Aktualitások a Gasztroenterológiában

Aktualitások a Gasztroenterológiában

Aktualitsok a Gasztroenterolgiban Dr. Szalki Tibor PhD. osztlyvezet forvos Jvorszky Krhz Gasztroenterolgia PPI hasznlat riziki Clostridium difficile infekci 54 957 PPI-t szed beteg rizikja C. difficile infekcira 2.40 volt. Az els 2 htben kaptk meg a betegek s nem volt klnbsg a PPI-k kztt. Roughead EE, Chan EW, Choi NK, Griffiths J, Jin XM, Lee J, Kimura M, Kimura T, Kubota K, Lai EC, Man KK, Nguyen TA, Ooba N, Park BJ6 Sato T, Shin JY, Wang T, Wong IC, Yang YK, Pratt NL. Proton pump inhibitors and risk of Clostridium difficile infection: a multi-country study using sequence symmetry analysis.

Expert Opin Drug Saf. 2016 [Epub ahead of print]. Msik tanulmnyban az antibiotikumokkal val egytt adskor volt nagyobb esly a C.diff. fertzdsre. Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ. 2004;171(1):338. PPI hasznlat riziki Carcinogenesis Hypergastrinemia alakul ki. Ez lehetsges oka lenne a carcinoidok, gyomor polypok, gyomor s and colon carcinomk kialakulsnak mivel az

emelkedett serum gastrin trophicus hats a neoplasticus nvekedsre a gastrointestinal tractusban? (Jeong Soo Ahn, Chun-Sick Eom, Christie Y Jeon, Sang Min Park : Acid suppressive drugs and gastric cancer: A meta-analysis of observational studies World J Gastroenterol. Apr 28, 2013; 19(16): 2560-2568 Published online Apr 28, 2013. doi: 10.3748/WJG.v19.i16.2560 ) PPI hasznlat riziki Fogbeltetsre vr betegnl 2,73 szoros rizik, hogy sikertelen lesz a beltets. (Wu X1, Al-Abedalla K1, Abi-Nader S1, Daniel NG2, Nicolau B1, Tamimi F3. Proton Pump Inhibitors and the Risk

of Osseointegrated Dental Implant Failure: A Cohort Study. Clin Implant Dent Relat Res. 2016 Oct 20. doi: 10.1111/cid.12455. [Epub ahead of print]) PPI hasznlat riziki Sperma minsgt rontja (Huijgen NA1, de Ridder MA2, Verhamme KM2, Dohle GR3, Vanrolleghem AM2, Sturkenboom MC4, Laven JS5, Steegers-Theunissen RP6 :Are proton-pump inhibitors harmful for the semen quality of men in couples who are planning pregnancy? Fertil Steril. 2016 Oct 12. pii: S0015-0282(16)62800-5. doi: 10.1016/j.fertnstert.2016.09.010. [Epub ahead of print]) 6 hnapos PPI hasznlat nem ront a spermn, viszont, 6-12 hnapos PPI hasznlat utn a 3 szoros a rizik, hogy a mozg alakok szma cskken.

Gyermekvllals esetn ill. medd proknl gondoljunk erre is! Inhibiting the proton pump: mechanisms, benefits, harms, and questions (Jeffrey K. Aronson BMC Medicine 2016:14:172 DOI: 10.1186/s12916-016-0724-1 The Author(s). 2016 Published: 9 November 2016) 1. Gastroesophageal reflux disease (GERD, including non-erosive reflux esophagitis and Barretts esophagus): the mainstay of medical treatment 2. Eosinophilic esophagitis: a first-line treatment

3. Helicobacter pylori eradication and peptic ulcer disease: a key component of current regimens 4. ZollingerEllison syndrome: the drugs of choice 5. Stress ulcer prophylaxis: the drugs of choice for acid suppression 6. Dyspepsia: treatment should be attempted in patients with persisting symptoms despite successful eradication or naveuninfected patients with epigastric pain syndrome 7. NSAID-associated gastrointestinal (GI) symptoms and lesions: standard doses indicated more effective than H2 receptor antagonists 8. Corticosteroid use: not routinely indicated

