[Hemobilia caused by gallbladder's polyps in liver cirrhosis]

Extremely unusual cause of hemobilia from polypus of the Gallbladder in 29 years old patient with liver cirrhosis is reported. The patient died with clinical features of hepatic encephalopathy. The olygosympthomatic clinical course is the reason for unrecognized hemobilia. The ultrasonographic diagnosis was "cholelithiasis" instead of gallbladder's polypus and endoscopy established large ulcer in the duodenum. The role of hemorrhagic diathesis in chronic liver disease is discussed. As is the extent of liver cirrhosis, cholestasis and hepatic encephalopathy deterioration caused by bleeding. Whether timely cholecystectomy could change the course and prognosis of chronic liver disease is also discussed.

[Acute surgical abdomen in idiopathic haemochromatosis]

The acute abdomen (AA) is a typical but very rare complication of idiopatic haemochromatosis (IH). The possible mechanisms are not sufficiently clarified. We report a case with IH who died with clinical features of (AA) 20 hours after gastroscopy was performed. The histological examination established nonspecific damage of visceral peritoneum and ascites. Fulminant form of spontaneous bacterial peritonitis (SBP) as a reason of death is discussed, nevertheless endoscopic esophageal varices sclerotherapy was not performed. The role of pulmonary infection and intestinal bacterial overgrowth with possible bacterial translocation in mesenterial lymph nodes, ascitic fluid, and blood is also discussed. The source of infection is usually unknown. The iron is important factor for bacterial growth. The pluriglandular deposition of iron including the suprarenal glands is precondition to development of collapse. The possible pathogenesis of SBP in IH is discussed. It is important to mention that unlike SBP the clinical course of IH AA might appear which does not necessary require surgical management.

[Classifications and prognosis of hepatocellular carcinoma]

In this study are included 78 patients with hepatocellular carcinoma (HCC). In 22 the diagnosis is verified pathologically (obduction), while in the other patients the diagnosis is made by laparoscopy, laparoscopical ultrasonography and morphological verification (through FNAB cytology and/or histology). In 69.2% HCC is associated with cirrhosis. The prognosis of HCC associated with cirrhosis is evaluated through the classification of S. Chevret et all., and is compared to the Child-Pugh scoring system. 38.9% of patients in Chevret's class C score are in class B in the Child-Pugh score, while 25.9% of patients are in class C in both classifications, but Child-Pugh's class C patients are most often in B-C transition. It might be assumed that the prognosis of HCC depends more on the tumor prognosis than on the prognosis of the liver cirrhosis itself. Every classification which does not take in to account the liver function (like TNM system) and the whole characteristics of the tumor, would be incomplete, in some extent, in the prognosis of HCC with cirrhosis. In HCC without cirrhosis, the BCLC classification reflects both the liver function and the tumor characteristics. In BCLC class A patients hepatic resection or transplantation is recommended but hyperbilirubinemia and ascites, which might be seen in A3 and A4 classes contraindicate resection of the liver. All scoring systems define lower HCC stage than it is really found (personal and reference data), so there are no arguments to take classification scores as absolute treatment decision making rules.

[The indications and choice of the technic for pancreatic resections]

The progress of pancreatic surgery naturally leads to broadening the scope of indications for resection of the gland. Over the period 1970 through 1993, in the Clinic of Abdominal Surgery are performed 99 pancreatic resections for carcinoma of the pancreas (including cancer of papilla Vateri (45), endocrine-active tumor of pancreas (5), benign tumor (1), chronic pancreatitis (4), pseudocysts of the pancreas (4), cancer of an adjacent organ infiltrating the pancreas (36), benign lesions to a neighbouring organ (4). The size of resection depends on a number of factors of which location of the neoplasm and stage of the disease are the leading ones. Operations done: duodenopancreatic resection--47, left side hemipancreatectomy--13, resection of the body region and tail of pancreas--14, and partial resection--19. The choice of operative technique is discussed against the background of the variety of indications for pancreatic resection. Special attention is focused on the operative technique used in pancreatoduodenal resection. The practicability of performing pylorus-preserving intervention, the need of vagotomy and its scope are precisely determined. Also discussed are issues relating to the choice of organ for anastomosis with the pancreas and its protection, as well as the variants of successiveness of anastomoses with the biliary canal, residual pancreas and stomach. Morbidity and mortality rates show a decrease parallel to the surgical experience gained.

[Treatment of peptic ulcer with sucralfate]

Sucralfate made in Bulgaria (Farmaphim) and its Yugoslavian analogue venter have been tried in gastroduodenal ulcer. The drugs were given per os (1 g, 1 tablet) 4 times a day before meals for 20 days. Sucralfate treatment was assigned to 26 patients with gastric and 26 with duodenal ulcer. The other 20 gastric ulcer patients received venter. 10 patients with gastric and 20 with duodenal ulcer entered the control group receiving placebo. Attenuation of the symptoms was reported as early as on day 4 of the treatment in 85-100% of the patients both with gastric and duodenal ulcer. The 20-day course of sucralfate treatment brought about a complete epithelization on gastric ulcer in 54% while in venter treatment in 55% of those treated versus placebo group 10%. Duodenal ulcer epithelization occurred in sucralfate-treated group in 58% against placebo group 17%. The differences in treatment results between sucralfate and venter are immaterial, whereas against placebo they are significant (p less than 0.05). Side effects were not serious.

