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1.  Body mass index and colon cancer screening: The road ahead 
Screening for colorectal cancer (CRC) has been associated with a decreased incidence and mortality from CRC. However, patient adherence to screening is less than desirable and resources are limited even in developed countries. Better identification of individuals at a higher risk could result in improved screening efforts. Over the past few years, formulas have been developed to predict the likelihood of developing advanced colonic neoplasia in susceptible individuals but have yet to be utilized in mass screening practices. These models use a number of clinical factors that have been associated with colonic neoplasia including the body mass index (BMI). Advances in our understanding of the mechanisms by which obesity contributes to colonic neoplasia as well as clinical studies on this subject have proven the association between BMI and colonic neoplasia. However, there are still controversies on this subject as some studies have arrived at different conclusions on the influence of BMI by gender. Future studies should aim at resolving these discrepancies in order to improve the efficiency of screening strategies.
PMCID: PMC4316079  PMID: 25663756
Body mass index; Colorectal cancer; Colon cancer screening; Adenomas; Adipokines; Obesity
2.  Same-day colonoscopy preparation with Senna alkaloids and bisacodyl tablets: A pilot study 
World Journal of Gastroenterology : WJG  2014;20(41):15382-15386.
AIM: To evaluate the efficacy of same-day bowel preparation with Senna alkaloids combined with bisacodyl tablets in routine colonoscopy procedures.
METHODS: Between March and June 2013, a same-day bowel preparation was implemented in our endoscopy unit. The preparation consisted of a semi-liquid, fiber-free diet one day prior to the procedure, with two bisacodyl tablets after lunch and dinner, and 250 mL of Senna alkaloid with 1.5 L of drinking water at 6 am the day of the procedure. The quality control parameters of colonoscopy were evaluated and implemented according to the guidelines of the American Society for Gastrointestinal Endoscopy. The pre-procedure, during-procedure and post-procedure patient data were collected and analyzed: (1) pre-procedure (age, gender, comorbid diseases, colonoscopy indications, complete lack of compliance with the bowel preparation protocol); (2) during-procedure (sedation dose, duration of colonoscopy, withdrawal time, cecal intubation rate, polyp detection rate, Boston Bowel Preparation Scores and presence of foam and clear liquid); and (3) post-procedure (visual analogue scale score, pain during the procedure, patient satisfaction and premature withdrawal due to the insufficient bowel preparation).
RESULTS: A total of 75 patients were included in this study with a mean age of 54.64 ± 13.29 years; 53.3% (40/75) were female and 46.7% (35/75) were male. A complete lack of compliance with the bowel preparation protocol was seen in 6.7% of patients (5/75). The mean total duration of colonoscopy was 16.12 ± 6.51 min, and the mean withdrawal time was 8.89 ± 4.07 min. The cecal intubation rate was 93.8% (61/64) and the polyp detection rate was 40% (30/75). The mean Boston Bowel Preparation Score was 7.38 ± 1.81, with the following distribution: right colon, 2.34 ± 0.89; transverse colon, 2.52 ± 0.67; left colon, 2.52 ± 0.63. The mean visual analogue scale score was 4.59 ± 1.57. Due to insufficient bowel preparation, seven patients (7/75; 9.3%) were asked to repeat the procedure. Of these, five patients had poor or modest compliance with the protocol, and two patients reported constipation. Premature withdrawal due to insufficient bowel preparation was 2.7% (2/75). The overall satisfaction with the protocol was 86.7% (65/75), with patients reporting they would prefer the same protocol in a repeat procedure.
CONCLUSION: The same-day administration of Senna alkaloids appears to be a safe and effective bowel cleansing protocol for colonoscopy procedures.
PMCID: PMC4223273  PMID: 25386088
Bisacodyl; Bowel preparation; Colonoscopy; Same-day preparation; Senna alkaloid
3.  Protective effects of intravenous anesthetics on kidney tissue in obstructive jaundice 
AIM: To evaluate the protective effects on kidney tissue of frequently used intravenous anesthetics (ketamine, propofol, thiopental, and fentanyl) in rats with obstructive jaundice.
METHODS: There is an increased incidence of postoperative acute renal failure in patients with obstructive jaundice. Thirty-two Wistar-albino rats were randomly divided into four equal groups. Laparatomy was performed on each animal in the four groups and common bile ducts were ligated and severed on day 0. After 7 d, laparotomy was again performed using ketamine, propofol, thiopental, or fentanyl anesthesia whose antioxidative properties are well known in oxidative stress in a rat liver model of obstructive jaundice. After 2 h, the rats were sacrificed. Renal tissue specimens were analyzed for catalase, superoxide dismutase and malondialdehyde enzymes activities. All values are expressed as the mean ± SD. P values less than 0.05 were considered statistically significant.
