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Acute pancreatitis (AP) is a clinical condition that arises acutely in the pancreas through various inflammatory pathways due to multiple causes. Turkish Society of Gastroenterology Pancreas Working Group developed comprehensive guidance statements regarding the management of AP that include its epidemiology, etiology, clinical presentation, diagnostic criteria, disease severity, treatment, prognosis, local and systemic complications. The statements were developed through literature review, deliberation, and consensus opinion. These statements were ultimately used to develop a conceptual framework for the multidisciplinary management of AP.

Pancreatic exocrine insufficiency (PEI) is a prevalent disease that is often underdiagnosed and undertreated, leading to resulting in diminished health-related quality of life. The PEI questionnaire (PEI-Q), a patient-reported outcome questionnaire developed to diagnose and evaluate PEI, is available only in English. The study aimed to provide a Turkish translation of PEI-Q and validate its reliability and diagnostic performance in a Turkish-speaking population with PEI. This study included 161 participants: 98 patients with PEI and 63 healthy controls. Participants underwent the PEI-Q test, and the results were statistically analyzed for reliability and validity. The diagnostic value of PEI-Q was determined using receiver operating characteristic (ROC) curves. Cronbach's alpha was used to assess internal consistency, while exploratory factor analysis was performed to determine construct validity and reveal the factor structure. The mean age of participants was 45.0 years, and 60.2% were male. Participants with PEI were significantly older than those without. Scores for abdominal, bowel movement, and total symptoms were significantly higher in patients with PEI than in controls. ROC analysis revealed good diagnostic value for PEI-Q, with areas under the curve ranging from 0.798 to 0.851 for different symptom scores. Cronbach's alpha coefficients were above 0.70, indicating good internal consistency, and exploratory factor analysis supported a 4-factor structure, accounting for 68.9% of the total variance. The Turkish version of the PEI-Q is a reliable, easy-to-use, and valid screening tool for diagnosing PEI. It consistently assesses symptoms and quality of life in patients with PEI, helping to inform diagnosis and treatment.

Background: Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management., Methods: All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria., Results: The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically., Conclusions: This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects., (Copyright © 2023 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: Prokinetics are a class of pharmacological drugs designed to improve gastrointestinal (GI) motility, either regionally or across the whole gut. Each drug has its merits and drawbacks, and based on current evidence as high-quality studies are limited, we have no clear recommendation on one class or other. However, there remains a large unmet need for both regionally selective and/or globally acting prokinetic drugs that work primarily intraluminally and are safe and without systemic side effects., Purpose: Here, we describe the strengths and weaknesses of six classes of prokinetic drugs, including their pharmacokinetic properties, efficacy, safety and tolerability and potential indications., (© 2024 John Wiley & Sons Ltd.)

Liver fibrosis is the most important factor in the prognosis and treatment plan of patients with chronic hepatitis B (CHB). Aspartate aminotransferase (AST)-to-platelet ratio index (APRI), fibrosis index based on 4 factors (FIB-4), and fibrosis index based on 5 factors (FIB-5) scores are noninvasive fibrosis markers, and previous comparative studies have shown that they are as effective as liver biopsy in detecting liver fibrosis in different liver diseases. The aim of our study is to investigate whether existing scoring systems are effective in demonstrating fibrosis in CHB patients and to compare the APRI, FIB 4, and FIB 5 scores in differentiating early and advanced fibrosis in 123 patients who underwent liver biopsy for CHB infection. APRI, FIB-4, and FIB-5 scores of patients who underwent liver biopsy due to CHB were calculated by means of calculators and recorded to be compared with liver biopsies in terms of fibrosis scoring. One hundred twenty-three patients who underwent liver biopsy due to chronic hepatitis B were included in the study. APRI (area under the receiver-operating characteristic [ROC] curve 0.728), FIB-4 (area under the ROC curve 0.693) and FIB-5 (area under the ROC curve 0.643) scores were evaluated as significant predictors of advanced fibrosis. The scoring system with the highest positive and negative predictive value was evaluated as FIB-4. APRI, FIB-4, and FIB-5 scoring systems are appropriate scoring systems in the assessment of advanced fibrosis in patients with CHB. Our study is the first to compare APRI, FIB-4, and FIB-5 values in CHB patients, and more comprehensive studies are needed., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: There is limited data in the literature analyzing the efficacy of methotrexate in Crohn's disease used after thiopurine analogs. We aimed in our study to show the efficacy of methotrexate in Crohn's disease patients who failed to respond to thiopurine treatment., Methods: The study included 29 azathioprine refractory patients with Crohn's disease. Intramuscular methotrexate (25 mg/week) in the induction of remission and intramuscular methotrexate (15 mg/week) in 29 CD patients with a median follow-up time of 13 months was performed. In 15 (51.7%) patients, methotrexate was used in combination with anti-Tumour necrosis factor (TNF) (combination group), while it was used in 14 (48.3%) patients in monotherapy (monotherapy group)., Results: The mean Harvey-Bradshaw index score significantly decreased in the follow-up period (Wk0 = 7.6, last visit = 4.5, P < .001). Remission and response rates at week 12 were 75.9% and 79.3%, respectively. Maintenance of remission (77.8% vs 37.5%, respectively, P = .1) and response rates (77.8% vs 50%, respectively, P = .3) due to last visit examination were numerically higher in combination group but they were not statistically significant. The cumulative probability of remission maintenance in patients with methotrexate therapy was 72.7%, 33.1%, and 22.0% at 1, 2 ,and 4 years after starting methotrexate, respectively., Conclusion: Our results show that parenteral use of methotrexate is efficacious in inducing and maintaining remission as a step-up agent in azathioprine refractory Crohn's disease patients.

