[Endoscopy in cholestasis]. / Endoskopie bei Cholestase.

The spectrum of causes of cholestasis ranges from microscopically recognizable damage to the parenchymal cells of the liver to obstruction of the ductus choledochus und papilla Vateri. Liver biopsy on the one hand and ERCP on the other therefore constitute the morphological methods that come closest to the pathological substrate. Obligatory sonography serves the restriction of diagnosis to a large extent. Laparoscopy is nearly always dispensable. Even in case of liver biopsy the therapeutic consequences should have an influence. Consequently, for transpapillary endoscopic methods in obstructive jaundice it is essential to remove the obstruction (papillotomy and extraction of the calculus or nasobiliary probe or intraluminal tube) if possible in one and the same session. The purely diagnostic ERC possibly causes dangerous cholangitis in mechanical icterus. Transpapillary and percutaneous transhepatic endoscopic methods are becoming more and more sophisticated and new indications are being discovered. However, the results of sonography and endoscopy in obstructive jaundice depend very much on the equipment available and experience of the investigator. He should realistically estimate what he is able to do as well as the patients' chances of recovery. In addition he should maintain contact to large departments of surgery and endoscopy.

[Lipid metabolism disorders in primary biliary cirrhosis (PBC)]. / Fettstoffwechselstörungen bei primär biliärer Zirrhose (PBC).

40 women, average age 52.5 years, with varying stages of primary biliary cirrhosis, were observed. One third of them suffered from a mild anaemia, mean plasma concentrations of ALAT were increased four times and those of AP six times. Despite the hepatocellular damage products of the liver synthesis such as transport proteins or coagulation factors were found to be normal or enhanced. 60% of the patients had a hypercholesterolaemia. The risk factors low density lipoprotein (LDL)- and very low density lipoprotein (VLDL)-cholesterol showed normal levels, but the protective factor high density lipoprotein (HDL)-cholesterol was clearly increased. Apart from the low blood pressure in most of the patients and the absence of other risk factors these observations explain, why patients with PBC and hypercholesterolaemia don't usually develop arteriosclerotic complications. Only in case of severe cholestasis a lipid constellation comes into being accompanied by high risk for the blood vessels, but in these cases the terminal stage of PBC limits the survival. Positive correlations between markers of cholestasis and lipid parameters let an enhanced production and simultaneous impaired excretion of cholesterol be assumed.

Prophylactic endoscopic sclerotherapy of esophageal varices--a prospective randomized trial.

Sixty-three patients with degree III or IV esophageal varices and the so-called red color sign, but without previous bleeding were randomly assigned to either prophylactic sclerotherapy (PST) (n = 30) or to a control group (n = 33). In 58 cases the portal hypertension was caused by liver cirrhosis (40% alcoholics). The two groups were comparable with respect to demographic data and endoscopic appearance, causes and severity of liver damage. Sclerotherapy was performed as combined intra-and paravariceal injections of 2 or 3% polidocanol. All patients, both in the treatment and in the control groups, who bled from varices after randomization, received sclerotherapy until the varices were eradicated, and remained in their groups. After a mean follow-up of 44.5 months, the bleeding rate in the PST group was significantly lower (30% vs 75%, p less than 0.01). The difference became significant from the second year onward. Fourteen patients of the PST group and 19 of the controls died (4 and 14, respectively, p less than 0.05 as a result of the bleeding). Life table analysis (Kaplan-Meier) revealed no differences in survival between the two groups. At the present time PST cannot yet be recommended as a method for clinical routine use.

[Gastroscopy before cholecystectomy]. / Die Gastroskopie vor der Cholecystektomie.

In a prospective study the routine endoscopy of the upper gastrointestinal tract was carried out in 100 patients before they underwent elective cholecystectomy for gallstones. In 31/100 patients we detected abnormalities which changed the plan of therapy. In 18/100 patients the cholecystectomy was performed 4 to 8 weeks later, after additional medical treatment. 7 patients were discharged from the cholecystectomy. The preoperative endoscopy of the upper gastrointestinal tract should be used in patients undergoing cholecystectomy to exclude other gastrointestinal disorders.

[Pathogenetic factors of hemorrhage from esophageal varices]. / Pathogenetische Faktoren der Osophagusvarizenblutung.

Esophageal varices nearly always rupture at or just above the gastro-esophageal junction. Mucosal changes on top of the varices, the so-called red colour sign, are found in the majority of patients with a positive bleeding history. An increase of intraabdominal pressure and consequently a sudden pressure rise in the varices is thought of as a trigger cause. The larger the esophageal varices the higher the intravariceal and the transmural varix pressures. The portal pressure in patients with portal hypertension is subjected to considerable changes. Therefore, hemodynamic measurements at rest may have a prognostic value with regard to predisposition to hemorrhage, but they are less significant than endoscopic parameters. Disturbances of blood hemostasis and ascites indicating an impaired liver function are essential predisponable factors for the onset of bleedings. A peptic lesion caused by acid gastric-esophageal reflux is of less importance for the occurrence of variceal hemorrhage.

