Gastroenterology and Hepatology is an official peer-reviewed journal of the Czech Society of Gastroenterology and the Czech Society of Hepatology, the Slovak Society of Gastroenterology and the Slovak Society of Hepatology, published by the Czech Medical Association of J. E. Purkyně by the publishing house Care Comm. It is published on 6× a year. The articles are published in Czech, Slovak and English. The journal has been published since 1999, its previous name was Czech and Slovak Gastroenterology and Hepatology (ISSN 1213-323X). Gastroenterology and hepatology are indexed in the following databases: SCOPUS, CHEMICAL TITLES, EXCERPTA MEDICA/EMBASE, CHEMICAL ABSTRACTS, INIS Atomindex, Food Science and Technology Abstracts, Bibliographia Medica Čechoslovaca, Index Copernicus.
Doporučené postupy České gastroenterologické společnosti ČLS JEP pro diagnostickou a terapeutickou koloskopii – aktualizované vydání 2024
Low serum deoxyribonuclease I activity is associated with antiTNF-alpha induced skin adverse events in patients with inflammatory bowel disease
Background: A significant proportion of inflammatory bowel disease (IBD) patients develop skin complications during infliximab or adalimumab therapy. Both drugs are thoughtto act via induction of apoptosis in activated inflammatory cells. Deoxyribonuclease (DNase) I is endonuclease hydrolyzing double-stranded DNA during apoptosis and its deficiency has been implicated in several autoimmune disorders. Aim: To assess activity of DNase I in patients with IBD and to identify its impact together with other factors on development of skin immunopathological complications of biological therapy. Methods: IBD patients treated with infliximab or adalimumab at our centre from 2007-2009 were studied retrospectively for occurrence of skin non-infectious complications during this treatment and assessed for DNase I activity. A random sample of IBD patients treated with biological therapy without skin complications was also assessed. Serum was used to determine DNase I activity by enzyme-linked immunosorbent assay. Results: During the study period 313 patients with IBD were treated with biological therapy. Of them, 43 patients experienced non-infectious skin complications. 95 IBD patients on biological therapy without skin complications were also included. Univariate analysis identified female gender, adalimumab therapy, no concomitant corticosteroids and low DNase I activity as risk factors for skin complications. In multivariate analysis only low activity of DNase I (OR 0.45; 95% CI 0.29-0.71; p < 0.001) and adalimumab therapy (OR 30.8; 95% CI 6.87-138.16; p < 0.001) were associated with skin adverse events. Conclusions: Low DNase I activity may be a risk factor for development of immune-mediated skin complications during biological therapy in patients with IBD.
Komentář ke článku „Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission“ (Clinical Infectious Diseases)
Hereditary diffuse gastric cancer (HDGC) is an inherited form of the diffuse type of gastric cancer and a highly invasive type of tumour. Approximately 10% of patients with gastric cancer showfamiliar clustering and 3% autosomal dominance with a high HDGC penetration. It is an autosomal dominant inherited cancer syndrome in which affected individuals develop a diffuse type of gastric cancer at a young age. Inactivating mutations in the E-cadherin gene CDH1 have been identified in 30-50% of patients. CDH1 mutations carriers have an approximately 70% lifetime risk for developing diffuse gastric cancer (DGC) and affected women carry an additional 20-40% risk for developing lobular breast cancer. Common white light endoscopic surveillance is ineffective in identifying early HDGC. Gene-directed prophylactic total gastrectomy is currently being offered for CDH1 mutations carriers. Total gastrectomy is offered to patients who are five years younger than the youngest family member who developed gastric cancer, usually to patients older than 20. When refusing surgery, intensive endoscopic surveillance twice a year with multiple "protocol-based" and targeted biopsies combined with chromoendoscopy or NBI respectively are offered as an alternative option. Preventive total gastrectomy currently remains the only curative option for patients with HDGC.
