The esophageal hiatus: what is the normal size?

BACKGROUND: A hiatal hernia is defined as the protrusion of intra-abdominal organs through a dilated esophageal hiatus. The esophageal hiatus and its function have been described extensively, but an exact anatomical determination of its normal size is lacking. It seems important to define the normal size, as crural closure is an important part of surgical treatment of gastroesophageal reflux disease (GERD) and hiatal or paraesophageal hernias. The aim of this study was to determine normal values for the size of the esophageal hiatus. METHODS: In a prospective study 50 consecutive cadaver autopsies were performed between February and May 2008. The subjects had died from several diseases not related to GERD. Size of the esophageal hiatus was measured after opening the abdominal cavity before extirpation of any organs. Distance of the cardia and gastroesophageal junction and position of the angle of His were further measured. A formula was used to calculate the hiatal surface area (HSA). Results were analyzed regarding subject height, weight, body mass index (BMI), and chest circumference. RESULTS: In all 50 cadavers (24 male/26 female) the autopsy was performed and all measurements were obtained. Mean age was 74 years (40-90 years), mean height was 1.68 m (1.39-1.83 m), mean weight was 71 kg (40-120 kg), and mean body mass index (BMI) was 25 kg/m(2) (14-40 kg/m(2)). Mean chest circumference was 101 cm (75-178 range). Mean HSA was 5.84 cm(2) (3.62-9.56 cm(2)). In all cadavers the gastroesophageal junction was intraabdominal, the mean distance to the angle of His was 3.6 cm (2.7-4.6 cm), the mean length of the right and left crura was similar at 3.6 cm (2.7-4.6 cm), and the opening segment had a mean length of 2.4 cm (1.7-4.0 cm). CONCLUSION: The mean HSA was determined in these normal subjects to be 5.84 cm(2). It was directly proportional to chest circumference and independent of height, weight, BMI, and gender.

[Malacoplakia: a possible complication of poorly controlled diabetes mellitus?]. / Malakoplakie--eine mögliche Komplikation bei Diabetes mellitus mit schlechter Stoffwechsellage?

HISTORY AND ADMISSION FINDINGS: A 47-year-old woman with poorly controlled diabetes mellitus (HbA1C 9.2%, fasting blood glucose > 200 mg/dl) had complained of moderately severe stabbing pain in the left abdomen. On admission there were no abnormal findings on abdominal palpation. INVESTIGATIONS: Abdominal ultrasound and computed tomography (CT) revealed a partly solid partly cystic well-circumscribed space-occupying lesion, about 15 cm in diameter, in the left abdomen, extending from the lower third of the kidney into the pelvis. DIAGNOSIS, TREATMENT AND COURSE: Biopsy of the lesion showed chronic granulating inflammation with foamy histiocytes (Hansemann macrophages) as characteristic substrate of extensive malakoplakia. Despite the size of the lesion it was not excised but long-term treatment with ciprofloxacin undertaken. At the same time, the diabetes was carefully controlled with ordinary insulin. Ten months later there was no longer any evidence of the lesion by ultrasound and CT. CONCLUSIONS: Even extensive malakoplakia can be successfully treated with ciprofloxacin. Poorly controlled diabetes together with a weak immune status (CD4/CD8 < or = 1) may have favoured the occurrence of malakoplakia.

Effect of mild dietary protein restriction on urinary protein excretion in patients with renal transplant fibrosis.

