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N 1 AUGUST 1999
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BULGARIAN JOURNAL OF HEPATOGASTROENTEROLOGY 1999;1,N1: 4-7
Barrett?s Esophagus - Diagnostic And Surveillance Problems
Atanassova M.,I. Kotzev ,B.Manevska*, M.Stam-bolijska, E.Kantchev*A.Klisarova**, K.Zonev **
Clinic of Gastroenterology; Department of General and Clinical Pathology*;Department of Radiology**
Medical University ? Varna
The columnar replacement of squamous epithelium in the lower esophagus, named Barrett?s esophagus(BE), is a result of chronic gastroesophageal reflux(GER).The lesion is associated with an increased incidence of adenocarcinoma(AC),ulcers(U) and strictures(S) of the esophagus,which determines the necessity of early diagnosis, surveillance and treatment in order to eradicate the BE.
AIMS: To study the prevalence and clinical, endoscopic,cyto- and histological, scintigraphic and radiological findings in cases of BE, diagnosed for 11 years period in the University Clinic of Gastroenterology.
METHODS: From 1987-1998 92 cases of BE have been evaluated morphologically on endoscopic biopsies.A 5 years follow-up study was performed in 48 of them.The patients were investigated by upper endoscopy,videoendoscopy,forceps-and brush biopsy for standart morphology and for staining methods with alcian blue / periodic acid Schiff, cell - DNA content analysis with the CAS-100 system,Tc-99m scintigra-phy,barium pharmacoradiography.
RESULTS:The 92 cases of BE are 0,6% from all upper endoscopies for this period(15000) and 10,5% from the cases of GER(875).The mean age is 51,8+-10,male-49,female-43. The clinical symptoms were nonspecific.The most common endoscopycall picture was that of a polipoid elevated "salmon red" mucosa(48,2%).Histologically different mucosal type of BE was observed: in 44 pts(47,8%) - junctional, in 39(42,3%) - fundic and in 9(9,8%) - intestinal.In 50 cases (60,2%) with junctional and fundic type BE focal intestinal metaplasia was found.
The character of mucus secretion was type ||B byJass.Dysplasia in BE was found in 45 pts(48,9%),AC in17(18,4%).During the 5 years follow-up period 1(2%) developed esophageal AC and in 5 pts(10,4%) the grade of dysplasia worsend.The cell - DNA content analysis showed >10%S-phase fractions.
This high proliferative activity did not decrease after a long time PPI treatment.U was found in pts(7,6%),S-in15(16,3%).Tc-99m scintigraphy in 15 pts with BE showed a good mapping of the metaplasia and her size and could be benefitial in the complex diagnostical procedurs. Focal defects in the esophageal contour and limited distensibility of the esophageal wall were found on barium study in BE.
Key words : Barrett?s Esophagus, diagnosis, surveillance
BULGARIAN JOURNAL OF HEPATOGASTRO-ENTEROLOGY 1999;1,N1: 8-12
Expression of the interferon induced Mx A protein in the liver of patients with chronic viral liver diseases
Milen Vassilev, Krassimir Antonov, Ivan Michailov* , Zachariy Krastev
Clinic of Gastroenterology & *Department of Pathology Medical University, Sofia
Background: In humans the MxA protein confers the natural resistance against several RNA viruses and is regulated by type I interferons. In acute hepatitis B and C, the Mx A content of the PBMC is significantly lower as compared to acute hepatitis A. In chronic hepatitis B with high levels of HBV replication, the ability of the exogenous interferon to induce Mx A in PBMC is suppressed.
AIM: To study whether the endogenous type I interferons reach the hepatocytes and induce in them Mx A protein during chronic viral hepatitis B and C with ongoing replication.
Material&Methods: We developed an immunohistochemical technique for the detection of Mx A protein in liver tissue and compared the expression of Mx A protein in the liver biopsy form patients without viral infection (n=10) and with chronic hepatitis B(n=16) and C(n=20).
Results: The results are presented in the following table.
Mx A expression in: control HBV HCV chronic hepatitis
(* Fisher exact P< 0.01) group infection infection CPH CAH LC
(n=10) (n=16) (n=20) (n=5) (n=19) (n=8)
hepatocytes as:
- large graunular 10 5* 9* 4 6* 2*
- fine granular 1 14* 18* 5 16* 8*
- periportal areas 2 11* 17* 5 14* 8*
sinusoidal & Kupffer cells 5 6 3 1 7 1
biliary cells 1 8* 8* 1 14* 3
portal infiltrate 0 12* 18* 5 17* 8
Conclusion: In chronic viral hepatitis there was an increase of the fine granular expression of Mx A protein in the hepatocytes, mainly periportal and in the portal infiltrate. This correlated with the histological activity and the presence of liver cirrhosis. These findings suggest a role of the type I interferons in the pathogenesis of the advanced liver disease.