Copyright (c) Array Gastroenterologie a hepatologie
Pancreatic cancer surveillance in high-risk individuals Position statement of professional societies
17th educational and discussion gastroenterology days
Diagnóza nízkého stupně dysplazie u pacientů s Barrettovým jícen - pravděpodobně "overdiagnosed"
výsledky a postupy - zhodnocení (zdravotní péče)
Switch from original to bio­similar adalimumab SB-5 in patients with Crohn‘s disease – long-term results
Background and aims: Originator-adalimumab, an established treatment for patients with Crohn‘s disease (CD) showed no difference in efficacy or adverse events vs the adalimumab biosimilar SB5 (SB5-adalimumab) over 10 weeks of treatment. To understand the long-term efficacy of SB5-adalimumab in CD, patients who switched from originator-adalimumab to SB5-adalimumab were compared to a cohort who remained on originator-adalimumab over a follow up of 104 weeks. Methods: In this analysis, data on patients ≥18 years and diagnosed with CD treated at the IBD ISCARE centre were collected prospectively between July 2018 and January 2021. Clinical disease activity as measured by Harvey-Bradshaw index (HBI) at Week 52 was the primary outcome, while C-reactive protein (CRP), faecal calprotectin (FC), adalimumab trough levels in Weeks 10, 26, 52, 78, and 104, adverse events leading to therapy withdrawal, and persistence on treatment were secondary outcomes. To ensure comparable treatment cohorts, patients were propensity score matched (PSM) for age, gender, diagnosis, and disease activity. Results: A total of 54 patients were matched according to the given criteria in each group. At Week 52, the mean [SD] HBI score was 3.2 (2.5) in the originator-adalimumab group and 4.0 (3.6) in SB5-adalimumab patients (difference [95% CI] –0.78 [–2.8, 1.3]). Similarly, no clinically significant differences in CRP, FC, or trough levels were noted between originator-adalimumab and SB5-adalimumab cohorts through Week 52. The Kaplan-Meier estimates (95% CI) of patients remaining on treatment for the originator-adalimumab vs SB5-adalimumab cohorts were 0.870 (0.785–0.965) vs 0.648 (0.533–0.789) at Week 52. Conclusions: These long-term study results in CD patients after a non-medical switch from originator-adalimumab to SB5-adalimumab showed that the biosimilar SB5 had similar therapeutic effects as originator-adalimumab in terms of clinical disease activity, biological parameters, and pharmacokinetics profile at the primary endpoint of 52 weeks, as well as 104 weeks. Differences in persistence were not clinically driven. Persistence on treatment was lower in patients treated with biosimilar adalimumab SB-5.
Dia­gnosis and endoscopic intervention in rare MALT lymphoma of the proximal jejunum
Extranodal lymphoma from the marginal zone mucosa-associated lymphoid tissue (MALT lymphoma) is one of the primary extranodal non-Hodgkin‘s lymphomas with low degrees of malignancy but with the risk of spreading to distant locations in the body. B-lymphomas are sometimes associated with other diseases (eg. Helicobacter pylori and Campylobacter jejuni infections or inflammatory bowel disease). B-lymphomas may manifest with a variety of clinical signs, from dyspeptic syndrome with malabsorption and weight loss to ileus or massive gastrointestinal bleeding. Diagnosis is based on the clinical condition and the results of laboratory tests and imaging techniques, while endoscopy is the essential procedure for visualizing the tumor mass and collecting a biopsy sample to determine the definitive histopathological diagnosis. MALT lymphoma treatment is managed by oncologists and includes chemotherapy and/or radiotherapy, with resection indicated in rare cases. In this case report we present an elderly female patient who was referred to our IBD centre for non-specific abdominal pain with a positive fecal occult blood test. Computed tomography (CT) examination was used before endoscopy and showed an infiltration of the splenic flexure by an unspecified mass, a subsequent colonoscopy showed intact mucosa of the colon, including the terminal ileum. In the second reading of the CT scan the location of the infiltrate was identified more specifically as the area of the proximal jejunum and jejunal mesentery. Subsequent upper endoscopy revealed a stenosing exulcerated tumor in the proximal jejunum, with the stenosis impassable even for a pediatric colonoscope. The diagnosis of MALT lymphoma was confirmed by a histological examination of the biopsied tissue. A follow-up upper endoscopy was performed after the patient had completed her oncological treatment (chemotherapy in combination with radiotherapy), showing the presence of stenosis at the proximal jejunum, still impassable for the endoscope. In clinical terms, the patient experienced weight loss, which was to some extent caused by intermittent pseudo-obstruction when on a solid diet, therefore we decided to enrich her oral intake with high-calorie sip feed. The next follow-up CT scan of the abdomen showed a regression of the infiltrate, but the stenosis of the proximal jejunum, about 7 centimeters long, persisted. To respect the patient‘s wishes, no surgical resection of the stenotic section of the intestine was performed, but we proceeded with endoscopic dilatation of the stenotic section of the jejunum with a balloon. After the first two endoscopic dilatations of the stenotic area the patient experienced a temporary improvement in solid food tolerance. Because of restenosis, a third endoscopic dilatation was performed, with the development of complications that included short-term circulatory instability with abdominal pain and eventually required an urgent surgical solution.
