[Short version of the updated S3 (level 3) guidelines for diagnosis and treatment of gallstones of the German Society for Digestive and Metabolic Diseases and the German Society for the Surgery of the Alimentary Tract]. / Kurzfassung der aktualisierten S3-Leitlinie der DGVS und DGVC zur Diagnostik und Behandlung von Gallensteinen.

This short version of the guidelines summarizes the evidence-based key recommendations for the diagnosis and treatment of gallstones. The guidelines were developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, and patient support groups, under the auspice of the German Society for Gastroenterology and Metabolic Diseases and the German Society for General Surgery and Surgery of the Alimentary Tract. It used structural level 3 consensus-based methodology and includes statements on clinical practice, prevention, quality assurance, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone disease.

Endosonographic elastography in the diagnosis of mediastinal lymph nodes.

BACKGROUND AND STUDY AIMS: Ultrasonographic elastography is a new technique for describing the mechanical properties of tissue during real-time ultrasonography. The aim of this study was to test the feasibility of this method in endosonography (EUS) of the dorsal mediastinum, and to compare the elastographic patterns of lymph nodes with results from EUS-guided fine-needle aspiration biopsy (FNAB). PATIENTS AND METHODS: 50 consecutive patients undergoing EUS-guided FNAB of at least one paraesophageal lymph node were included. Each of these targeted lymph nodes was examined also elastographically. The elastographic patterns were described and compared with the histologic results by a first examiner. The elastographic classification was subsequently further tested by two blinded reviewers. RESULTS: In total, 66 lymph nodes were examined; 37 lymph nodes revealed benign and 29 malignant tissue at the histologic evaluation. Good elastographic records were obtained for all lymph nodes. Of the 37 benign lymph nodes, 31 showed a homogeneous pattern of intermediate elasticity, whereas a dominance of hard tissue with variable patterns was found in 23 of 29 malignant lymph nodes. Applying these criteria, the accuracy range among the three examiners was between 81.8 % and 87.9 % for benign lymph nodes and between 84.6 % and 86.4 % for malignant ones. The interobserver agreement was excellent (kappa = 0.84). CONCLUSION: EUS elastography of mediastinal lymph nodes can be performed reliably. The results are good for a noninvasive technique, but they remain inferior to the success rate of EUS-guided FNAB. The method might occasionally be useful for targeting the most suitable lymph nodes for FNAB.

[S3-guidelines for diagnosis and treatment of gallstones. German Society for Digestive and Metabolic Diseases and German Society for Surgery of the Alimentary Tract]. / S3-Leitlinie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten und der Deutschen Gesellschaft für Viszeralchirurgie zur Diagnostik und Behandlung von Gallensteinen.

This guideline provides evidence-based key recommendations for diagnosis and therapy of gallstones and upgrades version 2000. It was developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, external comparative quality assurance and patient support groups under the auspices of the German Society for Digestive and Metabolic Diseases and the German Society for Surgery of the Alimentary Tract. The guideline used structural S3 consensus-based methodology and includes statements on clinical practice, prevention, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone diseases.

[The liver and hereditary hemorrhagic telangiectasia]. / Leber und hereditäre hämorrhagische Teleangiektasie (Morbus Osler).

Hereditary hemorrhagic teleangiectasia, or Rendu-Osler-Weber syndrome, is an autosomal dominant inherited disease characterized by vascular derangement in many organs. The vascular derangement includes teleangiectases, arteriovenous fistulas and aneurysms. Liver involvement in hereditary hemorrhagic teleangiectasia is a rare and sometimes severe disease which was unknown and mostly detected at autopsy until a few decades ago. Typical findings are vascular malformations and connective tissue formation with fibrosis and atypical cirrhosis. In the last years we observed five Osler patients with exclusive or prevailing involvement of the liver. An unambiguous diagnosis can be ascertained by means of a hazardous liver puncture with typical histological findings. Angiography allows a reliable identification of even minor vascular deformities. The present study was undertaken to demonstrate the courses of disease, the techniques of examination and the therapeutical options of this rare manifestation of Osler-disease. In every case one could observe hepatic malformations which were established as typical Osler findings with the assistance of histological and above all sonographical/color-Doppler-sonographical devices. These special sonographic/color-Doppler-sonographic features make it possible to give up the histological diagnostics or exhaustive investigations by means of angiography, computer-tomography or MRI.

The thermodilator: an effective instrument in the palliative therapy concept of malignant bile duct stenosis.

