The role of serum liver enzymes in the diagnosis of choledocholithiasis

BACKGROUND/AIMS

The introduction of laparoscopic cholecystectomy has increased the need for preoperative diagnosis of common bile duct stones. The purpose of this study is to verify the sensitivity of the liver function tests in the detection of duct stones.

METHODOLOGY

We evaluated 438 patients (223 retrospectively and 215 prospectively) who underwent endoscopic papillotomy for bile duct stones in two different services. In every case, blood samples for liver function tests levels were collected prior to endoscopic retrograde cholangiopancreatography.

RESULTS

The most sensitive test was gamma-glutamyl transpeptidase, that was abnormal in 92.2% of the cases. Alkaline phosphatase was elevated in 74.7% of the patients with choledocholithiasis. The least sensitive parameter was AST, altered in only 50.8% of times. The sensitivity of all liver tests for the diagnosis of choledochal stones taken together was 94.3%.

CONCLUSIONS

Liver function tests are very sensitive in the detection of common bile duct stones, however these blood tests are in the normal range of about 5% of endoscopically treated patients.

Long-term follow-up of patients with iron deficiency anemia after a close endoscopic examination of the upper and lower gastrointestinal tract

BACKGROUND

In patients with Iron Deficiency Anemia (IDA) occult gastrointestinal bleeding is generally investigated by bidirectional endoscopy. The aim of our study was to examine the long-term follow-up of patients with IDA where the sources of bleeding couldn't be detected despite close endoscopic and radiologic examination of the GI tract.

METHODS

Based on the endoscopic data base we examined consecutive patients who were referred for gastrointestinal endoscopy due to IDA with a negative endoscopic (upper GI endoscopy and colonoscopy) evaluation. Further diagnostic work up (repeated endoscopy of the upper and lower GI tract by an experienced investigator, small bowel enteroclysis, push enteroscopy, proctoscopy, intraoperative enteroscopy, angiography, scintigraphic examinations) was recorded. The eligible patients were divided into 2 groups: Group 1 (no identification of the source of bleeding in the GI tract); group 2 (source of gastrointestinal blood loss was found). Long-term follow-up was performed by telephone interview with patients and/or with their general practitioner.

RESULTS

79 patients (mean age 58.8 years [17-83, 44] female) with IDA met the inclusion criteria. In 42 patients (53%) the endoscopic and radiographic evaluation was unable to find the source of gastrointestinal blood loss. 29 of these patients (69%) showed a resolved anemia after a mean follow-up of 48 months (18 months-5 years). 10 patients had a mild anemia, 3 required blood transfusions. In group one Helicobacter pylori infection was significantly more prevalent in comparison with group 2 (57% vs. 38%, p = 0.032).

CONCLUSION

Based on our data, the prognosis of IDA with negative endoscopy is favorable. The pathogenic role of Helicobacter pylori infection should be evaluated in further studies.

Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive and increasingly used procedure in cases involving biliary and pancreatic diseases. However, the accuracy of MRCP in differential diagnosis between pancreatic cancer and chronic pancreatitis has never been documented in a large prospective controlled study.

METHODS

124 patients were recruited for the study, selected from 141 consecutive patients with an average age of 55 years (range 19-80) who presented to our department between February, 1996, and January, 1998, with a strong clinical suspicion of pancreatic cancer. MRCP images were interpreted by a radiologist and a gastroenterologist who were unaware of the clinical diagnosis of patients. The exact diagnosis was based upon histological evidence from biopsy examination (surgical and fine needle biopsy) or a follow-up of at least 12 months.

FINDINGS

Of the 124 patients, 37 (30%) had pancreatic carcinoma; 17 (14%) had other neoplastic pancreatic diseases; 57 (46%) had chronic pancreatitis; 13 (10%) pancreatic ducts were clear. The sensitivity of MRCP with respect to diagnosing pancreatic cancer was 84% and its specificity 97%. The corresponding values for endoscopic retrograde cholangiopancreatography (ERCP) were 70% and 94%, respectively.

INTERPRETATION

MRCP is as sensitive as ERCP when detecting pancreatic carcinomas. Furthermore, it is feasible to presume that the use of MRCP may prevent inappropriate explorations of the pancreatic and common bileducts in cases of suspected pancreatic carcinomas, where interventional endoscopic therapy (ie, palliative common-bileduct drainage) is unlikely.

