Benign Hydronephrosis and Elevated of Serum Levels of Carbohydrate Antigen CA 19-9: A Case Report.

BACKGROUND: Carbohydrate tumor-associated antigen (CA 19-9) has been shown to be upregulated in other malignant tumors including gastric, ovarian, hepatocellular, and colorectal carcinoma as well as benign diseases of the biliary track such as pancreatitis, cholangitis, and choledocholithiasis. According to the available literature, in several cases of benign hydronephrosis and in a few cases of benign renal diseases, elevated CA 19-9 has been noted. CASE REPORT: A 58-year-old Caucasian male patient was admitted in our clinic with complaints about blunt abdominal pain in the past two-month period localized in the right lumbar region and irradiating into the right inguinal area, constipation, abdominal bloating, and intermittent hematuria. The concentration of serum CA 19-9 was 3500 U/mL. Urine cytology provided no signs of abnormality. Intravenous urography visualized right-sided pyelon and ureter duplex with the defect in contrast shade of the pyelon, caused by a stag horn calculus. Contrast added computerized axial tomography of the abdomen and pelvis visualized the pyelon casted concretion spreading throughout the right pyelon, with ureterohydronephrosis with the distal block for passage of the contrast to the distal part of the ureter. CONCLUSIONS: There is no doubt that CA 19-9 level is occasionally elevated in patients with obstructive urolithiasis as it was in our case. In the routine medical praxis, urolithiasis should not be neglected in the differential diagnosis of elevated concentrations of CA 19-9 marker.

Anismus as a cause of functional constipation--experience from Serbia.

UNLABELLED: BACKROUND/AIM: Anismus is paradoxal pressure increase or pressure decrease less than 20% of external anal sphincter during defecation straining. This study analyzed the presence of anismus as within a group of patients with the positive Rome III criteria for functional constipation. We used anorectal manometry as the determination method for anismus. METHODS: We used anorectal water-perfused manometry in 60 patients with obstructive defecation defined by the Rome III criteria for functional constipation. We also analyzed anorectal function in 30 healthy subjects. RESULTS: The presence of anismus is more frequent in the group of patients with obstructive defecation compared to the control group (a highly statistically significant difference, p < 0.01). Furthermore, we found that the Rome III criteria for functional constipation showed 90% accuracy in predicting obstructive defecation. We analyzed the correlation of anismus with the presence of weak external anal sphincter, rectal sensibility disorders, enlarged piles, diverticular disease and anatomic variations of colon. We found no correlation between them in any of these cases. CONCLUSION: There is a significant correlation between anismus and positive Rome III criteria for functional constipation. Anorectal manometry should be performed in all patients with the positive Rome III criteria for functional constipation.

The role of D-dimer in prediction of the course and outcome in pediatric acute pancreatitis.

BACKGROUND: Current predictive severity scores for pediatric acute pancreatitis are either extrapolated from adult studies or difficult to use in practice. The aim of this study was to assess the value of the plasma D-dimer level as a marker of severity and outcome in pediatric AP. METHODS: 36 patients (aged 1-17 yrs) with AP were included in the study. Levels of D-dimer and other routine laboratory parameters for AP were determined on admission. The Pediatric Acute Pancreatitis Severity Score was used to assess disease severity. The development of systemic and local complications was also recorded. RESULTS: D-dimer level was significantly higher in a group of patients with complications, median 1189.5 (271-4800) vs 172.5 (105-1086) in a group of patients without complications (p < 0.001). D-dimer showed high precision in the prediction of acute necrotic collection, with the optimal cut-off values of 442.5 µg/L, Sensitivity (Sn) 100%, Specificity (Sp) 62.1% and in the prediction of multiple organ failure with optimal cut-off value 1189 µg/L, Sn 100% and Sp 87.5%. According to the areas under the curve (AUCs) of each parameter, D-dimer seemed to have predictive power similar to PAPS score and higher than C-reactive protein and Lactate dehydrogenase level. CONCLUSION: D-dimer level may be a simple clinical predictor of severity in pediatric acute pancreatitis.

Bradbury-Eggleston syndrome - an unusual cause of gastroesophageal reflux disease (GERD).

The report presents a case of a 46-year-old male patient, previously treated because of dysphagia, pyrosis, vertigo while standing up and impotency. Manometric and pH-metric analysis showed presence of gastroesophageal reflux disease (GERD) caused by transient relaxation of lower esophageal sphincter (TRLES). Heart-rate variability showed decreased sympathetic function. Electromyoneurography showed a neurological lesion in muscles of upper extremities. The patient received midodrine and clonazepam which resolved this condition. These findings suggest that a neurological disorder can be a cause of GERD.