9. Anti-platelet or anticoagulant therapy: standard dose therapy advised 10. Peptic ulcer bleeding: endoscopy is the mainstay of treatment; PPI therapy [thereafter] reduces the risk of re-bleeding, requirement for surgery, and mortality in high-risk patients 11. Patients with cancer: could be indicated to treat or/and prevent [symptomatic] chemotherapy-induced GERD and gastroduodenal ulceration; patients with GI mucositis or dysphagia might also benefit [poor-quality evidence] 12. Cirrhosis: not justified

13. Pancreatic disease: not recommended The appropriate use of proton pump inhibitors (PPIs): Need for a reappraisal. Savarino V1, Dulbecco P2, de Bortoli N3, Ottonello A4, Savarino E5. Eur J Intern Med. 2016 Oct 23. pii: S09536205(16)30362-4. doi: 10.1016/j.ejim.2016.10.007. [Epub ahead of print] Tlhasznlat okai: Alacsony rizikj betegben gastroduodenalis fekly prevencit vgznk. Nem ITO-n lv betegben stressz ulcus profilaxist adunk. Steroid kezels mell PPI-t adunk. Alacsony gastroduodenalis krosodsi rizikval rendelkez betegnek anticoagulls mell PPI-t adunk. Funkcionlis dyspepsist tlkezeljk PPI-vel. Egyszeren nem savhoz kttt betegsg okozza a beteg

panaszait. Alarm tnetek esetn gasztroszkpia! dysphagia, odynophagia, slyveszts, hasi fjdalom

hnys (vrhnys) Helicobacter pylori Egyre rosszabbak az eradikcis eredmnyek Az optimlis kezelsi peridusban sincs egyetrts (7-14 napig) Sokfle eradikcis kezelst prbltak/ prblnak Helicobacter pylori eradikci

PPI + 2 antibioticum triple therpia PPI bismuth-alap quadruple therpia PPI + hrom antibioticum quadruple kezels PPI+ 1 antibioticum H2-receptor antagonista+bismuth quadruple therpia HRA bismuth-alap triple therpia RA bismuth-alap triple therpia HRA bismuth-alap triple therpia RA + 2 antibioticumos triple therpia bismuth + 2 antibioticummal vgzett hrmas kezels

Helicobacter pylori eradikci PPI hrmas kezelssel PPI + clarithromycin + amoxicillin (PCA) PPI + clarithromycin + nitroimidazole (PCN) PPI + amoxicillin + nitroimidazole (PAN) PPI + amoxicillin + quinolone (PAQ) PPI + amoxicillin + nitrofuran (PAN). Cochrane Database Syst Rev. 2013 Dec 11;(12):CD008337. doi: 10.1002/14651858.CD008337.pub2.

Optimum duration of regimens for Helicobacter pylori eradication. Yuan Y1, Ford AC, Khan KJ, Gisbert JP, Forman D, Leontiadis GI, Tse F, Calvet X, Fallone C, Fischbach L, Oderda G, Bazzoli F, Moayyedi P. Tekintet nlkl az antibioticum tpusra s dzisra a PPI triple therapia 7 rl 14 napra val nvelse significansan megnvelte a H. pylori eradicatios rtt (45 vizsglat, 72.9% versus 81.9%) Minimlisan, de significansan emelkedett az adverse esemnyek szma is a 7-rl 14 napra val nvelskor Szignifikns eradikcis siker volt a 7-rl 10 napra s a 10-rl 14 napra val terpis id megnvelsekor is. Tovbbi vizsglatok kellenek a sikeresebb eradikci

elrshez Hp. erad. ha clarithromycin resist.<15% 2xPPI+2x500mg clarithromycin+2x1000mg amoxicillin Vagy 2xPPI+2x500mg clarithromycin+2x500 mg metronidazol 14 napos a kra! Bizmut alap ngyes kezels, ha clarithromycin resistencia>15% 2xPPI+4x120mg bizmut citrt+3x500mg metronidazol+4x500mg tetracyclin

