ASSESSMENT OF ADRENOCORTICAL DYSFUNCTION IN PATIENTS WITH STABLE LIVER CIRRHOSIS

INTRODUCTION

Relative adrenal insufficiency (RAI) is common in the setting of critical illness as well as in hemodynamically instable cirrhotic patients with sepsis. Several studies have also shown that RAI is frequent in patients with stable cirrhosis without sepsis. The aim of this study was to prospectively assess the incidence of RAI in patients with stable cirrhosis.

PATIENTS AND METHODS

Forty-seven patients with hemodynamically stable liver cirrhosis without sepsis were prospectively included. RAI, assessed by using low dose-short Synacthen test (LD-SST), was defined as either a basal total cortisol concentration below 3.6 µg/dL or a peak total serum cortisol ≤ 16 µg/dL at 30 min after stimulation.

RESULTS

RAI was present in 10 (21.3%) of 47 cirrhotic patients. Peak cortisol level was negatively correlated with the severity of cirrhosis evaluated by Child-Turcotte-Pugh (CTP) (r=-0.46; P=0.001) and Model for End-Stage Liver Disease (MELD) (r=-0.51; P=0.001) scores. The frequency of RAI increased from CTP-A (10%) to CTP-B (30%) to CTP-C (60%).

CONCLUSION

RAI diagnosed by LD-SST is frequent in patients with stable cirrhosis and is related to the severity of liver disease. Further studies are needed to define clinical importance of RAI in stable cirrhotic patients.

CORTICOSTEROID TREATMENT IN THE SETTING OF DECOMPENSATED LIVER CIRRHOSIS WITH RELATIVE ADRENAL INSUFFICIENCY: A CASE REPORT AND A BRIEF REVIEW OF THE LITERATURE

Relative adrenal insufficiency (RAI) is the term used to describe inadequate production or action of glucocorticoids with respect to the severity of the illness. RAI is frequently found in critically ill patients particularly with septic complications and it is also present in both critically ill and stable patients with liver cirrhosis. In the following study a case report of a patient with decompensated cirrhosis and RAI is presented followed by a brief review of the literature. A 65-year-old male with liver cirrhosis of alcoholic etiology was admitted to hospital with bilateral leg edema, ascites, and marked weakness. At admission, his blood pressure was 82/52 mmHg and he had sinus tachycardia of 130/min. Laboratory analysis revealed hyponatremia (122 mmol/L), while ascites fluid analysis showed no infection. During the first 48 hours of hospitalization the patient remained persistently hypotensive despite adequate vascular filling and the addition of noradrenaline. A standard-dose short synacthen test was performed which revealed a poor cortisol response, which is a compatible criterion for the diagnosis of RAI. Intravenous hydrocortisone therapy was initiated, which resulted in a rapid improvement in patient's general condition, and increase in blood pressure. As the patient became hemodynamically stable without the need of noradrenaline, the hydrocortisone dose was weaned progressively, and he was discharged after 18 days of hospitalization in a stable condition.

PLATELET INDICES AND LIVER FIBROSIS EVALUATION IN CHRONIC HEPATITIS C

Recently, several studies have reported that the mean platelet volume and platelet distribution width may give information about liver fibrosis severity in chronic hepatitis C. The aim of the present study was to evaluate whether platelet indices correlate with hepatic fibrosis measured by transient elastography in patients with chronic hepatitis C.

MATERIALS AND METHODS

Patients with chronic hepatitis C were prospectively enrolled. Samples for complete blood count and routine biochemical parameters were collected and analyzed in the same day with liver fibrosis assessment by transient elastography. Mean platelet volume, platelet large cell ratio and platelet distribution width were compared with stages of liver fibrosis. Statistical analysis was carried out using SPSS 17.0 software. A P-value of less than 0.05 was considered statistically significant.

RESULTS

There were 139 patients with chronic hepatitis C (70.5% males, mean age 54.8 +/- 16.7 years). Compared with mild/moderate liver fibrosis patients, those with advanced liver fibrosis had an increased mean platelet volume (10.4 +/- 0.7 vs. 10.9 +/- 0.9, p < 0.002), platelet large cell ratio (28.5 +/- 5.3 vs. 32.5 +/- 7.2, P < 0.0001), and platelet distribution width (12.8 +/- 1.5 vs. 14.1 +/- 2.7, P = 0.003).

CONCLUSIONS

Increased platelet indices were associated with advanced liver fibrosis stages evaluated by transient elastography in patients with chronic hepatitis C.

NONSELECTIVE BETA-BLOCKERS IN PATIENTS WITH CIRRHOSIS: "THE THERAPEUTIC WINDOW"

For over 30 years, nonselective beta-blockers (NSBB) have been successfully used for preventing variceal bleeding in patients with cirrhosis and portal hypertension. Nevertheless, recent studies suggest that NSBB may be effective only within a particular "therapeutic window" in patients with advanced liver disease. Outside of this window, in early stages of cirrhosis and in very advanced cirrhosis, NSBB may be ineffective and even potentially harmful. In this paper we review the beneficial effects and potential harms of beta-blocker therapy in cirrhosis and underline the most recent recommendations for their use in very advanced cases of liver disease.

Clostridium difficile infection in patients with liver disease: a review

Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.

Randomised clinical trial: alisporivir combined with peginterferon and ribavirin in treatment-naïve patients with chronic HCV genotype 1 infection (ESSENTIAL II)

BACKGROUND

Alisporivir (ALV) is an oral, host-targeting agent with pangenotypic anti-hepatitis C virus (HCV) activity and a high barrier to resistance.

AIM

To evaluate efficacy and safety of ALV plus peginterferon-α2a and ribavirin (PR) in treatment-naïve patients with chronic HCV genotype 1 infection.

METHODS

Double-blind, randomised, placebo-controlled, Phase 3 study evaluating ALV 600 mg once daily [response-guided therapy (RGT) for 24 or 48 weeks or 48 weeks fixed duration] or ALV 400 mg twice daily RGT with PR, compared to PR alone. Following a Food and Drug Administration partial clinical hold, ALV/placebo was discontinued and patients completed treatment with PR only. At that time, 87% of patients had received ≥12 weeks and 20% had received ≥24 weeks of ALV/PR triple therapy.

RESULTS

A total of 1081 patients were randomised (12% cirrhosis, 55% CT/TT IL28B). Addition of ALV to PR improved virological response in a dose-dependent fashion. Overall, sustained virological response (SVR12; primary endpoint) was 69% in all ALV groups vs. 53% in PR control. Highest SVR12 (90%) was achieved in patients treated with ALV 400 mg twice daily and PR for >24 weeks. Seven cases of pancreatitis were reported, with similar frequency between ALV/PR and PR control groups (0.6% vs. 0.8% respectively). Adverse events seen more frequently with ALV/PR than with PR alone were anaemia, thrombocytopenia, hyperbilirubinaemia and hypertension.

CONCLUSIONS

Alisporivir, especially the 400 mg twice daily regimen, increased efficacy of PR therapy in treatment-naïve patients with HCV genotype 1 infection. The mechanism of action and pangenotypic activity suggest that alisporivir could be useful in interferon-free combination regimens.

