[Treatment of chronic constipation with swelling substances]

In 20 patients with chronic constipation and, in many cases, years of laxative abuse, in a prospective and randomized study, treatment with new, specially prepared swelling substances administered at the recommended doses, was carried out after first stopping the use of laxatives. After only one week of this treatment, a marked increase in the weight of the stools, and a reduction in stool transit time (p less than 0.05 in each case) were observed.

Splenic abscess-clinical symptoms and diagnostic possibilities

A 71-yr-old female patient was admitted for investigation of a massive leukocytosis and loss of weight. Physical examination revealed a reduction in the respiratory excursion of the left lung, a left pleural friction rub located ventrobasally and tension of the upper abdominal wall. Additional diagnostic procedure excluded extrasplenic disease. Ultrasound-guided puncture demonstrated the presence of pus in the splenic bed, and splenic abscess was diagnosed. Subsequent surgery confirmed this diagnosis. Histological findings revealed extensive splenic infarction. Since bacteriological investigation revealed the identical pathogens in the pus obtained with the puncture needle, in the intraoperative swab and in the midstream urine, the splenic abscess was most likely caused by hematogenous spread of a urinary tract infection into the splenic infarction. The postoperative course was uneventful, and the patient was discharged on the 11th postoperative day, free of symptoms. The clinical picture, radiological diagnosis, origin, therapy and course of splenic abscess are discussed with reference to the literature.

[Treatment of Crohn's disease with metronidazole (author's transl)]

The therapeutic effect of metronidazole, alone or in combination with the basic treatment schedule of corticosteroids, salazosulphapyridine or dietary formula was analysed retrospectively for 34 patients with active Crohn's disease who had previously been treated without success on the basic schedule. Clinical remission was achieved in all ten patients with highly florid Crohn's disease but no fistulae, regardless of whether metronidazole was given alone or in combination with the basic treatment regimen. Complete closure of the fistulae was achieved in 12 or 24 patients with fistulae, while marked regression of fistulae secretion occurred in a further five. It is concluded that metronidazole is of value particularly in cases resistant to basic treatment or with fistulae.

[Chronic pancreatitis and the neighboring organs]

The close topographic relationship between pancreas and the functional entity of the upper abdominal organs causes in about 20 percent of the patients with chronic pancreatitis alterations of the surroundings. In 531 patients compression of the common bile duct was found in 18.1%, duodenal stenosis in 17.7%, pleural thickening in 6.6%, splenic vein thrombosis in 5.1%, gastric outlet obstruction in 3.2% and colonic stenosis in 0.4%. In primary asymptomatic chronic pancreatitis these local complications may be the first hint to pancreatic disorders. Occasionally these changes demand operative interventions or alleviate the decision for resectional therapy.

[The ultrastructure of intestinal amyloidosis]

Amyloidosis nearly always goes along with manifestations of the gastrointestinal tract. It can mimic a variety of different clinical syndromes. Pathogenetically amyloidosis leads to an organ insufficiency due to local infiltration of amyloid or to replacement of tissue with amyloid fibrils. Characteristic ultrastructure is composed of an irregular network of fibrils without any periodicity. The topographic position gives an explanation for the intestinal symptoms. Involvement of the intramural nerve system is responsible for motility disorders like diarrhoea or constipation. In case of perivasal infiltration hemorrhage and inflammatory changes can be found, as well as malabsorption syndromes, when subepithelial amyloid layers are present. Electron microscopy therefore may contribute to the pathogenetic understanding of morphological findings in regard to clinical symptoms.

[Early diagnosis of primary biliary cirrhosis (author's transl)]

Electron microscopic investigations of liver biopsy specimens in 16 patients with a clinically suspected diagnosis of chronic obstructive non-purulent cholangitis as the early stage of primary biliary cirrhosis showed characteristic changes of the intrahepatic biliary canaliculi. These consist of a coarsening and reduction of microvilli, thickening of pericanalicular ectoplasm and intercellular gaps as well as increasing obliteration of the canalicular lumen. Typical primary biliary cirrhosis developed in 6 patients over an observation period of 3 years. The ultrastructural findings may contribute towards identification of morphogenesis of this disease. They are possibly pathognomonic for the early stage of the disease. However, the precipitating factor remains unknown.

Tuberculosis of the pancreas

In a case report, the rate condition of tuberculosis of the pancreas is described. There are two conceivable ways in which the pancreas may become diseased: 1. toxic-allergic reaction of the pancreas in response to generalized tuberculosis (so-called concomitant pancreatis) 2. Invasion of the pancreas by tubercle bacteria disseminated via the blood, or through penetration of the organ by adjacent caseating abdominal lymph nodes. Histologically, epithelioid cells and Langhans' giant cells are only rarely found; caseation usually develops, with subsequent calcification, which can lead to stenosis of the pancreatic duct. In patients with generalized tuberculosis and abdominal complaints, the diagnosis is most reliably established on the basis of ERCP and CAT. In the presence of pain, resection of the affected portion of the pancreas may be considered as means of treatment.

