Are the definitions for chronic diarrhoea adequate? Evaluation of two different definitions in patients with chronic diarrhoea.

BACKGROUND: The classical definition of chronic diarrhoea is ≥3 defecations/day, with a stool weight of more than 200 g and duration of ≥4 weeks. However, with this definition many patients with substantial symptoms and pathology will be excluded from further investigations. As a consequence other definitions have been proposed, mainly based on evaluation of the stool form. OBJECTIVE: To evaluate the accuracy of the classic criteria for diarrhoea in comparison with a definition based on stool consistency, using the Bristol Stool Form Scale. METHODS: All patients were investigated with laboratory tests, upper and lower gastrointestinal endoscopy with biopsies, and SeHCAT test. They were asked to complete a diary recording stool frequency and consistency during a week, as well as other gastrointestinal symptoms (pain, bloating and gas). RESULTS: One hundred and thirty-nine subjects were eligible for analysis. Ninety-one had an organic cause of diarrhoea. Fifty-three patients had ≥3 loose stools/day, whereas 86 reported <3 stools/day. Ninety had a median stool consistency that was mushy or loose and 49 had harder stools. A higher proportion of subjects with an organic cause of their diarrhoea compared with subjects with a functional bowel disorder had ≥3 loose stools/day, 43/91 (47%) vs. 10/48 (21%) (p < 0.01). Similarly, more subjects with an organic cause of their diarrhoea versus patients with a functional bowel disorder had a median stool consistency that was mushy or watery, 73/91 (80%) vs. 17/48 (35%), p < 0.0001. When diarrhoea was defined according to stool form, more patients were classified correctly as having a functional disorder or organic disorder, compared with the classical definition (p < 0.05). CONCLUSION: Loose stools defined according to the Bristol Stool Form scale seem to be the best predictor of having an organic cause of the diarrhoea.

Nitinol versus steel partially covered self-expandable metal stent for malignant distal biliary obstruction: a randomized trial.

BACKGROUND AND STUDY AIMS: Covered nitinol alloy self-expandable metal stents (SEMSs) have been developed to overcome the shortcomings of steel SEMS in patients with malignant biliary obstruction. In a randomized, multicenter trial, we compared stent patency, patient survival, and adverse events in patients with partly covered stents made from steel or nitinol. PATIENTS AND METHODS: A total of 400 patients with unresectable distal malignant biliary obstruction were randomized at endoscopic retrograde cholangiopancreatography (ERCP) to insertion of a steel or nitinol partially covered SEMS, with 200 patients in each group. The primary outcome was confirmed stent failure during 300 days of follow-up.  RESULTS: At 300 days, the proportion of patients with patent stents was 77 % in the steel group, compared with 89 % in the nitinol group (P = 0.01). Confirmed stent failure occurred more often in the steel SEMS group compared with the nitinol SEMS group, in 30 versus 14 patients (P = 0.02). Stent migration occurred in 13 patients in the steel group and in 3 patients in the nitinol group (P = 0.01). Median patient survival (secondary outcome) was 137 days and 120 days in the steel SEMS and nitinol SEMS groups, respectively (P = 0.59). CONCLUSIONS: The nitinol SEMS showed longer patency time, and the nitinol group had fewer patients with stent failure, compared with the steel SEMS group. We could not detect any differences between the two groups regarding survival time, and regarding adverse event rate.Clinical trial registration : NCT 00980889.

Celiac disease and other autoimmune diseases in patients with collagenous colitis.

BACKGROUND AND AIMS: Collagenous colitis (CC) is associated with autoimmune disorders. The aim of the present study was to investigate the relationship between CC and autoimmune disorders in a Swedish multicenter study. METHODS: Patients with CC answered questionnaires about demographic data and disease activity. The patient's files were scrutinized for information about autoimmune diseases. RESULTS: A total number of 116 CC patients were included; 92 women, 24 men, median age 62 years (IQR 55-73). In total, 30.2% had one or more autoimmune disorder. Most common were celiac disease (CeD; 12.9%) and autoimmune thyroid disease (ATD, 10.3%), but they also had Sjögren's syndrome (3.4%), diabetes mellitus (1.7%) and conditions in skin and joints (6.0%). Patients with associated autoimmune disease had more often nocturnal stools. The majority of the patients with associated CeD or ATD got these diagnoses before the colitis diagnosis. CONCLUSION: Autoimmune disorders occurred in one-third of these patients, especially CeD. In classic inflammatory bowel disease (IBD), liver disease is described in contrast to CC where no cases occurred. Instead, CeD was prevalent, a condition not reported in classic IBD. Patients with an associated autoimmune disease had more symptoms. Patients with CC and CeD had an earlier onset of their colitis. The majority of the patients with both CC and CeD were smokers. Associated autoimmune disease should be contemplated in the follow-up of these patients.

