[Chronic inflammatory bowel diseases. Pathophysiology and drug therapy]
von Ritter C.
Medizinische Klinik II, Klinikum Grosshadern, Ludwigs-Maximilians-Universitat, Munchen.
Recent studies indicate that the normal intestinal flora, an exaggerated reaction of the intestinal immune system and a decreased epithelial barrier function of the gut play an important role in the pathogenesis of Crohn's disease and ulcerative colitis. The medical therapy of inflammatory bowel disease aims to correct these alterations. Aminosalicylates, corticosteroids, immunosuppressants and antibiotics are the four main groups of substances which are currently used for the therapy of inflammatory bowel diseases. Slow release formulation allow specific targeting of 5-aminosalicylic acid to the inflamed sections of the gut; with budesonid a corticosteroid therapy with minimal systemic side effects is possible. Future therapeutic options include specific immuno-modulatory therapy with cytokines or cytokine antibodies. Maintenance therapy may, conceivably, be performed with probiotics or antioxidants. Therefore, despite continued uncertainty about the cause of inflammatory bowel diseases, recent advances nourish the hope for further improvement of the control of disease activity and a better quality of life for patients with inflammatory bowel diseases.
[Surgical treatment of inflammatory bowel diseases]
Furst H. Schildberg FW.
Chirurgische Klinik und Poliklinik, Ludwig Maximilians Universitat Munchen, Klinikum Grosshadern, Munchen.
PURPOSE: To summarize current knowledge on surgical therapy in patients with inflammatory bowel disease (Crohn's disease, ulcerative colitis and diverticulitis). MATERIAL AND METHODS: To discuss surgical indications and strategies, we reviewed major peer review publications of the last 10 years, and we also analysed data from patients with Crohn's disease who were treated in our institution between 1978 and 1994. RESULTS: With Crohn's disease (305 patients), emergency surgery should be avoided as much as possible, since morbidity (50% vs 8.8%) and mortality (11% vs 0.6%) rise significantly in comparison to elective procedures. With ulcerative colitis, operative therapy is indicated in patients with secondary malignoma, and urgent surgery is requested in cases with associated perforation, toxic megacolon or massive bleeding. With diverticulitis, the first episode should be managed conservatively. Surgery is indicated in patients with recurrent episodes or with secondary complications. DISCUSSION: For treating patients with Crohn's disease or with diverticulitis, an indication for surgery should not be delayed and should be made before complications develop to avoid high risk emergency surgery. Elective surgery in patients with ulcerative colitis usually consists in proctocolectomy. Individual findings and aspects will determine the decision whether to construct an ileoanal pouch or whether ileostoma is more appropriate.
[Radiologic evaluation of Crohn disease]
Schober E. Turetschek K. Mostbeck G.
Klinische Abteilung Rontgen fur konservative Facher, Universitatsklinik fur Radiodiagnostik, Wien.
PURPOSE: This paper discusses the role of different imaging modalities in the diagnostic work-up of Crohn's disease (CD). METHODS: We present a concept, which emphasizes different diagnostic aspects with regard to primary diagnosis, follow-up and assessment of complications of CD. The most effective imaging approach to various diagnostic problems of CD is discussed in detail. DISCUSSION: With regard to the primary diagnosis barium studies should contribute to differentiate between CD and ulcerative colitis. Beyond that, these studies should evaluate location and extent of disease. During the follow-up bowel sonography provides staging of disease and enables the detection of complications at an early stage. CT is a valuable tool in the preoperative assessment of complications, such as fistulae and abscesses.
[MRI of the abdomen combined with enteroclysis in Crohn disease using oral and intravenous Gd-DTPA]
Rieber A. Wruk D. Nussle K. Aschoff AJ. Reinshagen M. Adler G. Brambs HJ. Tomczak R.
Abteilung Rontgendiagnostik, Radiologische Klinik der Universitat Ulm.
In spite of the improved MR-diagnosis of the abdomen, MRI is not used as a routine method for the diagnosis of inflammatory small bowel disease. The aim of this study was--after optimazation of the bowel opacification--the correlation of the findings obtained with enteroclysis and MRI in patients with known Crohns' disease. 60 patients between 17 and 72 years of age were investigated. First, an enteroclysis was performed in typical manner. The applicated methylcellulosis was blended with positive oral MR contrast media (Magnevist oral, Schering). After enteroclysis, MRI of the abdomen was performed using T1- and T2-weighted breathhold sequences (Flash 2D pre- and postcontrast and TSE) in axial and coronal planes. The length of the affected bowel and the stenosis seen with enteroclysis correlated well with the visible thickening of the small bowel wall and the stenosis seen in MRI. Using MRI, additional findings could be obtained in 28 patients, such as fistulas, abscesses or a hydronephrosis, or a better assessment of the stenosis was possible with MRI, because of the avoidance of overshadowing of the affected bowel loop with MRI. A brilliant MR-tomographic imaging of the small bowel is possible under the condition, that the small bowel contrast is optimal. The main prerequisite is a large filling volume of the small bowel to reach a homogeneous contrast and a good distension of the small bowel lumen.
