Clarifying the relationship between ABO/Rhesus blood group antigens and upper gastrointestinal bleeding.

BACKGROUND AND AIM: The relationship between blood group antigens and peptic ulcer disease has been widely evaluated in the past. Data concerning the same association with upper gastrointestinal bleeding are very limited. We aimed to evaluate this association and we thought it was worthwhile to try to determine whether these components take some part in this complication. METHODS: The study population consisted of 1,098 adults (364 patients and 734 volunteer blood donors as controls). Demographic features, comorbid illnesses, and use of aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) were recorded. Blood groups were examined by gel centrifugation method. We included only patients with bleeding from peptic ulcer disease and erosive gastropathy. Ulcers were classified by using Forrest's classification system in terms of rebleeding risk. Helicobacter pylori was examined by histology. RESULTS: The gender distribution was similar in both groups. The ABO blood group phenotype distribution in patients and controls (respectively) was as follows: 46.2% versus 34.9% for group O, 32.4% versus 39.5% for group A, 15.7% versus 18.4% for group B, and 5.8% versus 7.2% for group AB. Blood group O was found to have higher frequency in the patient group than in the control group (P=0.004). Rh positivity was also higher in patients than in controls (P=0.007). H. pylori positivity was similar between blood groups among patients. The rebleeding and mortality rates between blood groups were also similar. CONCLUSION: ABO blood group O had an important role in patients with upper gastrointestinal bleeding. The impact of blood group on rebleeding and mortality may be a focus for further studies.

Long-term conventional interferon alpha in combination with lamivudine for chronic hepatitis B: data from Turkey.

BACKGROUND/AIMS: Standard interferon or lamivudine monotherapy has been shown to induce a low response rate in patients with chronic hepatitis B infection. Genotype D represents almost the whole of chronic HBV infection of Turkish population. The aim of this study was to evaluate the efficacy and safety of the long-term interferon-alpha plus lamivudine on these patients, and thereafter the co-effect of maintenance therapy by lamivudine. METHODOLOGY: This prospective study was carried out between the late 1999 and 2005. A total of 37 (24 HBeAg-positive and 13 HBeAg-negative) patients were enrolled in the study. These patients received standard interferon-alpha (9/10 MU) three times sc. a week plus lamivudine 100mg po. daily, for 52 weeks. After the interferon discontinuation, lamivudine monotherapy was assigned to be given until 4-6 months after the occurrence of HBeAg seroconversion in the HBeAg-positive patients and at least three years in HBeAg-negative patients. Response-1 was defined as the response at the end of combination therapy at the 52nd week, and Response-2 as response at the end of the follow-up period under lamivudine monotherapy. An intention-to-treat analysis was performed. RESULTS: Patients' follow-up ranged between 7-67 months, with a mean duration of 29.64 +/- 14.01 months. Twenty-six patients (70.3%) had a Response-1, both virological and biochemical. A biochemical Response-2 was achieved in 24 patients (64.9%), while virological Response-2 in 17 (45.9%). Response-1 and Response-2 were similar between HBeAg-positive and HBeAg-negative patients (p = 0.262 and p = 0.734, respectively). HBeAg seroconversion was achieved only in 8 (33.3%) of HBeAg-positive patients. Clinical resistance to lamivudine developed only in 9 (24.3%) of the patients. Decompensation or hepatocellular carcinoma did not observe in any case. CONCLUSIONS: This study showed the efficacy of the 'long-term' anti-viral maintenance along with the combination therapy in genotype D predominant chronic hepatitis B patients. A low clinical resistance rate to lamivudine was achieved.

Does adding misoprostol to standard intravenous proton pump inhibitor protocol improve the outcome of aspirin/NSAID-induced upper gastrointestinal bleeding?: a randomized prospective study.

