Update on Endoscopy-Based Imaging Techniques in the Diagnosis of Esophageal Cancer.

The early diagnosis of esophageal cancer is necessary for improving the surviving of patients with this disease. To ensure an accurate staging, there are necessary imaging tests to establish the local and regional extension, as well as excluding the metastases. Computed tomography (CT), endoscopic ultrasonography (EUS), and positron emission computed tomography (PET-CT) constitute standard methods for esophageal cancer staging. These techniques are complementary; using only one of these tests is not suitable for correct staging. The role of EUS has improved the doctors' ability to evaluate and select the patients to undergo surgery, radiotherapy, or chemotherapy.

Advanced Endoscopic Imaging Techniques for the Study of Colonic Mucosa in Patients with Inflammatory Bowel Disease.

BACKGROUND: Crohn's disease and ulcerative colitis are inflammatory bowel diseases (IBD) associated with colorectal cancer risk in long-standing diseases. In order to assess the colonic mucosa and to discover dysplastic or neoplastic lesions, advanced endoscopic techniques are needed. Such techniques are detailed in this review: chromoendoscopy, autofluorescence imaging (AFI), narrow band imaging (NBI), i-SCAN, Fujinon Intelligent Color Enhancement (FICE) and confocal laser endomicroscopy (CLE). AIM: The aim of the review is to describe and establish the clinical impact of advanced endoscopic techniques, that could be used in IBD patients'examination in order to assess mucosal healing, microscopic inflammation, dysplasia or neoplasia. MATERIALS AND METHODS: A literature research about new endoscopic approaches of patients with IBD was made. RESULTS: A lot of studies have been performed to reveal which imaging technique might be used for IBD surveillance. Regarding dysplasia or neoplasia detection and mucosal healing or inflammation assessment, CE proved to be superior to white light endoscopy (WLE), while NBI and AFI did not show an encouraging result. I-SCAN did not improve the colonoscopy quality while FICE has been used in a few studies. CLE could be used to characterize a lesion, providing the same results as conventional histology. CONCLUSION: At the moment, CE is the only technique which has been included in guidelines for IBD surveillance. CLE can be used to assess any lesion detected with WLE during surveillance, while the other imaging techniques require.more studies to determine their efficacy or inefficacy.

Real Time Elastography Assessment of Fibrosis In Chronic Viral Hepatitis.

Fibrosis assessment is a necessary component of liver disease evaluation not only for prognosis but also for future therapeutic management. Our study objective was to evaluate the accuracy of quantitative assessment of liver fibrosis in patients with chronic viral hepatitis B or C, relying on RTSE results, a method approved and acknowledged in Europe. MATERIAL AND METHODS: Sixty-three consecutive patients diagnosed with chronic viral hepatitis B or C between January 2014 and December 2014 at the Emergency County Hospital of Craiova were enrolled in the study. Patients underwent both TE and RTSE. RESULTS: The reference method used for staging liver fibrosis was TE, based on its recognition and validation by the European guidelines. Fibrosis was classified as follows: 17.47% of patients were staged as F0, 11.11% of patients staged as F1, 14.28% as F2, 17.47% as F3, and 39.68% as F4. Correlation coefficients between measurements for each parameter was done with ANOVA test, in order to identify any differences, according to the fibrosis stage. Valuable information was obtained suggesting that MEAN, SD, %AREA, COMP, Skewness, IDM and Contrast had highly significant differences when related to the Fibrosis Stage (FS) (p<0,001) and ASM had significant differences (p<0,05). As for Kurtosis, ENT and Correlation parameters no significant differences with the FS was found. CONCLUSIONS: Imaging methods of assessing liver fibrosis are of special interest in chronic liver fibrosis assessment. RTSE comes as a potential new technology based on elastogram evaluation which may prove to be more efficient along with larger prospective studies.

A pilot study of real time elastography in the differentiation of focal liver lesions.

