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Introduction: Antineutrophil cytoplasmic antibodies (ANCA) are known as a serologic marker of immune disturbances in IBD. The most specific are perinuclear ANCA (pANCA). The aim of this study was to investigate their significance for the diagnosis of inflammatory bowel disease (IBD) in Romania., Material and Methods: A prospective longitudinal study, comprising all patients admitted to our Center in 2000 with ulcerative colitis--UC group (33 patients) and with Crohn's disease--CD group (40 patients). The control group (C) included 22 healthy individuals, with similar age and sex distribution. ANCA was tested in serum by indirect immunofluorescence at Leuven University, Belgium., Results: ANCA prevalence in UC group was 12/33 (36.4%), in CD group was 6/40 (15%), while in the C group all sera tested negative (p=0.004). All ANCA antibodies in patients with IBD were perinuclear type. In the UC group, the prevalence of pANCA was higher in females compared to males (52.9% versus 16.7%, p=0.04). The phenotype pANCA+ did not correlate with disease extension, severity, the evolutive form or complications. In the CD group, the phenotype pANCA+, although more frequently found in colonic involvement and in non-obstructive non-fistulizing forms to associate with pANCA+, did not reach statistical significance (p=0.59). A higher severity of CD was associated with higher pANCA titers (p=0.05)., Conclusion: pANCA prevalence in UC in Romania was lower in comparison with other studies (36.4% versus 50-80%). The highest prevalence was found in females with UC. In CD, pANCA+ was associated with a higher severity. pANCA assessment remains at a research level, further in-vestigations being necessary in order to demonstrate its clinical importance.

A 61 year old man was referred for upper digestive endoscopy having dyspeptic syndrome. He also associated hoarseness. The examination revealed an ulcer scar on the gastric angle (chronic gastritis upon histological examination) and a well differentiated spinocellular laryngeal carcinoma, further treated by surgical excision.

Objectives: The objectives of this study were to compare the effect of the treatment with propranolol to that with propranolol and isosorbide-5-mononitrate in portal hypertension, as assessed by Doppler ultrasound parameters in patients with cirrhosis., Methods: A prospective study of two groups, each of 30 patients with cirrhosis Child-Pugh A was performed. In one group 40 mg/day propranolol were administered for 6 months and in the other, a combined treatment with propranolol 40 mg/day and isosorbide-5-mononitrate 40 mg/day was administered for 6 months. In all patients the presence of esophageal varices was confirmed by upper gastrointestinal endoscopy and abdominal ultrasonography and Doppler ultrasonography of the portal vein was performed. The patients were monitored for: the velocity of blood flow in the portal vein, the cross sectional area of the portal vein and the portal vein congestion index. Data analysis used t-Student test, Pearson and Spearman correlation. A p value of <0.05 was considered to be significant., Results: A significant decrease of all parameters after 6 months was observed in the group with combined therapy with propranolol and isosorbide-5-mononitrate (p<0.05). The relative decrease of the cross sectional area of the portal vein and of the portal vein congestion index was more important when patients had higher initial values of the two parameters, indicating an increased hemodynamic impairment (Pearson, p<0.001). In patients treated only with propranolol, the relative decrease correlated with its initial value for all parameters., Conclusion: The combined therapy with propranolol and isosorbide-5-mononitrate proved to be superior to the mono-therapy with propranolol in decreasing the hemodynamic parameters in portal hypertension, probably by an additive effect.

