Bohuslav Kianička

Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejuno anastomosis

AIM To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepaticojejunoanastomosis (HJA). METHODS The study took place from January 2009 to December 2011 and we retrospectively assessed 15 patients with Roux-en-Y HJA who had signs of biliary obstruction. In total, 23 ERC procedures were performed in these patients and a single balloon videoenteroscope (Olympus SIF Q 180) was used in all of the cases. A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope. Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of ≤ 5.4 kPa. The technical limitations or rather the parameters of the single balloon enteroscope (working length - 200 cm, diameter of the working channel - 2.8 mm, absence of Albarran bridge) showed the need for special endoscopic instrumentation. RESULTS Cannulation success was reached in diagnostic ERC in 12 of 15 patients. ERC findings were normal in 1 of 12 patients. ERC in the remaining 11 patients showed some pathological changes. One of these (cystic bile duct dilation) was subsequently resolved surgically. Endoscopic treatment was initialized in the remaining 10 patients (5 with HJA stenosis, 2 with choledocholithiasis, and 3 with both). This treatment was successful in 9 of 10 patients. The endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis - 11 times (7 patients); choledocholitiasis extraction - five times (5 patients); biliary plastic stent placement - six times (4 patients); and removal of biliary stents placed by us - six times (4 patients). The mean time of performing a single ERC was 72 min. The longest procedure took 110 min and the shortest took 34 min. This shows that it is necessary to allow for more time in individual procedures. Furthermore, these procedures require the presence of an anesthesiologist. We did not observe any complications in these 15 patients. CONCLUSION This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy. However, it is effective, safe, and widens the possibilities of resolving biliary pathology.

Unusual Multiorgan Immunoglobulin G4 (IgG4) Inflammation: Autoimmune Pancreatitis, Mikulicz Syndrome, and IgG4 Mastitis

Autoimmune pancreatitis (AIP) type 1 is commonly associated with simultaneous involvement of extrapancreatic organs. Sclerosing cholangitis, sialadenitis, retroperitoneal fibrosis, Sjögren syndrome, and other extrapancreatic lesions are often observed concurrently with AIP. High levels of immunoglobulin G4 (IgG4) in the blood serum and affected tissues are typical of this diagnostic entity. We describe a case report of a 58-year-old female with findings of AIP (according to Asian criteria), IgG4-positive mastitis, and histologically verified Mikulicz syndrome. The effect of corticoid therapy supported the diagnosis of AIP and simultaneously led to the eradication of recurrent mastitis. To the best of our knowledge, this is the first reported case of concurrent findings of AIP and IgG4 mastitis. Our case report supports the concept of systemic IgG4 syndrome with multisystem involvement. Timely diagnosis and appropriate therapy can be effective in a high percentage of patients.

Autoimmune pancreatitis--recent advances.

Autoimmune pancreatitis (AIP) is recognized as a distinct clinical entity, identified as a chronic inflammatory process of the pancreas in which the autoimmune mechanism is involved. Clinically and histologically, AIP has two subsets: type 1 – lymphoplasmatic sclerosing pancreatitis with abundant infiltration of the pancreas and other affected organs with immunoglobulin G4-positive plasma cells, and type 2 – duct centric fibrosis, characterized by granulocyte epithelial lesions in the pancreas without systemic involvement. In the diagnosis of AIP, two diagnostic criterions are used – the HISORt criteria and Asian Diagnostic Criteria. In the differential diagnosis, the pancreatic cancer must be excluded by endosonographically guided pancreatic biopsy. Typical signs of AIP are concomitant disorders in other organs (kidney, liver, biliary tract, salivary glands, colon, retroperitoneum, prostate). Novel clinicopathological entity was proposed as an ‘IgG4-related sclerosing disease’ (IgG4-RSC). Extensive IgG4-positive plasma cells and T lymphocyte infiltration is a common characteristics of this disease. Recently, IgG4-RSC syndrome was extended to a new entity, characterized by IgG4 hypergammaglobulinemia and IgG4-positive plasma cell infiltration, this being considered an expression of a lymphoproliferative disease, ‘IgG4-positive multiorgan lymphoproliferative syndrome’. This syndrome includes Mikulicz’s disease, mediastinal fibrosis, autoimmune hypophysitis, and inflammatory pseudotumor – lung, liver, breast. In the therapy of AIP, steroids constitute first-choice treatment. High response to the corticosteroid therapy is an important diagnostic criterion. In the literature, there are no case-control studies that determine if AIP predisposes to pancreatic cancer. Undoubtedly, AIP is currently a hot topic in pancreatology.

