The Role of Endoscopic Ultrasound in Evaluation of Gastric Subepithelial Lesions

A subepithelial mass is a common finding during endoscopic procedures. Endoscopic ultrasound (EUS) is an important diagnostic modality in the evaluation of subepithelial lesions of the gastrointestinal tract. EUS is the diagnostic test of choice to assess the size, margins, the layer of origin, echotexture, and to differentiate between an intramural and extramural lesion. However, the EUS imaging lacks the specificity. EUS-guided fine needle aspiration (EUS-FNA) or core biopsy can help establish a tissue diagnosis and potentially characterize malignant risk. The aim of this article is to review the diagnosis and management of the most common subepithelial gastric lesions with an emphasis on the role of endoscopic ultrasound

Neuroendokrini tumor gušterače s izraženim karcinoidnim sindromom: prikaz slučaja

Carcinoid is the most common neuroendocrine tumor. It is primarily localized in the ileum and the appendix, whereas other localizations are rare. Only a small number of the carcinoids present with carcinoid syndrome (flushing, diarrhea), usually after tumor has already metastasized. A case of carcinoid tumor of uncommon localization is reported. A 54-year-old male patient presented for evaluation because of weight loss, flushing and diarrhea. Laboratory value of 5-HIAA was 775.5 mmol/l (normal values up to 72.8) and the pancreatic tumor marker CA 19-9 was increased. Ultrasonographic and magnetic resonance find-Rings localized the tumor in the prepapillary pancreatic region and visualized the spread to the liver. The diagnosis was confirmed by pathohistologic evaluation of a liver biopsy specimen. The patient was treated with Sandostatin (octreotide analog), which led to significant relief of the symptoms, although control 5-HIAA values were not reduced.Iako su karcinoidi rijetki, predstavljaju najčešći tip neuroendokrinih tumora, primarno smještenih u tankom crijevu i apendiksu. Mali broj ovih tumora, nakon što metastazira u jetru, prezentira se simptomima karcinoidnog sindroma (rumenjača, proljevi). Prikazan je karcinoid gušterače, neuobičajene lokalizacije za ovu vrst tumora. Bolesnik u dobi od 54 godine upuaen je u kliniku zbog gubitka na težini, rumenjače i proljeva. Vrijednosti 5-HIAA i CA 19-9 bile su izrazito povišene. Ultrazvučno i magnetskom rezonancom prikazan je tumor predpapilarnog područja te uvećana jetra prožeta višestrukim sekundarizmima, a patohistološki nalaz govorio je u prilog neuroendokrinog tumora tipa karcinoida. S obzirom na proširenost procesa odustalo se od kirurškog liječenja te je započeta terapija Sandostatinom uza značajno kliničko poboljšanje, no bez učinka na 5-HIAA

Hemangiopericitom ili hemangiopericitomu nalik tumor jednjaka: prikaz slučaja i pregled literature

