Observational multicentric study to evaluate efficacy, adverse effects and acceptance of bowel cleansing prior to colonoscopy with sodium picosulfate / magnesium citrate formulation CitraFleet®.

The various efficient methods available for bowel preparation prior to colonoscopy differ in patient acceptance. Combining the laxative sodium picosulfate with hyperosmotic magnesium citrate, used in this study in the formulation CitraFleet(®), allows the uptake of the purgative substances as a solution of low volume. This observational study with 737 patients evaluated efficacy of bowel preparation, potential side or adverse effects and patient acceptance of this medicinal product when used by resident physicians in Germany.Colon cleansing with CitraFleet(®) was considered very good to sufficient in 95.2 % of the patients and inadequate in only 4.8 %. In 75 % of the colonoscopies, bowel preparation was rated very good or good. Compared to the standard regimen of two portions taken the day before endoscopy, cleaning efficacy was better when patients received one of the doses on the morning of the day of colonoscopy. The quality of bowel preparation was rated lower by gastroenterologists without any prior experience with sodium picosulfate/magnesium citrate. The overall assessment of the colon cleansing procedure by the 76 participating physicians was very positive and patient acceptance was also very high which can be considered a clear advantage over alternative methods. Efficacy of colon cleansing with CitraFleet(®) was not substantially affected by typical deviations from the recommended standard procedure, emphasizing the robustness of the method. Only one of the patients reported a mild adverse effect potentially caused by the cleansing agents.

[Chest pain - not always the heart! Clinical impact of gastrointestinal diseases in non-cardiac chest pain]. / Brustschmerz - nicht immer das Herz! Klinische Bedeutung gastrointestinaler Erkrankungen beim nicht-kardialen Thoraxschmerz.

Non cardiac chest pain (NCCP) are recurrent angina pectoris like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70 % and may be detected in this order at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life in NCCP is comparable, partially even higher compared to cardiac chest pain. Reasons for psychological strain are symptom recurrence in app. 50 %, nonspecific diagnosis with resulting uncertainty and insufficient integration of other medical disciplines in diagnostic work-up. Managing of patients with NCCP has to be interdisciplinary because non cardiac causes of chest pain may be found frequently. Especially gastroenterological expertise is required because in 50 - 60 % of cases gastroesophageal reflux disease (GERD), in 15 - 18 % hypercontractile esophageal motility disorders with nutcracker, jackhammer esophagus or distal esophageal spasmus or achalasia and in 32 - 35 % other esophageal alterations (e. g. infectious esophageal inflammation, drug-induced ulcer, rings, webs, eosinophilic esophagitis) as cause of chest pain may be detected. This implicates that regular interdisciplinary round wards and management of chest pain units are mandatory.

English language version of the S3-consensus guidelines on chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis.

Chronic pancreatitis is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganization of the pancreas leads to a progressive exocrine and endocrine pancreatic insufficiency. In addition, characteristic complications arise, such as pseudocysts, pancreatic duct obstructions, duodenal obstruction, vascular complications, obstruction of the bile ducts, malnutrition and pain syndrome. Pain presents as the main symptom of patients with chronic pancreatitis. Chronic pancreatitis is a risk factor for pancreatic carcinoma. Chronic pancreatitis significantly reduces the quality of life and the life expectancy of affected patients. These guidelines were researched and compiled by 74 representatives from 11 learned societies and their intention is to serve evidence-based professional training as well as continuing education. On this basis they shall improve the medical care of affected patients in both the inpatient and outpatient sector. Chronic pancreatitis requires an adequate diagnostic workup and systematic management, given its severity, frequency, chronicity, and negative impact on the quality of life and life expectancy.

[Screening for colorectal cancer: even with virtual colography?]. / Screening des Kolonkarzinoms: Auch mit virtueller Kolographie?

