Successful results of early nucleos(t)ide analogue treatment for liver transplantation candidates with severe acute hepatitis B infection.

BACKGROUND: Early treatment of severe acute hepatitis B virus (HBV) infection with nucleos(t)ide analogues may prevent progression to acute liver failure (ALF). PATIENTS AND METHODS: The charts of 24 patients who were treated for severe acute HBV infection (either INR ≥ 1.5 or INR≥ 1.4 and total bilirubin ≥ 20 mg/dL at the referring institution or after admission) between April 2021 and May 2023 (inclusive) were evaluated retrospectively. Twelve patients were women; median [range] age: 48 [35-68]. Entecavir (0.5 mg/day) (n = 16) or tenofovir disoproxil fumarate (245 mg/day) (n =8) were used depending on availability. RESULTS: Two patients required liver transplant which was performed successfully in one (no suitable donor for the other). Deterioration to ALF was prevented in 22 of the 24 cases (92%); these patients could be discharged after median (range) 12 (5-24) days following initiation of the antiviral drug. There was no significant difference in efficacy between the two antiviral agents. The anti-HBsAg antibody became positive in 16 patients (73%); one other patient became HBsAg negative at 1 month after discharge but was lost to follow up. Five patients (23%) are still HBsAg positive but all except one have started treatment in the last 6 months. One of the recently treated 4 patients stopped taking the antiviral drug at his own will and one has become anti-HIV antibody positive during follow up. CONCLUSION: Early treatment of severe acute HBV infection with entecavir or tenofovir disoproxil fumarate prevents the need for liver transplant and consideration of living donors.

Entecavir-induced neutropenia in an adult living donor liver transplant recipient: Successful conversion to tenofovir alafenamide.

At 22 weeks post-transplantation for HBV-related cirrhosis, an adult woman developed neutropenia which was aggravated by COVID-19 (ANC 0.4 × 109/L). Covid resolution and all "conventional" modifications were ineffective. Success within 2 weeks was achieved by switching entecavir to tenofovir alafenamide. A step-by-step judicious approach to post-transplant neutropenia is vital.

Evaluation of QT and P wave dispersion and mean platelet volume among inflammatory bowel disease patients.

BACKGROUND: In inflammatory bowel disease (IBD) number of thromboembolic events are increased due to hypercoagulupathy and platelet activation. Increases in mean platelet volume (MPV) can lead to platelet activation, this leads to thromboembolic events and can cause acute coronary syndromes. In IBD patients, QT-dispersion and P-wave dispersion are predictors of ventricular arrhythmias and atrial fibrilation; MPV is accepted as a risk factor for acute coronary syndromes, we aimed at evaluating the correlations of these with the duration of disease, its localization and activity. METHODS: The study group consisted of 69 IBD (Ulcerative colitis n: 54, Crohn's Disease n: 15) patients and the control group included 38 healthy individuals. Disease activity was evaluated both endoscopically and clinically. Patients with existing cardiac conditions, those using QT prolonging medications and having systemic diseases, anemia and electrolyte imbalances were excluded from the study. QT-dispersion, P-wave dispersion and MPV values of both groups were compared with disease activity, its localization, duration of disease and the antibiotics used. RESULTS: The P-wave dispersion values of the study group were significantly higher than those of the control group. Duration of the disease was not associated with QT-dispersion, and MPV levels. QT-dispersion, P-wave dispersion, MPV and platelet count levels were similar between the active and in mild ulcerative colitis patients. QT-dispersion levels were similar between IBD patients and the control group. No difference was observed between P-wave dispersion, QT-dispersion and MPV values; with regards to disease duration, disease activity, and localization in the study group (p>0.05). CONCLUSIONS: P-wave dispersion which is accepted as a risk factor for the development of atrial fibirilation was found to be high in our IBD patients. This demonstrates us that the risk of developing atrial fibrillation may be high in patients with IBD. No significant difference was found in the QT-dispersion, and in the MPV values when compared to the control group.

The Relationship between Ocular Vascular Changes and the Levels of Malondialdehyde and Vascular Endothelial Growth Factor in Patients with Inflammatory Bowel Disease.

