[Complications of endoscopic retrograde cholangiopancreatography and how to minimize them]. / Komplikácie endoskopickej retrográdnej cholangiopankreatikografie alebo ako ich znízit' na najmensiu moznú mieru.

Endoscopic retrograde cholangiopancreatography in the recent past was one ofthe basic diagnostic and therapeutic methods of several biliary and pancreatic diseases. It was and is still associated with several complications that can lead to exit the patient and is therefore considered invasive methods. The most serious complications include acute pancreatitis and acute cholangitis. Bleeding and perforation may complicate papillosphincterotomy that precedes another performance (extraction of stones, drainage of biliary and pancreatic duct. The incidence of serious complications have led to efforts to reduce the number of ERCP. This allowed in particular the introduction of new diagnostic methods, especially MRCP and EUS, which led to the practical exclusion of diagnostic ERCP. At present, ERCP is considered to be purely therapeutic method. In addition, considerable experience has been published to reduce the incidence of complications in ERCP. Many of them can be applied to our clinic, which has experience of more than 10 000 ERCP performed.

[Short bowel syndrome and limits of small intestinal resections]. / Short bowel syndróm a limity resekcnej chirurgie tenkého creva.

Short bowel syndrome (SBS) is a malabsorption syndrome resulting from anatomical or functional loss of a significantly long small intestinal segment. A loss over 80% of the small intestinal length is associated with increased urgency for supportive parenteral nutrition and results in reduced overall survival of the patients. The ileocaecal valve (valvula Bauhini) loss results in bacterial contamination of the small intestine, affecting tolerability of the oral, ev. enteral nutrition. The authors present a case review of a 27-year-old patient with repetitive small intestinal resections. The last procedure included the Bauhini valve and, finally, the patient has only 70 cm of the jejunum preserved.

The correlation of procalcitonin serum levels with the presence of biliary obstruction.

INTRODUCTION: There is still no general agreement as to which patients suffering from attacks of acute biliary pancreatitis should undergo emergent endoscopic retrograde cholangiopancreatography (ERCP) with subsequent endoscopic intervention (endoscopic papilotomy, stent placement etc.). Many authors have described large differences in Procalcitonin (PTC) serum levels in patients suffering from biliary pancreatitis as opposed to patients whose acute pancreatitis is based on toxic etiology. Therefore, we have investigated the correlation of Procalcitonin serum levels with the presence of biliary obstruction in patients undergoing ERCP examination. MATERIAL AND METHODS: From 1.8.2004 to 31.3.2005, 97 patients undergoing ERCP were enrolled into the study. Blood samples were taken from each patient just before their ERCP examinations, and PCT serum levels were subsequently correlated to ERCP findings. RESULTS: ERCP examinations were completed in 90 out of 97 patients. Bile ducts obstructions were confirmed in 61 out of 90 patients and the mean serum level of PTC was 0.078 ng/ml. In the remaining 29 patients ERCP revealed normal findings and the mean PCT value was 0.069 ng/ml. There was no statistical correlation between PCT serum levels and the presence of biliary obstruction on ERCP findings. CONCLUSION: The measurement of PCT serum levels is of no help in the identification of patients, who should undergo emergent ERCP due to acute biliary pancreatitis (Tab. 1, Fig. 1, Ref. 6).

The clinical value of the procalcitonin in prediction of severity and outcome in acute pancreatitis.

BACKGROUND/AIMS: Early identification of patients with severe forms of acute pancreatitis (AP) and subsequent management of these high risk patients are the most important aims in order to decrease mortality from AP. Procalcitonin (PCT) as a marker for systemic inflammation appears to be a useful marker for early identification of severe forms. METHODOLOGY: 101 patients with confirmed AP have been admitted to department of general surgery. PCT values were measured in each patient on admission and after 12 hours. PCT levels were correlated to the disease's course and prognosis. Results are given through PPV and NPV. Immunoluminometric assay (BRAHMS Diagnostica) was used for measurement. RESULTS: PPV and NPV for prediction of disease's course were better for PCT than for CRP PPV 64.7% versus 36% and NPV 82,6% versus 79.6% and for prediction of fatal outcome PCT reached 75% and 100% for cut off value 5 ng/ml. CONCLUSIONS: PCT seems to be a useful screening parameter for detecting severe AP and for identifying the patients who need ICU treatment, ATB covering and who can benefit from the novel therapies.

Report of first experience with endoscopic ultrasonography in Slovak Republic.

