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Endocrine diseases may have systemic involvement. The aim of this paper is to review gastrointestinal and motility dysfunction in endocrine diseases. We review motility disturbances in thyroid disorders, acromegaly, Cushing syndrome, neurohypophysis disorders, diabetes, para thyroid diseases, and multiple endocrine neoplasia, with emphasis placed on the correlation with the blood levels of gastrointestinal hormones that may inter fere with the brain‑gut axis at various levels.

The hamartomatous polyps in Peutz-Jeghers syndrome may have malignant potential. To differentiate between hamartomatous and adenomas polyps, vascular characterization can be assessed using noninvasive procedures, such as contrast-enhanced ultrasound (CEUS). The neo-angiogenic characteristics of colorectal adenomas and carcinomas are expressed as an anarchic vascular pattern observed on CEUS. Using CEUS in a patient with Peutz-Jeghers syndrome, we describe for the first time the vascularization of a hamartomatous colonic polyp that exhibits a hierarchy branching pattern.

A fecal microbiota transplant has proved to be an extremely effective method for patients with recurrent infections with Clostridium difficile. We present the case of a 65-year-old female patient with multiple Clostridium difficile infection (CDI) relapses on the rectal remnant, post-colectomy for a CDI-related toxic megacolon. The patient also evidenced associated symptomatic Clostridium difficile vaginal infection. She was successfully treated with serial fecal “minitransplants” (self-administered at home) and metronidazole ovules.Abbreviations: GI: gastrointestinal; MRI: magnetic resonance imaging; CDI: Clostridium difficile infection; FMT: fecal microbiota transplant.

Background and aims. Fecal microbiota transplantation is used with success in persistent (more than two episodes) Clostridium Difficile Infection; it has also gained importance and started to be used in inflammatory bowel disease. There are theoretical arguments that justify its use in ulcerative colitis or Crohn’s disease. Based on our clinical cases we tried to evaluate the indications of fecal microbiota transplantation young patients with ulcerative colitis and multiple relapses, in which biological or immunosuppressive treatment were ineffective.Methods. Five patients with moderate-severe ulcerative colitis or Clostridium Difficile infection who ceased to have a therapeutic response to biological therapy, were given fecal microbiota transplant as an alternative to biological therapy and/or immunosuppression. Fecal microbiota transplant was administered via colonoscopy using healthy donors from their family.Results. The results were favorable and spectacular in all patients and complete remission was achieved for at least 10 months. Clinical remission was achieved in all patients. Endoscopic appearance of ulcers in patients improved. In 2 patients the effect of the fecal microbiota transplant diminished after 10-12 months and the tendency to relapse appeared (3-4 stools/day, blood streaks present sometimes in the stool). Reintroduction of systemic therapy or immunosuppression demonstrated that patients regained the therapeutic response to these treatments, and remission was maintained.Conclusion. Fecal microbiota transplantation can be used as salvage therapy in patients refractory to biological therapy, as elective therapy in clostridium difficile infection or as an alternative therapy in young patients with multiple relapses who have reservations regarding biological or immunosuppressive treatment.

Background Whitish intraluminal esophageal masses might represent the endoscopic feature of a bezoar or a pedunculated tumor, most likely a fibrovascular polyp, without exclusion of other mesenchymal tumors (leiomyoma, lipoma, gastrointestinal stromal tumor, leiomyosarcoma, granular cell tumor). If a process of dystrophic calcification is also encountered the differential diagnosis can be a challenge even after histological analysis, as it is highlighted by our case. Case presentation A 65-year-old female whom took lactate calcium tablets for 5 years presented with progressive dysphagia. A whitish esophageal mass with an appearance of a pharmacobezoar was detected at esophagoscopy. A pedunculated tumor was considered in the differential diagnosis, but the imagistic studies ruled out a pedicle. This intraluminal esophageal mass highly suggestive for a pharmacobezoar was endoscopically removed. The challenge of correct diagnosis was raised by histological examination performed after immersion into trichloracetic acid for decalcification. The identification of hyaline fibrous tissue, with numerous crystalline basophils deposits of minerals, rare fibrocytes and very few vessels brought in discussion a mesenchymal originating mass, most likely a fibrovascular polyp, even the pedicle was not detected. Conclusion Based on our challenging and difficult to diagnose case we proposed an uncommon evolution: auto-amputation and calcification of an esophageal mesenchymal originating tumor (most likely a fibrovascular polyp).

