Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO.

Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.

What is the incidence of celiac disease in patients with microscopic colitis? Why are these two diseases related?

Introduction: Although there are studies in the literature showing that celiac disease (CD) is more common in patients with microscopic colitis (MC), there are publications to the contrary. The pathophysiologies of both diseases are different from each other. Aim: To investigate the frequency of CD in MC patients, the different features of these 2 diseases, and the relationship between them. Material and methods: In our prospective and cross-sectional analytical study, the presence of CD was investigated in 90 patients diagnosed with MC by colonoscopy and biopsy due to chronic diarrhoea between September 2011 and December 2021. Results: We detected MC in 102 (9.3%) of 1096 patients investigated for chronic diarrhoea. We detected CD in 1 (1.1%) of 90 patients with MC who participated in the study. Only 10% of the patients were positive for AGA IgA, 3.3% for EMA IgA, and 2.2% for Anti-TG2 IgA. There was no difference in autoantibody titre in treatment-responsive and treatment-resistant MC patients. HLA DQ2 was positive in 32.2% (n = 29) of the MC patients, and HLA DQ8 was found in 5.5% (n = 5). Intraepithelial lymphocyte increase was remarkable in the duodenal biopsies of MC patients who did not respond to treatment (40% vs. 11.4%; p = 0.007). Conclusions: We did not reach the conclusion that CD is more common in MC patients. An increase in IEL may also occur in the small intestine in patients with MC who do not respond to treatment.

The relation between pathogenesis of liver cirrhosis, hepatic encephalopathy and serum cytokine levels: what is the role of tumor necrosis factor α?

BACKGROUND/AIMS: Hepatic encephalopathy (HE) is a major complication of acute or chronic liver disease characterized by neuropsychiatric symptoms. It's etiology and pathogenetical mechanisms are not clearly understood and probably it is multifactorial. In this study, we aimed to investigate the relation between pathogenesis of HE and TNF-alpha, IL-1beta, IL-2R, IL-6, IL-8 and IL-10, and between the severity of HE and the levels of these cytokines. METHODOLOGY: Eighty patients with liver cirrhosis [50 patients with clinical findings of HE (group 1) and 30 without any symptoms of HE (group 2)] and 30 healthy controls (group 3) were included into the study. Serum TNF-alpha, IL-1beta, IL-2R, IL-6, IL-8 and IL-10 levels of patients and control subjects were studied with the chemiluminescent method. RESULTS: There were statistically significant difference between serum TNF-alpha, IL-1beta, IL-2R, IL-6 and IL-8 levels of patients with liver cirrhosis and healthy subjects (p<0.05), and between patients with and without HE (p<0.05). There was a correlation between the severity of liver cirrhosis according to Child-Pugh classification and cytokine levels. The severity of HE (grade 1-4) was closely related with cytokine levels, especially TNF-a. On the other hand, there was no relation between cytokine levels and the etiological factors. CONCLUSION: We found a positive correlation between serum inflammatory cytokine levels (TNF-alpha, IL-1beta, IL-2R, IL-6, IL-8) and the severity of liver cirrhosis. In addition, our findings suggested that this relation is independent from etiological factors.

Biliary Fasciola gigantica case report from Turkey.

We present a case of Fasciola gigantica-induced biliary obstruction and cholestasis diagnosed and treated via endoscopy and trichlorobendazole treatment. This is the first case of Fasciola gigantica treated via endoscopic biliary extraction during ERCP and drug treatment reported from Turkey.

A case of biliary Fascioliasis by Fasciola gigantica in Turkey.

A case of Fasciola gigantica-induced biliary obstruction and cholestasis is reported in Turkey. The patient was a 37- year-old woman, and suffered from icterus, ascites, and pain in her right upper abdominal region. A total of 7 living adult flukes were recovered during endoscopic retrograde cholangiopancreatography (ERCP). A single dose of triclabendazole was administered to treat possible remaining worms. She was living in a village of southeast of Anatolia region and had sheeps and cows. She had the history of eating lettuce, mallow, dill, and parsley without washing. This is the first case of fascioliasis which was treated via endoscopic biliary extraction during ERCP in Turkey.

Insulin resistance in liver cirrhosis.

