Massive Gastrointestinal Bleeding and Obstruction of the Ureter Caused by the Migration of a Swallowed Toothpick from the Sigmoid Colon – A Case Report

In this study, a case of an ingested toothpick partially migrating from the sigmoid colon, causing massive lower gastrointestinal bleeding due to arterial-colic fistula, and stricture of the left ureter is presented. A 70-year-old male was admitted to the emergency department after having feces mixed with fresh and coagulated blood for the past two days. Computed tomography and retrograde ureteropyelography showed the stricture of the left ureter, 1.5 cm below the branching of iliac artery, without any signs of malignancy. Colonoscopy showed fresh blood in the rectum and sigmoid colon up to the neoplasm like granulation tissue mixed with fresh and coagulated blood, which almost obstructed the lumen. Explorative laparotomy showed a foreign body (toothpick) perforating the sigmoid colon through the mesenterial wall, and being stocked with one-third into the left internal iliac artery, causing arterial-colic fistula. The remaining part of the toothpick was surrounded by granulation tissue and chronic inflammatory process, pressing on the distal third of the left ureter. We conclude that a swallowed toothpick may cause a significant gastrointestinal injury with a wide variety of clinical manifestations, and it must be treated with caution. The imaging studies are often inadequate in detecting toothpicks, and thus, we insist on a physical examination, as the best indicator of injury

Obesity and Gastroesophageal Reflux Disease

Gastroezofagealna refluksna bolest (GERB) jedan je od najčešćih razloga posjeta liječniku. Etiologija i patogeneza bolesti multifaktorske su i stalni su predmet brojnih istraživanja. Pretilost, čija je prevalencija znatno porasla posljednjih desetljeća, deEnirana je kao neovisni čimbenik rizika od razvoja GERB-a. Pritom je centralni tip pretilosti, neovisno o indeksu tjelesne mase, zasebni faktor rizika od nastanka komplikacija GERB-a, od kojih su najčešće erozivni gastritis, Barrettov jednjak i adenokarcinom. Time se znatno povećava socioekonomski aspekt povezanosti debljine i GERB-a. Prekomjerna tjelesna težina porastom intraabdominalnog tlaka i sniženjem tonusa donjeg ezofagealnog sEnktera mehanički povećava vjerojatnost re-uksne bolesti. S druge strane, patogeneza GERB-a može se objasniti i hormonalnom te endokrinom aktivnošću masnog tkiva. Redukcija tjelesne mase, kao dio prve linije terapije, znatno poboljšava simptomatologiju GERB-a kod pretilih bolesnika.Gastroesophageal re-ux disease (GERD) is one of the most common reasons for visiting a physician. Etiology and pathogenesis of the disease is multifactorial and is still the subject of numerous studies. Obesity, whose prevalence has significantly increased over recent decades, is defined as an independent risk factor for GERD development. The central type of obesity, independently of the body mass index, is a separate risk factor for the emergence of GERD complications, including erosive gastritis, Barrett\u27s esophagus, and adenocarcinoma. This significantly increases the socioeconomic aspect of obesity and GERD. Excess body weight mechanically increases the likelihood of reflux disease, increases intraabdominal pressure, and decreases tonus of the lower esophageal sphincter. On the other hand, GERD pathogenesis can be explained by both hormonal and endocrine fatty tissue activity. Body mass reduction, as part of the Erst line of therapy, significantly improves GERD symptomatology in obese patients

