Ivan Jovanovic

Complications of Peptic Ulcer Disease

There are four major complications of peptic ulcer disease (PUD): bleeding, perforation, penetration, and obstruction. Complications can occur in patients with peptic ulcer of any etiology. Despite improvements in the medical management and the lower overall incidence of PUD, there are conflicting data about the incidence of potentially life-threatening ulcer complications. There are important time trends embedded within this stable overall rate of complications: the dramatic decline in the prevalence of Helicobacter pylori (comparing the cohort born from 1900 to 1920 to cohorts born after 1940); an increased use of nonsteroidal anti-inflammatory drugs, and an increased rate of ulcer complications related to such drug use, especially in the elderly. As a result of these trends, ulcer complications are on the rise in older patients but on the decline in younger individuals. Hemorrhage is the most frequent PUD complication and its incidence is increasing in comparison to perforation and stenosis. Therapeutic endoscopy is considered the treatment of choice for bleeding ulcers, reducing the need for emergent surgical procedures to 10–20% of the cases. In recent years, besides the success of angiographic embolization, the containment of massive hemorrhage must also be taken into account. Transcatheter arterial embolization is also an effective and safe treatment in patients with duodenal ulcers re-bleeding after therapeutic endoscopy or surgery.

Multi-criteria ranking of copper concentrates according to their quality – An element of environmental management in the vicinity of copper – Smelting complex in Bor, Serbia

The results of multi-criteria ranking of copper concentrates by their quality, according to their content of useful and harmful components, are presented in this paper. Cu, Ag and Au were taken as useful components, while Pb, Zn, As, Cd, Hg, Bi and Sb were considered as harmful with adequate weight parameters. Considering its specific role in copper metallurgy, sulfur in the concentrate was considered in two scenarios. In the first scenario S was considered as a useful and in the other one as a harmful component. The ranking is done by implementing the PROMETHEE/GAIA method with an additional implementation of the special PROMETHEE V method, using the standard limitations of the heavy metals content in the concentrate. In this way, it is possible to perform an optimization of the input charge for the copper extraction from two aspects. The first aspect covers benefits from the content of useful metals, while the second deals with the protection of the environment, considering the content of harmful components of the charge. Using multi-criteria decision making for the sake of ranking the quality of copper concentrates, as described in this paper, could be considered as a contribution to the methodology of forming the market price of this product.

Advanced Endoscopic Imaging Methods for Colon Neoplasia

The main goal of lumenal endoscopic visualization of the colon is to detect mucosal pathologies, which when removed will result in cure or palliation of a disease process. Whereas traditionally endoscopic imaging was performed with fiber-optic technology, currently there are many new methods that improve our visual acuity when evaluating the colon mucosa. Most of these methods are collectively called ‘advanced colonic imaging’. The 2 main aims of standard (white light) and advanced colonic imaging are to enhance the superficial mucosal detail (i.e. ‘pit pattern’) and allow a detailed view of the submucosal capillary pattern, thus potentially improving the detection characterization of pathological lesions. However, the current literature dealing with most methods used for advanced endoscopic imaging of the colon is fraught with many controversial findings which have resulted in opposing views regarding its utility. Whereas some investigators vehemently support the use of most of these methods in routine clinical practice, most experts and practicing endoscopists still refuse to accept that these methods aid in the clinical routine. For now, white light video-colonoscopy and high-definition white light video-colonoscopy will remain the standard endoscopic methods for investigating the colon mucosa until new methods convincingly and clearly prove their superiority over white light endoscopy.

Therapeutic Double-Balloon Enteroscopy: A Binational, Three-Center Experience

Background/Aims: There are few reports focusing on therapeutic small bowel endoscopy. The aim of this study was to analyze the results of therapeutic small bowel endoscopy in a large cohort of patients. Methods: A retrospective study of a prospectively collected database comprising all patients undergoing diagnostic and therapeutic small bowel endoscopy in three centers. Results: A total of 614 double-balloon enteroscopies were performed in 534 patients. The most common pathological findings were angiodysplasias and vascular lesions (n = 98, 18%), mucosal ulcers and erosions (n = 95, 17.8%), polyps and tumors (including patients with familiar polyposis syndrome such as Peutz-Jeghers syndrome, familiar adenomatous polyps syndrome, neurofibromatosis, adenocarcinoma, neuroendocrine tumors and gastrointestinal stromal tumors) (n = 52, 9.7%), and strictures (Crohn’s disease, ischemia, tumors) (n = 12, 2.2%). The mean duration of therapeutic small bowel enteroscopy was 67 min (range 30–115) compared to 50 min (range 25–105) for diagnostic procedures (p < 0.05). A therapeutic small bowel endoscopy was performed in 121 patients (22%). Therapeutic procedures included argon plasma coagulation of vascular lesions (n = 73), polypectomy (n = 49), mucosectomy (n = 5), stricture dilation (n = 7), foreign body extraction (n = 7), injection of fibrin glue (n = 10), and clip placement (n = 5). There were a total of 5 complications (0.9%; paralytic ileus, n = 2, pancreatitis, n = 1, bleeding n = 2). No perforations or deaths occurred. Conclusion: Endoscopists performing double-balloon enteroscopy should be trained and prepared to provide therapeutic interventions for small bowel disorders including argon plasma coagulation, injection, hemoclipping, polypectomy, mucosectomy and foreign body extraction. Therapeutic small bowel endoscopy, albeit associated with complications in about 1% of cases, can be considered a relatively safe procedure.

