Constipation and colonoscopy.

Constipation is a significant sociomedical problem, which can be caused by various reasons. In the diagnostic approach to patients with constipation, the following data are usually sufficient: History, complete physical examination (including rectal examination), and additional diagnostic tests. A colonoscopy is not a necessary diagnostic method for all patients with constipation. However, if patients have alarm symptoms/signs, that suggest an organic reason for constipation, a colonoscopy is necessary. The most important alarm symptoms/signs are age > 50 years, gastrointestinal bleeding, new-onset constipation, a palpable mass in the abdomen and rectum, weight loss, anemia, inflammatory bowel disease, and family history positive for colorectal cancer. Most endoscopists do not like to deal with patients with constipation. There are two reasons for this, namely the difficulty of endoscopy and the adequacy of preparation. Both are adversely affected by constipation. To improve the quality of colonoscopy in these patients, good examination techniques and often more extensive preparation are necessary. Good colonoscopy technique implies adequate psychological preparation of the patient, careful insertion of the endoscope with minimal insufflation, and early detection and resolution of loops. Bowel preparation for colonoscopy often requires prolonged preparation and sometimes the addition of other laxatives.

Intestinal Ultrasonography as a Tool for Monitoring Disease Activity in Patients with Ulcerative Colitis.

Background: Ultrasonography is a noninvasive, inexpensive, and widely available diagnostic tool. In the last two decades, the development of ultrasound techniques and equipment has significantly increased the usage of intestine ultrasound (US) in the assessment of the gastrointestinal tract in patients with inflammatory bowel disease (IBD). Although current guidelines suggest routine utilization of US in patients with Crohn's disease, data regarding US usage in ulcerative colitis are still scarce. We aimed to assess the reliability of intestinal ultrasonography in the assessment of disease activity and extension of patients with ulcerative colitis. Methods: Fifty-five patients with a histologically confirmed diagnosis of ulcerative colitis, treated at University Clinical Center of Serbia in the period from 2019 to 2022 were included in this retrospective observational study. The data were obtained from the patient's medical records including history, laboratory, US, and endoscopy findings. US examined parameters were as following: bowel wall thickness (BWT), presence of fat wrapping, wall layer stratification, mesenteric hypertrophy, presence of enlarged mesenteric lymph nodes, and absence or presence of ascites. Results: Our results suggest that there is a strong correlation of BWT and colonoscopy findings regarding disease extension (r = 0.524, p=0.01, p < 0.05). Furthermore, our results have shown a statistically significant correlation of BWT with the Mayo endoscopic score (r = 0.434, p=0.01, p < 0.05), disease activity score (r = 0.369,p=0.01, p < 0.05), degree of ulcerative colitis burden of luminal inflammation (r = 0.366, p=0.01, p < 0.05), and Geboes index (r = 0.298, p=0.027, p < 0.05). Overall accuracy of US for disease extension and activity was statistically significant (p < 0.05). Conclusions: Our results suggest that US is a moderately accurate method for the assessment of disease activity and localization in patients with UC.

Assessment of depression and anxiety in patients with chronic liver disease.

BACKGROUND/AIM: In recent years mental health of patients including those with chronic liver disease (CLD), has become interesting because its disturbance leads to reduced quality of life, that is associated with worsening of clinical outcome, reduced compliance and increased mortality. The aim of the study was to determinate the frequency and severity of depression and frequency of anxiety in patients with CLD and to assess the contribution of selected socio-demographic, clinical and laboratory risk factors for depression and anxiety. METHODS: In this cross-sectional study, we used the Hamilton depression rating scale (HDRS) and Hamilton anxiety rating scale (HARS) in patients with CLD. RESULTS: The study included 54 male and 43 female patients. Depression was present in 62.9%, and anxiety in 13.4% of the patients. A higher HDRS was noted in the patients older than 50 years (p = 0.022) and unemployed patients (p = 0.043). The patients with at least one episode of gastrointestinal bleeding had a significantly higher frequency of anxiety than those without bleeding (p = 0.018). A higher HARS score was present in the women (p = 0.011), unemployed patients (p = 0.008) and those with non-alcoholic liver disease (p = 0.007). There was a significant correlation between the mean corpuscular volume (MCV) and the value of the HDRS score, and between serum potassium and sodium levels and HDRS score. CONCLUSION: Age and the mean corpuscular volume have significant influence on the HDRS score while unemployment, gastrointestinal bleeding, serum potassium and serum sodium have predictive value for HARS score.

Validation of the chronic liver disease questionnaire in Serbian patients.

