Analysis of the patients with nonvariceal upper gastrointestinal bleeding and comparison of Rockall and Glasgow-Blatchford scores.

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (UGB) has important morbidity and mortality. Predicting high-risk patients for mortality and rebleeding is necessary for a treatment plan. In the present study, we aimed to define the epidemiological and etiological characteristics of patients presenting with nonvariceal UGB and to observe mortality and morbidity rates. We also aimed to compare Rockall and Glasgow-Blatchford scoring systems in predicting rebleeding and mortality. METHODS: Subjects presenting with nonvariceal UGB over a 3-year period were included. Demographic characteristics, symptoms, and signs on physical examination, laboratory data, endoscopic signs and diagnosis, interventions during hospitalization and follow-up period were recorded. Glasgow-Blatchford and Rockall scores were calculated for every participant at the first day of the admission. RESULTS: A total of 709 patients were enrolled in the study. A total of 490 of them (69.1%) were men. The mean age of the women and men was 60.7±1.2 and 58.6± 0.7 years, respectively. Melena was the most common presenting symptom. Duodenal ulcer (31%), gastric ulcer (20.7%), and erosive disease (17.6%) were the most common causes of bleeding. History of use of aspirin and/or nonsteroidal anti-inflammatory drug use were present in 63.7% of the subjects. All patients were followed up for 30th-day mortality. Overall, rebleeding and mortality rates were 11% and 7%, respectively. A Rockall score greater than 6 was the most important predictor of mortality (odds ratio:39.1) and rebleeding (odds ratio:4.7). CONCLUSION: Nonvariceal UGB patients with a Rockall score greater than 6 should undergo aggressive endoscopic treatment and inpatient care.

Melena: An Unusual Manifestation of Metastatic Lung Cancer.

Lung cancer is the most common cancer around the world, and the leading cause of cancer-related deaths. Clinical manifestations of lung cancer may vary from non-specific respiratory symptoms to symptoms due to metastases. The most common sites of metastases are the lymph nodes, liver, adrenals, bone, and brain. Metastasis of lung cancer to stomach is very rare. Here, we present a case of squamous cell lung cancer in a 71-year male metastasing to the stomach, a very uncommon site of metastasis. Key Words: Lung cancer, Melena, Metastasis, Stomach.

Endoscopic Ultrasonography in Pediatric Patients with Pancreatobiliary Disease: Single-Center Trial.

PURPOSE: The use of Endoscopic ultrasonography (EUS) in pediatric patients is not as common as in adults. The aim of this study is to evaluate the role of EUS in the diagnosis of pancreatobiliary disease in childhood. METHODS: Between December 2016 and January 2018, the findings of patients who underwent EUS were evaluated retrospectively. RESULTS: Of the 41 patients included in the study 25 were girls (61.0%), mean age was 12.2±4.2 years. EUS was performed for biliary colic in 21 (51.2%), for recurrent pancreatitis in 12 (29.2%), for cholecystitis/cholangitis in 5 (12.2%), and for acute pancreatitis in 3 (7.4%) patients. EUS had a significant clinical effect in the decision of treatment and follow-up of 6/21 biliary colic cases, in diagnosis and follow-up of 6/12 recurrent pancreatitis cases, in decision-making and monitoring of invasive procedures (ERCP/surgery) of 3/5 acute cholecystitis/cholangitis and 2/3 of acute pancreatitis cases as well as in follow-up of the other cases. The effectiveness of EUS in determining direct treatment and invasive intervention was 43.9%. None of the patients had complications related to the EUS procedure. CONCLUSION: Although current guidelines show that EUS can be used in pediatric patients, this is limited to a few published studies. In this study, it is shown that EUS is a safe method for the diagnosis, follow-up and treatment of common pancreatobiliary pathologies in childhood.

The telomere length of gastric mucosal samples and peripheral blood lymphocytes in patients who have undergone Billroth II distal gastrectomy.

INTRODUCTION: Telomeres play an important role in maintaining chromosomal integrity. Functional loss of telomeres increases the risk of cancer by causing genomic instability. Telomere length abnormalities have been reported in several precancerous lesions. There is no study that evaluates telomere length in Billroth II distal gastrectomy, which is known as a risk factor for gastric stump carcinogenesis, in the literature. The aim of this study was to assess the relationship between the telomere length of residual gastric mucosal samples, peripheral blood lymphocytes, and other clinicopathological parameters of patients who had undergone Billroth II distal gastrectomy. MATERIAL AND METHODS: There were two groups: a control group (n = 15) and a patient group (n = 15). In all cases, upper gastrointestinal endoscopy was performed, and biopsies were taken during endoscopy. Telomere lengths were measured by qRT-PCR. RESULTS: It was observed that the lengths of the telomeres were shortened as the time of postoperative period increased in the patient group (r = -0.126) (p > 0.05). Also, the lengths of the telomeres were shortened in chronic inflammation, neutrophil activity, glandular atrophy, and intestinal metaplasia. CONCLUSIONS: The telomere length was shortened as the time of postoperative period increased in the patient group. The telomeres were also shorter in chronic inflammation, neutrophil activity, intestinal metaplasia, and glandular atrophy, in all of the study groups. Telomere length abnormalities in gastric stump carcinogenesis process may be a guide for early diagnosis and treatment.