10-14 napos a kezels! Capsula bismuthi Rp. Bismuthi citras milligrammata centum et viginti (120mg) Lactosi vel Amyli tritici quantum satis Dent. tal. dos.No. 28 (viginti et octo) Ut f.l.a.caps. DS: 4x1 caps. naponta tkezs utn caps. mrete:00 (kemny zselatin) Bizmut s metronidazol egyben

Rp.: Bismuthi citras milligrammata centum et viginti (120 mg) Metronidazoli milligrammata tricenti septuaginta et quinque (375 mg) Lactosi vel Amyli tritici quantum satis Dent.tal.dos.No.28 (viginti octo) Ut f.l.a.caps. DS: naponta 4x1 caps. tk. Utn caps. mrete:00 (kemny zselatin) Capsula bismuthi Mindig tkezs utn!

Terhessgben s szoptatsban ellenjavallt! Nincs antacid, tejtermk, alkohol s dohnyzs! Elegend folyadkbevitel! mellkhatsok:hasmens, nyelv elsznezdse, hnyinger, fmes szjz, fekete szklet Csak a bizmut citrt! Mert a gyomor savas millijben oldhatatlan csapadkot kpez gy a bltraktusbl nem vagy igen csekly mrtkben szvdik fel Szervezet szmra kzmbs anion van a

bizmut mellett Savas kzegben olddik a bizmut oxid, bizmut subnitrt s bizmut subsalicylt, gy szisztms mellkhatsok (encephalopathia, nefrotoxicitas, neurotoxicitas) lehetnek bizmut citrt Keltot kpez a nyh. glikoproteinjeivel elssorban a feklyes terleten (vdrteg) Gtolja a pepszin aktivitst Fokozza a prostaglandin szintzist Hp. ostoraihoz ktdik, gtolja mozgst, bactericid Nveli az antibioticumok bactericid hatst

Gyri, Mo-n nem elrhet szerek (De-Nol, Pylorid, Pylera) is bizmut citrtot tartalmaznak Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines Authors: Andrew M. Veitch, Geoffroy Vanbiervliet, Anthony H. Gershlick, Christian Boustiere, Trevor P. Baglin, Lesley-Ann Smith, Franco Radaelli, Evelyn Knight, Ian M. Gralnek, Cesare Hassan, Jean-Marc Dumonceau (Endoscopy 2016; 48: 118.) Egyre nagyobb az anticoagullt betegek szma Egyre tbb az ASA szed Szmos betegnk van ASA+clopidogrel

kezelsen Kb. 25 % a NOAC-ot szedk arnya az antitrombotikumokat ignylkn bell aspirin Mindegyik endoscopos beavatkozs elvgezhet aspirin szedkben kivve a nagy vastagbl polypusok eltvoltsa (>2 cm) az EMR s ESD valamint a Vater papilla ampullectomia Alacsony rizikj endoscopos bevatkozsoknl Clopidogrel vagy a ketts trombocyta

gtls tovbb szedhet Warfarin vagy acenocumarol tovbb adhat, ha az endoscopia eltti hten az INR a terpis hatron bell van. Aznap ne szedje be a NOAC-ot a beteg Magas rizikj endoscopos beavatkozs alacsony trombzis rizikval Clopidogrelt 5 nappal eltte hagyja el Ketts TAG eseteiben az ASA tovbb szedhet Beavatkozs eltt 5 nappal a warfarin/ acenocumarol elhagyand, aznap INR mrs, mely 1,5-nl kisebb kell legyen

Magas rizikj endoscopos beavatkozs magas trombzis rizikj betegben Aspirin tovbb szedhet, clopidogrel elhagys rizikjrl kardiolgussal kell egyeztetni Warfarin/ acenocumarol tmenetileg elhagyand s LMWH-ra tlls javasolt NOAC 2 nappal eltte abbahagyand (eGFR-tl fggen hamarbb) ltalnossgban

A nem anticoagullt betegekhez kpest a warfarin/ acenocumarol szedkben nagyobb a beavatkozs utni vrzsi rizik A anticoagulls vagy trombocyta gtl kezels elhagysa esetn a vrzsi s trombzis rizik mrlegelse utn 48 rn bell visszaadand a szer j vastagbl lzik: serrated adenoma, lateral spreading tumor, besppedt carcinomk.

