Thrombin activatable fibrinolysis inhibitor as an indicator of the severity of acute pancreatitis.

BACKGROUND/AIMS: Thrombin Activatable Fibrinolysis Inhibitor (TAFI), in addition to suppressing fibrinolysis, can be involved as a natural anti-inflammatory molecule in the inflammatory process in acute pancreatitis (AP). The goal of this study was to discover the significance of early determination of the values of TAFI in the assessment of the severity of AP. MATERIALS AND METHODS: The prospective study included 92 patients with AP. In accordance with the revised Atlanta classification, we divided all patients into 3 groups (I-mild AP, II- moderate AP and III-severe AP). All patients were further classified into group A (mild AP) and group B (moderate and severe AP) with the aim of separating the patients with complicated and potentially bad prognosis. Biochemical markers, inflammatory biomarkers, coagulation parameters and TAFI were analyzed in all patients. RESULTS: The level of TAFI were significantly higher among the patients with the complicated form (group B) of AP (p=0.002). The analysis of the ROC curve in regard to the inflammatory biomarkers (fibronectin and CRP) has shown that TAFI possesses the best discriminatory ability for complicated forms of AP (AUC=0.724, p=0.013), with the sensitivity of 83.30% and the specificity of 56.00%. CONCLUSION: The level of TAFI in plasma is higher in patients with moderate or severe AP. Determining the level of TAFI as a single parameter has a greater significance in the early estimation of the severity of AP than inflammatory biomarkers that we have analyzed.

Clinical connection between rheumatoid arthritis and liver damage.

When liver damage is present in rheumatoid arthritis (RA) patients, it is sometimes difficult to determine whether it is a hepatic manifestation of RA, associated primary liver disease or hepatotoxic liver disease which developed during the treatment of RA. Liver damage during RA is most common in the form of asymptomatic abnormal liver tests. Occasionally, liver damage may progress to cirrhosis. Patients with RA are more susceptible to an associated autoimmune liver disease. Medications used in rheumatology are often hepatotoxic and it is difficult to differentiate between hepatic manifestations of the primary disease and potential hepatotoxicity of the administered medications. The significance of the paper is in the fact that it includes the most relevant and the latest information on this commonly present problem in clinical practice. The aim of the author is to provide comprehensive but at the same time concise data which will be useful to the doctors who come into contact with RA patients with symptomatic or asymptomatic liver disease. Timely diagnosis and treatment of liver disease in RA patients can significantly influence the course and outcome of rheumatoid arthritis.

Irritable bowel syndrome - from etiopathogenesis to therapy.

Irritable bowel syndrome (IBS) is a chronic and relapsing functional gastrointestinal disorder that affects 9-23% of the population across the world. Patients with IBS are often referred to gastroenterology, undergo various investigations, take various medicines, take time off work and have a poor quality of life. The pathophysiology of IBS is not yet completely understood and seems to be multifactorial. Many pathogenetic factors, in various combinations, and not all necessarily present in each patient, can play an important role. Discomfort or abdominal pain relieived by defacation, asociated with a change in stool form, is a typical clinical manifestation of IBS. Many factors, such as emotional stress and eating, may exacerbate the symptoms. A timely diagnosis of IBS is important so that treatment which will provide adequate symptomatic relief (diarrhoea, constipation, pain and boaring) can be introduced. The diagnosis of IBS is not confirmed by a specific test or structural abnormality. It is made using criteria based on clinical symptoms such as Rome criteria, unless the symptoms are thought to be atypical. Today the Rome Criteria IV is the current gold-standard for the diagnoses of IBS. Treatment of patients with IBS requires a multidisciplinary approach. Some patients respond well to non-pharmacological treatment, while others also require pharmacological treatment. This review will provide a summary of pathophysiology, diagnostic criteria and therapies for IBS.

Faecal occult blood screening for colorectal cancer in Serbia: a pilot study.

