Comorbidity in acute pancreatitis relates to organ failure but not to local complications.

OBJECTIVE: Organ failure and local complications contribute to morbidity and mortality in acute pancreatitis. Comorbidity is known to be related to organ failure. The impact of comorbidity on local complications has not yet been delineated. Moreover, it is not clear if the outcome of first-attacks and acute-on-chronic episodes, respectively, differs from outcome in all episodes. METHODS: Consecutive cases of confirmed acute pancreatitis in a four-year period were reviewed. Charlson comorbidity index (CCI), complications (organ failure and local complications), disease severity (according to the revised Atlanta Classification), need for intensive care, and mortality were derived from the charts. RESULTS: A total of 391 episodes of acute pancreatitis were included. Patients with organ failure were significantly older (P< 0.001) und had a higher CCI (P< 0.001) than patients without organ failure. Patients with and without local complications did not significantly differ in age or CCI. The complication rate of the entire cohort (n = 391; 47.1 %) was comparable with the complication rate of first-attacks (n = 269; 46.8 %) and acute-on-chronic episodes (n = 68; 47.1 %). The majority of the twelve deceased patients had been old and/or chronically ill. Six of these patients had an advanced malignant disease. CONCLUSIONS: Comorbidity and age clearly are contributors to organ failure and mortality. Local complications occur independently of age and concomitant diseases. The overall complication rate is not significantly influenced by preceding inflammation of the pancreas. To further improve care in patients with acute pancreatitis special attention should be given to old and multi-morbid patients.

Ischemic colitis following uncomplicated colonoscopy.

BACKGROUND/OBJECTIVE: Ischemic colitis is a disorder of the intestine arising from a multitude of reasons thus representing a challenge for causal research. Our aim was to shed further light on the course, etiology and triggers of non-occlusive ischemic colitis by presenting an atypical complication after colonoscopy. DESIGN: We present the case report of a 77-year-old male patient presenting with ischemic colitis after an uneventful outpatient colonoscopy two days prior to onset of symptoms. RESULTS: So far only few cases of post-colonoscopy ischemic colitis have been reported. In the present case no single reason was identified. It remains to be assumed that a combination of predisposing conditions with a modest decrease of blood pressure and short-term increased intraluminal pressure during colonoscopy may have led to ischemic colitis. CONCLUSION: Awareness of ischemic colitis as a complication in comparable settings is favorable. So far, early countermeasures against even modest hypotension in patients with comparable past history may be considered on an individual basis depending on the entirety of risk factors. However, prospective studies are necessary to evaluate potential risk profiles for ischemic colitis in terms of colonoscopy.

Long-term Outcomes in Steroid-refractory Ulcerative Colitis Treated with Tacrolimus Alone or in Combination with Purine Analogues.

BACKGROUND AND AIMS: Tacrolimus is recommended for the treatment of steroid-refractory ulcerative colitis (UC). Concomitantly started purine analogues (PAs) are used for the maintenance of remission, though their therapeutic relevance remains uncertain. Here we studied the role of PAs in the long-term outcome of steroid-refractory UC after tacrolimus treatment. METHODS: In five centres, charts of tacrolimus-treated UC patients with a steroid-refractory moderate to severe course were reviewed. Long-term efficacy was determined by colectomy rates and clinical remission in cases of colectomy-free survival for 3 months. RESULTS: We identified 156 patients (median age 34 years) with a median Lichtiger score of 12 (4-17) and pancolitis (E3) in 65% (101). The Kaplan-Meier curve for colectomy-free survival after month 3 showed a benefit in the PA group (p = 0.02). In patients treated with PA clinical remission was achieved in 82% (65/79) vs 67% (39/58) in those not treated with PA (p = 0.02). Time to colectomy was 2 years (median, 0.7-5.8) in the PA group and 0.8 years (0.3-4.7) in the group not treated with PAs (p = 0.02). Time to relapse was 1.2 years (median, 0.3-6.2) in patients with PA treatment and 0.5 years (0.3-3.9) in those without PA treatment (p = 0.05). Overall, clinical remission was achieved in 67% (104/156) of patients. Colectomy was performed in 29% (45/156) 0.5 years (median, 0.04-5.79) after initiation of tacrolimus. Ten (6%) patients had to stop tacrolimus due to adverse events and two (without PA treatment) died. CONCLUSIONS: Our study supports the efficacy of tacrolimus in steroid-refractory UC. Purine analogues appear to be beneficial for the long-term outcome of these patients.

