[69 year-old patient with chronic abdominal pain and anemia in neurofibromatosis]. / 69-jähriger Patient mit chronischen Bauchschmerzen und Anämie bei Neurofibromatose.

The case of a patient with neurofibromatosis type 1 with chronic abdominal pain and iron deficiency anemia is described. Diagnostic procedures including esophagogastroduodenoscopy and ileocolonoscopy did not disclose a definitive cause. CT scan and MRI revealed multiple intraluminal tumors in the small bowel, especially in the ileum. These findings were verified by double balloon enteroscopy. Endoscopic resection was not performed due to size and number of the polyps, and the patient was sent for diagnostic laparotomy. A conglomerate tumor of the ileum was resected. Histopathological analysis revealed 13 inflammatory polyps and 2 gastrointestinal stroma tumors.

Contrast-enhanced ultrasound improves real-time imaging of ablation region during radiofrequency ablation: preliminary results.

PURPOSE: To assess the added value of depicting tumour microvascularisation, using dynamic contrast enhanced (CEUS), during radiofrequency ablation, as a means of achieving a complete ablation (CA) of malignant liver lesions. MATERIAL AND METHODS: 18 consecutive patients (2 female, 16 male, age range 52-79 years, mean 64.1 ± 9.9 years) with 22 histologically confirmed hepatic malignancies (HCC: n = 10, liver metastases: n = 12) underwent RFA. Before RFA treatment, conventional US, CEUS and contrast enhanced CT (ceCT) of the liver were performed. During the CT-guided RFA procedure, CEUS was performed to asses the ablation defect. In case of partial ablation a subsequent ablation was performed with a corrected electrode position and evaluated again using CEUS. This procedure was repeated until a CA was achieved. The number of ablations per patient was recorded. Secondary efficacy parameters assessed were lesion detectability in the different imaging modalities and contrast phases. RESULTS: Overall intraprocedural CEUS led to a change in therapeutic management in 59% of cases, resulting in 17 additional ablation cycles. Lesion detectability during CT Fluoroscopy was the sole statistical significant predictor of incomplete ablations (p = 0.008). The mean number of ablations for detectable lesions was 1.27 vs. 2.27 ablations for not detectable lesions (p = 0.002). The combined CT and CEUS RFA procedure led to a CA for all treated lesions in follow up 3 month post intervention. CONCLUSION: CEUS does allow a reliable and immediate assessment of therapeutic efficacy of percutaneous RFA procedures of malignant liver lesions, through the continuous dynamic evaluation of tumour microcirculation.

Contrast-enhanced ultrasound in diagnosing liver malignancy.

PURPOSE: The use of contrast enhancers has widened the possibilities of sonographic imaging, and allows the differentiation of characteristic enhancement patterns leading to diagnosis in focal liver lesions. The aim of our study was to evaluate contrast ultrasound signs in diagnosing malignant liver lesions. METHODS: 86 patients with 100 solid liver lesions were enrolled. A baseline gray-scale sonogram was obtained with a multifrequency 4 C convex array probe, followed by contrast-enhanced sonography with a low mechanical index (<0.2) over 300 seconds. Final diagnosis was confirmed by histology or in case of haemangioma by CT/NMR and quantitative contrast harmonic imaging (CHI) with perfusion analysis (contrast). RESULTS: 55 malignant (6 HCC, 46 secondary malignant lesions - 3 of them lymphoma, 3 cholangiocarcinoma), and 45 benign lesions (8 FNH, 1 von Meyenburg complex, 1 granuloma, 3 adenoma, 21 hemangioma, 2 focal fat storage imbalances, 7 abscesses, one scar, and in one case normal liver) were found. 51/55 malignant (all but one filia and three HCC), but also 17/45 benign lesions showed hypoperfusion in the late phase. The ultrasound pattern in the arterial phase differed in malignant lesions: 22 lesions were initially hypervascular, 20 had rim enhancement and in 13 lesions there was a non-specific vascularisation. In all but one malignant lesion a diminishing of contrast agent in the late phase compared to the arterial phase with respect to the surrounding liver tissue was observed. Only three benign lesions with this later sign were falsely diagnosed as malignant: one adenoma, one epitheloid granuloma, and a scar. Quantitative perfusion pattern was analyzed exemplary. Diminishing of contrast agent in the late phase compared to the arterial phase with respect to the surrounding liver tissue as a sign for malignancy had a positive predictive value of 95%, a sensitivity of 98%, a negative predictive value of 98%, and a specificity of 93%. CONCLUSIONS: Diminishing of contrast agent in the late phase compared to the arterial phase with respect to the surrounding liver tissue is a helpful sign in contrast enhanced ultrasound to diagnose malignancies.

