A Critical Approach of Guideline Therapeutic Recommendations for NAFLD.

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) as progressive form of the disease are associated with cardiovascular risk factors including obesity, dyslipidaemia, hyperglycaemia and hypertension. When NAFLD is associated with cardiovascular disease, mortality of NAFLD patients is increased due to cardiovascular disease. Prevalence of NAFLD and NASH is high, but it seems that epidemic of the disease is under-recognized and under-appreciated. Linking pathophysiological mechanisms are complex and still not well understood. The main related pathophysiological mechanisms are lipid factors, insulin resistance, inflammation, proinflammatory cytokines, oxidative stress, pro-coagulant status, hyperglycaemia and adipokines. First-line management focuses on lifestyle modifications in both diseases. Several therapeutic interventions, insulin sensitizer agents, lipid lowering drugs, antioxidants, such as vitamin E, have been proposed. Statins appear to be safe, but their use in the treatment of NAFLD and NASH is under-appreciated. Many different agents are being investigated as future drugs for the treatment of this clinical entity. The aim of the review is to examine the extent of the epidemic and the mediating mechanisms, to critically evaluate current guideline recommendations, and to consider current and future medications for this disease.

Predictors of Mortality in Long-Term Follow-Up of Patients with Terminal Alcoholic Cirrhosis: Is It Time to Accept Remodeled Scores?

OBJECTIVE: To identify the prognostic score that is the best predictor of outcome in patients hospitalized with decompensated liver cirrhosis. MATERIAL AND METHODS: In this prospective study, 126 patients were enrolled and followed up for 29 months. For each patient, prognostic scores were calculated; these included the Child-Turcotte-Pugh score (CTP score), CTP creatinine-modified I score, CTP creatinine-modified II score, Model for End-Stage Liver Disease (MELD score), MELD model for end-stage liver disease sodium-modified score, Integrated MELD score, updated MELD score, United Kingdom MELD, and the MELD score remodeled by serum sodium index (MESO index). Cox regression analysis was used to assess the ability of each of the scores for predicting mortality in patients with alcoholic cirrhosis. Their discriminatory ability was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS: The updated MELD score had the highest predictive value (3.29) among the tested scores (95% CI: 2.26-4.78). ROC curve analysis demonstrated that the MELD score of 22.50 (AUC = 0.914, 95% CI: 0.849-0.978; p < 0.001) had the best discriminative ability for identifying patients with a high risk of mortality; the next best was the MESO index of 16.00 (AUC = 0.912, 95% CI: 0.847-0.978; p < 0.001). CONCLUSION: The risk of mortality was highest in patients with the highest updated MELD score, and those with MELD scores >22.50 and a MESO index >16.00.

Faecal occult blood screening for colorectal cancer in Serbia: a pilot study.

Colorectal cancer (CRC) is becoming a major public health problem in the Republic of Serbia. Organized mass screening has been shown to decrease CRC mortality and even its incidence. The aim of this study was to assess the acceptability of a faecal immunochemical test for haemoglobin proposed by primary care physicians. From August to November 2013, a pilot study for CRC screening was organized in individuals aged 50 to 74 years. The study included 50 primary healthcare centres from all 25 administrative regions of Serbia. A qualitative immunochromatographic faecal immunochemical test for human haemoglobin detection was used. Overall, 50 894 individuals were invited. The participation rate was 67.8 and 3.4% of the tests were positive. Among individuals with a positive test, 69.7% agreed to undergo colonoscopy. The positive predictive value was 27.1% for adenoma and 14.6% for carcinoma. This was the first CRC screening project encompassing approximately one-third of primary healthcare facilities in all regions across the country. It showed a good response of the target population and satisfactory cooperation of the healthcare professionals involved.

Obesity and metabolic syndrome as risk factors for the development of non-alcoholic fatty liver disease as diagnosed by ultrasound.

