Clinical scores for the prediction of esophageal varices in patients with liver cirrhosis.

INTRODUCTION: Esophageal bleeding is one of the most important and dramatic complications of liver cirrhosis in our everyday practice. Considering the costs of repeated upper endoscopy (UE) there is an increasing number of studies focusing on noninvasive para-meters for the assessment of esophageal varices (EV). PATIENTS AND METHODS: Retrospective study included 74 patients with alcoholic and viral liver cirrhosis treated at Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia. The data were obtained from patients medical records including history, biochemical, ultrasonography and UE findings. RESULTS: The average value of the RLLD/INR for patients who showed evidence of EV during UE and in those who didn't was 10.46 ±â€ˆ3.09 and 12.24 ±â€ˆ3.43, respectively (p = 0.019, p < 0.05). Cutoff value (11.5) of RLLD/INR showed a sensitivity of 64.15% and specificity of 66.67% (1.92LR+, and 0.54 LR-, AUROC 0.639) for the detection of EV. The average value of PC/SBD for patients who showed evidence of EV during UE and in those who didn't was 619.79 ±â€ˆ492.96 and 1423.1 ±â€ˆ908.2, respectively (p = 0.0, p < 0.05). The average value of RLLD/SA was 5.5 ±â€ˆ0.17 and 4.57 ±â€ˆ0.17 (p = 0.015, p < 0.05) for patients who showed evidence of EV -during UE and in those who didn't, respectively. CONCLUSION: Noninvasive assessment of EV using scores based on ultrasonography and laboratory is simple, inexpensive, and could be a useful tool in limiting the number of repeated UE.

Endoscopic ultrasound for differential diagnosis of duodenal lesions.

PURPOSE: Duodenal tumors are rare and require a different management from that of esophagogastric neoplasia. The present study retrospectively analyses the endoscopic ultrasound (EUS) features of duodenal tumors of both epithelial and subepithelial origin. MATERIALS AND METHODS: During a 12 year period, all duodenal tumors with histologic confirmation by surgery or biopsy were collected including endoscopic and endosonographic images. EUS images were analyzed for specific features (echogenicity, wall layer structure and relation, outer margins) to possibly distinguish epithelial (polyps and carcinoma versus lymphoma) and subepithelial (tumor type) tumors. RESULTS: 53/80 cases had histologic confirmation (mean age 53.1 ±â€Š11.4 years, m:f = 33:20), 31 were epithelial (13 adenomas, 12 carcinomas, 6 lymphomas) and 22 subepithelial (11 GISTs, 7 Brunneromas, 1 lipoma, 3 NETs). EUS did not recognize carcinomas in 2/13 adenomas. EUS features suggesting carcinoma were loss of wall layers and irregular margins. 5/6 lymphomas showed inhomogeneous thickening with layers partially recognizable. Tumor type of subepithelial lesions correlated with echogenicity: GIST tumors were mostly (62.5 %) hypocheoic with the 3 malignant cases being characterized by heterogeneous echopattern with irregular outer margins. Of the hyperechoic lesions, lipomas had a homogeneous whitish appearance, while NET and Brunneromas were less hyperechoic. In the latter, the endoscopic aspect was also helpful for differential diagnosis. Accuracy of combined endoscopic/EUS imaging for all duodenal lesions was 84.9 % (45/53). No procedural complications occurred among all patients that received EUS examinations. CONCLUSION: EUS contributes to the differential diagnosis of epithelial lesions known to be malignant; in subepithelial tumors, tissue confirmation is still required.

[Scoring system for evaluation of clinical outcome of severe injuries in patients].

A trauma-scoring system converts the severity of injury into a number, so helping clinicians to define patient's condition. Aim of our investigation was assessment of scoring systems in clinical outcome of patients with severe traumatic injury, as well as ISS, AIS, APACHE II and SOFA score were counted. Mean age of traumatized patients was 35 yrs, predominantly males. Based on results of our investigation we concluded that ISS, APACHE II and SOFA score adequately can be used for predicting clinical outcome of severe traumatized patients.

[Blood replacement in severely injured patients].

