Serum neutrophil gelatinase-associated lipocalin (NGAL) correlates with clinical and endoscopic activity in ulcerative colitis but fails to predict activity in Crohn's disease.

Serum neutrophil gelatinase-associated lipocalin (NGAL) is a low molecular weight protein released from activated neutrophils and intestine epithelium whose mRNA expression is increased in inflamed intestinal tissue. The purpose of this study was to explore the relationship between serum NGAL level and activity of inflammatory bowel diseases. A total of 120 patients, 79 with Crohn's disease (CD) and 41 with ulcerative colitis (UC) were prospectively included into the study. Serum NGAL was measured by ELISA. The inflammatory activity of UC was assessed by Mayo score and of CD by CDAI and SES-CD scoring systems. Increasing endoscopic severity of UC from remission/mild to moderate/severe was associated with increasing NGAL levels from 46.9 to 66.4 ng/ml (P = 0.002). NGAL concentrations were significantly lower in patients with complete endoscopic and histologic remission than in the active UC (46.9 versus 66.4 ng/ml, P = 0.009). Also deterioration of the clinical activity of UC patients was associated with increasing level of NGAL from 44.9 in remission/mild to 68.0 ng/ml in moderate/severe grade (P = 0.002). NGAL levels correlated with CRP (r = 0.49), ESR (r = 0.48) and iron concentrations (r = -0.63), but not with faecal calprotectin. NGAL showed ability to distinguish endoscopically active from inactive UC with AUC-ROC of 0.758 (sensitivity 96% and specificity 54%). However NGAL levels showed no significant relationship with either clinical or endoscopic activity of CD. We conclude that serum NGAL level corresponds to clinical and endoscopic activity of UC and accurately predicts disease endoscopic remission.

Differentiation of pancreatobiliary cancer from benign biliary strictures using neutrophil gelatinase-associated lipocalin.

Aim of the study was to investigate the value of serum and bile neutrophil gelatinase-associated lipocalin (NGAL) for distinguishing malignant strictures caused by cholangiocarcinoma (CCA) or pancreatic cancer from benign biliary strictures. The study was performed prospectively on patients admitted for endoscopic or radiologic biliary decompression. Forty patients with dilated biliary ducts, including 16 cases of CCA, 6 cases of pancreatic cancer, and 18 cases of benign biliary stricture were enrolled. Their sera and bile were collected to measure NGAL. Routine biochemistry including measurement of serum levels of carbohydrate antigens (CA) 19-9 and carcinoembryonic antigen (CEA) was also performed. The serum CA19-9, serum CEA, and bile NGAL levels were significantly increased in patients with malignant strictures as compared with patients with benign biliary diseases. Serum NGAL had no significant value for discriminating between malignant and benign biliary strictures. Bile NGAL levels had a receiver characteristic area under the curve of 0.74, sensitivity 77.3, and specificity 72.2% for discriminating between pancreatobiliary cancer and benign biliary diseases. Bile NGAL and serum CA19-9 were independent parameters and their combined use improved diagnostic accuracy (sensitivity 91%, negative predictive value 85.7%). We conclude that measurement of biliary, but not serum NGAL, may differentiate malignant pancreatobiliary from benign biliary strictures, serving as a complementary biomarker for serum CA19-9.

Acute biliary pancreatitis in a 9-year-old child treated with endoscopic sphincterotomy.

Acute biliary pancreatitis is a well recognized complication of gallstone disease in adults. Acute pancreatitis in childhood is usually caused by congenital anomalies of the pancreatico-biliary ducts, viral infections, drug toxicity or abdominal trauma. We report the case of a 9-year-old girl with acute biliary pancreatitis and cholangitis. On urgent endoscopic retrograde cholangiopancreatography a bulging papilla with impacted stone was seen. She was treated with endoscopic sphincterotomy without complications. The disease resolved rapidly and uneventfully after the endoscopic treatment.

Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) with radial scanning is an efficient diagnostic tool where there is suspicion of common bile duct (CBD) stones. Little is known about the use of linear EUS in this condition. The aim of this study was to evaluate the diagnostic efficiency of linear EUS in a large group of patients suspected to have bile duct stones, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and exploration of the CBD using a Dormia basket, or surgical choledochotomy with choledochoscopy, as diagnostic "gold standards." PATIENTS AND METHODS: 134 patients with clinical suspicion of CBD stones were included in the study and prospectively evaluated, using EUS, and ERCP with endoscopic sphincterotomy (127 patients), or choledochotomy with choledochoscopy where ERCP was unsuccessful (seven patients). EUS was done before ERCP using an echo endoscope (Pentax FG 32 UA; 5 - 7.5 MHz) and Hitachi EUB 405 ultrasound machine. ERCP was done using the TFJ 100 or TJ 20 Olympus duodenoscope. ERCP was carried out within a mean of 2 days after EUS. The longest time between EUS and ERCP was 3 days. The examiners were blinded to the results of the other method used. RESULTS: CBD stones were found in 91 (68 %) patients at ERCP with ES or at surgery. The correct diagnosis was established by EUS in 85 patients. The remaining 43 patients without CBD stones were correctly diagnosed in 41 cases by means of EUS, giving an accuracy of 94 %, sensitivity of 93 %, specificity of 93 %, a positive predictive value of 98 %, a negative predictive value of 87 %, and a Youden's index of 89 %. CONCLUSIONS: Linear EUS is a fairly reliable method for the evaluation of patients with high suspicion for CBD stones. The usefulness of linear EUS in the evaluation of patients with low or moderate suspicion for CBD stones warrants further study.

A prospective, randomized, placebo-controlled trial of prednisone and allopurinol in the prevention of ERCP-induced pancreatitis.

BACKGROUND AND STUDY AIMS: Acute pancreatitis is the most frequent and difficult-to-avoid complication of endoscopic retrograde cholangiopancreatography (ERCP). Corticosteroids, potent anti-inflammatory drugs, and allopurinol--a xanthine oxidase inhibitor that blocks the generation of oxygen-derived free radicals--may be potentially effective in preventing post-ERCP pancreatitis. The aim of this prospective study was to determine the effect of prophylactic oral corticosteroids and allopurinol on the incidence and severity of procedure-induced pancreatitis. PATIENTS AND METHODS: 300 patients were randomly assigned to receive oral prednisone (40 mg), allopurinol (200 mg), or placebo 15 h and 3 h prior to ERCP. The diagnosis and grading of ERCP complications were based on commonly accepted criteria. Patients receiving prednisone or allopurinol were compared with the placebo group in a search for differences in pancreatitis rates associated with endoscopic techniques. RESULTS: The overall incidence of pancreatitis was 10.7 %, with 12 % in the prednisone group, 12.1 % in the allopurinol group, and 7.9 % in the placebo group. There were no statistical differences in the incidence or distribution of severity grades between the groups, although severe pancreatitis occurred only in the prednisone and allopurinol groups. Multiple cannulations and prolonged manipulations of the papilla of Vater were identified as risk factors for ERCP-induced pancreatitis. CONCLUSIONS: Neither prednisone nor allopurinol showed a beneficial influence on the incidence and severity of post-ERCP pancreatitis.

The frequency of bile duct crystals in patients with presumed biliary pancreatitis.

BACKGROUND: Previous studies of biliary microlithiasis in acute pancreatitis of uncertain etiology were conducted a few weeks to months after the acute episode. Bile obtained during urgent ERCP (less than 24 hours after admission) was studied for the presence of microlithiasis during the acute phase of acute pancreatitis of suspected biliary origin. METHODS: Fifteen consecutive patients with acute pancreatitis of suspected biliary origin were recruited from a population of 309 patients with acute pancreatitis (5%) treated during the last 4 years. Patients with gallstones on US and/or ERCP and those in whom the etiology of acute pancreatitis was certain were excluded. RESULTS: Microlithiasis (mostly calcium bilirubinate granules) was found in 12 (80%) cases. Despite endoscopic sphincterotomy 3 patients died within 2 weeks because of multisystemic organ failure. Among the 12 remaining patients, 2 (16%) developed gallbladder stones and 1 underwent cholecystectomy for cholecystitis (8%) during follow-up. The average length of follow-up was 30 months. No episodes of acute pancreatitis were noted during follow-up. CONCLUSIONS: In the acute phase of acute pancreatitis of suspected biliary origin, biliary microlithiasis was found in most cases. Endoscopic sphincterotomy appears to protect patients from further episodes of acute pancreatitis.

