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Bile duct lesions with leakage and stenosis can occur after open or laparoscopic cholecystectomy. Multiple factors are involved either related to the patient or external due to technical equipment or surgeon. Bismuth classification is generally accepted. The aim is to restore the bile duct and to prevent short-term and long-term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis, and secondary biliary cirrhosis. Endoscopic therapy with biliary sphincterotomy alone or with the additional placement of a biliary/nasobiliary stent drainage is recommended. Stenting should be avoided if complete strictures exist or a circumferential resection of the duct. Endotherapy can be considered a sensible option and should be the main-stay treatment in these patients but one must keep in mind it is costly and is usually practiced by experienced teams in tertiary centers. The purpose of our paper is to exemplify this complication which is inherently rare, to highlight the diagnostic and treatment tools with minimal long-term sequelae.

Gastrointestinal bleeding is a common cause of hospitalization, with a high hospital morbidity and mortality rate, but decreasing compared to previous years due to an important progress in therapeutic endoscopic techniques. It is estimated that 5-7% of gastrointestinal bleedings are of obscure origin, with a normal upper and lower gastrointestinal endoscopy. The capsule endoscopy is the state-of-the-art, non-invasive procedure, providing a fine diagnosis of intestinal lesions, especially those found in the small bowel, difficult to address by other methods. Many studies have been published during the past years regarding the sensibility and outcome of capsule endoscopy in patients with gastrointestinal bleeding, but few underline its definitive role in the diagnosis of digestive bleeding. This review looks at the role of capsule endoscopy in the evaluation of patients with gastrointestinal bleeding from the small bowel and the therapeutic options available.

Introduction. Esophageal dysphagia can be caused by functional or structural abnormalities of the esophagus like esophageal strictures due to acid reflux disease, eosinophilic esophagitis, tumors and extrinsic compression, or by neuromuscular disorders like achalasia and diffuse spasm. The true prevalence of esophageal dysphagia is unknown, although epidemiological studies estimate a prevalence rate of 16% to 22% among individuals over 50 years of age. Case presentation. We present the case of a 55-year-old man, admitted to our hospital with progressive dysphagia for solids and important weight loss over the last two months. The upper endoscopy revealed an extrinsic compression of the middle esophagus. At this point, a thorax and abdomen computed tomography scan was performed, that showed a retrohilar mass of 58/44/38 mm, which compressed the right inferior lobar bronchus at the origin and the thoracic esophagus in the middle part. Endoscopic ultrasound and fine needle aspiration were performed. The anatomopathological examination of the biopsy reveals elements of chronic inflammation with neutrophils and lymphocytes, and granulomas with areas of necrosis, highly suggestive for tuberculosis. Conclusions. Dysphagia is a rare manifestation of tuberculosis, most commonly caused by an extrinsic compression mechanism due to mediastinal adenopathies. The particularity of this case is related to the contradicting imaging studies, that suggested either an esophageal or a pulmonary tumor, with mediastinal adenopathies, and the importance of endoscopic ultrasound with fine needle aspiration in determining the benign or malignant nature of injuries that are hardly accessible to non-invasive diagnostic methods.

Pancreatic cancer has the worst prognosis among gastrointestinal cancers. The high mortality is justified by the paucity of symptoms and by the lack of response to treatment. The lack of sensitive tumor markers specific to early diagnosis has a major contribution to the poor prognosis.

Introduction: Self expandable metal stents (SEMS) are developed lately, as an effective and safe, less invasive alternative of surgery for the treatment of malignant intestinal/biliary obstruction. Recently, SEMS are also introduced in benign pathology. Aim: The aim of this presentation is to report a retrospective analysis of the total number of SEMS placed for esophageal, enteral, colorectal and biliary obstruction during the last 3 years in Clinical Emergency Hospital Bucharest, as well to review the literature published on this issue. Methods: Between 2013-2015 in Clinical Emergency Hospital Bucharest, we have placed: 232 esophageal stents, 23 enteral stents, 5 colonic stents and 75 biliary stents under radiologic guidance. The main parameters followed were represented by: sex, age, grades of obstruction, stent diameter and type, immediate and late complications and survival rate. Results: Regarding the esophageal stenting, most of the indications were malignant obstruction (155 cases of esophageal cancer and 30 cases of extrinsic compression), but also for esophageal fistula, peptic stenosis and even traumatic esophageal rupture. The majority of the enteral and colonic stents were inserted for malignant obstructions, having only 2 cases with benign obstructions. This is also the case for biliary stenting, were most of the indications were represented by pancreatic cancer. Technical and clinical success rates were approximately 92% and 80%, respectively. There were no major complications of perforation, bleeding, or death. Conclusions: SEMS insertion can be performed safely, with minimal complications and hospitalization allowing the restart of oral feeding and improvement of nutritional status for the digestive obstruction or jaundice disappearance in case of biliary obstruction. It represents the first option for unresectable digestive/biliary malignant obstruction.

