[Takayasu arteritis after COVID-19 infection in a 26-year-old female patient with Crohn's disease]

Extraintestinal manifestations, e.g. of the skin, joints or liver, are frequently found in Crohn's disease. We report about a 26-year-old female patient with longstanding Crohn's disease, who was admitted to our hospital with suspicion of an acute attack with suggestive symptoms and increased significantly inflammatory parameters. Shortly before, symptomatic COVID-19 disease (SARS-CoV-2 variant omicron) had been made. Comprehensive endoscopic and imaging diagnostics ruled out active Crohn's disease. However, inflammatory thickening of the aortic arch was seen, and a diagnosis of Takayasu arteritis (type II b) was made. Steroid therapy resulted in a rapid and sustained improvement of clinical symptoms. The occurrence of Takayasu arteritis is extremely rare outside Japan. An coincidence has been described in chronic inflammatory bowel diseases and is discussed as a possible extraintestinal manifestation. The occurrence of immune-mediated disease after COVID-19 disease has been described and may be triggered by the infection. Patients with inflammatory bowel disease may represent a special risk population.

[Costs of potentially outpatient endoscopic procedures in cases with a 1-day hospital stay versus a longer stay]

INTRODUCTION

The transfer of patient care and medical interventions that was previously provided on an inpatient basis to outpatient settings is a stated goal of health politics. It is unclear to what extent costs of an endoscopic procedure and the disease severity depend on the duration of inpatient treatment. We therefore examined whether endoscopic services for cases with a one-day length of stay (VWD) are comparably expensive to cases with a longer VWD.

METHODS

Outpatient services were selected from the DGVS service catalog. Day cases with exactly one such gastroenterological endoscopic (GAEN) service were compared with cases with VWD>1 day regarding their patient clinical complexity levels (PCCL) and mean costs. Data from the DGVS-DRG project with §21-KHEntgG cost data from a total of 57 hospitals from 2018 and 2019 served as the basis. Endoscopic costs were taken from cost center group 8 of the InEK cost matrix and plausibility checked.

RESULTS

A total of 122,514 cases with exactly one GAEN service were identified. Statistically equal costs were shown in 30 of 47 service groups. In 10 groups, the cost difference was not relevant (<10%). Cost differences >10% existed only for EGD with variceal therapy, insertion of a self-expanding prosthesis, dilatation/bougienage/exchange with PTC/PTCD in place, non-extensive ERCP, endoscopic ultrasound in the upper gastrointestinal tract, and colonoscopy with submucosal or full thickness resection, or foreign object removal. PCCL differed in all but one group.

CONCLUSION

Gastroenterology endoscopy services provided as part of inpatient care but potentially performable on an outpatient basis are predominantly equally expensive for day cases as for patients with a length of stay greater than one day. The disease severity is lower. Calculated §21-KHEntgG cost data thus form a reliable basis for the calculation of appropriate reimbursement for hospital services to be provided as outpatient services under the AOP in the future.

Differentiation of Spontaneous Bacterial Peritonitis from Secondary Peritonitis in Patients with Liver Cirrhosis: Retrospective Multicentre Study

Ascitic fluid infection is a serious complication of liver cirrhosis. The distinction between the more common spontaneous bacterial peritonitis (SBP) and the less common secondary peritonitis in patients with liver cirrhosis is crucial due to the varying treatment approaches. This retrospective multicentre study was conducted in three German hospitals and analysed 532 SBP episodes and 37 secondary peritonitis episodes. Overall, >30 clinical, microbiological, and laboratory parameters were evaluated to identify key differentiation criteria. Microbiological characteristics in ascites followed by severity of illness and clinicopathological parameters in ascites were the most important predictors identified by a random forest model to distinguish between SBP and secondary peritonitis. To establish a point-score model, a least absolute shrinkage and selection operator (LASSO) regression model selected the ten most promising discriminatory features. By aiming at a sensitivity of 95% either to rule out or rule in SBP episodes, two cut-off scores were defined, dividing patients with infected ascites into a low-risk (score ≥ 45) and high-risk group (score < 25) for secondary peritonitis. Overall, the discrimination of secondary peritonitis from SBP remains challenging. Our univariable analyses, random forest model, and LASSO point score may help clinicians with the crucial differentiation between SBP and secondary peritonitis.

A Novel Machine Learning-Based Point-Score Model as a Non-Invasive Decision-Making Tool for Identifying Infected Ascites in Patients with Hydropic Decompensated Liver Cirrhosis: A Retrospective Multicentre Study

This study is aimed at assessing the distinctive features of patients with infected ascites and liver cirrhosis and developing a scoring system to allow for the accurate identification of patients not requiring abdominocentesis to rule out infected ascites. A total of 700 episodes of patients with decompensated liver cirrhosis undergoing abdominocentesis between 2006 and 2020 were included. Overall, 34 clinical, drug, and laboratory features were evaluated using machine learning to identify key differentiation criteria and integrate them into a point-score model. In total, 11 discriminatory features were selected using a Lasso regression model to establish a point-score model. Considering pre-test probabilities for infected ascites of 10%, 15%, and 25%, the negative and positive predictive values of the point-score model for infected ascites were 98.1%, 97.0%, 94.6% and 14.9%, 21.8%, and 34.5%, respectively. Besides the main model, a simplified model was generated, containing only features that are fast to collect, which revealed similar predictive values. Our point-score model appears to be a promising non-invasive approach to rule out infected ascites in clinical routine with high negative predictive values in patients with hydropic decompensated liver cirrhosis, but further external validation in a prospective study is needed.

