Therapeutic double-balloon enteroscopy: a binational, three-center experience.

BACKGROUND/AIMS: There are few reports focusing on therapeutic small bowel endoscopy. The aim of this study was to analyze the results of therapeutic small bowel endoscopy in a large cohort of patients. METHODS: A retrospective study of a prospectively collected database comprising all patients undergoing diagnostic and therapeutic small bowel endoscopy in three centers. RESULTS: A total of 614 double-balloon enteroscopies were performed in 534 patients. The most common pathological findings were angiodysplasias and vascular lesions (n = 98, 18%), mucosal ulcers and erosions (n = 95, 17.8%), polyps and tumors (including patients with familiar polyposis syndrome such as Peutz-Jeghers syndrome, familiar adenomatous polyps syndrome, neurofibromatosis, adenocarcinoma, neuroendocrine tumors and gastrointestinal stromal tumors) (n = 52, 9.7%), and strictures (Crohn's disease, ischemia, tumors) (n = 12, 2.2%). The mean duration of therapeutic small bowel enteroscopy was 67 min (range 30-115) compared to 50 min (range 25-105) for diagnostic procedures (p < 0.05). A therapeutic small bowel endoscopy was performed in 121 patients (22%). Therapeutic procedures included argon plasma coagulation of vascular lesions (n = 73), polypectomy (n = 49), mucosectomy (n = 5), stricture dilation (n = 7), foreign body extraction (n = 7), injection of fibrin glue (n = 10), and clip placement (n = 5). There were a total of 5 complications (0.9%; paralytic ileus, n = 2, pancreatitis, n = 1, bleeding n = 2). No perforations or deaths occurred. CONCLUSION: Endoscopists performing double-balloon enteroscopy should be trained and prepared to provide therapeutic interventions for small bowel disorders including argon plasma coagulation, injection, hemoclipping, polypectomy, mucosectomy and foreign body extraction. Therapeutic small bowel endoscopy, albeit associated with complications in about 1% of cases, can be considered a relatively safe procedure.

Angiotensin-converting enzyme gene insertion/deletion polymorphism in patients with chronic pancreatitis and pancreatic cancer.

The purpose of this study was to determine the frequency of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and to investigate its role as a potential risk factor in patients with chronic pancreatitis and pancreatic cancer. Deletion polymorphism of the 287-bp fragment of intron 16 of the ACE gene results in higher levels of circulating enzyme and therefore may represent a risk factor for disease development. The study included 55 patients with chronic pancreatitis, 45 patients with pancreatic cancer and 128 healthy subjects. The presence of I and D variants in the ACE gene was analyzed by a polymerase chain reaction (PCR) method. Distribution of ACE ID genotypes was analyzed by means of logistic regression. When chronic pancreatitis and pancreatic cancer groups were compared in the univariate analysis, the following factors were identified as statistically significant predictors of pancreatic disease: age, gender, smoking, fat intake, ACE II genotype and ACE DD genotype. However, in the multivariate analysis, only age, gender and smoking were singled out as predictors for the occurrence of pancreatic disease. Our findings indicate that the ACE I/D polymorphism could play a role in the development of chronic pancreatitis and pancreatic cancer through interaction with other genetic and environmental factors.

MTHFR C677T polymorphism in chronic pancreatitis and pancreatic adenocarcinoma.

Chronic pancreatitis and pancreatic adenocarcinoma are extensively studied as common and potentially lethal disorders. However, their causes and genetic background in most cases remain unclear. The C677T polymorphism in 5',10'-methylenetetrahydrofolate reductase (MTHFR) gene may modulate the risk of pancreatic disorders. In this study, we tested whether MTHFR C677T polymorphism is associated with chronic pancreatitis and pancreatic adenocarcinoma in the Serbian population. DNA was extracted from blood samples of 51 chronic pancreatitis patients, 21 pancreatic adenocarcinoma patients, and a control group consisting of 50 healthy smokers. The MTHFR C677T polymorphism was analyzed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Although, no statistically significant differences were observed in the distribution of MTHFR genotype or allele frequencies between patients and control groups, the results showed an increased frequency of homozygotes for MTHFR C677T polymorphism in chronic pancreatitis patients (14%) and a decreased frequency in pancreatic adenocarcinoma patients (5%) in comparison to the control group (8%). We speculate that the MTHFR C677T polymorphism could act as a possible risk factor for chronic pancreatitis and a possible protective factor in pancreatic adenocarcinoma. This observation needs further investigation in prospective studies on a larger number of patients, in which the effect of other genetic and environmental factors should also be taken into consideration.

Double common bile duct: a case report.

