A pilot study evaluating a new low-volume colon cleansing procedure for capsule colonoscopy.

BACKGROUND AND STUDY AIMS: Colon capsule endoscopy (CCE) offers an alternative approach for endoscopic visualization of the colon. Some of the current CCE bowel cleansing regimens use sodium phosphate, which has raised safety concerns. Therefore, the aim of the current study was to test the feasibility and efficacy of a new low-volume, sodium phosphate-free polyethylene glycol (PEG) bowel preparation. METHODS: The first 26 patients (original cleansing procedure) received a colon cleansing regimen of PEG plus ascorbic acid: patients drank 1 L in the evening and 0.75 L in the morning before capsule ingestion. Patients also drank an additional 0.5 L PEG boost and an optional 0.25 L PEG boost during the capsule procedure. Following an interim analysis, the cleansing procedure of the subsequent 24 patients was modified, with the morning intake before capsule ingestion being increased to 1 L, as well as the second boost (0.25 L) being administered 1 - 2 hours earlier (modified cleansing procedure). RESULTS: The overall colon cleanliness was considered to be good or excellent in 83 % (original cleansing procedure) and 82 % (modified cleansing procedure) of patients, without any significant difference between regimens (P > 0.05). In 37 /49 (76 %) of the CCE procedures, the hemorrhoidal plexus was identified and thus the examination was considered complete, with no significant differences between the two CCE cleansing procedures. The capsule sensitivity and specificity for detecting colonic polyps ≥ 6 mm were 91 % (95 %CI 70 % - 98 %) and 94 % (95 %CI 87 % - 97 %), respectively, compared with standard optical colonoscopy. CONCLUSION: A colon cleansing procedure using PEG + ascorbic acid for capsule colonoscopy yielded an adequate cleansing level in > 80 % of patients, a completion rate of 76 %, and good accuracy for detecting polyps. This procedure may be considered as an alternative, particularly for patients in whom sodium phosphate-based preparations are contraindicated.

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Outcome and clinical course of EHEC O104 infection in hospitalized patients: A prospective single center study.

OBJECTIVES: Shiga-toxin producing O157:H7 Entero Haemorrhagic E. coli [STEC/EHEC] are the most common cause of Haemolytic Uraemic Syndrome [HUS] related to infectious haemorrhagic colitis. Nearly all recommendations on long term treatment of EHEC infections refer to this strain. The 2011 outbreak in Northern Europe was the first of this dimension to be caused by the serotype O104:H4. We report on the 3.5 year follow up of 61 patients diagnosed with symptomatic EHEC O104:H4 infection in spring 2011. METHODS: Patients with EHEC O104 infection were followed in a monocentric, prospective observational study at four time points: 4, 12, 24 and 36 months. These data include the patients' histories, clinical findings, and complications. RESULTS: Sixty-one patients suffering from EHEC O104:H4 associated enterocolitis participated in the study at the time of hospital discharge. The mean age of patients was 43 ± 2 years, 37 females and 24 males. 48 patients participated in follow up 1 [FU 1], 34 patients in follow up 2 [FU 2], 23 patients in follow up 3 [FU 3] and 18 patients in follow up 4 [FU 4]. Out of 61 patients discharged from the hospital and included in the study, 54 [84%] were examined at least at one additional follow up. Serum creatinine decreased significantly between discharge and FU 1 from 1.3 ± 0.1 mg/dl to 0.7 ± 0.1 mg/dl [p = 0.0045]. From FU 1 until FU 4, no further change in creatinine levels could be observed. The patients need of antihypertensive medications decreased significantly [p = 0.0005] between discharge and FU 1 after four months. From FU 1 until FU 3, 24 months later, no further significant change in antihypertensive treatment was observed. CONCLUSIONS: Our findings suggest that patients free of pathological findings at time of discharge do not need a specific follow up. Patients with persistent health problems at hospital discharge should be clinically monitored over four months to evaluate chronic organ damage. Progressive or new emerging renal damage could not be observed over time in any patient.

