[Heavy diarrhea by low malignant B cell lymphoma]

A 52-year old female presented with a low, malignant centroblastic-centrocytic lymphoma. After splenectomy and under steroid therapy it came to the eruption of a latent Strongyloides stercoralis infection, which the patient had presumably been suffering from for several years. Due to the immunodeficient condition and under continued steroid therapy even three courses of high dose anthelmintic therapy could not eradicate the parasites. The patient died of fulminant sepsis.

[Eradication and chronic acid suppression. Advances and pseudo-advances]

Guidelines for Helicobacter pylori therapy were proposed at the Maastricht 2/2000 conference. Since then no further major developments have been made. An evidenced based choice of treatment is thereby nearly impossible as large randomized trials have not been performed. Minor progress could be achieved in the areas of second-line and rescue treatment options after failure of the standard therapy. At present proton pump inhibitors are the most powerful drugs for the treatment of gastro-oesophageal reflux disease. No additional progress has been achieved concerning therapy of reflux disease in the last years. Reasonable anxiety about the safety of long-term acid suppression with proton pump inhibitors diminished over years as no significant increase in cancer development could be detected.

cagA-positive Helicobacter pylori strains and gastro-oesophageal reflux disease: still puzzling?

Gastro-oesophageal reflux disease (GORD) and Helicobacter pylori infection are both common in Western countries. A recently published meta-analysis has shown an association between an absence of H. pylori infection and GORD symptoms. Infection with cagA-positive H. pylori strains is a causative factor for the development of duodenal ulcer and is a risk factor for gastric cancer. Data about a protective role of cagA-positive H. pylori strains against more severe reflux oesophagitis are documented in several studies, but questioned by some other studies. There is a need for further studies to clear the definite role of cagA-positive H. pylori strains in severe reflux oesophagitis and their possible effect on the development of Barrett's adenocarcinoma. The role of Helicobacter pylori in gastro-oesophageal reflux disease (GORD) is still discussed controversially. Different factors might be responsible for the remarkably heterogeneous results of previously performed studies (e.g. location, environmental factors and different virulence factors of H. pylori strains). A very recently published meta-analysis has shown a significant association between the absence of H. pylori infection and GORD symptoms, and a positive correlation between anti-H. pylori therapy and the occurrence of both de-novo and rebound/exacerbated GORD. The results of this meta-analysis are questioned by some authors because of single larger trials and geographical variations of the studies analysed. Data on the role of the cytotoxic-associated antigen (cagA)-positive H. pylori strains are contradictory. Several studies have provided evidence supporting the protecting role of cagA-positive H. pylori strains against GORD, but these results were not confirmed by all studies. A multitude of patients suffer from H. pylori infection and GORD, simultaneously. Therefore, further studies are needed to clearly answer the question whether infection with cagA-positive H. pylori strains, which bear a well-documented risk for gastric cancer and gastro-duodenal ulcer, is really helpful against more severe reflux oesophagitis and, in consequence, perhaps protective against Barrett's oesophagus and Barrett's adenocarcinoma.

�sophagus- und Magenkarzinom

There are several different approaches available for the palliation of esophago-gastric cancer. The decision on which type of therapy is used should be made individually based on an interdisciplinary consensus.In case of inoperable esophageal carcinoma, it becomes the primary objective of the therapy to maintain oral nutrition. This can be achieved through the insertion of self expanding metal stents as a minimally invasive procedure which results in an immediate elimination of dysphagia. As alternative and/or complementary therapy, radiological techniques (external beam radiation, brachytherapy) can be applied. Other locally endoscopic techniques (laser, APC-beamer) are often used for treating local complications of esophageal and inoperable stomach carcinomas. For these carcinomas palliative chemotherapy with cisplatin has been established as a standard regimen.

Successful treatment of pancreatobiliary fistula by endoscopic stenting

An unusual pancreatobiliary fistula occurred as a complication of chronic pancreatitis. Endoscopic papillotomy was performed and a plastic endoprosthesis was inserted into the main pancreatic duct. The pancreatic stenting led to the closure of the fistula and no additional surgical treatment was necessary.