Double common bile duct (DCBD) is a rare congenital anomaly in which two common bile ducts exist. One usually has normal drainage into the papilla duodeni major and the other usually named accessory common bile duct (ACBD) opens in different parts of upper gastrointestinal tract (stomach, duodenum, ductus pancreaticus or septum). This anomaly is of great importance since it is often associated with biliary lithiasis, choledochal cyst, anomalous pancreaticobiliary junction (APBJ) and upper gastrointestinal tract malignancies. We recently recognized a rare case of DCBD associated with APBJ with lithiasis in better developed common bile duct. The opening site of ACBD was in the pancreatic duct. The anomaly was suspected by transabdominal ultrasonography and finally confirmed by endoscopic retrograde cholangiopancreatography (ERCP) followed by endoscopic sphincterotomy and stone extraction. According to the literature, the existence of DCBD with the opening of ACBD in the pancreatic duct is most frequently associated with APBJ and gallbladder carcinoma. In case of DCBD, the opening site of ACBD is of greatest clinical importance because of its close implications with concomitant pathology. The adequate diagnosis of this rare anomaly is significant since the operative complications may occur in cases with DCBD which is not recognized prior to surgical treatment.

Mucinous cystadenoma of the appendix associated with adenocarcinoma of the sigmoid colon and hepatocellular carcinoma of the liver: report of a case.

Mucinous cystadenoma of the appendix is a rare condition and represents one of the three entities with the common name mucocele of the appendix. It is characterized by a cystic dilatation of the lumen with stasis of mucus inside it. Histopathologically mucocele is divided into three groups: focal or diffuse mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma. This condition is often associated with other neoplasia, especially adenocarcinoma of the colon and ovaries. We here describe a 57 year old male patient who presented with abdominal discomfort, constipation, fresh blood in stool and frequent urination. He had a big cystadenoma of the appendix associated with adenocarcinoma of the colon and hepatocellular carcinoma of the liver. The patient underwent right haemicolectomy, sigmoid colon resection and segmental resection of the liver. Now 3 years later he has no evidence of disease relapse. According to this, we stress the need of accurate preoperative diagnosis and intraoperative exploration of the whole abdomen in these patients.

EUS diagnosis of ectopic opening of the common bile duct in the duodenal bulb: a case report.

Among the various congenital anomalies of the biliary system, an ectopic opening of the common bile duct (CBD) in the duodenal bulb is extremely rare. ERCP is essential for diagnosing the anomaly. A 55-year-old male was admitted to hospital for severe right upper quadrant abdominal pain, followed by fever, chills, elevated body temperature and mild icterus. The diagnosis of ectopic opening of CBD in the duodenal bulb was established on endoscopic ultrasonography (EUS), which clearly demonstrated dilated CBD, with multiple stones and air in the lumen, draining into the bulb. A normal pancreatic duct, which did not drain into the bulb, was also observed. This finding was confirmed on ERCP and surgery. As far as we know, this is the first case of this anomaly diagnosed by EUS. Ectopic opening of the CBD in the duodenal bulb is not an incidental finding, but a pathologic condition which can be associated with clinical entities such as recurrent or intractable duodenal ulcer, recurrent biliary pain, choledocholithiasis or acute cholangitis. Endoscopic ultrasonography features allow preoperative diagnosis of this anomaly and can replace ERCP as a first diagnostic tool in such clinical circumstances. Embryology of the anomalies of the extrahepatic biliary tree has been also reviewed.

Anismus as a cause of functional constipation--experience from Serbia.

UNLABELLED: BACKROUND/AIM: Anismus is paradoxal pressure increase or pressure decrease less than 20% of external anal sphincter during defecation straining. This study analyzed the presence of anismus as within a group of patients with the positive Rome III criteria for functional constipation. We used anorectal manometry as the determination method for anismus. METHODS: We used anorectal water-perfused manometry in 60 patients with obstructive defecation defined by the Rome III criteria for functional constipation. We also analyzed anorectal function in 30 healthy subjects. RESULTS: The presence of anismus is more frequent in the group of patients with obstructive defecation compared to the control group (a highly statistically significant difference, p < 0.01). Furthermore, we found that the Rome III criteria for functional constipation showed 90% accuracy in predicting obstructive defecation. We analyzed the correlation of anismus with the presence of weak external anal sphincter, rectal sensibility disorders, enlarged piles, diverticular disease and anatomic variations of colon. We found no correlation between them in any of these cases. CONCLUSION: There is a significant correlation between anismus and positive Rome III criteria for functional constipation. Anorectal manometry should be performed in all patients with the positive Rome III criteria for functional constipation.

Bradbury-Eggleston syndrome - an unusual cause of gastroesophageal reflux disease (GERD).