Trimming of a Broken Migrated Biliary Metal Stent with the Nd:YAG Laser.

Biliary metal stents are a permanent solution for bile duct stenosis. Complications can arise when the stent migrates, breaks or is overgrown by tumour. The following case demonstrates how a Nd:YAG laser can be used to solve these problems. A 93-year-old man presented with jaundice and fever. Two years earlier a 6-cm metal stent had been implanted into a postinflammatory stenosis of the common bile duct after recurrent cholangitis and repetitive plastic stenting. Duodenoscopy showed that the stent was broken. It had migrated about 3 cm into the duodenum, leading to kinking of the stent and breaking of the wires. The stent was also occluded. It was necessary to purge the common bile duct and to introduce a second stent. However, the only way to reach the papilla was through the broken wires. Placing a second stent this way was impossible. Thus we trimmed the stent with a Nd:YAG laser. The piece that had migrated into the duodenum was retrieved. Now the papilla could be reached. The rest of the metal stent was purged with NaCl 0.9%. A second metal stent was placed. Since an Nd:YAG laser is part of the equipment of most endoscopy units, it can be used to trim a broken or migrated biliary metal stent.

Microcirculation and perfusion with contrast enhanced ultrasound (CEUS) in Crohn's disease: first results with linear contrast harmonic imaging (CHI).

AIM: To evaluate a newly introduced high resolution linear transducer for vascularization and mural perfusion assessment using contrast harmonic imaging (CHI) with quantitative time intensity curve analysis (TIC) in patients with active Crohn's disease (CD). MATERIAL AND METHODS: We prospectively evaluated 14 consecutive patients (7 women, 7 males, age range 19-42 years, median 28 years) with histologically proven CD having an acute episode of the disease applying contrast enhanced MRI and high resolution ultrasound. For the ultrasound we used a newly introduced high resolution linear multi-frequency transducer (6-9 MHz, Logiq 9, GE). Ultrasound was performed by an experienced radiologist applying color coded Doppler sonography (CCDS), power Doppler (PD) and contrast enhanced CHI using the 'true agent detection mode'. Additionally, 5 healthy volunteers were examined by ultrasound applying CCDS, PD and CHI. After the injection of 2.4 ml ultrasound contrast agent (SonoVue) the dynamic CHI cine sequences were recorded as digital raw data for 60 seconds. Therefore we were able to perform a quantitative perfusion analysis using TIC retrospectively. CCDS, PD and CHI with TIC were compared and analyzed. RESULTS: In all 14 patients MRI showed inflammatory changes in the terminal or pre-terminal ileum. Using PD and CCDS enlarged vessels surrounding the bowel wall were visualized in all patients. PD as well as CCDS diagnosed just in 9 of 14 patients augmented mural vessels. Having CHI with TIC increased mural contrast enhancement was diagnosed in all 14 patients. Patients with CD showed a maximum enhancement 36 s after injection with 9 dB (range 5.9-13.2 dB), while healthy volunteers reached the maximum level of 2.8 dB (range 2-3.8 dB) after 23 s (p<0.05). CONCLUSION: Using high resolution linear transducer mural perfusion changes in active Crohn's disease can be appreciated applying CHI with TIC. This technique could be an effective dynamic imaging modality for diagnosis and especially follow-up examination to monitor treatment in CD.

Endoscopic retrograde cholangiography of a hepaticojejunostomy using double balloon enteroscopy.

Examination of a biliodigestive anastomosis presents a diagnostic and therapeutic challenge. Visualization of biliodigestive anastomosis and endoscopic retrograde cholangiography with intervention is possible with a double balloon enteroscope.

[Minimal invasive therapy in a patient with necrotizing pancreatitis and disrupted duct by percutaneous endoscopy: report of a case and review of literature]. / Minimalinvasive Therapie einer Patientin mit nekrotisierender Pankreatitis und unterbrochenem Pankreasgang: Darstellung des Falles und Review der Literatur.

