[Protection of the mucosal barrier by nutritional strategies. What are the therapeutic options?]. / Protektion der Mukosabarriere durch Strategien der Ernährung. Welche therapeutischen Optionen gibt es?

The dysfunction of intestinal barrier allows the translocation of both endotoxin and whole bacterial organisms. It plays an important role in the development of multiple organ failure (MOF). The mucosa ia one component of this barrier. Trauma, atrophy and the "systemic inflammatory response syndrome" increase gastrointestinal permeability. These abnormalities may contribute to the pathophysiology of sepsis. Malnutrition per se compromises the gut's barrier function. Maintenance of gastrointestinal blood flow may be facilitated by (glutamine-enriched?) enteral diets. The most important conclusions of the majority of controlled trials support the concept of the very early enteral nutrition (within 24 hours after trauma): the outcome of seriously ill patients is improved, the rate of complications and infections is reduced. Gastrointestinal motility disorders may interfere with the initiation and tolerance of early enteral nutrition. They may be managed by prokinetic agents (cisapride, erythromycin) or by bypassing the stomach with a nasoenteric tube.

Postprandial changes of electrical activity of the stomach after different meals.

AIM: The aim of the study was to investigate the response of the electrical activity of the stomach (electrogastrogram, EGG) to meals, different with respect to consistency, nutrient and caloric composition. METHODS: EGG was recorded in ten healthy volunteers for 30 min before and 45 min after a meal. All subjects received three different meals: A standard 500 kcal solid, a 500 cc isocaloric liquid diet of identical composition (55% carbohydrates, 15% protein, 30% fat) or 500 cc water. Data were analyzed off-line for postprandial changes. RESULTS: Water as well as liquid diet induced a significant postprandial decrease, while solid food induced a slight initial decrease and a subsequent marked increase of the dominant frequency above the fasting level. The response to the solid meal was significantly different from both tap water and liquid diet, but there was no difference between liquid diet and water. All meals significantly increased the signal power with a more sustained effect over time for the liquid diet and water than the solid meal. CONCLUSION: EGG changes seem to be more dependent on the consistency than the caloric and nutrient composition. Because of the dissociation between the timing of EGG changes and the known emptying kinetics, EGG changes seem to reflect other gastric functions rather than being associated with gastric emptying.

[Enteral feeding]. / Enterale Ernährung.

In patients with normal gastrointestinal functions, enteral nutrition is safe, efficious and inexpensive. The knowledge of enteral products and the correct selection of application techniques are important for a successful therapy. Long-term enteral nutrition of different subgroups of patients is possible by percutaneous endoscopic gastrostomy (PEG). Many complications may be avoided by changing the modalities of application.

[Inflammatory esophageal diseases caused by herpes simplex virus infections--overview and report of 15 personal cases]. / Entzündliche Speiseröhrenerkrankungen durch Herpes-simplex-Virusinfektionen--Ubersicht und Bericht über 15 eigene Fälle.

Frequency of herpes simplex virus(HSV)-induced esophagitis was reported to range from 0.5% to 6% in non-selected patients according to autopsy and clinical studies. In case of gastrointestinal involvement, affinity of herpes simplex virus to squamous epithelia predisposes the esophagus to be affected. Typically, patients complain about acute onset of odynophagia, retrosternal pain, or symptoms of gastrointestinal blood loss, while systemic signs of inflammation are often absent. Endoscopic examination usually reveals disseminated, roundish mucosal defects with distinct borders preferably in the distal part of the esophagus. If suspected clinically and by endoscopy, a histological and/or cytological diagnosis should be achieved by carefully taking multiple biopsies from the edge of the suspicious lesions. Antiviral therapy is not obligatory, since HSV esophagitis often resolves spontaneously. In the presence of preexisting immunodeficiency, marked clinical symptoms, or complicated course, however, the guanosine analogue aciclovir is the treatment of choice. In view of a comparably low sensitivity of macroscopic assessment and an expected increase in incidence of this viral infection, a high index of suspicion for this disorder appears to be necessary for all clinicians working in the field of endoscopy. Based on 15 personal observations recorded from 1983 to 1995, epidemiological, pathogenetic, morphological, and clinical features of HSV esophagitis will be summarized and discussed in the light of the pending literature on this subject.

Prospective study on the detection of insulinomas by endoscopic ultrasonography.

