[Acute pancreatitis caused by atrial fibrillation?]. / Vorhofflimmern als mögliche Ursache für eine akute Pankreatitis?

HISTORY: We report three male patients who had atrial fibrillation with a rapid and irregular ventricular rate, aged 60, 69 and 70 years, respectively, in whom development of acute pancreatitis occurred simultaneously with other ischaemic events. INVESTIGATIONS: One of these patients simultaneously suffered from a transient ischaemic attack (TIA), another developed a stroke and an infarction of the spleen, while the third one had a splenic infarction and an embolism in the region of the mesenteric arteries. Two patients had paroxysmal atrial fibrillation, while the third suffered from ischemic cardiomyopathy with chronic atrial fibrillation. DIAGNOSIS AND TREATMENT: Oedematous pancreatitis occurred in one patient while, in the two others, the diagnosis of severe necrotizing pancreatitis was made. CONCLUSION: Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice and a recognized risk factor for the development of peripheral embolism, which often takes the form of an ischaemic stroke. It is a major cause of stroke, especially in the elderly. Because of the simultaneous occurrence of thromboembolic events in all three patients, an ischaemic cause for the acute pancreatitis can be assumed with a high degree of probability. This is one of the first reports of acute ischaemic pancreatitis probably caused by microembolization secondary to atrial fibrillation. Because of the relatively frequent occurrence of atrial fibrillation, this factor deserves increased attention in the differential diagnosis of supposedly idiopathic pancreatitis.

Gastric schwannoma as a rare differential diagnosis of pleural effusion.

We report a case of solitary gastric schwannoma that initially manifested with recurrent left pleural effusion caused by an inflammatory reaction. A 75-year-old female was primarily admitted with progressive dyspnoea and left sided effusion. History as well as clinical examination, gastroscopy, computed tomography (CT) and transabdominal ultrasound of the abdomen suggested the diagnosis of a benign tumour of the stomach. The tumour was resected and a fundectomy with a security distance of 3-5 cm performed. Histological assessment revealed a large intramural schwannoma of the gastric wall, arising from the submucosal layer. There was no evidence of malignancy. During a three year follow-up the patient has not shown any evidence of relapse or pleural effusion. This is a very rare manifestation of this benign tumour, representing a rare differential diagnosis in a case of left sided pleural effusion.

[Long-term results of ultrasound-guided ethanol injections in patients with autonomous thyroid nodules and hyperthyroidism]. / Langzeitergebnisse der ultraschallgesteuerten Alkoholinstillation bei Patienten mit fokaler Schilddrüsenautonomie und Hyperthyreose.

AIM: The aim of this study was to evaluate the long-term efficacy of treatment of autonomous thyroid nodules with percutaneous ethanol injection under ultrasound guidance. PATIENTS AND METHODS: In a period of 56 months, 20 patients (13 women and seven men, mean age 67.5 +/- 12.3 years) with autonomous toxic thyroid nodules were treated with percutaneous ethanol injection under ultrasound guidance. Ethanol was injected percutaneously on an outpatient basis for a mean of 2.85 +/- 1.1 injections per patient, mainly depending on the nodule's size. The mean volume of injected ethanol was 4.63 ml. The median follow-up time was 763 +/- 452 days. RESULTS: The injection was well tolerated by the patients, a mild to moderate local pain occurred in 21% of sessions. Undesirable effects were not serious and only transient and receded. Major complications like transient dysphonia or common jugular vein thrombosis have not been observed. After a mean time of 50 +/- 23 days an euthyroid state with normalized basal levels of TSH, fT3 and fT4 was maintained in 16 patients (80%), while four patients (20%) did not completely respond to the treatment. In this patients a therapy with methimazole was carried out. The rate of reduction in the nodular volume was 60.8%. CONCLUSION: The percutaneous ethanol injection appears to be an effective, harmless and low-cost alternative treatment of autonomous thyroid nodules, especially in older and multimorbid patients.

Stability of human gallbladder bile: effect of freezing.