A 51-year-old male without significant medical history was admitted to the emergency department for two-week history. The patient reported a two-week history of fever, right upper quadrant abdominal pain, nausea and vomiting. He did not respond to empirical ampicillin treatment. He admitted a history of alcohol consumption and smoking. The clinical examination revealed mild jaundice, poor dentition and moderate right upper quadrant tenderness. Laboratory analysis detected leukocytosis with neutrophilia, thrombocytosis, iron deficiency anemia, mild elevation of direct bilirubin level and moderate cholestasis.

Hemosuccus pancreaticus is defined as upper gastrointestinal hemorrhage from the ampulla of Vater via the pancreatic duct. It is a rare disease, with non-specific presentation, challenging to diagnose and difficult to treat, with high mortality rates in untreated patients with massive bleeding. Given the intermittent nature of the bleeding, delays in diagnosis frequently occur. Timely diagnosis and treatment seem to result in markedly reduced mortality, therefore we emphasize the diagnostic contribution of imaging techniques by presenting the case of a patient with chronic pancreatitis in whom computed tomography established the diagnosis of blood in the Wirsung duct and contrast-enhanced ultrasound brought its added value by excluding the active bleeding.

Atypical symptoms of celiac disease may cause a late diagnosis, revealed by the onset of complications, which may inaccurately be attributed to Crohn's disease, as manifestations frequently overlap. Assessing the entire small bowel mucosa, capsule endoscopy may be an accurate procedure in these challenging situations. We present four Crohn's disease patients diagnosed with ulcerative jejunoilieitis complicating celiac disease after capsule endoscopy procedure. In three of these patients, the ulcerative jejunoileitis led in time to stricture formation, suggesting Crohn's disease. Administration of non-steroidal anti-inflammatory drugs made the diagnosis even more difficult in one case. In patients with Crohn's disease not responding to immunosuppressive or biological treatment, complicated celiac disease should be considered and capsule endoscopy should be performed for reassessing the diagnosis.

Dieulafoy's-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.

Normal and pathological vascularization can be examined using imaging methods. The use of contrast agents (CA), tracers or markers within the bloodstream, has gained more and more applications in the last years. The dynamics of the CA passing through a region of interest is directly correlated with the morphological and functional characteristics of the bloodstream in that particular area. Doppler ultrasonography provides information only regarding the flow within large vessels, the method having limited spatial resolution and sensitivity in the assessment of the capillary flow. Contrast-enhanced ultrasonography (CEUS) enables the detection of very slow blood flow or stagnating blood in vessels measuring as little as 40 microns. This feature is extremely valuable in the characterization of a circulatory bed and for the evaluation of the tumoral angiogenesis process. CEUS may be used both for diagnosis and for the assessment of treatment efficiency. Further on various aspects regarding this method, its advantages and limitations and arguments for its systematic use in oncology, will be presented in this review.

Recent studies suggest that Candida albicans colonization is associated with several gastrointestinal inflammatory disorders and is also responsible for the delay in ulcer healing. No data are reported about the effects of C. albicans on the nonsteroidal anti-inflammatory drugs (NSAIDs)-induced necroinflammatory lesions. On the other hand, beneficial effects of NSAIDs regarding the colonization potential with C. albicans have been reported. Our aim was to investigate whether the association between NSAIDs and C. albicans could potentially induce necroinflammatory lesions in the guinea pigs gastric and enteral mucosa. Three interventional groups of 11 guinea pigs each were investigated after 5 days of receiving indomethacin, C. albicans or the association of both. C. albicans and necroinflammatory lesions were graded based on histological examinations. Statistical analysis used Mann-Whitney nonparametric test. NSAIDs did not significantly decrease C. albicans colonization grades on gastrointestinal mucosa. Administration of indomethacin subsequent to C. albicans determined significantly more severe necroinflammatory lesions compared to group that only received C. albicans. The association of NSAIDs and C. albicans did not cause significantly more severe degenerative or inflammatory lesions compared to the administration of only NSAIDs in this experimental model. Associations between NSAIDs and C. albicans caused significantly more severe necroinflammatory injuries than the lesions produced by C. albicans, without enhancing the mucosal injury or inflammation caused by NSAIDs.

