TASL practice guidance on the clinical assessment and management of patients with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primar-ily intended for gastroenterology, endocrinology, metabolism diseases, cardi-ology, internal medicine, pediatric specialists, and family medicine specialists

Real-world efficacy and safety of Ledipasvir plus Sofosbuvir and Ombitasvir/Paritaprevir/Ritonavir +/- Dasabuvir combination therapies for chronic hepatitis C: A Turkish experience

Background/Aims: This study aimed to evaluate the real-life efficacy and tolerability of direct-acting antiviral treatments for patients with chronic hepatitis C (CHC) with/without cirrhosis in the Turkish population.Material and Methods: A total of 4,352 patients with CHC from 36 different institutions in Turkey were enrolled. They received ledipasvir (LDV) and sofosbuvir (SOF)+/- ribavirin (RBV) ombitasvir/paritaprevir/ritonavir +/- dasabuvir (PrOD)+/- RBV for 12 or 24 weeks. Sustained virologic response (SVR) rates, factors affecting SVR, safety profile, and hepatocellular cancer (HCC) occurrence were analyzed.Results: SVR12 was achieved in 92.8% of the patients (4,040/4,352) according to intention-to-treat and in 98.3% of the patients (4,040/4,108) according to per-protocol analysis. The SVR12 rates were similar between the treatment regimens (97.2%-100%) and genotypes (95.6%-100%). Patients achieving SVR showed a significant decrease in the mean serum alanine transaminase (ALT) levels (50.90 +/- 54.60 U/L to 17.00 +/- 14.50 U/L) and model for end-stage liver disease (MELD) scores (7.51 +/- 4.54 to 7.32 +/- 3.40) (p<0.05). Of the patients, 2 were diagnosed with HCC during the treatment and 14 were diagnosed with HCC 37.0 +/- 16.0 weeks post-treatment. Higher initial MELD score (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.22-2.38; p=0.023]), higher hepatitis C virus (HCV) RNA levels (OR: 1.44, 95% CI: 1.31-2.28; p=0.038), and higher serum ALT levels (OR: 1.38, 95% CI: 1.21-1.83; p=0.042) were associated with poor SVR12. The most common adverse events were fatigue (12.6%), pruritis (7.3%), increased serum ALT (4.7%) and bilirubin (3.8%) levels, and anemia (3.1%).Conclusion: LDV/SOF or PrOD +/- RBV were effective and tolerable treatments for patients with CHC and with or without advanced liver disease before and after liver transplantation. Although HCV eradication improves the liver function, there is a risk of developing HCC.Turkish Association for the Study of The Liver (TASL

Karaciğer sirozu histopatolojik bulguları ile özofagus varisi varlığı arasındaki ilişki

Çesitli çalısmalarda özofagus varisi varlığını predikte eden bazı parametreler ortaya konulmustur. Bu çalısmanın amacı, siroz histopatolojik bulgularının klinik ve laboratuvar parametrelerle birlikte değerlendirilerek; portal hipertansiyon bulgusu olan özofagus varisi ile iliskisini incelemektir. Çalısmaya histopatolojik olarak siroz tanısı alan ve dosya bilgileri retrospektif olarak incelenen 42 erkek, 25 kadın, ortalama yas 51.6 ± 19.0 (yas aralığı 1-81) yıl olan toplam 67 hasta alındı. Biyopsi örnekleri fibrozis, nodülarite, portal alan kaybı, santral ven kaybı, inflamasyon ve steatoz açısından derecelendirildi. Ultrasonografik olarak dalak boyutu ve endoskopik olarak da özofagus varisleri derecelendirildi. Ayrıca trombosit değerleri ve Child-Pugh skorları kaydedildi. Hastaların 12’sinde (%17.9) mikronoduler, 27’sinde (%40.3) mikst noduler, 28’inde (%41.8) makronoduler siroz saptandı. Child-Pugh A, B ve C dağılım oranları sırasıyla %74.6, %11.9 ve %13.4 idi. Tek değiskenli analizle incelendiğinde yas ( p<0.001), trombosit sayısı (p=0.04), Child- Pugh puanı (p=0.001), özofagus varisi (p=0.001), büyük özofagus varisi (p=0.03) ve splenomegali varlığı (p=0.02) ile nodül morfolojisi, Child-Pugh puanının yüksekliği (p= 0.047) ile septal fibrozis kalınlığı, santral ven kaybı ile özofagus varisi varlığı (p= 0.03) ve cinsiyet ( p=0.02 ), hepatosteatoz ile Child-Pugh puanı (p=0.005) arasında anlamlı iliskili bulundu. Bu anlamlı iliskilere karsın diğer histolojik parametreler olan; sinüzoidal fibrozis, portal alan kaybı ve interfaz inflamasyon (interfaz hepatit) ile portal hipertansiyonun klinik ve laboratuvar parametreleri ve yas-cinsiyet gibi demografik parametreler arasında istatistiki olarak anlamlı bir iliski gözlenmedi. Tek değiskenli analizde özofagus varis varlığı ile iliskili bulunan parametrelerin çok değiskenli regresyon analizi yapıldığında; ileri hastalık evresi [Child-Pugh puanı OR: 1.47, (C.I. % 95,0 ): 1.018-2.121, p=0.040 ], mikronodülarite varlığı [OR: 0.318, (C.I. % 95,0 ): 0.120-0.842, p=0.021] ve santral ven kaybının derecesi [OR: 5.231, (C.I. % 95,0 ): 1.132-24.176, p=0.034]ile özofagus varis varlığı arasında iliski saptandı. Ancak büyük özofagus varisi varlığı açısından benzer anlamlı bir iliski bulunamadı. Trombositopeni ile de anlamlı bir iliski görülemedi. Sonuç olarak, trombositopeni ve splenomegali büyük özofagiyal varis varlığını predikte edebilse de; varis varlığında asıl etken siroz histopatolojisi ile ilgili özelliklerdir. Varis taramasında bazı histolojik lezyonların eslik ettiği siroz tanısının kendisi önemli ve yeterli bir sebep olarak görünmektedir

