49 research outputs found
Gastrointestinal Endoscopy and Acetylsalicylic Acid: What a Family Physician Needs to Know?
PodruÄje gastrointestinalne endoskopije kod bolesnika na antiagregacijskoj terapiji karakteriziraju dva kliniÄka scenarija. Zbog ulceriformnog potencijala acetilsalicilne kiseline postoji poveÄan rizik od nastanka gastrointestinalnog krvarenja, osobito u bolesnika starije životne dobi. U ovom kontekstu uloga lijeÄnika obiteljske medicine oÄituje se u prepoznavanju populacije s Äimbenicima rizika od nastupa krvarenja te poduzimanju prikladnih mjera prevencije. Drugi scenarij ukljuÄuje pripremu bolesnika na antiagregacijskoj terapiji za intervencijske gastrointestinalne zahvate. Odluka o prekidu antiagregacijske terapije ovisi o ravnoteži rizika od nastanka tromboembolijskog incidenta s jedne strane te rizika od nastanka postproceduralnog krvarenja s druge strane. LijeÄnik obiteljske medicine treba biti upoznat s navedenim Äimbenicima rizika radi adekvatne pripreme bolesnika za endoskopsku proceduru. Ipak, bolesnici s visokim rizikom od nastanka tromboembolijskog incidenta u kojih se planira zahvat s visokim rizikom od nastanka postproceduralnog krvarenja zaslužuju zajedniÄku odluku gastroenterologa i kardiologa, i to za svakog bolesnika individualno.Gastrointestinal endoscopy in patients on antiplatelet therapy is characterised by two clinical scenarios. Due to the ulcerogenic potential of acetylsalicylic acid, there is an increased risk of gastrointestinal haemorrhage, especially in the elderly. In that regard, the role of the family physician is to recognise the population at risk and to implement preventive measures. The other clinical situation is the preparation of patients on antiplatelet therapy for invasive gastrointestinal endoscopy interventions. A decision whether or not to discontinue antiplatelet therapy is balanced against the risk of thromboembolic events and the risk of post-procedural bleeding. The family physician should be aware of both these risk factors before the planned procedure. However, in patients with a high risk of thromboembolic events in whom a high-risk procedure is contemplated, this decision is made jointly by cardiologist and endoscopist on an individual basis
Novosti u endoskopskoj dijagnostici tumora debelog crijeva
Colorectal cancer (CRC) is the third most commonly diagnosed malignant tumor and the fourth leading cause of cancer death in the world. Since it is known that most of colorectal cancers arise from adenomatous polyps, screening programmes were developed in order to improve detection of polyps and early diagnosis of carcinoma. Colonoscopy is the gold standard for diagnosis of CRC. Because of its high adenoma missing rates and lower ability to differentiate between benign and malignant lesions novel techniques are being developed in order to improve mucosal visualization, reduce adenoma missing rates and enable in-vivo optical diagnosis. Methods can roughly be divided into three categories, ones that present improved visualization techniques (endoscopes with increased field of view, auxiliary imaging devices, so called addon devices), ones that enable more detail tissue characterization presenting the possibility for virtual biopsy (conventional or virtual chromoendoscopy, confocal laser endomicroscopy and endocytoscopy), and other minimally or non-invasive techniques. Further investigation is needed, but hopefully these innovations with continuous technical improvement might help to reduce the colorectal cancer incidence and mortality.Karcinom debelog crijeva treÄi je najÄeÅ”Äe dijagnosticiran maligni tumor I Äetvrti vodeÄi uzrok smrti od raka na svijetu. BuduÄi da je poznato da veÄina karcinoma debelog crijeva nastaje malignom alteracijom adenomatonih polipa, razvijeni su brojni programi probira s ciljem poveÄanja detekcije polipa I karcinoma u ranom stadiju. Kolonoskopija je zlatni standard u dijagnostici kolorektalnog karcinoma. Zbog visokog udjela propuÅ”tenih adenoma I slabije moguÄnosti diferencijacije benignih od malignih lezija razvijaju se nove endoskopske tehnike s ciljem unaprijeÄenja vizualizacije sluznice, sniženja udjela propuÅ”tenih adenoma te