[Magnetic resonance imaging vs. three-dimensional scintigraphy in the diagnosis and monitoring of mandibular osteomyelitis]

Bone scintigraphy is routinely used in the diagnosis of lower jaw osteomyelitis; however, the radiation dosage of 3.5 mSv is quite high. Magnetic resonance imaging (MRI) gives information about soft tissue and bone marrow alterations. This study compares the sensitivity of the two imaging modalities in the diagnosis of lower jaw osteomyelitis. Thirteen patients with clinical signs of the disease were examined and followed up using both methods, three-phase bone scintigraphy and MRI. Compared to three-phase bone scintigraphy, MRI has the same diagnostic sensitivity. However in one case of active osteomyelitis bone scintigraphy showed a false-negative result. MRI once indicated a higher activity rate but never failed to provide the diagnosis. In addition, it gives exact information about the location, size and involvement of the soft tissue. A STIR sequence should be performed in addition to the native and contrast-enhanced T1-weighted spin echo sequence. The metal artifacts of the antibiotic chain on the MRI can be eliminated by replacing the wire by nonresorbent suture material. In the diagnosis of lower jaw osteomyelitis, three-phase bone scintigraphy can be replaced by the MRI.

[Magnetic resonance tomography in the diagnosis of mandibular osteomyelitis]

PURPOSE

A prospective study of the value of MRI in the diagnosis of osteomyelitis of the mandible with special reference to the suitability of different MR sequences.

MATERIAL AND METHODS

In 13 patients, average age 55 years (12-82), with clinical suspicion of osteomyelitis of the mandible, 18 MRI examinations were carried out (STIR, TSE T2, proton and SE T1 weighted scans with and without contrast, slice thickness 3.5 to 6 mm). Image quality of the sequences was evaluated as well as the suitability of the various sequences for showing the lesion, its location and extent. Activity of the osteomyelitis was judged by the degree of contrast uptake and was correlated with 3-phase bone scintigraphy and with histological findings.

RESULTS

In 9 of the 14 cases the findings on MRI and of the scintigraphy agreed with the histology. In two patients the activity of the inflammatory process was exaggerated by the MRI. In another follow-up examination it was slightly underestimated. All lesions were shown to be highly active by the histology were recognized as such by MRI. For the localisation and recognition of the extent of the inflammatory processes STIR sequences and T1 weighted non-enhanced SE sequences proved the most suitable. Contrast medium is essential to evaluate the inflammatory activity.

CONCLUSION

MRI is a sensitive diagnostic method; it is as good as 3-phase bone scintigraphy in demonstrating osteomyelitis of the mandible and of its activity but is superior for showing the pathological anatomy.

Serum laminin and hyaluronan in liver cirrhosis: markers of progression with high prognostic value

BACKGROUND/AIMS

In a prospective study with a mean follow-up period of 12.5 +/- 3.5 months, we investigated the extracellular matrix components laminin and hyaluronan in serum for their diagnostic value in portal hypertension and in clinically severe complications of progressive liver cirrhosis.

METHODS

In 38 patients with liver fibrosis (n = 4) and cirrhosis (Child A: n = 17, B: n = 7, C: n = 10), the serum concentrations of laminin and hyaluronan were determined. Portal hypertension was assessed by endoscopic control of the esophageal varices and by Doppler sonography of the portal blood flow.

RESULTS

Neither laminin nor hyaluronan correlated with portal hypertension, but highly significantly increased (p < 0.001) concentrations of 3.25 +/- 0.2 U/ml (laminin) and 493 +/- 248 ng/ml (hyaluronan) were found in patients with complications of liver cirrhosis when compared to those without complications (Ln: 2.13 +/- 0.26 U/ml, HA: 206 +/- 184 ng/ml). At cut-off levels of 2.6 U/ml (laminin) and 200 ng/ ml (hyaluronan), the diagnostic sensitivity and specificity for severe complications of liver cirrhosis was 0.71 and 0.86 (Ln) and 0.90 and 0.67 (HA), respectively. The positive predictive values were of 0.8 (laminin) and 0.6 (hyaluronan). The relative risk of patients presenting elevated concentrations of laminin or hyaluronan at the start of the study for later development of severe complications was 2.7.

