[Contrast-enhanced ultrasonography of testicular tumours]. / Kontrastmittelsonographie bei Hodentumoren.

Scrotal ultrasound with high-resolution transducers and additional display of vascularisation in colour-coded ultrasonography is the method of choice for the detection and characterisation of testicular tumors. Within the last decade, testicular ultrasonography has been further refined and improved by the possibilities of contrast-enhanced ultrasound (CEUS).CEUS may be especially helpful in the assessment of vascularisation disorders (e.g., incomplete torsion, segmental perfusion disorders, abscesses) or testicular foci remaining equivocal even after colour-coded ultrasonography.The basic idea in the application of CEUS in scrotal sonography is the possibility to differentiate between avascular, hypo- and hypervascular findings, with a lack of perfusion generally considered as a sign of benignity. Vice versa, detection of vascularisation speaks for neoplasia but not necessarily for malignity (e.g., Leydig cell tumors). CEUS is especially valuable in the correct classification of small (<1.5 cm) testicular foci.This review summarizes the present knowledge on indications, implications and limitations of the application of CEUS in testicular tumors.

Testicular epidermoid cysts: a reevaluation.

BACKGROUND: Testicular epidermoid cysts (TECs) are rare benign testicular neoplasms. As TECs are rarely associated with germ cell tumours (GCTs), the understanding of biological behaviour and clinical management of TEC is unresolved. METHODS: We retrospectively searched the files of patients treated for testicular neoplasms and germ cell cancer in the time from 2000 to 2017. Those with TEC were subjected to closer review looking to clinical and histological features, and to results from imaging with ultrasonography (US), contrast enhanced sonography (CEUS) and magnetic resonance imaging (MRI). RESULTS: Among 589 patients undergoing surgery for testicular tumour, nine simple TECs were identified (1.5, 95% confidence intervals 0.53-2.50%). Median age was 26 years. Imaging revealed sharply demarcated roundish lesions with avascular central areas. Eight patients underwent testis-sparing excision with no recurrence ensuing. One had orchiectomy because of large size of the mass. Histologically, TECs consisted of cornifying squamous cell epithelium and no accompanying germ cell neoplasia in situ. Two additional cases (0.3% of all) required orchiectomy because these TECs were associated with ipsilateral GCT. CONCLUSIONS: TEC is usually a benign lesion that can safely be diagnosed with US, CEUS and MRI due to its roundish shape and its avascular centre. Histologically, this TEC corresponds to the prepubertal-type teratoma unrelated to germ cell neoplasia in situ of the 2016 WHO classification. The other subtype of TEC that is associated with invasive GCT represents a teratoma of postpubertal-type. From a clinical point of view it could be easier to differentiate between a "simple TEC" which is benign (prepubertal type) and a "complex TEC" which is malignant because of its association with invasive GCT.

Appendico-ileal knotting mimicking adhesive bowel disease.

Appendico-ileal knotting is a very rare and widely unknown cause of closed loop bowel obstruction. In most cases it is discovered incidentally during surgery. We report a 59 year old female with a previous history of a total abdominal hysterectomy who presented with features of intestinal obstruction and was thought to suffer from postoperative adhesions. At laparotomy, appendico-ileal knotting was found; after appendectomy, she made a full recovery. Appendico-ileal knotting should be known as a possible differential diagnosis when managing patients with features of intestinal obstruction and symptoms or signs of appendicitis.

Contrast-enhanced ultrasound and real-time elastography for the diagnosis of benign Leydig cell tumors of the testis - a single center report on 13 cases.

