[Bleeding oesophageal varices--therapeutic options].

INTRODUCTION: Emergency endoscopy plays the most important role in diagnosis and treatment of patients with esophageal variceal bleeding. Endoscopic sclerotherapy (EST), placement of esophageal band ligatures (EVL), medicamentous treatment using somatostatin and its derivatives and balloon tamponade are the methods most frequently applied in treatment of the bleeding esophageal varices. PATIENTS AND METHODS: Endoscopic reports on the patients with bleeding esophageal and gastric varices were retrospectively analyzed in the emergency unit of the Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia over the five-year period--since January 2001 till December 2005. RESULTS: The total of approximately 3, 954 emergency upper endoscopies were performed due to the upper gastrointestinal tract bleeding. Out of the total number of patients, bleeding was diagnosed in 324 (8.2%) patients due to the esophageal varices. In the group of patients with bleeding esophageal varices, the total of 252 (77.8%) males and 72 (22.2%) females averagely aged 56.8 + 7.5 years (range 24 - 80 years) were examined. The primary sclerosant therapy with absolute alcohol was applied in 118 (36.4%) patients, while Blakemore probe tamponade was performed in 145 (44.8%) patients with bleeding esophageal varices. The total of 240 (74.1%) patientswere treated with vasoactive substances (somatostatin and its analogues), as additional therapy and control of the primary hemostasis. It was evidenced that out of 118 patients intra and paravariceally treated with the sclerosant agent (absolute alcohol) hemostasis was achieved in 47 (39.8%). Out of 145 patients subjected to Blakemore probe placement, bleeding was successfully arrested in 117 (80.7%) patients. Somatostatin and its analogues as primary and only treatment of the bleeding esophageal varices were applied in 71 (29.6%) patients, while in the remaining 169 (70.4%) patients, they were applied as additional therapy to the endoscopic sclerotherapy and mechanical treatment of bleeding. Out of 71 patients treated with somatostatin preparations as the only therapeutic option, 45 (63.4%) responded positively by arrest of bleeding for 72 hours. CONCLUSION: Treatment of the acute bleeding esophageal varices is focused on the arrest of bleeding, prevention of early recurrent bleeding and reduction of mortality. Based on the most recent studies, efficacy of the modern endoscopic therapy in the form of sclerotherapy and band ligature placement, as well as application of vasoactive substances reaches up to 90%. Our results evidence minimal efficacy of the sclerotherapy (approximately 40%), which indicates the need of better preparation of patients for the intervention itself and additional education of the personnel.

[Endoscopic ultrasound (EUS) in initial assessment and follow-up of patients with MALT lymphoma treated drug therapy].

BACKGROUND: Endoscopic ultrasonography (EUS) is an important tool for diagnosis and pretreatment staging of primary gastric lymphoma. The aim of the study was to evaluate the diagnostic importance of endosonography (EUS) in gastric lymphoma; to assess the depth of tumoral infiltration in low-grade gastric lymphoma of mucosa-associated lymphoid tissue (MALT) and to assess EUS response to medical treatment (Cyclophosphamid/Mabtera and/or anti-Helicobacter pylori therapy). METHODS: 26 patients with MALT gastric lymphoma were investigated by EUS. Six of them were evaluated after the eradication of Helicobacter pylori infection and 20 after and during the cyclophosphamide/Mabtera and anti H. pylori treatment. EUS staging was compared with histopathology. Tumours were staged according to the 2000 TNM and modified Ann Arbor classification. RESULTS: Six patients were treated with anti - Helicobacter pylori eradication therapy. Full regression of lymphoma was observed in 2 of 6 (33.3%) patients, which was endoscopicaly and histologicaly proved. EUS correlated with histology in all (6/6). In 20 patients treated with cyclophosphamide/Mabtera therapy, EUS revealed regression of lymphoma in 14 cases. Positive correlation with histology was found in 11 patients (11/14; 78%). The initial EUS showed an increased wall thickness more than 5mm in 24 of 26 patients (92%). The thickening was predominantly of mucosa and submucosa and in 11 patients extended the muscularis propria. After the therapy, the gastric wall thickening returned to normal in 14 patients, however, 3 of them still had positive histology findings. In 2 cases, during the follow-up, the EUS showed remained thickening of gastric wall, whereas biopsies were negative. Six months later histology revealed progressive low-grade MALT lymphoma in this cases. CONCLUSION: EUS appears to be a sensitive procedure for initial staging and assessment of treatment response and long-term follow up in patients with gastric lymphoma. The importance of EUS lies in abbility to detect relapse early, too.