Could near focus endoscopy, narrow-band imaging, and acetic acid improve the visualization of microscopic features of stomach mucosa?

BACKGROUND: Conventional magnifying endoscopy with narrow-band imaging (NBI) observation of the gastric body mucosa shows dominant patterns in relation to the regular arrangement of collecting venules, subepithelial capillary network, and gastric pits. AIM: To evaluate the effectiveness of a new one-dual (near) focus, NBI mode in the assessment of the microscopic features of gastric body mucosa compared to conventional magnification. METHODS: During 2021 and 2022, 68 patients underwent proximal gastrointestinal endoscopy using magnification endoscopic modalities subsequently applying acetic acid (AA). The GIF-190HQ series NBI system with dual focus capability was used for the investigation of gastric mucosa. At the time of the endoscopy, the gastric body mucosa of all enrolled patients was photographed using the white light endoscopy (WLE), near focus (NF), NF-NBI, AA-NF, and AA-NF-NBI modes. RESULTS: The WLE, NF and NF-NBI endoscopic modes for all patients (204 images) were classified in the same order into three groups. Two images from each patient for the AA-NF and AA-NF-NBI endoscopic modes were classified in the same order. According to all three observers who completed the work independently, NF magnification was significantly superior to WLE (P < 0.01), and the NF-NBI mode was significantly superior to NF magnification (P < 0.01). After applying AA, the three observers confirmed that AA-NF-NBI was significantly superior to AA-NF (P < 0.01). Interobserver kappa values for WLE were 0.609, 0.704, and 0.598, respectively and were 0.600, 0.721, and 0.637, respectively, for NF magnification. For the NF-NBI mode, the values were 0.378, 0.471, and 0.553, respectively. For AA-NF, they were 0.453, 0.603, and 0.480, respectively, and for AA-NF-NBI, they were 0.643, 0.506, and 0.354, respectively. CONCLUSION: When investigating gastric mucosa in microscopic detail, NF-NBI was the most powerful endoscopic mode for assessing regular arrangement of collecting venules, subepithelial capillary network, and gastric pits among the five endoscopic modalities investigated in this study. AA-NF-NBI was the most powerful endoscopic mode for analyzing crypt opening and intervening part.

Helicobacter pylori resistance to clarithromycin and quinolones in patients with dyspepsia in Tuzla Canton, Bosnia and Herzegovina.

Aim To evaluate Helicobacter pylori (H. pylori) resistance to clarithromycin and quinolones in patients with dyspepsia in Tuzla Canton, Bosnia and Herzegovina, a region with no data on clarithromycin or quinolones resistance. Methods A prospective cross-sectional study was conducted at the Department of Gastroenterology and Hepatology at University Clinical Centre Tuzla between January 2021 and June 2022. The study included 99 patients who underwent esophagogastroduodenoscopy (EGDS) due to dyspepsia. In all patients biopsies were taken for rapid urease test (RUT) and histology findings, concomitantly with blood samples for IgG serology. All RUT positive patient samples were tested for clarithromycin and quinolones susceptibility with GenoType HelicoDr, a PCR method which detects point mutations in 23S rRNA and mutations in the gyrA gene. Results Out of 99 dyspeptic patients, 67 (67.7%) were serologically positive to H. pylori, 46 (46.4.%) were RUT positive, and 19 (19.2 %) had a positive histology finding. Antibiotic (AB) resistance was tested in the total of 46/99 (46.4%) patients. Resistance to clarithromycin was detected in 28.26% (13/46), quinolones resistance in 36.96% (17/46) , and resistance to both AB was detected in 8.69% (4/46) tested biopsies. Conclusions Due to high clarithromycin and quinolones resistance rates, we recommend the use of bismuth quadruple or non-bismuth concomitant quadruple therapy for H. pylori eradication in Tuzla Canton, Bosnia and Herzegovina.

Portal vein aneurysm-etiology, multimodal imaging and current management.

Portal vein aneurysm (PVA) is a rare vascular abnormality, representing 3% of all venous aneurysms in the human body, and is not well understood. It can be congenital or acquired, located mainly at the level of confluence, main trunk, branches and bifurcation. A PVA as an abnormality of the portal venous system was first reported in 1956 by Barzilai and Kleckner. A review from 2015 entitled "Portal vein aneurysm: What to know" considered fewer than 200 cases. In the last seven years, there has been an increase in the number of PVAs diagnosed thanks to routine abdominal imaging. The aim of this review is to provide a comprehensive update of PVA, including aetiology, epidemiology, and clinical assessment, along with an evaluation of advanced multimodal imaging features of aneurysm and management approaches.