A 68-year-old lady was admitted to a primary care centre with abdominal pain. She presented with a tender abdomen and a lipase level of 29 456 U/L. Cholecystectomy had been performed in 1971. Because her clinical state worsened the patient was transferred to our intensive care unit. Computed tomography and contrast ultrasound revealed necrotising pancreatitis. Antibiotics were started immediately. 10 days later the patient became febrile and an area of liquid necrosis between the spleen and the left kidney was drained under sonographic guidance by a 12 Fr pigtail. Every ten days the drain was replaced by a larger one. ERCP revealed a communication between the pancreatic duct and the growing necrotic cavity. A 7 Fr/ 7 cm plastic stent was put in. After 30 days an unsuccessful endoscopic necrosectomy was attempted with the cholangioscope through a 28 Fr peel-away sheath. In a further session an effective percutaneous necrosectomy was possible through a laparascopy trocar with a standard gastroscope. The patient became afebrile and signs of infection decreased. The persisting communication between the pancreatic duct and the necrotic cavity was closed with onyx. In the following days the dimensions of the necrotic cavity decreased rapidly. Finally the patient could be discharged home in good health. Antibiotics were stopped and the percutaneous drain was taken out after some weeks of ambulatory care.

Bleeding jejunal diverticulosis in a patient with myasthenia gravis.

A seventy-year-old male presented with severe myasthenia gravis and an episode of obscure bleeding. There was a history of gastric ulcer leading to Billroth II surgery twenty-five years ago. Upper endoscopy revealed no pathology. Colonoscopy showed a few solitary diverticula and traces of old blood in the terminal ileum. Capsule endoscopy pictured red smear in the upper jejunum. Diverticula were seen as well. Suspecting bleeding jejunal diverticulosis double balloon enteroscopy was performed. The complete jejunal ascending loop and about 100 cm of the jejunum through the descending jejunal loop could be inspected. Large diverticula with fecoliths were found in both loops. Bleeding had ceased. The patient was discharged to neurology for optimizing therapy for myasthenia gravis.

[The diagnostic approach to hepatocellular carcinoma]. / Diagnostik des hepatozellulären Karzinoms.

Risk factors and symptoms of hepatocellular carcinoma (HCC): The main risk factors of HCC include infection with hepatitis B or C virus, as well as alcohol consumption. There are no specific symptoms of HCC, making early diagnosis and detection of the disease difficult. When HCC presents with specific clinical symptoms, the tumour is typically very far advanced. Surveillance in liver cirrhosis: The most common serological marker used in HCC diagnosis is alpha-fetoprotein (AFP), but other tumour markers such as the des-gamma-carboxyprothrombin (DGCP) or fractions of AFP (AFP-L3) exist and there use is discussed in this context. Surveillance should be done by sonography at 6 (to 12) months intervals. The single nodule in the cirrhotic liver: Ultrasound is the most commonly used imaging modality for detecting HCC tumour nodules with a large range of reported sensitivities. HCC may appear as a hypoechoic, isoechoic, or hyperechoic round or oval lesion with intratumoural flow signals on Doppler or power Doppler sonography. The differentiation of smaller malignant lesions in cirrhotic livers can be improved by contrast-enhanced ultrasound (CEUS). Spiral computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast enhancement play an important role in the diagnosis and staging of HCC. If the vascular pattern on imaging is not typical, biopsy becomes necessary. The patient with known HCC: Different tumour markers are used in the evaluation of tumour progression, prediction of patient outcome and treatment efficacy. Among the various staging systems used in the context of HCC, the Barcelona-Clinic-Liver-Cancer (BCLC) staging system is currently the only staging system that takes into account tumour stage, liver function, physical status and cancer-related symptoms. Beside surgical resection, non-surgical treatments such as percutaneous ethanol injection (PEI), radiofrequency thermoablation (RFTA) and trans-arterial chemoembolisation (TACE) are used. Successful tumour "bridging" with ablative therapy methods can be achieved in carefully selected patients on the waiting list for orthotopic liver transplantation. Contrast-enhanced sonography is able to control the ablation treatment of HCC.

Placement of a biliary metal stent to expand a choledochus stenosis after Frey's surgery.

