[Classifications and prognosis of hepatocellular carcinoma]. / Klasifikatsii i prognoza na khepatotselularniia kartsinom.

In this study are included 78 patients with hepatocellular carcinoma (HCC). In 22 the diagnosis is verified pathologically (obduction), while in the other patients the diagnosis is made by laparoscopy, laparoscopical ultrasonography and morphological verification (through FNAB cytology and/or histology). In 69.2% HCC is associated with cirrhosis. The prognosis of HCC associated with cirrhosis is evaluated through the classification of S. Chevret et all., and is compared to the Child-Pugh scoring system. 38.9% of patients in Chevret's class C score are in class B in the Child-Pugh score, while 25.9% of patients are in class C in both classifications, but Child-Pugh's class C patients are most often in B-C transition. It might be assumed that the prognosis of HCC depends more on the tumor prognosis than on the prognosis of the liver cirrhosis itself. Every classification which does not take in to account the liver function (like TNM system) and the whole characteristics of the tumor, would be incomplete, in some extent, in the prognosis of HCC with cirrhosis. In HCC without cirrhosis, the BCLC classification reflects both the liver function and the tumor characteristics. In BCLC class A patients hepatic resection or transplantation is recommended but hyperbilirubinemia and ascites, which might be seen in A3 and A4 classes contraindicate resection of the liver. All scoring systems define lower HCC stage than it is really found (personal and reference data), so there are no arguments to take classification scores as absolute treatment decision making rules.

[Hemobilia caused by gallbladder's polyps in liver cirrhosis]. / Khemobiliia ot polip na zhluchniia mekhur pri chernodrobna tsiroza.

Extremely unusual cause of hemobilia from polypus of the Gallbladder in 29 years old patient with liver cirrhosis is reported. The patient died with clinical features of hepatic encephalopathy. The olygosympthomatic clinical course is the reason for unrecognized hemobilia. The ultrasonographic diagnosis was "cholelithiasis" instead of gallbladder's polypus and endoscopy established large ulcer in the duodenum. The role of hemorrhagic diathesis in chronic liver disease is discussed. As is the extent of liver cirrhosis, cholestasis and hepatic encephalopathy deterioration caused by bleeding. Whether timely cholecystectomy could change the course and prognosis of chronic liver disease is also discussed.

[Acute surgical abdomen in idiopathic haemochromatosis]. / Ostur khirurgichen korem pri idiopatichna khemokhromatoza.

The acute abdomen (AA) is a typical but very rare complication of idiopatic haemochromatosis (IH). The possible mechanisms are not sufficiently clarified. We report a case with IH who died with clinical features of (AA) 20 hours after gastroscopy was performed. The histological examination established nonspecific damage of visceral peritoneum and ascites. Fulminant form of spontaneous bacterial peritonitis (SBP) as a reason of death is discussed, nevertheless endoscopic esophageal varices sclerotherapy was not performed. The role of pulmonary infection and intestinal bacterial overgrowth with possible bacterial translocation in mesenterial lymph nodes, ascitic fluid, and blood is also discussed. The source of infection is usually unknown. The iron is important factor for bacterial growth. The pluriglandular deposition of iron including the suprarenal glands is precondition to development of collapse. The possible pathogenesis of SBP in IH is discussed. It is important to mention that unlike SBP the clinical course of IH AA might appear which does not necessary require surgical management.

[The indications and choice of the technic for pancreatic resections]. / Pokazaniia i izbor na tekhnika za rezektsii na pankreasa.

The progress of pancreatic surgery naturally leads to broadening the scope of indications for resection of the gland. Over the period 1970 through 1993, in the Clinic of Abdominal Surgery are performed 99 pancreatic resections for carcinoma of the pancreas (including cancer of papilla Vateri (45), endocrine-active tumor of pancreas (5), benign tumor (1), chronic pancreatitis (4), pseudocysts of the pancreas (4), cancer of an adjacent organ infiltrating the pancreas (36), benign lesions to a neighbouring organ (4). The size of resection depends on a number of factors of which location of the neoplasm and stage of the disease are the leading ones. Operations done: duodenopancreatic resection--47, left side hemipancreatectomy--13, resection of the body region and tail of pancreas--14, and partial resection--19. The choice of operative technique is discussed against the background of the variety of indications for pancreatic resection. Special attention is focused on the operative technique used in pancreatoduodenal resection. The practicability of performing pylorus-preserving intervention, the need of vagotomy and its scope are precisely determined. Also discussed are issues relating to the choice of organ for anastomosis with the pancreas and its protection, as well as the variants of successiveness of anastomoses with the biliary canal, residual pancreas and stomach. Morbidity and mortality rates show a decrease parallel to the surgical experience gained.