Alcoholic liver disease--epidemiology and risk factors

Alcoholic liver disease (ALD) accounts for the majority of chronic liverdiseases in Occidental countries and remains a major cause of liver-related mortality in worldwide. The spectrum of ALD includes steatosis in patients which consume over 80g of alcohol per day, alcoholic steatohepatitis and liver cirrhosis in approximately 15% of patients. Once cirrhosis is established, the annual risk for hepatocellular carcinoma is about 1-2%. Environmental factors such as drinking patterns, coexisting liver disease, obesity, diet and co-medication may affect the natural course of ALD. Abstinence is the hallmark of therapy for ALD, and nutritional therapy is the first line in therapeutical intervention.

Clostridium difficile infection and inflammatory bowel disease: what gastroenterologists and surgeons should know

Over the past two decades there has been a dramatic increase worldwide in both incidence and severity of Clostridium difficile infection (CDI). Paralleling the rising incidence of CDI in the general population, there has been an even higher increase in the incidence of CDI among patients with inflammatory bowel disease (IBD). CDI may mimic a flare of IBD as symptoms and laboratory parameters are often similar, and therefore, screening for CDI is recommended at every flare in such patients. Enzyme immunoassay to detect Clostridium difficile toxin A and B in stool is still the most widely used test for CDI diagnosis despite its low sensitivity. Metronidazole for mild/moderate CDI,and vancomycin for severe CDI are the preferred agents for the treatment of infection. CDI has a negative impact both on short- and long- term IBD outcomes, increasing the need for surgery, as well as the mortality rate and healthcare costs. All gastroenterologists and surgeons should have a high index of suspicion for CDI when evaluating a patient with IBD flare, as prompt diagnosis and adequate treatment of infection improve outcomes. Measures must be taken to prevent spreading of infection in gastroenterology /surgery settings.

Infectious complications in patients with liver cirrhosis

Liver cirrhosis is the end stage of any chronic liver disease. Complications occurring in patients with liver cirrhosis may be specific to this pathology and to gastroenterology (upper gastrointestinal bleeding, hepatic encephalopathy) or may interfere with other specialties (hepatorenal syndrome, spontaneous bacterial peritonitis, and other localized infectious complications). Over the past few decades, major efforts have been made to increase survival in patients with cirrhosis, but unfortunately, few therapeutic methods have been proven effective. Bacterial infections are frequent and serious complications of liver cirrhosis, resulting in high morbidity and mortality, especially in hospitalized patients, despite significant progress in health care for those with advanced liver disease.

Assessing the risk of decompensation by ascites and spontaneous bacterial peritonitis in cirrhosis

AIM

The current trend is to analyze predictive factors of transition from compensated to decompensated stage by the onset of ascites and later of spontaneous bacterial peritonitis (SBP), which would make possible an early diagnosis of liver cirrhosis at the compensated stage. The aim of the study is to evaluate patients with liver cirrhosis, assessing the rate and the risk factors of decompensation by ascites and SBP.

MATERIAL AND METHODS

The prospective study included patients with cirrhosis of different etiologies admitted to a ward of the Institute of Gastroenterology and Hepatology of Iaşi in the period 1st January 2010-31st December 2010, which were reassessed clinically and in laboratory for 2 years. The essential criteria for the diagnosis of SBP were the presence of > 250 PMN/mm3. Compensated cirrhosis was defined as the absence of ascites. The presence of ascites and/or upper gastrointestinal hemorrhage (UGH) marks the state of decompensated cirrhosis. To assess the severity of liver cirrhosis there were used Child-Pugh score and MELD score. Diagnostic paracentesis and ascitic fluid sampling were performed at admission to hospital and during hospitalization, in the event of signs and symptoms of SBP, after antibiotic treatment. Macroscopic, biochemical (albumin, protein), cytological (cellularity) and bacteriological (smear and culture) investigations of the ascetic fluid were performed. Lack of response to empirical treatment was considered in cases of general condition deterioration and decreased PMN < 25% of baseline.

RESULTS

By comparing the mean values of patients with and without SBP, it is noted that bilirubin and creatinine were significantly higher in patients with SBP, and total protein, albumin and prothrombin time were significantly lower in patients with SBP, these biochemical parameters correlate with the degree of hepatic impairment and may be considered risk factors for SBP. In relation to the mentioned elements, the most important predictors of PBS risk are low protein concentration in ascitic fluid under 1g/dl, increased levels of serum bilirubin and low platelet count. Impaired liver function, infectious complications, and previous episodes of SBP, UGH are risk factors for an episode of SBP. Empirical therapy of nosocomial SBP with third-generation cephalosporins is often inefficient due to the high prevalence of multiresistant (MR) bacteria.

CONCLUSIONS

Assessment of clinically significant portal hypertension (PHT) and the degree of hepatic impairment may stratify patients with cirrhosis according to the risk of decompensation, making possible the identification of high risk patients. The knowledge of the risk factors in SBP is important not only to identify patients who could benefit from preventive therapy, but also in understanding the pathogenesis of the disease.

The influence of antibiotic treatment on the dynamics of oxidative stress in spontaneous bacterial peritonitis

Bacterial infections play an important role in liver cirrhosis complications, being together with variceal bleeding and hepatic encephalopathy an important cause of morbidity and mortality in cirrhotic patients. Spontaneous bacterial peritonitis (SBP) is a major complication of liver cirrhosis, with a significant mortality. Recent studies have demonstrated the involvement of oxygen free radicals in the pathogenesis of liver cirrhosis, but the role of oxidative stress in the development of SBP is not very clear yet.

PURPOSE

This study aims to evaluate the role of oxidative stress in the pathogenesis of spontaneous bacterial peritonitis and its changes after therapy.

MATERIAL AND METHODS

The study is a prospective case-control, which included 33 patients divided into 3 groups: group I- 10 patients with decompensated cirrhosis and SBP, group II - 17 patients diagnosed with decompensated liver cirrhosis with ascites, and group Ill - 6 patients with compensated liver cirrhosis. The control group consisted of 19 healthy subjects recruited from hospital staff, adapted to patients by age and sex. Malonildyaldehida (MDA), a product of lipid peroxidation, was dosed in the blood and ascitic fluid of patients by assay thiobarbituric acid reactive substances (TBARS).

RESULTS

Serum MDA significantly increased in the group with decompensated cirrhosis and SBP compared with the control group. MDA levels in ascitic fluid showed a statistically significant increase in the SBP group compared with patients without SBP. There was a decrease of MDA after 6 months of antibiotic treatment compared with the initial stage, while MDA values increased in the absence of treatment.

CONCLUSIONS

The study demonstrates the increased oxidative stress markers in the blood and ascitic fluid of cirrhotic patients with SBP, which can be considered a predictor of SBP and also a marker of treatment response.

KEYWORDS

SPON-

Platelet indices in patients with de novo portal vein thrombosis and liver cirrhosis

Platelet indices are markers of platelet reactivity used for thrombotic risk assessment in patients with cardiovascular diseases, and recently in venous thrombosis.