PURPOSE: To describe sonomorphological features in testicular Leydig cell tumors (LCTs) with a special focus on contrast-enhanced ultrasonography (CEUS) and real-time elastography (RTE). PATIENTS AND METHODS: In a series of 186 patients with testicular surgery for neoplastic disease, 13 benign LCTs (in 12 patients) were histopathologically diagnosed. Preoperatively, all patients had been examined with a standardized protocol (high-resolution grayscale and color-coded ultrasonography, CEUS). 5 patients underwent RTE. In CEUS, the filling time of the lesion was compared to that of 14 size-matched germ cell tumors (GCT). RESULTS: 10/13 LCTs had a size of < 10 mm, and a sharply demarcated hypoechoic appearance was typical (10/13). Color-coded ultrasonography detected signals in 8 lesions, while CEUS showed clear hypervascularization in all. LCTs had a significantly shorter filling time than GCTs (p < 0.0005), with 9/13 LCTs being completely filled within 4 s. In RTE, all 5 examined lesions were clearly "harder" than the surrounding testicular tissue. CONCLUSION: Contrary to some earlier reports, we could demonstrate marked hypervascularization in LCTs. This feature clearly allows for the differentiation of a small LCT from focal scars. However, it may only be visible on CEUS. In CEUS, LCT is suggested by the findings of a short filling time or by a circumferential vessel with a rapid centripetal filling, combined with a "harder" appearance in RTE. These features along with the findings of a small and peripherally situated hypoechoic tumor would justify an operative strategy with frozen section examination and possibly organ sparing surgery instead of orchiectomy.

[Impending liver failure after chemoimmunotherapy-induced reactivation of hepatitis B - successful treatment with entecavir]. / Drohendes Leberversagen nach Chemoimmuntherapie-induzierter Reaktivierung einer Hepatitis B - erfolgreiche Therapie mit Entecavir.

HISTORY AND CLINICAL FINDINGS: An 83-year old woman had been treated with bendamustin and rituximab for prolymphocytic leukemia. Two weeks after cycle 6 of chemotherapy, signs and symptoms of a severe hepatitis occurred. INVESTIGATIONS: Highly elevated values for AST (1353 U/l) and bilirubin (27.8 mg/dl), impaired coagulation parameters (INR 1,68) and the detection of ascites led to the diagnosis of an impending liver failure induced by reactivation of a hitherto unknown hepatitis B (HBs antigen pos., HBe antigen pos., anti HBc IgG pos., HBV DNA 1,65 Mio copies/ml). TREATMENT AND COURSE: After an immediately started treatment with entecavir (0.5 mg/d po), symptoms and laboratory parameters rapidly improved. 4 months later liver chemistry was completely normal and HBV DNA was negative. After 8 months, a seroconversion to anti HBs was noted. CONCLUSION: In single cases, life threatening complications of chemotherapy induced reactivation of hepatitis B may be successfully treated by potent and stabile nucleosidanalogs.

[Tubular ectasia of rete testis: a pitfall in ultrasonographic diagnostics of intratesticular cysts]. / Tubuläre Ektasie des Rete testis : Die Differenzialdiagnose von zystischen Veränderungen im Hoden.

BACKGROUND: Tubular ectasia of the rete testis (TERT) sonographically consists of a cluster of anechoic foci located at the mediastinum testis. TERT is important diagnostically, because it might be confused with malignant teratoma that may likewise contain cystic areas. PATIENTS AND METHODS: Twenty-four patients with TERT were identified sonographically. Ten of these patients underwent additional magnetic resonance imaging (1.5 T), and three had contrast-enhanced scrotal sonography. A descriptive analysis was done regarding clinical details and sizes of the single anechoic foci and of the entire areas involved with cystic changes. RESULTS: The median age of the patients with TERT was 60 years. Diagnosis was based on incidental findings or uncharacteristic symptoms in three quarters of the cases. The size of the single cysts was ≤ 3 mm, 4-6 mm and ≥ 7 mm in 12, 6 and 6 patients, respectively. The size of the entire area involved with cystic changes ranged from 0.5 x 1.2 cm to 2.5 x 3.0 cm. Six patients had TERT bilaterally, and 18 had concomitant spermatoceles. T2-weighted MRI demonstrated high signal intensity of the cystic areas. No signal enhancement was found in these areas after application of contrast agent. Contrast-enhanced sonography did not show uptake in the TERT areas. Histological evidence for dilatation of the rete testis was found in the two patients undergoing diagnostic surgery. CONCLUSIONS: TERT is a benign lesion of the testis that is increasingly detected sonographically. Knowledge of TERT is essential for the urologic sonographer to avoid unwarranted diagnostics and surgery as well as costs.