BACKGROUND AND METHODS: In the case of incurable malignant bile duct stenosis the aim of therapy is to secure the bile flow. Sometimes dilation of the stenosis is necessary to enable the introduction of a biliary duodenal stent or the replacement of a small-bore stent by a large-bore one. The previously most commonly used methods - bougienage and balloon dilation - can be unsuccessful with severe stenoses, which means that an extension of the endoscopic therapeutic instrumentarium is desirable. We examined the success rates and complications of a thermodilator which can be used to dilate bile duct stenoses. RESULTS AND CONCLUSIONS: In 21 out of 24 applications the therapeutic objective was achieved. In one case we observed an endoscopically controllable bile duct hemorrhage. The thermodilator is therefore a valuable addition to the endoscopic treatment possibilities of malignant bile duct stenosis.

The liver in hereditary hemorrhagic telangiectasia (Weber-Rendu-Osler disease).

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT, Osler disease) is an inborn error in the structure of different vessels. This leads to vascular malformations in multiple organ systems. In the liver vascular abnormalities are associated with a marked fibrosis and/or cirrhosis. METHODS AND RESULTS: We found hepatic manifestation of Osler disease in four women and one man (51-63 years old) presenting initially with slight disturbances of liver function. In three patients progressive liver insufficiency developed. The characteristic histologic and sonographic findings are described and discussed. CONCLUSION: Ultrasonography with color and Doppler analysis is diagnostic, replacing more extensive procedures like angiography, computer tomography, or magnetic resonance tomography.

[Clinical value of endoscopic ultrasound-guided transesophageal fine needle puncture of mediastinal lesions]. / Zum klinischen Stellenwert der endosonographisch gesteuerten transösophagealen Feinnadelpunktion von Mediastinalprozessen.

BACKGROUND AND OBJECTIVE: As the mediastinum has been a region difficult to access for biopsy, mediastinoscopy has been required in most cases. In a prospective study the value of transoesophageal endoscopic ultrasound (TEUS) guided aspiration biopsy was assessed as an alternative. PATIENTS AND METHODS: TEUS-guided fine-needle aspirations were performed between May 1995 and March 1998 in 35 patients with mediastinal space-occupying lesions. In all cases the conventional endoscopic method or percutaneous puncture-sonography had been impossible or had failed. In one patient it had been performed after a negative mediastinoscopy. RESULTS: In 34 patients (97%) the aspirated tissue cylinder could be evaluated histologically. There were no complications. Malignancy was demonstrated in 24 patients, and there were one case each of sarcoidosis, silicoanthracosis and two cases of retrosternal goitre. In four of seven patients the negative preoperative diagnosis was confirmed at operation or by follow-up. There were two false-negative results and in one patient there has been no definitive diagnosis. The accuracy of the method was thus 91.4%, the positive predictive value for malignancy 88.9% and the negative predictive value for malignancy 72.7%. Ultrasound alone was a poor predictor of malignancy in lymph node enlargement. CONCLUSION: TEUS-guided fine-needle aspiration of space-occupying mediastinal lesions is an effective and low-risk method that can in selected cases shorten the diagnostic process and avoid methods that are expensive or lead to complications such as transpulmonary biopsy guided by computed tomography or mediastinoscopy.

[Non-operative management of pancreatitis with splenic involvement]. / Nichtoperatives Management bei pankreatitischer Milzbeteiligung.

Pancreatitic pseudocysts of the spleen are rare events. We report two cases of conservative management of splenic involvement in pancreatitis by ultrasound-guided aspiration. The first patient was admitted with clinical and biochemical signs of acute exacerbation of chronic pancreatitis. The ultrasound examination showed a subcapsular anechoic zone in the spleen as well as pancreatic pseudocysts. The laboratory examination of the fluid obtained by ultrasound-guided aspiration confirmed the presence of an intrasplenic pancreatitic pseudocyst which disappeared completely after a second percutaneous aspiration. The second patient was admitted with acute exacerbation of chronic pancreatitis and septic symptoms caused by an abscess near the left lobe of the liver. After successful surgical drainage of the abscess the patient developed an expanding anechoic subcapsular fluid zone in the spleen. Quantitative decompression by ultrasound guided fine needle-aspiration confirmed the pancreatitic origin of the lesion which vanished within a few days without further treatment. We conclude that fine-needle aspiration of splenic pseudocysts under ultrasound control permits a differential diagnostic distinction from splenic abscess or hematoma and accelerates healing. There is thus a nonsurgical option for treatment of pancreatitic intrasplenic pseudocysts, provided that the patient is under close clinical observation.

Argon plasma coagulation (APC) in gastroenterology: experimental and clinical experiences.

