The safety and efficacy of ERCP in octogenarians: a comparison of two geriatric age cohorts.

BACKGROUND AND AIMS: The application of endoscopic retrograde cholangiopancreatography (ERCP) in the octogenarian population is limited. The aim of the study was to compare the clinical characteristics and outcomes of ERCP in octogenarian patients with non-octogenarian elderly patients. MATERIALS METHODS: A total of 1044 patients who underwent ERCP for the first time and are over the age of 65 were enrolled in this study. Data regarding demographic characteristics, medical history of patients, indications, technical success rate, final clinical diagnosis and complications were analyzed. 284 patients and 760 patients composed the octogenarian and non-octogenarian group, respectively. RESULTS: The mean ages in octogenarian and non-octogenarian groups were 83.99±3.85 and 71.50±4.27 years of age respectively. Both groups had similar values with regards to chronic concomitant diseases (96.6% vs. 96.5%). The most common indication of ERCP in the two groups was common bile duct stones. There was no significant difference in technical success and failure of cannulation in procedures of either group (p > 0,05). The duration of overall ERCP procedure was shorter in length in the non-octogenarian group in comparison to the octogenarian group (p = 0.004). The overall complication rate was similar in both groups (p > 0.177). The most common complication in either group was post-ERCP pancreatitis. CONCLUSIONS: ERCP is an effective and safe procedure in both octogenarian and non-octogenarian patients with naive papilla when performed by experienced endoscopists.

Unsedated transnasal versus conventional oral endoscopy in endoscopy naïve patients.

BACKGROUND AND STUDY AIMS: Unsedated transnasal upper endoscopy (TNE) has been suggested as a more comfortable and safer method than unsedated transoral endoscopy (TOE). However, the numbers of comparative trials are limited. The current study aimed to assess the tolerability, safety, and efficacy of TNE in endoscopy naïve patients. PATIENTS AND METHODS: The current study was designed as a randomized, prospective, parallel arm trial including all eligible patients referred for upper endoscopy. Patients were randomized with a 1:1 ratio to undergo either unsedated TOE using a standard endoscope or unsedated TNE using an ultrathin endoscope. Postprocedure, all patients were asked to complete a questionnaire to assess pain, discomfort, distress and tolerability using a 10 cm visual analog scale (VAS). Patients' expectations and future preferences were also determined by multiple choice questions. Endoscope insertion rate, procedure duration, and side-effects were recorded for each patient. RESULTS: Each group included 200 patients. With the exception of nasal pain, mean VAS scores were significantly lower in TNE patients when compared to TOE patients (p = 0.0001). 85% and 54.5% of patients in TNE and TOE groups, respectively, found the procedure better than expected (p = 0001). A repeat procedure was significantly more acceptable for TNE than TOE (82.4% and 60.5%, respectively). Endoscope insertion failed in 3.5% of TNE patients. Mild epistaxis was observed in 4% of TNE patients. CONCLUSION: Unsedated TNE was tolerated better in endoscopy naive patients than unsedated TOE in a large parallel arm trial.

Fascioliasis: a report of five cases presenting with common bile duct obstruction.

Fascioliasis is a zoonotic infection caused by Fasciola hepatica. It is rarely seen with icterus caused by obstruction of the common bile duct. We report five patients with obstructive jaundice due to Fasciola hepatica, who were diagnosed and managed with endoscopic retrograde cholangiopancreatography (ERCP). All cases were admitted to hospital with complaints of icterus and pain in the right upper quadrant of the abdomen; their biochemical values were interpreted as obstructive jaundice. Ultrasound and computer tomography (CT) revealed biliary dilatation in the common bile duct, but did not help to clarify the differential diagnosis. ERCP showed the presence of Fasciola hepatica in the common bile duct. After removing the flukes, the symptoms disappeared and the biochemical values returned to normal. Biliary fascioliasis should be considered in the differential diagnosis of obstructive jaundice. This report confirms the diagnostic and therapeutic role of ERCP in patients with obstructive jaundice caused by biliary fascioliasis.

Frequency of hepatitis G virus and transfusion-transmitted virus infection in type II diabetes mellitus.

