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Summary: Background: Hot-snare polypectomy is a standard method for removal of polyps larger than 10 mm. It is recommended to discontinue anticoagulant therapy before this procedure to reduce a bleeding risk. In contrast, diagnostic colonoscopy and cold-snare polypectomy up to 10 mm are considered safe during uninterrupted anticoagulation therapy (with only omission of the direct oral anticoagulant therapy on the day of the procedure). The increasing number of anticoagulated individuals undergoing a colorectal cancer screening program leads to efforts to individualize the interruption of anticoagulation therapy. Aim: Estimation of probability that adenomatous polyp over 10 mm is detected during preventive colonoscopy in the Czech Republic in particular population groups according to gender and age. Methods: We retrospectively analyzed data from prospective database (Registry of Preventive Colonoscopies) covering screening colonoscopies and colonoscopies indicated for immunochemical faecal occult blood test positivity (FIT-positive). A distinction was made between adenoma polyps ≤10 mm and >10 mm. The patient was categorized according to the largest polyp diameter in case of detection of multiple polyps. Results: Between 2016 and 2020, 16,942 and 52,052 adenomatous polyps were found during 55,546 screenings and 119,229 FIT-positive colonoscopies, representing adenoma detection rate (ADR) of 31% and 44%, respectively. The estimate of probability of significant polyp detection (over 10 mm) and the need of hot-snare polypectomy ranged widely (2.3–21.6%) depending on age, sex and indication. It can be estimated to 7% in females and 5–10% in males undergoing screening colonoscopy. For colonoscopies indicated for positive stools for occult bleeding, this probability is approximately two to three times higher in FIT-positive colonoscopies: it exceeds 10% in woman over 60 years of age and is 15% and more in men of all ages (over 20% in men over 60 years of age). Conclusions: The decision to discontinue anticoagulation therapy prior to preventive colonoscopy can be individualized with respect to the indication (screening vs. FIT-positive), age and gender of examined person – we prefer to discontinue the anticoagulation therapy in FIT-positive people over 60 years and/or of male gender. The individual thromboembolic risk during interruption of anticoagulation therapy must be considered depending on the specific indication (e. g. CHA2DS2 VASc score in atrial fibrillation). Key words: colonoscopy – anticoagulant therapy – direct-acting oral anticoagulants – cancer screening – personalized medicine

Introduction: To date, there is not generally accepted and universal indicator of activity, and functional integrity of the small intestine in patients with coeliac disease. The aim of our study was to investigate whether serum concentrations of the non-essential amino acids citrulline and ornithine might have this function. Methods: We examined serum citrulline and ornithine concentrations in a subgroup of patients with proven coeliac disease and healthy controls (blood donors). Results: A total of 94 patients with coeliac disease (29 men, mean age 53 ± 18 years; 65 women, mean age 44 ± 14 years) and 35 healthy controls (blood donors) in whom coeliac disease was serologically excluded (10 men, mean age 51 ± 14 years; 25 women, mean age 46 ± 12 years) were included in the study. Significantly lower concentrations of serum ornithine were found in patients with coeliac disease (mean 65 ± 3 μmol/L; median 63 μmol/L, IQR 34 μmol/L, p < 0.001). No statistically nor clinically significant differences were found in the citrulline concentrations between the study and control group. Conclusions: Serum ornithine (but not citrulline) may be useful for assessing the functional status of the small intestine in uncomplicated coeliac disease. Further studies involving more detailed analysis of dietary and metabolic changes in patients will be needed to reach definitive conclusions.