Obesity and Gastroesophageal Reflux Disease

Gastroezofagealna refluksna bolest (GERB) jedan je od najčešćih razloga posjeta liječniku. Etiologija i patogeneza bolesti multifaktorske su i stalni su predmet brojnih istraživanja. Pretilost, čija je prevalencija znatno porasla posljednjih desetljeća, deEnirana je kao neovisni čimbenik rizika od razvoja GERB-a. Pritom je centralni tip pretilosti, neovisno o indeksu tjelesne mase, zasebni faktor rizika od nastanka komplikacija GERB-a, od kojih su najčešće erozivni gastritis, Barrettov jednjak i adenokarcinom. Time se znatno povećava socioekonomski aspekt povezanosti debljine i GERB-a. Prekomjerna tjelesna težina porastom intraabdominalnog tlaka i sniženjem tonusa donjeg ezofagealnog sEnktera mehanički povećava vjerojatnost re-uksne bolesti. S druge strane, patogeneza GERB-a može se objasniti i hormonalnom te endokrinom aktivnošću masnog tkiva. Redukcija tjelesne mase, kao dio prve linije terapije, znatno poboljšava simptomatologiju GERB-a kod pretilih bolesnika.Gastroesophageal re-ux disease (GERD) is one of the most common reasons for visiting a physician. Etiology and pathogenesis of the disease is multifactorial and is still the subject of numerous studies. Obesity, whose prevalence has significantly increased over recent decades, is defined as an independent risk factor for GERD development. The central type of obesity, independently of the body mass index, is a separate risk factor for the emergence of GERD complications, including erosive gastritis, Barrett\u27s esophagus, and adenocarcinoma. This significantly increases the socioeconomic aspect of obesity and GERD. Excess body weight mechanically increases the likelihood of reflux disease, increases intraabdominal pressure, and decreases tonus of the lower esophageal sphincter. On the other hand, GERD pathogenesis can be explained by both hormonal and endocrine fatty tissue activity. Body mass reduction, as part of the Erst line of therapy, significantly improves GERD symptomatology in obese patients

Posttraumatic hepatic artery pseudoaneurysm presenting as gastrointestinal bleeding

Posttraumatic hepatic artery pseudoaneurysm is a rare, but life threatening condition which should be considered in patients with a history of blunt abdominal trauma who present with abdominal pain or gastrointestinal bleeding. We report a case of a patient with such a pseudoaneurysm discovered five months after a bicycle accident resulting in hepatic rupture that was treated conservatively. The patient presented with fatigue, dizziness, inability to tolerate major exertion and gastrointestinal bleeding. After extensive diagnostic procedures, a right hepatic artery pseudoaneurysm was found. The condition was treated successfully with transcatheter coil embolization

Coincidence of colorectal cancer and diverticular disease of the colon

Uvod: Divertikuloza (DK) debeloga crijeva i karcinom debeloga crijeva (KDC) imaju neke zajedničke karakteristike (npr. češći su u zapadnom dijelu svijeta i kod starijih osoba, slične prehrambene značajke uključene su u obje bolesti) a povremena povezanost između njih je ispitivana. Naš cilj je bio procijeniti koincidenciju KDC-a i DK u kontinentalnoj i primorskoj Hrvatskoj, kao i prehrambenu varijabilnost u našoj populaciji - prehrana s manjim udjelom vlakana u kontinetalnoj Hrvatskoj i mediteranska prehrana u primorskoj Hrvatskoj stvara povoljnu situaciju za istraživanje bolesti sa sumnjom na prehrambenu etiologiju. Metode: Analizirane su medicinske povijesti 710 bolesnika iz kontinentalne regije i 406 bolesnika iz primorske regije s dijagnozom KDC od 2011. do 2016. godine s obzirom na prevalenciju DK. Skupine su nadalje podijeljene prema različitim dobnim i spolnim skupinama, a prevalencija DK u svakoj skupini izračunata je i uspoređena. Analizirane su i distribucije DK i KDC-a za skupine KDC u usporedbi s DK. Rezultati: Prevalencija DK u skupini KDC u obalnom području iznosila je 32,3%, a u kontinentalnoj regiji 11,5%. Prevalencija DK u primorskom području bila je znatno veća u ukupnom broju u usporedbi s kontinentalnom regijom, kao i u ukupnom broju muškaraca i žena, te u dobno stratificiranoj skupini > 65. Lijevi kolon je češće zahvaćen s DK i KDC u obje skupine. Zaključci: Naši podaci upućuju da bolesnici s KDC i DK mogu proizaći iz različitih ispitivanih skupina, a učinak prehrane tek treba ustanoviti.Background: Diverticular disease (DD) of the colon and colorectal cancer (CRC) have common characteristics (e.g. more common in the westernized world and in the elderly, similar dietary features implicated for both diseases) and a casual relationship between them has been suggested. Our aim was to evaluate the coincidence of CRC and DD in continental and coastal Croatia as a dietary variability observed in our population – low fiber diet in the continent and Mediterranean diet on the coast creates a favourable situation for the investigation of diseases with suspected nutritional aetiology. Methods: Medical histories of 710 patients from the continental region and 406 from the coastal region diagnosed with CRC from 2011 to 2016 were analyzed with regard to the prevalence of DD. The groups were furthermore divided in different age and sex groups and the prevalence of DD in each group was calculated and compared. Distribution of DD and CRC in the colon for the groups of CRC in concomitance with DD were also analyzed. Results: The prevalence of DD among the CRC group in the coastal region was 32.3% and in the continental region 11.5%. The prevalence of DD in the coastal region was significantly higher in the overall number compared to the continental region as well as in the overall number of men and women, and in the age-stratified group > 65. The left colon was affected more often with DD and CRC in both groups. Conclusions: Our findings suggest that patients with CRC and DD could derive from distinct groups and the effect of the diet has yet to be established

