Clinical and Virological Features of Acute Hepatic Exacerbations in Patients With Chronic Hepatitis B Virus Infection.

BACKGROUND AND AIM: In this study, we aimed to perform a comprehensive analysis of patients with acute hepatic flares observed during the course of chronic hepatitis B infection in order to provide early diagnosis, management, and best characterization of this unique group of hepatitis B patients. PATIENTS AND METHODS: The study was designed in a retrospective and prospective manner. Chronic hepatitis B patients with acute hepatic flares, admitted to the Department of Gastroenterology and Hepatology were enrolled in the study. Demographic, clinical, biochemical, and virological findings were recorded via pre-prepared forms. RESULTS:  The study was conducted on 125 patients. The mean age was 34.08 ± 12.68 and the male to female ratio was determined as 2.28. Over 117 patients (93.6%) had at least one symptom. The most common symptoms and signs were fatigue (81.6%), anorexia (64%), jaundice (60%), and nausea (52%). Anti-HBc immunoglobulin M (IgM) antibody was detected in 24 patients (19.2%) and serum hepatitis B virus (HBV) deoxyribonucleic acid (DNA) was positive in 107 (85.6%) patients. The most common cause of exacerbations was spontaneous hepatic flares (80.8%). CONCLUSION: According to the results of this single-center study, acute hepatic exacerbations are more common in young men. The disease usually presents with non-specific symptoms and jaundice is the most common finding. As a sign of intensive inflammation and hepatocellular injury, serum ferritin levels seem to be high. Serum HBV DNA and anti-HBc IgM positivity with elevated alpha-fetoprotein (AFP) levels are presenting features of acute hepatic exacerbations.

Clinicopathological characteristics of patients with oesophageal squamous papilloma in Turkey and comparison with the literature data: The largest case series ever reported from Turkey.

AIM: Oesophageal squamous papilloma (ESP) is a rare tumoural lesion of the oesophagus considered to have a benign course. Due to the fact that they are rare lesions, there are not many publications with large case series on ESPs in the literature. In this study, we aimed to investigate the clinical, endoscopic and histopathological characteristics of ESPs. METHODS: Reports of upper gastrointestinal endoscopies performed in the endoscopy unit within the Division of Gastroenterology of a tertiary care hospital in the Southeastern Anatolia Region of Turkey in the last 8-year period were evaluated retrospectively. Patients who were determined to have oesophageal polypoid lesions during the endoscopic procedure and were then diagnosed with oesophageal squamous cell papilloma in the histopathological examination were included in the study. RESULTS: Of 11 541 patients who underwent upper gastrointestinal endoscopy, 51 were diagnosed with a total number of 55 ESPs (0.44%). In addition, 26 of these patients (51%) were female, and the mean age of the patients at the time of diagnosis was 42.2 years. The average size of the ESPs was 3.47 mm, and the most frequent location was the middle oesophagus with 51%. No statistically significant relationship was found between the location of ESPs and gender, endoscopy indication, oesophagitis, lower oesophageal sphincter dysfunction, hiatal hernia, gastroesophageal reflux disease (GERD) and Helicobacter pylori positivity. CONCLUSION: In this study with the largest case series ever reported from Turkey, it was determined that ESPs were seen in younger ages in Turkey and were also smaller in size, which is not in agreement with the literature data. Besides, this study, in which ESPs were most frequently detected in the middle oesophagus, supports the view that GERD may not be the main factor in ESP aetiology.

Brucellosis as a rare cause of granulomatous hepatitis with hepatic and bone marrow granulomas: A case report.

