[Injuries in Karate Sports: A Survey Performed During the World Championship 2014]

Background: In literature, the competitive sport of modern karate is almost always characterised as a combat sport involving injuries caused by impact effects and physical contact with opponents. There is a lack of data regarding the outcome after karate injuries, specifically with a view to the contact-free Kata karate. Methods: Performing a random test using a questionnaire, we collected data concerning regular medical treatment, prior surgeries of the locomotor system, and medical care. This study included 300 athletes from 65 countries (average age: 24.1 years; 176 male, 124 female) participating in the Karate World Cup 2014. Seven participants competed in both disciplines, 87 only in the Kata discipline, and 206 only in Kumite (the discipline involving physical contact with opponents). The statistical analysis was performed using a two-sided Chi-square test and the Fisher's exact test. Results: Recurrent medical treatment was most commonly required for the knee region (Kata 28.7 %, Kumite 26.7 %). In Kata the shoulder region came second (22.9 %), in Kumite the ankle region (21.8 %), followed by hand and foot in both groups. Medical treatment of the elbow area was more frequent in the Kata Group (p = 0.033), while in Kumite athletes' hand (p = 0.002) and foot injuries (p = 0.007) prevailed. Prior surgeries of athletes of both disciplines most commonly concerned the knee, followed by the ankle region in the Kata group and by the hand and head region in the Kumite group. Statistically significant differences between the two disciplines were found in head injuries (p = 0.004), which commonly do not occur in the Kata discipline. During the World Cup, 56.0 % of the athletes had no individual medical care and 24.6 % received no sports-related medical care in their home countries. Conclusion: Although the risk of injuries in Kumite Karate has been reduced by the introduction of gumshields, hand and foot protectors as well as a reform of the scoring system, the potential for chronic physical damage should not be underestimated. Since in athletes competing in the Kata discipline the rate of surgeries and injuries is only slightly lower than in the Kumite group, Kumite Karate may be regarded as a martial arts competitive sport with a relatively low risk of injuries. In contrast, the risk of chronic musculoskeletal damage in Kata athletes seems to be underestimated thus far. Suggested improvements concern the training techniques and conditions (i. e. the tatami material), and there is a need for regular medical care, including preventative care, to be provided for these athletes.

Ultrasonography for acute appendicitis - the way it looks today

Despite sophisticated physical examination and laboratory support, diagnosis of acute appendicitis remained challenging in clinical practice with a negative appendectomy rate of 15 - 30 %. As a remarkable clue and as early as 1986, ultrasonography (US) has been proven a reliable diagnostic method that is also explicitly helpful in difficult cases with atypical presentation and enables to rule out many differential diagnoses.Recent publications emphasized the role of multidetector computed tomography (CT) resulting in a significant reduction of false negative findings at operation. Extensive as well as uncritical application of this method even in children inevitably causes substantial radiation exposure, a sequel to either pure ignorance or unqualified/inadequate performance of US in this particular situation, which in turn can be considered sequel to either egocentric or economic preponderance.Recent data shed new light on the role of US (and CT) in acute appendicitis. Therefore, 1 generation after US with graded compression was etched in stone as the method of choice for diagnosing acute appendicitis (Puylaert), a visual arousal fostering its role and performance in clinical medicine appears justified.

Intestinal Ultrasound in Rare Gastrointestinal Diseases, Update, Part 2

Intestinal ultrasound has become an established and valid diagnostic method for inflammatory bowel disease, diverticulitis, appendicitis, bowel obstruction, perforation and intussusception. However, little is known about sonographic findings in other rarer intestinal diseases. Ultrasound may display the transformation of the intestinal wall from a normal to a pathological state both in inflammatory and neoplastic disease. Besides demonstrating the transmural aspect, it also shows the mesenteric reaction as well as complications such as fistula, abscesses, stenosis, or ileus. Furthermore, in some diseases intestinal ultrasound may serve as a diagnostic clue if typical patterns of the bowel wall and impaired peristalsis can be demonstrated. This may lead to an important reduction of invasive and expensive (follow-up) procedures. The information gained by ultrasound regarding intestinal disease, however, is as important and valid as e. g. in case of focal lesions of the liver. Serving as tertiary referral centers for a broad spectrum of intestinal diseases, we therefore report some aspects of ultrasound in patients with less often recognized diseases. The article is divided into two parts, the first focusing on examination techniques, infectious diseases and celiac sprue and the second on hereditary, vascular and neoplastic diseases and varia.

