Is the transnasal access for esophagogastroduodenoscopy in routine use equal to the transoral route? A prospective, randomized trial.

BACKGROUND AND STUDY AIMS: Routine esophagogastroduodenoscopy (EGD) is increasingly performed without sedation. Transoral (TO) and transnasal (TN) EGD offer different patient comfort and complications. PATIENTS AND METHODS: For a controlled, randomized, clinical trial comparing TN-EGD with TO-EGD without sedation, patients were assigned to TN-EGD using a thin endoscope (group 1, 93 patients), or TO-EGD using a standard endoscope (group 2, 90 patients). Physician-rated procedural time and complications as well as patient-rated side effects and preferences were compared. In group 3, patients (118) who had previously undergone TO-EGD, now underwent TN-EGD. RESULTS: Between group 1 and 2 there was no significant difference for procedural time. Nausea (p = 0.047) and epistaxis (p < 0.001) were significantly more frequent for TN-EGD. Conversion rate from TN- to TO-EGD was low with 4.3 %. For TN-EGD, patients' tolerance was better (p < 0.001), gagging was less (p < 0.001). In case of a future EGD, patients who know both procedures (group 3), strongly vote for TN-EGD (80 %). All groups vote against sedation for future procedures (90 %/90 %/89 %). CONCLUSIONS: Epistaxis can be relevant after TN-EGD, but can mostly be managed conservatively. TN-EGD is superior to TO-EGD regarding subjective and objective gagging as well as procedural tolerance. Patients who experienced both access routes, prefer TN-EGD. TN-EGD without sedation should be aspired for patient comfort and is recommended for routine use.

[Uncommon condition of the upper gastrointestinal tract: double pylorus]. / Seltene Befunde am oberen Gastrointestinaltrakt: Der Doppelpylorus.

Double pylorus and gastroduodenal fistula are uncommon conditions that are either congenital or acquired. Acquired double pylorus in most cases resulted from a penetrating peptic ulcer creating a fistula between the duodenal bulb and the prepyloric antrum. The diagnosis is usually made by endoscopy. Surgical intervention should be only considered for patients with refractory symptoms, recurrent ulcers and other complications. We report the case of a 85-year-old man with an acquired duodenal-antral fistula resulting from a retrograde penetration of an ulcus duodeni and simulating a double pylorus.

[Requirements and recommendations for performing endosonographies]. / Voraussetzungen und Empfehlungen zur Durchführung von Endosonographien - Eine Stellungnahme der Arbeitsgemeinschaft für endoskopischen Ultraschall in Nordrhein-Westfalen (AGEUS).

For improvement of quality the working group of the Society of Gastroenterology in Nordrhein-Westfalen (Germany) was engaged with the questions, which apparative, personal and training conditions for endoscopic ultrasound are useful. The following proposals were preliminarily presented at the annual Congress of the DGVS (German Society of Digestive and Metabolic Diseases) 2001. They are thought to be subject of discussion for guidelines to be elaborated by this national society.

[Prospective study comparing conventional and transnasal esophagogastroduodenoscopy for routine diagnosis]. / Prospektive Studie zum Vergleich von herkömmlicher und transnasaler Osophago-Gastro-Duodenoskopie in der Routinediagnostik.

INTRODUCTION: Transnasal gastroscopy (TNG) is the result of ongoing improvements in endoscopic device development. These ultrathin endoscopes are planned to improve patient satisfaction with the endoscopic procedure. AIM: The aim of the current study was to prospectively evaluate the performance and patient acceptance of transnasal gastroscopy. PATIENTS AND METHODS: Sixty-three consecutive patients (40 males, 23 females, mean age 58.5 years) referred for routine upper gastrointestinal endoscopy to our tertiary care referral centre were assigned to one of three groups: first time transnasal gastroscopy (group 1, TNG), first time transoral gastroscopy (group 2, TOG) and transnasal gastroscopy after a previous unsedated transoral gastroscopy (group 3). All examinations were performed without intravenous sedation. Patients answered a standardised questionnaire immediately following the examination. RESULTS: The three groups of patients did not differ in age, gender or reason for gastroscopy. Investigations performed using transnasal technique were significantly shorter (TNG 8.9 min and 9.2 min vs. TOG 11.9 min, p = 0.011 and p = 0.026, respectively) than those performed in transoral technique. Nosebleeding, albeit not clinically significant, and the urge to wretch were significantly more common in the transnasal technique group (p > 0.001). Patient acceptance tended to score higher in the transnasal technique groups, however not statistically higher. A greater number of patients from group 3 (TNG after previous TOG) would prefer a repeat exam via the transnasal route. CONCLUSIONS: Transnasal gastroscopy represents a possible alternative to the conventional transoral technique. TNG entails less subjective patient discomfort, and patients experienced in both techniques prefer the transnasal route. Shorter examination times and lack of intravenous sedation result in several benefits: no sedation-related complications, shorter post-procedure observation times, and subsequently shorter time off work for patients.