Nem gy alakulnak a dolgok, ahogy kpzeltk Nem vrt szmban jelentkeznek az un. intervallum colorectalis carcinomk Jobb oldali colorectalis rkok szma nem cskkent (ntt?) Nem csak adenoma-carcinoma szekvencia ltezik Hyperplasticus polyp-carcinoma szekvencia igazolst nyert Post colonoscopis (intervallum) carcinomk Magval a colonoscopival kapcsolatos

okok: nem optimlis elkszts, nem kellen kpzett vizsgl, nem HD eszkzzel vgzett vizsglat Biolgiai okok: non polypoid carcinogenezis, gyorsabban carcinomba progredil lesik, helytelenl megvlaszott coloscopos control idpont Mlt szzad vgig Colorectalis polypok ktszint osztlyozsa -non neoplasticus hyperplasticus polypus -neoplasticus adenomk (tubularis, tubulovillosus, villosus), megklnbztetve

bennk a dysplasit, intraepithelialis neoplasit s egyedl az adenomkat tartva colorectalis carcinoma elalaknak Fleg a proximalis colonflben a hyperplasticus polypusokbl s az un. serrated lesiokbl alakul ki a neoplasmk 15-20 %-a (Jass JR. Hyperplastic polyps and colorectal cancer: is there a link? Clin Gastroenterol Hepatol 2004;2:1-8.) (Jass JR. Classification of colorectal cancer based on correlation of clinical, morphological and molecular feaures. Histopathology 2007;50:113-30) (Hertzel JT, Huang CS, Coukos JA, et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol 2010;105:2656-64.)

(Snover DC. Update on the serrated pathway to colorectal carcinoma. Hum Pathol 2011;42:110.) Ma gy tnik, hogy fleg az elvtett/elnzett serrated lesioknak ksznhet, hogy a colonoscopia nem vd a jobb oldali CRC ellen (Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010;362:1795-803.) Mi az a serrated? A serrated lesio lapos vagy sessilis, kicsiny nyh. elvltozs fleg a jobb colonflben ltni

Knnyen elnzhet, mivel lapos, sznben alig tr el a krnyezettl Hatra bizonytalan, alakja aszimmetrikus Frszfogszer (serrated) mintzat a mikroszkp alatt Serrated lesio inkbb, mint serrated polyp A serrated csoportban LESIO sz jobban kifejezi a CRC premalignus elalakjainak soksznsgt, mint a polyp. (Vieth M, Quirke P, Lambert R et al. Annex. Annotations of colorectal lesions. In: Segnan N, Patnick J von Karsa L, editors. European guidelines for quality assurance in

colorectal cancer screening and diagnosis. Publications Office of the European Union, Luxembourg 2010. p. 235-50.) Mivel a histolgiai diagnosztikus kritriumok s a nomenklatra valamelyest konfzus s nem egysges ma sem, az endoszkposnak elegendnek tnik az albbi egyszer beoszts: Hyperplasticus polypus Sessilis serrated lesio Tradicionlis serrated adenoma Kevert polypus Hyperplasticus polypus A leggyakoribb serrated lesio, fleg a

rectosigmoid terleten ltjuk, rtalmatlan Jelenltekor gondoljunk proximalisan elhelyezked nagyobb serrated lesio jelenltre (Kaminski MF, Mroz A, Kraszewska E, et al. Risk factors for large serrated polyps. Gastroenterology 2011;104(Suppl 1):S-410.) High-risk HP: ha sok van (>20), ha nagy(>10mm), ha proximalis, ha van familiaris CRC terhels el kell tvoltani! (Jass JR. Hyperplastic polyps of the colorectum-innocent or guilty? Dis Colon Rectum 2001;44:163-6.) (Rex DK, Ulbright TM. Step section of proximal colon polyps that appear hyperplastic by endoscopy. Am J Gastroenterol 2002;97:1530-4,)

