Are changes in the blood count clinically useful marker of azathioprine dose?

INTRODUCTION

The 6-thioguanine nucleotide (6-TGN) level, may be used to estimate dose-adequacy of azathioprine (AZA) therapy. 6-TGN test is not commercially available. The aim of the study was to determine whether a blood cell changes correlate also with the dose of AZA and may serve as a predictor of the dose adequacy (for MCV > 6 fl).

METHODS

Retrospective, multicentre study in subjects with IBD treated with azathioprine. Demographic data, leukocyte, platelet counts, erythrocyte (MCV) and thrombocyte (MPV) volume, azathioprine dose, inflammatory activity in the 3rd, 6th and 12th months of treatment and presence of sideropenia were recorded.

RESULTS

103 subjects analysed. To increase the MCV by 6 fl, the AZA dose above 2 mg/kg is needed (p = 0.04). The MCV increases within 165 days (95% CI, 154-181 days, p = 0.002). Sideropenia has no impact on the MCV change. Number of leukocytes and thrombocytes decreases during treatment (p < 0.001). Change in their number as well as MPV, does not correlate with MCV change and is not affected by activity of the inflammation.

CONCLUSION

The MCV dynamics (> 6 fl within 6 months) is the only relevant indicator during AZA treatment. Changes in the number of leukocytes, platelets and their volume can not be used to assess the sufficiency of the AZA dose. Sideropenia has no impact on the dynamics of MCV.

Acute portal vein thrombosis in noncirrhotic patients - different prognoses based on presence of inflammatory markers: a long-term multicenter retrospective analysis

Background: Portal vein thrombosis (PVT) is a partial or complete thrombotic occlusion of the portal vein and is rare in noncirrhotic patients.Patients and methods: 78 adult patients with noncirrhotic acute PVT without known malignity were evaluated. Patients with initial CRP level 61-149 mg/l were excluded.Results: Patients were divided into two groups - the first one (33 patients) was characterized with signs of inflammation and CRP over 149 mg/l. The second group (45 patients) was without signs of inflammation and CRP level less than 61 mg/l. The frequency of prothrombotic hematologic factors was statistically significantly different in levels of factor VIII and MTHFR 677 C mutation. All patients from both groups underwent the same oncologic and hemato-oncologic screening which was positive in 23 patients (51.1%) in the group without signs of inflammation. In the group of patients with clinical and laboratory signs of inflammation oncologic and hemato-oncologic screening was positive only in 1 patient (3.0%). Complete portal vein recanalization was achieved in 19.2%, partial recanalization in 26.9%.Conclusions: Patients with clinical signs of inflammation and acute PVT have a low risk of malignancy in contrast to patients without signs of inflammation and acute PVT, which have a high risk of oncologic or hemato-oncologic disease. Patients with negative hemato-oncologic screening should be carefully observed over time because we expect they are at higher risk for the development of hemato-oncologic disease, independent from the presence and number of procoagulation risk factors.

Prokinetics and their use in gastroenterology

Gastrointestinal motility disorders are reflected in clinical medicine not only in the form of functional disorders but also as primary organic units or secondary manifestations of other diseases and physicochemical effects. Recent sophisticated diagnostic methods and basic research in the field of digestive tract motility have shown significant development. However, causal treatment of prokinetic motility disorders is still marginalized. A number of new effective drugs have been withdrawn from the market due to their significant side effects. The efficacy of others is limited to individual parts of the gastrointestinal tract (GIT), e.g. only the stomach or the intestine. The article presents an overview of prokinetic indications with an effect on selected pathological conditions. In addition to isolated administering of prokinetics, they can also be used in combination with other drugs, for example in the treatment of gastroesophageal reflux disease with proton pump inhibitors. There is currently no "gold standard" prokinetic, which would globally therapeutically and, at the same time, causally affect such a complicated pathophysiological chain of GIT dysmotility. There is ongoing research to develop new drugs with a beneficial effect on the propulsion activity disorder which, while maintaining a prokinetic effect over the full length of the GIT, would not show any adverse or side effects. Patient access in this case needs to be individualized according to the proven type of motility disorder. Key words: gastroesophageal reflux disease - gastrointestinal dysmotility - gastroparesis - intestinal pseudo-obstruction - obstipation.

[Effective bowel preparation before coloscopy - low-volume PEG in the divided dose regimen]

INTRODUCTION

The good and safe bowel cleansing is key to the success of coloscopy. The standard preparation involves 4 l polyethylene glycol (PEG). Now the combination of PEG and ascorbic acid (PEGA) of half the volume is available. Besides the type of product also the time factors which are not clarified, play a role during the bowel preparation. The aim of the study was to compare the efficiency and tolerance of both the agents and evaluate the effect of the time regimen of preparation.

METHODS

380 individuals were included in the evaluation in 4 cohorts which used 4 l PEG (Fortrans) in a single dose or split into 3 + 1 l and PEG + ascorbic acid (Moviprep) split into 1 + 1 l or 2 l one day before examination.

RESULTS

There was no difference between the agents as to the quality of bowel preparation, when they were used in the same regimen. The bowel cleansing was better in both cases in the divided dose regimen (p < 0.001), and it was inversely proportional to the length of preparation (p = 0.003) and directly proportional to the length of time between the end of preparation and coloscopy (p < 0.001). PEGA was better tolerated (p < 0.028), regardless of the preparation regimen.

CONCLUSION

PEG and PEGA are similarly efficient in the bowel preparation before coloscopy provided they are used in a similar regimen. The best results are reached when the preparation is divided into 2 days. PEGA is better tolerated than PEG, regardless of the used regimen. The quality of bowel cleansing is affected by the length of preparation (optimally up to 12 hours) and the time elapsed from the preparation until examination (up to 8 hours).

