Factors affecting colonoscopy comfort and compliance: a questionnaire based multicenter study.

AIMS: Colonoscopy screening reduces colorectal cancer-related mortality and incidence. However, many patients are reluctant to undergo colonoscopy or return for follow-up because of the investigation's cumbersome and unpleasant nature. We aimed to identify patient-related factors significantly influencing comfort and quality of colonoscopy analyzing responses to a self-administered validated questionnaire. METHODS: Patients undergoing colonoscopy under sedation in two high-volume endoscopy units were invited to answer a short prevalidated questionnaire regarding preprocedure anxiety, satisfaction with information provided, most worrisome aspect of the procedure and knowledge of the benefits of colonoscopy. Self-reported comfort during colonoscopy as graded on a 10 point visual analog scale was the main variable considered. Univariate analysis identified factors possibly associated with a higher degree of comfort during colonoscopy that were then tested through multivariate logistical regression. RESULTS: 452 questionnaires were returned. Most patients reported an acceptable degree of discomfort during colonoscopy but 70.2% of the respondents considered the information provided prior to the procedure to be insufficient. On multivariate analysis older age, higher degree of satisfaction with information provided (p = 0.04), lower preprocedure anxiety levels (p < 0.01) and endoscopy center (p < 0.01) were shown to correlate with increased comfort during colonoscopy. Education level, previous colonoscopy, gender and bowel prep quality did not influence patient comfort. CONCLUSIONS: Patient comfort during colonoscopy is dependent on satisfaction with the information provided before the procedure. Higher availability of the physician and better interaction with the patient might decrease patient perceived burden of colonoscopy and lead to higher return rates in the screening and surveillance setting.

Novel predictors of intrapulmonary vascular dilatations in cirrhosis: extending the role of pulse oximetry and echocardiography.

BACKGROUND AND STUDY AIMS: Intrapulmonary vascular dilatations (IPVDs) are a criterion for the diagnosis of hepatopulmonary syndrome in patients with liver cirrhosis. We aimed to show that IPVDs are more common than suspected in a heterogenous cirrhotic population and to identify new diagnostic parameters. PATIENTS AND METHODS: Forty-three consecutive patients with cirrhosis admitted to our Gastroenterology department were included in this prospective study. History, physical examination, ECG and, when warranted, pulmonary function tests and chest radiograph were used to exclude patients with significant cardiac or pulmonary disease. Contrast enhanced transthoracic echocardiography (CEE) was used to determine the presence of IPVDs. Pulse oximetry readings were taken in the supine and standing positions. RESULTS: We found 12 patients with IPVDs. Statistical analysis proved the correlation between IPVDs and systolic pulmonary artery pressure (sPAP) (p= .049), right ventricle wall width (RVW) (p = .013) and E/A ratio (p = .034) but not left atrial or ventricular diameter. Orthodeoxia was also present more frequently in patients with positive CEE. The difference between supine and standing oxygen saturation (changeSat) proved a fair diagnostic test for detecting IPVDs, with an area under the receiver operated curve (AUROC) of 0.823. CONCLUSIONS: Our study shows that RVW, sPAP, E/A and orthodeoxia determined by pulse oximetry are valuable novel predictors of IPVDs, encouraging the routine use of pulse oximetry and echocardiography in cirrhotic patients.

Technical performance of colonoscopy -- multicenter study in university and non-university centers of Romania.

UNLABELLED: The aim of the paper was to evaluate the national availability of colonoscopy and the quality parameters of this procedure in our country. MATERIAL AND METHOD: During a 6 months period (01.07- 31.12.2009), we performed a prospective multicenter study in which 76 centers were invited to respond to a questionnaire regarding colonoscopy, 39 centers agreeing to participate. We assessed: the number of colonoscopies, the number of total colonoscopies and the causes of incomplete colonoscopies. RESULTS: During the study period, 16,083 colonoscopies were performed, 12,294 (76.4%) of them total colonoscopies. In 1,191 cases, stenosis was the cause of incomplete colonoscopy. If we consider this an objective reason for an incomplete colonoscopy, there were 12,294 total colonoscopies (82.4%). Comparing university centers with non-university ones, the proportion of total colonoscopies was 10,400/12,475 (83.4%) vs. 1,894/2,417 (78.4%) (p less then 0.0001). However, comparing the present study with previous ones, performed in 2003 and 2007, the proportion of total colonoscopies increased from 70.5% to 76.9% and 82.4% respectively (2003 vs. 2007 p less then 0.0001; 2007 vs. 2009 p less then 0.0001), while the quality difference between university and non-university hospitals persisted. CONCLUSIONS: the quality of colonoscopy in Romania increased in the last 5 years, while the quality difference between university and non-university hospitals persisted.