Clinical implications of diabetes in chronic liver disease: Diagnosis, outcomes and management, current and future perspectives

Diabetes mellitus (DM) is common in liver cirrhosis (LC). The pathophysiological association is bidirectional. DM is a risk factor of LC and LC is a diabetogenic condition. In the recent years, research on different aspects of the association DM and LC has been intensified. Nevertheless, it has been insufficient and still exist many gaps. The aims of this review are: (1) To discuss the latest understandings of the association of DM and LC in order to identify the strategies of early diagnosis; (2) To evaluate the impact of DM on outcomes of LC patients; and (3) To select the most adequate management benefiting the two conditions. Literature searches were conducted using PubMed, Ovid and Scopus engines for DM and LC, diagnosis, outcomes and management. The authors also provided insight from their own published experience. Based on the published studies, two types of DM associated with LC have emerged: Type 2 DM (T2DM) and hepatogenous diabetes (HD). High-quality evidences have determined that T2DM or HD significantly increase complications and death pre and post-liver transplantation. HD has been poorly studied and has not been recognized as a complication of LC. The management of DM in LC patients continues to be difficult and should be based on drug pharmacokinetics and the degree of liver failure. In conclusion, the clinical impact of DM in outcomes of LC patients has been the most studied item recently. Nevertheless many gaps still exist particularly in the management. These most important gaps were highlighted in order to propose future lines for research.

[Endoscopic tunneling procedures in achalasia and gastroparesis]

Since the first publication of peroral endoscopic myotomy (POEM) by Haruhiro Inoue et al. in 2008 in Japan, various novel endoscopic procedures have been established, which are performed after iatrogenic creation of a submucosal tunnel as a "new space" 1. Through the artificially formed access in the tela submucosa, interventions in the muscular layer of the esophagus and stomach can be performed while carefully sparing the mucosal layer 2. These include, peroral myotomy of the esophageal muscle layer in patients with achalasia (POEM) and myotomy of the pylorus in patients with gastroparesis (antropyloromyotomy, G-POEM). Further indications include splitting of Zenker diverticulum in POEM technique ("Z-POEM") as well as the removal of subepithelial tumors (STER: submucosal tunneling, endoscopic resection). The long-term therapeutic success (with > 80 % response) of these innovative procedures has now been proven by controlled studies, especially in achalasia 2 3 4 5 6.

Damage control strategy in perforated diverticulitis with generalized peritonitis

Background

The best treatment for perforated colonic diverticulitis with generalized peritonitis is still under debate. Concurrent strategies are resection with primary anastomosis (PRA) with or without diverting ileostomy (DI), Hartmann’s procedure (HP), laparoscopic lavage (LL) and damage control surgery (DCS). This review intends to systematically analyze the current literature on DCS.

Methods

DCS consists of two stages. Emergency surgery: limited resection of the diseased colon, oral and aboral closure, lavage, vacuum-assisted abdominal closure. Second look surgery after 24–48 h: definite reconstruction with colorectal anastomosis (−/ + DI) or HP after adequate resuscitation. The review was conducted in accordance to the PRISMA-P Statement. PubMed/MEDLINE, Cochrane central register of controlled trials (CENTRAL) and EMBASE were searched using the following term: (Damage control surgery) AND (Diverticulitis OR Diverticulum OR Peritonitis).

Results

Eight retrospective studies including 256 patients met the inclusion criteria. No randomized trial was available. 67% of the included patients had purulent, 30% feculent peritonitis. In 3% Hinchey stage II diverticulitis was found. In 49% the Mannheim peritonitis index (MPI) was greater than 26. Colorectal anastomosis was constructed during the course of the second surgery in 73%. In 15% of the latter DI was applied. The remaining 27% received HP. Postoperative mortality was 9%, morbidity 31% respectively. The anastomotic leak rate was 13%. 55% of patients were discharged without a stoma.

Conclusion

DCS is a safe technique for the treatment of acute perforated diverticulitis with generalized peritonitis, allowing a high rate of colorectal anastomosis and stoma-free hospital discharge in more than half of the patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01130-5.

Overlap of concurrent extrahepatic autoimmune diseases is associated with milder disease severity of newly diagnosed autoimmune hepatitis

BACKGROUND

Concurrent extrahepatic autoimmune disorders (CEHAID) are frequently observed in autoimmune hepatitis (AIH). It is not clear whether there is any prognostic significance of CEHAID on AIH. The aim of this study was to examine the prognostic impact of CEHAID and the correlation with the disease severity of AIH.

METHODS

This study included 65 hospitalized subjects who fulfilled the accepted criteria for AIH during an 8-year period (2009-2016). All records were manually screened for presence of associated autoimmune diseases. Disease severity of AIH was assessed by liver laboratory tests including the ratio of aspartate aminotransferase to alanine aminotransferase (AST/ALT) and liver histology.

RESULTS

Among the enrolled patients, 52 (80%) were female (median age 61 years, IQR 45-75). Fifty-six (86.2%) were classified as type-1 AIH. In 26 (40%) patients at least one additional extrahepatic autoimmune disease was diagnosed. Thirty-four subjects were referred to our hospital because of acute presentation of AIH (supposed by an acute elevation of hepatic enzymes) for subsequent liver biopsy resulting in initial diagnosis of AIH. This group was stratified into 3 subgroups: (A) AIH alone (n = 14); (B) overlap with primary biliary cirrhosis (PBC) / primary sclerosing cholangitis (PSC) (n = 11); and (C) with CEHAID (n = 9). AST/ALT ratio was the lowest in subgroup C (median 0.64, IQR 0.51-0.94; P = 0.023), compared to subgroup A (median 0.91, IQR 0.66-1.10) and subgroup B (median 1.10, IQR 0.89-1.36). Patients with AIH alone showed a trend to the highest grade of fibrosis (mean 2.3; 95% CI: 1.5-3.0) with no statistical significance compared to subjects with CEHAID (lowest grade of fibrosis; mean 1.5; 95% CI: 0.2-2.8; P = 0.380) whereas the ongoing inflammation was comparable.