Colonic lipomas are relatively rare benign tumors which are composed of mature fat cells and occur most frequently in the large intestine. The occurrence of colonic lipomas in the transverse colon is relatively uncommon. Generally, colonic lipomas are asymptomatic, and many individuals might not experience any noticeable symptoms. Therefore, they are usually discovered incidentally during colonoscopy or as a result of diagnostic imaging prescribed for other reasons. The size and location of the lipoma could influence the clinical presentation. If symptoms occur, they include abdominal pain, changes in bowel habits, or gastrointestinal bleeding. The prognosis for colonic lipomas is generally excellent but it requires an individualized approach based on the specific characteristics of the tumor, the patient’s symptoms, and other clinical considerations. We report a case of a colonic intussusception caused by a colonic lipoma in an adult who underwent surgery, with an uneventful recovery.

Abstract There are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p

Foreign bodies in the digestive tract represent a frequent pathology for the emergency service. Foreign bodies are represented by impacted food bolus or voluntarily and involuntarily swallowed objects. Involuntary swallowing of objects occurs most frequently in children, especially between six months and three years of age. Food impaction is mostly encountered among adults with different pathologies. For the removal of swallowed foreign bodies, digestive endoscopy is the gold standard method, being successful in over 95% of cases without significant complications. For the endoscopic management of foreign bodies, it is crucial to be aware of the indications, devices, techniques and patient preparation in order to achieve successful and safe removal from the digestive tract. Recommendations in this article are based on a review of the literature and extensive personal experience.

Cholangiocarcinoma (CCA) is an adenocarcinoma originating from the epithelial cells of the bile ducts/hepatocytes or peribiliary glands. There are three types of cholangiocarcinoma: intrahepatic, perihilar and distal. CCA represents approximately 3% of the gastrointestinal malignancies. The incidence of CCA is higher in regions of the Eastern world compared to the Western countries. There are multiple risk factors associated with cholangiocarcinoma such as liver fluke, primary sclerosing cholangitis, chronic hepatitis B, liver cirrhosis and non-alcoholic fatty liver disease. Endoscopy plays an important role in the diagnosis and management of cholangiocarcinoma. The main endoscopic methods used for diagnosis, biliary drainage and delivering intrabiliary local therapies are endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. The purpose of this review is to analyze the current data found in literature about cholangiocarcinoma, with a focus on the actual diagnostic tools and endoscopic management options.

Liver transplantation represents the definitive intervention for various etiologies of liver failure and encompasses a spectrum of rare indications crucial to understanding the diverse landscape of end-stage liver disease, with significantly improved survival rates over the past three decades. Apart from commonly encountered liver transplant indications such as decompensated cirrhosis and liver cancer, several rare diseases can lead to transplantation. Recognition of these rare indications is essential, providing a lifeline to individuals facing complex liver disorders where conventional treatments fail. Collaborative efforts among healthcare experts lead not only to timely interventions but also to the continuous refinement of transplant protocols. This continued evolution in transplant medicine promises hope for those facing diverse and rare liver diseases, marking a paradigm shift in the landscape of liver disease management.

This study aimed to compare microbial species and multidrug resistance patterns in acute cholangitis patients with and without a history of cholecystectomy, highlighting potential differences We hypothesized that post-cholecystectomy patients would exhibit distinct microbial spectra and resistance patterns. Conducted at a western Romanian hospital specializing in gastroenterology and hepatobiliary diseases from 2020 to 2023, this retrospective study included 488 acute cholangitis patients, divided into groups based on their cholecystectomy history. Bile and blood samples were analyzed for microbial identification and antibiotic susceptibility using VITEK®2. Positive biliary cultures were found in 66% of patients. The cholecystectomy group showed a higher prevalence of multidrug-resistant organisms, with 74.4% exhibiting resistance compared to 31.5% in the non-cholecystectomy group (p < 0.001). Notable microbial differences included higher occurrences of Escherichia coli (40.2%) and Enterococcus spp. (32.4%) in the cholecystectomy group. Resistance to Piperacillin/Tazobactam and Penems was significantly higher in this group, with odds ratios of 3.25 (p < 0.001) and 2.80 (p = 0.001), respectively, for the development of multidrug-resistant (MDR) bacterial species. The study confirmed our hypothesis, revealing distinct microbial profiles and a higher prevalence of multidrug resistance in acute cholangitis post-cholecystectomy patients. These findings underscore the need for tailored antibiotic strategies in managing acute cholangitis in this patient demographic.