Aspirin and nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal bleeding is recognized as an important health problem. We performed a single-center randomized clinical trial to compare the effect of high-dose intravenous proton pump inhibitor (omeprazole) alone (group 1) with omeprazole in combination with a low-dose prostaglandin analog (misoprostol; group 2) on clinical outcomes in patients with aspirin/NSAID-induced upper gastrointestinal bleeding. Additionally, we evaluated the contribution of Helicobacter pylori eradication therapy on the late consequences. Patients were recruited to the study if they had upper gastrointestinal bleeding with history of taking aspirin or other NSAIDs within the week before the onset of bleeding. All were evaluated in terms of probable risk factors. After the standard treatment protocol, patients with histologically proven H pylori infection were prescribed a triple eradication therapy for 14 days. The primary end points were recurrent bleeding, surgery requirement, and death rates before discharge and at the end of follow-up period. This study lasted for 2 years. A total of 249 patients with upper gastrointestinal bleeding were admitted, and 49.7% of these patients were users of aspirin/NSAIDs. There were 67 patients in group 1 and 56 in group 2. The distributions for gender, age, comorbidity, H pylori infection, and high-risk ulcer rate were similar in both groups. Among aspirin/NSAID users, endoscopy revealed duodenal ulcer in 47 (38.2%), gastric ulcer in 10 (8.1%), and erosive gastropathy in 33 (26.8%). The overall rebleeding occurred in 12.2%, death in 2.4% of the patients. The in-hospital death (P=.414), rebleeding (P=.925), and surgery (P=.547) rates were similar in both treatment groups. After the follow-up period of 3 months, overall rebleeding occurred in 4.1%, and death in 4.8% of the patients. The overall mortality rate was highest in those >65 years old, who were chronic low-dose aspirin users with comorbidity. One died of transfusion-related graft-versus-host disease. In this pilot study, we indicated that adding misoprostol (600 microg/day) to standardized proton pump inhibitor treatment did not improve or change the rebleeding or mortality rates of patients with upper gastrointestinal bleeding related to aspirin/NSAID use. Other prospective studies on higher doses of misoprostol are needed to establish the coeffect. One should bear in mind that all blood products must be irradiated before transfused to the host.

Fenofibrate treatment in two adults with Crigler-Najjar syndrome type II.

Crigler-Najjar syndrome type II is a rare familial disorder of bilirubin conjugation with consecutive life-long unconjugated hyperbilirubinemia. In the presence of severe hyperbilirubinemia, a fetus or an adult is at risk for neurological defects in this syndrome. This paper is the first report emphasizing details about this disorder in two patients from Turkey. The diagnosis was made on the basis of history and laboratory findings excluding other causes of unconjugated hyperbilirubinemia. Phenobarbital loading test and C bile analysis also supported the diagnosis. There was a study in the literature in which treatment with chlofibrate had been recommended in this syndrome. Based on the results of that study, we administered fenofibrate treatment to our patients for one month and analyzed serum bilirubin levels before and after this procedure. No improvement in bilirubin levels was observed in either case.

A head to head comparison of oral vs intravenous omeprazole for patients with bleeding peptic ulcers with a clean base, flat spots and adherent clots.

AIM: To compare the effect of intravenous and oral omeprazole in patients with bleeding peptic ulcers without high-risk stigmata. METHODS: This randomized study included 211 patients [112 receiving iv omeprazole protocol (Group 1), 99 receiving po omeprazole 40 mg every 12 h (Group 2)] with a mean age of 52.7. In 144 patients the ulcers showed a clean base, and in 46 the ulcers showed flat spots and in 21 old adherent clots. The endpoints were re-bleeding, surgery, hospital stay, blood transfusion and death. After discharge, re-bleeding and death were re-evaluated within 30 d. RESULTS: The study groups were similar with respect to baseline characteristics. Re-bleeding was recorded in 5 patients of Group 1 and in 4 patients of Group 2 (P = 0.879). Three patients in Group 1 and 2 in Group 2 underwent surgery (P = 0.773). The mean length of hospital stay was 4.6 +/- 1.6 d in Group 1 vs 4.5 +/- 2.6 d in Group 2 (P = 0.710); the mean amounts of blood transfusion were 1.9 +/- 1.1 units in Group 1 vs 2.1 +/- 1.7 units in Group 2 (P = 0.350). Four patients, two in each group died (P = 0.981). After discharge, a new bleeding occurred in 2 patients of Group 1 and in 1 patient of Group 2, and one patient from Group 1 died. CONCLUSION: We demonstrate that the effect of oral omeprazole is as effective as intravenous therapy in terms of re-bleeding, surgery, transfusion requirements, hospitalization and mortality in patients with bleeding ulcers with low risk stigmata. These patients can be treated effectively with oral omeprazole.

Changes in pulse oximetry levels and factors affecting oxygen saturation during routine upper gastrointestinal endoscopy with or without sedation.

