[Clinical nutrition therapy in patients with short bowel syndrome in line with principles of personalized medicine]. / Klinikai táplálásterápia rövidbél-szindrómában a személyre szabott orvoslás elvei szerint.

Home parenteral nutrition administered in selected care centres has been financed in Hungary since January, 2013. The authors discuss diagnostic issues, treatment and nutrition therapy of short bowel syndrome patients in line with the principles of personalised medicine. The most severe form of short bowel syndrome occurs in patients having jejunostomy, whose treatment is discussed separately. The authors give a detailed overview of home parenteral feeding, its possible complications, outcomes and adaptation of the remaining bowel. They describe how their own care centre operates where they administer home parenteral nutrition to 12 patients with short bowel syndrome (5 females and 7 males aged 51.25±14.4 years). The body mass index was 19.07±5.08 kg/m2 and 20.87±3.3 kg/m2, skeletal muscle mass was 25.7±6.3 kg and 26.45±5.38 kg, and body fat mass was 14.25±8.55 kg and 11.77±2.71 kg at the start of home parenteral nutrition and presently, respectively. The underlying conditions of short bowel syndrome were tumours in 4 patients, bowel ischaemia in four patients, surgical complications in three patients, Crohn's disease in one patient, and Crohn's disease plus tumour in one patient.

[Potential relevance of microRNAs in the diagnostics of inflammatory bowel diseases]. / A mikro-RNS-ek szerepe a gyulladásos bélbetegségek diagnosztikájában.

Inflammatory bowel diseases are chronic inflammatory disorders characterized by relapses and remissions. Several factors have been suggested to participate in their development, although their detailed pathogenesis still remains largely unknown. MicroRNAs are single strained, non-coding RNAs, consisting of 18-25 nucleotides that regulate gene expression at the posttranscriptional level. Aberrant expression of microRNAs has been found in several malignant tumors. Recently the role of microRNAs in the pathogenesis of inflammatory-autoimmune disorders (such as inflammatory bowel disease) is being intensively investigated. Beside their pathogenic roles, microRNAs can also be exploited as diagnostic markers, especially in cases where the interpretation of histological data is difficult. In this review the authors discuss recent findings in the field of microRNAs in the diagnosis and pathogenesis of inflammatory bowel diseases.

[Significance of microRNA expression in body fluids in the diagnosis of gastrointestinal tumors]. / A testváladékok mikro-RNS-kifejezodésének jelentosége a gyomor-bél rendszeri tumorok diagnosztikájában.

MicroRNAs are small, non-coding, single strained RNAs that regulate gene expression at the posttranscriptional level. They are involved in all major aspects of cellular functions, such as cell cycle, differentiation, migration, apoptosis etc. The role of microRNAs as potential biomarkers of several malignant diseases is being intensively investigated, since they can be found in the body fluids, too, besides their usual intracellular localisation. MicroRNAs have been detected in blood, saliva, stool, breast milk, urine, bile etc. In this review the authors discuss recent findings in the field of microRNAs in stool, bile and saliva, underlying their potential significance in the diagnosis of gastrointestinal tumors.

Autoimmune pancreatitis in Hungary: a multicenter nationwide study.

BACKGROUND: To date, most cases of autoimmune pancreatitis (AIP) have been reported from Japan. The aim of the present study was to assess the clinical features and management of AIP cases in Hungary. METHODS: The demographics, clinical presentation, laboratory and imaging findings, extrapancreatic involvement, treatment response and recurrence were evaluated in the first 17 patients diagnosed with AIP in Hungary. RESULTS: The mean age at presentation was 42.7 years (range: 16-74); 47% of the patients were women. New-onset mild abdominal pain (76%), weight loss (41%) and jaundice (41%) were the most common symptoms, with inflammatory bowel disease being the most frequent (36%) extrapancreatic manifestation. Diffuse pancreatic swelling was seen in 7 patients (41%) and a focal pancreatic mass in 8 (47%). Endoscopic retrograde cholangiopancreatography revealed pancreatic duct strictures in all study patients. The serum IgG4 level at presentation was elevated in 62% of the 8 patients in whom it was measured. All the percutaneous core biopsies (5 patients) and surgical specimens (2 patients), and 2 of the 4 biopsies of the papilla of Vater revealed the typical characteristic findings of AIP: a diffuse lymphoplasmacytic infiltration, marked interstitial fibrosis and obliterative phlebitis. Immunostaining indicated IgG4-positive plasma cells in 62% of the 8 patients in whom it was performed. Granulocytic epithelial lesions (GEL) were present in 3 patients. The patients without GELs were older (mean age 59 years), while those with GEL were younger (mean age 34 years), and 2 of 3 were female and had ulcerative colitis. A complete response to steroid treatment was achieved in all 15 patients. Because of the suspicion of a pancreatic tumor, 2 patients with focal AIP underwent partial pancreatectomy. One patient relapsed, but responded to azathioprine. CONCLUSIONS: This first Hungarian series has confirmed several previously reported findings on AIP. AIP with GEL was relatively frequent among our patients: these patients tended to be younger than in earlier studies and displayed a female preponderance with a high coincidence of ulcerative colitis. Performance of a percutaneous biopsy is strongly recommended. The response to immunosuppressive therapy was excellent. and IAP.

Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents.

