Clostridium difficile infection and inflammatory bowel disease: what gastroenterologists and surgeons should know.

Over the past two decades there has been a dramatic increase worldwide in both incidence and severity of Clostridium difficile infection (CDI). Paralleling the rising incidence of CDI in the general population, there has been an even higher increase in the incidence of CDI among patients with inflammatory bowel disease (IBD). CDI may mimic a flare of IBD as symptoms and laboratory parameters are often similar, and therefore, screening for CDI is recommended at every flare in such patients. Enzyme immunoassay to detect Clostridium difficile toxin A and B in stool is still the most widely used test for CDI diagnosis despite its low sensitivity. Metronidazole for mild/moderate CDI,and vancomycin for severe CDI are the preferred agents for the treatment of infection. CDI has a negative impact both on short- and long- term IBD outcomes, increasing the need for surgery, as well as the mortality rate and healthcare costs. All gastroenterologists and surgeons should have a high index of suspicion for CDI when evaluating a patient with IBD flare, as prompt diagnosis and adequate treatment of infection improve outcomes. Measures must be taken to prevent spreading of infection in gastroenterology /surgery settings.

Alcoholic liver disease--epidemiology and risk factors.

Alcoholic liver disease (ALD) accounts for the majority of chronic liverdiseases in Occidental countries and remains a major cause of liver-related mortality in worldwide. The spectrum of ALD includes steatosis in patients which consume over 80g of alcohol per day, alcoholic steatohepatitis and liver cirrhosis in approximately 15% of patients. Once cirrhosis is established, the annual risk for hepatocellular carcinoma is about 1-2%. Environmental factors such as drinking patterns, coexisting liver disease, obesity, diet and co-medication may affect the natural course of ALD. Abstinence is the hallmark of therapy for ALD, and nutritional therapy is the first line in therapeutical intervention.

Platelet indices in patients with de novo portal vein thrombosis and liver cirrhosis.

UNLABELLED: Platelet indices are markers of platelet reactivity used for thrombotic risk assessment in patients with cardiovascular diseases, and recently in venous thrombosis. AIM: To assess the diagnostic value of platelet indices in patients with non-malignant de novo portal vein thrombosis and liver cirrhosis. MATERIAL AND METHODS: We conducted a prospective, case-control study on patients admitted to a tertiary center in the interval January, 2010 - December, 2012. Included in the study were 54 patients with portal vein thrombosis (PVT) and 54 controls. Patients with known malignancy, sepsis, thrombophilia, on anticoagulant or antiaggregant therapy, acute or chronic inflammatory diseases, severe anemia, renal failure, acute coronary syndrome, and chronic pulmonary disease were excluded from the study. RESULTS: Both groups were comparable for baseline characteristics. Mean platelet volume, platelet distribution width (PDW) and plateletcrit were higher in the PVT group. In a multivariate logistic regression analysis, significant predictors of the presence of PVT were mean platelet volume (MPV), PDW, and procalcitonin (PCT). CONCLUSION: Our data suggest that increased platelet indices contribute to the prethrombotic state in liver cirrhosis and that larger platelets may play a specific role in thrombosis despite thrombocytopenia.

A prospective study of pre-illness diet in newly diagnosed patients with Crohn's disease.

BACKGROUND: Environmental factors, including diet, seem to participate in the etiology of inflammatory bowel disease. The kind of dietetic habits before the appearance of the illness in patients with Crohn's disease (CD) has not been studied extensively. AIM: To prospectively assess the kind of food consumption in patients with CD exactly at the time of diagnosis and to identify dietary constituents as risk factors for development of CD. PATIENTS - METHODS: Twenty eight patients with a newly established diagnosis of CD (2-4 weeks), (12 men and 16 women), 30 patients with previously (between 2 - 11 years) established diagnosis of CD (14 men and 16 women) and 38 age- and sex-matched healthy controls (16 men and 22 women) were included in the study. Dietary intake was assessed by means of special questionnaire. RESULTS: Comparisons between controls and newly diagnosed patients showed that increased consumption of milk and yogurt (P = 0.042), fruits (P = 0.0001), citrus (P = 0.0001), vegetables (P = 0.0001), carrots (P = 0.0001), legumes (P = 0.036), fish and selfish (P = 0.001), honey (P = 0.003), and nuts (P = 0.038), was associated with decreased risk for CD. On the other hand, significantly increased intake of fat (P = 0.041), olive oil (P = 0.038), margarine (P = 0.038), sugar (P = 0.02), alcohol drinks (P = 0.009), fried food (P = 0.0001), and pasta (P = 0.0001), was noticed on recently diagnosed patients in comparison with the healthy control group. On logistic regression analysis foods remaining statistically significant were: margarine, pasta, fried foods, fat, olives, sugar (increased risk), and yogurt, honey, fruits, nuts, fish, and citrus fruits (decreased risk). Newly diagnosed patients were significantly overweighed (64%) compared to healthy people (26%) and old patients (7%). CONCLUSION: Significant differences in many kinds of food between newly diagnosed patients with CD, patients with established CD and normal people certainly exist. Our results suggest that specific dietary patterns could be associated with higher or lower risks for CD in adults. However, whether these dietary factors are important for the development of CD or modulate the effect of other environmental factors is unknown.

