Publications by authors named "Ivan Budimir"

27 Publications

  • Page 1 of 1

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

Diagnostics (Basel) 2021 Oct 31;11(11). Epub 2021 Oct 31.

Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia.

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.
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http://dx.doi.org/10.3390/diagnostics11112021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8618190PMC
October 2021

A CROSS-SECTIONAL STUDY OF HEPATITIS B AND HEPATITIS C KNOWLEDGE AMONG DENTAL MEDICINE STUDENTS AT THE UNIVERSITY OF ZAGREB.

Acta Clin Croat 2021 Jun;60(2):216-230

1Department of Pharmacology, University of Zagreb School of Medicine, Zagreb, Croatia; 2University of Zagreb School of Dental Medicine, Zagreb, Croatia; 3Department of Environmental and Occupational Health and Sports, Andrija Štampar School of Public Health, University of Zagreb School of Medicine, Zagreb, Croatia; 4Department of Periodontology, University of Zagreb School of Dental Medicine, Zagreb, Croatia; 5Gastroenterology and Hepatology Division, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 6Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb, Croatia; 7Cardiovascular Division, Zagreb University Hospital Centre, Zagreb, Croatia; 8Gastroenterology Unit, Dr. Ivo Pedišić General Hospital, Sisak, Croatia; 9Department of Internal Medicine, University of Zagreb School of Dental Medicine, Zagreb, Croatia.

Dental health care workers, particularly dental medicine students (DMS), are at an increased risk of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. The aim of our study was to assess the level of knowledge on HBV and HCV, estimate needlestick injury (NSI) prevalence and reporting practice in DMS at the University of Zagreb, and analyze how enrolment in obligatory and supplemental courses affects knowledge and NSI reporting practice. The knowledge was assessed by our questionnaires based on the Centers for Disease Control general handouts. Additional information was collected to examine the prevalence and reporting practice of NSI. Data were analyzed by descriptive statistical analysis, independent-samples t-test, proportion analyses, and combined factor analyses of categorical and quantitative variables in SPSS and R. In total, 206 students participated in the survey. The overall level of HBV- and HCV-related knowledge was poor, with the mean scores of 61.90% and 51.35%, respectively. Moreover, students enrolled in the first year demonstrated significantly lower levels of knowledge in comparison with their older peers. Of all participants, 18.2% had sustained a NSI and the majority of them (78.95%) had never reported the injury. In conclusion, DMS have low levels of knowledge on important occupational pathogens and poor NSI reporting practice. Moreover, formal education in the current form has failed to significantly improve student competence and theoretical knowledge translates poorly into more conscientious injury reporting practice. We should look for a better way to increase student awareness and level of knowledge on this topic.
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http://dx.doi.org/10.20471/acc.2021.60.02.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8564850PMC
June 2021

Inferior lateral tunneling (ILT) composite separation technique.

J Plast Reconstr Aesthet Surg 2021 12 17;74(12):3443-3476. Epub 2021 Sep 17.

Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital "Dubrava", Zagreb, School of Medicine, Josip Juraj Strossmayer University of Osijek and University of Zagreb Croatia.

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http://dx.doi.org/10.1016/j.bjps.2021.08.040DOI Listing
December 2021

An unusual cause of chronic back pain: retroperitoneal ganglioneuroma.

Br J Hosp Med (Lond) 2018 Oct;79(10):591

Professor, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Sestre milosrdnice University Hospital Center, Zagreb, Croatia.

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http://dx.doi.org/10.12968/hmed.2018.79.10.591DOI Listing
October 2018

Bleeding Peptic Ulcer - Tertiary Center Experience: Epidemiology, Treatment and Prognosis.

Acta Clin Croat 2017 Dec;56(4):707-714

Magdalena Department of Cardiovascular Diseases, Osijek School of Medicine, Krapinske Toplice, Croatia.

The aim of this study was to demonstrate epidemiological, clinical and endoscopic characteristics of acute upper gastrointestinal bleeding (UGIB) with special reference to peptic ulcer bleeding (PUB). The study included 2198 consecutive patients referred to our emergency department due to acute UGIB from January 2008 to December 2012. All patients underwent urgent upper GI endoscopy within 24 hours of admission, and 842 patients diagnosed with PUB were enrolled and prospectively followed-up. The cumulative incidence of UGIB was 126/100,000 in the 5-year period. Two out of five patients had a bleeding peptic ulcer; in total, 440 (52.3%) had bleeding gastric ulcer, 356 (42.3%) had bleeding duodenal ulcer, 17 (2%) had both bleeding gastric and duodenal ulcers, and 29 (3.5%) patients had bleeding ulcers on gastroenteric anastomoses. PUB was more common in men. The mean patient age was 65.9 years. The majority of patients (57%) with PUB were taking agents that attenuate the cytoprotective function of gastric and duodenal mucosa. Rebleeding occurred in 77 (9.7%) patients and 47 (5.9%) patients required surgical intervention. The 30-day morality was 5.2% and 10% of patients died from uncontrolled bleeding and concomitant diseases. In conclusion, PUB is the main cause of UGIB, characterized by a significant rebleeding rate and mortality.
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http://dx.doi.org/10.20471/acc.2017.56.04.18DOI Listing
December 2017

Scoring systems for peptic ulcer bleeding: Which one to use?