Introduction/Aim: Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease of a broad histological spectrum, characterized by the accumulation of triglycerides in more than 5% of hepatocytes in the absence of consuming alcohol in quantities harmful to the liver. The aim of our study was to determine the importance of anthropometric and laboratory parameters as well as metabolic syndrome (MS) for the diagnosis of NAFLD and to estimate their influence on the degree of liver steatosis as evaluated by ultrasound (US). Methods: The study included 86 participants, 55 of whom had fatty liver diagnosed by ultrasound and they comprised the study group. The control group consisted of 31 control subjects. During the course of hospitalization at the Clinic of Gastroenterology and Hepatology, Clinical Centre Nis, the patients had their anamnesis taken, and anthropometric measurements as well as biochemical blood analyses and abdominal ultrasound were performed. Results: The patients with NAFLD had statistically higher values of body mass index (BMI), waist circumference (WC), systolic (SBP) and diastolic blood pressure (DBP), levels of alanin and aspartate aminotransferase (ALT, AST), gamma-glutamyl transpeptidase (GGT) (p<0.001), low-density lipoprotein cholesterole (LDL), total bilirubin (TBIL) (p<0.05), total cholesterol (p<0.01), triglycerides (TGL), urates, C-reactive protein (CRP), ferritin, fibrinogenes, fasting blood glucose (FBG), insulin and Homeostasis Model Assessment (HOMA-IR) (p<0.001), whereas the levels of high-density lipoprotein cholesterol (HDL) were higher in the control group (p<0.05). In the NAFLD group, there were statistically significantly more patients with hypertension (72.73% vs. 12.90%, p<0.001) and type 2 diabetes mellitus (DM) (47.27%). Metabolic syndrome was determined in 48 (87.27%) patients of the study group. An equal number of patients, 16 of them (29.09%), had 3, 4 and 5 components of MS. In the NAFLD group there were 17 overweight (30.91%) (BMI from 25 kg/m2 to 29.9 kg/m2) and 38 (69.09%) obese patients. (BMI ≥ 30.0 kg/m2). The largest number of patients in the obesity group, 22 (40.00%) of them, had the first degree obesity (BMI from 30 kg/m2 to 34.99 kg/m2). The largest number of the NAFLD group patients - 23 (41.82%), had an ultrasound finding of grade 3 fatty liver, 20 patients (36.36%) had grade 2 and 12 (21.82%) grade 1 fatty liver. Kruskal-Wallis test and ANOVA analysis showed statistically significant differences between groups with different US grade for insulin, LDL-cholesterol, WC, BMI (p<0.05), as well as HOMA-IR and body weight (BW) (p<0.01). Metabolic syndrome was statistically more present in patients with US finding grades 2 and 3 (p<0.01) in relation to grade 1 US finding, as well as obesity, hypertension and DM type 2 (p<0.05). Conclusion: The results of our study have confirmed that a high percentage of patients with high risk factors (DM, MS, dyslipidemia, hypertension) have NAFLD.

Treatment of low-grade gastric MALT lymphoma using Helicobacter pylori eradication.

BACKGROUND/AIM: Lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach usually occurs as a consequence of Helicobacter pylori (H. pylori) infection. The aim of this study was to investigate the long-term effect of treatment of low-grade gastric MALT lymphoma with the H. pylori eradication method. METHODS: In the period 2002-2012 in 20 patients with dyspepsia, mean age 55.1 years, the endoscopic and histologic diagnosis of gastric MALT lymphoma in the early stages were made. Histological preparations of endoscopic biopsy specimens were stained with hematoxyllineosin (HE), histochemical and immunohistochemical methods. RESULTS: Endoscopic findings of gastritis were documented in 25% of the patients, and 75% of the patients had hypertrophic folds, severe mucosal hyperemia, fragility, nodularity, exulcerations and rigidity. Histopathologically, pathognomonic diagnostic criterion were infiltration and destruction of glandular epithelium with neoplastic lymphoid cells, the so-called lymphoepithelial lesions. In all 20 patients H. pylori was verified by rapid urease test and Giemsa stain. After the triple eradication therapy complete remission of MALT lymphoma was achieved in 85% of the patients, with no recurrence of lymphoma and H. pyloi infection in the average follow-up period of 48 months. In 3 (15%) of the patients, there was no remission of MALT lymphoma 12 months after the eradication therapy. Of these 3 patients 2 had progression of MALT lymphoma to diffuse large-cell lymphoma. CONCLUSION: Durable complete remission of low-grade gastric MALT lymphoma is achieved in a high percentage after eradication of H. pylori infection, thus preventing the formation of diffuse large-cell lymphoma and gastric adenocarcinoma.

[Comparison of biohumoral and morphological parameters in acute pancreatitis].