Background: The treatment of solitary rectal ulcer (SRU) is challenging and controversial; generally, no response to conventional treatments can be obtained, particularly in patients with dyssynergic defecation (DD). We assessed the efficiency of biofeedback therapy (BFT) in patients who did not respond to conservative treatments and had coexistence of SRU and DD., Methods: BFT responses, as well as anorectal manometry and rectoscopy results of 20 patients with the coexistence of SRU and DD, were assessed., Results: Mean age was 32.5 years. Of the patients, 12 were female, and 8 of them were male. An average of 12 sessions of BFT was performed on the patients. Ulcer disappeared in 11 patients (55%) after BFT, and the ulcer size decreased in 3 patients (15%). However, ulcers healed in 9 (90%) of 10 patients whose DD pattern disappeared following BFT, and ulcers healed in only 20% of patients whose DD pattern continued (p = 0.005). The change in anal resting pressure after BFT was significant (p = 0.016). Ulcers were healed in 87.5% (7/8) of the patients whose anal resting pressure decreased after BFT and whose DD disappeared, while ulcers remained untreated in 85.7% of the patients whose anal resting pressure decreased, but the DD pattern continued (p = 0.005)., Conclusions: SRU patients with DD are typically unresponsive to medical treatments. Ameliorating anorectal dyssynergia should be the priority of treatment in these patients. BFT is an effective treatment for DD. BFT enhances the healing of ulcers in patients with SRU by restoring coordination of the pelvic floor., (© 2022 S. Karger AG, Basel.)

Background: The purpose of this study was to compare the clinical symptoms and pathological consequences of Helicobacter pylori (H. pylori) infection between children and adults and determine the levels of expression of FOX3P and IL-17A to examine the Th17/Treg balance., Methods: Forty pediatric and 40 adult patients who were followed up at the Pediatric Gastroenterology and Internal Medicine Gastroenterology Departments were enrolled in the study. In our case-control study, gastric tissue specimens were evaluated using the updated Sydney system, and the number of cells expressing FOXP3/IL-17A (T reg and Th17 cell markers) was analyzed immunohistochemically. In addition, each case was evaluated using a clinical follow-up questionnaire., Results: Clinical signs and symptoms of children and adults were similar. IL-17A and FOXP3 levels were significantly higher in children and adults with H. pylori (+) than in those without H. pylori (-) (p < .001). In patients with H. pylori (+), the mean FOXP3 level was significantly higher, whereas the mean IL-17A level was significantly lower in children than in adults (p < 0001 for both groups). In children with H. pylori (+), bacterial density was negatively correlated with IL-17A level and positively correlated with FOXP3 level. In adults with H. pylori (+), there was a statistically significant, highly positive correlation between bacterial density and levels of IL-17A and FOXP3., Conclusions: T reg cells are suggested to more predominant in children than in adults, IL-17A levels decrease as H. pylori bacterial density increases. In conclusion, immune responses incline toward T reg , which increases the susceptibility to persistent infections., (© 2021 John Wiley & Sons Ltd.)

The COVID-19 pandemic, caused by the novel severe acute respiratory syndrome coronavirus 2, has resulted in high mortality and morbidity worldwide and is still a growing problem. Inflammatory bowel disease (IBD) is a chronic inflammatory disease for which a substantial number of patients are treated with immunosuppressive medications, either occasionally or long-term. Despite the accumulating evidence, there is still a lack of knowledge about the impact of COVID-19 on IBD patients, especially those who are under immunosuppressive treatment. Moreover, following the emergence of several COVID vaccines, there are concerns regarding vaccine effectiveness and possible side effects in such patients. In this context, we tried to briefly summarize the accumulating evidence and recommendations for the management of IBD in the context of the COVID-19 pandemic.