[Endoscopic ultrasonography in the preoperative localization of a pancreatic tumor producing insulin (insulinoma)]. / Ultrasonografia endoskopowa w przedoperacyjnej lokalizacji guza trzustki produkujacego insuline (insulinoma).

Pancreatic endocrine tumors include insulinomas, gastrinomas and some other less frequent neoplasms produce different GI hormones. Preoperative localization of the tumor in patients with evident clinical and biochemical features is usually difficult to obtain in conventional imaging methods. This is due to typically small size of these tumors. Non-invasive methods (conventional ultrasound, computerized tomography, nuclear magnetic resonance, positron emission tomography) and invasive methods (visceral angiography, portal veins catheterization) are often of no use in such condition, as their sensitivity is low. Preoperative localization is of importance for the surgeon, as he can plan his operation for reducing the length of the procedure with obvious consequences. This paper describes for the first time on Polish literature the usefulness of endoscopic ultrasonography in preoperative assessment of insulinoma in one patient. This finding was confirmed during surgery. The operation led to enucleation of two small insulinomas in the head of the pancreas and resulting in complete healing of the patient as found in one year follow up.

[Peak fibrinogen level as a prognostic indicator in acute biliary pancreatitis]. / Szczytowe stezenie fibrynogenu jako wskaznik prognostyczny w ostrym zólciopochodnym zapaleniu trzustki.

Early prediction of acute pancreatitis outcome is based on clinical classifications, but their complexity is limiting factor. The aim of this study was prospective, dynamic evaluation of plasma fibrinogen (Fb) concentration in acute pancreatitis and testing preselected, single Fb value as predictor of pancreatic and systemic complications. Serial measurement of Fb was done in 64 patients with acute biliary pancreatitis. Peak concentration of Fb was 5.93 +/- 1.08 g/L and was found 5-8 days following onset of the disease. The peak concentration differentiated patients with mild and complicated course of pancreatitis (5.68 +/- 1.00 g/L vs 6.31 +/- 1.10 g/L; p < 0.05), with the 67% sensitivity and 72% specificity. Similarly, Ranson's score distinguished mild from complicated form of pancreatitis (1.7 +/- 1.1 vs 2.6 +/- 1.3 points; p < 0.01), with the 58% sensitivity and 73% specificity. These data indicate that peak Fb concentration is useful as a single prognostic factor in acute biliary pancreatitis.

[Isotope methods in diagnosis of portal vein occlusion]. / Metody izotopowe w diagnostyce niedroznosci zyly wrotnej.

The dynamic intravenous hepato-scintigraphy with pertechnetate Tc-99m enables a quantitative evaluation of portal and arterial blood flow in the liver. A case is presented of thrombotic occlusion of the portal vein with rapidly growing oesophageal varices in which hepato-scintigraphy showed the absence of portal blood flow in the liver, being the decisive diagnostic method. Using the dynamic transrectal porto-scintigraphy an evaluation was done of the degree of collateral circulation development in the area of the inferior mesenteric vein, obtaining indirect information about localization and duration of portal vein occlusion.

[Effect of bismuth salts in elimination of Helicobacter pylori from gastric mucosa in patients with duodenal ulcer]. / Wplyw soli bizmutu na eliminacje Helicobacter pylori z blony sluzowej zoladka u chorych z wrzodem dwunastnicy.

Bismuth salts belong do basic drugs used for elimination of Helicobacter pylori (HP), a microorganism which is postulated to participate in etiopathogenesis of duodenal ulcer. The study was aimed at evaluation of effectiveness of application of tripotassium bismuth citrate (Ventrisol-Polfa) in elimination of HP and its influence on treatment of the ulcer. In 30 patients with diagnosed endoscopically duodenal ulcer, Ventrisol in tablets was applied (2 x 2); it was also used in its fluid form (4 x 5 ml). The time of treatment amounted to 28 days. During endoscopy, samples from various parts of the stomach were taken for microbiological inspection and they were studied in direct smear and in culture. HP was isolated from 20 out of 30 patients (37%) before treatment. After application of Ventrisol, the bacteria were present in 11/30 (34%) treated patients (p < 0.05). There was no influence of the form of drug for elimination of HP. No dependence was also found between elimination of HP and healing of the ulcer.