INTRODUCTION: Acute pancreatitis occurs as a result of autodigestive activation of pancreatic proenzymes, within the parenchyma of the glands. OBJECTIVE: The goal of the work was to establish possible connection of etiology and severity of the acute pancreatitis and biohumoral parameters, ultrasound and CT. METHODS: The study included 273 patients with pancreatitis, classified by Ranson's score, according to degree of severity and etiology, whose biohumoral parameters were correlated with each other, and with the ultrasound and CT findings. RESULTS: The values of amylase and ALT were significantly higher in the severe form of pancreatitis and biliary etiology compared to etilic (p < 0.05).The ratio of AST/ALT was significantly higher in the group of etilic compared to biliary etiology (p < 0.05). LDH was significantly higher in the severe form group compared to moderate form of pancreatitis (p < 0.01). Cholesterol was significantly higher in the group of biliary compared to the group of etilic pancreatitis (p < 0.05). There was a negative low correlation between the value of calcium ions in the plasma and CT analysis (p = 0.05). Low degree negative correlation between the value of calcium ions and ultrasound analysis was established (p = 0.0001). CONCLUSION: There was a negative correlation between the level of ionized calcium in the blood and the degree of the acute pancreatitis by the Balthazar score. Mean value of alpha amylase, total value of cholesterol and ALT were significantly higher in the group of biliary compared to the group of etilic acute pancreatitis. The average values of the alpha amylase, LDH and ALT were significantly higher in the group of severe form of the acute pancreatitis compared to the group of moderate form. The ratio AST/ALT was significantly higher in the group of etilic than in the group of biliary pancreatitis.

The activities of acid DNase and 5'nucleotidase in erosive reflux esophagitis and Barrett's epithelium.

BACKGROUND/AIMS: The study examines the relationship between activity of acid DNase and 5'nucleotidase (5'NT) and histological changes in reflux esophagitis. METHODOLOGY: Thirty-three patients were examined, 15 of whom with mild esophagitis, 12 with severe esophagitis and 6 with Barrett's epithelium. Patients were classified into 3 groups, according to Ismail-Beigi histological criteria: mild esophagitis group (ME); severe esophagitis group (SE); Barrett's esophagitis group (BE). DNase and 5'NT levels were measured biochemically both in healthy and injured tissue samples. RESULTS: Difference of acid DNase and 5'NT activity in healthy tissue versus injured tissue samples was the lowest in ME group: 0.55±4.47 U/g for acid DNase and 11.56±37.11 U/g for 5'NT, the difference increased to 4.43±1.64 U/g for acid DNase and 105.57±54.11 U/g for 5'NT in the SE group, while 6.07±2.92 U/g for acid DNase and 109.83±14.02 U/g for 5'NT as the highest levels were measured in the BE group. Difference in BE group is statistically significantly higher (p <0.05) compared to the ME group, confirmed by ANOVA with Dunnett's post hoc test. CONCLUSIONS: The study shows significant decrease of apotosis level that is detectable even before metaplasia was morphologically defined.

Correlation of inflammation parameters and biochemical markers of cholestasis with the intensity of lipid peroxidation in patients with choledocholithiasis.

BACKGROUND/AIM: During choledocholitiasis inflammatory oxidant stress involves the promotion of mitochondrial dysfunction through an intracellular oxidant stress in hepatocytes leading mainly to necrosis and less to apoptosis. The product of oxidative stress, malondialdehyde (MDA), is extremely cytotoxic and damages cell membranes and intracellular macromolecules. The toxicity of MDA is based on its ability to act as a mutagenic agent in a cell. Therefore, the aim of this prospective study was to establish correlation of the parameters of inflammation and biochemical markers of cholestasis with the intensity of oxidative stress in pathogenesis of liver function disorders. METHODS: Seventy adult subjects of either sex included in the study were devided into two groups: I--40 patients with obstructive icterus caused by choledocholithiasis, and II--30 healthy individuals. All the participants were subjected to a clinical, laboratory and ultrasonic check-up at the Internal Department of the Military Hospital in Nis. The parameters of oxidative stress: MDA, a measure of lipid peroxidation, and inflammation parameters: C-reactive protein (CRP), fibrinogen, albumins, number of leukocytes (Leu), granulocytes (Gr), lymphocytes (Ly) and monocytes (Mo) and biochemical markers of cholestasis: activity of gamma-glutamyltransferase (gamma-GT) and alkaline phosphatase (AP) enzymes, the level of total, direct and indirect bilirubin were determined by standard biochemical methods. RESULTS: Lower values of albumin (p < 0.001), and significantly higher values of fibrinogen (p < 0.05) and CRP (p < 0.001) were found in the blood of the patients with cholestasis due to choledocholithiasis in relation to the controls. Significantly higher values of Leu (p < 0.01) and Gr (p < 0.001) with decreasing number of Ly (p < 0.001) and Mo (p < 0.001) were found in blood of the patients with cholestasis due to choledocholithiasis in relation to the control. Similarly, higher values of gamma-GT, and AP (p < 0.001), as well as the level of total, direct and indirect bilirubin (p < 0.001) were found in blood of the patients with cholestasis due to choledocholithiasis in relation to the controls. The concentration of MDA (p < 0.001) was increased in the patients with choledocholithiasis in relation to the controls. There was a significant positive linear correlation of the number of leukocytes (r = 0.51, p < 0.05) and the concentration of total (r = 0.87, p < 0.01), direct (r = 0.85, p < 0.01) and indirect (r = 0.88, p < 0.01) bilirubin with the concentration of MDA in the group of patients with choledocholithiasis. CONCLUSION: Neutrophils and the levels of total, direct and indirect bilirubin have a significant positive linear correlation with the level of lipid peroxidation in patients with choledocholithiasis. Neutrophilia and hiperbilirubinemia observed in this way represent important parameters in estimating the level of liver tissue damage in choledocholithiasis.