World J Gastroenterol 2017 Nov;23(41):7450-7458

Division of Gastroenterology, Department of Internal Medicine, "Sestre Milosrdnice" University Hospital Center, Zagreb 10000, Croatia.

Aim: To compare the Glasgow-Blatchford score (GBS), Rockall score (RS) and Baylor bleeding score (BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers.

Methods: Between January 2008 and December 2013, 1012 consecutive patients admitted with peptic ulcer bleeding (PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores (RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics (AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.

Results: PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome (AUROC 0.82 0.67 0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality (AUROC 0.84 0.57 0.64), rebleeding (AUROC 0.75 0.61 0.53), need for blood transfusion (AUROC 0.83 0.63 0.58) and surgical intervention (0.82 0.63 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome (AUROC 0.82 0.69, respectively).

Conclusion: The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.
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http://dx.doi.org/10.3748/wjg.v23.i41.7450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685851PMC
November 2017

Abdominal Ultrasound – The Leading Method in Duodenal Gist Diagnostics

Acta Clin Croat 2017 03;56(1):183-187

Department of Pathology, Sestre milosrdnice University Hospital Center, School of Medicine and School of Dental Medicine, University of Zagreb, Zagreb, Croatia

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract and are generally asymptomatic. A 39-year-old female patient was hospitalized in 2012 at Clinical Department of Internal Medicine, Sestre milosrdnice University Hospital Center, for a focal hypodense irregular circular lesion located in segment III of the left hepatic lobe, accidentally found by ultrasonography and verified by computed tomography. The findings were also verified with nuclear magnetic resonance and esophagogastroduodenoscopy. A biopsy sample of the lesion was analyzed by histologic and immunohistochemical methods and identified as GIST. The patient underwent surgical operation (tumor excision with terminoterminal anastomosis created between the second segment of duodenum and jejunum and resection of liver segment III). The histopathologic findings matched GIST with a high probability of relapse according to the localization, size, mitotic activity and Ki-67 values. Therefore, therapy with imatinib at a dose of 400 mg/day was administered. Three years after the operation, the patient is still in remission.
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http://dx.doi.org/10.20471/acc.2017.56.01.26DOI Listing
March 2017

Changes in pulmonary artery systolic pressure correlate with radiographic severity and peripheral oxygenation in adults with community-acquired pneumonia.

J Clin Ultrasound 2018 Jan 22;46(1):41-47. Epub 2017 Sep 22.

Department of Cardiology, University Hospital "Thalassotherapia Opatija", Opatija, Croatia.

Purpose: The aim of this prospective observational study was to evaluate the relationship between changes in pulmonary artery systolic pressure (ΔPASP) and both severity of community-acquired pneumonia (CAP) and changes in peripheral blood oxygen partial pressure (PaO ).

Materials And Methods: Seventy-five consecutive adult patients hospitalized for treatment of CAP were recruited in this single-center cohort study. Doppler echocardiographic measurement of PASP was performed by 2 staff cardiologists. Follow-up assessment was performed within 2 to 4 weeks of ending antibiotic treatment at radiographic resolution of CAP. Fifteen patients were excluded during follow-up due to confirmation of chronic obstructive pulmonary disease.

Results: Pneumonia was unilateral in 40 (66.7%) and bilateral in 20 (33.3%) patients. Radiographic extent of pneumonia involved 2 pulmonary segments in 31 patients (51.7%), 3 to 5 pulmonary segments in 25 (41.7%), and 6 pulmonary segments in 4 patients (6.6%). ΔPASP between hospital admission and follow-up correlated with the number of pulmonary segments involved (Rho = 0.953; P < .001) and PaO (Rho = -0.667; P < .001). The maximum PASP was greater during pneumonia than after resolution (34.82 ± 3.96 vs. 22.67 ± 4.04, P < .001).