[Endoscopic sclerotherapy of esophageal varices--studies of the technic and follow-up]. / Endoskopische Sklerotherapie (EST) von Osophagusvarizen--Studien zur Technik und zum Krankheitsverlauf.

Several prospective studies on the efficiency and technique of endoscopic sclerotherapy (EST) were performed among 300 patients with bleeding esophageal varices, 173 of which had been treated by EST. Contrasted with a comparable control group (n = 80), EST (n = 100) reduced the incidence of rebleedings (40% vs 13.3%; p less than 0.0005) and the lethality (46.7% vs 30.6%; p less than 0.05) during the observation period of 21 months. The paravariceal and the intravariceal injection techniques were compared in 20 patients each. A higher number of initial and repeated treatment sessions argued against the paravaricel technique (mean follow up: 4 years). In a randomized study on prophylactic EST we found a lower bleeding frequency (13% vs 39%) in 16 patients treated by EST compared to 18 controls.

[B-cell and T-cell immunoblastic lymphomas of baboons]. / B- i T-kletochnye immunoblastnye limfomy pavianov.

The results of morphological study of B- and T-cellular immunoblast baboon lymphomas are presented. Differences are found both in the structure of tumour cells and in the histostructure of tumours as a whole. The tumor cells of B-immunoblastic lymphomas expressed mainly IgM. The tumour cells of certain T-immunoblastic lymphomas being investigated by means of monoclonal OKT4 antibodies had a surface phenotype peculiar to T-helper cells.

[Vascular anomalies of the gastrointestinal tract--an unusual case of multiple intra-abdominal hemangiomas]. / Gefässanomalien des Gastrointestinaltraktes--ein ungewöhnlicher Fall multipler intraabdomineller Hämangiome.

A case of multiple abdominal haemangiomas (mesentery, intestine, liver) in a 19 year-old patient is described. The anomalies, at first incidentally found during appendectomy, were confirmed by angiographies and vascular surgery. Ascites and bleeding esophageal varices developed in further course. A short review of literature and classifications is given.

[Differential diagnosis and staging of chronic nonsuppurative destructive cholangitis in liver biopsies]. / Differentialdiagnose und Stadieneinteilung der chronischen nichteitrigen destruktiven Cholangitis in der Leberbiopsie.

Based on 28 histologically well-established cases of chronic non-suppurative destructive cholangitis, clinico-pathological aspects of differential diagnosis and staging are reported. In only half of the cases could the diagnosis be made on the first liver biopsy. In 14 cases, two or more liver biopsy specimens were necessary for diagnosis. The most frequent and most difficult differential diagnostic issue was to distinguish between chronic non-suppurative destructive cholangitis and chronic aggressive hepatitis of viral or autoimmune origin. The histochemical demonstration of copper by the rhodanine method was of particular value for differentiating between chronic non-suppurative destructive cholangitis and chronic aggressive hepatitis as well as for diagnosis of mixed types. In two cases of mixed type, the HBs-Antigen in ground glass hepatocytes and copper-associated protein in periportal hepatocytes could be demonstrated simultaneously with Shikata's Orcein-staining. Compared with the previously used system (Scheuer 1967) the staging concept proposed by Ludwig et al. (1978) has proved to be more useful and easier to apply. This system permits recognition of the stage on routinely obtained specimens regardless of specific differential diagnostic features. Most liver biopsy specimens were assigned to stage III. Features considered characteristic of the earlier phases (inflammatory bile duct destruction and granulomas) frequently coexist with more advanced lesions in late stage.

[Endoscopic papillotomy in East Germany]. / Endoskopische Papillotomie (EPT) in der DDR.

Through a survey 751 patients, in whom an endoscopic papillotomy (EPT) had been tried, were registered to the end of 1981. EPT was technically successful in 695 cases (92,5%). Control investigations were available for 650 patients, the aim of therapy being achieved in 594 cases (91,4%). The main indication was choledocholithiasis, 90,2%--among them 10% with gallbladder in situ--followed by benign papillary stenosis without stones (5,9%), carcinoma of the Vaterian papilla (3,2%) and rare indications such as ascaridiasis, choledochocele and stones of the pancreatic duct (0,7%). 53 patients suffered from more serious complications (7,6%), 18 had to be operated on (2,6%), and 7 patients died due to EPT (1%). The results are in agreement with those of other statistics from various countries.