[Horseshoe kidney--is the diagnosis possible by ultrasound? (author's transl)]. / Hufeisenniere--ist sonographisch die Diagnose möglich?

Within one year among six-thousand patients eight with horseshoe kidney were examined by sonography. In four patients the primary diagnosis was made by ultrasonic demonstration. In two patients a lymphoma and an aortic aneurysm were supposed; the correct diagnosis was established by angiography and computer tomography. In the other two patients with already known diagnosis a typical ultrasonic picture was found. The diagnostic difficulties in ultrasonic demonstration of horseshoe kidney are discussed.

[Computer tomographic and sonographic diagnosis of echinococcus (author's transl)]. / Computertomographische und sonographische Diagnostik der Echinokokkose.

In 33 patients (18 cystic echinococci, 15 alveolar) both methods produced the following findings which could be correlated with the pathological results: single or multi-centric lesions, sharp or indefinite demarkation and abnormalities in the shape and size of the liver. The sonographic findings were analysed with respect to the echo characteristics, whereas the computer tomographically demonstrated lesions were examined densitometrically in order to show calcification. Both methods demonstrate the pathological changes satisfactorily. Computer tomography is more effective in alveolar echinococcus lesions by showing the different types of calcification, whereas sonography provides a more accurate picture of the internal structure of the cysts in cystic echinococcus. Comparison of the methods in 19 patients examined by both showed a high accuracy in each method, but sonography was relatively poor in demonstrating lesions in the spleen.

[Leukopenia and consumption coagulopathy in miliary tuberculosis]. / Leukopenie und Verbrauchskoagulopathie bei Miliartuberkulose.

Unusual clinical courses and symptoms in miliary tuberculosis cause difficulties in early diagnosis. In a patient with fever of unknown origin, leuko- and thrombocytopenia and hypoplastic bone marrow, tuberculous infection was not diagnosed because drug-induced damage to bone marrow was assumed. A second patient with squamous cell carcinoma of the tongue, miliary tuberculosis and leuko- and thrombocytopenia died in spite of intensive antituberculous therapy. A further patient with miliary tuberculosis developed respiratory distress syndrome and disseminated intravascular coagulation. In fever of unknown origin, unexplained blood disorders, hyponatremia and respiratory distress syndrome without evident cause, "cryptic" miliary tuberculosis should be considered in established the differential diagnosis.

[Recurrence in ulcerative colitis following colectomy?--Only what may be, can be (author's transl)]. / Rezidiv einer Colitis ulcerosa im Dünndarm nach Kolektomie? Was nicht sein darf, das nicht sein kann.

A 19 year old patient developed signs of a "prestomal ileitis" 5 1/2 years following proctocolectomy for ulcerative colitis. A reoperation was necessary because of "toxic megaileum"; these signs were explained by recurrence of ulcerative colitis involving the terminal ileum. A first report from 1976 must be revised because of further observation of the patient: 1 1/2 year following this complication Crohn's disease in this patient could be proven by endoscopic and bioptic examination. This diagnosis was not possible at the time of first report: findings by x-ray, endoscopy and microscopy were lacking typical signs of Crohn's disease.

[Thallium intoxication treated by hemodialysis, forced diuresis and antidote (author's transl)]. / Thalliumvergiftung. Kombinationsbehandlung mit Hämodialyse, forcierter Diurese und Antidot

Mode of action and toxicity of thallium and former treatment of thallium intoxication are described. A case of thallium poisoning with a lethal dose of thallous sulfate which was successfully treated by hemodialysis, forced diuresis and antidote is reported. 43 percent of the thallium could be eliminated by continuous hemodialysis during 72 hours and forced diuresis within the third and seventh day after ingestion of the poison. The dialysance of thallium was 111,1 ml/min with a blood flow of 200 ml/min. Later damage can be prevented by early maximal elimination of thallium.

Acute pancreatitis in Crohn's disease.