The report presents a case of a 46-year-old male patient, previously treated because of dysphagia, pyrosis, vertigo while standing up and impotency. Manometric and pH-metric analysis showed presence of gastroesophageal reflux disease (GERD) caused by transient relaxation of lower esophageal sphincter (TRLES). Heart-rate variability showed decreased sympathetic function. Electromyoneurography showed a neurological lesion in muscles of upper extremities. The patient received midodrine and clonazepam which resolved this condition. These findings suggest that a neurological disorder can be a cause of GERD.

Achalasia--two types in the same patient: case report.

INTRODUCTION: A paper presented a case of esophageal achalasia with both type 2 and type 3 achalasia found in the same patient. CASE OUTLINE: High resolution impedance manometry of esophagus was performed. Liquid swallows induced panesophageal pressurization (achalasia type 2), whereas viscous swallows led to compartmentalized pressurization--distal two thirds of esophagus (achalasia type 3). No complete bolus transit was recorded. Patient refused any procedure. CONCLUSION: The aim of this paper was to show the necessity of performing manometry using both liquid and viscous swallows in GI departments where this approach has not been routinely used in order to establish proper diagnosis since therapy approach is different between type 2 and type 3 achalasia.

Portal hypertension caused by postoperative superior mesenteric arteriovenous fistula.

INTRODUCTION: Arteriovenous fistula of the superior mesenteric blood vessels is a rare complicaton in abdominal surgery. CASE REPORT: We presented a 49-year-old man with cramp-like abdominal pain, abdominal distension and weight loss symptoms, with a history of previous small bowel resection and right colectomy, due to Crohn disease, 16 years ago. Clinical examination revealed a paraumbilical pulsation with systolic murmur and thrill. Ultrasonography and computed tomography revealed cystic dilatation of the superior mesenteric vein, hepatomegaly and ascites. Upper endoscopy revealed grade I esophageal varices with portal hypertensive gastropathy. The diagnosis of arteriovenous fistula between superior mesenteric artery and vein was confirmed by angiogram of the superior mesenteric vessels and resection of the fistula was performed. Control examination after nine months showed no signs of portal hypertension. CONCLUSION: Early diagnosis and treatment of mesenteric blood vessel arteriovenous fistula prevents portal hypertension development and its complications.

[CFTR F508DEL mutation and 5T allele in patients with chronic pancreatitis and pancreatic adenocarcinoma].

INTRODUCTION: Mutations in the CFTR gene may be associated with various types of pancreatic pathology and result in higher risk of pancreatic disorders. While delta F508 is the most common mutation in cystic fibrosis patients, the allel 5T is associated with atypical forms of cystic fibrosis. STUDY AIM: The aim of this study was to establish the frequencies of F508del mutation and 5T allele in the CFTR gene in patients with chronic pancreatitis and pancreatic cancer, as well as to investigate whether these genetic variants represent risk factors for pancreatic diseases. STUDY METHODS: The study has encompassed 50 patients with chronic pancreatitis and 50 patients with pancreatic adenocarcinoma, as well as 124 healthy individuals. The analysis of F508del mutation and alleles 5T, 7T and 9T of the polythymidine tract was performed on DNA extracted from periferal blood by PCR-mediated site-direted mutagenesis (PSM) method. RESULTS: The frequency of F508del mutation in the group of patients with chronic pancreatitis (3.0%) was significantly increased (p = 0.032) in comparison to the group of healthy individuals (0.4%), while other analyzed differences were not statistically significant. CONCLUSION: The results of this study indicate that F508del mutation in the CFTR gene respresents a risk factor for the development of chronic pancreatitis.

Frequency and clinical caracteristics of colorectal adenoma and carcinoma in women.

INTRODUCTION: Available literature states that the incidence of colorectal adenomas and cancer is more common in men, however, lately has been observed increasing number of patients among women. AIM: to analyze the frequency and clinical characteristics of colorectal adenomas and cancer in women. MATERIALS AND METHODS: We performed a retrospective study in which data of 695 patients with colorectal adenomas and carcinomas have been analyzed from a total of 10,659 patients who underwent colonoscopy. RESULTS: Colonoscopy and colorectal neoplasms were more frequently diagnosed in man (71.88%/67.4%) than women (28.12%/32.65%), so the results must be interpreted with caution. CONCLUSION: The increase in the number of women who suffer from colorectal adenoma and carcinoma can be explained by balancing lifestyle and increasing the number of women who are examined, given up the initial resistance that women had to colonoscopy, which is a potentially painful and embarrassing.

[Argon-plasma coagulation as a primary therapeutic method for the treatment of flat duodenal adenomas].

