[Non-cirrhotic portal hypertension presented by acute upper gastrointestinal bleeding 7 years after oxaliplatin-chemotherapy]. / Nicht zirrhotische portale Hypertension mit bedrohlicher Blutungskomplikation 7 Jahre nach Oxaliplatin-Chemotherapie.

After having received adjuvant FOLFOX treatment consisting of oxaliplatin, folinic acid and fluoruracil following hemicolectomy in colon cancer 7 years ago, the findings of non-cirrhotic portal hypertension presented by acute upper gastrointestinal bleeding in a 49-year old woman were interpreted as oxaliplatin-associated. Imaging techniques, hepatic venous pressure measurement and liver biopsy supported pre-sinusoidal damage due to NRH (nodular regenerative hyperplasia) as the underlying cause, even though histological findings were moderate. Following primary endoscopic treatment, a stable condition has thus far been achievable with standard drug therapy.

[Cystic echinococcosis and hepatocellular carcinoma--a coincidence? A case report]. / Zystische Echinokokkose und hepatozelluläres Karzinom--zufällige Koinzidenz? Ein Fallbericht.

INTRODUCTION: The coincidence of echinococcosis and hepatocellular carcinoma (HCC) is quite rare. We report the case of a 45-year-old man who was admitted to our hospital because of abdominal pain in the right upper quadrant and jaundice. Clinical features and diagnostics: There was no history of weight loss or fever. No abdominal mass was palpable. The laboratory reports showed increased transaminase levels. Ultrasonography revealed an inhomogenous, cystic lesion measuring 6 cm in diameter in the segments VI and VII. Serology for echinococcosis was negative, alpha-fetoprotein (AFP) was considerably increased. CT scan showed a solid mass of 3,7 cm in diameter adjacent to the cystic lesion. THERAPY AND COURSE: Anthelminthic therapy with albendazole caused a massive increase of cholestasis parameters and treatment had to be stopped. The simultaneous occurrence of serologically negative cystic echinococcosis and HCC was suspected and partial liver resection was performed. Histological examination confirmed both diagnoses and tumor resection in healthy tissue. 5 months after resection CT scan showed multicentric HCC affecting the whole liver. Palliative therapy with sorafenib was established. DISCUSSION: The coincidence of HCC and cystic echinococcosis in the non-cirrhotic liver of a young man is a rare event. Despite resection in healthy tissue multicentric HCC was diagnosed 5 months later. Only few cases of simultaneous occurrence of HCC and echinococcosis have been published so far. Some authors considered echinococcosis as a trigger for HCC. A causal link between both entities has not been demonstrated until now.

[Cytological diagnosis of salivary gland tumours]. / Zytologie der Speicheldrüsentumoren. Erfahrungsbericht.

This review gives a short survey of cytological criteria of the most common salivary gland tumours. The emphasis is on a short and precise as well as practicable summary of the most important cytological criteria and comprehensive presentation without claiming completeness. In addition our own results were compared with other international data and publications.

Lansoprazole-associated collagenous colitis: a case report.

A 57-year-old man developed chronic, watery diarrhea four weeks after Helicobacter pylori eradication therapy including lansoprazole followed by lansoprazole monotherapy for gastroesophageal reflux disease. Four weeks later the patient was admitted to our hospital. By repeated testing other causes of diarrhea, e. g., infectious diarrhea including Clostridium difficile colitis were excluded. Endoscopy showed a normal colon, histopathology of random biopsies of all sections of the colon demonstrated the characteristic features of collagenous colitis. Withdrawal of lansoprazole lead to prompt and sustained relief. Two months later repeat colonoscopy with biopsies showed no evidence of collagenous colitis. Collagenous colitis as a subtype of microscopic colitis is a rare cause of chronic diarrhea with unknown pathogenesis. The reported case represents an unusual association between medication with the proton pump inhibitor lansoprazole and the development of collagenous colitis suggesting the importance of evaluation of drug use in patients with microscopic colitis.

[W.D.H.A. Syndrome due to occult neuroendocrine malignancy with concomitant liver metastases]. / Okkulte, maligne neuroendokrine Neoplasie mit Lebermetastasen als Ursache eines WDHA-Syndroms.