Is smoking a risk factor for collagenous colitis?

OBJECTIVE: The association between smoking and idiopathic inflammatory bowel disease is well known; smoking seems to have a diverse effect. Crohn's disease is associated with smoking, while ulcerative colitis is associated with non-smoking. Data on smoking in microscopic colitis of the collagenous type (CC) are lacking. The aim of this investigation was to study smoking habits in CC and to observe whether smoking had any impact on the course of the disease. MATERIALS AND METHODS: 116 patients (92 women) with median age of 62 years (interquartile range 55-73) answered questionnaires covering demographic data, smoking habits and disease activity. As control group we used data from the general population in Sweden retrieved from Statistics Sweden, the central bureau for national socioeconomic information. RESULTS: Of the 116 CC patients, 37% were smokers compared with 17% of controls (p < 0.001, odds ratio (OR) 2.95). In the age group 16-44 years, 75% of CC patients were smokers compared with 15% of controls (p < 0.001, OR 16.54). All CC smoker patients started smoking before the onset of disease. Furthermore, smokers developed the disease earlier than non-smokers--at 42 years of age (median) compared with 56 years in non-smokers (p < 0.003). Although the proportion with active disease did not differ between smokers and non-smokers, there was a trend indicating that more smokers received active treatment (42% vs. 17%, p = 0.078). CONCLUSIONS: Smoking is a risk factor for CC. Smokers develop their disease more than 10 years earlier than non-smokers.

Health-related quality of life is impaired in active collagenous colitis.

OBJECTIVES: The characteristic clinical symptoms of collagenous colitis are non-bloody diarrhoea, urgency and abdominal pain. Treatment is aimed at reducing the symptom burden and the disease impact on patients' health-related quality of life. The objective of this study was to analyse health-related quality of life in patients with collagenous colitis. METHODS: In a cross-sectional, postal HRQL survey, 116 patients with collagenous colitis at four Swedish hospitals completed four health-related quality of life questionnaires, two disease-specific (Inflammatory Bowel Disease Questionnaire and Rating Form of IBD Patient Concerns), and two generic (Short Form 36, SF-36, and Psychological General Well-Being, PGWB), and a one-week symptom diary. Demographic and disease-related data were collected. Results for the collagenous colitis population were compared with a background population controlled for age and gender (n = 8931). RESULTS: Compared with a Swedish background population, patients with collagenous colitis scored significantly worse in all Short Form 36 dimensions (p < 0.01), except physical function. Patients with active disease scored worse health-related quality of life than patients in remission. Co-existing disease had an impact on health-related quality of life measured with the generic measures. Lower education level and shorter disease duration were associated with decreased well-being. CONCLUSION: Health-related quality of life was impaired in patients with collagenous colitis compared with a background population. Disease activity is the most important factor associated with impairment of health-related quality of life. Patients in remission have a health-related quality of life similar to a background population.

Defining clinical criteria for clinical remission and disease activity in collagenous colitis.

BACKGROUND: Collagenous colitis is a chronic inflammatory bowel disease accompanied mainly by nonbloody diarrhea. The objectives of treatment are to alleviate the symptoms and minimize the deleterious effects on health-related quality of life (HRQOL). There is still no generally accepted clinical definition of remission or relapse. The purpose of this study was to analyze the impact of bowel symptoms on HRQOL and accordingly suggest criteria for remission and disease activity based on impact of patient symptoms on HRQOL. METHODS: The design was a cross-sectional postal survey of 116 patients with collagenous colitis. The main outcome measures were 4 HRQOL questionnaires: the Short Health Scale, the Inflammatory Bowel Disease Questionnaire, the Rating Form of IBD Patient Concerns, and the Psychological General Well-Being Index, and a 1-week symptom diary recording number of stools/day and number of watery stools/day. RESULTS: Severity of bowel symptoms had a deleterious impact on patients' HRQOL. Patients with a mean of ≥3 stools/day or a mean of ≥1 watery stool/day had a significantly impaired HRQOL compared to those with <3 stools/day and <1 watery stool/day. CONCLUSIONS: We propose that clinical remission in collagenous colitis is defined as a mean of <3 stools/day and a mean of <1 watery stool per day and disease activity to be a daily mean of ≥3 stools or a mean of ≥1 watery stool.

