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‹çindekiler Contents
Cilt:3 Say›:3 / Aral›k 2011
KL‹N‹K ÇALIfiMALAR
Extracorporeal shock wave lithotripsy treatment of renal and ureteral stones... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Böbrek ve üreter tafllar›n›n vücut d›fl› flok dalgalar› (ESWL) ile tedavisi Maltepe Üniversitesi Hastanesi deneyimi
Sinano¤lu et al.
Kad›n hastalarda negatif apendektomi ile jinekolojik patolojiler aras›ndaki iliflki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
The relationship between negative appendectomy and gynecological pathologies in female patients
Çitgez ve Arkadafllar›
Timing of expulsion observed, pain and bleeding after mifepristone and misoprostol – induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Mifepriston ve misoprostol ile indüklenen abortusta a¤r›n›n ve kanaman›n bafllama zaman› ve abortusun...
Ilir Tasha et al.
Üçlü tedavi sonras› semptomlar› kaybolan ancak Helikobakter pilori pozitifli¤i devam eden... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
The need of medical therapy in asymptomatic, Helicobacter pylori positive antral...
Manukyan ve Arkadafllar›
DENEYSEL ÇALIfiMA
Proksimal tubal oklüzyon iflleminin rat over histopatolojisi üzerine etkilerinin incelenmesi: Deneysel çal›flma . . . . . . . . . . . . . . . . . . . . . . . 19
Examination of the histopathological effects of proximal tubal occlusion procedure on rat ovaries: An experimental study
Çelik ve Arkadafllar›
OLGU SUNUMU
Nazal polipozis ve sinüzitin efllik etti¤i nadir görülen intranazal aktinomikozis... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Unusual intranasal presentation of actinomycosis with nasal polyposis and sinusitis
Çiftçi ve Arkadafllar›
Radikülopati ile prezente olan lumbar spinal kondroma: Olgu sunumu... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Lumbar spinal chondroma presented with radiculopathy: A case report
Karao¤lan ve Arkadafllar›
Gemifloxacin-associated fever, maculopapular rash and elevated liver enzymes: A case report... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Gemifloksasin ile iliflkili atefl, makülopapüler döküntü ve karaci¤er enzimleri yüksekli¤i: Olgu sunumu...
Sezgin ve Arkadafllar›
Rapid spontaneous resolution of traumatic acute subdural hematoma... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Travmatik akut subdural hematomun h›zl› spontan rezolüsyonu
Y›ld›r›m ve Arkadafllar›
Favorable outcomes of pregnancy with use of sibutramine in a woman with polycystic... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Polikistik over sendromu olan bir kad›nda sibutramin kullan›m› ile olumlu gebelik sonuçlar›: bir olgu sunumu
Sa¤lam ve Arkadafllar›
DERLEME
Prematürite ve çocukluk ça¤› psikiyatrik bozukluklar› . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Prematurity and childhood psychiatric disorders
Karaman ve Arkadafllar›

KL‹N‹K ÇALIfiMALAR
Extracorporeal shock wave lithotripsy
treatment of renal and ureteral stones
Maltepe University Hospital experience
Böbrek ve üreter tafllar›n›n vücut d›fl› flok
dalgalar› (ESWL) ile tedavisi
Maltepe Üniversitesi Hastanesi deneyimi
Orhun Sinano¤lu MD / Maltepe University Department of Urology Istanbul/TURKEY
Sinan Ekici MD / Maltepe University Department of Urology Istanbul/TURKEY
Naci Tatar MD / Maltepe University Department of Urology Istanbul/TURKEY
Güven Turan MD / Maltepe University Department of Urology Istanbul/TURKEY
Ahmet Kelefl MD / Maltepe University Department of Urology Istanbul/TURKEY
ÖZET
Amaç: Vücut d›fl› flok dalgalar› ile tafl tedavisi (ESWL)
ürolitiyazis tedavisinde kullan›lan invazif olmayan bir yöntemdir.
Bu çal›flman›n amac› ürolitiyaziste kullan›lan ESWL
tedavisinin sonuçlar›n› ve uygun endikasyonlar›n› ortaya
koymakt›r.
Yöntem: Temmuz 2009-Temmuz 2011 aras›nda üriner
sistemde soliter tafl nedeniyle ESWL tedavisine al›nan
51 hasta çal›flmaya al›nd›. ESWL seanslar›n› takibeden 3 ay
içinde tafls›zl›k durumu ve komplikasyonlar gözlenip de¤erlendirildi.
Bulgular: Ellibir hastan›n 38’i (% 74.5) erkek 13’ü kad›nd›
(% 25.5). Hastalar›n yafllar› 20-73 aras› de¤iflmekteydi
(ort. 41.7 y›l). K›rkdört hastada (% 86) üç ay sonunda
tafltan tam ar›nma gerçekleflti. Otuzüç böbrek ve 18 üreter
tafl›n›n s›ras›yla 29’unda (88 %) ve 13’ünde (72%) ar›nma
sa¤land›. ESWL yap›lan 7 hastada baflar› sa¤lanamad›, Üreterorenoskopik
litotripsi ve perkütan nefrolitotomi gibi invazif
giriflimler uyguland›.
Sonuç: ESWL özellikle ürolitiyazis tedavisinde son derece
etkin ve invazif olmayan bir tedavi yöntemidir. Bu çal›flmada
böbrek ve üreter tafllar›nda baflar› flans› s›ras›yla %88
ve %72 bulunmufltur. Ayr›ca tafl üriner sistemde ne kadar
distalde ise baflar› flans› o kadar düflmektedir.
Anahtar kelimeler: vücut d›fl› flok dalgalar›, nefrolitiyazis
ABSTRACT
Objective: Extracorporeal Shock Wave Lithotripsy
(ESWL) is an effective noninvasive method to treat
urolithiasis. This study aims to evaluate the outcome and the
appropriate indication of ESWL for urolithiasis.
Material and methods: The data of 51 patients
undergoing ESWL for the management of solitary
urolithiasis during a period of 2 years (July 2009-July 2011)
were reviewed. Stone-free status and complications were
observed and evaluated within a period of three months
following the last ESWL treatment session.
Results: Out of these 51 patients, 38 were male
(74.5%) 13 were female (25.5%). Ages varied from 20 to
73 (mean 41.7 years). Forty-four patients (86%) had
complete clearance of stone by the end of 3 months. Out
of 33 renal and 18 ureteral stones 29 (88%) and 13
(72%) were succesfuly cleared. ESWL was unsuccessful in
7 patients that required adjunct invasive intervention
including ureterorenoscopic lithotripsy and percutaneous
nephrolithotomy.
Conclusions: ESWL is a highly effective noninvasive
modality in the management of urolithiasis. The success
rates in this study for kidney and ureteral stones were found
to be 88% and 72% respectively. Furthermore the more
distal the stone’s position is, the less success ESWL has.
Key words: extracorporeal shock wave lithotripsy,
nephrolithiasis

8
Sinano¤lu et al
Maltepe T›p Dergisi/ Maltepe Medical Journal
INTRODUCTION
Before Chaussy used extracorporeal shock wave
lithotripsy (ESWL) in 1980, invasive methods have been
used in the treatment of urinary stones (1). Since then,
(ESWL) has been the treatment of choice for renal stones
of ≤ 2 cm maximal length located in the calices or the renal
pelvis (2). Considering its high efficacy, low rate of
morbidity and complication, 3rd generation lithotriptors
used in outpatient clinics became the major treatment
option in urolithiasis. The higher trend to treat patients
with ESWL can also be explained with no requirement of
anesthesia. Although the definite time and criteria to
evaluate stone-free status of a patient after ESWL
treatment remained controversial for many years, it is now
certain that clearance of disintegrates by three months is
necessary to say that ESWL is succesful (3). The
disintegration depends on stone volume (4), stone
composition and localization, and type of lithotripter,
applied shock wave number and energy (5). Clearance of
disintegrates depends on their localization and is worse for
those in the lower calyces than for those in the middle or
upper calyces.
In this study we report the early outcomes of 51
patients treated with electrohydrolic Lithoshock ESWL
device with fluoroscopic stone focusing.
MATERIALS AND METHODS
The data of 51 patients with diagnosis of urolithiasis
undergoing endoscopic shock wave lithotripsy between
July 2009 and July 2011 were reviewed. The diagnosis of
urolithiasis was done either with Kidney Ureter Bladder film
(KUB) plus ultrasound (US) or with computed tomography
(CT). The calculi were focussed with C-Arm Fluoroscopy.
Patients having pain, hydronephrosis due to stone
obstruction, and stone size 5 ≥ mm were treated with
ESWL. The patients with ureteropelvic junction
obstruction, renal failure and urinary obstruction were
excluded. Asymptomatic patients with stone size < 5 mm
and no obstruction were followed up for spontaneous
passage. If they are not stone-free during this period,
ESWL or percutaneous nephrolithotomy for kidney stones
and ureterorenoscopic lithotripsy for ureteral stones were
carried out. Complete blood count, blood urea analysis,
coagulation parameters were done before the procedure.
Double-J catheters were inserted to 9 patients (%17)
before ESWL sessions.
Parenteral diclofenac or fentanyl was used in order to
ensure analgesia. Electrohydrolic (Ultralith) ESWL device
with fluoroscopic C-arm focussing was used. One to 5
ESWL sessions (mean 3) were performed. 500 to 3500
shock waves (Mean 2567) were applied for each session.
Shock wave intensity varied from 10 to 22 kv (mean 18 kv).
On 10th, 30th and 90th days following the last ESWL
session, patients were checked with KUB films and/or
ultrasound, stone free status were defined with evidence
of disintegration and spontaneous passage of
disintegrates.
RESULTS
Of these 51 patients, 38 were male (74.5 %) 13 were
female (25.5 %). Ages varied from 20 to 73 (mean 41.7
years). Three had (5.9%) upper calyceal, 9 had (%17.6) mid
calyceal, 12 had lower calyceal (23.5%), 9 had renal pelvis
(17.6%) and, 18 had ureteral(35.3%) stones. Stone sizes
varied from 5-30 mm (mean 10.5). After 3 months follow
up 44 patients became stone free (86%.) Out of 33 renal
and 18 ureteral stones 29 (88%) and 13 (72%) were
succesfuly cleared. Table 1 shows the success rate of ESWL
with respect to stone localization. Two patients required
ureterorenoscopic lithotripsy due to the complication of
distal ureteral obstruction by abundant stone fragments
which is also called as “Steinstrasse” phenomenon. Table 2
gives the status of complete stone disintegration and
clearance as well as treatment failure in details. Five patients
underwent invasive intervention modalities including
ureterorenoscopic lithotripsy and percutaneous
nephrolithotomy due to ESWL failure. Complications such as
renal hematoma, hypertension, renal failure or infection
were not seen in any patients after ESWL treatment.
Petechiae, ecchymosis, and macroscopic hematuria shorter
than 24 hours were seen in all cases. The success rates for
Stone localization Stone Free Success Rate
Upper Calyx 2/3 67%
Mid Calyx 9/9 100%
Lower Calyx 11/12 92%
Renal Pelvis 7/9 78%
Proximal Ureter 12/13 92%
Mid Ureter 1/3 33%
Distal Ureter 0/2 0%
Table 1. Success rates according to stone localization
Stone status # Patients Percentage
*Stone free 44 87 %
**Non Stone free 5 16 %
***Steinstrasse 2 3 %
Total 51 100 %
Table 2. Overall success and failure rates after ESWL
treatment *Complete disintegration and passage of
disintegrates, **Incomplete disintegration or failure to pass
disintegrates ***Persistent ureteral obstruction due to
impacted disintegrates requiring immediate endoscopic
intervention

the kidney stones and ureteral stones were found to be
88% and 68% respectively.
DISCUSSION
Follow-up, ESWL, ureterorenoscopic lithotripsy,
percutaneous lithotripsy and open surgery are the
treatment options for urolitihiasis. The management of
urolithiasis depends on the factors such as stone size,
localization, presence of obstruction and renal function.
Since its introduction in 1980, ESWL became the preferred
treatment option for the majority of renal calculi because
of its non-invasive nature and low potential of
complications (6).
The overall success of ESWL in this study was 88 % and
68 % for kidney and ureteral stones, respectively. The
success rate of ESWL in proximal ureteral stones reported
to be 89-95.5 % in the literature and is in accordance with
our findings. As to the mid ureteral stones, either ESWL or
ureterorenoscopic lithotripsy can be prefered. Although
the overall ESWL success for mid ureteral stones in
previous reports was about % 65, this rate was much
lower in our study. Furthermore, ESWL was unsuccesful in
lower ureteral stones in contrast to previous reports (6).
The surprising fact is ESWL success rate in this study
(%92) for lower calyceal stones was higher than the
cumulative stone free rate of 41-73% for lower pole
stones in many reports (7). This high rate can be due to
some facts; First the stone burden in lower calyces was low
in our patients, second we recommended vibratory
massage in hand stand position as suggested a previous
report with stone-free rate of % 62.5 in patients with
massage and up side down position following ESWL
sessions in contrast to 35.4 % stone free rate in patients
with ESWL alone (8). The stone-free rate for upper calyceal
stones is reported to be high in the literature, however the
number of patients undergoing ESWL for upper calyceal
stones was very small in our series making the comparison
with the results of these series impossible.
We evaluated the stone free status with KUB films
and/or urinary ultrasound by 3 months. These imaging
modalities seem to have lower sensitivity and specifity in
detection of small disintegrates and calculi. The question
here is whether it is necessary to evaluate stone-free rate
using the more sensitive tools such as computed
tomography with more radiation exposure, if these
clinically insignificant residual fragments (CIRF) have no
therapeutic consequences. Some authors reported that
78% of CIRF pass spontaneously, and only around 20% of
patients with CIRF had recurrent stones requiring
treatment (9). It remains unclear whether these patients
would not have stone recurrences when they had been
completely stone free. More aggressive and invasive
treatment of lower pole calculi with percutenous
nephrolithotomy (PCNL) instead of ESWL is not justified if
Maltepe T›p Dergisi/ Maltepe Medical Journal
the only advantage is a better clearance of CIRF, also it
cannot be shown that PCNL has a significantly lower longterm
recurrence rate due to fewer CIRF (10).
In conclusion, urolithiasis management with Lithoshock
ESWL device was found to be effective. According to the
location, the procedure seems more succesful in kidney
stones than in ureteral stones, and not succesful in lower
ureteral stones which requires mostly invasive endoscopic
procedures.
REFERENCES
1. Chaussy C, Schmiedt E, Jocham D, Walter V, Brendel
W. First clinical experience with extracorporeally
induced destruction of kidney stones by shock waves.
J Urol. 1982;127:417-420.
2. Tiselius HG, Ackermann D, Alken P, Buck C, Conort P,
Gallucci M. Guidelines on urolithiasis. In: Guidelines
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3. Zehnder P, Roth B, Birkhäuser F, Schneider S, Schmutz
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Cilt:3 Say›:3 / Aral›k 2011
9

Kad›n hastalarda negatif apendektomi ile
jinekolojik patolojiler aras›ndaki iliflki
The relationship between negative appendectomy
and gynecological pathologies in female patients
Dr. Bülent Çitgez / fiiflli Etfal E¤itim ve Araflt›rma Hastanesi, II. Genel Cerrahi Klini¤i
Dr. Gürkan Yetkin / fiiflli Etfal E¤itim ve Araflt›rma Hastanesi, II. Genel Cerrahi Klini¤i
Dr. ‹smail Akgün / fiiflli Etfal E¤itim ve Araflt›rma Hastanesi, II. Genel Cerrahi Klini¤i
Dr. Mehmet Uluda¤ / fiiflli Etfal E¤itim ve Araflt›rma Hastanesi, II. Genel Cerrahi Klini¤i
Dr. Mehmet Velidedeo¤lu / fiiflli Etfal E¤itim ve Araflt›rma Hastanesi, II. Genel Cerrahi Klini¤i
Dr. Adem Akçakaya / fiiflli Etfal E¤itim ve Araflt›rma Hastanesi, II. Genel Cerrahi Klini¤i
ÖZET
Amaç: Akut apandisit her yafl grubunda görülebilen,
eriflkinde akut kar›n hastal›klar›n›n yar›s›ndan fazlas›n› oluflturan
bir hastal›kt›r. Kad›n hastalarda jinekolojik patolojilerin
akut apandisiti taklit etmesi nedeniyle bu oran daha da
yükselmektedir. Bu çal›flmada, akut apandisit ön tan›s›yla
ameliyat edilen ve normal apendiks saptad›¤›m›z kad›n
hastalarda tespit etti¤imiz jinekolojik patolojilerin tedavi
yaklafl›mlar›n› ve oranlar›n› sunmay› amaçlad›k.
Yöntem: Ocak 2008 Ocak 2010 tarihleri aras›nda klini-
¤imize baflvuran ve akut apandisit ön tan›s›yla opere edilen
420 hasta retrospektif olarak incelendi. Hastalar›n tan›lar›
fizik muayene, laboratuar bulgular ve radyolojik bulgulara
göre konulmufltur. Hastalar›m›zda peroperatif apendiksin
durumu ve jinekolojik patoloji makroskobik olarak de¤erlendirilmifltir.
Bulgular: Hastalar›n 260’› (%61,9) erkek, 160’›
(%38,1) kad›nd›. Tüm hastalar›n 28’inde (%6,6) ameliyat
esnas›nda normal apendiks saptand›. Bu hastalar›n 19’u
(%67) kad›nd›. Negatif apendektomi oran› kad›nlarda erkeklere
göre istatistiksel olarak anlaml› bir flekilde daha
yüksekti (p

