[Colocutaneous fistula after a PEG procedure with introducer technique and gastropexy]. / Kolokutane Fistel nach PEG-Anlage mittels Introducer-Technik mit Gastropexie.

INTRODUCTION: The pull-PEG (percutaneous endoscopic gastrostomy) is the most commonly used procedure for PEG placement. Alternative methods may be used in patients with an obstructed oesophagus. We here present the case of an unusual complication during PEG placement with the new introducer technique and gastropexy. CASE REPORT: A 74-year-old men with progressive thymus cell carcinoma was referred for a PEG procedure. Since the tumour stenosis in the oesophagus was only passable with a slim-sight endoscope (5,9 mm), we decided in favour of the direct PEG method with gastropexy. The procedure was performed without any complications. 35 days later we changed the balloon catheter and were able to easily inflate the balloon. Surprisingly, the X-ray performed thereafter, revealed a misplacement of the catheter in the colon without any notable contrast medium in the stomach. Although the patient expressed no complaints, he underwent surgery on the same day proving the colocutaneous fistula. There were no signs of peritonitis. The patient's postoperative recovery was uneventful. DISCUSSION: Pull-PEG requires an intact oesophageal passage. The spread of bacteria and tumour cells is a possible risk factor. Direct punction PEG might be better in these cases. This method is not a standard procedure, but the recent implementation of an additional gastropexy represents a significant improvement. We experienced a rare complication, which was first described in 1987. However, this case is the first documented complication in association with gastropexy. This case shows that even gastropexy does not prevent colon interposition. Therefore, an endoscopic or radiological control of the tube placement after changing seems to be necessary.

Examination, prevention and treatment of osteoporosis in patients with inflammatory bowel disease: recommendations and reality.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and osteoporosis. Our aim was to evaluate the current practices of examination, prevention and treatment of osteoporosis in IBD patients in a routine clinical setting. METHODS: A total of 154 consecutive patients with IBD (63 female, 91 male; 36 ulcerative colitis, 115 Crohn's disease, 3 indeterminate colitis), referred to two gastroenterological units for scheduled follow-up examinations, were included. Patient charts were evaluated regarding bone densitometry already performed and any prophylactic or therapeutic interventions in cases of low bone mineral density. RESULTS: Bone mineral density (BMD) measurements had been performed only in 38 patients (25%). BMD was abnormally low in 27 of the examined patients (71%), 20 of whom had osteopenia and seven had osteoporosis. Among the subgroup of patients on long-term steroid therapy (77 patients), 30 had been referred to bone densitometry during the course of disease, and 21 of them were found to have low bone mineral density. Preventive measures were prescribed in 12 patients (9% of the whole study population). In the majority of the patients with low bone mineral density, calcium and vitamin D were used as treatment. CONCLUSIONS: Despite the high prevalence of osteopenia and osteoporosis in patients with IBD, only a minority of these patients were included in a structured program in accordance with modern guidelines for diagnosing and preventing this extraintestinal complication in a routine clinical setting.

[Indications and results of endoscopic examinations in intensive care units]. / Indikation und Resultate der Endoskopie auf Intensivstationen.

The aim of the study was to analyze retrospectively all endoscopies performed on 3 intensive care units in a tertiary referral center with more than thousand beds during a period of ten years. The study evaluates all endoscopies with regard to indication and findings. In the years 1989-1998 a total of 326 endoscopic examinations was performed, most of them were done as an upper gastrointestinal endoscopy (88%). In more than 87% the indication was a suspected gastrointestinal bleeding. The most frequent findings consisted in ulcers of the stomach or duodenum and esophageal varices, then followed by Mallory-Weiss-lesions, esophagitis and erosive gastritis. The etiology of gastrointestinal bleeding was similar to that of non intensive care patients. Specific causes of bleeding such as esophagitis caused by nasogastric tubes were only found in 3% of all bleedings. The numbers of endoscopies on the 3 intensive care units were increasing during the ten year period, however the numbers of the patients treated on the intensive care units were also increasing, but the increase of endoscopies was not always parallel to the rising number of intensive care patients.