Celiac disease prevalence in epileptic children from Serbia.

Celiac disease (CD) is a genetically determined autoimmune enteropathy, induced by gluten ingestion. To date, different prevalences of CD in children with epilepsy have been reported. The aim of this study was to determine CD prevalence in our patients with epilepsy, using anti-tissue transglutaminase (tTG) antibodies as a screening test. One hundred twenty-five children (72 girls, 53 boys; age range: 2-18 years, mean age: 10.51 +/- 3.53) with idiopathic epilepsy from South East Serbia were tested for immunoglobulin (IgA) tTG antibodies. All positive patients were offered endoscopic small bowel biopsy. Biopsies were examined histopathologically in order to confirm the CD diagnosis. The control group consisted of 150 healthy children. Three patients with epilepsy were positive for IgA tTG antibodies. In all of them, small bowel biopsy was performed, and only one was proven to have CD by histopathology (Marsh IIIa grade). The prevalence of biopsy-proven CD in children with epilepsy was not significantly higher in the study group compared to controls (0.8% vs.0.6%, p > 0.05). The results of this study indicate that children with idiopathic epilepsy from our region should not be routinely tested for CD.

Esophagitis and almost complete esophageal occlusion in a girl with epidermolysis bullosa.

Epidermolysis bullosa is a genetically transmitted skin disorder that typically manifests with trauma-induced skin blistering, scarring and in some cases mucosal involvement. Esophageal webs, strictures or stenosis can be found in about a third of the patients with the recessive dystrophic type of this disease. We report a six-year-old girl with recessive dystrophic epidermolysis bullosa and progressive dysphagia. Almost complete esophageal occlusion was found on barium swallow and esophagoscopy (endoscopic signs of esophagitis were also seen). She was treated successfully with fluoroscopically guided balloon dilatation and esomeprazole. Fluoroscopically guided balloon dilatation and postdilatation use of esomeprazole is a safe and effective therapy for recessive dystrophic epidermolysis bullosa patients with almost complete esophageal occlusion and esophagitis.

Rapunzel syndrome.

INTRODUCTION: Trichobezoars are foreign bodies in gastrointestinal tract, composed of hair. They occur mainly in children and adolescents suffering from trichotillophagia. They commonly occur in the stomach, but as they enlarge over time, they can extend through the pylorus into distal parts of the small intestine resembling a tail. This rare form of trichobezoar is named Rapunzel syndrome. CASE REPORT: We presented a 19-year-old female patient, who suffered from trichotillomania and trichotillophagia, which led to trichobezoar formation. Intra-abdominal tumour was suspected after initial clinical examination. Abdominal echosonography, endoscopy and abdominal computed tomography (CT scan) in the pre-operational period revealed trichobezoar formation. The patient was operated on and subjected to further psychiatric treatment. CONCLUSION: Trichobezoar should be differentially diagnostically taken into consideration in younger women with abdominal pain, nausea, vomiting, palpable abdominal mass and psychiatric disorders. Most trichobezoar cases require surgical treatment, whereas the patients need long-term psychiatric treatment and monitoring.