Haemorrhage remains a leading cause of early death in injured and application of concentrated RBC transfusion in the treatment of multiple injuries is the basis and potential component of saving lives. The aim of this study was to analyze the received amount reimbursed blood in patients with severe trauma, depending on the outcome, severity and mechanism of injury. Collected data on gender, age and age as the mechanism of injury, amount of blood recovered intraoperatively and during the first six days of hospitalization, which were analyzed according to outcome of treatment, ISS, AIS, and APACHE II score. Results showed that patients with lethal outcome received a larger amount of blood, there is a statistically significant correlation with ISS and AIS score for extremity injuries, and that larger amount of blood received patients injured in the traffic accidents, as pedestrians and motorcycle riders/bike, and there is no correlation with APACHE II score. Based on the importance of this topic for further research are necessary in this area in order to more accurately define indications and dosage and method of reimbursement of blood in patient with severe trauma.

[Occurrence and risk factor for development of pancreatitis and asymptomatic hyperamylasemia following endoscopic retrograde cholangiopancreatography--our experiences].

INTRODUCTION: Chronic pancreatitis is defined as chronic inflammatory lesion of pancreatic parenchyma leading to destruction and fibrosis of exocrine pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) is the most sensitive and specific method for detection of morphological alterations in chronic pancreatitis. ERCP is inevitably associated to post-ERCP acute pancreatitis, as well as hyperamilasemia. STUDY AIM: This study aims to determine frequency of post-ERPC pancreatitis and asymptomatic hyperamilasemia. STUDY METHODS: We have studied 160 patients who underwent ERCP in Institute of Digestive Diseases, Clinical Centre of Serbia in Belgrade. Data regarding cholecystectomy, papillotomy, peripapillary diverticulosis, Oddi's sphincter hypertension, choledoch canulation and diameter, Wirsung duct canulation, minor duodenal papilla patency, anomalies of BP junction, as well as chronic pancreatitis has been analysed and correlated with eventual development of post-ERCP pancreatitis and asymptomatic hyperamilasemia. RESULTS: Asymptomatic hyperamilasemia was determined in 51 subjects (31.9%), while pancreatitis has been developed in 5 patients (3.1%) subsequent to ERCP. It has been proofed that Wirsung duct canulation plays significant role in development of post-ERCP complications. CONCLUSION: Although numerous factors may potentially contribute to development of post-ERCP pancreatitis, none of them, with the exception of Wirsung duct canulation, has been determined to play significant role in development of these complications.

[Medicolegal aspects in gastroenterology].

INTRODUCTION: Medical practice is under continual public scrutiny. There are increasing concerns on medical malpractice and its consequences - further deterioration of health and death. Public criticism of medical practice very often outrageous, but sometimes medical negligence is obvious. AIM OF THE STUDY: We are presenting basic medicolegal analysis of causation in cases of medical malpractice with subsequent fatal outcome. CASE STUDY: We are reporting on two cases from archives of Institute of Forensic Medicine. The selected cases (biliary ileus and pseudomembranous colitis subsequent to elective cholecistectomy) may reflect common gastroenterological pathology. The analysis of medical practice and its consequences, i.e. analyse of causation has been presented and commented in regard to the pertinent legislation. CONCLUSION: Doctors ought to be familiar with medicolegal aspects of their practice. This might affect them to improve the quality of health care, and to increase protection, both of health care personal and patients.

[The role of wireless capsule endoscopy in the evaluation of patients with suspected small bowel bleeding: a single center experience].

BACKGROUND: Capsule endoscopy (CE) is a new diagnostic tool for the study of patients with suspected small bowel pathology. The aim of the study was to clarify the usefulness of CE in the group of patients with obscure (overt / occult) gastrointestinal (GI) bleeding. PATIENTS AND METHODS: Thirty patients (14 men, 16 women, mean age 50 years, range 9 -79 years) were enrolled in the study. All of them undergone non-diagnostic esophagogastroduodenoscopy, colonoscopy and barium follow-through of the small bowel. All patients underwent capsule endoscopy. Fourteen patients had overt and sixteen occult bleeding. The single senior endoscopist interpreted CE findings in an unblinded manner. RESULTS: CE identified a source of bleeding in 14/30 patients (46.6%). Lesions identified were: tumors in five pts, vascular lesions, Crohnzs disease and Meckelzs diverticulum in two pts and fresh bleeding, segmental celiac disease and colonic diverticulosis in one patient each. CE identified a source of bleeding in 9/14 (64.3%) of patients with ongoing overt bleeding and in only 5/16 (31.3%) of patients with occult bleeding. The positive suspicious findings were seen in 6/30 (20%) of patients (2/14 with overt bleeding and 4/16 with occult bleeding. In 3/14 (21.4%) with overt and 7/16 (43.7%) with occult bleeding findings on CE were negative. All patients with negative findings on follow-up remained asymptomatic for one year. Capsule retention because of unsuspected stenosis occurred in a single patient and required surgery, which resolved the problem. CONCLUSION: CE is an effective diagnostic tool for patients with obscure GI bleeding. It is safe and painless technique which can diagnose the bleeding site beyond the reach of conventional endoscopy. The best candidates for the procedure are those with ongoing and overt bleeding.

