Association of polymorphic variants in serotonin re-uptake transporter gene with Crohn's disease: a retrospective case-control study.

AIM: To analyze the distribution of SLC6A4 gene polymorphisms in Crohn's disease (CD) patients and their association with the disease. METHODS: We evaluated the presence/absence of promoter (5-HTTLPR, rs25531) and intron 2 (STin2 VNTR) polymorphic variants of SLC6A4 gene in a retrospective case-control study including 192 CD patients and 157 healthy controls (HC). Genotyping was performed by polymerase chain reaction. The association of polymorphisms with CD and its clinical subtypes was analyzed using χ2 and Fisher exact test, binary logistic regression, and haplotype analysis. RESULTS: CD patients and healthy controls had similar sex (88 [45.8%] vs 84 [53.5%] women, respectively; P=0.154) and age (41.3±12.8 years vs 41.7±8.8 years, respectively, P=0.091) distribution. Significant differences were observed in the STin2 genotype and allele distribution between CD patients and healthy controls (P=0.003 and P=0.002, respectively) and between the corresponding female subgroups (P=0.004 and P=0.007, respectively), with a significant negative association of biallelic ss (STin2.9 and Stin2.10) STin2 genotype with CD (P=0.013, age- and sex-adjusted odds ratio [OR] 0.5, 95% confidence interval [CI] 0.29-0.86; women: P=0.006, age-adjusted OR 0.32, 95% CI 0.14-0.72) and a significantly higher S-STin2.12 (5-HTTLPR/rs25531: S-STin2: STin2.12) haplotype distribution in CD patients (P=0.004, OR 1.62, 95% CI 1.16-2.26). There was no significant association between 5-HTTLRP and rs25531 genotype or allele frequencies and CD and between any SLC6A4 polymorphic loci with clinical CD subtypes. CONCLUSION: STin2 VNTR polymorphism of SLC6A4 gene may contribute to CD pathogenesis.

[Croatian guidelines for gastric cancer prevention by eradication of Helicobacter pylori infection]. / Hrvatski postupnik za prevenciju zelucanog raka eradikacijom infekcije Helicobacterom pylori.

Gastric cancer is the fourth most common type of cancer and the second leading cause of cancer-related death in the world. Although gastric cancer has a multifactorial etiology, infection with Helicobacter pylori is highly associated with gastric carcinogenesis. Carcinogenesis is also influenced by some environmental factors and host genetic diversity, which engenders differential host inflammatory responses that can influence clinical outcome. Chronic gastritis induced by H. pylori is the strongest known risk factor for adenocarcinoma of the distal stomach, but the effects of bacterial eradication on carcinogenesis have remained unclear up to now. Although eradication of H. pylori infection appears to reduce the risk of gastric cancer, several recent controlled interventional trials by H. pylori eradication to prevent gastric cancer have yielded disappointing results. To clarify this problem in a high-risk population, the investigators conducted a prospective, randomized, double-blind, placebo-controlled, population-based studies. The results of previous studies highlight the importance of longer and careful follow-up after eradication therapy. It seems that eradication treatment is effective in preventing gastric cancer if it is given before preneoplastic conditions/lesions, gastric atrophy, metaplasia, and dysplasia, have had time to develop. Furthermore, the significant efficacy of treatment observed in younger patients suggests the need to eradicate H. pylori as early as possible. This consensus aimed to propose guidelines for the diagnosis, management and control of individuals with chronic gastritis, atrophy, intestinal metaplasia, or dysplasia.

Prior statin therapy is associated with milder course and better outcome in acute pancreatitis--a cohort study.

