[Postoperative upper gastrointestinal bleeding in patients with cardiovascular surgery]

Patients with cardio-vascular surgery are at risk for upper digestive bleeding due to several factors.

AIM

To determine the utility of medication and endoscopy in preventing gastrointestinal bleeding (GB) after cardiovascular surgery.

MATERIAL AND METHOD

79 patients (60 males and 19 women, mean age 61 +/- 16.1 years) were prospectively included in the study from the 850 patients operated in the period 2004 - 2006. Inclusion criteria were: patients with digestive symptoms (dyspepsia) and with risk for GB (personal history of peptic ulcer, gastroduodenitis, esophagitis, hiatus hernia, gastric cancer, gastric surgery and GB). All patients with symptoms and partially patients with risk were evaluated by endoscopy. Patients received standard medication for prevention of GB.

RESULTS

Prophylactic medication was partially efficient in GB prophylaxis vs. no prophylaxis (7% vs. 11% p < 0.05). Patients with endoscopy examination before surgery had significantly lower incidence of bleeding (6.6% vs. 10.9%, p < 0.05%).

CONCLUSIONS

Gastrointestinal bleeding may occur despite prophylactic medication. Gastrointestinal endoscopy prior surgery may be useful in preventing the bleeding.

Endoscopic diagnosis of Helicobacter pylori in patients with bleeding peptic ulcers

Helicobacter pylori (H. pylori) is the main etiologic factor for peptic ulcers (PU), and it has been shown that H. pylori eradication therapy is effective in preventing recurrent bleeding from PU.

AIM

The aim of this study was to establish the prevalence of H. pylori infection in patients with bleeding PU using two endoscopic-based methods--rapid urease test (RUT) and histology--and to compare their diagnostic accuracy.

METHODS

All patients underwent emergency endoscopy during which a biopsy specimen from the pre-pyloric antrum for RUT and two other specimens from the antrum and gastric corpus for histological assessment were taken.

RESULTS

Ninety-one patients (52 men, 39 women, aged 18-78 years) were included; 69 patients had duodenal ulcer (DU), 18 had gastric ulcer (GU) and four had both duodenal and gastric ulcers. The most frequent presentation was melena (72.5%). Hemoglobin concentration ranged from 3.9 to 14.8 g/dL, and blood in the stomach was present in 59 (64.8%) of patients. Sixty-two patients (68.9%) were diagnosed by RUT as H. pylori-positive, while 81 patients (89.0%) were found to be positive by histology, the difference being statistically significant (p = 0.0048, 95% CI) The sensitivity and specificity of RUT were 76.5% and 100%, respectively. The presence of blood in the stomach did not influence the results of both RUT and histology. The study confirmed the high prevalence of H. pylori infection in patients with bleeding DU.

CONCLUSION

RUT has a low sensitivity, and thus it is unreliable for the diagnosis of H. pylori infection in patients with bleeding PU; however, RUT has a high specificity and therefore, it should be used as the first choice test for the diagnosis of H. pylori in such patients undergoing emergency endoscopy. Additional biopsies should be taken during endoscopy and proceeded with histological examination when RUT is negative.

Accuracy of colonoscopy in localizing colonic cancer

It is important to establish the precise localization of colonic cancer preoperatively; while colonoscopy is regarded as the diagnostic gold standard for colorectal cancer, its ability to localize the tumor is less reliable.

AIM

To define the accuracy of colonoscopy in identifying the location of colonic cancer.

METHODS

All of the patients who had a colorectal cancer diagnosed by colonoscopy at the Institute of Gastroenterology and Hepatology, Iaşi and subsequently received a surgical intervention at three teaching hospitals in Iaşi, between January 2001 and December 2005, were included in this study. Endoscopic records and operative notes were carefully reviewed, and tumor localization was recorded.

RESULTS

There were 161 patients (89 men, 72 women, aged 61.3 +/- 12.8 years) who underwent conventional surgery for colon cancer detected by colonoscopy during the study period. Twenty-two patients (13.66%) had erroneous colonoscopic localization of the tumors. The overall accuracy of preoperative colonoscopic localization was 87.58%.

CONCLUSIONS

Colonoscopy is an accurate, reliable method for locating colon cancer, although additional techniques (i.e., endoscopic tattooing) should be performed at least for small lesions.

Transient elastography--an alternative to liver biopsy in patients with chronic hepatitis C?

Liver fibrosis is the main determinant of clinical outcomes of chronic hepatitis C. Liver biopsy is still considered the gold-standard for assessing liver fibrosis. However, liver biopsy is an invasive procedure associated with morbidity and mortality and has several limitations. Moreover, liver biopsy is not well accepted by the patients, especially when repeated examinations are needed, and its accuracy in assessing fibrosis is questionable due to sampling errors, intraobserver and interobserver discrepancies. Therefore, over the last years there has been an increasing interest and desire for non-invasive tests to assess the stage of liver fibrosis in patients with chronic hepatitis C. There are three main groups of non-invasive methodologies for the assessment of liver fibrosis: serum markers, imaging techniques, and transient elastrography. This review summarizes current information on transient elastography used for non-invasive diagnosis of liver fibrosis in patients with chronic hepatitis C.

