BACKGROUND: Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all "undesirable" events and "true" adverse events in patients undergoing POEM and to compare the outcomes when either Clavien-Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied. METHODS: This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient's discharge) undesirable events (including those not fulfilling criteria for AEs) and "true" AEs according the definition in either of the classifications. RESULTS: A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model. CONCLUSION: Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure.
- MeSH
- achalázie jícnu * chirurgie MeSH
- chirurgie trávicího traktu * MeSH
- dolní jícnový svěrač chirurgie MeSH
- endoskopické operace přirozenými otvory * metody MeSH
- lidé MeSH
- myotomie * metody MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
Východiská: Pneumatická dilatácia (PD) je stále obľúbenou liečbou achalázie pažeráka. Táto retrospektívna analýza informuje o našich 16-ročných skúsenostiach s pneumatickou dilatáciou pri liečbe pacientov s achaláziou. Pacienti a metódy: Za sebou nasledujúci pacienti s achaláziou, ktorí podstúpili endoskopickú balónovú dilatáciu, boli retrospektívne analyzovaní. Úspešnosť endoskopickej pneumatickej dilatácie bola definovaná tak, že okrem pneumatickej dilatácie nebola potrebná žiadna ďalšia liečba a celkové klinické Eckardtovo skóre muselo byť ≤ 3 (a zároveň každá jednotlivá položka < 2). Výsledky: V období január 2004 až december 2019 podstúpilo za sebou pneumatickú dilatáciu 140 pacientov s achaláziou (67 mužov [47,9 %], priemerný vek 54,9 ± 16,2 rokov). Medián sledovania pacientov od prvej dilatácie bol 125 mesiacov (6–263 mesiacov). Liečba pneumatickou dilatáciou (vrátane opakovaných PD) mala celkovo pozitívny efekt u 130 zo 140 pacientov (92,9 %), u 2 pacientov došlo počas prvej dilatácie k perforácii (1,4 %) a u 8 pacientov nebol efekt dostatočný (5,7 %). Zo 140 pacientov podstúpilo celkovo len jednu PD 107/ 140 (76,4 %), len dve PD podstúpilo 22/ 140 (15,7 %), celkovo len tri PD podstúpilo 8/ 140 (5,7 %) a celkovo 4 PD podstúpili 3/ 140 (2,1 %). Zlyhanie liečby sme pozorovali u 3 pacientov s 1 PD (37,5 %) oproti 5 pacientom s 2 a viac PD (62,5 %); p = 0,019. Záver: Endoskopická balónová dilatácia, začínajúca s 35-mm balónom, je z krátkodobého ako aj dlhodobého hľadiska efektívnou liečbou achalázie, s minimálnou morbiditou. Prípadný neúplný efekt dilatačnej terapie sa častejšie prejavuje už v skoršom období po úvodnej dilatačnej terapii.
Background: Pneumatic dilation (PD) is still a common treatment of oesophageal achalasia. This retrospective analysis informs about 16 years of experience with pneumatic dilation in the treatment of patients with achalasia. Patients and methods: Consecutive patients with achalasia treated with endoscopic balloon dilation therapy were analysed retrospectively. The success of endoscopic pneumatic dilation was defined as no treatment other than pneumatic dilation and the overall clinical Eckardt score ≤ 3 (and at the same time each individual item <2). Results: From January 2004 to December 2019, 140 patients with achalasia consecutively underwent pneumatic dilation (67 males [47.9%], mean age 54.9 ±16.2 years). The median follow-up since the first dilation was 125 months (range 6–263 months). Satisfactory results were observed in 130 patients (92.9%). Out of the remaining ten patients, two (1.4%) had periprocedural oesophageal perforation and in 8 (5.7%) patients the treatment eff ect was insufficient. Out of all patients, 107/ 140 (76.4%) had only one PD, 22/ 140 (15.7%) had two PDs, three PDs were performed in 8/ 140 (5.7%) and four PDs in 3/ 140 (2.1%). Treatment failure was more common in patients who had more pneumatic dilations (1 PD 37.5%, 2 and more PDs 62.5%; P = 0.019). Conclusions: Endoscopic balloon dilation, starting with a 35 mm balloon, is an effective treatment for achalasia in the short and long term, with minimal morbidity. The possible incomplete effect of dilation therapy is more often manifested in an earlier period after the initial dilation therapy.