Part 2 – Epidemiology of inflammatory bowel diseases in the Czech population: available data sources, prevalence of treated patients and overall mortality
Colorectal cancer screening program in the Czech Republic – 2021 quality indicators evaluation
Background: Compared to other European countries, the Czech Republic has long been one of the countries with high rates of incidence and mortality of colorectal cancer. The screening program was implemented in 2000 and has become an essential part of prevention policy in the Czech Republic. Continuous monitoring of the entire screening process is necessary to ensure high quality and the resulting success of the program. The aim of the paper is to present the current results of the National Colorectal Cancer Screening Program using selected indicators in accordance with established recommendations. Material and Methods: The analysis was performed on data on preventive colonoscopies performed in Centers for screening colonoscopy (Centers) in 2021, with selected performance indicators being evaluated (number of preventive colonoscopies, adequate bowel preparation, caecal intubation rate and adenoma detection rate). The resulting performance indicators were evaluated by the published recommendations of the Czech Gastroenterological Society to point to the results of the program as a whole, not to assess individual Centers. Results: The majority (94.7%) of the Centers achieved the basic performance indicator (number of preventive colonoscopies). The performance indicator of adequate bowel preparation was met by 83.6% of Centers (the average proportion of colonoscopies with adequate bowel preparation in the Czech Republic is 93.8%). The optimal proportion of caecal intubation (90.0%) was reached by 87.2% of Centers in 2021. Only 16 Centers (8.5%) did not meet the adenoma detection rate indicator, but a high variability was observed across the Centers (11.6% to 68.2%) – a similar situation was observed in evaluation by gender and indication. A relatively low adenoma detection rate in follow-up colonoscopies after positive FOBT could be related to high and variable FOBT, which may indicate redundant colonoscopies and overburden the Centers. Conclusion: Some Centers do not reach the reference values for performance indicators according to reference values. It is necessary to continue monitoring performance indicators at the level of individual Centers to improve the quality of the entire program.
IBD patient care – the clinical practice of gastroenterology outpatient centres in the Czech Republic
The number of patients with inflammatory bowel disease (Crohn’s disease and ulcerative colitis) has increased steadily. Gastroenterology outpatient centres are playing a very important role in care for these patients. Clinical practice of care for patients suffering from idiopathic inflammatory bowel diseases at these centres was assessed in our study. The data was obtained using a structured questionnaire comprising four major topics (characteristics of the centre, diagnosis, therapy and monitoring of patients). The obtained data was compared with the local and international recommendations and showed high professional standards of care.
