Acute pancreatitis in Turkey: Results of a nationwide multicenter study.

BACKGROUND: Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management. METHODS: All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria. RESULTS: The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically. CONCLUSIONS: This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.

Clinicopathological profile of gastrointestinal tuberculosis: a multinational ID-IRI study.

Data are relatively scarce on gastro-intestinal tuberculosis (GITB). Most studies are old and from single centers, or did not include immunosuppressed patients. Thus, we aimed to determine the clinical, radiological, and laboratory profiles of GITB. We included adults with proven GITB treated between 2000 and 2018. Patients were enrolled from 21 referral centers in 8 countries (Belgium, Egypt, France, Italy, Kazakhstan, Saudi Arabia, UK, and Turkey). One hundred four patients were included. Terminal ileum (n = 46, 44.2%), small intestines except terminal ileum (n = 36, 34.6%), colon (n = 29, 27.8%), stomach (n = 6, 5.7%), and perianal (one patient) were the sites of GITB. One-third of all patients were immunosuppressed. Sixteen patients had diabetes, 8 had chronic renal failure, 5 were HIV positive, 4 had liver cirrhosis, and 3 had malignancies. Intestinal biopsy samples were cultured in 75 cases (78.1%) and TB was isolated in 65 patients (86.6%). PCR were performed to 37 (35.6%) biopsy samples and of these, 35 (94.6%) were positive. Ascites samples were cultured in 19 patients and M. tuberculosis was isolated in 11 (57.9%). Upper gastrointestinal endoscopy was performed to 40 patients (38.5%) and colonoscopy in 74 (71.1%). Surgical interventions were frequently the source of diagnostic samples (25 laparoscopy/20 laparotomy, n = 45, 43.3%). Patients were treated with standard and second-line anti-TB medications. Ultimately, 4 (3.8%) patients died and 2 (1.9%) cases relapsed. There was a high incidence of underlying immunosuppression in GITB patients. A high degree of clinical suspicion is necessary to initiate appropriate and timely diagnostic procedures; many patients are first diagnosed at surgery.

Synchronous duodenum and descending colon metastasis from primary lung neuroendocrine small-cell carcinoma: A case report and review of the literature.

INTRODUCTION: Metastasis to the gastrointestinal tract from lung cancer is very uncommon and is often asymptomatic. Although small bowel metastasis may commonly occur, metastases to the stomach and colon are uncommon. CASE REPORT: In this paper, we present a previously healthy 57-year-old male patient, a 60-packet per year smoker, who was taken to the emergency room with complaints of increasing abdominal pain, rectal bleeding, weight loss, and dyspnea for the last three months. Endoscopic examination revealed polypoid lesions in the duodenum and the descending colon. We diagnosed neuroendocrine small-cell lung cancer based on histopathological and immunohistochemical staining.Management and outcome: A cisplatin (d1, 60 mg/m2/day)-etoposide (d1 to d3, 120 mg/m2/day) regimen was given every three weeks as palliative chemotherapy. After the three course of chemotherapy, the lung radiograph showed a decline in hilar expansion and there was no pleural effusion. Then, he died of acute respiratory failure two weeks after radiotherapy of brain. DISCUSSION: Gastrointestinal tract metastasis of lung cancer is recognized synchronously with or rarely before diagnosis. It is generally recognized after the diagnosis of lung cancer. These patients often have other concurrent body metastases. Prognosis is poor, and survival expectation is short. The most common metastases to the gastrointestinal tract are squamous and large cell lung cancer metastases. Our aim is to emphasize the importance of immunohistochemical examination for masses in the gastrointestinal tract and to present this rare case of synchronous duodenal and colonic metastases of small-cell lung cancer.

The accuracy of 3T magnetic resonance cholangiopancreatography in suspected choledocholithiasis.

