Endoscopic Treatment of Pancreatic Diseases

Endoscopic therapy has been increasingly recognized as an effective method of treatment in selected patients with pancreatic diseases. Various endoscopic procedures, classical and modified, are used for the complex treatment of acute and chronic pancreatitis, as well as their complications. In pancreatic carcinoma, some endoscopic methods are applied mainly as palliative measures. There are still open questions regarding the placing and timing of various endoscopic procedures in the multidisciplinary management approach of pancreatic diseases

Up-To-Date View on the Clinical Manifestations and Complications of Chronic Pancreatitis

Chronic pancreatitis is an inflammatory disease that causes irreversible anatomical changes including infiltration of inflammatory cells, fibrosis and pancreatic calcification with destruction of the structure of the gland, leading to abdominal pain, endocrine and exocrine dysfunction. Pancreatic exocrine insufficiency (PEI) prevalence in chronic pancreatitis varies between 40 and 94%. PEI is diagnosed by direct and indirect tests. Nutritional status is assessed by anthropometric indicators; laboratory tests—hemoglobin, plasma proteins (albumin, prealbumin, retinol-binding protein, transferrin), fat-soluble vitamins A, D, E, K; micronutrients. Pancreatic enzyme replacement therapy (PERT) is a fundamental part of PEI treatment. An optimal PERT could prevent serious PEI complications such as metabolic bone disease, adverse cardiovascular events, cachexia, poor quality of life and mortality. A periodic screening for PEI complications with a respect to their primary and secondary prophylaxis is mandatory. Diabetes mellitus secondary to pancreatic disease is defined as pancreatogenic diabetes or type 3c diabetes mellitus. Patients with chronic pancreatitis are at increased risk for pancreatic cancer influenced by smoking, alcohol abuse, chronic inflammation and pancreatic stellate cells over-proliferation. However, chronic pancreatitis could be further complicated with splenic vein thrombosis, pseudocysts, duodenal or biliary obstruction, pseudoaneurysm and pancreatic duct stones which might require endoscopic or surgical treatment

Application of MRI for detection of some congenital malformation of the bile and pancreatic systems

Магнитнорезонансната холангиопанкреато- графия (MRCP) притежава редица предимства, включващи отсъствие на йонизираща радиа- ция и на инвазивност, както и липса на усложне- ния като остър панкреатит и холангит, харак- терни за директните холангиографски методи- ки. MRCP представлява метод на избор за неин- вазивното изследване на вродени малформации на жлъчната и на панкреасната система. Чер- нодробните резекции и трансплантации заемат важно място в хирургията на жлъчното дърво и черния дроб. Ето защо доброто познаване и раз- биране на анатомията, вариантите и вродени- те малформации е от особена важност.Magnetic resonance cholangiopancreatography (MRCP) has a number of advantages including the ab- sence of radiation and invasiveness, as well as a lack of complications such as acute pancreatitis and chol- angitis characteristic of direct cholangiographic meth- ods. MRCP is a method of choice for non-invasive ex- amination of congenital malformations of the biliary and pancreatic systems. Hepatic resections and trans- plants occupy an important place in gall bladder and liver surgery. That is why a good knowledge and un- derstanding of anatomy, variants and congenital mal- formations is of particular importance

Periampullary duodenal diverticula as a predictor for development of stenosing papillitis - construction of mathematical model

Стенозата на папилата на Фатер представлява доброкачествено заболяване, обусловено от възпалителни изменения и ръбцови промени, които предизвикват непроходимост на жлъчнияи панкреатичния канал и свързаните с това патологични процеси в жлъчните пътища и панкреаса. Възпалителни и фиброзни процеси в папилата на Фатер често се наблюдават при пациенти с периампуларен дуоденален дивертикул (ПДД). Създаването на математически модел показва зависимостта на папилита от наличието на периампуларен дуоденален дивертикул. Прилагането на логистична регресия доказва, че ПДД не е предиктор за развитие на папилит.The stenosis of the papilla of Fater is a benign disease, determined by inflammatory changes and scar tissue changes that cause obstruction of the bile and pancreatic duct and the associated pathological processes in the biliary tract and pancreas. Inflammatory and fibrotic processes in the papilla of Fater are frequently observed in patients with periampullary duodenal diverticulum (PDD). The creation of a mathematical model shows the dependence of papilitis on periampullary duodenal diverticulum. The application of logistic regression proves that the PDD is not a predictor for the development of papillitis

