[The impact of antisecretory therapy on gastroduodenal ulcers healing after acute bleeding]

In this paper we compared the efficacy of proton pump inhibitors (PPIs) and H2 receptor antagonists on the morphogenesis of the marginal zone of gastric and duodenal ulcers in 56 patients withacute gastroduodenal bleeding. It is shown that the antisecretory drugs in the treatment of patients with acute ulcerative bleedingnot only affect on the secretory activity of the glands in gastroduodenal zone, but it also modulates inflammatory reparative process and the status of mucous and bicarbonate barrier. A greater anti-inflammatory effect of PPI in comparison with H2-receptor antagonists has been proved. Appointment of PPIs had more pronounced stimulation of angiogenesis and cell proliferation of the surface epithelium.

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding.

METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed.

RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05).

CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.

[New possibilities of Doppler flowmetric ultrasound diagnosis of portal hypertension complicated with varicose veins of the esophagus and bleeding prediction]

Liver cirrhosis as a stage in chronic diffuse liver diseases development manifests itself in structural remodeling of parenchyma and appearance of the main syndrome--portal hypertension. In turn it leads to hemorrhage in 54,3% with death rate of 30-50%. In the article research of hemodynamics in abdominal vessels by the means of modified sonographic Doppler flowmetry and prognosis of high risk esophageal varices are described. On the basis of statistical dependency between degree of esophageal varices, cirrhotic gastropathy and results of modified protocol close correlation is shown, which allow to recommend them as alternative in non-invasive diagnosis of liver cirrhosis complications.

[Pharmacotherapy of portal hypertension and its complications: analysis of efficacy of preparations for clinical practice and discussion of promising methods of treatment]

Bleeding from oesophageal varicose veins is the terminal stage of a sequence of complications of liver cirrhosis caused by progressive fibrosis, circulation blockade, and development of portal hypertension syndrome followed by collateral shunt. It leads to progressive vein dilation and their rupture. The main issue of today is to prevent the development of successive stages of portal hypertension, to search for therapeutic and surgical methods for marked reduction of pressure in the portal system, and to prevent the risk of hemorrhage from varicose veins. Another approach is to use local endoscopic treatment of varicose veins for prevention of their rupture. The authors analyse the efficacy of pharmacotherapy in patients with liver cirrhosis and portal hypertension and discuss the existing recommendations on the prevention of hemorrhage with special reference to the yet unsolved problems and prospects for the improvement of therapy.

[Risk factors of gastroduodenal bleeding in patients with severe burns]

An experience of treatment of 133 patients with severe bums was analyzed. Bleedings from the upper parts of the gastrointestinal tract were diagnosed in 16 patients in different terms since their admission to the hospital. At the moment of carrying out of the endoscopic research all bleedings were considered as taking place. Statistically significant risk factors of the development of gastroduodenal bleedings were considered to be an alcoholic intoxication at the moment of injury and insufficient fluid therapy during the pre-admission stage and young age of the patients. The antisecretory therapy showed that the detection of risk factors in question should be regarded as an indication to the reinforced regime of preventive measures for gastroduodenal injuries.

The Blatchford score is an useful index in the management of Mallory-Weiss tear and gastrointestinal bleeding: experience from an urban community hospital

OBJECTIVES

The purpose of this study was to determine the utility of individual clinical parameters as well as a composite index like the Blatchford score in predicting the need for endoscopic intervention and prognosticating the out come in patients with Mallory Weiss tear presenting with gastrointestinal bleeding.

METHODS

We retrospectively reviewed our endoscopy database and our EMR system to identify patients with Mallory Weiss tear and collect relevant data.

RESULTS

A total of 38 cases with Mallory-Weiss tear were identified at our center over a 5 year period. Thirty-two patients presented with gastrointestinal bleeding constituting 3.1% of all cases presenting with upper gastrointestinal bleeding. Nine (28%) of 32 patients were found to have active bleeding or stigmata of recent bleeding at endoscopy and required endoscopic therapy. The Blatchford score ranged from 0 to 11 in the patients with gastrointestinal bleeding. Nine patients had a Blatchford score < 6 (four 0, five 1-4) while 23 patients had a score > 6. None of the patients with a score < 6 required endoscopic intervention or a blood transfusion while 9 (39%) patients with a score > 6 required endoscopic intervention and 17 (74%) required a blood transfusion. Length of stay was significantly longer in patients with a score > 6.

CONCLUSIONS

The Blatchford score can be a useful index to risk stratify patients with Mallory Weiss tear who present with gastrointestinal bleeding with regards to hospital admission and identifying patients who warrant urgent endoscopic intervention, require blood transfusion and are likely to have a longer length of stay.

