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.

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.

One-year real life data of our patients with moderate-severe Crohn's disease who underwent ustekinumab therapy.

AIM: The aim of this study was to present one-year real-life data of our patients with CD who showed unresponsiveness and/or intolerance to biological agents and then received ustekinumab treatment through an early access program. MATERIALS AND METHODS: The retrospective study reviewed the 52-week clinical data of 10 patients with moderate or severe CD who underwent ustekinumab therapy. RESULTS: The 10 patients comprised 7 (70%) men and 3 (30%) women with a mean age of 38 ± 11.3 years. Mean disease duration was 13.5 ± 8.5 years. Mean pretreatment CDAI score was 273.5 ± 92 and mean pretreatment HBI score was 11.6 ± 3.8. At the end of the 8-week intravenous induction treatment, 5 (55%) patients showed clinical remission according to the CDAI and HBI scores. Additionally, 62.5% of the patients were in clinical remission at the end of week 52 according to the CDAI and HBI scores. No drug-related side effects were observed in any patient throughout the treatment. CONCLUSION: Ustekinumab appears to be effective and safe in the treatment of moderate and severe CD, particularly in cases of unresponsiveness and intolerance to biological agents such as anti-TNF, and in the achievement of clinical remission.

Tp-e Interval, Tp-e/QTc Ratio, and Fragmented QRS Are Correlated with the Severity of Liver Cirrhosis.

BACKGROUND: Arrhythmias and electrocardiographic changes are reported in several noncardiac diseases, including liver cirrhosis (LC). We intended to evaluate the interval from the peak to the end of the electrocardiographic T wave (Tp-e), Tp-e/QTc ratio, and fQRS as presumed markers of arrhythmias in LC. METHODS: In this cross-sectional study, a total of 88 consecutive patients with LC according to clinical, biological, ultrasonographic, or histological criteria and 73 control subjects were enrolled. The severity of cirrhosis was classified according to Pugh-Child's classification and Model for End-Stage Liver Disease (MELD) score. Tp-e interval, Tp-e/QTc ratio, and fQRS rates were measured from the 12-lead electrocardiogram. RESULTS: Tp-e interval, Tp-e/QTc ratio and fQRS rates were significantly increased in parallel to the severity of LC (P < 0.001, P < 0.001, and P = 0.003, respectively). In correlation analysis, Pugh-Child stage showed a significantly positive correlation with Tp-e interval (r = 0.462, P < 0.001), QTc interval (r = 0.373, P < 0.001), Tp-e/QTc ratio (r = 0.352, P < 0.001), and fQRS (r = 0.407, P < 0.001). Furthermore, Tp-e interval (r = 0.414, P < 0.001) and Tp-e/QTc ratio (r = 0.426, P< 0.001) had significant positive correlation with MELD score. CONCLUSIONS: Our study demonstrated that Tp-e interval, Tp-e/QTc ratios, and fQRS rates were significantly increased in parallel to the severity of LC. Thus, these findings may implicate that Tp-e interval, Tp-e/QTc ratio, and fQRS may be novel and useful indicators for prediction of arrhythmias in LC.

Pneumatic Dilation in Geriatric Achalasia Patients.

BACKGROUND: The aim of the study was to share the effectiveness of pneumatic dilation in geriatric achalasia patients. METHODS: Achalasia patients over the age of 65 and those under the age of 65 as the control group who received pneumatic dilation as the first-line treatment were evaluated in the study. RESULTS: The average age of geriatric patients was 72.5 ± 55.92 years (65-90), with 50.3% of them being male. Follow-up was conducted for a mean of 64.52 ± 38.73 months. While pneumatic dilation was successful in 98.6% (141/143) of geriatric patients, it was also successful in 94% (141/150) of non-geriatric patients. Remission after single balloon dilatation was observed in 81.8% of geriatric patients, while it was observed in only 52.7% of non-geriatric patients (P = .000). When comparing remission after single dilatation and multiple dilatations, it was observed that geriatric patients who achieved remission after multiple balloon dilatation had higher lower esophageal sphincter pressure and Eckardt scores at the diagnosis and higher lower esophageal sphincter pressure and esophageal body resting pressures after the first balloon dilatation. CONCLUSIONS: The proportion of elders in the world population is increasing daily and this disease has been known to disproportionately afflict this group. Although surgical treatments, in particular per-oral endoscopic myotomy, have recently gained popularity as therapies for achalasia, pneumatic dilation remains the most commonly used in geriatric patients.

