Falk Symposium 185
Falk Symposium
185
Interfaces and Controversies in Gastroenterology October 3 – 4, 2012 Congress Center Mainz Mainz, Germany
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Abstracts of Invited Lectures Poster Abstracts
Falk Symposium 185
INTERFACES AND CONTROVERSIES IN GASTROENTEROLOGY
Mainz (Germany) October 3 – 4, 2012
Scientific Organization: C. Ell, Wiesbaden (Germany) P.R. Galle, Mainz (Germany) J. Mössner, Leipzig (Germany) C. Meyenberger, St. Gallen (Switzerland) S.J. Spechler, Dallas (USA) H. Yamamoto, Kawachi (Japan)
CONTENTS
page Session I
Esophagus Chair: P. Bhandari, Cosham C. Ell, Wiesbaden D. Lorenz, Wiesbaden Eosinophilic esophagitis: A bulk of mysteries A. Straumann, Olten Barrett’s esophagus: The American perspective S.J. Spechler, Dallas
17
18 – 19
Barrett’s esophagus (non-neoplastic/neoplastic) – The European perspective O. Pech, Wiesbaden
20
Advanced esophageal cancer – Evolution and surgical options and outcomes D.E. Low, Seattle
21
Advanced esophageal cancer – Radiochemotherapy C. Rödel, Frankfurt
22
Session II
Stomach Chair: T. Hauge, Oslo M. Jung, Mainz A. Repici, Rozzano Helicobacter pylori: Kill or leave it P. Malfertheiner, Magdeburg
25
Early stomach cancer: Limits of detection and endoscopic resection H. Yamamoto, Kawachi
26
MALT-lymphoma: Forget surgery? W. Fischbach, Aschaffenburg
27 3
Session III
Pancreas Chair: D. Lorenz, Wiesbaden J. Mössner, Leipzig Autoimmune pancreatitis: Avoid surgery by improved diagnosis S.T. Chari, Rochester
31
Chronic pancreatitis – Conservative options M. Löhr, Stockholm
32
Acute/Chronic pancreatitis: Surgical options (No abstract) H. Zirngibl, Wuppertal Pancreatic cancer: Are there any limits? T. Hackert, M.W. Büchler, Heidelberg
33 – 34
Session IV
Small Bowel Chair: M. Löhr, Stockholm H. Yamamoto, Kawachi Gluten-free diets: When should we use them? C.J.J. Mulder, Amsterdam Modern imaging techniques: Which – when – why A. May, Wiesbaden
Faculty Endoscopy Team HSK Wiesbaden, Endoscopy Team University Mainz, Endoscopy Team Catholic Hospital Mainz International Faculty P. Bhandari, Cosham (Great Britain) T. Hauge, Oslo (Norway) M. Löhr, Stockholm (Sweden) C. Meyenberger, St. Gallen (Switzerland) C.J.J. Mulder, Amsterdam (The Netherlands) A. Repici, Rozzano (Italy) J. Spicák, Prague (Czech Republic) H. Yamamoto, Kawachi (Japan) 4
37 – 38
39
Session V
LIVE-Demonstration Chair: C. Ell, Wiesbaden T. Hauge, Oslo C.J.J. Mulder, Amsterdam
Session VI
LIVE-Demonstration Chair: M. Jung, Mainz C. Meyenberger, St. Gallen A. Repici, Rozzano
Session VII
Large Bowel Chair: P.R. Galle, Mainz J.F. Riemann, Ludwigshafen H. Zirngibl, Wuppertal Appendicitis/diverticulitis: Diagnostics and conservative treatment W. Kruis, Cologne
43
Appendicitis/diverticulitis: Minimal-invasive surgery D. Mutter, J. Marescaux, Strasbourg
44
Serrated polyposis syndrome (SPS) E. Dekker, Amsterdam
45
Colorectal cancer prevention: What is the best? N. Arber, Tel Aviv
46 – 47
Presentation of Poster Prizes C. Ell, Wiesbaden
5
Session VIII
IBD Chair: A. Dignass, Frankfurt R. Kiesslich, Mainz C. Meyenberger, St. Gallen Staging and surveillance: What is the standard of care? R. Kiesslich, Mainz
51
Step down or step up in Crohn’s disease? G. Rogler, Zurich
52
Colitis ulcerosa: Current and future treatment strategies B. Siegmund, Berlin
53
List of Chairpersons, Speakers and Scientific Organizers
6
55 – 57
Poster Abstracts 1.
Endoscopic band ligation versus injection sclerotherapy of bleeding internal haemorrhoids in patients with liver cirrhosis A. Awad, H. Soliman, S. Abou Saif, A.M. Nooman, S. Mosaad, A. Elfert, M. Sharaf-Eldin (Tanta, EG)
2.
The anti-Helicobacter pylori therapy in gastric extranodal marginal impact zone B-cell lymphoma of MALT D. Badea, M. Badea, A. Genunche-Dumitrescu, A. Badea (Craiova, RO)
3.
Extranodal non-Hodgkin's lymphomas of gastrointestinal tract M. Badea, D. Badea, A. Genunche-Dumitrescu, A. Badea, D. Iordache (Craiova, RO)
4.
Terminal ileum lymphoma – Case report A. Bartkova, M. Liberda (Valasske Mezirici, CZ)
5.
Whether the existence of fat in the liver increases the risk of cancer and operation M. Basaranoglu (Istanbul, TR)
6.
Features of the Crohn's disease in Transylvania in the last 10 years S. Bataga, I. Torok, D. Georgescu, M. Macarie, T. Bataga (Tirgu Mures, RO)
7.
Whipple's disease: A challenge of clinical, histopathological and electronomicroscopical diagnosis. Experience of a Romanian Tertiary Center – A five-case series with long-term follow-up G. Becheanu, A. Pop, E. Mandache, M. Gherghiceanu (Bucharest, RO)
8.
Double-headed colonic polyp: Double amount of abdominal fat? G. Becheanu, M. Ciocirlan, M. Dumbrava, S. Costinean (Bucharest, RO; Columbus, US)
9.
Caerulein regulates the ghrelin molecular system in the pancreatic acini J. Bonior, J. Jaworek, M. Kot, S.J. Konturek (Krakow, PL)
10. A case report of Clostridium difficile infection in patient with ulcerative colitis P. Boykova, M. Stamboliyska, I. Kotzev (Varna, BG) 11. Long-term follow-up of chronic hepatitis C patients with virological and biochemical response to therapy B. Ceylan, M. Fincanci, C. Muderrisoglu, F. Soysal, G. Eren, M. Basaranoglu (Istanbul, TR) 12. Long term follow-up of patients with anti-hepatitis D antibody B. Ceylan, M. Fincanci, C. Muderrisoglu, F. Soysal, G. Eren, M. Basaranoglu (Istanbul, TR) 7
13. Comparison of chronic hepatitis B patients using tenofovir and entecavir in terms of viral kinetics, virologic response and side effects B. Ceylan, M. Fincanci, C. Muderrisoglu, F. Soysal, G. Eren, M. Basaranoglu (Istanbul, TR) 14. Eosinophilic oesophagitis – Our experience and evolving service K. Charles, J. Turner, J. Swift, J. Green, S. Dolwani (Cardiff, GB) 15. Treatment with UDCA and neuroendocrine tumor C. Cimpoeru (Bucharest, RO) 16. Survey of the efficacy and safety of infliximab in the first paediatric patients with Crohn's disease treated in Romania A. Constantinescu, L. Gheorghe, R. Vadan, C. Gheorghe (Bucharest, RO) 17. Frequency, endoscopic characteristics and therapeutic possibilities for dysplastic lesions in inflammatory bowel disease A. Constantinescu, C. Gheorghe, R. Vadan, L. Gheorghe (Bucharest, RO) 18. Diagnostic accuracy of quantitative endoscopic ultrasound elastography for discriminating malignant from benign solid pancreatic masses: A prospective, single-centre study M.F. Dawwas, H. Taha, J.S. Leeds, M.K. Nayar, K.W. Oppong (Newcastle upon Tyne, GB) 19. Inflammatory bowel disease – Ultrasound assessment of the enthesopathy C. Deliu, D. Neagoe, S. Enculescu, C. Hoanca (Craiova, RO) 20. Helicobacter pylori infection is associated with erosions in the small bowel J. Derova, A. Derovs, J. Pokrotnieks (Riga, LV) 21. Specific pathological changes in the small bowel mucosa in patients with Crohn's disease A. Derovs, J. Pavlova, J. Pokrotnieks (Riga, LV) 22. TGF-β, TGFBR1 and Ki67 espression in intestinal type of gastric carcinomas A.O. Docea, P. Mitrut, D. Calina, E. Gofita, A. Genunche-Dumitrescu, D. Badea, R. Mitrut (Craiova, RO) 23. Ulcerative colitis: Is there diagnosis beyond colonoscopy? M. Dranga, O. Nedelciuc, I. Pintilie, C. Cijevschi Prelipcean (Iasi, RO) 24. Is Crohn's disease milder in older people? M. Dranga, M. Badea, G. Dumitrescu, C. Cijevschi Prelipcean (Iasi, RO) 25. The influence of age on the phenotype and activity in ulcerative colitis M. Dranga, G. Dumitrescu, A. Blaj, C. Mihai (Iasi, RO)
8
26. The effect of intravenous iron administration on thrombocytosis in inflammatory bowel disease G. Dumitrescu, M. Badea, D. Chirita, C. Cijevschi Prelipcean (Iasi, RO) 27. Ignore or treat osteoporosis in inflammatory bowel disease? G. Dumitrescu, M. Dranga, O. Nedelciuc, C. Mihai, C. Cijevschi Prelipcean (Iasi, RO) 28. Anaemia in inflammatory bowel disease: A common complication? G. Dumitrescu, O. Nedelciuc, A. Blaj, C. Cijevschi Prelipcean (Iasi, RO) 29. Efficiency correction of anemia with oral iron vs. intravenous iron G. Dumitrescu, M. Dranga, I. Pintilie, C. Mihai (Iasi, RO) 30. Is vitamin D deficit a determining factor regarding the decrease of bone mineral density in patients with Crohn’s disease? G. Dumitrescu, M. Dranga, I.A. Pintilie, C. Mihai (Iasi, RO) 31. Complications of chronic pancreatitis in obese patients: The beneficial effects of alcohol abstinence and loss weight A. Genunche-Dumitrescu, D. Badea, M. Badea, P. Mitrut, A. Badea (Craiova, RO) 32. Relationship between history of Helicobacter pylori infection and precancerous changes in develop gastric cancer A. Genunche-Dumitrescu, D. Badea, M. Badea, P. Mitrut, A. Badea (Craiova, RO) 33. The prevalence and risk factors of colorectal dysplasia in patients with Crohn's disease C. Gheorghe, R. Vadan, A. Constantinescu, L. Gheorghe (Bucharest, RO) 34. Effect of different sedation methods on the critical flicker frequency in a tertiary centre endoscopy unit F. Grünhage, A. Seegmüller, F. Lammert (Homburg, DE) 35. Portal vein thrombosis in liver graft ten years after liver transplantation due to Budd-Chiari syndrome: Case report A. Husic-Selimovic, S. Gornjakovic, M. Schuchmann, Z. Vukobrat-Bijedic (Sarajevo, BA; Mainz, DE) 36. Treating Helicobacter pylori infection in patients with Parkinson’s disease: How long? G. Iliescu, A. Bold, V. Biciusca (Craiova, RO) 37. Role of Smad4 and Smad7 proteins in development of gastric cancer K. Ivanova, J. Ananiev, A. Julianov, M. Gulubova (Stara Zagora, BG) 38. Cap polyposis: A report of two cases R. Ivanova, D. Kyosseva, G. Trifonov, R. Nikolov (Sofia, BG) 9
39. Serrated polyps of the colon – Clinico-morphological and immunohistochemical characteristics R. Ivanova, D. Kyosseva, R. Nikolov, S. Deredjian, Z. Spassova (Sofia, BG) 40. Azathioprine and allopurinol co-therapy for IBD patients is a safe and effective treatment option in a District General Hospital H.E. Johnson, S.A. Weaver, S.D. McLaughlin (Bournemouth, GB) 41. Helicobacter pylori isolates recovered from antral gastric biopsies of patients with dyspeptic symptoms: Antimicrobial resistance of metronidazole, clarithromycin and amoxicillin F. Kalem, M. Özdemir, M. Basaranoglu, H. Toy, B. Baysal (Istanbul, TR) 42. Laparoscopic approach as primary treatment of cholelithiasis and common bile duct stones in children with biliary pancreatitis K. Kalinova, A. Karachmalakov, O. Brankov, P. Stefanova, Y. Dimcheva, M. Haddad (Stara Zagora, BG) 43. Case report of atypical enteric amebiasis M. Kanashvili, N. Rukhadze, T. Kuchuloria, D. Kikabidze, G. Gogishvili (Tbilisi, GE) 44. Accuracy of visual estimation of adenoma size – A comparison with direct measurement in the pathology department J. Kinchen, E. Harrod, K. Wright, A. Evans, N. Chandra (Reading, GB) 45. Endoscopic treatment of biliary obstruction due to alien bodies and parasites V. Kolomiytsev, O. Kushniruk, M. Pavlovsky (Lviv, UA) 46. Impact of pancreatic pseudocysts features and procedural factors on complication rate and long-term outcome after endoscopic treatment O. Kushniruk, V. Kolomiytsev, I. Tumak (Lviv, UA) 47. Molecular basis for the Fumonisin B1-dependent promotion of the esophageal cancer E.A. Martinova (Moscow, RU) 48. The predictive value of IL28B genotype in a population with HVB or HVC infections with spontaneous healing or with antiviral treatment G. Minzala, L. Iliescu, A. Martiniuc, M. Voiculescu (Bucharest, RO) 49. Digestive manifestations in chronic kidney disease with hemodialysis P. Mitrut, A.O. Docea, A. Genunche-Dumitrescu, D. Badea, A. Enescu, E. Gofita, D. Calina, D. Salplahta (Craiova, RO) 50. Distribution of villous adenomas in patients admitted for colonoscopy V. Mokricka, A. Pukitis (Riga, LV)
10
51. Differential Smad2/3 expression and decreased Smad2/3 activation are associated with characteristics of poor prognosis in ICC S. Munker, Q. Li, F. Li, Y. Liu, C. Meyer, S. Dooley, H. Weng, J. Li (Mannheim, Tübingen, DE) 52. Adipokines and their role in patients with obesity and Barrett’s esophagus D. Neagoe, G. Ianosi, A. Amzolini, M. Filip, C. Georgescu, T. Ciurea (Craiova, RO) 53. Health-related quality of life in Crohn's disease O. Nedelciuc, I. Pintilie, G. Dumitrescu, C. Cijevschi Prelipcean (Iasi, RO) 54. Easy to live with ulcerative colitis patients? O. Nedelciuc, M. Dranga, M. Badea, C. Mihai (Iasi, RO) 55. Abdominal pain in patients with acquired immunodeficiency syndrome (AIDS) C. Olariu, A. Nurciu, O. Schiopu (Bucharest, RO) 56. Hepatitis C virus infection (HCV) in patients of the University Emergency Hospital Bucharest (UEHB) Romania – Hemodialysis Center between 2005–2010 D. Olteanu, A.C. Diaconescu, S. Scarlatescu (Bucharest, RO; Charleston, US) 57. Gastrointestinal hemorrhagic complications during chronic antithrombotic prevention with vitamin K antagonists S. Ostrowski, M. Sawa, A. Prystupa, J. Mosiewicz (Lublin, PL) 58. Analysis of the risk of biliary pancreatitis using routine biochemical data, parameters of imaging techniques in patients with choledocholithiasis confirmed by ERCP I. Ozola Zalite, A. Pukitis (Riga, LV) 59. Neuroticism and depression in inflammatory bowel disease – Clinically significant? D. Panova, S. Deredjian, R. Nikolov, Z. Spassova, Z. Krastev (Sofia, BG) 60. Histopathological and immunohistochemical changes in Helicobacter pylori colonized gastric mucosa G. Parlog, S. Parlog (Bacau, Bucharest, RO) 61. Inflammatory bowel disease and Helicobacter pylori I. Pintilie, O. Nedelciuc, M. Badea, C. Cijevschi Prelipcean (Iasi, RO) 62. Epidemiologic, etiological and age aspects of the syndrome of diarrhea in children N.V. Pronko (Grodno, BY) 63. Colorectal cancer in the centre of Romania – Differences between urban and rural areas M. Pumnea, E.C. Rezi (Sibiu, RO) 11
64. Immunosuppression monitoring in inflammatory bowel disease: A comparison between primary and secondary care A. Rehman Farooqi, D. Durai (Cardiff, GB) 65. The association of dyslipidemia with dysplastic colorectal polyps in a population from southern Transylvania E.C. Rezi, M. Pumnea (Sibiu, RO) 66. Manifestation of acute pancreatitis in urogenital sepsis (case report) N. Rukhadze, M. Kanashvili, D. Kikabidze, M. Javakhadze (Tbilisi, GE) 67. H. pylori eradication problems. Different ways leading to one goal M. Rustamov, L. Lazebnik (Minsk, BY; Moscow, RU) 68. Role of sucralfate in post band variceal ulcer M. Sakr, W. Hamed, H. Hamdy, M. El Gafaary, R. El-Folly, M. El-Hamamsy (Cairo, EG) 69. Unusual cause of gastrointestinal bleeding: Hepatocellular carcinoma with gastric invasion L. Sandulescu, A. Saftoiu, S. Cazacu, F. Scutelnicu, C. Popescu, D. Dumitrescu (Craiova, RO) 70. Role of contrast enhanced ultrasonography in the diagnosis and monitoring of a patient with Crohn's disease L. Sandulescu, A. Saftoiu, T. Cartana (Craiova, RO) 71. Pancreatic pseudocysts: What therapeutic options do we have? S. Sandulescu, V. Surlin, S. Ramboiu, I. Georgescu (Craiova, RO) 72. Factors influencing the survival in hepatocellular carcinoma: Mersin University Hepatoma Working Group O. Sezgin, E. Altintas, F. Ates, S. Yaras, B. Saritas, A. Kocatürk, F.D. Apaydin, E. Kara, M. Dirlik, H. Canbaz, A. Arican, A. Ata, G. Orekici (Mersin, TR) 73. The effect of yoghurt probiotic bacteria on pro- and anti-inflammatory cytokine response of mononuclear cells of ulcerative colitis patients A. Sheikhi, H. Banaei, N. Yahaghi, M. Nazarian (Dezful Khuzestan, Fars, Zanjan, IR) 74. Functional prevention of colorectal cancer risk K. Shemerovskii (St. Petersburg, RU) 75. The value of matrix metalloproteinases investigation for Crohn's disease pathogenesis I. Silosi, C.A. Silosi, M. Cojocaru, M.V. Boldeanu, T. Ciurea (Craiova, RO) 76. The laparoscopic surgery – Preferential diagnosis and therapeutic option for postoperative adherential syndrome I. Silosi, C.A. Silosi (Craiova, RO) 12
77. Basic pathogenetical mechanisms of non-alcoholic steatohepatitis I.N. Skrypnyk, G. Maslova, L. Mandryka (Poltava, UA) 78. The value of platelet activity indices in patients with autoimmune gastritis I. Soykan, M. Yakut, O. Keskin (Ankara, TR) 79. Diverticular disease – Clinical and diagnostic aspects M. Stamboliyska, D. Gancheva-Tomova, S. Banova, I. Kotzev (Varna, BG) 80. Fecal calprotectin level in inflammatory bowel disease (IBD) and noninflammatory gastrointestinal disease R. Surjadinata, R. Sosrosumihardjo, M. Simadibrata, A. Setiawati (Jakarta, ID) 81. Endoscopic grading of reflux esophagitis in a private medical center in Turkey N. Turkel Kucukmetin, G. Bostas (Istanbul, TR) 82. Long-term efficacy of maintenance treatment with infliximab in current clinical practice: A prospective study in patients with Crohn's disease R. Vadan, L. Gheorghe, A. Constantinescu, S. Suciu, M. Diculescu, C. Gheorghe (Bucharest, RO) 83. Scope to improve. A multicentre audit of 16,064 colonoscopies looking at caecal intubation rates, over a two year period A. Verma, N. McGrath, P. Bennett, J. de Caestecker, A. Dixon, J. Eaden, P. Wurm, A. Chilton (Kettering, Coventry, Leicester, GB) 84. Small bowel capusle endoscopy – A review of 232 studies undertaken at a single centre A. Verma, R. Ramiah, D. Legge, A. Dixon (Kettering, GB) 85. Gender differences – Analysis of 5162 colonoscopies over 4 years reveals higher caecal intubation rates in male patients A. Verma, N. McGrath, A. Dixon, A. Chilton (Kettering, GB) 86. Endoscopic versus conventional conservative therapy in chronic pancreatitis B. Vladimirov, R. Mitova, N. Grigorov, D. Damjanov, B. Korukov, P. Parvanov (Sofia, BG) 87. Magnifying chromoendoscopy is useful for detection of Barrett's metaplasia and low-grade dysplasia recurrence after argon plasma coagulation (APC) B. Vladimirov, I. Terziev, B. Korukov, R. Ivanova (Sofia, BG) 88. ERCP – Can District General Hospitals provide a satisfactory service? 10 year literature review and our unit's experience M. Yiasemidou, D. Glassman, S. Stock (Guildford, Douglas, GB) 89. A giant left adrenal pseudocyst presented as abdominal discomfort at gastroenterology K. Yildiz, M. Tozlu, A.T. Ince, O. Kocaman, M. Basaranoglu, H. Sentürk (Istanbul, TR) 13
90. Malabsorption syndrome – Case report of a rare infection A. Zafosnik, M. Knehtl, N. Gorisek-Miksic, R. Kavalar, P. Skok (Maribor, SI) 91. Comparison of partial splenic embolisation versus splenic irradiation as treatment of hypersplenism in advanced cirrhosis D. Ziada, H. Soliman, M. Sharaf-Eldin, A. Al-Badery, N. El Mashad, S. Khodeir (Tanta, EG)
14
Session I
Esophagus
15
Eosinophilic esophagitis: A bulk of mysteries Alex Straumann Chairman Swiss EoE-Clinic and Swiss EoE-Research-Group, Olten, Switzerland Eosinophilic Esophagitis (EoE), first described in the early 1990’s, has rapidly evolved as distinctive chronic inflammatory esophageal disease. The diagnosis is based clinically by the presence of symptoms related to an esophageal dysfunction and histologically by an eosinophil-predominant inflammation once other conditions leading to esophageal eosinophilia are excluded. This striking male-prevalent disease has an increasing incidence and prevalence in the westernized countries. Currently, EoE represents the main cause of dysphagia and bolus impaction in adult patients. Despite the fact that EoE often occurs in atopic patients, the value of allergic testing is still under discussion. Topical corticosteroids lead to a rapid improvement of active EoE clinically and histologically; they are therefore regarded as first-line drug therapy. Elimination diets have similar efficacy as topical corticosteroids, but their long-term use is limited by practical issues. Esophageal dilation of EoE-induced strictures can also be effective in improving symptoms, but this therapy has no effect on the underlying inflammation. Neither the diagnostic nor the long-term therapeutic strategies are yet fully defined. Currently the list of unsolved issues, of mysteries, is still long and a concerted effort on behalf of clinicians and scientists is required to improve the understanding and the therapeutic management of this mysterious disease.
17
Barrett’s esophagus: The American perspective Stuart Jon Spechler, M.D. Professor of Medicine, Berta M. and Cecil O. Patterson Chair in Gastroenterology, UT Southwestern Medical Center at Dallas; Chief, Division of Gastroenterology, VA North Texas Healthcare System, Dallas, TX, USA In a recent medical position statement, the American Gastroenterological Association (AGA) defined Barrett’s esophagus as the condition in which any extent of metaplastic columnar epithelium that predisposes to cancer development replaces the stratified squamous epithelium that normally lines the distal esophagus. Barrett’s metaplasia is a major risk factor for esophageal adenocarcinoma, a tumor whose frequency has increased more than seven-fold over the past three decades in the United States. For patients who have Barrett’s esophagus without dysplasia, the rate of cancer development is approximately 0.25% per year. For patients with high-grade dysplasia in Barrett’s esophagus, in contrast, that rate is approximately 6% per year. The AGA now recommends endoscopic eradication therapy rather than surveillance for treatment of patients with confirmed high-grade dysplasia in Barrett’s esophagus. In surgical series of patients who have had esophagectomy for high-grade dysplasia or intramucosal adenocarcinoma in Barrett’s esophagus, a recent systematic review reported that lymph node metastases are found in only approximately 1–2%. Thus, endoscopic therapy has a high potential for cure of neoplasms that do not extend beneath the muscularis mucosae. For neoplasms in Barrett’s esophagus that extend into the submucosa, however, the frequency of lymph node metastases often exceeds 20%. Thus, endoscopic therapy generally is not considered definitive for patients whose neoplasms involve the submucosa. In a multicenter, randomized, sham-controlled trial of radiofrequency ablation (RFA), 127 patients with dysplasia in Barrett's esophagus (64 low-grade, 63 high-grade) were randomized to receive either RFA (ablation group) or a sham procedure (control group). At one year, intention-to-treat analyses revealed complete eradication of dysplasia in 90.5% of patients with low-grade dysplasia in the ablation group, compared to 22.7% of those in the control group (p < 0.001). Similarly, complete eradication was found in 81.0% of patients with high-grade dysplasia in the ablation group, compared to 19.0% of those in the control group (p < 0.001). Patients in the ablation group had less progression in their degree of neoplasia (3.6% vs. 16.3%, p = 0.03) and fewer cancers noted at one year (1.2% vs. 9.3%, p = 0.045). RFA is now considered the ablation procedure of choice for the treatment of mucosal neoplasia in Barrett’s esophagus. Especially contentious is the issue of whether RFA should be offered to patients who have Barrett’s esophagus without dysplasia. Unanswered questions regarding the durability of the eradication, the frequency with which ablation “buries” metaplastic glands under a layer of neo-squamous epithelium, and the clinical importance of those buried glands raise doubt regarding the cost-effectiveness of RFA for nondysplastic Barrett’s metaplasia. Clinicians should appreciate that: 1) RFA generally requires several endoscopic procedures to achieve complete eradication, 2) RFA has a complication rate that is low but appreciable, 3) the durability of the procedure is 18
disputed, 4) the frequency and importance of buried glands are not clear, 5) the efficacy of RFA in reducing the already low rate of cancer development is not established and, therefore 6) after RFA, patients almost certainly will require some kind of surveillance. In its recent medical position statement, the AGA concluded, “Endoscopic eradication therapy is not suggested for the general population of patients with Barrett’s esophagus in the absence of dysplasia.” However, they added that, “RFA should be a therapeutic option for select individuals with non-dysplastic Barrett’s esophagus who are judged to be at increased risk for progression to high grade dysplasia or cancer.” Unfortunately, specific criteria that identify this population have not been fully defined.
19
Barrett’s esophagus European perspective
(non-neoplastic/neoplastic)
–
The
Oliver Pech, M.D., Ph.D. Department for Gastroenterology, St. John of God Hospital, Regensburg, Germany, E-Mail:
[email protected] The cancer risk of non-dysplastic Barrett’s esophagus is very low (0.33–0.5 per patient year). Therefore, any endoscopic ablation technique is an overtreatment. Patients with low-grade intraepithelial neoplasia confirmed by a specialized GI pathologist seem to have a significant risk for developing high-grade intraepithelial neoplasia (HGIN) or cancer. Therefore, endoscopic treatment in this case seems to be justified. However, up to now there is no prospective study supporting this. In recent years, endoscopic treatment of high-grade intraepithelial neoplasia and mucosal Barrett’s cancer has become a widely accepted treatment approach and even the therapy of choice in many countries. Endoscopic resection (ER) is the best validated treatment method in patients with high grade intraepithelial neoplasia and mucosal Barrett’s cancer and is widely used all over the world. In contrast to ablative treatment methods like argon plasma coagulation and radiofrequency or cryoablation, ER allows histological assessment of the resected specimen in order to assess the depth of infiltration of the tumor. However, ER of the neoplastic lesions should always be followed by ablation of the non-dysplastic remaining Barrett’s esophagus in order to reduce the risk of recurrence or metachronous neoplasia. The long-time complete remission rate with this two-step-strategy is ≥ 95%. A matter of continuing debate is whether patients with Barrett’s cancer infiltrating the upper third of the mucosal layer (pT1sm1) can be treated by ER. Data from our and other centers indicate that a subgroup of patients with pT1sm1 adenocarcinomas without the presence of risk factors (poor differentiation grade, lymph or blood vessel infiltration, size > 20 mm, ulcerated lesion) have a very low risk for lymph node metastasis (< 2%) and endoscopic therapy can be an alternative to radical surgery.
20
Advanced esophageal cancer – Evolution and surgical options and outcomes D.E. Low General, Thoracic and Vascular Surgery, Virinia Mason Medical Center, Seattle, WA, USA Historically, the treatment for invasive esophageal cancer has focused on surgical resection. The complexity of the operative procedure has been underscored by international mortality rates as high as 20% as recently as 10–20 years ago. As a result of the perception of unacceptable levels of mortality and the general impression of post-operative poor quality of life, the role of surgery is being critically reassessed with endoscopic techniques in all superficial esophageal cancers, and with definitive radiation chemotherapy protocols with respect to the definitive treatment of squamous cell cancer. The role of surgery is to provide complete regional clearance of cancer in patients with localized disease. Paralleling goals include an appropriate lymph node dissection while carrying out a controlled operation from which the patient can recover quickly, along with a reconstructive approach which will facilitate the patient resuming normal oral intake and maintaining a good quality of life. Surgeons have typically advocated one surgical approach as superior over another. The literature is dominated by reports of the superiority of the Transhiatal, Ivor Lewis, Radical three-field or Minimally invasive esophageal resections. The reality is that each approach has its potential advantages and drawbacks. Surgeons should be adopting the approach to surgical resection to match the individual physiologic and tumor characteristics of each patient. There is also increasing recognition that while the surgical procedure itself remains the most critical individual issue affecting outcome, there are other factors such as nutritional support, appropriate utilization of fluid and blood products, routine application of regional anesthetics and pain team management as well as early mobilization protocols, which can also impact short- and long-term results. These and many other issues are best applied to standardized clinical pathways or enhanced recovery programs run by dedicated cancer care coordinators. New minimally invasive, robotic and hybrid approaches, as well as selective adaption of techniques such as an inversion esophagectomy, all hold unproven promise of decreasing the impact of surgery to patients while maintaining or improving outcomes. There should be the expectation that high volume surgical esophageal centers will limit mortality with respect to esophageal resection to 2–4%, which is approximately the same level of major morbidity and mortality associated with definitive chemoradiation. There is also increasing evidence to demonstrate that esophagectomy can be done in high volume units with maintenance of quality of life while limiting perioperative complications and costs.
