Acute peripancreatic fluid collection in acute pancreatitis: Incidence, outcome, and association with inflammatory markers.

Background: The hospital outcomes and predictors of acute peripancreatic fluid collection (APFC) have not been well-characterized. In this study, we aimed to investigate the clinical outcomes of APFC in patients with acute pancreatitis (AP) and the role of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and C-reactive protein (CRP) level in predicting the occurrence of APFC. Methods: In this retrospective study, the complicated group (patients with APFC) and the uncomplicated group (patients without APFC) were compared for their clinical characteristics, hospital outcomes (mortality rate, intensive care unit admission rate, and length of hospital stay), pseudocyst formation, CRP levels, SII, and SIRI on admission and at 48 hours. Results: Of 132 patients with AP, 51 (38.6%) had APFC and eight (6.1%) had pancreatic pseudocysts. Of 51 patients with APFC, 15.7% had pancreatic pseudocysts. Pseudocyst did not develop in the uncomplicated group. SII value at 48 h [median 859 (541-1740) x 109/L vs. 610 (343-1259) x 109/L, P = 0.01] and CRP level at 48 h [89 (40-237) mg/L vs. 38 (12-122) mg/L, P = 0.01] were higher in the complicated group than in the uncomplicated group. The length of hospital stay was longer in the complicated group, compared with the uncomplicated group [median 8 days (5-15), vs. 4 days (3-7), P < 0.001, respectively]. No significant difference was detected between the two study groups' mortality rates and intensive care unit admission rates. Conclusions: While 38.6% of the AP patients had APFC, 6.1% of all patients and 15.7% of the patients with APFC had pancreatic pseudocysts. APFC was found to lengthen the hospital stay and to be associated with the SII value and CRP level measured at 48 h.

Effect of Direct-acting Oral Anticoagulants and Warfarin on Hospital Outcomes in Upper Gastrointestinal Bleeding.

OBJECTIVE: To evaluate the comparison of direct-acting oral anticoagulants (DOACs) and warfarin for their effects on major bleeding and hospital outcomes in patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB). STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Tekirdag Namik Kemal University Hospital, Hitit University Erol Olçok Education and Research Hospital, between January and December 2021. METHODOLOGY: Adult patients prescribed warfarin and DOACs were followed up for one year. Their length of hospital stay, need for intensive care unit admission, need for red blood cell transfusion, and major bleeding rates were compared. RESULTS: Thirty-two patients (61.5%) were user of DOACs (DOAC group), and 20 patients (38.5%) were users of warfarin (warfarin group). No statistically significant difference was determined between patients in warfarin group and DOAC group for the number of packed red blood cells transfused [median 3 (0-6) units, 3 (0-10) units, p=0.229, respectively], length of hospital stay [median 5 days (3-10), and 4.5 days (2-20), p=0.739, respectively], rate of intensive care unit admission [(n=9, 45%; and n=10 (31%), p=0.623, respectively] and the occurrence of major bleeding events (warfarin-70%; DOACs-78%; p=0.529). CONCLUSION: Major bleeding episodes and hospital outcomes of acute NVUGIB were similar between patients receiving warfarin and DOACs. KEY WORDS: Direct-acting oral anticoagulants, Warfarin, Gastrointestinal bleeding, Outcome, Mortality.

Gastric neuroendocrine neoplasms: A review.

Gastric neuroendocrine neoplasms (g-NENs) or neuroendocrine tumors are generally slow-growing tumors with increasing incidence. They arise from enterochromaffin like cells and are divided into four types according to clinical characteristic features. Type 1 and 2 are gastrin dependent, whereas type 3 and 4 are sporadic. The reason for hypergastrinemia is atrophic gastritis in type 1, and gastrin releasing tumor (gastrinoma) in type 2 g-NEN. The diagnosis of g-NENs needs histopathological investigation taken by upper gastrointestinal endoscopy. g-NENs are positively stained with chomogranin A and synaptophysin. Grading is made with mitotic index and ki-67 proliferation index on histopathological analysis. It is crucial to discriminate between types of g-NENs, because the management, treatment and prognosis differ significantly between subtypes. Treatment options for g-NENs include endoscopic resection, surgical resection with or without antrectomy, medical treatment with somatostatin analogues, netazepide or chemotherapy regimens. Follow-up without excision is another option in appropriate cases. The prognosis of type 1 and 2 g-NENs are good, whereas the prognosis of type 3 and 4 g-NENs are close to the prognosis of gastric adenocancer.

