUC expression (P = .584)., Conclusion: We did not detect a significantly moderate or good agreement between the prespecified MUC types and SS test. MUC1 was highly expressed in malignant mucinous cysts; however, it was incompatible with the SS test. MUC4 expression showed mild agreement with the SS test in a small number of patients.

Introduction: Mucosal healing (MH) has been a treatment target with the introduction of biological agents in Crohn's disease (CD). Histone H4 increases in chronic inflammation., Aim: Our goal was to investigate the role of serum histone H4 in predicting MH., Material and Methods: The study included 44 patients who applied to the endoscopy unit for ileocolonoscopic evaluation with the diagnosis of ileocecal CD and 26 healthy controls. After ileocolonoscopic evaluation, we divided the patients into 2 groups: those with and those without MH, according to the presence of endoscopic ulcer or erosion findings. Blood samples were taken from these patients to analyse serum histone H4 before the endoscopic procedure. We first compared serum histone H4 levels between CD patients and the healthy control group and then between those with and those without MH among the CD patients. Finally, we compared CRP, ESR, and serum histone H4 levels in patients with CD according to the presence of MH and symptoms., Results: Serum histone H4 levels were significantly higher in ileocolonic CD patients compared to the healthy control group ( p = 0.002). Also, serum histone H4 levels were significantly higher in CD patients with no MH ( p = 0.028) or symptomatic patients ( p = 0.033). We did not find a significant difference in C-reactive protein and erythrocyte sedimentation rate levels between CD patients in the presence of MH ( p = 0.281 and p = 0.203, respectively) or symptoms (0.779 and 0.652, respectively)., Conclusions: Serum histone H4 might be a useful biomarker for MH prediction in ileocolonoscopic CD patients. Validation is needed for large numbers of patients., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Termedia.)

Background/aims: The role of cyst fluid carcinoembryonic antigen (CEA) level in differentiating mucinous pancreatic cystic lesions (PCLs) is controversial. We investigated the role of cyst fluid CEA in differentiating low-risk (LR)-intraductal papillary mucinous neoplasms (IPMNs) from high-risk (HR)-IPMNs and LR-mucinous cystic neoplasms (MCNs)., Methods: This was a retrospective study of 466 patients with PCLs who underwent endoscopic ultrasound-guided fine-needleaspiration over a 7-year period. On histology, low-grade dysplasia and intermediate-grade dysplasia were considered LR, whereas high-grade dysplasia and invasive carcinoma were considered HR., Results: Data on cyst fluid CEA levels were available for 50/102 mucinous PCLs with definitive diagnoses. The median CEA (range) levels were significantly higher in HR cysts than in LR cysts (2,624 [0.5-266,510] ng/mL vs. 100 [16.8-53,445]ng/mL, p=0.0012). The area under the receiver operating characteristic curve (AUROC) was 0.930 (95% confidence interval [CI], 0.5-0.8; p<0.001) for differentiating LR-IPMNs from LR-MCNs. The AUROC was 0.921 (95% CI, 0.823-1.000; p<0.001) for differentiating LR-IPMNs from HR-IPMNs. Both had a CEA cutoff level of >100ng/mL, with a negative predictive value (NPV) of 100%., Conclusion: Cyst fluid CEA levels significantly vary between LR-IPMNs, LR-MCNs, and HR-IPMNs. A CEA cutoff level of >100ng/mL had a 100% NPV in differentiating LR-IPMNs from LR-MCNs and HR-IPMNs.

Background/aims: Despite various scoring systems and imaging methods, it is hard to predict the severity and the course of acute pancreatitis (AP), thereby necessitating better and more reliable markers. Since inflammation plays a key role in the pathogenesis of AP, we sought to determine whether histone, which is a novel inflammatory marker, may play a role in the prediction of severity and prognosis., Materials and Methods: A total of 88 consecutive adult patients (>18 years) with a first AP episode were prospectively enrolled in the study. Severe AP was defined as having a revised Atlanta score >3 in the first 48 h after admission. Circulating histone 3 and 4 levels were measured using the enzyme-linked immunosorbent assay method., Results: Eighty-eight consecutive adult patients with a first episode of AP were divided into two groups according to severity, in which 56 (63.6%) were assigned to the mild AP group and 32 (36.4%) to the severe AP group. White blood cell, hemoglobin, creatinine, and aspartate aminotransferase levels were significantly higher in the severe AP group. However, there was no difference in serum histone levels between the groups, and there was no correlation between revised Atlanta score and serum histone levels either., Conclusion: Serum histone levels did not significantly differ between the severe and mild AP groups. Therefore, these markers may not provide additional benefit for determining the severity of AP.

Background: Hypertriglyceridemia (HTG)-induced acute pancreatitis (AP) leads to higher morbidity and mortality compared with other etiologies. The role of plasma exchange (PE) in this context is still not well established. We aimed to assess the clinical outcomes of patients with HTG-induced AP who underwent PE and compare it with those who did not., Patients and Methods: We retrospectively evaluated the data of patients who were admitted with HTG-induced AP between January 2013 and May 2018. The endpoint of the study was to assess the clinical outcomes, which included complication rates, mortality, and pancreatitis recurrence rate., Results: Overall, 41 patients were included in the final analysis. Of these, 12 (29.2%) underwent PE. Patients undergoing PE had more severe pancreatitis on the basis of the Japanese Severity Score [10 (83.3%) vs. 14 (48.3%), P=0.03, respectively). Although mortality was higher in patients who underwent PE [three (25.0%) vs. zero, P<0.01, respectively], there was no difference in terms of complications and recurrence rates. Over a median 21 months of follow-up, 11 (26.8%) patients had recurrent AP., Conclusion: Although PE effectively reduced plasma triglyceride levels, there was no decrease in mortality or recurrences.

