Dtsch Med Wochenschr

[Intermittent bile duct obstruction as the first manifestation of a hepatocellular carcinoma]

Troschel P. Leipner N. Bodor Z. Tschubel K.
Medizinische Abteilung, Evangelischen Krankenhauses Bad Godesberg.
HISTORY AND CLINICAL FINDINGS: For two months a 73-year-old woman had been suffering from intermittent colicky upper abdominal pain. She had also noted transient colourless stools and finally jaundice. Suspected cholelithiasis led to her admission for cholecystectomy. She had slight jaundice of skin and sclerae. Physical findings were unremarkable except for pain on epigastric palpation. INVESTIGATIONS: Sonography and computed tomography showed dilatation of the intrahepatic biliary passages and the proximal common bile duct, the latter containing a polycyclic mass that on endoscopic retrograde cholangiography appeared ovular and was surrounded by contrast medium. It was thought to be an intraductal bile stone. TREATMENT AND COURSE: Laparotomy, performed to remove the suspected stone, revealed a floating intraductal tumour, histologically a hepatocellular carcinoma. Further imaging discovered the primary hepatic tumour. CONCLUSION: Although a smooth-walled contrast-sparing mass in the common bile duct usually denotes a stone, other structures may rarely imitate this picture, in particular atypical tumour growth.

[Intramural pseudodiverticulosis of the esophagus. Diagnosis on second look]

Gillessen A. Laufer U. Pohle T. Liermann D. Henning B.
Medizinische Klinik I, Universitatsklinik Marienhospital Herne.
HISTORY: Case 1. A 56-year-old man had experienced increasing dysphagia for 6 months, accompanied by a weight loss of 20 kg. A stenosing oesophageal carcinoma was suspected. Case 2. A 82-year-old man had been suffering intermittently from nausea for some years but had maintained his weight (80 kg; height 173 cm). Endoscopy 4 months before this admission had revealed a duodenal ulcer; its treatment briefly improved the symptoms. INVESTIGATIONS, DIAGNOSIS AND TREATMENT: Endoscopy in case 1 detected a severe oesophageal stenosis which could not be passed, and its cause could not be ascertained despite biopsy, barium swallow and computed tomography. After bougie dilatation an endoscope was finally passed and the typical picture of oesophageal pseudodiverticulosis (OPD) seen. In case 2, endoscopy at first indicated only marked Candida oesophagitis. But after antimycotic treatment a second endoscopy revealed OPD. No treatment is known nor necessary since OPD causes no clinical symptoms unless there are complications. CONCLUSIONS: OPD, a rare condition, presents in various ways, both in its symptoms and at endoscopy. In case of oesophageal stenosis of unknown cause or Candida oesophagitis repeat endoscopy my be necessary to establish the true diagnosis: OPD should be included in the differential diagnosis.

[Value of tumor-associated antigens CA 72-4 vs. CEA and CA 19-9 in the follow-up after stomach cancer]

Gartner U. Scheulen ME. Conradt C. Wiefelsputz J. Kruck P. Aghabi E. Delbruck H.
Paracelsus-Klinik, Bad Gandersheim.
OBJECTIVE: To compare the value of tumour markers CA-72-4 and CA 19-9 and the cardioembryonic antigen (CEA) in the follow-up of patients after potentially curative surgery of gastric carcinoma. PATIENTS AND METHODS: CA 72-4, CA 19-9 and CEA were measured prospectively in 279 patients 1-36 months after potentially curative primary surgery for histologically proven gastric carcinoma. Evaluation was by "receiver-operating-characteristics" (ROC) curves using "believe the positive" rules as well as by linear combinations. RESULTS: Recurrences were found in 54 patients. CA 72-4 (by radioimmunoassay) was the most sensitive single test (sensitivity 43%, specificity 95%). Radioimmunological and enzyme-immunological tests of CA 79-4 correlated well (r = 0.8). The various values, obtained by certain test kits, when newly calculated for the purpose of after-care, differed markedly from upper limits reported by the manufacturers. Measurement of both CA 72-4 and CA 19-9 increased the sensitivity to 54%. INTERPRETATION: Special levels of CA 72-4 and CA 19-9 have been identified which are of value in the follow-up of patients after operation for gastric carcinoma. Single measurements of CA 74-2 are as a rule preferable to those of CA 19-9 or of both CA 11-9 and CEA. In fact, CEA should be measured only in exceptional circumstances. But combined measurements of CA 72-4 and CA 19-9 increase sensitivity and prognostic value of the results.