Colorectal cancer (CRC) is responsible for 27,000 deaths and 65,000 new cancers in Germany each year, although this should be unnecessary as CRC is preventable because it is possible to remove the precursors, harmless polyps and adenomas. However, only 2.5 % of people in health insurance make use of screening colonoscopy annually so that it becomes necessary to check out other screening tests. The most commonly used test is the Guaiak-based test for fecal occult blood (gFOBT) which is highly specific but not very sensitive (only approximately 10 %). New immunological stool tests are more sensitive but the specificity is reduced from 90 % to approximately 80 %. Virtual colonoscopy based on computed tomography (CT) or magnetic resonance imaging (MRI) is comparable to endoscopy for diagnostics with overall accuracy rates of approximately 80-90 % for polyps larger than 5 mm but for radiation protection reasons CT is not usable in Germany and MRI is internationally not adequately established by large study trials. For the future there is much hope in molecular blood tests. It is of great importance that every physician is aware of the different tests, their strengths and weaknesses and advises all patients to use the different screening possibilities.

[Diverticulitis--conservative therapy]. / Divertikulitis--Konservative Therapie.

BACKGROUND: Diverticulitis due to diverticulosis of the colon is a common clinical problem with a high morbidity and socio-economic consequences. Frequent clinical signs are flatulence, abdominal pain, stool problems which may often be misinterpreted as the symptoms of an irritable bowel or a colitis. Accordingly, the diagnostic work-up must be adequate to allow for the stage-adapted planning and performance of the therapy. MATERIAL AND METHODS: The following questions will be addressed in this review: What do we need to clarify diagnosis? Which antibiotics should be used? What is the best conservative approach for treatment? RESULTS AND CONCLUSIONS: Basic conservative therapy consists of systemic antibiosis which can be extended by a topical antibiosis, and administration of aspirin as well as probiotics. The indications for a specific therapy is made on an individual basis according to stage (Hansen and Stock). Above all, a "team approach" and close communication between gastroenterologists and surgeons are mandatory for adequate treatment of these patients.

A pilot study evaluating a new low-volume colon cleansing procedure for capsule colonoscopy.

BACKGROUND AND STUDY AIMS: Colon capsule endoscopy (CCE) offers an alternative approach for endoscopic visualization of the colon. Some of the current CCE bowel cleansing regimens use sodium phosphate, which has raised safety concerns. Therefore, the aim of the current study was to test the feasibility and efficacy of a new low-volume, sodium phosphate-free polyethylene glycol (PEG) bowel preparation. METHODS: The first 26 patients (original cleansing procedure) received a colon cleansing regimen of PEG plus ascorbic acid: patients drank 1 L in the evening and 0.75 L in the morning before capsule ingestion. Patients also drank an additional 0.5 L PEG boost and an optional 0.25 L PEG boost during the capsule procedure. Following an interim analysis, the cleansing procedure of the subsequent 24 patients was modified, with the morning intake before capsule ingestion being increased to 1 L, as well as the second boost (0.25 L) being administered 1 - 2 hours earlier (modified cleansing procedure). RESULTS: The overall colon cleanliness was considered to be good or excellent in 83 % (original cleansing procedure) and 82 % (modified cleansing procedure) of patients, without any significant difference between regimens (P > 0.05). In 37 /49 (76 %) of the CCE procedures, the hemorrhoidal plexus was identified and thus the examination was considered complete, with no significant differences between the two CCE cleansing procedures. The capsule sensitivity and specificity for detecting colonic polyps ≥ 6 mm were 91 % (95 %CI 70 % - 98 %) and 94 % (95 %CI 87 % - 97 %), respectively, compared with standard optical colonoscopy. CONCLUSION: A colon cleansing procedure using PEG + ascorbic acid for capsule colonoscopy yielded an adequate cleansing level in > 80 % of patients, a completion rate of 76 %, and good accuracy for detecting polyps. This procedure may be considered as an alternative, particularly for patients in whom sodium phosphate-based preparations are contraindicated.

