Validation of Risk Scoring Systems in Ursodeoxycholic Acid-Treated Patients With Primary Biliary Cholangitis.

INTRODUCTION: Risk stratification based on biochemical variables is a useful tool for monitoring ursodeoxycholic acid (UDCA)-treated patients with primary biliary cholangitis (PBC). Several UDCA response criteria and scoring systems have been proposed for risk prediction in PBC, but these have not been validated in large external cohorts. METHODS: We performed a study on data of 1746 UDCA-treated patients with PBC from 25 centers in Europe, United States, and Canada. The prognostic performance of the risk scoring systems (GLOBE and UK-PBC) and the UDCA response criteria (Barcelona, Paris I, Paris II, Rotterdam, and Toronto) were evaluated. We regarded cirrhosis-related complications (ascites, variceal bleeding, and/or hepatic encephalopathy) as clinical end points. RESULTS: A total of 171 patients reached a clinical end point during a median 7 years (range 1-16 years) of follow-up. The 5-, 10- and 15-year adverse outcome-free survivals were 95%, 85%, and 77%. The GLOBE and UK-PBC scores predicted cirrhosis-related complications better than the UDCA response criteria. The hazard ratio (HR) for a 1 standard deviation increase was HR 5.05 (95% confidence interval (CI): 4.43-5.74, P < 0.001) for the GLOBE score and HR 3.39 (95% CI: 3.10-3.72, P < 0.001) for the UK-PBC score. Overall, the GLOBE and UK-PBC risk scores showed similar and excellent prognostic performance (C-statistic, 0.93; 95% CI: 0.91%-95% vs 0.94; 95% CI: 0.91%-0.96%). DISCUSSION: In our international, multicenter PBC cohort, the GLOBE and UK-PBC risk scoring systems were good predictors of future cirrhosis-related complications.

The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps.

BACKGROUND: Polypectomy with jumbo forceps (JF) and polypectomy with hot biopsy forceps (HBF) are still widely used techniques for removal of diminutive colorectal polyps (DCPs). JF may be more effective for the removal of DCPs because of their larger size. AIM: To evaluate the histological quality and adequacy of DCPs resected using JF compared with HBF. METHODS: One hundred and seventy-nine patients with 237 DCPs were included in this study. DCPs were removed using either JP or HBF. RESULTS: The tissue architecture was good in 29.9 % of the HBF group, in comparison with 90 % of the JF group (p < 0.001). No cautery damage or crash artifact was observed in 93.3 % of JF group and in 8.5 % of HBF group (p < 0.001). Moreover, there were statistically significant differences between the groups with regard to the high level of cautery damage or crush artifact (p < 0.001). The overall diagnostic quality of the specimens removed using JF was significantly better than that of the specimens removed by HBF (96 vs. 80 %, respectively, p < 0.001). There were statistically significant inverse associations between cautery damage or crush artifact and overall diagnostic quality of HBF and JF (r = -0.373, p < 0.001; r = -0.382, p < 0.001, respectively). Surgical margins were determined as negative in 87.5 % of the JF group and in 76.1 % of the HBF group (p = 0.022). A total of 80.8 % of the JF specimens and 30.8 % of the HBF specimens were well evaluated for two lateral and deep surgical margins (p < 0.001). CONCLUSION: JF was superior to HBF for histopathological interpretation and eradication of DCPs.

The diagnostic accuracy of the Forns index, platelet count and AST to Platelet Ratio Index derived fibrosis index for the prediction of Hepatitis C virus-related significant liver fibrosis and cirrhosis.