Conclusions: Changes in PASP strongly correlated with radiological severity of CAP and PaO . During pneumonia, PASP appeared increased without significant change in left ventricular filling pressures. This suggests that disease-related changes in lung tissue caused by pneumonia may easily and reproducibly be assessed using conventional noninvasive bedside diagnostics such as echocardiography and arterial blood gas analysis.
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http://dx.doi.org/10.1002/jcu.22523DOI Listing
January 2018

Right coronary ostial extra anatomical bypass following an aortic root false aneurysm after a composite graft procedure.

J Card Surg 2017 Sep 25;32(9):595-596. Epub 2017 Aug 25.

Department of Surgery, University Hospital, Zurich, Switzerland.

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http://dx.doi.org/10.1111/jocs.13195DOI Listing
September 2017

Portal systemic shunt between the hepatic portal vein and right renal vein in a patient with multifocal hepatocellular carcinoma: Case report.

J Clin Ultrasound 2017 Oct 2;45(8):524-527. Epub 2017 Feb 2.

Division of Clinical Immunology, Pulmonology, and Rheumatology, Department of Internal Medicine, "Sestre milosrdnice" University Hospital Center, Medical and Dental Faculty, University of Zagreb, Zagreb 10000, Vinogradska 29, Croatia.

Portal hypertension is a clinical syndrome characterized by the development of collateral circulation and portosystemic shunts, as well as ascites and hepatic encephalopathy. We present the case of a large portosystemic shunt between the hepatic portal vein and aneurysmal right renal vein in a cirrhotic 64-year-old man with thrombosis of the portal vein and hepatocellular carcinoma. This is a very rare clinical manifestation which, to our knowledge, has been described only once previously in the literature. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:524-527, 2017.
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http://dx.doi.org/10.1002/jcu.22437DOI Listing
October 2017

CX43 Expression in Colonic Adenomas and Surrounding Mucosa Is a Marker of Malignant Potential.

Anticancer Res 2016 10;36(10):5437-5442

Division of Gastroenterology, Department of Internal Medicine, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine and University of Zagreb School of Dental Medicine, Zagreb, Croatia.

Background/aim: Colorectal cancer is a major public health problem. The adenoma-carcinoma sequence offers potential for screening and surveillance. We tested the clinical behavior and diagnostic utility of connexin 43 (CX43) in connection with pathohistological risk.

Patients And Methods: Immunohistochemical expression of CX43 in colonic adenomas and surrounding mucosa from 87 patients was determined.

Results: CX43 expression was higher in mucosa surrounding adenomas with high-grade dysplasia (p=0.047), larger adenomas (p=0.015) and villous adenomas (p=0.02). No difference of CX43 expression in adenomas according to grade of dysplasia was found (p=0.87). CX43 expression in adenomas was dependent on the patient's hemoglobin level (p=0.002), family history of colorectal cancer (p=0.009) and statin therapy (p=0.049).

Conclusion: CX43 expression in mucosa surrounding adenoma could be an additional factor indicative of malignant potential. CX43 expression in colonic adenoma seems to be closely related to family history of colorectal cancer, statin therapy and hemoglobin level.
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http://dx.doi.org/10.21873/anticanres.11122DOI Listing
October 2016

Changes in metabolic hormones after bariatric surgery and their predictive impact on weight loss.

Clin Endocrinol (Oxf) 2016 Dec 19;85(6):852-860. Epub 2016 Aug 19.

Department of Endocrinology, Diabetology and Metabolic diseases "Mladen Sekso", University Hospital Center "Sestre milosrdnice", University of Zagreb School of Medicine, Zagreb, Croatia.

Background: Although various metabolic hormones have been implicated in bariatric-related weight loss, their use as predictors of weight loss is unknown. Our study evaluates changes in metabolic hormones after bariatric surgery, and their role as predictors of weight loss.

Methods: This nonrandomized study included 51 patients, 21 underwent laporascopic adjustable gastric banding (LAGB), 15 laparoscopic sleeve gastrectomy (LSG) and 15 Roux-en Y gastric bypass (RYGB). Serum ghrelin, leptin, insulin, growth hormone, HOMA-IR and HOMA-β was recorded at baseline and 1, 3, 6 and 12 months, and correlated with weight loss. Successful weight loss was defined as excess weight loss >50% at 12 months for all groups.

Results: Weight loss pattern was similar in all groups. Ghrelin increased only in the LAGB group (P = 0·016). However, baseline ghrelin concentrations >664·6 pg/mL in the LSG group predicted successful weight loss with 81·8% sensitivity and 100·0% specificity, and ghrelin >969·8 pg/mL in the 1st postoperative month predicted success with 83·3% sensitivity and 83·3% specificity in the LAGB group. Insulin and HOMA-IR decreased significantly in the LSG and RYGB group, HOMA-β increased in the LAGB and LSG group. Serum leptin decreased and GH increased in all groups (P < 0·001 for all changes). Changes in insulin, leptin and growth hormone were not predictors, but a consequence of weight loss.

