Massive lower gastrointestinal bleeding associated with solitary rectal ulcer in a patient with Behçet's disease.

Solitary rectal ulcer syndrome is a rare benign disorder that has a wide range of clinical presentations and variable endoscopic findings which makes it difficult to diagnose and treat. The clinical and endoscopic picture in this condition can also mimic malign ulceration, malignancy or Crohn's disease. Behçet's disease can affect the gastrointestinal tract. However to the best of our knowledge, no case with solitary rectal ulceration has been reported so far in literature. We herein present a patient diagnosed with Behçet's disease admitted to our clinic with rectal bleeding due to solitary rectal ulceration.

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.

Liver abscess: a rare but an important complication that must be considered in Crohn's disease.

Liver abscess is a quite rare complication in Crohn's disease. Early diagnosis and differentiation of pyogenic abscess from amoebic abscess are as important as the choosing of proper treatment in the management of liver abscess. Herein, 28-year-old man with Crohn's disease developing liver abscess is presented. He was treated with surgical drainage.

Effect of prolonged gastric distention on lower esophageal sphincter function and gastroesophageal reflux.

OBJECTIVES: Morbidly obese patients treated with an intragastric balloon report a transient increase in gastroesophageal reflux (GER) symptoms. In the present study, we evaluated the underlying mechanisms of GER and examined the effect of prolonged gastric distention on lower esophageal sphincter function. METHODS: Fasting and postprandial manometric studies were performed in obese subjects (n = 15) before, immediately after, and 10 and 20 wk after placement of a 500-ml water-filled balloon. RESULTS: Residual lower esophageal sphincter (LES) pressure after water swallows was not affected after balloon placement, excluding mechanical interaction with sleeve function. Postprandial LES pressure was significantly increased after 10 and 20 wk. GER was increased in the right recumbent position until 10 wk after balloon placement, mainly because of an increased percentage of transient lower esophageal sphincter relaxations (TLESRs) accompanied by GER. TLESRs were the main mechanisms underlying reflux both before and after balloon placement. The rate of TLESRs was increased significantly immediately after introduction of the balloon, returning to baseline values after 20 wk. After balloon placement, reflux episodes were evoked by gastric contractions that were not inhibited by meals. CONCLUSIONS: Chronic distention by an intragastric balloon increased reflux up to 10 wk after placement because of an increase in the percentage of TLESRs accompanied by a reflux episode. In addition, prolonged balloon distention increased the rate of TLESRs and created a postprandial state even 10 wk after balloon placement. After 20 wk these effects largely resolved, illustrating adaptation to this artificial situation.

Primary sclerosing cholangitis in patients with inflammatory bowel disease in Turkey.

BACKGROUND: Primary sclerosing cholangitis (PSC), which is a progressive cholestatic liver disease of unknown etiology, is strongly correlated with inflammatory bowel disease (IBD). GOALS: To determine the prevalence and describe the characteristics of PSC in patients with IBD in Turkey. STUDY: We determined the prevalence of PSC in patients with IBD admitted to our department during a 6-year period. Also, patients with PSC were investigated from an IBD aspect. Regardless of whether the patient had symptoms such as itching, jaundice, and abdominal pain, endoscopic retrograde cholangiopancreatography was performed on those with elevated alkaline phosphatase, and liver biopsy was done if endoscopic retrograde cholangiopancreatography failed to bring about the diagnosis. RESULTS: Overall prevalence of PSC was 9 of 386 (2.3%) patients with ulcerative colitis (UC) and 4 of 110 (3.6%) patients with Crohn's disease (CD). Inflammatory bowel disease was established in 13 of 18 (72.2%; UC, 50.0%; CD, 22.2%) patients who were being observed for PSC. The male-to-female ratio was 5:4 in UC and 3:1 in CD patients with PSC. The mean age at diagnosis of PSC was 43.6 years (range, 30-54 years) in patients with UC and 30.5 years (range, 26-41 years) in patients with CD. In patients with UC, the extension of colitis was total in seven patients (7/110, 6.3%) and left-sided in two patients (2/142, 1.4%). In patients with CD, the disease was located in the ileum and colon in one patient (1/47, 2.1%) and in colon alone in three patients (3/21, 14.2%). CONCLUSIONS: Prevalence of PSC-associated IBD in the Turkish community appear to be similar to the results of western origin studies.

Transrectal ultrasound in the diagnosis and management of inflammatory bowel disease.

