Search results

1

Multichannel Intraluminal Impedance and pH Testing - A New Diagnostic Technique for Gastroesophageal Reflux Disease. Own Experience

100%

Wallner G., Solecki M., Huk J., Dąbrowski A., Majewski M., Dombroskyy A.

Polish Journal of Surgery

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2007

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vol. 79

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issue 7

490-495

EN

In 2001 FDA (Food and Drug administration, USA) gave its permission for simultaneous oesophageal intraluminal impedance examination and pH testing in the clinical practice. In 2002 in Porto, Portugal, a committee of international experts proposed a new classification of reflux types.Material and methods. From October 2005 to June 2006, we examined 36 patients sent to the clinic with GERD symptoms using a Sleuth® recording device.Results. The group of 36 patients (19 women and 17 men); mean age of 47 years with a range of 16-74 years) was examined. The mean length of time for the examination was 22 h 47 min, the shortest one lasting 18 h 36 min; brakes were caused by battery failure. 1509 episodes of reflux were confirmed by impedance channels. Only 538 (35.65%) of these reflux episodes were acidic or weakly acidic and 971 (64.35%) were non-acidic. There was one patient without acid reflux episodes during examination and only 12 non-acidic episodes. The proximal extend, defined as 15 cm above the LES, achieved 616 reflux episodes (40.82%). None of the patients had abnormal physical clearing times; 5 had extended chemical clearing times (13.8%) in recumbent positions.Summary. This paper is not a statistical evaluation of a MII-pH study and is only a report of our first experiences with this new diagnostic method. Objective evaluation of symptom correlation to reflux in MII and the chemical character of the refluxate gives a much more precise qualification to the best type of treatment. In cases of non-acidic reflux, MII-pH testing hastens decision making about surgery.

2

What’s new about symptomatic reflux disease

100%

Solecki M., Wallner G., Masiak W., Ćwik G.

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issue 1

17-19

EN

During the last 4 decades reflux disease (GERD) has evolved from being a rare clinical problem to a disease with high incidence. This automatically rises its social costs. First descriptions came from western countries only but nowadays there are many published papers from Asia and Middle East that can be found on the Internet. There is no clear explanation for this fact. Our understanding of GERD has changed over the time. At first GERD, hiatal hernia and oesophagitis were synonyms. Since the 1940s when the first manometrical studies were done it was concerned as lower oesophageal sphincter or peristaltic disfunction. The following years gave a definition of acid-peptic disorder. Nowadays all this concepts are mixed together and we are considering GERD as a heterogeneous clinical problem. In this paper we would like to present up-to-date knowledge about GERD.

3

The Usefulness of the Original Questionnaire in the Evaluation of Quality of life in Patients with Gastroesophageal Reflux Disease

100%

Huk J., Wiktor W., Pedowski T., Masiak W., Wallner G.

Polish Journal of Surgery

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2011

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vol. 83

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issue 7

377-385

EN

Gastroesophageal reflux disease (GERD) constitutes a significant health problem in societies of high socioeconomic status. The notion of quality of life is broader than the definition of health and encompasses two aspects: the subjective and objective one. The tools used for the evaluation of quality of life are questionnaires.The aim of the study was the evaluation of the original quality of life questionnaire in patients with gastroesophageal reflux disease treated for 4 weeks with a single dose of omeprazole at 20 mg daily.Material and methods. The original quality of life questionnaire was formulated based on the Likert method. Four time levels of complaint persistence were introduced. The patients were asked 10 questions with earlier prepared answers marked by the respondents. Each of the questions corresponded to a certain time level of complaint persistence. The data obtained from the questionnaires were subject to statistical analysis. The studies were conducted on a group of 10,623 patients. Adequate methods were used in the statistical analysis of data from obtained answers. The significance threshold for each of the studies was p < 0.01, which means that the obtained conclusions are true with the probability of at least 99%. The majority of statistical calculations were performed with the use of STATISTICA 7.0 and Excel software.Results. Improvement of quality of life was found in all the studied aspects: physical (questions 1, 3, 4, 5, 7), functional (question 6), emotional (questions 2, 10) and social (questions 8, 9). No correlation with age or gender was found. The analysis of test correctness was conducted, revealing reliability, validity, sensitivity, appropriateness and practicality of the questionnaire.Conclusions. 1. The original quality of life questionnaire meets the requirements for the tools evaluating quality of life in gastroesophageal reflux disease. 2. The usefulness of questionnaire was confirmed in a group of 10,623 patients with gastroesophageal reflux disease in the Polish population. 3. The questionnaire equals the international tests, while its advantages are the ease of completion and high level of perception.

