[Fever and right upper abdominal pain in a 26-year-old returning from travel abroad]. / Fieber und rechtsseitige Oberbauchschmerzen bei einem 26-jährigen Reiserückkehrer.

Persistent fever and unspecific general symptoms need a complete and detailed medical history and search for infection. We report on a case of amebiasis with liver abscesses of a 26-year-old man. He had stayed several weeks in India and South America. After being free of complaints for 4 months, unspecific general symptoms and fever appeared. Due to proven liver abscesses, a combination treatment was given. Within 12 days, he was free of symptoms and could be discharged.

Complications in gastrointestinal endoscopy: a summary at the first international symposium in Hannover 2009.

Following the recent success of the Second International Symposium on Complications in Gastrointestinal Endoscopy (17-18 June 2011, Hannover, Germany), it would be worth reminding ourselves of the key points and highlights of the first symposium held in Hannover in June 2009. The congress, which is endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) under the patronage of the European Society for Gastrointestinal Endoscopy (ESGE), is designed to bring together endoscopists and support staff to present and discuss the diagnosis, treatment, and prevention of complications associated with gastrointestinal endoscopy, including effective communication strategies and management in particular patient groups. This current report is a brief summary of topics discussed at the inaugural symposium in 2009.

[Advantages of endoscopic stenting for malignant gastrointestinal obstructions]. / Maligne Passagestörungen. Möglichkeiten des endoskopischen Stentings.

Self-expanding stents play a major role in the interdisciplinary treatment of gastrointestinal obstructions in patients with local nonresectable tumors, advanced metastasis, and pronounced comorbidity. Reinstenting the passage and sealing esophagotracheal fistulae is very effective as palliative treatment for esophageal tumor complications. In hepatobiliary occlusions, the success rate against cholestasis is also high. Enteral and colorectal stents are gaining favor. Required are an experienced endoscopy team and adequate equipment. The rate of procedural complications is generally low, but rare and severe complications such as perforation must be considered. Further improvements in the materials and construction of stents can be expected.

Medical and endoscopic treatment in primary sclerosing cholangitis.

Primary sclerosing cholangitis is an important cause of chronic cholestatic liver disease. The aetiology is still unknown and an immunological basis is discussed. The disease results in diffuse narrowing and irregularities of intra- and extra-hepatic bile ducts that may lead to biliary cirrhosis. Progression of the disease is highly variable and fluctuating. An important issue is the risk for developing cholangiocarcinoma. For end-stage disease liver transplantation is the only therapeutic option. If strictures of the extra-hepatic bile ducts are demonstrable, endoscopic interventions are effective palliative treatment options. The use of immunosuppressive or anti-inflammatory drugs has been shown to have no influence on the course of primary sclerosing cholangitis.

Cystic echinococcosis with perforation into the biliary tract in an eight-year-old girl.

Cystic echinococcosis (CE) is a zoonotic infection caused by echinococcus granulosus and is still frequent in endemic areas. CE is predominantly localised in the liver. The therapy of choice is the surgical sanitation of the lesions, increasingly through interventional procedures such as percutaneous punctation of the cysts, aspiration of the cystic fluid, instillation of a protoscolicidal solution and reaspiration of this solution (PAIR). However, in some cases, such as perforation into the biliary tract, PAIR is not feasible. We report on an eight-year-old girl who suffered from CE with perforation of one cyst into the biliary tract. The diagnosis was confirmed by ERCP and cholangioscopy and a right hemihepatectomy was performed. The girl received adjuvant chemotherapy with albendazol perioperatively and is still asymptomatic with no indications of disease 10 months after the operation.

[Zenker's diverticulum: pro endoscopic treatment]. / Zenker-Divertikel: Pro endoskopische Septumdurchtrennung.

Zenker's diverticulum occurs as a result of impaired relaxation of the cricopharyngeal muscle primarily causing dysphagia. Affected are elderly patients with several comorbidities. By means of endoscopic intervention the septum is divided between the diverticulum and esophagus which allows unobstructed passage of food and liquids to the diverticulum into the esophagus. Advantages of this technique are manifold: usually general anesthesia is not required, the intervention can be performed in an outpatient setting or if necessary, hospital stay is short and the complication rate is low. Therefore, it is a suitable option for multimorbid patients. In approximately 90% of interventions symptoms of dysphagia are improved after the first treatment resulting in excellent effective medium term results in most cases.

