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Novel direct oral anticoagulants (DOACs) are prescribed worldwide in the treatment of non-valvular atrial fibrillation. Adverse reactions have been reported following the use of DOACs. One notable trend in the literature is the growing number of reported cases of esophagitis dissecans superficialis (EDS) generated by DOAC use. We hereby report the case of a 73-year-old woman who presented to the hospital with asthenia, dysphagia, and melena two days prior to admission. The patient had taken apixaban due to non-valvular paroxysmal atrial fibrillation for a few weeks. The biological panel showed moderate anemia with a hemoglobin level of 7.7 g/dL Apixaban-induced EDS was diagnosed by the characteristic endoscopic findings. The patient received treatment with a proton pump inhibitor (pantoprazole) in a double dose. Also, an iron treatment was recommended for a period of six months. The follow-up endoscopy at one month confirmed the healing of the esophageal lesions. The case was discussed with the cardiologist. The first anticoagulant treatment proposed after discharge was a vitamin K antagonist (acenocumarol) but the patient refused this medication and thus it was decided to initiate rivaroxaban. Although DOACs have demonstrated their efficacy in the prevention and treatment of stroke and thromboembolism among the aging demographic, cases of DOAC-induced EDS will continue to pose numerous challenges for physicians worldwide. [ABSTRACT FROM AUTHOR]

The association of gastric neuroendocrine tumour type I with macrocytic anaemia due to vitamin B12 deficiency is commonly encountered. For the subsequent treatment guidance, the etiological cause of macrocytic anaemia must always be precisely established. We presented the case of a 63-year-old patient admitted for marked physical asthenia, palpitations, abdominal pain, flatulence, paresthesia in the upper and lower limbs and concentration difficulties. Clinical examination revealed pale, dry skin, Hunter's glossitis, and tachycardic heart sounds. Bloodwork showed pancytopenia with macrocytic normochromic anaemia, vitamin B12 within normal limits, but with low folic acid levels. The reticulocyte crisis was documented on day 3 after initiating folic acid treatment. Exploration by upper digestive endoscopy and colonoscopy described multiple polypoid tumours in the greater curvature of the stomach. The histopathological and immunohistochemical examination lead to the diagnosis of gastric neuroendocrine tumours (NET) type G1. To our knowledge, there are no reports in the literature about an association of this type of tumour with folate deficiency-induced anaemia. [ABSTRACT FROM AUTHOR]

Vegetal compounds are known for their therapeutic actions in correlation with their antioxidant activity so that in recent times the interest in their properties has greatly increased. The phytocomplex obtained by combining the Zingiber officinale extract, Piper nigrum and Piper cubeba oil is distributed and recommended in European space as a multi-benefit nutritional supplement for swine, poultry, cattle, horses and others. As the individual properties of the three compounds are known, we aimed to test the antimicrobial activity of the phytocomplex on various Gram negative pathogens. In the time-kill assay, in vitro inhibitory effects were visible after 15 minutes of contact and total inhibition of the species Samonella enteritidis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa was obtained after 24 hours. The results obtained in vitro showed a very good antimicrobial activity which clearly contributes to the overall beneficial effects of the Zingiber officinale extract, Piper nigrum and Piper cubeba oil phytocomplex. [ABSTRACT FROM AUTHOR]