[Conventional ultrasound in the diagnosis of bile duct calculi]

Transabdominal ultrasound (US) is one of the most useful methods in the diagnosis of biliary stones.

AIM OF THE STUDY

To appreciate the value of US in the diagnosis of bile duct stones.

MATERIAL AND METHOD

989 patients, explored in the Institute of Gastroenterology and Hepatology Iaşi by US compared with ERCP, MRCP, operative diagnosis and the final diagnostic.

RESULTS

The sensitivity of US in the detection of bile duct stones was 78.39% and specificity was 72.22% in the first group of 650 patients, and bile duct stones were identified in 139 cases of 339 of the second group where US could not identify the cause of bile duct dilatations.

DISCUSSION

The results were comparable with the most recent studies in the literature.

CONCLUSION

US is an efficient method for the diagnosis of bile duct stones in many cases and remains the first step in the diagnosis.

[Colorectal cancer in Romania: epidemiological trends]

Traditionally, gastric cancer was considered the main digestive cancer. In Romania, in the last decade, the experts from all university centers noticed an alarming increase of colorectal cancer (CCR) incidence, the fraction gastric/colorectal cancer being now inversed.

AIM

To study the epidemiological trends of CCR in Romania in different counties and to analyze the proportion of cases diagnosed in 4 traditional endoscopy units.

METHODS

We have analyzed the CCR data from National Institute of Statistics (NIS) and those available from medical archives of 4 important GI units for establishing the annual incidence of CCR in all counties of Romania, and the distribution of CCR in relation with age and gender. We made a specific analysis of incidence trend in CCR for each county.

RESULTS

The data obtained from NIS showed an increase of the number of new diagnosed cases of CCR in Romania from 2971 to 5185, which means an increase with 74.5% ; in incidence term means an increase from 13.5/100000 to 23.57. More than half (55.8%) of new cases of CCR were diagnosed in 14 counties (less than one third of population). A high frequency of CCR seems related to the report urban/rural, the economic development, the average income, but also the access to a Endoscopy Unit. The data collected from 4 university centers showed the same ascendant epidemiological trend.

CONCLUSION

The incidence of CCR is in a continuous increase in Romania, the epidemiologic trends being similar with those recorded in Western Europe until 90th. In western countries, the increase awareness about CCR and methods of screening and early diagnosis determined a stabilization of incidence of CCR. Similar efforts of society and sanitary system are required in

[Role of video-capsule endoscopy in Crohn's disease]

The technical and scientific improvements of the miniature electronic equipment made possible the occurrence of video-capsule endoscopy (VCE), which is a device having an enormous noninvasive investigation potential of the small intestine. One of the most attractive indications of VCE is the suspicion of Crohn's disease that has not been confirmed using standard imaging techniques.

AIM

To assess the value of VCE in the diagnostic work-up of patients in whom there is clinical suspicion of small bowel Crohn's disease that cannot be confirmed using conventional techniques (upper and lower endoscopy, small bowel follow-through).

PATIENTS AND METHODS

A total of 21 patients (10 men, 11 women, mean age 36 +/- 7 years) with clinical and biochemical suspicion of Crohn's disease were included in the study. All the patients were evaluate before by the small bowel follow through, upper gastrointestinal endoscopy and colonoscopy.

RESULTS

In 15 patients (68%), lesions supporting the Crohn's disease diagnosis were detected by VCE. Complete visualization of the small bowel was achieved in all patients except for one where the capsule stopped upstream of a stenosis located at the terminal ileum level. The most frequent lesions included mucous erosions, aphthae, lineal or serpiginous mucous lesions, ulcers and fissures.

CONCLUSIONS

VCE is an effective modality for diagnosis patients with suspected Crohn's disease undetected by conventional diagnostic techniques.

[The gastro-esophageal reflux disease and its psycho-somatic component]

Different factors may be involved in the occurrence of gastro-esophageal reflux disease (GERD) symptoms. This review presents the importance of psychic factors in GERD symptom genesis, especially in patients with no esophagitis. In addition, these factors could be involved in the pharmacological therapy, with educational and behavioral implications increasing the cost-efficacy of the therapy.

[Radiofrequency ablation of malignant liver tumours]

Both primary and secondary liver tumors are common problems. Hepatocellular carcinoma (HCC) is a tumor with rapid progression and poor prognosis. The standard in the treatment of liver tumors is surgical resection. The majority of patients with primary or metastatic hepatic tumors are not candidates for resection because of tumor size, location near major intrahepatic blood vessels precluding a margin-negative resection, multifocality, or inadequate hepatic function due to coexistent cirrhosis. Only 20-30% of patients undergoing potentially curative liver resection will not suffer from tumor recurrence. Radiofrequency ablation (ARF) is an evolving technology used to treat patients with non-removable primary and metastatic hepatic cancers. ARF produces coagulative necrosis of tumor through local tissue heating. Liver tumors are treated percutaneously, laparoscopically, or during laparotomy using ultrasonography to identify their position and guide the ARF needle electrode. The indications, treatmentplanning, and limitations of hepatic ARF must be defined. ARF of hepatic malignancies is a safe and promising technique to produce coagulative necrosis of non-removable hepatic malignancies. Experience with this treatment is not yet rich enough to establish long-term outcomes.

