Aim To analyse the impact of the length of antiviral therapy with tenofovir disoproxil fumarate (TDF) on the renal function in patients with chronic hepatitis B (CHB). Methods A cross-sectional study included 75 patients with CHB treated with tenofovir, who had a normal renal function at the beginning of the treatment. Renal function was determined based on glomerular filtration rate (eGFR) value using the Modification of Diet in Renal Disease formula (MDRD). Measurement of serum creatinine concentration and urinary protein excretion were performed using standard laboratory analyses. Viral load quantification (HBV-DNA) was determined by polymerase chain reaction (PCR). The degree of liver fibrosis was determined using fibrosis4 (FIB-4) and aspartate transaminase to platelet ratio index (APRI) fibrosis score. Results Out of 75 CHB patients, 37 were on antiviral treatment for up to 2 years (group 1) and 38 patients on antiviral treatment longer than two years (group 2). Mean age of patients was not significantly different between the groups (p=0.076), nor was the gender distribution. There was no statistically significant difference between the mean values of the eGFR in the two groups (91.89±9.24 vs. 88.42±7.84 mL/min/1.73m2; p=0.42), as well as between the mean values of serum creatinine (p=0.360) and 24-hour urine protein excretion (p=0.380). There was no statistically significant correlation between renal parameters and viral load, APRI and FIB-4 fibrosis score. Conclusion Results of our study did not show significant changes in the measured parameters of renal function in group 1 and group 2 of patients, regardless of the length of antiviral treatment, indicating a good renal safety profile of TDF.

Aim To present our experience with a diagnostic ability of endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP) in cases of choledocholithiasis verified by endoscopic retrograde cholangiopancreatography (ERCP). Methods This retrospective study was conducted after a collection of data involving 58 suspected choledocholithiasis patients who underwent ERCP from January 2013 to December 2015. Patients who were diagnosed with choledocholithiasis on the basis of clinical symptoms and radiological findings and who underwent ERCP were included in this study. The first group (29 patients) underwent EUS, and the second group (29 patients) underwent MRCP. The ERCP was performed in both groups. Sensitivity, specificity and diagnostic accuracy of EUS and MRCP were determined by comparing them with ERCP, which was considered to be a gold standard. Results Gender representation was in favour of males, 58:42%. The mean age was 55.5 years. In the group 1 (EUS) 22 patients were found to have choledocholithiasis using ERCP. The EUS stone detection rate was 88%. Endoscopic ultrasound showed sensitivity (97%), specificity (67%) and accuracy (88%), positive predictive value (PPV) of 88%, negative predictive value (NPV) of 80%. In the group 2 (MRCP) 16 patients were found to have choledocholithiasis by ERCP. MRCP sensitivity was 81%, specificity 40%, PPV of 74%, NPV of 50%. Conclusion The EUS was a superior non-invasive tool in comparison with MRCP for detecting choledocholithiasis, which was confirmed using ERCP.

Aim To present our experience with a diagnostic ability of endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP) in cases of choledocholithiasis verified by endoscopic retrograde cholangiopancreatography (ERCP). Methods This retrospective study was conducted after a collection of data involving 58 suspected choledocholithiasis patients who underwent ERCP from January 2013 to December 2015. Patients who were diagnosed with choledocholithiasis on the basis of clinical symptoms and radiological findings and who underwent ERCP were included in this study. The first group (29 patients) underwent EUS, and the second group (29 patients) underwent MRCP. The ERCP was performed in both groups. Sensitivity, specificity and diagnostic accuracy of EUS and MRCP were determined by comparing them with ERCP, which was considered to be a gold standard. Results Gender representation was in favour of males, 58:42%. The mean age was 55.5 years. In the group 1 (EUS) 22 patients were found to have choledocholithiasis using ERCP. The EUS stone detection rate was 88%. Endoscopic ultrasound showed sensitivity (97%), specificity (67%) and accuracy (88%), positive predictive value (PPV) of 88%, negative predictive value (NPV) of 80%. In the group 2 (MRCP) 16 patients were found to have choledocholithiasis by ERCP. MRCP sensitivity was 81%, specificity 40%, PPV of 74%, NPV of 50%. Conclusion The EUS was a superior non-invasive tool in comparison with MRCP for detecting choledocholithiasis, which was confirmed using ERCP.