In the present study, the stability of the most essential biliary parameters of human gallbladder bile at -18 degrees C was examined over several months. In 12 patients with gallstone disease (10 female, two male; 52.1+/-13.3 years of age), bile was obtained through fine needle puncture of the gallbladder under local anesthetic. The concentrations of total lipids, cholesterol, phospholipids and bile acids, and the cholesterol saturation index and crystal appearance time were determined before and after freezing over a mean period of 4.38+/-2.9 months. Gallbladder bile obtained by fine needle puncture has proved to be of excellent quality. The total lipid concentration was unchanged before (8.30+/-4.16 g/dL) and after freezing (9.16+/-4.54 g/dL, P=0.6027). The biliary cholesterol, phospholipids and bile acid concentrations, and cholesterol saturation index showed no statistically significant differences before and after freezing. A significant difference arises in the context of subdivision of the group to the nucleation time. Before freezing, most patients had a nucleation time between five and eight days, which shortened to between one and four days after thawing (P=0.0100). The authors conclude that, with the exception of the nucleation time, human gallbladder bile can be stored at -18 degrees C for four months with stability of major lipid components.

[The curative therapy of primary hyperparathyroidism by percutaneous ethanol injections]. / Kurative Therapie eines primären Hyperparathyreoldismus durch perkutane Athanolinjektion.

HISTORY AND CLINICAL FINDINGS: An 86-year-old woman was admitted because of acute nonspecific upper abdominal symptoms and vomiting. She was occasionally disoriented, generally slower in movement and reaction, apathetic and mainly bed-ridden. She was a known insulin-dependent diabetic who had sustained a posterior wall myocardial infarction and cerebrovascular accident and had undergone a cholecystectomy. On physical examination her upper abdomen was painful to pressure, blood pressure was 180/95 mm Hg, but there were no other findings. INVESTIGATIONS: Sonography demonstrated bile-duct dilatation, confirmed at endoscopic retrograde cholangiopancreatography, and a prepapillary choledochal concrement of about 10 mm. Sonography also revealed an echo-poor tumour of the right caudal parathyroid. The calcium concentration was raised to 2.94-3.16 mmol/l and the parathormone level was also increased (99.5 pmol/l, normal 1.2-5.7 pmol/l), as were amylase (375.6 U/l) and lipase (1038-5394 U/l). TREATMENT AND COURSE: After papillotomy and extraction of the choledochal concrement the acute biliary pancreatitis quickly improved. Operation on the parathyroid tumour was not undertaken because of the patient's various illnesses. Instead, 95% alcohol was instilled, 3.5 and 4.5 ml respectively, into the tumour, under sonographic control in two sessions, 3 days apart. Her clinical condition clearly improved and serum calcium became normal and the parathormone level fell significantly. CONCLUSION: Percutaneous ethanol injection of a parathyroid tumour can be a curative and sparing alternative to operation in patients with hyperparathyroidism seemed too ill for surgery.

[Positive effect of ursodeoxycholic acid on liver enzymes in autoimmune hepatitis with little activity--a pilot study]. / Positiver Effekt der Ursodeoxycholsäure auf die Leberenzyme bei der wenig aktiven Autoimmunhepatitis--Eine Pilotstudie.

In a pilot study we investigated the effect of ursodeoxycholic acid therapy in 11 patients (mean age 45.8 +/- 13.2 years) with chronic active, ANA- and/or SMA-positive autoimmune hepatitis of moderate severity. All patients were clinical asymptomatic and no indication for immunosuppressive therapy could be established in any patient. After a washout period of at least 3 months, the treatment was administrated with 500 mg ursodeoxycholic acid twice daily. A statistically significant improvement in all important hepatic parameters was achieved within 3 months of therapy. No further improvement could be observed once 6 months had elapsed. Significant decreases of SGOT (29.9 +/- 20.2 vs 17.7 +/- 7.1 U/l, p = 0.020), SGPT (43.8 +/- 31.0 vs. 19.6 +/- 6.7 U/l, p = 0.0012), GLDH (20.1 +/- 20.9 vs. 5.2 +/- 2.6 U/l, p = 0.0001) und gamma-GT (152.0 +/- 124.8 vs. 60.6 +/- 49.2 U/l, p = 0.0064) were observed during treatment. Despite tendential improvement, serum biliruhin, levels (18.2 +/- 9.4 vs. 16.9 +/- 9.4 mumol/l, p = 0.287) did not change significantly during treatment. Ursodeoxycholic acid may be beneficial in altering the natural course of chronic active hepatitis and of value in preventing mild attacks of immune hepatitis. The simple fact that ursodeoxycholic acid administration is essentially free of side-effects can go a long way towards justifying further clinically controlled studies.