CONCLUSIONS

Both parameters, especially serum laminin, can be used as prognostic markers in addition to the Child criteria in liver cirrhosis.

[The clinical value of laminin determination in advanced liver cirrhosis]

OBJECTIVE

To test prospectively whether serum laminin levels, which is taken to indicate portal hypertension, can predict the occurrence of severe complications in advanced cirrhosis of the liver.

PATIENTS AND METHODS

In 38 patients (21 men, 17 women; mean age 55.6 +/- 13.4 years) with liver fibrosis (n = 4) or liver cirrhosis (n = 34) serum laminin was measured by a commercially available radioimmunoassay (Behring, Marburg). The severity of liver cirrhosis was graded according to the Child-Pugh-Christensen criteria. Portal hypertension was assessed by standard endoscopic methods and portal-vein duplex sonography. Within a mean observation period of 12.5 +/- 3.5 months, the following were used as signs of severe clinical complications of liver cirrhosis: stages III and IV of hepatic coma, treatment-refractory ascites, portal vein thrombosis and death due to multi-organ failure. Acute bleeding from oesophageal varices was confirmed by emergency endoscopy.

RESULTS

At laminin concentrations of 3.25 +/- 0.20 U/ml there was a highly significant correlation (P < 0.001) with complications of liver cirrhosis. Using 2.6 U/ml as the critical level, the occurrence of severe complications had a positive predictive value of 0.80 with a sensitivity and specificity of 0.71 and 0.86 respectively. This means that a patient who, at the beginning of the study period, had a raised laminin concentration, had a relative risk of 2.65 (1.41-4.97) for later severe complications.

CONCLUSION

Serum laminin concentration has a diagnostic efficiency of 0.79 as a prognostic indicator and can thus serve as a valuable addition to the Child-Pugh-Christensen classification of liver cirrhosis.

Portal duplex sonography in liver cirrhosis. A useful supplement to endoscopic evaluation of bleeding risk of esophageal varices?

BACKGROUND

In a prospective study we investigated whether the endoscopic assessment of the bleeding risk of esophageal varices could be supported by portal duplex sonography.

METHODS

Over the time span of 2.5 years (range, 13 +/- 5 months) we observed 41 patients with liver cirrhosis. During that time 17 patients had acute esophageal variceal hemorrhage and constituted the bleeding group, and the remaining 24 patients without a hemorrhage constituted the non-bleeding group.

RESULTS

Within the bleeding group the mean portal blood flow velocity (Vm) was 0.093 +/- 0.033 m/sec, and the mean flow volume (Fm) was 0.371 +/- 0.173 l/min. Both results were significantly lower than the corresponding results of the nonbleeding group (p < 0.017; p < 0.05). By assuming cut-offs for Vm of 0.12 m/sec and for Fm of 0.420 l/min, we obtained a diagnostic sensitivity for hemorrhage of 0.88 and 0.65.

CONCLUSION

Our results show that portal duplex sonography may improve the evaluation of endoscopically ascertained bleeding risk of esophageal varices.

[Diagnostic value of portal duplex ultrasound in liver cirrhosis]

AIM

In a prospective study we investigated if the endoscopical evaluation of the bleeding risk of esophageal varices in cirrhotics could be improved by additional duplex sonography of the portal vein.

METHOD

The trial involved 41 patients with endoscopically diagnosed esophageal varices (27 male, 14 female) who were followed up over a period of 30 months (mean of 13 +/- 3). According to the Child-Pugh-Turcotte -classification, 14 patients were classified as grade A, another 14 as grade B, and 13 as grade C. The cause of the cirrhosis included virus infection (n = 14), alcohol (n = 17) and miscellaneous disorders (n = 9, primary biliary = 3, autoimmune = 2, idiopathic = 4).