BACKGROUND: Statin treatment was shown to be associated with improved outcomes in several inflammatory conditions. We wanted to evaluate the effects of statin therapy on the course and outcome of acute pancreatitis (AP). METHODS: A prospective cohort study included patients with acute pancreatitis divided into two groups according to statin use prior to hospitalization. Age, sex, etiology of AP, Ranson's score, APACHE II score and maximal CRP were recorded. Outcome measures were hospital length of stay and mortality. Matching of patients for matched analyses was done using individual matching and propensity score matching using variables a priori associated with course and outcome of acute pancreatitis. RESULTS: Inclusion criteria were met for 1062 patients of whom 92 were taking statins. Statin users were older and had higher body mass indexes. Severe disease was more common in the no-statin group than in statin group (20.6% vs. 8.7% respectively). All severity markers were also higher in the no-statin group. All cause mortality was not different, while cardiovascular mortality was higher in the statin group in the cohort analysis. After matching by either method, the severity of disease was greater for the patients without statins treatment. Pancreatitis related mortality was higher in the no-statin group after matching. Among patients who developed severe AP, statin users showed lower Ranson's and APACHE II scores and lower maximal CRP. CONCLUSIONS: Prior statin treatment significantly reduces morbidity and mortality in acute pancreatitis. Further studies are needed to evaluate possible therapeutic use of statins in acute pancreatitis.

MDR1 polymorphisms are associated with inflammatory bowel disease in a cohort of Croatian IBD patients.

BACKGROUND: Inflammatory bowel diseases (IBD) are chronic diseases of unknown etiology and pathogenesis in which genetic factors contribute to development of disease. MDR1/ABCB1 is an interesting candidate gene for IBD. The role of two single nucleotide polymorphisms, C3435T and G2677T remains unclear due to contradictory results of current studies. Thus, the aims of this research were to investigate the association of MDR1 polymorphisms, C3435T and G2677T, and IBD. METHODS: A total of 310 IBD patients, 199 Crohn's disease (CD) patients and 109 ulcerative colitis (UC) patients, and 120 healthy controls were included in the study. All subjects were genotyped for G2677T/A and C3435T polymorphism using RT-PCR. In IBD patients, review of medical records was performed and patients were phenotyped according to the Montreal classification. RESULTS: Significantly higher frequency of 2677T allele (p=0.05; OR 1.46, 95% CI (1.0-2.14)) and of the 3435TT genotype was observed among UC patients compared to controls (p=0.02; OR 2.12; 95% CI (1.11-4.03). Heterozygous carriers for C3435T were significantly less likely to have CD (p=0.02; OR 0.58, 95% CI (0.36-0.91)). Haplotype analysis revealed that carriers of 3435T/2677T haplotype had a significantly higher risk of having UC (p=0.02; OR 1.55; 95% CI (1.06-2.28)). CONCLUSION: MDR1 polymorphisms are associated with both CD and UC with a stronger association with UC.

[Assessment of liver disease severity in patients with chronic viral hepatitis]. / Procjena tezine ostecenja jetre u bolesnika s kronicnim virusnim hepatitisom.

The best indicator of the severity of liver damage and prognosis in chronic viral hepatitis is extension of liver fibrosis. Extension of liver fibrosis can be assessed by liver biopsy and non-invasive physical or biological methods. Biopsy is used to define ethiology, severity (stage of fibrosis) and prognosis of liver disease. These informations are also usefull when estimating the risk-benefit and deciding on the modalities of antiviral therapy. Serological tests and elastography may distinguish significant fibrosis (F > or = 2) from baseline fibrosis (AUROC 0.77-0.83 for serology and 0.84 for elastography) and cirrhosis from noncirrhotic stages (AUROC 0.77-0.86 for serology and 0.9-0.94 for elastography). Individual method of choice with best performance to distinguish cirrhosis from noncirrhotic stages of liver is elastography. Combination of serological tests and transient elastography has 93-95% accuracy to predict liver cirrhosis, and in case of concordant values of both tests biopsy could be avoided in 77-80% of patients. In case of discordant values or those in favour of intermediate stages of fibrosis liver biopsy should be performed because in these situations non-invasive tests are less reliable. According to several studies liver stiffness as assessed by transient elastography has high predictive value for the development of decompensated cirrhosis and portal hypertensive complications and may also discriminate the patients with respect to the predicted 5-year survival.