Sessilis serrated lesio (sessile serrated adenoma/polyp) Endoscopos helytelenl HP-nek tarthatja Halvnyabb a krnyezetnl Nyk sapka (mucus cap) bortja, mely srgs vagy rozsdaszn sznezetet mutat 2 altpusba soroljk attl fggen, hogy mutat-e cytolgiai dysplasit vagy sem Foklis cytol. dyspl. carcinomv progredilhat. Serrated dysplasia agresszvabb lehet, mint azt konvencionlis adenomnl ltni (Snover DC, Ahnen DJ, Burt RW et al. Serrated polyps of the colon and rectum and serrated polyposis. In:Bosman FT, Carneiro F, Hruban RH, et al, editors. WHO classification of tumours of the digestive system. World Health

Organization classification of tumours. Lyon, France:IARC Press;2010.p.160-5.) Sessilis serrated lesio az endoszkpos szempontjbl Ellenttben a HP-al, jobb oldali nagy (>10mm) klnsen hajlamos CRC-ba progredilni, ezrt in toto eltvolts javasolt (Huang CS, OBrien MJ, Yang S et al. Hyperplastic polyps, serrated adenomas, and the serrated polyp neoplasia pathway. Am J Gastroenterol 2004;99:2242-55.) ( Oh K, Redston M, Odze RD. Support of hMLH1 and MGMT silencing as a mechanism of tumorigenesis in the hyperplastic-adenoma-carcinoma (serrated) carcinogenetic pathway in the colon. Hum Pathol 2005;36:101-11.) >10 mm serrated lesio fggetlen rizikfaktor

szinkron CRC-re (lvarez C, Andreu M, Castells A, et al. Relationship of colonoscopy-detected serrated polyps with synchronous advanced neoplasia in average-risk individuals. Gastrointest Endosc 2013;77: 1-9.) Veszlyesebb-e, mint a konvencionlis adenoma? Egyesek szerint a sessilis serrated lesio agresszvabb, mint az adenoma Msok a carcinomba val talakulst 2-3x hosszabb idejnek (10-15 vig tartnak) talltk (Oono Y, Fu K, Nakamura H et al. Progression of sessile serrated adenoma to an early invasive cancer within 8 months. Dig Dis Sci 2009;54:906-9) (Goldstein NS. Small colonic microsatellite unstable adenocarcinomas and highgrade epithelial dysplasias in sessile serrated adenoma polypectomy

specimens: a study of eight cases. Am J Clin Pathol 2006;125:132-45.) (Sheridan TB, Fenton H, Lewin MR, et al. Sessile serrated adenomas with low-and high-grade dysplasia and early carcinomas:an immunohistochemical study of serrated lesions caught in act. Am J Clin Pathol 2006;126:564-71.) Tradicionlis serrated adenoma Az sszes polyp 0,6-1,3%-a az adenomk 1,7%-a Fleg a rectum-sigmban ltjuk, de a jobb colonflben is lehet, gyakran >10 mm Endoscopinl gyakran peduncullt, de 1,2-12,2 %ban lapos vagy sznyeg-szer (Tsuda S, Veress B, Tth E, et al.Flat and depressed colorectal tumors in a southern Swedish population: a prospective chromoendoscopic and histopathological study. Gut 2002;51:550-5)(Jaramillo E, Watanabe M, Slezak P. et al. Flat neoplastic lesions of the colon and rectum detected by highresolution video endoscopy and chromoscopy. Gastrointest Endosc 1995;42:114-22.)

2 fajta dysplasia lehet benne: serrated vagy hagyomnyos adenoma tpus (Rex DK, Ahnen DJ, Baron JA et al. Serrated lesions of the colorectum:review and recommendations from an expert panel. Am J Gastroenterol 2012;107:1315-28) Malignus transformci kb. mint adenomknl, de a nagyobb, proximalis gyorsabban mehet t CRC-be (Fogt F, Brien T, Brown CA,et al. Genetic alterations in serrated adenomas. Comparison to conventional adenomas and hyperplastic polyps. Hum Pathol 2002;33:87-91.) Van-e specifikus endoszkpos jel? Azaz hogyan lehet