Immunoglobulin G4, autoimmune pancreatitis and pancreatic cancer.

Background: Immunoglobulin G4 (IgG4)-related diseases are a group of diseases characterized by enlargement of the affected organs, elevation of serum IgG4, massive infiltration of affected organs with lymphocytes and plasma cells with IgG4 positivity and tissue fibrosis. Type I autoimmune pancreatitis is one form of IgG4-related disease. For IgG4-related diseases, various localizations are described for up to 10% of malignancies. The aim of our study was to examine IgG4 serum levels and pancreatic tissue with respect to the simultaneous presence of autoimmune pancreatitis in patients with pancreatic cancer. Methods: IgG4 serum levels were examined In 106 patients with histologically confirmed pancreatic cancer. The level of 135 mg/dl was considered as the normal value. Pancreatic tissue was histologically examined with respect to the presence of markers of autoimmune pancreatitis. Results: A higher IgG4 level than the cut-off value of 135 mg/dl was proven in 11 patients with pancreatic cancer. Of these 11 patients, 7 had levels twice the normal limit (65.6%). Autoimmune pancreatitis was diagnosed in these individuals. In the case of 1 patient, it was basically an unexpected finding; another patient was initially diagnosed with autoimmune pancreatitis. Repeated biopsy of the pancreas at the time of diagnosis did not confirm the presence of tumour structures, therefore steroid therapy was started. At a check-up 6 months after starting steroid therapy, the condition of the patient improved subjectively and IgG4 levels decreased. However, endosonographically, malignancy was suspected, which was subsequently confirmed histologically. This patient also demonstrated an IgG4 level twice the normal limit. Conclusion: IgG4-related diseases can be accompanied by the simultaneous occurrence of malignancies, which also applies to autoimmune pancreatitis. Chronic pancreatitis is considered a risk factor for pancreatic cancer. It cannot be reliably confirmed whether this also applies to autoimmune pancreatitis. In accordance with other works, however, it is evident that, despite the described high sensitivity and specificity for IgG4 elevation in the case of autoimmune pancreatitis, even levels twice the normal limit are demonstrable in some individuals with pancreatic cancer, without the presence of autoimmune pancreatitis. We believe that patients with IgG4-related disease, including autoimmune pancreatitis, must be systematically monitored with respect to the potential presence of malignancy.

24 hour ambulatory blood pressure values corresponding to office blood pressure value of 130/80 mm Hg

BACKGROUND 24 hour ambulatory blood pressure monitoring (ABPM) values for patients who have office BP of 130/80 mm Hg have not been clearly reported. AIM The determination of ABPM values in treated hypertensive subjects corresponding to a mean office BP of 130/80 mm Hg. METHODS BP measurement in subjects 40-70 years old, by ABPM and mercury sphygmomanometer. The inclusion criteria were: mean office BP systolic (SBP) 128-132 mm Hg and diastolic (DBP) 78-82 mm Hg. Seventy six subjects met all study inclusion criteria. RESULTS Mean office BP: SBP 129.5 ± 1.1 mm Hg, DBP 79.9 ± 1.3 mm Hg. Mean 24 hour BP: SBP 121.9 ± 2.0 mm Hg, DBP 73.1 ± 1.9 mm Hg. Mean awake BP: SBP 124.9 ± 2.4 mm Hg, DBP 75.5 ± 2.2 mm Hg. Mean asleep BP: SBP 109.1 ± 3.9 mm Hg, DBP 63.3 ± 4.0 mm Hg. CONCLUSIONS The target values of ABPM identified in this study can be used in clinical practice and will contribute to risk stratification and treatment of hypertension.

Pitfalls of pancreatobiliary endoscopy after Billroth II gastrectomy.