[Non-invasive evaluation of liver fibrosis in chronic hepatitis C].

Chronic hepatitis C (CHC) is a major public health concern, with around 180 million individuals affected worldwide. Liver fibrosis and its end-point cirrhosis are the main causes of morbidity and mortality in patients with CHC. Liver biopsy (LB) has traditionally been considered the "gold standard" for pre-treatment evaluation of liver fibrossis in patients with CHC. However, LB is an invasive procedure with several shortcomings (intra- and interobserver variability, sampling errors, expensive) and the risk of rare but potentially life-threatening complications (biliary peritonitis, hemo-peritoneum, and death in 1/10,000). The aforementioned shortcomings of LB have led to development of several non-invasive methods for the assessment of liver fibrosis in CHC. Among the non-invasive methods, Fibrotest and Fibroscan are the most widely used in our country and offer a viable alternative to LB for pre-treatment assessment of liver fibrosis in patients with CHC. This review aims to discuss the advantages and usefulness of non-invasive methods of liver fibrosis in CHC.

Colon capsule endoscopy compared to colonoscopy for colorectal neoplasms diagnosis: an initial experience and a brief review of the literature.

Conventional colonoscopy is regarded as the gold standard procedure for the diagnosis of colorectal neoplasms despite its several limitations including invasiveness, discomfort and potential complications. Colon capsule endoscopy (CCE) could be an attractive alternative method to the invasive colonoscopy for the diagnosis of colorectal cancer and polyps. Publications regarding the use of CCE for detecting colorectal cancer and polyps, as well as our experience, were reviewed. The new second-generation CCE (PillCam COLON 2) has improved accuracy compared with the first-generation system for detecting colorectal neoplasms.

[The role of capsule endoscopy in suspected Crohn's disease]. / Rolul videocapsulei endoscopice în boala Crohn suspectata.

Capsule endoscopy (CE) revolutionized the small bowel examination. We emphasize the role of CE in suspected Crohn's disease, studying 24 investigations performed in the Institute of Gastroenterology and Hepatology. The global diagnostic yield was 54%, the specific diagnostic yield for Crohn's disease was 37.5%, the specificity was 100% and the retention rate was 4.1%. For maximum accuracy and efficiency, unitary administration and diagnostic criteria are needed, and for minimising the risk of complications, specific prior investigations would be suitable.

[High levels of sterigmatocystin in patients with chronic liver diseases]. / Detectarea sterigmatocistinei la pacientii cu boala ii hepatica cronica.