AIM

To assess the diagnostic value of platelet indices in patients with non-malignant de novo portal vein thrombosis and liver cirrhosis.

MATERIAL AND METHODS

We conducted a prospective, case-control study on patients admitted to a tertiary center in the interval January, 2010 - December, 2012. Included in the study were 54 patients with portal vein thrombosis (PVT) and 54 controls. Patients with known malignancy, sepsis, thrombophilia, on anticoagulant or antiaggregant therapy, acute or chronic inflammatory diseases, severe anemia, renal failure, acute coronary syndrome, and chronic pulmonary disease were excluded from the study.

RESULTS

Both groups were comparable for baseline characteristics. Mean platelet volume, platelet distribution width (PDW) and plateletcrit were higher in the PVT group. In a multivariate logistic regression analysis, significant predictors of the presence of PVT were mean platelet volume (MPV), PDW, and procalcitonin (PCT).

CONCLUSION

Our data suggest that increased platelet indices contribute to the prethrombotic state in liver cirrhosis and that larger platelets may play a specific role in thrombosis despite thrombocytopenia.

Different profile of peripheral antioxidant enzymes and lipid peroxidation in active and non-active inflammatory bowel disease patients

BACKGROUND

The role of oxidative stress in inflammatory bowel diseases (IBD) has been extended lately from a simple consequence of inflammation to a potential etiological factor, but the data are still controversial. Active disease has been characterized before by an enhanced production of reactive oxygen species and the increased peroxidation of lipids, but patients in remission were generally not considered different from healthy people in terms of oxidative stress.

AIMS

We evaluated the antioxidant defense capacity and lipid peroxidation status in the serum of patients with active and non-active disease compared with healthy matched control subjects.

METHODS

The study included 20 patients with confirmed IBD in clinical and biological remission, 21 patients with active disease, and 18 controls. We determined the serum levels of two antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GPX), and a lipid peroxidation marker, malondialdehyde (MDA).

RESULTS

Active disease patients had an increased activity of both SOD and GPX, as well as significant high values of MDA versus controls. Furthermore, patients being in remission had significantly lower values of antioxidant enzymes (SOD and GPX) and increased lipid peroxidation measured by MDA serum levels, as compared with healthy control subjects.

CONCLUSIONS

Our study confirmed the presence of high oxidative stress in active IBD. More importantly, we have demonstrated a lower antioxidant capacity of patients in remission versus control group. This may represent a risk factor for the disease and can be an additional argument for the direct implication of oxidative stress in the pathogenesis of IBD.

The risk of thrombotic events in patients with liver cirrhosis

AIM

To evaluate the incidence and risk factors for thrombotic events (deep vein thrombosis and portal vein thrombosis) in patients with liver cirrhosis.

MATERIAL AND METHODS

we studied patients diagnosed with liver cirrhosis admitted in our department between January 2010-December 2011, which were divided in two groups: liver cirrhosis with thrombotic events and without thrombotic events.

RESULTS

we included 3108 patients, the incidence of deep vein thrombosis was 0.99% and portal vein thrombosis was 1.51%, the incidence of all thrombotic events was 2.5%. In the univariate analysis serum albumin was significantly lower in cases than controls, and MELD score, mean platelet volume were higher in cases than controls. The presence of sepsis and diabetes mellitus were demonstrated like risk factors by the univariate analysis. In multivariate analysis, albumin level< 3mg/dl (HR=1.65, CI 1.10-2.51, p=0.018) and MELD score >13 (HR=2.94, CI 1.61-5.47, p=0.001) remained independently predictive of thrombotic events.

CONCLUSIONS

The incidence of thrombotic events in patients with liver cirrhosis was 2.5%. Low serum albumin and high MELD score could predict the development of thrombotic events in patients with liver cirrhosis.

Colon capsule endoscopy compared to colonoscopy for colorectal neoplasms diagnosis: an initial experience and a brief review of the literature

Conventional colonoscopy is regarded as the gold standard procedure for the diagnosis of colorectal neoplasms despite its several limitations including invasiveness, discomfort and potential complications. Colon capsule endoscopy (CCE) could be an attractive alternative method to the invasive colonoscopy for the diagnosis of colorectal cancer and polyps. Publications regarding the use of CCE for detecting colorectal cancer and polyps, as well as our experience, were reviewed. The new second-generation CCE (PillCam COLON 2) has improved accuracy compared with the first-generation system for detecting colorectal neoplasms.

Non-invasive evaluation of liver fibrosis in chronic hepatitis C

Chronic hepatitis C (CHC) is a major public health concern, with around 180 million individuals affected worldwide. Liver fibrosis and its end-point cirrhosis are the main causes of morbidity and mortality in patients with CHC. Liver biopsy (LB) has traditionally been considered the "gold standard" for pre-treatment evaluation of liver fibrossis in patients with CHC. However, LB is an invasive procedure with several shortcomings (intra- and interobserver variability, sampling errors, expensive) and the risk of rare but potentially life-threatening complications (biliary peritonitis, hemo-peritoneum, and death in 1/10,000). The aforementioned shortcomings of LB have led to development of several non-invasive methods for the assessment of liver fibrosis in CHC. Among the non-invasive methods, Fibrotest and Fibroscan are the most widely used in our country and offer a viable alternative to LB for pre-treatment assessment of liver fibrosis in patients with CHC. This review aims to discuss the advantages and usefulness of non-invasive methods of liver fibrosis in CHC.

A prospective study of pre-illness diet in newly diagnosed patients with Crohn's disease

BACKGROUND

Environmental factors, including diet, seem to participate in the etiology of inflammatory bowel disease. The kind of dietetic habits before the appearance of the illness in patients with Crohn's disease (CD) has not been studied extensively.

AIM

To prospectively assess the kind of food consumption in patients with CD exactly at the time of diagnosis and to identify dietary constituents as risk factors for development of CD. PATIENTS - METHODS: Twenty eight patients with a newly established diagnosis of CD (2-4 weeks), (12 men and 16 women), 30 patients with previously (between 2 - 11 years) established diagnosis of CD (14 men and 16 women) and 38 age- and sex-matched healthy controls (16 men and 22 women) were included in the study. Dietary intake was assessed by means of special questionnaire.

RESULTS

Comparisons between controls and newly diagnosed patients showed that increased consumption of milk and yogurt (P = 0.042), fruits (P = 0.0001), citrus (P = 0.0001), vegetables (P = 0.0001), carrots (P = 0.0001), legumes (P = 0.036), fish and selfish (P = 0.001), honey (P = 0.003), and nuts (P = 0.038), was associated with decreased risk for CD. On the other hand, significantly increased intake of fat (P = 0.041), olive oil (P = 0.038), margarine (P = 0.038), sugar (P = 0.02), alcohol drinks (P = 0.009), fried food (P = 0.0001), and pasta (P = 0.0001), was noticed on recently diagnosed patients in comparison with the healthy control group. On logistic regression analysis foods remaining statistically significant were: margarine, pasta, fried foods, fat, olives, sugar (increased risk), and yogurt, honey, fruits, nuts, fish, and citrus fruits (decreased risk). Newly diagnosed patients were significantly overweighed (64%) compared to healthy people (26%) and old patients (7%).

