Endoscopic treatment of biliary complications in donors after living donor liver transplantation in a high volume transplant center.

BACKGROUND/AIMS: Although living donor liver transplantation (LDLT) has been accepted as a primary treatment for adults with end-stage liver disease, concerns about donor health have been emerged. As LDLT is technically complex, it creates perioperative morbidity and mortality risk in donors. Biliary complications such as stricture and leakage are seen most frequently in donors after liver transplantation. While some of these complications get treated with conservative approach, endoscopic, surgical, and percutaneous interventions may be required in some others. We aimed to present endoscopic retrograde cholangiography (ERC) results in donors who developed biliary complications after LDLT. MATERIALS AND METHODS: Between June 2010 and January 2018, a total of 1521 donors (1291 right lobe grafts, 230 left lobe grafts) of patients who underwent LDLT, were retrospectively reviewed. 63 donors who underwent ERC due to biliary complication, were included in the study. RESULTS: Biliary stricture was found in 1.6% (25/1521), biliary leakage in 2.1% (33/1521), and stricture and leakage together in 0.3% (5/1521) donors. Our endoscopic success rates in patients with biliary leakage, biliary stricture, and stricture and leakage were 85% (28/33), 92% (23/25), and 80% (4/5), respectively. Surgical treatment was performed on 12.6% (8/63) donors who failed ERC. CONCLUSION: We found that ERC is a successful treatment for post-LDLT donors who have biliary complications.

A mitochondrial neurogastrointestinal encephalomyopathy with intestinal pseudo-obstruction resulted from a novel splice site mutation.

Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is an autosomal recessive disorder characterized by gastrointestinal dysmotility, cachexia, ptosis, peripheral neuropathy and leukoencephalopathy. The diagnosis is often not made until 5-10 years after the onset of symptoms. MNGIE is caused by mutations in thymidine phosphorylase gene TYMP. Here, we present a 19-year-old boy with MNGIE who had a chronic intestinal pseudo-obstruction, and we describe his family history. Genetic analysis revealed a novel homozygous c.765+1G>C intronic mutation which is expected to disrupt splicing of TYMP in the patient. Family screening revealed that the brother was also affected and the mother was a carrier. MNGIE should be considered and genetic testing instigated if individuals with cachexia have neuromuscular complaints or symptoms of chronic intestinal pseudo-obstruction.

Alterations in the pulmonary function tests of inflammatory bowel diseases.

BACKGROUND/AIMS: We aimed to determine the changes in the pulmonary function tests of the patients with inflammatory bowel diseases. METHODS: Forty inflammatory bowel dieases patients; 30 ulcerative colitis and 10 Crohn's disease, and ageand sex-matched control group, consisting of 30 healthy persons, were included in the study. Disease activity in patients with ulcerative colitis was assessed by Truelove and Witts Criteria and in Crohn's disease patients by Chron's Disease Activity Index. RESULTS: Pulmonary function tests were found abnormal at least in one parameter in 17/30 ulcerative colitis patients (56%) and in 5/10 Crohn's disease patients (50%) in the activation period and in 5/30 ulcerative colitis patients (17%) and in 2/10 Crohn's disease patients (20%) in the remission period of the diseases of the same patients. Forced vital capacity, first second, residual volume/total lung capacity, diffusing capacity of the lung for carbon monoxide and diffusing capacity of the lung for carbon monoxide per liter alveolar volume values were found significantly impaired in the activation period in comparison with the values of the same patients in the remission period (p<0.01). It was found that pulmonary function test values in patients with inflammatory bowel dieases were not affected by either the type of disease or treatment with 5-aminosalicylic acid. However, they were affected notably by the disease activity. CONCLUSION: Pulmonary function test abnormalities were found frequently in patients with inflammatory bowel dieases without presence of any respiratory symptoms and lung radiograph findings. The severity and frequency of these pulmonary function test abnormalities which were detected even in the remission periods increase with the activation of the disease. Therefore, pulmonary function test may be used as a non-invasive diagnostic procedure in determining the activation of inflammatory bowel dieases and might aid to the early diagnosis of the latent respiratory.

Hypovolemia-related gastric tissue damage in the setting of upper gastrointestinal bleeding.