Background: Acute pancreatitis (AP) is a proteiform disease which may lead to various complications. Pancreatic pseudocysts and fluid collections are among the most frequent of them. The aim of our study was to find predictive factors of their occurrence., Methods: We carried out a retrospective cohort study comprising one year patients admitted to our department with AP. Fisher's exact and U Mann Whitney tests were used for correlations, with a probability of error < 5% (p<0.05)., Results: We included 62 patients with a mean age of 49 years; 77.4% were males. AP etiology was due to alcohol (58.1%), biliary disorders (22.6%), hyper-triglycerides (8.1%) and post-ERCP (3.2%). Pancreatic cancer was revealed in (6.5%) patients. From the whole group 2 patients (3.2%) died. There were 22 patients with pseudocysts (35.5%) and 13 patients with acute fluid collections (21%). Multiple pseudocysts were present in 12 cases (54.5%), mean diameter was 39.5 mm. Pancreatic head localization was most frequent (63.6%). Alcoholic etiology was associated with acute pseudocysts formation (p=0.007) as well as lower values of alkaline phosphatase (96 U/L versus 286 U/L, p = 0.016). The area under the receiver operating characteristics curve demonstrated values of alkaline phosphatase < 2 x upper normal values were predicting pseudocyst occurrence with > 90% specificity. Presence of ascites predicted formation of acute fluid collections, (p < 0.001)., Conclusions: Alcoholic etiology and low values of serum alkaline phosphatase seem to predict pseudocysts formation in acute pancreatitis, while ascites forecast acute fluid collections occurrence.

Introduction: Anti-Sacharomyces cerevisiae antibodies (ASCA) represent the immunologic marker correlated with Crohn's disease because of their high specificity (80-95%). The aim of this study is to confirm their value in a Romanian population with IBD., Material and Methods: A prospective longitudinal study was performed, which included patients admitted to Center of Gastroenterology and Hepatology Fundeni, Bucharest, in 2000 with ulcerative colitis (33 patients) - UC group, or Crohn's disease (40 patients) - CD group, and a control group (C) consisting of 22 healthy subjects. ASCA determination from serum samples was performed in the Erasmus University by ELISA technique., Results: ASCA+ prevalence in CD group was 5 in 40 patients (12.5%), in UC group 0/33 (0%), 1/21 C group (4.9%), p=0.05. ASCA+ phenotype was found only in patients with CD diagnosed before the age of 40 years (A1), p=0.04. Also, ASCA+ phenotype correlated significantly with the colonic (L2) or ileocolonic (L3) extension (p=0.05). ASCA+ status did not correlate with the evolutive pattern of CD (stricturing, penetrating or non- stricturing non-penetrating), and neither did the clinical severity., Conclusions: ASCA+ prevalence in CD patients is much lower compared with North-American or West-European studies (12.5% versus 40-70%). In Romanian patients, ASCA assessment may be helpful in achieving a diagnosis of Crohn's disease, especially in those younger than 40 years, or in those with colonic or ileocolonic extension.

Aim: Fluid and electrolyte hypersecretion in the villous adenoma of the rectum is presented in the case of a 74 year old man presenting with a severe fluid imbalance., Case Report: The patient had a 2-year history of mucous diarrhea and, on admission, presented prerenal uremia, hyponatremia and severe hypokalemia. At sigmoidoscopy, a 6/4 cm villous adenoma of the rectum was found. The increased loss of volume, followed by exhaustion of the physiological compensation mechanisms, led to a life-threatening hypokalemia, as well as to acute renal failure. Conservative treatment was followed by a temporary improvement of the renal function. Alternative treatment was: endocavitary irradiation, endoscopic resection and radical tumor surgery. The surgical removal of the adenoma led to complete recovery of the symptoms., Conclusion: The McKittrick-Wheelock syndrome can be a problem of difficult diagnosis, both for the gastroenterologist and also for the nephrologist. The patient may develop severe complications, which require a sustained treatment.

Background and Aim: The real-life clinical setting has been known to provide, sometimes, results different from controlled study outcomes. IPEP (InPractice Evaluation Program) was designed to evaluate the efficacy of esomeprazole in providing symptom relief in patients with reflux disease who present to primary care physicians for heartburn and symptoms that are poorly controlled by other drugs, thus testing the efficacy of the drug in day-to-day practice., Methods: 119 primary care physicians and 22 internal medicine specialists, widely distributed geographically, participated in the program. The frequency and severity of three symptoms (heartburn, acid regurgitation and upper abdominal pain) were assessed before and at the end of one month treatment with esomeprazole 40 mg once daily., Results: Follow-up data from 747 patients enrolled in IPEP was available to evaluate the efficacy of the intervention. Over 80% of the enrolled patients reported a decrease in the frequency of symptoms to less than one episode per week for all the three major symptoms (heartburn, acid regurgitation and upper abdominal pain). Regarding the severity of symptoms, 50-60% of the patients reported total relief, while 30-40% reported persistence of symptoms, but admitted them to be milder and with lower frequency. At the end of treatment, no patient reported severe or extremely severe symptoms., Conclusions: The results of this routine clinical practice program are consistent with data reported in controlled trials indicating the efficacy of esomeprazole even in patients with upper gastrointestinal symptoms "refractory" to treatments prescribed by primary care practitioners.