In June 1999, a 62-year-old man is hospitalised to evaluate the sonographic suspicion of liver metastases. The biopsy of the liver shows a malignant neuroendocrine tumour. Further diagnostic investigation including gastroscopy, colonoscopy, enteroclysis, thoracal and abdominal CT and somatostatin-receptor-scintigraphy does not localise the primary tumour. In the absence of clinical symptoms a wait and see procedure with clinical and imaging controls at regular intervals is arranged. Beginning in spring of 2001--nearly two years after the initial diagnosis--the patient suffers from progredient diarrhoea and weight loss leading to hospitalisation in September 2001. The existence of secretory diarrhoea, hypokalaemia and hypercalcaemia arouses suspicion of vipoma. This is proven by a remarkably elevated plasma concentration of vasoactive intestinal peptide (VIP). Once more, an accurate investigation is started but no primary tumour can be discovered despite extensive liver metastases. A vipoma is a rare differential diagnosis of secretory diarrhoea. This case report describes the remarkable constellation of liver metastases of a malignant neuroendocrine neoplasm without a primary tumour and the clinical presentation of a W.D.H.A. syndrome (watery diarrhoea, hypokalaemia and hypo- or achlorhydria). Despite extensive disease, therapy with octreotide and prednisolone provides a good clinical response.

[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.

[Gastrointestinal hemorrhage needing blood transfusion as the first manifestation of small bowel carcinoid tumor]. / Transfusionspflichtige gastrointestinale Blutung als Erstmanifestation eines Dünndarmkarzinoids.

Carcinoid tumors arise from enterochromaffin or enterochromaffin-like cells that are present in the gastrointestinal tract, ovaries, and lungs. Over 90% of carcinoids originate in the gastrointestinal tract with the most common sites in order of frequency being the appendix, terminal ileum, rectum, and the remainder of the colon. Gastroduodenal and pancreatic carcinoids are infrequent. Carcinoid syndrome is associated with small intestine carcinoids in about 40%. Common symptoms include intermittent intestinal obstruction with crampy abdominal pain and vomiting, and weight loss. Upper gastrointestinal bleeding with melaena or hematochezia is a relatively rare early symptom of patients with small intestine carcinoid tumors. We report on a 69-year-old man, treated with acenocoumarol for previous thromboembolic complications of hereditary protein S deficiency. He was admitted to hospital because of an acute episode of hematochezia followed by melaena. Endoscopic evaluation of esophagus, stomach, duodenum and colonoscopy revealed no apparent source of bleeding. Selective angiographic evaluation of mesenterial arteries showed pathologic vasculature approximately in mid jejunum. Laparotomy revealed bleeding from a small submucosal malignant carcinoid tumor in small intestine and multiple large metastases within mesenteric tissue. Segmental resection of small intestine and exstirpation of the metastatic masses was performed. Postoperative period was uneventful. Cytotoxic chemotherapy in this adjuvant setting has not been recommended. Small intestinal carcinoid tumor has to be considered as a rare cause of gastrointestinal bleeding with melaena or hematochezia. Nevertheless, bleeding is a relatively rare early symptom of patients with small intestine carcinoid tumor.

[Cholestatic hepatitis as a rare side effect of therapy with ticlopidine]. / Cholestatische Hepatitis als seltene Nebenwirkung einer Therapie mit Ticlopidin.

A 71-year-old man with chronic atrial fibrillation was treated with aspirin because of a right cerebral infarction. Oral anticoagulation was not initiated because of a secondary hemorrhagic transformation. Six years later after a left cerebral transient ischemic attack aspirin was replaced by ticlopidine. Two weeks after starting ticlopidine he experienced abdominal cramps and diarrhea. Also dark urine and gray-colored stools were noticed, so that the patient stopped taking ticlopidine. 40 days after starting ticlopidine he was admitted to our hospital because of cholestatic jaundice. Serum alkaline phosphatase (305 U/l) and gamma GT (143 U/l) were elevated, the total bilirubin was 18.6 mg/dl at peak. GOT and GPT were 2.7 fold increased. After exclusion of a viral infection and autoimmune disease liver biopsy was performed, which showed a centroacinar cholestasis compatible with a drug-induced liver damage. 79 days after discontinuation of the drug laboratory signs of cholestasis had disappeared. In patients in whom long-term therapy with ticlopidine is indicated regularly laboratory tests and clinical examinations should be done to recognize infrequent side effects such as the cholestatic hepatitis in time.

[A 24-year-old patient with decreased libido and erectile dysfunction as initial manifestations of hemochromatosis]. / Ein 24jähriger Patient mit Libidoverlust und erektiler Dysfunktion als Erstmanifestation einer Hämochromatose.