AIM: To provide a simple fibrosis index combining the routine laboratory markers for predicting significant fibrosis (SF) and cirrhosis in patients with chronic HCV. METHODS: Platelet count, ALT, AST, AST to ALT Ratio, AST to Platelet Ratio Index (APRI), Forns index, FIB-4 and Age Platelet Index of 202 liver biopsy performed HCV-infected patients were reviewed. METAVIR classification was used to determine the stage of liver fibrosis. The predictive fibrosis index was constructed by multiple linear regression analysis (- 2.948 + 0.562 × Forns index + 0.288 × APRI + 0.006 × platelet count [10(9)/L]). RESULTS: Median (25th-75th interquartile range) age was 52 (42-59) years, and 61% were male. 65.8% (n = 133) had SF (F2-F4) and 23.3% (n = 47) had cirrhosis (F4). For discrimination of SF, AUROCs were: Fibrosis index = 0.869, Forns index = 0.837, APRI = 0.814, platelet count = 0.764. For cirrhosis, AUROCs were: Fibrosis index = 0.911, Forns index = 0.883, APRI = 0.847, platelet count = 0.827. A cut-off point of ≤ 1.2 for fibrosis index excluded SF in 89% of patients with sensitivity of 96%, while > 2.0 predicted SF in 88% of patients with specificity of 86%. Threshold of ≤ 1.9 excluded cirrhosis in 95% of patients with sensitivity of 94%, while > 2.7 showed cirrhosis in 88% of patients with specificity of 95%. In multivariate logistic regression analysis, OR (95% CI) of fibrosis index was 7.825 (3.682-16.629) for SF (p < 0.001) and was 8.672 (4.179-17.996) for cirrhosis (p < 0.001). CONCLUSION: SF and cirrhosis were predicted with accuracy of 82% and 89% and were excluded with accuracy of 74% and 82% using this fibrosis index which may potentially decrease the need for liver biopsy in 76% and 83% of patients, respectively.

Relationship between neutrophil gelatinase-associated lipocalin (NGAL) levels and inflammatory bowel disease type and activity.

BACKGROUND AND AIM: Neutrophil gelatinase associated lipocalin (NGAL) is a recently identified molecule, which is bacteriostatic, has tissue destructive effects and is pro-inflammatory with chemoattractant molecule binding properties. Our aim was to investigate the relationship between serum NGAL levels and the type and level of disease activity of IBD. METHODS: A total of 92 patients [43 with Crohn's disease (CD) and 49 with ulcerative colitis (UC)], and 30 age- and sex-matched healthy controls (HC) were included in this study. Serum NGAL levels were measured using ELISA. RESULTS: Serum NGAL levels were elevated in the IBD group [median 171, range (57-312) ng/mL] compared to the HC group [107 (45-234) ng/mL] (p<0.0001) and were elevated in UC patients [188 (74-312) ng/mL] compared to CD patients [168 (57-279) ng/mL] (p=0.006). When NGAL levels were further analysed based on localization of the CD and UC, the levels in ulcerative pancolitis [233 (144-312) ng/mL] were significantly higher (p=0.004) than the left-sided colitis [156 (103-309) ng/mL]. Similarly, NGAL levels were significantly higher in colonic CD [207 (125-249) ng/mL] than ileal CD [114 (78-210) ng/mL], and also in ileocolonic CD [198 (57-279) ng/mL] than ileal CD (p=0.033). When CD and UC groups were further categorized as active and inactive according to clinical and endoscopic activity indices, serum NGAL concentrations did not differ between inquiescent versus active stages. When a cut-off level of 129 ng/mL was used to distinguish IBD from HC, a sensitivity of 76.1% and a specificity of 60.9% was reached. CONCLUSIONS: The serum NGAL levels in the IBD group was significantly higher than the HC group. Serum NGAL levels were higher in more extensive colonic involvement.

Re-evaluation of cases with gastroenteropancreatic neuroendocrine tumors between 2004 and 2012 according to the 2010 criteria.

BACKGROUND/AIMS: We re-evaluated the clinical, histopathological and immunohistochemical features of neuroendocrine tumors (NETs) diagnosed in our pathology laboratory between 2004 and 2012 and re-classified them according to the WHO-2000 and WHO-2010 criteria. METHODOLOGY: The study included NET samples of 106 patients having gastroenteropancreatic and hepatobiliary tumors. The histopathological findings were re-assessed. The cases were re-appraised based on the WHO-2000 and WHO-2010 criteria. The association between survival and Ki-67 index was analysed. RESULTS: The most frequent localization was the stomach. The average tumor size was 3.0±4.1 cm. Differentiation was poor in 17 cases (16.0%). Lymphovascular invasion was detected in 16.1% (n = 17) and necrosis was identified in 15.1% (n = 16). The average number of Ki-67 was 9.1±19.9. Ki-67 measurements were significantly higher in patients who died compared to those who survived (p <0.01). In ROC analysis, the cut-off point for Ki-67 was 5. CONCLUSIONS: Our study is a single-center study comprising patients from Turkey for a period of 8 years. We found that the most frequent localization is the stomach. This ratio is associated with common use of endoscopy in our center. The specimens were re-evaluated according to the WHO-2000 and WHO-2010 classification systems the data and terminology have been updated.