Background: Because molecular diagnosis is considered impractical and no patognomonic features have been described, diagnosis of Wilson's disease (WD) using clinical and biochemical findings is still challenging., Patients and Method: We analysed predictive factors for the diagnosis in 55 patients with WD diagnosed in our centre between 1st January 1999 and 1st April 2004. All patients presented predominant liver disease classified as: 1) asymptomatic, found incidentally, 2) chronic hepatitis or cirrhosis, or 3) fulminant hepatic failure. Diagnosis was considered as classic (two out of the three following criteria: 1) serum ceruloplasmin < 20 mg/dl, 2) the presence of Kayser-Fleischer rings and/or 3) hepatic copper > 250 mg/g dry weight liver tissue), and non-classic (clinical manifestations plus laboratory parameters suggesting impaired copper metabolism). The association between the predictive factors and non-classic diagnosis was assessed based on the level of statistical significance (p value<0.05) associated with the chi-squared test in contingency tables. Multivariate analysis was performed by logistic regression using SPSS 10., Results: There were 31 males (56.3%) and 24 females (43.7%) with the mean age at diagnosis of 20.92 +/- 9.97 years (4-52 years); 51 patients (92.7%) were younger than 40 years. Asymptomatic WD was diagnosed in 14 patients (25.4%), chronic liver disease due to WD in 29 patients (52.8%) and fulminant hepatic failure in 12 patients (21.8%). The classic diagnosis was made in 32 patients (58.18%). In the univariate analysis the non-classic diagnosis was associated with: age>18 years (p=0.03), increased copper excretion (p<0.0001), Coombs-negative hemolysis (p=0.03), absence of neurological manifestations (p<0.0001). Multivariate analysis identified age over 18 years, increased urinary copper, and isolated hepatic involvement as independent predictors., Conclusion: In clinical practice, WD should be considered also in patients who do not fulfil classic criteria. Independent factors associated with non-classic diagnosis were age over 18 years, increased cupruresis and isolated liver disease.

Background: The purpose of the study was to assess whether folic acid supplementation and long term therapy with sulfasalazine can reduce the risk of colorectal cancer (CRC) development in longstanding extensive ulcerative colitis., Material and Methods: A meta-analysis was performed including the last 10 years published and Medline indexed studies on this subject., Results: 3 studies have been included concerning the protective effect of folate supplementation in development of CRC. The association of these two factors is significant (effect size r =0.124, p = 0.025). The fail-safe number of studies with an opposite result should be 4 to revert the significance. 4 studies regarding sulfasalazine's protective effect in longstanding extensive ulcerative colitis have also been evaluated. A similar significance has been obtained, r = 0.148, p = 0.0007 and a fail-safe number of studies equal to 7. The homogeneity of these studies is validated by standard tests., Conclusions: Both sulfasalazine therapy and folate supplementation have a protective effect in colorectal cancer development in a population of patients with longstanding ulcerative colitis. Randomized controlled trials are needed to explore these hypotheses.

