[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.

[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.

[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.

Clinical onset of the Crohn's disease after eradication therapy of Helicobacter pylori infection. Does Helicobacter pylori infection interact with natural history of inflammatory bowel diseases?

BACKGROUND: There are conflicting reports concerning the prevalence of Helicobacter pylori infection in patients with inflammatory bowel diseases: some studies connected Sulphasalazine therapy and lower incidence of Helicobacter pylori infection, but others showed lower prevalence of Helicobacter pylori infection in inflammatory bowel diseases despite the choice of therapy. CASE REPORT: A 28-year-old male patient presented in January 1996 with the symptoms of ulcer like dyspepsia. There was no significant abnormality on physical examination, laboratory testing and abdominal ultrasound. Histology examination of the biopsy specimen taken during the upper endoscopy revealed Helicobacter pylori associated active gastritis only in the corporal part of the stomach. After two weeks eradication therapy (Omeprazole, Amoxicillin) he was well. Three months later, at the control endoscopy, granulomatous gastritis of the corporal localization was detected, without Helicobacter pylori present. Antral mucosa appeared normal, both, on endoscopy and histology examination. In July 1996 he started with cramping abdominal pain, mild periodical fever and episodes of watery diarrhea. In laboratory results we found nonspecific signs of inflammation. We repeated upper endoscopy, colonoscopy and enteroclysis--with evidence of segmental stenotic lesions of the upper part of ileum and jejunum. Again, we confirmed granulomatous gastritis and small granuloma in the proximal jejunum. After starting the 5-ASA therapy in combination with Metronidazol, patient was better clinical condition, and laboratory results were normal. We suggested mesalamine maintenance therapy 1 gr. every day, and three years later he is well, in clinical remission of Crohn's disease. CONCLUSION: The clinical course of the Crohn's disease maybe "sui generis" connected with Helicobacter pylori infection- but the exact mechanisms remain to be discovered.

Computerized planimetry of normal and abnormal postmortem pancreatograms.

The aim of this study was to evaluate postmortem pancreatograms by means of computerized planimetry of the ductal drainage area. This method was applied to a total of 136 pancreatograms from autopsy specimens of the human duodenopancreas, with and without pathological changes. The mean value of the total ductal drainage surface area was 5,054 mm2 for normal specimens and 3,938 mm2 in cases with chronic pancreatitis; this difference was statistically highly significant. The analyses also included measuring the accessory duct drainage area (if an accessory duct was present), and the percentage of its share in the total gland area. This share was significantly larger in cases with chronic pancreatitis (24.4%) in comparison to the normal specimens (16.8%). In conclusion, computerized planimetry of pancreatograms supplies valuable data not only on the pathogenesis of chronic inflammation of the gland, but also on some of the possible predisposing factors for this condition.

[Endoscopy in inflammatory bowel disease]. / Endoskopija u inflamatornim bolestima creva.

Fiberoptic endoscopy is well established, safe and accurate for diagnosis and management of inflammatory bowel disease (IBD). Direct visualization of the mucosa and biopsy of suspected abnormalities are possible. The principal applications of endoscopy in IBD include discrimination of Crohn's disease from ulcerative colitis of o other inflammatory conditions (acute infectious colitis, chronic infections, microscopic colitis, ischemic/radiation colitis, colitis induced by NSAID), delineation of the sites of disease or extent, grading of endoscopic disease severity, and confirmation of complications such as stricture, fistula or mass. Finally, diagnosis of pouchitis, surveillance to detect precancer, or therapeutic interventions such as dilatation of strictures of electrocautery of bleeding sites are also important endoscopic applications.

Cardiovascular evaluation of the worker and workplace: a practical guide for clinicians.

Unlike several other branches of medicine (e.g., pulmonology), primary cardiology has yet to fully develop a discipline of occupational cardiology. The authors outline an approach for including a focused occupational history in the CV work-up and present a graded, risk-stratified algorithm for occupational cardiologic assessment. This work-up can help clinicians make specific recommendations concerning working conditions, as these impact upon the patient's CV status.

Relationship between enterogastric reflux estimated by scintigraphy and the presence of Helicobacter pylori.

The aim of the study is assessment of the relationship between enterogastric reflux and the presence of Helicobacter pylori infection as factors that cause gastritis, peptic ulcer and adenocarcinoma ventriculi. The study was performed in 52 patients with different digestive disorders, using gamma camera, during 90 min (1 frame/min) after intravenous injection of 185 MBq 99mTc-dietil IDA in the cubital vein. According to time/activity curves from the region of hepatobiliary system and stomach, index of enterogastric reflux (EGR) was assessed. There was no correlation between the presence of Helicobacter pylori and EGR (r = 0.181, df = 52, p > 0.05). However, Helicobacter pylori was present more frequently in the patients with positive EGR (p < 0.01), but there were no significant differences (p > 0.05) in reflux value in patients with either positive or negative findings of Helicobacter pylori.

