Risk factors for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and the third greatest cause of cancer-related death worldwide, incidence is increasing. The aim of this retrospective study is to estimate the incidence of HCC and to identify the risk factors for HCC in patients who have passed through the Clinic of Hepatogastroenterology, Varna. All they have serologic tests, imaging examinations (abdominal ultrasonography, CT, MRI) and fine needle biopsy. Men are 125 of pts. and women are 55 (2.3:1). The average age at diagnosis is 62±9.44 (m) and 65±12,02 (f) years. The majority of patients (68%) with HCC had cirrhosis. Viral infection was found in 54% of the cases: hepatitis C (HCV) - 46 pts. (26%), hepatitis B (HBV) - 52 pts (29%). Diabetes mellitus have 40 pts (22%). Alcohol abuse was observed in 38 pts. of the surveyed (21%). These study shows that the main risk factors for HCC are male gender, older age, viral hepatitis (HCV and HBV), alcohol intake, presence of cirrhosis and diabetes. Thus, the best strategy is eliminating modifiable risk factors (alcohol, diabetes) and to treat with viral infections (HBV, HCV)

Disability in patients with Crohn‘s disease

Болестта на Крон (БК) се характеризира с хронично рецидивиращо протичане, с различна интензивност и продължителност на тласъците на болестта. Поради това при тези пациенти често се налага болнично лечение, което води до отсъствие от работа и временна нетрудоспособност. Целта на настоящото изследване е да се проучи как БК оказва влияние при инвалидизиране на пациентите.За период от 5 години са изследвани ретроспективно 140 пациенти с БК. Резултатите са обработени с помощта на статистическата програма SPSS v.20, като са използвани количествени и качествени методи (t - коефициент на Student, χ 2).В нашата извадка, пациентите, които са освидетелствани за трайна или намалена неработоспособност от съответната Териториална експертна лекарска комисия (ТЕЛК) и/или Национална експертна лекарска комисия (НЕЛК), са 34 (24.3%), като преобладават жените (61.8 %). Интересен е фактът, че от освидетелстваните лица само 3.0% са тежка активност на заболяването. Средната стойност на активността на БК, определена по индекса на BEST (CDAI - Crohn Disease Activity Index) на освидетелстваните лица, е 230,9±115,5 (SD), като не беше доказана съществена разлика спрямо неосвидетелстваните лица. Не беше намерена сигнификантна разлика в обхвата на заболяването и инвалидизирането на пациентите. Малко над 1/3 от пациентите (38.2%) имат интестинални усложнения, свързани с болестта, a 29.4% са с екстраинтестинални такива.Резултатите от нашето изследване показват, че тежестта на заболяването и наличието на усложнения не са пряко свързани с инвалидизирането на пациентите. Обхватът на заболяването не може да бъде приет за водещ мотив за инвалидизиране на болните. Друг факт, който ни води на мисълта, че инвалидизацията се дължи на други причини, е това, че само 3.0 % от изследваната група са с тежка форма на протичане на болестта.Crohn‘s disease (CD) is characterized by chronic, relapsing course, with varying intensity and duration of the bouts of the disease. Therefore, these patients often require hospitalization, leading to absence from work and temporary disability. The aim of this study is to examine how CD affects the disability of patients. For a period of 5 years 140 patients with CD were studied retrospectively. The results were processed with a statistical program SPSS v. 20 using quantitative and qualitative methods (t-Student factor, χ 2).In our sample, the patients who were assessed to suffer from permanent or reduced disability by the Territorial Expert Medical Commission (TEMC) and/ or the National Expert Medical Commission (NEMC) were 34 (24.3%), predominantly women (61.8%). Interesting was the fact that from the attested for disability persons only 3.0% have a severe disease. The average value of the activity of CD, determined by the index of BEST (CDAI - Crohn Disease Activity Index) of attested for disability persons was 230.9±115.5 (SD) and no significant difference was detected in comparison to non-attested for disability patients. No significant difference in the extent of disease and disability of the patients was found. Slightly more than 1/3 of the patients (38.2%) had intestinal complications associated with the disease and 29.4% had extraintestinal manifestations.The results of our study showed that the severity of the disease and the presence of complications were not directly related to the disability of the patients. The extent of the disease could not be accepted as a leading reason for the disability of the patients. Another fact which lead us to believe that disability is due to other reasons was that only 3.0% of the study group had a severe disease

Correlation between the number of hospitalizations and the severity of the disease in patients with Crohn‘s disease

