English language version of the S3-consensus guidelines on chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis.

Chronic pancreatitis is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganization of the pancreas leads to a progressive exocrine and endocrine pancreatic insufficiency. In addition, characteristic complications arise, such as pseudocysts, pancreatic duct obstructions, duodenal obstruction, vascular complications, obstruction of the bile ducts, malnutrition and pain syndrome. Pain presents as the main symptom of patients with chronic pancreatitis. Chronic pancreatitis is a risk factor for pancreatic carcinoma. Chronic pancreatitis significantly reduces the quality of life and the life expectancy of affected patients. These guidelines were researched and compiled by 74 representatives from 11 learned societies and their intention is to serve evidence-based professional training as well as continuing education. On this basis they shall improve the medical care of affected patients in both the inpatient and outpatient sector. Chronic pancreatitis requires an adequate diagnostic workup and systematic management, given its severity, frequency, chronicity, and negative impact on the quality of life and life expectancy.

[How safe is sedation in gastrointestinal endoscopy? A multicentre analysis of 388,404 endoscopies and analysis of data from prospective registries of complications managed by members of the Working Group of Leading Hospital Gastroenterologists (ALGK)]. / Wie sicher ist die Sedierung in der gastrointestinalen Endoskopie? Eine multizentrische Auswertung von 388 404 Endoskopien und Auswertung der Daten aus prospektiv geführten Komplikationsregistern von Mitgliedern der Arbeitsgemeinschaft leitender Gastroenterologen im Krankenhaus (ALGK).

BACKGROUND: Gastrointestinal endoscopies are increasingly being carried out with sedation. All of the drugs used for sedation are associated with a certain risk of complications. Data currently available on sedation-associated morbidity and mortality rates are limited and in most cases have substantial methodological limitations. The aim of this study was to record severe sedation-associated complications in a large number of gastrointestinal endoscopies. METHODS: Data on severe sedation-associated complications were collected on a multicentre basis from prospectively recorded registries of complications in the participating hospitals (median documentation period 27 months, range 9 - 129 months). RESULTS: Data for 388,404 endoscopies from 15 departments were included in the study. Severe sedation-associated complications occurred in 57 patients (0.01 %). Forty-one percent of the complications and 50 % of all complications with a fatal outcome (10/20 patients) occurred during emergency endoscopies. In addition, it was found that 95 % of the complications and 100 % of all fatal complications affected patients in ASA class ≥ 3. CONCLUSIONS: Including nearly 400,000 endoscopies, this study represents the largest prospective, multicenter record of the complications of sedation worldwide. The analysis shows that sedation is carried out safely in gastrointestinal endoscopy. The morbidity and mortality rates are much lower than previously reported in the literature in similar groups of patients. Risk factors for the occurrence of serious complications include emergency examinations and patients in ASA class ≥ 3.

[Chronic abdominal pain--internistic-psychosomatic aspects]. / Bauchschmerz aus internistisch-psychosomatischer Sicht. Gestresster Magen--gereizter Darm?

Abdominal pain is considered to be chronic when it persists for at least three months or when a patient experiences such pain for a total of three months during the course of a year. Pathophysiologically, nociceptive/neuropathic functional pain syndrome, mental disorders with the cardinal symptom of chronic pain, and mixed forms can be distinguished. In 50% of the patients, the cause of chronic abdominal pain is a functional gastrointestinal disorder e.g. functional dyspepsia irritable bowel syndrome. On the basis of a structured pain history, a physical examination and a basic "technical" diagnostic program (laboratory investigations, abdominal ultrasonography, Esophagogastroduodenoscopy, colonoscopy), correct assignment to one of the above-mentioned can be achieved in most of the cases.

[Requirements and recommendations for performing endosonographies]. / Voraussetzungen und Empfehlungen zur Durchführung von Endosonographien - Eine Stellungnahme der Arbeitsgemeinschaft für endoskopischen Ultraschall in Nordrhein-Westfalen (AGEUS).

For improvement of quality the working group of the Society of Gastroenterology in Nordrhein-Westfalen (Germany) was engaged with the questions, which apparative, personal and training conditions for endoscopic ultrasound are useful. The following proposals were preliminarily presented at the annual Congress of the DGVS (German Society of Digestive and Metabolic Diseases) 2001. They are thought to be subject of discussion for guidelines to be elaborated by this national society.

[Endoscopic ultrasonography (EUS) of the upper gastrointestinal tract - prospective multicenter study to evaluate time and staff requirements]. / Endosonographie (EUS) des oberen Gastrointestinaltrakts - Prospektive Multizenterstudie zur Analyse von Zeit- und Personalbedarf.

