Acute pancreatitis in Turkey: Results of a nationwide multicenter study.

BACKGROUND: Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management. METHODS: All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria. RESULTS: The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically. CONCLUSIONS: This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.

Benign biliary strictures associated with acute biliary pancreatitis.

BACKGROUND AND AIMS: There are limited data about the benign biliary strictures (BBS) which can develop during the clinical course of acute biliary pancreatitis (ABP) due to compression of the common bile duct (CBD) by edematous and inflamed pancreatic tissue. We aimed to determine the incidence of BBS due to ABP and its clinical course after endoscopic management. METHODS: The study was retrospectively conducted among patients with ABP who were admitted to a single tertiary reference center during 3 years. BBS-ABP was defined as distal narrowing of the CBD with proximal dilatation and delayed drainage of the contrast into the duodenum. Endoscopic treatment was performed by inserting a single 7F or 10F plastic stent which was exchanged every 3 months until stricture resolution. Patients were followed for 1 year after stricture resolution. RESULTS: Seven hundred and twenty-one patients had ABP during the study period. Among them, 257 (35.6%) patients underwent ERCP and 26 patients (3.6%) had CBD stricture due to ABP. A 7 Fr plastic stent was inserted in 18 patients and 10 Fr in 8 patients. The stricture was completely resolved at 3 months in 66.7%, at 6 months 23.8% and at 9 months (9.5%) of the patients. There was no procedure-related complications other than asymptomatic stent migration in 4 (19%) patients. None of the patients had recurrent biliary stricture during the 1 year stent-free follow-up period. CONCLUSION: BBS-ABP is a frequently seen clinical entity. In most patients, the stricture improves within 3 months and temporary endoscopic stenting prevents the patients from the consequences of the obstruction during this period.

Hepatitis B Reactivation in Patients Treated with Direct-Acting Antivirals for Hepatitis C.

INTRODUCTION: There is limited research about HBV reactivation (HBVr) due to direct-acting antivirals (DAA) for HCV and most are limited by short duration of follow-up, small sample size, and absence of baseline HBV DNA. We aimed to determine the incidence and clinical course of HBVr in HBsAg and/or anti-HBcIgG positive patients treated with DAA for HCV. METHODS: Seven centers retrospectively analyzed their database on HCV patients treated with DAA between 2015 and 2019. Patients with HBV coinfection or resolved HBV infection were enrolled. Serum transaminases, HBsAg, HBeAg, and HBV DNA were followed every 4 weeks during DAA treatment and every 12 weeks 1 year after treatment. Entecavir or tenofovir disoproxil fumarate was started in case of HBVr. The development of HBVr, HBV flare, liver failure, and mortality were determined. RESULTS: 852 patients received DAA treatment for HCV. Among them, 35 (4.1%) had HBV coinfection and 246 (28.9%) had resolved HBV infection. 257 patients (53.3% male, mean age: 63 ± 9) constituted the study group (29 with coinfection and 228 with resolved infection). Three patients with coinfection were HBV DNA positive. HBVr developed in 10 (34.5%) HBsAg positive patients, either during (n = 3) or 12-48 weeks after finishing DAA treatment. HBV flare and acute liver failure developed in 1 patient (3.4%), each. Two patients with resolved infection developed HBVr (0.87%) and one (0.44%) had HBV flare. Overall, none of the patients died or underwent liver transplantation due to HBVr. CONCLUSION: Patients with HBV/HCV coinfection have a high risk of HBVr after DAA treatment and should receive antiviral prophylaxis. Patients with resolved infection have a low risk of HBVr and can be monitored by serial ALT measurements.

Hepatitis B reactivation after oral capecitabine treatment in a rectum cancer patient with isolated anti-HBc IgG positivity.