Brucellosis is a zoonotic infection that may involve the liver in a variety of ways, however, data on the histopathology of liver effects in brucellosis are limited. Brucellosis is generally characterized by a high fever, joint or back pain, and hepatosplenomegaly. This report illustrates a case of granulomatous hepatitis with granulomas in the liver and bone marrow in a patient who presented with non-specific symptoms, hepatomegaly, splenomegaly, digital clubbing, and laboratory signs of intrahepatic cholestasis. Granulomas were detected in the bone marrow and hepatic specimens. The diagnosis of brucellosis was based on the isolation of Brucella mellitensis in a blood culture and serum agglutination titers of 1:640. Treatment for brucellosis led to improved laboratory and clinical findings. Brucellosis should be considered in regions where it is endemic in cases of an elevated transaminase level and related clinical findings. Brucellosis should also be considered in the differential diagnosis of intrahepatic cholestasis and/or granulomas in hepatic and bone marrow biopsies. This case report provides valuable histopathological features and detailed information of liver involvement in a case of brucellosis.

Lighter Ingestion as an Uncommon Cause of Severe Vomiting in a Schizophrenia Patient.

Background. Foreign bodies in the gastrointestinal tract are important morbid and mortal clinical conditions. Particularly, emergency treatment is required for cutting and drilling bodies. The majority of ingested foreign bodies (80-90%) leave gastrointestinal tract without creating problems. In 10-20% of cases, intervention is absolutely required. Less than 1% of cases need surgery. In this paper, we present a schizophrenia patient who swallowed multiple lighters. Case. A 21-year-old male schizophrenic patient who uses psychotic drugs presented to the emergency department with the complaints of abdominal pain, severe vomiting, and inability to swallow for a week. His physical examination revealed epigastric tenderness. A plain radiograph of the abdomen revealed multiple tiny metallic densities. Gastroscopy was performed. The lighters were not allowing the passage, and some of them had penetrated the gastric mucosa, and bezoars were observed. One lighter was extracted with the help of the polypectomy snare. Other lighters as a bezoar were removed by surgery. Conclusion. Excessive vomiting of swallowed foreign bodies in the etiology of psychotic patients should be kept in mind. Endoscopic therapy can be performed in the early stages in these patients, but in the late stage surgery is inevitable.

Cholestasis caused by Fasciola gigantica.

Fascioliasis is an infectious disease caused by the hepatic trematodes Fasciola hepatica and Fasciola gigantica. Here, we report the case of Fasciola gigantica presenting with biliary obstruction and abdominal pain that was diagnosed and treated by endoscopic retrograde cholangiography (ERCP). A 46-year-old woman presented with right upper quadrant abdominal pain and jaundice. Physical examination revealed icterus and hepatomegaly. Laboratory findings revealed an increase in liver transaminases and bilirubin. Abdominal ultrasonography showed extrahepatic and intrahepatic bile duct dilatation. The patient underwent ERCP. One live Fasciola gigantica was removed from the common bile duct by ERCP. In conclusion, fascioliasis should be considered in the differential diagnosis of obstructive jaundice, especially in endemic regions, and it should be kept in mind that ERCP plays an important role in the diagnosis and treatment of these patients. To our knowledge, this is the second case report of Fasciola gigantica treated by ERCP in Turkey.

The correlation between serum VEGF levels and known prognostic risk factors in colorectal carcinoma.

BACKGROUND/AIMS: In the present study, we analyzed serum vascular endothelial growth factor (VEGF) levels and its correlation with the other clinicopathological characteristics of patients with colorectal carcinoma (CRC). METHODOLOGY: Seventy-one patients (F/M, 29/42; Mean age +/- SD, 53.3 +/- 13.1 years) were included. The results of serum VEGF were analysed with respect to stage, gender, age, CEA, metastases and topographical tumour localization. RESULTS: Patients with stage 3-4 disease had significantly higher values of VEGF (253.41 pg/mL +/- 302.24) than patients with stage 1-2 (49.99 pg/L +/- 100.30) (P < 0.003). Patients with the primary tumour localized in the colon had no significantly higher levels of serum VEGF than patients with the primary tumour localized in the rectum (225.97 +/- 324.88 pg/mL vs. 153.76 +/- 205.66 pg/ mL, respectively, P = 0.269). The VEGF expression significantly correlated with serum CEA level (P < 0.01) and clinical stages of colorectal cancer (P < 0.01). The VEGF expression was not correlated with patients' age (P = 0.955) and gender (P = 0.740). CONCLUSIONS: The VEGF expression significantly correlated with advanced stage, and metastases but not age, gender, and tumour localization. VEGF may play an important role in the invasion and metastasis of CRC. Therefore, VEGF could be applied as prognostic markers in CRC.

