Tomasz Marek

Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 - 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

Multivariate Analysis of Risk Factors for Development of Duodenal Ulcer in Helicobacter pylori-Infected Patients

Background: Although Helicobacter pylori is a significant etiologic factor of peptic ulcer disease, it remains unknown why ulcers develop only in the minority of infected individuals. Aim: The aim of this cross-sectional study was to evaluate the association between the presence of duodenal ulcer in H. pylori-infected patients and different risk factors. Methods: A total of 122 H. pylori-infected patients were enrolled; 79 had duodenal ulcer and 43 gastritis. Univariate analysis was conducted using either Fisher’s exact test or exact Cochrane-Armitage trend test. In multivariate analysis the logistic model was used. Results: Univariate analysis indicated six factors (male sex, smoking, antral H. pylori density, cagA presence in antrum, and vacA s1a presence in antrum and corpus). Four factors (sex, smoking-alcohol index, H. pylori density index, and cagA index) were found to be significant in multivariate analysis. The best model predicting duodenal ulcer included male sex, smoking, presence of H. pylori on histopathology in antrum and cagA presence in corpus. Conclusion: Although several risk factors were significantly associated with duodenal ulcer, we failed in the identification of either a single risk factor or a set of factors that can unequivocally differentiate patients with ulcer from those with gastritis.

Therapeutic and prophylactic management of bleeding from oesophageal and gastric varices – recommendations of the Working Group of the National Consultant for Gastroenterology

Gastroesophageal varices are one of the most serious consequences of portal hypertension. One-third of patients with varices will develop variceal haemorrhage. Despite significant improvements in the outcomes of treatment, mortality due to bleeding from gastro-oesophageal varices still remains very high. These recommendations present optimal management of patients with non-bleeding and bleeding varices.

Serum and Bile Insulin-Like Growth Factor I, Interleukin-6 and Tumor M2- Pyruvate Kinase in Differentiation Malignant from Benign Biliary Strictures - Preliminary Report

Objective: To determine the value of serum and bile insulin-like growth factor I (IGF-I), interleukin-6 (Il-6) and tumor M2-pyruvate kinase (Tu M2-PK) in distinguishing pancreatobiliary cancers from benign biliary strictures. Material and methods: The study was performed prospectively on forty jaundiced patients admitted for biliary decompression due to bile duct strictures. Malignant strictures were diagnosed in 22 patients including 15 cases of CCA and 7 cases of pancreatic cancer, and benign biliary strictures in 18 cases. IGF-I, Il-6 and Tu M2-PK were measured in sera and bile by ELISA and compared to serum levels of carbohydrate antigens (CA) 19-9 and carcinoembryonic antigen (CEA). Results: Serum levels of IGF-I (74.4 vs. 117.0 ng/mL, p=0.03), Il-6 (37.1 vs. 17.0 pg/mL, p=0.04), CA19-9 (5689 vs. 38.9 U/mL, p<0.001) and CEA (27.5 vs. 1.9 ng/mL, p<0.0001) differed significantly between patients with malignant and benign biliary strictures, whereas biliary concentrations of IGF-I and Il-6 and serum and biliary levels of Tu M2-PK were comparable. Biliary IGF-I levels were significantly increased in pancreatic cancer as compared to cholangiocarcinoma and benign biliary strictures groups (966 vs. 137 ng/mL, p=0.03 and 966 vs. 90.6 ng/mL, p=0.01, respectively). The AUC-ROCs for serum IGF-I and serum Il-6 were 0.336 and 0.606, respectively, what was worse than that of CA 19-9 (0.855) and CEA (0.794). Conclusion: Measurement of serum IGF-I and Il-6 may be helpful in differentiation malignant from benign biliary strictures and biliary IGF-I seems to be a promising marker for distinguishing pancreatic cancer from cholangiocarcinoma and benign biliary occlusions.

Comparison of patency and cost-effectiveness of self-expandable metal and plastic stents used for malignant biliary strictures: a Polish single-center study.

Introduction Most patients with malignant biliary obstruction are suited only for palliation by endoscopic drainage with plastic stents (PS) or self-expandable metal stents (SEMS). Objective To compare the clinical outcome and costs of biliary stenting with SEMS and PS in patients with malignant biliary strictures. Patients and methods A total of 114 patients with malignant jaundice who underwent 376 endoscopic retrograde biliary drainage (ERBD) were studied. Results ERBD with the placement of PS was performed in 80 patients, with one-step SEMS in 20 patients and two-step SEMS in 14 patients. Significantly fewer ERBD interventions were performed in patients with one-step SEMS than PS or the two-step SEMS technique (2.0±1.12 vs. 3.1±1.7 or 5.7±2.1, respectively, P<0.0001). The median hospitalization duration per procedure was similar for the three groups of patients. The patients’ survival time was the longest in the two-step SEMS group in comparison with the one-step SEMS and PS groups (596±270 vs. 276±141 or 208±219 days, P<0.001). Overall median time to recurrent biliary obstruction was 89.3±159 days for PS and 120.6±101 days for SEMS (P=0.01). The total cost of hospitalization with ERBD was higher for two-step SEMS than for one-step SEMS or PS (1448±312, 1152±135 and 977±156&OV0556;, P<0.0001). However, the estimated annual cost of medical care for one-step SEMS was higher than that for the two-step SEMS or PS groups (4618, 4079, and 3995&OV0556;, respectively). Conclusion Biliary decompression by SEMS is associated with longer patency and reduced number of auxiliary procedures; however, repeated PS insertions still remain the most cost-effective strategy.

Methotrexate in the treatment of inflammatory bowel disease

Leczenie immunosupresyjne w nieswoistych chorobach zapalnych jelit (NChZJ) jest istotną, a często najważniejszą składową terapii. Glikokortykosteroidy ze względu na działania niepożądane nie powinny być stosowane przewlekle, a poza tym u części chorych nie są skuteczne. Kolejną grupą leków immunosupresyjnych są analogi puryn (azatiopryna i 6-merkaptopuryna) – podstawowe leki u większości osób z chorobą Leśniowskiego-Crohna oraz u chorych z wrzodziejącym zapaleniem jelita grubego, z postacią steroidozależną lub steroidooporną tej choroby. U ok. 20% chorych leki te nie są jednak skuteczne, a u podobnego odsetka występują działania niepożądane prowadzące do ich odstawienia. U chorych tych zwykle rozważa się leczenie biologiczne lub chirurgiczne, rzadko bierze się pod uwagę trzecią opcję leczenia immunosupresyjnego – terapię metotreksatem. Lek ten, dość szeroko stosowany od wielu lat w ciężkich postaciach reumatoidalnego zapalenia stawów i łuszczycy, w gastroenterologii wykorzystuje się stosunkowo rzadko. W niniejszym opracowaniu omówiono mechanizmy działania, dawkowanie i bezpieczeństwo leku oraz przedstawiono dotychczasowe jego zastosowania u osób z NChZJ. Abstract