Endoscopic Improvement of the Adenoma Detection Rate during Colonoscopy - Where Do We Stand in 2015?

BACKGROUND: The presence of colorectal adenomas is considered a major risk factor for colorectal cancer development. The implementation of screening colonoscopy programs in the Western world has led to a substantial reduction of colorectal cancer death. Many efforts have been made to reduce the adenoma miss rates by the application of new endoscopic devices and techniques for better adenoma visualization. SUMMARY: This special review gives the readership an overview of current endoscopic innovations that can aid in the increase of the adenoma detection rate (ADR) during colonoscopy. These innovations include the use of devices like EndoCuff® and EndoRings® as well as new technical equipment like third-eye endoscope® and full-spectrum endoscopy (FUSE®). KEY MESSAGE: Technical improvements and newly developed accessories are able to improve the ADR. However, additional costs and a willingness to invest into potentially expensive equipment might be necessary. Investigator-dependent skills remain the backbone in the ADR detection.

Novel endocuff-assisted colonoscopy significantly increases the polyp detection rate: a randomized controlled trial.

GOALS AND BACKGROUND: Screening colonoscopy for colorectal cancer has proven to reduce mortality rates. Recently the Endocuff (EC), an attachment to the distal tip of the colonoscope, was introduced. The aim of our study was to compare EC-assisted colonoscopies with standard colonoscopies for the detection of colonic polyps. STUDY: This study is a randomized prospective 2-center trial. The study was conducted at 2 tertiary care centers. PARTICIPANTS: A total of 498 patients [249 males; median age 67 y; interquartile range (IQR), 56-75 y] for colon adenoma screening purposes were included. All patients underwent standard colonoscopy with or without the use of EC. Overall polyp detection rate, the number of colonic polyps, and the polyp distribution in the colon were measured. Difference in recognition of polyps with or without the use of EC was assessed. Statistical analysis was applied. RESULTS: In the EC group, the number of polyps detected per patient was 63% higher [2.00 (IQR, 1.00-4.00) vs. 1.00 (IQR, 1.00-2.25), P<0.0001]. The polyp detection rate in patients increased by 14% with the use of EC (56% vs. 42%, P=0.001). For polyp detection, superiority by use of EC could be observed in the sigmoid (P=0.001) and cecum (P=0.002) for polyps <1 cm in diameter. In the EC group, the number of adenomas detected per patient significantly increased by 86% (P=0.002). No major complications occurred in both groups. CONCLUSIONS: The use of the EC is feasible and safe with significantly higher polyp detection rates, especially for those located in the sigmoid region. The cuff system has the potential to improve the accuracy of screening colonoscopies.

CO2 insufflation during single-balloon enteroscopy: a multicenter randomized controlled trial.

BACKGROUND AND STUDY AIMS: Carbon dioxide (CO2) insufflation has previously been shown to have advantages over air insufflation in terms of procedure-related pain and oral insertion depth during double-balloon enteroscopy. The aim of this prospective study was to evaluate the performance of CO2 vs. air insufflation during single-balloon enteroscopy. PATIENTS AND METHODS: This study was a randomized European multicenter trial (ClinicalTrials.gov: NCT01524055). Patients and endoscopists were blinded to the type of insufflation gas used. Patient discomfort during and after the procedure was scored using a visual analog scale. RESULTS: A total of 107 patients were enrolled in the study (52 in the CO2 group and 55 in the air group). Patient characteristics were comparable in both groups. The mean (±SD) oral intubation depth was not significantly deeper in the CO2 group vs. the air group (254±80 vs. 238±55 cm; P=0.726). However, in patients with previous abdominal surgery, oral intubation depth was significantly higher in the CO2 group compared with the air group (258±84 vs. 192±42 cm; P<0.05). In patients undergoing SBE via the anal approach, CO2 showed no significant difference in intubation depth compared with air insufflation (86±67 vs. 110±68 cm; P=0.155). The diagnostic yield was comparable (CO2 67%; air 73%). Procedure times, dosage of sedation, and therapeutic interventions did not differ between the two groups. Patients in the CO2 group reported less pain than those in the air group. CONCLUSIONS: This study demonstrated an advantage of using CO2 insufflation during single-balloon enteroscopy in patients with a history of previous abdominal surgery. Overall, single-balloon enteroscopy was a well-tolerated procedure that may benefit from the use of CO2 insufflation to reduce post-procedural pain.

Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 - 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography in patients with surgically altered anatomy: higher failure rate in malignant biliary obstruction - a prospective single center cohort analysis.

INTRODUCTION: The performance of endoscopic retrograde cholangiopancreaticography (ERCP) in patients with post-surgically altered anatomy is technically ambitious. Our study aimed at comparing a cohort of patients having successfully undergone single-balloon enteroscopy (SBE)-assisted ERCP to those in whom SBE-ERCP failed. METHODS: This trial is a prospective single center cohort study. Participants included 30 patients (median age 69.5 years, range 20-86 years) with previous pancreaticobiliary surgery. First, a conventional ERCP approach was attempted in all patients. Additionally, those patients in whom prior conventional ERCP had failed underwent SBE-ERCP (n = 26). Patients' baseline characteristics were retrieved and patient cohorts with and without successful SBE-ERCPs were compared and analyzed. Statistical analysis was applied. Univariate analysis was performed to detect possible risk factors of SBE-ERCP failure. RESULTS: The overall success rate of SBE-ERCP, including two patients with percutaneous transhepatic cholangiography- assisted rendezvous technique was 65.4% (17/26). Patients with malignant obstructive cholestasis had a significantly higher failure rate compared to those with benign strictures (84.2% vs. 14.2%, p < 0.001). DISCUSSION: SBE-ERCP is a promising tool for diagnostic and therapeutic procedures in the pancreaticobiliary system of selected, previously operated patients with failure of conventional ERCP. However, higher failure rates in malignant biliary obstruction should be taken into account.

Clearance of refractory bile duct stones with Extracorporeal Shockwave Lithotripsy: higher failure rate in obese patients.

OBJECTIVE: Bile duct stones that cannot be removed endoscopically are still a challenge in interventional gastroenterology. Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option if other endoscopic means are not successful. Our study aimed to investigate the efficacy and safety of ESWL for clearance of refractory bile duct stones. MATERIAL AND METHODS: A total of 73 consecutive patients treated for refractory choledocholithiasis with ESWL were retrospectively analyzed. Success and complication rates were calculated. RESULTS: Complete stone clearance was achieved in 66 cases (90%). Patients with complete clearance had a significantly lower body mass index or BMI (25.55 ± 5.01 kg/m² vs. 31.60 ± 6.26 kg/m², p = 0.035) and needed less ESWL treatments (3.61 ± 1.87 vs. 5.00 ± 1.63, p = 0.048). A relevant drop of hemoglobin occurred significantly more often in the group with partial clearance (43% vs. 6%, p = 0.005). CONCLUSIONS: ESWL proves to be an excellent clearing approach to refractory bile duct stones with high success rates. However, obesity is one risk factor for ESWL failure and higher procedural hazard.

Miniprobe endoscopic ultrasound accurately stages esophageal cancer and guides therapeutic decisions in the era of neoadjuvant therapy: results of a multicenter cohort analysis.

BACKGROUND: Despite recent advances in imaging techniques, adequate classification of esophageal lesions is still challenging. Accurate staging of tumors of the esophagus is a precondition for targeted therapy. In this retrospective, multicenter study, we report the role of high-frequency endoscopic ultrasound (EUS) catheter probes in pretherapeutic staging of esophageal neoplasms and thus guiding treatment decisions. METHODS: A total of 143 patients (mean age of 63.8 ± 10.7 years) with esophageal carcinoma were recruited from five German centers (Münster, Oldenburg, Hannover, Wiesbaden, and Lüneburg). Tumor type was adenocarcinoma in 112 (78 %) cases and squamous cell carcinoma in 31 (22 %). Tumor localization was as follows: proximal 3, mid esophagus 7, and distal third 133. Histological correlation either through EMR or surgery was available. In all patients, pretherapeutic uT and uN classifications were compared to pT/pN classification obtained from surgically (esophagectomy, n = 93) or endoscopically (EMR, n = 50) resected tissue. RESULTS: Overall, accuracy of uT classification was 60 % and of uN classification was 74 %. Sensitivity, specificity, and accuracy rates for local tumor extension were as follows (%): T1: 68/97/83; T2: 39/84/75; T3: 72/81/79; T4: 13/97/93; T1/2: 73/81/75; T3/4: 78/82/81. Relating to positive lymph node detection, sensitivity and specificity were 76 and 71 %, respectively. CONCLUSIONS: Miniprobe EUS is an established method for the staging of esophageal tumors. Our large multicenter cohort shows a solid accuracy of miniprobe EUS with respect to differentiating locally advanced from limited cancer and assisting to determine the treatment regimen in the era of neoadjuvant therapy; consequently, 78 % of patients would have been assigned to the adequate therapeutic regimen, whereas 11 % of patients would have been overtreated and 11 % undertreated.