Често хоспитализациите при пациентите с болестта на Крон (БК) се свързват с извънредни ситуации като тежки чревни обструкции или обостряне състоянието на пациента. Редица проучвания показват, че половината от хоспитализациите при пациентите с БК се дължат именно на спешни състояния. Целта на нашето изседване е да проследим дали броя на болничните пролежавания при пациентите с БК са свързани с тежестта на заболяването.За период от 5 години са изследвани ретроспективно 140 пациенти с БК. Резултатите са обработени с помощта на статистическата програма SPSS v.20, като са използвани количествени и качествени методи (t - коефициент на Student, χ2).Средният брой хоспитализации на изследваните пациенти е 2,1±1,7 (SD), като минималните са 1, a максималните са 10. Най-голяма честота имат пациентите с първа (50%) и втора (22.1%) хоспитализация. Не беше намерена зависимост между индекса на BEST (CDAI - Crohn Disease Activity Index) и броя на хоспитализациите при изследваните пациенти, но интерес представлява резултатът, че пациентите с умерено тежка болест стигат до 9 хоспитализации. По отношение на обхвата на заболяването най-голяма е честотата на пациентите с тънкочревна локализация (34%), следвани от тези с дебелочревна локализация (33%). Съществена разлика беше намерена по отношение броя на хоспитализациите при пациентите с екстраинтестинални прояви на болестта. Можем да кажем, че наличието на този вид прояви на болестта води до повече хоспитализации, в сравнение с пациентите с интестинални усложнения.Въз основа на получените резултати можем да заключим, че броят на хоспитализациите при пациентите с БК не е свързан толкова с тежестта на заболяването, колкото със съпътстващите екстраинтестинални прояви на заболяването.Often hospitalizations of patients with Crohn`s disease (CD) are associated with emergencies, such as intestinal obstructions or disease exacerbation. Several studies show that half of the hospitalizations of patients with CD were due to emergencies. The aim of our retrospective study is to track whether the number of hospitalized with CD is associated with the disease severity.For a period of 5 years 140 patients with CD were studied retrospectively. The results were processed with a statistical program SPSS v. 20 using quantitative and qualitative methods (t-Student factor, x2).The average number of hospitalizations of followed patients was 2.1±1.7 (SD), the minimum was 1 and the maximum was 10. There was a higher incidence of patients with a first (50%) and a second (22.1%) hospitalization. No correlation was found between the index of BEST (CDAI - Crohn Disease Activity Index) and the number of hospitalizations in the studied patients, but it is interesting to note that patients with moderate disease severity reached 9 hospitalizations. In regard to the extent of the disease, the frequency of patients with small intestine localization was the highest (34%), followed by those with colonic localization (33%). A significant difference was found in the number of hospitalizations of patients with extraintestinal manifestations of the disease. We can say that the existence of such manifestations leads to twice the number of hospitalizations, compared to patients with intestinal complications.Based on the results, we can conclude, that the number of hospitalizations of patients with CD was not so much related to the disease severity, as to the accompanying extraintestinal manifestations of the disease

Evaluation of some parameters of copper metabolism and leipzig scoring system in the diagnosis of wilson disease

PURPOSE: Wilson disease (WD) is an autosomal recessively inherited disorder of copper accumulation and toxicity. Its recognition is easy in the presence of typical clinical presentations. Unexplained liver test abnormalities are a diagnostic challenge and require more examinations. The objective of this study is to assess the diagnostic value of ceruloplasmin, 24-hour urine copper excretion and Leipzig scoring system in WD.MATERIAL AND METHODS: Sixty-five patients with WD (22 females and 43 males) and control group of 17 patients with other chronic liver diseases (CLD) were analyzed. The values of the parameters of copper metabolism and Leipzig scoring system were evaluated.RESULTS: Average ceruloplasmin level was under 0,2 g/L and 24-hour urinary copper concentration was increased. D-penicillamine challenge test showed a mean value of 17,4 µmol/24 hours of urinary copper excretion in WD patients versus 5,46 µmol/24 hours in CLD ones. According to the Leipzig scoring diagnostic criteria, 58 WD patients (89,23% of the cases) presented with a score ≥4 (maximal value of 12). Score 3 was found out in seven patients, however, the exclusion of other etiology and the clinical course of the disease confirmed the diagnosis. The control subjects presented with a score ≤3 as it was ≤2 in 76,5% of the cases.CONCLUSION: Our results confirm the diagnostic value for WD of the Leipzig scoring system combined with clinical symptoms, laboratory parameters of copper metabolism, genetic testing and liver biopsy in clinical practice

