[Incidental findings in gastroscopy and colonoscopy]. / Zufallsbefunde in Gastroskopie und Koloskopie.

For many specific and nonspecific gastrointestinal symptoms, endoscopic diagnostic procedures play an important role. Gastroscopy and colonoscopy are easily available diagnostic and interventional procedures with low risk. The technical development of gastrointestinal endoscopy has led to an improvement in diagnostics and therapy. In addition to frequent and expected findings, incidental findings may occur. The incidental findings can distinguish rare diseases of unexpected diagnoses. Rare diagnoses usually require an individualized therapy. Unexpected diagnoses can take place during (not properly detected) or after an endoscopy (overlooked or newly appeared) occur. This overview deals with the question of how to minimize unexpected diagnoses and how to diagnose and treat incidental findings.

Health care and cost of medication for inflammatory bowel disease in the Rhein-Main region, Germany: a multicenter, prospective, internet-based study.

BACKGROUND: Studies examining the treatment reality of IBD patients in Germany have been limited, as networking among deliverers of care and reliable documentation of medical, demographic, and economic data are lacking. The aim of the present study was to establish an internet-based treatment registry in order to evaluate treatment of IBD patients in Germany. METHODS: Between November 1(st), 2005, and January 31, 2007, 1024 outpatients with prevalent IBD from 10 gastroenterological private practices and 3 hospitals (UC = 439, CD = 567, ID = 18) were enrolled in the study. An internet-based registry was established that included data about medical history, disease status, diagnostic procedures, laboratory test results, and medical treatment. Data for private practices and hospitals were pooled in order to compare treatment habits between these types of medical facilities. The cost of medication was determined according to medications prescribed. RESULTS: There was no significant difference between the 2 patient groups in demographic and clinical characteristics. Marked differences were observed in medical treatment. The most frequently prescribed medications in the private practices for patients in remission and those with active disease were aminosalicylates and corticosteroids. Immunomodulators played a marginal role. In contrast, in the hospitals azathioprine/6-MP was predominantly used for the maintenance of remission. Patients with fistulizing CD were treated with infliximab. The mean annual cost of medications was 1826 +/- 1331euro/patient (median 1353euro) in the private practices and 1849euro +/- 2897euro/patient (median 960euro) at the University Hospital. CONCLUSIONS: The registry provides the first detailed data about the reality of treatment of IBD patients in Germany and reveals the necessity for networking among attending physicians in order to implement guidelines-conformed treatment.

[Effectiveness of antiviral therapy in patients with chronic hepatitis C treated by private practice gastroenterologists]. / Effektivität der antiviralen Behandlung von Patienten mit chronischer Hepatitis C in der gastroenterologischen Facharztpraxis.

The standard treatment for patients with chronic hepatitis C consists of pegylated interferon (PegIFN) alpha in combination with ribavirin. Information on treatment effectiveness outside clinical trials is sparse. To study community-based health care, a regional network supported by the German network of competence for hepatitis (Hep-Net) was created between gastroenterologists in private practice and a tertiary referral centre. A treatment register containing evidence-based guidelines was established and 212 consecutive patients who were treated with either PegIF Nalpha 2a/ribavirin (n = 126) or PegIFNalpha2b/ribavirin (n = 86) for 24 weeks (HCV genotype 2, 3) and 48 weeks (HCV genotype 1, 4, 5), respectively, were included and followed prospectively. Twenty-four weeks after cessation of antiviral treatment a sustained virological response was achieved in 54 % of the patients. By univariate analyses, infection with HCV genotypes 2 or 3 (p < 0.0001), younger age (p < 0.0001), normal gamma-glutamyltransferase levels before initiation of treatment (p = 0.003), and absence of language communication problems (p = 0.023) were associated with a sustained virological response. The presence of liver cirrhosis in patients with HCV genotype 1, 4, 5 infection was associated with lower sustained response rates (p = 0.025). Patients infected with HCV genotype 1 in whom the PegIFNalpha dose was reduced had higher virological relapse rates (p = 0.049). With regard to the treating physician, sustained virological response rates ranged from 26 - 67 % in patients infected with HCV genotype 1. Our study shows that virological response rates similar to those in international randomised clinical trials can be achieved by private practice gastroenterologists. The presented network allows characterization of the treatment outcome in chronic hepatitis C not only with regard to virus- and host-related factors but also on an individual physician basis.

[Use of SPIO-enhanced T1- and T2-weighted images for the differentiation of liver lesions: an ROC analysis]. / Differenzierung von Leberläsionen mit SPIO-gestützten T1-w und T2-w MRT-Aufnahmen: Eine ROC-Analyse.