BACKGROUND/AIMS: Liver cirrhosis is a chronic disease by degeneration, regeneration and fibrosis in the liver parenchyma, caused by many diseases. Insulin resistance can be defined as any type of decrease in the effect that may occur at the phases following insulin's secretion from beta-cells of the pancreas, where it is produced, until it has the expected effects in the target cells. The aim of the present study is to demonstrate the presence of insulin resistance in LC, which is common in our country and region, and investigate the existence of association between insulin resistance occuring in LC and cytokine levels, age, gender, CRP, Hs-CRP, Child-Pugh score and etiology of LC. METHODOLOGY: A total of 79 patients with liver cirrhosis (group 1) were included in the study, and 50 subjects as controls (group 2). Of liver cirrhosis patients, 49 (62%) were male and 30 (38%) were female, with a mean age of 54.71 +/- 14.68. Of the controls, 23 (46%) were male and 27 (54%) were female, with a mean age of 41.9 +/- 11.54. Severity of cirrhosis was assessed by Modified Child-Turcoutte-Pugh score. Seven cases (8.9%) were at the Child-Pugh stage A, 35 cases (44.3%) at the Child-Pough stage B, and 37 cases (46.8%) at the Child-Pough stage C. HOMA-IR was calculated and values > 2.7 were regarded as presence of insulin resistance (HOMA-IR +). Serum glucose, albumin, bilirubin values were studied with enzymatic method (Architect C-16000); serum CRP, Hs-CRP values with nephelometric method by Beckman Coulter Image Nephelometer (immunochemistry system); insulin, C-peptide with electrochemiluminance immunological method; prothrombin time with radiation method by ACL-Advance brand device. RESULTS: In this study, glucose (p = 0.004), insulin (p = 0.010), C-peptide (p < 0.001), HOMA-IR (p < 0.001), TNF-alpha (p < 0.001), IL-2RES (p < 0.001), IL-6 (p = 0.002), CRP (p < 0.001) and HsCRP (p = 0.006) levels are elevated in LC patients, compared to control group. Consequently, high HOMA-IR in LC supports the fact that insulin resistance develops in LC, as it is reported in similar studies. When HOMA-IR positive and negative patients within LC patients are compared, it is seen that insulin resistance develops independently of age, etiology, gender, Child-Pugh classification, spleen size, TNF-alpha, IL-16, IL-2RES, IL-6, IL-10, CRP, Hs-CRP (p > 0.05) levels.

Mast cells count and serum cytokine levels in patients with irritable bowel syndrome.

BACKGROUND/AIMS: Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder. Psychological factors and subtle histopathological changes have been implicated in IBS. In some studies, mast cell infiltration has been determined in colon mucosa of the patients with IBS. The aim of this study was to investigate the relationship between mast cell counts and cytokine levels and IBS. METHODOLOGY: 72 consecutive IBS patients fulfilling the Rome III criteria and 50 asymptomatic healthy controls underwent colonoscopic biopsy. 15 patients in diarrhea-predominant IBS group which were performed colonoscopy were made a biopsy from caecum, other 25 patients in diarrhea-predominant IBS and 32 patients in constipation predominant IBS were performed a biopsy from rectum. Additionally, serum cytokines were analysed in the patients with IBS and in control group. RESULTS: The results showed significantly increased mast cells in the IBS-diarrhea group compared to IBS-constipation and the control groups (p < 0.0001). The statistical analysis of the inflammatory cytokine data obtained in the present study showed significantly higher levels for the sIL-2 receptor in the IBS-diarrhea group compared to other groups. CONCLUSIONS: Histopathologic and laboratory data demonstrate low-grade mucosal inflammation in a subset of patients with IBS. Mast cells and cytokines may be related to the pathophysiologic mechanism of IBS.

Pseudoxantoma elasticum, as a repetitive upper gastrointestinal hemorrhage cause in a pregnant woman.

Pseudoxantoma elasticum is a rare, hereditary, multisystemic disease affecting the skin, eye, and cardiovascular system. A twenty-eight-year-old female has presented to emergency unit with the complaint of gastrointestinal hemorrhage. This patient, who had been monitored in the gastroenterology clinic more than 10 times in the past 8 years, noted a repetitive hemorrhage during her previous pregnancy in her history. The examination of the patient revealed the following signs and symptoms: atrophy in the epithelium of the retina pigment; typical angioid streaks and peau d'orange finding in the fundus; thinning of the retinal nerve fiber in OCT (optic coherence tomography); bilateral and reticular papillary lesions with yellowish-color in the neck region (plucked chicken appearance); presence of bleeding foci in fundus; and nephrocalcinosis in kidneys. In light of these symptoms, the patient was diagnosed with pseudoxantoma elasticum. Skin biopsy confirmed the pseudoxantoma elasticum diagnose. PXE is an uncommon, hereditary disease. Early diagnosis of pseudoxantoma elasticum cases, is important for minimalizing systemic complications and informing the other family members through genetic counseling.