Endoscopic ultrasound and pancreas divisum.

Pancreas divisum is the most common congenital anatomic variation of the pancreatic ductal anatomy and in most of the individuals it is asymptomatic. However, in minority of individuals it is presumed to cause recurrent acute pancreatitis and chronic pancreatitis. Endoscopic retrograde cholangiopancreatography is the gold standard for its diagnosis, but is invasive and associated with significant adverse effects. Endoscopic ultrasound (EUS) allows the detailed evaluation of the pancreaticobiliary ductal system without injecting contrast in these ducts. Moreover, it provides detailed images of the parenchyma also. Therefore EUS, both radial and linear, has potential for being a minimally invasive diagnostic modality for pancreas divisum. A number of EUS criteria have been suggested for the diagnosis of pancreas divisum. These criteria have varying sensitivity and specificity and hence there is a need for objective and uniform criteria that have the best diagnostic accuracy. Secretin EUS has a potential for diagnosing minor papilla stenosis and thus help in planning appropriate therapy. EUS guided pancreatic duct interventions can help in draining dorsal duct in symptomatic patients with failed minor papilla cannulation. But these techniques are technically demanding and associated with potential severe complications.

The Role of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) in Atrial Fibrillation: Treatment Management Based on Patient and Drug Characteristics.

Data from Turkey revealed that atrial fibrillation patient percentage under adequate anti- coagulation in Turkey is less than that in other countries due to multiple parameters such as treatment adherence problems, failure to follow guideline recommendations, negative perspective on the use of new drugs, drug costs, and payment conditions. The aim of this article is to provide physicians with a compiled resource that focuses on the differences between non-vitamin K antagonist oral anticoagulants and heterogeneity of atrial fibrilla- tion patients by reviewing the global and national data from a multidisciplinary perspective and provide guidance on the choice of non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients. A gastroenterologist, 2 neurologists, and 11 cardiologists from university and training and research hospitals in Turkey who are experienced in atrial fibrillation and non-vitamin K antagonist oral anticoagulant treatments gathered in 3 separate meetings to identify the review topics and evaluate the outcomes of the systematic literature search. Based on the pharmacological characteristics, clinical studies, and real-world data compari- sons, it has been revealed that non-vitamin K antagonist oral anticoagulants are not similar. Thromboembolism and bleeding risks, renal and hepatic functions, coexisting conditions, and concomitant drug usage have been shown to affect the levels of benefits gained from non-vitamin K antagonist oral anticoagulant in atrial fibrillation patients. Although Turkish patients with atrial fibrillation have been observed to be younger, they are more likely to have coexisting cardiovascular conditions compared to the atrial fibrillation patients in other countries. Selection of an appropriate non-vitamin K antagonist oral anticoagulant in line with the available evidence and recent guidelines will provide substantial benefits to atrial fibrillation patients.

Impact of intestinal ultrasound with a portable system in the management of Crohn's disease.