G‹R‹fi
Akut apandisit her yafl grubunda görülebilen, eriflkinde
akut kar›n hastal›klar›n›n yar›s›ndan fazlas›n›n nedenini
oluflturan bir hastal›kt›r (1). Tüm özellikleri ve cerrahi tedavisi
bilinmesine ra¤men, apandisit hala en yüksek yanl›fl tan›
oran›na sahip acil cerrahi durumdur (1,2).
Geliflen teknoloji ve artan tan› yöntemleriyle beraber
negatif appendektomide (NA) azalma olmas›na ra¤men,
akut apandisit tan›s›na yönelik zorluklar devam etmektedir
ve NA’lar halen büyük bir sorun oluflturmaktad›r (3,4). NA,
kad›n hastalarda jinekolojik patolojilerin akut apandisiti
taklit etmesi nedeniyle daha s›k görülmektedir (4).
Bu çal›flmada akut apandisit ön tan›s›yla laparotomi uygulay›p,
jinekolojik patoloji ile karfl›laflt›¤›m›z hastalar›, patolojileri
ve tedavi yaklafl›mlar›n› sunmay› amaçlad›k.
GEREÇ VE YÖNTEMLER
Ocak 2008-Ocak 2010 tarihleri aras›nda klini¤imize baflvuran
ve akut apandisit ön tan›s›yla opere edilen 420 hasta
retrospektif olarak incelendi. Akut apandisit tan›s› fizik muayene,
laboratuvar ve radyolojik bulgulara göre konulmufltur.
Kad›n hastalar›m›zda ultrasonografik görüntülemenin
yan›nda kad›n hastal›klar› konsültasyonu istenmifltir.
Hastalar›m›zda jinekolojik patoloji ve peroperatif apendiksin
durumu makroskobik olarak de¤erlendirilmifltir. Bulgular istatistiksel
olarak ki-kare testi ile de¤erlendirilmifltir.
BULGULAR
Hastalar›n 260’› (%61,9) erkek, 160’› (%38,1) kad›nd›.
Tüm hastalar›n 28’inde (%6,6) operasyon esnas›nda normal
apendiks ile karfl›lafl›lm›flt›r. Negatif apendektomi saptanan
28 hastan›n 19’u (%67) kad›nd›. Negatif apendektomiler
kad›nlarda erkeklere göre istatistiksel olarak anlaml›
bir flekilde daha s›k gözlendi (p

12
Çitgez ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
rüntü saptanmas›na ra¤men operasyon esnas›nda hastalarda
jinekolojik patoloji saptanm›flt›r.
NA oranlar› %11 ile %18 aras›nda de¤iflmektedir (4,8).
Geçmifl y›llarda yüksek orandaki NA sonuçlar›, apandisitin
perfore olmas›na engel oldu¤u düflünüldü¤ü için kabul edilebilir
görülüyordu (2,4,8). Bununla birlikte NA, uzun yat›fl
süreleri, yüksek enfeksiyon riski ile morbididite ve mortaliteyi
artt›rmaktad›r (2). Buna paralel olarak Seetahal ve ark.
(4); 1998 ile 2007 aral›¤›nda 475651 apendektomiyi inceledikleri
derlemede 1998 y›l›nda NA insidans› 5514
(%14,7) iken, 2007 y›l›nda 4346 (%8,4) olarak tespit edilmifltir.
Ayn› çal›flmada NA oran›n›n kad›n hastalarda istatistiksel
olarak daha s›k oldu¤u saptanm›flt›r. Bizim çal›flmam›zda
NA 28 (%6,6) hastaya uygulanm›fl ve bayanlarda istatistiksel
olarak daha fazla bulunmufltur. Biz NA say›m›z›n
düflüklü¤ünü akut apandisit düflünülen her hastaya bat›n
ultrasonografisi ve kad›n hastalarda operasyon öncesi kad›n
do¤um konsültasyonu istememize ba¤lamaktay›z.
Tan› yöntemlerindeki geliflmeye ra¤men negatif apendektomi
oranlar› kad›nlarda yüksek seyretmektedir. Negatif
apendektomiyi önlemek için özellikle kad›n hastalar daha
dikkatli de¤erlendirilmeli ve jinekolojik patolojilerin de
akut apandisiti taklit edebilece¤i ak›lda tutulmal›d›r. Bu durumun
göz önünde bulundurulmas› ve flüpheli olgularda jinekolojik
patolojilere yönelik tetkik yap›lmas› kad›nlarda
NA oranlar›n›n azalt›lmas›nda etkili olaca¤›n› düflündürmektedir.
KAYNAKLAR
1. Lally KP, Cox CS, Andrassy RJ. Appendix. In: Townsend
CM (ed). Sabiston. Textbook Of Surgery. 16 th
edition. Philadelphia: WB. Saunders; 2001. 916-927.
2. Flum DR, Koepsell T. The clinical and economic corelates
of misdiagnosed appendicitis: nationwide analysis.
Arch surg 2002; 137:799-804.
3. Blomqvist PG, Andersson RE, Granath F, Lambe MP,
Ekbom AR. Mortality after appendectomy in Sweden,
1987-1996. Ann Surg 2001; 233:455-460.
4. Seetahal SA, Bolorunduro OB, Sookdeo TC, Negative
appendectomy: a 10-year review of a nationally representative
sample. Am J.Surg 2011; 201: 433-437.
5. Bilgin N. Akut apandisit. In: Sayek ‹ (ed). Temel Cerrahi.
3.bask›. Ankara: Günefl Kitapevi; 2004. 1191-1196.
6. Piper HG, Rusnak C, Orrom W, et al. Current management
of appendicitis at a community center—how
can we improve? Am J Surg 2008;195:585–588.
7. Velanovich V, Satava R. Balancing the normal appendectomy
rate with the perforated appendicitis rate:
implications for quality assurance. Am Surg
1992;58:264 –269.
8. Ma KW, Chia NH, Yeung HW, Cheung MT. If not appendicitis,
then what else can it be? A retrospective
review of 1492 appendectomies. Hong Kong Med J.
2010;16:12-17.
9. Nakgevery KB, Clarke LE. Acute appendicits in women
of childbearing age. Arch Surg 1986. 121: 1053-
1055.
10. Gökçe AH, Aren A, Gökçe FS ve ark. Akut apandisitte
ultrasonografinin güvenilirli¤i Ulus Travma Acil Cerrahi
Derg 2011;17:19-22.
11. Sitter H, Hoffmann S, Hassan I, Zielke A. Diagnostic
score in appendicitis. Validation of a diagnostic score
(Eskelinen score) in patients in whom acute appendicitis
is suspected.Langenbecks Arch Surg
2004;389:213-218.
12. Saidi HS, Chavda SK. Use of a modified Alvorado score
in the diagnosis of acute appendicitis. East Afr Med
J 2003;80:411-414.
13. Turan A, Kapan S, Kütükçü E, Yi¤itbafl E, Hatipo¤lu S,
Aygün E. Comparison of operative and non operative
managment of acut appendicitis. Ulusal Travma Acil
Cerrahi Derg 2009;15:459-462.

Timing of expulsion observed, pain
and bleeding after mifepristone and
misoprostol – induced abortion
Mifepriston ve misoprostol ile indüklenen
abortusta a¤r›n›n ve kanaman›n bafllama zaman›
ve abortusun oluflma süresi aras›ndaki iliflki
Ilir Tasha MD. / Obstetric – Gynaecology Albanian Association. Obstetric - Gynaecology University Hospital. Tirana. Albania.
Nikita Manoku MD. Proffessor / Obstetric – Gynaecology Albanian Association. Obstetric - Gynaecology University Hospital. Tirana. Albania.
Donika Beba MD. / Obstetric – Gynaecology Albanian Association. Obstetric - Gynaecology University Hospital. Tirana. Albania.
ÖZET
Bu çal›flman›n amac› oral, düflük doz 200 mg Mifepristone
ve oral 400 mcg Misoprostol ile tedavi edilen hastalarda
a¤r›n›n tam olarak bafllama zaman›, düflü¤ün meydana
geldi¤i zaman› ve kanama miktar› hakk›nda bilgileri
güncellemektir.
Ekibimiz, 56.güne kadar olan gebeliklerde oral mifespriston’dan
48 saat sonra misoprostol alan hastalarda
kramplar, düflük zaman› ve kanaman›n bafllang›ç zaman›n›
analiz etti.
Hastalar›n semptom günlüklerinden bilgileri ald›k ve
semptom bafllang›c›n› 3 kategoriye ay›rd›k: misoprostol
kullan›m›ndan önce, misoprostol kullan›m›ndan 24 saat
sonra, ve misoprostol kullan›m›ndan 48 saat sonra.
200 hastadan 175’inde (%87,5) kramplar, gözlenen
düflük ve kanama bafllang›ç zaman› ile ilgili bilgiler al›nabildi,
ancak 175 hastadan 30’u (%17,1) embriyoyu tan›yamad›klar›ndan
çal›flma d›fl› b›rak›ld›lar.
Bütün gruplarda, 6 hasta (%4,13) gebelik materyalini
gördü, s›ras›yla 37 (%25,5) ve 49 (%33,7) hastan›n misoprostol
öncesi kanama ve kramp tarz›nda a¤r›s› oldu.
Tedavi gruplar› aras›nda erken kramplar ve kanamas›
olan hastalar›n oran› anlaml› olarak yüksek bulundu ve bu
durum mifepriston ile misoprostol aras›ndaki interval ile
ba¤lant›l› idi.
Kramplar ve kanama misoprostol kullan›m›ndan 48 saat
sonra belirgin olarak s›rayla 8 (%5,5) ve 10 (%6,89) hastada
azald›.
Düflük materyalinin görülmesi, kanama, kramplar, misoprostol
kullan›m›ndan 24 saat sonra en yüksek oranda
görüldü.
Anahtar kelimeler: mifepriston, misoprostol, abortus
ABSTRACT
The objectives of this study were to date exactly the
time of onset of pain, expulsion, and bleeding in subjects
treated with low – dose 200 mg Mifepristone orally and
400 mcg Misoprostol by mouth as well.
Our team did analysis the cramping, expulsion
observed and bleeding onset patterns in subjects till to 56
days pregnant who used misoprostol at 48 hours after
mifepristone orally.
We collected data from patient’s symptom diaries, and
we divided symptom onset into 3 categories: before
misoprostole use, 24 hours following misoprostol, and 48
hours after misoprostol.
Of the 200 patients, cramping, expulsion observed,
and bleeding onset data were available for 175 (87.5 %),
but 30 of 175 subjects (17.1 %) were not able to identify
their embryo, so we excluded from the study.
Across all groups, 6 patients (4.13 %) observed their
product of pregnancy, 37 (25.5 %) and 49 (33.7 %)
experienced respectively bleeding and cramping before
misoprostol use.
There were a significantly higher percentage of
subjects who experienced early cramping and bleeding
between three treatment groups, and this was related to
the interval between mifepristone and misoprostol.
This percentage was significantly reduced in subjects
who experienced cramping and bleeding 48 hours after
misoprostol use respectively 8 (5.5 %) and 10 ( 6.89 %).
The incidence of expulsion observed, bleeding,
cramping was highest 24 hours after misoprostol use.
Key words: mifepristone, misoprostol, abortion

14
Ilir Tasha et al
Maltepe T›p Dergisi/ Maltepe Medical Journal
INTRODUCTION
It was essential to let you know that this study applied for
the first time in our hospital and in our country as well. For the
first time, women in our country seeking abortion have had
the option of either a surgical or medical abortion. In addition,
we familiarized with idea that many women prefer medical
abortion as it allow them greater privacy and control over
their abortion. Since 1992 women in Albania have had the
legal right to an abortion. The laws related to abortion were
further liberalized in 1995 with the passage of the “Law on
Interruption of Pregnancy”, which permits abortion up to 12
weeks from the presumed date of conception. After the
legalization of abortion in 1992, abortion ratios increased
dramatically between 1992 and 1997 with over 40 abortion
for every 100 live births.(1) However, as family planning has
become more available, abortion ratios have decreased in
recent years. Recent estimates range from a ratio of 7.3
abortion to 17.2 abortions per 100 live births. (2) In Albania,
abortion must be performed by a physician, in either a public
or private health institution (2,3).
Mifepristone, a synthetic progesterone, is used to
competitively block the effects of progesterone and weaken
the attachment of an early pregnancy on the endometrium.
Mifepristone serum levels do not increase proportionally with
increasing oral doses(4,5). Misoprostol, a synthetic
prostaglandin, is used 48 hours after mifepristone to induce
cervical softening and dilatation, and uterine contractions to
assist in the expulsion of the pregnancy (5). The efficacy of the
reduced dose has been demonstrated in research by the
World Health Organisation and in clinical studies in the USA
(5,7).
MATERIALS AND METHODS
The study was performed from February 2006 – May
2008 in Obstetric – Gynaecology University Hospital of Tirana
, Albania. Our hospital regularly provides abortion service
using dilatation and curettage under local anesthesia and is
among the largest abortion provider in Albania. Women
made two clinic visits ore more. At the first visit, they received
200 mg mifepristone and were asked to select clinic or home
administration of misoprostol.
All subjects more than 18 years old who desired
pregnancy termination, enrolled in our clinic.
Inclusion and exclusion criteria for eligibility in medical
abortion was demonstrated in Table 1.
Eligibility and method selection:
If all of the answers to Questions 1 to 16 appear in bold
sections, the woman is eligible for medical abortion (6).
If the woman choose to participate in the study and has
signed the consent form, administered mifepristone
At the initial visit (study day 1), a clinician confirmed
gestational age by transabdominal ultrasound.
After the patient signed an informed consent, they
swallowed a single pill of 200 mg mifepristone under direct
observation, and study personnel recorded the time. Subjects
were then randomly assigned to self – administered 400 mcg
p/os misoprostol at about 48 hours after receiving
mifepristone. All subjects were given the option of returning
to the clinic for misoprostol swallowing.
Subjects received a symptom diary to record the date and
time of misoprostol use as well as the onset of cramping,
expulsion observed and bleeding. All subjects were required
to return for a follow – up visit at the end of fortnight. At the
follow – up visit, a clinician determined treatment success by
pelvic exam or transabdominal ultrasound. The clinician also
collected symptom diary at this time, and usually confirmed
the times of medication use and the times of symptoms
onset. For each subject, we calculated the intervals between
mifepristone & misoprostol swallowing and the onset of
symptoms.
We excluded subjects who did not return to their follow
– up appointments (subjects lost to follow – up). We also
excluded subjects for whom timing intervals could not be
computed due to irresolvable data entry errors and all this
subjects who were not able to identify the embryo. We
divided timing of symptom (pain, expulsion observed, and
bleeding) onset into three categories : before misoprostol
swallowing, 24 hours and 48 hours after receiving of
misoprostol.
Outcome measures included time between mifepristone
and misoprostole use and the onset of symptoms; time of 24
hours from receiving of misoprostol to the onset of symptoms;
time of 48 hours from receiving of misoprostol to the
onset of symptoms.
Data are drawn from a prospective study of 200 women
who presented for an abortion with amenorrhea of ≤ 56 days
.
RESULTS
This analysis included 200 women who enrolled from
February 2006 – May 2008.
In related to symptoms we followed at the same time 145
subjects for; bleeding, cramping and expulsion observed in
three points of the time: before misoprostol use, 24 hours
after misoprostol use, 48 hours after misoprostol use.
In related to the expulsion observed 6 (4.13 %) of the
subjects noticed their embryo before misoprostol use; 24
(16.55 %) of the subjects noticed their conceptus 24 hours
after receiving the misoprostol; 38 (26.2 %).
Timing of onset of cramping is scheduled as below:
49 subjects (33.7 %) experienced onset of pain before
misoprostol use.
24 subjects (16.55 %) did experience onset of pain , 24
hours after misoprostol use.
8 subjects (5.5%) experienced onset of pain , 48 hours
after receiving misoprostol.

1 At least 18 years old (age of patient)? Yes No
2 Positive urine pregnancy test? Yes No
3 Gestational age, LM month....day.....year...... Yes No
4 Willing to come for at least one follow-up visit? Yes No
5 Willing to provide an address and/or phone Nr. where she
can be contacted?
Yes No
6 Willing to fill out a short diary of side effects? Yes No
7 Have an IUD in place? Yes No
8 Clotting disorders or anticoagulant therapy? Yes No
9 Long – term glucocorticoide - steroid therapy? Yes No
10 Adrenal insufficiency? Yes No
11 Vaginal bleeding? Yes No
12 Suspicion of ectopic pregnancy? Yes No
13 Documented history of familial porphyries? Yes No
14 Known allergy to mifepristone? Yes No
15 Known allergy to misoprostole? Yes No
16 Signs of severe ill health? Yes No
Table 1
Timing of onset of bleeding:
37 (25.5%) subjects experienced onset of bleeding before
misoprostol use.
49 (33.7%) subjects experienced the first bleeding 24
hours after receiving misoprostol.
10 (6.89 %) subjects experienced onset of bleeding 48
hours after misoprostol use.
There was not a small number of patients that ended their
abortion using only mifepristone. This result was confirmed
by our colleagues in China, Tunisia(8).
Across all groups 6 patients (4.13%) observed their
concepts, 37 (25.5%) and 49 (33.7%) experienced
respectively bleeding and cramping before misoprostol use.
There was a significantly higher percentage of subjects
who experienced early cramping and bleeding between three
treatment groups, and this was related to the interval
between mifepristone and misoprostol.
This percentage was significantly reduced in subjects who
experienced cramping and bleeding 48 hours after
misoprostol use respectively 8 (5.5 %) and 10 (6.89 %).
The incidence of expulsion observed, bleeding and,
cramping was highest 24 hours after misoprostol use.
DISCUSSION
This analysis provides information about the timing of
cramps, bleeding and expulsion observed relative to
misoprostol use during medical abortion. The study results
showed a high rate of success and high level of satisfaction
with this method.
This study had several limitations.
Subject’s self – report of symptoms may have resulted in
recording errors of digit – preference recording. Application
of 200 mg mifepristone in medical abortion confirmed one
more time that mifepristone serum levels do not increase
Maltepe T›p Dergisi/ Maltepe Medical Journal
proportionally with increasing of oral doses. Providers and
patients may find such information useful if patients could not
avoid following up.
REFERENCES
1. Nuri, B. In: Trageakes, E. ed. Health Care Systems in
Transition: Albania Copenhagen: European Observatory
on Health Care Systems, 2002;4:60.
2. Herold J, Seither R, Ylli A et al. Reproductive Health
Survey, Albania 2002: Preliminary Report, Atlanta,
GA,USA. Centre for Disease Control, 2003.
3. World Health Organization. Task Force on Postovulatory
methods of Fertility Regulation Comparison of two
doses of Mifepristone in combination with misoprostol
for early abortion. A randomised trial. Br J Obstet
Gynaecol 2000:107;524 – 530.
4. Schaff E, Eisinger S, Stadalius L, et al. Low – dose
mifepristone 200 mg and vaginal misoprostol for
abortion. Contraception 1999; 59: 1–6.
5. Ulmann, André. “The development of mifepristone: a
pharmaceutical drama in three acts”. J Am Med
Womens Assoc. 2000; 55: 117–120.
6. Bracken H, Gliozheni O, Manoku N, Moisiu R, Shanon C,
TASHA I. et al. Mifepristone medical abortion in Albania:
Results from a pilot clinical research study. The European
Journal of Contraception and Reproductive Health Care.
2006; 11: 38–46.
7. Winikoff B, Ellertson C, Clark s. Analysis of failure in
medical abortion. Contraception 1996; 54: 323-327.
8. Hagri S, Blum J, Gueddana N, et al. Expanding medical
abortion in Tunisia: Women’s experience from a
multisite expansion study, Contraception 2004; 69:
63–69.
Cilt:3 Say›:3 / Aral›k 2011
15