Periodontal treatment is more effective in gastric Helicobacter pylori eradication in those patients who maintain good oral hygiene.

OBJECTIVES: This study aimed to investigate the effect of periodontal treatment and oral hygiene on the eradication of gastric Helicobacter pylori. MATERIALS AND METHODS: In this clinical trial, the 98 patients with gastric H. pylori infection that were enrolled received either triple-therapy regimen only or triple-therapy regimen plus periodontal treatment given during triple therapy. Eradication of H. pylori was checked at 3 months, and then after therapy using the urea breath test. RESULTS: The triple-therapy plus periodontal treatment regime resulted in a 64.7% eradication rate, and the triple-therapy regime alone resulted in a 51.1% eradication rate (P = 0.17). Additionally, subgroup analysis indicated that the beneficial effect of periodontal treatment on the gastric H. pylori eradication rate improved if adequate plaque control was maintained (P = 0.02). Multivariate logistic regression analysis showed that post-treatment oral hygiene status [as indicated by the Oral Hygiene Index (OHI)] was associated with H. pylori eradication (P = 0.02), but not with pretreatment oral hygiene status (P = 0.24). Oral hygiene measures without periodontal treatment appear to have a limited impact on H. pylori eradication. Post-treatment oral hygiene level (OHI ≤ 1.25) had a positive effect on H. pylori eradication, increased the gastric eradication rate, with an OR of 3.19, and the oral H. pylori eradication rate, with an OR of 4.57. Furthermore, if periodontal treatment was unsuccessful in eliminating oral H. pylori, as tested using the Campylobacter-like organism test, the OR for the unsuccessful gastric eradication increased 64-fold. Conclusion This result illustrates that the key factors for achieving successful gastric H. pylori eradication are professional periodontal treatment and the patients' later adherence to an oral hygiene regimen.

Inflammatory markers C-reactive protein and PLR in relation to HCC characteristics.

INTRODUCTION: Several markers of systemic inflammation, including blood C-reactive protein, platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) have been identified as independent prognosticators for hepatocellular carcinoma (HCC). METHODS: To attempt to understand the significance of these markers, they were examined in relation to 4 tumour parameters, namely maximum tumour diameter (MTD), tumour multifocality, portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels. RESULTS: Using linear and logistic regression models, we found that C-reactive protein and PLR on single variables, were statistically significantly related to the tumour parameters. In a logistic regression final model, CRP was significantly related to MTD, AFP and PVT, and the Glasgow Index significantly related to MTD and AFP. Results of the area under the receiver operating characteristic curves (ROC), showed that the areas for PLR and CRP were statistically significant for high versus low MTD and for presence versus absence of PVT. CRP alone was significant for high versus low AFP. CONCLUSIONS: These analyses suggest that the prognostic usefulness of the inflammatory markers PLR and CRP (but not NLR) may be due to their reflection of parameter values for tumour growth and invasiveness.

C-Reactive Protein and Platelet-Lymphocyte Ratio as Potential Tumor Markers in Low-Alpha-Fetoprotein Hepatocellular Carcinoma.

The hepatocellular carcinoma (HCC) tumor marker alpha-fetoprotein (AFP) is only elevated in about half of the HCC patients, limiting its usefulness in following the effects of therapy or screening. New markers are needed. It has been previously noted that the inflammation markers C-reactive protein (CRP) and platelet-lymphocyte ratio (PLR) are prognostically important and may reflect HCC aggressiveness. We therefore examined these 2 markers in a low-AFP HCC cohort and found that for HCCs > 2 cm, both markers significantly rise with an increasing maximum tumor diameter (MTD). We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Youden index value for each marker, and their area-under-the-curve values for each MTD group. Patients were dichotomized into 2 groups based on the CRP and PLR from the receiver-operating characteristic curve analysis. In the logistic regression models of the 4 different MTD patient groups, CRP and PLR levels were statistically significant to estimate MTD in univariate logistic regression models of MTD groups > 2 cm. CRP and PLR were then combined, and the combination was statistically significant to estimate MTD groups of 3-, 4-, and 5-cm cutoffs. CRP and PLR thus have potential as tumor markers for low-AFP HCC patients, and possibly for screening.