Self-expandable biodegradable biliary stents in porcine model

BACKGROUND

Treatment or prevention of a benign biliary tree stricture is an unresolved problem. A novel self-expandable biodegradable polydioxanon biliary stent in a porcine model was studied.

MATERIALS AND METHODS

This new stent was used in 23 pigs. Feasibility and safety of surgical stenting, time of biodegradation, and histologic reaction in 2, 8, 13, and 20 wk of a follow-up were studied. All stents were inserted into a common bile duct through a duodenal papilla following small dilatation. After surgical evaluation of abdominal cavities, the pigs were sacrificed to remove common bile ducts with the stents. All bile ducts were assessed by macroscopic and histopathologic examination.

RESULTS

Self-expansion was correct in all cases. Neither bile duct obstruction nor postsurgical complications were observed. Macroscopic evaluation indicated lightening of the stent color in 2 wk, a partial disintegration in 8 wk, and a complete absorption in 13 and 20 wk. Histologic evaluation in general substantiated a mild-to-moderate inflammatory reaction in the lamina propria during the whole follow up and had no clinical consequences. No cholangitis, necrosis, abscess, or excessive fibroplasia was found in a hepatoduodenal ligament.

CONCLUSIONS

Our results suggest that polydioxanon biodegradable self-expanding stents seem to be useful for biliary system implantation, offer a good biocompatibility, and completely degrade within 13 wk.

[Adherence to the guidelines for treatment of mild biliary acute pancreatitis in the setting of tertiary center in the Czech Republic]

INTRODUCTION

Cholecystectomy (CCX) represents the crucial procedure in preventing relapses of biliary acute pancreatitis (BAP). Endoscopic papilosphincterotomy (EPST) represent an acceptable alternative in patients unsuitable for surgery. Current guidelines recommend patients with mild BAP to undergo CCX in 2 maximally 4 weeks following discharge from the hospital, ideally during the same hospital stay. Adherence to the guidelines differs significantly between particular countries and institutions.

AIM

To evaluate adherence to the guidelines of BAP management in conditions of tertiary hospital in the Czech Republic.

METHODS

Retrospective analysis of consecutive patients hospitalized in the Clinic of Gastroenterology, University Hospital Brno for acute pancreatitis in years 2007-2012. Cases with both sonographic findings of lithiasis/sludge and 3-fold AST/ALT elevation were considered of clearly biliary etiology.

RESULTS

We identified 328 patients treated for acute pancreatitis. Clearly biliary etiology was identified in 116 cases (54 male, 62 female). From 114 analyzed patients with complete documentation 81 underwent CCX, 23 were not operated and 10 cases were patients with history of previous CCX. Total mortality of the group was 5.3%. Out of 81 patients who had CCX was 48 cases of mild BAP. CCX was done during the same hospital stay and/or within 4 weeks from dismissal in 20 patients, therefore, current guidelines were followed in 41.7% of our study group. Eighteen out of the remaining 28 patients underwent ERCP with EPST. Therefore, within 4 weeks from dismissal 75% of our patients underwent a procedure (CCX and/or EPST) with a potential to reduce the risk of BAP recurrence.

CONCLUSION

When longer (4 weeks) interval between mild BAP and CCX is applied, the current guidelines are followed in 41.7% of patients treated at our institution, which is comparable with the literature data. As much as 75% of our patients underwent a procedure (CCX and/or EPST) with a potential to reduce the risk of BAP recurrence. However, only 12.5% of index CCX is not favorable outcome that needs improvement. Similar difficulties are being dealt with in the most countries in the World.

[The new blood test bio-marker SEPT9 and colorectal carcinoma screening]

Due to its high incidence and mortality rates, the colorectal carcinoma represents a crucial medical issue. However, when it is detected in early stage there is high rate of successful treatment. Thats why, early stage cancer screening programmes were introduced into the clinical practice. They focus on the finding of hidden bleeding, using various laboratory techniques, sigmoidoscopy, and, primarily, colonoscopy. However, screening programmes have not yet reached the effect required. New techniques are therefore being developed, such as the detection of blood bio-markers. This group includes also methylated SEPT9 (mSEPT9) detection in blood. We applied this test on 57 patients; we divided the group into two parts. There were 33 asymptomatic individuals in the first group. In this group, we were got only one positive mSEPT9 result. The consequent colonoscopies were negative. The other group had 24 proven carcinomas. Of them, two had negative mSEPT9 results. The remaining in all 22 patients was tested mSEPT9 positive. After its efficiency is tested by further studies, this test may be used especially for patients with low compliance, as it only requires routine blood drawing.

[Prokinetic agents--their contribution to practice of gastroenterology]

Motility plays a fundamental role in the functioning of the gastrointestinal tract. Prokinetic agents are thus an important treatment modality in patients with functional and certain organ diseases with underlying functional modifications. Gastro-oesophageal reflux disease is frequently associated with a disorder ofoesophageal motility, an alteration of gastric evacuation may manifest as an atypical dyspeptic complaint. Prokinetic agents may also be effective in other disease states, such as diabetic gastroparesis, malignant conditions associated with nausea and vomiting, motility disorders in preterm babies etc.

