Coagulation parameters in inflammatory bowel disease.

Thromboembolic events represent a major cause of morbidity and mortality in patients with inflammatory bowel disease and they may occur both at the gastrointestinal tract and at extraintestinal sites. This study aimed to examine the alterations in coagulation parameters involved at different steps of hemostasis in patients with Crohn's disease and ulcerative colitis, in comparison with healthy individuals. Fifty-one patients with inflammatory bowel disease and 26 healthy controls were included in this study. Plasma levels of PT, APTT, AT III, plasminogen, fibrinogen, D-dimer, factor V, factor VIII, protein C, protein S, and APCR were measured and factor V Leiden mutation was examined in both patients and controls. Two patients with ulcerative colitis had a history of previous thromboembolic event. Inflammatory bowel disease was associated with significantly higher levels of fibrinogen, PT, factor V, factor VIII, plasminogen and thrombocyte. Protein S, fibrinogen, plasminogen and thrombocyte levels were associated with disease activity, depending on the type of the disease (Crohn's disease or ulcerative colitis). The coagulation abnormalities detected in this study seems to be a secondary phenomena resulting from the disease process, which is more likely to be associated with a multitude of factors rather than a single abnormality.

Can an immunohistochemistry method differentiate intestinal tuberculosis from Crohn's disease in biopsy specimens?

BACKGROUND: It is sometimes difficult to diagnose whether a patient has intestinal tuberculosis or Crohn's disease because both have similar clinical, pathologic, and endoscopic features. However, their therapies are completely different and a mistake in diagnosis can result with deterioration. Many laboratory methods for the diagnosis of tuberculosis require considerable time to receive a diagnostic result. We wanted to evaluate whether an immunohistochemical tuberculosis staining method can be helpful for faster differentiation of biopsy materials. METHODS: We used formalin-fixed paraffin-embedded histologically diagnosed small intestine (n=1), colon (n=7), skin (n=8), lung (n=5), lymph node (n=24) tuberculosis and Crohn's disease (n = 28) biopsy materials only with granulomas. Demographic characteristics like age and gender were also obtained. Pathology specimens were stained immunohistochemically with an antibody to VP-M660, targeting the 38-kDa antigen of Mycobacterium tuberculosis. RESULTS: In the M. tuberculosis group, 33/45 of patients have positive immunohistochemistry (IHC) staining (73% sensitivity, 93% specificity), whereas only two of 28 patients have positive staining in the Crohn's group (p<0.001). The positive staining with IHC was detected as 85.7, 75, 75, and 60% in colon, lymph node, skin, and lung granulomas, respectively, in M. tuberculosis patients. CONCLUSIONS: Immunohistochemical staining of biopsy specimens with anti-VP-M660 seems to be a simple and fast technique with 73% sensitivity and 93% specificity for establishing an earlier differentiation of M. tuberculosis from Crohn's disease.

Clinical characteristics of inflammatory bowel disease in Turkey: a multicenter epidemiologic survey.

AIM: To investigate the epidemiologic and clinical characteristics of inflammatory bowel disease (IBD) patients in a large multicenter, countrywide, hospital-based study in Turkey. MATERIALS AND METHODS: Twelve centers uniformly distributed throughout Turkey reported through a questionnaire the new IBD cases between 2001 and 2003. The incidence of ulcerative colitis (UC) and Crohn's disease (CD) has been reported per 100,000 people. Epidemiologic features and clinical characteristics of both diseases were analyzed. RESULTS: During the study period, 661 patients of UC and 216 patients of CD were identified. The incidence in the referral population was 4.4/100,000 and 2.2/100,000 for UC and CD, respectively. The age of the patients showed the characteristic biphasic distribution with 2 peaks between 20 and 30 and 50 and 70 years. A male predominance was observed in both diseases. A history of smoking was detected in 15.5% of UC patients and 49.3% of patients with CD. Family history was positive in 4.4% in UC and 8.3% in CD patients. Concomitant amebiasis was observed in 17.3% of patients with UC and 1.3% of patients with CD. A history of appendectomy was reported in 15% of patients with CD and only 3% of patients with UC. Both extraintestinal and local complications were more frequent in CD patients, whereas arthritis was most common in both diseases. CONCLUSIONS: IBDs are frequently encountered in Turkey. IBD incidence is lower than North and West Europe but close to Middle East in our country. The majority of IBD cases are diagnosed in young people (20 to 40 y) with predominance in males. The rate of both intestinal and extraintestinal complications in our population was low when compared with the data reported in the literature. IBD and especially UC, can coexist with amebiasis or become manifest with amebic infestation. The presence of concomitant ameba may create confusion and cause dilemmas in the diagnosis and treatment of UC.