BACKGROUND AND STUDY AIMS: The correct localization of insulinomas using endoscopic ultrasonography (EUS) has been reported to be as high as 80% in multicenter patient cohorts. PATIENTS AND METHODS: Over 24 months, we prospectively investigated 14 patients (11 women, three men) with a definite biochemical diagnosis of endogenous hyperinsulinism prior to surgical exploration and removal of an insulinoma. The endoscopic investigator was not aware of any other imaging results if they had been performed in referring hospitals. RESULTS: The overall sensitivity of EUS in the detection of pancreatic insulinomas was 57% (eight of 14 tumors); the sensitivity for insulinomas in the head of the pancreas was 83% (five of six); and 37% (three of eight) for tumors in the tail of the pancreas. The actual median diameter of undetected tumors was 11 x 9.5 mm, the median volume 0.66 ml (range 0.13 - 2.6 ml). The median diameter of correctly detected tumors was 16 x 11 mm, the median volume 1.37 ml (range 0.7 - 6.3 ml), the differences not being significantly different. In two patients, false-positive results were caused by peripancreatic lymph nodes. CONCLUSIONS: The sensitivity of EUS in the detection of pancreatic insulinomas depends on the location of the tumor, and possibly on the size of the tumors. Tumors not detected by EUS were likely to be smaller than detected tumors, and were likely to be located in the tail of the pancreas.

Comparison between intraluminal multiple electric impedance measurement and manometry in the human oesophagus.

Conventional oesophageal manometry and intraluminal electrical impedance measurement were simultaneously applied in eight healthy volunteers to study the effect of wet and semisolid bolus viscosities on oesophageal motility and bolus transit. Contraction front velocity measured by electrical impedance and manometry were identical for wet and semisolid swallows and highly associated. Bolus front velocity as measured by electrical impedance was significantly faster than contraction front velocity in both wet and semisolid swallows. Bolus front velocity during semisolid swallows was significantly slower compared to wet swallows. It is concluded that intraluminal electrical impedance measurement is a reliable technique to detect oesophageal motility as well as to differentiate between transit of wet and semisolid bolus consistencies.

[Diet therapy in cancer]. / Ernährungstherapie bei Tumorerkrankungen.

Cancer cachexia is a syndrome with weight loss, anorexia, and loss of host body cell mass. Tumor cachexia may be an early symptom of a neoplasm. Low food intake is the main reason for weight loss. Surgery, chemotherapy and radiation remain primary therapeutic modalities to overcome cancer cachexia. Artificial nutrition is able to avoid progressive weight loss; nutrition alone may not preserve fat-free body cell mass. Parenteral nutrition reduces perioperative morbidity and mortality. Nutritional support failed to show a benefit in patients with malignancies which are treated with therapeutic radiation or chemotherapy. For patients with unresectable neoplasms of the upper GI-tract conventional palliative regimens (bougienage, laser, etc.) do not support a satisfactory nutritional state. Ambulatory enteral tube feeding via percutaneous endoscopic gastrotomy (PEG) as an adjunct to therapy is useful and safe in providing adequate fluid and substrates.

Long-term efficacy of biofeedback training for fecal incontinence.

PURPOSE: Biofeedback therapy in fecal incontinence has been reported to improve continence in more than 70 percent of patients, but most studies have followed patients for less than two years. METHODS: Patients treated by biofeedback training between 1985 and 1986 were given a questionnaire in 1991, as were incontinent patients who had not entered this treatment program. All were asked for the occurrence, frequency, and severity of incontinence events in the past two weeks. Anamnestic and anorectal manometry data from the initial visit were also compared. RESULTS: Eighteen of 24 treated patients and 40 of 71 untreated patients responded. Of those treated by biofeedback, 78 percent reported episodes of fecal incontinence as compared with 77.5 percent of those not treated by biofeedback. Severity of incontinence, however, was significantly less (P < 0.02) in the treatment group (mean number of events, 0.2/day) than in those without treatment (1/day). In biofeedback-treated patients, it was identical with the frequency and severity reported immediately after therapy. No differences were found with respect to initial clinical data and anorectal manometry between both groups. CONCLUSION: Biofeedback training improves continence in patients not only during treatment and within the first two years but also for several years after therapy.

Colonic and anorectal dysfunction in a patient with the tethered cord syndrome.

