High Dose Oral Furosemide with Salt Ingestion in the Treatment of Refractory Ascites of Liver Cirrhosis.

PURPOSE: We aimed to evaluate and compare the efficacy and safety of high-dose furosemide+salt orally by comparing HSS+ furosemide (i.v.) and repeated paracentesis in patients with RA. METHODS: This was a prospective study of 78 cirrhotic patients with RA, randomized into three groups: Group A (n= 25) i.v. furosemide (200-300 mg bid) and 3% hypotonic saline solution (HSS) (once or twice a day); Group B (n= 26) oral furosemide tablets (360-520 mg bid) and salt (2.5 g bid); and, Group C (n= 27) repeated large-volume-paracentesis (RLVP) with albumin infusion. Patients without hyperkalemia were administrated 100 mg of spironolactone/day. During the follow-up; INR, creatinine, and total bilirubin levels were measured to determine the change in MELD (model of end stage liver disease) score. RESULTS: Hepatic encephalopathy (HE), severe episodes of spontaneous bacterial peritonitis (SBP) and pleural effusions (PE) occurred more frequently in Group C. Improvement in Child-Pugh and MELD score was better in Group A and B than Group C. In Group B, improvements were seen in the Child-Pugh and MELD score, reduction in body weight, duration and number of hospitalization. In Groups A and B, remarkable increases in diuresis were observed (706±116 to 2425±633 mL and 691±111 to 2405±772 mL) and serum sodium levels also improved. HE and SBP were occurred more often in group C (p<0.002). Hospitalization decreased significantly in Group B (p<0.001). There was no significant difference in survival among groups. CONCLUSION: High dose oral furosemide with salt ingestion may be an alternative, effective, safe and well-tolerated method of therapy for RA.

Nasobiliary Drainage for Benign Recurrent Intrahepatic Cholestasis in Patients Refractory to Standard Therapy.

PURPOSE: Benign recurrent intrahepatic cholestasis (BRIC) is characterized by episodic cholestasis and pruritus without anatomical obstruction. The aim of this study was to evaluate the safety and efficacy of nasobiliary drainage (NBD) in patients with BRIC refractory to medical therapy and to determine whether the use of NBD prolongs the episode duration. METHODS: This was a multicenter retrospective study consisting of 33 patients suffering from BRIC. All patients were administrated medical treatment and 16 patients who were refractory to standard medical therapies improved on treatment with temporary endoscopic NBD. Duration of treatment response and associated complications were analyzed. RESULTS: Sixteen patients (43% females) underwent 25 NBD procedures. The median duration of NBD was 17 days. There were significant improvements in total and direct bilirubin and alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and gamma-glutamyl transpeptidase on the 3rd day of NBD. Longer clinical remission was monitored in the NBD group. Post-endoscopic retrograde cholangiopancreatography pancreatitis was observed in one of 16 cases. CONCLUSION: NBD effectively eliminates BRIC in all patients and improves biomarkers of cholestasis. It can be suggested that patients with attacks of BRIC can be treated with temporary endoscopic NBD; however, the results of this study should be confirmed by prospective studies in the future.

The Abdominal Ultrasonography Results of Cappadocia Cohort Study of Turkey Reveals High Prevalence of Fatty Liver.