RESULTS: All animals survived without complications until the end of the study. Enlargement in the bile duct and obstructive jaundice were observed in all rats. Catalase was found to be significantly lower in the fentanyl group than in the ketamine (P = 0.039), propofol (P = 0.012), and thiopental (P = 0.001) groups. Superoxide dismutase activities were similar in all groups (P > 0.05). Malondialdehyde was found to be significantly lower in the ketamine group than in the propofol (P = 0.028), thiopental (P = 0.002) and fentanyl (P = 0.005) groups. Malondialdehyde was also lower in the fentanyl group than in the thiopental group (P = 0.001). The results showed that obstructive jaundice sensitizes renal tissue to damage under the different anesthetics.
CONCLUSION: Among the agents tested, ketamine and propofol generated the least amount of oxidative stres on renal tissues in this rat model of obstructive jaundice created by common bile duct ligation. The importance of free radical injury in renal tissue in obstructive jaundice under different intravenous anesthetics during hepatobiliary and liver transplant surgery should be considered for prevention of postoperative acute renal failure.
PMCID: PMC3964402  PMID: 24695809
Obstructive jaundice; Postoperative acute renal failure; Oxidative stress; Intravenous anesthetics; Renal tissue damage
4.  Biliary fistula after treatment for hydatid disease of the liver: When to intervene 
AIM: To determine the outcome of patients with biliary fistula (BF) after treatment for hydatid disease of the liver.
METHODS: Between January 2000 and December 2010, out of 301 patients with a diagnosis of hydatid cyst of the liver, 282 patients who underwent treatment [either surgery or puncture, aspiration, injection and reaspiration (PAIR) procedure] were analysed. Patients were grouped according to the presence or absence of postoperative biliary fistula (PBF) (PBF vs no-PBF groups, respectively). Preoperative clinical, radiological and laboratory characteristics, operative characteristics including type of surgery, peroperative detection of BF, postoperative drain output, morbidity, mortality and length of hospital stays of patients were compared amongst groups. Multivariate analysis was performed to detect factors predictive of PBF. Receiver operative characteristics (ROC) curve analysis were used to determine ideal cutoff values for those variables found to be significant. A comparison was also made between patients whose fistula closed spontaneously (CS) and those with intervention in order to find predictive factors associated with spontaneous closure.
RESULTS: Among 282 patients [median (range) age, 23 (16-78) years; 77.0% male]; 210 (74.5%) were treated with conservative surgery, 33 (11.7%) radical surgery and 39 (13.8%) underwent percutaneous drainage with PAIR procedure A PBF developed in 46 (16.3%) patients, all within 5 d after operation. The maximum cyst diameter and preoperative alkaline phosphatase levels (U/L) were significantly higher in the PBF group than in the no-PBF group [10.5 ± 3.7 U/L vs 8.4 ± 3.5 U/L (P < 0.001) and 40.0 ± 235.1 U/L vs 190.0 ± 167.3 U/L (P = 0.02), respectively]. Hospitalization time was also significantly longer in the PBF group than in the no-PBF group [37.4 ± 18.0 d vs 22.4 ± 17.9 d (P < 0.001)]. A preoperative high alanine aminotransferase level (> 40 U/L) and a peroperative attempt for fistula closure were significant predictors of PBF development (P = 0.02, 95%CI: -0.03-0.5 and P = 0.001, 95%CI: 0.1-0.4), respectively. Comparison of patients whose PBF CS or with biliary intervention (BI) revealed that the mean diameter of the cyst was not significantly different between CS and BI groups however maximum drain output was significantly higher in the BI group (81.6 ± 118.1 cm vs 423.9 ± 298.4 cm, P < 0.001). Time for fistula closure was significantly higher in the BI group (10.1 ± 3.7 d vs 30.7 ± 15.1 d, P < 0.001). The ROC curve analysis revealed cut-off values of a maximum bilious drainage < 102 mL and a waiting period of 5.5 postoperative days for spontaneous closure with the sensitivity and specificity values of (83.3%-91.1%, AUC: 0.90) and (97%-91%, AUC: 0.95), respectively. The multivariate analysis demonstrated a PBF drainage volume < 102 mL to be the only statistically significant predictor of spontaneous closure (P < 0.001, 95%CI: 0.5-1.0).
CONCLUSION: Patients with PBF after hydatid surgery often have complicated postoperative course with serious morbidity. Patients who develop PBF with an output < 102 mL might be managed expectantly.