Background: We investigated the sensitivity of neutrophil to lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), as well as a combination of NLR and PLR to predict endoscopic disease severity based on mucosal assessment in ulcerative colitis (UC)., Methods: The study group consisted 104 patients with active UC, 104 patients in remission, and 105 healthy individuals. Disease activity was described with Rachmilewitz endoscopic activity index (EAI). Curve analysis was used to determine the optimal cutoff values of NLR and PLR for obtaining remission. The patients with both PLR and NLR values higher than the cutoff values were coded as »high risk,« those with one parameter higher were coded as »moderate risk«, those with both parameters lower than the cutoff values were coded as »low-risk« patients., Results: The mean NLR and PLR values in the endoscopically active disease group were higher than the others, with higher values in the endoscopic remission group compared with the control group (p<0.001). Rachmilewitz EAI in high-risk patients was significantly higher than that in others (p<0.001). In Cox regression analyses, moderate and high risk, high erythrocyte sedimentation rate and high EAI were found as independent predictors of endoscopic active disease., Conclusions: This is the first study that investigated the use of NLR and PLR combination to assess endoscopic disease severity in UC. Either high NLR or PLR levels can predict active endoscopic disease. However, the use of these parameters in combination is more accurate in evaluating mucosal disease and inflammation in UC., Competing Interests: Conflict of interest statement The authors stated that they have no conflicts of interest regarding the publication of this article.

Gastroesophageal reflux disease (GERD) is frequently seen during pregnancy. In the medical treatment of pregnant women with GERD, alginic acid and sucralfate can be used. Calcium- and magnesium-based antacids can also be used, particularly for patients with preeclampsia. In particular, ranitidine -a histamine-2 receptor blocker- is preferred. In the case of non-responsiveness to the abovementioned treatments, proton pump inhibitors (PPIs), except omeprazole, can be given considering the benefit-harm ratio for the mother and fetus after the first trimester. In cases with GERD during the lactation period, drugs having minimum systemic absorption, such as sucralfate and alginic acid, are preferable but there is no data.

Proton pump inhibitors (PPIs) are the most effective agents in the first-line and maintenance treatment of gastroesophageal reflux disease. As the grade of esophagitis increases, an increase is also observed in the level of endoscopic response to PPIs. In the first-line therapy of patients with severe esophagitis (Los Angeles (LA) Grade C-D), administration of a standard dose of PPIs bid has been reported to be more beneficial than PPIs qd. While any intermittant and low dose-continuous treatment can be chosen for the maintenance therapy of patients with non-erosive reflux disease or mild esophagitis (LA Grade A-B), continuous use of a standard dose of PPIs is preferred in the maintenance therapy of patients with severe esophagitis (LA Grade C-D). In patients who use PPIs for a long time, the drug must be stopped by gradually decreasing the dose.

Lifestyle modification has an important role in the treatment of gastroesophageal reflux disease (GERD). The development of GERD symptoms with various foods shows individual differences. Although there is not enough evidence that certain substances in a diet could lead to GERD symptoms, the literature suggests that there might be a relationship between reflux development and salt, salted foods, chocolate, fatty foods, and fizzy drinks. Because lying on the left side and raising the head of the bed in a supine position reduces the development of nocturnal reflux symptoms, the head should be elevated for patients with reflux symptoms at night, and the patient should lie on the left side. Smoking and obesity (especially abdominal) trigger GERD symptoms. Whereas excessive physical activity is a significant risk factor for the development of GERD, regular and mild-moderate physical activity has been shown to reduce the symptoms of reflux.

The aim is to compare high-dose rabeprazole and amoxicillin containing modified dual therapy (MDT) with bismuth subcitrate containing standard quadruple therapy (SQT) as the first-line Helicobacter pylori eradication treatment in terms of efficacy, safety, and adherence to treatment. A total of 200 consecutive patients diagnosed endoscopically with nonulcer dyspepsia with H. pylori infection were randomly assigned into 2 groups, 1 treated with amoxicillin 750 mg thrice daily plus rabeprazole 20 mg thrice daily (MDT group) or rabeprazole 20 mg b.i.d., bismuth subcitrate 120 mg q.i.d., tetracycline 500 mg q.i.d., metronidazole 500 mg t.i.d. (SQT group). Overall, 196 patients (98 in the MDT group and 98 in the SQT group) completed the study. H. pylori eradication was achieved in 84.7% of patients in the MDT group by intention to treat analysis and 84.9% by per-protocol analysis, which were comparable with SQT group (87.8% and 88.8%, respectively). Adverse events including nausea (P = 0.03), dysgeusia (P < 0.001), diarrhea (P = 0.001), black colored stool (P < 0.001), headache (P = 0.01), and abdominal pain (P = 0.05) were significantly higher in SQT group. The MDT is an efficient and safe treatment choice that could be recommended in the first-line eradication treatment of H. pylori.