[Endoscopic ultrasonography (EUS) of the upper gastrointestinal tract - prospective multicenter study to evaluate time and staff requirements]. / Endosonographie (EUS) des oberen Gastrointestinaltrakts - Prospektive Multizenterstudie zur Analyse von Zeit- und Personalbedarf.

BACKGROUND AND AIMS: Endoscopic ultrasonography is an important procedure in the diagnostic work-up of gastrointestinal and mediastinal masses. To evaluate the time and staff requirements for the examination, a prospective multicenter study was carried out. METHODS: 27 centers were asked to document their endoscopic ultrasonographic procedures over a 4-month period, using a standardized protocol comprising several parameters: time and staff requirements (overall and related to organs), time spent on informing the patients, preparation, performance and monitoring of the examination and subsequent care of patient as well as of endoscopic equipment. RESULTS: 484 examinations from 11 centers were suitable for evaluation, 25 % of the patients were out-patients. Median examination time was 20 minutes (range: 5 - 60 min) without significant differences concerning the device but with greater differences concerning the different organs (pancreas 23.5 minutes, esophagus 15 minutes). Median time of subsequent care was 35 minutes in out-patients, 25 minutes in hospitalized patients, with a great variety between different centers. In 70 % of examinations one doctor and one nurse were involved. For sedation midazolam was used in 90 % of cases, pethidin for analgesia in 30 % of cases. CONCLUSIONS: The obvious time and staff requirements for endoscopic ultrasonography are comparable to historical data for the performance of a colonoscopy. In out-patients the time required seems to be higher.

Positron emission tomography reveals a leiomyosarcoma causing proteinuria.

Obstruction of the renal veins may result in proteinuria and is frequently caused by thrombosis or tumorous processes. Since thrombosis and malignancy may occur simultaneously in the venous outflow of the kidneys, search for an underlying intraluminal tumor may be impeded by extensive thrombosis in the lumen of renal and caval veins. We report the case of a 30-year-old man with moderate proteinuria which was caused by an obstructing process of the vena cava inferior and the renal veins. While the obstructive mass was initially misdiagnosed as thrombosis, positron emission tomography helped to reveal the tumorous character of the lesion and fine-needle biopsy allowed rapid diagnosis of a leiomyosarcoma originating from the caval or renal veins. We conclude that undelayed diagnosis of the cause of renal and caval vein obstruction is facilitated by early positron emission tomography and subsequent fine-needle biopsy to identify possible tumorous lesions.

Low dose balsalazide (1.5 g twice daily) and mesalazine (0.5 g three times daily) maintained remission of ulcerative colitis but high dose balsalazide (3.0 g twice daily) was superior in preventing relapses.