PMCID: PMC3554819  PMID: 23372357
Hydatid disease; Biliary fistula; Postoperative complications; Surgery
5.  Hepatitis B virus pre-S2 start codon mutations in Indonesian liver disease patients 
AIM: To identify the prevalence of pre-S2 start codon mutations and to assess their association with liver disease progression.
METHODS: The mutations were identified by direct sequencing from 73 asymptomatic carriers, 66 chronic hepatitis (CH), 66 liver cirrhosis (LC) and 63 hepatocellular carcinoma (HCC) patients. Statistical significances were determined using Fisher’s exact test, χ2 test, and t-test analyses whenever appropriate. Pre-S mutation as a risk factor for advanced liver disease was estimated by unconditional logistic regression model adjusted with age, sex, and hepatitis B e antigen (HBeAg). P < 0.05 was considered significant.
RESULTS: Mutation of the hepatitis B virus (HBV) pre-S2 start codon was found in 59 samples from 268 subjects (22.0%), with higher prevalence in patients with cirrhosis 27/66 (40.9%) followed by HCC 18/63 (28.6%), chronic hepatitis 12/66 (18.2%) and asymptomatic carriers 2/73 (2.7%) (P < 0.001). Logistic regression analysis showed that pre-S2 start codon mutation was an independent factor for progressive liver disease. Other mutations, at T130, Q132, and A138, were also associated with LC and HCC, although this was not statistically significant when adjusted for age, sex, and HBeAg. The prevalence of pre-S2 start codon mutation was higher in HBV/B than in HBV/C (23.0% vs 19.1%), whilst the prevalence of T130, Q132, and A138 mutation was higher in HBV/C than in HBV/B. The prevalence of pre-S2 start codon mutation was higher in LC (38.9%) and HCC (40.0%) than CH (5.6%) in HBeAg(+) group, but it was similar between CH, LC and HCC in HBeAg(-) group.
CONCLUSION: Pre-S2 start codon mutation was higher in Indonesian patients compared to other Asian countries, and its prevalence was associated with advanced liver disease, particularly in HBeAg(+) patients.
PMCID: PMC3471111  PMID: 23082059
Hepatitis B virus; Pre-S2 start codon; Liver disease; Hepatitis B e antigen seroconversion; Indonesia
6.  Gastric carcinogenesis 
Gastric cancer is the second most common cancer worldwide and the second most common cause of cancer-related deaths. Despite complete resection of gastric cancer and lymph node dissection, as well as improvements in chemotherapy and radiotherapy, there are still 700 000 gastric cancer-related deaths per year worldwide and more than 80% of patients with advanced gastric cancer die of the disease or recurrent disease within 1 year after diagnosis. None of the treatment modalities we have been applying today can influence the overall survival rates: at present, the overall 5-year relative survival rate for gastric cancer is about 28%. Cellular metaplasia due to chronic inflammation, injury and repair are the most documented processes for neoplasia. It appears that chronic inflammation stimulates tumor development and plays a critical role in initiating, sustaining and advancing tumor growth. It is also evident that not all inflammation is tumorigenic. Additional mutations can be acquired, and this leads to the cancer cell gaining a further growth advantage and acquiring a more malignant phenotype. Intestinalization of gastric units, which is called “intestinal metaplasia”; phenotypic antralization of fundic units, which is called “spasmolytic polypeptide-expressing metaplasia”; and the development directly from the stem/progenitor cell zone are three pathways that have been described for gastric carcinogenesis. Also, an important factor for the development of gastrointestinal cancers is peritumoral stroma. However, the initiating cellular event in gastric metaplasia is still controversial. Understanding gastric carcinogenesis and its precursor lesions has been under intense investigation, and our paper attempts to highlight recent progress in this field of cancer research.
PMCID: PMC3468847  PMID: 23066309
Gastric Cancer; Cancer Stem Cell; Carcinogenesis; Oncogenesis; Tumorigenesis
7.  p53 antibodies, metallothioneins, and oxidative stress markers in chronic ulcerative colitis with dysplasia 
AIM: To investigate the role of p53 antibodies (p53Abs), metallothioneins (MTs) and oxidative stress markers in the early detection of dysplasia in chronic ulcerative colitis (UC).
METHODS: The study included 30 UC patients, 15 without dysplasia (group II) and 15 with dysplasia (group III), in addition to 15 healthy volunteers (group I, control subjects). The enzyme-linked immunosorbent assay technique was used to measure serum p53Abs and MTs, while advanced oxidation protein products (AOPPs), and reduced glutathione (GSH) levels were measured by spectrophotometric method in all subjects.