Endoscopic transpapillary biopsies are of limited value in the diagnostics of bile duct strictures of unknown etiology-results of a histopathologically controlled study in 312 patients.

BACKGROUND/AIMS: Our investigation aimed to evaluate the impact of endoscopic transpapillary forceps biopsies (ETP) in bile duct strictures of unknown etiology based on the largest European patient cohort at a tertiary referral center. To date only studies with limited patient numbers exist. METHODOLOGY: Three-hundred-and-twelve patients (162 males, 150 females, mean age 62±12.7 years) with bile duct strictures of unknown etiology were examined with ETP. Sensitivity, specificity and accuracy of ETP were compared to the definite diagnosis proved by histopathology of surgical resection specimens or long-term follow-up of those patients not undergoing surgery. RESULTS: Using ETP a correct pe-interventional diagnosis was achieved in 211 out of 312 patients resulting in an accuracy rate of 67.6%. Eighty-six out of 187 malignant stenoses were correctly diagnosed by ETP, giving rise to sensitivity and specificity rates of 46 and 100%, respectively. Sensitivity of ETP in cholangiocellular carcinoma was significantly superior to that in pancreatic carcinoma (52.5% vs. 35.6%, p = 0.026). Sensitivity and accuracy rates of ETP did not depend on the localization of the stenosis in the common bile duct. CONCLUSIONS: ETP alone is not reliable enough in diagnosing bile duct malignancies as shown by low sensitivity and accuracy rates (false-negative rate of 32%).

Feasibility of snare papillectomy in ampulla of Vater tumors: meta-analysis and study results from a tertiary referral center.

BACKGROUND/AIMS: Ampulla of Vater tumors represent a rare tumor entity and bear a malignant potential. This study at our tertiary referral center aimed at evaluating the feasibility of endoscopic snare papillectomy and long-term endoscopic surveillance in comparison to results of a meta-analysis of comparative trials. METHODOLOGY: Retrospective study in comparison to results of a meta-analysis. Twenty-one patients (mean age 60.2±12.8 years) with ampullary adenoma were included. All patients had undergone ERCP with endoscopic forceps biopsies prior to endoscopic snare papillectomy. Statistical analysis was applied including descriptive analysis of symptoms, therapy and complications. RESULTS: ESP was technically successful in all 21 patients. Histopathology showed 18 adenomas and 3 focal adenocarcinomas which were referred to surgery for modified Whipple's procedure. Follow-up was available in all patients with a mean follow-up of 64 months. Adenoma recurrence occurred in three patients with a mean recurrence time of 25 months (range, 4-66 months). One patient had residual adenoma growth. CONCLUSIONS: In the majority of cases ampullary adenomas can be treated endoscopically. Forceps biopsies alone are not reliable enough in detecting malignancy. All patients with ampullary tumor should therefore undergo ESP. Due to the recurrence rate of 16% patients should have close follow-up.

Single-step versus multi-step transmural drainage of pancreatic pseudocysts: the use of cystostome is effective and timesaving.

BACKGROUND AND AIMS: Pancreatic pseudocysts are a major complication of chronic and acute pancreatitis and often require endoscopic intervention. Endoscopic single-step and multi-step transmural drainage techniques have been reported in the literature. The aim of this study was to evaluate and compare technical results and clinical outcome rates of the single-step versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts of >4 cm size. DESIGN: Retrospective study at an academic tertiary referral center. PATIENTS AND METHODS: A total of 38 consecutive patients comprising 42 interventions were studied: 16 patients with pancreatic pseudocysts (18 interventions) had undergone single-step EUS-guided transmural cystostome drainage between 2007 and 2010. Results were compared with a cohort of 22 patients who had submitted to multi-step EUS-guided transmural drainage of pancreatic pseudocysts in 24 cases between 2005 and 2007. RESULTS: The technical success rate for using the single-step procedure was 94% compared with multi-step procedure with 83% (n.s.). Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the single-step group compared with 62 ± 12 min for the multi-step access (p < 0.001). CONCLUSIONS: The use of single-step cystostome appears useful in managing selected patients with symptomatic pancreatic pseudocysts as it is effective and timesaving.