[Therapy of pancreatic and bile duct tumors: value of radiotherapy and photodynamic therapy]

Prognosis of pancreatic cancer and bile duct cancer is extraordinary poor. Despite of the improvement in diagnostic procedures and the development of more radical resectional procedures prolongation of survival could not have been achieved yet. At the time of diagnosis only 20-30% of patients are suitable for resection, thus the value of non resectional methods for palliation has to be determined. Despite of numerous efforts to increase the local radiation dosage by means of distinguished radiation techniques none of these procedures could achieve an unequivocal prolongation of survival. After promising preliminary results of intraoperative radiotherapy (IORT) in pancreatic cancer following studies could not show a survival benefit for IORT allone or in combination with extracorporal radiotherapy (EBRT). EBRT is indicated at best for local pain control and is limited by the high radiation sensitivity of the adjacent organs. Intracorporal radiotherapy or brachytherapy with iridium 129-labelled wires leeds to local, intraluminal tumour control, but has also no influence on survival time. Up to now, photodynamic therapy (PDT) of pancreatic cancer must be characterized as highly experimental. But PDT can contribute to local tumour control. Preliminary data of photodynamic therapy in bile duct cancer show good results concerning reduction of cholestasis, improvement of life quality and even prolongation of survival time. The value of these preliminary results is being proved at present in controlled studies in comparison to mere endoprosthetic supply at a few centers.

Maternally inherited diabetes and deafness (MIDD): unusual occult exocrine pancreatic manifestation in an affected German family

The mitochondrial (mt) 3243 DNA mutation is an underlying cause of maternally inherited diabetes and deafness (MIDD) syndrome and the syndrome of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS). We report an affected German MIDD pedigree with maternal lineage over three generations. The index patient, her mother, her maternal aunt and her maternal grandmother all suffered from diabetes and premature hearing loss and were positive on testing for the mt 3243 DNA mutation. The 27-year-old index patient had a history of grand mal seizures. As sequela of abdominal ultrasound and confirmed by magnetic resonance cholangio-pancreaticography, she was diagnosed with chronic pancreatitis with pancreatic calcifications and pancreatic duct dilation, although she was completely asymptomatic and with no signs of steatorrhoea. She did not have gallstones and the common bile duct was normal. A possible etiopathogenic pathway for pancreatitis could be a suppressive effect of the mt 3243 mutation on the oxidative phosphorylation in affected mitochondria. Although pancreatitis and pancreatic dysfunction in association with the mt 3243 mutation, especially in patients with comorbidity of MELAS and diabetes, has previously been described as a rare manifestation, this case is specific because of the discrepancy of advanced morphological pancreatic alterations and complete lack of pancreatogenic symptoms.

[Prevention of colorectal carcinoma. Annual hemoccult test and sigmoidoscopy every 5 years]

The slow development of colorectal carcinoma from adenoma over dysplastic state to malignancy within 10-15 years results in a long preclinical phase during which the tumor is readily detectable and curable. Therefore and because of the lack of early alerting signs colorectal cancer is highly suited to screening. The faecal occult blood test has been added to the yearly program of cancer prevention for each individual age 45 and higher. This test has been evaluated in controlled prospective trials. For several reasons the combination of faecal occult blood test with flexible sigmoidoscopy at five year intervals is recommended. Concerning colonoscopy as a screening test to date no data from controlled trails are available. Virtual colonoscopy and gene-based screening which are currently being developed may be future options.

Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive and increasingly used procedure in cases involving biliary and pancreatic diseases. However, the accuracy of MRCP in differential diagnosis between pancreatic cancer and chronic pancreatitis has never been documented in a large prospective controlled study.

METHODS

124 patients were recruited for the study, selected from 141 consecutive patients with an average age of 55 years (range 19-80) who presented to our department between February, 1996, and January, 1998, with a strong clinical suspicion of pancreatic cancer. MRCP images were interpreted by a radiologist and a gastroenterologist who were unaware of the clinical diagnosis of patients. The exact diagnosis was based upon histological evidence from biopsy examination (surgical and fine needle biopsy) or a follow-up of at least 12 months.

FINDINGS

Of the 124 patients, 37 (30%) had pancreatic carcinoma; 17 (14%) had other neoplastic pancreatic diseases; 57 (46%) had chronic pancreatitis; 13 (10%) pancreatic ducts were clear. The sensitivity of MRCP with respect to diagnosing pancreatic cancer was 84% and its specificity 97%. The corresponding values for endoscopic retrograde cholangiopancreatography (ERCP) were 70% and 94%, respectively.

INTERPRETATION

MRCP is as sensitive as ERCP when detecting pancreatic carcinomas. Furthermore, it is feasible to presume that the use of MRCP may prevent inappropriate explorations of the pancreatic and common bileducts in cases of suspected pancreatic carcinomas, where interventional endoscopic therapy (ie, palliative common-bileduct drainage) is unlikely.