PURPOSE: The purpose of this study was to investigate interobserver agreement during magnetic resonance cholangio-pancreatography (MRCP) evaluation and the sensitivity and specificity of MRCP obtained with 3T scanners in cases of bile duct obstruction. MATERIAL AND METHODS: A total of 37 patients who had MRCP and endoscopic retrograde cholangiography (ERCP) were included. Choledochal pathology was divided into two groups regarding the presence of stones as "there is stone or not". MRCPs were performed with a 3-Tesla system using respiratory triggered HASTE technique in axial and coronal planes and with T2 SPACE sequence in the coronal plane. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated separately for each observer. The average of both observers was calculated for comparison with other studies. RESULTS: Thirty-seven patients were in the study population. Agreement between the observers was analysed, and Cohen's κ value was evaluated as 0.84. For two observers, the sensitivity of MRCP was 93%, whereas the specificity was 75% for the first observer and 62% for the second. CONCLUSIONS: In this study we found a high level of interobserver agreement in evaluating MRCP. MRCP has a high sensitivity in detecting choledocholithiasis.

Weight loss at the time of diagnosis is not associated with prognosis in patients with advanced-stage non-small cell lung cancer.

PURPOSE: To investigate the prognostic value of weight loss before diagnosis in patients with advanced stage non-small cell lung cancer (NSCLC) treated with first-line chemotherapy. METHODS: A total of 81 NSCLC patients with stages IIIB/IV were included in this retrospective cross-sectional study. Study variables were weight loss in the last 3 months before diagnosis, patient demographic, clinical and laboratory characteristics and histological features of the tumor before administering first-line chemotherapy. Then, the patients were stratified into 4 groups based on their weight loss before being diagnosed with NSCLC. RESULTS: The patients were predominantly male (68%), with a smoking history (62%), 5 to 10 kg weight loss in the last 3 months (31%), and had metastatic disease (64%) and adenocarcinoma (40%) at the time of diagnosis. On the other hand, most of the patients with 5 to 10 kg weight loss in the last 3 months before diagnosis had squamous cell carcinoma (44%), stage IV disease (56%), and the first disease progression was in the brain (64%). Pre-diagnosis weight loss had a negative impact on progression-free survival (PFS), independent from weight loss during first-line chemotherapy, but no such effect was noticed on overall survival (OS). CONCLUSIONS: Pre-diagnosis weight loss was found to have a negative impact on PFS in patients with NSCLC treated by first-line chemotherapy. Similar studies in larger patient series are warranted.

Cardiac Events Within the 30-Day Postoperative Period Is Associated With Increased 1-Year Mortality Among Deceased-Donor Liver Transplant Recipients.

OBJECTIVES: Each year in the United States, approximately 40000 patients with a liver disorder will progress to end-stage liver disease and about 30000 of those patients will subsequently die from this condition. Liver transplant remains the definitive treatment option for end-stage liver disease, and understanding the causes of posttransplant mortality is an ongoing area of investigation. MATERIALS AND METHODS: In this retrospective cohort study, patients who underwent orthotopic liver transplant between January 2012 and January 2015 at the Johns Hopkins Hospital Liver Transplant Program were reviewed by a single reviewer for cardiac events in the 30 days after transplant or during the index admission. RESULTS: Of the 145 patients included, 30 (20.6%) were identified as having experienced a cardiac event during the defined postoperative period. Overall 1-year mortality for the cohort of 145 patients was 11.7%; however, 1-year mortality in those who had a cardiac event was 36.7% compared with 5.2% in the noncardiac event group (odds ratio = 18.17; P < .001). Although there was a statistically significant difference in age between the groups (58.6 vs 52.3 years old), once accounted for in multivariate analysis, a posttransplant cardiac event was still a statistically significant variable in 1-year mortality (odds ratio = 89.16; 95% confidence interval, 2.71-2933.95; P = .012). Similarly, hepatocellular carcinoma, sex, age, and presence of diabetes had little effect on 1-year mortality when we compared those patients who experienced a cardiac event in the first 30 days versus those who did not (odds ratio = 100.82; 95% confidence interval, 2.15-4726.12; P = .019). CONCLUSIONS: Recipients who experience cardiac events within 30 days after transplant have increased 1-year posttransplant mortality. This highlights the importance of cardiac risk stratification before transplant.