CONCLUSIONS

AST/ALT ratio and extent of fibrosis were lower in subjects with AIH and CEHAID, compared to subjects with only AIH. Therefore, the occurrence of CEHAID might be a predictor for lower disease severity of newly diagnosed acute onset AIH, possibly caused by an earlier diagnosis or different modes of damage.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels

Introduction

Endoscopic full-thickness resection (eFTR) using the full-thickness resection device (FTRD®) is a novel minimally invasive procedure that allows the resection of various lesions in the gastrointestinal tract including the colorectum. Real-world data outside of published studies are limited. The aim of this study was a detailed analysis of the outcomes of colonoscopic eFTR in different hospitals from different care levels in correlation with the number of endoscopists performing eFTR.

Material and methods

In this case series, the data of all patients who underwent eFTR between November 2014 and June 2019 (performed by a total of 22 endoscopists) in 7 hospitals were analyzed retrospectively regarding rates of technical success, R0 resection, and procedure-related complications.

Results

Colonoscopic eFTR was performed in 229 patients (64.6% men; average age 69.3 ± 10.3 years) mainly on the basis of the following indication: 69.9% difficult adenomas, 21.0% gastrointestinal adenocarcinomas, and 7.9% subepithelial tumors. The average size of the lesions was 16.3 mm. Technical success rate of eFTR was achieved in 83.8% (binominal confidence interval 78.4–88.4%). Overall, histologically complete resection (R0) was achieved in 77.2% (CI 69.8–83.6%) while histologically proven full-wall excidate was confirmed in 90.0% (CI 85.1–93.7%). Of the resectates obtained (n = 210), 190 were resected en bloc (90.5%). We did not observe a clear improvement of technical success and R0 resection rate over time by the performing endoscopists. Altogether, procedure-related complications were observed in 17.5% (mostly moderate) including 2 cases of acute gangrenous appendicitis requiring operation.

Discussion

In this pooled analysis, eFTR represents a feasible, effective, and safe minimally invasive endoscopic technique.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07772-5) contains supplementary material, which is available to authorized users.

G-POEM in patients with gastroparesis - gambling for healing or bigger armamentarium ? A case series and review of the literature

Approximately 30% of all affected patients suffering from gastroparesis do not respond to any available treatment modality. Gastric peroral endoscopic myotomiy (G-POEM, antropyloromyotomy) represents a new principle of therapy. In this single center study, G-POEM showed a high technical success rate with a very low procedural complication rate. However, the clinical response beyond a short-term post-interventional improvement did not succeed in a single patient. The heterogeneity of the clinical picture, which represents a spectrum of different pathophysiological, etiological and clinical characteristics, still requires a therapy tailored to the individual patient. G-POEM should be considered especially in patients with pylorus-dominant gastroparesis.

Small intestinal dysmotility in cirrhotic patients: correlation with severity of liver disease and cirrhosis-associated complications

INTRODUCTION

 Altered small intestinal motility has been observed in various manometry studies in patients with cirrhosis. Since small bowel manometry is available only in a few centers, interpretation of dysmotility in cirrhosis is controversial.

PATIENTS AND METHODS

 In this study, both fasting and postprandial manometric tracings of 24-hour antroduodenojejunal manometries were analyzed using both visual analysis and computer-aided analysis.

RESULTS

 In 34 patients (83 %), the mean migrating motor complex (MMC) cycle length was different compared with healthy controls. Phase II was prolonged in 27 patients (66 %), while phase I showed a reduced duration in 23 (56 %) and in phase III in 13 individuals (32 %). We also observed special motor patterns, e. g., migrating clustered contractions (MCCs) or retrograde clustered contractions (RCCs), which were present during fasting (69 %) and postprandial (92 %) motility, while none of the healthy controls showed any special motor patterns. Special motor patterns showed a significant correlation with the severity of cirrhosis (Child-Score; p > 0.05) and the existence of ascites (p < 0.05).

DISCUSSION

 This study in a large cohort of patients with cirrhosis by using 24-hour, solid state portable manometry showed in most individuals disturbances of cyclic fasting motility. Special motor patterns like RCCs during fasting and postprandial motility could be observed exclusively in the cirrhosis group, showing a significant correlation with severity of cirrhosis and the occurence of associated complications.

Calprotectin as Diagnostic Marker for Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis in Cirrhosis

BACKGROUND

Calprotectin is a well-established marker for intestinal inflammation, mainly in inflammatory bowel disease, and represents one of the most studied biomarkers in stool samples.

METHODS

Apart from its important diagnostic role in inflammatory bowel disease, there are few studies showing that calprotectin can also be used as a diagnostic tool in patients suffering from hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP) in cirrhosis.

RESULTS

Since calprotectin concentration in the human stool or in ascites is elevated at an early stage of inflammation, it might serve as an early screening tool for patients suffering from cirrhosis who are at risk to develop these conditions. As detection and monitoring of HE and SBP may be unclear and resource-intensive, identification of valid new markers of disease activity is necessary. In this review, we summarize the current knowledge of calprotectin as a diagnostic biomarker in cirrhosis, indicating that it is a highly promising diagnostic surrogate marker to screen for the presence of HE and SBP.