Pseudotumor of the sigmoid mimicking carcinoma

On colonoscopy, the macroscopic aspect of a lesion is an important criterion for the differential diagnosis. We present a case of an apparently malignant tumor in the sigmoid. Histological investigation failed to support the diagnosis made from the gross appearance seen on colonoscopy. After surgical resection, the lesion turned out to be a reactive pseudotumor caused by fibroepithelial hyperplasia related to a severe diverticulitis with perforation of the intestinal wall.

[Diagnostic and therapeutic enteroscopy. Its current status]

In many gastroenterological departments, the push-enteroscopy has become a well-established method to investigate the small bowel. Compared to the sonde-enteroscopy, this method has the advantage of offering the opportunity to intervene (e.g., taking biopsies, polypectomy, electrocoagulation) since the push-enteroscope has a working channel. The main indication for an endoscopic procedure is still the search for intestinal sources of bleeding after more frequent sources in the gastrointestinal tract have been ruled out. Other diagnostic and therapeutic indications are less frequent. In this overview we will first describe the procedure. Then we will review the most recent diagnostic and therapeutic aspects of the push-enteroscopy and compare it to other procedures.

Mucinous cystadenomas and intraductal papillary mucinous tumors of the pancreas in magnetic resonance cholangiopancreatography

BACKGROUND AND STUDY AIMS

In mucin-producing tumors of the pancreas, diagnosis using endoscopic retrograde cholangiopancreatography (ERCP) is limited to cystic formations that communicate with the main pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) is a new, sophisticated method which is currently under evaluation. The authors describe the usefulness of MRCP in diagnosis of mucin-producing tumors.

PATIENTS AND METHODS

Six patients with mucin-producing tumors were investigated using MRCP and ERCP. Imaging was compared with surgery and histopathological examinations.

RESULTS

Three patients were found to have mucinous cystadenomas (MC), two patients had intraductal papillary mucinous tumors (IPMT) and one patient had a cystadenocarcinoma. MRCP demonstrated the cystic formations in all patients. Magnetic resonance imaging (MRI) showed contrast-mediated enhancement of the cystic wall in patients with MC, and visualized the pancreatic ducts completely in patients with IPMT. ERCP failed to visualize the cystic lesion in one patient with MC of the pancreatic tail. Furthermore, ERCP showed evidence of IPMT in dilated main ducts with multiple filling defects but did not visualize the ducts completely.

CONCLUSIONS

MRCP provides visualization of pancreatic ducts, extraductal variations, and cystic formations more completely than ERCP does. It avoids complications seen in ERCP. MRCP may replace ERCP in the evaluation of mucin-producing tumors of the pancreas.

The role of Doppler ultrasound in gastrointestinal bleeding

The management of acute gastrointestinal bleeding is the domain of endoscopy. More than half of all episodes of upper gastrointestinal bleeding are attributed to bleeding peptic ulcers, and it is important to assess the risk of recurrent bleeding and to determine the appropriate treatment. However, the visual assessment of lesions (Forrest classification) is not always accurate and shows high interobserver variability (especially for visible vessels at the ulcer base, associated with a high rate of re-bleeding). Doppler ultrasound was thus introduced, and several studies have demonstrated that, with Doppler examination, these vessels can be identified. Doppler ultrasound is also used to monitor the effects of endoscopic therapy. In a prospective randomized trial, Doppler ultrasound proved superior to the Forrest classification. Treatment based on this technique resulted in significantly lower rates of re-bleeding and mortality. The Doppler classification may be able to contribute to a safer and more cost-effective management of patients with acute peptic ulcer bleeding.

Magnetic resonance imaging in gastroenterology: time to say good-bye to all that endoscopy?

Magnetic resonance imaging (MRI) has been described as the most important development in medical diagnosis since the discovery of the roentgen ray more than 100 years ago. The effectiveness of MRI has been extended to make it applicable in a wide variety of gastrointestinal disorders. The attention of gastroenterologists is currently focusing on pancreaticobiliary and bowel diseases. Magnetic resonance cholangiopancreatography (MRCP) has become a competitive alternative to diagnostic endoscopic retrograde cholangiopancreatography in a variety of hepatobiliary and pancreatic diseases. Magnetic resonance enteroscopy has the potential to become the preferable method for evaluating the entire small bowel; virtual colonoscopy, on the other hand, is far from the stage at which it could be promoted as a tool for general screening purposes in suspected colonic diseases. Its drawbacks include problems with standardization, implementation of the techniques in generalized settings, and patient acceptance.