[Severe segmental colitis due to anisakiasis. Unusual manifestation of a rare infection in Germany]. / Schwere segmentale Kolitis durch eine Anisakiasis. Ungewöhnliche Manifestation einer in Deutschland seltenen Infektion.

HISTORY AND CLINICAL FINDINGS: A 43 years old worker of a fish factory was admitted for spasmodic lower abdominal pain lasting for some hours. Physical examination revealed diffuse abdominal tenderness with a maximum in the right upper and lower abdomen. INVESTIGATIONS: Laboratory values showed a slight rise in leucocytes with otherwise normal inflammation parameters. In abdominal ultrasonography some free fluid in the gallbaldder region and an impressing thickening of the walls of the ascending and transverse colon were found. A CT scan described an "intraluminal process" and a pericolic infiltration. TREATMENT AND COURSE: Laparoscopy was performed and revealed a swelling of the whole right colon with pronounced edema. After an extension to laparotomy and colotomy, massive mucosal edema was seen (explaining the intraluminal process); furthermore, there was a filiform whitish structure of around 15 mm length in the colonic mucosa. Histology ascertained the macroscopic diagnosis of a small worm which was identified as an anisakis larva. After intraoperative removal of the worm and an anthelminthic therapy the patient's complaints and the impressing mucosal edema disappeared completely. CONCLUSIONS: Anisakiasis is a very rare infection in Germany. In single cases, a history of the place of work may be helpful in diagnosis. Usually the larva penetrate into gastric or intestinal mucosa. The case presented here illustrates the possibility of an anisakiasis infection in severe and otherwise unexplainable segmental colitis, especially with a history of a possible ingestion of raw fish.

[Sonographic diagnosis of Bouveret's syndrome]. / Sonographische Diagnose eines Bouveret-Syndroms.

MEDICAL HISTORY: A 76-year-old woman with known dementia was admitted to hospital for postprandial vomiting and increasing upper abdominal pain for 2 days. Gallstones and a chronic cholecystitis had been previously documented. INVESTIGATIONS: Laboratory tests revealed slight hypochromic anemia (Hb 10.6 g/dl) and an increase in gammaGT (439 U/l) and AP (277 U/l) with a normal bilirubin. The gall bladder was very small sonographically, compared to an examination 6 months earlier. Furthermore, there was a marked aerobilia in the peripheral bile ducts. DIAGNOSIS: Bouveret;s syndrome, with a 6 cm concrement in the duodenal bulb, was suspected at the initial ultrasound examination and confirmed by endoscopy and radiology. TREATMENT AND FOLLOW-UP: When the patient was operated the following day, a chronically inflamed gall bladder with perforation into the duodenum was found, but no concrement in the duodenal bulb. The operative field was extended and revealed a distal small bowel obstruction caused by an incarcerated stone at the ileocecal valve. The concrement was removed and a cholecystectomy with closure of the fistula performed. However, 8 days later the patient died from multiorgan failure. CONCLUSION: This was a rare case of a "classical" Bouveret's syndrome that spontaneously changed into a distal small bowel obstruction by gall stones. In an appropriate clinical setting, this condition can be diagnosed by a simple abdominal ultrasound examination.

Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks.

