25 BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGY ...

Institute of Medical Biochemistry and Laboratory Diagnostics1st Faculty of Medicine, Charles UniversityGeneral Faculty Hospital, PragueMUDr.Petr Kocna CSc.http://www.lf1.cuni.cz/~kocna/pkweb1.htmcz/~ /~kocna/pkweb1.htmGASTROENTEROLOGY,LABORATORY DIAGNOSTICS- CASESSeminar Seminář Medical Faculty ÚLBLD, - Prague, listopad November 20122012

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.HELICOBACTER PYLORIPEPSINOGENS, , GASTRITISISCOELIAC SCREENING - THERAPYCHRONIC PANCREATITISISEXOCRINE PANCREATIC FUNCTIONQUANTITATIVE FITCOLORECTAL CANCER SCREENING2

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.HELICOBACTER PYLORIPEPSINOGENS, , GASTRITISISCOELIAC SCREENING - THERAPYCHRONIC PANCREATITISISEXOCRINE PANCREATIC FUNCTIONQUANTITATIVE FITCOLORECTAL CANCER SCREENING3

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.GASTRITISIS - CARCINOMA A SEQUENCESNORMAL MUCOSAATROPHIC GASTRITISHp - IARC 19941.class cancerogencINTESTINAL METAPLASIA4GASTRIC CANCER

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-01Male - J.N. - IT specialist - born 1978in childhood common childhood diseases,none of injury, none of hospitalization, parents in healthy,severe disease in the family - who do not know.Now does not have any subjective complainrts.On the internet he found - Hp is cancerogenof the 1.classOn the internet he found - LG laboratory, ry, non-invasive ive Hp test5Comes to LG laboratories with requirement for Hp test - UBT

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-01- laboratory data13C-UBT performed on the individual wish (self-paying)Value of 13 C DOB – 14.1 ‰, Hp - positive( Normal values up to DOB 5 ‰ )On the internet he found - suitable eradication therapyComes to GE ambulance with requirement foreradicationtherapy, which the alone cannot pay6

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.European Helicobacter Pylori Study GroupCurrent Concepts in the Management ofHelicobacter pylori InfectionThe Maastricht 2-200022000 Consensus ReportSeptember 2000WHO TO TREAT - STRONGLY RECOMMENDED INDICATIONSDU/GU(active or not, including complicated PUD) 1MALToma 2Atrophic gastritis 2Post-gastric cancer resection 3Patients - first degree relatives of gastric cancer patients 3Patients wishes (after full consultation with their physician) 47

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.HOW TO PREDICT RESULT of Hp INFECTIONH.Pylori+ hostHClHClDUODENALULCERGASTRIN ↑NODISEASEGASTRIN ↑ATROPHYCANCER8BACTERIAL TRIBE - GENETIC DISPOSITION - ENVIRONMENT - DIETS ?

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.Suspected - Gastritis - Hp infection- Gastric-cancercancerdetection HpPGI/PGII, G-17bnegative Hp,normal PGI/PGIInormal G-17bpositive Hp,normal PGI/PGIInormal G-17bHp +/-,low PGI/PGIIhigh G-17bpositive Hp,low PGI/PGIIlow G-17bH. pylori gastritisAtrophic gastritisNo risk ofa stomachdiseaseIncreased risk ofgastric or duodenalulcerIncreased risk ofgastric cancerEradicate H. pylori infection + consider gastroscopy9Rationale in diagnosis and screening of atrophic gastritis with stomach-specificspecificplasma biomarkers. Agréus L, Kuipers EJ, Kupcinskas L, Malfertheiner P, et al.Scand J Gastroenterol. . 2012; 47(2):136-147147

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.Hp INFECTIONDIAGNOSTIC non-invasive test, gold standard,specificity and sensitivity 95% - 13C UBT,breath test with 13C-urea non-invasive test, if 13C-UBT not available,Hp antigen in stool rapid urease test (CLO test) - if thegastroscopy clinically indicated, requiredbioptic samples from at least threedifferent gastro-duodenal positions IgA-IgG antibodies determination in serumdoes not have primary diagnosticimportance, as positivity to Hp-antibodiesin subjects > 60 years could be 85%10