[Short-term (6 days) eradication of Helicobacter pylori infection in the practice of a health insurance physician]

Seelis RE. Dohmen W.
No information.
OBJECTIVE: To obtain epidemiological data concerning Helicobacter pylori (H.p.) infections and peptic ulcer in patients with upper abdominal pain in a routine non-hospital based health-insurance practice, as well as to test the efficacy of H.p. eradication, especially with a new shortterm treatment scheme in this setting. PATIENTS AND METHODS: H.p. status and possible peptic ulceration (urease test, biopsies of gastric antrum and body) were determined in 1242 consecutive patients with upper abdominal pain examined gastroscopically. Patients who were H.p. positive and had a peptic ulcer or recurrent gastritis with erosions were given dual or triple medication (lansoprazole or pantoprazole with one or two antibiotics: amoxycillin, clarithromycin, azithromycin, tinidazole), under conditions of controlled compliance. RESULTS: The H.p. infection rate was 45.9% for the whole group (mean age: 49.9 years). An acute ulceration was found in 10.4% of the whole group, i.e. 20.1% of the 129 H.p. positive patients. 194 patients were given an eradication treatment. In 62 of them, put on a new 6-day eradication regimen (azithromycin, 1 x 500 mg daily; tinidazole, 1 x 2000 mg/d; and pantoprazole, 2 x 40 mg/d), an eradication rate of 93% (under protocol) or 92% (intention to treat) was achieved. INTERPRETATION: In routine non-hospital practice a 6-day modified triple-medication treatment with azithromycin, tinidazole and pantoprazole proved efficacious in eradicating H.p. infection. It not only caused few side effects and was cheap, but also achieved high patient compliance.

[A 35-year old male patient with fever and painful swelling of the pectoral glands following a short visit to Sri Lanka]

Alkadhi H. Tschop M. Marschang A. Langenmayer I. Feucht HE. Strasburger CJ.
Medizinische Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universitat, Munchen.
HISTORY AND CLINICAL FINDINGS: One week after returning from a two-week holiday in Sri Lanka a 35-year-old man started to have recurrent bouts of fever, up to 39.2 degrees C, as well as pain over the left upper abdomen, the back of the right thorax and bilateral pain on pressure with swelling of both breasts. He went to the Tropical Institute in Munich to have malaria excluded. There signs of cholestasis were noted and sonography revealed multiple round foci in the liver. As he had lost 10 kg in 3 weeks he was admitted to a medical unit for further tests. Physical examination now showed bilateral gynaecomastia and marked pressure resistance in the upper abdomen. Proprioceptor reflexes were greatly increased but equal bilaterally. INVESTIGATIONS: Inflammatory parameters were raised (C-reactive protein 22.6 mg/dl, ferritin level 2674 micrograms/l, erythrocyte sedimentation rate 50/82 mm), there also were a leucocytosis (20,600 WBC/mm3) and a raised lactate dehydrogenase level of 613 U/l. In addition, thyroid stimulating hormone was reduced to < 0.03 microU/ml, while free thyroxine was raised to 2.7 ng/dl. The pregnancy test was positive. On quantitative analysis the human beta-chorionic gonadotropin (hCG) level was markedly raised to 193,200 mIU/ml. Abdominal and thoracic computed tomography revealed multiple round metastasis-like masses in the liver and in the lung, and a thickened cardia. Serology for malaria, amoebiasis and echinococciasis was negative, sonography of the testes and thyroid was unremarkable. Endoscopy revealed a polypoid tumour at the gastro-oesophageal junction which histologically was an undifferentiated hCG-positive choriocarcinoma. TREATMENT AND COURSE: The neoplasm at first responded with partial remission (hCG minimally 39 mIU/ml) to chemotherapy (PEI schema: cisplatin, etoposide, ifosfamide) but then progressed, also under treatment of recurrences with paclitaxel, ifosfamide and cisplatin. The patient has since received high-dosage chemotherapy with autologous stem-cell transplantation.