Role of nucleoside/nucleotide analogues and low-dose hepatitis B immune globülin in prophylaxis of hepatitis B recurrence among cadaveric liver transplant recipients.

BACKGROUND/AIMS: Hepatitis B core antibody (HBcAb) positivity of the donor or the recipient may pose a risk of hepatitis B virus (HBV) reactivation following liver transplantation (LT). We retrospectively investigated patient survival and reactivation among recipients who were given low-dose Hepatitis B Immune Globulin (HBIG) plus antiviral agent (AV) versus AV only. MATERIALS AND METHODS: Records of cadaveric LT recipients, between 2013 and 2016, with positive Hepatitis B surface Antigen (HBsAg) and/or HBcAb and recipients who had received LT from HBcAb-positive donors were reviewed. Patient characteristics and clinical data were extracted. Donor variables were retrieved from the United Network of Organ Sharing (UNOS) database. HBIG (1560 IU/mL) Intravenous (IV) was intraoperatively administered with three daily doses. Entecavir 1 mg daily was also given. STATA was used for statistical analysis. RESULTS: There were 53 recipients; 39 (73.6%) were male with a median age of 59 y. HCV was the major indication in 30 (55.6%) patients. There were 28 recipients (52.8%) who received HBIG plus AV and 25 (47.2%) received AV only. The Model of End Stage Liver Disease (MELD) score between the groups were similar. Survival rates at 6, 12, and 24 months were 100% (n=53), 93.2% (n=44), and 100.0% (n=26), respectively. There was no reactivation; two recipients in the AV group and one in the HBIG plus AV group died within 12 months. CONCLUSION: This study supports the use of low-dose HBIG and AV for post-LT prophylaxis to be as effective as conventionally used high-dose HBIG (9600 IU) plus AV. Future prospective larger studies are warranted to examine the potential benefits of using AV alone without HBIG.

A rare association of celiac disease and rectal neuroendocrine tumor.

Celiac disease (CD) is a chronic immune-mediated enteropathy which is triggered by dietary gluten in genetically predisposed individuals. Increased risk of all gastrointestinal cancers was found during the first year after diagnosis of CD. Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a heterogeneous tumor group originating from the diffuse neuroendocrine system. Today, the incidences of both GEP-NETs and CD have increased due to the increased availability of diagnostic tools and awareness. Association of GEP-NETs with CD is rarely seen. Here we aimed to present a case in which we diagnosed CD with concurrent rectal NET. Association of CD and rectal NET has not been reported in the literature, and we believe that our case report can contribute to the epidemiological data.

Hyperuricemia at The Time Of Diagnosis is a Factor for Poor Prognosis in Patients With Stage II and III Colorectal Cancer (Uric Acid and Colorectal Cancer)

Purpose: In this pilot study we investigated whether serum levels of uric acid, the final breakdown product of purine metabolism, might influence cancer-related events in stage II and III colorectal cancer patients. Material and methods: In this cross-sectional retrospective study, a total of 150 stage II and III colorectal adenocarcinoma patients with no exclusion criteria were included. Serum uric acid levels of the patients measured at diagnosis and demographic, clinical, laboratory analyses were performed and histologically features recorded. Patients were stratified into quartiles according to serum uric acid level with different cut-off values. Results: The mean serum uric acid level of all patients was determined o be 6.97±2.87 md/dL (range, 3.1-12.4). Median follow-up time was 98 (range 9-98) months and the proportion of patients who did not relapse was 22%. It was determined that majority of the patients who had serum uric acid levels over 8.37 mg/dL had stage IIIB lesions, were smokers, were among those who lost weight, with metastasis to the liver and with significantly leukocyte and platelet counts. Conclusions: Serum uric acid levels measured at the time of diagnosis may be associated

The Role of Fecal Calprotectin in Evaluating Intestinal Involvement of Behçet's Disease.

