Proliferating cell nuclear antigen (PCNA) as a prognostic factor for colorectal cancer.

PCNA (proliferating cell nuclear antigen) is a cell cycle related protein that is maximally elevated in late G1 and S-phase of proliferating cells. 114 biopsy specimens of colorectal cancer were immunolabeled with PC 10 which specifically recognizes PCNA; Dukes' staging and histological grading were estimated for each case. All patients were followed-up for at least 60 months or to death. All data were analysed by the computer program NCSS (Number Cruncher Statistical System). According to the results, PCNA-index may be considered an independent prognostic factor for colorectal cancer; it may also be helpful in supporting the therapeutic strategies based only on Dukes' stage.

Diagnosis and treatment of liver hydatid disease.

BACKGROUND/AIMS: Human echinococcosis is endemic in some areas of the world, including Mediterranean countries. The liver is the most frequent seat of echinococcosis, involved in about 70% of cases. Because there is still no effective medical therapy, surgery remains the treatment of choice. METHODOLOGY: Twenty-seven patients operated on for liver hydatid disease between 1990 and 1995 were analyzed and compared with results obtained from a study undertaken at our clinic between 1960 and 1988. RESULTS: The diagnosis was established by typical case history, clinical features and laboratory tests, of which imaging methods proved most informative. Radical procedures (total pericystectomy and liver resection) seem to be too aggressive for treatment. Marsupialization and drainage were mostly abandoned, because of high morbidity rates. CONCLUSIONS: Among surgical procedures used at our clinic, evacuation of the cyst with partial excision of the pericyst and omentoplasty resulted in the lowest morbidity and, thereupon, the shortest post-operative hospital stay and the best clinical results.

Duodenal obstruction from chronic pancreatitis.

The fibrosclerosing process of the pancreas in the chronic pancreatitis may constrict not only the pancreatic duct but also the bile duct, splenoportal venous system and duodenum. In our retrospective study we analysed 24 patients with duodenal obstruction associated with chronic pancreatitis. Duodenal obstruction was suspected whenever repeated vomiting occurred or large volumes of nasogastric aspirate were obtained. The diagnosis was confirmed by barium meal and endoscopic examination. Duodenal obstruction was relieved by gastrojejunostomy in eight patients, gastrojejunostomy and vagotomy in eight patients, gastroduodenostomy and vagotomy in two patients, vagotomy with Finney pyloroplasty in one patient, duodenoplasty with vagotomy in one patient and Whipple procedure in four patients. We concluded that vagotomy and gastroenterostomy are the procedures of choice. Bypass surgery is helpful to relieve the obstruction of the common bile duct and pancreatic duct. Whipple procedure should be reserved for the small duct form of chronic pancreatitis and for the cases in which there is high suspicion of malignancy.

Congenital choledochal cysts in adults--comparative study.

Congenital choledochal cysts are rare anomalies of the biliary tree and their presentation in adults is infrequent. They are more common in Asia. Females are more commonly affected. Surgery remains the treatment of choice. Nine patients were operated for congenital choledochal cysts in the last fifteen years, i.e. from 1988 to 2002. The diagnosis was established by case history, clinical features and laboratory tests. The imaging methods proved to be the most informative among them. Classification of the choledochal cysts was based on modified Todani classification. All patients have undergone cyst excision with Roux-en-Y hepaticojejunostomy. The complications, like recurrent cholangitis or pancreatitis, were avoided.

Lansoprazole versus omeprazole in the treatment of reflux esophagitis.

To evaluate the therapeutic potential of the newly developed proton pump inhibitor lansoprazole in patients with reflux esophagitis (grade I and II according to Savary Müller criteria), the authors performed a single blind, randomized clinical trial comparing 20 mg omeprazole and 30 mg lansoprazole, involving 60 patients at two clinical hospitals. The treatment period was or 8 weeks, and main efficacy variables were healing of endoscopic changes and relief of reflux symptoms. No significant difference in terms of healing and relief of reflux symptoms was found either after 4 or after 8 weeks of treatment. In conclusion, 30 mg lansoprazole daily was found to be safe and effective therapy comparable to omeprazole in the short-term treatment for reflux esophagitis (grade I and II).

[Biliary calculosis--new possibilities of treatment]. / Bilijarna kalkuloza--nove mogucnosti lijecenja.