Carbohydrate antigen 19.9 (CA 19.9) is a specific tumour marker of the biliary, pancreatic and gastrointestinal tracts. Autoimmune hepatitis is a chronic immune-mediated liver disorder characterised by female predominance. We report a case of approximately 30-fold increased serum CA 19.9 in a 57-year-old woman who was diagnosed with autoimmune hepatitis. She had no evidence of any malignant disease in pancreatobiliary or gastrointestinal tracts. CA 19.9 levels decreased to normal levels with immunosuppressive treatment. Markedly elevated serum CA 19.9 levels might be encountered with benign liver diseases such as autoimmune hepatitis.

Background/aim: The clinical significance of gastric xanthelasmas is unknown. We conducted a case-control study in order to evaluate whether gastric xanthelasma is an indicator of advanced atrophic gastritis and intestinal metaplasia., Material and Method: The study was conducted among 1400 patients who underwent elective upper endoscopy. Patients with gastric xanthelasma and atrophy and/or intestinal metaplasia constituted the study group (n = 55). The control group involved patients with only atrophic gastritis and/or intestinal metaplasia (n = 50). Histopathologic findings of the groups including the distribution of atrophic gastritis and/or intestinal metaplasia, operative link on gastritis assessment score, operative link on gastritis intestinal metaplasia assessment (OLGIM) score, and presence of dysplasia and malignancy were compared. Subgroup analysis was performed in order to establish the relation between the characteristics (size, number, and localization) of xanthelasmas, atrophy, and intestinal metaplasia., Results: Multifocal atrophic gastritis was significantly more common in patients with a gastric xanthelasma (41.8 vs. 26.0 %, p = 0.03). Patients with multiple xanthelasmas had a significantly higher rate of intestinal metaplasia (p = 0.02) and a higher OLGIM score (p = 0.02) compared to those with a single xanthelasma. Dysplasia was detected in 8 (14.5 %) patients with a xanthelasma and 4 (8.0 %) patients without a xanthelasma (p = 0.2)., Conclusion: Gastric xanthelasma(s) is a warning endoscopic sign for the presence of multifocal atrophic gastritis and advanced intestinal metaplasia.

Background and Aim: Currently there is no satisfactory treatment of chronic HDV. We aimed to evaluate the long term efficacy of PEG-interferones., Patients Methods: Patients who received PEG-interferone for chronic delta hepatitis during a 7-year period were retrospectively analysed. End of treatment response, virologic response at 6 months after treatment, and long term efficacy were evaluated. Predictors of treatment response were determined., Results: The study group consisted of 31 patients. Twenty-three patients received either PEG-interferone alfa-2a (n=8) or PEG-interferone alfa-2b (n=15) for at least 48 weeks. Thirteen patients had an end of treatment virologic response (ITT:56.5%, PP:68.4%). HDV RNA negativity after 6 months off PEG-interferone treatment was achieved in 12 patients (ITT:52.1%, PP:63.1%). The patients were followed for a median duration of 36 months after PEG-interferone treatment (min-max:12-120 months). Four patients (33.3%) relapsed during the follow-up. Sustained virologic response (ITT) was 34.8% in the long term. Undetectable HDV RNA level at week 24 of treatment and biochemical response were independent predictors of end of treatment response and sustained virologic response in the long term, respectively., Conclusion: PEG-interferones have an unsatisfactory efficacy on the treatment of HDV because of a considerable relapse in the long term. (Acta gastro-enterol. belg., 2016, 79, 329-335).

Background: In several studies, different risk factors other than antibiotic resistance have been documented with Helicobacter pylori eradication failure. We aimed in this study to investigate the relationship of gastric density of H. pylori, the occurrence/degree of gastric atrophy, and intestinal metaplasia (IM) with success rate of H. pylori eradication., Methods: Two hundred consecutive treatment naive patients who received bismuth containing standart quadruple treatment due to H. pylori infection documented by histopathological examination of two antral or two corpal biopsies entered this retrospective study. The updated Sydney system was used to grade the activity of gastritis, density of H. pylori colonization, atrophy, and IM. Stages III and IV of operative link for gastritis assessment (OLGA) or the operative link on gastric intestinal metaplasia assessment (OLGIM) stages was considered as severe gastritis. H. pylori eradication was determined via stool H. pylori antigen test performed 4 weeks after the end of therapy., Results: The presence of gastric atrophy and IM was significantly higher in patients with eradication failure (p = 0.001 and 0.01, respectively). Severe gastritis (OLGA III-IV and OLGIM III-IV) rates were higher in eradication failure group. A multiple linear regression analysis showed that OLGA and OLGIM stages were to be independent risk factors for eradication failure (p = 0.03 and 0.01, respectively)., Conclusion: Our results suggested that histopathologically severe gastritis may cause H. pylori eradication failure. In addition, we found that H. pylori density was not a risk factor for treatment failure in patients who receive quadruple treatment.