Hemangiopericytoma is a rare malignant vascular tumor deriving from pericytes. It usually occurs in the extremities and retroperitoneum, and extremely rarely in the gastrointestinal tract. A case of hemangiopericytoma in the gastroesophageal region is reported. A 56-year-old man was treated with H2-receptor antagonist for dyspeptic symptoms that had occurred three months before. Therapy failed to prove successful and gastroendoscopy was performed in March 2001 to reveal slightly reddish ventricular mucosa with normal rugal folds and a sessile, polypoid, grayish mass of rough surface located at the gastroesophageal junction. Histopathologic examination of polypoid mass samples revealed a vascular tumor covered with squamous epithelium. The hallmarks of the tumor were numerous branching, slit-like capillary channels with "staghorn" appearance, and large gaping sinusoidal spaces enclosed within nests of ovoid cells. Vascular invasion, mitotic activity, giant cells and necrosis were not found. Immunohistochemical analysis showed diffuse and strong reactivity for vimentin and focal, low or moderate reactivity for actin, S-100 and smooth muscle actin. Proliferation index measured by PCNA and Ki-67 ranged from 2% to 13% (median 11.2%) and from 5% to 18% (median 7.6%), respectively. A diagnosis of hemangiopericytoma with low malignant potential was made. Almost two years of the intervention, the patient is alive and free from any signs of tumor spread.Hemangiopericitom je rijedak maligni vaskularni tumor koji potječe od pericita. Najčešće je javlja na ekstremitetima, te u području peritoneuma, a iznimno rijetko ga se nalazi u probavnom sustavu. Opisuje se slučaj hemangiopericitoma nađenog u gastroezofagusnom području. Bolesnik star 56 godina liječen je tri mjeseca antagonistima H-2 receptora zbog dispeptičnih problema. Preporučena terapija nije pokazala očekivani rezultat, pa je učinjena gastroskopija. Nađena je sesilna polipozna tvorba veličine novčića, sivkaste boje i neravne površine u gastroezofagusnom području. Histopatološki je odstranjena tvorba bila građena od razgranatih kapilarnih prostora tipa "staghorn", okruženih gnijezdima ovalnih stanica koje su tvorile solidan uzorak. Nekroze, vaskularna invazija, velike stanice i mitoze nisu nađene. Tumorske stanice su pokazivale difuznu, izrazito pozitivnu imunoreakciju na vimentin, dok je reakcija na aktin, S-100 i glatkomišićni aktin bila žarišna i slabog intenziteta. Proliferacijska aktivnost tumora iznosila je između 2% i 13% (medijan 11,2%) mjerena pomoću PCNA, te između 5% i 18% (medijan 7,6%) mjerena pomoću Ki-67. Postavljena je dijagnoza hemangiopericitoma niskog malignog potencijala. Skoro dvije godine nakon postavljene dijagnoze bolesnik je bez znakova bolesti

Endoskopsko liječenje pseudociste gušterače

Pancreatic pseudocyst, the most common cystic lesion of the pancreas, may occur as a consequence of acute or chronic pancreatitis, pancreatic trauma, or obstruction of the pancreatic duct. Symptomatic, complicated, or enlarging pseudocysts require therapy that can be endoscopic (transmural and transpapillary drainage), percutaneous, or surgical. We present a patient with pancreatic pseudocyst treated by blinded endoscopic transgastric puncture and stenting after an unsuccessful attempt at endoscopic transpapillary drainage, suggesting that this simple approach is safe and effective in a selected group of patients.Pseudocista gušterače kao najčešće cistično oštećenje gušterače može nastati kao posljedica akutnog ili kroničnog pankreatitisa, traume gušterače ili opstrukcije gušteračnog kanala. Simptomatične, komplicirane ili pseudociste koje se povećavaju zahtijevaju liječenje koje može biti endoskopsko (transmuralna i transpapilarna drenaža), perkutano ili kirurško. Prikazuje se bolesnica s pseudocistom gušterače liječenom endoskopskom transgastričnom punkcijom naslijepo i postavljanjem stenta nakon neuspjelog pokušaja endoskopske transpapilarne drenaže. Ukazuje se na to da je ovaj jednostavan pristup siguran i učinkovit u odabranoj skupini bolesnika

