Extrahepatic complications of chronic cholestasis: current diagnosis and treatment.

Pruritus, fatigue and osteoporosis are the main symptoms of the extra hepatic manifestations of chronic cholestasis that affect patients' quality of life. Pruritus affects more often female patients, varies as intensity during a day and for longer period of time, typically can be localized on the palms of hands and soles of feet or can be generalized. Pruritus can be treated with anions resines exchange--cholestiramine, the pregnanne X receptor agonist Rifampicine, Naltrexone. Liver transplantation can be considered if severe pruritus remains refractory to all medical treatments. Fatigue is the most disabling complain in chronic colestasis. No specific therapies are available for fatigue and liver transplantation doesn't improve it. Osteoporosis and the risk of fractures are more severe with the duration and severity of hepatic disease. For treatment are recommended regular physical exercise, vitamin D and Ca supplimentation and bisphosphonates (Alendronate 70 mg/week) in severe cases. Only patients with atherosclerotic risk and hyperlipemia can be treated with statines. Fat soluble vitamin supplementation can be administrated only in symptomatic and proved vitamin deficiency.

Lower extremity amputations--a review of global variability in incidence.

AIM: To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes mellitus. METHODS: An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for incidence of lower extremity amputation. The literature review conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. RESULTS: Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 10(5) in the population with diabetes compared with 5.8-31 per 10(5) in the total population. Major amputation ranges from 5.6 to 600 per 10(5) in the population with diabetes and from 3.6 to 68.4 per 10(5) in the total population. Significant reductions in incidence of lower extremity amputation have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics. CONCLUSION: Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation reporting methods demonstrate significant variation with no single standard upon which to benchmark care. Effective standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the growing multidisciplinary team effect on lower extremity amputation rates globally.

Screened individuals' preferences in the delivery of abdominal aortic aneurysm repair.

BACKGROUND: This study aimed to determine preferences for service attributes in a population screened for abdominal aortic aneurysm. METHODS: A questionnaire was designed to encompass various aspects of service provision. Questions were calibrated against the time an individual was willing to travel to access specific attributes. Subjects attending an aneurysm screening programme were asked to complete a questionnaire before their screening ultrasound scan. Statistical analysis was through pairwise analysis of the median travel times with the signed rank test. The Wilcoxon rank sum, analysed by the Kruskal-Wallis test, was used to compare preference ratings. RESULTS: A total of 262 individuals were asked to complete the questionnaire; the response rate was 98.5 per cent. Approximately 92 per cent of individuals stated a willingness to travel for at least 1 h beyond their nearest hospital in order to access services with a 5 per cent lower perioperative mortality rate, a 2 per cent lower amputation or stroke rate, a high annual caseload of aneurysm repairs, and routine availability of endovascular repair. CONCLUSION: Patients attending aneurysm screening were willing to travel beyond their nearest hospital to access a service with better outcomes, higher surgical volumes and endovascular surgery.

Indications for thrombolysis in deep venous thrombosis.

OBJECTIVES: Deep venous thromboses (DVTs) are a significant cause of morbidity and mortality in the general and inpatient population. Current anticoagulation therapy is efficient in reducing thrombus propagation but does not contribute to clot lysis or prevention of post-thrombotic limb syndrome. Catheter directed thrombolysis (CDT) is an alternative method for treating DVTs but there is no consensus regarding indications for its use. DATA SOURCES: PubMed and Cochrane library were searched for all articles on deep vein thrombosis and thrombolysis. REVIEW METHOD: Articles presenting data on DVT thrombolysis, DVT anticoagulation, mechanical thrombectomy, venous stenting and May-Thurner's syndrome were considered for inclusion in the review. RESULTS: CDT reduced clot burden, DVT recurrence and may prevent the formation of post-thrombotic syndrome. Indications for its use include younger individuals with a long life expectancy and few co-morbidities, limb-threatening thromboses and proximal ilio-femoral DVTs. There is a marked lack of randomised controlled trials comparing CDT-related mortality and long term outcomes compared to anticoagulation alone. The effectiveness of combined pharmaco-mechanic thrombectomy, although promising, need to be further investigated, as is the role of caval filters in preventing DVT-associated pulmonary emboli. CONCLUSIONS: These results suggest that the outcome of CDT in DVT management are encouraging in selected patient cohorts, but further evidence is required to establish longer term benefits and cost-effectiveness.

[Variceal upper digestive bleeding--an ever new complication in liver cirrhosis]. / Hemoragia digestiva superioara variceala-- complicatie mereu in actualitate in ciroza hepatica.

Variceal bleeding in liver cirrhosis is a medical emergency with a high mortality. The therapeutic options in patients with portal hypertension are: treatment of acute bleeding from varices, prevention of the first bleeding episode and prevention of rebleeding. Treatment of acute bleeding from varices includes: blood volume restitution, use of antibiotics for preventing bacterial infections, vasoactive drug therapy (terlipressin, somatostatin, vapreotide, octreotide), endoscopic band ligation for acute esophageal bleeding and endoscopic therapy with tissue adhesive (cyanoacrylate) for acute gastric variceal bleeding. Endoscopic treatments are best used in association with pharmacological therapy. In primary prophylaxis non-selective beta- blocker therapy and endoscopic band ligation are useful. Beta blockers, band ligation or both should be used for prevention of recurrent bleeding. In patients who fail endoscopic and pharmacological treatment for prevention of rebleeding TIPS and transplantation should be considered.