CONCLUSIONS

To screen cirrhotic patients for SBP, calprotectin should be assessed in ascitic fluid while it should be measured in feces when screening for HE. However, the value of calprotectin in managing individual patients must be considered in the specific clinical context.

Role of Brain Biomarkers S-100-Beta and Neuron-Specific Enolase for Detection and Follow-Up of Hepatic Encephalopathy in Cirrhosis before, during and after Treatment with L-Ornithine-L-Aspartate

Introduction

Hepatic encephalopathy (HE), in the context of liver cirrhosis, seems to result from low-grade cerebral edema of the astrocytes. Serum brain biomarkers S-100-beta und neuron-specific enolase (NSE) are often elevated in brain injury. We hypothesized that neuromarkers S-100-beta and NSE can be used in the diagnosis of HE, compared with standardized diagnostic tools.

Material and Methods

A prospective non-randomized intervention study was performed using L-ornithine-L-aspartate (LOLA) for HE treatment. Primary endpoint was the evaluation of neuromarkers S-100-beta and NSE for detection and diagnosis of follow-up of HE. As secondary endpoints, the efficacy of LOLA on the course of HE and the diagnostic role of Portosystemic-Encephalopathy-Syndrome score (PHES) and critical flicker frequency (CFF) were analyzed. For diagnosis of covert (CHE) and overt (OHE) HE, West-Haven criteria (WHC), PHES and CFF were assessed at study entry. LOLA was applied (20 g i.v.) for 6 days. At the end of the study, HE evaluation was repeated. S-100-beta, NSE and ammonia were assessed in each patient before, during and after therapy with LOLA.

Results

30 patients were included. At study entry, CHE was diagnosed in 50% and OHE in 50% of all subjects. A total of 25 participants completed the study. After LOLA therapy, deterioration of HE occurred in <11%, while most patients showed improvement (e.g. improved CFF in 79%). No significant correlation with HE severity (as diagnosed by WHC, PHES and CFF) could be demonstrated for any biochemical parameter. In addition, there were no significant changes in brain biomarkers during the treatment period.

Discussion

While CFF as well as PHES showed good correlation with treatment response, S-100-beta and NSE did not significantly correlate with HE severity compared to proven diagnostic methods, and do not seem reliable biochemical markers for the follow-up under therapy.

Mortalität und ökonomische Auswirkungen der hepatischen Enzephalopathie bei Leberzirrhose in deutschen Krankenhäusern auf der Basis von G-DRG-Kostendaten

Einleitung Die hepatische Enzephalopathie (HE) ist eine häufige Komplikation der Leberzirrhose, die für betroffene Patienten mit vielfältigen negativen Auswirkungen im Alltag verbunden ist. Die Prävalenz klinisch manifester Stadien wird auf 30–45 % geschätzt. Ungeachtet ihrer klinischen und prognostischen Bedeutung gilt die HE als unterdiagnostiziert.

Methoden Ziele der Studie waren neben der systematischen Analyse der Krankenhausletalität der HE erstmals eine Untersuchung der ökonomischen Auswirkungen und der Vergütungssituation einer HE bei Leberzirrhose in Deutschland. Für die retrospektive Studie standen die anonymisierten Fall- und Kostendaten (§ 21 Abs. 4 KHEntgG) von 74 Krankenhäusern des DRG-Projekts der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) aus den Jahren 2011 bis 2015 zur Verfügung. Außerdem wurden diese Ergebnisse mit denen aller deutschen Krankenhäuser auf der Basis der Falldaten des Statistischen Bundesamtes (Destatis, Wiesbaden) verglichen.

Ergebnisse In den Häusern des DRG-Projekts der DGVS wurden 59 093 Behandlungsfälle mit Leberzirrhose erfasst, bei denen in 14,6 % eine HE kodiert war. Die Krankenhausletalität von Zirrhose-Patienten mit HE war gegenüber derjenigen von Patienten ohne HE nahezu dreifach erhöht (20,9 versus 7,7 %). Die Zahl der Behandlungsfälle mit Leberzirrhose ebenso wie der Anteil von Patienten mit HE stieg kontinuierlich über den Erfassungszeitraum an. Im Gegensatz zu Patienten mit Zirrhose allgemein ist die Behandlung von Patienten mit HE nicht kostendeckend (Unterdeckung bis zu 634 € bei HE Grad 4).

Diskussion Die Letalität war bei Patienten mit Zirrhose dreifach erhöht, wenn gleichzeitig eine HE diagnostiziert wurde. In den am DGVS-DRG-Projekt teilnehmenden Häusern wurde die HE um 2 % häufiger erfasst als im Rest der Kalkulationshäuser, was entweder in einer höheren Fallschwere oder in einer besseren Kodierqualität begründet ist. Gegenwärtig ist die Behandlung der HE bei Zirrhose nicht kostendeckend im DRG-System.

Frequency of Polyps and Adenocarcinoma in Colon Interposition After Esophagectomy in Adulthood - A Systematic Review

BACKGROUND/AIM

Colon interposition counts among the most common techniques for reconstruction after esophagectomy. Availability of data on metachronous mucosal pathologies is weak. The aim of this review was to identify all reports on the development of metachronous adenoma and adenocarcinoma in colon interposition after esophagectomy in adulthood.

MATERIALS AND METHODS

A comprehensive search was conducted in MEDLINE/PubMed, Science Direct, Cochrane Library, Bayerische Staatsbibliothek München. All studies reporting on patients who received colon interposition as substitute after esophagectomy in adulthood for benign and malignant reasons were included.