Hemosuccus pancreaticus--a rare cause of gastrointestinal bleeding: diagnosis and interventional radiological therapy

Hemorrhage from the pancreatic duct, i.e. hemosuccus pancreaticus (HP), is a rare cause of gastrointestinal bleeding. Pancreatic hemosuccus is usually due to the rupture of an aneurysm of a visceral artery, most likely the splenic artery, in chronic pancreatitis. Other causes of HP are rare. We present a case of HP in a female patient with no history but with positive findings of chronic calcifying pancreatitis upon ultrasonographic investigation, computed tomography scan, and endoscopic retrograde cholangiopancreatography. With detectable fresh blood in the descending duodenum, angiography of the celiac artery revealed an aneurysm of the splenic artery as the suspected cause of intermittent bleeding from the pancreatic duct. The treatment is traditionally surgical or by interventional radiological means. This is the first case described in the literature in which interventional radiological therapy involved implantation of an uncoated metal Palmaz stent in the splenic artery. In the follow-up of 18 months no relapse of HP was observed.

Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up

AIMS

To compare the efficacy and the complication rate between endoscopic snare resection of adenomas of Vater's papilla and endoscopic palliation.

METHODS

In a retrospective, non randomized manner, we compared long-term results of our endoscopic strategies in 36 patients with histologically confirmed adenoma of Vater's papilla submitted either to local endoscopic snare resection (n=18) or to simple endoscopic palliation (n= 18), respectively.

RESULTS

Between 1985 and 1998 results were reviewed. Median age was 76.5 (range 42-89) years in the palliation, and 64.0 (23-89) years in the endoscopic snare resection group. Median duration of follow-up was 33 (6-135) and 75.0 (27-123) months, respectively. The incidence of adenocarcinoma of Vater's papilla was 1 per 52.8 patient-years after endoscopic snare resection and 1 per 15.5 patient-years in the group treated with endoscopic palliation. Compared to the results of endoscopic palliation (prosthesis, sphincterotomy), we found a significant reduction of carcinoma-related death (p=0.0045, McNemar) and adenoma carcinoma-sequence (p=0.007, McNemar) after snare resection.

CONCLUSIONS

This retrospective study suggests that complete endoscopic snare resection of adenomas of Vater's papilla will lead to a lower rate of adenoma-carcinoma sequence, to a lower carcinoma-related death rate and probably improves patient survival. These results should be proven prospectively.

Choledochocele imaged with magnetic resonance cholangiography

Choledochal cysts are rare developmental malformations of the biliary tree. Percutaneous and endoscopic ultrasound, as well as endoscopic retrograde cholangiopancreatography, are recommended diagnostic tools. Magnetic resonance cholangiography may also contribute to the workup and treatment plan of patients with choledochal cysts. We report a 25-yr-old white woman with episodic nausea and moderate epigastric discomfort. Magnetic resonance cholangiography showed a rather spherical, cyst-like, fluid-filled structure in continuity with the prepapillary segment of the common bile duct, thus making a choledochocele (type III choledochal cyst) likely. The patient was treated by endoscopic sphincterotomy and, after a 6-month follow-up, is without complaints.

Emergency endoscopy

The need for emergency endoscopy is a matter of debate. The time interval for emergency procedures remains to be defined. Most authors propose a time span of 24 h as emergency time, while some define a period of 72 h (especially in acute pancreatitis). Several studies have shown a possible benefit for a select group of patients. Four main indications are established for emergency endoscopy: acute gastrointestinal bleeding (variceal and nonvariceal), acute biliary pancreatitis and acute cholangitis. In the case of upper gastrointestinal bleeding, emergency endoscopy enables exact diagnosis and appropriate therapy, and provides important prognostic information. There is some evidence that emergent endoscopic injection therapy improves clinical outcome and reduces mortality in patients with acute ulcer bleeding. Patients do not benefit if endoscopy is performed only as a diagnostic procedure. Controversial results were published recently for emergency endoscopy in acute biliary pancreatitis. There is good evidence that emergency endoscopic retrograde cholangiopancreatography is helpful in patients with severe pancreatitis and stone impaction if performed within the first 24 h after onset of symptoms. However, emergency endoscopic retrograde cholangiopancreatography is not beneficial for patients with mild pancreatitis if performed later than 72 h (or 24 h) after onset of symptoms. There is a limited number of well established evidence-based indications for emergency endoscopy. Some other indications are still a matter of debate, and controversial opinions have been published.