Macroscopic Portal Vein Thrombosis in HCC Patients.

Macroscopic portal vein invasion (PVT) by hepatocellular carcinoma (HCC) in the liver is one of the most important negative prognostic factors for HCC patients. The characteristics of a large cohort of such patients were examined. We found that the percent of patients with PVT significantly increased with increasing maximum tumor diameter (MTD), from 13.7% with tumors of MTD <5cm to 56.4% with tumors of MTD >10cm. There were similar numbers of HCC patients with very large tumors with and without PVT. Thus, MTD alone was insufficient to explain the presence of PVT, as were high AFP levels, since less than 50% of high AFP patients had PVT. However, the percent of patients with PVT was also found to significantly increase with increasing blood alpha-fetoprotein (AFP) levels and tumor multifocality. A logistic regression model that included these 3 factors together showed an odds ratio of 17.9 for the combination of MTD>5.0cm plus tumor multifocality plus elevated AFP, compared to low levels of these 3 parameters. The presence or absence of macroscopic PVT may therefore represent different HCC aggressiveness phenotypes, as judged by a significant increase in tumor multifocality and AFP levels in the PVT positive patients. Factors in addition to MTD and AFP must also contribute to PVT development.

Turkey 2017 Clinical Practice Guidelines on recommendations for screening diagnosing and managing hepatitis C virus.

The present guideline updates the Turkish recommendations for the screening, diagnosis and management of Hepatitis C virus (HCV) infection prepared by the Turkish Association for the Study of the Liver (TASL) and Viral Hepatitis Society (VHS). The aim of this guidance was to provide updates recommendations to physicians, who are interested in HCV care on the optimal screening, diagnosis and pre-treatment management for patients with HCV infection in Turkey. These recommendations, produced by panel experts, were aimed to addresses the management issues ranging from diagnosis and linkage to care, to the optimal treatment regimen in patients with HCV infection. Recommendations are based on evidence and opinions of more than 70% of the panelists. This guidance is supported by the memberships of two societies and not by pharmaceutical companies. This guidance will be updated frequently as new data become available.

Embryonal Testicular Cancer with Duodenal Metastasis: Could Nausea and Vomiting be Alarm Symptoms?

AIM: Duodenal metastasis of testicular cancer is an uncommon condition in clinical practice. Here, we have reported a case of this nature. BACKGROUND: Testicular cancers are among the most seen cancer types among young men. Metastasis of testicular cancer generally occurs through hematogenous and lymphatic drainage. Gastrointestinal (GI) metastasis of testicular cancer has been reported rarely. CASE REPORT: A duodenal mass was seen in esophagogastroduodenoscopic examination in a man who was admitted into hospital for medical treatment of resistant nausea and vomiting. He was previously diagnosed with testicular cancer. Computed tomography (CT) views were compatible with primary duodenal tumor. The duodenal mass was compatible with germ cell neoplasm metastasis. He received chemotherapy regime which includes cisplatin, paclitaxel, and ifosfamid. Nausea and vomiting symptoms decreased and metastatic mass and lymph nodes were regressed. CONCLUSION: Duodenum metastasis of testicular cancer can be treated with a chemotherapy regimen, and patients can improve radiologically and symptomatically without the need of any surgery. Physicians should keep in mind that GI metastasis of testicular cancer may present with nausea and vomiting symptoms. HOW TO CITE THIS ARTICLE: Duygulu ME, Kaymazli M, Goren I, Yildirim B, Sullu Y, Nural MS, Bektas A. Embryonal Testicular Cancer with Duodenal Metastasis: Could Nausea and Vomiting be Alarm Symptoms? Euroasian J Hepato-Gastroenterol 2016;6(2):198-201.

Mantle cell lymphoma mimicking rectal carcinoma.

Mantle cell lymphoma (MCL) is a mature B-cell non-Hodgkin lymphoma. After the (11;14) translocation was identified as its constant finding in 1992, MCL was recognized as a separate subgroup of non-Hodgkin lymphoma (NHL). In MCL, extranodal involvement may be observed in the bone marrow, the spleen, the liver, and the gastrointestinal system (GIS). Cases of MCL that present with a massive and solitary rectal mass are rare in the literature. In this case report, our aim was to present an MCL patient with a rarely observed solitary rectal involvement mimicking rectal carcinoma and to discuss treatment options for this patient.

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.

Helicobacter pylori eradication increases telomere length in gastric mucosa.