BACKGROUND/AIMS: We aimed to investigate whether endoscopy or midazolam as premedication causes oxygen desaturation and to determine factors which may affect the occurrence of oxygen desaturation. METHODS: Totally 200 patients with various indications (103 men and 97 women), who presented to the Endoscopy Unit of Dicle University Hospital for upper gastrointestinal endoscopy examination, were included in the study. Anamnesis and anthropometric values of the patients were taken. Preoperative oxygen saturation, hemoglobin levels and heart rate per minute were recorded. Patients with initial oxygen saturation levels <90% were excluded. Patients were divided into two groups. The first group included 100 patients who underwent endoscopic examination without sedation and the second group included 100 patients who underwent endoscopic examination with sedation [midazolam (2-5 mg)]. At the end of endoscopy, intravenous flumazenil (0.2 mg) was administered to the premedication patients. Patients were monitored for oxygen saturation and heart rate starting before the sedation and oropharynx anesthesia and lasting until 1 min after the end of the procedure. During the endoscopic examination, minimum oxygen saturation and maximum heart rate values were recorded. The duration of the oxygen saturation <90% was recorded throughout the procedure and the relation of this time with the total time of the endoscopic examination was evaluated. RESULTS: The mean age of the 200 patients included in the study was 45 and 44 years for Group 1 and Group 2, respectively. No differences were found between the two groups in terms of body mass index, smoking, hemoglobin and basal maximum pulse rate, duration of endoscopy, minimum basal oxygen saturation, duration of hypoxia and time to hypoxia. No relation was determined between oxygen desaturation and gender, duration of the endoscopy, basal pulse rate or hemoglobin level. It was found that smoking made significant contributions to the oxygen desaturation. CONCLUSION: Midazolam premedication for upper gastrointestinal system endoscopy is a reliable procedure and does not contribute an additional risk in individuals without serious comorbidities. Smoking habits should be taken into account in endoscopy patients.

Analysis of 1242 cases with upper gastrointestinal system bleeding in Southeastern Turkey: a different etiologic spectrum.

BACKGROUND/AIMS: There are few detailed reports on gastrointestinal system bleeding in Turkey. The aim of this study is to analyze the characteristics of the patients with upper gastrointestinal system bleeding who were hospitalized in our clinic. METHODOLOGY: The patients who were hospitalized in Dicle University Hospital Department of Gastroenterology from March 1992 to June 2002 were analyzed retrospectively. RESULTS: During this period of time, 296 females (23.8%) and 946 males (76.2%), total 1242 patients were hospitalized for upper gastrointestinal system bleeding. Mean age was 47 for both sexes. Distribution of the cases was as follows: 31.6% duodenal ulcer (n: 393), 30.5% esophageal variceal bleeding (n: 379), 13.7% erosive gastritis (n: 171), 6.8% erosive duodenitis (n: 85), 4.9% gastric ulcer (n: 62), 2.8% carcinoma (n: 35), and 3.5% other causes. Peptic ulcer related bleeding was the most encountered reason (37.5%, n: 466). Four percent of the cases other than esophageal variceal bleeding underwent urgent surgical intervention. Eleven percent of the cases (n: 138) resulted in death of which 65.9% were esophageal variceal bleeding (n: 91). CONCLUSIONS: The most striking result is the very high rate of esophageal variceal bleeding. This finding is in concordance with the high prevalence of the viral hepatitis in the region.

Evaluation of optimal gastric mucosal biopsy site and number for identification of Helicobacter pylori, gastric atrophy and intestinal metaplasia.

BACKGROUND/AIMS: The study is designed to identify the optimal gastric mucosal biopsy site and number for identification of Helicobacter pylori, gastric atrophy and intestinal metaplasia. METHODOLOGY: Ninety-two patients were included in the study, gastric biopsies were obtained from 5 different sites: lesser curvature of the mid-antrum (A1), greater curvature of the mid-antrum (A2), incisura angularis (IA), lesser curvature of the mid-corpus (B1), greater curvature of the mid-corpus (B2). Helicobacter pylori was evaluated in sections stained with toluidine blue, and histopathological examination was performed in sections stained with hematoxylin-eosin. RESULTS: Seventy-three patients were positive for Helicobacter pylori at least in one biopsy site. Helicobacter pylori was positive in 47 patients (64.3%) in A1, in 54 patients (73.9%) in A2, in 60 patients (82.1%) in IA, 44 patients (60.2%) in B1, and in 42 patients (57.5%) in B2. The highest positivity determined was in the combination of A2 and IA sites (95.8%). Gastric atrophy was determined in 35 of 73 patients (27.1% in A1, 20% in A2, 25.7% in IA, 20% in B1, and 7% in B2). Intestinal metaplasia was determined in 31 of the Helicobacter pylori-positive patients (18% in A1, 16% in A2, 30.9% in IA, 21.8% in B1, 12.7% in B2). CONCLUSIONS: It is considered that taking biopsies from both A1 and IA sites has the highest sensitivity in detecting Helicobacter pylori. However, it is difficult to define a specific site for detecting gastric atrophy and intestinal metaplasia.

