The Role of Video Capsule Enteroscopy in Obscure Haemorrhage

Opskurna krvarenja iz GI trakta ona su koja se ne mogu otkriti rutinskim endoskopskim ili radiološkim pretragama. Od svih gastrointestinalnih krvarenja 5% njih odnosi se na opskurna krvarenja. U oko 75% slučajeva izvorište krvarenja je u tankom crijevu, a u ostalih 25% u gornjem ili donjem dijelu GI trakta koje se previdi tijekom gornje ili donje endoskopske pretrage. Enteroskopija videokapsulom (EVK) i enteroskopima potpomognutim balonom (EPB) revolucionirale su pregled tankoga crijeva; bolje su dijagnoza bolesti, njezina klasifikacija, terapijske odluke i procjena ishoda bolesti. EVK je prvo prihvaćena kao važan inicijalni dijagnostički postupak u otkrivanju upravo opskurnih krvarenja iz probavnog sustava neinvazivnim putem. Točnost otkrivanja opskurnih krvarenja videokapsulom varira od 50% do 81%. Kombinirani pristup opskurnim krvarenjima prvo kapsulom i nakon toga EPB-om uz endoskopsku hemostazu, ako je ona indicirana, vrijedan je dijagnostički i terapijski postupak koji zamjenjuje mnogo kompleksnije i rizičnije metode. Radiološki prikaz tankoga crijeva i njegove vaskularizacije ili intraoperativna enteroskopija komplementarne su metode.Obscure gastrointestinal (GI) haemorrhages are those that cannot be detected by routine endoscopic or radiologic examination. Obscure haemorrhages account for 5% of all GI haemorrhages. In 75% of cases, the haemorrhage originates in the small intestine, and in 25% in upper or lower GI tract passing unnoticed during upper or lower GI endoscopy. Video capsule enteroscopy (VCE) and balloon-assisted enteroscopy (BAE) have revolutionized small intestine examination by improving disease diagnosis and classification, therapeutic decisions and evaluation of disease outcome. VCE was first accepted as an important initial diagnostic procedure for non-invasive detection of obscure GI haemorrhages. The accuracy of obscure haemorrhage VCE detection ranges from 50% to 81%. A combined approach to obscure haemorrhages by VCE followed by BAE with endoscopic haemostasis, if indicated, is a valuable diagnostic and therapeutic procedure replacing more complex and risk methods. Complementary methods include radiology of the small intestine and its vascularisation or intraoperative enteroscopy

The Role of Video Capsule Enteroscopy in Obscure Haemorrhage

Opskurna krvarenja iz GI trakta ona su koja se ne mogu otkriti rutinskim endoskopskim ili radiološkim pretragama. Od svih gastrointestinalnih krvarenja 5% njih odnosi se na opskurna krvarenja. U oko 75% slučajeva izvorište krvarenja je u tankom crijevu, a u ostalih 25% u gornjem ili donjem dijelu GI trakta koje se previdi tijekom gornje ili donje endoskopske pretrage. Enteroskopija videokapsulom (EVK) i enteroskopima potpomognutim balonom (EPB) revolucionirale su pregled tankoga crijeva; bolje su dijagnoza bolesti, njezina klasifikacija, terapijske odluke i procjena ishoda bolesti. EVK je prvo prihvaćena kao važan inicijalni dijagnostički postupak u otkrivanju upravo opskurnih krvarenja iz probavnog sustava neinvazivnim putem. Točnost otkrivanja opskurnih krvarenja videokapsulom varira od 50% do 81%. Kombinirani pristup opskurnim krvarenjima prvo kapsulom i nakon toga EPB-om uz endoskopsku hemostazu, ako je ona indicirana, vrijedan je dijagnostički i terapijski postupak koji zamjenjuje mnogo kompleksnije i rizičnije metode. Radiološki prikaz tankoga crijeva i njegove vaskularizacije ili intraoperativna enteroskopija komplementarne su metode.Obscure gastrointestinal (GI) haemorrhages are those that cannot be detected by routine endoscopic or radiologic examination. Obscure haemorrhages account for 5% of all GI haemorrhages. In 75% of cases, the haemorrhage originates in the small intestine, and in 25% in upper or lower GI tract passing unnoticed during upper or lower GI endoscopy. Video capsule enteroscopy (VCE) and balloon-assisted enteroscopy (BAE) have revolutionized small intestine examination by improving disease diagnosis and classification, therapeutic decisions and evaluation of disease outcome. VCE was first accepted as an important initial diagnostic procedure for non-invasive detection of obscure GI haemorrhages. The accuracy of obscure haemorrhage VCE detection ranges from 50% to 81%. A combined approach to obscure haemorrhages by VCE followed by BAE with endoscopic haemostasis, if indicated, is a valuable diagnostic and therapeutic procedure replacing more complex and risk methods. Complementary methods include radiology of the small intestine and its vascularisation or intraoperative enteroscopy