Outcome of supraselective transarterial chemoembolization in patients with hepatocellular carcinoma.

OBJECTIVE: Hepatocellular carcinoma (HCC) is the most common tumor in cirrhotic patients with a median survival of only 8-10 months if untreated. Supraselective transarterial chemoembolization (STACE) is supposed to be a well-established method for treating HCC patients. In the present study, we evaluated the effect of STACE on post-transplant survival in patients with HCC. MATERIAL AND METHODS: The charts of 53 HCC patients were retrospectively analyzed. Twenty-seven patients had STACE as a bridging therapy while 26 patients were scheduled for liver transplantation (LTX) without prior STACE therapy. A total of 53% of the patients who underwent LTX preoperatively fulfilled the Milan criteria, while 70.6% fulfilled the expanded University of California, San Francisco (UCSF) transplant criteria. Primary endpoint was the post-transplant survival. Statistical analysis included Kaplan-Meier-method, log rank, and chi square tests. RESULTS: Between the LTX groups (STACE vs. non-STACE), there was no significant difference in terms of age, Child classification, Okuda stage, co-morbidities, underlying disease, and post-transplant survival (p > 0.05). Independent of prior STACE, however, disease-free survival after LTX was highly significantly prolonged if LTX was performed within 3 months after initial diagnosis of HCC (p < 0.01) or if patients met the expanded transplant UCSF criteria (p = 0.02). Post-transplant survival did not depend on tumor size. CONCLUSIONS: We conclude that STACE performed prior to LTX does not secure any post-transplant survival benefit, while early LTX, i.e. within 3 months after HCC diagnosis, does improve survival regardless of whether STACE was performed or not. Additionally, fulfillment of the expanded transplant UCSF criteria leads to a prolonged post-transplant survival.

Out-of-hospital sepsis recognition by paramedics improves the course of disease and mortality: A single center retrospective study.

BACKGROUND: Early recognition of sepsis and a prompt initiation of goal-directed therapy is important for sepsis survival. Little is known about the impact of early recognition of sepsis in the out-of-hospital setting when paramedics are the 1st medical professionals arriving on the scene. OBJECTIVES: To characterize the impact of sepsis recognition by paramedics in the 1st out-of-hospital contact and to establish a predictive model by combining preclinical patient characteristics. MATERIAL AND METHODS: In this retrospective single-center cohort study, we included a total of 263 patients diagnosed with sepsis after admission to the emergency department and correlated them to the emergency medical protocols of the paramedics who have seen the patient out-of-hospital. RESULTS: Only 25 patients were correctly diagnosed by paramedics out-of-hospital. If sepsis was diagnosed, the median time to antibiotic administration was significantly lower (136.50 min compared to 206.98 min, p = 0.0069) and mortality was reduced from 22.8% to 8% (p = 0.0292). We have identified predictors for prognosis and calculated a predictive model with a modified quick Sepsis-related Organ Failure Assessment (qSOFA) score, which fits the needs for out-of-hospital usage and results in a better discrimination of vitally threatened patients (receiver operating characteristic (ROC) area under curve (AUC) of 0.641 compared to 0.719), as compared to the standard qSOFA. CONCLUSIONS: Sepsis recognition by paramedics at the 1st out-of-hospital contact significantly reduces sepsis mortality. The qSOFA and modified qSOFA are suitable tools for sepsis recognition, and have an impact on mortality and disease management when used.

Soluble syndecan-1 as marker of intestinal inflammation: A preliminary study and evaluation of a new panel of biomarkers for non-invasive prediction of active ulcerative colitis.