Ultrasonography analysis of gallbladder motility in patients with functional dyspepsia.

BACKGROUND: Gallbladder motility has been studied in patients with functional gastrointestinal disorders, such as functional dyspepsia, irritable bowel syndrome and biliary disorders without gallstones and results of these observations are often inconclusive and conflicting. METHODS: The investigation was performed on 180 therapy-naïve newly diagnosed patients with functional dyspepsia (97 females and 83 males), aged 20-79 in which we have investigate ultrasonographically parameters of gallbladder motility. RESULTS: Bonferroni post hoc correction stressed that fasting gallbladder volume and ejection fraction were significantly distorted in individuals with postprandial distress syndrome, although, the residual gallbladder volume was significantly lower in patients with epigastric pain syndrome comparing with other examinees. Ejection fraction of the gallbladder negatively correlated with body mass index. CONCLUSION: The impaired contractibility of the gall bladder in patients with functional dyspepsia, based on the results of this study, is illustrated by the changes in the ejection fraction, which was more pronounced in patients with the postprandial distress syndrome.

Celiac disease diagnosed after uncomplicated pregnancy in a patient with history of bulimia nervosa.

INTRODUCTION: The association between celiac disease and eating disorders has been very rarely reported. This is the first report on celiac disease associated with bulimia in this part of Europe. CASE REPORT: An adult female patient with history of bulimia and one uncomplicated pregnancy was admitted to the Gastroenterology Department, due to long lasting dyspeptic symptoms, constipation, major weight loss and fatigue. After positive serological screening, the diagnosis of celiac disease was confirmed with histopathology examination of duodenal biopsy specimen. CONCLUSION: Complicated interactions between celiac disease and bulimia can make them difficult to diagnose and treat. It is important to consider the presence of celiac disease in patients with bulimia and gastrointestinal symptoms.

Achalasia--two types in the same patient: case report.

INTRODUCTION: A paper presented a case of esophageal achalasia with both type 2 and type 3 achalasia found in the same patient. CASE OUTLINE: High resolution impedance manometry of esophagus was performed. Liquid swallows induced panesophageal pressurization (achalasia type 2), whereas viscous swallows led to compartmentalized pressurization--distal two thirds of esophagus (achalasia type 3). No complete bolus transit was recorded. Patient refused any procedure. CONCLUSION: The aim of this paper was to show the necessity of performing manometry using both liquid and viscous swallows in GI departments where this approach has not been routinely used in order to establish proper diagnosis since therapy approach is different between type 2 and type 3 achalasia.

Dilated cardiomyopathy associated with celiac disease: case report and literature review.

INTRODUCTION: Celiac disease is an inflammatory condition of the small intestinal mucosa induced by gluten consumption in genetically susceptible individuals, leading to a spectrum of gastrointestinal presentation. A number of autoimmune and other disorders are highly associated with celiac disease. Cardiomyopathy associated with celiac disease has been rarely reported in the literature. CASE OUTLINE: We present a case of a 27-year-old male with one month history of diarrhea, weight loss, fatigue, dyspeptic symptoms, peripheral edema, and cardiac palpitations. After positive serological screening with immunoglobulin A anti-tissue transglutaminase antibody test, the diagnosis of celiac disease was confirmed with histopathology examination of duodenal biopsy specimen. Echocardiographic findings were consistent with acute myocarditis. After common causes of myocarditis had been excluded, probable celiac disease-associated autoimmune myocarditis was diagnosed. The patient was recommended to undergo a strict life-long gluten-free diet. IgA anti-transglutaminase antibodies, and anti-gliadin antibodies, were both significantly elevated during the 6-, 12- and 18-month follow-up. Low compliance to gluten-free diet in our patient led to progressive worsening of the left ventricular ejective fraction and other serious cardiac complications which warranted invasive cardiac interventions. CONCLUSION: Dilated cardiomyopathy associated with celiac disease is a serious condition which requires multidisciplinary approach involving gastroenterologist and cardiologist. Compliance with gluten-free diet is mandatory if patients are to avoid progression of cardiomyopathy. Screening of patients with idiopathic dilated cardiomyopathy for celiac disease is advisable.

Laboratory parameters and nutritional status in patients with functional dyspepsia.