Cytomegalovirus Cholangiopathy in an Immunocompetent Patient: A Case Report and Literature Review.

A 37-year-old man presented with jaundice, upper right quadrant pain, and intermittent fever with chills. Laboratory assessment showed biliary stasis, with total bilirubin of 203 µmol/L (2-20), conjugated bilirubin of 105 µmol/L, and alkaline phosphatase of 556 U/L (30-120). Markers for hepatitis A-E viruses were negative. Serology assessment for rubeola, herpes simplex virus, Epstein-Barr virus, and Toxoplasma gondii showed negative IgM antibodies. HIV serology status was negative. For cytomegalovirus, both types of antibodies (IgM and IgG) were positive, with an IgM level >300 U/mL. pp65 antigen was also detected as well as CMV DNA. Diagnostic imaging of the abdomen except the dilated common bile duct showed a normal appearance of the gallbladder, liver, pancreas, spleen, and both kidneys. To our knowledge, cytomegalovirus cholangiopathy in the absence of any other underlying disease has not been reported. Therefore, the presence of cholangiopathy in our patient is interesting from an imaging, laboratory, and clinical point of view.

Silence pancreatitis in systemic lupus erythematosus.

We present here a systemic lupus erythematosus (SLE) related biochemically silent pancreatitis which was assessed via computed tomography in a 35-year-old woman. A patient with a twelve-year history of SLE presented with exacerbation of symptoms of the basic disease, with SLE Disease Activity Index > 15. She was referred to inpatient care. Dosage of corticosteroid and azathioprine for SLE was increased; subclinically and biochemically silent pancreatitis had developed, and was not diagnosed within an appropriate time. On the 15th hospital day, the patient died due to multisystem organ failure, which was defined as a consequence of clinically and biochemically silent pancreatitis in systemic lupus erythematosus.

NOD2/CARD15 mutations in Polish and Bosnian populations with and without Crohn's disease: prevalence and genotype-phenotype analysis.

Data on prevalence and phenotypic consequences of nucleotide-binding oligomerisation domain 2/caspase recruitment domains 15 (NOD2/CARD15) variants in Crohn's disease (CD) population in Poland and Bosnia and Herzegovina (B&H) are nonexistent. We aimed to determine the prevalence of NOD2/CARD15 mutations and their association with disease phenotype in Polish and Bosnian patients with CD and in healthy controls. We prospectively recruited 86 CD patients and 83 controls in Poland and 30 CD patients and 30 controls in B&H, 229 in total. We determined the prevalence of NOD2/CARD15 mutations and their association with the disease phenotype according to Montreal classification. Participants were genotyped for Leu1007fsinsC and Gly908Arg mutations. At least one CD-associated allele was found in 29/86 (33.7%) of Polish CD patients and in 9/83 (10.8%) of healthy controls (p<0.001). In both CD patients and controls in Bosnian sample, at least one NOD2 mutation was found in equal number of patients (3/30; 10%) with all of the NOD2 mutation positive CD patients being homozygous, while controls being heterozygous. In Polish sample, perianal disease was less frequent in CD patients with any NOD2 mutation (1/21; 4.8%) compared to those without (11/41; 26.8%; p=0.046). Higher percentage of patients with NOD2 mutations had history of CD related surgery when compared with those without mutations (66.7% vs. 43.3%; p=0.05). The risk for CD is increased in patients with NOD2 mutations (Poland) and especially in the presence of homozygous NOD2 mutations (Poland and Bosnia). The presence of variant NOD2 alleles is associated with increased need for surgery and reduced occurrence of perianal disease.

Enhanced therapeutic response with addition of loratadine in subserosal eosinophilic gastroenteritis.

A case of a 45-year-old Caucasian male initially reported with symptoms of acute intestinal obstruction was presented. Diagnostic tests revealed presence of eosinophilic ascites with marked peripheral eosinophilia, a significant thickening of stomach and intestinal wall and infiltration of gastric and duodenal mucosa with eosinophiles. Findings were conclusive with subserosal type of eosinophilic gastroenteritis and the patient's treatment started with a combination of parenteral methylprednisolone and oral loratadine. A prompt clinical response was encountered after 5 days of treatment with complete resolution.