Plasma cytokine levels in ulcerative colitis.

BACKGROUND/AIMS: Some immunological factors are responsible in the pathogenesis of ulcerative colitis. There is a relationship between cytokines and ulcerative colitis. METHODOLOGY: In this study 20 ulcerative colitis patients (mean age 36.2 years old, 9 women, 11 men) and 20 healthy control groups (mean age 27.2 years old, 11 women, 9 men) were involved in the study. RESULTS: We established that IL-2Rsp, IL-6, IL-8 and IL-10 levels were different at the patients and control groups (p < 0.005). TNF-alpha and IL-1 beta were similar at the both groups. CONCLUSIONS: According to these results, IL-2Rsp, IL-6, 11-8 and IL-10 play an important role in the pathogenesis of ulcerative colitis. We consider that these cytokines are beneficial parameters in the diagnosis, treatment and prognosis of ulcerative colitis.

Evaluation of CA 72-4 as a new tumor marker in patients with gastric cancer.

BACKGROUND/AIMS: The place of CA 72-4, a new tumor marker in the prognosis of stomach cancer were studied, METHODOLOGY: Endoscopically and histologically diagnosed 47 gastric patients were studied. CEA, CA 19-9, CA 125, CA 15-3, CA 72-4 levels were measured. RESULTS: We determined that serum CA 72-4 level in the group with cancer was significantly elevated. In patients particularly having liver metastases, CA 72-4 level was found to be greater. CONCLUSIONS: We are of the opinion that serum CA 72-4 level is a valuable parameter in the prognosis of stomach cancer.

Cholangiocarcinoma: New Insights

Cholangiocarcinoma is a malignant neoplasm originating from biliary epithelial cells. The incidence and mortality of this cancer are rising in the world. Currently, cholangiocarcinoma is accepted as a stem cell disease with many risk factors. Diagnosis is relatively simple but therapy is extremely difficult. Surgery is the mainstay of treatment for early stage patients. Endobiliary approaches, chemotherapy and radiotherapy are other therapeutic approaches.

Prevalence of occult HBV infection in haemodialysis patients with chronic HCV.

AIM: To study the prevalence and clinical effects of occult HBV infection in haemodialysis patients with chronic HCV. METHODS: Fifty chronic hemodialysis patients with negative HbsAg, and positive anti-HCV were included in the study. These patients were divided into two groups: HCV-RNA positive and HCV-RNA negative, based on the results of HCV-RNA PCR. HBV-DNA was studied using the PCR method in both groups. RESULTS: None of the 22 HCV-RNA positive patients and 28 HCV-RNA negative patients revealed HBV-DNA in serum by PCR method. The average age was 47.2 +/- 17.0 in the HCV-RNA positive group and 39.6 +/- 15.6 in the HCV-RNA negative group. CONCLUSION: The prevalence of occult HBV infection is not high in haemodialysis patients with chronic HCV in our region. This result of our study has to be evaluated in consideration of the interaction between HBsAg positivity (8%-10%) and frequency of HBV mutants in our region.

Etiopathogenesis of Gastric Cancer.

Gastric cancer is a multifactorial and complex malignant disease seen commonly worldwide. It is one of the few malignant conditions in which the etiology involves infectious agents (Helicobacter pylori), but there are many other risk factors incuding high salt intake. Its pathogenesis generally involves interactions between environmental factors and genetic disposition. It is currently onsidered that stem cells may play a central role in gastric cancer development.

Gallstone Etiopathogenesis, Lith and Mucin Genes and New Treatment Approaches.

Gallstones constitute one of the more common and relatively costly conditions of the gastrointestinal system and are a major risk factor for gallbladder cancer. Most gallstone cases involve individuals younger than 60 years of age, those older representing 9% of the total in one series. There are many risk factors for gallstones and Lith and Mucin genes, for example, play important roles in their formation. Surgery is one therapeutic approach but in the future it is to be expected that drugs for prevention of gallstones will be developed in the future. This will have clear implications for gallbladder cancer control.