Endoscopic Retrograde Cholangiopancreatography During the COVID-19 Pandemic: Effects of Enhanced Personal Protective Equipment.

BACKGROUND AND AIMS: Personal protective equipment (PPE) decreases the risk of disease contagion, and because of the COVID-19 pandemic, enhanced PPE (EPPE) is widely used during endoscopic procedures including endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to investigate the effects of EPPE on ERCP success parameters compared to standard PPE (SPPE). METHODS: ERCP procedures were evaluated retrospectively and ERCP outcomes were compared for similar time periods as before and after the COVID-19 pandemic. Primary outcomes were cannulation time, number of cannulation attempts, cannulation success rate, difficult cannulation rate, undesired pancreatic duct cannulation rate, ERCP-related adverse events, and length of hospital stay. RESULTS: Three hundred and eighty ERCP procedures were examined. One hundred and fifty-nine procedures were excluded due to missing data, previous sphincterotomy or altered anatomy. Of the final eligible sample size of 221 ERCPs, 93 were performed using SPPE and 128 were performed under EPPE. Indications of ERCP and demographic parameters were similar between groups. The majority of the ERCP cases included were for benign biliary obstruction of common bile duct stones (88.7%). No significant differences were detected in overall technical success (91.4% vs 92.2%, p = 0.832), cannulation success rates (94.6% vs 96.8%, p = 0.403), cannulation times (median times of both groups were 3 min, p = 0.824), difficult cannulation rates (37.6% vs 33.6%, p = 0.523), undesired pancreatic duct cannulation rates (29% vs 22.7%, p = 0.593), number of cannulation attempts (2.80 vs 2.71, p = 0.731), ERCP-related adverse events (9.7% vs 10.9%, p = 0.762), and length of hospital stay (6.63 vs 6.92 days, p = 0.768) between SPPE and EPPE groups, respectively. CONCLUSION: Biliary obstructions of common bile duct stones were the major indication of ERCP in the current study. The use of EPPE had no negative effects on ERCP performance in this patient group. ERCP can be effectively performed under EPPE.

The age, bilirubin and albumin (ABA) index: a novel noninvasive index for predicting liver fibrosis in patients with chronic hepatitis C infection.

AIM: It was to assess the diagnostic performance characteristics of a novel index, (ABA), which utilizes age, bilirubin and albumin to predict significant and severe fibrosis, and cirrhosis in patients with chronic hepatitis C infection. METHODS: A total of 114 patients were included in this study. The liver biopsies were graded using the Ishak scoring system. Diagnostic performance of the ABA index was compared to aspartate aminotransferase (AST) to alanine aminotransferase ratio, age platelet index, AST to platelet ratio index, γ-glutamyl transpeptidase (GGT) to platelet ratio index, FIB-4, FibroQ, Goteborg University Cirrhosis Index, King's score, GGT/international normalization ratio, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, white blood cell to platelet distribution width ratio and mean platelet volume to platelet distribution width ratio (MPV/PDW) by receiver operating characteristics (ROC) curve analysis. RESULTS: The ABA index was formulated as 1.5 + (0.065 × age) + (1.85 × bilirubin) - (1.65 × albumin) according to the multivariate logistic regression analysis. According to the ROC curve analyses, the ABA index had the area under these ROC curves (AUROCs) of 0.805 [95% confidence interval (CI), 0.727-0.883] for significant fibrosis, 0.874 (95% CI, 0.804-0.943) for severe fibrosis and 0.895 (95% CI, 0.828-0.961) for cirrhosis. CONCLUSION: The ABA index was found to be superior to other evaluated noninvasive indexes of liver fibrosis by use of the cutoff point of 0 and 1. These findings should be confirmed by prospective and multicenter studies in patients with chronic hepatitis C infection.

Development and evaluation of a novel noninvasive index for predicting significant fibrosis, advanced fibrosis, and cirrhosis in patients with chronic hepatitis B infection.