Background: Acute respiratory distress syndrome (ARDS) is life treating condition, with intensive general inflammation. Objective: Inflammation can be present with infection or without. Septic embolism, according to our previous experience, is more often multiple, than single. General hypoxia of hall body cause damage of all tissue, and generalinflammationintensifies. A vicious circle was formed and inflammation runs its course in what is very often irrelevant how it was begun.How often pulmonary embolism causes ARDS and what are the main features of this disease, is the goal of the study. Methods: Patients with ARDS, treated in pulmonary intensive care unit were analyzed. Chest X-ray, microbiological analysis of sputum or bronchoalveolar lavage specimen, chest CT scan, blood culture, CRP (mg/dl), deep-dimmer and blood cell count, were performed for all cases. Results: In three years period 53 patients with ARDS were treated. Out of all 19 with septic pulmonary embolism (14 multiple), (CRP 198±28). In only 12 patients origin of venous thrombus was found. Out of all 6 patients have massive non septic embolism (CRP 28±7), 18 heavy pneumonia (CRP 166±28), 4 with interstitial pneumonia (CRP 76±19), 5 with massive TB with caverns (CRP 35±13) and 6 with not well defined cause. Blood culture was positive in 14 cases with septic embolism and in 11 cases with pneumonia. CRP was elevated in all cases but highest was in septic embolism (Mann-Whitney test p=0,024). Conclusion: Septic pulmonary embolism was common cause of ARDS, mostly as multiple, and should be considered even if origin of thrombus was found or not.

P Herzegovina Introduction: The hepatocellular carcinoma (HCC) is one of the most common malignant tumors and carries a poor survival rate. Increased understanding of cancer biology and technological advances have enabled identification of a multitude of pathological, genetic, and molecular events that drive hepatocarcinogenesis leading to discovery of numerous potential biomarkers in this disease. The transforming growth factor-beta (TGF- β ) cytokine and its isoforms initiate a signaling cascade which is closely linked to liver fibrosis, cirrhosis and subsequent progression to HCC. Methods: Totalof 150 subjects were divided into four groups, depending on the stage of HCC (BCLC scoring system). Group1: earlystage; group 2: intermediate stage; group 3: advanced stage; group 4: terminal stage and the control group. The analysis included serum levels of cytokine TGF- β 1. Used statistical methods: discriminant multivariate analysis, ANOVA test, multiple correlation test and Student ’ st-testfor independent samples. Charlson comorbidity index was determined forany possible influence of othercomorbid conditions. The analysis of serum levels of TGF- β 1 in HCC patients, according to BCLC scoring system has been performed, to evaluate its role as biomarker. Results: The highest mean concentration of this cytokine was in group 3 (advanced stage of HCC): 1023,55 pg/ml. ANOVA analysis provesthat serum levels of TGF- β 1 in the control group differed with respect to the otheras follows: in relation to group 1 at the level of statistical significance p=0.0028 (F=143.67); in relation to a group of 2 to p=0.0001 level (F=230.23); in relation to group 3 at p<0.0001 (F=2584). By Student ’ s T