[Treatment of peptic ulcer with sucralfate]. / Lechenie iazvennoi bolezni sukral'fatom.

Sucralfate made in Bulgaria (Farmaphim) and its Yugoslavian analogue venter have been tried in gastroduodenal ulcer. The drugs were given per os (1 g, 1 tablet) 4 times a day before meals for 20 days. Sucralfate treatment was assigned to 26 patients with gastric and 26 with duodenal ulcer. The other 20 gastric ulcer patients received venter. 10 patients with gastric and 20 with duodenal ulcer entered the control group receiving placebo. Attenuation of the symptoms was reported as early as on day 4 of the treatment in 85-100% of the patients both with gastric and duodenal ulcer. The 20-day course of sucralfate treatment brought about a complete epithelization on gastric ulcer in 54% while in venter treatment in 55% of those treated versus placebo group 10%. Duodenal ulcer epithelization occurred in sucralfate-treated group in 58% against placebo group 17%. The differences in treatment results between sucralfate and venter are immaterial, whereas against placebo they are significant (p less than 0.05). Side effects were not serious.

Cisapride and cimetidine in the treatment of erosive esophagitis.

The efficacy of cisapride, as compared with cimetidine, in the treatment of erosive esophagitis was studied in a double-blind trial. One hundred and twenty-nine patients were assigned to one of four dosage schedules: cisapride 10 mg b.i.d. (20 mg group) or q.i.d. (40 mg group), or cimetidine 400 mg b.i.d. (800 mg group) or q.i.d. (1600 mg group). Treatment lasted 8 to 12 weeks. The degree of esophagitis and the severity of diurnal and nocturnal heartburn and regurgitation were significantly (p less than 0.01) reduced in the four treatment groups. Endoscopy did not show any significant differences among the four groups, although cisapride tended to be more effective in moderate to severe esophagitis, in which cases mucosal healing (i.e. absence of erosions and ulcers) was observed in 69%, 64%, 55% and 55% of the patients treated with cisapride 40 mg, cisapride 20 mg, cimetidine 1600 mg and cimetidine 800 mg. Improvement in reflux symptoms in the two cisapride groups was not significantly different from that in the cimetidine 1600 mg group, but was better (p less than 0.05) than that in the cimetidine 800 mg patients. The severity score for all reflux symptoms had decreased by 79%, 74% (cisapride 40 mg and 20 mg), 69% and 57% (cimetidine 1600 mg and 800 mg) by the end of treatment. These results show that cisapride is at least as effective as acid-suppressing therapy in patients with reflux esophagitis, and is therefore a valuable alternative to it.

[The carcinoembryonic antigen in chronic pancreatitis]. / Kartsinoembrionalen antigen pri khronichen pankreatit.

The fasting carcinoembryonal antigen (CEA) concentrations in the serum and duodenal juice and after venous stimulation of the exocrine pancreas with the hormones CCK and secretin (Boots) were studied. Radioimmunologic test with a kit of the firm "Labimex"--PPR was used. 28 patients with clinically proved chronic pancreatitis and a control group of 27 healthy persons were examined. The fasting CEA serum concentrations in the patients with chronic pancreatitis were statistically significantly higher than those of the healthy persons--mean--16.5 ng/ml vs mean--8.2 ng/ml (p less than 0.001). In 14% of the healthy persons and 57% of of the patients with chronic pancreatitis the basic CEA concentrations were significantly increased. After stimulation with CCK and secretin the serum CEA concentration did not change substantially. The duodenal juice CEA concentrations after CCK and secretin stimulation were about 11 times higher than those in the serum--mean--113 ng/ml and mean--104 ng/ml for the control group vs mean--118 ng/ml and mean--110 ng/ml for the patients with chronic pancreatitis. No statistically significant difference between the patients with chronic pancreatitis and the control group of healthy persons was established. The results reveal the low specificity of the CEA as a "tumor marker".

[Treatment of duodenal ulcer with ranitidine]. / Lechenie na duodenalnata iazva s ranitidin.

30 patients with endoscopically proved duodenal peptic ulcer were treated with Bulgarian drug Ranatidin in a dose of 150 mg twice daily in the course of 20 days. The pains were relieved up to the third day in 90% of the patients treated and the dyspeptic complaints disappeared in 1-3 days in 96-100% of the patients. Following the treatment course a statistically significant decrease of the gastric secretion indices was established (V, V1) and of the basic acid production (BAO, MAO, PAO) in comparison with the values before the treatment. Full epithelialization of the ulcer was found endoscopically in 60% of the patients treated and in the remaining 40% the size of the ulcer has diminished. The ulcer epithelialization is related to its initial size. The results achieved do not differ from those achieved with the analogous English drug Zantac. No side effects were observed in the course of treatment with Ranatidin.