IgG4-related sclerosing cholangitis, a biliary manifestation of an IgG4-related disease, belongs to the spectrum of sclerosing cholangiopathies which result in biliary stenosis. It presents with signs of cholestasis and during differential diagnosis it should be distinguished from cholangiocarcinoma or from other forms of sclerosing cholangitis (primary and secondary sclerosing cholangitis). Despite increasing information and recently established diagnostic criteria, IgG4-related sclerosing cholangitis remains underdiagnosed in routine clinical practice. The diagnosis is based on a combination of the clinical picture, laboratory parameters, histological findings, and a cholangiogram. Increased serum IgG4 levels are nonspecific but are indeed a part of the diagnostic criteria proposed by the Japan Biliary Association and the HISORt criteria for IgG4-SC. High serum IgG4 retains clinical utility depending on the magnitude of elevation. Approximately 90% of patients have concomitant autoimmune pancreatitis, while 10% present with isolated biliary involvement only. About 26% of patients have other organ involvement, such as IgG4-related dacryoadenitis/sialadenitis, IgG4-related retroperitoneal fibrosis, or IgG4-related renal lesions. A full-blown histological finding characterized by IgG4-enriched lymphoplasmacytic infiltrates, obliterative phlebitis, and storiform fibrosis is difficult to capture in practice because of its subepithelial localization. However, the histological yield is increased by immunohistochemistry, with evidence of IgG4-positive plasma cells. Based on a cholangiogram, IgG-4 related sclerosing cholangitis is classified into four subtypes according to the localization of stenoses. The first-line treatment is corticosteroids. The aim of the initial treatment is to induce clinical and laboratory remission and cholangiogram normalization. Even though 30% of patients have a recurrent course, in the literature data, there is no consensus on chronic immunosuppressive maintenance therapy. The disease has a good prognosis when diagnosed early.
- MeSH
- gastroenterologie * MeSH
- kongresy jako téma MeSH
- Publikační typ
- zprávy MeSH
Vyšetrenie plazmatickej aktivity aspartát aminotransferázy, alanín aminotransferázy, γ-glutamyltransferázy a alkalickej fosfatázy patrí k základným testom používaným v diagnostike ochorení pečene. Hodnotenie abnormálnych výsledkov si vyžaduje istú mieru skúsenosti. Najvhodnejšie je riadiť sa určitým štandardizovaným postupom, aby nedošlo k prehliadnutiu závažnejšej patológie, ale ani k zbytočnému indikovaniu vyšetrení. Prístup k pacientovi závisí od naliehavosti stavu, načasovania elevácie a sprievodných okolností. Tento článok ponúka prehľadný návrh, ako postupovať pri vyšetrení elevácie pečeňových enzýmov aj z pohľadu evidence-based medicine.
The evaluation of increased plasmatic aspartate transaminase, alanine transaminase, γ-glutamyl transpeptidase, and alkaline phosphatase activities is fundamental to a differential diagnosis of liver disease. The correct interpretation of the results of tests for these activities demands much experience. The best option is to use the standardized guidelines to avoid overlooking important pathologies and performing unnecessary tests. Individual patients should be evaluated depending on the urgency of the situation, the timing of the elevation in liver enzymes, and other circumstances. This paper presents a simple recommendation about how to proceed when evaluating elevated liver enzyme levels with respect to evidence-based medicine.
