ABSTRACT
Pulmonary vein isolation (PVI) using cryoenergy is safe and efficient for treatment of atrial fibrillation (AF). Pre-existing upper gastrointestinal (GI) pathologies have been shown to increase the risk for AF. Therefore, this study aimed at assessing incidental pathologies of the upper GI tract in patients scheduled for PVI and to analyse the impact of patients' characteristics on PVI safety outcome. In 71 AF patients, who participated in the MADE-PVI trial, oesophagogastroduodenoscopy and endosonography were prospectively performed directly before and the day after PVI to assess pre-existing upper GI pathologies and post-interventional occurrence of PVI-associated lesions. Subgroup analysis of the MADE-PVI trial identified clinically relevant incidental findings in 53 patients (74.6%) with age > 50 years being a significant risk factor. Pre-existing reflux oesophagitis increased risk for PVI-associated mediastinal oedema, while patients already treated with proton pump inhibitors (PPI) had significantly fewer mediastinal oedema. Our results suggest that AF patients with pre-existing reflux oesophagitis are at higher risk for PVI-associated mediastinal lesions, which is decreased in patients with constant PPI-treatment prior to PVI. Since PVI-associated mediastinal lesions are regarded as surrogate parameter for an increased risk of the fatal complication of an oesophago-atrial fistula, our findings hint at a beneficial effect of pre-interventional prophylactic PPI-treatment to reduce risk for PVI-associated complications.German Clinical Trials Register (DRKS00016006; date of registration: 17/12/2018).
Subject(s)
Cryosurgery/methods , Proton Pump Inhibitors/therapeutic use , Pulmonary Veins/surgery , Aged , Atrial Fibrillation/surgery , Cryosurgery/adverse effects , Female , Gastroesophageal Reflux/complications , Humans , Male , Middle Aged , Prospective Studies , Treatment OutcomeSubject(s)
Cyclophosphamide/therapeutic use , Immunosuppressive Agents/therapeutic use , Systemic Vasculitis/diagnostic imaging , Systemic Vasculitis/drug therapy , Aged , Azathioprine/therapeutic use , Brain Ischemia/etiology , Enteritis/etiology , Female , Humans , Mesenteric Artery, Inferior/diagnostic imaging , Mesenteric Artery, Superior/diagnostic imaging , Radiography , Systemic Vasculitis/complicationsABSTRACT
BACKGROUND AND STUDY AIMS: Double-balloon enteroscopy (DBE) is the first choice endoscopic technique for small-bowel visualization. However, preparation and handling of the double-balloon enteroscope is complex. Recently, a single-balloon enteroscopy (SBE) system has been introduced as being a simplified, less-complex balloon-assisted enteroscopy system. PATIENTS AND METHODS: This study was a randomized international multicenter trial comparing two balloon-assisted enteroscopy systems: DBE vs. SBE. Consecutive patients referred for balloon-assisted enteroscopy were randomized to either DBE or SBE. Patients were blinded with regard to the type of instrument used. The primary study outcome was oral insertion depth. Secondary outcomes included complete small-bowel visualization, anal insertion depth, patient discomfort, and adverse events. Patient discomfort during and after the procedure was scored using a visual analog scale. RESULTS: A total of 130 patients were included over 12 months: 65 with DBE and 65 with the SBE technique. Patient and procedure characteristics were comparable between the two groups. Mean oral intubation depth was 253 cm with DBE and 258 cm with SBE, showing noninferiority of SBE vs. DBE. Complete visualization of the small bowel was achieved in 18 % and 11 % of procedures in the DBE and SBE groups, respectively. Mean anal intubation depth was 107 cm in the DBE group and 118 cm in the SBE group. Diagnostic yield and mean pain scores during and after the procedures were similar in the two groups. No adverse events were observed during or after the examinations. CONCLUSIONS: This head-to-head comparison study shows that DBE and SBE have a comparable performance and diagnostic yield for evaluation of the small bowel.