Pancreatitis as an extraintestinal manifestation of Crohn's disease (CD) is controversial. We review the episodes of acute pancreatitis in patients with CD. Of 852 patients, 12 developed clinically overt pancreatitis, representing a frequency of 1.4% in a follow-up period of 10 years. In 10 patients, common causes of pancreatitis were excluded. In 2 patients, drug-induced disease (azathioprine, sulfasalazine) could not be ruled out. Recurrence of pancreatitis was observed in only 2 patients. Younger patients and those with active disease seemed more at risk for development of pancreatitis. If prednisolone was needed for treatment of active CD, no adverse effect was observed for the pancreatitis. Along with the clinical features, we studied autoantibodies against exocrine pancreas; the incidence of autoantibodies in patients with pancreatitis was the same as in the controls who did not develop pancreatic abnormalities. This does not support the hypothesis that acute pancreatitis in CD is associated with the formation of pancreatic autoantibodies.

Oral manifestations of Crohn's disease. An analysis of 79 cases.

We report four new cases of oral manifestation in Crohn's disease (CD) and evaluate 75 reported cases for morphology and site of oral and intestinal manifestations of CD, clinical manifestation, and treatment. Oral CD was the presenting symptom in 43 of 72 (60%) patients and relapsed in 34 of 60 (57%). Median age at presentation was 22 (range 6-57) years, and males were affected more often (1.85:1, male:female ratio). From a total of 228 oral lesions in 79 patients, lips (57 lesions), gingiva (40 lesions), vestibular sulci (31 lesions), and buccal mucosa (25 lesions) were the sites most frequently affected. Edema (62 lesions), ulcers (57 lesions), and polypoid papulous hyperplastic mucosa (45 lesions) were the most common type of lesions. The rate of granuloma detection was high in oral (67-77%) and intestinal lesions (45-71%). A total of 66 courses of drug therapy in 51 patients were analyzed. Complete remission of oral symptoms was achieved by systemic steroids and/or azathioprine in 13 of 26 (50%) patients, whereas strictly topical treatment with steroids resulted in complete remission of oral symptoms in 7 of 12 (58%). We conclude that oral CD exhibits a characteristic morphologic appearance, as often as not preceding intestinal symptoms in adolescents and young adults. Thus, patients with orofacial granulomatosis CD should be vigorously searched for by complete gastrointestinal endoscopic investigation. Oral CD may cause disabling pain and facial distortion, and results of treatment remain unrewarding. In the absence of data from controlled therapeutic trials, systemic steroids and/or azathioprine are recommended if topical treatment has failed to control symptoms.

[Small bowel biopsy as a cause of pseudomonas aeruginosa septicemia in a patient with intestinal lymphoma? (author's transl)]. / Dünndarmbiopsie als Ursache einer Pseudomonas-aeruginosa-Sepsis bei einem Patienten mit intestinalem Lymphom?

A patient with intestinal lymphoma developed a gram-negative septicemia 48 hours following a peroral biopsy of the small intestine. The bacteriological examination of the instrument proved the same bacteria (Pseudomonas aeruginosa) which was the cause of septicemia. On the basis of our observation and of other reports it seems reasonable besides gassterilization or effective disinfection of the instruments to carry out cultural examinations of the instrument before and following endoscopic and bioptic investigations of patients with impaired resistance; it would then be possible to start an appropriate antibiotic treatment in case of a septic complication.

[Intravenous subtraction angiography as a control examination following blood vessel surgery]. / Die intravenöse Subtraktionsangiographie (ISA) als Kontrolluntersuchung nach Gefässeingriffen.

21 patients were examined after different, mostly peripheral vessel operations by intravenous angiography in combination with photographic subtraction. In all cases there was a diagnostic reliability on the documented findings. Structure of vessel-side, morphology of stenoses, formation of a collateral circulation, functioning of bypasses and arteriovenous shunts could be judged sufficiently by the conventional intravenous subtraction angiography (ISA). As a convenient method for the control of the arterial vessel side after vessel operation and angioplasty, the ISA is a suitable method when the digital subtraction angiography is not available. The image quality of the ISA at present is at least equivalent to that of the DVSA .

[Polypoid pansinusitis in an unusual, extra-intestinal manifestation of Crohn disease]. / Polypöse Pansinusitis als eine ungewöhnliche, extraintestinale Manifestation des Morbus Crohn.

A 17-year-old female patient with known Crohn's disease developed a polypoid pansinusitis and a peritonsillitis during an acute inflammatory phase of her disease. The symptoms observed in the paranasal sinuses and in the oropharynx disappeared after treatment with cortisone and antibiotics was started. The histological findings in the biopsy specimens taken from the affected regions as well as the course of the disease suggest the extraintestinal manifestation of Crohn's disease.