Acute pancreatitis after kidney transplantation.

Acute pancreatitis is a rare but life-threatening complication in patients with transplanted kidney. The incidence of acute pancreatitis after kidney transplantation ranges from 2% to 7%, with mortality rate between 50 and 100%. We report a case of a female patient aged 46 years, developing an interstitial acute pancreatitis 8 years following a renal transplantation. The specific aethiological factor was not clearly established, although possibility of biliary pancreatitis with spontaneous stone elimination and/or medication-induced pancreatitis remains the strongest. Every patient after renal transplantation with an acute onset of abdominal pain should be promptly evaluated for presence of pancreatitis with a careful application of the most appropriate diagnostic procedure for each individual patient.

Simple uninvestigated dyspepsia: age threshold for early endoscopy in Bosnia and Herzegovina.

OBJECTIVE: To establish an optimal age threshold for endoscopy referral in patients with simple uninvestigated dyspepsia in the setting of European developing country (Bosnia and Herzegovina) with low availability and high workload of endoscopy units. METHODS: We reviewed patient information on all upper endoscopies performed during a 6-year period (2000-2005). Different age thresholds were evaluated in terms of their predictive power for absence of malignancy. RESULTS: A total of 82 of 4403 (1.86%) dyspeptic patients had upper gastrointestinal (GI) malignancy. Age cutoffs of 40 years for men and 45 years for women had the best predictive power, without any cases of upper GI malignancies below those thresholds. Age cutoffs of 45 years for men and 50 years for women also had excellent negative predictive values (99.7 and 99.9%, respectively) with 1.45 and 0.98 cases of missed upper GI malignancies per 1000 endoscopies, respectively. A total of 1709 of 4403 (38.8%) of endoscopies might have been avoided in men of less than 45 and women of less than 50 with uninvestigated dyspepsia. CONCLUSION: (i) Age thresholds for endoscopy referral are lower than in Western countries and should be different for men and women. (ii) Cutoff values of 40 and 45 years for men and women, respectively, are completely safe to use. (iii) Thresholds of 45 years for males and 50 years for females have a small level of risk of missing upper GI malignancy, but are acceptable to use in areas of low availability of endoscopy.

Non perianal fistulas in Crohn's disease and short bowel syndrome: what we can do?

Crohn's disease (CD) is a lifelong disease arising from an interaction between genetic and environmental factors, but seen predominantly in the developed countries of the world. The precise etiology is unknown and therefore a causal treatment is not yet available. Fistulating Crohn's disease includes fistulas arising in the perianal area, together with those communicating between the intestine and other organs or the abdominal wall. Non perianal fistulas include fistulas communicating with other viscera (urinary bladder, vagina), loops of intestine (enteroenteral fistulas) or the abdominal wall (enterocutaneus fistulas). The diagnostic approach is a crucial aspect in the management of fistulating CD as the findings influence the therapeutic strategy. Short bowel syndrome caused by extensive bowel resection should be initially treated with nutritional support and can caused serious treatment and reevaluating problems. We review this uncommon manifestation in a high risk patient after multiple operations and severely shortened bowel and also with non perianal fistulating CD.

Crohn's disease in Tuzla region of Bosnia and Herzegovina: a 12-year study (1995-2006).

BACKGROUND: Bosnia and Herzegovina (B&H) is one of the Eastern European countries with lacking data on Crohn's disease (CD) epidemiology. GOAL: We aimed to assess incidence of CD in Tuzla Canton of B&H during a 12-year period (1995-2006). METHODS: We retrospectively evaluated hospital records of both CD inpatients and outpatients residing in Tuzla Canton of B&H (total of 496,280 inhabitants) between 1995 and 2006. Patient that satisfied previously described criteria were included in the study. Incidence rates were calculated with age standardisation using European standard population. Trends in incidence were evaluated as moving 3-year averages. RESULTS: During the observed period, 140 patients met the diagnostic criteria for CD. Mean annual incidence was found to be 2.3/10(5) (95% CI=1.6-3.0) inhabitants ranging from 0.20 to 6.45 per 10(5). Mean annual crude incidence during the last 5 years of study (2002-2006) was 4.15/10(5) (95% CI=3.35-4.95). The prevalence of CD, at the end of the observed period was found to be 28.2/10(5) (95% CI=23.5-32.9). CD incidence increased dramatically from 0.27/10(5) in 1995-1997 to 4.84/10(5) in 2004-2006, as well as did the number of colonoscopies performed; from 29 in 1995 to 850 in 2006. We observed almost constant trend of around three new cases of CD per 100 colonoscopies performed. CONCLUSIONS: (1)Our area is the region of moderate incidence of CD with the trend that remains toward continuing increase in the rates of CD, which is most likely a direct consequence of the growing number of performed colonoscopies. (2) We believe that in the future years, CD incidence in our region will probably further increase and stabilise at a level of around five cases per 10(5) inhabitants.