omoguÄavanja postavljanja in-vivo optiÄke dijagnoze. Metode se mogu podijeliti u tri skupine, one koje omoguÄuju bolju vizualizaciju (ukljuÄujuÄi kolonoskope sa poveÄanim opsegom pregleda te koriÅ”tenje takozvanih āadd-onā ureÄaja), one koje omoguÄuju detaljniji pregled I diferencijaciju detektiranih lezija (konvencionalna I virtualna kromoendoskopija, konfokalna laserska endomikroskopija I endocitoskopija), te ostale minimalno invazivne I neinvazivne tehnike. Daljnja istraživanja s ciljem evaluacije navedenih metoda svakako su potrebna, uz nadu da Äe njihovo koriÅ”tenje uz daljnji tehniÄki napredak pomoÄi u redukciji incidencije I mortaliteta od kolorektalnog karcinoma
EUS Elastography and Virtual Biopsy
Endoskopska ultrazvuÄna elastografija (EUZ-E) s visokom senzitivnosti i specifiÄnosti razlikuje tumor guÅ”teraÄe od kroniÄnog pankreatitisa. Na osnovi iskustva možemo takoÄer razlikovati ova dva entiteta s jednakom pouzdanosti veÄ i obiÄnim EUZ pregledom. Za lege artis terapijski pristup u konaÄnici trebamo histoloÅ”ku potvrdu. S druge strane, nakon endoskopske pretrage, a Äesto i histoloÅ”ke analize ne uspijevamo definirati fenotip upalne bolesti crijeva. Kvantitativna elastografska analiza sa SR (strain ratio) analizom osigurava vrijednu informaciju o kompresibilnosti rektalnog i perirektalnog tkiva, Å”to nam dopuÅ”ta da s velikom sigurnosti razlikujemo morbus Crohn od ulceroznog kolitisa, izdvajajuÄi na taj naÄin transrektalnu ultrazvuÄnu elastografiju kao korisnu metodu u fenotipizaciji upalnih bolesti crijeva. Na osnovi izloženih rezultata zakljuÄujemo da je EUZ elastografija obeÄavajuÄa slikovna tehnika poglavito u definiranju upalnih bolesti crijeva, znatno prije nego u onkologiji.Endoscopic ultrasound elastography (EUS-E) shows a highly significant sensitivity and specificity in differentiating between PC and CP. Based on our experience, the EUS without elastography can also differentiate between PC and CP, but appropriate treatment should be based on histological confirmation. On the other hand, endoscopy, which is often combined with histology, is not conclusive enough for defining the IBD phenotype. Quantitative elastography with SR calculation provides the information on the stiffness of the rectal and perirectal tissue, which enables us to differentiate between CD and UC and thus makes TRUS-E a valuable tool in defining the IBD phenotype. On the basis of current results, we can conclude that TRUS-E is a promising imaging technique in defining inflammatory diseases. Furthermore, the use of elastography is more promising in IBD than in oncology
Endoskopske inovacije u dijagnostici i lijeÄenju kolorektalnog karcinoma
Colonoscopy is the gold standard in diagnosis of colorectal cancer that in most instances arises from precursor lesion, adenomatous polyp. However, white ligh forward viewing colonoscopy is not a pefect method, up to a quarter of adenomas are being missed during standard procedures. Therefore, new techniques and technologies are being developed in order to increase adenoma detection rate, either through better resolution and magnification of the image (highdefinition, high-magnification endoscopes) or by augmenting the overview of colonic mucosa (Full Spectrum Endoscopy colonoscope, Third-Eye Retroscope). Besides adenoma detection, new technologies allow better tissue characterisation and in vivo discrimination between nonneoplastic and neoplastic lesions (conventional chromoendoscopy, virtual chromoendoscopy, confocal laser endomicroscopy, endocytoscopy). In additon to diagnostic procedures, therapeutic techniques are also evolving. Formerly, all of the flat or depressed colorectal lesions, encountered during colonoscopy, were reffered to surgery. Today, endoscopic mucosal resection is becoming a routine method for the treatment of early gastrointestinal mucosal lesions of less than 2 cm in diameter. For larger lesions, endoscopic submucosal dissection, a state-of-the-art technique, is indicated, but currently carried out only in tertiary centres. Endoscopic innovations are leading into new era of colorectal cancer diagnosis and management, hopefully resulting in decrease of incidence, morbidity