Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation.

PURPOSE: There is currently no imaging procedure that allows precise differentiation between inflammatory and malignant lesions of the papilla of Vater (papilla) in a satisfying manner. The aim was to study whether endoscopic ultrasonography (EUS) as an initial diagnostic step 1. may have the potential to distinguish between different tissue characteristics, such as tumor growth or inflammation of the papilla, because of its high resolution capacity and 2. is superior to the accuracy of histologic investigations of mucosal biopsies by means of a prospective collection and retrospective evaluation of the data. PATIENTS AND METHODS: Between 1995 and 2002, a significant pathologic finding in the papilla and the peripapillary region was revealed using EUS in 311 patients (overall, 4,832 EUS investigations); the comparison of this suspicion with the results of histologic investigation was only possible in 183 subjects. In 133/183 patients, a biopsy for histologic investigation was not able to be obtained prior to the use of EUS. Diagnosis was set up using EUS, which tried to differentiate between benign or malignant lesions of the papilla. Histologic investigation of the 133 tumor lesions of the papilla became possible by taking deep transpapillary biopsies following papillotomy, papillectomy or by obtaining specimens from surgical resections. RESULTS: Using EUS, differentiation between inflammatory and neoplastic lesions of the papilla or the peripapillary region was correct in 109 of 133 cases (82%), while suspected EUS-based diagnosis "papillitis stenosans" (inflammatory lesions of the papilla of Vater) in 4 subjects (3%) was corrected to adenoma and carcinoma, respectively (n=2 each) by histologic investigation. In 20 of 133 patients with suspected neoplastic lesions, inflammatory lesion of the papilla of Vater was detected resulting in an overall sensitivity of 92.3% and specificity of 75.3%. CONCLUSIONS: EUS makes it possible to detect small intraampullary tumors and segmental thickening of the wall of the prepapillary biliary duct, which cannot be revealed by conventional imaging. In patients with biliary symptoms, EUS can reliably visualize and characterize a malignant lesion as a first diagnostic tool (detection rate, 82%) and may be considered the basis for subsequent diagnostic steps for verifying diagnosis correctly, e. g., using histologic investigation.

Successful endoscopic management of iatrogenic mediastinal infection and subsequent esophagomediastinal fistula, following endosonographically guided fine-needle aspiration biopsy.

Complications following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy are rare. A 75-year-old man underwent EUS-FNA biopsy of an enlarged mediastinal lymph, which histologic investigation revealed to be a metastasis of a hepatocellular carcinoma. The patient developed the postinterventional complication of suppurative infection within the mediastinum. Under EUS guidance, a pigtail catheter and a soft tube were inserted to respectively drain and rinse the mediastinal lesion for 8 days. The remaining esophagomediastinal fistula was closed by gathering the fistula margins, using band ligations and an Endoloop. The fistula healed with no further complaints or dysphagia. Infection is a possible complication of endoluminal FNA biopsy. An endoscopically guided therapeutic approach can be favored as the initial treatment of choice and as a reasonable alternative that avoids surgical intervention.

[How much diagnostics in patients with pancreatic cancer?]. / Wie viel Diagnostik ist beim Pankreaskarzinom nötig?

The possibilities which actually exist in order to obtain an earlier diagnosis in pancreatic carcinoma, a better differentiation of mass-forming pancreatitis and of other pancreatic tumors and an improved staging for reducing unnecessary operations are presented and evaluated. Possible relevant hints of the history and indicators for diagnostic procedures in view of a pancreatic carcinoma are upper abdominal complaints especially in relation to a new developed diabetes mellitus and/or unexplained elevations of pancreatic enzymes. The endosonography in combination with a target biopsy is of important value as well for the diagnosis of pancreatic cancer as for differentiation against a segmental chronic pancreatitis. In cases where differentiation is impossible even intraoperatively, we recommend the use of intraoperative fine needle biopsy.

Ambulatory electrogastrography in patients with sclerodermia, delayed gastric emptying, dyspepsia, and irritable bowel syndrome. Is there any clinical relevance?