Aim: The aim of the study was to report the efficacy and tolerability of infliximab therapy in the first 24 patients with refractory and fistulizing Crohn's disease (CD) treated at our center between August 2000-May 2002., Patients and Methods: The medical records of 24 patients (13 males, 11 females) treated with infliximab for refractory or fistulizing CD were reviewed. CD was diagnosed using conventional clinical, endoscopical and histological criteria. Infliximab was administered at a dose of 5 mg/kg body mass as a 2-hours i.v. infusion in a single infusion for inflammatory CD, and a triple infusion regimen for fistulizing CD (at 0, 2, and 6 weeks). Efficacy was analysed by means of 1) clinical outcome, 2) mucosal healing, 3) steroid tapering/sparing effect and 4) need for surgery., Results: Sixteen patients were treated for inflammatory CD, 7 patients for fistulizing CD and 1 patient for both inflammatory and fistulizing CD. A total number of 49 infusions were administered during the study interval (median number 2); the median time of follow-up was 26 weeks (12-79 weeks). An overall positive clinical response was seen in 12/16 patients (75 % with inflammatory CD and 5/7 patients (71.4 %) with fistulizing CD. The median time to clinical response was 5.6 days (range 1-11 days) and the median duration of clinical response was 6.53 mo. (4 weeks-21 months). Mucosal healing was noted in 10/17 (58 %). Steroid tapering or cessation was succesfully attempted in 17 patients (80.9 %), complete steroid withdrawal being possible in 15 patients (71.4 %). Three non-responder patients required surgical therapy. Infusion-related adverse reactions were seen in 4 patients (16.6 %). Two patients (8.3 %) developed severe adverse events; one of them, a young female patient with intrapartum onset of a severe CD developed sepsis and deceased from intavascular disseminated coagulopathy. During the follow-up, none of our patients developed serious infections, tuberculosis or malignancy., Conclusion: Our study provides additional evidence that infliximab is beneficial and safe in clinical practice for refractory and fistulizing CD patients. Additionally, our study proved the high mucosal healing rate and the steroid-sparing and surgery-saving properties of infliximab

Unlabelled: It has been a consensus that prognostic factors should always be taken into account before planning treatment in colorectal cancer., Aim: A 5 year prospective study was conducted, in order to assess the importance of several histopathological and clinical prognostic variables in the prediction of evolution in colon cancer. Some of the factors included in the analysis are still subject to dispute by different authors., Methods: 46 of 53 screened patients qualified to enter the study and underwent a potentially curative resection of the tumor, followed, when necessary, by adjuvant chemotherapy. Univariate and multivariate analyses were carried out in order to identify independent prognostic indicators. The endpoint of the study was considered the recurrence of the tumor or the detection of metastases., Results: 65.2% of the patients had a good evolution during the follow up period. Multivariate survival analysis performed by Cox proportional hazard model identified 3 independent prognostic factors: Dukes stage (p = 0.00002), the grade of differentiation (p = 0.0009) and the weight loss index, representing the weight loss of the patient divided by the number of months when it was actually lost (p = 0.02). Age under 40 years, sex, microscopic aspect of the tumor, tumor location, anemia degree were not identified by our analysis as having prognostic importance., Conclusions: Histopathological factors continue to be the most valuable source of information regarding the possible evolution of patients with colorectal cancer. Individual clinical symptoms or biological parameters such as erytrocyte sedimentation rate or hemoglobin level are of little or no prognostic value. More research is required relating to the impact of a performance status index (which could include also weight loss index) as another reliable prognostic variable.

Carcinoid tumours are enigmatic, slow growing malignancies, which occur most frequently (74%) in the gastrointestinal tract. Symptoms of the carcinoid syndrome (flushing and diarrhoea) are infrequent, occurring in approximately 10% of the patients with small bowel carcinoid. A 45-year-old patient with multiple liver metastases, diagnosed in 1994 with nonHodgkin's lymphoma after undergoing surgery for a distal ileal tumour, was referred to us by the Department of Haematology. At that moment the issue of a differential diagnosis with a carcinoid tumour arose, due to the long evolution and lack of evidence to support the initial diagnosis. The carcinoid syndrome was in fact present (the patient experiencing flush after small amounts of alcohol and emotions) and also we identified elevated values of 5HIAA. Reevaluation of the histologic sections of the ileal tumour as well as an ultrasound guided fine needle aspiration of an intrahepatic lesion confirmed the diagnosis of "carcinoid tumour". This conclusion lead to new therapeutic options for this patient. One of the main therapeutic options used in treating multiple liver metastases from a carcinoid tumour is chemoembolization and this case offered an excellent opportunity to present this therapy.