[Irritable bowel syndrome]

Irritable bowel syndrome is a frequent functional disorder of gastrointestinal tract. Its high incidence represents an important socioeconomic concern. The diagnosis of irritable bowel syndrome is indirect and requires exclusion of an organic lesion within as well as outside the gastrointestinal tract. No algorithms--so called treatment guidelines--are available for pharmacological or non-pharmacological treatment of the irritable bowel syndrome. Long-term and comprehensive care of patients with functional diseases is an important component of the management of patients with irritable bowel syndrome.

[Does the medicine have its "trendy" diseases?]

The development of new knowledge in medicine is associated with periodical changes in frequency with which certain "interesting" diseases are being diagnosed. Their frequency might be determined by accessibility of information as well as, to a certain extent, by "popularity" of these conditions within the society.

Combined treatment of achalasia - botulinum toxin injection followed by pneumatic dilatation: long-term results

Injection of botulinum toxin (BT) and pneumatic dilatation are available methods in nonsurgical treatment of achalasia. Authors anticipate beneficial effect of prior BT injection on the success of pneumatic dilatation and duration of its effect. There are no long-term data available to assess efficacy of combined treatment. From 1998 to 2007, 51 consecutive patients (20 men and 31 women, age 24-83) with achalasia were included and prospectively followed up. Each patient received injection of 200 IU of BT into the lower esophageal sphincter (LES) during endoscopy and 8 days later pneumatic dilatation (PD) under X-ray control was performed. The follow-up was established every 3 months first year and then annually. The efficacy was evaluated by a questionnaire concerning patient's symptoms and manometry. Results were compared with 40 historical controls (16 men and 24 women, age 26-80) treated by PD alone using the same method and follow-up. Fifty-one patients underwent combined treatment. Four patients failed in follow-up and were not included for analysis. The mean duration of follow-up was 48 months with range 12-96 months. Thirty-four of forty-seven (72%) patients were satisfied with results with none or very rare and mild troubles at the time of the last visit. Forty-one patients were followed up more than 2 years. Effect of therapy lasted in 75% (31/41) of them. In 17 patients, more than 5 years after treatment, effect lasted in 12 (70%). Mean tonus of LES before therapy was 29 mm Hg (10-80), 3 months after therapy decreased to 14 mmHg (5-26). The cumulative 5 years remission rate (+/-95% CI) in combined treated patients 69% +/- 8% was higher than in controls 50% +/- 9%; however it, was not statistically significant (P= 0.07). In control group 1, case of perforation (2.5%) occurred. Eight patients (17%) with relapse of dysphagia were referred to laparoscopic Heller myotomy with no surgical complication. The main adverse effect was heartburn that appeared in 17 patients (36%). Initial injection of BT followed by PD seems to be effective for long-term results with fewer complications. But the combined therapy is not significantly superior to PD alone.

[Gastroesophageal reflux disease. Standards of the Czech Society of Gastroenterology--actualization 2009]

Presently, gastroesophageal reflux disease is defined as a disorder where reflux of the stomach content is bothersome and/or brings about complications. The state when macroscopically detectable erosions of mucosa are present is known as erosive reflux disease and the term non-erosive reflux disease is used for the condition with no macroscopic erosions. Reflux oesophagitis is a frequent sign of the disease. A condition, where reflux symptoms persist or new occur and oesophagitis healing fails to take place despite maximum treatment, is classified as refractory gastroesophageal reflux disease. The main symptoms of gastroesophageal reflux disease include heartburn and regurgitation. Gastroesophageal reflux disease may, less frequently, manifest itself with isolated non-oesophageal symptoms, e.g. recurring upper respiratory tract infections or bronchial asthma. Etiopathogenesis involves refluxate, motility disorders, altered anatomic proportions, protective mechanisms disorder and external factors. Diagnosis takes place on the basis of typical symptomatology and endoscopic examination. Complications include bleeding, ulceration, strictures and Barrett's oesophagus. Lifestyle and dietary measures are an important treatment approach as are pharmacological (antisecretion and prokinetic agents) as well as surgical management.

Achalasia--which method of treatment to choose for senior patients?

BACKGROUND

Achalasia is an uncommon illness affecting 1 per 100,000 patients a year. It encompasses a rare, primary motor disorder of the distal esophagus.

METHODS

Over the period 1998-2006, 115 patients underwent various treatments for achalasia; the subgroup of seniors consisted of 26 patients. Six patients of these (age 69.7 y) underwent a modified Heller cardiomyotomy due to failure of previous endoscopic interventions. Standard esophageal manometry and 24 hour pH metry were performed pre- and postoperatively.

RESULTS

Six senior patients with achalasia underwent a laparoscopic Heller myotomy. Average preoperative tonus of the LES was 55 mmHg, postoperative tonus of the LES decreased to 11 mmHg. We performed Toupet partial fundoplication in all patients; no microperforation of the esophagus was found in the preoperative esophagoscopy. We recorded minimal pathological gastroesophageal reflux in pH metry - the average preoperative DeMeester score was 8, postoperatively 10.5. Prolonged dysphagia was not present in any patient--preoperative GIQLI score was 94, postoperative score was 106. There was no mortality or morbidity in the group of the operated patients.

CONCLUSION

Our operational results and postoperative follow-up show that laparoscopic Heller myotomy with Toupet partial fundoplication is a safe and effective treatment and can be recommended as the method of first choice for senior patients with no contraindication for laparoscopic operation.

[Higher incidence of thyropathy in patients with oesophageal achalasia. Genetic, autoimmune, regional or just a random association?]

INTRODUCTION

The etiology of esophageal achalasia is still largely unknown. Inflammatory response to an initial stimulus on the level of genetic and/or immune predisposition may be the underlying cause of the disease. The final result is progressive disappearance of ganglion cells in the myenteric plexus and motility disorder. Autoimmune thyropathy (AIT) is a typical disease involving genetic background and immune response disorder.

