ESPEN Guidelines on Enteral Nutrition: Pancreas.

The two major forms of inflammatory pancreatic diseases, acute and chronic pancreatitis, require different approaches in nutritional management, which are presented in the present guideline. This clinical practice guideline gives evidence-based recommendations for the use of ONS and TF in these patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. In mild acute pancreatitis enteral nutrition (EN) has no positive impact on the course of disease and is only recommended in patients who cannot consume normal food after 5-7 days. In severe necrotising pancreatitis EN is indicated and should be supplemented by parenteral nutrition if needed. In the majority of patients continuous TF with peptide-based formulae is possible. The jejunal route is recommended if gastric feeding is not tolerated. In chronic pancreatitis more than 80% of patients can be treated adequately with normal food supplemented by pancreatic enzymes. 10-15% of all patients require nutritional supplements, and in approximately 5% tube feeding is indicated.

Visceral metastases of melanoma-single institution experience an analysis of 15 cases.

Authors analysed 15 cases with visceral metastasis of melanoma. In eight cases the primary was unknown but in seven cases the data about primary was known. From 15 patients 10 were male and 5 female. All metastases were in abdominal cavity (liver-3, abdominal lymph nodes-4. stomach-2, bowel-4, omentum-1, spleen-1, oesophagus-1, adrenal-2 cases. In one case metastatic deposit was in brain and in one case i the vertebral body. In 6 cases visceral metastases were in more than one location.

[Aspiration biopsy, puncture and neurolysis of coeliac plexus with guided linear endoscopic ultrasonography--personal experience].

Endoscopic ultrasonography, as relatively new diagnostic procedure, has made a significant progress in detection and presentation of small lesions of digestive tract, as well as in other organs. By introducing linear ultrasonography in clinical practice, the possibilities of this procedure became even more apparent, anabling even more precise diagnosis and various therapeutic procedures. With endoscopic ultrasound (EUS) guided aspiration biopsy it is possible to obtain samples in specific, well defined layer of gastrointestinal tract wall, and also from different parts of other organs and formations, which finaly enables establishing definite patohystologic diagnosis. First linear EUS procedure in this part of south-east Europe, was performed in University Clinical Center "Bezanijska Kosa" (N. Milinic, M. Petrovic) in 1999, and first EUS guided aspiration biopsy was performed on July 4th 2000 (N. Milinic--biopsy of pancreas). Using "Pentax" FG-36UX linear echo-endoscope, until now, 40 pancreas biopsies, 34 stomach biopsies, 9 biopsies of mediastinal lymph nodes, cysts and tumors, 22 biopsies of masses in retroperitoneal region, 7 biopsies of papilla Vateri, 4 biopsies of left suprarenal gland, 2 punctures of renal cysts, 14 biopsies of focal liver lesions, 2 punctures of liver cysts, and 5 neurolyses of coeliac plexus was performed. From 134 EUS guided biopsy samples, 114 was, according to pathologist, adequate for patohystologic evaluation, and in 96 cases obtained samples was essential for obtaining definite diagnosis. The major problem in this issue was a lack of well trained and expirienced cytologist, as also is the current problem in Western countires with more expirience and practice in this field. EUS guided aspiration biopsy, as the procedure itself, was successful in all cases. There were no major complications during the procedures, mainly because of using Colour-Doppler technique in defferentiating vascular from other structures. Results so far are showing that linear endoscopic ultrasonography is extremely precise diagnostic method, and should be used in establishing definite diagnosis in many well defined indications, and also is showing the consecutive need for specialy trained and expirienced citologists.

[Endoscopic ultrasonography (EUS) in preoperative localization of neuroendocrine tumors (NET) of the pancreas].

BACKGROUND: Preoperative localization of pancreatic neuroendocrine tumours (NET) is usually very difficult. Noninvasive, imaging tests, such as abdominal ultrasound, CT or MRI are not sensitive enough as well as selective angiography. The aim of the study was to clarify the usefulness of the EUS in preoperative localization of the pancreatic NET. METHODS: From September 1998 March 2005, EUS was performed in 1600 patients. Among them, in 10 (0.7%), this examination was carried out due to previous biochemical tests, which diagnosed the pancreatic NET. We studied the location, the size and echo-pattern of the neoplasm. The results were compared with operation and histology or EUS- FNA guided pancreatic biopsy in 9/10 patients. All EUS examinations were performed using Olympus GIF-130 videoecho-endoscope with 7,5 /12MHz switchable radial probe. RESULTS: EUS correctly localized the pancreatic NET in 7/8 cases, (sensitivity:87.5%). In 2 patients, EUS accurately exclouded pancreatic NET. There were no false positive findings (specificity 100%). Six tumours were benign (75%), and two were malign (25%). We localized 6 insulinomas and single pancreatic carcinoid tumour. The median tumour size detected by EUS was 21mm. CONCLUSION: EUS is highly accurate in preoperative localization of the pancreatic NET-s and We confirmed it in our study. EUS presents the method of choice for preoperative localization of the pancreatic NET.

[Personal experience in embolization of liver hemangiomas]. / Nase iskustvo u embolizaciji hemangioma jetre.

