[Percutaneous endoscopic colostomy for treatment of an antibiotic-induced pseudomembranous colitis]. / Perkutane endoskopische Kolostomie ("PEC") zur Behandlung einer therapierefraktären pseudomembranösen Kolitis.

HISTORY AND ADMISSION FINDINGS: A 61-year-old man was admitted with diffuse abdominal pain and diarrhea for one week. A few weeks before admission he had been given antibiotics for an exacerbation of his chronic obstructive pulmonary disease. On physical examination he presented with bronchospasm, abdominal tenderness, active bowel sounds and slight edema in both legs. INVESTIGATIONS: Blood tests detected an acute inflammation and colonoscopy revealed a massive inflammation of the bowel with pseudomembranes. Clostridium difficile and Clostridium toxin was isolated from the feces. TREATMENT AND COURSE: Oral antibiotic treatment with metronidazole and thereafter vancomycin was without effect. However, the colitis receded rapidly after vancomycin was given into the colon via a percutaneous endoscopic colostomy placed in the proximal ascending colon. CONCLUSION: There are increasing numbers of reports on severe Clostridium colitis. The percutaneous endoscopic colostomy with local application of antibiotics may improve outcome.

[Whipple's disease with segmental lesions in the proximal small intestine]. / Morbus Whipple mit segmentalem Befall des tiefen Duodenums.

HISTORY AND ADMISSION FINDINGS: A 67-year-old man with anemia was referred to our hospital. He had suffered from rheumatoid arthritis for ten years. Two months before admission he had been an inpatient at another hospital because of heart failure. He presented with edema, slightly elevated temperature and effusion in the right knee. INVESTIGATIONS: Laboratory findings revealed a chronic inflammation and an anemia of iron malabsorption. Duodenal histology showed PAS-positive macrophages typical for Whipple's disease. Tropheryma whippelii-DNA was found by polymerase chain reaction (PCR) in synovial and cerebrospinal fluid and broncho-alveolar lavage. TREATMENT AND COURSE: Antibiotic therapy was initiated, the antirheumatic medication terminated and iron was administered intravenously. The outcome was satisfactory. CONCLUSIONS: Rare systemic diseases should be considered in patients presenting with symptoms involving several organs. Whipple's disease can be cured only by adequate antibiotic therapy. The use of PCR facilitates the correct diagnosis.

[Stroke unit in a medical clinic: one year results and perspectives]. / Ein Jahr Schlaganfall-Station an einer Medizinischen Klinik. Ergebnisse und Perspektiven.

BACKGROUND: For patients with cerebral ischemia treatment on specialized stroke units is helpful. Details concerning organisation, diagnostic and therapy are discussed controversially. We report about a concept and the one-year results on a stroke unit in a major medical clinic. METHODS: The unit consists of four beds and is organizationally attached to the intensive care unit. Immediate diagnosis allows an early etiologic classification. Management of main cofactors (hypertension, heart rate, blood glucose, temperature) are regarded important. Neurologic and neuroradiologic expertise are available at any time. Patients are taken care of by specially trained staff (nursing/medical care, physiotherapy, ergotherapy, logopedics). RESULTS: Within a year (1.10.1999-30.9.2000) 340 patients with cerebral ischemia were treated in our stroke unit (152 men, 188 women, median age 75 years). Approximately 60% of the patients were admitted within 6 hours after the event. The Rankin-Scale was improved from 4 to 1, the Barthel-Index from 50 to 90. Over 60% of the patients were discharged home, 20% were transferred to a rehabilitation unit, 5% into a nursing home, 6% died. 5 patients with carotid stenosis underwent surgical treatment. CONCLUSION: Effective diagnosis and treatment of stroke is achievable under certain qualified conditions in a medical clinic and is indispensable for sufficient care.

[Normal values for 24-hour manometry of the esophagus]. / Normalwerte für die 24-Stunden-Manometrie der Speiseröhre.

OBJECTIVE: To obtain normal values of 24-hour manometry of the oesophagus. SUBJECTS AND METHODS: Oesophageal pressures were measured in 41 healthy volunteers who had given informed consent. Recordings were made for 24 hours via a two-channel catheter in 27 and via a 4-channel one in 14 subjects. The catheter orifices were 5 and 15 cm respectively 5, 10, 15 and 20 cm above the lower oesophageal sphincter. RESULTS: Median of contractions was 1523 at 5 cm and 1500 at 15 cm (1635 at 10 cm and 2135 at 20 cm) contraction amplitudes were 31 mm Hg at 5 cm, 26 mm Hg at 15 cm; 26 mm Hg at 10 cm and 37 mm Hg at 20 cm. On average 44% of the contractions were propulsive, 17% simultaneous and 30% nonpropulsive, the remainder not clearly defined. Neither age nor sex had a significant influence on the results. Motor activity was reduced during sleep. During eating the number of contractions, their amplitude and propulsive force increased. CONCLUSION: The listed measurements, by defining normal values, make it possible to diagnose hypo- and hypermotility of the oesophagus during long-time manometry. Two-point measurement is sufficient for assessing the smooth-muscle component.

Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.

BACKGROUND: Although injection treatments for ulcer haemostasis seem to be effective, recurrent bleeding remains a serious problem. Large randomised clinical trials are required to show differences between treatment modalities for gastrointestinal bleeding. The aim of this study was to compare the safety and efficacy of repeated endoscopic injection of fibrin glue (FG) with that of single endoscopic injection of polidocanol in the prevention of recurrent bleeding. METHODS: 854 patients with active gastroduodenal bleeding (spurting, oozing), or ulcers with a visible non-bleeding vessel, were randomly assigned one of three endoscopic treatments: single application of polidocanol 1%, single application of FG, or daily repeated application of FG until the visible vessel had disappeared. All patients were pretreated with local injection of epinephrine (1/10,000), and had daily repeat endoscopies until the vessel observed at initial endoscopy was no longer visible. FINDINGS: Recurrent bleeding rates among the 790 patients in whom the rates could be assessed were 58 (22.8%) of 254 in the polidocranol group, 51 (19.2%) of 266 in the FG-single group, and 41 (15.2%) of 270 in the FG-repeated group. The difference between FG-repeated treatment and polidocanol was significant (p = 0.036). Treatment failed, making other treatments (including surgery) necessary, in 34 (13.0%) of 261 in the polidocanol group, 34 (12.4%) of 274 in the FG-single group, and 21 (7.7%) of 274 in the FG-repeated group. The difference between FG-repeated treatment and polidocanol was significant (p = 0.046). The 30-day-mortality rates were low in all three treatment groups (polidocanol 4.7%; FG-single treatment 5.3%, FG-repeated treatment 4.3%). The safety profiles of the three treatment strategies were similar. INTERPRETATION: Repeated injection with FG glue is significantly more effective than injection with polidocanol 1% in the treatment of bleeding from gastroduodenal ulcers.

[Possibilities of ultrasonography of gastric emptying]. / Möglichkeiten der Magenentleerungssonographie.

Assessment of gastric emptying time by ultrasonography is increasingly used to evaluate gastroparesis. At first normal values have to be defined. In 20 healthy volunteers the upper value of half emptying time after a semisolid meal was 50 min. A good correlation of gastric emptying time evaluated by scintigraphy was found. Diabetics with autonomous neuropathy had a remarkable delay in gastric emptying, not seen in patients with functional dyspepsia. In dyspeptic patients pathologic width of the antrum (measured by planimetry after overnight fasting) decreased during therapy with cisapride in correlation to the improvement of symptoms.

[Do proton pump inhibitors after endoscopic control of acute ulcer hemorrhage have an advantage over H2 receptor antagonists?]. / Sind Protonenpumpenhemmer nach endoskopischer Stillung der akuten Ulcusblutung gegenüber H2-Rezeptorantagonisten von Vorteil?

During a two year period (1992-1993) we investigated whether or not, after endoscopic therapy of bleeding ulcers, the suppression of gastric acid secretion with an administration of a proton pump blocker (Omeprazol) is more effective than the administration of H2-receptor antagonist (Ranitidin) with respect to prevention of recurrent bleeding episodes, frequency of surgical intervention and mortality. 106 patients (64 men, 42 women) were treated with the proton pump blocker and 126 patients (82 men, 44 women) received the H2-receptor antagonist. Patients were treated either with an initial dose of 80 mg Omeprazol followed by 3 x 40 mg Omeprazol i.v. or with a daily dose of 3 mg/kg body weight Ranitidin i.v. No significant differences could be detected between the two treatment regimes with respect to the parameters mentioned above. Rebleeding which could be controlled by endoscopic hemostasis occurred in 19.8% vs. 17.5% (Omeprazol/Ranitidin) of patients. Surgical intervention because of rebleeding was necessary on 8.5% vs. 8.7% of the patients. Mortality due to hemorrhage was 5.7% vs. 4.0%. From these results we conclude that, following endoscopic hemostasis of bleeding ulcers, Omeprazol has no advantage over Ranitidin using our dosage regimes.

[The value of the urea/creatinine ratio for differentiation of up and lower gastrointestinal hemorrhage]. / Wertigkeit der Harnstoff/Kreatinin-Ratio zur Unterscheidung einer oberen von einer unteren gastrointestinalen Blutung.

The urea/creatinine-ratio has been proposed as an instrument for differentiating upper from lower gastrointestinal haemorrhages. The predictability of this method was investigated in 105 cases with the source of bleeding to be in the upper gastrointestinal tract and in 31 cases in the lower gastrointestinal tract. Determination of the urea/creatinine-ratio predicted the site of bleeding in only 60% of the patients. The use of the ratio in diagnostic decision making would increase the number of unnecessary colonoscopies. Thus, the urea/creatinine-ratio does not appear to be clinically useful in predicting the localization of a gastrointestinal bleeding with adequate certainty.