BACKGROUND: Endoscopic ultrasonography (EUS) is a method that takes the advantage of a combination of endoscopy and ultrasound, where a miniature probe that functions as a transducer (which functions as both a transmitter and a receiver of ultrasound), is incorporated in the tip of the endoscope. From the introduction, this modality has found it s uninterchangable place all over the world not only in the diagnosis, but also in the therapy of gastrointestinal diseases and the diseases of the surrounded structures and organs. Indications for EUS can be simply divided into three main categories: submucosal abnormalities, staging of tumors of the gastrointestinal tract and pancreatobiliary diseases. In December 2000 we began at the Clinic of Gastroenterology of Slovak Postgraduate Academy of Medicine at St. Cyril and Method s Hospital in Bratislava, Slovak Republic with the EUS evaluation with radial mechanical probe, as the first one in the Slovak Republic. In this article we describe our first experience with the EUS at our clinic. CONCLUSIONS: All together 64 patients were evaluated from December 2000 to the end of March 2001 from all over the Slovakia. In this article we describe in more detailed form the indications and also the findings in our group of patients.

[Endoscopic therapy of pancreatic pseudocysts]. / Endoskopická liecba pseudocýst pankreasu.

BACKGROUND: Pancreatic pseudocysts are a complication of both acute and chronic pancreatitis. Incidence in patients with acute pancreatitis is 2-50%, in patients with chronic pancreatitis 20-40%. Pseudocysts are a cause of many symptoms, e.g. nausea, vomitus, pain, biliary obstruction, bleeding and perforation. Successful treatment of pseudocysts is not only surgical and percutaneous, but also endoscopic. OBJECTIVES: The aim of this study was to answer the following questions. First, what is the clinical success rate of endoscopic drainage of pancreatic pseudocysts? Second, what are the complications? Finally, how often is endoscopic drainage a definite treatment? METHODS: The records of all patients (11) with chronic pancreatitis and endoscopic drainage of symptomatic pseudocysts hospitalized between December 1993 and April 1999 at our clinic were retrospectively studied. RESULTS: Patients (5) were followed for a mean duration of 30 months. Endoscopic drainage was definitive treatment in 80%, after transgastric drainage in 50%, after transpapillary drainage in 100% and after the use of more than one drainage procedure in 0%. The prognostic factors for longterm success of endoscopic drainage could not be evaluated, because of the small number of treated patients. CONCLUSIONS: Endoscopic treatment of pancreatic pseudocysts (endoscopic cystogastrostomy, cystoduodenostomy and transpapillary drainage) is nowadays highly effective method, technically feasible in most patients, with a relative degree of safety when performed by experienced endoscopist. (Tab. 2, Ref. 16.)

Review article: the clinical influence of Helicobacter pylori in effective acid suppression-implications for the treatment of gastro-oesophageal reflux disease.

The relationship between gastro-oesophageal reflux disease (GERD) and Helicobacter pylori is unclear. Recent data indicate that H. pylori probably exerts a protective effect against GERD. In recent years, the interaction between H. pylori, proton pump inhibitors and GERD has been widely studied. Currently available proton pump inhibitors produce significantly higher intragastric pH in H. pylori-positive patients than in those who are H. pylori negative, and this phenomenon may be clinically relevant. The mechanisms responsible for this difference in efficacy are not fully understood, although there are two major theories. Ammonia, produced by H. pylori, is able to neutralize gastric acid, and thus apparently increase the effect of acid suppressive agents (the 'ammonia theory'). The other theory is that decrease in acid output is due to the development of corpus gastritis during treatment with a proton pump inhibitor (the 'gastritis theory'). Treatment strategies to overcome this lowered sensitivity to acid suppression are to increase the frequency/dose of a proton pump inhibitor or to add an H2-receptor antagonist in the evening-but both have pharmaco-economic implications. An agent that could provide adequate pH control regardless of H. pylori status would be highly beneficial in the treatment of GERD, and may also lower treatment costs.

[Hepatorenal syndrome]. / Hepatorenálny syndróm.

