Intra-esophageal whitish mass - a challenging diagnosis.

BACKGROUND: Whitish intraluminal esophageal masses might represent the endoscopic feature of a bezoar or a pedunculated tumor, most likely a fibrovascular polyp, without exclusion of other mesenchymal tumors (leiomyoma, lipoma, gastrointestinal stromal tumor, leiomyosarcoma, granular cell tumor). If a process of dystrophic calcification is also encountered the differential diagnosis can be a challenge even after histological analysis, as it is highlighted by our case. CASE PRESENTATION: A 65-year-old female whom took lactate calcium tablets for 5 years presented with progressive dysphagia. A whitish esophageal mass with an appearance of a pharmacobezoar was detected at esophagoscopy. A pedunculated tumor was considered in the differential diagnosis, but the imagistic studies ruled out a pedicle. This intraluminal esophageal mass highly suggestive for a pharmacobezoar was endoscopically removed. The challenge of correct diagnosis was raised by histological examination performed after immersion into trichloracetic acid for decalcification. The identification of hyaline fibrous tissue, with numerous crystalline basophils deposits of minerals, rare fibrocytes and very few vessels brought in discussion a mesenchymal originating mass, most likely a fibrovascular polyp, even the pedicle was not detected. CONCLUSION: Based on our challenging and difficult to diagnose case we proposed an uncommon evolution: auto-amputation and calcification of an esophageal mesenchymal originating tumor (most likely a fibrovascular polyp).

The role of narrow band imaging in colorectal polyp detection.

Colonoscopic detection and removal of polyps represent the most important prevention method for colorectal cancer. We aimed to investigate the diagnostic yield of narrow band imaging (NBI) colonoscopy for polyp detection compared with standard colonoscopy. In this prospective study, 505 patients that underwent total colonoscopy were randomized into two groups: 226 patients in NBI group and 279 in non-NBI group (standard colonoscopy). The primary endpoints were polyp detection rate (PDR) and adenoma detection rate (ADR) in both groups. Polyps detected with NBI technique were characterized according to the NBI International Colorectal Endoscopic (NICE) classification. The total number of polyps detected in NBI group was significantly higher compared with non-NBI group (325 polyps in 226 patients versus 189 polyps in 279 patients, respectively). PDR in NBI group was 55.3%, versus 43.3% in non-NBI group. ADR in NBI group was significantly higher compared with non-NBI group (35.3% versus 20%, respectively). The proportion of detected adenomas in the left-sided colon was significantly higher in NBI group (72.8% versus 61.06% in non-NBI group), which was related to an increased number of small adenomas detected in NBI group. Also, in NBI group, a significant number of flat adenomas were detected (28 versus 9 in non-NBI group). A total of 147 (45.2%) polyps were classified according to the NICE classification, and showed a good correlation with histological analysis. In conclusion, this study demonstrated increased PDR and ADR for NBI colonoscopy. A good correlation between the NICE classification and histological analysis was also observed.

Proposed score for the self-assessment of an endoscopy department performance in colonoscopy screening.

The aim of the paper was to propose a score for performance evaluation in colonoscopy units. METHOD: We proposed a score (CDCD score - Cecal intubation, polyp Detection rate, Cleansing and Documentation of cecal intubation) based on the following parameters that assess the quality of colonoscopy units: total colonoscopies rate, polyp detection rate, rate of cecal intubation photo record, rate of recorded Boston bowel preparation scale (BBPS) (rated 1 to 5 stars). The mean score obtained based on the above mentioned criteria was used as a quality parameter of the endoscopy unit. We applied and calculated this score in all screening colonoscopies performed in our Endoscopy Department during the last 4 years. RESULTS: The study group included 856 screening colonoscopies. The rate of total colonoscopies was 92.1% (789/856 cases) and the polyp detection rate was 23.9%. Regarding the quality of bowel preparation, the BBPS was recorded in 51.1% cases. The cecal intubation was photo recorded in 44% of cases. We considered that of the 4 parameters, the highest weight for an excellent quality belonged to the cecal intubation rate, followed by the polyp detection rate, because they evaluate the endoscopic technique, while the other 2 are more administrative. Thus, for the unit's assessment we used the following equation: UNIT'S QUALITY CDCD SCORE = (3×cecal intubation rate+3×polyp detection rate+1×photo documentation+1×BBPS documentation)/8. Thus, the CDCD Score for our unit was ≈4 stars (3.7 stars). CONCLUSION: The proposed CDCD score may be an objective tool for the quality assessment in different endoscopy units.