SummaryObjective: To assess the ability of a contrast-enhanced magnetic resonance imaging (MRI) technique to quantitatively determine glycosaminoglycan content in canine articular cartilage.Methods: Fifty-four full-thickness cartilage discs were collected from the femorotibial and scapulohumeral joints of three adult dogs immediately following euthanasia. One set of discs from each dog was analysed for glycosaminoglycan content using a colourimetric laboratory assay. The remaining position-matched set of discs from contralateral limbs underwent pre- and post-contrast gadolinium-enhanced MRI, using repeated saturation recovery pulse sequences which were used to generate calculated T1 maps of the cartilage discs. Linear regression analysis was then performed relating delayed gadolinium-enhanced MRI T1 calculated signal intensity to the cartilage glycosaminoglycan content normalized to DNA content. Repeatability of triplicate measurements was estimated by calculating the coefficient of variation.Results: Mean coefficient of variation estimates for the gadolinium-enhanced MRI T1 signal intensity values for nine sampling sites from three dogs ranged from 5.9% to 7.5%. Gadolinium-enhanced MRI T1 signal intensity was significantly correlated (p Clinical significance: Gadolinium-enhanced MRI assessment of cartilage may be predictive of glycosaminoglycan content and therefore offer an in vivo assessment of changes in cartilage characteristics over time. Additional studies appear indicated to determine the reliability and clinical applicability of gadolinium-enhanced MRI in detecting changes in cartilage over time.

The noninvasive diagnosis of the malignant tumors is an important issue in research nowadays. Our purpose is to elaborate computerized, texture-based methods for performing computer-aided characterization and automatic diagnosis of these tumors, using only the information from ultrasound images. In this paper, we considered some of the most frequent abdominal malignant tumors: the hepatocellular carcinoma and the colonic tumors. We compared these structures with the benign tumors and with other visually similar diseases. Besides the textural features that proved in our previous research to be useful in the characterization and recognition of the malignant tumors, we improved our method by using the grey level cooccurrence matrix and the edge orientation cooccurrence matrix of superior order. As resulted from our experiments, the new textural features increased the malignant tumor classification performance, also revealing visual and physical properties of these structures that emphasized the complex, chaotic structure of the corresponding tissue.

Endocrine diseases may have systemic involvement. The aim of this paper is to review gastrointestinal and motility dysfunction in endocrine diseases. We review motility disturbances in thyroid disorders, acromegaly, Cushing syndrome, neurohypophysis disorders, diabetes, parathyroid diseases, and multiple endocrine neoplasia, with emphasis placed on the correlation with the blood levels of gastrointestinal hormones that may interfere with the brain-gut axis at various levels.

The inflammatory bowel diseases (IBD) are severe, chronic and recurring disorders, requiring continuous patient monitoring. The most reliable methods for the diagnosis of the inflammatory bowel diseases are invasive (endoscopy, colonoscopy, histopathology) or irradiating (CT). We aim to develop computerized methods for the noninvasive assessment of the bowel inflammation level based on information obtained from ultrasound images. In this work, we study the role of the textural parameters in characterizing different types of inflammatory bowel diseases and the colorectal tumors. The dimensionality reduction techniques are taken into consideration in order to obtain the relevant textural features and to improve the result of the automatic diagnosis. The Principal Component Analysis (PCA) method and the Correlation based Feature Selection (CFS) method, as well as their combinations, are assessed for this purpose. The methods of Support Vector Machines (SVM) and Multilayer Perceptron (MLP), which gave very good results in our former experiments, are implemented for the automatic diagnosis. B-mode ultrasound images belonging to biopsied patients, are used. The patients were suffering from the following types of diseases: Crohn’s disease, ulcerative recto-colitis, colo-rectal cancer.

