Neven Franjić

Transient elastography (FibroScan(®)) with controlled attenuation parameter in the assessment of liver steatosis and fibrosis in patients with nonalcoholic fatty liver disease - Where do we stand?

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Currently, the routinely used modalities are unable to adequately determine the levels of steatosis and fibrosis (laboratory tests and ultrasonography) or cannot be applied as a screening procedure (liver biopsy). Among the non-invasive tests, transient elastography (FibroScan(®), TE) with controlled attenuation parameter (CAP) has demonstrated good accuracy in quantifying the levels of liver steatosis and fibrosis in patients with NAFLD, the factors associated with the diagnosis and NAFLD progression. The method is fast, reliable and reproducible, with good intra- and interobserver levels of agreement, thus allowing for population-wide screening and disease follow-up. The initial inability of the procedure to accurately determine fibrosis and steatosis in obese patients has been addressed with the development of the obese-specific XL probe. TE with CAP is a viable alternative to ultrasonography, both as an initial assessment and during follow-up of patients with NAFLD. Its ability to exclude patients with advanced fibrosis may be used to identify low-risk NAFLD patients in whom liver biopsy is not needed, therefore reducing the risk of complications and the financial costs.

Factors associated with significant liver steatosis and fibrosis as assessed by transient elastography in patients with one or more components of the metabolic syndrome

BACKGROUND/AIMS We examined the relationship between controlled attenuation parameter (CAP) and liver stiffness measurements (LSM), as assessed by transient elastography (TE), and different clinical and biochemical parameters in patients with one or more components of the metabolic syndrome (MetS). The hypothesis of the study was that LSM and CAP values correlate with the number of MetS components. METHODS In this cross-sectional study a total of 648 consecutive patients were recruited during the years 2013-2015. Significant liver steatosis was defined as a CAP value≥238dB/m, whereas significant fibrosis was defined as an LSM value>7.0 kPa. RESULTS The prevalences of patients with CAP≥238dB/m and LSM>7.0 kPa were 88.3% and 16.5%, respectively. Patients with CAP≥238dB/m (n=572) had a markedly higher prevalence of the MetS and all its individual components, as well as higher levels of serum liver enzymes and uric acid compared with those with normal CAP. Moreover, CAP measurements increased progressively with the number of MetS components. Similarly, among patients with CAP≥238dB/m, those with LSM>7.0 kPa (n=103) had higher serum liver enzymes and a greater prevalence of the MetS and its individual components than those with LSM≤7.0 kPa. In multivariable regression analysis the factors independently associated with elevated CAP were the presence of the MetS (or its individual components), insulin resistance (defined by HOMA-IR score), increased serum uric acid and LSM>7 kPa. Similarly, the MetS (or its individual components), insulin resistance and increased serum uric acid levels were also independently associated with LSM>7.0 kPa. CONCLUSIONS Patients with one or more MetS components have a high prevalence of NAFLD and advanced liver fibrosis. LSM and CAP correlate with the number of MetS components.

Metabolic syndrome and acute pancreatitis

AIM The aim of our study was to investigate the influence of metabolic syndrome on the course of acute pancreatitis determined by disease severity, the presence of local and systemic complications and survival rate. PATIENTS AND METHODS 609 patients admitted to our hospital in the period from January 1, 2008 up to June 31, 2015 with the diagnosis of acute pancreatitis were analyzed. The diagnosis and the severity of acute pancreatitis were made according to the revised Atlanta classification criteria from 2012. RESULTS Of 609 patients with acute pancreatitis, 110 fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome had statistically significantly higher incidence of moderately severe (38.2% vs. 28.5%; p=0.05) and severe (22.7% vs. 12.8%; p=0.01) acute pancreatitis in comparison to those without metabolic syndrome, while patients without metabolic syndrome had higher incidence of mild acute pancreatitis in comparison to those patients with metabolic syndrome (58.7% vs. 39.1%; p<0.001). Patients with metabolic syndrome had a higher number of local and systemic complications, and higher APACHE II score in comparison to patients without metabolic syndrome. In multivariable logistic regression analysis, the presence of metabolic syndrome was independently associated with moderately severe and severe acute pancreatitis. Comparing survival rates, patients suffering from metabolic syndrome had a higher death rate compared to patients without metabolic syndrome (16% vs. 4.5%; p<0.001). CONCLUSION The presence of metabolic syndrome at admission portends a higher risk of moderately severe and severe acute pancreatitis, as well as higher mortality rate.

Stomach - Key Player in the Regulation of Metabolism

Although the stomach is often perceived as a crude, food-grinding, muscular bag, scientific breakthroughs have shown us that in the case of the stomach there is more than meets the eye. The endocrine function of the stomach is mainly exerted through the actions of ghrelin, an acylated peptide hormone that is the first known and so far most extensively studied endogenous orexigenic substance. The satiety-hunger balance is kept in check by many anorexigenic gut hormones among which is the deacylated form of ghrelin - desacyl ghrelin. The interplay of gut hormones affects the brain directly, as most gut hormones cross the blood-brain barrier and bind to their respective receptors in the central nervous system. Other hormones like obestatin and nesfatin are secreted from the stomach along with ghrelin, yet their physiological function is to be elucidated. The importance of the satiety-hunger balance can be seen in its most typical derangement - obesity. Some studies imply that ghrelin, along with other gut hormones, plays an important part in the pathophysiology of obesity. More importantly, it seems that the mechanisms by which bariatric surgery procedures induce weight loss are primarily based on changing the gut hormone levels, including ghrelin. If proven, ghrelin antagonists could be the renaissance of pharmacological obesity treatment.