BACKGROUND/AIMS: Much is known about the gastric tissue damage that is associated with hypovolemic stress, but gastrointestinal bleeding due to gastric injury and further gastric injury due to hypovolemia have not been evaluated in previous research. The aim of this study was to assess oxidative gastric tissue damage specifically linked to hypovolemia in patients with upper gastrointestinal bleeding. METHODS: The study included 30 patients who presented with acute upper gastrointestinal bleeding and 30 controls. Each patient's history and laboratory findings were recorded, and multiple biopsies of the gastric antrum were obtained at diagnostic endoscopy on admission (day 1) and five days later. A set of antral biopsies was also collected from each control subject. Each tissue specimen was analyzed for levels of glutathione peroxidase, superoxide dismutase and catalase activity, and level of malondialdehyde. RESULTS: First day glutathione peroxidase, superoxide dismutase and catalase levels were significantly lower and malondialdehyde levels were higher than on the 5th day, and 1st day and 5th day levels were significantly different from controls (p<0.05). A moderate level of correlation was detected between catalase and hemoglobin (r:-0.59) and hematocrit (r:-0.61) and between malondialdehyde and systolic blood pressure (p:0.58), hematocrit (r:0.45) and hemoglobin (r:0.49). CONCLUSIONS: In this study, gastric tissue oxidative markers showed antral oxidative changes to be significantly correlated with patients' hemodynamics. Oxidative stress may not be a clinical condition but it obviously shows gastric tissue damage and may explain many of the patients' additional diagnosis of gastric erosions. Interestingly, the oxidative change does not completely recover even on the 5th day.

Prevalence of gallstones in patients with chronic myelocytic leukemia.

OBJECTIVE: The aim of the present case-control study was to determine whether or not the prevalence of gallbladder stones (GBS) was increased in patients with chronic myelocytic leukemia (CML) and to investigate clinical and laboratory characteristics of CML patients with GBS. SUBJECTS AND METHODS: This study included 56 patients with CML and 55 sex- and age-matched healthy controls. All participants underwent abdominal ultrasonography and the main clinical and laboratory characteristics were recorded. RESULTS: Gallbladder stones were detected in 13 (23.6%) patients with CML and in 3 (5.4%) control individuals (p < 0.05). The mean follow-up period of CML patients after diagnosis was 54.6 months, range 3-120 months. Hemoglobin levels were higher in the control group than in CML patients. However, total bilirubin, unconjugated bilirubin, lactate dehydrogenase levels, leukocyte and thrombocyte counts, frequency of splenomegaly and hepatomegaly were higher in the CML than in the control group (p < 0.05). Other clinical and laboratory values were not significantly different between the groups. CML patients with and without GBS were also compared for clinical and laboratory values. Age and follow-up period of CML patients after diagnosis were higher in the CML patients with GBS (p < 0.05). CONCLUSIONS: Higher prevalence of GBS in CML patients than in healthy controls was detected. We suggest that CML may increase the frequency of GBS, apart from other well-known risk factors. This risk is probably related to increased unconjugated bilirubin, which determines hemolysis, older age and long follow-up period of CML patients after diagnosis.

The relationship between severity of liver cirrhosis and pulmonary function tests.