4

Protection and regeneration of esophageal, pharyngeal, and laryngeal mucosa as a major element in therapy of patients with esophageal and extraesophageal reflux symptoms

100%

Gąsiorowska A.

Polish Journal of Otolaryngology

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2020

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vol. 74

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issue 4

40-45

EN

Treatment of esophageal and extraesophageal reflux syndromes is mainly focused on inhibiting the secretion of hydrochloric acid. In spite of the high efficacy of proton pump inhibitors, approx. 30–60% of GERD patients experience daily symptoms. Beside acid reflux, other factors such as abnormal esophageal peristalsis, visceral hypersensitivity, ineffective esophageal clearance mechanisms, and impaired mucosal barrier also play an important role in generating GERD symptoms. An additional therapeutic proposition is a procedure aimed at improving the defense mechanisms of esophageal mucosa rather than inhibiting the damage-inducing factors. The preparation consisting of hyaluronic acid (HA), chondroitin sulfate (SC) and poloxamer 407 protects against harmful factors (hydrochloric acid, pepsin) and accelerates mucosal healing and regeneration, constituting a substantial element of monotherapy or add-on therapy in patients with gastroesophageal reflux disease.

5

Protection and regeneration of esophageal, pharyngeal, and laryngeal mucosa as a major element in therapy of patients with esophageal and extraesophageal reflux symptoms

100%

Gąsiorowska A.

|

EN

Treatment of esophageal and extraesophageal reflux syndromes is mainly focused on inhibiting the secretion of hydrochloric acid. In spite of the high efficacy of proton pump inhibitors, approx. 30–60% of GERD patients experience daily symptoms. Beside acid reflux, other factors such as abnormal esophageal peristalsis, visceral hypersensitivity, ineffective esophageal clearance mechanisms, and impaired mucosal barrier also play an important role in generating GERD symptoms. An additional therapeutic proposition is a procedure aimed at improving the defense mechanisms of esophageal mucosa rather than inhibiting the damage-inducing factors. The preparation consisting of hyaluronic acid (HA), chondroitin sulfate (SC) and poloxamer 407 protects against harmful factors (hydrochloric acid, pepsin) and accelerates mucosal healing and regeneration, constituting a substantial element of monotherapy or add-on therapy in patients with gastroesophageal reflux disease.

6

Itopride in treatment of laryngopharyngeal symptoms of gastroesophageal reflux disease

100%

Janiak M.

Polish Journal of Otolaryngology

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2021

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vol. 75

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issue 6

38-44

EN

In everyday otolaryngological and gastroenterological practice, the diagnosis and treatment of extraesophageal forms of gastroesophageal reflux disease are often challenging. It is sometimes the case that treatment ordered by other specialists proves ineffective or even worsens the symptoms. There is no golden standard of diagnosis for otolaryngological forms of GERD, and currently used tools (gastroscopy, laryngoscopy, impedance and pH testing) have low sensitivity and specificity. After finishing a course of successful treatment, the patients often come back to our offices with the very same symptoms. In order to improve the efficacy of treatment, a prokinetic agent can be added to the standard proton pump inhibitor therapy.

7

The importance of obesity and carbohydrate metabolism disorders on the course of gastroesophageal reflux disease – a pilot study

100%

Pardak P., Filip R., Krzaczek M.

European Journal of Translational and Clinical Medicine

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2022

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vol. 5

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issue 1

17-26

EN

BackgroundCarbohydrate metabolism disorders, obesity and a severe course of gastroesophageal reflux correlate with more frequent development of esophageal complications. The aim of this study was to assess the influence of obesity and carbohydrate disorders on the characteristics of gastroesophageal reflux disease (GERD).Material and methodsThe study included 58 patients with excess weight. Anthropometric parameters (including the body mass index, BMI), data regarding GERD (severity of symptoms, gastroscopy and esophageal pH monitoring results) were included in the study. Correlations between obesity and GERD parameters were analyzed. Subjects were divided into a diabetic and a control group and the severity of GERD was compared.ResultsGERD was diagnosed in 40 patients and occurred more frequently in the obese group (73%) than in the overweight group (57%). Increased GERD severity was associated with increased BMI only for postprandial parameters. GERD was diagnosed in most of the group with carbohydrate disorders (78% vs 63% in the non-diabetic group). No differences in the severity of GERD were observed between groups depending on carbohydrate disorders.ConclusionsIn our study, GERD was common in obesity and in diabetic disorders. Increased severity of postprandial reflux was associated with an increased BMI. Diabetic disorders were not associated with more severe GERD.