Üçlü tedavi sonras› semptomlar› kaybolan ancak
Helikobakter pilori pozitifli¤i devam eden antral
gastrit hastalar›nda ek tedavi gereksinimi
The need of medical therapy in asymptomatic,
Helicobacter pylori positive antral gastritis
patients after a triple eradication therapy
Dr. Manuk N Manukyan / Maltepe Üniversitesi T›p Fakültesi Genel Cerrahi Ana Bilim Dal›
Dr. U¤ur Deveci / Maltepe Üniversitesi T›p Fakültesi Genel Cerrahi Ana Bilim Dal›
Dr. Nefle Yener / Maltepe Üniversitesi T›p Fakültesi Patoloji Ana Bilim Dal›
Dr. Ahmet Midi / Maltepe Üniversitesi T›p Fakültesi Patoloji Ana Bilim Dal›
Dr. Sertan Kapakl› / Maltepe Üniversitesi T›p Fakültesi Genel Cerrahi Ana Bilim Dal›
Dr. Ka¤an Gökçe / Maltepe Üniversitesi T›p Fakültesi Genel Cerrahi Ana Bilim Dal›
Dr. Abut Kebudi / Maltepe Üniversitesi T›p Fakültesi Genel Cerrahi Ana Bilim Dal›
ÖZET
Amaç: Üçlü tedavi sonras› semptomlar› kaybolan ancak
Helikobakter pilori (Hp) pozitifli¤i devam eden hastalara
ek tedavi gereksinimini ortaya koymak.
Yöntem: Klini¤imizde yap›lan gastroskopilerinde yaln›zca
antral gastrit saptanan semptomatik 321 hastan›n
248’inde biyopsi ile Hp (+) gösterildi. Hp(+) hastalara
amoksisilin 1 gr 2x1 klaritromisin 500mg 2x1 14 gün boyunca
ve pantoprazol 40 mg iki ay boyunca verildi. Tedavi
sonras› yap›lan gaita analizlerinde 74 hastada Hp eradikasyonunun
baflar›s›z oldu¤u görüldü. Eradikasyonun baflar›s›z
oldu¤u bu hastalardan 42’si semptomlar›n›n tümü ile yok
oldu¤unu ifade etti. Asemptomatik hastalar iki gruba ayr›ld›.
Birinci gruptakilere tetrasiklin 2x500mg ve metranidazol
4x500mg’l›k ikinci basamak tedavisi verildi. ‹kinci gruptaki
hastalara sadece beslenme önerilerinde bulunuldu. Her iki
grup hasta 6 ay sonra tekrar kontrole ça¤r›ld›.
Bulgular: Birinci gruptaki 21 hastan›n gaitada Hp analizleri
tekrarland›. Sadece 9 hastada pozitifli¤in devam etti-
¤i ancak bu gruptaki 9 (dördü H(p-)) hastada semptomlar›n
tekrar bafllad›¤› görüldü. Sadece diyet verilmifl olan ikinci
gruptaki hastalar›n ise 10’u flikayetlerinin tekrarlad›¤›n›
ifade etti.
Sonuç: Antibiyotik tedavisi sonras› semptomlar› düzelen
ancak Hp pozitifli¤i devam eden hastalarda Hp eradikasyonu
amac› ile ikinci basamak tedavi vermenin klinik
yarar› tart›flmal›d›r.
Anahtar kelimeler: helikobakter pilori, eradikasyon,
semptom, antral gastrit.
ABSTRACT
Objective: To determine the need of medical therapy
in asymptomatic, Helicobacter pylori positive antral gastritis
patients after a triple eradication therapy.
Material and methods: Gasatroscopically detected
symptomatic antral gastritis patients were evaluated. 248
of 321 were Helicobacter pylori (+).These patients were
treated by amoxicilin 1 gr 2x1 clarithromycin 500 mg 2x1
for forteen days and pantoprazol 40 mg daily for two
months. After the therapy 74 patients were still Hp(+)
according to the stool analyzes and eradication was
unsuccesfull.. 42 of those patients whom erradication
therapy failed were completely asymptomatic.
Asymptomatic patients were seperated into two groups.
First group was treated by tetracycline 2x500mg and
metranidazole 4x500 mg. The second group did not use
any drugs and only dietary regulations were suggested. Six
moths later both groups were controlled again.
Results: The stool analyzes of 21 patients in the first
group were repeated. Only 9 were positive but the
symptoms reoccured in 9 (4 Hp(-)) patients. ‹n the second
group 10 patients were symptomatic after the dietary
regulations.
Conclusion: The need of second line medical therapy
in asymptomatic, Hp positive antral gastritis patients after
a triple erradication therapy is controversial
Key words: helicobacter pylori, eradication, symptom,
antral gastritis

G‹R‹fi
Helikobakter pilori (Hp) geçen yüzy›l›n t›bb›na damgas›n›
vuran en önemli kefliflerden birisidir. Polimorfonükleer
lokosit infiltrasyonunun görüldü¤ü kronik aktif gastritle
spiral bakterilerin iliflkili olabilece¤i 1983 y›l›nda duyruldu(1).Ard›ndan
kronik aktif gastrit ve peptik ülser etyolojisinde
önemli bir faktör oldu¤u tespit edildi (2).Hp nedenli
kronik gastrit hastalar›n›n %15-20’sinde peptik ülser, yaklafl›k
%1’inde gastrik malinite geliflti¤i bilinmektedir(3,4).
Hp eradikasyonu peptik ülser nüksünü azalmakta, erken
dönem MALT (mucosa associated lymphoid tissue) lenfoma
remisyona sokulabilmektedir(5).
Hp dünya nüfusunun yar›s›ndan fazlas›nda görülen yayg›n
bir enfeksiyondur ancak geliflmekte olan ülkelerde yap›lan
epidemiyolojik çal›flmalar›n yetersizli¤i nedeniyle veriler
yeterli de¤ildir. Hp tan›s›nda kullan›labilecek özgüllük ve
duyarl›l›¤› yüksek testler mevcuttur. Bunlardan histopatoloji,
sitoloji, bakteri kültürü, biyopsi, üreaz testi ve Hp PCR
testi endoskopi gerektirirken; seroloji, üre nefes testi ve gaitada
antijen testi non invaziv testlerdir(6,7). 1990’l› y›llarda
tercih edilen tedavi rejimleri tekli tedavilerdi, daha sonra üçlü
ve dörtlü tedaviler kullan›lmaya bafllanm›flt›r(8). Bugün
yan etkisi az, baflar› oran› yüksek, 1 veya 2 hafta süre ile ve
sabah akflam uygulanan proton pompa inhibitörü + klaritromisin
2x500 mg + amoksisilin 2x1000 mg kombinasyonudur.
Ancak kimler tedavi edilmelidir sorusunun cevab›
asemptomatik olan hastalar tedavi edilmemelidir fleklindedir.
Bizim çal›flmam›z›n amac› Hp pozitif ve semptomatik
olup üçlü tedavi sonras› semptomlar› kaybolan ancak Hp
pozitifli¤i devam eden hastalara ek tedavi gereksinimini ortaya
koymakt›r.
GEREÇ VE YÖNTEM
Klini¤imizde yap›lan gastroskopilerde yaln›zca antral
gastrit saptanan semptomatik 321 hastada Hp araflt›rmas›
için endoskopik ifllem esnas›nda antrumdan iki adet biyopsi
al›nd›. Biyopsi örnekleri %10 formalin solusyonu içerisinde
patoloji labarotuvar›na yolland›. Patoloji laboratuvar›nda
4 μm kal›nl›¤›nda doku kesitleri elde edildi. Kesitler, Hp enfeksiyonu
tan›s› için Giemsa ile boyand›. Ifl›k mikroskobunda
spiral (yay) seklinde basillerin görülmesi ile Hp enfeksiyonu
teflhis edildi.. Hp(+) hastalara amoksisilin 1 gr 2x1 klaritromisin
500mg 2x1 14 gün boyunca ve pantoprazol 40
mg iki ay boyunca verildi. Tedavi sonras› yap›lan gaita analizlerinde
Hp eradikasyonu baflar›s›z olan hastalardan
asemptomatik olanlar iki gruba ayr›ld›. Birinci gruptakilere
tetrasiklin 2x500mg ve metranidazol 4x500mg’l›k ikinci basamak
tedavisi verildi. ‹kinci gruptaki hastalara sadece beslenme
önerilerinde bulunuldu. Her iki grup hasta 6 ay ve 1
y›l sonra tekrar kontrole ça¤r›ld›.
SONUÇLAR
Yaln›zca antral gastrit saptanan semptomatik 321 hastan›n
248’inde biyopsi ile Hp pozitifli¤i gösterildi. Hp(+)
Maltepe T›p Dergisi/ Maltepe Medical Journal
hastalara tedavi sonras› yap›lan gaita analizlerinde 74 hastada
Hp eradikasyonunun baflar›s›z oldu¤u görüldü. Eradikasyonun
baflar›s›z oldu¤u bu hastalardan 42’si semptomlar›n›n
tümü ile yok oldu¤unu ifade etti. Asemptomatik
hastalar iki gruba ayr›ld›. Birinci gruptaki ikinci basamak tedavi
verilen 21 hastan›n gaitada Hp analizleri tekrarland›.
Sadece 9 hastada (%43) pozitifli¤in devam etti¤i ancak bu
gruptaki 9 (dördü Hp-) hastada (%43) semptomlar›n tekrar
bafllad›¤› görüldü. Sadece diyet verilmifl olan ikinci gruptaki
hastalar›n ise 10’u (%47) flikayetlerinin tekrarlad›¤›n› ifade
etti.Her iki grup Ki-kare testi ile k›yasland›¤›nda istatistiksel
olarak fark olmad›¤› görüldü.
TARTIfiMA
Antrumda bafllayan yüzeysel gastritin zaman içersinde
tüm mideye yay›lmas›n›n yan›nda, inflamasyonun derinleflerek
tam kat mukozal gastrite ve ard›ndan da atrofi ve intestinal
metaplazi ve displazi gibi daha ciddi histopatolojik
de¤iflikliklere yol açabilece¤i anlafl›lm›flt›r. Hp enfeksiyonunun
en a¤›r komplikasyonu gastrik adenokanserdir. Gastrik
maltoma’n›n prognozu daha iyi olup Hp eradikasyon tedavisinden
fayda görülebilir. Hp eradikasyonu ile MALT lenfomada
sa¤lanan iyileflme %60-83 aras›nda de¤iflmektedir.
Hp eradikasyonu ayr›ca skuamöz hücreli özefagus kanseri
ile de iliflkili bulunmufltur. Baz› vaka raporlar›na göre ise Hp
eradikasyonu peptik ozefajite neden olabilir. Bu muhtemelen
kardia bölgesindeki bakterilerin koruyucu etkisine ba¤l›d›r(9).
Bu bilgiler ›fl›¤›nda antral gastrit ve Hp(+) tespit edilen
hastalarda eradikasyon tedavisi mutlaka verilmelidir.
Hp’de antibiyotiklere karfl› primer (do¤al) direnç ve/veya
sekonder (kazan›lm›fl) direnç bulunabilir. Bu durum eradikasyon
tedavilerinde baflar›s›zl›¤a neden olur(10).Ancak
eradikasyon baflar›s›z dahi olsa hastalar›n bir k›sm›nda klinik
semptomlar iyileflmektedir, bu hastalar›n asemptomatik
hastalar olarak kabul edilip edilmeyece¤i ve ikinci basamak
eradikasyon gereklili¤i tart›flmal›d›r. Çal›flmam›zda Hp eradikasyonu
ilk basamak sonras› baflar›s›z olan iki grup hastadan
tekrar eradikasyon tedavisi verilen ve verilmeyen grup
aras›nda anlaml› farkl›l›k olmad›¤› görülmüfltür.
Antibiyotik tedavisi sonras› semptomlar› düzelen ancak
Hp pozitifli¤i devam eden hastalarda Hp eradikasyonu
amac› ile ikinci basamak tedavi vermenin 1 y›ll›k k›sa dönemde
klinik yarar› yoktur. Ancak bu durumun yukar›da
belirtilen malinite geliflme gibi olas›l›klar› incelemek için
toplum tabanl› çok yüksek hastal›kl› çal›flmalara ihtiyaç
vard›r.
KAYNAKLAR
1. Warren JR, Marshall BJ. Unidentified curved bacilli on
gastric epithelium in active chronic gastritis. Lancet
1983;1:1273-1275.
2. Marshall BJ, Warren JR. Unidentified curved bacilli in
thestomach of patients with gastritis and peptic ulceration.Lancet
1984;1:1311-1315.
Cilt:3 Say›:3 / Aral›k 2011
17

18
Manukyan ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
3. Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am
Fam Physician 2007;76:1005-1012.
4. Duggan A. Helicobacter pylori: when is treatment
now indicated? Intern Med J 2002;32:465–469.
5. Zullo A, Hassan C, Andriani A. Eradication therapy for
Helicobacter pylori in patients with gastric MALT
lymphoma: a pooled data analysis. Am J Gastroenterol.2009;104:1932-1937.
6. Sezgin O, Alt›ntafl E, Üçbilek E, Tataro¤lu C. Bizmuthbased
therapies for the first step eradication of Helicobacter
pylori. Turk J Gastroenterol 2006;17:90-93.
7. Goodwin CS, Mendall MM, Northfield TC. Helicobac-
ter pylori infection. Lancet 1997; 349:265-269
8. Vaira D, Malfertheiner P, Megraud F, Axon AT Deltenre
M, Gasbarrini G, Garcia JMP et al. HpSA European
Study Group. Diagnosis of Helicobacter infection with
a new non-invasive antigen-based assay. Lancet
1999; 354:30-33
9. Helikobakter pilori: Nobel t›p ödülünü hak etti mi?
Yusuf Bayraktar 8. Ulusal iç hastal›klar› kongresi. P
256
10. Ba¤lan HP, Özden A. Helicobacter pylori’nin antibiyotiklere
direnci. Güncel Gastroenteroloji 2003;7:220-
225.

DENEYSEL ÇALIfiMA
Proksimal tubal oklüzyon iflleminin rat
over histopatolojisi üzerine etkilerinin
incelenmesi: Deneysel çal›flma
Examination of the histopathological effects
of proximal tubal occlusion procedure on rat
ovaries: An experimental study
Dr. Aygen Çelik / Maltepe Üniversitesi T›p Fakültesi Kad›n hastal›klar› ve Do¤um
Dr. Remzi At›lgan / F›rat Üniversitesi T›p Fakültesi Kad›n hastal›klar› ve Do¤um
Dr. Berna Halilo¤lu / Maltepe Üniversitesi T›p Fakültesi Kad›n hastal›klar› ve Do¤um
Dr. Erdin ‹lter / Maltepe Üniversitesi T›p Fakültesi Kad›n hastal›klar› ve Do¤um
Dr. Tonguç Gündüz / Maltepe Üniversitesi T›p Fakültesi Kad›n hastal›klar› ve Do¤um
Dr. Nusret Akpolat / F›rat Üniversitesi T›p Fakültesi Patoloji Anabilimdal›
Dr. Ekrem Sapmaz / Kad›n Hastal›klar› ve Do¤um AD, F›rat Üniversitesi T›p Fakültesi, Elaz›¤
ÖZET
Amaç: Bipolar koter kullan›larak yap›lan unilateral proksimal
tubal oklüzyon iflleminin birinci ve alt›nc› aylarda rat over histopatolojisi
üzerine etkilerinin incelenmesi.
Yöntem: Eriflkin 28 Wistar albino rat östrus faz›nda rastgele
4 gruba ayr›ld›.
G1 (n=7): Bat›n aç›l›p kapat›lan ve 1 ay sonra sol ooferektomi
yap›lan grup.
G2 (n=7): Sol proksimal tubal oklüzyon yap›l›p 1 ay sonra sol
ooferektomi yap›lan grup.
G3 (n=7): Bat›n aç›l›p kapat›lan ve 6 ay sonra sol ooferektomi
yap›lan grup.
G4 (n=7): Sol proksimal tubal oklüzyon yap›l›p 6 ay sonra sol
ooferektomi yap›lan grup.
Sol over örnekleri formaldehitle tespit edildi. Hematoksilen
Eozin ile boyanan preparatlarda over folikül rezervi saptand›. Atretik
foliküllerin say›s›, corpus luteum, corpus albicans tespit edildi.
Corpus luteum içi anjiogenesiz varl›¤›ndaki gerileme ve ovaryan
stromada fibrozis varl›¤› incelendi. Overdeki folikül kisti say›ld›.
G1-G2 ile G3-G4 ile karfl›laflt›r›ld›. Ordinal veriler için Mann
Whitney U testi, nominal veriler için x 2 testleri kullan›ld›. p0.05, Mann Whitney U test). Corpus luteum
içi anjiogenezisdeki gerileme G2 ve G4’de anlaml› olmamakla
birlikte azalm›flt›. Hiçbir grupta makroskobik veya mikroskobik
kist geliflmedi
Sonuç: Ratlarda bipolar koter kullan›larak yap›lan unilateral
proksimal tubal okluzyon ifllemi, erken ve geç dönemde over histopatolojisi
üzerine herhangi bir zararl› etki yapmam›flt›r.
Anahtar kelimeler: ovaryan histopatoloji, proksimal tubal
oklüzyon, rat.
ABSTRACT
Objective: Examination of the effects of unilateral proximal
tubal oclusion procedure by bipolar electrical coagulation on rat’s
ovarian histopathology at the first and six months.
Material and Methods: Adult 28 Winstar albino rats at
eustrous phase randomly divided into 4 groups.
G1 (n=7): Left oopherectomy, one month after laparatomy.
G2 (n=7): Left oopherectomy, one month after proximal
tubal oclusion.
G3 (n=7): Left oopherectomy, six months after laparatomy.
G4 (n=7): Left oopherectomy, six months after proximal
tubal oclusion.
Left ovary specimens fixed with formaldehyde, dyed with
Hematoxylen-Eosin and ovarian reserve examined. The number
of atretic follicles, corpus luteum and corpus albicans
determined. Angiogenesis in corpus luteum and presence of
ovarian stromal fibrosis examined. G1and G2 were compared
with G3 and G4. Statistical analysis of ordinal results were
examined by Mann Whitney U test and nominal results by x 2 test
f. P0.05, Mann Whitney U test ).
Angiogenesis regression in corpous luteum were lower in both
G2 and G4. No macroscopic or microscopic cyst formation
obtained in all groups.
Conclusion: Proximal tubal occlusion procedure by
bipolar coagulation has no harmful effect on rat oavarian
histopathology at both early and late period.
Key words: ovarian histhopathology, proximal tubal
occlusion, rat.