BACKGROUND AND AIMS: Development of noninvasive liver fibrosis indexes has been research of interest due to the limitations of liver biopsy. Therefore, we aimed to develop and evaluate the diagnostic accuracy of a novel noninvasive index for predicting significant fibrosis, advanced fibrosis and cirrhosis in patients with chronic hepatitis B (CHB) infection based on age and routine clinical laboratory tests. METHODS: A total of 396 treatment naïve liver biopsy performed patients were divided into training (n = 262) and validation cohorts (n = 134). Histological staging was assessed by Ishak fibrosis scoring system. RESULTS: In training cohort, we developed a novel fibrosis index, GAPI, using γ-glutamyl transpeptidase (GGT), age, platelet, and international normalized ratio (INR) results. The diagnostic accuracies of alanine aminotransferase ratio, age platelet index, aspartate aminotransferase to platelet ratio index, GGT to platelet ratio index, AST to lymphocyte ratio index, fibrosis index based on the four factors, Fibro Q, Goteborg University Cirrhosis Index, King's score, Pohl score, Wang I, fibrosis index, fibrosis cirrhosis index, cirrhosis discriminant score, Lok score, Doha score, Mehdi's model, GqHBsAg, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, RDW to lymphocyte ratio, RDW to platelet ratio, GGT/INR, GGT/albumin, white blood cell/platelet distribution width (PDW), mean platelet volume/PDW and platelet/PDW indexes were compared to GAPI index. For the prediction of significant fibrosis, advanced fibrosis and cirrhosis, the area under the receiver operating characteristic curves (AUROCs) of GAPI index were 0.776, 0.868, and 0.885 in training cohort, and 0.731, 0.883, and 0.919 in validation cohort, respectively. The AUROCs of the GAPI index were higher than those of the evaluated 27 noninvasive indexes to predict significant fibrosis, advanced fibrosis, and cirrhosis. CONCLUSION: In resource limited settings, GAPI is a promising noninvasive liver fibrosis index for predicting significant fibrosis, advanced fibrosis and cirrhosis, and for decreasing the need for liver biopsy in patients with CHB infection using cutoff points of 2.00 and 3.50.

Assessment of left ventricular contractile functions in inflammatory bowel disease according to disease activity.

OBJECTIVES: The study aimed to investigate the subclinical involvement of cardiac functions in patients with inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD) according to their disease activity status by two-dimensional speckle tracking echocardiography (2DSTE). METHODS: This prospective study included 72 consecutive patients with IBD and 93 age- and sex-matched healthy controls (HC). All participants underwent conventional and 2DSTE assessments. The IBD patients were subdivided into active disease and remission groups for further investigation of the effect of disease activity on left ventricular (LV) contractile functions. RESULTS: The longitudinal strain values differed significantly between the IBD group and the control group (global longitudinal strain [GLS] from two-chamber view: [-15.74 ± 6.33]% vs [-18.8 ± 2.87]%, P = 0.001; GLS from four-chamber view: [-16.61 ± 9.91]% vs [-20.12 ± 2.57]%, P = 0.008; GLS: [-15.47 ± 6.87]% vs [-19.48 ± 2.16]%, P = 0.0001). The circumferential strain measurements showed a nonsignificant trend of depressed contractile functions in the IBD group. Patients with active IBD had similar GLS and global circumferential strain (GCS) values as those in remission. A correlation analysis revealed that the neutrophil-lymphocyte ratio was positively correlated and the platelet count was negatively correlated with GCS. Deterioration of LV diastolic functions examined with E/e' and mitral deceleration time was found in the IBD group compared with the controls. CONCLUSIONS: LV global longitudinal contractile and diastolic functions were decreased in patients with IBD. Clinicians should maintain patients' remission periods and prevent flare-ups.

The use of prealbumin as a predictor of malnutrition in cirrhotic patients and the effect of nutritional support in patients with low prealbumin levels

Background/aim: Malnutrition is an important and commonly seen prognostic factor in patients with cirrhosis. The diagnosis of malnutrition in cirrhosis patients may be challenging, and an easily measured and widely usable marker is lacking. Prealbumin, however, is an easily measured marker. In the current study we measured prealbumin levels in cirrhotic patients with no clinically apparent malnutrition and used it as a malnutrition marker. Another aim of this study was to evaluate the effect of nutritional support on patient with low prealbumin levels. Materials and methods: Fifty-two patients with Child A and Child B cirrhosis were selected for the study. Prealbumin levels were studied, and Child and MELD scores were calculated. Patients with prealbumin levels ˂180 mg/L were considered to have malnutrition, and two different types of nutritional products were given to these patients. The patients given nutritional support were investigated a month later, and parameters were compared. Results: According to the prealbumin threshold of 180 mg/L, malnutrition frequencies were 59.3% for Child A and 95% for Child B cirrhosis. After the provision of nutritional support statistically significant improvements in albumin and INR levels were detected. In addition, the MELD score decreased; however, it was not statistically significant (P: 0.088). A statistically significant decrease in the MELD score was only obtained in patients with Child B cirrhosis (P: 0.033). When the oral replacement therapies were investigated separately, a statistically significant decrease in MELD scores was detected with product 1 (P: 0.043). Conclusion: Prealbumin can be used as an easily measured parameter for earlier detection of malnutrition in patients with cirrhosis and without clinically apparent malnutrition. Oral nutritional support, especially with products containing relatively high carbohydrate levels and low protein, may have a favorable effect on MELD scores.

