Quantification of hepatitis C virus RNA by RT-PCR in comparison to the branched DNA method.
Roth WK. Lee JH. Ruster B. Zeuzem S.
Georg-Speyer-Haus, Frankfurt am Main, Germany.
INTRODUCTION: Quantification of hepatitis C virus (HCV) serum viremia levels is an important measure to predict and monitor response to interferon-alpha therapy as well as to predict clinical outcome. We were interested to compare the most widely used HCV quantification methods, quantitative RT-PCR (qRT-PCR) and the branched DNA (bDNA) method, with respect to sensitivity and reliability. RESULTS: In the present study, 101 serum samples from patients chronically infected with HCV were simultaneously quantified by an in-house reverse transcriptase (RT)-PCR assay and the branched DNA Quantiplex HCV RNA kit 1.0 and 2.0. The concentration of HCV RNA molecules/ml serum ranged from 1.5 x 10(4) to 1.0 x 10(8) as assessed by our quantitative (q)RT-PCR. Serum concentrations of HCV-genotype 1 were significantly higher when measured with bDNA 1.0 compared to bDNA 2.0 and qRT-PCR, whereas measurements by qRT-PCR and bDNA 2.0 were concordant. Measurements of genotypes 2 and 3 by bDNA 2.0 were significantly higher than by bDNA 1.0. Significantly lower measurements were obtained for genotype 3 by qRT-PCR in comparison to bDNA 2.0. CONCLUSION: Despite subtype-specific differences, there is clinically sufficient agreement in measurements between qRT-PCR and bDNA of HCV RNA concentrations. However, with respect to the therapeutic monitoring of the individual patient, kits and methods should not be exchanged.
[Photodynamic therapy of early squamous epithelial carcinomas and severe squamous epithelial dysplasias of the esophagus with 5-aminolevulinic acid]
Gossner L. Stolte M. Sroka R. May A. Hahn EG. Ell C.
INTRODUCTION: Photodynamic therapy (PDT) is a new local, endoscopically controlled therapeutic concept based on the selective sensitization of malignant and precancerous lesions prior to light-induced tissue destruction. 5-aminolaevulinic acid (5-ALA) appears to be a promising alternative photosensitizer with a high mucosa specificity without phototoxic side effects on the skin. We report on our experience with this new form of PDT in 24 patients. PATIENTS AND METHODS: Five females and 19 males (aged 50 to 79 years) with histologically proven high-grade dysplasia (n = 9) and early cancer (normal EUS or uTlNOMO, n = 15) of the esophagus were included in this study. Four to six hours after oral ingestion of 5-ALA (dosage of 60 mg/kg b.w.) laser light irradiation was conducted with a dye laser system (XP 800 KTP/YAG, Laserscope, San Jose, USA) at a wavelength of 635 nm. With a light dose of 150 J/cm2. RESULTS: The length of the segment with severe dysplasia or mucosal cancer varied between 0.5 and 9 cm (mean length: 3.6 cm). High-grade dysplasia was eradicated in all patients (9/9). In addition, 16 mucosal carcinomas in 15 patients were successfully treated in 8/16 cases with an average of 1.8 treatment sessions and a mean follow-up of 14.5 months (range: 3-31 months). A method-related mortality and morbidity was not observed. CONCLUSIONS: Severe dysplasia and superficial (< or = 2 mm) mucosal cancer of the esophagus can be completely ablated by 5-ALA-PDT. Patients with early carcinoma thicker than 2 mm are not suitable for 5-ALA-PDT. PDT with 5-ALA has few side effects and might offer an alternative to esophagectomy or radio-chemotherapy.
Rexroth G. Altmannsberger HM. Hassenstein EO. Rosch W.
Medizinische Klinik, Krankenhauses Nordwest, Frankfurt/M.
A 58-year old patient with metastasizing squamous cell carcinoma of the left lung developed fever, diffuse abdominal pain and profuse diarrhea while treated with paclitaxel and radiation therapy. A sigmoidoscopy was performed to exclude pseudomembranous colitis but showed multiple mucosal petechiae. Histologic examination disclosed neutropenic colitis. Conservative treatment was successful.
A rare case of bloody diarrhea: thrombosis of the V. mesenterica inferior following laparoscopic cholecystectomy.
Klugewitz K. Rehermann B. Seifert U. Boker KH. Stolte M. Meier PN. Wagner S. Manns MP.
Abteilung fur Gastroenterologie und Hepatologie, Medizinische Hochschule Hannover.
Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholecystolithiasis. The most common complications, as current experiences show, are bleeding, bile duct injury and non-technical complications like pneumonia. In some individual cases ischemic lesions of bowel by injury or thrombosis of intestinal vessels are described. Here we report the rare case of intestinal venous thrombosis following laparoscopic cholecystectomy. The complication clinically appeared within 24 h after operation starting with bloody diarrhea and mimicking inflammatory bowel disease. The patient, a 41-year old man, was treated with high-dose heparin and could be discharged after 44 days without complaints. Coloscopy six months after the event showed a restitution ad integrum.
[Significance of coinfection with hepatitis G virus for chronic hepatitis C--a review of the literature]
Rambusch EG. Wedemeyer H. Tillmann HL. Heringlake S. Manns MP.
Medizinische Hochschule Hannover, Zentrum Innere Medizin und Dermatologie.
BACKGROUND: The clinical significance of the recently discovered hepatitis C virus (HGV/GB virus C (GBV-C) is not conclusively clarified. The aim of this analysis was to evaluate the frequency of HGV/GBV-C coinfection at existing hepatitis C infection, the significance for the course of the liver disease, and its response to antiviral therapy. METHODS: The literature available by medline and the PubMed Retrieval System as well as abstracts of recent German, European, and American conferences on liver diseases (GASL, EASL, ASSLU) concerning HCV/GBV-C-coinfection were analyzed. RESULTS: We identified 66 references with 5,388 patients suffering from HCV-infection. 941 (17.5%) were coinfected with GBV-C. Excluding some groups at risk (intravenous drug abusers, dialysis patients, patients after liver transplantation), the rate of coinfection varied significantly in respect to geography: 20.5% in European vs. 10.9% in Japan (p < 0.0001). Additionally, coinfection occurred in 38% of intravenous drug users. The studies showed that coinfection was related to the frequency of blood transfusions. Furthermore, the parenteral transmission route of GBV-C was generally confirmed. Overall GBV-C does not seem to have any negative influence on the course of HCV-related chronic liver disease or the development of chronicity of acute hepatitis C infection, nor does it have any influence on histology, transaminase-levels or response of HCV to antiviral therapy; GBV-C was shown to be sensitive to interferon-alpha with a relapse rate up to 53% comparable to HCV. There is no correlation between response of HCV and GBV-C to interferon. CONCLUSION: This analysis of the published data concerning coinfection of HCV and HGV/GBV-C revealed no influence of GBV-C on the course of HCV-related liver disease (clinical, biochemical, histological). GBV-C does not modify the response rate of HCV to interferon-alpha, but GBV-C is sensitive to interferon with high relapse rates.
[Use of metal stents in gastroenterology]
Neuhaus H. Schumacher B.
Evangelisches Krankenhaus Dusseldorf.
A variety of metal stents have been increasingly used for malignant esophageal, biliary and colorectal stenoses. Esophageal self-expandable stents significantly reduce the early morbidity after implantation compared to conventional plastic prostheses. However they offer no benefit in the long-term due to various late complications. Biliary stents offer a significantly longer patency than plastic devices. This advantage is however clinically relevant only for patients with a survival time of more than three months. Preliminary trials indicate promising results for palliation of colorectal stenoses with metal stents in selected cases. Due to a lack of comparative studies the different types of metal stents must be selected on basis of their physical characteristics and clinical experiences. Most of the prostheses are irremovable which is a limitation for use in benign stenoses of the gastrointestinal and biliary tract. In addition metal stents are extremely expensive so that carefully designed trials are warranted for evaluation of the cost-benefit ratio.
Evaluation of a cacao drink as a simple oral stimulus to assess gallbladder contraction.
Nitsche R. Hinrichsen H. Herzig KH. Hopfner M. Nustede R. Folsch UR.
I. Medizinische Universitatsklinik Kiel, Germany.
Gallbladder contractility plays an important role in the pathogenesis of gallstones and in the course of cholelithiasis. Furthermore, a functioning gallbladder is an important condition for performing a successful disolution of gallstones by bile acids. Therefore, a reliable simple physiological test is desired to assess gallbladder contractility. In ten volunteers gallbladder contraction was stimulated by 50 g chocolate, 330 ml cacao drink or in comparison by intramuscular injection of 0.3 microgram/kg ceruletide. Gallbladder volume was measured sonographically and CCK in serum was determined by radioimmunoassay (RIA) after 0, 15, 30 and 45 min. Additionally gallbladder contraction was determined in 20 patients with symptomatic gallstones using cacao drink on ceruletide. In health volunteers remaining gallbladder volume after 30 min was 28% +/- 5% using ceruletide and 37% +/- 7% using cacao. Stimulation by chocolate resulted in a remaining volume of 59% +/- 12% after 45 min only. Simultaneously to gallbladder contraction an increase of CCK in serum was registered. 30 min after cacao CCK had increased from 0.9 to 3.3 pmol/l. Using chocolate an increase of CCK amounted to 2.1 pmol/l after 45 min only. In patients with gallstones the positive predictive value of the cacao test for a functioning gallbladder was 91% and the negative predictive value was 78% in comparison to the unphysiologic stimulation by ceruletide injection. CONCLUSION: Cacao test but not chocolate is suitable and reliable to assess gallbladder contraction in patients with symptomatic gallstones.
