Comparison of Glasgow-Blatchford Score and Rockall Score in Patients with Upper Gastrointestinal Bleeding.

INTRODUCTION: Upper gastrointestinal bleeding can be a life-threatening condition and requires careful evaluation from the very first episode in order to reduce the risk of rebleeding, hemorrhagic shock and death. The outcome of a patient with upper gastrointestinal bleeding depends on resuscitation measures taken during admission to the hospital and an adequate assessment of the patient's risk level. AIM: The aim of the study is to compare Glasgow Blatchford score and Rockall score and to identify the most accurate score used in predicting unfavorable outcomes and the need for intervention. METHODS: This study involves 237 patients with upper gastrointestinal bleeding. The accuracy of the scoring systems was assessed by plotting receiver-operating characteristic curves (ROC curves) and was calculated for GBS and RS with 95% confidence interval (CI). RESULTS: As for mortality prediction, RS was superior to GBS (AUC 0.806 vs. 0.750). The GBS had a higher accuracy in detecting patients who needed transfusion units and was superior to the RS (AUC 0.810 vs.0.675). In predicting the need for intervention, RS was superior to GBS (AUC 0.707 vs. 0.636. CONCLUSION: GBS and RS are developed to help clinicians to triage patients appropriately in order to assess endoscopic therapy within a suitable time frame, as well as identify low risk patients for possible outpatient management. High accuracy of the GBS in predicting a need for transfusion represents an important endpoint to assess. RS was superior to GBS in predicting a need for intervention as well as mortality. Currently, a combination of these scoring systems is the best way for proper assessment.

Impact of Different Sources of Infection on Therapy Response in Chronic Hepatitis C.

INTRODUCTION: Prior to the 1990s, the most common sources of HCV infections were blood transfusions, unsafe injections and I.V drug use. Screening of blood products for HCV has eradicated transfusion-transmitted hepatitis C in most countries since 1992-in Bosnia and Herzegovina, however, since 1995, due to the war. AIM: To investigate the impact of the source of HCV infection on the therapeutic response in patients treated for chronic HCV infection with dual combined therapy. METHODS: We diagnosed chronic HCV infections amongst 246 patients over a period of five years and selected them according to the reported source of infection. Pegylated interferon alfa 2a or alfa 2b with ribavirin was administered during the time that was genotype-dependent. HCV RNA levels in sera were measured by real time PCR. Liver histology was evaluated in accordance with the level of necroinflammation activity and the stadium of fibrosis. RESULTS: Regardless of the genotype of the virus and the source of infection, SVR was achieved in 67% of the patients. Therapeutic response (ETR) was not achieved in 25% of the patients who were infected with an untested blood transfusion and 6% of the patients who had had wartime surgery. Amongst the different sources of infections, patients with a war-surgery source of infection responded better to therapy than those with a blood transfusion source of infection (p = 0.023). A blood transfusion source of infection implies a larger fibrosis stage than in blood donors; (g = 1.177; s2 = 0.577). A blood transfusion source of infection implies a significantly larger necroinflammatory activity than in blood donors; (g = 1.456; s2 = 0.618). CONCLUSIONS: An untested blood transfusion was a significant risk factor for more advanced liver diseases in regards to necroinflammatory activity and the fibrosis stage. This source of infection was also a risk factor for low responses to antiviral therapy. At the same time, I.V. drug users had more progressive necroinflammatory activity, but a high therapeutic response to antiviral therapy.

Prognostic Significance of Ascites and Serum Sodium in Patients with Low Meld Scores.

OBJECTIVE: to determine ascites and serum sodium significance in short term mortality prediction in patients with advanced liver cirrhosis. METHODS: a cohort of 115 cirrhotic patients referred to our Department were followed up for 6 months in non-transplant settings. The c index equivalent to the area under the receiver operating curve (ROC) was calculated and compared to estimate the short-term prognostic accuracy of the following parameters: ascites, serum sodium and MELD score. RESULTS: in patients with a MELD score less than 21, ascites and low serum sodium (c index 0,687, p<0 0,001 and 0,748, p<0,001 respectively) showed better prognostic accuracy and were independent predictors of mortality. For MELD scores above 21, only MELD was an independent mortality prognostic factor (c index 0,710, p<0,001). CONCLUSION: in our study, sample ascites and low serum sodium help identify patients with advanced liver disease who are at high risk of mortality despite low MELD scores. These parameters should be considered as additional prognostic parameters that could improve available treatment options and outcomes in this group of patients.