21
Advanced esophageal cancer – Radiochemotherapy Claus Rödel Department of Radiotherapy and Oncology, University of Frankfurt, Germany Despite recent improvements in surgery and radiotherapy (RT), and refinements of systemic treatment options, including incorporation of targeted agents, long-term survival remains poor for patients with esophageal cancer. Whilst surgical resection alone remains the standard approach for early stage disease (stage I), multimodality therapy, including perioperative chemotherapy and neoadjuvant or definitive chemoradiotherapy (CRT), are internationally accepted treatment options for patients with locally advanced disease. In lower oesophageal and oesophagogastric junction adenocarcinomas, data from large, randomized phase III trials and meta-analyses support the use of both perioperative chemotherapy alone or neoadjuvant concurrent CRT. In patients with locally advanced squamous cell carcinoma (SCC) of the esophagus, neoadjuvant CRT but not neoadjuvant chemotherapy alone is the preferred treatment approach. Definitive CRT without surgery has also emerged as a useful option for the treatment of resectable SCC of the oesophagus, avoiding potential surgical morbidity and mortality, with salvage surgery reserved for those with persistent disease. Functional imaging modalities, such as PET-CT, may create new opportunities for a more adequate therapy response assessment and patient selection: Patients with SCC that show clinical response by PET-CT are considered to have a more favourable outcome, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved. Recent technological advances in RT, such as intensity-modulated RT, image guided-RT, and PET-CT based RT-planning, may further improve the therapeutic ratio of CRT. Moreover, the traditional backbone of CRT, platinum plus fluorouracil, may be supplanted by more modern and easier-toadminister regimens incorporating taxanes, irinotecan, and targeted agents.
22
Session II
Stomach
23
Helicobacter pylori: Kill or leave it Prof. Dr. P. Malfertheiner Universitätsklinikum Magdeburg AöR, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Leipziger Str. 44, 39120 Magdburg, Germany Helicobacterr pylori is a pathogen and causes chronic inflammation of the gastric mucosa in all infected individuals. However only a subset of these subjects (~15–20%) will eventually develop clinical symptoms and manifestations that include “non-ulcer” dyspepsia, peptic ulcer disease and gastric neoplasia. More recently the list of associated diseases has been extended to extra-gastric manifestations and a benefical effect of H. pylori eradication has been proven in selected patients with idiopathic thrombocytopenic purpura, iron deficiency anemia and vitamin B12 deficiency. A comprehensive overview of the clinical management of H. pylori infection with all the supporting evidence in the various indications has been published recently (1). Since nearly 80% of infected will never experience any significant clinical symptoms or complication and because of roughly the half world´s population being infected, intensive research has been devoted to identify factors at risk for the development of the most severe complications, ulcer disease and gastric cancer. Several bacterial virulence factors, host susceptibility genes and facilitating environmental factors have been found to carry an increased risk for severe complications in H. pylori infected – but still their implementation for the clinical management have not been established. There is some kind of risk for everyone infected to get the most severe complication, gastric cancer. The logical consequence: kill H. pylori whenever diagnosed! There is a warning however against a potential “global overkill” as there is epidemiological and experimental evidence to claim that H. pylori may confer some benefits, especially to children and young adults. The claim of a beneficial effect of H. pylori is within the context of the “hygiene theory” and suggests that individuals exposed to H. pylori in childhood get a certain protection against the development of atopic diseases (2). The rationale for it is the different conditioning of the immune system by early childhood infection with H. pylori. Protagonists of this theory propose: leave H. pylori! In the balance of harm and “potential” benefit the conclusion is: kill it! To leave an infection with possible unpredictable severe sequelae including gastric cancer demand for proactive strategies to get an “H. pylori free stomach”.
References: 1.
Management of Helicobacter pylori infection – the Maastricht IV/Florence Consensus Report. Malfertheiner P, Megraud F, O'Morain et al. Gut. 2012; 61(5):646–64.
2.
The impact of Helicobacter pylori on atopic disorders in childhood. Holster IL, Vila AM, Caudri D, den Hoed CM, Perez-Perez GI, Blaser MJ, de Jongste JC, Kuipers EJ. Helicobacter. 2012;17(3):232–7. 25
Early stomach cancer: Limits of detection and endoscopic resection Hironori Yamamoto Jichi Medical University, Kawachi, Japan Although recent progress in chemotherapy for gastrointestinal cancer has been remarkable, early detection and complete resection are still the principal treatment strategies for gastric cancer. Curative treatment of gastric cancer can be achieved by complete resection of the neoplasm as long as it is localized without distant metastasis. If the tumor is localized, without lymph node metastases, endoscopic therapy alone can be curative. In order to achieve curative endoscopic resection, detection of gastric cancers in an early stage and use of a reliable method of resection are important. To detect early gastric cancers, subtle changes in morphology and/or mucosal color must be identified. The morphological characteristics of early gastric cancer include mild elevation or shallow depression of the mucosa, as well as discontinuity with the surrounding mucosa and an uneven surface. Changes in color, pale redness or fading are important. Flexible spectral imaging color enhancement (FICE) is a digital color enhancement technique which can improve the detection rate of early gastric cancer. Endoscopic submucosal dissection (ESD) is an endoscopic technique which involves incision of the mucosa surrounding a lesion and removal of the mucosa by submucosal dissection using an electrosurgical knife instead of a snare. With ESD, a reliable en bloc resection of early gastric cancer is obtained with a low recurrence rate. En bloc resection is important for the accurate histopathologic determination of a curative resection. In this lecture, practical methods and limits of detection and resection of early gastric cancers are presented.
26
MALT-lymphoma: Forget surgery? W. Fischbach Medizinische Klinik II und Klinik für Palliativmedizin, Klinikum Aschaffenburg – Akademisches Lehrkrankenhaus der Universität Würzburg, Aschaffenburg, Germany The question raised in the title of my presentation can be shortly answered by a Yes! Neither in the German S3 Guideline “Helicobacter pylori and gastroduodenal ulcer disease” 2009 (1) nor in the European Consensus Report of 2011 (2) surgery is recommended for treatment of gastric MALT Lymphoma. For decades surgical resection was the standard therapeutic approach. It offered excellent long-term survival (3). However, conservative organ-preserving therapeutic strategies have shown equal results (4). Considering quality of life a conservative therapeutic strategy should be clearly favored (5). Therefore, surgery is nowadays restricted to the treatment of very rare complications such as perforation or bleeding that cannot be controlled endoscopically. The following figure summarizes the treatment of gastric MALT lymphoma depending on the stage of the disease.
Therapy of gastric MALT-Lymphoma Deutsche S3 LL 2009; EGILS Consensus Report 2011
EI1 / cT1-2N0
EI2 / cT3-4N0
EII/cT1-4N1-2
EIII/IV / N3M1
Hp Eradication
Hp Eradication
Hp Eradication
Hp Eradication
CR
Follow-up
pMRD,(rRD)
watch-and-wait
(NC), Progress
RTx
CR
Follow-up
pMRD,(rRD)
watch-and-wait
(NC), Progress
RTx
CR
Follow-up
pMRD,(rRD)
watch-and-wait
(NC), Progress
RTx
CTx
CTx
Chemotherapy
CR: complete remission; pMRD: probable minimal residual disease; rRD: responding residual disease; NC: no change; RTx: radiotherapy; CTx. chemotherapy
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Session III
Pancreas
29
Autoimmune diagnosis
pancreatitis:
Avoid
surgery
by
improved
S.T. Chari Professor of Medicine, Mayo Clinic Rochester, MN, USA Both autoimmune pancreatitis (AIP) and pancreatic cancer frequently present with obstructive jaundice. The clinical challenge between the two diseases because they have vastly different therapeutic and prognostic implications. AIP has recently been sub-classified into types 1 and 2. Both can present with obstructive jaundice with or without pancreatic enlargement and both respond to steroids. However, only type 1 AIP has additional collateral evidence such as elevated serum IgG4 elevation and other organ involvement. When adequate and representative pancreatic histology is available, it can distinguish between the two forms of AIP. Recently International Consensus Diagnostic Criteria for AIP have been published. In a recent study we found that AIP can be diagnosed using ICDC in ~70% with imaging and collateral evidence alone or in combination with steroid response. In 10% either a diagnostic ERP or pancreatic histology is needed to confirm the diagnosis. In 20% of type 1 AIP who have no collateral evidence, pancreatic histology is required to make the diagnosis. Since a subset of AIP undergoes pancreatic resection, we studied the outcomes in 74 resected AIP. Indication for surgical intervention was concern for malignancy (n = 59, 80%), pancreatitis (n = 9, 12%), malignancy on pre-operative biopsy (n = 4, 5%), and unknown (n = 2, 2.7%). Surgical resection in AIP resulted in few pancreatic fistulae and a low rate of re-intervention. Nearly a quarter of patients received post-operative steroids. Current diagnostic criteria
31
Chronic pancreatitis – Conservative options Matthias Löhr Gastrocentrum, Karolinska Institutet, Stockholm, Sweden The symptoms of chronic pancreatitis that warrant treatment are determined by the ongoing inflammation as a cause of pain and the loss of endocrine and exocrine function. The most important measures are to cease the etiological causes of chronic pancreatitis, if it is alcohol consumption and smoking. This is best accomplished in an orderly fashion in clinical programs where gastroenterology and specialists in pain and addiction medicine join. It is, however, a clinical reality that it is much easier to refrain from alcohol compared with smoking. The impairment of endocrine and exocrine function needs to be assessed accordingly with fasting blood sugar and HbA1c measurements for the endocrine function. The exocrine function can be determined with fecal elastase-1 or the C13 mixed triglyceride breath tests. As a consequence, the default involvement of a dietician is mandatory to appropriately treat diabetes mellitus and pancreatic exocrine insufficiency (PEI). The early and sufficient pancreatic enzyme replacement therapy (PERT) is a key in treating the malnutrition in these patients. Whether untreated or undertreated PEI is the cause of further problems as a consequence of the malnutrition, e.g. low vitamin D and resulting osteoporosis is a matter of ongoing discussions. Complications of chronic pancreatitis are obstructive jaundice, pancreatic duct stones and cysts that all can be treated with interventional endoscopy. However, indication for therapeutic ERCP should be agreed upon in a multidisciplinary team (MDT) with decision-making conference as for most patients the long-term outcomes are better with surgical interventions. Obstructive jaundice caused by an inflammatory pancreatic head tumor can be treated with plastic stents or fully-covered removable self-expanding metal stents (SEMS) in conjunction with conservative treatment to eventually reduce inflammation and abstinence. The only rationale to treat pancreatic duct stones are those singular ones in the main pancreatic duct (MPD) close to the papilla obstructing the outflow. Even in this group, a satisfactory result can best be achieved in juvenile chronic pancreatitis. In contrast to bile duct stones, electrohydraulic lithotripsy (EHL) does not work well. Best is a combination of ESWL and endoscopic removal with baskets. The third indication for therapeutic ERCP are cysts that can be drained transpapillary or with help of EUS transgastrically. It needs to be stressed, however, that endoscopic intervention in chronic pancreatitis can only be a temporary therapy as the long-term results of surgery are more favorable.
Further reading: M. Löhr, Å. Andrén-Sandberg: Pancreatitis – Diagnosis and Therapy. UNI-MED Verlag, Bremen, 2011
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Pancreatic cancer: Are there any limits? Thilo Hackert, M.D.; Markus W. Büchler, M.D. Department of General Surgery, University of Heidelberg, Heidelberg, Germany Pancreatic cancer is the fourth leading cause of cancer related mortality in the Western world and remains a therapeutical challenge [1]. Surgery is the only treatment with the chance of cure [2]. Standard resections include pancreaticoduodenectomy for pancreatic head tumors, which account for the majority of pancreatic cancers. Tumors in the body or tail of the pancreas are treated by left resection or total pancreatectomy. Pancreatic surgery can be performed with mortality rates below 5% in specialized high volume institutions today [3, 4]. Besides standard resections, extended approaches for locally advanced cancer are technically feasible, including resection of the superior mesenteric or portal vein, multivisceral resections and arterial resection with reconstruction of the celiac axis. These approaches have been evaluated in clinical studies for their morbidity and oncological value. Venous resections can be carried out without increased morbidity and mortality and are not compromised by higher R1 or N+ rates [5, 6]. Arterial tumor invasion is still regarded controversially due to a high rate of R1 resections, making this concept – although surgically feasible – oncologically questionable [7, 8]. Multivisceral resections can be carried out with low morbidity and mortality if a radical tumor resection can be achieved [9]. Operation of tumor recurrences in pancreatic carcinoma has been investigated in a recent study showing that it tends to improve survival, which should is currently addressed to in further studies [10]. All surgical approached should be part of interdisciplinary multimodal treatment concepts to improve the patients’ prognosis.
References: 1. 2. 3. 4. 5. 6. 7. 8.
Jemal A, Siegel R, Xu J, Ward E.12. Cancer statistics, 2010. CA Cancer J Clin. 2010;60:277–300. Wagner M, Redaelli C, Lietz M, Seiler CA, Friess H, Buchler MW. Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg. 2004;91:586–594. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128–1137. Hartwig W, Hackert T, Hinz U, Gluth A, Bergmann F, Strobel O, Büchler MW, Werner J. Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg. 2011;254:311–319. Michalski CW, Weitz J, Buchler MW. Surgery insight: surgical management of pancreatic cancer. Nat Clin Pract Oncol. 2007;4:526–535. Weitz J, Kienle P, Schmidt J, Friess H, Buchler MW. Portal vein resection for advanced pancreatic head cancer. J Am Coll Surg. 2007;204:712–716. Reddy SK, Tyler DS, Pappas TN, Clary BM. Extended resection for pancreatic adenocarcinoma. Oncologist. 2007;12:654–663. Nakao A, Takeda S, Inoue S, Nomoto S, Kanazumi N, Sugimoto H, Fujii T. Indications and techniques of extended resection for pancreatic cancer. World J Surg. 2006;30:976–982. 33
9.
Hartwig W, Hackert T, Hinz U, Hassenpflug M, Strobel O, Büchler MW, Werner J. Multivisceral resection for pancreatic malignancies: risk-analysis and longterm outcome. Ann Surg. 2009;250:81–87. 10. Kleeff J, Reiser C, Hinz U, et al. Surgery for recurrent pancreatic ductal adenocarcinoma. Ann Surg. 2007;245:566–572.
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Session IV
Small Bowel
35
Gluten-free diets: When should we use them? Chris J.J. Mulder Coeliac Center Amsterdam, VU Medical Center, Amsterdam, The Netherlands The spectrum of gluten-related disorders in the early 1980’s was simple: CD and Dermatitis herpetiformis. Wheat allergy, Gluten ataxia and Non-Coeliac Gluten Sensitivity are new gluten-related topics. The only treatment for CD, gluten-free diet (GFD).
Table 1: Spectrum of gluten-related disorders
Wheat allergy
Coeliac Disease Dermatitis herpetiformis Gluten ataxia
Non-Coeliac Gluten Sensitivity
Allergy
Autoimmunity
Immune-mediated (?) (innate-immunity)
Coeliac Disease Until the 1990’s merely patients with malabsorption were evaluated for CD. The introduction of antibodies revealed that CD is more common than thought. As opposed to patients identified by case-finding, most of the screen-detected coeliacs experience little symptoms of malabsorption. The consensus is to screen high-risk individuals, relatives of coeliacs, Down Syndrome, DM I, anaemia, transaminitis, osteoporosis and arthritis. Adherence to a GFD is accompanied by psychosocial and economic burdens. Symptomatic coeliacs accept this. Asymptomatic coeliacs consider GFD as an unnecessary, unwanted, overdone treatment. Dermatitis herpetiformis This chronic skin condition is characterized by intense burning, itchy and blistering rash. Treatment for DH is a GFD for life. In the majority of patients, Dapsone® may be prescribed to reduce the itching. Gluten ataxia As gluten sensitivity is a systemic illness, involvement of the cerebellum is an extraintestinal manifestation. Antigliadin antibodies are sensitive markers for the diagnosis. Only an early diagnosis can improve ataxia. 37
Wheat intolerance It is estimated that of individuals only 0.1% has a documented wheat allergy. Wheat allergy usually develops during the early infancy and is less common in adults. Gluten sensitivity Recent studies suggest a new condition, Non-Coeliac Gluten Sensitivity. Many individuals experience better health on a GFD, in absence of typical histological, serological, immunological signs of CD. We struggle to define this syndrome. NCGS can be recognized by intestinal symptoms, such as diarrhoea, abdominal discomfort or pain, bloating and flatulence. Gluten restriction in the management of NCGS can’t be denied anymore. Coeliacs will benefit by large NCGS-groups on GFD, the economic burden will give rise to new products, product lines etc. Conclusion Gluten-free diet was the monopoly for coeliacs and DH-patients. Since NCGS appeared, especially in Australia and New Zealand, there is GF-business everywhere. NCGS may be a new paradigm that is hard for us as Coeliac Research Groups to absorp. Rejection is neither rational nor helpful. For coeliacs there is a high priority of highly sensitive non-invasive tests to investigate histologic recovery after GFD.
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Modern imaging techniques: Which – when – why Andrea May, M.D., Ph.D. HSK Wiesbaden, Germany In the diagnostic work-up of small bowel diseases ultrasound of the small bowel, radiological imaging techniques such as CT or MR enteroclysis or angiography and different enteroscopy techniques are available. The main indication for investigation of the small bowel is still mid GI bleeding, that means that the bleeding source is located in the small bowel, followed by Crohn’s disease and polyposis syndromes. Abdominal ultrasound is a basis method, which is helpful in the majority of small bowel disorders. MR enteroclysis is mainly used for patients suffering from Crohn’s disease and polyposis syndromes like Peutz-Jeghers polyposis. CT resp. CT angiography plays a role in case of small bowel bleeding. Conventional angiography plays a role for therapeutic interventions like embolisation in case of strong small bowel bleeding. Due to the technical development within the last decade actually a variety of endoscopic devices is available: capsule endoscopy. Push enteroscopy, push-andpull enteroscopy in double (DBE) and single balloon (SBE) technique and balloonguided enteroscopy (NaviAidTM) as well as spiral enteroscopy. The less invasive capsule endoscopy is a safe, but pure diagnostic tool and represents a good screening method, whereas all flexible enteroscopy techniques are more invasive, but offer the option of taking biopsy samples and performing therapeutic interventions such as hemostasis, dilation, polypectomy or foreign body extraction. Push enteroscopy is an easy, fast and cheap method, but allows only insertion down to the proximal jejunum. For deep small bowel endoscopy, balloon-assisted enteroscopy (BAE: DBE, SBE) is actually the preferred method. The balloon-guided enteroscopy (NaviAidTM) plays no important role because of limited insertion depth. The spiral enteroscopy helps to reduce investigation time, but seems to be inferior to BAE regarding anal approach. Double balloon enteroscopy is still the gold standard enteroscopy technique at present, because it provides the highest rates for complete enteroscopy. The second balloon at the tip of the endoscope helps to hold the scope position in difficult anatomical conditions during advancement of the overtube and is probably less traumatic for holding the scope position compared e.g. with the flexed tip used in SBE, helps to stabilize the position during endoscopic therapy and helps to pull apart the pleated folds during withdrawal and therefore probably might reduce the percentage of missed lesions. Disclosure of conflicting interests Speakers honorarium and support of research is given by Fujinon and Given.
39
Session V + Session VI
LIVE Demonstrations Session VII
Large Bowel
41
Appendicitis/diverticulitis: Diagnostics and conservative treatment Wolfgang Kruis Ev. Krankenhaus Kalk, Universität zu Köln, Cologne, Germany Acute appendicitis is usually diagnosed by clinical measures. If clinical diagnosis is performed in a more systematic manner using a validated score (e.g. the Alvarado score) diagnostic accuracy can be improved. Inflammation and the extent of the disease (complicated or uncomplicated) of the appendix should be regularly confirmed by ultrasound. Recently, a growing number of studies demonstrate procalcitonin as a marker of severity and prognosis. Diverticulitis is defined as symptomatic diverticular disease with signs of inflammation. The most significant methods for the diagnosis of inflammatory reactions and complications are CT-scan and ultrasound. Both procedures, a history and physical examination are indispensible for an appropriate pretreatment evaluation. The choice of treatment is according to the disease status of the individual patient: Acute attack of diverticulitis – complicated or uncomplicated; in cases with uncomplicated divertiulitis, is it a mild, moderate or severe attack? Recurrent diverticulitis needs different therapeutic strategies, either for final solution or secondary prevention. Complicated attacks of acute diverticulitis or recurrent diverticulitis with chronic structural alterations are usually subject to interventional or surgical treatment. Acute uncomplicated diverticulitis is treated by diet restrictions up to nothing by mouth, fluid supplementation, analgesics and in moderate/severe cases with combined antibiotics while in mild cases 5-aminosalicylic acid may be sufficient. Relapses of acute attacks in diverticular disease without chronic structural alterations can be successfully prevented by physical activity and sufficient amounts of fibre additives. Recent data point towards an effective prevention with cyclically given antibiotics and/or 5-aminosalicylic acid. Probiotics may be a promise for the future. In general, the prognosis particularly for patients with asymptomatic diverticulosis but also for patients with diverticulitis is good. Complications occur in about 5% of the patients.
43
Appendicitis/diverticulitis: Minimal-invasive surgery D. Mutter, M.D., Ph.D., FACS; J. Marescaux, M.D., Hon FRCS, FACS, Hon FJSES IRCAD-EITS, University Hospital of Strasbourg, France Complicated intra-abdominal infections represented by acute appendicitis and complicated diverticulitis are diagnostic and therapeutic challenges. Both diseases, even if different in many ways, are caused by the obstruction of a blind pouch leading to inflammation, abscesses and perforation of the surroundings tissues. Acute appendicitis has been managed for many decades through a conventional surgical incision in the right iliac fossa. As for other diseases, there is a significant tendency to propose less invasive treatments. For many teams, laparoscopy, leading to less post-operative pain, a short in-hospital stay and a quicker recovery, represents the standard of care to perform an appendectomy. For selected cases, a medical approach can be proposed with satisfactory outcomes. Besides, the management of complicated diverticulitis is also moving quickly towards less invasive procedures than the deleterious “3 phases surgery” which are the Hartmann’s procedure, the secondary reversal protected with a stoma, and the final stoma closure. Thanks to the evolution of antimicrobial therapy and interventional radiology, many complicated cases classified as Hinchey stage I and as Hinchey stage II complicated diverticulitis, are nowadays treated medically. CT images allow identifying patients requiring radiological drainage of localised abscesses or collections over 5 cm in size. Patients with Hinchey stage III sigmoiditis may benefit from an initial laparoscopic exploration allowing, in some cases, a conservative non-resection approach that will avoid laparotomy and stoma. Major resection leading to temporary or definitive stoma is usually indicated for stage IV complications and is exceptionally required. Although a surgical intervention can be the definitive treatment for complicated intraabdominal infections, multidisciplinary management including radiology, medical treatment and laparoscopic surgery, may limit the severe consequences of acute surgical approach in patients suffering from complicated appendicitis and diverticulitis. The final goal of the management of an acute infected abdomen is nowadays to reduce hospital stay, disability, and numerous operations for these patients.
44
Serrated polyposis syndrome (SPS) Evelien Dekker, M.D., Ph.D. Academic Medical Center, University of Amsterdam, The Netherlands SPS is characterized by the presence of multiple serrated polyps spread throughout the colorectum and has been redefined by the World Health Organization in 2010 as the presence of at least five histologically diagnosed serrated polyps proximal to the sigmoid colon, of which 2 larger than 10 mm in diameter, or more than 20 serrated polyps distributed throughout the colon. SPS is associated with an increased risk for colorectal cancer (CRC), although clinical evidence for this increased risk is thus far based on cohort studies with associated ascertainment bias. The molecular evidence for the serrated pathway to CRC is currently further elucidated, facilitated by the identification of this syndrome. Current data suggest that the actual prevalence of SPS is more frequent in occurrence than other polyposis syndromes such as FAP (1:13.000). A genetic substrate has not yet been identified, but first-degree family members have an increased risk for CRC and both an autosomal recessive and autosomal dominant inheritance are considered. SPS patients are either advised to undergo endoscopic surveillance with removal of polyps or a surgical colonic resection. Expert opinions recommend surveillance intervals ranging from one to three years. Serrated polyps, which are the overall majority, are generally flat in shape and unremarkable in color and therefore easily missed during endoscopy. High quality colonoscopy with excellent bowel preparation is therefore important, and advanced endoscopic imaging techniques could add to this. From a clinical viewpoint, a further reclassification of SPS based on clinical as well as molecular/genetic risk may help to identify subtypes that have a higher risk of CRC development and to adjust surveillance intervals.
45
Colorectal cancer prevention: What is the best? Nadir Arber M.D., M.Sc., MHA Professor of Medicine and Gastroenterology, Yechiel and Helen Lieber Professor for Cancer Research, Head – The Integrated Cancer Prevention Center, Head – Cancer Research Center, Head – Djerassi Oncology Center, Tel-Aviv Sourasky Medical Center, Tel Aviv University, 6 Weizman St. Tel Aviv, Israel 64239, Tel: +972 3 6974968/3561, Fax: +972 3 6974867 Cancer prevention is the new frontier for cancer therapy. This is especially significant because cancer is the leading cause of death, surpassing heart disease. Colorectal cancer (CRC) prevention has become an important goal for health providers, physicians and the general public. CRC is a prevalent disease that is associated with considerable mortality and morbidity rates, with more than 1,200,000 new cases and > 600,000 deaths expected, worldwide, in 2012. However, since the progression of adenomatous polyps to overt cancer span over a decade, it provides a window of opportunities to prevent the disease. The progression of normal mucosa through adenoma to overt adenocarcinomas span over more than a decade. It provides a window of opportunities for early detection and chemoprevention interventions. Life style modifications are particularly important as they can prevent many cancers, in particular GI cancers, but other diseases as well. The most significant one are regular physical activity, abstinence from smoking and a healthy diet. Chemopreventive strategies have been extensively studied to prevent the recurrence of adenomas and/or delay their development. The non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin have been proven as promising and the most attractive candidates for CRC clinical chemoprevention. The preventive efficacy of these agents is supported by hundred of well conducted animal studies, and in 69 out of 71 epidemiological studies, all of them clearly demonstrating that NSAID and aspirin consumption prevents adenoma formation and decreases the incidence of, and mortality from CRC. Aspirin chemoprevention may be effective in preventing CRC within the general population, while aspirin and celecoxib may be effective in preventing adenomas in high risk patients. Nevertheless, the consumption of NSAID, aspirin and in particular COX-2 inhibitors is not toxic free. Well known serious adverse events to the gastrointestinal, renal and cardiovascular systems have been reported. These reports have led to some promising studies related to the use of lower doses and in combination with other chemopreventive agents and shown efficacy. The American Gastroenterological Association guidelines recommend colonoscopy every 10 years for average-risk individuals older than 50 years. There is no doubt that screening colonoscopy can reduce significantly the incidence, morbidity and mortality from CRC. However, screening colonoscopy is associated with significantly reduced mortality from left-sided lesions but only miniscule advantage for right-sided lesions. In the intriguing jigsaw puzzle of cancer prevention, we now have a definite 46
positive answer for the basic question “if”, but several other parts of the equationproper patient selection, the ultimate drug, optimal dosage and duration are still missing. It is suggested that aspirin should be combined with screening colonoscopy to achieve the greatest effect in CRC prevention. Obviously, the entire picture should be put in place, e.g., personalised medicine. The benefit-to-risk balance for cancer prevention should be weight in conjunction with the benefits in prevention of vascular and Alzheimer diseases. Aspirin might be an attractive candidate for reducing overall morbidity and mortality.
47
Session VIII
IBD
49
Staging and surveillance: What is the standard of care? R. Kiesslich Interdisziplinäre Endoskopie, I. Medizinische Klinik, Universitätsmedizin Mainz, Mainz, Germany, E-Mail:
[email protected] Colorectal cancer (CRC) is a serious potential complication of inflammatory bowel disease (IBD). Regular surveillance colonoscopy to diagnose early neoplasia is the mainstay of CRC prevention in IBD. Traditional surveillance recommendations advocate for obtaining random biopsies at regular intervals throughout the colon, as IBD patients have a propensity towards developing early flat and subtle neoplasms that may evade detection and rapidly progress to CRC. Total proctocolectomy (TPC) is further recommended for the treatment of advanced pre-cancerous lesions in IBD, including dysplasia-associated lesion or mass (DALM) and high-grade intra-epithelial neoplasia. However, newer endoscopic technologies, including high-definition endoscopy, chromoendoscopy, and confocal endomicroscopy, have significantly improved the neoplasia detection and characterization capabilities of endoscopic imaging and have the potential to alter the surveillance paradigm in IBD in favour of targeted neoplasia detection with endoscopic resection of even advanced pre-cancerous lesions. In my talk, I will present evidence supporting the adoption of such a strategy in the routine surveillance and staging of IBD patients.
References: Murthy S, Goetz M, Hoffman A, Kiesslich R. Novel colonoscopic imaging. Clin Gastroenterol Hepatol. 2012;10(9):984–7. Kiesslich R, Neurath MF. Chromoendoscopy in inflammatory bowel disease. Gastroenterol Clin North Am. 2012;41(2):291–302. Kiesslich R, Goetz M, Hoffman A, Galle PR. New imaging techniques and opportunities in endoscopy. Nat Rev Gastroenterol Hepatol. 2011;8(10):547–53.
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Step down or step up in Crohn’s disease? Gerhard Rogler Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürcher Zentrum für Integrative Humanphysiologie (ZIHP), Universität Zürich, Switzerland Crohn’s disease (CD) is a chronic inflammatory disease of the intestinal mucosa. Classically it has been treated with aminosalicylates, steroids or immunosuppressants such as azathioprine, 6-mercaptopurine or methotrexate in a step up approach if symptoms could not be controlled. In recent years anti-TNF antibodies have been firmly established in the therapy of CD. It was shown that their application is safe and not associated with higher risks of infections as compared to steroids or “classical” immunosuppressants. Anti-TNF antibodies have brought significant progress into CD therapy. Biologicals have been shown to reduce the need for both hospitalization and surgery in IBD patients. They are able to induce mucosal healing, a treatment goal that might become a new paradigm in CD management. They have especial beneficial effects if they are used during early disease courses. The use of biologicals after years of disease is compromised by the fact that the inflammation in CD induces tissue damage and loss of function to involved bowel segments as well as fibrotic changes that cannot be resolved upon anti-inflammatory therapy. Therefore the optimal time point for the start of anti-TNF therapy is crucial and has been discussed extensively. Several international experts now suggest a “top down” approach in which a combination therapy of azathioprine and anti-TNF is started after diagnosis and then stepwise de-escalated. There is mainly one study by D'Haens and co-workers that supports the concept. The CALM trial which will provide additional important insights unfortunately has just been started and is still in the early phase of recruitment. In general – despite the beneficial effect of guidelines and treatment algorithms – there is no “one fits all”-therapy in CD. An individual patient should receive an individualized therapy. A number of factors have to be considered to choose the optimal therapy for a patient suffering from CD: Age at onset, extraintestinal complications, smoking status, disease activity, disease location, early complications (such as perforations or strictures) are crucial factors that influence the appropriate choice of medication. In addition we have to keep in mind that our patients have different personalities determining their treatment preferences. To allow patients to make the appropriate treatment choices up-to-date “risk communication” appears to be important.