[Gastroesophageal reflux involvement in ENT disorders]

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.

Capsule endoscopy--a new frontier

Capsule endoscopy (CE)--about the size of a vitamin pill--has enormous potential for the noninvasive investigation of diseases of the small bowel--"the last frontier" of endoscopy. Its use is spreading rapidly-over 150,000 capsules have been ingested worldwide since CE was introduced in 2001--reflecting the enormous impact of CE on the field of gastroenterology. CE has a higher diagnostic yield in recognizing Crohn's disease than any other method available. CE is able to establish a diagnosis in a high proportion of patients with obscure gastrointestinal bleeding, detecting small bowel lesions. New indications and applications of CE are emerging: CE has proven useful in the diagnosis of celiac disease, NSAID enteropathy and small bowel malignancies, its use in pediatric gastroenterology, the new Pill Cam ESO specifically-designed to visualize the esophageal mucosa etc. The objectives of this article are to present an overview of the CE: its history and development, indications, contraindications, and CE role in the diagnosis of small bowel diseases. Finally, it is presented the experience with CE at our institutions.

[Abdominal pain in liver cirrhosis patient--an unusual case]

We present the case of a 62 years male subjects, known with liver cirrhosis diagnosed in 2000 during a laparoscopy. The subject presented with important atypical abdominal pain, leucocytosis, thrombocytosis, small ascites; pneumatosis and hydro-aeric images of small intestine at abdominal X Ray, thickened bowel wall at CT-scan. Laparoscopy revealed mesenteric venous thrombosis, intestinal infarction and the standard surgical treatment was enterectomy. Mesenteric thrombosis may rarely occur in liver cirrhosis due to portal hypertension. This rare but severe complication is usually difficult to diagnose..

[Endo-Lap method in the management of biliary lithiasis (gallbladder and common bile duct)]

AIM

To present the results of the biliary endoscopic approach (ERCP) followed by laparoscopic cholecystectomy (LC) in the management of biliary lithiasis (gallbladder and common bile duct--CBD).

PATIENTS AND METHOD

From 1997 to March 2003 37 patients with biliary lithiasis were treated by endoscopic sphincterotomy (ES) with stone extraction, followed after 24-48 hours by LC. The indications for ERCP were presence of an obstructive jaundice (n=32) and a dilated CBD at the ultrasound examination (n=5).

RESULTS

Selective biliary cannulation was obtained in 35 (94.6%) cases, in all of them with successful papillotomy. Stones were found in all patients. CBD clearances for calculi (from 1 to 8) was obtained in 33 of 35 patients (94.3%), the rest of 2 being managed by open laparotomy. Antibiotics were administrated in all patients. Laparoscopic cholecystectomy was performed after 24-48 hours, with one conversion (3%). Postoperative morbidity was 12.1%: 2 transitory pancreatic reactions and 2 wound infections.

CONCLUSION

Endo-Lap method is a useful management alternative for combined gallbladder and CBD lithiasis. It has all the advantages of the two mini-invasive procedures (fast recovery, short hospitalization, low costs) and a less postoperative morbidity in patients with high risk.

[The changing spectrum of lower gastrointestinal haemorrhages]

Lower gastrointestinal haemorrhage (LGH) is a frequent reason for medical referral. It has an annual incidence ranging between 17 and 20.5 cases per 100,000 adults and represents 20-30% of all gastrointestinal haemorrhages.

OBJECTIVE

To evaluate the evolution of the etiologic spectrum of lower gastrointestinal bleeding.

METHODS

All the files of patients with lower gastrointestinal bleeding admitted in our unit between 1990 and 2001 were reviewed retrospectively. The annual admission and annual admission rates for each disease (disease/total LGH in a specific year) were analysed using linear regression.

RESULTS

We identified 2565 patients with LGH (mean age 50.8+/-8.7 years, 1338 (52%) men and 1227 (48%) women). The annual number of patients had a linear increase (p<0.05) from 103 in 1990 to 399 in 2001. The mean age of the patients increased linearly from 48.5 to 53 years (p<0.05). The annual rate for some specific diseases has changed over time. There was a trend of increase for the colorectal cancer and polyps, which reach statistical significance for diverticular disease and haemorrhoids (p<0.05). While the annual incidence for ulcerative colitis remained constant the annual rates decrease. For Crohn disease, angiodysplasia and radiation colitis no changes was found.