and mortality.Kolonoskopija je zlatni standard u dijagnostici kolorektalnog karcinoma koji u veÄini sluÄajeva nastaje iz prekursorske lezije, adenoma. MeÄutim, standardna kolonoskopija nije savrÅ”ena metoda; prema rezultatima tandem studija Äak Äetvrtina adenoma ostaje neotkrivena. Stoga se razvijaju nove tehnike i tehnologije koje omoguÄuju bolju detekciju adenoma uveÄanjem i boljom rezolucijom slike (āāhigh-definitionāā, āāhigh-magnificationāā endoskopi) te boljim pregledom sluznice debelog crijeva (āāFull Spectrum Endoscopyāā kolonoskop, āāThird-Eye Retroscopeāā). Nove tehnologije takoÄer omoguÄuju i napredniju karakterizaciju kolorektalnih promjena i in vivo razlikovanje ne-neoplastiÄnih i neoplastiÄnih lezija (konvencionalna kromoendoskopija, virtualna kromoendoskopija, konfokalna laserska endomikroskopija, endocitoskopija). Osim dijagnostiÄkih, napreduju i terapijske endoskopske metode. Do sada su sve ne-polipoidne kolorektalne promjene lijeÄene kirurÅ”ki, a danas je endoskopska mukozna resekcija postala rutinska metoda za lezije do 2 cm u promjeru. U sluÄaju veÄih promjena inidicirana je endoskopska submukozna disekcija, state-of-the-art tehnika koja se trenutno izvodi samo u tercijarnim centrima. Inovacije u endoskopiji vode u novu eru dijagnostike i lijeÄenja kolorektalnog karcinoma te nagovijeÅ”taju bolju prevenciju i smanjenje incidencije ove Äeste maligne bolesti
Helicobacter Pylori Detection in Histological Samples
HistoloÅ”ka analiza materijala uzetog endoskopski iz gornjega dijela probavnog sustava kod bolesnika s dispeptiÄkim tegobama ima veliku važnost u prepoznavanju preneoplastiÄnih promjena sluznice i stanja vezanih uz posljedice kroniÄne upale koja nose odreÄeni rizik od razvoja karcinoma želuca. Na taj naÄin gastroenterolog dobiva relevantne podatke o prognozi i planira praÄenje bolesnika. Uvjet za adekvatnu histoloÅ”ku analizu i iscrpan i vrijedan nalaz jest koliÄina materijala dobivena za histoloÅ”ku analizu. OpÄeprihvaÄeni kriteriji uzimanja najmanje pet biopsija iz razliÄitih dijelova želuca svakako daju optimalne rezultate u histoloÅ”koj analizi uz moguÄnost davanja iscrpnih i pouzdanih podataka. Isto tako potrebna je i standardizacija naÄina izvjeÅ”tavanja o promjenama koje nose rizik od razvoja karcinoma kao Å”to je atrofija sluznice želuca za koje se rabe noviji kriteriji OLGA. Modificirani Sydneyski sustav skoriranja (Houstonski kriteriji) rabe se joÅ” i sada u nekim centrima za procjenu proÅ”irenosti i tipa upalne reakcije, prisutnosti metaplastiÄnog epitela te procjenu stupnja atrofije sluznice i gustoÄe kolonizacije H. pylori.Histological examination of endoscopic gastric mucosa in patients with dyspeptic signs has a great value in the recognition of preneoplastic mucosal changes and conditions related to chronic gastric mucosa inflammation, which carries some risk for stomach carcinoma. In this way, a gastroenterologist can get the relevant prognostic factors and criteria for patients follow-up. The prerequisite for the appropriate histological examination is the amount of the obtained biopsy samples. At least five biopsy samples from different sites in the stomach, as generally accepted, yield optimal results in histological analysis. Furthermore, the parameters for reporting all preneoplastic conditions, which are described by the new OLGA staging system and which may lead to the development of carcinoma, such as gastric mucosa atrophy, should be standardized. The Modified Sydney Score (Houston System) is still used by some institutions for reporting atrophy score and H. pylori colonization
Diagnostic Accuracy of NICE Classification System for Optical Recognition of Predictive Morphology of Colorectal Polyps