Evaluation of four methods for detection of Clostridium difficile or C. difficile toxin: cytotoxin assay, culture, latex agglutination, and a new rapid immunoassay (C. difficile toxin A test).
Fille M. Larcher C. Dierich MP. Allerberger F.
Institut fur Hygiene der Universitat Innsbruck, Austria.
The performance of C. difficile toxin A test (Oxoid, Basingstoke, UK), an immunoassay for the detection of C. difficile toxin A in fecal samples, for the diagnosis of C. difficile-associated diarrhea was compared with those of cytotoxin assay, culture, and a latex agglutination assay (Culturette Brand CDT Rapid Clostridium difficile test; Becton Dickinson, Cockeysville, MD). A total of 105 stool specimens from 71 patients were tested. Of the 105 specimens analyzed, 6 (5.7%) samples were positive by all four methods, 66 samples (62.9%) were concordant negative. Two patients fulfilled all clinical criteria for C. difficile-associated diarrhea but had negative results in the cytotoxicity tests. The sensitivity and specificity, as determined against cytotoxin assay results, were, respectively 52.4% and 93.9% for latex agglutination, 68.2% and 84.3% for rapid immunoassay and 36.4% and 92.8% for culture. No single laboratory test yields a definitive diagnosis of C. difficile-associated diarrhea at present. Test results by any of these methods must be used in conjunction with patient history when making the diagnosis to avoid indiscriminate treatment of individuals without disease or the lack of treatment for individuals with a serious infection. We consider the rapid and easy-to-perform C. difficile toxin A test not to be an essential adjunct for the diagnosis of C. difficile-associated diarrhea.
[Value of endosonography in diagnosis of diffusely growing stomach carcinomas]
Will U. Zinsser E. Raabe G. Bosseckert H.
Klinik Innere Medizin I, Friedrich-Schiller-Universitat Jena.
The diagnosis of diffuse type gastric carcinoma is very difficult. The delay of diagnosis is often due to false-negative endoscopic and histologic evaluation. The architecture of the stomach can be clearly visualized by endosonography. Therefore, already minor destructions of the gastric layers can be found. The endosonographic picture includes the presence of the layers, which are larger and of irregular contour. In infiltrating gastric cancer typically the submucosal layer and the muscularis are concentrically enlarged and appear folded. Based on the endosonographic picture diffuse type gastric carcinoma has been diagnosed in 32 patients. When compared to the histologic diagnosis after gastrectomy or autopsy the accuracy of the endosonographic diagnosis was 87.5%, (28 out of 32 patients). From the remaining four patients diagnosed to have diffuse type gastric cancer by endosonography three patients turned out to have malignant infiltrating tumors of different histologies. Therefore, the positive predictive value of endosonography in detection of infiltrating malignant tumors was 96.8% in our group. In contrast the accuracy of preoperative histologic diagnosis by biopsies was only 58%. Suspicious results of gastroscopy, especially in combination with a negative biopsy, should lead to further evaluation by endosonography to detect diffuse type gastric cancer earlier.
Transjugular intrahepatic portosystemic stent-shunt after orthotopic liver transplantation in a patient with early recurrence of portal hypertension of unknown origin.
Nolte W. Canelo R. Figulla HR. Kersten J. Sattler B. Munke H. Hartmann H. Ringe B. Ramadori G.
Division of Gastroenterology and Endocrinology, Georg-August-Universitat, Gottingen, Germany.
A 65-year-old italian patient developed complicated portal hypertension immediately after orthtopic liver transplantation (OLT) necessitating shunt creation. One to five weeks after OLT, massive ascitic fluid losses of up to 121/day developed. Vascular and major hepatic-parenchymal abnormalities were excluded by duplexsonography, angiography and initial histology, respectively. A peritoneovenous shunt (Denver-shunt) on day 31 after OLT reduced (by about 50%) but did not stop ascitic fluid losses. Furthermore, three variceal bleedings occurred after implantation of the Denver-shunt. Direct portography on day 45 after OLT revealed portal hypertension (pressure gradient of 26 mmHg) requiring the implantation of a transjugular intrahepatic portosystemic stent-shunt (TIPS) leading to a reduction of the pressure gradient to 13 mmHg. Subsequently, ascites resolved within ten days and esophageal varices improved. Liver function parameters normalized inspite of recurrence of HCV infection with detection of HCV RNA in serum already in the fifth week after OLT. During follow-up, histological findings deteriorated from mild changes to extended fibrosis at day 61 after OLT, which might have contributed to the maintenance of portal hypertension. The deterioration of liver histology was accompanied by an improvement/normalization of liver graft function. There was no evidence for additional viral liver infections, e.g. hepatitis B or cytomegalovirus infection. This case illustrates an etiologically unclear syndrome developing directly after OLT and reaffirms the effectiveness of TIPS in the treatment of complicated portal hypertension even after liver transplantation.