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.HELICOBACTER PYLORIPEPSINOGENS, , GASTRITISISCOELIAC SCREENING - THERAPYCHRONIC PANCREATITISISEXOCRINE PANCREATIC FUNCTIONQUANTITATIVE FITCOLORECTAL CANCER SCREENING11

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-02Woman - L.J. - born 1972in childhood anemic, asthenic, often in sanatoria,mother and sister followed for thyreopathyastheny, height 171 cm, weight 52 kgmenarche at 15 years, married,at the time of diagnosis (2005) after 1 spont. abortion 199412

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-022005 admitted to gastroenterology y clinicwith requiremed of colonoscopy for hypochrome anemiaColonoscopy opy - normal findingsHistology of bioptical samples - normal findings13Routine laboratory test indicated

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-02- laboratory datahaemoglobin117 g/l, haematocrit 0.352albumin 46.6 g/lalkalinephosphatase phatase 1.54ukat/lalanine aminotransferasease 0.52ukat/laspartate aminotransferasease 0.43ukat/lgamma-glutamyl glutamyl transpeptidasease 0.16ukat/lcalcium2.35mmol/lphosphate phate 1.22mmol/lferrum 22.9 mmol/ltotal cholesterol 3.19 mmol/ltriglycerideses 0.65 mmol/l14

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-02- laboratory datacoeliac c screening markers - 11/4/05:IgA anti-transglutaminase transglutaminasease 132 U/mlIgA anti-gliadin 30 U/mlIgG anti-gliadin 132 U/mlIgA anti-endomysium- positive15Histology - small bowel biopsy:active coeliac, , subtotal l atrophy,decreased lactase, ase, , IEL 50/100

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.ICEBERG HYPOTHESIS OF COELIAC INCIDENCEINCIDENCE 1:1000CLINICAL CSCLINICAL Dg.TRANSIENT CS(NONCS)SILENT CSATYPICAL CSMUCOSAL DEFECT, ASYMPTOMATICHISTOLOGY Dg.LATENT CSNORMAL MUSOCA, + MARKERYPOTENTIAL CSHLA DQw2, IEL, γ/δ IELINCIDENCE 1:200INCIDENCE 1:100SEROLOGY Dg.16

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.17TARGETED COELIAC SCREENINGDermatitis herpetiformisOsteoporosis, unexplained fracturesUnexplained anaemiaChronic fatigue syndromeMAIN RISK GROUPSResistent irritable bowel syndromeSpont. abortion and fetal growth retardationUnexplained anaemia (iron, folic acid)HypertransaminasemiaCD SUSPECTED SYMPTOMSRecurrent aphthous stomatitisDental enamel hypoplasia Diabetes mellitus type 1.Autoimmune thyroiditisAutoimmune liver diseaseAUTOIMUNNE DISEASESSystemic lupus erythematosusSjögren syndromePrimary biliary cirrhosis or sclerosing cholangitis

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.negative antibodiesLow probabilityof coeliacsTargeted screening of coeliac diseasehigh clinicalsuspicionnegativebiopsyIgA atTG / IgA EmAandtotal IgAIntestinalbiopsypositiveantibodieshistologic features of CDIgA deficientIgG atTG , IgG EmAor IgG AGAIncreased probabilityof coeliacspositiveantibodiesHLA typingng,biopsy y re-evaluationevaluationProvisional diagnosis of CDGluten free dietclinical and histologic improvement18Definitive diagnosis of CDC. Briani et al. . / Autoimmunity Reviews 7 (2008) 644–650650