The NICE classification is an international endoscopic classification of colorectal neoplasia through a narrowband spectrum that on the basis of lesion colors, vascular pattern, and structure of the surface of the mucous membrane classifies colorectal neoplasms in three categories: type 1 as hyperplastic lesions, type 2 as adenomas, and type 3 as invasive tumors. The aim of this study was to verify diagnostic accuracy of the NICE classification system compared to the reference standard: histopathological analysis. This retrospective study was conducted by ten physicians on a sequential sample of 418 patients and 735 polyps. The total diagnostic accuracy of the NICE classification system is found to be 76.7%. Optical recognition is significantly better with larger polyps, high-risk lesions (HGIEN), and neoplastic lesions. This research has shown that the NICE classification system is at the moment inferior to histopathological analysis. However, it is noticed that some physicians achieve significantly better results, with the accuracy of diagnosis ranging from 59.5% to 84.2%. These results show that with proper training of physicians and the use of endoscope enhancements to improve image quality, the NICE classification system could in the future potentially replace the histopathological diagnosis process
WHITE PAPER Croatian Society of Gastroenterology Consensus October 2019
Jedan od kljuÄnih elemenata zdravstvene zaÅ”tite nedvojbeno je dostupnost. Imati jednaku zdravstvenu zaÅ”titu i moguÄnost ostvarenja najviÅ”e razine zdravstvene usluge temeljno je pravo svakog pojedinca. To pravo nije samo humano i etiÄki neosporno, nego je i defi nirano zakonom. U tom smislu jasno je da pravo na zdravstvenu zaÅ”titu ne smije biti privilegija veÄ imperativ postupanja.
Znanjem, entuzijazmom i dobrom organizacijom, Äak i u materijalno ograniÄenim okolnostima, može se postiÄi vrlo mnogo. Republika Hrvatska je zemlja posebnih geografskih obilježja i koliko je to Äini lijepom u svoj njenoj raznolikosti toliko nerijetko otežava dostupnost najkvalitetnijim oblicima zdravstvene zaÅ”tite i zdravstvenih postupaka. Formiranjem visoko specijaliziranih centara objedinjenih u dobro organiziranu mrežu i uz organiziranu i koordiniranu komunikaciju zdravstvenih djelatnika, svim bolesnicima sa specifi Änom i zahtjevnom problematikom može biti pružena najbolja zdravstvena zaÅ”tita.
U gastroenterologiji akutni kolangitis, akutni bilijarni pankreatitis i komplikacije kolecistektomije u obliku postoperacijskih ozljeda žuÄovoda, dijagnoze su koje zahtijevaju postupak endoskopske retrogradne kolangiopankreatografi je (ERCP) unutar 72 sata, a u pojedinim sluÄajevima i unutar 24 sata. Nažalost, Äinjenica je da trenutno u Republici Hrvatskoj takvi bolesnici nerijetko Äekaju na intervenciju znatno duže jer ne postoji organizirana mreža slanja i prihvata spomenute kategorije bolesnika.
Radna skupina Hrvatskog gastroenteroloÅ”kog druÅ”tva izradila je predložak āHrvatske mreže intervencijske gastroenterologije ā ERCPā i nakon Å”iroke javne rasprave SkupÅ”tina DruÅ”tva prihvatila je spomenuti
dokument kao konsenzus Hrvatskog gastroenteroloÅ”kog druÅ”tva. Implementacijom navedenog konsenzusa u svakodnevnu kliniÄku praksu osigurava se ostvarivanje prava svih graÄana Republike Hrvatske
na jednaku dostupnost najbolje zdravstvene zaÅ”tite, oÄuvanje i poboljÅ”anje zdravlja uz dulji i kvalitetniji život velikog broja ovih bolesnika. Mreža CRO-GASTRONET-ERCP osmiÅ”ljena je i s nakanom da se svim zdravstvenim djelatnicima, u svim zdravstvenim ustanovama Republike Hrvatske olakÅ”a brza komunikacija s devet visoko specijaliziranih tercijarnih centara za djelatnost ERCP-a sa ciljem uske suradnje u smislu najboljeg i najbržeg moguÄeg lijeÄenja bolesnika s dijagnozama akutnog kolangitisa, akutnog bilijarnog pankreatitisa ili komplikacija kolecistektomije u obliku postoperacijskih ozljeda žuÄovoda. Jasno defi niranim postupnicima omoguÄit Äe se standardizacija zdravstvenih usluga u korist bolesnika, ali i najuÄinkovitije koriÅ”tenje ekonomskih resursa. Svaki poÄetak je težak, ali se kako predvidive tako i nepredvidive prepreke mogu uspjeÅ”no rijeÅ”iti zajedniÄkim konstruktivnim radom i naporima svih dionika zdravstvenog sustava.Availability is undoubtedly one of the key elements of the healthcare system. Th e fundamental right of every person is to have the highest level of healthcare service based on excellence and equality. Th is right is indisputable not only from the human and ethical viewpoint, but is also defined by law. In this regard, it is clear that the right to healthcare service must not be merely a privilege but rather an imperative.