AIM: To translate into Serbian and to investigate the validity of the cross-culturally adapted the chronic liver disease questionnaire (CLDQ). METHODS: The questionnaire was validated in 103 consecutive CLD patients treated between October 2009 and October 2010 at the Clinic for Gastroenterology, Clinical Centre of Serbia, Belgrade (Serbia). Exclusion criteria were: age < 18 years, psychiatric disorders, acute complications of CLD (acute liver failure, variceal bleeding, and spontaneous bacterial peritonitis), hepatic encephalopathy (grade > 2) and liver transplantation. Evaluation of the CLDQ was done based on the following parameters: (1) acceptance is shown by the proportion of missing items; (2) internal reliabilities were assessed for multiple item scales by using Cronbach alpha coefficient; and (3) in order to assess whether the allocation of items in the domain corresponds to their distribution in the original questionnaire (construction validity), an exploratory factor analysis was conducted. Discriminatory validity was determined by comparing the corresponding CLDQ score/sub-score in patients with different severity of the diseases. RESULTS: The Serbian version of CLDQ questionnaire completed 98% patients. Proportion of missing items was 0.06%. The total time needed to fill the questionnaire was ranged from 8 to 15 min. Assistance in completing the questionnaire required 4.8% patients, while 2.9% needed help in reading, and 1.9% involved writing assistance. The mean age of the selected patients was 53.8 ± 12.9 years and 54.4% were men. Average CLDQ score was 4.62 ± 1.11. Cronbach's alpha for the whole scale was 0.93. Reliability for all domains was above 0.70, except for the domain "Activity" (0.49). The exploratory factor analysis model revealed 6 factors with eigenvalue of greater than 1, explaining 69.7% of cumulative variance. The majority of the items (66%) in the Serbian version of the CLDQ presented the highest loading weight in the domain assigned by the CLDQ developers: "Fatigue" (5/5), "Emotional function" (6/8), "Worry" (5/5), "Abdominal symptoms" (0/3), "Activity" (0/3), "Systemic symptoms" (3/5). The scales "Fatigue" and "Worry" fully corresponded to the original. The factor analysis also revealed that the factors "Activity" and "Abdominal symptoms" could not be replicated, and two new domains "Sleep" and "Nutrition" were established. Analysis of the CLDQ score/sub-score distribution according to disease severity demonstrated that patients without cirrhosis had lower total CLDQ score (4.86 ± 1.05) than those with cirrhosis Child's C (4.31 ± 0.97). Statistically significant difference was detected for the domains "Abdominal symptoms" [F (3) = 5.818, P = 0.001] and "Fatigue" [F (3) = 3.39, P = 0.021]. Post hoc analysis revealed that patients with liver cirrhosis Child's C had significantly lower sub-score "Abdominal symptoms" than patients without cirrhosis or liver cirrhosis Child's A or B. For domain "Fatigue", patients with cirrhosis Child's C had significantly lower score, than non-cirrhotic patients. CONCLUSION: The Serbian version of CLDQ is well accepted and represents a valid and reliable instrument in Serbian sample of CLD patients.

Portal hypertension caused by postoperative superior mesenteric arteriovenous fistula.

INTRODUCTION: Arteriovenous fistula of the superior mesenteric blood vessels is a rare complicaton in abdominal surgery. CASE REPORT: We presented a 49-year-old man with cramp-like abdominal pain, abdominal distension and weight loss symptoms, with a history of previous small bowel resection and right colectomy, due to Crohn disease, 16 years ago. Clinical examination revealed a paraumbilical pulsation with systolic murmur and thrill. Ultrasonography and computed tomography revealed cystic dilatation of the superior mesenteric vein, hepatomegaly and ascites. Upper endoscopy revealed grade I esophageal varices with portal hypertensive gastropathy. The diagnosis of arteriovenous fistula between superior mesenteric artery and vein was confirmed by angiogram of the superior mesenteric vessels and resection of the fistula was performed. Control examination after nine months showed no signs of portal hypertension. CONCLUSION: Early diagnosis and treatment of mesenteric blood vessel arteriovenous fistula prevents portal hypertension development and its complications.

[Whipple's disease: a case report].

INTRODUCTION: Whipple's disease is a chronic, multisystem, infectious disease caused by Tropheryma whipplei. It most commonly affects Caucasian males, middle-aged. Morbus Whipple is primarily gastrointestinal disease, manifested as malabsorption syndrome, and diagnosed by endoscopy and intestinal biopsy. Extraintestinal manifestations are not rare. CASE REPORT: A 48-year-old male was admitted due to diarrhea, weight loss and weakness in the extremities. Physical examination findings pointed out diffuse hyperpigmentation, pleural effusion and leg edema. Anemia, inflammatory syndrome and malabsorption signs were discovered through laboratory tests. The diagnosis was confirmed by intestinal biopsy. The patient was treated with antibiotic and symptomatic therapy. After 9 months, the patient had no symptoms, and clinical and laboratory findings were regular. CONCLUSION: Whipple's disease is a rare disease. A high degree of clinical suspicion for the disease (malabsorption, arthritis, fever, neurological symptoms) is the most important for diagnosis. Timely diagnosis and appropriate therapy prevent the disease progression and fatal outcome.

Ultrasound measurement of visceral fat in patients with primary biliary cirrhosis.

BACKGROUND/AIM: Primary biliary cirrhosis (PBC) is a progressive, chronic liver disease with elevated serum lipids, but it is unclear whether hyperlipidemia in PBC patients is associated with atherosclerosis. Metabolic syndrome promotes development of atherosclerotic cardiovascular disease related to abdominal type obesity and insulin resistance. The aim of our study was to assess abdominal adiposity in patients with PBC. METHODS: The study included 40 patients with PBC and 50 healthy controls. Age, sex and anthropometric measurements (weight, height, body mass index and waist circumference) were registered for all patients and controls. We used ultrasonography to measure subcutaneous (SF) and visceral fat (VF) diameter, subcutaneous area (SA) and visceral area (VA), as well as perirenal fat diameter (PF). RESULTS: Values of SF, VF and PF thicknesses in PBC patients were 19.23 +/- 5.85 mm, 10.92 +/- 3.63 mm, and 7.03 +/- 1.82 mm, respectively. In controls these measurements were 22.73 +/- 6.70 mm, 16.84 +/-5.51 mm and 10.50 +/- 2.70 mm respectively. In PBC patients SA and VA were calculated to 983.64 +/- 322.68 mm2 and 403.64 +/- 166.97 mm2 and in controls 1124.89 +/- 366.01 mm2 and 720.57 +/- 272.50 mm2 respectively. Significant difference was found for VF, VA and RF values. CONCLUSIONS: Considering that the amount of visceral fat plays an important role in development of metabolic syndrome and cardiovascular diseases, we concluded that the lower amount of visceral fat in PBC patients could be related to lower incidence of cardiovascular events, despite hyperlipidemia.