In response to rising concerns over multidrug resistance patterns in acute cholangitis patients, this retrospective study was conducted at the Emergency County Hospital Timisoara, Romania, encompassing patients treated between August 2020 and August 2023. The study aimed to investigate the influence of prior interventions, specifically sphincterotomy (with or without stent placement), on the current clinical and microbiological profiles of acute cholangitis patients. By differentiating between patients with a history of sphincterotomy and the endoscopic retrograde cholangiopancreatography (ERCP)-naïve, we assessed the resistance of bacterial strains to antibiotics by the Tokyo Guidelines 2018, using bile cultures from 488 patients. The study identified various multidrug-resistant organisms, with a total multidrug resistance incidence of 19.9%. Significant variations were observed in the distribution of specific microorganisms and resistance patterns across different intervention groups. Patients with previous interventions, particularly those with both sphincterotomy and stent, exhibited elevated white blood cells (WBC) and C-reactive protein (CRP) levels in comparison to their ERCP-naïve counterparts. This group also presented a striking prevalence of two bacteria in their bile cultures at 50.0%, compared to 16.1% in ERCP-naïve individuals. Regarding multidrug resistance, the prior sphincterotomy with stent placement had a prevalence of 50.0%. The presence of ESBL bacteria was also significantly higher in the same group at 28.7%, contrasting with the 8.9% in ERCP-naïve patients. Additionally, the same group had a higher burden of Klebsiella spp. infections, at 37.2%, and Enterococcus spp. at 43.6%. On the antibiotic resistance front, disparities persisted. Piperacillin/Tazobactam resistance was notably more rampant in patients with a previous sphincterotomy and stent, registering at 25.5% against 11.1% in the ERCP-naïve group. This study underscores a substantial discrepancy in multidrug resistance patterns and antibiotic resistance among acute cholangitis patients with previous manipulation of the bile ducts, without expressing significant differences by the type of stent used.

Background: The COVID-19 pandemic has had a negative impact on the training process for resident physicians. The objective of this study was to evaluate the impact of the COVID-19 pandemic on professional training, and also the subjective perception of the levels of stress, anxiety, and depression among resident doctors specializing in gastroenterology in Romania. Methods: We conducted an observational cross-sectional study, for a period of two months, among 180 resident doctors specializing in gastroenterology, working in university hospitals in Romania. A questionnaire consisting of 29 questions distributed through social media platforms was completed in Google Forms. Statistical analyses were performed using IBM SPSS software v.20. Results: A linear relationship was identified between the number of daily hospitalizations in the gastroenterology department and the rate of SARS-CoV-2 infection among resident physicians. In total, 80% of the participants reported an increase in the levels of stress, anxiety, and depression during the COVID-19 pandemic, and 88.3% stated that they were unsatisfied by online courses. Conclusions: The COVID-19 pandemic has had negative effects on both professional training and levesl of stress, anxiety and depression of resident doctors specializing in gastroenterology. In the specialty of gastroenterology there may be certain peculiarities, due to the interventional aspects that this medical specialty involves, for example, endoscopic procedures. Thus, the necessity to acquire practical skills in addition to theoretical knowledge increases the negative impact on gastroenterology internship.

Bilio-pancreatic malignant neoplastic diseases are characterized by aggressive evolution and low 5-year survival rates. The only therapeutic method with curative potential remains surgical treatment. Unfortunately, a very high percentage of patients are diagnosed in advanced stages, no longer suitable for surgical resection. Studies in recent years have focused on identifying new therapeutic techniques to improve the quality of life and survival of these patients. One of these techniques is endoscopic radiofrequency ablation, that showed good results in terms of morbidity and mortality, with an acceptable rate of complications.

Introduction. The impact of inflammatory bowel diseases (IBD) on the quality of life (QoL) of patients is significant and it has important social and professional consequences. Materials and methods. We aimed to describe the patients’ perspective regarding the impact of IBD on their overall QoL and to evaluate the differences between men and women. An observational cross-sectional study, that included 180 patients with IBD in clinical remission, was conducted. All the patients completed a number of 3 questionnaires in order to evaluate the general aspects of their QoL. A separate questionnaire was created regarding genderspecific issues in women with IBD encounter. Also, particular features such as the incidence of anemia and osteoporosis among IBD patients were documented. The data obtained were analyzed and compared between the two genderclassified groups. Results. According to the Short Inflammatory Bowel Disease Questionnaire (SIBDQ), patients had a general perception of a good QoL, but the impact was higher in women. Fatigue and tiredness were severely perceived almost to the same degree regardless of their gender, whereas anxiety and unemployment were more present in men. No significant differences in women with IBD during the active disease and during disease remission were found. Conclusions. The overall quality of life of IBD patients is affected in many aspects, leading to the deterioration of their social and professional lives, for both men and women, but some aspects remain gender-specific and require a personalized standard of care.

Introduction. Ultrasound-guided (US-guided) percutaneous drainage (PD) of abdominal collections represents the first-choice alternative to surgical intervention. The aim of our study was to assess the efficacy and safety of PD of visceral and non-visceral abdominal collections by reviewing our personal experience over a period of 5 years. Material and methods. The present study included 66 patients who underwent PD under ultrasound guidance. We analyzed clinical variables (collection size, catheter diameter, collection type, microbiological analysis, antibiotic regimens) along with the outcomes of the procedure. Results. Visceral collections were predominant, encompassing 38 hepatic abscesses and 1 splenic hematoma. Microbiological analysis showed that the majority (54%) were monomicrobial. The most encountered pathogens were Klebsiella pneumoniae and Escherichia coli. Technical success was achieved in all cases and clinical success was observed in 84.6% of the cases. No immediate procedural complications were detected. There were 6 patients who needed reinterventions, either by catheter replacement or by surgical treatment. The mortality rate was 4.5%, due to patients’ poor overall status and oncological comorbidities. Conclusions. Percutaneous drainage under ultrasound guidance is a safe and effective procedure in the management of abdominal collections.

