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Background & Aims: Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD. Methods: Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted. Results: All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however, proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy. Conclusions: This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice. [ABSTRACT FROM AUTHOR]

Infection with Strongyloides stercoralis (S. stercoralis) is rarely reported in temperate countries. In addition, there are few reported cases of patients with ascites with S. stercoralis worldwide, usually in immunocompromised subjects. We present the case of a young patient with alcoholic liver disease and acute pancreatitis, who developed ascites with S. stercoralis. The patient had no evident immunosupression (HIV negative and absence of immunosupressive therapy). This is the first reported case where acute pancreatitis could have precipitated infection of ascitic fluid with S. stercoralis. [ABSTRACT FROM AUTHOR]

Background & Aims: Pancreatic cancer is associated with poor survival and quality of life. In Romania the prognostic influence of known risk factors for pancreatic adenocarcinoma, such as age, smoking, chronic pancreatitis, diabetes mellitus, and obesity is little known. Their importance in developing cancer in families with a history of adenocarcinoma is less studied. This study aims to assess the risk factors in pancreatic ductal adenocarcinoma, in familial pancreatic adenocarcinoma, in neuroendocrine tumors and to evaluate their predictive role on survival. Methods: We performed a prospective bicentric study of patients with pancreatic tumors detected in transabdominal imaging; we assessed the risk factors and their possible association with survival. Results: 312 pancreatic cancer patients (279 with pancreatic ductal adenocarcinoma and 24 patients with neuroendocrine tumors, and nine patients with other malignant types) and 312 controls were included. The median body mass index was significantly higher in patients with neuroendocrine tumors. Positive family history for pancreatic cancer was found in 4% of patients with pancreatic cancer. The risk for familial pancreatic carcinoma was associated with the presence of new-onset diabetes (OR: 4.64, p=0.018). The multivariate logistic analysis suggested that advanced age (OR: 1.67), smoking (OR: 1.67), low body mass index (OR: 12.07), and diabetes (OR: 3.91) were risk factors for pancreatic cancer. The overall survival analysis after adjustment for age and tumor stage showed only advanced tumoral stage (HR=1.6, p=0.003) and metastasis as independent predicting factors (HR=1.67, p<0.001). Conclusion: Our study suggests that diabetes, smoking, underweight, and age over 60 years are risk factors for pancreatic cancer. Patients with a family history of pancreatic cancer, especially those with new-onset diabetes, should be followed carefully and considered for screening. Only an advanced tumor stage was associated with poor overall survival for patients with pancreatic ductal adenocarcinoma. [ABSTRACT FROM AUTHOR]

There is scarce information on the prevalence of irritable bowel syndrome (IBS) in East Europe. Most countries have small, local studies or studies that to our knowledge are not published in internationally available journals. This is a report from the NeurogastRO 2019 meeting held in Iași, Romania, 7-9 November 2019. During the meeting, specialists from 12 East and Central European countries presented data on IBS epidemiology in their countries. We report the stage of knowledge in each of these countries. [ABSTRACT FROM AUTHOR]

Introduction. Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopy. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way. Case report. We report the case of a 83 years old female patient admitted for chest pain associated with difficulty in breathing and fatigue, the symptoms subside at rest. Acute myocardial infarction was excluded but severe anemia was detected with a haemoglobin of 5.9 g/dl. The patient was known with paroxysmal atrial fibrillation controlled by amiodarone, rheumatoid arthritis for which the patient administered methotrexate, the treatment was ceased several years ago due to the reduction of disease activity. Due to CHADs-VASc score of 5, the patient was under chronic anticoagulation with DOAC. In order to identify the source of the supposed bleeding, a Upper Digestive Endoscopy was performed. The investigation revealed grade I esophageal varices without signs of recent bleeding and antral vascular ectasia. Due to local conditions, endoscopic band ligation was preferred. After the management of the anemia the patient was discharged with a haemoglobin of 9 g/dl. After a month from the EBL the patient restarted administration of DOAC which lead to a new episode of acute GI bleeding, a second session of EBL was performed with the recommendation not to administer anticoagulants until a third session which was set after 2 months. Discussion. The first line treatment is considered argon plasma coagulation (APC), given its wider availability, safety, efficacy and cost-effectiveness, though different types of endoscopic treatments are available. Given the condition of a specific patient, the physician can choose which is more appropriate for a better management. Conclusion. A patient with multiple comorbidities must have a comprehensive approach and a good understanding of bleeding versus thrombotic risks. [ABSTRACT FROM AUTHOR]