Combined bile acid therapy is more effective on biliary lipids and dissolution rates than monotherapy after gallstone lithotripsy.

BACKGROUND: Accurate sampling of gallbladder bile for biliary analysis is essential for determining any potential difference between combined bile acid therapy and monotherapy in gallstone patients. METHODS: In 104 gallstone patients undergoing extracorporeal shock wave lithotripsy with following bile acid therapy [either chenodeoxycholic acid (500 mg/day) and ursodeoxycholic acid (500 mg/day), group I (n = 53), or ursodeoxycholic acid alone (1000 mg/day), group II (n = 51)], bile samples, obtained by direct fine needle puncture of the gallbladder, were investigated for biliary lipids, total biliary protein concentration, and nucleation time before and after 12 months of bile acid therapy. RESULTS: Initially, a negative correlation was found between nucleation time and number of gallstones and between total biliary protein concentration and nucleation time (r = -0.52 and r = -0.49 in group I vs r = -0.56 and r = -0.51 in group II, p < 0.01 in each group). The correlation between total biliary protein concentration and nucleation time was also found after 12 months of bile acid treatment (r = -0.54 in group I vs r = -0.47 in group II, p < 0.01 in each group). In group I, the decrease in cholesterol saturation index, biliary cholesterol, cholic acid, deoxycholic acid, and total protein concentration was more pronounced than in group II (p < 0.01). The same effect was found concerning the prolongation of nucleation time (p < 0.01). Furthermore, dissolution rates were higher in group I compared with group II (80.4 vs 69.0%, p < 0.01). CONCLUSION: In gallstone patients, combined therapy with urso- and chenodeoxycholic acid is superior to either ursodeoxycholic acid alone or biliary parameters in bile samples obtained by direct fine needle puncture of the gallbladder.

Effect of extracorporeal shock-wave lithotripsy on gallbladder emptying in patients with solitary and multiple gallbladder stones.

In a prospective study, we investigated the effect of extracorporeal shock-wave lithotripsy (ESWL) on gallbladder contractility and on fasting and residual gallbladder volume in patients with solitary and multiple gallbladder stones with stone densities < 100 Hounsfield units (HU) and adequate gallbladder function. Twenty-five patients (seven males and 18 females, mean age 48.5 +/- 11.7 years) treated with ESWL were assigned to either group I, consisting of 13 patients with solitary stones < 20 mm diameter, or group II, including patients with two to three stones and maximum stone diameter of 30 mm. ESWL was performed with the MPL 9000 lithotripter. Gallbladder ejection fraction was determined using the method of Dodds after a 12-hr fast and following application of a standard stimulative meal. Gallbladder volume was measured by ultrasound over 90 min at 10-min intervals before ESWL, then at 1, 30, 120, and 210 days after ESWL. At 24 hr after ESWL, residual gallbladder volume increased in group I from 7.4 ml to 13.9 ml (P = 0.0567) and in group II from 6.5 ml to 20.2 ml (P = 0.0076). Thereafter, residual volumes returned to pre-ESWL levels. In group II, post-ESWL fasting volumes were significantly increased over initial values at all time intervals. Correspondingly, only at 24 hr after ESWL, ejection fractions decreased from 73.1% to 64.9% in group I and from 76.5% to 62.7% in group II. No statistically significant differences in gallbladder contractility between the two groups were observed at any point of the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic value of fine-needle puncture of the gallbladder: side effects, safety, and prognostic value.