[MRI of the small intestine with rapid MRI sequences in Crohn disease after enteroclysis with oral iron particles]
Holzknecht N. Helmberger T. von Ritter C. Gauger J. Faber S. Reiser M.
Institut fur Radiologische Diagnostik, Klinikum Grosshadern, Ludwig-Maximilians-Universitat, Munchen.
PURPOSE: To evaluate the efficacy of breathhold MRI following enteroclysis with addition of oral magnetic particles to study the extension, detection of stenoses and extraluminal manifestations in Crohn's disease. MATERIAL AND METHODS: 18 patients with Crohn's disease and potential of surgical intervention were studied with enteroclysis with addition of oral magnetic particles. T1-/T2-weighted breathhold MRI w/o spectral fat suppression w/o i.v. Gd-DTPA was applied. RESULTS: Typical findings were marked bowel wall thickening with strong contrast enhancement. 95.8% of affected small bowel segments and 94.7% of stenoses were correctly detected by MRI. All four fistulas were detected and important extraluminal findings were seen in 6/18 patients. Additionally, one ileoileal and two ileosigmoidal adhesions, two extraluminal abscesses and affection of the right ureter were delineated. CONCLUSION: MRI in Crohn's disease offers the potential to avoid radiation exposure in this relatively young patient group. Important additional findings relevant to indication of surgery are seen in approximately one third of cases. The replacement of transduodenal intubation by oral contrast application remains to be further studied.
[Mesenteric lymphadenopathy in Yersinia enterocolitica infection]
Trommer G. Bewer A. Kosling S.
Klinik und Poliklinik fur Diagnostische Radiologie der Universitat Leipzig.
We report a case of previously undiagnosed Yersinia enterocolitica infection in a 46-year old woman. She consulted her physician because of continual weight loss and physical lassitude. A leucocytosis was found. Sonography revealed an excessive enlargement of abdominal lymph nodes. A malignant lymphoma was suspected and the patient underwent a staging by CT. There the disease was limited on mesenteric and retroperitoneal lymph nodes. Bone marrow biopsy and CT-guided lymph node biopsy did not confirm a systemic lymphatic disease. The patient did not undergo a special therapy. After six months, CT showed a clear regression of enlarged lymph nodes. Finally, a previous Yersinia enterocolitica infection of immunotype 03 could be proved serologically. At this time, the patient had no complaints. Diagnostic and differential diagnosis of benign abdominal lymph node enlargement are discussed based on literature.
[Inflammatory bowel diseases. Colon contrast enema and CT]
Abteilung fur Radiologie, Klinikum Kempten-Oberallgau.
Among the many inflammatory diseases of the colon, Crohn's disease and ulcerative colitis occur most frequently. For primary evaluation, endoscopy has widely replaced the barium enema (BE) as diagnostic method. BE, however can provide important additional informations in the differential diagnosis of chronic inflammatory colonic diseases. Purpose of this article is the demonstration of typical, but also of atypical radiological changes in different stages of Crohn's disease and ulcerative colitis, as well as calling attention to the importance of CT. A BE demands a refined examination technique using double contrast. All CT-examinations have to be scrutinized for changes of the bowel and mesentery. A dedicated spiral-CT examination might be indicated in a known disease in order to obtain special informations. The advantage of a BE over endoscopy is a clear and reproducible demonstration of the patterns of distribution and character of the disease as well as the detection of fistulae. The classification into one or the other disease entity can be better accomplished. CT is superior in detecting bowel wall thickening, extraintestinal disease and complications. In diagnostic imaging of chronic inflammatory bowel diseases, endoscopy and radiologic techniques are used complementarily.
[Postoperative complications after larynx resection: assessment with video-cinematography]
Kreuzer S. Schima W. Schober E. Strasser G. Denk DM. Swoboda H.
Univ.-Klinik fur Radiodiagnostik, Wien.
In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.
[Pathologic swallowing pattern after tumor surgery of oro- and hypopharynx. Analysis with differentiated deglutition imaging]
Oursin C. Trabucco P. Bongartz G. Steinbrich W.
Departement fur Diagnostische Radiologie, Universitatsklinik Basel.
Dysphagia is a common complaint following surgical intervention in the oral cavity and hypopharynx, often leading to prolonged postoperative recovery. Videofluoroscopy allows detailed visualization of deglutition, demonstrating the morphology as well as the functional aspects. Therefore, videofluoroscopy provides the basis for further therapeutic management. We discuss the pathology of deglutition in 19 patients recovering from tumor surgery of the oro- and hypopharynx. In most cases the results demonstrated severe impairment of both the oral and pharyngeal phase of deglutition. Our data emphasize the importance of the oral phase of deglutition for preparation and initiation of the following phases.
[Septic focus in the retroperitoneum--iatrogenic foreign body of cotton (gossypiboma)]
Romaneehsen B. Bahner ML. Delorme S.
Abteilung Onkologische Diagnostik und Therapie, Deutsches Krebsforschungszentrum Heidelberg.