Introduction. Multichannel intraluminal esophageal impedance combined to pH-metry (pH-MII) is a sensitive tool for evaluating gastroesophageal reflux disease (GERD). The impedance-pH monitoring diagnostic test determines the frequency of reflux episodes (both acid or nonacid and liquid, gas or mixed) and the time relationship of reflux episodes and symptoms. Extradigestive manifestations and refractory GERD are two of the main recommendations for the assessment of upper digestive tract by pH-MII. Material and method. We conducted a prospective study between January 2022 - March 2023 at our tertiary referral center in North-Eastern Romania that included 26 patients suspected of GERD. All patients were investigated through pHMII. We used a ZepHr® system from Sandhill Scientific and single-use catheters with one pH electrode and 6 impedance electrodes. Patients who underwent MII-pH testing for refractory GERD were tested on proton pump inhibitor (PPI), while patients with no previous evidence of GERD were assessed off PPI. The diagnosis of GERD and phenotypes were based on Lyon metrics. Results. Out of the 26 patients, 14 (53.8%) were male and 12 (46.2%) female, with a mean age of 48.6±13.5 years. Nineteen patients (73.07%) presented with extradigestive GERD symptoms, of whom 7 patients (36.8%) with chronic cough, 7 patients (36.8%) with chronic laryngitis, 4 patients (21.05%) with non-cardiac chest pain and 1 patient (5.26%) with bronchial asthma. The rest of 7 (26.92%) patients were investigated for refractory GERD. After the final analysis of pH-MII tracks, we found GERD in 10 (38.5%) patients, functional heartburn in 6 (23.1%) patients and hypersensitive esophagus in 3 (15.4%) patients. All the 10 patients diagnosed with GERD had acid reflux, with a mean DeMeester Score of 46.7±83.8 and a mean AET of 12.8±20.9%. The mean total number of GERD episodes was 100.3±7.5 and the mean longest reflux episode was of 53.7±85.7 minutes. Conclusion. Multichannel intraluminal esophageal impedance combined to pH-metry represents an important instrument for assessing extradigestive GERD and refractory GERD. [ABSTRACT FROM AUTHOR]

Introduction. High-resolution manometry (HRM) is one of the most notable recent advances in the field of esophageal function. In the absence of organic lesions, HRM provides measurements of esophageal function, identifies the pathology and guides the treatment. The aim of this study was to assess the HRM particularities of diagnosis, clinical features and therapeutic management in patients evaluated for esophageal motor dysfunction. Material and Methods. Our study included all patients suspected of esophageal motility disorders, admitted in our tertiary referral center in North-Eastern Romania between July 2022 and March 2023. Demographic, clinical and laboratory characteristics were carefully collected from the patients' medical charts. All patients were investigated by upper digestive endoscopy and barium esophagogram prior to HRM. Patients diagnosed with eosinophilic esophagitis were excluded from the study. An ISOLAB HR® system from Standard Instruments, with a 36-pressure channels solid-state catheter was used. The HRM diagnosis of esophageal motor diseases was established based on Chicago 4 protocol and classification. Results. Out of the 38 patients included in the study, 15 (39.5%) were female and 23 (60.5%) male, with a mean age of 61.2±11.9. Regarding clinical features, the majority of patients presented with dysphagia (80.4%). Seven (18.4%) patients associated significant weight loss and 6 (15.8%) reported non-cardiac chest pain. Esophageal motility disorders were found in 29 patients (76.3%), 9 patients (23.6%) having a normal HRM aspect. Achalasia was identified in 15 patients (39.5%), with type I in 3 patients (7.9%), type II in 7 patients (18.4%) and type III in 5 patients (13.2%). Distal esophageal spasm was found in 4 patients (10.5%), hypercontractile esophagus in 2 patients (5.3%), esophagogastric junction outflow obstruction (EGJOO) in 2 patients (5.3%), ineffective esophageal motility in 1 patient (2.6%), absent contractility in 4 patients (10.5%) and dyshagia lusoria was identified in only one patient (2.6%). Regarding therapeutic management, endoscopic dilation was performed in 10 patients (26.3%) and 3 patients (7.8%) were referred to surgery. Conclusion. Esophageal HRM remains an important tool for assessing esophageal motor dysfunction. The esophageal motility disorders still represent a diagnostic and therapeutic challenge in clinical practice. [ABSTRACT FROM AUTHOR]

Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the standard technique for fixing the tube in place for levodopa carbidopa intestinal gel (LCIG) infusion. The Romanian Society of Digestive Endoscopy (RSDE) decided to create a consensus paper to meet the needs in medical training and practice. After reviewing the available published data and existing recommendations, a consensus process was carried out involving the leaders of opinion in this field. The resulting text and recommendations were approved, after reaching expert consensus, and reflects the views of the RSDE for the best practice of PEG/J tube placement. The pull through method ("pull technique") is the prevailing PEG-tube placement procedure in Romania. The procedure can be performed with intravenous sedation combined with local anesthesia. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Redo procedures are sometimes necessary and clinicians should be aware of these situations. [ABSTRACT FROM AUTHOR]

Pancreatic pseudocysts are frequent complications of both acute and chronic pancreatitis. By contrast, pancreatico-pleural fistula is rare. Here we report a case of massive pleural effusion secondary to a fistula in the left hemi-diaphragm, between a pancreatic pseudocyst and the left pleura, in a patient with a right kidney tumor and bilateral massive pulmonary thromboembolism. This fistula developed after several episodes of un-investigated acute pancreatitis. The pleural effusion was treated by three thoracocenteses, without recurrence. [ABSTRACT FROM AUTHOR]

Introduction. High-resolution manometry (HRM) is one of the most notable recent advances in the field of esophageal function. In the absence of organic lesions, HRM provides measurements of esophageal function, identifies the pathology and guides the treatment. The aim of this study was to assess the HRM particularities of diagnosis, clinical features and therapeutic management in patients evaluated for esophageal motor dysfunction. Material and Methods. Our study included all patients suspected of esophageal motility disorders, admitted in our tertiary referral center in North-Eastern Romania between July 2022 and March 2023. Demographic, clinical and laboratory characteristics were carefully collected from the patients' medical charts. All patients were investigated by upper digestive endoscopy and barium esophagogram prior to HRM. Patients diagnosed with eosinophilic esophagitis were excluded from the study. An ISOLAB HR® system from Standard Instruments, with a 36-pressure channels solid-state catheter was used. The HRM diagnosis of esophageal motor diseases was established based on Chicago 4 protocol and classification. Results. Out of the 38 patients included in the study, 15 (39.5%) were female and 23 (60.5%) male, with a mean age of 61.2±11.9. Regarding clinical features, the majority of patients presented with dysphagia (80.4%). Seven (18.4%) patients associated significant weight loss and 6 (15.8%) reported non-cardiac chest pain. Esophageal motility disorders were found in 29 patients (76.3%), 9 patients (23.6%) having a normal HRM aspect. Achalasia was identified in 15 patients (39.5%), with type I in 3 patients (7.9%), type II in 7 patients (18.4%) and type III in 5 patients (13.2%). Distal esophageal spasm was found in 4 patients (10.5%), hypercontractile esophagus in 2 patients (5.3%), esophagogastric junction outflow obstruction (EGJOO) in 2 patients (5.3%), ineffective esophageal motility in 1 patient (2.6%), absent contractility in 4 patients (10.5%) and dyshagia lusoria was identified in only one patient (2.6%). Regarding therapeutic management, endoscopic dilation was performed in 10 patients (26.3%) and 3 patients (7.8%) were referred to surgery. Conclusion. Esophageal HRM remains an important tool for assessing esophageal motor dysfunction. The esophageal motility disorders still represent a diagnostic and therapeutic challenge in clinical practice. [ABSTRACT FROM AUTHOR]