Electrohydraulic lithotripsy treatment of gallstone after disimpaction of the stone from the duodenal bulb (Bouveret's syndrome)

A 75-year-old man with right upper quadrant abdominal pain was diagnosed by gastroscopy to have an impacted gallstone in the duodenal bulb. Using the polypectomy loop, the stone was extracted from the bulbus and mobilized into the stomach. After failure to remove the stone from the stomach as well as fragmentation by mechanical lithotripsy, electrohydraulic lithotripsy was used to break up the stone, parts of which passed spontaneously through the bowel. Thus, it was unnecessary to proceed with surgical enterolithotomy to remove, from the duodenal bulb, the impacted gallstone responsible for the gastric outlet obstruction.

Current role of magnetic resonance cholangiopancreatography in the diagnosis of common bile duct and pancreatic diseases

Magnetic resonance cholangiopancreatography is a noninvasive procedure that is increasingly used in patients with hepatobiliary and pancreatic diseases. The accuracy of magnetic resonance cholangiopancreatography has dramatically improved during the last few years, and there is no doubt that magnetic resonance cholangiopancreatography will have a major impact on the gastroenterologist's diagnostic work-up of patients. The key for success in dealing with hepatobiliary and pancreatic diseases is the precise knowledge of their course, the indications for treatment, and the therapy available. Thus, a team approach with strong representation from gastroenterology and radiology will be the most optimal path to an improved understanding of the value of Magnetic Resonance technology.

Adverse effects of nonsteroidal anti-inflammatory drugs on the small and large bowel

Nonsteroidal anti-inflammatory drugs (NSAID) account for a large part of prescriptions and self-administered medication worldwide. The adverse effects on the upper gastrointestinal tract are well documented. However, in an increasing number of publications adverse effects in the small and large intestine distal to the duodenum are being reported. This paper provides an updated review of current as well as earlier literature on the pathogenesis of such adverse effects and the potential damage to the small and large bowel caused by NSAID. In addition, suggestions for an appropriate diagnostic workup of NSAID damage are discussed.

Treatment of difficult intrahepatic stones by using extracorporeal and intracorporeal lithotripsy techniques: 10 years' experience in 55 patients

BACKGROUND

Intrahepatic lithiasis still is a complicated disease and merits special attention during therapeutic intervention. Although resection of the affected liver lobe or segment is the best therapeutic option to completely remove the source of recurrent infection, the need for endoscopic treatment modalities is evident because hepatic resections are combined with a high morbidity and mortality rate.

METHODS

Over a 10-year period (1988-1997) 55 patients with intrahepatic stones that were not accessible to routine endoscopic extraction were treated at our department. These patients underwent either extracorporeal shock-wave lithotripsy (n=27) or intracorporeal electrohydraulic (n=12) or laser lithotripsy (n=16).

RESULTS

Using these techniques, we achieved stone fragmentation in 33.3%, 41.6%, and 75%, respectively. With a combination of the different methods, more than 90% of intrahepatic stones could be removed endoscopically. Overall complication rate was 12.7%; complete recovery was achieved in all patients with conservative management.

CONCLUSION

The endoscopic approach to intrahepatic lithiasis appears to be a useful alternative to surgery, with a lower morbidity and mortality. If endoscopic therapy fails, surgery is still possible.

[Treatment of Barrett esophagus with argon plasma coagulation with acid suppression--a prospective study]

26 patients with a Barrett's esophagus of at least 2 cm length (medium 4.9 cm) were treated with a combination of repeated argon-plasma-coagulation (APC) and a long-term acid suppression using proton pump inhibitors controlled by a 2 h pH monitoring. Eleven out of 26 patients (42%) showed endoscopically and histologically a complete eradication of the metaplastic cylindric epithelium (intention--to treat analysis). Nine patients (35%) had an endoscopic complete remission but remnants of the cylindric epithelium were found at the histologic examination. On an average one APC-session was necessary for 1 cm of initial length of the Barrett's esophagus. No serious complications were seen. It remains unclear if this therapy can reduce the long-term risks for adenocarcinoma of the esophagus in patients with Barrett's esophagus.

The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer

Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.

Long term follow up of patients with chronic pancreatitis and pancreatic stones treated with extracorporeal shock wave lithotripsy

BACKGROUND

There have been conflicting reports as to whether pancreatic ductal drainage achieved by endoscopy and lithotripsy improves the clinical outcome of patients with chronic pancreatitis.

AIMS

To determine the clinical outcome in patients with chronic pancreatitis who received extracorporeal shock wave lithotripsy (ESWL), and were followed up for two to eight years.

METHODS

Eighty patients with severe chronic pancreatitis and endoscopically unretrievable obstructive stones underwent ESWL with a piezoelectric lithotripter between 1989 and 1996. Clinical status, relief of symptoms, further endoscopic or surgical interventions, and mortality were defined.