Long-term follow-up after endoscopic sphincterotomy

Endoscopic sphincterotomy has become a well-accepted procedure in choledocholithiasis and papillary stenosis. Long-term follow-up data covering an observation period of 7 years disclose that about 90% of the patients are either completely relieved of symptoms, or show marked improvement. Re-stenosis or recurrent concrements seem are events; in primary papillary stenosis, however, long-term results are less favorable.

Non-surgical biliary drainage - technique, indications and results

Nonsurgical biliary drainage offers a therapeutic alternative in the palliation of malignant obstructive jaundice. Two basic approaches are available. The percutaneous transhepatic method can be employed either for external drainage or for the placement of an internal endoprosthesis. In the case of the transduodenal, transpapillary approach, either a pigtail catheter can be placed, after prior papillotomy, or - with or without the need to split the papillar - a nasobiliary drainage tube can be introduced. Successful drainage was achieved in 67 patients. In the majority of cases, external drainage was performed as a palliative measure in inoperable carcinoma of the biliodigestive system. In addition, however, pre-operative temporary drainage was also carried out to reduce the risks of surgery in patients with severe obstructive jaundice. The complication rate was low. Apart from biliary peritonitis, cholangitis and minor bleeds were observed. The rate of failure for technical reasons was a relatively low 10%.

Mucosal suggillation in the colon in secondary amyloidosis

Amyloidosis of the gastrointestinal tract can mimic a variety of different conditions. The symptoms and findings depend upon the localization and extent of the amyloid deposits. This report concerns a 53-year-old female patient with secondary amyloidosis in the presence of a plasmocytoma, in whom, at endoscopy, petechial mucosal suggillation were observed in the distal colon. The cause of the mucosal petechiae were probably vascular changes induced by deposits of amyloid.

[Effects of uric acid on the B cell in the isolated perfused rat pancreas (author's transl)]

Methylxanthines, such as caffeine and theophylline, show effects increasing the secretion of insulin. Perfusion experiments were intended to find out whether insulin secretion is influenced by uric acid, which is chemically closely related. Besides, it was to be demonstrated that uric acid causes no damages to islet cell structures for it is well established that alloxan, which is chemically related to uric acid, produces necroses in B cells. Isolated rat pancreata were stimulated by glucose at concentrations of 100 mg/100 ml and 300 mg/100 ml. In part of the experiments uric acid was added to the perfusion medium at a concentration of 12 mg/100 ml. We found that uric acid has no influence on insulin secretion if it is stimulated by glucose at a concentration of 100 mg/100 ml. However, if B cells are stimulated by glucose at a concentration of 300 mg/100 ml insulin secretion is enhanced by the addition of uric acid by more than 100%. This indicates that this substance exhibits a glucose-potentiating effect. The characteristic dynamics of insulin secretion demonstrate together with light- and electron-microscopic investigations that uric acid causes a real additional secretion and no leaking of intracellular insulin as a result of destruction of islet cell structures by an effect of uric acid similar to that of alloxan.

The "Internal Leak" as a possible cause in the pathogenesis of peptic ulcer

In cat gastric mucosa stimulated with histamine and damaged by direct application of acetylsalicylic acid, the fluorescent dye acridine orange may be found outside the parietal cell. Normally it is distributed throughout, or bound to the limiting membrane of, the vesicles in the parietal cell. The special properties of this cationic dye in an acid environment, support the hypothesis that a so-called "internal leak" may possibly play an important role in the pathogenesis of peptic ulcer.

[Amyloidosis of the intestinal tract (author's transl)]

Amyloidosis may afflict different organs of the body and thus cause a variety of clinical symptoms. Amyloidosis of the gastro-intestinal tract can mimic several gastric and intestinal disorders, as for instance disturbances of motility, vascular processes and tumors. The amyloid infiltrates the tissue affected, replaces it and thus cause insufficient organ function. The disease usually progresses slowly, in some cases however, acutely life threatening situations may occur. Biopsy of the rectal mucosa will allow to establish the diagnosis; generalized amyloidosis was present in about 80% of the cases analysed. A medical management has to be done.

[Internist therapy of cholelithiasis]

Medical treatment of gallstones as an alternative to cholecystectomy has been established in recent years. Considering certain conditions--i.e. radiolucent cholesterol gallstones, functioning gallbladder, stone size, patients' cooperation--it is possible in up to 70% to dissolve gallstones completely or partially, using a therapeutic regimen of chenodeoxycholic or ursodeoxycholic acid at a dosage of 10 mg or 15 mg/kg body weight respectively. Side effects as diarrhoea or slight increase of serum transaminase levels are harmless and occur only with chenodeoxycholic acid. Therapeutic success may be controlled either by ultrasound or by cholecystography. Recurrence rate after dissolution is about 20%. Stones of the common bile duct can be treated easily by endoscopic papillotomy (EPT). In many cases the stone has to be removed with a basket; however, it may pass spontaneously. Certain indications for this procedure are obligatory. In the first place there is the patient over 50 years of age with the gallbladder already removed.