Gastroesophageal Reflux Disease

Gastroezofagealna refl uksna bolest (GERB) česta je bolest, poglavito zapadne populacije, sa spektrom simptoma i znakova bolesti nastalih refl uksom sadržaja želuca i dvanaesnika u jednjak, usta i dišne putove. GERB bitno remeti kvalitetu života oboljelih, što mu daje važnost i sa socioekonomskog stajališta. Unatoč visokoj učestalosti GERB-a i kronicitetu bolesti, mortalitet je nizak. Razlog zašto ta u osnovi benigna bolest pobuđuje sve veći interes leži u činjenici da postoji snažna uzročna veza između GERB-a i pojave adenokarcinoma jednjaka te bolesti ekstraezofagealnih organa poput astme, laringitisa, otitisa, sinusitisa, apneje u snu i sl. Nekompetentna antirefl uksna barijera, nastala disrupcijom uz razvoj hijatalne hernije ili zbog tranzitorne relaksacije donjeg sfi nktera jednjaka, dominantan je uzrok nastanka GERB-a. Astma, kronični kašalj ili laringitis kao najčešći ekstraezofagealni oblici GERB-a nastaju izravnim oštećenjem sluznice kiselinom i pepsinom, mikroaspiracijom ili vagusnim refl eksnim mehanizmom. Dijagnoza GERB-a postavlja se na temelju anamneze, endoskopskog pregleda, a u određenim slučajevima i pH-metrijom. Važnu komplikaciju GERB-a, Barrettov jednjak, otkrivamo endoskopskim putem i potvrđujemo histološkim pregledom uzoraka promijenjene sluznice jednjaka. Kako je GERB bolest ovisna o kiselini, najbolji terapijski učinak imaju inhibitori protonske pumpe. Primjenjuju se inicijalno ili “na zahtjev“ ili pak dugotrajno, što ovisi o težini GERB-a, endoskopskom nalazu i oštećenju ekstraezofagealnih organa. S obzirom na to da neće u svih bolesnika s Barrettovim jednjakom nastati adenokarcinom, potrebno je otkriti one bolesnike koji imaju visok rizik od nastanka tog karcinoma. Možda će pomoći otkrivanje molekularnih biljega. Za sada nema općeprihvaćenog stava o indikaciji za kirurško liječenje GERB-a. Općenito, kirurška terapija, najbolje laparoskopska fundoplikacija u rukama iskusnih kirurga u velikim centrima, daje dobre rezultate. Ta je terapija ograničena na strogo selekcionirane bolesnike. Endoskopska ili endoluminalna antirefl uksna terapija u eksperimentalnoj je fazi i tek će dobro kontrolirane studije potvrditi uspješnost tih metoda u rješavanju GERB-a.Gastroesophageal refl ux disease (GERD) is a common illness, especially in western population, with a spectrum of symptoms and signs produced by the gastric and duodenal content refl ux to the esophagus, mouth and airways. GERD causes considerable impairment of the patient’s quality of life thus posing a socioecononic problem. The mortality rate is low in spite of the high prevalence and chronic course of GERD. The ever growing interest in this basically benign disease is underlain by the strong causal relationship of GERD with the occurrence of esophageal adenocarcinoma and extraesophageal organ diseases such as asthma, laryngitis, otitis, sinusitis, sleep apnea, etc. GERD is predominantly caused by incompetent antirefl ux barrier due to disruption with the development of hiatal hernia, or transitory relaxation of lower esophageal sphincter. Asthma, chronic cough or laryngitis, as the most common extraesophageal forms of GERD, occur due to direct mucosal damage by acid and pepsin, microaspiration or vagal refl ex mechanism. The diagnosis of GERD is based on history data, endoscopy, and in some cases pH metry. Barrett’s esophagus, as a major complication of GERD, is detected by endoscopy and verifi ed by histology of esophageal mucosal lesions. As GERD is an acid dependent disease, proton pump inhibitors produce the best therapeutic effects. These agents are used initially or “on demand” or at long term, depending on GERD severity, endoscopic fi nding and extraesophageal organ lesions. As not all patients with Barrett’s esophagus will develop adenocarcinoma, those at a high risk should be timely identifi ed. Discovery of the respective molecular markers may potentially help in this issue. At present, there is no consensus on the indications for operative treatment of GERD. Operative therapy, preferably laparoscopic fundoplication performed by experienced surgeons at large centers, generally produces favorable results. This therapy is reserved for strictly selected patients. Endoscopic or endoluminal antirefl ux therapy is in the experimental phase, and the success of these methods in the management of GERD can only be confi rmed by properly controlled studies

