[The new blood test bio-marker SEPT9 and colorectal carcinoma screening]. / Nový krevní test bio-markeru SEPT9 a screening kolorektálního karcinomu.

Due to its high incidence and mortality rates, the colorectal carcinoma represents a crucial medical issue. However, when it is detected in early stage there is high rate of successful treatment. Thats why, early stage cancer screening programmes were introduced into the clinical practice. They focus on the finding of hidden bleeding, using various laboratory techniques, sigmoidoscopy, and, primarily, colonoscopy. However, screening programmes have not yet reached the effect required. New techniques are therefore being developed, such as the detection of blood bio-markers. This group includes also methylated SEPT9 (mSEPT9) detection in blood. We applied this test on 57 patients; we divided the group into two parts. There were 33 asymptomatic individuals in the first group. In this group, we were got only one positive mSEPT9 result. The consequent colonoscopies were negative. The other group had 24 proven carcinomas. Of them, two had negative mSEPT9 results. The remaining in all 22 patients was tested mSEPT9 positive. After its efficiency is tested by further studies, this test may be used especially for patients with low compliance, as it only requires routine blood drawing.

[Irritable bowel syndrome]. / Drázdivý tracník.

Irritable bowel syndrome is a frequent functional disorder of gastrointestinal tract. Its high incidence represents an important socioeconomic concern. The diagnosis of irritable bowel syndrome is indirect and requires exclusion of an organic lesion within as well as outside the gastrointestinal tract. No algorithms--so called treatment guidelines--are available for pharmacological or non-pharmacological treatment of the irritable bowel syndrome. Long-term and comprehensive care of patients with functional diseases is an important component of the management of patients with irritable bowel syndrome.

[Prokinetic agents--their contribution to practice of gastroenterology]. / Prokinetika--jejich prínos v klinické praxi gastroenterologické.

Motility plays a fundamental role in the functioning of the gastrointestinal tract. Prokinetic agents are thus an important treatment modality in patients with functional and certain organ diseases with underlying functional modifications. Gastro-oesophageal reflux disease is frequently associated with a disorder ofoesophageal motility, an alteration of gastric evacuation may manifest as an atypical dyspeptic complaint. Prokinetic agents may also be effective in other disease states, such as diabetic gastroparesis, malignant conditions associated with nausea and vomiting, motility disorders in preterm babies etc.

[Does the medicine have its "trendy" diseases?]. / Vyskytují se v medicíne "módní"' choroby?

The development of new knowledge in medicine is associated with periodical changes in frequency with which certain "interesting" diseases are being diagnosed. Their frequency might be determined by accessibility of information as well as, to a certain extent, by "popularity" of these conditions within the society.

Combined treatment of achalasia - botulinum toxin injection followed by pneumatic dilatation: long-term results.

Injection of botulinum toxin (BT) and pneumatic dilatation are available methods in nonsurgical treatment of achalasia. Authors anticipate beneficial effect of prior BT injection on the success of pneumatic dilatation and duration of its effect. There are no long-term data available to assess efficacy of combined treatment. From 1998 to 2007, 51 consecutive patients (20 men and 31 women, age 24-83) with achalasia were included and prospectively followed up. Each patient received injection of 200 IU of BT into the lower esophageal sphincter (LES) during endoscopy and 8 days later pneumatic dilatation (PD) under X-ray control was performed. The follow-up was established every 3 months first year and then annually. The efficacy was evaluated by a questionnaire concerning patient's symptoms and manometry. Results were compared with 40 historical controls (16 men and 24 women, age 26-80) treated by PD alone using the same method and follow-up. Fifty-one patients underwent combined treatment. Four patients failed in follow-up and were not included for analysis. The mean duration of follow-up was 48 months with range 12-96 months. Thirty-four of forty-seven (72%) patients were satisfied with results with none or very rare and mild troubles at the time of the last visit. Forty-one patients were followed up more than 2 years. Effect of therapy lasted in 75% (31/41) of them. In 17 patients, more than 5 years after treatment, effect lasted in 12 (70%). Mean tonus of LES before therapy was 29 mm Hg (10-80), 3 months after therapy decreased to 14 mmHg (5-26). The cumulative 5 years remission rate (+/-95% CI) in combined treated patients 69% +/- 8% was higher than in controls 50% +/- 9%; however it, was not statistically significant (P= 0.07). In control group 1, case of perforation (2.5%) occurred. Eight patients (17%) with relapse of dysphagia were referred to laparoscopic Heller myotomy with no surgical complication. The main adverse effect was heartburn that appeared in 17 patients (36%). Initial injection of BT followed by PD seems to be effective for long-term results with fewer complications. But the combined therapy is not significantly superior to PD alone.