Prevalence of Hepatitis C in adults in the south-eastern region of Anatolia: a community-based study.

Aim: There is a limited number of studies on the general population about prevalence of Hepatitis C virus (HCV) in Turkey. The estimated prevalence of HCV in the Southeastern region of the country was obtained from the data of the blood donors. There is no study reflecting the general population of this region, leading us to plan this study. Material and method: Four provinces in the Southeastern Anatolia were randomly selected and sample sizes were determined by Epi Info Programme, and blood samples were collected from 2888 individuals. Questionnaires in which demographic information and probable risk factors for Hepatitis C were investigated and were applied on subjects who gave their consent to participate in the study. Anti-HCV was examined by using Cobas Core II immunochemistry system (Roche). All positive samples were further tested for the presence of HCV RNA by RT-PCR. Crude odds ratios (OR) and 95% confidence intervals (CI) were calculated and Chi-square analyses were performed. Epi Info 2000 Programme was used to perform the analysis. Results: Of the 2888 individuals, 17 (0.6%) were anti-HCV positive and 13 (82%) of them were confirmed as positive for HCV-RNA. No difference was found between rural and urban regions with respect to HCV prevalence ( [Formula: see text] ). The prevalence of HCV in 35-44 years of age group was found to be different from those of the other age groups ( [Formula: see text] ). It was determined that the risk for HCV in this age group was 4.23 times ( [Formula: see text]; [Formula: see text];1.02-20.15; CI 95%:) higher with a prevalence rate of 1.6%. In this age group, anti-HCV was positive in 6 male (2.4%) and 2 female (0.8%), of whom 7 were living in urban (2.2%) and 1 in rural area (0.5%). The overall prevalence of HCV was not found to be different for sex ( [Formula: see text] ). Similarly, there was no difference between the married and single individuals for the prevalence ( [Formula: see text] ). Anti-HCV positivity did not change for the level of education. We could not determine any factor that might play a role in transmission of HCV. Conclusion: This is the first population-based study to be performed in order to determine the prevalence of HCV in the south-eastern region of Anatolia (Turkey). This region has a low prevalence of HCV. The extremely rare prevalence of homosexuality and intravenous drug addiction might have a role in this low prevalence.

The efficacy of flumazenil in subclinical to mild hepatic encephalopathic ambulatory patients. A prospective, randomised, double-blind, placebo-controlled study.

OBJECTIVES: Hepatic encephalopathy (HE) is a neuropsychiatric syndrome associated with fulminant hepatic failure and chronic liver disease. Its pathogenesis is unclear. One of the factors implicated is enhanced GABA-ergic tone, which is probably related to increased concentrations of cerebral benzodiazepine (BNZ). In the present study, we tested flumazenil, a cerebral BNZ antagonist, in cirrhosis patients with hepatic encephalopathy. METHODS: Out of 47 patients, 7 were excluded prior to randomization for various reasons. Twenty patients were included in the flumazenil group and 20 in the placebo group in a prospective, randomized, double-blind, placebo-controlled study. Patients were given flumazenil (1 mg/h, continuous IV infusion) or an equal volume of saline solution for 5 hours. Before and after treatment, portosystemic encephalopathy (PSE) stage and number connection test (NCT) scores were checked every half hour for 5 hours. EEG was recorded 15 minutes before and 1 hour after treatment. RESULTS: While significant improvements were determined in PSE stage and NCT score in the flumazenil group, there were no such improvements in the placebo group. There was no statistically significant difference between pre- and post-treatment EEGs in either group. CONCLUSION: It was concluded that continuous IV infusion of flumazenil had beneficial and safe effects in the treatment of hepatic encephalopathy patients.

Primary squamous cell carcinoma of the stomach: a case report and review of the literature.

Primary squamous cell carcinoma of the stomach is extremely rare. To date, only 80 cases have been reported. A 65-year-old man with complaints of epigastric pain and cachexia for the past year is presented. He had a tumour with infiltration of the corpus and antrum of the stomach. The tumour was unresectable, and the patient died within 3 months.