Smoking and Crohn`s disease

Редица изследвания в областта на възпалителните заболявания на червата (IBD) проучват тютюнопушенето като рисков фактор както за настъпването на болестта, a също и за развитие на усложненията. Последните проучвания доказват, че лицата с болестта на Крон (БК), които пушат, имат по-тежко протичане на болестта, което влошава качеството им на живот. Целта на настоящото изследване е да се проучи честотата на тютюнопушенето сред пациентите с БК.За период от 5 години са изследвани ретроспективно 140 пациенти с БК. Резултатите са обработени с помощта на статистическата програма SPSS v.20, като са използвани количествени и качествени методи (t - коефициент на Student, χ2).Средната възраст на пациентите с БК в нашата извадка е 40,8 години ±13,6 (SD). Минималната възраст е 18 години, a максималната е 82 години. Приблизително половината от изследваните пациенти (47.1%) са активни пушачи, a 36.8% са бивши. Доказа се наличието на сигнификантна разлика между пациентите активни пушачи или бивши такива, които имат по-тежко протичане на болестта, и непушачите, при които над 50% са в ремисия. Също така в нашето изследване жените, които са както активни, така и бивши пушачи, имат по-тежко протичане на зaболяването. По отношение на обхвата на заболяването при пушачите преобладават пациентите с илеоколонна локализация (40.0 %), при бившите пушачи - тези с тънкочревно засягане (40.0%), a при непушачите - тези с дебелочревно засягане (54.5%).Резултатите от нашето изследване потвърждават тези на други автори, които определят жените пушачи като рискова група, но опровергават други като например преобладаването на пациентите с тънкочревно засягане.Numerous studies in the field of inflammatory bowel disease (IBD) examine smoking as a risk factor for the onset of a disease, as well as the development of complications resulting from it. Recent studies have shown that smokers with Crohn‘s disease (CD) are at risk for developing a severe disease, which deteriorates their quality of life. The aim of this study was to examine the incidence of smoking among patients with CD.For a period of 5 years 140 patients with CD were studied retrospectively. The results were processed with a statistical program SPSS v 20 using quantitative and qualitative methods (t-Student factor, χ2).The average age of our patients with CD was 40.8 years ±3.6 (SD). The youngest patient was 18 years old and the oldest was 82 years old. Approximately half of the patients (47.1%) were current smokers and 36.8 % were former smokers. We found that patients who were current smokers or quitters had a much higher risk for developing a severe disease than non-smokers. Also, our study showed that women, both current and former smokers, had more severe diseases compared to men. With regard to the extent of the disease, in current smokers prevail patients with ileocolic localization (40.0%), in former smokers - patients with small intestine involvement (40.0%) and in non-smokers - those with colonic involvement (54.5%).The results from our study confirmed those of other authors, who identify female smokers as a risk group, but refute others, reporting the prevalence of patients with small intestine involvement

Mucosal pattern of the upper gastrointestinal tract viewed by magnification Endoscopy in combination with narrow-band imaging

The introduction of white light endoscopy has improved dramatically the management of gastrointestinal tract disorders. Tissue sampling, however, is mandatory for accurate diagnosis, especially if dysplasia, cancer or H. pylori infection is suspected. It is also associated with high missing rates due to the uneven distribution of the mentioned pathology. Chromoendoscopy has proven to be superior to standard white light for detecting of lesions but requires different dyes and a long learning curve. On the other hand, narrow band imaging in combination with magnification endoscopy shortens the procedure time, allows close observation of the mucosal surface gaining excellent real-time images, and guides the endoscopist for target biopsies of suspected areas. This review will briefly cover the current knowledge of high quality endoscopy of the upper gastrointestinal tract

Non-invasive biomarkers for assessment of non-alcoholic fatty liver disease

Background and Aim: Non-alcoholic fatty liver disease (NAFLD) is a major public health problem afflicting approximately one billion individuals worldwide. Liver biopsy is considered the gold standard for assessment of liver disease severity in patients with NAFLD. It is invasive and is associated with adverse effects, and also has higher inter-observer variability. Liver biopsy is impractical because of large number of individuals who have NAFLD and is not appropriate for screening. Therefore, non-invasive biomarkers to assess disease severity in NAFLD are needed. We use a combined approach of non-invasive imaging modalities and clinical, biochemical, metabolic and lipid biomarkers to grade liver fat and liver fibrosis, to assess presence of NAFLD, and to detect the progressive form of NAFLD, termed non-alcoholic steatohepatitis.Methods: We evaluated 60 patients with presence of metabolic syndrome and suspected NAFLD. Other liver diseases, alcohol consumption ≥ 20 g/day, and use of drugs associated with liver steatosis were excluded. Anthropometric variables (weight, BMI, waist circumference), liver function tests, full blood count, serum lipids, fasting glucose, abdominal ultrasonography, liver transient elastography (TE) with fibroscan M probe (XL probe only in 5%) and CAP (controlled attenuation parameter) were assessed. The cut-off values for CAP and TE were defined as previously published. Indirect markers for fibrosis and steatosis were calculated.Results: The mean age was 59 years, 59% female. 72% patients had diagnosis of diabetes mellitus (DM). The median weight was 90.3 kg, median BMI 32 kg/m² and median waist circumference – 112.8 cm. According to the Hepatic Steatosis Index, 4% of the patients were without NAFLD (HSI below 30) and 92% showed HSI higher than 36. Abdominal ultrasonography findings of hepatic steatosis were: 6% with no evidence of steatosis, 15% with grade I, 26% with grade II, and 53 % with grade III. The share of patients with CAP value under 215 db/m was 6% (suggestive steatosis under 33%), with CAP value between 217 db/m and 252 db/m – 10% (steatosis 34%-66%), with CAP value between 253 db/m and 296 db/m – 25% (steatosis over 67%), and 58% of patients had CAP value over 297 db/m. A FIB-4 index below 1.3 was found in 70% of patients. Respectively, 22% had FIB-4 index between 1.3 and 2.67. The share of patients with significant fibrosis with higher FIB-4 was 7.5%. TE values ≥ 7.9 kPa were identified in 34% of patients.Conclusion: A combined approach of non-invasive biomarkers is better recommended for the diagnosis and grading of liver steatosis and for the detection of progressive forms of NAFLD

