Best Practice Recommendations for Dysphagia Management in Intensive Care Unit (ICU): A Delphi Study from Multidisciplinary Experts in Turkey.

There is no study about all aspects of oropharyngoesophageal (OPE) dysphagia from diagnosis to follow-up in a multidisciplinary manner in the world. In order to close this gap, we aimed to create a recommendation study that can be used in clinical practice, addressing all aspects of dysphagia in the ICU in detail with the opinion of experienced multidisciplinary experts. This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-modified Delphi round via e-mail. Firstly, 15 open-ended questions were created, and then detailed recommendations including general principles, management, diagnosis, rehabilitation, and follow-up were created with the answers from these questions, Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation), and divergent consensus (not recommended).In the first Delphi round, a questionnaire consisting of 413 items evaluated with a scale of 0-10 was prepared from the opinions and suggestions given to 15 open-ended questions. In the second Delphi round, 55.4% were accepted and revised suggestions were created. At the end of the third Delphi round, the revised suggestion form was approved again and the final proposals containing 133 items were created. This study includes comprehensive and detailed recommendations, including a broad perspective from diagnosis to treatment and follow-up, as detailed as possible, for management of dysphagia in patients with both oropharyngeal- and esophageal-dysphagia in ICU.

Endoscopic retrograde cholangiopancreatography-oriented surgery for accomplished treatment of Mirizzi syndrome: a single-center experience.

BACKGROUND: Mirizzi syndrome is a gallstone disease characterized by compression of extrahepatic biliary duct with an impacted stone. Our aim is to identify and describe the incidence, clinical presentation, operative details and the association postoperative complication of Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS: The ERCP procedures were held in Gastroenterology Endoscopy Unit and retrospectively evaluated. The patients were divided into two groups, the cholelithiasis + common bile duct (CBD) stone group and the Mirizzi syndrome group. These groups were compared with the demographic characteristics, ERCP procedures, types of Mirizzi syndrome and surgical technique. RESULTS: A total of 1018 consecutive patients who underwent ERCP were scanned retrospectively. Of the 515 patients fulfilling the criteria for ERCP, 12 had Mirizzi syndrome and 503 had cholelithiasis and CBD stones. Half of the Mirizzi syndrome patients were diagnosed with pre-ERCP ultrasonography. The mean diameter of choledoc was found to be 10 mm in ERCP. ERCP-related complication rates (pancreatitis, bleeding and perforation) were the same in the two groups; 66.6% of the Mirizzi syndrome patients applied cholecystectomy and placement of T-tube surgical procedures, and there were no postoperative complications. CONCLUSION: Surgery is the definitive treatment of Mirizzi syndrome. Thus patients should have a correct preoperative diagnosis for an appropriate and safe surgery. We think that ERCP could be the best guide for this. Also, we believe that intraoperative cholangiography with ERCP and hybrid procedures for guiding surgical treatment may become an advanced treatment option in the future.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up.

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation.

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Assessment of Ankaferd Blood Stopper in experimental liver ischemia reperfusion injury

Background/aim: To investigate possible protective effects of Ankaferd Blood Stopper® (ABS) in an experimental liver ischemia reperfusion injury (IRI) model. Materials and methods: The study was carried out on 30 female rats separated into 3 groups as sham, control (IRI), and treatment (IRI + ABS) groups. In the IRI + ABS group, 0.5 mL/day ABS was given for 7 days before surgery. In the IRI and IRI + ABS groups, the hepatic pedicle was clamped for 30 min to apply ischemia. Then, after opening the clamp, 90-min reperfusion of the liver was provided. Blood and liver tissue samples were taken for biochemical and histopathological analyses. Results: Compared to the sham group, the IRI group had significantly higher levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total oxidant status (TOS), malondialdehyde (MDA), fluorescent oxidant products (FOP) and lower expression of albumin and total antioxidant status (TAS) (P < 0.05). Compared to the IRI group, the IRI+ABS group showed lower expression of AST, ALT, TOS, MDA and FOP and higher expression of albumin and TAS (P < 0.05). In the histopathological analysis, congestion scores were statistically significantly lower in the IRI + ABS group than in the IRI group. Conclusions: ABS has a strong hepatoprotective effect due to its antioxidant and antiinflammatory effects and could therefore be used as a potential therapeutic agent for IRI.

Midkine level may be used as a noninvasive biomarker in Crohn's disease

Background/aim: Crohn's disease (CD) is a kind of inflammatory bowel disease. Midkine (MDK) is an endogenous inflammatory marker. We aimed to investigate the relationship between MDK levels and inflammation and hence determine whether MDK can be used as a noninvasive biomarker in active CD. Materials and methods: Sixty-five consecutive patients over the age of 18 with CD and 36 healthy controls were included in this study. CD patients' venous blood samples were taken before treatment. Serum MDK levels were determined in human plasma samples by enzyme-linked immunosorbent assay (ELISA) method. Results: The mean age of the study patients was 44.8 ± 12.5 years, 35 patients were female, and 30 were male. Of these 65 patients, 37 had active CD and 28 were in the remission phase. MDK levels were significantly higher in active and remission CD than in healthy controls (P = 0.01, P = 0.038, respectively). Conclusion: e report that there is an association between MDK levels and CD activation, and therefore with enhanced inflammation. MDK levels were significantly correlated with inflammatory indices. In line with our findings, we suggest the theory that MDK inhibitors may be useful in treating Crohn's disease.