The Relationship Between Achalasia and Esophageal Cancer: The Experience of a Tertiary Center.

OBJECTIVE: We examined the prevalence of esophageal cancer in 828 patients diagnosed with achalasia and the characteristics of patients who developed esophageal cancer. MATERIAL AND METHODS: The demographic characteristics and medical records of the patients who were followed up with a diagnosis of achalasia between 1995 and 2019 were investigated from the patient files. RESULTS: The mean age of the patients was 51 ± 17.3, 390 of them were males (47.1%) and 438 were females (52.9%). The mean diagnosis age of the patients was 45.4 years. The median follow-up duration of the patients was 73 months (12-480). Esophageal cancer developed in 5 patients (0.6%) during follow-up. Three of these 5 patients had squamous cell carcinoma (60%) and 2 had adenocarcinoma (40%). Three of these patients were males (60%) and 2 were females (40%). The mean age of the patients was 68 (56-78), and cancer developed after a median of 156 months (24-216) after the achalasia diagnosis. Balloon dilation therapy was performed for the treatment of achalasia in all 5 patients who developed esophageal cancer. CONCLUSION: Achalasia patients have an increased risk of developing esophageal cancer compared to the general population, and patients should be followed closely for cancer development.

Parenteral Methotrexate Is Efficient in the Treatment of Azathioprine Refractory Crohn's Disease.

BACKGROUND: There is limited data in the literature analyzing the efficacy of methotrexate in Crohn's disease used after thiopurine analogs. We aimed in our study to show the efficacy of methotrexate in Crohn's disease patients who failed to respond to thiopurine treatment. METHODS: The study included 29 azathioprine refractory patients with Crohn's disease. Intramuscular methotrexate (25 mg/week) in the induction of remission and intramuscular methotrexate (15 mg/week) in 29 CD patients with a median follow-up time of 13 months was performed. In 15 (51.7%) patients, methotrexate was used in combination with anti-Tumour necrosis factor (TNF) (combination group), while it was used in 14 (48.3%) patients in monotherapy (monotherapy group). RESULTS: The mean Harvey-Bradshaw index score significantly decreased in the follow-up period (Wk0 = 7.6, last visit = 4.5, P < .001). Remission and response rates at week 12 were 75.9% and 79.3%, respectively. Maintenance of remission (77.8% vs 37.5%, respectively, P = .1) and response rates (77.8% vs 50%, respectively, P = .3) due to last visit examination were numerically higher in combination group but they were not statistically significant. The cumulative probability of remission maintenance in patients with methotrexate therapy was 72.7%, 33.1%, and 22.0% at 1, 2 ,and 4 years after starting methotrexate, respectively. CONCLUSION: Our results show that parenteral use of methotrexate is efficacious in inducing and maintaining remission as a step-up agent in azathioprine refractory Crohn's disease patients.

Use of Vedolizumab in Inflammatory Bowel Disease: A Single-Center Experience.