Guidelines for the administration of biological therapy in patients with inflammatory bowel diseases: 2nd edition
Gastroscopy – quality standards of the Czech Society of Gastroenterology
Effect of a synbiotic, ColonFit, in patients with irritable bowel syndrome, functional constipation and functional diarrhea
Background: Supplementary dietary fiber and probiotics may improve bowel symptoms due to changes in microbiome and fermentation. The aim of the study was the evaluation of symbiotic with psyllium, ColonFit, in patients with functional colonic diseases. Patients and Methods: A prospective observational study in patients with irritable bowel syndrome, functional constipation and functional diarrhea for a 4-week intake of ColonFit 10 g daily. The type and severity of bowel symptoms (scale 1–5), number and consistency of stool and quality of life features were analyzed in subgroups according to dominant initial symptoms. Results: Complete data were available from 110 patients (mean age 49.9 ± 15.3 years, 58.2% females). Constipation related symptoms were predominant in 46 (41.8%) patients, diarrhea in 28 (25.5%) and mixed type in the rest. The symptoms in constipation predominant group were more severe than in others. The significant change in softening of stool consistency (from 1.9 to 3.8 in Bristol stool scale; p < 0.001), an increase in spontaneous bowel movements (from 3.1 to 5.6× weekly; p = 0,001) and reduction of incomplete bowel movements of 40% and abdominal pain of 42% were observed in constipated patients. The reduction in a number of bowel movement per week (from 17.8 to 13.6; p = 0.001) and improvement of abdominal cramps by 27% and reduction of dietary limitations by 30% were recorded in diarrhea subgroup. The beneficial effect lasted for a two-week follow up after the discontinuation of ColonFit use. Conclusion: The ColonFit use was most beneficial in constipated patients. The improvement of several symptoms was observed in other subtypes of irritable bowel syndrome without any worsening of troubles. The use of the combination of psyllium, inulin and probiotics may offer an effective alternative for the management of functional bowel diseases.
Životné jubileum prof. MUDr. Rudolfa Hyrdela, CSc.
Exocrine pancreatic insufficiency – clinical practice in 2024
Exocrine pancreatic insufficiency (EPI) is characterized by insufficient secretion of pancreatic digestive enzymes. According to the mechanistic theory, the lack of pancreatic enzymes in the small intestine does not ensure the digestion of food, which is mainly associated with the lack of essential fatty acids and liposoluble vitamins and, as a result, leads to the inability to ensure the nutritional and metabolic needs of the organism. In diagnostics, the standard is determination of fecal elastase. This determination is simple, the limitation is the low sensitivity to determine possible changes in pancreatic function already in the so-called initial stages of the dis ease. An alternative to fecal elastase testing is the use of breath tests using a mixture of triglycerides, radioactively labeled with carbon C13. Although the test is non-invasive, it is time-consuming and more difficult to access. The clinical symptoms of EPI are mainly those related to microbial digestion and subsequent malabsorption/maldigestion of micro- and macronutrients. In addition to the subjective feeling of bloating, borborygmy or osmotic diarrhea, low levels of liposoluble vitamins and some trace elements are frequent findings. Osteoporosis or sarcopenia belong to the picture of EPI. In EPI therapy, diet therapy and pancreatic enzyme replacement are essential approaches. The principle is to administer an adequate dose, especially of pancreatic lipase: 40,000–50,000 units with main meals, with application during meals. Smaller meals (snacks) are substituted with half the dose. The optimal galenic form is capsules with a protective cover, against the inactivation of enzymes by gastric acid, before they enter the duodenum. The galenic form is capsules containing enzymes in microparticles, 1.0–2.0 mm in size, which are released from the capsule upon entering the duodenum. This is the so-called controlled synchronization of the liberalization of the enzymes contained in the capsule. EPI is an underdiagnosed and undertreated condition in the population. The control of patients must therefore include, in addition to the evaluation of the overall clinical condition, the monitoring of changes that may manifest malabsorption. It is recommended to monitor the nutritional status at least once a year, at regular intervals.
Bronchogenic duplication arises during embryogenesis from an abnormal budding of the ventral diverticulum of the foregut or the tracheobronchial tree. In this case report, we present a 50-year-old woman with an esophageal-intramural, bronchogenic cyst who showed symptoms of dysphagia progression. The final diagnosis of the cyst was unclear until definitive histology findings were obtained. After esophageal resection was performed, the postoperative course was uneventful.