Colonoscopy screening: status in Europe.

Europe has made significant progress in recent years by introducing population-based screening programs for colorectal cancer. Due to excellent evidence-based results on the basis of large prospective randomized trials, mass screening using the fecal occult blood test is currently the procedure of choice. Endoscopy-based programs do afford quality insurance programs which are outlined in the recommendations of the European Commission.

[Early detection of colonic cancer in the National Cancer Program--present status and recommendations]. / Darmkrebsfrüherkennung im Nationalen Krebsplan--Aktueller Stand und Empfehlungen für die Weiterentwicklung.

The National Cancer Programme of the German Federal Administration aims to assess the present status of the national fight against cancer in Germany. Experts in their field have analysed the present target-performance comparison in different working groups dealing with topics from cancer prevention to follow-up and have developed recommendations as to how improvements in the various fields of cancer care may be achieved and mainly how these imrpovements may be implemented in day-to-day cancer care. The working group "Advancement of Colon Cancer Screening, Early Detection and Prevention" proposes the establishment of regulatory proposals for a nationwide, population-based, postal invitational process and, according to Pilot-Projects in Bavaria and Baden-Wuerttemberg, to evaluate the essential recommendations in data protection, logistics, documentation and financing. There are already several programmes in preparation--for example, the Saarland Offensive, based on the results of the KolosSal-Study.

Effectiveness and Safety of PRECISE APC for the treatment of bleeding gastrointestinal angiodysplasia--a retrospective evaluation.

BACKGROUND: APC is a thermal coagulation technique that uses ionized argon to transmit high-frequency electrical current, contact-free, to tissue. Precise APC is one of the new modes and is characterized by a small and distinctive energy input, higher reproducibility of tissue effects which is almost independent of the probe distance. The aim of the study was the evaluation of precise APC in patients with bleeding angiodysplasia's in the cecum or the small bowel. AIM/METHODS: Patients (pts.) with bleeding angiodysplasia of the cecum or small bowel were prospectively enrolled. Effectivity and safety of APC was assessed by evaluating the local coagulation effect, number of rebleedings and transfusions and complications (perforation, infection). RESULTS: There were 50 males and 44 females, median age 65.5 ± 8.5 years. 58 pts. (62 %) had lesions in the small bowel, 28 pts. (30 %) lesions in the cecum and 8 pts. (8 %) lesions in small bowel and cecum. All 234 visible lesions in 94 pts. were coagulated successfully. There was no perforation, active bleeding and tissue carbonization after the procedure. Re-bleeding was recognized in 18 pts. (19 %) after a mean follow-up of 6.1 months and new lesions in the same area were seen in 15 / 18 pts (16 %). CONCLUSION: In a historical comparison to forced or pulsed APC, precise APC may be a more appropriate option for the treatment of bleeding angiodysplasia's in critical locations like the cecum or small bowel. The coagulation effect seems to be comparable and due to its better depth control we assume a better safety, especially in preventing perforations.

Effectivity of current sterility methods for transgastric NOTES procedures: results of a randomized porcine study.