CONCLUSION

Significant differences in many kinds of food between newly diagnosed patients with CD, patients with established CD and normal people certainly exist. Our results suggest that specific dietary patterns could be associated with higher or lower risks for CD in adults. However, whether these dietary factors are important for the development of CD or modulate the effect of other environmental factors is unknown.

Efficacy of Helicobacter pylori eradication therapy in cirrhotic patients with peptic ulcer disease

Few studies have been focused on the role of Helicobacter pylori eradication in cirrhotic patients with peptic ulcer and the reported results are conflicting.

AIM

To evaluate the efficacy of proton pump inhibitor (PPI)-based triple therapy on peptic ulcer course in patients with liver cirrhosis.

MATERIAL AND METHODS

This prospective study was carried out in a tertiary-care hospital. Of the 63 consecutive cirrhotic patients with peptic ulcer identified by endoscopy 39 (22 males, 14 females, aged 53 to 62 years) entered the study. The patients with peptic ulcer and H. pylori infection received eradication therapy, while H. pylori negative patients received PPI treatment. H. pylori eradication was confirmed by rapid urease test and histological examination. Follow-up endoscopies were performed at 6 and 12 months. The patients with peptic ulcer recurrence were treated with PPI.

RESULTS

Of the 39 selected patients 22 (56.4%) were H. pylori positive, and 17 (43.6%) were H. pylori negative. H. pylori was eradicated in 63.6% (14/22) of the patients. During the follow-up period 2 H. pylori negative patients died from variceal bleeding and hepatic encephalopathy, respectively, and one H. pylori positive patient did not return for further assessment). Ulcers recurring within 1 year were found in 14 of 36 (38.8%) patients. Peptic ulcer recurred in 4 of 21 (19.0%) H. pylori positive patients and in 10 of 15 (47.6%) H. pylori negative patients at study entry. Patients' age (p = 0.018), Child-Pugh stage (p = 0.019), peptic ulcer site (p = 0.008), and H. pylori negative status (p = 0.004) were significantly related to ulcer recurrence.

CONCLUSIONS

Eradication of H. pylori infection in patients with liver cirrhosis and peptic ulcer disease could be helpful, but does not protect all cirrhotic patients from peptic ulcer recurrence. Most relapsed ulcers were gastric ulcers in H. pylori negative patients.

[The role of capsule endoscopy in suspected Crohn's disease]

Capsule endoscopy (CE) revolutionized the small bowel examination. We emphasize the role of CE in suspected Crohn's disease, studying 24 investigations performed in the Institute of Gastroenterology and Hepatology. The global diagnostic yield was 54%, the specific diagnostic yield for Crohn's disease was 37.5%, the specificity was 100% and the retention rate was 4.1%. For maximum accuracy and efficiency, unitary administration and diagnostic criteria are needed, and for minimising the risk of complications, specific prior investigations would be suitable.

[High levels of sterigmatocystin in patients with chronic liver diseases]

Sterigmatocystin (STC) is a wide spread mycotoxin produced by Aspergillus fungi, with hepatotoxic and carcinogenetic proprieties.

OBJECTIVES

To determine the STC concentration in blood and urine from patient with liver cirrhosis (LC) and hepatocellular carcinoma (HCC), with correlation with liver function parameters.

MATERIAL AND METHODS

The study enrolled 166 patients divided in three groups: control--55 patients (27M, 28F); LC--58 patients (31M, 27F); HCC--53 patients (26M, 27F). 20 ml of blood and 50 ml of urine were collected from each patient and liver enzymes and alfa-fetoprotein (AFP) were measured. STC was determined by high performance liquid chromatography, with concomitant detection in ultraviolet and fluorescence.

RESULTS

STC was detected in 26.2% of samples, more frequently in LC and HCC groups (p < 0.001). STC mean values were 0.014 ng/ml and 0.005 ng/ml in blood, respective urine of controls, rising to 0.626 ng/ml (p = 0.003) respective 1.053 ng/ml (p = 0.049) in LC and 2.02 ng/ml in blood (p < 0.0001) and 9.39 ng/ml in urine (p = 0.003) in patients with HCC. There is a perfect correlation between serum and urinary levels of STC in controls (r = 1), that become weak in patients with LC (r = 0.48) and insignificant in HCC (r = 0.15). AFP values were significantly correlated with STC concentration in patient with HCC, in both blood (r = 0.31) and urine (r = 0.84).

CONCLUSIONS

STC values in patients with LC and HCC were significantly higher compared to controls. Strong positive correlation of STC with AFP in patients with liver cancer suggested a possible role of this mycotoxin in pathogenesis of the disease.

[Peptic ulcer disease in liver cirrhosis: role of Helicobacter pylori infection and therapeutic approach]

Peptic ulcer has frequently been associated with liver cirrhosis. The death rate for peptic ulcer in cirrhotics has been reported to be five times higher than in general population. The underlying mechanisms are poorly understood. Different factors have been claimed to be involved, such as alterations in serum gastrin level, gastric acid secretions, mucosal blood flow and decreased prostaglandin production in gastric mucosa. Moreover, Helicobacter pylori infection, when accurately assessed, is detectable in most peptic ulcer cirrhotics. Since the H. pylori infection strongly correlates with peptic ulcer in general population, it is necessary to clarify the role of H. pylori in the pathogenesis of peptic ulcer in cirrhosis before eradication can be proposed as a preventive measure.

[Colonoscopic screening of asymptomatic individuals with a family history of colorectal cancer]

BACKGROUND AND AIMS

First-degree relatives of colorectal cancer (CRC) patients are at increased risk for developing colorectal neoplasm. The aim of our study was to evaluate the use of total colonoscopy as the screening test in asymptomatic individuals with a family history of colorectal cancer.

MATERIAL AND METHOD

Colonoscopy was performed in 125 asymptomatic individuals (64 men and 61 women; mean age 51.7 +/- 11.5 years, range 24-77 years) who had one or two first-degree relatives with CRC.

RESULTS

Forty-five colorectal lesions were found in 36 subjects (28.8%): one (0.8%) adenocarcinoma, and 44 polyps (31 adenomas; 13 hiperplasic) (28.0%). The cecum was intubated in 96% of cases, and the procedure was generally well tolerated without complications.

CONCLUSIONS

Total colonoscopy is a useful and safe screening procedure for the examinations of asymptomatic individuals with a family history of CRC.

[Capsule endoscopy role in diagnosis of small bowel tumors]

Since the introduction of capsule endoscopy (CE), several studies suggested a higher frequency of small bowel tumors (SBTs) than previously reported.

MATERIAL AND METHOD

We evaluated the prevalence, presentation and diagnostic work-up of SBTs in patients undergoing CE in a single referral center. During 2003 - 2009, 102 patients underwent CE. For each patient with suspected SBT at CE, with subsequent histological confirmation, we registered clinical and biological features, imaging methods performed and management.