Background and Aim: The aim of this study was to evaluate the efficacy of bismuth-based quadruple regiment as a first-line treatment for Helicobacter pylori (H. pylori) eradication in patients with unexplained iron deficiency anemia (IDA). The serum hepcidin-25, iron, ferritin levels and total iron-binding capacity were evaluated at baseline and after H. pylori eradication in order to assess whether H. pylori eradication plays a role in IDA related to H. pylori infection., Methods: The study included 80 patients with unexplained IDA and H. pylori infection. All patients received pantoprazole (40 mg b.i.d.), bismuth subcitrate (120 mg q.i.d.), tetracycline (500 mg q.i.d.) and metronidazole (500 mg t.i.d.) over 14 days as H. pylori eradication regimen. In all patients, blood samples were drawn at baseline and 1 month after eradication therapy. In all patients, serum hepcidin-25 levels were determined by using commercially available enzyme-linked immunosorbent assay kits., Results: There was an improvement in hemoglobin, iron, total iron-binding capacity and ferritin values after H. pylori eradication in all subjects. Serum hepcidin-25 levels significantly decreased after H. pylori eradication (p < 0.001)., Conclusion: Gastric H. pylori infection is a common cause of IDA of unknown origin in adult patients. Our results provide evidence indicating that hepcidin level decreases after successful H. pylori eradication with improvement in IDA.

Ischaemic colitis results from a chronic or acute drop in the blood supply to the bowel and accounts for 6‒18% of the causes of acute lower gastrointestinal bleeding. Diabetes mellitus, hypotension, advanced age, aortic surgery and peripheral vascular disease have also been suggested to be predisposing factors for ischaemic colitis (1). In this report, we present a case of ischaemic colitis in haemodialysis with a good response to conservative treatment.

Interleukin 33 (IL-33) is a cytokine belonging to the IL-1 superfamily. Soluble ST2 (sST2) binds to IL-33 and by functioning as trap receptor inhibits signal sending to Th2 via transmembrane ST2. Because Th2-type cytokines play an important role in fibrosis, the aim of this study is to determine whether sST2 can be used as a marker of fibrosis in chronic hepatitis B (CHB) patients or not.The study included 19 healthy controls, 54 patients with CHB, and 14 patients with cirrhosis because of CHB. The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the 4 factors (FIB-4) scores also calculated, and correlations between liver biopsies, sST2 levels, and these scores were analyzed in CHB and cirrhosis patients.The sST2 levels in patients with CHB were significantly higher than those in the control group subjects (median: 1133 pg/mL vs 762.5 pg/mL, respectively [P = 0.035]). In CHB patients, the METAVIR fibrosis score (stages from 0 to 4) showed a moderate correlation with serum sST2 level (r = 0.396, P = 0.004) and a weak correlation with FIB-4 score (r = 0.359, P = 0.008), but no correlation with APRI score (r = 0.253, P = 0.06). The under the curve value of serum sST2 was 0.68, and its prediction of significant fibrosis (METAVIR score ≥2) in values >674 pg/mL had a sensitivity of 91.7% and specificity of 40% (P = 0.009). According to multiple logistic regression analysis, only METAVIR fibrosis stage was found to be an independent predictor of serum sST2 elevation in CHB patients (P = 0.04).The sST2 level can be used for differentiating significant fibrosis from mild fibrosis in CHB patients. However, the efficacy of this marker should be verified by larger studies in the future., Competing Interests: The authors have no funding and conflicts of interest to disclose.

Objective: We aimed to compare the plasma pantoprazole level (PPL) between patients with type 2 diabetes mellitus and non-diabetic patients during Helicobacter pylori (H. pylori) eradication treatment and to explore the role of PPL in predicting the treatment success rates., Methods: This study included 40 diabetic and 40 non-diabetic treatment-naive H. pylori-infected patients. Bismuth-based standard quadruple treatment for H. pylori eradication was used for 14 days in both groups. PPL was measured using the square-wave voltammetry method., Results: H. pylori eradication rate (60.0% vs 87.5%, P = 0.005) and PPL (0.25 ± 0.03 μg/mL vs 0.34 ± 0.03 μg/mL, P < 0.001) was significantly lower in the diabetic group compared with the controls. Patients with treatment failure had lower PPL than those with successful treatment (P < 0.001). The receiver operating characteristics curve demonstrated that PPL had a significant predictive value for the outcome of H. pylori eradication., Conclusion: Type 2 diabetic patients had lower PPL than the non-diabetic controls, which led to their lower H. pylori eradication rates., (© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

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.