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Colitis ulcerosa: Current and future treatment strategies Britta Siegmund Charité Universitätsmedizin Berlin, Medical Department (Gastroenterology/Rheumatology/Infectious Diseases), CBF, Berlin, Germany The incidence of inflammatory bowel diseases including ulcerative colitis is continuously increasing worldwide, thus there is a strong need for more effective treatment strategies. To this day there is no therapy allowing for healing ulcerative colitis, consequently the available medications will have to be applied at its best. The preferred option for mild pan- or left-sided colitis is still mesalazine either administered systemically or locally. One can only emphasize that the formulations allowing for once daily dosing are not only equally effective but even more facilitate the implication of long-term therapy in daily life. In case steroids are frequently required to control disease, further immunosuppressive therapy should be introduced in order to minimize steroid exposure. Thiopurine represent the first choice immunosuppressive medication. In more severe cases even early escalation to combinatory therapies with anti-TNF antibodies should be considered with the possibility of therapy deescalation after induction of remission. The difficulties start with steroid refractory acute flares. Here ciclosporin as well as anti-TNF strategies can be initiated. However, in case of severe disease the high one-year colectomy rate of about 50% should be considered. If short-term surgery is an option due to disease severity ciclosporin might be advantageous since the half-life is short compared to inflximab or adalimumab, respectively. The central problem of all therapeutic approaches is that we chase after the disease, thus solid markers that allow for prediction of the future disease course are desirable. In fact, the CD8+ transcriptome might fill this gap and will potentially lead to the classification of patients in low and high-risk groups.
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List of Chairpersons, Speakers and Scientific Organizers
Prof. Dr. Nadir Arber Tel Aviv Medical Center Ichilov Hospital Department of Gastroenterology 6, Weizman Street 64239 Tel Aviv Israel Prof. Dr. Pradeep Bhandari Queen Alexandra Hospital Department of Gastroenterology Southwick Hill Road Cosham PO6 3LY Great Britain Prof. Dr. Dr. h. c. mult. Markus W. Büchler Allgemein-/Viszeralchirurgie Universitätsklinikum Heidelberg Im Neuenheimer Feld 110 69120 Heidelberg Germany Suresh T. Chari, M.D. Mayo Clinic Miles & Shirley Fiterman Center for Digestive Diseases 200 First Street SW Rochester, MN 55905 USA Dr. Evelien Dekker Univ. van Amsterdam, Tytgat Institute for Liver & Intestinal Research Afd. MDL C2-331 Meibergdreef 9 1105 AZ Amsterdam The Netherlands Prof. Dr. Axel Dignass Innere Medizin I AGAPLESION Markus Krankenhaus Wilhelm-Epstein-Str. 4 60431 Frankfurt Germany
Prof. Dr. Christian Ell Innere Medizin II HSK Dr. Horst Schmidt Klinik Ludwig-Erhard-Str. 102 65199 Wiesbaden Germany Prof. Dr. Wolfgang Fischbach Innere Medizin II Klinikum Aschaffenburg Am Hasenkopf 1 63739 Aschaffenburg Germany Prof. Dr. Peter R. Galle Innere Medizin I Universitätsmedizin der Johannes Gutenberg-Universität Langenbeckstr. 1 55131 Mainz Germany Dr. Truls Hauge Associate Professor Oslo University Hospital Department of Gastroenterology 0407 Oslo Norway Prof. Dr. Michael Jung Innere Medizin Katholisches Klinikum Mainz St. Hildegardis-Krankenhaus Hildegardstr. 2 55131 Mainz Germany Prof. Dr. Ralf Kießlich Innere Medizin I Universitätsmedizin der Johannes Gutenberg-Universität Langenbeckstr. 1 55131 Mainz Germany
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Prof. Dr. Wolfgang Kruis Innere Medizin Evang. Krankenhaus Kalk Buchforststr. 2 51103 Köln Germany
Prof. Dr. Christa Meyenberger Kantonsspital FMH Gastroenterologie Rorschacherstr. 95 9007 St. Gallen Switzerland
Prof. Dr. Matthias Löhr Karolinska University Hospital Huddinge CLINTEC, K53 141 86 Stockholm Sweden
Prof. Dr. Joachim Mössner Gastroenterologie/Rheumatologie Universitätsklinikum Leipzig AöR Liebigstr. 20 04103 Leipzig Germany
Prof. Dr. Dietmar Lorenz Allgemein-/Viszeralchirurgie HSK Dr. Horst Schmidt Klinik Ludwig-Erhard-Str. 102 65199 Wiesbaden Germany
Prof. Dr. Christinus J.J. Mulder Vrije Universiteit Medisch Centrum Afd. MDL de Boelelaan 1117 1081 HV Amsterdam The Netherlands
Prof. Donald E. Low Virginia Mason Seattle Main Clinic Head of Thoracic Surgery and Thoracic Oncology 1100 Ninth Ave. Seattle, WA 98101 USA Prof. Dr. Peter Malfertheiner Gastroenterologie/Hepatologie Universitätsklinikum Otto-von-Guericke-Universität Leipziger Str. 44 39120 Magdeburg Germany Prof. Dr. Andrea May Innere Medizin II HSK Dr. Horst Schmidt Klinik Ludwig-Erhard-Str. 102 65199 Wiesbaden Germany
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Prof. Dr. Didier Mutter Hôpitaux Universitaires 1, Place de l'Hopital 67091 Strasbourg France PD Dr. Oliver Pech Innere Medizin II HSK Dr. Horst Schmidt Klinik Ludwig-Erhard-Str. 102 65199 Wiesbaden Germany Prof. Dr. Alessandro Repici Istituto Clinico Humanitas IRCCS Department of Digestive Endoscopy Via Manzoni, 56 20089 Rozzano Italy Prof. Dr. Jürgen Ferdinand Riemann c/o Stiftung Lebensblicke Parkstr. 49 67061 Ludwigshafen Germany
Prof. Dr. Claus Rödel Strahlentherapie und Onkologie Klinikum der Johann Wolfgang Goethe-Universität Frankfurt Theodor-Stern-Kai 7 60596 Frankfurt Germany Prof. Dr. Dr. Gerhard Rogler Universitätsspital Zürich Klinik für Gastroenterologie & Hepatologie Rämistr. 100 8091 Zürich Switzerland
Prof. Dr. Hironori Yamamoto Jichi Medical School Division of Gastroenterology 3311-1, Yakushiji, Minamikawachi Kawachi, Tochigi 329-0498 Japan Prof. Dr. Hubert Zirngibl Chirurgie Helios Klinikum Wuppertal Heusnerstr. 40 42283 Wuppertal Germany
Prof. Dr. Britta Siegmund Gastroenterologie Charité Universitätsmedizin Campus Benjamin Franklin (CBF) Hindenburgdamm 30 12203 Berlin Germany Stuart J. Spechler, M.D. Professor of Medicine VA Medical Center Department of Gastroenterology 4500 S. Lancaster Road Dallas, TX 75216-7167 USA Prof. Dr. Julius Spicák Institute for Clinical and Experimental Medicine Videnska 1958/9 140 21 Praha 4 Czech Republic Prof. Dr. Alex Straumann FMH Gastroenterologie Römerstr. 7 4600 Olten Switzerland
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POSTER ABSTRACTS Poster Numbers 1 – 91
Author Index to Poster Abstracts
1 Endoscopic band ligation versus injection sclerotherapy of bleeding internal haemorrhoids in patients with liver cirrhosis Atif Awad1, Hanan Soliman1, Sabry Abou Saif1, Abdel Monem Nooman2, Samah Mosaad1, Asem Elfert1and Mohamed Sharaf-Eldin1 Tropical Medicine & Infectious Diseases1 Department and Diagnostic Radiologyb Department, Faculty of Medicine, Tanta University, Tanta, Egypt2 Background and study aims: Bleeding internal haemorrhoids are common and used to be treated surgically with too many complications. Sclerotherapy and rubber band ligation are the candidates to replace surgical therapy especially in patients with liver cirrhosis. The aim of this study was to compare endoscopic injection sclerotherapy (EIS) to endoscopic rubber band ligation (EBL) regarding effectiveness and complications in the treatment of bleeding internal haemorrhoids in Egyptian patients with liver cirrhosis. Patients and methods: One hundred and twenty adult patients with liver cirrhosis and bleeding internal haemorrhoids were randomised into two equal groups; the first treated with EBL using Saeed multiband ligator, and the second with EIS using either ethanolamine oleate 5% or N-butyl cyanoacrylate. All groups were matched as regards age, sex, Child score. Patients were followed up clinically and with abdominal ultrasound. Results: Both techniques were highly effective in the control of bleeding from internal haemorrhoids with a low rebleeding (10% in the EBL group and 13.33% in the EIS group) and recurrence (20% in the EBL group 20% in the EIS group) rates. Child score had a positive correlation with rebleeding and recurrence in EIS group only. Pain score and need for analgesia were significantly higher while patient satisfaction was significantly lower in EIS compared to EBL (p < 0.05). No significant difference between ethanolamine and cyanoacrylate subgroups was found (p > 0.05). Conclusions: Both EBL and EIS were effective in the treatment of bleeding internal haemorrhoids in patients with liver cirrhosis. EBL had significantly less pain and higher patient satisfaction than EIS. EBL was also safer in patients with advanced cirrhosis.
2 The anti-Helicobacter pylori therapy in gastric extranodal marginal impact zone B-cell lymphoma of MALT Daniela Badea, M. Badea, Amelia Genunche, A. Badea UMF Craiova, Dolj, Romania Introduction: The treatment of gastric extranodal marginal zone B-cell lymphoma of MALT type (E-MZL) is dictated primarily by stage and histological grade and optimal management requires an integrated multidisciplinary approach involving medical oncologists, radiation oncologists, pathologists, and surgeons. Methods: During the last 15 years, there were registered eleven lesions of E-MZL with gastric determinations. Results: From the eleventh cases with E- MZL gastric, eighth (72.72%) present themselves in localized stage, IE, IIE. Six of these ones (75%) responded the Helicobacter pylori (HP) triple eradication therapy. In evolution, two patients relapsed locally (range 25–37 months). Both patients responded to CVP chemotherapy and the estimated survival rate, of localized stage group, at 5 years being 100%. Three patients (27.27%) presented with an advanced stage of the disease (IIIE and IVE), two of them has laparotomy for diagnostic/treatment reason, with partial gastric resection. Two of the three of advanced stage patients underwent eradication therapy for HP, but only one patient presented a partial response. A whole lot of patients who was in an advanced stage/relapsed lymphoma were treated with protocols of CVP or CHOP type by rapport of the presence of confluent clusters or sheets of large cells resembling centroblasts. The rate of response was also 100%. Two of these patients presented multiple relapses, controlled by chemotherapy. The survival rate of 5 years in this lot has been of 66.67%. Median follow-up was 75 months (range, one to 116). Discussion/Conclusion: The E-MZL therapy presents characteristics through the response to the HP eradication therapy manly in the localized stage. Systemic chemotherapy is effective in advanced and relapsed E-MZL. The 5 years survival rate for this group of patents is 90%.
3 Extranodal non-Hodgkin's lymphomas of gastrointestinal tract M. Badea, Daniela Badea, Amelia Genunche, A. Badea, Doina Iordache UMF Craiova, Dolj, Romania Introduction: The gastrointestinal tract (GI) is the predominant site of extranodal non-Hodgkin's lymphomas (NHLs). Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies with this localisation. Methods: During the last 15 years there were registered 19 patients with primary GI NHLs. Results: The stomach is the most frequently affected parts of the GI 73.68%, being followed by the colonic 21.05% and intestinal localization 10.55%. Histologic 68.42% are extranodal marginal zone B-cell lymphoma of MALT type (E-MZL), 21.05% diffuse large-B cell lymphoma (DLCL), and 10.55% mantle cell lymphoma (MCL). Gross pathology of these tumors differs: a mass or polypoid lesion with or without ulceration in 63.15%, benign-appearing gastric ulcer in 42.1%, nodularity thickened, cerebroid gastric folds in 21.5% of cases and infiltrative lesions in 16%. The majority of lesions are unifocal but 10.55 are multiple extralymphoid determinations. The medium age of the lot is 58 ± 4 years and the sex ratio favor male gender 63.15%. 8 (42.1%) cases are localized stage (IE/IIE) and 87.5% of this are E-MZ, while only 63.63% of the advanced stages are of E-MZL type. No matter which is the histology and localization primarily symptom was the abdominal pain present in 89.47% of the cases, followed by anorexia in 50% of the cases and weight loss in 30% of the cases. The evolution of symptoms from the debut to the diagnostic ranges from 4 weeks to one year. Discussion/Conclusion: Despite their rarity, primary NHL lymphomas of the GI tract are important, since their management and prognosis are distinct from that of adenocarcinomas of the GI tract.
4 Terminal ileum lymphoma – Case report Alice Bartkova MD, Martin Liberda MD Department of Gastroenterology, Valasske Mezirici Hospital, Valasske Mezirici, Czech Republic The authors present a case report concerning the patient reffered to colonoscopy due to faecal occult blood test (FOBT) positivity. Intubation of terminal ileum, which is not ussually performed as a standard during colonoscopy, revealed difuse large B-cell lymphoma in early stage and therefore with a good prognosis. Lymphomas constitute 6% of newly diagnosed malignancies, 85% of which are nonHodgkin’s lymphomas (NHL). The most frequent type of NHL is diffuse large B-cell lymphoma (DLBCL). Primary extranodal DLBCL occurs in up to 40%, most commonly in GIT (stomach, ileocaecal area). The list of pathological findings in terminal ileum contains tumors, inflammatory diseases, infections, drug induced and ischaemic laesions. Indication for terminal ileum intubation has not been clearly defined yet, most often it is performed in patients suffering from right lower quadrant abdominal pain and/or persistent diarrhoea. The diagnostic yield of terminal ileum intubation still remains controversial. Terminal ileum intubation improves and maintains the endoscopists’ skills and is a prerequisite for successful implementation of this maneuver when necessary. It also proves the colonoscopy completeness. With gradual practice we can achieve up to 85% success and in experienced endoscopists’ hands colonoscopy is prolonged by only 3 minutes on average. Therefore, we recommend a trial of terminal ileum intubation as a routine during diagnostic colonoscopy.
5 Whether the existence of fat in the liver increases the risk of cancer and operation M. Basaranoglu BezmiAlem Vakif University, Istanbul, Turkey Background and aim: Whether fatty liver which occurs in about 20–30% of adults increases the risk of cancer and operation has not been clearly evaluated. Moreover, whether there is a family risk factor such as cancer in this group of patients (with fatty liver) is not known. We investigated the frequency of both past abdominal operation and cancer in these patients with fatty liver and in their first degree relatives. Material and methods: In this study, we evaluated 105 patients with NAFLD, 121 patients with hep C (61 with hepatic steatosis and 60 without steatosis), 50 patients with IBD and 109 patients with dyspepsia, retrospectively. Alcohol history was excluded from each patient. Results: There was no difference for gender, marital status, and the mean age among the groups; except, the patients with IBD were younger than the others (p < 0.001). The frequency of cancer in their relatives was 18%, 9%, 28%, 21.5% and 27% in patients with IBD, dyspepsia, Hep C with steatosis and without steatosis, and NAFLD, respectively (p = 0.006). The frequency of past operation in the patients was 4%, 40%, 45%, 41% and 44% in patients with IBD (after the exclusion of intestinal surgeries due to the IBD as a complication), dyspepsia, Hep C with steatosis and without steatosis, and NAFLD, respectively (p = 0.001). In further analysis, there was no difference among the groups for the cancer frequency after the exclusion of patients with dyspepsia (9%), and the past operation frequency after the exclusion of patients with IBD (4%). Then, we divided the study group into two groups as group 1: IBD + dyspepsia + Hep C without steatosis and group 2: Hep C with steatosis + NAFLD, and performed the same analysis as follows: the frequency of cancer in the relatives was 16% vs. 24.4% (p = 0.037) and the prevalence of past operation in the patients was 33% vs. 43% (p = 0.043). Conclusion: Independently from the underlying chronic disesase, the relatively higher prevalence of previous operation history and cancer diagnosis in patients with fatty liver and in their relatives merits further research. Understanding the underlying causes of fatty liver forms the basis for rational preventive and treatment strategies.
6 Features of the Crohn’s disease in Transylvania in the last 10 years Simona Bataga1, Imola Torok1, Dan Georgescu1, Melania Macarie1, Tiberiu Bataga2 1 1st Gastroenterology Clinic, UMF, Tg-Mures, Romania 2 University of Medicine and Pharmacy, Tg-Mures, Romania Introduction: The aim of the study is to determine the changes in incidence and features of Cohn’s disease in our region. Methods: Two groups of patients who underwent colonoscopy on a period of five years each entered this study. The diagnosis was put on endoscopy and histology. Group A included 2027 pacienţi (median age 62.3 years, 61% males) investigated between 1996–2000, and group B consisted of 4012 patients (median age 60.1 years, 62% males) investigated between 2006–2010. Results: From group A, 58 (2.86%) had IBD, 52 (2.61%) had ulcerative colitis (UC) and 6 (0.24%) had CD. From the patients with CD in 3 patients surgery was needed, having small bowel disease, presenting with stenosis and diagnosed on surgery. All the patients received anti-TNF-α (Infliximab) 5 mg/kg at 0, 2 and 6 weeks, 5-ASA (Salofalk®), corticosteroids and azathioprine with good evolution. The other 3 patients had Crohn’s colitis. Two patients received also anti-TNF-α in induction treatment, as it was the protocol on that period. From group B 125 (3.11%) had IBD, 106 (2.64%) UC and 19 (0.47%) CD. CD included 19 patients, 5 patients needed surgery having stenosis and one died comming to our hospital with pseudomembranous colitis. 5 patients needed antiTNF-α, the others have a good evolution on Azathioprine, corticosteroids and 5- ASA. Discussion/Conclusion: IBD are increasing in our region, especially CD that increased statistically significant in the last 5 years (p < 0.05), more than three times. Biological treatment is now a national program, all the Cohn’s patients being evaluated and the treatment is approved as emergency when it is needed.
7 Whipple’s disease: A challenge of clinical, histopathological and electronomicroscopical diagnosis. Experience of a Romanian Tertiary Center – A five-case series with long-term follow-up Gabriel Becheanu1, Anamaria Pop2, Eugen Mandache3, Mihaela Gherghiceanu3 1 Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania 3 Victor Babes National Institute of Pathology, Bucharest, Romania Introduction: Whipple’s disease is an chronic inflammatory systemic disease caused by Tropheryma whipplei, an ubiquitous Gram-positive Actinobacteria. The incidence of the disease is very low worldwide, less than 1 per 1 million. We report five new consecutive cases, four males and one female patient, diagnosed in our clinic from August 2002 to January 2012. Methods: Diagnosis was reached with the help of gastroduodenal endoscopy and histopathological examination of the duodenal biopsies, by lymph node biopsy and by electron microscopy. Results: The main symptoms were arthralgia, weight loss and diarrhea. The endoscopic aspect of the small bowel mucosa varied from congestion, granularity of the mucosa to whitish plaques. All patients showed PAS positive, diastase resistant, Ziehl-Neelsen negative macrophages in the lamina propria of the duodenal mucosa and, in one patient, suspected for lymphoma, in an abdominal lymph node. The diagnosis was confirmed by electron microscopy in all cases. Classic Whipple's disease was the diagnosis in all five cases, but one patient showed involvement of the endocardium and two patients showed lymphadenopathies. Clinical evolution was favourable under long-term antibiotics (Cephtriaxone/ Trimethoprim-Sulfamethoxazole) with lack of symptoms and weight gain. The longterm follow-up (2–9 years) with repeated biopsies at six months and one year showed a normal endoscopical mucosa and an evident reduced but persistent number of PAS positive macrophages in the duodenal mucosa. Discussion/Conclusion: Whipple’s disease is an extremely rare systemic disorder and untreated has a poor prognosis. But long-term antibiotic therapy and follow-up with repeated biopsies can assure at least a clinical and endoscopical remission, even if some macrophages are still detected at one year on digestive mucosal biopsy.
8 Double-headed colonic polyp: Double amount of abdominal fat? Gabriel Becheanu1, Mihai Ciocirlan2, Mona Dumbrava3, Stefan Costinean4 1 Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania 3 Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania 4 Department of Pathology, Comprehensive Cancer Center, Ohio State University, Columbus, Ohio, USA Introduction: Different studies revealed a correlation between obesity and the presence of colonic adenomas, usually advanced polyps. We studied bizarre colonic polyps, included one of our cases. Methods: A 35-year-old female patient was investigated for rectal bleeding by colonoscopy and a bizarre polyp was discovered. A polypectomy was performed from the base of the common stalk and both heads of the polypoid lesion were examined on HE stain. Results: The polyp showed a bi-head adenoma feature with low-grade dysplasia and normal endoscopic aspect was observed after one year and three years follow-up. The BMI of the patient was 31.2. This is the fourth case of doubled-headed colonic polyp described in the literature and we noticed that three of these cases present a common feature – obesity. The two polyps had either identical histology, e.g. adenomas or could exhibit different histological features: adenocarcinoma – adenoma, hamartomatous polyp – leiomyoma. Discussion/Conclusion: We suggest that obesity not only increase the incidence of colonic adenomas but also could be a significant factor for the appearance of such atypical intestinal polyps.
9 Caerulein regulates the ghrelin molecular system in the pancreatic acini J. Bonior1, J. Jaworek1, M. Kot1, S.J. Konturek2 1 Department of Medical Physiology Faculty of Health Sciences, 2Chair of Physiology Medical Faculty, School of Medicine Jagiellonian University, Krakow, Poland Introduction: Ghrelin, an endogenous ligand for the growth hormone (GH) secretagogue receptor (GHS-R) was originally isolated from the stomach and identified in the pancreas. Ghrelin protects the pancreas from the damage caused by caerulein-induced pancreatitis, but the implication of GHS-R and its endogenous ligand in the pancreatic protection is unclear. The aim was to determine the effect of ghrelin and caerulein on mRNA and protein levels of GHS-R1a subtype and of acylated ghrelin in isolated pancreatic acini. Methods: Wistar rats were injected with ghrelin (12.5, 25.0 or 50.0 µg/kg i.p.) or with physiological saline (control). 48 h later pancreatic acini were isolated and subjected to caerulein stimulation (10-12, 10-10 or 10-8 M) for: 0 h, 20’, 1, 3 or 5 h at 37°C. The most effective time of incubation was 3 h. High doses of ghrelin and caerulein were selected for further experiments. RT-PCR and Western blot methods were used to determine mRNA and protein levels. Results: GHS-R1a and acylated ghrelin were identified in the pancreatic acini isolated from control rats. Pretreatment of the rats with ghrelin resulted in the significant and dose-dependent upregulation of both investigated parameters. On the contrary, application of caerulein to the acini significantly and dose-dependently downregulated GHS-R1a, but failed to affect the signal for ghrelin. Pretreatment of the rats with ghrelin prevented from caerulein-induced downregulation of GHS-R1a. Discussion/Conclusion: Caerulein is able to modify the GHS-R1a subtype in the pancreatic acini. This effect could be prevented by pretreatment with ghrelin and perhaps might be implicated in the mechanism of pancreatic damage induced by caerulein overstimulation.
10 A case report of Clostridium difficile infection in patient with ulcerative colitis Pavlina Boykova, Miglena Stamboliyska, Prof. Iskren Kotzev Department of Gastroenterology, University Hospital “St. Marina”, Varna, Bulgaria Introduction: Antibiotic-associated (C. difficile) colitis is an infection of the colon caused by C. difficile that occurs primarily among individuals who have been using antibiotics. Traditionally, antibiotic use is often considered the most important factor for the development of C. difficile colitis. Increasingly, C. difficile colitis is diagnosed in patients without previous antibiotic exposure. This is especially true in patients with Crohn's disease or ulcerative colitis. Case: Thirty-two year old woman presenting with bloody diarrhea – 15 to 16 times daily, abdominal pain and fatigue for the last four days. Ulcerative colitis (UC) – pancolitis was diagnosed before two years based on clinical presentation, colonoscopic and histological examination. The patient has been admitted several times in hospital because of exacerbation of the disease. Previous hospitalization was 17 days ago when she was treated with antibiotics – medaxon 2 mg/day for 7 days and metronidazole 2 x 500 mg i.v. for 10 days, systemic corticosteroids at initial dose of 40 mg/day, 5-ASA 4 g/day, azathioprin 100 mg/day, probiotics and PPI. The patient was discharged in clinical remission. At the last admission in the hospital laboratory test results were as following: Hgb – 134; Ht – 0.38; RBC – 4,17; WBC – 11.64; CRP – 13.83; ESR – 25 mm/h. Stool microscopy did not show parasites and amebiasis. Microbiological examination of the stool did not find Salmonella, Shigella and E.Coli. Clostridium difficile toxin A and toxin B were detected in stool sample. Colonoscopy was not performed because of the severity of colitis. Vancomycin 500 mg four times a day was initiated in addition to firstly started medications for treatment of UC – systemic corticosteroids at initial dose of 60 mg/day, 5-ASA 4 g/day, azathioprin 100 mg/day, probiotics, metronidazole 2 x 500 mg i.v., and PPI and p.e. nutrition. Patient’s symptoms resolved rapidly. The duration of treatment with Vancomycin was 7 days. At the end of treatment patient had one defecation daily without blood. Discussion/Conclusion: This is an example of severe exacerbation of UC due to overlap of C. difficile infection. C. difficile colitis should be considered while evaluating patients with severe acute colitis who have been treated with antibiotics.
11 Long-term follow-up of chronic hepatitis C patients with virological and biochemical response to therapy Bahadir Ceylan, Muzaffer Fincanci, Cuneyt Muderrisoglu, Ferda Soysal, Gulhan Eren and Metin Basaranoglu* SB Istanbul Training and Research Hospital, Division of Infectious Diseases and Clinical Microbiology, Samatya, Istanbul, Turkey Background and aim: To determine the long-term effect of pegylated interferon plus ribavirin therapy on the biochemical and virological markers of hepatitis C virusinfected patients who responded to treatment. We performed a long-term biochemical and virological follow-up of the end of treatment virological responders. Material and methods: Eighty-nine patients were included in this retrospective study. Results: The duration of biochemical and virological follow-up was 17.57 months (range, 1–42 months) after therapy. Virological relapse during the follow-up was observed in 13 patients (14%) among “the end of treatment virological responders”. All relapses occurred within the first six months following the treatment. The virological relapse was accompanied by elevation of serum alanine transaminase levels. The patients with no virological relapse during the follow-up did not experience biochemical relapse. The only significant predictor of virological relapse was HCV RNA levels of > 2 x 106 copies/ml before the treatment. Conclusion: Our results indicate that virological relapse is not expected in patients who have virological response within the first six months after the treatment and that relapse after treatment is associated with high HCV-RNA levels prior to therapy.
12 Long-term follow-up of patients with anti-hepatitis D antibody Bahadir Ceylan1, Muzaffer Fincanci2, Cuneyt Muderrisoglu3, Ferda Soysal2, Gulhan Eren2*, Metin Basaranoglu1 1 Bezmialem Vakıf University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology 2 Ministry of Health’s, Istanbul Training and Research Hospital, Division of Infectious Diseases and Clinical Microbiology 3 Ministry of Health’s, Istanbul Training and Research Hospital, Istanbul Training and Research Hospital, Division of Internal Diseases, Istanbul, Turkey *Presenter: Metin Basaranoglu, MD Aims: To investigate long-term outcome of anti-HDV positive patients, and to evaluate factors associated with treatment response. Patients: Treated and untreated patients with anti-hepatitis delta seropositivity. Investigations: Records of baseline demographics, liver biopsy findings, virologic activities for hepatitis B and D, investigation for hepatocellular carcinoma, treatment regimens and duration in the last 7 years. Evaluation: Virological response rates and variables associated with virological response at the twelfth month, at the end of therapy and at the end of follow-up for 1–4 years. Results: Seventeen (94%) of 18 anti-hepatitis delta positive patients had detectable HDV RNA at first visit. Thirteen patients had standard interferon for 12–24 months. Virological response rates were 7/13 (53%) at the twelfth month, and 6/13 (46%) at the end of the treatment, but dropped to 3/10 (30%) at first year and 2/13 (15%) at 4th after treatment. The patients with serum ALT levels higher than 90 U/l responded better to therapy at the end of treatment. Conclusions: Our results suggest that most of the patients with anti-hepatitis D antibody have detectable HDV RNA, and long-lasting remission after treatment with standard interferon is low, and patients with higher serum ALT levels respond better to interferon therapy.
13 Comparison of chronic hepatitis B patients using tenofovir and entecavir in terms of viral kinetics, virologic response and side effects Bahadir Ceylan, Muzaffer Fincanci, Cuneyt Muderrisoglu, Ferda Soysal, Gulhan Eren and Metin Basaranoglu* SB Istanbul Training and Research Hospital, Division of Infectious Diseases and Clinical Microbiology, Samatya, Istanbul, Turkey Background and aim: The aim of this study is to compare chronic hepatitis B patients using tenofovir or entecavir in terms of viral kinetics, side effects and virologic response. Material and methods: Subjects who used tenofovir or entecavir for chronic hepatitis B infection for varying durations were included in this retrospective study. Subjects were divided into groups as the ones whose HBV DNA levels reduced or not 2.4 and 6 log10 unit at 3, 6. and 12. months of therapy and whether tenofovir or entecavir use affected HBV DNA reduction rates. Additionally, whether tenofovir or entecavir therapies were different in terms of side effects and virologic response was investigated. Results: A total of 135 subjects (79 males, 58.5% and 56 females, 41.5%) aged between 43–79 years were included in the study. Tenofovir or entecavir use did not affect the reduction rates of HBV DNA at 3., 6. and 12. months of therapy. In multivariate survey analysis, virologic response was seen to be better in case of tenofovir use and serum HBV DNA level < 100,000 U/ml (for tenofovir use odds ratio 0.642 and p = 0.028; for serum HBV DNA level < 100,000 U/ml, odds ratio 0.430 and p = 0.01). While side effects developed in 7 subjects who used tenofovir and 3 subjects who used entecavir, there was not a difference between case groups in terms of side effect frequency. Conclusions: Results of this study suggested that virologic response rates were better in chronic HBV infected subjects who used tenofovir compared to entecavir and there was not a difference between two groups in terms of side effect rates.
14 Eosinophilic oesophagitis – Our experience and evolving service K. Charles, J. Turner, J. Swift, J. Green, S. Dolwani Llandough Hospital, Cardiff, Wales, United Kingdom Introduction: Eosinophilic oesophagitis is a recently recognised chronic inflammatory disease of the GI tract. Patients often present with symptoms of dysphagia and food impaction and the condition may remain undiagnosed for years. Diagnosis is made through proximal oesophageal biopsies demonstrating a raised eosinophil count (15–20 per HPF). We present 4 years of data from our unit and propose a nurse led treatment and follow up service for this condition. Methods: Cases were identified from a prospectively held gastroenterology database between April 2008–April 2012. A simple proforma was completed for each patient recording length of symptoms, previous investigations and treatments, allergy history and endoscopic findings. The specialist nurse gave written and verbal information, recorded symptom response and made treatment adjustments in the outpatient clinic. Results: 13 patients (10 male and 3 female) were diagnosed, median age at diagnosis – 44 (range 31–84). 12 patients had an atopic history. All patients had dysphagia to solids, 8 reported food bolus obstruction. Median length of symptoms – 2 years (range 4 months to 5 years). With treatment, 6 patients had full response to swallowed fluticosone, 3 are awaiting review. 1 patient relapses off topical fluticosone. 3 patients did not attend any further appointments. Discussion/Conclusion: The demographics and good response to topical steroids in our cohort of patients is consistent with published data1. Due to the complex nature of this condition, we feel our patients have benefitted from having a detailed explanation and discussion of treatment by the specialist nurse and we plan to develop this service further.