RESULTS

SBTs were detected in 4.9% of patients undergoing CE. The main indication for CE was obscure gastrointestinal bleeding. All patients had undergone, before CE, at least one procedure evaluating the small bowel. All patients had iron-deficiency anemia, some presented also other gastrointestinal symptoms. The main SBT type was gastrointestinal stromal tumor. Three patients underwent single-balloon enteroscopy; surgery was performed in all patients. No retention of capsule occurred. CE could be used as first choice as diagnostic tool when SBTs are suspected.

Hereditary hemochromatosis in north-eastern Romania

Hereditary hemochromatosis is a genetic disturbance of iron metabolism resulting in iron overload in several organs and their functional failure. Early diagnosis is necessary to start a simple and effective therapy: bleeding. It is the most frequent genetic disease in some populations. Our objectives were 1. An estimate of the expectancy of the disease in the population of our geographic region, and 2. To diagnose the disease by applying the established methods and estimate the efficiency of our diagnosis.

METHODS

1.To estimate the expectancy, we genotyped 200 persons for the most frequent mutations causing the disease: HFE-C282Y and HFE-H63D by PCR-RFLP. 2. To diagnose the disease phenotypically we determined plasma iron level, ferritin level and transferrin saturation index in 549 patients previously diagnosed as chronic hepatitis or cirrhosis and genotyped those with hemochromatosis phenotype.

RESULTS

1. We found allelic frequencies of 1.75% and 13.25% for the HFE-C282Y and H63D mutant alleles respectively. From these frequencies we calculated that a severe case caused by a C282Y/C282Y homozygote can arise in 816 people and a mild case caused by a C282Y/H63D compound heterozygote can arise in 100 people 2. Among 549 patients we found 10 to have the phenotype of hemochromatosis and 3 out of the 10 were found to carry mutations: two in the HFE gene (one homozygous C282Y and one compound heterozygous C282Y/H63D) and one in the hemojuvelin (HJV) gene (a G320V).

Colonoscopic screening of asymptomatic first-degree relatives of colorectal cancer patients

AIM

First-degree relatives of colorectal cancer (CRC) patients are at increased risk for developing colorectal neoplasm, and current guidelines recommend screening colonoscopy in such individuals. The aim of this study was to evaluate the use of colonoscopy as the screening test in asymptomatic first-degree relatives of CRC patients.

MATERIAL AND METHOD

Colonoscopy was performed in 102 asymptomatic individuals who had at least one first-degree relatives with CRC. Subjects included in the screening program were aged between 36 and 72 years, and majority came from two counties (Suceava, Iaşi) located in north-eastern Romania.

RESULTS

Thirty colorectal lesions were found in 17 individuals: two (6.6%) had adenocarcinomas, and remaining 15 patients had 28 polypoid lesions: 14 (46.6%) adenomas, 5 (16.6%) tubulovillous adenomas, 3 (10%) adenomas with high grade dysplasia and 6 (20%) had hyperplasic polyps.

CONCLUSION

Colonoscopy is a useful, feasible and safety initial screening tool for first-degree relatives of patients with CRC.

[Helicobacter pylori infection and symptoms of gastroesophageal reflux disease]

The effect of Helicobacter pylori (H. pylori) on gastroesophageal reflux disease (GERD) is controversial. The aim of this study was to assess the relationship between H. pylori infection and symptoms of GERD.

MATERIAL AND METHOD

112 patients (41 men, 71 women; mean 51 +/- 9.54 yeas, range 21-71 yeas) with symptomatic GERD were studied. The serologic evidence of H. pylori infection (IgG antibodies) was determined by means of ELISA ( enzyme-liked immunosorbent assay) in all patients.

RESULTS

There were 59 (53.2%) patients infected with H. pylori. Statistical analysis did not reveal any significant different symptom scores between patients with and those without H. pylori infection.

CONCLUSIONS

H. pylori infection plays no role on the development of GERD symptoms.

Tailoring gold nanostructures for near-field optical applications

A method of combined thin-film deposition, electron beam lithography, and ion milling is presented for the fabrication of gold and silver nanostructures. The flexibility of lithographical processes for the variation of geometric parameters is combined with three-dimensional control over the surface evolution. Depending on the etching angle, different shapes ranging from cones over rods to cups can be achieved. These size- and shape-tunable structures present a toolbox for nano-optical investigations. As an example, optical properties of systematically varying structures are examined in a parabolic mirror confocal microscope.

Nanoscale spectroscopic imaging of organic semiconductor films by plasmon-polariton coupling

Tip-enhanced near-field optical images and correlated topographic images of an organic semiconductor film (diindenoperylene, DIP) on Si have been recorded with high optical contrast and high spatial resolution (17 nm) using a parabolic mirror with a high numerical aperture for tip illumination and signal collection. The DIP molecular domain boundaries being one to four molecular layers (1.5-6 nm) high are resolved topographically by a shear-force scanning tip and optically by simultaneously recording the 6x10{5} times enhanced photoluminescence (PL). The excitation is 4x10{4} times enhanced and the intrinsically weak PL-yield of the DIP-film is 15-fold enhanced by the tip. The Raman spectra indicate an upright orientation of the DIP molecules. The enhanced PL contrast results from the local film morphology via stronger coupling between the tip plasmon and the exciton-polariton in the DIP film.

[Prevalence of Helicobacter pylori infection in patients with gastroesophageal reflux disease]

The relationship between Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease (GERD) is controversial. Epidemiological studies are heterogenous, geographical location being an important determinant. The aim of present study was to evaluate the prevalence of H. pylori infection in patients with GERD in evidence at a tertiary medical center from the north-eastern region of Romania.

MATERIAL AND METHODS

Between January 2006 and April 2009 a prospective study was performed in 112 patients (41 men, 71 women mean age: 51 +/- 18 yeas, range 21-71 years) with GERD in order to determine the prevalence of H. pylori infection. H. pylori status was determined by serology and urease test.

RESULTS

H. pylori infection was found in 59 (53.3%) patients with GERD, and in 46 (45.1%) subjects from control group, the difference being statistically not significant.

CONCLUSIONS

Current data do not provide sufficient evidence to define the relationship between H. pylori and GERD. Based on our findings, the prevalence of H. pylori infection in patients with GERD is in the range of that found in general population from the north-eastern region of Romania.

[Aflatoxin contamination of food: additional risk factor for chronic liver diseases]

Aflatoxins are over all spread toxic metabolites of fungi, able to induce chronic liver damages.

AIM

To establish the correlation between the degree of liver disease and risk of chronic intake of aflatoxin contaminated foods.

MATERIAL AND METHOD

123 patients divided in three groups (controls, chronic hepatitis and liver cirrhosis) completed a food frequency questionaire (FFQ) estimating the intake risk of foods with a high potential of contamination with aflatoxins and alcohol consumption.

RESULTS

Frequent intake of high risk foodstuff was declared by 37% of the participants, without any differences between the three groups. Foods with a very high risk of contamination were more frequently consumed in rural areas (predominant maize and oily seeds), while in the urban areas spices and coffee prevailed. In countryside, the feeding risk decreased with the gravity of liver disease, but alcohol consumption was significantly greater.