In recent studies, it has been demonstrated that strict dietary protein restriction has a beneficial effect on renal transplant patients who show chronic rejection, or transplant fibrosis respectively; however, the protein intake in those investigations usually has been below 0.6 g/kg day, and such a strong restriction may be associated with both a negative nitrogen balance, and low patient compliance. Our study was therefore undertaken to investigate whether the same beneficial effect could be attained with a more moderate dietary protein restriction in renal transplant recipients. In a randomized cross-over study, 14 patients with biopsy-proven transplant fibrosis received a mildly protein restricted diet (0.7 g/kg/day), and a normal protein diet (1.2 g/kg/day) respectively during two 3-week periods. In the patients undergoing moderate protein restriction, a significant reduction in urinary albumin, and total protein excretion, as well as a decrease in albumin/creatinine ratio was observed at the end of the 3-week period when compared to the patients on normal protein diet (p < 0.05). The 51Cr-EDTA-clearance did not differ at the end of each of these dietary periods. In contrast to earlier studies with lower protein intake, the moderate protein restriction in our investigation was not associated with a decrease in serum proteins. In conclusion, a mildly restricted protein intake has also proved effective in significantly reducing the urinary protein excretion in patients with renal transplant fibrosis, yet, without causing decreasing serumprotein-concentrations, which are a sign for a negative nitrogen balance.

[Schoenlein-Henoch syndrome with abdominal manifestations without skin involvement]. / Schoenlein-Henoch-Syndrom mit Abdominalmanifestation ohne Hautbeteiligung.

The etiology of Schoenlein-Henoch' Syndrome has not yet been fully clarified [10, 15]. An allergically toxic genesis is under discussion [8, 19]. The classical combination of symptoms consists of urticariel efflorescences, bleeding of skin and lining tissue and arthralgies [8, 19]. Involvement of kidneys and abdomen may occur [8, 19]. Our case report concerns exclusively an abdominal form with colics, vomiting and diarrhea [10, 18, 16]. Chemical tests reveal a reduction of factor XIII [1, 5, 21]. There is no involvement of kidneys, skin or joints. With reference to literature and this particular case, etiology, diagnosis and therapy are dealt with.

[Indications for immunoscintigraphy in orthopedics and its interpretation]. / Indikationen zur Immunszintigraphie in der Orthopädie und deren Deutung.

In the view of an orthopedist the immunscintigraphy is a diagnostic and differential diagnostic enrichment. The MAK BW 250/183 is stored in a lyophiled shape. The MAK is marked with 99m Tc with little expense and in a short time. The advantage of the immunscintigraphy is the high sensitivity for places where granulocytes are gathered. The immunscintigraphy proved to be a very good proceed in recording acute inflammations.

[Kinetics and immunocytochemical staining of 99mTc-labeled monoclonal anti-CEA antibodies against granulocytes following intravenous administration]. / Kinetik und immunzytochemische Färbung monoklonaler 99mTc-markierter Anti-CEA-Antikörper gegen Granulozyten nach intravenöser Applikation.

Until now the clinical identification of the affinity of monoclonal 99mTc-anti-CEA antibodies (MAK BW 250/183) on granulocytes was made with tumor cells carrying the same epitope on NCA-95 and human granulocytes in vitro. As this antibody only binds human granulocytes, animal experiments are impossible. 3 patients had their blood withdrawn within 6 h after injection, another patient had his left hip-joint biopsied after 24 h, the samples undergoing subsequent immunocytochemical dyeing. Dyeing of granulocytes all over the smears was evident whereas lymphocytes, monocytes and erythrocytes did not show any reaction. After 6 h there seemed to be a large difference between a relatively high quantity of 86% unlabelled 99mTc-MAb and 75% of immunocytochemically stainable granulocytes in the blood through an excess of binding epitopes. Six h after injection 27% of the activity were, on average, detectable in whole blood. At this time the activity in blood was reduced to an extent that scintigraphic imaging was feasible.

["Diabetic" proliferative retinopathy and nodular glomerulosclerosis without diabetes mellitus]. / "Diabetische" proliferative Retinopathie und noduläre Glomerulosklerose ohne Diabetes mellitus.