BACKGROUND AND AIM: Natural-orifice transluminal endoscopic surgery (NOTES) is an emerging transluminal technique in which interventions are carried out by entering the abdominal cavity via a natural orifice such as the stomach. Infection is a potential risk of the procedure, and the potential pathogens are different from those encountered with skin incisions. Currently, available data regarding prophylactic anti-infective treatment are limited. We compared the effectiveness of topical antimicrobial lavage of mouth and stomach and proton pump inhibitor therapy with gastric cleansing with sterile saline solution in preventing NOTES-related contamination and infection. METHODS: A randomized survival swine study was performed. Eight pigs underwent preparation with intravenously administered proton pump inhibitors, mouth and gastric lavage (chlorhexidine), and gastric irrigation (diluted neomycin), plus single-shot intravenous antibiotics. Control group (n = 8) underwent gastric cleansing with sterile saline solution. Peritoneal biopsy, multiple smears, and dilutions for cultures were taken and incubated. The swine were sacrificed after 14 days. Bacterial load was expressed in colony-forming units (CFU). RESULTS: One pig died due to gallbladder perforation after 3 days, 2/15 swine presented minor clinical signs of infection in the 14-day follow-up (all 3 pigs were in the control group). Mean C-reactive protein levels were 5.7 +/- 2.4 g/dL (therapy group) and 12.2 +/- 3.8 g/dL (control) ( P = 0.17). Bacterial growth was seen in 1/8 swine (therapy group) and 6/8 swine (control group) ( P = 0.002). Bacterial load was 282 CFU/mL (therapy) vs. 3.2 x 10 (5) CFU/mL (control) ( P = 0.023) in the follow-up. CONCLUSION: The use of intravenous antibiotics in addition to topical antimicrobial lavage of mouth and stomach and treatment with proton pump inhibitors decreased the peritoneal bacterial load to almost zero and this was associated with a significantly lower peritoneal infection rate compared with saline-only lavage.

Endoscopic resection of "giant" colorectal lesions: long-term outcome and safety.

BACKGROUND: Today, endoscopic resection is a standard procedure for the resection of colonic polyps. Before the establishment of endoscopic techniques, the surgical approach was a clearly preferred method for removal of polyps with a size larger than three centimeters. The safety and effectiveness concerning endoscopic resections of colorectal polyps also with a size of more than 3 cm have been demonstrated in numerous studies. PATIENTS AND METHODS: Data from 165 patients (age: 68 +/- 10.4 years) harboring 167 polyps with a minimum diameter of 3 cm were retrospectively evaluated. Objects of interest were macroscopic morphology and histopathology of the polyps, their localization in the colon, the modality of endoscopic resection and follow-up. In those cases with macroscopic signs of malignancy the patients were excluded. RESULTS: Successful endoscopic resections were obtained in 72.5 %. Therefrom, resection in the piecemeal-technique was necessary in 73.6 %. Recurrence polyps after endoscopic complete resections occurred in 26.3 % after a mean follow-up of 16 +/- 12.5 months. We registered a complication rate of 19.2 %. Relevant bleeding and perforation were registered as early complications in 18.6 %. We observed no intervention-related mortality. CONCLUSION: Endoscopic mucosal resection is a safe and efficient method even for removing giant colorectal polyps. Controls are recommended at defined intervals for detecting polyp recurrence.

[Endoscopy of the small bowel: light into the dark]. / Dünndarmendoskopie: Licht ins Dunkel.

Since the introduction of capsule endoscopy and later balloon enteroscopy in clinical practice, endoscopic examination of the small bowel has dramatically improved. For the first time, it is possible to diagnose the whole small bowel without the necessity of laparotomy and intraoperative enteroscopy. The methods revolutionized the field of small bowel diagnostic and therapy and become part of daily clinical practice. This article provides a review of small bowel enteroscopic methods.

Fragmentation of bile duct stones: a prospective systematic in vitro evaluation of argon plasma coagulation, cryotechnology, and water-jet technology.