UNLABELLED: Sterigmatocystin (STC) is a wide spread mycotoxin produced by Aspergillus fungi, with hepatotoxic and carcinogenetic proprieties. OBJECTIVES: To determine the STC concentration in blood and urine from patient with liver cirrhosis (LC) and hepatocellular carcinoma (HCC), with correlation with liver function parameters. MATERIAL AND METHODS: The study enrolled 166 patients divided in three groups: control--55 patients (27M, 28F); LC--58 patients (31M, 27F); HCC--53 patients (26M, 27F). 20 ml of blood and 50 ml of urine were collected from each patient and liver enzymes and alfa-fetoprotein (AFP) were measured. STC was determined by high performance liquid chromatography, with concomitant detection in ultraviolet and fluorescence. RESULTS: STC was detected in 26.2% of samples, more frequently in LC and HCC groups (p < 0.001). STC mean values were 0.014 ng/ml and 0.005 ng/ml in blood, respective urine of controls, rising to 0.626 ng/ml (p = 0.003) respective 1.053 ng/ml (p = 0.049) in LC and 2.02 ng/ml in blood (p < 0.0001) and 9.39 ng/ml in urine (p = 0.003) in patients with HCC. There is a perfect correlation between serum and urinary levels of STC in controls (r = 1), that become weak in patients with LC (r = 0.48) and insignificant in HCC (r = 0.15). AFP values were significantly correlated with STC concentration in patient with HCC, in both blood (r = 0.31) and urine (r = 0.84). CONCLUSIONS: STC values in patients with LC and HCC were significantly higher compared to controls. Strong positive correlation of STC with AFP in patients with liver cancer suggested a possible role of this mycotoxin in pathogenesis of the disease.

Colonoscopic screening of asymptomatic first-degree relatives of colorectal cancer patients.

AIM: First-degree relatives of colorectal cancer (CRC) patients are at increased risk for developing colorectal neoplasm, and current guidelines recommend screening colonoscopy in such individuals. The aim of this study was to evaluate the use of colonoscopy as the screening test in asymptomatic first-degree relatives of CRC patients. MATERIAL AND METHOD: Colonoscopy was performed in 102 asymptomatic individuals who had at least one first-degree relatives with CRC. Subjects included in the screening program were aged between 36 and 72 years, and majority came from two counties (Suceava, Iasi) located in north-eastern Romania. RESULTS: Thirty colorectal lesions were found in 17 individuals: two (6.6%) had adenocarcinomas, and remaining 15 patients had 28 polypoid lesions: 14 (46.6%) adenomas, 5 (16.6%) tubulovillous adenomas, 3 (10%) adenomas with high grade dysplasia and 6 (20%) had hyperplasic polyps. CONCLUSION: Colonoscopy is a useful, feasible and safety initial screening tool for first-degree relatives of patients with CRC.

[Capsule endoscopy role in diagnosis of small bowel tumors]. / Rolul videocapsulei endoscopice in diagnosticul tumorilor de intestin subtire--analiza unei serii.

UNLABELLED: Since the introduction of capsule endoscopy (CE), several studies suggested a higher frequency of small bowel tumors (SBTs) than previously reported. MATERIAL AND METHOD: We evaluated the prevalence, presentation and diagnostic work-up of SBTs in patients undergoing CE in a single referral center. During 2003 - 2009, 102 patients underwent CE. For each patient with suspected SBT at CE, with subsequent histological confirmation, we registered clinical and biological features, imaging methods performed and management. RESULTS: SBTs were detected in 4.9% of patients undergoing CE. The main indication for CE was obscure gastrointestinal bleeding. All patients had undergone, before CE, at least one procedure evaluating the small bowel. All patients had iron-deficiency anemia, some presented also other gastrointestinal symptoms. The main SBT type was gastrointestinal stromal tumor. Three patients underwent single-balloon enteroscopy; surgery was performed in all patients. No retention of capsule occurred. CE could be used as first choice as diagnostic tool when SBTs are suspected.

[Colonoscopic screening of asymptomatic individuals with a family history of colorectal cancer]. / Screening-ul colonoscopic la persoane asimptomatice cu istoric familial de cancer colorectal.

BACKGROUND AND AIMS: First-degree relatives of colorectal cancer (CRC) patients are at increased risk for developing colorectal neoplasm. The aim of our study was to evaluate the use of total colonoscopy as the screening test in asymptomatic individuals with a family history of colorectal cancer. MATERIAL AND METHOD: Colonoscopy was performed in 125 asymptomatic individuals (64 men and 61 women; mean age 51.7 +/- 11.5 years, range 24-77 years) who had one or two first-degree relatives with CRC. RESULTS: Forty-five colorectal lesions were found in 36 subjects (28.8%): one (0.8%) adenocarcinoma, and 44 polyps (31 adenomas; 13 hiperplasic) (28.0%). The cecum was intubated in 96% of cases, and the procedure was generally well tolerated without complications. CONCLUSIONS: Total colonoscopy is a useful and safe screening procedure for the examinations of asymptomatic individuals with a family history of CRC.