A 65-year-old woman of normal weight, hospitalized because of pleuritis, was found to have chronic renal failure (creatinine clearance 20 ml/min). Renal biopsy (light and electron-microscopy) revealed nodular glomerulosclerosis (Kimmerstiel-Wilson disease), described as a diabetes-specific renal change. Fundoscopy discovered bilateral proliferative retinopathy as seen in diabetes. But oral and intravenous glucose tolerance tests were normal, excluding a manifest diabetic metabolic disorder. No other cause of the glomerulosclerosis (such as amyloidosis or multiple myeloma) was found. The patient had been overweight for a time when younger, reversed by dieting. It is suggested that the "diabetic" changes in the kidneys and eyes without diabetes could be the result of a transitory disorder of glucose tolerance during the period of obesity.

Fibrin glue coating of e-PTFE prostheses enhances seeding of human endothelial cells.

A laboratory study was undertaken to improve the initial count of endothelial cells (EC) adhering to the wall of e-PTFE prostheses when seeding of human EC is attempted. In our experiments pretreatment of the prosthetic wall with commercially available fibrin glue (Tissucol) improved the reliability of the seeding procedure. The number and the distribution of EC seeded onto fibrin glue presealed e-PTFE prostheses was compared to the number and distribution of EC adhering to blood preclotted grafts 24 hours following the initial seeding procedure. Fibrin glue presealed grafts showed a higher number of initially adhering EC and a more equal distribution over the graft surface when compared to blood pretreated grafts. Our results suggest that the use of fibrin glue enhances the seeding of human EC on e-PTFE grafts.

[Familial juvenile nephronophthisis--a cause of chronic renal failure in childhood]. / Die familiäre juvenile Nephronophthise--eine Ursache des chronischen Nierenversagens im Kindersalter.

Familial juvenile nephronophthisis (FJN) represents an important cause of chronic renal insufficiency in the first two decades of life. Its frequency is reported to vary between 7 and 20% of all cases of terminal renal failure in childhood. Usually the onset is insidious, with polyuria, polydipsia and anaemia being the main clinical features. The diagnosis is based on clinical, laboratory and pathological findings. The purpose of our report is to emphasize the importance of this pathological entity with respect to the clinical symptoms and signs and diagnostic approach on the basis of the case reports of four patients.

[The clinical picture in shunt nephritis]. / Zum Krankheitsbild der Shuntnephritis.

Report on three children with hydrocephalus in whom an immune complex nephritis ("shunt-nephritis") had occurred in consequence of an infected atrioventricular shunt. Besides the clinical course, the histological findings which are of particular significance with regard to pathogenesis are discussed as well as the serum complement system on the basis of the laboratory data. Removal of the valve system led to a complete normalization of the laboratory parameters and to a subsidence of the clinical symptoms in all patients. The necessity of a perioperative antibiotic prophylaxis in the insertion of an atrioventricular shunt is explicitly emphasized. Narrow-interval follow-up investigations should enable early detection of cases of shunt nephritis and thus prevent functional residues or even fatalities. Knowledge of this immune complex nephritis is also very important because it is one of the few forms of nephritis in which a causal therapy is available with removal of the infected shunt.

[111-Indium-labeled thrombocytes in the diagnosis of acute kidney transplant rejections and in monitoring the therapy of rejection reactions with prostacyclin]. / 111-Indium-markierte Thrombozyten in der Diagnostik von akuten Nierentransplantatabstossugen und zur Observierung der Therapie von Abstossungsreaktionen mit Prostacyclin.

33 patients were examined daily under a gamma camera after weekly injections of 111-In-labelled autologous platelets over a period of at least 4 weeks after transplantation. A group of 33 patients with long-term stable and well-functioning grafts served as controls. By means of a computerized recording technique, platelet trapping in the graft was measured and expressed as platelet-uptake index (PUI). The method worked well for the early diagnosis of acute rejection signified by an increase in PUI, accompanied by a shortening of platelet half life (t/2). 6 patients suffering from acute rejection received infusions of prostacyclin in addition to conventional high-dose methylprednisolone therapy. In 4 cases the PUI decreased again and an improvement in graft function was observed. Prostacyclin infusion treatment was applied also in 12 patients with histologically-proven chronic transplant rejection. Decreased platelet consumption by the graft and a temporary improvement in transplant function were achieved. We suggest that prostacyclin could enrich the possibilities of anti-rejection treatment by providing a tool for the suppression of platelet trapping in the graft. The platelet scan served as a useful method for the early detection of acute rejection, as well as the monitoring of prostacyclin anti-rejection treatment.