20
Çelik ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
G‹R‹fi:
Hidrosalpinksli olgularda IVF-ET (in vitro fertilizasyonembryo
transferi) sonuçlar› implantasyon, ve gebelik oranlar›
aç›s›ndan olumsuz yönde etkilenir (1-3). En kötü sonuçlar
özellikle büyük hidrosalpinks tespit edilen vakalarda ortaya
ç›kar (4). Hidrosalpinks tedavisinde salpenjektomi en
s›k kullan›lan yöntemdir (5–7). Ayr›ca neosalpingostomi,
drenaj ve proksimal tubal oklüzyon da kullan›labilir (8–13).
Salpingostomi vakalar›nda salpenjektomi veya tubal oklüzyona
göre daha fazla ektopik gebelik saptan›r (8). Drenaj ifllemi,
al›nan s›v›n›n üç gün içinde tekrar birikmesi sonucunda
implantasyon ve gebelik oranlar› üzerine etkisiz oldu¤u
tespit edilmifltir (14,15). Salpenjektomi IVF-ET baflar›s›n› anlaml›
olarak art›r›r (4–7). Ancak salpenjektominin insanlarda
ve ratlarda over kan ak›m›n› bozarak over fonksiyonlar›
ve rezervi üzerine olumsuz etki yapt›¤› ve postoperatif yo-
¤un pelvik adezyonlara neden oldu¤u düflünülmüfltür
(10,16,17).
Dar P. ve arkadafllar› (18) ektopik gebelik nedeniyle laparoskopik
salpenjektomi yap›lan vakalarda over üzerine
herhangi bir olumsuz etki saptamam›flken, Chan ve ark.
(19) ektopik gebelik vakalar›nda laparatomi ile yap›lan salpenjektominin
herhangi bir olumsuz etkisinin olmad›¤›n›
ancak laparoskopik salpenjektominin overi olumsuz etkiledi¤ini
savunmufltur.
Oysa daha kolay ve az invaziv bir ifllem olan, baflar›s› salpenjektomi
ile benzer bulunan proksimal tubal oklüzyonda,
mezosalpinkse travma olas›l›¤› azald›¤› için over rezervi
daha az etkilenebilir ve adezyon azalabilir (9,10)
GEREÇ VE YÖNTEMLER:
Bu deneysel çal›flma F›rat Üniversitesi T›p Fakültesi Deney
Hayvanlar› laboratuar›nda yap›ld›. 28 adet düzenli siklusa
sahip, 190-220 g a¤›rl›¤›nda, 14 haftal›k, eriflkin difli
Wistar Albino cinsi rat 12 saat ›fl›k (08-22), 12 saat karanl›k
fotoperiyodunda ve 21-23 C sabit s›cakl›ktaki odada,
standart pellet yemi ve flehir suyu ile beslendi. Bu çal›flma
için F›rat Üniversitesi T›p Fakültesi etik komitesinden izin
al›nd› ve deney flartlar› “Guide for the Care and Use of Laboratory
Animals” prensiplerine uygun olarak düzenlendi.
Deneyden 18 saat önce oral beslenme kesildi, sadece su içmelerine
izin verildi. Vajinal sitoloji takibinde estrus faz›nda
(Resim:1) tespit edilen ratlara anestezi sa¤lamak amac›yla
400 mg/kg/IP dozunda kloral hidrat uyguland›. Ratlar s›rt
üstü operasyon masas›na yat›r›ld›, bat›n orta hat insizyonla
aç›ld›. Ratlar rastgele 4 gruba ayr›ld›.
28 adet 3,5 ayl›k rat rastgele 4 gruba ayr›ld›.
G1 (n=7): Bat›n aç›l›p kapat›lan ve 1 ay sonra sol ooferektomi
yap›lan grup.
G2 (n=7): Bipolar koterle sol proksimal tubal oklüzyon
yap›l›p 1 ay sonra sol ooferektomi yap›lan grup.
G3 (n=7): Bat›n aç›l›p kapat›lan ve 6 ay sonra sol ooferektomi
yap›lan grup.
G4 (n=7): Bipolar koterle sol proksimal tubal oklüzyon
Resim 1: Östrus faz›ndaki bir ratta vajinal smearda sadece
keratinize olmufl (kornufiye) süngerimsi hücreler görülüyor
(HE, X 40).
yap›l›p 6 ay sonra sol ooferektomi yap›lan grup.
Bat›n tabakalar› ve cilt 3/0 ipekle kapat›ld›. Ratlar deney
sonuna kadar ayr› ayr› yediflerli kafeslerde tutuldu. Sol over
dokusu histopatolojik inceleme için %10’luk formaldehitle
fikse edildi, parafin bloklara gömüldü, 4 mikrometre kal›nl›¤›nda
kesit al›nd›. Kesitler hematoksilen eozin (HE) ile boyand›.
Ifl›k mikroskopisi alt›nda incelenen preparatlarda primordial,
primer, sekonder ve tersiyer foliküller say›ld›. Hepsi
toplanarak over folikül rezervi hesapland› (20). Atretik foliküller,
corpus luteum (CL), corpus albicans say›ld›. Toplam
corpus geliflimi hesapland›. CL içi anjiogenesiz varl›¤›ndaki
gerileme incelendi. Ovaryan stromada fibrozis varl›¤› incelendi.
CL içi anjiogenezisdeki gerileme ve fibrozis varl›¤› için
ordinal skala (yok=0p, var=1p, Çok var=2p) oluflturuldu.
Overdeki folikül kisti mikroskopik say›ld›. Overdeki folikül
kisti için ayr›ca nominal skala (makroskobik olarak yok=0p,
var=1p) oluflturuldu. G1-G2 ile G3-G4 ile karfl›laflt›r›ld› (yafl
karfl›laflt›rmal› gruplar). Ordinal veriler için Mann Whitney U
testi, nominal veriler için x 2 testleri kullan›ld›, p0.05, Mann Whitney U test).
CL içi anjiogenezisdeki gerileme G2 ve G4’de azalm›flt›.

Resim 2: Foliküler geliflimin tüm safhalar›n›n net olarak izlendi-
¤i (genç, 4.5 ayl›k) G1 ratlara ait preparat. Corpus luteum içi anjiogenezis
tamamen sonlanm›fl. Fibrozis yok. (HE, X 40)
Resim 3: Foliküler geliflimin tüm safhalar›n›n net olarak izlendi-
¤i (9.5 ayl›k) G3 ratlara ait preparat. Over Folikül rezerv elemanlar›nda
G1’e göre azalma mevcut. Corpus luteum içi anjiogenezis
tamamen sonlanm›fl. Fibrozis yok. (HE, X 40).
Resim 4: Proksimal tubal okluzyon 1. Ay. X 40. Atretik folikül
mevcut. Atretik folikül ve di¤er foliküllerde normal damarlanma
izleniyor. (HE, X 40).
Maltepe T›p Dergisi/ Maltepe Medical Journal
Resim 5: Proksimal tubal okluzyon 1. Ay. Korpus luteum içi anjiogenezisteki
gerilemede anlaml› azalma mevcut. Atretik folikül
ve fibroziste art›fl var. (HE, X100).
Resim 6: Proksimal tubal okluzyon 6. Ay. Korpus luteum içi anjiogenezisteki
gerilemede anlaml› azalma ve konjesyon izleniyor.
(HE,X40).
Resim 7: Proksimal tubal okluzyon 6. Ay. Corpus luteum içi anjiogenezisteki
gerilemede azalma, ovaryan stromadaki fibroziste
ve atretik folikül say›s›nda art›fl izleniyor. (HE,X40).
Cilt:3 Say›:3 / Aral›k 2011
21

22
Çelik ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
CL ve total corpus de¤eri G2’de ve G4’te hafif yüksek olmas›na
ra¤men istatistiksel fark tespit edilmedi (p>0.05,
Mann Whitney U test).
Gruplar›n hiçbirinde makroskopik veya mikroskopik folikül
kistine rastlanmad› Tüm gruplara ait incelenen parametreler
Tablo I’de gösterildi.
TARTIfiMA:
Ratlarda laparatomi yoluyla bipolar koterle yapt›¤›m›z
sol proksimal tubal oklüzyon ifllemi gerek 1. ve gerekse 6.
aylarda over histopatolojisi üzerine herhangi bir anlaml› etki
yapmam›flt›r.
Rat yafl› artt›kça over fonksiyonlar› gerilemektedir (21).
Deneyimizde yafllar› ayn› rat grubu karfl›laflt›r›larak, yafla
ba¤l› ortaya ç›kabilecek hatalar›n önlenmesine çal›fl›ld›.
G4’de ve özellikle G2’de CL içinde anjiogenezise ait de-
¤iflikliklerin gerilemesinde G3 ve G1’e göre ortalama de-
¤erlerde azalma tespit edildi. Ancak istatistiksel anlam tes-
Tablo I: Tüm gruplara ait incelenen parametreler.
pit edilemedi. Normal rat overinde CL’da ortaya ç›kan kapiller
yap›lar regrese olur. CL’daki bu yap›lar›n ortaya ç›kmas›nda
en önemli rolü vasküler endotelial growth faktör
(VEGF) oynar. VEGF’ün en önemli uyaranlar›ndan birisi hipoksidir
(22–25). Proksimal tubal oklüzyon ifllemi esnas›nda
utero-ovaryan anastomozdaki kan ak›m›n› çok az bozdu¤umuz
için overde hipoksi ortaya ç›kmakta (17), bu da
muhtemelen VEGF üzerinden CL’daki anjiogenezisin artmas›na,
regresyonundaki gerilemenin azalmas›na neden
olmaktad›r. Çünkü G2’de G4’e göre anjiogenezisdeki gerileme
daha yüksektir. Bu da akut dönemdeki hipoksiye ba¤l›
olabilir. Uzun dönemde geliflen anastomozlar sayesinde
hipoksinin etkisi göreceli olarak azalabilir. Çünkü ovaryan
arter ligasyonunun (OL) ovulasyon üzerine olan etkisi saatler
ilerledikçe artarken, uterin arter ligasyonun (UL) etkisi
saatler ilerledikçe azalmaktad›r (17). Bu da G4’deki anjiogenezisdeki
gerilemenin G2’ye göre daha iyi olmas›n›
aç›klayabilir.
Parametre G1 G2 P G3 G4 P
Primordial folikül (adet) 11.14±4.05 10.42±4.07 N 8.00±3.36 7.57±2.99 N
Primer follikül (adet) 21.00±8.48 20.28±8.69 N 9.42±2.14 9.28±2.36 N
Sekonder follikül (adet) 7.00±1.82 6.71±2.05 N 1.28±0.48 1.14±0.37 N
Tersiyer follikül (adet) 2.28±1.49 2.14±1.34 N 3.00±0.57 3.00±0.57 N
Over follikül rezervi (adet) 41.42±8.65 39.57±8.58 N 21.71±2.81 21.00±3.00 N
Corpus luteum (adet) 5.00±1.91 5.28±1.60 N 6.57±1.27 7.14±1.46 N
Corpus albicans (adet) 0.14±0.37 0.14±0.37 N 0.00±0.00 0.00±0.00 N
Toplam 5.14 ±1.67 5.42±1.39N N 6.57±1.27 7.14±1.46 N
Atretik follikül (adet) 0.14±0.37 0.28±0.48 N 0.14±0.37 0.42±0.53 N
C.L.Anjiogenezis (puan) 0.0±0.0 0.42±0.53 N 0.00±0.00 0.14±0.37 N
Stromal fibrozis (puan) 0.0±0.0 0.14±0.37 N 0.00±0.00 0.14±0.37 N
Kistik follikül (makroskobik) 0 0 N 0.0 0.0 N
Kistik follikül (mikroskobik) 0 0 N 0.0 0.0 N
n De¤erler ortalama ± SD ve n, % ( ) olarak gösterilmifltir.

Anderson ve ark ( 26 ) uterusta yap›lan luteolitik faktörler
(bunlar luteal hücrelerdeki mitokondri ve lizozomlar› etkileyerek
CL’un regresyonunu sa¤larlar) oldu¤unu ve kan
ak›m›n›n bozulmas› nedeniyle bu maddelerin overe tafl›namad›¤›
için CL’un regresyonunda gecikme oldu¤unu tespit
etmifllerdir. Gruplar aras›nda istatistiksel fark olmamakla
beraber G2 ve G4’teki CL’un ortalama de¤erlerinin G1 ve
G2’ye göre daha fazla olmas› ile uyumludur.
Ovaryan fibrozis ve atretik folikül say›s› G1 ve G3’de az
iken, G2 ve G4’de çok hafif artm›flt›r. ‹nsan over stroma yap›s›
yaflla birlikte de¤ifliklik gösterir. Reprodüktif yaflta, korteks
farkl› evrelerdeki foliküllerle doludur ve medulla elastik
fibrillerle gevflek konnektif doku, kan damarlar›, lenfatikler
ve sinir liflerinden oluflur. Menapozdan sonra over hacmi
gözle görülür derecede azal›r. Stromada daha fazla fibröz
konnektif doku ile birlikte korpus albikans, kan damarlar›,
lenfatikler ve sinirler bulunur (27). Kan veya lenfatik dolafl›m
bozuklu¤unda kollajen neoformasyonu sitimüle olur
(20). Uterin ve tubal lenfatikler broad ligament içerisinde
birbirlerine çok yak›n seyrederler (28). Bulgular›m›za göre
proksimal tubal oklüzyon ifllemi esnas›nda kollajen oluflumunda
art›fla neden olan lenfatik dolafl›mda hasar meydana
gelebilir.
G1 ve G3’de istatistiksel olarak anlaml› olmamakla birlikte,
over folikül rezervi ortalama de¤erleri G2 ve G4’e göre
daha fazla idi. Bunun nedeni over folikül rezervindeki azalmaya
kompansatuar olarak fibrozisde art›fl olmas›d›r (20).
Akut veya kronik hipoksi durumunda overlerde, di¤er
organlarda oldu¤u gibi hipoksi induced faktör-1 ( HIF-1 )
aktive olur (30-32). HIF-1 alfa ve hipoksik ortam, foliküllerde
regresyon ve apoptozise, sonuçta atretik foliküllerde art›fla
ve foliküler rezervde azalmaya neden olur (30). G2 ve
G4’teki atretik foliküllerdeki ve fibrozisdeki istatiksel olarak
anlams›z art›fl›n nedeni kronik hipoksinin apoptotik etkisine
ba¤l› olabilir (32). HIF-1 alfa ayn› zamanda VEGF sal›n›m››n›
art›r›r. VEGF anjiogenezisi, vasküler geçirgenlikte art›fl›, overlerde
follikülogenezisin normal iflleyiflini, overde folikül kisti
geliflimini, uzun dönemde ise fibroblast growth faktör-2 üzerinden
fibrozis geliflmesini uyar›r (24,25,29,33). G2 ve G4’teki
hafif derecede fibrozis art›fl›n›n nedeni VEGF olabilir.
Çünkü VEGF, 3. haftadan itibaren fibrozisi uyaran fibroblast
growth faktör-2’nin sentezini modüle eder. G4’de
fibrozisin G2’ye göre biraz fazla olmas›n›n nedeni G2’nin
bir ayl›k zaman diliminde iflleme tabi tutulmas› olabilir. Ayr›ca
VEGF’in direk kollajen sentezini uyar›c› etkisi de vard›r
(33, 34 ).
IVF tedavisinden önce unilateral veya bilateral hidrosalpinksli
kad›nlarda proksimal tubal okluzyon yap›lmas› gebelik
oranlar›n› klinik olarak anlaml› derecede yükseltir. Salpenjektominin
teknik olarak uygulanmas›n›n zor oldu¤u
vakalarda ise proksimal tubal okluzyon tercih edilebilir (35).
Sonuç olarak, ratlarda laparatomi yoluyla bipolar koterle
yapt›¤›m›z sol proksimal tubal oklüzyon iflleminin birinci
ve alt›nc› aylar›n sonunda over histopatolojisi üzerine an-
Maltepe T›p Dergisi/ Maltepe Medical Journal
laml› say›labilecek herhangi bir olumsuz etki yapmam›flt›r.
Bu bulgular ›fl›¤›nda hidrosalpenks tespit edilen vakalarda
enfeksiyon, torsiyon ve oosit toplanmas›n› engellemesini
önlemek için salpenjektomi yerine proksimal tubal oklüzyon
tercih edilebilen bir yöntem olabilir.
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Awad MM, Amin Y. Transvaginal ultrasonic guided
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Fertil Steril 2006;86:1642-1649.