Palliative Treatment of Hepatocellular Carcinoma with Percutaneous Ethanol Injection Using Tumor’s Feeding Artery Occlusion Under the Ultrasonic Color Doppler Guidance

We evaluate the efficacy of PEIT in patients with HCC using duplex color Doppler US. The study included 27 HCC patients admitted to the University Hospital Centre Zagreb, between 1993 and 1997. PEIT was performed for ablation of tumor supplying vessels in HCCs of < 5 cm in diameter, and as a palliative measure for tumor feeding vessel obliteration in larger tumors. The efficacy of PEIT was evaluated with duplex color Doppler US, and controlled by dynamic CT scan (16 patients) or selective angiography of hepatic artery (11 patients). All patients had well vascularized tumors before PEIT, and after therapy 25 of them showed absent or minimal tumor vascularization. Recanalization of the tumor feeding vessel was detected with Doppler US within 9 months after therapy. Study results suggested that duplex color Doppler US should be the method of choice in the evaluation of PEIT as well as in the follow-up of HCC patients after PEIT

Osobitosti korisnika i evaluacija elektroničkih tečajeva trajne medicinske izobrazbe na PLIVAmed.net portalu i web sjedištu Teleinterventna gastrnterologija (Tigel)

Provedeno je ispitivanje korisnika sudionika elektroničke trajne medicinske izobrazbe (e-TMI) u Hrvatskoj, putem web ankete, s ciljem uvida u demografske, i karakteristike korištenja Interneta među korisnicima. Također, evaluirani su postojeći tečajevi TMI je na PLIVAmed.net portalu te web sjedištu projekta "Teleinterventna gastrnterologija".Anketni upitnik ispunio je 34% ispitanika (61/179). Bilo je 36% muških (22/61) i 64% (39/61) ženskih ispitanika, od kojih 91,8% (56/61) mlađe od 50 godina. Velik broj ispitanika (45,9%) koristi internet više od 5 godina, u prosjeku dnevno provedu manje od 2 sata (32,8%) i to uglavnom od kuće (78,8%), putem "dial-up" veze (80,3%).  Ispitanicima su bila dostupna 4 tečaja, koji su uglavnom ocjenjeni korisnima u svakodnevnom radu (za tečaj "Gastrzofagelana bolest" 43,2% ispitanika, "Depresija i anksiozni poremećaji" 60%, "Dijagnostika i liječenje urogenitalnih infekcija i spolno prenosivih bolesti" 62,2 %,"Izabrana poglavlja iz kliničke farmakologije" 80,8%).Među prednostima eTMI istaknute su pristup recentnim informacijama, mogućnost višekratnog čitanja sadržaja, mogućnost edukacije kolega koji rade u izoliranim sredinama (ispitanik br.7), te ušteda u financijskim izdatcima. S druge strane, kao glavne prepreke na putu šire primjene e-TMI., ispitanici navode slabu opremljenost i needuciranost u uporabi računalne opreme, dobne barijere, te nedostatak vremena i neadekvatnost ponuđenih tekstova (1 ispitanik).U odnosu na tradicionalne, e-TMI, u ovom trenutku još je uvijek u zametcima. Potrebna su daljnja ispitivanja za provjeru dobno-spolnih razlika među liječnicima koji sudjeluju u e-TMI, u odnosu na druge liječnike, korisnike Interneta, kao i za procjenu učinkovitosti ovog oblika edukacije u svakodnevnoj kliničkoj praksi