Importance of certain pro-inflammatory indices in patients with liver cirrhosis and bacterial infection on prognosis and course of the disease.

INTRODUCTION: Certain pro-inflammatory indices serum levels, such as leucocytes count and C-reactive protein appears to be a significant and simple clinical tool in prediction of unfavorable course of liver cirrhosis, its complications due to the bacterial infections, length ofhospitalisation and lethal outcome. Cirrhotic patients often have a complications due to bacterial infection, demanding the unexpected need for hospitalization in 30% to 50% of the cases. THE AIM of this study was to assess the impact of pro-inflammatory indices in patients with liver cirrhosis, in relation to bacterial infection and their evaluation as possible prognostic factors on functional liver deterioration, length of hospitalization and lethal outcome. MATERIAL AND METHODS: The research was conducted as a prospective study, on 120 patients with liver cirrhosis, who were in divided into two groups: I-experimental one of 60 patients with bacterial infection and II-control one of 60 patients, with no infectious complications diagnosed end treated in period 2005.-2010. Year. RESULTS: Most of the patients of experimental group were in C stage of disease, compared to those in the control one (p < 0.001). They had also, initially significantly higher increased values of pro-inflammatory indices, which were significantly reduced during the treatment (p < 0.001), with average longer length of hospitalisation and lethal outcome (p < 0.001; p < 0.01). CRP and the Le count values were most significant predictive factors for length of hospitalisation and lethal outcome. DISCUSSION: Pro-inflammatory indices values may predict an unfavorable course and lethal outcome in cirrhotic patients with bacterial infections. Prevention of bacterial infection in those patients improves their long-term survival, achieving the slower course of the underlying disease.

Narrow band imaging versus conventional white light colonoscopy for the detection of colorectal polyps.

BACKGROUND: It has been suggested that narrow band imaging colonoscopy (NBI) might be better for detection of colorectal polyps than white light colonoscopy (WLC). OBJECTIVES: To compare standard or high definition white light colonoscopy with narrow band imaging colonoscopy for detection of colorectal polyps. SEARCH METHODS: We searched The Cochrane Library, MEDLINE, and EMBASE to August 2011. We scanned bibliographies of relevant publications and wrote to experts for additional trials. SELECTION CRITERIA: Two authors (NA and GB) independently applied the inclusion criteria and extracted the data to all potential studies without blinding. DATA COLLECTION AND ANALYSIS: Authors extracted data independently. Trials with adequate randomisation, allocation concealment, and complete outcome data reporting, as well as without selective outcome reporting or other bias were classified as having a lowest risk of bias. Random-effects and fixed-effect meta-analyses were conducted. MAIN RESULTS: We identified 11 randomised trials comparing WLC with NBI for detection of colorectal polyps. In total eight randomised trials with 3673 participants provided data for our analyses. There was no statistically significant difference between WLC (standard definition and high definition pooled) and NBI for the detection of patients with colorectal polyps (6 trials, n = 2832, RR 0.97, 95% CI 0.91 to 1.04), patients with colorectal adenomas (8 trials, n = 3673, RR 0.94, 95% CI 0.87 to 1.02), or patients with colorectal hyperplastic polyps (2 trials, n = 645, RR 0.87, 95% CI 0.76 to 1.00). Number of patients with at least one colorectal adenoma was not significantly different between WLC and NBI group irrespective of adenoma size (< 5 mm:RR 0.95, 95% CI 0.84 to 1.08, I(2) = 56%; 6 to 9 mm: RR 1.06, 95% CI 0.81 to 1.39, I(2) = 0%; ≥ 10 mm: RR 1.06, 95% CI 0.77 to 1.45, I(2) = 0%). Number of patients with at least one colorectal polyp, or colorectal adenoma was significantly lower in the standard definition WLC group compared to NBI group in fixed-effect meta-analysis (RR 0.87, 95% CI 0.78 to 0.97, I(2) = 78%; RR 0.87, 95% CI 0.77 to 0.99, I(2) = 0%, respectively), but not significantly different in random-effects meta-analysis (RR 0.86, 95% CI 0.68 to 1.10, I(2) = 78%). There was no statistically significant difference between high definition WLC and NBI in the number of patiens with at least one colorectal polyp or colorectal adenoma (RR 1.10, 95% CI 0.95 to 1.28; RR 0.87, 95% CI 0.77 to 0.99, I(2) = 0%, respectively). AUTHORS' CONCLUSIONS: We could not find convincing evidence that NBI is significantly better than high definition WLC for the detection of patients with colorectal polyps, or colorectal adenomas. We found evidence that NBI might be better than standard definition WLC and equal to high definition WLC for detection the patients with colorectal polyps, or colorectal adenomas.