[Gastroesophageal reflux disease. Standards of the Czech Society of Gastroenterology--actualization 2009]. / Refluxní choroba jícnu. Standardy Ceské gastroenterologické spolecnosti--aktualizace 2009.

Presently, gastroesophageal reflux disease is defined as a disorder where reflux of the stomach content is bothersome and/or brings about complications. The state when macroscopically detectable erosions of mucosa are present is known as erosive reflux disease and the term non-erosive reflux disease is used for the condition with no macroscopic erosions. Reflux oesophagitis is a frequent sign of the disease. A condition, where reflux symptoms persist or new occur and oesophagitis healing fails to take place despite maximum treatment, is classified as refractory gastroesophageal reflux disease. The main symptoms of gastroesophageal reflux disease include heartburn and regurgitation. Gastroesophageal reflux disease may, less frequently, manifest itself with isolated non-oesophageal symptoms, e.g. recurring upper respiratory tract infections or bronchial asthma. Etiopathogenesis involves refluxate, motility disorders, altered anatomic proportions, protective mechanisms disorder and external factors. Diagnosis takes place on the basis of typical symptomatology and endoscopic examination. Complications include bleeding, ulceration, strictures and Barrett's oesophagus. Lifestyle and dietary measures are an important treatment approach as are pharmacological (antisecretion and prokinetic agents) as well as surgical management.

Achalasia--which method of treatment to choose for senior patients?

BACKGROUND: Achalasia is an uncommon illness affecting 1 per 100,000 patients a year. It encompasses a rare, primary motor disorder of the distal esophagus. METHODS: Over the period 1998-2006, 115 patients underwent various treatments for achalasia; the subgroup of seniors consisted of 26 patients. Six patients of these (age 69.7 y) underwent a modified Heller cardiomyotomy due to failure of previous endoscopic interventions. Standard esophageal manometry and 24 hour pH metry were performed pre- and postoperatively. RESULTS: Six senior patients with achalasia underwent a laparoscopic Heller myotomy. Average preoperative tonus of the LES was 55 mmHg, postoperative tonus of the LES decreased to 11 mmHg. We performed Toupet partial fundoplication in all patients; no microperforation of the esophagus was found in the preoperative esophagoscopy. We recorded minimal pathological gastroesophageal reflux in pH metry - the average preoperative DeMeester score was 8, postoperatively 10.5. Prolonged dysphagia was not present in any patient--preoperative GIQLI score was 94, postoperative score was 106. There was no mortality or morbidity in the group of the operated patients. CONCLUSION: Our operational results and postoperative follow-up show that laparoscopic Heller myotomy with Toupet partial fundoplication is a safe and effective treatment and can be recommended as the method of first choice for senior patients with no contraindication for laparoscopic operation.

[Higher incidence of thyropathy in patients with oesophageal achalasia. Genetic, autoimmune, regional or just a random association?]. / Vyssí výskyt tyreopatií u achalázie jícnu. Genetická, autoimunitní, regionální ci jen náhodná souvislost?