Physician awareness of hepatitis C virus among different departments.

AIM OF THE STUDY: To determine the anti-hepatitis C virus (HCV) positivity in our region and to evaluate physician awareness of HCV among different inpatient and outpatient departments in a tertiary reference center in Turkey. MATERIAL AND METHODS: This retrospective study was conducted between January 2017 and January 2020. The patients tested for anti-HCV for any reason were enrolled from the data of all patients admitted to our hospital, which is the reference center of the region. RESULTS: A total of 121,492 anti-HCV assays were screened from the computerized database. Total number of patients with a positive anti-HCV result was 891 (0.81%). HCV RNA was positive in 147 (16.5%) of 891 patients and negative in 389 (43.7%) patients. Unfortunately HCV RNA was not tested in 355 (39.8%) patients. The percentages of the untested patients regarding the departments were 65.38% (n = 85/130) in medical inpatient clinics, 61.02% (n = 72/118) in surgical clinics, 16.67% (n = 88/528) medical outpatient departments, 96.8% (n = 91/94) in surgical outpatient departments, and 90.5% (n = 19/21) in the emergency department. CONCLUSIONS: The prevalence of anti-HCV positivity was found to be 0.81% and was stable in Turkey. However, the level of physician awareness for HCV was unsatisfactory, and differed between departments. Because HCV is commonly asymptomatic, positive patients should not be overlooked and adequate treatment should be administered. Awareness of physicians should be increased to prevent delays in the diagnosis of hepatitis C and to reduce the number of untreated patients.

Can pancreatic steatosis affect exocrine functions of pancreas?

BACKGROUND/AIMS: Pancreatic steatosis (PS) is a generally used term to define accumulation of fat in the pancreas. In theory PS may be able to affect the exocrine function of pancreas. In this study we aimed to determine the effect of PS on exocrine pancreas function. MATERIALS AND METHODS: Forty-three patients with PS determined by 3 tesla magnetic resonance imaging (MRI) and 48 patients without PS were included in this study. Patients with PS were classified as group 1 and control patients were classified as group 2. Fecal elastase-1 levels were determined. Fecal elastase-1 levels <200 µg/g were defined as exocrine pancreatic insufficiency (EPI). Patients with PS were further grouped according to severity and anatomic distribution of steatosis based on findings of 3 tesla MRI. RESULTS: Fecal elastase-1 levels was significantly lower in group 1 compared to group 2 (319.76±45.7 vs 549.31±69.4, respectively, p=0.003). Proportion of patients with EPI was significantly higher in group 1 than group 2 (35.5% vs 12% p=0.042). There were no significant differences in terms of severity or the anatomic distribution of PS in patients with PS with EPI based on MRI (p=0.052, p=0.198, p=0.405) Conclusion: Current study demonstrates that PS can cause EPI.

Comparison between different first-line therapy protocols in eradicating Helicobacter pylori in a region with high clarithromycin resistance.

INTRODUCTION: Helicobacter pylori infection is encountered in more than 50% of the world population. A high rate of clarithromycin resistance is observed among Helicobacter pylori strains in some regions because clarithromycin is a drug commonly used for the treatment of other infections. AIM: To identify an efficient eradication protocol for patients infected with H. pylori and to suggest an alternative first-line therapy particularly in countries with high clarithromycin resistance. MATERIAL AND METHODS: Patients (18-75 years old) having dyspeptic complaints in a 1-year period and diagnosed with H. pylori infection by gastric biopsy were included and randomised to three groups, each receiving different sequential eradication therapy (LAM-B: lansoprazole, amoxicillin, metronidazole, bismuth: LAM-T: lansoprazole, amoxicillin, metronidazole, tetracycline; LAM-BT: lansoprazole, amoxicillin, metronidazole, bismuth, tetracycline). Eradication was evaluated via urea breath test. RESULTS: This study included 166 patients (mean age: 40 ±12 years; female, 68.7%) with H. pylori infection. Among them, 50 (30.1%) were in the LAM-B group, 59 (35.5%) were in the LAM-T group, and 57 (34.3%) were in the LAM-BT group. The non-steroidal anti-inflammatory drug use was the lowest in the LAM-BT group. Eradication rates were over 80% and similar in each group, with the highest rate in the LAM-BT group (93%). Adverse event rate was the highest in the LAM-T group. Helicobacter pylori eradication was achieved in 143 (86.1%) patients. CONCLUSIONS: The combination regimens without clarithromycin achieved an eradication rate over 80% in all groups. Knowing and monitoring the regional antibiotic resistance rates is important for successful treatment of H. pylori infections.