Obesity and acute pancreatitis

Evidence accumulated for the past two decades leads to the conclusion that obesity enhances the development of acute pancreatitis and worsens its clin

Thoracic aortic aneurysm rupture into the esophagus.

A 73-year-old female with a history of mild hematemesis was transported to the hospital emergency department. Although she was under the influence of alcohol, the patient remained alert. She had hypotension (100/60 mmHg) and anemia (red cell count 2.80 9 10/L; hemoglobin 86 g/L; hematocrit 0.265 L/L). A digital rectal examination performed after admission revealed black, formed stool. She had medical comorbidities of choleithiasis and a history of alcohol abuse. An emergency upper digestive endoscopy was performed immediately, which showed blood clots and fresh blood in the stomach. There was a protrusion near the gastro-esophageal junction but, despite intensive examination, the immediate place of bleeding could not be identified. As the exact site of bleeding was undeterminable diluted adrenaline was injected into the suspected area of hemorrhage at the fundus of the stomach. The patient was transferred to the intensive care unit where intravenous fluids and a blood transfusion were administered. The patient became stable upon aggressive fluid administration and a surgeon was requested for consultation. The surgeon advised the hospital staff caring for the patient to continue with the conservative therapy course (that included frequent monitoring of hemodynamic parameters) until the exact bleeding site could be identified. However, a few hours after admission the patient started to vomit blood vigorously and became hypotensive. A diagnosis of thoracic aortic aneurysm (TAA) with esophageal fistula was made. Emergency surgical treatment was ordered. The patient was transferred to the operating room, where she collapsed and became unconscious and asystolic. She died one hour later despite critical life support measures. Although a complaint of medical negligence was not raised in this case, an autopsy was performed in accordance with Croatian law, which requires that all patients who die within 24 h of hospital admission have to be examined by a certified pathologist. The autopsy revealed a large spherical aneurysm, 5 cm in diameter, of the descending thoracic aorta; 1.5 cm below the tracheal bifurcation (Fig. 1). Rupture into the esophagus was observed, with an aorto-esophageal fistula (AEF) around 2 cm in diameter (Fig. 1). On the aortic side of the fistula, the opening was covered with laminated thrombus that was firm on palpation. The rest of the intima of the thoracic and abdominal aorta did not exhibit severe atherosclerotic changes. The stomach was completely filled with blood and clots (about 800 mL); with bloody and tarry contents in the intestines. Tissue histology around the fistula (the aortic and esophageal wall) showed hemorrhage, inflammation and fibrosis. The aortic wall was severely infiltrated with neutrophils around the rupture site (Fig. 2). The laminated thrombus appeared to have acted as a lid covering the fistula opening. There was no histological evidence of cystic medial degeneration in the aortic wall. No significant pathology was observed in any other organs.

Acid Inhibition and Peptic Ulcer Bleeding

Peptic ulcer bleeding is one of the most common emergency situations in medicine. Combined pharmacological and endoscopic therapy together with emerging interventional radiological procedures are successfully treating peptic ulcer disease, reserving surgical procedures for only a small portion of patients unresponsive to ‘conventional’ therapy. Technological advancement has seen a great improvement in the field of endoscopic treatment in the form of various methods of hemostasis. However, pharmacological therapy with proton pump inhibitors still plays the central role in the peptic ulcer bleeding treatment algorithm.

Personalized Medicine in Gastroenterology

Personalized medicine systematically uses all available information about a patient, including his/her molecular make-up, in order to optimize preventive, diagnostic, and/or therapeutic measures. In gastroenterology, it is mainly applied for managing inflammatory bowel diseases (therapeutic approach, drug toxicity), gastrointestinal malignancies (development of biomarkers of early recognition, therapy optimization), viral hepatitis (markers of response to therapy, optimization of therapy), H. pylori associated diseases (virulency, tendency to develop certain complications, response to therapy), and many other diseases. Despite the anticipated financial and ethical obstacles, personalized medicine offers the possibility of more precise diagnostics, more accurate therapy, and better prevention, which will in turn result in better long-term treatment outcomes.

Mean platelet volume (MPV) as prognostic factor in acute pancreatitis (AP)

Introduction: Mean platelet volume (MPV) is a machine-calculated measurement of the average size of platelets and is typically included in blood tests as part of the complete blood count. Vascular thrombosis and systemic hypercoagulable states are well documented complications of acute pancreatitis (AP). Higher values of MPV have been associated with thrombotic disorders. According to the literature, only few studies have investigated the association between AP and MPV. Objectives: To determine whether the value of MPV at admission correlates with the occurrence of local and systemic complications of AP ; lethal outcomes ; and severe form of AP, according to modified Atlanta criteria. Patients and methods: 53 patients (35 male and 18 female) were enrolled in this retrospective study. MPV values were obtained on an automated hematology analyzer (Olympus AU 640, Tokio, Japan). Student’s t-test was used for statistical analysis. Results: There were no statistically significant differences in the average values of MPV regarding local complications (7.51±0.99 vs. 7.91±1.24, p=0.22), systemic complications (7.60±1.05 vs. 7.72±1.22, p=0.76), severe form of AP (7.47±0.97 vs. 7.94±1.22, p=0.13) or lethal outcomes (7.58±1.03 vs. 7.97±1.38, p=0.41). Conclusion: Our study did not confirm the value of MPV in predicting complications in the course of AP.

The relation of metabolic syndrome with complications in acute pancreatitis

U retrospektivnoj studiji s pacijentima koji boluju od akutnog pankreatitisa dokazana je veca ucestalost težih oblika bolesti i sistemskih komplikacija u osoba s metabolickim sindromom u odnosu na one bez.