Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Faecal immunoreactive lipase: a simple diagnostic test for cystic fibrosis.

UNLABELLED: The study evaluates faecal immunoreactive lipase (IRL) measurement in spot stool samples as an index of exocrine pancreatic function in patients with cystic fibrosis (CF). Stool samples (211) from 183 healthy volunteers (age range: 2 days-14.2 years) showed a normal log distribution of IRL values with a median concentration of 71.4 micrograms/g (range: 0.53-4160 micrograms/g). In 156 stool samples from 58 patients with proven CF, the median IRL concentration of 0.4 microgram/g (range: 0.003-107 micrograms/g) was significantly lower (P < 0.001) than that of normal controls. In healthy controls, IRL levels were age related with significantly higher levels (P < 0.001) shortly after birth compared to older children. Stimulation of the exocrine pancreas by oral milk feeding resulted in a significant (P < 0.001) increase in a faecal IRL concentration. Faecal IRL concentrations in meconium were very low and of the same magnitude as in patients with CF. CONCLUSION: Faecal IRL determination had a high diagnostic sensitivity (87%) and excellent diagnostic specificity (97%) in patients with CF. A negative test result (PVneg. 99%) virtually excluded CF under screening conditions.

Familial progressive tubulo-interstitial nephropathy and cholestatic liver disease -- a newly recognized entity?

UNLABELLED: We describe two siblings (female and male) with progressive tubulo-interstitial nephropathy and cholestatic liver disease. The main characteristics were progressive renal failure and elevated liver enzymes (AST, ALT and gamma-GT). Dialysis was started at the age of 1.9 and 6.5 years, respectively. Renal histology disclosed sclerosed glomeruli and atrophic tubules; the interstitium was fibrotic and infiltrated by lymphocytes. Endoscopic retrograde cholangiopancreatography revealed segmental irregularities and narrowing of the intrahepatic bile ducts, consistent with early primary sclerosing cholangitis. Liver histology showed enlarged portal triads, mild proliferation and inflammation of bile ducts, and fibrosis. At 5.9 years the girl underwent a successful renal transplantation whereas the boy is still on dialysis. CONCLUSION: The association of progressive tubulointerstitial nephropathy and cholestatic liver disease, consistent with early primary sclerosing cholangitis, constitutes a distinct autosomal recessive entity.

[Experiences with a computer-assisted concept for patient education in gastroenterologic endoscopy]. / Erfahrungen mit einem computergestützten Konzept zur Patienteninformation in der gastroenterologischen Endoskopie.

The purpose of this study was the assessment of the effect of audio-visual information, based on computer technology, on the reduction of anxiety in patients referred for gastrointestinal endoscopies. 72 of 100 consecutive patients (38 females, 34 males; median age 49 years [13-80 years]) were willing to study the available computer program for pre-diagnostic information. They were questioned regarding their anxiety about the forthcoming examination, and the acceptance and handling of the computer system. Anxiety levels were measured by a Visual Analogue Scale directly before endoscopy and after the examination. Nearly two thirds of the patients (60%) stated, that their anxiety level was reduced by watching the computer program. 96% of the patients felt comfortable with this type of information. Thus, the pre-procedure information demonstrated by the computer (backgrounds, instruments and procedural technics) relieves in a surprisingly large percentage of patients fears and worries about endoscopic procedures.

Long-term follow-up after treatment of common bile duct stones by extracorporeal shock-wave lithotripsy.

BACKGROUND AND STUDY AIMS: The efficacy of extracorporeal shock-wave lithotripsy (ESWL) of difficult bile duct stones that were not amenable to routine endoscopic extraction was assessed, with evaluation of the long-term follow-up after successful treatment. PATIENTS AND METHODS: Fifty-four patients (mean age 74 years, range 33-92) were treated with ESWL for difficult bile duct stones. Treatment was performed either with the Dornier HM3 kidney lithotriptor (49 patients) or with the MPL 9000 lithotriptor (five patients). RESULTS: Stone disintegration was achieved in 50 patients (93%), with complete stone clearance in 45 patients (83%) (mean 1.2 session). Patients with successful stone removal after one session had significantly smaller stones than patients with treatment failure (20 +/- 9 versus 27 +/- 8 mm; p < 0.05). An intrahepatic location of stones was significantly associated with treatment failure (p < 0.005). Serve complications occurred in 7% (procedure-related 5%), with a 30-day mortality rate of 0% (in-hospital mortality rate of 2%). Minor side effects such as fever, petechiae, and mild arrhythmias were frequent (37%), and microhematuria (95%) occurred in nearly all of the patients. Symptomatic recurrent bile duct stones were observed in two patients (5%) after three and four years, respectively (mean follow-up 5.3 years). CONCLUSION: Extracorporeal shock wave lithotripsy represents a safe and effective treatment modality for difficult bile duct stones, with a low rate of symptomatic recurrences.