RESULTS

During the observation time, 17 patients who developed an acute esophageal variceal hemorrhage were put in the bleeding group (mean portal flow velocity Vm = 9.29 +/- 3.31 cm/s, mean flow volume Fm = 371 +/- 173 ml/min), while the remaining 24 patients formed the non-bleeding group (Vm = 13.29 +/- 5.12 cm/s, FV = 500 +/- 200 ml/min). The bleeding group had significantly lower mean portal flow velocities (p < 0.017) and mean flow volumes (p < 0.05) than the non-bleeding group. By adopting cut-off values of 12 cm/s for Vm and 420 ml/min for FV we obtained a diagnostic sensitivity for predicting esophageal variceal hemorrhage of 0.88 and 0.65 respectively.

CONCLUSION

Portal duplex sonography may improve the evaluation of bleeding risk in patients wit endoscopically diagnosed esophageal varices and could influence the decision for prophylactic treatment.

Fibronectin in human bile fluid for diagnosis of malignant biliary diseases

In a preliminary study, we demonstrated a strong association between the concentration of the glycoprotein fibronectin (FN) in human bile fluid and the presence of malignant biliary diseases. We now present the results of measurements of total FN (tFN) and cellular FN (cFN) within a larger group of 71 patients. Bile fluid was collected during routine endoscopic retrograde cholangiography or by transhepatic puncture, respectively, from patients admitted for examination/treatment of biliary obstruction. Determination of tFN in bile was performed using a previously described time-resolved fluorescence immunoassay (TRFIA). For cFN, a newly developed TRFIA, using a specific monoclonal antibody for the EDA epitope of cFN, was applied. Within the noncarcinoma group of patients (n=50), consistently low concentrations of tFN (median = 5 ng/mL) were found. In most of these cases, the corresponding concentrations of cFN were below the detection limit (2.6 ng/mL) of this assay. Highly significantly elevated concentrations were found for both tFN (median = 1,220 ng/mL) and cFN (median = 243 ng/mL) in the carcinoma group (n = 21) in comparison with the noncarcinoma group (P < or = .01). By adopting cutoff values of 60 ng/mL for tFN and >0 ng/mL for cFN, diagnostic sensitivities for carcinoma of the biliary tract of 0.89 and 0.92, and specificities of 0.96 and 0.98, respectively, were computed. FN in bile fluid is suggested as a sensitive, specific, and easily determined marker for differential diagnosis of malignant and benign diseases of the biliary tract.

Omeprazole-amoxycillin therapy for eradication of Helicobacter pylori in duodenal ulcer bleeding: preliminary results of a pilot study

Thirty-five patients with duodenal ulcer bleeding and Helicobacter pylori-colonization were assigned to receive 2 x 20 mg omeprazole and 3 x 750 mg amoxycillin daily for 2 weeks. Eradication was defined as no evidence of H. pylori infection by urease test and by histology 4 weeks after completion of therapy. Two patients were lost to follow up. All ulcers healed completely (100% ulcer healing rate). Twenty-nine out of the 33 patients were H. pylori-negative (87.9% eradication rate). Three patients complained of typical side effects of amoxycillin (9.1% side effect rate). The patients were prospectively followed for 12 months. After ulcer healing, no maintenance therapy was given. One of the 29 patients in whom H. pylori eradication had been successful suffered a second ulcer hemorrhage with H. pylori reinfection (3.4% relapse rate of ulcer bleeding), and this was managed endoscopically. Recurrent ulcer hemorrhage occurred in 2 out of 4 H. pylori-resistant patients. At the end of the follow-up period, of the patients in whom H. pylori eradication had been initially successful, only the patient with re-bleeding remained reinfected. The 4 H. pylori-resistant patients showed persistent H. pylori colonization. In conclusion, omeprazole plus amoxycillin is a safe and effective treatment for eradicating H. pylori; this treatment reduces the relapse rate of duodenal ulcer bleeding.