RESULTS

Forty three (54%) patients were treated successfully with ESWL. The only feature associated with treatment success was the presence of a single stone rather than multiple stones. Successfully treated patients tended to experience less pain, although this did not reach statistical significance. A slight increase in weight was noted in our patients; however, there was no notable improvement in anomalous stools and diabetes mellitus. Five patients died due to extrapancreatic reasons. No pancreatic carcinomas developed.

CONCLUSIONS

ESWL associated with endoscopic drainage is a safe technique that is particularly successful in patients with a single stone. However, pancreatic drainage by endoscopy and ESWL has almost no effect on pain in chronic pancreatitis. Furthermore, endoscopic management and ESWL does not prevent or postpone the development of glandular insufficiency.

[A rare cause of iron deficiency anemia: recurrent hemorrhage from a carcinoid of the jejunum--diagnosis and therapy with enteroscopy]

We report a 66-year-old patient with previously diagnosed iron deficiency anemia. He complained of fatigue, but had no further symptoms. Hemoglobin was 9.1 g/dl. Test for occult blood in stool was positive, but gastroduodenoscopy and colonoscopy revealed no bleeding source. The man was referred to our department for push-type enteroscopy. By enteroscopy we diagnosed a pedunculated, large polyp in the upper jejunum. The polyp seemed to be submucosal, but had some ulcerations on its surface as the probable bleeding source. In the lower parts of the small intestine no further polyps were detected. After endoscopic doppler examination we injected adrenaline into the base of the polyp to prevent bleeding and the polyp was removed by snare without complications. The polyp was diagnosed to be a carcinoid and was removed in sano.

Typhoid fever due to Salmonella Kapemba infection in an otherwise healthy middle-aged man

We report the case of a patient with a Salmonella Kapemba infection, who suffered, 3 weeks after a holiday in Israel, occurrences of high fever and lower back pain for 10 days and icterus for 2 days before admission. Laboratory findings revealed a slight cholestasis and elevation of acute phase protein levels. In the blood culture a Salmonella Kapemba-type organism was cultured. The patient was afebrile for 10 days after hospitalization and then suddenly developed a temperature of 40 degrees C again. At the same time leukopenia, thrombocytopenia, and a rise of D-dimer levels were detected. The patient was admitted to the intensive care unit for a few days, because a disseminated intravascular coagulation was suspected. With magnetic resonance imaging and bone scintigraphy no osteomyelitis or abscess formation could be found. A transesophageal ultrasonography of the heart revealed no signs of endocarditis. In multiple stool cultures no salmonellas could be detected. After antibiotic treatment with ciprofloxacin the fever and lower back pain subsided, and the patient was discharged a fortnight later. This is the first reported case of typhoid fever due to the bacterium Salmonella Kapemba.

[Gastrointestinal complications of diabetes mellitus]

BACKGROUND

Diabetes mellitus leads to a broad spectrum of symptoms and manifestations in the field of gastroenterology.

BASIS

This article reviews the pathophysiology, differential diagnoses and secondary diseases of the gastrointestinal tract in diabetic patients.

CLINICAL APPEARANCE

Motility disorders, infectious complications, secondary diseases of the stomach, liver, pancreas, gall bladder, small and large bowel are considered and discussed. Diagnostic and therapeutic approaches for the management of diabetic enteropathy are presented.

CONCLUSION

The new strategies in diagnosis and therapy for a successful prevention or treatment of gastrointestinal complications due to diabetes mellitus need good cooperation of clinical specialties.

Improved tumor staging by diagnostic laparoscopy

This study was performed to assess the role of additional diagnostic laparoscopy in the preoperative staging of patients with adenocarcinoma of the esophagus, gastric cancer and pancreatic cancer prior to intended curative surgery. 89 patients with primary solid abdominal tumors were eligible for evaluation; of those 49 patients had a gastric cancer, 33 a pancreatic cancer and seven an adenocarcinoma of the esophagus. Patients without histologically proven metastases proceeded to laparotomy. Metastases were detectable laparoscopically in nine of 49 patients (18.4%) with gastric cancer (peritoneum n = 5, omentum n = 2, liver n = 2). Intraoperatively metastases were evident in further five cases (liver n = 3, peritoneum n = 2). In eleven of 33 patients (33%) with pancreatic cancer metastases were detected by laparoscopy (liver n = 6, peritoneum n = 2, liver and peritoneum n = 3) and in further four patients intraoperatively (liver n = 2, peritoneum n = 2). One of seven patients with an adenocarcinoma of the esophagus had liver metastases detected by laparoscopy. Intraoperatively no metastases were evident in those patients. Laparotomies were avoidable in 21 of the 89 patients (23.6%) who had a diagnostic laparoscopy prior to intended curative resection. Preoperative staging by additional diagnostic laparoscopy proved effective in patients with gastric and pancreatic cancer.

