The Efficacy of Biofeedback Therapy in Patients with Solitary Rectal Ulcer and Dyssynergic Defecation.

BACKGROUND: The treatment of solitary rectal ulcer (SRU) is challenging and controversial; generally, no response to conventional treatments can be obtained, particularly in patients with dyssynergic defecation (DD). We assessed the efficiency of biofeedback therapy (BFT) in patients who did not respond to conservative treatments and had coexistence of SRU and DD. METHODS: BFT responses, as well as anorectal manometry and rectoscopy results of 20 patients with the coexistence of SRU and DD, were assessed. RESULTS: Mean age was 32.5 years. Of the patients, 12 were female, and 8 of them were male. An average of 12 sessions of BFT was performed on the patients. Ulcer disappeared in 11 patients (55%) after BFT, and the ulcer size decreased in 3 patients (15%). However, ulcers healed in 9 (90%) of 10 patients whose DD pattern disappeared following BFT, and ulcers healed in only 20% of patients whose DD pattern continued (p = 0.005). The change in anal resting pressure after BFT was significant (p = 0.016). Ulcers were healed in 87.5% (7/8) of the patients whose anal resting pressure decreased after BFT and whose DD disappeared, while ulcers remained untreated in 85.7% of the patients whose anal resting pressure decreased, but the DD pattern continued (p = 0.005). CONCLUSIONS: SRU patients with DD are typically unresponsive to medical treatments. Ameliorating anorectal dyssynergia should be the priority of treatment in these patients. BFT is an effective treatment for DD. BFT enhances the healing of ulcers in patients with SRU by restoring coordination of the pelvic floor.

[Neurological disorders in liver transplantation].

Background and purpose: Liver transplantation is the only curative treatment in patients with end-stage liver failure. It has been associated with neurological disorders more frequently than other solid organ transplantations. We aimed to detect neurological disorders in liver transplantation patients and determine those that affect mortality. Methods: One hundred eighty-five patients, 105 with and 80 without neurological disorders, were included in this study. The follow-up was categorized into three periods: preoperative, early postoperative and late postoperative. We analyzed all medical records, including demographic, laboratory, radiological, and clinical data. Results: Neurological disorders were observed in 52 (28.1%) patients in the preoperative period, in 45 (24.3%) in the early postoperative, and in 42 (22.7%) in the late postoperative period. Hepatic encephalopathy in the preoperative and altered mental state in the post-operative period were the most common neurological disorders. Both hepatic encephalopathy (37.5%) and altered mental state (57.7%) caused high mortality (p=0.019 and 0.001) and were determined as indepen-dent risk factors for mortality. Living donor transplantation caused less frequent mental deterioration (p=0.049). The mortality rate (53.8%) was high in patients with seizures (p=0.019). While mortality was 28.6% in Wilson's disease patients with neurological disorders, no death was observed in patients without neurological disorders. Conclusion: We identified a wide variety of neurological disorders in liver transplantation patients. We also demonstrated that serious neurological disorders, including hepatic encephalopathy and seizures, are associated with high morbidity and mortality. Therefore, in order to avoid poor outcomes, hepatic encephalopathy should be considered as a prioritization criterion for liver transplantation.

Role of hepatosteatosis in HBsAg seroconversion in HBeAg-negative chronic hepatitis B patients.

BACKGROUND: In chronic Hepatitis B virus (HBV) infection, certain individual and viral characteristics such as advanced age, presence of hepatic steatosis (HS), normal ALT levels, initially negative HBeAg and HBV DNA, and genotype of the virus are associated with HBsAg seroclearance and seroconversion. Herein, we report the results of our study evaluating the association between hepatosteatosis and HbsAg seroconversion. METHODS: The clinical and biochemical data of patients with CHB and hepatosteatosis (HS) (HBsAg seroconversion, n:52, and non-HbsAg seroconversion, n:352), and the rate of development of HBsAg seroconversion were evaluated. RESULTS: We collected data from 404 patients with HBeAg negative CBH (mean age ± SD: 36.2 ± 11 years; 223 [55.2%] men, 181 [44.8%] women). The mean age at diagnosis of disease was 36.2 ± 11 years. The mean duration of the disease was 10.6 ± 7 years. Seroconversion developed in 52 patients (12.8%) with serum HBsAg positive (mean ± SD: 12.7 ± 5.8). Elderly age and the duration of disease time were significantly associated with seroconversion (P < .001). The presence of serum HBsAg seroconversion was significantly associated with hepatosteatosis (OR: 3.06, 95% CI 1.64-5.71, P < .01). Serum HBsAg seroconversion was more frequent in patients with mild HS than patients with moderate-severe HS (P = .04). In multivariate regression analysis, the presence of HS was found to be an independent factor predicting the development of HBsAg seroconversion (OR: 2.07 95% GA:1.07-4.0 P = .03). CONCLUSION: The presence of mild HS in HBeAg negative chronic hepatitis B patients contributes to HBsAg seroconversion. Further studies are required to better understand the relationship between steatosis and HBsAg seroconversion.