Esomeprazole in acute and maintenance treatment of reflux oesophagitis: a multicentre prospective study.

INTRODUCTION: The aim of this study was to assess the efficacy and safety of esomeprazole 40 mg once daily (q.d.) in healing reflux oesophagitis at 4 and 8 weeks, and the efficacy of esomeprazole 20 mg q.d. for 12 weeks in the maintenance of remission. METHODS: A total of 235 patients with endoscopically proven reflux oesophagitis were enrolled in this study, which consisted of two phases (healing and maintenance therapy). Patients who showed complete endoscopic and symptomatic healing at the end of 4 or 8 weeks were switched to maintenance treatment with esomeprazole 20 mg q.d. for 12 weeks. The primary efficacy endpoint was healing of reflux oesophagitis at week 8. Secondary assessments included the proportion of patients with symptomatic relapse in the maintenance phase. RESULTS: At the end of week 8, 88% (95% life-table confidence intervals [CI]: 84%, 92%) of patients were healed endoscopically and 90.6% of the patients were asymptomatic. Patient age, gender and Helicobacter pylori status had no effect on the efficacy of treatment. During the 12-week maintenance treatment phase, symptomatic relapse ratios were 0.5%, 2.2%, and 0%, for the first, second, and third 4-week periods, respectively. The proportions of patients satisfied with treatment were 95% and 99.4% at the end of acute and maintenance treatment, respectively. The most common adverse effects were headache, upper respiratory tract infection and abdominal pain. CONCLUSIONS: Esomeprazole is effective in the healing of reflux oesophagitis, the resolution of heartburn, and in maintaining symptomatic remission. The effectiveness of esomeprazole in patients with gastroesophageal reflux disease is not affected by the presence of H. pylori.

Serum copper, ceruloplasmin and 24-h urine copper evaluations in celiac patients.

The aim of the study is to evaluate the serum copper, ceruloplasmin and 24-h urine copper levels in celiac patients. Serum copper, ceruloplasmin and 24-h urine measurements were evaluated in patients with celiac (n = 32), Crohn's (n = 25), Wilson's (n = 11) and in a healthy group (n = 35). Serum and 24-h urine zinc levels, AST, ALT, BUN, creatinine, iron, hemoglobin, hematocrit, lymphocyte, sedimentation and CRP levels were also measured. Results were evaluated statistically and significance was accepted as meaningful if P < 0.05. In celiacs, levels of urine copper were high (52 +/- 29 microg/day, P < 0.000) but serum copper was the same as in controls (105 +/- 16 microg/dl, P < 0.158). High urinary copper of celiacs were coming out in women (56 +/- 30 microg/day) and in man (33 +/- 17 microg/day, P < 0.115). Most celiacs were female (P < 0.001). Serum copper and ceruloplasmin levels in all groups were higher in women than in men and this was meaningful for serum copper in the control group (P < 0.045) and for ceruloplasmin in Crohn's (P < 0.055) and control groups (P < 0.031). Serum (70 +/- 14 microg/dl, P < 0.000) and urine zinc levels (25 +/- 15 microg/dl, P < 0.039) of celiacs were low. Ceruloplasmin levels were higher in celiacs (337 +/- 64 U/1) and Crohn's patients (366 +/- 47 U/l, P < 0.000). Correlations observed in the groups of celiac (P < 0.029) and Crohn's (P < 0.024), celiac and Wilson's (P < 0.001) and Crohn's and Wilson's (P < 0.001) between the ceruloplasmin and 24-h urine copper parameters. AST and ALT levels were higher in celiac and Wilson's patients than in Crohn's patients and controls. Mean CRP levels were significantly higher in Crohn's than others. Lymphocyte counts were meaningfully higher in celiacs. Statistically, while mean iron, hemoglobulin and hematocrit levels of celiac and Crohn groups were meaningfully lower than the normal and Wilson's group, it was similar in Wilson's and the control group. Serum copper (85 +/- 26 microg/dl, P < 0.158) and ceruloplasmin (219 +/- 83 U/l, P < 0.001) levels were low and 24-h urine copper levels were high (415 +/- 346 microg/day) in Wilson's group. Increased urinary loss may be another cause of copper deficiency in female celiacs besides malabsorption and this topic needs more investigation. Increased urinary copper levels in celiac women should not always be regarded as a diagnosis of Wilson's disease.

