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Eosinophilic esophagitis is an inflammatory condition of esophagus. It is generally seen in childhood and young population. Men are more commonly affected than women. However, it is not common in an advanced age. Eosinophilic esophagitis decreases the ability of the esophagus to stretch and accommodation against foods. Therefore, the major symptom in adults with eosinophilic esophagitis is difficulty in swallowing solid food (dysphagia). Specifically, the food gets stuck in the esophagus after it is swallowed. Less common symptoms include heartburn and chest pain. Because of this, it may be incorrectly diagnosed as a gastroesophageal reflux disease. Here, we reported a case presented with food impaction at advanced age. As a conclusion, eosinophilic esophagitis is a rare entity that must be remembered in advance aged patients presenting with food impaction.

Background & Aims: Data are limited on the efficacy and safety of tenofovir and entecavir when given for more than 1 year to patients with hepatitis B-related cirrhosis. We investigated the long-term safety and efficacy of these antiviral drugs in patients with chronic hepatitis B virus (HBV) infection, with compensated or decompensated cirrhosis, and compared results with those from lamivudine., Methods: We performed a retrospective analysis of data from 227 adult patients with chronic HBV infection who were diagnosed with cirrhosis, beginning in 2005, at 18 centers throughout Turkey. There were 104 patients who had decompensated cirrhosis, and 197 patients were treatment naive before. Seventy-two patients received tenofovir (followed up for 21.4 ± 9.7 mo), 77 patients received entecavir (followed up for 24.0 ± 13.3 mo), and 74 patients received lamivudine (followed up for 36.5 ± 24.1 mo). We collected data on patient demographics and baseline characteristics. Laboratory test results, clinical outcomes, and drug-related adverse events were compared among groups., Results: Levels of HBV DNA less than 400 copies/mL were achieved in 91.5%, 92.5%, and 77% of patients receiving tenofovir, entecavir, or lamivudine, respectively. Levels of alanine aminotransferase normalized in 86.8%, 92.1%, and 71.8% of patients who received tenofovir, entecavir, and lamivudine, respectively. Child-Turcotte-Pugh scores increased among 8.5% of patients who received tenofovir, 15.6% who received entecavir, and 27.4% who received lamivudine. Frequencies of complications from cirrhosis, including hepatic encephalopathy, variceal bleeding, hepatocellular carcinoma, and mortality, were similar among groups. Lamivudine had to be changed to another drug for 32.4% of the patients., Conclusions: Tenofovir and entecavir are effective and safe for long-term use in patients with compensated or decompensated cirrhosis from HBV infection., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Competing Interests: We have no conflict of interest disclosure.

Background/aims: Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones. The goal of this study was to investigate the effect of cholecystectomy on alkaline reflux, histopathological changes in the gastric mucosa and H. pylori colonization., Methodology: Eighty five patients who had undergone laparoscopic cholecystectomy were included in this trial (20 males; 65 females; 44.97 ± 11.22 years). All the patients had an upper gastrointestinal endoscopy before and 6 months after the surgery and biopsies in the antrum and corpus were taken to investigate the mucosal changes and assay for the presence of H. pylori., Results: At 6 months post-surgery, the presence of bile in the fasting gastric fluid and an increase in the endoscopic gastritis findings were detected. While none of the patients had chemical gastritis prior to surgery, 7 patients were diagnosed with this condition after surgery. Intestinal metaplasia was detected in 6 patients prior to surgery and 20 patients after surgery. H. pylori was observed in 64 patients before surgery and 52 patients after surgery., Conclusions: An increase in duodenogastric reflux, alkaline reflux gastritis and intestinal metaplasia, and a reduction in H. pylori colonization were observed to occur post-cholecystectomy.