BACKGROUND: The association of renal failure with terminal liver insufficiency is referred to as hepatorenal syndrome (HRS). It is characterized by impaired renal function together with abnormalities in arterial circulation and activity of endogenous vasoactive system. In the pathogenesis of HRS, vasodilatation in the splanchnic circulation plays a major role. This leads to underfilling in arterial circulation in this area with subsequent vasoconstriction in renal arteries leading to lower renal circulation and functional renal failure. One of the most difficult tasks in clinical evaluation of patients with cirrhosis is to diagnose renal functions, because the standard methods used in evaluation of glomerular filtration are not reliable. The most important agents in the treatment of patients with cirrhosis, ascites and HRS are identification, prevention of precipitating factors, correction and treatment of prerenal failure and acute tubular necrosis. Up to now, the only effective treatment of HRS is ortothopic liver transplantation, which cannot be applied in all patients. CONCLUSIONS: HRS is a serious complication of liver diseases with a very bad prognosis qouad vitam and qouad sanationem, which is only rarely reversible. After diagnosing HRS, the renal insufficiency is already mostly progressive, and patients have only a minimal chance to improve their renal functions. The only currently proved treatment modality, which is successful in terms of improving renal functions and long-term survival rate is liver transplantation. (Tab. 2, Fig. 1, Ref. 28.)

Pulmonary complications in patients with inflammatory bowel disease.

BACKGROUND/AIMS: Between 1996 and 1998 we investigated the occurrence of lung disorders in 82 patients with inflammatory bowel disease (30 patients with ulcerative colitis and 52 patients with Crohn's disease) and a control group of 60 subjects. The aim of our study was to determine the occurrence of pulmonary complications in patients with inflammatory bowel disease, to investigate whether ulcerative colitis or Crohn's disease are connected with a typical lung function disorder, with the inflammatory activity of the disease or if they depend on the presence of other extraintestinal manifestations. METHODOLOGY: We investigated the occurrence of lung disorders in terms of the following parameters: clinical pulmonary symptoms, chest radiography and pulmonary function tests (body plethysmography, pneumotachography, lung transfer capacity for carbon monoxide, and blood gas analysis). RESULTS: Lung function abnormalities were significantly more frequent in patients with inflammatory bowel disease as compared to controls (p<0.001). There was no apparent correlation between these abnormalities and either bowel disease activity or drug administration (sulphasalazine, mesalazine). CONCLUSIONS: Despite the lack of radiological abnormalities, we identified a high incidence of pulmonary function abnormalities (suspicious of interstitial lung disorder) in patients with inflammatory bowel disease; 56.7% of patients with ulcerative colitis and 57.7% of patients with Crohn's disease had reduced lung transfer factor.

[Treatment and prevention of gastrointestinal complications caused by non-steroidal antiphlogistic agents]. / Liecba a prevencia gastrointestinálnych komplikácií vyvolaných nesteroidovými antiflogistikami.

The aim of our study is to give a survey of the most efficient methods for treatment and prevention of non-steroidal anti-inflammatory drug (NSAID)-induced gastrointestinal adverse in cases when antiphlogistic treatment cannot be discontinued due to active and progressive joint disease. Analysis of published studies shows that, the proton pump inhibitors (omeprazole) are the most efficient agents in treatment of gastric and duodenal ulcers induced by NSAIDs. The analysis shows a reliable effect of prostaglandin analogues (misoprostol) as well. Prostaglandin analogues (misoprostol) proved the most effective in treatment of gastric erosions. Prophylaxis of adverse gastrointestinal mucosal abnormalities can be primary or secondary. Secondary prevention is intended for patients with gastrointestinal symptoms or those treated for mucosal defects (ulcer, erosions). The standard prevention using H2-antagonists or sucralphate does not provide sufficient protection against NSAID in these patients, but omeprazole reduces the chance of a peptic lesion relapse. Primary prevention is intended for patients with a higher risk of gastrointestinal complications (age above 60, history of peptic ulcer, a higher dose of NSAID, simultaneous treatment with glucocorticoids or anticoagulants). Diclofenac with misoprostol and nabumetone reduce the incidence of gastroduodenal ulcers and their complications in short-term as well long-term studies. Meloxicam reduces the incidence of gastroduodenal mucosal abnormalities is short-term studies. Nimesulide is associated with a lower incidence of adverse gastrointestinal events, but the fact is that, reliable data on gastroduodenal ulcer incidence reduction or their complications are not available.

[Endoscopic therapy of biliary tract diseases]. / Endoskopická liecba chorôb biliárneho traktu.

Endoscopy plays a dominant role in the diagnosis and treatment of biliary tract disease and disease of pancreas as well. The authors of the article present their own experience with the endoscopic treatment of these diseases which they have obtained since 1982 by performing endoscopic papilosphincterotomy in 2000 patients (1340 female and 660 male patients). The most common indication for this treatment was choledocholithiasis and benign stenosis of Vater's papila (or dysfunction of Oddi's sphincter). They succeeded in 97.9%, the worst results were in patients after the B II-resection of the stomach. The occurrence of complications was 3.4% in the entire group of patients, mortality was 0.5%. In the next part of the article the authors present other methods of treatment of choledocholithiasis and other diseases of biliary a pancreatic duct system (extraction of biliary stones, lithotripsy, biliary and pancreatic drainage). According to the literary data and own experience the endoscopic treatment of biliary diseases is highly effective and relatively safe when performed by experienced specialists. (Tab. 2, Ref. 16.)