[Endoscopic therapy of gallstones. Indications for ERCP]. / Endoskopische Therapie der Gallensteine. Indikationen für die ERCP.

Bile duct stones are associated with a high rate of severe complications such as bile duct obstruction, cholangitis and biliary pancreatitis; therefore, stones of the common bile duct should always be removed. Today the endoscopic sphincterotomy and stone removal are the therapy of choice. When the gallbladder is still present, the duct stones should be removed endoscopically before laparoscopic cholecystectomy. For difficult bile duct stones, various procedures like mechanical lithotripsy, intracorporeal shock wave lithotripsy (ISWL), intracorporeal laser lithotripsy (ILL) and extracorporeal shock wave lithotripsy (ESWL) have been shown to increase the success rate of duct clearance to up to 95 to 100%. Before laparoscopic cholecystectomy, an ERCP should be performed, if there is a history or repeated biliary colic pain, cholangitis or biliary pancreatitis, if on ultrasound the diameter of the common bile duct is greater than 6mm, or if there are signs of cholestasis in the laboratory. In acute cholangitis, urgent endoscopic sphincterotomy has been shown to decrease the morbidity and mortality rate compared to surgical interventions. In acute biliary pancreatitis, early sphincterotomy also decreases the rate of morbidity significantly.

Chlorpromazine-induced vanishing bile duct syndrome leading to biliary cirrhosis.

We describe a 33-yr-old pregnant woman in whom a primary biliary cirrhosis-like syndrome developed after 2 wk of chlorpromazine therapy. The clinical course was characterized by severe jaundice lasting 22 mo, intense pruritus, fever, steatorrhea, high alkaline phosphatase levels and hypercholesterolemia. Jaundice resolved with initiation of ursodeoxycholic acid therapy, but subclinical cholestasis and low-level inflammatory activity persisted and ultimately evolved into biliary cirrhosis. The pathological substrate of this severe and prolonged cholestatic reaction was found to be the vanishing bile duct syndrome with a marked transient pseudoxanthomatosis.

[Results and risks of needle papillotomy]. / Ergebnisse und Risiken der Nadel-Papillotomie.

Needle knife papillotomy is an effective endoscopic procedure by which endoscopic sphincterotomy can be performed when conventional techniques have failed. We performed 35 (25%) pre-cut papillotomies, out of 142 therapeutic sphincterotomies, to enhance the cannulation of the bile duct in order to complete endoscopic sphincterotomy using standard techniques. In 30/35 patients pre-cut alone was sufficient to cannulate the duct, while in 4 of the remaining 5 patients a further ERCP after 2-8 days after the initial pre-cut was necessary to complete sphincterotomy. Only 4 episodes of bleeding were observed. One patient required transfusion of two units of blood. In our opinion needle knife papillotomy is a safe procedure for increasing the cannulation rate of the bile duct, and thus allow endoscopic sphincterotomy to be performed when conventional technique fails.

[Eosinophilia in primary biliary cirrhosis: regression under therapy with ursodeoxycholic acid]. / Eosinophilie bei primär biliärer Zirrhose: Regredienz unter Therapie mit Ursodesoxycholsäure.