PURPOSE: The superparamagnetic iron oxide (SPIO) Resovist is a contrast media with shortening of both T(1) and T(2) relaxation time. This study evaluates the impact of SPIO-enhanced T(1)- and T(2)-weighted images for the differentiation of liver lesions. MATERIALS AND METHODS: SPIO-enhanced MRI examinations (1.5 T, Symphony Quantum) of 61 patients were analyzed. Thirty-seven patients had malignant liver lesions (metastases n = 32, HCC n = 5) proven by biopsy or laparotomy, 11 patients had benign liver lesions (FNH n = 2, hemangiomas n = 4, benign cysts n = 5, normal liver on laparoscopy n = 13). After unenhanced T(1)- and T (2)-weighted imaging, a bolus injection of 1.4 ml SPIO (Resovist) was given, followed by T(1)-weighted imaging at 20 s, 60 s, and 5 min and T(2)-weighted imaging at 10 min post injection. A score from 1 (benign) to 5 (malignant) was used by three blinded radiologist for the ROC analysis of the unenhanced T(1)-/T(2)-weighted images (set 1) and of the combinations of unenhanced T(1)/T(2)-weighted and SPIO T(1)-weighted images (set 2), unenhanced T(1)/T(2) and SPIO T(2)-w images (set 3) and all images (set 4). RESULTS: The accuracy of plain MRI (set 1: 56 %) was increased by SPIO-enhanced T(1)-weighted images (set 2: 81 %) and SPIO-enhanced T(2)-weighted images (set 3: 90 %). Best results were obtained using unenhanced T(1)-weighted, unenhanced T(2)-weighted and both SPIO T(1)-weighted and T(2)-weighted images (set 4: 93%). The accuracy of predicting histopathologic diagnosis was 91%. CONCLUSION: For the differentiation of liver lesions, SPIO-enhanced T(2)-weighted images had a greater impact on the accuracy of MRI than T (1)-weighted images, but SPIO-enhanced T(1)-weighted images provided additional information in some patients and should not be deleted.

Characterization of BrkA expression in Bordetella bronchiseptica.

BrkA confers resistance to killing by complement in Bordetella pertussis. Complement resistance in Bordetella bronchiseptica was examined. Four B. bronchiseptica strains possessed the brkA gene; however, only three expressed the protein. Only the strain lacking BrkA was susceptible to complement. Introduction of the B. pertussis brkA gene restored BrkA expression to this strain but did not confer resistance. brkA was mutated in the strains that naturally expressed BrkA, and loss of BrkA did not confer sensitivity to complement. As a species, B. bronchiseptica is more resistant to complement than B. pertussis, and BrkA does not mediate resistance.

Double-blind, multicenter, placebo-controlled evaluation of clarithromycin and omeprazole for Helicobacter pylori-associated duodenal ulcer.

BACKGROUND: Eradication of Helicobacter pylori leads to faster ulcer healing and a significant decrease in ulcer recurrence. Clarithromycin is the most effective monotherapy for eradicating H. pylori from the gastric mucosa, and omeprazole frequently is used for the treatment of duodenal ulcer disease, prompting the interest to investigate rigorously the combination of clarithromycin and omeprazole for eradicating H. pylori. MATERIALS AND METHODS: The aim of this double-blind, randomized, multicenter (n = 30), multinational (n = 10) study was to compare clarithromycin and omeprazole with omeprazole monotherapy for the eradication of H. pylori from the gastric mucosa, endoscopic healing, and reduction of symptoms and ulcer recurrence in patients with active duodenal ulcer. Patients with active duodenal ulcer associated with H. pylori infection were randomized to receive omeprazole, 40 mg every morning for 14 days, with either clarithromycin, 500 mg, or placebo three times daily, which was followed by omeprazole, 20 mg every morning for 14 days. Patients underwent endoscopy before enrolling in the study, immediately after finishing treatment, and at 4- to 6-week and 6-month follow-up evaluations or at the recurrence of symptoms. RESULTS: Two hundred and eight patients with active duodenal ulcer associated with confirmed H. pylori infection were randomized to treatment with either clarithromycin and omeprazole (n = 102) or omeprazole and placebo (n = 106). Four to six weeks after treatment was completed, H. pylori was eradicated in 74% (95% confidence interval, 63.0%-82.4%) of patients receiving clarithromycin and omeprazole, compared with 1% (0.0%-6.2%) of patients receiving omeprazole monotherapy (p < .001). Clarithromycin resistance developed in eight patients treated with clarithromycin and omeprazole and in none given omeprazole and placebo. Ulcers, which were healed following treatment in more than 95% of study patients, recurred by the 6-month follow-up visit in 10% (5%-19%) of dual therapy recipients, compared with 50% (39%-61%) of those who took omeprazole alone (p < .001). CONCLUSION: Clarithromycin and omeprazole dual therapy is simple and well-tolerated and leads to consistently high eradication rates for patients with duodenal ulcer associated with H. pylori infection.

