[Short version of the updated S3 (level 3) guidelines for diagnosis and treatment of gallstones of the German Society for Digestive and Metabolic Diseases and the German Society for the Surgery of the Alimentary Tract]. / Kurzfassung der aktualisierten S3-Leitlinie der DGVS und DGVC zur Diagnostik und Behandlung von Gallensteinen.

This short version of the guidelines summarizes the evidence-based key recommendations for the diagnosis and treatment of gallstones. The guidelines were developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, and patient support groups, under the auspice of the German Society for Gastroenterology and Metabolic Diseases and the German Society for General Surgery and Surgery of the Alimentary Tract. It used structural level 3 consensus-based methodology and includes statements on clinical practice, prevention, quality assurance, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone disease.

[S3-guidelines for diagnosis and treatment of gallstones. German Society for Digestive and Metabolic Diseases and German Society for Surgery of the Alimentary Tract]. / S3-Leitlinie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten und der Deutschen Gesellschaft für Viszeralchirurgie zur Diagnostik und Behandlung von Gallensteinen.

This guideline provides evidence-based key recommendations for diagnosis and therapy of gallstones and upgrades version 2000. It was developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, external comparative quality assurance and patient support groups under the auspices of the German Society for Digestive and Metabolic Diseases and the German Society for Surgery of the Alimentary Tract. The guideline used structural S3 consensus-based methodology and includes statements on clinical practice, prevention, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone diseases.

Effect of intraduodenal administration of ursodeoxycholic acid on interdigestive interaction between gallbladder motility, pancreatic secretion and endocrine activity.

BACKGROUND: Gastroduodenal motorfunction, gallbladder motility, and pancreatic secretion are closely related during the interdigestive state. The extent to which application of ursodeoxycholic acid (UDC) influences this process is only partly understood. AIM: As UDC is widely used for the therapy of gallbladder stones and of cholestatic liver disease, we wanted to define the immediate effect of UDC on interdigestive gallbladder and antroduodenal motility, biliary-pancreatic secretion and hormone release in man. METHODS: Interdigestive gastrointestinal function in 10 healthy males (26-35 years) was studied twice after 12-hour fasting on 2 different days. Antroduodenal motility was continuously recorded manometrically over a complete interdigestive migrating motor complex (MMC) cycle. Gallbladder volume was evaluated sonographically in 5- to 7-min intervals during the MMC cycle. Pancreatic and biliary secretion was determined by a standard duodenal perfusion technique measuring chymotrypsin, amylase, lipase and bile salts in duodenal aspirates every 15 min. Plasma levels of pancreatic polypeptide (PP) and motilin were determined by radioimmunoassay in 15-min intervals. On 2 separate days, 7-10 days apart, each subject received intraduodenally either 10 mg/kg UDC (pH 8) or placebo 30 min after the first recorded duodenal MMC cycle phase III. RESULTS: With placebo, the fasting gallbladder volume decreased slightly from phase I (32 +/- 8 ml) to the end of phase II (24 +/- 13 ml), but increased significantly from 31 +/- 14 ml (phase I) to 46 +/- 11 ml (phase III) after intraduodenal UDC application (p < 0.01). Pancreatic secretion was significantly reduced after UDC application at the end of phase II (secretion of chymotrypsin 10 +/- 3 U/min vs. 5 +/- 2 U/min, p < 0.01). Serum levels of PP were also reduced by UDC during the entire MMC cycle. This reached statistical significance at the end of phase II (84 +/- 8 pg/ml vs. 57 +/- 14 pg/ml; p < 0.05) and during phase III (86 +/- 19 pg/ml vs. 64 +/- 22 pg/ml; p < 0.05), while motilin slightly increased during the MMC cycle after UDC application. UDC instillation did not affect antroduodenal motility. CONCLUSION: UDC exerts significant inhibitory effects on interdigestive gallbladder contractility, pancreatic secretion, and PP release. Whether these inhibitory effects are mediated by cholinergic pathways or other mechanisms requires further investigation.

[Acute biliary colic. Etiology, diagnosis and therapy]. / Akute Gallenkolik. Ursachen, Diagnostik und Therapie.

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.

Three-dimensional magnetic resonance cholangiopancreatography with respiratory triggering in the diagnosis of primary sclerosing cholangitis: comparison with endoscopic retrograde cholangiography.