[Sensorimotor polyneuropathy and systemic amyloidosis as paraneoplastic symptoms of a carcinoid-like well differentiated carcinoma of the breast]

Year 1998
Kruger S. Kreft B. Heide W. Siebel U. Djonlagic H. Reusche E.
Institut fur Pathologie, Medizinischen Universitat zu Lubeck.
HISTORY AND ADMISSION FINDINGS: A 75-year-old woman was admitted because of weakness and paraesthesias in both legs. 15 years earlier a chest radiogram had shown numerous round foci of uncertain cause. Physical examination confirmed muscular weakness in all limbs, especially the legs, as well as abnormal superficial and deep sensory perception. INVESTIGATIONS: Electromyography registered a patchy pattern of intentional muscular activity and marked denervation activity but largely normal nerve conduction. There was no evidence of inflammatory disease in the laboratory tests, including the CNS. DIAGNOSIS, COURSE AND TREATMENT: The neurological findings indicated progressive axonal sensorimotor polyneuropathy. A paraneoplastic cause was suspected, but search for a primary tumour was unsuccessful. The patient developed a urinary infection from which she died in septic shock. A carcinoid-like well-differentiated carcinoma of the breast with hematogenous metastases to liver, spleen and lung was discovered at autopsy. It also revealed severe systemic AA-type amyloidosis, involving liver, spleen heart and kidneys. In addition there was a severe progressive axonal neuropathy and marked neurogenic atrophy of the peripheral skeletal musculature. No amyloid deposition was seen. CONCLUSION: In case of amyloidosis and polyneuropathy of uncertain cause a paraneoplastic pathogenesis should be considered in the differential diagnosis, even in the absence of proven malignancy.

[Chronic HIV- and chronic HBV infection with hematuria and proteinuria]

Year 1998
von Appen K. Beuers U. Muhlhofer A. Weiss M. Thoenes GH. Samtleben W.
Medizinische Kliniken, Klinikum Grosshadern. Kai.vonAppen@lrz.uni-muenchen.de
HISTORY AND CLINICAL FINDINGS: A medical examination, undertaken in an apparently healthy 30-year-old man because of his occupational exposure to chemicals, revealed haematuria and proteinuria. Physical examination was unremarkable except for oral hair-leukoplakia and swelling of the cervical, supraclavicular, axillary and inguinal lymph nodes. INVESTIGATIONS: Examination of the urine demonstrated selective glomerular proteins (1.5 g/24 h) and dysmorphic erythrocytes. SGOT and SGPT activities were raised (73 and 129 IU/l, respectively). Active hepatitis B virus (HBV) and human immunodeficiency virus (HIV-1) infections were demonstrated virologically. The CD4+ count in blood was reduced to 200 cells/microliter. Renal biopsy showed an IgA nephropathy. TREATMENT AND COURSE: Antiretroviral treatment with zidovudine and lamivudine were started. SGOT and SGPT activities and HIV load fell steadily, while CD4+ cell count rose markedly. Renal functions have remained stable during the past 6 months. CONCLUSION: Signs of glomerular damage are not unusual in systemic diseases, tumors or infections (Hepatitis B and HIV in this case) and they may be the first manifestations of the underlying disease.

[Ticlopidine-induced acute cholestatic hepatitis]

Year 1998
Wegmann C. Munzenmaier R. Dormann AJ. Huchzermeyer H.
Medizinische Klinik, Klinikum Minden.
HISTORY AND ADMISSION FINDINGS: A 52-year-old man who had sustained a cerebellar infarct was given the platelet inhibitor ticlopidine (2 x 250 mg/d) to prevent further thromboses. 28 days after starting the medication he complained of itchings, feeling unwell and diarrhoea. He had also noted darkened urine and faecal discoloration. Physical examination revealed marked jaundice and multiple scratch marks over the entire body. INVESTIGATIONS: The activities in serum of alkaline phosphatase (420 U/l) and of gamma-GT (470 U/l) were markedly elevated and total bilirubin concentration was maximally 26.4 mg/dl. Activities of GPT (197 U/l) and GOT (44 U/l) were slightly increased. No cause was found for any extra- or intrahepatic cholestasis with or without mechanical obstruction (e.g. viral or autoimmune hepatitis). A biopsy, which showed centro-acinar cholestasis also suggested drug-induced liver damage. TREATMENT AND COURSE: Despite discontinuing ticlopidine, the signs of cholestatic hepatitis had only disappeared 2 1/2 months after the onset of symptoms. CONCLUSION: Changes in the blood picture, allergic skin reactions and gastrointestinal disorders are among the significant clinical side effects of ticlopidine. As this drug is increasingly being prescribed world-wide, the possibility of toxic liver damage should be taken into account.