[Protein-losing giant fold gastritis in childhood--a case report and differentiation from Menetrier disease of adulthood]
Kindermann A. Koletzko S.
Kinderpoliklinik, Ludwig-Maximilians-Universitat Munchen.
We report on a 2.5-year-old boy, who presented with vomiting since one week and periorbital and pitting edema. Laboratory studies revealed hypoproteinemia and hypoalbuminemia without signs of renal or liver disease. The cause of protein loss was giant fold gastritis disclosed by upper endoscopy. Biopsies revealed foveolar hyperplasia with cystic dilatation of the glands, identical to Menetrier's disease in adulthood. About 55 cases of hypertrophic gastropathy in children have been published. In contrast to the chronic course of Menetrier's disease in adults, the pediatric cases are generally benign, self-limited with complete resolution typically within a few weeks. While the etiology of Menetrier's disease is still unknown, the benign pediatric hypertrophic gastropathies have been associated with infections, primarily CMV and occasionally helicobacter pylori, herpes simplex and mycoplasma. Supportive treatment with a high-protein-diet and intravenous albumin transfusions is recommended. H2-receptor antagonists might improve symptoms.
[A system of nonspecific defense in chronic inflammatory bowel diseases--pathophysiologic and therapeutic aspects]
Lugering N. Kucharzik T. Stoll R. Domschke W.
Medizinische Klinik und Poliklinik B, Universitatsklinikum Munster.
Monocytes/macrophages are a prominent feature of the inflammatory infiltrate in inflammatory bowel disease (IBD). Progress in the development of monoclonal antibodies has provided a powerful means to identify and study various subsets of macrophages in the intestinal mucosa. In both Crohn's disease and ulcerative colitis distinct macrophage populations have been found being prominent in active disease, but absent from normal mucosa. Studies of our group show that the Ca(2+)-binding proteins MRP8 and MRP14 as well as their heterocomplex MRP8/14 (27E10 epitope) can be immunolocalized in the majority of granulocytes and macrophages in active but not inactive IBD. Serum MRP8/14 concentrations are significantly increased in patients with active IBD compared with patients suffering from inactive/mild disease. In vitro studies revealed that IL-13, IL-10 and IL-4 strongly suppress secretion of monocytic proteins. Differential responses of monocytes and macrophages towards the inhibitory effects of TH2-cytokines can be observed in both patients with IBD and control groups. Combined treatment with TH2-cytokines may effectively suppress the response of activated monocytes/macrophages thus being of potential therapeutic benefit for patients with IBD.
Erythromycin, a motilin agonist, increases postprandial gallbladder emptying during therapy with ursodeoxycholic acid.
Neubrand M. Sauerbruch T.
Department of General Internal Medicine, University of Bonn, Germany.
Sufficient gallbladder emptying accelerates early gallstone clearance after extracorporeal shock wave lithotripsy (ESWL). Litholytic therapy with ursodeoxycholic acid (UDC) subsequent to ESWL increases fasting volume (FV) and postprandial residual volume (RV) of the gallbladder. This may lead to retention of cholesterol crystals and small fragments within the gallbladder. In order to find out whether erythromycin, a motilin agonist, improves gallbladder emptying, we tested gallbladder motility after administration of ursodeoxycholic acid with and without oral application of erythromycin. Ten healthy males (age 26-35 years) obtained 10 mg/kg/d of UDCA as a single bedtime dose for three weeks. Prior and after UDCA administration, gallbladder FV was determined sonographically after overnight fasting. After a test meal (490 kcal), gallbladder volume was measured every 5 min until the gallbladder had reached its minimal RV. The next day the same procedure was repeated with 500 mg erythromycin p.o. 45 min prior to test meal application. FV, RV, ejection volume (EV = FV-RV) and ejection fraction (EF = EV/FV x 100) were calculated and differences were compared by the student's t-test. FV (29 ml +/- 8 ml vs. 38 ml +/- 10 ml), RV (12 ml +/- 6 ml vs. 17 ml +/- 6 ml) and EV (17 ml +/- 5 ml vs. 21 ml +/- 6 ml) increased significantly during therapy with UDCA (p < 0.05). EF did not change significantly. After erythromycin application RV decreased to its original values (13 ml +/- 6 ml), whereas EV (24 ml +/- 6 ml) and EF (58% +/- 9% vs. 66% +/- 11%) increased significantly (p < 0.05). Thus, administration of a motilin agonist blunts unwanted effects on gallbladder motility during litholytic therapy with UDC.