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.Asymptomatic person at genetic risk for coeliac diseasenegative HLAHLA DQ2 and/or DQ8positive HLANo risk for CDnegative antibodiesExclude IgA deficiencyLow gluten intakeIgA atTG2 2 & total IgAanti TG2> 3x normalanti TG2< 3x normalIgA EmAMarsh 0 or 1Normal dietFalse positive testsPotential CDIntestinal biopsyMarsh2 or 3Definitive diagnosis of CDEmA positiveEmAnegativeTransient false pozit.anti TG2Normal dietFurther serology testing19New ESPGHAN guidelines for the diagnosis of Coeliac Disease inChildren and Adolescents - Steffen Husby, Odense University Hospital, Denmark

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.ACTUAL PROTOCOLOLANTIBODIES DETERMINATION(EVIDENCE - BASED)IgA atTGPERSPECTIVTIVE PROTOCOLOLANTIBODIES DETERMINATION(WORKINGHYPOTHESISHESIS)IgA atTG+ +IgA EmA+ +IgAAGAAGA+ +IgGDGPINCREASE OF IgA atTG SPECIFICITYINCREASE OF IgA atTG SPECIFICITYCOELIAC DETECTION WITH IgA DEFFICIENCYFICIENCY+ IgG atTGCOELIAC DETECTION IN CHILDRENS < 2 YRCOELIAC DETECTION WITH IgA DEFFICIENCYFICIENCYCOELIAC DETECTION IN CHILDRENS < 2 YR20Old and new serological tests for celiac disease screening.Volta U., Fabbri A., Parisi C. et al. . Expert Rev. Gastroenterol. Hepatol. . 2010, 4(1)

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.INTESTINAL BIOPSY IN THE COELIAC DISEASE DIAGNOSTICSMarsh 0 Marsh 1Marsh 2 Marsh 3a Marsh 3b Marsh 3c21Clinical practice - Coeliac disease - Eur J Pediatr. - online March 2012C. M. Frank Kneepkens & B. Mary E. von Blomberg

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.GLUTEN FREE DIET (GFD) - SCREENING & DIAGNOSTICSNORMAL MUCOSANEGATIVE ANTIBODIESHEALTHY SUBJECTTRATED COELIACTREATED COELIAC ?OTHER AUTOIMMUNITY MUNITY ?22FLORID COELIACUNTREATEDPOSITIVE E ANTIBODIESTOTAL ATROPHY

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.ENDOSCOPIC MARKERS OF COELIAC DISEASEEnterscopyMosaic c pattern ofduodenal mucosaNormal duodenalmusocaChromoendoscopyopywith indigocarmineine23http://www.lfhk.cuni.cz/kcvl/stranky/ENTERO/E-cel1.htmlcz/kcvl/stranky/ENTERO/E-cel1. cel1.html

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CAPSULE ENDOSCOPYNON-INVASIVE ENDOSCOPICEXAMINATIONNormal duodenalmusocaMosaic c pattern ofduodenal mucosa24 http://www.lfhk.cuni.cz/kcvl/stranky/Kapsle/C-CE1.htmlcz/kcvl/stranky/Kapsle/C-CE1. CE1.html

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.MESENCHYMALCELLSTISSUETRANSGLUTAMINASEM. CELLStTGDEAMIDATIONaccording to Mowat AT, Lancet 2003, 361: 129033-mer PEPTIDEGLIADINGASTRIC, PANCREATICPEPTIDASES, PROLYL-ENDOPEPTIDASEWHEATCOELIAC VILLUSATROPHYCD4+ TCELLTH2-CELLTH1-CELLINFLAMMATION25B-CELLANTIBODIESIL 4,5,10IL2, γIFN, TNFCOELIACCRYPTS HYPERTROPHY

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.COELIAC THERAPYxx2. ENZYMESES PEP, EP-B23. TG2 INHIBITOR1. GLUTEN-FREE DIETx5. NON-TOXIC WHEAT4.HLA BLOCATION26