Background: We evaluated ocular hemodynamic changes, malondialdehyde(MDA) and vascular endothelial growth factor (VEGF) levels in patients with IBD.Methods: We used ocular color Doppler ultrasonography to analyze 56 eyes with Crohn's disease (CD), 62 eyes with ulcerative colitis (UC), 68 eyes of healthy volunteers. We measured peak systolic velocity (PSV),end-diastolic velocity (EDV),and the resistivity index (RI) of ophthalmic artery (OA) and central retinal artery (CRA). MDA and VEGF levels were measured in the plasma samples.Results: MDA levels were significantly higher in both UC and CD patients, whereas VEGF levels were only higher in the CD group (p = .003,p < .001,p = .01).The PSV and EDV of the OA were significantly lower in CD patients (p = .017,p = .001). The EDV of the CRA was significantly lower in CD patients than UC patients and controls (p = .014,p < .001).Conclusions: CD patients exhibited decreased blood flow in both the OA and CRA. Ocular vascular flow was only affected in CD patients. We found that ocular ischemia may occur in CD patients even in the absence of any clinical finding.

Electron microscopic findings in non-alcoholic fatty liver disease: is there a difference between hepatosteatosis and steatohepatitis?

BACKGROUND AND AIMS: Non-alcoholic fatty liver disease has long been accepted as benign; however, recent evidence suggests that the disease may progress to cirrhosis and hepatocellular carcinoma, although the natural course of the disease is still unclear. This study was designed to comparatively evaluate electron microscopic features of non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH). METHODS: Quantitative and semi-quantitative ultrastructural evaluations were performed on liver biopsies from 23 patients, 10 with NAFL and 13 with NASH. RESULTS: No statistically significant difference was noted between NAFL and NASH patients in ultrastructural features of hepatocytes including megamitochondria, intramitochondrial crystalline inclusions, mitochondrial matrix granules, foamy cytoplasmic appearance, electron-lucent and glycogen-containing nuclear regions, lipofuscin granules, or an increased frequency of vesicles containing electron-dense material in peribiliary Golgi zone; however, the mitochondrial diameter was significantly higher in the NASH patients. Intercellular distance and microvilli between hepatocytes, collagen and electron-dense material accumulation in the space of Disse, electron-dense material accumulation and microvillus density in bile canaliculi did not differ significantly between the groups. CONCLUSIONS: Our data show that, although NAFL and NASH can be distinguished by their distinct light microscopic features, ultrastructural characteristics are similar, which suggests that NAFL may also have the potential to progress to fibrosis and cirrhosis like NASH.

The value of hepatic diffusion-weighted MR imaging in demonstrating hepatic congestion secondary to pulmonary hypertension.

BACKGROUND: Congestive hepatomegaly might be the first sign for pulmonary hypertension. Apparent diffusion coefficient (ADC) value obtained with quantitative diffusion-weighted magnetic resonance imaging (DW-MRI) is affected by liver fibrosis and perfusion. We aimed to evaluate the diagnostic value of DW-MRI in cooperation with biochemical markers, ultrasonography (US) and echocardiography (TTE) in determining the degree of hepatic congestion secondary to pulmonary hypertension (PHT). METHODS: 35 patients with PHT and 26 control subjects were included in the study. PHT was diagnosed if pulmonary artery systolic pressure (PASP) was measured above 35 mmHg with TTE. Study group was classified into mild and moderate PHT. DW-MRI was performed with b-factors of 0, 500 and 1000 sec/mm(2). Mean ADC, ADC-II (Average of the ADC values of right lobe anterior and posterior segments), US, TTE and blood biochemical parameters of both groups were compared. RESULTS: There exists a positive correlation between liver size and the diameters of vena cava inferior, right atrium, right hepatic vein(RHV), mid-hepatic vein(MHV), left hepatic vein(LHV) (p < 0.01). There was a positive correlation between PASP and RHV, MHV, LHV. The patients had lower ejection fractions (p < 0.01) and higher LDH (p < 0.01) and ALP (p < 0.05) levels than the control group. The ADC values of the patients with moderate PASP were higher than those with a mild PASP (p < 0.05). Mean ADC was higher in patients with moderate PHT compared to control group (p = 0.009). There was a positive correlation between PASP and ADC values of right lobe posterior segment of the liver (p < 0.05). The ADC-II and mean ADC values of the patients with moderate PASP were higher than those of the control group (p < 0.01). CONCLUSIONS: Congestion due to moderate PHT might be diagnosed with DW-MRI. As PASP increase; mean ADC and ADC-II values increase.

The Coexistence of Autoimmune Pancreatitis and Crohn's Disease in an Adolescent Case.