[Hormonal influence on gastrointestinal reflux during pregnancy]

Gastroesophageal reflux (GER) occurs in 30-50% of all pregnancies. The progressive rise in plasma progesterone has been suggested as a possible mediator of GER during pregnancy. It is not known whether progesterone, at physiological concentrations, has an effect on acid contact time. The study includes 70 women--50 pregnant and 20 non pregnant healthy menstruating female volunteers. We used immunoenzymatic tests for determination of estradiol, progesterone and beta HCG hormones during pregnancy. The 50 pregnant women with GER symptoms heartburn, acid regurgitations had increased levels of steroid hormones. 24-h ambulatory esophageal pH monitoring and serum progesterone levels were determined in 20 healthy women known to have normal menstrual cycles. All tests were performed during the follicular phase days 2-7 and the luteal phase days 22-28 of one or two consecutive menstrual cycles. The fluctuations in progesterone levels across the normal menstrual cycle have no significant impact on 24-h ambulatory pH parameters.

CONCLUSIONS

Progesterone, at physiological concentrations, does not predispose to GER in healthy menstruating women. Thus, it is likely that if progesterone, with or without estrogen, contributes to GER in pregnancy, this effect takes place only at the high concentrations observed during this condition. After delivery, GER disappear with decreasing hormonal levels and uterine volume.

Therapy of chronic hepatitis B: today and tomorrow

Hepatitis B virus infection represents an important health problem all around the world, with almost 350 million people chronically infected and 1 million death per year. Despite an efficient vaccination program and despite therapeutic progresses, chronic hepatitis B is still a disease with severe evolution and an increased prevalence in many countries, including Romania. Today, we have two groups of drug that are used for chronic hepatitis B treatment: interferon and lamivudine. Unfortunately, long term results for interferon or lamivudine treatment are far from satisfactory, fact that explains the interest for new antiviral agents, which are under evaluation procedures in many clinical trials. A combination of two or more new antiviral action agents it is believed to be the optimum therapy of chronic hepatitis B in the future.

Informed consent for gastrointestinal endoscopy: a 2002 ESGE survey

BACKGROUND/AIM

Gastroenterologists are required to obtain informed consent before undertaking any endoscopic examination. Published data indicate that in practice there are many deficiencies in this process. The aim of this survey was to determine the quality of information given to patients before the endoscopic procedures in countries that are members of the European Society of Gastrointestinal Endoscopy (ESGE).

METHODS

A structured questionnaire was sent to representatives of endoscopic societies that are members of ESGE regarding the quality of informed consent.

RESULTS

The response rate was 59% (26/44). The endoscopist is responsible for giving the required information prior to written consent in only 23.1% (6/26) of the countries. Although information about the procedure is given to the patients in 96% of the responding countries, in only 77% is there sufficient time for the patients to ask questions about the nature of the procedure. In 15% (4/26) of the countries neither the diagnostic or therapeutic alternatives to endoscopy are discussed nor the potential complication rates. Finally, the procedure-related mortality is provided in only 23% (6/26) of countries.

CONCLUSION

The procedure of obtaining informed consent for endoscopy varies considerably and may need reevaluation.

Are gastroenterologists aware of the role of ethics committees?

BACKGROUND/AIMS

A hospital ethics committee (EC) is an organized body of people, convened to identify, analyze and help resolve moral problems that arise in the care of patients. The aim of this study was to investigate the need to educate endoscopists about the role of the ECs in European and Mediterranean countries.

METHODS

A structured questionnaire concerning the role of ECs was sent to the representatives of endoscopy societies, which are also members of the European Society of Gastrointestinal Endoscopy.

RESULTS

The response rate was 59% (26/44). About half of the responding representatives had attended more than 1 lecture or read more than 1 article about ethics during the previous 10 years. The percentage of hospitals with an established EC varied between countries. In 15% of the countries <20% but in 58% of the countries >60% of the hospitals have established ECs. Sixty-five percent of the responders believe that the EC is an advisory committee and 31% an executive committee. Endoscopists believe that ECs have been of great help to their specialty in their country.

CONCLUSIONS

The roles of the ECs are not clear to endoscopists and there is a need for education in this field.

[Liver metastases with unknown primary site]

Patients with unknown primary site cancer represents 5% to 10% of all neoplasia patients. Liver is a favourite site for gastrointestinal tumors, but not only. The adenocarcinomas represents 60% of patients from this group. A detailed physical examination, extensive laboratory and imaging procedures are necessary to locate the primary tumor. However, liver biopsy could be essential for histological diagnosis and important to identify the tumors who may benefit from specific and effective therapy (breast cancer, prostate cancer, ovarian cancer and small-cell carcinoma of the lung). Systemic chemotherapy represents the most frequently treatment, but only patients with good performance status and without co-morbidities may benefit. "Best supporting care" may be the optimal treatment for most patients, majority with poor performance status at the time of diagnosis.