The hepatitis G virus (HGV) and transfusion-transmitted virus (TTV) are recently defined hepatitis viruses that the pathogenic roles in liver diseases are still not clear. It has been well known that some hepatitis virus, such as hepatitis C, might have an affinity to pancreatic islet cells. To investigate the relationship between the newly defined hepatitis viruses and diabetes mellitus (DM), we studied the prevalence of TTV and HGV in a type 2 diabetic patient population. Serum samples of 60 patients with DM and 45 healthy volunteers as control were taken. HGV RNA and TTV DNA was investigated by polymerase chain reaction. HGV was detected in none of diabetic patients (0%) and only one in control group (2.2%). However, TTV DNA was detected in 16 patients with DM (26%) and in five controls (11%). TTV was more prevalent in diabetic patients, but the difference between groups was not statistically significant (p > 0.05). These results revealed that TTV is more common in diabetic patients than in controls. At present, we don't know if this result is only a coincidence or a sign of potential association between TTV and DM. Further studies are certainly needed to elucidate a potential relationship.

The influence of delay on perforation in childhood appendicitis. A retrospective analysis of 58 cases.

OBJECTIVE: Appendicitis is the most common non-traumatic surgical abdominal disorder in children aged 2-years or older. It is generally believed that delay in diagnosis and surgery of acute appendicitis is associated with a more advanced stage of disease and a higher morbidity. The aim of this retrospective study was to document the clinical features of acute appendicitis (AA), and to describe the factors associated with appendiceal perforation (AP) among children. METHODS: This study included 58 patients who underwent emergency appendectomy during the period January 1998 through to December 2002, Suleyman Demirel University Hospital, Isparta, Turkey. They were proven to have AA by operative findings and pathology reports, and were further included in this study. RESULTS: The preadmission delay which is mostly due to parents and post admission delay which is due to physicians other than pediatric surgeons were found as highly associative factors for AP. Perforation is unlikely in AA patients in the first 48-hours of the abdominal pain. CONCLUSION: Associated symptoms of the abdominal pain may cause delay to diagnosis. The children who have abdominal pain and associated symptoms should be consulted with a pediatric surgeon.

Doxycycline-induced pill esophagitis.

Pill-induced esophagitis is a complication seen in patients who use certain medications such as tetracycline and non-steroidal anti-inflammatory drugs. In this short report, we described five cases of doxycycline-induced esophagitis with endoscopic images. All of the patients were young or middle-aged women. Dysphagia or odynophagia with retrosternal pain were the main presenting symptoms in all cases. The observed injuries were at the middle third of esophagus with a normal surrounding mucosa. All patients had a history of swallowing the capsule with a small amount of water or in a recumbent position. Two patients with dysphagia were managed by intravenous fluid support and parenteral acid suppression. The symptoms were improved in 2-7 days after the ceasing of the drug and control endoscopies were completely normal in all cases after 3-4 weeks of admission. The drug-induced esophagitis is not rare with certain drugs and should be suspected in all patients presenting with chest pain and dysphagia. Physicians must warn the patients to take the pills and capsules with enough liquid and in the upright position.

Paget's disease of the esophagus.

We describe the case of a 72-year-old male patient who was suffering from Pagetoid spread to the esophageal mucosa from adenocarcinoma located in the distal esophagus and proximal stomach. Esophageal Paget's disease is rare. The histogenesis of extramammary Paget's disease has remained controversial. In the majority of cases, it originates from a primary esophageal tumor. In this report, we describe a patient who was suffering from esophageal adenocarcinoma and discuss the origin of extramammary Paget's disease in the light of the literature.

Prevalence of hepatitis G virus (HGV) infection in patients with chronic liver disease.

Hepatitis G virus (HGV) may cause acute and chronic infection in humans but its role in liver injury and chronic hepatitis is unclear. In this study, the prevalence of HGV was investigated in patients with chronic liver diseases in an endemic area of hepatitis B and C virus. Sixty patients with chronic liver diseases, 11 with hepatitis B virus, 44 with hepatitis C virus and 5 patients with hepatitis of unknown etiology and 60 healthy blood donors as the control were included in the study. HGV RNA was investigated by the reverse transcription polymerase chain reaction. HGV RNA was detected in none of the patients with chronic liver diseases (0%) and only one patient (1.6%) in the control group. There was no difference between the groups. This observation indicated that the prevalence of HGV is very low in patients with chronic liver diseases and healthy people in our geographical area. The role of this novel virus in the pathogenesis of chronic liver injury seems insignificant.

Serum L-selectin and P-selectin levels in lymphomas.

