Acute lower gastrointestinal bleeding is most commonly found in the older population, whose age, comorbidities, and ongoing therapy have impact on bleeding lesions, diagnostic and therapeutic modalities and the outcomes of bleeding. Endoscopic procedures are still the gold standard in diagnostics.

Introduction. Primary intestinal lymphangiectasia is a rare disorder, characterized by abnormal dilation of intestinal lymphatic vessels and extensive enteric loss of lymph rich in plasma proteins, lymphocytes and chylomicrons. The main characteristics of the disease are hypoalbuminemia, hypogammaglobulinemia, lymphocytopenia, and more rarely, the deficit of liposoluble vitamins and anemia. Except for primary, there are secondary lymphangiectasia, associated with celiac disease, malignant, infective and inflammatory diseases of the small intestine, fibrosis, liver and cardiovascular diseases. Case report. A male, 33 years of age, presented for his medical examination suffering from diarrhea and edema. The diagnosis was established upon the histological examination of a small intestine biopsy during double balloon enteroscopy, which revealed changes only in one segment of the intestine examined. Such a finding was later confirmed by the video endoscopy capsule. Conclusion. The diagnosis of intestinal lymphangiectasia is usually established before the age of 3, but it can also be diagnosed in adults. The diagnosis is based on the histological analysis of the intestinal mucosa biopsy, obtained by endoscopic procedures. The diagnosis of primary intestinal lymphangiectasia is also made upon the exclusion of secondary causes.

Introduction. The development of inflammatory bowel disease during the treatment with tumor necrosis factor-α inhibitors is seen in patients with ankylosing spondylitis. Crohn´s disease is the mainly developing form, and etanercept is most frequently associated agent.Although thrombocytosis in patients with ankylosing spondylitis and inflammatory bowel diseases is often seen due to chronic inflammation, iron deficiency anemia or drugs administration, presence of essential thrombocythemia is not common. According to our knowledge, there is no literature reporting of coexistence of these three diseases in one patient. Case report. We report a complex case of 35-year patient with practically simultaneous presentation of ankylosing spondylitis and essential thrombocythemia. Due to hepatotoxicity of initial treatment with sulfasalazine and metotrexate, tumor necrosis factor α inhibitor (etanercept) was introduced. Both diseases were well controlled until Crohn´s disease emerged. Two years after switching from etanercept to adalimumab all three coexisting diseases are in remission. Conclusion. Treatment with tumor necrosis factor-α inhibitors significantly improved clinical outcome of patients with chronic inflammatory diseases. However, appearance of adverse effects may cause change or discontinuation of the drug. Existence of co morbidities additionally complicates treatment of such patients. Key words: ankylosing spondylitis, Crohn´disease, essential thrombocythemia, tumor necrosis factor-α inhibitors. Apstrakt Uvod. Tokom terapije inhibitorima faktora nekroze tumora alfa kod bolesnika sa ankilozirajućim spondilitisom može doći do nastanaka inflamatorne bolesti creva . Kronova bolest je najčešća forma, a etanercept je lek koji se najviše povezuje sa pojavom bolesti. Iako se trombocitoza često javlja kod bolesnika sa ankilozirajućim spondilitisom kao rezultat hronične inflamacije, sideropenijske anemije ili administracije lekova, pojava esencijalne trombocitemije nije česta. Nema literaturnih podataka koji opisuju koegzistenciju ove tri bolesti kod jednog bolesnika. Prikaz bolesnika. Prikazujemo složen slučaj 35-godišnjaka sa praktično istovremenom pojavom ankilozirajućeg spondilitisa i 4 esencijalne trombocitemije. Obzirom na hepatotoksičnost izazazvanu inicijalno uvedenim lekovima-sulfasalazinom i metotreksatom, započinje se terapija tumor nekrozis faktor alfa inhibitorom-etanerceptom. Obe bolesti su bile zadovoljavajuće kontrolisane sve dok nije dijagnostikovana Kronova bolest. Dve godine nakon promene etanercepta u adalimumab sve tri bolesti su u remisiji. Zakljuĉak. Terapija inhibitorom faktora nekroze tumora alfa je značajno poboljšala klinički ishod bolesnika sa hroničnim inflamatornim bolestima. Ipak, pojava neželjenih efekata može usloviti prekid ili promenu leka. Prisustvo komorbiditeta dodatno komplikuje terapijski pristup ovim bolesnicima. Kljuĉne reĉi: ankilozirajući spondilitis, Kronova bolest, esencijalna trombocitemija, inhibitori faktora nekroze tumora alfa