[Acute upper gastrointestinal nonvariceal bleeding--how to determine low risk patients for rebleeding and mortality after endoscopic sclerotherapy?].

INTRODUCTION: Successful endoscopic sclerotherapy is effective in securing hemostasis for bleeding lesions and remains the first line and only needed therapy for most of the patients (pts), but bleeding reoccurs in 10% to 30% pts, and 4% to 14% of the pts die after acute nonvariceal upper gastrointestinal bleeding (UGIB). The need for hospitalization and its duration for all the bleeding pts is still a controversial question. AIM: To create the simple scoring system able to determine low risk pts for rebleeding and mortality by establishing the relative importance of risk factors for rebleeding and mortality after successful endoscopic sclerotherapy of acute nonvariceal UGIB. PATIENTS AND METHODS: Prospective study included 3 15 pts who where admitted to hospital because of acute nonvariceal UGIB. All of them underwent gastroscopy with successful sclerotherapy within 12 hours after the admission. We investigated the episode of rebleeding and death during the initial hospitalization, and analyzed the following parameters: age, gender, drug intake, shock, bleeding stigmata, location of bleeding lesion and comorbidity. RESULTS: Rebleeding occurred in 53 pts (16.8%) and was determined by shock, bleeding stigmata and comorbidity. Eleven pts (3.5%) died and shock, rebleeding and comorbidity were all independent, statistically significant predictors of pts' mortality. The numerical scores for determination of pts with different risk levels for rebleeding and mortality have been developed using the significant predictors of rebleeding and death. The score values for rebleeding ranged from 3 to 9 and pts with values < or = 4 had low risk of rebleeding. We identified 59 pts (18.7% of all) with score for rebleeding < or = 4. Score values for mortality risk ranged from 3 to 8 and the values < 5 revealed negligible risk of death. In our group we found 290 pts (92.1% of all) with low mortality score values. CONCLUSION: Following the successful initial endoscopic sclerotherapy, these scores can help to identify pts with low risk of rebleeding and negligible risk of death, so they can be treated as outpatients.

[Surgical treatment of gastroduodenal ulcer bleeding-our experience].

INTRODUCTION: Acute bleeding from the upper gastrointestinal tract remains the commonest emergency in gastroen-terology, and is most often caused by gastroduodenal ulcer disease. Despite introduction of novel endoscopic techniques and pharmacological treatment, 6-15% patients have to be operated. The aim of our investigation is analyze data of patients treated for gastrointestinal ulcer bleeding in our institution, their treatment options and outcome. PATIENTS AND METHODS: We included 2237 patients admitted in the Department for Emergency medicine of Clinical center of Serbia during the period from January 1999 until December 2003. because of gastroduodenal ulcer bleeding. We analyzed age, gender treatment option, hospital stay and mortality. RESULTS: The mean age of our patients was 61.58 years, 1346 male and 891 female. The majority of patients were conservatively treated (84.5%). Operated patients mostly undergo Billroth II resection (57.8%). The mean hospital stay was 7.3 days. Average mortality was 14.4%. CONCLUSIONS: Despite adequate endoscopic management of bleeding gastroduodenal ulcer, surgeons will continue to treat this patients for emergency surgery.

[Endoscopic ultrasonography in pancreatic carcinoma].

