On demand pancreatic stenting in chronic pancreatitis might provide good palliation of pain.

BACKGROUND AND AIM: Chronic pancreatitis (CP)-related pain is a considerable problem in gastroenterology practice that frequently requires several endoscopic interventions. We aimed to investigate the efficacy of pancreatic duct stenting performed on demand, instead of at defined intervals, for the management of the CP-related pain. METHODS: This study is a retrospective evaluation of thirteen years of data. Sixty-seven patients with CP who suffered from intractable pain were enrolled in the study. Pancreatic stenting was performed mainly with single stents according to the diameter of the pancreatic duct and width of the stricture or, less frequently, with multiple stents aiming to achieve stricture resolution. The subsequent endoscopic session was scheduled based on the patient's symptoms. RESULTS: Overall, 65 of 67 patients underwent successful pancreatic cannulation (technical success rate 97%). Fifty-seven patients with a pancreatic stenting history were still undergoing follow-up. Of these patients, 26 patients still had pancreatic ductal stents; however, the stents were removed from 31 patients. Only 8 patients (25%) required further endoscopic or surgical intervention because of the re-emergence of pain after a median stent-free period of 17 months (3-127 months). One patient with a biliary stricture and one patient with a pancreatic mass underwent surgery. Pancreatic stents remained for a median length of 14 months (3-84 months). During the follow-up period, 55 of 65 patients became pain-free or had partial pain relief (clinical success rate 84%). CONCLUSIONS: On demand replacement of pancreatic stent is feasible in patients with CP and it might provide a good palliation of CP-related pain.

Spontaneous abdominal esophageal perforation in a patient with mitochondrial neurogastrointestinal encephalomyopathy.

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an autosomal recessive multisystem disorder caused by thymidine phosphorylase deficiency. Severe denutrition is almost constant during the course of the disease which leads to severe malnutrition and requires long-term parenteral nutrition in most cases. Patients with MNGIE syndrome and chronic intestinal pseudo-obstruction have a particularly poor prognosis and they usually die around 40 years of age. Gastrointestinal perforation associated with MNGIE is extremely rare. Herein we present our unique case with MNGIE associated abdominal esophageal perforation.

Evaluation of preoperative predictors of development of pouchitis after ileal-pouch-anastomosis in ulcerative colitis.

INTRODUCTION: In this retrospective study, we aimed to evaluate preoperative predictive risk factors for development of pouchitis in the ulcerative colitis (UC) patients with ileal pouch-anal anastomosis (IPAA). METHODS: The records of UC patients who underwent IPAA surgery and were under follow-up in the inflammatory bowel disease (IBD) clinic of our hospital between January 1994 and September 2009 were retrieved. Preoperative clinical, biochemical, and endoscopic findings, as well as preoperative endoscopic activity index (EAI), preoperative disease activity index (DAI) and operative characteristics were recorded. Patients with endoscopic, histological and clinical findings consistent with pouchitis were identified. RESULTS: Out of a total of 49 patients who underwent IPAA for UC, pouchitis was identified in 20 (40.8%) of them. Overall, 37 (75.5%) patients had chronic active disease, eight (16.3%) patients had chronic intermittent disease with frequent relapses, and four (8.2%) patients had fulminant colitis prior to surgery. There was a statistically significant difference (P=0.02) among these patients for the development of pouchitis in postoperative period. The mean EAI (10.1 vs. 8.7, P=0.02) and DAI (10.0 vs. 8.6, P<0.01) in patients with pouchitis were significantly higher than that of patients who did not develop pouchitis. Multivariate analysis revealed steroid dependency (P=0.02), and a higher DAI (P=0.02) to be independent risk factors for the development of pouchitis. CONCLUSION: A more severe preoperative clinical course and steroid dependency, as well as higher endoscopic and disease activity scores may be useful as preoperative predictors of subsequent pouchitis in UC patients undergoing IPAA surgery.

Incidence of acute hepatitis B in patients with spinal cord injury.