Effect of sevoflurane anaesthesia on nasal mask in endoscopic retrograde cholangiopancreatography: is it a preferred alternative?

Background/aim: Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation. Propofol provides adequate sedation and amnesia at subhypnotic doses, but safe guarding the patient's airway is important for preventing respiratory depression or hypoxic events. This study compared sedation levels, operator satisfaction, intraoperative and recovery characteristics using sevoflurane with nasal mask and propofol in ERCP. Material and methods: Sixty-one patients underwent ERCP (Group I: propofol, n = 31; Group II, sevoflurane, n = 30), with sedation controlled by the Ramsay sedation scale (RSS). The patients' demographic data, procedure length, overall drug dose, hemodynamic changes, duration of recovery and Aldrete scores during recovery were evaluated. In addition, satisfaction of the gastroenterologist was evaluated. Results: The mean sphincterotomy satisfaction scores were statistically significant (P= 0.043). The Aldrete scores and RSS of the groups were similar; there was a significant difference between groups at the beginning of the procedure regarding peripheric oxygen saturations and Group II's saturation levels increased during sedation. Conclusion: In ERCP, propofol infusion provides shorter recovery duration and adequate sedation levels. Sevoflurane and oxygen with a nasal mask can be chosen to generate specific anaesthesia in patients, especially for strong airway support and safety treating hypoxemic patients.

The presence of periampullary diverticulum increased the complications of endoscopic retrograde cholangiopancreatography.

BACKGROUND: The use of needle-knife fistulotomy technique in patient with periampullary diverticula (PAD) for biliary duct cannulation may lead to risk of complications. The present study aimed to investigate the association between PAD and the complications of endoscopic retrograde cholangiopancreatography (ERCP), unsuccessful cannulation rates and to determine the rates of cannulation complications using sphincterotomy and needle-knife fistulotomy. MATERIALS AND METHODS: The ERCP procedures were held in Gastroenterology Endoscopy Unit between September 2015 and October 2016 and were retrospectively evaluated. The patients were divided into two groups, a PAD group and a non-PAD group. These groups were compared regarding demographic characteristics, ERCP complications and mortality. RESULTS: A total of 827 patients fulfilling the criteria for ERCP were enrolled in the study. Of 827 patients, 164 had PAD and 663 did not have PAD (non-PAD). The success rate of cannulation was 98.8% in patients with PAD and 98.6% in patients without PAD. There was no statistical difference of cannulation types with sphincterotomy and with needle-knife fistulotomy between the two groups. Mean baseline number of guide wire cannulation attempts was 1.96±0.20 in PAD group. No complications were observed in PAD patients treated with needle-knife fistulotomy. ERCP-related complications rates (bleeding, pancreatitis, and perforation) were higher in the PAD group (P=0.007). CONCLUSION: In conclusion, there is a strong association between PAD and higher rates of cannulation complications, independent of cannulation technique. In certain situations, and in the hands of experienced endoscopists, needle-knife fistulotomy might be a feasible option for successful biliary cannulation in certain patients with PAD.

Dysphagia in myasthenia gravis: the tip of the Iceberg.

We evaluated swallowing function in patients with myasthenia gravis (MG) with or without dysphagia symptoms using different evaluation parameters and compared the results with those of healthy subjects. A total of 36 patients with MG and 25 healthy volunteers were included in the study. The subjects were classified into three groups; patients without dysphagia (group 1), patients with dysphagia (group 2), and healthy participants (group 3). The presence and severity of dysphagia, the oropharyngeal, pharyngeal, pharyngoesophageal, and esophageal phases were assessed using a screening test, manometric test, electrophysiologic studies [electroneuromyography (EMG)], fiberoptic endoscopic evaluation of swallowing (FEES), and barium swallow pharyngeal esophagography (BSPE), respectively. There was a significant difference between group 1 and group 3 in terms of BSPE (p = 0.001) and manometry tests (p = 0.001). A significant difference was found in all methods between group 2 and group 3 (p = 0.001, for all). In the comparison of the patient groups, although the number of patients with dysphagia in group 2 was significantly higher in the clinical tests (p = 0.007), FEES (p = 0.001), and EMG (p = 0.043) than in group 1, no difference was detected for BSPE (p = 0.119) and manometry (p = 0.644). Swallowing functions in patients with MG may be affected even without symptoms. This condition should be considered in their follow-up.

Boceprevir-induced Herpes Zoster.

Herpes zoster is caused by reactivation of the varicella zoster virus (VZV), that attacks peripheral or cranial nerves and result in painful cutaneous inflammation. Boceprevir is a protease inhibitor which used as a new therapeutic agent for chronic hepatitis C infection. Boceprevir associated herpes zoster is extremely rare condition. We present herpes zoster infection assosiated Boceprevir in patint with chronic hepatitis C. How to cite this article: Babali A, Cakal B, Tanoglu A, Karaahmet F, Kekilli M. Boceprevir-induced Herpes Zoster. Euroasian J Hepatogastroenterol, 2018;8(2):161-162.