RESULTS

Five retrospective studies were included, reporting on 1016 patients. Therein, no interval lesion was identified. One further study, which formally must be excluded for a misfit to inclusion criteria reports on three interval carcinomas within 365 patients. Because these lesions were the only ones found within a cohort analysis, results were supplementary reported in this review. Additionally, 31 case reports including 32 patients with benign (n=7) or malignant (n=25) findings were analyzed. Median age was 63.5 years (interval carcinoma) and 69 years (benign lesion). Benign and malignant lesions were diagnosed after a median of 8.5 years.

CONCLUSION

Due to the rareness of respective cohort studies, the frequency of metachronous lesions cannot be calculated accurately. The estimated rate of interval carcinoma is 0-0.22%. Life-long endoscopic surveillance of patients with colon interposition is recommended.

[Updated S2k-Guideline "Complications of liver cirrhosis". German Society of Gastroenterology (DGVS)]

This guideline provides evidence-based key recommendations for diagnosis and therapy of complications of liver cirrhosis and upgrades the 2011 version. An interdisciplinary team of medical experts and patient support groups developed the guideline following the AWMF recommendations for evidence based consensus guidelines. New chapters concerning diagnosis and therapy of hepatic encephalopathy were added.

[Patient perception and approval of fecal microbiota transplantation (FMT) as an alternative treatment option for ulcerative colitis]

INTRODUCTION

 Fecal microbiota transplantation (FMT) represents a treatment option for recurring Clostridium difficile-associated colitis. However, there is also evidence that FMT can be effective in treating ulcerative colitis. This study examined the approval and willingness of affected patients who underwent FMT.

METHODS

 A standardized questionnaire containing 27 polar and open questions was dispatched to a cohort of 262 patients suffering from UC. It included questions regarding the FMT process, donors, and possible concerns. Additionally, aspects of social background and disease activity were addressed.

RESULTS

 The response rate was 31.3 % (n = 82). Forty-eight (58.5 %) patients were already aware of FMT. Forty-six (56.1 %) were willing to undergo FMT if given a respective indication. The effectiveness of the procedure (40.2 %), followed by failure of all other therapies (17.1 %), formed the principal motivation. The transmission of possible infectious agents (26.8 %), and the potential contamination of the stool graft leading to a deterioration of clinical symptoms, raised the most concerns. (20.7 %).The preferred delivery system of FMT was capsules (67.1 %), followed by colonoscopic application (47.6 %). The patients were in favour of a donor proposed by the physician (52,4 %). Willingness to undergo FMT did not differ significantly between genders (56.4 % women vs. 57.1 % men). Smokers (88.9 %), patients who did not watch television at all (77.8 %) and those with private health insurance, showed an increased willingness to undergo FMT.

CONCLUSION

 For the majority of the UC patients surveyed, FMT represents a feasible treatment option. Approximately half of the respondents would consider FMT as an alternative treatment option, even inspite of a satisfactory disease response to current standard therapies. Unsurprisingly, there are concerns regarding the transmission of possible infectious agents and the hygienic implementation of FMT itself.

[Deficits in Health-Literacy of Inpatients - a Cross-Sectional Study]

INTRODUCTION

Systematic investigations of health literacy in German patients are rare and mostly based on subjective self-assessment.

METHODS

In a cross-sectional survey, 196 patients (female 38 %, male 62 %) in medical and surgical units were asked to complete a questionnaire that we had developed for this purpose. This questionnaire contained 43 questions about common medical terms. We investigated whether patients were familiar with these terms and could name the meaning according to correct definition. Furthermore, the association with the patients' socio-economic and demographic parameters (e. g. education, insurance status, utilization of media) was analyzed.

RESULTS

Among all questions of the questionnaire, more patients claimed to know their meaning than this was the case by objective testing. Association of medical knowledge with demographic and socio-economic data revealed that correct answers were more frequent among women compared to men (51.1 % vs. 47.2 %; p = 0.12). Patients' age was negatively correlated with medical knowledge (p < 0.001). Higher educational level was associated with a higher percentage of correct answers (p < 0.001). Private insurance status had significant influence on medical knowledge (p = 0.002). Male patients working intellectually (compared to working physically) had a higher percentage of correct answers (p = 0.001). Other factors like reading newspapers, watching TV and number of consultations per year did not influence the percentage of correct answers.

SUMMARY

Physicians should make sure by active inquiries whether the patient understands them correctly. Furthermore, there is a considerable gap between subjective and objective medical knowledge that future evaluations of health literacy should be aware of.

Patient perception and approval of faecal microbiota transplantation (FMT) as an alternative treatment option for obesity

INTRODUCTION

Fecal microbiota transplantation (FMT) represents a treatment option for some diseases, e.g. recurring Clostridium difficile-associated colitis. However, there is also evidence that FMT can be effective in treating obesity. This pilot study established the approval and willingness of obese patients to undergo FMT.

METHODS

We conducted a survey of adults with obesity using a questionnaire containing 21 both multiple choice and open questions was dispatched to a cohort of 101 persons with obesity. It included questions aiming at the process of FMT itself, donors as well as possible concerns. Additionally aspects of social background and disease activity were dealt with.

RESULTS

The response rate amounted to 30.1% (n = 31). In our population, mean BMI was 40.5 kg/m2 while the vast majority already tried out treatment modalities to lose weight before. 25.8% of persons with obesity were aware of FMT. 62.1% were willing to undergo FMT if the donor was healthy and anonymous while only 6.9% clearly refused this option. Sixty preferred an anonymous donor or a person proposed by their doctor while colonoscopy was the preferred application by 76.7%. The absence of risks of the procedure (47.8%) formed the principal motivation while reduction of medication was considered as least important reason (in 26.1). Insufficient testing of the faeces concerning infections raised the most concerns (in 61.6%).