[The role of anti-TNF therapy in ulcerative colitis]. / Mjesto anti-TNF terapije u lijecenju ulceroznog kolitisa.

Anti-TNF-alfa molecules are currently being used to treat ulcerative colitis regarding to the fact that TNF-alpha has an important role in the pathogenesis of IBD. Although these drugs improved the therapy of patients, immunogenicity limits their potential for clinical use. Infliximab and adalimumab are effective for induction and maintenance of remission in outpatients with moderate to severe steroid-refractory ulcerative colitis. Biologics can be a drug of choice for patients with refractory proctitis and refractory pouchitis. In hospitalized patients with steroid-resistant severe ulcerative colitis who are candidates for colectomy, infliximab may be second-line option. Adequate long-term maintenance therapy with anti-TNF is required after rescue therapy for a sustained benefit. Regarding to the known risk for side-effects of anti-TNF drugs especially in patients concomitantly treated with thiopurines it is urgent future research.

[Croatian consensus on the treatment of inflammatory bowel diseases with biologic therapy]. / Hrvatski konsenzus o lijecenju upalnih bolesti crijeva bioloskom terapijom.

Introduction of biologic therapy in clinical practice represented significant progress in the treatment of inflammatory bowel diseases (IBD) because of its proven efficacy and due to the fact that biologics are the first drugs used in the treatment of IBD that can change the natural course of this diseases. At the same time, biologics are very expensive drugs with complex mechanism of action and important side effects and their use requires evidence-based clinical guidelines. These were the reasons that Referral Center of the Croatian Ministry of Health for IBD and the IBD Section of the Croatian Society of Gastroenterology organised Croatian consensus conference that defined guidelines for the treatment of IBD with anti-TNF drugs. The text below includes definitions of IBD, general principles of IBD therapy, comments on the importance of mucosal healing, analysis of reasons for nonresponse and loss of response to anti-TNF drugs, recommendation for the duration of anti-TNF therapy, rules of screening for opportunistic infections prior to anti-TNF therapy, comments on the problems with reproduction in IBD and finally guidelines for the treatment of various phenotypes of IBD including extraintestinal manifestations with anti-TNF therapy.

[Viralhepatitis. Croatian Consensus Statement 2013]. / Virusni hepatitis. Hrvatska konsenzus konferencija 2013.

Croatian Consensus Conferences on Viral Hepatitis took place in 2005 and 2009. Considering the numerous novel concepts on the epidemiology, diagnosis and management of viral hepatitis (chronic hepatitis C genotype 1 in particular) that have emerged in the past four years, a new Croatian Consensus Conference on Viral Hepatitis was held in Zagreb on February 28, 2013. The abridged text of the Croatian Consensus Conference on Viral Hepatitis 2013 presents the new concepts on the epidemiology of viral hepatitis, serologic and molecular diagnosis of viral hepatitis, determination of the IL-28 gene promoter polymorphism, fibrosis grading, algorithm for patient diagnostic follow up, treatment of chronic hepatitis C (genotypes 1-6) and hepatitis B, treatment of special populations (children, dialysis patients, transplanted patients, individuals with HIV/HCV co-infection), and therapy side effects.

[Inflammatory bowel disease]. / Upalne bolesti crijeva.

Inflammatory bowel disease (IBD) is heterogenous group of inflammatory disorders characterized by chronic immune activation and inflammation of the gastrointestinal tract, associated with numerous extraintestinal manifestations. Two most important forms are Crohn's disease and ulcerative colitis with several phenotypes. Etiopathogenesis of IBD is still unknown. Diagnostic and therapeutic approach of IBD is very complex and requires excellent knowledge of the clinical course and complications of the disease itself and therapy. The paper provides present therapeutic strategy with emphasis on the importance of mucosal healing and analysis of present knowledge of the role of biologics in the therapy of IBD.

