Diverticular disease: diagnosis and treatment.

Diverticular disease is one of the most common gastroenterological diseases. Its morphological basis are diverticula, whose prevalence in adults nears 50 %, with 25% clinical symptomatology and 5% occurrence of complications. It is a disease of older age, however its incidence is also rising in younger individuals, where it takes a more severe course. Its incidence is ascribed to a diet with a relatively low fibre content, however studies do not yield such clear results. Further risk factors include smoking, use of opiates and corticoids, obesity, alcoholism and smoking, hypertension, polycystosis, immunosuppression and use of non-steroid antiflogistics. Patients with diverticular disease also present with abnormal intestinal motility, intestinal dysbiosis and other physiological and morphological abnormalities. The most types of diverticulosis occur in the sigmoid colon, though especially in Asia the colon ascendens is more frequently affected. There are several classification schemes among which an individual assessment of complications is gaining in importance. The diagnosis includes clinical data, routine laboratory tests for inflammation, calprotectin in stool, coloscopy, ultrasound, CT and magnetic resonance. The basis for the treatment of symptomatic uncomplicated diverticular disease consists of drugs bringing symptomatic relief, fibre, probiotics, mesalazine and non-absorbable antibiotics, nonetheless the results of a number of studies are not fully convincing. The recommended treatment should be initiated with dietary fibre and probiotics, in the case of lasting problems add a non-absorbable antibiotic rifaximine with cyclic administration. Mild diverticulitis should essentially be treated by means of hydration and adjustments in the dietary regimen, antibiotics are not necessary when its course is uncomplicated and improvement is achieved, however the decision is individual and risk factors such as immunosuppression, diabetes, old age, pregnancy etc. Antibiotics are reserved for the treatment of severe or repeated diverticulitis, sepsis and complications. As prevention of further attacks, again probiotics, mesalazine and cyclically non-absorbable antibiotics are used, e,g. for a period of 10 days at monthly intervals. The proportion of surgeries is decreasing also where acute conditions are concerned and the efficiency of conservative treatment of diverticulitis is on the increase. Abscess should primarily be treated via non-surgical drainage. Even perforation and peritonitis can be treated via laparoscopic drainage without subsequent surgery being necessary, of course considering an overall condition an individual decision needs to be made. Generalized and fecal peritonitis are treated by open surgery. Earlier, elective resection was recommended after 2 attacks of diverticulitis, currently an individual approach is emphasized with respect to age, comorbidities and a character of the complaint and it is only indicated exceptionally. The proportion of laparoscopic resections is growing. The results are basically identical for Hartmann's procedure as well as primary resection. Key words: calprotecin - diverticular disease - dietary fibre - diverticulosis - mesalazine - non-absorbable antibiotics - probiotics.

[Liver transplantation in patients with portal vein thrombosis]. / Transplantace jater u pacientu s trombózou v. portae.

BACKGROUND: Portal vein thrombosis has (PVT) long been an absolute contraindication to liver transplantation. In patients scheduled for liver transplantation, portal vein thrombosis occurs in 4-15%. METHODS AND RESULTS: The authors retrospectively collected data on 740 patients who underwent an initial orthotopic liver transplant at the authors' institution between 1996 and 2009. Mean follow-up was from 1 day to 6 years. There were 437 male patients and 303 female patients. We have performed this procedure in 57 recipients with PVT; this constitutes 7.7% of the overall transplant population. There was a 10.5% incidence of liver graft dysfunction, 10.5% of hepatic artery thrombosis, 19.3% of acute rejection and 17.5% of biliary complications. The overall incidence of relaparotomy for bleeding was 28% (16 patients). In-hospital mortality and late mortality were 15.8% and 31.6%, respectively. Volumes transfused were 17.1 (0-425) transfusion units of red blood cell, 27.1 (0-132) of fresh-frozen plasma and 2.6 (0-20) of platelets respectively. CONCLUSIONS: We confirm that PVT is not a contraindication to LTx at the present time.