CONCLUSION

For the majority of the persons with obesity surveyed FMT represents a treatment option. Approximately two thirds of the questionees would consider FMT as an alternative treatment option, even in spite of a satisfactory disease response to current standard therapies. Unsurprisingly there are concerns in regard to the transmission of possible infectious agents as well as to the hygieneic implementation of FMT itself.

Olfactory Function is Affected in Patients with Cirrhosis Depending on the Severity of Hepatic Encephalopathy

INTRODUCTION AND AIM

Olfactory functions are altered to a variable degree by chronic liver disease. Few studies including only small populations of patients emphasized the possibility of hepatic encephalopathy (HE) influencing olfactory nervous tasks. So far, no study has explicitly focused on olfactory function depending on the severity of HE as assessed by objective diagnostic procedures. Thus we performed a study using the "Sniffin' Sticks" test system, critical flicker-fusion frequency (CFF) and clinical West Haven criteria.

MATERIAL AND METHODS

54 cirrhotic patients with liver cirrhosis were included. Furthermore, 43 adult volunteers participating as a non-cirrhotic control group. Olfactory testing was performed using the "Sniffin' Stick" test battery (Burghart Medizintechnik, Wedel, Germany) which renders a widely-used tool both in clinical and research settings for the assessment of olfactory threshold, odor identification and discrimination. Several complications of cirrhosis were diagnosed by reference methods. Statistical analysis of cirrhosis-associated complications and their relation to olfactory function was performed. Assessment of HE and classification of different stages were performed according to clinical criteria (West- Haven criteria) and according to CFF, which was determined using a portable analyzer.

RESULTS

Olfactory function was significantly reduced in cirrhotic patients (in 61.1%) compared to controls (p &lt; 0.001). Among cirrhotics patients, the prevalence of olfactory deficits (hyposmia, anosmia) increased with the severity of HE as assessed by CFF and clinical criteria (p = 0.008 and p = 0.097, respectively). No correlation was observed between olfactory deficits and severity of liver disease as assessed by Child-Pugh-Score, etiology of cirrhosis and complications of cirrhosis such as ascites and portal venous hypertension.

CONCLUSIONS

Olfactory testing serves as a screening tool for HE and may facilitate grading of HE-severity.

Hepatopathie bei systemischem Lupus erythematodes – Ergebnisse einer explorativen Beobachtungsstudie

Einleitung Der systemische Lupus erythematodes (SLE) stellt eine klinisch sehr variabel verlaufende Autoimmunerkrankung dar, welche zahlreiche Organsysteme befallen kann. Eine Manifestation an der Leber gilt als selten. Unklar ist insbesondere, ob eine Hepatopathie bei SLE von prognostischer Bedeutung ist und z. B. mit der Aktivität der Erkrankung korreliert.

Methodik Unser Patientenkollektiv umfasste 172 Patienten mit gesichertem SLE, welche am Klinikum Bogenhausen im Zeitraum 01.01.2009 bis 31.12.2015 behandelt wurden. Ausgewertet wurden retrospektiv alle ambulanten und/oder stationären Patientenvorstellungen (n = 671; durchschnittlich 3,9 pro Patient). Eine Leberschädigung wurde laborchemisch anhand von pathologischen Leberenzymprofilen oder bildgebend diagnostiziert. Die Krankheitsaktivität des SLE wurde anhand des European Consensus Lupus Activity Measurement (ECLAM)-Score ermittelt. Zusätzlich wurden Parameter der Grunderkrankung wie Krankheitsdauer, Organschädigung sowie immunsuppressive Medikation ausgewertet und die mögliche Assoziation mit einer Hepatopathie analysiert.

Ergebnisse Erhöhte Leberwerte (ASAT, ALAT, GGT, AP) als Ausdruck einer Hepatopathie waren bei 109 Patienten (63,4 % der Gesamtpopulation) nachweisbar und waren signifikant mit Krankheitsaktivität (auf der Basis des ECLAM-Score, p < 0,001), Behandlungsdauer, Häufigkeit der Vorstellungen (jeweils p < 0,01), Anzahl der eingesetzten Immunsuppressiva (p < 0,018), erhöhter Blutsenkungsgeschwindigkeit (p < 0,001) sowie Erniedrigung des Serumkomplements (p < 0,03) assoziiert. Pathologische Sonografiebefunde an der Leber (z. B. nicht-alkoholische Fettleber) waren in 19,8 % der Fälle nachweisbar.

Diskussion Erhöhte Leberwerte kommen bei Patienten mit SLE sehr häufig vor, insbesondere bei erhöhter Krankheitsaktivität (basierend auf ECLAM-Score oder intensivierter immunsuppressiver Therapie) und längerer Erkrankungsdauer. Leberwertbestimmungen sollten daher bei Patienten mit SLE regelmäßig erfolgen und eine weitere differenzialdiagnostische Abklärung angestrebt werden. Zukünftige prospektive Studien könnten klären, ob pathologische Leberwerte in Aktivitätsindizes zur Beurteilung der Krankheitsaktivität bei SLE einbezogen werden müssen.

Design of the Weight-loss Endoscopy Trial (WET): a multi-center, randomized, controlled trial comparing weight loss in endoscopically implanted duodenal-jejunal bypass liners vs. intragastric balloons vs. a sham procedure

Background

Obesity is a global problem leading to reduced life expectancy, cardiovascular diseases, diabetes and many types of cancer. Even people willing to accept treatment only achieve a mean weight loss of about 5 kg using commercial weight loss programs. Surgical interventions, e.g. sleeve gastrectomy or gastric bypass are effective but accompanied by risk of serious complications and side effects. Less invasive endoscopic procedures mainly comprise the intragastric balloon (IB) and the duodenal-jejunal bypass liner (DJBL). To date, a randomized comparison between these devices has not been undertaken or shown to be superior to a sham procedure.