[Evaluation of the function of the tubular esophagus in patients with progressive systemic scleroderma based on a standardized symptom score]

Year 1998
Kohler H. Adamek RJ.
Medizinische Klinik, Ruhr-Universitat, St. Josef-Hospital, Bochum.
BACKGROUND AND OBJECTIVE: The oesophagus is the internal organ most often affected in progressive systemic scleroderma (PSS). Suitable methods for demonstrating oesophageal involvement are available in only a few centres. Aim of this study was to validate a standardized symptom score for assessing oesophageal function in patients with PSS. PATIENTS AND METHODS: Oesophageal symptoms of dysphagia, odynophagia (pain on swallowing), heartburn and regurgitation were assessed in 27 consecutive patients with PSS. Intensity (0 to 3 points) and frequency (1 to 4 points) of these symptoms were quantified using a standardized system (after de Dombal and Hall): points per symptom (0 to 12) and points per patient (0 to 48). Results were compared with long-term manometric recordings as reference. The control group consisted of 20 healthy volunteers matched for age and sex. RESULTS: Healthy controls and patients with PSS had significantly different oesophageal motility: 22 of 27 patients fulfilled the criteria of oesophageal hypomotility. Using a total symptoms score of 8 points (points per patient) as limit of normal, the sensitivity of the scoring for the diagnosis of abnormal oesophageal function was 68%, with a specificity of 100%, positive predictive value of 100% and a negative predictive value of 42%. INTERPRETATION: The reported method of symptom scoring provides a valid means of positive prediction of (abnormal) oesophageal function, making manometric investigation unnecessary. Absence or an only mild degree of oesophageal symptoms does not exclude abnormal motility so that manometry must be performed in such patients.

[Pyostomatitis vegetans and Crohns disease. A specific association of 2 diseases]

Year 1998
Oettinger R. Gerner P. Borner N. Schopf RE.
Hautklinik, Johannes-Gutenberg-Universitat Mainz.
HISTORY AND CLINICAL FINDINGS: A 27-year-old man was referred to the dermatological out-patient clinic because of inflammatory changes in the oral mucosa of unknown cause. 5 months earlier he had been diagnosed as having Crohn's disease of the terminal ileum. On both sides of the buccal mucosa there were rough erythematous vegetations and disseminated miliary abscesses, which extended to the labial gingiva and the soft palate. Further physical examination was unremarkable. INVESTIGATIONS: Several inflammatory parameters were increased: C-reactive protein 100 mg/l, erythrocyte sedimentation rate 55/88 mm, eosinophilic cationic protein 35.8 ng/ml (normal range 2.3-16 ng/ml). White cell count was normal (7,25/nl), with a lymphocytopenia of 11.9%. There was no eosinophilia. Haemoglobin was reduced to 11.6 g/dl and the platelets raised to 526/nl. Smears of the oral mucosa showed no fungal, viral or bacterial infection. Biopsy revealed leucocytic microabscesses in the epithelium, granulation tissue and flat ulcerations with adjoining superficial necrotic zones. DIAGNOSIS, TREATMENT AND COURSE: The clinical and histological picture as well as the association with Crohn's disease (CD) suggested pyostomatitis vegetans (PV). The PV was treated with disinfectant mouth washes which improved the subjective findings. Budesonide was given for CD. CONCLUSION: PV is a rare and usually isolated condition, but it can also occur in association with a chronic gastrointestinal disease such as ulcerative colitis and Crohn's disease. The diagnosis of PV indicates a thorough gastroenterological investigation.