Colorectal cancer (CRC) is becoming a major public health problem in the Republic of Serbia. Organized mass screening has been shown to decrease CRC mortality and even its incidence. The aim of this study was to assess the acceptability of a faecal immunochemical test for haemoglobin proposed by primary care physicians. From August to November 2013, a pilot study for CRC screening was organized in individuals aged 50 to 74 years. The study included 50 primary healthcare centres from all 25 administrative regions of Serbia. A qualitative immunochromatographic faecal immunochemical test for human haemoglobin detection was used. Overall, 50 894 individuals were invited. The participation rate was 67.8 and 3.4% of the tests were positive. Among individuals with a positive test, 69.7% agreed to undergo colonoscopy. The positive predictive value was 27.1% for adenoma and 14.6% for carcinoma. This was the first CRC screening project encompassing approximately one-third of primary healthcare facilities in all regions across the country. It showed a good response of the target population and satisfactory cooperation of the healthcare professionals involved.

Can probiotics improve efficiency and safety profile of triple Helicobacter pylori eradication therapy? A prospective randomized study.

Background/Aim: Some studies suggest the benefit of applying different probiotic strains in combination with antibiotics in the eradication of Helicobacter pylori (H. pylori) infection. The aim of this study was to evaluate the effect of co-administration of multiple probiotic strains with triple H. pylori eradication therapy.This prospective study included 167 patients with dyspeptic symptoms and chronic gastritis who were diagnosed with H. pylori infection and randomized into two groups. The group I of 77 patients underwent triple eradication therapy, for 7 days, with lansoprazole, 2 × 30 mg half an hour before the meal, amoxicillin 2 × 1.000 mg per 12 hours and clarithromycin 2 × 500 mg per 12 hours. After the 7th day of the therapy, lansoprazole continued at a dose of 30 mg for half an hour before breakfast for 4 weeks. The group II of 90 patients received the same treatment as the patients of the group I, with the addition of the probiotic cultures in the form of a capsule comprising Lactobacillus Rosell-52, Lactobacillus Rosell-11, Bifidobacterium Rosell-1755 and Saccharomyces boulardii, since the beginning of eradication for 4 weeks. Eradication of H. pylori infection control was performed 8 weeks after the therapy by rapid urease test and histopathologic evaluation of endoscopic biopsies or by stool antigen test for H. pylori.Eradication of H. pylori infection was achieved in 93.3% of the patients who received probiotics with eradication therapy and in 81.8% of patients who were only on eradication therapy without probiotics. The difference in eradication success was statistically significant, (p < 0.05). The incidence of adverse effects of eradication therapy was higher in the group of patients who were not on probiotic (28.6%) than in the group that received probiotic (17.7%), but the difference was not statistically significant.Multiple probiotic strains addition to triple eradication therapy of H. pylori achieves a significantly better eradication success, with fewer side effects of antibiotics.

Treatment of low-grade gastric MALT lymphoma using Helicobacter pylori eradication.

BACKGROUND/AIM: Lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach usually occurs as a consequence of Helicobacter pylori (H. pylori) infection. The aim of this study was to investigate the long-term effect of treatment of low-grade gastric MALT lymphoma with the H. pylori eradication method. METHODS: In the period 2002-2012 in 20 patients with dyspepsia, mean age 55.1 years, the endoscopic and histologic diagnosis of gastric MALT lymphoma in the early stages were made. Histological preparations of endoscopic biopsy specimens were stained with hematoxyllineosin (HE), histochemical and immunohistochemical methods. RESULTS: Endoscopic findings of gastritis were documented in 25% of the patients, and 75% of the patients had hypertrophic folds, severe mucosal hyperemia, fragility, nodularity, exulcerations and rigidity. Histopathologically, pathognomonic diagnostic criterion were infiltration and destruction of glandular epithelium with neoplastic lymphoid cells, the so-called lymphoepithelial lesions. In all 20 patients H. pylori was verified by rapid urease test and Giemsa stain. After the triple eradication therapy complete remission of MALT lymphoma was achieved in 85% of the patients, with no recurrence of lymphoma and H. pyloi infection in the average follow-up period of 48 months. In 3 (15%) of the patients, there was no remission of MALT lymphoma 12 months after the eradication therapy. Of these 3 patients 2 had progression of MALT lymphoma to diffuse large-cell lymphoma. CONCLUSION: Durable complete remission of low-grade gastric MALT lymphoma is achieved in a high percentage after eradication of H. pylori infection, thus preventing the formation of diffuse large-cell lymphoma and gastric adenocarcinoma.