Subject(s)
Endoscopes, Gastrointestinal , Endoscopy, Gastrointestinal/instrumentation , Intestinal Diseases/diagnosis , Intestine, Small , Abdominal Pain/etiology , Adolescent , Adult , Aged , Aged, 80 and over , Analysis of Variance , Double-Balloon Enteroscopy/adverse effects , Endoscopy, Gastrointestinal/methods , Female , Humans , Male , Middle Aged , Time Factors , Young AdultSubject(s)
Capsule Endoscopy , Colonic Neoplasms/pathology , Hemangioma/pathology , Intestine, Small/pathology , POEMS Syndrome/diagnosis , Colonic Neoplasms/complications , Colonic Neoplasms/diagnosis , Colonoscopy/methods , Follow-Up Studies , Hemangioma/complications , Hemangioma/diagnosis , Humans , Intestinal Mucosa/pathology , Intestinal Neoplasms/complications , Intestinal Neoplasms/diagnosis , Male , Middle Aged , POEMS Syndrome/complications , Risk Assessment , Sensitivity and SpecificitySubject(s)
Capsule Endoscopy , Graft vs Host Disease/diagnosis , Hematopoietic Stem Cell Transplantation/adverse effects , Intestinal Diseases/diagnosis , Intestine, Small/pathology , Disease Progression , Fatal Outcome , Female , Graft vs Host Disease/etiology , Hematopoietic Stem Cell Transplantation/methods , Humans , Intestinal Diseases/etiology , Leukemia, Myeloid/diagnosis , Leukemia, Myeloid/surgery , Middle Aged , Multiple Organ Failure/diagnosis , Risk Assessment , Severity of Illness Index , Transplantation, Homologous/adverse effectsABSTRACT
BACKGROUND AND STUDY AIMS: Double-balloon enteroscopy (DBE) has been proven effective for deep intubation of the small bowel. However, intubation depth is limited by distention of the small bowel due to air insufflation during the procedure. The present trial investigated whether carbon dioxide (CO (2)) instead of standard air insufflation would improve intubation depth during DBE, as well as reduce postprocedure pain. PATIENTS AND METHODS: One hundred and twelve consecutive patients scheduled for DBE at two centers were randomly assigned to either CO (2) or air insufflation during DBE. Patients and endoscopists were blinded with regard to the type of gas used. Intubation depth was registered using a validated form. Patients scored pain and discomfort during and after the examination on a 100-mm visual analog scale. RESULTS: One hundred patients were eligible for data analysis (48 in the CO (2) group and 52 in the air group). The mean small-bowel intubation depth was extended by 30 % in the CO (2) group compared to the air group (230 vs. 177 cm, P = 0.008). The superiority was most pronounced for oral DBE, with a 71-cm improvement in intubation depth when using CO (2) (295 cm in the CO (2) group vs. 224 cm in the air group, P < 0.001). Patient pain and discomfort were significantly reduced in the CO (2) group at 1 and 3 hours after the examination. CONCLUSIONS: CO (2) insufflation significantly extended intubation depth in DBE. CO (2) insufflation also reduces patient discomfort. CO (2) insufflation may lead to a higher diagnostic and therapeutic yield of DBE, with reduced patient discomfort.
