A Case Report of Bulimia Induced Dental Erosion in a Female Adolescent

Vrlo teški oblici dentalne erozije rijetki su u adolescentskoj populaciji. Ovaj rad opisuje 17-godišnju pacijenticu koja se žalila na pojačanu osjetljivost zuba na hladan podražaj i dodir. Stomatološkim kliničkim pregledom ustanovljene su teške promjene - dentalna erozija svih zuba, što je tipično za intrinzične čimbenike dentalne erozije. Pacijentica je također ispunila upitnik kako bi se povezali erozija i mogući etiološki čimbenici. Odgovori iz upitnika, heteroanamnestički podaci i dentalni status, potvrdili su preliminarnu dijagnozu bulimije nervoze koja je rezultirala, za tu dob, rijetkom dentalnom destrukcijom i to u razdoblju od samo tri godine.Very severe forms of dental erosion are uncommon finding in adolescent population. This paper describes a 17-year old female who complained of increased teeth sensitivity to cold temperature and to touch. Dental examination revealed extensive and severe pattern of dental erosion of all teeth typical for intrinsic causes of dental erosion. She also completed a questionnaire investigating any association between the presence of erosion and possible etiological factors. Questionnaire responses, heteroanamnestic data and dental status confirmed our preliminary diagnosis of bulimia nervosa that resulted in a rarely significant dental destruction for that age in only three years period

Inflammatory Bowel Diseases

Upalne bolesti crijeva (engl. infl ammatory bowel diseases – IBD) jesu idiopatske, infl amatorne, kronične bolesti gastrointestinalnog sustava nepredvidiva tijeka. Prema epidemiološkim podacima raste im incidencija, a u patogenezi bolesti prepoznati su genski faktori i faktori okoliša. Laboratorijski podaci potvrđuju da je bolest rezultat poremećenog imunosnog odgovora u genski podložnih bolesnika, a prvi identifi cirani gen odgovoran za nastanak Crohnove bolesti je NOD2/CARD15. Glavna karakteristika Crohnove bolesti je transmuralnost upale koja može zahvatiti bilo koji dio probavne cijevi za razliku od ulceroznog kolitisa kod kojeg je upala ograničena samo na sluznicu kolona, a promjene se nalaze u kontinuitetu od rektuma prema proksimalnijim dijelovima crijeva. Ekstraintestinalne manifestacije (koža, zglobovi, oči) pojavljuju se i u jednoj i drugoj bolesti. Upalne bolesti crijeva liječe se medikamentno i kirurški. Lijekovi koje primjenjujemo u ovih bolesnika su aminosalicilati, kortikosteroidi, imunomodulatori, antibiotici i u novije vrijeme biološki lijekovi od kojih je trenutačno jedini registriran i klinički dostupan infl iksimab.The chronic infl ammatory bowel diseases (IBD) are idiopathic, infl ammatory chronic diseases of the gastrointestinal tract, unpredictable in the course. Epidemiological data show a rise in the incidence and suggest that both environmental and genetic infl uences are involved in the pathogenesis of chronic infl ammatory bowel diseases. Laboratory data suggest that the disease is a result of aberrant mucosal immune response in genetically susceptible individuals. NOD2/CARD15 has been identifi ed as a fi rst gene defi nitely linked to Crohn’s disease. Crohn’s disease is characterised by patchy transmural infl ammation affecting any part of the gastrointestinal tract, whereas ulcerative colitis characteristically is limited to the colon, producing continuous mucosal infl ammation always involving the rectum. Extra-intestinal manifestations affecting the skin, joints, and the eyes occur in both Crohn’s disease and ulcerative colitis. The current treatment of Crohn’s disease and ulcerative colitis comprises a combination of medical (aminosalicylates, corticosteroids, antibiotics, immunosuppressive agents, biologicals – infl iximab only registered and clinically available) and surgical therapy

Brain-gut axis dysfunction in young athlete with unfulfilled dreams - irritable bowel syndrome

Irritable bowel syndrome (IBS) is a disorder characterized by recurrent abdominal pain and bowel movement alterations in combination with psychological complaints. The exact etiology of IBS is not fully understood, however it seems that gut-brain dysfunction is the predominant cause