INTRODUCTION: The etiology of esophageal achalasia is still largely unknown. Inflammatory response to an initial stimulus on the level of genetic and/or immune predisposition may be the underlying cause of the disease. The final result is progressive disappearance of ganglion cells in the myenteric plexus and motility disorder. Autoimmune thyropathy (AIT) is a typical disease involving genetic background and immune response disorder. PATIENTS AND METHODS: 44 patients (of which 30 women and 14 men) with diagnosed esophageal achalasia and a control group of patients with esophageal reflux of corresponding age and sex were screened for thyroid disease. RESULTS: Thyroid disease was diagnosed in 15 out of 44 patients with achalasia (34%). Thyropathy was detected in 11 women (37%) and 4 men (28%). AIT was detected in 10 patients, in 4 of whom with hypfunction, nontoxic cystic or nodular goitre was detected in 4 patients, 1 patient was after strumectomy for benign node. Positive antithyroid antibody was newly detected in 4 patients with achalasia; subclinical hypothyreosis was found in one of them. There were two cases ofAIT with subclinical hypofunction and 1 case of nontoxic goitre in the control group (7%). The difference was statistically significant (p < 0.01). CONCLUSION: The incidence of thyroid disease proved higher in patients with achalasia than in the controls. The rate of occurrence of thyroid disease exceeded significantly the occurrence in the population. The association of achalasia with prevailingly autoimmune thyropathy may corroborate the importance of autoimmunity in the etiopathogenesis of the disease.

[Lower dyspeptic syndrome. Recommended diagnostic and therapeutic procedures for general practitioners 2006]. / Dolní dyspeptický syndrom doporucený diagnostický a lécebny postup pro vseobecné praktické lékare 2006.

Lower dyspeptic syndrome is a bowel disease manifesting namely with pain or sensation of abdominal discomfort and bowel movement problems (changes in the frequency and stool consistency). Symptoms include sensation of intraabdominal pressure and fullness, diarrhoea (with or without pain), sensation of incomplete defecation, constipation or bowel movement problems (with or without pain), irregular stool, collywobbles and bowel content flow (borborygia with spasms), meteorism, flatulency. Prevalence of the Irritable Bowel Syndrome in the European population is estimated to be 5 to 25 %. In the Czech Republic the total prevalence of dyspepsias is about 13 %. To the pathogenesis of the lower dyspeptic syndrome contribute: 1. abnormal motility, 2. abnormal visceral perception, 3. psychosocial factors, 4. luminal factors, 5. imbalance of neurotransmitters and/or intestinal bacteria and 6. possible inflammatory changes of the intestinal mucosa. Infectious diarrhoea is one of the causes. Functional bowel defects represent various combinations of chronic and recurrent symptoms from the digestive tract which cannot be explained by structural or biochemical abnormalities. Irritable bowel syndrome is a functional defect manifesting with abdominal pain, intestinal dyspepsia and compulsive defecations. Subtypes with typical symptomatology are characterized by circumstances which bring about pain and compulsive defecations (morning fractional defecation, postprandial defecation, debacles). Functional diarrhoea manifests with diarrhoea without intensive pain. Spastic obstipation manifests by abdominal pain, obstipation, compulsive defecations are absent, stool is cloddish, fragmented by spastic haustration, or it has a ribbon-form. Changes in the intestinal chemism include fermentative and putrefactive dyspepsia. Among the incomplete and atypical forms the isolated meteorism, irregular defecation, flatulency, abdominal pain--syndrome of the left or right epigastium or the syndrome of the right hypogastrium can be included. In patients with typical set of symptoms the working diagnose of the lower dyspeptic syndrome can be done by general practitioner. Complete history of the disease can reveal possible extra abdominal cause of dyspepsia, recognise alarming symptoms and consider circumstances elevating or lowering the probability of functional problems. Functional bowel problems have usually long-term character and represent clinically demanding challenge. Only few therapeutic regimens are successful and the therapy aimed at the abolishment of one symptom need not bring general improvement. For the clinical studies of the therapy of functional bowel problems significant placebo effect is typical. Quoad vitam prognosis is good, quoad sanationem it is rather doubtful.