BACKGROUND: Vedolizumab, which is a monoclonal antibody that selectively binds to α4ß7 integrin in the gastrointestinal system, may be an effective and safe treatment alternative in those with anti-tumor necrosis factor-resistant inflammatory bowel disease. METHODS: Patients administered vedolizumab due to anti-tumor necrosis factor resistant or anti-tumor necrosis factor side effects between August 2017 and November 2020 were included in the study. Crohn's patients were evaluated using the Harvey-Bradshaw index and Simple Endoscopic Score for Crohn's Disease, whereas ulcerative colitis patients were evaluated with the Partial Mayo Score Index and Rachmilewitz score. All patients were followed up for 3 months and their blood samples were taken every 3 months. Hemoglobin, white blood cell, leukocyte, lymphocyte, and platelet counts of the patients were performed. Albumin, C-reactive protein, and erythrocye sedimentation rate values were recorded. The side effect profile for vedolizumab was evaluated for all patients. Among the side effects, arthralgia and flu-like symptoms were observed. RESULTS: A total of 48 patients (18 ulcerative colitis and 30 Crohn's disease) were included in the study. Vedolizumab therapy was initi- ated in the patients due to anti-tumor necrosis factor resistance (17 ulcerative colitis and 26 Crohn's disease) or anti-tumor necrosis factor side effects (1 ulcerative colitis and 4 Crohn's disease). A total of 30 (63%) patients, including 15 (83%) ulcerative colitis and 15 (50%) Crohn's disease, responded to treatment (both response and remission). The mean duration of response to treatment was 4.5 ± 1.5 months. A total of 20 (42%) patients in the vedolizumab therapy subgroup (10/10, ulcerative colitis/Crohn's disease) went into remission. The mean Harvey-Bradshaw Index value was 9.8 ± 2.8 in the Crohn's disease patients at the time of initial treatment. The mean Simple Endoscopic Score for Crohn's disease value was 11.2 ± 3.1 at the time of initial treatment. The mean Harvey-Bradshaw Index value was 6.5 ± 3.0 and the mean Simple Endoscopic Score for Crohn's disease value was 4.9 ± 3.6 at 6 months post-treatment. The mean Ulcerative Colitis Endoscopic Index (Rachmilewitz) value was 9.3 ± 1.2 at the time of initial treatment. In addition, the mean Partial Mayo Scoring Index was 6.4 ± 1.5 at the time of initial treatment. The mean Ulcerative Colitis Endoscopic Index (Rachmilewitz) value was 0 (0-6.0), and the mean Partial Mayo Scoring Index was 1.5 (0.3-4.0) at 6 months post-treatment. CONCLUSION: Vedolizumab therapy is effective in both induction and maintenance of remission in inflammatory bowel disease patients who are resistant to anti-tumor necrosis factor or who can not receive anti-tumor necrosis factor therapy due to side effects. No signifi- cant side effect was observed in the patients during follow-up.

Relationship Among Helicobacter Pylori, Lower Esophagus Sphincter Pressure, and Gastroesophageal Reflux: A Single-Center Experience.

Objectives: The aim of the study was to evaluate the relationship among lower esophageal sphincter pressure (LESP), Helicobacter pylori (Hp), and gastroesophageal reflux (GER). Methods: The retrospective study included patients with isolated hypertensive or hypotensive lower esophageal sphincter (LES) who underwent esophageal manometry in our gastroenterology motility laboratory and had normal manometry results. Demographic characteristics, complaints on admission, upper endoscopy findings, 24-h esophageal pH monitoring results, and presence of Hp in gastric biopsy were evaluated. Results: A total of 1226 patients were included in the study, among whom women comprised 54% of all patients. Mean age was 45.4±13.4 years. Most common presenting complaint was pyrosis (85.4%). Pathological reflux was detected in 61.4% of the patients in 24-h esophageal pH monitoring. Reflux esophagitis was detected in 22.9% and LES laxity was present in 17.4% of the patients. In gastric biopsy, Hp was positive in 40% of the patients. The age of patients with hypertensive LES was significantly higher and female gender and body mass index (BMI) were associated with hypertensive LES. Pyrosis was significantly less prevalent in patients with hypertensive LESP. Esophagitis and LES laxity were significantly more prevalent in patients with hypotensive LES. No significant difference was found among the three groups with regard to reflux and Hp positivity. No significant difference was found between Hp-positive and Hp-negative groups with regard to reflux and reflux esophagitis. Conclusion: No clear relationship was found among LES disorders, GER, and Hp. Moreover, no significant difference was found among LES disorders with regard to GER, while the presence of hypotensive LESP, rather than Hp, was found to be an important factor in the development of reflux esophagitis.

Characteristics of patients with hepatocellular carcinoma: A multicenter study.