Although visceral dysfunction is commonly encountered in the tethered cord syndrome, alteration of intestinal motor and sensory function has not yet been specifically addressed in this neurological disorder. We report the case of a 54-yr-old woman with a rare form of adult onset tethered cord syndrome who presented to us for preoperative assessment of marked constipation, urinary and fecal incontinence, and a rectal prolapse. It is shown that the tethered cord syndrome causes complex clinical patterns of bowel dysfunction and that careful efforts are mandatory to differentiate their underlying pathology. Specific diagnostic procedures directed to intestinal motility and perception were of decisive importance in enabling us to apply the appropriate treatment to our patient.

[Sclerosing cholangitis with papillary stenosis in an HIV-infected patients with Cryptosporidium infection]. / Sklerosierende Cholangitis mit Papillenstenose bei einem HIV-infizierten Patienten mit Cryptosporidieninfektion.

We report the case of a 46-year old HIV-infected patient who suffered from severe recurrent diarrhoea for 18 months. In stool cultures cryptosporidiae were identified. The cryptosporidial enteritis was unresponsive to therapy. In the further course of cryptosporidial infection the patient developed HIV-associated cholangitis with increasing upper abdominal pain, progredient laboratory cholestasis and morphological changes indicating posthepatic cholestasis. Papillary stenosis with erosive papilitis caused by cryptosporidia was diagnosed. Sphincterotomy significantly improved the clinical status of the patient. Cholangitis with associated crytosporidial infection in a HIV-infected patient ist discussed and necessary diagnostic and differential therapeutic approaches are described.

Anatomy of the anal sphincters. Comparison of anal endosonography to magnetic resonance imaging.

PURPOSE: A recent application of endosonography in the evaluation of anal sphincter morphology has led to controversy about the possibility of precisely assessing the diameter of external and internal anal sphincter muscles. On the other hand, magnetic resonance imaging (MRI) has been proposed to allow a more detailed view of the anatomy of the pelvic floor. However, both techniques have not yet been compared directly. METHODS: Eight healthy volunteers (age range, 25-40 years; 5:3, male:female) participated. Anal ultrasound was performed using a 7.5-MHz rectal transducer which produced a transversal panorama display of 360 degrees, allowing an image perpendicular to the anal canal. Imaging of the diameter of the internal and external anal sphincter muscles was performed with the transducer placed in the midanal canal, and measurement was always performed by the same investigator in dorsal projection. MRI was performed using a 1.5 Tesla Magnetom (Siemens, Erlangen, Germany) to obtain sagittal and angled axial (perpendicular to the anal canal) planes for consecutive 3-mm slices which were evaluated by four independent raters. RESULTS: Muscle thickness of the sphincter muscles in dorsal projection was 1.96 +/- 0.61 mm for the internal sphincter and 6.35 +/- 1.07 mm for the external sphincter using ultrasound. It was 1.72 +/- 0.13 mm and 3.99 +/- 0.99 mm, respectively, using MRI. When both measures were compared, only the internal sphincter data correlated significantly (r = 0.818, P = 0.0023) between both measures. Sagittal resonance imaging of the anal canal did not allow for differentiation of both muscles at all. Differentiation among mucosa, submucosa, and internal anal sphincter is not possible with MRI but may well be performed with high-resolution ultrasound. CONCLUSION: Anal ultrasound carries the potential of becoming a routine clinical procedure for evaluation of the anal anatomy and morphology in defecation disorders, but current MRI assessment of the anal anatomy is elaborate, costly, and does not provide any further insights.

Endosonography of the anal sphincters: incontinent and continent patients and healthy controls.

It has previously been shown that in healthy subjects anal sphincter functions as assessed by anorectal manometry and anal sphincter anatomy as measured by endoluminal ultrasound are poorly correlated. It remains to be shown, however, whether this is true for a larger series of patients with anorectal dysfunctions such as incontinence, and what is the clinical relevance of anal sonography. Anal sonography was performed in 42 consecutive patients with fecal incontinence, in 19 patients with constipation and/or anal pain, and in 15 healthy volunteers to determine anal sphincter integrity and the dorsal diameter of the internal and external anal sphincter muscles. Conventional multilumen anorectal manometry was performed in all subjects and patients to determine, among others, external and internal sphincter (EAS, IAS) performance at rest and during squeezing. It was shown that healthy subjects exhibit significantly higher muscle diameters of the IAS than both patient groups, but the EAS was similar in all groups. In 11/42 cases of incontinent patients, in 3/19 constipated patients, but in none of the controls a muscle defect of the EAS was found with sonography. Thirteen of these 14 patients were women with previous birth traumas. EAS but not IAS muscle thickness and muscle performance (squeezing and resting, respectively) were significantly correlated. Across all groups, women had smaller EAS muscle diameters than men. It is concluded, that in incontinent patients anal sonography may reveal additional information of clinical relevance in a substantial fraction of patients, and, thus, both anal manometry and anal ultrasound are of clinical value.

