Bleeding gastric metastases from cutaneous melanoma.

UNLABELLED: 7% of gastrointestinal tract (GIT) involvements with metastatic cutaneous melanoma concerns the stomach. The aim of the study was to describe a rare case of the cutaneous melanoma metastazing to the stomach. MATERIAL AND METHODS: . Bearing in mind the rarity of such cases, we present our experiences based on the history of 42-year-old woman, who underwent surgical excision of skin tumour located on the trunk. RESULTS: Histopathological examination of the skin tumor led to the diagnosis of melanoma (Clark IV, Breslow 5mm) with ulceration and a number of mitoses 40/10 HPF. PET-CT demonstrated multiple organ dissemination. Patient was admitted to the hospital due to severe, symptomatic anaemia. RBC and FFP transfusions were necessary. Gastroscopy revealed multiple gastric and duodenal ulcers and histopathology confirmed metastatic melanoma. Attempts to achieve endoscopic hemostasis were ineffective due to the extent of lesions. CONCLUSION: In the presence of any alarming GIT symptoms or unclear anaemia, any physician treating patient with a history of melanoma should exclude metastatic tumour. Endoscopy may be useful both for the diagnosis and local treatment of gastric metastases and should be routinely and cautiously conducted.

Gastrointestinal image: a true giant transverse colon diverticulum.

UNLABELLED: Giant colonic diverticulum is an extremely rare condition in colonic diverticular disease. More than 90% of giant colonic diverticula are found in the sigmoid colon. Inflammatory and pseudodiverticula are the most frequent. Only one case of a true diverticulum of the transverse colon has been reported in the literature. CASE REPORT: We report a case of a 22-year-old woman presenting with constipation and meteorism from childhood. A plain abdominal X-ray showed a round radiolucent air-filled cyst. Barium enema revealed a single, large diverticulum of the transverse colon. An extended right hemicolectomy with primary end-to-end anastomosis was performed. The postoperative course was uneventful, and she was discharged in 1 week without any complications. Histopathology showed a true diverticulum containing all layers of the colon.

[Significance of serum concentrations of pro- and anti-inflammatory cytokines in identification of patients with Crohn's disease]. / Znaczenie surowiczych stezen cytokin pro- i przeciwzapalnych w identyfikacji chorych na chorobe Crohna.

UNLABELLED: A simple, non-invasive examination separating patients with irritable bowel syndrome from those affected by Crohn's disease (CD) has not been found, so far. Immune disturbances associated with release of various cytokines play an important role in CD pathogenesis. The aim of the study was to investigate the diagnostic efficacy of serum levels of broad panel of pro- and anti-inflammatory cytokines in differentiation between patients with CD and intact bowel. MATERIAL AND METHODS: To the study were included 57 patients with established diagnosis of ileo-coecal CD (according to endoscopic, radiologic and histopathologic criteria) and 21 subjects with no organic bowel pathology. Serum concentrations of CRP and proinflammatory (IL-1beta, IL-6, TNF-alpha) and anti-inflammatory (IL-10, IL-1, IL-1RA, IL-6sR, TNF-alpha R2) cytokines were measured by immunoenzymatic method in both groups. RESULTS: Serum levels of IL-1beta, IL-6, IL-10, TNF-alpha and TNF-alpha R2 were significantly different in CD patients than in control group. Among these cytokines TNF-alpha serum level showed the highest discriminative diagnostic efficacy between both groups. The diagnostic efficacies of CRP (cut-off value was 4.25 mg/dl) and TNF-alpha (cut-off value 2.5 microg/ml) were similar, showing respectively an accuracy of 81% and 74%, sensitivity of 79% and 65% and specificity of 89% and 100%. CONCLUSION: TNF-alpha showed the highest diagnostic efficacy in differentiating patients with CD from healthy subjects, however, the TNF-alpha does not exceed diagnostic value of CRP.