Bolesti probavnog sustava u 80 skladatelja

Based on study of pathographies we noticed eighty cases of digestive diseases among composers. The most important composers are presented in the form of short pathographies, and the others were briefly mentioned in the following list. Mentioned diseases influenced the creativity of composers and their life expectancy.Proučavajući patografije skladatelja zabilježili smo osamdeset slučajeva bolesti probavnog sustava. Najznačajniji skladatelji prikazani su u obliku kratkih patografija, a ostali su navedeni u priloženoj listi na kraju rada. Navedene bolesti utjecale su na kreativnost autora i njihov životni vijek

THE OVER-THE-SCOPE-CLIP FOR THE TREATMENT OF THE DIGESTIVE TUBE LEAKS AND TEARS: A CASE-SERIES

Oštećenja probavne cijevi terapijski su izazov za liječnike koji se bave gastrointestinalnom endoskopijom. Nedavno je u kliničku praksu uvedena endoskopska stezaljka za nekirurško liječenje fistula, perforacija, anastomotskih propuštanja i refraktornih krvarenja. U članku prikazujemo iskustva o primjeni stezaljke u našoj seriji bolesnika. Endo­skopska stezaljka primijenjena je kod devet ispitanika (šest muškaraca, tri žene, medijan dobi 72 godine, raspon 58 – 86 godina). Indikacije za primjenu stezaljke uključivale su: krvarenje iz gornjeg dijela probavne cijevi (neuspjeh endoskopske hemostaze kod pet ispitanika te velik promjer krvne žile kod jednog ispitanika), endoskopsko liječenje fistula probavne cijevi kod dva ispitanika te liječenje ijatrogene perforacije sigme kod jednog ispitanika. Upotrebljavane su stezaljke s oštrim i tupim zupcima i dvostruki hvatač. Kod svih ispitanika iskorištena je samo jedna stezaljka i nije se rabila dodatna endoskopska terapija. Registrirana je 100%-tna tehnička primjena stezaljke. U podgrupi bolesnika s krvarenjima klinički uspjeh iznosio je 50%, a kod ispitanika s perforacijama i fistulama 67%. Prosječno vrijeme praćenja bolesnika bilo je 34 dana (raspon 3 – 452). Endoskopska stezaljka siguran je i učinkovit pribor za endoskopsko liječenje oštećenja probavne cijevi. Ipak, klinički uspjeh procedure bio je manji u podgrupi bolesnika s krvarenjem iz gornjeg dijela probavne cijevi, uglavnom zbog primjene stezaljki s oštrim zupcima.Digestive tube damages represent a therapeutic challenge for the gastrointestinal endoscopists. Recenty, a novel device – the-over-the-scope clip (OTSC) – has been introduced for non-surgical treatment of gastrointestinal perforations, fistula, anastomotic leaks and refractory gastrointestinal bleeds. This study aimed to evaluate the therapeutic efficacy of OTSC in our case series. A total of nine patients were included (six males, medain age 72 years, range 58-86). The indications were upper gastrointestinal bleeding (refractory to standard endoscopic treatment: five patients, a vessel with a large caliber: one patient), fistula in two patients, and iatrogenic perforation of the sigmoid colon in one patient. Atraumatic and traumatic versions of OTSCs with twin graspers were used. All of the patients were treated with only one OTSC, and none of the patients required additional endoscopic treatment. The OTSC procedure had 100% technical success. In a subgroup of patients with perforation and fistulae, the clinical success was 67%, whereas in those with the bleedings it was 50%. The median follow-up was 34 days (range: 3-452). OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy was subopimal in patients with the upper gastrointestinal bleedings possibly due to the application of the sharp-teeth OTSC