CONCLUSION

FFQ revealed a high risk of ingestion of aflatoxin contaminated foodstuff in general population, greater in rural areas. The risk of aflatoxin intake seems unreleated with the gravity of chronic liver disease.

[Prevalence of delayed gastric emptying of solids in functional dyspepsia and its relationship to symptoms]

The relationship between functional dyspepsia and delayed gastric emptying of solids is still unclear. This study evaluated the prevalence of delayed gastric emptying of solids in functional dyspepsia patients and its relationship to dyspeptic symptoms.

MATERIAL AND METHOD

142 patients with functional dyspepsia were prospectively assessed, the solid gastric emptying was measured using 13C-acid octanoic breath test and the severity of six dyspeptic symptoms (postprandial fullness, early satiety, bloating, abdominal discomfort, nausea and vomiting) was scored.

RESULTS

Gastric emptying of solids was delayed in 45 (31.7%) dyspeptic patients. Multivariate analysis showed that the presence and severity of nausea and vomiting were associated with delayed solid gastric emptying (p < 0.05). Female gender was also associated with the risk of delayed gastric emptying (p < 0.05).

CONCLUSIONS

A subset of functional dyspepsia patients has delayed gastric emptying of solids. Female sex, the presence and severity of nausea and vomiting are independently associated with delayed gastric emptying of solids in these patients.

[Prevalence of Helicobacter pylori in liver cirrhosis complicated with hepatic encephalopathy]

Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis, and plasma ammonia plays a pivotal role in its pathogenesis. Helicobacter pylori (H. pylori) urease activity is a potential source of ammonia in the stomach of patients with cirrhosis and may contribute to hyperammonemia in these patients, but conflicting data are available in the literature. The aim of our study was to evaluate the prevalence of H. pylori infection in cirrhotic patients with HE admitted in a tertiary medical center from nord-eastern region of Romania.

RESULTS

seroprevalence of H. pylori infection in cirrhotic patients with HE did not significantly differ from cirrhotic patients without HE (51.61% vs. 48.39%). Clinical and biochemical parameters were almost similar between patients with HE H. pylori-positive and those H. pylori-negative.

CONCLUSIONS

the prevalence of H. pylori infection in cirrhotic patients with HE is almost similar to that found in patients with liver cirrhosis without HE. Our results suggest that H. pylori infection is not an independent risk factor for HE in cirrhotic patients.

[Prevalence of Helicobacter pylori infection in patients with diabetes mellitus]

Helicobacter pylori (H. pylori) and diabetes mellitus are the most important causes of dyspepsia. The aim of this study was to evaluate the prevalence of H. pylori infection in patients with diabetes mellitus, and to assess whether the infection was associated with severity of dyspeptic syndrome and metabolic glycemic control.

MATERIAL AND METHOD

100 patients with diabetes mellitus type 1 and 2 (41 men and 59 women, mean age 58.59 ani) were included in our study. Each patient completed a self-report questionnaire to obtain information concerning the presence and severity of upper gastrointestinal tract symptoms. H. pylori status was confirmed by serological test and histophatology study of gastric biopsy or 13C-urea breath test.

RESULTS

Prevalence of H. pylori infection was found not to be significantly higher in diabetics than in controls (70% vs 73% ). 49% H. pylori positive diabetics had type 2 insulinonecesitant diabetes mellitus, 27% had type 1 diabetes mellitus and 24% had type 2 diabetes mellitus, with no statistically significant difference (p > 0.05). We found no statistically significant difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. The main value of HbA1 levels in H. pylori--infected diabetics was 7.31% and 7.47% in H. pylori non-infected diabetics, without significant difference.

CONCLUSION

There was no statistically significant difference in the prevalence of H. pylori infection between diabetics and non-diabetics patients and no difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. H. pylori in diabetics appears no influence glycemic status.

13C-urea breath test for the diagnosis of Helicobacter pylori infection in bleeding duodenal ulcer

Helicobacter pylori (H. pylori) is the main etiologic factor for duodenal ulcer (DU). Bleeding is still a frequent and sometimes severe complication, with unacceptable mortality despite modern therapeutic modalities. The importance of diagnosing and treating H. pylori infection in bleeding DU is underlined by the fact that eradication therapy is effective in preventing recurrent bleeding. The aim of this study was to evaluate the prevalence of H. pylori infection by means of 13C urea breath test (13C-UBT) in patients with bleeding DU.

MATERIAL AND METHOD

Thirty-nine patients (25 men, 14 women) hospitalized with bleeding DU underwent emergency endoscopy and treated with intravenous proton pump inhibitors (PPIs), and a 13C-UBT was performed the day after the resuming oral feeding.

RESULTS

Twenty-seven patients (19 men, 8 women) (69.3%) had a positive 13C-UBT. All patients received intravenous PPIs (22 pantoprazole, 17 esomeprazole) after emergency endoscopy (80 mg bolus + 8 mg/hour infusion/day) for 3-4 days. The time elapsed between admission and performance of 13C-UBT did not differ significantly between patients having a positive or negative 3C-UBT (5.6 vs 6.1 days). Eight of the twelve patients (66.6%) with a negative 13C-UBT had a repeated test two month later, and five of them became positive; therefore, H. pylori infection was finally detected in 32 (82%) out of 39 patients with bleeding DU.

CONCLUSION

Most patients with bleeding DU have a positive 13C-UBT although they were taking PPIs.

[The relationship between bile reflux and symptoms in patients with gallstones before and after cholecystectomy]

Many hypotheses affirm that postcholecystectomy syndrome is caused by alterations in bile flow due to the loss of the reservoir function of the gallbladder. We aimed to establish the relationship between postcholecystectomy symptoms and bile reflux.

MATERIAL AND METHOD

Thirty patients with gallstones were included in the study. All patients underwent combined ambulatory pH and bile monitoring (Bilitec). Three months after cholecystectomy, the tests were repeated.

RESULTS

Before surgery, the median (interquartile range) total time pH < 4 was 2.8% (0.2-14%) and bilirubin absorbance > 0.14 was 4.1% (0-17%). After cholecystectomy, the median total time pH < 4 was 3.7% (1.5 %-11.4%) and bilirubin absorbance > 0 14 was 13.25% (5.30%-26.5%). The correlation between total time pH < 4 and total time bilirubin absorbance > 0.14 for all patients was good: r = 0.55, p < 0.001. Before surgery 65.03% of symptoms were not associated with neither acid nor bile reflux and postcholecystectomy 37.87% of symptoms were associated with bile reflux and 36.95% without any reflux. Cholecystectomy determines increased biliary reflux compared to the patients with gallstones. Related to gallstones, after cholecystectomy dyspeptic complains are more often related to bile reflux.

CONCLUSION

Although cholecystectomy itself does cause increased biliary reflux, in most patients with significant duodenogastric reflux symptoms were not correlated with biliary reflux.