Ateroskleroz ve asetilsalisilik asit gastrik ve duodenal ülser kanaması için bağımsız risk faktörleridir

Üst gastrointestinal (Gİ) endoskopide gastrik ve/veya duodenal ülser saptanan vakalarda ülser kanaması için risk faktörleri araştırıldı. Yöntemler: Üst Gİ endoskopisinde duodenum ve gastrik ülser saptanan 350 vakanın (226 Erkek, 124 Kadın) dosyalarından retrospektif analiz yapıldı. İncelenen 92 vakada endoskopi sırasında Gİ kanama saptanmıştı. Kanaması olan ve olmayan hastaların tümünde nonsteroidal antienflamatuvar ilaç (NSAID) ve asetil salisilik asit (ASA) kullanımı ile koroner arter hastalığı (KAH) varlığı araştırıldı. Sonuçlar Ki-kare testi ve lojistik regresyon analizi ile değerlendirildi. Bulgular: Vakaların yaş ortalaması 50.4±15.7 (25- 82) yıl idi. Doksan iki vakada (%26) gastrik veya duodenal ülsere bağlı kanama görüldü. Kanamalı hastalarda yaş ortalaması 64.6±11.4/ yıl, kanama olmayanlarda 45.7±13.9/yıl idi. Ülser kanaması olan vakalarda ASA kullanımı daha fazlaydı (NSAID, n=35 (%40); ASA, n=51 (%60); p=0.035). Ülseri olan kadınların %20’sinde kanama görülürken, erkeklerin %28’inde kanama görüldü (p=0.055). Kanama riski KAH’lı vakalarda (OR:24.75, %95 güven aralığı (GA)=1.6-96.7, p=0.001), ASA (OR:9.76, %95 GA=2.1-37.5, p=0.021), NSAID (OR:4.72, %95 GA=1.1-16.5 p=0.032), yaş (OR:11.59, %95 GA=2.7-12.1, p=0.001), erkek cinsiyet için (OR:2.56, %95 GA=0.8, 9.6, p=0.052) olarak belirlendi. Sonuç: İleri yaş, ateroskleroz, erkek cinsiyet ve NSAİD (özellikle aspirin) kullanımı gastrik ve/veya duodenal ülserli hastalarda üst Gİ kanaması bakımından majör risk faktörleridir.Risk factors for hemorrhage due to gastric and/or duodenal ulcer in patients diagnosed by upper gastrointestinal (GI) endoscopy were investigated in the present study. Methods: Medical records of 350 patients (226 males, 124 females) diagnosed as duodenal or gastric ulcers by GI endoscopy in the gastroenterology clinic were scanned retrospectively. Upper GI hemorrhage was detected in 92 patients by upper endoscopic examination. The medical history of non-steroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA) usage and the presence of coronary artery disease (CAD) were investigated in all patients with or without hemorrhage. Results were evaluated by Chi-square test and logistic regression analysis. Results: The mean age of the patients was 50.4±15.7 years (range: 25 to 82 years). Hemorrhage due to gastric or duodenal ulcer was identified in 92 patients (26%). Mean age was 64.6±11.4 years in patients with hemorrhage and 45.7±13.9 years in patients without hemorrhage. ASA usage was more common than NSAID in patients with ulcer hemorrhage (NSAID usage n=35 (40%); ASA usage n=51 (60%); p=0.035). Hemorrhage was reported in 20% of the females and in 28% of the males who have ulcer (p=0.055). Risk factors for hemorrhage were CAD (OR:24.75, 95% CI=1.6-96.7, p=0.001), ASA usage (OR:9.76, 95% CI=2.1-37.5, p=0.021), NSAID usage (OR: 4.72, 95%CI=1.1-16.5, p=0.032), age (OR: 11.59, 95% CI= 2.7-12.1, p=0.001), and male gender (OR: 2.56, 95% CI= 0.8, 9.6, p=0.052). Conclusion: Advanced age, atherosclerosis, male gender and NSAID administration (particularly aspirin) are the major risk factors of upper GI hemorrhage in patients with gastric and/or duodenal ulcer