The gallstone prevalence rate in Croatia is in the range of 10 to 20 per cent and for the population above age 65 years is around 30 per cent. Human gallstones are classified into two categories, i.e. cholesterol stones and pigment stones. Cholesterol stones account for 70-80% of gallstones. They are formed due to the bile supersaturation with cholesterol and later nucleation of cholesterol vesicles and crystal formation. Pigment stones of black type account for 20-25% of gallstones. They are formed as a result of chronic hemolysis. Surgery is still a method of choice in treatment of majority of patients with gallstones. It is a low-risk therapy with high success rate that can be used regardless the size, number, composition and localisation of gallstones. Cholesterol stones can be dissolved by direct instillation of methyl tert-butyl ether (MTBE therapy), fragmented by extracorporeal shockwaves (ESWL) and dissolved using bile salts chenodeoxycholic acid and ursodeoxycholic acid. The problems with these treatment modalities is high recurrence rate and limitation described for each method. Choledocholithiasis can be treated surgically, by endoscopic sphincterotomy combined with stone extraction and by extraction via T-tract. The decision on the best treatment modality in gallstone patients should be made only after careful evaluation of all relevant facts (type of stone, number and size of stones, localisation of stones, patient's age and general condition) taking into consideration the team experience. It is imperative not to use the treatment method with possible complication that cannot be dealt with in the institution performing the treatment.

[Therapeutic dilemmas in children with esophageal achalasia]. / Terapijske dileme u djece s ahalazijom jednjaka.

Two patients with oesophageal achalasia are presented. The first patient, a 22-month-old girl, had medical, endoscopic and surgical treatment. The effectiveness of drug therapy with nifedipine was good but short in duration. Endoscopic bougienage dilatation has not been definitely successful. Operative treatment, two years after the first symptoms, permanently resolved the problem of spastic lower oesophageal sphincter. The second girl, 13.5 years old, responded very well to nifedipine therapy during hospitalisation. Because of inadequate drug usage, oesophageal myotomy was performed relatively soon. In follow-up both girls were in good health condition. The treatment of oesophageal achalasia in children is still controversial. Therapeutic approach and decision on the treatment strategy depend primarily on patient's age, duration and severity of clinical signs and symptoms Etiology, pathogenesis, and possibilities of achalasia treatment are discussed.

[Nodular lymphoid hyperplasia of the colon and terminal ileum. Case report]. / Nodularna limfoidna hiperplazija kolona i terminalnog ileuma. (Prikaz bolesnika).

A patient admitted to our hospital because of diarrhea and hematochesia is presented. These complaints appeared eight months before, and were not accompanied by other disturbances. All hematological, biochemical and microbiological findings were normal, but endoscopic, x-ray and histologic examination of the gastrointestinal tract showed nodular lymphoid hyperplasia of the colon and terminal ileum. Since an immunological derangement was not verified, this seems to be a rare benign disorder as a response to repeated antigenic stimuli. In our patient these were recurrent parasitoses. The treatment is not needed, but due to the possibility of late onset hypogammaglobulinemia. Long-term patient follow up is required.

[Adenocarcinoma of the colon in a 14-year-old boy]. / Adenokarcinom debelog crijeva u 14-godisnjeg djecaka.

We report the case of a 14-year-old boy with adenocarcinoma of the colon. The diagnosis was established 3 months following the initial symptoms. The tumor was located in the region of the descending colon and was of Dukes B stage. The patient underwent left hemicoloctomy followed by chemotherapy and irradiation. In the follow-up period of two years the patient has been well. It is concluded that early diagnosis, adequate monitoring of patients by the determination of carcinoembryonic antigen and regular follow-up visits could lead to better prognosis.

[Familial adenomatous colonic polyposis]. / Obiteljska adenomatozna polipoza crijeva.

We described two patients (brother and sister) with familial adenomatous polyposis of the colon. It is an inherited disease with autosomal dominant pattern of inheritance. The incidence is 1:8.000, with usual onset of polyps development late in the first decade of life or during adolescence, and malignant alteration up to the fourth decade of life. APC gene located on long arm of chromosome 5 is responsible for occurrence of the disease that presents with onset of multiple adenomatous polyps in the colon (from some of them to 1000). The treatment includes chemoprevention by sulindac or aspirin that prevents or reverse process of carcinogenesis. Surgical approach is preventive colectomy up to 20 (25) years of life. APC gene mutation (deletion at codon 1309-1311) was proven by DNA analysis from blood and polyp in both patients. There was no evidence of mutations of genes p53 and K-ras. Preventive colectomy is planned as soon as possible.

[Ultrasound image of an echinococcus daughter cyst in the gallbladder]. / Sonographisches Bild einer Echinokokkus-Tochterzyste in der Gallenblase.

By the case presented, which is a clear example of a daughter cyst of an echinococcus in the gall bladder lumen, we have extended our knowledge of the possibility of ultrasound for demonstration of abdominal pathology. Besides the well-known sonographic picture of the liver echinococcus, we now know that we are in certain cases in a position to represent also the echinococcus daughter cyst in the biliary tree. Characteristic is its annular pattern. In cases like this one, we give ultrasound preference over the ERCP and CT.

Biochemical parameters in the early differentiation of the etiology of acute pancreatitis.