[Fever and weight loss as leading symptoms of infection with giardia lamblia]. / Status febrilis und Gewichtsverlust als Leitsymptome einer Giardiasis*

Infections, malignancies and autoimmune diseases are the most important causes of fever of unknown origin.A case report of a 80-year old patient is described, who was admitted to our hospital because of fever lasting more than 2 weeks, weight loss and lack of appetite. Physical examination did not provide any relevant information, laboratory tests revealed an elevation of inflammation markers and anemia. Serological tests for infectious and autoimmune diseases and cultures of stool, blood and urine were all negative. Imaging did not show any pathological findings, colonoscopy and gastroscopy were macroscopically normal. Surprisingly, histology showed massive giardiasis of the duodenum. After initiation of therapy with metronidazol, fever and inflammation markers declined and the patient could be discharged from hospital without complaints on the 15(th) day after admission. Giardia lamblia is one of the most common intestinal pathogens worldwide. Infection can cause acute diarrhea, but may also be responsible for chronic abdominal complaints or may stay asymptomatic. To our knowledge, giardiasis has not been described as differential diagnosis of fever of unknown origin so far. In synopsis of clinical presentation and outcome after antibiotic therapy, we postulate that Giardia lamblia was the relevant cause of fever and weight loss in this case. In patients presenting with these symptoms, Giardia lamblia should be considered as differential diagnosis.

[Obstructive jaundice and acute pancreatitis due to an obstruction of the afferent loop after billroth-II-resection]. / Verschlussikterus und akute Pankreatitis durch Obstruktion der zuführenden Schlinge nach Billroth-II-Resektion.

An obstruction of the afferent loop after Billroth-II-resection is an extremely rare late complication of this procedure. We report on a 76-year-old female patient with a history of Billroth-II-resection 11 years ago who was admitted due to acute pancreatitis and obstructive jaundice. Abdominal sonography lead to the suspicion of a dilated afferent loop, which could be proven by means of magnetic resonance imaging. A tumorous lesion as cause of the obstructive jaundice was not detectable. Intraoperatively a volvulus of the small intestine and strangling adhesions near the Braun's anastomosis were seen, causing the obstruction of the afferent loop. Following reposition of the small intestine and adhesiolysis the patient gained a quick relief of symptoms and the jaundice disappeared completely.

[Colonoscopy and sigmoidoscopy in patients aged eighty years or older]. / Koloskopie und Sigmoidoskopie bei über achtzigjährigen Patienten.

BACKGROUND: The demographic development will lead to an increase in endoscopic examinations in elderly patients. Indications, feasibility and therapeutic consequences following detection of pathologic findings are important assessing the relevance of endoscopy in geriatric patients. METHODS: We analyzed all colonoscopies and sigmoidoscopies which were performed between January 1995 and December 2000 in patients older than 80 years. The parameters indication, sedation, colonoscopy completion rate, endoscopic findings, therapeutic consequences and complications were evaluated. RESULTS: A total of 951 endoscopies in patients older than 80 years (781 colonoscopies, 170 sigmoidoscopies; mean age 84.3 years) were performed. The most frequent indications were: abdominal pain (n = 144; 15 %), bleeding (n = 115; 12 %), constipation (n = 97; 10 %), anemia (n = 85; 9 %), and history of polyps (n = 78; 8 %). Sedation was used in 183 examinations (19 %), mostly with midazolam (n = 179). Colonoscopy was completed successfully to the coecum in 71 %. 214 examinations were unremarkable (23 %). Frequent pathologic findings were: diverticular disease (n = 396; 42 %), polyps (n = 256; 27 %), and colorectal carcinoma (n = 75; 8 %). Curative surgery was possible in 55 % and palliative surgery in 9 % of patients with colorectal carcinoma, respectively. A complication was observed in six patients (0.6 %), four bleedings following polypectomy, one perforation after dilatation of a stenotic tumor, and one transient neurologic deficit. CONCLUSIONS: Endoscopy of the lower gastrointestinal tract is feasible in geriatric patients with a low rate of complications. The low number of normal findings and the frequent diagnosis of colorectal carcinoma were remarkable. In spite of old age more than half of the patients with carcinoma could be operated curatively emphasizing the importance of endoscopic investigations in this age group.

[Current concepts in therapy of reflux disease]. / Aktuelle Konzepte in der Therapie der Refluxerkrankung.

Proton pump inhibitors have replaced H2-blockers as first line agents for the therapy of gastroesophageal reflux disease due to their effective acid suppression and faster healing rate. The endoscopic severity of esophagitis and the clinical response are the most important determinants of dosing and duration of therapy. In patients with severe esophagitis continuous maintenance treatment with proton pump inhibitors is recommended. In recent years antireflux surgery has been established as an important alternative therapy.

[Risk of osteoporosis in steroid therapy. When and how to counter the risk]. / Osteoporosegefahr unter Steroidtherapie. Wann und wie Sie gegensteuern.