Even though pancreatic cancer is not such a common diagnosis, its treatment is very expensive and it has a great economic impact to the health system. 5-year survival rates after excessive surgical treatment is only 5%, which imposes more careful selection of patients that have to be surgically treated. According to experience from some medical centers all over the world, EUS is considered as a high sensitive diagnostic method for establishing a diagnosis of pancreatic cancer and evaluation of TNM staging. The main purpose of this survey is to present our experience in using of EUS as a diagnostic method in establishing a diagnosis of pancreatic cancer, as well as to evaluate how reliable this method is in preoperative evaluation if tumor could be successfully resected. We examined the group of 63 patients with pancreatic cancer, which were surgically explored after EUS examination. We wanted to compare TNM status before and after the surgical treatment. All patients were examined by Olympus equipment for endoscopic ultrasound with radial probe working with the frequency of 7,5 and 12 MHz at the Department for Endoscopic Ultrasound of the Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia. Evaluation of pancreatic tumor extension to local organs (pancreas, duodenum, choledochus, stomach, colon and large veins) was performed for all patients. All regional lymph nodes were also explored. Due to low penetration ability of the probe working with the frequency of 7.5 MHz, EUS is not a suitable method for evaluation of M stage (figure 8,9). Patients were divided in different groups, specified by TNM status. For 10 patients resection was estimated as a probably successful solution, but only 8 of them was surgically treated. According to this, our estimation was 79.7% accurate, which is in accordance to results obtained from other medical centers all over the world.

[Peritoneal hepatobiliary cystadenoma--case report].

Hepatobiliary cystadenoma with mesenchymal stroma are infrequent form of cystic neoplasm that may be found in females only. It is difficult to reach correct diagnosis prior to surgery. We are presenting a case of 32 years-old female referred to our institution for revealing a cause of discomfort and pain in right subcostal region whereas peritoneal hepatobiliary cystadenoma has been determined. Abdominal ultrasonography and computerized tomography revealed cystic lesion adjacent to gall bladder, which was initially thought to be of echynococcal origin. At surgery, a mesenterial cystic neoplasm has been revealed, having a close contact with gall bladder, without signs of its infiltration. Pathophysiology discovered hepatobiliary cystadenoma with mesenchymal stroma. Pre-surgical differential diagnosis in hepatobiliary cystadenoma may be very difficult, especially if, like in the presented case, neoplasm has extra hepatic localization. Radical surgical excision is treatment of choice, concerning malignant potential of these neoplasms.

[Gastrointestinal stromal tumor of small intestine--case report]. / Gastrointestinalni stromalni tumor tankog creva.

Gastrointestinal stromal tumor is a form of mesenchimal neoplasm that may be present in all parts of gastrointestinal system. We are reviewing diagnostic and therapeutic algorithms for patient with diagnosed gastrointestinal neoplasm of small intestine, experiencing repeated episodes of painful bleeding from gastrointestinal trackt.

[Surgical importance of anatomic features of the pancreatic head and tail]. / Hirurski znacaj nekih anatomskih osobenosti tela i repa pankreasa.

The surgical anatomy of the left pancreatic portion includes topography of this entity in relation to the peritoneum and the adjacent organs, variations of the arterial vascularization and venous drainage, and of the ductal system. A particular emphasis was on the practical significance of the variations of the pancreatic tail, the arterial anastomoses of the corporocaudeal region, and the position and morphology of the pancreatic veins. Ending remarks include a small review on distal pancreatectomy.

[Topographic and structural characteristics of the minor duodenal papilla]. / Topografske i strukturne karakteristike papillae duodeni minor.

The study of minor duodenal papilla topography and structure was carried out on 36 fresh autopsy specimens of human duodenopancreas. We performed precise measurements of its distance to the major duodenal papilla and to the superior duodenal flexure. There was no correlation between the position of the minor papilla and the incidence of duodenal ulcer disease. Microdissection and histological staining of the minor papilla did not reveal an anatomically defined sphincter around the terminal portion of the accessory pancreatic duct. All the specimens of the minor papilla contained within acini of pancreatic tissue. A terminal dilation of the accessory pancreatic duct was found in 22% of the cases.

Serum insulin-like growth factor (IGF)-II is more closely associated with liver dysfunction than is IGF-I in patients with cirrhosis.

The aim of this investigation was to determine the total concentrations of the insulin-like growth factors (IGF-I and IGF-II) in the blood serum of patients with liver cirrhosis and to evaluate their association with the condition. Cirrhosis was alcohol induced (n=27), of viral origin (n=17) or due to combined or other causes (n=21) and was moderate or severe in similar numbers of cases (Child A: n=21; Child B: n=21; Child C: n=23). While serum levels of both peptides were lower in patients than in age-matched healthy subjects (n=81), there was considerable overlap into the lower normal range for IGF-I. Moreover, no correlation between disease severity (Child score) and serum IGF-I was observed. Since a total of 78% of the results for IGF-II were outside the normal range (95% confidence interval) and serum concentrations were correlated with Child score (P=0.007), it is suggested that serum IGF-II concentrations may reflect compromised hepatic function more closely than IGF-I.