BACKGROUND: To investigate differences in laboratory markers, nutritional status parameters and eating patterns among newly diagnosed patients with functional dyspepsia. METHOD: The investigation was performed on 180 newly diagnosed patients with functional dyspepsia, aged 20-79, which were referred to the gastroenterology unit of the Clinical and Hospital Center "Bezanijska Kosa" from April to October 2009. Rome II criteria were used for further classification. RESULTS: ANOVA Bonferroni post hoc correction outlined that concentrations of serum magnesium and calcium were significantly lower in subjects with ulcer-like dyspepsia, while vitamin B12, glucose and immunoglobulin G level was significantly higher in group with dismotility-like dyspepsia. Statistical analysis revealed that the numbers of meal taken per day were significantly different. There was a statistical trend to skipping meals and to eat fast in patients with ulcer-like and dismotility-like functional dyspepsia when compared with non-specific dyspeptic subjects. CONCLUSION: Patients with ulcer-like functional dyspepsia suffered from epigastric pain and burning and from heartburn, while persons with dismotility-like dyspepsia were complaining about postprandial fullness, bloating and early satiety. They skipped meals more frequently and avoided intake of certain supplies which, together with eating habits, provoked or emphasized the annoying symptoms.

Comparison of two nutritional assessment methods in gastroenterology patients.

AIM: To investigate and compare efficacy and differences in the nutritional status evaluation of gastroenterology patients by application of two methods: subjective global assessment (SGA) and nutritional risk index (NRI). METHODS: The investigation was performed on 299 hospitalized patients, aged 18-84 years (average life span 55.57 +/- 12.84), with different gastrointestinal pathology, admitted to the Department of Gastroenterohepatology, Clinical and Hospital Center "Bezanijska Kosa" during a period of 180 d. All the patients, after being informed in detail about the study and signing a written consent, underwent nutritional status analysis, which included two different nutritional indices: SGA and NRI, anthropometric parameters, bioelectrical impedance analysis, and biochemical markers, within 24 h of admission. RESULTS: In our sample of 299 hospitalized patients, global malnutrition prevalence upon admission varied from 45.7% as assessed by the SGA to 63.9% by NRI. Two applied methods required different parameters for an adequate approach: glucose level (5.68 +/- 1.06 mmol/L vs 4.83 +/- 1.14 mmol/L, F = 10.63, P = 0.001); body mass index (26.03 +/- 4.53 kg/m(2) vs 18.17 +/- 1.52 kg/m(2), F = 58.36, P < 0.001); total body water (42.62 +/- 7.98 kg vs 36.22 +/- 9.32 kg, F = 7.95, P = 0.005); basal metabolic rate (1625.14 +/- 304.91 kcal vs 1344.62 +/- 219.08 kcal, F = 9.06, P = 0.003) were very important for SGA, and lymphocyte count was relevant for NRI: 25.56% +/- 8.94% vs 21.77% +/- 10.08%, F = 11.55, P = 0.001. The number of malnourished patients rose with the length of hospital stay according to both nutritional indices. The discriminative function analysis (DFA) delineated the following parameters as important for prediction of nutritional status according to SGA assessment: concentration of albumins, level of proteins, SGA score and body weight. The DFA extracted MAMC, glucose level and NRI scores were variables of importance for the prediction of whether admitted patients would be classified as well or malnourished. CONCLUSION: SGA showed higher sensitivity to predictor factors. Assessment of nutritional status requires a multidimensional approach, which includes different clinical indices and various nutritional parameters.

Autonomic dysfunction in alcoholic cirrhosis and its relation to sudden cardiac death risk predictors.

Patients with liver cirrhosis have autonomic dysfunction and complex cardiovascular changes. Increases risk for sudden cardiac death (SCD) was recently recognized in liver cirrhosis. This study analyzed risk predictors for SCD related to autonomic dysfunction in patients with alcoholic liver cirrhosis (ALC). Twenty five patients with ALC were examined and compared with healthy control group. Cardiovascular autonomic reflex tests, comprehensive ECG with QTc interval, late potentials, short-term heart rate variability (HRV) analysis (time domain, spectral and nonlinear-Poincare plot analysis) and 24-h Holter ECG with long-term HRV analysis were done. According to autonomic reflex tests patients with ALC had high incidence (56%) of severe autonomic dysfunction, manifested as pronounced damage of vagal function. Patients had significantly depressed HRV (SDNN, SDANN, triangular index, LF and HF) and more frequently had serious arrhythmias, prolonged QTc and Poincare plot in a shape of dot (p < 0.001). In patient group QTc significantly inversely correlated with spectral components from short-term HRV analysis (ln(LF): r = -0.53, ln(HF): r = -0.47; p < 0.05), and Lown class significantly correlated with total autonomic function score (r = 0.64, p = 0.04). This study indicates that in ALC autonomic neuropathy with vagal impairment and sympathetic predominance is related to SCD risk predictors and onset of serious ventricular arrhythmias.