BACKGROUND AND STUDY AIMS: The purpose of this study was to evaluate the accuracy of respiratory-triggered three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) for the detection of primary sclerosing cholangitis (PSC) and to compare the specific findings of magnetic resonance cholangiography and endoscopic retrograde cholangiography in patients with PSC. PATIENTS AND METHODS: The MRCP findings were evaluated in 150 patients with clinical symptoms (progressive fatigue, pruritus followed by icterus) and/or elevated values for alkaline phosphatase and serum aspartate transaminase, and occasionally an elevated serum concentration of bilirubin as a sign of cholestasis, who were consecutively referred for magnetic resonance imaging. Two observers independently classified bile duct abnormalities and established the MRCP diagnosis in a consensus reading. The results of MRCP were compared with the definitive diagnosis, which was based on the clinical history and laboratory and histological data, as well as on endoscopic retrograde cholangio-pancreatography (ERCP) findings. In a second step, the observers compared the delineation of the biliary system and morphological findings using MRCP and ERCP in patients with confirmed PSC. RESULTS: Diagnostic examinations were obtained in 146 of the 150 MRCPs (97 %). The diagnosis of PSC was confirmed by clinical data and ERCP in 34 of these 150 patients (23 %). The sensitivity and specificity of MRCP for diagnosing PSC were 88 % (29 of 33) and 99 % (108 of 109), respectively. MRCP and ERCP yielded similar scores for the delineation of the biliary system (P = 0.2) in patients with PSC. However, different bile duct abnormalities leading to the diagnosis of PSC were depicted by MRCP and ERCP; more bile duct stenoses and pruning were seen with ERCP and more skip dilatation with MRCP (P < 10(-4)). CONCLUSION: In patients with PSC, MRCP is a highly sensitive method and its diagnostic accuracy is comparable to that of ERCP.

Long-term results and prognostic factors in the treatment of achalasia with botulinum toxin.

BACKGROUND AND STUDY AIMS: Endoscopic therapy of achalasia by injection of botulinum toxin into the lower esophageal sphincter has very limited adverse effects and is initially successful in 70 % of patients. However, this result only lasts for 6 - 9 months on average in most patients and only half of them benefit for more than 1 year. The aim of this study was to find out which factors are predictive for a good long-term success. PATIENTS AND METHODS: We retrospectively studied 25 patients with achalasia. The diagnosis had been proven by barium swallow and esophageal manometry. Therapy was carried out endoscopically between June 1996 and December 1998 by injection of 25 mouse units (MU) botulinum toxin into each of the four quadrants of the lower esophageal sphincter (LES). Lower esophageal sphincter pressure (LESP) was measured prior to and 1 week after endoscopic therapy. A standardized questionnaire was used for symptom assessment, at the initial presentation, at 1 week and at 2.5 +/- 0.8 years after treatment. RESULTS: The LESP was significantly reduced (pre-treatment 62.1 +/- 15.2 mmHg vs. post-treatment 43.1 +/- 12.5 mmHg; P < 0.01). Symptoms improved in 16 patients (pre-treatment symptom score 9.5 +/- 2.9 vs. post-treatment symptom score 4.7 +/- 1.8; P < 0.01). Nine patients showed no relevant improvement. From the 16 patients with a good initial response, two were lost to follow-up. In nine patients the outcome was still satisfactory after a mean of 2.5 years (1.5 - 4 years) (pre-treatment symptom score 9.5 +/- 2.9 vs. symptom score at 2.5 years after Botox 5.1 +/- 1.5; P < 0.05). These patients were on average 67.7 +/- 12.5 years old. The remaining five patients received a second or third injection of botulinum toxin, but none improved substantially for more than 6 months. One of them eventually underwent pneumatic dilation, and three laparoscopic myotomy. Thus, botulinum toxin treatment was unsuccessful in 14 patients in all. These 14 patients were, on average, significantly younger than the nine successfully treated patients (46.1 +/- 12.6 years vs. 67.7 +/- 12.5 years; P < 0.01) and had significantly higher LESP values prior to botulinum toxin therapy (72.8 +/- 8.9 mmHg vs. 47.8 +/- 9.2 mmHg; P < 0.01). CONCLUSIONS: The long-term success of botulinum toxin injection into the LES in patients with achalasia is highest in elderly patients and in patients with an LESP not exceeding the upper normal level prior to treatment by 50 % or more. On the basis of our results, younger patients (< 55 years) with a severe increase in LESP do not seem to benefit from botulinum toxin injection and pneumatic dilation or myotomy may be more advantageous to them.

[Value of selective MIP reconstructions in respiratory triggered 3D TSE MR-cholangiography on a workstation in comparison with MIP standard projections and single-shot MRCP]. / Stellenwert selektiver MIP-Rekonstruktionen einer atemgetriggerten 3D-TSE-MR-Cholangiographie an einer Workstation gegenüber den MIP-Standardprojektionen und einer Single-Shot-MRCP.