Conclusions: LSG is the most effective procedure for improvement of beta-cell function. High baseline ghrelin in the LSG group and an adequate 1st month increase in the LAGB group are associated with greater weight loss. Validation studies are required to confirm the role of ghrelin in predicting weight loss after bariatric surgery, but also in selecting candidates for specific bariatric procedures.
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http://dx.doi.org/10.1111/cen.13160DOI Listing
December 2016

Glasgow Blatchford, pre-endoscopic Rockall and AIMS65 scores show no difference in predicting rebleeding rate and mortality in variceal bleeding.

Scand J Gastroenterol 2016 Nov 29;51(11):1375-9. Epub 2016 Jun 29.

c Magdalena - Clinic for Cardiovascular Diseases of the Faculty of Osijek , Krapinske Toplice , Croatia.

Objective: To compare the performance of the Glasgow Blatchford score (GBS), pre-endoscopic Rockall score (PRS) and AIMS65 score in predicting specific clinical endpoints following variceal upper gastrointestinal hemorrhage (UGIH).

Material And Methods: Between January 2008 and December 2013, we retrospectively analyzed 225 consecutive hospitalized patients managed for endoscopically confirmed UGIH.

Results: A total of 225 patients (mean age 61.3 years), mostly diagnosed with alcoholic cirrhosis (195/86.7%), presented with variceal UGIH during the study period. Rebleeding occurred in 22 (9.8%) patients and 30-day mortality was 39 (17.3%). Initial hemostasis was achieved with N-butyl cyanoacrylate (151/79.1%) and endoscopic variceal ligation (40/20.9%), while secondary rebleeding prophylaxis in 110 (48.9%) patients was accomplished using endoscopic variceal ligation (92%). The majority of patients died from the underlying disease, while 12 (30.8%) died from bleeding. Median hospital stay was 6 (1-35) days. There was no statistically significant difference among AIMS65, GBS and PRS in predicting mortality (AUROC 0.70 vs. 0.64 vs. 0.66) or rebleeding rates (AUROC 0.74 vs. 0.60 vs. 0.67). The GBS was superior in predicting the need for blood transfusion compared to AIMS65 score (AUROC 0.75 vs. 0.61, p = 0.01) and PRS (AUROC 0.75 vs. 0.58, p = 0.009).

Conclusions: The AIMS65, GBS and PRS scores are comparable but not useful for predicting outcome in patients with variceal UGIH because of poor discriminative ability. The GBS is superior in predicting the need for transfusion compared to AIMS65 score and PRS.
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http://dx.doi.org/10.1080/00365521.2016.1200138DOI Listing
November 2016

ILEAL HERNIATION THROUGH THE FORAMEN OF WINSLOW: OVEREATING AS A RISK FACTOR FOR INTERNAL HERNIATION.

Acta Clin Croat 2016 Mar;55(1):167-71

Internal hernias have an overall incidence of less than 1% and are difficult to diagnose clinically due to their nonspecific presentation. Most internal hernias present as strangulating closed-loop obstruction and delay in surgical intervention is responsible for a high mortality rate (49%). We present a case of ileal herniation through the foramen of Winslow. A 29-year-old previously healthy female presented with acute onset right upper quadrant pain, abdominal fullness, and nausea. The pain was sudden in onset and began shortly after a dinner party where she consumed larger portions of food. Laboratory investigations revealed mild leukocytosis with left shift. Dual-phase multi-detector computed tomography disclosed herniation of the small bowel into the lesser sac. The patient underwent an emergency median laparotomy that revealed ileal herniation through the foramen of Winslow. Adhesiolysis and manual reduction of the bowel was performed, and the reduced bowel showed only congestive changes. The postoperative recovery was uneventful and the patient was discharged on the third postoperative day. Risk factors for internal herniation still remain unclear, although excessively mobile bowel loops and an enlarged foramen of Winslow have been described. Our case demonstrated that overeating could be an additional risk factor for internal herniation. We describe our clinical and radiology findings, as well as surgical management. Due to the high rates of morbidity and mortality, it is imperative that clinicians be aware of the possible risks factors for internal herniation. Internal hernias should be included in the differential diagnosis of small bowel obstruction so that appropriate steps can be made in the work-up of these patients, followed by timely surgical intervention.
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http://dx.doi.org/10.20471/acc.2016.55.01.23DOI Listing
March 2016

Initial Weight Loss after Restrictive Bariatric Procedures May Predict Mid-Term Weight Maintenance: Results From a 12-Month Pilot Trial.

