Chronic nausea as the leading symptom: an indication for double-contrast examination of the upper intestinal tract following normal gastroscopy.

We report a patient with chronic nausea as the leading symptom of a primary carcinoma of the duodenum located at the flexura duodeno-jejunalis. The tumour was not reached at gastroscopy, which was performed twice. Since this area usually cannot be seen upon gastroscopy or upon small bowel enteroclysma according to Sellink, a double-contrast investigation of the upper gastrointestinal tract using a hypotonic agent should be performed when nausea persists although gastroscopy is normal.

[Immediate or interval operation of acute cholecystitis in patients over 70]. / Sofort- oder Intervalloperation der akuten Cholezystitis bei Patienten über 70 Jahre.

Among 1372 cholecystectomies there were 152 patients suffering from acute cholecystitis. 54 patients were over 70 years of age. On suspecting a free or covered perforation surgery took place immediately (11 patients). In case of rapidly progressing abdominal symptoms during the first 48 hours these patients also underwent surgery (17 patients): 6 patients came to death (mortality rate: 21%). In the beginning 50 patients were treated conservatively without any positive result in more than half of the patients because the inflammation in the stone-filled gallbladder could not be brought to a standstill. 15 patients had a delayed cholecystectomy within the first 3 weeks after the onset of symptoms and 11 patients within the first 3 months. The outcome of these delayed operations was infavourable. Therefore, we recommend the early operation as far as patients over 70 years are concerned.

[Surgical treatment of sigmoid diverticulitis]. / Die chirurgische Behandlung der Sigmadivertikulitis.

UNLABELLED: From 1972 to 1982 113 patients suffering from diverticulitis of the sigmoid colon were admitted to our hospital. 63 patients underwent conservative-, 50 patients surgical therapy (23 emergency procedures, 27 elective operations). COMPLICATIONS: 8 times free perforation, 15 times retroperitoneal abscess formation, 6 times haemorrhage, 3 times fistulae to the urinary bladder, 9 patients suffered from acute obstruction of the bowel. The infectious focus should be removed completely as early as possible. As an emergency procedure Hartmann's operation is recommended, this means resection of the sigmoid colon and temporal colostomy. In this way the patients life is not endangered by an anastomosis. Only in elective operations we combine resection of the sigmoid colon and anastomosis as one-stage procedure.

[Primary fibrotic bile duct stenosis]. / Die primär fibröse Gallengangsstenose.

The author reports about five patients suffering from a primary fibrotic stenosis of the biliary system. All patients were assigned into hospital with a painless jaundice. In all cases a diagnosis was secured histologically. Four patients had a stenosis of the biliary system and a hepatico-jejunostomy as Y-anastomosis was possible to be applied. In one case both Ductus hepatici were taken ill symmetrically. A biliodigestive anastomosis was not practicable. After having widened the narrow intra-hepatitic biliary system, the stenosis appeared once more. It could not be found that the total intra- and extra-hepatic biliary system had fallen ill symmetrically. The cause of the illness is still uncertain. Based on clinical and histological findings an inflammatory process is not probable. The pathological anatomical findings were marked by a network-like filament of collagene without inflammation.

[The significance of the duodenal papilla within the framework of diseases of gallbladder and bile ducts]. / Die Bedeutung der Papilla duodeni im Rahmen der Erkrankungen der Gallenblase und Gallenwege.

On the basis of 3185 biliary tract operations performed at the city hospitals of Braunschweig and Lüneburg, 12% of which included papillotomies, the frequency and pathogenesis of Vater's papilla stenosis is discussed. About 5% of all stenoses of Vater's papilla do not appear in connection with lithiasis in the biliary tract; these are defined as primary stenoses. 95% of Vater's papilla stenoses occur with lithiasis and inflammatory diseases of biliary tract. Stenosis of Vater's papilla is most often seen in connection with severe cholecystitis and pericholecystitis. There exists in most cases a purely inflammatory swelling of papillas mucosa which decreases following sanitation of the biliary tract. Intraoperative findings show good dilatation through catheterization and Vater's papilla should therefore not be discised. In opposite the concommitant stenoses of Vater's papilla caused by choledocholithiasis, chiefly in case of calculus near the papilla, are signed by severe deforming alterations even concerning deeper layers of papilla wall. The high grade destruction of muscle tissue leads to a not retrogressive stenosis, even after sanitation of biliary tract, which principally should be discised. 211 biopsies of papilla were taken and histologically analyzed. A specific pathologic-anatomic substrate of stenosis of Vater's papilla could not be found.