[Novel oral anticoagulants in gastroenterology routine]. / Bedeutung der neuen oralen Antikoagulanzien in der Gastroenterologie.

Novel direct-acting oral anticoagulants (NOAC) represent an effective new familiy of drugs and an interesting alternative to optimise and simplify anticoagulation. Rates of bleeding complications by NOAC are comparabel to those of warfarin but a previously assumed increase in gastrointestinal bleeding complications was meanwhile confirmed. Therefore, indications and contraindications concerning the use of NOAC should be closely considered. The endoscopic approach of gastrointestinal bleeding is conform to the recommended management of gastrointestinal bleeding complications under conventional anticoagulants or inhibitors of platelet aggregation. There are no specific antidotes to the anticoagulant effects of NOAC in case of bleeding. The recommendation concerning elective endoscopic procedures with high risk of bleeding more or less reflects expert oppinion. There are no recommendations on the basis of randomised studies. However, because of the short plasmatic half-life time of NOAC, their utilisation seems to be well controllable even in cases of high risk endoscopic interventions. More evidence based data about the periinterventional use of NOAC in endoscopic routine, in cases of endoscopic interventions with high bleeding risk or bleeding complications, bridging and the possibility of specific antidots in case of bleeding would be desirable.

[Ferritin and soluble interleukin-2-receptor in the diagnosis of fever of unknown origin]. / Ferritin und löslicher Interleukin-2-Rezeptor als Schlüsselbefunde bei unklarem Fieber.

UNLABELLED: HISTORY UND CLINICAL FINDINGS: Within a few weeks, two patients aged 16 and 75 years with fever of unknown origin were referred to the emergency unit. INVESTIGATIONS: Laboratory tests revealed increased aminotransferase levels, progressive cytopenia and an increase of inflammatory markers. In the older patient a rapid clinical detoriation with multi organ failure was observed. Progressively increasing levels of ferritin and soluble-interleukin-2-receptor levels led to the diagnosis of hemophagocytic lymphohistiocytosis, which was confirmed by bone marrow examination in the case of the younger patient. TREATMENT AND COURSE: Immunsuppressive treatment induced a clear improvement of clinical and laboratory findings and in the case of the older patient finally led to convalescence. CONCLUSION: Hemophagocytic lymphohistiocytosis is a rare but potentially fatal differential diagnosis, which should be considered in patients with fever and cytopenia.

[Capsule Endoscopy in Patients with Cardiac Pacemakers and Implantable Cardioverter Defibrillators - Is the Formal Contraindication still Justified?]. / Kapselendoskopie bei Patienten mit Herzschrittmachern und implantierbaren Cardioverter-Defibrillatoren - Ist die formale Kontraindikation noch gerechtfertigt?

BACKGROUND AND AIMS: Capsule endoscopy is an established tool for investigation of the small intestine. Because of limited clinical experience in patients with cardiac devices the US Food and Drug Administration and the manufacturers recommend not to use capsule endoscopy in these patients. METHODS: Studies investigating possible interference between small bowel capsule endoscopy and cardiac pacemakers and implanted cardioverters were analysed. For the review we considered studies published in English or German and indexed in PubMed (Medline) as well as relevant abstracts and technical data from the manufacturer. RESULTS: In vitro and in vivo studies applying real capsules revealed no clinically relevant interference with pacemakers and implanted cardioverters. This evidence already has had an impact on clinical practice and recommendations of scientific societies. On the other hand wireless telemetry can interfere with CE video. CONCLUSION: According to present evidence, small bowel capsule endoscopy can be used in patients with pacemakers and implanted cardioverters after obtaining informed consent concerning the formal existence of contraindication.

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.

Effectiveness and Safety of PRECISE APC for the treatment of bleeding gastrointestinal angiodysplasia--a retrospective evaluation.