Methods

We designed a multi-center, randomized, patient and assessor-blinded, controlled trial comparing weight loss in endoscopically implanted IB vs. DJBL vs. a sham procedure. A total of 150 patients with a BMI > 35 kg/m² or > 30 with obesity-related comorbidities and indication for proton pump inhibitors are randomized to receive either IB, DJBL or a sham gastroscopy (2:2:1 ratio). All participants undergo regular dietary consultation. The IB will be removed after 6 months, whereas the DJBL will be explanted after 12 months. All patients will receive gastroscopies at implantation and explantation of the devices or sedation without gastroscopy to maintain blinding. Main exclusion criteria are malignant diseases, peptic ulcer or previous bariatric intervention. Weight loss 12 months after explantation of the devices, changes in comorbidities, quality of life, complication rates and safety will be evaluated.

Discussion

This trial could help to identify the most effective and safest endoscopic device, thus determining the new standard procedure for endoscopic bariatric treatment.

Trial registration

16th January 2017. DRKS00011036. Funded by the German Research Foundation (DFG).

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project]

Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

Traveler's Diarrhea, vision abnormalities and unsteady gait in a young woman

We report on the course of disease in a young woman, originally admitted with suspected refractory infectious tropical traveler's diarrhea. However, symptoms did not resolve upon either symptomatic or subsequent antibiotic therapy. When neurologic deterioration was observed, imaging studies revealed a dramatic series of thromboembolic events, including intracranial hemorrhage caused by extensive sinus vein thrombosis as well as thrombi of the right cardiac ventricle. Colonic mucosal biopsy samples finally led to the histologic diagnosis of ulcerative colitis. Having excluded thrombophilia or any other disease potentially related to a prothrombotic state, we interpreted the thromboembolic events as secondary to the primary manifestation of the underlying inflammatory bowel disease.The increased risk of thromboembolic complications-especially deep vein thrombosis and pulmonary embolism-in inflammatory bowel disease is well documented in the literature. However, sinus vein thrombosis and cardiac thrombi represent a remarkable dimension of this risk and a rare course of coagulopathy secondary to an acute flare of ulcerative colitis. Still, there is a lack of awareness of this risk, resulting in poor implementation of preventive measures modifying risk factors and allowing for pharmacological prophylaxis. We therefore emphasize that-in line with the 2014 German S3 Guideline-thromboprophylaxis in the setting of an acute flare of inflammatory bowel disease is mandatory and should not be restricted because of safety concerns.

Seventy-two Cycles of FOLFIRINOX: Long Term Treatment in a Patient with Metastatic Adenocarcinoma of the Pancreatic Tail

CONTEXT

Pancreatic adenocarcinoma is one of the most lethal malignancies worldwide. In patients with unresectable tumor there are several strategies of palliative chemotherapy, either gemcitabine based regimens or FOLFIRINOX, which is supposed to be most efficient but also most toxic. Hence, management of toxicity is crucial to perform a therapy consisting of FOLFIRINOX.

CASE REPORT

We report on a 69-year-old female patient suffering from adenocarcinoma of the pancreatic tail with multiple liver metastases. Palliative chemotherapy comprising leucovorin, fluorouracil, oxaliplatin and irinotecan (FOLFIRINOX) was initiated in February 2011 and was tolerated very well. Subsequent computed tomography-scans showed significant reduction of the tumor load in the liver as well as in the primary pancreatic tumor. The serum levels of the tumor marker CA 19-9 were elevated initially and decreased concomitantly. Thus, chemotherapy was continued for more than 3 years, and up to 72 cycles were administered until April 2014. Due to intermittent neutropenia and mucositis the initial dose was reduced to 60% of the calculated standard dose. In April 2014, an intermediate staging by computed tomography and FDG-PET revealed significant reduction of the size of the primary pancreatic tumor compared with February 2011. Liver metastases could hardly be detected anymore. After pausing chemotherapy for 12 weeks, one liver metastasis reappeared and was treated by RFA in August 2014. Meanwhile, in October 2014 there is no radiological evidence on any existing tumor or metastasis.

CONCLUSION

Our report demonstrates that a sufficient tolerance of chemotherapy with FOLFIRINOX is achievable, what makes a long term treatment with FOLFIRINOX feasible and can lead to impressive results.

Neuroendocrine pancreatic carcinoma after initial diagnosis of acute postpartal coeliac disease in a 37-year old woman - fatal coincidence or result of a neglected disease?

An acute presentation after pregnancy of coeliac disease (CD) in the puerperium is a rare condition which has been described mostly in primigravidae in patients highly suspicious of latent CD. We report the case of a 37-year-old woman who was referred to our Hospital because of refractory watery diarrhea and malnutrition syndrome. Endoscopy of the upper gastrointestinal tract revealed the classic visual features of CD and in addition, some duodenal ulcers negative for Helicobacter pylori, which seems to be another clinical feature in patients with CD. The diagnosis of acute onset of fulminant postpartal CD (Marsh score stage 3c) was confirmed histologically. Remarkably, simultaneous well-differentiated neuroendocrine non-functioning pancreatic neuroendocrine carcinoma (PNET) was diagnosed on radiological abdominal imaging which was performed since serum gastrin was remarkably high, treated by distal pancreatectomy and splenectomy. This report is, to our knowledge, the first description of the two entities, CD and PNET occurring together. Since results of antral histological studies showed diffuse hyperplasia of G-cells, probably in response to hypergastrinaemia, enterochromaffin cell carcinogenesis might have served as a possible link between both diseases.