felfedezni a sessilis serrated lesit? HP-tl val elklnts? Elre megjsolhat-e a histolgia? -lesio nem jl kivehet, bizonytalan hatr (HR-WLE s NBI) -felhszer felszn nodulris, cumulus-szer (HR-WLE s NBI) -szablytalan alak (aszimmetrikus, szemben a kis HP s adenoma krszer alakjval) (NBI) -stt pontok ltszanak a nyitott cryptkban (NBI) {HR-WLE-nl piros pontok} voltak azok az endoscopos jelek, melyek elre jsoltk a serrated histolgit. (Hazewinkel Y, Lpez-Cern M, East JE, et al. Endoscopic features of sessile serrated adenomas: validation by international experts using high-resolution white-light endoscopy and narrow-band imaging. Gastrointest Endosc 2013;77:916-924.)

DE: tovbbi prospektv tanulmnyok, real-time colonoscopikkal szksgesek annak bizonytsra, hogy a fenti jelek hasznosak-e az endoszkpos gyakorlatban! Hyperplasticus/serrated polyposis Legalbb 5, szvettannal altmasztott hyperplasticus/serrated polyp a sigmtl proximalisan, melyek kzl legalbb 2 tmrje >10 mm, vagy Akrmennyi serrated polyp a sigmtl proximalisan olyan betegben, akinek van serrated polyposisos elsfok rokona, vagy Tbb, mint 20 brmekkora serrated polyp

szerte a colonban (Snover DC, Ahnen DJ, Burt RW et al. Serrated polyps of the colon and rectum and serrated polyposis. In:Bosman FT, Carneiro F, Hruban RH, et al, editors. WHO classification of tumours of the digestive system. World Health Organization classification of tumours. Lyon, France:IARC Press;2010.p.160-5.) (NCCN Clinical Practice Guidelines in Oncology. Colorectal Cancer Screening; V 2.2012. Available at: www.nccn.org. ) CRC kialakuls serrated tja Normal mucosa (BRAF mutci) Microvesicularis hyperplasticus polypus (promoter hypermetilci) Sessilis serrated lesio (mikroszatellita instabilits) Sessilis serrated lesio dysplasival (kevert polypus)

Tradicionlis serrated adenoma (tumor suppressor gnek s oncognek megnvekedett mutcija) High-grade dysplasia (egyb gnek mutcii s metilcii) Carcinoma (Orlowska J. Serrated lesions and hyperplastic (serrated) polyposis relationship with colorectal cancer: classification and surveillance recommendations. Gastrointest Endosc 2013;77:858-871.) Serrated lesiok surveillance-a A legtbb tmutat nem ad tmpontot a serrated lesik kvetshez Proximalis, elemelked, nagy serrated lesiok megnvekedett CRC rizikval

jrnak Izollt HP eltv. utn nincs specifikus ajnls Riziks HP kvetse = mint adenoma Teendink Serrated lesiok megtanulsa, a diagnosztikus munka javtsa (legalbb 5%-ban kell proximalis serrated lesiot tallni!) {kromoendoszkpia s NBI szerepe} (East, JE. Proximal serrated polyp detection at colonoscopy: the best of timesthe worst of times? Gastrointest Endosc 2012;75:521-4.) Terpia az in toto eltvolts

Patholgusok bevonsa, a 2010-ben megjelent WHO kritriumok szerinti szvettani diagnzis krse (Snover DC, Ahnen DJ, Burt RW et al. Serrated polyps of the colon and rectum and serrated polyposis. In:Bosman FT, Carneiro F, Hruban RH, et al, editors. WHO classification of tumours of the digestive system. World Health Organization classification of tumours. Lyon, France:IARC Press;2010.p.160-5.) (Ensari A, Bilezikci B, Carneiro F, et al. Serrated polyps of the colon: how reproducible is their classification? Virchows Arch 2012;461:495-504) Laterally spreading tumor (LST) non polypoid lesio, melynek

szlessge meghaladja a 10 mm-t. magassg/szlessg arnya<1:3 magassga< 2,5 mm (The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach and colon: November 30 to December 1, 2000. Gastrointest Endosc 2003;58 (S6): S3-43.) (Lambert R, Kudo SE, Vieth M et al. Pragmatic classification of superficial neoplastic colorectal lesions. Gastrointest Endosc 2009;70:1182-1199.) DE! lehet polypoid is, ha a magassg nem