Diagnosis and treatment control of bleeding intestinal angiodysplasias with an endoscopic Doppler device

OBJECTIVE

To investigate the effectiveness of prophylactic injection therapy in vascular malformations after acute hemorrhage. To review recent advances in diagnosis and treatment control of bleeding intestinal angiodysplasias with an endoscopic Doppler device.

DESIGN

Open prospective study involving 34 patients with bleeding from gastroduodenal and colorectal angiodysplasias.

INTERVENTIONS

In order to detect the superficial arterial vessels responsible for the bleeding, a total of 79 lesions were scanned by transendoscopic Doppler ultrasonography. 70 vascular ectasias (88.6%) were Doppler-positive and had injection therapy with epinephrine and polidocanol.

RESULTS

Out of the 70 sclerosed angiodysplasias, 63% (90.0%) could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 7 visible malformations, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 1 year of follow-up, 2 of the 34 treated patients (5.88%) relapsed with actively bleeding cecal angiodysplasias. After repeated endoscopic hemostasis, no more hemorrhage was observed in both patients. The results were partly published in previous publications.

CONCLUSION

Endoscopic Doppler ultrasonography may help in identification and treatment of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy.

Extragastric Dieulafoy's disease as unusual source of intestinal bleeding. Esophageal visible vessel

Dieulafoy's disease is a gastric vascular malformation, which typically causes massive hemorrhage. The lesion is most often found in the proximal stomach, but has also been reported in the esophagus and in the small intestine. Three patients with esophageal Dieulafoy's anomaly and recurrent bleeding are reported. For the first time, transendoscopic Doppler ultrasound was used to identify arterial blood flow from the lesions. The ulcerations were treated by injection of adrenaline. Successful therapy resulted in the disappearance of arterial pulsations and no rebleeding occurred. Doppler-controlled endoscopic intervention should be the first line of treatment in the esophageal vessel stump.

[A rare etiology for HBs-Ag negative acute hepatitis B--coinfection by hepatitis B and delta]

An unusual case of a 25-year-old male Italian is reported. The patient endured an acute hepatitis without detectable HBs-antigen by coinfection with hepatitis-B and Delta. Coincidently, a cured hepatitis-C was present. Firstly hepatitis-B-virus DNA could be demonstrated in a small quantity by serodiagnosis (6 pg/ml, hybridization technique). Subsequently, the identification of B-virus DNA was only possible in liver tissue (PCR-technique), but no longer by serodiagnosis. The probable enduring inhibition of hepatitis-B-virus replication by Delta virus resulted in a self limitation of the disease within 2 months (HDV-RNA negative, HBs-Ag and HBe-Ag negative; Anti-HBs negative, Anti-HBe and Anti-HBc positive). In spite of negativation of replication markers for hepatitis-B a subsequent reactivation of the infection was possible by viral material which persisted in liver tissue.

[Bouginage of peptic esophageal stenoses. Results of one year with long-term omeprazole medication]

METHOD

Within the framework of an open prospective study, 47 patients with chronic reflux esophagitis, unresponsive to H2-receptor blockers and complicated by stenosis, underwent endoscopic bougienage. Unsuccessful treatment with H2-receptor blockers was followed in all patients by antisecretion treatment with omeprazole at a dose of 40 mg/day.

RESULTS

At the latest after 3 months, stenotic and inflammatory changes had cleared up in all patients and under continued omeprazole over the long-term, remission of at least one year was achieved.

CONCLUSION

A combination of endoscopic bougienage and simultaneous treatment with the proton pump blocker, omeprazole, represents effective treatment of chronic reflux disease complicated by stenosis.