BACKGROUND: APC is a thermal coagulation technique that uses ionized argon to transmit high-frequency electrical current, contact-free, to tissue. Precise APC is one of the new modes and is characterized by a small and distinctive energy input, higher reproducibility of tissue effects which is almost independent of the probe distance. The aim of the study was the evaluation of precise APC in patients with bleeding angiodysplasia's in the cecum or the small bowel. AIM/METHODS: Patients (pts.) with bleeding angiodysplasia of the cecum or small bowel were prospectively enrolled. Effectivity and safety of APC was assessed by evaluating the local coagulation effect, number of rebleedings and transfusions and complications (perforation, infection). RESULTS: There were 50 males and 44 females, median age 65.5 ± 8.5 years. 58 pts. (62 %) had lesions in the small bowel, 28 pts. (30 %) lesions in the cecum and 8 pts. (8 %) lesions in small bowel and cecum. All 234 visible lesions in 94 pts. were coagulated successfully. There was no perforation, active bleeding and tissue carbonization after the procedure. Re-bleeding was recognized in 18 pts. (19 %) after a mean follow-up of 6.1 months and new lesions in the same area were seen in 15 / 18 pts (16 %). CONCLUSION: In a historical comparison to forced or pulsed APC, precise APC may be a more appropriate option for the treatment of bleeding angiodysplasia's in critical locations like the cecum or small bowel. The coagulation effect seems to be comparable and due to its better depth control we assume a better safety, especially in preventing perforations.

Effectivity of current sterility methods for transgastric NOTES procedures: results of a randomized porcine study.

BACKGROUND AND AIM: Natural-orifice transluminal endoscopic surgery (NOTES) is an emerging transluminal technique in which interventions are carried out by entering the abdominal cavity via a natural orifice such as the stomach. Infection is a potential risk of the procedure, and the potential pathogens are different from those encountered with skin incisions. Currently, available data regarding prophylactic anti-infective treatment are limited. We compared the effectiveness of topical antimicrobial lavage of mouth and stomach and proton pump inhibitor therapy with gastric cleansing with sterile saline solution in preventing NOTES-related contamination and infection. METHODS: A randomized survival swine study was performed. Eight pigs underwent preparation with intravenously administered proton pump inhibitors, mouth and gastric lavage (chlorhexidine), and gastric irrigation (diluted neomycin), plus single-shot intravenous antibiotics. Control group (n = 8) underwent gastric cleansing with sterile saline solution. Peritoneal biopsy, multiple smears, and dilutions for cultures were taken and incubated. The swine were sacrificed after 14 days. Bacterial load was expressed in colony-forming units (CFU). RESULTS: One pig died due to gallbladder perforation after 3 days, 2/15 swine presented minor clinical signs of infection in the 14-day follow-up (all 3 pigs were in the control group). Mean C-reactive protein levels were 5.7 +/- 2.4 g/dL (therapy group) and 12.2 +/- 3.8 g/dL (control) ( P = 0.17). Bacterial growth was seen in 1/8 swine (therapy group) and 6/8 swine (control group) ( P = 0.002). Bacterial load was 282 CFU/mL (therapy) vs. 3.2 x 10 (5) CFU/mL (control) ( P = 0.023) in the follow-up. CONCLUSION: The use of intravenous antibiotics in addition to topical antimicrobial lavage of mouth and stomach and treatment with proton pump inhibitors decreased the peritoneal bacterial load to almost zero and this was associated with a significantly lower peritoneal infection rate compared with saline-only lavage.

Endoscopic resection of "giant" colorectal lesions: long-term outcome and safety.

BACKGROUND: Today, endoscopic resection is a standard procedure for the resection of colonic polyps. Before the establishment of endoscopic techniques, the surgical approach was a clearly preferred method for removal of polyps with a size larger than three centimeters. The safety and effectiveness concerning endoscopic resections of colorectal polyps also with a size of more than 3 cm have been demonstrated in numerous studies. PATIENTS AND METHODS: Data from 165 patients (age: 68 +/- 10.4 years) harboring 167 polyps with a minimum diameter of 3 cm were retrospectively evaluated. Objects of interest were macroscopic morphology and histopathology of the polyps, their localization in the colon, the modality of endoscopic resection and follow-up. In those cases with macroscopic signs of malignancy the patients were excluded. RESULTS: Successful endoscopic resections were obtained in 72.5 %. Therefrom, resection in the piecemeal-technique was necessary in 73.6 %. Recurrence polyps after endoscopic complete resections occurred in 26.3 % after a mean follow-up of 16 +/- 12.5 months. We registered a complication rate of 19.2 %. Relevant bleeding and perforation were registered as early complications in 18.6 %. We observed no intervention-related mortality. CONCLUSION: Endoscopic mucosal resection is a safe and efficient method even for removing giant colorectal polyps. Controls are recommended at defined intervals for detecting polyp recurrence.