[Chronic hepatitis B virus infection]

Chronic hepatitis B virus infection affects approximately 350 million people worldwide and 1.1 million in Romania. Despite the tremendous progress in the management of virus B infection, the treatment of chronic hepatitis B remain difficult and often disappointing. The aim of treatment is sustained suppression of HBV replication and remission of liver disease. Treatment is not indicated in immune tolerance phase or in the inactive carrier state, but it is necessary in immune clearance phase, after 3-6 months of surveillance. Two antiviral drugs are accepted: alpha-interferon and lamivudine. The results of both treatments are far of being perfect; new, more potent antiviral drugs are required.

Helicobacter pylori infection in patients with diabetes mellitus

Data concerning the prevalence of Helicobacter pylori (H. pylori) in diabetic patients are scanty and controversial. The aim of this study was to evaluate the prevalence of H. pylori infection in patients with diabetes mellitus (DM), and to assess whether the presence of bacterium was associated with severity of dyspeptic symptoms and endoscopic findings in such patients. The study involved 42 patients (19 men, 23 women; mean age 55 years, range 34-75 years) with DM and dyspeptic symptoms. Sixteen patients (38%) were classified as having type 1 diabetes and 26 (62%) patients as having type 2 diabetes. All patients had chronic dyspepsia, and each patient has completed a self-report questionnaire to obtain information concerning the presence and severity of upper gastrointestinal tract symptoms. H. pylori status was confirmed by 13C-urea breath test (13C-UBT), and diabetic patients underwent upper gastrointestinal endoscopy. Twenty-six (61.9%) of patients with DM were positive for 13C-UBT. There were no statistically significant differences in the infection rate between patients with type 1 and type 2 diabetes, and the prevalence of H. pylori infection was not associated with the known duration of diabetes. There was no significant difference in the symptoms score between H. pylori-positive and H. pylori-negative diabetic patients, and endoscopic findings in patients with DM were in the same range with those found in dyspeptic subjects from the same region. In conclusion, H. pylori infection is not associated with DM, duration of diabetes, or severity of dyspeptic symptoms in patients with DM.

[Diagnosis of gastric cancer on endobiopsies using the WHO classification]

Gastric cancer (GC), one of the most frequent malignancies can be early detected on endobiopsies. Our aim was to evaluate histologically the GC on endobiopsies, using WHO 2000 and Lauren classifications. The study included 2424 gastric endobiopsies, routine processed; sections stained with HE, Giemsa, PAS and AB. GC was diagnosed in 451 cases (19%), mostly in men (311 cases--69%). The highest incidence was in 60-69 year-old aged patients (34%). Using Lauren classification, 279 cases were included in diffuse type (62%), 167 intestinal-type (37%) and 5 (1%) mixed type. Each of these three types were also histologically analyzed considering the WHO classification. We pointed out that GC can be diagnosed histologically on endobiopsy specimens, although it is difficult to diagnose the GC--mixt type, due to reduced size of endobiopsies. Lauren classification (including the two major types: diffuse and intestinal) is very useful, especially if correlated with histological criteria of WHO classification.

[Functional digestive disorders and the relationship with psychiatric diseases]

Functional gastrointestinal disorders are frequent causes for medical consultations. Features related to disease, patient or the environment could influence the medical referral. The aim of the study was to estimate the importance of psychiatric disorders in patients with functional gastrointestinal disorders.

MATERIAL AND METHOD

The study was designed to have two phases. Phase I consisted in studying the prevalence of Irritable Bowel Syndrome (IBS) and psychiatric past history in a random sample of 338 from an urban community of 18000 people. Phase II consisted in studying the presence of psychiatric history in patients referred for IBS symptoms.

RESULTS

The prevalence of IBS symptoms in the general population was: 14.4% (8.4% in males and 17.7% in females). Psychiatric positive history was present in 6.2% of the general population and in 6.1% of IBS subjects (p > 0.05). Psychiatric disorders were more common in the IBS subjects who were seeking medical assistance (18%) than in subjects with same symptoms from the general population (6.2%) (p < 0.05).

CONCLUSIONS

Psychiatric disorders may influence the medial referral for patients with IBS.

Hepatitis C virus serotypes in Romanian patients with chronic hepatitis and cirrhosis

OBJECTIVES

To determine the prevalence of hepatitis C virus (HCV) serotypes in Romanian patients with chronic hepatitis infections and the association between them and disease's severity.

PATIENTS AND METHODS

Anti-HCV antibodies were first investigated by an indirect ELISA (Murex IIIrd generation). From 55 patients positive for anti-HCV, 22 patients (11 female and 11 male) with chronic active hepatitis (CAH--6 cases), chronic persistent hepatitis (CPH--11 cases) and cirrhosis (C--5 cases) were tested for HCV serotypes using an indirect ELISA (Murex HCV Serotypes 1-6 Assay). The average age for the selected group was 47.2 years (range 27 divided by 68).

RESULTS

In the first study from our region concerning this subject we have found the following serotypes distribution: serotype 1--68.18% (6/11--CPH; 4/6--CAH; 5/5--C); serotypes 2, 3, 4, and 6--4.54% for each of them (all were CPH cases); untypable--13.65% (2 with CAH and 1 CPH respectively).