Prvi prikaz slučaja probavnog stromalnog tumora (GIST) pozitivnog na koneksin 43

Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms most frequently found in the stomach and presenting without symptoms or with unspecific ones such as hemorrhage and abdominal pain. The malignant potential of GIST is variable and there are several prognostic indexes for treatment and follow up. The superior diagnostic method is endoscopic ultrasound combined with fine needle aspiration biopsy (EUS-FNA) immunocytochemistry. Surgery is the preferable treatment option, while recurrent or advanced disease is best managed with thyrosine kinase inhibitors. We report a case of a 20-year-old man that presented with gastrointestinal bleeding and anemia. Upper gastrointestinal endoscopy detected a submucosal lesion and computerized tomography revealed a node near the liver. EUS-FNA immunocytochemistry found CD-117 positive cells suggestive of GIST and the patient was operated on. The diagnosis was confirmed by histopathology with immunostaining. Prognostic assessment was done according to tumor size and Ki-67 index with mitosis count on microscopy. Many studies have shown that tumors demonstrate an abnormal number, structure and occurrence of connexin proteins with altered connexin-mediated intercellular communication. Since a great deal of gastroenterological tumors express connexin 43, our aim was to find out whether it was present in GIST. Immunohistochemically, the tumor was positive for connexin 43, which was not previously described as typical. The early postoperative course was uneventful, free from complications. At three-year postoperative follow-up, the patient was subjectively well and without clinical signs of disease recurrence.Gastrointestinalni stromalni tumor (GIST) spada u novotvorine mezenhimnog podrijetla, a najčešće se nalazi u želucu. Često bude bez simptoma ili se prezentira paletom nespecifičnih simptoma poput gastrointestinalnog krvarenja ili boli u abdomenu. Maligni potencijal GIST-a je raznolik te postoji nekoliko prognostičkih indeksa za dijagnostiku i praćenje. Najznačajniju dijagnostičku metodu čini endoskopski ultrazvuk kombiniran s citološkom biopsijom. S terapijske strane najpoželjniji izbor je kirurško liječenje, a za uznapredovale ili recidivne oblike bolesti liječenje je farmakološko inhibitorima tirozin-kinaze. Ovdje se prikazuje slučaj 20-godišnjeg mladića koji je došao na obradu zbog gastrointestinalnog krvarenja i anemije. Gastroskopijom se otkrila submukozna promjena koja se na kompjutoriziranoj tomografiji prikazala kao čvor uza stražnji rub jetre. Citopunkcijom uz pomoć endoskopskog ultrazvuka nađene su stanice pozitivne na CD-117 koje ukazuju na GIST, te je bolesnik operiran. Dijagnoza je potvrđena patohistološki uz imunohistološko bojanje. Prognostička patohistološka procjena je učinjena prema veličini tumora, Ki 67 mitotskom indeksu. Brojne studije su pokazale kvantitativne ili kvalitativne promjene koneksinskih proteina te promijenjene međustanične komunikacije posredovane tijesnim vezama. Kako je u velikom broju tumora probavne cijevi primijećena promjena ekspresije koneksina Cx43, naš je cilj bio ispitati zastupljenost u GIST-u. Naš slučaj bio je pozitivan na Cx43, što nije ranije opisano kao očekivano. Rani poslijeoperacijski tijek u bolesnika je bio bez komplikacija, a dosad se kroz ambulantno praćenje unatrag 3 godine osjeća dobro, kontrolni nalazi labolatorija su uredni, te se kliničkom obradom ne nalazi znakova recidiva bolesti

Ultrazvuk abdomena – vodeća metoda u dijagnostici GIST-a duodenuma

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract and are generally asymptomatic. A 39-year-old female patient was hospitalized in 2012 at Clinical Department of Internal Medicine, Sestre milosrdnice University Hospital Center, for a focal hypodense irregular circular lesion located in segment III of the left hepatic lobe, accidentally found by ultrasonography and verified by computed tomography. Th e findings were also verified with nuclear magnetic resonance and esophagogastroduodenoscopy. A biopsy sample of the lesion was analyzed by histologic and immunohistochemical methods and identified as GIST. The patient underwent surgical operation (tumor excision with terminoterminal anastomosis created between the second segment of duodenum and jejunum and resection of liver segment III). The histopathologic findings matched GIST with a high probability of relapse according to the localization, size, mitotic activity and Ki-67 values. Th erefore, therapy with imatinib at a dose of 400 mg/day was administered. Three years after the operation, the patient is still in remission.Gastrointestinalni stromalni tumori (GIST) najčešći su mezenhimni tumori probavnog trakta i najčešće su asimptomatski. Naša 39-godišnja bolesnica hospitalizirana je 2012. godine na Klinici za internu medicinu KBC-a Sestre milosrdnice zbog ultrazvučno slučajno nađene i kompjutorskom tomografijom potvrđene hipodenzne nepravilne okrugle lezije lokalizirane u 3. segmentu lijevog jetrenog režnja. Nalaz je potvrđen magnetskom rezonancijom i ezofagogastroduodenoskopijom. Histološkim i imunohistološkim metodama obrade uzorak biopsije se identificirao kao GIST. Učinjena je primarna resekcija (potpuna ekscizija tumora s terminoterminalnom anastomozom između II. odsječka dvanaesnika i jejunuma i resekcijom 3. segmenta jetre). Patohistološki nalaz je potvrdio dijagnozu GIST-a, a s obzirom na lokalizaciju, veličinu, mitotsku aktivnost i vrijednosti Ki-67 tumor je svrstan u skupinu visokorizičnih za recidiv. Zbog toga je indicirana terapija imatinibom u dozi od 400 mg/dan. Tri godine nakon operacije bolesnica je i dalje u remisiji