Reference: 1. Straumann A. Eosinophilic Esophagitis: a rapidly emerging disorder. Swiss Medical Weekly. 2012; 142: w13513
15 Treatment with UDCA and neuroendocrine tumor Dr. Claudia Cimpoeru Medical, Diagnosis, Ambulatory Treatment and Preventive Medicine Center Bucharest, Romania Introduction: UDCA is a nontoxic hydrophilic bile acid used to treat predominantly cholestatic liver disorder; it is of unproven efficacy in non-cholestatic disorder such as acute rejection after liver transplantation, non-alcoholic steatohepatitis, alcoholic liver disorder, chronic viral hepatitis, drug induced hepatitis, tumor prevention. Cholelithiasis is a very common adverse reaction reported during octreotide therapy. Methods: A 69-year-old women presented with asthenia, mild right upper quadrant complaints. Results: Biological: transaminases, γ-GT and glicemia were slightly increased. Ultrasonography: criteria of severe non-alcoholic steatohepatitis, sludge in gallbladder. Endoscopic examination reveal a one cm tumor in duodenum with normal mucosal surface; endoscopic ultrasonography showed hypoechogene structure which was though to arise from the sub mucosal layer. Upon informed consent the tumor was removed by endoscope resection for diagnosis and treatment. Pathologic examination revealed neuroendocrine tumor with incert potential of malignancy. Imunohistochimy: neuroendocrine tumor CROMO positive, SYN positive, GAS positive, glucag negative, VIP negative KI 67 positive. The patient start therapy with octreotide 20 mg im monthly and UDCA 15 mg/kg/body. Patient's progress was evaluated at three, six and twelve months and all laboratory test values falling within the normal range. There was no evidence of disease recurrence after one year of follow-up. Discussion/Conclusion: Non-alcoholic steatohepatitis, cholelithiasis and endocrine system are closely related. The extent to which application of UDCA influence this process is only partly understood. In this case treatment with acidum ursodeoxicolicum was useful not only for treatment of NASH but also for prophylaxis of stone of gallbladder; another beneficial effect of UDCA is to prevent reccurence of duodenal tumor. This case emphasis the need of further researches for a better understanding of the NASH, cholelithiasis and gastrointestinal hormone secretion.
16 Survey of the efficacy and safety of infliximab in the first paediatric patients with Crohn’s disease treated in Romania Alexandrina Constantinescu, Liana Gheorghe, Roxana Vadan, Cristian Gheorghe Paediatric Clinic, Gastroenterology & Hepatology Center, Fundeni Clinical Institute, Bucharest, Romania Introduction: Biological agents have contributed significantly in controlling inflammatory bowel disease at children. The aim of this study is to evaluate the efficacy and safety of Infliximab in the first paediatric patients treated in Romania. Methods: Between Jul. 2004 and Jan. 2011 in Paediatric Clinic and Gastroenterology & Hepatology Center, Fundeni Clinical Institute, Bucharest, Romania were treated with Infliximab 8 patients with moderate-to-severe Crohn’s disease (CD), one with fistulising CD. Patients were 9 to 16 years of age at diagnosis and 11 to 18 years of age at biological therapy initiation; raport M:F = 4:5. Patients received an induction regimen of Infliximab 5 mg/kg – 3 infusions at weeks 0–2–6. Initial dose for maintenance of remission was 5 mg/kg – 1 infusion at 8 weeks. To optimize the response to treatment the dose was adjusted: doubled to 10 mg/kg at 8 weeks interval or the time between infusions shortened < 8 weeks. Results: After 12 weeks all patients were in clinical remission (PCDAI ≤ 10 points). All responsive patients were able to stop corticosteroids. The patient with fistulizing CD (with previous total proctocolectomy and ileal pouch with perianal complex fistulas) did not respond to Infliximab therapy and finally ileostomy was performed. After 24 weeks 6 patients (75%) were in endoscopic remission with absence of the mucosal ulcerations. Median duration of treatment was 36 months. Only one patient developed infusion reaction.Clinical response to Infliximab therapy is associated with an improvement in linear growth in the short term. The height z-scores improved significantly from baseline. Discussion/Conclusion: The long-term maintenance of remission is especially evident in the changes observed in patient’s quality of life.
17 Frequency, endoscopic characteristics and therapeutic possibilities for dysplastic lesions in inflammatory bowel disease Andra Constantinescu1, Cristian Gheorghe2, Roxana Vadan2, Liana Gheorghe2 1 Institute of Oncology “Prof. Dr. Al. Trestioreanu”, Bucharest, Romania 2 Gastroenerology and Hepatology Center, Fundeni Clinical Institute, Bucharest, Romania Introduction: Inflammatory bowel disease (IBD) have an increasing incidence and a long evolution of the disease has a high risc for develop dysplasia or colorectal cancer. The prognostic is strictly depending on early detection of premalignant and malignant lesions. The aim of our study was to analyze dysplastic lesions in IBD in terms of frequency, endoscopic characteristics and therapeutic possibilities. Methods: Prospective study of a group of 463 patients hospitalized in The Center for Gastroenterology and Hepatology, Fundeni Clinical Institute, between 2008–2010, diagnosed with IBD, 211 patients with UC (ulcerative colitis) and 252 patients with CD (Crohn’s disease). All patients were evaluated by colonoscopy and biopsies were taken. Results: Dysplastic lesions were diagnosed in 18 patients (4%), 9 patients with UC and 9 patients with CD. There were 15 low grade dysplasia (LGD), 1 high grade dysplasia (HGD) and 3 dysplasia associated lesion or mass (DALM), from which 2 LGD and 1 HGD. The character of dysplastic lesions: pedunculated polyps (LGD and HGD), sessile polyps (LGD) and raised areas (LGD and DALM). Were performed 8 polypectomies for LGD, 1 colectomy for a raised aria with LGD, HGD was managed by polypectomy. DALM with LGD is still monitored and DALM with HGD was managed by segmentary resection. One patient with CD and pedunculated polyps has both LGD and HGD. Discussion/Conclusion: Diagnosis and staging of dysplasia by endoscopic and biopsy surveillance plays a decisive role in the management of patients with IBD.
18 Diagnostic accuracy of quantitative endoscopic ultrasound elastography for discriminating malignant from benign solid pancreatic masses: A prospective, single-centre study M.F. Dawwas, H. Taha, J.S. Leeds, M.K. Nayar, K.W. Oppong Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK Introduction: Recent data suggest that quantitative endoscopic ultrasound elastography (QEUSE), a novel technique that allows real-time quantification of tissue stiffness, can accurately differentiate benign from malignant solid pancreatic masses. The aim of this study is to prospectively validate the diagnostic utility of this technique in an independent cohort. Methods: 104 patients with evidence of a solid pancreatic mass on cross-sectional imaging and/or endosonography underwent 111 QEUSE procedures. Multiple elastographic measurements of the mass lesion and soft tissue references areas were undertaken and the corresponding strain ratios were calculated. Final diagnosis was based on pancreatic cytology or histology. The area under the receiver operating curve, sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of QEUSE for discriminating malignant from benign pancreatic masses were calculated. Results: The final diagnoses were primary pancreatic carcinoma (71.2%), neuroendocrine tumor (10.6%), metastatic cancer (1.9%) and pancreatitis (16.3%). Malignant masses had a higher strain ratio (p = 0.01) and lower mass elasticity (p = 0.003) than inflammatory ones. The area under the receiver operating curve for detection of pancreatic malignancy for both strain ratio and mass elasticity (0.69 and 0.72, respectively) was less favourable than reported recently. At the cutpoints providing the highest accuracy in this cohort (4.65 for strain ratio and 0.27% for mass elasticity), QEUSE had a sensitivity of 100.0% and 95.7%, specificity of 16.7% and 22.2%, positive predictive value of 86.1% and 86.4%, negative predictive value of 100.0% and 50.0%, and overall accuracy of 86.5% and 83.8%, respectively. Conclusion: In the largest single-centre study to date, the diagnostic utility of QEUSE for discriminating pancreatic masses was modest suggesting that it may only complement rather than substitute the role of pancreatic cytology in the future.
19 Inflammatory bowel disease – Ultrasound assessment of the enthesopathy C. Deliu, D. Neagoe, S. Enculescu, C. Hoanca Medical Clinic I, Emergency County Hospital, Craiova, Romania Enthesitis indicate the place of the tendons, ligaments, aponeuroses, or join to bone and one of the most common and specific manifestations of spondyloarthropathy. Introduction: The objectives of the study were to determine the prevalence of subclinical entheseas involvement in inflammatory bowel disease (Crohn’s disease and ulcerative colitis) patients in lower limbs. Methods: The study was included 40 patients diagnosed with inflammatory bowel disease aged between 35 and 42 years without known history of enthesal involvement. Besides, 40 healthy sex- and age-matched controls were included. Between patients with inflammatory bowel disease, 24 patient (M/F = 11/13, mean age 38.33 years) were affected by Crohn’s disease and 16 patients (M/F = 9/7, mean age 32.23 years) of ulcerative colitis. Clinical examination and ultrasound were consecutively performed at each of the entheses to detect signs indicative of enthesopathy. Results: A total of 160 enthesis in patient with inflamatory bowel disease were evaluated by ultrasonography. Enthesitis it was significantly more frequent in patient with inflammatory bowel disease than the control group (22.6% vs. 4.36%). Between patients with this patology, enthesitis was more common in patient with Chron’s disease than ulcerative colitis patients (76.5% vs. 23.5%). All patients had involvement enthesitis a longer duration of disease. Discussion/Conclusion: Our results indicate that enthesitis a characteristic clinical manifestation of spondyloartropathy, is an important clinical manfestation of inflammatory bowel disease, occurring frequently in patients with Croh’s disease with joint involvement. Additional studies are needed on the prognostic value of ultrasound findings to estimate clinical onset of enthesal involvement.
20 Helicobacter pylori infection is associated with erosions in the small bowel J. Derova1, A. Derovs1,2,3, J. Pokrotnieks2,3 1 Gastroklinika, Latvian Maritime Medicine Centre, Riga, Latvia 2 Riga Stradins University, Riga, Latvia 3 P. Stradins Clinical University Hospital, Riga, Latvia Introduction: The development of excavated lesions in the stomach is associated with Helicobacter pylori infection. We hypothesised that there is a correlation between H. pylori and excavated lesions (erosions) in the small bowel (SB). If this relationship exists, a reconsideration of the role of H. pylori in the SB would be necessary. Methods: The aim of this study was to assess the possible correlation between the erosions, in the SB, and H. pylori infection in the stomach. Patients undergoing CE were prospectively studied. The inclusion criteria were as follows: 1) completed CE investigation; 2) the patient has been examined for H. pylori infection at least 6 months before the CE. Special study protocol with more than 370 parameters (anamnesis, CE data, laboratory data) was fulfilled for each patient. Statistical analysis was made using SPSS ver. 16. The impact of additional factors was also evaluated. Results: A total number of 292 capsule endoscopies were performed. 167 cases did not satisfy the inclusion criteria. From the rest 131 H. pylori was found in 51 patients (32 females and 19 males) and was negative in 80 cases (44 females and 36 males). Patients' age in both groups was similar and ranged from 15 to 79 years (mean 41.98 ± 15.94). A positive correlation between erosions in the SB and H. pylori infection (p = 0.045) was found. We did not find statistically significant impact of additional factors on the existence of erosions in the SB. Discussion/Conclusion: The finding of erosions in the SB during CE correlated with Helicobacter pylori infection. However, the clinical usefulness of this correlation is not yet clear.
21 Specific pathological changes in the small bowel mucosa in patients with Crohn’s disease A. Derovs1,2, J. Pavlova1, J. Pokrotnieks1,2 1 Riga Stradins University, Riga, Latvia 2 P.Stradins Clinical University Hospital, Riga, Latvia Introduction: Inflammation in Crohn's disease (CD) often is discontinuous along the longitudinal axis of the intestine. However specific pathological changes in the small bowel (SB) mucosa in case of CD are not described very well. Methods: Aim of work was to evaluate the specific changes in the SB mucosa in patients with CD using the capsule endoscopy (CE). Data of CD patients, who underwent CE in period from 2007 to 2011, was evaluated. Three independent interpreters performed the analysis of each patient’s CE recording. Internationally recognised definitions and criteria were used for these interpretations. Special study protocol with more than 370 parameters (anamnesis, CE data, laboratory data) was fulfilled for each patient. All the data was entered into the database with consecutive statistical analysis using SPSS ver.16. Results: In total 272 CE were performed. 196 CE cases were entered into the database. Out of these, 45 patients had CD. 25 (55.6%) were females and 20 (44.4%) – males. Patients’ age was from 13 to 73 (average 36.04 ± 14.90) years. There was no statistically significant difference found between patient age or gender. Positive statistically significant correlation was observed between presence of CD and: lumen stenosis (p = 0.001); lumen strictures (p < 0.000001); eritematous mucosa (p = 0.029); oedemic mucosa (p < 0.000001); granular mucosa (p = 0.014); presence of aphtae in the SB (p = 0.015); presence of ulcers (p = 0.008) in the SB. Discussion/Conclusion: CD correlates with the presence of eritematous, oedemic and granular mucosa, aphthae and ulcers in the SB. CD is one of the risk factors for the development of lumen stenosis and strictures in the SB.
22 TGF-β, TGFBR1, and Ki67 expression in intestinal type of gastric carcinomas A.O. Docea, P. Mitrut, D. Calina, E. Gofita, A. Genunche-Dumitrescu, D. Badea, R. Mitrut University of Medicine and Pharmacy, Craiova, Dolj, Romania Introduction: Although in the last decades the incidence of gastric cancer declined, at present it is ranked worldwide on the fourth place between all human cancer pathology. Also, it has an aggressive behavior, the majority of patients being diagnosed in advanced stages. One of the key factors to control survival improvement of those patients is to clarify the molecular mechanisms involved in initiation, progression, invasion and metastasis of gastric cancer. Objectives: We thus investigated the immunoreactivity for TGF-β, TGFBR1, and Ki67 of 25 specimens of intestinal gastric adenocarcinomas, and compared this with the correspondent reactivity for three specimens of diffuse gastric carcinomas; in the end we tried to establish a statistical correlation with major clinicomorphological parameters. Material and methods: We selected a total number of 25 tumor specimens collected from patients aged 45–78 (average 59 ± 3.8) years that were predominantly men (male:female ratio of 2.1:1). None of the patients received any adjuvant treatment prior to surgery. Tissue sections were fixed in 10% buffered formalin, embedded in paraffin, sectioned at 4 μm and stained with hematoxylin and eosin (HE). For each case, all available HE stained slides were reviewed. The histopathological diagnosis confirmed that they were intestinal type of gastric adenocarcinoma, and in terms of their degree of differentiation most of them were well- and moderately differentiated (10 and respective 12 cases). Immunohistochemistry was performed on 4 μm sections from one selected block for each case. Briefly, the primary antibodies were used at a dilution of 1:1000 for TGF-β (Mouse monoclonal, TB21, AbD Serotec, Albedo, Romania, Code: MCA797T), 1:300 for TGFBR1 (Rabbit polyclonal, T-19, Santa Cruz Biotechnology, Redox, Romania, Code: sc-402) and 1:50 for Ki67 (Mouse monoclonal, Mib-1, Dako, Redox, Romania, Code: M7240). Results and discussions: In intestinal metaplasia and dysplastic lesions the reactivity to TGF-β1 and TGFBR1 was more intense than in normal mucosa, especially in the cytoplasm of the goblet cells and mucosal epithelial cells from the gastric pits and the neck of the glands. TGF-β1 expression was detected in 15 intestinal-type of gastric adenocarcinomas (60%), while TGFBR1 was present in 20 tumors (80%). All three cases of diffuse gastric carcinomas were positive for both TGF-β1 and TGFBR1. In addition, the TGF-β1 reactivity was observed in cancerassociated fibroblasts, especially in poor differentiated intestinal adenocarcinoma and in diffuse adenocarcinoma tumors.
Conclusions: In conclusion, we have shown here that TGF-β1 has an active role in progression of intestinal type of gastric adenocarcinomas as its reactivity progressively increased along the normal epithelium-intestinal metaplasia-dysplasiacarcinoma sequence. Also, determination of TGF-β1 reactivity has a prognostic value, considering the fact that its tissue level statistically correlated with the tumor degree of differentiation and proliferative activity measured by Ki67.
23 Ulcerative colitis: Is there diagnosis beyond colonoscopy? Mihaela Dranga2, Otilia Nedelciuc1, Iulia Pintilie1, Cristina Cijevschi Prelipcean2 1 Center of Gastroenterology and Hepatology, “Spiridon Hospital”, Iasi, Romania 2 University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania Introduction: The golden standard in diagnosis of Inflammatory bowel disease (IBD) is colonoscopy with biopsy. IBD are chronical idiopathic diseases, with evolution marked by periods of activity and remission. For establishing the diagnostic and monitorisation of the evolution, a patient is necesary to perform over two hundred colonoscopy during his/her life. aimed to assess the correlation between endoscopic and clinical activity in patients with fecal calprotectina and ulcerative colitis (UC). Methods: 25 patients with UC were evaluated using clinical and endoscopic activity scores. They were made a full haematological and biochemical balance. They collected samples of stool for the determination fecal calprotectine. The results were compared with those obtained in a control group of 56 patients with irritable bowel syndrome, in which colonoscopy was ruled out an organic lesion. Results: Fecal calprotectin was significantly higher in patients with UC than in patients with IBS (p < 0.005). Significant correlations were found between the FC’s value and disease activity (severe p < 0.001, moderate p < 0.005, mild p < 0.001). FC value was higher in the UC remission, but no significant differences compared with IBS. Discussion/Conclusion: Fecal calprotectin in ulcerative colitis significantly correlated with activity. This is an argument for recommending this marker in monitoring patients with ulcerative colitis. Fecal calprotectin can be used as a marker in the differential diagnosis between functional and organic pathology.
24 Is Crohn's disease milder in older people? Mihaela Dranga, Mircea Badea, Gabriela Dumitrescu, Cristina Cijevschi Prelipcean Center of Gastroenterology and Hepatology, Iasi, Romania University of Medicine and Pharmacy, Iasi, Romania Introduction: Crohn's disease presents very heterogeneous features from a clinical point of view, and classifying Crohn's disease patients in homogeneous subgroups is challenging. The Montreal classification for Crohn's disease was proposed in 2005 as an effort to characterize patients with Crohn's disease according to the latest clinical and research advances in inflammatory bowel diseases. Aim: Crohn's disease evidence of phenotypic features of adult population and observation of their differences to extreme categories of age (< 40, > 65 years). Methods: 51 patients with Crohn's disease, admitted to the Institute of Gastroenterology and Hepatology Iasi, between January 2010 and December 2011, were studied prospectively. We assessed demographic characteristics, clinical onset of disease, age at diagnosis for illness, disease location and behavior, presence of extraintestinal manifestations, treatment with biological agents and a history of surgery. Results: Patients were predominantly female (60.6%), urban (81.81%) with a mean age at diagnosis of 34 ± 12 years. Most patients were diagnosed between 18 and 40 years (82%), with predominant localization in the terminal ileum (54.54%) with a nonstricturing, nonpenetrating behavior (68.62%). The young patienţs had as onset symptoms abdominal pain and diarrhea, and elderly patients had the main manifestation bloody stools. Complications (stenosis, fistulas, abscesses) were significantly more in younger patients group (67.67% vs. 33.34%, p = 0.0386). Regarding treatment, the need to maintain remission with imunmodulators was also increased in the young population (44.44% vs. 16.6%, p = 0.3644). Biological therapy was necessary only in younger patients. Surgical therapies were more frecquent in patients under 40 years (51.8% vs. 16.67% p = 0.1861). Discussion/Conclusion: Young patients have more severe forms of disease activity requiring imunsupresor therapy and biological agents. There were no significant differences in the disease phenotype. Young people had more frequent complications and surgery compared with older people. Studies are needed on larger groups of patients to confirm or refute the data obtained.
25 The influence of age on the phenotype and activity in ulcerative colitis Mihaela Dranga, Gabriela Dumitrescu, Andreea Blaj, Catalina Mihai Center of Gastroenterology and Hepatology, Iasi, Romania University of Medicine and Pharmacy, Iasi, Romania Introduction: The ulcerative colitis (UC) is a chronic disease with extremely varied clinical manifestations. The purpose of the study was to assess the impact of age on the phenotype and activity of UC. Methods: A prospective study includes 105 patients hospitalized between January 2010–December 2011. We have noted: age, sex, area of origin, status smoker/nonsmoker, presenting symptoms, presence of inflammatory syndrome, the extension of lesions, severity, treatment, complications, need for surgery. All the patients were examined by colonoscopy and diagnosis of UC was confirmed histologically. The activity of the disease was quantified using Truelove and Witts clinical score of: mild, moderate and severe. Results: Patients were divided into 3 groups according to age: group 1: 51 patients ≤ 40 years, group 2: 36 patients, 41–64 years and group 3: 18 patients ≥ 65 years. Characteristics of extreme groups were followed by age (young < 40 years and elderly > 65 years), to clarify whether there are significant differences between them on UC behavior. At the time of diagnosis 48.5% were younger than 40 years and 17.15% had more than 65 years. In both groups were predominantly men from urban area. The smoking status was more common in younger patients than elderly, but no statistically significant differences (18/51 vs. 6/18, p = 1). Regarding the symptoms of debut, in the young prevailed diarrhea (younger vs. older 41.8% 58.8%, p = 0.09), and in the elderly frankly bloody diarrhea (41.1% vs. 66.67% young, p = 0.089). Proctitis was met in 2.94% of the cases (only in the elderly), left-sided colitis as 71.1% – more frequently in young (52.17% vs. 18.8%) and pancolitis 26% of cases (29.4% vs. 16.66%, p = 0.36). As severity, there is a significantly large number of moderate to severe forms of the young versus elderly (60.8% vs. 13.04%, p = 0.028). In all patients had received aminosalicylates, 14, 49% is the only therapy during follow-up, all elderly patients. The necessary of introducing the immunosuppressive therapies (corticosteroids) and biological therapy was increased in young people with moderately severe forms of disease (corticosteroids: 47.05% vs. 16.67%, p = 0.0270; biological agents: 23.52% vs. 5.55%, p = 0.0279). Discussion/Conclusion: A more aggressive phenotype with extensive localization of lesions and more severe activity was seen in younger patients. They had an increased need for steroids and biological therapy. Elderly patients experienced mild forms, with limited extension of the lesions, and the majority were able to remain in remission only with salicylates.
26 The effect of intravenous iron administration on thrombocytosis in inflammatory bowel disease Gabriela Dumitrescu1, Mircea Badea2, Dinu Chirita2, Cristina Cijevschi Prelipcean1,2 1 University of Medicine and Pharmacy “Gr. T. Popa”, Iasi 2 Center for Gastroenterology and Hepatology, Iasi, Romania Introduction: Patients with inflammatory bowel disease (IBD) often present thrombocytosis considered chronic inflammation marker, and partly due to iron deficiency. Aim: To evaluate the effect on the platelets after iv iron infusion administered for correcting anemia in IBD patients. Methods: A prospective study was developed in the Center for Gastroenterology and Hepatology Iasi, between June 2009–February 2012 which included 65 IBD patients in clinical and biological remission with associated iron deficiency anemia (Hb < 12 g/dl in women and < 13 g/dl in men). All patients were treated with injectable iron, and the dose was calculated with Ganzoni’s formula. Complete blood counts were performed at week 0 and after 4 weeks. Results: From the 65 patients included in the study, 44 (67.69%) had ulcerative colitis (UC) and 21 (32.30%) Crohn's disease (CD). Mean Hb level was 9.4 g/dl. The mean dose of intravenous iron (iron sucrose) was 1300 mg. Haematopoietic response (Hb increase > 2 g/dl after 4 weeks) was obtained in 47 (72.30%) patients receiving iv iron infusion. Thrombocytosis was observed in 24 patients (36.92%) before and in 6 patients (9.23%) after iv iron infusion. There was a significant reduction in platelet count (W0: PLT = 392 ± 143 x 103/mm3 vs. W4: PLT = 267 ± 104 x 103/mm3, p < 0.05). Conclusions: Thrombocytosis in IBD is not absolutely a marker of inflammation, it could also appear as reactive to chronic blood loss. Acknowledgements: This work was supported by the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectorial Operational Programme for Human Resources Development 2007–2013 (POSDRU/107/1.5/S/78702).
27 Ignore or treat osteoporosis in inflammatory bowel disease? Gabriela Dumitrescu1, Mihaela Dranga1,2, Otilia Nedelciuc1,2, Catalina Mihai1,2, Cristina Cijevschi Prelipcean1,2 1 University of Medicine and Pharmacy “Gr. T. Popa”, Iasi 2 Center for Gastroenterology and Hepatology, Iasi, Romania Introduction: Decreased bone mineral density is common in patients with inflammatory bowel disease (IBD). Objectives: To evaluate the efficiency of treatment with calcium and vitamin D3 in IBD patients with decreased bone mineral density. Methods: A prospective study developed between June 2010–April 2012, in The Center for Gastroenterology and Hepatology Iasi, which included 82 IBD patients with confirmed diagnosis of osteopenia (T score = -1, -2.5) and osteoporosis (T score < -2.5). All patients received 1000 mg/day of calcium and 0.5 mcg/day Alpha D3. Dual energy X ray absorptiometry (DEXA) was repeated at one year. Results: Of the 82 patients, most were men (57.31%), and 57 patients had ulcerative colitis (18 patients with osteoporosis and 39 with osteopenia) and 25 Crohn's disease (10 patients with osteoporosis and 15 with osteopenia). Average T score was -2.6 for osteoporosis and -1.5 for osteopenia. At 12 months of treatment, 35 patients (61.4%) with ulcerative colitis (UC) and 12 patients (48%) with Crohn’s disease (CD), showed improved T score (T range = -1.8). 24 patients with UC and 6 patients with CD had normal T score (< -1). Conclusions: The diagnosis and rapid treatment of osteoporosis in IBD patients are important factors for improving bone mineral density, especially for patients with ulcerative colitis. Acknowledgements: This work was supported by the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectorial Operational Programme for Human Resources Development 2007–2013 (POSDRU/107/1.5/S/78702).
28 Anaemia in inflammatory complication?
bowel
disease:
A
common
Gabriela Dumitrescu1, Otilia Nedelciuc1,2, Andreea Blaj2, Cristina Cijevschi Prelipcean1,2 1 University of Medicine and Pharmacy “Gr. T. Popa”, Iasi 2 Center for Gastroenterology and Hepatology, Iasi, Romania Introduction: It is well known that anemia is common in inflammatory bowel disease (IBD). There were identified three major causes: iron deficiency, inflammation and malabsorption. Aim: To determine the prevalence of anemia in IBD patients and to identify production mechanisms. Methods: Prospective study conducted between 15 March 2011–15 April 2012 included 148 IBD patients in The Center for Gastroenterology and Hepatology Iasi. Blood tests were performed for all patients. Anemia was defined as hemoglobin values for males Hb < 13 g/dl and females Hb < 12 g/dl. Iron deficiency anemia (IDA): MCV < 80 μc, ferritin < 30 µg/L and reticulocytes < 5‰, ACD (anemia from chronical disease) 80 μc < MCV < 96 μc, ferritin > 100 mg, CRP > 5 mg/l and anemia due to malabsorption: MCV > 96 μc, vitamin B12 < 200 pg/ml, folate < 3 μg. Results: From 148 patients, 39 (26.36%) had Crohn’s disease (CD) and 109 (73.64%) ulcerative colitis (UC). Mean age was 42.1 years and 84 (56.75%) were male. Anemia was present in 48 patients (32.43%) of 148: 30.76% (n = 12) had CD and 33.02% (n = 36) UC. IDA was observed in 21 patients (43.75%), and ACD in 17 patients (35.41%) and 4 (8.33%) patients had anemia due to malabsorption. Anemia with multiple mechanisms of production was observed in 6 patients (12.5%). However, only 13 patients (27.08%) had severe anemia (Hb < 10 g/dl) and they required intravenous iron administration. To be mentioned that only 32 patients had active disease at endoscopic exploration. Conclusions: Anemia was present in more than one third of the patients. No differences of anemia’s prevalence were observed among patients with Crohn's disease and those with ulcerative colitis. Only patients with Crohn's disease had anemia due to malabsorption. Anemia remains a disorder frequently associated with inflammatory bowel disease and requires specific management. Acknowledgements: This work was supported by the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectorial Operational Programme for Human Resources Development 2007–2013 (POSDRU/107/1.5/S/78702).
29 Efficiency correction of anemia with oral iron vs. intravenous iron Gabriela Dumitrescu1, Mihaela Dranga1,2, Iulia Pintilie2, Catalina Mihai1,2 1 University of Medicine and Pharmacy “Gr. T. Popa”, Iasi 2 Center for Gastroenterology and Hepatology, Iasi, Romania Introduction: Both in literature and current practice we observed the presence of iron deficiency anemia in more than one third of patients with inflammatory bowel disease (IBD). Aim: To evaluate the effectiveness and tolerance of iron replacement therapy, administered orally or intravenously to patients with iron deficiency anemia associated with inflammatory bowel disease. Methods: A prospective study conducted in The Center for Gastroenterology and Hepatology Iasi between 15 March 2010–15 April 2012 included 54 IBD patients with iron deficiency anemia. Iron deficiency anemia was defined in hemoglobin values for males Hb < 13 g/dl and females Hb < 12 g/dl according to World Health Organization (WHO), MCV < 80 μc, ferritin < 30 μg/L, sideremia < 50 mcg/dL and reticulocytes < 5‰. Patients with Hb > 10 g% followed treatment with oral iron and those with Hb < 10 g% received infusion of iron preparation. Patients intolerant to oral iron preparation also received infusion of iron preparation. Haematological and clinical response was evaluated at 6 weeks and 3 months respectively. Results: 15 patients had CD (Crohn's disease) and 39 patients UC (ulcerative colitis). Mean age was 42.7 years, and most (57.4%) were male. Mean Hb was 9.8 ± 1.2 g/dl. 33 patients (61.12%) received oral iron preparations and 21 patients (38.88%) infusion of iron preparation. Normalization of Hb level was obtained in 23 patients (69.69%) treated with oral iron and 18 patients (85.71%) treated with iron infusion. There was one case of adverse effect to manage their iv iron preparation by the appearance of local pain and swelling. Conclusions: Treatment with oral preparations is efficient and well tolerated in most patients. Infusion with iron preparation is an effective and safe alternative for patients with low Hb values for those with intolerance to oral therapy. Acknowledgements: This work was supported by the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectorial Operational Programme for Human Resources Development 2007–2013 (POSDRU/107/1.5/S/78702).
