Intestinal barrier dysfunction in liver cirrhosis assessed by iohexol test.

OBJECTIVE: To study gut barrier function in patients with liver cirrhosis (LC) by evaluating the intestinal permeability (IP) and its relationship with the severity and etiology of the disease. PATIENTS AND METHODS: The study included 31 patients with LC and 25 healthy controls. Child-Pugh score was used for evaluation of the LC severity. IP was assessed by the rise in levels of iohexol, which was administered orally (25 mL, 350 mg/mL) 2 h after breakfast. Three and six hours later serum (SIC mg/L) and urine (UIC g/mol) iohexol concentrations were determined by a validated HPLC-UV technique. RESULTS: Patients with LC had significantly higher mean SIC value compared with control group at 3 h (2.05 ± 1.67 vs. 1.25 ± 1.41 mg/L, p=0.021, as well as at 6 h (2.20 ± 2.65 vs. 1.11 ± 1.06 mg/L, p=0.001) after ingestion. No significant difference was found in mean SIC value of patients at 3 and 6 h. 23% of the patients had an increased IP. The mean iohexol urine recovery of patients was similar to that of the controls both at 3 h and at 6 h. Mean SIC values were significantly higher in patients with advanced Child C class than in healthy controls or the subgroup with Child B class, both at 3 h (2.54 ± 1.95 mg/L vs. 1.11 ± 1.06 mg/L, p=0.007) or (2.57 ± 1.85 mg/L vs. 1.35±1.32 mg/L, p=0.005) and at 6 h (2.57 ± 1.85 mg/L vs. 1.25 ± 1.40 mg/L, p=0.002) or 2.54 ± 1.95 mg/L vs. 1.07 ± 0.35 mg/L, p=0.02). Cirrhotic patients with ascites had significantly higher SIC in comparison with the controls, both at 3 h (2.31 ± 1.74 vs. 1.25 ± 1.41 mg/, p=0.009) and at 6 h (2.20 ± 1.87 vs. 1.11 ± 1.06 mg/l, p=0.007). In the subgroup of patients with alcoholic LC, the mean SIC values at 3 and 6 h (2.29 ± 1.80, 2.33 ± 1.85 mg/L, respectively) were significantly higher (p= 0.016, p=0.003) compared to the control group (1.25 ± 1.41, 1.11 ± 1.06 mg/L, respectively). CONCLUSIONS: Increased IP is found in 23% of cirrhotic patients. Permeability alterations are significantly more pronounced in patients with advanced LC with the presence of ascites and in those with alcoholic etiology.

Serum trefoil factor 3 predicts disease activity in patients with ulcerative colitis.

OBJECTIVE: In this study, we aimed to evaluate the role of serum trefoil factor 3 (TFF3) as a biomarker of disease activity in patients with inflammatory bowel disease (IBD) and to compare TFF3 values with those of fecal calprotectin (FC). PATIENTS AND METHODS: 128 patients with IBD were divided into four groups: 1) active ulcerative colitis (UC); 2) quiescent UC; 3) active Crohn's disease (CD); 4) quiescent CD. The serum levels of TFF3 and FC levels were assessed in all patients and 16 controls. RESULTS: Patients with active UC had higher TFF3 levels than those with quiescent UC (p<0.001), those with active (p<0.001) or quiescent CD (p<0.001) and controls (p <0.001). We found a correlation between TFF3 and FC values in patients with active (r = 0.478, p = 0.006) and quiescent UC (r=0.528, p=0.002). TFF3 levels correlated with endoscopic activity in UC (evaluated by UC Endoscopic Index of Severity - UCEIS) (r=0.662, p<0.001). CONCLUSIONS: Serum TFF3 is able to identify patients with active UC. It could be used as a marker to predict disease activity in patients with UC.

Endorectal power Doppler ultrasonography is a reliable method for evaluation of rectal cancer angiogenesis.

OBJECTIVE: We aimed to assess the preoperative rectal cancer angiogenesis with Endorectal Power Doppler Ultrasonography by using the Power Doppler Vascularity Index (PDVI) calculated by imaging analysis software, and to compare it with the microvessel density (MVD) in surgical specimens PATIENTS AND METHODS: This study included 110 patients (39 females; mean age 61.5 years) with rectal cancer. Immunohistochemical staining of surgical specimens with anti-CD-31 antibody was used for MVD evaluation. The PDVI of each tumor was calculated using Endorectal Power Doppler with computer-assisted quantification of colour pixels. RESULTS: Mean MVD - 163 ± 69 microvessels/mm2 (50-328) was used as a cutoff point, differentiating two groups of tumors with high (> 160 mm2) and low (≤ 160 mm2) angiogenic activity. Mean PDVI of 8.9 ± 6.0% (0-27.3) was used as a cutoff point, dividing two groups of tumors with high (> 8%) and low (≤ 8%) PDVI. The MVD and the PDVI showed a good positive correlation (r = 0.438, p = 0.002). Patients with low PDVI had 25 months longer overall survival (p < 0.05) than patients with high PDVI. Patients with low MVD had 36 months longer survival (p < 0.05). CONCLUSIONS: Endorectal Power Doppler Ultrasonography is a reliable and noninvasive method for assessment of the extent of rectal cancer angiogenesis. Tumor angiogenesis assessed by the PDVI correlated with histological MVD determination and could predict survival rates. Endorectal Power Doppler examination is a useful and reproducible method for in vivo preoperative quantitative assessment of tumor vascularization.