[Lymphographic findings in AIDS patients]. / Lymphographische Befunde bei AIDS-Patienten.

The lymphographic findings in 20 patients with AIDS-most in clinical stage IV-can be divided into four categories. In six there were no specific changes and in a further six the storage pattern was that of sinus histiocytosis. One patient showed transition to malignant lymphoma and another patient had atypical mycobacterial infection of the retroperitoneal lymph nodes. Six patients showed a lymphographic pattern of scarring. The results of this study show that lymphography is a sensitive method that can provide important additional information.

Investigation of the effect of duodenoscopy on sphincter of Oddi manometry.

To investigate whether endoscopy affects sphincter of Oddi (SO) manometry, three patients who had undergone previous cholecystectomy and had a T-tube in situ for drainage were studied. Manometry was performed using a perfused triple lumen manometry catheter (diameter 1.7 mm), which was advanced into the SO lumen through the T-tube. SO motility, baseline pressure, common bile duct pressure and duodenal pressure were monitored before and during endoscopy while the tip of the endoscope was in the mouth, esophagus (upper third, precardial), stomach and duodenum. Endoscopy and even a moderate insufflation of air necessary to pass the pylorus and inspect the papilla of Vater did not affect the parameters mentioned. Thus, ERCP manometry is a reliable method for evaluation of SO motility which is not affected by endoscopy. Duodenal pressure is a stable parameter and suitable for serving as reference pressure.

[Computerized tomography differentiation of pigment and cholesterol bile duct calculi]. / Computertomographische Differenzierung von Pigment- und Cholesteringallensteinen.

Successful oral litholytic and other non-operative therapies of gallstones require exact determination of the stone components. Since computed tomography (CT) provides highly sensitive measurement of density, we performed a study to evaluate whether CT measurement of stone density allows to predict the composition of radiolucent gallstones. 28 patients presenting with 29 radiolucent gallbladder (n = 17) or common bile duct stones (n = 12) were included. Prior to operative or endoscopic therapy the attenuation values (Hounsfield Units/HU) were assessed in vivo by CT under standardised conditions (Somatom II; 125 KV; 130 mAs). After surgical or endoscopic stone removal the concrements were dehydrated, homogenised and then analysed by infrared spectroscopy. 18 cholesterol and 11 pigment stones could be identified. The attenuation values (Hounsfield Units) of cholesterol stones amounting to 28-98 HU (48.7 +/- 4.4 HU) differed significantly (p less than 0.001) from pigment stones (90-120 HU/105.5 +/- 2.8 HU). We conclude that computed tomography provides exact discrimination between cholesterol and pigment stones in vivo. Since only cholesterol stones can be dissolved by cheno/ursodeoxycholic acid we recommend to measure the radiodensity of gallstones by CT prior to any litholytic therapy.

[Extrasystoles during extracorporeal biliary shockwave lithotripsy. Their incidence and clinical significance]. / Extrasystolie während extrakorporaler biliärer Stosswellenlithotripsie. Inzidenz und klinische Bedeutung.

Incidence and clinical significance of cardiac side effects of extracorporeal shock-wave lithotripsy (ESWL) were prospectively analysed for 85 patients (26 men, 59 women; mean age 44 [17-81] years) with cholecystolithiasis (n = 70) or choledocholithiasis (n = 15). 24-hour ECG monitoring was undertaken on the day of treatment. Additionally, during ESWL cardiac rhythm and blood pressure were monitored. ESWL was performed with an electromagnetic lithotriptor under light anaesthesia with intravenous diazepam (10 mg) and pethidine (75-100 mg). There were no superventricular premature systoles in any of the patients during treatment. In 15 patients with occasional ventricular premature systoles (VPS) (6-81 per 23 hours) in the 24-hour ECG the number of VPS increased during the one-hour ESWL procedure significantly to 6-55 (P less than 0.05). 14 of these patients had an unremarkable cardiac history. Changing the lithotriptor coupling angle failed to suppress the VPS in only two patients. In these two it was necessary to trigger the shock wave with the ECG. Blood pressure rose markedly (up to 220 mm Hg systolic) during ESWL in only three patients, known hypertensives. But this rise was easily controlled with nifedipine, 10 mg sublingually. These data demonstrate that ESWL is a safe alternative to operative treatment, even in the presence of existing cardiac disease. Nonetheless, precautions should be taken in case there are complications.