BACKGROUND: Balsalazide is a new 5-aminosalicylic acid (5-ASA) containing prodrug. Its efficacy in comparison with standard mesalazine therapy and the optimum dose for maintaining remission of ulcerative colitis are still unclear. AIMS: To compare the relapse preventing effect and safety profile of two doses of balsalazide and a standard dose of Eudragit coated mesalazine. METHODS: A total of 133 patients with ulcerative colitis in remission were recruited to participate in a double blind, multicentre, randomised trial: 49 patients received balsalazide 1.5 g twice daily, 40 received balsalazide 3.0 g twice daily, and 44 received mesalazine 0.5 g three times daily. Efficacy assessments were clinical activity index (CAI) and endoscopic score according to Rachmilewitz, and a histological score. In addition, laboratory tests were performed and urinary excretion of 5-ASA and its metabolite N-Ac-5-ASA was analysed. The study lasted for 26 weeks. RESULTS: Balsalazide 3.0 g twice daily resulted in a significantly higher clinical remission rate (77.5%) than balsalazide 1.5 g twice daily (43.8%) and mesalazine 0.5 g three times daily (56.8%) (p=0.006). The respective times to relapse were 161 days, 131 days (p=0.003), and 144 days (NS). Accordingly, pairwise contrasts of the final endoscopic score demonstrated a significant difference (p=0.005) between the two balsalazide treatment groups while differences between either of these two groups and mesalazine were not statistically significant. Patients treated with balsalazide excreted less 5-ASA and N-Ac-5-ASA than patients receiving mesalazine but these differences were not statistically significant. Discontinuation of the trial because of adverse effects occurred in nine patients: three in the balsalazide 1.5 g twice daily group, two in the balsalazide 3.0 g twice daily group, and four in the mesalazine 0.5 g three times daily group. No clinically important new drug safety related findings were identified in this study. CONCLUSIONS: High dose balsalazide (3.0 g twice daily) was superior in maintaining remission in patients with ulcerative colitis compared with a low dose (1.5 g twice daily) or a standard dose of mesalazine (0.5 g three times daily). All three treatments were safe and well tolerated.

[Preparation for colonoscopy: A comparison between 3 commercially available Golytely solutions]. / Koloskopievorbereitung: ein Vergleich von 3 Fertig-Golytely-Lösungen.

The preparation for colonoscopy is essential for the results of the examination. The effectiveness of 3 commercially available Golytely solutions for colonoscopy (Original-Golytely-salt, Oralav and Delcoprep) were compared in a randomized prospective study. 310 outpatients were randomized into 3 groups. One of the above-mentioned solutions were used in these patients. Before the examination the patients were asked to drink 3 l of the given solution within 2 h. The colonoscopy was realized within 3-5 h after the end of preparation. Outcome criteria were the subjective acceptability of the solution for the patient, cleanness of the bowel and the formation of foam. In all 3 groups sufficient up to very good results could be achieved. There were no significant differences in the 3 groups. We conclude that the used procedure is absolutely sufficient to prepare for colonoscopy and that administration of liquids of more than 3 l or the use of enema or laxans on the previous day, are unnecessary. The suggested procedure can be used for children, too.

Olsalazine versus mesalazine in the treatment of mild to moderate ulcerative colitis.

AIM: To compare the efficacy and tolerability of olsalazine sodium with enteric-coated mesalazine in inducing endoscopic remission in patients with mild to moderate active ulcerative colitis. PATIENTS AND METHODS: Patients with mild to moderate active ulcerative colitis were randomized to receive either olsalazine sodium, 3 g/day (n = 88), or mesalazine, 3 g/day (n = 80), for up to 12 weeks. RESULTS: Of the patients treated with olsalazine sodium, 52.2% achieved endoscopic remission, compared with 48.8% of patients treated with mesalazine. This difference was not significant (P = 0.67). There was a nonsignificant trend for patients with left-sided colitis or a more severe endoscopic grade to achieve remission if they were treated with olsalazine sodium than if they were treated with mesalazine. Both treatments were comparable with respect to clinical activity index and an investigator's global assessment. Seventy patients reported one or more adverse events; adverse events were seen in 45% of olsalazine sodium-treated patients and in 36% of mesalazine-treated patients. Eleven patients treated with olsalazine sodium and nine patients treated with mesalazine withdrew from the study because of adverse events. One patient treated with olsalazine sodium compared with two treated with mesalazine stopped treatment because of diarrhoea. Serious adverse events occurred in three patients treated with olsalazine sodium and in four treated with mesalazine. CONCLUSION: Therapeutic effectiveness and tolerance to the treatment did not differ between olsalazine sodium, 3 g/day, and mesalazine, 3 g/day, in inducing endoscopic remission in patients with mild to moderate active ulcerative colitis within 12 weeks of treatment.

[Stomach volume reduction balloon for weight loss: what is the justification for this controversial method?]. / Der Magenvolumen-Reduzierungsballon zur Gewichtsreduktion: Welche Berechtigung hat diese umstrittene Methode?