Pulmonary complications, mainly hepatopulmonary syndrome (HPS), are frequently observed in liver cirrhosis. In this study, the aim was to investigate the frequency of hypoxemia and impairment of pulmonary function tests (PFT) in patients with liver cirrhosis and to examine the relationships of these impairments with liver failure. A total of 39 patients with cirrhosis, 24 males and 15 females, were included in our study. The mean age of the patients was 47.5 +/- 17.2 years. Arterial blood gases, PFT, and carbon monoxide diffusion tests (DLCO) were performed in all patients. Out of 39 cirrhotic patients, 21 (53.8%) had ascites, whereas 18 (46.2%) did not. Seven patients were in the Child-Pugh A group, 21 in the Child-Pugh B group, and 11 patients were in the Child-Pugh C group. Hypoxia was found in 33.3% of the patients. Although the PaO2 and SaO2 values of patients with ascites were lower compared to those without ascites (P < 0.05), no statistically significant difference was determined in the comparison of hypoxia between the groups (P > 0.05). Among the PFT parameters, FEV1/FVC and FEF25-75% values were found to be lower in patients with ascites than those without (P < 0.05). No differences were established between these two groups of patients in terms of DLCO (P > 0.05). While no differences were found in comparison of the DLCO values in between the groups (P > 0.05), there was a statistically significant difference in the ratio of DLCO to the alveolar ventilation (DLCO/VA) in between the groups (P < 0.05). On the other hand, a negative correlation was found between the DLCO/VA and Child points when the relationship between the Child-Pugh score and PFT parameters were investigated (r = -0.371, P < 0.05). Consequently, a relationship was established between the severity of liver failure and diffusion tests showing pulmonary complications invasively. We believe diffusions tests should be performed in addition to the PFT in order to determine pulmonary involvements particularly in patients who are candidates for liver transplantation.

Pancreatic pseudocyst development due to organophosphate poisoning.

BACKGROUND/AIMS: Acute pancreatitis is a serious complication of organophosphate poisoning. There is no report in the literature dealing with the development of a pancreatic pseudocyst after complication of organophosphate-induced acute pancreatitis. Therefore, we present a case who developed pancreatic pseudocyst after complication of organophosphate-induced acute pancreatitis. METHODS: A 17-year-old female patient with a history of ingestion of complication of organophosphate insecticide (DDVP EC 550, dichlorvos) was admitted with cholinergic symptoms. On admission, serum amylase and lipase levels were high and abdominal ultrasonography showed an edematous pancreas. No etiological factor for acute pancreatitis was evident. RESULTS: We diagnosed complication of organophosphate-induced acute pancreatitis. After four weeks, abdominal abdominal ultrasonography and computerized tomography revealed a pancreatic pseudocyst of 6 cm diameter. During follow-up, the pancreatic pseudocyst size regressed to 4 cm. CONCLUSION: Complication of organophosphate poisoning can cause acute pancreatitis and its complications. Early diagnosis and appropriate treatment may reduce morbidity and mortality.

QT interval analysis in patients with chronic liver disease: a prospective study.

In previous studies, it has been shown that QT interval prolongation is related to an increased mortality rate in chronic liver disease (CLD). But QT dispersion (QTd) and its clinical significance in CLD has not been well studied. The objectives of this study were to investigate the relation between QTd and severity of the disease and determine its prognostic value in cirrhotic patients. Thirty-three consecutive patients with cirrhosis and 35 sex- and age-matched healthy subjects were studied. QT intervals and QT dispersions were measured on admission, and all intervals were corrected for heart rate according to Bazett's formula. The authors analyzed the potential relationship between QT parameters and the disease severity according to Child-Pugh classification and compared these values between survivors and nonsurvivors after a 3-year follow-up. Child-Pugh classification is used to assess liver function in cirrhosis. Corrected QT (QTc) prolongations were found in 32% of patients with cirrhosis and 5.7% of the healthy controls (p <0.001). The prevalence of increased (>70 ms) corrected QT dispersion (QTcd) was 45% in patients with cirrhosis. According to Child-Pugh criteria: QTd, maximum QT interval (QTmax), corrected QTmax (QTcmax), and QTcd in class C were significantly higher than those of class A and B (p <0.05, for all comparison). But there was no significant difference between class A and B in QTmax, QTcmax, QTd, and QTcd. There were 10 (30%) deaths from all causes during 3-year follow-up in the study group. Cox regression analysis showed that QTd and QTcd were better mortality indicators than QTmax and QTcmax, and Child's classification was the best predictor for mortality among all variables. In conclusion, QT dispersion and corrected QT dispersion parameters were better mortality indicators than other QT interval parameters and also may give additional prognostic information in patients with chronic liver disease.

Gastric tissue oxidative changes in portal hypertension and cirrhosis.