[Treatment of peptic ulcer using proglumide (Milid)]. / Lechenie na iazvenata bolest s proglumid (milid)]

20 patients with peptic gastric ulcer and 30 patients with peptic duodenal ulcer were treated with Milid (Proglumid). The following results were achieved: in 85% of the patients with peptic gastric ulcer and in 93% of the patients with duodenal ulcer the pain was relieved on the 4th day on the average. In 95-96% of the patients treated the dyspeptic complaints disappeared on the 2-3 day. The endoscopic examination performed on the 20th day revealed full epithelization of the ulcer in 30% of the patients with gastric ulcer and in 43.3% of the patients with duodenal ulcer. Following the treatment course the basic secretion and acid production fell statistically significantly in the patients with gastric ulcer while in the patients with duodenal ulcer the basic and stimulated secretion and acid production were suppressed. The drug Milid does not change the serum gastrin level but suppresses the gastrin secretion in the gastric juice. The Milid treatment leads to an increase of the quantity of the N-acetylneuraminic acid in the gastric juice which partly reflects the cytoprotective action of Milid. The drug can be used in the everyday practice for the treatment of peptic ulcer.

[The differential diagnosis of chronic pancreatitis and pancreatic cancer]. / Vurkhu diferentsialnata diagnoza na khronichniia pankreatit i raka na pankreasa.

The following examinations were carried out in patients with chronic pancreatitis and pancreatic cancer: pancreozymin-secretin test, sonography, computed axial tomography, endoscopic retrograde cholangiopancreatography (ERCP) and thin-needle aspiration pancreatic biopsy. In 93.4% of the patients with chronic pancreatitis and in 93.8% of the patients with pancreatic cancer statistically significant changes in the pancreatic exocrine secretion were found after pancreozymin-secretin stimulation. Changes in the pancreatic function cannot be used as a reliable criterion for the differential diagnosis between chronic pancreatitis and pancreatic cancer. The ultrasound examination ensured correct diagnosis in 79% of the patients with chronic pancreatitis and in 76.4% of the patients with pancreatic cancer while the computed tomography gave the correct diagnosis in 80% and 79.4% of the patients respectively. The endoscopic retrograde pancreatography enabled correct diagnosis in 90% of the patients with chronic pancreatitis and in 86.2% of the patients with pancreatic cancer. The thin-needle biopsy revealed malignant cells in 97.5% of the patients with pancreatic cancer. The differential diagnosis between chronic pancreatitis and pancreatic cancer was not decided in 16.2% of the patients examined by sonography, 12% of the patients examined by computed tomography, 7.4% of the patients examined by ERCP and in only 2.5% of the patients examined cytologically.

[Biotidin treatment of duodenal ulcer]. / Lechenie na duodenalna iazva s biotidin.

The results of the treatment with the Bulgarian drug biotidin of 30 patients with endoscopically proved duodenal peptic ulcer are presented. The drug was given in a dose of 150 mg twice daily in the course of 20 days. The pain ceased up to the third day in 93.3% of the patients treated and the dyspeptic complaints vanished up to the second day of treatment in 96.6% of the patients. Following the treatment a statistically significant lowering of the indices of gastric secretion (V abd V1) and acid production (BAO, MAO, PAO) was found compared to those before the treatment. Endoscopically full epithelialization was found in 63.3% of the patient, in 33.3% of the patients the size of the ulcer diminished and in only 3.4% of the patients there was no change of the ulcer size. The ulcer epithelialization was related to the initial ulcer size. The results achieved do not differ substantially from those achieved with the English drug Zantac. In the course of treatment with biotidin no side effects were observed and no changes of the basic biochemical indices were found.

[Computed tomography in cholestasis]. / Kompiuturna tomografiia pri kholestaza.

116 patients with jaundice were examined by computer tomography. In 92.3% of the patients examined the computer tomography gave correct information for the etiology of the jaundice: in 36 patients (31%) obstructive jaundice was established; in 71 patients (61.3%) the jaundice was nonobstructive and in 9 patients (7.7%) the etiology was not established. The characteristics of the CT findings in obstructive and nonobstructive jaundice are discussed. The causes of the diagnostic mistakes in CT examinations of patients with jaundice are also discussed.

[Diagnostic potentials of computed tomography in focal liver diseases]. / Diagnostichni vuzmozhnosti na kompiuturnata tomografiia pri ognishtnite zaboliavaniia na cherniia drob.