Electromagnetically generated extracorporeal shock wave lithotripsy and adjuvant combined oral litholysis for therapy of symptomatic gallbladder stones.

A prospective study was conducted to evaluate effectivity, problems and adverse effects of extracorporeal shock wave lithotripsy (ESWL) using a newly developed electromagnetic biliary lithotriptor (Lithostar Plus, Siemens, Erlangen, FRG) for the treatment of selected patients presenting with symptomatic cholecystolithiasis. In addition to generally accepted criteria for the selection of patients, gallbladder contractility was established and pigment stones were excluded by computed tomography (CT). 80 out of 486 patients (63 females, 17 males, mean age 36, range 17-76 years) were selected for ESWL using a standardized diagnostic program. 62 out of 80 patients participating in the study had solitary concrements (diameter 23.3 +/- 6.4 mm) while in 18 patients 2 or 3 stones (diameter below 10 mm) were observed. Stone fragmentation was achieved after an average of 1.35 treatment sessions (range 1-3) in 78 (97.5%) patients. No clinically relevant adverse effects were observed. Immediately after ESWL, ultrasound revealed misleading results with regard to stone fragmentation. 98.7% of patients (n = 77) were seen for follow-up investigations 3, 6 and 9 months after ESWL, and 82% at 12 months. A total of 40 (53%) patients became free of stones. Subgroup analysis showed that 68% of the patients were free of stones (stone diameter 10-20 mm), 54% (20-30 mm) and 33% (multiple stones), respectively. We therefore conclude that ESWL should be restricted to highly selected patients presenting with small (10-20 mm) solitary concrements.

Analysis of radiolucent gallstones by computed tomography for in vivo estimation of stone components.

Successful oral litholytic and other nonoperative therapies of gallstones require exact determination of the stone components. Since computed tomography (CT) provides highly sensitive measurement of density, we performed a study to evaluate whether CT measurement of stone density allows a prediction of the composition of radiolucent gallstones. Twenty-eight patients presenting with 29 radiolucent gallbladder (n = 17) or common bile duct stones (n = 12) were included. Prior to operative or endoscopic therapy the attenuation values (Hounsfield Units, HU) were assessed in vivo by CT under standardized conditions (Somatom II, 125 KV, 130 mAs). After surgical or endoscopic stone removal the concrements were dehydrated, homogenized and then analysed by infra-red spectroscopy. The previously measured Hounsfield units were not known to the investigator. Eighteen cholesterol and 11 pigment stones could be identified. The attenuation values (Hounsfield units) of cholesterol stones amounting to 28-98 HU (48.7 +/- 4.4 HU) differed significantly (P less than 0.001) from pigment stones (90-120 HU/105.5 +/- 2.8 HU). We conclude that computed tomography provides exact discrimination between cholesterol and non-cholesterol stones in vivo. Since only cholesterol stones can be dissolved by cheno- and ursodeoxycholic acid we recommend measurement of the radiodensity of gallstones by CT prior to any litholytic therapy. Furthermore the prediction of the stone composition facilitates the decision on extracorporeal shock wave lithotripsy and the selection of specific solvents for contact lysis via a nasobiliary probe.

[Esophageal varices: is bleeding predictable?]. / Osophagusvarizen: Ist die Blutung vorhersehbar?

Hemorrhage of oesophageal varices is still a life-threatening complication of portal hypertension. Parameters to identify patients being on risk to bleed are on demand for prophylactic therapy. Recent studies showed that bleeders present with larger varices, red color sign of the variceal wall and higher intravariceal hydrostatic pressure than patients without previous hemorrhage. Advanced liver disease (Child C) is an additional risk factor. The clinical value of the parameters appears to be decreased by a significant overlap of the findings obtained in bleeders and non-bleeders. However, patients with small varices, low variceal pressure (less than 12 mmHg) and fair condition are considered to be not on risk to bleed from varices. An additional clinical value of the parameters is provided by the potency to define patients more accurately for future clinical studies.

Electromagnetically generated extracorporeal shockwaves for fragmentation of extra-and intrahepatic bile duct stones: indications, success and problems during a 15 months clinical experience.