Introduction. Multichannel intraluminal esophageal impedance combined to pH-metry (pH-MII) is a sensitive tool for evaluating gastroesophageal reflux disease (GERD). The impedance-pH monitoring diagnostic test determines the frequency of reflux episodes (both acid or nonacid and liquid, gas or mixed) and the time relationship of reflux episodes and symptoms. Extradigestive manifestations and refractory GERD are two of the main recommendations for the assessment of upper digestive tract by pH-MII. Material and method. We conducted a prospective study between January 2022 - March 2023 at our tertiary referral center in North-Eastern Romania that included 26 patients suspected of GERD. All patients were investigated through pHMII. We used a ZepHr® system from Sandhill Scientific and single-use catheters with one pH electrode and 6 impedance electrodes. Patients who underwent MII-pH testing for refractory GERD were tested on proton pump inhibitor (PPI), while patients with no previous evidence of GERD were assessed off PPI. The diagnosis of GERD and phenotypes were based on Lyon metrics. Results. Out of the 26 patients, 14 (53.8%) were male and 12 (46.2%) female, with a mean age of 48.6±13.5 years. Nineteen patients (73.07%) presented with extradigestive GERD symptoms, of whom 7 patients (36.8%) with chronic cough, 7 patients (36.8%) with chronic laryngitis, 4 patients (21.05%) with non-cardiac chest pain and 1 patient (5.26%) with bronchial asthma. The rest of 7 (26.92%) patients were investigated for refractory GERD. After the final analysis of pH-MII tracks, we found GERD in 10 (38.5%) patients, functional heartburn in 6 (23.1%) patients and hypersensitive esophagus in 3 (15.4%) patients. All the 10 patients diagnosed with GERD had acid reflux, with a mean DeMeester Score of 46.7±83.8 and a mean AET of 12.8±20.9%. The mean total number of GERD episodes was 100.3±7.5 and the mean longest reflux episode was of 53.7±85.7 minutes. Conclusion. Multichannel intraluminal esophageal impedance combined to pH-metry represents an important instrument for assessing extradigestive GERD and refractory GERD. [ABSTRACT FROM AUTHOR]

Introduction. High-resolution manometry (HRM) is one of the most notable recent advances in the field of esophageal function. In the absence of organic lesions, HRM provides measurements of esophageal function, identifies the pathology and guides the treatment. The aim of this study was to assess the HRM particularities of diagnosis, clinical features and therapeutic management in patients evaluated for esophageal motor dysfunction. Material and Methods. Our study included all patients suspected of esophageal motility disorders, admitted in our tertiary referral center in North-Eastern Romania between July 2022 and March 2023. Demographic, clinical and laboratory characteristics were carefully collected from the patients' medical charts. All patients were investigated by upper digestive endoscopy and barium esophagogram prior to HRM. Patients diagnosed with eosinophilic esophagitis were excluded from the study. An ISOLAB HR® system from Standard Instruments, with a 36-pressure channels solid-state catheter was used. The HRM diagnosis of esophageal motor diseases was established based on Chicago 4 protocol and classification. Results. Out of the 38 patients included in the study, 15 (39.5%) were female and 23 (60.5%) male, with a mean age of 61.2±11.9. Regarding clinical features, the majority of patients presented with dysphagia (80.4%). Seven (18.4%) patients associated significant weight loss and 6 (15.8%) reported non-cardiac chest pain. Esophageal motility disorders were found in 29 patients (76.3%), 9 patients (23.6%) having a normal HRM aspect. Achalasia was identified in 15 patients (39.5%), with type I in 3 patients (7.9%), type II in 7 patients (18.4%) and type III in 5 patients (13.2%). Distal esophageal spasm was found in 4 patients (10.5%), hypercontractile esophagus in 2 patients (5.3%), esophagogastric junction outflow obstruction (EGJOO) in 2 patients (5.3%), ineffective esophageal motility in 1 patient (2.6%), absent contractility in 4 patients (10.5%) and dyshagia lusoria was identified in only one patient (2.6%). Regarding therapeutic management, endoscopic dilation was performed in 10 patients (26.3%) and 3 patients (7.8%) were referred to surgery. Conclusion. Esophageal HRM remains an important tool for assessing esophageal motor dysfunction. The esophageal motility disorders still represent a diagnostic and therapeutic challenge in clinical practice. [ABSTRACT FROM AUTHOR]

Biliary hamartoma or von Mayenburg complex (VMCs) is a rare benign congenital malformation of the biliary duct. Patients are usually asymptomatic. Hepatic lesions are incidentally discovered on ultrasonography (US) and subsequent radiological methods are necessary for confirmation. A correct diagnosis is established when typical imaging findings are present, otherwise histological confirmation might be needed [ABSTRACT FROM AUTHOR]