INTRODUCTION: Cavernous haemangioma is the most often found benign liver tumour. Its size usually does not change, although there are cases in which it grows. Large haemangiomas can cause hepatomegaly, pain in the right subcostal area, and spontaneous ruptures. By modern diagnostic procedures they are detected more often and therefore gained more diagnostic importance. Cavernous haemangiomas, especially giant ones, can be treated surgically (enucleation or resection of a part of the liver), by embolization or by other procedures. The aim of the study was to determine the important role of embolization in the treatment of symptomatic haemangiomas with risk of rupture. MATERIAL AND METHODS: Over a period of 5 years, at the Department of Gastroenterology and Hepatology, haemangioma was discovered in 35 of 178 patients with focal liver lesions. Eighteen (51%) patients were males and 17 (49%) females. In 21 (60%) patients, the size of the tumour was 2-4 cm, in 10 (29%) 5-10 cm, and in 4 more than 10 cm. Ultrasonography, computerized tomography, celiacography, scintigraphy with blood pool and ultrasound guided liver biopsy were used to diagnose haemangiomas. Polyvinyl-alcohol (Ivalon) was used for embolization. Through femoral catheter truncus coeliacus was reached, a. hepatica was catheterized, contrast was injected, and then microembolization of peripheral branches was performed. In 10 patients, because of the size of haemangioma, symptoms or localization, and a high risk of bleeding, embolization was performed. Biochumoral parameters were analyzed on the first, the second and the seventh day after the intervention. Within the period of five years, control ultrasound examinations were performed in all patients, and results were compared. In 9 patients control liver scintigraphy with blood pool was carried out. RESULTS: Embolization was performed with polyvinyl-alcohol. During angiography which followed, avascular zones were seen. There was no statistically significant difference between biochumoral parameters before and after embolization. Five years after the embolization, a reduced size of haemangioma was found in 8 patients. The echosonographic appearance of the tumour was changed in almost all patients. All clinical symptoms disappeared. There was no bleeding. In 8 of 9 patients liver scintigraphy with blood pool was performed, and there were no "warm fields." DISCUSSION: Due to modern diagnostic procedures, haemangiomas are now more often detected. However, ultrasonography is not always specific in discovering haemangiomas. Liver scintigraphy does not always reveal the typical shape of these tumours. Every procedure has its advantages and disadvantages. Once haemangioma is detected, it is the question how to treat it. Experience of most hepatologists suggests that interventions should be performed only in case of symptomatic haemangiomas, progressively growing haemangiomas, and in case of the high risk of bleeding. Embolization of the hepatic artery, previously used only as the first part of surgical procedures is now used as the only procedure in the treatment of these tumours. Some authors reported pain and fever after this intervention, which were also noticed in our patients. The reported agranulomatous arteritis with eosinophilic infiltration was not found in our patients. There were no significant changes in biochumoral analysis; this finding confirmed that there was no necrosis around embolized haemangioma. On the basis of the follow-up of our patients we came to the conclusion that embolization of haemangioma, performed by an experienced radiologist, is a very useful procedure in the therapy of symptomatic haemangiomas and haemangiomas with a high risk of bleeding.

[Leiomyoma of the esophagus. Case report]. / Leomiom jednjaka. Prikaz bolesnika.

Of all oesophageal tumours benign tumours account for less than 10%, of which 4% are leiomyomas. These tumours are most frequently asymptomatic, mostly localized in the lower oesophageal third. The most frequent symptoms, if any, are the following: dysphagia, unspecific retrostemal pain, heartburn, and occasionally, weight loss. Tumour enucleation is a therapy of choice in patients with oesophageal leiomyoma. In case of successful surgical removal, the prognosis is good and complains are practically eliminated. A male patient, aged 53, with paroxysmal tachycardia, in whom transhiatal enucleation was carried out in order to remove a large oesophageal leiomyoma after which cardiac complains were eliminated, is reported.

[Echohistograms of circumscribed liver lesions]. / Ehohistogrami cirkumskriptnih lezija jetre.

The term focal liver changes usually applies to benign and malignant primary and secondary tumours. However, according to echotomographic findings, tumour-like diseases, such as focal nodular hyperplasia and diseases caused by bacteria, fungi, protozoa and parasites may also be included. Improvement in echotomographic technique and use of echohistogram have recently enabled provision of data determining the aetiology, i.e. pathohistological structure of changes with computerized analysis. The study included 178 patients with circumscribed liver lesions: thirty patients had primary carcinoma, 39 had secondary carcinoma, 41 had cystic disease, 35 hemangioma, 10 focal steatosis, 23 had other circumscribed lesions, as well as 175 subjects with healthy liver. The examinations were performed using the real-time ulstrasound apparatus (Toshiba SA 100 A). Echohistograms were obtained by placing certain amount of liver tissue onto X and Y axes, to be processed and graphically presented by the apparatus. X axis showed the number of particles (N) of liver tissue on certain surface, while Y axis showed the average value (M) and maximal value (Max) of particles. Analysis of echohistographic parameters evidenced the following: mean distribution values of M, Max and N differed in different pathological conditions (Tables 1 and 2). Correlation analysis of the studied parameters revealed different values among the studied groups of patients (Table 3, Figure 1). Analysis of echohistograms and their parameters revealed differences between the tissues of the "healthy" and "affected" liver which may be significant in diagnosis of circumscribed liver changes. N/Max:N/M ratio was higher in normal liver when compared to the studied groups of patients (except for N/M subration in focal changes). Our study, as well as the studies performed by aforementioned authors, evidenced close correlation of the appearance of echohistograms and parameter ratio with density, homogenicity and greatly with vascularization of the studied tissue. It has also been evidenced that the interrelations between the echosistographic parameters are in a complexly interwoven, and partly in aetiology, or it is better to say in relations between the healthy tissue and pathological liver changes. However, it must be concluded that the series of the described cases is small to enable establishment of diagnostic criteria exclusively based on echohistograms. Similar analysis of echohistograms in circumscribed liver diseases was not evidenced in the referential literature published so far. We consider the method useful and believe that the future development of computerized ultrasound extensions will enable differentiation of lesions.