[The present and future status of "scarless" surgery]. / Das Konzept der narbenlosen Eingriffe ("scarless surgery"). Ein Weg in die Zukunft?

The concept of scarless surgery aims at further minimization of diagnostic and therapeutic interventions. Based on the success of flexible gastroenterological endoscopy and laparoscopic surgery, it combines their advantageous approaches in a synergistic manner. Animal experiments have achieved encouraging results in respect to the feasibility of various types of interventions in the peritoneal and retroperitoneal cavity. Further studies and improvement of instruments will have to prove the practicality and superiority of this concept for medical outcome and efficiency compared to present standards of practice in the potential fields of application. The replacement of certain minimally invasive procedures with scarless intervention techniques seems reasonable, as do new fields of application. After further improvement of the methodology, adequate organization, infrastructure, and teaching structures will have to be developed. If they succeed, the concept of scarless surgery can expect a promising future.

Expression of CD66a (human C-CAM) and other members of the carcinoembryonic antigen gene family of adhesion molecules in human colorectal adenomas.

Among the members of the carcinoembryonic antigen (CEA) family, CD66a (human C-CAM) and CGM2 (CEA gene family member 2) mRNAs are frequently down-regulated in colorectal cancer. In contrast, nonspecific cross-reactive antigen (NCA) mRNA is overexpressed in the majority of these carcinomas. In animal models, the rodent homologues of CD66a have been shown to act as tumor suppressors, suggesting an important role in carcinogenesis. Here we investigate the mRNAs of CD66a, CGM2, and NCA in 22 human colorectal adenomas and the respective normal mucosa specimens by Northern blots. The expression of both CD66a and CGM2 changed in a concomitant fashion. Using oligonucleotides specific for the N-terminal domains, two CD66a transcripts 3.9 and 1.5 kb in size were identified. These showed a greater than 50% down-regulation in 20 of 22 and 18 of 22 adenomas, respectively. Reduction of the CGM2 message was observed in 21 of 22 cases. Complete or near-complete losses of the CD66a 3.9-kb mRNA and the CGM2 message were found in 13 of 22 and 15 of 22 of the tumors, respectively. The medians of CD66a and CGM2 expressions were between 0.3 and 0.0, respectively. The tumor:normal ratio of NCA mRNA expression was increased up to 2.4-fold in 11 of 22 adenomas. Altogether, these results compare well to the changes reported previously for colorectal carcinomas. The high frequency and early appearance of dysregulation of members of the carcinoembryonic antigen family during colorectal tumorigenesis suggests that these changes may be important for the development of the malignant phenotype.

Mismatch negativity: Alterations in adults from the general population who report subclinical psychotic symptoms.

BACKGROUND: Deficits of mismatch negativity (MMN) in schizophrenia and individuals at risk for psychosis have been replicated many times. Several studies have also demonstrated the occurrence of subclinical psychotic symptoms within the general population. However, none has yet investigated MMN in individuals from the general population who report subclinical psychotic symptoms. METHODS: The MMN to duration-, frequency-, and intensity deviants was recorded in 217 nonclinical individuals classified into a control group (n=72) and three subclinical groups: paranoid (n=44), psychotic (n=51), and mixed paranoid-psychotic (n=50). Amplitudes of MMN at frontocentral electrodes were referenced to average. Based on a three-source model of MMN generation, we conducted an MMN source analysis and compared the amplitudes of surface electrodes and sources among groups. RESULTS: We found no significant differences in MMN amplitudes of surface electrodes. However, significant differences in MMN generation among the four groups were revealed at the frontal source for duration-deviant stimuli (P=0.01). We also detected a trend-level difference (P=0.05) in MMN activity among those groups for frequency deviants at the frontal source. CONCLUSIONS: Individuals from the general population who report psychotic symptoms are a heterogeneous group. However, alterations exist in their frontal MMN activity. This increased activity might be an indicator of more sensitive perception regarding changes in the environment for individuals with subclinical psychotic symptoms.

[Palliative options for esophageal carcinoma]. / Palliative Therapiemöglichkeiten beim Osophaguskarzinom.