Antibodies to a trypsin sensitive pancreatic antigen in chronic inflammatory bowel disease: specific markers for a subgroup of patients with Crohn's disease.

The presence of antibodies against pancreatic juice (PAB) in patients with Crohn's disease has recently been reported. In our study sera from 273 patients with inflammatory bowel disease (222 with Crohn's disease, 51 with ulcerative colitis) have been examined for PAB and also for antibodies against gut tissues by means of indirect immunofluorescence. PAB were found in 68 of the 222 patients with Crohn's disease (31%), with titres ranging from 1/10 to 1/1280, and in only two patients with ulcerative colitis (4%), with titres of 1/20. None were found in 198 patients with various chronic inflammatory diseases and healthy control subjects. No differences were found between the PAB positive and negative patients when the following parameters were compared: disease activity (Crohn's disease activity index), involvement of bowel segments, incidence of extraintestinal disease, or treatment with anti-inflammatory drugs. Only seven of the patients with Crohn's disease had a history of pancreatic disease and of these, four had detectable pancreatic antibodies. Longitudinal observations of 40 patients with Crohn's disease showed a stable pattern for PAB, independent of disease activity and treatment. Partial characterisation of the PAB antigen, isolated from pancreatic juice, showed a trypsin sensitive macromolecular protein of more than 10(6) daltons not identical with a panel of defined exocrine pancreatic proteins. By contrast, antibodies against goblet cells (GAB) were found in 13 of 51 patients with ulcerative colitis (29%) and in none of the patients with Crohn's disease or control subjects. PAB were found as a highly specific serological marker for Crohn's disease and GAB for ulcerative colitis, but the relevance of PAB and GAB in the pathogenesis in Crohn's disease remains unclear.

Autoimmune hepatitis in inflammatory bowel disease: report of two unusual cases.

Elevated transaminases occur in up to 17% in patients with inflammatory bowel disease. Primary sclerosing cholangitis (PSC) is an important cause for elevated liver enzymes in these patients whereas autoimmune hepatitis is rare. Both diseases can overlap. We report two patients with an autoimmune hepatitis. One patient had Crohn's disease and arthritis with morphological liver changes typical for autoimmune hepatitis but without the characteristic autoantibody pattern. The other patient suffered from ulcerative colitis. He had antinuclear and antiactin antibodies as in autoimmune hepatitis type I. however, histological examination of the liver showed bile duct changes. Transaminases declined significantly in both patients after onset of steroid treatment. Therefore, the diagnosis of autoimmune hepatitis in patients with inflammatory bowel disease must not be missed, as immunosuppressive therapy improves the prognosis of the illness.

[Ultrasonography--diagnosis of fistulas and abscesses in Crohn's disease (author's transl)]. / Sonografie: Darstellung von Fisteln und Abszessen beim Morbus Crohn.

An essential complication of Crohn's disease was diagnosed at an early time by ultrasonography in three young women suffering from a highly active form of this disease: intraabdominal fistulas could be demonstrated and documented. In two cases these fistulas were connected to an abscess. Early limited surgery was indicated in this particular situation; such surgery was performed and lead to fast improvement. The diagnostic value of ultrasonography in Crohn's disease with palpable abdominal tumor is demonstrated by these case reports.

[Eosinophilic gastroenteritis with ascites]. / Eosinophile Gastroenteritis mit Aszites.

Eight years after the onset of bronchial asthma a 28-year-old woman fell ill with abdominal pain, diarrhoea and rapidly increasing ascites. Increased numbers of eosinophils in the protein-rich ascitic fluid and histologically demonstrated eosinophilic infiltration of the intestinal mucosa, together with the history and symptoms, established the diagnosis of eosinophilic gastroenteritis. The disease proved self-limiting without specific treatment. Within four years of first manifestations there were two short recurrences with rapid regression without specific treatment.

[Primary biliary liver cirrhosis and granulomatous pulmonary infiltrates]. / Primär biliäre Leberzirrhose und granulomatöse Lungeninfiltrate.

Primary biliary cirrhosis was diagnosed in a 48-year-old woman in the light of clinical and laboratory data, antimitochondrial antibodies and histologic features in liver biopsy. Four years later the patient developed pulmonary infiltration of changing localization. Histologic investigation of transbronchial biopsy revealed granulomas in the bronchial mucosa and peribronchial tissue. There were no further signs of sarcoidosis. The question is discussed whether granulomatous pulmonary infiltrations are an extrahepatic manifestation of primary biliary cirrhosis.