PATIENTS AND METHODS

44 patients (of which 30 women and 14 men) with diagnosed esophageal achalasia and a control group of patients with esophageal reflux of corresponding age and sex were screened for thyroid disease.

RESULTS

Thyroid disease was diagnosed in 15 out of 44 patients with achalasia (34%). Thyropathy was detected in 11 women (37%) and 4 men (28%). AIT was detected in 10 patients, in 4 of whom with hypfunction, nontoxic cystic or nodular goitre was detected in 4 patients, 1 patient was after strumectomy for benign node. Positive antithyroid antibody was newly detected in 4 patients with achalasia; subclinical hypothyreosis was found in one of them. There were two cases ofAIT with subclinical hypofunction and 1 case of nontoxic goitre in the control group (7%). The difference was statistically significant (p < 0.01).

CONCLUSION

The incidence of thyroid disease proved higher in patients with achalasia than in the controls. The rate of occurrence of thyroid disease exceeded significantly the occurrence in the population. The association of achalasia with prevailingly autoimmune thyropathy may corroborate the importance of autoimmunity in the etiopathogenesis of the disease.

[Lower dyspeptic syndrome. Recommended diagnostic and therapeutic procedures for general practitioners 2006]

Lower dyspeptic syndrome is a bowel disease manifesting namely with pain or sensation of abdominal discomfort and bowel movement problems (changes in the frequency and stool consistency). Symptoms include sensation of intraabdominal pressure and fullness, diarrhoea (with or without pain), sensation of incomplete defecation, constipation or bowel movement problems (with or without pain), irregular stool, collywobbles and bowel content flow (borborygia with spasms), meteorism, flatulency. Prevalence of the Irritable Bowel Syndrome in the European population is estimated to be 5 to 25 %. In the Czech Republic the total prevalence of dyspepsias is about 13 %. To the pathogenesis of the lower dyspeptic syndrome contribute: 1. abnormal motility, 2. abnormal visceral perception, 3. psychosocial factors, 4. luminal factors, 5. imbalance of neurotransmitters and/or intestinal bacteria and 6. possible inflammatory changes of the intestinal mucosa. Infectious diarrhoea is one of the causes. Functional bowel defects represent various combinations of chronic and recurrent symptoms from the digestive tract which cannot be explained by structural or biochemical abnormalities. Irritable bowel syndrome is a functional defect manifesting with abdominal pain, intestinal dyspepsia and compulsive defecations. Subtypes with typical symptomatology are characterized by circumstances which bring about pain and compulsive defecations (morning fractional defecation, postprandial defecation, debacles). Functional diarrhoea manifests with diarrhoea without intensive pain. Spastic obstipation manifests by abdominal pain, obstipation, compulsive defecations are absent, stool is cloddish, fragmented by spastic haustration, or it has a ribbon-form. Changes in the intestinal chemism include fermentative and putrefactive dyspepsia. Among the incomplete and atypical forms the isolated meteorism, irregular defecation, flatulency, abdominal pain--syndrome of the left or right epigastium or the syndrome of the right hypogastrium can be included. In patients with typical set of symptoms the working diagnose of the lower dyspeptic syndrome can be done by general practitioner. Complete history of the disease can reveal possible extra abdominal cause of dyspepsia, recognise alarming symptoms and consider circumstances elevating or lowering the probability of functional problems. Functional bowel problems have usually long-term character and represent clinically demanding challenge. Only few therapeutic regimens are successful and the therapy aimed at the abolishment of one symptom need not bring general improvement. For the clinical studies of the therapy of functional bowel problems significant placebo effect is typical. Quoad vitam prognosis is good, quoad sanationem it is rather doubtful.

Intraoperative manometry of the lower esophageal sphincter pressure during laparoscopic antireflux surgery with a mechanical calibration--early results

BACKGROUND/AIMS

Persistent postoperative dysphagia diminishes the good effect of laparoscopic anti-reflux surgery. An excessive increase of the intraoperative lower esophageal sphincter pressure (LESp) is supposed to be related to the persistent postoperative dysphagia and its knowledge could lead to the modification of the surgical technique followed by improved clinical outcomes. This study aims to describe the relation between the intraoperative LESp increase and the incidence of postoperative dysphagia and to find whether a combination of intraoperative manometry and mechanical calibration of the wrap is able to decrease the incidence of the persistent postoperative dysphagia.

METHODOLOGY

The randomized, prospective, two-branch study included 39 patients suffering from symptoms of gastroesophageal reflux disease. All patients underwent pre- and postoperative manometry, 24-hour pH-metry and laparoscopic anti-reflux surgery. The intraoperative LESp was measured in the study arm only.

RESULTS

A higher incidence of persistent postoperative dysphagia was revealed in patients with the intraoperative LESp increase more than 15 mmHg. This complication was not found in patients with the LESp increase under 8 mmHg with no impact on the efficacy of the surgery. The combination of the intraoperative manometry and the mechanical calibration of the wrap seems to bring the benefit only to a small number of the patients.

CONCLUSIONS

According to our results, the intraoperative LESp measurement proved to be a useful supplementary method which was easy to perform, and which enables a modification of the surgical technique to decrease the incidence of the persistent postoperative dysphagia.

[Laparoscopic procedure according to Heller]

Oesophageal achalasia is a rare disorder. For patients in good overall condition, surgical management--myotomy--is one of the treatment options. This study describes the technique of laparoscopic myotomy sured by partial antireflux cuff. 35 patients were operated. Only in 3 cases, further follow-up was required for dysphagia. None of the patients required re-operation. No serious peroperative or postoperative complications were recorded. Importance of peroperative oesophagogastroscopy in assessment of adequate extent of myotomy and in excluding perforations of the oesophageal mucosa is put forward.