[Prevalence of Helicobacter pylori infection in patients with diabetes mellitus]. / Prevalenta infectiei cu Helicobacter pylori la pacientii cu diabet zaharat.

UNLABELLED: Helicobacter pylori (H. pylori) and diabetes mellitus are the most important causes of dyspepsia. The aim of this study was to evaluate the prevalence of H. pylori infection in patients with diabetes mellitus, and to assess whether the infection was associated with severity of dyspeptic syndrome and metabolic glycemic control. MATERIAL AND METHOD: 100 patients with diabetes mellitus type 1 and 2 (41 men and 59 women, mean age 58.59 ani) were included in our study. Each patient completed a self-report questionnaire to obtain information concerning the presence and severity of upper gastrointestinal tract symptoms. H. pylori status was confirmed by serological test and histophatology study of gastric biopsy or 13C-urea breath test. RESULTS: Prevalence of H. pylori infection was found not to be significantly higher in diabetics than in controls (70% vs 73% ). 49% H. pylori positive diabetics had type 2 insulinonecesitant diabetes mellitus, 27% had type 1 diabetes mellitus and 24% had type 2 diabetes mellitus, with no statistically significant difference (p > 0.05). We found no statistically significant difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. The main value of HbA1 levels in H. pylori--infected diabetics was 7.31% and 7.47% in H. pylori non-infected diabetics, without significant difference. CONCLUSION: There was no statistically significant difference in the prevalence of H. pylori infection between diabetics and non-diabetics patients and no difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. H. pylori in diabetics appears no influence glycemic status.

[High blood and urine concentration of hepatotoxic mycotoxins (aflatoxin B1, sterigmatocystin) in patients with liver cirrhosis]. / Detectarea micotoxinelor hepatotoxice la pacienti cu ciroza Hepatica.

UNLABELLED: Aflatoxins and sterigmatocystin are potent carcinogens, certainly involved in pathogenesis of liver cancer. AIM: To evaluate the risk of mycotoxin intake and to determine the presence of aflatoxin B1 (AFB1) and sterigmatocystin (STC) in patients with liver cirrhosis. MATERIAL AND METHOD: The study included 92 patients (33 controls, 59 liver cirrhosis) that completed a food frequency questionnaire (FFQ). Blood and urine samples were collected and mycotoxins determined by high performance liquid chromatography. RESULTS: 18.18% samples in controls and 72.88% in cirrhosis group presented detectable levels of mycotoxins. The mean values of AFB1 in blood were 0.7 ng/mL in controls and 1.67 ng/mL in test group (p = 0.11); STC presented 60 times higher levels in second group (p < 0.01). AFB1 presented a mean level of 1.2 ng/mL in urine of test group (not detected in controls); STC presented 256 time higher concentration in urine of cirrhotic patients, with a perfect correlation between blood and urine levels in control (r=1) and no correlation in test group (r = 0.05). There were no correlations between mycotoxin, liver enzymes, alpha-fetoprotein and mycotoxin intake risk estimated by FFQ. CONCLUSION: Most of the patients presented detectable levels of mycotoxins, significantly increased in cases with liver cirrhosis, probable due to a specific metabolic pattern.

[The relationship between bile reflux and symptoms in patients with gallstones before and after cholecystectomy]. / Influenta refluxului biliar asupra simptomatologiei la pacientii cu litiaza biliara veziculara pre- si postoperator.

UNLABELLED: Many hypotheses affirm that postcholecystectomy syndrome is caused by alterations in bile flow due to the loss of the reservoir function of the gallbladder. We aimed to establish the relationship between postcholecystectomy symptoms and bile reflux. MATERIAL AND METHOD: Thirty patients with gallstones were included in the study. All patients underwent combined ambulatory pH and bile monitoring (Bilitec). Three months after cholecystectomy, the tests were repeated. RESULTS: Before surgery, the median (interquartile range) total time pH < 4 was 2.8% (0.2-14%) and bilirubin absorbance > 0.14 was 4.1% (0-17%). After cholecystectomy, the median total time pH < 4 was 3.7% (1.5 %-11.4%) and bilirubin absorbance > 0 14 was 13.25% (5.30%-26.5%). The correlation between total time pH < 4 and total time bilirubin absorbance > 0.14 for all patients was good: r = 0.55, p < 0.001. Before surgery 65.03% of symptoms were not associated with neither acid nor bile reflux and postcholecystectomy 37.87% of symptoms were associated with bile reflux and 36.95% without any reflux. Cholecystectomy determines increased biliary reflux compared to the patients with gallstones. Related to gallstones, after cholecystectomy dyspeptic complains are more often related to bile reflux. CONCLUSION: Although cholecystectomy itself does cause increased biliary reflux, in most patients with significant duodenogastric reflux symptoms were not correlated with biliary reflux.