[Differential diagnosis of diarrhoea]

Diarrhoea is a common symptom and numerous differential diagnoses must be considered. This article illustrates approaches for a rational and efficient work-up based on practical facilities in acute diarrhoea and fostered by 4 key questions scrutinising chronic diarrhoea. The applications of imaging methods (endoscopy, ultrasonography) are discussed along with infectious topics and function testing. The aim of this contribution is to help patients to get a precise diagnosis in a most rational way. This implies a transparent and targeted medical strategy, avoiding selective intuitions ("trial and error") as well as extensive diagnostic overdoing in the case of only putative diarrhoea. Knowing the potential of diagnostic methods which are (or can) possibly not performed regularly in the physician's office, and their requirements/limitations is an important component in this situation. The basic fundament for application of such methods, however, and the clue to economic diagnosis as well as the differential diagnosis of diarrhoeal diseases are the history and simple tests.

13C-breath tests: current state of the art and future directions

13C-breath tests provide a non-invasive diagnostic method with high patient acceptance. In vivo, human and also bacterial enzyme activities, organ functions and transport processes can be assessed semiquantitatively using breath tests. As the samples can directly be analysed using non-dispersive isotope selective infrared spectrometers or sent to analytical centres by normal mail breath tests can be easily performed also in primary care settings. The 13C-urea breath test which detects a Helicobacter pylori infection of the stomach is the most prominent application of stable isotopes. Determination of gastric emptying using test meals labelled with 13C-octanoic or 13C-acetic acid provide reliable results compared to scintigraphy. The clinical use of 13C-breath tests for the diagnosis of exocrine pancreatic insufficiency is still limited due to expensive substrates and long test periods with many samples. However, the quantification of liver function using hepatically metabolised 13C-substrates is clinically helpful in special indications. The stable isotope technique presents an elegant, non-invasive diagnostic tool promising further options of clinical applications. This review is aimed at providing an overview on the relevant clinical applications of 13C-breath tests.

Antibiotic-associated diarrhea: therapeutic aspects and practical guidelines--an interdisciplinary approach to a common problem

Antibiotic-associated diarrhea (AAD) is a common complication of antibiotic treatment, most often seen in non-hospitalised patients. In principle, such diarrhea can be triggered by any antibiotic. An interdisciplinary working group discussed the different aspects of AAD in view of its gastroenterological, microbiological, paediatric, general medical and pharmaceutical implications, also in consideration of the position of patients and health insurance funds. This paper implies therapeutic aspects and practical guidelines to raise awareness of these problems also in routine situations and to enable the persons and institutions involved on the various levels of the health-care system (patients, pharmacists, family doctors, specialists and hospitals) to handle the problem of AAD more easily in a standardised way as far as diagnostics, therapy and prevention are concerned.

Antibiotic-associated diarrhea: incidence, risk factors of antibiotics and patients, pathophysiology and differential diagnosis--an interdisciplinary approach to a common problem

Antibiotic-associated diarrhea (AAD) is a common complication of antibiotic treatment, most often seen in non-hospitalised patients. In principle, such diarrhea can be triggered by any antibiotic. An interdisciplinary working group discussed the different aspects of AAD in view of its gastroenterological, microbiological, paediatric, general medical and pharmaceutical implications, also in consideration of the position of patients and health insurance funds. The incidence, risk factors of antibiotics and patients, the pathophysiology of the various types of AAD and the differential diagnosis are reviewed.

Increased serum bone sialoprotein concentrations in patients with Crohn's disease

INTRODUCTION

Impaired calcium homeostasis and/or the administration of corticosteroids are considered to be among the factors contributing to the pathogenesis of osteopenia in patients with inflammatory bowel disease. There is an increasing evidence suggesting that certain pro-inflammatory cytokines may also directly influence the bone metabolism in these patients. Routine measurement of bone mass and loss usually include dual energy X-ray absorptiometry as well as urinary and serum assessment of collagen crosslinks. More recent studies include likewise the detection of bone sialoprotein into a specific diagnostics of bone turnover.

