[Whether or not to perform an early endoscopy following ingestion of potentially caustic agents - a retrospective longterm analysis in a tertiary referral institution]. / Wann sollte eine frühe endoskopische Inspektion bei Verletzungen des oberen Gastrointestinaltrakts nach Ingestion von potenziell ätzenden Substanzen und anderen Noxen erfolgen? - Eine retrospektive 13-Jahres-Analyse in einem tertiären Haus der Maximalversorgung.

BACKGROUND: The optimal clinical management of patients following ingestion of potentially caustic lesions is still undetermined. In particular, the indication for early upper GI endoscopy in this context remains unclear. PURPOSE: To draft recommendations regarding the use of early upper GI endoscopy following hospital admissions of patients after ingestion of potentially caustic agents. METHODS: For this purpose, a retrospective cohort study of patients treated for ingestion of potentially caustic substances during a 13 year-period at the university hospital of Berne was performed. RESULTS: In total, 61 patients with acute ingestion of potentially caustic substances were identified. Overall mortality was 5 %. 11/61 patients had to be admitted to the intensive care unit. Most ingestions were performed in suicidal intention (62 %). In 53 % of these patients, a combined ingestion of several substances occurred. In 33 % of patients, an early upper GI endoscopy was performed within 24 hours after ingestion. The degree of burn depended upon the hazard potential of the respective substance. In patients with ingestion of low risk substances, upper GI endoscopy was only performed when additional risk factors were present. CONCLUSION: Based upon the results of the present study, ingestion of potentially caustic agents requires an individualized strategy whether or not to perform early endoscopy.

Esophageal strictures in adult eosinophilic esophagitis: dilation is an effective and safe alternative after failure of topical corticosteroids.

Strictures are a frequent complication of eosinophilic esophagitis. The efficacy and safety of topical corticosteroids and of dilation of eosinophilic esophagitis-associated strictures have not yet been thoroughly clarified. We present a retrospective analysis of 10 adult patients with eosinophilic esophagitis who had symptomatic esophageal stenosis that was unresponsive to topical corticosteroids, and who were treated using bougienage. Eight patients had one single stricture, one patient had two, and another had three strictures; mean stricture length was 2.1 cm (range 1 - 6 cm). Bougienage led to prompt symptom relief. Apart from transient postprocedural odynophagia, no severe complications occurred. During the follow-up (mean 6 months; range 2 - 11 months), all patients enjoyed sustained treatment response.

Effects of pinaverium bromide and verapamil on the motility of the rat isolated colon.

Pinaverium bromide was 30 times less potent than verapamil in inhibiting intraluminal pressure responses of in vitro rat colonic segments to barium chloride, acetylcholine, FK 33-824 or field stimulation. The inhibitory effects of both verapamil and pinaverium bromide on the pressure responses to field stimulation were antagonized similarly by exogenous calcium administration. These results support the concept that pinaverium bromide acts on calcium channels in the smooth muscle cell membrane.

Does intravenous ondansetron affect gastric emptying of a solid meal, gastric electrical activity or blood hormone levels in healthy volunteers?

BACKGROUND: In previous studies, tropisetron has been shown to accelerate gastric emptying of a solid meal. However, it is uncertain whether other specific 5-hydroxytryptamine-3 receptor antagonists, such as ondansetron, also have a gastroprokinetic effect in humans. AIM: To evaluate the effect of ondansetron on gastric half-emptying time (T1/2) of a solid meal, gastric myoelectrical activity and hormone levels in 14 healthy volunteers. METHODS: In a placebo-controlled, randomized, crossover study, we investigated the effects of ondansetron (8 mg intravenously) on the gastric emptying of solids (by scintigraphy), gastric myoelectrical activity (by electrogastrography) and the post-prandial release of cholecystokinin, gastrin, human pancreatic polypeptide, gastric inhibitory polypeptide, vasoactive intestinal polypeptide, motilin, substance P and galanin. RESULTS: The average T1/2 values were 86 min and 85.5 min without lag time (P=0.082) and 92 min and 93 min with lag time (P=0.158) for the placebo and ondansetron treatments, respectively. The average T1/2 of female volunteers was significantly longer than that of male volunteers. The dominant gastric electrical frequency and hormone plasma concentrations were not altered by ondansetron. CONCLUSIONS: Ondansetron did not affect the gastric emptying of solids, the dominant gastric electrical frequency or the plasma concentrations of the analysed gastrointestinal peptides.

Influence of naloxone on gastric emptying of solid meals, myoelectrical gastric activity and blood hormone levels in young healthy volunteers.