Lusutrombopag for the Treatment of Thrombocytopenia in Patients With Chronic Liver Disease Undergoing Invasive Procedures (L-PLUS 2).

Thrombocytopenia may be associated with increased bleeding risk impacting timing and outcome of invasive procedures in patients with chronic liver disease (CLD). Lusutrombopag, a small-molecule, thrombopoietin (TPO) receptor agonist, was evaluated as a treatment to raise platelet counts (PCs) in patients with thrombocytopenia and CLD undergoing invasive procedures. L-PLUS 2 was a global, phase 3, randomized, double-blind, placebo-controlled study. Adults with CLD and baseline PCs < 50 × 109 /L were randomized to receive once-daily lusutrombopag 3 mg or placebo ≤ 7 days before an invasive procedure scheduled 2-7 days after the last dose. The primary endpoint was avoidance of preprocedure platelet transfusion and avoidance of rescue therapy for bleeding. A key secondary endpoint was number of days PCs were ≥ 50 × 109 /L throughout the study. Safety analysis was performed on patients who received at least one dose of study drug. This study occurred between June 15, 2015, and April 19, 2017, with a total of 215 randomized patients (lusutrombopag, 108; placebo, 107); 64.8% (70/108) of patients in the lusutrombopag group versus 29.0% (31/107) in the placebo group met the primary endpoint (P < 0.0001; difference of proportion 95% confidence interval [CI], 36.7 [24.9, 48.5]). The median duration of PCs ≥ 50 × 109 /L was 19.2 days with lusutrombopag (without platelet transfusion) compared with 0.0 in the placebo group (with platelet transfusion) (P = 0.0001). Most adverse events were mild or moderate in severity, and rates were similar in the lusutrombopag and placebo groups (47.7% and 48.6%, respectively). Conclusion: Lusutrombopag was superior to placebo for reducing the need for platelet transfusions and achieved durable PC response in patients with thrombocytopenia and CLD undergoing invasive procedures, with a safety profile similar to placebo.

Genome-wide Association Study Identifies Genetic Variants Associated With Early and Sustained Response to (Pegylated) Interferon in Chronic Hepatitis B Patients: The GIANT-B Study.

BACKGROUND: (Pegylated) Interferon ([Peg]IFN) therapy leads to response in a minority of chronic hepatitis B (CHB) patients. Host genetic determinants of response are therefore in demand. METHODS: In this genome-wide association study (GWAS), CHB patients, treated with (Peg)IFN for at least 12 weeks ± nucleos(t)ide analogues within randomized trials or as standard of care, were recruited at 21 centers from Europe, Asia, and North America. Response at 24 weeks after (Peg)IFN treatment was defined as combined hepatitis B e antigen (HBeAg) loss with hepatitis B virus (HBV) DNA <2000 IU/mL, or an HBV DNA <2000 IU/mL for HBeAg-negative patients. RESULTS: Of 1144 patients, 1058 (92%) patients were included in the GWAS analysis. In total, 282 (31%) patients achieved the response and 4% hepatitis B surface antigen (HBsAg) loss. GWAS analysis stratified by HBeAg status, adjusted for age, sex, and the 4 ancestry components identified PRELID2 rs371991 (B= -0.74, standard error [SE] = 0.16, P = 3.44 ×10-6) for HBeAg-positive patients. Importantly, PRELID2 was cross-validated for long-term response in HBeAg-negative patients. G3BP2 rs3821977 (B = 1.13, SE = 0.24, P = 2.46 × 10-6) was associated with response in HBeAg-negative patients. G3BP2 has a role in the interferon pathway and was further examined in peripheral blood mononuclear cells of healthy controls stimulated with IFNα and TLR8. After stimulation, less production of IP-10 and interleukin (IL)-10 proteins and more production of IL-8 were observed with the G3BP2 G-allele. CONCLUSIONS: Although no genome-wide significant hits were found, the current GWAS identified genetic variants associated with (Peg)IFN response in CHB. The current findings could pave the way for gene polymorphism-guided clinical counseling, both in the setting of (Peg)IFN and the natural history, and possibly for new immune-modulating therapies. CLINICAL TRIALS REGISTATION: NCT01401400.