Background/aims: The aim of this study was to compare the utility of the revised Mayo risk model (rMRM) and Child-Pugh scores (CPSs) for predicting the prognosis of disease in patients with primary sclerosing cholangitis (PSC)., Materials and Methods: Patients were divided into 2 groups: Group I (37 patients; alive and not requiring liver transplantation) and Group II (8 patients; deceased or requiring liver transplantation). rMRM suggests the possible survival percentage over a 4-year period. Thus, rMRM scores and CPSs on the first visit were calculated from the data at the time of diagnosis for patients diagnosed with PSC <4 years ago. rMRM scores and CPSs of patients with >4 years of follow-up were calculated using data from the visit 4 years prior to their last follow-up., Results: Bivariate analyses showed that need for liver transplantation/mortality was correlated with either first visit CPS (r=0.481, p=0.001) or rMRM (r=0.452, p=0.002). Analysis of the area under the curve showed that both models performed similarly in terms of predicting the need for liver transplantation/mortality (rMRM: 0.780; CPS: 0.762; p=0.8). There was a significant difference in Kaplan-Meier survival rates between Group I and Group II for both risk models (rMRM: p<0.001; CPS: p<0.001) when the decisive event was death or need for liver transplantation., Conclusion: Both rMRM and CPSs are useful in risk assessment of patients with PSC. The ability to predict prognosis is similar for both risk models.

Background/aims: We aimed to describe the clinical course of Ulcerative colitis (UC) and the factors that predict the need for total colectomy in Turkish patients with severe UC receiving regular follow up., Materials and Methods: We analyzed the demographic and clinical characteristics of 612 patients with UC receiving regular follow up between 1994 and 2010 in a tertiary referral center in Ankara., Results: Men accounted for 58% of patients (M:F ratio, 1.4:1), and the mean age at diagnosis was 37.9 years. Of these, 32% had distal colitis and 8.8% had further extension, and 39 patients (6.4%) had chronic active disease. Steroid dependency and steroid resistance rates were 7.5% and 17.2%, respectively. In multivariate analysis, steroid dependency (p=0.04), steroid resistance (p=0.002), further extension (p<0.001), presence of extensive disease (p=0.006), and chronic active disease (p<0.001) were independent predictors of the need for total colectomy. Patients with chronic active disease had lower total colectomy free survival (p<0.001)., Conclusion: The predictors of total colectomy were comparable with those previously reported in the literature. However, we identified further extension in disease localization to predict the need for total colectomy.

Purpose: The outcome of endoscopic treatment for the management of surgical end-to-side hepaticoduodenostomy (HD) has not been extensively studied. The aim of this study was to evaluate the results of endoscopic management of HD., Methods: The medical records of 17 patients with HD stenosis who were referred to the ERCP unit between August 2003 and June 2012 for endoscopic intervention were retrospectively analyzed., Results: Fourteen patients presented with cholangitis, of whom, jaundice was the presenting complaint in 3 patients. Eight patients (47.1%) who had stents placed for a median of 2 (min, 1; max, 3) ERCP periods remained asymptomatic for a median stent-free period of 19.5 months (min, 7; max, 96 mo). Five patients (29.4%) who had stents placed for a median of 2 (min, 1; max, 5) ERCP periods presented with an episode of stone-related cholangitis for a mean of 41.8±28.9 months after stent removal. These 5 patients remained asymptomatic for a median of 9.5 months (min, 5; max, 40 mo) after endoscopic stone extraction. Three patients with HD (17.6%) were followed up with stents for 4 to 19 ERC periods. One HD patient (5.9%) who had cholangitis associated with secondary biliary cirrhosis died of cholangitis-related complications, despite the treatment with stents for 4 ERC periods., Conclusion: Endoscopic management is also a realistic treatment option for stenotic HD anastomosis, although success rates may vary.