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has shown constant incidence throughout time, despite advances in endoscopic technology, devices, or personal skills of the operating endoscopists, with prevention and prediction of severity in PEP being constant concerns. Several prospective studies have investigated the role of systemic inflammatory response syndrome (SIRS) criteria or the quick Sequential Organ Failure Assessment (qSOFA) score in the PEP severity assessment. However, there are no clearly defined tools for the prediction of PEP severity. Methods: A total of 403 patients were prospectively monitored 60 days after ERCP for the detection of PEP development. Consequently, we evaluated the lengths of stay, incidence of organic dysfunction, and mortality rates of these patients. The predictive power of the univariate model was evaluated by using the receiver operating characteristic curve and analyzing the area under the curve (AUC). Results: Incidence of PEP was similar to that reported in the majority of trials. The 60-day survival rate of PEP patients reached 82.8%. A qSOFA score ≥ 1 is a very good predictor for organ dysfunction (AUC 0.993, p < 0.0001). SIRS can also be considered a significant predictor for organic dysfunctions in PEP patients (AUC 0.926, p < 0.0001). However, only qSOFA was found to significantly predict mortality in PEP patients (AUC 0.885, p = 0.003), with SIRS criteria showing a much lower predictive power. Neither SIRS nor qSOFA showed any predictive value for the length of stay of PEP patients. Conclusion: Our study offers novel information about severity prediction in PEP patients. Both SIRS criteria and qSOFA showed good predictive value for organic dysfunction, mortality, and hospitalization.

Duodenal gangliocytic paragangliomas are rare neuroendocrine tumors primarily localized in the periampullary area. Though mostly asymptomatic, they can present with various symptoms, most often jaundice, anemia and abdominal pain. The present paper is a case series report, describing our personal experience with patients presenting to the Emergency Unit with different symptoms due to duodenal gangliocytic paraganglioma. Endoscopic resection is safe and indicated in most of the cases, being also associated with lower medical costs. EUS plays a central role in the pre-resection management and in surveillance, and immunostaining is decisive to ascertain the tumor histologic origin. In addition to reporting our experience, we researched the literature regarding these rare tumors and performed a comprehensive review.

Artificial intelligence (AI) is a term that covers a multitude of techniques that are used in a manner that tries to reproduce human intelligence. AI is helpful in various medical specialties that use imaging for diagnostic purposes, and gastroenterology is no exception. In this field, AI has several applications, such as detecting and classifying polyps, detecting the malignancy in polyps, diagnosing Helicobacter pylori infection, gastritis, inflammatory bowel disease, gastric cancer, esophageal neoplasia, and pancreatic and hepatic lesions. The aim of this mini-review is to analyze the currently available studies regarding AI in the field of gastroenterology and hepatology and to discuss its main applications as well as its main limitations.

Background and Objectives: Biologic therapy has fundamentally changed the opportunity of medical treatment to induce and maintain remission in inflammatory bowel disease (IBD). Nevertheless, the rate of surgery is still at a very high rate, profoundly affecting the quality of life. We aimed to analyze surgical cases at three major IBD units in order to identify the main risk factors and the impact of biologic therapy on pre- and postsurgical outcomes. Material and Methods: This was a multicenter retrospective cohort study that included 56 patients with IBD-related surgical interventions from 3 tertiary care hospitals in Bucharest, Romania. The study was conducted between January 2017 and June 2021. All data were retrospectively collected from the medical records of the patients and included the age at diagnosis, age at the time of surgery, IBD type and phenotype, biologic therapy before or/and after surgery, timing of biologic therapy initiation, extraintestinal manifestations, type of surgery (elective/emergency), early and long-term postoperative complications and a history of smoking. Results: A low rate of surgical interventions was noted in our cohort (10.3%), but half of these occurred in the first year after the IBD diagnosis. A total of 48% of the surgical interventions had been performed in an emergency setting, which seemed to be associated with a high rate of long-term postoperative complications. We found no statistically significant differences between IBD patients undergoing treatments with biologics before surgery and patients who did not receive biologics before the surgical intervention in terms of the IBD phenotype, type of surgery and postoperative complications. Conclusion: Our study showed that biologics initiated before the surgical intervention did not influence the postoperative complications. Moreover, we demonstrated that patients with Crohn’s disease and no biologics were the most susceptible to having to undergo surgery. Conclusion: In conclusion, the management of patients with IBD requires a multidisciplinary approach that considers an unpredictable evolution.