1007fs, G908R, R702W mutations and P268S, IVS8+158 polymorphisms of the CARD15 gene in Turkish inflammatory bowel disease patients and their relationship with disease-related surgery.

INTRODUCTION: CARD15 gene mutations may present different frequencies in populations and sometimes surgical interventions may become a necessary therapy for inflammatory bowel disease patients. Mutations of 1007fs, G908R, R702W and polymorphisms of P268S, IVS8+158 of the CARD15 gene and their relation with disease-related surgery were investigated in Turkish inflammatory bowel disease patients in this study. MATERIAL AND METHOD: 1007fs, G908R, R702W mutations and P268S, IVS8+158 polymorphisms of CARD15 gene were analyzed in 130 inflammatory bowel disease patients (67 Crohn's disease, 63 ulcerative colitis) and 87 healthy controls. After obtaining DNA samples, genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. Results were evaluated by statistical analysis and accepted as significant if P < 0.05. RESULTS: R702W gene mutation was significantly lower in the inflammatory bowel disease group (1.5%) than the controls (4.8%) (P < 0.05). The overall allele frequency of mutations in the inflammatory bowel disease group (2.7%) was lower than in controls (6.6%) (P < 0.05). Disease-related surgery history was present in 20 Crohn's and 25 ulcerative colitis patients; familial history was present in four Crohn's and five ulcerative colitis patients. Statistically, no relationship was detected between disease-related surgeries and the investigated genetic tests. CONCLUSION: In Turkish patients, no important relationship was detected between the investigated allele frequencies of the CARD15 gene and inflammatory bowel disease nor between disease-related surgeries and inflammatory bowel disease.

Cyclooxygenase-2 expression in gastroenteropancreatic neuroendocrine tumors.

BACKGROUND/AIMS: The aim of this multicenter study was to investigate cyclooxygenase-2 protein expression in gastroenteropancreatic neuroendocrine tumors and to examine the relationship to various clinicopathological parameters. METHODOLOGY: Thirty-seven gastroenteropancreatic neuroendocrine tumor specimens were analyzed immunohistochemically. Correlations between expression and some parameters such as age, sex, tumor size, location, presence of multiple neuroendocrine tumor, lymphatic/vascular/muscularis propria invasion and lymph node metastases were evaluated. Results were interpreted as significant if p < 0.05. RESULTS: Mean age of patients (15 men/22 women) was 52 +/- 17. Tumor size varied between 0.1 and 12 cm. (mean; 3.17 +/- 3.29 cm). Expression was detected in 75% of cases and in 92% of gastric neuroendocrine tumors. Expression in mixed endocrine and non-endocrine carcinomas was found to be significantly higher than in well-differentiated neuroendocrine tumors and carcinomas (p = 0.016). A relationship was observed between overexpression and lymphatic and vascular invasion (p = 0.029). However, no significant correlation was found between expression and sex, tumor location, size, muscularis propria invasion and lymph node metastasis. CONCLUSIONS: Cyclooxygenase-2 expression may play a role in the evolution of gastroenteropancreatic neuroendocrine tumors. However, further studies are necessary to determine the importance of this role, prognostic relevance and whether cyclooxygenase isoenzyme can be a target for treatment in these tumors.

Pit pattern type analyses of colon polyps with high-resolution colonoscope.

BACKGROUND/AIMS: Correlations among pit pattern types and some characteristics of colon polyps were assessed with high-resolution colonoscope in Turkish patients. METHODOLOGY: Sixty-five patients were included in the study. All visible polyps and distal 30cm of colon were stained with indigo carmine 0.4% after standard colonoscopic examination. Then, pit pattern analyses were done. Correlations were evaluated and results were interpreted as significant if p < 0.05. RESULTS: There were correlations among the pit pattern types of polyps and their size, location, morphology and histology. Adenomatous polyps (type III,IV,V) were mostly located in the right colon, nonadenomatous polyps (type I/II) were mostly in the left. Ratio of having adenomatous structure increased in a parallel course with increase in polyp's size. While most of the nonadenomatous polyps were with type I,II, adenomatous polyps were with type III, IV, V patterns. Most of the type II, III, IV polyps were sessile and type I polyps were flat. Sensitivity and specificity of adenomatous and nonadenomatous polyps were 80% and 89% respectively and overall accuracy rate was 87%. Type III/IV were the best estimated type among the others. After chromoendoscopy, 35% increase in polyp number was also detected. CONCLUSIONS: High-resolution endoscope is successful for prediction of histology of colorectal polyps.