Pancreatic Cancer: Pathogenesis and Diagnosis.

Pancreatic cancer is a fatal malignancies which is predominantly seen in men and at advanced age (40-85 years) and has an aggressive course. Its frequency is gradually increasing over the past years. It accounts for 2% of all cancers and 5% of cancer-related deaths. Pancreatic cancer takes the first place among asymptomatic cancers. Ninety percent of cases are adenocarcinomas. Ten percent of the patients have a familial disposition. The disease is very difficult to detect as it has no early signs and spreads rapidly to surrounding organs is one of the most deadly types of cancer. Pancreatic cancer may result from hereditary germline or somatic acquired mutations in cancer-related genes and mutations also cause cancer progression and metastasis.

A Case of Acute Pancreatitis developing after Extracorporeal Shock Wave Lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) is a standard treatment method used for the treatment of renal calculi and upper ureteral calculi. Acute pancreatitis is a serious condition which develops due to multiple etiologic factors and is characterized by autodigestion of the pancreas. A case of acute pancreatitis which developed following ESWL performed for right renal calculi treatment is presented here. HOW TO CITE THIS ARTICLE: Goral V, Sahin E, Arslan M. A Case of Acute Pancreatitis developing after Extracorporeal Shock Wave Lithotripsy. Euroasian J Hepato-Gastroenterol 2015;5(1):52-54.

Ogilvie's syndrome in a patient with multiple myeloma.

Ogilvie's syndrome is characterized by physical examination and radiologic findings indicative of mechanical obstruction but in which no physical obstructive process can be found. Many factors have been associated with this syndrome which include electrolyte imbalance, systemic infection, drugs, and occasionally, neurologic disease. A case of acute colonic pseudoobstruction is presented which developed in a patient with multiple myeloma. The patient presented with severe thoracic pain, persistent and increasing abdominal distention and lack of bowel sounds. Plain radiography and ultrasonography revealed massive dilatation of the right and transverse colon. Nasogastric aspiration was initiated and all analgesic drugs were withdrawn. Erythromycin was given for nine days as prokinetic and a rectal tube was inserted for one day. Abdominal distention gradually disappeared within one day of nasogastric and rectal tube insertion and with multiple myeloma management. Ogilvie's syndrome is a very rare complication of multiple myeloma. Only one case of Ogilvie's syndrome with multiple myeloma has been reported in the literature. This case report of Ogilvie's syndrome in a patient with multiple myeloma is the second case report in the literature.

A Case of Breast Cancer Following Infliximab Treatment for Treatment-Refractory Crohn's Disease.

Crohn's disease is a chronic, or long lasting inflammatory disease in the gastrointestinal (GI) tract. Most commonly, Crohn's disease affects the small intestine and the beginning of the large intestine. Treatment for Crohn's disease usually involves drug therapy or, in certain cases, surgery. Several side effects develop from the use of drugs. A case with Crohn's disease refractory to 5-ASA, corticosteroid and azathioprine treatments who developed breast carcinoma following infliximab treatment is being presented in this report. CASE: SE, aged 44 years, presented to our polyclinic with weight loss, abdominal pain and flatulence. The patient had no response to mesalazine, steroid and azathioprine therapy. Upon identifying inflammatory stricture with abdominal MR, the medicines the patient has been using was discontinued and anti-TNF alpha (infliximab) treatment was initiated after receiving the consent of the patient. At 3rd month of treatment, the patient detected a small mass at the left breast. Mastectomy was performed and axillary lymph nodes were resected. Because breast cancer was detected following infliximab treatment in this case, we believe that a breast examination (physical examination, mammary USG) must be performed in female patients prior to infliximab therapy. How to cite this article: Goral V, Unsal B, Sivrikoz ON. A Case of Breast Cancer Following Infliximab Treatment for Treatment-Refractory Crohn's Disease. Euroasian J Hepato-Gastroenterol 2014;4(2): 104-106.

Malignant melanoma of the stomach presenting in a woman: a case report.