8

Antireflux surgery is required after endoscopic treatment for Barrett’s esophagus

88%

Tyselskyi V., Poylin V., Tkachuk O., Kebkalo A.

Polish Journal of Surgery

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2021

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vol. 93

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issue 5

1-5

EN

Introduction: Barrett’s esophagus is an acquired condition that develops as a result of transformation of normal stratified squamous epithelium in the lower part of the esophagus into columnar epithelium. Barrett’s esophagus is considered to be a complication of gastroesophageal reflux disease (GERD). Various endoscopic techniques have been shown to be successful in the treatment of this condition. However, long-term success in preventing further esophageal dysplasia is not clear. Biological welding consists in the application of controlled high-frequency current on living tissues and has been used to stop gastrointestinal bleeding, similarly to the APC technique which involves ablation of small intestinal metaplasia of the esophageal mucosa. Aim: The goal of this study was to evaluate the effectiveness of endoscopic techniques in the treatment of Barrett’s esophagus and verify the need for a subsequent surgical intervention in patients with GERD complicated by Barrett’s esophagus. Material and methods: Patients with Barrett’s esophagus C1-3M2-4 (Prague classification from 2004) and high dysplasia without nodules, as well as patients with confirmed GERD without hiatal hernia, were included in this study. Endoscopic treatment was performed with the use of argonoplasmic coagulation (APC) and high-frequency welding of living tissues (HFW). After the examination the patients were re-examined. Patients with recurrence of metaplasia and high DeMeester score (˃ 100) underwent antireflux surgery – crurography and Nissen fundoplication with creation of a soft and short cuff.Results: A total of 89 patients were included in the study, 81 of whom were reexamined after ablation of Barrett’s esophagus.In 12 patients, a recurrence of intestinal metaplasia resembling the small intestine was identified. Implementation of two-stage treatment was required for 9 patients – it involved a second procedure of ablation of the esophagus, followed by antireflux surgery. Surgical treatment was refused by 3 patients, who underwent only the second ablation procedure. All patients received drug therapy, consisting of prokinetics and proton pump inhibitors. Esophageal pH monitoring was repeated 3 months after surgery, showing normalization of the DeMeester score. As a result, the patients experienced no complaints such as heartburn, chest pain or dysphagia, which significantly improved their quality of life. Esophagogastroduodenoscopy and biopsy of the mucous membrane of the lower third of the esophagus were performed in accordance with the Seattle Protocol. After examining histological specimens, no regions of metaplasia were identified. Conclusion: Antireflux surgery is required as a part of the treatment for Barrett’s esophagus, which prevents further dysplasia and development of esophageal cancer.

9

Laryngological symptoms of gastroesophageal reflux disease

88%

Mierzwa G., Sinkiewicz A.

Polski Przegląd Otorynolaryngologiczny

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2017

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vol. 6(2)

70-75

EN

The artical presents a case of a 32 years old men with extraoesophagal symptoms of gastroesohagal reflux disease and laryngopharyngeal reflux. He was by ph-impedance monitoring, stroboskopy and gastrointestinal endoscopy with biopsy diagnosed. PPI therapy with dexlansoprasole was most efficient.

10

Extraesophageal manifestations of gastroesophageal reflux disease – pathophysiology, diagnosis and management

75%

Dobrzyński P., Ziuzia L.