Bile sampling without the risk of contamination by pancreatic and duodenal secretions and avoiding unpredictable influences of general anesthesia during biliary surgery on biliary analytics are feasible with percutaneous puncture of the gallbladder. In 207 patients with gallstones, gallbladder puncture was performed under local anesthesia with a 22-gauge spinal needle under continuous real-time ultrasound guidance. Bile samples were investigated for biliary lipids and nucleation time. Complete aspiration of gallbladder bile could be achieved in all patients without complications such as bleeding, bile leak, or inflammation. Of these patients, 11.6% reported mild abdominal problems, 3.4% required analgetics, and in 1.0% biliary colics were observed. Elective cholecystectomy was performed in 1 patient. Of the bile samples, 10.1% were contaminated with bactobilia. Biliary lipids, cholesterol saturation index (CSI), total lipid concentration (TLC), and bacteriological contamination were independent of gallstone number, whereas patients with solitary gallbladder stones exhibited a significantly longer nucleation time (NT) in comparison with those with multiple stones. In patients with gallstones, fine-needle puncture of the gallbladder represents an important diagnostic procedure and can be performed within minutes without major side effects if performed by an experienced sonographer.

Plasminogen activator inhibitor type 2: an intracellular keratinocyte differentiation product that is incorporated into the cornified envelope.

Human epidermal keratinocytes synthesize a complex plasminogen activator proteolytic cascade, consisting of two plasminogen activating enzymes and two inhibitors, that is thought to play a role in epidermal migration and differentiation as well as in several cutaneous diseases. Quantification of the plasminogen activator cascade proteins in keratinocytes reveals that plasminogen activator inhibitor type 2 (PAI-2) is distinct from the other components (i.e., urokinase and tissue-type plasminogen activators and inhibitor type 1) in several respects: (i) PAI-2 remains mostly cell-associated, rather than secreted; (ii) The level of cell-associated PAI-2 is at least 50-fold greater than that of the other components; (iii) PAI-2 is the only component whose level is enhanced upon elevation of the Ca2+ concentration, which is well known to induce a more differentiated phenotype in keratinocyte culture. Immunocytochemical localization experiments reveal that most keratinocytes contain PAI-2, which in a subpopulation of more differentiated cells is resistant to detergent extraction. Additional immunocytochemical localization and immunoblot experiments demonstrate that some of the PAI-2 becomes incorporated into the cornified envelope during terminal differentiation of the keratinocyte. These studies raise the possibility that PAI-2 may have an intracellular role associated with the terminal stage of keratinocyte differentiation.

Gallbladder sludge: spontaneous course and incidence of complications in patients without stones.

Although the ultrasonic detection of gallbladder sludge is relatively frequent, its clinical importance remains unclear, partly because of the paucity of reliable investigations regarding its natural course in patients without stones. In a retrospective study we investigated the course and clinical significance of gallbladder sludge in patients without stones or other identified gallbladder abnormalities. The diagnosis of gallbladder sludge was made by ultrasound scan in 286 (1.7%) of 17,021 patients. The mean follow-up period for these patients was 20.3 +/- 11.5 mo. Of this group 56 patients were without both stones and sludge at the initial examination, and gallbladder sludge developed after a mean observation period of 11.2 +/- 10.6 mo. Within 2.0 +/- 3.5 mo after sludge detection, 40 (71.4%) patients were free of sludge and showed normal gallbladder findings. Gallbladder stones without sludge persistence developed in five patients (8.9%) within 2.5 +/- 0.6 mo after diagnosis of sludge, and gallstones with persistence of sludge developed in two other patients (3.6%) after 6.1 and 30.7 mo, respectively. In no cases did the stones become clinically symptomatic in the course of the follow-up period. Acute acalculous cholecystitis developed in four patients (7.1%) from 6.5 to 37.5 mo after the first examination. In five patients, sludge persisted after a mean 22.3 +/- 13.5 mo of follow-up. Although our data show that gallbladder sludge disappeared spontaneously within a relatively short time in 71.4% of patients, gallbladder sludge must be considered an important pathologic entity because gallbladder stones or complications such as acute cholecystitis occurred in 19.6% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Yersinia enterocolitica infection with extraintestinal manifestations: case report and overview]. / Yersinia-enterocolitica-Infektion mit extraintestinaler Manifestation: Fallbericht und Ubersicht.