Short-term efficacy of tacrolimus in steroid-refractory ulcerative colitis - experience in 130 patients.

BACKGROUND: Steroid-refractory ulcerative colitis (UC) remains a challenging condition warranting surgery upon failure of pharmacological treatment. Calcineurin inhibitors or infliximab are alternatives in this situation. Data on the efficacy and safety of tacrolimus in this setting are limited. AIM: To study the short-term efficacy and safety of tacrolimus in moderate-to-severe steroid-refractory UC. The role of thiopurines in this situation and predictors of colectomy were evaluated. METHODS: In three centers, all charts from tacrolimus-treated patients with steroid-refractory UC were reviewed. Efficacy was assessed by colectomy-free survival and clinical remission at 3 months. RESULTS: We identified 130 patients with pancolitis in 75 (59%), left-sided disease in 35 (27%) and proctitis in 18 patients (14%) (disease localisation not obtainable in two patients). The median age was 40 (range: 18-81). Clinical activity according to the median Lichtiger score decreased from 13 (range: 4-17) at baseline to 3 (0-14) at week 12. Eighteen patients underwent colectomy within the first 3 months of treatment with tacrolimus (14%). Clinical remission was achieved in 94 patients (72%) in this period. Thiopurines given in parallel to tacrolimus tended to limit colectomy and significantly increased remission (P = 0.002) in the short-term. No other predictors of colectomy or remission were identified. Side effects were noticed in 53% of patients and no severe events occurred. CONCLUSION: This large survey confirms the efficacy and safety of tacrolimus in patients with steroid-refractory ulcerative colitis.

[CEUS as a tool to uncover an unusual cause of obstructive jaundice]. / KM-verstärkter Ultraschall zur Erkennung der seltenen Ursache eines obstruktiven Ikterus.

Aneurysms within the visceral arteries are rare. Among these, aneurysms of the splenic artery occur most frequently followed by aneurysms of the hepatic arteries. An early diagnosis is easily missed and almost all patients become symptomatic with an acute rupture associated with high mortality. Here we demonstrate the case of a 76-year-old patient who presented with acute upper abdominal pain accompanied by a single episode of vomiting and pyrexia of 39 °C. Laboratory results presented the picture of an obstructive jaundice without evidence for accompanying pancreatitis. Inflammatory markers were within normal limits at onset, but increased dramatically within the next few days. An acute calculous cholecystitis was diagnosed on abdominal ultrasound whereas gastroscopy revealed no relevant changes. Computed tomography was suspicious for pancreatitis of the head with obstruction of the bile duct. Choledocholithiasis was ruled out by ERCP, but symptoms persisted despite papillotomy. Due to raising inflammatory markers and an ongoing impairment of the patients condition, an abdominal CT scan was repeated which revealed the suspicion of a ruptured aneurysm of the common hepatic artery. At the time of transferral we were able to confirm the diagnosis by contrast-enhanced ultrasound and angiography. The patient was immediately forwarded to surgery due to lack of satisfactory endovascular procedures. In summary, the patient suffered from a ruptured spurial aneurysm of the right gastric artery thereby obstructing the common bile duct. Beside CT scans and angiography, this case documents a pivotal role for contrast-enhanced ultrasound in the work-up of visceral artery aneurysms.

Clinical trial: cyclophosphamide pulse therapy - a promising therapeutic alternative in refractory Crohn's disease.