PATIENTS AND METHODS

We investigated 47 patients with inflammatory bowel disease (Crohn's disease N = 41, ulcerative colitis N = 6) and 17 healthy volunteers to assess and compare serum levels of bone sialoprotein and other routine parameters of bone turnover. Bone sialoprotein levels were measured by using a recently described radioimmunoassay.

RESULTS

In comparison to the control group, bone sialoprotein and urinary crosslinks were significantly increased only in patients with Crohn's disease, while other markers of bone turnover (e. g. alkaline phosphatase, carboxylterminal propeptide of typ I procollagen, urinary deoxypyridinoline, vitamin D, phosphate and calcium) did not differ significantly between the patients' groups.

CONCLUSION

According to these data, increased serum bone sialoprotein concentrations seem to be an additional valuable and sensitive marker of bone resorption in patients with Crohn's disease.

[Colorectal cancer and folate]

Nutritional factors are important contributors to colorectal cancer prevention. There is some evidence to suggest that a high dietary folate intake is associated with a reduced risk of colorectal cancer. Folate, which is found in green leafy vegetables, is involved in C1 group transfer and contributes to purin and thymi-dilate synthesis as well as to DNA methylation. Alterations in gene expression and DNA damage are discussed to result from low folate levels and might be associated with an elevated risk of colorectal malignancies. This hypothesis can be supported by the finding that a common polymorphism in the methylentetrahydrofolate reductase gene enhances the risk of colorectal cancer when folate status is low. Both retrospective and prospective epidemiologic studies confirm the observation that a high intake of folate correlates with a lower risk of colorectal cancer. There is also evidence from epidemiological studies that diets which are low in methyl donors, such as low contents of folate and/or methionine combined with relatively high alcohol consumption, even enhance the risk of colorectal cancer. A small number of intervention trials provide first evidence that folate intakes far above recommended dietary allowances might influence possible biomarkers of colorectal tumours.

Long-term cisapride treatment improves diabetic gastroparesis but not glycaemic control

BACKGROUND

In patients with diabetic gastroparesis, delayed food delivery to the intestine may become a major obstacle to post-prandial glycaemic control.

AIM

To investigate whether cisapride accelerates gastric emptying in the long term or improves diabetes control in patients with diabetic gastroparesis.

METHODS

Eighty-five patients with long-standing insulin-dependent diabetes mellitus (glycosylated haemoglobin (HbA1c) > 7.0%), dyspepsia and diabetic neuropathy were tested for impaired gastric emptying of solids by the 13C-octanoate breath test. Nineteen of these patients with severe diabetic gastroparesis (i.e. t1/2 > 170 min) were randomly treated with 10 mg cisapride t.d.s. (n=9) or placebo (n=10) for 12 months. Thereafter, the breath test, dyspeptic symptoms and HbA1c values were reassessed.

RESULTS

Half emptying times in nine patients with diabetic gastroparesis were significantly shortened by cisapride (175 +/- 46 min vs. 227 +/- 40 min; P < 0.03). Half emptying times in the 10 patients taking placebo did not change (205 +/- 37 min vs. 211 +/- 36 min, P=0.54). Cisapride significantly reduced dyspepsia (score: 4.1 +/- 1.6 vs. 2.0 +/- 0.5, P=0.002). HbA1c values after 12 months of treatment were not different (cisapride: 7.7 +/- 0.4% vs. 7.6 +/- 0.9%, P=0.76; placebo: 7.5 +/- 0.6% vs. 7.6 +/- 1.5%, P=0.89).

CONCLUSIONS

Prokinetic treatment with cisapride accelerates gastric emptying of solids and improves dyspeptic symptoms in diabetic gastroparesis. Glycaemic control, however, is not affected by cisapride.

Correlation between sphincter of Oddi manometry and intraductal ultrasound morphology in patients with suspected sphincter of Oddi dysfunction

BACKGROUND AND STUDY AIMS

Intraductal ultrasonography (IDUS) makes it possible to study sphincter of Oddi morphology during endoscopy. Two recent IDUS studies have described the sphincter of Oddi as a circumferential hypoechoic layer in the papilla, but there have as yet been few published data from patients with suspected sphincter of Oddi pathology.

