RJGE VOL.12, NR.2, JUNE 2003

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1 RJGE VOL.12, NR.2, JUNE 2003 ORIGINAL PAPER Correlation of sicam-1 and svcam-1 Level with Biochemical, Histological and Viral Findings in Chronic Hepatitis C after Interferon-a+ Ribavirin Therapy Corina Radu 1, Doru Dejica 1, Grigorescu Mircea 1, Zaharie Teodor 1, Daniela Neculoiu 2 The Prevalence of Coeliac Disease at Endoscopy Units in Romania: Routine Biopsies during Gastroscopy Are Mandatory (A Multicentre Study) Daniela Dobru 1, Oliviu Pascu 2, Marcel Tantau 2, Cristian Gheorghe 3, Adrian Goldis 4, Gheorghe Balan 5, Ilie Olteanu 6, Alexandru Fraticiu 7, Eugen Dumitru 8, Eftimie Miutescu 9, Chris Mulder 10, Simona Podoleanu 11 Autoantibodies and Histogenesis of Celiac Disease Kamran Rostami 1, Chris J.J. Mulder 2, Steven Stapel 5, B. Mary E. von Blomberg 3, Jo Kerckhaert 6, Jos W.R. Meijer 7, Salvador A. Pena 4, Hugo S.A. Heymans 8 Argon Plasma Coagulation for Radiation Proctitis Cristian Gheorghe, Liana Gheorghe, Razvan Iacob, Speranta Iacob, Iulia Simionov, Ion Bancila Radiofrequency by Open Surgical Approach in the Treatment of Hepatic Tumours: Early Experience with 14 Cases* Liviu Vlad, G. Osian, Horatiu Branda, Zeno Spârchez, D. Miclaus, L. Furcea, O. Anton, Iurie Acalovschi Perforating Veins - a Parameter of Recurrence of Esophageal Varices Zhu Saihong, Liu Xunyang, Huang Feizhou, Nei Wanping, Liu Bo, Li Reizheng, Cai Lifeng, Wang Wei, Yang Minshi, Ren Shuping Gastric Bleeding Due to Dieulafoy s Lesion, Successfully Treated by Endoscopic Hemoclipping Gheorghe Ghidirim, Igor Mishin, Eugen Gutsu, Andrei Dolghii Primary Malignant Mesothelioma of the Peritoneum Petar Svorcan 1, Jelena Djordjevic 1, Nadezda Colic 1, Njegica Jojic 1, Vladimir Vukcevic 1, Slobodan Bojovic 2, Branka Dapcevic 1 Screening for Familial Colorectal Cancer: the Need for Continuing Education. A Case Report Adina Neagoe, Olimpia Chira, Monica Acalovschi, Dana Dumitra Ultrasound Guided Percutaneous Ethanol Injection of Hepatocellular Carcinoma Zeno Spârchez 1, Nicolae Bolog 2 You can ask a free issue editor_rjge@ .ro 1

2 original papers Correlation of sicam-1 and svcam-1 Level with Biochemical, Histological and Viral Findings in Chronic Hepatitis C after Interferon-a + Ribavirin Therapy Corina Radu 1, Doru Dejica 1, Grigorescu Mircea 1, Zaharie Teodor 1, Daniela Neculoiu 2 1) Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca; 2) Institute of Urology and Renal Transplant, Cluj Napoca. Intercellular cell adhesion molecules-1 (ICAM-1) and vascular cell adhesion molecules-1 (VCAM-1) are expressed in a high quantity on hepatocytes and at the level of endothelium cells from sinusoidal vessels in the liver tissue of patients with chronic hepatitis C. The soluble forms of these molecules sicam-1 and svcam-1 can be determined in the serum of patients through the immunoenzymatic technique (ELISA). The aim of the study was to analyse the base level of these molecules and the changes induced through the combined treatment of interferon-a (IFN- a) and ribavirin (Rib). Materials and methods. Twenty patients suffering from viral chronic hepatitis C were studied: 10 patients responded completely to antiviral treatment and 10 patients showed no response at the end of the treatment. At the end of the therapy patients were placed under biochemical observation for a further six months. The serum concentration of sicam-1 and svcam-1 was measured using ELISA assay at the beginning and the end of the combined treatment: six months IFN 3MU (three times a week) associated with Rib. Results. Statistically, a significant correlation was observed between the values of sicam-1 pretreatment and the level of viremia, g glutamiltrans-peptidase (GGT), but without correlation to the alanin amino transferase (ALT) level. The value of sicam-1 was significantly higher in patients who had fibrosis score F: 3-4. After the treatment, the serum concentration of sicam-1 dropped significantly in patients with sustained biochemical response in comparison to patients who had an unsustained response or had no response whatsoever. A significant correlation between the svcam-1 pre-treatment value and the level of viremia, GGT, ALT was not established. Conclusions. The level of sicam-1 could be a useful parameter in the observation of the disease evolution of patients with viral chronic hepatitis C treated with IFN-alpha and Rib. Chronic hepatitis C - intercellular adhesion molecule 1 (sicam-1) - vascular adhesion molecule 1 (svcam-1) You can ask a free issue editor_rjge@ .ro 2