tbb, mint a horizontlis kiterjeds 1/3a szles alap adenomk, melyek felletesen terjednek a nylkahrtyn, krkrsen kvetik a vastagbl fal kontrjt ltalban idsebb betegekben ltjuk frfiakban valamelyes gyakoribb LST tpusai Granulris, mely kiss elevlt, nodulris felszn Non granulris, mely lehet kiemelked vagy bespped, sima felsznnel. Elklnts indigkarmin festssel vagy

elektronikus kromoendoszkpival ill. nagyt endoszkpival (Kudo S, Kashida H, Tamura T et al. Colonoscopic diagnosis and management of nonpolypoid early colorectal cancer. World J Surg 2000; 24:1081-1090) (Kudo S, Tamura S Kakajima T et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996;44:8-14) LST jelentsge CRC non polypoid precursoraihoz tartozik Emelked szm kzlemny szmol be rla mind Japnban mind nyugaton

Prevalencijt illeten igazbl nincsenek adatok Jelenleg inkbb hipotzisekkel rendelkeznk semmint bizonytkokkal A LST specilis, mert Magasabb apoptosis s alacsonyabb prolifercis index jellemzi (Eguchi H, Hasegawa H, Yamada H et al. Large granule-aggregating non-polypoid colorectal neoplasm: a clinically-important entity with unique cell loss and proliferation kinetics. Eur J. Med Res 2007;12:277-283) Elterl terjedst mutat Csekly az adenocarcinomba alakuls veszlye

Mg malignus talakuls utn is ritka a submucosus invzi Gyakran trsul msik, polypoid vagy non polypoid lesikkal (40%) (Rotondano G, Bianco MA, Buffoli F et al. The Cooperative Italian FLIN Study Group: prevalence and clinico-pathological features of colorectal laterally spreading tumors. Endoscopy 2011;43:856-861) LST mirt rdekes? Coloscopik kb. 1%-ban ltjuk Kb. 5% az sszes precancerosus colorectalis lesio kzl Fleg a proximlis colonban fordul el Nagy nodulus s deprimlt felszn malignus

talakulsra gyans EMR vagy ESD ltalban alkalmazhat (90%) Malignits valsznsge itt is a mrettl fgg Az esetek 37%-ban adenoma slyos dysplasival, mucosalis vagy submucosalis carcinoma a szvettani lelet (Rotondano G, Bianco MA, Buffoli F et al. The Cooperative Italian FLIN Study Group: prevalence and clinico-pathological features of colorectal laterally spreading tumors. Endoscopy 2011;43:856-861) LST-nl endoscopos resectio Ritka a submucosus invzi Idelis esetben lift and cut technique EMR vagy ESD

Nagy nodulus s granulris LST-nl elszr a nagy nodulust prbljuk meg reseclni a piecemeal technikval (Uraoka T, Saito Y, Matsuda T et al. Endoscopic indication for endoscopic mucosal resection of laterally spreading tumours in the colorectum . Gut 2006;55:15921597) Non granulris esetn en block, mivel a submucosus terjeds s invzi szvettani megtlse itt nehezebb (Toyonaga T, Man-i M, Fujita T et al. Retrospectice study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum. Endoscopy 2010;42:714-722) LST-G s LST-NG

LST-G: inkbb a rectumban fordul el, piece-meal EMR lehetsges, mivel kicsi a sm invasio lehetsge (7-8%). Nagy nodulus gyakran trsul sm invasioval. LST-NG: gyakoribb a jobb colonflben, sm invasio 17%. ESD en block, mivel gyakori az invasio s endoscoposan nehz a mlysget s az invasio kiterjedst megtlni s a pit pattern sem segt. Ha tmr>20 mm, akr 43%-os sm invasio is lehetsges. (Hayashi T,. Kudo S-E , Maeda Y, et al. ENDOSCOPIC MUCOSAL RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL LATERALLY SPREADING TUMORS. Endoscopy 2011; 43 (Suppl I) A39.) (Yagawa Y, Kudo S-E, Miyachi H, et al. CLINICOPATHOLOGICAL CHARACTERISTICS AND THERAPEUTIC STRATEGY OF LATERALLY SPREADING TUMORS IN THE