[Long-term follow-up of the first 500 liver transplant recipients transplanted at the Institute for Clinical and Experimental Medicine in Prague]. / Výsledky dlouhodobého sledování prvních 500 pacientu po transplantaci jater provedených v institutu klinické a experimentální medicíny v Praze.

BACKGROUND: Between April 1995 and November 2005, 500 liver transplantations were performed in 476 patients of age from 3, till 70, at the Transplantation center of the Institute of Clinical and Experimental Medicine (IKEM) in Prague. The most common indications for liver transplantation were alcoholic liver cirrhosis (23%), hepatitis C cirrhosis (17%), and cholestatic cirrhosis (PBC and PSC, 9% each). Mean MELD score of recipients at the transplantation was 15-18 for each year of transplantation. Ten-years patient survival was 79.1 +/- 2.2%, and graft survival 74.1 +/- 2.1% respectively. Best patient and graft survival was achieved among patients transplanted for autoimmune liver diseases, the worst in group of patients with alcoholic cirrhosis. Malignancies were the most common cause of death during the period of follow-up (17 patients). METHODS AND RESULTS: Patients were followed longitudinally at the Department of hepatogastroenterology IKEM according to prospective protocol included protocol biopsies. Hypertension (in 71% of recipients), and overweight or obesity (in 56.3%), were the most prevalent medical complications among long-term survivors. Diabetes was found in 28.6%, of which 14.7% was de-nove diabetes after transplantation. Renal insufficiency (S-creatinin > 150 micromol/l) was present in 61 of 348 (17.6%) survivors. Out of these, 16 needed chronic hemodialysis, and 12 underwent kidney transplantation subsequently. Protocol biopsy at 5 years after transplantation was evaluated in a sample of 102 unselected liver transplant recipients. Normal liver was found in 4% of recipients, minor non-specific changes in 36% of them. Disease recurrence was present in all of 16 recipients transplanted for HCV cirrhosis, in one third of them graft cirrhosis was already present. Disease recurrence was found in patients transplanted for autoimmune disease frequently, PBC in 40%, PSC in 25%, and autoimmune hepatitis in 60% of recipients. Graft steatosis greater than 33% was present in 13% of recipients. CONCLUSIONS: Liver transplantation is highly effective method of treatment of end stage liver disease. Despite frequent medical complications, and disease recurrence on histological examination almost 80% of recipients transplanted in the liver transplantation program in IKEM survived more than 10 years after procedure. The survival achieved was far above that of the European liver transplant registry.

Discrimination between acute and chronic decline of Central European forests using map algebra of the growth condition and forest biomass fuzzy sets: A case study.

Forest decline is either caused by damage or else by vulnerability due to unfavourable growth conditions or due to unnatural silvicultural systems. Here, we assess forest decline in the Czech Republic (Central Europe) using fuzzy functions, fuzzy sets and fuzzy rating of ecosystem properties over a 1×1km grid. The model was divided into fuzzy functions of the abiotic predictors of growth conditions (Fpred including temperature, precipitation, acid deposition, soil data and relative site insolation) and forest biomass receptors (Frec including remote sensing data, density and volume of aboveground biomass, and surface humus chemical data). Fuzzy functions were designed at the limits of unfavourable, undetermined or favourable effects on the forest ecosystem health status. Fuzzy sets were distinguished through similarity in a particular membership of the properties at the limits of the forest status margins. Fuzzy rating was obtained from the least difference of Fpred-Frec. Unfavourable Fpred within unfavourable Frec indicated chronic damage, favourable Fpred within unfavourable Frec indicated acute damage, and unfavourable Fpred within favourable Frec indicated vulnerability. The model in the 1×1km grid was validated through spatial intersection with a point field of uniform forest stands. Favourable status was characterised by soil base saturation (BS)>50%, BCC/Al>1, Corg>1%, MgO>6g/kg, and nitrogen deposition<1200mol(H+)/ha·year. Vulnerable forests had BShumus 46-60%, BCC/Al 9-20 and NDVI≈0.42. Chronic forest damage occurs in areas with low temperatures, high nitrogen deposition, and low soil BS and Corg levels. In the Czech Republic, 10% of forests were considered non-damaged and 77% vulnerable, with damage considered acute in 7% of forests and chronic in 5%. The fuzzy model used suggests that improvement in forest health will depend on decreasing environmental load and restoration concordance between growth conditions and tree species composition.