BACKGROUND: In severe steroid-refractory Crohn's disease (CD), established therapies fail in a relevant proportion of patients. Recent pilot studies indicated the efficacy of cyclophosphamide pulse therapy in these patients. AIM: To provide further and substantial evidence for the rationale to apply cyclophosphamide pulse therapy as therapeutic option in severe courses of CD. METHODS: Fifteen patients with steroid-refractory (n = 13) or steroid-dependent (n = 2) CD received 2-6 (median 3) monthly pulses of 750 mg cyclophosphamide in an open-label fashion. Eleven patients were on concomitant immunosuppression (azathioprine/mercaptopurine n = 9; methotrexate n = 2). RESULTS: Thirteen of 15 patients (87%) had a clinical response (CDAI decrease >100). Ten patients (67%) went into remission (CDAI <150) after 8 weeks. Steroid-free remission was achieved in eight patients (54%). Two patients (13%) failed to respond. Median CDAI decreased from 420 (245-550) to 100 (26-538) at week 8. Remission lasted 16 months (median, range 4-40). In three patients, arthritis, erythema nodosum and episcleritis completely resolved. Cyclophosphamide pulse therapy administration was well tolerated in all subjects. CONCLUSIONS: Cyclophosphamide pulse therapy is safe and highly effective for induction and maintenance of remission in steroid-refractory/-dependent CD. There is a strong need for additional experience to improve the setting of the encouraging cyclophosphamide treatment in CD.

Comparison of nickel-titanium and stainless-steel spreader penetration and accessory cone fit in curved canals.

The purpose of this study was to compare nickel-titanium and stainless-steel spreader penetration in curved canals. Twenty prepared plastic blocks with a 30 degrees curvature were used for each part of the study. In part 1, the force required to insert each spreader to within 1 mm of working length in an empty canal was measured. In part 2, the force required to insert each spreader to within 3 mm of working length was measured in a canal containing a master cone. In part 3, the depth of penetration of each spreader with a master cone in place using a 1.5 kg force was measured. Additionally, in part 3, the depth of penetration of the first accessory cone was measured. The results from part 1 showed that a nickel-titanium spreader required significantly less force than a stainless-steel spreader (0.30 kg vs. 0.59 kg). In part 2, a nickel-titanium spreader required significantly less force than a stainless-steel spreader (1.56 kg vs. 2.42 kg). In part 3, a nickel-titanium spreader penetrated significantly deeper than a stainless-steel spreader (15.0 mm vs. 14.0 mm). There was no significant difference in the depth of penetration of the first accessory cone used after either spreader (0.8 mm vs. 0.7 mm). Therefore, the potential for vertical root fracture in curved canals during lateral condensation may be minimized by using nickel-titanium spreaders.

[Development of treatment guidelines and procedure guidelines within the scope of developing case fees and a modular quality management system (MQM)]. / Die Entwicklung von Behandlungsleitfäden und Verfahrensrichtlinien im Rahmen der Erarbeitung von Fallpauschalen und eines Modularen Qualitätsmanagement-Systems (MQM).

Since 1991 Diagnostic Related Groups (DRGs) are systematically developed for standardized operation procedures. They are included in a Quality Management System of the DIN EN ISO 9001 ff. norm and are part of the process system. In additional the internal and external evaluation of quality completes a Modular Quality Management System (MQM). These procedures meet the requirements for a Total Quality Management (TQM).

[Mechanical and functional complications in endemic struma (author's transl)]. / Mechanische und funktionelle Komplikationen bei der endemischen Struma

Of 1294 patients examined with struma of magnitude I to III, complications in the form of mechanical effects on the neighboring organs, disturbances of thyroid function and pathological anatomical changes in the struma were demonstrated in 1051 cases. The appearance of high-seated esophageal varices is described in 33 patients with primary struma of magnitude II and III. 72 patients had congenital or postnatal hypothyroidism, and 164 patients a subclinical one. The carcinoma ratio (2.9%) was in the lower range of the normal for the endemic areas. Because of the high complication rate, every struma should be clarified diagnostically and specifically treated.