BACKGROUND/AIMS: Our purpose in this study was to analyze telomere length and telomerase activity before and after eradication treatment in gastric mucosa in patients positive for H. pylori. METHODOLOGY: There were two groups: a control group (n=17) and a study group (n=21). For H. pylori eradication, the patients were administrated proton pump inhibitor (PPI) + clarithromycin + amoxicillin or PPI + metronidazole + tetracycline + bismuth for 14 days. Telomere length was analyzed with RT-PCR and telomerase activity with PCR-ELISA on biopsy specimens from the antrum. The result p<0.05 was considered significant. RESULTS: Prior to eradication, there was no significant difference between telomere lengths of the patient and control groups (2481.2±1823 and 2958.9±1345.7 bp, p=0.11, respectively). The telomere length of the study group became longer after eradication (before 2481.2±1823bp, after 3766.3±1608.8bp, p=0.01). Telomerase activity was not detected in either the patient or the control group. CONCLUSIONS: An increase in telomere length was observed with H. pylori eradication. This finding may indicate the importance of H. pylori eradication to avoid the development of gastric cancer.

Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis and bronchial asthma: a case report.

OBJECTIVE: Strongyloides stercoralis is a soil-transmitted intestinal nematode that has been estimated to infect at least 60 million people, especially in tropical and subtropical regions. Strongyloides infection has been described in immunosupressed patients with lymphoma, rheumatoid arthritis, diabetes mellitus etc. Our case who has rheumatoid arthritis (RA) and bronchial asthma was treated with low dose steroids and methotrexate. METHODS: A 68 year old woman has bronchial asthma for 55 years and also diagnosed RA 7 years ago. She received immunusupressive agents including methotrexate and steroids. On admission at hospital, she was on deflazacort 5 mg/day and methotrexate 15 mg/week. On her physical examination, she was afebrile, had rhonchi and mild epigastric tenderness. She had joint deformities at metacarpophalengeal joints and phalanges but no active arthritis finding. RESULTS: Oesophagogastroduodenoscopy was performed and it showed hemorrhagic focus at bulbus. Gastric biopsy obtained and showed evidence of S.Stercoralis infection. Stool and sputum parasitological examinations were also all positive for S.stercoralis larvae. Chest radiography result had no pathologic finding. Albendazole 400 mg/day was started for 23 days. After the ivermectin was retrieved, patient was treated with oral ivermectin 200 µg once a day for 3 days. On her outpatient control at 15th day, stool and sputum samples were all negative for parasites. CONCLUSION: S.stercoralis may cause mortal diseases in patients. Immunosupression frequently causes disseminated infections. Many infected patients are completely asymptomatic. Although it is important to detect latent S. stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. In immunosupressed patients, to detect S.stercoralis might help to have the patient survived and constitute the exact therapy.

Association between adiponectin, resistin, insulin resistance, and colorectal tumors.

PURPOSE: In this study, we have examined the correlation between colorectal cancer (CRC) and serum adiponectin and resistin levels, body mass index and insulin resistance. METHODS: The relation between serum adiponectin and resistin levels, obesity and insulin resistance in 36 CRC patients and 37 controls was examined. RESULTS: Insulin and homeostasis model assessment insulin resistance index (HOMA-IR) levels were higher, and adiponectin levels were significantly decreased in patients versus controls, whereas, resistin levels were significantly increased. A negative correlation between adiponectin, HOMA-IR, and insulin and a positive correlation between HOMA-IR, insulin, and stage were detected. There was no correlation between the stage and resistin. Adiponectin level negatively correlated with the stage. Adiponectin and resistin could play a role in colon cancer carcinogenesis, and adiponectin could be responsible for poor prognosis in colorectal cancer.

Incisional hernia as an unusual cause of hepatic encephalopathy in a 62-year-old man with cirrhosis: a case report.

INTRODUCTION: Hepatic encephalopathy may be initiated by many factors such as gastrointestinal bleeding, infections, fluid and electrolyte disturbances. Hypokalemia is one of the most commonly encountered electrolyte abnormalities causing hepatic encephalopathy in patients with cirrhosis. CASE PRESENTATION: We present the case of a 62-year-old Caucasian man with decompensated liver cirrhosis having multiple episodes of hepatic encephalopathy precipitated by vomiting. He had an incisional hernia at the right lumbar region. A barium contrast study of the small intestine and magnetic resonance imaging showed that the hernial sac included gastric antrum and bowel. We observed that hepatic encephalopathy coincided with hypokalemia as a result of a large volume of vomiting triggered by the collapsed hernial sac. Hepatic encephalopathy was resolved by administration of intravenous potassium. CONCLUSION: This case illustrates that a hernia causing a large volume of vomiting may be a precipitant factor in the development of hepatic encephalopathy.