[Is surgical treatment indicated in choledocholithiasis?]. / Je chirurgická liecba choledocholitiázy indikovaná?

Surgical exploration of the biliary pathways on account of relapsing or forgotten concrements in the biliary pathways in patients above 70 years with associated diseases has a high morbidity and mortality. The authors present an account of a group of patients from their departments; these patients with choledocholithiasis were treated by the at present ever more frequently used method--endoscopic sphincteropapillotomy. In the discussion the authors deal with possibilities to use EPS in the treatment of choledocholithiasis with a cholecyst in situ, acute pancreatitis with biliary genesis but also acute cholangoitis with the background of choledocholithiasis. They consider EPS the therapeutic method of choice in choledocholithiasis and report very good immediate as well as long-term results.

[The significance of nonsurgical bile duct drainage in patients with icterus]. / Význam neoperacnej drenáze zlcových ciest u ikterických pacientov.

Operation of the biliary pathways in patients with obstructive jaundice is still associated with a significant morbidity and high mortality, in particular in geriatric patients. Recently in the therapy of icteric patients percutaneous or endoscopic drainage of the biliary pathways was introduced. At the Surgical Clinic of the Hospital with Policlinic, Bezrucova in Bratislava in 1988 52 patients with obstructive jaundice were hospitalized. In patients with more than three risk factors the authors introduced preoperative drainage of the biliary pathways. In patients with malignant disease they describe preoperative percutaneous transhepatic drainage with subsequent enterobiliary anastomosis with an in-dwelling drain. Of 52 patients 9 died, i.e. 17.3%. Non-surgical drainage of the biliary pathways in icteric patients reduces the number of risk factors, eliminates the adverse effects of jaundice and improves the prognosis of the icteric patient.

[Modern therapeutic endoscopy of the pancreato-biliary region]. / Soucasnost terapeutické endoskopie pankreatobiliární oblasti.

Therapeutic endoscopy of the pancreatobiliary region has brought about a significant shift as regards therapeutic possibilities of choledocholithiasis, stenotio processes of the biliary pathways and some changes affecting the pancreatic duct. It made it possible to treat without surgery also those patients whose general health status rules out classical surgical treatment. In the CSSR in recent years in this area a considerable development was observed and practically all methods of therapeutic endoscopy are available in Czechoslovakia. The authors draw attention to the need to develop central endoscopic departments which alone, when properly staffed, can implement effective endoscopic treatment of pancreatobiliary diseases.

[Surgical and endoscopic papillosphincterotomy in surgery of the bile ducts]. / Chirurgische und endoskopische Papillosphinkterotomie in der Chirurgie der Gallenwege.

Surgical transduodenal papillosphincterotomy (TPS) on 119 patients was compared with endoscopic papillosphincterotomy (EPS) on 507 patients for rate of success and directly related complications. No major differences were found to exist between both approaches with regard to frequency or pathologico-anatomic nature of complications. Satisfactory experience has been obtained by the authors primarily from EPS on patients in advanced age or high-risk patients with choledocholithiasis following cholecystectomy (n = 320), benign and malignant stenosis of Vater's papilla (n = 97), and choledocholithiasis with gall-bladder in situ (n = 94). Intervention endoscopy of bile ducts is preferred primarily for patients in advanced age or for high-risk patients.

Endoscopic sclerotherapy of oesophageal varices.

The authors present their experience with the outcome of gastrofibroscopic sclerotherapy of oesophageal varices, performed in a total of 70 patients with portal hypertension. All patients were classified in classes B and C according to Child's criteria, and 68 of them had variceal bleeding before receiving sclerotherapy. Acute bleeding was successfully arrested in seven cases, and elective sclerotherapy in between bleeding episodes was carried out in 60 cases. To date, complete obliteration has been noted in 34 patients. An effect of previous sclerotherapy was observed during the next therapeutic session in 18, and eight patients died from progressive hepatic insufficiency. In the discussion section, the authors analyse current concepts on the technique of sclerotherapy related to complications, on instrumentarium and sclerosing solutions, and on the significance of prophylactic, acute and elective sclerotherapy, with the importance of endoscopic sclerotherapy of oesophageal varices perceived mainly in comparison with the results of surgery from the point of view of long-term patient survival.