Although autoimmune pancreatitis is not seen in children frequently, it is included in the etiology of chronic pancreatitis. A 16-year-old girl who was diagnosed with chronic pancreatitis 4 months previously, presented to the outpatient clinic with abdominal pain on the epigastric region, and left lower abdominal quadrant and bloody defecation. Remarkable laboratory test results were as follows: amylase: 109 U/L, lipase: 196 U/L, Ig G:13.70 g/L, IgG4:2.117 g/L, fecal calprotectin 573 µg/g. In the MRCP examination, revealed enlarged pancreas with a heterogeneous appearance, dilated main pancreatic duct. Colonoscopic and histopathological findings were consistent with inflammatory bowel disease. The case was diagnosed as Crohn's disease coursing with autoimmune pancreatitis. Clinical and laboratory findings regressed after steroid treatment. Autoimmune pancreatitis is important in that it is rarely seen in children and though less frequently it is associated with Crohn's disease. It should be kept in mind that inflammatory bowel disease may develop in the follow-up of autoimmune pancreatitis and autoimmune pancreatitis may be present in the etiology of chronic pancreatitis.

A new agent for tumour necrosis factor-alpha inhibition: In vitro effects of dipyridamole in Crohn's disease.

BACKGROUND: Tumour necrosis factor-alpha (TNF-alpha) plays a central role in inflammatory cascade in Crohn's disease (CD). Our study aims to investigate the in vitro effects of dipyridamole (DP) on the TNF-alpha and interleukin-10 (IL-10) production in the intestinal mononuclear cells of CD patients. MATERIAL AND METHODS: Thirteen patients with CD and in 17 healthy individuals underwent colonoscopy and biopsy samples were taken. Cultured mononuclear cells were preincubated with DP1 (0.7 microg/ml), DP2 (1.25 microg/ml), methotrexate (MTX)1 (0.5 nmol/L) and MTX2 (1.5 nmol/L). These cells were then stimulated with lipopolysaccaride (LPS) and phytohemagglutinin (PHA). The levels of TNF-alpha and IL-10 in supernatants were measured with standard immunoassay monoclonal antibody method. RESULTS: An appropriate cell culture could be obtained in 10 patients with CD and 12 healthy individuals. In LPS stimulated cells, MTX1 and MTX2 were superior to DP1 and DP2 in suppressing TNF-alpha in both groups. In PHA stimulated cells, while MTX1 was superior to DP1, MTX2 and DP2 had an equivalent effect in CD patients (p<0.05, p>0.05, respectively). In LPS-stimulated cells DP2 was significantly superior to MTX2 in increasing IL-10 levels in both groups (p<0.05). In PHA stimulated cells, DP1 and DP2 caused a higher increase in IL-10 levels compared with MTX1 and MTX2 in CD group (p<0.05). CONCLUSIONS: Dipyridamole suppresses TNF-alpha similar with MTX. It seems to be superior to MTX in increasing IL-10 levels. Addition of DP to anti-TNF medications may create a synergy in cytokine modulation.

Intestinal metaplasia in portal hypertensive gastropathy: a frequent pathology.

OBJECTIVE: To compare the frequency of intestinal metaplasia (IM) in patients with portal hypertensive gastropathy (PHG) to the control group with functional dyspepsia. METHODS: Two-hundred and eighty-nine cases were prospectively evaluated in three groups (controls:group I--123 patients; cirrhotics: group II--135 patients; noncirrhotic portal hypertensives: group III--31 patients). Mucosal biopsies (three antrum, one angulus, two corpus) were taken and examined for atrophy, IM, dysplasia, Helicobacter pylori (Hp) and histologic PHG. RESULTS: Frequencies of IM in groups I, II and III were 17.1% (type I, 3.3%; type II, 10.6%; type III, 3.3%), 34.3% (type I, 9.6%; type II, 17%; type III, 6.7%) and 33.3% (type I, 9.7%; type II, 12.9%; type III, 9.7%), respectively. In patients with PHG, frequency of IM was significantly higher than in control group (P<0.05) and correlated with the severity of PHG (P<0.05). The frequency of type III IM was not statistically different among the three groups. Frequency of atrophy in cirrhotic patients was higher than in control group (17.9% in group I, 32.6% in group II, 25.8% in group III; P<0.05). In the control group, Hp prevalence was significantly higher than in patients with PHG (P<0.05) and there was a positive correlation between Hp and atrophy (P<0.05). In multivariate analysis, PHG and age were found as independent predictors for IM; PHG, age and Hp for atrophy. CONCLUSION: Frequencies of atrophy and IM are higher in patients with PHG. PHG is a reliable marker for IM and atrophy in gastric mucosa.