The evaluation of digestive wall lesions has benefited in latter years from advanced, noninvasive techniques such as contrast enhanced ultrasound (CEUS). This method appreciates the microcirculation in inflamed bowel segments in terms of qualitative and quantitative parameters. Based on precise and reproducible criteria it evaluates the extension and the activity of disease, as well as the presence of complications. Monitoring studies using quantitative measurements of inflammation could lead to the development of prognostic factors regarding the treatment efficacy. The performance of this method can be improved by the use of intraluminal contrast media.

The pathology of the digestive tract, extremely popular, with equal sex distribution, can have a clinical history of chronic illness or emergency. Diagnosis is based on endoscopy (identifies the lesion, permits histological sample under visual control, and minimally invasive treatment for polypoid benign tumors). Ultrasonography, being non-invasive and very accessible, is often used as the initial imaging procedure to detect or exclude digestive pathology with similar symptoms. Understanding digestive ultrasound is conditioned by the image quality which can be achieved by removing air and food debris. Even so, the characteristics of the inflammatory diseases and the detection of tumors, particularly those with endoluminal development, can be difficult. In recent years transabdominal ultrasound examination of the digestive tract was supplemented with more precise methods of investigation of the lumen and circulation of the intestinal wall. These methods are represented by the administration of oral or ano-rectal homogenous substances (hydrosonography) and the by intravenous administration of agents containing stabilized microbubbles (CEUS). With these methods useful information are being obtained, high in sensitivity and specificity of lesions characterization. Judicious selection of the cases and of the examination technique remains the key to a successful diagnosis in all situations.

Alkaline reflux esophagitis is a complication that might develop in patients with total gastrectomy. The aim of the study was to analyze the prevalence and severity of reflux esophagitis and the occurence of complications (Barrett's esophagus and esophageal stenosis) in patients with total gastrectomy and Roux en Y esojejunostomy.92 patients with total gastrectomy performed for gastric cancer were included in the study. None of the patients had esophagitis prior to gastrectomy. The patients were assessed clinically and endoscopically after a certain interval from surgery.An important number of patients (14 out of 92, 15.22%) had reflux esophagitis; 5.43% of the patients had also complications of reflux esophagitis (Barrett's esophagus and benign esophageal stenosis) and 6.52% had local tumor recurrence. Of the 14 patients with reflux esophagitis, the majority (9/14) had Los Angeles (LA) grade C esophagitis. The mean interval between surgery and the endoscopic evaluation was 4.43 years. Barrett's esophagus and benign stenosis were diagnosed after a longer period of time (10.33 and 8 years, respectively) as compared to reflux esophagitis (5.29 years). More than half of the esophagitis patients had reflux symptoms.Although Roux en Y esojejunostomy is a reconstructive technique which prevents the reflux, an important percentage of our patients developed alkaline reflux esophagitis. In most cases, the esophagitis was moderate or severe. Complications of alkaline reflux, i.e. benign stenosis and Barrett's esophagus, also occurred after longer periods of time (8 to 10 years) in a small percentage of patients.

The N34S mutation in the serine protease inhibitor Kazal type I (SPINK1) gene has been associated with chronic pancreatitis. Clinical data about the phenotypic expression of alcoholic chronic pancreatitis with the N34S variant are limited. The prevalence of the N34S mutation in patients with chronic pancreatitis and healthy individuals from Eastern Europe is unknown.We studied Romanian patients with chronic pancreatitis and investigated the clinical presentation in patients with N34S mutation. The SPINK1 N34S variant was analysed in 94 chronic pancreatitis patients and 96 healthy controls by an allele specific PCR method and a restriction fragment length polymorphism method. A meta-analysis was conducted with previous N34S association studies. The clinical course of alcoholic pancreatitis was evaluated according to the severity criteria of the M-ANNHEIM classification system of chronic pancreatitis.A heterozygous N34S mutation was found in 1 of 96 healthy individuals (1%) and in 4 of 80 patients (5%) with alcoholic chronic pancreatitis. The meta-analysis confirmed the status of N34S as a risk factor for the development of alcoholic chronic pancreatitis (OR=5.3). However, the clinical course of the disease was similar in patients with and without N34S mutation.The N34S mutation is a weak risk factor for alcoholic chronic pancreatitis.