Efficacy, safety and tolerability of vidofludimus in patients with inflammatory bowel disease: the ENTRANCE study.

BACKGROUND: Vidofludimus (SC12267) is a novel oral immunomodulator inhibiting dihydroorotate dehydrogenase (DHODH) and the expression of proinflammatory cytokines including interleukin-17 (IL17A and IL17F) and interferon-gamma. The objective of the study was to explore the efficacy, safety and tolerability of vidofludimus in steroid-dependent inflammatory bowel disease (IBD). METHODS: The open label uncontrolled ENTRANCE study (ClinicalTrials.gov NCT00820365) has been conducted at 13 study centers in Germany, Bulgaria and Romania. Thirty-four steroid-dependent patients with a confirmed diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were treated with a once daily 35mg oral dose of vidofludimus over 12weeks. Steroids were tapered during the first 8weeks followed by a steroid-free treatment period of 4weeks. Complete response was defined as steroid-free clinical remission at week 12; partial response was defined as being in remission at steroid dose equal or lower than the individual patient's threshold dose for relapse. RESULTS: Of the thirty-four patients enrolled in this trial 26 were evaluable for primary efficacy assessment. After completion of the 12weeks treatment phase 8 out of 14 (57.1%) patients with CD and 6 out of 12 (50.0%) patients with UC were in steroid-free remission (complete responders). Another 4 (28.6%) patients in CD and 5 (41.7%) patients in UC were partial responders. Vidofludimus was well tolerated, no drug-related serious adverse events were observed. CONCLUSIONS: This trial provides first evidence of clinical efficacy of vidofludimus in IBD. Although the safety and tolerability profile seems favorable, long-term controlled studies are needed to further investigate its potential as novel IBD therapy.

Endoscopy: possibilities and limitations in the management of GIST of the upper GI tract.

Gastrointestinal stromal tumors (GISTs) have been a topic of increasing interest since the discovery of their cellular activation pathway via the receptor for tyrosine kinase (KIT) leading to the possibility of targeted molecular therapy in the form of imatinib mesylate. Endoscopic diagnostic and therapeutic possibilities have also been developing at a rapid pace in recent years. Endoscopic ultrasonography (EUS) allows for an accurate assessment of submucosal tumors and can provide tissue samples for diagnostic purposes using fine needle aspiration techniques. Several newer endoscopic techniques, including contrast enhanced EUS and endoscopic submucosal dissection, have also proven useful in the management of GISTs. Although the many recent studies have focused on the role of endoscopy in diagnosing and treating GISTs, we still need better evidence in order to formulate accurate guidelines.

The influence of Helicobacter pylori presence on the immunophenotype of inflammatory infiltrate in gastric diseases.

The first medical hypothesis about the possible relationship between chronic inflammatory response and carcinogenesis belongs to Virchow and it was published in 1893. In these days, multiple studies demonstrate the certain involvement of chronic inflammation as trigger of progression towards malignancy. The fact that in 1994, the International Agency for Research on Cancer considered Helicobacter pylori as first class carcinogenic agent, is postulating the existence of the pathogenical chain carcinogenesis, of chronic inflammatory lesions as it was described by Correa, as a first step. Our study including 75 patients who underwent surgical procedures for gastric lesions uses immunohistochemical studies for lymphocytes phenotyping, to identify the nature of inflammatory cells involved, correlating the results with the presence of Helicobacter pylori. We tried to bring new information needed for establish to what extent the chronic inflammation of gastric mucosa is a response to the presence of bacteria and is implicated in tumorigenesis. We used T cells antibodies: CD3, CD4, CD5, CD8, CD57, GranzymeB and B cells antibodies: Cd20 and CD23. Our results revealed the presence of immune cellular response to Helicobacter pylori in gastric mucosa, based on T helper, cytotoxic and NK cells. B cells have a minor role in this response. CD4+ cells seem to be involved in local protection response as well as in carcinogenesis, while CD8+ have a minor or no role in carcinogenesis.