RESULTS: In group II and group III compared to group I, there were significant increases in serum levels of AOPPs (145.94 ± 29.86 μmol/L and 192.21 ± 46.71 μmol/L vs 128.95 ± 3.06 μmol/L, P < 0.002 and P < 0.001, respectively), MTs (8.18 ± 0.35 μg/mL and 9.20 ± 0.58 μg/mL vs 6.12 ± 0.25 μg/mL, P < 0.05 and P < 0.05, respectively), and p53Abs (20.19 ± 3.20 U/mL and 34.66 ± 1.34 U/mL vs 9.42 ± 1.64 U/mL, P < 0.001 and P < 0.001, respectively). There were significantly higher levels of AOPPs (P < 0.05) and p53Abs (P < 0.001) in UC patients with dysplasia compared to those without dysplasia, while MTs showed no significant difference between the 2 groups (P > 0.096). In contrast, GSH levels showed a significant decrease in both patients’ groups (1.87 ± 0.02 μmol/mL and 1.37 ± 0.09 μmol/mL vs 2.49 ± 0.10 μmol/mL, P < 0.05 and P < 0.05 in groups II and III, respectively) compared with group I, and the levels were significantly lower in group III than group II (P < 0.05). There was a positive correlation between AOPPs and both MTs (r = 0.678, P < 0.001) and p53Abs (r = 0.547, P < 0.001), and also between p53Abs and MTs (r = 0.739, P < 0.001). There was a negative correlation between AOPPs and GSH (r = -0.385, P < 0.001), and also between GSH and both MTs (r = -0.662, P < 0.001) and p53Abs (r = -0.923, P < 0.001).
CONCLUSION: Oxidative stress and oxidative cellular damage play an important role in the pathogenesis of chronic UC and the associated carcinogenetic process. p53Abs levels could help in early detection of dysplasia in these conditions.
PMCID: PMC3103795  PMID: 21633642
Ulcerative colitis; Advanced oxidation protein products; Reduced glutathione; Metallothionein
8.  Levels of matrix metalloproteinase-1 and tissue inhibitors of metalloproteinase-1 in gastric cancer 
AIM: To evaluate the levels of preoperative serum matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in gastric cancer.
METHODS: One hundred gastric cancer patients who underwent gastrectomy were enrolled in this study. The serum concentrations of MMP-1 and TIMP-1 in these patients and in fifty healthy controls were determined using an enzyme-linked immunosorbent assay.
RESULTS: Higher serum MMP-1 and TIMP-1 levels were observed in patients than in controls (P < 0.001). Serum MMP-1 and TIMP-1 levels were positively associated with morphological appearance, tumor size, depth of wall invasion, lymph node metastasis, liver metastasis, perineural invasion, and pathological stage. They were not significantly associated with age, gender, tumor location, or histological type.
CONCLUSION: Increased MMP-1 and TIMP-1 were associated with gastric cancer. Although these markers are not good markers for diagnosis, these markers show in advanced gastric cancer.
PMCID: PMC3084396  PMID: 21547130
Gastric cancer; Matrix metalloproteinase-1; Tissue matrix metalloproteinase-1
9.  Insulin like growth factor-1 increases fatty liver preservation in IGL-1 solution 
AIM: To investigate the benefits of insulin like growth factor-1 (IGF-1) supplementation to serum-free institut georges lopez-1 (IGL-1)® solution to protect fatty liver against cold ischemia reperfusion injury.
METHODS: Steatotic livers were preserved for 24 h in IGL-1® solution supplemented with or without IGF-1 and then perfused “ex vivo” for 2 h at 37°C. We examined the effects of IGF-1 on hepatic damage and function (transaminases, percentage of sulfobromophthalein clearance in bile and vascular resistance). We also studied other factors associated with the poor tolerance of fatty livers to cold ischemia reperfusion injury such as mitochondrial damage, oxidative stress, nitric oxide, tumor necrosis factor-α (TNF-α) and mitogen-activated protein kinases.
RESULTS: Steatotic livers preserved in IGL-1® solution supplemented with IGF-1 showed lower transaminase levels, increased bile clearance and a reduction in vascular resistance when compared to those preserved in IGL-1® solution alone. These benefits are mediated by activation of AKT and constitutive endothelial nitric oxide synthase (eNOS), as well as the inhibition of inflammatory cytokines such as TNF-α. Mitochondrial damage and oxidative stress were also prevented.