Hepatitis B core-related antigen monitoring during peginterferon alfa treatment for HBeAg-negative chronic hepatitis B.

Serum Hepatitis B core-related antigen (HBcrAg) level moderately correlates with cccDNA. We examined whether HBcrAg can add value in monitoring the effect of peginterferon (PEG-IFN) therapy for HBeAg-negative chronic hepatitis B (CHB) infection. Thus, serum HBcrAg level was measured in 133 HBeAg-negative, mainly Caucasian CHB patients, treated with 48 weeks of PEG-IFN alfa-2a. We assessed its association with response (ALT normalization & HBV DNA < 2000 IU/mL) at week 72. HBcrAg level strongly correlated with HBV DNA level (r = 0.8, P < 0.001) and weakly with qHBsAg and ALT (both r = 0.2, P = 0.01). At week 48, mean HBcrAg decline was -3.3 log U/mL. Baseline levels were comparable for patients with and without response at week 72 (5.0 vs 4.9 log U/mL, P = 0.59). HBcrAg decline at week 72 differed between patients with and without response (-2.4 vs -1.0 log U/mL, P = 0.001), but no cut-off could be determined. The pattern of decline in responders resembled that of HBV DNA, but HBcrAg decline was weaker (HBcrAg -2.5 log U/mL; HBV DNA: -4.0 log IU/mL, P < 0.001). For early identification of nonresponse, diagnostic accuracy of HBV DNA and qHBsAg decline at week 12 (AUC 0.742, CI-95% [0.0.629-0.855], P < 0.001) did not improve by adding HBcrAg decline (AUC 0.747, CI-95% [0.629-0.855] P < 0.001), nor by replacing HBV DNA decline by HBcrAg decline (AUC 0.754, CI-95% [0.641-0.867], P < 0.001). In conclusion, in Caucasian patients with HBeAg-negative CHB, decline of HBcrAg during PEG-IFN treatment was stronger in patients with treatment response. However, HBcrAg was not superior to HBV DNA and qHBsAg in predicting response during PEG-IFN treatment.

Long-term follow-up of patients treated with entecavir and peginterferon add-on therapy for HBeAg-positive chronic hepatitis B infection: ARES long-term follow-up.

Addition of peginterferon alpha (PEG-IFN add-on) to entecavir (ETV) treatment after a short lead-in phase results in more response than ETV monotherapy in HBeAg-positive chronic hepatitis B infection (CHB). This study is the first to assess long-term efficacy of this treatment strategy. Patients who received ETV ± 24 weeks of PEG-IFN add-on in a global trial (ARES study) and completed follow-up were eligible to participate in this observational LTFU study if they had at least one combined HBeAg and HBV DNA measurement beyond week 96 of the ARES study. The primary endpoint was combined response (HBeAg loss and HBV DNA <200 IU/mL) at LTFU. In total, 48 patients treated with PEG-IFN add-on and 48 patients treated with ETV monotherapy were included. The median follow-up duration was 226 (IQR 51) weeks, and 86/96 (90%) patients were initial non-responders. At LTFU, combined response was present in 13 (27%) vs 11 (23%) patients (P = 0.81), and 1 log10  HBsAg decline in 59% vs 28% (P = 0.02) for PEG-IFN add-on and ETV monotherapy, respectively. In 41 initial non-responders who continued ETV therapy, combined response at LTFU was present in 9 patients (PEG-IFN add-on: 5/22 [23%]; ETV monotherapy: 4/19 [21%]). Beyond week 96 of follow-up, rates of serological response became comparable between PEG-IFN add-on and ETV monotherapy. Although in this LTFU study initial non-responders were overrepresented in the add-on arm, PEG-IFN add-on possibly leads rather to accelerated HBeAg loss than to increased long-term HBeAg loss rates.

Low recurrence rate of hepatocellular carcinoma following ledipasvir and sofosbuvir treatment in a real-world chronic hepatitis C patients cohort.