Clinical manifestations and treatment options in patients with cirrhosis and diabetes mellitus

BACKGROUND

Diabetes is frequently diagnosed in patients with cirrhosis and represents an important risk factor for morbidity and mortality. Pharmacological therapy is limited due to hepatotoxicity and the risk of hypoglycemia. Investigations on medical practice in this patient population, frequency of diabetes-associated complications and the impact of quality of metabolic control are rare.

AIMS AND METHODS

A retrospective analysis was performed to compare the effects of hypoglycemic treatment, the achieved glycemic control under therapy, the prevalence of typical cirrhosis-related or microangiopathic complications, and cardiovascular comorbidities between a group of diabetic patients with cirrhosis (n = 87) and a nondiabetic cirrhotic population (n = 198).

RESULTS

The prevalence of diabetes in our cohort was 30.5%. Of all diabetic patients, 39.1% received therapy which might potentially result in serious side effects in patients with end-stage liver disease. The rate of ongoing alcohol abuse (28.7%) and noncompliance under medication (41.4%) was high. Only 28.7% of all diabetic subjects showed satisfactory (as defined by HbA1c ≤ 6.5%) glycemic control under therapy. Patients achieving satisfactory control experienced a lower rate of certain cirrhosis-related complications such as hepatic encephalopathy (HE) and hepatocellular carcinoma (HCC), arterial hypertension, and hypercholesterolemia. HE was significantly more frequent in diabetic than nondiabetic cirrhotic patients.

How to diagnose hepatic encephalopathy in the emergency department

INTRODUCTION

Blood ammonia-measurements are often performed in the emergency departments to diagnose or rule out hepatic encephalopathy (HE). However, the utility and correct interpretation of ammonia levels is a matter of discussion. At this end the present prospective study evaluated whether blood ammonia levels coincide with HE which was also established by the West Haven criteria and the critical flicker frequency, respectively.

MATERIAL AND METHODS

In 59 patients with known cirrhosis ammonia-levels were determined and patient were additionally categorized by the West-Haven criteria and were also evaluated psychophysiologically using the critical flicker frequency, CFF for the presence of HE.

RESULTS

When false positive and false negative results were collapsed the determination of blood ammonia levels alone resulted in 40.7% in a misdiagnoses of HE compared to the West-Haven criteria (24/59 when using West-Haven criteria, 95% confidence interval [CI], 28.1% to 54.3%) and 49.2% when compared with the results of the CFF (29/59, when using CFF, 95% CI, 35.9% to 62.5%).

DISCUSSION

Ammonia blood levels do not reliably detect HE and the determination of blood ammonia can not be regarded a useful screening test for HE. Its use as sole indicator for a HE in the Emergency Department may frequently result in frequent misinterpretations.

Accuracy of anorectal manometry in patients with fecal incontinence

BACKGROUND/AIM

Patients with fecal incontinence (FI) have lower anal resting (MRP) and squeeze (MSP) pressure and an impaired sensitivity compared to healthy people. However, whether anorectal manometry (ARM) can separate precisely between health and disease is discussed controversially. The aim was to evaluate the accuracy of ARM in a huge cohort of patients and controls.

METHODS

ARM was obtained in 144 controls and in 559 FI patients. MRP, MSP, and balloon volume at first perception (BVP) and urge sensation (BVU) were determined. Receiver operating curve analysis was used to determine optimal cut-offs and sensitivity, specificity and accuracy calculated.

RESULTS

FI patients showed lower MRP, MSP, BVU (p < 0.001) and a higher BVP (p = 0.007). Deterioration of the ARM parameter increased with FI severity. ARM demonstrated an excellent sensitivity (91.4%) and accuracy (85.8%), but only a moderate specificity (62.5%). The sensitivity of ARM rose with FI severity. The pressure data showed higher sensitivity and accuracy than the sensory data despite comparable specificity.

CONCLUSIONS

Sensitivity and accuracy of single ARM parameters is only moderate for the pressure data and poor for the sensory data. In contrast, ARM demonstrated an excellent sensitivity, a moderate specificity, and a convincing accuracy justifying its use in clinical routine.

The effect of osmolarity and caloric load on small bowel motility

BACKGROUND

Although there is profound knowledge about cyclic fasting motility, the postprandial intestinal motor response is not well investigated. It is intriguing to speculate that nutrient composition alters small bowel motility significantly and, in a clinical setting, may account for adverse gastrointestinal symptoms in enteral nutrition (EN). We aimed to assess the impact of different caloric loads and osmolarities of EN on human jejunal motility.

METHODS

Sixteen healthy subjects underwent a series of duodenal infusions of EN solutions, either with iso-osmolar solution with different caloric loads (1.32, 2.64, or 3.96 kcal min(-1)), or with solutions of different osmolarities with constant caloric loads (300, 600, or 1200 mosmol). Jejunal solid-state manometry was analyzed over 90 min both visually and using dedicated computer software.

KEY RESULTS

All tested nutrient solutions were able to trigger conversion to a postprandial jejunal motility pattern after a mean lag phase of 9.4 + 2.3 min (P = NS between different nutrient solutions). Different caloric loads did not result in significant differences in small bowel motility. However, increasing osmolarities caused a significant inhibition of contractile and propagative activity.

CONCLUSIONS & INFERENCES

Small bowel motility under duodenal infusion of nutrient solutions is not influenced by caloric load in a physiological range, whereas high osmolarities inhibit small bowel motility.