Transpapillary intraductal ultrasound in the evaluation of dominant bile duct stenoses in patients with primary sclerosing cholangitis.

OBJECTIVE: Primary sclerosing cholangitis (PSC) is associated with the development of cholangiocarcinoma (CC) in approximately 9% of patients. Neither cholangiography nor endoscopic tissue sampling can reliably distinguish between CC and benign dominant bile duct stenosis. The aim of the present study was to assess the value of intraductal ultrasonography (IDUS) in distinguishing between benign and malignant dominant stenoses in PSC patients. MATERIAL AND METHODS: Forty PSC patients with dominant bile duct stenoses were studied prospectively. Transpapillary IDUS and endoscopic tissue sampling were performed in addition to endoscopic retrograde cholangiography (ERC). Cholangiography and IDUS findings were classified as malignant or benign by the investigators. Final diagnosis of malignant stenosis was based on positive histology and/or cytology, whereas a benign character was assumed in cases of negative tissue sampling and uneventful extended clinical follow-up. RESULTS: Eight PSC patients (20%) had dominant bile duct stenoses caused by CC, whereas 32 out of 40 patients (80%) had benign dominant bile duct stenoses. IDUS was significantly superior to ERC for detection of malignancy in terms of sensitivity (87.5% versus 62.5%, p=0.05), specificity (90.6% versus 53.1%, p<0.001), accuracy (90% versus 55%, p<0.001), positive predictive value (70% versus 25%, p<0.001), and negative predictive value (96.7% versus 85%, p=0.049). CONCLUSIONS: Transpapillary IDUS significantly increases the ability to distinguish malignant from benign dominant bile duct stenoses in patients with PSC.

Cholangioscopic characterization of dominant bile duct stenoses in patients with primary sclerosing cholangitis.

BACKGROUND AND STUDY AIMS: Primary sclerosing cholangitis (PSC) is associated with the development of cholangiocarcinoma in up to 10 % of patients. Cholangiography or endoscopic tissue sampling does not reliably distinguish between cholangiocarcinoma and a benign dominant bile duct stenosis. The aim of the present study was to assess the value of cholangioscopy for distinguishing between benign and malignant dominant stenoses in PSC patients. PATIENTS AND METHODS: Fifty-three PSC patients with dominant bile duct stenoses were prospectively studied. Transpapillary cholangioscopy and endoscopic tissue sampling were carried out in addition to endoscopic retrograde cholangiography (ERC). The cholangiography and cholangioscopic findings were classified as malignant or benign by the investigators. A final diagnosis of malignant stenosis was based on positive histology and/or cytology, whereas a benign condition was assumed in cases of negative tissue sampling and uneventful extended clinical follow-up. RESULTS: Twelve PSC patients (23 %) had dominant bile duct stenoses caused by cholangiocarcinoma, whereas 41 of the 53 patients (77 %) had benign dominant bile duct stenoses. Cholangioscopy was significantly superior to ERC for detecting malignancy in terms of its sensitivity (92 % vs. 66 %; P = 0.25), specificity (93 % vs. 51 %; P < 0.001), accuracy (93 % vs. 55 %; P < 0.001), positive predictive value (79 % vs. 29 %; P < 0.001), and negative predictive value (97 % vs. 84 %; P < 0.001). Transpapillary cholangioscopy is more sensitive and specific for characterizing malignant bile duct stenosis in comparison with endoscopic brush cytology. CONCLUSIONS: Transpapillary cholangioscopy significantly increases the ability to distinguish between malignant and benign dominant bile duct stenoses in patients with PSC.

Selective expression of histamine receptors H1R, H2R, and H4R, but not H3R, in the human intestinal tract.