Immunoregulatory cytokines influence the persistence of hepatitis C virus chronic infection and the extent of liver damage. Interleukin-1 plays an important role in the inflammatory process. Some studies have demonstrated that IL-1 production was impaired in patients with chronic infections of hepatitis C virus, implying that IL-1 may play a role in viral clearance. In this study, along with routine laboratory tests, has been performed the analysis of serum levels of proinflammatory cytokine IL-1α in order of better understanding and monitoring of chronic hepatitis C. The aim of study was to analyze the usefulness of laboratory tests, which are routinely used in the assessment of liver disease with specified immunological parameters, in patients with chronic hepatitis C. Total of 60 subjects were divided into two groups: HCV-PCR positive and negative group. The control group of 30 healthy participans was included. Apart from standard laboratory tests, the analysis included serum levels of cytokine IL-1α. IL-1α had the highest mean concentration in group of viral hepatitis C, with PCR positive test (5.73 pg/mL), and then in of chronic viral hepatitis C, PCR negative test (5.39 pg/mL). ANOVA test proves that IL-1α in the healthy group was different from other groups as follows: in relation to HCV-RNA-PCR positive patients statistical significance level was p < 0.001 (F = 32,755); in relation to HCV-RNA-PCR negative was also statistically significant at p < 0.001 (F = 182,361); Cytokine IL-1 was statistically analyzed separately and compared by group 1 and 2 using Student t-test for independent samples. Statistical significance was observed at p = 0.026. IL-1α was positively correlated with the duration of the illness (p < 0.01) and with serum ALT activity (p < 0.01) and serum AST activity (p < 0.01). Using multivariate analysis model "Factor Analysis", was made significant stratification predic- tive parameters in relation to the cytokine IL-1α, stratified significance is indicated as follows: 1. Age, 2. history of receiv- ing transfusions, 3. ALT 4. AST, 5. MELD score (negative), 6. Child-Pugh score (negative). IL-1α was significantly ele- vated in inflammatory conditions of pronounced activity (PCR positive hepatitis). IL-1α may have important role as marker of both inflammation and hepatic injury, particularly in the course of hepatitis C. Results suggest that inflammatory and immune parameters, analyzed together can significantly contribute to the understanding and predicting of chronic liver damage.

The goal: The goal of this work was to give advantage to EUS as endoscopic method in diagnosis and following therapeutic treatment of pancreatic cancer in relation to radiological methods of CT and CTA. Material and Methods: The study included 49 patients, 20 women and 29 men hospitalized at the Clinic for gastroenterohepatology, due to suspicion on pancreatic cancer during observed 2 years period. All cancers were histologically and cytologically confirmed. The patients underwent ERCP as a mandatory part of staging and all patients underwent endoscopic ultrasound as well as CT or CT angiography. Results: Testing of differences was carried out using Fisher’s exact test in open-source software R. The following characteristics were tested: involvement of the blood vessels, lymph nodes, metastases, tumor size and duodenum infiltration. Results showed statistically significant difference at the 0.05 level for EUS, CT and CT angiography. Risk ratio showed that EUS is less effective in detecting infiltration of blood vessels within a malignant process then CTA where RR=0.52, CI 0.2–1.38, p-value=0.33. EUS and CTA are equal in the diagnosis of enlarged lymph nodes affected by malignancy where RR=1.3, CI 0.75–1.42, p-value=0.09. Comparison according to distant metastases showed that EUS is less effective compared to CT in approximately 30% of cases. In the diagnosis of duodenal infiltration EUS is in 5% of cases less accurate than the CT with the RR=0.95, CI 0.27–3.32, p-value=0.76, but the CTA method is more efficient because the comparison of EUS and CTA showed RR=12.52, CI 0.2–1.38, p-value=0.33. EUS as a diagnostic method is dominant in determining the size of malignant lesions located in the pancreas as compared to CT and CTA. Conclusion: EUS as endoscopic method compared to CT and CTA is one of the more invasive methods of examination but due to its ability to be performed immediately, to locate a changes smaller than 5 mm and the target biopsy option, to measure the change and that in many cases determine the relationship of malignant lesions with blood vessels, along with visualization of the surrounding lymph nodes and metastases in neighboring organs, we may give this method an advantage over other methods in the preoperative staging of patients with pancreatic cancer.