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.COELIAC THERAPY: ENZYMIC HYDROLYSISYSISBACTERITERIALPROLYL-ENDOPEPTIDENDOPEPTIDASE,CYS-PEPTIDPEPTIDASE FROM BARLEYPROLYL-ENDOPETIDENDOPETIDASELACTOBACILLUS, ASPERGILUSPROTEASES27PRE-GASTRONOMICDETOXIFICATIONTIONMODIFICATION OF FOODINTRA-DIGESTIVDIGESTIVEDETOXIFICATIONTIONPERORAL APPLILICATION OFENZYMESES - HYDROLASESAlvine Pharmaceuticals Reports PositiveResults With ALV003 In Phase 1 Trial ofTherapy In Development For Celiac DiseaseOctober 30, 2008

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.T cell receptorGLUTEN FREE DIET - CEREALSDQ2 moleculeDECREASING PATOGENICITY FOR CSWHEAT RYE BARLEY OATS RICE SORGHUM MILLET MAIZEGLIADIN SECALIN HORDEIN AVENINZEINmAbGliadinstandardDECREASING TEST SENSITIVITY28

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.GLUTEN FREE DIET - DAY QUANTITY50day amount - mg gliadin/50kgweight250 g gluten free foodhigh - 9,9 mg gliadin40Therapy errorFood with high gliadin level3020102901 3 5 7 9 11 13 15 17 19 21 23 25 27 29Hodnocení bezpečnosti potravin pro bezlepkovou dietu,Gabrovská D. VÚPP-Praha, Praha, 2009 - projekt1B53002

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-02- THERAPYsince 11/2005 complete gluten-freediet2008 gave birth to a healthy daughter, who has not coeliac,follows the diet - is on remisionCASE: 12-02- laboratory data30coeliac specific antibodies - 24/4/06:IgA anti-transglutaminase transglutaminasease 2 U/mlIgA anti-gliadin 7 U/mlIgG anti-gliadin 29 U/mlIgA anti-endomysium- negative

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-02- laboratory dataimmunological markers - 24/7/12:interferron ron gamma, IFNγ 57,7 (normal up tol 31 %)tumor necrosis factor, TNFα 74,7 (normal up to 44 %)interleukin, IL2 - 47,9 (normal up to 28 %)31

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.COELIAC C DISEASE SUMMARY‣ LIFELONG DISEASE, PERMANENT INTESTINALINTOLERANCE OF GLUTEN, PROLAMIN PROTEINS‣ GENETIC FACTORS - HLA-B8, HLA-DR3, HLADQ2‣ INITIALISING FACTORS - GLIADIN OR SIMILAR PEPTIDES‣ IMMNOLOGY RESPONSE, AUTOIMMUNE TYPE OFDISEASE‣ DAMAGE OF SMALL INTESTINAL MUCOSA‣ MALABSORPTION SYNDROME‣ RESPONSE TO GLUTEN FREE DIET32

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.SMALL BOWEL ABSORPTION - FUNCTION TESTSH 2a 13 C - BREATH TESTSHydrogen analyserLacto FANRegression of lactose malabsorption in coeliac patientsafter receiving a gluten-free diet.Scand J Gastroenterol. 2008;43(2):174-17717713C-xylose and 14C-xylose breath tests for the diagnosisof coeliac disease.Scand J Gastroenterol. 2008;43(2):166-173173LACTOSEBREATH TEST20g LACTOSE DOSAGEHYDROGEN DETERMINATIONS 5 HOURSCUT-OFFVALUE 20 ppmD-XYLOSEBREATH TEST100mg 13C-XYLXYLOSE DOSAGERATIO 12C:13C DETERMINATIONBREATH INDEX 30min/210min3313-C analyserHeli FAN

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.LACTOSE INTOLERANCE DIAGNOSISHISTOCHEMICAL DETECTIONOF LACTASE ACTIVITYIN THEENTEROCYTE E BRUSH BORDERIMMUNOHISTOCHEMICAL TEST34MODERN RAPID TESTLACTASE ACTIVITYDETECTIONCHROMOGENICMETHOD

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.HELICOBACTER PYLORIPEPSINOGENS, , GASTRITISISCOELIAC SCREENING - THERAPYCHRONIC PANCREATITISISEXOCRINE PANCREATIC FUNCTIONQUANTITATIVE FITCOLORECTAL CANCER SCREENING35