Background and Aim: The aim of the present study was to examine the etiology of hepatocellular carcinoma (HCC) by underlying cause and determine the characteristics and clinical features of patients with HCC. Materials and Methods: The study comprised 1802 HCC patients diagnosed and followed up by Liver Diseases Outpatient Clinics in 14 tertiary centers in Turkey between 2001 and 2020. Results: The mean age was 62.3±10.7 years, and 78% of them were males. Of the patients, 82% had cirrhosis. Hepatitis B virus (HBV) infection was the most common etiology (54%), followed by hepatitis C virus (HCV) infection (19%) and nonalcoholic fatty liver disease (NAFLD) (10%). Of the patients, 56% had a single lesion. Macrovascular invasion and extrahepatic spread were present in 15% and 12% of the patients, respectively. The median serum alpha-fetoprotein level was 25.4 ng/mL. In total, 39% of the patients fulfilled the Milan Criteria. When we compared the characteristics of patients diagnosed before and after January 2016, the proportion of NAFLD-related HCC cases increased after 2016, from 6.6% to 13.4%. Conclusion: Chronic HBV and HCV infections remain the main causes of HCC in Turkey. The importance of NAFLD as a cause of HCC is increasing.

Incidence, Risk Factors, and Treatment of Proximally Migrated Pancreatic Stents.

AIM: The aim of this study was to investigate the incidence, risk factors, and treatment strategies of proximally migrated pancreatic stents. MATERIALS AND METHODS: The data of 626 sessions of 421 patients with pancreatic duct stenting were retrospectively analyzed between 2010 and 2018, and patients with proximally migrated stents were included in the study. RESULTS: Of 626 stents examined, 77 migrated proximally (12%). The migration rate (MR) was 16%, 2%, and 7%, respectively, in patients treated with chronic pancreatitis, malignancy, and pancreatic leakage indication. The MR was 14% in procedures with pancreatic duct stenosis, 21% in procedures with pancreatic sphincterotomy, and 27% in procedures performed from minor papillae. The MR of the 5, 7, and 10 Fr stents was 4%, 17%, and 10%, respectively. Of the 77 migrated stents, 64 were successfully removed (83%). This success rate (SR) was 84% in procedures with chronic pancreatitis indication, 83% in procedures with pancreatic duct stenosis, 79% in procedures with sphincterotomy, and 75% in procedures performed from minor papillae. The SR of the 5, 7, and 10 Fr stents was 100%, 79%, and 92%, respectively. It was also determined that 33 stents were fractured and migrated (43%). The SR of the fractured stents was 76%. Moreover, of the stents that were successfully removed, 35 were removed with forceps (55%) and 15 (23%) were removed with a balloon. Furthermore, in 47 cases, the stent was removed in the first session (73%). Acute pancreatitis occurred in 5 patients (8%) and perforation occurred in 1 patient (2%). CONCLUSION: In this study, it was shown that proximal migration of pancreatic stents is frequent and most of these stents can be removed successfully.

The Efficacy of Biofeedback Treatment in Patients with Fecal Incontinence.

BACKGROUND: The initial treatment for fecal incontinence (FI) includes supportive treatment and medical treatment. If the initial treatment fails, biofeedback therapy (BFT) is recommended. However, there are limited and conflicting results in the literature supporting the beneficial effect of BFT for FI. The aim of the study is to analyze the efficacy of BFT in 126 patients who have FI due to several causes. METHODS: The data of 126 patients (88 females (69.8%) and 38 males (30.2%)) were collected retrospectively. Colonoscopy, anorectal manometry (ARM), and 3D-Endoanal ultrasonography (EAUS) were performed for all patients before applying BFT. In addition, all patients received toilet training instruction and training in Kegel and other pelvic floor strengthening exercises from an experienced nurse, before BFT. RESULTS: The median age of participants was 54 years (range 18-75 years). While 80 patients (63.5%) had clinical and manometric benefit from BFT, 46 patients (36.5%) did not respond to BFT. According to the EAUS and ARM findings, BFT was beneficial in patients who had partial external sphincter failure, and was unsuccessful in patients who had both internal and external sphincter failure, both internal and external sphincter tears, and external sphincter tear rates of more than 25%. After BFT, significant increases in squeeze pressures were observed, with this increase being higher in the positive-response group. CONCLUSION: The results suggest that BFT is effective in the treatment of FI for specific patient populations.

Endoscopic retrograde cholangiography via a permanent access loop.

