[Show abstract][Hide abstract] ABSTRACT: Infection in the bile tract is a major cause of bacteremia and is related to high morbidity and mortality. We examined the changes in bacteria types and antibiotic susceptibility in bile cultures and simultaneous blood cultures taken from patients who applied for endoscopic retrograde cholangio pancreatography (ERCP)/percutaneous transhepatic cholangiography (PTC) for different bile duct diseases in recent years.
The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology 06/2014; 25(3):284-290. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Duodenal wall perforations are traditionally managed surgically. There are isolated case reports or small case series reporting successful endoscopic closure of duodenal perforations. Endoscopic closure techniques include the use of endoclips, fibrin glue, and endoloops. Herein we report the largest series containing 4 cases of successful endoscopic closure of iatrogenic duodenal perforations related to endoscopic retrograde cholangiopancreatography by using endoclips and briefly review the endoscopic methods used in the closure of perforations in the light of current literature.
[Show abstract][Hide abstract] ABSTRACT: Bile leaks are a major cause of mortality and morbidity after liver resections. We prospectively evaluated the safety and efficacy of endoscopic treatment of biliary fistulas developing after liver resections in 15 patients. Fistulas developed after extended right hepatectomy in 4, extended left hepatectomy in 8, and segmentectomy in 3 patients. Median time interval between surgery and endoscopic intervention was 10 days (range, 7 to 35 d). Endoscopic sphincterotomy followed by a nasobiliary drain insertion was the initial treatment. If the fistula persisted after 2 weeks, nasobiliary drain was replaced by a plastic stent. The effect of output (low in 10 and high in 5 patients) and the origin of fistula (stump in 10 and resection surface of the liver in 5 patients) on the time for closure were evaluated. Bile leakage ceased by only nasobiliary drainage catheter placement in 11 patients (73.3%). Plastic stents were inserted in 4 patients. There was a significant correlation between the output of bile leakage and the time needed for fistula closure. Endoscopic treatment methods are effective in patients with bile leaks due to liver resections.
[Show abstract][Hide abstract] ABSTRACT: 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%.
A prospective randomized trial was conducted to assess whether alteration of patient position during colonoscopy withdrawal increases the adenoma detection rate (ADR).
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.
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.
Alteration of patient position during colonoscopy withdrawal is a simple and effective method to improve ADR.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 09/2013; 27(9):509-12.
[Show abstract][Hide abstract] ABSTRACT: Background/aims: Endoscopic retrograde cholangiopancreatography has become the standard treatment for common bile duct stones worldwide. However, there are only a few reports with small number of patients concerning the factors that contribute to the technical difficulty of endoscopic retrograde cholangiopancreatography in these patients. In this study we aimed to investigate these factors in a large group of patients. Materials and Methods: All patients with a naıïve papilla (n=1850) who underwent endoscopic retrograde cholangiopancreatography during a study period of 2 years were prospectively evaluated. Of these, 757 patients with common bile duct stones were included in the study. Following successful cannulation, patients who needed either more than one episode for stone extraction or mechanical lithotripsy, extracorporeal shock wave lithotripsy, or patients in whom stone extraction could not be achieved endoscopically and underwent surgery were regarded as having "difficult stones". Age, sex, laboratory parameters, endoscopic and cholangiographic findings were recorded in all patients. Predictive factors for difficult stones were investigated using univariate and multivariate analysis. Results: The study group consisted of 432 women and 325 men with a mean age of 60±16 years (range, 4-96). Of the total 757 patients, 654 (86.4%) had easy and 103 (13.6%) had difficult stones. Endoscopic stone extraction was successful in 98.1% of patients. A stricture distal to the stone (OR: 8.248), smaller common bile duct/stone diameter ratio (OR: 0,348), stone diameter (OR: 1,187) stone impaction (OR: 1,117) and higher bilirubin levels (OR: 1,1) were found to be independent predictors of difficult stone extraction on multivariate analysis. Conclusion: Endoscopic retrograde cholangiopancreatography is a very effective method for the treatment of common bile duct stones. Presence of a stricture distal to the stone, smaller common bile duct/stone diameter ratio, stone diameter, impacted stone, and higher bilirubin levels are significant predictors of difficult stone.