INTRODUCTION: Malignant melanoma is reported to metastasize to all organs of the human body. Although it is common for it to metastasize to the gastrointestinal tract, a melanoma located primarily in the gastric mucosa is an uncommon tumor. Gastrointestinal metastases are rarely diagnosed before death with radiological and endoscopic techniques. CASE PRESENTATION: In this case report the clinical course and treatment of a woman with melanoma of the stomach, without any other detectable primary lesion, is presented and discussed. A 55-year-old Turkish woman presented to our clinic with complaints of muscle pain and bone pain in the left side of her chest. During an upper gastrointestinal system endoscopy, dark cherry-colored, light elevated, round-shaped lesions were taken from her gastric fundus and from the first part of her duodenum. Biopsies from these samples were determined to be malignant melanoma by the pathologist. CONCLUSION: Metastatic malignant melanoma cases should be examined through endoscopy for gastrointestinal metastases.

Hepatic osteodystrophy and liver cirrhosis.

AIM: To investigate the correlation between hepatic osteodystrophy and osteoporosis in patients with liver cirrhosis. METHODS: Bone mineral density of the patients (n = 55) and that of the control group (n = 30) were measured by dual-energy X-ray absorptiometry. All the women in the study were premenopausal. Deoxypyridinoline, pyridinoline and urinary Ca(2+) were measured as bone destruction markers, while alkaline phosphatase (ALP), osteocalcin and insulin-like growth factor-1 (IGF-1) were measured as bone formation markers. Furthermore, interleukin-1 (IL-1), IL-6, tumor necrosis factor alpha (TNF-alpha), vitamin D3, direct bilirubin, albumin, cortisol and parathyroid hormone (PTH) levels were measured. The independent Student t test and chi(2) test were employed in comparing both groups, and the Pearson correlation test was used to determine associations. RESULTS: Comparing cirrhosis and control groups, lumbar total T-score (-1.6 + or - 1.2 g/cm(2) vs -0.25 + or - 1.3 g/cm(2), P < 0.001), lumbar total Z-score (-1.2 + or - 1.23 g/cm(2) vs -0.6 + or - 1.3 g/cm(2), P < 0.001), total femur T-score (-0.05 + or - 1 g/cm(2) vs -0.6 + or - 0.9 g/cm(2), P = 0.003) and total femur Z-score (-0.08 + or - 1.5 g/cm(2) vs 0.7 + or - 0.9 g/cm(2), P = 0.003) showed significantly lower values in the cirrhosis group. Blood ALP level (109.2 + or - 57 U/L vs 62.6 + or - 32.5 U/L, P < 0.001), IL-6 level (27.9 + or - 51.6 pg/mL vs 3.3 + or - 3.1 pg/mL, P = 0.01), TNF-alpha level (42.6 + or - 33.2 pg/mL vs 25.3 + or - 12.3 pg/mL, P = 0.007) and direct bilirubin level (0.9 + or - 0.7 mg/dL vs 0.3 + or - 0.2 mg/dL, P < 0.001) were significantly higher in the cirrhosis group. IGF-1 level (47.7 + or - 26.2 ng/mL vs 143.4 + or - 53.2 ng/mL, P < 0.001), osteocalcin level (1.05 + or - 2.5 ng/mL vs 7.0 + or - 13 ng/mL, P = 0.002) and 24 h urinary Ca(2+) (169.6 + or - 227.2 mg/dL vs 287 + or - 168.6 mg/dL, P = 0.003) were significantly lower in the cirrhosis group. Urinary deoxypyridinoline/creatinine (9.4 + or - 9.9 pmol/micromol vs 8.1 + or - 5.3 pmol/micromol, P = 0.51), urinary pyridinoline/creatinine (51.3 + or - 66.6 pmol/micromol vs 29 + or - 25.8 pmol/micromol, P = 0.08), blood IL-1 level (3.4 + or - 8.8 pg/mL vs 1.6 + or - 3.5 pg/mL, P = 0.29), vitamin D3 level (18.6 + or - 13.3 microg/L vs 18.4 + or - 8.9 microg/L, P = 0.95), cortisol level (11.1 + or - 4.8 microg/dL vs 12.6 + or - 4.3 microg/dL, P = 0.15) and PTH level (42.7 + or - 38 microg/dL vs 34.8 + or - 10.9 microg/dL, P = 0.27) were not significantly different. CONCLUSION: Hepatic osteodystrophy is an important complication encountered in patients with liver cirrhosis and all patients should be monitored for hepatic osteodystrophy.