30 Is vitamin D deficit a determining factor regarding the decrease of bone mineral density in patients with Crohn’s disease? Gabriela Dumitrescu1, Mihaela Dranga1,2, Iulia Andreea Pintilie2, Catalina Mihai1,2 1 University of Medicine and Pharmacy “Gr. T. Popa”, Iasi 2 Center for Gastroenterology and Hepatology, Iasi, Romania The decrease of bone density is frequent among patients with intestinal inflammatory disease. A possible risk factor for osteopenia and osteoporosis associated with BII could be an inadequate level of vitamin D. Purpose: The purpose of this study was to determine the prevalence of vitamin D deficit and its possible influence on the decrease of bone density among patients with IBD. Subjects and method: 23 patients with CD (11 men and 12 women) were included in a prospective study which has been conducted between 1 January 2010 and 30 December 2011. The serum level of 25-OH-D3 and the bone density at lumbar and femoral neck level has been determined for all patients using dual-energy X-ray absorbtiometry (DEXA). A level of 25-OH-D3 < 20 ng/ml was considered a vitamin D deficit, one between 20–32 ng/ml was considered insufficient, while a level between 33–80 ng/ml was considered adequate. Results: 16 patients (70%) had levels of 25-OH-D3 < 20 ng/ml, while only 3 of them (13%) had an adequate level > 33 ng/ml. The rest of the patients (4) had an insufficient level of vitamin D. 13 patients (56.5%) had osteopenia, while osteoporosis was diagnosed for 4 patients (17%). A statistical positive correlation between patients with inadequate levels of 25-OH-D3 and low values of DMO was not observed. Conclusions: Vitamin D deficit had a high prevalence among patients with CD. The lack of statistical correlation between vitamin D deficit and the presence of osteopenia/osteoporosis suggests that there are other important risk factors which lead to a decrease of bone mineral density in these patients (for example, corticotherapy).
31 Complications of chronic pancreatitis in obese patients: The beneficial effects of alcohol abstinence and loss weight Amelia Genunche-Dumitrescu, D. Badea, M. Badea, P. Mitrut, A. Badea University of Medicine and Pharmacy, Clinical Hospital of Emergency, Craiova, Romania Introduction: The aim of this study was to describe the beneficial effect of reducing alcohol consumption and weight loss, on the incidences and severity of complications in chronic pancreatitis (CP), in obese patients. Methods: We studied retrospectively 88 patients with CP and obesity: A group consist of 54 patients with alcoholic CP and B group composed of 34 patients with non-alcoholic pancreatitis (biliary 18 cases, hypercalcemia 2 cases, hypertrygliceridemia 9 cases, idiopatic 4 cases and trauma 1 case). We monitored, for a five years period, the incidence of complications and relationship between evolution of CP and reduced of alcohol consumption and loss weight. Results: At baseline, the mean value of BMI was 37.11 + 4.79 kg/qm and his repartition indicate the predominance of the severely obesity: moderate (35 cases), severe (43 cases) and very severe obesity (10 cases). The alcohol consumption was classed: > 80 mg alcohol-intake/day (31 cases), 40–80 mg alcohol-intake, 3–4 times/week (15 cases) and 20–40 mg 1–3 times/week (8 cases). The complications of CP was: pancreatic cancer (29 cases), pseudocysts (7 cases), abscess (4 cases), hemorrhage of the digestive tract (4 cases) and diabetes (15 cases). Multiple complication with severe evolution was observed in patients with alcoholic CP. Liver cirrhosis were associated with CP in 14 heavy-drinkers patients. Comparatively, in B group, the incidences of complications was reduced: 35.29%. In A group, the alcohol consumption was reduced in 30 cases (abstinence or halving the previous amount). Also, low caloric diet associated with loss weight (BMI diminuation > 5 kg/qm) was observed in 40 cases: 19 cases in A group and 21 cases in B group. In A group, the incidence of complications were decreased in 22 patients which associated the therapy with alcohol abstinence, low caloric diet and loss weight. We identified a relationship between the risk of complication and the age of starting drinking (r = 0.39, p < 0.01). Frequency of complications was correlated with BMI values and alcohol consumption categories. Discussion/Conclusion: Alcohol consumption and obesity remains the main risk factors for develop complications in CP. The therapy in association with alcohol abstinence, low caloric diet and loss weight is more effective in obese patients.
32 Relationship between history of Helicobacter pylori infection and precancerous changes in develop gastric cancer Amelia Genunche-Dumitrescu, D. Badea, M. Badea, P. Mitrut, A. Badea University of Medicine and Pharmacy, Clinical Hospital of Emergency, Craiova, Romania Introduction: The aim was to assess the risk of evolution from precancerous changes (PC) to gastric cancer (GC) in patients with Helicobacter pylori (HP) eradicated comparative with never infected patients. Methods: A multi-annual and comparative study was performed on 125 patients with preexistent PC. A group consist of 77 cases with history of HP infection, who was eradicated three years ago (HP absence was monitoring in last three years) and B group contain 48 patients never infected with HP. The history and duration of HP eradication was also quantified. We monitored evolution of PC and evaluated the cancer risk comparatively in these groups. Results: The incidence of the PC were: atrophic gastritis (66 cases), gastric ulcer (18 cases), gastrectomy (23 cases), gastric polyps (13 cases) and Menetrier gastritis (5 cases). A group contain all Menetrier gastritis cases, atrophic gastritis (41 cases), gastric ulcer (12 cases), gastrectomy (9 cases), gastric polypus (10 cases). GC was develop in 29 patients (37.66%) of the A group and in 8 cases (16.66%) of the B group. Majority of Menetrier gastritis cases (4 cases) developed GC. In A group, endoscopic forms of the early GC were: type I (polypoid) in 8 cases, type II (superficial) in 4 cases and type III (ulcerated) in 5 cases. In advanced GC we found type Borrmann I in 4 cases, type II in 7 cases and Borrmann IV only one case. Group B had advanced GC in Borrmann forms: II (4 cases), III (3 cases). The early GC we found in only one case. Comparative with other PC, atrophic gastritis was more frequent associate with history of HP infection (p = 0.01). The risk of GC development was not corelated with duration of HP eradication (r = 0.103, p > 0.05) and number of therapy cures. Discussion/Conclusion: The risk of development GC, in patients with PC, was significantly increased after HP eradication comparative with never infected patients. Atrophic gastritis was more frequent associate with history of HP infection.
33 The prevalence and risk factors of colorectal dysplasia in patients with Crohn’s disease Cristian Gheorghe, Roxana Vadan, Andra Constantinescu, Liana Gheorghe Gastroenterology and Hepatology Centre, Fundeni Clinical Institute, Bucharest, Romania Introduction: Data in the literature have shown an increasing cumulative risk of developing colorectal dysplasia and cancer in patients with inflammatory bowel disease (IBD), the risk in Crohn’s disease (CD) being considered equivalent with that in ulcerative colitis. However, data from countries with low prevalence for IBD are scarce. The aim of our study was to assess the prevalence and risk factors of CDassociated colorectal cancer (CRC) and colorectal dysplasia (CRD) in a Romanian cohort of Crohn’s disease patients. Methods: We evaluated the CD patients registered prospectively in IBD Electronic Database (that comprises all inpatients or outpatients with IBD admitted in our department) between Jan 2008–Jan 2012. Data from 296 CD patients were reviewed and analysed. Demographic (current age, age at diagnosis, smoking state, first degree relatives with IBD or CCR) disease characteristics (localization, extent, and duration) and current/previous therapy were noted. All patients were evaluated by standard colonoscopy and target biopsies were taken. The diagnosis of CRC or CRD was made based on pathological report from biopsies taken during colonoscopy and/or after surgical resection and dysplasia was classified as low grade (LGD) and high grade (HGD). Results: CRC was diagnosed in 2 patients (0.67%) both with ileocolonic CD, in both cases duration of disease being less than 10 years (6 and respectively 9 years of evolution). CRD was diagnosed in 11 (3.71%) patients (9 cases of LGD – 4 with sessile adenomatous polyps, 4 pedunculated adenomatous polyps, 1 DALM and 2 cases of HGD one DALM and one pedunculated adenomatous polyp). Duration of disease did not differ significantly between CD patients with and without CRD or CRC. In our study young age at onset of disease, disease extension, stenosing CD pattern, presence of inflammatory pseudopolyps and also smoking habit, family history of CCR or IBD did not correlate with the presence of neoplasia or dysplasia. Discussion/Conclusion: The prevalence of dysplasia and cancer in CD patients is low. Since short duration of disease can be associated with the presence of high grade dysplasia or cancer, periodic colonoscopy even in the first 10 years of disease evolution is important for early diagnosis and an improved prognosis of these patients.
34 Effect of different sedation methods on the critical flicker frequency in a tertiary centre endoscopy unit Frank Grünhage, Anke Seegmüller, Frank Lammert Department of Medicine II, Saarland University Medical Center, Homburg, Germany Introduction: Driving after sedation for endoscopic procedures is a matter of debate and recent results from a large study (Horiuchi et al. Am J Gastroenterol. 2009) suggest that driving home after propofol sedation might be safe. We used CFF analysis to assess the time-dependent effects of different sedation methods on brain function. Methods: Overall, 83 patients were included in the study. All patients received a CFF analysis before, 30, 60, 90 and 120 min after endoscopy. CFF results were correlated to sedation methods and doses. Differences in the CFF between groups and within groups were tested by non-parametric Mann-Whitney U or paired t-Test comparisons as appropriate. Results: In this cohort, 33.7% of patients received no sedation ('control group'), 26.5% were sedated with propofol (P) alone and 38.6% of patients received a combination of propofol with midazolam (P/M). While in the control group no changes in CFF results were detected, patients with sedation experienced a clear drop in CFF results at 30 min. This difference was more pronounced in patients after P/Msedation as compared to P-mono sedation (CFF after 30 min: 37.6 Hz vs. 42.2 Hz). In addition, the effect of sedation was detectable for > 120 min in P/M-sedated patients, whereas CFF results in patients with P-mono sedation recovered to baseline values within 60 min. Conclusions: Our study clearly shows that combination of propofol with midazolam leads to long lasting effects that might negatively affect driving capability, whereas sedation with propofol wears off after 60 min. CFF analysis might be a helpful tool to assess the ability to safely participate in traffic after sedation.
35 Portal vein thrombosis in liver graft ten years after liver transplantation due to Budd-Chiari syndrome: Case report Azra Husić-Selimović1, Srdjan Gornjaković1, Marcus Schuchmann2, Zora Vukobrat-Bijedić1 1 Gastroenterohepatology Department, University Hospital Sarajevo, Sarajevo, Bosnia and Herzegovina 2 Klinik and Poliklinik Lagenbeckstrasse, Mainz, Germany Introduction: Budd-Chiari syndrome is a rare but life-threatening disorder characterized by obstruction of the hepatic venous outflow. Treatment depends on underlying cause, extent of the obstruction and functional capacity of the liver. When all other therapy options are unsuccessful, liver transplant should be considered. Portal vein thrombosis (PVT) is a frequent event in patients with cirrhosis which can be treated with anticoagulants, but there are limited data regarding safety and efficacy of this approach. Methods: We present case report of thirty five old female patient with postparthal Budd-Chiari syndrome who underwent liver transplant on 2002, and developed portal vein thrombosis in liver graft ten years later. We also evaluated safety of application of anticoagulant therapy in this patients. In few years after liver transplantation patient developed fibrosis of liver graft with porthal hypertension. Thrombosis was diagnosed, and recanalization was evaluated by using Doppler ultrasound. We performed elective esophageal variceal band ligation in order to prevent bleeding. As soon as we prevented possible complications, anticoagulant therapy (martefarin) was administred. Results: Complete recanalization of portal vein was achieved after four months period. Early initiation of anticoagulation was associated with complete recanalization. Our case suggested that appropriate and well prepared anticoagulant therapy in portal vein thrombosis of liver graft could prolonge „life time“ of graft. Discussion/Conclusion: Anticoagulation is a relatively safe treatment that leads to partial or complete recanalization of the portal venous of patients with cirrhosis and PVT; it could be maintained for longer period to prevent rethrombosis.
Picture 1: Trombus in perihilar part of portal vein. Picture 2: Nomal portal bload flow with complete (14 x 20 mm) and in parenchimal part (9 x 19 mm). recanalisation after four months
36 Treating Helicobacter pylori infection Parkinson’s disease: How long?
in
patients
with
Gabriela Iliescu, Adriana Bold, Viorel Biciusca Clinical Emergency County Hospital, Craiova, Romania Introduction: Data from different studies suggest that gastrointestinal Helicobacter pylori infection could contribute to the development of Parkinson's disease in humans. Last findings show that eradication modifies disease progression and marked deterioration accompanies eradication-failure. In Romania, routinely there are used rapid tests for HP infection. Methods: We present a case of a female patient, aged 64, weight 77 kg, height 159 cm; diagnosed with PD at age 61 with tremor and bradykinesia, treated with ropinirolum and rasagiline. Results: We noted tremor 100 none–0 worst, bradykinesia and postural abnormalities. Rare and minor gastrointesinal disorders. Blood tests: all tests in normal ranges except hypercholesterolemia 280 mg/dl; rapid test for HP positive. She received pantoprazol 20 mg twice daily, amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily for 14 days. During treatment all clinical parameters improved; a new test for HP was negative. Post-treatment clinical parameters reached the baseline values. Even the rapid test was negative, we decided a new course of treament after one month with no clinical improvement. Discussion/Conclusion: Rapid tests used for HP infection could provide a false result about the infection status. In order to eradicate the infection, high-sensitive tests are required.
37 Role of Smad4 and Smad7 proteins in development of gastric cancer Koni Ivanova1, Julian Ananiev1, Alexander Julianov2, Maya Gulubova1 1 Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria 2 Department of Surgery, Medical Faculty, Trakia University, Stara Zagora, Bulgaria Introduction: Gastric cancer is still the most prevalent neoplasia in many countries. Wide range of molecular markers from tumor and different types of cells in tumor environment could be prognostic markers for progression of the neoplasm and prognosis for the patients.There is mounting evidence of the role of Smad proteins – part of TGF-beta pathway in patients with this type of cancer and Smad protein group is directly involved in signal transduction in this pathway. Methods: The immunohistochemical expression of Smad4 and -7, TGF-beta1 and TGF-betaRII was evaluated in 55 patients (34 males and 21 women) with gastric cancer. Results: We found that 80% of intestinal type gastric cancer expressed Smad4 vs. 50% of diffuse type (Χ2 = 3.88; p = 0.04). Statistically significant correlations was observed between TGF-beta1 expression and expression of Smad4 in tumor cells (Χ2 = 7.23, p = 0.007) and Smad4 and TGF-betaRII (Χ2 = 5.89; p = 0.015). Also, there was a relation between expression of Smad7 and TGF-beta1, so 88.9% of tumor expressed Smad7 had TGF-beta1 expression (Χ2 = 4.61, p = 0.032). There was no statistically significant correlation between Smad proteins expression, survival, T stage, N stage and tumor grade. Discussion/Conclusion: Our results suggest that the expression of Smad4 and Smad7 proteins had strong relation with activation of TGF-beta1 and it’s receptor – RII, and it could be important prognostic factor for future development of this type of cancer.
38 Cap polyposis: A report of two cases R. Ivanova1, D. Kyosseva1, G. Trifonov2, R. Nikolov3 1 Laboratory of Clinical Pathology, St. Ivan Rilski University Hospital, 2Second Surgical Clinic, University Hospital Alexandrovska, 3Clinic of Gastroenterology, St. Ivan Rilski University Hospital, Medical University, Sofia, Bulgaria Introduction: Cap polyposis is a rare colorectal disease characterized by mucoid, bloody diarrhea associated with multiple inflammatory polyps covered by a cap of fibrinopurulent mucous. The disorder was first described in 1985 and up to date a small number of cases have been discused in literature. Methods: We report two cases with multiple polyps of rectum and sigma, which were histologically diagnosed as cap polyposis. Results: The cases were two males with age of 18 years and 64 years. In both cases there was a history of mucoid and bloody diarrhea. On the basis of colonoscopy findings, in the young patient there was a broad differential diagnosis including Crohn’s disease, inflammatory polyps and Cronkhite-Canada syndrome. In the second case the clinical diagnosis was polyps of sigma. Endoscopic biopsies and polypectomy were done. In both cases, the histology showed typical histological features of cap polyposis – polypoid lesions containing elongated, tortuous and often distended crypts covered by a cap of inflammatory granulation tissue. Discussion/Conclusion: The recognition of this rare disease is of practical significance because its clinical symptoms have some similarity with inflammatory bowel disease and other colon diseases.
39 Serrated polyps of the colon – Clinico-morphological and immunohistochemical characteristics R. Ivanova1, D. Kyosseva1, R. Nikolov2, S. Deredjian2, Z. Spassova2 1 Laboratory of Clinical Pathology, 2Clinic of Gastroenterology, St. Ivan Rilski University Hospital, Medical University, Sofia, Bulgaria Introduction: Serrated polyps of the large intestine, including traditional hyperplastic polyps, mixed hyperplastic-adenomatous polyps, traditional serrated adenomas (TSA) and sessile serrated adenomas (SSA), have gained increased recognition because of the existence of a "serrated neoplasia pathway" leading to microsatellite unstable colorectal carcinoma. The aim of this study was to evaluate the clinical, morphological and immunohistochemical features of serrated polyps. Methods: A total of 118 consecutive polyps in 85 patients, found through colonoscopy and after endoscopic biopsy/polypectomy, were studied. The histological type of the polyps was defined according to the accepted criteria and immunohistochemical staining of cytokeratin 7/20 and MIB-1 was done. Results: The histological analysis found 91 (77%) serrated polyps/adenoma and 28 (23%) traditional adenomas. Among the serrated polyps, the hyperplastic polyps were the most often – 67 (74%), following the mixed polyps (n = 14), SSA – n = 6 (7%) and TSA – 4 (4%). The hyperplastic and mixed polyps were found mainly in the left colon and with size of 5–10 mm. Serrated adenomas were localized mainly in the right colon and were with larger size, up to 20 mm. In 3 of TSA there was low-grade dysplasia and in 1 – a focal high grade dysplasia. Immunohistochemistry showed coexpression of CK 7 and CK 20 among the serrated polyps and also varying number of MIB-1 positive nuclei along the crypts. Discussion/Conclusion: Our results show that serrated adenomas are rare, but the recognition of their specific features is important for the early diagnosis of serrated adenocarcinoma of the colon.
40 Azathioprine and allopurinol co-therapy for IBD patients is a safe and effective treatment option in a District General Hospital H. Johnson, S.A. Weaver, S.D. McLaughlin Department of Gastroenterology, Royal Bournemouth Hospital, Bournemouth, UK Specialist IBD units have demonstrated that allopurinol and low-dose thiopurine cotherapy is an effective treatment option in patients who have failed standard dose therapy. There is little experience however from the District General Hospital (DGH) setting. Co-therapy was introduced in our unit in September 2010. Introduction: Evaluate the therapeutic outcome of IBD patients treated with azathioprine and allopurinol co-therapy at our institution. Methods: A prospective database of all patients treated with allopurinol co-therapy is maintained. We reviewed the database entries and case notes of all patients. Results: 25 patients were identified, five were excluded because of insufficient follow-up (< 3 months) 1 patient was lost to follow-up. Median length of co-therapy was 9 (3–12) months. Diagnosis was UC (12), CD (7), IBD-U (1). Indications for cotherapy were abnormal LFTs (3), drug side effects (8), high MMP (5), gout (2), therapeutic failure (10). 6-TGN levels were measured before co-therapy, 50.0% were therapeutic. Following co-therapy 6-TGN levels were therapeutic in 81.8%. OF THOSE WHO WERE SUBTHERAPEUTIC. Co-therapy was effective and well tolerated in 19 (68.4%). Two (10%) patients developed side effects from allopurinol both had been treated with 200 mg od. Discussion/Conclusion: We have previously published our long-term outcome data of IBD patients treated with thiopurines, 55% of these patients stopped thiopurine therapy due to therapeutic failure or side effects. The current data demonstrate that the majority of this refractory group can be rescued with co-therapy. These data demonstrate that co-therapy is a safe and effective treatment option in the DGH setting.
41 Helicobacter pylori isolates recovered from antral gastric biopsies of patients with dyspeptic symptoms: Antimicrobial resistance of metronidazole, clarithromycin and amoxicillin Fatma Kalem1, Mehmet Özdemir2, Metin Başaranoğlu3, Hatice Toy4, Bülent Baysal1 BezmiAlem Vakif University, Istanbul, Turkey Background and aim: Drug resistance in Helicobacter pylori infection is increasing worldwide. This is the main cause of failure of eradication therapy. The aim of this study was to determine in vitro resistance of commonly used antibiotics in H. pylori strains isolated from city of Konya in Turkey. Material and methods: 103 patients with dyspeptic symptoms were included in this study. Upper gastrointestinal endoscopy was performed in each patient. Biopsy specimens obtained were cultured on selective medium Pylori agar. The MIC for amoxicillin, clarithromycin, and metronidazole were determined by the Epsilometer test on Mueller-Hinton 7% sheep blood agar plates. Results: Of the 103 specimens, 40 (38.8%) were positive for culture. Of the 40 strains, 28 were tested for in vitro antibiotic susceptibility of metronidazole, clarithromycin and amoxicillin by E-test method. All strains were susceptible to amoxicillin. Resistance to clarithromycin and metronidazole were detected in 8 (28.5%) and 11 (39.2%) isolates, respectively. Conclusion: As resistance patterns in H. pylori isolates differ according to the geographical variation by time, it should be monitored locally for current recommending treatment regimen in every year. It was considered that performing culture and sensitivity testing of H. pylori resistance for prospective surveillance should be useful.
42 Laparoscopic approach as primary treatment of cholelithiasis and common bile duct stones in children with biliary pancreatitis K. Kalinova, A. Karachmalakov, O. Brankov, P. Stefanova, Y. Dimcheva, M. Haddad Pediatric Surgery, Clinic – Stara Zagora, Sofia and Plovdiv, University Hospital, Stara Zagora, Bulgaria Background: A preoperative miniinvasive endoscopic procedure is an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. Several international guidelines concerning the treatment of acute pancreatitis has been published during the last decades. We analyzed our series of laparoscopic approach for the management of cholelithiasis and choledocholithiasis in children to determine if it is an effective procedure. Patients and methods: Between 2002 and 2012, 188 adults and 13 children were treated for cholelithiasis in our institution; 3 children were managed for a choledocholithiasis. All patients that presented with gallstone pancreatitis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. Results: The mean age at clinical signs was 12.9 years (range 13–18 years). Ten children had a laparoscopic cholecystectomy. A choledocholithiasis was found in 3 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted. One child needed a conversion to open surgery. All children are symptom-free with an average follow-up of 36 months. There was no significant difference between mortality, morbidity, re-exploration rates and analgesic requirement between MAS and open surgery. There was a significant difference in the length of stay in hospital, in favour of laparoscopic cholecystectomy. Conclusion: Laparoscopic cholecystectomy and exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children. Most CBD stones in children pass spontaneously. Endoscopic sphincterotomy appears to be safe with no long-term sequelae. Current guidelines suggesting the appropriateness of waiting up to 2 weeks for cholecystectomy for biliary pancreatitis may place patients at unacceptably high risk for recurrence. Endoscopic sphincterotomy does not eliminate the risk of gallstone-related events.
43 Case report of atypical enteric amebiasis M. Kanashvili1, N. Rukhadze2, T. Kuchuloria2, D. Kikabidze1, G. Gogishvili2 1 Bochorishvili Antisepsis Centre, Tbilisi, Georgia 2 Tbilisi State Medical University, Tbilisi, Georgia During amebiasis outbreak in Georgia there were cases with erased enteric manifestation presenting with extra enteric features complicating disease diagnosis. To demonstrate this we would like to report the following case. A 35-year-old male patient was hospitalized 1.5 months after the disease initiation with fever (38.5°C axillary) and rigors. Erythema migrans was observed on the left shin; left ankle was red, swollen, painful (arthritis); both resolved spontaneously without any treatment after several days, but fever remained. HIV, brucellosis, TB was excluded; patient was diagnosed FUO. On admission patient had 38.7°C fever spike with rigors at night and transient abdominal distention without pain. Objectively visceral abnormalities were not observed. Chest x-ray, abdominal and pelvic CT was normal. ESR was moderately elevated. Serology showed positivity for Lyme disease IgM and Q-fever IgG, but treatment targeting these diseases did not have any result. Patient without any improvement was discharged from the hospital with the diagnoses of FUO. 5 days since discharge acute abdominal emergency led to the surgical intervention which revealed ascending colon amebic abscess verified by pathology. Enteric resection and antiamebic treatment led to the disease resolution. Described case is interesting for the practicing physicians, since enteric amebiasis may not manifest classically and as in this case cross-reactivity attributable to the serologic assays may have negative contribution to the establishment of the correct diagnoses.
44 Accuracy of visual estimation of adenoma size – A comparison with direct measurement in the pathology department J. Kinchen1,*, E. Harrod1, K. Wright1, A. Evans1, N. Chandra1 1 Gastroenterology, Royal Berkshire Hospital NHS Foundation Trust, Reading, United Kingdom Introduction: Large adenomatous colonic polyps (> 10 mm) are associated with an increased risk of development of adenocarcinoma. Recent national guidelines require the ability to distinguish polyps above and below 10 mm in size to determine the optimal surveillance interval. There is no standardised technique to measure polyp size either in the literature that underpins current guidelines or in practice. Visual estimation at endoscopy is widely used. Small prospective studies have shown this method to be inaccurate when compared to direct measurement in the pathology department. This retrospective study aims to establish the accuracy of visual estimation of polyp size in usual clinical practice comparing to direct measurement. Methods: A search for the word 'polyp' was performed on the pathology reports for all colonoscopies and flexible sigmoidoscopies performed during a one-year period. The pathology and endoscopy reports of the resultant cases were reviewed. Only adenomas completely removed by snare polypectomy without lifting and retrieved intact, where both endoscopic and measured sizes were recorded, and where the measured size was 5 to 15 mm were included. The direct measurement was subtracted from the visual estimate to give a size difference. The paired-sample t-test was used to test the null hypothesis that there was no difference between the mean sizes determined using the two methods for the group as a whole or for individual endoscopists. Results: In a total of 4285 procedures, 79 polyps met the criteria for inclusion. In 39 cases (49%), the difference between visual estimate and direct measurement was greater than 2 mm. In ascertaining whether a polyp was above or below the 10 mm cut-off, visual estimate and direct measurement were discordant in 21 cases (27%). Despite these disparities, there was no overall tendency to over or underestimate polyp size for the group as a whole (mean difference 0.05 mm p = 0.88). Of the 15 individual endoscopists, the two with the highest procedure counts both showed significant tendencies to underestimate polyp size, while a third showed significant overestimation.
Discussion/Conclusion: In clinical practice, visual estimation of polyp size is often inaccurate. Individual endoscopists may systematically over or underestimate polyp sizes. Direct measurement should be preferred in determining surveillance intervals.
45 Endoscopic treatment of biliary obstruction due to alien bodies and parasites V. Kolomiytsev, O. Kushniruk, M. Pavlovsky Lviv National Medical University, Lviv, Ukraine Introduction: We present our experience of endoscopic diagnosis and treatment of biliary obstruction due to alien bodies and parasites. Methods: During the last 10 years, 5283 patients were underwent to endoscopic retrograde cholangiography (ERC) for diagnosis and treatment with sphincterotomy. 5 patients had obstruction with broken external biliary drainage; 14 patients – with dislocated stent; 6 patients – with parasites (4 patient with Fasciola Hepatica and 2 patients with Ascaris lumbricoides); one patient – with ligature obstruction, and another one – with 45 cm suture material. For correct diagnosis, ultrasonography, EUS, CT, MRCP and ERC were used. Results: After sphincterotomy, alien bodies and parasites were successfully removed. Choice of the method of alien body fixation and extraction depended on the size and shape of an object. After the endoscopic removing of alien bodies and parasites patients had fast relief from the complications and jaundice with the help of medications. Discussion/Conclusion: Endoscopic retrograde cholangiography and sphincterotomy in the patients with biliary obstruction by alien bodies and parasites should prevent late complications, delay in treatment, and helps to avoid laparotomy.
46 Impact of pancreatic pseudocysts features and procedural factors on complication rate and long-term outcome after endoscopic treatment O. Kushniruk, V. Kolomiytsev, I. Tumak Medical University, Lviv, Ukraine Introduction: Pancreatic pseudocysts (PP) features and endoscopic drainage (ED) peculiarities can predict early complication (CR) and recurrence rate (RR) after endoscopic treatment. Methods: 89 patients with PP (mean size 99 ± 37.9 mm) were treated. PP complicated the course of acute in 20 (22.5%) and chronic pancreatitis in 69 (77.5%) patients. Conventional ED (CED) was transpapillary in 15 patients (16.9%) and transmural in 44 (49.4%). Endosonography was used in 30 (33.7%) patients. Combination of methods in 13 (14.6%) patients we used. Results: Minor complications occurred in 15 (16.8%) patients; all of them but two treated endoscopically. One patient died (1.1%) from not related to ED cause. Higher level of septic complication after ED of “younger” PP (8–12 weeks) was found (р = 0.089). CR was higher after introduction of straight stents (р = 0.037). EUS-guided drainages completely prevented bleeding. Cyst recurrence was observed in 8 (11.7%) from 68 patients. “Free of relapse” survival analysis showed better prognosis in alcohol PP vs. biliary (p = 0.017), cystostomy balloon dilation (p < 0.001), stents in situ more than 3 months. There was no recurrence in pancreatic body cysts, but 15.6% in head and 21.4% in tail cysts (p = 0.07 and p = 0.03). Better results were in patients with more than 2 stents (0 vs 13%) and with pseudocyst without PD communication (0 vs 12%). Discussion/Conclusion: The prevention of stent dislocation for the decreasing of CR and prophylaxis of recurrence is important. Pig-tail stent fits the best for these purposes. Balloon dilation and setting of more than 2 stents is necessary for diminishing of RR especially of pancreatic head and tail cysts in biliary pancreatitis.
47 Molecular basis for the Fumonisin B1-dependent promotion of the esophageal cancer E. Martinova Institute of General Pathology and Pathophysiolgy, Russian Academy of Medical Sciences, Moscow, Russia Introduction: Human esophageal cancer is known to be promoted by mycotoxin Fumonisn B1 (FB1) which is produced by fungi Fusarium moniliforme and other related species and contaminates the corn. Molecular mechanism of this specific action is not known. Because we previously shown that FB1 may regulate the signaling pathways of mTOR kinase – the key regulator of cell response to the stress, nutrients, insulin, etc., we now aimed to investigate the FB1-dependent regulation of mTOR signaling in the human primary esophageal cells. Methods: Samples of the esophageal tissues were obtained from 12 young men (18–26 years old) died accidently. Pathological examinations have revealed neither tumors not specific diseases. Esophageal tissues were homogenized, filtered, and washed. Separated cells were incubated in DMEM medium supplemented by 10% fetal bovine serum. FB1 was added for 3 hours [1.0–20.0 microM, 1 x 106 cells/ml], after that cells were washed, fixed in 4% paraformaldehyde with 0.1 saponin, and stained by monoclonal antibodies directed to the mTOR signaling. Results: In the primary human esophageal cells, FB1 has been found to modulate an expression of the upstream and downstream messengers connected with C1 and C2 mTOR complexes followed by an activation of protein synthesis, cell proliferation, and an inhibition of an apoptosis. FB1 has been also shown to modulate the signals connected with insulin and an expression of the glucose transporters. Conclusion: Mycotoxin Fumonisin B1 regulates the kinase mTOR-dependent signaling pathways in the primary human esophageal cells followed by the activation of cell proliferation and inhibition of apoptosis.