Gastric mucosal lesions are very common in portal hypertension and cirrhosis. The aim of this study was to assess for oxidative gastric tissue damage in cirrhosis and evaluate relations with portal hypertension and cirrhosis parameters. The study included 30 patients with cirrhosis and 30 controls. Each patient's history, physical examination, and laboratory findings were recorded, and multiple biopsies of the gastric antrum were obtained at endoscopy. A set of antral biopsies was also collected from each control subject. Each tissue specimen was analyzed for levels of glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) activity and level of malondialdehyde (MDA). Patients' gastric GPX, SOD, and CAT levels were significantly lower, and MDA levels were higher, than in the control group. The GPX activity level in the specimens was moderately negatively correlated with portal vein diameter (P<0.05, r=-0.45) and spleen length (P<0.05, r=-0.45). In this study gastric tissue oxidative markers showed that antral oxidative factors worsen in cirrhosis. Oxidative stress may not be a clinical condition but it obviously shows gastric tissue damage and may explain many patients' gastric lesions and hemorrhage.

Scalp ulcer as first sign of cholangiocarcinoma.

Metastases from distant primary tumors are rarely the first indicators of cancer. However, cutaneous metastases are not uncommon in cases of internal malignancy. This article describes the case of a 65-year-old man with cutaneous metastasis of cholangiocarcinoma who presented with a scalp ulcer as the only initial sign. This is only the third reported case of cholangiocarcinoma with distant cutaneous metastasis.

The relationship of heart rate variability with severity and prognosis of cirrhosis.

Many studies have demonstrated that cirrhosis is frequently associated with autonomic dysfunction. The aim of this study was to test autonomic dysfunction in cirrhotic patients by analyzing heart rate variability (HRV), to determine whether or not the degree of autonomic dysfunction is correlated with the severity of disease, and, also, to compare the changes of HRV between survivor and nonsurvivor groups after 2-year follow-up periods. HRV was analyzed using 24-hr ECG recording in 30 cirrhotic patients and 28 normal controls. The changes in HRV parameters including mean normal-to-normal (N-N) interbeat intervals (mean NN), standard deviation of all N-N intervals (SDNN), standard deviation of the average of N-N intervals for each 5-min period over 24 hr (SDANN), root mean square succesive differences (r-MSSD; msec), and percentage of adjacent N-N intervals that are >50 msec apart (pNN50), all as time domain parameters, were evaluated. The cirrhotic patients were also evaluated according to Child-Pugh classification scores as markers of the disease severity. The time-domain measures of HRV in cirrhotic patients were significantly reduced compared with those in the control group (for all parameters; P < 0.001). The severity of disease was associated with reduced HRV measures (for all parameters; P < 0.001). After the 2-year follow-up periods, HRV measurements in cirrhotic patients were significantly much lower in nonsurvivors than in survivors (P < 0.001 for all). We conclude that increasing severity of cirrhosis is associated with a reduction in HRV. This finding may be an indicator of poor prognosis and mortality for cirrhosis.

The effects of Gingko biloba extract on acetic acid-induced colitis in rats.

BACKGROUND/AIMS: Gingko biloba is an antioxidant substance which has antagonistic activity on platelet-activating factor. We aimed to investigate the antioxidant effect and the histopathologic changes caused by Gingko biloba on acetic acid-induced colitis. METHODS: Totally 22 rats were divided into three groups. Group 1 (n=7) served as the control group. Group 2 (n=7) and Group 3 (n=8) were given 2 ml/day of 4% acetic acid by intracolonic instillation for three days. Gingko biloba (100 mg/kg) was then given only to Group 3 intraperitoneally for three days. Oxidative stress was assessed by determinate tissue and serum malondialdehyde (MDA) levels, and colonic damage was assessed by histologic examination. RESULTS: Depth of necrosis, extent of necrosis, degree of inflammation, extent of inflammation, fibrosis and total histologic scores in Group 2 were significantly higher than in the control group (p<0.05). The same parameters were lower in Group 3 versus Group 2, but the difference was not significant. Tissue and serum MDA levels in Group 2 were significantly higher than Group 1 (p<0.01 and 0.05, respectively). Again, the same parameters in Group 3 were lower than in Group 2, but the difference was not significant statistically. CONCLUSIONS: Gingko biloba did not significantly affect histopathological and oxidative stress parameters in experimental colitis.

Clinical significance of pulmonary function tests in patients with acute pancreatitis.