PURPOSE: Comparison of anatomical visualisation and diagnostic value of selective MIP reconstructions of respiratory triggered 3D-TSE-MRCP versus standard MIP reconstructions and single-shot MRCP. MATERIAL AND METHODS: 50 patients with pancreaticobiliary disease were examined at 1.5 Tesla (ACS NT II, Philips Medical Systems) using a breath-hold single-shot (SS) and a respiratory triggered 3D-TSE-MRCP technique in 12 standard MIP projections. Additional selective MIP reconstructions with different slice thickness (2, 4, 10 cm) and projections were performed on a workstation. Visualization of the pancreaticobiliary system and the diagnostic value of the examinations were analysed. RESULTS: Single-shot and 3D-TSE in standard projections showed comparable anatomical visualisation. On selective MIP reconstructions the biliary system (SS p < 0.002; 3D-TSE p < 0.000) and the periampullary region (SS p < 0.000; 3D-TSE p < 0.003) were more clearly seen than on SS and standard MIP reconstructions. Furthermore, superior visualisation of the pancreatic duct could be achieved with additional selective MIP reconstructions in contrast to standard MIP (p < 0.003). Sensitivity and diagnostic accuracy showed superior results for selective and standard MIP reconstructions, but no significant differences between the three techniques were found. CONCLUSION: SS and standard MIP reconstructions showed comparable anatomical visualisation. Selective MIP postprocessing on a workstation offers a better visualisation of the pancreaticobiliary system and is useful for detecting pathological alterations.

[3D-TSE MR cholangiopancreatography with breath triggering to clarify unclear hepatopathies in children]. / 3D-TSE MR-Cholangiopankreatikographie mit Atemtriggerung zur Abklärung von unklaren Hepatopathien bei Kindern.

PURPOSE: Evaluation of 3D-TSE MR-cholangiography with respiratory triggering in the work up of hepatopathies in infants and young children. PATIENTS AND METHOD: 16 infants (4-16 years) with increased transaminases, two with recurrent pancreatitis, were examined at 1.5 T (ACS-NT II, Philips Medical Systems) using a 3D-TSE MRCP with respiratory triggering in addition to a regular MRI of the liver. The MRCP was compared to ERCP. Two radiologists and one gastroenterologist evaluated the technical quality, visualization of the pancreaticobiliary system, and the diagnostic value of the examinations. RESULTS: Technically feasible were 14/16 MRCPs and 13/16 ERCPs. Two MRCP were not of diagnostic value due to motion artifacts and in three ERCP cannulation of the papilla was not possible. 14/16 ERCP required general anaesthesia, while MRCP needed i.v. sedation in two patients only. Extrahepatic ducts/cystic duct/pancreatic duct were visualized in 14/12/8 patients using MRCP, and in 13/10/3 patients using ERCP, both without adverse effects or complications. Intrahepatic ducts were better delineated with MRCP. In 10 patients with histologically proven periportal fibrosis (n = 7) and liver fibrosis (n = 1) or antineutrophil cytoplasmatic antibodies and associated inflammatory bowel disease, MRCP and ERCP revealed pathological results. CONCLUSION: MRCP using a 3D-TSE sequence with respiratory triggering is a good non-invasive technique for delineation of the biliary tract in infants and young children for the work up to hepatopathies.

Prediction of the lower esophageal sphincter pressure after oral molsidomine by sydnonimine plasma concentrations.

BACKGROUND/AIMS: Recent studies suggest that endogenous nitric oxide decreases lower esophageal sphincter pressure (LESP). Substances leading to the formation of nitric oxide, such as molsidomine, decreases the human LESP. It is not yet clear whether this reduction is related to plasma concentrations of molsidomine, the nitrate-active substance sydnonimine (SIN-1) or to serum concentrations of nitrate/nitrite (NOx) as a stable end-product of volatile nitric oxide. METHODOLOGY: We performed a double blind controlled crossover trial in 8 healthy male volunteers. Plasma concentrations of molsidomine, SIN-1 and serum concentrations of NOx as well as esophageal manometry were determined. RESULTS: Mean basal LESP was significantly decreased from 25.4 +/- 2.8 mmHg to 21.9 +/- 2.7 mmHg and 21.4 +/- 2.6 mmHg 2 and 3 hours after molsidomine administration, respectively (mean +/- SEM; n = 8; p < 0.05). The maximum decrease of LESP from the baseline within 1-4 hours after molsidomine administration was 7.6 +/- 1.5 mmHg (mean +/- SEM; n = 8; p < 0.01). The decrease of the LESP correlated significantly with plasma concentrations of SIN-1 (r = -0.53; p = 0.002). NOx levels remained unchanged. CONCLUSIONS: Molsidomine decreases the LESP and plasma concentrations of the active metabolite SIN-1 may predict the potency of molsidomine to lower LESP. NOx was useless as a control metabolite to measure the LESP in response to molsidomine in healthy volunteers.

