DOI: 10.3897/folmed.68.e163476

Authors: Yanislav Grishev Iliev, Vladimir Nikolov Andonov, Elena Galabova Poryazova-Markova

Abstract: Abstract Introduction: Colorectal cancer is a leading cause of morbidity and mortality worldwide. Immunoscore provides important prognostic information in early-stage colorectal cancer, beyond traditional TNM staging. Aim: To investigate the Immunoscore in early-stage colorectal cancer and its prognostic value. Patients and methods: A retrospective pilot cohort of 35 patients was evaluated for recurrence, survival, toxicity, and clinical correlations with Immunoscore. Results: High Immunoscore was associated with better outcomes, including zero recurrence. Immunoscore showed trends by tumor location, with stronger associations in younger patients. There was no correlation with carcinoembryonic antigen levels. Conclusion: Our findings support the incorporation of Immunoscore into future colorectal cancer staging models.

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DOI: 10.3897/folmed.67.e159151

Authors: Nikola Boyanov, Nikol Milinich, Aleksandar Balabanski, Katina Shtereva, Katerina Madzharova, Ivan Tishkov, Alexander Katzarov, Ivan Popadiyn, Galabina Hinkova, Stoilka Tufkova

Abstract: Aim: Colonoscopy is the gold standard for colorectal cancer screening and prevention. This multicenter study aims to evaluate and compare the effectiveness, cost-efficiency, and patient tolerability of different bowel preparation regimens for colonoscopy using a high-volume polyethylene glycol-based solution. Materials and methods: A total number of 746 patients were enrolled from three Bulgarian centers and were randomly assigned to various bowel preparation protocols categorized as previous-day, split-day, and same-day regimens. Effectiveness was assessed using the Boston Bowel Preparation Scale, cost-efficiency was determined by healthcare facility expenses, and patient tolerability was evaluated through patient-reported questionnaires. Results: The split-dose regimens achieved the highest bowel cleansing quality, significantly outperforming the other two groups. Furthermore, SPLIT4, one of the split-dose regimens, achieved the highest median Boston Bowel Preparation Scale (BBPS) score of 8, significantly outperforming previous-day and other split-dose protocols (p<0.001), while maintaining excellent patient tolerability (mean score 1.25). Conclusion: Split-dose preparation using a high-volume polyethylene glycol solution demonstrated superior bowel cleansing and favorable patient tolerability, supporting current clinical guidelines. Future research should further investigate comparisons between high-volume and low-volume polyethylene glycol solutions to optimize patient adherence and outcomes.

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DOI: 10.3897/folmed.66.e106586

Authors: Bozhidar Hristov, Daniel Doykov, Desislav Stanchev, Emiliya Nacheva-Georgieva, Krasimir Kraev, Petar Uchikov, Gancho Kostov, Siyana Valova, Eduard Tilkiyan, Katya Doykova, Mladen Doykov

Abstract: Bouveret’s syndrome (BS) represents an exceedingly rare clinical entity characterized by gastric outlet obstruction induced by a gallstone passing through a cholecystoduodenal, cholecystogastric or choledochoduodenal fistula and impacting in the duodenum or pylorus. Endoscopy is the preferred first-line therapy. It has a favorable safety profile, but requires high level of expertise to achieve stone clearance. We report here the case of a 75-year-old Caucasian male who presented with vomiting and upper gastrointestinal bleeding and was diagnosed with BS by upper endoscopy. A single session stone extraction utilizing mechanical lithotripsy and laser lithotripsy was executed. Complete clearance of the duodenum and gallbladder was achieved, extracting successfully all fragments larger than 5 mm. The rarity of BS and its non-specific presentation makes it largely overlooked leading commonly to delayed diagnosis, which results in a high mortality rate of 12-30%. Computer tomography is the diagnostic method of choice. Upper endoscopy can establish the presence of obstruction, but fails to visualize a stone in up to 1/3 of the cases. Management is either endoscopic or surgical. Endoscopic treatment has a good safety profile (mortality 1.6% vs. 17.5-25% for surgery) but poor success rate – 43% vs. 94.1%. To achieve higher success rate, more advanced techniques are required such as mechanical or laser lithotripsy. Laser lithotripsy is a feasible option for endoscopic treatment of BS, but the duration of the procedure might be an issue in frail patients.