[Consensus conferences and guidelines in gastroenterology: a valid approach]

The rapid and continuous increase in knowledge has meant that medicine has become more complex and involved, and at the same time less transparent, for physicians and patients. To ensure quality and improve patients confidence, new structures in quality management are necessary. Guidelines, standards and consensus conferences by experts are valid ways of ensuring the future quality of medical care.

[Prospective Epidemiologic Study of Epigastric Discomfort (PRESTO). Ground work and preliminary results]

BACKGROUND AND OBJECTIVE

Symptoms of dyspepsia (indigestion; upper abdominal discomfort) are one of the most frequent reasons for consulting a general practitioner or internist. Yet there are no up-to-date national data on the epidemiology and course of this symptom complex.

PATIENTS AND METHODS

In an open, prospective, multicentre, epidemiological study (PRESTO) 3016 patients with the suspected diagnosis of "functional dyspepsia" (1228 males, 1788 females, mean age 50 +/- 15 years) were followed for 2 years by 983 physicians in private practice (general practitioners or specialists in internal medicine). Patients with proven gastro-oesophageal reflux or peptic ulcer were excluded. Treatment was at the discretion of the physician. Patients were seen after one month (if under treatment) and then at 6, 12, 18 and 24 months. In addition to personal data, (1) symptoms, diagnosis and treatment of the dyspepsia, (2) socioeconomic aspects and (3) any limitations and the quality of life of each patient were recorded in a standard manner.

RESULTS

At the first interim analysis more than half the patients judged there situation to be one of "chronic stress" or having to cope with a stressful event; nearly 50% thought this to be the cause of the symptoms. Concomitant illnesses were present in 63% of patients. Oesophagogastroduodenoscopy with subsequent medication was performed in 20.6%, a trial of medication (usually drugs stimulating gastric motility) in 65%. No medication was initially given to 14.4% of patients. The most common symptoms were feeling of fullness (92.9%, epigastric pressure sensation (91.5%) and flatulence (87.4%).

CONCLUSION

These preliminary results indicate that a large epidemiological study can be performed by general practitioners and has advantages over the more usual method of enquiry by telephone. Dyspepsia exerts an unusually high degree of stress and results in considerable demands on medical facilities.

[The endoscopic diagnosis and therapy as well as the long-term course of Dieulafoy ulcer hemorrhage]

OBJECTIVE

To assess the effectiveness of endoscopic diagnosis and treatment as well as the long-term course in patients with bleeding from Dieulafoy's ulcer (DU).

PATIENTS AND METHODS

Data were gathered on all cases coded "bleeding from Dieulafoy's ulcer" in an endoscopic data-bank. The following items were obtained from the case-notes: clinical symptoms, mean haemoglobin concentration, demand for infusion of erythrocyte concentrates and endoscopic procedures undertaken for diagnosis and treatment. There were 15 patients (mean age 64.8 years; 9 men and 6 women), seen between 1985 and 1998 with the diagnosis of DU. All lesions were located in the proximal stomach. The effectiveness of the various parameters was analysed. The long-term course was ascertained by telephone interviews with the patients and (or) their general practitioner.

RESULTS

The suspected diagnosis of DU was confirmed by additional endoscopic means such as endoscopic Doppler sonography or endosonography. A combination of endoscopic techniques of stopping the bleeding (epinephrine injection and, if necessary, haemoclip application) was effective in 14 of the 15 patients, operative intervention being required in one. Three patients died during follow-up, none of bleeding. No recurrence of bleeding had occurred in the 10 patients followed for a mean of 20 (6-31) months.

CONCLUSIONS

The endoscopic diagnosis of DU bleeding can be confirmed by endoscopic Doppler sonography or endosonography. It remains to be proven whether miniscope endosonography is of additional value. The combined method of stopping the bleeding has been effective in this patient collective, both during hospitalization and on long-term follow-up.

[Value of ultrasound guided piezoelectric shock wave lithotripsy in the treatment of pancreatic stones]

AIM

Most patients with pancreatic duct stones have been treated with lithotripters that use x-ray for stone targeting. We wanted to evaluate ultrasound guided lithotripsy in clinical use.

METHODS

In a prospective clinical study 80 patients (62 men) with symptomatic obstructive chronic pancreatitis were treated with a piezoelectric lithotripter under ultrasound guidance (two in-line 4-MHz-Scanners).