Considering the limited chances of radically curing esophageal carcinoma, most of these patients are candidates for palliative therapy. Priority should be given to rapid relief of dysphagia. Endoscopic implantation of esophageal prostheses is immediately effective in 90% of patients, whereas the onset of relief is slower with any alternative method. Long-term complications necessitate an endoscopic reintervention in 30% of the prosthesis carriers. Endoscopic prosthesis implantation is also the first-choice treatment for esophagotracheal fistulae. Self-expanding stents need only minimized preceding bougienage, which has lower complication rates than conventional plastic prostheses. Endoscopic laser radiation is better tolerated by patients than prosthesis implantation but is effective only in very short stenoses. Endoluminal brachytherapy with (192)iridium can be justified in patients with a survival expectancy of more than 6 months, the onset of its effect being slower but longer lasting. Palliative chemotherapy and radiochemotherapy are indicated when metastatic dissemination dominates the symptoms.

Brain correlates of verbal fluency in subthreshold psychosis assessed by functional near-infrared spectroscopy.

The prevalence of subthreshold psychotic symptoms in the general population has gained increasing interest as a possible precursor of psychotic disorders. The goal of the present study was to evaluate whether neurobiological features of subthreshold psychotic symptoms can be detected using verbal fluency tasks and functional near-infrared spectroscopy (fNIRS). A large data set was obtained from the Zurich Program for Sustainable Development of Mental Health Services (ZInEP). Based on the SCL-90-R subscales 'Paranoid Ideation' and 'Psychoticism' a total sample of 188 subjects was assigned to four groups with different levels of subthreshold psychotic symptoms. All subjects completed a phonemic and semantic verbal fluency task while fNIRS was recorded over the prefrontal and temporal cortices. Results revealed larger hemodynamic (oxy-hemoglobin) responses to the phonemic and semantic conditions compared to the control condition over prefrontal and temporal cortices. Subjects with high subthreshold psychotic symptoms exhibited significantly reduced hemodynamic responses in both conditions compared to the control group. Further, connectivity between prefrontal and temporal cortices revealed significantly weaker patterns in subjects with high subthreshold psychotic symptoms compared to the control group, possibly indicating less incisive network connections associated with subthreshold psychotic symptoms. The present findings provide evidence that subthreshold forms of psychotic symptoms are associated with reduced hemodynamic responses and connectivity in prefrontal and temporal cortices during verbal fluency that can be identified using fNIRS.

A Simple Evaluation Tool (ET-CET) Indicates Increase of Diagnostic Skills From Small Bowel Capsule Endoscopy Training Courses: A Prospective Observational European Multicenter Study.

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

Effect of roxatidine acetate on daytime and night-time peptone-stimulated gastric acid secretion.

A double-blind, randomised, crossover study in 12 healthy volunteers was performed to assess the effects of roxatidine acetate 75 mg or placebo administered at 8 am and 9 pm on peptone-stimulated hydrochloric acid secretion. In comparison to placebo, roxatidine acetate produced an average reduction of daytime hydrochloric acid output of 86% and 32%, respectively, for the 4- to 6-hour and 10- to 12-hour post-drug administration phases. In addition, roxatidine acetate produced reductions in nocturnal hydrochloric acid output of 75 to 92% with an associated rise in intragastric pH of around 2 units compared to placebo. No side effects or clinically significant alterations in haematological or biochemical values were reported following roxatidine acetate administration. These results suggest that roxatidine acetate is a potent and effective inhibitor of day and night-time intragastric acid secretion.

Public awareness of risk factors and screening for colorectal cancer in Europe.