Acute brucellosis associated with leukocytoclastic vasculitis and splenic infarct.

Brucellosis is globally the most prevalent multisystem infection of zoonotic origin, while it is still one of the most important public health problems in Turkey as non-pasteurised milk and dairy products are consumed. Early diagnosis is vital to prevent the possibly lethal complications caused by the disease. However, diagnosis might be delayed as the disease does not have a single and typical manifestation and presents with various symptoms of different systems. Brucellosis and associated splenic infarct have rarely been studied, there being few cases in the literature. One of the rare involvements in this disease is dermatological involvement, which has been found in less than 10 percent of brucellosis cases. In this study, we discuss a 17 year old male patient who was admitted to our hospital due to fever, abdominal pain, arthralgia and rash on legs, diagnosed with brucellosis through brucellosis tube agglutination test and found to have splenic infarct upon examination and leukocytoclastic vasculitis according to the skin biopsies in the light of the present literature.

Increased bone mineral density in patients with non-alcoholic steatohepatitis.

AIM: To determine the relationship between non-alcoholic steatohepatitis (NASH) and bone mineral density (BMD). METHODS: A total of 38 patients (25 males) with a diagnosis of histologically proven NASH and 42 healthy controls (24 males) were enrolled in the study. Demographic features, clinical findings, complete blood count and routine biochemical analysis, as well as adrenal, thyroid and gonadal functions, were recorded. Additionally, intact parathormone, 25-OH-vitamin-D3, tumor necrosis factor-α, interleukin-6, interleukin-1, insulin-like growth factor-1 and insulin-like growth factor binding protein-3 levels were measured in both groups. Furthermore, lumbar spine and femoral neck BMD of both groups were measured by the dual-energy X-ray absorptiometry (DXA) method. RESULTS: The mean age was 41 ± 12 years in the NASH group and 43 ± 11 years in the control group. Among demographic features, waist circumference was significantly larger in the NASH group compared to the control group (P < 0.019). Among laboratory parameters, serum triglyceride (P < 0.008), alanine transaminase (P < 0.0001), aspartate transaminase (P < 0.001), alkaline phosphatase (P < 0.016), gamma glutamyl transferase (P < 0.0001), ferritin (P < 0.001) and 25-OH-vitamin-D3 levels (P < 0.0001) were significantly higher in the NASH group compared to the control group. Lumbar BMD was significantly higher in the NASH group compared to the control group (1.057 ± 0.119 g/cm(2) vs 0.941 ± 0.133 g/cm(2); P < 0.001, respectively). In the NASH group, there was no significant relationship between BMD and fibrosis stage in liver biopsy. CONCLUSION: NASH increases BMD and may be related to an elevated serum 25-OH-vitamin D3 level.

The value of micro-ELISA test in the diagnosis of Fasciola hepatica infection.

OBJECTIVE: In sero-diagnosis of parasitic infection, it is essential to inspect cross-reactivity between the target parasite and other parasites in order to assess diagnostic performance. The aim of this study was to determine the cut-off value of antibody titer for diagnosis of F. hepatica (FH) infection by using the micro-ELISA and diagnostic performance of this test. METHODS: The study population consisted of the following groups: FH group (n=42), Echinococcus granulosus (EG) group (n=27) and control group (n=33). The micro-ELISA test for detection of anti-F. hepatica antibody was performed in all groups. RESULTS: The test was positive in all patients with FH, in 3 out of 27 (11%) patients with EG and in none of the control group. Mean antibody titer was significantly higher in the FH group compared to the EG group (23.8 ± 0.9 DU vs. 5.7 ± 1.2 DU; p < 0.001) and compared to the control group (23.8 ± 0.9 DU vs. 2.4 ± 0.2 DU; p < 0.001). When we used 11,5 DU as a cut-off value for sero-diagnosis of FH, the positive predictive value was 93.3%, negative predictive value was 100%, sensitivity was 100%, and specificity was 95%. CONCLUSION: Cross-reactions are an important issue in serological diagnosis of parasitic infections. The micro-ELISA test for FH antibody can not definitely discriminate fascioliasis from hydatid disease.