Prognostic markers in patients with decompensated cirrhosis.

AIM: To evaluate the easily available laboratory and clinical markers in patients with decompensated cirrhosis and compare their prognostic value. METHODS: The study sample included a group of 80 patients with an established diagnosis of decompensated cirrhosis, hspitalizsed at the Department of Gastroenterohepatology, Clinical Center of the University of Sarajevo, between 2009 and 2011, followed up for 6 months either as outpatients or through repeated hspitalizsation. It was estimated that the accuracy (c-index) of the six variables, laboratory (serum bilirubin, creatinine, International Normalised Ratio (INR) and albumine) and clinical variables (hepatic encephalopathy and ascites) reflect the function of the liver in their ability to predict 6-month mortality. RESULTS: Laboratory values of serum creatinine equvivalent to the area under the receiver operating characteristic curve (AUC) 0.787, 95% CI 0,667-0,898), serum bilirubin (0.701 95% CI 0,582- 0,820), INR (0.647 95% CI 0,526-0,768) and clinical parameter ascites (0.7 95%CI 0,598-0,827), showed a statistically significant prognostic accuracy in predicting six-month mortality, but none of the parameters showed excellent diagnostic accuracy . CONCLUSION: Serum creatinine had the best diagnostic accuracy in predicting 6-month mortality in patients with decompensated cirrhosis and as easily available variable which could be used as predictive parameter in early prognostic assessment ofliver cirrhosis.

Clinical significance of haemostatic tests in chronic liver disease.

OBJECTIVE: To determine different haemostatic tests in patients with various degrees of liver parenchymal damage and to rule out their role in assessing parenchymal hepatocyte dysfunction. METHODS: Seventy-five patients with chronic liver disease were included and due to their degree of liver damage categorized into three groups: group one patients with chronic viral hepatitis and early stage of fibrosis (n=30), group two patients with compensated cirrhosis (n=17) and group three patients with decompensated liver cirrhosis (n=28). The following haemostatic tests were measured: activated partial thromboplastin time, prothrombin time, plasma fibrinogen, antithrombin III and protein C and plasma D-dimer. RESULTS: Antithrombin III levels showed significant reduction in compensated (83.86 +/- 19.49%) and decompensated cirrhosis (52.64 +/- 14.31%; p < 0.001), while protein C activity exhibited significant decrease in all the patients group, including patients with chronic viral hepatitis (90.58 +/- 11.03, 74.65 +/- 19.56, 41.11 +/- 18.35%; p < 0.001) in comparison with controls. Correlation between antithrombin III (Pearson ro = -.931, p < 0.01) and protein C (Pearson ro = -.789, p < 0.01) and clinical degree of chronic liver disease were found. D-dimer levels were significantly increased in decompensated cirrhosis (832.26 +/- 537.19 microg/L; p < 0.001) and no significant difference was found in group two and three when compared with healthy controls. CONCLUSIONS: In advanced chronic liver disease anticoagulant activitiy may reflect hepatocellular dysfunction. Protein C activity may be used as a senstive marker of hepatocellular damage even in those patients with mild liver affection whereas D-dimer levels may be considered as an important sign of decompensation in cirrhotic patients. Further studies are necessary to approve whether these parameters could be used as clinical routine markers of hepatocyte function in chronic liver disease.

Evaluation of the diagnostic accuracy of the endoscopic ultrasonography results in the patients examined in a period of three years.