INTRODUCTION: Hepatitis B virus (HBV) reactivation in the setting of chemotherapy and immunosuppressive therapy is associated with significant morbidity and mortality. Herein we present a case of HBV reactivation after oral capecitabine treatment in a patient with rectum cancer and isolated anti-HBc IgG positivity. CASE REPORT: A 57-year-old man was consulted from the oncology clinic because of increased serum liver tests after chemotherapy. He underwent surgery for early-stage rectal cancer and received adjuvant chemotherapy with oral capecitabine. After cessation of chemotherapy, his laboratory tests revealed severe liver dysfunction. HBV markers showed positivity for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc). HBV DNA level was markedly elevated. MANAGEMENT AND OUTCOME: A review of medical records revealed that, before chemotherapy, the patient was positive for anti-HBc IgG but negative for HBsAg, and serum aminotransferases were within the normal limits. A diagnosis of HBV-related hepatitis due to capecitabine use was made, and the patient was put on tenofovir treatment. Six months later, HBV DNA decreased, and liver function tests were normalized. DISCUSSION: To the best of our knowledge, this is the first case report describing HBV reactivation after chemotherapy with capecitabine for rectal cancer in a patient with isolated anti-HBc IgG positivity. Our case shows that HBV reactivation may develop in a low-risk patient with a low degree of immunosuppression.

Comparison of Tenofovir Disoproxil Fumarate and Entecavir in the Prophylaxis of HBV Reactivation.

INTRODUCTION: Current guidelines recommend starting antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in patients receiving immunosuppressive treatments (IST). The aim of this study was to compare the efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) for prophylaxis. METHODS: Patients, who were HBsAg and/or anti-HBc IgG positive and scheduled to receive IST for oncologic and hematologic diseases, were enrolled into the study. Those who were already receiving an antiviral treatment for HBV or had an associated HIV, hepatitis C, D were excluded. The remaining patients with a prophylaxis indication according to the AGA guideline were randomized to receive either ETV (0.5 mg/day) or TDF (245 mg/day). Prophylaxis was continued for 6-12 months after completion of IST. Patients were followed up for 1 year after completion of prophylaxis. The HBV reactivation rates and side effects of the drugs were compared. RESULTS: The study group included 120 patients. There was no significant difference between the demographic data, viral serologic parameters and reactivation risk profiles of the ETV (n = 60) and TDF (n = 60) groups. Forty-one patients in the ETV and 36 in the TDF group completed the antiviral prophylaxis, and no HBV reactivation was observed. HBV reactivation was observed in 4 of 37 patients (10.8%) in the ETV group and 5 of 35 (14.3%) patients in the TDF group (including one with flare) during the follow-up after completion of prophylaxis. Ten patients in the ETV group (16.7%) and 14 patients (23.3%) in the TDF group experienced side effects (p = 0.77). One patient in the TDF group had to switch to ETV due to severe itchy, maculopapular rash-like lesions. CONCLUSIONS: ETV and TDF had a similar efficacy in the prophylaxis of HBV reactivation in patients undergoing IST, with none of the patients experiencing reactivation.

Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial (with video).

BACKGROUND AND AIMS: Although various methods are used in the treatment of peptic ulcer bleeding, there is not a standard recommended approach. The choice depends on multiple factors such as location of the ulcer, clinical experience of the endoscopist, and local facilities of the clinic. We aimed to compare the efficacy of monopolar hemostatic forceps soft coagulation (MHFSC) and hemoclips (HCs) in the treatment of peptic ulcer-related upper GI bleeding. METHODS: The study group included patients who had GI bleeding due to Forrest 1a, 1b, and 2a gastric or duodenal ulcers within 1 year. Patients with bleeding diathesis, history of gastrectomy, pregnancy, or younger than age 18 years were excluded. The remaining were randomized to MHFSC and HC treatment groups and compared in terms of clinical and endoscopic features, initial hemostasis success rates, recurrent bleeding rates within the first 7 days, time to achieve hemostasis, length of hospitalization stay, and adverse events. RESULTS: One hundred twelve patients were randomized to MHFSC (n = 56) and HC (n = 56) groups. There was no statistically significant difference between the groups with respect to demographic features, medications, underlying chronic diseases, location, and Forrest classification of the ulcers. The initial hemostasis success rate was 98.2% (55/56) in the MHFSC group and 80.4% (45/56) in the HC group (P = .004). Recurrent bleeding was detected in 2 patients in the MHFSC group (3.6%) and 8 patients in the HC group (17.7%; P = .04). The duration of endoscopic procedures (302 ± 87.8 vs 568 ± 140.4 seconds) and the length of hospital stay (3.50 ± 1.03 vs 4.37 ± 1.86 days) were significantly shorter in the MHFSC group. There were no adverse events in either group. CONCLUSIONS: MHFSC is more effective in achieving initial hemostasis compared with HCs in the treatment of peptic ulcer bleeding and provides a shorter procedure time and a lower recurrent bleeding rate.

Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting in patients with difficult biliary cannulations.

BACKGROUND AND AIMS: Cannulation of the major papilla can be problematic, and selective biliary cannulation may fail in up to 18% of cases. Various techniques, such as double-guidewire technique (DGWT), wire-guided cannulation over a pancreatic stent (WGC-PS), the precut endoscopic sphincterotomy (needle-knife precutting technique (NKP), and transpancreatic septostomy have been used to improve the success rate of biliary cannulation. We conducted a prospective, randomized study in order to compare the biliary cannulation success rates of DGWT and WGC-PS techniques in patients with inadvertent passage of guidewire to the pancreatic duct. METHODS: A total of 100 patients were included in the study and randomized to DGWT (n = 50) or WGC-PS (n = 50) groups. The primary outcome was successful selective cannulation, defined as deep cannulation with selective injection of radiographic contrast material into the common bile duct within 5 minutes by DGW or WGC-PS techniques without performing precut sphincterotomy. RESULTS: Successful selective cannulation was achieved in 45 patients in the DGWT group (90%) and in 27 patients in the WGC-PS group (54%) (P < .001). Five patients (10%) in the DGWT group and 23 (46%) in the WGC-PS group required NKP for biliary access (P < .001). The overall cannulation rate was 98% for DGWT and 98% for WGC-PS (P = 1.00). CONCLUSIONS: In patients with unintentional passage of a guidewire into the pancreatic duct during biliary cannulation attempts, the WGC-PS technique significantly increased the need for NKP compared with DGWT.

Rheumatologists' awareness of hepatitis B reactivation before immunosuppressive therapy.

HBV reactivation (HBVr) is a well-known complication of immunosuppressive (IS) treatment. The aim of this study was to evaluate the awareness of rheumatologists about the risk of HBVr. A survey was sent via e-mail to 270 members of the Turkish Society for Rheumatology. It consisted of fourteen questions on their awareness of the major society guidelines, approach to hepatitis B virus (HBV) screening according to different IS regimens, decision process in screening patients for HBV, knowledge of antiviral treatments for HBV, follow-up strategies, experience and postgraduate training on HBVr. Forty-eight (17.8%) rheumatologists responded to the survey. Of the respondents, 93.8% reported that they screened all patients before IS treatment, while 6.2% screened patients with a high risk of HBV infection only. The screening rate was 95.8% (46/48) in patients undergoing high-risk IS treatment and 35.4% (17/48) in those undergoing low-risk treatment. All respondents screened for HBsAg, and 83.3% (40/48) screened for anti-HBc IgG and anti-HBs. Forty-four (91.7%) rheumatologists had previously initiated antiviral prophylaxis, and 14 (29.2%) had detected HBVr in at least one patient. Rheumatologists had a high awareness of the necessity for HBV screening before IS treatment. However, the screening rates were still lower than desired, especially in patients receiving IS treatments with moderate or low risk of reactivation.

Similar subclinical enthesitis in celiac and inflammatory bowel diseases by ultrasound suggests a gut enthesis axis independent of spondyloarthropathy spectrum.

Objective: Higher subclinical enthesitis on US has been reported in IBD and celiac disease, separately. The objective of this study was to compare IBD and celiac disease for enthesitis on US. Higher enthesitis scores in IBD compared with celiac disease would support a shared pathogenic mechanism between IBD and spondyloarthritis, whereas similar scores may suggest a general impact of gut inflammation on the enthesis. Methods: Patients with IBD, celiac disease and healthy controls (HCs) were recruited and 12 entheses were scanned by US, blind to the diagnosis and clinical assessment. Elementary lesions for enthesitis were scored on a scale between 0 and 3, for inflammation, damage and total US scores. Results: A total of 1260 entheses were scanned in 44 patients with celiac disease, 43 patients with IBD and 18 HCs. The three groups were matched for age and BMI. Patients with celiac disease and IBD had higher inflammation scores than HCs [10.4 (6.5), 9.6 (5.4) and 5.6 (5.2), respectively, P = 0.007) whereas damage scores were similar. Both age and BMI had significant effects on the entheseal scores, mostly for inflammation scores but when controlling for these the US enthesopathy scores were still higher in celiac disease and IBD. Conclusion: The magnitude of subclinical enthesopathy scores is similar between celiac disease and IBD in comparison with HCs. These findings suggest that the common factor between both diseases and enthesopathy is abnormal gut permeability, which may be modified by the genetic architecture of IBD leading to clinical arthropathy.