Epidemiološka studija varijanti tiopurin-metiltransferaze u skupini hrvatskih bolensika s upalnim bolestima crijeva

Thiopurine S-methyltransferase (TPMT) is an enzyme that converts thiopurine drugs into inactive metabolites. Over 20 variant TPMT-encoding alleles, which cause reduced enzymatic activity, have been discovered so far. Our aim was to investigate the frequencies of variant alleles, i.e. genotypes in inflammatory bowel disease (IBD) patients and healthy individuals and to compare these frequencies with selected world populations. The most common variant alleles TPMT*2, TPMT*3A, TPMT*3B and TPMT*3C were analyzed with polymerase chain reactionbased assays and allele-specific polymerase chain reaction-based assays in 685 participants including 459 IBD patients and 226 healthy volunteers. Study results revealed 434/459 (94.55%) IBD patients and 213/226 (94.25%) healthy subjects to be homozygous for the wild-type allele (TPMT*1/*1). TPMT*1/*2 and TPMT *1/*3C genotypes were found in 4/459 (0.87%) and 7/459 (1.53%) IBD patients, respectively; in healthy volunteers they were not found. TPMT*1/*3A genotype was found in 14/459 (3.05%) IBD patients and 13/226 (5.75%) healthy subjects. Variant genotypes were statistically significantly more common in Crohn’s disease subgroup than in ulcerative colitis subgroup. The prevalence of variant genotypes was 23/338 (6.80%) in Crohn’s disease subgroup as compared with 2/121 (1.65%) in ulcerative colitis subgroup (χ2=4.59; p=0.032). In conclusion, the most frequently occurring nonfunctional TPMT allele in Croatian population is TPMT*3A. The overall frequency of mutant alleles in our population is statistically nonsignificantly lower when compared with other populations of Caucasian origin. The Crohn’s disease group had more mutant alleles than the ulcerative colitis group.Tiopurin S-metiltransferaza (TPMT) je enzim koji sudjeluje u konverziji tiopurinskih lijekova u inaktivne metabolite. Dosad je otkriveno više od 20 varijanti TPMT-kodirajućih alela. Ovi aleli uzrokoju smanjenu enzimatsku aktivnost. Naš cilj je bio istražiti frekvenciju varijantnih alela odnosno genotipova u bolesnika oboljelih od upalnih bolesti crijeva i u zdravih osoba te usporediti dobivene frekvencije s frekvencijama odabranih svjetskih populacija. Najčešći varijantni aleli TPMT*2, TPMT*3A, TPMT*3B i TPMT*3C analizirani su metodama lančane reakcije polimeraze, odnosno alelspecifičnim metodama lančane reakcije polimeraze. U istraživanje je bilo uključeno 685 ispitanika; 459 ispitanika bili su bolesnici s upalnom bolesti crijeva, a 226 bili su zdravi dobrovoljci. Rezultati su pokazali da su 434/459 (94,55%) pacijenata s upalnom bolesti crijeva i 213/226 (94,25%) zdravih osoba homozigoti za divlji tip alela (TPMT*1/*1). Genotipovi TPMT*1/*2 i TPMT*1/*3C nađeni su u 4/459 (0,87%) odnosno 7/459 (1,53%) bolesnika; u zdravih dobrovoljaca nisu nađeni. Genotip TPMT*1/*3A nađen je u 14/459 (3,05%) bolesnika i 13/226 (5,75%) zdravih dobrovoljaca. Varijantni genotipovi bili su statistički značajno češći u podskupini bolesnika s Crohnovom bolešću, s učestalošću od 23/338 (6,80%) u odnosu na podskupinu bolesnika s ulceroznim kolitisom, gdje je učestalost varijantnih genotipova bila 2/121 (1,65%) (χ2=4,46; p=0,035). U zaključku, najčešći nefunkcionalni TPMT alel u Hrvatskoj populaciji je TPMT*3A. Ukupna frekvencija varijantnih alela u našoj je populaciji statistički neznačajno niža u odnosu na druge populacije bjelačkog podrijetla. Bolesnici s Crohnovom bolešću imaju više varijantnih alela u odnosu na podskupinu bolesnika s ulceroznim kolitisom