The aims of the present study were to evaluate the efficacy and tolerability of ledipasvir/sofosbuvir (LDV/SOF) with or without ribavirin in the treatment of chronic hepatitis C (CHC) in patients with advanced liver disease and to analyse whether the use of LDV/SOF treatment is associated with a new occurrence of hepatocellular carcinoma (HCC) during and after LDV/SOF treatment. The Turkish Early Access Program provided LDV/SOF treatment to a total of 200 eligible CHC patients with advanced liver disease. The median follow-up period was 22 months. All patients were Caucasian, 84% were infected with genotype 1b, and 24% had a liver transplantation before treatment. The sustained virological response (SVR12) was 86.0% with ITT analysis. SVR12 was similar among patients with Child-Pugh classes A, B and C disease and transplant recipients. From baseline to SVR12, serum ALT level and MELD score were significantly improved (P < 0.001). LDV/SOF treatment was generally well tolerated. Only one patient developed a new diagnosed HCC. Seventeen of the 35 patients, who had a history of previous HCC, developed HCC recurrence during the LDV/SOF treatment or by a median follow-up of 6 months after treatment. HCC recurrence was less commonly observed in patients who received curative treatment for HCC compared with those patients who received noncurative treatment (P = 0.007). In conclusion, LDV/SOF with or without ribavirin is an effective and tolerable treatment in CHC patients with advanced liver disease. Eradication is associated with improvements in liver function and a reduced risk of developing a new occurrence of HCC.

Adding pegylated interferon to entecavir for hepatitis B e antigen-positive chronic hepatitis B: A multicenter randomized trial (ARES study).

UNLABELLED: Entecavir (ETV) is a potent inhibitor of hepatitis B viral replication, but long-term therapy may be required. We investigated whether adding on pegylated interferon (Peg-IFN) to ETV therapy enhances serological response rates. In this global investigator-initiated, open-label, multicenter, randomized trial, hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) patients with compensated liver disease started on ETV monotherapy (0.5 mg/day) and were randomized in a 1:1 ratio to either Peg-IFN add-on therapy (180 µg/week) from week 24 to 48 (n = 85) or to continue ETV monotherapy (n = 90). Response was defined as HBeAg loss with HBV DNA <200 IU/mL at week 48. Responders discontinued ETV at week 72. All patients were followed until week 96. Response was achieved in 16 of 85 (19%) patients allocated to the add-on arm versus 9 of 90 (10%) in the monotherapy arm (P = 0.095). Adjusted for HBV DNA levels before randomized therapy, Peg-IFN add-on was significantly associated with response (odds ratio: 4.8; 95% confidence interval: 1.6-14.0; P = 0.004). Eleven (13%) of the add-on-treated patients achieved disease remission after ETV cessation versus 2 of 90 (2%) of those treated with monotherapy (P = 0.007), which was 79% (11 of 14) versus 25% (2 of 8) of those who discontinued ETV (P = 0.014). At week 96, 22 (26%) patients assigned add-on versus 12 (13%) assigned monotherapy achieved HBeAg seroconversion (P = 0.036). Peg-IFN add-on led to significantly more decline in hepatitis B surface antigen, HBeAg, and HBV DNA (all P < 0.001). Combination therapy was well tolerated. CONCLUSION: Although the primary endpoint was not reached, 24 weeks of Peg-IFN add-on therapy led to a higher proportion of HBeAg response, compared to ETV monotherapy. Add-on therapy resulted in more viral decline and appeared to prevent relapse after stopping ETV. Hence, Peg-IFN add-on therapy may facilitate the discontinuation of nucleos(t)ide analogs.

Clinical and histological features of idiosyncratic liver injury: Dilemma in diagnosis of autoimmune hepatitis.

AIM: Drug-induced liver injury (DILI) is becoming a worldwide problem with its still unexplained properties. METHODS: The data of patients who were diagnosed with DILI between January 2008 and December 2013 were assessed. RESULTS: Five patients had been diagnosed with intrinsic and 82 patients with idiosyncratic DILI. The most common causative agents were antimicrobial drugs. The most common injury pattern was hepatocellular. When patients with bilirubin levels of more than 5 mg/dL were divided into two groups according to receiving steroid therapy (n = 11) or not (n = 40), there was not any significant difference according to their clinical results (P > 0.05). Five of the idiosyncratic DILI patients were diagnosed with drug-induced autoimmune hepatitis (DI-AIH). In histopathological examination, hepatic rosette formation and emperipolesis were observed to be more common among patients with DI-AIH when compared with ones without (P < 0.05). Interestingly, in the remaining patients with DILI (n = 77), three of them were diagnosed with classic autoimmune hepatitis during long-term follow up (range, 11-51 months). CONCLUSION: The most common causes were antimicrobials, but any agents that have not been defined to cause DILI can induce DILI. The efficacy of steroids in DILI has not been observed but all deaths were observed in the steroid-free group. The association of DILI and AIH was observed in two different types in terms of diagnosis in our study. The first association was DI-AIH. The second one is the classical AIH which developed in three patients after a few months following spontaneous recovery of DILI.