Introduction: Endosonography guided celiac plexus neurolysis is efficacious in the management of severe pain due to advanced pancreatic cancer. Although endoscopic ultrasound (EUS) guided celiac neurolysis (CN) is mostly a safer procedure than the percutaneous posterior approach, severe complications such as paraplegia have been reported., Case Report: We describe a patient with advanced adenocarcinoma of the pancreas and severe pain who developed irreversible paraplegia after EUS guided CN., Conclusions: Endosonography guided celiac plexus neurolysis also might be complicated with paraplegia as already observed with percutaneous approach. The underlying mechanism could not be explained clearly until now. We detected concomitant embolic occlusion of Adamkiewicz and anterior radicularis magna arteries in magnetic resonance angiography. So, this procedure must be considered only for malignancy patients.

In this study, we evaluated the clinical features, treatment modalities, including TNF-blockers, purified protein derivative (PPD) test, chest X-ray and HRCT results in our AS patients. We evaluated the clinical features, disease activity and PPD results in 88 AS patients (72 males, 16 females, mean age: 38.3+/-10) diagnosed at our center. 119 RA, 28 SLE and 27 gouty arthritis patients followed up at the same time period were taken as the control group. The mean disease duration in AS patients was 12.6+/-8.3 years. The frequency of PPD positivity in AS patients (77.3%) was similar to that in gouty arthritis (70.4%) patients; and significantly higher than the frequency in SLE (21.4%) and RA (35.3%) patients (P values<0.001). There was a chest X-ray abnormality in 20 AS patients (22.7%). When subjects (11 patients, 12.5%) with apical fibrosis, aspergillosis, previous or active TB on chest X-ray and/or HRCT were compared to others; it was observed that they were older (P<0.001), had longer disease duration (P=0.006); and less chest expansion (P=0.01). Fifty patients were administered TNF-blockers. The PPD test was positive in 38 of patients (76%) using TNF-blockers. All of these patients were given isoniazid prophylaxis. After a median follow up of 18 months, TB did not develop. In Turkey which is a country with a relatively high incidence of TB, in spite of a higher frequency of PPD positivity in AS patients compared to RA and SLE patients, TNF-blockers did not result in any TB with suitable prophylaxis.

Objectives: In this study, we aimed to evaluate the frequency of purified protein derivative (PPD) skin test positivity and associated clinical features in RA patients., Materials and Methods: We included 94 (80 F, 14 M, mean age: 55.8) consecutive RA patients with a disease duration of 8.7 years. PPD test was performed in all RA patients; clinical features were recorded down; chest x-ray, pulmonary function tests and HRCT were available in all cases. As the control group, we included data of 21 SLE, 44 AS, 27 OA, 16 gouty arthritis and 18 vasculitis patients., Results: The frequencies of PPD positivity in RA (29.8%) and SLE (19%) patients were lower than in patients with AS (65.9%), gouty arthritis (68.8%) and OA (63%) (all p values < 0.01). PPD-positive RA patients were more frequently smokers (p = 0.005) and had a higher rate of RF seropositivity (p = 0.04) than PPD-negatives. PPD was less frequently positive in erosive RA disease (p = 0.033). Chest x-rays and HRCT abnormalities were detected in 41.8% and 62.7% of RA patients, respectively. Frequencies of chest x-ray and HRCT abnormalities in PPD-positive and PPD-negative patients were not different from each other (p > 0.05)., Conclusion: In our country in which tuberculosis is relatively frequent -contrary to the situation in AS patients- we observed a lower frequency of PPD positivity in RA and SLE patients compared to patients with other rheumatic diseases. We did not find any relationship between PPD positivity and the frequency of chest x-ray, HRCT abnormalities.

Objective: In this study, we determined the frequency of gallbladder stone (GBS) in rheumatoid arthritis (RA) patients and evaluated factors which could affect the formation of GBS--such as lipids and the GB motilities of the patients., Methods: One hundred and thirteen RA patients (92F, 21M, mean disease duration: 8.9 years) and 117 healthy controls (94F, 23M) were included. In all RA patients, the clinical findings were recorded down; biochemical parameters and body mass index (BMI) were determined; and, abdominal ultrasonography was performed. In addition, 16 RA patients and 20 controls who were age-matched were randomly chosen for GB emptying monitored by ultrasound at 30-minute intervals for 2 hours after a mixed meal. Fasting volume (FV), residual volume (RV) and ejection fraction (EF) for all GBs were assessed., Results: There was a tendency towards a higher frequency of GBS including cholecystectomy (11 GBS, 11 cholecystectomy, 19.5%) in RA patients when compared to controls (8 GBS, 5 cholecystectomy, 11.1%) (p = 0.08). The frequency of GBS plus cholecyctectomy in female RA patients (22.8%) was significantly higher than the control group (11.7%, p = 0.044). Logistic regression analysis showed that only older age was significantly associated with the presence of GBS in RA (OR:1.05, p = 0.048). There was no difference between the 2 groups in FV (p > 0.05). RV, PRV and EF were significantly higher in RA patients than in the control group (p < 0.05)., Conclusion: We diagnosed a higher frequency of GBS in female RA patients when compared to controls. Impaired GB motility in RA patients might contribute to an increased incidence of GBS development.