Bariatr Surg Pract Patient Care 2015 Jun;10(2):68-73

Department of Endocrinology, Diabetology, and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sestre Milosrdnice," University of Zagreb School of Medicine , Zagreb, Croatia .

Bariatric procedures are effective options for weight loss (WL) in the morbidly obese. However, some patients fail to lose any weight after bariatric surgery, and mid-term weight maintenance is variable. The aim of this study was to investigate whether initial WL could predict mid-term weight maintenance. Eighty patients were enrolled, of whom 44 were treated with the BioEnterics Intragastric Balloon (BIB), 21 with laparoscopic adjustable gastric lap-banding (LAGB), and 15 with laparoscopic sleeve gastrectomy (LSG). Percentage of body WL and percentage of excess weight loss (EWL) were calculated at baseline and after 1, 3, 6, and 12 months. Successful WL was defined as EWL >20% for patients treated with BIB and >50% for patients treated with LAGB and SG. Success in the 6th and 12th month was achieved in 80% and 58% of patients in the BIB group, 33% and 40% in the LAGB group, and 60% and 73% in the LSG group. In the BIB group, WL in the 1st month correlated positively with WL at the 6th and 12th month, and an initial WL >6.5% best predicted success (sensitivity 50%, specificity 80%). A similar association was observed in the LAGB group at the 6th and 12th month and an initial WL >9.4% best predicted success (sensitivity 90.0%, specificity 81.2%). In patients treated with LSG, WL in the 3rd month correlated positively with EWL at the 6th and 12th month, with a cutoff value of 17% (sensitivity 66.7%, specificity 100%). WL in the 1st month in patients treated with BIB and LAGB and WL in the 3rd month in patients treated with LSG could be used as a prognostic factor to predict mid-term weight maintenance.
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http://dx.doi.org/10.1089/bari.2014.0049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4643675PMC
June 2015

Epithelioid hemangioma of the orbit: case report.

Acta Clin Croat 2015 Mar;54(1):92-5

Epithelioid hemangioma (EH) and Kimura's disease (KD) were once considered different stages of the same disease, as they share many clinical and histopathologic similarities. Nowadays, they are considered as two different entities, but some authors still confuse these terms. Our objective is to present a case of EH occurring in a very uncommon location and to emphasize the microscopic and clinical differences between EH and KD. We present a case of EH of the orbit in an 83-year-old man diagnosed after histopathologic evaluation of a mass that was surgically removed from the orbit. The tumor showed typical microscopic appearance with pathognomonic epithelioid endothelial cells. The diagnosis was also confirmed by immunohistochemical analysis. Our case clearly illustrates typical appearance of EH and the main differences between EH and KD are thoroughly discussed.
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March 2015

Biliary leakage after urgent cholecystectomy: Optimization of endoscopic treatment.

World J Gastrointest Endosc 2015 May;7(5):547-54

Neven Ljubičić, Alen Bišćanin, Tajana Pavić, Marko Nikolić, Ivan Budimir, Ana Đuzel, Division of Gastroenterology, Department of Internal Medicine, "Sestre milosrdnice" University Hospital, Zagreb 10000, Croatia.

Aim: To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up.

Methods: This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography (ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded.

Results: During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d (interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23 (77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy (median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed and the biliary stent was removed on gastroscopy. In seven (23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d (interquartile range, 28-43 d). Among the patients included in the follow-up (median 30.5 mo, range 7-59 mo), four patients (14.8%) died of severe underlying comorbid illnesses.

Conclusion: Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.
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http://dx.doi.org/10.4253/wjge.v7.i5.547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436923PMC
May 2015

Obstructive Jaundice as an Uncommon Manifestation of Metastatic Breast Cancer.

World J Oncol 2015 Feb 14;6(1):297-300. Epub 2015 Feb 14.

Department of Oncology, University Hospital Center "Sestre Milosrdnice", Ilica 197, Zagreb 10000, Croatia.