48 The predictive value of IL28B genotype in a population with HVB or HVC infections with spontaneous healing or with antiviral treatment G. Minzala, L. Iliescu, A. Martiniuc, M. Voiculescu Fundeni Clinical Institute, Bucharest, Romania Introduction: IL28B profile polymorphism is associated with increased sustained virologic respons rate, increased rapid virologic response and with increased rates of spontaneous virologic clearence for patients with HCV infection. There are not sufficient data about the impact of IL28B genotype on natural evolution in HBV. Methods: 58 patients included, classified into the following categories: 1. Subjects with spontaneous healing of HCV infection – 2 2. Subjects with sustained virologic response to standard therapy with Peginterferon and Ribavirin – 5 3. Patients with relapse to standard therapy with Peginterferon and Ribavirin – 12 4. Nonresponders to standard therapy with Peginterferon and Ribavirin – 28 5. Patients with chronic HBV infection treated with Peginrerferon or analogues 6. Inactive HBV carriers 7. Subjects with spontaneous healing of HBV infection The HCV/HBV viral load, IL28B profile, ALT level, serum level of vitamin D, the insulin resistance were determined to all subjects. Results and Conclusion: On the 57 subjects with HCV infection, the distribution according to the genotype was: • CC = 8 • CT = 35 • TT = 14 In the HCV nonresponders group no patient had CC profile, while 3 of the 5 patients with SVR had CC profile. IL28B, CC subgroup was associated with increased rates of spontaneous viral clearance and SVR.
49 Digestive manifestations in chronic kidney disease with hemodialysis P. Mitrut, A.O. Docea, A. Genunche-Dumitrescu, D. Badea, A. Enescu, E. Gofita, D. Calina, D. Salplahta University of Medicine and Pharmacy, Craiova, Dolj, Romania Introduction: Digestives manifestations are a severe complications of the chronic kidney disease with chronic hemodialysis. Gastric hypersecretion with hyperacidity is etiological factor in this complication. Aim of study: The aim of the study is the follow-up the endoscopical and histological changes of the gastric and duodenal mucosal in patients with chronic kidney disease with hemodialysis. Patients and methods: 212 patients with chronic kidney disease entered this study, between January 2010 and March 2012. Statistics analysis pointed out the prevalence of male (61.5%); average age 56.3 ± 5.65 years. The research protocol contained a clinical, biological and complete imagistic evaluation of the kidney and liver, neurological and endoscopic exams. Results and discussions: The digestive lesions were varied: uremic gastritis 21 cases, gastric ulcer 6 cases, duodenal ulcer 9 cases, gastric cancer 3 cases, peptic esophagitic lesions 24 cases associated with ather endoscopical lesions in 18 cases, esophageal and gastric varices in 2 cases. Hemorrhagic lesions was in 16 cases, epigastric pain in 24 cases and dyspeptic manifestations in 12 cases. H. pylori infection being indentified at 131 patients. Conclusions: The incidence of digestive manifestations is higher in patients with chronic kidney diseases with hemodialysis. The relative high percentage of patients with endoscopical lesions indicates the implication of ather factors in their etiology: neurological disorders, digestive effects of medications and HP infection.
50 Distribution of villous adenomas in patients admitted for colonoscopy V. Mokricka, A. Pukitis Pauls Stradins Clinical University Hospital, Riga, Latvia Villous adenoma (VA) is frequent asymptomatic lesion with potential risk of colon cancer. Aim of the study: To analyze the distribution and the frequency of VA relapses in correlation with morphological analysis among patients admitted for colonoscopy. Materials and methods: Retrospective study includes patients of 18 and older, obtained in the endoscopic examination database of the Gastroenterology Center, Pauls Stradins Clinical University Hospital, in the period from 2004 to 2010. Results: VA was diagnosed in 97 cases (50 men, 47 women, mean age 68) of 8006 colonoscopies. Incidence of VA among men and women is almost equal, for men 50/97 (95% CI: 42.3–61.2%), for women 47/97 (95% CI: 39.6–58.2%). Prevalence of VA was higher in patients after 60 and represents 64/97 (95% CI: 56.1–75.4%). The most frequent location of polyps was colon sigmoideum 24/97 (29.7% p = 0.2887) and rectum 23/97 (23.8%, p = 0.2268). 46/97 (47.4%) patients experienced concomitant diseases (colon diverticulosis 28.9%, intestinal polyposis 13.3%, ulcerative colitis or haemorrhoidal diseases accounted for 22.2%). Number of patients with a history of gastric resection was 15.6%. Conclusions: VA is equally common in both men and women, appears mostly after 60. The most common location of VA was colon sigmoideum (29.7%) and rectum (23.8%). Size of VA in the most cases was less than 1 cm. Morphologically 48.3% was villous adenoma, 32% tubulovillous adenoma and 19.7% VA with carcinoma. 47% of patients experienced concomitant bowel diseases. Recurrence after endoscopic polypectomy was observed in 8.2% of cases.
51 Differential Smad2/3 expression and decreased Smad2/3 activation are associated with characteristics of poor prognosis in ICC Stefan Munker1, Qi Li1, Feng Li1, Yan Liu1, Christoph Meyer1, Steven Dooley1, Hong-Lei Weng1, Jun Li2 1 Molecular Hepatology – Alcohol Associated Diseases, II. Medical Clinic Faculty of Medicine at Mannheim, University of Heidelberg, Germany; 2General, Visceral Surgery and Transplantation, University Hospital Tübingen, Germany Introduction: Incidence of cholangiocarcinoma (CC) rises in Western countries. TGF-β plays a dual role in the progression of human cancer and has been implicated in CC. It has been shown that Smad2 and Smad3, two canonical downstream signaling proteins of TGF-β, exert different roles in cancer. In the present study, we investigated the role of Smad2 and Smad3 in CC. Methods: Immunohistochemical staining for TGF-β1 and phospho-Smad2/3 was performed in 27 paraffin-embedded CC specimens paired with adjacent noncancerous tissue. The correlation between TGF-β1/Smad immunohistochemical score and characteristics of CC was evaluated. Western blot was used for analysis of TGF-β1/Smad signalling and target genes in tissue samples of 7 CC patients. In vitro, TFK-1, a cholangiocellular carcinoma cell line, was used to assess the impact of TGF-β1 on cancer cell proliferation and epithelial to mesenchymal transition (EMT). Interfering with Smad2 and Smad3 by RNAi and adenoviral overexpression was used to estimate effects of the two Smad proteins in proliferation and EMT of TFK-1 cells. Results: IHC revealed that decreased Smad2/3 activation in cancer cells correlates significantly with grading, metastasis and lymphnode metastasis of CC in 27 patients. In Western blot of 7 CC samples, we observed overexpression of Smad2 in 3 tumor samples. Smad2 overexpression significantly correlated with strong Smad2 activation and interestingly also with Smad3 activation. Smad3 activation was significantly associated with p21 expression. In vitro, Smad3 knockdown reversed TGF-β mediated cell cycle arrest, as measured by an increased incorporation of BrdU, elevated PCNA and reduced p21 levels. Adenoviral overexpression only of Smad3 but not Smad2 resulted in elevated p21 levels. Knockdown of Smad3 decreased TGF-β mediated EMT, suggesting a central role of Smad3 in EMT of this cancer. Discussion/Conclusion: Decreased Smad2/3 signaling is significantly associated with cancer properties indicating a poor prognosis, such as metastasis and high invasiveness. In vitro, Smad3 is the main mediator of EMT like changes.
52 Adipokines and their role in patients with obesity and Barrett’s esophagus D. Neagoe, G. Ianosi, A. Amzolini, M. Filip, C. Georgescu, T. Ciurea University of Medicine and Pharmacy, Craiova, Romania Introduction: Obesity, defined by the body mass index (BMI), is a recognized risk factor of gastroesophageal reflux disease, erosive esophagitis and esophageal adenocarcinoma but the impact on the risk of Barrett’s esophagus is unclear. Aim of our study was to evaluate the role of adipokines (leptin and adiponectin) in obese patients with or without Barrett’s esophagus. Methods: We included 56 patients obese with Barrett’s esophagus confirmed histological (group A) and 54 patients obese without Barrett’s esophagus (group B). In all patients we measured BMI, waist circumference, C reactive protein, insulin, leptin, and adiponectin level. Results: There were no statistically differences in age or gender distribution between 2 groups. We observed that group A had a higher BMI but not statistically significant, a significantly greater waist circumferences (92 vs. 102 cm, p = 0.005) and in kilo (10 vs. 15 kg, p = 0.003) waist circumference didn’t correlate adiponectin level but correlated with leptin in both groups (p = 0.000 and p = 0.001). Insulin, CRP and leptin (p = 0.04) were significantly higher in Barrett’s group and adiponectin was decreased in both groups without differences (p = 0.56). Highest level of insulin and leptin was found in patients with long segment Barrett, but we had only 8 patients and it is difficult to appreciate the real relationship between long segment Barrett and insulin or leptin level. Discussion/Conclusion: Our study suggest that obesity defines as BMI is not a risk factor by itself for Barrett’s esophagus but leptin and insulin level are strong associated with these disease.
53 Health-related quality of life in Crohn's disease O. Nedelciuc, I. Pintilie, G. Dumitrescu, C. Cijevschi Prelipcean University of Medicine and Pharmacy, Iasi Center of Gastroenterology and Hepatology, Iasi, Romania Objective: The aim of this study was to assess the quality of life (QoL) of patients with Crohn's disease (CD) prospectively over 1 year and to determine factors of influence. Methods: A total of 105 CD patients were included. At month 0 (M0), M6 and M12, patients were given a validated QoL questionnaire (self-administered) to fill in and a clinical form referring to the period of 6 months before the visit. Each patient completed a standardized questionnaire on QoL in IBD (IBDQ Bowel Disease Questionnaire 32-inflammatory). The impact on QoL of the following factors was analyzed: age, gender, CD duration and localization, presence of extradigestive manifestations or concomitant disease, disease course, medical treatments, and surgery. We studied the correlations between QoL and disease activity assessed by both patients and investigators by a visual analog scale. Results: At M0, all the scores of the IBDQ-32 were significantly lower than those of a standard population (90–180 vs 150–220, p, 0.05). Patients' main worries were first "having an ostomy bag" followed by "uncertain nature of the disease," "energy level." and finally "having surgery." A significant lower scores we found in those who had long and severe period of activity (50–140) and, in those, with frecquent relapsing (50–100). At M6 and M12, QoL was better in those patients who quit smoking (p < 0.05), and in those enter in remision (p < 0.05). An important factor was the therapy given: biological agents tend to increease QoL (110–200), while the continuing need of corticoids decrease it (80–170). Qol correlated with assessment of disease course by the patient than by the investigator. Significant factors of impairment in QoL were female gender, tobacco, active CD, involvement of the colon, hospitalization, corticoid treatment, and surgery in the past 3 months. Biological agents improved quality of life. Conclusion: Health quality og life is impaired in CD patients. Tobacco, hospitalization, and use of corticoids have a negative impact on QoL. The use of biological agents is associated with a better QoL.
54 Easy to live with ulcerative colitis patients? O. Nedelciuc, M. Dranga, M. Badea, C. Mihai Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Iasi, Romania Background: Patients with inflammatory bowel disease (IBD) have to live with the perspective of a potential disability, which may lead in time to impaired quality of life (QoL) and even major mental disorders. To fully understand the impact of IBD on patients and their carers we need to quantify the QoL. Methods: Prospective study included 105 patients hospitalized between January 2010–December 2011. We have noted: age, sex, area of origin, status smoker/nonsmoker, presenting symptoms, presence of inflammatory syndrome, the extension of lesions, severity, treatment, complications, need for surgery. All the patients were examined by colonoscopy and diagnosis of UC was confirmed histologically. The activity of the disease was quantified using Truelove and Witts clinical score of: mild, moderate and severe. To all patients was administered a self completed questionnaire with four different scores for intestinal symptoms (IS), systemic symptoms (SS), emotional function (EF), social function (SF) and an overall quality-of-life (QoL) score. Higher scores were related to a worse QoL. Statistical analisis was performed with Kruskal-Wallis test and differences were considered significant when p ≤ 0.05. Results: Ninty-one percent (91%) were admitted for a flare while they were asked to fulfill the IBD-Q questionnaire. Proctitis was met in 2.94% of the cases left-sided colitis as 71.1% and pancolitis 26% of cases. As the severity, there were 32 patients with mild activity, 62 patients with moderate activity and only 3 patients were having sever activity. The range score for QoL was 90–180. In proctitis: 80–190, in left side colitis: 120–200, in pancolitis: 70–160 (p > 0.05). The patients with severe form had a a lower score (50–140) than patients in remission (130-180) (p < 0.01). Conclusion: Patients with UC. have significantly influenced QoL compared to the general population. We found no significant differences regarding the extension of the lesions, although there was expected that the patients with extensive forms had lower QoL.The severity of the flare had a significant impact on the Qol.
55 Abdominal pain in patients with acquired immunodeficiency syndrome (AIDS) Cristina Olariu1, Adriana Nurciu2, Oana Schiopu2 1 “Prof. Dr. Matei Bals” National Institute of Infectious Diseases, Bucharest, Romania 2 University Emergency Hospital Bucharest (UEHB), Bucharest, Romania Introduction: In most patients with AIDS abdominal pain is directly related to human immunodeficiency virus (HIV) and its consequences. We evaluated the most common causes of abdominal pain in patients with AIDS and the diagnostic methods. Methods: Between January 2011 and April 2012, 36 consecutive patients with AIDS were submitted with abdominal pain (20 males, 16 females), mean age 21.82 ± 9.97 years. Generally, the same work up as for a patient without AIDS should be initiated: previous or recent history, physical exam, blood tests, O&P (ova and parasites) and abdominal ultrasonography were performed for all patients. Abdominal plain films, stool culture, sigmoidoscopy, upper endoscopy, CT (computer tomography) scanning or MRCP (magnetic resonance cholangiopancreatography) were done in selective cases. Results: Clinically four of the cases (11%) were with sign of bowel obstruction, 10 (28%) were with infectious enteritis (CMV or Cryptosporidium), 12 (33%) were with cholecystitis, cholangitis or ischemic cholangiopathy; edematous pancreatitis was observed in 6 cases (17%) and 4 patients (11%) were with infectious peritonitis(Mycobacterium tuberculosis). However, there was a striking correlation between the severity of gastrointestinal diseases and the CD4 lymphocite count. Discussion/Conclusion: Most common gastrointestinal consequences of infection with HIV are infectious enteritis (with CMV or Cryptosporidium) and AIDS cholangiopathy. Survival and outcomes are linked to severity of immunodeficiency.
56 Hepatitis C virus infection (HCV) in patients of the University Emergency Hospital Bucharest (UEHB) Romania – Hemodialysis Center between 2005–2010 Dan Olteanu1, Alexandru Cristian Diaconescu1, Sorin Scărlătescu2 1 st I Department of Internal Medicine and Nephrology, UEHB, Bucharest, Romania 2 Charleston Area Medical Center, Charleston, WV, USA Introduction: HCV infection has high prevalence among hemodialysis worldwide. In Moldavia, one region of Romania, was 75%. In Bucharest the data were almost nonexistent, but those of UEHB not seems to be concerning. Methods: UEHB operate in 4 then 2 dayshifts using Fresenius 4008 monitors. HCV patients have dedicated machines, no "yellow rooms”. Staff members uninfected. Testing for anti-HCV performed at entry then twice a year (MonoLisa3 then chemiluminescence technique – 41 positives). Results: A 32 fold increase in transiting patients. Mean age 60.57 ± 15.42, duration of dialysis 1.53 years. 63.52% pensioners, 4% working. 3/4 Romanian-ethnicity, Roma 1/5. Among hypertensives (72%), 56% had secondary hypertension. Central venous catheter use is 91%. Psychiatric illnesses in 54%. 28% of patients using alcohol. Discharged by transfer 47%, death 28%, only five renal transplants 1.02%, four to peritoneal dialysis 0.82%. Increase in new cases in UEHB starting 2009 (but no seroconversions). Incidences: 2008: 1.9%, 2009: 4.95%, 2010: 5.38%. Discussion/Conclusion: Risk factors: - younger age (current and at HD start). - longer duration of dialysis. - transfusion history - less weighed - hepatic cytolysis; good marker for acute infection. Protective effect of infection on survival. 2010-prevalence lower than in other (private) centers. We found only one seroconversion (after the end-date of study). Strict adherence to universal precautions is effective and sufficient at sites with low prevalence (like ours): no isolation measures are imposed.
57 Gastrointestinal hemorrhagic complications during chronic antithrombotic prevention with vitamin K antagonists Stanisław Ostrowski, Małgorzata Sawa, Andrzej Prystupa, Jerzy Mosiewicz Department of Internal Medicine, Medical University of Lublin, Lublin, Poland The use of vitamin K antagonists is effective for primary and secondary prevention of thrombo-embolic episodes. Once the indications for oral antithrombotic therapy were established, the number of patients using this form of prevention increased. However, the therapy leads to some complications: hemorrhages, often life threatening, and additional hospitalizations. The resultant complications have to be treated and clotting parameters periodically monitored. Thus, it appears that the health care systems are faced with another challenge. Aim: The aim of the present study was to determine the incidence of hospitalizations due to complications related to vitamin K antagonist therapy and to define their types. Methods: A preliminary survey of medical records of patients admitted to the Department of Internal Diseases, Teaching Hospital no 1 in Lublin in the years 2007–2010. Results: In the years 2007–2010, 10,079 patients were admitted to the Department of Internal Diseases of the Teaching Hospital No 1 in Lublin; 64 (0.63%) patients were hospitalized due to elevated INR levels, including 44 (66%) women and 23 (34%) men. On admission, the levels of INR of these 64 patients ranged from 3.5 to undetectable, and was comparable in female (3.5 to undetectable) and male patients (3.67 to undetectable). In the period 2007–2010, the number of patients admitted with elevated INR (above 3) steadily increased, i.e. in 2007 – 6 patients (3 women and 3 men), in 2008 – 15 (9 and 6), in 2009 – 21 (12 and 9), in 2010 – 25 patients (20 and 5, respectively). In the period studied, 5 patients admitted because of overdose of vitamin K antagonists died. Hemorrhagic complications developed in 91% of patients. Gastrointestinal hemorrhages constituted almost a half (47%) of all complications, including tarry stools (33%), hematemesis (10%), coffeeground vomiting (9%) and fresh blood in stools (3%). The most common extraalimentary complications included nosebleeds, gingival bleedings (15%), genitourinary bleedings (13%) as well as bruises, subcutaneous hematomas or bruises of unknown origins (6%). In 9% of patients, hemorrhagic complications caused by oral anticoagulant overdose were not observed. Conclusions: In the years 2007–2010, the number of patients admitted to the Department with elevated INR levels steadily increased. The majority (91%) of patients with elevated INR developed symptoms of gastrointestinal hemorrhages. Gastrointestinal hemorrhages constituted almost a half (47%) of all complications.
58 Analysis of the risk of biliary pancreatitis using routine biochemical data, parameters of imaging techniques in patients with choledocholithiasis confirmed by ERCP I. Ozola Zalite, A. Pukitis Pauls Stradins Clinical University Hospital Riga, Latvia Predictive factors as alanine transaminase, comorbid conditions and older age can predispose development of the complications of choledocholithiasis. Study aim was to evaluate biochemical parametra and routinely aplied imaging techniques for patients with choledocholithiasis and biliary pancreatitis who undergone ERCP. Methods: The study was conducted in Gastroenterology center, Pauls Stradins Clinical University Hospital during 2010–2012 including patients who had biochemical and visual diagnostic imaging examination data showing choledocholithiasis confirmed by ERCP. Data analysis was focused on evaluation of predictive role of the risk of biliary pancreatitis. Results: 180 patients were included prospectively (male 36%, female 64%, mean age of 65 years). Choledocholithiasis was confirmed by ERCP in 42.77% (77 patients), biliary pancreatitis 19.48% (15). ALT in biliary pancreatitis cases was elevated more than threefold in 80% (sensitivity 80%, specificity 32.07%, PPV 25%, NPV 85%). Sensitivity of hyperbilirubinemia was 60%, specificity 41.17% (PPV 23.08%, NPV 67.66%). US sensitivity for choledocholithiasis was 35.71%, specificity 93.39% (PPV 75.75%, NPV 71.52%), CT 25%, 88.64% (PPV 28.57%, NPV 86.67%), MRCP 81.25%, 80% (PPV 72.22%, NPV 86.96%), respectively. In patients group without pancreatitis common bile duct size on US was 11.33 mm in average, ERCP 13.58 mm; with biliary pancreatitis US 14.75 mm, ERCP 14.69 mm (p < 0.0001). There were no significant diferences in gender ratio and age distribution between both groups. Conclusion: Laboratory parameters as ALT, bilirubine, visual diagnostic data (common bile duct diameter) are useful indicators for decision making to predict the need for therapeutic ERCP in patients with choledocholithiasis and suspected biliary pancreatitis.
59 Neuroticism and depression in inflammatory bowel disease – Clinically significant? D. Panova, S. Derejan, R. Nikolov, Z. Spassova, Z. Krastev Clinic of Gastroenterology, St. Ivan Rilski University Hospital, Sofia, Bulgaria Medical University, Sofia, Bulgaria Introduction: Inflammatory bowel disease (IBD) is a life-long disorder that has a major impact on psychological well-being. Methods: We have evaluated psychological profile in 37 patients – 17 with Crohn’s disease (CD) and 20 with ulcerative colitis (UC); 23 subjects were female and 14 – male; in clinical remission were 18 and in exacerbation – 19. Psychological profile was evaluated with Minnesota Multiphasic Personality Inventory – 2 (MMPI-2). Results: We found that 73% of the patients had neurotic profile (clinically significant signs of depression, anxiety, hysteria, hypochondria and maladaptation); 8.1% were introverted; 5.4% were psychopathic and 13.5% had no deviation on MMPI-2. In exacerbation 90% were neurotic, also, 50% of patients in remission. All of the patients with IBD without any deviation on MMPI-2 were in clinical remission. There was no difference between CD and UC patients (p > 0.05) on the MMPI-2 scales, women with IBD had higher scores on hysteria and anxiety scales compared to men (p = 0.013 and p = 0.022 respectively). Discussion/Conclusion: Neurotic profile is closely linked to IBD, especially with clinical activity. Even when remission is achieved half of the patients remain neurotic. IBD is a major distress for patients, leads to significant psychological deviations and makes patients socially isolated. Both patients with CD and UC suffer equally. In the neurotic profile of women with IBD dominate the signs of anxiety and hysteria compared to men, who have more depressive features. Neuroticsm and depression in IBD must be treated.
60 Histopathological and immunohistochemical Helicobacter pylori colonized gastric mucosa
changes
in
Gabriela Pârlog, M.D.,* Ph.D., Sorina Pârlog, M.D.** *Department of Internal Medicine, Emergency Hospital, Bacău, Romania, **Hospital Saint John D’Jerusalem, Bucureşti Introduction: Helicobacter pylori (H. pylori) colonizes the gastric mucosa causing both inflammatory changes, premalignant lesions and malignant tumors, including gastric lymphoma and gastric carcinoma. In this study, our purpose was to evaluate the histopathological changes correlated with immunohistochemical results demonstrating the types of cellular infiltration and the proliferative activity of gastric mucosa infected with H. pylori. Methods: Gastric endoscopic examinations were performed on 68 patients with antiH. pylori antibodies and dyspeptic phenomena. Fragments witch had been endoscopically harvested in the stomac were fixed in formalin and processed by paraffin inclusion. Histological sections had been stained with hematoxylin-eosine and Giemsa. In 65 cases, endobiopsic fragments (36 cases: deep chronic gastritis with intestinal metaplasia, glandular atrophy and intraepithelial neoplasia and 29 cases: carcinomas) immunohistochemical reactions had been performed by applying reagents for identifications of H. pylori colonies, of T lymphocytes (CD3) and macrophages (CD68) and Ki-67 reagent for proliferating nuclear antigen labelling. Results: H. pylori was found in all endoscopic specimens by Giemsa stain or by antiH. pylori antibodies, in the cases with low degree of colonization with H. pylori. Histological diagnosis was: 463 cases: superficial and deep gastritis associated with premalignant lesions, 29 cases: carcinomas, 2 cases non-Hodgkin lymphoma and 1 case of adenomatous polyp. Immunohistochemically, inflammatory infiltrate consisted in numerous T lymphocytes, macrophages and lymphoid follicles. The nuclei of foveolar cells, in the area of intraepithelial neoplasia and carcinomatous cells were intensely stained with Ki-67, demonstrating increased proliferation. Discussions/Conclusions: In gastric infection with H. pylori, inflammatory infiltrate consists of abundant macrophages and T lymphocytes. Ki-67 was absent or minimal in chronic gastritis, while in areas of intraepithelial neoplasia was positive in both foveolar and coating epithelium. Anti-H. pylori antibodies in human serum remains one of the simplest methods to detect H. pylori, therefore it plays an important role in practice. Medical eradication of bacteria may cancel inflammatory changes, metaplasia and proliferation of gastric mucosa and thus it prevents the cascade of carcinogenesis.
61 Inflammatory bowel disease and Helicobacter pylori Iulia Andreea Pintilie, Otilia Nedelciuc, Mircea Alexandru Badea, Cristina Cijevschi Prelipcean Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Iasi, Romania There are recent data which support a low prevalence of Helicobacter pylori infection in patients with intestinal inflammatory disease as opposed to general population. Aim: To determine the prevalence of Helicobacter pylori infection in IBD patients in comparison to a non-IBD control group. Both groups presented dyspeptic symptomatology. Materials and method: A prospective study has been conducted between 1 January 2010–30 December 2011 on 98 patients diagnosed with IBD (60 men and 38 women; 23 with CD – 23.5% and 75 with UC – 76.5%) and a control group of 950 patients (494 men and 456 women) who addressed the Gastroenterology Centre with dyspeptic symptomatology. Serum tests have been performed on all patients in order to detect Ac anti-Helicobacter pylori and also superior digestive endoscopy in order to correlate the presence of infection with Hp and the changes at the level of esogastro-duodenal mucous. Results: Presence of Helicobacter pylori was inversely associated with IBD. Thus, 5 of the IBD patients have been diagnosed with Ac anti- Helicobacter pylori (1 with BC – 4.3% and 4 with UC – 5.3%), while 598 patients were diagnosed with Helicobacter pylori chronic infection (63% of the control group). In contrast with the Hp infection prevalence, 37 patients (38%; 15 with CD – 65% and 22 with UC – 30%) were diagnosed with antral gastritis. Out of the 950 patients in the control group, 605 have been diagnosed with modifications like esophagitis, gastro-duodenite, and gastric and duodenal ulcers. 423 (70%) of these 605 patients were tested positive for Helicobacter pylori. Conclusions: The study highlighted an inverse association between H. pylori and IBD and a proportional one between negative H. pylori and IBD, data contrasting those of the control group. The question whether IBD is a protection factor or not against H. pylori infection is still open.
62 Epidemiologic, etiological and age aspects of the syndrome of diarrhea in children N.V. Pronko Grodno State Medical University, Grodno, Belarus Aims: The aim of our research was to study epidemiologic, etiological and age aspects of the syndrome of diarrhea in children. Results: We observed 5885 children hospitalized with the syndrome of diarrhea to Grodno Regional Infectional Clinical Hospital from 2005 to 2010. According to the final clinical diagnosis the patients were distributed in the following way: acute noninfectious gastroenterocolite – 2680 patients (45.5%), acute infectious gastroenterocolite – 1389 (23.6%), rotaviral infection (RVI) – 1009 (17.2%), salmonellosis – 667 (11.3%), enteroviral infection – 87 (1.5%) and acute dysentery – 53 patients (0.9%). A decrease of infectious morbidity indices was observed for the period analyzed. The level of dysentery morbidity lowered from 19.58 to 0.94 per 100,000 population. The ratio of viral diarrheas in the total amount of intestinal infections increased from 27.7% in 2005 to 37.5% in 2010. RVI came to the forefront among viral diarrhea in children. RVI was characterized by winter and spring seasonal prevalence. It is reasonable to examine for RVI from November to April. RVI assumed a severe course in children of early age with unfavorable pre-morbid background. The etiological structure of bacterial diarrhea had an increased proportion of salmonellosis and conventionally pathogenic flora (staphylococcus, Proteus, Friedländer’s bacillus, citrobacter and enterobacter). The high frequency of acute gastroenterocolites of unspecified etiology may be related to untimely laboratory examinations. The most vulnerable contingents are children of 0 to 3 years. Discussion/Conclusion: At a pre-hospital period, intestinal infections in children are often hyperdiagnosed. The majority of diagnosis disagreements were found in the group of children of early age. Antibiotics were prescribed more frequently than the clinical situation required. A high level of acute noninfectious gastroenterocolites has been registered in recent years. Therefore pediatricians-gastroenterologists should carry out differential diagnostics of the syndrome of diarrhea to exclude intestinal inflammation.
63 Colorectal cancer in the centre of Romania – Differences between urban and rural areas M. Pumnea1,2, E.C. Rezi2 1 Lucian Blaga University, Sibiu, Romania 2 Polisano Medical Centre, Sibiu, Romania Introduction: The epidemiology of the colorectal cancer in Transylvania was less studied. Our aim was to study which is the prevalence and other epidemiological features of the colorectal cancer among the hospitalized patients from the centre of Romania and to analyse if there are any differences between urban and rural areas regarding this disease. Methods: We have performed a retrospective study on a 7 years period of observation. From the total of 7224 patients who were hospitalized in the Gastroenterology and Medical Departments of the Clinical County Hospital from Sibiu, 301 were diagnosed with colorectal cancer. Results: The colorectal cancer prevalence was 4.16%. From these, 72.66% patients were from urban areas and 27.34% from rural areas. The medium age of the patients with colorectal cancer was 67.28 ± 10.04 years. 28.57% of those from rural areas were diagnosed in an operable stage, while only 19.35% of those from urban areas were diagnosed in an operable stage. At those from rural areas: 14% had metastases when diagnosed and 5.71% of the tumours were invading in other organs or structures, while at those from urban areas 16.2% had metastases and 9.67% of the tumours were invading in other organs at the time of diagnosis. Discussion/Conclusion: The prevalence of the colorectal cancer among the hospitalized patients in Gastroenterology Units from centre Romania is about 4.16%. There are significant geographic differences in colorectal cancer incidence. The majority (72%) of the patients diagnosed with colorectal cancer live in urban areas. They seem to have a poorer prognosis as they are diagnosed in more advanced stages then the others. The diet and the sedentary habits of the patients from urban areas may be a reason for these differences between urban and rural areas.
64 Immunosuppression monitoring in inflammatory bowel disease: A comparison between primary and secondary care Dr Amer Rehman Farooqi*, Dr D. Durai** *Speciality Registrar Gastroenterology, **Consultant Gastroenterologist University Hospital Wales, Cardiff, United Kingdom Introduction: Azathioprine and 6-Mercaptopurine are most widely use immunosuppressive therapies in inflammatory bowel disease. Due to variable thiopurine methyl transferase (TPMT) activity different doses and escalation regimes are used and robustly monitored. Aim: The aim of our study was to compare monitoring standards between primary and secondary care and also the initial drug escalation monitoring. Methods: This was a retrospective analysis of shared care agreements of Azatihioprine monitoring between primary and secondary care. Results: A total of 101 patients were audited (57 hospital, 44 General practice patients). Regular monitoring between the two arms was comparable, with 93% patients under general practice having regular 2–3 monthly bloods and 94% of the hospital patients). Initial blood monitoring showed 94% having baseline bloods, 78.7% at 2 weeks and 82.8% at 4 weeks. Another significant secondary data was prevalence of vitamin D deficiency in 43% of our patients who had there levels checked. Discussion/Conclusion: Regular monitoring of azathioprine and 6-MP between primary and secondary care is very similar. Initial blood monitoring needs improvement. Vitamin D deficiency in these patients is common and perhaps should be checked routinely.