Polski Przegląd Otorynolaryngologiczny

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2016

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vol. 5(2)

26-45

EN

Gastroesophageal reflux disease (GERD) is defined as a condition in which the reflux of stomach contents causes troublesome symptoms and/or complications. This common disease may also present with atypical, extraesophageal symptoms. Laryngopharyngeal reflux (LPR) is the reflux of gastric contents into the throat and larynx, which causes symptoms such as globus, throat clearing, hoarseness and chronic cough. GERD and LPR may be related to many dis-eases, including laryngitis, asthma, COPD, chronic rhinosinusitis, otitis media, dental erosions, and even laryngeal cancer or life-threatening events. The diagnosis of LPR is based on clinical symptoms (measured by RSI), laryngoscop-ic signs (evaluated in RFS), an empiric trial of proton pomp inhibitor (PPI) therapy, 24-hour pH monitoring, impedance monitoring, esophageal manometry and endoscopic examination. The most common management is double-dose PPI therapy for at least six months. When this treatment is ineffective, the surgery should be considered. However, di-agnosis and treatment of LPR is still controversial. Further studies are necessary to establish an optimal algorithm for the management of LPR.

11

Zastosowanie nowych parametrów w ocenie 24-godzinnej pH-metrii z impedancją

63%

Korszun K., Dyrla P., Gil J.

Pediatria i Medycyna Rodzinna

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2016

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vol. 12

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issue 3

256-263

EN

24-hour oesophageal multichannel impedance and pH monitoring is the gold standard in the diagnostic process of gastroesophageal reflux disease. Together with oesophagogastroduodenoscopy, it enables to distinguish different kinds of this disease and implement appropriate treatment. Recently, thanks to impedance, it was attempted to evaluate new parameters that could be helpful in diagnosis of gastroesophageal reflux disease and its differentiation from functional heartburn. One of these parameters is baseline impedance. It is measured when no swallows and refluxes occur in the oesophagus, i.e. when the oesophageal wall stays still. Postreflux swallow-induced peristaltic wave (PSPW) index is another parameter measured in 24-hour oesophageal multichannel intraluminal impedance and pH-monitoring. It is a quotient of the number of reflux episodes with postreflux swallow-induced peristaltic wave and the total number of reflux episodes. It was proven that baseline impedance and postreflux swallow-induced peristaltic wave index are correlated with oesophageal mucosa integrity. Values of these parameters differ in healthy volunteers, patients with functional heartburn as well as with erosive and nonerosive gastroesophageal reflux disease. They may be useful in the diagnosis, but also in making decisions about pharmacological or surgical treatment. These parameters are not evaluated during 24-hour oesophageal multichannel impedance and pH-monitoring on a routine basis. Since the available studies have been carried out on small groups of patients, there is a need for further investigation to assess the diagnostic value of baseline impedance and PSPW.

PL

Złotym standardem rozpoznawania choroby refluksowej przełyku jest 24-godzinna pH-metria przełyku z impedancją. Wraz z ezofagogastroduodenoskopią umożliwia ona różnicowanie postaci tego schorzenia oraz zastosowanie odpowiedniego leczenia. W ostatnim czasie dzięki wykorzystaniu 24-godzinnej pH-metrii z impedancją próbowano oceniać nowe parametry, które mogą być pomocne w diagnostyce choroby refluksowej przełyku i różnicowaniu jej ze zgagą czynnościową. Jednym z nich jest wartość podstawowej impedancji. Mierzona jest w czasie, gdy nie występują w przełyku przełknięcia ani epizody refluksowe – czyli gdy ściana przełyku pozostaje w spoczynku. Kolejnym parametrem jest wskaźnik PSPW (postreflux swallow-induced peristaltic wave index – porefluksowa fala perystaltyczna indukowana przełknięciem), będący ilorazem liczby epizodów refluksowych z następową falą perystaltyczną indukowaną przełknięciem przez liczbę wszystkich incydentów refluksowych. Wykazano korelację podstawowej impedancji i wskaźnika PSPW z integralnością błony śluzowej przełyku. Wartości tych parametrów różnią się u osób zdrowych, u pacjentów ze zgagą czynnościową oraz z nadżerkową i nienadżerkową postacią choroby refluksowej przełyku. Parametry te mogą być zatem pomocne w diagnostyce, jak również w podejmowaniu decyzji o wyborze sposobu leczenia farmakologicznego lub zastosowaniu leczenia operacyjnego. Nie są one rutynowo oceniane podczas analizy 24-godzinnej pH-metrii przełyku z impedancją. Dostępne badania były wykonywane na niewielkich grupach pacjentów, dlatego potrzebne są dalsze prace oceniające wartość diagnostyczną podstawowej impedancji i wskaźnika PSPW.