Antithrombotic therapy and digestive endoscopy Antithrombotic therapy comprises anticoagulation and antiplatelet treatment. The number of patients treated with various forms of antithrombotic therapy is growing. Procedures of digestive endoscopy are very frequently indicated by general practitioners and doctors of various specialisations. Interdisciplinary cooperation and mutual understanding are required in order for digestive endoscopy to be effective and safe. Hence, we present an overview based on recent European, British (1), and North American guidelines (2) for endoscopic procedures, with respect to guidelines for perioperative care in general (3). Antithrombotic therapy management in patients undergoing digestive endoscopy procedures is based on individual consideration of postprocedural bleeding (particularly a delayed one) on one hand, and thromboembolic risk on the other hand, ideally in cooperation with the physician prescribing antithrombotic therapy. Despite all efforts, patients taking antithrombotic medication are at a higher risk of postprocedural bleeding in comparison with those without this risk; this fact should be accepted by attending physicians and patients should be informed of it. Postprocedural bleeding is mostly manageable with a subsequent endoscopic procedure. By contrast, cerebral and cardiovascular thromboembolic complications are often life-threatening and not uncommonly disabling. One should always consider postponing an elective procedure in a patient with temporary antithrombotic therapy (after pulmonary embolism or after coronary stent insertion). Basic principles of administration of antithrombotic therapy in the context of an endoscopic procedure are described in Table 1. Digestive endoscopy procedures can be categorized according to postprocedural bleeding risk (Table 2). Postprocedural bleeding risk can be specifically reduced in some procedures (ERCP with papillary balloon dilation instead of sphincterotomy, mechanical securing of polypectomy base, etc.). Acetylsalicylic acid administered as secondary prevention (primary preventive indications are very narrow nowadays) should not be discontinued perioperatively (discontinuation is associated with an approximately threefold increase in thrombotic complications!). The riskiest procedures are the only exception in which discontinuation is explicitly requested by the digestive endoscopist. Reduction of dual antiplatelet therapy is better abandoned in high-risk patients - particularly those with recently implanted coronary stents (Table 3) - and postponement of an elective procedure should always be considered. Bridging of warfarin with low-molecular-weight heparin (LMWH) is not indicated routinely (in some cases, this practice increases the bleeding risk). Bridging with LMWH is appropriate in patients with high (or moderate) thromboembolic risk (Table 5). Furthermore, LMWH therapy carries specific risks, particularly in patients with renal function impairment (Table 4). In patients with a high thromboembolic risk, a statement of the physician indicating anticoagulation is always appropriate before an elective procedure (Table 6). Direct oral anticoagulants (DOACs) should not be administered on the day of the procedure, not even in one with a low risk (e.g., biopsy); a longer withdrawal is recommended in high-risk procedures (this cessation should not be bridged with LMWH given the rapid onset and elimination half-time) (Table 7). Recommencement of antithrombotic therapy after a high-risk endoscopic procedure should always be determined by the endoscopist and the recommended intervals should be considered minimal: 1-2 days after the procedure in the case of P2Y12 inhibitors; 2-3 days after the procedure in the case of DOACs; in the evening of the day of the procedure for warfarin with a maintenance (not saturation) dose; and 48 hours after the procedure in the case of LMWH at a therapeutic dose. Earlier administration of a lower-than-therapeutic dose of LMWH (twice a day per weight) can be considered in this context: prophylactic (once a day) or higher prophylactic (once a day per weight) doses. In general, a full anticoagulation effect should not be achieved earlier than approximately 48 hours after the procedure. The patient should be properly informed of the course of antithrombotic therapy before and after the endoscopic procedure, including a written form (a calendar can be downloaded online for this purpose).

Liver cirrhosis represents a common condition with substantial mortality. Manifestation and progression of ascites, hepatic encephalopathy or gastrointestinal bleeding are among main reasons for hospital admission. Infections represent another specific area in cirrhotic patients. Timely and correct diagnosis and therapy of these conditions are the mainstay of optimal outcome. Manifestation of complications of liver cirrhosis significantly deteriorates prognosis of the patient. Ascites in portal hypertension develops as a result of sodium and consequently water retention. Therapy comprises of restriction of sodium intake, diuretic therapy with combination of spironolactone and furosemide, alternatively large-volume paracentesis. Hepatic encephalopathy comprises a spectrum of neuropsychiatric abnormalities from subtle changes to overt desorientation and asterixis to hepatic coma. Treatment includes correcting of predisposing conditions, administering of non-absorbable disaccharides or rifaximin. The most common cause of bleeding in a cirrhotic patient is oesophageal bleeding. Therapy is complex including hemodynamic stabilisation, antibiotic prophylaxis, vasoactive and endoscopic treatment. Infections are common causes of decompensation and occurrence of complications of advanced chronic liver disease. Their unfavourable outcome is a result of a complex immune disorder in cirrhotic patients. Specific type of infection in cirrhosis is spontaneous bacterial peritonitis, which has to be always excluded with diagnostic paracentesis. The mainstay of successful therapy of infections is timely and vigorous broad spectrum antibiotic therapy which can significantly improve otherwise unfavourable outcome of these patients.

Doporucene postupy Ceske gastroenterologicke spolecnosti k zavedeni perkutanni endoskopicke gastrostomie.