Diagnostic yield of colonoscopy based on symptoms.

OBJECTIVE: There are only a few data on the diagnostic yield of colonoscopy in different symptoms. The aim of this study was to assess the outcome of colonoscopy in patients with various gastrointestinal symptoms and to estimate the relation between the findings and the presenting symptoms. MATERIAL AND METHODS: 1121 consecutive colonoscopies were registered during 1 year. Asymptomatic subjects and patients with known inflammatory bowel disease (IBD) were excluded, leaving 767 eligible for the study. Symptoms, findings and clinical judgement about their relation were recorded. RESULTS: In patients with bleeding symptoms (n=405), serious colonic pathology--cancers and adenomas >1 cm, IBD and angiodysplasia--was found in 54 (13.3%), 83 (20.5%) and 20 (4.9%) patients, respectively; 162 (40%) patients had findings that could be related to the symptom. In 173 subjects with non-bloody diarrhoea, the diagnostic yield was 31.2%, i.e. mostly IBD and microscopic colitis. In 189 subjects with other gastrointestinal symptoms, the diagnostic yield was 13.2%. Serious colonic pathology was found in 8 of 362 (2.2%) subjects examined because of non-bleeding symptoms. CONCLUSION: The diagnostic yield of colonoscopy is high in patients with bleeding symptoms or diarrhoea, while the prevalence of significant findings is equal to a screening population in patients with other symptoms.

Fate of patients with obstructive jaundice.

BACKGROUND/OBJECTIVE: Systematic data are limited on the etiology and prognosis of unselected patients with obstructive jaundice (OJ). We aimed to review the clinical features, etiology, and prognosis of patients with OJ. METHODS: All adult patients with bilirubin >or= 5.85 mg/dL (100 micromol/L) at a university hospital in Sweden in 2003-2004 were identified. Medical records from patients with OJ were reviewed. RESULTS: Seven hundred and forty-nine patients were identified, of whom 241 (32%) had OJ (median age 71 years, 129 women). No one was lost to follow-up. The biliary obstruction of 154 patients (64%) was a result of a malignancy: 69 patients (46%) had pancreatic cancer, 44 (29%) had cholangiocarcinoma (CC), 5 (3%) had papilla vateri cancers, and 36 patients (23%) had other malignancies. Of the 87 patients with a benign obstruction, 57 (65%) had choledocholithiasis, 7 (8%) had biliary strictures, 6% had PSC, and the obstruction of 16 patients (20.7%) had other causes. A total of 115 of the 242 patients (48%) had abdominal pain associated with jaundice, whereas 52% had painless jaundice. Thirty-four percent of patients with a malignant obstruction had abdominal pain versus 71% of patients with a benign obstruction (P < .05). At the end of follow-up, only 5% (8 patients) with a malignant obstruction were alive versus 78% with a benign obstruction. CONCLUSIONS: Obstructive jaundice was the cause of the severe jaundice of one third of patients. Most cases of OJ were a result of a malignancy, which carried a very poor prognosis, with a 2-year mortality rate of 95%.

The bile acid turnover rate assessed with the (75)SeHCAT test is stable in chronic diarrhoea but slightly decreased in healthy subjects after a long period of time.

The stability of bile acid turnover rate was evaluated retrospectively using repeat SeHCAT tests in patients with chronic diarrhoea and prospectively for 16 years in healthy subjects. The SeHCAT values were stable in 39 patients with chronic diarrhoea, as shown by a comparison of the test results [data presented as median and (25th-75th percentile)]: 18% (8-23) in the first test versus 14% (9-21) in the second test [n = 39, P = 0.37, time interval 44 months (16-68), repeatability index >95%]. In contrast, they were reduced after 16 years in healthy subjects: 38% (30-49.5) in the first test versus 31% (21-49.5) in the second test (P < 0.03). In healthy subjects, the body mass index increased by 13% from 23.2 kg/m(2) (21-24.6) to 26.2 kg/m(2) (22.5-27.8) (P < 0.01) during the 16 years. There was a negative correlation between hepatic bile acid synthesis and the SeHCAT values (r = -0.615, P = 0.02, n = 14). In conclusion, the turnover rate of bile acids is stable over a long period of time in patients with chronic diarrhoea irrespective of bile acid malabsorption, suggesting that a repeat SeHCAT test is dispensable. There is a significant negative correlation between bile acid synthesis and SeHCAT test results in healthy subjects. The SeHCAT test values are slightly reduced in healthy subjects after 16 years.