Hereditary hemorrhagic telangiectasia (HHT) has significant morbidity due to multiorgan involvement and an unpredictable disease course. We analyzed the data of 14 patients diagnosed with HHT. The case series comprised 14 patients with a median age at presentation of 48 years old (41–74 years). In twelve patients (85.7%), the diagnosis was confirmed by using the Curacao Criteria. The most common reason for admission was epistaxis, with 9 patients (57%) presenting with nosebleed refractory to prolonged self-tamponade. The biochemical abnormalities identified were elevations in AP and gamma-GT; liver synthetic function was generally normal, even though 21% of patients had clinical or imaging findings for cirrhosis. Nosebleeds were the main reason for admission and significantly impacted quality of life through anemia and frequent hospital admissions. However, the visceral manifestations seemed to be more serious. The hepatic arteriovenous malformations (AVMs) appeared to remain asymptomatic or led to minimal changes for the majority of patients; some cases were associated with liver and biliary tract ischemia, necrosis leading to acute liver failure and even death. Hepatic AVMs can also lead to high-output heart failure due to arterio-venous shunting. The most frequent AVM was hepatic artery to hepatic vein, with secondary hepatic vein dilation and hemodynamic consequences.

Introduction. Eosinophilic esophagitis (EoE) is a rare pathology characterized by chronic inflammation with mucosal eosinophilic infiltrate of the esophagus. The clinical symptoms vary according to the age group, from recurrent abdominal and thoracic pain, vomiting, dysphagia, food impaction and gastroesophageal reflux symptoms refractory to treatment with proton pump inhibitors. In the recent years, different studies suggest that EoE is now the leading cause of food impaction in the adult population. Case presentation. A 30-year-old female, without a pathological personal history, was admitted with symptoms of esophageal food impaction. Upper endoscopy revealed esophageal rings and the bolus impacted in the lower esophagus. Biopsy samples were obtained from several different locations, including areas away from the site of food impaction. Histopathologic examination revealed esophageal mucosal eosinophilic infiltrate >15 eosinophils per high-power field. Proton pump inhibitor (PPI) therapy, twice-daily dosing for 8 weeks was administered, as the first line treatment. Conclusions. Consensus guidelines for the diagnosis of EoE require symptoms of esophageal dysfunction, 15 or more eosinophils per high-power field on microscopic examination of esophageal biopsy after 8 weeks on a high-dose proton pump inhibitor (PPI), and the absence of alternative causes of eosinophilia.

Background: Cholangiocarcinoma is the most common malignancy of the bile ducts causing intrahepatic, hilar, or distal bile duct obstruction. Most jaundiced patients are diagnosed with unresectable tumors in need for palliative bile duct drainage and chemotherapy. Endobiliary radiofrequency ablation (RFA) is an adjuvant technique that may be applied prior to biliary stenting. The aim of our study was to assess the efficacy of endobiliary RFA prior to stent insertion in patients with unresectable distal cholangiocarcinomas. Methods: Twenty-five patients (eight treated with RFA and stenting and 17 treated with stenting alone) were included in a case-controlled study. We prospectively assessed the impact of RFA on the survival rate, the patient performance status, and the preservation of eligibility for chemotherapy based on the patient laboratory profile. Results: Patients treated with RFA prior to stenting proved to have a significantly longer survival interval (19 vs. 16 months, p = 0.04, 95% CI) and significantly better performance status. Moreover, the laboratory profiles of patients treated with RFA has been proven superior in terms of total bilirubin, liver enzymes, and kidney function, thus making patients likely eligible for palliative chemotherapy. Post-ERCP adverse events were scarce in both the study group and the control group. Conclusion: Given the isolated adverse events and the impact on the patient survival, performance, and laboratory profile, RFA can be considered safe and efficient in the management of patients with unresectable distal cholangiocarcinomas.

Background and Aim. Endoscopic therapy is the method of choice in the management of biliary strictures after orthotopic liver transplantation (OLT). Even though the mainstay approach for OLT stricture complications is represented by consecutive procedures of multiple plastic stents (MPS) insertion, a valuable alternative is the use of fully covered self-expandable metal stents (FCSEMS). The aim of the study was to compare MPS with FCSEMS used in the management of OLT biliary strictures, in terms of clinical outcomes and complications. Material and Methods. This is a retrospective, single-center study conducted between February 2014 and November 2019 in the Clinical Emergency Hospital of Bucharest, Romania. We enrolled all consecutive patients who developed biliary strictures after OLT and were treated by endoscopic retrograde cholangiopancreatography (ERCP) either with MPS or FCSEMS. Results. Thirty-six patients were included in the study, 27 patients had MPS and nine patients had FCSEMS. 106 ERCP procedures were performed and 159 stents were inserted. The mean number of ERCP procedures required per patient was significantly higher for MPS than for FCSEMS (3.34 ± 1.46 vs. 2.11 ± 0.33, p < 0.001). In the FCSEMS group only one patient had three procedures, due to stent migration. Difficult cannulation was encountered in 22 patients, 18 patients from MPS group and four patients from FCSEMS group. Dilation was performed in 20 (77%) MPS patients and in four FCSEMS patients (44%). Overall, we used 159 stents for stricture resolution, 149 plastic stents and 10 FCSEMS. Mean number of stents inserted was significantly lower in the FCSEMS group compared to MPS group (1.16 ± 0.40 vs. 5.73 ± 2.64, p < 0.001). Conclusions. Stricture resolution using FCSEMS is comparable to MPS and even has some advantages. In line with prior studies, FCSEMS are effective, with fewer complications and similar outcome compared to plastic stents. Other particular aspects should be further assessed, especially long-term follow up of FCSEMS and their cost efficiency.