OLGU SUNUMU
Nazal polipozis ve sinüzitin efllik etti¤i
nadir görülen intranazal aktinomikozis
Unusual intranasal presentation of
actinomycosis with nasal polyposis and
sinusitis
Dr. Zafer Çiftçi / Erzurum Bölge E¤itim ve Araflt›rma Hastanesi, KBB Klini¤i
Dr. Damla Nihan Çak›r / Nam›k Kemal Üniversitesi T›p Fakültesi, KBB Hastal›klar› ve Bafl – Boyun Cerrahisi Anabilim Dal›
Dr. Aklime Ifl›k / Nam›k Kemal Üniversitesi T›p Fakültesi, KBB Hastal›klar› ve Bafl – Boyun Cerrahisi Anabilim Dal›
Dr. Öner Çelik / Maltepe Üniversitesi T›p Fakültesi, KBB Hastal›klar› ve Bafl – Boyun Cerrahisi Anabilim Dal›
Dr. Erdogan Gültekin / Nam›k Kemal Üniversitesi T›p Fakültesi, KBB Hastal›klar› ve Bafl – Boyun Cerrahisi Anabilim Dal›
ÖZET
Aktinomikozun sadece nazal kavite ile s›n›rl› oldu¤u durumlar
nadirdir. Bu vaka sunumunda, intranazal aktinomikoz,
kronik rinosinüzit ve tek tarafl› nazal polipozis izlenen
37 yafl›nda kad›n hasta bildirilmektedir. Hastan›n paranazal
sinus bilgisayarl› tomografisinde (BT) sol maksiller sinüste ve
etmoid sinüslerde havalanma kayb› izlenmifltir. Hastan›n sol
nazal pasaj›n›n tamamen poliplerle oblitere oldu¤u ve poliplerin
içerisinde yüksek metalik dansitesi olan bir obje oldu¤u
izlenmifltir. Yüksek metalik dansitesi olan objenin boyutlar›
0.5 cm x 0.5 cm olarak ölçülmüfltür. Hastaya nazal
polipektomi ve fonksiyonel endoskopik sinus cerrahisi yap›lm›flt›r.
Yüksek dansiteye sahip objenin, nazal poliplerle
orta konka aras›nda s›k›flm›fl bir kalsifiye materyal yuma¤›
oldu¤u anlafl›lm›flt›r. Kalsifiye materyal ve polipler histopatolojik
inceleme sonucu tan›s› ‘izole intranazal aktinomikoz’
olarak saptanm›flt›r. Hastal›¤›n bu formu oldukça nadirdir.
Bu vaka sunumunda, literatürün ›fl›¤› alt›nda, hastal›¤›n
etyopatogenezi, tan›sal yaklafl›mlar ve tedavi modalitelerini
tart›flarak, aktinomikozun çok nadir görülen bir klinik
prezentasyonunu bildirmeyi amaçlad›k.
Anahtar kelimeler: nazal polip, aktinomikoz
G‹R‹fi
‘Aktinomikoz’ terimi zaman zaman yanl›fl anlafl›lmalara
yol açabilmektedir. Fungal bir enfeksiyon olmad›¤› halde,
‘mikoz’ teriminden dolay› halen fungal bir enfeksiyon oldu-
¤u düflünülmektedir. Hastal›¤›n etkeni anaerobik, filamentöz
ve gram pozitif bir organizma olan Aktinomyces isrelii’dir.
Hastal›k oldukça yavafl ve progresif bir seyir izler ve bir-
ABSTRACT
Actinomycosis involving the nasal cavity is a rarely
encountered situation. We report the case of a 37 years
old woman diagnosed as having intranasal actinomycosis,
chronic rhinosinusitis and unilateral nasal polyposis.
Paranasal computerized tomography (CT) showed loss of
aeration of the left maxillary sinus and ethmoid cells. The
left nasal passage was obliterated by polyps and an
object with a high metallic density. The dimensions of the
object were 0, 5 x 0, 5 cm. Nasal polypectomy and functional
endoscopic sinus surgery were performed. The
high density object was found to be a lump of calcified
material located between the nasal polyps and middle
turbinate. The material and nasal polyps were sent to
histopathological evaluation. The diagnosis was
‘intranasal actinomycosis’ which is a rarely encountered
clinical presentation of the disease. In our case report, we
present the history, diagnostic approaches and treatment
modalities of the disease under the scope of the literature.
Key words: nasal polyps, actinomycosis
birine benzer lezyonlar oluflturur(1). Hastal›¤›n insidans›
1970’lerde ABD’de 1:300.000 kifli/y›l iken, 1984 y›l›nda Almanya’da
1:40.000 kifli/y›l oldu¤u bilbirilmifltir(2). Aktinomikoz
tüm sosyoekonomik seviyedeki insanlar› ve tüm ›rklar›
etkilemektedir ve erkek – kad›n oran› 3:1 dir. Bu oran›n,
erkeklerde kad›nlara oranla fasiyal ve oral travma görülme

26
Çiftçi ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
olas›l›¤›n›n daha yüksek olmas› ve oral hijyen azl›¤›na ba¤l›
oldu¤u düflünülmektedir. Hastal›¤›n bi–modal yafl da¤›l›m
paterni vard›r. Hastal›k 11–20 yafllar aras›nda görülebilmekte
ancak bir çok seride 4 ve 5. dekadlar aras›nda belirgin
bir insidans art›fl› oldu¤u bildirilmektedir (3). Aktinomikozun
5 – 16 yafl aras›ndaki çocuklarda s›kl›kla karfl›lafl›ld›-
¤› da bildirilmifltir (4). Aktinomikozun nazal kavitede görülmesi
çok daha nadir görülen bir durumdur ve literatürde
bir kaç vakada bu durum bildirilmifltir (5, 6). Bu vaka sunumunda,
37 yafl›ndaki bir kad›n hastada, tek tarafl› nazal polipozis
ve sinüzitin efllik etti¤i, sol nazal kavite ile s›n›rl› kalan
bir aktinomikoz vakas› sunulmaktad›r. Tek tarafl› intranazal
aktinomikoz ile nazal polipozis ve sinüzit birlikteli¤inin
oldu¤u bir vaka daha önce hiç bildirilmemifltir. Aktinomikozun
geleneksel tedavisinde medikat tedavi, arkas›ndan
cerrahi tedavi ve gerekirse tamamlay›c› medical tedavi
kullan›l›rken, bizim vakam›zda cerrahi tedavi sonras› yap›lan
takiplerde hastal›¤a dair bulgu ve semptom izlenmedi-
¤i için, medikal tedavi kullanma ihtiyac› görülmemifltir.
OLGU SUNUMU
Otuzyedi yafl›nda bayan hasta Nam›k Kemal Üniversitesi
T›p Fakültesi Hastanesi Kulak Burun Bo¤az poliklini¤i’ne son
iki y›ldan beri devam eden nazal obstrüksiyon, nazal ak›nt›,
bafl a¤r›s› ve burundan kötü koku gelmesi flikayetleriyle baflvurdu.
Hastan›n sistemik herhangi bir hastal›k, immünsupresyon,
diyabet veya alkol kullan›m› anamnezi yoktu. Yirmi
paket – y›l sigara anamnezi vard›. Geçirilmifl bir nazal travma
veya nazal cerrahi hikayesi olmayan hastan›n oral hijyeninin
iyi oldu¤u ve herhangi bir dental sorununun olmad›¤›
görüldü. Nazal endoskopik muayenesinde sol nazal kaviteyi
oblitere eden polipler izlendi. Paranazal sinus BT’sinde sol
maksiller sinus ve etmoid hücrelerin, mukoza hipertrofisi,
polipler ve sekresyonlar nedeniyle oblitere oldu¤u izlendi.
Sol nazal pasaj nazal poliplerce ve yüksek metalik dansitesi
olan bir obje ile oblitere görünümdeydi. Objenin boyutlar› 0,
5 cm x 0, 5 cm olarak ölçüldü. (Resim 1 ve 2). Tam kan say›m›
ve sedimentasyon h›z› normal olarak bulundu.
Hastaya nazal polipektomi ve fonkiyonel sinus cerrahisi
uyguland›. Yüksek dansiteli objenin kalsifiye materyal yuma¤›
oldu¤u izlendi. Objenin orta konkan›n lateralinde lokalize
oldu¤u ve poliplerle çevrili oldu¤u görüldü. Kalsifiye
materyal ve nazal polipler histopatolojik de¤erlendirme için
gönderildi. Histopatolojik tan› ‘aktinomikoz’ olarak bidirildi.
‹ki ay sonra çekilen paranazal sinus BT’de paranazal sinus
aerasyonunun tamamen restore oldu¤u, nazal kavite ve
paranazal kavitede hastal›¤a ait herhangi bir residüel bulguya
rastlanmad›¤› görüldü (Resim 3).
TARTIfiMA
Aktinomikoz fistül traktlar›, multipl abseler ve fibrozisle
seyreden subakut veya kronik, süpüratif ve granülomatöz
bir enfeksiyondur. Actinomycete ailesinin sufllar›n›n neden
oldu¤u bir hastal›kt›r. Hastal›¤a, s›kl›kla anaerobik gram
Resim 1: Preoperatif BT, koronal kesit.
Resim 2: Preoperatif BT, aksiyel kesit.
Resim 3: Postoperatif BT, hiçbir enfeksiyon bulgusu izlenmemektedir.
pozitif bir mikoorganizma olan Actinomyces israelii neden
olur (7). Aktinomiçesler oral kavite floras›n›n önemli bir k›sm›n›
olufltururlar ancak alt gastrointestinal sistem ve kad›n
genital sisteminde daha nadir olarak bulunurlar. Aktinomikozis
vakalar›n›n % 50’si bafl – boyun bölgesindedir (serviko
– fasiyal aktinomikoz), % 15’i toraksta, % 20’si bat›nda
yer al›r ve geri kalan› pelvis, kalp ve beyinde yer al›r (3). Enfeksiyonun
karakteristik bulgusu a¤›zda, akci¤erlerde veya
sindirim sisteminde a¤r›l› abseler oluflumudur. Nadiren, tek
bafl›na veya di¤er dento – maksillo – fasiyal hastal›klarla iliflkili
olarak paranazal sinus aktinomikozu da görülebilmektedir
(8).

Aktinomiçes sufllar› insanlarda oral kavitenin do¤al flora
elemanlar›ndand›r ve genellikle kona¤a zarar vermezler.
Bununla beraber, enflamatuar yan›tl› bir enfeksiyona neden
olduklar›nda, parazitik bir rol oynamaya bafllarlar.
Mycobacterium tuberculosis’e benzer bir flekilde konak
hücreler taraf›ndan fagosite edilseler bile hayatta kal›rlar ve
intrasellüler parazitler olarak adland›r›labilirler (9).
Orofarengeal bölgenin veya paranazal sinüslerin aktinomikozunda
genellikle travma veya cerrahi hikayesi vard›r.
Difl çürükleri veya oral hijyen eksikli¤inin de enfeksiyona
neden olabilece¤i bildirilmifltir (10). Bununla beraber, bizim
vakam›zda, yukar›da bahsedilen faktörlerden hiç biri
bulunmuyordu.
SONUÇ
Paranazal sinüslerin aktinomikozu nadir görülen bir durumdur
ve hastal›¤›n klinik prezentasyonu spesifik bir tan›
akla getirmez (11). Bizim vakam›zda, nazal polipozis nedeniyle,
nazal endoskopide hastal›¤›n boyutlar› ile ilgili yeterli
bilgi al›namad›¤› için, hastan›n paranazal sinus BT’si çekilmifltir.
Medikal tedaviye yan›ts›z rinosinüzit vakalar› paranazal
sinus BT ile de¤erlendirilmelidir.
Aktinomikoz vakalar›n›n ço¤unda, sadece medikal tedavi
kullan›m› yeterli olmaktad›r. Seçilmifl vakalarda, tamamlay›c›
tedavi olarak cerrahi kullan›labilir. Aktinomikozis
tedavisinde tercih edilen ilaç Penisilin G dir. Tedavi enfeksiyon
bulgular› ortadan kalk›ncaya kadar devam edilmelidir.
Bizim vakam›zda hastan›n operasyondan iki ay sonra çekilen
kontrol BT’sinde, rezidüel veya rekürren enfeksiyona
dair bir bulguya rastlanmam›flt›r. Hastal›k sadece cerrahi giriflim
ile tedavi edilmifltir ve detekleyici antimikrobiyal tedaviye
ihtiyaç duyulmam›flt›r.
Medikal tedaviye yan›t vermeyen ve kronik bir seyir izleyen
rinosinüzit vakalar›nda, ay›r›c› tan›da aktinomikoz düflünülmelidir.
Maltepe T›p Dergisi/ Maltepe Medical Journal
KAYNAKLAR
1. Pulverer G, Schütt-Gerowitt H, Schaal KP. Human cervicofacial
actinomycoses: microbiological data for
1997 cases .Clin ‹nfect Dis. 2003;37:490-497.
2. Ryan KJ; Ray CG. Sherris Medical Microbiology (4th
ed.). McGraw Hill. ISBN 0–8385–8529–9
3. Mabeza GF, Macfarlane J. Pulmonary actinomycosis.
Eur Respir J 2003; 21: 545–551.
4. Melgarejo Moreno P, Hellin Meseguer D, Marco Garrido
A, Galindo Ortego X, Ruiz Macia JA, Hostalet F A
correlation between age and Actinomyces in the adenotonsillar
tissue of children B-ENT. 2006;2:95-97.
5. Chobaut JC, Maniere C, Badet JM, Spicarolen T, Kantelip
B. Actinomycosis in otorhinolaryngology. Apropos
of a case with localization in the nasal cavity. Ann
Otolaryngol Chir Cervicofac. 1994; 111:292–294.
6. Ozcan C, Talas D, Görür K, Aydin O, Yildiz A. Actinomycosis
of the middle turbinate: an unusual cause
of nasal obstruction. Eur Arch Otorhinolaryngol.
2005; 262:412-415.
7. Mehta V, Balachandran C Primary cutaneous actinomycosis
on the chest wall Dermatol Online J. 2008; 14:13.
8. Lee JD, Kim PG, Jo HJ, Park DH, Seo EJ. A case of primary
hepatic actinomycosis. J Korean Med Sci. 1993;
8:385–389.
9. Friduss ME, Maceri DR. Cervicofacial actinomycosis in
children. Henry Ford Hosp Med J. 1990; 38:28–32.
10. Zwaveling-Soonawala N, Spanjaard L, van de Wetering
M, Winterberg DH. Intracranial actinomycosis in
a child with dental caries. Ned Tijdschr Geneeskd.
2003; 147:2386–2389.
11. Damante JH, Sant’Ana E, Soares CT, Moreira CR.
Chronic rhinosinusitis unresponsive to medical therapy;
a case of maxillary sinus actinomycosis focusing
on computed tomography findings. Dentomaxillofac
Radiol, 2006; 35:213–216.
Cilt:3 Say›:3 / Aral›k 2011
27

Radikülopati ile prezente olan lumbar
spinal kondroma: Olgu sunumu
Lumbar spinal chondroma presented
with radiculopathy: A case report
Dr. Alper Karao¤lan / T.C.Maltepe Üniversitesi T›p Fakültesi Nöroflirürji Anabilim Dal›, ‹stanbul
Dr. Bilal Kelten / T.C.Maltepe Üniversitesi T›p Fakültesi Nöroflirürji Anabilim Dal›, ‹stanbul
Dr. Osman Akdemir / T.C. Taksim E¤itim ve Araflt›rma Hastanesi, Nöroflirürji Klini¤i, ‹stanbul
Dr. Mehmet Alpay Çal / T.C.Maltepe Üniversitesi T›p Fakültesi Nöroflirürji Anabilim Dal›, ‹stanbul
ÖZET
Kondromalar s›k rastlanan k›k›rdak kaynakl› benign kemik
tümörleri olmakla beraber spinal yerleflimli kondromalar
nadirdir. Spinal yerleflimli kondromalar klinik olarak lokal
kitle, lokal a¤r›, kord bas›s› semptomlar›, cauda equina
sendromu veya daha da seyrek olarak radiküler semptomlar
ile belirti verebilirler. Burada bel a¤r›s›n›n sol baca¤›na
yay›lmas› flikayetiyle baflvuran bir lumbar spinal kolon kondroma
olgusu sunulmufltur. Bu olgularda lezyonun preoperatif
de¤erlendirilmesi dikkatli yap›lmal›, major nörolojik hasar
geliflmeden önce kitlenin eksizyonu yap›lmal› ve lezyonun
malin transformasyon gösterme potansiyeli nedeniyle
lezyonun histopatolojik de¤erlendirmesi yap›lmal›d›r.
Anahtar kelimeler: kondroma, lumbar vertebra, radikülopati
G‹R‹fi
Kondromalar s›k rastlanan k›k›rdak kaynakl› benign kemik
tümörleri olup genellikle el ve ayaklar›n uzun kemikleri
ile daha seyrek olarak kaburgalar ve pelviste lokalize olurlar.
Spinal yerleflimli kondromalar ise oldukça nadirdir ve tüm
kondromalar›n yaklafl›k %3’ü ile spinal tümörlerin yaklafl›k
%2’sini olufltururlar (1). Omurgan›n herhangi bir noktas›ndan
köken alabilirler ve klinik olarak lokal kitle, lokal a¤r›,
kord bas›s› semptomlar›, cauda equina sendromu veya daha
da seyrek olarak radiküler semptomlar ile belirti verebilirler.
Özellikle lumbar bölgede disk hernisi veya spinal stenoz
bulgular› ile ortaya ç›kabilen kondromalar, histolojik olarak
küçük bölgelerde malignite gösterebildiklerinden ay›r›c› tan›da
hat›rlanmal›d›r (2). Biz de bel ve bacak a¤r›s› ile ortaya
ç›kan ve radyolojik olarak osteoartrotik de¤ifliklik olarak de-
¤erlendirilen bir spinal kondroma olgusunu bildiriyoruz.
ABSTRACT
Although chondromas are common benign cartilaginous
bone tumors, spinal chondromas are very unusual.
However, spinal chondromas may present with local mass,
local pain, spinal cord compression symptoms, cauda
equina syndrome; they also present with radicular symptoms
rarely. Here, a patient with the chief complaint: progressive
low back pain radiating left leg, is presented as a
case of lumbar spinal chondroma. In this kind of cases;
preoperative evaluation of the lesion must be done carefully,
total excision of the lesion must be done before neurological
damages develop, and also histopathological studies
must be done because of a potential risk of malign
transformation as a cardinal importance.
Key words: chondroma, lumbar vertebrae, radiculopathy
OLGU
66 yafl›nda kad›n hasta yaklafl›k bir y›ld›r devam eden
bel a¤r›s›n›n son bir ayd›r sol baca¤›na yay›lmas› ve analjezik
tedaviye yeterli yan›t al›namamas› flikayeti ile baflvurdu.
L3 dermatomuna uyan hipoestezi d›fl›nda nörolojik muayenesinde
baflka bir özellik saptanmad›. Lumbar spinal MR;
L2-3 seviyesinde dural keseye sol posterolateralden bas›
oluflturan faset eklemde osteoartrozik de¤iflikliklere sekonder
osseöz tüberkül olarak de¤erlendirildi (fiekil 1, fiekil 2).
Hasta operasyona al›narak sol L2 hemiparsiyel laminektomi
ile sol L2-3 faset eklem medialinden kaynakland›¤› izlenimi
veren sar›ms› beyaz renkli kitleye ulafl›ld› ve kitle total olarak
ç›kar›ld› (fiekil 3). Lezyonun histopatolojik incelemesinde
mavi-gri renkli prolifere kondrosit lobülleri izlendi ve kesin
tan› kondroma olarak rapor edildi (fiekil 4). Operasyon
sonras›nda hastan›n yak›nmalar›n›n geriledi¤i görüldü.