Colorectal cancer (CRC) is the commonest site for malignancy in Europe. The Commissioner for Health wishes to promote screening for colorectal, breast and cervical cancer in Europe. The aim of this study was to assess public knowledge of CRC in Europe and likely take up of free screening. To this end 20710 members of the public from 21 European countries were interviewed by means of a regular survey amongst consumers (Omnibus survey) using 13 stem questions. Forty-eight per cent thought the population were at equal risk of CRC, only 57% were aware of age and 54% of family history as risk factors. Although 70% were aware of dietary factors, only 30% knew that lack of exercise might be a risk factor. Only 51% had knowledge of CRC screening but 75% were 'very', or 'quite interested, in taking up faecal occult blood (FOB) screening if offered free. Barriers to screening were lack of awareness of risk (31%), youth (22%) and an un-anaesthetic test (19%). There was a big cultural difference in willingness of the public to discuss bowel symptoms: there was a major barrier in Finland (91%), Britain (84%), Luxembourg (82%), Poland (81%) and Portugal (80%); less of a barrier in Spain (49%), Italy (44%) and Iceland (39%). In conclusion, the challenge of achieving high compliance for CRC screening must be a major objective amongst EU member states and non-aligned countries of Europe in the next decade, because it is known that the non-compliant group are those at greatest risk of death from CRC. This study has shown that awareness of CRC is low in Europe and that an educational programme will be essential to achieve high compliance for CRC screening as a means of reducing deaths from bowel cancer.

The minimal standard terminology for digestive endoscopy: introduction to structured reporting.

The wider use of computers for the management of endoscopic data and the use of electronic endoscopes for the production of high quality endoscopic images has made the standardization of terminology and images formats necessary in digestive endoscopy reports. The European Society for Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy have combined their efforts to propose a Minimal Standard Terminology for Computerized Databases in Endoscopy. This terminology is based on the following principles: no term describing findings less frequent than 1%, of the daily practice, and no term based on subjective impressions. The Minimal Standard Terminology has been developed according to the natural process of constructing an endoscopic report in natural language and deals with the following: reasons for performing the examination, endoscopic findings, endoscopic diagnosis, additional therapeutic and diagnosis procedures (biopsies, etc.). It is subdivided according to the main organs examined with an endoscopy. Until now, the Minimal Standard Terminology was tested in many centers and was shown to accurately cover 95% of routine examinations for the upper gastrointestinal tract, colonoscopy and cholangio-pancreatography. It is currently being tested in an a prospective way in several centers in Europe (with a grant from the European Commission DGXIII-C4) and in the USA (with grant from the AHDHF).

[Acute pancreatitis. Early elective endoscopic intervention]. / Akute Pankreatitis. Die früh-elektive endoskopische Intervention.

Early endoscopic intervention is required in the treatment of biliary pancreatitis in the presence of cholangitis or jaundice, possibly with dilated common bile duct. Also patients with predicted severe disease, lack of spontaneous clinical improvement or progressive jaundice might benefit from endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. If endoscopy is indicated, it should be performed as soon as possible. Injection of contrast medium into a dilated bile duct is accompanied by the risk of cholangitis. Therefore therapeutic decompression by sphincterotomy and stone extraction is necessary, or, if this is not possible, insertion of a naso-biliary tube for drainage. Prophylactic use of antibiotics is recommended periinterventionally. Early endoscopic intervention is not necessary in patients with mild biliary pancreatitis and spontaneous clinical improvement. Here, ERCP can be performed later, if indicated.

[Nasobiliary tube in management of postoperative bile fistulas]. / Die nasobiliäre Sonde in Management postoperative Gallefisteln.

A postoperative bile fistula is a rare but severe complication after biliary surgery. Clinical signs, laboratory findings, ultrasound and ERC lead to diagnosis. We report on 40 cases with postoperative bile leakage after cholecystectomy treated by a nasobiliary tube. In all patients the fistula healed within 7 days after placement of the tube. Two patients needed operative treatment of a subhepatic abscess, and in 2 patients drainage of a bilioma was performed. In 2 cases with biliary peritonitis, a step-by-step lavage was necessary. The nasobiliary tube for postoperative bile fistula offers regular radiological control and reduces the necessity of operative reintervention in the biliary tract.

Endoscopic biliary drainage.