PATIENTS AND METHODS

Twenty-one consecutive patients with suspected biliary sphincter of Oddi dysfunction (seven men, 14 women; age 54 +/- 17 years) were enrolled in the study. Endoscopic sphincter of Oddi manometry was carried out using a 4-Fr electronic microtransducer device. After this, a wire-guided 6-Fr ultrasound catheter was placed in the common bile duct (CBD), and IDUS was carried out while the ultrasound catheter was being withdrawn from the CBD toward the duodenum.

RESULTS

Sphincter of Oddi manometry and IDUS were carried out successfully in 18 of the 21 patients. Sphincter of Oddi manometry revealed sphincter of Oddi hypertension (baseline pressure > 35 mmHg) in eight patients. The mean sphincter of Oddi baseline pressure was 32 +/- 17 mmHg, and the mean phasic sphincter of Oddi pressure was 132 +/- 31 mmHg. During IDUS, a circumferential hypoechoic layer was clearly delineated in all patients. There was a significant correlation between the manometrically determined length of the sphincter of Oddi (8 +/- 2 mm) and the thickness of the hypoechoic layer (6 +/- 2 mm) as assessed by IDUS (r = 0.66, P < 0.001). However, no correlation was found between the baseline or phasic sphincter of Oddi pressures and the thickness of the hypoechoic layer. Accordingly, IDUS did not allow identification of patients with sphincter of Oddi hypertension. Mild pancreatitis was observed in one of the 18 patients (6 %).

CONCLUSIONS

The circumferential hypoechoic layer of the papilla visualized by IDUS is the ultrasonographic correlate of the sphincter of Oddi. IDUS of the papilla is technically feasible and safe in patients with suspected sphincter of Oddi dysfunction. IDUS may provide additional information at the sphincter of Oddi level, but cannot be used as a substitute for sphincter of Oddi manometry.

Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter of Oddi dysfunction

AIM

To evaluate the technical feasibility, safety, and short-term efficacy of botulinum toxin injection for pancreatic sphincter of Oddi dysfunction and to analyse whether the symptomatic response to botulinum toxin might be a predictor of outcome for endoscopic sphincterotomy.

METHODS

Fifteen consecutive patients (nine female, aged 38 +/- 12 years) with frequent attacks (median four) of acute pancreatitis within 6 months, and manometrically proven pancreatic sphincter of Oddi dysfunction underwent endoscopic injection of 100 units of botulinum toxin into the major papilla. All patients underwent prospective follow-up thereafter and in cases of recurrent pancreatitis manometry this was repeated and pancreatic sphincterotomy was performed.

RESULTS

No side-effects occurred after botulinum toxin injection in any patient. Within 3 months after botulinum toxin treatment, 12 out of 15 patients remained asymptomatic (80% primary response). Only one out of three patients without symptomatic benefit showed continued elevated pancreatic sphincter pressure at manometry and only this patient benefited from pancreatic sphincterotomy later on. Eleven of the 12 patients initially responding to botulinum toxin injection developed a symptomatic relapse 6 +/- 2 months after botulinum toxin treatment. These patients then achieved long-term clinical remission from pancreatic or combined (biliary and pancreatic, n=5) sphincterotomy (median follow-up, 15 months).

CONCLUSION

Endoscopic botulinum toxin injection into the papilla of Vater is a safe procedure for treatment of pancreatic sphincter of Oddi dysfunction that may provide short-term relief in about 80% of the patients. Those patients who respond to botulinum toxin may subsequently gain definitive cure from sphincterotomy.

Differential expression of human alpha- and beta-defensins mRNA in gastrointestinal epithelia

BACKGROUND

While defensins have received great attention for their role in bronchial innate immune defence, little is known about the expression levels of the four human epithelial defensins (HD5, HD6, hBD1 and hBD2) in the digestive tract. In this study we quantified the alpha- and beta-defensins mRNA in biopsies obtained from the gastrointestinal mucosa and identified the cells expressing the beta-defensin hBD1 mRNA in ileal mucosa.

MATERIAL AND METHODS

Biopsies from human stomach (corpus and antrum), duodenum, jejunum, ileum and colon were analysed for their expression of alpha- and beta-defensins. The mRNA of defensins was quantified by semiquantitative reverse transcription-polymerase chain reaction. Cells expressing beta-defensin hBD1 mRNA were identified by in situ hybridization with 35S-labelled RNA probes in tissue sections of human ileum.