BACKGROUND: There is limited data about the prevalence of frequent gastrointestinal diseases in developing parts of the world based on community-based screening studies. Therefore, we aimed to present the detailed transabdominal ultrasonography results of the previously completed Turkey Cappadocia cohort study, which included a population-based evaluation of gastrointestinal symptoms and diseases in adults. METHODS: This cross-sectional study was conducted in Cappadocia cohort. The transabdominal ultrasonography, anthropometric measurements, and disease questionnaires were applied to cohort persons. RESULTS: Transabdominal ultrasonography was performed in 2797 subjects (62.3% were female and the mean age was 51 ± 15 years). Among them, 36% were overweight, 42% were obese, and 14% had diabetes mellitus. The most common pathological finding in transabdominal ultrasonography was hepatic steatosis (60.1%). The severity of hepatic steatosis was mild in 53.3%, moderate in 38.8%, and severe in 7.9%. Age, body mass index, liver size, portal vein, splenic vein diameter, hypertension, diabetes mellitus, and hyperlipidemia were significantly higher while physical activities were significantly lower in hepatic steatosis group. Ultrasonographic grade of hepatic steatosis was positively correlated with liver size, portal vein and splenic vein diameter, frequency of diabetes mellitus, hypertension, and coronary artery disease. Hepatic steatosis was observed in none of the underweight, 11.4% of the normal weights, 53.3% of the overweight, and 86.7% of the obese subjects. The percentage of hepatic steatosis cases with normal weight (lean nonalcoholic fatty liver disease) was 3.5%. The rate of lean nonalcoholic fatty liver disease in the entire cohort was 2.1%. Regression analysis revealed male gender (hazard ratio [HR]: 3.2), hypertension (HR: 1.5), and body mass index (body mass index: 25-30 HR: 9.3, body mass index >30 HR: 75.2) as independent risk factors for hepatic steatosis. The second most common ultrasonographic finding was gallbladder stone (7.6%). In the regression analysis, female gender (HR: 1.4), body mass index (body mass index: 25-30 HR: 2.1, body mass index >30 HR: 2.9), aging (30-39 age range HR: 1.5, >70 years HR: 5.8), and hypertension (HR: 1.4) were the most important risk factors for gallbladder stone. CONCLUSIONS: Cappadocia cohort study in Turkey revealed a high prevalence of hepatic steatosis (60.1%) while the prevalence of gallbladder stones was 7.6% among the participants. The results of the Cappadocia cohort located in central Anatolia, where overweight and lack of physical activity are characteristic, showed that Turkey is one of the leading countries in the world for nonalcoholic fatty liver disease.

Continuous insulin therapy versus apheresis in patients with hypertriglyceridemia-associated pancreatitis.

BACKGROUND: The optimal treatment modality for lowering the triglyceride level in patients with hypertriglyceridemia (HTG)-associated acute pancreatitis is unknown. We evaluated the efficacy of continuous insulin infusion and apheresis procedures as triglyceride-lowering therapy. MATERIALS AND METHODS: Clinical, demographic, and laboratory data were retrospectively evaluated for patients with HTG-associated pancreatitis who received continuous insulin infusion or apheresis in a single tertiary center. The endpoints were modality effectiveness and clinical outcomes. RESULTS: The study included 48 patients (mean age, 40.4 ± 9.9 years). Apheresis and insulin infusion were performed in 19 and 29 patients, respectively, in the first 24 h of hospital admission. Apheresis procedures included therapeutic plasma exchange in 10 patients and double filtration plasmapheresis in nine patients. Baseline mean triglyceride level was higher in the apheresis group. The two groups were similar in terms of other baseline clinical and demographic characteristics. Seventeen patients (58.6%) in the insulin group and nine patients (47.4%) in the apheresis group exhibited Balthazar grades D-E. There was a rapid reduction (78.5%) in triglyceride level after the first session of apheresis. Insulin infusion resulted in a 44.4% reduction in mean triglyceride level in the first 24 h. The durations of fasting and hospital stay, and the rates of respiratory failure and hypotension, were similar between groups. More patients in the apheresis group experienced acute renal failure or altered mental status. Prognosis did not significantly differ between groups. CONCLUSION: Although apheresis treatments are safe and effective, they provided no clear benefit over insulin infusion for HTG-associated pancreatitis.

Early effect of peginterferon alpha-2b plus ribavirin treatment on blood pressure and insulin resistance in patients with chronic hepatitis C.

BACKGROUND/AIM: To investigate the early effects of peginterferon alpha-2b plus ribavirin therapy on blood pressure and related cardiovascular risk parameters, and also insulin resistance in patients with chronic hepatitis C virus (HCV) infection. METHODOLOGY: Twenty-nine patients with chronic hepatitis C (CHC) were enrolled in the study. Twenty-four hour ambulatory blood pressure monitoring (ABPM) of all patients was recorded in the pre-treatment period, and after the 1st and 8th weeks of treatment. Lipid profile, insulin resistance (IR), body mass index (BMI), complete blood counts and transaminase levels were also recorded at the same time periods. RESULTS: Fifteen of the 29 patients studied were hypertensive before treatment. The baseline, 1st week and 8th week recordings of ABPM (daytime, nighttime, mean systolic and diastolic measurements) did not show any significant change. Among hypertensive patients, differences in pretreatment, 1st and 8th week of treatment values of median systolic and diastolic blood pressures were not statistically significant. After the 8th week, total cholesterol, LDL, HDL, hemoglobin, white blood cell, platelet and AST/ALT were significantly decreased (p<0.05). Serum triglyceride levels increased significantly (p<0.0001) and HOMA-IR decreased (p=0.07). CONCLUSION: Peginterferon alpha-2b plus ribavirin therapy did not cause any increase in blood pressure in hypertensive and normotensive CHC patients in the early period of treatment. This treatment resulted in early but not significant changes in the IR status of CHC patients.