Spontaneous regression of hepatocellular carcinoma in a cirrhotic patient: possible vascular hypothesis

Spontaneous regression of hepatocellular carcinoma is extremely rare, and the exact pathogenesis leading to this remarkable phenomenon remains unclear. We describe a case of spontaneous regression of an incidentally discovered hepatocellular carcinoma in a 63-year-old man with hepatitis C cirrhosis. The regression followed a series of events, in particular, an upper gastrointestinal haemorrhage. Ischaemic insult may be a major pathway leading to tumour regression. As limited data is available in the literature, knowledge and recognition of this rare event will have implications for patient management and may alter treatment. Further, data may be useful to assess if these patients have an altered prognosis with improved survival.

[About some features of formation of "spots of Vishnevsky" in general hypothermia]

The article describes the features of formation of "spots of Vishnevsky", in general hypothermia. It is proved that the wedge shape of hemorrhages in the gastric mucosa caused by swelling and discrepancy of the paries of stomach pits with the filling of forming wedge-shaped cavity with blood from the arrosive capillaries. It is noted that the dynamics of accumulation of PAS-positive material in the gastric pits in the gastric mucosa in case of total of hypothermia is directly dependent on the growth of intracellular acidosis and disintegration of plasmolemma of parietal cells.

Management of non-variceal upper gastrointestinal tract hemorrhage: controversies and areas of uncertainty

Upper gastrointestinal tract hemorrhage (UGIH) remains a common presentation requiring urgent evaluation and treatment. Accurate assessment, appropriate intervention and apt clinical skills are needed for proper management from time of presentation to discharge. The advent of pharmacologic acid suppression, endoscopic hemostatic techniques, and recognition of Helicobacter pylori as an etiologic agent in peptic ulcer disease (PUD) has revolutionized the treatment of UGIH. Despite this, acute UGIH still carries considerable rates of morbidity and mortality. This review aims to discuss current areas of uncertainty and controversy in the management of UGIH. Neoadjuvant proton pump inhibitor (PPI) therapy has become standard empiric treatment for UGIH given that PUD is the leading cause of non-variceal UGIH, and PPIs are extremely effective at promoting ulcer healing. However, neoadjuvant PPI administration has not been shown to affect hard clinical outcomes such as rebleeding or mortality. The optimal timing of upper endoscopy in UGIH is often debated. Upon completion of volume resuscitation and hemodynamic stabilization, upper endoscopy should be performed within 24 h in all patients with evidence of UGIH for both diagnostic and therapeutic purposes. With rising healthcare cost paramount in today's medical landscape, the ability to appropriately triage UGIH patients is of increasing value. Upper endoscopy in conjunction with the clinical scenario allows for accurate decision making concerning early discharge home in low-risk lesions or admission for further monitoring and treatment in higher-risk lesions. Concomitant pharmacotherapy with non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents, such as clopidogrel, has a major impact on the etiology, severity, and potential treatment of UGIH. Long-term PPI use in patients taking chronic NSAIDs or clopidogrel is discussed thoroughly in this review.

[Clinical investigation of primary amyloidosis with autologous hematopoietic stem cell transplantation]

OBJECTIVE

To investigate the treatment of primary amyloidosis with high-dose melphalan and autologous hematopoietic stem cell transplantation to further examine the survival, hematologic response, and improvement of amyloid-related organ dysfunction.

METHODS

Retrospective analysis of 20 patients with primary amyloidosis treated with autologous hematopoietic stem cell transplantation. The status of major organ function before transplantation, mobilization programs and conditioning regimen as possible risk factors for survival were also investigated.

RESULTS

Of 20 cases, 11 out of 15 evaluable cases achieved hematologic response, among them, 6 got complete remission (CR, 40%) and 5 partial remission (PR, 33%). The median onset time was 3.0 months (1.5 - 4.0 months) and 4 months (3 - 5 months), respectively after transplantation. The overall hematologic response was 73%. The 11 hematologic responders also had kidney responses. The median time to achieve kidney response was 3 months (2 - 6 months). The 3-year overall survival of the cohort of cases was 71.4%. The major causes of death were heart failure, renal dysfunction and gastrointestinal bleeding. G-CSF alone could obtain satisfactory mobilization results and most of patients well tolerated to the conditioning regimen of melphalan doses from 140 mg/m(2) to 200 mg/m(2).

CONCLUSION

Treatment of primary amyloidosis with high-dose melphalan followed by autologous peripheral blood stem cell transplantation produced high efficacy. The cardiovascular system involvement, renal dysfunction and the abnormality of coagulation function before transplantation may be the risk factors for survival.

Acute variceal hemorrhage in patients with liver cirrhosis: weekend versus weekday admissions

PURPOSE

Little is known about the impact of weekend admission on acute variceal hemorrhage (AVH). Thus, we investigated whether day of admission due to AVH influenced in-hospital mortality.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 294 patients with cirrhosis admitted between January 2005 and February 2009 for the management of AVH. Clinical characteristics were compared between patients with weekend and weekday admission, and independent risk factors for in-hospital mortality were determined by multivariate binary logistic regression analysis.