HISTORY AND CLINICAL FINDINGS: A 24 year old yugoslavian father of two children, complained of decreased libido and impotence since seven months. He also described recurrent joint pains in the knees and wrist joints. The urological and internal examination was unremarkable. INVESTIGATIONS: Except for slightly elevated liver enzymes and a mild thrombocytopenia the laboratory tests were normal. Testosteron, follicle stimulating hormone and luteinizing hormone concentrations were markedly decreased. Hepatosplenomegaly was demonstrated by ultrasound. TREATMENT AND COURSE: During testosteron administration for hypogonadotrophic hypogonadism erectile dysfunction improved. 9 months later the patient became diabetic and was referred to our department. Hemochromatosis was confirmed by serum ferritin concentration of 4010 micrograms/l, transferrin saturation of 85% and hepatic iron concentration of 27,900 micrograms/g dry weight. Molecular genetics showed no mutation of the hemochromatosis gene HFE. After venesection the ferritin concentration decreased, the loss of libido and subfertility improved with testosterone administration. CONCLUSION: In subfertility from an endocrine disorder primary hemochromatosis should be considered in the differential diagnosis. Only early diagnosis and prompt iron depletion may improve the prognosis of these patients.

Stabilization of fibrin-chondrocyte constructs for cartilage reconstruction.

Cartilage replacement is a challenging issue in reconstructive surgery. In the past few years, tissue engineering has been tested as a means of cartilage reconstruction. Tissue engineering of cartilage depends on the use of adequate polymers. In addition to several natural and synthetic polymers, fibrin gel has been tested for cartilage reconstruction. However, fibrin is intrinsically unstable. The purpose of this study was to stabilize fibrin by increased fibrinolytic inhibition and to test these preparations for cartilage reconstruction with human nasal septum chondrocytes. Increased fibrinolytic inhibition was achieved with aprotinin and tranexamic acid. Stabilized fibrin-chondrocyte constructs were cultivated for 4 weeks in vitro and compared with constructs made of standard, commercially available fibrin gel. The effect of several cell densities on stability, and the production of extracellular matrix components, were assessed on the basis of histology and immunohistochemistry. In contrast to constructs made of standard fibrin gel, stabilized constructs were stable for the entire observation period and demonstrated no or only minor shrinkage. Cells in these constructs appeared to be viable, and an extracellular matrix could be demonstrated in all constructs. The authors conclude that fibrin-chondrocyte constructs stabilized by increased fibrinolytic inhibition could be an adequate tool for cartilage reconstruction.

[Aneurysm of the cystic artery as a rare cause of hemobilia]. / Aneurysma der Arteria cystica als seltene Ursache einer Hämobilie.

A 52-year old woman was admitted to the hospital because of upper abdominal pain and hematemesis. Laboratory parameters showed marked cholestasis. Endoscopic retrograde cholangiopancreatography (ERCP) lead to the diagnosis of hemobilia. CT-scan and angiography revealed an aneurysm of the cystic artery as the cause of hemobilia. Cholecystectomy was performed because of concomitant cholecystitis. Anatomical examination confirmed clinical diagnosis.

[Spontaneous regression of a small cell bronchial carcinoma]. / Spontanregression eines kleinzelligen Bronchuskarzinoms.

A circular focus of 1 cm diameter was discovered by chance on a thoracic x-ray of a female patient of 66 years of age suffering from chronic interstitial nephritis due to analgesics. Bronchoscopic suction revealed histologically a small-cell carcinoma of the lung but there was no indication of formation of metastases. The patient refused any tumor-specific treatment. In the further course of the disease the focus showed up radiologically for seven months and was then no longer visible throughout the following 14 months. The patient finally died subsequent to an extensive posterior myocardial infarction. Postmortem examination excluded the presence of a primary tumor of the lung or metastases. Our case suggests the rare occurrence of a spontaneous regression of a small-cell bronchial carcinoma. Although spontaneous regression of malignant diseases is ascribed to immunological factors, such regression can also occur if the immunological system is impaired, as had been the case in this particular patient with chronic renal insufficiency.

[Stereotactically guided histologic punch biopsy of the breast in comparison with stereotactically guided cytologic puncture]. / Die stereotaktisch gezielte histologische Stanzbiopsie der Mamma im Vergleich zur stereotaktisch gezielten zytologischen Punktion.

Stereotactic large-core biopsy provides better results in comparison to stereotactic cytologic fine-needle aspiration. Good results arise in 92.52% of the cases; that is 13.17% better than fine-needle aspiration. Technique and indication of the cases are described.