Endoscopic manometry of esophageal varices: evaluation of a balloon technique compared with direct portal pressure measurement.

BACKGROUND/AIMS: Recently, a non-invasive endoscopic balloon technique for esophageal manometry was published. In the present study, we assess its methodological aspects together with the relationship to portal pressure. METHODS: In 20 patients with liver cirrhosis who had received an intrahepatic portosystemic stent-shunt (TIPS), we evaluated portal and variceal pressure before and after balloon occlusion of TIPS (random order). Portal pressure was measured continuously via a portal venous catheter, and variceal pressure was determined at the same time independently by two endoscopists using two balloon techniques (inflation until varix collapses; deflation until varix reappears). RESULTS: Overall, mean (+/-SD) portal pressure (28.5+/-7 mmHg) was significantly higher (p<0.001) than mean variceal pressure (24.4+/-6 mmHg). Balloon manometry-determined variceal pressure values were 10+/-15% higher with the inflation technique (26.2+/-7 mmHg) than with the balloon deflation technique (22.6+/-6 mmHg, p<0.001). Portal pressure and variceal pressure correlated significantly (p<0.001; balloon inflation: r=0.61, balloon deflation: r=0.66, mean values of inflation and deflation: r=0.68). Short-term TIPS occlusion led to mean increases of 52% and 35% in portal pressure and variceal pressure, respectively. The manometry results of both endoscopists correlated well with either balloon technique (r> or =0.93; p<0.001) and we saw no adverse effects. CONCLUSIONS: Variceal balloon manometry provides non-invasive variceal pressure data which correlate to portal pressure assessed prior to and after short-term TIPS occlusion. However, probably due to variance in collateral anatomy, variceal pressure does not exactly predict portal pressure and its acute changes in the individual patient. The averaged variceal pressure of the inflation and deflation balloon technique provides the best relation to portal pressure combined with a good interobserver reliability and warrants further clinical evaluation.

Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique.

BACKGROUND AND STUDY AIMS: Recently, details of a noninvasive balloon manometry technique for endoscopic measurement of variceal pressure (VP) have been published. However, to date, only few data exist on its feasibility and virtually none on its relation to endoscopic or clinical variables of portal hypertension. PATIENTS AND METHODS: We investigated a total of 64 patients with esophageal varices using a scaled transparent balloon and a calibrated pressure manometer. Averaged from both fivefold balloon insufflation (variceal collapse) or desufflation (variceal appearance), we took measurements of the VP (mmHg) using the two techniques. These measurements were correlated between two investigators as well as to both clinical and endoscopic signs of portal hypertension. Furthermore, pressures were assessed prospectively before and during propranolol application. RESULTS: Measurements were successful in > 95% of all sessions without side effects. The intraobserver variance was 11.0 +/- 13.1%. Measurements correlated significantly between two observers (r = 0.80, insufflation technique, p < 0.01/r = 0.81, desufflation technique, p < 0.01). Pressures correlated positively to variceal sizes (p < 0.05). The presence of fundic varices was strongly associated with higher pressures (p < 0.02). In patients without medical decompressive therapy we found a significant relationship between VP and the presence of red colour signs or previous bleeding episodes. Clinical parameters did not correlate with VP (p > 0.05). As assessed by this technique, 8/11 patients receiving propranolol showed a decrease in VP (18.6 +/- 19.5% after 1.5 months and 33.3 +/- 11.9% after 3 months). CONCLUSIONS: This noninvasive balloon technique is a safe and practical method for estimating VP in patients with portal hypertension. As found by invasive methods, patients with large varices and concomitant fundic varices have higher VP. A drop in intravariceal pressure after propranolol therapy appears to be assessable.

Erythromycin, a motilin agonist, increases postprandial gallbladder emptying during therapy with ursodeoxycholic acid.