Celiac Disease in Adults

Celijakija je česta kronična autoimunosna bolest koja se javlja u 1% zapadne populacije, a karakterizira je doživotna nepodnošljivost glutena u genski predisponiranih osoba. Bolest ima vrlo šarenu kliničku sliku, može se očitovati u bilo kojoj životnoj dobi, a mogu nastupiti teške komplikacije ako se ne liječi. Zlatni standard u postavljanju dijagnoze celijakije u odrasloj populaciji je patohistološka verifikacija atrofije tankog crijeva iako su serološki testovi (protutijelo na tkivnu transglutaminazu, antiendomizijsko protutijelo) prvi korak u identifikaciji potencijalnih bolesnika. Dijagnostičku obradu (serološki testovi i biopsija sluznice) potrebno je zaključiti prije isključivanja glutena iz dijete. Bolest se liječi isključivo doživotnom bezglutenskom prehranom. Edukacija bolesnika ključna je za uspješno liječenje. Neliječeni bolesnici imaju veće zdravstvene rizike od bolesnika koji se pravilno pridržavaju bezglutenske prehrane. Osim celijakije gluten u ljudi može izazvati još dva poremećaja: alergiju i osjetljivost na gluten. U podlozi ovih poremećaja različiti su patomehanizmi i vrlo je važno razlikovati ih i pravilno dijagnosticirati.Celiac disease is a frequent chronic autoimmune disease affecting approximately 1 % of the population in the Western hemisphere. It is characterized by an abnormal response to gluten in genetically predisposed individuals. The disease has various clinical manifestations and serious complications can occur if left untreated. It can develop at any point in time during life. Intestinal biopsy with confirmation of mucosal atrophy is the gold standard in diagnosing adult celiac disease, but serologic tests (anti-endomysial antibody, anti-tissue transglutaminase antibody) provide an effective first step in identifying biopsy candidates. Serologic testing and biopsy should be done before initiating a gluten-free diet. A lifelong adherence to a gluten-free diet is the only available treatment. Patient education is crucial to successful treatment. Patients with untreated celiac disease have greater health risks than those who adhere to this treatment. Besides celiac disease, there are two forms of gluten-related diseases: wheat allergy and gluten sensitivity. Due to pathogenic differences, it is very important to properly diagnose various forms of gluten-related disorders

Dijetoterapija upalnih bolesti crijeva

Prehrana ima neupitno važnu ulogu u terapiji upalnih bolesti crijeva. U prvom redu važna je u prevenciji i liječenju pothranjenosti ili malnutricije, kao i prevenciji osteoporoze, a u djece je važno istaknuti ulogu prehrane u promoviranju optimalnog rasta i razvoja. Uloga prehrane u prevenciji upalnih bolesti crijeva nije do kraja razjašnjena. U aktivnoj fazi Crohnove bolesti, nutritivna terapija primjenom enteralnih pripravaka pokazala se učinkovitom primarnom terapijom za mnoge bolesnike. Enteralna prehrana trebala bi se danas smatrati standardnom primarnom terapijom u liječenju pedijatrijskih bolesnika s Crohnovom bolešću. Važnost enteralne prehrane osobita je u djece s lošim nutritivnim statusom i usporenim rastom. Postoje brojne teorije o prehrani koje se vežu uz etiologiju upalnih bolesti crijeva, međutim, do danas ni jedan prehrambeni pristup nije adekvatno znanstveno utemeljen da bi se moglo sa sigurnošću tvrditi kako smanjuje rizik od nastanka upalnih bolesti crijeva. Neki nutrijenti imaju gotovo farmakološki terapijski potencijal u liječenju i potpornoj terapiji upalnih bolesti crijeva. Posebna se pažnja pridaje protuupalnom djelovanju kratkolančanih masnih kiselina, prije svega butiratu, zatim ulozi probiotika i prebiotika te omega-3 masnih kiselina. Također, valja istaknuti i novije strategije terapijskog pristupa, kao što je enteralna prehrana s dodatkom transformirajućeg čimbenika rasta-beta (TGF-beta)