[The relation of GERD, bronchial asthma and the upper respiratory tract]

Gastroesophageal reflux disease (GERD) is one of the most common diseases affecting upper gastrointestinal tract. It is a chronic disease, whith stadily growing incidence and prevalence in west countries during last 30 years. GERD is caused by pathologic gastroesophageal reflux (GER). GERD includes endoscopically positive, endoscopically negative and extraesophageal reflux disease. Extraesophageal symptoms of GERD have been of a growing attention and discussion during last few years. The most discussed topics are the relation of GERD and bronchial asthma (BA), chronic cough and symptomatology from ear, nose and throught (ENT) regions, but also non - cardial chest pain and many others.

AIM

In our clinic we ran a 5 years study which aim was to evaluate the presence of GERD in patients with bronchial asthma, chronic cough and affections from ENT regions. To assess if 3 months GERD treatment would improve lung function, subjective complaints (cough) and GERD control in asthmatics; if this treatment would allow to step - down with antiasthma medication. To assess if 3 months GERD treatment can improve objective and subjective assessments in patients with chronic cough and findings in ENT regions. As for GERD, we evaluated the improvement of pH and subjective complaints (pyrosis).

METHODS

We examined 86 patients with different severity of bronchial asthma, 54 patients with chronic cough and 31 patients with ENT symptoms. All patients underwent 24 hour esophageal pH metry, spirometry with lung function evaluation and objective ENT examination by flexible laryngoscopy. In case of pathologic finding on 24 hour pH-metry 3 months full antireflux treatment with proton pump inhibitors (PPI) and prokinetics was introduced. After 3 months of GERD treatment we performed control 24 hour esophageal pH metry, control spirometry and ENT examination by flexible laryngoscopy. Patients were asked to make their subjective symptoms assessments.

RESULTS

We found that GERD prevalence in patients with respiratory symptoms was very high. Three months GERD treatment improved lung function (FEV1) with statistical significance (p = 0.0319), and so improved GERD control (in 60.7% of patients with high statistical significance p = 0.0009). Subjective complaints (cough) also improved in most patients. 3 months GERD treatment did not allow to step down with maintenance BA therapy according to GINA guidelines, but it enabled to decrease the rescue medications in 50% of patients. Patients with chronic cough can benefit from GERD treatment as cough improved in 75.8% of patients.

CONCLUSION

Objective findings as well as subjective complaints improved in 75% of patients with ENT symptomatology. GERD control (DeMeester score and pyrosis if present) was highly statistically significant in all three groups of patients. It is necessary to mention, that there is a high presence of nocturnal acid breakthrough (NAB) in patients with respiratory symptoms: 30.3 % in patients with bronchial asthma, 63.6 % in patients with chronic cough and 45 % of patients with ENT manifestations.

[What has changed in knowledge of etiopathogenensis, diagnostics and therapy of gastroesophageal reflux over last 15 years?]

An incidence of gastroesophageal reflux disease (GERD) in population is continuously increasing. A probable etiology, except anatomical changes (such as hiatus hernia, transient lower esophageal sphincter relaxation etc.), can also include a change in life style For diagnostic purposes upper endoscopy and in unclear cases esophageal pH-metry is used. From an etiopathogenetic point of view, besides reflux of acidic content, the alkaline content and night change in production of hydrochloric acid during treatment with proton pump blockers (PPI) are considered to be important too. Attention should be paid to extraesophageal signs of GERD. In treatment prevail PPI, in resistant cases and in younger patients fundoplications are considered, and, also therapeutic endoscopy becomes more important (application of gel prostheses, electricity to cardiac part followed with scaring or ligatures).

Treatment of patients with achalasia with botulinum toxin: a multicenter prospective cohort study

Botulinum toxin (BT) injection is an alternative treatment of achalasia. The aim of the study was to examine outcomes of patients treated with BT in the Czech Republic. Since 1997, 49 patients with achalasia have been treated with BT. We prospectively evaluated the effect of BT injection on 41 patients during a median follow-up of 24 months (range 9-62). Esophageal manometry was performed before and at 3-5 months after the injection. In 16 patients, BT was injected from the antegrade angle only (subgroup A), in 15 patients, BT was injected from both retrograde and antegrade angles (subgroup B) and, in 10 patients, BT injection was combined with subsequent balloon dilatation (subgroup C). Immediate clinical response was achieved in 93% of patients. Clinical remission was sustained beyond 3 months in 83% of patients (responders). Fourteen responders (41%) did not experience a relapse during the median of 22 months. Twenty responders (59%) experienced symptomatic relapse approximately 8 months after the injection. Ten relapsers underwent BT reinjection, five (50%) of them were asymptomatic for another 14 months. The remaining five (50%) patients reported a second relapse approximately 6 months after the reinjection. Median duration of the symptom-free period was 11.5 months after the first BT injection, and 10.5 months after the second (P = 0.21). We did not find any significant predictor of a favorable outcome; responders tended to be older and to have a lower basal lower-esophageal-sphincter pressure. Patients in subgroup C were more likely to be in remission at 1 and 2 years as compared with patients in subgroup A. BT injection is an effective treatment of achalasia in the short term. However, almost 70% of patients experience a relapse within 2 years. BT injection should therefore be reserved for patients at risk for more invasive procedures or for patients who prefer this treatment.