- MeSH
- akutní nemoc MeSH
- alanintransaminasa analýza krev metabolismus MeSH
- algoritmy MeSH
- alkalická fosfatasa analýza krev metabolismus MeSH
- alkoholické nemoci jater enzymologie MeSH
- aspartátaminotransferasy analýza krev metabolismus MeSH
- autoimunitní hepatitida enzymologie MeSH
- cholestáza MeSH
- gama-glutamyltransferasa analýza krev metabolismus MeSH
- játra * enzymologie patologie MeSH
- léčivé rostliny klasifikace škodlivé účinky MeSH
- lidé MeSH
- nealkoholová steatóza jater enzymologie MeSH
- nemoci jater enzymologie metabolismus MeSH
- transaminasy * analýza klasifikace krev metabolismus MeSH
- virová hepatitida u lidí enzymologie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
BACKGROUND: Alcoholic liver disease is a major cause of liver cirrhosis and the hepatorenal syndrome is a serious complication. Risk factors for hepatorenal syndrome (HRS) in alcoholic liver cirrhosis are not entirely explored. AIM: To assess the risk factors for hepatorenal syndrome in alcoholic liver cirrhosis. PATIENTS AND METHODS: Consecutive patients with alcoholic liver disease were followed for two months, development of renal failure, classified either as HRS or renal failure not fulfilling criteria of HRS, was the main outcome. RESULTS: Of 171 patients, 14 (8.2%) developed HRS and 13 (7.6%), renal failure not fulfilling the HRS criteria. A significant difference was found between patients with and without HRS in serum sodium (131.1±3.8 vs. 135.7±5.2; P = 0.003), creatinine, (94.1±26.8 vs. 80.3±20.2; P < 0.001), albumin (23.5±4.9 vs. 29.9±5.8; P < 0.001), INR (1.76±0.45 vs. 1.44±0.41; P < 0.001), bilirubin (252.3±179.4 vs. 91.2±101.0; P < 0.001), MELD (23±6 vs 15±5; P < 0.001) and MELD-Na score (27±5 vs. 18±6; P < 0.001). Multivariate analysis adjusted for sex and age showed that sodium together with creatinine are the strongest HRS predictors, followed by bilirubin with respective odds´ ratios (95% CI) of 1.041 (1.012-1.072) for creatinine, 0.870 (0.766-0.988) for serum sodium and 1.005 (1.001-1.010) for serum bilirubin. CONCLUSION: Serum levels of sodium, creatinine and bilirubin are important predictors of the hepatorenal syndrome.
- MeSH
- akutní poškození ledvin etiologie MeSH
- albuminy terapeutické užití MeSH
- alkoholická cirhóza jater komplikace MeSH
- analýza rozptylu MeSH
- antihypertenziva terapeutické užití MeSH
- hepatorenální syndrom diagnóza farmakoterapie etiologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- lypresin analogy a deriváty terapeutické užití MeSH
- následné studie MeSH
- rizikové faktory MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
Duálna protidoštičková liečba (DAPT) s kyselinou acetylsalicylovou (ASA) a klopidogrelom signifikantne redukuje riziko vzniku infarktu myokardu a rekurentnej ischémie po akútnej koronárnej príhode oproti monoterapii s ASA. Pre zvýšené riziko krvácania u pacientov na DAPT, podľa súčasných konsenzuálnych odporúčaní, sú inhibítory protónovej pumpy (PPI) odporúčané pacientom s anamnézou predchádzajúceho krvácania do horného tráviaceho traktu a považované za vhodné u pacientov s viacerými inými rizikovými faktormi, ktorí potrebujú DAPT. V priebehu posledných rokov vznikli obavy ohľadom potenciálneho efektu PPI, predovšetkým omeprazolu, na zníženie účinnosti klopidogrelu, pričom tak Americká agentúra pre potraviny a liečivá (FDA), ako aj Európska agentúra pre lieky (EMA) vydali varovania týkajúce sa súčasného užívania týchto medikamentov. Predovšetkým farmakodynamické štúdie podporujú interakciu PPI – klopidogrel, zatiaľ čo klinické dôkazy, ktoré sú založené predovšetkým na nerandomizovaných, observačných štúdiách a sekundárnych analýzach randomizovaných štúdií, sú protichodné. Nateraz sa dá povedať, že klinická validita alebo závažnosť hypotetickej interakcie PPI – klopidogrel ostáva otázna. Tento článok poskytuje prehľad dostupných údajov zaoberajúcich sa liekovou interakciou medzi PPI a klopidogrelom.
Dual antiplatelet therapy (DAPT) with aspirin (ASA) and clopidogrel significantly reduces the risk of myocardial infarction and recurrent ischemia after an acute coronary syndrome as compared to ASA monotherapy. Due to the increased risk of bleeding in patients on DAPT, current consensus recommendations state that proton pump inhibitors (PPIs) are recommended in patients with prior upper gastrointestinal bleeding and considered appropriate in patients with multiple other risk factors who require DAPT. During the past few years concerns have been raised about the potential for PPIs, especially omeprazole, to decrease the efficacy of clopidogrel, and both the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) have issued warnings regarding the concomitant use of these medications. Above all the pharmacodynamic studies support PPI-clopidogrel interaction, whereas the clinical evidence, which is mainly based on nonrandomized, observational studies and secondary analyses of randomized trials, is conflicting. Up to now the clinical validity or relevance of the hypothesized PPI-clopidogrel interaction remains questionable. This article reviews existing data regarding the drug-drug interaction between PPIs and clopidogrel.