fiekil 1: Lumbar MR T2 sagital görünüm
fiekil 2: Lumbar MR T2 aksiyel görünüm
TARTIfiMA
Benign k›k›rdak tümörleri tüm spinal tümörlerin %2’sini
ve tüm benign kemik tümörlerinin %2.6’s›n› olufltururlar.
Patolojik olarak benign k›k›rdak tümörleri; kondromalar,
osteokondromalar, kondroblastomlar ve kondromiksoid
fibromalar olarak s›n›fland›r›l›rlar (1). Benign kemik tümörleri
içinde osteokondroma en yayg›n olan›d›r (3). Kondromalar
vücudun herhangi bir yerinde k›k›rdak ve kemik
dokulardan kaynaklanabilirler. Bu tip tümörler vertebra cismine
s›n›rl› kalarak semptom vermeyebilirler (1) . Semptomatik
kondromalar ise çok nadir izlenirler. Patolojik s›n›fland›rma
olarak kondroblastik kemik tümörleridir (4). Kendili¤inden
malin de¤iflim gösterme oran› çok nadirdir. Multipl
ya da tek olabilirler. Ollier sendromu (multipl encondromatosis)
ve maffucci sendromlar›nda multipl (multipl encondromatosis
ve yumuflak doku hemangiomu) görülür
(5). Kondromalar 1.-6. dekatlarda görülürler, 2-3. dekatlarda
pik yaparlar. Vertebral kolonda lokalize olan kondromalar
genellikle end-plate ve faset eklemi gibi konnektif doku
kaynakl› olabilir. Spinal kanal içine do¤ru geliflerek yap›n›n
sinir kökü bas›s› oluflturmas› nadirdir (6). Bunlar spinal ka-
Maltepe T›p Dergisi/ Maltepe Medical Journal
nal›n içinde kitle etkisi ya da paravertebral yap›lar›n ödemi
sonucu nörolojik semptoma neden olabilirler (3,7).
Spinal lezyonlar› radyografik olarak aç›klamak zor olabilir
çünkü süperpoze görüntüler çeflitli yorumlara neden olur
(8). Bilgisayarl› tomografi (CT) yaln›zca aç›k görüntü sa¤lamakla
kalmay›p ayn› zamanda tümör alan› ve onun komflu
dokularla ba¤lant›s› hakk›nda da de¤erli bilgi vermektedir
(9). Manyetik rezonans görüntüleme (MRI) ise nörolojik yap›lar
hakk›nda de¤erli deliller sunmakta tümör T1 a¤›rl›kl›
görüntülerde düflük sinyal T2 a¤›rl›kl› görüntülerde yüksek
sinyal vermektedir (9).
Olgumuzda tümör kayna¤›n›n faset eklemi oldu¤unu
düflünüyoruz. Spinal kondromalar bu olguda oldu¤u gibi
faset eklem osteoartrozunu ve intervertebral disk herniasyonunu
radyolojik ve klinik olarak taklit edebilece¤inden
ay›r›c› tan›da mutlaka ak›lda tutulmal›d›r. Bu olgularda kesin
tan› histolojik inceleme ile konur ve malinite de¤iflimi
gösterebilen bu tümörlerin histopatolojik incelemesinde
küçük bölgelerde malinite iflaretleri olabilece¤inden lezyonun
tümü taranmal›d›r (4).
Tedavi yöntemi, lezyonun total olarak ç›kar›lmas›d›r. Tan›
ve tedavi erken dönemde gerçeklefltirildi¤i zaman iyi sonuç
al›nabilir ve tam flifa neredeyse kurald›r. Buna ra¤men
baz› hastalarda geçici veya kal›c› nörolojik defisitler meydana
gelebilir (8). Tan› ve tedavi sürecindeki gecikmeler ise
kal›c› nörolojik hasarlar ile sonuçlanabilir.
fiekil 3: Kitlenin makroskopik görünümü
fiekil 4: Mavi-gri renkli prolifere kondrosit lobülleri
Cilt:3 Say›:3 / Aral›k 2011
29

30
Karao¤lan ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
KAYNAKLAR
1. Gaetani P, Tancioni F, Merlo P, Villani L, Spanu G,
Baena RR. Spinal chondroma of the lumbar tract: case
report. Surgical Neurology. 1996;46(6):534-539.
2. Panelos J, Voulgaris S, Michos E, Doukas M, Charalabopoulos
K, Batistatou A. Chondrosarcoma of the
spine: A rare case with unusual presentation. Diagnostic
Pathology. 2006;1:39.
3. Faik A, Filali SM, Lazrak N, El Hassani S, Hajjaj-Hassouni
N. Spinal cord compression due to vertebral osteochondroma:report
of two cases. Joint Bone Spine
2005;72:177–179.
4. Camins MB, Jenkins III AL, Singhal A, Perrin RG. Tumors
of the Vertebral Axis: Benign, Primary Malignant
and Metastatic Tumors. In: Winn HR, editor. Youmans
Neurological Surgery. 5th Saunders, 2001;
4835-4868.
5. Lane J, Cammisa FJ, Glasser D. Benign cartilage tumors
of the spine. In: Sundaresan N, Schmidek HH,
Schiller AL, Rosenthal DI, eds. Tumors of the spine: Diagnosis
and Clinical Management. WB Saunders, PL.
1990;146-148.
6. Emanuelson I, Kyllerman M, Roos A. Hereditary multiple
exostosis with spinal cord compression in a 13year-old
boy. J Neurol Neurosurg Psychiatry.
1994;57:238-239.
7. Scarborough M, Moreau G. Benign cartilage tumors.
Ortop Clin North America 1996;27:583-589.
8. Albrecht S, Crutchfield JS, Segal GK. On spinal osteokondromas.
J Neurosurg 1992;77:247-252.
9. Woertler K. Benign bone tumors and tumor-like lesions:
value of cross-sectional imaging European Radiology
2003;8:1820-1835.

Gemifloxacin-associated fever, maculopapular
rash and elevated liver enzymes: A case report
Gemifloksasin ile iliflkili atefl, makülopapüler döküntü
ve karaci¤er enzimleri yüksekli¤i: Olgu sunumu
Gulbuz Sezgin, MD / Maltepe University Departments of Internal Medicine
Melahat Cengiz, MD / Maltepe University Departments of Infectious Diseases
Oya Uygur-Bayramicli, MD / Maltepe University Departments of Gastroenterology
A.Melih Ozel, MD / Maltepe University Departments of Gastroenterology
ÖZET
Girifl: Fluorokinolonlar 25 y›ldan daha uzun süredir kullan›lmakta
olan genifl spektrumlu antibiyotiklerdir. Jenerasyon
say›lar› artt›kça etkinlik spektrumu da artm›flt›r, ancak
yan etkilere dikkat etmek gereklidir ve bu ilaçlar gerçek endikasyonlar›
d›fl›nda kullan›lmamal›d›r. Burada ilaçla iliflkili
yan etkilerin genifl yelpazesini vurgulamak ve antibiyotiklerin
rasyonal kullan›m›na dikkat çekmek üzere bir gemifloksasin
toksisitesi olgusu sunulmaktad›r.
Olgu sunumu: Burada, nazal polip nedeni ile ameliyat
haz›rl›¤› yap›lmakta iken profilaktik olarak gemifloksasine
320 mg. tb kullan›m› sonras›nda, yüksek atefl, ›fl›¤a duyarl›l›k,
ciltte makulopapüler döküntüler ve yüksek karaci¤er
enzimleri nedeni ile acil servise müracaat eden 33 yafl›nda
bir erkek hasta sunulmaktad›r. Yap›lan genifl incelemede
baflka herhangi bir infeksiyöz ya da metabolik neden saptanmad›.
Hastan›n klinik durumu ilac›n kesilmesinden sonra,
herhangi bir tedavi ifllemi yap›lmaks›z›n kendili¤inden
tamam› ile düzeldi.
Sonuç: Bu olgu klinisyenlerin antibiyotik kullan›rken ne
kadar dikkatli olmalar› gerekti¤ini vurgulamaktad›r. Çeflitli
infeksiyon hastal›klar›n›n tedavisi için gemifloksasin ve di-
¤er fluorokinolonlar›n kullan›m› giderek artarken artan bir
dikkat ve kontrol sürdürülmelidir. Zira bu ilaçlar nadir olarak
bildirilen yan etkilerin olas›l›klar›n› art›rabilmektedir.
INTRODUCTION
Quinolones are chemically obtained synthetic
medications. Starting from the incidental production of
nalidixic acid during synthesis of chloroquin, they have
been a large family of wide spectrum chemotherapeutics
ever since (1). They have a large list of indications from
community acquired pneumonias to nosocomial
pneumonias, from complicated urinary system infections
ABSTRACT
Introduction: Fluoroquinolones are wide spectrum
bactericidal antibiotics being used for over 25 years.
Increasing number of generations increased spectrum of
efficacy, but caution is needed for side effects and these
medications should not be used without true indication.
We report with a case a gemifloxacin toxicity to underline
the wide spectrum of medication-related adverse effects
and to draw attention to rational use of antibiotics.
Case presentation: We report a 33-year-old man
presented with high fever, photosensitivity, maculopapular
rash and elevated liver enzymes after prophylactic use of
gemifloxacine 320 mg tablet, in the course of preparation
for surgery for nasal polyp. A thorough diagnostic
investigation did not reveal any other metabolic or
infectious etiology. His clinical findings resolved completely
after cessation of the medication without any definitive
treatment.
Conclusion: This case highlights the need for clinicians
to be cautious when using antibiotics. Continued care and
caution is recommended as gemifloxacin and other
fluoroquinolone usage is increasing for various infectious
diseases, since these medications may increase likelihood
of adverse effects, which are reported infrequently.
to bone infections and from gastrointestinal infections to
pelvic infections (2). Because quinolones, especially the
new generation forms, are readily absorbable from the
gastrointestinal tract and because the pharmacokinetics of
the medication is favorable (e.g. rapid elevation to peak
serum values, better tissue distribution, longer elimination
time etc), they are commonly used in daily clinical practice.
It is important, however, to be aware of the possible

32
Sezgin ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
serious side effects of these commonly used medications,
which may cause serious organ injuries.
We report a case of gemifloxacine related maculopapular
rash accompanied by high fever and elevated
liver enzymes to draw attention to this important clinical
possibility.
CASE PRESENTATION
A 33-year-old man presented to the emergency
department with facial and corporal rash and fever for two
days. Ten days earlier he had taken prophylactic
gemifloxacine tablets 320 for 7 days, in the course of
preparation for surgery for nasal polyp. Skin rashes and
fever occurred right after the cessation of the medication
and he was seen by a physician who prescribed
antihistaminic tablets which were not helpful in controlling
either the fever or the rashes two days before his arrival to
our hospital. He complained that his rashes increased in
these two days and his fever was 38,3 °C in the emergency
room. He was admitted to the hospital. His past medical
history was non-contributory. Physical examination
revealed normal findings except for high fever (38,3 °C),
high heart rate (124/min) and conjunctival redness.
Laboratory findings were also normal except for elevation
of alanin aminotranspeptidase (ALT 96 IU/L, range:15-65).
Cultures (urine, throat, blood) and viral markers for
hepatotropic viruses were negative as were CMV IgM,
Coxackie A and B IgM, and Rubeola IgM. The patient was
put on IV fluids and antihistaminics and palliative measures
for his fever (e.g. lukewarm bath). Next day his fever
started lowering and his rashes were coalesceing along
with resolution of conjuctival redness and photosensitivity.
On the third day his symptoms were normal and he was
discharged pending outpatient follow up. His laboratory
tests returned to normal the next week after his discharge
from the hospital with no fever or rashes.
DISCUSSION
A case for gemifloxacin-related rash, photosensitivity
and liver enzyme elevation was consistent with this
patient’s presentation and with treatment initiation. The
search for other reasons in this patient revealed no other
probable cause and the patient did not have any symptom
progression after the cessation of the medication.
Because of its easy use single dose administration and
high bioavailability (>70%) gemifloxacine has found a
wide area of usage among medical community dealing
with infectious diseases (2); however increasing usage
brought increased side effects such as gastrointestinal
intolerance, hypersensitivity reactions, central nervous
system reactions etc. (3).
Any kind of antibiotics can lead to medication-related
fever and fluoroquinolone related fever cases have been
reported (4). Fever in our patient had started right after
medication usage and no other causative agent have been
revealed with diagnostic work up and gemifloxacine
seemed like the only probable cause. Accompanying
maculopapular rash is a known adverse effect of
gemifloxacine (5). Ball et al has reported such rash with
gemifloxacine without severe eruptions (5). Fever and rash
resolved completely without any definitive treatment in a
few days. Photosensitivity was a mild symptom and lasted
shorter than fever and rash and we believe that these
symptoms are interrelated.
Pharmacokinetic studies has shown that gemifloxacine
is a well tolerated medication and that elevations ALT levels
were reported with use of 600 mg gemifloxacine for 6
days (5). This patient used standard dose of the medication
(320 mg) for 7 days and elevated ALT level has returned to
normal in a week without any other therapeutic
intervention which makes us believe that it is related with
the medication.
CONCLUSION
This case highlights the need for clinicians to be
cautious when using antibiotics. Continued care and
caution is recommended as gemifloxacin and other
fluoroquinolone usage is increasing for various infectious
diseases, since these medications may increase likelihood
of adverse effects, which are infrequently reported.
REFERENCES
1. Andriole VT: The quinolones: past, present and
future. Clin Infect Dis 2005;41:119-129.
2. Von Bambeke FV, Michot JM, von Eldere JV, Tulkens
PM: Quinolones in 2005:an update. Clin Microbiol
Infect 2005; 11: 256-280.
3. Stahlmann R, Lode H: Safety considerations of
fluoroquinolones in the elderly: an uptake. Drug
Aging. 2010; 27: 193-209.
4. Smith CR: The adverse effect of fluoroquinolones. J
Antimicrob Chemother. 1987;19: 709-712.
5. Ball P, Mandell L, Patou G (eds): A new respiratory
fluoroquinolone, oral gemifloxacin: a safety profile in
context, Int J Antimicrob Agents 2004; 23: 421-429.