Eosinophilia can be observed in up to 40% of patients with primary biliary cirrhosis (PBC). Eosinophilia is transient, tends to occur in the early stages of the disease and seems to be associated with episodes of florid bile duct destruction [42-45]. 14 Patients with PBC were examined before and during treatment with ursodeoxycholic acid (UDCA) (10 mg/kg/d) for episodes of eosinophilia and the number of eosinophilic granulocytes in differential white blood cell counts. Group A consisted of 5 patients with one or several episodes of eosinophilia before the start of UDCA. Group B included 9 patients without known episodes of eosinophilia. Observation time before and after start of treatment for group A was 3-96 (mean 25) months and 6-24 (mean 14) months, and for group B 3-108 (mean 34) months and 6-27 (mean 19) months respectively. During treatment with UDCA the mean counts of eosinophilic granulocytes decreased in both groups from 309 +/- 47/mm3 to 135 +/- 14/mm3 (p < 0.001). In group A there was a decrease from 529 +/- 89/mm3 to 157 +/- 17/mm3 (p < 0.001) and in group B from 151 +/- 15/mm3 to 128 +/- 15/mm3 B (n.s.). In group A 9/18 differential white blood cell counts showed eosinophilia before UDCA medication (3 x relative [> or = 6%], 6 x absolute [> or = 500/mm3]) and 0/24 after the onset of UDCA (p < 0.001). In group B 0/25 differential white blood cell counts showed eosinophilia before UDCA and 2/72 after start of the therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Duodenal ulcer disease: a defect in the secretory immune response to Helicobacter pylori?]. / Ulcus-duodeni-Erkrankung: ein Defekt in der sekretorischen Immunantwort auf Helicobacter pylori?

In a prospective study we examined 20 Helicobacter pylori (HP)-positive duodenal ulcer patients (5 female, 15 male; age 26-70 [mean 43] years), 20 HP-positive patients with non-ulcer dyspepsia (10 female, 10 male; age 26-79 [mean 48] years) and 10 HP-negative patients with non-ulcer dyspepsia (5 female, 5 male; age 21-76 [mean 45] years) during upper GI-endoscopy. HP was detected by histology (H&E, Giemsa), rapid urease test (CLO) and serology (Cobas Core Anti-H. pylori EIA). IgA anti-HP in gastric juice was determined by ELISA. HP-positivity included positivity in all methods, and HP-negativity failure to detect HP-infection by all methods used. Of the 20 duodenal ulcer patients, 10 patients (2 female, 8 male; age 26-70 [mean 42] years) had an endoscopically documented duodenal ulcer at an earlier endoscopy with no current ulcer, 10 patients had florid duodenal ulcer disease at the time of examination. Duodenal ulcer patients compared with non-ulcer dyspepsia patients were tended to have higher serum IgG anti-HP (551 +/- 240 vs. 338 +/- 159 U/ml) and significantly higher gastric juice IgA anti-HP (50.0 +/- 7.3 vs. 26.5 +/- 4.3 relative units). Concentrations of both serum IgG anti-HP and gastric juice IgA anti-HP tended to be higher in patients with positive ulcer history but no present ulcer compared with patients with florid ulcer disease (934 +/- 456 vs. 170 +/- 63 U/ml and 60.0 +/- 8.6 vs. 40.8 +/- 10.4 relative units).(ABSTRACT TRUNCATED AT 250 WORDS)

[Suppression of Helicobacter pylori by local secretory immune response?]. / Suppression von Helicobacter pylori durch die lokale sekretorische Immunantwort?

54 patients (22 females, 32 males, age 21-79, mean 45 years) referred for upper gastrointestinal endoscopy were investigated. Helicobacter pylori (HP) infection was determined using histology (H&E and Giemsa stain), rapid urease test (CLO) and serology (Cobas Core Anti-H. pylori EIA). Density of HP colonization was determined in gastric antral (3 biopsy specimens) and body mucosa (2 biopsy specimens) and semiquantitatively graded on a scale of 0 to 3. Gastric colonization was obtained by addition of the two scores. IgA anti-HP concentration was determined by ELISA using the same FPLC purified HP-antigen mixture as for serology. Gastric juice IgA anti-HP concentration in HP-positive patients (n = 40) was significantly higher than in HP-negative (n = 14) patients (38.3 +/- 4.6 vs. 5.4 +/- 1.2 relative units, p < 0.001). Comparison of HP-colonization density of gastric mucosa with gastric juice IgA anti-HP concentration of the 54 patients by binominal regression analysis yielded a correlation coefficient of 0.65 (p < 0.01). The biphasic course of the curve suggests a mutual relationship of HP-colonization density and IgA immune response. Increasing colonization densities seemed to induce increasing secretory immune responses. Half-maximal and higher immune responses, however, seemed to suppress further HP colonization in vivo without eradicating the infection.