[Increased occurrence of esophageal hypermotility disorders in patients with arterial hypertension]

Year 1998
Adamek RJ. Bock S. Szymanski C. Hagemann D. Pfaffenbach B.
Medizinische Klinik, Ruhr-Universitat, St. Josef-Hospital, Bochum. Romuald.J.Adamek@ruhr-uni-bochum.de
BACKGROUND AND OBJECTIVE: It has been noted in previous manometric examinations of the oesophagus in patients with chest pain that abnormal motility was often associated with arterial hypertension. A systematic study of this relationship was therefore undertaken. PATIENTS AND METHODS: In 40 patients with chest pain (18 women and 22 men, mean age 54.7 [24-70] years) and in 20 healthy volunteers (12 men, 8 women, mean age 50.8 [22-63] years) standardized oesophageal manometry and arterial blood pressure monitoring were performed over 24 hours. Coronary heart disease and gastrointestinal lesions had been excluded by angiography and endoscopy, respectively. RESULTS: 20 patients (group H) had hypertension (median 24-hour blood pressure > 135/85 mmHg), while 20 patients (group N) and the normal controls (group K) were normotensive. Oesophageal manometry data differed significantly between the three groups regarding distal pressure amplitude (in hPa [hectopascals]; group H: 62 hPa*,**, group N 44 hPa* and group K 36 hPa**; [*P < 0.0005]) and the proportion of simultaneous contractions (group H 23%, group N 22%**, group K 10%***; ***P < 0.001). The hypertensive patients had significantly more frequent motility abnormalities than normal controls (13/20 vs 4/20, P < 0.001); while normotensive patients had more frequent episodes of abnormal propulsion in the oesophagus (proportion of propulsive contractions in group H: 53%, in N: 44%, in K: 59%; P < 0.01). CONCLUSION: Oesophageal motility differed significantly in patients with chest pain from that in healthy controls. Patients with chest pain and hypertension more frequently had oesophageal hypermotility. This suggests a generalized abnormality of smooth muscle.

[Polyposis of the gastrointestinal tract as a manifestation of diffuse follicular lymphatic hyperplasia]

Year 1998
Storr M. Weigert N. Fellbaum C. Classen M.
II. Medizinische Klinik und Poliklinik, Technischen Universitat Munchen. martin.storr@stud.uni-muenchen.de
HISTORY AND ADMISSION FINDINGS: A 21-year-old previously healthy Turkish man who had been living in Germany for 15 years was admitted because of worsening cramp-like abdominal pain with nausea, vomiting and watery diarrhoea. Palpation elicited diffuse muscular guarding over the entire abdomen and a mass of about 8 cm in the right lower abdomen. INVESTIGATIONS: Abnormal laboratory results were erythrocyte sedimentation rate (55 mm), C-reactive protein (6.2 mg/dl), total bilirubin (2.1 mg/dl), creatine kinase (137 U/l) and thymidine kinase (5.5 U/l). There was a slight leucocytosis (13,700/microliter) and mild anaemia (haemoglobin 13.4 g/dl) with a normal differential count. Listeria ivanovii was repeatedly cultured from stool. Ultrasonography and computed tomography of the abdomen demonstrated a 6 cm mass in the right lower abdomen, splenomegaly (15.5 x 5 cm) and several lymphomas, up to 1.8 cm in diameter. Endoscopy revealed dense, in part grass-like, polyps, 3 to 6 mm deep, in the mucosa from the terminal ileum to the rectum, and to a lesser extent also in the duodenum. Histological examination of the polyps demonstrated diffuse follicular hyperplasia without evidence of malignancy. TREATMENT AND COURSE: On antibiotic treatment with ofloxacin (2 x 400 mg intravenously) the symptoms quickly regressed, but the endoscopic findings remained unchanged. CONCLUSION: Diffuse follicular lymphatic hyperplasia manifested itself in this patient as diffuse gastrointestinal polyposis. Listeria ivanovii cannot be ruled out as a causative factor.