3 The Prevalence of Coeliac Disease at Endoscopy Units in Romania : Routine Biopsies during Gastroscopy Are Mandatory (A Multicentre Study) Daniela Dobru 1, Oliviu Pascu 2, Marcel Tantau 2, Cristian Gheorghe 3, Adrian Goldis 4, Gheorghe Balan 5, Ilie Olteanu 6, Alexandru Fraticiu 7, Eugen Dumitru 8, Eftimie Miutescu 9, Chris Mulder 10, Simona Podoleanu 1) Gastroenterology Department, University of Medicine and Pharmacy Tg.Mures. 2) 3 rd Medical Clinic, University of Medicine and Pharmacy Cluj Napoca. 3) Gastroenterology and Hepatology Center, Fundeni Clinical Institute, Bucharest. 4) Gastroenterology Clinic, University of Medicine and Pharmacy Timisoara. 5) Gastroenterology and Hepatology Institute, Iasi.6) Gastroenterology Department, District Hospital, Brasov. 7) Gastroenterology Departament, District Hospital, Sibiu.8) 1 st Medical Clinic, Constanta. 9) Gastroenterology Department, District Hospital, Arad. 10) Free University of Medicine, Amsterdam, The Netherlands. 11) Pathology Department, University of Medicine and Pharmacy Tg.Mures The incidence and prevalence of coeliac disease vary internationally. In Eastern Europe little is known about the prevalence of coeliac disease.the aim of this study was to evaluate the prevalence and the clinical features of coeliac disease in adults biopsied during upper endoscopy in Romania.This is the first incidence study of the coeliac disease in Romania. Methods: The study was initiated by the Romanian Society of Digestive Endoscopy for the period 1 January May It was carried out in 9 Academic Centres in Romania, which ensured an even geographical distribution and therefore significant statistical results at a national level. The study included 2436 patients according to following criteria: age over 16 years, both no known history of coeliac disease,visiting the participating upper endoscopy units or patients with documented coeliac disease presenting for follow-up check or recurrence of clinical symptoms. At least two bioptic samples were obtained from the distal duodenum, as distally as possible, which were submitted to histopathological examination and scored according to the modified UEGW Marsh criteria (2001). A database was set up to include all the patients with data regarding sex, age, urban or rural background, full clinical diagnosis, clinical symptoms, history of the coeliac disease. Results: Of the 2436 patients studied, 54 (2.22%) were diagnosed with coeliac disease. Their demographic features: 48.15% men, 51.85% women, 68.52% living in urban areas, 31.48% in rural ones, mean age years. The most frequent reasons for performing upper digestive endoscopy were: dyspeptic syndrome 15.93%, anemia 24.07%, and chronic diarrhoea 22.22%. The most frequently recorded clinical manifestations were: chronic diarrhoea in 46.3%, asthenia in 29.63%, anemia in 24.07%, aphthae in 24.07%. Histopathological results according to Marsh classification were: Marsh III %, Marsh II-35.19%. Conclusions: The prevalence of the coeliac disease in Romania is 2.22%: its sex distribution is fairly equal, the age distribution includes two peaks, at and years respectively, and patients from urban areas predominate. The most frequent (over You can ask a free issue editor_rjge@ .ro 3

4 50% of the cases) histological type was M III. The most common clinical symptoms were diarrhoea, asthenia, anemia, aphthae, while the most frequent associated diseases were diabetes mellitus and Duhring-Brocq dermatitis. Coeliac disease - prevalence Marsh classification pathology diagnosis dermatitis herpetiformis diabetes mellitus You can ask a free issue editor_rjge@ .ro 4