Population-based assessment of gastrointestinal symptoms and diseases: Cappadocia Cohort, Turkey.

BACKGROUND/AIMS: The aim of this study was to determine the prevalence of symptoms and diseases of the lower and upper gastrointestinal system (GIS) in a population-based sample. MATERIALS AND METHODS: The cross-sectional cohort study was conducted in Cappadocia cohort comprising the Gülsehir and Avanos districts. The "Gastrointestinal Symptom Questionnaire" was applied to persons over the age of 18 years. RESULTS: The GI Symptom Questionnaire was applied to 3369 subjects, and height and body weight were measured in 2797 consenting subjects. Of the participants, 61% were female and the mean patient age was 50±15 years. At least one GI symptom was present in 70.6% of the cohort. The most common upper GI symptoms were gastric bloating (31.0%) and heartburn (29.1%). The most common lower GI symptom was abnormal defecation (33.5). The prevalence of upper GIS and lower GIS diseases was 32.7% and 12.9%, respectively, and the prevalence of togetherness of upper and lower GIS diseases was 9.9%. Prevalence of GIS disease was approximately 3 times higher in females (p<0.001). All of the upper and lower GI symptoms and the prevalence of upper GIS disease increased in line with Body mass index (BMI). CONCLUSION: This first population-based, cross-sectional cohort study revealed that the prevalence of GIS diseases is critically high for optimal public health. Special attention must be paid to these diseases while planning health policies and reimbursements.

The relationship between fibrosis and nodule structure and esophageal varices.

BACKGROUND/AIMS: The aim of the present study was to evaluate the histopathological findings of cirrhosis together with clinical and laboratory parameters, and to investigate their relationship with esophageal varices that are portal hypertension findings. MATERIALS AND METHODS: A total of 67 (42 male and 25 female) patients who were diagnosed with cirrhosis were included in the study. The mean age of the patients was 51.6±19.0 (1-81) years. The biopsy specimens of the patients were graded in terms of fibrosis, nodularity, loss of portal area, central venous loss, inflammation, and steatosis. The spleen sizes were graded ultrasonographically, and the esophageal varices were graded endoscopically. RESULTS: In the multivariate regression analysis, there was a correlation between the advanced disease stage (Child-Pugh score odds ratio (OR): 1.47, 95% confidence interval (CI): 1.018-2.121, p=0.040), presence of micronodularity (OR: 0.318, 95% CI: 0.120-0.842, p=0.021), grade of central venous loss (OR: 5.231, 95% CI: 1.132-24.176, p=0.034), and presence of esophageal varicose veins. CONCLUSION: Although thrombocytopenia and splenomegaly may predict the presence of large esophageal varices, cirrhosis histopathology is the main factor in the presence of varices.

Thrombopoietin or interleukin-6 has no effect on thrombocytopenia of cirrhosis.

BACKGROUND/AIMS: We aimed to compare the level of thrombocytopenia in cirrhotic patients with HBV and those with HCV, and to investigate whether the reduced serum level of IL-6 in patients with HCV is responsible for the lower platelet count compared to those with HBV through the effect on serum thrombopoietin level. METHODOLOGY: Fifty-three patients with liver cirrhosis, 28 of who were HBV- seropositive (Group A), 25 of who were HCV- seropositive (Group B) and 15 healthy controls were enrolled in this study. RESULTS: Platelet count in group B [75 (1.5-99) K/microL] were lower than those of group A [140 (62-374) K/microL] (p < 0.001). The median levels of serum thrombopoietin in patients [group A: 31.9 (31-113) pg/mL and group B: 38.0 (31.2-102) pg/mL] and controls [31.3 (31-153) pg/mL] did not show statistically significant difference. The patients compared to controls, had higher serum IL-6 levels [3.6 (2-1150) vs. 2.0 (2-9.9) pg/mL], (p < 0.01), which showed similarity in group A and B patients [3.65 (2-1150) vs. 3.3 (2-45) pg/mL], (p=NS). Serum thrombopoietin level was not correlated with serum IL-6 levels in any group. Serum thrombopoietin and IL-6 levels had no relationship with platelet count and with Child-Pugh score. CONCLUSIONS: Our study showed that cirrhotic patients with HCV had lower platelet count than those with HBV and controls, and this difference does not appear to be related with either serum thrombopoietin or IL-6 level.