The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology 06/2013; 24(3):260-5. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Rheumatology International 12/2012; · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 45-year-old woman with the diagnosis of primary sclerosing cholangitis and ulcerative colitis admitted with the complaints of pruritus and jaundice. Endoscopic retrograde cholangiography revealed entirely narrow, irregular common bile duct and common hepatic duct and unusual cystic dilations in the common hepatic duct and left hepatic duct. Balloon dilation of the common bile duct was performed, and a 10 F double pigtail stent was inserted into the cyst. Three months after the endoscopic retrograde cholangiography, cystic dilatations had completely resolved. Primary sclerosing cholangitis may present with cystic dilatations upto a level that it may resemble Caroli disease.
The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology 12/2012; 23(6):792-4. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Anaplastic carcinoma of the pancreas is a rare and very aggressive tumor. It accounts for 2-7% of all pancreatic malignancies and occurs usually in older male patients (1,2). Three major histologic types have been described: spindle cell, sarcomatoid and pleomorphic carcinoma (3). While diagnosis can be made with surgical excision or surgical biopsy, diagnosis with endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) biopsy has become useful to obtain tissue samples in order to recognize this distinct entity. There have been only a few reports describing diagnosis of anaplastic carcinoma with EUS-FNA (4-6). A 60-year-old male was admitted complaining of abdominal pain, nausea, vomiting, and weight loss (8 kg/3 months). The patient had jaundice and had been examined in another center two weeks before, and was referred to us after placement of a plastic stent in the common bile duct. Laboratory investigations revealed hemoglobin (Hb): 12 g/L, total/direct bilirubin: 2.5/1.9 mg/dl, CEA: 8.5 (0-3.4) ng/ml, and CA19-9: 218.7 (<39) U/ml. Transabdominal US showed suspected pancreatic mass lesion, and abdominal computed tomography (CT) revealed a hypoechoic mass lesion in the head of the pancreas. Thin-section pancreatic-phase sequence showed circumferential encasement of the celiac axis as well as hepatic artery and peripancreatic lymphadenopathies. Tumor stage was determined as T4N1M0 and classified as unresectable. The pancreatic duct measured 5 mm at the body of the pancreas. EUS showed a hypoechoic, heterogeneous mass lesion (26x32 mm) in the pancreatic head and peripancreatic lymphadenopathies (Figure 1). EUS-FNA was performed to obtain histological confirmation of the lesion. Cytologically, the tumor, which consisted of distinctive pleomorphic cells, was diagnosed as an anaplastic carcinoma (Figure 2). The patient received two cycles of chemotherapy (gemcitabine). He had stent exchange due to occlusion of the stent at the common bile duct. He is still alive four months after the diagnosis. Anaplastic carcinoma of the pancreas is a rare and very aggressive tumor with survival prognosis oF several months. A variety of terms have been used to describe these tumors, including undifferentiated or pleomorphic carcinoma, pleomorphic giant cell carcinoma, small cell carcinoma, and sarcomatoid carcinoma (2,3). Weight loss, fatigue, loss of appetite, abdominal pain, nausea, and vomiting are the usual clinical presenting symptoms. There are two large series of anaplastic pancreatic carcinoma in the literature. Paal et al. (2) and Khashab et al. (4) described 35 and 13 anaplastic carcinomas of the pancreas, respectively. Paal's study was based on pathologic specimens of surgical materials, whereas in Khashab's study, the diagnosis was performed with cytologic samples of EUS-FNA biopsies (n=5) and surgical pathologies. There are also a limited number of case reports of anaplastic carcinoma diagnosed with EUS-FNA biopsy (5,6). Our case could be diagnosed based on cytologic examination obtained from the FNA biopsy. Cytopathologic examination revealed