[Clinical symptomatology of chronic pancreatitis]

The author describes the clinical picture of chronic pancreatitis, incl. less commonly used clinical examinations.

[Barrett's esophagus]

Barrett's oesophagus is a premalignant metaplastic change of the oesophageal mucosa. Due to its relationship with oesophageal reflux disease and the development of adenoma-carcinoma of the oesophagus the problem arouses increasing interest. In the wide pathogenesis of the disease most probably the composite effect of the refluxed HCl content and duodenal juices play a part. In the diagnosis in addition to fundamental methods--endoscopy and histology--increasingly chromoendoscopy and fluorescent endoscopy are involved. Dispensarization of patients is essential and depends on the degree of pathohistological epithelial changes. Treatment of Barrett's oesophagus can be divided into conservative, where the drug of choice are proton pump inhibitors, and surgical treatment. Promising is endoscopic ablation of the epithelium in combination with subsequent antisecretory therapy.

[Pathologic gastroesophageal reflux in patients with bronchial asthma]

Gastrooesophageal reflux (GER) and asthma bronchiale are frequent diseases. Asthma affects some 3-10% of adults. Gastrooesophageal reflux is present in some 45-89% asthmatic patients. Symptoms of GER are not only gastrooesophageal, and recently increased attention is focused on extraoesophageal symptoms where in particular the relationship of GER and asthma or chronic cough is investigated. At our clinic we implemented a pilot study with the objective to monitor the presence of pathological GER in patients with asthma and to assess whether antireflux therapy will influence the respiratory complaints of the patients. The group was formed by 14 patients selected at random with different severity of asthma and different symptoms of GER. The patients had a baseline examination evaluating the presence of GER (24-hour pH metry) and pulmonary function (FEV1). In case of a pathological GER the patients were treated by antireflux therapy and then check-up examinations were made. It was found that after treatment of GER in patients with asthma in particular subjective symptoms improved such as cough and pyrosis which leads to a substantial improvement of the quality of life. On the other hand reflux treatment did not exert a basic effect on pulmonary functions and it was not possible to reduce the medication of asthma.

[Importance of assessment of Helicobacter pylori antigen in faeces]

Diagnostic methods for the detection of Helicobacter pylori (H.P.) can be divided into invasive and non-invasive ones. Among non-invasive methods we can include now also detection of H.P. antigen in faeces. The objective of our study was to evaluate the sensitivity ans specificity of the test when monitoring the eradication therapy, as compared with another non-invasive test and to test the method in common clincal practice. H.P. positivity was based on the result of the histological examination and CLO test. Repeatedly samples of faeces were collected to detect H.P. antigen in faeces before the onset of and after eradication treatment. For detection of H.P antigen the commercial Premier Platinum HpSa set was used which was developed on the principle of enzyme immunoanalysis. From the assembled data the sensitivity value (87.1%) and specificity values (88.5%) was calculated. The test correlates well with the results of the CLO test, histological examination and the breath test and is thus a suitable method for the detection of H.P. positive subjects as well as for checking the success of eradication treatment of H.P.

[Is complex therapy of achalasia using botulinum toxin combined with balloon dilatation an effective approach?]

BACKGROUND

Achalasia (ACHL) is not a very frequent disease and its etiology is still unclear. In addition to the oldest therapeutical approach represented by myotomy, two conservative methods are commonly used--balloon dilatation and application of botulotoxin. So far, both methods have been used only separately, and their effects have been compared. Literature provides no evidence of the renewal of oesophageal propulsive peristalsis in result of conservative treatment.

OBJECTIVES

The aim is to use both approaches subsequently within a short period of time, in order to potentiate their effects and at the same time to reduce the risk of possible complications.

METHODS

The group was formed by 9 patients. Achalasia was diagnosed by flow manometry. Pseudoachalasia was excluded endoscopically and endosonographically. The treatment included application of 250 J of botulotoxin (Dysport) into the region of the lower oesophageal sphincter, and balloon dilatation which was applied 7 days later. Following this treatment, patients were observed for 24 hours. The clinical and manometric examinations were performed in 3-month intervals.

RESULTS

All patients felt significantly better after treatment. The clinical state in two patients required the performance of Heller's myotomy. After 1 year, evident clinical and manometric improvement was observed in 7 patients. The longest improvement so far lasted for 36 months. The treatment has renewed the propulsive oesophageal peristalsis in two women.

CONCLUSION

The treatment of primary achalasia by means of combining the application of botulotoxin (Dysport) and balloon dilatation is effective, and it is possible to assume that the clinical remission will last longer than that in result of separate use of just one of the methods. The synchronous treatment of functional blocks in the cervical and thoracic regions of the spine and continuous rehabilitation can participate in the favourable clinical effect. The renewal of primary peristalsis of the oesophagus was achieved in two out of 9 patients. No such change has been either manometrically verified or described in literature. (Fig. 5, Tab. 1, Ref. 39.)

[Barrett's esophagus]

Barrett's esophagus is a pre-malignant change in esophageal mucosa. Its relation to the reflux disease of the esophagus and the origin of adenocarcinoma (which currently has an increasing incidence) experiences its renaissance. The pathogenesis of this disease is based on the composite effect of reflux contents of hydrochloric acid and duodenal juices. In addition to endoscopy and histology, chromoendoscopy and fluorescent endoscopy are gradually starting to be put into diagnostic routine practice. The control of patients is a necessity which depends on the degree of pathohistological changes within the epithelium. The therapy of the Barrett's esophagus can be either conservative which is currently carried out by proton pump inhibitors or surgical. Ablation of epithelium in combination with a subsequent long-term antisecretory therapy appears to be a promising treatment. (Ref. 23.)