Extraintestinal Manifestations of Autoimmune Pancreatitis

The term autoimmune pancreatitis (AIP) was first used in Japan in 1995 to describe a newly recognized form of chronic pancreatitis, after the description of Yoshida and colleagues. But Sarles in 1961, first described a form of idiopathic chronic inflammatory sclerosis of the pancreas, suspected to be due to an autoimmune process. AIP has become a widely accepted term because clinical, serologic, histologic, and immunohistochemical findings suggest an autoimmune mechanism. Most affected patients have hypergammaglobulinemia and increased serum levels of IgG, particularly IgG4. Recently published International Consensus Diagnostic Criteria for Autoimmune Pancreatitis include Guidelines of the International Association of Pancreatology, classifying AIP into types 1 and 2, using five cardinal features of AIP, namely imaging of pancreatic parenchyma and duct, serology, other organ involvement, pancreatic histology, and an optional criterion of response to steroid therapy. Extrapancreatic presentations can include sclerosing cholangitis, retroperitoneal fibrosis, sclerosing sialadenitis (Küttner tumor), lymphadenopathy, nephritis, and interstitial pneumonia. Increased IgG4+ plasma cell infiltrate has been reported in sclerosing lesions from other organ sites, including inflammatory pseudotumors of the liver, breast, mediastinum, orbit, and aorta, and it has been observed with hypophysitis and IgG4-associated prostatitis. Abundant IgG4+ plasma cells were also confirmed in Riedel thyroiditis, sclerosing mesenteritis, and inflammatory pseudotumor of the orbit and stomach. Extrapancreatic lesions could be synchronously or metachronously diagnosed with AIP, sharing the same pathological conditions, showing also a favorable result to corticosteroid therapy and distinct differentiation between IgG4-related diseases from the inherent lesions of the corresponding organs.

Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: A practical classification.

AIM To study the endoscopic and radiological characteristics of patients with hepaticojejunostomy (HJ) and propose a practical HJ stricture classification. METHODS In a retrospective observational study, a balloon-assisted enteroscopy (BAE)-endoscopic retrograde cholangiography was performed 44 times in 32 patients with surgically-altered gastrointestinal (GI) anatomy. BAE-endoscopic retrograde cholangio pancreatography (ERCP) was performed 23 times in 18 patients with HJ. The HJ was carefully studied with the endoscope and using cholangiography. RESULTS The authors observed that the hepaticojejunostomies have characteristics that may allow these to be classified based on endoscopic and cholangiographic appearances: the HJ orifice aspect may appear as small (type A) or large (type B) and the stricture may be short (type 1), long (type 2) and type 3, intrahepatic biliary strictures not associated with anastomotic stenosis. In total, 7 patients had type A1, 4 patients A2, one patient had B1, one patient had B (large orifice without stenosis) and one patient had type B3. CONCLUSION This practical classification allows for an accurate initial assessment of the HJ, thus potentially allowing for adequate therapeutic planning, as the shape, length and complexity of the HJ and biliary tree choice may mandate the type of diagnostic and therapeutic accessories to be used. Of additional importance, a standardized classification may allow for better comparison of studies of patients undergoing BAE-ERCP in the setting of altered upper GI anatomy.

