Functional gastrointestinal disorders among soldiers in peacetime versus out-of-area missions.

Functional gastrointestinal syndromes are chronic disorders of the abdomen with an absence of organic findings. The aim of this study was to compare the frequency and symptomatology of functional abdominal syndromes in soldiers during an out-of-area mission versus during peacetime at home. We examined 124 soldiers who sought medical care for abdominal symptoms at the German Field Hospital Trogir, Croatia. The control group consisted of 113 soldiers who were referred with abdominal symptoms to the Central Hospital of German Armed Forces Koblenz, Germany. After excluding an organic disease, the diagnosis of a functional disorder was made. Fourteen percent of the Implementation Force soldiers had symptoms of a functional syndrome. At home, the frequency of functional gastrointestinal disorders was 50%, significantly greater than the rate during the out-of-area mission (p < 0.0001). We conclude that functional gastrointestinal disorders are more rare during out-of-area missions than during peacetime. They are probably as frequent away from home as at home, but "health care seeking" is less frequent under the stressful conditions of out-of-area missions.

[Acute renal failure due to hypercalcemia and peripheral polyneuropathy--rare manifestations of sarcoidosis]. / Akutes Nierenversagen auf dem Boden einer Hyperkalzämie und periphere Polyneuropathie--seltene Manifestationen einer Sarkoidose.

BACKGROUND: Sarcoidosis can involve many organs. Whereas lung and intrathoracal lymph nodes are most often effected, there are some rare manifestations as renal failure and neuropathy. CASE REPORT: A 57-year-old male patient was referred to hospital with dyspnea on exertion, hypercalcemia and acute renal failure after holidays in Southern Europe. The diagnosis of sarcoidosis with the extraordinary manifestations of a nephropathia based on hypercalcemia and a sensitive polyneuropathy was made. CONCLUSION: These findings suggest that an asymptomatic sarcoidosis can develop hypercalcemia with renal failure by increased ultraviolet exposure. Patients with sarcoidosis should avoid marked exposure to UV light.

[Duplex ultrasound of the liver and portal vein system]. / Die Duplexsonographie der Leber und des Pfortadersystems.

Duplex ultrasound allows direct access to portal venous and hepatic vein hemodynamics. This method has been accepted as a reliable procedure to detect portal and splenic venous thrombosis, Budd-Chiari's syndrome, portosystemic collateralisation and changes in the portal venous blood flow direction with a high rate of sensitivity. Besides these qualitative findings Doppler flowmetry allows quantitative measurement of portal venous blood flow velocities. The estimation of portal hypertension and the prediction of the risk of variceal bleeding by quantitative Doppler flowmetry is of increasing clinical importance. In monitoring the efficiency of medicational prophylaxis against gastrointestinal bleeding is also helpful. Duplex ultrasound can be used to evaluate the function of portocaval shunts including the intrahepatic stent shunt as well as to detect vascular complications after liver transplantation. Furthermore the method is gaining importance in the diagnosis and monitoring of therapy of acute liver transplant rejection. In case of liver tumors duplex ultrasound is of value for tumor staging and provides information about the dignity on the basis of perfusion patterns.

[Bleeding from Dieulafoy's ulcer after argon-plasma laser coagulation of gastric angiodysplasia in Heyde's syndrome]. / Dieulafoy-Blutung nach Argon-Plasma-Koagulation einer Angiodysplasie beim Heyde-Syndrom.

HISTORY: A 75-year-old, pale-looking man with known severe valvar aortic stenosis and three-vessel coronary artery disease previously treated with two bypass grafts was referred for elucidation of anaemia before further coronary artery surgery. INVESTIGATIONS: In addition to chronic iron-deficiency anaemia (haemoglobin 9.5 g/dl) endoscopy revealed gastric angiodysplasia. Endoscopy of the colon was negative. DIAGNOSIS, TREATMENT AND COURSE: Argon-plasma laser coagulation (APC) for the angiodysplasia was performed twice. Although there were no complications at first, five days later tarry stools were noted and hypovolaemic shock developed. Emergency gastroscopy revealed a bleeding vessel stump (Dieufaloy's lesion) proximal to the APC-induced ulcer (stage Ib bleeding [Forrest's classification]). Epinephrine and fibrin glue were applied endoscopically. The patients died 20 days later of septicaemic and multiorgan failure, the result of left-heart failure with pneumonia. CONCLUSION: APC, usually described as being a low-risk procedure, can cause mucosal damage resulting in Dieulafoy's lesion. APC should therefore be carefully monitored.

[Asymptomatic diclofenac-induced acute hepatitis]. / Asymptomatische Diclofenac-induzierte akute Hepatitis.