Electromagnetically generated extracorporeal shock waves (without waterbath) were applied after intravenous premedication with 10-15 mg diazepam and 100 mg tramadol in the treatment of 33 patients (aged 32 to 91 years) with multiple intrahepatic stones (n = 4) or huge common bile duct stones (n = 29, 18-30 mm in diameter), which could not be removed by conventional endoscopy. Stone disintegration was achieved in 70% of common bile duct stones and in all intrahepatic concrements after 800-7500 discharges, which were applied during one (n = 21), two (n = 6) or three sessions (n = 6). Apart from mild fleabite-like petechiae at the side of shock wave transmission no other side effects were observed for a total of 51 procedures. We believe electromagnetically generated shock waves are safe, easy to apply, and relatively effective in the therapy of common bile duct and intrahepatic stones.

[Retractile mesenteritis. Diagnostic and therapeutic aspects]. / Die retraktile Mesenteritis. Diagnostische und therapeutische Aspekte.

An 18-year-old boy, who had severe abdominal pain for 18 months associated with marked weight loss, was found to have a stenosed ileal sling on double-contrast radiology of the small intestine. At operation a plate-like tumour was extending from the pancreas to the aortic bifurcation. Histological examination of removed tissue revealed retractile mesenteritis (mesenteric panniculitis; liposclerotic mesenteritis). The symptoms regressed and the patient again gained weight under immunotherapy with 1 mg/kg of prednisone and 2 mg/kg of cyclophosphamide daily. Subsequently, under prednisone alone, there was a recurrence, which responded within five weeks to daily 60 mg prednisone and 125 mg cyclophosphamide. The patient remains symptom-free on 125 mg cyclophosphamide and 10 mg prednisone daily.

[Extracorporeal shockwave lithotripsy of gallstones: how many patients are suitable for it?]. / Extrakorporale Stosswellenlithotripsie von Gallenblasensteinen: Wie viele Patienten sind geeignet?

The proportion of patients with gallbladder stones suitable for extracorporeal shockwave lithotripsy (ESWL) was analysed prospectively in 200 patients aged 17-76 years (62 males, 138 females) with symptomatic cholecystolithiasis. Criteria for inclusion were clinical symptoms, solitary stones (diameter 10-30 mm) or up to three stones with comparable total volume, contractile gallbladder, no calcification of stones, normal biliary tract anatomy. To check these criteria a step-by-step diagnostic procedure was instituted which consisted of history, ultrasonography with contractility test, abdominal X-ray film, computed tomography measurement of stone density, and endoscopic retrograde cholangiography. Only 19 patients fulfilled the criteria. The others had to be excluded because of history (35), stone size or number (73), impaired gallbladder contractility (27), calcified stone (30), pigment content (12), and/or biliary tract anatomy. Thus only a surprisingly small percentage (about 10%) of patients with symptomatic gallbladder stones is suitable for ESWL.

[Duplex sonography of the portal vein. Procedure in healthy probands and patients with portal hypertension]. / Duplexsonographie der Pfortader. Vorgehen bei Gesunden und Patienten mit portaler Hypertension.

Duplex ultrasonography is a useful non-invasive means of investigating portal vein blood flow in cases of liver disease. A group of 50 selected consecutive patients with portal hypertension revealed a significant increase in portal vein diameter of 3.5 mm on average, and a significant decrease in mean flow rate of, on average, 3.1 cm/s, in comparison with a group of 50 healthy control subjects. In contrast, alcohol-induced portal hypertension appeared always to be associated with an elevated flow rate. On average, the flow volume increased by 200 ml/min. With the exception of vessel diameter, which remains virtually unchanged, both patients and controls revealed, postprandially, a comparable increase in the parameters measured.

Electromagnetically generated extracorporeal shock waves for gallstone lithotripsy: in vitro experiments and clinical relevance.

First generation shock wave sources have been proved to disintegrate gallstones effectively, but they require the immersion of the patient's body in a tank of water. A recently developed second generation shock wave source (Siemens-Lithostar, Erlangen, FRG) generates shock waves electromagnetically. It presents several novel features. In particular the waterbath can be omitted and due to lower shock wave pressure general anaesthesia is not required. In vitro studies showed that 36 out of 38 gallstones (11-30 mm in diameter) could be disintegrated. Two concrements resisting lithotripsy were pure white cholesterol stones. Independent of shape, size, and composition (cholesterol or pigment) the maximum diameter of remaining fragments after lithotripsy was between 1 and 8 mm. For sufficient disintegration precise focusing (+/- 1 cm) of the stones and maximum power of the shock wave generator were required.