BACKGROUND: Syndecan-1 (Sdc1) is a heparin sulfate proteoglycan expressed in intestinal epithelium, which plays a crucial role in inflammation and epithelial repair. Sdc1-knockout mice have a deteriorated course of dextran sulfate sodium-induced colitis as compared to controls. Syndecan-1 is also shed into the serum during inflammation of the epithelium. We hypothesized that an increased serum level of soluble Sdc1 is a biomarker of intestinal inflammation in ulcerative colitis (UC). OBJECTIVES: To evaluate serum soluble Sdc1 as a biomarker of intestinal inflammation in UC. MATERIAL AND METHODS: This is a proof-of-concept study. Patients were recruited by the University Hospital Münster and HELIOS Albert Schweitzer Klinik Northeim (Germany). Blood samples were collected from UC patients actively suffering from this condition and those in remission. The levels of Sdc1 were measured with Diaclone CD 138 ELISA kit (Diaclone Research, Besançon, France) and routine clinical data were collected (C-reactive protein (CRP) levels, calprotectin in stool samples). Data were analyzed using SPSS software. RESULTS: Soluble Sdc1 levels were significantly elevated in the active UC group as compared to the inactive UC group (94.5 ±68.1 ng/mL compared to 28.3 ±12.6 ng/mL, p = 0.0020). The levels of Sdc1 also significantly correlated with the severity of UC as measured with the Mayo score (p = 0.0248). Receiver operating characteristic (ROC) analysis showed a good correlation of Sdc1 with an endoscopic Mayo score ≥2, with a value of 0.7747 (95% confidence interval (95% CI) = 0.5775-0.9718). A cutoff value of 37.1 ng/mL of Sdc1 showed a sensitivity of 78% and a specificity of 77%. A panel of biomarkers including CRP, hemoglobin, hematocrit, and Sdc1 was able to precisely predict active UC with an area under the curve (AUC) = 0.9395 (95% CI = 0.8509-1.0000). CONCLUSIONS: Serum soluble Sdc1 correlates significantly with mucosa inflammation and Mayo score in UC. Clinical trials No. NCT02333526.

Standard versus Endocuff versus cap-assisted colonoscopy for adenoma detection: A randomised controlled clinical trial.

BACKGROUND AND AIMS: Adenoma detection rate (ADR) in colon cancer screening is most important for cancer prophylaxis. This work is the first three-armed randomised controlled clinical trial aimed at comparing a head-to-head setting standard colonoscopy (SC) with Endocuff-assisted colonoscopy (EC) and cap-assisted colonoscopy (CAC) for improvement of ADR. METHODS: Patients from Poland and Germany with independent indication for colonoscopy were randomised into three arms of this trial: EC, CAC and SC. Exclusion criteria were age <18 years, active Crohn's disease or ulcerative colitis, known stenosis and post-colonic resection status. RESULTS: A total of 585 patients (195 SC, 189 EC and 186 CAC) were enrolled in this study. Indications were not different between the groups (colorectal cancer screening 51%, diagnostic colonoscopy in 31% and post-polypectomy follow-up in 18%; p = 0.94). Withdrawal time was a mean of 7 min in all groups (p = 0.658), and bowel preparation did not differ between the groups. The time to reach the caecum was significantly reduced when using the cap (a mean of 6 min for CAC vs. 7 min for SC; p = 0.0001). There was no significant difference in the primary outcome of the ADR between the groups (EC 32%, CAC 30%, SC 30%; p = 0.815). EC proved to be superior (EC vs. SC) in the sigmoid colon and transverse colon for polyp detection. CONCLUSION: The use of EC increased the total number of polyps seen during colonoscopy. In contrast to recent studies, no significant improvement of the ADR was detected.

Novel score predicts risk for cytomegalovirus infection in ulcerative colitis.

BACKGROUND: Cytomegalovirus (CMV) infection is associated with relapse and exacerbation of ulcerative colitis (UC), especially in immunosuppressed patients. OBJECTIVES: The aim of this study was to identify risk factors for CMV colitis and to develop a predictive risk score to estimate the probability of CMV colitis in UC patients supporting clinical decision making. STUDY DESIGN: A cohort of 239 UC-patients was retrospectively analyzed. Univariate and multivariate regression analysis identified several independent risk factors for CMV colitis and a predictive risk score was established using ROC analysis. RESULTS: CMV colitis is common in patients with severe ulcerative colitis. Clinical UC activity, disease duration and extent as well as the use of steroids and anti-TNF-α agents were identified as risk factors (p < 0.05 each). Based on five predictive parameters, a web-based risk score was developed. A strong correlation between the predicted and actual rates of CMV colitis was found (AUC: 0.855; 95% CI 0.79-0.92; p < 0.0001). CONCLUSIONS: Our study supports the pathogenic relevance of CMV in UC. The predictive risk score estimates the risk of CMV colitis and might aid in clinical decision making, especially when timely modifications of therapeutic regimens are needed and reliable diagnostic tools are not readily available.