INTRODUCTION: Real time-sonoelastography (RTE) is a new developed technique that reveals the physical properties of the tissue by characterizing the difference in hardness between diseased tissue and surrounding tissue. Elasticity measurements have been already reported to be useful for the diagnosis and differentiation of many tumors: breast lesions, prostate cancer, lymph nodes and pancreatic masses but there are only few studies for the focal liver lesions. The aim of the study was to analyze whether computer enhanced dynamic analysis of elastography images is able to better characterize and differentiate benign and malignant liver lesions. MATERIAL AND METHODS: The study group included, in total thirty nine liver tumors. RTE was performed by EUS or transabdominal ultrasound. ROC analysis for the mean hue obtained through histogram analysis of the region of interest (liver lesion) after averaging individual pixels over a 10-second elastography movies was used to assess the color information inside the region of interest and to consequently differentiate benign and malignant liver lesions. Based on a cutoff of 170 for the mean hue histogram values recorded on the region of interest, the sensitivity, specificity, and accuracy of differentiation of benign and malignant masses were 92.5%, 88.8%, and 88.6%, respectively. The positive and negative predictive values were 86.7% and 92.3%, respectively. In conclusion, real time sonoelastography is a promising technique that might improve the characterization and differentiation between benign and malignant focal liver lesions visualized during transabdominal or endoscopic ultrasound.

The role of endoscopic examination accompanied by histological examination on biopsy samples in the diagnosis of gastric carcinoma.

INTRODUCTION: Endoscopic evaluation is one of the most important explorations in the diagnosis of gastric cancer, increasing its value by adding biopsy sampling and histopathologic examination, especially in early forms of gastric malignant proliferations. The aim of this study was to evaluate some descriptive parameters of macroscopic and microscopic aspects of gastric carcinomas defined with the help of endoscopic investigation and gastric biopsies sampled during endoscopic examination, and their correlation with patient survival. MATERIALS AND METHODS: The study was performed on a group of 119 patients diagnosed with gastric carcinoma. The study material was represented by: tissue fragments obtained by endoscopic biopsy, clinical observation charts, histopathologic diagnosis records, ledgers for records of endoscopic investigation, and endoscopic images recorded for each patient. Biopsies were taken preferentially from areas with the highest risk of malignancy. Tumor fragments were subjected to conventional histological processing techniques (fixation and inclusion in paraffin) and then were stained with HIM. The study included two chapters: the imagistic study and the pathologic study. The parameters assessed were: the site of the lesion within the stomach, the endoscope macroscopic appearance, the microscopic appearance of the endoscope biopsy sample, and the survival, followed up until 48 months. RESULTS: The most frequently observed macroscopic aspect was the fungating one, in more than two thirds of all cases, followed by the infiltrating one, but all with a poor survival - about 25-30% at 24 months. The most frequent location was the antro-pyloric region, with the highest survival rate of 25% at 24 months, followed by the gastric corpus and the lesser curvature. Most of the tumors were restricted to a single segment of the stomach. The most frequent microscopic aspect was the tubular one (75% of all cases) with its poorly differentiated variant (39 of the 91 cases). The 24 months survival was under 50% for all morphological types of carcinoma, with the lowest ones in the tubular and mucinous types (around 25%). The secretory pattern was identified on biopsy samples stained with HE in only 15% of the cases, and did not influence the survival of the patients. CONCLUSIONS: The combined histologic and endoscopic morphologic investigation allowed the shaping of an accurate morphologic and prognostic preoperative profile in gastric carcinomas.

Videocapsule endoscopy and single balloon enteroscopy: novel diagnostic techniques in small bowel pathology.