Laparascopic-assisted endoscopic mucosal resection of a polyp in sigma and laparoscopic right hemicolectomy for adenocarcinoma in colon ascendens - case report

Today, endoscopic polypectomy has become a daily-performed routine procedure in the operating room. Almost every polyp in the colon can be removed endoscopically, but there are some problematic adenomas which are either large in size or difficult to approach. We present 80 years old white woman with a tubulo­villous adenoma with high-grade dysplasia on a flat surface located in sigma with 4 x 5cm in size and also synchronously found in colon ascendens a well differentiated G1 adenocarcinoma with 2 x 2cm in size on a flat surface. The abdominal ultrasound did not find any liver metastases. Because of the difficult location and the size of the two lesions in the right and left colon, we make a decision for a laparoscopic-assisted en­doscopic mucosal resection (piece-meal) of the polyp in sigma and for the adenocarcinoma in colon ascen­dens the procedure was followed by laparoscopic right hemicolectomy in one step approach. The both inter­ventions were performed without complications and good postoperative period. Hybrid endoscopic and lap­aroscopic interventions are very effective approach that can resect large tubulovillous polyps and adenocar­cinoma of the colon, with a lesser risk of complications. Combining the methods in one surgery save time, make endoscopy more easy to perform and can save one-half of the colon in cases of synchronous lesions of the colon. Scr Sci Med 2017; 49(3): 49-5

<em>Helicobacter pylori</em> Infection

Helicobacter pylori (H. pylori) is a Gram-negative spiral bacterium commonly found in the stomach. Major part of the world’s population is infected with H. pylori and is at increased risk of severe gastritis, peptic ulcer disease, and gastric cancer. Most studied virulence factors of the bacterium are the cytotoxin-associated gene (CagA) and the vacuolating cytotoxin A (VacA). The H. pylori infection is diagnosed by invasive (histological examination, culture, and rapid urease test, which require endoscopy and biopsy) and noninvasive methods (serology, urea breath test, and stool antigen test). H. pylori eradication is preferred for a long-term prevention of complications. Current treatments consist of antibiotics and adequate PPI dose and can be divided into two strands—with or without bismuth. Achieving an eradication rate of >90% is an indicator for effective treatment. Due to the increasing levels of antibiotic resistance, the standard triple therapy is largely replaced with a quadruple therapy, especially in countries with high resistance rates. Antimicrobial susceptibility testing should be performed after the second-line treatment failure, leading to an individualized patient treatment. Clear explanations and patients’ compliance are of great importance for a better outcome

Current View on Autoimmune Gastritis

Autoimmune gastritis (AIG) is a chronic inflammatory disease of the gastric corpus and fundus. Although still unclear, genetic and environmental factors, antigenic mimicry or cross-reactivity are proposed pathogenic mechanisms. Parietal cells destruction results in loss of intrinsic factor and increased gastric pH due to hypochlorhydria and G-cell proliferation. Furthermore, atrophy, intestinal, pancreatic and spasmolytic polypeptide-expressing metaplasia are observed. AIG is underdiagnosed, however, proper diagnostic approach, including endoscopic, serological and histopathological assessment, is required. Gastroscopy with corpus and fundus biopsies is a gold standard. A serological combination of anti-parietal cell antibodies, intrinsic factor antibody, anti-Helicobacter pylori IgG, gastrin, pepsinogen I and pepsinogen I/II ratio improves the diagnostic sensitivity and specificity and allows atrophy level prediction. AIG might manifest with multifactorial iron deficiency anemia, vitamin B12 deficiency (pernicious anemia), neurological and neuropsychiatric conditions, small intestinal bacterial overgrowth and gastrointestinal infections. AIG association with other autoimmune diseases is well-established. Gastric cancer and gastric carcinoid are neoplastic transformations of a continuous chronic inflammation. Patients with AIG should be carefully monitored as no specific AIG therapy is available and disease complication could be fatal