Background: HCV infection is characterized by a tendency towards chronicity. Acute HCV infection progresses to chronic infection in 70% of cases. Hepatitis C virus infection can cause progressive liver injury and lead to fibrosis and eventually cirrhosis. The degree of histologic fibrosis is an important marker of the stage of the disease. One of current standard treatment for CHC infection is the combination of PEG-IFN α and ribavirin. Objectives: The aim of the study was to investigate the effect of the therapy with Peginterferon alfa-2a or alfa-2b plus Ribavirin on evolution of liver fibrosis in patients with chronic hepatitis C. Also, our aim was to examine whether there was a difference between the genders in the efficacy of these antiviral therapy. Our goal also was to determine effect of the therapy with Peginterferon alfa-2a or alfa-2b plus Ribavirin on evolution of liver steatosis in patients with chronic hepatitis C. Patients and Methods: A retrospective study was made of chronic hepatitis C patients who had been treated from 2005 to April 2014 at the Clinic of Gastroenterohepatology, Clinical Center University of Sarajevo. We reviewed 40 patient medical records to collect demographic, epidemiological and clinical information, as information on liver biopsies that was performed prior to the antiviral therapy and FibroScan® test that was performed after the antiviral therapy. For the processing of data SPSS (Statistical Package for the Social Sciences Program) for Windows, ver. 21.0 statistical software was used. Comparisons between qualitative and quantitative variables were performed using the Student t-test. Mann Whitney U test was used to compare differences in variables such as fibrosis stage and steatosis grade. A value of p<0.05 was considered as statistically significant. Results: After treatment, there was a statistically significant increase in the number of patients with no fibrosis (p<0.05). There was no statistically significant reduction in the number of patients with cirrhosis (F4) (p>0.05). There was significantly higher decrease of fibrosis progression at the patients that were in an mild-to-moderate fibrosis (F1/F2/F3), patients that were in advanced stage of fibrosis (F4) at the time of the pre-treatment did not have a statistically significant fibrosis reduction. We found significant association in evolution of fibrosis after treatment with PEG-IFN α2a (40) kD and PEG-IFNα2a (12,5) kD with ribavirin (p< 0.05). We also found significant association in evolution of steatosis after treatment with PEG-IFN α2a (40) kD and PEG-IFNα2a (12,5) kD with ribavirin (p < 0.05). There was statistically significant differences (p<0.05) between genders within fibrosis qualitative evolution. Conclusions: There were significant regression of fibrosis especially at the patients that were in an mild-to-moderate fibrosis (F1/F2/F3), patients that were in advanced stage of fibrosis (F4) at the time of the pre-treatment did not have a statistically significant fibrosis reduction after treatment with PEG-IFN α2a (40) kD and PEG-IFNα2b (12,5) kD with ribavirin. Our results showed significant improvement in steatosis in patients infected with HCV after treatment with PEG-IFN α2a (40) kD and PEG-IFNα2b (12,5) kD with ribavirin. Those results provides further evidence for direct involvement of HCV and antiviral therapy in the pathogenesis of hepatic steatosis. Female gender showed a higher degree of fibrosis reduction.