Glycaemic index of modified cornstarch in solutions with different viscosity. A study in subjects with diabetes mellitus type 2.

BACKGROUND & AIMS: Modified cornstarch may be used to increase the viscosity of liquid food for patients with swallowing abnormalities. The aim of this study was to estimate glycaemic index (GI) of modified cornstarch in solutions with different viscosities. METHODS: Eight subjects with diabetes mellitus type 2 participated in the study. Their mean+/-SD glycosylated haemoglobin was 7.1+/-0.6%. Twenty-five gram of carbohydrate from the modified cornstarch was studied in 150 and 300 g water, respectively, and compared with white bread. RESULTS: GI for the pudding was found to be 77 (P<0.05 compared to white bread) and 88 for the stew (N.S.). The peak time of blood glucose was earlier for stew and pudding, 45 min (P=0.009) and 75 min (P=0.01), respectively, compared with 90 min for white bread. Both stew and pudding produced lower glucose levels at 180 min than the white bread. CONCLUSIONS: The meal with the highest viscosity, pudding, had a GI of 77. The pudding has a more favourable postprandial blood glucose profile than thinner solutions. GI appears to be misleading in subjects with DM. The postprandial glucose profile should be determined in subjects with DM for selection of food products suitable for these patients.

Brush cytology is superior to biopsies obtained by a new device in bile duct strictures.

BACKGROUND/AIMS: Brush cytology during ERCP has been reported to have a low sensitivity. A new device, Howell biliary system (Wilson-Cook), enables targeted biopsies for histopathologic assessment. The aim was to compare histopathology with brush cytology. METHODOLOGY: Brush cytology followed by biopsies obtained by the Howell device was taken consecutively from bile duct strictures. Coded slides were scored by 3 pathologists and 2 cytologists in a 3-graded scale; 2: benign; 3: suspicious of malignancy; 4: malignant. The clinical outcome including autopsy served as the gold standard for the definite diagnoses. RESULTS: Twenty-one malignant and 6 benign strictures were evaluated. The histopathology revealed 11 out of the 21 malignant as certain or suspected malignant (score > or = 3) (sensitivity: 0.52). The cytology scored 17 out of 21 > or = 3 (sensitivity: 0.80). The in pair kappa values for the 3 pathologists were: (0.37; 0.26; 0.41) vs. 0.56 for the 2 cytologists. Among the evaluable strictures the pathologists scorings were; (median: 3.0, SD: 0.72) for the malignant and (median: 2.3, SD: 0.98) for the benign (p = 0.27) and the cytology scorings were; (median: 3.5, SD: 0.73) for the malignant and (median: 2.7, SD: 0.65) for the benign (p = 0.09). CONCLUSIONS: Brush cytology has a higher accuracy than the targeted biopsies and should be used in combination with other methods to reach the correct diagnosis.

Granulocyte, monocyte/macrophage apheresis for inflammatory bowel disease: the first 100 patients treated in Scandinavia.

OBJECTIVE: Selective leukocyte apheresis is a new type of non-pharmacological treatment for patients with active ulcerative colitis and Crohn's disease. Preliminary data have indicated that this type of therapy is safe and efficacious, and large sham-controlled studies are currently in progress. In Scandinavia, a substantial number of patients with chronic inflammatory bowel disease have already received leukocyte apheresis on a compassionate use basis and the aim of this study was to report the clinical outcome and adverse events in the first patients treated. MATERIAL AND METHODS: Clinical details of the first consecutive 100 patients with inflammatory bowel disease treated with granulocyte, monocyte/macrophage (Adacolumn) apheresis in Scandinavia were prospectively registered. Median length of follow-up was 17 months, (range 5-30). RESULTS: The study population comprised 52 patients with ulcerative colitis, 44 patients with Crohn's disease and 4 patients with indeterminate colitis. In 97 patients the indication for Adacolumn treatment was steroid-refractory or steroid-dependent disease. Clinical remission was attained in 48% of the patients with ulcerative colitis, and an additional 27% had a clinical response to the apheresis treatment. The corresponding figures for patients with Crohn's disease were 41% and 23%, respectively. Complete steroid withdrawal was achieved in 27 out of the 50 patients taking corticosteroids at baseline. Adverse events were reported in 15 patients and headache was most frequently reported (n=7). CONCLUSIONS: Granulocyte, monocyte/macrophage apheresis treatment seems to be a valuable adjuvant therapy in selected patients with refractory inflammatory bowel disease. The risk for toxicity or severe adverse events appears to be low.