Whipple`s disease - clinical spectrum and diagnostic approach (with a contribution of eight cases)

PURPOSE: Whipple`s disease (WD) is a rare systemic infection caused by the bacterium Tropheryma whipplei. Since the clinical features of the disease are non-specific, diagnosis still remains a challenge. The aim of the study is to analyse the clinical presentation and diagnostic approach in patients with WD.MATERIAL AND METHODS: Eight patients, six females and two males at an average age of 59 years (range, 46-79 years) were diagnosed with WD from January, 2012 to May, 2013 in the Clinic of Hepatogastroenterology, St. Marina University Hospital of Varna. Laboratory tests, endoscopic, radiologic, ultrasound and histomorphological examinations were performed.RESULTS: The main symptoms are abdominal pain, chronic diarrhoea and meteorism. Only one female patient presents with clinical signs of malabsorbtion, such as weight loss, anasarca, ascites, pleural effusions and anaemia. There are no extraintestinal manifestations. Tests for Chlamydia trachomatis, tuberculosis and Clostridium difficile are negative. Stool examination does not show any parasitic or bacterial infection. Coeliac disease (CD) serological tests are negative, except in one female with co-existing gluten enteropathy since childhood onwards, where Crohn colitis is diagnosed, too. Endoscopy demonstrates mild to moderate atrophy of the intestinal mucosa. Histological examination establishes mild villous atrophy, lymphoplasmatic infiltration and lymph vessel dilation. All the biopsies show PAS-positive inclusions in the macrophages. Doxycycline therapy exerts a favourable effect on the clinical symptoms in all the patients.CONCLUSION: Whipple`s disease (WD) is a rare systemic disease that is commonly late or falsely diagnosed. The prognosis of non-treated patients is poor. The disease should be considered in any patients with prolonged gastrointestinal symptoms such as unexplained abdominal pain, diarrhoea and features of malabsorption syndrome. The appropriate antibiotic treatment achieves remission and improves the patient's quality of life.Keywords: Whipple disease, diagnosis, histology, malabsorption, treatmen

MONITORING OF CASES WITH A CHRONIC PERSISTENT INFECTION WITH HELICOBACTER PYLORI

Introduction: The patients with persistent forms of Helicobacter pylori (HP) infection are refractory to eradication treatment. They receive unsuccessful therapies, experience frequent recurrences and re-infections. One of the main reasons for the development of persistent forms is an inadequate and insufficient treatment. The persistent forms of HP infection create conditions for the maintenance of activity and for the progression of the induced chronic gastritis. In this aspect these cases will be at a higher risk for the development of gastric cancer. The aim of this study is: to monitor and analyze the cases with persistent HP infection and to establish an approach for their management. Clinical material and methods: The study includes 12 patients (8 female and 4 male) at a middle age of 63,7, with a persistent HP infection, who have been observed for a period of five years. Two methods for the detection of HP infection are used – one invasive and one non-invasive. Upper endoscopy with morphological examination was performed. Results: In 9/12 patients HP was unsuccessfully treated for three times, in 2 patients – four times, and in 1 patient – five times. In all patients the initial treatment consisted of a standard triple therapy (STT). In 5 of them STT was conducted twice, with the same regimen for a period of seven days. Two patients received three courses of STT. In four patients an antibiotic resistance was established by means of a cultured assessment. In three cases an HP resistance to Clarithromycine and Metronidazole was demonstrated. Significant gastro-duodenal pathology with atrophic gastritis, intestinal metaplasia, and hyperplastic polyposis was found in all patients. The persistent clinical symptoms had 9 patients. Conclusion: We believe that a devised and proposed step strategy which covers early detection of infection, reliable diagnosis, adequate and successful treatment, and dispensary monitoring, contributes to the prevention of gastric cancer