[Transient eosinophilia in primary biliary cirrhosis]. / Flchtige Eosinophilie bei primär biliärer Zirrhose.

We reviewed 144 differential white blood cell counts from 23 patients with primary biliary cirrhosis (PBC, 21 females, 2 males) for occurrence of eosinophilia. Over an average observation time of 43 +/- 9 months, 9/23 (39%, 9 female) patients were found to have transient absolute (> 500/mm3, n = 5) or relative (> or = 6%, n = 4) blood eosinophilia. The maximum value of eosinophilic granulocytes observed was 1385/mm3 (19%). Other causes of eosinophilia had been ruled out. Eosinophilia was transient, disappearing without treatment. Significantly younger patients with eosinophilia also had a tendency to prognostically more favourable values for serum albumin, prothrombin time, bilirubin and galactose elimination capacity. None had edema, compared to two patients with edema in the group without eosinophilia. Two patients died during the observation period; both were from the group without eosinophilia. The average 5- and 7-year survival probability, calculated on the Mayo survival model, tended to be higher for patients with eosinophilia (92% and 87%) compared to patients without eosinophilia (79% and 72%). In patients with eosinophilia, disease stage I (5/6 vs 1/9) and epitheloid cell granuloma (4/6 vs 1/9) were significantly more frequent. Blood eosinophilia in PBC seems to be an indicator of an early disease state with florid bile duct lesions. Primary biliary cirrhosis should therefore be considered--with other hepatopathies--as a possible cause of eosinophilia of otherwise unknown origin. These observations could be of importance for future therapeutic concepts, at least for patients in early disease states.

[IgA-antibodies against Helicobacter pylori in gastric secretions: gastric secretory immune response or salivary contamination?]. / IgA-Antikörper gegen Helicobacter pylori im Magensekret: gastrische sekretorische Immunantwort oder Speichelverunreinigung?

IgA anti-HP concentrations in both gastric juice and saliva samples of 40 HP+ patients (15 f, 25 m) randomly referred for upper GI-endoscopy were measured. The presence of HP was investigated using histology (H&E and Giemsa stain), rapid urease test (CLO) and serology (Cobas Core Anti-H. pylori EIA, F. Hoffmann-La Roche). IgA anti-HP in gastric juice and saliva was determined by ELISA; the same HP antigen was used as for serology (FPLC-purified native cell surface antigens including urease, free of cross-reacting flagellar proteins). The 40 HP+ patients were positive for HP by all three methods (except 4x CLO false neg, 1x serology false neg). A control group consisted of 12 patients (6 f, 6 m) with no HP detectable by each of the three methods used. No correlation was discernible between IgA anti-HP concentration in saliva and gastric juice of HP-positive patients (R = 0.05). In contrast, the correlation coefficient in HP-negative patients was R = 0.69 (p < 0.02). Great interindividual differences in specific IgA concentrations of both secretions were found. Surprisingly, in saliva and gastric juice IgA anti-HP was also detectable in some subjects negative for HP by all three tests applied. This finding remains to be elucidated but could represent ongoing local immune response in the absence of HP gastritis. In conclusion, saliva was found to contain IgA binding to HP-antigen. In HP-negative subjects contamination of gastric juice by saliva seems to be responsible when small concentrations of IgA anti-HP antibodies were detectable in gastric juice.(ABSTRACT TRUNCATED AT 250 WORDS)

[How does oligo- en asymptomatic non-tropical sprue present itself?]. / Wie manifestiert sich die oligo- und asymptomatische nichttropische Sprue?