Videocapsule endoscopic (VCE) exploration represents a major breakthrough in non-invasive imagistic, especially of the small bowel. Our study group consisted of 29 initial subjects admitted in the 1st Internal Medicine and Gastroenterology Clinic at the Emergency County Hospital of Craiova between June 2008 and March 2009. We have excluded a number of eight subjects from the VCE-group, as their pathology represented an absolute contraindication for capsule ingestion. The remaining 21 patients (11 men - 52.38% vs. 10 women - 47.61%) underwent videocapsule diagnostic investigation followed by single balloon enteroscopy with biopsy or surgical removal, where case. Large resection cups were histologically prepared in the Pathology Department of the Emergency County Hospital of Craiova. We performed a statistical analysis of the data using Fisher's Exact Test, which is applicable to small numbered lots. In five cases (23.80%) VCE investigation did not reveal any abnormalities. Five (23.80%) cases had non-tumoral pathology, all of them being inflammatory lesions. We found tumoral lesions in 11 (52.38%) cases: five (23.80%) benign and six (28.57%) malign. We found that inflammatory lesions predominantly affected subjects in the 15-30 and 30-45 years intervals (p=0.00103), whereas tumoral lesions are positively correlated with old age, predominantly affecting the 45-60 and above 60-year-old groups (p=0.00216). VCE combined with SBE open new frontiers for small bowel exploration. Histology remains the single most accurate test for establishing the nature of a lesion.

Crohn disease or intestinal fistulising tuberculosis? Diagnosis difficulties in a case treated with infliximab and corticosteroids.

UNLABELLED: Crohn disease represents an idiopathic inflammatory bowel disorder with possibility of local and extra intestinal complications. Infliximab therapy is one of major therapeutic alternatives but this treatment may by followed by several possible infections, especially the reactivation of a latent tuberculosis. We present a case of a 28-year-old patient who was admitted in our hospital with clinical signs of bowel obstruction. Colonoscopy revealed close stenosis al the level of splenic flexure. Surgery was soon performed for the imminence of occlusion and pathology has revealed chronic inflammatory infiltrate with lymphocytes and plasma cells, interpreted as Crohn disease complicated with stenosis. A treatment with prednisone 30 mg/day, ciprofloxacin 1000 mg/day administrated intermittently and sulphasalasine 3 g/day for one year was indicated but the patient develop external abdominal fistula. Infliximab therapy 5 mg/kg/dose was administered at two weeks interval, with initial good results after two doses. At two weeks after the second dose, the patient has presented fever and weight loss; abdominal CT-scan has revealed inflammatory adherences of right flexure of the colon with external fistula, resolved by surgery. The evolution was later complicated by right tibio-tarsian involvement, which imposed orthopedic intervention. Pathology has revealed bone tuberculosis and antibacillary therapy was initiated with good results. CONCLUSIONS: Bone tuberculosis may represent a rare evolutive modality at a patient with Crohn disease treated by Infliximab and corticoids. Infliximab therapy in a patient with immunosuppressant (previous corticotherapy, splenectomy) may activate a latent center of tuberculosis. Ciprofloxacin therapy may explain insidious modality of evolution by minor antibacillary effect.

Endoscopic papillectomy into the treatment of neoplastic lesions of vater papilla.

UNLABELLED: Adenomas of the duodenal papilla are rare. The frequency of malignant adenomas is 15-30%. Villous adenoma is a premalignant lesion with the highest rate of transformation. Options for surgical treatment include endoscopic and ablation resection, transduodenal ampullectomy, duodeno-pancreatectomy. AIM: Evaluation of the efficacy and safety of endoscopic papillectomy for ampullary adenomas. MATERIAL AND METHOD: 12 patients were selected (F:M, 5:7, age range 37 - 68 years) with ampullary adenoma, treated by endoscopic papillectomy. Biliary sphincterotomy was performed in 6 cases; and pancreatic sphincterotomy was performed in 3 cases. Biliary stenting was performed in 2 cases; pancreatic stent was placed in 11 cases. RESULTS: En bloc resection was performed in 8 cases, and piecemeal resection in 4 cases. Complete resection R0 was noted in 10 cases. Pathology examination has show: tubulo-villous adenoma (5 patients); villous adenoma (4 patients), tubular adenoma (2 cases), adenocarcinoma (one case). Complications were immediate: bleeding (2 cases) and pancreatitis (1 case). Follow-up endoscopy reveals no ductal stenosis or recurrence. CONCLUSION: Endoscopic papillectomy is a safe and well-tolerated alternative to surgical treatment of ampullary adenoma.