Retained surgical towels (gossypiboma) present a diagnsotic problem if they remain asymptomatic for many years. We report on one 51 year old patient with repeated septic temperatures in the early post-operative phase after hemicolectomy. The contrast enhanced CT of the abdomen revealed a well-defined round soft-tissue mass with a dense, enhanced wall containing an internal high-density wavy and striped area. At laparotomy a secondary infected surgical sponge with abscess formation was found.
[Focal liver diseases]
Helmberger T. Holzknecht N. Gregor M. Gauger J. Helmberger R. Reiser M.
Institut fur Radiologische Diagnostik, Klinikum Grosshadern, Ludwig-Maximilians-Universitat Munchen.
INTRODUCTION: Advanced therapies are improving significantly the survival of patients with malignant focal liver disease. For efficient implementation of these surgical and interventional techniques a clear concept of the diagnostic procedure is mandatory. METHODS: Based on a review of the current literature, the different imaging modalities, including ultrasound, computed tomography, magnetic resonance tomography, nuclear medicine and angiography, are discussed and evaluated for their diagnostic efficacy in focal hepatic disease. RESULTS: Considering clinical, diagnostic, and economical appropriateness, recommendations for diagnostic strategies in different clinical scenarios regarding focal heptic disease are presented. CONCLUSION: If the power of specific imaging methods are relevant clinical information is known, problem-based diagnostic strategies help to avoid unnecessary, expensive and time-consuming studies in the work-up of focal liver lesions.
[Rational diagnosis of the bile ducts]
Helmberger H. Huppertz A. Rull T. Zillinger C. Ehrenberg C. Rosch T.
Institut fur Rontgendiagnostik, Klinikum rechts der Isar, Technischen Universitat M[nchen.
Since the introduction of MR cholangiography (MRC) diagnostic imaging of the biliary tract has been significantly improved. While percutaneous ultrasonography is still the primary examination, computed tomography (CT), conventional magnetic resonance imaging (MRI), as well as the direct imaging modalities of the biliary tract--i.v. cholangiography, endoscopic-retrograde-cholangiography (ERC), and percutaneous-transhepatic-cholangiography (PTC) are in use. This article discusses the clinical value of the different diagnostic techniques for the various biliary pathologies with special attention to recent developments in MRC techniques. An algorithm is presented offering a rational approach to biliary disorders. With further technical improvement shifts from ERC(P) to MRC(P) for biliary imaging could be envisioned, ERCP further concentrating on its role as a minimal invasive treatment option.
[Hydro-CT in detection and staging of pancreatic carcinoma]
Richter GM. Wunsch C. Schneider B. Dux M. Klar E. Seelos R. Kauffmann GW.
Abteilung Radiodiagnostik, Universitatsklinik Heidelberg.
PURPOSE: To document our experience with spiral hydro-CT of the pancreas based on a combination of pharmacologic intestinal paralysis and water distension of the stomach and duodenum with specific reference to tumor detection rate, differentiation of malignant versus benign tumors and assessment of tumor resectability in a prospective study on 211 consecutive patients. MATERIAL AND METHODS: Between May 1994 und September 1997, 211 patients with suspect of pancreatic neoplasm from clinical, laboratory or other imaging data were examined. Our Hydro-CT techniques were based on intravenous injection of 40 mg N-butylscopolaminiumbromid (Buscopan) for intestinal paralysis, gastric and duodenal wall distension by oral administration of an average of 1.5 l warm tap water, 30 degrees RAO patient's positioning, individualized contrast injection technique using portal vein enhancement as reference and thin slice spiral CT (3 mm slice thickness, 6 mm table feed and 3 mm secondary reconstruction). Examined parameters were: (1) tumor detection rate, (2) differentiation of malignant versus benign disease, (3) differential diagnosis and (4) accuracy of assessment of resectability by identification of infiltration into adjacent organs and vessel structures relevant for resectability such as splenic, superior mesenteric, portal vein and celiac trunk, superior mesenteric, splenic and hepatic arteries. As gold standard for positive tumor detection and description surgery (of potentially resectable tumors) and microscopic diagnosis (of clearly unresectable tumors) were used and for negative tumor detection an event-free survival of six months, respectively. RESULTS: 96% of the examinations were well tolerated. In only 4% was on-site administration of a gastric tube required because of vomiting. In 2% of the patients a slight allergic reaction to the contrast medium was seen. The prevalence of a pancreatic neoplasm was 37.8%. In tumor detection Hydro-CT reached an overall accuracy of 94.8% with a sensitivity of 93.7% and a specificity of 95.2%. 52 patients underwent surgical exploration 34 of whom with tumorfree resection margins (RO resection) corresponding to a resection of 42.5%. In those assessment of resectability reached an overall accuracy of 94.6% with a sensitivity of 91.2% and specificity of 95.6%. CONCLUSION: The new technique of Hydro-CT based on the slice and spiral methodology including pharmacologic intestinal paralysis and water distension results in a high tumor detection rate and reliable assessment of resectability.