[Benign non-peptic esophageal stenosis: causes, treatment and outcome in routine clinical practice]. / Ursachen, Therapie und Verlauf benigner, nicht-peptischer Osophagusstenosen in der klinischen Routine.

BACKGROUND AND OBJECTIVE: Benign non-peptic esophageal stricture (BNES) is a rare condition in routine clinical practice. The distribution of different diseases causing BNES is not known and the efficacy and safety of endoscopic treatment in this setting has not been established. PATIENTS AND METHODS: All patients with BNES undergoing endoscopic treatment at our hospital between 2000 and 2006 were assessed retrospectively and questioned by telephone. RESULTS: A total of 26 patients with BNES had been treated at our institution (median age 65 years, range 15-90) during this period. Common causes were esophageal intramural pseudodiverticulosis (n=11), caustic ingestion (n=4) and eosinophilic esophagitis (n=3). Other causes were Schatzki (-Gary) ring, incomplete esophageal atresia, heterotopic gastric mucosa, mucosal pemphigoid, spondylotic caused stenosis, epiphrenic diverticulum, unspecified stenosis. Median time until definitive diagnosis was five-and-a-half years. 20 patients were treated by bougienage, 3 were treated by balloon dilatation, 2 by medication alone and one patient did not require treatment. Lasting successful treatment was achieved in all There were no treatment-related complications. CONCLUSIONS: Benign, non-peptic esophageal stricture is a rare condition in routine clinical practice and can be caused by various diseases. Time to exact diagnosis is often very long. When the underlying diagnosis is clear, excellent results of symptomatic endoscopic therapy can be achieved in a gastroenterological center.

[Endoscopy of the small bowel: light into the dark]. / Dünndarmendoskopie: Licht ins Dunkel.

Since the introduction of capsule endoscopy and later balloon enteroscopy in clinical practice, endoscopic examination of the small bowel has dramatically improved. For the first time, it is possible to diagnose the whole small bowel without the necessity of laparotomy and intraoperative enteroscopy. The methods revolutionized the field of small bowel diagnostic and therapy and become part of daily clinical practice. This article provides a review of small bowel enteroscopic methods.

[Dysphagia, heartburn and esophageal bolus impaction in a 43-year old male patient: not always reflux disease]. / Dysphagie, Sodbrennen und Bolusobstruktion bei einem 43-jährigen Mann: Nicht immer Refluxkrankheit.

We report a case of a 43 year old male patient, who was admitted with recurring esophageal bolus impactions. Since his childhood he has been complaining about dysphagia and was unable to swallow medication. He also complained about heartburn. The last esophageal bolus impaction was some weeks ago. After elimination of the bolus impaction with a rigid endoscope we found a high grade stenosis in the proximal esophagus that could not even be passed with a children's endoscope. An initial treatment of eosinophil esophagitis would be the therapy with a local corticoid for 6-9 month. In patients with typical rings or stenosis a dilation therapy might be necessary.

Do endoscopy capsules interfere with implantable cardioverter-defibrillators?

BACKGROUND AND STUDY AIMS: Capsule endoscopy is already an established diagnostic tool, and the newly introduced capsule PillCam COLON is now entering clinical studies. Because of the very limited clinical experience in patients with implantable cardioverter-defibrillators (ICDs), it is generally recommended that capsule endoscopy should not be used in these patients. Therefore, we investigated, in vitro, the possible interference between three different endoscopy capsules (Given Imaging and Olympus) and ICDs. MATERIALS AND METHODS: A total of 45 ICD devices were separately placed in a tank filled with a 0.9 % saline solution. With the help of pin jacks, the pacing pulses of ICDs were recorded and inhibiting signals could be coupled in. The capsules were placed in different positions near to the lead and the ICD device, and finally placed on the case of the device for 1 minute each. The function of each device was observed continuously. RESULTS: Even when the capsules were in closest proximity to the ICDs, no interference was observed. CONCLUSION: The clinical use of the three tested capsule devices is safe in patients with ICDs.