Invasive ductal carcinoma is the most common type of breast cancer and accounts for about 70-85% of all invasive breast carcinomas. It primarily metastasizes to the bone, lungs, regional lymph nodes, liver and brain. Most of breast cancer recurrence occurs within the first 5 years of diagnosis, particularly for ER negative disease. Gastrointestinal tract involvement is very rare and is detected in only 10% of all the cases, and it usually derives from lobular breast cancer rather than the much more common cell type of ductal breast cancer. Early diagnosis is very important because it enables prompt and adequate choice of treatment and improves patient's long-term prognosis. In this report we describe an unusual case of obstructive jaundice caused by metastases from invasive ductal breast cancer to the lymph nodes of the hepatoduodenal ligament with extramural compression of the distal common bile duct and tumor invasion to the lumen of the duct. Our goal is to emphasize possible diagnostic pitfalls and increase the clinical awareness and the importance of intensive follow-up in patients with breast cancer, even years after the initial diagnosis.
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http://dx.doi.org/10.14740/wjon762wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649949PMC
February 2015

North vs south differences in acute peptic ulcer hemorrhage in Croatia: hospitalization incidence trends, clinical features, and 30-day case fatality.

Croat Med J 2014 Dec;55(6):647-54

Neven Ljubičić, Department of Internal Medicine, "Sestre Milosrdnice" Clinical Hospital Center, University of Zagreb School of Medicine and School of Dental Medicine, Vinogradska 29, Zagreb 10000, Croatia,

Aim: To assess the seven-year trends of hospitalization incidence due to acute peptic ulcer hemorrhage (APUH) and associated risk factors, and examine the differences in these trends between two regions in Croatia.

Methods: The study collected sociodemographic, clinical, and endoscopic data on 2204 patients with endoscopically confirmed APUH who were admitted to the Clinical Hospital Center "Sestre Milosrdnice," Zagreb and Clinical Hospital Center Split between January 1, 2005 and December 31, 2011. We determined hospitalization incidence rates, 30-day case fatality rate, clinical outcomes, and incidence-associated factors.

Results: No differences were observed in APUH hospitalization incidence rates between the regions. Age-standardized one-year cumulative APUH hospitalization incidence rate calculated using the European Standard Population was significantly higher in Zagreb than in Split region (43.2/100 000 vs 29.2/100,000). A significantly higher APUH hospitalization incidence rates were observed in the above 65 years age group. Overall 30-day case fatality rate was 4.9%.

Conclusion: The hospitalization incidence of APUH in two populations did not change over the observational period and it was significantly higher in the Zagreb region. The incidence of acute duodenal ulcer hemorrhage also remained unchanged, whereas the incidence of acute gastric ulcer hemorrhage increased. The results of this study allow us to monitor epidemiological indicators of APUH and compare data with other countries.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295080PMC
http://dx.doi.org/10.3325/cmj.2014.55.647DOI Listing
December 2014

Waldenström's macroglobulinemia as a diagnostic challenge: case report.

Acta Clin Croat 2014 Mar;53(1):94-7

Waldenström's macroglobulinemia is a distinct clinicopathologic entity defined as a B-cell neoplasm characterized by lymphoplasmacytic infiltrate in the bone marrow, with an associated immunoglobulin (Ig) M paraprotein. Clinical manifestations are due to deposition of IgM in the liver, spleen, and/or lymph nodes, so it presents with anemia, hyperviscosity, lymphadenopathy, hepatomegaly, splenomegaly and neurologic symptoms. The main diagnostic criteria are a typical peak on serum protein electrophoresis and malignant cells in bone marrow biopsy samples. There is no standard therapy for the treatment of symptomatic Waldenstrom's macroglobulinemia and no agents have been specifically approved for this disease, but initial treatment usually starts with the monoclonal anti-CD20 antibody rituximab, either alone or in combination with other agents, rather than chemotherapy alone. This article confirms that, despite the existence of more modern imaging methods, ultrasonography still has a significant diagnostic role.
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March 2014

Endoscopic balloon dilatation of postsurgical intestinal strictures in Crohn's disease: case report and review of the literature.

Acta Clin Croat 2013 Sep;52(3):374-9

Division of Gastroenterology, Department of Internal Medicine, Sestre milosrdnice University Hospital Center, School of Medicine and Dental Medicine, University of Zagreb, Zagreb, Croatia.

Strictures are one of the most common complications of Crohn's disease. If symptomatic and resistant to medical anti-inflammatory therapy, and especially in cases of acute obstruction, surgical correction may be unavoidable. Although surgical treatment is dramatically effective in curing Crohn's disease strictures, a high rate of postsurgical restenosis has been recognized, ultimately requiring additional surgery. To avoid the risks and costs entailed by repeated surgical resection, endoscopic balloon dilatation (EBD) has been proposed as a conservative treatment option for intestinal strictures in Crohn's disease, in which the stricture is pneumatically dilated with through-the-scope balloons of different diameters. The main clinical indication for EBD is the appearance of obstructive symptoms associated with the stricture, especially if they are postoperative and shorter than 4 centimeters. Usually more than one dilatation session is required for every stricture. EBD is applied infrequently, possibly due to the perceived risk of perforation and early stricture recurrence, but studies have demonstrated that EBD has a high success rate, a low chance of complications, excellent symptomatic response, as well as good short-term and long-term outcomes, proving that it is a relatively simple and successful technique that provides long-term effective palliation of the symptoms with minimal risk in patients with simple strictures, and offers a reasonable alternative to surgery.
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September 2013

Mortality in high-risk patients with bleeding Mallory-Weiss syndrome is similar to that of peptic ulcer bleeding. Results of a prospective database study.