BACKGROUND: Diathermy procedures are indispensable in interventional endoscopy. Argon beam coagulation is an innovative no-touch electrocoagulation technique in which high-frequency alternating current is delivered to the tissue through ionized argon gas. METHOD AND PATIENTS: Before clinical application, we conducted in-vitro studies to investigate the depth and diameters of tissue coagulation in fresh operative specimens from the stomach, small intestine and colon. Five different power/gas flow settings between 40 and 155 W and 2 and 7 l/min were used. The impact time (1-10s) and the incident angle of the probe (45 degrees and 90 degrees) were also varied. The maximum depth of necrosis was 2.4 mm, the maximum diameter 1.1 cm. No perforation occurred even in critical areas such as the colon and duodenum. We therefore performed argon beam coagulation in 66 consecutive patients. Two power/gas flow settings of 40 and 70 W and 2 and 3 l/min, respectively, were used. The impact time and incident angle were varied individually. RESULTS: In 49 of the 50 patients with oozing haemorrhage from angiodysplastic lesions, polypectomy sites, erosions or ulcers or oozing of blood due to vascular penetration by tumours, definitive haemostasis was achieved in one to two sessions. In all 11 patients with residual sessile adenoma tissue, complete removal was possible. Oesophageal patency was restored in all five patients with stenosing tumours. In one patient with angiodysplasia of the caecal pole, an asymptomatic accumulation of gas in the submucosa was observed which resolved spontaneously. In two patients with extensive oesophageal carcinoma, there was a transitory--also asymptomatic--accumulation of gas in the mediastinum and peritoneal cavity but no evidence of perforation. CONCLUSION: Argon plasma electrocoagulation is an effective and relatively low-cost alternative to laser therapy in gastrointestinal endoscopy.

[Transcutaneous sonography of the gastroesophageal junction in prospective comparison with endoscopy]. / Die transkutane Sonographie des gastroösophagealen Uberganges im prospektiven Vergleich mit der Endoskopie.

BACKGROUND AND OBJECTIVE: Despite its practical value, few data exist on assessing the gastrooesophageal junction by transcutaneous sonography (TS). A prospective study was undertaken to compare TS and endoscopy (ES) of this region. PATIENTS AND METHODS: Between 1 September, 1994 and 31 May, 1995 TS of the lower oesophagus was followed by ES of this region in 211 patients (116 women, 95 men; mean age 58.9 [14-90] years). None had previously been examined by ES or radiological contrast study of the oesophagus and stomach. Endoscopist and sonographer were blinded to each other's findings. The ability to visualize the abdominal oesophagus by TS and to recognize abnormalities were compared with ES results, both quantitatively and descriptively. RESULTS: The diaphragmatic course of the terminal oesophagus or (where present) a gastric hernia were well visualized by TS in all 211 patients. In 78 patients with normal results on TS and ES the visible length of the oesophagus was 3.3 +/- 0.8 cm, with a wall thickness of 4.5 +/- 1.0 mm (mean +/- standard deviation). In seven of eight patients with echo-poor wall thickness between 9 and 27 mm, suspected of being malignant, ES revealed neoplasm of the terminal oesophagus or cardia (six T2 to T4 carcinomas; one MALT lymphoma). One patient had involvement of the oesophagus and cardia as part of Crohn's disease. No case of malignancy remained unrecognized by ES. 64 of 77 hiatal hernias diagnosed by ES were also recognized by TS. Hiatal hernia was falsely diagnosed by TS in four patients. Oesophageal varices were correctly identified by TS in three of eight patients, as was one case of achalasia. CONCLUSION: Transcutaneous sonography is a good screening method with a high sensitivity for changes in wall architecture and it provides indications for further selective diagnostic procedures.

[The sono-capsule: a new method for measuring gastrointestinal motility]. / Die Sono-Kapsel: Eine neue Methode zur Messung der gastrointestinalen Motilität.

PURPOSE: We developed a noninvasive procedure using ultrasound and a specially designed capsule to permit determination of transit times in the gastrointestinal tract. METHODS: The ultrasound capsule consisted of a latex balloon of 1 cm diameter filled with water and containing a solid metal ball. After ingestion the marker was visualised in the gastrointestinal tract at defined intervals using conventional ultrasound machines. The various transit times were determined in 10 healthy volunteers. RESULTS: On account of its artifact-in-artifact structure (cystic configuration and reverberation), the ultrasound capsule was first detected in the stomach without any difficulty. During its further passage through the gastrointestinal tract the location of the capsule in the small and large bowel could be identified on the basis of the surrounding plicae circulares and haustrations. The mean oropyloric transit time was 2.4 hours; passage through the small bowel took 1.5 to 3 hours, and pyloro-anal transit times between 6 and 10 hours. CONCLUSION: the ultrasound capsule is a suitable method for investigating the gastrointestinal transport. It is non-invasive and does not expose the patient to radiation.

[Endoscopic therapy in acute hemorrhage caused by duodenal diverticula]. / Endoskopische Therapie einer akuten Blutung aus einem Duodenaldivertikel.