Intraoperative manometry of the lower esophageal sphincter pressure during laparoscopic antireflux surgery with a mechanical calibration--early results.

BACKGROUND/AIMS: Persistent postoperative dysphagia diminishes the good effect of laparoscopic anti-reflux surgery. An excessive increase of the intraoperative lower esophageal sphincter pressure (LESp) is supposed to be related to the persistent postoperative dysphagia and its knowledge could lead to the modification of the surgical technique followed by improved clinical outcomes. This study aims to describe the relation between the intraoperative LESp increase and the incidence of postoperative dysphagia and to find whether a combination of intraoperative manometry and mechanical calibration of the wrap is able to decrease the incidence of the persistent postoperative dysphagia. METHODOLOGY: The randomized, prospective, two-branch study included 39 patients suffering from symptoms of gastroesophageal reflux disease. All patients underwent pre- and postoperative manometry, 24-hour pH-metry and laparoscopic anti-reflux surgery. The intraoperative LESp was measured in the study arm only. RESULTS: A higher incidence of persistent postoperative dysphagia was revealed in patients with the intraoperative LESp increase more than 15 mmHg. This complication was not found in patients with the LESp increase under 8 mmHg with no impact on the efficacy of the surgery. The combination of the intraoperative manometry and the mechanical calibration of the wrap seems to bring the benefit only to a small number of the patients. CONCLUSIONS: According to our results, the intraoperative LESp measurement proved to be a useful supplementary method which was easy to perform, and which enables a modification of the surgical technique to decrease the incidence of the persistent postoperative dysphagia.

[Laparoscopic procedure according to Heller]. / Laparoskopická Hellerova operace.

Oesophageal achalasia is a rare disorder. For patients in good overall condition, surgical management--myotomy--is one of the treatment options. This study describes the technique of laparoscopic myotomy sured by partial antireflux cuff. 35 patients were operated. Only in 3 cases, further follow-up was required for dysphagia. None of the patients required re-operation. No serious peroperative or postoperative complications were recorded. Importance of peroperative oesophagogastroscopy in assessment of adequate extent of myotomy and in excluding perforations of the oesophageal mucosa is put forward.

[The relation of GERD, bronchial asthma and the upper respiratory tract]. / Vztah refluxní choroby jícnu k astmatu bronchiale a horním cestám dýchacím.

UNLABELLED: Gastroesophageal reflux disease (GERD) is one of the most common diseases affecting upper gastrointestinal tract. It is a chronic disease, whith stadily growing incidence and prevalence in west countries during last 30 years. GERD is caused by pathologic gastroesophageal reflux (GER). GERD includes endoscopically positive, endoscopically negative and extraesophageal reflux disease. Extraesophageal symptoms of GERD have been of a growing attention and discussion during last few years. The most discussed topics are the relation of GERD and bronchial asthma (BA), chronic cough and symptomatology from ear, nose and throught (ENT) regions, but also non - cardial chest pain and many others. AIM: In our clinic we ran a 5 years study which aim was to evaluate the presence of GERD in patients with bronchial asthma, chronic cough and affections from ENT regions. To assess if 3 months GERD treatment would improve lung function, subjective complaints (cough) and GERD control in asthmatics; if this treatment would allow to step - down with antiasthma medication. To assess if 3 months GERD treatment can improve objective and subjective assessments in patients with chronic cough and findings in ENT regions. As for GERD, we evaluated the improvement of pH and subjective complaints (pyrosis). METHODS: We examined 86 patients with different severity of bronchial asthma, 54 patients with chronic cough and 31 patients with ENT symptoms. All patients underwent 24 hour esophageal pH metry, spirometry with lung function evaluation and objective ENT examination by flexible laryngoscopy. In case of pathologic finding on 24 hour pH-metry 3 months full antireflux treatment with proton pump inhibitors (PPI) and prokinetics was introduced. After 3 months of GERD treatment we performed control 24 hour esophageal pH metry, control spirometry and ENT examination by flexible laryngoscopy. Patients were asked to make their subjective symptoms assessments. RESULTS: We found that GERD prevalence in patients with respiratory symptoms was very high. Three months GERD treatment improved lung function (FEV1) with statistical significance (p = 0.0319), and so improved GERD control (in 60.7% of patients with high statistical significance p = 0.0009). Subjective complaints (cough) also improved in most patients. 3 months GERD treatment did not allow to step down with maintenance BA therapy according to GINA guidelines, but it enabled to decrease the rescue medications in 50% of patients. Patients with chronic cough can benefit from GERD treatment as cough improved in 75.8% of patients. CONCLUSION: Objective findings as well as subjective complaints improved in 75% of patients with ENT symptomatology. GERD control (DeMeester score and pyrosis if present) was highly statistically significant in all three groups of patients. It is necessary to mention, that there is a high presence of nocturnal acid breakthrough (NAB) in patients with respiratory symptoms: 30.3 % in patients with bronchial asthma, 63.6 % in patients with chronic cough and 45 % of patients with ENT manifestations.