BACKGROUND/AIMS The aim of this retrospective study is the analysis of the success rate of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in our group of patients with Billroth II gastrectomy. METHODOLOGY The study of the group was carried out during 14 years, i.e. from November 1994 to December 2008. It retrospectively evaluates 120 patients with Billroth II gastrectomy. RESULTS A cannulation success rate of 90.8% (109 of 120 patients) was reached in performing ERCP in 120 patients with Billroth II gastrectomy. There were normal ERCP results in 4 patients. ERCP results in the remaining 105 patients were pathological. Endoscopic treatment was started in all of these 105 patients immediately after diagnostic ERCP. Overall, therapeutic ERCP was completely successful in 91 of 105 patients (86.66%) who were originally treated with endoscopy. CONCLUSIONS ERCP in patients with Billroth II gastrectomy is much more demanding in contrast with standard procedure due to different postoperative anatomy. ERCP success is determined mainly by great personal experience and skillfulness of the endoscopist. ERCP performed lege artis in patients with Billroth II gastrectomy is a highly effective and safe method where the success rate reached can be almost the same as in a normal anatomical situation.

Rare neurological presentation of human granulocytic anaplasmosis

Human granulocytic anaplasmosis (HGA) is a tick-borne, acute illness with increasing incidence [1]. It is caused by Anaplasma phagocytophilum proved to have a tick vector Ixodes ricinus in Europe. HGA is usually a mild or even asymptomatic illness with non-specific influenza-like symptoms, and is associated with variable but suggestive laboratory alterations. When comparing HGA with human ehrlichiosis caused by Ehrlichia chaffeensis, beside differences in geographical distribution, there is a close association with higher hospitalization rate (36% vs. 48.6%), morbidity and life-threatening complications (e.g. adult respiratory distress syndrome, disseminated intravascular coagulopathy, meningoencephalitis, renal failure) and mortality (0.6% vs. 1.9%) in E. chaffeensis cases [1]. A rush, as a clinical presentation, is also more frequently reported in patients with E. chaffeensis. HGA occurs in previously healthy individuals, and the disease severity is associated with the degree of compromised immunity of infected patients. The diagnosis is confirmed retrospectively using specific laboratory tests, which include positive polymerase chain reaction (PCR), identification of A. phagocytophilum in a culture of acute-phase blood, or the detection of specific antibodies to A. phagocytophilum in convalescent-phase serum samples. Doxycycline provides rapid and effective treatment.

Ambulatory blood pressure monitoring and hypertension related cardiovascular risk in patients with rheumatoid arthritis

Background: To assess hypertension related cardiovascular risk parameters in patients with rheumatoid arthritis. To determine the effect of long-term treatment with corticosteroids, non-steroid antiinflammatory drugs, and methotrexate on diurnal BP variability. Material and methods: 60 patients with clinically stable rheumatoid arthritis and treated hypertension. Casual blood pressure measurement and 24-hour ambulatory blood pressure monitoring. Results: Mean casual systolic blood pressure 139.0 ± 14.6 mmHg, diastolic blood pressure 85.7 ± 6.5 mmHg, and heart rate 74.9 ± 7.2 beats.min-1. Mean 24-hour systolic blood pressure 129.0 ± 12.7 mmHg, diastolic blood pressure 77.6 ± 7.4 mmHg, and heart rate 73.9 ± 8.7 beats.min-1. Mean casual pulse pressure 54.7 ± 15.6 mmHg, and the mean 24-hour ambulatory pulse pressure 50.1 ± 11.0 mmHg. The mean morning surge of systolic blood pressure 35.3 ± 11.00 mmHg. The number of patients with increased short-term variability of their systolic blood pressure using the coefficient of variation 30 (50%). A number of systolic nondippers in the group were treated with corticosteroids and non-steroidal anti-inflammatory drugs 34% and 35%, respectively, and a number of excessive diastolic dippers in the group were treated with methotrexate 49%. Conclusions: Certain hypertension characteristics in patients with rheumatoid arthritis can increase cardiovascular risk: Higher pulse pressure, elevated levels of morning surge of systolic blood pressure, increased short-term 24-hour blood pressure variability, higher number of systolic nondippers treated with corticosteroids and non-steroidal anti-inflammatory drugs, and excessive diastolic dippers treated with methotrexate. In addition increased heart rate may contribute to higher cardiovascular risk.