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-03Male- A.A. - born 1938history of gallbladder problems - (cholecystolithiasis) is)hypertension treatment on Ca blockers, obesityDietary error - goulash, beerAbdominal pain around the navel broadening in the back, vomitingS-amylase20,2, , C-reactive Cprotein 1.day 5 g/l, calcium 1,85 mmol/lAbdominal ultrasound - cholecystolithiasa36Admitted to surgary clinic – emmergency unitliquid saturation – 5000 ml/24 hrs

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-035.day- CT abdomenSevere acute necrotizing pancreatitis (more than 60%)ATB administration - cefotaxime 10 days, parenteral nutrition,febricity,25.day– necrosis drainage under CTComplications:Renal insufficiency, borderline cardiac compensation37

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.38CASE: 12-03- laboratory data2 3 5 7 45 90creatinin 130 88 79 73 75 75urea 9.2 6.6 4.3 6.9 2.5 4.7albumin 39 27.8 24.5 24.5 20.5 38Na + 133 135 135 131 / 135 135 143K + 3.7 3.6 3.4 3.4 / 3.9 4.0 4.9Cl - 98 103 100 93 / 96 102 104pH 7.43 7.46 / 7.47pCO 25.34 6.91 / 5.58BE 2.4 10.9 / 6.2HCO - 326.3 34.6 / 3.011-2 2 day dehydratation 7 day metabolic alkalosis alosis

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-0345.den abdominal CT native and contrast - enhanced biphasic.In comparison with the presence of 8.9.08 slightly accentuatednecrotic deposit in pancreatic body, about 39 x 30 mm, minorhypodense districts in cauda of the pancreas which is the borderwidth, with unsharp bounded. Pancreatic head not enlarged,without any deposits. Dc. pankreaticus unextended.Peripancreatical fluid better highlightet, particular craniallyfrom the pancreas - 100 x 110 mm and anterior to the pancreas110 x 60 mm, fluid collection up to the front of the left renal fascia.Cholecystolithiasis. Fluidothrax right posterior 71 x 25 mm.39Transfer to metabolic unit of 2nd. medical clinic

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-0345.day transfer to metabolic unit of 2nd. medical clinicintroduced naso-jejunal probe, pulled the drain, gradually increasedenteral nutrition to 2200 ml per day (2200 kcal, 85 g protein)Drugs: proton pump inhibitors (omeprazole 2x20 mg),substituted pancreatic enzymes (Creon 25000j 3 x 1 cps),liquid free, probiotics. Conducted training for homeenteral nutrition and released to home careThe ICU 52 days, 55 days in the hospital, then home enteralnutrition 93 days, gradual transfer to oral intake.Proton pump inhibitors discontinued,and patient gradually discontinued probiotics ,,40

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-0390.day- CT and contrast - enhanced abdominal natively.Conclusion: Compared with the measurement of 19.9.08increased pancreatic pseudocyst extending peripherally to themediastinum. Splenic vein thrombosis with colleterals at largecurvature of the stomach. Necrosis of the pancreatic body,relatively less is its head and tail. Small deposit in the liver,nonspecific appearance. Multiple cholecystolithiasis.Duodenal diverticulum..41Cholecystectomy tomy performed after 5 months.Continued pancreatic enzyme e application,Creon 25000 - 3 x 1 cps, total 1,5 year with good effect. e

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CASE: 12-03- laboratory dataAfter 1,5 year executed exocrine pancreatic secretion tests :FELA (fecal(elastase-1) ase-1) 378 μg/g(normal above 200 μg/g)13 C-MTGbreath test, 6hr. cPDR - 51 % (normal above 30 %)Pancreatic enzyme substitutiontion discontinued,at this time gall diet without pancreatic substitution.42