A novel technique for the endoscopic treatment of complete biliary anastomosis obstructions after liver transplantation: through-the-scope magnetic compression anastomosis.

BACKGROUND AND AIMS: Magnetic compression anastomosis is a rescue technique for recanalization of complete biliary strictures. Here, we present magnetic compression anastomosis with novel through-the-scope magnets in patients with complete duct-to-duct anastomosis obstruction after liver transplantation. METHODS: The magnets were 2 and 2.4 mm in diameter, with a hole at the center for inserting a guidewire. One of the magnets was advanced through the scope up to the distal site of the stricture by using a 7F pusher. The other magnet was pushed percutaneously through the 10F sheath. The procedure was terminated when the magnets were approximated or properly aligned. Recanalization was followed by percutaneous cholangiography. Patients underwent multiple plastic stenting after recanalization was achieved. RESULTS: Nine patients with a stricture length of less than 1 cm, a stump in the donor bile ducts close to the stricture, and proper positioning of the bile duct stumps, underwent magnetic compression anastomosis. Seven patients had a live donor-related liver transplantation. The mean stricture time was 24.1 ± 17.1 months. The mean stricture length was 4.0 ± 1.2 mm. Recanalization was achieved in 7 patients (77%) after a mean recanalization time of 8.1 ± 4.7 days. There was no recurrence after 4.8 ± 3.8 months of stent-free follow-up. No adverse events were observed. CONCLUSIONS: The through-the-scope magnet procedure was effective in the recanalization of complete anastomotic biliary obstructions after liver transplantation in a selected group of patients with a short stricture length and an appropriate anatomy.

Endoscopic treatment of biliary stones in patients with liver transplantation.

BACKGROUND: Biliary complications develop in 10-40 % of patients following liver transplantation. Biliary strictures, leaks, and stone are the most common type of complications. In this study, we focused on the endoscopic treatment of biliary stones. METHODS: Among 142 patients with liver transplantation [22 deceased donor related (DDLT), 120 live donor related liver transplantation (LDLT)] who underwent endoscopic retrograde cholangiopancreatography (ERCP) between December 2013 and September 2015, 33 (11 with DDLT, 28 male, mean age 45 ± 13 years) had one or more biliary stones. ERCP was performed through papilla in all of the patients other than a patient with hepaticojejunostomy. RESULTS: Biliary stones were extracted in all 6 patients without anastomosis stricture (AS), 3 of 6 (50 %) patients with DDLT and AS, in 13 of 16 (81.5 %) patients with LDLT and AS, and in 3 of 5 (60 %) patients with non-anastomosis stricture (NAS). The total number of sessions required for the extraction of stones was less in patients with biliary stones without AS [1.5 (1-2)] compared to those with AS and DDLT [2 (1-6)] or LDLT [3 (1-5)]. Patients with NAS (n = 5) required a greater number of sessions [7 (1-10)]. CONCLUSIONS: Stone extraction is difficult in patients with NAS and requires a greater number of ERCP sessions. The treatment of biliary stones proximal to an AS in patients with DDLT or LRLT is possible in most cases.

Bioimpedance spectroscopy for the differential diagnosis of hyponatremia.

BACKGROUND: Hyponatremia is classified according to volume status with the help of physical examination, biochemical measures, urine and serum osmolalities, and echocardiography. Bioimpedance spectroscopy (BIS) has been getting popularity for revealing tissue compositions of various patient groups. The aim of this observational study was to investigate the role of BIS for the differential diagnosis of hyponatremia (ClinicalTrials.gov Identifier: NCT01838759). PATIENTS AND METHODS: Personal characteristics of age, sex, weight, height, and blood pressure were recorded. Body composition monitor (BCM) was used for hydration status for each individual. Primary outcome was investigated by the accuracy of volume status measured by BIS. STATISTICS: Kappa statistic (K) is a measure of agreement between two sources, which is measured on a binary scale (i.e., condition present/absent). K statistic can take values between 0 and 1: poor agreement: K < 0.20, fair agreement: 0.2.0-0.3.9, moderate agreement: 0.40-0.59, substantial: 0.60-0.79, very good agreement: 0.80-1.00. RESULTS: Fifty-eight hyponatremia-diagnosed patients, 32 (55.2%) of male with the mean age of 65.2 ± 11 (40-89) years were included. Kappa statistic (K) were very good (K = 0.925) for male (p < 0.00), substantial agreement (K = 0.601) for female (p < 0.002) with the use of BIS for the differential diagnosis of either hypo or hypervolemia in hyponatremic patients compared with gold standard tests which were the combination of echocardiography, serum, and urine osmolality biochemical tests, and physical examination. CONCLUSION: Bioimpedance spectroscopy is a practical and an inexpensive method. This is the first study in the literature showing the role of BIS for the determination of the volume status and differential diagnosis of hyponatremia when compared with echocardiography.