[Gastroparesis--diagnosis and treatment]

Gastroparesis is a disorder characterized by a delay in gastric emptying of a meal in the absence of a mechanical gastric outlet obstruction. Diagnosis of gastroparesis is based on the presence of symptoms ( nausea, vomiting, postprandial abdominal fullness), excluded mechanical obstruction (endoscopy) and on objectively determined delay in gastric emptying. Gastric emptying can be assessed by scintigraphy and stable isotope breath tests. The true prevalence of gastroparesis is unknown. The aetiology of gastroparesis is diverse. In approximately one third of cases, gastroparesis is related to the presence of diabetes mellitus; one third of case is of unknown cause (idiopathic). Mild disease will respond to dietary and life style measures and prokinetics (domperidone, metoclopramide, erytromicyne). Severe disease can benefit from intrapyloric botulinum toxin injection, gastric pacing or more radical surgical interventions (partial or total gastrectomy).

[High blood and urine concentration of hepatotoxic mycotoxins (aflatoxin B1, sterigmatocystin) in patients with liver cirrhosis]

Aflatoxins and sterigmatocystin are potent carcinogens, certainly involved in pathogenesis of liver cancer.

AIM

To evaluate the risk of mycotoxin intake and to determine the presence of aflatoxin B1 (AFB1) and sterigmatocystin (STC) in patients with liver cirrhosis.

MATERIAL AND METHOD

The study included 92 patients (33 controls, 59 liver cirrhosis) that completed a food frequency questionnaire (FFQ). Blood and urine samples were collected and mycotoxins determined by high performance liquid chromatography.

RESULTS

18.18% samples in controls and 72.88% in cirrhosis group presented detectable levels of mycotoxins. The mean values of AFB1 in blood were 0.7 ng/mL in controls and 1.67 ng/mL in test group (p = 0.11); STC presented 60 times higher levels in second group (p < 0.01). AFB1 presented a mean level of 1.2 ng/mL in urine of test group (not detected in controls); STC presented 256 time higher concentration in urine of cirrhotic patients, with a perfect correlation between blood and urine levels in control (r=1) and no correlation in test group (r = 0.05). There were no correlations between mycotoxin, liver enzymes, alpha-fetoprotein and mycotoxin intake risk estimated by FFQ.

CONCLUSION

Most of the patients presented detectable levels of mycotoxins, significantly increased in cases with liver cirrhosis, probable due to a specific metabolic pattern.

[Liver hemosiderosis study in chronic viral hepatitis]

In chronic viral hepatitis the histopathological exam can reveal the presence of liver iron deposits in 10 to 73% of patients. Iron deposits are usually found in Kupffer cells, in endothelial cells and portal macrophages, and extremely rarely in hepatocytes.

AIM

To evaluate the incidence of hepatic hemosiderosis in chronic viral hepatitis.

METHODS

549 morphopathological features of liver biopsy specimens performed in the Gastroenterology and Hepatology Institute IaSi, between January 1 2003 and December 31 2007 have been analyzed. Semiquantitative assessment of the degree of hepatic iron overload was performed and the localization of haemosiderin deposits: at the level of hepatocytes, the reticuloendothelial system or mixedly. The same anatomopathologist examined the blades and interpreted the results.

RESULTS

The medium age of patients who underwent liver biopsy was 45.08 years +/- 10.045. Positive iron staining was found in 22.8% of cases, more frequently in males (31%), and in 91.82% of cases iron deposits were grade 1-2. The association of alcoholic etiology did not influence the incidence of hemosiderosis: 23% in patients with hepatitis and no ethanol exposure vs 25% in cases of strictly viral etiology. Deposits of haemosiderin were more frequent in viral hepatitis B (38.6%) than in viral hepatitis C (26.9%). In 34% of cases stainable iron was found only in reticuloendothelial system and in 46% of cases both in Kupffer cells and hepatocytes.

CONCLUSION

Almost a quarter of chronic viral hepatitis cases are associated with liver deposits of haemosiderin, with features of secondary iron overload (deposits localized in the mesenchymal areas or mixedly). There is a higher risk of hemosiderosis in men, especially for those between 30 and 50. Liver iron overload levels in chronic viral hepatitis are, in most cases, low or medium, and the association with an alcoholic etiology does not influence the incidence of hemosiderosis in chronic viral hepatitis.

[Prevalence and role of Helicobacter pylori infection in some gastroduodenal and hepatic complications in cirrhotic patients]

It has been clearly established that Helicobacter pylori (H. pylori) infection plays a pivotal role in the pathogenesis of chronic gastritis, peptic ulcer, gastric adenocarcinoma, and gastric lymphoma MALT (mucosa-associated lymphoid tissue) in the general population, but data regarding the prevalence and the role of H. pylori infection in liver cirrhosis are conflicting. Most serological studies estimated a high prevalence of H. pylori infection in patients with liver cirrhosis; however, when other methods (urea breath test, histology, culture, rapid urease test) were used, the overall H. pylori prevalence was similar to that in controls. Although the prevalence of both gastric ulcer (GU) and duodenal ulcer (DU) is higher in cirrhotic patients than in general population, the relationship between H. pylori infection and peptic ulcer in cirrhosis remains controversial. Our data regarding peptic ulcer prevalence in cirrhotic patients are in agreement with previous studies that suggest an increased prevalence of both GU and DU. The incidence of bleeding peptic ulcer is high in cirrhotic patients and carries an increased risk of complications or death in these patients and therefore eradication of H. pylori infection might be as effective in preventing ulcer relapse and bleeding as it is in noncirrhotic ulcer patients. Hepatic encephalopathy is a frecquent complication of liver cirrhosis, and it is widely accepted that ammonia plays a major role in its pathogenesis. The ammonia production by H. pylori urease does not increase blood ammonia levels during cirrhosis, and eradication of H. pylori infection does not affect hepatic encephalopathy status.

[Unusual forms of liver abscesses]

Liver abscess is a rare disease. In this paper we present five unusual cases of liver absceses. These cases represents 5.68% from all patients with liver abscesses treated in the First Surgical Clinic Iaşi, from 1977 to 2007. The ethiology of the abscesses was different: intrahepatic biliary duct migration of Ascaris lumbricoides, migration of a foreign body (toothpick) from stomach into the liver, infected hydatid cyst with a large biliary leak and cholangitis and, residual cavities after surgical treatment of hepatic hydatid cyst associated with foreign bodies. Another case was a patient with a very large, multilocular liver abscess (2000 mL) with biliary ethiology. In all cases a surgical drainage was performed. In the cases with hydatid cysts and biliary leakage, ERCP procedures were performed. The postoperative course was uneventful.

CONCLUSIONS

Surgical treatment remains a valuable option in the treatment of pyogenic hepatic abscesses especially in unusual form.