[Serum level of TNF-alpha receptor type II better correlates with severity of Crohn's disease than other cytokines and conventional clinical activity indicators]. / Surowicze stezenie receptora typu II dla TNF-alpha wykazuje lepsza korelacje z ciezkoscia choroby Lesniowskiego-Crohna niz inne cytokiny i konwencjonalne wskazniki aktywnosci choroby.

UNLABELLED: Crohn's disease activity index (CDAI) and serum C-reactive protein (CRP) levels are not prefect indicators of Crohn's disease severity. Magnetic resonance enteroclysis (MRE) is a method allowing simultaneous assessment of lesions involving an entire intestinal wall as well as intra- and extraintestinal spaces. This method, however, is not appropriate for monitoring the course of disease and therapeutic effects. THE AIM OF THE STUDY: To evaluate which of the extensive panel of pro- and anti- inflammatory cytokines correlates with an actual severity of CD assessed by MRE. MATERIAL AND METHODS. 57 patients with endoscopically diagnosed ileocecal form of CD (28 women, age 29 + 11 yrs, range 18-62 yrs) hospitalized in 2007-2008. The mean CDAI was 293 + 119 points, range 18-503 points and serum CRP level was 17.5 + 31 mg/l, range 0.1-122 mg/l. MRE was performed in each patient not later than 3 days after entry to the study. The summarized score was calculated using standardized protocol, assessing the intestine wall thickness and length of its involvement (ileocecal region), pattern of mural contrast enhancement, presence of fistulas or other extraintestinal lesions and enlargement of mesenteric lymph nodes. At admission the blood was taken to measure following cytokines: IL-la, IL-1 receptor antagonist, IL-6, soluble IL-6 receptor, TNF-alpha, TNF-alpha type II receptor and IL-10. RESULTS: In Spearman's correlation test the MRE score showed the strongest relationship with serum level of TNF-alpha type II receptor (r = 0.52, p < 0.001), correlating less significantly with IL-6 level (r = 0.37, p < 0.01) and CDAI (r = 0.40, p < 0.001). CONCLUSION: TNFalpha receptor type II shows better correlation with the severity of ileocecal CD (assessed by MRE) than CDAI or serum levels of other cytokines and CRP.

Composite neuroendocrine and adenomatous carcinoma of the papilla of Vater.

Malignant tumors of papilla are usually adenocarcinomas. We present a 67-year-old female who became icteric as result of a malignant tumor infiltrating the papilla of Vater. Histopathological assessment of surgically excised tumor showed both neuroendocrine and adenocarcinomatous features. To our knowledge, this is the seventh report of this rare neoplastic association in the duodenal periampullary region.

[Comparison of technical aspects of colonoscopy in various gastroenterologic centres]. / Porównanie aspektów technicznych kolonoskopii w róznych osrodkach gastrologicznych.

There are ongoing multicenter European trials analyzing, among other factors, technical aspects of colonoscopy in various countries. The aim of the study was to compare the techniques of preparation and performance of colonoscopy in the Department of Gastroenterology at Medical University of Silesia in Katowice and other gastroenterology centers throughout Europe. The trial was conducted between January 1st 2001 and May 30th 2001 in 18 centers in 9 European countries. 307 consecutive patients, who signed consent forms, were recruited in Katowice, while 5697 patients were enrolled in other centers. The data were collected in a dedicated sheet, prepared in the coordinating center in Lausanne (Switzerland). The part concerning methods of bowel preparation was filled in before colonoscopy and the remaining questions (sedation, number of persons involved, duration, completeness, diagnosis, complications) were answered after the procedure. The data from all centers were analyzed in Lausanne and the results were sent back to the participants. The comparison of results from Katowice and other centers was performed in Katowice. We found out, that the type of cleansing the gut did not influence the quality of bowel preparation. Colonoscopy was performed under deep sedation (in the presence of anesthesiologist and anesthesiology nurse) more frequently in Katowice than in other centers. Differences between Katowice and the rest of centers in the other technical aspects of colonoscopy were of minor importance.

[Estimation of appropriateness of colonoscopy using RAND/UCLA method]. / Ocena zasadnosci przeprowadzania kolonoskopii z wykorzystaniem metody RAND/UCLA.