BACKGROUND AND STUDY AIMS: To aim of the present study was to determine the value of transrectal ultrasonography (TRUS) in the assessment of disease activity in ulcerative colitis patients, and in differentiating between mucosal inflammation and transmural inflammation. PATIENTS AND METHODS: TRUS examinations were used to study 30 control individuals and 76 patients with inflammatory bowel disease, including 50 cases of ulcerative colitis and 26 of Crohn's disease. A rigid linear endorectal probe was used to examine the rectal wall. RESULTS: In the 30 control individuals, the rectal wall showed five layers, with a mean total diameter of 2.6 mm. There were significant differences between patients with quiescent ulcerative colitis, active ulcerative colitis, and control individuals with regard to the total rectal wall thickness (P<0.001), submucosal thickness (P<0.001) and mucosal thickness (P<0.001). Using cut-off values, differentiation between active ulcerative colitis and remission ulcerative colitis was found to be 100% specific and 73 % sensitive for submucosal thicknesses. TRUS revealed a 100% specificity in differentiating between remission ulcerative colitis and control cases based on the total rectal wall thickness, submucosal, and mucosal thicknesses. In the differential diagnosis of active and remission ulcerative colitis, an increase in submucosal wall thickness and the existence of arterial and venous capillary flow in the submucosa were found to be specific and more sensitive than the other parameters. TRUS examination revealed transmural inflammation in 21 of the 26 Crohn's disease patients, and mucosal inflammation in all 50 of the ulcerative colitis patients. CONCLUSION: TRUS is a reliable and easy method of assessing ulcerative colitis activity and differentiating between rectal diseases.

Caroli's disease: 1977-1995 experiences.

OBJECTIVE: Until recently, congenital cystic dilatation of the intrahepatic biliary ducts (Caroli's disease) has been recognized infrequently. This report aimed to analyse and discuss our observations on 21 adult patients with the disease. PATIENTS: From 1977 to 1995, 21 patients (eight women and 13 men), aged 17 to 68 years, were diagnosed and treated for Caroli's disease at Yuksek Ihtisas Hospital. The mean duration of the disease was 6.5 years. RESULTS: The commonest presenting symptom was abdominal pain, a feature in 18 cases. The distribution of the biliary lesions was bilobar in 12 patients and monolobar in nine. Two of them were congenital hepatic fibrosis. Twenty-one patients had coexisting hepatobiliary disease, associated with Caroli's disease. Approximately 95% of our patients had cystolithiasis, cholelithiasis or both. Surgical treatment was used in 18 patients, a partial hepatectomy being carried out in seven of them, an internal biliary drainage by choledocystojejunostomy in five cases, and by choledochotomy in four cases. Three cases with Caroli's disease were treated with endoscopic sphincterotomy and stone extraction. In the follow-up period, four of our patients died. CONCLUSION: Caroli's disease is being diagnosed more frequently as a result of improved diagnostic capabilities. The aim of the treatment is to obtain sufficient biliary drainage and to relieve the symptoms.

The role of reactive oxygen metabolites in ulcerative colitis.

SUMMARY: : Reactive oxygen metabolites (ROMs) contribute to tissue injury in inflammatory bowel disease. The aim of this study is to examine the role of ROMs in the tissue injury in ulcerative colitis (UC). The study group consisted of 27 patients with UC (14 active, 13 quiescent) and a control group of 10 patients with various anal diseases. We measured the content of malondialdehyde (MDA), superoxide dismutase (SOD), and myeloperoxidase (MPO) in colorectal biopsies. MDA was measured by the thiobarbituric acid assay. SOD and MPO were measured using the nitro blue tetrazolium and odianisidine methods, respectively. The MDA, SOD, and MPO tissue levels were significantly different between the patients with active UC, the patients with quiescent UC, and the control subjects (p < 0.001). A positive correlation was found between the tissue concentrations of MDA and MPO and the activity of the disease (p < 0.001). The SOD tissue concentrations were negatively correlated with the disease activity (r = -0.507, p < 0.05).

Intussusception due to inflammatory fibroid polyp of the ileum. A report of two cases from Turkiye.

Intussusception due to inflammatory fibroid polyps is a very rare entity. In this article two cases of inflammatory fibroid polyps of the ileum (A 32-year old man and a 50-year old woman) in Turkiye are described. Both patients were admitted to the hospital because of acute intestinal obstruction as a result of an intussusception caused by a polyp. The lesions were characterized by an eozinophil containing loosely structured fibrous tissue comprising an onion-skin like arrangement of reticular fibers with spindle-shaped nuclei localised in the submucosa and the base of the mucosa, and variable proliferation of fibroblasts and small vessels. The aetiology of these polyps remains obscure but they appear to be a reactive process (allergic or foreign body reaction) rather than neoplastic. Nkanze et al reported 12 cases of intussusception due to fibroid polyps in Africa. Our two cases are the first cases in Turkiye.

Human fascioliasis.

Infestation with fasciola hepatica is not often seen in humans. Only a few cases have been reported previously, while in our clinic only three cases have been observed in 20 years. All three cases (two males aged 35 and 40 and a 45-year-old female) were operated on with the possible diagnosis of choledocholithiasis, and parasites were later incidentally discovered at operation. In recent years praziquantel has been used with a high rate of success in the medical treatment of this disease. We have also prescribed praziquantel for our last two cases in order to prevent recurrence and to kill any parasites that might still remain after the operation. In the post-operative follow-up a complete cure was observed in all cases.