Interobserver agreement in defecography--an international study.
Muller-Lissner SA. Bartolo DC. Christiansen J. Ekberg O. Goei R. Hopfner W. Infantino A. Kuijpers HC. Selvaggi F. Wald A.
Department of Internal Medicine, Park-Klinik Weissensee, Berlin, Germany.
BACKGROUND: Defecography is considered to be an essential investigation in the evaluation of functional anorectal disorders, but the agreement between observers from different clinical centers has never been evaluated. METHODS: 14 defecographic studies were selected aimed to cover the most relevant defecographic findings responsible for disordered defecation. Eight studies were considered unequivocal, but six were thought to be controversial. All were sent to the ten participants in Europe and the US (five proctosurgeons, three radiologists, two gastroenterologists). They evaluated the studies using a previously agreed upon questionnaire. Interobserver agreement was quantified by kappa statistics and by the proportions of positive and negative agreement as compared to chance agreement, respectively. RESULTS: Overall, only the completeness of rectal emptying and the presence of a rectocele achieved acceptable kappa values above 0.4. When restricting the evaluation to the studies considered to be unequivocal, agreement improved considerably and was moderate to good for all items describing the images (kappa 0.43-0.63). However, whether proctosurgery should be performed and whether defecography contributed to the management of the particular patient remained controversial with very low kappa. CONCLUSIONS: It is doubtful whether defecography contributes substantially to the management of patients with disordered defecation.
The role of enteroclysis in the diagnosis of unexplained gastrointestinal symptoms: a prospective assessment.
Lankisch PG. Gaetke T. Gerzmann J. Becher R.
Department of Internal Medicine, Municipal Hospital of Luneburg, Germany.
The purpose of this prospective study performed at a non-university hospital was to assess the role of enteroclysis in the diagnosis of unexplained gastrointestinal symptoms such as abdominal pain, gastrointestinal bleeding, and chronic diarrhea done following inconclusive imaging or endoscopic procedures. 184 consecutive patients were subjected to enteroclysis over 25 months. 84 (46%) had abdominal pain, 52 (28%) gastrointestinal bleeding, and 48 (26%) chronic diarrhea. Findings were categorized as normal and abnormal (subdivided into main, i.e., explanatory of symptoms; and secondary, i.e., not explanatory of symptoms). Main findings were further divided into those exclusively detected by enteroclysis and those confirmed by this procedure. Normal enteroclysis investigations were obtained in 159 (86%) patients and abnormal in 25 (14%). Main findings were present in 19 (10%) patients, in ten (5%) of them exclusively detected by enteroclysis. Secondary findings were present in six (3%) patients, also detected only by enteroclysis. The highest rate of main findings exclusively detected by enteroclysis related to patients with chronic diarrhea (8%), compared with 6% and 2% with abdominal pain and gastrointestinal bleeding, respectively. For the inspection of the small bowel, enteroclysis shall remain the gold standard for detecting abnormal findings in the small bowel until user-friendly enteroscopes are developed.
Short-term efficacy and long-term outcome of cyclosporine treatment in patients with severe ulcerative colitis.
Wenzl HH. Petritsch W. Aichbichler BW. Hinterleitner TA. Fleischmann G. Krejs GJ.
Department of Medicine, Karl-Franzens University, Graz, Austria.
Cyclosporine A (CyA) has been recommended for the treatment of severe steroid-resistant ulcerative colitis, however, long-term results are scarce. We prospectively followed a treatment plan in 14 patients with severe ulcerative colitis receiving intravenous CyA after failure to respond to at least eight days of standard therapy with prednisolone (1-1.5 mg/kg/day). CyA was delivered in a daily dose of 5 mg/kg i.v. for a mean of 14 days (range 7-28) in addition to ongoing medical therapy. CyA whole blood levels were monitored by HPLC and maintained between 100 ng/ml and 400 ng/ml. Responders were switched to oral CyA (5-7.5 mg/kg/day) for a mean of two months, and steroids were gradually tapered. Eleven patients (79%) initially responded to i.v. CyA, three patients failed to respond and underwent urgent colectomy. Time until response averaged seven days (range 3-13). Four of the eleven responders underwent colectomy because of severe relapse after one, eleven, twelve and 13 months of follow-up. The remaining seven patients were followed for a median of 48 months. During the first year of follow-up three out of seven had a severe relapse and responded to steroids (two patients) or to a further course of i.v. CyA (one patient). During CyA therapy one patient developed staphylococcal sepsis, other adverse events were mild and reversible. The results confirm that CyA is effective in severe steroid-refractory ulcerative colitis. Severe relapse and colectomy are uncommon after the first year of follow-up and the colon preserving effect of CyA can be maintained in up to 50% of patients over a period of four years.