[Lead poisoning caused by a Greek ceramic cup]

Year 1998
Autenrieth T. Schmidt T. Habscheid W.
Medizinische Klinik des Paracelsus-Krankenhauses Ruit, Ostfildern.
HISTORY AND ADMISSION FINDINGS: A 24-year-old woman, an administrative employee, was admitted with colicky abdominal pain and constipation, as well as breathing-related chest pain of recent onset with cough and sometimes blood-streaked sputum. She had previously been unsuccessfully treated for gastritis and adnexitis. On physical examination revealed diffuse, ill-defined abdominal pain on pressure and mild tachycardia, but was otherwise unremarkable. INVESTIGATIONS: Electrocardiogram, chest radiogram, lung scintigraphy, abdominal sonography, oesophago-gastro-duodenoscopy and gynaecological examination indicated nothing abnormal. Laboratory tests showed microcytic anemia, slight leucocytosis and anisocytosis, as well as polychromasia and basophilic stippling of erythrocytes. The 24-h urinary porphyrin concentration was elevated. DIAGNOSIS TREATMENT AND COURSE: Precise differentiation of porphyrins in urine, stool and erythrocytes by enzymatic measurement first raised the suspicion of lead poisoning. Whole-blood lead concentration was markedly raised to 600 micrograms/l (normal up to 90 micrograms/l) and 170 micrograms/dl in urine (normal up to 80 micrograms/dl). A ceramic cup from Greece was traced as the source of the lead, the patients having regularly for over 2 1/2 months drunk lemon instant-tea from it. She was treated with oral doses of DMPS (sodium salt of 2,3-dimercapto-1-propanesulphonic acid), 5-10 mg/kg 3x daily for 2 days, followed by 2.5 mg/kg 2 x daily, until lead concentrations in blood and urine had become normal, when all symptoms disappeared: detoxification was complete within 4 months. CONCLUSION: This case impressively illustrates how difficult it can be to diagnose lead poisoning and identify its source. Oral DMPS is a practicable and efficacious form of treatment.

[Strongyloides stercoralis infection in a patient with AIDS and non-Hodgkin lymphoma]

Year 1998
Muller A. Fatkenheuer G. Salzberger B. Schrappe M. Diehl V. Franzen C.
Klinik I fur Innere Medizin, Universitat zu Koln.
HISTORY AND CLINICAL FINDINGS: The patient, now 50 years old, an immigrant miner from the former Yugoslavia who was known to have AIDS, was in 1992 found to have non-Hodgkin lymphoma of the oesophagus and given five cycles of multiple chemotherapy (CHOP) with complete remission. Subsequently he complained of retrosternal pain, dysphagia, dry cough and upper abdominal discomfort. On admission he had slight fever of 39.1 degrees C, but physical examination was unremarkable. LABORATORY TESTS: Blood count revealed an eosinophilia of 41%. IgE concentration was raised to 432IU/ml. The CD4+ T-cell count was reduced to 10/microliter, that of CD8+ to 89/microliter. ADDITIONAL TESTS: Blood culture, fecal and sputum samples and bronchoalveolar lavage demonstrated Mycobacterium avium intracellulare. TREATMENT AND COURSE: Treatment of the disseminated atypical mycobacterial infection was started with clarithromycin, rifabutin, ciprofloxacin and ethambutol. There was no improvement of the upper abdominal discomfort, but the fever subsided. Oesophagogastroscopy excluded recurrence of the lymphoma. Biopsy and examination of the duodenal juice revealed worms and larvae of Strongyloides stercoralis. Stool samples contained no mycobacteria, but strongyloides larvae were demonstrated. Albendazole was given (2 x 400 mg daily for 6 days, followed by a maintenance dose of 1 x 400 mg daily). Repeat endoscopy and stool sample after a month no longer showed any parasites. CONCLUSION: Even in Western Europe, persons coming from endemic areas who, as this patient, have various risk factors that may facilitate the occurrence of strongyloidiasis. With early diagnosis and treatment albendazole is an efficacious drug.

