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Endoclips were among the earliest accessories developed for gastrointestinal endotherapy. Now they are currently used for the control of gastrointestinal bleeding and for the closure of perforations, fistulas, and anastomotic leaks. Numerous technical improvements of the original device have led to the development of new devices: rotatable clip, preloaded hemoclip, TriClip and repositioning clip device. The endoclip devices are easy to use. The technique comprises three steps: exposing the clip from the sheath, opening the clip to the maximum, and deploying the clip. Dieulafoy's lesion is an abnormal, submucosal "caliber-persistent artery" that protrudes through a minute mucosal defect. Although it accounts account for up to 5% of acute upper gastrointestinal bleeding, only a few cases involving colo-rectum have been reported. We report a case of Dieulafoy's lesion of the colon which has given us the opportunity to briefly review the indications and technique of endoclipping.

Aim: The Romanian Society of Digestive Endoscopy proposed a multicentric study to evaluate the prevalence of gastric cancer in the adult population referred to gastroenterology medical services, and also the demographic features of this pathology., Methods: . The study was carried out over the period 1 January 2003 - 31 December 2003 in 11 academic centers in Romania, specialized in gastroenterology, with a uniform national distribution (all areas in the country were represented) and with adequate diagnostic and therapeutic facilities. All centers used identical definition criteria and reported the data using the same protocol and a Microsoft Excel database., Results: During the study period, 640 cases of gastric cancer were reported. In the first stage, the prevalence in each geographical region was calculated. The national prevalence of gastric cancer in the population referred to gastro-intestinal endoscopy services was 2.9 per 100,000 inhabitants over 18 years of age. The demographic data of the studied group were the following: 66.4% men, 33.6% women, 51.7% urban population, 48.3% rural population, mean age 63.07 +/- 12.10 years. The most frequent indications for upper digestive endoscopy were: dyspepsia, weight loss and appetite. 88% of patients had no history of disease with a high risk of gastric cancer. The majority of patients (95.5 %) had advanced gastric cancer at the time of diagnosis, located in the gastric body (40.1 %) and in the antrum (33.8 %). According to Borrmann's classification, 31.4% had type I fungating gastric cancer and 32.1% had type III ulcero-infiltrative gastric cancer. According to the Lauren classification, the most frequent histological type was intestinal adenocarcinoma (63.8 %). Early gastric cancer was found in 4.4% of patients., Conclusions: The prevalence of gastric cancer in the population referred to digestive endoscopy services in Romania is 2.9%, with relatively wide variations at a national level. The study confirms the fact that Romania is a country with a low prevalence of gastric cancer, in accordance with the literature data published for the south of Europe.

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.

Mucosa-associated lymphoid tissue (MALT) lymphomas represent a relatively new described class of rare lymphomas, characterized by an indolent course and favourable outcome with specific therapy. Gastric MALT lymphomas are associated with chronic Helicobacter pylori (HP) infection. We report the case of a 67 year old man admitted for an 8-month history of epigastric pain, anorexia and progressive weight loss. He was diagnosed with low-grade primary gastric MALT lymphoma by endoscopy, histopathological examination of gastric mucosa (light microscopy and immunohistochemistry) and endoscopic ultrasonography (EUS). The patient received a 2-week course of anti-HP therapy and chemotherapy with Chlorambucil 0.1 mg/kg/day was started. During the follow-up, continuous improvement of clinical status, endoscopic and EUS appearance was noted. We conclude that, facing the trend toward nonsurgical treatment modalities for primary gastric lymphoma, EUS appears an important tool for staging the disease and defining cases suitable for anti-HP, radio- and chemotherapy, as well as for the detection of local recurrence.

Objectives: To evaluate the frequency of cholestatic pattern in patients with autoimmune hepatitis (AIH) and to identify predictive factors associated with the development of the overlap syndrome., Methods: Eighty-two consecutive patients diagnosed with AIH at the referral centre between January 1998 and June 2002 were included in the study. The new scoring system modified by the International Autoimmune Hepatitis Group was used to classify patients as definite/probable. Overlap syndrome was considered when the patient had clinical, serological and histological characteristics of two conditions: AIH and primary biliary cirrhosis (PBC) or AIH and primary sclerosing cholangitis (PSC)., Results: From the 82 AIH patients (76 female and six male), 84.1% presented definite AIH (> 15 points) and 15.9% probable AIH (10 - 15 points). The frequency of the overlap syndrome was 20%: 13% with PBC and 7% with PSC. In the univariate analysis the overlap syndrome was associated with male gender (P = 0.01), age < 35 years (P < 0.0001), histopathological aspect of cholestasis (P < 0.0001), suboptimal response to treatment (P < 0.0001) and probable AIH (P < 0.0001). Age < 35 years, probable AIH and the absence of anti-nuclear antibody (ANA) have been identified as independent indicators of the overlap diagnosis by the logistic regression analysis., Conclusion: Patients with overlap syndrome between AIH and primary cholestatic liver disease are frequently diagnosed in clinical practice, representing 20% of AIH cases in our study. The independent predictive factors associated with the diagnosis of overlap syndrome are young age, ANA(-) profile, and probable diagnosis according with the scoring system for AIH.