Filiform polyposis: a case report describing clinical, morphological, and immunohistochemical findings.

Filiform polyposis (FP) is a rare condition of uncertain pathogenesis, 28 cases of which have been published since it was first described in 1965. It is usually found in association with chronic inflammatory bowel disease, especially Crohn's disease and ulcerative colitis. The condition is characterized by the presence of numerous, densely packed, filiform polyps in the colon, which may resemble villous adenomas on endoscopy. We describe a case of FP occurring in a 33-year-old man with a 5-year history of Crohn's disease, in whom subtotal colectomy was performed because of perforation of the sigmoid colon. Microscopy revealed inflammatory pseudopolyps covered by largely normal and non-dysplastic colonic epithelium. The neuroendocrine system of the intestine in FP was investigated for the first time in this case: marked hyperplasia of endocrine cells immunoreactive for serotonin, somatostatin and enteroglucagon and of neural structures immunoreactive for substance P and vasoactive intestinal peptide was noted in the polyps and the adjacent intestinal mucosa. The patient has experienced no further complications in the 12 months since the operation. Medication administered in FP depends mainly on the nature of the underlying disease, and the amount of information published about this condition is as yet insufficient to allow any one specific type of treatment to be recommended. FP alone is not an indication for bowel resection but complications, such as massive haemorrhage or intestinal obstruction, may necessitate surgical intervention.

Lethal complications in a case of sigmoid diverticulitis. A case report.

A 61-year-old female complaining of arthralgia was repeatedly treated with antibiotics and also with prednisolone. A chronic polyarthritis was assumed. In hospital, leukocytosis of 21.000 was found one day before death as well as moderate anemia. Colonoscopy was rejected by the patient. A computer tomography revealed destructive arthritis of the symphysis, vertebral osteochondrosis L5/S1, and sigmoid diverticulosis. The patient died with clinical signs of central dysregulation. At autopsy, a covered perforation of a sigmoid diverticulum with purulent peridiverticulitis was found. The 5th lumbal vertebra and the symphysis showed hematogenic abscesses. Microabscedating pneumonia, purulent meningitis and hypophysitis, and mycotic aneurysm of the basilar artery with lethal rupture were further results of hematogenic spread. Death was caused by massive subarachnoidal hemorrhage. This history is not untypical for elder patients with complicated diverticular disease. The intestinal perforation is often clinically occult due to only few and unspecific symptoms which cannot be exactly attributed to the colon. In the last ten years, we have found lethal complications of sigmoid diverticulitis at a frequency of 0.32% (5 cases in 1.557 subsequent autopsies). The clinical differential diagnosis included diverticulitis in none of the cases. This underlines the importance of autopsies for quality control in medicine, because modern diagnostic methods such as computer tomography were not able to give the correct diagnosis in these cases.

[Pericardial effusion during the therapy of Crohn's disease with 5-aminosalicylic acid]. / Perikarderguss während der Therapie eines Morbus Crohn mit 5-Aminosalicylsäure.

A 22-year-old woman with Crohn's disease was treated with 5-aminosalicylic acid (Claversal), four times 500 mg daily, because of increased inflammatory activity. Retrosternal pain set in after two weeks; in another two weeks a moderately enlarged heart was noted on the chest X-ray and pericardial effusion diagnosed echocardiographically. After stopping the medication the pericardial effusion resolved without further treatment. Immunoserology failed to demonstrate autoantibodies, but a repeat lymphocyte stimulation test was positive. There is a possible causal relationship between 5-aminosalicylic acid medication and the pericardial effusion, although the pathogenetic mechanisms is not known.

[Cheilitis granulomatosa as the first manifestation of Crohn's disease]. / Cheilitis granulomatosa als erste Manifestation eines Morbus Crohn.

A 39-year-old man developed a painless swelling of the lower lip, which histologically was a granulomatous inflammation of the corium as in granulomatous cheilitis. Four weeks after onset of the disease recurrent diarrhoea set in, the result of Crohn's disease of the jejunum, terminal ileum and caecum. Granulomatous cheilitis, occurring as sole sign of the Melkersson-Rosenthal syndrome, is a manifestation of Crohn's disease. Even if there are no intestinal symptoms. Crohn's disease must be excluded in the differential diagnosis.