Scand J Gastroenterol 2014 Apr 5;49(4):458-64. Epub 2014 Feb 5.

Department of Internal Medicine, Division of Gastroenterology, "Sestre milosrdnice" University Hospital Center, Medical and Dental Faculty, University of Zagreb , Zagreb 10000, Vinogradska 29 , Croatia.

Objective: The aim of this study was to identify the predictive factors influencing mortality in patients with bleeding Mallory-Weiss syndrome in comparison with peptic ulcer bleeding.

Material And Methods: Between January 2005 and December 2009, 281 patients with endoscopically confirmed Mallory-Weiss syndrome and 1530 patients with peptic ulcer bleeding were consecutively evaluated. The 30-day mortality and clinical outcome were related to the patients' demographic data, endoscopic, and clinical characteristics.

Results: The one-year cumulative incidence for bleeding Mallory-Weiss syndrome was 7.3 cases/100,000 people and for peptic ulcer bleeding 40.4 cases/100,000 people. The age-standardized incidence for both bleeding Mallory-Weiss syndrome and peptic ulcer bleeding remained unchanged during the observational five-year period. The majority of patients with bleeding Mallory-Weiss syndrome were male patients with significant overall comorbidities (ASA class 3-4). Overall 30-day mortality rate was 5.3% for patients with bleeding Mallory-Weiss syndrome and 4.6% for patients with peptic ulcer bleeding (p = 0.578). In both patients with bleeding Mallory-Weiss syndrome and peptic ulcer bleeding, mortality was significantly higher in patients over 65 years of age and those with significant overall comorbidities (ASA class 3-4).

Conclusion: The incidence of bleeding Mallory-Weiss syndrome and peptic ulcer bleeding has not changed over a five-year observational period. The overall 30-day mortality was almost equal for both bleeding Mallory-Weiss syndrome and peptic ulcer bleeding and was positively correlated to older age and underlying comorbid illnesses.
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http://dx.doi.org/10.3109/00365521.2013.846404DOI Listing
April 2014

Decrease in insulin resistance has a key role in improvement of metabolic profile during intragastric balloon treatment.

Endocrine 2014 Mar 17;45(2):331-4. Epub 2013 Oct 17.

Department of Endocrinology, Diabetology and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre milosrdnice", University of Zagreb School of Medicine, Vinogradska cesta 29, Zagreb, Croatia.

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http://dx.doi.org/10.1007/s12020-013-0069-xDOI Listing
March 2014

Secondary arterio-enteric fistula: case report and review of the literature.

Acta Clin Croat 2012 Mar;51(1):79-82

Department of Gastroenterology and Hepatology, University Department of Medicine, Sestre milosrdnice University Hospital Center, Zagreb, Croatia.

Arterio-enteric fistula is a rare, but potentially deadly cause of gastrointestinal bleeding. The disease occurs in two forms: primary as a result of atherosclerotic aortic aneurysm, aortitis, trauma, radiation, tumor invasion or penetrating ulcer, and secondary as a consequence of surgical aortal reconstruction. The clinical manifestation is mostly gastrointestinal bleeding, rarely back pain, fever and sepsis. Computed tomography with contrast medium is the most suitable diagnostic test, however, the diagnosis frequently requires explorative laparotomy. A case is presented of secondary arterio-enteric fistula, found two years after surgical treatment of chronic pancreatitis with pseudocystojejunostomy, which clinically manifested with gastrointestinal bleeding. Although there was strong suspicion of arterio-enteric fistula, the diagnosis was not verified by routine workup, but only on explorative laparotomy.
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March 2012

The influence of etiologic factors on clinical outcome in patients with peptic ulcer bleeding.

Dig Dis Sci 2012 Dec 27;57(12):3195-204. Epub 2012 Jun 27.

Division of Gastroenterology, Department of Internal Medicine, Medical and Dental Faculty, Sestre Milosrdnice University Hospital Center, University of Zagreb, Vinogradska 29, 10000, Zagreb, Croatia.

Background: Peptic ulcer bleeding remains an important cause of morbidity and mortality.