[Occurrence of Helicobacter pylori in mucous membrane of stomach in patients with duodenal ulcer and inflammation of stomach mucous membrane]. / Wystepowanie Helicobacter pylori w blonie sluzowej zoladka u chorych z wrzodem dwunastnicy i zapaleniem blony sluzowej zoladka.

In 1990-1991 microbiological studies were performed aimed at determination of frequency of occurrence of Helicobacter pylori in patients treated because of peptic ulcer in Department of Gastroenterology in Katowice. Studies were performed in 112 patients. Out of these, in 73 duodenal ulcer was detected endoscopically (group I), in 26--inflammation of stomach mucous membrane with erosion (group II), and in 13--both duodenal ulcer and erosion of stomach membrane (group III). Samples from mucous membrane of pylorus and of stomach taken endoscopically were tested microscopically and in culture. Helicobacter pylori was found in 74 patients (66.1%). Frequency of isolation was different in individual groups. Helicobacter pylori was found in 51 patients (70%) of group I, 15 (58%) of group II and in 8 (61%) of group III. Helicobacter pylori was most frequently isolated from patients with duodenal and stomach ulcer (81.3%).

[Primary sclerosing cholangitis and primary biliary liver cirrhosis as the causes of intrahepatic cholestasis]. / Pierwotne stwardniajace zapalenie dróg zólciowych i pierwotna marskosc zólciowa, jako przyczyny cholestazy wewnatrzwatrobowej.

Primary sclerosing cholangitis and primary biliary cirrhosis are rarely diagnosed diseases which should, however, be considered in the diagnosis of cholestasis. The authors present an outline of the modern knowledge on these diseases with particular reference to differential diagnosis.

[Manometric evaluation of the effects of intravenous administration of glucagon, buscopan and papaverine on the contractile activity of the sphincter of Oddi]. / Manometryczna ocena wplywu dozylnego podania glukagonu, buskopanu i papaweryny na czynnosc skurczowa zwieracza Oddiego.

Endoscopic manometric technique was used to investigate the effects of spasmolytic drugs on the sphincter of Oddi (s.O.) motility. 41 patients were randomly divided into 4 groups. In every patient the characteristics of the s.O. was monitored before and during 5 min. period after i.v. administration of: 20 mg buscopan, 1 mg glucagon, 40 mg papaverine or 2 ml of 0.9% NaCl solution. After buscopan administration the amplitude and frequency of phasic contractions of the s.O. were decreased as well as a baseline pressure in the s.O. Glucagon reduced frequency and amplitude of phasic contractions of the s.O. without influencing the baseline pressure. Papaverine reduced only frequency of phasic contractions. Physiological saline caused no change in pressure characteristics of the s.O.

[Emergency endoscopic sphincterotomy in acute obstructive cholangitis]. / Dorazna sfinkterotomia endoskopowa w ostrym zaporowym zapaleniu dróg zólciowych.

In 45 patients with acute obstructive cholangitis (AOC) endoscopic sphincterotomy (ES) was performed within 24 hours after admission. Criteria for the diagnosis of AOC were as follows: clinical symptoms consisting of fever and chills, right upper abdominal pain, and jaundice (Charcot's triad) with coexisting laboratory data as elevated WBC, ERS, bilirubin level and evidence of obstructive biliary disease confirmed by endoscopic retrograde cholangiopancreatography. The causes of AOC were: in 38 patients (84.5%)--common bile duct stones, in 2 patients (4.5%)--carcinoma of the papilla of Vater, and in 5 patients (11%)--benign stenosis of the papilla of Vater. A rapid clinical improvement was observed in 40 patients after ES. Within 24 hours after ES patients had relief of pain, fever subsided and white blood cell count returned from 11.7 +/- 6.9 G/l to 7.0 +/- 3.0 G/l. Bilirubin level decreased from 101 +/- 86 mumol/l to 77 +/- 68 mumol/l. Endoscopic drainage failed only in 4 patients (9%) who required surgery. One patient (2%)--died. In the treatment of acute obstructive cholangitis urgent endoscopic sphincterotomy should be a method of choice. Surgery should be reserved only for patients in whom ES failed.