[Comparison of biohumoral and morphological parameters in acute pancreatitis].

INTRODUCTION: Acute pancreatitis occurs as a result of autodigestive activation of pancreatic proenzymes, within the parenchyma of the glands. OBJECTIVE: The goal of the work was to establish possible connection of etiology and severity of the acute pancreatitis and biohumoral parameters, ultrasound and CT. METHODS: The study included 273 patients with pancreatitis, classified by Ranson's score, according to degree of severity and etiology, whose biohumoral parameters were correlated with each other, and with the ultrasound and CT findings. RESULTS: The values of amylase and ALT were significantly higher in the severe form of pancreatitis and biliary etiology compared to etilic (p < 0.05).The ratio of AST/ALT was significantly higher in the group of etilic compared to biliary etiology (p < 0.05). LDH was significantly higher in the severe form group compared to moderate form of pancreatitis (p < 0.01). Cholesterol was significantly higher in the group of biliary compared to the group of etilic pancreatitis (p < 0.05). There was a negative low correlation between the value of calcium ions in the plasma and CT analysis (p = 0.05). Low degree negative correlation between the value of calcium ions and ultrasound analysis was established (p = 0.0001). CONCLUSION: There was a negative correlation between the level of ionized calcium in the blood and the degree of the acute pancreatitis by the Balthazar score. Mean value of alpha amylase, total value of cholesterol and ALT were significantly higher in the group of biliary compared to the group of etilic acute pancreatitis. The average values of the alpha amylase, LDH and ALT were significantly higher in the group of severe form of the acute pancreatitis compared to the group of moderate form. The ratio AST/ALT was significantly higher in the group of etilic than in the group of biliary pancreatitis.

Endoscopic mucosal resection of flat and sessile colorectal adenomas: our experience with long-term follow-ups.

BACKGROUND/AIM: Endoscopic mucosal resection (EMR) or mucosectomy is a removing method of flat or sessile lesions, laterally spreading tumors and carcinoma of the colon or the rectum limited to mucosa or the surface part of the submucosa. The aim of the study was to estimate the efficacy and safety of EMR in removing flat and sessile colorectal adenomas. METHODS: This prospective study involved 140 patients during the period of 8 years. A total of 187 colorectal adenomas were removed using the EMR method "inject and cut with snare". RESULTS: The approximate size of mucosectomised adenomas was 13.6 mm (from 8 mm to 60 mm). There was a total of 48 (25.7%) flat adenomas and 139 (74.3%) sessile adenomas, P < 0.01). Using "en bloc" and "piecemeal" resection, 173 (92.5%) and 14 (7.5%) of colorectal adenomas were removed, respectively. In all the cases, a complete removal of colorectal adenomas was achieved. Two (1.4%) patients had adenoma removal with intramucosal carcinoma each. In the average follow-up period of 21.2 +/- 17.8 months, 2 (1.4%) patients had adenoma relapse after EMR. Considering complications, there was bleeding in 1 (0.7%) patient with a big rectum adenoma removed with EMR. Furthermore, one (0.7%) patient had a postcoagulation syndrome after cecal adenoma was removed by EMR. CONCLUSION: EMR is an efficient, safe and minimally invasive technique of removing flat and sessile adenomas in the colon and the rectum, with a very low percentage of adenoma recurrence over a long period of monitoring.

Could application of epinephrine improve hemostatic efficacy of hemoclips for bleeding peptic ulcers? A prospective randomized study.