BACKGROUND AND STUDY AIMS: Extensive anastomotic leaks after esophageal resection and esophageal perforations are a therapeutic challenge. The aim of the present study was to assess the potential of the self-expandable Polyflex plastic stent for the treatment of these conditions. PATIENTS AND METHODS: Between January 2002 and March 2003, nine patients were treated with a self-expandable Polyflex plastic stent for sealing of thoracic esophagoenteric anastomotic leaks following surgical resection (n = 5) or esophageal perforation (n = 4). RESULTS: In all patients the stents were inserted successfully without technical problems. In all but two patients complete sealing of the leak was achieved as demonstrated by radiography with water-soluble contrast media. The stent migration rate was 30 % and repositioning of the migrated stents was possible in all cases. Complete mucosal healing of the esophageal leaks and stent extraction was achieved in six patients. The stents were in situ for an average period of 135 +/- 78 days. Two critically ill patients with anastomotic leaks died in spite of stent insertion due to sepsis and one patient with esophageal perforation died due to the underlying malignant disease. CONCLUSIONS: Our preliminary experience with the self-expanding and removable Polyflex plastic stent for the sealing of anastomotic leaks and esophageal perforations suggests that this stent is a feasible treatment option, in particular, for more extensive esophageal defects, patients with co-morbid conditions, and critically ill patients.

A patient with myelofibrosis complicated by refractory ascites and portal hypertension: to tips or not to tips? A case report with discussion of the mechanism of ascites formation.

In patients with myelofibrosis, clinically significant portal hypertension is known to be predominantly presinusoidal; however, the exact mechanisms are still controversial. The pathophysiology is particularly enigmatic in those patients without histological and angiographic evidence of significant intra- or extrahepatic obstruction to portal blood flow, respectively. Moreover, ascites formation has been reported in such cases, but in general is rare in presinusoidal portal hypertension. Here we present such a patient in which ascites developed even in the presence of unchanged serum protein levels (oncotic pressure) and was refractory to sodium restricted diet and high-dose diuretic treatment. A discussion on the parameters influencing fluid exchange and ascites formation particularly emphasizing the potential importance of the hyperdynamic circulation in this case is given. Finally, the patient was treated by implanting a transjugular intrahepatic shunt (TIPS), exerting a diuretic effect sufficient enough to avoid re-formation of ascites for several months. However, ascites re-accumulated potentially due to the appearance of ectopic peritoneal myeloid metaplasia and the patient died soon afterwards. In conclusion, TIPS may be considered as rescue management for refractory ascites secondary to portal hypertension, but caution in respect to the presence and/or development of peritoneal or other ectopic haematopoesis has to be taken.

[Cholestasis and vomiting: unusual differential diagnosis in a case of Peutz-Jeghers syndrome]. / Cholestase und Erbrechen. Eine ungewöhnliche Differentialdiagnose bei Peutz-Jeghers-Syndrom.

HISTORY AND CLINICAL FINDINGS: A 54-year-old patient with painless jaundice and vomiting had been diagnosed with a Peutz-Jeghers syndrome 20 years before. INVESTIGATIONS: The blood analysis showed a cholestatic constellation as well as increased transaminases. Sonographic, radiological, endoscopic and histological findings indicated multiple hamartomatous polyps of the Peutz-Jeghers' type in the entire small and large bowel with occlusion of the papilla of Vater and the superior gastrointestinal tract by a big polyp. TREATMENT AND COURSE: After an initial percutaneous transhepatic cholangiographic drainage, Whipple's operation and a segmental resection of small and large bowel were performed. A highly differentiated adenocarcinoma of the duodenum was found in the resected specimen. CONCLUSION: This case demonstrates the potentially severe complications of a Peutz-Jeghers syndrome that had been neglected for years.

Orofacial granulomatosis as initial manifestation of Crohn's disease: a report of two cases.

Patients with Crohn's disease generally present with chronic diarrhoea and/or abdominal pain. However, it may be the extraintestinal manifestations as orofacial granulomatosis (OFG)--a rare syndrome with chronic swelling of the lips and the lower half of the face combined with oral ulcerations and hyperplastic gingivitis--that urge patients to seek medical advice. We report two rare cases in which swelling of the lips and cheeks were the initial symptoms that finally led to the diagnosis of Crohn's disease.

Early shifts of adrenal steroid synthesis before and after relief of short-term cholestasis.