Chronic pancreatitis is due mostly to alcohol consumption in industrialized countries. However, beside alcohol consumption there are other known etiologic risk factors, some patients combining more of them. The aim of our study was to assess the different etiologic risk factors in patients with chronic pancreatitis in Romania.There were 94 patients with chronic pancreatitis (CP) enrolled in this prospective study. The diagnosis of CP was established by typical findings on ultrasonography, computed tomography, endoscopic retrograde cholangiography. The visits included a careful history of alcohol use, smoking, drug use, a clinical examination and laboratory tests. The previous hospital records of each patient were reviewed.Out of the 94 patients, 80 had alcoholic chronic pancreatitis (ACP), 10 idiopathic pancreatitis (ICP), 2 patients had obstructive chronic pancreatitis due to pancreas divisum, 1 patient chronic pancreatitis due to hypertriglyceridemia and 1 patient posttraumatic chronic pancreatitis. The most frequent risk factors were alcohol consumption and smoking, the association of these two factors was found in 91% of patients with ACP and a large proportion of patients continued to smoke after diagnosis was established.Similar to other countries alcoholic chronic pancreatitis is the most frequent etiology, followed by the idiopathic one. Patients with ICP must be tested for gene mutations in the future. A small proportion of patients have other etiologies like pancreas divisum, which require specific treatment.

Using the same principles as small bowel capsule endoscopy, a new wireless device has been developed to explore the colon. Colon capsule endoscopy (CCE) is a safe and non-invasive method in visualizing the entire large bowel mucosa. A special preparation of the digestive tract is necessary to ensure the cleanliness of the colon and the progression of the capsule. CCE acquires images with a very good quality and accuracy. The actual experience confirms the possibility of using CCE as a method for screening colorectal polyps and cancer.

Background & Aims: To assess the role of diffusion weighted imaging sequence (DWI), routinely used in hepatic magnetic resonance imaging (MRI) for the differentiation of focal liver lesions (FLLs) as benign or malignant. Method: 99 FLLs assessed by liver MRI in 80 patients were included in the present study. All lesions were retrospectively analyzed by two experienced radiologists, independent from each other, who were not aware of the previous results obtained by using different imaging techniques. All included FLLs had a final histological diagnosis or a final diagnosis based on consensus reading by two experienced radiologists and follow-up at 6 months. The FLLs signal was qualitatively appreciated on the b-800 sequences and on the apparent diffusion coefficient (ADC) map. The ADC value of each FLL was measured and the ADC ratio between the ADC value of the assessed FLL and that of the surrounding liver parenchyma were calculated. Results: The mean ADC value for benign FLLs as assessed by the two independent readers was 1.78 x 10¯³ and 1.72 x 10¯³, respectively. The mean ADC value for malignant FLLs was 0.92 x 10¯³ for the first reader and 0.95 x 10¯³ for the second reader. The mean ADC ratio for benign FLLs was 1.91 and 1.85 for the two readers and for malignant FLLs was 0.91 and 0.94, respectively. Using an ADC value lower than 1.024 x 10¯³ offers a specificity of 100% and a sensitivity of 62.5% for the diagnosis of malignant FLLs. The ADC value is an indicator which is less prone to interobserver variability (correlation of 0.919→1). The ADC ratio has, as the analysis of the ROC curve shows, the best predictive value for differentiation between benign and malignant FLLs. Analysis of the signal intensity on the DWI b-800 image alone is of no significance in differentiating benign from malignant FLLs (p>0.05). Conclusions: The ADC value and the ADC ratio assessed on liver DWI are useful diagnostic tools in the differential diagnosis of benign vs. malignant FLLs. Quantitative methods such as calculating the ADC value or ADC ratio have better diagnostic value than the qualitative techniques.