Introduction. Colorectal cancer is one of the most common malignancies and is still one of the major causes of cancer-related mortality worldwide. Laterally spreading colorectal tumors (LSTs) are nonpolypoid neoplastic lesions with a diameter of at least 10 mm, which typically extend laterally rather than vertically along the interior luminal wall. LTSs have recently received special attention due to the significant degree of dysplasia and the diagnostic and therapeutic challenge that it represents for clinical practice. LTSs can reach impressive sizes, most of them larger than 2 cm and the classification into granular and non-granular is an important characteristic for establishing the degree of dysplasia and choosing the appropiate treatment. Case presentation. A 73-year-old patient with significant cardiovascular (cardiac pacemaker) and metabolic diseases (diabetes mellitus type 2 and morbid obesity), without a history of digestive diseases, was admitted to our department for abdominal pain. At admisson, blood tests revealed a non-specific inflammatory syndrome, liver cytolysis, without signs of cholestasis and moderate anemia. Likewise, carcinoembryonic antigen and CA19.9 were elevated. Plain X-ray ruled out pneumoperitoneum or intestinal obstruction. Abdominal ultrasound revealed multiple hepatic metastases with the largest measuring approximately 75 mm. Upper digestive endoscopy was performed identifying a deep duodenal ulceration suggestive of possible extrinsic invasion, but with a histopathological result of benign ulceration, without tumoral elements. A computed tomography was then performed with exclusion of a pancreatic neoplasia. We decided to perform a colonoscopy that revealed a pseudodepressed flat type LST which was about 2 cm in diameter, located at about 30 cm from the anal verge with slight central depression (0-IIa+IIc). Histopathology report showed a moderately differentiated adenocarcinoma. Discussion. The initial suspicion of diagnosis was neoplasm of pancreas with liver metastases, with a malignant duodenal invasion, diagnosis that was infirmed by the anatomopathological result that obiectivated the benign etiology of the ulcer. The final diagnosis was colonic adenocarcinoma with hepatic metastases. The patient was addressed to Regional Institute of Oncology for oncological treatment. Conclusion. This case offers a broad and multidirectional diagnostic perspective in a patient without significant symptoms and with multiple comorbidities. [ABSTRACT FROM AUTHOR]

Introduction. The role of the Mediterranean diet (MD) in the management of NASH has been intuited for a long time but current scientific data bring information beyond the obvious regarding its effectiveness associated with physical activity (PA) for which reason is recommended by EASL-EASDEASO. Material and method. We have compared recent studies regarding components of MD to identify what exactly of this diet is essential in the treatment of NASH and what is the weight of each element in the regression of lesions in NASH. Results. MD includes large amounts of: water, vegetables, fruits, grasses, olive oil, in moderate amounts olives, fish, vegetable spices, peanuts, nuts, seeds, potatoes and in small amounts red or processed meat, sweets, alcohol. The social component of MD is essential, often involving meal preparation and family serving. MD adherence (quantified by score) was shown to be directly proportional to reduction in hepatic steatosis in both NASH patients and those with associated diabetes. Fish and seafood contain omega 3 fatty acids that cannot be produced in the body and have been shown to reduce lipid accumulation, reduce liver cytolysis enzymes, decrease insulin resistance, and have an anti-inflammatory effect; their reduction is associated with steatosis and fibrosis. Olive oil contains MUFAs and smaller amounts of ALA and palmitic acid, polyphenols and antioxidants and has a beneficial effect on NASH but also on the other components of the metabolic syndrome. Fruits and vegetables: NASH patients have a lower consumption of fruits and vegetables than the general population. They also intervene by reducing the overall energy density of diet generating small portions that contribute to weight loss, but also their composition of phenols and flavonoids have antiinflammatory and anti-fibrotic effects, inhibit neolypogenesis and stimulate hepatic beta-oxidation. Integral grasses act through the following mechanisms: reduce energy intake, modulate the microbiota, specific phytochemical effects. Reducing red meat consumption is essential in MD because it is positively associated with NASH but also with insulin resistance, abdominal obesity and metabolic syndrome. Most authors noted better resolution of NASH in nondrinkers. Conclusion. MD is proven to be the most effective diet in adjusting liver status even in the absence of weight loss, which makes it more attractive than other diets. Obviously, associated with caloric reduction, the benefit is also evident on the other components of the metabolic syndrome. [ABSTRACT FROM AUTHOR]