Cisapride and cimetidine in the treatment of erosive esophagitis

The efficacy of cisapride, as compared with cimetidine, in the treatment of erosive esophagitis was studied in a double-blind trial. One hundred and twenty-nine patients were assigned to one of four dosage schedules: cisapride 10 mg b.i.d. (20 mg group) or q.i.d. (40 mg group), or cimetidine 400 mg b.i.d. (800 mg group) or q.i.d. (1600 mg group). Treatment lasted 8 to 12 weeks. The degree of esophagitis and the severity of diurnal and nocturnal heartburn and regurgitation were significantly (p less than 0.01) reduced in the four treatment groups. Endoscopy did not show any significant differences among the four groups, although cisapride tended to be more effective in moderate to severe esophagitis, in which cases mucosal healing (i.e. absence of erosions and ulcers) was observed in 69%, 64%, 55% and 55% of the patients treated with cisapride 40 mg, cisapride 20 mg, cimetidine 1600 mg and cimetidine 800 mg. Improvement in reflux symptoms in the two cisapride groups was not significantly different from that in the cimetidine 1600 mg group, but was better (p less than 0.05) than that in the cimetidine 800 mg patients. The severity score for all reflux symptoms had decreased by 79%, 74% (cisapride 40 mg and 20 mg), 69% and 57% (cimetidine 1600 mg and 800 mg) by the end of treatment. These results show that cisapride is at least as effective as acid-suppressing therapy in patients with reflux esophagitis, and is therefore a valuable alternative to it.

[Computed tomography and echography in chronic pancreatitis and pancreatic carcinoma]

The diagnostic possibilities of computer tomography and echographic investigations were studied in 58 patients with chronic pancreatitis and 36 patients with carcinoma of pancreas. Positive morphological signs for the existence of chronic pancreatitis were established in 75,9 per cent in computer tomography and in 83,93 per cent in echographic investigations. The difference in the diagnostic sensitivity of both diagnostic methods is not significant (p greater than 0,05). The calcifications in pancreas are better detected by computer tomography whereas both methods are equivalent in the diagnosis of the pancreatic cystes. In carcinoma of pancreas computer tomography gives the correct diagnosis of the disease (p greater than 0,05) in 69,5 per cent and echography--in 78,8 per cent of the patients. With computer tomography false negative results amount to 30,5%; in 13,9 per cent normal pancreas was described and in 16 per cent--pseudocyst in pancreas. With echography--false negative results were established in 21,2 per cent of the patients; 12,1 per cent chronic pancreatitis was described, in 9,1 per cent--pseudocyst in pancreas but, at the same time, pancreas was not properly visualized in 8,3 per cent of the examined. Making use of both methods, accurate diagnosis was made in 83,3 per cent of the patients with carcinoma of pancreas.

[Treatment of duodenal ulcer with biomet]

The results are reported from the treatment of 30 patients with the Bulgarian preparation biomet, which is a blocker of histamine H2-receptors. The treatment lasted 20 days with 3 X 20 mg biomet, after meals, and 400 mg in the evening before going to bed. Pains disappeared in 86,6 per cent with biomet treatment, pyrosis--in 95,8 per cent, eructation--in 95,3 per cent, nausea--in 84,7 per cent, vomiting--in 100 per cent of the patients, etc. (the clinical symptoms completely disappeared in 76,7 per cent after the treatment and were substantially reduced in 16,7 per cent). A statistically significant reduction of the basic parameters of gastric secretion and acid output occurred after biomet treatment as compared with the initial values. The fibroendoscopic study of the duodenal ulcer, after the treatment, revealed a complete epithelization in 52 per cent and diminished ulcer size--in 44 per cent. No pronounced adverse effects were observed during biomet treatment. The Bulgarian preparation biomet is fully equivalent to the English Cimetidine (the latter being more expensive) and should find a broad application in the treatment of duodenal ulcer.

[Chronic recurrent pancreatitis with erosive gastritis in a patient with primary hyperparathyroidism]

A female with premary hyperparathyroidism and secondary renal lesions, as well as lesions of the stomach and pancreas is described. The initial illness was manifested by repeated renal crises. Later, gastroenterological complaints appeared--epigastralgia, vomiting, frequent hematemesis with melena. That was the cause for a gastric resection, diffuse erosive gastritis being found. After the operation, the pains and the vomiting of hematin matter repeatedly recidivated. Clinically and at the laboratory, data were formed for a chronic recidivating pancreatitis with the presence of primary hyperparathyroidism. The postoperative treatment of the parathyroid adenoma led to an improvement of the gastroenterological complaints.