Sonographic, manometric, and myographic evaluation of the anal sphincters morphology and function.

PURPOSE: A direct comparison of anal sphincter physiology (muscle performance and anatomy-muscle thickness) has not yet been undertaken but may be of importance in patients with defecation disorders. METHODS: We evaluated 15 healthy volunteers by means of anorectal manometry to determine pressure functions of the internal and external and sphincter. Transcutaneous electromyography was recorded to assess the electrical activity of the external anal sphincter. Thickness of the anal sphincter muscles was measured sonographically from within the anal canal with dorsal projection using a 7.5-MHz 360 degrees rectal panorama scanner. RESULTS: It was shown that neither is the muscle thickness of the external anal sphincter during rest (6.26 +/- 1.02 mm) or during squeezing (7.40 +/- 1.39 mm) correlated to its squeeze pressure (138.8 +/- 15.2 mmHg), nor is the diameter of the internal anal sphincter (2.09 +/- 0.58 mm) correlated to its resting pressure (61.1 +/- 15.2 mmHg). Finally, the thicker the internal and sphincter muscle, the lower the electrical activity of the external anal sphincter during squeezing (r = 0.74, P < 0.001). CONCLUSION: It is concluded that both manometry to assess sphincter function and sonography to determine sphincter morphology are important measures in the evaluation of continence function.

[Effect of body position and food composition on esophageal motility in healthy probands]. / Einfluss von Körperposition und Nahrungsbeschaffenheit auf die Osophagusmotilität bei Gesunden.

In this study we investigated the influence of body position and bolus consistency on esophageal motility. Esophageal motility was investigated during randomized swallowing (10 women, 10 men) of liquid (5 ml water) and solid boluses (piece of apple). Esophageal motility was altered by body position and bolus consistency: Contraction amplitude, duration, percentage of multipeaked and repetitive contraction and the resting pressure of the lower sphincter were significantly reduced and the relaxation duration of the lower sphincter was significantly prolonged in sitting as compared to supine position. With a food bolus compared to swallows of water we found significantly higher values for the contraction amplitude and the percentage of repetitive contractions, for the duration and for the percentage of multipeaked contractions at some orifices and for the relaxation duration of the lower esophageal sphincter. Propagation velocity and the resting pressure of the lower esophageal sphincter were significantly reduced with the food as compared to the water bolus. The alterations of esophageal motility by body position and bolus consistency has to be taken into account in clinical manometry.

The effect of trospium chloride on oesophageal motility.

Trospium chloride is a muscarinergic antagonist acting on oesophageal smooth muscle and on ganglionic and/or myenteric neurons. The effect of this drug on oesophageal motility was tested in 16 healthy male subjects in a double-blind randomized cross-over examination of trospium chloride or placebo following phentolamine or placebo application. Each subject underwent two separate investigations at least one week apart. Trospium chloride was effective in the oesophagus to reduce contractile activity (amplitude and duration of peristalsis) in all parts of the oesophageal body, and this effect was not blocked by phentolamine. Its potent action and its minor side-effects appear to be promising for clinical use in patients with motility disorders such as the hypercontractile oesophagus.

[Irritable colon and colonic disease due to laxatives]. / Colon irritabile und Laxantienkolon.

Diarrhea of colonic origin is fairly common in irritable colon and after long term abuse of laxatives. This form of diarrhea causes difficulties not only in diagnosis but also in treatment. Irritable colon is a functional disorder sometimes involving other segments of the bowel. The term "irritable bowel disease" is thus more appropriate. Extraintestinal symptoms are in addition quite common. Although the diagnosis can be established with great reliability using an index we consider some laboratory tests, recto-sigmoidoscopy and abdominal sonography essential to rule out organic lesions. Therapy comprises (small) psychotherapy, dietary measures and eventually transient medication. Symptoms usually persist but tolerance of the disorder should be improved. Laxative-induced colonic dysfunction results usually from false assumptions about normal defecation. Loss of water and potassium deteriorates the symptomatology leading to a vicious circle. Alterations of neurons in the enteric nervous system of the colon can be the cause but eventually the consequence of chronic intake of laxatives. Hidden abuse of laxatives can cause great diagnostic difficulties. The therapy of choice is weaning which usually is only possible gradually. Cisapride can be a useful adjuvant.