BACKGROUND AND AIMS: Histamine is known as a regulator of gastrointestinal functions, such as gastric acid production, intestinal motility, and mucosal ion secretion. Most of this knowledge has been obtained from animal studies. In contrast, in humans, expression and distribution of histamine receptors (HR) within the human gastrointestinal tract are unclear. METHODS: We analysed HR expression in human gastrointestinal tissue specimens by quantitative reverse transcription-polymerase chain reaction and immunostaining. RESULTS: We found that H1R, H2R, and H4R mRNA were expressed throughout the gastrointestinal tract, while H3R mRNA was absent. No significant differences in the distribution of HR were found between different anatomical sites (duodenum, ileum, colon, sigma, and rectum). Immunostaining of neurones and nerve fibres revealed that H3R was absent in the human enteric nervous system; however, H1R and H2R were found on ganglion cells of the myenteric plexus. Epithelial cells also expressed H1R, H2R and, to some extent, H4R. Intestinal fibroblasts exclusively expressed H1R while the muscular layers of human intestine stained positive for both H1R and H2R. Immune cells expressed mRNA and protein for H1R, H2R, and low levels of H4R. Analysis of endoscopic biopsies from patients with food allergy and irritable bowel syndrome revealed significantly elevated H1R and H2R mRNA levels compared with controls. CONCLUSIONS: We have demonstrated that H1R, H2R and, to some extent, H4R, are expressed in the human gastrointestinal tract, while H3R is absent, and we found that HR expression was altered in patients with gastrointestinal diseases.

[Cholangiolar carcinoma]. / Das cholangioläre Karzinom.

Cholangiocarcinoma affects both sexes equally, is more prevalent in individuals age 50 to 70. Associations with many other diseases are known, in particular with primary sclerosing cholangitis, ulcerative colitis and parasitic infestation (Clonorchis sinensis, Opisthorchis viverrini). About 95% are histopathologically classified as adenocarcinoma. The localisation of the tumor determines clinical course and prognosis. If the tumor is located above the hepatic duct bifurcation, only one side of the biliary tree may be obstructed, resulting in atrophy of the corresponding liver lobe, without clinical manifestation of jaundice. Obstructive jaundice is the characteristic symptom of hilar tumor localisation. Laboratory examinations show hyperbilirubinemia and liver enzymes indicating cholestatis are elevated. Pathological levels of the tumor markers carcinoembryonic antigen (CEA) and CA 19-9 are frequently found. Ultrasonography in combination with endoscopic retrograde or percutaneous transhepatic cholangiography and cytological examination of aspirates are of main diagnostic importance. Treatment consists of curative resection or palliative decompression to relieve jaundice, the latter can be performed using endoscopic implantable self-expanding metal stents. Cytotoxic chemotherapy or liver transplantation show no satisfactory results. The prognosis is mainly poor, only few patients survive more than 6 months after diagnosis.

[Collagenous duodenitis and ileitis in a patient with collagenous colitis]. / Kollagene Duodenitis und Ileitis bei einer Patientin mit kollagener Kolitis.

Collagenous colitis is a disease accompanied by chronic watery diarrhea, of which the etiology is unknown. Sporadic cases of collagen deposits in the upper gastrointestinal tract are meanwhile reported. We here report the case of a 53-year-old female patient suffering from collagenous colitis with additional collagen deposits in the duodenum and ileum. The favourable effect of a therapeutical trial with bismuth nitrate is described.

Evaluation of endoscopic retrograde cholangiopancreatography under conscious sedation and general anesthesia.

BACKGROUND AND STUDY AIMS: In adults, general anesthesia is usually only provided during endoscopic retrograde cholangiopancreatography (ERCP) when prior attempts using conscious sedation have failed. It was hypothesized that in our hospital, other factors might be associated with general anesthesia for ERCP. The aim of this study was therefore to assess the indications for ERCP under general anesthesia, and to evaluate the underlying diseases, type, and efficacy of ERCP under general anesthesia in comparison with conscious sedation. PATIENTS AND METHODS: We retrospectively analyzed 1,056 ERCPs that had been carried out with the patients under general anesthesia or conscious sedation. The indications for general anesthesia were recorded, and the underlying diseases, the type and success of the interventions, and the causes of premature ERCP termination in both groups were assessed. RESULTS: Eighteen percent of the ERCPs were performed under general anesthesia and 82% under conscious sedation. The indications for general anesthesia were related to the type of procedure planned (46%), premature termination of ERCP under conscious sedation (28%), and other reasons. Patients with primary sclerosing cholangitis and liver transplant recipients received general anesthesia more frequently (general anesthesia vs. conscious sedation, 36% vs. 16%, P < 0.0001 and 22% vs. 13%, P = 0.003). Conscious sedation was provided more frequently in patients with neoplasms and cholelithiasis (21% vs. 12%, P = 0.004 and 13% vs. 3%, P < 0.001). Painful dilations were performed more frequently with the patients under general anesthesia (60% vs. 19%, P < 0.001), whereas major papillotomies were preferably performed with conscious sedation (34% vs. 21%, P = 0.006). More interventions per ERCP were performed with the patient under general anesthesia compared to conscious sedation (P < 0.001), during the same time (51 +/- 28 min vs. 52 +/- 26 min, P = 0.39). With conscious sedation, the ERCP failure rate was double that with general anesthesia (7% vs. 14%, P = 0.012), mainly due to inadequate conscious sedation (61%). CONCLUSIONS: The frequent use of general anesthesia for ERCP at our institution is related to the underlying diseases, which are frequently treated with complex and painful ERCP procedures. The efficacy of ERCP with general anesthesia supports a continued preference for general anesthesia rather than conscious sedation when complex and painful interventional ERCP procedures are planned.