The effectiveness of lamivudine treatment in cirrhotic patients with HBV precore mutations: a prospective, open-label study.

In this study, the effect of lamivudine therapy on viral suppression, Child-Pugh score, and survival was assessed in patients with decompensated cirrhosis due to precore mutant hepatitis B virus and the results were compared with those for nonreplicative cirrhotic patients. Twenty-three replicative patients who received lamivudine and 15 nonreplicative patients were included and followed up for an average of 23.7+/-13.4 months. At baseline, there were no significant differences between the groups with regard to clinical and biochemical parameters or Child-Pugh scores, except for serum alanine aminotransferase levels (P<0.05) and quantitative hepatitis B virus DNA measurements (P<0.001). Compared to baseline, there was no significant difference in Child-Pugh score in the lamivudine group at the last visit (P=0.202), whereas a marked increase was observed in nonreplicative patients (P=0.002). Mortality rates in the lamivudine and nonreplicative groups were 17.43% and 13.3%, respectively (P=0.556), and there was no difference in survival analysis (P=0.809). Lamivudine therapy stabilizing clinical situation in decompensated cirrhotics with precore mutation makes the natural history of the disease equal with nonreplicative decompensated cirrhotics or even provides some advantages over them.

Relationship between Helicobacter pylori status and serum pepsinogens as serologic markers in atrophic gastritis.

BACKGROUND/AIMS: Serum pepsinogen levels are considered as a non-endoscopic blood test in the diagnosis of atrophic gastritis. The objective of the present study was to investigate whether there is any difference between pepsinogen levels in Helicobacter pylori-positive and -negative patients with atrophic gastritis, and to analyze the relationship between histopathology and pepsinogen levels after treatment in H. pylori-positive patients with atrophic gastritis. METHODS: The study enrolled a total of 30 cases with atrophic gastritis (18 H. pylori-positive and 12 H. pylori-negative). The H. pylori-positive cases received a one-week eradication treatment. Initially for all and after the treatment for H. pylori-positive cases, serum pepsinogen I and II levels, anti-H. pylori IgG titration and histopathologic analysis were carried out. RESULTS: In the H. pylori-positive patients with atrophic gastritis, the levels of pepsinogen I and pepsinogen I/II ratio were lower while the levels of pepsinogen II were higher compared to the H. pylori-negative patients (p<0.05 for all). The post-treatment serum pepsinogen I levels and pepsinogen I/II ratios did not change in the H. pylori-positive group, while the levels of pepsinogen II, H. pylori antibody titration and gastric atrophy degree remarkably decreased (p<0.05 for all). CONCLUSIONS: In atrophic gastritis, the levels of serum pepsinogen and pepsinogen I/II ratio show a difference in H. pylori-negative versus -positive cases. Additionally, the usage of pepsinogen II as a serum marker in predicting the eradication of H. pylori with atrophic gastritis could be more reliable than pepsinogen I or the I/II ratio.

Risk factors associated with gallstone and biliary sludge formation during pregnancy.

AIM: To define the risk factors in gallstone and sludge formation, and to investigate the incidence of gallstone and biliary sludge formation during pregnancy in a group of healthy pregnant women. METHODS: Sixty-nine healthy pregnant women in early gestation and 28 nulliparous healthy controls were enrolled. Gallbladder volumes, gallbladder ejection fraction (GBEF), serum triglyceride and cholesterol levels were determined in both groups. In the pregnant group, repeated measurements were performed immediately after delivery and compared with initial levels. Risk factors, which are associated with gallstone and biliary sludge development during pregnancy, were determined by linear regression analysis. RESULTS: No statistically significant difference was observed in the assessed parameters of pregnant women in early gestation and controls (both P > 0.05). In the pregnant group, gallstone and biliary sludge development during pregnancy were detected in 6.3% and 10.9% of cases, respectively. The detected parameters were significantly higher early after delivery than in early gestation, while GBEF was lower (both P < 0.001). Lower GBEF was the most significant factor (P < 0.001) associated with gallstone and sludge formation during pregnancy, while multiple childbirths was the other (P = 0.04). CONCLUSION: Decrease in GBEF is the most significant risk factor for newly developed gallstone and sludge in pregnant women, while multiple childbirths is the other but less important risk factor.