65 The association of dyslipidemia with dysplastic colorectal polyps in a population from southern Transylvania E.C. Rezi1, M. Pumnea2 1 Polisano Medical Centre, Sibiu, Romania 2 Lucian Blaga University, Sibiu, Romania Introduction: It is known that the hypercaloric and hyperlipidic diet is involved in the appearance of the colorectal cancer. Obesity, dyslipidemia and diabetes mellitus constitute risk factors for this neoplasm. Our aim was to study the association of dyslipidemia with the presence of the dysplastic colorectal polyps. Methods: We have performed a retrospective study on a 3 years period of observation. A total of 849 colonoscopies and rectosigmoidoscopies were performed in the medical departments of the Clinical County Hospital from Sibiu, Romania. A number of 144 colorectal polyps were found. The results were statistically analyzed using the relative risk and the t Student test. Results: The medium age of the patients presenting colorectal polyps was 63.76 ± 12.29 years of age. The gender distribution was 37.5% women, versus 62.5% men. At 35 patients (24.3%), the histological exam of the polyps showed high or moderate grade of dysplasia. At 53 patients (36.8%) a polypectomy was performed. At the rest of them, biopsies were taken. The relative risk of developing a colorectal cancer at the patients presenting a colorectal polyp was 2.10. The medium value of cholesterol level at the patients who proved to have dysplastic polyps was 221.31 mg/dl, comparing with 190.95 mg/dl at the patients with non-dysplastic polyps (p = 0.05). The triglycerides level was, in average 226.21 mg/dl at the patients with dysplasia, comparing with only 127.05 mg/dl at the patients without dysplasia (p = 0.031). The relative risk of developing dysplastic polyps at the patients having metabolic syndrome, comparing with those not having metabolic syndrome was 1.35, which means that they are more exposed of developing polyps with high-grade dysplasia. Discussion/Conclusion: Our study suggests that dyslipidemia is associated with colorectal dysplasic polyps in a population from southern Transylvania. In patients with colorectal polyps, the coexistence of the metabolic syndrome may portend an increased risk of dysplasia. At the patients with dyslipidemia, the colorectal cancer has a higher prevalence comparing with those without dyslipidemia. Life style interventions may prevent the appearance of the dysplastic colorectal polyps.
66 Manifestation of acute pancreatitis in urogenital sepsis (case report) N. Rukhadze, M. Kanashvili, D. Kikabidze, M. Javakhadze Tbilisi State Medical University, Bochorishvili Antisepsis Centre, Tbilisi, Georgia Nowadays the acute pancreatitis is still problematic in medicine. The aim of our study was to describe a case of acute pancreatitis caused by the acute sepsis. Patient, 45 years old woman admitted the hospital with complaint for fever – t 39°C and increased frequency of urination, filling of heaviness in the small pelvic area, moderate edema of all body, tongue dry, heart tones stupefied; there was heard a vesicular breath in the lungs. Liver was enlarged about 3–4 cm, Pasternack’s symptom was negative in both sides. On the fifth day of the beginning of antibacterial therapy in spite of positive dynamic there was revealed the pain in the hypochondriac region with irradiation to hypogastry and the left kidney. There was added diarrhea, which wasn’t cut off by the probiotics. On the fourth day of the onset of pain there was manifested acute surrounded pain in hypogastry and temperature was increased up to 38.9°C. Laboratory tests revealed the increased level of amylase in the blood and diastase in the urine which noted to the acute pancreatitis with accompanying infection. During the antibacterial, fermentative, non-steroid anti-inflammatory and diet therapy patient’s condition was improvedstep by step. On the fourth day the pain was much decreased. Fever released in five days, and after two weeks she was healthy clinically. The described case is interesting because the damage of pancreas followed by the generalization of uro-genital tracts is not described in the references and we haven’t met it in our practice yet.
67 H. pylori eradication problems. Different ways leading to one goal Mirzabey Rustamov1, Leonid Lazebnik2 1 Minsk Diagnostic Centre, Minsk, Belarus, 2 Central Research Institute of Gastroenterology, Moscow, Russia Purpose: To investigate effects of proton pump inhibitors (PPIs), probiotics and mineral water in patients with H. pylori-positive duodenal ulcer and to elaborate optimal H. pylori eradication regimens. Materials and methods: 250 patients were randomized into 5 groups, 50 in each. Endoscopy, pH-metry, blood analyses were performed. Next regimens were recommended: group I – 10-days twice PPIs, amoxicillin 1000 mg, clarithromycin 500 mg; 20-days PPIs; II – same treatment plus probiotics; III – PPIs, probiotics, hydrocarbonate-chloride sodium mineral water; IV – PPIs, probiotics, chloride sodium mineral water; V – probiotics and PPIs. Findings: In 50% of patients of group I increased dyspeptic complaintsand in 42% appeared firstly. In group II dyspeptic complaints disappeared in 74%. Dyspeptic complaints disappeared 78%, 76%, 74% in III, IV, V groups respectively. Eradication rate were 70%, 82%, 80%, 78%, 68% in I, II, III, IV, V groups respectively. Healing of duodenal ulcer were 82%, 84%, 86%, 84%, 78%, in I, II, III, IV, V groups respectively. Intragastric and intraduodenal pH increased in all groups, especially in III. In group I increased alanine transaminase, asparagines transaminase, alkaline phosphatase, triglycerides. In III, IV, V groups decreased alanine transaminase, asparagines transaminase, blood bilirubin, alkaline phosphatase, cholesterol and triglycerides. Conclusions: Triple therapy causes or increases dyspeptic complaints, has low efficacy and hepatotoxic effect. Eradication regimen containing PPIs, mineral water and probiotics is more preferable, safe regimen among above mentioned ones.
68 Role of sucralfate in post band variceal ulcer Mohamed Sakr1, Waleed Hamed1, Hassan Hamdy1, Maha El Gafaary2, Runia EL-Folly1, Manal EL-Hamamsy3 Tropical Medicine1, Statistics and Community Medicine2, Faculty of Medicine1,2 Department of Clinical Pharmacy3, Faculty of Pharmacy3, Ain Shams University, Cairo, Egypt Manal EL-Hamamsy: E-Mail:
[email protected] Introduction: Sucralfate can be described as mucosa-protective because it strengths the natural defense mechanisms of GI tract and because it protects the ulcerated area against attack by acid and pepsin. Specific hypotheses were that patients treated with sucralfate following band ligation would have fewer and smaller post banding ulcers and they would experience less chest pain, dysphagia and rebleeding. Therefore, we need to assess the use of sucralfate after variceal band ligation (VBL) and its effect on post VBL ulcers. Methods: Sixty-two patients with oesophageal varices eligible for band ligation represented the population of the study. The recruited patients were allocated into two groups: Group I (study group): Included 31 patients in whom endoscopic band ligation was done then received sucralfate 1 gm every 6 hours for 2 weeks. Group II (control group): Included 31 patients in whom endoscopic band ligation was done then received placebo every 6 hours for 2 weeks. Results: During the follow up endoscopy, 2 weeks after band ligation we observed that: All post-banding ulcers in both groups were superficial, 12 patients (38.7%) in the study group developed post-band ulcers versus 23 patients (74.2%) in the control group with a statistically significant difference (p-value, 0.005). Also, there was a statistically significant difference between both groups regarding the size of the post banding ulcers as the mean size of ulcers was 2.7 mm ± 1.2 in study group whereas it was 3.8 mm ± 1.7 in control group with P value (0.043). Discussion/Conclusion: Sucralfate has a significant role in decreasing the rate of occurrence of variceal post-banding ulcers and as well their size.
69 Unusual cause of gastrointestinal bleeding: Hepatocellular carcinoma with gastric invasion L. Sandulescu, A. Saftoiu, S. Cazacu, F. Scutelnicu, C. Popescu, D. Dumitrescu University of Medicine and Pharmacy, Research Center in Gastroenterology and Hepatology, Craiova, Romania Gastrointestinal invasion of hepatocellular carcinoma is extremely rare and when it occurs, the diagnosis is difficult; bleeding is the most common presentation. A 73-year-old man presented with anemia (hemoglobin, 5.9 mg/dl) and a history of alcoholic liver disease. Ultrasonography and IRM demonstrated a 12/10 cm tumor in right abdominal flank, from unknown origin (Fig. 1). CEUS showed a typical pattern of HCC (Fig. 2). Endoscopic gastroscopy revealed a hemorrhagic ulcerative tumor in antral region (Fig. 3). Biopsy from the antral tumor revealed a typical pattern of hepatocellular carcinoma (Fig. 4). After 6 months of paliative treatment and follow-up, the patient died from hepatic insufficiency. Until now, only seventeen cases of HCC invading the stomach with upper GI bleeding have been reported. The prognosis is dismal when the GI tract is involved, and in cases of gastric invasion it is even worse or less than one-year survival.
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70 Role of contrast enhanced ultrasonography in the diagnosis and monitoring of a patient with Crohn’s disease L. Sandulescu, A. Saftoiu, T. Cartana University of Medicine and Pharmacy, Research Center in Gastroenterology and Hepatology, Craiova, Romania Contrast enhanced ultrasonography (CEUS) has recently been proposed for evaluating inflammatory bowel disease, as a high resolution, non-invasive, radiationfree method. We present the case of a patient diagnosed 2 years ago, by endoscopy and histopathological examination, with ileocolic Crohn’s disease with stenosis of the ascending colon. Despite pathogenic treatment (5-ASA, systemic corticosteroids) the patient presented repeatedly in our clinic with refractory anemia, persistent biologic inflammatory syndrome, and we decide to initiate biological therapy with Infliximab. CEUS was used to evaluate our patient before and after the specific induction therapy, assessing the intestinal wall thickness and the microvascularization pattern. Before therapy CEUS visualized the thickening of the bowel wall with increased vascularity after administering the contrast agent (Sonovue®). Furthermore, we injected the same contrast agent through the opening of a fistula during endoscopic examination identifying the route of the entero-enteral fistula by transabdominal ultrasonography. After the induction therapy the patient’s evolution was favorable, with reduction of the intestinal wall thickness and of the vascular enhancement at CEUS examination.
71 Pancreatic pseudocysts: What therapeutic options do we have? S. Sandulescu, V. Surlin, S. Ramboiu, I. Georgescu University of Medicine and Pharmacy, Craiova, Romania Currently, at least three principle forms of active therapy are available: percutaneous drainage, endoscopic drainage, and surgical interventions. Each patient requires an multidisciplinary approach, thereby obtaining optimal treatment outcome. Introduction: An acute pancreatic pseudocyst (PP) is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of acute pancreatitis. Pancreatic pseudocysts that develop in this setting, particularly when greater than 6 cm in diameter and present for more than 4 weeks, have a high incidence of complications. Methods: We managed 46 patients with PP who developed after an episode of acute pancreatitis. The risk for occurrence of PP was 26.7%. Results: At 26 patients (56.52%) symptomatic treatment was applied until spontaneous resolution. Percutaneous drainage under CT guide was applied to 2 patients (4.34%). 16 patients (34.78%) were managed by endoscopic ultrasound-guided internal drainage, 10 patients (21.7%) with successful drainage and 6 patients unsuccessful. Surgical interventions were necessary to 8 patients (17.39%), 4 gastropseudocystostomy, 3 jejunopseudocystostomy and 1 external drainage. Discussion/Conclusion: Asymptomatic pseudocysts, can be safely managed with a nonoperative approach. Close monitoring of such patients is mandatory. Percutaneous catheter drainage of pseudocysts may be especially useful in the management of immature and symptomatic pseudocyst and those who present infection, including patient at highrisk for other procedures. Endoscopic methods for draining pseudocysts are indicated especially for PP who is close to gut lumen or who communicates with pancreatic ducts. Surgical approach is usually chosen for the patients with recurrent pseudocysts, pseudocysts combined with common bile duct or duodenal stenosis, symptomatic pseudocysts associated with a dilated pancreatic duct.
72 Factors influencing the survival in hepatocellular carcinoma: Mersin University Hepatoma Working Group Orhan Sezgin1, Engin Altıntaş1, Fehmi Ateş, Serkan Yaraş1, Bünyamin Sarıtaş1, Altan Kocatürk2, Feramuz Demir Apaydın2, Engin Kara2, Musa Dirlik3, Hakan Canbaz3, Ali Arıcan4, Alper Ata4, Gülhan Orekici5 1 Mersin University Faculty of Medicine, 1Gastroenterology, 2Radiology, 3Surgery, 4 Medical Oncology, 5Biostatistics Departments, Mersin, Turkey Introduction: Hepatocellular cancer is an important health problem as it is the fifth one among the most frequent malignancies. With the datas of the patients with hepatocellular cancer from our hospital, this study aimed to search the factors affecting the survival status. Methods: 102 patients diagnosed as hepatocellular cancer (clinical, radiological and/or histopathological) at Mersin University Faculty of Medicine Gastroenterology Clinics between the years 2001–2011 included in this study. It is searched from the official records, whether the patient still alive or not. Results: 87 male and 15 female patients icluded. The average age was 65.16 years. The average of the serum AFP level was calculated 12,114.99 IU/ml (higher than the upper limit of normal for 77 patients from the total 102). BCLC stages were stage 0 for two patients, stage A for 31 patients, stage B for 21 patients, stage C for 9 patients and stage D for 39 patients. The average survival was calculated 287.13 days. Survival rates calculated higher for the patients with tumors localized only in the left lobe (p < 0.005). Metastases observed in 6 patients, 4 as lung and 2 as bone. Presence of metastatic disease found to affect the suvival. (p < 0.005). TACE (n = 22) was effective on the survival if the patients respected all together (adminstered group 417.26 days vs. unadminested-red group 245.2 days, p < 0.005), but is not effective if the convenience to the Milan Critereae considered (convenied (n = 13) 345 days vs. unconvenied (n = 9) 279 days. (p = 0.0561). Discussion/Conclusion: The observation that TACE was effective on the survival may be caused from that the CTP and BCLC stages of these subjects lower than the others. TACE can be considered as a convenient choice of treatment for the patients awaiting for the liver transplantation.
73 The effect of yoghurt probiotic bacteria on pro- and antiinflammatory cytokine response of mononuclear cells of ulcerative colitis patients A. Sheikhi1, H. Banaei2, N. Yahaghi1, M. Nazarian3 1 Immunology Department, Dezful Faculty of Medical Sciences, Dezful Khuzestan, Iran; 2Allameh High School, Shiraz, Fars, Iran; 3 Department of Internal Medicine, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran Background: There is evidence for the immunomodulation disorders in the response to intestinal flora in inflammatory bowel disease. Yoghurt is a fermented milk product made with a starter culture consisting of different lactic acid bacteria (LAB) species which could be colonized in intestine after yoghurt consumption. However, the role of LAB in the aetiopathogenesis of ulcerative colitis (UC) has not been clarified. In order to determine how the immune system responds to these bacteria in-vitro this study was planned. Methods: Pasteurized yoghurt was cultivated on MRS broth and centrifuged the bacteria at stationary phase. Then the bacteria were killed with UV light. Peripheral blood mononuclear cells (PBMCs) of 17 UC patients were separated from heparinized blood by Ficoll-Hypaque centrifugation and co-cultured with different concentrations of killed bacteria in RPMI-1640 plus 10% FCS for 48 and 72 h. IL-10 and TNF-α was measured in supernatant of PBMCs by ELISA. Results: The yoghurt derived bacteria strongly and significantly induced TNF-α and IL-10 in a manner of dose and time dependent at different bacteria:cell ratios in comparison with control. Conclusion: These data show that pasteurized yoghurt derived bacteria may trigger the pro-inflammatory and anti-inflammatory immune response of ulcerative colitis patients. So there could be some species of LAB in the yoghurt which trigger IL-10 separately. Key words: immunomodulation, ulcerative colitis, lactic acid bacteria, yoghurt, IL-10, TNF-α.
74 Functional prevention of colorectal cancer risk Konstantin Shemerovskii Institute of Experimental Medicine, St. Petersburg, Russia E-Mail:
[email protected] Aim: The aim of study was to proof the possibility of functional prevention of colorectal cancer. Methods: Chronoenterography – weekly monitoring of the circadian rhythm of bowel habit. Study on quality of life. Examined 2500 persons in the age of 24–75 years. Three stages of colorectal bradyarrhythmia (CRBA) were allocated: I – 5–6 bowel movements per week (bm/w), II – 3–4 bm/w, III – 1–2 bm/w. Results: Normal colorectal rhythm (NCRR, 7 bm/w) was detected in 56% but CRBA – in 44% of persons. CRBА-I was found in 27% of subjects, CRBА-II – in 13%, CRBA-III – (constipation) in 4%. Inadequate nutrition increased constipation risk in 1.2 times, physical inactivity – in 1.4 times, disturbed sleep – in 1.5 times, lack of morning stool – in 3.7 times. Quality of life in subjects with CRBA (1–6 bm/w) was about 20% lower than in individuals with NCRR (7 bm/w). Discussion: If constipation increases the risk of the CRC in 2.5 times [1, 2, 3], we assumed that prevention of constipation can reduce CRC risk almost 2.5 times. Functional prevention of CRBA-I and -II can prevent CRC risk 10 times more (in 25 times). Conclusion: 1. CRBA-I and CRBA-II was diagnosed 10 times more, than constipation (CRBA-III). 2. The quality of life in subjects with CRBA was about 20% lower than in individuals with NCRR. 3. Absence of morning stool increases CRBA risk in 4 times. 4. Functional prevention of colorectal cancer is possible by means of morning stool restoration and by restoration of NCRR (7 bm/w). References: [1] Kojima M et al. Bowel movement frequency and risk of colorectal cancer in a large cohort study of Japanese men and women. Br J Cancer. 2004; 90 (7): 1397–1401. [2] Watanabe T et al. Constipation, laxative use and risk of colorectal cancer: The Miyagi Cohort Study. Eur J Cancer. 2004; 40 (14): 2109–2115. [3] Talley NJ, Lasch KL, Baum CL. A gap in our understanding: chronic constipation and its comorbid conditions. Clin Gastroenterol Hepatol. 2009; 7: 9–19.
75 The value of matrix metalloproteinases investigation for Crohn's disease pathogenesis Isabela Silosi*, C.A. Silosi**, M. Cojocaru***, M.V. Boldeanu**** T. Ciurea***** *Department of Immunology, University of Medicine and Pharmacy, Craiova, Romania **Department of Surgery, University of Medicine and Pharmacy, Craiova, Romania ***Department of Physiology, ”Titu Maiorescu” University, Faculty of Medicine, Bucharest, Romania ****Department of Immunology, University of Medicine and Pharmacy, Craiova, Romania *****Department of Internal Medicine, University of Medicine and Pharmacy, Craiova, Romania Introduction: Inflammatory bowel diseases (IBD), are characterized by an inflammatory cascade of mediators capable of degrading and modifying bowel wall structure as well as inducing the formation of chronic inflammatory lesions of the digestive tract. MMPs are recognized to play both a physiological role in intestinal homeostasis as well as a pathogenetic role in the initiation and perpetuation of intestinal inflammatory response. It was shown that MMP-7 (matrilysin) is expressed in epithelial cells of normal and diseased tissues and that MMP-9 mediates tissue damage during intestinal inflammation.The aim of this study was to evaluate the implication of MMP-7 and MMP-9 in the pathogenesis of Crohn's disease (CD). Methods: 12 patients with CD and 14 healthy controls (HC) participated in this study. Serum samples were collected before the start of therapy and analyzed for MMP-7 and MMP-9 concentrations by means of commercially available enzyme-linked immunosorbent assays Quantikine kit R&D Systems, Minneapolis, USA. Disease activity was monitored by serological inflammation markers (erythrocyte sedimentation rate and C reactive protein (CRP) evaluation. Results: Serum MMP-9 levels (201 ± 147 ng/ml) and MMP-7 levels (10.24 ± 1.35 ng/ml) were significantly higher in the patients group compared with those controls (30.18 ± 20.02 ng/ml and 2.20 ± 0.7 ng/ml, respectively) MMP-9 levels differed in moderate and severe CD from concentrations of patients with mild CD. In 75% of CD patients we found increased levels of CRP. Because 25% of patients with established CD do not have increased levels of CRP, we suspected that other studies probably overestimated the sensitivity of this test in detecting CD. MMP-9 concentrations correlated positively with CRP levels but the levels of MMP-7 did not correlated with serological inflammation markers. Discussion/Conclusion: Our data support the opinion that dysregulated expression of some the MMPs (MMP-7 and MMP-9) during inflammation may play a role in pathogenesis of CD.Targeted therapies against specific MMPs are highly promising and novel strategies in the treatment of CD.
76 The laparoscopic surgery – Preferential diagnosis and therapeutic option for postoperative adherential syndrome Isabela Silosi, C.A. Silosi University of Medicine and Pharmacy, Craiova, Romania Introduction: Postoperative adhesions offer a frequent explanation for postoperative chronicle abdominal pains or abnormalities of the functions of abdominal organs and intestinal obstructions. Methods: Our study included 22 patients with postoperative adherential syndrome of which the abdominal pains and functional abnormalities of the abdominal organs disapeared after laparoscopic adhesiolysis. Results: We observed three peroperative complications (intraabdominal bleeding) resolved by laparoscopy. There were not postoperative complications. In 11 cases we encountered supramezocolic postoperative adhesions (after colecistectomy, gastrectomy, splenectomy), in 6 cases submezocolic postoperative adhesions (after apendicectomy, enterectomy, colectomy, histerectomy, anexectomy) and in 5 cases supra- and submezocolic adhesions. In all patients we made open laparoscopy. Discussion/Conclusion: Besides general advantages the exploration of the abdominal cavity, minimal trauma, laparoscopy proves to be a good method for the confirmation of the diagnosis and the good therapeutic procedure for postoperative abdominal adhesions.
77 Basic pathogenetical mechanisms of non-alcoholic steatohepatitis I. Skrypnyk, G. Maslova, L. Mandryka Ukrainian Medical Stomatological Academy, Poltava, Ukraine NASH and DM of the type 2 combining is a typical sample of mutual “overtaxing” syndrome. Nevertheless the mechanisms of NASH development under the condition of its combination with DM type 2. The aim is to investigate the main pathogenetical mechanisms of NASH formation in DM type 2 patients. The study involved 145 NASH patients in combination with DM type 2 (88 [60.7%] women, 57 [39.3%] men, age 56.9 ± 2.9 years). Duration of NASH was 4.3 ± 0.9 years, DM type 2 7.5 ± 1.7 years. In all patients with DM type 2 in the stage of compensation and subcompensation: HbA1c level did not exceed 7.5%, ketoacidosis was not observed, glycosuria was absent or did not exceed 3%. Discovered ALT activity increase in 2.7 times, AST in 2 times, alkaline phosphatase in 1.7 times, GGT in 1.9 times, bilirubin in 2.2 times (p < 0.01) in serum blood relatively to the norm. Diagnosed rise levels of total cholesterol in 1.3 times, triglycerides in 1.5 times (p < 0.01) compared to the norm. Detected the direct correlation between the triglycerides level and ALT activity (r = +0.64), cholesterol and AST activity (r = +0.51, p < 0.05). Concentration of malonic dialdehyde (MDA) increased in 1.7 times for the simultaneous reduction of superoxide dismutase activity in 1.6 times (p < 0.01). Established correlation between the MDA level and ALT (r = +0.57). The grow production of TNF-α, IL-6 and IL-8 in 3.4; 3.2 and 2.8 times was set respectively (p < 0.001) in serum compared to healthy. Available direct correlation between the concentration of TNF-α and MDA in serum (r = 0.69). The arginase activity decreased in 1.7 times compared with healthy (p < 0.001). So the basic pathogenetical mechanisms of NASH combined with DM type 2 is breaking the functional liver condition, increasing the proinflammatory cytokine production, lipid metabolism dysbalance, activation of lipid peroxidation on the background of antioxidant protection, increasing metabolic intoxication intensity and reducing liver detoxicating function.
78 The value of platelet activity indices in patients with autoimmune gastritis Irfan Soykan, M.D., Mustafa Yakut, M.D., Onur Keskin, M.D. Ankara University Faculty of Medicine, Ibni Sina Hospital, Gastroenterology, Ankara, Turkey Introduction: Autoimmune gastritis (AIG) is an organ-specific inflammatory autoimmune disease characterized by antibodies to gastric parietal cells leading loss of gastric parietal cells. Mean platelet volume and plateletcrit are surrogate markers of platelet function and used as a marker of inflammation in various inflammatory diseases such as ulcerative colitis, Crohn’s disease and rheumatoid arthritis. Since AIG is an autoimmune and inflammatory disease, the aim of this study were to investigate the possible association between mean platelet volume, plateletcrit and AIG and to identify associated factors that might affect mean platelet volume and plateletcrit levels. Methods: A total of 135 patients with AIG gastritis were enrolled into the study. 94 functional dyspepsia patients who were referred for gastroscopic examination without any known systemic diseases served as controls. Mean platelet volume (MPV), plateletcrit, platelet and white blood cell count were measured by using an autoanalyzer. Demographic data and laboratory parameters including serum gastrin and vitamin B12, anti-parietal cell antibody (APCA), anti-Helicobacter pylori IgG were also studied. Results: There were no difference in terms of age and gender [mean age: 51.65 ± 13.79 years vs. 48.23 ± 13.60 p = 0.082, and 71% of patients were women vs. 61% of control group, p = 0.089]. MPV was significantly higher in AIG patients compared to control group (9.4 ± 1.1 fl vs. 10.4 ± 1.2, p < 0.045), and plateletcrit was also significanlty higher in patients compared to control group (0.231 ± 0.06%) vs. 0.209 ± 0.047%, p = 0.04). However, no significant differences were found in platelet count (p = 0.063), red cell count (p = 0.219) and white blood cell count (p = 0.202) between patients with AIG and control group. Among 135 AIG patients, 103 were APCA positive and in 29 patients were anti-Helicobacter pylori IgG positive. Logistic regression analysis revealed that there was no correlation between APCA positivity (p = 0.849, p = 0.744), low vitamin B12 level (p = 0.552, p = 0.325), anti-Helicobacter pylori IgG positivity (p = 0.849, p = 0.744) and MPV and plateletcrit levels. Discussion/Conclusion: MPV and plateletcrit levels are higher in patients with AIG compared to control group. MPV and plateletcrit can both be related with disease activity in patients with AIG. MPV and plateletcrit are easy and inexpensive complementary tests which may be a useful marker for the evaluation of patients with AIG in the clinical settings.
79 Diverticular disease – Clinical and diagnostic aspects M. Stamboliyska, D. Gancheva, S. Banova, I. Kotzev Clinic of Gastroenterology, University Hospital “St. Marina”, Varna, Bulgaria Introduction: Diverticulosis of the colon is an acquired condition that results from herniation of the mucosa through defects in the muscle layer. The great importance of this “disease of civilization”, diverticular disease (DD), for every patient of clinical practice is determined by the incidence of the disease, frequent hospital admissions, severe complications and mortality. Methods: The study’s aim – To evaluate clinical appearance and diagnostic approaches. Patients, (186), with a diagnosis of diverticular of colon, were retrospectively studied, for a period of five years. The age, sex, localization, clinical picture and complications were evaluated. The diagnostic methods – endoscopic, radiologic and ultrasound examination (US) were performed. Results: 186 patients (117 females, 49 male), with an average age of 60 years, were diagnosed with diverticulosis of the colon. 116 patients, were asymptomatic in respect to diverticulosis and were occasionally diagnosed. The main symptom was colicky abdominal pain involving the left low abdominal quadrant in 65 patients (93%). All patients had stool irregularities: constipation (36%) and diarrhea (64%). The complications in 38.5% were observed: diverticulitis in 51.4%, rectal bleeding in 33% and stenosis in 11.4% The colonoscopy was the main diagnostic method. Segmental colitis and chronic inflammation were observed in 70% of the patients, confirmed by histological examination. Some patients (42.8%) were diagnosed by barium enema or computed tomographic (CT) colonoscopy. In cases of acute diverticular disease the CT examination was the preferred method. Colonic stenosis was detected by US in 11.4% The co-existing findings were polyps, colorectal carcinoma, irritable bowel syndrome and inflammatory bowel disease. Discussion/Conclusion: Diverticular disease is a frequent pathologic change of the colon in the over 50 years and has to be considered in cases with dramatic abdominal pain and signs of peritonitis.
80 Fecal calprotectin level in inflammatory bowel disease (IBD) and non-inflammatory gastrointestinal disease R. Surjadinata*, R. Sosrosumihardjo**, M. Simadibrata***, A. Setiawati**** *Department of Clinical Pathology, Medical Faculty of Indonesia University, Ciptomangunkusumo Hospital, **Department of Clinical Pathology, Medical Faculty of Indonesia University, Ciptomangunkusumo Hospital, ***Department of Gastroenterology, Internal Medicine, Medical Faculty of Indonesia University, Ciptomangukusumo Hospital, ****Department of Pharmacology, Medical Faculty of Indonesia University, Jakarta, Indonesia Introduction: Inflammatory bowel disease (IBD) is a chronic inflammation disease of gastrointestinal tract characterized by remmision and relapse. Early diagnostic of IBD is important to avoid complications. Clinicians often have problems in distinguish IBD from non-inflammatory gastrointestinal disease. Colonoscopy and biopsy are IBD tools diagnostic but invasive. Development noninvasive fecal marker such as fecal calprotectin can be expected to help early diagnostic of IBD. Types of spicy and seasoned food like Indonesian food is expected to induce more inflammation and influence fecal calprotectin level. Methods: This is a pilot study about IBD in Indonesia. We performed fecal calprotectin level with ELISA technique in 20 patients IBD dan 20 patients noninflammatory gastrointestinal disease. Diagnostic of IBD and non-inflammatory gastrointestinal disease was performed by anamnesis, physical diagnostic, laboratory tests, colonoscopy, and biopsy. Results: Median of fecal calprotectin in IBD group was 528.7 μg/g feces (107.07– 3195.29 μg/g feces). Median of fecal calprotectin in non-inflammatory gastrointestinal disease was 30.43 μg/g (8.09–47.34 μg/g feces). There was a significant difference between fecal calprotectin level of IBD and non-infllamatory gastrointestinal disease statistically. Discussion/Conclusion: Fecal calprotectin with ELISA technique can be considered as a early diagnostic tool of IBD. More study about fecal calprotectin is required to develop diagnostic and therapy monitoring of IBD.