Pregabalin: A New Adjunct in Calcineurin Inhibitor Pain Syndrome Treatment.

Tacrolimus and cyclosporin are calcineurin inhibitors (CIs) commonly used in organ transplants. These agents rarely cause a severe, debilitating pain syndrome of especially lower extremities, known as CI pain syndrome (CIPS). Although the pathogenesis is not well understood, neuropathic pain mechanisms have started to be discussed in the recent literature. Here, presenting a 48-year-old male with CIPS who recovered after pregabalin 150 mg twice daily, we aimed to emphasize the importance of this syndrome and offer a new approach for the treatment. This is the first report in the literature where pregabalin is demonstrated to be effective in CIPS.

A Single-Center Retrospective Comparison of Doxorubicin-Loaded HepaSphere Transarterial Chemoembolization with Conventional Transarterial Chemoembolization for Patients with Unresectable Hepatocellular Carcinoma.

PURPOSE: To compare doxorubicin-loaded HepaSphere transarterial chemoembolization versus conventional transarterial chemoembolization in terms of survival, time to recurrence, acute reversible hepatotoxicity, postembolization syndrome, and chemoembolization-related mortality and morbidity. MATERIALS AND METHODS: One hundred twenty-six patients (103 men, 23 women; mean age, 64.3 y) with unresectable hepatocellular carcinoma (HCC) who underwent conventional chemoembolization between January 2007 and March 2011 or drug-eluting embolic (DEE) chemoembolization (after the protocol change) between March 2011 and October 2014 were included in a retrospective analysis. Primary outcome measures were survival and time to recurrence. Secondary outcome measures were frequency of recurrence, technical success, acute reversible hepatotoxicity, postembolization syndrome, and chemoembolization-related mortality and morbidity. RESULTS: The technical success rate was 97.1%. There were no significant differences between the conventional and DEE chemoembolization groups with regard to mean survival duration (39.0 vs 37.4 mo), recurrence (32.9% vs 39.6%), postembolization syndrome (90% vs 89%), and chemoembolization-related mortality (5.5% vs 1.9%) and morbidity (9.6% vs 9.4%; P > .05). The time to recurrence was shorter in DEE chemoembolization-treated patients than in conventional chemoembolization-treated patients (5.0 vs 11.5 mo; P = .006), and acute reversible hepatotoxicity occurred more frequently after conventional chemoembolization (P = .019). CONCLUSIONS: Conventional chemoembolization and DEE chemoembolization were safe and effective interventions for unresectable HCC. DEE chemoembolization was not better than conventional chemoembolization in terms of survival and was associated with a shorter time to recurrence. Acute reversible hepatotoxicity occurred more frequently after conventional chemoembolization.

Features of systemic lupus erythematosus in patients with autoimmune hepatitis.

Although systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH) are distinct diseases, in clinical practice differentiation of one from other may be difficult. The aim of this study was to asses features of SLE in patients with diagnosis of AIH.Thirty patients [mean age: 52.4 ± 11.8 years; 23 (76.7 %) female] were included in the study. Seven (23.3 %) of the patients full filled 4 or more criteria for classification of SLE. None of the patients had muco-cutaneous lesions characteristic to SLE. Three patients had rheumatoid factor negative arthritis, and 2 patients had pericardial effusion. Four patients had significant thrombocytopenia (<100 × 10(3)/µL), and one of these patients had pancytopenia. None of the patients had hematuria, but 3 patients had proteinuria which did not affect renal function during the study period. One patient died due to pancytopenia-associated pulmonary infection. Among the treated patients with SLE features, 2/5 (40 %) achieved ALT normalization and 9/12 (75 %) of the remaining patients achieved ALT normalization (Fisher's exact test; p = 0.28) during the study period. Although the difference is non-significant, treatment response of AIH patients with SLE features seemed to be delayed and incomplete compared to other patients, but with the limited number of patients it is inconvenient to reach a definitive conclusion. Further studies are needed to identify role of features of SLE on treatment response in patients with AIH.