BACKGROUND: Intestinal ultrasound (IUS) is a valid cross-sectional imaging technique for the evaluation of Crohn's disease (CD). With advancements in technology, portable ultrasound systems are becoming widely available, and the inevitable change to their use by non-radiologist clinicians would be a valuable contribution to improving patient care. This study aimed to investigate the diagnostic yield of IUS examination performed by a gastroenterologist with a portable system as an adjunct imaging modality in the routine care of CD patients. METHODS: A total of 117 CD patients were assessed by IUS imaging. Pre- and post-IUS clinical-management decisions were recorded. The primary outcome was to evaluate the change in the patients' clinical-management decision following the IUS examination. The diagnostic accuracy was compared against the reference decision reached via a multidisiplinary meeting after the evaluation of all patient-related data. The endoscopic disease activity was determined using the simple endoscopic score for Crohn's disease (SES-CD). RESULTS: The initial clinical-management decision was changed in 47 patients (40.2%) after the IUS examination (P = 0.001). The accuracy of patient-management decisions improved from 63.2% to 90.6% in comparison to reference decisions (P < 0.001). After IUS examination, a further 13 cases (11.1%) were identified for urgent surgical/interventional procedures. The accuracy of colonoscopic (SES-CD ≥3) assessment was shown to be comparable to that of IUS (94% vs 91%). The sensitivity for disease presence was 95% with colonoscopy and 94% with the IUS assessment. CONCLUSION: IUS examination with the use of a portable ultrasonography system significantly improves clinical-management decisions. With further supporting data, this practice would possibly become a requirement for CD management.

Characteristics of Newly Diagnosed Hepatocellular Carcinoma Patients Across Turkey: Prospective Multicenter Observational 3K Registry Study.

AIMS: To evaluate patient profile for epidemiological and clinicopathological characteristics and potential risk/prognostic factors in newly diagnosed hepatocellular carcinoma (HCC) patients across Turkey. METHODS: A total of 547 patients (mean (SD) age 62.6 (10.3) years, 81.9% were males) were included in this registry study. Data on patient characteristics, etiologies of HCC, laboratory values, and tumor characteristics and stages were recorded at study enrollment. RESULTS: HBV infection (68.2%) was the leading etiology, followed by HCV infection (17.2%), HDV infection (5.5%), alcohol (6.4%), and NAFLD (3.5%), as the major etiologies. Considering that 51.6% of the patients had >5 cm HCC, 44% were Child-Pugh B/C and 57% were BCLC B-D, it appears that a significant group of HCC patients were diagnosed at advanced stages. Of 540 patients, 271 (50.2%) were referred or applied with the diagnosis of HCC. Patients with HCC at presentation had larger tumor size (median (min-max) 6.6 (0-30) vs. 4.8 (0-90) cm, P < .001) and more advanced BCLC stage (Stage C-D in 40.8% vs. 26.4%, respectively, P = .005), compared to patients who were diagnosed during follow-up. CONCLUSIONS: Our findings revealed that HBV infection was the leading etiology and a moderate-to-advanced disease was evident in more than half of patients at the time of diagnosis. HCC patients diagnosed at follow-up had smaller tumor size and earlier BCLC stage.

Benign solitary cecal ulcer: a condition that mimics plastron appendicitis.

The benign solitary cecal ulcer is a rare clinical entity that is not usually included in the differential diagnosis of the cecal diseases. The etiology is unknown, and there are no pathognomonic lesions or symptoms. Pre-operative and intra-operative diagnosis is difficult. Definitive diagnosis is generally obtained by histologic evaluation of the surgical specimen after a right hemicolectomy performed for a suspected neoplasm of the cecum. We herein describe a 70-year-old woman with solitary cecal ulcer presenting with abdominal pain, palpable mass on the right lower quadrant and leukocytosis, mimicking plastron appendicitis on initial evaluation.

Comparison of high resolution magnifying endoscopy and standard videoendoscopy for the diagnosis of Helicobacter pylori gastritis in routine clinical practice: a prospective study.