There is considerable evidence that opioid mechanisms are involved in the mediation of pyloric motor responses that in turn regulate gastric emptying. The purpose of this randomized, placebo-controlled crossover study was to investigate the effect of naloxone on gastric emptying of a solid meal, gastric myoelectrical activity and the postprandial release of gastrointestinal peptides and neuropeptides in 20 healthy volunteers. Naloxone was administered as an intravenous bolus, followed by continuous infusion according to an intravenous dosing nomogram. Gastric emptying time was evaluated by scintigraphy and gastric myoelectrical activity was evaluated by cutaneous electrogastrography. Naloxone did not significantly alter gastric half-emptying time and postprandial dominant gastric electrical frequency compared with placebo. It also did not significantly change the plasma levels of several peptide hormones with the exception of neuropeptide Y, which was significantly increased (P = 0.001). In conclusion, in doses that influence human intestinal motility, naloxone had no effect on gastric motility and release of several peptide hormones in healthy male volunteers. The importance of the isolated increased neuropeptide Y plasma level needs further investigation.

Dysphagia in Crohn's disease: a diagnostic challenge.

Dysphagia is a rare manifestation in a patient with Crohn's disease. We report on the case of a patient with long-standing Crohn's disease who developed progressive dysphagia over 3 years. Endoscopy showed minimal distal oesophagitis with non-specific histological findings. Further investigation with cinematography, barium swallow and manometry established an achalasia-like motility disorder. Biopsies obtained from the oesophagus were non-specific. Balloon dilatation was performed. Initial success was followed by recurrent dysphagia. At repeat endoscopy, an oesophageal fistula was detected. An attempt at conservative medical management failed and oesophagectomy was successfully performed. Pathology results of the resected specimen confirmed the suspected diagnosis of oesophageal Crohn's disease. Even if achalasia is suspected in a Crohn's patient, it should be taken into consideration that the motility disorder could be the result of a transmural inflammation with or without fibrosis caused by Crohn's disease.

[CT and ERCP for the combined study of biliary tract diseases]. / CT und ERCP als Kombinationsuntersuchung bei Erkrankungen der Gallenwege.

The value of combined CT and ERCP for examining the bile ducts was studied retrospectively. CT on its own led to a correct diagnosis in 59% of cases. CT was valuable for estimating the calibre of the bile ducts, for localising the level of obstruction, for demonstrating calcified biliary concrements, and for showing peribiliary tumours. ERCP yielded a correct diagnosis in 67% of cases. The value of ERCP lies in the demonstration of poorly calcified and small concrements, strictures, tumours with ductal infiltration, and for investigating the post-cholecystectomy syndrome. Combining these two types of examination increases diagnostic accuracy to 82%.

[Sonography and endoscopic retrograde cholangio-pancreatography in the diagnosis of diseases of the pancreas and biliary system (author's transl)]. / Sonographic und endoskopisch retrograde Cholangio-Pankreatikographie zur Diagnostik von Pankreas- und Gallenwegserkrankungen.

The value of sonography and ERCP was studied in a retrospective series of 128 patients with pancreatic and biliary disease. Sonography and ERCP employed singly provided a correct diagnosis in 68% and 75.5% respectively; combined diagnostic accuracy rose to 85%. The inclusion of other diagnostic information produced almost identical figures for sonography and ERCP of 82% and 86% respectively. Consequently, sonography must be recommended in the first place as a non-invasive method for the diagnosis of pancreatic and biliary disease. The indications for ERCP are for the elucidation of chronic pancreatitis without pseudo-cysts and for other pancreatic abnormalities not clearly shown by sonography, and also for the demonstration of the biliary system in non-obstructive jaundice.

Pre-, intra- and postoperative staging of gastric carcinoma and clinical outcome.

BACKGROUND: We compared preoperative (combined clinical and radiological staging and endoscopical Borrmann classification), intraoperative (by the surgeon: curative/palliative; R0/R1/R2-resection; intraoperative stage I to IV) and postoperative staging including histological results (pTNM) in respect of resectability and prognosis. METHODS: All patients with adenocarcinoma of the stomach were prospectively and consecutively included in the study protocol and were staged during the hospitalisation by the different specialists. Out of 215 patients with malignant tumors of the stomach, 153 were finally evaluated for the study. We excluded 62 patients with other malignancies or with a follow up of less than 6 months. Preoperative endoscopic Borrmann classification was done by the gastroenterologist, preoperative TNM-classification by the radiologist and surgeon, intraoperative classification by the surgeon and postoperative classification by the pathologist. All results were immediately described in the protocol. Follow-up and survival curves were performed by the Regional Tumor Registry and statistics by the Statistical Department of the University using Kaplan-Meier survival curves and Log-Rank and Wilcoxon Test for significance. RESULTS: Preoperative staging was unreliable and there was no relationship between preoperative and postoperative staging nor survival. In opposite intra- and postoperative staging correlated significantly between the different groups and with survival (p < 0.001). CONCLUSIONS: As long as preoperative staging systems are not improved (which may be in the future the case with endosonography), all operable patients with gastric carcinoma should undergo a laparotomy or laparoscopy, because only intraoperative evaluation of the surgeon allows a decision on a possible curative resection. Patients with stages I-III should be resected radically with complete dissection of lymph node compartments 1 and 2. This policy is justified especially in view of a minimal hospital mortality (3%).