[Photodynamic diagnosis of gastrointestinal precancerous lesions after sensitization with 5-aminolevulinic acid. A pilot study]

Year 1998
Messmann H. Knuchel R. Endlicher E. Hauser T. Szeimies RM. Kullmann F. Baumler W. Scholmerich J.
Klinik und Poliklinik fur Innere Medizin I, Universitat Regensburg.
BASIC PROBLEM AND OBJECTIVE: Endoscopic diagnosis of gastrointestinal precancerous and cancerous lesions is difficult, often even impossible. This study was undertaken to find out whether premalignant or suspected malignant tumors can be diagnosed by preceding sensitization with 5-aminolaevulinic acid (ALA), which in tumors is transformed in increased amounts into photosensitizing protoporphyrin IX, the latter being recognized by its characteristic red fluorescence on exposure to blue light. PATIENTS AND METHODS: 20 patients with known mild or moderately severe dysplasias (Barrett's esophagus, n = 8; colorectal adenoma, n = 3; ulcerative colitis n = 2, and gastric polyps or mucosal changes suspicious of malignancy, n = 5. Two patients with squamous-cell carcinoma, who after radio- and chemotherapy were endoscopically free of tumor, were sensitized with different concentrations of ALA (orally: 5-30 mg/kg; or locally: 3 g in 100 ml 0.9% NaCl). Photodynamic diagnosis (PDD) took place 4-8 h after oral and ca. 1-2 h after local sensitization with blue light (D-light, Storz, Tuttlingen, Germany). RESULTS: Definite red fluorescence with demonstration of dysplasia was found in three of four patients with Barrett's esophagus. Biopies from nonfluorescent areas were free of dysplasia. Two gastric adenomas (10 mg/kg ALA with high-grade dysplasia were definitively endoscopically by their red fluorescence. In one patient mild dysplasia was found in a non-fluorescent area after radio- and chemotherapy of an esophageal carcinoma. Dysplasias were also seen in the rectal biopsy after local applications. CONCLUSIONS: PDD makes it possible for the first time to visualize precancerous lesions of the gastrointestinal tract after preceding ALA sensitization. PDD is a highly promising method for monitoring patients with gastrointestinal disease and an increased risk of cancer, and for clarifying the diagnosis of mucosal changes suspicious of malignancy.

[Progress of acute liver failure and indications for liver transplantation]

Year 1998
Paar WD. Muller A. Spengler U. Fischer HP. Hertfelder HJ. Hirner A. Sauerbruch T.
Medizinische Universitatsklinik und Poliklinik-Allgemeine Innere Medizin, Bonn. w.d.paar@uni-bonn.de
OBJECTIVE: To analyse the course of acute liver failure and the indications for liver transplantation. PATIENTS AND METHODS: In 16 patients who developed acute liver failure between July 1992 and July 1997 the indications for liver transplantation and total survival time were analysed retrospectively. RESULTS: Intensive medical care (ventilation, dialysis) was necessary in 60% of the patients to bridge organ failure until liver transplantation. In 14 patients liver transplantation was indicated. Eleven of the patients, with a minimal Quick value of less than 10%, presented with the prognostically poorest London criteria. In two patients the combination of three additional criteria of the London classification led to liver transplantation being indicated. In one patient with Wilson's disease the transplantation was undertaken despite good clotting factor synthesis, because an encephalopathy occurred. In two patients liver transplantation was not undertaken even though indicated, in one because liver functions improved, in the other because necrotizing pancreatitis had occurred. In another patient, who had been poisoned by eating the mushroom Amanita phalloides, the attempted transplantation was cut short, because intestinal necrosis had developed, and the patient died during the operation. Nine of the eleven patients who had a transplantation and three of the four treated conservatively survived. CONCLUSION: The 60-day survival rate in this series, achieved in a recently established transplantation programme, is high (12 of 16; 75%), being comparable to those in larger transplantation centres.