CONCLUSION: IGL-1® enrichment with IGF-1 increased fatty liver graft preservation through AKT and eNOS activation, and prevented TNF-α release during normothermic reperfusion.
PMCID: PMC2997984  PMID: 21128318
AKT; Institut georges lopez-1® solution; Insulin like growth factor-1; Ischemia reperfusion injury; Nitric oxide; Oxidative stress; Steatotic graft preservation
10.  Outcome of surgical treatment of intestinal perforation in typhoid fever 
AIM: To represent our clinical experience in the treatment of intestinal perforation arising from typhoid fever.
METHODS: The records of 22 surgically-treated patients with typhoid intestinal perforation were evaluated retrospectively.
RESULTS: There were 18 males and 4 females, mean age 37 years (range, 8-64 years). Presenting symptoms were fever, abdominal pain, diarrhea or constipation. Sixteen cases were subjected to segmental resection and end-to-end anastomosis, while 3 cases received 2-layered primary repair following debridement, one case with multiple perforations received 2-layered primary repair and end ileostomy, one case received segmental resection and end-to-end anastomosis followed by an end ileostomy, and one case received segmental resection and end ileostomy with mucous fistula operation. Postoperative morbidity was seen in 5 cases and mortality was found in one case.
CONCLUSION: Intestinal perforation resulting from Salmonella typhi is an important health problem in Eastern and Southeastern Turkey. In management of this illness, early and appropriate surgical intervention is vital.
PMCID: PMC2932920  PMID: 20806433
Intestinal perforation; Typhoid fever; Treatment
11.  Hypoxia inducible factor-1α accumulation in steatotic liver preservation: Role of nitric oxide 
AIM: To examine the relevance of hypoxia inducible factor (HIF-1) and nitric oxide (NO) on the preservation of fatty liver against cold ischemia-reperfusion injury (IRI).
METHODS: We used an isolated perfused rat liver model and we evaluated HIF-1α in steatotic and non-steatotic livers preserved for 24 h at 4°C in University of Wisconsin and IGL-1 solutions, and then subjected to 2 h of normothermic reperfusion. After normoxic reperfusion, liver enzymes, bile production, bromosulfophthalein clearance, as well as HIF-1α and NO [endothelial NO synthase (eNOS) activity and nitrites/nitrates] were also measured. Other factors associated with the higher susceptibility of steatotic livers to IRI, such as mitochondrial damage and vascular resistance were evaluated.
RESULTS: A significant increase in HIF-1α was found in steatotic and non-steatotic livers preserved in IGL-1 after cold storage. Livers preserved in IGL-1 showed a significant attenuation of liver injury and improvement in liver function parameters. These benefits were enhanced by the addition of trimetazidine (an anti-ischemic drug), which induces NO and eNOS activation, to IGL-1 solution. In normoxic reperfusion, the presence of NO favors HIF-1α accumulation, promoting also the activation of other cytoprotective genes, such as heme-oxygenase-1.
CONCLUSION: We found evidence for the role of the HIF-1α/NO system in fatty liver preservation, especially when IGL-1 solution is used.
PMCID: PMC2909549  PMID: 20653058
Fatty liver; Tissue preservation; Hypoxia inducible factor-1α; IGL-1; Nitric oxide; Trimetazidine
12.  Comparison of a modified anoscope and the purse-string anoscope in stapled haemorrhoidopexy 
AIM: To compare the results of the anoscope of the PPH kit and a modified anoscope during stapled haemorrhoidopexy.
METHODS: The hospital records of 37 patients who underwent stapled haemorrhoidopexy between 2001 and 2006 were reviewed. The purse-string suture anoscope in the PPH kit was used on 15 patients (Group 1), and the modified anoscope was used on 22 patients (Group 2). Demographic characteristics of the patients, operation time, surgeon’s performance, analgesic requirement, and complications were compared.
RESULTS: Operation time was significantly longer in Group 1 (42.0 ± 8.4 min vs 27.7 ± 8.0 min, P = 0.039). The surgeons reported their operative performance as significantly better in Group 2 (the results of the assessments were poor in ten, medium in four and good in one in Group 1, while good in all patients in Group 2, P < 0.001). The need for haemostatic sutures was significantly higher in Group 1 (six cases) and was needed in two cases in Group 2 (P = 0.034).
CONCLUSION: Operation time decreased and the surgeon’s satisfaction increased with use of the modified anoscope, and fewer haemostatic sutures were required if the surgeon waited longer before and after firing the stapler.