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DOI: 10.3897/folmed.66.e116660

Authors: Iliya Todorov, Daniela Trayanova, Yordan Tsenovski

Abstract: Introduction: Obstructive jaundice is a clinical syndrome that is commonly seen in gastroenterology. Endoscopic retrograde cholangiopancreatography (ERCP) has been recognized as a first-choice therapeutic approach, with percutaneous biliary interventions (PBIs) being a viable alternative. Recent data questions the performance and safety profile of PBIs. Aim: The aim of the present study was to assess retrospectively the short-term clinical outcomes of PBIs in terms of technical and clinical success and adverse events (AEs) rate. Patients and methods: This is a retrospective, single-center cohort study of 62 consecutive patients subjected to PBI between January 2019 and August 2022. Results: Technical and clinical success rates of 97.10% and 79.40%, respectively were established. No PBI showed statistically significant superiority over the others. None of the evaluated factors showed significant influence on the therapeutic outcome and AEs. A total AE rate of 26.5% was calculated. All AEs were moderate to severe (grade III-IV according the Clavien-Dindo system). The mean hospital stay was 7.11±3.68 days. A total of 44.1% of the patients required multiple admissions. Existing studies establish similarly high technical (75%-100%) and acceptable clinical (84%) success rates. Alarmingly high AEs incidence of almost 50% has been found in recently published studies. Infection was the most common adverse event we found in our study. Almost universally, PBIs are used as salvage techniques in patients with malignant disease, failed prior ERCP, and poor performance status. Conclusion: PBIs remain a viable option to ERCP, but stricter patient selection and a gradual transition to EUS-guided draining procedures are likely required.

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DOI: 10.3897/folmed.66.e115645

Authors: Nikola Boyanov, Vladimir Andonov

Abstract: One of the most common stressors is so-called “occupational stress.” It is defined as the sum of physical, mental and physiological responses to work in situations where the workload or stress associated with it intensifies for an extended period of time. It is a gradual process in which individual cognitive assessments of occupational stressors generate adverse health events and may lead to burnout. Since it has become a major problem in the medical field, studying, measuring and limiting it have been set as goals for the future. We present a literature review on the topic of measuring stress using non-invasive means, such as cardiac indices measured through different devices, electrodermal activity, skin temperature, and salivary biomarkers. A virtual reality simulation could be used in conducting such experiments in order to provide a standardized environment with set variables for researchers to discern the most precise indices to be used in a real-life setting.

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DOI: 10.3897/folmed.65.e106764

Authors: Bozhidar Hristov, Emiliya Nacheva-Georgieva, Desislav Stanchev, Krasimir Kraev, Petar Uchikov, Gancho Kostov, Siyana Valova, Eduard Tilkiyan, Katya Doykova, Mladen Doykov

Abstract: Introduction: There are numerous imaging modalities available to describe pancreatic parenchyma. None of the broadly accepted diagnostic methods uses elasticity as an indicator of tissue damage. Aim: The aim of the present study was to establish reference values of parenchymal stiffness of normal pancreatic parenchyma through point shear wave elastography. Materials and methods: The design of the study is prospective single-center cohort study. Sixty patients were included in the study. The ultrasound-based point shear wave elastography (pSWE) imaging technique was applied. The mean and median shear wave velocity values of the pancreatic parenchyma in the head, body and tail were calculated. The influence of certain variables on the shear wave velocity (SWV) values was estimated. Results: A reference range for the entire pancreatic parenchyma of 0.66-1.62 m/s and a mean value of 1.17±0.22 m/s were calculated. Apart from age, none of the evaluated factors proved to have statistically significant influence on the obtained results. A measurement success rate of 94.5%, 97.2%, and 95.8% was established for the head, body, and tail of the pancreas, respectively. Transabdominal pSWE could be utilized for assessment of pancreatic parenchyma with high success rate. A mean value of 1.17 m/s was measured which is consistent with the existing literature on the matter. None of the external factors examined in the study, apart from age, was found to have statistically significant influence on the SWV values. Conclusions: The obtained results suggest that pSWE is a highly objective method for evaluating pancreatic parenchyma. Calculated reference range and mean values could be used in future studies to assess the capabilities of the method for differentiating between normal pancreatic parenchyma and diffuse and focal pancreatic disorders.