undifferentiated carcinoma with bizarre, pleomorphic cells in addition to spindle-shaped sarcomatous cells. EUS-FNA has become a widely accepted modality for the tissue diagnosis of pancreatic lesions. Moreover, EUS-FNA of pancreatic masses is safe and has an overall accuracy of 90% (7). EUS-FNA plays an important role in differentiating ductal carcinoma from other rare pancreatic mass lesions such as small cell carcinoma and pancreatic lymphoma, and from benign conditions like autoimmune pancreatitis, although the necessity of obtaining a cytologic or tissue diagnosis in pancreatic cancer prior to surgery remains controversial and is highly dependent on the institution (8). Arguments in favor of preoperative biopsy include its ability to provide proof of pathology prior to surgery, to exclude unusual pathologies, and to provide evidence of disease before the initiation of a multidisciplinary treatment, such as neoadjuvant chemotherapy. There can be only one potential problem for EUS-FNA, i.e. tumor seeding, but it is a very rare entity, with only two case reports at present (9,10). For unresectable cases, histologic confirmation and typing are absolutely necessary for chemotherapy. Although there are some CT and EUS features for discriminating between malignant and benign processes, their ability is limited, and EUS-FNA is one of the best procedures for obtaining a tissue diagnosis. Anaplastic carcinoma usually presents with giant mass lesion, and diagnosis is based on histology. In our case, the patient presented with jaundice, which enabled the definition of early diagnosis and better survival. Definitive diagnosis was made by EUS-FNA. Anaplastic pancreas carcinomas are associated with poorer survival when compared to invasive ductal adenocarcinomas. Neither curative resection nor chemotherapy or radiotherapy has been shown to have any benefit due to the aggressive nature and rapid recurrence rates of the disease (11). Palliative care and close monitoring are the only therapeutic options in most of the cases. Treatment alternatives for this dismal disease remain to be defined.
The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology 12/2012; 23(6):828-9. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND AIM: Endoscopic methods are effective in the control of endoscopic sphincterotomy (ES) bleeding. Initial failure or recurrent bleeding may develop in some patients, which may require angiographic or surgical interventions. We aimed to determine the factors leading to failure of endoscopic treatment methods. METHODS: Forty-six patients (1.37%) had endoscopic and/or clinically significant bleeding among a total of 3354 ESs (2998 primary, 356 re-ES) performed within 3 years. Forty-one patients (21 immediate, 20 late onset bleeding) underwent endoscopic treatment. Nineteen patients were treated initially by epinephrine injection and 22 with heat probe. The relation between demographic, laboratory parameters, presence of comorbidity, cholangitis, coagulopathy, and juxtapapillary diverticula, pre-cutting, type of ES, time and pattern of bleeding, treatment modality, the success and relapse of endoscopic treatment were evaluated. RESULTS: The first method was successful in the treatment of bleeding in 18 patients with heat probe and epinephrine injection, each. Presence of cholangitis, coagulopathy and increased international normalized ratio (INR) levels were found to determine the success of first treatment method. Bleeding could be stopped in all of the patients either with initially preferred or combined methods. Five patients developed recurrent bleeding. Presence of cholangitis, coagulopathy, increased INR levels, low thrombocyte counts and performance of precutting were factors predicting recurrence. Both of the treatment methods were 100% effective in patients without coagulopathy and none of the patients developed recurrent bleeding. CONCLUSIONS: Treatment of ES bleeding in patients with high risks such as coagulopathy require new effective methods. Patients with coagulopathy must be carefully followed for the development of recurrent bleeding.