Polypectomy practices in a real life setting. Do we do enough for our patients? A review of 1061 colonoscopies.

UNLABELLED: Endoscopic removal of colon polyps is the main tool in colorectal cancer prevention programs. Although several quality indicators and guidelines have been proposed, polypectomy practices are still subject to great variation among endoscopist and little data is available regarding polypectomy practices in real life settings. METHODS: The records of the 1061 screening colonoscopies performed in 2010 in a tertiary care teaching hospital in Bucharest were reviewed and all colonoscopies where at least one polyp was detected were selected for analysis. The number of detected polyps, the resection rate and method used for polypectomy were studied and compared to colonoscopy quality indicators previously reported in literature. RESULTS: 941 polyps were detected in 395 patients. Invasive colorectal cancer was found in 42 patients. 548 polyps (58.23%) were removed endoscopically, with at least one polyp being resected in 283 patients (71.5%), resulting in a polypectomy rate of 26.67% in the entire study population. Cold forceps resection was the most commonly used method for the resection of polyps less than 5 mm in size, while for larger polyps hot snare was the preferred method. Concomitant invasive carcinoma and a larger number of polyps were predictive of incomplete removal of all detected polyps. CONCLUSION: Most quality indicators were met in our study group, with suboptimal performance regarding histological documentation of detected polyps and establishing a polyp-free colon.

Regression of precancerous epithelial alteration in patients with Helicobacter pylori chronic gastritis.

As a Group 1 carcinogen for gastric cancer, Helicobacter pylori (H. pylori) was involved in many studies and researches focused on physiopathology and morphopathologic changes induced by this bacterium. The study included 3069 gastric endoscopies performed between January 2005 and December 2009 in "Colentina" Clinical Hospital. During upper endoscopy biopsies from antro-pyloric and corporeo-fundic region were collected. Histopathologic diagnosis of these biopsies was made using Sydney criteria. The patients were divided in two groups, based on the presence or absence of H. pylori: group A included 1414 H. pylori positive patients and group B included 1653 H. pylori negative patients. We evaluated several histopathological parameters, correlating the degree of inflammation, atrophy, metaplasia, regenerative hyperplasia and dysplasia with the presence of H. pylori infection. Our study identifies an overall tendency towards regression of premalignant lesions of gastric epithelium (regenerative epithelial hyperplasia, atrophy and intestinal metaplasia) after H. pylori eradication, as well an increasing number of patients diagnosed with early gastric cancer, thus consolidating the results of studies who foretell the significant decrease of gastric cancer mortality. These lesions are present years before becoming clinically manifest, and consequently treatable. In respect of carcinogenic mechanisms, some of our results confirm the carcinogenic cascade triggered by the H. pylori infection, as it was proposed by Correa et al. in 1975. However, we obtained data leading to the idea that the "precursor lesions" could appear (and subsequently histopathologically evaluated) independent one to the other, through other steps then Correa's model.

E-cadherin and beta-catenin expression in gastric neoplastic and non-neoplastic lesions--correlations with H. pylori infection.

Gastric cancer is one of the most aggressive malignancies, as incidence and as evolution as well. Although, due to the new findings about etiology, carcinogenesis, precancerous conditions and their detection, as well as the treatment, in the latest decade, there is an improvement in these data, gastric cancer remains a redoubtable enemy because of its incidence, prevalence and mortality. Researches are focusing on early detection of precursor lesions and on establishing their reversibility potential by bringing more clinical and statistical information and by setting new clinical hypotheses. In this context, the present article is trying to study immunohistochemical expression of two oncogenic markers, the cell adhesion protein antibodies E-cadherin and beta-catenin. Cell to cell and cell to extracellular matrix interactions are crucial for neoplastic transformation and for metastasizing process. The importance of these antibodies in maintaining cell adhesion suggests that their abnormal expression is playing an important role in tumorigenesis. In this article, authors are presenting a study about E-cadherin and beta-catenin expression in 75 patients who underwent gastrectomy for suspicions of gastric malignancies. The variables of the study are the presence or absence of Helicobacter pylori, type I carcinogenetic agent for gastric carcinoma (especially intestinal type adenocarcinoma) and the presence of tumoral or non-tumoral gastric lesions.