[Lichen planus esophagitis without skin, genital or oral mucosa involvement]. / Lichenoide Osophagitis ohne Haut-, Genital- oder Mundschleimhautbeteiligung.

Lichen ruber planus is a common skin and mucosal disease, with very rare involvement of the esophagus. We report on a 68-year-old patient suffering from dysphagia, with a reduced general condition and weight loss of 12 kg in the past 6 months due to lichen planus of the esophagus. Treatment by bougienage was very successful. This case report describes a lichen ruber planus of the esophagus without involvement of skin, genital or oral mucosa.

Clinical significance of the colonoscopic allergen provocation test.

BACKGROUND: To improve the diagnosis of intestinal allergy, we developed a colonoscopic allergen provocation (COLAP) test. METHODS: The cecal mucosa was challenged with three food antigen extracts, a buffer control and a positive control (histamine). The mucosal wheal and flare reaction was registered semiquantitatively 20 min after challenge, and selected tissue biopsies were examined for mast cell and eosinophil activation by immunohistochemistry and electron microscopy. The COLAP test was performed on 70 adult patients with abdominal symptoms suspected to be related to food allergy and in 5 healthy volunteers. In parallel, skin prick tests were performed and IgE was measured in serum. RESULTS: 97 out of 210 antigen challenges performed in the patient group induced a significant wheal and flare reaction of the mucosa (46%), whereas no reaction in response to antigen was observed in healthy volunteers. Antigen-induced wheal and flare reactions were dependent on patients' histories of adverse reactions to food, but not on serum levels of specific IgE or skin test results. Degranulation of mast cells was observed in almost all tissues in which food antigens caused a wheal and flare reaction. Eosinophil activation was also highly correlated with the extent of the wheal and flare reaction (r(s) = 0.86). CONCLUSIONS: The data suggest that the COLAP test may be a useful diagnostic means in patients with suspected intestinal food allergy and a new tool for the study of underlying mechanisms.

Analysis of factors contributing to higher erythropoietin levels in patients with chronic liver disease.

BACKGROUND: Dysregulated erythropoietin (EPO) plasma levels may play a role in the pathophysiology of chronic liver disease (CLD) because chronic anaemia is frequently observed in patients with liver cirrhosis. We aimed to identify the factors contributing to EPO regulation in patients with CLD. METHODS: Plasma EPO concentrations were correlated with clinical and laboratory parameters in 111 CLD patients and 220 healthy controls. RESULTS: Anaemia, though generally mild, was common in CLD patients, and thrombocytopenia and previous bleeding episodes were observed in two-thirds of the patients. Plasma EPO levels were significantly elevated in CLD patients (P < 0.001). EPO increased according to Child's stages of cirrhosis, independently of the aetiology of CLD. EPO correlated with haemoglobin (r= -0.498, P < 0.001). Additionally, EPO independently correlated with markers of liver dysfunction, e.g. prothrombin time, albumin concentration or cholinesterase activity, and platelet count. EPO was also significantly elevated in patients with a current bleeding tendency and with prior gastrointestinal haemorrhages. EPO levels were increased in patients with impaired pulmonary function, e.g. decreased diffusion capacity, vital capacity or hyperventilation. Interestingly, plasma interleukin-6 (IL-6) concentrations positively correlated with EPO (r=0.277, P = 0.003), suggesting a possible mechanism of EPO upregulation in patients with CLD through IL-6 dependent pathways, e.g. binding of STAT transcription factors in the putative EPO promoter region. CONCLUSIONS: EPO is upregulated in patients with chronic liver diseases in response to anaemia, bleeding complications, impaired pulmonary function, thrombocytopenia and liver dysfunction. IL-6 dependent pathways could be involved in mediating elevated EPO levels in CLD patients.