Background & Aim: This study aimed to compare the efficacy and safety of bismuth-included standard regimen and modified sequential treatments in Turkey, where the success rate of standard triple therapy is very low., Methods: One-hundred and sixty patients with dyspeptic complaints and naïve Helicobacter pylori infection were randomized into four groups: 41 patients received standard 14-day quadruple treatment (STD) (Rabeprazole 20mg-bid, bismuth subcitrate (120 mg-qid), Tetracycline 500 mg-qid, Metronidazole 500 mg-tid) for 2 weeks. The modified sequential therapy groups received 20 mg rabeprazole and 1g amoxicillin, twice daily for the first 5 days, followed by Rabeprazole 20mg-bid, bismuth subcitrate (120 mg-qid), Tetracycline 500 mg-qid, Metronidazole 500 mg-tid for the remaining 5 (10 day sequential therapy group-10S) (42 patients), 7 (12 day sequential therapy group-12S) (42 patients) and 9 (14 day sequential therapy group-14S) (41 patients) days., Results: The overall compliance and H. pylori eradication rate among the 160 patients who completed the H. pylori eradication regimens were 86.9% (139/160) and 78.1% (125/160), respectively. The results were not statistically different between groups in the eradication rates. Per-protocol eradication rates were 76.5% in STD, 71.4% in 10S, 82.4% in 12S and 83.3% in 14S groups (p=0.7). Intention-to-treatment rates were 77.5% in STD, 72.5% in 10S, 82.5% in 12S and 80.0% in 14S groups (p=0.5)., Conclusion: The eradication rates of standard 14-day and different sequential quadruple treatment regimens are comparable and much more higher than with standard 14-day triple H. pylori eradication treatment that has been reported previously in Turkey., (Copyright © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Background and Aims: The aim of this prospective study is to evaluate the safety of both diagnostic and therapeutic endosonography (EUS) in geriatric population., Methods: The study population, consisting of 222 patients who underwent endosonographic evaluation for different indications, was divided into two groups. Group I consisted of 165 patients, ≥ 65 years old; Group II consisted of 57 controls, <65 years old. The demographic information with clinical parameters, procedure medication used and complications was noted., Results: The median age of Group I was 72 years (range 65-93 years) vs. 46 years (range 26-64 years) for Group II. Female-to-male ratio was 82/83 in Group I, while 32/25 in Group II. Pulse rate (84 vs. 89 beats/min, p = 0.024) and basal oxygen saturation (94 vs. 97 %, p < 0.001) levels were lower in Group I when compared with the control group, while systolic blood pressure measurements (150 vs. 130 mmHg, p < 0.001) were significantly higher in Group I. No cases of procedure-related bleeding, perforation and mortality were observed in both groups., Conclusion: Despite the well-known relative increased procedural risks, advanced age is not a contraindication for advanced endoscopic interventions. EUS can be regarded as a safe and effective procedure in ≥ 65 years old population.

Background: Colonoscopy is currently considered to be the gold standard method for detecting and removing adenomatous polyps. However, tandem colonoscopy studies reveal a pooled polyp miss rate of 22%., Objective: A prospective randomized trial was conducted to assess whether alteration of patient position during colonoscopy withdrawal increases the adenoma detection rate (ADR)., Method: The study group included 120 patients who presented for elective colonoscopic examination. After reaching the cecum, patients were randomly assigned in a 1:1 ratio to examination in either the left lateral position or other positions (left lateral position for the cecum, ascending colon and hepatic flexure; supine for transverse colon; and supine and right lateral position for splenic flexure, descending and sigmoid colon) first. Examination of the colon was performed segment by segment. The size, morphology and location of all polyps were recorded. Polyps were removed immediately after examination of a colon segment when all positions were completed. ADR and polyp detection rates (PDR) were calculated., Results: A total of 102 patients completed the study. Examination in the left lateral position revealed 66 polyps in 31 patients (PDR 30.3%) and 42 adenomas in 24 patients (ADR 23.5%). PDR increased to 43.1% (81 polyps in 44 patients) and the ADR to 33.3% (53 adenomas in 34 patients) after the colon was examined in the additional positions (P<0.001 and P=0.002, respectively). The increase in the number of adenomas detected was statistically significant in the transverse and sigmoid colon. The addition of position changes led to a 9.8% increase in the ADR in the transverse colon, splenic flexure, and descending and sigmoid colon. The frequency of surveillance interval was shortened in nine (8.8%) patients after examination of the colon in dynamic positions., Conclusion: Alteration of patient position during colonoscopy withdrawal is a simple and effective method to improve ADR.

Although systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH) are distinct diseases, in clinical practice differentiation of one from other may be difficult. The aim of this study was to asses features of SLE in patients with diagnosis of AIH.Thirty patients [mean age: 52.4 ± 11.8 years; 23 (76.7 %) female] were included in the study. Seven (23.3 %) of the patients full filled 4 or more criteria for classification of SLE. None of the patients had muco-cutaneous lesions characteristic to SLE. Three patients had rheumatoid factor negative arthritis, and 2 patients had pericardial effusion. Four patients had significant thrombocytopenia (<100 × 10(3)/μL), and one of these patients had pancytopenia. None of the patients had hematuria, but 3 patients had proteinuria which did not affect renal function during the study period. One patient died due to pancytopenia-associated pulmonary infection. Among the treated patients with SLE features, 2/5 (40 %) achieved ALT normalization and 9/12 (75 %) of the remaining patients achieved ALT normalization (Fisher's exact test; p = 0.28) during the study period. Although the difference is non-significant, treatment response of AIH patients with SLE features seemed to be delayed and incomplete compared to other patients, but with the limited number of patients it is inconvenient to reach a definitive conclusion. Further studies are needed to identify role of features of SLE on treatment response in patients with AIH.