and rating the usefulness of each of these pre-sets. The comparison of accuracies in correctly categorizing the images was performed between the two readings (McNemar’s test). Results: Between the first (WLI only) and the second (chromoendoscopy-aided) reading, in terms of accuracy there was a global 16.5% [95% CI:13.6 - 19.4%] improvement (p!0.001), derived from 22% [95% CI: 18.9 - 25.1%] improvement in the evaluation of true ulcerative images (p!0.001), and 11% [95% CI: 4.1 - 17.7%] decrease in the evaluation of faked ones (p Z 0.003), results reproduced for each of the four readers. FICE 1 and 2 pre-sets were rated as most useful. Conclusions: The use of FICE pre-sets 1 and 2 may be clinically meaningful in order to better categorize difficult to interpret small bowel mucosal ulcerative lesions. These pre-sets seem to provide a high level of visibility by transparent-‘izing’ opaque luminal content or enhancing the color differences associated with ulcerated mucosa. However, care must be taken, and individual images should only be evaluated as part of a succession in a recording, as the technology could also misguide the interpretation of artifacts as ulcerative lesions, extra caution being necessary under poor bowel preparation. Acknowledgement: The work has been funded by the Sectoral Operational Programme Human Resources Development 2007-2013 of the Ministry of European Funds through the Financial Agreement POSDRU/159/1.5/ S/132395.

Background Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS. Case presentation We report a case of an immediate internal spurting arterial bleeding precipitated during EUS-guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self-expandable metal stent through mechanical hemostasis. Conclusion In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during pseudocyst drainage, the placement of an expandable metal stent proved to be useful.

Background & Aims: A gradual shift of colorectal adenoma and carcinoma location toward the proximalcolon has been recently observed both in the United States and Europe. We aimed to study the polyp andadenoma detection rate in a major endoscopy center of northwestern Romania over a 16-year period, and to characterize the distribution and the pathological features of the removed polyps according to age and sex, in order to assess the trend of proximal adenoma prevalence in our population.Methods: We retrospectively analyzed 9,230 consecutive colonoscopies performed between 1996 and 2011 in a high-volume outpatient clinic in Cluj-Napoca, Romania. We analyzed 2,436 complete colonoscopies that detected 3,642 polyps in two time periods: 1996 to 2003 and 2004 to 2011. We compared the number, size and histopathological features of the polyps removed from the right-sided colon and the left sided-colon in the two periods.Results: An increasing trend of polyp detection rate in the right-sided colon was observed, from 9.36% in the first period to 12.17% in the second period (p

Background The cavitating mesenteric lymph node syndrome (CMLNS) is a rare manifestation of celiac disease, with an estimated mortality rate of 50%. Specific infections and malignant lymphoma may complicate its clinical course and contribute to its poor prognosis. Diagnosing the underlying cause of CMLNS can be challenging. This is the first report on contrast enhanced ultrasound (CEUS) findings in enteropathy associated T-cell lymphoma (EATL) complicating CMLNS in a gluten-free compliant patient with persistent symptoms and poor outcome. Case presentation We present the case of a 51-year old Caucasian male patient, diagnosed with celiac disease and CMLNS. Despite his compliance to the gluten-free diet the symptoms persisted and we eventually considered the possible development of malignancy. No mucosal changes suggestive of lymphoma were identified with capsule endoscopy. Low attenuation mesenteric lymphadenopathy, without enlarged small bowel segments were seen on computed tomography. CEUS revealed arterial rim enhancement around the necrotic mesenteric lymph nodes, without venous wash-out. No malignant cells were identified on laparoscopic mesenteric lymph nodes biopsies. The patient died due to fulminant liver failure 14 months later; the histopathological examination revealed CD3/CD30-positive atypical T-cell lymphocytes in the liver, mesenteric tissue, spleen, gastric wall, kidney, lung and bone marrow samples; no malignant cells were present in the small bowel samples. Conclusions CEUS findings in EATL complicating CMLNS include arterial rim enhancement of the mesenteric tissue around the cavitating lymph nodes, without venous wash-out. This vascular pattern is not suggestive for neoangiogenesis, as arteriovenous shunts from malignant tissues are responsible for rapid venous wash-out of the contrast agent. CEUS failed to provide a diagnosis in this case.