BACKGROUND/AIM: Bleeding from peptic ulcers can be effectively and safely treated with endoscopic hemoclips therapy. However, due to certain limiting factors of hemoclips, application of combination with another endoscopic method may give better results. The aim of this study was to examine the efficacy and safety of endoscopic hemoclips therapy and to evaluate potential benefits of this therapy combined with epinephrine in the treatment of bleeding peptic ulcers. METHODS: This prospective randomized study included 70 patients with bleeding gastric or duodenal ulcer. In 34 of the patients endoscopic hemoclips therapy was applied (group I), and in 36 of them a combined therapy of hemoclips and epinephrine (group II). RESULTS: Initial hemostasis was achieved in most patients treated with endoscopic hemoclips therapy (94.1%) as well as in the patients treated with combination therapy (97.2%). After initial hemostasis achieved rebleeding occurred in 3 (9.3%) patients treated with hemoclips and in 2 (5.7%) patients treated with combination therapy, but this difference was not statistically significant (p > 0.05). The difference in the achieved final hemostasis between the group I (91.1%) and the group II (94.4%) was not statistically significant. Also, the differences between the two groups of patients in the need for blood transfusions, length of hospital stay, need for surgery and mortality were not statistically significant (p > 0.05). CONCLUSION: Endoscopic hemoclips therapy is effective and safe in treatment of bleeding peptic ulcers. Combination therapy of hemoclips and epinephrine has no advantage over hemoclips monotherapy.

[Comparison of haemostatic efficacy for endoscopic injection therapy of epinephrine and combination therapy of epinephrine and hemoclips for bleeding peptic ulcers].

INTRODUCTION: Endoscopic injection therapy of epinephrine is safe and effective in the treatment of bleeding peptic ulcer, but with high risk of rebleeding. The combination therapy of epinephrine and hemoclips could lead to a reduction of rebleeding and a potential reduction in mortality. OBJECTIVE: To investigate the efficacy and safety of epinephrine injection therapy and combination therapy with epinephrine and hemoclips in treating bleeding peptic ulcers. METHODS: A prospective randomized study included 58 patients with bleeding gastric or duodenal ulcer. In 30 patients endoscopic injection therapy with diluted epinephrine was applied (group I), while in 28 patients combination therapy of epinephrine and hemoclips was applied (group II). RESULTS; Initial haemostasis was achieved in most patients treated with epinephrine injection therapy (93.3%) and patients treated with combination therapy of epinephrine and hemoclips (96.4%). After initial haemostasis was achieved rebleeding was significantly more frequent in the patients treated with epinephrine (28.5%) than in the patients treated with combination therapy (3.7%, p < 0.05). Two patients treated with epinephrine injection therapy were subjected to surgical intervention, whereas no patient treated with combination therapy needed surgery. Lethal ending occurred in one patient treated with epinephrine and in one patient treated with combination therapy. The difference between the two groups of patients in need for surgical intervention and mortality was not statistically significant. CONCLUSION: Combination therapy with epinephrine and hemoclips is more efficient than epinephrine alone in the treatment of bleeding peptic ulcers.

[Endoscopic treatment of gastric and duodenal angiodysplasias by elastic rings ligation].

INTRODUCTION: The most frequently applied methods of endoscopic treatment of angiodysplasias, such as argon plasma coagulation, multipolar coagulation and heater probe, proved to be effective with certain shortcomings and the possibility of complications. There are very scarce data in the literature about the treatment of angiodysplasias with endoscopic ligature. OBJECTIVE: The aim of the study was to examine the efficacy and safety of endoscopic treatment of gastric and duodenal angiodysplasias by ligation with elastic rings. METHODS: In 12 patients (10 male and 2 female, mean age 65.9 years) the endoscopic ligation of gastric and duodenal angiodysplasias was applied. Eight patients (66.6%) had solitary angiodysplasias in the stomach, two patients (16.6%) had solitary angiodysplasias in the descending part of the duodenum and two patients (16.6%) had multiple angiodysplasias in the stomach and duodenum.Two patients (16.6%) had active bleeding from angiodysplasias, while 10 patients (83.3%) had recent bleeding. We used the Cook Endoscopy system with 4 or 6 elastic rings for endoscopic ligation of angiodysplasias. Patients were under follow-up after 2-3 days, 30 days and then every 6 months following the endoscopic ligation of angiodysplasias. RESULTS: Active bleeding from angiodysplasias was stopped in two patients (100%) by endoscopic ligation with elastic rings. The average number of applied ligation sessions in our 12 patients was 1.6, with an average of 1.8 ligatures per session. There were no complications after ligation of angiodysplasias. Recurrence of bleeding occurred in one patient (8.3%) with multiple gastric and duodenal angiodysplasias.The average period of follow-up of patients was 22.8 +/- 17.6 months. CONCLUSION: Endoscopic ligation with elastic rings can be effective and safe for treatment especially of solitary gastric and duodenal angiodysplasias.