INTRODUCTION: Endoscopic ultrasonography (EUS) is a well-established method of evaluating patients with gastrointestinal diseases, especially malignancies. EUS is like other similar endoscopy techniques, based on high frequency ultrasonography. This high level technology allows examination of tissue to almost microscopic level, not only in digestive system but its surrounding structures. OBJECTIVE: The aim of this study was to determine the contribution of endoscopic experience, based on the number of endosopic ultrasonography examination performed in the three years period, to obtain 80% diagnostic accuracy with staging of the disease in order to achieve a 30-60% change rate in treatment decisions which is accepted standard. RESULTS: First group with 210 patients was examined in the first year of work; 325 examined in the second year of work and 295 in the third year. DIAGNOSTIC: Accuracy in the first year of work, were 45% (p<0.001 for the choledocholithiasis; p=0.197 for the pancreatic cancer; p=0.195 for LN detection in the gastric cancer). In the second year of work diagnostic accuracy were 78%/p=0.550 for the choledocholithiasis; p=0.228 for the pancreatic cancer; p=0.503 for LN detection in the gastric cancer/. Diagnostic accuracy in the third year of work were 81%/p<0.001 for the choledocholithiasis; p=0.018 for the pancreatic carcinoma; p=0.042 LN detection in the gastric cancer/. CONCLUSION: Application of Endoscopic ultrasonography in diagnostics, based on number of EUS examination performed, after three years of work, achieved 80% diagnostic accuracy, compared to standard imaging methods and results of surgery in staging of the disease. EUS results made a change in treatment decisions in 30-60% of patients which is world standard and completely justify use of endoscopic ultrasonography in clinical practice.

[Imaging procedures in gastroenterology]. / Slikovne procedure u gastroenterologiji.

Recent achievements in fields of physics, microelectronical devices and informatical sciences opened huge possibilities of applications in medical specialities. Spread imaging over routine high-resolution instruments continue to be in focus of scientific researches varying from simple staining techniques to most sophisticated photodynamical techniques. Magnetic resonance imaging and computed tomography are radiological specialties, however; we mentioned them for promising achievements in computed data analysis and further improvements of virtual colonoscopy. During the last few years techniques of magnifying endoscopy have been improved including trials with narrow band endoscopy, autoflourescence endoscopy, elastic scattering spectroscopy and laser confocal microscopy. In many indications capsula endoscopy have been applied successfully.

Portal hypertensive gastropathy (PHG).

Portal hypertenisive gastropathy (PHG) and GAVE syndrome are recently discovered entities who can be associated with bloodloss from gastrointestinal tract at patients with or without liver cirrhosis. PHG will be developed at 65% of patients with portal hypertension caused by liver cirrhosis but it could be developed at portal hypertension which is not caused by the liver cirrhosis. PHG is often assosiated with portal hypertension patients and presence of esofageal and /or gastric varices. Mechanism of pathogenesis PHG is still not completely cleared up, but regulation of gastric nitric oxide level, postaglandins, tumor necrosis factor (TNF) and epidermal growth factor production could be important factors in development of portal hypertensive gastropathy. Mechanisms who participate in originating of Gastric Antral Vascular Ectasia (GAVE) are also not completly clear. Classic characteristics of this syndrome are red, often haemorrhagic lesions most often located in stomach antrum, and who could result in blood loss. More than 70% of patients with GAVE syndrome have no cirrhosis or portal hypertension. But when liver cirrhosis is present, it is very difficult to make difference between GAVE and PHG. This review will be focused on incidence, clinical importance, etiology, pathofisiology and treatment of PHG, and how to differentiate between GAVE syndrom and PHG in a case that there exists.

[Therapy of chronic viral hepatitis B]. / Terapija hronicnog virusnog hepatitisa B.

In chronic HBV infection, studies of outcome have shown that successful antiviral treatment undertaken early in course of diseases, may improve health and quality of life. Aims of treatment are: decrease of aminotransferase level to normal, histological necroinflammatory reduction, sustain loss of HbeAg and HBV DNA, antibodies on Hbe occurrence and loss of HbsAg with complete eradication of viral infection. Three therapeutical options are available: thymosine, lamivudine and standard interferon alpha. In future options, promising results are expecting from pegylated interferon, adefovire and entecavire.