CROATIAN GUIDELINES FOR DIAGNOSTICS AND TREATMENTS OF HELICOBACTER PYLORI INFECTION

Dosadašnjim 30-godišnjim istraživanjima potvrđena je temeljna uloga bakterije Helicobacter pylori pri razvoju kroničnoga gastritisa, želučanog i duodenalnog ulkusa, a potom i njegova etiološka uloga u patogenezi želučanog karcinoma i MALT limfoma. Godine 1996. održan je prvi sastanak Europske grupe za istraživanje infekcije Helicobacterom pylori i publicirane prve smjernice za dijagnostiku i terapiju te infekcije, revidirane 2000., 2007. i 2010. godine. Već 1998. godine održan je i prvi sastanak hrvatskih liječnika s istim ciljem – stvaranja hrvatskih preporuka za dijagnostiku i terapiju infekcije Helicobacterom pylori u našoj zemlji. Posljednjih se godina nametnula potreba za revizijom starih smjernica. Godine 2012. osnovana je ekspertna grupa gastroenterologa koja je u prosincu 2012. godine održala u Zagrebu Konsenzusnu konferenciju za donošenje novog postupnika za dijagnostiku, liječenje i praćenje bolesnika s infekcijom Helicobacterom pylori u Hrvatskoj. Obrađene su ove teme iz problematike infekcije Helicobacterom pylori: 1. indikacije i kontraindikacije za dijagnostiku i liječenje, 2. dijagnostičke metode i 3. terapija primjerena za našu zemlju.In the past 30-year period of investigations, the crucial role of Helicobacter pylori in chronic gastritis, gastric and duodenal ulcer development, and subsequently in gastric cancer and MALT lymphoma pathogenesis, has been recognized. During the first meeting of European Helicobacter Study Group in 1996 in Maastricht, the first recommendations for diagnostics and treatments of Helicobacter pylori infection were published, later reviewed in 2000, 2007 and 2010. The first meeting of Croatian doctors focusing on the same topics, but suitable to specific national circumstances, was held as early as 1998. The need for updating the old guidelines has emerged during the last years. The working expert group of gastroenterologists was formed and gathered on Consesus Conference in December 2012 in Zagreb, to arrive to current guidelines for the clinical management of Helicobacter pylori infection in Croatia. The following topics relating to Helicobacter pyloriinfection were examined: 1. indications and contraindications for diagnostics and treatments; 2. diagnostic methods and 3. treatments applicable in our country