Background: Various complications occur in patients with advanced stages of liver diseases. Renal dysfunction, a parameter included in the MELD score, is the most important prognostic factor. There is a strong need in clinical practice to estimate the GFR in this patients. Objectives: The aim of our study was to detect differences in renal function among patients with different stages of chronic liver diseases caused by HBV and HCV, also to determine the impact of viral etiology and gender on the values of eGFR and renal function. Patients and Methods: This was an observational cross-sectional study performed on patients with HBV and HCV chronic hepatitis, cirrhosis and HCC caused by these viruses hospitalized during period 2009–2014 in the Clinic of Gastroenterohepatology, Clinical Center University of Sarajevo. The estimated GFR (eGFR) was evaluated by the MDRD4 method. For the processing of data SPSS 21.0 statistical software was used. Statistical methods used in this study where: analysis of variance test (ANOVA test), Student’s t-test for independent samples and Pearson coefficient of correlation. The level of significance was p <0.05. Results: Among this three groups of patients there was a statistically significant difference in eGFR (F= 18.79, p<0.05), i.e. increase of degree of liver damage was related with increase of renal impairment, as reflected by a significant reduction in estimated glomerular filtration rate. Gender had no significant effect on eGFR and renal function (p>0.05), except in group of patients with HCC (p<0.05). Etiology had no significant effect on eGFR and renal (p>0.05). There was statistically significant inverse correlation between glomerular filtration rate and liver enzymes AST (-.184) and GGT (-.181). Conclusions: By calculation of GFR, we determined the existence of a significant reduction of kidney function through progression of liver damage from HBV and HCV chronic hepatitis, liver cirrhosis to HCC caused by these viruses, which drawing attention to the importance of the assessment of renal function in patients with this liver pathologies. Gender and etiology had no significant effect on eGFR and impairment of renal function. Given the statistically significant inverse correlation between eGFR and AST and GGT this liver enzymes may have important role as marker for both renal and hepatic injury.

Background: Endoscopic ultrasonography (EUS) is considered to be the most precise method for locoregional staging, was commonly used for differentiating mucosal lesions from submucosal lesions. By contrast, computed tomography (CT) was used to detect the presence of distant metastasis. Both are valuable tools for the pre-operative evaluation of gastric cancer. With the introduction of new therapeutic options and the recent improvements in CT technology, further evaluation of the diagnostic accuracy of EUS and multidetector CT (MDCT) is needed. Aim: The present study was conducted to compare the staging accuracy of EUS with that of MDCT in series of patients and to evaluate their usefulness in association with the clinicopathological factors. Patients and Methods: In total, 277 patients with gastric lesions who underwent EUS and CT, hospitalized at Department of Gastroenterology and Hepatology, Clinical Center, University of Sarajevo. The results from the pre-operative EUS and MDCT were compared with the post-operative pathological findings. Results: Among the 277 patients, the overall accuracy of EUS and MDCT for T staging was 74.7% and 76.9%, respectively. Among the 141 patients with visualized primary lesions on MDCT, the overall accuracy of EUS and MDCT for T staging was 61.7% and 63.8%, respectively. The overall accuracy for N staging was 66% and 62.8%, respectively. The performance of EUS and MDCT for large lesions and lesions at the cardia and angle had significantly lower accuracy than that of other groups. For EUS, the early gastric cancer lesions with ulcerative changes had significantly lower accuracy than those without ulcerative changes. Conclusions: For the pre-operative assessment of individual T and N staging in patients with gastric cancer, the accuracy of MDCT was close to that of EUS. Both EUS and MDCT are useful complementary modalities for the locoregional staging of gastric cancer.