Sufficient gallbladder emptying accelerates early gallstone clearance after extracorporeal shock wave lithotripsy (ESWL). Litholytic therapy with ursodeoxycholic acid (UDC) subsequent to ESWL increases fasting volume (FV) and postprandial residual volume (RV) of the gallbladder. This may lead to retention of cholesterol crystals and small fragments within the gallbladder. In order to find out whether erythromycin, a motilin agonist, improves gallbladder emptying, we tested gallbladder motility after administration of ursodeoxycholic acid with and without oral application of erythromycin. Ten healthy males (age 26-35 years) obtained 10 mg/kg/d of UDCA as a single bedtime dose for three weeks. Prior and after UDCA administration, gallbladder FV was determined sonographically after overnight fasting. After a test meal (490 kcal), gallbladder volume was measured every 5 min until the gallbladder had reached its minimal RV. The next day the same procedure was repeated with 500 mg erythromycin p.o. 45 min prior to test meal application. FV, RV, ejection volume (EV = FV-RV) and ejection fraction (EF = EV/FV x 100) were calculated and differences were compared by the student's t-test. FV (29 ml +/- 8 ml vs. 38 ml +/- 10 ml), RV (12 ml +/- 6 ml vs. 17 ml +/- 6 ml) and EV (17 ml +/- 5 ml vs. 21 ml +/- 6 ml) increased significantly during therapy with UDCA (p < 0.05). EF did not change significantly. After erythromycin application RV decreased to its original values (13 ml +/- 6 ml), whereas EV (24 ml +/- 6 ml) and EF (58% +/- 9% vs. 66% +/- 11%) increased significantly (p < 0.05). Thus, administration of a motilin agonist blunts unwanted effects on gallbladder motility during litholytic therapy with UDC.

Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey.

Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

Variability of gallbladder emptying after oral stimulation.

BACKGROUND: To date, the intraindividual reproducibility of fasting and postprandial gallbladder (GB) volumes has not been established satisfactorily. Hence we examined the variability of postprandial GB motility, using the biplane Simpson method as a new sonographic tool for GB volume determination. METHODS: The biplane Simpson method was validated in vitro and in vivo and compared with the sum-of-cylinders method. Thereafter, postprandial GB emptying after a defined test meal was examined in 10 healthy volunteers over 108 min on days 1, 31, and 61. RESULTS: The results of the biplane Simpson method correlated with real volumes (r = 0.99) and provided a intra- and inter-observer variation of less than 5%. Intraindividually, differences in fasting GB volume ranged from 1.9 to 24.0 ml within the observation period. The patterns of GB emptying also showed fluctuations characterized by a rather large interindividual and intraindividual variability. CONCLUSIONS: The biplane Simpson method is a reliable tool for measuring GB volumes. The fasting and the postprandial GB volumes vary considerably within individuals when measured over a period of 2 months.

Physical laws of cholesterol gallstone fragmentation.

Efficient fragmentation is the most important prerequisite for successful treatment of gallstones by extracorporeally induced shock waves. No data are available on the amount of energy necessary for stone disintegration and on the threshold energy below which no further fragmentation occurs. We therefore performed an in vitro investigation on human cholesterol gallstones to elucidate physical laws governing shock-wave lithotripsy. First, the focal pressure of the lithotripter was measured to calculate the energy traversing a stone. Second, 96 gallstones from 16 gall bladders were analysed with respect to physicochemical composition, radiological features and ultrasound before fragmentation was performed. Energy for stone disintegration was constant within each stone family but varied between 4.6 mL-1 and 36.8J mL-1 in different families. This energy correlated linearly with stone volume. None of the radiological and physicochemical factors revealed a clear-cut correlation of the different energies necessary for similar stone disintegration. The threshold energy differed between 0.26 mJ and 1.04 mJ per pulse. In conclusion, stone volume was the best parameter predicting stone fragmentation. However, in cholesterol stones with a similar composition the required energy per volume varies considerably together with the threshold energy. Radiological and ultrasound parameters appear to be of minor importance in explaining these differences.

Treatment of Barrett's esophagus by endoscopic argon plasma coagulation.

Barrett's esophagus is a premalignant condition characterized by the presence of specialized columnar epithelium in the distal esophagus. Conventional medical or surgical treatments do not consistently lead to a regression of Barrett's epithelium. However, restoration of squamous mucosa can occur in an anacid environment after endoscopic ablation of metaplastic epithelium. We report here on two patients with long-standing history of Barrett's esophagus who were treated with endoscopic argon plasma coagulation. By six months of endoscopic treatment, Barrett's epithelium had regressed by more than 50%, being replaced by apparently normal squamous epithelium in both patients. Extensive histological sampling confirmed the presence of squamous epithelium indistinguishable from normal esophageal mucosa. Both patients were asymptomatic under concomitant therapy with proton pump inhibitors with the exception of slight retrosternal discomfort the day after treatment. This demonstrates that endoscopic argon plasma coagulation may be considered for the treatment of Barrett's esophagus.