[Multiple anatomical malformations in 25-year old patient with heterotaxy--case report].

INTRODUCTION: Heterotaxy or situs ambiguus is a rare congenital disorder, characterized by abnormal situs with either left or right isomerism that usually coincides with A complex malformation. The classic left isomerism or bilateral left-sidedness or heterotaxy syndrome with polysplenia implies that patients have bilateral bilobed lungs, bilateral pulmonary atria, a centrally located liver, a stomach in indeterminate position, and multiple spleens, occasionally associated with interruption of the inferior cava with azygos or hemiazygos continuation. CASE REPORT: We present a case of situs ambiguus associated with severe heart and vascular abnormalities in a 25-year-old male patient. On the admittance to our clinic the patient had history of biliary colic, moderate jaundice of the conjunctive and sclerae, and severe central cyanosis. The echocardiography revealed a large atrial septal defect, complete absence of the interventricular septum resulting in the single ventricle and the inversion of atria. The angiography obtained the hypoplastic inferior vena cava continuing with azygos vein that flowed into the left superior vena cava. The computerized tomography scans showed three splenuli in the right upper quadrant of the abdomen, and a single gallstone appeared in the left-positioned gallbladder. The contrast radiography showed complete transposition of the guts and stomach. DISCUSSION AND CONCLUSION: To our knowledge, our patient with described severity of the anomalies had the longest life span in this part of Europe, although the longer survivors have been described in the other parts of the world. Furthermore, clinical characteristics of both left and right isomerism have been obtained in the patients with anatomically pronounced left isomerism.

Clinical and laboratory features of the catastrophic antiphospholipid syndrome.

Catastrophic antiphospholipid syndrome (CAPS, Asherson's syndrome) is an unusual form of antiphospholipid syndrome (APS) characterized by multi-organ failure and high mortality. Fortunately, CAPS accounts for less than 1% of APS cases. Due to the rarity of the condition, an international registry of CAPS patients was created in 2000 supported by the European Forum on Antiphospholipid Antibodies held in Taormina, Italy at the Tenth International Congress on Antiphospholipid Antibodies. Clinical and laboratory features are the most important in the criteria for the diagnosis of this syndrome and can affect many organ systems. The majority of patients presented with multiple organ involvement at the time of CAPS. The combination of pulmonary, cardiac, and renal involvement was most commonly seen. The organ systems most commonly involved at the onset include the cardiopulmonary system, primarily characterized by dyspnea and respiratory failure, the central nervous system, and the renal system. Laboratory criteria for the classification of CAPS include the presence of antiphospholipid antibodies-LA and/or aCL and/or beta(2)-GPI antibodies.

[William Stewart Halsted--110 years of the use of surgical gloves].

INTRODUCTION: William Stewart Halsted was born in New York in 1852 and is generally regarded as the most innovative and influential surgeon the United States has produced. CONTRIBUTIONS TO SURGERY: The number and magnitude of Halsted's contributions to surgery are staggering. They range from the development of a surgical procedure for breast cancer, to the introduction of rubber gloves in the operating room. They include some of the earliest operations on the biliary tract, introduction of the plate and buried screw technique in the management of long bone fractures, and some of the earliest and most innovative approaches to the treatment of aneurysms of the great vessels. Halsted also developed the submucosal intestinal suture, which allowed the development of the broad field of alimentary tract surgery. He made important contributions in the area of parathyroid and thyroid surgery, and his monograph on thyroid goiter became a classic. Halsted developed an operation for inguinal hernia repair in an era in which they virtually were incurable. One of his most notable contributions was the introduction of local and regional anesthesia. He was the first surgeon in the U.S. who promulgated the philosophy of "safe" surgery. He advocated the gentle handling of tissues during surgery, careful hemostasis, avoidance of dead space, and a meticulous surgical technique at a time when speed, lack of attention to hemostasis and rough handling of tissues were the rule. Perhaps his most important contribution to surgery, however, was the introduction of a new system of training young surgeons. He died in 1922.

[Acute appendicitis in a femoral hernia].