Position paper on treatment of hepatitis C in Romania, 2017. Part one.

BACKGROUND AND AIMS: Hepatitis C Virus (HCV) infection is a common condition with endemic prevalence in some areas of the world. In Romania the mean prevalence is about 3%. New treatments became available on the market in recent years and new drugs are in the pipeline. A re-evaluation of HCV therapy was considered mandatory. The Romanian Society of Gastroenterology and Hepatology undertook this task for the practitioners of this country. METHODOLOGY: A group of recognized experts was created who screened the available literature and the major available guidelines. A list of items requiring attention has been created. These items were discussed and rated. Decisions were taken by consensus. RECOMMENDATIONS: We present here the first of the two parts of our Society's recommendations for chronic HCV infection treatment. An agreement was reached regarding the diagnostic tools, the assessment of severity and the up-dated therapy schedules. CONCLUSIONS: This Position Paper represents a guide for the assessment and the therapy of HCV infection. The recommendations are in concordance with other guidelines but are applied to the real-life conditions in this country.

Position Paper on Treatment of Hepatitis C in Romania 2017. Part Two.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) infection is a common condition with endemic prevalence in some areas of the world. In Romania, the mean prevalence is about 3%. New treatments have become available on the market in recent years and new drugs are in the pipeline. A re-evaluation of HCV therapy was considered mandatory. The Romanian Society of Gastroenterology and Hepatology undertook this task for the practitioners of this country. METHODOLOGY: A group of recognized experts was created who screened the available literature and the major available guidelines. A list of items requiring attention was created and these were discussed and rated. Decisions were taken by consensus. RECOMMENDATIONS: We present here the second part of the Society's recommendations for chronic HCV infection treatment. An agreement between experts was reached regarding the therapy of the special categories of patients infected with HCV, complications and monitoring of the therapy, follow-up of the patients who reached sustained virologic response and re-treatment of the patients with therapy failure. CONCLUSIONS: This Position Paper represents a guide for the assessment and the therapy of HCV infection. The recommendations are in concordance with other guidelines but are applied to real-life conditions in Romania.

Fecal transplantation indications in ulcerative colitis. Preliminary study.

BACKGROUND AND AIMS: Fecal microbiota transplantation is used with success in persistent (more than two episodes) Clostridium Difficile Infection; it has also gained importance and started to be used in inflammatory bowel disease. There are theoretical arguments that justify its use in ulcerative colitis or Crohn's disease. Based on our clinical cases we tried to evaluate the indications of fecal microbiota transplantation young patients with ulcerative colitis and multiple relapses, in which biological or immunosuppressive treatment were ineffective. METHODS: Five patients with moderate-severe ulcerative colitis or Clostridium Difficile infection who ceased to have a therapeutic response to biological therapy, were given fecal microbiota transplant as an alternative to biological therapy and/or immunosuppression. Fecal microbiota transplant was administered via colonoscopy using healthy donors from their family. RESULTS: The results were favorable and spectacular in all patients and complete remission was achieved for at least 10 months. Clinical remission was achieved in all patients. Endoscopic appearance of ulcers in patients improved. In 2 patients the effect of the fecal microbiota transplant diminished after 10-12 months and the tendency to relapse appeared (3-4 stools/day, blood streaks present sometimes in the stool). Reintroduction of systemic therapy or immunosuppression demonstrated that patients regained the therapeutic response to these treatments, and remission was maintained. CONCLUSION: Fecal microbiota transplantation can be used as salvage therapy in patients refractory to biological therapy, as elective therapy in clostridium difficile infection or as an alternative therapy in young patients with multiple relapses who have reservations regarding biological or immunosuppressive treatment.