Electronic Alert System Significantly Increases HBV Screening Rates Before Immunosuppressive Treatments.

BACKGROUND: Hepatitis B Virus (HBV) screening rates before starting immunosuppressive treatments are suboptimal. The aim of the study was to evaluate the efficacy of a new electronic alert system in increasing HBV screening rates. METHODS: The electronic alert system, HBVision2, identifies patients at risk of HBV reactivation when a pre-determined International Classification of Diseases (ICD)-10 code is entered into the hospital's database or immunosuppressive treatment is prescribed. The system evaluates the prior Hepatitis B Surfage Antigen (HBsAg) and anti-Hepatitis B Core Immunglobulin G (HBc IgG) results and sends an alert code to the clinician for screening if serology is not completely available or consult a specialist in case of positive serology. The HBV screening and consultation rates of patients before (control group) and after HBVision2 were retrospectively compared. The clinical course of unscreened and/or unconsulted patients was determined, and the clinical efficacy of HBVision2 in preventing HBVr was predicted. RESULTS: Control group included 815 patients (52.6% male, mean age: 60 ± 12, 82.5% with oncologic malignancy) and study group included 504 patients (56% male, mean age: 60 ± 13, 91.4% with oncologic malignancy). Groups were similar with respect to gender, mean age, and HBVr risk profile of the immunosuppressive treatment protocols. Overall, both HBsAg (from 55.1% to 93.1%) and anti- HBc IgG screening rates significantly increased (from 4.3% to 79.4%) after the electronic alert system (P < .001, for both). Consultation rates of anti-HBc IgG-positive patients significantly increased from 40% to 72.7% (P = .012). HBVr developed in 2 patients (2.6%) who were not screened and/or consulted after the alert system. Alert program prevented the development of HBVr in 10 patients (1.9%) of the study group and decreased the development of HBVr by 80%. CONCLUSION: Electronic alert system significantly improved HBsAg and anti-HBc IgG screening rates before starting immunosuppressive treatment and prevented the development of HBVr to a great extent. However, screening rates are still below optimal and need to be improved.

Validation of the Revised Atlanta Criteria in determining the severity of acute pancreatitis.

BACKGROUND/AIM: Determining the severity of acute pancreatitis (AP) is crucial for patient management. The aim of our study was to assess the accuracy and limitations of the Revised Atlanta Criteria (RAC) in determining the severity of AP. MATERIALS AND METHODS: The study was retrospectively conducted on AP patients admitted to the Gastroenterology Department of Sakarya University Faculty of Medicine. The severity, morphology and local complications of AP were evaluated according to the RAC. Laboratory parameters, clinical scores predicting disease severity and Computer Tomography Severity Index scores were assessed. RESULTS: The study group included 113 patients. Ninety-eight (86.7%) had interstitial edematous, and 15 (13.3%) had necrotizing pancreatitis. AP pancreatitis was mild in 69 (61.1%), moderate in 33 (29.2%), and severe in 11 (9.7%). Compared to the moderate group, patients in the severe group had a higher hematocrit, creatinine, SIRS and BISAP scores at admission and more length of hospital stay, more ICU requirements, and higher mortality rates ( P  < 0.05). Eleven patients had single or multiple persistent organ failure (POF). The mortality rate of patients who developed early POF (n = 6) was higher compared to the group of patients who developed late POF (n = 2) (83.3% and 40%, respectively). CONCLUSION: Severity assessment using the RAC in patients with AP is consistent with laboratory parameters and scoring systems predicting severity. Severe pancreatitis cases who develop early POF may be classified separately.