[Dyspeptic complaints in diabetic patients]

Diabetes is a frequent metabolic disease which affects also the digestive tract. Functional disorders of the latter have a negative impact on the stabilization of diabetes. An important factor as regards motility is the blood sugar level. Subjective complaints of the patients frequently do not correlate with the objectively assessed functional state of the digestive tract. The authors remind of contemporary available diagnostic and therapeutic possibilities.

Radionuclide oesophageal transit scintigraphy--a useful method for verification of oesophageal dysmotility by cervical vertebropathy

We followed up a group of 43 patients suffering from cervical vertebropathy. Dynamic scintigraphy revealed a significant prolongation of oesophageal transit time of 10 ml of labelled liquid (mean transit time, MTT) in comparison with a control group. Patients treated with acupuncture showed a significant reduction in MTT in comparison with patients receiving a placebo needle application. The group of patients treated with manipulative techniques showed in addition to symptom alleviation a significant reduction in MTT. Dynamic scintigraphy facilitates verification of oesophageal dysmotility in patients suffering from vertebropathy and enables the success of therapy to be readily monitored.

Restoration of propulsive peristalsis of the esophagus in achalasia

The set consisting of 3 patients with esophageal achalasia diagnosed by manometry, pseudoachalasia excluded by esophagoscopy and endosonography, was treated with combined conservative procedure. Botulinum toxin 250u (Dysport) was applied to the area of lower esophageal sphincter and after 7 days balloon dilatation was carried out. Treatment efficacy was evaluated by the data obtained about the subjective condition, manometrically and endoscopically. The spine condition was evaluated in all patients before treatment and functional blockades were released by manual medicine and even by acupuncture. We succeeded in restoring propulsive peristalsis of the esophagus in all of them. It is objectively proven in the longest duration of 44 months in the case of a patient treated with a balloon dilatation.

[Treatment of hemorrhoids from the viewpoint of the gastroenterologist. Personal experience with the Ginkor Fort preparation]

Pathological changes in hemorhoid plexes are frequently occurring mainly in elderly. In development of this disease are mainly involved changes in the vessel wall, pressure changes in basin, disturbances in passage of stool and also infectious disease. Instead of the correction of the life-style in therapy are used locally-acting drugs whose basis are local anesthetics, spasmolytics, antiflogistics, antipruriginostics and corticoids in many combinations. The main aim of the orally administered drugs is influence of the vessel-wall tone, decrease of the capillary permeability, circulation betterment, decrease of the oedema and blockage of the inflammatory mediators. In the group of 45 patients is documented benefit in use of Gincor-fort in dose of 2 cps bid in first week and 2 cps daily in the second week of the treatment. We presume that this drug can influence all of above mentioned factors during the acute hemorrhoidal attack.

Dynamic esophageal scintigraphy in patients with achalasia

BACKGROUND

Dynamic esophageal scintigraphy has been proven as an efficient technique of diagnosis of esophageal dysmotility.

METHODS

The authors monitored the transit velocity, anti-peristalsis and the retention of radioactivity in the esophagus by dynamic esophageal scintigraphy in a group of 50 patients (37 control patients and 13 patients with achalasia).

RESULTS

They found a significantly longer period of radioactivity passage via the esophagus compared to the control group (p < 0.001%).

CONCLUSIONS

We observed the statistically significant transit prolongation of radioactivity through the esophagus during dynamic esophageal scintigraphy (41.2 seconds) in our group of patients with achalasia compared to the control group (7.9 seconds). Anti-peristalsis and even the radioactivity retention have occurred statistically more frequently compared to the control group.

[Esophageal reflux disease--comments on confusion in terminology, diagnosis and therapy]

Oesophageal reflux disease is a serious condition with an impact on the entire population. The provoking factor of the disease is gastroesophageal reflux which itself is not a disease but a normal physiological process. Reflux is described as pathological it is damages the oesophagus and respiratory tract. Oesophageal reflux disease develpomeps when antiferlux mechanisms fail, it is the consequence of impaired motility where the crucial role is played by dysfunction of the lower oesophageal sphincter. The most frequent consequence and manifestation of gastrooesophageal reflux is reflux oesophagitis which may be macroscopically obvious (endoscopically positive) or detectable only on histological examination (endoscopically negative--microscopic). Symptoms of reflux disease do not correlate with the severity of the disease. Some cases of roflux eosophagitis may be symptom-free. The diagnosis of oesophageal reflux disease is based in particular on an aimed case-history, endoscopy, histology and pH-metry. An open problem remains the relationship of reflux disease and the presence of Helicobacter pylori infection. In tratment either selective treatment (one drug) is used or graded (upward or downward) treatment. The upward therapeutic strategy (strating treatment with proton pump inhibitors) is as a rule economically more effective than the traditional downward strategy (strating treatment with less intensely acting drugs). Tretment is of long-term (maintenance treatment) which may be medicamentous or surgical. In oesophageal reflux disease there still remain controversial areas which must be elcudated as its incidence is rising and it is considered a disease of the 21st century.

[Esophageal reflux disease--role of 24-hour pH measurement]

24-hour ph-metry of the oesophagus is a standard examination method in patients with reflux complaints. For objective evaluation of the record the following points are most important: 1. calibration of the instrument, 2. precise placement of the pH-probe, preferably under manometric control, 3. elimination of medication (inhibitors of proton pump, H-2 blockers, antacids, prokinetic preparations), 4. cooperation of the patient. A 24-hour record makes it possible to analyze in detail the type of reflux, and when using available software, also its quantity.