[Involvement and role of iron in nonalcoholic steatohepatitis]

Nonalcoholic steatohepatitis (NASH) was described by Ludwig mainly in obese, middle-aged women, often associated with diabetes mellitus and hyperlipidemia. In the recent years, NASH was found to be associated with male, nonobese, nondiabetic patients and with liver iron overload, which led to the hypothesis of iron playing a role in NASH pathogenesis. Increased ferritin with normal transferrin saturation is frequently found in fatty liver patients, but it reflects iron overload only in those patients in which it persists despite an appropriate diet. Insulin resistance hepatic iron overload (IR-HIO) is a new condition of hepatic iron overload, characterized by hyperferritinemia with normal or slightly increased transferrin saturation in the absence of hemochromatotic gene mutations. Although patients with IR-HIO have a high prevalence of insulin resistance-related metabolic disorders, the relationship of IR-HIO and NASH is unclear. Two characteristics allow differentiation of IR-HIO from genetic haemochromatosis: iron overload is heterogeneous from one hepatocyte to another in the periportal area, and sinusoidal iron is distributed throughout the lobule. In IR-HIO, fibrosis develops at a much lower hepatic iron burden than in genetic haemochromatosis, and sinusoidal iron, steatosis and inflammation could represent the histological mark of activity and progression of liver disease in IR-HIO.

Tighter focusing with a parabolic mirror

We demonstrate experimentally and theoretically that a parabolic mirror (PM) with a high numerical aperture (NA) of 1 focuses a radially polarized laser mode to the smallest diffraction-limited spot at a fixed NA and wavelength, having an area of 0.134 lambda(2). The measurements were performed with a confocal microscope, using the PM as a focusing and collecting element. The results stand in accordance with the theoretical calculations presented by Davidson and Bokor [Opt. Lett. 29, 1318 (2004)], who predicted a reduction in the total focal spot size of 43% as compared with an aplanatic lens.

[Colorectal polyps: clinical, endoscopic, and histopathologic features]

AIM

To evaluate the prevalence of colorectal polyps in a population from North- Eastern Romania, which underwent colonoscopic examination and to identify their clinical, endoscopic and histopathologic characteristics.

METHODS

A retrospective prevalence study of subjects aged 18-95 years, with no personal or familial history of familial adenomatous polyposis and inflammatory bowel disease, who underwent a colonoscopy. The number, size, gross endoscopic appearance, histopathological examination, and the anatomic location of colorectal polyps were analyzed, as well as the associated diseases.

RESULTS

Enrolled were 1001 patients (647 men, 354 women), aged 18-95 years (mean: 62.8 +/- 11.4 years) who were diagnosed with colorectal polyps. Overall, there were 1.534 colorectal polyps, and the majority of them (83.0%) were present in patients over the age of 50 years, from urban area (73.9%) and most of the patients were men (63.8%), and had solitary polyps (61.1%). Three-quarters of polyps were distal (rectum, sigmoid, and descendent colon) in location, and most of them (75.8%) had a size less than 10 mm. Over half of all polyps (54.7%) were pedunculated. Based on the histological structural configuration, 76.5% of all polyps were adenomas, and of these 62.6% were tubular adenomas; malignant polyps have been diagnosed in 82 (5.4%) patients. Associated hemorrhoids, diverticulosis, colorectal cancer, and angiodysplasia were identified in 9.6%, 10% and 1.3%, respectively.

CONCLUSION

The prevalence of colorectal polyps in our geographical area is in the range with that observed in other regions of our country. Most of polyps were identified in patients older than 50 years, predominantly men, located in distal colon, had a tubular adenoma histological structure, and frequently associated with hemorrhoids and diverticular disease.

[Eosinophilic esophagitis--from a rare pediatric disease to the forefront of adult gastroenterology]

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.

Pregnancy and inflammatory bowel disease: a prospective case-control study

OBJECTIVE

Taking into account the relative confusion in the literature concerning the influence of pregnancy on the underlying inflammatory bowel disease (IBD) and vice versa, as well as the influence of drugs on the foetus and the gestation itself, we performed this prospective study, in order to further elucidate this interesting topic.

PATIENTS AND METHODS

Prospective follow-up study of 9 pregnant women with previously established IBD, 4 with ulcerative colitis (UC) and 5 with Crohn's disease (CD). Results were compared to those of 9 non-pregnant women with IBD with similar clinico-demographic characteristics (disease control group), and 18 healthy pregnancy women (healthy control group).

RESULTS

(a) Patients with IBD and gestation vs. healthy control group: Significantly impaired body weight in newborns from IBD mothers compared to healthy women (2530 +/- 961 g vs. 3242 +/- 582 g, P = 0.035) was found. Significantly more cases of therapeutic or spontaneous abortion and premature delivery in pregnant women with IBD compared to healthy pregnant women [5/ 9(56.6%) vs 1/18 (5.6%), P = 0.008] were also noticed. Concerning drug consumption, it was noticed that azathioprine was taken regularly in one case of spontaneous abortion and in one case of premature delivery. No significant differences concerning other parameters such as smoking habit and death of foetus were observed. (b) Patients with IBD and gestation vs. patients with IBD without gestation: No significant differences in the history of various parameters of the disease (number of operations, presence of fistulas), previous gestations, and course of the disease during the period of gestation were found. (c) Course of the disease six months after delivery: No significant differences between patients with IBD and pregnancy and disease control group were noticed.

CONCLUSION

It is concluded that gestation in women with IBD is accompanied by some unwanted events such as premature delivery, therapeutic or spontaneous abortion, and reduced newborn body weight. Clinicians must bear in mind the possibility of the appearance of some unwanted events in pregnant women with IBD during their gestation.

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.

[Hereditary hemochromatosis]

Hereditary hemochromatosis is an inherited disorder of iron metabolism in the Caucasian population with an autosomal recessive inheritance and a prevalence between 1 in 200 and 1 in 500. Until the discovery of HFE gene the diagnosis of hemochromatosis required documentation of iron overload or family linkage using HLA testing. The discovery of HFE gene has established the foundation for a better understanding of iron homeostasis and has changed hemochromatosis management: liver biopsy, gold standard diagnostic, was replaced by genetic test and it was suggested that population screening using genetic testing might be ideal for HFE related hemochromatosis. Considered for long time a unitary disease, a monogenic disorder characterized by excess tissue deposits of iron and subsequently organ damage, hemochromatosis is in fact a polygenic disease with many faces. The Online Mendelian Inheritance in Man database has lists four types of hereditary hemochromatosis, each of them caused by a different gene mutation (hepcidine, hemojuvelin, transferring receptor 2, ferroportin). The basic features shared by iron overload disorders associated with mutation in HFE, hepcidine, hemojuvelin, transferring receptor 2, ferroportin gene indicate that they are genetic variation of the same syndrome. Hereditary hemochromatosis must be distinguished from the other syndrome of iron overload and the classic term hereditary hemochromatosis should be reserved only for HFE related hemochromatosis.

Computer-based simulator for training in gastrointestinal endoscopy

The concept of a simulator as a training tool is well established, notably in aviation. Skills in gastrointestinal endoscopy mainly depend on experience and are routinely acquired by practicing on patients, initially under supervision of a senior endoscopist. Increased public's attention to medical errors, the legal and ethical issues, the progress in computer technology, the continuous introduction of new endoscopic techniques, and the changes in medical practice that limit patient availability,--all are forcing us as educators to rethink previously established principles and to use endoscopy simulators with the aim to teach fundamental endoscopic skills in a risk-free setting, away from the patient. This article reviews currently available endoscopy computer-based simulators and their potentially role in digestive endoscopic training.