[Intraductal papillary mucinous neoplasm of the pancreas: case report and review of the literature]. / Intraduktalna papilarna mucinozna novotvorina gusterace: prikaz slucaja i pregled literature.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively rare clinical entity with a main characteristic being mucus production. Extension of IPMN along pancretic ducts and mucus production lead to ductal obstruction and dilatation, resulting in recurrent episodes of acute pancreatitis. Molecular background of IPMN-a comprises several aberrations, with the K-ras gene mutation being the likely trigger that initiates further genetic changes. Due to its indolent nature, IPMN is most commonly diagnosed in the 7th decade of life. Depending on the histology type, IPMN has a malignant potential. Therefore, surgical therapy remains a "gold standard" of treatment. Insidious, slow progression of the disease and absence of symptoms in a certain number of patients makes diagnostic approach to this entity difficult. In this paper we present a patient with IPMN of the pancreas, in whom the episodes of acute pancreatitis had been present for 22 years.

A pilot study of transrectal endoscopic ultrasound elastography in inflammatory bowel disease.

BACKGROUND: Using standard diagnostic algorithms it is not always possible to establish the correct phenotype of inflammatory bowel disease which is essential for therapeutical decisions. Endoscopic ultrasound elastography is a new endoscopic procedure which can differentiate the stiffness of normal and pathological tissue by ultrasound. Therefore, we aimed to investigate the role of transrectal ultrasound elastography in distiction between Crohn's disease and ulcerative colitis. METHODS: A total 30 Crohn's disease, 25 ulcerative colitis, and 28 non-inflammatory bowel disease controls were included. Transrectal ultrasound elastography was performed in all patients and controls. In all ulcerative coltis patients and 80% of Crohn's disease patients endoscopy was performed to assess disease activity in the rectum. RESULTS: Significant difference in rectal wall thickness and strain ratio was detected between patients with Crohn's disease and controls (p = 0.0001). CD patients with active disease had higher strain ratio than patients in remission (p = 0.02). In ulcerative colitis group a significant difference in rectal wall thickness was found between controls and patients with active disease (p = 0.03). A significant difference in rectal wall thickness (p = 0.02) and strain ratio (p = 0.0001) was detected between Crohn's disease and ulcerative colitis patient group. Crohn's disease patients with active disease had a significantly higher strain ratio compared to ulcerative colitis patients with active disease (p = 0.0001). CONCLUSION: Transrectal ultrasound elastography seems to be a promising new diagnostic tool in the field of inflammatory bowel disease. Further study on a larger cohort of patients is needed to definitely assess the role of transrectal ultrasound elastography in inflammatory bowel disease.

Pegylated interferon for treatment of chronic hepatitis C in hemodialysis patients in Croatia.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) infection is a frequent complication among long-term dialysis patients. The aim of the present study was to evaluate the efficacy and side effects of pegylated interferon-α(2a) (PEG-IFN-α(2a)) treatment in hemodialysis patients. METHODS: We retrospectively reviewed charts of 16 HCV-RNA-positive hemodialysis patients. RESULTS: There were 11 male and 5 female patients treated with dialysis for 6-28 years. Twelve patients had HCV genotype 1b, 2 patients had 3a, and 1 patient had genotype 2a. Although only 10 out of 16 patients completed 48 weeks of treatment, early virological response and end-of-treatment virological response were achieved in 9 and 13 patients, respectively. Sustained virological response was recorded in 9 patients. The most common side effect was anemia. A flu-like syndrome was documented in 6, myalgia in 4, and arthralgia in 5 patients. Rectorrhagia, endocarditis and severe cough were recorded in 1 patient each. Nine patients received a renal transplant, and all 6 responders remained HCV-RNA-negative. CONCLUSIONS: PEG-IFN-α(2a) has limited efficacy in dialysis patients. A significant proportion of patients discontinued treatment because of side effects. Additional studies with long-term follow-up are needed to determine the optimal treatment of HCV infection in the dialysis population.