Five weeks after a four-day visit to Malta, a 39-year old white male German national developed septic temperatures of up to 40 degrees C, progressive jaundice and a pronounced hepatosplenomegaly. The initial examination showed a very sick, somnolent patient with jaundice, cyanosis, tachypnea and a markedly enlarged liver on both physical examination and sonography. The laboratory evaluation revealed a moderate leukocytosis, markedly accelerated ESR, poor liver function with strongly elevated gamma-GT and alkaline phosphatase levels. Primary antibiotic therapy consisted of doxycycline. Ultrasound examination of the liver four days after admission revealed multiple hypodense abscesses. On the sixth day after admission, gram-negative rods were first isolated from blood cultures; antibiotic therapy was switched to ofloxacin (2 x 400 mg/day) and amoxycillin (3 x 2 g/day) after sensitivity testing. As a result of treatment with this combination of antibiotics, the patient was free of fever 10 days after hospitalization; on the same day yersinia enterocolitica was isolated from the first blood cultures taken on admission. The diagnosis of non-enteric forms of yersinia infection can prove very difficult, especially if the serology is not clear cut and there are no immunological complications. A presentation including intermittent fever, moderate leukocytosis, strongly accelerated ESR and multiple hypodense abscesses in the liver should lead one to consider a non-enteric type of yersinia infection. Hepatic abscesses usually occur in patients who have an iron overload.

Does adequate patient selection reduce the risk of gallstone recurrence after successful extracorporeal shockwave lithotripsy?

To determine the risk of gallbladder stone recurrence in these patients, 58 of the first consecutive 61 patients with solitary stones achieving complete stone clearance after ESWL and adjuvant bile acid therapy were included in a prospective study. All patients were observed for at least 12 months following discontinuation of oral bile acids. Twenty-one patients fulfilled our postulated ideal criteria (solitary radiolucent stones between 10-20 mm initial diameter, initial stone density < 50 HU, gallbladder ejection fraction > 70%). The remaining patients (n = 37) fulfilled the criteria of the Munich study group. In patients fulfilling our ideal criteria, stone recurrence was not observed in any patient, while in those fulfilling solely the criteria of the Munich group, five instances of stone recurrence were observed (13.5% [n = 37], p < 0.1). Initial stone count is only one factor influencing the probability of gallstone recurrence following ESWL and discontinuation of oral bile acids. Our data suggest that factors such as low initial stone density at gallbladder CT and good gallbladder function not only accelerate initial stone clearance but also reduce the risk of stone recurrence after ESWL once oral bile acids have been discontinued.

Transhepatic topical dissolution of gallbladder stones with MTBE and EDTA. Results, side effects, and correlation with CT imaging.

Forty-two patients with symptomatic gallstones (28 women, 14 men, mean age 49.8 +/- 13.2 years) were recruited for contact dissolution therapy. Pretreatment CT scans of the gallbladder were obtained in every patient under standard conditions. For contact dissolution treatment of heterogeneous gallstones or gallstones with attenuation values of more than 50 Hounsfield units, methyl tert-butyl ether and bile acid ethylene diaminetetraacetic acid were used in alternating administration at time intervals and durations adapted to the individual tolerance of the patients. In the case of gallstones with mean attenuation values under 50 Hounsfield units, the dissolution therapy was performed with methyl tert-butyl ether alone. In 12 (28.6%) patients a complete dissolution of gallbladder stones could be achieved; 11 patients (26.2%) revealed gallbladder sludge but no radiologically or sonographically visualized residual stone debris. The remaining 19 (45.2%) patients had residual gallstone debris. Shell fragments in three of five rimmed gallstones, seven of eight laminated gallstones, and all densely calcified stones were refractory to contact dissolution therapy. Dissolution rates correlated well with mean attenuation values, whereas no significant correlation was found between stone number and dissolution rates or between stone diameter and dissolution rates respectively. The mean instillation time required for stones with a mean density of more than 50 HU was 17.7 +/- 11.5 hr of bile acid ethylene diaminetetraacetic acid and 5.8 +/- 3.2 hr of methyl tert-butyl ether. In the case of isodense stones, the average instillation time of methyl tert-butyl ether was 12.3 +/- 4.7 hr.(ABSTRACT TRUNCATED AT 250 WORDS)