COLORECTUM.Endoscopy 2011; 43 (Suppl I) A109. Besppedt carcinomk The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach and colon: November 30 to December 1, 2000. Gastrointest Endosc 2003;58 (S6): S3-43.) (Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005;37:570-8.) Non-polypoid Slightly elevated 0-IIa Completely flat 0-IIb Slightly depressed 0-IIc De novo carcinomk

Besppedt tpus CRC-k nem az adenomacarcinoma utat kvetik Els rnzsre 0-Is tpusnak gondoljuk Chromoendoscopia utn meglthatjuk a deprimlt terlete(ke)t 0-Is+IIa, 0-Is+IIc az j vlemny sm invasio kzel 100 %-os Kicsinysgk ellenre sebszhez irnytjuk a beteget (Kudo S-E, Watanabe D, Mori Y et al. SMALL SESSILE NEOPLASMS DERIVED FROM DE NOVO CANCER IN THE COLORECTUM. Endoscopy 2011; 43 (Suppl I) A116) (KudoS-E, Matsudaira S, Miyachi H. et al. WHAT IS DISTINCTIVE MALIGNANT NATURE?; CLINICOPATHOLOGICAL FEATURES OF DEPRESSED-TYPE COLORECTAL CARCINOMAS COMPARED WITH FLAT- OR PROTRUDED-TYPE. Gut 2012; 61 (Suppl 3) A414.)

Generikus gygyszerek Helyettesthetsg (felcserlhetsg) (interchangeability) az a gyakorlat, melynek alapjn kt gygyszer ksztmny egymssal kicserlhet egszsgkrosods jelents kockzata nlkl A csere trtnhet automatikusan gygyszertri szinten Klinikai gygyszervlts az a gyakorlat, melynek sorn a kezel orvos dntse alapjn a beteget azonos terpis cllal egyik gygyszer ksztmnyrl egy msik ksztmnyre lltjk t a kezels hatsossgnak fokozsa s/vagy a mellkhatsok cskkentse vgett A vlts trtnhet helyettesthet, illetve hasonl vagy analg gygyszerksztmnyek kztt

Generikus gygyszerek kiterjesztett meghatrozsa Gygyszerszeti egyenrtksg azonos hatanyag azonos mennyisg azonos gygyszerforma Gygyszerszeti alternatvk azonos hatanyagot tartalmaznak, melyek bizonyos tulajdonsgaikban eltrhetnek, de llatokban nincs klnbsg a farmakolgiai hatsban a hatanyag kmiai formjban (sk, szterek, izomrek s izomr keverkek,terek, komplexek stb.) gygyszerformban (pl. tabletta, kapszula), azonos beviteli t mellett

hatserssgben (10 mg, 20 mg, 30 mg) Azonos hatanyag, de eltr segdanyagok vannak benne Az egyes generikumok egymstl eltr, farmakolgiailag hatstalan segdanyagokat tartalmaznak A klnbz segdanyagokra s szennyezdseikre a betegek eltrn reaglhatnak Generikumok kztt hatanyagtl fggetlen, segdanyag specifikus mellkhatsok lphetnek fel

Szk terpis ablakkal rendelkez gygyszerek Szk terpis ablakkal rendelkez gygyszerek esetn kis mret plazmaszint emelkeds jelents toxicitshoz vezethet Szk terpis ablak (index) gygyszereknek nevezzk azokat a szereket, melyekben a minimum (medin) toxikus s a minimum (medin) terpis plazmaszintek kztti arny kisebb, mint 2 Szk terpis ablak gygyszerek

Aminophylline/Theophylline Lithium Thyroxine Warfarin Antiepileptikumok (Kivve benzodiazepineket) Immunoszupresszive gygyszerek

Citotoxikumok Antiarrhythmikumok Triciklikus antidepresszivumok Helyettestst fokozott orvosi kontroll mellett javasolt vgezni (dzis titrls, gygyszerszint monitorizls, stb.)

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