Normal or increased bile acid uptake in isolated mucosa from patients with bile acid malabsorption.

INTRODUCTION: Bile acid malabsorption as reflected by an abnormal Se-labelled homocholic acid-taurine (SeHCAT) test is associated with diarrhoea, but the mechanisms and cause-and-effect relations are unclear. OBJECTIVES: Primarily, to determine whether there is a reduced active bile acid uptake in the terminal ileum in patients with bile acid malabsorption. Secondarily, to study the linkage between bile acid malabsorption and hepatic bile acid synthesis. METHODS: Ileal biopsies were taken from patients with diarrhoea and from controls with normal bowel habits. Maximal active bile acid uptake was assessed in ileal biopsies using a previously validated technique based on uptake of C-labelled taurocholate. To monitor the hepatic synthesis, 7alpha-hydroxy-4-cholesten-3-one, a bile acid precursor, was assayed in blood. The SeHCAT-retention test was used to diagnose bile acid malabsorption. RESULTS: The taurocholate uptake in specimens from diarrhoea patients was higher compared with the controls [median, 7.7 (n=53) vs 6.1 micromol/g per min (n=17)] (P<0.01) but no difference was seen between those with bile acid malabsorption (n=18) versus diarrhoea with a normal SeHCAT test (n=23). The SeHCAT values and 7alpha-hydroxy-4-cholesten-3-one were inversely correlated. CONCLUSIONS: The data do not support bile acid malabsorption being due to a reduced active bile acid uptake capacity in the terminal ileum.

Luminal nitric oxide in ileal reservoirs for continent cutaneous diversion or orthotopic bladder reconstruction.

OBJECTIVES: To measure mucosal inflammation as reflected in nitric oxide (NO) production in ileal reservoirs for the storage of urine and to correlate it with the growth of bacteria as well as CRP. METHODS: Intraluminal gas NO concentrations were determined using the chemoluminescence technique in 25 patients with continent cutaneous ileal reservoirs (Kock pouch) and 12 patients with orthotopic bladders (hemi-Kock or T-pouch). NO concentrations were determined in both intestinal reservoir gas and silicon catheter balloon gas. Urinary culture and blood CRP determinations were performed. RESULTS: NO concentrations in reservoir gas were higher than in silicon catheter balloons. Bacteriuria was associated with approximately 20 times higher NO concentrations than sterile urine. NO concentrations did not differ between continent cutaneous reservoirs or orthotopic bladders when due attention was paid to variance in the rate of bacteriuria. Elevated CRP was associated with higher NO concentrations. Bacteriuria with acinetobacter, enterococci and pseudomonas appeared to cause comparatively lower NO concentrations. The inflammatory response of reservoir walls to bacteriuria did not decrease with time. CONCLUSIONS: Urine in itself causes much less intestinal wall inflammation than bacteriuria, as reflected in NO production. High CRP values are associated with high NO concentrations. The inflammatory response varies with the bacterial specimens.

Gut transit in celiac disease: delay of small bowel transit and acceleration after dietary treatment.