RESULTS

The hBD1 mRNA was expressed at low levels with little variability throughout the gastrointestinal tract and was detected in all epithelial cells of ileal mucosa. HD5 and HD6 mRNA expression was restricted to the intestine and displayed high interindividual variability. The highest expression levels were observed in jejunum and ileum. Biopsies obtained from duodenum displayed low levels or no expression of HD5 and HD6. The expression level increased considerably in a biopsy obtained from a patient with acute coeliac sprue. In contrast, low levels were observed in a biopsy from a patient with coeliac sprue in remission.

CONCLUSIONS

The expression levels of hBD1, HD5 and HD6 throughout the gastrointestinal tract are tissue and peptide specific and these defensins are expressed with high interindividual variability.

[Ultrasound diagnosis of penicillin-induced segmental hemorrhagic colitis]

INTRODUCTION

Penicillin-induced segmental haemorrhagic colitis (SHC) is a characteristic and striking but rarely diagnosed clinical entity. Bloody diarrhea and abdominal cramps start a few days after the intake of oral penicillin derivatives. We report the ultrasonographic and clinical findings in nine patients with SHC and compare the results with the findings in ten patients with antibiotic-related pseudomembranous colitis (PMC).

METHODS

Nine consecutive patients with SHC (age: 32 +/- 10 years; five males, four females) with PMC-negative proctoscopic findings, stool cultures and negative clostridium difficile toxin and ten patients with PMC (age: 50 +/- 18 years; six males, four females) with positive proctoscopy and Clostridium difficile toxin were clinically evaluated and examined by high resolution ultrasonography. The sonographic findings of the colonic and small bowel walls as well as the clinical course of the diseases were documented.

RESULTS

In all nine patients with SHC the wall of the ascending colon was asymmetrically thickened with loss of layer structure. Neither the small bowel nor the cecum were involved in patients with SHC. In all cases a distinct border between involved and uninvolved colon wall was found. During follow-up all patients recovered soon after stopping antibiotic treatment and symptomatic care. In seven of ten patients with PMC pancolitis and in three of ten with left-sided colitis were found at ultrasonography. In all patients with PMC the bowel wall was symmetrically thickened with the layers remaining distinct.

DISCUSSION

The knowledge of the clinical characteristics and sonographic findings of penicillin-induced segmental haemorrhagic colitis may reduce the need for invasive endoscopic and radiological investigations in diagnosis and follow-up. The age of patients, clinical course and sonographic findings may be helpful in differentiating patients with SHC and PMC.

[Intestinal B-mode sonography in patients with endemic sprue. Intestinal sonography in endemic sprue]

AIM

The value of ultrasonography in the diagnosis, follow-up and for the detection of complications in patients with celiac sprue has not yet been sufficiently evaluated. A pronounced back and forth motility with echo-rich hump reflexes in a fluid-filled small bowel with a reduction of Kerckring's plicae circulares and with a loss of their density and uniformity was empirically defined as a diagnostic sign of celiac sprue. In the present study, the sonographic signs of celiac sprue were examined as an indicator of active sprue.

METHOD

50 patients with histologically proven celiac sprue were examined with real time ultrasonography (3.5-7 MHz). The detection or exclusion of the defined sonographic signs of celiac sprue with intensified motility and reduction of Kerckring's plicae circulares with a loss of their density and uniformity were evaluated by two independent examiners and documented without knowledge of the clinical findings. The clinical activity (active vs. remission) was assessed according to clinical criteria (diarrhea, steatorrhea, weight loss). 38 healthy subjects and 50 patients with Crohn's disease served as controls.

RESULTS

In all 138 patients and controls adequate visualization of the bowel was achieved. In 16/50 (32%) patients with active celiac sprue changes of motility and reduction of Kerckring's plicae circulares with a loss of their density and uniformity were detected, whereas all 34/50 (68%) of patients with celiac sprue in remission did not have this pattern. In none of the controls with Crohn's disease or in the healthy subjects comparative sonographic signs of active celiac sprue were observed. In four patients with active celiac sprue a circumscript echopoor tumor of the small bowel wall could be sonographically detected, which turned out to be T-cell lymphoma in three and a carcinoma of the small intestine in one patient. An increased number of and/or enlarged mesenteric lymph nodes were found in patients with active celiac sprue.

CONCLUSION

Changes of motility and reduction of Kerckring's plicae circulares with loss of density and uniformity at ultrasonography are a reliable indicator of active celiac sprue.