Helicobacter pylori: pathological mechanism involved in gastric colonization.

Since 1982, when Marshall and Warren highlighted the presence of H. pylori at the apical pole of the epithelial gastric cells, the medical literature has registered a cascade of subsequent researches concerning this amazing bacterium, its action on the human body and the body response. The apogee of these studies and conclusions about the pathogenic role of HP was touched with its certain recognition as class one carcinogenic agent (Peura 1997, WHO), becoming the first bacteria with such an action. The data gathered in the last period identify different virulence factors of HP, but fail to fully explain the relatively low incidence of gastric cancer in HP carriers; therefore, it is now considered that the carcinogenic potential related to HP infection in humans is due to the synergic and complementary association of the bacterial genetic equipment with diet and host response.

Malignancy and overdiagnosis of malignancy in Peutz Jeghers polyposis.

Peutz Jeghers (PJ) polyps are rare hamartomatous tumors of the gastrointestinal tract frequently associated with skin and mucosal pigmentation. Despite their benign nature there is a certain increased risk of progression to malignancy in some cases, justifying a sustained follow-up of the patients. We present 3 cases of Peutz Jeghers syndrome (PJS) diagnosed in our hospital on gastrointestinal specimens obtained by endoscopy and opened surgery. We analyzed different degrees of dysplastic changes, epithelial intussusception, association with other types of polypoid lesions and other various aspects possibly related with disease progression. Clinico-pathological correlations were made. Two of these cases were related (mother and daughter); both of them were operated in another hospital for small bowel tumors with a subsequent diagnosis of adenocarcinoma. The daughter (28 years old) was referred to our hospital for endoscopic follow-up; a small polyp of the transverse large bowel was excised by colonoscopy with a histopathologic diagnosis of PJ polyp; a careful histopathologic reevaluation of both specimens of enterectomy (slides and paraffin blocks) revealed an overdiagnosis of cancer due to the epithelial cystic dilatation and pseudoinvasion in both patients. The other case showed diagnostic changes of PJS and also various aspects of adenomatous polyps some of them with mild and moderate dysplastic changes. When a PJ polyp is diagnosed, the possibility of pseudoinvasion should be kept in mind, in order to avoid overdiagnosis of malignancy; also, due to the fact that the malignant transformation of a PJ polyp is still on debate (hamartoma-dysplasia-carcinoma sequence versus malignant transformation of an adenomatous aria of a hamartoma versus coincidental association of a digestive cancer due to genetic aberrations of PJS), all the other associated microscopic aspects of the lesion should be carefully analyzed.

The immunopathogenesis of viral hepatitis.

The outcome of the HBV and HCV infections is influenced by the status of the immune system. Both of the viruses are believed not to be directly cythopathic, and the host immune response is responsible for the viral clearance and cellular injury. An energic response of the natural immunity allows the control of the virus. Rapid development of specific neutralizing antibodies is essential for the clearance of VHB. The chronic phase of the disease is often associated with abnormal and weak T-cell response and viral persistence. The pathogenesis of the HCV infection is not yet completely understood. HCV persists in patients without any apparent evidence of immune deficits depending on virus or host-related factors. The recent studies revealed that both cellular and humoral immunity appear to be active, despite the progression of the disease.

The treatment of chronic hepatitis B.

The diagnosis of chronic hepatitis does not necessarily imply a treatment. This statement is endorsed by the fact that many forms of the disease are non-evolving or very slow evolving, and therefore development of cirrhosis or hepatocarcinoma is extremely unlikely in these minimal and mild forms of the disease. Furthermore, drugs used today occasionally lead to virus annihilation and, in any case, do not operate upon virus integration into the hepatocyte genome. However, at present there is a consensus regarding the opportunity of therapeutical intervention in chronic hepatitis B with major biological and histological signs of activity, although there remain two important issues to approach. The first one is the relatively low efficacy of therapy referred to the cost (i.e. a maximum of 40% of cases with long-lasting therapeutic response to interferon), while the second is the presence of various side effects, which can force the reducing of dosage or even the discontinuation of treatment. Antiviral therapies, which were using acyclovir, didanosine, zidovudine and vidarabine, have demonstrated their inefficiency. Therefore, two groups are still used nowadays: interferon and nucleosides analogues. Each of the medication enounced has defined dosages, treatment extent, indications and contraindications, side effects and therapy expectancies. Proper management in chronic hepatitis B can achieve the following end-points: obtaining HBeAg-to-anti-HBe seroconversion, prevention of the disease progression and quality-of-life improvement. The treatment of chronic hepatitis B is an ever-changing issue and our expectation for better results grows proportionally with the knowledge brought everyday by new research and clinical experience.

