Transrektalna elastografija u razlikovanju Crohnove bolesti i ulceroznoga kolitisa [Transrectal elastography in differentiation between Crohn's disease and ulcerative colitis]

The patterns of inflammation and collagen deposition differ between Crohn's disease (CD) and ulcerative colitis (UC). Assuming that both processes alter the mechanical properties of the bowel wall, its stiffness is a potential discriminatory feature between the two diseases. The aim of this study was to determine whether is it possible to differentiate between active Crohn's colitis, with rectal involvement, and active ulcerative colitis, on the grounds of pseudoquantitative measurements obtained by transrectal ultrasound-guided strain elastography. 28 CD patients, 30 UC patients and 30 controls were enrolled in the study. Regions of interest were placed over the rectal wall and the adjacent perirectal tissue. Relative strain and average Histogram values were measured in every region and Strain Ratio (SR) and Histogram Ratio (HR) were calculated. There were no statistically significant differences in SR and HR between the three groups. The relative rectal wall strain was lower in CB group compared to UC group (P=0,035), average rectal wall Histogram value was higher in CB group compared to UC group but the difference did not reach statistical significance (P=0,067). According to our results, SR and HR measurements do not discriminate between UC and CB, however, relative strain differences between the two groups suggest that strain elastography might have a role in inflammatory bowel disease diagnostics

Rectal cancer and Fournier's gangrene - current knowledge and therapeutic options

Fournier's gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects

Endoskopske inovacije u dijagnostici i liječenju 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 većini slučajeva nastaje iz prekursorske lezije, adenoma. Međutim, standardna kolonoskopija nije savršena metoda; prema rezultatima tandem studija čak četvrtina adenoma ostaje neotkrivena. Stoga se razvijaju nove tehnike i tehnologije koje omogućuju bolju detekciju adenoma uvećanjem i boljom rezolucijom slike (‘’high-definition’’, ‘’high-magnification’’ endoskopi) te boljim pregledom sluznice debelog crijeva (‘’Full Spectrum Endoscopy’’ kolonoskop, ‘’Third-Eye Retroscope’’). Nove tehnologije također omogućuju i napredniju karakterizaciju kolorektalnih promjena i in vivo razlikovanje ne-neoplastičnih i neoplastičnih lezija (konvencionalna kromoendoskopija, virtualna kromoendoskopija, konfokalna laserska endomikroskopija, endocitoskopija). Osim dijagnostičkih, napreduju i terapijske endoskopske metode. Do sada su sve ne-polipoidne kolorektalne promjene liječene kirurški, a danas je endoskopska mukozna resekcija postala rutinska metoda za lezije do 2 cm u promjeru. U slučaju većih 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 liječenja kolorektalnog karcinoma te nagoviještaju bolju prevenciju i smanjenje incidencije ove česte maligne bolesti