Effect of anti-HCV positivity on markers of malnutrition and inflammation in hemodialysis patients.

AIM: To investigate the influence of anti-HCV positivity on markers of malnutrition and inflammation in hemodialysis (HD) patients. METHODS: Stable HD patients who had persistently negative or positive HCV antibodies (at least three) and without elevated aminotransferase levels in routine periodical tests with a duration of more than 12 months were included. Patients with conditions known to be associated with acute-phase responses or clinically active (HCV RNA positive) or advanced liver failure were excluded. Thirty-six anti-HCV-positive patients (22 male, 14 female, mean age 47.3 +/- 14.5 years, mean time on HD 72.0 +/- 39.0 months), were compared with 36 anti-HCV negative patients with similar age and HD duration (25 male, 11 female, mean age 49.2 +/- 13.8 years, mean time on HD 59.7 +/- 27.1 months). Malnutrition-Inflammation Score (MIS), a fully quantitative score adopted from subjective global assessment, was recorded for each patient (ranges from 0 to 30). High sensitivity serum C-reactive protein (hs-CRP), interleukin-6 (IL-6), erythrocyte sedimentation rate (ESR), and hematocrit-corrected ESR were compared as indices of the degree of inflammation beyond anthropometric evaluation and routine laboratory tests. RESULTS: There was no significant difference in MIS of two groups (6.1 +/- 3.2 vs. 5.6 +/- 3.2, p > 0.05). In the comparison of components of MIS, co-morbidity including number of years on dialysis was higher in anti-HCV-positive patients (p = 0.04). Anthropometric values and serum levels of hs-CRP, IL-6, ESR, and hematocrit-corrected ESR of two groups were not statistically different from each other (p > 0.05 for all). ALT (p = 0.0001) and AST (p = 0.001) levels were higher in anti-HCV-positive patients. CONCLUSION: Anti-HCV positivity without active infection seems to have no additional negative effect on malnutrition and inflammation in maintenance HD patients.

Turkish doctors' cohort: healthy despite low screening.

OBJECTIVES: We aimed to determine the prevalence of chronic diseases and unhealthy lifestyle behaviors of Turkish doctors as compared with the general population and the frequency of compliance with preventive clinical practices among doctors. METHODS: This was an observational, prospective cohort study that enrolled graduates between 1975 and 2004 from six medical schools in Turkey. Data on demographics, disease conditions, and unhealthy lifestyle behaviors were gathered. Preventive care practices were analyzed with regards to age and gender. RESULTS: A total of 7228 doctors participated in the study. Comparison with the national data revealed higher hyperlipidemia and coronary artery disease rates. While 54.5% of the doctors had a doctor visit in the last 12 months, only 31.5% of those over 40 years of age reported a recent blood pressure measurement. Colon cancer screening rate over 50 years of age with any of the acceptable methods was only 3%. One-fourth of the female doctors over 40 years of age underwent mammography within the last two years. Only 7.1% of the doctors over 65 years of age and 10% of the doctors having an indication for a chronic disease had a pneumococcal vaccine, while nearly one-fifth had no hepatitis B vaccine. CONCLUSION: In this cohort of mainly middle-aged Turkish doctors, the age-standardized rates of chronic diseases were lower than the rates in the general population except for the rates of hyperlipidemia and coronary artery disease. However, doctors did show quite low rates of receipt of screening practices. These results might provoke questions about how to use Turkish doctors' health behaviors to further improve doctors' and, relatedly, patients' health.

The importance of salivary cortisol in the diagnosis of adrenal insufficiency in cirrhosis.