Background: Irritable bowel syndrome (IBS) is a chronic functional bowel disorder. The frequency of microscopic colitis and focal active colitis in the colonic mucosa has been investigated in IBS patients., Methods: Between June 2007 and September 2010, 378 patients (between 16 and 84 years) were recruited prospectively. Of these 378 patients, 226 patients were diagnosed with IBS using the Rome III criteria. 152 control patients were also enrolled who were undergoing colonoscopy for colorectal cancer screening or investigation of anemia. Histopathological abnormalities identified during colonoscopy were compared between the IBS and control groups., Results: The average age of the IBS group was 46.13 ± 14.16 years and and the average age of the control group was 57.01 ± 13.07 years. The prevalence of microscopic colitis (MC) in the diarrhea predominant and the mixed subgroup of IBS patients was 4.32% (7/162) whereas in all IBS patients, the prevalence was 3.09% (7/226). MC was not found in the 152 control cases, (p = 0.045). Lymphocytic colitis was seen in 7 IBS patients, with 1 case in the mixed group and 6 cases in the diarrhea group and there was a significant difference in the frequency of lymphocytic colitis between the IBS subgroups (p < 0.01). Focal active colitis was found in 6.6% (15/226) of the IBS patients and in none of the controls (p < 0.01), and there was no differences between IBS subtypes., Conclusion: Microscopic colitis was more often found in the diarrhea predominant/mixed subgroups of IBS patients and in patients who were older women. In patients who are older woman with non-constipated IBS, it may be reasonable to perform a biopsy to screen for microscopic colitis. Focal active colitis was significantly increased in patients with IBS compared to controls.

Situs inversus totalis is is a congenital anomaly associated with various visceral abnormalities, but there is no data about the relationship between secondary biliary cirrhosis and that condition. We here present a case of a 58 year-old female with situs inversus totalis who was admitted to our clinic with extrahepatic cholestasis. After excluding all potential causes of biliary cirrhosis, secondary biliary cirrhosis was diagnosed based on the patient's history, imaging techniques, clinical and laboratory findings, besides histolopathological findings. After treatment with tauroursodeoxycholic acid, all biochemical parameters, including total/direct bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and gama glutamyl transferase, returned to normal ranges at the second month of the treatment. We think that this is the first case in literature that may indicate the development of secondary biliary cirrhosis in a patient with situs inversus totalis. In conclusion, situs inversus should be considered as a rare cause of biliary cirrhosis in patients with situs inversus totalis which is presented with extrahepatic cholestasis.

Background/aims: Development of resistance to standard therapy for Helicobacter pylori (H. pylori) eradication is rapid. The aim of this study is to compare the efficacy of alternative treatment modalities for H. pylori. Compared treatments were standard triple treatment plus probiotic, sequential therapy with levofloxacin, and a 14-day regimen of PPI (proton pump inhibitor) and levofloxacin/amoxicillin combination., Methodology: Overall 285 patients were enrolled in the study and allocated into three groups. Group I (n=98) received lansoprazole, clarithromycin, amoxicillin and saccharomyces boulardii (probiotic) and group II (n=95) received esomeprazole, levofloxacin and amoxicillin for 14 days. Finally, group III (n=92) received esomeprazole and amoxicillin for five days, followed by esomeprazole, levofloxacin and metronidazole for seven days. Testing for H. pylori infection post-treatment was done using a stool antigen test five weeks after the completion of therapy., Results: Patients in all three groups were treatment-naive. Response to treatment (Per Protocol/ITT analysis) was 77.1/72.4% in Group I, 89.1/86.3% in Group II, and 95.5% in Group III. Response to treatment was significantly higher in Groups II and III compared to Group I (p=0.03 and p<0.001, respectively). There was no difference between Groups II and III in terms of response to treatment (p=0.1)., Conclusions: Levofloxacin-based sequential therapy and levofloxacin based triple therapy were significantly superior to standard triple therapy plus probiotic.

We report the case of a 32-year-old man with new diagnosed Behcet's disease (BD) with cardiac, central nervous system and vascular involvement. Transthoracic echocardiography disclosed a thrombus in the right ventricle and another thrombus in the inferior vena cava (IVC). The color Doppler imaging was compatible with Budd-Chiari syndrome. Magnetic resonance imaging (MRI) of the brain revealed atrophy of brain stem and right hemisphere and a milimmetric lacunar infarct. Although therapy with urokinase, pulse methylprednisolone and cyclophosphamide was administered immediately, the patient died due to hepatic failure. BD should always be considered in the differential diagnosis of thromboses in the young and thrombotic events should be evaluated during the clinical course of BD.