BACKGROUND AND STUDY AIM: Choledocholithiasis is a common disease in the West. Lithotripsy by mechanical methods using baskets and by laser or electrohydraulic methods varies in effectiveness. With argon plasma coagulation (APC), high temperatures are used for devitalization and fragmentation; cryogenic techniques use the selective controlled application of freeze-thaw cycles to devitalize pathological tissue; and the dissecting water jet exploits the high pressure action of a thin laminar jet. We aimed to assess the feasibility and effectiveness of APC, cryotechnology, and the dissecting water jet as options for the fragmentation of bile duct stones. METHODS: In an in vitro feasibility study, we evaluated the fragmentation of 120 bile duct stones treated with the three methods. Primary measures were assessment of the fragmentation rate, fragmentation effect, and energy application for each technology. RESULTS: Fragmentation was seen in only 10 % of stones treated cryogenically using liquid nitrogen. APC at a power setting of 30 - 50 W fragmented all the cholesterol stones, but results with hard pigment stones were unsatisfactory even at high energies of a 100 W setting and long application time. Using the water jet, all 40 stones (100 %) were cracked effectively and completely with a pressure of 10 - 50 bar. CONCLUSION: In this feasibility study, the first of its kind, only the water-jet device demonstrated efficient fragmentation of large bile duct stones in vitro. APC and cryotechnology are not suitable for the treatment of bile duct stones; the fragmentation rate with these methods was inadequate.

[Actual state of knowledge of the german population about the early detection of colorectal cancer--a study by the "Stiftung LebensBlicke" in cooperation with the institute for demoscopy in Allensbach]. / Aktueller Wissensstand der Bevölkerung zur Darmkrebsvorsorge - eine Untersuchung der Stiftung LebensBlicke mit dem Institut für Demoskopie in Allensbach.

Colorectal cancer is the most common cancer in Germany. The LebensBlicke foundation and it's supporting alliance have or many years, like others, been pushing information campaigns abour early detection measures and their chances for the general population. With the aid of the institute for public opinion research in Allensbach a representative cross-sectional investigation about the state of knowledge, opinions and attitudes concerning this topic was carried out. Surprisingly, it was demonstrated that an information deficit no longer exists and that especially people of older age are concerned about this topic. It is also remarkable that more than 40 % of the individuals over 50 years of age have had a colonoscopy at least once in their lifetime, that there is still a lack of knowledge in terms of familiy and genetic risk factors and that a doctor's recommendation is the most important driving factor to choose to undertake preventive measures. The data of this investigation will of course influence not only the work of the foundation in the next years, but should also be of major importance for medical societies and last not least for the politicians who control the health system.

[Gastroenterology in Germany: results of a survey in hospitals and practices]. / Status quo Gastroenterologie.

In future, the profile of gastroenterology in Germany - as in other countries - will change. New achievements such as capsule endoscopy, aero-scopes and advanced CT and MRI technology and others will become alternatives to conventional endoscopy. Additional emphasis in clinical and outpatient gastroenterology is shifted towards gastrointestinal oncology, dietetics, nutrition and metabolism and in the clinical setting onto infectious diseases, endocrinology/diabetology, intensive care medicine, emergency service and geriatric medicine. The German Confederation of Gastroenterology (BVGD) initiated two Germany-wide surveys on the current diagnostic and therapeutic spectrum in hospitals and out-patient facilities to achieve a base for future discussions regarding the development of gastroenterology. The number of gastroenterologists working in hospitals and in out-patient facilities has been analysed as well as the number of examinations passed successfully during the last few years in the speciality "gastroenterology". The results of this survey offer a valid basis for continuing discussions as to how gastroenterology should develop in Germany.

Expression of the multidrug resistance proteins MRP2 and MRP3 in human cholangiocellular carcinomas.