Preoperative diagnosis of jejunal adenocarcinoma--a case report.

We report herein the case of a preoperatively diagnosed small bowel adenocarcinoma. A 57-year-old man was hospitalized twice for a month in the Gastroenterology Clinic due to complaints lasting a year before hospitalization and consisting of heaviness and spastic pain in the left upper abdomen. None of the numerous methods used in this case (fibrogastroduodenoscopy, ileocolonoscopy, barium series and CT) could reveal a tumor. Ultrasound (US) examination showed a polycyclic formation in the left hypochondrium with enlarged regional lymph nodes. An US-guided fine (20 gauge) needle aspiration (FNA) cytology of the mass was performed and showed moderately differentiated adenocarcinoma of intestinal origin. Thanks to Doppler US guidance during FNA a massive bleeding from an identified arterial vessel with high systolic speed was avoided. On surgical exploration a jejunal tumor of high consistency was found, located 15 cm distantly from the Treitz ligament, infiltrating up to 2/3 of the bowel circumference and partly obstructing its lumen. The histological evaluation of the resected material showed highly to moderately differentiated adenocarcinoma with 5 regional lymph node metastases. The combination of US with Doppler and FNA established preoperatively the malignant small bowel disease.

Complicated small bowel diverticulosis--a case report and literature review.

We report herein the case of a small bowel diverticulum perforation which has caused peritonitis and consequently has led to operation. The patient, a 79-year old woman, was hospitalized due to etiological clarifying and specifying of a newly diagnosed diffuse liver pathology. During the hospital stay, she has received severe abdominal pain with features of peritonitis. Suspecting perforated appendicitis she has undergone an operation. The explorative laparotomy has identified a purulent exudation in the abdominal cavity, resulting from a perforated inflammatory jejunal diverticulum and multiple middle-size diverticula all along the small bowel and the colon. The reported case as well as the review of the literature have shown that various and sometimes potentially fatal complications could occur even for such a relatively banal insignificant entity as is diverticular disease in elderly patients.

Topical mononitrate treatment in patients with anal fissure.

AIM: To assess the efficacy and patient compliance of topical mononitrate hydrogel for the treatment of anal fissure. MATERIALS AND METHODS: Nineteen patients with symptomatic chronic anal fissures were randomly allocated to receive either active (10 patients) or placebo (nine patients) gel treatment. Rectal administration of hydrogel containing 0.2% isosorbide-5-mononitrate was prescribed. Patients were instructed on its application to the anal canal twice daily for 3 weeks. A questionnaire was used to determine patient compliance with therapy. Anal manometry was performed before and after therapy. RESULTS: At the end of therapy, the fissures were healed in 80% of actively treated patients compared with 22% of the control group. There was a mean reduction of 28% in mean resting anal pressure. Two actively treated patients (20%) suffered from mild headache relieved with oral analgesics and menthol lozenges. Faecal incontinence was not observed. There were no recurrences during at least 3 months of follow-up. CONCLUSIONS: Topical mononitrate gel therapy of anal fissures is an effective and safe approach. In this study, the few cases of headache were rapidly relieved with oral analgesia and menthol lozenges.

[Contrast-enhanced endoanal and transanal sonography for perianal fistulas].

AIM: Perineal and endorectal sonographic investigation before and after the contrast enhancement with hydrogen peroxide for patients with fistule pathology has been perfomed aimed at the development of the perianal fistules diagnostics. MATERIAL AND METHODS: Five patients (4 men and 1 woman) with perianal fistulas have been tested. Four of them are operated. The only woman in the group is with the active illness of Crohn. After the native (without contrast) transperineal and endoanal sonographies, hydrogen peroxide has been insuflated in the fistulas and the sonographic tests have been repeated. RESULTS: All fistulas have been identified by native endoanal and transperineal sonographies. The contrast application additionally specifies the fistula location and its connection with the anal lumen. For the tested patients the fistulas are as follows: intersphincteric - for 2 patients, transsphincteric - for 2 and suprasphincteric complicated (with 2 ducts) fistula - for 1 patients. The sonographic tests findings have been conformed intraoperatively. Hypervascularization in the wall has been established by Doppler technique for 3 of patients. For 2 of them both arterial and vine blood streams are registered, while for the third of them - only arterial blood stream is observed. CONCLUSION: The joint application of the endoanal and transperineal sonographies, combined with the possibilities of the Doppler technique and the hydrogen peroxide contrast enhancement is represents and effective method of finding and anatomotopographic localization specification of the perianal fistulas.