INTRODUCTION: Acute appendicitis in a femoral hernia is an uncommon condition that can be serious. Complications are more frequent if the diagnosis is delayed and surgery is not performed on time. CASE REPORT: We present a 71-year-old man with a painful swollen mass. The patient presented with fatigue and loss of appetite, while body temperature was normal. The abdomen was not painful, and peristaltic was normal. All laboratory findings were normal. After anamnesis and physical examination, the presumed diagnosis was incarcerated femoral hernia and the patient was sent to the operating room. Intraoperative findings revealed an incarcerated femoral hernia within a phlegmonous inflammated appendix. Appendectomy and McVay hernioplastics were done. The postoperative course was without complications. CONCLUSION: It is very important to bear in mind that right femoral hernia with signs of incarceration and inflammation may contain an acutely inflamed appendix. Delayed diagnosis and misdiagnosis cause greater morbidity and mortality.

Depression and anxiety levels in therapy-naive patients with inflammatory bowel disease and cancer of the colon.

AIM: To assess whether depression and anxiety are more expressed in patients with the first episode of inflammatory bowel disease (IBD) than in individuals with newly discovered cancer of the colon (CCa). METHODS: A total of 32 patients with IBD including 13 males and 19 females, aged 27 to 74, and 30 patients with CCa including 20 males and 10 females, aged 39-78, underwent a structured interview, which comprised Hamilton's Depression Rating Inventory, Hamilton's Anxiety Rating Inventory and Paykel's Stressful Events Rating Scale. RESULTS: Patients of the IBD group expressed both depression and anxiety. Depressive mood, sense of guilt, psychomotor retardation and somatic anxiety were also more pronounced in IBD patients. The discriminant function analysis revealed the total depressive score was of high importance for the classification of a newly diagnosed patient into one of the groups. CONCLUSION: Newly diagnosed patients with IBD have higher levels of depression and anxiety. Moreover, a psychiatrist in the treatment team is advisable from the beginning.

[Pulsed Doppler tissue imaging in the early diagnosis of coronary artery disease].

INTRODUCTION: Cardiovascular diseases are the leading cause of death in the majority of well-developed countries. IMPORTANCE OF EARLY DIAGNOSIS: Early diagnosis of coronary artery disease is difficult due to blood vessels remodeling, late manifestations of reduced maximal and normal coronary blood flow, and negative correlation between stenosis and plaque burden. PULSED DOPPLER TISSUE IMAGING: Pulsed Doppler tissue imaging is used for assessment of myocardial velocity, whereas classical Doppler imaging is used for measurement of blood flow velocity. Systolic myocardial velocity profile During the systolic phase only a single myocardial motion is registered--S wave. DIASTOLIC MYOCARDIAL VELOCITY PROFILE: There are early and late myocardial relaxation velocities. Impact of coronary artery disease on myocardial velocities Early to late myocardial relaxation velocity ratio is influenced by coronary artery disease. This paper provides practical guidelines for using pulsed doppler tissue imaging. CONCLUSION: Pulsed Doppler tissue imaging is an excellent procedure for early diagnosis of coronary artery disease.

[A historical perspective of tissue Doppler--when the starlight illuminates the myocardial function].

In 1842, an Austrian professor of mathematics and practical geometry, Christian Doppler, presented results of his investigations in the field of astronomy, without any clue that they would become important principles of modern ultrasound diagnostics. Almost a century later, at the University of Osaka, Japan, S. Satomura first applied these principles to measure the blood flow velocities in peripheral and extracranial brain-supplying vessels. The father of tissue Doppler imaging is Karl Isaaz, a French scientist, who was the first to realize the importance of clinical and diagnostic potentials of tissue Doppler imaging. Today, this noninvasive echocardiographic method is widely used in evaluation of myocardial function, especially in diagnosing of diastolic heart failure and early diagnosis of coronary artery disease, but also in diffrential diagnosis of restrictive cardiomyopathy and constrictive pericarditis and aberrant myocardial conduction. It is also an antecedent of "stain rate", a new sensitive method for diagnosing myocardial diseases.

[Rene Favaloro--a surgeon who has changed the history of coronary disease].

Rene Favaloro was one of the most distinguished surgeons of the 20th century. He was the first to introduce the original technique of aortocoronary bypass grafting, entering the new era of coronary artery disease treatment. Working at the Cleveland Clinic, together with Mason Sones and Effler, he became a member of the medical team which performered the first aortocoronary bypass grafting and showed the functional competence of the new graft. Although today percutaneous coronary interventions and coronary artery stents have a very important role in coronary artery disease treatment, five years after his death aortocoronary bypass grafting is the method of choice in selected groups of patients. Nowadays, when urgent percutaneous coronary interventions are an important treatment option in our country, it is good to remember that this also was the idea of Rene Favaloro and Mason Sones, who discussed agressive treatment in the first hours of myocardial infarction, and to remember his tremendous contributions and life dedicated to cardiosurgery.