What is the reason of elevated alanine aminotransferase level in HBeAg negative patients with low viremia: NAFLD or chronic hepatitis?

BACKGROUND AND STUDY AIMS: Increased alanine aminotransferase (ALT) levels with negative hepatitis B virus (HBV) DNA by hybridization is a common problem in Turkey where is a mild endemic region. We aimed to evaluate the causes of elevated ALT levels in patients who are negative for hepatitis B e antigen (HBeAg) and HBV DNA (by hybridization) for at least 6 months. PATIENTS-METHODS: Forty-nine patients were enrolled in this study. Histological changes [histological activity index (HAI), and the extent of fibrosis] were assessed according to the Knodell scoring system and steatosis were graded by Brunt's classification for NAFLD in all patients. RESULTS: A mean age of the patients was 34.9 +/- 12.1 years (16-70). 43 (87.8%) of them were male. Mean ALT level was 95 +/- 39.7 IU/L (50- 258). Hyperglycemia (>100 mg/dL) and hyperlipidemia were found in 12 and 24 patients, respectively. Hepatic steatosis (7 patients grade 1; 5 patients grade 2; and 7 patients grade 3), ground-glass hepatocyte, chronic hepatitis, and Wilson disease were found in liver biopsy in 38.8%, 32.6%, 26.6%, 2%, respectively. Mean HAI was 6.5 +/- 3.6 (4-12) in chronic hepatitis. Seven patients (53.9%) were in stage 1 and 2 while 6 patients (46.1%) were in stage 3 and 4. CONCLUSIONS: Nonalcoholic fatty liver disease is the most common cause of elevated ALT levels in HBeAg negative/HBV DNA negative patients. Chronic hepatitis B was found in 26.6% of these patients.

N-Terminal pro-B-Type Natriuretic Peptide Levels are Linked with Modified Child-Pugh Classification in Patients with Nonalcoholic Cirrhosis [NT-ProBNP and Liver Cirrhosis].

Excess N-terminal pro-brain natriuretic peptide secretion has been linked to cirrhosis in previously studies. The relationship of plasma N-terminal pro-brain natriuretic peptide levels and cardiac dysfunction determined by echocardiography were investigated in patients with nonalcoholic cirrhosis and a control group of chronic hepatitis. This study was designed as a cross-sectional study. Thirty-two men and thirty-three women who gave informed consent who were followed-up for chronic liver failure were enrolled. All patients gave clinical history, physical examination was carried out and information about ongoing medication has been obtained. Serum N-terminal pro-brain natriuretic peptide level was measured in all patients. The same cardiologist determined ejection fraction, end-diastolic left ventricular diameter, interventricular septum, and posterior wall on transthoracic echocardiography. Patients with extensive liver disease according to Child-Pugh classification from A to C had increasing N-terminal pro-brain natriuretic peptide levels in association (P < .001). According to the Child-Pugh classification there were no significant difference between groups for echocardiographic measurements (P > .05). N-terminal pro-brain natriuretic peptide may be an important marker for cardiac dysfunction in patients with chronic liver failure in accordance with Child-Pugh stage.

Treatment of pregnant women with a diagnosis of inflammatory bowel disease.

The frequency of diagnosis of inflammatory bowel disease (IBD) has increased in younger populations. For this reason, pregnancy in patients with IBD is a topic of interest, warranting additional focus on disease management during this period. The main objective of this article is to summarize the latest findings and guidelines on the management of potential problems from pregnancy to the breastfeeding stage. Fertility is decreased in patients with active IBD. Disease remission prior to conception will likely decrease the rate of pregnancy-related complications. Most of the drugs used for IBD treatment are safe during both pregnancy and breastfeeding. Two exceptions are methotrexate and thalidomide, which are contraindicated in pregnancy. Anti-tumor necrosis factor agents are not advised during the third trimester as they exhibit increased transplacental transmission and potentially cause immunosuppression in the fetus. Radiological and endoscopic examinations and surgical interventions should be performed only when absolutely necessary. Surgery increases the fetal mortality rate. The delivery method should be determined with consideration of the disease site and presence of progression or flare up. Treatment planning should be a collaborative effort among the gastroenterologist, obstetrician, colorectal surgeon and patient.

The relationship between FGF-23 and ghrelin levels in CKD patients: preliminary data.