Laparoscopic transhiatal resection of a large mid-esophageal diverticulum: a case report

This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk

Cholestatic Liver Diseases

Kolestatske bolesti jetre predstavljaju rijetke bolesti koje zahvaćaju hepatocite, ekstrahepatalne i/ili intrahepatalne žučne vodove, a dovode do smetnji u stvaranju ili otjecanju žuči. Primarni bilijarni kolangitis (PBC) predstavlja novi naziv za bolest ranije poznatu kao primarna bilijarna ciroza. Imunološki napad dovodi do progresivnog oštećenja malih žučnih vodova unutar jetrenih lobula s razvojem fibroze, a u konačnici može dovesti do ciroze i zatajenja jetrene funkcije. Primarni sklerozirajući kolangitis (PSC) obilježava kronična upala praćena oštećenjem i fibrozom žučnih vodova s posljedičnom segmentalnom obliteracijom lumena, a može zahvatiti intrahepatalne ili ekstrahepatalne žučne vodove, ili oboje. PBC češće zahvaća žene, a PSC mušku populaciju. Umor, svrbež kože i žutica predstavljaju najčešće simptome kolestatskih bolesti jetre. Obje bolesti često se otkrivaju u asimptomatskoj fazi, kolestatskim profilom jetrenih enzima u laboratorijskim nalazima, odnosno dominantno povišenim vrijednostima alkalne fosfataze (ALP) i gama-glutamil transpeptidaze (GGT). Bolesnici često imaju pridružene druge autoimune bolesti. Za PBC karakterističan je nalaz antimitohondrijskih protutijela (AMA), dok se PSC dokazuje kolangiografijom. Komplikacije bolesti mogu biti posljedica kolestaze, upalnog (autoimunog) zbivanja te ciroze jetre ili razvoja tumora. Ursodeoksikolna kiselina predstavlja terapiju izbora u liječenju PBC-a jer usporava tijek bolesti, dok za PSC ne postoji dokazano djelotvorna medikamentozna terapija koja utječe na tijek osnovne bolesti. U obje bolesti primjenjuju se i simptomatske mjere te postupci usmjereni zbrinjavanju komplikacija, kao što su svrbež, malapsorpcija masti i vitamina topivih u mastima, ili striktura žučnih vodova. Povećana učestalost tumora zahtijeva trajni nadzor i pravodobno liječenje koje utječe na preživljenje bolesnika. Transplantacija jetre predstavlja metodu izbora u završnom stadiju obje bolesti.Cholestatic liver diseases are rare diseases that affect hepatocytes and intrahepatic and/or extrahepatic bile ducts, causing interruptions in bile production or flow. Primary biliary cholangitis (PBC) is a new term for primary biliary cirrhosis. Immune-mediated attack leads to progressive destruction of small intralobular bile ducts and may lead to the development of fibrosis, cirrhosis and liver failure. Primary sclerosing cholangitis (PSC) is characterized by chronic inflammation with damage and fibrosis of bile ducts, causing structuring and obliteration of the lumen. It can affect the intrahepatic and/or extrahepatic biliary tree. PBC mostly affects women, while PSC is more common in men. Fatigue, pruritus and jaundice represent the most common complaints of patients with cholestatic liver diseases. Both diseases are often diagnosed in early, asymptomatic phase, as part of the assessment of abnormal liver tests which demonstrate cholestatic pattern, with predominant elevation of the alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT). Patients often have other concurrent autoimmune diseases. PBC is characterized by the presence of anti-mitochondrial antibodies (AMA), while cholangiography is the method of choice for the diagnosis of PSC. Complications can result from cholestasis, inflammatory (autoimmune) process, liver cirrhosis or cancer development. Ursodeoxycholic acid is the therapy of choice for PBC as it slows the disease progression. However, there is no proven treatment that significantly impacts the course of PSC. For both diseases management is aimed at treating symptoms and managing complications such as pruritus, malabsorption of fat and fat-soluble vitamins, or bile duct strictures. Increased incidence of malignant tumours requires ongoing monitoring and timely treatment in order to improve patient survival. Liver transplantation represents the treatment of choice in the advanced stage of both diseases