HISTORY AND ADMISSION FINDINGS: After removal of an herniated intervertebral disc a 49-year-old man had recurrent pain in the lumbar region, treated with diclofenac and flupirtine. 4 months postoperatively he was referred to the author's hospital because of progressive rise in transaminase levels and in cholestasis parameters. Physical examination on admissions was unremarkable, except for jaundice. INVESTIGATIONS: Laboratory tests showed an increases in transaminases (GPT 769 U/l [normal: < 23 U/l], GOT 285 U/l [normal: < 19 U/l]) and in cholestasis-related values (gamma-GT 172 U/l [Norm 6-28 U/l], alkaline phosphatase 207 U/l [normal < 175 U/l], total bilirubin: 2.5 mg/dl [Norm < 1.1 mg/dl]). This corresponded to the histological finding of toxic damage to the liver parenchyma. Viral, autoimmune and metabolic causes had been excluded. DIAGNOSES, TREATMENT AND COURSE: The history as well as laboratory and histological findings indicated diclofenac-induced toxic hepatitis. The drug was discontinued and without any treatment all laboratory values returned to normal within 9 weeks. CONCLUSION: Diclofenac, a frequently prescribed non-steroid anti-inflammatory drug, is generally thought to be relatively safe. But it can produce toxic hepatitis which may be asymptomatic (but this patient was jaundiced) and may take an unforeseeable course. This should be taken account of by regularly monitoring liver functions.

Gastric stromal tumor--a rare cause of an upper gastrointestinal bleeding.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms arising from connective tissue elements of the gastrointestinal wall. They show a great heterogeneity with respect to their histogenetic, morphologic and prognostic characteristics. GISTs are known with myoid, neural or mixed features of differentiation. Clinical findings are gastrointestinal bleeding, abdominal pain and weight loss. We report on the case of a 50-year-old male patient who presented with melena and acute anemia (hemoglobin 10.5 g/dl). Esophagogastroduodenoscopy revealed a broad-based, centrally ulcerated polypoid formation of 3 cm in the gastric corpus as the cause of the upper gastrointestinal bleeding. Multiple endoscopic biopsies were negative for neoplastic changes. Because of no tendency of healing after triple eradication therapy of Helicobacter pylori and following proton pump inhibitor medication, the patient underwent distal gastrectomy with gastrojejunostomy. GIST of combined smooth muscle and neural type was diagnosed by histological and immunohistochemical examination. The features with increased mitotic activity and cellularity were those of a borderline stromal tumor. 6 months after surgery the patient is well with no signs of residual malignancy. This case demonstrates that rare stromal neoplasms have to be taken into account in the differential diagnosis of gastrointestinal tumors even if endoscopic biopsies are negative for neoplastic changes. Because of the uncertain biological behavior of the GISTs an early surgical intervention is recommended.

[The coexistence of 2 different neuroendocrine tumors of the upper gastrointestinal tract and pancreas]. / Koexistenz von zwei unterschiedlichen neuroendokrinen Tumoren des oberen Gastrointestinaltraktes und des Pankreas.

HISTORY AND CLINICAL FINDINGS: A 41-year-old obese patient presented with cramp-like abdominal pain, watery diarrhoea with partly digested food particles, projectile vomiting and newly diagnosed diabetes mellitus. For the preceding 6 years he had been treated for recurrent gastric and duodenal ulcers. Although the fasting gastrin level was raised and Zollinger-Ellison syndrome suspected, computed tomography (CT), magnetic resonance imaging (MRI) and coeliac angiography at another hospital had failed to discover a tumor. INVESTIGATIONS: Biochemical tests were unremarkable except for an increased GPT concentration, slight fasting hyperglycemia and hypertriglyceridemia. The gastrin and chromogranin A levels were markedly elevated (15,590 pg/ml and 584.2 U/l, respectively). Gastroscopy revealed, in addition to multiple small duodenal ulcers, a round polypoid mass (diameter of 0.7 cm) lateral to the papilla of Vater, histologically an APUDoma. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a 0.5 cm long compression of the duct of Wirsung in the region of the head of the pancreas. Liver metastases were excluded by magnetic resonance imaging and computed tomography. Endosonography showed a ca. 4 mm space-occupying lesion in the region of the body of the pancreas. Octreotide scintigraphy demarcated two foci at the level of the head of the pancreas (somatostatin-receptor positive). TREATMENT AND COURSE: After a pylorus-preserving partial duodenopancreatectomy with lymph node dissection N1/N2, histology confirmed a gastrinoma of the duodenum and a glucagonoma of the pancreas (pT3pN1pMx). Postoperatively the patient became symptom-free and both the blood sugar level and the tumor marker were normal. CONCLUSION: Combined ERCP, endosonography and scintigraphy are more sensitive than other radiological examinations (CT and MRI) in diagnosing and localizing neuroendocrine tumours of the gastrointestinal tract. Despite the low incidence of such tumours, the possible synchronous occurrence of several such tumour should not be ignored.