[The presence and significance of Helicobacter pylori in patients with enterogastric reflux]. / Prisustvo i znacaj helikobaktera pilori kod bolesnika sa enterogastricnim refluksom.

The aim of the study is assessment of the relationship between enterogastric reflux and the presence of Helicobacter pylori infection as a factors that cause gastritis, peptic ulcer and adenocarcinoma ventriculi. The study was performed in 52 patients with different digestive disorders, using gamma camera, during 90 minutes (1 frame/min) after intravenous injection of 185 MBq 99mTc-dietil IDA in cubital vein. According to time activity curves from the region of hepatobiliary system and gaster, index of enterogastric reflux was assessed (EGR). There is no correlation between the presence of Helicobacter pylori and EGR (r = 0.181, DF = 52, P < 0.05). However, Helicobacter is present more frequently in the patients with positive EGR (p 0.01). However, there is no significant difference (p < 0.05) in reflux value in patients with both positive and negative finding of Helicobacter.

Endoscopic biliary manometry in cholecystectomized patients with and without choledocholithiasis.

BACKGROUND/AIMS: Direct study of the function of the sphincter of Oddi became possible recently with the advent of endoscopic manometry. A dysfunction of the bilio-pancreatic sphincter apparatus has been implicated in some bilio-pancreatic disorders. The purpose of this study was to examine the relation between dysfunction of the sphincter of Oddi and the formation of common bile duct stones. METHODOLOGY: Endoscopic biliary manometry was performed on 45 cholecystectomized patients. Endoscopic retrograde cholangiography showed choledocholithiasis in 26 patients while 19 patients were free of common bile duct stones. Nine healthy subjects served as controls. RESULTS: Manometric investigation showed a significant increase in the percentage of retrograde phasic contractions of the sphincter of Oddi (SO) in patients with choledocholithiasis compared to the control group (p < 0.05). Also, a significantly higher frequency of SO phasic contractions was found in the group of patients with choledocholithiasis when compared to the cholecystectomized group without common bile duct stones (p < 0.05), but there was no difference when compared with the control group. Markedly increased SO basal pressure was found in 5 patients with choledocholithiasis as well as in one cholecystectomized patient without choledocholithiasis (greater than x + 3SD). However, the SO basal pressure, phasic SO pressure, amplitude and duration of the phasic contractions as well as the choledochal pressure did not differ significantly between the groups. CONCLUSIONS: This study demonstrates manometric abnormalities in the SO of patients with choledocholithiasis which suggests that SO dysfunction and pathophysiological mechanisms are related to the formation of common bile duct stones.

Endoscopic manometry of the sphincter of Oddi and pancreatic duct in patients with chronic pancreatitis.

CONCLUSION: Endoscopic manometry in patients with chronic pancreatitis has demonstrated some manometric abnormalities in the sphincter of Oddi, but these abnormalities have no significant role in the pathogenesis of chronic pancreatitis. BACKGROUND: The study was undertaken to determine whether the sphincter of Oddi dysfunction plays a significant role in the pathogenesis of chronic pancreatitis. METHODS: Manometric investigation was performed in 32 patients with chronic pancreatitis. Twenty-three of them had alcohol-induced chronic pancreatitis, seven had biliary pancreatitis, and two patients had annular pancreas with chronic pancreatitis. Fifteen of them had dilated main pancreatic duct. Twenty-one cholecystectomized patients with no abnormality of the pancreas and biliary system served as controls. RESULTS: This study showed no significant difference in the mean pressures in the pancreatic duct, sphincter of Oddi (basal and phasic), and frequency of the sphincter of Oddi phasic contractions when comparing patients and controls. Sphincter of Oddi basal pressure (26-44 mmHg) was markedly increased in seven patients, whereas three patients (two of them had increased sphincter of Oddi basal pressure) had increased pancreatic duct pressure (20-24 mmHg). Increased numbers of retrograde contractions were found in seven patients.

Exercise testing of young, apparently healthy professional drivers.

OBJECTIVES: The purpose of this study was to examine the responses of young, apparently healthy professional drivers to exercise testing. METHODS: A bicycle exercise test was performed by a randomly selected group of 42 apparently healthy, male professional drivers aged 20 to 40 years and a group of 30 building workers, who formed a reference group. RESULTS: The mean maximal exercise level was significantly lower for the drivers [139 (SD 32) W] than for the referents [155 (SD 31) W] (P < 0.05). The mean systolic blood pressure and heart rate did not differ significantly between the groups at the end of the exercise, but the mean double product was significantly higher for the drivers. The mean diastolic blood pressure at the end of the exercise was 97 (SD 14) mm Hg [12.9 (SD 11.9) kPa] for the drivers and 79 (SD 19) [10.5 (SD 2.5) kPa] for the referents (P < 0.01). The exercise was stopped due to diastolic hypertensive reactions [diastolic blood pressure > 115 mm Hg (> 15.3 kPa)] in 13 (31%) of the drivers and 3 (10%) of the referents (P < 0.05). Eight of the thirteen drivers with a hypertensive reaction had three or more cardiac risk factors. CONCLUSIONS: There seems to be a high occurrence of diastolic hypertensive reactions to exercise among professional drivers. These reactions may be associated with risk of ischemic heart disease and hypertension. Further exercise testing of professional drivers is warranted. More sensitive methods may be indicated in selected cases, since the cardiovascular status of this cohort is a vital concern with respect to traffic safety.