Budesonide MMX in the treatment of ulcerative colitis
udesonide MMX is a novel formulation with extended release of the drug throughout the colon. Budesonide MMX is indicated for the induction of remission in patients with mild to moderate active ulcerative colitis where mesalamine treatment was not sufficient or tolerated. Thanks to low systemic availability, the treatment is not associated with traditional complications of glucocorticoid treatment and its safety profile is comparable to placebo. Limited data suggest that budesonide MMX may be effective for long-term maintenance treatment in selected patients. 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The selection from international journals
International experience with Crohn’s disease exclusion diet (CDED) with partial enteral nutrition (PEN)
The role of dietary intervention in the induction of remission of Crohn’s disease (CD) has been confirmed again by the recent ECCO (European Crohn’s and Colitis Organization) and ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) guidelines. Exclusive enteral nutrition (EEN) should be the method of choice in induction of remission of active luminal CD in children. Steroids should be reserved for situations when intolerance or infectivity of EEN is present. The main limitations of EEN consist of its monotony and palatability. In search for a safe and at least similarly effective diet, Crohn’s disease exclusion diet (CDED) was developed. The number of published data regarding its safety and efficacy has increased significantly since the publication of the first randomized controlled trial in 2019. CDED seems, to be safe and its efficacy is very promising. It seems that CDED could be used in three scenarios: as a monotherapy, as a part of complex treatment and as rescue therapy in cases of loss of response. The use of CDED is promising but further research for evaluation of its efficacy, including the necessity of using partial enteral nutrition, on larger patient cohorts is required.
Primary malignant tumours of the small intestine are rare; they only represent around 2% of all malignant tumours in the gastrointestinal system. Small intestine lymphomas represent less than one fifth of them. They create a quite heterogeneous group of mainly B-cell type non-Hodgkin's lymphomas. Their more difficult diagnostics ensues from their localisation with a need to use specialised endoscopy, imaging and immunohistochemical methods. Determination of the diagnosis is usually delayed due to the non-specific symptoms of the disease. Quite frequently we can experience complications. A spontaneous perforation of the small intestine requiring an urgent surgical solution occurs in 9% of patients. Capsule endoscopy and balloon enteroscopy, which have so far been the gold standard of the diagnostics of small intestine diseases, have an irreplaceable role in the diagnostics. Co-operation of a gastroenterologist, a pathologist and a hemato-oncologist is necessary as regards early diagnostics and therapy for these diseases as well as for further follow-up care of patients with a small intestine lymphoma.
Dispensarisation of patients after introduction of transjugular intrahepatic portosystemic shunt - diagnostics of shunt dysfunction and the possibilities of intervention
An article focuses on the overview of dispensarisation of patients after the introduction of transjugular intrahepatic portosystemic shunt mainly from the viewpoint of the diagnostics of shunt dysfunction and the possibilities of its solution.
transjugulární intrahepatální portosystémový zkrat
American gastroenterology - is the situation worsening?
Recommended surgical treatment methods in patients with idiopathic inflammatory bowel diseases – part 1: pre‑operative preparation
Medical care for patients with inflammatory bowel diseases (IBD) is complex. The gastroenterologist and surgeon are the most engaged specializations. Surgical treatment improves the quality of life, however its results depend on the correct indication for surgery, on the patient’s preconditioning and appropriate timing. The aim of the working group for inflammatory bowel disease is to create a review of conditions for surgical treatment, its relationship to conservative treatment and appropriate operating procedures for optimal care of patients with IBD. The first part of the review is focused on the preparation of patients for surgery.