Endoscopic drainage of the occluded biliary system through the papilla Vateri consists of two different methods, i.e. bilio- nasal and bilio-duodenal drainage. For bilio-nasal drainage a 250-cm- long preformed polyethylene tube is placed above the stenosis to provide the flow out of the congested bile duct. This external drainage is indicated to prevent the blockade of a ductal stone after endoscopic papillotomy (EPT), to treat septic cholangitis, and to dissolve big ductal stones chemically. Insertion of a bilio-nasal probe succeeds in 95% of hte cases. Internal bilio-duodenal drainage is more difficult and succeeds in 87%, its main indication is the inoperable malignant bile duct obstruction. The value of a preoperative biliary drainage is in discussion. Internal bilio-duodenal drainage will perhaps not prolong the survival time of patients with malignant biliary obstruction but it will improve the life quality in the majority of the patients. The decrease of serum bilirubin after the implantation of the prosthesis and the localization of the tumor are of prognostic significance.

Diagnostic efficacy of endoscopic ultrasound tomography in pancreatic cancer and cholestasis.

By direct access to the target organs and by improved detail resolution, endoscopic ultrasound tomography (EUT) broadens the range of sonographic diagnostics. In this preliminary study, the accuracy of EUT was tested in 34 patients with suspected pancreatic carcinoma and/or painfree jaundice. In all 10 patients with pancreatic carcinoma and in all 6 patients with chronic pancreatitis, the diagnosis made by EUT was correct. Three patients with benign tumors of the pancreas were also diagnosed correctly. The diagnostic sensitivity of EUT in pancreatic cysts was in 4 of 5 cases 80%, in dilatations of the main pancreatic duct in 10 of 11 cases 91%, and in cholestasis in 14 of 15 cases 93%. All 5 common bile duct concrements and all 3 tumors of the papilla Vateri were diagnosed by EUT. The differential diagnosis between pancreatic tumor and pancreatitis was improved by EUT in 1 of 18 cases. In the region of the papilla Vateri, EUT was superior to conventional UT in the diagnosis of ampullary concrements and papillary tumors in 6 of 8 cases (4/5 and 2/3, respectively). EUT could become an important complementary diagnostic method for disorders of the pancreas and the common bile duct with a particular sensitivity for the region of the papilla Vateri.

Computer-aided formulation of physician's reports and storage of ERCP data.

In the 2nd Medical Dept. of the Technical University of Munich, endoscopic retrograde cholangiopancreatography (ERCP) reports are written with the aid of a computer. The doctor doing the examination enters the ERCP data into screen masks. The data are stored at once in a data bank. This data bank system permits immediate error checks of the variables entered, singly and in combination. Errors can be corrected in a loop. Generating of ERCP reports is controlled by a text file, which contains both control statements and standard phrases. A special program for the document generating was developed by the authors and has been used for 15 years in various applications.

Effect of sucralfate on peptic ulcer recurrence: a controlled double-blind multicenter study.

We entered 174 patients with healed duodenal ulcer and 77 with healed gastric ulcer into a double-blind, placebo-controlled, 6-month trial to investigate the efficacy of 1 g sucralfate twice daily in preventing ulcer recurrence. Endoscopy was performed after 6 months or earlier for symptoms compatible with ulcer disease. The relapse rate in the 126 patients with duodenal ulcer who could be evaluated for efficacy was 14/66 (21.2%) under sucralfate and 30/60 (50%) under placebo treatment (p less than 0.01). No significant difference in relapse rate was found in the 55 gastric ulcer patients who could be evaluated; 11 of 30 (37%) relapsed on sucralfate and 11 of 25 (44%) relapsed on placebo. Among the duodenal ulcer patients in the placebo group, those who had been treated initially with H2-receptor blockers for acute ulcer had significantly more relapses than patients who had been treated with other drugs. The recurrence rate was independent of prior treatment in the sucralfate group. Duodenal ulcer patients with a history of multiple episodes of active ulcer disease had a significantly higher rate of relapse than patients with only a few previous episodes. Both treatments were well tolerated. Two patients in each treatment group complained of nausea and epigastric pain immediately after drug intake. No other drug-related symptoms were observed. We conclude that sucralfate is effective in the prophylaxis of duodenal ulcer. No significant effect was found in the prevention of gastric ulcer recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

[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.