81 Endoscopic grading of reflux esophagitis in a private medical center in Turkey Nurten Turkel Kucukmetin, Gungor Bostas International Hospital Istanbul Gastroenterology Department, Istanbul, Turkey Esophagitis is inflammation of the esophagus, the most common cause of esophagitis is gastroesophageal reflux disease, called reflux esophagitis. The severity of esophagitis is commonly classified into four grades according to the Los Angeles Classification. Introduction: The aim of this study is to determine the severity reflux esophagitis classified according to the Los Angeles Classification in a private hospital in Istanbul (Turkey). Methods: We retrospectively evaluated 1580 patients who had endoscopy done with two experienced endoscopist for any gastrointestinal symptoms between January 2009 and May 2012 in our center. Four hundred of 1580 patients (25.31%) who had reflux esophagitis were included in this study. Endoscopic grading of reflux esophagitis was done according to the Los Angeles Classification. Results: Among the 400 patients studied, 269 (67.25%) were male, 131 (32.75%) were female. The age of patients ranged from 18 to 90 years with an overall mean of 45.98 ± 11.28. Two hundred eighty-seven (71.75%) of the erosive esophagitis cases were grade A, 73 (18.25%) grade B, 38 (9.5%) grade C, and 2 (0.5%) grade D. Discussion/Conclusion: Among the 400 patients studied, 269 (67.25%) were male, 131 (32.75%) were female. The age of patients ranged from 18 to 90 years with an overall mean of 45.98 ± 11.28. Two hundred eighty-seven [287/400 – (71.75%)] of the erosive esophagitis cases were grade A, 73 (18.25%) grade B, 38 (9.5%) grade C, and 2 (0.5%) grade D.
82 Long-term efficacy of maintenance treatment with infliximab in current clinical practice: A prospective study in patients with Crohn’s disease Roxana Vadan, Liana Gheorghe, Alexandrina Constantinescu, Sebastian Suciu, Mircea Diculescu, Cristian Gheorghe Gastroenterology and Hepatology Centre, Fundeni Clinical Institute, Bucharest, Romania Introduction: In the majority of the published studies the efficacy of Infliximab (IFX) for maintenance of Crohn’s disease (CD) remission is reported after one year of follow up, the data on longer periods of time being scarce. The aim of our study was to evaluate the efficacy of IFX in maintaining clinical and endoscopic remission long term, in current clinical practice. Methods: Patients with moderate/severe flares of CD that responded to induction treatment and received maintenance IFX were prospectively followed. At each treatment visit (every 8 weeks) patients were clinically evaluated and every 6 months colonoscopy was performed. CD flare was defined by CDAI score > 150. Endoscopic remission was defined as the absence of ulcerations. The sustained character of clinical response and remission was defined as the absence of flares of disease, respectively absence of endoscopic ulcerations any time during the follow up period. Results: 42 patients (22 men and 20 women) mean age 36.51 years received IFX maintenance for more than one year, for a mean time of 30.26 ± 15.06 (14–72) months. Ten patients (23.8%) presented disease flares during follow up. The mean time until flare was of 23.87 ± 13.09 (6–46) months. For these patients the IFX dose was doubled, in eight cases with favourable response, in two cases loss of response was noted. Clinical remission at two years was observed in 79.31% of patients and from the ten patients treated over three years nine were still in clinical remission at the end of follow up. A number of 76.19% patients presented sustained clinical remission. Endoscopic remission was obtained in 52.38% cases, being sustained for 68.18% of them. Discussion/Conclusion: Scheduled Infliximab treatment determines long term control of the clinical symptoms in the majority of patients with CD. Sustained endoscopic remission can be obtained in half of the patients on maintenance treatment with IFX.
83 Scope to improve. A multicentre audit of 16,064 colonoscopies looking at caecal intubation rates, over a two year period Ajay Verma1, Nadine McGrath1, Paula Bennett3, John Andrew Dixon1, Jayne Eaden3, Peter Wurm2, Andrew Chilton1 1 Kettering General Hospital, Kettering, UK 2 University Hospitals Leicester, Leicester, UK 3 University Hospitals Coventry and Warwickshire, Conventry, UK
de
Caestecker2,
Introduction: Colonoscopy is the gold standard assessment for large bowel mucosal pathology, but a complete examination is an essential requirement. The first UK national colonoscopy audit in 1999 demonstrated caecal intubation rates (CIRs) of 56.9%, which was described as “unacceptably low”. As a result the Joint Advisory Group on Gastrointestinal endoscopy (JAG) launched a programme of continuous quality improvement by standardising training, peer review and audit. JAG recommends practitioners undertake 100+ procedures per annum with target CIRs of 90%. This audit provides an assessment of performance against these quality standards. Methods: Data were collected from procedures undertaken in 2008–2009 from 6 hospitals across 3 English regions. Results: Gastroenterologists = 91.01% (95% CI: 90.32–91.70%) Surgeons = 91.03% (90.27–91.79%) Operators doing < 100 procedures p.a. = 87.77% (86.99–88.55%) Operators doing 100+ procedures p.a. = 91.76% (91.33–92.19%) Bowel cancer screening programme (BCSP) = 97.71% (97.07–98.34%) Non-screening = 88.31% (87.68–88.94%) 16,064 colonoscopies total. CIR = 90.57% (95% CI: 90.11–91.01%) Discussion/Conclusion: This audit of 16,064 colonoscopies across 3 regions demonstrates aggregated achievement of the CIR quality standard, which is evidence of the effects of improvements in training and the implementation of standards Introduced by JAG. There is however a significant performance gap when comparing BCSP colonoscopists with non-screening colonoscopists, the overall CIR > 90% is supported by the BCSP work load. Endoscopists performing low volume colonoscopy have a CIR of < 90%. Endoscopists who do not meet the quality standards should engage in skills augmentation plus further training and increase the numbers of procedures performed with local mentorship, or stop performing colonoscopy.
84 Small bowel capsule endoscopy – A review of 232 studies undertaken at a single centre Ajay Verma, Rekha Ramiah, Dee Legge, Andrew Dixon Kettering General Hospital, Kettering, UK Introduction: Capsule endoscopy (CE) is the modality of choice for investigating small bowel pathology. It is non-invasive, tolerated, safe and reliable. The British Society of Gastroenterology have issued guidance on the use of CE for patients with obscure gastrointestinal bleeding (OGB) and those with a high suspicion of small bowel Crohn’s disease undetected by conventional means, in Kettering General Hospital CE has been used extensively for this as MR enteroclysis is not available. As of January 2012, 232 studies have been reported. Patients take 2 sachets of Klean prep. Patients do not undergo patency capsule testing. Methods: A database of the studies and analysed. Results: Overall 232 studies, mean/median age = 54.93/57.31. Yield of pathology = 100 studies (43.10%) 3 capsules retained (1.72%) – 2 strictures, 1 trapped in diverticulum. OGB/anaemia indication 174 studies, yield = 72 studies (41.38%) Diagnoses: angioectasia = 13, erosions/ulcers = 11 (gastric = 3), Crohn’s disease = 6, tumours = 6, active bleeding = 5, polyps = 5, stenosis/stricture = 5. Other indication 58 studies: ?Crohn’s disease = 46 (yield = 22/47.83%), known Crohn’s = 6, abnormal imaging = 3, other = 3. Discussion/Conclusion: This series of CE reveals a 43.10% yield with a low capsule retention rate of 1.73%. As patients have had multiple investigations (endoscopies/cross sectional imaging) it suggests those patients with suspected small bowel pathology, CE is useful (with a high yield) and safe. For OGB the yield is 41.38% with common diagnoses being angioectasia, ulcers/erosions. Occasionally active bleeding, polyps and tumours are seen. This confirms the importance of CE in investigating OGB. For suspected Crohn's disease the yield is high (47.83%). This confirms that as long as patients don’t have symptoms of sub-acute small bowel obstruction, CE is a very useful and safe diagnostic tool for small bowel Crohn’s disease.
85 Gender differences – Analysis of 5162 colonoscopies over 4 years reveals higher caecal intubation rates in male patients Ajay Verma, Nadine McGrath, Andrew Dixon, Andrew Chilton Kettering General Hospital, Kettering, UK Introduction: Higher caecal intubation rates (CIR) in male patients versus female patients has been shown in the literature. Several theories are mooted for this difference such as female patients with previous hysterectomy, low BMI and the suggestion that female patients have longer colons. The published papers on this subject are mostly over 10 years old and colonoscopy practice has changed dramatically over the last decade in the UK. The Joint Advisory Group on Gastrointestinal endoscopy (JAG) has run a programme of continuous quality improvement by standardising training, peer review and audit. The bowel cancer screening programme (BCSP) was rolled out since 2006–2007. This large audit revisits this subject to see if the improvements in colonoscopic practice have evened out the differences. Methods: Data was collected from all colonoscopies undertaken at Kettering General Hospital between July 2007 and June 2011. Results:
Females Males TOTAL
Number of colonoscopies 2440 2772 5162
Reached caecum 2138 2524 4662
Failed
CIR%
95% CI
392 198 500
87.62 92.73 90.31
86.26–88.87 91.69–93.64 89.48–91.09
Discussion/Conclusion: Analysis of the data reveals significant differences in CIR between female and male patients (87.62% vs 92.73% (p = < 0.0001) NNT 19.57). This large audit shows that despite the improvements in training and practice overseen by JAG and the introduction of BCSP, significant gender differences remain in CIR. Perhaps it would be prudent for endoscopy units to delineate these differences in gender and the potential ramifications (missed pathology) when giving information and consenting patients for colonoscopy. Further analysis of the reasons for the gender differences in CIR would be desirable.
86 Endoscopic versus conventional conservative therapy in chronic pancreatitis B. Vladimirov1, R. Mitova1, N. Grigorov1, D. Damjanov2, B. Korukov2, P. Parvanov2 1 Clinic of Gastroenterology, University Hospital Tz. Joanna, Medical University; 2 Clinic of Abdominal Surgery, University Hospital Tz. Joanna, Sofia, Bulgaria Introduction: The role of ERCP based therapeutic endoscopic procedures in patients with chronic pancreatitis is not still clearly defined. The aims of this study were to evaluate the endoscopic methods of therapy in patients with chronic pancreatitis, and tо compare the results to that of control group of patients, treated by conventional conservative methods. Methods: A total of 214 patients with chronic pancreatitis and impaired drainage were matched into 2 groups. Group I included 114 patients managed endoscopically and received conventional conservative therapy, and group II – 100 controls, treated by conventional conservative methods only. All cases were followed up for a period of 3 years. Results: The early and late results shown that endoscopic treatment led to clearance of common pancreatic duct by stone extraction (82% and 71%), control of strictures/fistulae by stenting (76% and 68%), and pseudocyst decompression by cystogastrostomy under EUS plus dilation and stenting (73% and 30%). Symptoms improvement, especially pain, was observed in 86% vs. 17% (6th mo) and 70% vs. 14% (3rd year) in group I and group II respectively (p < 0.001). Endoscopic treatment also significantly reduced the incidence of new pancreatic attack (p < 0.01). New formation of pancreatic duct stones occurred in 2/17 patients. Replacement of pancreatic prostheses was needed in 41%. New ductal or parenchymal changes were observed in 25%. Discussion/Conclusion: Endoscopic procedures are one alternative strategy in chronic pancreatitis with impaired drainage leads to pancreatic duct or pseudocysts drainage, reduction of pain and incidence of pancreatic attack, but recurrent and complications rates are higher.
87 Magnifying chromoendoscopy is useful for detection of Barrett’s metaplasia and low-grade dysplasia recurrence after argon plasma coagulation (APC) B. Vladimirov1, I. Terziev2, B. Korukov3, R. Ivanova4 1 Clinic of Gastroenterology, 2Department of Pathology, 3Clinic of Abdominal Surgery, University Hospital Tz. Joanna, 4Laboratory of Clinical Pathology, St. Ivan Rilski University Hospital, Medical University, Sofia, Bulgaria Introduction: APC is capable to ablate Barrett’s metaplasia, but risk for recurrence exists. The aim of this study was to clarify the clinical significance of magnifying endoscopy and chromoendoscopy for detection of Barrett’s metaplasia and dysplasia recurrence after argon plasma coagulation (APC). Methods: A total of 50 patients with Barrett’s metaplasia and low-grade dysplasia were treated by APC + PPI and followed up for a period of 8–10 years. Recurrence of metaplasia and dysplasia was assessed by conventional endoscopy with multiple biopsies, magnifying chromoendoscopy (GIF-Q160Z) with methylene blue and/or indigo carmine staining and histological examination. APC was reapplied in cases with uncompleted epithelium repair or metaplasia recurrence on the control endoscopy. Results: Conventional endoscopy and histology showed mucosal reparation and normal squamous epithelium in 33/50 patients. Barrett’s metaplasia and low-grade dysplasia (LGD) appeared de novo in 17 cases after initial complete mucosal repair. The surface analysis by magnifying chromo endoscopy showed islands of superficial lesions suspicious for intestinal metaplasia in 3 cases. The directed biopsies and histological examination confirmed Barrett’s type intestinal metaplasia. Concomitant carditis with (n = 1) or without (n = 3) intestinal metaplasia was also diagnosed. Barrett’s metaplasia appeared de novo in 17 cases with additional islands of LGD (n = 6 and n = 10 cases on 60th and 120th month respectively) after initial complete mucosal repair using conventional endoscopy. The magnifying chromoendoscopy detected Barrett’s metaplasia in a total 23 patients and LGD in 10 and 12 cases on 60th and 120th month respectively. Discussion/Conclusion: Magnifying chromoendoscopy is helpful for detection of intestinal metaplasia and dysplasia of esophageal and cardiac mucosa, especially in cases with focal islands and short-segment. It also increases the diagnostic rate of island with Barrett’s metaplasia or dysplasia after endoscopic ablation.
88 ERCP – Can District General Hospitals provide a satisfactory service? 10 year literature review and our unit’s experience Marina Yiasemidou1, Daniel Glassman2, Simon Stock1 Nobles Hospital, Douglas, Isle of Man 2 The Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
1
Introduction: Currently, UK District General Hospitals (DGH) are encouraged to refer complex cases necessitating an ERCP to specialised centres. Conversely, the American Society for Gastrointestinal Endoscopy (ASGE) has announced favourable results of community based hospitals ERCP success rates, compared to university hospitals. In order to investigate this controversy we conducted a review of the 10-year literature and compared ERCP success rates in our unit in Nobles Hospital, a DGH, to the Joint Advisory Group (JAG, UK) and ASGE (US) recommended competency levels. ASGE recommend 90% successful duct cannulation, 85% successful stone removal and 90% successful drainage of a blocked duct. JAG recommend > 90% of procedures to be therapeutic and 80% successful procedures. Methods: 15 relevant studies were identified in PubMed database. 10 studies were excluded for including data prior to 2002. In Nobles, 42 ERCPs were performed between December 2010 and January 2012. Chi-square test was used for statistical analysis. Results: 3 studies identified reported success rates in DGHs. All matched JAG criteria of > 80% successful procedures and 2 of > 90% therapeutic procedures. However, no study matched ASGE criteria. Williams et al associated success rates with training grade rather than volume. Testoni et al demonstrated similar post ERCP pancreatitis rates in low and high volume units. In Nobles success rate was 85.7%. 97.6% were therapeutic. No statistically significant difference was found between ASGE and Nobles figures (p-value: Duct cannulation 0.724, Stone removal 0.679, Drainage of duct, identical values). Discussion/Conclusion: The above study provides evidence that ERCP can be successfully performed in a DGH.
89 A giant left adrenal pseudocyst presented as abdominal discomfort at gastroenterology Kemal Yildiz, Mukaddes Tozlu, Ali Tüzün Ince, Orhan Kocaman, Metin Basaranoglu*, Hakan Sentürk (*presenter) BezmiAlem Vakif University, Medical Faculty, Division of Gastroenterology, Istanbul, Turkey Cysts are a rare pathology of adrenal glands (1–6). There are no clear guidelines and recommendations in case of adrenal cysts so far. In this case presentation, we reported a young lady with a giant left adrenal pseudocyst presented as abdominal discomfort in the gastroenterology clinic and laparoscopic adrenalectomy performed as a therapy menagement. Case: A 21-year-old female patient was presented at our gastroenterology out – patient clinic with abdominal pain, fullness filling and constipation. Physical examination showed no abnormality. Biochemistry and whole blood count were normal. Abdominal ultrasound, Magnetic resonance imaging and computerized tomography showed that there was a cystic lesion in the left adrenal gland with thiny internal septations, size 11 x 9 cm in diameter (Fig. 1). Then, echoendoscopy revealed a cyst with 11 x 8 cm in diameter. Fine needle aspiration (FNA) performed with 22 gauge needle. A serous material aspirated and sent to further investigations such as biochemistry, tumor markers, pathological and microbiologically. All were normal. Then, laparoscopic left adrenalectomy performed (Fig. 2) and showed pseudocyst by pathological examination. Discussion: In a previous study, out of the whole number of 345 patients who underwent laparoscopic surgery for adrenal tumors, 28 had adrenal cysts. The average cyst diameter in CT was 5.32 cm (1.1–10 cm). The files of 245 patients presenting with adrenal masses was reviewed retrospectively, 26 (11%) patients presented with adrenal cysts. At a mean follow-up of 90 months all patients were symptom free, with no radiological evidence of recurrence. Unlike aspiration of cyst contents, there currence of adrenal cysts after surgical removal is unlikely. Laparoscopic adrenalectomy is a safe and effective treatment for benign adrenal cysts. References: 1. Sroujreh AS, Farah GR, Haddad MJ, Abu-Khalaf MM. Adrenal cyst: diagnosis and treatment. Br J Urol. 1990; 65: 570–575. 2. Bellanton R, Ferrante A, Raffaelli M et al. Adrenal cystlesions: report of 12 surgically treated cases and review of literature. J Endocrinol Invest. 1998; 21: 109–114. 3. Abeshouse GA, Goldstein RB, Abeshouse BS. Adrenal cysts review of literature and report of three cases. J Urol. 1959; 81: 711–719.
4. Castillo OA, Litvak JP, Kerkebe M, Urena RD. Laparoscopic management of symptomatic and large adrenal cysts. J Urol. 2005; 173: 915–917. 5. Mohan H, Aggarwal R, Tahlan A, Bawa AS, Ahluwalia M. Giant adrenal pseudocyst mimicking a malignant lesion. Can J Surg. 2003; 46: 474. 6. Schmid H, Mussack T, Wornle M, Pietrzyk MC, Banas B. Clinical management of large adrenal cystic lesions. Int Urol Nephrol. 2005; 37: 767–771. 7. Major P, Pędziwiatr M, Matłok M, Ostachowski M, Winiarski M, Rembiasz K,Budzyński A. Cystic adrenal lesions – analysis of indications and results of treatment. Pol Przegl Chir. 2012; 84 (4): 184–189. 8. El-Hefnawy AS, El Garba M, Osman Y, Eraky I, El Mekresh M, Ibrahim el-H. Surgical management of adrenal cysts: single-institution experience. Br J Urol. 2009; 104 (6): 847–850.
Fig. 1: CT images showing an adrenal pseudocyst.
Fig. 2: High-powerlight microscopys howing a pseudocyst. Haematoxylinandeosin x 400.
90 Malabsorption syndrome – Case report of a rare infection A. Zafošnik1, M. Knehtl1, N. Gorisek-Miksic2, R. Kavalar3, P. Skok1,4 1 Department of Gastroenterology, 2Department of Infectious Diseases, 3Department of Pathology, University Clinical Center Maribor, Maribor, Slovenia, 4Medical Faculty Maribor, University of Maribor, Maribor, Slovenia Introduction: Many diseases can cause malabsorption, including different systemic infections. Whipple's disease is an extremely rare, chronic infection with a grampositive bacterium Tropheryma whipplei, with an estimated incidence of below 1/1,000,000. The small intestine is affected most often, but other organs also can be involved, including central nervous system (CNS), the heart, joints and others. Case report: A 65-year-old smoker, with chronic obstructive bronchitis and benign prostatic hypertrophy, was transfered to our ward for the problem of diarrhea (6 stools per day), and weight loss (17 kg over the past 2 years). Previously he was treated at Dept. of Neurology under the suspicion of cerebral ischemic insult. The neurological examination revealed mild left hemiparesis, and a slight left-sided central facial palsy. In the diagnostic procedure we confirmed malabsorption syndrome with normocytic anemia (Hb 97 g/l), trombocytosis (511 x 109/l), moderately elevated CRP (42 mg/l), hypocalcemia (i-Ca 1.09), vitamin D hypovitaminosis (< 10 nmol/l), iron deficiency (serum iron 2.2 mcmol/l, transferrin 1.7 g/l, ferritin 32 mcg/l), hypoproteinemia (54 g/l), hypoalbuminemia (27.9 g/l). Upper endoscopy showed erosive gastritis and duodenitis with thickening of the duodenum mucosa. Histological examination of duodenal biopsies revealed atrophy of the villi and diffuse infiltration with PAS-positive foamy macrophages in the lamina propria. The polymerase chain reaction (PCR) of small bowel biopsies was positive for T. whipplei DNA, which confirmed the diagnosis. Abdominal lymphadenopathy of the paraaortic region was revealed by the abdominal CT scan. PCR of the cerebrospinal fluid was negative for T. whipplei DNA. Transesophageal echocardiography revealed a vegetation in the posterior cusp of the mitral valve (9 x 5 mm) with minimal mitral valve regurgitation. Our patient was treated with ceftriaxone iv (2 g once a day) for four weeks. This was followed by oral maintainance therapy with sulfamethoxazol 80 mg + trimethoprim 400 mg twice a day. The patient's response to treatment was prompt: he quickly regained weight, 11 kg in first 2 months, all together 15 in 6 months. At the 4 months follow-up his left side hemiparesis disappeared completely, his neurological performance was almost normal except of his right ankle. At the 12-month follow-up the size of the vegetation was 2 x 2 mm with minimal mitral regurgitation still present. Conclusion: The clinical picture of Whipple's disease was first described as intestinal lipodystrophy in 1907 by George H. Whipple. Due to the broad spectrum of unspecific symptoms the diagnosis of this disease is often delayed even in the present time.
91 Comparison of partial splenic embolisation versus splenic irradiation as treatment of hypersplenism in advanced cirrhosis Dina Ziada1, Hanan Soliman1, Mohamed Sharaf-Eldin1, Amr Al-Badery2, Nehal El Mashad3, Samy Khodeir4 1 Tropical Medicine and Infectious Diseases Department, 2Radiology Department, 3 Oncology and Nuclear Medicine, and 4Internal Medicine Department, Tanta University Hospital, Tanta, Egypt Introduction: Management of Hypersplenism in advanced cirrhotic patient is a conflicting issue as surgical splenectomy carries high perioperative morbidity and mortality rates. Partial splenic embolization (PSE) and low dose splenic irradiation (LDSI) are alternative procedures available in Egypt. The aim of this prospective controlled study was to compare (PSE) versus (LDSI) for ablation of spleen as treatment of hypersplenism in advanced cirrhosis. Methods: Seventy one cirrhotic patients suffering from hypersplenism diagnosed by liver function tests, INR, CBC, bone marrow examination and abdominal ultrasonography. They were enrolled in 3 groups. Group (I): 26 patients treated by (LDSI), Group (II): 25 patients treated by (PSE) and Group (III): 20 patients received conventional therapy including blood transfusion as control group then we followed up these patients for 6 months. Results: LDSI group showed steady progressive increase in all CBC elements. A significant increase in platelets started by week 2, and that of Hb and WBCs started by first month. While, in PSE (group II) all CBC elements showed significant increase within one week of therapy compared to both LDSI (group I) and control groups. This elevation reached its peak by 2nd week in all elements then drop by first month to lower levels which were still significantly higher than pre treatment levels and control but not in comparison to LDSI group. Both procedures were well tolerated by the patients but more complications were reported with PSE. Both LDSI and PSE didn't affect liver functions. Discussion/Conclusion: Both low dose splenic irradiation (LDSI) or PSE can be used effectively to treat hypersplenism in decompensated cirrhosis with improvement of cytopenia and splenomegaly. The rapid onset and higher efficacy of PSE with prerequisites must be fulfilled should be weighed against the wider safety and slow moderate efficacy of spelnic irradiation. The corresponding author: Dina Hazem, E-Mail:
[email protected].
Author Index to Poster Abstracts (Name – Poster Number)
Abou Saif, S. Al-Badery, A. Altintas, E. Amzolini, A. Ananiev, J. Apaydin, F.D. Arican, A. Ata, A. Ates, F. Awad, A. Badea, A. Badea, D. Badea, M. Badea, M. Banaei, H. Banova, S. Bartkova, A. Basaranoglu, M. Bataga, S. Bataga, T. Baysal, B. Becheanu, G. Bennett, P. Biciusca, V. Blaj, A. Bold, A. Boldeanu, M.V. Bonior, J. Bostas, G. Boykova, P. Brankov, O. Calina, D. Canbaz, H. Cartana, T. Cazacu, S. Ceylan, B. Chandra, N. Charles, K. Chilton, A. Chirita, D.
1 91 72 52 37 72 72 72 72 1 2, 3, 31, 32 2, 3, 22, 31, 32, 49 2, 3, 31, 32 24, 26, 54, 61 73 79 4 5, 11, 12, 13, 41, 89 6 6 41 7, 8 83 36 25, 28 36 75 9 81 10 42 22, 49 72 70 69 11, 12, 13 44 14 83, 85 26
Cijevschi Prelipcean, C. Cimpoeru, C. Ciocirlan, M. Ciurea, T. Cojocaru, M. Constantinescu, A. Costinean, S. Damjanov, D. Dawwas, M.F. de Caestecker, J. Deliu, C. Deredjian, S. Derova, J. Derovs, A. Diaconescu, A.C. Diculescu, M. Dimcheva, Y. Dirlik, M. Dixon, A. Docea, A.O. Dolwani, S. Dooley, S. Dranga, M.
23, 24, 26, 27, 28, 53, 61 15 8 52, 75 75 16, 17, 33, 82 8
Durai, D.
86 18 83 19 39, 59 20 20, 21 56 82 42 72 83, 84, 85 22, 49 14 51 23, 24, 25, 27, 29, 30, 54 8 69 24, 25, 26, 27, 28, 29, 30, 53 64
Eaden, J. El Gafaary, M. El Mashad, N. Elfert, A. El-Folly, R. El-Hamamsy, M. Enculescu, S. Enescu, A. Eren, G. Evans, A.
83 68 91 1 68 68 19 49 11, 12, 13 44
Dumbrava, M. Dumitrescu, D. Dumitrescu, G.
Filip, M. Fincanci, M.
52 11, 12, 13
Gancheva-Tomova, D. 79 Genunche2, 3, 22, 31, Dumitrescu, A. 32, 49 Georgescu, C. 52 Georgescu, D. 6 Georgescu, I. 71 Gheorghe, C. 16, 17, 33, 82 Gheorghe, L. 16, 17, 33, 82 Gherghiceanu, M. 7 Glassman, D. 88 Gofita, E. 22, 49 Gogishvili, G. 43 Gorisek-Miksic, N. 90 Gornjakovic, S. 35 Green, J. 14 Grigorov, N. 86 Grünhage, F. 34 Gulubova, M.V. 37 Haddad, M. Hamdy, H. Hamed, W. Harrod, E. Hoanca, C. Husic-Selimovic, A. Ianosi, G. Iliescu, G. Iliescu, L. Ince, A.T. Iordache, D. Ivanova, K. Ivanova, R. Javakhadze, M. Jaworek, J. Johnson, H.E. Julianov, A. Kalem, F. Kalinova, K. Kanashvili, M. Kara, E. Karachmalakov, A. Kavalar, R. Keskin, O.
42 68 68 44 19 35 52 36 48 89 3 37 38, 39, 87 66 9 40 37 41 42 43, 66 72 42 90 78
Khodeir, S. Kikabidze, D. Kinchen, J. Knehtl, M. Kocaman, O. Kocatürk, A. Kolomiytsev, V.I. Konturek, S.J. Korukov, B. Kot, M. Kotzev, I.A. Krastev, Z. Kuchuloria, T. Kushniruk, O. Kyosseva, D. Lammert, F. Lazebnik, L. Leeds, J.S. Legge, D. Li, F. Li, J. Li, Q. Liberda, M. Liu, Y. Macarie, M. Mandache, E. Mandryka, L. Martiniuc, A. Martinova, E.A. Maslova, G. McGrath, N. McLaughlin, S.D. Meyer, C. Mihai, C. Minzala, G. Mitova, R. Mitrut, P. Mitrut, R. Mokricka, V. Mosaad, S. Mosiewicz, J. Muderrisoglu, C. Munker, S. Nayar, M.K. Nazarian, M. Neagoe, D.
91 43, 66 44 90 89 72 45, 46 9 86, 87 9 10, 79 59 43 45, 46 38, 39 34 67 18 84 51 51 51 4 51 6 7 77 48 47 77 83, 85 40 51 25, 27, 29, 30, 54 48 86 22, 31, 32, 49 22 50 1 57 11, 12, 13 51 18 73 19, 52
Nedelciuc, O. Nikolov, R. Nooman, A.M. Nurciu, A.
23, 27, 28, 53, 54, 61 38, 39, 59 1 55
Olariu, C. Olteanu, D. Oppong, K.W. Orekici, G. Ostrowski, S. Özdemir, M. Ozola Zalite, I.
55 56 18 72 57 41 58
Panova, D. Parlog, G. Parlog, S. Parvanov, P. Pavlova, J. Pavlovsky, M. Pintilie, I.
59 60 60 86 21 45 23, 29, 30, 53, 61 20, 21 7 69 62 57 50, 58 63, 65
Pokrotnieks, J. Pop, A. Popescu, C. Pronko, N.V. Prystupa, A. Pukitis, A. Pumnea, M. Ramboiu, S. Ramiah, R. Rehman, A. Rezi, E.C. Rukhadze, N. Rustamov, M.
71 84 64 63, 65 43, 66 67
Saftoiu, A. Sakr, M. Salplahta, D. Sandulescu, L. Sandulescu, S. Saritas, B. Sawa, M. Scarlatescu, S. Schiopu, O. Schuchmann, M. Scutelnicu, F. Seegmüller, A. Sentürk, H. Setiawati, A.
69, 70 68 49 69, 70 71 72 57 56 55 35 69 34 89 80
Sezgin, O. Sharaf-Eldin, M. Sheikhi, A. Shemerovskii, C. Silosi, C.A. Silosi, I. Simadibrata, M. Skok, P. Skrypnyk, I.N. Soliman, H. Sosrosumihardjo, R. Soykan, I. Soysal, F. Spassova, Z. Stamboliyska, M. Stefanova, P. Stock, S. Suciu, S. Surjadinata, R. Surlin, V. Swift, J. Taha, H. Terziev, I. Torok, I. Toy, H. Tozlu, M. Trifonov, G. Tumak, I. Turkel Kucukmetin, N. Turner, J. Vadan, R. Verma, A. Vladimirov, B. Voiculescu, M. Vukobrat-Bijedic, Z.
72 1, 91 73 74 75, 76 75, 76 80 90 77 1, 91 80 78 11, 12, 13 39, 59 10, 79 42 88 82 80 71 14 18 87 6 41 89 38 46 81 14 16, 17, 33, 82 83, 84, 85 86, 87 48 35
Weaver, S.A. Weng, H. Wright, K. Wurm, P.
40 51 44 83
Yahaghi, N. Yakut, M. Yaras, S. Yiasemidou, M. Yildiz, K.
73 78 72 88 89
Zafosnik, A. Ziada, D.
90 91
Falk Symposium 185
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Interfaces and Controversies in Gastroenterology October 3 – 4, 2012 Congress Center Mainz Mainz, Germany
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