Preoperative prediction of curative surgery of perihilar cholangiocarcinoma by combination of endoscopic ultrasound and computed tomography.

BACKGROUND: Perihilar cholangiocarcinomas are often considered incurable. Late diagnosis is common. Advanced disease therefore frequently causes questioning of curative surgical outcome. AIM: This study aimed to develop a prediction model of curative surgery in patients suffering from perihilar cholangiocarcinomas based on preoperative endosonography and computer tomography. METHODS: A cohort of 81 patients (median age 67 (54-75) years, 62% male) with perihilar cholangiocarcinoma was retrospectively analyzed. Multivariate logistic regression analysis of staging variables taken from the European Staging System was performed and applied to ROC analysis. RESULTS: The correlation of predicted rates of eligibility for surgery with actual rates reached AUC values between 0.652 and 0.758 for endosonography and computer tomography (p < 0.05 each). Best prediction for curative surgical option was achieved by combining endosonography and computer tomography (AUC: 0.787; 95% CI 0.680-0.893, p < 0.0001). A predictive model (pSurg) was developed using multivariate analysis. CONCLUSIONS: Our predictive web-based model pSurg with inclusion of T, N, M, B, PV, HA and V stage of the recently published European Staging System for perihilar cholangiocarcinoma results in highly significant predictability for curative surgery when combining preoperative endosonography and computer tomography, thus allowing for better patient selection in terms of possibility of curative surgery.

Hepatorenal syndrome: outcome of response to therapy and predictors of survival.

Aim. Treatment of hepatorenal syndrome (HRS) in patients with liver cirrhosis is still challenging and characterized by a very high mortality. This study aimed to delineate treatment patterns and clinical outcomes of patients with HRS intravenously treated with terlipressin. Methods. In this retrospective single-center cohort study, 119 patients (median [IQR]; 56.50 [50.75-63.00] years of age) with HRS were included. All patients were treated with terlipressin and human albumin intravenously. Those with response to treatment (n = 65) were compared to the patient cohort without improvement (n = 54). Patient characteristics and clinical parameters (Child stage, ascites, hepatic encephalopathy, HRS type I/II, and initial MELD score) were retrieved. Univariate analysis of factors influencing the success of terlipressin therapy and Cox regression analysis of factors influencing survival was carried out. Results. One-month survival was significantly longer in the group of responders (p = 0.048). Cox regression analysis identified age [Hazard ratio, 95% confidence interval (CI); 1.05, 1.01-1.09, resp.], alcohol abuse [HR 3.05, 95% CI 1.11-8.38], duration of treatment [HR 0.92, 95% CI 0.88-0.96], and MELD score [HR 1.08, 95% CI 1.02-1.14] to be independent predictors of survival. Conclusions. Survival of HRS patients after treatment depends on age, etiology of liver disease, and the duration of treatment.

[Conservative treatment of acute pancreatitis]. / Internistische Therapie der akuten Pankreatitis.

The incidence of acute pancreatitis per 100,000 population ranges from 10 to 46. The mortality of acute edematous interstitial pancreatitis is < 1%, while patients suffering from hemorrhagic necrotizing pancreatitis die from their disease in 10-24%. 80% of all cases of acute pancreatitis are etiologically correlated to diseases of the biliary tract or an excess alcohol consumption. As of today, no specific and causal treatment for acute pancreatitis has been established. Early prognostic factors for the evaluation of the clinical course of acute eipancreatitis are three or more indicators of organ failure in the Ranson or Imrie score, the development of extrapancreatic complications or the detection of pancreatic necrosis on contrast-enhanced CT scans. Elevated C-reactive protein (CRP) levels > 130 mg/l can predict a severe course of acute pancreatitis with a high sensitivity. The foundation of medical treatment in acute pancreatitis is the substitution of fluids to counteract hypovolemia. Furthermore, the relief of sometimes severe visceral pain has the highest priority. Infusion of procaine has been found to be ineffective for this purpose. The use of antibiotics should be restricted to patients with pancreatic necrosis. Enteral nutrition has no adverse effect compared to parenteral nutrition and is likely to be beneficial to the course of pancreatitis.