[Effect of H. pylori eradication regimes on the proliferation index of gastric mucosa]

Eradication regimes with the blocking agent of the proton pump and without it do not influence the activity of cell division after treatment of Helicobacter pylori (H.p.) when using cytoflowmetric evaluation. The non-significant difference in proliferation activity of the gastric mucosa after treatment of H.p. can be also a sign of more rapid repair of the gastric mucosa after elimination of the inflammatory elements.

[Levels of vitamins A, E and C in serum and gastric juice in relation to gastric mucosa and occurrence of Helicobacter pylori]

Colonization of the gastric mucosa with Helicobacter pylori H.p. reduces the vitamin C concentration of gastric juice. Eradication of H.p. within four weeks after completed treatment does not exert a significant effect on changes in the concentration of vitamins A, E and C in gastric juice or serum. Despite this after eradication a rising trend of vitamin E in gastric juice was recorded. Substitution of vitamin C and E in gastritis associated with colonization with H.p. has a favourable effect and may reduce the risk of malignization.

[Cisapride (Prepulsid) in the prevention of postoperative gastrointestinal atony]

Administration of cisapride, 3 x 5 mg in a suspension one day before surgery and 30 mg 3 and 8 hours after abdominal surgery with subsequent administration of 2 x 30 mg in suppositories up to the time when oral ingestion is possible, hastens significantly the restoration of GIT motility as compared with placebo. It can be therefore recommended as effective medication in the prevention of complications caused by impaired motility of the digestive tract.

[Prevalence of Helicobacter pylori infection in the Czech Republic--the South Moravia Region]

The prevalence of Helicobacter pylori is influenced in a significant way by geographical conditions and depends to a certain extent also on the economic standard of different countries. Some published work provides evidence that Helicobacter pylori infections in eastern European countries are in general more frequent than in western European countries. It cannot be ruled out, however, that in different countries there are regional differences as far as Helicobacter pylori is concerned. In a group of 309 subjects, none of those treated previously to eradicate H.pylori, at least three weeks before blood sampling no preparations of the type of H2 blockers, proton pump blockers or drugs containing bismuth were administered. In these patients serological examinations of H.pylori antibodies were made, using kits of TEST-LINE Brno. The examined subjects were divided into six age groups by decades, starting at the age of 20 years. The general prevalence of H.pylori in the examined group was 58.8%, in the group of 20-year-old ones less than 46%. The highest prevalence was recorded in subjects aged 50-59 years and amounted to 67.3%. The authors compare their own results with findings assembled in the Czech Republic and abroad and draw attention to the necessity of an extensive epidemiological survey of H.pylori prevalence in the Czech Republic. The survey should be done by regions, using the same diagnostic method.

[Treatment of esophageal motility disorders with acupuncture of the ear (preliminary report)]

Impaired motility of the oesophagus is relatively frequent in patients with functional blocks of the cervical spine. The patient does not always realize oesophageal dysmotility. Auricular acupuncture focused on reflex relations seems to be a useful therapeutic procedure.

[Functional disorders of the digestive tract and possibilities of therapy with Prepulside (cisapride)]

The authors give an account of functional disorders of the digestive tract. They deal briefly with possibilities of their medicamentous treatment with regard to the pharmacological action of prokinetics. Finally they review indications for Prepulside.

[Therapy of ulcer disease using gastrinal-sucralfate produced in Czechoslovakia]

The authors present their experience with the use of the Czechoslovak preparation Gastrinal-Sucralphate in the treatment of 40 subjects with gastroduodenal ulceration. Moreover, they compared two forms of the drug--tablets and granulate. The healing effect of the drug is very high, in tablets 77.0%, in granulate as much as 89.5%. As far as tolerance is concerned, it was obviously better after the granulate, subjective side-effects were very rare. The drug does not affect any basic biochemical parameters which were monitored during administration of the drug.

Intravenous xylene poisoning

A 30-year-old man injected intravenously 8 ml of xylene in a suicidal attempt. After 10 min he developed acute pulmonary failure requiring intubation, controlled ventilation with PEEP and high FiO2. Combined hemoperfusion and hemodialysis were carried out for 4 h. By 8 days later the patient was weaned from the ventilator and after 14 days transferred to the Department of Psychiatry with normal blood gases. Pulmonary failure threatened the patient's life, therefore treatment of this was dominant in the therapy.

[Sulpiride (Eglonyl Alkaloid) in the treatment of functional disorders of the digestive tract]

Sulpirid was administered in an open clinical trial--150 mg/day for 4 weeks--to 31 patients (15 man and 16 women, mean age 31.5 years, mean duration of complaints 1 month to 6 years) suffering from functional disorders of the digestive system. Their health status was evaluated by a specialist in internal medicine, by a psychiatrist and a self-administered SCL-90 questionnaire before the onset of treatment and after four weeks. In 29 patients the complaints disappeared or improved markedly and this improvement persisted also after discontinuation of the drugs. In the entire group a significant drop of the mean initial intensity of psychopathological feature in all dimensions of the questionnaire occurred; the improvement was more marked in men where the mean baseline values of psychopathology were higher. There was also a significant decline of the mean numbers of positively evaluated items in 9 of 10 dimensions of the questionnaire. The drug was well tolerated by the patients with the exception of one transient allergic skin reaction. So far the exact ratio of improvement of psychopathology as a therapeutic response to sulpirid administration and the placebo effect on the patient's complaints cannot be exactly evaluated. Sulpirid has some advantages, as compared with other psychopharmaceutic preparations used in this indication (e.g. amitriptyline, dosulepine).