Impact of anti-TNFα exposure in utero on the development of immune systems of exposed children – a controlled, multicentre observational study
Background: Data on safety of in utero exposure to anti-tumor necrosis factor (TNF) α on long-term childhood development are sparse. Our aim was to assess the impact of in utero exposure to anti-TNFα on the postnatal development of immune systems of exposed children. Methods: Children (≥ 12 months of age) born to mothers with inflammatory bowel disease (IBD) (2007–2016) treated with anti-TNFα during pregnancy in three centres were included. Unexposed children of non-IBD mothers who came for mandatory check-up to the general pediatrician served as a control group. A predefined questionnaire was distributed by the pediatricians to collect data on the perinatal period, infectious complications, antibiotic use, and vaccination. Results: We included 72 exposed and 69 unexposed children (median age 35 months and 50 months, respectively). No significant difference in infectious complications ≤ 1st year of life (23.9 vs. 17.4%, p = 0.36) or during the whole follow-up (p = 0.32) was found between exposed infants and controls. Concomitant immunosuppressive therapy during pregnancy and anti-TNFα levels in cord blood did not increase the infection rate ≤ 1st year of life (p > 0.05). Protective titers of antibodies to vaccination were found in > 95% of exposed children except for H. influenzae and mumps vaccines. However, these two vaccines had the lowest serologic response in the control group, too. Conclusions: Treatment with anti-TNFα during pregnancy seemed to be safe with regard to postnatal development of the immune systems of exposed children.
Therapy of colorectal carcinoma liver metastases
Introduction: Sixty percent of patients with colorectal carcinoma develop liver metastases (LMKRK). Surgical treatment is the most frequent treatment modality and has a 5-year survival rate of near 50%. However, less than 20% of patients with LMKRK undergo lLiver resection. Systematic treatment may allow resection of primary unresectable patients or may significantly prolong life expectancy. The optimal treatment strategy is decided by a multidisciplinary team. Surgical treatment: We defined the technical and oncological aspects of resectability and evaluated the incidence of liver remnants, eventually possibilities of its enlargement. We also mention the different surgical treatment methods including type of resection method, multi-step approach, liver first approach, and radiofrequency ablation. Systemic treatment: Developes rapidly, current options for chemotherapy and biological treatment are mentioned. Also, the indications for perioperative treatment in patients with resectable disease are mentioned. Conversion therapy in patients with primary unresecable disease is discussed. Conclusion: Despite developments in systematic therapy, liver resection is still the best curative method for LMKRK treatment. Close cooperation with liver surgeon and a clinical oncologist within a multidisciplinary team is a crucial condition for increasing resectability in patients with LMKRK.
The avareness and participation in preventive programs for colon and breast cancer – study from Nothern Bohemia
SUMMARY Pechová P, Suchánek Š, Zavoral M, Závada F, Deák M, Martínek J. The avareness and participation in preventive programs for colon and breast cancer - study from Nothern Bohemia Introduction: Colorectal cancer (CRC) and breast cancer (BC) belongs to the most oft en occurring tumor in the Czech population. Based on this fact, national preventive programs (mammography, FOBT, colonoscopy) were introduced. However, the awareness and participation of the target population in those programs are unknown. The aim: The main aim of the study was to assess the awareness and participation of the target population in preventive programs of both CRC and BC in the Česká Lípa County. Material and methods: According to a population register in the cities Nový Bor and Cvikov, anonymous questionnaires were distributed randomly to the persons older than 50 years. We distributed 260 questionnaires, backflow was 96%. Both, men (n = 116) and women (n = 133) were questioned about CRC and only women were questioned about BC. Th e average age of the respondents was 58.3 (±5.4) years. Results: Seventy-nine percent of the respondents were informed about CRC (81% women, 77.6% men; NS). The most important source of in formation was the media (62%). The second most important source of information was a general practitioner (26%). However, only 30.5% of persons participated in the screening program (with no difference in gender). The main reason not to participate was a low priority for screening (39.2%), anxiety (21%) and abashment (16%). Ninety-nine percent of all asked women were informed about the BC screening and 90.2% came to a screening mammography. The main source of information was their doctor-gynecologist (74%) followed by the media and publicity (17.6%). Conclusion: The awareness of the population about the screening program of CRC is relatively good but the participation (30%) of the target population is insufficient. The awareness and the participation in the BC screening program are high approaching almost 100%. People are informed about CRC mostly from the media, while the information about BC comes mostly from gynecologists. Th us, gynecologists could play a positive role in the national screening program of CRC. Key words: breast cancer - colorectal cancer - prevention - screening.