Clinical presentation of abdominal tuberculosis in HIV seronegative adults.

BACKGROUND: The accurate diagnosis of abdominal tuberculosis usually takes a long time and requires a high index of suspicion in clinic practice. Eighty-eight immune-competent patients with abdominal tuberculosis were grouped according to symptoms at presentation and followed prospectively in order to investigate the effect of symptomatic presentation on clinical diagnosis and prognosis. METHODS: Based upon the clinical presentation, the patients were divided into groups such as non-specific abdominal pain & less prominent in bowel habit, ascites, alteration in bowel habit, acute abdomen and others. Demographic, clinical and laboratory features, coexistence of pulmonary tuberculosis, diagnostic procedures, definitive diagnostic tests, need for surgical therapy, and response to treatment were assessed in each group. RESULTS: According to clinical presentation, five groups were constituted as non-specific abdominal pain (n = 24), ascites (n = 24), bowel habit alteration (n = 22), acute abdomen (n = 9) and others (n = 9). Patients presenting with acute abdomen had significantly higher white blood cell counts (p = 0.002) and abnormalities in abdominal plain radiographs (p = 0.014). Patients presenting with alteration in bowel habit were younger (p = 0.048). The frequency of colonoscopic abnormalities (7.5%), and need for therapeutic surgery (12.5%) were lower in patients with ascites, (p = 0.04) and (p = 0.001), respectively. There was no difference in gender, disease duration, diagnostic modalities, response to treatment, period to initial response, and mortality between groups (p > 0.05). Gastrointestinal tract alone was the most frequently involved part (38.5%), and this was associated with acid-fast bacteria in the sputum (p = 0.003). CONCLUSION: Gastrointestinal tract involvement is frequent in patients with active pulmonary tuberculosis. Although different clinical presentations of patients with abdominal tuberculosis determine diagnostic work up and need for therapeutic surgery, evidence based diagnosis and consequences of the disease does not change.

Child-Pugh classification dependent alterations in serum leptin levels among cirrhotic patients: a case controlled study.

BACKGROUND: As anorexia and hypermetabolism are common in cirrhosis, leptin levels may be increased in this disease. In this study, we investigated the relation between the severity of disease and serum leptin levels in post-hepatitis cirrhosis and the role of body composition, gender and viral aetiology of cirrhosis in this association. METHODS: Thirty-five cases with post-hepatitis cirrhosis and 15 healthy controls were enrolled in this study. Body composition including body mass index, body fat percentage and body fat mass were determined. Serum leptin levels were assayed. RESULTS: Leptin levels were significantly higher among cirrhotic patients independent of sex compared to controls (p = 0.001). Female patients in both groups have had higher leptin levels than males (in cirrhotics p = 0.029, in controls p = 0.02). Cirrhotic patients in each of A, B and C subgroups according to the Child- Pugh classification revealed significantly different levels compared to controls (p = 0.046, p = 0.004, p = 0.0001, respectively). Male cirrhotics in Child-Pugh Class B and C subgroups had significantly higher leptin levels compared to male controls (p = 0.006, p = 0.008). On the other hand, female patients only in Child Pugh class C subgroup have had higher levels of serum leptin compared to controls (p = 0.022).Child-Pugh classification has been found to be the sole discriminator in determination of leptin levels in cirrhotics by linear regression (beta: 0.435 p = 0.015). CONCLUSION: Serum leptin levels increase in advanced liver disease independently of gender, body composition in posthepatitic cirrhosis. The increase is more abundant among patients that belong to C subgroup according to the Child- Pugh classification.

Malposition of internal organs: a case of situs ambiguous anomaly in an adult.

Situs ambiguous anomaly is a rarely encountered condition in clinical practice that is characterized by the presence of multiple congenital anomalies relevant to intraabdominal organs and the cardiovascular system. While this syndrome is mostly diagnosed as a serious cyanotic cardiac disease in the first year of life, only 5% may survive beyond five years of life, and it can be a diagnostic challenge. In this report, we present an adult case of situs ambiguous anomaly which was diagnosed incidentally. The patient had centrally located liver, multiple splenules, interrupted inferior vena cava with azygos continuation, and bilateral bilobed lungs. Furthermore, she had a history of an atrial septal defect operation 20 years previously. These congenital anomalies were found to be compatible with situs ambiguous anomaly (its polysplenia variant). The interesting points of this patient are that she reached an advanced age without complaint in spite of congenital heart disease, and that the diagnosis was made incidentally during routine examination.