BULGARIAN JOURNAL OF HEPATOGASTRO-ENTEROLOGY 1999;1,N1: 13-16
Incidence and Ultrasonographic Characteristics Of Spleen Lesions
Gr.Mechkov,R.Balabanska, R.Tzonev - Internal Medicine Clinic - Fifth City Clinical Hospital - Sofia
The aim of the study is to evaluate the incidence of the spleen lesions and the importance of their ultrasonographic characteristic for prompt and correct clinical diagnosis.
For a period of 4 years 14138 abdominal ultrasound studies were performed and spleen lesions have been detected in 56 patients. The highest incidence is of calcificates in the spleen ( characteristic findings of "sky with stars" ) after malaria, tuberculosis or long-standing venous congestion accompanying portal hypertension - 42 patients. There have been 3 cases of lymphoma infiltration ( hypoechogenic lesions), 2 cases of subcapsular hematoma following trauma, 2 cases of splenic infarction, ans 1 case of echinoccoccus with "daughter bubbles" the parasitic disease involving no other organ. Metastatic spleen lesions are detected only in 2 cases - the first being Malignant melanoma with multiple metastases in the liver and spleen, and the second a female patient with carcinoma of the ovari. One case with enlarged spotty spleen was associated with myelo-fibrosis,and another the lesions in the liver and spleen were associated with pituitary tumor with acromegaly and histologic findings of liver APUD`oma, 2 cases of hyperechogenic spleen lesions ( hemangiomas?) remained undiagnosed.
Spleen lesions are rarely encountered, but their ultrasonographic detection is an alarming symptom demanding urgent diagnosis and therapeutic plan - conservative or surgical manag-ment.Provided a precise diagnosis is needed, correct interpretation of the ultrasonographic findings is of utmost importance.
BULGARIAN JOURNAL OF HEPATOGASTRO-ENTEROLOGY 1999;1,N1: 17-20
Evaluation Of Portal Circulation By Per-Rectal Portal Scintigraphy With Technetium-99M Pertechnetate
P.Akrabova , V.Stanchev , I.Stanchev
Departments of Gastroenterology and Nuclear Medicine
High Medical Institute , Plovdiv
AIMS
The aim of the study is to asses the diagnostic possibility of a modified method for per-rectal scintigraphy with technetium-99m Pertechnetate for quantitative evaluation of disorders in portal circulation in patients with chronic liver diseases.
METHODOLOGY
Per-rectal scintigraphy was applied to 32 patients-21 with chronic liver diseases and 11 as a control group without a liver damage. A solution containing technetium-99m pertechnetat was instilled into the rectum and serial scintigrams were taken for 4 min. The detector of the camera (DIACAM, Siemens) was positioned over the patient?s abdomen so that the field of view would include the heart and the liver.
The time-activity curves for the heart and the liver were analysed.By quantitative assessment of the curves the portal systemic shunt index (SI) was calculated:the relation of the heart activity over the sum of heart and liver activities for a period of 20 sec., expressed as %.
RESULTS:
The mean SI in the control group was 3.84%. In patients with chronic liver diseases the mean SI was significantly higher - 64.23% where there was cirrhosis with portal hypertension while in those with chronic liver diseases without portal hypertension the mean SI was 7.42%.
CONCLUSIONS:
Per-rectal portal scintigraphy with technetium-99m pertechnetate is clinically useful for evaluation of portal hypertension in patients with liver cirrhosis. The method is noninvasive, simple and with low cost.
Key Words:
Per-rectal Portal Scintigraphy,Portal Hypertension, Portal Systemic Shunt Index
BULGARIAN JOURNAL OF HEPATOGASTRO-ENTEROLOGY 1999;1,N1: 21-24
Doppler Sonographic Evaluation Of Portal And Splanchnic Hemodynamics In Chronic Pancrearitis
Mitova R., L.Tankova, N.Grigorov, A.MendizovaClinical Centre of Gastroenterology, University Hospital "Queen Joanna", MU-Sofia
Aims: To study the hemodynamic consequences and the prevalence of segmental portal hypertension in chronic pancreatitis by the use of Doppler ultrasound(US).
Methodology: Twenty one patients (20 men, 1 woman, mean age 46,2) with chronic pancreatitis (CP), by 14 complicated with pseudocysts were studied prospectively. By means of duplex and triplex Doppler US were evaluated qualitative (vessel patency, collateral network), semiquantitative ( arterial resistance index -RI) and quantitative (diameter, mean velocity and volume ) parameters of portal and splanchnic hemodynamics . The results were compared to 40 healthy controls.
Results: A tendency towards hyperdynamic portal circulation with significant raise of the flow volume of v.lienalis(649ml/min vs. 446 ml/min) and CI of v. portae(0,050cm.s vs. 0,038cm.s) is outlined in the studied series. In 10 (48%) of the patients additionally is observed arterial hypervascularization in the pancreatic region . Segmental portal hypertension with thrombosis of v. lienals - v. portae and cavernous transformation is detected in 3 (14,4%) cases, which is confirmed by the presence of varices of the fundus.
Conclusions: Doppler sonography is method of choice in the diagnosis of portal obstruction and segmental portal hypertension in CP. The complication is comparatively rare, in the rest of the cases with CP the portal and splanchnic circulation tend to be hyperdynamic, probably as a response to the longlasting inflammatory process.