[Endoscopic mucosal resection of colorectal tumors--our first experience].

BACKGROUND/AIM: Endoscopic mucosal resection (EMR) or mucosectomy is an interventional procedure for minimal invasive endoscopic removal of benign and malignant digestive tract tumors. Mucosectomy removes flat and sessile neoplasms, early colorectal cancer (CRC) confined to mucosa or submucosa and lateral spreading tumors. The aim of the study was to show our first experience in application of this procedure in everyday practice in regarding completeness and efficacy of the procedure, complication rate and incidence of recurrent adenomas. METHODS: In the prospective study 51 colorectal adenomas were removed in 44 patients by EMR. RESULTS: Single mucosectomy was done in 43 patients, while multiple (8) in one patient. Complete resection was obtained in all procedures. In 36 (68.62%) procedures "en block" resection was done, but in 15 (31.37%) procedures "piece meal" resection was performed. Synchronous colorectal tumors (benign or malignant) were detected in 20 (45.45%) patients. Moderate dysplasia was found in 30 (58.82%) adenomas, but high grade dysplasia in 9 (17.64%) of adenomas. Intramucosal CRC was detected in 11.77% of adenomas. A total of 37 (72.54%) advanced adenomas were removed. There were 3 (5.88%) of recurrent adenomas, 6-30 months after the EMR. Only one (2.2%) case of post procedure bleeding was observed. CONCLUSION: EMR is a safe and efficious method for removal of flat, sessile adenomas, as well as early CRC. EMR is a routine endoscopic procedure in everyday practice of interventional endoscopist.

[Prediction of renal dysfunction in patients with obstructive icterus].

INTRODUCTION: Renal dysfunction is one of complications in patients with obstructive icterus. It is important to recognize it early and take adequate measure to prevent its occurrence. One third of the patients with obstructive icterus have deterioration of renal function before surgical intervention. The aim of the research was to assess the renal dysfunction markers in patients with obstructive icterus. The following factors were examined: diuresis, urinary sodium concentration, sodium excretory fraction, urine osmolality, osmotic concentration index, creatinine concentration index and renal index of lesion. MATERIAL AND METHODS: The study included 85 patients with obstructive icterus (50 patients before surgical intervention and 35 after surgical intervention) and 30 patients without icterus as a control group. The patients with normal renal function before the development of the disease were included. RESULTS: Malignant etiology was present in 39 patients and benign in 46 patients of the examined group. The evaluation parameters (of renal function were examined in all of the patients. Creatinine concentration index led to the greatest change in the coefficient value of an internal consistency, showing that it was the best renal function marker in the examined group of patients with icterus. The next one was the urinary osmolality, since its exclusion would lead to a decrease in the value of Cronbach a coefficient to 0.06. Icterus and surgical intervention show statistically significant effects to change in the value of the markers of laboratory differentiation of renal function, observed as an entire set. DISCUSSION AND CONCLUSION: The examination showed that the concentration clearances of creatinine and urine osmolality are the parameters which point to the probability of renal dysfunction occurrence in obstructive icterus.

Antioxidant supplements for liver diseases.