Association of Low Fecal Elastase-1 and Non-Ulcer Dyspepsia.

Non-ulcer dyspepsia (NUD) is a term used to define a set of symptoms that are believed to originate from the gastroduodenal region, and no underlying organic, systemic, or metabolic reason can be found. The majority of patients suffer from chronic symptoms although half of the patients report improvement in symptoms with time. The potential role exocrine pancreatic insufficiency in NUD patients has not been clarified yet. We aimed to identify exocrine pancreas function with pancreatic fecal elastase-1 in patients diagnosed with non-ulcer dyspepsia and no typical exocrine pancreatic insufficiency (EPI) symptoms. Thirty-five patients referred to gastroenterology clinics with NUD and 35 people with no dyspeptic symptoms as a control group were included in this prospective study. Non-ulcer dyspepsia patients were classified as group 1 and control subjects classified as group 2. Upper gastrointestinal endoscopies were performed in both groups. Assessment of exocrine pancreatic function was performed by measuring fecal elastase-1 concentration with a commercial ELISA kit using polyclonal antibodies (BioServ Diagnostics) in NUD patients compared to control subjects. Mean fecal elastase-1 levels were significantly lower in group 1 patients compared with group 2 (367.47 ± 43.27; 502.48 ± 50.94 respectively; p = 0.04). The percentage of the patients with EPI was significantly higher in group 1 (p = 0.02). Patients with NUD should be re-evaluated if they do not show satisfactory improvement with treatment. Exocrine pancreatic insufficiency was significantly higher in patients with NUD in our study. Evaluation for the presence of EPI can be a cost effective approach in management of refractory patients during the process of ruling out organic reasons.

Dynamic thiol/disulphide homeostasis in acute pancreatitis.

BACKGROUND/AIMS: The dynamic thiol/disulfide homeostasis plays pivotal roles in many physiological mechanisms in an organism. We aimed to investigate whether dynamic thiol/disulfide homeostasis changes among patients with acute pancreatitis. MATERIALS AND METHODS: This prospective trial contained 45 patients with acute pancreatitis and 45 sex-and age-matched healthy volunteers as control group. Thiol/disulfide homeostasis parameters were measured by a novel and automated assay, and detected results were compared between the two groups. RESULTS: Disulfide/total thiol percent ratio and disulfide/native thiol percent ratios were significantly higher in acute pancreatitis group; besides the native thiol, total thiol levels and native thiol/total thiol percent ratios were significantly lower (for all p < 0.001). CONCLUSION: The thiol/disulfide homeostasis is impaired in acute pancreatitis with a shift toward the oxidative status, and this deficiency might be a pathogenic factor in acute pancreatitis. The correction of this thiol/disulfide imbalance may be a new target in the management of acute pancreatitis.

Association between antioxidants and mild acute pancreatitis.

BACKGROUND AND STUDY AIMS: The mechanisms underlying acute pancreatitis have not been well elucidated. Over the last 20 years, there has been increasing awareness regarding the role played by oxidative stress in acute pancreatitis, but it is less well defined in human clinical trials. The aim of this study was to identify the relationship between antioxidants and acute pancreatitis. PATIENTS AND METHODS: We performed a cross-sectional trial on patients with mild acute pancreatitis. The study population consisted of 53 patients with mild acute pancreatitis and 55 healthy controls. Serum paraoxonase, arylesterase activity, total antioxidant status, total oxidant status and thiol levels were measured, and oxidative stress index was calculated. RESULTS: Paraoxonase, arylesterase activity, thiol and total antioxidant status levels were significantly lower in the acute pancreatitis group than in the control group (p = .024, p < .001, p < .001, p = .010, respectively). Oxidative stress index and total oxidant status levels were higher in the acute pancreatitis group than in the control group, but the difference was not statistically significant (p = .135, p = .253, respectively). CONCLUSIONS: This study demonstrates that decreased antioxidant levels are associated with mild acute pancreatitis. No association was observed between mild acute pancreatitis and total oxidant status.