BACKGROUND/AIMS: Reports on adrenal insufficiency (AI) are unexpectedly high in cirrhosis, and the diagnosis of this condition remains a challenge. We aimed to define the prevalence rate of AI in stable cirrhotic patients and determine the correlations of free cortisol and salivary cortisol with total cortisol. MATERIALS AND METHODS: Between January 2011 and September 2011, 110 consecutive cirrhotic patients without any infection or hemodynamic instability were enrolled. Baseline total and salivary cortisol levels were measured. The free cortisol level was calculated according to the Coolens' formula. Post-stimulation total and salivary cortisol levels were measured, and the free cortisol level was recalculated. RESULTS: The mean age of the patients was 62.1±11.4 years. There were 54 males (49.1%). The mean Child-Turcotte-Pugh (CTP) score was 7.2±2.3. Twenty-two (20%) patients were at the CTP-C level. AI was present in 23 (20.9%) and 17 (15.5%) of all patients according to the total and free cortisol criteria, respectively. For basal and stimulated levels, salivary cortisol rather than total cortisol correlates well with free cortisol. CONCLUSION: The diagnosis of AI on the basis of total cortisol measurement overestimates the prevalence of AI in cirrhosis. Salivary cortisol, which correlates well with free cortisol, is a promising alternative for the diagnosis of AI in cirrhotic patients.

Viral hepatitis screening guideline before biological drug use in rheumatic patients.

Biological drugs (tumor necrosis factor inhibitors, rituximab, tocilizumab, abatacept, and tofacitinib) are important treatment alternatives in rheumatology, particularly for resistant patients. However, they may cause hepatitis B virus (HBV) and hepatitis C virus (HCV) reactivation; for instance, HBV reactivation may occur in a patient who is an inactive hepatitis B surface antigen (HBsAg) carrier or who has resolved HBV infection. Therefore, the screening of patients before biological treatment and the application of a prophylactic treatment, particularly with respect to latent HBV infections, are recommended when necessary. This guideline covers pre-treatment screening and follow-up recommendations, if required, with respect to viral hepatitides in rheumatology patients who are planned to be given biological drugs. Although this guideline is prepared for biological disease-modifying antirheumatic drugs (DMARDs), it is recommended to be used also for target-oriented DMARDS and medium-high dose corticosteroids (>7.5 mg prednisolone/day equivalent). It should be considered that the reactivation risk is higher when more than one immunosuppressive drug is used.

Helicobacter pylori eradication lowers serum homocysteine level in patients without gastric atrophy.

AIM: To determine whether Helicobacter pylori (H pylori)infection caused hyperhomocysteinemia by altering serum vitamin B(12), serum folate and erythrocyte folate levels and whether eradication of this organism decreased serum homocysteine level. METHODS: The study involved 73 dyspeptic H pylori-positive patients, none of them had gastric mucosal atrophy based on rapid urease test and histology. Out of 73 patients, 41 (56.2%) showed a successful eradication of H pylori 4 wk after the end of treatment. In these 41 patients, fasting serum vitamin B(12), folate and homocysteine levels, and erythrocyte folate levels before and 4 wk after H pylori eradication therapy were compared. RESULTS: The group with a successful eradication of H pylori had significantly higher serum vitamin B(12) and erythrocyte folate levels in the post-treatment period compared to those in pre-treatment period (210+/-97 pg/mL vs 237+/-94 pg/mL, P<0.001 and 442+/-212 ng/mL vs 539+/-304 ng/mL, P = 0.024, respectively), but showed no significant change in serum folate levels (5.6+/-2.6 ng/mL vs 6.0+/-2.4 ng/mL, P = 0.341). Also, the serum homocysteine levels in this group were significantly lower after therapy (13.1+/-5.2 micromol/L vs 11.9+/-6.2 micromol /L, P = 0.002). Regression analysis showed that serum homocysteine level was positively correlated with age (P = 0.01) and negatively with serum folate level before therapy (P = 0.003). CONCLUSION: Eradication of H pylori decreases serum homocysteine even in patients who do not exhibit gastric mucosal atrophy. It appears that the level of homocysteine in serum is related to a complex interaction among serum vitamin B(12), serum folate and erythrocyte folate levels.

Autonomic neuropathy and gallbladder motility in patients with liver cirrhosis.

BACKGROUND/AIMS: Impaired gallbladder motility has been suggested as a contributor to increased incidence of gallstones in patients with liver cirrhosis. The purpose of this study was to determine gallbladder function and its relation with autonomic neuropathy in liver cirrhosis. MATERIALS AND METHODS: Gallbladder function was measured using ultrasonography in 48 patients with liver cirrhosis and in 31 controls. Autonomic neuropathy tests were applied in patients with liver cirrhosis. Patients with liver cirrhosis were analyzed in subgroups according to the severity of disease using the Child-Pugh classification. RESULTS: Fasting gallbladder volume was 16.2 mL (range: 2.1 mL-71.9 mL) in patients and 17.6 mL (range: 4.9 mL-76.6 mL) in controls. There were no differences in fasting gallbladder volume among the study groups (p>0.05). Gallbladder ejection fraction was significantly higher in patients compared with controls (84% vs. 65%) (p<0.001). No correlation was found between gallbladder ejection fraction and autonomic neuropathy (p>0.05). CONCLUSION: Our results indicate that liver cirrhosis does not impair gallbladder emptying, and that there is no association between gallbladder motility and autonomic neuropathy. Further investigations are required to explain increased gallbladder motility in liver cirrhosis.