Sphincter of Oddi dysfunction after successful gallstone lithotripsy (postlithotripsy syndrome): manometric data and results of endoscopic sphincterotomy

After successful gallstone lithotripsy, biliary pain recurs in about one third of patients. However, gallstone recurrence can be shown in only 40-60% of these patients. Therefore, other causes, such as sphincter of Oddi dysfunction (SOD), may be suspected. Twenty-two consecutive patients with recurrent biliary pain after successful gallstone lithotripsy without evidence of gallstone recurrence at ultrasonography were enrolled. Liver tests were elevated in 13 patients and ERC showed a dilated bile duct in nine. All 22 patients underwent sphincter of Oddi (SO) manometry, bile sample analysis for microlithiasis, endoscopic sphincterotomy (ES), and bile duct exploration with a Dormia basket. Thereafter, the patients were clinically followed at bimonthly intervals. SO manometry revealed SOD in 15/22 patients. This was more often the case in patients with initially larger (>2 cm) or multiple stones than after lithotripsy for solitary small stones (P < 0.01). Microlithiasis was detected in one patient, another patient had small biliary calculi at bile duct exploration (both without SOD). After ES, 14/15 patients with biliary SOD but none of the five without SOD improved (median follow-up: two years; P < 0.01). The one patient with CBD stones became symptom-free after ES, while the patient with microlithiasis improved after additional cholecystectomy only. Overall, ES proved to be the adequate therapy in 15/22 patients (68%, median follow-up: 22 months). After gallstone lithotripsy, SOD is found in about two thirds of patients with recurrent symptoms but without gallstone recurrence. In this group CBD stones or microlithiasis are rare. Therefore, SOD has to be suspected in this situation and ES gives favorable results, even when performed on a clinical basis only (without SO manometry).

Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study

BACKGROUND

Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The short-acting anesthetic propofol offers certain potential advantages for endoscopic procedures, but controlled studies proving its superiority over benzodiazepines for ERCP are lacking.

METHODS

During a 6-month period 198 consecutive patients undergoing routine ERCP randomly received either midazolam (n = 98) or propofol (n = 99) for sedation. Vital signs (heart rate, blood pressure, oxygen saturation) were continuously monitored and procedure-related parameters, the recovery time and quality (recovery score) as well as the patient's cooperation and tolerance of the procedure (visual analog scales) were prospectively assessed.

RESULTS

Patients receiving propofol or midazolam were well matched with respect to demographic and clinical data, ERCP findings, and the performance of associated procedures. Propofol caused a more rapid onset of sedation than midazolam (p < 0.01). Clinically relevant changes in vital signs were observed at comparable frequencies with temporary oxygen desaturation occurring (< 85 %) in 6 patients in the propofol group and 4 patients receiving midazolam (not significant). However, an episode of apnea had to be managed by mask ventilation via an ambu bag (lasting 8 minutes) in one of the patients receiving propofol sedation. Mean recovery times as well as the recovery scores were significantly shorter with propofol (p < 0. 01). Propofol provided significantly better patient cooperation than midazolam ( p < 0.01), but procedure tolerability was rated the same by both groups of patients (not significant).

CONCLUSIONS

Intravenous sedation with propofol for ERCP is (1) more effective than sedation with midazolam, (2) safe under adequate patient monitoring, and (3) associated with a faster postprocedure recovery.

Long-term results of endoscopic injection of botulinum toxin in elderly achalasic patients with tortuous megaesophagus or epiphrenic diverticulum

BACKGROUND AND STUDY AIMS

Recent studies suggest that endoscopic injection of botulinum toxin (BTX) for achalasia is a safe procedure giving short-term relief of symptoms mainly in elderly patients (> 50 years). The aim of the study was to evaluate the clinical efficacy of periodic BTX treatments in high risk achalasia patients.

PATIENTS AND METHODS

A total of 20 consecutive achalasia patients, aged > 60 years (11 women; 71+/-11 years), with general (ASA class III or IV) and local risk factors (i.e. tortuous megaesophagus or epiphrenic diverticulum) for complications associated with pneumatic dilation, were treated by local injection of 100 U of BTX into the gastric cardia, using the four-quadrant technique. The patients were prospectively followed for a median period of 2 years (range 5-48 months), using a symptom score (1-14 points) and barium esophagograms.