[Rare cause of acute pancreatitis: phytobezoar in an intraluminal diverticulum in type I duodenal atresia, intestinal malrotation and rudimentary pancreas anulare]
Kestel W. Fischbach W. Wilhelm A.
II. Medizinische Klinik, Klinikum Aschaffenburg.
A 28-year-old woman was hospitalized because of the third episode of acute pancreatitis. No hint for an extrinsic cause was evident. Under conservative treatment pancreatitis and signs of intestinal obstruction were persisting. Imaging procedures showed an undefinite mass in the neighbourhood of the pancreatic caput. Endoscopy revealed a phytobezoar in a wind sock web, a special form of congenital duodenal atresia. Obstructing the papilla of Vater the bezoar had caused acute pancreatitis. After endoscopical removal the symptoms of pancreatitis disappeared immediately. Web excision and duodenoduodenostomy were performed. At operation further anomalies of the gastrointestinal tract frequently associated with duodenenal atresia were found.
[Barrett esophagus with severe dysplasia in argon beam therapy]
Maass S. Martin WR. Spiethoff A. Riemann JF.
Medizinische Klinik C, Klinikums Ludwigshafen gGmbH.
A curative therapy of Barrett's esophagus is not established, yet. However, in prospective clinical research trials, a combined therapy of potent pharmacological acid suppression with superficial coagulation of metaplastic epithelium is examined. By local coagulation using photodynamic therapy, laser or argon plasma coagulation, a complete reconstitution of squamous epithelium should be achieved. We report on a case of a patient with Barrett's esophagus and low-grade dysplasia, who developed high-grade dysplastic cell formations under argon plasma coagulation therapy. As part of a clinical study, the patient was treated over a period of one year monthly. We monitored the result of the therapy over the period of one year with endoscopy, histolgical investigations and DNA image cytometry. Ultimately a decision in favour of a further surgical management was made. The diagnostic instruments to identify patients with a high risk for the development of adenocarcinoma are discussed.
[Current aspects of pathogenesis, diagnosis and therapy of primary MALT stomach lymphomas]
II. Med. Klinik, Klinikum Aschaffenburg.
Primary gastrointestinal lymphoma of MALT occupy a special position which is documented in their own histological classification. Our knowledge about pathogenesis, biological and therapeutical behaviour of this lymphoma entity has increased substantially during recent years. Considering epidemiological, histomorphological and experimental data Helicobacter pylori infection undoubtless plays an important role in the development and progression of gastric MALT-lymphoma. In view of histological malignancy (low or high grade) and dissemination of the disease (stage) as decisive prognostic factors and therapeutical determinants endoscopic-bioptical diagnosis as well as endoscopic ultrasound are of major importance. In case of localized low-grade lymphoma eradication of Helicobacter pylori offers a promising therapeutic option. Surgical resection and radiochemotherapy have proven to be effective treatment modalities. There is a need for randomized trials to clarify if operative or conservative therapeutic strategies have to be favored in the future.
Assessment of afferent gut--brain function using cerebral evoked responses to esophageal stimulation.
Hollerbach S. Kamath MV. Lock G. Scholmerich J. Upton AR. Tougas G.
Klinik und Poliklinik fur Innere Medizin I, Universitat Regensburg, Germany.
Increasing awareness is attributed to altered sensory perception in the pathogenesis of gastrointestinal disorders. Evoked potentials (EP), which represent the brain's electrical response to peripheral stimulation, have recently been used to investigate where and how (GI) afferent information is processed along the brain-gut axis. EP can be obtained with electrical stimulation or balloon distention in the esophagus in humans. Stimulation of afferent neural pathways in the esophagus produces cerebral evoked responses allowing assessment of the peripheral afferent neural pathways involved, and of the function of integrative neural centers within the brain. Recent studies using esophageal EP indicate that the cerebral response to either mode of stimulation depends on the perception of the stimuli. Using electrical stimulation, a clear dose-response relationship is found. The EP response obtained with electrical stimulation is in keeping with those recorded using direct cervical stimulation of the vagus nerve, supporting evidence that esophageal EP are produced by activation of afferent vagal pathways. From the conduction velocity of the autonomic (vagal) nerves conveying information from esophagus to brain, it was concluded that non-painful electrical stimuli predominantly activate fast conducting myelinated afferent sensory fibers (A-fibers), while EP to balloon distention are largely due to activation of unmyelinated C-fibers. Techniques, however, vary widely amongst different investigators, and some electrophysiological parameters remain controversial, as there is no standard approach. Using balloon distention, EP waveforms vary widely between laboratories, suggesting that EP are substantially influenced by the stimulator devices (pump, respirator). EP to balloon distention are hampered by a relatively low signal-to-noise ratio (SNR), which is probably due to long inflation-deflation time (> 200 ms). With electrical stimulation, there is much less variability between different groups, and SNR is distinctly higher. This method appears to be most attractive for studies of afferent esophageal function. Standardization of the techniques is important, before esophageal EP can be regarded as a useful diagnostic approach in patient groups.