[Recurrent upper gastrointestinal bleeding in a 61 year-old man with infrarenal abdominal aortic aneurysm]. / Rezidivierende obere gastrointestinale Blutungen bei einem 61-jährigen Patienten mit infrarenalem Bauchaortenaneurysma.

A 61-year-old man was admitted to hospital due to recurrent upper gastrointestinal bleeding. Four weeks ago, he had been treated with epinephrine and endoclips by endoscopy due to an arterial gastrointestinal bleeding. The patient had a history of coronary and peripheral artery disease, diabetes, and an abdominal aortic aneurysm. Urgent endoscopy suggested the presence of an ulcus Dieulafoy but no definitive bleeding source could be seen. Due to ongoing melena an abdominal computer tomography was performed and a primary aortoduodenal fistula was suspected caused by the infrarenal abdominal aortic aneurysm. Laparatomy was undertaken emergently and an aortoduodenal fistula was found in the descending part of the duodenum. Repair of the duodenal rent was performed and the aortic aneurysm was replaced by a Dacron prosthesis. The patient was transferred to the intensive care unit. 4 days after initial admission, he died due to septic shock.

Capsule endoscopy and cardiac pacemakers: investigation for possible interference.

BACKGROUND AND STUDY AIMS: The diagnostic benefit of capsule endoscopy in suspected small-bowel disease is high and seems to be superior to that with conventional methods and scintigraphy. Because of the limited clinical experience in patients with cardiac pacemakers and other implanted electrical devices, it is recommended that capsule endoscopy should not be used in such cases. We investigated the potential for capsule endoscopy to interfere with cardiac pacemakers in vitro. MATERIAL AND METHODS: 21 different pacemakers and leads were positioned in a 0.9 % saline solution in a tank. Pin jacks were placed that were in contact with the solution. The pacemaker impulse was recorded and an inhibiting signal could be coupled in. The capsules (Given Imaging and Olympus) were placed in different positions relative to the cardiac pacemaker and finally placed on the case of the pacemaker, for 1 minute in each site. The functioning of the pacemaker was observed continuously. The effect on the pacemaker was noted particularly as inhibition, synchronization, or no effect. The pacemaker was then inhibited using a standard test signal. RESULTS: There was no interference between the video capsule and the cardiac pacemakers in our experiment in spite of the close proximity of the two devices. CONCLUSION: The clinical use of capsule endoscopy is unproblematic in patients with cardiac pacemakers.

Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness of the new pulsed APC versus forced APC.

BACKGROUND AND STUDY AIM: Argon plasma coagulation (APC) has become an established noncontact method of tumor palliation in a variety of locations. The present prospective study evaluated a new APC system (APC-2) using amplified power settings and different application modes, such as intermittent energy delivery (pulsed APC) in comparison with the conventional technique (forced APC). PATIENTS AND METHODS: A total of 100 patients with esophageal, gastric, or rectal tumors were alternately (but not randomized) enrolled and treated with either pulsed APC (n = 46) or forced APC (n = 54). Parameters to assess the palliative effect were: amount of lumen restoration ((1/3), (2/3), complete), objective planimetry, stenosis length, treatment time, and number of APC sessions. RESULTS: Overall response rate was similar in both groups (pulsed 83 %, forced 87 %), the same was found in the subgroups with different amounts of lumen restoration and for the other objective parameters. However, the tumor debulking effect was achieved in a significantly shorter median treatment time with forced compared with pulsed APC (13.6 vs. 18.2 minutes, P = 0.03), with a similar number of treatment sessions in both groups. Complications also occurred with similar frequency in both groups. CONCLUSIONS: There was no significant difference in overall local tumor response between the two modes of APC application. However, data from this nonrandomized study suggest a faster achievement of response with forced APC. A combination of both modes may be superior.