[Anorectal functional tests--essence and value]. / Anorektalni funktsionalni testove--sushtnost i stoinost.

Anorectal disturbances are one of the most frequent functional bowel disorders. A lot of motor- and sensor anorectal tests are available. At the same time in Bulgaria anorectal disorders are unknown for the most of the gastroenterologists and surgeons, and that's why they are misdiagnosed and not treated correct. The aim of our paper is to summarize the experience with these techniques in patients with anorectal disorders. We are giving the definition of fecal incontinence, constipation, levator ani syndrome and proctalgia fugas. We revue some aspects of anatomy and physiology of the anorectum. We introduce all anorectal functional tests, the place of the tests in diagnostic algorithm, and the real value of each single test to conform diagnosis of common syndromes.

Endosonography for assessment of anorectal changes in patients with fecal incontinence.

Our aim was to evaluate the anorectal changes in patients with fecal incontinence by using different endoultrasound techniques. Eighteen females with fecal incontinence and 14 healthy controls (females) were examined. Rigid linear transducer and 10 MHz radial scanning miniprobe were used. Statistically significant difference was found in the mean percentage of decreasing of the anorectal angle during contraction between healthy subjects (21.4%) and incontinent patients (7.5%). The mean percentage of shortening of the puborectal muscle length during squeezing was significantly lower in patients (9.6%) than in controls (17.9%). By means of miniprobe the anal sphincter defects were clearly demonstrated. Endosonography with a radial scanning miniprobe and rigid linear transducer ensures complex morphological and functional assessment of the anorectal region.

[Continence of anorectal sphincter complex in the early postoperative period after direct colo-anal anastomoses with colo-colic J pouch]. / Kontinentnost na anorektalniia sfinkteren kompleks v ranniia sledoperativen period sled direktni koloanalni anastomozi i koloanalni anastomozi s kolokolichen J pouch.

UNLABELLED: According to up-to-date concepts for local spread of a rectal cancer it is possible to perform a radical rectal resection with a restorative anastomosis inspite of the fact that the tumor is located in the middle or the distal third of the rectum. Usually a total resection of the rectum and coloanal anstomosis have to be performed. There are two ways to restore the continuity of the gut: a straight coloanal anstomosis or J pouch anastomosis. 22 patients with rectal cancer localized between 4 and 9 cm from the anal verge, were operated and restorative anastomoses were performed. The first 18 patients were with a straight coloanal anastomosis. In the last 4 cases coloanal anastomoses were done between the anus and colocolic 7 cm J pouch. During the first month there were 6 patients with total and 9 with partial incontinence in the group with straight coloanal anastomosis. Transrectal sonography confirmed contractility of the puborectal muscle and sphinctermanometry showed lower resting tone and squeeze pressure in cases with incotinence. No incontinence was observed in the group with J pouch and the shinctermanometry data were the same as these of healthy controls. CONCLUSION: The rectal ampula has reservoir function and its loss after total resection of the rectum is the reason for frequent bowel movements, urgency and leakage. Reconstruction with a colonic J pouch is associated with better bowel function compared to the straight coloanal anastomosis.

[The proarrhythmogenic activity of non-anti-arrhythmia drugs. Is treatment with antihistamines and cisapride safe?]. / Proaritmogenna aktivnost na neantiaritmichni medikamenti. Bezopasno li e lechenieto s antikhistamini i s tsizaprid?

The non-antiarrhythmic drugs, which possess antiarrhythmic properties could induce dangerous, potentially fatal arrhythmias--extrasystoles, ventricular tachycardia, sudden cardiac arrest. The arrhythmogenic properties are due to block of the potassium channels of the cells and are realized by prolongation of the QT interval on ECG. Accelerating mechanisms are the bradycardia and the hypokalemia. Such drugs are the H1 blockers--astemisol (hismanal) and terfenadine, the prokinetic cisaprid (prepulsid, propulsid, coordinax) and the macrolides. These preparations should be carefully prescribed and not combined with each other, as well as, with antiarrhythmics and blockers of the cytochrome oxidase system (antifungal antibiotics, metronidazole, cyprofloxacin, antidepressants). During their use the patients have to be followed up for changes in QT, bradycardia, arrhythmia, hypokalemia.