Multicenter European trials estimating appropriateness of colonoscopy are one of the hot topics in gastroenterology. The aim of the study was the estimation of appropriateness of colonoscopy and usefulness of panel experts criteria (elaborated according to RAND/UCLA method) in Department of Gastroenterology of Medical University of Silesia in Katowice and other gastroenterology centers throughout Europe. The trial was conducted between January 1st 2001 and May 30th 2001 in 18 centers in 9 European countries. 307 patients, who signed informed consent, were recruited in Katowice, while 5697 patients were enrolled in the other centers. The data have been collected in a prospective manner on a dedicated sheet, prepared in the coordinating centre in Lausanne (Switzerland). The part of the sheet with evaluation of appropriateness of colonoscopy was filled in before the procedure. The endoscopic (and histopathologic if necessary) diagnosis was collected after the procedure. The data from all centers were analyzed in Lausanne and the results were sent to the participants. The comparison of results from Katowice and of all the other centers was performed in Katowice. We found out, that self-estimation (made by colonoscopist), but also what is much more important the estimation done according to objective criteria of the panel of experts were significantly higher in our department, than in the other participating centers. The overestimation of self-judgment has been significantly higher in the other centers, than in our department. The higher percentage of therapeutic colonoscopies in our department can be responsible for such results.

[Evaluation of probability of bile duct stone presence by using of non-invasive procedures]. / Ocena prawdopodobienstwa wystepowania kamicy zólciowej przewodowej oparta na badaniach nieinwazyjnych.

Precise evaluation of bile duct stones presence in particular moment, performed using the most non-invasive method, is important for the planning of optimal treatment. Not only simple imaging procedures (like conventional transabdominal ultrasound--US) but also more sophisticated imaging methods (CT or MRI) are frequently useless. The "gold standards" of bile duct stones diagnosis are still endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and surgical choledochotomy. However, the ERCP expose the patients to the risk of some serious complications. The aim of the study was to evaluate the diagnostic capabilities of patients case history data and non-invasive tests (such as biochemistry, ultrasound data) in order to establish a risk scale in cases suspected for common bile duct stones. The investigated group comprised of 135 patients treated from January 1996 through March 1997 in the Department of Gastroenterology Silesian Medical Academy. In patients prospectively enrolled to the study case history and a set of blood biochemical examinations were completed. In following, US was performed. The verification of the biliary tree (done with ERCP with endoscopic sphincterotomy or surgical choledochotomy) was performed. Examiners (US, ERCP) were blind to the other results of a patient. Case history data, laboratory blood tests and US results were used to select parameters significantly differing between patients with and without bile duct stones. Thirteen parameters were tested using Mann-Whitney's and chi 2 tests and four parameters were finally selected. For every selected parameter cut off values (i.e. values best differentiating patients with and without stones) were chosen on the basis of the chi 2 value, 95% confidence interval of risk ratio and Youden's index (gamma-GTP, alanine transaminase, enlarged bile ducts on US, bile duct stones on US). In the next step a set of different combinations of selected parameters was tested to find out the best waged scale for bile duct stones risk diagnosis. Finally, diagnostic efficacy of the best constructed scales and US alone were compared. Constructed risk scales can not be employed in the primary selection of patients, as their positive predictive value is quite high, but negative predictive value is low. US is also not valuable in evaluation of patients suspected for common bile duct stones.

[Digestive tract hemorrhage and recurrent ileus. Peutz-Jeghers syndrome-case report]. / Krwawienie z przewodu pokarmowego i nawrotowa niedroznosc--opis przypadku zespolu Peutz-Jeghersa.