RESULTS

Stone targeting by ultrasound guidance was possible in 76 patients. Fragmentation succeeded in 53 patients (70%). Complete or partial stone clearance was achieved in 43 patients, a success rate of 54%.

CONCLUSION

Ultrasound guided shock wave lithotripsy of pancreatic duct stones plays an important role in the treatment of chronic pancreatitis.

The role of endoscopic Doppler-sonography

Endoscopic Doppler sonography is a useful method that permits a differentiation to be made between high-risk lesions in danger of rebleeding and prognostically harmless ulcerations. Using this technique, vessels in the base of the ulcer can be reliably identified, and the indication for local endoscopic treatment established. The pulsed Doppler can be used to test the efficacy of prior endoscopic therapy within the framework of follow-up investigations; when arterial blood flow signals are found to persist, treatment needs to be repeated. With the aid of this "programmed" Doppler sonography-controlled endoscopic approach, which in some cases may be repeatable, the number of rebleeds, emergency operations, and probably also mortality, can be permanently lowered. Endoscopic Doppler sonography can also provide important additional information in the area of primary diagnosis and endoscopic treatment of esophageal and gastric varices. The Doppler exploration facilitates the assessment of the sclerosing effect, and is capable of identifying gastric varices and distinguishing these from other submucosal processes. For an assessment of the butyl cyanoacrylate varix, the Doppler is of particular value.

Prevalence and clinical importance of Helicobacter pylori infection in patients after partial gastric resection for peptic ulcer disease. A prospective evaluation of Helicobacter pylori infection on 50 resected patients compared with matched nonresected controls

There have been only a few surveys on the prevalence of persistent Helicobacter pylori (Hp) infection in patients who have undergone surgery for peptic ulceration. The aim of the study was to evaluate the prevalence and clinical importance of Hp infection after partial gastric surgery due to peptic ulcer disease.

METHODS

We examined 50 patients who had partial gastric resection for peptic ulcer disease and years later underwent upper gastrointestinal (GI) endoscopy. 50 controls matched with respect to indication for GI endoscopy, age and gender were also studied. Three specimens from the fundus of gastric remnant were examined for Hp infection (histology and rapid urease test). The prevalence of Hp infection and pathology findings were compared between the two groups using chi-square statistics.

RESULTS

32 men and 18 women were examined (40 x BII, 10 x BI). The prevalence of Hp infection was 38% in the resected group compared to 60% in the control group (p = 0.015). We found a significant association (p = 0.0004) between Hp infection and endoscopic findings in the control group but not in the group of partially resected patients (p = 0.66).

CONCLUSION

The prevalence of Hp infection in hospitalized patients with partial gastric resection is significantly lower than in matched controls. Hp infection does not play a significant pathogenic role in recurrent ulcer after partial gastric resection in these patients.

[Endoscopy 2000]

The trends and developments in endoscopy of the coming years are many-sided. Improved fiber-optics and invention of computer technology lead to smaller endoscopes with higher resolution. Electronic image processing makes three dimensional measurement or presentation of objects possible. In endosonography a trend to miniaturization is also obvious. Advances in molecular biology and imaging procedures will strengthen the importance of endoscopy in the future. Moreover a differentiated use of new laser technologies will improve the possibilities of endoscopic diagnosis and therapy. The use of electronic diagnostic documentation systems will contribute to a standardized nomenclature and to a quality-improvement of documentation in the near future. The utilization of modern electronic communication systems will facilitate intra- and interdisciplinary exchange of information.

[Percutaneous transhepatic metal stents in therapy of bile duct stenoses]

Treatment of choice for obstructive jaundice of different origin is the percutaneous transhepatic placement of endoprostheses if the endoscopic access fails for technical or anatomical reasons. Expandable metallic stents are generally preferred to plastic endoprostheses because of higher patency rates. Purpose of this study was to retrospectively evaluate the clinical efficiency and the occlusion rates of percutaneous placed metallic stents in 39 patients with malignant and benign biliary obstruction and to compare the results to a review of the literature. Placement of the stents was successful in all cases. Patients were followed-up for a mean of seven months (1-42 months). 54% of the patients had recurrent jaundice after a mean period of seven months (1-38 months). 35% were treated with a second procedure. Since the occlusion rates of percutaneous transhepatic metallic stents increase after six months and follow-up in most studies is short the real occlusion rates must be expected to be higher than reported. Therefore and in view to the high costs indication for the use of metal stents in biliary obstruction should be carefully checked.

Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms

BACKGROUND

The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms.

METHODS

Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners.

RESULTS

The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035).

CONCLUSIONS

The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.