STUDY DESIGN: Retrospective case survey. OBJECTIVE: To examine incidence and clinical characteristics of hepatitis B infection in individuals with spinal cord injury (SCI). SETTING: Inpatient clinic within a physical medicine and rehabilitation hospital specialized in rehabilitation. PARTICIPANTS: A total of 161 patients with SCI. INTERVENTIONS: Patients' records were investigated and the status of hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (HCV), anti-hepatitis B surface antigen positivity, alanine aminotransferase levels, duration of hospitalization and cost were recorded. MAIN OUTCOME MEASURES: Incidence of acute hepatitis B. RESULTS: Six patients were diagnosed with acute hepatitis B on the first hospitalization for rehabilitation. A total of 11 patients (4.2%) were HBsAg positive with a previously established diagnosis of hepatitis B virus infection, 1 patient (0.4%) was anti-HCV positive. After a follow-up of 6 months, three of the acute hepatitis B patients progressed into chronic hepatitis B stage. In acute hepatitis B patients' initiation of the rehabilitation was delayed, duration of hospitalization was increased. CONCLUSIONS: After SCI, patients are at high risk of acute hepatitis B infection. A high rate of chronicity may be associated with impaired immune response, secondary to neurological deficit. Screening and vaccination protocols may prevent the spread of the hepatitis B infection, healthcare losses and financial loss.

Concomitant Hodgkin's lymphoma and gastric adenocarcinoma: a rare coincidence.

Gastric adenocarcinomas may be seen together with colon, prostate, breast, liver, lung and gynecological malignancies as synchronous or metachronous cancer. However, Hodgkin's lymphoma (HL) is rarely diagnosed with solid tumors. Herein, a 72-year-old man with both gastric adenocarcinoma and HL has been presented. Mass lesions far away from the primary tumor in cancer patients can be not only the sign of distant metastasis but also another primary malignancy. In the English literature, synchronous gastric adenocarcinoma and HL has been rarely reported, and as far as we know, this is the third case to be reported.

Treatment of chronic delta hepatitis with lamivudine vs lamivudine + interferon vs interferon.

Chronic delta hepatitis is the most severe form of chronic viral hepatitis for which interferon (IFN) is the only available treatment. In 39 patients (25 were treatment-naïve, 14 had previously used IFN), efficacy of 1-year treatment with IFN (9 MU, t.i.w.) or lamivudine (LAM; 100 mg, q.d.) alone was compared with IFN and LAM combination (2 months of LAM to be followed by combination treatment). IFN monotherapy was given only to treatment-naïve patients. In both treatment-naïve and previous IFN users, end of treatment virological and biochemical responses were similar with IFN-LAM combination and superior to LAM monotherapy (P < 0.05). Improvement in liver histology occurred more often with IFN +/- LAM than with LAM alone (P < 0.05). In treatment-naïve patients, combination treatment was not superior to IFN monotherapy. After treatment discontinuation, virological and biochemical response rates decreased in LAM and IFN combination and IFN monotherapy. On treatment virological response at month 6 of treatment predicted sustained virological response. The results of this study suggest that addition of LAM to IFN for the treatment of delta hepatitis is of no additional value and that both treatment modalities are superior to LAM monotherapy.

A pilot study of 2 years of interferon treatment in patients with chronic delta hepatitis.

High dose interferon treatment for 1 year is the only established treatment for chronic hepatitis D, but it is associated with a high relapse rate after treatment discontinuation. In this study, patients were treated with 10 MU interferon alpha 2b, thrice weekly for 2 years. Twenty-three patients were recruited and 15 completed the 2-year treatment and 6 months follow-up periods. Treatment response was assessed biochemically [normal alanine aminotransferase (ALT)], virologically (undetectable hepatitis D virus RNA) and histologically (at least 2 point decrease in the Knodell score) at the end of treatment (EOT) and at the end of follow-up. Out of 15 patients who finished the 2-year treatment period, seven patients (47%) had a biochemical response but only two (13%) had a normal ALT after follow-up. ALT decreased from the baseline value of 143.1 +/- 121.7 (mean +/- SD) to 39.7 +/- 20.6 (P < 0.01) at EOT. Virological response was observed in six patients at EOT and in two patients at follow-up. Two patients lost hepatitis B surface antigen. Of the 12 patients with paired liver biopsies, a histological improvement was observed in eight patients. Interferon treatment leads to a complete or partial response in a substantial number of patients but 2 years of treatment does not appear to increase sustained response rates over 1 year treatment.