Liver Cirrhosis Complications and Their Treatment

Procjenjuje se da više od milijun ljudi u svijetu godišnje umire od ciroze jetre. Alkohol je najčešći etiološki čimbenik razvoja ciroze, ali unatrag dva desetljeća prati se i značajan porast incidencije ciroze uzrokovane nealkoholnim steatohepatitisom. Ciroza je dugo definirana kao difuzni proces u jetrenom parenhimu koji dovodi do promjene arhitekture jetre i smatrana je ireverzibilnim procesom. Međutim, napredovanje fibroze uvelike ovisi o podležećoj bolesti, a moguća je i regresija, ovisno o mogućnosti liječenja osnovnog patogenetskog mehanizma. Podjela ciroze na kompenziranu i dekompenziranu nije dovoljna zbog neadekvatne mogućnosti stratifikacije rizika razvoja komplikacija pa je nužno prepoznavati potkategorije ciroze. Postavlja se i imperativ ranog otkrivanja fibroze u čemu sve više pribjegavamo neinvazivnim metodama, a serološki markeri svakako su dobrodošli. Prijelaz kompenzirane u dekompenziranu fazu bolesti događa se frekvencijom 5 − 7 % godišnje. Prijelazom u dekompenziranu fazu bolesti ciroza postaje sistemska bolest s multiorganskom disfunkcijom. Komplikacije dekompenzirane ciroze jetre su brojne, a najčešće su: ascites i spontani bakterijski peritonitis, gastrointestinalno krvarenje, hepatorenalni sindrom i encefalopatija. Bolesnici s cirozom imaju i značajne promjene u koagulacijskoj kaskadi. Oni nisu prirodno antikoagulirani i tromboembolijski incidenti nisu rijetkost. Terapija i profilaksa tromboembolijskih incidenata u cirozi jetre razlikuje se u odnosu na bolesnike bez ciroze i zahtijeva multidisciplinarni pristup. Malnutricija i sarkopenija nisu komplikacije samo dekompenzirane ciroze jetre, već ih treba pravovremeno detektirati i liječiti i u svim stadijima jetrene bolesti.It is estimated that more than a million people worldwide die from liver cirrhosis every year. Alcohol consumption is still the most common cause of cirrhosis, but over the last two decades we have been witnessing a significant increase in the incidence of cirrhosis caused by non-alcoholic steatohepatitis. For a long time, cirrhosis was defined as a diffuse irreversible process causing architectural changes in the liver parenchyma. However, the progression of fibrosis largely depends on the underlying condition. There is even a possibility of regression, which depends on the options of treating the primary pathogenetic mechanism. Distinguishing between compensated and decompensated cirrhosis is not sufficient, as it does not allow proper stratification of risk for the development of complications, which require a subdivision of cirrhosis. It is also crucial to detect fibrosis at an early stage, preferably by non-invasive methods as well as serological markers. The transition from compensated to decompensated cirrhosis occurs at a rate of about 5% to 7% per year. Once decompensation occurs, cirrhosis becomes a systemic disease with multi-organ dysfunction. Decompensated cirrhosis has multiple complications, with ascites, spontaneous bacterial peritonitis, gastrointestinal bleeding, hepatorenal syndrome and encephalopathy being the most frequent. Patients with cirrhosis also present considerable changes in the coagulation cascade. Their natural anticoagulant mechanism is impaired and thromboembolic events are not rare. Therapy and prophylaxis of thromboembolic events in cirrhosis differ from those in patients without cirrhosis, and as such require a multidisciplinary approach. Malnutrition and sarcopenia are not characteristic only of decompensated cirrhosis and should be detected and treated in all stages of liver disease

Extramedullary Plasmacytoma Imitating Neoplasm of the Gallbladder Fossa after Cholecystectomy

Extramedullary plasmacytomas are plasma cell tumors that arise outside of the bone marrow. They account for approximately 3% of plasma cell neoplasms and are most frequently located in the head and neck region. Five months after undergoing cholecystectomy, a 69-year-old patient presented with the pain under the right costal margin and a 12 kg weight loss. Computed tomography of the abdomen demonstrated irregular, vascular mass in the gallbladder fossa that dents towards the duodenum and the pylorus and lowers caudally to the hepatic flexure. His laboratory tests indicated normocytic anemia and showed elevated sedimentation rate. During operative procedure, a tumorous mass in the gallbladder fossa was found, inseparable of the peritoneum of the hepatoduodenal ligament and the IVb liver segment. Histopathological examination and immunohistochemical staining determined the diagnosis of the plasmacytoma. Total resection of the tumor was achieved and after 24-month follow-up patient showed no signs of local recurrence or dissemination of the disease

Giant Basal Cell Carcinoma of the Back: A Case Report and Review of the Literature

Basal cell carcinoma (BCC) is the most common cutaneous malignancy and the most common human malignancy in general. Out of all basal cell carcinomas, giant basal cell carcinoma represents less than 1%. Only 10% of all basal cell carcinomas are located on the trunk and majority is located on the head and neck. We describe a patient with a exophytic giant basal cell carcinoma of the back size 8.5 x 8 x 6 cm, infiltrating skin 1.5 cm. Two years after the lesion has occurred, diagnosis was made by pathohistological analysis. The patent was treated surgically, by excision. Review of the literature that refers to giant basal cell carcinoma was carried out