Higher Complications During the Waiting Period for Interval Cholecystectomy in Patients With Mild Biliary Pancreatitis.

BACKGROUND: Although current guidelines recommend cholecystectomy during the same admission in patients with mild acute biliary pancreatitis (ABP), it involves a waiting list most of the time. We aimed to assess the risk of complications and determine predictors during the waiting period for cholecystectomy after the first episode of ABP. METHODS: A prospective observational study was conducted in patients with mild ABP. Follow-ups were done by phone calls or using electronic health records for a maximum of 6 months after discharge or until cholecystectomy. RESULTS: A total of 194 patients were included in the study. Although all patients were referred to surgeons, only 81 (41.8%) underwent cholecystectomy within 6 months after discharge. During the observation period, gallstone-related biliary events (GRBEs) developed in 68 (35.1%) patients, which included biliary colic, recurrent ABP, acute cholecystitis, choledocholithiasis, gallbladder perforation, cholangitis, and liver abscess. The overall readmission rate was 25.2%, with 44.8% occurred within 4 weeks after discharge. The odds ratio of any complication was 1.58 (95% CI, 1.42 to 1.76, P =0.028) and 1.59 (95% CI, 1.42 to 1.78, P =0.009) in the patients who did not have surgery within 2 to 7 days and 8 to 15 days, respectively. A 4-fold increased risk of readmission was detected (95% CI, 1.16 to 13.70, P =0.019) if cholecystectomy was not performed within 31 to 90 days. The patients who developed complications had significantly higher C-reactive protein at admission, longer waiting time, and had 3 or more gallstones on imaging. CONCLUSIONS: Interval cholecystectomy was associated with a high risk of complications during the waiting period in patients with mild ABP.

Can neutrophil-lymphocyte ratio predict mortality in acute non-variceal upper gastrointestinal bleeding?

BACKGROUND: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the common gastrointestinal problems and has a high mortality, especially in patients with poor hemodynamics. Therefore, treatment and follow-up should be managed dy-namically. Neutrophil-lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are fast workable, cheap, and easy to calculate he-matological parameters. We need easily accessible parameters as well as routine classifications such as Rockall score in the treatment and follow-up of NVUGIB patients, whose hemodynamics are unstable and progress with high mortality. In this study, we planned to evaluate NLR and PLR levels in patients with NVUGIB in the treatment follow-up with other scoring systems and their relationship with mortality in these patients. METHODS: Two hundred and forty-nine patients who were admitted to our clinic between January 2015 and January 2017 diag-nosed with NVUGIB, and who underwent necessary examinations and follow-ups, were included in the study. The patients' Glasgow Blacthford, Rockall Score, NLR, and PLR levels were calculated at the first admission. RESULTS: One hundred and fifty-six of the patients were male (70.6%) and the mean age of all patients was 64.5±18.0 years. After follow-up and treatment, 28 (11.2%) patients died due to bleeding. High NLR and tachycardia at the time of admission and high patient age were found to be independent risk factors affecting the long of hospital stay. High Rockall score, high NLR at admission, and hy-potension at admission were shown to be independent risk factors affecting mortality. CONCLUSION: Besides the use of various scoring systems in patients with NVUGIB, we think that the use of simple hematological parameters may be appropriate and the use of these hematological parameters may be useful in the management of patients with unstable hemodynamics.

A Simple Method for Endoscopic Treatment of Large Gastric Phytobezoars: "Hand-Made Bezoaratome".