[Endoscopic mucosal resection of sessile polypoid colorectal lesions: a two-year retrospective study, technique description, indications and complications]. / Endoskopska mukozna resekcija sesilnih polipoidnih lezija debelog crijeva: dvogodisnja retrospektivna analiza, prikaz tehnike, indikacija i komplikacija.

INTRODUCTION: Endoscopic mucosal resection (EMR) is a therapeutic method for removal of sesile premalignant lesions and intramucosal carcinoma of the gastrointestinal tract. No reports on EMR data in Croatia have been published yet. MATERIALS AND METHODS: All patients included in the study were managed at the University Hospital Centre Zagreb between December 2006 and December 2008. EMR was performed using strip technique with submucosal injection of epinephrine (dilution with saline 1:5000-10000). RESULTS: EMR of sessile polypoid colorectal lesions was performed in 95 patients. The most common localisation of the disease was rectum (52 pts - 54.7%). In most patient size of the lesion was between 16-25 mm (43 pts - 45%). En-bloc resection was performed in 75 patients and piecemeal resection in the rest. Bleeding occurred immediately during the EMR in 5 pts (5.3%). Patohistological diagnosis revealed tubulovillous adenoma in 67 pts (70%). Invasive carcinoma was observed in 6 pts (6.3%) and intramucosal carcinoma in 20 pts (21%). On follow up, 73 pts (77%) did not show and sign of disease recurrence. Surgery was needed in 6 pts (6.3%) due to the diagnosis of invasive carcinoma. CONCLUSION: EMR is safe and reliable method with low risk of serious complications and acceptable recurrence rate.

[Croatian guidelines for use of enteral nutrition in Crohn's disease]. / Hrvatske smjernice za primjenu enteralne prehrane u Crohnovoj bolesti.

Nutrition has an important role in the management of inflammatory bowel disease (IBD), especially in patients with Crohn's disease (CD). This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and the promotion of optimal growth and development in children. In active Crohn's disease, nutritional therapy (in the form of enteral feeding) is an effective primary therapy for pediatric patients. Studies have shown that there is no difference in the efficacy of elemental, oligomeric and polymeric enteral formulas. Therefore, the use of polymeric formula is recommended because of higher palatability, better acceptance by patients, lower rate of complications and lower cost when compared with other enteral formulas. Today we have knowledge that some nutrients which are added to modified special enteral formulas have almost pharmacological terapeutic potential in the management of inflammatory bowel disease. Novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta-enriched (TGF-beta2) enteral feeding, showed beneficial effects in several clinical studies. Croatian guidelines for enteral nutrition in Crohn's disease have been developed by interdisciplinary expert group of Croatian clinicians involved with inflammatory bowel disease. The guidelines are based on evidence from relevant medical literature and clinical experience of working group.

Inflammatory bowel diseases: controversies in the use of diagnostic procedures.