[Duplication cyst of the stomach antrum as the cause of an acute gastric emptying disorder in an adult]

Year 1998
Pacher K. Fluckiger R. Schaub N. Wegmann W. Huber A.
Chirurgische Klinik, Kantonsspital Bruderholz.
HISTORY AND CLINICAL FINDINGS: A 35-year old woman without previous history of gastrointestinal complaints developed increasing upper abdominal pain with nausea and postprandial vomiting over 2 days during which she had been unable to take any food. She had no fever; her general physical condition was slightly reduced. While her abdomen felt soft on palpation, she had epigastric pain on pressure but no resistance to palpation. INVESTIGATIONS: Blood picture and routine laboratory tests were unremarkable. Plain film of the abdomen demonstrated marked gastric retention. Abdominal ultrasound showed an invagination in the gastric antrum suggesting a layering phenomenon. Gastroscopy revealed a submucosal tumour-like lesion with central ulceration which obstructed gastric exit. TREATMENT AND COURSE: After conclusion of the diagnostic tests on the first hospital day partial gastric resection (Billroth I) was performed as, in the absence of any surrounding reaction, a leiomyoma had been suspected. The further course was without complication and she was discharged on the 13th hospital day. The surgical specimen revealed a duplication cyst of the gastric antrum. CONCLUSION: (Endo)sonography, computed tomography and endoscopy make it possible to diagnose duplication cyst, as long as it is included in the differential diagnosis of acute abdomen in an adult. Emergency resection of the cyst is indicated because of the acute nature of the symptoms. But even in less urgent cases or as an incidental finding it is the treatment of choice.

[Unwanted drug effects in clinical practice]

Year 1998
Schoenemann J. Munter KH. Enayati-Kashani S.
Medizinische Abteilung, St. Elisabeth-Krankenhauses Koln.
BACKGROUND AND OBJECTIVE: Unwanted drug reactions (UDR) in routine clinical practice remain largely unrecorded, even though such documentation can significantly contribute to quality assurance in drug therapy. This prospective study was undertaken to ascertain within a defined time period the frequency and significance of UDR in the medical wards of a general hospital (focus on gastroenterology) and find the organisational structures needed for its documentation. PATIENTS AND METHODS: All observed UDRs among a total of 4032 in-patients were recorded on a simple registration form, filled in by doctors assigned to collect the information, which was then analysed in cooperation with the Drug Commission of the German Medical Council (AKdA). RESULTS: UDRs were recorded in 315 patients (7.8%), 135 of them (43%) already present on admission. 101 patients had been admitted because of the UDR. Gastrointestinal disorders, particularly peptic ulcer, and skin rash were the most common UDRs. Individual drugs most frequently responsible were acetylsalicylic acid, cyclophosphamide and digoxin, the most common drug groups were nonsteroid analgesics, antibiotics and cytostatic drugs. The method employed proved to be practicable and cost-effective. CONCLUSIONS: A simple and cost-effective system, integrated into the daily medical routine, can heighten awareness of UDRs among doctors and thus improve drug safety in hospitals, while concomitantly providing an important feature of further medical education.

[Diagnosis of a hereditary pancreatitis by the detection of a mutation in the cationic trypsinogen gene]

Year 1998
Gress TM. Micha AE. Lacher U. Adler G.
Abteilung Innere Medizin I, Universitat Ulm.
HISTORY AND CLINICAL FINDINGS: A 71-year-old woman was admitted with the suspected diagnosis of pancreatic carcinoma. As a child she had had repeated attacks of abdominal pain of undetermined cause. When aged 48 years she had developed diabetes mellitus. Her now 42-year-old daughter had from the age of 9 years suffered from repeated attacks of acute pancreatitis that had finally led to chronic pancreatitis. The patient's 15-year-old grandchild was having recurrent bouts of abdominal pain. INVESTIGATIONS: Imaging procedures revealed calcifications in the pancreas and an infiltrating space-occupying lesion, about 3 cm in diameter, in the head of the pancreas with lymph node and liver metastases. Cytological analysis of material aspirated from the space-occupying mass showed typical findings of ductal pancreatic carcinoma. FURTHER TESTS, TREATMENT AND COURSE: At first the patient's course was not typical for a genetically-determined disease, but the family history raised the suspicion of hereditary pancreatitis. A genetic test (Afl-III-RFLP test) demonstrated the mutation Arg 117 His in the cationic trypsinogen gene in all diseased or symptomatic family members. The patient died of the complications of the pancreatic cancer. CONCLUSION: Genetic tests are valuable in the diagnosis of hereditary pancreatitis, because the increased cancer risk can be met by frequent examinations in affected family members.