HISTORY AND CLINICAL FINDINGS: A 70-year-old previously healthy woman had been feeling nauseous for one day and had passed several liquid tarry stools. A barium meal previously done as an out-patient had shown a duodenal diverticulum 3.5 cm in diameter with marked contrast-medium retention. Her general condition was impaired, her skin pale and cold, while heart rate and blood pressure were normal. Rectal examination confirmed tarry stool and thus suggested upper gastrointestinal bleeding, the contrast-medium retention pointing to the duodenal diverticulum as a likely site. INVESTIGATIONS: Haemoglobin concentration was 9.1 g/dl, the haematocrit 26.6%. Total protein was reduced to 4.4 g/dl. Esophagogastroduodenoscopy (performed about 10 hours after the barium meal) showed erosion at the duodenal bulb and contrast retention in the juxtapapillary diverticulum, but no acute bleeding was discovered. TREATMENT AND COURSE: Repeat endoscopy on the following day revealed acute bleeding (Forrest stage Ia) from an arterial stump in the diverticulum. It was stopped with local injection of adrenaline (6 ml of 1:10,000 solution) and fibrin glue, but the injections had to be repeated twice. Another endoscopy 30 days after the first showed merely a mucosal scar. CONCLUSION: Early endoscopy enables one to make the diagnosis and to provide minimally invasive treatment of bleeding from a duodenal diverticulum.

[Non-contact argon gas coagulation in flexible endoscopy of the gastrointestinal tract: in vitro studies and initial clinical experiences]. / Kontaktlose Argon-Gas-Koagulation in der flexiblen Endoskopie des Gastrointestinaltraktes: In-vitro-Untersuchungen und erste klinische Erfahrungen.

Diathermocoagulation is indispensable in interventional endoscopy. The argon beam coagulation represents an innovative electrocoagulation method, where high-frequency alternating current is conducted to tissues by ionized argon gas without contact. Before clinical application we performed in vitro studies to evaluate depth and diameter of tissue coagulation of fresh resectations from stomach, small intestine and colon. Power and gas flow were graduated in five steps from 40 to 155 W and from 2 to 7 l/min respectively. Coagulation time (1 s-10 s) and angle of the probe in relation to tissue surface (45 degrees, 90 degrees) were varied. The maximal depth of necrosis was 2.4 mm, the maximal diameter 1.1 cm. There was no perforation found, even in critical areas like colon and duodenum. Accordingly argon beam coagulation was performed in 41 consecutive patients. The power and gas flow were varied in two stages between 40 and 75 watts and 2 and 3 l/min respectively. Coagulation time and angle of the probe were handled individually. In 32 of the 33 patients with bleeding from angiodysplastic lesions or polypectomy sites, with oozing of blood from erosions or ulcers or with bleeding due to vascular penetration by tumors definitive hemostasis was achieved in one to two sessions. In all of the four patients with residual sessile adenoma tissue complete removal was possible. Esophageal patency was restored in all four patients with stenosing tumors. In one patient with angiodysplasia of the cecal pole an asymptomatic accumulation of gas in the submucosa was observed which cleared spontaneously. In two patients with extensive esophageal carcinoma there was a transitory--also asymptomatic--accumulation of gas in the mediastinum and peritoneal cavity but no reference to perforation. The non-contact argon electrocoagulation is in gastrointestinal endoscopy an effective and non-expensive alternative to laser-technique.

[ESWL-therapy of pancreatic duct calculi]. / ESWL-Therapie von Pankreasgangsteinen.

In 23 patients suffering from pancreatic duct stones, extracorporeal shock wave lithotripsy (ESWL) was performed in combination with endoscopic sphincterotomy (EST). Calculi-disintegration and resolution of obstruction was achieved in all cases. Completely stone-free ducts were achieved in 7 patients, some peripheral asymptomatic stone material remained in 16. 8 patients became completely asymptomatic, 11 reported a marked reduction of their pain. 15 patients gained weight. No major complications were observed. ESWL combined with EST is a successful non-operative new treatment option in pancreatic stone disease.

[Chronic mesenteric ischemia--a rare differential diagnosis of Crohn disease]. / Chronische Mesenterialischämie--eine seltene Differentialdiagnose des Morbus Crohn.

A 59-year-old patient was treated for six years assuming Crohn's disease. Recurrent segmental colitis, spontaneous perforation of the jejunum and chronic weight loss were suggestive of this diagnosis despite a missing typical histology, even in the resected part of jejunum. Only unspecific inflammatory changes were found. Typical angina abdominalis occurred late. Angiography showed a complete occlusion of the coeliacaxis and both mesenteric arteries. Only the slow progress of occlusion of the visceral arteries with extensive collateral circulation from iliacal arteries explains the absence of severe bowel infarction. After aortomesenteric bypass operation the patient is without any complaint.