Acute esophageal necrosis associated with alcoholic hepatitis: is it black or is it white?

Acute esophageal necrosis is an uncommon condition diagnosed during endoscopy from the black appearance of the esophagus. We report three cases of acute esophageal necrosis, associated with severe alcoholic hepatitis. The pathogenesis was multifactorial in our patients, with gastroesophageal reflux combined with hypoperfusion probably being the key factor for the esophageal lesions. The patients presented a continuum of endoscopic appearances, ranging from the characteristic black esophageal mucosa with ulcerations to a thick white exudate that peeled away (pseudomembranes). However, esophageal biopsy specimens from all three patients had the same histological pattern of severe inflammation and necrosis. Thus, the possibility of acute esophageal necrosis should also be considered in patients with extensive necrosis covered by a white exudate, but without the characteristic pattern of a "black esophagus"; and the diagnosis should subsequently be confirmed by mucosal biopsies. Our report showed that ethanol-induced acute esophageal necrosis can appear in patients with a high alcohol intake, especially in immunosupressed patients with alcoholic hepatitis.

Endoscopical and histological features in bile reflux gastritis.

Bile reflux gastritis is due to an excessive reflux of duodenal contents into the stomach. The increased enterogastric reflux may provide the basis for increased mucosal injury. Bile reflux gastritis can appear in two circumstances: gastric resection with ablation of pylorus and primary biliary reflux due to the failure of pylorus. The aim of the study was to evaluate the endoscopical and histological changes caused by duodenal reflux on the gastric mucosa. The mucosal features were correlated with the risk factors involved in the development of bile reflux gastritis. Our study included 230 patients with alkaline reflux gastritis admitted in Medical Clinic no. 1, Emergency County Hospital Craiova. In all cases we performed an upper gastrointestinal endoscopy. Multiple biopsies were taken from gastric mucosa in 89 patients and the histological features were scored in accordance with the Sydney system. The average age of the patients with bile reflux gastritis was 58.387 years and the incidence of alkaline reflux gastritis was higher between 51 and 80 years. Reflux gastritis was noted to 138 males lpar;60%rpar; and 92 females (40%), ratio males/females was 1.5/1. The most frequent risk factors for bile reflux gastritis were gastric and biliary surgery. Alkaline reflux gastritis was observed in 167 cases (72.6%) after gastric surgery, consisting in gastric resection, pyloroplasty and gastroenteric-anastomosis. Gastroduodenal reflux after biliary surgery was noted in 17 cases (7.39%), 13 cases (5.69%) with cholecystectomy and four cases (1.73%) with biliary anastomosis. The average time interval from original operation to the discovery of the alkaline reflux gastritis was 14.91 years after gastric surgery and 15.29 years after biliary surgery. The commonest endoscopic alterations were: erythema of the gastric mucosa in 139 cases (64.43%), the presence of bile into the stomach in 133 cases (57.83%), the thicken of gastric folds in 22 cases (9.55%), erosions in 12 cases (5.22%), gastric atrophy in 12 cases (5.22%), petechiaes in five cases (2.17%), intestinal metaplasia one case (0.43%) and gastric polyp one case (0.43%). The histologic alterations observed from tissues collected during endoscopic examination were: chronic inflammation in 75 cases (84.06%), foveolar hyperplasia in 36 cases (40.44%), intestinal metaplasia in 31 cases (34.83%), acute inflammation in 16 cases (16.08%), Helicobacter pylori infection in 16 cases (16.08%), chronic atrophic gastritis in 12 cases (13.46%), gastric polyps in 12 cases (13.46%), dysplasia in 10 cases (11.23%), benign ulcerations in seven cases (3.04%), edema in six cases (6.74%) and neoplasia two cases (2.24%). Conclusions. Bile reflux gastritis was more frequent to male gender. The most frequent risk factors for alkaline reflux gastritis were gastric and biliary surgery. Reflux gastritis after gastric resection, pyloroplasty and gastroenteric-anastomosis were more frequent to male gender, while cholecystectomy and biliary anastomosis were predominantly to female gender. The average time interval from original operation to the discovery of the bile reflux gastritis was similar after gastric and biliary surgery. The commonest endoscopic alterations were: erythema of the gastric mucosa, the presence of bile into the stomach, thickens of gastric folds, erosions, gastric atrophy, petechiaes, intestinal metaplasia and gastric polyp. Acute inflammation, Helicobacter pylori infection, gastric polyps and benign ulcerations were more frequent in patients with bile reflux gastritis after gastric surgery, while edema and dysplasia were increased after biliary surgery.