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.CHRONIC PANCREATITIS IS DIAGNOSTICSDiagnostic imaging for mild chronic pancreatitisEndoscopic ultrasound (EUS)Endoscopic retrograde cholangiopancreatography (ERCP)Magnetic resonance cholangiopancreatography (MRCP)EUSERCPMRCPSENSITIVITY 56% (40-72)72% (58-86)86) 54% (44-64)SPECIFICITY 81% (68-95)75% (60-90)78% (72-83)43Diagnosis of mild chronic pancreatitis (Cambridge classification)Sai JK, Suyama M, Kubokawa Y, Watanabe S.World J Gastroenterol 2008 February 28; 14(8): 1218 - 1221Researchers Test the Value of ERPC for the Detection of Early Chronic PancreatitisFrei R. - Gastroent.Endoscop.News 2007, 58, 02

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.MRCP - SECRETION VOLUMEMATHEMATICAL PROCEDUREPANCREATIC FUNCTION TEST44Quantitative MRCP assessment of pancreatic exocrine reserve and itscorrelation with faecal elastase-1 1 in patients with chronic pancreatitisManfredi R. el al. Radiol med. - DOI 10.1007/s11547-011-0774-6011-0774-6

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.EXOCRINE PANCRAETIC FUNCTION TESTSSTOOL SAMPLING - 72hr.STANDARD METHODFOREXOCRINE PANCREATIC FUNCTIONFAT 72 hr.S-CCKTEST45

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.EXOCRINE PANCRAETIC FUNCTION TESTSWITHOUTSTIMULATIONINDIRECTSTIMULATIONPERORAL ADMINISTRATIONSTIMULATINGTINGMEALSUBSTRATEMAIZE BREAD20g FAT13 C-MARKERANALYSISSUBSTITUTIONUTIONTHERAPYFECALELASTASEPANCREATICLIPASE250mg13 C-MTGDRUGLIPASESECRETORY CAPACITYGRADING CHPDIGESTIVE FUNCTIONOF (LIPID) DIGESTION46

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.13 C- MTG BREATH TESTmeal = bread + fatperoraladminitration13 C-substratemeasurementof 13 C/ 12 CratioCO 2 excretionCO 213 CO2enzymichydrolyticGIT function13 C13 Celiminationcummulative mulativeCO 2 output47absorptioncPDR

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.PANCREAS RESECTIONSUBSTITUTION THERAPY40 - 120 kIU LIPASETHERAPY OKFAILED THERAPYCOMBINATION WITH PPITHERAPY OKPABA, PLT, 13C-MTG TESTWITH SUBSTITUTIONTHERAPY OKFAILED THERAPY48 Kahl S.,Best Pract.Res.Clin.Gastro. 2004MALABSORPTIONSYNDROMEOTHER SOURCES

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.13 C-MTG - BREATH TEST WITH MIXED TRIGLYCERIDEcPDR 13C403513 CCF without enzyme therapy2400 IU lipase/kg/food4800 IU lipase/kg/food302520151050ControlCyFi10 mg/kg 13 C-MTGcPDR 6 hours4913Carbon mixed triglyceride breath testand pancreatic enzyme supplementation in cystic fibrosisAmarri S. et al.:Archives of Disease in Childhood 1997; 76: 349–351351

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.13 C-MTG - BREATH TEST & FECAL ELASTASEcPDR MTG (%)CUT-OFF FELA: : 200 μg/g100 μg/g80,070,060,050,0NORMALCHP-ACHP-BCHP-CCHP-DNON-CHP40,030,0CUT-OFF MTG: 30 %5020,010,0PANCREATITIS246 BREATH TESTS S WITH 13 13 C-MTG160 CHP - 73 CONTROLS (NON-CHP)CONFORMITY MTG & FELA - 80.2% ((191/238)0,0-50 50 150 250 350 450 550 650 750 850 950FELA μg/g