PMCID: PMC2785061  PMID: 19938197
Haemorrhoidal disease; Modified anoscope; Purse-string suture; Stapled haemorrhoidopexy; Stapled anopexy
13.  An adult case of celiac sprue triggered after an ileal resection for perforated Meckel’s diverticulum 
Celiac disease can be triggered by upper abdominal surgery, such as vagotomy, oesophagectomy, pancreaticoduodenectomy, and gastrojejunal anastomosis. Here we report a case of a 24 year-old woman who developed celiac disease after an ileal resection for perforated Meckel’s diverticula. This is the first reported celiac case that has been triggered, not by upper abdominal surgery, but after ileal resection for Meckel’s diverticula.
PMCID: PMC2731962  PMID: 19705507
Celiac disease; Meckel’s diverticula; Ileal resection
14.  Endoscopic retrograde cholangiopancreatography during pregnancy without radiation 
AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy.
METHODS: Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure.
RESULTS: The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen.
CONCLUSION: Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.
PMCID: PMC2721239  PMID: 19653343
Cholangitis; Choledocholithiasis; Endoscopic retrograde cholangiopancreatography; Jaundice; Pregnancy
15.  Adult hereditary fructose intolerance 
Hereditary fructose intolerance (HFI) is an under-recognized, preventable life-threatening condition. It is an autosomal recessive disorder with subnormal activity of aldolase B in the liver, kidney and small bowel. Symptoms are present only after the ingestion of fructose, which leads to brisk hypoglycemia, and an individual with continued ingestion will exhibit vomiting, abdominal pain, failure to thrive, and renal and liver failure. A diagnosis of HFI was made in a 50-year-old woman on the basis of medical history, response to IV fructose intolerance test, demonstration of aldolase B activity reduction in duodenal biopsy, and molecular analysis of leukocyte DNA by PCR showed homozygosity for two doses of mutant gene. HFI may remain undiagnosed until adult life and may lead to disastrous complications following inadvertent fructose or sorbitol infusion. Several lethal episodes of HFI following sorbitol and fructose infusion have been reported. The diagnosis can only be suspected by taking a careful dietary history, and this can present serious complications.
PMCID: PMC2684612  PMID: 19452588
Adults; Fructose intolerance; Diet; Fructose; Sorbitol
16.  Cytomegalovirus colitis in a patient with Behcet’s disease receiving tumor necrosis factor alpha inhibitory treatment 
Anti-tumor necrosis factor alpha (TNF-α) inhibitors are effective in the treatment of various inflammatory rheumatic conditions. Increased risks of serious infections are the major issues concerning the long-term safety of these agents. We present a case of a young male Behcet’s patient whose disease was complicated by cytomegalovirus (CMV) colitis. Colitis started 10 d after the third Infliximab dose and responded to the cessation of TNF blocking treatment and administration of ganciclovir. Tumor necrosis factor alpha and interferon gamma act at several levels in combating viral infections. CMV infections should be kept in mind and included in the differential diagnosis of severe gastrointestinal symptoms in patients receiving anti-TNF agents.
PMCID: PMC2710737  PMID: 18473420
Tumor necrosis factor alpha inhibitors; Adverse effects; Virus diseases
17.  Effect of thermal cutaneous stimulation on the gastric motor activity: Study of the mechanism of action 
AIM: To investigate the mechanism of action of thermal cutaneous stimulation on the gastric motor inhibition.
METHODS: The gastric tone of 33 healthy volunteers (20 men, mean age 36.7 ± 8.4 years) was assessed by a barostat system consisting of a balloon-ended tube connected to a strain gauge and air-injection system. The tube was introduced into the stomach and the balloon was inflated with 300 mL of air. The skin temperature was elevated in increments of 3°C up to 49°C and the gastric tone was simultaneously assessed by recording the balloon volume variations expressed as the percentage change from the baseline volume. The test was repeated after separate anesthetization of the skin and stomach with lidocaine and after using normal saline instead of lidocaine.
RESULTS: Thermal cutaneous stimulation resulted in a significant decrease of gastric tone 61.2% ± 10.3% of the mean baseline volume. Mean latency was 25.6 ± 1.2 ms. After 20 min of individual anesthetization of the skin and stomach, thermal cutaneous stimulation produced no significant change in gastric tone.
CONCLUSION: Decrease in the gastric tone in response to thermal cutaneous stimulation suggests a reflex relationship which was absent on individual anesthetization of the 2 possible arms of the reflex arc: the skin and the stomach. We call this relationship the “cutaneo-gastric inhibitory reflex”. This reflex may have the potential to serve as an investigative tool in the diagnosis of gastric motor disorders, provided further studies are performed in this respect.