[Kidney involvement in liver diseases: morphology]. / Nierenbeteiligung und Lebererkrankungen: Morphologie.

Primary liver diseases are often associated with disturbance of the renal function, but only two hepatic lesions are due to glomerular changes: hepatitis B and alcoholic liver disease. Hepatitis B associated with immune complex glomerulonephritis seems to be a rare condition in adults, however children are more often involved. Glomerular changes consist of membranous deposition of immune complexes, mainly corresponding to membranous glomerulonephritis, seldom to the membranoproliferative type. Because membranous glomerulonephritis develops due to deposition of small size soluble complexes, and the hepatitis B antigens alone are estimated to be greater than soluble nephritogenic complexes, most probably low molecular weight antigenic components of the hepatitis antigens are involved in the formation of glomerulonephritis. Alcoholic liver disease is often combined with glomerulosclerosis and mesangial IgA deposition resembling the morphological pattern of IgA mesangial glomerulonephritis. These common features implicate a similar pathogenesis of both diseases. Furthermore, experimental and clinical data indicate raised serum levels of IgA and IgA deposition within glomerula and other organs in the same manner, but the cause of high serum levels of IgA remains still obscure, and may be different in both diseases.

[ Fournier gangrene: a rare complication of multiple myeloma]. / Fournier-Gangrän: Eine seltene Komplikation bei multiplem Myelom.

A 69-year-old male patient with multiple myeloma developed a dolent swelling of the right side of his scrotum at the time of maximal leukocyte depression after cytostatic drug therapy. Within a few hours the scrotal skin became gangrenous. After surgical debridement of the necrotic tissues and simultaneous antibiotic therapy the necrosis showed a favorable course.

IGA mesangial glomerulonephritis; significance and pathogenesis of segmental-focal glomerular lesions.

A review of 430 renal biopsies from patients with various nephropathies processed by light microscopy, immunofluorescence and in part by electron microscopy revealed 82 cases with diffuse mesangial IgA deposition. Sixty-three cases appearing without signs of systemic disease were included in this study. The glomerular changes consisted of mesangial increase (31 cases mild, and 32 cases severe) and segmental-focal glomerular lesions (40 cases). Immunofluorescence revealed granular deposits of immunoglobulins and complement within the mesangium (IgG 9, IgM 25, IgA 63, C3 27, C1q 0) as well as segmentally in the wall of capillary loops (IgG 4/26, IgM 20/26, IgA 0/26, C3 16/26, C1q 7/26). Electron microscopic studies (40 cases) showed electron dense deposits in the mesangial region in all biopsies and deposits either electron dense (11 cases) or radiolucent (26 cases) at various sites along the basement membrane of capillary loops. Comparison between morphological findings and clinical data showed a significant correlation between segmental-focal glomerular lesion on the one hand, and proteinuria (p less than 0.01), immune deposits along the capillary basement membrane (p less than 0.01), and the increased mesangium (p less than 0.001) on the other. Considering the macromolecular mesangial clearing function, the segmental-focal glomerular lesions may be due to newly arrived, infection related immune complexes which may not be cleared promptly by the mesangium, because its clearing function is impaired due to IgA deposition.

Increased deposition of 111Indium labelled platelets in chronically rejected kidney transplants.

Increased deposition of 111In-oxine labelled autologous platelets in chronically rejected kidney transplants was demonstrated using a gamma-camera and by measurement of a platelet uptake index (PUI). In this group of patients the PUI correlated indirectly with the platelet half-life and was statistically different from the PUI found in stable transplant patients who acted as controls. It is therefore suggested that platelets may play a key role in chronic rejection by the release of a mitogenic factor which promotes the development of obliterative arterial lesions in the transplant.