[Importance of functional diagnostics in gastroenterology]. / Stellenwert der Funktionsdiagnostik in der Gastroenterologie.

In this review article important and frequently used investigation methods for gastrointestinal functional diagnostics are presented. Some other rarely used special investigations are also explained. The hydrogen breath test is simple to carry out, ubiquitously available and enables the detection of lactose, fructose and sorbitol malabsorption. Furthermore, by the application of glucose, the test can be carried out when there is a suspicion of abnormal intestinal bacterial colonization and using lactulose for measuring small intestinal transit time. The 13C urea breath test is applied for non-invasive determination of Helicobacter pylori infections and assessment of gastrointestinal transit time, liver and exocrine pancreas functions. The secretin cholecystokinin test was the gold standard for the detection of exocrine pancreas insufficiency. However, measurement of pancreatic elastase in stool is less invasive but also less sensitive. Scintigraphy and capsule investigations with pH and temperature probes constitute important methods for determination of gastric emptying, intestinal and colon transit times. For evaluation of constipation panoramic abdominal images are taken after intake of radiologically opaque markers (Hinton test). For the diagnosis of functional esophageal diseases manometry is indispensable. In addition, manometry is only occasionally used for diagnosing a dysfunction of the sphincter of Oddi, due to the danger of inducing pancreatitis. A 24 h pH-metry is applied for the detection of non-erosive gastroesophageal reflux disease and, if necessary, with impedance measurements. Recent investigation procedures, e. g. specific MRI sequences, sonographic determination of gall bladder ejection fraction, analysis of gastric accomodation or real-time lumen imaging, require further evaluation prior to clinical application.

Factors associated with non-participation and dropout among cancer patients in a cluster-randomised controlled trial.

We investigated the impact of demographic and disease related factors on non-participation and dropout in a cluster-randomised behavioural trial in cancer patients with measurements taken between hospitalisation and 6 months thereafter. The percentages of non-participation and dropout were documented at each time point. Factors considered to be potentially related with non-participation and dropout were as follows: age, sex, marital status, education, income, employment status, tumour site and stage of disease. Of 1,338 eligible patients, 24% declined participation at baseline. Non-participation was higher in older patients (Odds Ratio [OR] 2.1, CI: 0.6-0.9) and those with advanced disease (OR 2.0, CI: 0.1-1.3). Dropout by 6 months was 25%. Dropout was more frequent with increased age (OR 2.8, CI: 0.8-1.2), advanced disease (OR 3.0, CI: 1.0-1.2), being married (OR 2.4, CI 0.7-1.1) and less frequent with university education (OR 0.4, CI -1.3 to -0.8) and middle income (OR 0.4, CI -0.9 to -0.7). When planning clinical trials, it is important to be aware of patient groups at high risk of non-participation or dropout, for example older patients or those with advanced disease. Trial designs should consider their special needs to increase their rate of participation.

[Proctology for internists]. / Proktologie für Internisten.

In proctology patients can often be helped with very little effort. With knowledge of the most common disease symptoms the treating physician can in many cases correctly recognize the cause of the complaints and initiate the appropriate therapy or arrange referral to a proctological institution. This article aims to briefly and succinctly present the most common diseases in proctology (e.g. mariscae, hemorrhoids, anal fissures, perianal venous thrombosis, abscesses and fistulas, condyloma acuminatum and anal carcinoma) and to provide the treating internist, even outside of gastroenterology, assistance with the management of proctological symptoms.

[Fecal microbiota transplantation]. / Fäkaler Mikrobiomtransfer.

The human intestinal microbiome has important metabolic and immunological functions for the host and is part of the defense against pathogens in the gastrointestinal tract. Antibiotics, probiotics, dietary measures, such as prebiotics, and the relatively newly established method of fecal microbiota transplantation (FMT, also known as fecal microbiome transfer) all influence the intestinal microbiome. The FMT procedure comprises the transmission of fecal microorganisms from a healthy donor into the gastrointestinal tract of a patient. The aim of this intervention is to restore a normal microbiome in patients with diseases associated with dysbiosis. The only indication for FMT is currently multiple recurrence of Clostridium difficile infections. Approximately 85% of affected patients can be successfully treated by FMT compared to only about 30% treated conventionally with vancomycin. Other possible therapeutic applications are chronic inflammatory and functional bowel diseases, insulin resistance and morbid obesity but these have to be evaluated further in clinical trials. Knowledge on the optimal donor, the best dosage and the most appropriate route of administration is still limited. A careful donor selection is necessary. The implementation of FMT in Germany is subject to the Medicines Act (Arzneimittelgesetz, AMG) with a duty of disclosure and personal implementation by the attending physician. By documentation in a central register long-term effects and side effects of FMT have to be evaluated.

[Endoscopic treatment of obesity and complications following bariatric surgery]. / Endoskopische Therapie von Adipositas und von Komplikationen nach bariatrischer Chirurgie.