Increased anti-Echinococcus granulosus antibody positivity in Fasciola hepatica infection.

BACKGROUND/AIMS: Parasitic helminths express some antigen, which often accounts for serological cross-reactions. The aim of this study was to determine the prevalence of anti-Echinococcus granulosus antibody in patients with Fasciola hepatica infection using indirect immunofluorescence assay. MATERIALS AND METHODS: The study population consisted of the following groups: Fasciola hepatica group (n=22), hydatid disease group (n=22) and healthy control group (n=24). Indirect immunofluorescence assay for Echinococcus granulosus was performed in all groups. RESULTS: Indirect immunofluorescence assay was positive in all patients with hydatid disease, in 13 of 22 (59%) patients with fascioliasis and in 2 of 24 (8%) healthy subjects. The positivity rate of indirect immunofluorescence assay was significantly higher in the hydatid disease group compared to the fascioliasis group (p<0.001) and compared to the control group (p<0.001), and it was significantly higher in the fascioliasis group compared to the control group (p=0.001). Antibody titer was 1/100 in 7 patients, 1/320 in 12 patients and 1/1000 in 3 patients with hydatid disease. Indirect immunofluorescence assay was positive in 10 of 15 patients with hepatic phase and in 3 of 7 patients with biliary phase of fascioliasis. The antibody titer was 1/100 in 6 and 1/320 in 7 patients with fascioliasis. The antibody titer was 1/100 in both healthy subjects. CONCLUSIONS: Indirect immunofluorescence assay for Echinococcus granulosus may be positive in a majority of patients with Fasciola hepatica infection and in some healthy subjects.

Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients.

AIM: To identify the frequency of bacterial growth, the most commonly grown bacteria and their antibiotic susceptibility, and risk factors for bacterial colonization in bile collected from patients with different biliary diseases. METHODS: This prospective study was conducted between April 2010 and August 2011. Patients with various biliary disorders were included. Bile was aspirated by placing a single-use, 5F, standard sphincterotome catheter into the bile duct before the injection of contrast agent during endoscopic retrograde cholangiopancreaticography (ERCP). Bile specimens were transported to the microbiology laboratory in blood culture bottles within an anaerobic transport system. Bacteria were cultured and identified according to the standard protocol used in our clinical microbiology laboratory. The susceptibilities of the organisms recovered were identified using antimicrobial disks, chosen according to the initial gram stain of the positive cultures. RESULTS: Ninety-one patients (27% male, mean age 53.7 ± 17.5 years, range: 17-86 years) were included in the study. The main indication for ERCP was benign biliary disease in 79 patients and malignant disease in 12 patients. The bile culture was positive for bacterial growth in 46 out of 91 (50.5%) patients. The most frequently encountered organisms were Gram-negative bacteria including Escherichia coli (28.2%), Pseudomonas (17.3%) and Stenotrophomonas maltophilia (15.2%). There were no significant differences between patients with malignant and benign disease (58% vs 49%, P = 0.474), patients with acute cholangitis and without acute cholangitis (52.9% vs 50%, P = 0.827), patients who were empirically administered antibiotics before intervention and not administered (51.4% vs 60.7%, P = 0.384), with regard to the bacteriobilia. We observed a large covering spectrum or low resistance to meropenem, amikacin and imipenem. CONCLUSION: We did not find a significant risk factor for bacteriobilia in patients with biliary obstruction. A bile sample for microbiological analysis may become a valuable diagnostic tool as it leads to more accurate selection of antibiotics for the treatment of cholangitis.