The migration of normal and malignant lymphoid cells is governed by specific adhesion molecules. Selectins comprise a family of adhesion receptors expressed by leukocytes, platelets and endothelial cells. In this study, the serum levels of soluble L-selectin and P-selectin were measured in patients with non-Hodgkin's lymphoma and Hodgkin's disease and found to be significantly elevated in both patient groups compared to healthy controls. This result provides evidence that alterations in the expression and function of adhesion molecules may play an important role in the progression of lymphomas. Further studies are awaited to establish the exact roles of these adhesion molecules in distinct patterns of growth and spread of lymphomas.

Circulating intercellular adhesion molecule-1 and E-selectin levels in gastric cancer.

A diversity of adhesive interactions occur between the cancer cell and host extracellular matrix which potentiate neoplastic expansion and metastatic dissemination. In miscellaneous malignant diseases, tumour progression has been observed to be associated with alterations in adhesion molecule expression. Recently, circulating soluble intercellular adhesion molecules have been identified. In this study, serum levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble E-selectin (sE-selectin) were determined in patients with gastric cancer. The study group consisted of 27 patients with previously untreated gastric adenocarcinoma. Four patients had stage II, two patients stage III and 21 patients stage IV disease according to the TNM classification. Nineteen patients had distant metastasis. The sera obtained from 18 healthy volunteers served as controls. Serum sICAM-1 and sE-selectin concentrations were determined by enzyme-linked immunosorbent assay (ELISA). In addition, we also studied other tumour-associated antigens, i.e. CEA and CA 19-9. Serum sICAM-1 levels were significantly increased in patients with gastric cancer (P < 0.0001). However, sE-selectin levels did not differ from the controls. sICAM-1 concentrations were also significantly higher in patients with distant metastasis and peritoneal spread (P = 0.0045 and P = 0.0157 respectively), whereas sE-Selectin levels were elevated only in patients with peritoneal metastasis (P = 0.033). Serum concentrations of sICAM-1 and sE-selectin correlated with CEA levels (P = 0.0013 and P = 0.003 respectively). Elevated levels of sE-selectin were associated with poorer prognosis (P = 0.0099), whereas sICAM-1 had no significant impact on survival. Our results suggest that increased sICAM-1 serum levels may reflect widespread disease and contribute directly to the progression of gastric cancer. Further investigation of the molecular mechanisms of adhesive tumour-host interactions may lead to a better understanding of the natural history of gastric cancer.

Elevated serum CA 125 concentration in patients with tuberculous peritonitis: a case-control study.

OBJECTIVES: High serum cancer antigen (CA) 125 levels have been shown to be present in patients with ovarian carcinoma, nongynecological cancers, and some benign diseases and have been used as a useful marker for monitoring patients with epithelial ovarian cancer. Although tuberculous peritonitis with elevated serum CA 125 levels is an important diagnostic problem because it may lead to misdiagnosis as ovarian carcinoma and unnecessary laparatomies, the levels of CA 125 in patients with tuberculous peritonitis has not been studied in detail. METHODS: Serum CA 125 levels in 11 consecutive patients (2 males, 9 females) with tuberculous peritonitis admitted to Hacettepe University and 20 healthy adult controls (7 males, 13 females) were studied. RESULTS: Serum CA 125 levels were found to be elevated in all patients with tuberculous peritonitis. The mean level in the study group was 316.6 IU/ml, whereas the level was 13.8 IU/ml in the control group (p < 0.0001). Serum CA 125 normalization showed a very close correlation with the response to antituberculous therapy. CONCLUSIONS: Tuberculous peritonitis must be considered in a differential diagnosis of patients with elevated serum CA 125 concentration. Correct diagnosis may prevent unnecessary laparatomies performed under the assumption of ovarian carcinoma, because it is cured completely by antituberculous therapy. Serum CA 125 level might be used as an effective marker in the diagnosis and follow-up of patients with tuberculous peritonitis.

Multiple lymphomatous polyposis.

Multiple lymphomatous polyposis (MLP) is a distinctive and particularly rare clinical type of malignant gastrointestinal lymphoma, which is classified as B-cell centrocytic non-Hodgkin's lymphoma. this rare entity has been recently reclassified as mantle cell lymphoma. We herein report three additional cases of MLP involving various segments of the gastrointestinal tract. MLP has an aggressive biologic behavior and a relatively poor prognosis and must be treated accordingly as a high-grade lymphoma with systemic chemotherapy.