[Experiences with endoscopic placed endoprosthesis in stenosing malignancies of the esophagus and cardia]. / Erfahrungen mit endoskopisch plazierten Endoprothesen bei stenosierenden Malignomen von Oesophagus und Kardia.

Seventy-five patients with obstructing esophagogastric malignancies were palliatively treated by fiberendoscopic insertion of prosthetic tubes. The indications for endoscopic intubation are discussed, the procedure is described. The mortality rate was 6.6%. Complications were obstructions due to food impaction (10), tumor overgrowth (5) or mucosa folds (3), reflux and aspiration (7), dislocation of the prosthesis (5), perforation (1) and desintegration of the tube (1). Normal swallowing was restored in 98% and in general, there was a marked improvement in the quality of life. In summary, we conclude palliative fiberendoscopic intubation as the best existing procedure in patients with an incurable obstructing esophagogastric neoplasm.

[Dysphagia]. / Dysphagie.

Dysphagia is a symptom of numerous disorders which should always alert the physician and induce further examinations as soon as possible. For clinical purposes, a subdivision of dysphagia according to the region of interest in oropharyngeal and esophageal types and according to its causes in mechanical and motor types, facilitates the choice of the diagnostic procedure. A subtle history and precise physical examination in most cases allow a correct diagnosis. Endoscopy with sampling material for histology, cytology, bacteriology, mycology and virology, fine needle punction, endosonography, radiologic examinations, such as video-barium-swallow, CT/NMR, longterm pH-manometry and pharmaco-manometry may be needed to confirm the diagnosis and to plan the accurate treatment.

[Pancreatic carcinoma: diagnosis]. / Pankreaskarzinom: Diagnostik.

Early detection, tumor diagnosis with histological proof and tumor-staging are the principle aims of diagnostic approaches in patients suffering from pancreatic cancer. Asymptomatic and small cancers are often missed since they produce no or no typical symptoms and no reliable screening methods are available. Symptomatic pancreatic cancers are often so advanced that only about 20-30% of patients qualify for curative treatment. The diagnosis of pancreatic cancer with histological characterization occurs by imaging techniques [sonography and CT-scan with guided fine needle punction, MRI, ERCP with biopsy or aspiration cytology, endoscopic sonography] and in some cases by laparoscopy or laparotomy. The combined use of tumor markers [CA 19-9, CEA, elastase-1] support the diagnosis of pancreatic cancer. The same methods used for diagnosis are also used for the preoperative tumor staging. Unfortunately the accuracy of these methods is smaller than 77%. The involvement of lymph nodes, encasement of large vessels and small liver metastases or a peritoneal spread of the tumor may be difficult to visualize and the real extent of the disease may only be observed during laparotomy.

Chronic bile exposure increases resistance of canine gastric mucosa to bile.

Because four successive weekly exposures of the gastric mucosa of intact dogs to bile did not alter the appearance or the barrier function of the mucosa during subsequent challenges with bile, the effects of chronic continuous exposure to bile were tested. This was accomplished by diversion of the flow of bile from the duodenum into the stomach by cholecystogastrostomy and diversion of the common bile duct. After four weeks, on endoscopic examination the mucosa was dark red but covered in some areas by a creamy coloured, strongly adherent pseudomembrane. Histologically the mucosa was normal. Ion fluxes, when an acid test solution was used, were close to normal. Differences between control dogs and those with chronic bile diversion became very evident, however, when the mucosa was exposed to increasing concentrations of bile. The control dogs displayed increases in net fluxes of H+, Na+, Cl- and K+ as the concentration of the bile was increased but the dogs with chronic bile diversion did not. Also the changes in PD and fluxes in K+ were less in the dogs with bile diversion. In the intact control dogs bile placed in the stomach always produced bleeding and hemorrhagic erosion; in the dogs with chronic bile diversion added bile in the stomach never caused bleeding and the mucosa appeared normal on endoscopic and histological examination. We conclude that the resistance of the gastric mucosa to the barrier breaking action of bile was increased in the dogs with chronic gastric bile diversion.