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DOI: 10.3897/folmed.65.e89756

Authors: Timothy Kravchenko, Aasim Chaudhry, Zeeshan Khan

Abstract: Gastric antral vascular ectasia (GAVE), also known as “Watermelon stomach”, is a rare cause of upper gastrointestinal bleeding (UGIB). It is characterized by an endoscopic appearance of flat red blood vessels traveling from the pylorus to the antrum. Patients often present with chronic blood loss resulting in iron deficiency anemia, or, less commonly, with acute gastropathy resulting in massive hemorrhage. The etiology of GAVE is unknown but the disorder has been more commonly observed in patients with cirrhosis, especially with portal hypertension, as well as in those with systemic sclerosis and other connective tissue disease. There is no definitive cure for GAVE, but the condition can be managed with a variety of endoscopic techniques, including heater probes, bipolar probes, plasma coagulators, laser therapy, and radiofrequency ablation. In rare cases, patients also require blood transfusions. Here we present an interesting case of upper GI bleeding resulting in symptomatic anemia in a 69-year-old female patient with GAVE following cocaine use. The patient was initially admitted for fatigue and shortness of breath and required multiple units of pRBCs. She was also found to have a urine drug screen positive for cocaine. Following stabilization, she underwent endoscopy which revealed the characteristic “watermelon stomach” appearance consistent with GAVE syndrome. The patient was discharged on an oral proton-pump inhibitor with instructions to follow-up outpatient with Gastroenterology. This case is presented as an example of a risk factor for acute exacerbation of a rare cause of UGIB. This patient presentation also represents an example of the importance of strict follow-up for those with risk factors for exacerbation of chronic GI conditions.

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DOI: 10.3897/folmed.65.e76329

Authors: Nikola Mumdzhiev, Borislav Borisov, Rumen Tenev, Mariana Radicheva

Abstract: Intrahepatic cholangiocarcinoma is a rare type of cancer that is usually discovered at an advanced stage where surgical treatment is not an option. When compared to standard systemic therapy, transarterial chemoembolization (TACE) can provide a survival benefit to unresectable patients. Extrahepatic tumor spread is not rare, but cardiac involvement is an unusual complication. We present the case of a 56-year-old man with histologically proven intrahepatic cholangiocarcinoma. Oncologic risk factors include hepatitis B and liver cirrhosis. Being in an unresectable stage of the disease, three TACE procedures were performed. Partial response was achieved (according to RECIST) leading to a 16-month survival. However, disease progression was present, with unusual heart metastases. TACE can bring a survival benefit to unresectable cholangiocarcinoma patients. Defining the best disease stages in which TACE can be implemented and introducing it as part of standard treatment guidelines still presents a challenge.

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DOI: 10.3897/folmed.64.e90599

Authors: Nikola Boyanov, Katina Shtereva, Katerina Madzharova, Vladimir Andonov, Neno Shopov, Petko Dimov

Abstract: Achalasia is a rare motility disorder with unknown etiology that results in failure of relaxation of the lower esophageal sphincter (LES). As there is no etiological treatment, different pharmacological agents and invasive techniques have been used for relieving the symptoms. For the past decade, peroral endoscopic myotomy (POEM) has proven to have excellent results. We present a retrospective study of five patients that underwent POEM for primary achalasia. We used anterior approach for the submucosal tunneling. The procedure showed immediate results and no severe short- or long-term adverse events. We have been following the patients up for more than 3 years now. Since its invention more than ten years ago, the POEM procedure and its advantages and disadvantages compared to the pneumatic dilatation and the Heller myotomy have been extensively studied. There is still no universal opinion on which procedure should be the first line treatment.