[Diagnosis of biliary tract carcinoma]

There are several diagnostic tools available in the diagnosis of bile duct cancer. Tumors of the middle and distal part of the extrahepatic bile duct are accessible to endosonography. Endoscopic retrograde cholangiopancreatography (ERC) and percutaneous transhepatic cholangiography (PTC) are the most invasive procedures for diagnosis of bile duct cancer. However, they offer the opportunity to obtain material for cytological or histological investigation. Moreover, bile flow can be assured by inserting endoprostheses during the procedure. Cholangioscopy and/or intraductal ultrasonography can be performed during ERC. They confer to the diagnosis of a malignant bile duct tumor and are the most accurate methods to diagnose the extent of longitudinal spread. Magnetic resonance imaging-cholangiography is an efficient diagnostic procedure which should be used first, if the bile duct tumor is located in the hilar region.

Staging of abdominal metastases in pancreatic carcinoma by diagnostic laparoscopy and magnetic resonance imaging

BACKGROUND

Different noninvasive and invasive techniques are available for the detection of abdominal metastases in pancreatic carcinoma. Since small hepatic or peritoneal metastases are a crucial problem which precludes resection, accurate detection is mandatory. We compared laparoscopic staging of abdominal metastases in adenocarcinoma of the pancreas with MRI.

METHODS

55 patients with pancreatic adenocarcinoma had been screened and 49 entered the retrospective study. All patients had undergone MRI of the upper abdomen with concomitant MR-cholangiopancreatography (MRCP) and diagnostic laparoscopy under conscious sedation. Patients without histologic proof of abdominal metastases underwent laparotomy.

RESULTS

In 6/10 patients, metastases were correctly detected by laparoscopy, yielding a sensitivity of 60% and a specificity of 92%.MRI predicted metastases in 6/10 patients with 60% sensitivity and 100% specificity. Laparoscopy showed metastases in 3 patients that were missed by MRI, but failed to identify metastases in 3 of 6 patients with metastases on MRI. Though only one patient showed previously undetected metastases during laparotomy, 3 patients with abdominal metastases underwent unnecessary laparotomy due to a lack of histologic proof of malignancy.

CONCLUSIONS

Whereas diagnostic laparoscopy is sensitive for the detection of small metastases and offers histologic verification, intrahepatic alterations are not detectable by sole visual inspection.MRI may compensate for this deficiency, but histologic proof of malignancy may be problematic. To date, no definite decision in favor of one of the presented procedures for the staging of abdominal metastases can be given.

[Mirizzi Syndrome without Cholecystolithiasis]

BACKGROUND

Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis.

CASE REPORT

A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice.

CONCLUSION

In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.

[Endoscopic drainage of symptomatic pancreatic pseudocysts. An efficient and safe therapy in the clinical routine?]

BACKGROUND AND OBJECTIVE

Clinical studies have demonstrated excellent success and low complication rates of endoscopic therapy of pancreatic pseudocysts. But it is not known, if these results can be reached in gastroenterological centers outside clinical studies.

PATIENTS AND METHODS

We investigated the outcome of endoscopic therapy in 21 patients (15 male, 6 female, age 40 - 81) with pancreatic pseudocysts treated in our clinic between 1997 and 2002. A follow-up examination was included.

RESULTS

Similar to the results of reported clinical studies the initial clinical success rate was 18/21 with symptomatic recurrences in two patients. All therapy-induced complications were successfully treated conservatively.

CONCLUSION

Excellent results of endoscopic therapy of pancreatic pseudocysts can be reached in a gastroenterological center. Surgical treatment can be reserved for cases, when endoscopic therapy fails.

[The importance of rectoscopy and colonoscopy in Internal Medicine]

The endoscopic examination of the large intestine can be considered today a routine examination in internal medicine. Since the introduction of flexible videoendoscopy, evaluating diseases in the distal colon using rectoscopy has become less important. Anoproctoscopy is an obligatory component for a complete colon diagnostic after a flexible ileo-colonoscopy has been performed. Colonoscopy has improved significantly the diagnosis and therapy of diseases in the large intestine since it has been introduced more than 30 years ago. By introducing modern videocolonoscopy in addition to other instruments, there is today a broad spectrum of diagnostic and therapeutic indications available. Specifically, due to its frequency and prognostic relevance, colonoscopy has become the most powerful and important procedure in the early detection and prevention of colon cancer.

Schwannoma of the common bile duct: a rare cause of obstructive jaundice

The endoscopic diagnosis of bile duct lesions has improved over recent years through the introduction of cholangioscopy and intraductal ultrasound. Combining this with biopsies examined using routinely administered immunohistochemical markers, the diagnosis of tumors of the extrahepatic bile duct can be improved substantially. We report a rare case of a schwannoma of the bile duct causing obstructive jaundice.