Introduction. The anamnesis is the basis of the doctor-patient relationship at the time of the first visit and along the course of the disease, bringing important data with diagnostic relevance and allowing to adopt an optimal plan of investigations, likely to lead to the shortest and fastest path to the therapeutic strategy. Objectives. In the era of technological development, anamnesis tends to be replaced by certain investigations (some useful, some not, but certainly some risky). Materials and method. We have analyzed some current trends regarding anamnesis from the perspective of clinical experience. Results and discussion. Excessive use of digital technology alters the patient's ability to understand, express and communicate symptoms, making it difficult to understand them; it can be alleviated by patience of the doctor, with the use of differently formulated questions, with the invitation to describe the symptoms in their own terms but also with synonyms. The (sometimes unreasonable) expectations of the patient, often informed by online media (but without having the discriminating ability and understanding of the disease phenomenon as a particularity different from one person to another) sometimes "forces" the doctor to satisfy the demands; it can be corrected by giving the patient detailed, pathophysiological, investigative, therapeutic explanations, but it is time-consuming and depends on the patient's cognitive abilities. Hiding or minimizing some symptoms that the doctor may find out in a long collateral way or not at all; it can be solved by direct point questions, possibly by hetero-anamnesis. The decrease in the patient's or relatives' sense of reasonableness in relation to the disease can be avoided or corrected by providing prognostic information from the beginning, which can be changed during the course of the disease; keeping the patient all the time informed about the chances is also a sign of assertiveness of the doctor and maintains a healthy doctor-patient relationship. Poly-medication is sometimes a true anamnestic information-gathering expedition, some not knowing what drugs they are taking, others considering alternative therapies without risks, elements with possible causal significance for iatrogenic pathology; it can be corrected by analyzing the entire medical file if it is available. Conclusion. Multiple new problems of recent appearance impact on a good correct anamnesis and their recognition allows the development of correction strategies and the restoration of the position of the anamnesis in the medical approach. [ABSTRACT FROM AUTHOR]

Irritable bowel syndrome with diarrhoea (IBS-D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS-D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work-up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS-D and FDr. In terms of diagnosis, the consensus supports a symptom-based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C-reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo-, di-, monosaccharides and polyols, gut-directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5-hydroxytryptamine-3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS-D and FDr., (© 2022 The Authors. United European Gastroenterology Journal published by Wiley Periodicals LLC on behalf of United European Gastroenterology.)

Aim: Malignant tumors localized in the digestive tract have a tendency to local growth and invasion with lymph node metastasis. Distant metastases through blood with prevalent liver location are detected late in disease progression, in an advanced stage, when therapeutic possibilities are often limited to palliative therapy., Material and Methods: The study included a series of 139 patients with liver metastases admitted to the Center of Gastroenterology and Hepatology lasi between January 1 and October 10, 2011 for the identification of primitive tumor. The patients were investigated by endoscopy, imaging, laboratory tests including tumor markers., Results: At 99 of the patients (71%) we identified primitive digestive tumors, in 19 patients (13.6%) we found tumors with extradigestive location and in 21 patients (15%) the primitive tumor could not be identified. Primitive.tumor was located in various segments of the digestive tract, liver, and pancreas was follows: esophagus 4 - (4%), eso-cardial-tuberositary 2 - (2%), eso-cardial-tuberositary with pancreatic invasion 1 -(1%), stomach 15 - (15%), ileocolon 1 - (1%), colon 19 - (19%), rectum 12 - (12%), liver, multicentric hepatolcellular carcinoma 23 - (23%) billiary tract - cholangiocarcinoma 2 (2%), pancreas 2 - (20%). In a series of 586 patients with malignant tumors of the digestive organs referred to the Iasi Oncology Outpatient Unit between January 1 and September 30, 2011, 132 patients (23%) had liver metastases at the time of diagnosis; the most common locations were the stomach 41% cases (42/119 patients), followed by the pancreas, 35%, and colon 31% patients (28/79 patients and 37/119 patients, respectively). Males were most affected, regardless of primitive tumor., Conclusions: Although diagnostic and therapeutic methods have made remarkable progress in recent years, these tumors, by their frequency and advanced stage at diagnosis, remain both an oncologic and public health problem mainly due to the limitations of curative treatment.