The follow-up of the efficacy of antiviral therapy at patients with chronic hepatitis C.

Hepatitis C virus infection can cause progressive liver injury and lead to fibrosis and eventually cirrhosis. Peginterferon alfa-2a represents a significant advance in the treatment of patients with chronic hepatitis C. The aim of the study was to investigate the efficacy, safety and tolerability of the therapy with Peginterferon alfa-2a plus Ribavirin in patients with chronic hepatitis C. The study was made on a number of 37 patients with chronic hepatitis C, admitted in Medical Clinic no. 1, Emergency County Hospital Craiova. The diagnosis of chronic hepatitis was established by means of clinical, biological and morphological investigations. Patients received 180 mug subcutaneously of Pegasys, once weekly, along with either 1000 or 1200 mg/day of Copegus, depending on their weight, for 48 weeks, with 24 weeks of treatment -- free follow-up. We evaluated: sustained virological response, histological response and adverse events. All patients were monitored using blood tests, control of viremia and liver functional tests. Analysis viral response revealed that 11 patients (29.72%) achieved sustained virological response. Histological response was obtained in 20 cases (54.05%) with chronic hepatitis C. The adverse events for Pegasys and Copegus combination therapy were reported in 21 cases (56.72%). Antiviral therapy had positive effect on subjective symptoms in almost half of patients included in our study. An improvement of liver functional tests was noted in the most cases. A third of patients who received Peginterferon alfa-2a plus Ribavirin had sustained virological response. Histological response was noted both at patients with sustained virological response and with unsustained virological response. The side effects of the antiviral treatment are frequent and the severe ones, which require dose reduction, are present at a low number of patients.

[A rare cause of upper digestive tract bleeding--pancreatic papillary adenocarcinoma]. / Hemoragie digestiva superioara de cauza rara--adenocarcinom papilifer pancreatic.

Authors present a rare case of upper digestive bleeding, the etiology of which is represented by a pancreatic papillary adenocarcinoma placed in the body and tail of the pancreas, with bleeding through the Oddi's sphincter, which causes difficult problems of medical and surgical diagnosis and treatment. The patient was known with acute cholecysto-pancreatitis of lithiasic cause, which has been surgically cured in 1977, being under treatment in the last years for the pancreatic injury which had been chronic pancreatitis and for hyperglycemia. The laboratory explorations emphasized a severe anaemia which was identified through upper digestive endoscopy (intermittent active bleeding from the major papilla) confirmed by echo and CT exam (heterogeneously body tissue of 10/8 cm diameter, involving the body and the tail of the pancreas). The medical treatment was complex, including proteic, hematologic, acido-basic, balance of hyperglycemia, and was followed by the surgical intervention consisting in body and tail pancreatico-splenectomy, followed by a postsurgical abscess, which required drainage. The surgical evolution was favorable. 6 months after leaving the hospital, the patient was admitted to medical diseases clinic with the diagnosis of deep right ileofemoral thrombophlebitis, duodenal acute ulcer and acute pneumonia of average right lobe, causing difficult problems of medical treatment. On this pathologic background, the diabetic failure also appears and the echo exam showing multiple secondary hepatic and peritoneal metastatic determinations. In medical literature we only met 13 similar communications, problems of diagnosis and treatment being very much alike to those presented.