Aim: To identify the role of anti-pancreatic antibody (PAB) in the diagnosis of inflammatory bowel diseases (IBD) among Turkish patients, and its frequency in first-degree relatives., Methods: PAB and anti-Saccharomyces cerevisiae (ASCA) were examined in serum samples of 214 subjects including patients with Crohn's disease (CD, n = 64), ulcerative colitis (UC, n = 63), first-degree relatives of patients with CD (n = 25), first-degree relatives of patients with UC (n = 28),and a control group with gastrointestinal symptoms other than (IBD) (n = 34) by indirect immunofluorescence Positivity of PAB and ASCA was compared in terms of Vienna classification, disease activity and medications used., Results: In terms of PAB positivity, no difference was found between patients with CD (14.1%) and UC (7.9%) however, significant difference was observed between patients with CD and subjects in the control group (P < 0.05). No difference was found between patients with CD and their relatives in terms of ASCA positivity, whereas a significant difference was found between other groups (P < 0.001). Compared to ASCA, the sensitivity of the PAB was 19% (7/37), its specificity was 93% (25/27), positive predictive value was 77% (7/9) and negative predictive value was 45% (25/55). ASCA was found with significantly higher prevalence in patients with CD activity index > 150 (P < 0.05)., Conclusion: PAB is valuable in the diagnosis of IBD rather than CD, but cannot be used alone for diagnostic purposes. PAB is not superior to ASCA in CD diagnosis and in detecting CD among relatives of patients with CD.

Background: The aim of this study was to investigate the prevalence of Helicobacter pylori (H. pylori) infection and intestinal metaplasia in adult dispeptic patients. (attending an endoscopy clinic at our training and referral hospital in Turkey)., Methodology: A total of 3301 consecutive dyspeptic patients, with a mean age +/- SD of 45.97 +/- 15.15 years, had two antral and two corporal biopsies, during routine upper gastrointestinal endoscopy. Patients were divided into three groups according to age; 18-40 years old, 41-60 years old and over 60 years old. Histological specimens were examined and graded according to the Updated Sydney System for H. Pylori infection and intestinal metaplasia., Results: H. pylori was established in 2353 patients (71.3%). Intestinal metaplasia was found in 586 patients (17.8%). Of these patients, 86% (n:504) had complete and 14% (n:82) had incomplete intestinal metaplasia. Frequency and severity of H. pylori infection decreased significiantly in the older group (p < 0.001). Patients with intestinal metaplasia were older (53.6 +/- 14.9 years) than patients without intestinal metaplasia (44.3 +/- 14.7 years) (p < 0.001). There was no statistically significant relationship between intestinal metaplasia and H. pylori presence (p > 0.05). Intestinal metaplasia was more prevalant in patients with mild infection (21.9%) than in patients without Helicobacter pylori infection (16.3%) or with moderate (16.2%) or severe infection (14.6%) (p < 0.01), Conclusion: H. pylori infection and density decreases, while the prevalence of intestinal metaplasia and incomplete intestinal metaplasia percentage increases in older dyspeptic patients. Mild H. Pylori colonisation could be a sign of intestinal metaplasia, especially in the elderly.

Purpose: Irritable bowel syndrome is generally diagnosed according to the symptoms of the patient, and gluten enteropathy can also be presented with similar symptoms (diarrhea and/or constipation) of irritable bowel syndrome. Aimed to assess the association and the frequency of gluten enteropathy in a group of Turkish patients diagnosed as irritable bowel syndrome., Results: Found anti-gliadin IgA positivity only in four patients among patients with irritable bowel syndrome. However, none of these four patients had anti-endomycium positivity or any histopathological findings specific for gluten enteropathy. All these four patients had normal histology in their small bowel biopsies., Conclusion: Irritable bowel syndrome is a common problem in the population, but gluten enteropathy is not associated with the vast majority of subjects with irritable bowel syndrome as expected. The need for screening gluten enteropathy among these patients is still unclear, and screening with serology only without small bowel biopsy may lead to false positive results.