98 patients with focal liver diseases were examined by computer tomography: 29 patients with primary liver cancer, 44 patients with liver metastases, 16 patients with liver cysts, 4 patients with hemangioma and 5 patients with liver abscess. In 92.9% of the patients examined the computer tomographic examination gave accurate information about the focal liver disease. Only in 7 patients (7.1%) the examination failed. The characteristics of the liver changes found by computer tomography in primary liver cancer, liver metastases, cysts, hemangioma and liver abscess are discussed as well as the factors for the failure of the examination.

[Differential diagnosis of jaundice]. / Diferentsialna diagnoza na zhultenitsite.

Patients with jaundice and hyperbilirubinemia over 34 mumol/l have been examined by different methods in order to assess the diagnostic value of the methods. 340 patients were examined clinically and by laparoscopy, 168 patients and 92 healthy persons were examined by 10 laboratory indices, 639 patients--by ultrasonography, 95 patients--by scintigraphy, 116 patients--by computer tomography, 83 patients--by endoscopic retrograde cholangio-pancreatography (ERCPG), 17 patients--by percutaneous transhepatic cholangiography (PTC), 70 patients--by directed liver biopsy. In the patients with cholestasis the 5'-nucleotidase, alkaline phosphatase, glutamyl transpeptidase (lipoprotein X is positive in 92% of the patients) and cholesterol are increased most. The extrahepatic obstructions are diagnosed by ultrasonography in 94.8% of the patients (the biliary ducts are dilated), in 88.7% of the patients the localization of the obstruction and in 74.7% of the patients the cause of the obstruction are found. In parenchymal jaundice the sonography reveals the disease which has caused jaundice in 62.1% of the patients. The scintigraphy gives correct diagnosis in 50% of the patients with hepatitis and jaundice, in 78% of the patients with cirrhosis and jaundice and in 87.5% of the patients with liver cancer. The computer tomography reveals the obstructive jaundice in 94.7% of the patients and the focal processes in the liver in 96.7% of the patients. The ERCPG gives a clear picture of the biliary ducts in 72.28% and of the pancreatic duct in 83.13% of the patients with jaundice, simultaneously the biliary and the pancreatic ducts--in 45.78% of the patients and correct diagnosis in 83.1% of the patients examined.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serum immunoreactive trypsin in chronic pancreatitis patients]. / Serumen imunoreaktiven tripsin pri bolni s khronichen pankreatit.

The serum immunoreactive trypsin (determined by RIA-gnost Trypsin of the firm Höchst) was studied in 30 patients with chronic pancreatitis: 16 patients in a stage of exacerbation and 14 patients with clinical remission. Via pancreozymin-secretin test pancreatic exocrine insufficiency was established in all patients: 24 patients with moderate disorders and 6 patients with total secretory deficiency. The results were compared with a control group of 13 healthy subjects. In the mixed group of patients with chronic pancreatitis, serum immunoreactive trypsin did not differ from that of the control group (p greater than 0,05). The values of immunoreactive trypsin in serum, in the patients with chronic pancreatitis in a stage of exacerbation, are higher, with a statistical significance (p less than 0,001). In chronic pancreatitis, in a stage of remission, the level of serum immunoreactive trypsin is significantly lower as compared with the control group (p less than 0,01). The determination of serum immunoreactive trypsin could be used as a test in the diagnostics of recurrences of chronic pancreatitis but it is not a sure marker for the presence of pancreatic exocrine insufficiency.

[Treatment of duodenal ulcer with Zantac-ranitidine]. / Lechenie na duodenalnata iazva sus Zantac-ranitidine.

The results from the treatment with the preparation Zantac -Ranitidine of 30 patients with duodenal ulcers are reported. The treatment was carried out with 2 X 150 mg ranitidine daily for 20 days. As early as the second or third day after the initiation of the treatment, the pain disappeared in 96,6 per cent, the sense of heaviness and eructation -- in 100 per cent, pyrosis and palpation pain -- in 96,6 per cent an nausea - in 93,3 per cent. All indices of the gastric secretion (V, BAO, MAO and PAO) were reduced with a statistical significance after 20-day ranitidine treatment, as compared with the initial values. Epithelization (healing) of the ulcer was fibroendoscopically established in 73,3 per cent by 20th day, and by 40th -- in 93,3 per cent. The bigger ulcers were more slowly epithelized . Ranitidine was very well tolerated and gave no adverse effects. Better results, with a statistical significance, were obtained with ranitidine treatment of the duodenal ulcer, both as regards the effect on the subjective symptoms and epithelization of the ulcer as compared with the control group.