Interferon prophylaxis of hepatic carcinoma.

The present article reveals the importance of hepatic carcinoma among the other diseases in digestive oncology, and also the importance of a correct designation of these cases. Epidemiology and actual hypothesis on the mechanisms of oncogenesis are discussed. There are reviewed some studies in the literature concerning infection with hepatitis B virus, hepatitis C virus, coinfection (B and C viruses, B and D viruses), the role of interferon prophylaxis in such cases. Also there is present a statistics on chronic viral hepatits, cirrhosis of viral etiology and hepatic carcinoma, diagnosed in patients in "N.Gh.Lupu" Hospital, over two decades.

Gastro-intestinal lesions induced by non-steroidal anti-inflammatory drugs.

Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with serious and sometimes fatal side effects as gastrointestinal ulcers, bleeding and less frequently kidney and liver damage. These side effects are caused primarily by the reduction of prostaglandin synthesis, which in turn deprives the stomach's self-protection mechanism. NSAIDs prevent prostaglandin formation by inhibiting the enzyme cyclooxygenase. Recent research has shown that there are two types of cyclooxygenase, one that produces the form of prostaglandin involved in the gastric protection and the other that produces the form of prostaglandin involved in inflammation. Current NSAIDs inhibit both forms of cyclooxygenase. Gastrointestinal lesions associated with NSAIDs are predominantly observed in the stomach and are defined under the term of "NSAID gastropathy". Intestinal lesions secondary to the ingestion of NSAIDs were only recently described. Rectocolic lesions induced by NSAID are frequent and severe. The noxious effect of NSAID on preexisting low pathologies can be differentiated from "de novo" induced acute and chronic lesions.

Treatment with alpha-interferon in chronic hepatitis.

The treatment of chronic viral hepatitis with Interferon has been introduced in clinical practice over the past decade an represents an important step in the management of those diseases. The data existing in literature are conflicting about the dose and period of treatment with Interferon, many treatment schedules being proposed. There are also a lot of markers used or proposed to be used to determine the response to treatment, their predicting efficacy being largely studied. The response to alpha-Interferon in a standard 6 month regimen in chronic hepatitis B, chronic hepatitis C and chronic hepatitis B and C is studied; alanine-aminotransferase (ALAT) and aspartate-aminotransferase (ASAT) are the markers used to determine the response to treatment.

Duodenal ulcer and infection with Helicobacter pylori.

The incidence of gastritis with Helicobacter pylori (HP) was studied in 225 patients with active duodenal ulcer diagnosed endoscopically. The infection was diagnosed by the urease test and in some cases by histopathological examination. Infection with Helicobacter pylori was detected in 55% of the patients, a proportion much smaller than the one generally reported in the literature, a rather surprising fact for our sanitary conditions. This might mean that in our country unlike the west-European countries other pathogenetic factors could be more important than HP.

New data in the management of digestive steroses.

The report is a review of the perendoscopic methods of treatment of stenoses at the level of the digestive tract and of the excretion canals of the annex glands. After a short description of the methods as well as of the necessary equipment, the authors discuss the indications according to the etiology of stenoses. The indications and contraindications are enumerated and an estimation is made of the therapeutic efficiency of the endoscopic methods as compared with the classical surgical methods. Emphasis is laid on the therapeutic advantages of the endoscopic palliative methods as an alternative to the surgical methods.

Nonsurgical treatment of biliary lithiasis.

The paper is a review of the clinical experience acquired during the last 15 years in the treatment of biliary lithiasis with cholecyst or choledochal localization using methods which were expected to exclude surgery. After a short presentation of lithogenesis a brief description is made of chemical litholysis, endoscopic treatment and extracorporeal shock wave lithotripsy (ESWL). The indications, techniques of treatment results, risks and accidents are also presented with an estimation on the financial efficiency of the new procedures.