BACKGROUND/AIMS: Chronic inflammatory diseases are characterised by a relative reduction of cortisol and adrenal androgens. The time point of appearance of these alterations is not known. Cholestasis may be a model of short-term inflammation to study early alterations of steroidogenesis. METHODS: We investigated 18 patients with cholestasis before and after therapeutic abolition of cholestasis (compared to nine control subjects, Co). RESULTS: Serum tumour necrosis factor (TNF) was increased in cholestatic patients as compared to Co (P at least <0.01). Co as compared to cholestatic patients without tumours had elevated levels of plasma adrenocorticotropic hormone (ACTH) and serum dehydroepiandrosterone sulfate (DHEAS) but serum cortisol levels were similar. Levels of ACTH and DHEAS in relation to serum IL-6 or TNF were higher in Co as compared to the cholestatic subgroup without tumours, whereas serum cortisol in relation to these cytokines was similar. In both subgroups of cholestatic patients, we observed the typical inflammation-dependent shift of adrenal hormones into the direction of cortisol in relation to DHEAS. Cholestatic patients with malignant tumours demonstrated an intermediate response pattern. CONCLUSIONS: Short-term cholestasis for 5-12 days induced marked alterations of adrenal steroidogenesis which partly resemble the changes observed in chronic inflammatory diseases.

[Intercostal percutaneous ultrasound guided decompressive gastrostomy (PUG)--a case report]. / Die interkostal angelegte perkutane ultraschallgesteuerte Entlastungsgastrostomie (PUG)--Ein Fallbericht.

Percutaneous gastrostomies (PG) are nowadays usually placed endoscopically (PEG). Due to stenoses in the pharynx or the esophagus or in case of a lack of diaphany, other methods for the placement of PG such as computed tomography (CT-) guided or ultrasound-guided PG (PUG) are performed. We present a case of a 63-year old male patient with a retroperitoneal liposarcoma and multivisceral resection who presented with the symptoms and signs of an ileus due to metastatic occlusion of the small bowel. The placement of a decompression-PEG was impossible due to interposition of colon between the stomach and the abdominal wall. After filling the stomach with water via a naso-gastral decompression tube, the stomach could be visualized at the left thoracic wall, since the spleen and the left kidney had been removed at prior surgery. A transcostal decompression-PUG was inserted. The intervention described is the first published ultrasound guided transcostal decompression gastrostomy and is an example for the growing significance of interventional ultrasound.

Hepatocellular carcinoma in southern Germany: epidemiological and clinicopathological characteristics and risk factors.

UNLABELLED: The aetiology of chronic liver disease leading to hepatocellular carcinoma (HCC) and the clinical characteristics of patients with HCC vary considerably internationally and intranationally. This study analyses the characteristics of HCC patients in southern Germany, a low endemic area of HCC. METHODS: The files of 118 consecutive patients with HCC observed in a single tertiary care hospital between 1994 and 2000 have been reviewed. Epidemiological and clinicopathological characteristics such as age at presentation, ethanol consumption, serological hepatitis virus markers, and fibrosis were studied. Additionally, serum levels of alpha-fetoprotein (AFP) were analysed at the time of diagnosis in 77 patients. RESULTS: The male:female ratio was 4:1 and the mean age at presentation was 61.8 years. Alcohol abuse (49.2%) and chronic hepatitis C infection (17.8%) were the most frequent risk factors. Histologically proven liver cirrhosis in the surrounding non-tumorous tissue was present in only 59.0% of cases. AFP levels were elevated in 78% of cases, but only 34% reached >500 ng/ml, a value considered to be significant for the diagnosis of HCC. AFP levels correlated with the stage of fibrosis. SUMMARY AND CONCLUSIONS: The sensitivity of AFP serum levels as a tumour marker is poor but might help to detect at least a minority of cases. As in other populations within Europe, chronic alcohol abuse is frequently associated with HCC in southern Germany, confirming that alcohol is still the most important risk factor for hepatocarcinogenesis in areas with low hepatitis virus prevalence. Considering the poor prognosis of HCC, prevention is of pivotal importance, particularly for patients with chronic liver disease and other risk factors for the development of HCC.