Terminal ileum resection as a trigger for strongyloides stercoralis hyperinfection and ensuing serial sepsis in a 37-year-old patient with complicated Crohnʼs disease: a case report

The nematode Strongyloides stercoralis, outside the tropics and subtropics present in small endemic foci, can cause an infection after direct skin contact with contaminated soil containing infective filariform larvae and, rarely, after intimate interhuman contact or after transplantation of an infected solid organ. Following skin penetration, migration, and maturation through several stages, a small number of invasive filariform larvae can develop anew in the gut lumen, perpetuating new cycles of penetration, tissue migration, and reproduction, without leaving the host. In a state of immunosuppression, autoinfection can progress to life-threatening hyperinfection and/or infection disseminated through virtually any organ. In developed countries, the most frequently recognized risk for severe hyperinfection is corticosteroid therapy, but this has been also described in malnourished, alcoholic, cancer, and transplant patients. Due to the frequent need for immunosuppressive therapy, patients suffering from inflammatory bowel disease (IBD) are susceptible to develop overwhelming strongyloidiasis. Strongyloidiasis can be easily overlooked in clinical settings, and in many European regions there is poor insight into the epidemiological burden of this disease. We present a case of S. stercoralis hyperinfection that triggered 3 successive episodes of sepsis caused by pathogens of the gut flora in a young patient suffering from stenotic form of Crohn's disease. S. stercoralis hyperinfection occurred in the corticosteroid-free period, shortly after resection of the terminal ileum, which was probably the trigger for the overwhelming course. The patient was successfully treated with 10-day albendazole therapy

Increased arterial stiffness – similar findings in patients with inflammatory bowel disease without prior hypertension or diabetes and in patients with well-controlled hypertension

PURPOSE: Chronic inflammatory diseases are related with earlier onset of atherosclerosis. We hypothesized that inflammatory bowel disease patients with chronic, systemic inflammation have an increased arterial stiffness associated with the disease duration. Also, we wanted to compare arterial stiffness markers between inflammatory bowel disease and well-controlled hypertension patients. ----- MATERIALS AND METHODS: A total of 89 inflammatory bowel disease patients (60 patients with Crohn's disease and 29 patients with ulcerative colitis, age range 20-64 years) without history of arterial hypertension or diabetes were enrolled and age matched with a control group of patients (73 patients, age range 25-69 years, 41 (56.1%) males) with known history of well-controlled arterial hypertension. We have used a noninvasive device that simultaneously measures brachial blood pressure and estimates PWV and AIx in inflammatory bowel disease and hypertension groups of patients. ----- RESULTS: Patients with pathological PWV values were significantly older, had significantly longer duration of inflammatory bowel disease, higher values of serum cholesterol and HDL-cholesterol, and higher AIx (17.4% vs. 9.8%) (all p < .05). Higher PWV was associated with age and duration of inflammatory bowel disease in the linear regression model. PWV values were higher in hypertensive patients in the first two age quartiles while interestingly, in the last two quartiles, PWV was lower than in inflammatory bowel disease group of patients. ----- CONCLUSIONS: Chronic subclinical inflammation is responsible for dyslipidemia and accelerated atherosclerosis which consequently alterates arterial elasticity. Inflammatory bowel disease and its duration should also be considered a risk factor for subclinical organ damage, as well as hypertension

Association of polymorphic variants in serotonin re-uptake transporter gene with Crohn’s disease: a retrospective casecontrol study