[Eosinophilic esophagitis--from a rare pediatric disease to the forefront of adult gastroenterology]. / Esofagita eosinofilica--de la o afectiune sporadica la copil la o boala digestiva de prim rang a adultului.

Eosinophilic esophagitis (EE) is a disease whose presence has exploded in clinical practice. Because of its relative novelty, the epidemiology, pathogenesis, clinical manifestations, diagnosis and treatment of EE are constantly evolving. EE was first recognized as a disease predominantly of children, but the publications in the last few years describe it like an adult disease, too. It is not known if its frequency is truly increasing in an antigen underexposed society or the disease was previously not recognized. The diagnosis requires the histologic finding of more than 20 eosinophils per high powered field in esophageal squamous mucosa. The specific antigens that initiate EE are unknown, but both food and aeroallergens are involved. The mechanisms by which EE induces esophageal dis-motility, chronic inflammation with fibrosis, and stricture formation are still unclear. The mucosa of the patients affected by EE contains increased numbers of CD8 lymphocytes, tumor necrosis factor alpha, I1-5 and eotaxin. The main symptoms in adult are: dysphagia and food impaction. Endoscopy commonly reveals strictures, mucosal rings, linear furrowing, corrugation, and white plaques. The common treatment regimens in children and adults involve the ingestion of topical corticosteroids.

Extragastric manifestations of Helicobacter pylori infection.

The role of Helicobacter pylori (HP) in some digestive diseases (gastritis, ulcer, gastric cancer, MALT lymphoma) is well known. It has been suggested relatively recently that infection with HP can be involved in various extra-digestive conditions: respiratory disorders (chronic obstructive pulmonary disease, bronchiectasis, lung cancer, pulmonary tuberculosis, bronchial asthma); vascular disorders (ischaemic heart disease, stroke, primary Raynaud phenomena, primary headache); autoimmune disorders (Sjogren syndrome, Henoch-Schonlein purpura, autoimmune thrombocytopenia, autoimmune thyroiditis, Parkinson's disease, idiopathic chronic urticaria, rosacea, alopecia areata); other disorders (iron deficiency anaemia, growth retardations, liver cirrhosis). Case studies, small patient series and non-randomized trials that have shown a beneficial effect of HP eradication in different conditions are not convincing. According to Mastricht III the only conditions where HP eradication is indicated are immune thrombocytopenic purpura and iron deficiency anaemia.

[Under-evaluated extrahepatic manifestations of cholestasis]. / Complicatii extrahepatice subevaluate în colestaza.

Biliary stasis can occur in many different diseases. Pruritus, metabolic bone disease, deficiencies of fat-soluble vitamins, steatorrhea, hyperlipidemia and fatigue represent the major extra-hepatic manifestations of cholestatic liver disease that considerably affect the patient's quality of life. The present article reviews pathogenetic and clinical aspects of and current therapeutic approaches to extra-hepatic manifestations of cholestatic liver disease.

Osteoporosis in liver cirrhosis--overview.

Osteoporosis can occur as a result of liver cirrhosis. The pathogenesis of reduced bone mineral density in liver cirrhosis is multifactorial. It can be caused by alterations in calcium and vitamin D homeostasis, as well as nutritional and dietary factors. Dual-energy X-ray absorptiometry (DXA) has become the gold standard in assessing bone mineral density in patients with liver cirrhosis. In such cases, patients can be treated with calcium and vitamin D supplements, bisphosphonates and hormonal replacement therapy (HRT).

[Gastroesophageal reflux involvement in ENT disorders]. / Implicarea bolii de reflux gastroesofagian in patologia orl.

It is admitted that gastroesophageal reflux patients may presents ear, nose, and throat (ENT) symptoms and signs, condition known as laryngo-pharyngeal reflux. It is estimated that as many as 10% of patients presenting to an ENT specialist have a clinical condition that might be attributed to gastroesophageal reflux. The diagnosis is challenging since no laryngeal signs are pathognomonic. A combination of ENT and esophageal symptoms and signs may suggest the necessity of further investigations. Adapted 24h pH study or better an esophageal impedance study may reveal the involvement of gastroesophageal reflux. Alternatively, a short trial with omeprazole or another proton pump inhibitor may be the simplest way for diagnosis. The standard treatment for gastroesophageal reflux is the valid treatment for these patients.

Temporomandibular joint ankylosis. A possible complication in juvenile psoriatic rheumatism.

The authors present a rare case of bilateral temporomandibular joint ankylosis secondary to polyarticular juvenile psoriatic arthritis in a 24 year-old man. The patient first presented with arthritis of his right elbow joint at the age of 9, followed by involvement of the distal inter-phalangeal joints of his right foot and both sacroiliac joints. Serum rheumatoid factor was not detected. At the age of 16 he developed psoriatic lesions affecting his nails and skin. By the age of 20, clinical and radiological evidence of arthritis was detected in his temporomandibular joint (TMJ). Subsequently, the patient developed bilateral TMJ ankylosis over a period of 4 years. The patient was managed by bilateral resection of the ankylosis bone blocks, mobilization of the mandible and interposition of Dacron material between the two neo-articular surfaces. 10 months postoperatively the patient maintained an inter-incisal distance of 3 cm. Postoperative mechano-therapy was hindered by the limited use of the patients' hands.