Physiology and pathology of the oesophagus in the elderly patient.

In the 1960s, the term 'presbyoesophagus' was introduced for what were felt to be the characteristics of the oesophagus in old age. Since then a number of sophisticated studies using modern manometric, radiological, pH-metric or endoscopic equipment have been performed to better study this subject. Although results in some aspects are still contradictory, these studies have provided us with some more detailed information on the physiology of the ageing oesophagus. Beginning with an overview of what is currently known and discussed about age-induced physiological changes in oesophageal function, this review will then focus on specific problems of oesophagus-related diseases in the elderly. The main topics discussed will include presentation, diagnosis and treatment of primary and secondary motility disorders, oesophageal manifestations of neuromuscular and neurological disease, gastro-oesophageal reflux disease and oesophageal cancer in the elderly.

[Liver histology in hepatitis C: correlation with different biochemical and virological parameters]. / Leberhistologie bei Hepatitis C: Korrelation mit verschiedenen biochemischen und virologischen Parametern.

BACKGROUND AND AIM: According to the German consensus statement, the indication for treatment of HCV-RNA-positive chronic hepatitis C is not derived from histopathology but from elevated aminotransferases. The indication for liver biopsy has been discussed controversely. This study aimed at investigating the correlation between different biochemical and virological parameters and histological scores of inflammation and fibrosis in chronic hepatitis C. PATIENTS AND METHODS: In a retrospective study, data of 126 patients with chronic hepatitis C who had undergone liver biopsy between January 1994 and March 1998 were analyzed. Histology was interpreted according to a defined numerical score of inflammation and fibrosis by a single pathologist. Scores of fibrosis and inflammation were correlated with biochemical and virological parameters. RESULTS: Inflammatory grading showed a moderate but significant correlation with ALT (r = 0.33, p < 0.001), whereas staging of fibrosis did not correlate with ALT (r = 0.15). There was no association between grading or staging and HCV genotype (n = 110) or serum viral load (n = 57). Grading and staging showed a significant association with each other (p < 0.0001). CONCLUSION: Aminotransferases as "surrogate markers" reflect more or less the histological inflammatory activity but do not allow any estimation of the extent of fibrosis. Some patients may have a high inflammatory activity with low aminotransferases or high aminotransferases with low inflammatory activity. Virological parameters such as HCV genotype or viral load do not allow an estimation of histological findings. If prior to treatment of chronic hepatitis C liver biopsy is omitted and the decision for treatment depends solely on the measurement of surrogate markers, considerable misjudgement of the actual status of liver inflammation or fibrosis may result.

[The ultrasound centre as a medically and economically relevant alternative--a report of the Regensburg experience]. / Das Ultraschallzentrum als ökonomisch und medizinisch sinnvolle Alternative--ein Erfahrungsbericht über das Regensburger Modell.

In most medical centres, ultrasonography is performed independently by several departments. In october 1997, the University hospital of Regensburg founded an ultrasound centre, integrating surgical and medical departments as well as the institutes for radiology and nuclear medicine. The aims of this centre were the concentration of organization, machines, financial resources, manpower and know-how, standardized training and quality, and strengthening of interdisciplinary cooperation in clinic, medical education and research. Booking, standardized reports and a joint archiving of reports are assisted by a collective computer system. Most examinations in the centre are performed by three all-day present gastroenterology, surgery and radiology residents who are supported by licensed sonographers of the other departments. Training is standardized, and the certification for ultrasound examinations is acquired after a test with theoretical and practical parts. The integration of various departments in the ultra-sound on-call service has led to significant savings. The pool of ultrasound machines is used jointly, department-specific resources for new machines have been put together. We are convinced that this way of a close interdisciplinary cooperation will result in improvements in quality, utilization of financial resources and clinical research.