[What has changed in knowledge of etiopathogenensis, diagnostics and therapy of gastroesophageal reflux over last 15 years?]. / Co se zmenilo ve znalostech etiopatogeneze, diagnostiky a terapie gastroezofageálního refluxu za posledních 15 let?

An incidence of gastroesophageal reflux disease (GERD) in population is continuously increasing. A probable etiology, except anatomical changes (such as hiatus hernia, transient lower esophageal sphincter relaxation etc.), can also include a change in life style For diagnostic purposes upper endoscopy and in unclear cases esophageal pH-metry is used. From an etiopathogenetic point of view, besides reflux of acidic content, the alkaline content and night change in production of hydrochloric acid during treatment with proton pump blockers (PPI) are considered to be important too. Attention should be paid to extraesophageal signs of GERD. In treatment prevail PPI, in resistant cases and in younger patients fundoplications are considered, and, also therapeutic endoscopy becomes more important (application of gel prostheses, electricity to cardiac part followed with scaring or ligatures).

Treatment of patients with achalasia with botulinum toxin: a multicenter prospective cohort study.

Botulinum toxin (BT) injection is an alternative treatment of achalasia. The aim of the study was to examine outcomes of patients treated with BT in the Czech Republic. Since 1997, 49 patients with achalasia have been treated with BT. We prospectively evaluated the effect of BT injection on 41 patients during a median follow-up of 24 months (range 9-62). Esophageal manometry was performed before and at 3-5 months after the injection. In 16 patients, BT was injected from the antegrade angle only (subgroup A), in 15 patients, BT was injected from both retrograde and antegrade angles (subgroup B) and, in 10 patients, BT injection was combined with subsequent balloon dilatation (subgroup C). Immediate clinical response was achieved in 93% of patients. Clinical remission was sustained beyond 3 months in 83% of patients (responders). Fourteen responders (41%) did not experience a relapse during the median of 22 months. Twenty responders (59%) experienced symptomatic relapse approximately 8 months after the injection. Ten relapsers underwent BT reinjection, five (50%) of them were asymptomatic for another 14 months. The remaining five (50%) patients reported a second relapse approximately 6 months after the reinjection. Median duration of the symptom-free period was 11.5 months after the first BT injection, and 10.5 months after the second (P = 0.21). We did not find any significant predictor of a favorable outcome; responders tended to be older and to have a lower basal lower-esophageal-sphincter pressure. Patients in subgroup C were more likely to be in remission at 1 and 2 years as compared with patients in subgroup A. BT injection is an effective treatment of achalasia in the short term. However, almost 70% of patients experience a relapse within 2 years. BT injection should therefore be reserved for patients at risk for more invasive procedures or for patients who prefer this treatment.

[Barrett's esophagus]. / Barrettuv jícen.