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.13 C-MTG - BREATH TEST & FECAL ELASTASEcPDR MTG (%)80,070,0100 μg/gCUT-OFF FELA: : 200 μg/gNORMALSUBSTITUTION THERARYEXCESSEDIN 93 % PATIENTS60,050,040,030,020,010,0CUT-OFF MTG: 30 %GROUP OF 28 CHP OF FTN WITH NORMALVALUES OF BOTH PANCEATIC TESTSFELA > 200 mg/g MTG > 30.0 %510,0-50 50 150 250 350 450 550 650 750 850 950FELA μg/g

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.52EXOCRINNE PANCREATIC FUNCTION TESTS13 C-breath test provides a comprehensive assessment of MTGdigestive process - digestion of lipidsValues of cPDR 13 C-MTG test are cummulative data, whichincludes as well the pancreatic function, as substitution therapyCut-off value of cPDR 13 C-MTG test, lower limit of normalsestablished by mathematical approximation is 30%To assess exocrine pancreatic function testing is an appropriatecombination of 13 C -MTG breath test and determination offaecal elastase 1, affecting various aspectsEconomical benefit of exocrine pancreatic function tests is inpossibility to exclude pancreatic substitution therapy in morethan three-fourths patients with suspected pancreaticinsufficiency.

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.HELICOBACTER PYLORIPEPSINOGENS, , GASTRITISISCOELIAC SCREENING - THERAPYCHRONIC PANCREATITISISEXOCRINE PANCREATIC FUNCTIONQUANTITATIVE FITCOLORECTAL CANCER SCREENING53

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.‣ Colorectal carcinoma is the most common tumor of the GE tract‣ In the Czech Republic (2008) was diagnosed 8236 subjects with CRC,C,on CRC died 4313 patients, more than 50% of the mortality isdue to the high proportion of patients diagnosed in advancedstages III and IV‣ Screening over 50 years - the target population in the Czech Republicincludes 3,782,524 subjects‣ FOBT/TOKS screening test was carried out in 2010 only in 370,905persons, ie. 9.8%‣ FOBT/TOKS + indicated colonoscopyin 2009 found only 618 CRC of8236 diagnosed CRC, which is only 7.5%Recommendations for the Ministry of Health Commissionproposes a solution which enables1. increase the number r of subjects with FOBT/TOKSTOKS2. increase the detection of early CRCwith more accurate test TOKSregional cooperation with general practitionersand offer quantitative FIT for FOBT/TOKS54

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.g-FOBT– GUAJAC TEST, HAEMOCCULT10028,7% 56,8% 83,4%806040200g-FOBT i-FOBT qi-FOBTHaemoccultg-FOBTWITH SENSITIVITY < 30% USED TILL 31.12. 201255Commitee of CRC screening at Ministry of health CR, July 2012

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.i-FOBTQUALITATIVE, RAPID TEST10028,7% 56,8% 83,4%806040200g-FOBTi-FOBTqi-FOBTRapid test562 TIMES HIGNER SENSITIVITY OF i-FOBTs TO GUAJAC g-FOBTsg

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.SAMPLINS SYSTEM - OC SENSOR μSTOOL SAMPLEINSERTALUMINIUM FOILPERFORATION25 μl INJECTTO CUVETTE57TRANSFER of 10 mgSTOOL SAMPLEFILTRATIONOF SAMPLE EXTRACT

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.ng Hb/ml16001400SYMPTOMATIC SUBJECTS FOR COLONOSCOPYOPY697 - 1477 ng/mlmean 1087 ng/mliFOBT - OC Micro - Eikencut-off 75 ng/ml1200581000800315 - 654 ng/mlmean 485 ng/ml600140 - 263 ng/ml400mean 202 ng/ml25200- 45 ng/mlmean 35 ng/ml0NORMAL ADENOM ADV.ADENOM CANCERLevi Z.,Rozen P.,HazaziR.,VilkinA.,WakedA.,MaozE.,BirkenfeldS.,LeshnoM.,Niv Y.Ann Intern Med. 2007;146:244-255255A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.DUTCH SCREENING STUDY 2008iFOBT - OC Micro - Eikencut-off 100 ng/ml20 623 SAMPLESRANDOMIZATIONg-FOBTi-FOBTINVIATION 10 301 10 322PARTICIPATION 4 836 6 157POSITIVE FOB TEST 117 339EXAMINATION 103 280POLYPS AND CANCER 80 218ADV.ADENOMAS AND CANCER 57 145COLORECTAL CANCER 11 2459van Rossum, , L.G., van Rijn, , A.F., Laheij, , R.J., van Oijen, M.G., Fockens, , P.,van Krieken, , H.H., Verbeek, , A.L., Jansen, , J.B., Dekker, , E., RandomComparison Of Guaiac And Immunochemical Fecal Occult Blood Tests ForColorectal Cancer In A Screening Population - Gastroenterology (2008)