Background & Aims: Gastroesophageal reflux disease (GERD) therapy is challenging and suppression of acid secretion or prokinetics do not cure all cases. Some drugs with protective action on the esophageal mucosa have been used alternatively or in association with proton pump inhibitors (PPIs) and/or prokinetics. The Romanian Society of Neurogastroenterology undertook an Evidence-Based analysis, from which this position paper evolved. Methods: We performed a systematic literature search in PubMed until October 2015, using the terms: sucralfate, guaiazulene, gaiazulene, dimethicone, alginate, antacids and gastroesophageal reflux. Forty-seven papers were included and analyzed. Several statements were elaborated regarding the use of these drugs in GERD. The evidence and recommendations were discussed between the authors. Results: There is evidence in the medical literature suggesting the benefit of these drugs in GERD. In patients with persistent or mild reflux symptoms antacids rapidly relieve heartburn. Alginate-antacid combination is superior both over placebo and antacids to treat mild reflux symptoms, and can be used to treat persistent reflux symptoms despite acid suppressant therapy. Sucralfate is superior over placebo in alleviating GERD symptoms and can be used as maintenance therapy. Guaiazulene-dimethicone improves the quality of life in patients with GERD. Conclusions: Drugs used to protect the esophageal mucosa against acid are useful in alleviating chronic heartburn, especially in patients with mild reflux symptoms. [ABSTRACT FROM AUTHOR]

The article presents a study which discusses the use of mebeverine, an antispasmodic drug, in the treatment of irritable bowel syndrome (IBS). The methodology used include selection of working group, development of draft statements, and a systematic literature review on the evidence to support the statement. Topics discussed include the use of antispasmodics in IBS treatment, impact of mebeverine on quality of life (QOL) of IBS patients, and prescription of mebeverine in Romania.

A letter to the editor is presented which discusses the diagnostic and therapeutic challenges of gastric bezoars in the Institute of Gastroenterology and Hepatology in Iasi, Romania.

Background & Aims. Recent papers highlight the role of the diet in irritable bowel syndrome (IBS), but very few population-based studies have evaluated this. The aim of the study was to determine the prevalence of IBS in the general urban population and to evaluate the type of diet associated with IBS symptoms. Methods.A randomized sample of subjects (n=300) from a general urban population in Romania selected from family doctors' patient lists was invited for interview in the doctor's office. Selected subjects were evaluated for the diagnosis of IBS using Rome III criteria and for their eating habits and diet using a food frequency questionnaire. Socio-demographic factors and general medical history were also included in the interview together with standard weight measurements. Results from logistic regression were presented as odd ratios and 95 % confidence intervals. Results. From the selected sample, 193 subjects (80 males, 113 women, mean age 50.8±16.2) agreed to participate (rate 64.3%). Prevalence of IBS was 19.1 % (19.4% for females and 18.7 % for males). IBS was associated with older age (1.05, 1.02-1.08, p<0.001) and past history of digestive diseases (5.0, 2.0-12.7, p<0.01). IBS subjects eat significantly more frequently canned food (23.74, 3.17-177.7, p<0.01), processed meat (4.7, 1.6-14.1, p<0.01), pulses (legumes) (4.0, 1.3-16.3, p<0.01), whole cereals (8.7, 2.0-37.8, p<0.01), confectionary (5.7, 1.8-23.2, p<0.01), fruit compotes (canned or not) (7.4, 2.5-23.1, p<0.001) and herb teas (4.0, 1.3-16.3, p<0.001). Conclusions. This study updates prevalence data and reveals a possible association between diet and irritable bowel syndrome. [ABSTRACT FROM AUTHOR]

A case study is presented on a 37 year old male with a history of binge alcohol consumption who went to the emergency department for several symptoms including nausea, sweating, and vomiting. Laboratory findings revealed an elevated bilirubin, C reactive protein, and serum glucose. Ophthalmoscopy of both eyes showed cotton wool spots while fluorescein angiography showed capillary leakage. The patient was diagnosed with Purtscher's like retinopathy, a complication of acute pancreatitis.