Background: Changes in electrogastrographic parameters are described in patients with irritable bowel syndrome, sclerodermia, dyspepsia, and delayed gastric emptying in static measurements. However, no information is available about changes in ambulatory measurements. The objective of this study was to find parameters that discriminate between these diseases using cutaneous 24-h-electrogastrography. Methods: Cutaneous 24-h electrogastrography (EGG) measurements were taken from 20 patients with dyspepsia, 10 patients with systemic sclerosis (sclerodermia, SSc), 7 patients with irritable bowel syndrome (IBS), 7 patients with delayed gastric emptying, and 10 healthy volunteers. Measurements were made using a DIGITRAPPER EGG (Synectics Medical Inc., Stockholm, Sweden) and the accompanying computerized data analysis package (ElectroGastroGram Version 6.30, Gastrosoft Inc., Synectics Medical Inc., Stockholm, Sweden). Frequency and power were compared pre- and postprandially, as well as during the entire day of measurement. Results: The 24-h measurements in healthy volunteers revealed 45.00%+/-12.12% normal values (2.4-3.7 cpm), 30.10%+/-7.15% bradygastric values (<2.4 cpm), and 24.20%+/-7.76% tachygastric values (>3.7 cpm). There was no significant change in frequency between rest and motion, but there was a significant increase in power (P<0.05). There was significantly more bradygastria in patients with dyspepsia periprandially as well as after 24 h (P<0.01) than in healthy volunteers. The mean power of patients with dyspepsia was significantly higher than that of patients with IBS (P<0.05). Conclusion: Cutaneous 24-h-EGG may be used as an additional means of differentiating between dyspepsia and IBS.

Oral zinc therapy in patients with supposed mild zinc deficiency--a critical review.

The importance of zinc in many processes of diseases remains unclear up today. Nevertheless many biochemical or clinical studies let support a high clinical relevance of trace elements especially zinc in the therapeutic concepts of diseases. Unfortunately the border between severe (or real) and mild (or subclinical) zinc deficiency is not clear defined. In addition methodical problems in determination of trace elements and misinterpretations of study results lead to unjustified assignment from several diseases in the group of zinc deficiency disorders. Another current problem is the consideration of bioavailability of oral commercial trace element products. Especially the regulation of zinc uptake in human under normal conditions and in case of zinc deficiency is not clear at this time. These problems let become tangled the actual literature for the clinical active physician at the field of zinc. In this mini review there is given an overview about published clinical studies with oral zinc supplementation in the past years.

Unusual negative side effects of non-steroidal anti-inflammatory drugs in the proximal colon.

Two cases of uncommon side effects of non-steroidal anti-inflammatory drugs (NSAID) are presented which show that in special cases NSAID lesions can be located predominantly in the proximal colon, that NSAID-caused lesions may present themselves as diaphragm-like strictures and that alterations by NSAID in this part of the bowel may bring enormous problems for the differential diagnosis.

[Diarrhea as the initial manifestation of medullary thyroid gland carcinoma]. / Diarrhö als Erstmanifestation eines medullären Schilddrüsenkarzinoms.

BACKGROUND: With the differential diagnosis of a diarrhea a lot of causes has to be considered. In very rare cases diarrhea can be the first symptom of a medullary thyroid carcinoma (MTC). CASE REPORT: A 28-year-old patient came to the admission department because of persisting diarrhea. A computerized tomography revealed multiple hepatic and pulmonary metastases. A medullary thyreoid carcinoma was found as the cause of it. The serum calcitonin values were highly increased, later the carcinoembryonal antigen (CEA), too. Sandostatin, a radioimmune therapy (131J-anti-CEA antibody) and adriamycin were therapeutically applied. The patient died 24 months after the occurrence of the first symptoms. CONCLUSION: In case of persisting diarrhea the differential diagnosis of a medullary thyroid carcinoma must be taken into consideration and a calcitonin determination has to be arranged. Yet, typical symptoms like struma nodosa, swollen neck lymph nodes or a CEA increase can still be missing in the initial phase.

[Problems in diagnosis and therapy of juxtapapillary, tubulovillous adenoma]. / Probleme in der Diagnostik und Therapie des juxtapapillären, tubulovillösen Adenoms.