12

Manifestacje okulistyczne w zespole Sjögrena – czy nieszczęścia chodzą parami? Opis przypadku

51%

Hitnarowicz A. M., Janocha A., Wielgos Z., Sarnat-Kucharczyk M., Pojda-Wilczek D.

Annales Academiae Medicae Silesiensis

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2023

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issue 77

108-114

EN

Sjögren’s syndrome (SS) is a chronic, systemic, autoimmune inflammatory disease. It is characterized by inflammatory lymphocytic infiltration of exocrine glands, leading to their significant dysfunction and destruction. Lacrimal and salivary glands are commonly affected, causing dryness of the eyes and mouth. The subject of the study is a case report of a 64-year-old woman who had been suffering from discomfort in her right eye for 6 years. Early stage cataract in both eyes, corneal ulceration of the right eye, and a right lower eyelid entropion requiring surgical intervention, were diagnosed at that time. Despite successful treatment, the eyelashes began to grow improperly again and irritated the cornea. Subsequently, the problem of trichiasis also affected the eyelid of the left eye. The eyelashes of both eyes were removed mechanically many times. Sjögren’s syndrome was diagnosed on the basis of the symptoms, a positive Schirmer test and the presence of SS-A antibodies. In the following years, the patient developed keratopathy with corneal epithelial defects, advanced stage cataract, and upper eyelid entropion with associated trichiasis in both eyes. These conditions required both intensive pharmacological and surgical treatment, including an amniotic membrane transplant onto the surface of the right eye, blepharoplasty, lacrimal puncta closure and cataract surgery. Despite the treatment, the patient currently has numerous conjunctival adhesions and vascularized corneal leucoma of the right eye. In addition to the ocular symptoms, the patient has presented other systemic signs.

PL

Zespół Sjögrena (Sjögren’s syndrome – SS) jest przewlekłą, autoimmunologiczną chorobą układową o charakterze zapalnym. Występują w nim limfocytarne nacieki zapalne w gruczołach wydzielania zewnętrznego, co prowadzi do ich znacznej dysfunkcji i zniszczenia. Stan chorobowy najczęściej obejmuje gruczoły łzowe i ślinianki, co powoduje suchość oczu i suchość w jamie ustnej. W pracy opisano przypadek 64-letniej kobiety, która od 6 lat odczuwała dyskomfort w prawym oku. Okulista rozpoznał zaćmę początkową obu oczu, owrzodzenie rogówki oka prawego i podwinięcie powieki dolnej prawej wymagające interwencji chirurgicznej. Pomimo udanego zabiegu rzęsy zaczęły nieprawidłowo odrastać i podrażniać rogówkę. W krótkim czasie problem nieprawidłowo rosnących rzęs objął również powieki lewego oka. Rzęsy powiek obu oczu wielokrotnie usuwano mechanicznie. Na podstawie objawów, dodatniego wyniku testu Schirmera oraz obecności przeciwciał SS-A rozpoznano SS. W kolejnych latach w obu oczach pacjentki rozwinęły się keratopatia wraz z ubytkami na-błonka rogówki, zaawansowana zaćma, podwinięcie górnych powiek oraz związany z tym nieprawidłowy wzrost rzęs. Stany te wymagały intensywnego leczenia farmakologicznego oraz chirurgicznego, w tym naszycia błony owodniowej na powierzchnię oka prawego, plastyki powiek, zamknięcia punktów łzowych i operacji zaćmy. Pomimo leczenia u pacjentki występują obecnie liczne zrosty spojówkowe oraz unaczynione bielmo rogówki prawego oka. Oprócz objawów ocznych pacjentka wykazuje objawy ze strony innych narządów.

13

Manifestacje okulistyczne w zespole Sjögrena – czy nieszczęścia chodzą parami? Opis przypadku

51%

Hitnarowicz A. M., Janocha A., Wielgos Z., Sarnat-Kucharczyk M., Pojda-Wilczek D.