Rapid spontaneous resolution of
traumatic acute subdural hematoma
Travmatik akut subdural hematomun
h›zl› spontan rezolüsyonu
Aziz Y›ld›r›m, MD, Specialist in Neurosurgery / Department of Neurosurgery, Bingol State Hospital, Bingol, Turkey;
Veysel Burulday, MD, Specialist in Radiology / Department of Radiology, Bingol State Hospital, Bingol, Turkey;
Alper Karao¤lan, MD, Assistant Professor in Neurosurgery / Department of Neurosurgery, Maltepe University, School of Medicine, Istanbul, Turkey;
Bilal Kelten, MD, Assistant Professor in Neurosurgery / Department of Neurosurgery, Maltepe University, School of Medicine, Istanbul, Turkey;
ÖZET
Travmatik akut subdural hematom yaflam› tehdit eden
bir durumdur. Akut subdural hematomun birkaç saat içinde
spontan rezolüsyonu nadir görülür. Bu olguda travmatik
akut subdural hematomun 5 saat içerisinde h›zl› rezolüsyonunu
iliflkili mekanizmalar eflli¤inde tart›flarak sunduk.
Anahtar kelimeler: akut subdural hematom, bilgisayarl›
tomografi, h›zl› rezolüsyon
INTRODUCTION
Posttraumatic acute subdural hematoma is a
neurosurgical emergency condition characterized by %
from 60 to 80 mortality rates. Acute subdural hematomas
(ASDH) seem to result either from large angular
acceleration-deceleration forces that result in rupture of
bridging veins over the cerebral surface or from impact,
with distortion and failure of deep draining veins (1).
According to the thickness of hematoma and the patient's
neurological status of acute subdural hematomas can be
treated conservatively and followed by serial computed
tomography (CT) scanning.
Rapid spontaneous resolution of the hematoma
treated conservatively has been reported in the few cases
(2-7). In the literature the earliest resolution was reported
within 3 hours (5).
A case of spontaneous rapid resolution of ASDH which
the CT scan 5 hours after admission showing resolution of
subdural hematoma was reported in this study.
CASE REPORT
An 17 year old male sufferred a traumatic head injury
ABSTRACT
Traumatic acute subdural hematoma is a life
threatening situation. Spontaneous resolution of acute
subdural hematoma within a few hours is seen rarely. We
present a case of rapid resolution of traumatic acute
subdural hematoma with resolution in 5 hours and we
discuss the mechanisims related to the resolution of acute
subdural hematoma.
Key words: acute subdural hematoma, computed
tomography, rapid resolution
in a traffic accident was transferred to our hospital. On
admission, he was lethargic, had a Glasgow Coma Score
(GCS) score of 14, pupils were isocoric and reacted normally
to light. The CT scan revealed a subdural hematoma with a
thickness of 6 mm in the right posterior parietal region
(Figure 1). There was no cranial fracture.
The follow-up CT was performed 5 hours after the initial
CT. The follow-up CT scan showed complete resolution of
acute subdural hematoma (Figure 2).
DISCUSSION
Traumatic acute subdural hematoma is life threatening
condition that requires immediate therapeutic intervention
(4,8). spontaneous resolution of traumatic acute subdural
hematoma is seen rarely. Because these patients usually
undergo an operation on an emergency basis (8).
Several possible mechanisms for the spontaneous
resolution of hematoma have been proposed (8,9).
Dilution and wash out of the hematoma by cerebrospinal
fluid due to tearing of the arachnoid membrane (7,10,11),
extracranial redistribution of the hematoma through skull
fractures (12), compression and redistribution of the

34
Y›ld›r›m ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
Figure 1: Initial computed tomography (CT) scan showing acute
subdural hematoma in the right posteriorparietal region
hematoma by acute brain swelling (13), redistribution of
the subdural hematoma to the spinal subdural space (14).
In addition, the HIV virus that causes acute subdural
hematoma due to cerebral atrophy and hematoma with
spontaneous resolution has also been reported (15).
Matsuyama et al. reported total disappearance of an
acute subdural hematoma with a thickness of a 1.5 cm.
They speculated, the absence of cerebral contusion is
necessary for spontaneous resolution of ASDH (5). Lee et
al. reported the thickness of subdural hematoma above
2.5 cm is an obstacle to total spontaneous resolution of
ASDH (8). In our case the thickness of subdural hematoma
was 6 mm and we observed complete rapid spontaneous
resolution of hematoma.
Several studies have been presented with an even more
rapid resolution of ASDH in recent years. Resolution of
traumatic acute subdural hematoma showing an earliest
resolution was reported within 3 hours (5). In our case, we
present this time (time between two CT) within 5 hours.
Case of ASDH (Glasgow Coma Scale (GCS) 11-15, a
thin hematoma

10. Inamasu J, Nakamura Y, Saito R, Kuroshima Y,
Mayanagi K, Ohba S, Ichikizaki K. Rapid resolution of
traumatic acute subdural hematoma by redistribution.
Am J Emerg Med 2002; 20: 376-377.
11. Polman CH, Gijsbers CJ, Heimans JJ, Ponssen H, Valk
J. Rapid spontaneous resolution of an acute subdural
hematoma. Neurosurgery 1986; 19: 446-448.
12. Kundra S, Kundra R. Extracranial redistribution
causing rapid spontaneous resolution of acute
subdural hematoma. Neurol India 2005; 53: 124.
13. Nagao T, Aoki N, Mizutani H, Kitamura K. Acute
Maltepe T›p Dergisi/ Maltepe Medical Journal
subdural hematoma with rapid resolution in infancy:
case report. Neorosurgery 1986; 19: 465-467.
14. Bartolotti C, Wang H, Fraser K, Lanzino G. Subacute
spinal subdural hematoma after spontaneous
resolution of cranial subdural hematoma: causal
relationship or coincidence?: case report. J Neurosurg
2004; 100: 372-374.
15. Cohen JE, Eger K, Montero A, Israel Z. Rapid
spontaneous resolution of acute subdural hematoma
and HIV related cerebral atrophy: case report. Surg
Neurol 1998; 50(3): 241-244.
Cilt:3 Say›:3 / Aral›k 2011
35

Favorable outcomes of pregnancy with use
of sibutramine in a woman with polycystic
ovary syndrome: a case report
Polikistik over sendromu olan bir kad›nda
sibutramin kullan›m› ile olumlu gebelik
sonuçlar›: bir olgu sunumu
Esra Sa¤lam, M.D. Associated Professor / Department of Medical Pharmacology, Maltepe University, ‹stanbul
Emine Nur Özdamar, M.D. / Department of Medical Pharmacology, Maltepe University, ‹stanbul
‹. Yaman Sa¤lam, M.D., Ph.D. / Medical Genetics Laboratory, Medical Park Göztepe Hospital, Kad›köy, ‹stanbul
ÖZET
Sibutramin fliflmanl›¤›n uzun vadeli tedavisi için kullan›lan
bir ilaçt›r. Gebelikte sibutramine maruz kalma ile ilgili s›n›rl›
say›da yay›nlanm›fl veri mevcuttur. Bu makalede, gebe
oldu¤unun fark›nda olmadan 1-6. gebelik haftalar› aras›nda
15 mg/gün sibutramine maruz kalan polikistik over sendromlu
29 yafl›ndaki Kafkas kökenli kad›n olgu sunulmufltur.
Gebeye 38. haftada sezaryen yap›lm›fl ve 4150 gr a¤›rl›¤›nda
sa¤l›kl› erkek yeni do¤an dünyaya gelmifltir. Bebek
bir sene boyunca takip edilmifl ve bu süre içinde hiçbir konjenital
anomali ya da geliflimsel bozuklu¤a rastlanmam›flt›r.
Polikistik over sendromlu bir kad›nda,fliflmanl›k tedavisi için
sibutraminin kullan›m› s›ras›nda baflar›l› spontan gebelik ve
olumlu gebelik sonuçlar›n›n sunumu, bu ilaca gebelikte
maruziyetle ilgili s›n›rl› bilgiye katk›da bulunacakt›r.
Anahtar kelimeler: sibutramin; polikistik over sendromu;
gebelik; sezaryen; fliflmanl›k
INTRODUCTION
The prevalance of obesity has started to increase
markedly during the last decades and the importance of
obesity has been recognised as a major public health
problem affecting both the developed and the developing
countries (1). At all ages women are commonly found to
have a higher mean body mass index (BMI) and higher
rates of obesity than men (2). Polycystic ovary syndrome
ABSTRACT
Sibutramine is a drug used for long-term management
of obesity. There is limited published data about
sibutramine exposure during pregnancy. In this article, we
present a 29-year-old, Caucasian woman with polycystic
ovary syndrome who exposed to 15 mg/day of sibutramine
during gestational weeks 1- 6 without knowing that she
was pregnant. At 38 th weeks, cesarean section was
performed and a healthy male newborn weighted 4150
gram was born. We followed the infant for one year. No
congenital abnormalities and developmental disorders
were seen during this period. This report of the successful
spontaneous pregnancy and favorable pregnancy
outcomes following the use of sibutramine for obesity
management in a woman with polycystic ovary syndrome
may contribute to the limited knowledge about the
exposure to this drug during pregnancy.
Key words: sibutramine; polycystic ovary syndrome;
pregnancy; cesarean section; obesity
(PCOS) is the most common form of female infertility and
associated with a number of metabolic disturbances.
Obesity is encountered in % 30- 70 of PCOS-affected
women (3). The world health organization (WHO) accepts
a body mass index (BMI) of 30 kg/m 2 or higher as obese.
Antiobesity pharmacotherapy is accepted as appropriate
for patients with a BMI of 30 kg/m 2 or higher without
concomitant risk factors or a BMI of 27- 29. 9 kg/m 2 with

a major obesity–related comorbidity (eg. hypertension,
diabetes) (4). There are only a few kinds of drugs available
for the treatment of obesity. Sibutramine is a serotonin
norepinephrine reuptake inhibitor that is approved for
long-term management of obesity (5,6). To a smaller
degree sibutramine also inhibits the reuptake of dopamine
(5). It is reported that sibutramin in combination with
lifestyle modifications result in significant weight reduction
in obese patients with PCOS (7).
There is limited published data about sibutramine
exposure during pregnancy. ‹n this report, we present a
pregnant woman who used sibutramin in early pregnancy
and her fetal outcomes.
CASE REPORT
Our case was a 29-year-old, Caucasian primigravida
who had a cesarean delivery of a healthy male infant one
year ago. She had some medical problems including
polycystic ovary syndrome, hypothyroidism and metabolic
syndrome. On physical examination, her calculated body
mass index (BMI) was 32 kg/m2 . The patient reported
taking 15 mg/day of sibutramine for losing weight during
gestational weeks 1- 6, without knowing that she was
pregnant. A chest x-ray was taken for check up in
gestational week 5 th . Her quad screen test in gestational
week 17 th
showed increased risk of trisomy 18.
Amniocentesis result was normal. Her serial obstetrical
ultrasounds showed normal fetal growth. At 38 th weeks,
she delivered a male infant (4150 gr; 51 cm) by cesarean
section. The infant had Apgar scores of 9 and 10, at 1 and
5 min, respectively. We followed the infant for one year.
No congenital abnormalities and developmental disorders
were seen during this period.
DISCUSSION
Orginally developed as an antidepressant, sibutramine
is an orally administered agent for the treatment of
obesity. Sibutramine is a serotonin norepinephrine
reuptake inhibitor that induces weight loss by suppressing
appetite, enhancing satiety and inducing thermogenesis
(8, 9, 10). Sibutramine is usually started at a dose of 10 mg
daily and the dose may be increased up to 15 mg daily
after 4 weeks in nonresponders (11).
Pharmacotherapy during pregnancy, presents a special
concern because of potential teratogenic effects of the
drugs. Physiologic changes of pregnancy affect the
pharmacokinetics of medications used by pregnant woman
and some medications can reach the fetus and cause harm
(12). Sibutramine belongs to pregnancy category C, hence
its use is not recommended during pregnancy (13). From
the studies in rats, there was no evidence of teratogenicity
at sibutramine doses of 1, 3 or 10mg/kg/day. Whereas in
rabbits maternal toxicity and increased cardiovascular
anomalies were found at high doses (13).
Maltepe T›p Dergisi/ Maltepe Medical Journal
There is little published evidence about human
pregnancy outcomes following prenatal exposure to
sibutramin (14, 15, 16, 17). Kadioglu et al. (14) reported
normal fetal outcomes of two pregnant women exposed
to sibutramine during the first trimester. Einarson et al.(15)
observed 10 pregnant women who took sibutramine
during the first trimester of pregnancy. Among these 10
women, 7 delivered normal healthy babies, 2 had
spontaneous abortions and 1 had therapeutic abortion. A
subsequent study described two pregnant women
exposed to sibutramine during the second trimester of
pregnancy. Among the two women, one delivered a
normal healthy newborn, one had spontaneous abortion
(16). Lastly, a study of 52 pregnant women exposed to
sibutramine during the first trimester showed no increase
in congenital anomalies or adverse pregnancy outcomes
(17).
PCOS is a common clinical disorder characterized by
ovulatory dysfunction, hyperandrogenaemia, rapid LH
(GnRH) pulsatility, increased LH concentrations and LH:
FSH ratios (18). It has been suggested that psychological
stress and neurotransmitter levels may be linked to some
of the hormonal derangements, including inappropriate
gonadotropin secretion and elevated adrenal androgen
levels in women with polycystic ovary syndrome (19).
Increased prevalance of depression has been found in
women with PCOS and an assosiation between depression
and insulin resistance and BMI has been observed (20). It
has been suggested that serotonin has an inhibitory effect
on GnRH stimulated LH release (21) and dopamine has
also been shown to supress serum LH levels (22). Based on
this findings, in this case sibutramine may have increased
the chance of spontaneous pregnancy by reducing stress
and increasing the levels of serotonin and dopamine which
supress LH release.
This report of the successful spontaneous pregnancy
and favorable pregnancy outcomes following the use of
sibutramine in a woman with polycystic ovary syndrome
may contribute to the limited knowledge about the
exposure to this drug during pregnancy.
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the problem. J Intern Med 2008; 263: 336–352.
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1197-1209.
3. Vrbikova J, Hainer V.: Obesity and polycystic ovary
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4. Padwal RS, Majumdar SR.: Drug treatments for
obesity: orlistat, sibutramine and rimonabant. Lancet
2007; 369: 71-77.
5. Tziomalos K, Krassas GE, Tzotzas T.: The use of
sibutramine in the management of obesity and
related disorders: An update. Vascular Health and
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38
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Maltepe T›p Dergisi/ Maltepe Medical Journal
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2000: a review of efficacy and safety. Arch Intern
Med 2001;161:1814- 1824.
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sibutramine on weight reduction in women with
polycystic ovary syndrome: a randomized, doubleblind,
plasebo-controlled trial. Fertil Steril 2008;89:
1221-1228.
8. Luque CA, Rey JA.: The discovery and status of
sibutramine as an anti-obesity drug. Eur J Pharmacol
2002;440:119-128.
9. Halford JCG, Harrold JA, Boyland EJ, Lawton CL,
Blundell JE.: Serotonergic drugs: effects on appetite
expression and use for the treatment of obesity.
Drugs 2007;67: 27- 55.
10. Halford JCG.: Pharmacotherapy for obesity. Appetite
2006;46:6-10.
11. Linne Y, Rossner S.: Pharmacotherapy of obesity.
Clinics in Dermatology 2004;22: 319- 24.
12. Sachdeva P, Patel BG, Patel BK.: Drug use in
pregnancy; a point to ponder. Indian J Pharm Sci.
2009; 71: 1–7.
13. Erkekoglu P, Giray B, Sahin G.: Toxicological
evaluation of antiobesity drug use during pregnancy
and lactation. Hacettepe Medical Journal 2008; 39:
121-133
14. Kadioglu M, Ulku C, Yaris F,et al.: Sibutramine use in
pregnancy: report of two cases. Birth Defects Res A
Clin Mol Teratol 2004;70:545-546.
15. Einarson A, Bonari L, Sarkar M, McKenna K, Koren G.:
Exposure to sibutramine during pregnancy: a case
series. Eur J Obstet Gynecol Reprod Biol 2004; 116:
112.
16. Ramzi F, Elias D, Mona S, Zreik TG.: Sibutramine in
pregnancy. Eur J Obstet Gynecol Reprod Biol
2005;122:243-244.
17. De Santis M, Straface G, Cavaliere AF, Carducci B,
Caruso A.: Early first-trimester sibutramine exposure:
pregnancy outcome and neonatal follow-up. Drug
Safety 2006;29: 255-259.
18. Blank SK, McCartney CR, Marshall JC.: The origins
and sequelae of abnormal neuroendocrine function in
polycystic ovary syndrome. Human Reproduction
Update 2006;12: 351–361.
19. Lobo RA, Granger LR, Paul WL, Goebelsmann U,
Mishell DR Jr.: Psychological stress and increases in
urinary norepinephrine metabolites, platelet
serotonin, and adrenal androgens in women with
polycystic ovary syndrome. Am J Obstet Gynecol
1983;145:496-503.
20. Rasgon NL, Rao RC, Hwang S, et al.: Depression in
women with polycystic ovary syndrome: clinical and
biochemical correlates. Journal of Affective Disorders
2003;74: 299–304.
21. Apfelbaum ME.: Effect of serotonin on the basal and
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of luteinizing hormone from rat pituitary glands in
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22. Smyte GA.: The role of serotonin and dopamine in
hypothalamic-pituitary function. Clinical
Endocrinology 1977; 7: 325-41.

DERLEME
Prematürite ve çocukluk ça¤›
psikiyatrik bozukluklar›
Prematurity and childhood
psychiatric disorders
Dr. Gökflin Karaman / Maltepe Üniversitesi T›p Fakültesi Çocuk ve Ergen Ruh Sa¤l›¤› ve Hastal›klar› Anabilim Dal›
Dr. Beril Taflk›n / Maltepe Üniversitesi T›p Fakültesi Çocuk ve Ergen Ruh Sa¤l›¤› ve Hastal›klar› Anabilim Dal›
Klinik Psikolog Elif Atla / Maltepe Üniversitesi T›p Fakültesi Çocuk ve Ergen Ruh Sa¤l›¤› ve Hastal›klar› Anabilim Dal›
ÖZET
Perinatal etkenlerin, çeflitli psikiyatrik bozukluklar›n gelifliminde
rolleri olabilece¤i uzun süredir düflünülmektedir.
Do¤um a¤›rl›¤› ve gestasyonel yafl azald›kça psikiyatrik bozukluklar›n
geliflme riskinin artt›¤› ileri sürülmüfltür. Bu gözden
geçirmede erken do¤um ve/veya düflük do¤um a¤›rl›-
¤› ile çocukluk ça¤› bafllang›çl› psikiyatrik bozukluklar aras›ndaki
iliflkinin incelenmesi amaçlanm›flt›r. Bu psikiyatrik
bozukluklar içinde, bafllang›c› çocukluk ça¤›na özgü olup
en çok çal›fl›lanlar dikkat eksikli¤i - hiperaktivite bozuklu¤u,
yayg›n geliflimsel bozukluklar ve emosyonel bozukluklard›r.
Erken do¤an ve/veya düflük do¤um a¤›rl›¤› olan bebeklerde
dikkat eksikli¤i ve hiperaktivite bozuklu¤unun dikkat eksikli¤inin
önde geldi¤i alt tipinin geliflme riski daha yüksek
bulunmufltur. Yayg›n geliflimsel bozukluklar ve prematürite
iliflkisinin incelendi¤i çal›flmalarda, düflük do¤um a¤›rl›¤›ndan
çok gebelik haftas›na göre beklenen a¤›rl›¤›n alt›nda
do¤man›n ve erken do¤umun daha önemli bir risk faktörü
oldu¤u sonucuna ulafl›lm›flt›r. Emosyonel bozukluklar ile
prematürite iliflkisi ele al›nd›¤›nda, bu grupta özellikle anksiyete
ve depresyonun s›k gözlendi¤i, ayr›ca k›z çocuklar›
için artm›fl bir risk bulundu¤u ortaya konmufltur. Sonuç
olarak erken ve/veya düflük do¤um a¤›rl›¤› ile çocukluk ça-
¤› bafllang›çl› psikiyatrik bozukluklar›n geliflimi aras›nda bir
iliflki oldu¤u aç›kt›r. Bu bebeklerde biliflsel ve davran›flsal geliflimin
yak›ndan gözlenmesi ve olas› psikiyatrik bozukluklar›n
erken dönemde saptanmas› erken müdahale flans›n›
artt›racakt›r.
Anahtar kelimeler: prematürite, düflük do¤um a¤›rl›-
¤›, psikiyatrik bozukluk, dikkat eksikli¤i ve hiperaktivite bozuklu¤u,
yayg›n geliflimsel bozukluklar, emosyonel bozukluklar.
ABSTRACT
Perinatal factors have long been implicated in the
genesis of psychiatric disorders. For many years
epidemiologic studies have identified preterm birth and low
birth weight as a significant risk factor for psychiatric
disorders. This review aims to evaluate the relationship of
preterm birth/low birth weight and the childhood
psychiatric disorders. The most studied disorders are
attention deficit/hyperactivity disorder, pervasive developmental
disorders and emotional disorders. In regard to
attention deficit/hyperactivity disorder research findings
indicate that children with very low birth weight especially
have increased risk of attention problems. As for pervasive
developmental disorders, preterm birth and being small for
gestational age are increased risk factors rather than low
birth weight. Regarding emotional disorders preterm birth
is a risk factor mainly for anxiety and depression and within
this group it can be claimed that female children are at risk
more than male children. In conclusion it is obvious that
there is a relationship between preterm birth/ low birth
weight and childhood-onset psychiatric disorders.
Monitoring the cognitive and behavioral development in
these infants will allow early detection of possible
psychiatric disorders and increase the chances of early
intervention.
Key words: prematurity, low birth weight, psychiatric
disorder, attention deficit/hyperactivity disorder, pervasive
developmental disorder and emotional disorder.