5 Autoantibodies and Histogenesis of Celiac Disease Kamran Rostami 1, Chris J.J. Mulder 2, Steven Stapel 5, B. Mary E. von Blomberg 3, Jo Kerckhaert 6, Jos W.R. Meijer 7, Salvador A. Pena 4, Hugo S.A. Heymans 8 1)Department of Gastroenterology Withybush General Hospital, Pembrokeshire, Haverfordwest, UK, 2) Department of Gastroenterology, 3) Pathology and 4) Gastrointestinal Immunogenetic Free University Amsterdam, 5) Central Laboratory of Blood Transfusion (CLB) Amsterdam, 6) Department of Immunology and 7) Pathology Rijnstate Hospital Arnhem, 8) Emm a Children Hospital AMC, University of Amsterdam, The Netherlands Objective. Autoantibodies are used as markers for celiac disease (CD) identifying patients with mucosal lesions. The purpose of this study was to evaluate the sensitivity and role of the autoantibodies such as IgA antiendomysium (EMA), IgA antigliadin (AGA) and the IgA antitissue transglutaminase (ttga) in histogenesis of celiac disease. Methods. Seventy-nine cases including 30 untreated celiacs, 5 celiacs on gluten-free diet (GFD), 41 first degree relatives and 3 non-relatives suspected for CD were investigated. Three untreated celiacs with IgA deficiency were excluded from this study group. IgA antibodies to ttga were determined by ELISA, as described before. Twelve of 41 relatives and 2 cases of non relatives suspected with positive serology underwent a small intestinal biopsy. Results were correlated with the degrees of abnormality of the intestinal mucosa in patients with CD. Intestinal biopsies obtained from study population were evaluated for histological quantification. Results. Celiacs and suspected cases with positive EMA/AGA and or ttga showed shorter villi (p < 0.007) and/or a higher number of intraepithelial lymphocytes (IEL) (p < 0.035). The sensitivity of serology (EMA, AGA, ttga) in patients with Marsh IIIc was 100%. However, in patients with Marsh IIIa the sensitivity for EMA, AGA, and ttga was 40%, 50% and 20% respectively. Conclusions. The appearance of antibodies is related to the degree of mucosal infiltration by IELs. Although ttga, like EMA provide a highly sensitive parameter for the detection of celiacs with severe mucosal damage, it appears to be less sensitive (even less than AGA) in celiac patients with milder histopathological abnormalities. However, it should be recognized that the substantial part of the celiac population present with these milder forms of mucosal abnormalities. Using ttga as a single test in screening may result in missing up to 60-70% of celiacs with mild mucosal abnormalities. Combination with other screening tests (at least with AGA) is essential and strongly recommended. Celiac disease autoantibodies gluten-free diet intraepithelial lymphocytes villous atrophy You can ask a free issue editor_rjge@ .ro 5

6 Argon Plasma Coagulation for Radiation Proctitis Cristian Gheorghe, Liana Gheorghe, Razvan Iacob, Speranta Iacob, Iulia Simionov, Ion Bancila Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania Radiation proctitis is a well-recognized complication following radiotherapy for pelvic malignancy. This study was designed to compare the efficacy and complications of argon plasma coagulation (APC) using the power setting of 50 W vs 60 W in a group of patients with radiation proctitis. Forty-two patients were randomized to undergo APC using the electrical power setting of 60 W (23 patients, group A) or 50 W (19 patients, group B). Patients were asked to estimate the severity of major symptoms before and after APC using a scoring system graded 0-4. The score of major symptoms before and after APC, mean duration of the procedure, number of sessions, side effects/complications were noted. Statistical analysis was performed using Fisher s Exact Test and the 2-tailed p value less than 0.05 was considered statistically significant. A significant improvement of major symptoms was noted in all patients treated with APC, irrespective of the wattage we used, apart from the presence and severity of tenesmus. The mean number of treatment sessions to achieve control of bleeding was 1.34 for group A and 1.9 for group B and the mean time of treatment sessions was significantly shorter for group A (15 min vs 17 min for group B). No significant differences in early side effects and long term complications between the two groups were evidenced. We can conclude that there is no statistical significance concerning efficacy and side effects of APC application between the 60W and 50W power setting, but the number of sessions and duration of the procedure tend to differ significantly. Rectal stenoses have been described only in patients treated with higher power settings. Argon plasma coagulation - hematochezia - radiation proctitis You can ask a free issue editor_rjge@ .ro 6

