Miroslav Šimunić

Use of modified multidetector CT colonography for the evaluation of acute and subacute colon obstruction caused by colorectal cancer: a feasibility study.

PURPOSE: This study was designed to evaluate the feasibility of using CT colonography with a modified procedural protocol for diagnosis and cancer staging in patients with suspected acute or subacute colon obstruction caused by colorectal cancer. METHODS: Following colonic cleansing with lukewarm water enemas, thin-collimation CT colonography was performed on 47 patients (15 women and 32 men, mean age, 68 years) in the precontrast prone position and in the supine position after the intravenous administration of a contrast agent. The surgical and pathologic findings served as a reference standard. RESULTS: In 44 of 47 patients, colon distention was caused by obstruction, and pathologic examination confirmed colorectal cancer in 41 of these 44 patients. CT colonography correctly located all tumors and successfully identified noncancerous causes of colon distention in five patients. The overall accuracy of staging was 97.6 percent for the T category, 73.2 percent for N, and 100 percent for M. Two synchronous colorectal cancers were correctly identified. CONCLUSIONS: When appropriate protocol modifications regarding colon cleansing and air insufflation are made to take the clinical situation into account, CT colonography is a technically feasible, accurate, and well-tolerated method for tumor evaluation and cancer staging in patients with acute and subacute colon obstruction.

Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings.

The Aim: To show histopathological diagnoses after colonoscopic polypectomy in the University Hospital Center (KBC) Split with recommendations on further follow-up colonoscopy depending on the endoscopic and histological findings. Patients and Methods: The study included 2842 patients who underwent colonoscopy in a two-year period (2008-2009), followed by a detailed analysis of 350 patients in which one or more polyps were simultaneously removed and 163 patients who were only sampled for histological analysis. Patients from the National Program for Colorectal Cancer Prevention and patients in which colonoscopy is indicated as part of daily outpatient or inpatient treatment were included as well. Results: During 2008 and 2009 in KBC Split, out of a total of 2842 colonoscopies, 350 patients underwent colonoscopic polypectomy, whereby 618 polyps were removed (1-8 polyps in individual patients), while in 163 patients only biopsy specimens were sampled. Out of the total of 557 polyps sent for histological analysis, 236 were hyperplastic (42%), 193 were identified as tubular adenoma (35%), 84 were tubulovillous (15%), 18 villous (3%), 9 were adenocarcinoma (2%) and other 17 (3%). In 35 (15.4%) polyps high-grade dysplasia was found. The largest number of nonpolypectomized changes confirmed the presence of adenocarcinoma (76-47%), adenomas and hyperplastic polyps were 37 (22%) and regular findings 23 (14%). Mucosal high-grade dysplasia was demonstrated in 35 (23.1%) biopsied changes. Conclusion: Colonoscopies with polypectomy decreased the risk of the formation of colorectal cancer in these patients almost to the level of risk in patients who have not even had a polyp during colonoscopy. Arguably the best method of prevention and early detection of colorectal cancer are already widely established national programs. The next qualitative level is constantly improving the quality of colonoscopy with clear criteria and the establishment of a body to evaluate the performers and the equipment, and making recommendations on the colonoscopy follow-up intervals depending on endoscopic and histopathological findings of patients who for any reason underwent colonoscopy.

The prevalence of celiac disease in patients with geographic tongue.

BACKGROUND Geographic tongue (GT) is a benign inflammatory condition usually involving the dorsal surface and lateral borders of the tongue. Numerous etiological factors of GT have been suggested, including immunological factors; genetic; atopic or allergic predisposition; emotional stress; and hormonal disturbances. GT may also coexist as one of the possible manifestations of celiac disease (CD). Therefore, the aim of this study was to investigate the prevalence of CD, positive serologic tests for CD screening, and HLA-DQ presence in patients with GT. METHODS Tissue transglutaminase antibodies (anti-tTG), antibodies against gliadin (AGA), and human leukocyte antigen (HLA) typing were assessed for 60 GT patients and 60 healthy control subjects. The duodenal biopsy was performed in patients with positive serologic tests. RESULTS We found that 9 (15%) GT patients were positive for IgA tTG, and in those patients histological changes consistent with CD were confirmed by duodenal biopsy. Only two of them reported the presence of gastrointestinal symptoms. There were statistically significant differences between the GT patients and control group for immunoglobulin (Ig) A tTG (P = 0.03), IgG tTG (P = 0.04), IgA AGA (P = 0.04), and IgG AGA (P = 0.02). CONCLUSION The results of our study demonstrated the increased prevalence of CD in patients with GT. Therefore, the clinical oral examination should be considered a diagnostic tool, especially in atypical or silent forms of CD, since it may contribute to provide an early diagnosis.

Successful endoscopic removal of a lighter swallowed 17 months before.

The majority of ingested foreign bodies will pass safely through the gastrointestinal tract, but long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation and bleeding. However, large foreign bodies which have been swallowed can remain trapped in the stomach over a longer period of time without any significant symptoms. This case report describes the case of a 36-year-old man addicted to heroin who purposefully swallowed a lighter (double wrapped in cellophane) and presented with hematemesis and melena 17 months after the ingestion of the foreign body. The lighter was successfully removed via flexible endoscopy using a polypectomy snare. Swallowed long and rigid foreign bodies trapped in the stomach over a long period of time always represent a special clinical and endoscopic challenge. In cases where endoscopic removal fails, a laparoscopic surgical approach may be an alternative.