40
Karaman ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
G‹R‹fi
Son y›llarda perinatal bak›ma verilen önemin artmas› ve
yeni do¤an yo¤un bak›m ünitelerinin yayg›nlaflmas› ile birlikte
preterm ve/veya düflük do¤um a¤›rl›kl› bebekler aras›nda
sa¤ kalma oranlar› giderek artmaktad›r. Erken do¤um
kavram› 3 kategoriden oluflmaktad›r; erken do¤um (

t›rmada bu grupta otizm riskinin artmad›¤› sonucuna ulafl›lm›flt›r
(28-32).
Gestasyonel yafl›n risk faktörü olarak ele al›nd›¤› dört
araflt›rmadan birinde göreli riskin 35 hafta alt›nda do¤an
çocuklar için 2.45 kat daha fazla oldu¤u saptanm›flt›r (32).
Hultmann ve ark. (2002) GHDDA bebeklerde otizm riskinin
artt›¤›n› göstermifllerdir (OR = 2.1) (29). 2005 y›l›nda yap›lan
di¤er bir çal›flmada GHDDA otizm için ba¤›ms›z bir risk
faktörü oldu¤u (göreli risk: 1.28), do¤um a¤›rl›¤›n›n ise iliflkili
olmad›¤› bulunmufltur (32). Schendel ve ark. 2008’deki
çal›flmalar›nda 2500 gram alt›nda ve 33 haftadan erken
do¤an bebekler aras›nda otizm riskinin 2 kat artt›¤›n› ve bu
riskin k›z bebekler aras›nda daha yüksek oldu¤unu saptam›fllard›r
(13). Johnson ve ark. 2010 y›l›nda yapt›klar› çal›flmada
219 afl›r› prematüre bebek ile 152 zaman›nda do¤an›
karfl›laflt›rm›fllard›r. Afl›r› prematüre grupta otizm s›kl›¤›
%8 bulunurken zaman›nda do¤anlar aras›nda otizm tan›s›
alan çocuk olmam›flt›r (20).
EMOSYONEL BOZUKLUKLAR
Çocukluk ça¤› psikiyatrik bozukluklar› içerisinde anksiyete
bozukluklar›na ve ergenlikle birlikte duygu durum bozukluklar›na
s›kça rastlanmaktad›r (33). Her iki tan› grubunun
da prematürite ve/veya düflük do¤um a¤›rl›¤› ile iliflkisi
birçok çal›flmada araflt›r›lm›flt›r.
Farooqi ve ark. 2006 tarihinde 86 çocukla yapt›¤› araflt›rmada
afl›r› prematüre çocuklar›n anksiyete, depresyon ve
içe kapal›l›k skorlar›n›n kontrole göre artm›fl oldu¤unu saptam›fllard›r
(34). Düflük do¤um a¤›rl›¤› olan çocuklarla yap›lm›fl
çal›flmalarda ise benzer flekilde depresyon ve anksiyete
skorlar›n›n kontrole göre daha yüksek oldu¤u sonucuna
ulafl›lm›flt›r. Botting ve ark.’n›n 1997’de 137 çocukla
yapt›klar› çal›flmada depresyon ve yayg›n anksiyete skorlar›
düflük do¤um a¤›rl›¤› olan çocuklarda daha yüksek bulunmufltur
(35). 2003 y›l›nda 263 çocukla yap›lan bir çal›flmada
afl›r› düflük do¤um a¤›rl›¤› olan çocuklarda depresyon
skorlar›n›n daha yüksek oldu¤unu saptam›fllard›r (36). Hack
ve ark.’n›n 2004 y›l›nda 474 çocukla yapt›klar› çal›flmalar›nda
düflük do¤um a¤›rl›kl› grupta özellikle k›z çocuklar›nda
kontrole göre daha yüksek anksiyete ve depresyon skoru
bulundu¤unu göstermifllerdir (37). Horwood ve ark.’n›n
1998’de 1413 çocukla yapt›klar› bir araflt›rmada düflük do-
¤um a¤›rl›¤› olan çocuklarda anksiyete ve geri çekilme skorlar›n›n
kontrol grubuna daha yüksek oldu¤u bulunmufltur
(38). Spittle ve arkadafllar›n›n 2009 y›l›ndaki 130 haftadan
erken do¤an ya da 1.250 gramdan düflük a¤›rl›kl› 88 erken
çocukla yapt›klar› çal›flmada, erken do¤an grupta emosyonel
bozukluklar kontrol grubuna göre daha s›k gözlemlenmifltir
(39). Johnson ve ark. 371 çocukla yapt›klar› çal›flmada
afl›r› düflük do¤um a¤›rl›¤› olan çocuklarda anksiyete bozukluklar›n›n
kontrole göre 3,5 kat daha yüksek oranda
bulundu¤unu saptam›fllard›r (20). 2011 y›l›nda yay›nlad›klar›
bir baflka çal›flmada ise AED’li çocuklar aras›nda emosyonel
bozukluk s›kl›¤›n› %9, zaman›nda do¤an çocuklar
Maltepe T›p Dergisi/ Maltepe Medical Journal
aras›nda ayn› oran› %2 olarak bildirilmifltir (4). Di¤er taraftan
Indredavik ve Johnson iki ayr› çal›flmada çok düflük do-
¤um a¤›rl›¤› olan çocuklarda rastlanan emosyonel bozukluklara
biliflsel yetersizliklerin efllik etti¤ini göstermifllerdir (9,
20).
TARTIfiMA
Çocukluk ça¤›nda s›k rastlanan psikiyatrik bozukluklar›n
etiyolojisinde genetik faktörlerin önemli rol oynad›¤› bilinmektedir.
Ancak genetik yatk›nl›¤›n yan› s›ra hastal›k geliflimine
katk›da bulunan çevresel etkenler de bulunmaktad›r.
Bu çevresel etkenler aras›nda perinatal olaylar›n çeflitli
psikiyatrik bozukluklar›n gelifliminde rolleri olabilece¤i düflünülmektedir.
Psikiyatrik ve geliflimsel problemlerle iliflkili
perinatal risk faktörleri içinde en belirgin olanlar erken do-
¤um ve düflük do¤um a¤›rl›¤›d›r. Bu alanda yap›lm›fl çal›flmalar
gözden geçirildi¤inde, çocukluk ça¤›nda bafllayan
psikiyatrik bozukluklar aras›nda en s›k DEHB, YGB ve emosyonel
bozukluklar›n erken do¤um ve/veya düflük do¤um
a¤›rl›¤› ile iliflkili oldu¤u görülmektedir. Erken ve/veya düflük
do¤um a¤›rl›kl› do¤an her dört bebekten birinde bafllang›c›
çocukluk ça¤›na özgü olan psikiyatrik bozukluklardan birinin
geliflti¤i bildirilmifltir (15).
DEHB bu riskli grupta en s›k görülen çocukluk ça¤› psikiyatrik
bozuklu¤udur (9,24). Erken do¤an ve/veya düflük
do¤um a¤›rl›¤› olan bebeklerde DEHB’nin dikkat eksikli¤inin
önde geldi¤i alt tipinin geliflme riski daha yüksek bulunmufltur
(9). Erken ve/veya düflük do¤um a¤›rl›¤› ile do¤an
çocuklarda görülen tablo klasik DEHB’den farkl› olarak erkek
predominans›n›n azald›¤›, sosyal iliflkilenme zorluklar›n›n
belirgin oldu¤u, y›k›c› davran›fllar›n bulunmad›¤› ve temel
olarak çal›flan bellek ve iflleme h›z›yla ilgili sorunlar›n ön
planda oldu¤u, özgül klinik bir durum olarak ortaya ç›kmaktad›r
(40). Bu farkl› klinik grupta DEHB’ nin gidifli, tedavi
yan›t› ve efl tan›lar aç›s›ndan tan›mlanabilir yeni özelliklerin
olup olmad›¤› ise araflt›r›lmay› bekleyen konulardand›r.
YGB ve prematürite iliflkisinin incelendi¤i çal›flmalarda,
düflük do¤um a¤›rl›¤›ndan çok GHDDA ve erken do¤umun
daha önemli bir risk faktörü oldu¤u sonucuna ulafl›lm›flt›r
(28, 29). Bu ba¤›ms›z bir risk faktörü olabilece¤i gibi, YGB’
den sorumlu olan genetik faktörlerle iliflkili obstetrik efl sorunlar
da durum için aç›klay›c› olabilir. Bu ayr›m›n daha net
yap›labilmesi için YGB deki ad› geçen risk faktörlerine iliflkin
ileri çal›flmalar›n genetik faktörlerin obstetrik efl sorunlarla
iliflkisi de göz önüne al›narak yap›lmas› gerekmektedir.
Emosyonel bozukluklar ile prematürite iliflkisi ele al›nd›-
¤›nda, bu grupta özellikle anksiyete ve depresyonun s›k
gözlendi¤i, ayr›ca k›z çocuklar› için artm›fl bir risk bulundu-
¤u ortaya konmufltur (36, 37). DEHB gibi, emosyonel bozukluklar›n
da bu popülasyonda özel bir klinik tablo ile ortaya
ç›kabilece¤i düflünülmektedir.
Sonuç olarak, erken ve/veya düflük do¤um a¤›rl›¤› ile
çocukluk ça¤› bafllang›çl› psikiyatrik bozukluklar›n geliflimi
aras›nda bir iliflki oldu¤u aç›kt›r. Bu bebeklerde biliflsel ve
Cilt:3 Say›:3 / Aral›k 2011
41

42
Karaman ve Arkadafllar›
Maltepe T›p Dergisi/ Maltepe Medical Journal
davran›flsal geliflimin yak›ndan gözlenmesi ve olas› psikiyatrik
bozukluklar›n erken dönemde saptanmas› erken müdahale
flans›n› artt›racakt›r.
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aras›ndaki iliflkinin klinikd›fl› bir grupta de¤erlendirilmesi.
21. Ulusal Çocuk ve Ergen Ruh Sa¤l›¤› ve Hastal›klar›
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17. Millichap JG. Etiologic classification of attention-deficit/hyperactivity
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18. Haberstick BC, Timberlake D, Hopfer CJ, Lessem JM,
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23. Ross G, Lipper EG, Auld PA. Educational status and
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24. Foulder-Hughes LA, Cooke RW. Motor, cognitive,
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CM. Perinatal and maternal risk factors for autism
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G, Hallmayer JF. Perinatal factors and the development
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F. Mental health and social competencies of 10- to
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in the: a Swedish national prospective follow-up
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deficit hyperactivity disorder and other psychiatric
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36. Saigal S, Pinelli J, Hoult L, Kim MM, Boyle M. Psychopathology
and social competencies of adolescents
who were extremely low birth weight. Pediatrics
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37. Hack M, Youngstrom EA, Cartar L, Schluchter M, Taylor
HG, Flannery D, Klein N, Borawski E. Behavioral
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39. Spittle AJ, Treyvaud K, Doyle LW, Roberts G, Lee KJ,
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Cilt:3 Say›:3 / Aral›k 2011
43

YAZARLARA B‹LG‹
1) Maltepe T›p Dergisi, sa¤l›k alan›ndaki bilimsel
araflt›rmalar, teknolojik geliflmeler, derlemeler, klinik çal›flmalar,
olgu bildirimleri, bilimsel toplant› özetleri, editöre
mektuplar, literatür özetleri ve biyografileri yay›nlar.
2) Dergi y›lda 3 say› yay›nlan›r.
3) Derginin yaz› dili Türkçe ve ‹ngilizcedir.
4) Yay›nlanmak üzere dergiye gönderilen yaz›lar›n
dergiye kabul edildikten sonra her türlü yay›n hakk› dergiye
aittir.Yaz›lar yay›n kurulu taraf›ndan incelendikten
sonra gerekli görülen düzeltmelerin yap›lmas› için yazara
geri gönderilir.Editör ve yay›n kurulu gerekli gördü-
¤ünde yaz›lar›n bilimsel dan›flma kurulu taraf›ndan incelenmesini
isteyebilir.Yaz›lar teslim tarihi göz önüne al›narak
yay›n kurulunun belirledi¤i s›raya göre yay›nlan›r.
Yaz›m Kurallar›
a) Dergiye gönderilen araflt›rmalar ve derlemeler oniki,
bilimsel toplant› özetleri on, olgu bildirimleri befl, editöre
mektuplar, literatür özetleri ve biyografiler ise üç
daktilo sayfas›n› geçmemelidir.
b) Yaz›lar A4, beyaz birinci hamur ka¤›d›n bir yüzüne
kenarlardan 2.5 cm boflluk kalacak flekilde 2 sat›r
aral›k olarak daktilo edilmesi, bilgisayar yaz›c›s› kullanacaksa
iyi kalite yaz›m modu seçilmelidir.
c) Gönderilen yaz›lar s›ra ile flu bölümlerden oluflmal›d›r.Bafll›k
sayfas›, Türkçe özet ve anahtar kelimeler, ingilizce
özet ve anahtar kelimeler, yaz› metni, kaynaklar,
tablolar, resim ve flekiller için alt yaz›. Olgu bildirimlerinde
ise girifl, bafll›k, ingilizce bafll›k, Türkçe özet, ‹nglizce
özet, olgu ve olgular›n sunumu, tart›flma ve kaynaklardan
oluflmal›d›r.
d) Yaz›n›n tamam› 3 kopya olarak kal›n bir zarf içinde
katlanmadan gönderilmelidir. Ayr›ca yaz›n›n Microsoft
Word Belgesi olarak kaydedilmifl disket ya da Cd’ si
de eklenmelidir.
Yaz› Düzeni
a) Bafll›k sayfas›
1) Makalenin Türkçe ve ingilizce bafll›¤›
2) Yazarlar›n tafl›d›¤› en yüksek akademik ünvan›,
yazarlar›n aç›k ad› ve ba¤l› bulundu¤u kurum.
3) Çal›flman›n yap›ld›¤› kurum veya kurumlar›n ad›.
4) Makale ile ilgili yaz›flmalardan sorumlu yazar›n
isim, adres ve telefonu numaras›.
5) Makale daha önce bir yerde sunulmufl ise bafll›k
sayfas›n›n en alt›nda belirtilmelidir.
b) Özet ve Anahtar Kelimeler
Özetler 250 kelimeyi geçmeyecek flekilde k›sa literatür
bilgisi, çal›flman›n amac›n›, gereç ve yöntemi, var›lan
sonuçlar› k›sa ve aç›k bir flekilde belirtilmelidir.
c) Yaz› Metni
Klinik ve deneysel araflt›rma yaz›lar› girifl, gereç ve
yöntem, sonuçlar ve tart›flma bölümlerinden oluflturulmal›d›r.
d) Kaynaklar
Kaynaklar yaz›da kullan›ld›¤› s›rayla numaralanmal›,
dergi isimleri Index Medicus’taki stil ile k›salt›lmal›d›r. Alt›dan
fazla yazar olan makalelerde ilk üç yazar›n ismi yaz›ld›ktan
sonra di¤er isimler ve ark. (et al) k›salt›lmas› ile
gönderilmelidir. Dergiler için yazar soyadlar›, adlar›n›n ilk
harfleri, makalenin bafll›¤›, derginin ad›, tarih, bölüm say›s›
ve sayfa olarak s›ralanmal›d›r.
Örnek: Templeton PA, Coston CI, Zorhouni EA.:
Current uses of CT and MR imaging in the stagini of the
lung cancer. Radiol Clin North Am 1990, 28: 631- 46.
Kitaplar için: Yazar isimleri, bölüm ad›, editör ismi, kitap
ad›, bas›m, flehir, yay›nevi, tarih ve sayfalar fleklinde s›ralanmal›d›r.
Örnek: Winfield HN, Schuersler W. Pelvic Iymphadenecomy.
‹n Claymon RV, Mc Dougo.II EM (eds). Laparoscopic
Urology, Guolity Medical Publiser, St. Louis,
1993, P. 225 – 260.
e) Tablolar, Resimler ve Alt Yaz›lar
Tablolar ayr› sayfalarda k›sa bir bafll›k içerecek flekilde
metinde bahsedilifl s›ras›na göre numaraland›r›larak
haz›rlanmal›d›r.
Foto¤raflar siyah beyaz ve net kalitede olmal›d›r. Foto¤raflar›n
arkalar›nda metindeki kullan›l›fl s›ras› ve üst
k›sm›n› gösterir bir ok iflareti konulmal›d›r. Resim altyaz›lar›
ayr› bir sayfada aral›kl› yaz›lmal›, resimler ayr› bir zarf
içerisinde gönderilmelidir.
* Yay›nlanan yaz›lar›n sorumlulu¤u yazarlara aittir.
Gönderilen yaz›lar iade edilemez.