UNLABELLED: Tubulovillous adenoma of the duodenum have a high potential for malignant transformation. An exact preoperative staging and an accurate histological examination are essential in order to choose a proper therapeutic strategy. We report on difficulties in the diagnostic and therapeutic process of a patient with a tubulovillous, juxtapapillary, duodenal adenoma. The adenoma had been resected by means of submucosal excision after infiltrative growth had been excluded endosonographically and malignancy had been ruled out by the histological examination of a taken biopsy. Furthermore no malignant changes had been found in the resected material. However an early recurrence of the tumor questioned the correctness of the first diagnosis. In fact, a retrospective histological examination of the resected specimen revealed an adenocarcinoma, which had been overlooked primarily. Finally the patient underwent duodenopancreatectomy and remains without signs of tumor recurrence so far. CONCLUSIONS: 1. Microinvasion of the submucosa can not be excluded endosonographically. Therefore endosonography can not specify the dignity of an unknown tumor with a sufficient safety, especially if there is only an intramural growth of the tumor without transmural spread. 2. Because of high recurrence rates and a distinct frequency of malignant transformation of duodenal adenomas, a submucosal resection should only be performed in high-risk patient. 3. In that patients the resected material has to be examined as accurately and subtly as possible to rule out a submucosal microinvasion. 4. Based on the above mentioned radical surgery (duodenopancreatectomy) should be performed in all normal risk patients with juxtapapillary adenomas.

Platelet activating factor in stool from patients with ulcerative colitis and Crohn's disease.

BACKGROUND/AIMS: Platelet activating factor (PAF) is a potent endogenous mediator in inflammatory processes. The role of this mediator, especially in connection with the unknown etiology of chronic inflammatory bowel diseases, remains poorly understood. A determination of PAF in stool may be helpful in recognizing quiescent inflammations in chronic inflammatory bowel diseases. A simple and reliable method for the determination of PAF in stool seems to be necessary to achieve this goal. METHODOLOGY: PAF analysis was performed with the help of a commercial PAF radioimmunoassay (RIA) kit after solid phase extraction (SPE) of ethanolic stool extracts. PAF was determined in stool from 10 healthy volunteers (m = 4; f = 6), 13 patients with ulcerative colitis (m = 7; f = 6) and 15 patients with Crohn's disease (m = 9; f = 6). Fecal PAF concentrations were compared with activity index of disease, endoscopic index, localization of lesions, leukocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), medical prednisolone treatment, sex and age of the patients. RESULTS: In healthy volunteers, no PAF was detectable in stool. In patients with Crohn's disease 319.2 +/- 143.5 pg PAF/g stool and in patients with ulcerative colitis 824.9 +/- 408.7 pg PAF/g stool could be determined. A significant correlation (p < 0.05) was found between PAF-content in stool and the endoscopical index and intestinal localization of inflammatory lesions. No further correlations could be detected in our patients. CONCLUSIONS: Fecal PAF assessment may be used clinically as a non-invasive method to estimate severity of mucosal inflammation in patients with inflammatory bowel disease (IBD).

[Success and complication rates of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography--a prospective study]. / Erfolgs- und Komplikationsraten der diagnostischen und der therapeutischen endoskopischen retrograden Cholangiopankreatikographie--eine prospektive Studie.

The aim of the prospective study was to evaluated the efficacy and the complications of 2,820 ERCP-examinations in 1,717 consecutive patients (performed over a three-year period). The rate of success was 82.8% for diagnostic ERCP, 96.6% for endoscopic sphincterotomy, 76.8% for the extraction of stones on common bile tract, 87.5% for drainage in bile tract obstruction, respectively. The rate of all complications amounted to 7.9% (4.9% diagnostic ERCP, 9.2% therapeutic ERCP, in detail: 3.8% acute pancreatitis, 2.1% cholangitis, 1.3% bleeding, 0.2% perforation, 0.5% other respectively). The total mortality was 0.1% (three cases of death). The frequency of complications increased with the number of procedure at the papilla Vateri in patients, who underwent needle knife papillotomy in combination with standard papillotomy.

Ecstasy pimples - a new facial dermatosis.