According to the computerized ICD registration, 20 new cases of non-tropical sprue were detected in our outpatient clinic between 1979 and 1990. 8 of these patients had an oligo- or asymptomatic form of this disease (40%). The clinical presentation and spectrum of abnormal laboratory findings in these 8 cases are described in detail. It is concluded that laboratory parameters indicating malabsorption, especially hematologic changes, are helpful for the detection of the oligo- and asymptomatic form of non-tropical sprue, and that, in cases with undetermined anemia, this form of sprue must be considered in etiologic differential diagnosis. Finally, it seems advisable to perform a biopsy as a routine procedure during endoscopy in cases with unclear anemia.

[Colonoscopic endosonography in the diagnosis and follow-up care of colorectal tumors]. / Koloskopische Endosonographie in der Diagnostik und Nachsorge kolorektaler Tumoren.

We studied the usefulness and accuracy of a flexible endoscopic ultrasound system (EUS) in preoperative staging of tumor invasion and involvement of lymph nodes of rectal tumors. Comparison of preoperative EUS findings with histopathologic TNM classification (UICC 1987) was possible in 12 patients. The depth of tumor invasion was correctly staged in 9/12 patients (75%), and lymph node staging was correctly predicted in 9/12 patients (75%). Our results indicate that flexible coloscopic ultrasonography is as accurate as rigid systems for staging of colorectal cancer. It will become a sensitive method for early diagnosis of local recurrence. The flexible endoscopes are well tolerated by patients and more proximal lesions which cannot be reached with the rigid instruments can also be examined.

[Helicobacter pylori colonization of the gastric remnant following partial resection]. / Helicobacter-pylori-Besiedlung des teilresezierten Magens.

Colonization by Helicobacter pylori (HP) in 53 patients after remote gastric surgery and Roux-en-Y anastomosis was investigated using a rapid urease test (CU-Test) and histology (H&E and Giemsa stain). The pH-value of gastric juice was measured. HP infection of the gastric remnant was found in 56% of 43 patients after partial resection and in no case after total gastric resection. HP-positive and HP-negative patients were comparable in age, sex distribution, indication and technique of gastric operation (except for total gastrectomy with jejunal gastric replacement), intake of acid inhibiting drugs and antibiotics was well as in the presence or absence of a macroscopically visible pathology of the gastric mucosa. On the other hand, the two groups differed in their histological findings, pH-value of gastric juice and time interval since surgery. HP infection of gastric remnants is associated with significant glandular atrophy and an additional rise in gastric intraluminal pH compared with HP-negative patients. Both changes may involve an increased risk for gastric cancer. In this report on patients with Y-en-Roux operation there is no decrease in gastric HP-colonization with an increasing interval since the time of operation, but rather an increase. This phenomenon seems to depend on the absence of enterogastric reflux.

[Endosonography: progress in the diagnosis of endocrine pancreatic tumors]. / Endosonographie: ein Fortschritt in der Diagnostik endokriner Pankreastumoren.

Diagnostic procedures for secreting endocrine pancreatic tumors comprise biochemical tests, CT scans, conventional abdominal sonography, angiography and occasionally MR imaging and isotope scans. Due to their small size, insulinomas and gastrinomas, the most common of these tumors, elude these diagnostic procedures. Preoperative sonography and CT scans were negative in over 60%, angiograms in 35% of the patients. The example of a patient with insulinoma demonstrates that in the future endosonography will offer itself as an accurate method with little risk.

[Diagnostic problems in infectious colitis in the framework of an HIV infection]. / Diagnostische Schwierigkeiten bei der infektiösen Kolitis im Rahmen der HIV-Krankheit.

Between 1988/89 1207 HIV-positive patients were registered at the Medical Policlinic of the University Hospital Zurich. In 57 of these patients colonoscopy or rectosigmoidoscopy was performed because of serious symptoms or symptoms refractory to therapy (diarrhea, bloody diarrhea, massive abdominal pain, weight loss). 24/57 (42%) had a negative colonoscopy and in 6/57 patients (10%) Kaposi's sarcoma was found. 14/57 (25%) had unspecific colitis. In 13/57 (23%) cases with colitis, one or multiple bacterial or viral agents were diagnosed: CMV (n = 5), herpes (n = 2), Mycobacterium avium-intracellulare (n = 3), different bacterial agents (n = 5), HIV (n = 1). One patient had a double and one a triple infection. Another had colitis with HIV as the only isolated pathogenic agent in the colon epithelium.