[Colorectal polyps: clinical, endoscopic, and histopathologic features]. / Polipii rectocolonici: caracteristici clinice, endoscopice si histopatologice.

AIM: To evaluate the prevalence of colorectal polyps in a population from North- Eastern Romania, which underwent colonoscopic examination and to identify their clinical, endoscopic and histopathologic characteristics. METHODS: A retrospective prevalence study of subjects aged 18-95 years, with no personal or familial history of familial adenomatous polyposis and inflammatory bowel disease, who underwent a colonoscopy. The number, size, gross endoscopic appearance, histopathological examination, and the anatomic location of colorectal polyps were analyzed, as well as the associated diseases. RESULTS: Enrolled were 1001 patients (647 men, 354 women), aged 18-95 years (mean: 62.8 +/- 11.4 years) who were diagnosed with colorectal polyps. Overall, there were 1.534 colorectal polyps, and the majority of them (83.0%) were present in patients over the age of 50 years, from urban area (73.9%) and most of the patients were men (63.8%), and had solitary polyps (61.1%). Three-quarters of polyps were distal (rectum, sigmoid, and descendent colon) in location, and most of them (75.8%) had a size less than 10 mm. Over half of all polyps (54.7%) were pedunculated. Based on the histological structural configuration, 76.5% of all polyps were adenomas, and of these 62.6% were tubular adenomas; malignant polyps have been diagnosed in 82 (5.4%) patients. Associated hemorrhoids, diverticulosis, colorectal cancer, and angiodysplasia were identified in 9.6%, 10% and 1.3%, respectively. CONCLUSION: The prevalence of colorectal polyps in our geographical area is in the range with that observed in other regions of our country. Most of polyps were identified in patients older than 50 years, predominantly men, located in distal colon, had a tubular adenoma histological structure, and frequently associated with hemorrhoids and diverticular disease.

[Involvement and role of iron in nonalcoholic steatohepatitis]. / Implicatiile si rolul fierului in steatohepatitele non alcoolice.

Nonalcoholic steatohepatitis (NASH) was described by Ludwig mainly in obese, middle-aged women, often associated with diabetes mellitus and hyperlipidemia. In the recent years, NASH was found to be associated with male, nonobese, nondiabetic patients and with liver iron overload, which led to the hypothesis of iron playing a role in NASH pathogenesis. Increased ferritin with normal transferrin saturation is frequently found in fatty liver patients, but it reflects iron overload only in those patients in which it persists despite an appropriate diet. Insulin resistance hepatic iron overload (IR-HIO) is a new condition of hepatic iron overload, characterized by hyperferritinemia with normal or slightly increased transferrin saturation in the absence of hemochromatotic gene mutations. Although patients with IR-HIO have a high prevalence of insulin resistance-related metabolic disorders, the relationship of IR-HIO and NASH is unclear. Two characteristics allow differentiation of IR-HIO from genetic haemochromatosis: iron overload is heterogeneous from one hepatocyte to another in the periportal area, and sinusoidal iron is distributed throughout the lobule. In IR-HIO, fibrosis develops at a much lower hepatic iron burden than in genetic haemochromatosis, and sinusoidal iron, steatosis and inflammation could represent the histological mark of activity and progression of liver disease in IR-HIO.

[Unusual forms of liver abscesses]. / Forme particulare de abces hepatic.