Classification of Chronic Pancreatitis

Chronic pancreatitis (CP), defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphological changes which typically cause abdominal pain and/or permanent impairment of pancreatic function, has proved resistant to categorization. The disease may present clinically either with an individual symptom or a combination of symptoms associated with loss of pancreatic function. The single most frequent symptom of CP is pain, either in the form of intermittent episodes or in a more chronic or persistent pattern. The natural history of CP is usually characterized by progression of tissue damage and various degrees of exocrine and endocrine pancreatic insufficiency, which will become apparent over time. The main reason for the lack of guided strategies in the therapeutic management of CP is the absence of a clinically applicable classification of CP. In the past, several classifications have certainly contributed to a better understanding of the pathogenesis and pathophysiology of CP. The meetings in Marseilles (1963 and 1984), Cambridge (1984) and in Rome (1985) added a great deal of information to our knowledge of the pathogenesis and evolution of CP. More recent work on understanding the temporal course of CP led to the Zurich international classification which has been used to define patient cohorts in recent studies of patients undergoing surgery for CP. In order to combine clinical experience in the field of CP with progress in diagnostic methods and new molecular technologies for the assessment of CP, a classification of CP based on key clinical aspects is crucial. A new classification should first be validated to determine whether it can be applied to the majority of patients with CP, and then the value of such a classification needs to be tested in our understanding of the natural course in different etiologies (progression, arrest, regression) and most importantly, to study the clinical outcome when different therapeutic strategies are applied.

Cystic Dystrophy in Heterotopic Pancreas of the Duodenal Wall

Background: Cystic dystrophy in heterotopic pancreas (CDHP) is a rare condition. It has been recently reported as one of the etiologic obstructive factors of chronic pancreatitis. The aim of our study was to evaluate diagnosis and management of CDHP in the duodenal wall in a surgical series. Methods: We retrospectively reviewed 13 patients with available clinical data. Results: There were 11 male and 2 female patients, median age 42 years. The average duration of symptoms was 7.5 months. 6 of them (46%) were alcoholics, and 10 (75%) had signs of chronic pancreatitis. Almost all of them (12/13; 92%) revealed disabling pain, while 4 (31%) had associated jaundice. In 4 of 7 patients (57%), weight loss was observed. Most often the patients were suspected of having pancreatic head mass with or without signs of chronic pancreatitis. All patients underwent surgical treatment. Pathological examination showed the presence of cysts surrounded by inflammation and fibrosis in the duodenal wall, as well as the presence of chronic pancreatitis in the pancreas proper. Conclusions: Cystic dystrophy of the duodenal wall represents a significant proportion of patients undergoing surgery for chronic pancreatitis. Pancreatoduodenectomy is the best therapeutic option.

CXCL16 haplotypes in patients with human carotid atherosclerosis: preliminary results.

AIM Chemokine CXC ligand 16 (CXCL16) has chemoattractive, adhesive and scavenging properties and may play a role in the formation of atherosclerotic lesions. However, studies of CXCL16 polymorphisms in patients with atherosclerosis are scarce. The missense polymorphisms I123T and A181V are potentially important factors in the regulation of presentation and shedding of the CXCL16 chemokine domain. The aim of this study was to analyze the association between I123T and A181V polymorphism haplotypes and the accumulation of carotid plaque as well as the effect of the haplotype on the CXCL16 mRNA expression in carotid plaques in patients with advanced atherosclerosis. Additionally, we performed a bioinformatic prediction analysis of the impact of CXCL16 protein sequence variation on CXCL16-CXCR6 interactions and analyzed the soluble CXCL16 plasma levels according to the CXCL16 haplotype. METHODS This study evaluated a total of 733 participants, including 283 controls and 450 patients with carotid atherosclerosis (CA) undergoing endarterectomy. Analyses of the polymorphisms and the gene expression were performed using real-time PCR. The soluble CXCL16 levels were measured with ELISA. RESULTS The missense allele haplotype, T123V181, was found to be significantly and independently associated with the occurrence of CA plaque (OR=1.27;1.02-1.57, p=0.03). This haplotype was predicted to significantly change the CXCL16-CXCR6 interaction, compared to I123A181. Neither the CXCL16 mRNA expression in the human plaques nor the soluble CXCL16 plasma levels differed according to the haplotype. CONCLUSIONS These results indicate that the CXCL16 T123V181 haplotype is a moderate genetic risk factor for the development of carotid plaque. Further functional and replication studies are needed to clarify the mechanisms by which this combination of alleles promotes advanced CA and validate its impact on disease progression.

Episodes of extremely high concentrations of SO2 and particulate matter in the urban environment of Bor, Serbia.

This paper presents the extremely high concentrations of SO2 and particulate matter measured in the urban area of the town Bor (Serbia) during August 2011. Concentrations of SO2 above 125 μg m(-3) and concentrations of particulate matter above 200 μg m(-3) recorded over several days indicate significant risk to human health and the ecosystem in this region.