The relationship of recurrent aphthous stomatitis and Helicobacter pylori, cytokine gene polymorphism and cobalamin

Background/Aims: The aim of the present study was to investigate whether Helicobacter pylori causes or triggers recurrent aphthous stomatitis (RAS) through cytokine gene polymorphism and/or cobalamin deficiency.Materials and Methods: Thirty-six patients with RAS and 130 patients without RAS were genotyped for IL-1? (?511C/T) and IL-6 (?174G/C) and evaluated for H. pylori infection and serum cobalamin level.Results: The patient groups according to RAS had similar rates of H. pylori gastritis and interleukin genotypes/alleles, and there was a non-significant difference between serum cobalamin levels (p>0.05). RAS patients with H. pylori gastritis showed a higher frequency (51.9%) of GC IL-6 genotype than RAS patients without H. pylori gastritis (11.1%) (p=0.036). Non-GG genotype and C allele were increased in patients without RAS and with H. pylori gastritis (p0.05). RAS patients with H. pylori gastritis showed a higher frequency (51.9%) of GC IL-6 genotype than RAS patients without H. pylori gastritis (11.1%) (p=0.036). Non-GG genotype and C allele were increased in patients without RAS and with H. pylori gastritis (p<0.05). Patients with H. pylori gastritis showed a lower value of serum cobalamin without statistical significance, although this difference was more prominent in RAS patients (p=0.07).Conclusion: The carriage of the C allele of IL-6 may lead a susceptibility to chronic gastric inflammation after contamination with H. pylori. If H. pylori infection is justified as a predisposing factor for RAS and its severity by further studies, we can speculate that subjects with genetic susceptibility to this infection may benefit from H. pylori eradication treatment with respect to RA

Multiple common bile duct and gallbladder stones: A case report and literature review

Ana safra yolu taşları, koledoktan kaynaklanan primer taşlar olabileceği gibi, safra kesesinden düşmüş sekonder taşlar şeklinde de gelişebilir. Bunlar tekli veya çoklu olabilirler. Safra kesesi taşı olan hastaların %15'inde ana safra yolunda taş bulunur. Sekonder taşlar genellikle bilirubin ve kolesterol taşlarıdır. Primer koledok taşları kolesistektomiden en az 2 yıl sonra oluşan taşlardır. Bunlar da genellikle bilirubin ve kolesterol taşları olup kalsiyum taşları nadir görülür. Burada sunduğumuz hastada endoskopik retrograt kolanjiopankreotografi (ERCP) ile koledoktan altmış beş adet yaklaşık 10 mm çapta kalsiyum taşı çıkarıldı. Daha önceden de aynı hastadan kolesistektomi ile birlikte kırk dört adet 10 mm ve yirmi iki adet 5-10 mm çapta taş çıkarılmıştı. Koledokta büyük boyutta ve çok sayıda sekonder gelişen kalsiyum taşlarının nadir görülmesi nedeniyle bu olgu ilginç bulunmuştur.Common bile duct stones may be primary stones originating from the duct itself or secondary stones that have fallen out of the gallbladder. They can be single or multiple. Common bile duct stones are found in 15 % of a group of patients with gallbladder stones. Secondary stones are generally bilirubin and cholesterol stones. Primary bile duct stones occur at least 2 years after cholecystectomy. These stones are also bilirubin and cholesterol stones and calcium stones are rarely detected. In this patient presented here, sixty five stones nearly 10 mm were extracted from the common bile duct by endoscopic retrograde cholangiopancreatography. Previously, fourty four 10 mm stones and twenty two 5 mm to 10 mm stones had been removed during cholecystectomy. This case is interesting for multiple and large size calcium carbonate stones that are secondary, which in the common bile duct are usually encountered