Subject(s)
Capsule Endoscopy/methods , Carbon Dioxide/administration & dosage , Intubation, Gastrointestinal/methods , Pneumoperitoneum, Artificial/methods , Adult , Aged , Air , Analysis of Variance , Double-Blind Method , Endoscopy, Gastrointestinal/methods , Female , Humans , Insufflation/methods , Male , Middle Aged , Pain Measurement , Pilot Projects , Probability , Reference Values , Risk Factors , Sensitivity and SpecificitySubject(s)
Catheterization , Endoscopy, Gastrointestinal , Intestinal Obstruction/surgery , Jejunal Diseases/surgery , Jejunal Neoplasms/surgery , Peutz-Jeghers Syndrome/surgery , Adult , Electrocoagulation , Female , Humans , Intestinal Obstruction/diagnosis , Jejunal Diseases/diagnosis , Jejunal Neoplasms/diagnosis , Peutz-Jeghers Syndrome/diagnosisSubject(s)
Embolism, Air/etiology , Intubation, Gastrointestinal/adverse effects , Jejunal Diseases/etiology , Portal Vein , Adult , Humans , Jejunum , MaleABSTRACT
BACKGROUND: Hepatitis C viral kinetic studies have demonstrated the increased anti-viral effect of higher than standard dosages of interferon and of daily treatment schedules. AIM: To compare, in a prospective, randomized, controlled trial, the efficacy and safety of high-dose interferon-alpha therapy vs. standard-dosage interferon-alpha therapy, in a triple therapy combination with ribavirin and amantadine. METHODS: Previously untreated patients with chronic hepatitis C were randomized to the standard interferon-alpha group (n = 15), receiving thrice weekly 6 MU interferon-alpha for 12 weeks, followed by 3 MU interferon-alpha for 36 weeks, or the high-dose interferon-alpha group (n = 15), receiving daily 9 MU interferon-alpha for 4 weeks, followed by 6 MU (weeks 5-8), 3 MU (weeks 9-12) and 1.5 MU (weeks 13-48) interferon-alpha. All patients were given ribavirin (1000-1200 mg) and amantadine (200 mg) daily for 48 weeks. RESULTS: At the end of treatment and after the 24-week follow-up period, serum hepatitis C virus RNA was undetectable in eight (53%) and six (40%) patients treated with standard-dosage interferon-alpha, respectively, compared with 11 (73%) and 10 (67%) treated with high-dose interferon-alpha, respectively (not significant). The safety profile of both treatment regimens was similar. Severe adverse events leading to withdrawal from the study occurred in one patient (7%) in each group, and in both groups one patient (7%) was lost during therapy for unknown reasons. CONCLUSIONS: The findings suggest that, although the difference between the response rates of standard and high-dose interferon-alpha regimens (within a triple anti-viral therapy combination) did not reach statistical significance, there was a clear trend towards a higher response with high-dose interferon-alpha therapy and an equal safety profile.
Subject(s)
Antiviral Agents/administration & dosage , Hepatitis C, Chronic/drug therapy , Interferon-alpha/administration & dosage , Adult , Amantadine/therapeutic use , Antiviral Agents/adverse effects , Antiviral Agents/therapeutic use , Dose-Response Relationship, Drug , Drug Administration Schedule , Drug Therapy, Combination , Female , Follow-Up Studies , Hepacivirus/isolation & purification , Hepatitis C, Chronic/pathology , Hepatitis C, Chronic/virology , Humans , Interferon alpha-2 , Interferon-alpha/adverse effects , Interferon-alpha/therapeutic use , Male , Middle Aged , Pilot Projects , Prospective Studies , RNA, Viral/analysis , Recombinant Proteins , Ribavirin/therapeutic use , Treatment OutcomeABSTRACT
MARS (Molecular Adsorbent Recycling System) as a novel hepatic detoxification procedure until orthotopic liver transplantation. We report the case of a 30-year-old man who was admitted because of acute liver failure due to longstanding ethanol abuse. On conservative treatment liver function progressively deteriorated and the patient was listed for orthotopic liver transplantation. Because of a rapidly progressive and clinically severe hepatic encephalopathy together with increasing bilirubin levels (maximum 39 mg/dl) we began intermittent extracorporeal detoxification with the Molecular Adsorbent Recycling System (MARS). Under MARS therapy serum bilirubin decreased significantly (to 20 mg/dl after three cycles) and encephalopathy improved rapidly until the patient was completely oriented. No effect of MARS on liver function could be demonstrated. MARS treatment was successfully continued until a cadaver liver became available after 48 days and the patient was transplanted in good clinical and neurological condition and without complications. MARS represents a novel detoxification technique which, in patients with acute liver failure, can successfully replace hepatic detoxification until orthotopic liver transplantation can be performed.