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

ABNORMALITIES OF HEMOSTASIS IN PATIENTS WITH LIVER CIRRHOSIS

Do početka 90-ih godina prevladavalo je uvriježeno mišljenje da su bolesnici s uznapredovalom jetrenom bolesti prirodno autoantikoagulirani i time zaštićeni od tromboembolijskih zbivanja. Međutim, novim saznanjima dugogodišnja je paradigma srušena. U bolesnika s cirozom jetre paralelno je reducirana sinteza prokoagulansa i endogenih antikoagulansa, dok je produkcija ekstrahepatalno sintetiziranih faktora, važnih za proces zgrušavanja i fibrinolize, očuvana. U stabilnoj jetrenoj bolesti sustav je „rebalansiran”, ali funkcionira u uskom rasponu homeostaze, što ga čini izuzetno fragilnim te ga i minimalni stres može uvesti u neželjeni ekstrem, trombozu ili krvarenje. Uz navedeno niz je drugih čimbenika koji prate jetrenu bolest, kao što su hemodinamske promjene, oštećenja drugih organa, ponajprije bubrega, te sklonost infekcijama, a koji pomiču ravnotežu prema sklonosti krvarenju ili pojačanom zgrušavanju. Konvencionalni laboratorijski testovi nisu prikladni za procjenu rizika od krvarenja u cirozi, rizični čimbenici za razvoj tromboze nisu nedvojbeno dokazani, a sigurnosni profil antitrombotskih lijekova u cirozi nije precizno utvrđen jer su ti bolesnici uglavnom isključeni iz velikih kliničkih studija. Zbog svega navedenoga dijagnostički i terapijski pristup u ovom je kontekstu kompleksan te nalaže timski rad hematologa, hepatologa i u fazi operativnog liječenja anesteziologa. U ovome preglednom radu osvrnut ćemo se na mehanizme poremećaja hemostaze i fibrinolize u bolesnika s cirozom jetre, incidenciju tromboembolijskih zbivanja, laboratorijsku dijagnostiku te profilaktičke i terapijske opcije u okviru internističke skrbi.Until the beginning of the 90ies, it was believed that patients with liver cirrhosis were auto-anticoagulated and thus protected from thromboembolic events. However, new discoveries have broken the longstanding paradigm. In deranged hepatic function there is a reduced synthesis of procoagulants and endogenous anticoagulants, however, extrahepatally synthesized hemostatic and fibrinolytic factors are disproportionately affected. In stable disease hemostatic system is ”rebalanced’’ but fragile, therefore, even a minimal stress can promote bleeding or thrombosis. Also, there are many concomitant factors, such as hemodynamic changes, other organ affection, namely kidney, and predisposition to infection, that shift the balance towards either bleeding or thrombosis. Conventional laboratory tests are not sufficient for evaluation of the bleeding risk, prothrombotic risk factors are not clearly identified, and safety profile of antithrombotic drugs is not precisely evaluated since cirrhotic patients are mainly excluded from big clinical trials. For all that is said, the diagnostic and therapeutic approach in this context is complex and requires teamwork of a hepatologist, hematologist and in a phase of operative treatment, the anesthesiologist. In this review article, we will discuss mechanisms of hemostatic and fibrinolytic abnormalities of liver cirrhosis, the incidence of thromboembolic events as well as prophylactic and therapeutic options in the setting of conservative treatment

Transrectal elastography in differentiation between Crohn's disease and ulcerative colitis