Ecstasy (XTC) has become a popular drug in the rave, dance and techno scene. Several severe disorders due to drug addiction have been described but no dermatological symptoms. We report on 2 patients (20-year-old female, 21-year-old male) with medical problems after taking XTC. Both developed a facial rash with reddish pimples after oral intake of XTC. The distribution resembled either periorificial dermatosis or acneiform rash without white- or blackheads. The lesions cleared without specific treatment. We suggest that XTC pimples represent an acneiform dermatosis in young people taking designer drugs. Though the dermatosis itself seems to be mild, it may be a cutaneous marker for drug abuse.

Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.

Abscesses in the gastric wall are extremely rare. As the mucosa remains intact in most cases, clear differential diagnosis is required in order to distinguish the condition from the more frequent intramural mesenchymal tumors. Endoscopic ultrasonography provides a valuable tool for imaging intramural tumors, but this approach does not allow a definitive assessment of malignancy. We report about two patients with intramural abscesses in the gastric wall. Endosonography showing eccentric tumors from the gastric wall in the two patients. The endosonographic image was inhomogenous, the wall layer structure of the gastric wall was not preserved. A laparotomy was carried out on the first patient. In the second case, the diagnosis was easy, as pus was emptying from a small opening in the mucosa, which had already been detected at gastroscopy. Endoscopic intervention was carried out based on the endosonographic findings. In one patient, mucosa and submucosa were opened by a needle knife. These cases show that gastric wall abscesses do not have a typical endoscopic ultrasound appearance. However, endosonography is an essential method prior to endoscopic interventional therapy.

[Value of endosonography in diagnosis of diffusely growing stomach carcinomas]. / Wertigkeit der Endosonographie in der Diagnostik diffus wachsender Magenkarzinome.

The diagnosis of diffuse type gastric carcinoma is very difficult. The delay of diagnosis is often due to false-negative endoscopic and histologic evaluation. The architecture of the stomach can be clearly visualized by endosonography. Therefore, already minor destructions of the gastric layers can be found. The endosonographic picture includes the presence of the layers, which are larger and of irregular contour. In infiltrating gastric cancer typically the submucosal layer and the muscularis are concentrically enlarged and appear folded. Based on the endosonographic picture diffuse type gastric carcinoma has been diagnosed in 32 patients. When compared to the histologic diagnosis after gastrectomy or autopsy the accuracy of the endosonographic diagnosis was 87.5%, (28 out of 32 patients). From the remaining four patients diagnosed to have diffuse type gastric cancer by endosonography three patients turned out to have malignant infiltrating tumors of different histologies. Therefore, the positive predictive value of endosonography in detection of infiltrating malignant tumors was 96.8% in our group. In contrast the accuracy of preoperative histologic diagnosis by biopsies was only 58%. Suspicious results of gastroscopy, especially in combination with a negative biopsy, should lead to further evaluation by endosonography to detect diffuse type gastric cancer earlier.

H2-receptor antagonists and antacids have an aggravating effect on Helicobacter pylori gastritis in duodenal ulcer patients.

BACKGROUND: Antacids, such as aluminium-magnesium hydroxide (AIMg(OH)3), or H2-receptor antagonists, such as ranitidine, are common drugs used for treating peptic ulcer disease and acid-related symptoms. METHODS: In a prospective double-blind controlled study, 174 patients were randomized to a 4-week course of treatment with either AIMg(OH)3 (acid-binding capacity: 280 mval/day) or ranitidine 300 mg for active Helicobacter pylori-associated duodenal ulcers (as determined by histology and the urease test). Before and after treatment, two biopsy specimens each were obtained from the antrum and corpus, and the grade and activity of gastritis, as well as H. pylori density, were determined using a score ranging from 0 = none to 4 = severe. RESULTS: Pre- and post-treatment histology were available for 138 patients (AIMg(OH)3: 67, ranitidine; 71). Treatment with AIMg(OH)3 significantly increased the activity of corpus gastritis (Wilcoxon signed-rank: P = 0.0014), while ranitidine treatment significantly increased both the grade and activity of corpus gastritis (P = 0.0002 and P = 0.0001 respectively). In the antrum, both regimens provoked a significant increase in the frequency of intestinal metaplasia, but this may be a consequence of sampling error. CONCLUSIONS: Ranitidine and AIMg(OH)3 have an aggravating effect on H. pylori gastritis in duodenal ulcer patients. This should be considered a side-effect of the respective drugs and is more pronounced with ranitidine.