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.60OPTIMIZATION OF CUT-OFF VALUE FOR qFITValue defined by manufacturer (Eiken): 100 ng/mlDutch study - GE specialization: 75 ng/mlCutoff value determines the performance of a semi-quantitativeimmunochemical faecal occult blood test in a colorectal cancer screening sprogramme.van Rossum LG, van Rijn AF et al. Br J Cancer. 2009;101:1274Pilot study y in the Czech Republic:75 ng/mlImprovements in colorectal cancer screening programmes – quantitativeimmunochemical faecal occult blood testing .Kovářová J.T., Zavoral M., Zima T., Žák A., Kocna P. et al. Biomed Pap 2012, 156:143Dutch study - economical: 50 ng/mlCost-effectiveness analysis of a quantitative immunochemical testfor colorectal cancer screening.Wilschut JA, Hol L, Dekker E et al. Gastroenterology. 2011;141:1648

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.Optimization of qFIT cut-off, for indication to colonoscopy:Indicate as much as possible, all pathology - with 15% healthy subjects ?NOT indicate healthy subjects, but decrease sensitivity about 15% ?95specificity90852145 subjects > 40 yearwith colonoscopy76 x CRC80sensitivity7550 75 100 125 150 200ng/ml61Higher Fecal Immunochemical Test Cutoff LevelsTerhaar sive Droste JS et al. Cancer Epidemiol Biomarkers Prev. . 2011; 20(2)

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.normal adenoma progressivecolon adenomalocatized CRC lymph node CRC liverCRC metastasis metastasis5 year survival rate (%)10 - 15 yearsCRC stage: Dukes DI-II III Dukes III Dukes IVProteomics of colorectal cancer: overview of discovery studies and identification ofcommonly identified cancer-associated associated proteins and candidate CRC serum markers.Jimenez CR, Knol JC, Meijer GA, Fijneman RJ. - J Proteomics. . 2010;73:1873-1895189562

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.MOLECULAR BIOLOGYDNA CHIPs FOR COLORECTAL CANCER SCREENING63PreGen-PlusPlus - DETECTIONTION23 MOLECULAR MARKERS S OF CR-CACA21 MUTATIONSTIONS - APC, , K-ras, Kp53MIKROSATELLITELITE INSTABILITY - BAT-26

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.http://www1.lf1.cuni.cz/~kocna/glab/glency1.htmcz/~ /~kocna/glency1.htmhttp://gelab.zde.cz64NLM Medline on-lineabstractsDirect link to MZČRNational lab.registry

BIOCHEMICAL DIAGNOSTICS IN GASTROENTEROLOGYKocna P.ON - LINE INTERNET RESOURCEShttp://www1.lf1.cuni.cz/~kocna/glab/glency1.htmcz/~ /~kocna/glency1.htmhttp://gelab.zde.czhttp://www1.lf1.cuni.cz/~kocna/ginet/index.htmcz/~ /~kocna/ginet/index.htmhttp://gweb.zde.czhttp://www1.lf1.cuni.cz/~kocna/ge_atlas/ge_frames.htmcz/~ /~kocna/ge_atlasge_frames.htmhttp://geatlas.zde.czhttp://www1.lf1.cuni.cz/ukb/lectures.htmcz/ukb/lectures.htm65