Does sclerotherapy of remnant little oesophageal varices after endoscopic ligation have impact on the reduction of recurrent varices? Prospective study.

INTRODUCTION: Endoscopic band ligation (EBL) is superior to endoscopic injection sclerotherapy (EIS) of oesophageal varices, however, EBL is associated with a higher rate of variceal recurrences. OBJECTIVE: To examine whether the reduction of recurrent varices can be achieved by additional sclerotherapy of remnant little varices after ligation. METHODS: Forty-eight patients with liver cirrhosis who had previously bled from oesophageal varices were examined. Endoscopic therapy was performed in order to prevent recurrent variceal bleeding. I group: in 23 patients ligation of oesophageal varices with multi band ligation device was applied (EBL group). II group: in 25 patients sclerotherapy using polydocanol or absolute alcohol was applied after reducing the size of varices using ligation (EBL and EIS group). RESULTS: There was no statistically significant difference between the examined groups of patients in relation to the number of sessions for variceal eradication, recurrence of variceal bleeding, deterioration of portal gastropathy and mortality in the observed period from 18.8 +/- 18.6 months (EBL group) and 22.2 +/- 26.2 months (EBL and EIS group). Variceal recurrence was verified in 21.7% of patients of the EBL group and 16% of the EBL and EIS group, but the difference was not statistically important. Several complications, such as dysphagia and chest pain, were statistically more frequent in the EBL and EIS group of patients. CONCLUSION: The combined method of ligation and extra sclerosing of remnant small oesophageal varices after ligation does not have advantage in relation to the ligation alone.

[Endoscopic resection of inflammatory gastric fibroid polyp--a case report].

INTRODUCTION: An inflammatory fibroid polyp is a rare condition with frequent localisation in the antrum of the stomach. Because of the localisation in the bottom parts of the mucosa and submucosa, a histological diagnosis is difficult to establish at endoscopic biopsies. So, a correct diagnosis is histologically possible after surgical excision which is a common manner of treatment. Many authors have shown that endoscopic removal of an inflammatory fibroid polyp is possible. CASE OUTLINE: We are presenting a case of complete endoscopic resection of an inflammatory fibroid polyp of the stomach antrum in a 72-year-old patient. He comllained of nausea, vomiting and loss of appetite. The polyp endoscopically looked like flat elevation with central umbilication, 16 mm in diameter and it was localised praepylorically. Pathohistologically, areas of severe epithelial dysplasia were verified at endoscopic biopsies which suggested early gastric cancer. Helicobacter pylori (H. pylori) infection was verified histologically and with rapid urease test. The patient was treated with triple eradication H. pylori therapy. Two months after the therapy, we decided to perform endoscopic resection of the polyp. We applied a suction technique of mucosal resection by which the polyp was completely resected. After complete endoscopic removal, the final diagnosis of an inflammatory fibroid polyp localised in the submucosa and mucosa of the antrum of the stomach was histologically made. On follow-ups, after 3, 6 and 12 months, there were no endoscopic and histological signs of either inflammatory fibroid polyp relapse, or recurrence of H. pylori infection. The patient had no dyspeptic symptoms. CONCLUSION: We recommend an endoscopic method of resection as a therapy of choice for an inflammatory fibroid polyp of the stomach.