UNLABELLED: Overweight and extreme morbid obesity are a common problem in our society. There are many therapeutic options currently available, but none of them can be considered as being ideal. One of these therapeutic interventions is the implantation of an intragastric balloon under endoscopic guidance. PURPOSE: Investigation of the effect of intragastric balloon Implantation on weight reduction. PATIENTS AND METHODS: In a prospective (and in part blinded) study 4 groups of patients (n = 10 each) were evaluated. In group I and II an intragastric balloon was implanted under endoscopic guidance. Group II had an intensive additional therapy by a dietition. Group I was advised to restrict themselves to a 1500 kcal diet. Group III did receive a sham implantation and the same additional therapy as group II. Group IV served as a control group and did not receive any type of treatment except the advice to restrict themselves to a diet. All balloons were explanted after 6 months. The overall follow-up rate was 18 months with a regular control of patients body weight. RESULTS: Patient inclusion criteria were comparable in all 4 groups. After 6 and 12 months a marked weight reduction was observed in group I and II when compared with group III and IV. This weight reduction was stable over time and reached statistical significance after 18 months. Additionally the results of group II (intensive additional therapy by a dietition) were better than in group I. Patients of group IV gained weight. No major complications due to the im- and explantation of the balloon were observed. CONCLUSIONS: The application of an intragastric balloon seems to be effective with regard of weight loss. The patient gets the chance to learn a more effective diet regimen which in our study population had a long lasting effect. Implantation of an intragastric balloon seems to be effective for a selective and highly motivated subpopulation of obese patients.

[Preparation for colonoscopy: a reliable and easily implemented regimen]. / Koloskopievorbereitung: ein sicheres und einfach zu handhabendes Regime.

Three different colonoscopy preparation methods were tested in 150 out-patients who received colonoscopies, 50 in each group, a randomized prospective simple blind study. The original Golytely-recepture with three litres of liquid was tested against Clean Prep which has to be dissolved in four litres of liquid. Both receptures had the same isotonic salt solutions. The third group was a method with a laxans (X-Prep) including eating restriction lasting three days. The judgment criteria were the cleanliness of the bowel, the formation of foam and the subjective sensitivity of the patient during the preparation phase. The preparation with the three bags containing three litres of Golytely solution according to the original recepture proved to be the least troublesome for the patients and was the most efficient method when it came to cleanliness and the formation of foam. The costs of this preparation methods were lower than those of the other methods.

Oesophageal ulceration by tuberculosis: a rare cause of dysphagia.

We report on a 58-year old female patient from Afghanistan, who developed a dysphagia within 3 weeks of arrival. On the basis of radiological and endoscopic examination, an oesophageal ulcer was regarded as a malignant tumour, but because of weight loss, fever and night sweats (B symptoms) the question of tuberculosis was also considered by the pathologist. Histological assessment of biopsies produced proof of epithelioid cell granulomas with marginally polygonal giant cells of Langhans-type, as of acid-fast bacilli. In a bacteriological test, three different types of mycobacteria were found. With adequate anti-tuberculosis therapy, the oesophageal ulcer and the mediastinal lymph nodes visible in the computed tomograph soon disappeared, and the patient became free of symptoms. The clinical picture was interpreted as a primary oesophageal tuberculosis with mediastinal lymph nodes as the primary complex. In cases of oesophageal ulcer or dysphagia, tuberculosis should be included in the differential diagnosis, particularly in patients from Asia.

[Whipple's disease--a rare cause of secondary amyloidosis]. / Morbus Whipple--seltene Ursache einer sekundären Amyloidose.

Two cases of Whipple's disease with secondary amyloidosis are described. One patient had a nephrotic syndrome, the other malabsorption. The chronic inflammatory stimulus of Whipple's disease is discussed as a trigger for the development of secondary amyloidosis. The clinical symptoms of seronegative arthritis, weight loss, chronic diarrhea, intermittent fever and lymphadenopathy may be the clue to the diagnosis of Whipple's disease. Peroral intestinal biopsy is the diagnostic procedure of choice. Adequate antibiotic treatment with a regimen of penicillin and trimethoprim-sulfamethoxazole is indicated and prevents the development of secondary amyloidosis.