BACKGROUND: It has been shown that standard endoscopic features often labeled as gastritis has a poor correlation with histopathology. Recently, high resolution magnifying endoscopy has been reported to be an effective method to diagnose gastritis. The aim of the present study was to compare standard endoscopy with magnifying endoscopy for the diagnosis of Helicobacter pylori gastritis, and to determine whether gastritis can be diagnosed based on findings at magnification endoscopy. MATERIALS AND METHODS: A total of 129 patients were enrolled into the study. Erythema, erosions, prominent area gastrica, nodularity, and regular arrangement of collecting venules (RAC) were investigated by standard endoscopy. Standard endoscopy was followed by magnifying endoscopy in all patients, and repeated in 55 patients after indigo carmine spraying. RESULTS: None of the standard endoscopic features showed a sensitivity of more than 70% for H. pylori gastritis, except RAC pattern analysis. Absence of a corporal RAC pattern had 85.7% sensitivity and 82.8% specificity for predicting H. pylori infection. Under magnification, the sensitivity and specificity of regular corporal pattern (regular collecting and capillary vascular structures with gastric pits resembling pinholes) for predicting normal histology were 90.3% and 93.9%, respectively. Loss of collecting venules, or both collecting and capillary structures was correlated with chronic inflammation and activity. With the progression of mucosal atrophy, irregular collecting venules became visible. The values for irregularly arranged antral ridge pattern for the prediction of antral gastritis were 89.3% and 65.2%, respectively. Indigo carmine staining increased sensitivity and specificity up to 97.6% and 100% for corporal gastritis, and up to 88.4% and 75.0% for antral gastritis, respectively. Indigo carmine staining significantly increases the detection of intestinal metaplasia. CONCLUSIONS: High resolution magnifying is superior to standard endoscopy for the diagnosis of H. pylori gastritis, and identification of specific histopathologic features such as atrophy and intestinal metaplasia seems possible.

Comparison of etomidate-remifentanil and propofol-remifentanil sedation in patients scheduled for colonoscopy.

OBJECTIVE: The aim of the study was to compare haemodynamic responses, recovery and discharge times, and physician satisfaction of etomidate-remifentanil and propofol-remifentanil combinations in patients undergoing elective colonoscopy. METHODS: Sixty patients, aged 18-65 years, scheduled for elective colonoscopy under sedation were prospectively randomized, double blind for the study. Two minutes after the beginning of a continuous remifentanil infusion (0.1 microg kg(-1) min(-1)), etomidate or propofol were administered. Patients in the etomidate group received a 0.05 mg kg(-1) maintenance dose of etomidate after an initial dose of 0.1 mg kg(-1), and patients in the propofol group received a 0.25 mg kg(-1) maintenance dose of propofol after an initial dose of 0.5 mg kg(-1) in order to have a Ramsay sedation score of 3-4. Basal values of heart rate, mean arterial pressure, oxygen saturation, respiratory rate and Ramsay sedation score were recorded. Values were recorded every 2 min for the first 10 min and every 5 min thereafter, until the completion of the procedure. RESULTS: Mean arterial pressure was lower at 4, 6, 8, 10, 15, 20 and 25 min in the propofol group (P = 0.001). Mean respiratory rate in the propofol group at 6, 8, 10, 15, 20, 25 min was also lower (P < 0.05). The incidence of apnoea and hypotension was significantly lower in the etomidate group (P < 0.001). Arrival time into the postoperative care unit and recovery time were shorter in the etomidate group (P = 0.001, P = 0.01, respectively). Physician satisfaction in both groups was similar. CONCLUSION: Etomidate-remifentanil administration for sedation and analgesia during colonoscopy resulted in more stable haemodynamic responses and shorter recovery and discharge times.

Cytomegalovirus colitis in a patient with Behcet's disease receiving tumor necrosis factor alpha inhibitory treatment.

Anti-tumor necrosis factor alpha (TNF-alpha) inhibitors are effective in the treatment of various inflammatory rheumatic conditions. Increased risks of serious infections are the major issues concerning the long-term safety of these agents. We present a case of a young male Behcet's patient whose disease was complicated by cytomegalovirus (CMV) colitis. Colitis started 10 d after the third Infliximab dose and responded to the cessation of TNF blocking treatment and administration of ganciclovir. Tumor necrosis factor alpha and interferon gamma act at several levels in combating viral infections. CMV infections should be kept in mind and included in the differential diagnosis of severe gastrointestinal symptoms in patients receiving anti-TNF agents.

Diagnostic yield of routine duodenal biopsies in iron deficiency anaemia: a study from Western Anatolia.

