Davor Hrabar

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding

AIM To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer. METHODS Between January 2005 and December 2009, 150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed (Forrest IIa) were included in the study. Patients were randomized to receive a small-volume epinephrine group (15 to 25 mL injection group; Group 1, n = 50), a large-volume epinephrine group (30 to 40 mL injection group; Group 2, n = 50) and a hemoclip group (Group 3, n = 50). The rate of recurrent bleeding, as the primary outcome, was compared between the groups of patients included in the study. Secondary outcomes compared between the groups were primary hemostasis rate, permanent hemostasis, need for emergency surgery, 30 d mortality, bleeding-related deaths, length of hospital stay and transfusion requirements. RESULTS Initial hemostasis was obtained in all patients. The rate of early recurrent bleeding was 30% (15/50) in the small-volume epinephrine group (Group 1) and 16% (8/50) in the large-volume epinephrine group (Group 2) (P = 0.09). The rate of recurrent bleeding was 4% (2/50) in the hemoclip group (Group 3); the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution (P = 0.0005 and P = 0.045, respectively). Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups. CONCLUSION Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.

North vs south differences in acute peptic ulcer hemorrhage in Croatia: hospitalization incidence trends, clinical features, and 30-day case fatality.

Aim To assess the seven-year trends of hospitalization incidence due to acute peptic ulcer hemorrhage (APUH) and associated risk factors, and examine the differences in these trends between two regions in Croatia. Methods The study collected sociodemographic, clinical, and endoscopic data on 2204 patients with endoscopically confirmed APUH who were admitted to the Clinical Hospital Center “Sestre Milosrdnice,” Zagreb and Clinical Hospital Center Split between January 1, 2005 and December 31, 2011. We determined hospitalization incidence rates, 30-day case fatality rate, clinical outcomes, and incidence-associated factors. Results No differences were observed in APUH hospitalization incidence rates between the regions. Age-standardized one-year cumulative APUH hospitalization incidence rate calculated using the European Standard Population was significantly higher in Zagreb than in Split region (43.2/100 000 vs 29.2/100,000). A significantly higher APUH hospitalization incidence rates were observed in the above 65 years age group. Overall 30-day case fatality rate was 4.9%. Conclusion The hospitalization incidence of APUH in two populations did not change over the observational period and it was significantly higher in the Zagreb region. The incidence of acute duodenal ulcer hemorrhage also remained unchanged, whereas the incidence of acute gastric ulcer hemorrhage increased. The results of this study allow us to monitor epidemiological indicators of APUH and compare data with other countries.

Inhibition and Stimulation of Prolactin Release : Delayed Response in Duodenal Ulcer Patients

Prolactin inhibitory tests (bromocriptine in a single dose 2.5 mg orally) as well as stimulatory tests (metoclopramide in a single dose of 10 mg intravenously) were performed in 33 patients with endoscopically proven duodenal ulcer and in 32 healthy volunteers. Delayed response in inhibition of prolactin release as well as in stimulation of prolactin release was observed in duodenal ulcer patients compared to healthy volunteers (P<0.01). The results implicate the role of the dopamine-prolactin axis in the pathogenesis of duodenal ulcer disease.

Laparoscopic transhiatal resection of a large mid-esophageal diverticulum: a case report

Abstract This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk.

Candidemia after endoscopic therapy with lumen-apposing metal stent for pancreatic walled-off necrosis

Necrotizing pancreatitis remains a challenging and unpredictable condition accompanied by various complications. Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with walled-off necrosis (WON). Endoscopic therapy via lumen-apposing metal stents (LAMS) with large diameters has shown success in the management of pancreatic fluid collections, but there are few data on specific complications of that therapy. We report a case of infected WON and concomitant fungemia following LAMS placement and necrosectomy. In addition, a systematic literature review of current related studies has been provided.

Bleeding Peptic Ulcer – Tertiary Center Experience: Epidemiology, Treatment and Prognosis

The aim of this study was to demonstrate epidemiological, clinical and endoscopic characteristics of acute upper gastrointestinal bleeding (UGIB) with special reference to peptic ulcer bleeding (PUB). The study included 2198 consecutive patients referred to our emergency department due to acute UGIB from January 2008 to December 2012. All patients underwent urgent upper GI endoscopy within 24 hours of admission, and 842 patients diagnosed with PUB were enrolled and prospectively followed-up. The cumulative incidence of UGIB was 126/100,000 in the 5-year period. Two out of five patients had a bleeding peptic ulcer; in total, 440 (52.3%) had bleeding gastric ulcer, 356 (42.3%) had bleeding duodenal ulcer, 17 (2%) had both bleeding gastric and duodenal ulcers, and 29 (3.5%) patients had bleeding ulcers on gastroenteric anastomoses. PUB was more common in men. The mean patient age was 65.9 years. The majority of patients (57%) with PUB were taking agents that attenuate the cytoprotective function of gastric and duodenal mucosa. Rebleeding occurred in 77 (9.7%) patients and 47 (5.9%) patients required surgical intervention. The 30-day morality was 5.2% and 10% of patients died from uncontrolled bleeding and concomitant diseases. In conclusion, PUB is the main cause of UGIB, characterized by a significant rebleeding rate and mortality.

Abdominal Ultrasound – The Leading Method in Duodenal Gist Diagnostics

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract and are generally asymptomatic. A 39-year-old female patient was hospitalized in 2012 at Clinical Department of Internal Medicine, Sestre milosrdnice University Hospital Center, for a focal hypodense irregular circular lesion located in segment III of the left hepatic lobe, accidentally found by ultrasonography and verified by computed tomography. The findings were also verified with nuclear magnetic resonance and esophagogastroduodenoscopy. A biopsy sample of the lesion was analyzed by histologic and immunohistochemical methods and identified as GIST. The patient underwent surgical operation (tumor excision with terminoterminal anastomosis created between the second segment of duodenum and jejunum and resection of liver segment III). The histopathologic findings matched GIST with a high probability of relapse according to the localization, size, mitotic activity and Ki-67 values. Therefore, therapy with imatinib at a dose of 400 mg/day was administered. Three years after the operation, the patient is still in remission.

The Association of Chronic Inflammation and Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs)

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare and heterogeneous neoplasms with overall increasing incidence, but not an associated increase in survival rate over the past few decades. Tumors originate from at least 16 different cells of diffuse endocrine system (DES), scattered through mucosa of gastrointestinal tract. They are mainly sporadic, but sometimes exhibit familial inheritance. Tumors often preserve the ability to synthesize, store and secrete numerous hormones and biogenic amines which sometimes lead to distinct hypersecretory and clinically recognizable syndromes (such as carcinoid, Zollinger-Ellison, WDHA etc.).1 The resulting clinical symptoms are generally well controlled by somatostatin analogs and/or interferon-┙.2