1 Klinika za gastroenterologiju i hepatologiju, Klinički centar Vojvodine, Novi Sad 2 Klinika za ginekologiju i akušerstvo, Klinički centar Vojvodine, Novi Sad Poremećaj testova funkcije jetre javlja se u 3-5% trudnoća, a uzroci su brojni, uključujući bolesti jetre koincidentne sa trudnoćom (najčešće virusne hepatitise ili žučne kamence), kao i od ranije postojeće bolesti jetre. Pruritus se javlja u oko 23% trudnoća, ali samo mali deo trudnica koje imaju izražen svrab će imati obstetričku holestazu. Intrahepatička holestaza u trudnoći (ICP) je holestatski poremećaj koji se karakteriše svrabom koji se javlja u drugom ili trećem trimestru trudnoće, povišenjem serumskih transaminaza i žučnih kiselina, kao i spontanim povlačenjem simptoma i znakova tokom druge-treće nedelje posle porođaja. Incidenca u centralnoj i zapadnoj Evropi i severnoj Americi je 0,4-1%. Genetski i hormonalni faktori, kao i faktori okoline mogu doprineti patogenezi ICP. Intrahepatička holestaza u trudnoći povećava rizik prevremenog porođaja (19-60%), plodove vode prebojene mekonijumom (27%), fetalne bradikardije (14%), fetalnog distresa (22-41%) i gubitka ploda (0,4-4,1%), posebno kada je serumski nivo žučnih kiselina >40 μmol/L. Kod ICP postoji promena u serumskom profilu žučnih kiselina, uključujući značajan porast u koncentraciji holne kiseline i povećane konjugacije sa taurinom. Ursodeoksiholna kiselina (10-20 mg/kg/d) je danas prva terapijska linija u lečenju intrahepatičke holestaze u trudnoći. Porođaj se preporučuje u 37-38 nedelji kada se konstatuje zrelost pluća fetusa.Ključne reči: Intrahepatička holestaza u trudnoći, testovi funkcije jetre, serumske žučne kiseline, fetalni, tretman UVODIntrahepatička holestaza u trudnoći (Intrahepatic cholestasis of pregnancy -ICP) je holestatski poremećaj koji se karakteriše pruritusom, povećanjem serumskog nivoa žučnih kiselina i transaminaza, a javlja se u drugom ili trećem trimestru trudnoće, pri čemu se simptomi se povlače spontano unutar prve dve do tri nedelje posle porođaja [1].Prvi opis ICP datira iz 1883. godine, kada je Ahlfeld opisao pruritus i žuticu kod trudnica u poslednjem trimestru trudnoće, što nestaje posle porođaja [2].Etiologija ICP je asocirana sa hormonalnim, genetskim i egzogenim faktorima. Značajnost ženskih polnih hormona uočava se iz činjenice da se bolest najčešće javlja u trećem trimestru trudnoće kada nivo estrogena dostiže svoj maksimum, kao i da je češća izraženost u blizanačkim trudnoćama i kod trojki zbog većeg nivoa estrogena. Kapacitet jetre tokom trudnoće postaje insuficijentan da metaboliše velike količine placentalnih hormona. Sinteza progesterona tokom ICP ostaje na normalnom nivou, ali su detektovani povišeni plazma nivoi sulfatnih progesteronskih metabolita. Bolest može biti precipitirana i primenom progesterona u trećem trimestru trudnoće [1,3,4].Genetski faktori podrazumevaju mutaciju u genima koji kodiraju hepatobilijarne transportne proteine sa njihovom konsekventnom insuficijencijom. U jednom od šest slučajeva ICP je familijarna bolest i u takvim slučaj-...

Introduction. Among the acute hepatic porphyrias, a small percentage of patients, predominantly female, present with recurrent cyclic attacks of acute intermittent porphyria (AIP) that occurs more than three times a year, and sometimes at intervals of less than a month. In women, the attacks are typically related to menstrual cycle, requiring several days of hospitalization and administration of heme arginate. For these patients, the prophylactic heme arginate therapy may be the optimal treatment modality. Case Report. We present a 40-year-old female patient who has been suffering from porphyria for seventeen years. The first attack occurred in 2003, presenting with severe neurological symptoms, requiring the use of heme arginate Normosang?, which resulted in a favorable therapeutic response. In 2004 and 2007, gonadorelin analogue Zoladex? (goserelin) was used, but without beneficial effects on the course of the disease. In 2008, a preventive administration of heme arginate was initiated. The patient received heme arginate in the early phase of symptoms, every month in the premenstrual phase of the cycle, which resulted in milder symptoms, full recovery within 24 hours, lower doses of Normosang? (1-2 ampoules) and fewer hospital days (1-2 days) per month. This regimen has significantly improved the patient's quality of life and reduced the risk of potential adverse effects. Conclusion. Preventive use of Normosang? is the optimal therapeutic modality in patients with frequent, recurrent severe attacks that are unresponsive to other therapeutic regimens. As a result, patients have a better quality of life due to an effective, short-term, targeted treatment regimen.