OBJECTIVE: The role of routine endoscopic duodenal biopsies obtained during the evaluation of iron deficiency anaemia is being increasingly emphasized, but insufficiently applied. Diagnostic yield of this practice, mainly identification of coeliac disease, differs in different populations and geographic regions. The aim of this study is to assess the usefulness of routine duodenal biopsies during upper endoscopy in patients presenting with iron deficiency anaemia in Western Anatolia. METHODS: Routine duodenal biopsies were evaluated over a 12-month period in 100 consecutive adult patients with iron deficiency anaemia undergoing upper endoscopy. All potential bleeding lesions were identified and gastric as well as duodenal biopsies were taken for histopathologic investigation. RESULTS: A bleeding lesion is identified in 44% of cases. Duodenal biopsy gives an additional 5% diagnostic yield and revealed three patients with coeliac disease and two patients with giardiasis. One of the patients diagnosed with coeliac disease had a second bleeding lesion at the upper endoscopic examination. Appearance of the duodenal mucosa was normal in all patients including those with diagnostic duodenal biopsy. CONCLUSIONS: Routine duodenal sampling during the upper endoscopic examination gives an additional 5% diagnostic benefit and this practice should be included in the diagnostic work-up of patients with iron deficiency anaemia. As one of the patients who was found to have coeliac disease had a second bleeding lesion that may otherwise explain iron deficiency anaemia, finding a source for bleeding at the upper endoscopy should not preclude duodenal biopsy. Moreover, performing duodenal biopsy is still necessary even though the endoscopic appearance of the mucosa is normal. Aside from coeliac disease, Giardia infestation could be identified as a contributory factor for iron deficiency anaemia, in endemic regions.

The clinicopathologic characteristics and prognostic factors of gastroesophageal junction tumors according to Siewert classification.

OBJECTIVE: The treatment of gastroesophageal junction tumors remains controversial due to confusion on whether they should be considered as primary esophageal or as gastric tumors. The incidence of these tumors with poor prognosis has increased, thus creating scientific interest on gastroesophageal cancers. Esophagogastric cancers are classified according to their location by Siewert, and the treatment of each type varies. We evaluated the prognostic factors and differences in clinicopathologic factors of patients with gastroesophageal junction tumor, who have been treated and followed-up in our clinics. MATERIAL AND METHODS: We retrospectively analyzed 187 patients with gastroesophageal junction tumors who have been operated and treated in the Oncology Department between 2005 and 2014. The chi-square test was used to evaluate differences in clinicopathologic factors among Siewert groups I, II and III. Prognostic factors were analyzed by univariate and multivariate analysis. RESULTS: The median age of our patients was 62 years, and approximately 70% was male. Nineteen patients (10.2%) had Siewert I tumors, 40 (21.4%) II, and the remaining 128 (64.4%) had Siewert III tumors. Siewert III tumors were at more advanced pathologic and T stages. Preoperative chemoradiotherapy was mostly applied to Siewert group I patients. There was no difference between the 3 groups in terms of recurrence. While the median overall survival and 2-year overall survival rate were 26.6 months and 39.6%, the median disease free survival and disease free survival rates were 16.5 months and 30.1%, respectively. The N stage, pathologic stage, vascular invasion, lymphatic invasion, perineural invasion, surgical margin, and grade were associated with both overall survival and disease free survival, while pathologic stage and presence of recurrence were significant factors for overall survival. The median disease free survival for Siewert III tumors was 20 months, 11.3 month for Siewert I tumors, and 14 months for Siewert II tumors, but the finding was not statistically significant (p=0.08). CONCLUSION: Although gastroesophageal junction tumors were grouped according to their location and they exerted different clinicopathologic properties, their prognosis was similar.

Rapid identification of Helicobacter pylori and assessment of clarithromycin susceptibility from clinical specimens using FISH.