KEY WORDS: Doppler US, Chronic pancreatitis, Segmental portal hypertension, Portal obstruction.
BULGARIAN JOURNAL OF HEPATOGASTRO-ENTEROLOGY 1999;1,N1: 25-27
Diagnostics Of Intestinal Ischemia In Abdo-minal Angina By Duplex - Doppler Ultrasonography
I. Shalev, I. Kotzev, I. Danev Clinic of Gastroenterology, Medical University - Varna
Abstract. The aim of the study was to establish the rate of mesenteric blood flow in patients with symptoms of chronic abdominal angina. Materials and methods. Ten patients at an average age of 68 years presenting with postprandial abdominal pain were studied. Non - vascular pathology as a cause of abdominal pain was excluded in all but one patient who had a duodenal ulcer. The maximal and minimal velocity of bloodflow through the superior ( SMA ) and inferior ( IMA ) mesenteric arteries was measured in a fasting state by duplex Doppler ultrasonography ( DDU ) and compared to those in a control group of 10 healthy persons. Serum cholesterol and triglycerides were analyzed and an ECG was recorded.
Results . 1)The mean maximal speed of bloodflow through the SMA was 2,4 ( 2,1-3,1 ) m/s and the mean minimal speed - 0,25 ( 0-0,50 ) m/s; the respective values for IMA were 1,68 ( 1,8-2,2 ) m/s and 0,1 ( 0-24 ) m/s. 2) In the control group SMA maximal speed was 1,52 ( 1,44-1,61 ) m/s, minimal - - 0,30 ( 0,3-0,45 ) m/s; for the IMA 1,12 ( 0,9-1,2) m/s maximal and 0,36 ( 0,30-0,39) m/s. 3) The mean resistance index ( RI ) for SMA was 0,9 in the patients with abdominal angina and 0,7 in the controls. 4) Calcifications and irregularity of the abdominal aorta wall were visualised in all patients with abdominal angina. An adherent thrombus of the abdominal aorta, reduction of bloodflow velocity and pulsatility of SMA were established in one patient. 5) All patients had a history of ischemic heart disease (IHD ) and elevated levels of cholesterol. 6) Intermittent claudication was present in three patients.
Conclusions: PDU of the mesenteric arteries in patients whose symptoms may be attributed to abdominal angina ( i.e. intestinal ischemia ) may demonstrate : 1) An increase of maximum bloodflow velocity above 1.8 m/s in AMS ( p<0.001) and 1,5 m/s in AMI ( p<0.05 ) due to reduced arterial wall elasticity ; 2) Elevated above 0.85 RI of the mesenterial bloodflow ( p<0.05 ); 3) A mesenteric sphygmogram characteristic of pulsus altus et celer in initial stenosis and pulsus parvus and tardus in advanced stenosis. PDU is a non-invasive and a reliable method for the diagnosis of mesenterial atherosclerosis and the disturbance of mesenterial circulation in patients with suspected abdominal angina.PDU of the mesenteric arteries should become routine in the patients with IHD, who complain of abdominal discomfort.
Key words: intestinal ischemia; pulse Doppler ultrasonography.
BULGARIAN JOURNAL OF HEPATOGASTRO-ENTEROLOGY 1999;1,N1: 28-31
Conventional, Endoluminal And Doppler Echography In The Complex Assessment Of The Activity Of Crohn`s Disease
The correct therapeutic approach in Crohn?s disease (CD) requires objective criteria for the real assessment of the inflammatory process severity.
AIM: To evaluate the possibilities of conventional, endoluminal and Doppler echography in the assessment of the activity of Crohn?s disease.
MATERIAL: The study includes 12 patients (6 males, 6 females, mean age 37,6) with CD of ileum terminale and/or right colon with active disease according to the Index of Best; 9 healthy controls (5 males, 4 females, mean age 45,2).
RESULTS: The mean thickness of the bowel wall is 9,8 � 2,3mm on conventional ultrasound. Endoluminal echography finds perianorectal fistulas ? in 2 patients and perirectal abscess ? in 1 patient. The mean velocity of the portal vein in healthy controls is 18,78 � 3,2cm/sec and in diseased patients ? 22,6 � 7cm/sec without significant difference. In controls the resistant index of a.mesenterica sup. (AMS) on fast (RI0) is 0,84 � 0,02, 15 min. after meal (RI1) is 0,74 � 0,03 and the difference of the basal and postprandial index (DRI) is 0,10 � 0,03. In cases with CD, RI0 is 0,83 � 0,05, RI1 - 0,77 � 0,05 and DRI - 0,06 � 0,02.
The difference between the basal and postprandial index in diseased patients is significantly lower compared to controls and correlates with the sonogra-phycally measured thickness of the bowel wall. Conventional, endoluminal and Doppler echography supplement complex of methods for activity evaluation and monitoring of patients with CD.
Doppler investigation provides additional information for the functional changes of splanchnic hemodynamic mainly of AMS resistance on fast and after meal.
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