A 47-year-old patient presented with jaundice. Laboratory examinations confirmed cholestasis. The patient had a long history of chronic pancreatitis. Subsequently, cholecystectomy and a duodenum-preserving resection of the pancreatic head (Frey's surgery) had been performed. Endoscopic retrograde holangiography was done. The endoscope was inserted the normal way to the untouched papilla vateri. After injection of contrast medium, only the side-to-side choledocho-jejunal anastomosis but not the common bile duct could be visualized because the catheter spontaneously slipped into the jejunum via the side-to-side choledocho-jejunal anastomosis. After introducing a catheter percutaneously into the intrahepatic bile duct system, a long stenosis of the common bile duct could be visualized. It was possible to overcome the stenosis with a wire, but the wire also dislocated into the jejunum via the side-to-side choledocho-jejunal anastomosis and could not be placed through the papilla into the duodenum. The problem was solved in a tricky way: A wire was introduced into the common bile duct via the papilla and placed into the duodenum. A loop was brought in percutaneously and was also placed in the jejunum. With the loop, the wire was grabbed and taken out percutaneously. Now a biliary metal stent could be positioned correctly over the wire to expand the stenosis. After the procedure jaundice was cured quickly. The further course was uneventful with complete recovery.

[Cholangitis with subphrenic abscess after complicated cholecystectomy due to occluded plastic stents]. / Cholangitis mit Ausbildung eines subphrenischen Leberabszesses nach komplizierter Cholezystektomie auf dem Boden verschlossener Plastikstents.

A 62-year-old lady presented with fever and abdominal pain. History revealed cholecystectomy two years ago due to cholecystolithiasis, complicated by perforation of the common bile duct, leading to hepaticojejunostomy, jejunocholedochostomy, endoscopic retrograde insertion of two plastic stents and percutaneous drainage of bilioma. The patient was lost to follow-up until she presented two years later in the emergency room. ERC was performed. Both stents were occluded. After extraction dirty bile popped out. Injection of contrast medium showed stones in the remaining common bile duct and dilatation of the intrahepatic bile ducts and the interposed jejunum. After stone extraction a subphrenic intrahepatic fluid collection became visible when injecting contrast medium in the intrahepatic bile ducts. Pus was aspirated. The abscess was drained with a nasobiliary tube. Antibiotics were given. Temperature and CRP normalized. The nasobiliary tube was removed when the biliary fluid was clear. Recovery was uneventful with complete resolution of symptoms.

[Chronic diseases after gastrointestinal surgery]. / Folgeerkrankungen nach gastrointestinalen Operationen.

Gastrointestinal surgery may not only lead to early postoperative complications but also chronic consequences. These have therapeutic implications for affected patients. The kind and extent of surgical intervention determines the spectrum of postsurgical phenomena which may occur. These chronic consequences are due to changes in gastrointestinal anatomy, the synchronization of digestive processes, or the ability to digest and absorb food. In case of transplantation surgery, adverse effects of immunosuppression have to be considered. Sometimes, chronic consequences of surgical procedures are difficult to recognize. The knowledge of typical problems associated with gastrointestinal surgery is necessary to enable early and timely diagnosis and treatment. Some negative effects can be avoided by early therapeutic interventions. This article summarizes typical chronic consequences of gastrointestinal surgery.

[Local ablation of malignant lesions of the liver - potential applications and limitations of the different methods]. / Lokale Ablationsverfahren als Ergänzung der Therapie maligner Leberläsionen.

Malignant lesions of the liver are among the most frequent and difficult problems in clinical practice. Liver tumors can be classified as primary (hepatocellular carcinoma HCC, cholangiocarcinoma CC) and secondary liver lesions (metastasis). The therapeutic principle of resecting liver tumours, applies to both types of liver lesions. Unfortunately many patients with primary and secondary liver lesions are inoperable because of technical difficulties or comorbidity. This stimulated the development of percutaneous ablation methods. These procedures allow to destroy tumors percutaneously with alcohol, acetic acid, radiofrequency, microwaves or laser. Potential applications and limitations of the methods are discussed.

[Systemic treatment for hepatocellular carcinoma]. / Medikamentöse Therapie des hepatozellulären Karzinoms.

Hepatocellular carcinoma (HCC) is one of the most frequent malignancies worldwide. A variety of pharmacological strategies has been evaluated in the treatment of HCC: classical chemotherapy, tamoxifen, octreotide, thymostimulin, pravastatin, (131)I-lipiodol as well as transarterial chemoperfusion (TAC) and chemoembolisation (TACE). TACE monotherapy or TACE combined with pravastatin resulted in a survival benefit of selected HCC patients. New strategies such as immunotherapy, antiangiogenic agents or cyclooxygenase inhibitors are under clinical investigation and might play a role in future therapies for HCC. Efficient strategies for the primary prevention of HCC are available and promising concepts in the secondary prevention have been reported.