OBJECTIVES: New studies indicate that body mass index (BMI) may influence gut transit. We studied gut transit and BMI in patients with celiac disease before and after treatment. METHODS: Twenty-seven (16 female) patients with untreated celiac disease were included for detailed gastrointestinal transit measurement and calculation of BMI. Ten patients (5 female) were also studied after dietary treatment. A newly developed radiological transit procedure was used. Eighty-three healthy subjects were used as controls. RESULTS: In untreated male patients BMI was significantly reduced compared to healthy males, and small bowel transit time (SBTT) was significantly longer compared with healthy males, 3.9 (1.2-5.5) versus 2.5 h (1.4-4.3), median and percentile 10 and 90, respectively, and p= 0.04. In the 10 men and women with repeated measurements, BMI increased significantly and small bowel transit accelerated after treatment and was 3.6 h (1.7-5.5) before treatment and 2.3 h (0.7-4.0) after treatment, and p= 0.007. In women, BMI did not differ significantly between untreated patients and healthy subjects, and 31% of the female patients were overweight. Small bowel transit was significantly faster in untreated female patients who were overweight compared with lean female patients. CONCLUSION: Small bowel transit seems to be delayed in lean patients with untreated celiac disease. BMI may have some influence on the variations of small bowel transit before and after treatment.

[Helicobacter pylori can in rare cases be the cause of iron and vitamin B 12 deficiency. No increased risk of iron and vitamin B 12 deficiency due to proton pump inhibitors]. / Helicobacter pylori kan i sällsynta fall orsaka järn- och vitamin B12-brist. Ingen ökad risk för järn- eller B12-brist med protonpumpshämmare.

This article reviews iron and vitamin B12 malabsorption due to the use of proton pump inhibitors (PPI) and infection with Helicobacter pylori. The bacterium is in some studies associated with low serum values of both ferritin and cobalamin and has in several cases been shown to cause reversible deficiency of these nutrients. PPI depresses absorption of vitamin B12, but only one case of deficiency has been reported in standard reflux therapy. Case reports exist of PPI-related iron deficiency, but studies have not confirmed these risks. General substitution with iron or B12 supplements in PPI therapy can't be advocated. The safety of long-term use of PPI is well documented, but it is still unclear whether PPI accelerates the development of atrophic corpus gastritis in the presence of H pylori.

Bone mineral density in patients with small intestinal bacterial overgrowth.

BACKGROUND/AIMS: Malabsorption has long been recognized as a cause of osteopenia, and mild forms of osteopenia are present in many gastrointestinal disorders. The aim of this study was to determine if osteopenia is common in patients with small intestinal bacterial overgrowth. METHODOLOGY: Bone mineral density was measured in fourteen patients with small intestinal bacterial overgrowth. Patients with obvious structural predisposing conditions such as previous gastric operations, small bowel strictures and small bowel diverticula, were excluded. Measurements were made in the distal right radius and ulna, in the hip and in the spine. The results were compared to those of a reference population. Radiographs of the spine were assessed for evidence of vertebral fractures. Blood samples were analyzed for serum concentrations of 25-hydroxyvitamin-D3 and 1,25-dihydroxyvitamin-D3, alkaline phosphatase activity, ionized calcium, intact parathyroid hormone and osteocalcin. All patients completed a questionnaire concerning, inter alia, previous fractures, past and current diseases, tobacco smoking and medication. RESULTS: Patients with small intestinal bacterial overgrowth had significantly low bone density in the femoral neck (p < 0.01) and in the lumbar spine (p < 0.05), compared to a reference population. Six of 14 (43%) patients had had fractures. CONCLUSIONS: Patients with small intestinal bacterial overgrowth have low bone mineral density. In patients with osteopenia of unknown origin, small intestinal bacterial overgrowth should be considered.

[Guidelines for management of patients with chronic pancreatitis. Report from a consensus conference]. / Riktlinjer för handläggning av patienter med kronisk pankreatit. Rapport från ett konsensusmöte.

Chronic pancreatitis has an incidence of 3-8 new cases per 100,000 inhabitants and year. Alcohol is the most common cause. It is, however, not an independent risk factor but rather a co-factor. Smoking and genetic predisposition are increasingly regarded as causative factors. The diagnosis is today based mainly on history and findings at imaging tests. Pain treatment starts with NSAID-medication with or without paracetamol. Oral pancreatic enzyme therapy for pain should be tested early in the course. Endoscopic stent insertion into the main pancreatic duct can be used in selected cases. Operation is not recommended until other less invasive methods have been tested but should ideally be performed before addiction to opiates occurs. Oral enzyme supplementation is effective in the majority of cases with malnutrition. Most patients with chronic pancreatitis and diabetes need insulin treatment. Interdisciplinary specialist treatment teams should be established and take responsibility for diagnosis, assessment and interventional procedures (e.g. endoscopy, surgery). Due to the low incidence of the disease 3-4 such teams/centres seem appropriate in our country to allow a critical patient load.