Percutaneous endoscopic gastrostomy in AIDS and control patients: risks and outcome.

OBJECTIVES: Wasting is a major feature of advanced HIV infection. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) is a safe and efficient therapy in malnutrition, but limited experience exists in wasted HIV patients. Here we report on outcome and risk of PEG-feeding in HIV patients compared with HIV-seronegative patients and with HIV patients without PEG. METHODS: In 47 HIV-infected patients, PEG was placed because of wasting (n = 33), neurologic deficits (n = 11), or dysphagia (n = 3). Clinical, immunological, and nutritional data were compared with those of i) 15 HIV patients who refused PEG placement despite an appropriate indication, ii) 76 HIV patients without signs of malnutrition, and iii) 43 miscellaneous PEG patients. RESULTS: PEG was as safe in HIV-infected as in HIV-seronegative patients. PEG feeding resulted in significant increases of body weight (+3.3 +/- 3.6 kg, p < 0.001), serum albumin concentration (+4.5 +/- 7.2 g/L, p < 0.005), and total iron-binding capacity (+9.5 +/- 11.5 mumol/L, p < 0.001). Moreover, our data indicate that PEG feeding may improve survival in wasted AIDS patients. CONCLUSIONS: PEG feeding is safe and effective in the treatment of the AIDS wasting syndrome. Further prospective investigations are necessary to answer the question of whether treatment of wasting improves patient survival.

K-ras mutations in the bile of patients with primary sclerosing cholangitis.

BACKGROUND AND AIMS: The development of cholangiocarcinoma (CCC) is a complication of primary sclerosing cholangitis (PSC). To date, no reliable factors have been described which can define those PSC patients at high risk for the development of CCC and the clinical diagnosis of CCC in PSC patients is difficult. Therefore, molecular markers of cholangiocarcinogenesis, such as K-ras mutations, may improve the early diagnosis of CCC or the timing of liver transplantation. METHODS: K-ras mutations were analysed by enriched polymerase chain reaction/restriction fragment length polymorphism in the bile fluid of 56 PSC patients and 20 patients with other cholestatic diseases. To assess the value of K-ras mutations as a risk factor for cholangiocarcinogenesis, patients were prospectively investigated over a mean period of 31.5 months. RESULTS: In contrast with the control group, 17 (30%) patients with PSC revealed K-ras mutations in bile fluid. The mean Mayo score was not significantly different between PSC patients with (mean score 0.70) and without (mean score 0.13; p=0.2) K-ras mutations. In contrast with the group of PSC patients without K-ras mutations, four CCCs and two dysplasia were diagnosed in the group of patients with K-ras mutations during the follow up investigation (p<0.001). CONCLUSIONS: Our results indicate that K-ras mutations in bile fluid of PSC patients represent frequent early events during cholangiocarcinogenesis. However, most of the PSC patients with K-ras mutations remained tumour free after a long follow up investigation which is in agreement with the fact that these mutations are not specific for malignancy but may also occur in normal bile duct mucosa or in dysplasias. Therefore, analysis of K-ras mutations in bile should not be used for diagnosis of CCC in PSC patients. However, the results of our prospective follow up investigation indicate that K-ras mutations in bile fluid of PSC patients have to be considered as risk factors for the development of CCC which may have implications for the timing of liver transplantation.

[Clinical effects of supplemental enteral nutrition solution in severe polytrauma]. / Klinische Auswirkungen einer supplementierten enteralen Nährlösung beim schweren Polytrauma.

Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.

Positron emission tomography and cholangiocarcinoma in primary sclerosing cholangitis.

We present the case of a 44-year-old male patient with a history of primary sclerosing cholangitis who developed a cholangiocarcinoma with pulmonary metastasis. The cholangiocarcinoma was identified in the PET scan by its enhanced 18F-FDG-uptake. Prospective studies should be performed to demonstrate whether PET will be suited to detect small and early cholangiocarcinomas, particular in young patients, who could be treated immediately and curatively by liver transplantation.