Ductal morphometry of ventral pancreas in pancreas divisum. Comparison between clinical and anatomical results.

Aim of the investigation is to precisely study the morphological features of ventral pancreas ductography in pancreas divisum, in order to improve the radiological interpretation and differential diagnosis of this frequent pancreatic anomaly. The clinical part of the study was based on 610 endoscopic retrograde pancreatograms, with pancreas divisum diagnosed in 14 (2.3%) cases; while the anatomical part consisted of 203 postmortem pancreatograms of human pancreas obtained at autopsy, where pancreas divisum was found in 12 (5.9%) cases. The following ductal features of the ventral pancreas were studied: length and calibre of the main duct, number of side branches, calibre of the common bile duct and the biliopancreatic junction angle. No significant differences were detected between the results from the 2 groups, with the exception of side branches, which were more numerous in the anatomical series, probably because of higher injection pressure and consequent better opacification. These results underline the potential of the anatomical pancreatography serving as a model for studying the ductal system of pancreas divisum.

Endoscopic manometry of the sphincter of Oddi in sphincterotomized patients.

BACKGROUND/AIM: Endoscopic sphincterotomy (ES) of the sphincter of Oddi (SO) has been accepted as an effective method in extraction of common bile duct stones in postcholecystectomy patients. The purpose of this study was to examine the completeness of the performed ES and observe the post sphincterotomy pancreatic duct sphincter (PDS) activity using endoscopic manometry. MATERIALS AND METHODS: Activity of the sphincter of Oddi was examined in 15 sphincterotomized patients using endoscopic manometry one to 2.5 years after endoscopic sphincterotomy for choledocholithiasis. RESULTS: In eight patients absence of choledochoduodenal gradient, baseline pressure and the sphincter of Oddi phasic activity up to 2.5 years after endoscopic sphincterotomy indicated a complete sphincterotomy. In seven patients with incomplete endoscopic sphincterotomy, manometry exhibited either a lower choledochoduodenal gradient and baseline pressure without phasic activity of the sphincter of Oddi (three patients), a sphincter of Oddi activity without choledochoduodenal gradient (one patient), or a complete restitution of the sphincter of Oddi activity 1 to 2 years after endoscopic sphincterotomy (three patients). In five patients, with complete endoscopic sphincterotomy, measurements of pancreatic sphincter activity showed lower values of the pancreatic ductal pressure and baseline pressure, while the pancreatic sphincter phasic activity was equal to that found in the control group. CONCLUSIONS: Endoscopic manometry is method which enables us to test the completeness of endoscopic sphincterotomy and to follow the restitution of the phasic contractile function of the sphincter. Manometric findings reveal pancreatic sphincter in most patients as a separate sphincteric entity, the function of which is reduced but not eliminated by a complete endoscopic sphincterotomy.

Event-related potentials in professional city drivers: heightened sensitivity to cognitively relevant visual signals.

Event-related potentials to visual stimuli were recorded in 24 healthy, young subjects: 15 professional Belgrade city drivers and nine nondriver controls (no amateur driving experience) during a tacitly neutral GO:NOGO CNV paradigm and during one which explicitly mimicked heavy traffic conditions. In both paradigms GO S1 was a 30 ms red light, NOGO S1 a green light of equal duration; S2 was, in both cases, a yellow light presented 1.5 s post-S1. Overall, the early and late CNV for GO conditions were significantly larger (more negative) than for NOGO. This GO:NOGO difference was accentuated in drivers, as seen by a significant group-condition interaction using analysis of variance. The mean late CNV was significantly greater in drivers compared to controls: for GO at Cz during the neutral paradigm -12.9 vs. -5.0 microV, respectively, and for the traffic paradigm -14.4 vs. -6.0 microV. There were no significant differences in the CNV between the neutral and the traffic paradigms in either group. The pattern of CNV response seen in these professional Belgrade city drivers seems to suggest a heightened sensitivity to the cognitive significance of visual stimuli. To our knowledge, event-related potentials are applied here for the first time in professional drivers, a cohort known to have a high incidence of psychosomatic disorders, presumably related to the demands made upon them by their occupation. Further investigation using such objective electrophysiologic methods is clearly warranted in this high-risk group.