CONCLUSIONS

(1) The serotype 1 seems to be predominant in our region in patients with chronic HCV infections and it is associated with the most severe cases. (2) The diversity of serotypes is higher compared with previous study group results (e.g. in haemodialized patients the serotype 1 was determined in almost 100% cases--unpublished data). (3) Untypable strains (13.65%) require the sequence analysis for HCV genome characterization.

[Prophylaxis of colorectal cancer with non steroidal anti-inflammatory drugs- a new reality?]

The use COX-2 inhibitors induces regression of adenoma polyps and disrupts the sequence adenoma colorectal carcinoma. So that, this can be used in chemoprevention of colorectal cancer and also in cancer localised in other segments of the digestive tract. So far there is no agreement regarding the beginning of the treatment, the minimal efficient dose, the span of time required for chemoprevention. As the current studies in this field are quite encouraging we believe that in the next future COX-2 inhibitors could be used not only in chemoprevention but also in tumoral regression, and as a codrug in chemiotherapy of colorectal cancer.

Pancreatic enzymes replacement therapy in chronic pancreatitis: an update

Chronic pancreatitis is the major cause of exocrine pancreatic insufficiency which should be compensated by pancreatic enzyme replacement therapy. There are now available a great number of pancreatic enzyme preparations, but encapsulated enteric-coated microspheres and minimicrospheres are considered the enzyme treatment of choice. However, full compensation of pancreatic exocrine insufficiency with enzyme replacement therapy cannot be obtained in all patients with chronic pancreatitis.

[Gastroesophageal reflux during pregnancy: 24-hour esophageal ph monitoring]

Gastroesophageal reflux (GER) occurs in 30-50% of all pregnancies. The progressive rise in plasma progesterone has been suggested as a possible mediator of GER during pregnancy. Recent advances in technology have made it possible to detect GER through monitoring of esophageal pH for prolonged periods, including sleep. 24-hour pH monitoring is the proper method for diagnosing GER in pregnant women. If 24-hour esophageal pH monitoring is to be a useful diagnostic tool, it must reliably discriminate GER patients despite daily variations in distal esophageal acid exposure. To address this issue, we studied 62 women (30 healthy non-pregnant women without GER symptoms and 32 pregnant women with GER symptoms-heartburn, acid regurgitation) with 24-hour esophageal pH monitoring. Intrasubject reproducibility of three pH parameters to discriminate the presence of abnormal acid reflux was determined (DeMeester score, Kaye score, circadian one hour diagram for pH < 4). Each patient was interviewed, using a reliable questionnaire detailing individual habits, life style characteristics and symptoms, at four time points during the first, second, third trimesters of pregnancy and post-partum period. Symptoms of GER are common in pregnancy and although GER rarely endangers maternal or fetal health, it can significantly affect patient comfort and quality of life. We conclude: 1. GER is almost constantly present during pregnancy, increasing with gestational age. 2. The most important pH--parameter is DeMcester score. 3. Heartburn disappear after delivery. 4. 24-hour esophageal pH monitoring is the gold standard for measuring acid exposure and is a reproducible test for the diagnosis of GER in pregnancy.

Apoptosis in human embryo development: 2. Cerebellum

We analysed the spatial and temporal distribution of apoptosis in human cerebellum development, during embryonic and fetal periods. Cerebella excised from two human embryos (8 weeks old) and eight fetuses (12-22 weeks old), were paraffin embedded and serially sectioned. Apoptotic cells were identified by propidium iodide staining, and TUNEL. In addition, immunohistochemistry for suicide receptor Fas(APO-1/CD95) was performed. We determined the distribution and percentage of apoptotic cells as well as Fas(APO-1/CD95)-positive cells in different regions and stages of development. Apoptotic cells were seen in both proliferative zones and postmitotic regions along the migratory pathways as well as in the developing cerebellar cortex in all examined stages. The Fas(APO-1/CD95) immunoreactivity was present in all examined stages in a small population of apoptotic cells: either neuroblasts or differentiated cells in postmitotic zones. These findings suggest that apoptosis drives the selection of the cells which are committed to differentiate during the early stages of cerebellar development. The differences between apoptotic cells distribution and Fas receptor expression suggest that cell selection is driven by different apoptotic pathways.

[Gastroesophageal reflux disease in pregnancy]

Gastroesophageal reflux disease (GERD) symptoms are common in pregnancy, occurring in approximately 45% to 80% of pregnant women. Although the symptoms associated with reflux in pregnancy are similar to those described in the nonpregnant state, some of the etiologies are distinct due to hormonal fluctuations and other physiologic changes often associated with pregnancy. Diagnostic tools and therapeutic regimens that might be used without hesitation in the nonpregnant patient must be given with cautious consideration in the gravid patient due to potential fetal risks. Pregnant patients with symptomatic GERD should be managed aggressively with lifestyle modification and dietary changes. Antacids and antacids/alginic acids combination or sucralfate should be considered first-line medical therapy; treatment with cimetidine or ranitidine should be considered; these H2 receptor antagonists are preferred during pregnancy. Proton-pump inhibitors should be used with caution because little human experience is available.