Subject(s)
Hemoperfusion/instrumentation , Hepatic Encephalopathy/therapy , Inactivation, Metabolic/physiology , Liver Failure, Acute/therapy , Liver Transplantation , Liver, Artificial , Adult , Follow-Up Studies , Hepatic Encephalopathy/physiopathology , Humans , Liver Cirrhosis, Alcoholic/physiopathology , Liver Cirrhosis, Alcoholic/therapy , Liver Failure, Acute/physiopathology , Liver Function Tests , Male , Treatment OutcomeABSTRACT
Ulcers of the small bowel have repeatedly been described as a late complication of celiac disease and they are considered a signum mali ominis. We report a case of a 53-year-old woman presenting with diarrhea, epigastric pain and abdominal distensions for a period of few weeks. At upper GI endoscopy, biopsies were taken showing complete atrophy of the villi and colonization of the small bowel mucosa. Additionally, uncommon multilocular peptic ulcers were seen in the gastric antrum. These ulcers proved to be Helicobacter pylori-negative with no evidence of Zollinger-Ellison syndrome. Biopsies of gastric ulcers showed signs of a lymphocytic gastritis with an extensive infiltration of the lamina propria by almost exclusively CD3- and CD45R0-positive T-lymphocytes. Intraepithelial T-lymphocytes were found to be increased in the antral as well as the corpus mucosa. Typing the patient for human leukocyte antigens showed a DQA1*0501 and DQB1*0201 phenotype. According to the present report, gastric peptic ulcers seem to be another phenomenon associated with celiac disease. In the case presented here, ulcers were diagnosed together with celiac disease already at first presentation of the patient.
Subject(s)
Celiac Disease/complications , Helicobacter Infections/complications , Helicobacter pylori , Stomach Ulcer/complications , Biopsy , Celiac Disease/pathology , Female , Gastric Mucosa/pathology , Gastritis/complications , Gastritis/pathology , Helicobacter Infections/pathology , Humans , Intestinal Mucosa/pathology , Lymphocytosis/complications , Lymphocytosis/pathology , Middle Aged , Stomach Ulcer/pathology , T-Lymphocytes/pathologyABSTRACT
This report describes the case of a patient with primary small bowel lymphoma. Well-established methods of imaging did not give a hint on diagnosis. Increased 18F-fluorodeoxyglucose uptake was visualized on performance of positron emission tomography, corresponding with the intraoperatively found tumorous process. The present case points to a potential superiority of positron emission tomography in visualizing primary small bowel lymphoma.
Subject(s)
Fluorodeoxyglucose F18 , Intestinal Neoplasms/diagnostic imaging , Intestine, Small , Lymphoma, Non-Hodgkin/diagnostic imaging , Radiopharmaceuticals , Tomography, Emission-Computed , Aged , Diagnosis, Differential , Female , HumansABSTRACT
We report the case of a 49-year-old male patient who was referred to our department in February 1998. Due to his complaints of dysphagia and retrosternal pain an upper gastrointestinal endoscopy was performed showing a polypoid lesion of the lower esophagus. This lesion presenting with a wide base and indurated surface was removed by endoscopic snare and forceps biopsies. Histologic and immunohistochemical analyses revealed this lesion to be a benign granular-cell tumor (Abrikossoff's tumor) which is considered to be of neuroectodermal origin. Abrikossoff's tumor is a rare differential diagnosis of polypoid lesions of the esophagus.
Subject(s)
Esophageal Neoplasms/diagnosis , Granular Cell Tumor/diagnosis , Diagnosis, Differential , Endoscopy, Digestive System , Esophageal Neoplasms/pathology , Esophageal Neoplasms/surgery , Granular Cell Tumor/pathology , Granular Cell Tumor/surgery , Humans , Immunohistochemistry , Male , Middle Aged , S100 Proteins/metabolismABSTRACT
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of complications due to portal hypertension. Possible shunt stenosis or shunt occlusion make periodical assessment of stent function necessary. Direct portal venography is the gold standard in morphologic and functional surveillance of TIPS. Controversially discussed is whether Doppler ultrasonography is effective in hemodynamical evaluation of TIPS and sufficient in prediction of shunt dysfunction. In 39 patients, 147 Doppler ultrasonographical examinations were performed and correlated with the results obtained by direct portal venography in TIPS follow-up, 43 of 47 hemodynamically relevant stenoses, including six shunt occlusions, were being diagnosed correctly by Doppler ultrasonography, by assessing maximal flow velocity in portal vein proximal to the TIPS (sensitivity 91.5%; specificity 97%). If Doppler ultrasonographical measurement of maximal flow velocity was performed within the proximal stent itself, sensitivity was only 70.4% and specificity 27%. In conclusion, assessment of portal maximal flow velocity more accurately represents hemodynamical TIPS function than Doppler ultrasonographical measurement within the proximal stent tract itself. Since, according to data presented. Doppler ultrasonography appears to be able to detect hemodynamically significant TIPS stenoses, it might reduce the number of invasive angiographies and thus contribute to more cost-effective follow-up of TIPS patients.