Introduction. Primary non-Hodgkin’s lymphoma of the extrahepatic bile duct presenting as obstructive jaundice is an extremely rare disease. Case presentation. We report a case of obstructive jaundice caused by primary non-Hodgkin’s lymphoma of the common bile duct (CBD), in a 67-year-old male patient. Our patient showed clinical evidence of obstructive jaundice, and tomography revealed a dilated common bile duct with the suspicion of intra ductal lithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, with efficient drainage and clinical resolution of the obstructive jaundice. One month later, the patient presented the same clinical signs of obstructive jaundice, only this time the ERCP revealed common bile duct distal stenosis. The next step was to perform an echoendoscopy (EUS), that visualized a homogeneous mass at the common bile duct distal level and cholangiocarcinoma was suspected. Fine needle aspiration (FNA) of the lesion obtained tissue fragments for histological examination. The diagnosis was diffuse B-cell type non-Hodgkin’s lymphoma in the marginal area, and the patient was evaluated in the Oncology Department for chemotherapy. Conclusions. It is very important to differentiate primary non-Hodgkin’s lymphoma of the bile ducts from other causes of obstructive jaundice, as the treatment approach and prognosis are fundamentally different. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the definitive diagnosis technique, avoiding surgical interventions and the classic exploratory laparotomy.

Introduction. Gastrointestinal bleeding is a life-threatening condition, with a mortality depending on the cause and severity. The objective of this study was to retrospectively evaluate the epidemiological, clinical and evolutionary aspects of a series of patients diagnosed with gastrointestinal bleeding, admitted to the Intensive Care Unit of the Clinical Emergency Hospital of Bucharest, Romania. Material and methods. A retrospective, descriptive study was carried out, of patients diagnosed with upper and lower gastrointestinal bleeding, admitted to the Intensive Care Unit of the Clinical Emergency Hospital of Bucharest, Romania, between January 1st, 2013 – December 30th, 2018. The clinical variables were collected in a database designed exclusively for the study. Results. We observed that most of the cases were bleedings situated above the Treitz’s angle; the most frequent causes were peptic ulcer disease, followed by variceal hemorrhage and erosive gastroduodenitis. The three most frequent causes of upper gastrointestinal bleeding in our series were peptic ulcer disease, variceal hemorrhage and erosive gastroduodenitis. The global mortality due to gastrointestinal bleeding was 9.8%, with all cases occurring in the group of patients with upper gastrointestinal bleeding. Conclusions. It should be noted that in the group of patients who died, all had hemorrhagic shock at the time of admission, a fact that occurred only in 23% of the cases who survived. This highlights the prognostic value of the hemorrhagic shock on admission.

The novel COVID-19 infection has spread all over the world and is still generating a lot of issues at different levels. There is a lack of control in disease early diagnosis and rapid evolution, which impacts both the medical and the economic system. Young gastroenterologists should adapt to overcome current difficulties and continue their life and general training. This is a multi-center national study, which aims to assess the general perspective of young gastroenterologists (residents and young specialists) from six university centers in Romania regarding their current training and the psychological effect the pandemic has on their life and job. An online survey with 58 items was distributed using Google Forms, and quality of life and anxiety were assessed. The validated instruments 15D (for assessing the health-related quality of life) and endler multidimensional anxiety scales (EMAS—for assessing anxiety) were used. All analyses were performed using SPSS 25. Of the 174 gastroenterologists approached, 96 (response rate of 55%) responded. A majority of the respondents were residents in gastroenterology (64%), and 40.6% were male. The pandemic influenced the number of examined patients as well as young gastroenterologists’ endoscopy training. Health-related quality of life was negatively associated with the level of anxiety generated by the cognitive component of anxiety as a state, the new and ambiguity of the state, and how threatened the respondent felt. The level of anxiety was moderate (median = 51), and no difference was found between the physicians working in a designated hospital or not. General caution should be considered for young gastroenterologists’ training, and continuous observation should be done to ensure better mental health on the current evolution. These findings would need to be verified in larger-sample studies and in different types of specialties.

Introduction and aim. Sleep disorders are highly prevalent in patients with liver cirrhosis. The aim of this study was to investigate the prevalence of restless legs syndrome (RLS), as well as its risk factors and possible predictors, in a cohort of patients with liver cirrhosis. Material and methods. We performed a cross-sectional prospective study over a period of 14 months and enrolled 69 patients with liver cirrhosis, after applying the inclusion and exclusion criteria. The cases of RLS were assessed according to the International Restless Legs Syndrome Study Group (IRLSSG) criteria and severity scale. Results. Out of the total number of patients, 55% fulfilled the criteria for RLS. Age, diabetes, severity of cirrhosis, serum creatinine, glomerular filtration rate (GFR), and mean hemoglobin were associated with the presence of RLS. Moreover, there was a significantly higher prevalence of RLS among patients with decompensated cirrhosis. From all the risk factors introduced into the multivariate analysis, only the GFR could predict the presence of RLS. Conclusions. This research shows that patients with liver cirrhosis have a high risk of RLS. Even though there are multiple risk factors associated with RLS, only the GFR could predict its occurrence in our cohort.