Epithelial markers of colorectal carcinogenesis in ulcerative colitis and primary sclerosing cholangitis.

AIM: To evaluate the expression of epithelial markers of colorectal carcinogenesis in patients with long-term ulcerative colitis (UC) and primary sclerosing cholangitis (PSC) before and after transplantation. METHODS: Eight patients with UC and PSC prior to liver transplantation (PSC-UC), 22 patients with UC after liver transplantation for PSC (OLT), 9 patients with active ulcerative colitis without PSC (UCA), 7 patients with UC in remission (UCR) and 10 controls (N) underwent colonoscopy with multiple biopsies. Specimens were analysed histologically and semi-quantitatively immunohistochemically for p53, Bcl-2 and cyclooxygenase-2 (COX-2) markers. Statistical analysis was performed by Kruskal-Wallis and Fisher's exact tests. RESULTS: PSC-UC had a statistically significantly higher expression of p53 in the nondysplastic mucosa as compared to OLT, UCA, UCR and N (P < 0.05). We also found a statistically significant positive correlation between the incidence of PSC and the expression of p53 (P < 0.001). UCA had a higher p53 expression as compared to UCR. OLT had a significantly lower expression of p53 as compared with PSC-UC (P < 0.001). Bcl-2 had a significant higher bcl-2 expression as compared with controls. No difference in COX-2 expression between PSC-UC, UCR and UCA was found. UCA had higher COX-2 expression as compared to UCR. We also found a statistically significant positive correlation between the expression of COX-2 and p53. Patients after liver transplantation for PSC had a statistically significantly lower expression of the p53 compared with PSC-UC (P < 0.001). PSC-UC had the same inflammatory endoscopic activity as OLT and UCR when evaluated with the Mayo score. CONCLUSION: Our study shows that the nondysplatic mucosa of UC patients with PSC is characterised by a higher expression of the tumour suppressor gene p53, suggesting a higher susceptibility of cancer. This p53 overexpression correlates with the presence of PSC whilst it is not present in patients with UC after liver transplantation for PSC.

Polypropylene mesh repair of incisional hernia after kidney transplantation: single-center experience and review of the literature.

BACKGROUND: Incisional hernia after kidney transplantation increases patient morbidity and impacts quality of life. Reports of hernia mesh repair after kidney transplantation are rare; thus, the benefit of mesh hernioplasty in transplanted patients is assumed. However, it is also assumed that transplant patients are susceptible to incisional and mesh infections. MATERIAL/METHODS: Between January 1, 2005 and December 31, 2010, we performed 1067 kidney transplantations. Twenty-eight patients developed incisional hernias (2.6%), and mesh repair was performed in 20 of them (8 women, 12 men; median age 59.5 years, range 43 to 68 years). We retrospectively studied this latter group. We also reviewed the literature regarding the results of this treatment. RESULTS: Postoperative mortality was zero, but postoperative wound bleeding led to surgical revision in 1 patient. Wound infection did not occur. During the follow-up period we observed 4 hernia recurrences (20%). CONCLUSIONS: In conclusion, our retrospective study and review of the literature confirmed the safety and low incidence (1.1% to 3.8%) of mesh hernia repair in chronic immunosuppressed patients after renal transplantation, which has a minimal risk of wound infection and no higher risk of hernia recurrence than in non-transplant patients.