[In-vitro experiments to study the role of contrast medium in pancreatitis due to ERCP (author's transl)]

The causes of hyperamylasaemia or pancreatitis, occasionally observed after the endoscopic retrograde cholangio-pancreatographie (ERCP), have been unequivocally identified as pressure, volume and the duration of contrast medium instillation. In a completely pressure free experimental model involving the perifusion of lobes of the pancreas of guinea pigs, a study has now been carried out to investigate the extent to which, in addition to these known causes, the contrast medium itself contributes to the development of enzymatic disorders. It was found that, merely as a result of stimulation through Ceruletid (Takus), the secretion of amylase was increased by more than 400%. Following the addition of 50% contrast medium to the perifusion medium, however, amylase secretion was completely suppressed. The electron-microscopic examination of the perifused pancreatic cells revealed that the contrast medium had a synthesis-enhancing effect on the production of zymogen granules in the cells of the acini, but that, however, throughout the duration of contrast medium perifusion, the extrusion of granules was suppressed. Only after the contrast medium had been washed out, an excessive secretion of amylase was observed. The findings show that, in addition to the increase of intraductal pressure, the contrast medium itself may also be possible causal factor in the development of hyperamylasaemia or pancreatitis.

Synopsis of endoscopic and other morphological findings in intestinal lymphangiectasia

Intestinal lymphangiectasia may present as a primary congenital disorder as well as a secondary form due to numerous underlying diseases. Endoscopically, whitish swollen tips of the villi are fairly characteristic; histologically, dilatation of the lymphatics can be demonstrated. By means of electron microscopy dilated intercellular spaces with aggregation of protein precipitations as well as ectatic lymph vessels with abnormal structure are found. Possible relations to the pathomechanism are discussed.

[Differentiated therapy in Crohn's disease]

Causal therapy of Crohn's disease up to now cannot be achieved due to the unknown etiology. However, randomized multicenter cooperative trials have demonstrated that adrenocorticoids and sulfasalazine are the most efficient basic therapeutics. In the acute attack additional supportive measures like hyperalimentation, transfusions or substitution of vitamins may become necessary. In contrast to former times a maintenance treatment is no longer justified. About 60% of all patients with Crohn's disease have to be operated because of complications of their disease. The knowledge of absolute and relative indications for surgery in Crohn's disease facilitates the decision. Therapy in Crohn's disease has to be differentiated in relation to severity of the disease and disease location.

Treatment of choledocholithiasis using the transpapillary perfusion technique

In 5 patients with common bile duct stones a dissolution therapy with the octanoate mixture Capmul 8210 was performed using the transpapillary perfusion technique. In 3 out of the 5 cases a passage of the stones without further endoscopic operative procedures could be achieved. Complaints were endurable except in one case. Further studies to dissolve common bile duct stones with a modified Capmul solution via a transpapillary tube seem justified.

New methods in gastroenterology

Major advances in gastroenterology are due in part to the rapid development of fiberendoscopes. Originally intended to improve gastroenterological diagnostics, the field of application was broadened by a variety of therapeutic procedures which now concur with the corresponding surgical approach. Endoscopic electro- and photocoagulation has considerably improved the outcome of acute gastrointestinal hemorrhage: endoscopic polypectomy is the procedure of choice today in benign and occasionally in malignant bowel tumors. Biliary tract surgery was revolutionized by endoscopic sphincterotomy, offering a low-risk procedure in high-risk patients with common bile duct stones. Endoscopic treatment of chronic pancreatitis by duct occlusion is just the beginning, and the old dream of dissolving gallstones rapidly by perfusing the biliary system with litholytic agents is now reality. Finally, the transhepatic or internal drainage in obstructive jaundice leads to transitory preoperative or permanent relief in malignant blockade of bile flow.

[Irrigation treatment of concrements in the common bile duct with octanoate (Capmul 8210) (author's transl)]

An irrigation treatment using the octanoate mixture Capmul 8210 of a maximum duration of 10 days was performed in 11 patients with concrements in the common bile duct using either a T-drain (n = 6) or a permanent naso-biliary tube (n = 5). In 6 out of the 11 cases total or partial dissolution led to voiding of concrements without further operative or invasive procedures. The treatment was tolerated in all but two cases. There was no evidence of systemic toxic side effects. Local inflammatory mucous membrane damage due to the instillation was observed in two cases.

Further evidence of gastric back diffusion. Autoradiographic and mass spectrographic studies

In further studies of the phenomenon of back diffusion (acid, hydrogen (H+) ions), two different experimental approaches were used. 1. Autoradiographic studies with tritium-labelled water instilled in the stomach of fasted rats, revealed the activity to be overwhelmingly concentrated in the mucus layer. In contrast, following aspirin-induced gastric mucosal barrier disruption, radioactivity was prevalent in the mucosal membrane, diffusely scattered. 2. To answer the question as to whether tritium has moved in the gastric mucosa as an ion or as a water molecule, mass spectrographic studies were performed. Using the same experimental approach, comparison of tritium-labelled water with water containing another isotope (O18-water) demonstrated that after damage to the gastric mucosa, a change in the mass spectra of the gastric tissue occurred with tritium-labelled water, but not with O18-water. The results indicate that, indeed, it is not water molecules, but ionic particles represented by tritium that back diffuse, thus giving reason to believe that this mechanism also applies in the case of hydrogen ions.