Intrafamilial transmission of hepatitis B in Tuzla region of Bosnia and Herzegovina.

OBJECTIVE: To determine (i) the prevalence of HBV infection in families of confirmed chronic carriers, (ii) possible routes of transmission and risk factors for the intrafamilial transmission, (iii) vaccination rate among family members of chronic carriers and (iv) family members with highest risk for infection. METHODS: A total of 172 family members of 67 hepatitis B surface antigen chronic carriers were tested for hepatitis B markers; 716 first-time blood donors from the same area were used as controls. RESULTS: Prevalence of hepatitis B surface antigen was higher (P<0.001) among family members of index cases (12.2%; 21/172) than among controls (3.6%; 26/716) with relative risk of 3.3 (95% confidence Intervals=1.9-5.8; P<0.05). Rate of exposure among family members was 37.8% (65/172); only 8.7% (15/172) had been vaccinated for hepatitis B virus. Difference (P<0.001) in exposure existed among family members; exposure increased with age (rhos=0.34; P<0.001). Prevalences of hepatitis B surface antigen positivity and hepatitis B virus exposure were higher among parents of index cases (P<0.005) and among offspring of female index cases (P<0.001). There were more (P<0.001) hepatitis B surface antigen-positive family members among those with mother-children relationship with index case (13/31; 41.9%) than among those with father-children (19/85; 22.4%) and horizontal (siblings and spouses) relationship (2/56; 3.6%). Significantly more (P<0.001) hepatitis B surface antigen-positive and hepatitis B virus-exposed offspring were found in families where only mother was hepatitis B surface antigen positive. Among family members of HBeAg-positive cases more hepatitis B surface antigen-positive cases and hepatitis B virus-exposed cases have been found (P<0.001). Combination of HBeAg positivity and female sex of index case significantly increased risk for chronic carriage among family members (relative risk=24.06; 95% confidence interval=8.88-65.21; P<0.05). CONCLUSION: In the area studied, both horizontal and vertical transmission exists, but maternal route is predominant. Female sex, HBeAg positivity of index carrier and presence of hepatitis B surface antigen-positive mother inside family increased risk for hepatitis B surface antigen positivity and exposure among family members. Vaccination rate of family members of index cases is alarmingly low.

Genetics, clinical manifestations and management of FAP and HNPCC.

Colorectal cancer occurs in the familial cancer syndromes in about 2 to 4 percent. The major genetic syndromes are Familial adenomatous polyposis (FAP) and Hereditary nonpolyposis colorectal cancer (HNPCC). FAP is caused by germline mutation of APC gene, and HNPCC is caused by germline mutation in one of five MMR genes. The identification of patients with inherited disease is very important in the management of colorectal cancer. But, it is impractical to test every patient with the disease for these mutations. The clinical and genetical screening programme should be advised for family members at risk and colectomy in affected individuals in purpose to reduce the frequency of colorectal cancer.

[Balloon dilatation in esophageal stenosis]. / Primjena balon dilatacije u stenozama jednjaka.

The most frequent causes of the stenosis are as follows: Schatzki rings, structures as the complications of GERB', postcorrosive and postoperative at nosis. The Balloon dilatation is one from the therapeutic procedures of stenosis of the esophagus. By the clinic research is included 12 patients with the stenoses of the esophagus of the various cause. It is used the balloon dilatator (Olympus) of the diameter 16 and 18 mm, and the analysis 40 mm. In 11 patients the balloon dilatation was successful and led to the walking of the esophagus for endoscope. Only in one patient the dilatation was unsuccesful, because was applied two years after the occurrence of the stenosis caused by the corrosive esophagisitis. It is concluded that the balloon dilatation of the therapeutic procedures of the choice in stenosis of the esophagus.