Percutaneous Endoscopic Gastrostomy: Mortality and Risk Factors for Survival.

BACKGROUND: The present study evaluated long-term risk factors for survival in patients who have undergone Percutaneous endoscopic Gastrostomy, as well as morbidity and mortality rates. METHODS: The retrospective study included 44 patients who underwent placement of a percutaneous endoscopic gastrostomy tube at various departments at Dicle University Medical Faculty between April 2008-September 2010. RESULTS: The study evaluated 23 women (52.3%) and 21 men (47.7%), with a median age of 50 ± 20 (17 - 87) years. Median time for Percutaneous endoscopic Gastrostomy placement was 23 ± 8.3 (5 - 45) minutes per patient. Total morbidity was 15.9%, including wound infection (4), tube occlusion (1), peristomal leakage (1), and abdominal wall bleeding (1). Short-term complications were not associated with albumin level (P = 0.312).The median hospital stay was 49.34 ± 60.99 (1 - 314) days. The mean follow-up period was 13.07 ± 13.12 (1 - 41) months. The above-normal level of albumin was found to be effective on survival (P = 0.024). Mortality occurred in 18 (40.9%) patients during the follow-up. CONCLUSIONS: Percutaneous endoscopic Gastrostomy is both safe and effective in that it does not require surgical operation and it can be performed under surface anesthesia. The serum albumin level with patients who have undergone percutaneous endoscopic gastrostomyis an effective factor for survival.

Clinical presentation and management of Fasciola hepatica infection: single-center experience.

AIM: To identify the characteristic clinical, laboratory and radiological findings and response to treatment in patients with fascioliasis. METHODS: Patients who were diagnosed with Fasciola hepatica infection were included in this prospective study. Initial clinical, laboratory and radiological findings were recorded. All patients were followed until a complete response was achieved or for 6 mo after treatment discontinuation. RESULTS: Fasciola hepatica infection was diagnosed in 30 patients (24 females; mean age: 42.6 years) between January 2008 and February 2011. Twenty-two (73%) patients had hepatic phase fascioliasis, 5 patients had biliary phase, and 3 patients had biliary phase associated with acute pancreatitis. Of the 8 patients with biliary phase fascioliasis, 2 patients displayed features that overlapped with both hepatic and biliary phase. Abdominal pain and right upper abdominal tenderness were the most prominent signs and symptoms in all patients. Eosinophilia was the most prominent laboratory abnormality in both patients with hepatic and biliary phase (100% and 50%, respectively). Multiple nodular lesions like micro-abscesses on abdominal computerized tomography were the main radiological findings in patients with hepatic phase. Small linear filling defects in the distal choledochus were the main endoscopic retrograde cholangiopancreatography (ERCP) findings in patients with biliary phase. Patients with hepatic phase were treated with triclabendazole alone, and patients with biliary phase were treated with triclabendazole and had live Fasciola hepatica extracted from the bile ducts during ERCP. CONCLUSION: Fasciola hepatica infection should be considered in the differential diagnosis of patients with hepatic or biliary disease and/or acute pancreatitis associated with eosinophilia.

Fenofibrate treatment in two adults with Crigler-Najjar syndrome type II.

Crigler-Najjar syndrome type II is a rare familial disorder of bilirubin conjugation with consecutive life-long unconjugated hyperbilirubinemia. In the presence of severe hyperbilirubinemia, a fetus or an adult is at risk for neurological defects in this syndrome. This paper is the first report emphasizing details about this disorder in two patients from Turkey. The diagnosis was made on the basis of history and laboratory findings excluding other causes of unconjugated hyperbilirubinemia. Phenobarbital loading test and C bile analysis also supported the diagnosis. There was a study in the literature in which treatment with chlofibrate had been recommended in this syndrome. Based on the results of that study, we administered fenofibrate treatment to our patients for one month and analyzed serum bilirubin levels before and after this procedure. No improvement in bilirubin levels was observed in either case.