[The examination of the digestive tract in patients with iron-deficiency anemia]

According to literature the gastroenterologic consultations for iron-deficiency anemia are quite frequent. The aim was the evaluation of the part played by gastrointestinal examinations for the diagnosis of iron-deficiency anemia. There were 115 patients admitted in the Medical Clinic between 1998-1999, with iron-deficiency anemia in the absence of macroscopic bleeding who carried out upper or lower endoscopy. A digestive lesion which account for iron deficiency anemia was identified in 35% of the cases. In the upper digestive tract there were 60%, in decreasing order of frequency: peptic ulcer, gastric cancer, erosive gastritis, angiodysplasia. In the lower digestive tract were 35% of the cases (colorectal cancer, polyps, angiodysplasia and hemorrhoids). In 5% of the cases there were found synchronization of the digestive tract lesions. So the digestive tract examination is worth doing because it establishes the diagnosis in 35% of the cases with few symptoms. The digestive tract lesions are more frequent in the upper tract, but they are more severe in the lower digestive tract. The possibility of the synchronization of lesions proves the necessity of carrying out the complete examination of the whole digestive tract.

[The prevalence of Helicobacter pylori infection in gastric cancer and gastric stump cancer]

In 1994, the International Agency for Research in Cancer recognized Helicobacter pylori (Hp) as "a definitive cause of human cancer". The present study aimed at determining the prevalence of Hp infection in the gastric cancer developed on the background of a disordered stomach as compared with gastric stump cancer. The prevalence of Hp infection was a twice higher in the patients with gastric cancer than in those with gastric stump cancer, and in both cases much lower than that reported in the literature. Possible explanation would be the much older mean age of the patients, the protective role of gastrectomy, and the multifactorial etiopathogenesis in both gastric and gastric stump cancers.

[The importance of ano-rectal manometry in irritable bowel syndrome]

Irritable Bowel Syndrome (IBS) represents a frequent cause for gastroenterological referral. 50% of all gastroenterological consultations are for functional gastrointestinal disorders (IBS included). Multiple motility abnormalities were described in IBS. The AIM of the study was to evaluate the role of ano-rectal manometry in the diagnosis of IBS.

STUDY DESIGN

24 patients with IBS (mean age 50.8 +/- 15.4) and a control group of 10 subjects with no abdominal symptoms (mean age 48.1 +/- 12.3) had each an ano-rectal manometry examination.

RESULTS

After exclusion of constipation predominant IBS subjects, the IBS patients presented lower perception threshold (22.1 +/- 10.9 ml) than the control group (60.2 +/- 11.3 ml) (p < 0.05) and than the constipation predominant group (81.3 +/- 44.0) (p < 0.05). In 44% of constipation predominant IBS concomitant pathology, revealed by manometry, was present: megarectum or hemorrhoids (spasm).

CONCLUSION

Anorectal manometry could be a useful tool for the evaluation of IBS patients.

[Seizures during the treatment with interferon for chronic C hepatitis]

Interferon alpha (IFN-alpha) is a well-established first-line treatment for chronic viral hepatitis. Side effects of IFN-alpha therapy are common but generally mild and self-limited. Generalized seizures during IFN-alpha therapy are very uncommon and are present in clinical isolated cases and usually in association with high doses of IFN-alpha. In our case a female of 39 years old, seizures have occurred at low doses of IFN-alpha used as therapy for chronic C viral hepatitis. As it comes to our knowledge, till now, there were published only 4 cases of generalized seizures that occurred during treatment with IFN-alpha for chronic C viral hepatitis. The physiopathology of this complication is unknown. Generalized seizures can be reasonable due to IFN-alpha therapy, as long as the patient didn't have any seizure history, or other factors, which can develop seizures. Neurological examination, EEG and brain scan were normal. The recurrence of these seizures was absent stopping IFN-alpha therapy without any other seizure treatment.

[Cystic dilatation of main biliary tract]

The choledochal cyst (particularly with congenital origin) is a clinical form from a complex syndrome of ecstasies of the intra-, extra-, or both situations of biliary tree. The disease has until now an unsure etiopathogeny. Very frequent to child, teen-ager and young adult the incidence decreases through the third age. During the period 1960-1998, 13 patients were operated on (annually rate 0.3). The extreme ages of our patients were 5 and 72 years; being operated six children and 7 adults (two of them being 63 and 72 years old). The clinical presentation was nonspecific. The jaundice (with or without cholangitis) (n: 7), right upper quadrant pain (n: 11), a palpable abdominal mass (n: 5) were registrated but the classic triad (Sénéque--Thailhefer) was in out series the exception rather than the rule. Concomitantly there were discovered different complications of the disease: hepatic biliary cirrhosis (n: 3--two macroscopic diagnosed and one microscopic confirmed), portal hypertension (n: 8), biliary lithiasis (including the intracystic stones) (n: 6) and cholangio-carcinoma (n: 1). The clinic and biologic preoperative diagnosis is up to date difficult and not sure like in our experience too. In our series, especially in the last 20 years, the accurate imaging diagnosis was helpful (the ultrasonography, CT, hepatic scintigrams). ERCP was not available for us until now. In concordance with Todani--Watanabe classification our patients were included in the following types: I-a (n: 6), I-b (n: 1), I-c (n: 2), II (n: 2), IV-a (n: 2). All patients were operated on: cysts-digestive derivations or partial excision of the cyst with billio-digestive reconstruction were the choice procedures at a beginning of our experience or for the very fragile patients (n: 5). The total excision of the cyst with choledochal--jejunostomy (Roux-en-Y) is the preferred method now (n: 8) when it is possible. The microscopic pathology of the disposable specimens (cystic wall) showed:--chronic intra- and perimural inflammation (n: 7);--severe displasia and metaplasia (n: 2); cholangiocarcinoma islands (n: 1); additional lesions: hepatic chirrosis (n: 1); hepatic fibrosis (n: 3).