Authors describe a case of 24 years old woman with recurrent lower GI bleeding and mechanical obstruction. Crohn's disease was diagnosed at the beginning. It was impossible to treat the patient's profound anemia with blood transfusions due to her religion believes. The diagnosis of Peutz-Jeghers syndrome was made postoperatively. During operation mechanical obstruction (invagination of terminal ileum into ascending colon) was released. The invagination was caused by 3 cm large polyp localized in terminal ileum. Subsequently, 8 polyps (varying in size between 0.5 and 3 cm) in the small intestine were localized using intraoperative upper GI endoscopy and enteroscopy and finally surgically removed. Typical hamartomas were found on histopathological examination of removed polyps. Authors present modern attitude to Peutz-Jeghers syndrome--its diagnostics, treatment and follow-up.

Endosonography with linear array instead of endoscopic retrograde cholangiography as the diagnostic tool in patients with moderate suspicion of common bile duct stones.

AIM: To evaluate the diagnostic efficiency of endoscopic ultrasound (EUS) as the main imaging modality in patients with moderate suspicion of common bile duct stones (CBDS). METHODS: 55 patients with moderate clinical suspicion of CBDS were prospectively included to the study and evaluated with EUS. This study was done in single blind method in the clinical and biochemical data of patients. EUS was done with echo-endoscope Pentax FG 32-UA (f=5-7.5 MHz) and Hitachi EUB 405 ultrasound machine. Patients diagnosed with CBDS by EUS were excluded from this study and treated with ERC. All the other patients were included to the follow up study obtained by mail every 6 months for clinical evaluation (need of ERC or surgery). RESULTS: CBDS was found in 4 patients by EUS. Diagnosis was confirmed in all cases on ERC. The remaining 51 patients without CBDS on EUS were followed up for 6-26 months (meanly 13 months) There were: 40 women, 42 cholecystectomized patients, aged: 55 (mean). Biochemical values (mean values) were as follows: bilirubin: 14.9 micromol/L, alkaline phosphatase: 95 IU/L(-1), gamma-GTP: 131 IU/L(-1), ALT: 50 IU/L(-1), AST: 49 IU/L(-1)(-1). Only 1 patient was lost for follow up. In the remaining 50 patients with follow up, there was only 1 (2 %) patient with persistent biliary symptoms in whom CBDS was finally diagnosed by ERC with ES. All other patients remained symptoms free on follow up and did not require ERC or biliary surgery. CONCLUSION: Vast majority of patients with moderate suspicion of CBDS and no stones on EUS with linear array can avoid invasive evaluation of biliary tree with ERC.

Presence and density of common bile duct microlithiasis in acute biliary pancreatitis.

AIM: Common bile duct microlithiasis (CBDM) is found in majority of patients with acute biliary pancreatitis (ABP) and no CBD stones in fluoroscopy during urgent ERCP. It is unclear, however, weather CBDM is a cause or the result of the disease. This prospective study was done to investigate the presence and density of CBDM in patients with ABP, when endoscopic retrograde cholangiopancreatography (ERCP) was done in different periods from the onset of the disease. METHODS: One hundred fifty one consecutive patients with ABP and no CBDS on ERCP, performed as an urgent (< 24h of admission) procedure, (101 - with gallbladder stones, 50 post-cholecystectomy patients), treated during last 4 years were prospectively included to the study. The presence and density of CBDM (cholesterol monohydrate crystals-CMCs and calcium bilirubinate granules-CBGs) in bile collected directly from common bile duct during ERCP was prospectively calculated according to Juniper and Burson criteria. High density of crystals was considered,when we found >10CMCs and/or >25 clusters of CBGs on 1 slide. RESULTS: CBD microlithiasis was present in given number of patients: on d1-30/34 (88.2%), on d2 41/49 (83.7%), on d3-23/33 (69.6%), on d4-7-24/35 (68.6%) ( P for trend=0.018). In patients with CBD microlithiasis the high density of crystals was observed in given number of patients:on d1-27/30 (90%), on d2-34/41 (82.9%), on d3-18/23 (78.3%), on d4-7-16/24 (66.7%)( P for trend=0.039). CONCLUSION: In patients with ABP and no CBDS on ERCP, CBD microlithiasis is observed in the majority of patients, especially during the first day of the disease. Density of CBD microlithiasis is the highest in the first day of the disease. This suggests that CBD microlithiasis can be the cause and not the result of ABP.