One of the regions of involvement of Behçet's disease (BD), a systematic inflammatory vasculitis with unknown etiology, is the gastrointestinal (GI) tract. Upper GI endoscopy, colonoscopy, and capsule endoscopy are frequently used methods to diagnose the intestinal involvement of BD. The aim of this study was to investigate the role of fecal calprotectin (FC) in the evaluation of intestinal involvement in BD. Material and Method. A total of 30 patients who were diagnosed with BD and had no GI symptoms and 25 individuals in the control group were included in this study. Results. Levels of FC were statistically significantly higher in patients with BD compared to the control group (p < 0.001). The correlation analysis performed including FC and markers of disease activity revealed a positive and statistically significant correlation between FC level and CRP and erythrocyte sedimentation rate (r: 0.255, p < 0.049, and r: 0.404, p < 0.001, resp.). FC levels in patients who were detected to have ulcers in the terminal ileum and colon in the colonoscopic examination were statistically significantly higher compared to the patients with BD without intestinal involvement (p = 0.01). Conclusion. The measurement of FC levels, in patients with BD who are asymptomatic for GI involvement, may be helpful to detect the possible underlying intestinal involvement.

Intestinal invagination secondary to intestinal adenocarcinoma in coeliac disease.

Invagination is defined as a medical condition in which a part of the gastrointestinal tract has entered into another section. Intestinal invagination is a rare clinical entity among adults and there is an underlying structural lesion in most of the cases. Coeliac disease is considered as a risk factor for intestinal invagination, because of the associated inflammatory processes and motility disorders as well as the increased risk for secondary malignancies. We report a case of intestinal invagination secondary to intestinal adenocarcinoma in a woman with coeliac disease, whose adherence to a gluten-free diet was poor.

A Large Intra-Abdominal Hiatal Hernia as a Rare Cause of Dyspnea.

Giant hiatal hernias, generally seen at advanced ages, can rarely cause cardiac symptoms such as dyspnea and chest pain. Here, we aimed to present a case with a large hiatal hernia that largely protruded to intrathoracic cavity and caused dyspnea, particularly at postprandial period, by compressing the left atrium and right pulmonary vein. We considered presenting this case as large hiatal hernia is a rare, intra-abdominal cause of dyspnea.

Angiotensin-converting enzyme for noninvasive assessment of liver fibrosis in autoimmune hepatitis.

BACKGROUND AND AIM: There are no validated noninvasive markers of liver fibrosis in autoimmune hepatitis (AIH). An activated renin-angiotensin system (RAS) and its key element angiotensin-converting enzyme (ACE) have been implicated in the pathogenesis of hepatic fibrogenesis. We aimed to study the assumed role of activated RAS in the fibrogenic process and whether the serum concentration of ACE can predict different fibrosis stages in AIH. PATIENTS AND METHODS: Serum samples of 73 consecutive patients who were diagnosed with AIH were analysed for ACE concentration. All patients underwent a liver biopsy. RESULTS: Serum ACE levels increased significantly for each fibrosis score. The median ACE was 45 U/l in patients with fibrosis score I, 54 U/l in patients with fibrosis score II, 68 U/l in patients with fibrosis score III and 87 U/l in patients with fibrosis score IV. For significant fibrosis (≤F2), a 56 U/l cut-off value of ACE had 95.5% sensitivity and 74.5% specificity, and receiver-operating characteristic curves showed an area under the curve (AUC) of 0.89. For advanced fibrosis (≤F3), a 64 U/l cut-off level of ACE had 85.2% sensitivity and 94.8% specificity, and AUC was 0.91. For cirrhosis, a 68 U/l cut-off level of ACE had 100% sensitivity and 84.4% specificity, and AUC was 0.95. CONCLUSION: Our results suggest that activated RAS may sustain hepatic fibrogenesis in AIH. Measurement of serum ACE offers an easy, accurate and inexpensive noninvasive method that differentiates significant from nonsignificant liver fibrosis in AIH. Blockade of RAS may exert beneficial effects on fibrosis progression in AIH.