Diagnosis and treatment of extrahepatic cholangiocarcinoma: results in a series of 124 patients.

AIM: The aim of the study was to evaluate the diagnostic methods and therapeutical results in patients with extrahepatic cholangiocarcinoma admitted between 2000 and 2003 and to assess the efficacy of various imaging methods. MATERIAL AND METHOD: We included 124 consecutive patients with suspected cholangiocarcinoma who underwent endoscopic retrograde cholangiopancreatography (ERCP) between 2000 and 2003. Every patient underwent an ultrasound (US) examination before ERCP. ERCP was considered as the "gold standard" for diagnosis. The therapy applied consisted of endoscopic stenting, US guided biliary drainage or surgery. The sensitivity, specificity and accuracy were calculated for every tumour localisation and also globally for all tumours. RESULTS: The sensitivity, specificity and accuracy of US were 85.9 %, 76.9 %, and 84.4 % for hilar localization, 59.1 %, 50 % and 57.1 % for the mid bile duct (CBD) and 33.3 %, 42.8 % and 36.8 % for the distal CBD tumours. The global performances for US in diagnosing extrahepatic cholangiocarcinoma were 73.5 %, 61.5 % and 70.9 %. In 73 cases (74.5%) an endoscopic stent was placed. In 11 cases (11.2%) we performed an US guided biliary drainage and in 14 cases (14.2%) surgery was recommended. CONCLUSIONS: Ultrasonography proved to be a reliable method for the diagnosis of cholangiocarcinoma in spite of its low accuracy for distal localization. The combination of the two investigations (US and ERCP) was very efficient in the management of these patients. Endoscopic stenting for hilar localization is a good therapeutical option.

Self-Administered Home Series Fecal "Minitransplants" for Recurrent Clostridium difficile Infection on a Rectal Remnant.

A fecal microbiota transplant has proved to be an extremely effective method for patients with recurrent infections with Clostridium difficile. We present the case of a 65-year-old female patient with multiple Clostridium difficile infection (CDI) relapses on the rectal remnant, post-colectomy for a CDI-related toxic megacolon. The patient also evidenced associated symptomatic Clostridium difficile vaginal infection. She was successfully treated with serial fecal "minitransplants" (self-administered at home) and metronidazole ovules.

Impaired health-related quality of life in Romanian patients with chronic viral hepatitis before antiviral therapy.

BACKGROUND AND AIM: Chronic hepatitis is a disabling condition leading to impairment of a patient's quality of life. We investigated the impact of chronic viral hepatitis on health-related quality of life. The relationship between transaminase level and score in the quality-of-life questionnaire was also investigated. METHODS: We studied 66 patients with chronic viral hepatitis (27 with hepatitis B, 38 with hepatitis C, 1 with hepatitis B+C; 32 men, 34 women) naive to any previous antiviral therapy. All had high levels of transaminases. Patients with chronic disease or those using drugs to modify their quality of life were discarded. The control group consisted of 36 healthy volunteers (17 men, 19 women). Both groups completed the Short Form 36 health survey, with the exception of the items concerning bodily pain. RESULTS: Significant differences between the two groups for every domain of quality of life (physical functioning, role physical, mental health, role emotional, social functioning, vitality and general health) were recorded. We found no significant correlation between the level of transaminases and any item of the health-related quality-of-life questionnaire. In hepatitis B patients, several quality-of-life scores (general health, social functioning, mental health) were better than in hepatitis C patients. CONCLUSIONS: Patients with chronic viral hepatitis not receiving antiviral therapy have an impaired quality of life as estimated by the Short Form 36 health survey.

Intra-oesophageal pH profiles and pharmacokinetics of pantoprazole and esomeprazole: a crossover study in patients with gastro-oesophageal reflux disease.