[Endocavitary echography following abdominoperineal extirpation of the rectum]. / Endokavitarna ekhografiia sled abdomino-perinealana ekstirpatsiia na rektuma.

Transrectal echography using a high-frequency transducer is a well established method for preoperative rectal carcinoma assessment, and for postoperative follow-up of patients with anterior resection for rectal carcinoma. Having in mind the impossibility for follow-up study of patients with abdominal perineal extirpation of the rectum by transrectal echography, a new pattern of application of the transducer employed for endorectal examination is suggested. In five patients (4 women and 1 man) endocavitary echography through the anal canal is done. In women the examination is supplemented by transvaginal echography. A local recurrence in the course, of transvaginal study is recorded in one patient. The technique of examination and the superiorities of the procedure are discussed.

[The place of echography in the clinical diagnosis of hepatic hemangioma]. / Miastoto na ekhografiiata v klinichnata diagnosa na chernodrobniia khemangiom.

On the basis of 104 hemangiomas diagnosed in 81 patients an ultrasound classification of the disease is made which includes four basic variants. Echotomography detects the tumor most successfully in group I (well outlined homogenous hyperechogenisity) while in the other groups it shows a low percentage of correct diagnoses. The average sensitivity of the method is 60.6%. The possibilities of the other basic diagnostic methods are discussed and a scheme for clinical investigation is proposed. Scintigraphy is of no substantial help, computed tomography increases the percentage of the correct diagnoses, angiography and correctly indicated laparoscopy most often end the clinical investigation. The patients with hemangioma are subjected to a prolonged clinical follow up and ultrasound tomography is the best suitable method for this.

[Laparoscopy and laparoscopic echography in the diagnosis and staging of gastrointestinal carcinomas]. / Laparoskopiia i laparoskopska ekhografiia v diagnostikata i stadiiraneto na gastrointestinalnite kartsinomi.

The clinical relevance of laparoscopy (LS) and laparoscopic echography (LSEG) in diagnosing and staging gastrointestinal carcinomas is assayed in the light of diagnostic methods in current use. The study covers 257 patients undergoing LS, and 23-LSEG. For the purpose a rigid 7.5 MHz echolaparoscopic probe is used. In 16 per cent of the cases LS fails to resolve the basic diagnostic problems faced, whereas in 35 per cent it alters completely the preliminary clinical diagnosis. In over 90 per cent of cases LSEG supplements or modifies the laparoscopic diagnosis. Emphasis is laid on the role played by LSEG in defining the loco-regional stage of gastric and colorectal carcinomas, as well as on the contribution of the method to establish pancreatic carcinomas not lending themselves to resection. What is more, LSEG demonstrates inoperable cases by detecting small, unsuspected metastases, not prominating above the hepatic surface.

[Endoluminal echography in rectal cancer--preoperative staging and postoperative control]. / Endolumenna exografiia pri rak na rektuma -- predoperativno stadiirane i sledoperativen kontrol.

The aim of this study is to determine the diagnostic potential of endoluminal echography and the pitfalls sources in the preoperative staging and postoperative follow-up in patients with rectal cancer. 245 patients with rectal carcinoma are evaluated during 10 years period (Jan. 1993-Jan. 2002 years). 96 patients are monitored in the early and late postoperative periods for the early detection of local recurrence as well as for the anorectal physiology assessment after low anterior rectal resection or coloanal anastomosis. Lineal transducer UST-657-5MHz (Aloka 620) and 10MHz miniprobe are applied. The accuracy for T-staging is 84% and for N-staging is 82%. The local recurrence is detected in 21 patients, on average 12.6 months after curative surgery. The local recurrence is more often in cases of lymph node involvement as well as if some specific echographic features for extramural vascular invasion are present. Endoluminal echography provides individual therapeutic management and postoperative control in patients with rectal cancer.

[Polyposis of the colon and cancer]. / Polipoza na debeloto chervo i rak.

Polyposis of the colon is a colon cancer predisposition syndrome. Familial adenomatous polyposis (FAP) accounts for 1% of the cases of inherited colorectal cancer (CRC). The National Register of inherited CRC and polyposis of the intestines keeps track of 18 patients from 14 families with FAP. Eight of them have been operated of CRC, on 6 patients preventive colectomy with ileorectal anastomosis has been done and four patients refused surgery. Colectomy has been done due to the malignant development also on a female patient with difused juvenile polyposis with adenomatosis. Of three patients under surveillance with the Peutz-Jeghers syndrome, surgery has been done on one female patient with ileus and bleeding large polyps.