Plummer-Vinson syndrome with pectus carinatum mitral valve prolapsus and exotropia in an 18-year-old boy.

The Plummer-Vinson syndrome is a clinical syndrome characterised by dysphagia, web or webs in upper oesophagus and iron-deficiency anaemia. The syndrome is often seen in women of age 40-70 years and rarely in adolescents. Plummer-Vinson syndrome might be associated with malignancy, myeloproliferative disorder and autoimmune diseases including coeliac disease, rheumatoid arthritis and Sjögren syndrome. However, according to our literature search, there are no reports of such case associated with thorax deformity, cardiac pathology and ocular findings. We present a case of an 18-year-old boy with a rare presentation of this syndrome including pectus carinatum, exotropia and mitral valve prolapsus.

Pregnancy in women with primary biliary cirrhosis.

BACKGROUND & AIMS: Primary biliary cirrhosis (PBC) may present in all decades of life, also in childbearing age. Data on maternal and fetal outcome is limited. We aimed to investigate the impact of pregnancy and childbirth on the disease course and possible effects of PBC on fetal outcome. METHODS: Retrospective study of local cases and a compact review of published reports between 1950 and 2014. RESULTS: Our cases along with literature review provided 98 pregnancies in 72 PBC patients. PBC was diagnosed during pregnancy in 26 (36%) patients and 46 (64%) had the diagnosis before conception. Twenty-four (30%) of the pregnancies were associated with biochemical flares and 55 (70%) with clinical improvement or stabilization. De novo onset or worsening of pruritus was seen in 49% (45/92). No maternal deaths were reported. Post-partum disease activation was observed in 60% (53/88). One patient was referred for liver transplantation after delivery. A miscarriage rate of 24% and three stillbirths were reported. Most patients were treated with ursodeoxycholic acid (UDCA) during breastfeeding and 12 patients also received UDCA during the first trimester without any identified side effects. CONCLUSION: Most women with PBC maintain a stable disease during pregnancy, but post-partum biochemical flares are common. Symptomatic pruritus may be challenging in pregnant PBC patients. UDCA appears to be safe during pregnancy and breastfeeding. A successful pregnancy outcome is a realistic expectation for women with PBC.

Liver biopsy is a superior diagnostic method in some patients showing the typical laboratory features of autoimmune hepatitis.

AIMS: To investigate whether liver diseases other than autoimmune hepatitis (AIH) can present with the typical features of AIH, and to determine the impact of liver biopsy for differentiating AIH from these conditions. PATIENTS AND METHODS: The study used data collected at Hacettepe university hospital and numune education and research hospital from 2007 to 2011. The clinical, laboratory and histological findings of patients diagnosed with non-alcoholic steatohepatitis, drug-induced liver injury, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis and Wilson's disease were evaluated to identify those who presented with the typical features of AIH, but had no liver histology compatible with or suggestive of AIH. RESULTS: A total of 386 patients were evaluated, and four patients with typical features of AIH were identified. Three patients were positive for antinuclear antibodies, and one was positive for smooth muscle antibodies. Also, all four had increased levels of immunoglobulin G, and aminotransferase levels that were five times above the upper limit. According to simplified AIH criteria, all patients had a score of 6, indicating probable AIH. On liver biopsy, two patients were diagnosed with non-alcoholic steatohepatitis, another with drug-induced liver injury and a further one with primary biliary cirrhosis. CONCLUSION: Liver diseases other than AIH can present with the typical laboratory features of AIH and, without liver biopsy, it is difficult to distinguish AIH than these conditions. Although histological findings have little impact on patients' management and outcomes, for a definitive diagnosis of AIH, liver biopsy is essential and should be performed in all patients in whom it is suitable and not contraindicated.