[New nondispersive infrared spectrometry in 13C-urea breath tests]

BACKGROUND AND OBJECTIVE

13C-urea breath tests have become clinical routine in the diagnosis of Helicobacter pylori infection. For the analysis of the 13CO2/12CO2 enrichment in breath, less expensive alternatives to the expensive mass spectrometry (IRMS) have been developed, based on isotope-selective infrared spectroscopy (NDIRS). In this prospective study we tested under clinical conditions a simplified and thus less expensive NDIR-spectrometer by comparing it with mass spectroscopy.

METHODS

100 patients (53 men, 47 women, mean age 59+/-14 years) with dyspeptic symptoms were tested for Helicobacter pylori infection using the 13C-urea breath test. The isotope ratio analysis of the breath samples was performed in duplicate, both using IRMS and NDIRS.

RESULTS

The results of the baseline-corrected 13CO2 -exhalation values between IRMS and NDIRS were in excellent agreement. The mean difference between both methods was 0.05+/-1.16 . Evaluating the qualitative urea breath test results in reference to IRMS as the reference, the NDIRS had a sensitivity of 95 % and a specificity of 99 %.

CONCLUSION

This newly developed isotope-selective nondispersive infrared spectroscopy is going to become a reliable, and low-cost alternative to expensive isotope ratio mass spectrometry in the analysis of 13C-breath tests. All these characteristics make NDIRS particularly suitable for laboratories where the daily number of assays is small or for use in the doctor's office

Self-expandable metal mesh stents for common bile duct stenosis in chronic pancreatitis: retrospective evaluation of long-term follow-up and clinical outcome pilot study

BACKGROUND

Symptomatic common bile duct strictures are frequently seen in the course of severe chronic pancreatitis with a reported incidence of 10-30%. The exact role of endoscopic stenting with metal prostheses as definitive treatment has not yet been clearly defined.

METHODS

Six patients with symptomatic distal common bile duct stricture in the setting of chronic pancreatitis were treated with a self-expandable metal stent in an attempt to achieve permanent drainage. All cases were approached non-operatively and underwent prior unsuccessful treatment with plastic prostheses.

RESULTS

The patients received a self-expandable metal Wall stent after a median follow-up of 14 months of plastic stenting. The median follow-up time was 58 months and the stents remained open for a median time of 20 months, respectively. Overall, in 2 of 6 cases the metal stent therapy was successful while 4 of 6 patients required additional endoscopic procedures.

CONCLUSIONS

Self-expandable metal stents could be useful and adequate in patients who suffer from symptomatic obstructive jaundice due to chronic pancreatitis. However, they provide acceptable dilation of the common bile duct for only a limited period of time. Overall, endoscopic stenting with self-expandable metal stents seems to be an advantageous treatment only for a subgroup of patients who are unfavorable candidates for surgical drainage. To clarify the role of the endoscopic approach, prospective trials with homogeneous and larger patient numbers are necessarily in the future.

Magnetic resonance cholangiopancreatography. The fine art of bilio-pancreatic imaging

With the introduction of endoscopic retrograde cholangio-pancreatography in the early 1970s, gastroenterologists have a lot of diagnostic options in the biliopancreatic system to their disposal. Meanwhile, magnetic resonance cholangiopancreatography (MRCP) has become a competitive replacement for diagnostic ERCP with the advantage of avoiding complications related to endoscopic techniques. Mounting evidence suggests that both MRCP and MRI (magnetic resonance imaging) have a profound influence of diagnostic algorithms in a variety of hepatobiliary and pancreatic diseases.

[Surgical therapy of inflammatory bowel diseases. Rational diagnosis--endoscopy, contrast media administration, CT? Indications for operation]

Some 10 to 25 percent of all patients with diverticulosis will come down with diverticulitis in the course of their lives. Apart from physical examinations, sonography and--if results are still unclear--computer tomography are seen as the most important diagnostic devices. 75 percent of patients with acute diverticulitis can initially be treated conservatively, and only one in four ever falls ill again with another inflammation. According to those numbers a conservative method is justified when dealt with a primary uncomplicated diverticulitis. If a second attack occurs, should an elective resection be considered. An increased mortality and morbidity exists among young and immunocompromised patients so that elective surgery is recommended already after the first incident.