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DOI: 10.3897/folmed.64.e66075

Authors: Desislava Dimitrova-Yurukova, Nikola Boyanov, Ventsislav Nakov, Radislav Nakov

Abstract: Both ulcerative colitis (UC) and irritable bowel syndrome (IBS) are chronic gastrointestinal (GI) conditions that show some typical features. Persistent GI symptoms typical for IBS are observed in patients with diagnosed UC. Both IBS and UC are characterised by dysregulation of the enteric nervous system, alterations in the gut flora, low-grade mucosal inflammation, and activation of the brain-gut axis. Therefore, it appears that there may be some overlap between the two conditions. It is rather difficult to tell if the lower gastrointestinal symptoms are secondary to coexisting IBS or a hidden UC condition. Given the disruptions in gut microbiota in UC and the likely role of the brain-gut axis in the production of such symptoms, treatments such as probiotics, fecal microbiota transplantation, antidepressants, and psychological therapy would appear to be sensible options to use in both illnesses. They are both chronic, causing patients to have a worse quality of life and everyday suffering, as well as incurring significant expenses for the health-care system. The aim of this review article was to give an up-to-date perspective on the diagnosis and management of IBS-like symptoms in UC.

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DOI: 10.3897/folmed.64.e65824

Authors: Maya Risteska, Ludmila Vladimirova-Kitova, Vladimir Andonov

Abstract: Introduction: Based on many previous studies, liver cirrhosis is traditionally associated with cardiac dysfunction. The main clinical features of cirrhotic cardiomyopathy include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities, and chronotropic incompetence. Previous studies have found that the levels of brain natriuretic peptide (BNP) and its precursor the N-terminal pro B-type natriuretic peptide (NT-proBNP) are elevated in cirrhosis with systolic as well as diastolic dysfunction. Aim: The aim of this study was to establish the association between early changes in cardiac function in patients with liver cirrhosis and NT- proBNP plasma levels. Materials and methods: Forty-two consecutive hospitalized patients with viral-related cirrhosis were studied. We also evaluated a control group of 20 age and sex-matched patients with arterial hypertension. All underwent abdominal ultrasound, upper GI endoscopy, ECG, and echocardiography, and their plasma levels of NT-proBNP were determined. Results: We observed higher NT-proBNP plasma levels in cirrhotic patients than in controls. We also found that atrial volumes, ejection fraction and partially left ventricular mass and PAPs (systolic pulmonary arterial pressure) were significantly altered in comparison with the hypertensive controls. Supporting previous studies, we also found that the mean QTc interval was prolonged in 65% of women and 96% of men. Conclusions: In conclusion, the present study shows that plasma NT-proBNP levels, LAD (left atrium diameter), the E/A ratio, EDT (end diastolic time) and E/e’ ratio may be reliable indicators of the extent of cardiac abnormalities in cirrhotic patients.

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DOI: 10.3897/folmed.64.e67044

Authors: Anna Rycyk, Beata Kasztelan-Szczerbinska, Halina Cichoz-Lach

Abstract: We report a rare case of Peutz-Jeghers syndrome (PJS) in a 35-year-old female. The patient was diagnosed with PJS when she was 11 years old. She has remained under observation since then. We strongly believe that PJS is a very rare diagnosis. However, it can have serious complications such as the intussusception we observed in our patient. Her condition (recurrent abdominal pain and vomiting) in childhood required further diagnostic procedures. Although the diagnosis of PJS was made, among many resected polyps, one of them appeared to be a juvenile polyp. The diagnosis was confirmed in the histopathology report, which was incredibly unique. Genetic testing revealed LKB1/STK11 gene mutation. Clinicians should be aware of the malignant potential in the course of PJS. Hence, these patients require tailor-made management, long-term follow-up, and our particular attention.

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DOI: 10.3897/folmed.63.e53726

Authors: Athena Myrou, Theodoros Aslanidis, Andreas Protopapas, Elisavet Psoma, Andreas Kontosis, Triantafyllia Koletsa

Abstract: Though being usually a cutaneous tumor, melanomas can occur in several extracutaneous sites. Primary mucosal melanomas are rare, and primary gastric mucosal melanomas are considered extremely rare. Compared with cutaneous and ocular melanoma, mucosal melanomas have the lowest five-year survival. High level of suspicion of such rare condition may be the only way for early detection, diagnosis and chance for successful management of similar cases. In the present report, a case of a primary gastric melanoma in a 73-year-old man is described, along with a short review of the literature

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