Crohnova bolest (CB) i ulcerozni kolitis (UK) razlikuju po obrascima upale i odlaganja kolagena u stijenku crijeva. Pod pretpostavkom da oba procesa mijenjaju mehanička svojstva stijenke, krutost stijenke njihovo je potencijalno razlikovno svojstvo. Cilj ovog istraživanja bio je utvrditi da li je moguće razlikovati aktivan Crohn kolitis, sa zahvaćanjem rektuma, i aktivan ulcerozni kolitis, temeljem pseudokvantitativnih mjerenja strain elastografije učinjene transrektalnim ultrazvukom. U istraživanje je uključeno 28 ispitanika s CB, 30 ispitanika s UK i 30 zdravih kontrola. Regije interesa postavljene su nad stijenku rektuma i nad perirektalno tkivo neposredno uz stijenku. Mjereni su relativni strainovi i prosječne vrijednosti Histograma u svakoj regiji a potom su izračunati omjeri dobivenih vrijednosti – Strain Ratio (SR) i Histogram Ratio (HR). Nije nađeno statistički značajne razlike između SR-a i HR-a između ispitivanih skupina. Relativni strain stijenke bio je niži u CB skupini u odnosu na UK (P=0,035), prosječna vrijednost Histograma stijenke bila je viša u CB skupini u odnosu na UK ali razlika nije dostigla statističku značajnost (P=0,067). Prema našim rezultatima, temeljem SR-a i HR-a nije moguće razlikovati CB i UK no razlike u relativnim strainovima stijenke rektuma sugeriraju da strain elastografija ima potencijal u dijagnostici upalnih bolesti crijeva.The patterns of inflammation and collagen deposition differ between Crohn's disease (CD) and ulcerative colitis (UC). Assuming that both processes alter the mechanical properties of the bowel wall, its stiffness is a potential discriminatory feature between the two diseases. The aim of this study was to determine whether is it possible to differentiate between active Crohn's colitis, with rectal involvement, and active ulcerative colitis, on the grounds of pseudoquantitative measurements obtained by transrectal ultrasound-guided strain elastography. 28 CD patients, 30 UC patients and 30 controls were enrolled in the study. Regions of interest were placed over the rectal wall and the adjacent perirectal tissue. Relative strain and average Histogram values were measured in every region and Strain Ratio (SR) and Histogram Ratio (HR) were calculated. There were no statistically significant differences in SR and HR between the three groups. The relative rectal wall strain was lower in CB group compared to UC group (P=0,035), average rectal wall Histogram value was higher in CB group compared to UC group but the difference did not reach statistical significance (P=0,067). According to our results, SR and HR measurements do not discriminate between UC and CB, however, relative strain differences between the two groups suggest that strain elastography might have a role in inflammatory bowel disease diagnostics

Transrectal elastography in differentiation between Crohn's disease and ulcerative colitis

Crohnova bolest (CB) i ulcerozni kolitis (UK) razlikuju po obrascima upale i odlaganja kolagena u stijenku crijeva. Pod pretpostavkom da oba procesa mijenjaju mehanička svojstva stijenke, krutost stijenke njihovo je potencijalno razlikovno svojstvo. Cilj ovog istraživanja bio je utvrditi da li je moguće razlikovati aktivan Crohn kolitis, sa zahvaćanjem rektuma, i aktivan ulcerozni kolitis, temeljem pseudokvantitativnih mjerenja strain elastografije učinjene transrektalnim ultrazvukom. U istraživanje je uključeno 28 ispitanika s CB, 30 ispitanika s UK i 30 zdravih kontrola. Regije interesa postavljene su nad stijenku rektuma i nad perirektalno tkivo neposredno uz stijenku. Mjereni su relativni strainovi i prosječne vrijednosti Histograma u svakoj regiji a potom su izračunati omjeri dobivenih vrijednosti – Strain Ratio (SR) i Histogram Ratio (HR). Nije nađeno statistički značajne razlike između SR-a i HR-a između ispitivanih skupina. Relativni strain stijenke bio je niži u CB skupini u odnosu na UK (P=0,035), prosječna vrijednost Histograma stijenke bila je viša u CB skupini u odnosu na UK ali razlika nije dostigla statističku značajnost (P=0,067). Prema našim rezultatima, temeljem SR-a i HR-a nije moguće razlikovati CB i UK no razlike u relativnim strainovima stijenke rektuma sugeriraju da strain elastografija ima potencijal u dijagnostici upalnih bolesti crijeva.The patterns of inflammation and collagen deposition differ between Crohn's disease (CD) and ulcerative colitis (UC). Assuming that both processes alter the mechanical properties of the bowel wall, its stiffness is a potential discriminatory feature between the two diseases. The aim of this study was to determine whether is it possible to differentiate between active Crohn's colitis, with rectal involvement, and active ulcerative colitis, on the grounds of pseudoquantitative measurements obtained by transrectal ultrasound-guided strain elastography. 28 CD patients, 30 UC patients and 30 controls were enrolled in the study. Regions of interest were placed over the rectal wall and the adjacent perirectal tissue. Relative strain and average Histogram values were measured in every region and Strain Ratio (SR) and Histogram Ratio (HR) were calculated. There were no statistically significant differences in SR and HR between the three groups. The relative rectal wall strain was lower in CB group compared to UC group (P=0,035), average rectal wall Histogram value was higher in CB group compared to UC group but the difference did not reach statistical significance (P=0,067). According to our results, SR and HR measurements do not discriminate between UC and CB, however, relative strain differences between the two groups suggest that strain elastography might have a role in inflammatory bowel disease diagnostics