BACKGROUND AND AIMS: Endoscopic ultrasonography is an important procedure in the diagnostic work-up of gastrointestinal and mediastinal masses. To evaluate the time and staff requirements for the examination, a prospective multicenter study was carried out. METHODS: 27 centers were asked to document their endoscopic ultrasonographic procedures over a 4-month period, using a standardized protocol comprising several parameters: time and staff requirements (overall and related to organs), time spent on informing the patients, preparation, performance and monitoring of the examination and subsequent care of patient as well as of endoscopic equipment. RESULTS: 484 examinations from 11 centers were suitable for evaluation, 25 % of the patients were out-patients. Median examination time was 20 minutes (range: 5 - 60 min) without significant differences concerning the device but with greater differences concerning the different organs (pancreas 23.5 minutes, esophagus 15 minutes). Median time of subsequent care was 35 minutes in out-patients, 25 minutes in hospitalized patients, with a great variety between different centers. In 70 % of examinations one doctor and one nurse were involved. For sedation midazolam was used in 90 % of cases, pethidin for analgesia in 30 % of cases. CONCLUSIONS: The obvious time and staff requirements for endoscopic ultrasonography are comparable to historical data for the performance of a colonoscopy. In out-patients the time required seems to be higher.

Persistently altered visceral perception after resection of an esophageal granular cell myoblastoma: a therapeutic concept revisited.

Granular cell tumors (GCTs) are rare and usually benign gastrointestinal tumors. Their most frequent symptoms are dysphagia and epigastric or retrosternal discomfort. We here report a case of esophageal GCT with continued symptoms of retrosternal discomfort, postprandial feeling of fullness, and early satiety despite complete thoracoscopic resection of the tumor. In contrast, all functional tests were in the normal range. We thus suggest that, due to their neuroectodermal origin, GCTs may affect neuronal alterations leading to a persistently disturbed visceral mechanosensory perception. Consequently, this case also cautions the therapeutic concept to solely relieve GCT symptoms by resection if the tumor is less than 20 mm in diameter.

Pancreatic intraductal ultrasonography (IDUS) allows early diagnosis of pancreatic carcinoma in situ: a case report.

A 66-year-old woman was admitted with diarrhea, weight loss, slight recurrent abdominal pain, and raised serum amylase and lipase. Lactose intolerance was diagnosed, and treatment was begun. The symptoms diminished. However, slight back pain and elevated serum amylase and lipase levels persisted. A pancreatic tumor was then suspected. Ultrasound, spiral computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) examinations were inconclusive. Endoscopic retrograde cholangiopancreatography (ERCP) showed a slight narrowing of the pancreatic duct within the pancreatic body, and endoscopic ultrasound (EUS) revealed a 10 mm intrapancreatic lesion. Finally, intraductal ultrasonography (IDUS) reliably identified a small pancreatic tumor. The tumor was resected, and histology confirmed a well-differentiated adenocarcinoma in situ (UICC stage 0, TisN0M0). This case shows that using high-resolution imaging techniques such as EUS plus IDUS, small malignant pancreatic lesions can be detected at an early stage, when curative action is possible.

Fire eater's risk: lipoid pneumonia following aspiration of a liquid hydrocarbon mixture.

Acute aspiration of a liquid hydrocarbon mixture by fire eaters may cause severe lipoid pneumonia. The toxic effect of ingested hydrocarbon chains depends on their length and biophysical qualities. We report the case of a patient who accidentally aspirated a hydrocarbon liquid resulting in a lipoid pneumonia. The pathomechanism, diagnostic work-up, and the therapeutic approach are discussed.

[Gastrocolic fistula - a rare cause of cachexia and polyneuropathy]. / Gastrokolische Fistel als seltene Ursache von Kachexie und Polyneuropathie.

Gastrocolic fistula is a rare clinical disorder which in the past most often occurred after gastric surgery or carcinoma of the gastrointestinal tract. However, during the last decade an increasing number of cases after benign gastric ulcers have been described. Most common symptoms have been weight loss, abdominal pain, diarrhea and copremesis. A 49-year-old cachectic patient presented with a 2-year history of abdominal discomfort and diarrhea. He reported a weight loss of 32 kg during this period and was finally unable to move because of exhaustion. Furthermore, he suffered of burning paresthesia of the legs and the abdomen. His medical history included a Billroth II operation because of recurrent ulcer disease in 1987. Barium enema revealed a gastrocolic fistula which caused small bowel bacterial overgrowth with villous atrophy and malabsorption and development of polyneuropathy. The fistula was surgically resected, and postoperatively, the patient improved and regained his weight. Gastrocolic fistula is a rare cause of diarrhea and should be considered in clinical practice. Barium enema is superior to endoscopy in detecting gastrocolic fistula.