RESULTS

No demographic differences were observed between patients according to admission day or in the clinical course during hospitalization. Seventeen (23.0%) of 74 patients with weekend admission and 48 (21.8%) of 220 with weekday admission died during hospitalization (p=0.872). Univariate and subsequent multivariate analysis showed that initial presentation with hematochezia [p=0.042; hazard ratio (HR), 2.605; 95% confidence interval (CI), 1.038-6.541], in-patient status at the time of bleeding (p=0.003; HR, 4.084; 95% CI, 1.598-10.435), Child-Pugh score (p<0.001; HR, 1.877; 95% CI, 1.516-2.324), and number of endoscopy sessions for complete hemostasis (p=0.001; HR, 3.864; 95% CI, 1.802-8.288) were independent predictors for in-hospital mortality.

CONCLUSION

Weekend admission did not influence in-hospital mortality in patients with cirrhosis who presented AVH.

[The modification of the M.D. Patsiora's operation by portal hypertension]

The direct transcutaneous transhepatic portography was performed in 85 patients with hystologically confirmed liver cirrhosis, portal hypertension and varices of the esophagus and stomach. It was found out, that the left gastric vein partakes the varicous transformation in 100% of cases. The least had an isolated division in 27% of the studied patients. 68% had the significant dilatation of the posterior gastric vein, whereas 19 (22%) patients had the combined posterior, left and short gastric veins dilatation. The study allowed the modification of the M.D. Patsiora's operation (the azygo-portal disintegration), by supplementing it with the gastric devascularization. The new method increased the 2-years survival from 77 to 97%, improved the hemostatic effect from 51 to 89% and decrease the recurrences from 25 to 5%.

[Splenic artery pseudoaneurism as a rare complication of acute and chronic pancreatitis]

Diagnostics and treatment of the splenic artery pseudoaneursm as a complication of acute pancreatitis were highlighted. Literature data is reviewed. Personal results of treatment of 5 such patients were thoroughly analyzed. The effective treatment and diagnostic algorithm was worked out. Technical aspects of visceral arteries' surgery were featured and optimized.

Long-term outcome of hemizygous and heterozygous carriers of a germline GATA1 (G208R) mutation

The transcriptional regulator GATA1 is crucially involved in megakaryocytopoiesis and erythropoiesis. Mutations of the gene which is located on the X chromosome have been associated with platelet and red blood cell abnormalities. We identified a family with a GATA1 (G208R) mutation in whom a low male birth rate and frequent miscarriages among heterozygous females suggested increased fetal death in male hemizygotes. Female mutation carriers had normal or near normal hemoglobin levels and platelet counts ranging from normal to severely reduced, probably reflecting skewed X chromosome inactivation. Platelets were dimorphous, and thrombocytopenia was associated with erythroblastosis. The only living male mutation carrier had severe macrothrombocytopenia with life-threatening bleeding episodes, moderate to severe anemia, eosinopenia, skeletal abnormalities, and abundant extramedullary hematopoiesis. Long-term sequelae in the 50-year-old patient included unilateral nephrectomy following misinterpretation of paraspinal hematopoiesis as renal cancer, spinal stenosis which was possibly favored by progressive bone marrow expansion, and severe secondary gout.

Nonsteroidal anti-inflammatory drug colopathy mimicking malignant masses of the colon: a report of three cases and review of the literature

The adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on the colon have been reported as a wide spectrum of symptoms, signs, and endoscopic findings. Despite the extensive use of NSAIDs, and the potential seriousness of NSAID colopathy, this condition often goes unrecognized or misdiagnosed. We report three cases of NSAID colopathy in which the diagnosis of malignancy was incorrectly made based on endoscopic findings. Before any surgical intervention, we entertained the diagnosis of NSAID colopathy based on clinical presentation. Ultimately, in two of the three cases, surgery was avoided and the lesions resolved. We present their clinical course and a review of the pertinent literature reviewing theories of the pathophysiology, the range of clinical presentations, and the pathological findings of this entity.

Acute gastric variceal bleeding during orthotopic liver transplant

We present a case of intraoperative gastric variceal bleeding during liver transplant. After an uneventful induction and surgical dissection, our patient developed hemodynamic instability during the anhepatic phase. We believe that an increase in portal pressures, owing to clamping of the portal system, led to spontaneous variceal rupture; however, placement of an oral gastric tube or transesophageal echocardiography probe may have contributed to this also. After intraoperative banding, the patient was stabilized and surgery proceeded uneventfully. The patient had no long-term sequelae. Anesthesiologists involved in the care of patients with end-stage liver disease should be aware of this infrequent intraoperative complication and be prepared to treat it appropriately.