The porphyrias are a group of disorders of the heme biosynthesis pathway that present with acute neurovisceral symptoms, skin lesions or both. Porphyria cutanea tarda, presenting as a non-acute form, is the most common type of porphyria that encompasses a group of related disorders, all of which arise from deficient activity of the heme synthetic enzyme, uroporphyrinogen decarboxylase, in the liver. In the literature, concomitant presentation of porphyria with hepatocellular carcinoma is common; however, no case of porphyria cutanea tarda associated with cholangiocarcinoma has been seen. Here, we present a case of porphyria cutanea tarda seen in the course of cholangiocarcinoma, which can be attributed to a paraneoplastic syndrome. Our case is of interest because of its rarity. We also give a brief review of the literature regarding porphyria and cholangiocarcinoma.

Background: Treatment of recontractures that were previously skin grafted or treated with Z-plasty is a challenge. Application of a subsequent Z-plasty is risky because of the possibility of tip necrosis of the triangular flaps, whereas donor-site morbidity is undesirable if subsequent skin grafting is planned. The subcutaneous pedicle rhomboid flap is an effective technique for the treatment of every type of contracture. This article presents the clinical results of the rhomboid flap used in treatment of recontractures as an alternate technique to Z-plasty and skin grafting., Methods: The authors operated on seven patients with recontractures (aged 4 to 45 years) using 19 rhomboid flaps. Flaps were applied in the upper extremity (seven flaps), lower extremity (five flaps), trunk (five flaps), neck (one flap), and axilla (one flap). Z-plasty scars were present in three locations, whereas skin grafting was previously applied in 16 locations. Preoperative rhomboid flap designs were made regardless of previous scars as single flaps in six locations and multiple flaps in 13 locations. Operations were performed under local and general anesthesia., Results: Patients were followed up for at least 6 months. All flaps achieved adequate relaxation postoperatively and healed uneventfully. The subcutaneous pedicle of the flap provided a distinct advantage in terms of vascularity. Recurrence was not seen in any of the patients., Conclusions: The subcutaneous pedicle rhomboid flap is an effective and reliable technique for the treatment of recontractures. Preoperative planning is simple and independent of previous scars. Because the rhomboid flap resurfaces the emerged defects generated by relaxation incisions, one should consider that the flexibility of a single flap may not be adequate in some cases, and multiple flaps should be used.

Background: Gynecomastia is enlargement of the male breast. Although treatment is not indicated in most cases, aesthetic reconstructive surgery is commonly performed for psychological reasons. The goals in surgical treatment are to restore the breast contour with minimal scar and to protect areolar anatomy and sensation. This clinical study investigates the results of the subareolar glandular pedicle technique, in which the pedicle is dissected 2 mm wider than the areola with a circumareolar incision and the breast tissue is excised en bloc. The technique differs from the classical circumareolar approach with its thinner pedicle and excision of the breast without leaving prepectoral tissue., Methods: We operated on nine patients with grades 1 and 2 gynecomastia using the subareolar glandular pedicle. Exposure was excellent with the circumareolar incision. Neither hematoma nor seroma formation was seen in any of the patients. Partial areola necrosis, which caused suture separation, was the only early postoperative complication seen, and this in a patient who smoked heavily. Patients were followed for at least 6 months., Results: Eight patients achieved a good aesthetic contour of the chest, and one patient needed a contour revision for the residual mass because of a bulky pedicle. Circumareolar scars were satisfactory for all the patients, including the patient with partial areola necrosis. Circumareolar hyperpigmentation developed in one patient, and areola sensation was preserved in seven patients., Conclusions: The subareolar glandular pedicle is indicated for grades 1 and 2 gynecomastia. Circumareolar incision provides perfect exposure. The technique is reliable if the pedicle is dissected 2 mm wider than the areola and dissection under the pedicle is avoided. Postoperative circumareolar scarring is minimal and nipple-areola sensation is preserved in most cases. However, experience is needed to determine the pedicle girth because a wide pedicle leads to subareolar bulk, whereas a thin pedicle may cause partial areola necrosis.