[Effect of proctocolectomy on fluid balance--comparison of conventional ileostomy, ileorectal anastomosis and ileoanal pouch operation]
Bruwer M. Stern J. Schmidt-Gayk H. Senninger N. Herfarth C.
Chirurgische Universitatsklinik Munster.
Total colectomy for ulcerative colitis (UC) and familiar adenomatous polyposis coli (FAP) is mainly performed as an ileoanal Pouch procedure (IAP). Alternatives are ileorectal anastomosis (IRA) and conventional proctocolectomy with Brooke ileostomy (CPS). The different surgical techniques may influence the excretion of water and electrolytes in stool and urine and may lead to a higher risk for urolithiasis. We investigated patients (12 IAP, 12 IRA and 8 CPS) several years after surgery and compared them to twelve normal controls. Total fecal and urinary output was collected at two consecutive days. Volume and electrolytes were determined in stool and urine. The risk for urinary stone formation was calculated by nomograms. Fecal volume and sodium (Na+) excretion was increased in all therapy groups compared to controls. IAP and IRA had significant less stool volume and Na+ excretion compared to CPS. Augmented fecal Na+ excretion was compensated by reduction of renal output after colectomy compared to controls. There were no significant differences in the daily urine volume between any groups. There was no urolithiasis in any groups. The nomograms showed a risk for all groups and controls to develop urinary stones.
Effect of different doses of erythromycin on colonic motility in patients with slow transit constipation.
Bassotti G. Chiarioni G. Vantini I. Morelli A. Whitehead WE.
BACKGROUND: Erythromycin has been proposed as a therapeutic agent for the treatment of functional motor disorders of the upper gastrointestinal tract. Moreover, some data exist showing a potential effect on colonic motility. AIMS: Since no data are available concerning erythromycin effects in chronically constipated patients, we investigated the effects of three different doses of the drug (50, 200, and 500 mg i. v.) on colonic intraluminal pressures in such patients. PATIENTS AND METHODS: 18 severely constipated women were studied by a colonoscopically-positioned manometric probe, and were randomized to receive one of three doses of erythromycin. Proximal and distal colonic motility was recorded basally, then during placebo infusion for 60 min and for a further 60 min after the drug had been infused. RESULTS: Analysis of the tracings showed that, except for the lowest dose in the distal colon, erythromycin failed to stimulate colonic motility in constipated patients. CONCLUSIONS: It is concluded that erythromycin cannot be considered a colokinetic agent, at least at doses commonly employed in the upper gut.
[MRCP (magnetic resonance cholangiopancreatography)--an assessment of current status]
Merkle EM. Nussle K. Glasbrenner B. Tomczak R. Preclik G. Rieber A. Adler G. Brambs HJ.
Abteilung fur Diagnostische Radiologie der Universitat Ulm.
For the first time, magnetic resonance cholangiopancretography (MRCP) provides images of the biliary and pancreatic ducts based on 3D data similar to those we are used to from endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). Extraordinarily impressing is the fact that no contrast media have to be applied. The following manuscript shows technical basics and the development of this technique from gradient echo sequences to the recent single-shot techniques. Furthermore possibilities and limitations of MRCP will be discussed with respect to certain illnesses.
[Interventional procedures of the bile duct in patients after stomach resections (Billroth II)]
Schulz HJ. Bertullies M. Drossel R.
In the hands of an experienced endoscopist ERCP is an important method for the diagnosis of biliopancreatic diseases of Billroth II patients, but less effective than in nonoperated patients. Percutaneous procedures increase the success rate of nonoperative therapy. We report our own results of in 386 Billroth II patients: Success rate of diagnostic ERCP was 73.6% (284/386). Interventional endoscopy was performed in 192 patients: Successful EST was carried out in 93.6% (160/171), and complete extraction of bile duct stones was achieved in 74.8% (107/143), sufficient bile drainage was achieved by placement of transpapillary endoprostheses in 96.3% (79/82), while successful PTCD and percutaneous therapy were performed in 21 cases. Technical problems result from a long afferent loop, the upside-down position in the duodenal stump and difficult bile duct anatomy. We observed a complications rate of 3.6% (14/386) and a mortality of 0.5% (2/386). Our results are comparable with those in the literature, in which a similar number of difficult patients are included.