Background: Malnutrition and cachexia are common in patients with advanced pancreatic ductal adenocarcinoma (PDAC) and have a significant influence on the tolerance and response to treatments. If timely identified, malnourished PDAC patients could be treated to increase their capacity to complete the planned treatments and, therefore, possibly, improve their efficacy.Aims: The aim of this study is to assess the impact of nutritional status, pancreatic exocrine insufficiency (PEI), and other clinical factors on patient outcomes in patients with advanced PDAC.Methods: PAncreatic Cancer MAlnutrition and Pancreatic Exocrine INsufficiency in the Course of Chemotherapy in Unresectable Pancreatic Cancer (PAC-MAIN) is an international multicenter prospective observational cohort study. The nutritional status will be determined by means of Mini-Nutritional Assessment score and laboratory blood tests. PEI will be defined by reduced fecal elastase levels. Main outcome: adherence to planned chemotherapy in the first 12 weeks following the diagnosis, according to patients' baseline nutritional status and quantified and reported as “percent of standard chemotherapy dose delivered.” Secondary outcomes: rate of chemotherapy-related toxicity, progression-free survival, survival at 6 months, overall survival, quality of life, and the number of hospitalizations. Analysis: chemotherapy dosing over the first 12 weeks of therapy (i.e., percent of chemotherapy received in the first 12 weeks, as defined above) will be compared between well-nourished and malnourished patients. Sample size: based on an expected percentage of chemotherapy delivered of 70% in well-nourished patients, with a type I error of 0.05 and a type II error of 0.20, a sample size of 93 patients per group will be required in case of a percentage difference of chemotherapy delivered of 20% between well-nourished and malnourished patients, 163 patients per group in case of a difference of 15% between the groups, and 356 patients per group in case of a 10% difference. Centers from Russia, Romania, Turkey, Spain, Serbia, and Italy will participate in the study upon Local Ethics Committee approval.Discussion: PAC-MAIN will provide insights into the role of malnutrition and PEI in the outcomes of PDAC. The study protocol was registered at clinicaltrials.gov as NCT04112836.

Introduction. Ingestion of corrosive substances often causes serious damage to the upper gastrointestinal mucosa, occasionally perforation and, in rare cases, death. Most of these events are accidental, especially in children and the elderly, and voluntary (for suicidal purposes) in adults. If the patient survives the acute episode, the long-term complications are mainly esophageal and/or gastric stenosis and esophageal cancer after 1-2 decades of evolution. Endoscopic treatment of benign esophageal stenosis consists of dilation with Savary bougies and dilation balloon, esophageal stent assembly, with the purpose of restoring esophageal luminal patency. Superior digestive endoscopy plays an important role in the evaluation of benign esophageal stenosis in terms of the severity and the extent of stenosis. Case presentation. We present the case of a 47-yearold patient admitted to our clinic for dysphagia for solid and semi-solid foods. Endoscopy revealed an esophageal stricture due to the voluntary ingestion of caustic substance with suicidal purpose, 9 months before presentation. After multiple sessions of endoscopic dilatation with Savary bougies, an esophageal stent was placed, that solved patient’s dysphagia. Conclusions. Post-caustic esophageal stenosis is a common cause of dysphagia in patients with ingestion of corrosive substances. Patients can benefit from endoscopic esophageal stent placement treatment.

Introduction. Duodenal duplication cyst (DDC) is a rare congenital malformation that appears in the embryonic development of the digestive tract. It is a benign condition usually diagnosed in infancy and early childhood, being a rare and difficult diagnosis in adult population. DDC is a recognized cause of duodenal obstruction, acute pancreatitis, obstructive jaundice and even digestive hemorrhage. Case presentation. We report the case of a young adult male with abdominal pain history, who presents with recurrent episodes of acute severe necrotic pancreatitis. The abdominal computed tomography scan revealed a Balthazar C necrotic pancreatitis with partial thrombosis of the splenic vein and a cystic mass in the second part of the duodenum. The endoscopic ultrasonography (EUS) established that the duodenal cystic lesion came from the second layer, meaning the submucosa. We performed endoscopic cystotomy with complete evacuation of the fluid content into the duodenum, with favorable clinical outcome. Conclusions. The particularity of the case is represented by the low incidence of this pathology and the rare form of presentation, meaning acute pancreatitis probably from pancreatic ductular hypertension caused by the DDC.