AIM: To compare the effect of pantoprazole and esomeprazole on intra-oesophageal pH and investigate their pharmacokinetics in patients with symptomatic gastro-oesophageal reflux disease (GORD). METHODS: Double-blind, randomized, two-period crossover study. Caucasian men with symptomatic GORD (n=48) were selected on the basis of clinical records of typical GORD symptoms, confirmed by a pathological reflux time (oesophageal pH<4 for > or =6% of the time). They received oral pantoprazole 40 mg once daily (od) or esomeprazole 40 mg od for seven days. Continuous 24 h oesophageal pH-metry was performed at baseline and day 7. Evaluations included: pre- and post-treatment differences in the percentage of time with pH<4.0 and <3.0 between baseline and day 7; area under the curve (AUC), Cmax, and T(1/2); point estimates and 90% confidence intervals (CI) on days 1 and 7, calculated for ratios of the AUC and Cmax. RESULTS: Both drugs decreased the mean total number of reflux episodes and reduced the percentage of reflux time within 24 h to <3%. No pathological reflux was detectable after repeated administration of either drug. The 90% CI were within the predefined range at all time points; thus, equivalence of pantoprazole and esomeprazole was concluded. For pantoprazole, Cmax and AUC were unchanged on day 7 vs day 1, confirming its high and constant bioavailability. For esomeprazole, Cmax and AUC were increased on day 7 vs day 1 by 80% and 50%, respectively, indicating low initial bioavailability. No clinically relevant side effects were seen for either drug. CONCLUSION: Pantoprazole and esomeprazole have equivalent effect on oesophageal pH, since no pathological reflux was detected after treatment with either drug. For esomeprazole, the Cmax and AUC increased after multiple dosing; for pantoprazole the pharmacokinetics were predictable and independent of the number of administered doses.

Epidemiology of inflammatory bowel disease in adults who refer to gastroenterology care in Romania: a multicentre study.

AIM: The Romanian Society of Gastrointestinal Endoscopy developed a multicentre, prospective study to evaluate the frequency and epidemiological features of inflammatory bowel disease (IBD) in an adult population that refers to gastroenterology centres in Romania. MATERIAL AND METHODS: Eighteen centres with adequate diagnostic and therapeutic facilities uniformly distributed across Romania reported through a proforma the new and old IBD cases between 1 June 2002 and 1 June 2003. The rates of incidence and prevalence of ulcerative colitis (UC) and Crohn's disease (CD) have been reported per 100 000 inhabitants. Epidemiological features and disease characteristics were analysed. RESULTS: During the study, 407 cases of UC (163 incident cases) and 254 cases of CD (85 incident cases) were identified. The incidence in the referral population was 0.97/100 000 and 0.50/100 000 for UC and CD, respectively, whereas the prevalences was 2.42/100 000 and 1.51/100 000 for UC and CD, respectively. A slight male predominance, wider age distribution and predominant urban residence were the main demographic features of incident cases; smoking and appendectomy/appendicitis were infrequent in UC, while a higher proportion of CD patients were smokers. Lower rates of severe, extensive or complicated IBD were noted as compared with the literature. CONCLUSION: Incidence and prevalence rates of IBD in Romania are low. Predominant male involvement and a wider distribution of incident cases were the main demographic features in our population. IBD in our patients had a more 'benign' course as compared with the literature, with lower rates of severe, extensive or complicated disease and a small proportion of patients who need surgery.

Barrett's Esophagus.

Barrett's esophagus is an alteration of the esophageal epithelium, regardless of length, evidenced by endoscopic examination (protrusion of the gastric mucosa into the esophagus in the shape of a flame) and confirmed by histological examination of the bioptic samples (intestinal metaplasia with mucosecretory cells). It develops following long-term gastro-esophageal reflux (GER). The documented risk factors are: long-term GER (duration more than 5 years), age over 50 years, male sex, Caucasian race, aggressiveness of the refluxed material, individual susceptibility of the esophageal mucosa to the refluxed material. The carcinogenic risk is 30 times higher than in the general population. Treatment targets the acid reflux, with proton pump inhibitors (PPI), prevention of carcinogenesis with cyclooxygenase 2 inhibitors, ablation of the metaplastic area by laser, plasma-argon mucosectomy, or photodynamic therapy and antireflux surgery.