Helicobacter pylori remains one of the most common bacterial infections worldwide. Clarithromycin resistance is the most important cause of H. pylori eradication failures. Effective antibiotic therapies in H. pylori infection must be rapidly adapted to local resistance patterns. We investigated the prevalence of clarithromycin resistance due to mutations in positions 2142 and 2143 of 23SrRNA gene of H. pylori by fluorescence in situ hybridisation (FISH), and compared with culture and antimicrobial susceptibility testing in 234 adult patients with dyspepsia who were enrolled. Antrum and corpus biopsy specimens were obtained for rapid urease test, histopathology and culture. Epsilometer test was used to assess clarithromycin susceptibility. H. pylori presence and clarithromycin susceptibility were determined by FISH in paraffin-embedded biopsy specimens. We found that 164 (70.1%) patients were positive for H. pylori based on clinical criteria, 114 (69.5% CI 62.5-76.6%) were culture positive, and 137 (83.5% CI 77.8-89.2%) were FISH positive. Thus the sensitivity of FISH was significantly superior to that of culture. However specificity was not significantly different (91.4 versus 100.0%, respectively). The resistance rate to clarithromycin for both antrum and corpus was detected in H. pylori-positive patients; 20.2% by FISH and 28.0% by E-test.The concordance between E-test and FISH was only 89.5% due to the presence of point mutations different from A2143G, A2142G or A2142C. We conclude that FISH is significantly more sensitive than culture and the E-test for the detection of H. pylori and for rapid determinination of claritromycin susceptibility. The superior hybridisation efficiency of FISH is becoming an emerging molecular tool as a reliable, rapid and sensitive method for the detection and visualisation of H. pylori, especially when the management of H. pylori eradication therapy is necessary. This is particularly important for the treatment of patients with H. pylori eradication failure.

Diffuse cavernous hemangioma of the rectosigmoid colon with extraintestinal involvement.

Cavernous hemangioma of the colon is a rare cause of gastrointestinal bleeding. These lesions can be encountered as solitary, multiple, or part of a more complex syndrome with cutaneous manifestations. We herein describe a 26-year-old woman with cavernous hemangioma involving the rectosigmoid area. Additional hemangiomas were identified in the pelvic structures, spine, iliac bone and spleen. This multi-visceral involvement without cutaneous manifestations represents an intermediate variety between solitary hemangioma and well-defined syndromes with cutaneous and structural anomalies. The potential presence of extraintestinal hemangiomatosis should be considered and investigated in patients with cavernous hemangioma of the colon even without cutaneous manifestations or with a limited colonic involvement.

Prominent gastroduodenal artery: Endosonographic sign of celiac artery stenosis.

Celiac artery (CA) stenosis is a relatively common finding in patients undergoing pancreaticoduodenectomy (PD). In the presence of CA stenosis, arterial blood supply to the celiac territory is usually sustained from the superior mesenteric artery (SMA) through well-developed collaterals. In this paper, the authors report endosonographically identified prominent gastroduodenal artery as the sign of CA stenosis for the first time. Uncovering previously unidentified vascular abnormality, endoscopic ultrasound (EUS) has improved patient management. The patient had uneventful collateral preserving PD.

High treatment modification rates with lamivudine therapy in HBV-infected patients with low baseline viremia and early virological response: A multicenter study.

OBJECTIVE: Low baseline viremia and an early treatment response predict the best outcomes in hepatitis B virus (HBV)-infected patients treated with nucleoside analogues with low barriers to resistance. The aim of this study was to assess the long-term results and effectiveness of lamivudine in patients with low baseline viremia and early virological treatment response. METHODS: In this multicenter, real-life setting study, 111 antiviral-naive patients with low baseline viremia (HBV DNA <10(7) copies/mL) plus an early virological response (HBV DNA <300 copies/mL at week 24) treated with lamivudine were enrolled. The primary end-point was treatment failure, defined as the re-emergence of detectable viremia or at least a 1 log increase in HBV DNA, resulting in a titer of ≥ 300 copies/mL with lamivudine treatment after week 24, which required treatment modification. RESULTS: Altogether 111 patients, including 78 non-cirrhotic and 33 cirrhotic patients, were included in the study. Treatment failure occurred in 30.8% of the non-cirrhotic patients over a median follow-up period of 32.5 months, and the 1-, 2-, 3-, 4- and 5-year treatment failure rates were 6.5%, 14.0%, 31.4%, 39.6% and 43.1%, respectively. Treatment failure occurred in 28.8% of the whole group. There were no differences between the cirrhotic and non-cirrhotic patients. CONCLUSIONS: Lamivudine treatment had a high treatment modification rate in patients with low baseline viremia and early virological response over a long-term follow-up in a real-life setting. The pretreatment and on-treatment favorable characteristics found in the studies with telbivudine appeared to be inapplicable to lamivudine.