Introduction. The colonic pathology associated with the administration of nonsteroidal anti-inflammatory drugs is vast and includes inflammation, ulcerations and sometimes strictures. It is important to identify the NSAIDs-induced alterations in the colon in order to differentiate them from other pathologies and to avoid treatment errors. The objective of this paper is to present a post-NSAIDs colopathy revealed by lower digestive bleeding – hematochezia. Material and methods. A 68 years old patient under treatment with NSAIDs is hospitalized for hematochezia. Laboratory tests, upper and lower digestive endoscopy are performed and multiple colonic ulcers are identified. Results. Following the investigations, the suspicion of post-NSAIDs colonic ulcers is raised and a differential diagnosis with inflammatory bowel disease is sought by taking multiple biopsies. The histopathological examination shows ischemic necrosis, with no pathognomonic elements linked to Crohn’s disease. Conclusions. The peculiarity of this case resides in the importance of identifying the NSAIDs-induced pathology and differentiating it from other pathologies to prevent treatment errors. Associating multiple ulcers in NSAIDs pathology is rare and often misdiagnosed as Crohn's disease. Keep in mind the importance of the histopathologic exam, which excluded the inflammatory bowel disease in a patient with inconclusive inflammatory biological evidence.

The topic on integrated systems of weapons represents an actual area of concern for many countries, which are interested in such systems and allocate funding for research programs. From this point of view, Romania is in a development stage, but the prospects are encouraging, more and more scientists being interested in the research connected with the development of such platforms. In this paper we present an analysis of the most advanced air defense systems that ensure proper airspace security, emphasizing on the need for their integration on a common weapons systems platform.

The combat features of the Ground Based Air Defence Systems represent the potential of search, discovery, indicate, combat and destruction of the enemy's air assets and the ability to manoeuvre of forces and combat means, for the purpose of capturing the enemy's airspace and avoid actions and attack to defend objectives (of troops) assigned in the area of responsibility tacking into account the conditions established by the mission. The paper is focused on a comparative study on the possibilities of target destruction of the Air Air Defence Systems (antiaircraft artillery and Surface-To-Air Missiles). Two situations were chosen: for the first case, related to S1, S2 and S3, we’ve assumed the presence of a flying target describing a uniform rectilinear trajectory both in the presence and in the absence of the enemy’s electronic jamming. For the second case concerning S4 we’ve assumed that the target changed its angle of flight.

Liver transplantation (LT) is considered the curative treatment option for selected patients who suffer from end-stage or acute liver disease or hepatic malignancy (primary). After LT, patients should be carefully monitored for complications that may appear, partially due to immunosuppressive therapy, but not entirely. Cardiovascular diseases are frequently encountered in patients with LT, being responsible for high morbidity and mortality. Patients with underlying cardiovascular and metabolic pathologies are prone to complications after the transplant, but these complications can also appear de novo, mostly associated with immunosuppressants. Metabolic syndrome, defined by obesity, hypertension, dyslipidemia, and hyperglycemia, is diagnosed among LT recipients and is aggravated after LT, influencing the long-term survival. In this review, our purpose was to summarize the current knowledge regarding cardiovascular (CV) diseases and the metabolic syndrome associated with LT and to assess their impact on short and long-term morbidity and mortality.

Objectives: Duodenoscopes have been widely used for both diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedures, but recently, numerous outbreaks of multidrug-resistant organisms (MDRO) infections have been reported which has led to extensive research for their possible causes. Consequently, the aim of this study is to search for possible duodenoscope surface damages that could provide an alternative and plausible source of infections. Materials and Methods: In order to assess both outer and inner surfaces, a duodenoscope was dismantled and samples were taken from the outer resin polymer and from the air/water, elevator, and working (biopsy) channels that were characterized by FTIR, DSC, TGA, AFM, SEM techniques and the antimicrobial activity were tested. Results: Alterations were noticed on both the coating and working channel polymers, with external alterations increasing progressively from the proximal sample to the distal sample near the tip of the scope. However, the results showed that the coating surface was still efficient against bacterial adhesion. Changes in surface texture and also morphological changes were shown. Conclusions: The study describes the impact of routine procedural use and reprocessing cycles on the duodenoscope, showing that these may possibly make it susceptible to bacterial contamination and MDRO biofilm formation due to difficult reprocessing of the altered surfaces.

Confronted with the spectacular evolution of the aircraft and other aerial vehicles, the systems destined to combat them, especially Surface-to-Air Missile Systems (SAMS), went through an accelerated loss of their performance. The financial crisis has forced an extension of the system operation even if the system is outdated. Therefore, a new modernized version has been designed. Many times, it is better to improve an existing system than to buy a new one. This article describes the diversity of SAMS’s challenges, involving a decrease in time regarding their number. The types of challenges can be divided in two categories: technical and institutional ones. The technical challenges can be also divided in two categories: deterioration of material and obsolescence. The classes of material that present interest for us are aerodynamic vector structure, propulsion, and special systems. From an institutional point of view, the main problems are: cost versus performance and cost versus the remaining lifetime (technical resource) of the air defense system. The article finishes with conclusions that support the possibility and necessity of a SAMS upgrade, given the change of the threats characteristics.