BACKGROUND: Several liver diseases have been associated with oxidative stress. Accordingly, antioxidants have been suggested as potential therapeutics for various liver diseases. The evidence supporting these suggestions is equivocal. OBJECTIVES: To assess the benefits and harms of antioxidant supplements for patients with liver diseases. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science to January 2011. We scanned bibliographies of relevant publications and asked experts and pharmaceutical companies for additional trials. SELECTION CRITERIA: We considered for inclusion randomised trials that compared antioxidant supplements (beta-carotene, vitamin A, C, E, and selenium) versus placebo or no intervention for autoimmune liver diseases, viral hepatitis, alcoholic liver disease, and cirrhosis (any aetiology). DATA COLLECTION AND ANALYSIS: Four authors independently selected trials for inclusion and extracted data. Outcome measures were all-cause mortality, liver-related mortality, liver-related morbidity, biochemical indices at maximum follow-up in the individual trials as well as adverse events, quality-of-life measures, and cost-effectiveness. For patients with hepatitis B or C we also considered end of treatment and sustained virological response. We conducted random-effects and fixed-effect meta-analyses. Results were presented as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). MAIN RESULTS: Twenty randomised trials with 1225 participants were included. The trials assessed beta-carotene (3 trials), vitamin A (2 trials), vitamin C (9 trials), vitamin E (15 trials), and selenium (8 trials). The majority of the trials had high risk of bias and showed heterogeneity. Overall, the assessed antioxidant supplements had no significant effect on all-cause mortality (relative risk [RR] 0.84, 95% confidence interval [CI] 0.60 to 1.19, I(2) = 0%), or liver-related mortality (RR 0.89, 95% CI 0.39 to 2.05, I(2) = 37%). Stratification according to the type of liver disease did not affect noticeably the results. Antioxidant supplements significantly increased activity of gamma glutamyl transpeptidase (MD 24.21 IU/l, 95% CI 6.67 to 41.75, I(2) = 0%). AUTHORS' CONCLUSIONS: We found no evidence to support or refute antioxidant supplements in patients with liver disease. Antioxidant supplements may increase liver enzyme activity.

Irritable bowel syndrome, anxiety, depression and personality characteristics.

BACKGROUND: Numerous studies have suggested that 54%-100% of patients with IBS may have associated psychiatric illness and personality pathology. This transversal controlled study was realized in order to evaluate anxiety and depression levels, as well as the personality characteristics of patients with IBS and to compare the results obtained with patients with episodes of depression and healthy individuals. SUBJECTS AND METHODS: The experimental group consisted of 30 IBS patients, while two control groups consisted of the same number of inpatients with episodes of depression and healthy individuals from the general population. There were equal number of men and women in the study sample and all subjects were aged between 25 to 65 years. Standard psychometric instruments employed included Hamilton anxiety scale, Zung depression scale, Hamilton depression scale, Minnesota Multiphasic Personality Inventory (MMPI), Eysenck Perosonality Inventory (EPI). RESULTS: The average Hamilton and Zung depression scores were significantly higher in patients with depressive episodes compared with the IBS patients, while the mentioned scores among them were also significantly higher compared with the healthy controls. There were no significant differences between IBS and the group with depressive episodes in the average Hamilton anxiety levels, EPI neuroticism and extraversion levels and MMPI neurotic scales levels (Hs, D, and Hy). The significant differences were observed comparing the IBS patients to healthy individuals. CONCLUSION: The patients suffering from irritable bowel syndrome who asked for medical help (consulters) because of their intestinal symptoms, presented emotional problems such as depression and anxiety and expressed neurotic personality characteristics.

[Synchronous colorectal adenomas].

INTRODUCTION: Colorectal adenomas which are discovered simultaneously or 6 months after the diagnosis of primary adenoma or colorectal cancer (CRC) are called synchronous adenomas. The presence of synchronous adenomas increases the probability of adenomas with severe dysplasia as well as CRC. OBJECTIVE: The aim of the study is to show the characteristics of synchronous colorectal adenomas and to present the relation between the index rectal adenoma and the proximal synchronous tumours. METHODS: The research included 114 synchronous colorectal adenomas diagnosed in 58 patients. Total colonoscopy was performed on all patients. RESULTS: The largest number of patients had two adenomas (p < 0.001). Synchronous adenomas were more often diagnosed in men older than 50 (p < 0.001). The largest number of adenomas was localized in the sigma (52 patients, 43.0%) (p < 0.001). The biggest number of tumours was localized in the combination of rectum-sigma segments (p < 0.001). There were 31 (25.6%) synchronous, that is index tumours of the rectum and 90 (74.4%) the so-called proximal synchronous tumours of the proximal part of the colon. In 33 (56.9%) patients, who did not have the index tumour, the prevalence of proximal synchronous tumours was the highest (57.0%) (p < 0.001). CONCLUSION: The probability of adenoma multiplication is higher in men, and it increases with age. Beside the fact that synchronous adenomas are more often found distally, a great probability of finding proximal tumours shows that total colonoscopy is the method of choice for the discovery of colorectal tumours. Complete colonoscopic mapping of all colorectal adenomas and their removal prevents the development of metachronous, overlooked benign CRC already present at the moment of initial diagnostics that could be the cause of the development of metachronous CRC.