The aim of the present study was to investigate changes in pulmonary function tests (PFTs) in patients with acute pancreatitis (AP), to compare them with those changes in healthy controls, and to analyze the relationship between these parameters and computed tomography severity index (CTSI) and Ranson's criteria scores as markers of disease severity. This study included 40 patients with AP without a diagnosis of any pulmonary disease and 40 sex- and age-matched healthy controls. All participants were evaluated with simple PFTs and single-breath carbon monoxide (CO) diffusion tests. Patients with AP were also evaluated according to their CTSI and Ranson's criteria scores as markers of disease severity. The forced vital capacity (FVC), forced expiratory volume in the first second (FEV(1)), FEV(1)/FVC, and peak expiratory flow, which determine lung capacity, were similar in the two groups. The forced expiratory volume during the middle half of the FVC (FEF(25 - 75%)), CO diffusing capacity (D(LCO)), and ratio of D(LCO) to alveolar ventilation (D(LCO)/V(A)), which determines alveolar membrane permeability, revealed a statistically significant decline in pulmonary gas exchange in patients with AP (P < 0.05). Correlation analysis showed that there is a significant negative relationship between CTSI and Ranson's criteria scores with FEF(25 - 75%), D(LCO), and D(LCO)/V(A) (P < 0.05). We suggest that AP may cause impaired alveolar gas exchange without manifest pulmonary diseases. The effect of AP on FEF(25 - 75%), D(LCO), and D(LCO)/V(A) appears to be dependent not only on the disease, but also on its severity. FEF(25 - 75%), D(LCO), and D(LCO)/V(A) may give additional prognostic information in patients with AP in the initial evaluation.

Brain natriuretic peptide and severity of disease in non-alcoholic cirrhotic patients.

BACKGROUND: Cirrhotic patients have a hyperdynamic systemic circulation. They have insidious cardiac problems besides well-known complications. Brain natriuretic peptide (BNP) relaxes vascular smooth muscle and has a portal hypotensive action. The relations between BNP levels and severity of disease, cardiac dysfunction and esophageal varices were studied in non-alcoholic cirrhotic patients. METHODS: Fifty-two non-alcoholic cirrhotic patients were evaluated for decompensation component of cirrhosis. The BNP concentration of echocardiographically examined patients was determined. RESULTS: The BNP levels were significantly higher in ascites, spontaneous bacterial peritonitis and hepatic encephalopathy history group (P = 0.033, P < 0.001, P = 0.014, respectively), but no significant difference were observed for presence of esophageal varices and bleeding history (P = 0.267, P = 0.429). A significant correlation was observed between BNP concentration and Child score (r = 0.427, P = 0.012), interventricular septal thickness (r = 0.497, P < 0.001) and left ventricular posterior wall thickness (r = 0.526, P < 0.001). According to Child-Pugh classification there were no significant difference between groups for echocardiographic measurements and blood pressure (P > 0.05), but plasma BNP levels were significantly higher in Child class B and C patients compared with class A patients (P < 0.05). CONCLUSION: Increased levels of BNP are more likely related to the severity of disease in non-alcoholic cirrhotic patients. The advanced cirrhosis is associated with more advanced cardiac dysfunction and BNP has prognostic value in progression of cirrhosis.

Memory impairment in patients with cirrhosis.

BACKGROUND AND AIM: Subclinical hepatic encephalopathy (HE) in cirrhotic patients is usually characterized by memory impairment and psychomotor slowing. Our aim was to investigate memory status in cirrhotic patients with and without clinically overt HE. MATERIAL AND METHODS: Thirty-two cirrhotic patients (10 female and 22 male) aged 49 +/- 17 years and 20 healthy subjects (six female and 14 male) aged 46 +/- 12 years were included in the study. Memory status was defined by Wechsler Memory Scale, verbal memory process and complex memory process tests. RESULTS: Grade-1 HE was detected in 7 (22%) patients with cirrhosis. We detected 36 to 92% decrement in various memory tests in cirrhotic patients without HE as compared to healthy subjects. The scores for all psychometric testing results were significantly lower in cirrhotic patients without HE as compared to healthy subjects. We detected 42.9 to 100% decrement in various memory tests in cirrhotic patients with HE than cirrhotic patients without HE. However, there was no statistical significant difference between cirrhotic patients with and without HE. There was no statistical significant difference in cirrhotic patients with Child-Pugh A, B, and C. CONCLUSION: In conclusion, memory status was influenced in which patients with cirrhosis yet has a normal mental and neurological status to routine clinical examination (subclinical HE). Occasionally, decreased memory performance may adversely affect the satisfaction and lifestyle of these patients. Therefore, subclinical HE is an important social problem.