Many chronic inflammatory diseases require treatment with steroids, however, a remarkable proportion of steroid-treated patients suffer from osteoporosis as a major complication following longterm treatment. Steroid-induced osteoporosis with its complex pathogenesis represents one of the most important secondary causes of osteoporosis. If we care for patients with steroid therapy we have both to consider this problem and to focus on strategies to evaluate patients at risk. The dosage of the steroid, life style factors, menopausal status, low bone mineral density at baseline and previous osteoporotic fractures predispose for the manifestation of steroid-induced osteoporosis. Decisions in regard of prevention and therapy depend on risk factors of the individual patient. Supplementation of calcium and vitamin D is usually appropriate, and postmenopausal women should be offered hormone replacement therapy. The prescription of bisphosphonates is strongly recommended to patients at elevated risk or to patients with already documented osteoporosis.

Concomitant manifestation of achalasia and sphincter of Oddi dysfunction.

We report the case of a 44-year-old woman who suffered from biliary-type pain after cholecystectomy, dysphagia, and weight loss. Examinations revealed sphincter of Oddi dysfunction (SOD) and achalasia. Complete relief of symptoms was achieved by endoscopic sphincterotomy and pneumatic dilation of the distal esophagus. This case report demonstrates for the first time the concomitant manifestation of two motility disorders of the upper gastrointestinal tract, i.e. achalasia and SOD. At present, any causal relationship seems speculative; however, both diseases were successfully treated using endoscopic procedures.

[Steroid-induced osteoporosis: pathogenesis and therapeutic consequences]. / Steroid-induzierte Osteoporose: Pathogenese und therapeutische Konsequenzen.

Many chronic inflammatory diseases require treatment with steroids, however, a remarkable proportion of steroid-treated patients suffer from osteoporosis as major complication after longterm treatment. Steroid-induced osteoporosis represents one of the most important secondary causes of osteoporosis. The pathogenesis is complex, there exists evidence that steroids cause a reduction of circulating testosterone and estrogen concentration and adversely affect calcium balance. The most important mechanism is a decrease in osteoblastic activity. As a consequence loss of bone mineral density and increased risk of fracture develop. In spite of better understanding of the causal relationships preventive strategies were infrequently applied. If we care for patients with steroid therapy we have both to consider the problem of steroid-induced osteoporosis and to focus on strategies to evaluate patients at risk. The dosage of the steroid, life style factors (such as lack of exercise, alcohol consumption and smoking), menopausal status, low bone mineral density at baseline and previous osteoporotic fractures predispose for the manifestation of steroid-induced osteoporosis. Therapeutic decisions depend on risk factors of the individual patient. Supplementation of calcium and vitamin D is usually appropriate, and postmenopausal women should be offered hormone replacement therapy. The prescription of bisphosphonates is strongly recommended to patients at elevated risk.

[Angioleiomyoma of the gallbladder: a rare cause of hemobilia in a patient on dialysis]. / Angioleiomyom der Gallenblase. Seltene Ursache einer Hämobilie bei einem Dialysepatienten.

HISTORY AND FINDINGS: Acute colicky upper abdominal pain occurred in a 47-year-old man on renal dialysis who also had chronic recurrent pancreatitis. On physical examination he was noted to be slightly jaundiced and he had slight pain when the liver edge was palpated. A few days later melaena developed and the haemoglobin concentration fell from normal levels to 6.9 g/dl. INVESTIGATIONS: Serology gave no evidence of acute pancreatitis, but biochemical tests indicated cholestasis. Ultrasonography revealed widening of the intra- and extrahepatic biliary tract. Endoscopic retrograde cholecystopancreatography demonstrated bleeding from the biliary tract (haemobilia) as the source of the bleeding. Selective angiography of the coeliac trunk showed extravasation in the region of the gallbladder. TREATMENT AND COURSE: As a vascular anomaly in the gallbladder was suspected, a cholecystectomy was performed. The surgical specimen revealed an angioleiomyoma of the gallbladder. The postoperative course was without complications and there was no further haemobilia. CONCLUSIONS: Haemobilia is a relatively rare cause of upper gastrointestinal bleeding. It is usually due to trauma (accidental or iatrogenic) to the liver or the biliary tract. Rarely, as in this case, it can be caused by a benign mesenchymal neoplasm. Clotting disorder in uraemia or intermittent heparin administration for dialysis may in this patient have contributed to the bleeding.