Endoscopic ultrasound (EUS) represents a highly sensitive method for the detection of pancreatic masses. When available, EUS-guided fine needle aspiration (FNA) is the best technique for the diagnosis and staging of pancreatic cancer due to its ability to obtain tissue for diagnosis. The standardized indications for pancreatic EUS-FNA comprise the definite diagnosis of malignancy and histopathological confirmation of adenocarcinoma before surgical resection, chemo/radiotherapy, or celiac plexus neurolysis. The technique of performing EUS-FNA is described in detail, from the vizualization of the target lesion and adequate placement of the transducer to allow optimal needle access, to needle penetration and sampling of the targeted lesion. We report a series of 9 patients who underwent EUS-FNA and shortly review the indications, technique, results and impact of EUS-FNA on the management of these patients.

Background and Aims: Among the histological lesions seen in chronic hepatitis C (CHC), the presence of steatosis, bile duct lesions and lymphoid aggregates are characteristic. Recent reports suggest that steatosis is an independent risk factor for liver fibrosis in CHC. The aim of our study was to determine the relative contribution of steatosis and moderate alcohol consumption to the severity of liver fibrosis in patients infected with genotype 1 hepatitis C virus., Methods: We evaluated the patients with biopsy proven CHC and no or only moderate alcohol intake (<40 g/day). The demographical parameters of the study population, the indices of alcohol consumption: erythrocyte median corpuscular volume (MCV), gamma-glutamyl transpeptidase (GGT), the histological characteristics were noted and a statistical analysis was performed in order to determine the factors independently associated with severe fibrosis and with severe steatosis., Results: From the 200 patients included in the study, 82 were males and 118 females, with a mean age of 47.75+/-10.42 years. At univariate analysis, advanced (grade 2, 3) fibrosis correlated with: the age at the time of biopsy, increased inflammatory activity (HAI), moderate/severe steatosis, alcohol intake, elevated GGT and MCV values. After multivariate logistic regression only age, HAI and steatosis were independently associated with advanced fibrosis stage. Regarding hepatic steatosis, from the factors found to correlate with severe steatosis at univariate analysis (alcohol intake, elevated GGT and MCV levels, severe fibrosis), after multivariate logistic regression only the elevated level of GGT was an independent prognostic factor for severe steatosis., Conclusions: Steatosis is an important risk factor for the severity of liver disease in CHC patients. Among patients with genotype 1 hepatitis C virus infection and moderate alcohol intake, those with serum levels of GGT over two times the normal value are at high risk for severe steatosis.

Radiation proctitis is a well-recognized complication following radiotherapy for pelvic malignancy. This study was designed to compare the efficacy and complications of argon plasma coagulation (APC) using the power setting of 50 W vs. 60 W in a group of patients with radiation proctitis. Forty-two patients were randomized to undergo APC using the electrical power setting of 60 W (23 patients, group A) or 50 W (19 patients, group B). Patients were asked to estimate the severity of major symptoms before and after APC using a scoring system graded 0-4. The score of major symptoms before and after APC, mean duration of the procedure, number of sessions, side effects/complications were noted. Statistical analysis was performed using Fisher's Exact Test and the 2-tailed p value less than 0.05 was considered statistically significant. A significant improvement of major symptoms was noted in all patients treated with APC, irrespective of the wattage we used, apart from the presence and severity of tenesmus. The mean number of treatment sessions to achieve control of bleeding was 1.34 for group A and 1.9 for group B and the mean time of treatment sessions was significantly shorter for group A (15 min vs. 17 min for group B). No significant differences in early side effects and long term complications between the two groups were evidenced. We can conclude that there is no statistical significance concerning efficacy and side effects of APC application between the 60W and 50W power setting, but the number of sessions and duration of the procedure tend to differ significantly. Rectal stenoses have been described only in patients treated with higher power settings.

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

Gastroduodenal tuberculosis is a rare location of abdominal tuberculosis. It usually occurs secondary to pulmonary tuberculosis. We report a case of a 63-year-old woman admitted to the referral center for symptoms of upper gastrointestinal obstruction caused by ulcerohypertrophic antroduodenal tuberculosis. The lesion was misdiagnosed as malignancy at endoscopy. Even at surgery, the lesion was considered gastric cancer and imposed an oncologic resection. The diagnosis was established in the presence of giant-cell granulomas with caseating necrosis in the surgical resected specimens. In our case, the rare gastroduodenal location of abdominal tuberculosis occurred as primary tuberculosis, in the absence of other identifiable locations.

European experience in endoscopic mucosal resection (EMR) for early gastric cancer is still relatively low, since early stomach cancer is diagnosed at a much lower rate in Europe than in Japan and generally operable patients are referred to surgery for radical resection. Endoscopic mucosal resection or mucosectomy was developed as a promising technology to diagnose and treat mucosal lesions in the esophagus, stomach and colon. In contrast to surgical resection, EMR allows "early cancers" to be removed with a minimal cost, morbidity and mortality. We present the case of a patient with hepatic cirrhosis incidentally diagnosed with an elevated-type IIa early gastric cancer. Echoendoscopy was performed in order to assess the depth of invasion into the gastric wall confirming the only mucosal involvement. We performed an EMR using "cup and suction" method. After the procedure, the patient experienced an acute upper gastrointestinal bleeding from the ulcer bed requiring argon plasma coagulation. The histopathological examination confirmed an early cancer, without involvement of muscularis mucosae. The patient has had an uneventful evolution being well at six months after the procedure