The term inflammatory bowel disease (IBD) denotes a genetically, immunologically and histopathologically heterogeneous group of inflammatory bowel disorders classified at present time as ulcerative colitis (UC), Crohn's disease (CD) and indeterminate colitis (IC). Diagnosis of IBD is based on a non-strictly defined combination of clinical and diagnostic parameters. In order to guide the treatment, patients must be assessed by determining IBD phenotype, disease extension and distribution, extraintestinal manifestations, disease behavior, disease severity and drug responsiveness. Each element of the diagnostic process cannot be looked at alone, but has to be incorporated into general clinical assessment, bearing in mind that different phenotypes and age groups require specific diagnostic solutions. Advances in technology provided the possibility for the assessment of the entire digestive system with endoscopy leading the way. Sophisticated imaging methods made the analysis of the bowel wall with its vascularity and adjacent mesentery possible. The challenge is still the small bowel, where a combination of endoscopy and imaging methods is used. The use of imaging methods should be, among other things, guided by level of irradiation which is especially important in young patients and in patients requiring repeated investigations. Using abdominal ultrasound as a low-cost, noninvasive procedure, one has to take into account that it is very operator-dependent method. In UC, endoscopy is used for the evaluation of the extent and activity of the disease and to assess complications like stricture, dysplasia and cancer. UC is classified by the disease extent into proctitis, left-sided colitis and extensive colitis beyond the splenic flexure. Pediatric patients with UC have more extensive disease than adults with rectal sparing in up to 30% of patients. The severity of mucosal changes are reported as Baron endoscopic score. Endoscopic findings correlate well with clinical activity and are commonly incorporated into Mayo index, combination of clinical Truelove Witts index and Baron score. Complications like strictures require imaging methods as supplement to endoscopy. The incidence of CD, particularly in children and adolescents, has risen during the past decade, with children often having extensive and severe disease The nature of CD requires the use of wide array of endoscopic and imaging methods, placed properly in the diagnostic algorithms for specific disease phenotypes and complications and adapted for specific age groups. Endoscopic features of CD are very variable and can be quantified as Crohn's Disease Endoscopic Index of Severity (CDEIS) or Simple Endoscopic Score for CD (SES-CD). Disease activity is most commonly assessed by CDAI. Perianal disease activity should be measured by PDAI due to low CDAI scores in these patients. The activity of CD in children should be assessed by the Pediatric Activity Index. IC is part of the IBD spectrum where chronic colitis cannot be defined as either UC or CD after sequential colonoscopies and colonic biopsies or at colectomy.

[Assessment of hepatic injury in patients with chronic viral hepatitis]. / Procjena ostecenja jetrenog parenhima u bolesnika s kronicnim virusnim hepatitisom.

The management and prognosis of chronic viral hepatitis greatly depend on the extent and progression of liver fibrosis. Although liver biopsy is still considered as the gold standard to evaluate hepatic fibrosis, it is an invasive procedure with rare but potentially severe complications. It is also prone to sampling errors. These limitations have stimulated the search for new noninvasive approaches. A number of noninvasive techniques such as indirect or direct markers and measurement of liver stiffness using transient elastography have been proposed for the assessment of hepatic fibrosis. The performance of simple tests derived from routine laboratory parameters appears to be similar to that of more complex and expensive fibrosis panels. Transient elastography seems to be more accurate than blood tests for diagnosing cirrhosis. The goal of disease specific, accurate and sensitive markers of fibrosis is worth the effort. The true success in such an attempt can be characterized as hopeful; however, these noninvasive methods can be anticipated to become an important tool in clinical practice.

[Retreatment options for patients with chronic hepatitis C]. / Mogucnosti reterapije bolesnika s kronicnim hepatitisom C.

Despite impressive therapy improvements, there still are a huge proportion of patients that will fail to achieve undetectable HCV. On the other hand, not all patients that demonstrate some response to treatment attain a sustained viral response. Patients with HCV non-response can be classified into several groups: 1) non-response (where the patient does not achieve undetectable HCV RNA at any time); 2) partial response (when the patient experiences some drop in HCV viremia but never below the detectable limit); 3) viral breakthrough (those associated with an initial virologic response, which is subsequently lost during treatment); and 4) relapse (those with an initial virologic response, which is lost upon treatment discontinuation). Most studies suggest that the major reason for breakthrough is missing the peginterferon alfa and/or ribavirin doses for various causes (significant adverse events, poor compliance, etc.). The main reasons for relapse include treatment initiation with insufficient ribavirin dosage or failure to continue treatment long enough, especially in patients with a slow virologic response. Patients with a well-defined non-response are poor candidates for retreatment. Such patients have no significant decline in HCV RNA during treatment and are essentially refractory to the effects of interferon. Patients with partial virologic response are excellent candidates for retreatment and can achieve undetectable HCV RNA if switched to a more intensive interferon regimen. Many other patients can be retreated successfully. The likelihood of achieving SVR (Sustained Virologic Response) with peginterferon alfa plus ribavirin retreatment depends on several factors, e.g., the agents used in previous treatment courses, total dose and duration of treatment, HCV genotype, level of viremia and previous drop in viremia. Patients previously treated with standard interferon alpha monotherapy are good candidates for retreatment, regardless of baseline liver histology. In this group, those that were previous responder-relapsers are most likely to respond to a course of peginterferon/ribavirin combination therapy, whereas previous non-responders can also achieve significant rates of SVR, particularly those infected with genotype 2 or 3 HCV There are several options for peginterferon alpha/ribavirin non-responders: 1) retreatment with the same protocol if adherence was a major problem; 2) administration of a longer treatment course (72 weeks) in slow responders; 3) retreatment with another interferon-based product (different peginterferon alpha, consensus interferon); 4) maintenance therapy; 5) clinical trials; and 6) wait and watch approach (respectable in many non-responders, particularly if fibrosis is not advanced and/or the patient experienced difficulties in tolerating therapy). Ongoing retreatment trials using specific antiviral drugs (valopicitabine, boceprevir, telaprevir) are of great interest, particularly in triple combination regimens.