BACKGROUND: A rare, late complication of endoscopic biliary sphincterotomy is the occurrence of short strictures extending from the papillary orifice to the distal parts of the extraduodenal common bile duct. METHODS: We evaluated the efficacy of the sequential insertion of multiple stents in the treatment of endoscopic biliary sphincterotomy associated common bile duct strictures. The design of the study is a prospective, single-arm observational study at a university-affiliated teaching hospital of 20 patients with distal common bile duct strictures because of choledocholithiasis-related endoscopic biliary sphincterotomy. Endoscopic treatment consisted of the sequential insertion of an increasing number of plastic stents with ever-larger diameters in 3-month follow-up intervals until stricture resolution. The primary outcome of the study was the rate of resolution of the stricture. The parameters measured were the duration of placement of stents, the maximum diameter, the total number of stents, and the total number of endoscopic sessions required for dilation of the strictures. RESULTS: After a median of 9.0 months of stent placement (range 3-22 months) and a median of 20F maximum stent diameter (range 10F-30F), 18 patients (90%) remained stent-free for a median of 14.5 months (range 6-38 months). Two patients (10%) had stricture recurrences at 10 and 24 months. Multivariate regression analysis demonstrated that the time elapsed after endoscopic biliary sphincterotomy was significantly associated with the stent-placement time (however, significance was removed by correction for multiple testing) and the number of ERCPs required for dilation. The initial common bile duct size was significantly associated with the total stent number and diameter needed for stricture resolution (however, significance was removed by correction for multiple testing). Limitations are the low case number and the single-arm, noncontrolled study design. CONCLUSIONS: Sequential insertion of an increasing number of biliary stents affords effective treatment of the distal biliary strictures that develop as a late complication of endoscopic biliary sphincterotomy.

Autoimmune pancreatitis associated with immune-mediated inflammation of the papilla of Vater: report on two cases.

Autoimmune pancreatitis (AIP) is defined histologically by periductal and interacinar lymphocytic infiltration. Immunohistochemically, the majority of these lymphocytes are identified as T cells. Epithelial HLA-DR antigen expression was also described as a marker of autoimmunity in this type of chronic pancreatitis. We report 2 cases, a 56-year-old man and a 29-year-old woman, with AIP associated with immune-mediated inflammation of the main duodenal papilla (MDP). Serologically, antinuclear antibody positivity was detected in the male patient. The female patient, treated medically for ulcerative proctitis, had no serological evidence of autoimmune disease. Macroscopic papillitis was present only in the male patient, and endoscopic biopsy samples were taken from this swollen MDP. Since we could not exclude malignancy, a pancreatic head resection was performed in both patients. The histologic and immunohistochemical studies of the resected specimens showed periductal T-lymphocytic infiltration in the pancreatic and papillary tissues. Furthermore, HLA-DR-antigen expression was also demonstrated in epithelial cells of the pancreas and MDP. The immunohistological features of endoscopic biopsy samples from the swollen MDP were identical as in the surgically resected specimens. Immune-mediated inflammation of the MDP may be associated with AIP.

ATP and ATPase secretion by exocrine pancreas in rat, guinea pig, and human.

ATP is an extracellular regulator in numerous physiological and pathologic processes. Recently, 7 different subtypes of purinoceptors were identified on either the basolateral or the luminal membrane of pancreatic duct cells. However, the in vivo regulatory role of ATP in pancreatic function has not been established. We investigated the possible regulatory role of endogenous ATP in pancreatic function by measuring ATP concentrations and ATPase activity in pancreatic juice obtained from anesthetized rats and guinea pigs and from human patients undergoing endoscopy. Juice was collected from the main pancreatic duct in rats and guinea pigs under basal conditions or during stimulation with CCK, bombesin, or secretin. In guinea pigs, CCK, bombesin, and secretin did not affect ATP output, although they did stimulate fluid secretion. ATPase activity in the juice was evaluated by measuring the rate of hydrolysis of added ATP. Consistent with the low ATP concentrations in rat pancreatic juice, we found high levels of ATPase activity in this species. This was confirmed by HPLC, which also showed the metabolites of ATP hydrolysis. Ecto-ATPase activity was demonstrated by enzyme histochemistry in both the pancreatic acini and ducts in rats, but it was not detectable in guinea pigs and humans. These differences in ATP levels and ATPase expression may indicate significant species differences in the purinergic regulation of pancreatic secretion.

Medium-term results of endoscopic treatment of common bile duct strictures in chronic calcifying pancreatitis with increasing numbers of stents.

OBJECTIVES: The goal of this study was to evaluate our medium-term results on common bile duct stenting with increasing numbers of stents on strictures due to chronic calcifying pancreatitis. BACKGROUND: Common bile duct strictures frequently complicate the course of chronic calcifying pancreatitis. The effectiveness of endoscopic stenting to resolve definitely these strictures is still debated. STUDY: Twenty-nine patients with common bile duct stricture due to chronic calcifying pancreatitis were stented and followed up. Biliary sphincterotomy, dilation of the stricture, and insertion of plastic biliary stents (7.5-10 F) were performed. Patients were scheduled for elective stent changing/restenting at 3-month intervals or any time when it was urgently indicated. Our basic intention was to insert the maximum possible number of stents to reach as large diameter as the stricture allowed. All stents were removed after the disappearance of common bile duct dilatation or left in place in cases of persisting strictures. RESULTS: Eighteen patients (60%) had complete radiologic and serologic recovery after a mean of 21.1 months overall stenting time and had a stent free follow-up period for a mean of 12.1 months without recurrence of stricture. Five patients (16%) still have stents in place after 26 months. Three patients (13%) required surgery. There were 3 deaths (10%): 1 for unrelated cause and 2 with septic shock of biliary origin. CONCLUSIONS: Most chronic calcifying pancreatitis patients with common bile duct strictures respond to the increasing numbers of endoscopic stents, and remain stent free for medium term periods. Less patients (30%) does not benefit of biliary stenting, who are candidates for surgery.