Association of peripapillary fistula with common bile duct stones and cholangitis.

BACKGROUND: Peripapillary choledochoduodenal fistula (PCDF) is occasionally detected during endoscopic retrograde cholangiopancreatography. Cholelithiasis and biliary bougienage are two suspected causes of PCDF. METHODS: The medical records for 841 patients who underwent endoscopic retrograde cholangiopancreatography between 1993 and 2002 were reviewed for evaluation of PCDF. RESULTS: A total of 327 patients had common bile duct stones, and 16 of these had a PCDF at the papilla of Vater. None of the 16 patients had a history of pancreatitis, duodenal ulcer, or had undergone endoscopic retrograde cholangiopancreatography previously. Seven of the 16 had not undergone biliary surgery. CONCLUSIONS: This study indicates that PCDF is a relatively common complication of common bile duct stones and cholangitis. According to the present results, PCDF is more frequently associated with common bile duct stones than with biliary surgery and bougienage.

Acute pancreatitis: an obscure complication of organophosphate intoxication.

Acute pancreatitis secondary to organophosphate intoxication is a rare and generally well-course condition, but it is important to be aware of this complication for appropriate clinical management. There are a few reports about this subject in the literature, but it is believed that there are more cases than are reported for this condition. Because symptoms of toxicity can mask this severe complication, we report two cases of acute pancreatitis due to organophosphate intoxication for alerting this condition.

Two findings of portal hypertension: evaluation of correlation between serum-ascites albumin gradient and esophageal varices in non-alcoholic cirrhosis.

BACKGROUND/AIMS: Esophageal varices and serum-ascites albumin gradient (SAAG) are two major findings of portal hypertension. Recently, correlation between these two findings in patients with cirrhosis due to alcohol has been attracted attention. We aimed at evaluating whether a correlation exists between these parameters in the patients with non-alcoholic cirrhosis. METHODS: Albumin levels in the serum and ascites and esophageal varices were studied and the correlation between these parameters was assessed in 45 patients with non-alcoholic cirrhosis detected between January 2002 and June 2003. RESULTS: Thirty-two of the patients were male and 13 female. The average age of the patients was 56.3+/-12.5 years (range 22-85 years). The causative agents were found to be hepatitis B virus in 35 patients and hepatitis C virus in six patients; no etiology could be determined in the remaining four patients. Serum level of albumin was determined as 2.53+/-0.53 g/dl, ascites level of albumin as 0.42+/-0.31 g/dl and SAAG as 2.1+/-0.51. Endoscopic esophageal examination revealed first-degree esophageal varices in 15 patients, second-degree esophageal varices in 18 patients and third-degree esophageal varices in eight patients; no esophageal varices could be found in four patients. There was no correlation between the degree of the esophageal varices and serum levels of albumin (p=0.7) and SAAG (p=0.2); but a weak correlation was found between the degree of the esophageal varices and ascites levels of albumin (p=0.03, r=0.30). Furthermore, the patients were classified by their SAAG values, and their varices were then assessed. Two of four patients with SAAG values between 1.1 and 1.49 had esophageal varices, as did 13 of 15 patients with SAAG values between 1.5 and 1.99, and all of the patients with SAAG values greater than 2.0. CONCLUSION: All SAAG values were greater than 1.1 in our non-alcoholic cirrhosis cases. The correlation that has been found to exist between SAAG and esophageal varices could not be found in our patients with non-alcoholic cirrhosis. It is remarkable that most of the patients with non-alcoholic cirrhosis presenting with ascites and all of the patients with an SAAG value greater than 2.0 had esophageal varices.