Barrett's oesophagus is a premalignant metaplastic change of the oesophageal mucosa. Due to its relationship with oesophageal reflux disease and the development of adenoma-carcinoma of the oesophagus the problem arouses increasing interest. In the wide pathogenesis of the disease most probably the composite effect of the refluxed HCl content and duodenal juices play a part. In the diagnosis in addition to fundamental methods--endoscopy and histology--increasingly chromoendoscopy and fluorescent endoscopy are involved. Dispensarization of patients is essential and depends on the degree of pathohistological epithelial changes. Treatment of Barrett's oesophagus can be divided into conservative, where the drug of choice are proton pump inhibitors, and surgical treatment. Promising is endoscopic ablation of the epithelium in combination with subsequent antisecretory therapy.

[Clinical symptomatology of chronic pancreatitis]. / Klinická symptomatologie chronické pankreatitidy.

The author describes the clinical picture of chronic pancreatitis, incl. less commonly used clinical examinations.

[Pathologic gastroesophageal reflux in patients with bronchial asthma]. / Patologický gastroezofageální reflux u pacientu s astmatem bronchiale.

Gastrooesophageal reflux (GER) and asthma bronchiale are frequent diseases. Asthma affects some 3-10% of adults. Gastrooesophageal reflux is present in some 45-89% asthmatic patients. Symptoms of GER are not only gastrooesophageal, and recently increased attention is focused on extraoesophageal symptoms where in particular the relationship of GER and asthma or chronic cough is investigated. At our clinic we implemented a pilot study with the objective to monitor the presence of pathological GER in patients with asthma and to assess whether antireflux therapy will influence the respiratory complaints of the patients. The group was formed by 14 patients selected at random with different severity of asthma and different symptoms of GER. The patients had a baseline examination evaluating the presence of GER (24-hour pH metry) and pulmonary function (FEV1). In case of a pathological GER the patients were treated by antireflux therapy and then check-up examinations were made. It was found that after treatment of GER in patients with asthma in particular subjective symptoms improved such as cough and pyrosis which leads to a substantial improvement of the quality of life. On the other hand reflux treatment did not exert a basic effect on pulmonary functions and it was not possible to reduce the medication of asthma.

[Importance of assessment of Helicobacter pylori antigen in faeces]. / Prínos stanovení antigenu Helicobacter pylori ve stolici.

Diagnostic methods for the detection of Helicobacter pylori (H.P.) can be divided into invasive and non-invasive ones. Among non-invasive methods we can include now also detection of H.P. antigen in faeces. The objective of our study was to evaluate the sensitivity ans specificity of the test when monitoring the eradication therapy, as compared with another non-invasive test and to test the method in common clincal practice. H.P. positivity was based on the result of the histological examination and CLO test. Repeatedly samples of faeces were collected to detect H.P. antigen in faeces before the onset of and after eradication treatment. For detection of H.P antigen the commercial Premier Platinum HpSa set was used which was developed on the principle of enzyme immunoanalysis. From the assembled data the sensitivity value (87.1%) and specificity values (88.5%) was calculated. The test correlates well with the results of the CLO test, histological examination and the breath test and is thus a suitable method for the detection of H.P. positive subjects as well as for checking the success of eradication treatment of H.P.

Restoration of propulsive peristalsis of the esophagus in achalasia.

The set consisting of 3 patients with esophageal achalasia diagnosed by manometry, pseudoachalasia excluded by esophagoscopy and endosonography, was treated with combined conservative procedure. Botulinum toxin 250u (Dysport) was applied to the area of lower esophageal sphincter and after 7 days balloon dilatation was carried out. Treatment efficacy was evaluated by the data obtained about the subjective condition, manometrically and endoscopically. The spine condition was evaluated in all patients before treatment and functional blockades were released by manual medicine and even by acupuncture. We succeeded in restoring propulsive peristalsis of the esophagus in all of them. It is objectively proven in the longest duration of 44 months in the case of a patient treated with a balloon dilatation.