BACKGROUND: Cholangiocellular carcinomas and gallbladder carcinomas are highly aggressive tumours with a poor prognosis and are generally regarded as chemoresistant tumours. Overexpression of ATP-binding cassette transporters of the multidrug resistance protein (MDR) and multidrug resistance-related protein (MRP) family in cancer cells is a major cause for the multidrug resistance phenotype in vitro and in vivo. To further define the role of MRP family members in biliary tract cancer, we studied the expression and localization of MRP2 and MRP3 in cholangiocellular carcinomas and gallbladder carcinomas. MATERIALS AND METHODS: The expression and cellular localization of the multidrug resistance proteins MRP2 and MRP3 in human cholangiocellular carcinomas and gallbladder carcinomas were analysed by immunohistochemistry using isoform-specific antibodies. Expression of MRP isoforms was studied in vitro in Mz-ChA-1 cells derived from gallbladder adenocarcinoma by reverse transcription-polymerase chain reaction (RT-PCR), immunoblotting and immunofluorescence microscopy. RESULTS: Mz-ChA-1 cells constitutively expressed MDR P-glycoproteins, MRP1, MRP2 and MRP3 by RT-PCR, immunoblotting and immunofluorescence microscopy. MRP2 and MRP3 are expressed in the respective apical and basolateral membrane domains. MRP3 was the predominant MRP isoform in gallbladder carcinomas (93%) and cholangiocellular carcinomas (57%), whereas MRP2 expression was detected in only 29% of gallbladder carcinomas and was undetectable in cholangiocellular carcinomas. CONCLUSIONS: Our findings suggest that the intrinsic multidrug resistance of cholangiocellular and gallbladder carcinomas seems to be independent of MRP2 expression while the expression of MRP3 may contribute to the MDR phenotype.

Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy.

BACKGROUND: Argon plasma coagulation (APC) is a thermal coagulation technique that uses ionized argon for contact-free transmission of high-frequency electrical current to tissue. Prospective data on complications with the new APC-2 (VIO) system are lacking. METHODS: A prospective trial was conducted with 152 patients treated for various gastrointestinal diseases using three modes of the APC-2. The study aimed to assess complications, focusing on the pain and neuromuscular stimulation (NMS) experienced during and after treatment. Patients reported pain and NMS using a scale ranging from 0 to 10 and were interviewed for symptoms such as tingling, paresthesia, muscle pain, and cramping or twitching. The endoscopists also graded NMS using a separate questionnaire. RESULTS: A total of 85 males and 67 females (median age, 66 years) were enrolled in the study. All APC therapies were completed successfully. Two peri-interventional perforations were recorded. Of the 152 patients, 26 (17%) reported pain sensation during or after APC. The median pain sensation reported by the patients on the standardized scale was 3.7. The findings showed NMS in 14 (9.2%) of the 152 patients. Significantly more NMS events were seen with pulsed APC than with forced or precise APC. Additional risk factors for NMS were gender (female) and type of sedation (combination midazolam and pethidine). No complications were noted among patients with intracardiac defibrillators or cardiac pacemakers. CONCLUSIONS: According to the findings, APC may be associated with minor complications such as pain sensation and NMS. These complications were rarely seen, but occurred more often with pulsed APC than with forced or precise APC. Physicians should be aware of these complications.

Gastric fundic gland polyps and colonic polyps - is there a link, really?

BACKGROUND AND AIM: A retrospective analysis of endoscopic investigation was carried out. Gastric fundic gland polyps occur in patients with familial adenomatous polyposis. The aim of our study was to investigate if colonic polyps is present and related to gastric fundic gland polyps. PATIENTS AND METHODS: A 6 years retrospective analysis was carried out. At baseline upper gastrointestinal endoscopy, gastric fundic gland polyps were diagnosed in patients suffered from intestinal bleeding. Subjects received a colonoscopy additionally. A total of 500 patients were enrolled into study: 250 fulfilled the diagnostic criteria for gastric fundic gland polyps and 250 age and sex matched served as controls. RESULTS: Colonic cancer was more frequently observed in 39 (15.5%) patients who met the criteria of gastric fundic gland polyps as compared to 23 (9.2 %) patients of the controls (p <0.05). Patients with gastric fundic gland polyps tended to have more often colonic polyps 122 vs. 111, but these differences were not statistically significant. CONCLUSION: The prevalence of colonic cancer was elevated in patients with gastric fundic gland polyp. Furthermore, this relationship did not differ significantly according to occurrence of colonic polyps. Even tough colonoscopy is prophylactic in preventing colonic cancer; the use of colonoscopy should be encouraged in patients with gastric fundic gland polyps.