PMCID: PMC2703850  PMID: 18407599
Gastric tone; Barostat; Gastric disorders
18.  Increased hepcidin expression in colorectal carcinogenesis 
AIM: To investigate whether the iron stores regulator hepcidin is implicated in colon cancer-associated anaemia and whether it might have a role in colorectal carcinogenesis.
METHODS: Mass spectrometry (MALDI-TOF MS and SELDI-TOF MS) was employed to measure hepcidin in urine collected from 56 patients with colorectal cancer. Quantitative Real Time RT-PCR was utilized to determine hepcidin mRNA expression in colorectal cancer tissue. Hepcidin cellular localization was determined using immunohistochemistry.
RESULTS: We demonstrate that whilst urinary hepcidin expression was not correlated with anaemia it was positively associated with increasing T-stage of colorectal cancer (P < 0.05). Furthermore, we report that hepcidin mRNA is expressed in 34% of colorectal cancer tissue specimens and was correlated with ferroportin repression. This was supported by hepcidin immunoreactivity in colorectal cancer tissue.
CONCLUSION: We demonstrate that systemic hepcidin expression is unlikely to be the cause of the systemic anaemia associated with colorectal cancer. However, we demonstrate for the first time that hepcidin is expressed by colorectal cancer tissue and that this may represent a novel oncogenic signalling mechanism.
PMCID: PMC2693679  PMID: 18322945
Iron; Hepcidin; Colon; Cancer; Anaemia; Mass spectrometry
19.  Duodeno-jejunal junction dyssynergia: Description of a novel syndrome 
AIM: To investigate the hypothesis that duodeno-jejunal dyssynergia existed at the duodeno-jejunal junction.
METHODS: Of 112 patients who complained of epigastric distension and discomfort after meals, we encountered nine patients in whom the duodeno-jejunal junction did not open on duodenal contraction. Seven healthy volunteers were included in the study. A condom which was inserted into the 1st duodenum was filled up to 10 mL with saline in increments of 2 mL and pressure response to duodenal distension was recorded from the duodenum, duodeno-jejunal junction and the jejunum.
RESULTS: In healthy volunteers, duodenal distension with 2 and 4 mL did not produce pressure changes, while 6 and up to 10 mL distension effected significant duodenal pressure increase, duodeno-jejunal junction pressure decrease but no jejunal pressure change. In patients, resting pressure and duodeno-jejunal junction and jejunal pressure response to 2 and 4 mL duodenal distension were similar to those of healthy volunteers. Six and up to 10 mL 1st duodenal distension produced significant duodenal and duodeno-jejunal junction pressure increase and no jejunal pressure change.
CONCLUSION: Duodeno-jejunal junction failed to open on duodenal contraction, a condition we call ‘duodeno-jejunal junction dyssynergia syndrome’ which probably leads to stagnation of chyme in the duodenum and explains patients' manifestations.
PMCID: PMC4205315  PMID: 17696232
Epigastric distension; Vomiting; Nausea; Dyspepsia; Chyme
20.  Safety and efficacy of hepatitis A vaccine in children with chronic liver disease 
AIM: To study the safety and efficacy of hepatitis A vaccine (HAV) in children with chronic liver disease of various etiologies.
METHODS: Eleven children with chronic liver disease and thirteen age- and sex-matched controls negative for HAV antibodies were vaccinated against hepatitis A after they gave their informed consent. Children with uncontrolled coagulopathy or signs of hepatic decompensation were excluded. The vaccine (Havrix: 720 ELISA units in 0.5 mL, from GlaxoSmithKline Biologicals) was given intramuscularly in the deltoid in 2 doses 6 mo apart. Children were tested for HAV antibodies one and six months after the 1st dose and one month after the 2nd dose. Total serum bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were determined immediately before and after one month of the 1st dose of the vaccine.
RESULTS: Only 7 out of the 11 patients were positive for HAV antibodies after the 1st dose of the vaccine, as compared to 100% of the controls. One month after the 2nd dose, all patients tested were positive for HAV antibodies. No deterioration in liver functions of patients was noted after vaccination. No adverse events, immediate or late, were reported by the mothers after each dose of the vaccine.
CONCLUSION: Hepatitis A vaccine is both safe and effective in this small studied group of children with chronic liver disease. Given the high seroconversion rate, post-vaccination testing for HAV antibodies is not needed.
PMCID: PMC4087494  PMID: 17143952
Children; Chronic liver disease; Hepatitis A; Hepatitis A vaccine
21.  Functional activity of the rectum: A conduit organ or a storage organ or both? 
AIM: To investigate whether the degree of rectal distension could define the rectum functions as a conduit or reservoir.