Aim: The aim of this study was to evaluate the prevalence of non-steroidal anti-inflammatory drugs (NSAID) use, Helicobacter pylori infection and non-H. pylori-non-NSAIDs causes of peptic ulcer bleeding and to identify the predictive factors influencing the rebleeding rate and in-hospital mortality in patients with bleeding peptic ulcer.

Methods: A total of 1,530 patients with endoscopically confirmed peptic ulcer bleeding were evaluated consecutively between January 2005 and December 2009. The 30-day mortality and clinical outcome were related to patient's demographic data, endoscopic and clinical characteristics.

Results: The age-standardized 1-year cumulative incidence for peptic ulcer bleeding was 40.4 cases/100,000 people. The proportion of patients over 65 years increased from 45.7 % in 2005 to 61.4 % in 2009 (p = 0.007). Overall 30-day mortality rate was 4.6 %, not significantly different for conservatively and surgically treated patients (4.9 vs. 4.1 %, p = 0.87). Mortality was significantly higher in patients over 65 years of age and those with in-hospital bleeding recurrence. Patients with non-H. pylori-non-NSAID idiopathic ulcers had significantly higher 30-day mortality rate than those with H. pylori ulcers and NSAID-H. pylori ulcers (7.1 vs. 0 vs. 0.8 %, p = 0.001 and p = 0.007, respectively). There was no statistically significant difference between patients with NSAID ulcers and non-H. pylori-non-NSAID idiopathic ulcers in terms of 30-day mortality rate (5.3 vs. 7.1 %, p = 0.445).

Conclusion: The incidence of peptic ulcer bleeding has not changed over a 5-year observational period. The overall 30-day mortality was positively correlated to older age, underlying comorbid illnesses, in-hospital bleeding recurrence and the absence of H. pylori infection.
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http://dx.doi.org/10.1007/s10620-012-2273-6DOI Listing
December 2012

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding.

World J Gastroenterol 2012 May;18(18):2219-24

Department of Internal Medicine, 'Sestre milosrdnice' University Hospital Center, 10000 Zagreb, Croatia.

Aim: To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer.

Methods: Between January 2005 and December 2009, 150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed (Forrest IIa) were included in the study. Patients were randomized to receive a small-volume epinephrine group (15 to 25 mL injection group; Group 1, n = 50), a large-volume epinephrine group (30 to 40 mL injection group; Group 2, n = 50) and a hemoclip group (Group 3, n = 50). The rate of recurrent bleeding, as the primary outcome, was compared between the groups of patients included in the study. Secondary outcomes compared between the groups were primary hemostasis rate, permanent hemostasis, need for emergency surgery, 30 d mortality, bleeding-related deaths, length of hospital stay and transfusion requirements.

Results: Initial hemostasis was obtained in all patients. The rate of early recurrent bleeding was 30% (15/50) in the small-volume epinephrine group (Group 1) and 16% (8/50) in the large-volume epinephrine group (Group 2) (P = 0.09). The rate of recurrent bleeding was 4% (2/50) in the hemoclip group (Group 3); the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution (P = 0.0005 and P = 0.045, respectively). Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups.

Conclusion: Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.
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http://dx.doi.org/10.3748/wjg.v18.i18.2219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351772PMC
May 2012

Relationship between polymorphonuclear leukocyte count in bronchoalveolar lavage fluid and bacterial content in Gram's stain and bacterial content in final microbiological report.

Coll Antropol 2010 Mar;34(1):1-6

Department of Internal Medicine, University Hospital "Merkur", Zagreb, Croatia.

Eighty samples of bronchoalveolar lavage fluid (BALF) were obtained from the total of 48 patients (22 females and 26 males) and analyzed. Eighteen of those patients were organ transplant recipients. The relationship between polymorphonuclear leukocyte (PMN) count in direct sample and semi quantitative Gram-positive and Gram-negative bacterial content were analyzed in BALF samples. PMN count in direct sample and Gram-positive and Gram-negative bacterial content of the final microbiological report was compared as well. On the total number of samples PMN count in direct samples of BALF was statistically significant regarding the presence of Gram-positive bacteria in the same sample; it was nearly significant regarding the presence of Gram-negative bacteria; and it was statistically significant for the total bacterial content. If BALF samples are divided into those obtained from organ-transplant and those obtained from non-organ-transplant patients, positive, statistically significant relationship is found in the organ-transplant group, more specifically for the relationship between PMNs and total bacterial content. When PMN count in direct microbiological sample was compared with the results of the final microbiological report, statistically significant relationship was found neither with respect to all BALF samples, nor after dividing them into "organ-transplant" and "non-organ-transplant" group. We did not find differences caused by gender.
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March 2010
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