[A rare combination of pheochromocytoma ans somatostatin-rich neuroendocrine tumor of Vaters papilla (carcinoid) in a patient with von Recklinghausen neurofibromatosis]
Hardt PD. Doppl WE. Klor HU. Hinrichs B.
Medizinische Klinik III und Poliklinik der Justus-Liebig-Universitat Giessen.
A 74-year-old male suffering from Recklinghausen's fibromatosis (NvR) is reported. He presented with weight loss, cholestasis, endocrine and exocrine pancreatic insufficiency. These symptoms were caused by a neuroendocrine tumor of the ampulla of Vater containing somatostatin. The tumor induced an obstruction of both the common bile and the pancreatic duct. In addition to this uncommon tumor, a silent pheochromocytoma was found. The patient was treated by endoscopic papillotomy, substitution of pancreatic enzymes and additional enteral nutrition. After recovery no progression of the disease was observed over one year. A review of the literature shows that patients with neurofibromatosis are at high risk for periampullar tumors. In particular, somatostatin-rich carcinoids were previously documented. Pheochromocytomas are also quite prevalent in NvR. However the combination of NvR, pheochromocytoma and somatostatin-rich neuroendocrine tumors of the duodenum has only been reported a few times. An explanation for the high prevalence of neuroendocrine tumors in NvR might be the loss of neurofibromin, a tumor suppressor protein, which is the main product of the neurofibromatosis-l-gene.
Metastatic pancreatic VIPoma: deteriorating clinical course and successful treatment by liver transplantation.
Hengst K. Nashan B. Avenhaus W. Ullerich H. Schlitt HJ. Flemming P. Pichlmayr R. Domschke W.
Department of Medicine B, University of Munster, Germany.
Gastrointestinal neuroendocrine tumors are slowly growing and metastases are often limited to the liver. As a result of their favorable biological behavior these tumors have a relatively good prognosis even in metastatic stage. Due to a variety of therapeutic options patients with malignant neuroendocrine tumors may survive for extended periods of time up to ten years. Often a combination of different treatments and also alternation between the different therapeutic regimes is needed. A patient with excessive WDHA-syndrome and severe metabolic disturbances due to a pancreatic VIPoma with metastatic spread into the liver and abundant hormonal secretion is presented. Cytotoxic agents (streptozocin, 5-fluorouracil and adriamycin) were able to alleviate clinical symptoms and to control tumor growth for six years. Analogues of somatostatin (octreotide) and interferon alpha had been very useful in controlling clinical symptoms and tumor progress for 18 months. Cytotoxic agents or octreotide were not able, however, to achieve any permanent cure. Eventually, treatment failure occurred with dramatic progression of symptoms and tumor growth, unresponsive to any medical therapy. Consequently, total hepatectomy and liver transplantation together with extirpation of the pancreatic primary tumor was performed and succeeded in providing a normal life to the patient. In our opinion the overall outcome of patients with metastatic VIPoma may be improved best by maintaining the patients on medical therapy until treatment failure occurs. In case of extended hepatic metastases orthotopic liver transplantation might be considered for patients with symptomatic disease who no longer respond to conventional treatment modalities.
Allgaier HP. Haag K. Blum HE.
Abteilung Innere Medizin II (Gastroenterologie, Hepatologie und Endokrinologie), Medizinische Universitatsklinik Freiburg.
The hepatopulmonary syndrome (HPS) is a reversible pulmonary insufficiency in association with liver disease, most frequently liver cirrhosis. The pathogenesis of HPS is poorly understood. HPS is characterized by arterial hypoxemia caused by intrapulmonary arteriovenous shunts or marked vasodilatation of the pulmonary vessels and ventilation-perfusion mismatch in the absence of intrinsic heart or lung disease. Typical clinical signs are dyspnea in the upright position which improves in supine position (platypnoe) and decrease of arterial pO2 in the upright position (orthodeoxia). The diagnosis of HPS is based on clinical features, arterial blood gas analyses in supine and upright position, contrast echocardiography and lung perfusion scanning. Arteriovenous fistula can be excluded by pulmonary angiography. There is no established medical treatment of HPS. New medical and noninvasive therapies, such as transjugular intrahepatic Stent-shunt (TIPS), lead to improvement of HPS. These treatment modalities need further elucidation. HPS was shown to be reversible after orthotopic liver transplantation (OLTx) in some cases. Severe HPS, therefore, may be an indication rather than a contraindication for OLTx.