[Viral hepatitis. Croatian consensus conference--2009]. / Virusni hepatitis. Hrvatska konsenzus konferencija 2009.

Summarized text of Croatian Consensus Conference on Viral Hepatitis of 2009 comprises the following chapters: 1) Epidemiology, 2) Clinical Picture, 3) Diagnostic Procedure, 4) Aims of Treatment of Viral Hepatitis, 5) Terminology, 6) Medicaments (6.1. Interferon, 6.2. Analogues of Nucleozides and Nucleotides), 7) Hepatitis B (7.1. Serologic and Molecular HBV Diagnostics, 7.2. Terminology, 7.3.Whom to Treat? 7.4. Therapy), 8) Hepatitis C (8.1. Serologic and Molecular HCV Diagnostics, 8.2. Terminology, 8.3. Whom to Treat? 8.4. Therapy). Clinical, laboratory and histologic assessment of patients with chronic viral hepatitis (algorythm of pretherapeutic treatment; histologic evaluation) and notions related to therapy of viral hepatitis (category of the patient and category of the response to treatment) are presented in related tables.

Treatment of extensive subacute portal, mesenteric and ileocolic vein thrombosis with recombinant tissue plasminogen activator.

Portal or/and mesenteric vein thrombosis is a rare condition with high mortality in an acute form. Therapy of thrombosis is not well defined, although there are some general guidelines that differ according to disease onset and clinical presentation. In acute thrombosis with bowel infarction, surgical resection with possible thrombolysis is advised. The best therapy for the subacute form is not known and the approach differs between centers. For chronic disease, prolonged anticoagulant therapy is recommended. Thrombolysis is well recognized in the treatment of acute ischemic coronary or cerebral diseases. Success of treatment is better if therapy is introduced within a few hours after symptoms have begun. We describe a 25-year-old patient with the subacute form of extensive portal, mesenteric and ileocolic vein thrombosis in the setting of underlying liver cirrhosis due to autoimmune disease. An aggressive therapeutic approach is advised, especially in patients who will eventually undergo liver transplantation, since portal and/or mesenteric vein thrombosis is relative contraindication for liver transplantation in the majority of transplant centers.

[Pseudocysto-gastrostomy guided by endoscopic ultrasound---new approach to old therapeutic problem]. / Pseudocistogastrostomija vodena endoskopskim ultrazvukom--novi pristup starom terapijskom problemu.

It has been appreciated for a long time that surgery is the treatment of choice for pancreatic pseudocysts. Endoscopic internal drainage is an alternative to surgical intervention, but requires bulging of pseudocyst in gastric lumen and carries the risk of bleeding from gastric vessels. Endosonographically guided pseudocyst drainage, an elegant one-step method to connect gastric lumen with pseudocyst avoiding the risk of bleeding using EUS guidance and Doppler is described with review of literature. The procedure was for the first time successfully performed in Croatia.