METHODS: Response of the rectal and anal pressure to 2 types of rectal balloon distension, rapid voluminous and slow gradual distention, was recorded in 21 healthy volunteers (12 men, 9 women, age 41.7 ± 10.6 years). The test was repeated with sphincteric squeeze on urgent sensation.
RESULTS: Rapid voluminous rectal distension resulted in a significant rectal pressure increase (P < 0.001), an anal pressure decline (P < 0.05) and balloon expulsion. The subjects felt urgent sensation but did not feel the 1st rectal sensation. On urgent sensation, anal squeeze caused a significant rectal pressure decrease (P < 0.001) and urgency disappearance. Slow incremental rectal filling drew a rectometrogram with a “tone” limb representing a gradual rectal pressure increase during rectal filling, and an “evacuation limb” representing a sharp pressure increase during balloon expulsion. The curve recorded both the 1st rectal sensation and the urgent sensation.
CONCLUSION: The rectum has apparently two functions: transportation (conduit) and storage, both depending on the degree of rectal filling. If the fecal material received by the rectum is small, it is stored in the rectum until a big volume is reached that can affect a degree of rectal distension sufficient to initiate the defecation reflex. Large volume rectal distension evokes directly the rectoanal inhibitory reflex with a resulting defecation.
PMCID: PMC4125645  PMID: 16874870
Anal pressure; Rectal pressure; Rectometry; First rectal sensation
22.  Computed tomographic findings of trichuriasis 
In this report, we present computed tomographic findings of colonic trichuriasis. The patient was a 75-year-old man who complained of abdominal pain, and weight loss. Diagnosis was achieved by colonoscopic biopsy. Abdominal computed tomography showed irregular and nodular thickening of the wall of the cecum and ascending colon. Although these findings are nonspecific, they may be one of the findings of trichuriasis. These findings, confirmed by pathologic analysis of the biopsied tissue and Kato-Katz parasitological stool flotation technique, revealed adult Trichuris. To our knowledge, this is the first report of colonic trichuriasis indicated by computed tomography.
PMCID: PMC4087392  PMID: 16830393
Trichuris trichiura; Colitis; Large bowel; Imaging findings; Computed tomography
23.  Situs inversus abdominus and malrotation in an adult with Ladd’s band formation leading to intestinal ischaemia 
Situs inversus abdominus with rotational anomaly of the intestines is an extremely rare condition. Although intestinal malrotation has been recognized as a cause of obstruction in infants and children and may be complicated by intestinal ischaemia, it is very rare in adults. When it occurs in the adult patient, it may present acutely as bowel obstruction or intestinal ischaemia or chronically as vague intermittent abdominal pain. Herein, we present an acute presentation of a case of situs inversus abdominus and intestinal malrotation with Ladd’s band leading to infarction of the intestine in a 32 year old woman.
PMCID: PMC4087730  PMID: 16810768
Situs inversus; Malrotation; Ischaemia; Intestine
24.  Controversies in the treatment of common anal problems 
Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.
PMCID: PMC4087955  PMID: 16718832
Anal problems; Treatment
25.  Trimetazidine: Is it a promising drug for use in steatotic grafts? 
AIM: Chronic organ-donor shortage has led to the acceptance of steatotic livers for transplantation, despite the higher risk of graft dysfunction or nonfunction associated with the ischemic preservation period of these organs. The present study evaluates the effects of trimetazidine (TMZ) on an isolated perfused liver model.
METHODS: Steatotic and non-steatotic livers were preserved for 24 h in the University of Wisconsin (UW) solution with or without TMZ. Hepatic injury and function (transaminases, bile production and sulfobromophthalein (BSP) clearance) and factors potentially involved in the susceptibility of steatotic livers to ischemia–reperfusion (I/R) injury, including oxidative stress, mitochondrial damage, microcirculatory diseases, and ATP depletion were evaluated.
RESULTS: Steatotic livers preserved in UW solution showed higher transaminase levels, lower bile production and BSP clearance compared with non-steatotic livers. Alterations in perfusion flow rate and vascular resistance, mitochondrial damage, and reduced ATP content were more evident in steatotic livers. TMZ addition to UW solution reduced hepatic injury and ameliorated hepatic functionality in both types of the liver and protected against the mechanisms potentially responsible for the poor tolerance of steatotic livers to I/R.
CONCLUSION: TMZ may constitute a useful approach in fatty liver surgery, limiting the inherent risk of steatotic liver failure following transplantation.
PMCID: PMC4066156  PMID: 16521219
Steatotic liver; Ischemia–reperfusion; UW preservation solution

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