BACKGROUND/AIMS: The aim of this study was to investigate the indications, technical and clinical success, and complications of the endoscopic retrograde cholangiography (ERC) via a permanent access loop (PAL). MATERIALS AND METHODS: Twenty patients who underwent ERC through PAL between 2009 and 2017 were included in this study. The technical success was described as achieving access to the bile ducts through PAL and the clinical success was described as the clinical and laboratory improvement of the patients after the procedure. RESULTS: The study was performed with 20 patients. The median follow-up duration was 24 months (3-96) and the median number of ERC sessions was 3.9 (1-10). The most common ERC indications through PAL were stones (40%) and cholangitis (30%). In 16 patients (75%), anastomotic or branched strictures were observed. The improvement of strictures via intermittent stenting and dilatation was observed in 6 patients, but no improvement was observed in 5 patients. The treatment of those 5 patients continues. In this study, the technical success was 100% and clinical success was 85%. While no mortality due to PAL-mediated ERC was observed, free wall perforation was seen in one patient who was referred to surgery. CONCLUSION: PAL-mediated ERC procedure is a technique with high technical and clinical success and low complication rate in patients who require frequent percutaneous procedures and those with difficult access to the biliary tract.

Bezoar in upper gastrointestinal endoscopy: A single center experience.

BACKGROUND/AIMS: We aimed to investigate the association of bezoar with endoscopic findings, risk factors for bezoar occurrence, and the success of endoscopic treatment in a tertiary center. MATERIALS AND METHODS: This retrospective study was conducted between January 2012 and December 2015. Overall, 8200 endoscopy records were examined and 66 patients with bezoar were included in the study. RESULTS: We enrolled 29 (44%) female and 37 (56%) male patients in this study. The mean age of the patients was 63±9.4 years. The most frequent risk factors were history of gastrointestinal surgery (23%), diabetes mellitus (17%), trichophagia (9%), and anxiety disorder (6%). Gastric ulcer, duodenal ulcer, erosive gastritis, and reflux esophagitis were present in 27%, 11%, 20%, and 23% of the patients, respectively. While bezoars were most commonly observed in the stomach (70%), the majority of them were phytobezoars (91%). The mean number of interventions for each patient was 1.5 (range, 1-6). Endoscopy was successful in removing bezoars in 86.5% of the patients. Among those referred to surgery, seven patients underwent gastrostomy (10.5%); one (1.5%) patient underwent gastroenterostomy because of concomitant pyloric stenosis; and one (1.5%) patient underwent fistula repair surgery due to the development of duodenal fistula caused by bezoar. CONCLUSION: The findings of this study indicated that bezoars are more common among subjects with history of gastrointestinal surgery, diabetes mellitus, or psychiatric disorders; bezoars are closely related to peptic ulcer and reflux esophagitis; and they can be successfully treated with endoscopy.

The role of the PLR-NLR combination in the prediction of the presence of Helicobacter pylori and its associated complications.

BACKGROUND/AIM: The aim of this study was to investigate the role of the platelet-to-lymphocyte ratio (PLR)-neutrophil-to-lymphocyte ratio (NLR) combination, in the prediction of the presence of Helicobacter pylori (HP) and its associated complications in the gastrointestinal system. PATIENTS AND METHODS: In all, 1289 patients who underwent esophagogastroduodenoscopy and biopsy for HP were included in the study. RESULTS: The ratio of patients with moderate and severe chronic gastritis was higher in HP (+) group than HP (-) group. The ratio of patients with levels 1-3 atrophy and intestinal metaplasia was higher in HP (+) group. Compared with HP (-) group, HP (+) had higher PLR and NLR levels. The ratio of HP (+) patients was higher in high-risk group compared with low- and medium-risk groups. HP invasion stage, the intestinal metaplasia level, and the ratio of patients with atrophy level "3" were higher in high-risk group compared with low- and medium-risk groups. Regression analysis showed that the PLR-NLR combination was an independent risk factor for both HP presence and moderate and severe chronic gastritis. CONCLUSION: We found the PLR-NLR combination to be a good predictor of HP presence and gastrointestinal complications associated with HP.