ABSTRACT Background: The reasons for the chronic viral persistence of hepatitis B virus infection (HBV) are unknown, but are probably related to host immune factors. Cytokines play a significant role in immune defense. Interleukin-1 (IL-1) is a proinflammatory cytokine and some studies have demonstrated that IL-1 production was impaired in patients with chronic infections of hepatitis B virus, implying that IL-1 may play a role in viral clearance, progression of fibrosis and in malignant potential of HBV. In this study, along with routine laboratory tests, has been performed the analysis of serum levels of proinflammatory cytokine IL-1 α in order of better understanding and monitoring of chronic hepatitis B. Objective: The aim of this study was to analyze the usefulness of laboratory tests, which are routinely used in the assessment of liver disease with specified immunological parameters in patients with chronic hepatitis B. Patients and methods: Total of 60 subjects was divided into two groups: HBV- PCR positive and negative group. The control group of 30 healthy participants was included. Apart from standard laboratory tests, the analysis included serum levels of cytokine IL-1 α. Results and discussion: IL-1α had the highest mean concentration in group 1–viral hepatitis C, with PCR positive test (5.73 pg / ml), and then in group 2- viral hepatitis B, PCR negative test (5.39 pg / ml). ANOVA test proves that IL-1α in the healthy group (3) was different from other groups as follows: in relation to group 1 statistical significance level was p <0.001 (F = 32 75 5); in relation to group 2 was also statistically significant at p <0.001 (F = 182 361); Cytokine IL-1 was statistically analyzed separately and compared by group 1 and 2 using Student t-test for independent samples. Statistical significance was observed at p = 0.026. IL-1 α was positively correlated with the duration of the illness (p <0.01) and with serum ALT activity (p <0.01) and serum AST activity (p <0.01). Using multivariate analysis model “Factor Analysis”, was made significant stratification predictive parameters in relation to the cytokine IL-1α, stratified significance is indicated as follows: 1. Age, 2. history of receiving transfusions, 3. ALT, 4. AST, 5. MELD score (negative), 6. Child-Pugh score (Negative). Conclusion: IL-1α was significantly elevated in inflammatory conditions of pronounced activity (PCR positive hepatitis). IL-1α may have important role as marker of both inflammation and hepatic injury, particularly in the course of hepatitis B. Results suggest that inflammatory and immune parameters, analyzed together can significantly contribute to the understanding and predicting of chronic liver damage. IL-1 can be used as important parameter of inflammatory activity and fibrosis evaluation and eventually prediction of malignant transformation in chronic liver damage.

Introduction: Colorectal cancer is the major diagnostic and therapeutic problem. The number of patients in the world has increased recently. In our country it is detected late and patients visit doctor in the advanced stage of the disease with already developed metastases. Material and methods: A clinical study was conducted at the Clinic of gastroenterohepatologists, Clinical Center of Sarajevo University on 164 patients. Special attention was given to the symptoms, which are considered to be a macroscopically visible as bleeding, anemia pain, weight loss and disturbance of defecation. Smoking had no effect because a small number of observed patients smoked. Endoscopic examination revealed localization of the tumor in the colon and then underwent targeted biopsy, histological analysis by pathologist, and we determined the concentration of CEA and CA19-9 in the serum. Results: In order to get the most relevant results we used larger data set. The program used to prepare the data was Microsoft Excel 2013, and for the creation of decision trees is a used software RapidMiner version 5. Our research has shown that patients older than 55 years with significant stenosis, metastasis and diarrhea that lasted longer than 3.5 months and bleeding that lasted up to 10 months had cancer of the rectum. Bleeding that lasts longer than 10 months indicated that it was the case of cancer that was localized in the rectum in men and sigma in women. Patients older than 82.5 years and had diarrhea up to 3.5 months developed cancer in the sigma part of the colon. Analyzing pain as a symptom of an alarm, the study found that pain that lasts longer than a few days, is caused by rectal cancer, and occurs after the age of 70.5 years, and in patients younger than 63 years anemia as a alarm symptom, which lasted more than two months in men was caused by cancer of the rectum and in women cancer in other localizations within colon. In patients without stenosis developed bleeding as the most important symptom. We can say that after the age of 74 years cancer of the rectum and sigmoid is more common in men and in women dominate sigma and other locations in the colon. In patients under the 70 years of age with short time of bleeding, cancer predominates in rectum. In patients younger than 63 years can be concluded that weight loss is greater than 8 kg follows rectal cancer. In patients with bleeding that lasted one month or more as classifier occurring the age and gender. Patients younger than 74 years have rectal cancer, while older than 73 years have cancer at other sites. In women these locations are sigma and rectum. Conclusion: Based on this study we can conclude that regardless of the technical advances in medicine must pay special attention to the symptoms that doctors will refer to the localization of the tumor, stenosis of the intestine and possibly metastasis. Key words: Colorectal cancer, diagnostic procedures, concentration of CEA and CA19-9.