7 Radiofrequency by Open Surgical Approach in the Treatment of Hepatic Tumours: Early Experience with 14 Cases* Liviu Vlad, G. Osian, Horatiu Branda, Zeno Spârchez, D. Miclaus, L. Furcea, O. Anton, Iurie Acalovschi 3 rd Surgical Clinic, University of Medicine and Pharmacy Cluj-Napoca The aim of the study was the evaluation of radiofrequency in the treatment of hepatic tumours during laparotomy performed for hepatic tumours. The initial experience with 14 patients operated for hepatic tumours (5 primary and 9 metastatic) is presented. The paper also presents the technique concerning the intensity and duration of the power applied, the association with the surgical resection, the immediate postoperative evolution and the dynamics of the hepatic enzymes as well as the postoperative results of ultrasound and CT examinations performed within the first 6 weeks. The indications of RF during laparotomy and the place of RF ablation in the treatment of liver tumours in comparison with other ablation techniques are discussed. Radiofrequency ablation - hepatocellular carcinoma - liver metastasis hepatectomy You can ask a free issue editor_rjge@ .ro 7

8 Perforating Veins - a Parameter of Recurrence of Esophageal Varices Zhu Saihong, Liu Xunyang, Huang Feizhou, Nei Wanping, Liu Bo, Li Reizheng, Cai Lifeng, Wang Wei, Yang Minshi, Ren Shuping Department of General Surgery, The Third Xiangya Hospital of Central- South University, Changsha, Hunan, P.R.China Objective:To study the role of perforating veins in predicting the likelihood of esophageal variceal rupture and variceal recurrences. Methods: In 70 patients with esophageal varices, a 20 MHz ultrasonographic transducer was used to image esophageal varices; the radius and perforating veins were calculated. Esophageal variceal pressure measurements were obtained by noninvasive pressure gauge. The relationship between the size of esophageal varices and the presence of perforating veins in the esophageal wall was studied using chi-square test; the patients were divided into two groups according to the presence of perforating veins, and the pressure in each group was compared by using Student s t test. In addition, the frequency of endoscopy sessions necessary for varix eradication, the dots of endoscopic variceal ligation and recurrence of esophageal varices within a year were also compared by the Mann-Whitney U test. Results: The presence of perforating veins in the esophageal wall was significantly higher in patients with large radius of varices than in patients with small radius. The esophageal variceal pressure in patients with perforating veins was greater than that of patients without perforating veins (23±4.5 vs 12±3.1mmHg, p<0.05). The frequency of endoscopy sessions required for varix eradication and the dots of EVL in patients with perforating veins was greater than that in patients without perforating veins (3.25±0.50 vs 2.11±0.78; 25±5.50 vs 18.56±5.46 p<0.05). The recurrence of esophageal varices within a year was higher in patients with than in patients without perforating veins (75.93 vs 18.75%, p<0.05). Conclusion: Perforating veins in the esophageal wall correlate with the recurrence of esophageal varices in patients with portal hypertension. Keywords Esophageal varices - perforating veins - varice recurrence You can ask a free issue editor_rjge@ .ro 8

9 case reports Gastric Bleeding Due to Dieulafoy s Lesion, Successfully Treated by Endoscopic Hemoclipping Gheorghe Ghidirim, Igor Mishin, Eugen Gutsu, Andrei Dolghii First Department of Surgery N.Anestiadi and Laboratory of Hepato- Pancreato-Biliary Surgery, Medical University N.Testemitsanu, Emergency Municipal Hospital, Kishinev, Moldova Dieulafoy s lesion is a rare arterial malformation, which may produce massive gastrointestinal hemorrhage. Most commonly, the lesion occurs in the proximal part of the stomach. We present the case report of a 59-year-old man who was admitted to our emergency unit with massive hematemesis. Urgent endoscopic examination revealed a Dieulafoy s lesion with spurting bleeding, which was located in the proximal part of the stomach. Bleeding was successfully stopped by endoscopic hemoclipping without any further recurrence. Follow-up endoscopy performed 3 days later showed that the hemoclips became detached, and the protruding artery disappeared. The patient was discharged 4 days after primary endoscopic procedure without any complications. There was no recurrence of the bleeding during the 12 months of observation. Thus, we found that hemoclipping represents an alternative method of achieving endoscopic hemostasis in Dieulafoy s lesions. Dieulafoy s lesion - endoscopic hemoclipping - gastric bleeding You can ask a free issue editor_rjge@ .ro 9