[Autoimmune pancreatitis]. / Autoimmune Pankreatitis.

Over the last years several case reports and articles have been published suggesting that a new form of chronic pancreatitis has been diagnosed and named autoimmune pancreatitis. The present overview scrutinizes the proposed evidence in the light of the current literature and aims to prove whether autoimmune pancreatitis is a special entity of chronic pancreatitis.

[Generalized pustulous psoriasis: A novel extraintestinal manifestation of Crohn's disease?]. / Psoriasis pustulosa generalisata: neue extraintestinale Manifestation des Morbus Crohn?

A 66-year-old female patient suffering for 10 years from Crohn's disease firstly presented with a parallel outbreak of generalized pustulous psoriasis and Crohn's disease. A second synchronous exacerbation of both disorders occurred after discontinuation of treatment with prednisolone, methotrexate, and mesalazine. As to their pathogenetic concepts, both disease entities reveal similar immunologic alterations, i. e. comparable patterns of cytokines, chemokines, and inflammatory cells (T cells and neutrophils). Generalized pustulous psoriasis, therefore, might develop as hitherto undescribed, more rare extraintestinal manifestation of Crohn's disease.

Campylobacter jejuni-induced severe colitis--a rare cause of toxic megacolon.

The development of toxic megacolon as a sequel of infectious colitis is rare. We have observed the very rare case of a campylobacter jejuni-induced toxic megacolon. A 28-year-old man was admitted with severe enterocolitis and appearance of blood in stools. He had been treated with loperamide without success. Two days after admission stool cultures revealed campylobacter jejuni and then an oral antibiotic therapy was started. On the fifth day clinical performance deteriorated again with development of toxic megacolon and consecutive subtotal colectomy. Rectoscopy before discharge after 13 days showed a normal mucosa. The unusual course with first improvement and then rapid deterioration despite adequate therapy was observed in 4 other cases, which may also be a hint of ensuing megacolon. Even in usually harmless enterocolitis like campylobacter infection, predisposing factors such as loperamide are known to precipitate toxic megacolon and should be considered in clinical practice.

Nonsurgical management of acute pancreatitis. Use of antibiotics.

In severe AP, infected necrosis is the leading cause of death. Prevention of pancreatic infection is the major goal in the treatment of patients with necrotizing pancreatitis. Adequate early antibiotic therapy seems to be promising in these patients. Their role and the optimal timing of the antibiotic therapy (e.g., benefit of prophylactic application) are discussed. Preliminary results of a study in patients with infected pancreatic necrosis and exclusively or primarily conservative treatment also are presented.

[Familial Mediterranean fever. New aspects with respect to molecular genetics and pathogenesis revealed in three case reports]. / Familiäres Mittelmeerfieber. Neue Aspekte zur molekularen Genetik und Pathogenese am Beispiel dreier Fallbeschreibungen.

HISTORY AND CLINICAL PRESENTATION: Three young Turkish males were admitted because of acute abdominal pain and fever. All 3 patients had recurrent attacks of these symptoms every few weeks since years with each attack lasting 2 to 3 days. One patient developed a renal amyloidosis with an end-stage renal failure. DIAGNOSTICS AND CLINICAL COURSE: All patients presented with local abdominal tenderness and an elevation of inflammatory parameters (WBC, ESR, CRP and fibrinogen). X-ray studies, ultrasound and upper endoscopy were normal. In 1 patient histology yielded amyloid fibrils in the antrum of the stomach. In a molecular genetic analysis 2 patients were compound heterozygous for 2 common mutations of the gene responsible for the familial Mediterranean fever (FMF). In all patients the symptoms vanished spontaneously according to an acute attack of FMF. After symptomatic treatment a prophylaxis with colchicine was started. CONCLUSION: Cloning of the FMF gene and its mutations and identification of the gene product "pyrin" reveals new aspects on genetics and pathophysiology. The improved diagnostic procedure enables an early start of colchicine treatment, especially to prevent renal amyloidosis.

Diagnostic dilemma in pancreatic lymphoma. Case report and review.

Non-Hodgkin's lymphoma predominantly involving the pancreas is a rare tumor of the gastrointestinal tract. Diagnosis can be difficult, since lymphoma may mimic carcinoma or pancreatitis. Lymphoproliferative diseases induced by immunosuppressive therapy frequently occur in the gastrointestinal tract of posttransplant patients. However, pancreatic involvement of posttransplant lymphoma is an exceptional condition. We present the case of a cyclosporin-treated renal transplant recipient with pancreatic lymphoma mimicking carcinomatous or inflammatory tumors. The diagnostic difficulties and treatment options of pancreatic lymphoma as well as lymphoproliferative disorders in immunosuppressed renal recipients are discussed in light of the current literature.