Dyspepsia predstavuje častý klinický problém so širokou diferenciálnou diagnózou a heterogénnou patofyziológiou. Dyspepsia postihuje takmer 40 % populácie a signifikantne znižuje kvalitu života. Na základe III. Rímskych kritérií je dyspepsia horného typu definovaná prítomnosťou jedného alebo viacerých z nasledujúcich symptómov: bolesť a/alebo pálenie v epigastriu (klasifikované ako syndróm epigastrickej bolesti), pocit plnosti po jedle a/alebo pocit skorej sýtosti (klasifikované ako syndróm postprandiálnej nevoľnosti). Iniciálne vyšetrenia by sa mali zamerať na identifikáciu a liečbu potencionálnych príčin symptómov, akými sú napr. refluxová choroba pažeráka, peptická vredová choroba a nežiaduce účinky medikamentov, ale takisto aj na rozpoznanie závažnejších príčin, ako je napr. rakovina žalúdka. Úvodným liečebným postupom u pacienta s dyspepsiou je buď empirický test s inhibítorom protónovej pumpy (PPI), alebo stratégia „testuj a lieč“ infekciu Helicobacter pylori, ktoré sú, v prípade ich zlyhania, nasledované endoskopickým vyšetrením. Diagnóza funkčnej dyspepsie sa stanoví až vtedy, keď sa vylúči organická príčina symptómov. V tomto článku autori poskytujú aktuálnu definíciu, etiológiu a všeobecný postup v diagnostike a liečbe pacientov s dyspepsiou, vrátane úlohy inhibítorov protónovej pumpy, liečby infekcie Helicobacter pylori a úlohy endoskopie. Kľučové slová: dyspepsia – funkčná dyspepsia – Helicobacter pylori – inhibítory protónovej pumpy
Dyspepsia is a common clinical problem with an extensive differential diagnosis and a heterogeneous pathophysiology. Dyspepsia affects up to 40 % of the general population and significantly reduces quality of life. According to the Rome III criteria, dyspepsia is defined as one or more of the following symptoms: epigastric pain and/or burning (classified as epigastric pain syndrome), postprandial fullness and/or early satiation (classified as postprandial distress syndrome). Initial evaluation should focus on the identification and treatment of potential causes of symptoms such as gastroesophageal reflux disease, peptic ulcer disease, and medication side effects but also on recognizing those at risk for more serious conditions such as gastric cancer. An empiric PPI trial or “test and treat” strategy for Helicobacter pylori are the initial approaches to a patient with dyspepsia, followed by endoscopy if initial management fails. Once an organic cause for symptoms is excluded, a diagnosis of functional dyspepsia is made. This article will review the definition, etiology, and general approach to the evaluation and management of the patient with dyspepsia including the role of proton-pump inhibitors, treatment of Helicobacter pylori, and endoscopy.
Endoskopia tráviaceho traktu, podobne ako všetky invazívne výkony, predstavuje možné riziko pre pacienta. Diagnostická a terapeutická ezofagogastroduodenoskopia (EGD), kolonoskopia a endoskopická retrográdna cholangiopankreatikografia (ERCP) sú špecializovanými endoskopickými výkonmi, ktoré vyžadujú osobitné podmienky na zabránenie vzniku komplikácií. So zvyšovaním počtu terapeutických endoskopických výkonov možno pozorovať zvyšujúci sa výskyt komplikácií neobvyklých po diagnostickej endoskopii. Dobrou prípravou a skúsenosťami možno mnohým komplikáciám predísť alebo ich úspešne zvládnuť. Včasné rozpoznanie komplikácií a ich okamžité riešenie znižujú nežiaduce následky pre zdravie pacienta. Táto práca prehľadovo uvádza výskyt, rozpoznanie a liečbu komplikácií po ezofagogastroduodenoskopii, kolonoskopii a endoskopickej retrográdnej cholangiopankreatikografii.
Endoscopy, like all invasive procedures, carries significant potential risks for the patient. Diagnostic and therapeutic esophagogastroduodenoscopy, colonoscopy and endoscopic retrograde cholangiopancreatography are specialized procedures that require sufficient experience to avoid the complications. With the growing use of therapeutic endoscopic procedures, complications that were uncommonly seen following diagnostic endoscopy occur more frequently. Having experience and skills many complications may be avoided and others successfully managed. Early recognition of complications and prompt intervention may minimize patient morbidity. This review provides the incidence, recognition and treatment of complications that may occur after esophagogastroduodenoscopy, colonoscopy and endoscopic retrograde cholangiopancreatography.