THE OVER-THE-SCOPE-CLIP FOR THE TREATMENT OF THE DIGESTIVE TUBE LEAKS AND TEARS: A CASE-SERIES

Oštećenja probavne cijevi terapijski su izazov za liječnike koji se bave gastrointestinalnom endoskopijom. Nedavno je u kliničku praksu uvedena endoskopska stezaljka za nekirurško liječenje fistula, perforacija, anastomotskih propuštanja i refraktornih krvarenja. U članku prikazujemo iskustva o primjeni stezaljke u našoj seriji bolesnika. Endo­skopska stezaljka primijenjena je kod devet ispitanika (šest muškaraca, tri žene, medijan dobi 72 godine, raspon 58 – 86 godina). Indikacije za primjenu stezaljke uključivale su: krvarenje iz gornjeg dijela probavne cijevi (neuspjeh endoskopske hemostaze kod pet ispitanika te velik promjer krvne žile kod jednog ispitanika), endoskopsko liječenje fistula probavne cijevi kod dva ispitanika te liječenje ijatrogene perforacije sigme kod jednog ispitanika. Upotrebljavane su stezaljke s oštrim i tupim zupcima i dvostruki hvatač. Kod svih ispitanika iskorištena je samo jedna stezaljka i nije se rabila dodatna endoskopska terapija. Registrirana je 100%-tna tehnička primjena stezaljke. U podgrupi bolesnika s krvarenjima klinički uspjeh iznosio je 50%, a kod ispitanika s perforacijama i fistulama 67%. Prosječno vrijeme praćenja bolesnika bilo je 34 dana (raspon 3 – 452). Endoskopska stezaljka siguran je i učinkovit pribor za endoskopsko liječenje oštećenja probavne cijevi. Ipak, klinički uspjeh procedure bio je manji u podgrupi bolesnika s krvarenjem iz gornjeg dijela probavne cijevi, uglavnom zbog primjene stezaljki s oštrim zupcima.Digestive tube damages represent a therapeutic challenge for the gastrointestinal endoscopists. Recenty, a novel device – the-over-the-scope clip (OTSC) – has been introduced for non-surgical treatment of gastrointestinal perforations, fistula, anastomotic leaks and refractory gastrointestinal bleeds. This study aimed to evaluate the therapeutic efficacy of OTSC in our case series. A total of nine patients were included (six males, medain age 72 years, range 58-86). The indications were upper gastrointestinal bleeding (refractory to standard endoscopic treatment: five patients, a vessel with a large caliber: one patient), fistula in two patients, and iatrogenic perforation of the sigmoid colon in one patient. Atraumatic and traumatic versions of OTSCs with twin graspers were used. All of the patients were treated with only one OTSC, and none of the patients required additional endoscopic treatment. The OTSC procedure had 100% technical success. In a subgroup of patients with perforation and fistulae, the clinical success was 67%, whereas in those with the bleedings it was 50%. The median follow-up was 34 days (range: 3-452). OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy was subopimal in patients with the upper gastrointestinal bleedings possibly due to the application of the sharp-teeth OTSC

Liječenje oštećenja probavne cijevi primjenom endoskopske stezaljke: prikaz serije bolesnika [The over-the-scope-clip for the treatment of the digestive tube leaks and tears: a case-series]

Digestive tube damages represent a therapeutic challenge for the gastrointestinal endoscopists. Recenty, a novel device – the-over-the-scope clip (OTSC) – has been introduced for non-surgical treatment of gastrointestinal perforations, fi stula, anastomotic leaks and refractory gastrointestinal bleeds. This study aimed to evaluate the therapeutic effi cacy of OTSC in our case series. A total of nine patients were included (six males, medain age 72 years, range 58-86). The indications were upper gastrointestinal bleeding (refractory to standard endoscopic treatment: fi ve patients, a vessel with a large caliber: one patient), fi stula in two patients, and iatrogenic perforation of the sigmoid colon in one patient. Atraumatic and traumatic versions of OTSCs with twin graspers were used. All of the patients were treated with only one OTSC, and none of the patients required additional endoscopic treatment. The OTSC procedure had 100% technical success. In a subgroup of patients with perforation and fi stulae, the clinical success was 67%, whereas in those with the bleedings it was 50%. The median follow-up was 34 days (range: 3-452). OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic effi cacy was subopimal in patients with the upper gastrointestinal bleedings possibly due to the application of the sharp-teeth OTSC