BACKGROUND: Argon-plasma coagulation is a method for tissue coagulation that uses high-frequency electric energy and ionized argon gas. It is used in endoscopic haemostasis and in coagulation of smaller, superficial lesion on gastrointestinal mucosa such as flat adenomas, but also in reduction of tumor tissue. CASE REPORT: We presented a patient with flat adenoma duodeni. Adenoma had been treated with argon plasma coagulation, in one act, and with a complete restitution of mucosa in further follows up. CONCLUSION: Argon plasma can be efficiently used in coagulation of superficial lesion of gastrointestinal mucosa, that belongs to the type of flat adenomas, as well as other superficial lesions of mucosa that require endoscopic mucosectomy from smaller, bordered spaces.

[Villous duodenal adenoma with II and III grade dysplasia and carcinoma in situ treated with cephalic duodenopancreatectomy].

BACKGROUND: Villous duodenal adenomas are rare, tend to malignant alteration and recurrency if surgical procedures are not sufficiently radical. They are mostly localized in the second portion of the duodenum and close to a papilla and are prone to malignant alteration. CASE REPORT: In this paper we presented a 79-year-old female patient already operated on twice elsewhere due to obstructive jaundice caused by villous duodenal adenoma, using, firstly, cholecystectomy and T-tube drainage of the choledoclus, and, then, an unsuccessful attempt of radical surgery--duodenopancreatectomy. The patient was some time wearing a T-tube drainage, and, then, submitted to endoscopic papillotomy, endoscopic stenting, and, finally to the insertion of a self-expandable metallic stent which got clogged three months later causing chalangitis. Three years following the first surgery, the patient presented to our institution and submitted to cephalic duodenopancreatectomy. Histology confirmed villous duodenal adenomas with II and III grade dysplasia and carcinoma in situ. The limph nodes were tumour-free. The postoperative recovery was somewhat prolonged due to cardiologic difficulties and a mild infection of the wound. CONCLUSION: Villous duodenal adenoma is curable if treated correctly and in a proper time. Radical treatment delay increases the risk for malignant alteration which was the case with our patient who was submitted to it three years after the histologic confirmation of the diagnosis.

[Correlation between findings of echosonography and endoscopic retrograde cholangiopancreatography examination in chronic pancreatitis patients].

BACKGROUND/AIM: Chronic pancreatitis is defined as an amount of chronic inflammatory lesions that lead to the destruction of pancreatic tissue and fibrosis development, whereas the later stages of the illness are characterized by the destruction of the endocrine portion of the organ. Although the results of different studies are abundant, chronic pancreatitis still remains enigmatic, both in its diagnostic and therapeutic aspect. To test the correlation between the findings of echosonography and endoscopic retrograde cholangiopancreatography (ERCP) examination in chronic pancreatitis patients. The observed degree of correlation may serve for the validation of echosonography as a diagnostic tool in chronic pancreatitis patients. METHODS: We collected and analyzed data on morphological features in chronic pancreatitis patients revealed by echosonography as well as endoscopic retrograde cholangiopancreatography. RESULTS: 35 patients 34-73 years of age were included in this study. In 60% (21 subject) history was subjective for alcohol abuse. Significant correaltion has been found between alcohol abuse and chronic pancreatitis (chi2 = 6.896; p < 0.05). Correaltion between groups of chronic pancreatitis patients diagnosed by echosonography and endoscopic retrograde cholangiopancreatography was highly significant (p = 0.799; p < 0.01). CONCLUSION: Echosonography was proved to be a suitable first choice imaging method for the examination of patients when chronic pancreatitis was suspected. Echosonography might provide conclusive information on the morphology of pancreatic canalicular system, as well as on the state of pancreatic parenchyma.

[Anomalous choledocho-pancretic ductal junction in a choledochal cyst--a case report]. / Anomalni spoj holedohusa i pankreasnog voda kod ciste holedohusa.

Choledochal cysts are rare congenital anomalies, mostly detected in adults. Pathogenesis of these cysts seems to be in anomalous junction between pancreatic and common bile duct, above the papillary sphincter and outside of the duodenal wall. The absence of the sphincter above the junction is followed by reflux of the pancreatic juice into the bile duct leading to dilatation and fibrous changes of bile duct wall. A 38-year-old female is presented in whom a choledochal cyst was found 11 years earlier, during the operation performed for obstructive jaundice, when cystojejunostomy with Roux-en Y Jejunal limb was carried out. In February 1990, she was admitted to our Institution forjaundice and biliary colic. The patient was reoperated. Operative cholangiography showed an anomalous pancreatobiliary junction, choledochal cyst, dilated cystic duct and moderate dilatation of intrahepatic bile ducts. Cholecystectomy, desanastomosis with partial excision of choledochal cyst, and retrocolic choledochojejunostomy with the same Roux-en-Y jejunal limb were performed. Total excision of choledochal cyst was too risky due to chronic inflammatory changes in the hepatoduodenal ligament. Postoperative recovery was uneventful and the patient remained symptom-free so far.