A great deal can be achieved with knowledge, enthusiasm and good organization, even under circumstances of material restrictions. Republic of Croatia is a country of specific geographical features, which makes it
beautiful in all its diversity but oft en makes the availability of specialized forms of healthcare service and procedures difficult. By forming highly specialized centers integrated into a well-organized network and with organized and coordinated communication of healthcare professionals, all patients with specifi c and demanding problems can be provided with the best healthcare service.
In gastroenterology, acute cholangitis, acute biliary pancreatitis and cholecystectomy complications in terms of postoperative bile duct injuries are diagnoses requiring endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours, and in some cases within 24 hours. Unfortunately, the fact is that currently in the Republic of Croatia, such patients oft en have to wait for intervention considerably longer because there is no organized network of referring and admitting this category of patients.
A working group of the Croatian Society of Gastroenterology has developed a model for the Croatian Interventional Gastroenterology Network-ERCP and, following a broad public discussion, the Assembly of the Society accepted the document as a consensus of the Croatian Society of Gastroenterology. Th e implementation of this consensus into everyday clinical practice provides for exercising the rights of all citizens of the Republic of Croatia to equal availability of the best healthcare service, and for preservation and improvement of health with longer and better quality life for a large number of these patients. Th e CRO-GASTRONET-ERCP has also been designed to facilitate all healthcare professionals at all healthcare institutions in the Republic of Croatia fast communication with nine highly specialized tertiary centers for ERCP, with the aim of achieving close cooperation in providing the best and fastest possible treatment of patients with the diagnoses of acute cholangitis, acute biliary pancreatitis or cholecystectomy complications in terms of postoperative bile duct injuries. Clearly defined protocols will make it possible to standardize healthcare services to the benefit of patients, but also to use economic resources most efficiently. Every beginning is hard, but both foreseeable and unforeseeable obstacles can be resolved successfully with joint constructive action and efforts of all stakeholders of the healthcare system
Manometrija visoke rezolucije u dijagnostici bolesti jednjaka
Uz endoskopske i radioloÅ”ke metode, osovinu dijagnostike funkcijskih poremeÄaja jednjaka Äini manometrija. Radi se o tradicionalnoj metodi kojom se ispituje funkcijska sposobnost gornjeg i donjeg sfinktera te tijela jednjaka. PrateÄi razvoj informatiÄke tehnologije, konvencionalna se manometrija tijekom proteklih desetljeÄa transformirala u manometriju visoke rezolucije. Tehnika visoke rezolucije omoguÄuje bolju prostornu razluÄivost svih segmenata jednjaka, znatno je olakÅ”ana inicijalna orijentacija prema svim strukturnim podjedinicama jednjaka te je kraÄe vrijeme pretrage, Å”to bolesniku uvelike olakÅ”ava podnoÅ”ljivost procedure. Manometrija visoke rezolucije koristi dvije vrste katetera ā Ävrsti i vodom-perfundirani (silikonski), u koje su ugraÄeni multipli senzori koji imaju moguÄnost radijalne detekcije signala iz bliskih dijelova tkiva. DanaÅ”nja tehnologija omoguÄuje i inkorporaciju impedancijskih senzora u kateter, koji temeljem promjena otpora u tkivu jednjaka detektiraju suptilne promjene u tranzitu bolusa hrane ili tekuÄine. Funkcijski, odnosno poremeÄaji motiliteta jednjaka prema definiranim parametrima Chicago klasifikacije kategoriziraju se hijerarhijski u poremeÄaje s opstrukcijom na razini ezofago-gastriÄnog spoja, velike poremeÄaje te male poremeÄaje peristaltike. UvoÄenje ove metode, kao i redovito ažuriranje Chicago klasifikacije, omoguÄuje znaÄajan napredak u dijagnostici, posljediÄno i lijeÄenju sve ÄeÅ”Äih funkcijskih poremeÄaja jednjaka