Revisiting the Ranson score in acute pancreatitis: Is the drop in hematocrit a worrisome sign?

BACKGROUND: The Ranson score has 11 parameters that are complex and laborious to implement. In this study, we aimed to create a revised Ranson score by modifying the parameters in Ranson. METHODS: A total of 938 patients diagnosed with acute pancreatitis (AP) between 2014 and 2021 were included in the study. The parameters of the Ranson score were included in the univariate and multivariate analyses. According to the results, some of these parameters were modified, and then the revised Ranson score was created. RESULTS: The revised Ranson system was created with nine parameters by modifying the hematocrit parameter at 48 hours and excluding the aspartate aminotransferase parameter from the scoring system. For in-hospital mortality, the area under the curve value of the revised Ranson was 0.959 (95% CI: 0.931-0.986), and it was significantly higher compared to the three scoring systems evaluated. At a cut-off value of 3.5, the revised Ranson had a sensitivity and specificity of 91.7% and 89.1%, respectively, for mortality. CONCLUSION: The revised Ranson scoring system had better predictive ability for all clinical outcomes compared to the original Ranson in our large sample of 938 patients. However, the revised version should be further validated by prospective and multicenter studies.

Impact of COVID-19 pandemic on diagnosis and treatment access of patients with viral hepatitis in Turkey.

INTRODUCTION: We aimed to evaluate access to diagnosis, treatment and follow-up in patients with viral hepatitis during the COVID-19 pandemic. METHODOLOGY: Patients who started treatment for hepatitis B and hepatitis C were included in the study and analyzed in two periods: before-pandemic and during-pandemic. Indication for treatment and frequency of laboratory follow-up was obtained from hospital records. A telephone survey was administered to evaluate treatment access and compliance. RESULTS: Four centers with 258 patients were included in the study. Of these 161 (62.4%) were male, median age was 50 years. The number of patients, admitted to outpatient clinics was 134647 in the before-pandemic period and 106548 in the during-pandemic period. Number of patients who started treatment for hepatitis B were significantly high during-pandemic period compared with before-pandemic (78 (0.07%); 73 (0.05%) respectively; p = 0.04). The number who received treatment for hepatitis C was similar in both periods: 43 (0.04%); 64 (0.05%), respectively (p = 0.25). Prophylactic treatment for hepatitis B, due to immunosuppressive agents was significantly higher in during-pandemic period (p = 0.001). In the laboratory follow-ups at 4th, 12th and 24th weeks of treatment, worse adherence was detected in during-pandemic (for all p < 0.05). Access to treatment and compliance of all patients was over 90% and did not differ in the two periods. CONCLUSIONS: During-pandemic, hepatitis patients' access to diagnosis, treatment initiation and follow-up had worsened in Turkey. The health policy implemented during the pandemic had a positive impact on patients' access to and compliance to treatment.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

The role of mean platelet volume in the diagnosis of hepatocellular carcinoma in patients with chronic liver disease.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) has poor long-term prognosis so we need new diagnostic techniques and markers to detect HCC in the early phases. The aim of this study was to analyze the levels of serum mean platelet volume in HCC. METHODOLOGY: The clinical data of 230 subjects with normal, chronic hepatitis, cirrhosis and HCC were retrospectively analyzed at our hospital between January 2009 and December 2009. The levels of MPV were determined in patients with liver disease and compared between patient groups and with healthy persons. RESULTS: Serum MPV levels were significantly increased compared to the patients with chronic hepatitis, cirrhosis, and the control group (p<0.01). The cut-off value for MPV for the detection of HCC in cirrhotic patients was calculated as ≥9.2fl using ROC analysis [Sensitivity: 68.3%, specificity: 62.1%, AUC: 0.676 (0.580-0.773), p<0.001]. Additionally, serum MPV levels show higher sensitivity for diagnosis of HCC than AFP. An AFP of more than 7.4IU/mL and an MPV of ≥9.2fl, both put together, had a specificity of 95.2%, while when used separately, they have a sensitivity of 87.5%. CONCLUSIONS: MPV may be a potential or adjunctive marker of HCC in patients with chronic liver disease.

Endoscopic and pathological aspects of gastric polyps: a Turkish referral center study.