Annales Academiae Medicae Silesiensis

|

2023

|

issue 77

EN

Sjögren’s syndrome (SS) is a chronic, systemic, autoimmune inflammatory disease. It is characterized by inflammatory lymphocytic infiltration of exocrine glands, leading to their significant dysfunction and destruction. Lacrimal and salivary glands are commonly affected, causing dryness of the eyes and mouth. The subject of the study is a case report of a 64-year-old woman who had been suffering from discomfort in her right eye for 6 years. Early stage cataract in both eyes, corneal ulceration of the right eye, and a right lower eyelid entropion requiring surgical intervention, were diagnosed at that time. Despite successful treatment, the eyelashes began to grow improperly again and irritated the cornea. Subsequently, the problem of trichiasis also affected the eyelid of the left eye. The eyelashes of both eyes were removed mechanically many times. Sjögren’s syndrome was diagnosed on the basis of the symptoms, a positive Schirmer test and the presence of SS-A antibodies. In the following years, the patient developed keratopathy with corneal epithelial defects, advanced stage cataract, and upper eyelid entropion with associated trichiasis in both eyes. These conditions required both intensive pharmacological and surgical treatment, including an amniotic membrane transplant onto the surface of the right eye, blepharoplasty, lacrimal puncta closure and cataract surgery. Despite the treatment, the patient currently has numerous conjunctival adhesions and vascularized corneal leucoma of the right eye. In addition to the ocular symptoms, the patient has presented other systemic signs.

PL

Zespół Sjögrena (Sjögren’s syndrome – SS) jest przewlekłą, autoimmunologiczną chorobą układową o charakterze zapalnym. Występują w nim limfocytarne nacieki zapalne w gruczołach wydzielania zewnętrznego, co prowadzi do ich znacznej dysfunkcji i zniszczenia. Stan chorobowy najczęściej obejmuje gruczoły łzowe i ślinianki, co powoduje suchość oczu i suchość w jamie ustnej. W pracy opisano przypadek 64-letniej kobiety, która od 6 lat odczuwała dyskomfort w prawym oku. Okulista rozpoznał zaćmę początkową obu oczu, owrzodzenie rogówki oka prawego i podwinięcie powieki dolnej prawej wymagające interwencji chirurgicznej. Pomimo udanego zabiegu rzęsy zaczęły nieprawidłowo odrastać i podrażniać rogówkę. W krótkim czasie problem nieprawidłowo rosnących rzęs objął również powieki lewego oka. Rzęsy powiek obu oczu wielokrotnie usuwano mechanicznie. Na podstawie objawów, dodatniego wyniku testu Schirmera oraz obecności przeciwciał SS-A rozpoznano SS. W kolejnych latach w obu oczach pacjentki rozwinęły się keratopatia wraz z ubytkami na-błonka rogówki, zaawansowana zaćma, podwinięcie górnych powiek oraz związany z tym nieprawidłowy wzrost rzęs. Stany te wymagały intensywnego leczenia farmakologicznego oraz chirurgicznego, w tym naszycia błony owodniowej na powierzchnię oka prawego, plastyki powiek, zamknięcia punktów łzowych i operacji zaćmy. Pomimo leczenia u pacjentki występują obecnie liczne zrosty spojówkowe oraz unaczynione bielmo rogówki prawego oka. Oprócz objawów ocznych pacjentka wykazuje objawy ze strony innych narządów.

Refine search results

Multichannel Intraluminal Impedance and pH Testing - A New Diagnostic Technique for Gastroesophageal Reflux Disease. Own Experience

What’s new about symptomatic reflux disease

The Usefulness of the Original Questionnaire in the Evaluation of Quality of life in Patients with Gastroesophageal Reflux Disease

Protection and regeneration of esophageal, pharyngeal, and laryngeal mucosa as a major element in therapy of patients with esophageal and extraesophageal reflux symptoms

Protection and regeneration of esophageal, pharyngeal, and laryngeal mucosa as a major element in therapy of patients with esophageal and extraesophageal reflux symptoms

Itopride in treatment of laryngopharyngeal symptoms of gastroesophageal reflux disease

The importance of obesity and carbohydrate metabolism disorders on the course of gastroesophageal reflux disease – a pilot study

Antireflux surgery is required after endoscopic treatment for Barrett’s esophagus

Laryngological symptoms of gastroesophageal reflux disease

Extraesophageal manifestations of gastroesophageal reflux disease – pathophysiology, diagnosis and management

Zastosowanie nowych parametrów w ocenie 24-godzinnej pH-metrii z impedancją

Manifestacje okulistyczne w zespole Sjögrena – czy nieszczęścia chodzą parami? Opis przypadku

Manifestacje okulistyczne w zespole Sjögrena – czy nieszczęścia chodzą parami? Opis przypadku