Time trends of primary antibiotic resistance of Helicobacter pylori isolates in Southern Croatia

Helicobacter pylori infection is an important factor in the pathogenesis of chronic gastritis, peptic ulcer, gastric adenocarcinoma, and primary gastric B-cell lymphoma. The efficacy of treatment depends on the susceptibility of H. pylori to the antibiotics provided in the therapy, and the resistance of H. pylori isolates to the antibiotics causes eradication treatment failure. A clarithromycin-based eradication regimen is still recommended as the first-line therapy in European regions with low clarithromycin primary resistance. Antibiotic resistance varies greatly between countries and geographical regions and is an increasing problem worldwide. Therefore, it is important to know the local data about the primary resistance of H. pylori isolates to most commonly used antibiotics in the eradication treatment, because therapy is still often started with antibiotics chosen on an empiric basis despite current guidelines. Therefore, recent consensus conference has recommended first-line treatment based primarily on local primary resistance to clarithromycin. This paper aims to establish best practice first-line eradication therapy in the region of Southern Croatia based on the prospective monitoring of local primary antibiotic resistance. H. pylori strains were isolated from gastric mucosal biopsy specimens obtained from 345 adult patients with ulcer disease and nonulcer dyspepsia in the period of 2008–2010 in the Department of Gastroenterology, University Hospital of Split. Specimens were streaked on Columbia agar (Becton Dickinson, Cockeysville, MD, USA) with 7% horse blood and an H. pylori selective supplement (Oxoid, Basingstoke, UK). Plates were incubated for 3–7 days at 37uC in a microaerophillic atmosphere (5% O2, 10% CO2 and 85% N2). Isolates were identified by Gram staining, and positive catalase, oxidase and urease tests. The susceptibility of H. pylori isolates to amoxicillin, tetracycline, clarithromycin, levofloxacin, and metronidazole was determined by Etest (AB Biodisk, Solna, Sweden). H. pylori isolates were subcultured and Etests were performed on Columbia agar plates with 7% horse blood without a supplement. Plates were inoculated with a bacterial suspension (turbidity of 3 McFarland) and incubated at 37uC for 72 hours under the same microaerophillic atmosphere. The antibiotic breakpoints employed for the Etest were >4 mg/l for amoxicillin, >1 mg/l for clarithromycin, >8 mg/l for metronidazole, >1 mg/l for levofloksacin, and >1 mg/l for tetracycline. The Chi-squared test was used to evaluate the differences between proportions. All differences in which the probability of the null hypothesis was P,0.05 were considered statistically significant. During the survey period (January 2008–December 2010) a total of 345 adult patients were included in this study. The overall resistance of H. pylori strains to clarithromycin was 21.2% (73 strains out of 345) (Table 1). We found that the prevalence of primary clarithromycin resistance significantly decreased during study period when compared with the period of 2006–2007 (P,0.05), but it is still high and it exceeds 20% (Fig. 1). The resistance rate for metronidazole was 10.2% (37 strains out of 345) (Table 1). It was lower than in the period of 2006–2007, when it was 11.4%, the difference being not significant (P.0.05) (Fig. 1). The primary antibiotic resistance to levofloxacin is relatively low (eight strains out of 175), and now stands at 4.6% (Table 1). No isolates were resistant to amoxicillin and tetracycline in this study. Despite intensive clinical research over the last 20 years, current treatment standards for H. pylori eradication still represent a clinical challenge. In Europe, based on the Maastricht III Consensus Report, in regions with a low primary resistance of H. pylori strains to macrolides, clarithromycin-based Correspondence to: A. Tonkic, Internal Clinic, Department of Gastroenterology, University Hospital Split, Spinciceva 1, 21 000 Split, Croatia. Email: ante.tonkic@hi.htnet.hr

Posttraumatic hepatic artery pseudoaneurysm presenting as gastrointestinal bleeding

Posttraumatic hepatic artery pseudoaneurysm is a rare, but life threatening condition which should be considered in pati-ents with a history of blunt abdominal trauma who present with abdominal pain or gastrointestinal bleeding. We report a case of a patient with such a pseudoaneurysm discovered five months after a bicycle accident resulting in hepatic rupture that was treated conservatively. The patient presented with fatigue, dizziness, inability to tolerate major exertion and gastro-intestinal bleeding. After extensive diagnostic procedures, a right hepatic artery pseudoaneurysm was found. The condition was treated successfully with transcatheter coil embolization.

Acute mesenteric ischemia due to superior mesenteric artery embolism in a patient with permanent atrial fibrillation.

Acute mesenteric ischemia (AMI) is an uncommon disorder with a high mortality rate. Reduction in mortality requires a high index of suspicion and prompt diagnosis. We describe a case of AMI in a 59-year old man with a history of permanent atrial fibrillation. Pathogenesis of AMI, clinical implications, diagnostic and therapeutic options are discussed.