The prevalence of obesity in the population has been increasing for many years. Due to associated comorbidities the treatment of obesity is becoming more important. Conservative treatment alone is often unsuccessful, particularly in cases of severe obesity. In these cases, multimodal therapy in specialized treatment units is warranted. Between conservative treatment and bariatric surgery, interventional endoscopic treatment options also play an increasing role. Nowadays, implantation of gastric balloons and duodenojejunal bypass liners (EndoBarrier) are the most often used endoscopic options. A further typical application of endoscopy in the treatment of obesity is the management of complications after bariatric surgery, such as stenosis and insufficiency. This article gives an overview on the currently available endoscopic options associated with treatment of obesity.

[S2k-guideline Helicobacter pylori and gastroduodenal ulcer disease]. / S2k-Leitlinie Helicobacter pylori und gastroduodenale Ulkuskrankheit.

In the line "bismuth-containing quadruple therapy" of Table 7 (p 342), in the column "dosage" incorrectly at the three antibiotics respectively 1-1-1-1. The correct is: 3-3-3-3.

English language version of the S3-consensus guidelines on chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis.

Chronic pancreatitis is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganization of the pancreas leads to a progressive exocrine and endocrine pancreatic insufficiency. In addition, characteristic complications arise, such as pseudocysts, pancreatic duct obstructions, duodenal obstruction, vascular complications, obstruction of the bile ducts, malnutrition and pain syndrome. Pain presents as the main symptom of patients with chronic pancreatitis. Chronic pancreatitis is a risk factor for pancreatic carcinoma. Chronic pancreatitis significantly reduces the quality of life and the life expectancy of affected patients. These guidelines were researched and compiled by 74 representatives from 11 learned societies and their intention is to serve evidence-based professional training as well as continuing education. On this basis they shall improve the medical care of affected patients in both the inpatient and outpatient sector. Chronic pancreatitis requires an adequate diagnostic workup and systematic management, given its severity, frequency, chronicity, and negative impact on the quality of life and life expectancy.

[Clinical impact of infections with carbapenem-resistant enterobacteriaceae in liver transplant recipients]. / Klinische Bedeutung von Infektionen durch Carbapenem-resistente Enterobakterien bei Lebertransplantierten.

Infections with carbapenem-resistant Enterobacteriaceae (CRE) are an emerging cause of morbidity and mortality among liver transplant recipients (LTR) worldwide, particularly Klebsiella pneumoniae carbapenemase (KPC)-producing organisms. Approximately 3 - 13 % of solid organ transplant recipients in CRE-endemic areas develop CRE infections, and the infection site correlates with the transplanted organ. The cumulative 30-day mortality rate of LTR infected with carbapenem-resistant K. pneumoniae is 36 %, and the 180-day mortality rate is 58 %. Awareness of the high vulnerability of LTR to fatal bacterial infection leads to the more frequent use of ultrabroad-spectrum empirical antibiotic therapy, which further contributes to the selection of extreme drug resistance. Moreover, it comprises a relevant risk of failure to initiate adequate empirical treatment due to the fact that culture-based techniques used to identify CRE imply a 48- to 72-hour delay from blood culture collection until administration of the targeted therapy. This vicious circle is difficult to avoid and leads to increased clinical intricacy and narrowed antimicrobial therapeutic options. Because available options are extremely limited, infection prevention measures have gained outstanding importance, particularly in the phase after liver transplant requiring intense immunosuppression early on. Improving clinical outcomes is a major challenge and involves a multi-targeted approach combining strictly applied hygiene measures, active surveillance tests, the use of modern, time-saving methods of molecular biology, and enforced antibiotic stewardship. This article reviews the current literature regarding the incidence and outcome of CRE infections in LTR, and it summarises current preventive and therapeutic recommendations to minimise the threat by CRE in real-life clinical transplant settings.

[Acute pancreatitis: guideline-based diagnosis and treatment]. / Akute Pankreatitis: Leitlinienbasierte Diagnostik und Therapie.

Acute pancreatitis is most frequently of biliary or alcoholic origin and less frequently due to iatrogenic (ERCP, medication) or metabolic causes. Diagnosis is usually based on abdominal pain and elevation of serum lipase to more than three-times the normal limit. Acute pancreatitis can either resolve quickly following an oedematous swelling or present as a severe necrotizing form. A major risk is the systemic inflammatory response syndrome (SIRS), which can cause multi-organ failure. Prediction of disease course is initially difficult, thus necessitating immediate therapy and regular re-evaluation. In order to prove or exclude biliary genesis, abdominal ultrasonography should first be performed and endoscopic ultrasound may also be required. Primary therapy includes rapid and correctly dosed fluid substitution. Biliary pancreatitis requires causal treatment. In the case of cholangitis, stone extraction must be performed immediately; in the absence of cholangitis, it might be advisable to wait for spontaneous stone clearance. Timely cholecystectomy is necessary in all cases of biliary pancreatitis.