CROATIAN GUIDELINES FOR USE OF ENTERAL NUTRITION IN CROHN’S DISEASE

Prehrana ima važnu višeznačnu ulogu u liječenju upalnih bolesti crijeva, poglavito u bolesnika koji boluju od Crohnove bolesti. U prvom redu adekvatna nutritivna potpora nužna je u prevenciji i liječenju malnutricije, kao i u prevenciji osteoporoze te u promicanju dobi primjerenog rasta u pedijatrijskih bolesnika. S druge strane, u aktivnoj fazi Crohnove bolesti u pedijatrijskih bolesnika enteralna je prehrana terapija izbora za uvođenje bolesnika u remisiju. Glede vrste enteralnih pripravaka istraživanja upućuju na jednaku učinkovitost elementarnih, oligomernih i polimernih enteralnih pripravaka. Uporaba standardnih polimernih enteralnih pripravaka danas se preporučuje i zbog boljeg okusa, lakšeg prihvaćanja od bolesnika, manje komplikacija te značajno nižih troškova u usporedbi s troškovima primjene ostalih enteralnih pripravaka. Najnovije spoznaje upućuju i na to da neki nutrijenti poput transformirajućeg čimbenika rasta beta (TGF-2), koji se nalaze u modificiranim polimernim enteralnim pripravcima, imaju farmakološki terapijski potencijal u liječenju upalnih bolesti crijeva, potvrđen u nekoliko kliničkih ispitivanja. Radna skupina koju su činili internisti gastroenterolozi i pedijatrijski gastroenterolozi, posebno upućeni u liječenje bolesnika s kroničnim upalnim bolestima crijeva izradila je Hrvatske smjernice za primjenu enteralne prehrane u Crohnovoj bolesti. Izrada smjernica temeljena je na dokazima iz relevantne medicinske literature te kliničkim iskustvima članova radne skupine.Nutrition has an important role in the management of inflammatory bowel disease (IBD), especially in patients with Crohn’s disease (CD). This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and the promotion of optimal growth and development in children. In active Crohn’s disease, nutritional therapy (in the form of enteral feeding) is an effective primary therapy for pediatric patients. Studies have shown that there is no difference in the efficacy of elemental, oligomeric and polymeric enteral formulas. Therefore, the use of polymeric formula is recommended because of higher palatability, better acceptance by patients, lower rate of complications and lower cost when compared with other enteral formulas. Today we have knowledge that some nutrients which are added to modified special enteral formulas have almost pharmacological terapeutic potential in the management of inflammatory bowel disease. Novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta-enriched (TGF-2) enteral feeding, showed beneficial effects in several clinical studies. Croatian guidelines for enteral nutrition in Crohn’s disease have been developed by interdisciplinary expert group of Croatian clinicians involved with inflammatory bowel disease. The guidelines are based on evidence from relevant medical literature and clinical experience of working group

CROATIAN GUIDELINES FOR USE OF ENTERAL NUTRITION IN CROHN’S DISEASE

Prehrana ima važnu višeznačnu ulogu u liječenju upalnih bolesti crijeva, poglavito u bolesnika koji boluju od Crohnove bolesti. U prvom redu adekvatna nutritivna potpora nužna je u prevenciji i liječenju malnutricije, kao i u prevenciji osteoporoze te u promicanju dobi primjerenog rasta u pedijatrijskih bolesnika. S druge strane, u aktivnoj fazi Crohnove bolesti u pedijatrijskih bolesnika enteralna je prehrana terapija izbora za uvođenje bolesnika u remisiju. Glede vrste enteralnih pripravaka istraživanja upućuju na jednaku učinkovitost elementarnih, oligomernih i polimernih enteralnih pripravaka. Uporaba standardnih polimernih enteralnih pripravaka danas se preporučuje i zbog boljeg okusa, lakšeg prihvaćanja od bolesnika, manje komplikacija te značajno nižih troškova u usporedbi s troškovima primjene ostalih enteralnih pripravaka. Najnovije spoznaje upućuju i na to da neki nutrijenti poput transformirajućeg čimbenika rasta beta (TGF-2), koji se nalaze u modificiranim polimernim enteralnim pripravcima, imaju farmakološki terapijski potencijal u liječenju upalnih bolesti crijeva, potvrđen u nekoliko kliničkih ispitivanja. Radna skupina koju su činili internisti gastroenterolozi i pedijatrijski gastroenterolozi, posebno upućeni u liječenje bolesnika s kroničnim upalnim bolestima crijeva izradila je Hrvatske smjernice za primjenu enteralne prehrane u Crohnovoj bolesti. Izrada smjernica temeljena je na dokazima iz relevantne medicinske literature te kliničkim iskustvima članova radne skupine.Nutrition has an important role in the management of inflammatory bowel disease (IBD), especially in patients with Crohn’s disease (CD). This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and the promotion of optimal growth and development in children. In active Crohn’s disease, nutritional therapy (in the form of enteral feeding) is an effective primary therapy for pediatric patients. Studies have shown that there is no difference in the efficacy of elemental, oligomeric and polymeric enteral formulas. Therefore, the use of polymeric formula is recommended because of higher palatability, better acceptance by patients, lower rate of complications and lower cost when compared with other enteral formulas. Today we have knowledge that some nutrients which are added to modified special enteral formulas have almost pharmacological terapeutic potential in the management of inflammatory bowel disease. Novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta-enriched (TGF-2) enteral feeding, showed beneficial effects in several clinical studies. Croatian guidelines for enteral nutrition in Crohn’s disease have been developed by interdisciplinary expert group of Croatian clinicians involved with inflammatory bowel disease. The guidelines are based on evidence from relevant medical literature and clinical experience of working group