Uvod: Koronarograficke vysetřeni (KG) je zlatým standardem v diagnostice obstrukcni koronarni aterosklerozy u pacientů s vysokou předtestovou pravděpodobnosti ischemicke choroby srdecni (ICHS PTP) a u pacientů se středni PTP s prokazanou prognosticky významnou ischemii při zatěžovem vysetřeni. Pro vyssi senzitivitu a specificitu jsou preferovany zatěžove zobrazovaci metody před zatěžovou elektrokardiografii. Cilem prace bylo analyzovat profil nemocných přichazejicich k elektivni KG z důvodu podezřeni na ICHS.Soubor a metody: Retrospektivně byl analyzovan soubor 184 pacientů, kterým byla provedena v obdobi od dubna do srpna 2016 v Kardiocentru Fakultni nemocnice Hradec Kralove elektivni KG pro podezřeni na ICHS. Analyzovali jsme rizikový profil pacientů, využiti testů k průkazu ischemie a vztah jejich výsledků k nalezu při KG. Za pozitivni KG nalez byla považovana stenoza věncite tepny ≥ 50 % v alespoň jednom koronarnim povodi.Výsledky: Ve sledovanem souboru převažovali pacienti se středni PTP - 154 (84 %), pacientů s nizkou a vysokou PTP bylo 6 (3 %), resp. 24 (13 %). Sto dvanact (61 %) pacientů mělo negativni a 72 (39 %) pozitivni nalez KG. Zatěžove vysetřeni bylo provedeno ve 43 připadech (23 %) z celeho souboru, výrazně převažovalo zatěžove elektrokardiograficke vysetřeni nad zatěžovými zobrazovacimi metodami - 37 (86 %) versus 6 (14 %). Ve skupině se střednim rizikem bylo provedeno zatěžove vysetřeni u 36 (23 %) pacientů, z toho se v 92 % jednalo o zatěžovou elektrokardiografii. Žadný pacient s nizkou PTP neměl pozitivni KG, ve střednim PTP byla pozitivni KG v 38 % a ve skupině s vysokým PTP v 54 %. U pacientů, kteři měli provedeno ergometricke vysetřeni s pozitivnim nalezem, byla pozitivni KG pouze v 10 %. Typickou anginu pectoris mělo 44 % pacientů s pozitivni a 39 % pacientů s negativni KG.Zavěr: Větsina pacientů odeslaných k elektivni KG ma středni riziko ICHS. Samotna anamneza neni dostacujici k spravnemu odhadu přitomnosti ICHS. Zatěžove metody k průkazu ischemie jsou provaděny omezeně, převažuje zatěžova elektrokardiografie, ktera neni k průkazu ischemie v praxi dostatecně spolehliva. Zatěžove zobrazovaci metody nejsou dostatecně využivany. Pocet negativnich elektivnich KG ve vysetřovanem souboru je vysoký.

Familial adenomatous polyposis (FAP) is a hereditary disease characterized by presence of numerous colorectal adenomas. It often exposes its carrier to absolute risk of colorectal cancer, but also to other extracolonic tumours (especially to duodenal cancer and desmoid). Screening and surveillance of FAP patients leads to reduction of colorectal cancer incidence and mortality. Colonoscopy/lower endoscopy and esophagogastroduodenoscopy (including use of side-viewing endoscope) are the principal examinations. Colectomy is the standard therapeutic procedure, but endoscopic therapy plays relevant role both in upper and lower gastrointestinal tract. Recent international guidelines and some new tools for severity classification enable effectively reduce the mortality related to this disease by individualized patient management. Key words: colorectal cancer - familial adenomatous polyposis.

Background: Occurrence of gastric metastasis as the first symptom of breast carcinoma with a long period of latency before presentation of the primary breast carcinoma is rare. Case Report: A patient with gastric metastasis as the first symptom of lobular breast carcinoma, treated by neoadjuvant preoperative chemoradiotherapy and total gastrectomy, with complete local control. Fourteen months after presentation of the gastric metastasis a primary lobular breast carcinoma was discovered, treated by radiotherapy, chemotherapy and hormonal treatment with complete local response. Twenty-three months after diagnosis of breast cancer multiple colorectal metastases from the breast cancer occurred, which were treated by chemotherapy and hormonal treatment. Eighty-six months after diagnosis of gastric metastasis the patient died due to progression of cancer. Conclusions: Metastases to gastrointestinal or gynaecological tracts are more likely in invasive lobular carcinoma than invasive ductal cancer. The pathologist should determine whether or not they check estrogen and progesterone receptor status not simply by signet ring cell morphology but also by consideration of clinic-pathological correlation of the patient, such as the presence of a past history of breast cancer, or the colorectal localization of poorly differentiated carcinoma, which may occur less frequently than in the stomach.