Aim To analyze the distribution of SLC6A4 gene polymorphisms in Crohn’s disease (CD) patients and their association with the disease. Methods We evaluated the presence/absence of promoter (5-HTTLPR, rs25531) and intron 2 (STin2 VNTR) polymorphic variants of SLC6A4 gene in a retrospective case-control study including 192 CD patients and 157 healthy controls (HC). Genotyping was performed by polymerase chain reaction. The association of polymorphisms with CD and its clinical subtypes was analyzed using χ2 and Fisher exact test, binary logistic regression, and haplotype analysis.Results CD patients and healthy controls had similar sex (88 [45.8%] vs 84 [53.5%] women, respectively; P = 0.154) and age (41.3 ± 12.8 years vs 41.7 ± 8.8 years, respectively, P = 0.091) distribution. Significant differences were observed in the STin2 genotype and allele distribution between CD patients and healthy controls (P = 0.003 and P = 0.002, respectively) and between the corresponding female subgroups (P = 0.004 and P = 0.007, respectively), with a significant negative association of biallelic ss (STin2.9 and Stin2.10) STin2 genotype with CD (P = 0.013, age- and sexadjusted odds ratio [OR] 0.5, 95% confidence interval [CI] 0.29-0.86; women: P = 0.006, age-adjusted OR 0.32, 95% CI 0.14-0.72) and a significantly higher S-STin2.12 (5-HTTLPR/ rs25531: S-STin2: STin2.12) haplotype distribution in CD patients (P = 0.004, OR 1.62, 95% CI 1.16-2.26). There was no significant association between 5-HTTLRP and rs25531 genotype or allele frequencies and CD and between any SLC6A4 polymorphic loci with clinical CD subtypes. Conclusion STin2 VNTR polymorphism of SLC6A4 gene may contribute to CD pathogenesis

Leukocitafereza u liječenju teškog, o steroidima ovisnog ulceroznog kolitisa

Ulcerative colitis (UC) is a multifactorial disease of unknown precise etiology and immunopathogenesis. Peripheral blood granulocytes and monocytes/macrophages are the major sources of cytokines, which regulate inflammation. Leukocytapheresis (LCAP) is a method where blood is processed by apheresis system that removes lymphocytes and plasma before being returned to the body. We report the first case in Croatia where we used LCAP in the treatment of a patient with severe steroid-dependent UC. After 12 LCAP procedures, good clinical response was obtained and there were no significant adverse side effects noticed. The patient remained in clinical remission over two years in which he underwent regular follow ups at outpatient clinic. Over a 10-year follow-up period after LCAP, the patient had only occasional clini-cal symptoms of disease activity. The clinical course was complicated with the development of metastatic colorectal carcinoma, which points to the importance of regular disease monitoring rather than the in-creased risk of malignant disease after LCAP. Patients with UC are a demanding group of patients that warrant the search for novel treatment strategies other than conventional pharmacological therapies. Alt-hough LCAP is still not a common treatment modality in our daily practice, data from recent studies sug-gest it to be an effective and safe procedure in the management of active UC patients.Ulcerozni kolitis (UC) je kronična bolest multifaktorske etiologije čiji detaljan mehanizam imunološkog procesa još nije sasvim razjašnjen, ali ključnu ulogu svakako imaju granulociti i monociti/makrofazi koji reguliraju i pojačavaju upalni proces lučenjem proupalnih citokina. Leukocitofereza (LCAP) je terapijski postupak kojim se prolaskom krvi kroz sustav za aferezu odstranjuju limfociti i plazma prije nego što se krv ponovno vrati u krvotok. U ovom radu je prikazan o steroidima ovisan bolesnik s teškim relapsom UC-a koji je, prvi put u Hrvatskoj, liječen protokolom LCAP. Nakon 12 terapijskih protokola LCAP kod bolesnika je došlo do značajnog kliničkog poboljšanja bez razvo-ja nuspojava. Bolesnik je ostao u kliničkoj remisiji tijekom dvije godine ambulantnog praćenja, a unutar 10 godina praćenja nakon LCAP bolesnik je imao tek povremene simptome aktivnosti bolesti. Klinički tijek bio je kompliciran razvojem metastatskog karcinoma debelog crijeva, što prvenstveno upućuje na važnost redovitog praćenja bolesti, a ne na povećan rizik maligne bolesti nakon LCAP. Bolesnici s UC-om su zahtjevna skupina pacijenata koja zahti-jeva potragu za novim terapijskim strategijama osim onih konvencionalnih farmakoloških. Iako LCAP nije čest modalitet liječenja u svakodnevnoj kliničkoj praksi, novije studije upućuju na to da je postupak učinkovit i siguran u liječenju bolesnika s aktivnim UC-om