Helicobacter pylori has no effect on plasma ghrelin levels.

OBJECTIVE: Helicobacter pylori is the major etiologic agent for chronic active gastritis, and it also plays a crucial role in gastric and duodenal ulcer disease, as well as in gastric carcinoma. H. pylori infection has been shown to decrease plasma somatostatin (SST) and increase plasma gastrin concentrations. Ghrelin is a recently discovered peptide produced mostly in the stomach of rodents and humans and is secreted into the bloodstream. There is no data in the literature about the relationship between H. pylori and ghrelin. DESIGN: Thirty-nine age- and BMI-matched H. pylori infection positive and negative women, from whom biopsy specimens were taken during gastric endoscopy, were included in the study. METHODS: Total ghrelin was measured by enzyme immunoassay (EIA) in Medistek. All samples were measured in duplicate and averaged; results differing by more than 20% were re-assayed. Two biopsy specimens from antrum, corpus and fundus were obtained. RESULTS: Fifteen of the subjects were H. pylori negative and 24 were H. pylori positive. Age, BMI, lipid profile and insulin sensitivity indices of the groups were similar. Plasma ghrelin levels (375.92+/-7.10 vs 370.00+/-4.14 pmol/l; P>0.05) of H. pylori negative and positive groups did not differ significantly. CONCLUSION: H. pylori has no effect on plasma ghrelin concentration.

Serum leptin level can be a negative marker of hepatocyte damage in nonalcoholic fatty liver.

BACKGROUND: The aim of this study was to determine whether leptin and insulin resistance (IR) showed differences between steatotic patients with and without elevated serum transaminases. METHODS: The study included 32 patients with fatty liver and high serum transaminase level (group I), 31 patients with fatty liver and normal serum transaminase level (group II), and 8 nonobese and nonsteatotic controls. The presence of steatosis was demonstrated by ultrasonography. Due to the effect of body mass index (BMI) on leptin levels, groups I and II were divided to form four subgroups for analysis (group IA, BMI 30; group IIA, BMI 30. RESULTS: The serum leptin levels in group IIB were significantly higher than the levels in group IB ( P = 0.017). Serum leptin was also higher in group IIA than in group IA, but this difference was not statistically significant ( P = 0.097). Logistic regression analysis revealed a significant negative correlation between serum leptin level and the presence of a high transaminase level (odds ratio, 0.97; 95% confidence interval, 0.95-0.99). The levels of IR in the four patient groups were comparable, but the controls had significantly lower IR levels than group IIA. CONCLUSIONS: Elevated serum leptin seems to be a feature of steatotic patients with normal transaminase levels, and the level of serum leptin seems to decrease as the hepatocyte injury develops. IR is a common feature of fatty liver disease, irrespective of the presence of hepatocellular necrosis.

Serum positive cagA in patients with non-ulcer dyspepsia and peptic ulcer disease from two centers in different regions of Turkey.

AIM: To investigate and compare frequencies of serum positive cagA in patients from two separate regions of Turkey who were grouped according to the presence of peptic ulcer disease or non-ulcer dyspepsia. METHODS: One hundred and eighty Helicobacter pylori-positive patients with peptic ulcer disease or non-ulcer dyspepsia were included in the study. One hundred and fourteen patients had non-ulcer dyspepsia and 66 had peptic ulcer disease (32 with gastric ulcers and/or erosions and 34 with duodenal ulcers). Each patient was tested for serum antibody to H. pylori cagA protein by enzyme immunoassay. RESULTS: The total frequency of serum positive cagA in the study group was 97.2 %. The rates in the patients with peptic ulcers and in those with non-ulcer dyspepsia were 100 % and 95.6 %, respectively. These results were similar to those reported in Asian studies, but higher than those that have been noted in other studies from Turkey and Western countries. CONCLUSION: The high rates of serum positive cagA in these patients with peptic ulcer disease and non-ulcer dyspepsia were similar to results reported in Asia. The fact that there was high seroum prevalence regardless of ulcer status suggests that factors other than cagA might be responsible for ulceration or other types of severe pathology in H. pylori-positive individuals.

