[Choosing wisely recommendations in gastroenterology]. / Klug-entscheiden-Empfehlungen in der Gastroenterologie.

The Choosing wisely initiative of the German Society of Internal Medicine addresses procedures which are inadequately implemented (deficits in patient care) as well as those which are performed too often but without proven benefits for patients (misuse or overuse of health services). Based on their guidelines, The German Society of Gastroenterology, Digestive and Metabolic Diseases has identified such aspects and incorporated them into the respective recommendations.

["Choosing wisely" in infectious diseases : Overuse of antibiotics - too few vaccinations]. / "Klug entscheiden" bei Infektionskrankheiten : Zu häufig Antibiotika - zu wenig Impfungen.

The "choosing wisely" recommendations of the German Society of Internal Medicine (DGIM) and its specialist societies address diagnostic and therapeutic procedures, which are of particular medical importance but applied too often or too rarely in clinical practice. The aim is to further improve treatment of patients. Important topics of overuse and insufficient treatment related to the diagnostics, therapy, prevention and exclusion of infectious diseases could be identified. These topics not only play an important role in the discipline of infectious diseases but are also relevant for other internal medical disciplines. These topics related to infectious diseases have also been integrated into the recommendations of the German Society of Gastroenterology, Digestive and Metabolic Diseases as well as the German Societies for Internal Intensive Care and Emergency Medicine, for Pneumology, for Nephrology and for Rheumatology. The pivotal issues of the recommendations are the inappropriate use of antibiotics and insufficient vaccination rates.

NMR and rheological study of Aloe barbadensis partially acetylated glucomannan.

The structural and rheological properties of the Aloe extract (AE) and the polysaccharidic fraction (PF) obtained from the leaves pulp of Aloe barbadensis Miller were investigated. Structural analyses carried out by composition, methylation analysis and NMR spectroscopy showed that PF is mainly constituted by a partially acetylated 4-linked ß-d-glucomannan. The acetyl groups are located at C-2, C-2 and C-3, C-3 and/or C-6. The acetylation pattern of this type of polysaccharide was for the first time established using bidimensional NMR analyses. AE and PF aqueous solutions at 25°C showed a non-Newtonian behavior (with pseudoplastic characteristics), however PF showed higher apparent viscosity than AE. Dynamic oscillatory analyses showed that both samples, at the same concentration, behaved as a concentrated solution. PF presented higher values of G' compared with those of AE and this behavior could be consequence of its higher content in partially acetylated glucomannan.

[Splenic injury after colonoscopy: a retrospective study and review of the literature]. / Milzverletzung nach Koloskopie. Eine retrospektive Studie und Analyse der Literatur.

BACKGROUND AND OBJECTIVE: The increasing number of preventive screening investigations in the course of obtaining early diagnosis of colon cancer, has been leading to an increase in the number of colonoscopies in Germany. Splenic injury is one of the complications to be aware of, if postinterventional abdominal symptoms occur. PATIENTS AND METHODS: This retrospective study was based on the answers to questionnaires sent to 220 members of the Working Party of Leading Hospital-Based Gastroenterologists. The response rate was 40%. RESULTS: Thirteen of the gastroenterologists reported a total of 16 splenic injuries, a rate of about one injury per 87,000 (about 0.001 %) this compares to a worldwide published splenic injury rate of 0.004 %. But the actual numbers are probably higher in Germany as well. CONCLUSIONS: In order to obtain a more exact complication rate in the future, splenic injuries should be reported centrally. This is possible by sending a report of the complication by e-mail to splenicinjury_colonoscopy@web.de.

[Diagnosis of gastroesophageal reflux disease and dyspepsia]. / Diagnostik der Refluxkrankheit und der Dyspepsie.

Prerequisite in the diagnosis of heartburn and dyspepsia is a careful medical history which has to take into account both the differential diagnosis as well as alarm symptoms necessitating immediate and more extensive diagnostic procedures. The by far most prevalent diseases are gastroesophageal reflux disease (GERD), functional dyspepsia and peptic ulcers (today overwhelmingly due to ulcerogenic drugs but less common to Helicobacter pylori). In the further diagnostic evaluation, endoscopy is the most valuable tool revealing GERD as the dominating lesion whereas ulcers become much less frequent and malignancies are rare under 50 years of age; thus, empiric therapy is an attractive strategy in such younger population. Ultrasound investigations are recommended predominantly in cases with suspected biliary disease but not in general. Apart from basic laboratory blood tests further diagnostic procedures do not play a role in the primary evaluation in this setting.