10 Primary Malignant Mesothelioma of the Peritoneum Petar Svorcan 1, Jelena Djordjevic 1, Nadezda Colic 1, Njegica Jojic 1, Vladimir Vukcevic 1, Slobodan Bojovic 2, Branka Dapcevic 1 1) Department of Gastroenterohepatology. 2) Department of Pathology, Zvezdara University Hospital Belgrade, Serbia and Montenegro Mesothelioma of the peritoneum represents an extremely rare malignancy of the abdominal cavity and forms about 10% of all mesotheliomas. The annual incidence of the tumor in the general population is 1-2 cases per million. The causative relationship between chronic exposure to asbestos and mesothelioma has been proved. Since the sympto-matology of the tumor is usually not specific, the diagnosis is made in the advanced stages of the disease, which is the limiting factor for therapy. Most patients die within 2 years from the diagnosis. We report a case of a primary malignant mesothelioma of the peritoneum in a 60-year old male, who presented with three-month history of ascites, weakness and appetite loss. The patient gave the information that he had been living for 15 years in a loft which was insulated by material consisting of asbestos. After investigations, primary neoplasm of the peritoneum was suspected, which was confirmed by the biopsy and the morphopathological examination. Due to the advanced spread of the tumor and the poor general condition, the patient underwent palliative therapy. The patient died 3 months after the diagnosis. Epidemiological data for chronic exposure to asbestos have to be considered as the etiological factor of disease in this particular patient. Keywords Malignant mesothelioma - peritoneum asbestos You can ask a free issue editor_rjge@ .ro 10

11 Screening for Familial Colorectal Cancer: the Need for Continuing Education. A Case Report Adina Neagoe, Olimpia Chira, Monica Acalovschi, Dana Dumitra 3 rd Medical Clinic, University of Medicine and Pharmacy, Cluj-Napoca A 37 year old female patient was diagnosed with sigmoid colon cancer in our clinic five years ago (January 1998). The family history revealed three deaths due to colorectal cancer ( maternal grandmother, mother s sister and patient s sister), and the patient s mother had been diagnosed with adenomatous polyps (endoscopically removed). Histo-pathological diagnosis was moderate / poorly differentiated adenocarcinoma. Resection of sigmoid colon was performed and adjuvant chemotherapy was carried out, with uneventful evolution. The patient was annually followed-up (colonoscopy, abdominal ultrasound, laboratory tests). The last admission was in January No recurrence or metastases were found. The patient s mother, who was admitted at the same time, had been diagnosed with urinary bladder tumor. Subjects with a personal or family history of colorectal cancer, should routinely have a colonoscopy beginning from age 40 or earlier. It is important for such patients to be followed-up closely not only for recurrence or metastases, but also for detection and treatment of a second primary cancer at an early stage. Familial colorectal cancer screening education You can ask a free issue editor_rjge@ .ro 11

12 clinical imaging/tehnique Ultrasound Guided Percutaneous Ethanol Injection of Hepatocellular Carcinoma Zeno Spârchez 1, Nicolae Bolog 2 1)3rd Medical Clinic, Department of Ultrasound, University of Medicine and Pharmacy, Cluj-Napoca; 2)Emergency Hospital, Department of Radiology, University of Medicine, Bucharest Percutaneous ethanol injection (PEI), as the first minimally invasive ablation method, has now been in use for more than 20 years. Its main indication is the treatment of small hepatocellular carcinomas superimposed on liver cirrhosis. PEI is highly effective for small tumors (<3 cm) with a complete response in 80% of patients. The efficacy for larger tumors (3-5cm) is lower, with a complete response in 50%. To increase the effect in larger tumors some special techniques have been developed: single session therapy in general anesthesia, multiple needles insertion, injection in the feeding artery. PEI is a well tolerated therapy, with a very low complication rate. Recurrences, either local or distant, may occur after PEI and can be treated with new sessions. Although it is still considered the standard percutaneous technique in the treatment of hepatocellular carcinoma, its place is challenged by the new thermal ablative percutaneous techniques, especially radiofrequency ablation Keywords Hepatocellular carcinoma percutaneous ethanol injection ultrasonography You can ask a free issue editor_rjge@ .ro 12