BACKGROUND: Fibroblast growth factor (FGF)-23 is a recently discovered phosphaturic hormone that increases in chronic kidney disease (CKD). It has been accepted as a determinant of mortality and a therapeutic target in these patients. Ghrelin is a hormone that has roles in energy and nutrient metabolism. Ghrelin level was found to be increased in CKD patients. This is a controlled study in which the relationship between FGF-23 and ghrelin levels in CKD patients has been studied. METHODS: Three groups were involved: 88 individuals. Dialysis group (DG, 33 patients) including patients on hemodialysis (21 patients) or peritoneal dialysis program (12 patients); predialysis group (PG, 29 patients) consisting of patients with stage-3 CKD; and the control group (CG, 29 individuals) of healthy adults. Serum FGF-23 and ghrelin levels were measured as well as routine biochemical parameters. RESULTS: FGF-23 levels were similar within the groups (CG: 268±45 pg/mL, PG: 284±94 pg/mL, DG: 259±87 pg/mL, P=0.11). Ghrelin level was higher in the PG group compared with the DG and CG, while DG had higher ghrelin level than the CG (CG: 2.79±0.38 ng/mL, PG: 4.53±1.18 ng/mL, DG: 3.98±0.89 ng/mL). When all groups were studied together; a strong correlation was found between FGF-23 and ghrelin levels. When the analysis was repeated with PG and DG accepted as CKD group; this strong correlation persisted; while it was not true for the CG. CONCLUSIONS: There might be a strong correlation between FGF-23 and ghrelin levels irrespective of the stage of CKD and the dialysis modality. There is need for further studies to clarify the pathophysiological link between these parameters.

A multicenter, randomized, prospective study of 14-day ranitidine bismuth citrate- vs. lansoprazole-based triple therapy for the eradication of Helicobacter pylori in dyspeptic patients.

BACKGROUND/AIMS: Proton-pump inhibitor and ranitidine bismuth citrate-based triple regimens are the two recommended first line treatments for the eradication of Helicobacter pylori. We aimed to compare the effectiveness and tolerability of these two treatments in a prospective, multicentric, randomized study. MATERIALS AND METHODS: Patients with dyspeptic complaints were recruited from 15 study centers. Presence of Helicobacter pylori was investigated by both histology and rapid urease test. The patients were randomized to either ranitidine bismuth citrate 400 mg bid plus amoxicillin 1 g bid plus clarithromycin 500 mg bid (n=149) or lansoprazole 30 mg bid plus amoxicillin 1 g bid plus clarithromycin 500 mg bid (n=130) treatment arm for 14 days. Adverse events have been recorded during the treatment phase. A 13 C urea breath test was performed 6 weeks after termination of treatment to assess the efficacy of the therapy. Eradication rate was calculated by intention-to-treat and per-protocol analysis. RESULTS: Two hundred seventy-nine patients (123 male, 156 female) were eligible for randomization. In per-protocol analysis (n=247), Helicobacter pylori was eradicated with ranitidine bismuth citrate- and lansoprazole-based regimens in 74,6% and 69,2% of cases, respectively (p>0,05). Intention-to-treat analysis (n=279) revealed that eradication rates were 65,1% and 63,6% in ranitidine bismuth citrate and in lansoprazole-based regimens, respectively (p>0,05). Both regimes were well-tolerated, and no serious adverse event was observed during the study. CONCLUSION: Ranitidine bismuth citrate-based regimen is at least as effective and tolerable as the classical proton-pump inhibitor-based regimen, but none of the therapies could achieve the recommendable eradication rate.

Cutaneous manifestations in brucellosis.

Brucellosis is a common worldwide zoonotic disease. Cutaneous manifestations are not specific and affect 1-14% of patients with brucellosis. Here, we describe 49-year-old female with fever and a diffuse maculopapular rash due to Brucella melitensis infection. Histopathology of skin biopsy revealed leukocytoclastic vasculitis; positive blood cultures for B. melitensis established the diagnosis of brucellosis. We provide a review of the relevant literature.

Is quantitative diffusion-weighted MRI a reliable method in the assessment of the inflammatory activity in ulcerative colitis?