CROATIAN CONSENSUS ON THE TREATMENT OF INFLAMMATORY BOWEL DISEASES WITH BIOLOGIC THERAPY

Uvođenje biološke terapije u kliničku praksu je značajan napredak u liječenju kroničnih upalnih bolesti crijeva, prije svega zbog njihove dokazane djelotvornosti te činjenice da su to prvi lijekovi kojima se uspjelo promijeniti prirodni tijek tih bolesti. Radi se, međutim, o vrlo skupim lijekovima s vrlo kompleksnim mehanizmima djelovanja i mogućim nuspojavama, te njihovo korištenje u vrlo kompliciranim bolestima kakve su upalne bolesti crijeva zahtijeva smjernice bazirane na rezultatima dobro kontroliranih studija. Referentni centar Ministarstva zdravlja i Sekcija za upalne bolesti crijeva Hrvatskog gastroenterološkog društva organizirali su stoga konsenzus konferenciju tijekom koje su definirane hrvatske smjernice za liječenje upalnih bolesti crijeva anti-TNF lijekovima. Tekst sa smjernicama uključuje definicije upalnih bolesti crijeva, opće principe liječenja upalnih bolesti crijeva, važnost mukoznog cijeljenja, analizu razloga nedjelotvornosti i gubitka djelotvornosti anti-TNF terapije, daje preporuke o dužini terapije, daje smjernice za probir na oportunističke infekcije prije početka anti-TNF terapije, osvrće se na probleme reprodukcije vezane za anti-TNF terapiju te konačno daje smjernice za liječenje raznih fenotipova upalnih bolesti crijeva i ekstraintestinalnih manifestacija upalnih bolesti crijeva.Introduction of biologic therapy in clinical practice represented significant progress in the treatment of inflammatory bowel diseases (IBD) because of its proven efficacy and due to the fact that biologics are the first drugs used in the treatment of IBD that can change the natural course of this diseases. At the same time, biologics are very expensive drugs with complex mechanism of action and important side effects and their use requires evidence-based clinical guidelines. These were the reasons that Referral Center of the Croatian Ministry of Health for IBD and the IBD Section of the Croatian Society of Gastroenterology organised Croatian consensus conference that defined guidelines for the treatment of IBD with anti-TNF drugs. The text below includes definitions of IBD, general principles of IBD therapy, comments on the importance of mucosal healing, analysis of reasons for nonresponse and loss of response to anti-TNF drugs, recommendation for the duration of anti-TNF therapy, rules of screening for opportunistic infections prior to anti-TNF therapy, comments on the problems with reproduction in IBD and finally guidelines for the treatment of various phenotypes of IBD including extraintestinal manifestations with anti-TNF therapy

Analiza konstruktivnih rješenja uređaja kod ofsetnih strojeva za tisak na arke

Postoje različiti ofset strojevi. Ponajprije postoje strojevi koji tiskaju iz arka, te strojevi koji tiskaju iz role. Princip otiskivanja je jednak kod obje vrste strojeva, ali postoje velike razlike u uređajima za izlaganje i uređajima za ulaganje. Ovaj završni rad opisuje isključivo ofsetne strojeve za tisak na arke i njegove osnovne dijelove. Osnovni dijelovi podijeljeni su u cjeline. To su uređaj za ulaganje, tiskovna jedinica i uređaj za izlaganje. Svaki dio ofsetnog stroja ima zadaću koju obavlja. Kako bi neki dio svoju zadaću obavio što bolje, njegova konstrukcija se unaprjeđuje i mijenja. Ovim završnim radom prikazat će se i opisati konstrukcija uređaja za ulaganje, tiskovne jedinice i uređaja za izlaganje. Tiskovna jedinica građena je od uređaja za vlaženje, obojenje i sistema valjaka. Uređaj za obojenje ima nekoliko različitih konstruktivnih rješenja isto kao i uređaj za vlaženje. Svako od konstruktivnih rješenja ima svoje prednosti i mane. Neki od tih rješenja detaljno su opisani u ovom završnom radu