What is the real prevalence of the D virus infection in chronic hepatitis and liver cirrhosis in Romania?

Virus D hepatitis continues to represent a public health problem in the south-eastern European countries, but the spread of the D virus infection in Romania is not completely elucidated. The paper proposes to assess the prevalence of the hepatitis D virus infection in patients with HBsAg-positive chronic hepatitis and liver cirrhosis in Romania. A number of 219 patients with chronic hepatitis and 168 with liver cirrhosis, all testing positive for HBsAg were studied. Viral markers were determined by immunoenzymatic methods. In HBsAg-positive chronic hepatitis the prevalence of the D virus was 37.9 % and in liver cirrhosis 51.19%. The great majority of the cases infected with hepatitis B virus were HBeAg-negative. These findings situate Romania among countries with a high prevalence of the hepatitis D virus infection, but which is decreasing as compared to the data communicated by previous reports.

[Treatment of pain in chronic pancreatitis by an endoscopic method]. / Traitement de la Douleur dans la Pancréatite Chronique par la Méthode Endoscopique.

UNLABELLED: The epigastric pain is the most frequent manifestation in chronic pancreatitis. It is due to intraductal pancreatic pressure, presence of compressive pseudocysts and probably to neuroinflammatory process caused by alcohol. AIM: The aim of our study was to assess the influence of endoscopic treatment on pain in chronic pancreatitis and the correlation between residual pain after endoscopic treatment and pancreatic morphology. PATIENTS: Forty-four patients from the Gastroenterology Department of Angers (France) with chronic pancreatitis were included in our retrospective clinical study. Thirty-seven patients underwent a diagnostic ERCP and only 28 needed an endoscopic treatment. The pain was evaluated semi-quantitatively before and after the endoscopic treatment. The mean follow-up was 28.6 months. RESULTS: Among the 28 patients with endoscopic treatment, 18 had a complete improvement of the pain, 4 an incomplete improvement and 6 had no improvement; these last were submitted to pancreatic surgery. The pain evolution had a good correlation with the reduction of Wirsung diameter; there was no correlation with ductal stenosis, residual lithiasis and pseudocysts presence. Alcohol consumption had no influence on the pain evolution. CONCLUSION: The endoscopic treatment of intraductal lithiasis and pseudocysts is a useful method for Wirsung decompression, improving the pain in chronic pancreatitis.

Ruptured hydatid cyst of the liver with biliary obstruction: presentation of a case and review of the literature.

The case of a 66 year old woman admitted with a picture of jaundice acute cholangitis is reported. Ultrasonography showed a dilatation of intrahepatic bile ducts, gallbladder hydrops with several stones, enlarged common bile duct (CBD) with hyperechoic material inside and a cystic tumor with hydatid features. With a strong suspicion of a hydatid cyst ruptured in the biliary tree with biliary obstruction, endoscopic cholangiopancreatography was performed. The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography and the hydatid membranes were extracted from the CBD with subsequent clinical improvement. The second step of treatment comprised the surgical cure of the cyst and cholecystectomy. The data from the literature are finally presented with a special emphasis on the ultrasound diagnosis and the endoscopic treatment.

Endoscopic mucosal resection for early esophageal cancer. A case report.

With the rapid progress of the diagnostic techniques, especially endoscopy, the discovery rate of early superficial cancer of the esophagus has increased markedly. Relatively recently introduced, endoscopic mucosal resection (EMR) is now widely used in the treatment of early stage cancer of the esophagus. We used EMR in the case of a patient who was incidentally diagnosed with a type IIa early esophageal cancer using a band-ligating device. We had no serious complications. At the histopathological examination we noticed that the carcinoma involved the upper third of the submucosal layer. For this reason the patient was given additional therapy (radiotherapy), too. A month after the EMR, at the histological examination we found no local signs of recurrent disease.