[Fibronectin in human bile--a new parameter for diagnosis of malignant bile duct processes?--A pilot study]

In a pilot study it was investigated whether concentration of the glycoprotein fibronectin in the bile fluid can assist in differentiating between malignant and benign biliary tract obstructions. During endoscopic-retrograde cholangiography (ERC) and percutaneous transhepatic cholangiography (n = 3) native bile was aspirated in 29 patients. The concentration of fibronectin was determined by time resolved fluorescence immuno-assay. In 19 patients no biliary malignoma was present (choledocholithiasis: n = 9, normal finding: n = 10). Ten patients suffered from biliary or pancreatic cancer (infiltrating pancreatic cancer: n = 6; primary biliary tract cancer: n = 3, Klatskin tumor: n = 1). In the non malignant group a median fibronectin concentration of 12.0 ng/ml (lower-upper quartile 5-30 ng/ml) was found. A highly significantly elevated (p < 0.001, non parametric Kruskal-Wallis-test) median fibronectin concentration of 1675 ng/ml (lower-upper quartile 155-3430 ng/ml) could be determined in the malignant group. Our results show that in analogy to ascites, the concentration of biliary fibronectin is an important and easily determinable parameter in the differential diagnosis of benign und malignant diseases of the biliary tract.

Diagnosis and treatment control of bleeding colorectal angiodysplasias by endoscopic Doppler sonography: a preliminary study

The diagnostic accuracy and practical impact of trans-endoscopic Doppler ultrasonography were prospectively investigated in an open preliminary study of patients with hemorrhage from colonic vascular malformations. From January 1, 1991, to December 31, 1992, 437 consecutive patients were seen with lower gastrointestinal bleeding. In 15 cases the source of hemorrhage proved to be colorectal angiodysplasias (3.4%). In all cases bleeding had stopped spontaneously before the endoscopic examination. Upper gastrointestinal causes of bleeding were excluded endoscopically in each patient. To detect the superficial arterial vessels responsible for the hemorrhage a total of 32 lesions were scanned by trans-endoscopic Doppler ultrasonography. Twenty-nine vascular malformations in 12 patients were Doppler-positive (91%) and 3 lesions in 3 patients were Doppler-negative without an arterial signal. All Doppler-positive lesions had injection therapy with epinephrine and polidocanol. Twenty-six of the 29 sclerosed angiodysplasias (90%) in 9 patients could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 3 visible malformations in the remaining 3 patients, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 6 months of follow-up, one of the 12 treated patients relapsed with an actively bleeding cecal angiodysplasia. After repeated endoscopic hemostasis, no further hemorrhage was observed in this patient. No bleeding recurred in the 3 patients with Doppler-negative lesions. Endoscopic Doppler sonography may help in the identification of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy.

[Endoscopic pseudocysto-gastric drainage involving the stomach after Billroth II operation]

A 45 years old female patient developed a large pseudocyst after an acute pancreatitis in 1987. In 1982 gastric resection with Billroth's anastomosis was performed. The patient underwent surgical internal and percutaneous external drainage in 1988, which both resulted unsuccessfully. The current admission was due to a complete occlusion of the gastric anastomosis, induced by a recurrent pseudocyst of 9.2 x 7.3 cm in diameter. Endoscopically guided pseudocysto-gastric drainage by means of electrocauterization was successful with nearly complete evacuation.

[Proctoscopic Doppler ultrasound in diagnosis and therapy of symptomatic first degree hemorrhoids ]

Within the framework of a prospective study two comparable collectives with each 62 patients and symptomatic first grade hemorrhoidal disease were examined. Guiding symptom was painless hematochezia. The hemorrhoids of collective A were evaluated with the aid of transproctoscopic Doppler ultrasound. The depth of the vessels was determined and a Doppler located injection therapy was performed. The patients of collective B were only investigated by means of proctoscopy and sclerosed without Doppler. Sclerosing injection was carried out in all cases with 6 ml Phenylamygdalic oil by 3, 7 and 11 o'clock lithotomy position. Success of therapy was controlled in all patients 2 weeks later Doppler sonographically. In 87% of the Doppler controlled treated patients the hemorrhoids were completely eliminated and no more arterial blood flow could be scanned. On the contrary only 37% of the initially not Doppler scanned patients were cured. Endoscopic Doppler ultrasound is and effective method in evaluation and treatment of symptomatic first grade hemorrhoids.