[Symptom- versus endoscopy-based diagnosis and treatment of gastroesophageal reflux disease (GERD)]. / Abklärung und Therapie von Refluxbeschwerden.

The current guidelines of the German Society for Digestive Diseases (DGVS) endoscopy recommends for patients representing with reflux symptoms. In daily routine as well as in Guidelines from other countries and international guidelines, however, a symptom-based strategy for the management of patients with reflux disease is favoured. Since either strategies is dependent on specific clinical findings, neither can be recommended. The preference for one or the other strategy depends on the prevalence of so-called alarm symptoms, risk factors for a reflux carcinoma or Barrett's metaplasia, demographic factors, e. g., age and gender, patient's wish and initial response to empirical therapy with proton pump inhibitors (PPI). However, most patients with characteristic reflux symptoms without any alarm symptoms and/or other risk factors can be safely managed with a symptom-based strategy in acute and long-term care.

[An evidence-based look at pharmacotherapy for gastroesophageal reflux]. / Medikamentöse Therapie der gastroösophagealen Refluxkrankheit Eine evidenzbasierte Ubersicht.

Acid-suppressant drugs predominate in the treatment of gastroesophageal reflux disease. Proton pump inhibitors (PPI) are the first-line choice in both reflux esophagitis and nonerosive reflux disease (NERD). H(2)-blockers play a minor role and should not be used in erosive esophagitis. Other drugs such as mucosa-protective compounds, prokinetics, and antacids do not play a role, either alone oder in combination with acid suppressants. Proton pump inhibitors should also be used in maintenance therapy which is not associated with significant risks. There is a general trend toward on-demand treatment (already established in NERD). In cases refractory to therapy, the choice of drug should be critically analyzed (in case H(2)-blockers are used), and increasing the PPI dose is recommended; persistent symptoms should lead to reevaluation of the diagnosis. Asymptomatic Barrett's esophagus represents no indication for treatment, which in symptomatic patients is carried out in the normal fashion.

Gastroesophageal reflux disease and Barrett's esophagus.

Gastroesophageal reflux disease (GERD) is a very common disorder, mainly occurring in Western countries. The nonerosive form of GERD, which occurs in more than half of the patients affected, deserves particular attention. Administering symptomatic therapy without a prior endoscopic examination has become an attractive option, since it also provides diagnostic information. Proton-pump inhibitors (PPIs) have become established as the standard therapy, but new insights into the pathophysiology of the condition may lead to new treatment options using gamma-aminobutyric acid (GABA) agonists. Endoscopic therapy is still at the experimental stage and has yet to prove its value as an alternative to PPI and surgery. However, it is questionable whether antireflux surgery is more cost-effective in the longer term.[nl]Gastroenterologists are now much more aware of Barrett's esophagus than was the case a few years ago. Barrett's esophagus is a frequent finding in patients with reflux symptoms, but is a rare cause of death in affected patients. For several reasons, there is a large gap between recommendations regarding surveillance, on the one hand, and everyday practice on the other. New diagnostic procedures such as chromoendoscopy may allow better detection of premalignant and malignant alterations in metaplastic mucosa, but the safety of such techniques has been questioned. Prophylactic ablation is a debatable approach, whereas endoscopic interventions in patients with high-grade dysplasia and early adenocarcinoma are continuing to develop as attractive alternatives to esophagectomy in selected patients. It remains to be seen whether chemoprevention using cyclooxygenase-2 (COX-2) inhibitors should be carried out in high-risk patients with Barrett's esophagus, in order to prevent malignant transformation to esophageal cancer.

[Diagnosis of gastro-esophageal reflux disease]. / Diagnostik der Refluxkrankheit.

The diagnosis of gastro-esophageal reflux disease (GERD) predominantly relies on the patient's history and endoscopically visible alterations of the esophageal mucosa. Heartburn as the dominating symptom is highly suggestive of GERD though not specific whereas heartburn as one complaint among others is of limited value. Endoscopy enables the definite diagnosis of reflux esophagitis; however, the majority of patients (approximately 60%) does not exhibit erosions (non-erosive form of GERD). In these patients a short course of empiric PPI therapy gives valuable information about the presence or absence of GERD. Only those patients non-responsive to adequate PPI doses should undergo pH-metry. Other diagnostic investigation (e.g. manometry) should be restricted to selected cases.