RESULTS

The postoperative morbidity--three patients--one of them died with a peritonitis. Long-term follow-up, effective for only 10 patients, reveled recurrent cholangitis in two cases treated by the reoperation of the former anastomosis; the other 8 patients had a normal evolution.

CONCLUSION

The choledochal cyst is an exclusive indication for surgery as soon as it was discovered.

Possible role of Ca2+ dependent ATPase in determining the relationship between stimulation frequency and action potential duration in the myocardial fibre

At present, action potential duration (APD) is considered to be dependent on the activation of the transient outward current. We applied a stimulation frequency (SF) pattern which was continuously and linearly increased (from the third stimulus on, every stimulus was applied 40 ms earlier than the previous one). Our previous results (Stanciu and Stanciu, 1995) have shown both a decrease of APD--in the interval between 0.5 Hz and 2 Hz, and in the one between 4 Hz and 8 Hz, and an increase of APD--in the interval between 2 Hz and 4 Hz. Triiodothyronine, which stimulates Ca2+ dependent ATPase, has positive effects on APD for all SF, ranging from 0.5 Hz to 6 Hz. On the contrary, increasing the pH value (from 7.4 to 8.6), which prevents Ca2+ binding to membrane proteins, determines a decrease of APD for the same SF levels. Therefore, we advance the assumption that there should be some attached protein molecules, having a role in Ca2+ storage, on the external side of the sarcolemmal membrane. In this case, it is the sarcolemmal Ca2+ dependent ATPase which performs the loading of those stores. The loading up to saturation state is accomplished during a time lapse that depends on the working rate of the Ca2+ dependent ATPase. The premature occurrence of a stimulus finds the store only partially loaded with Ca2+, which may explain the decrease in APD associated with the increase in SF. The continuous and linear increase of SF results in a high internal Ca2+ concentration and--consequently--in the stimulation of Ca2+ dependent ATPase. That explains the APD increase for SF ranging between 2 Hz and 4 Hz. The same pattern of SF increase (continuos and linear), but using frequencies higher than 4 Hz, results in an overflow of the maximal operating capacity of the Ca2+ dependent ATPase and also in the reduction of APD amplitude.

Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs, and gastroduodenal pathology: current status

Non-steroidal anti-inflammatory drugs (NSAIDs) are now widely used medicines and their relationship with gastroduodenal injury is well established. The overall risk for serious gastrointestinal side effects in patients taking NSAIDs is three times greater than that of control groups and this risk rises to more than five times in elderly patients. Moreover, the risk of gastrointestinal surgery is ten times greater in elderly patients taking NSAIDs than in controls. Therapeutic aspects like the necessity of eradication of Helicobacter pylori (H. pylori) in order to reduce the gastroduodenal risks for NSAIDs users, the indication for eradication of H.pylori of those with past history of peptic ulcer and require NSAID therapy, the role of eradication when the NSAIDs are used in association with misoprostol.

[Solitary intra-articular osteochondroma of the fingers in children]

In the hand, osteochondromas are rarely found. When encountered, these lesions occur at the metaphyseal region adjacent to the growth plate usually in patients with multiple hereditary exostosis. Our experience with solitary epiphyseal osteochondromas in the phalanges of seven children is reviewed. All patients presented a progressive angular deformity leading to limited function of the hand. Five patients had limited range of motion. Good restoration of motion and function was achieved by excision of the lesion and collateral ligament reconstruction. Early resection is recommended to correct and prevent further deformation in the growing skeleton of children.

Basic mechanical rhythm in the rat small intestine

The basic electrical rhythm (BER) of the small intestine in rat proves its physiological usefulness in generating the basic mechanical rhythm (BMR) as a specific form of muscular tonus in the interdigestive (respite) phases BMR is susceptible to amplitude modifications under the influence of factors that are intrinsic or extrinsic to the muscle fibre, an influence which is exerted either directly over the contractile phenomenon, or by means of electrical phenomena. Recording of BMR is made possible through the use of transducers appropriate in point of sensitivity and of size for the area from which information about the contraction force is collected.