Gastroentérologie Clinique et Biologique 11/2012; · 0.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/aims: Early repeat endoscopic retrograde cholangiopancreatography may be required due to various conditions in patients who underwent planned endoscopic retrograde cholangiopancreatography. We aimed to assess the factors leading to early repeat endoscopic retrograde cholangiopancreatography and to determine the patients who need closer follow-up. Materials and Methods: A total of 691 patients with a mean age of 60.3±16.4 years who had naive papilla on endoscopic retrograde cholangiopancreatography were involved in the study. The patients who required repeat endoscopic retrograde cholangiopancreatography were identified. Presentations, predictive factors, treatment modalities, and outcomes of the patients were investigated. Results: Early repeat endoscopic retrograde cholangiopancreatography was needed in 19 (2.7%) patients. The most common presentation was cholangitis in 10 (52.6%) and unresolved jaundice in 4 (21.1%). Multivariate analysis identified biliary stricture (p=0.024), stricture at the hilus (p=0.005) and unilateral drainage in the presence of hilar stricture (p=0.017) as the independent risk factors for early repeat endoscopic retrograde cholangiopancreatography. Stent migration or dysfunction was the most common underlying cause. Therapeutic interventions were nasobiliary drainage in 13, stent exchange in 4 and stone removal in 2. Additionally, percutaneous drainage in 4 patients, drainage of abscess in 2 patients and percutaneous drainage of gallbladder in 1 patient were performed. Three patients died due to their underlying illness. Conclusions: Unilateral stenting especially in hilar strictures is a predictive factor for early repeat endoscopic retrograde cholangiopancreatography with high mortality. These patients should be under close follow-up.
The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology 08/2012; 23(4):371-7. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Gastroentérologie Clinique et Biologique 06/2012; · 0.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The over-the-scope clip (OTSC) is a novel endoscopic tool used in the non surgical treatment of gastrointestinal perforations, fistula, and anastomotic leaks. AIMS: The aim of the present study was to evaluate the therapeutic efficacy of this new endoscopic device on anastomotic postsurgical leak and fistulas or GI perforation in a tertiary referral center. PATIENTS AND METHODS: The study group consisted of nine patients (three female, six male, age: 22-65 years). The indications were anastomotic leak in five patients, fistula in three patients, and perforation in one patient. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used. All of the patients were treated with only one OTSC. None of the patients underwent additional endoscopic treatments. RESULTS: The median size of the defects were 15mm (range 5-20mm). OTSC was favourable in five of nine patients (three with leak, and one with fistula and perforation, each). OTSC could not be deployed or partially closed the defect in the remaining four patients because of fibrosis at the edges of the defect. Excluding the case with perforation, the median time elapsed between the diagnosis and the placement of OTSC was 35 days (range: 20-80) in the successful group and 70 days (range: 38-94) in the unsuccessful group. There were no complications due to the OTSC application or the applicator cap. CONCLUSIONS: OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy is lower in cases with fistulas mainly due to associated fibrosis at the borders.
Gastroentérologie Clinique et Biologique 06/2012; · 0.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Juxtapapillary diverticula (JPD) can increase the difficulty of biliary cannulation. A number of additional methods have been defined in case of failed cannulation attempt by standard technique. We aimed to investigate the more commonly preferred and practical additional methods among them.
A total of 1,205 endoscopic retrograde cholangiopancreatographies (ERCP) performed during a study period of 14 months were prospectively entered into a database. Of these, 222 (18 %) had JPD (123 women, 99 men, mean age 69 years) and 983 had no diverticula (523 women, 460 men, mean age 57 years). Additional cannulation methods used in patients with JPD were recorded. Biliary cannulation time, total procedure time, use of pre-cut papillotomy, and therapeutic success of ERCP were compared between the groups as well.
Biliary cannulation was performed by standard technique in 210 patients with JPD (94.5 %). Cannulation was achieved by placement of a guidewire into the pancreatic duct in 6 (2.7 %) and use of two devices in one channel in 2 (0.9 %) patients. There was no significant difference between the total procedure time and therapeutic success of ERCP between the groups. Cannulation time was significantly longer in patients with JPD. Pre-cut papillotomy was performed less in patients with JPD.
Presence of JPD does not decrease the therapeutic success of ERCP. Placement of a guidewire in the pancreatic duct or use of two-devices-in-one-channel are practical, successful, safe, and preferred methods which can be used in patients with failed cannulation by standard technique.
Digestive Diseases and Sciences 05/2012; 57(11):2982-7. · 2.26 Impact Factor