UNLABELLED: Liver abscess is a rare disease. In this paper we present five unusual cases of liver absceses. These cases represents 5.68% from all patients with liver abscesses treated in the First Surgical Clinic Iasi, from 1977 to 2007. The ethiology of the abscesses was different: intrahepatic biliary duct migration of Ascaris lumbricoides, migration of a foreign body (toothpick) from stomach into the liver, infected hydatid cyst with a large biliary leak and cholangitis and, residual cavities after surgical treatment of hepatic hydatid cyst associated with foreign bodies. Another case was a patient with a very large, multilocular liver abscess (2000 mL) with biliary ethiology. In all cases a surgical drainage was performed. In the cases with hydatid cysts and biliary leakage, ERCP procedures were performed. The postoperative course was uneventful. CONCLUSIONS: Surgical treatment remains a valuable option in the treatment of pyogenic hepatic abscesses especially in unusual form.

[Prevalence and role of Helicobacter pylori infection in some gastroduodenal and hepatic complications in cirrhotic patients]. / Prevalenta si rolul infectiei cu Helicobacter pylori in determinarea unor complicatii gastroduodenale si hepatice la pacientii cu ciroza hepatica.

It has been clearly established that Helicobacter pylori (H. pylori) infection plays a pivotal role in the pathogenesis of chronic gastritis, peptic ulcer, gastric adenocarcinoma, and gastric lymphoma MALT (mucosa-associated lymphoid tissue) in the general population, but data regarding the prevalence and the role of H. pylori infection in liver cirrhosis are conflicting. Most serological studies estimated a high prevalence of H. pylori infection in patients with liver cirrhosis; however, when other methods (urea breath test, histology, culture, rapid urease test) were used, the overall H. pylori prevalence was similar to that in controls. Although the prevalence of both gastric ulcer (GU) and duodenal ulcer (DU) is higher in cirrhotic patients than in general population, the relationship between H. pylori infection and peptic ulcer in cirrhosis remains controversial. Our data regarding peptic ulcer prevalence in cirrhotic patients are in agreement with previous studies that suggest an increased prevalence of both GU and DU. The incidence of bleeding peptic ulcer is high in cirrhotic patients and carries an increased risk of complications or death in these patients and therefore eradication of H. pylori infection might be as effective in preventing ulcer relapse and bleeding as it is in noncirrhotic ulcer patients. Hepatic encephalopathy is a frecquent complication of liver cirrhosis, and it is widely accepted that ammonia plays a major role in its pathogenesis. The ammonia production by H. pylori urease does not increase blood ammonia levels during cirrhosis, and eradication of H. pylori infection does not affect hepatic encephalopathy status.

[Liver hemosiderosis study in chronic viral hepatitis]. / Studiul hemosiderozei hepatice in hepatopatiile cronice virale.

UNLABELLED: In chronic viral hepatitis the histopathological exam can reveal the presence of liver iron deposits in 10 to 73% of patients. Iron deposits are usually found in Kupffer cells, in endothelial cells and portal macrophages, and extremely rarely in hepatocytes. AIM: To evaluate the incidence of hepatic hemosiderosis in chronic viral hepatitis. METHODS: 549 morphopathological features of liver biopsy specimens performed in the Gastroenterology and Hepatology Institute IaSi, between January 1 2003 and December 31 2007 have been analyzed. Semiquantitative assessment of the degree of hepatic iron overload was performed and the localization of haemosiderin deposits: at the level of hepatocytes, the reticuloendothelial system or mixedly. The same anatomopathologist examined the blades and interpreted the results. RESULTS: The medium age of patients who underwent liver biopsy was 45.08 years +/- 10.045. Positive iron staining was found in 22.8% of cases, more frequently in males (31%), and in 91.82% of cases iron deposits were grade 1-2. The association of alcoholic etiology did not influence the incidence of hemosiderosis: 23% in patients with hepatitis and no ethanol exposure vs 25% in cases of strictly viral etiology. Deposits of haemosiderin were more frequent in viral hepatitis B (38.6%) than in viral hepatitis C (26.9%). In 34% of cases stainable iron was found only in reticuloendothelial system and in 46% of cases both in Kupffer cells and hepatocytes. CONCLUSION: Almost a quarter of chronic viral hepatitis cases are associated with liver deposits of haemosiderin, with features of secondary iron overload (deposits localized in the mesenchymal areas or mixedly). There is a higher risk of hemosiderosis in men, especially for those between 30 and 50. Liver iron overload levels in chronic viral hepatitis are, in most cases, low or medium, and the association with an alcoholic etiology does not influence the incidence of hemosiderosis in chronic viral hepatitis.