OBJECTIVES: We undertook a retrospective study to define the usefulness of various biochemical parameters in differentiation between alcoholic and nonalcoholic acute pancreatitis. METHODS: One hundred sixty-seven patients were divided into groups A (alcoholic pancreatitis) and NA (nonalcoholic pancreatitis). Group NA was further subdivided into groups B (biliary pancreatitis) and NANB (nonalcoholic, nonbiliary pancreatitis). The values of serum and urine amylase, serum lipase, AST, ALT, alkaline phosphatase, gamma glutamyl transferase, bilirubin, lipase/amylase ratio, and erythrocyte mean corpuscular volume were investigated. RESULTS: Serum amylase, ALT, AST, alkaline phosphatase (p < 0.001), and urine amylase (p < 0.01) were significantly lower in patients with alcoholic pancreatitis. Erythrocyte mean corpuscular volume and lipase/amylase ratio were significantly higher in patients with alcoholic pancreatitis (p < 0.001). There were no differences in lipase, bilirubin, and gamma glutamyl transferase between patients with alcoholic pancreatitis and those with nonalcoholic pancreatitis. Multivariate analysis showed that a combination of three variables (lipase/amylase ratio, erythrocyte mean corpuscular volume, and alkaline phosphatase) differentiated between alcoholic and nonalcoholic pancreatitis. CONCLUSIONS: Various biochemical parameters used together and with other clinical features can help in the early differentiation between alcoholic and nonalcoholic acute pancreatitis.

[Transhiatal esophagectomy for carcinoma of the esophagus--our ten years experience]. / 10-Jahres-Ergebnisse nach transhiataler Osophagektomie bei Osophaguskarzinomen.

During the past 10 years, at University Surgical Clinic Rijeka, 107 patients underwent operation for carcinoma of the esophagus and cardia. Transhiatal esophagectomy was performed in 29 patients; in 28 of them an esophagogastrostomy was performed, and in one patient a pharingogastrostomy. Of the 29 patients, there were 24 men (82.8 %) and 5 women (17.2 %), with an average age of 60.7 years. Histologically, 26 lesions (89.7 %) were squamous cell carcinomas, and 3 (10.3 %) were adenocarcinomas. According to the prognostic stage as defined by the UICC, 15 patients (51.7 %) were stage II A, and 14 (48.3 %) stage III. The lesion was located in the cervical esophagus in two, the thoracic esophagus in thirteen and the lower esophagus in fourteen patients. Six patients died, for a hospital mortality rate of 20.7 %; the most common cause of death was respiratory failure. Pulmonary complications occurred in 14 patients (48.3 %). Anastomotic leak with all clinical manifestations occurred in one patient, while in two patients the radiological diagnosis of anastomotic leakage was made without clinical manifestations. Five patients (17.2 %) developed anastomotic stenosis, which was satisfactory treated by endoscopic dilatation. Mean survival after surgery was 21 months. One-year survival was 65.5 %, two and three-year survival was 37.9 and 17.2 % respectively. Younger patients and patients with lower stage of disease survived significantly longer (p < 0.05).

Primary bile acid malabsorption. Histologic and immunologic study in three patients.

Three patients are presented with a history of chronic watery diarrhea due to bile acid malabsorption, proved by the tauro-23[75Se]selena-25 homocholic acid test and an unequivocal response to cholestyramine therapy. Fecal fat tests, Schilling tests, and barium studies of the small intestine and colon were all normal. Jejunal biopsies were normal but multiple biopsies of the terminal ileum, performed by retrograde ileoscopy, showed uniform crypt hyperplastic villous atrophy and features of colonic metaplasia with increased mononuclear infiltration of the lamina propria. All 3 patients demonstrated evidence of abnormal immune function, including the presence of serum autoantibodies, circulating immune complexes, and hypocomplementemia. One patient had Sjögren's syndrome. This disorder, which might be immunologically mediated, should be called primary bile acid malabsorption and should be distinguished from other ileal disorders.

Acute gastrointestinal bleeding due to Meckel's diverticulum heterotopic gastric mucosa.

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract occurring in approximately 2% of the population. In our retrospective study, we analyzed 58 surgical specimens of Meckel's diverticulum operated on in our hospital. Heterotopic gastric mucosa was found in ten. Aim of this study was to establish the aetiopathogenesis of inflammation and consequent haemorrhage in Meckel's diverticulum with heterotopic gastric mucosa. Some studies showed that Helicobacter-like bacteria could play an important role in determining local phlogosis in heterotopic gastric mucosa of Meckel's diverticulum, however, none were found in our biopsy specimens. Analyzing patients with acute intestinal haemorrhage (4 out of 10 with heterotopic gastric mucosa) in Meckel's diverticulum a history of previous oral administration of NSAID's was positive in 3 of them. Although in the recent literature there were few case reports on the use of NSAID's and bleeding from Meckel's diverticulum, our results suggest that even short-term use, in small quantities, of NSAID's can play an important role in determining acute bleeding from Meckel's diverticulum with heterotopic gastric mucosa.