[Extracorporeal shockwave therapy in endoscopic therapy-refractory gallstones]. / Extrakorporale Stosswellentherapie bei endoskopisch therapierefraktären Gallengangskonkrementen.

Extracorporeal shock-wave lithotripsy (ESWL) was undertaken in 36 patients (12 men, 24 women; mean age 70.9 +/- 2.4 years) with extra- or intrahepatic bile duct stones which could not be removed endoscopically. Stone fragmentation was successful in 32 patients with stones in the choledochal duct and in one with stones in the left hepatic duct. Fragmentation failed in two patients with stones in the left hepatic duct and one with stones in the cystic duct. 26 of the 36 patients were free of stone after spontaneous passage (n = 3) or after endoscopic removal of the residual concrements (n = 23). Complications occurred in only five patients during or after ESWL (cardiac arrhythmias, respiratory failure, pancreatitis, cholangitis).--These data point to ESWL being clearly preferable to surgical intervention in bile duct stones refractory to endoscopic treatment, especially in the elderly with an increased perioperative risk.

Structured reporting of medical findings: evaluation of a system in gastroenterology.

A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Increased gallbladder residual volume in nonresponders to extracorporeal shock wave lithotripsy of gallbladder stones.

In a prospective study of 63 patients, we purposed to determine whether gallbladder contractility or gallbladder volume before biliary lithotripsy are predictors of fragment disappearance. Percentage gallbladder contraction was calculated from the fractional difference in the sonographically measured gallbladder volume after a standard fatty meal. Statistical analysis showed no significant differences in gallbladder contractility between the fragment-free group and the residual-fragment group before (77.2 +/- 12.7% vs. 71.9 +/- 19.3%; p = 0.1044) biliary lithotripsy and after the termination of adjuvant cholelitholysis therapy (76.4 +/- 12.9% vs. 72.2 +/- 17.1%; p = 0.1341). Before treatment, there was no significant difference in fasting gallbladder volume in either group (29.9 +/- 15.4 ml vs. 36.6 +/- 18.8; p = 0.0682), but postprandial gallbladder volume was greater in nonresponders (10.4 +/- 9.4 ml vs. 6.5 +/- 3.8; p = 0.0164). After termination of the therapy, both the fasting gallbladder volume (41.2 +/- 24.2 ml vs. 29.8 +/- 10.3 ml; p = 0.0093) and the postprandial gallbladder volume (11.9 +/- 11.7 ml vs. 7.3 +/- 5.3 ml; p = 0.0267) were greater in the residual-fragment group. The increase of the fasting gallbladder volume in the residual-fragment group was statistically not significant. Our results indicate that the increased residual volume is a significant cause of therapeutic failure in nonresponders.

[Extracorporeal shock wave lithotripsy in patients with bile duct calculi]. / Extrakorporale Stosswellenlithotripsie bei Patienten mit Gallengangsteinen.

21 patients with choledocholithiasis, in whom methods such as endoscopy or mechanical lithotripsy were unsuccessful, extracorporeal shock wave lithotripsy was performed. Fragmentation could be achieved in 90%, complete stone clearance after endoscopic stone extraction occurred in 76%. Extracorporeal shock wave lithotripsy has proven highly effective with a low complication rate and zero lethality. Therefore, its role in the management of gall stone disease in the elderly patient at high perioperative risk cannot be overemphasized.