Subject(s)
Hypertension, Portal/surgery , Portasystemic Shunt, Transjugular Intrahepatic , Postoperative Complications/diagnostic imaging , Ultrasonography, Doppler , Adolescent , Adult , Aged , Blood Flow Velocity/physiology , Female , Follow-Up Studies , Humans , Hypertension, Portal/diagnostic imaging , Male , Middle Aged , Portal Vein/diagnostic imaging , Portography , Sensitivity and SpecificityABSTRACT
The causes of Budd-Chiari syndrome (BCS) comprise several diseases leading to thrombophilia. One of the most common thrombophilic disorders is resistance against activated protein C, caused by a single point mutation of the factor V gene. In December 1993, a 22-year-old patient was given a diagnosis of subacute BCS with occlusion of all major hepatic veins. Placement of a transjugular intrahepatic portosystemic stent shunt led to rapid disappearance of ascites and hepatic encephalopathy. During the following two years, recurrent partial occlusions of the shunt were treated by balloon angioplasty. The cause of the BCS still being unknown, in October 1996 we performed extensive laboratory investigations concerning states of thrombophilia and found moderately elevated IgG anticardiolipin antibodies (19.7 U/ml) and a resistance against activated protein C caused by heterozygosity for a point mutation of the factor V gene (1691G-->A; factor V Leiden). As a consequence, oral anticoagulation with coumarin was initiated. In October 1997, elective liver transplantation was performed which led to disappearance of APC resistance. Moreover, IgG anticardiolipin antibodies have been negative since then. If BCS is caused by APC resistance, liver transplantation not only treats the chronic liver disease but also cures the state of thrombophilia since factor V is mainly synthesized in the liver.
Subject(s)
Budd-Chiari Syndrome/therapy , Factor V/genetics , Liver Transplantation , Portasystemic Shunt, Transjugular Intrahepatic , Activated Protein C Resistance/genetics , Adult , Budd-Chiari Syndrome/blood , Budd-Chiari Syndrome/genetics , Combined Modality Therapy , Humans , Male , Point Mutation , Prognosis , Thrombophilia/genetics , Thrombophilia/therapyABSTRACT
Gastrointestinal neuroendocrine tumors are slowly growing and metastases are often limited to the liver. As a result of their favorable biological behavior these tumors have a relatively good prognosis even in metastatic stage. Due to a variety of therapeutic options patients with malignant neuroendocrine tumors may survive for extended periods of time up to ten years. Often a combination of different treatments and also alternation between the different therapeutic regimes is needed. A patient with excessive WDHA-syndrome and severe metabolic disturbances due to a pancreatic VIPoma with metastatic spread into the liver and abundant hormonal secretion is presented. Cytotoxic agents (streptozocin, 5-fluorouracil and adriamycin) were able to alleviate clinical symptoms and to control tumor growth for six years. Analogues of somatostatin (octreotide) and interferon alpha had been very useful in controlling clinical symptoms and tumor progress for 18 months. Cytotoxic agents or octreotide were not able, however, to achieve any permanent cure. Eventually, treatment failure occurred with dramatic progression of symptoms and tumor growth, unresponsive to any medical therapy. Consequently, total hepatectomy and liver transplantation together with extirpation of the pancreatic primary tumor was performed and succeeded in providing a normal life to the patient. In our opinion the overall outcome of patients with metastatic VIPoma may be improved best by maintaining the patients on medical therapy until treatment failure occurs. In case of extended hepatic metastases orthotopic liver transplantation might be considered for patients with symptomatic disease who no longer respond to conventional treatment modalities.