BACKGROUND/AIMS: The aim of the present study was to retrospectively analyze all the polyps of patients undergoing endoscopic polypectomy or forceps biopsy according to their types, frequency, localization, number and gender distribution. METHODOLOGY: Data from patients who underwent upper endoscopy in the Türkiye Yüksek Ihtisas Postgraduate Research Hospital between March 2007 and November 2009 were analyzed retrospectively. Forceps biopsy or polypectomy were performed for all polypoid lesions that were identified during the endoscopy. RESULTS: In the study period, 14,935 patients underwent 18,522 upper endoscopies. After excluding cirrhotic patients, and patients with a history of prior gastrectomy, chronic gastritis and edema or congestion, the remaining 124 (0.83%) patients with gastric polyps were included in the study. Histopathologically, the most frequently diagnosed polyps were hyperplastic polyps (55.6%). Fundic gland polyps (9.7%), foveolar hyperplasia (8.1%) and inflammatory polyps (7.3%) were also frequent. Adenocarcinoma was more frequently seen in males, whereas hyperplastic polyps and carcinoid tumors were found more often in females, and this difference was statistically significant (p<0.009). CONCLUSIONS: Results of the present study indicate that hyperplastic polyps make up the largest group. Although there is widespread PPI use, no increases in the frequency of fundic gland polyps were observed. However, increases in the ratio of carcinoid tumors suggest a suspicion of tumor development with PPI use.

Double balloon enteroscopy: a 3-year experience at a tertiary care center.

BACKGROUND/AIMS: To evaluate the indications, diagnostic yield, therapeutic interventions, complications and safety of double balloon enteroscopy (DBE) in clinical practice. METHODOLOGY: The medical records of the patients who underwent DBE at the Turkiye Yuksek Ihtisas Hospital between October 2007 and January 2010 were examined to note the demographic data, indications for the examination, results of previous non-invasive small bowel imaging and endoscopic procedures and the results of DBE including findings, endoscopic interventions, complications and pathological reports. RESULTS: A total of 139 procedures were performed in 118 patients. DBE was performed 81 times through mouth and 26 times through anus and additionally both approaches were used 16 times in the same patients. Panenteroscopy was successfully performed in 13 of 16 patients (87.5%) in whom it was attempted. The most common indication was obscure gastrointestinal bleeding (28.8%). DBE had an overall diagnostic and/or therapeutic contribution in 63 (53.4%) patients. The main pathologies detected on DBE were polyps (12.7%), infammation (10.7%) and vascular lesions (3.4%). Complications were recognized in four cases (3.4%) but no major complication occured. CONCLUSIONS: Our retrospective analysis showed that DBE is a useful, safe and well-tolerated method with a diagnostic and therapeutic impact for the management of small bowel diseases.

High Grade Serous Ovarian Carcinoma in a Liver Transplant Recipient Patient: A Case Report and Review of Literature.

According to GLOBOCAN 2020 data, the incidence of ovarian cancer is 1.6%. Ovarian cancer ranks 19th in incidence and 15th in mortality with a rate of 2.1%. High-grade serous ovarian cancer is the most common subtype of malignant ovarian tumors, and around 70% to 80% of all ovarian malignancies are included in this group. The incidence of gynecologic malignancies in liver transplant recipients is between 0% and 1.5%, and the duration of diagnosis for gynecologic cancer after transplantation is between 1 and 59 months. A 52-year-old patient was admitted to our hospital complaining of a periumbilical nodule. Her medical history revealed she had a cadaver liver transplantation in 2003 because of cirrhosis due to hepatitis B. On her physical examination, an erythematous nodular lesion was observed in the umbilical region. Ultrasonography demonstrated diffuse ascites and approximately 30 mm of a soft tissue density with lobulated contours located on the periumbilical skin. Both cytology and biopsy results were reported consistent with high-grade serous ovarian cancer. She underwent an operation, she had no problems during the postoperative follow-ups, and she was discharged on the eighth postoperative day. According to the 2018 International Federation of Gynecology and Obstetrics staging criteria for ovarian cancer, the patient's cancer was stage IVB. The patient received 6 cycles of adjuvant chemotherapy that included carboplatin (AUC = 6) and paclitaxel (175 mg/m2). The patient was evaluated as having a complete response according to Response Evaluation Criteria in Solid Tumors. The patient has been disease-free for 11 months after diagnosis.