Subepithelial basement membrane thickness in patients with normal colonic mucosal appearance in colonoscopy: results from southern Turkey.

AIM: Our aims were to determine the normal limits of subepithelial basement membrane (SEBM) thickness in order to more accurately diagnose collagenous colitis in the population from southern Turkey and to investigate into links between SEBM thickness and age, and sex. METHODS: The study included 100 patients (mean age 50.0+/-13.3 years; male, 34; female, 66) with miscellaneous gastrointestinal symptoms, and normal colonic mucosal appearance in colonoscopic evaluation. Biopsies were taken from five different regions of the colon. SEBM was measured with a calibrated eyepiece on specimens prepared with specific stains for collagen. Intensity of inflammatory cells was graded semiquantitatively. Differences in SEBM thickness among the different colon regions, and relationships between SEBM thickness and age, sex, and density of inflammatory cells were statistically evaluated. RESULTS: The cecum and rectum showed the largest amounts of infiltrate. None of the specimens showed histologic findings of collagenous colitis. The SEBM thicknesses measured for each case ranged from 3-20 microm. The biggest thickness was observed in rectal mucosa (median value: 10 microm). Cecum and ascending colon showed similar SEBM thickness (median value: 5 microm). SEBM thickness was not correlated with patient age or sex, but was positively correlated with the intensity of inflammatory cells in each colon segment. CONCLUSION: In this patient group from southern Turkey, SEBM was thickest in the rectum. Our results indicate that, in this population, SEBM thickness is not correlated with age or sex, but is positively correlated with severity of inflammation. The findings also support the concept that measuring SEBM thickness at one segment in the colon is inadequate and may be misleading.

Low eradication rate of Helicobacter pylori with triple 7-14 days and quadriple therapy in Turkey.

AIM: The eradication rate of Helicobacter pylori (H pylori) shows variation among countries and regimens of treatment. We aimed to study the eradication rates of different regimens in our region and some factors affecting the rate of eradication. METHODS: One hundred and sixty-four H pylori positive patients (68 males, 96 females; mean age: 48+/-12 years) with duodenal or gastric ulcer without a smoking history were included in the study. The patients were divided into three groups according to the treatment regimens. Omeprazole 20 mg, clarithromycin 500 mg, amoxicillin 1 g were given twice daily for 1 week (Group I) and 2 weeks (Group II). Patients in Group III received bismuth subsitrate 300 mg, tetracyline 500 mg and metronidazole 500 mg four times daily in addition to Omeprazole 20 mg twice daily. Two biopsies each before and after treatment were obtained from antrum and corpus, and histopathologically evaluated. Eradication was assumed to be successful if no H pylorus was detected from four biopsy specimens taken after treatment. The effects of factors like age, sex, H pylori density on antrum and corpus before treatment, the total H pylori density, and the inflammation scores on the rate of H pylori eradication were evaluated. RESULTS: The overall eradication rate was 42%. The rates in groups II and III were statistically higher than that in group I (P<0.05). The rates of eradication were 24.5%, 40.7% and 61.5% in groups I, II and III, respectively. The eradication rate was negatively related to either corpus H pylori density or total H pylori density (P<0.05). The median age was older in the group in which the eradication failed in comparison to that with successful eradication (55 yr vs 39 yr, P<0.001). No correlation between sex and H pylori eradication was found. CONCLUSION: Our rates of eradication were significantly lower when compared to those reported in literature. We believe that advanced age and high H pylori density are negative predictive factors for the rate of H pylori eradication.

Endoscopic extraction of living fasciola hepatica: case report and literature review.

Fasciola hepatica infestation is known to cause bile duct inflammation and biliary obstruction. Endoscopic retrograde cholangiopancreatography shows distinct features in some patients with fascioliasis, but the condition may be overlooked in chronic cases. The endoscopic retrograde cholangiopancreatograpy images must be carefully examined to rule out other possible causes of irregularity and thickening of the common bile duct wall. Parasite removal during endoscopic retrograde cholangiopancreatograpy is one therapeutic option in patients with acute obstructive cholangitis due to F. hepatica. We present a case of fascioliasis-induced acute cholangitis that was diagnosed and treated via endoscopy. A review of the literature on extraction of living parasites is also included.