Multilocular colorectal tuberculosis and hypogammaglobulinemia.

We present the case of a young male patient admitted for weight loss, diarrhea and rectal bleeding. The patient belonged to a low social class and had associated hypogammaglobulinemia. The endoscopy revealed different localized ulcerations of he rectum and a stenosis. By barium enema and hydrosonography multiple stenotic lesions were observed. The pathological examinations detected lesions suggestive for intestinal tuberculosis. A specific therapy led to the improvement of his general state and to the disappearance of diarrhea and rectal bleeding.

The prevalence of coeliac disease at endoscopy units in Romania: routine biopsies during gastroscopy are mandatory (a multicentre study).

UNLABELLED: The incidence and prevalence of coeliac disease vary internationally. In Eastern Europe little is known about the prevalence of coeliac disease. THE AIM: of this study was to evaluate the prevalence and the clinical features of coeliac disease in adults biopsied during upper endoscopy in Romania. This is the first incidence study of the coeliac disease in Romania. METHODS: The study was initiated by the Romanian Society of Digestive Endoscopy for the period 1 January 2002 - 31 May 2002. It was carried out in 9 Academic Centres in Romania, which ensured an even geographical distribution and therefore significant statistical results at a national level. The study included 2436 patients according to following criteria: age over 16 years, with no known history of coeliac disease, visiting the participating upper endoscopy units or patients with documented coeliac disease presenting for follow-up check or recurrence of clinical symptoms. At least two bioptic samples were obtained from the distal duodenum, as distally as possible, which were submitted to histopathological examination and scored according to the modified UEGW Marsh criteria (2001). A database was set up to include all the patients with data regarding sex, age, urban or rural background, full clinical diagnosis, clinical symptoms, history of the coeliac disease. RESULTS: Of the 2436 patients studied, 54 (2.22%) were diagnosed with coeliac disease. Their demographic features: 48.15% men, 51.85% women, 68.52% living in urban areas, 31.48% in rural ones, mean age 42 +/-17.0 years. The most frequent reasons for performing upper digestive endoscopy were: dyspeptic syndrome - 15.93%, anemia - 24.07%, and chronic diarrhoea - 22.22%. The most frequently recorded clinical manifestations were: chronic diarrhoea in 46.3%, asthenia in 29.63%, anemia in 24.07%, aphthae in 24.07%. Histopathological results according to Marsh classification were: Marsh III- 64.81 %, Marsh II-35.19%. CONCLUSIONS: The prevalence of the coeliac disease in Romania is 2.22%: its sex distribution is fairly equal, the age distribution includes two peaks, at 30-40 and 50-60 years respectively, and patients from urban areas predominate. The most frequent (over 50% of the cases) histological type was M III. The most common clinical symptoms were diarrhoea, asthenia, anemia, aphthae, while the most frequent associated diseases were diabetes mellitus and Duhring-Brocq dermatiti

Whipple's disease. Case report.

The paper reports the clinical case of a 58 -year-old male patient admitted for diarrhea (6-7 stools/day, diffuse abdominal pain, borborygma, weight loss (20 kgs in two years), asthenia and fatigue. Physical examination evidenced a poor nutritional state (body mass index 19 kg/m2). The abdomen was slightly distended. Biological tests evidenced moderate/severe anemia, hypoproteinemia and hypoalbuminemia. Endoscopic examination evidenced oedematous duodenal mucosa with white-yellowish deposits. Histology (HE stain) revealed the presence of foamy cells and the PAS-staining of the duodenal mucosa evidenced PAS-positive macrophages and numerous intracellular bacilli. Penicillin therapy 2 x 1 million U/day for 14 days, followed by tetracycline 4 x 250 mg/day improved the clinical picture, the patient had only one stool per day and gained weight. After 7 months of treatment the general condition was good and the patient had gained 17 kgs, the duodenal mucosa was normal. HE staining did not evidence foamy cells and no PAS-positive macrophages could be found.