BACKGROUND: Large gastric phytobezoars are generally resistant to standard chemical or endoscopic treatments. We presented our experience of an alternative endoscopic method using a hand-made tool called a "hand-made bezoaratome" for the treatment of large gastric phytobezoars. METHODS: Patients who consulted or who were diagnosed with gastric bezoars at an education and research hospital between January 2015 and December 2018 were prospectively included in the study. Patients with phytobezoars of 50 mm and larger were included in the study. Patients with trichobezoars, lactobezoars, pharmacobezoars, under 18 years of age, and pregnant women were excluded. A 0.25 mm diameter guidewire and a mechanical lithotripter sheath were used to prepare the "hand-made bezoaratome." After the first procedure, patients were advised to consume 2500 mL of Coca Cola® or the same amount of pineapple juice per day, until the next procedure. Endoscopic procedures were performed at 5-day intervals until complete reabsorption of the bezoar was achieved. Patients were followed up for 6 weeks. RESULTS: The study group included 37 (21 males, mean age: 57.6 ± 12.5 years) patients. The median size of the phytobezoars was 71 mm (50-90). The median endoscopic procedure time was 853 s (380-1940 s). The success rate for endoscopic fragmentation was found to be 100%. No major complications occurred during the endoscopic procedures, but 1 patient (2.7%) required surgery for ileus due to an obstruction at the distal part of the jejunum, 61 h after the second endoscopic session. The overall success rate of the endoscopic treatment was 97.3%. CONCLUSION: Using a "hand-made bezoaratome" is effective and reliable for the endoscopic treatment of large gastric bezoars.

The Importance of Eosinopenia for Predicting Treatment Response in Patients with Cholangitis.

OBJECTIVE: To compare recovery of eosinopenia, C-reactive protein (CRP) and procalcitonin levels in predicting the response to treatment in patients with cholangitis. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Department of Gastroenterology, Sakarya Training and Research Hospital, Turkey between September 2018 and February 2019. METHODOLOGY:  Patients with cholangitis, who underwent endoscopic retrograde cholangiopancreatography (ERCP), were inducted. Those with choledocholic thiasis alone were considered controls. Eosinophil count above 100.5 cells/µL was the limit value accepted as improvement. ERCP repeat was decided according to eosinophil count below 100.5 and not clinically improving. Relationship between inflammatory markers such as CRP, procalcitonin and eosinopenia values in patients with stone-associated cholangitis was investigated. RESULTS: The cholangitis group was comprised of 62 patients [mean age 67±14.57 years; 26 (41.9%) female], while control group was comprised  of 57 patients [mean age 57.4±18.10 years; 39 (68.4%) females, p=0.004]. At time of admission, median eosinophils was significantly lower in cholangitis group at 17.50 [9.82-84] ×103/µL compared to control group at 168 [100.11-270] ×103/µL (p=0.001). ERCP were repeated on two patients as their clinical conditions and unremitting eosinophil counts worsened. Eosinophil and CRP markers and clinical improvement were observed after  second ERCP procedure. CONCLUSION: Eosinopenia may be used as inflammatory marker in  evaluation of response to treatment and for predicting the need to repeat ERCP during clinical follow-up of patients who undergo cholangitis treatment. Key Words: Cholangitis, C-reactive protein, Endoscopic retrograde cholangiopancreatography, Eosinopenia, Procalcitonin.

Fully Covered Self-Expandable Metal Stens eliminate surgical repair requirement in both endoscopic sphincterotomy and precut sphincterotomy-related perforation (with video).

OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations occur in 0.3-0.6% of patients. The treatment of retroperitoneal paravaterian perforations (type II), which develop during endoscopic sphincterotomy or precut sphincterotomy, remains a matter of debate. We aimed to evaluate the efficacy of fully covered self expandable metal stent (Fc-SEMS) placement in the treatment of type II perforations. METHODS: The study was conducted in a tertiary ERCP reference center of Turkey between December 2013 and June 2016. Patients with type II ERCP-related perforation constituted the study group. Type II perforations were treated by insertion of an Fc-SEMS (10 mm × 60 mm) during the ERCP procedure or intraoperatively by surgery-endoscopy rendezvous technique, if biliary cannulation could not be achieved. RESULTS: A total of 2689 ERCPs were performed. ERCP-related perforation was observed in 12 procedures (0.4%). Eight patients had Stapfer type II perforations, which developed during endoscopic sphincterotomy in seven patients and precut sphincterotomy in one patient. Fc-SEMSs were inserted during the ERCP procedure in seven patients and intraoperatively by surgery-endoscopy rendezvous technique in one patient. None of the patients developed fever, hemodynamic instability, or peritoneal signs. Stents were removed after a median duration of 9 (3-14) days. All of the patients were uneventfully discharged after an average hospital length of stay of median 5 (1-9) days. CONCLUSION: Fc-SEMSs are highly effective in the nonoperative treatment of type II perforations and their intraoperative insertion in patients with unsuccessful cannulation may facilitate surgery by eliminating the need for duodenum repair surgery.