Both complete transection and accidental ligation of the main bile duct because of a cholecystectomy are the injuries that are not amenable to endoscopic treatment and require an additional surgery. Leaks resulting from the severance of an aberrant bile duct may be treated endoscopically, although such injuries are difficult to be identified, thus resulting in treatment delays. Presented here are the details and follow-up results of 7 cases of patients with postcholecystectomy aberrant bile duct injuries, which were treated by endoscopic treatment.

Background & Aims: There is limited data comparing influence of age on the presentation, clinical course, and therapeutic response of patients with ulcerative colitis. We aimed to compare the demographic and clinical characteristics of patients diagnosed with UC in older age vs. adulthood vs. early age., Methods: Five-hundred sixty one patients with UC seen at our center from 1995 to 2011 were categorized into early onset (EO), adult onset (AO) and late onset (LO) due to age at date of initial diagnosis. Patients diagnosed younger than age 17 were defined as EO, while those diagnosed between 17 and 60 were defined as AO and older than age 60 as LO. All patients were analyzed for demographic and clinical characteristics., Results: There was a male predominancy among LO patients (50% vs. 57.7% vs. 78.6%, p=0.004). Patients with EO UC were more likely to be non-smokers (p<0.001), and had higher family history of UC (p=0.02). Patients with EO UC had more steroid use (p=0.03), total colectomy (p=0.04), presence of chronic active disease (p=0.04) rates when compared with AO and LO groups. Patients in EO group had higher overall probability of surgery in 1, 5 and 10 years, when compared with patients in LO group (p=0.02), but it wasn't different between EO and AO groups (p=0.09)., Conclusions: Our study showed that clinical course of UC was more aggressive in younger ages. Also the difference between the demographic characteristics suggests that different age groups have different risk factors for the disease development., (Copyright © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objectives: The aim was to compare the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in cytology and the biochemical analysis of cyst fluid, together with the size of the lesion in the differentiation between benign and malignant pancreatic cystic lesions., Methods: Data of patients who underwent EUS-FNA for pancreatic cystic lesions in our center from January 2006 to October 2010 were retrospectively analyzed. The diagnostic accuracy of EUS-FNA was determined., Results: Of the 56 patients, 37 (66.1%) had evaluable cytology for diagnosis and sufficient cyst fluid was available for biochemical analysis in 58.9% (33/56) of the patients. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA for detecting malignancy were 63%, 100%, 100% and 85%, respectively. EUS-FNA was the most accurate diagnostic method for differentiating malignant and benign pancreatic cystic lesions (88%). Cyst fluid carcinoembryonic antigen (CEA) > 365 ng/mL had a sensitivity of 100% for the detection of malignant cystic lesions., Conclusions: Although the rate of insufficient cyst fluid aspiration is high, the combination of cytological evaluation and CEA analysis of cyst fluid obtained by EUS-FNA is accurate in differentiating malignant cystic lesions from benign ones. Safe techniques are essential to improve the yield of cyst fluid aspiration by EUS., (© 2012 The Authors. Journal of Digestive Diseases © 2012 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

Background and Aims: Liver biopsy is the gold standard procedure for documenting liver damage in chronic hepatitis C (CHC), as for many other chronic liver diseases. Mean platelet volume (MPV) is a laboratory marker obtained from complete blood count (CBC) analysers in routine clinical practice. The goal of the present study was to evaluate whether MPV would be useful in predicting liver histologic severity in CHC., Patients and Methods: A total of 59 patients with CHC and 25 control subjects were recruited into the present study. There were 26 men and 33 women in the CHC group and 12 men and 13 women in the control group. MPV was recorded at the time of admission. The clinical characteristics of CHC patients, including demographics, laboratory and liver biopsy findings, were reviewed., Results: A statistically significant increase in MPV values was observed in CHC patients (8.54 ± 0.63 fL) compared to healthy controls (7.65 ± 0.42 fL) (P < 0.001). Moreover, MPV values were significantly higher among patients with advanced fibrosis as compared to those with mild fibrosis (8.99 ± 0.57 fL vs. 8.19 ± 0.50 fL P < 0.001). Receiver operator characteristic (ROC) curve analysis suggested that the optimum cut-off point for MPV value in advanced fibrosis was 8.75 fL. (Sensitivity: 80.8%, specificity: 81.8%, positive predictive value [PPV] 77.8%, negative predictive value [NPV] 84.4%, accuracy 81.3%, AUC: 0.98 P < 0.001), Conclusion: The current study showed that MPV is increased in CHC with advanced fibrosis. Calculation of MPV along with the use of other markers may give further information about liver fibrosis severity in CHC., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)