PURPOSE: We investigated the relationship between the apparent diffusion coefficient (ADC) values of the colonic wall and the pathologic pericolonic lymph nodes (PCLNs) and inflammatory activity in ulcerative colitis patients by diffusion-weighted magnetic resonance imaging (DW-MRI). MATERIALS AND METHODS: A total of 28 ulcerative colitis patients (9 endoscopically active, 10 subacute and 9 in remission) were evaluated by DW-MRI with 0, 500 and 1000 s/mm² b-values. The ADC values of the rectum and sigmoid colon walls and the adjacent PCLNs were obtained for quantitative analysis. The DW-MRI findings were compared to the disease activity. RESULTS: The ADC values of the sigmoid colon were similar in patients with active, subacute and remissive ulcerative colitis (P = 0.472). The ADC values of the rectum were different (P = 0.009) between patients in the active (1.08 ± 0.14×10⁻³ mm²/s) and subacute phases (1.13 ± 0.23×10⁻³ mm²/s) of disease and those in remission (1.29 ± 0.17×10⁻³ mm²/s). The ADC values of the PCLNs (P = 0.899) did not differ with respect to disease activity. CONCLUSION: DW-MRI is useful in identifying disease activity in ulcerative colitis patients, especially with respect to the rectum. The ADC values of the rectum increase during remission and decrease in patients with active distal colitis. The ADC values of the PCLNs were not useful in determining disease activity.

Utility of diffusion-weighted MRI for assessing liver fibrosis in patients with chronic active hepatitis.

PURPOSE: We evaluated the utility of quantitative diffusion-weighted magnetic resonance imaging (DW-MRI) for assessing both the relationship between the degree of fibrosis and the histological activity index (HAI) in chronic hepatitis (CH) cases and attempted to determine whether the apparent diffusion coefficient value (ADC) could be used as a reference for the degree of fibrosis detected by histology. MATERIALS AND METHODS: The study population consisted of 55 CH patients (Group I) and a control group of 30 volunteers (Group II). Group I consisted of 31 CH-B (CHB), 18 CH-C (CHC) and 6 non-alcoholic steatohepatitis patients. DW-MRI of the liver with b values of 0, 500 and 1000 s/mm(2) was performed, and liver biopsies of the patients were obtained two weeks later. The ADC value, degree of liver fibrosis and HAI were compared within Group I, and the ADC values of both groups were compared with each other. RESULTS: The ADC was lower in Group I than in Group II (P < 0.05). The ADC of the left lobe lateral (LL) (P < 0.05), left lobe medial (LM) and right lobe anterior (RA) segments (P < 0.01) in Group I were lower than those of Group II. There was no relationship between HAI and the ADC of LL, LM, RA and right lobe posterior (RP) segments in Group I. Additionally, there was no correlation between fibrosis scores and ADC in Group I, whereas there was a negative correlation between fibrosis scores and ADC values of the LL (28.3%) and RP (29.5%). CONCLUSION: CH patients had lower ADC values. There was no correlation between ADC values and fibrosis stages or ADC and HAI values. Quantitative DW-MRI was not useful in determining the degree of fibrosis in liver tissue.

Response to hepatitis B vaccination in patients with celiac disease.

Abnormal immune response to gliadin, genetic, and environmental factors play a role in the pathogenesis of celiac disease (CD). Non-responsiveness to hepatitis B virus (HBV) vaccination is related to genetic features. Certain human leukocyte antigen (HLA) genotypes are more prevalent among non-responders to HBV vaccination. There is also a strong relationship between CD and these HLA genotypes. This study investigates the relationship between CD and non-responsiveness to HBV vaccination, with an emphasis on genotypic co-incidence. No statistically significant difference was noted between the ages and gender of CD patients and control subjects. Baseline serum IgA, IgM, and IgG levels of all CD patients were normal. Responsiveness to HBV vaccination was observed in 17 (68%) CD patients and all (100%) control subjects (P = 0.006). In conclusion, CD should also be sought in unresponders to HBV vaccine who are not immunosuppressed.

A rare cause of hemosuccus pancreaticus: primary splenic artery aneurysm ruptured into pancreatic serous cystadenoma.

Hemosuccus pancreaticus is a rare clinical condition defined as bleeding into the pancreatic duct from a peripancreatic artery. We present here a 57-year-old woman admitted to our clinic with abdominal pain, tar-colored stool and confusion. Further investigations were done because of severe anemia. Abdominal computerized tomography revealed intraabdominal hematoma. Laparotomy was performed, which confirmed that intraabdominal haemorrhagia had occurred with the rupture of a splenic artery aneurysm into a pancreatic serous cystadenoma, which ruptured into the abdomen because of high pressure. This is an interesting case diagnosed with multidisciplinary approaches.