A Rare and Late Postoperative Complication of Nissen Fundoplication: Mixed Hiatus Hernia.

How to cite this article: Kekilli M, Dogan Z, Karaahmet F. A Rare and Late Postoperative Complication of Nissen Fundoplication: Mixed Hiatus Hernia. Euroasian J Hepatogastroenterol, 2018;8(2):172.

Inflammatory arthritis complicated by inflammatory bowel disease: two case reports.

Coexistence of inflammatory arthritis disease and inflammatory bowel disease (IBD) is often considered to be relatively rare, and the underlying mechanisms of the association between them remain unclear. Herein, we report two cases of IBD which occurred during the course of inflammatory arthritis disease. The first case had psoriatic arthritis (PsA) for two and a half years complicated by Crohn's disease and accompanied by inactive carrier state of hepatitis B. The second case had rheumatoid arthritis (RA) complicated by ulcerative colitis four years after the onset of RA. In both cases, colonoscopy was performed, and their clinical presentations improved with a multidisciplinary approach. In the event of complaints related to the gastrointestinal tract in patients with PsA or RA, IBD should be kept in mind, and the clinical evaluation and multidisciplinary interventions should be planned to control the underlying autoimmune process.

The efficiency of endoclips in maintaining the gastrointestinal bleeding-related Dieulafoy's lesion.

BACKGROUND: Dieulafoy's lesion (DL) is a relatively uncommon medical condition characterized by a large tortuous arteriole in the submucosa of any part of gastrointestinal (GI) tract wall that bleeds via erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole. Compared with other endoscopic hemostatic techniques, clipping alone for DL is limited. AIMS: The aim of the present case series study is to identify common clinical and endoscopic features, rates of occurrence, to review the outcome of endoscopic management of upper GI tract DL, and to illustrate the use and the efficiency of endoclips in maintaining the GI bleeding due to DL. PATIENTS AND METHODS: This case series was conducted at Department of Gastroenterology, Diskapi Yildirim Beyazit Educational and Research Hospital. The patients who were admitted to the emergency department of Diskapi Yildirim Beyazit Educational and Research Hospital underwent gastrointestinal system (GIS) endoscopy between 2008 and 2013 and were assessed retrospectively. Five cases of GI bleeding related to DL were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated. RESULTS: The median number of endoscopic hemoclips application in first endoscopy was 4 (2-9). Rebleeding developed in all patients who had hemoclips applied. Re-endoscopy was performed in three of these patients, which controlled the bleeding. Two patients were transferred to surgery. CONCLUSIONS: Combination of endoscopic injection and mechanical therapies seems a suitable method for maintaining upper GIS bleeding due to DL. Also, further studies are needed to better define the best endoscopic approach for the treatment of DL.

Metastatic lung adenocarcinoma related α-Fetoprotein elevation in a patient with HBV-related cirrhosis.

HCC is the most common type of primary liver tumor. The Practice Guideline, AASLD, for HCC recommended surveillance of HBV carriers at high risk of HCC with US every 6-12 months. Laboratory surveillance option is the measurement of serum α-fetoprotein level which has long been used for the diagnosis of HCC. But, increased serum levels of α-fetoprotein are also seen in acute hepatitis, cirrhosis, and malignancies include yolk sac carcinoma, neuroblastoma, hepatoblastoma, gastric and lung carcinoma. Because of elevation α-fetoprotein in these malignancies, liver mass with an elevated α-fetoprotein does not directly indicate HCC. For these reason, clinicians evaluating patient with liver mass and HBV-related cirrhosis should be vigilant for other case of α-fetoprotein elevation.

Two gastrointestinal conditions with similar symptoms and endoscopic appearance: irritable bowel syndrome and microscopic colitis.

BACKGROUND/AIM: Irritable bowel syndrome (IBS) is a gastrointestinal condition characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any organic cause. This trial investigated the presence of microscopic colitis (MC) and associated factors related to MC in patients diagnosed with IBS. MATERIALS AND METHODS: The study group (group I) consisted of 91 consecutive patients diagnosed with IBS based on the Rome III Criteria for whom colonoscopic examination was requested. The control group (group II) had 41 patients diagnosed with IBS considered as eligible for colonoscopic investigation due to specific conditions, and for whom colonoscopic examination was recommended for screening purposes due to a familial history of colon cancer. Clinical data, endoscopic findings, and the effects of the therapy were evaluated. RESULTS: In the diarrhea-predominant IBS group, nine patients (9.89%) were diagnosed with microscopic colitis, seven with lymphocytic colitis (7.69%), and two with collagenous colitis (CC) (2.19%). None of the patients in group II were found to have MC (P = 0.007). There were no diagnoses of MC in the constipation-predominant and mixed type IBS groups. CONCLUSION: Clinicians should keep MC in mind for patients presenting with diarrhea-predominant IBS symptoms.