RESULTS

Symptomatic improvement (decrease of the symptom score > or = 3 points) was found in 16/20 patients (80%), 6 weeks after the first BTX injection, and the cardia diameter increased from 2.1+/-0.7 to 3.2+/-1.2 mm (P < 0.01) (data are means +/- SD). Those patients who initially responded to BTX treatment developed a symptomatic relapse after a median follow-up of 5+/-2 months. They were treated by subsequent BTX re-injections (2.5+/-1 sessions per patient, range 1-5) resulting in longer lasting symptom relief (10+/-3 months, P < 0.05 vs. initial BTX injection). At completion of the study, 14/20 high risk achalasia patients (70 %) treated with periodic BTX injections are still in clinical remission. One further patient died without relapse 6 months after a single BTX treatment as a consequence of progressive heart failure. Four patients who did not respond to BTX injection were successfully and uneventfully treated by careful pneumatic dilation (n = 3) or percutaneous endoscopic gastrostomy (n = 1).

CONCLUSION

Endoscopic botulinum toxin injection has reasonable long-term efficacy and safety in elderly achalasia patients who are at increased risk with regard to pneumatic dilation.

Nondispersive infrared spectrometry for 13CO2/12CO2-measurements: a clinically feasible analyzer for stable isotope breath tests in gastroenterology

BACKGROUND

13C-urea breath tests have become clinical routine for the diagnosis of Helicobacter pylori infection and other isotope breath tests have been invented e.g. for gastric emptying or quantitative liver function testing. Recently, isotope-selective nondispersive infrared spectrometers (NDIRS) have been developed for the analysis of the 13CO2/12CO2-enrichment in breath. In this study, we prospectively tested the validity of a newly developed NDIRS in comparison to isotope ratio mass spectrometry (IRMS).

METHODS

142 patients 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 0.28 +/- 1.93 delta/1000. Evaluating the qualitative urea breath test results in reference to IRMS as the reference the NDIRS had a sensitivity of 97.8% and a specificity of 98.9%.

CONCLUSION

The isotope-selective nondispersive infrared spectroscopy is going to become a reliable, but low-cost and easy-to-operate alternative to expensive isotope ratio mass spectrometry in the analysis of 13C-breath tests.

[Analysis of hepatic echo patterns in chronic hepatitis C]

AIM

Patients with chronic hepatitis C often present a bright echopattern of the liver. Our aim was to examine the relationship of the sonographic echotexture of the liver in relation to the histological findings in patients with chronic hepatitis C without cirrhosis.

METHODS

The livers of 68 patients with chronic hepatitis C (40 male, 28 female, age: 39 +/- 9 years) were evaluated by high resolution ultrasound equipment (3.5 and 5 MHz). Histologic specimens were obtained at the same time. Grading and staging was performed according to the histological activity index. 70 healthy subjects (40 male, 30 female, age: 35 +/- 9 years, no histology) were examined as controls.

RESULTS

A bright sonographic echotexture of the liver was found in 26/68 (38%) patients with chronic hepatitis C, which correlated with the degree of fatty infiltration in the liver. Other parameters of the histological activity index showed no significant correlation with the echotexture of the liver. Hypoechoic areas in the liver hilus were detected in 24/26 (92%) patients with chronic hepatitis C and a bright echotexture of the liver. In 6/70 (9%) healthy subjects a bright sonographic echotexture could be detected.

CONCLUSION

Patients with chronic hepatitis C typically show a bright echotexture of the liver, which correlates mainly with the histological finding of fatty infiltration. A hypoechoic lesion next to the liver hilus is present in almost all patients with bright echotexture of the liver and is a sonographic sign of fatty infiltration of the liver, which might represent an area of less fat content and/or more fibrous tissue which could be due to different vasculature.

[Intestinal ultrasound in rare small and large intestinal diseases]

Intestinal ultrasonography is a meanwhile established and valid diagnostic method in inflammatory bowel disease, diverticulitis, and appendicitis. Little, however, is known about other more rare intestinal diseases. Serving as a tertiary referral center for a broad spectrum of intestinal diseases we therefore report some aspects of ultrasonography in patients with acute and chronic enteritis and colitis of different origin, e.g., bacterial and viral colitis, ileocecal tuberculosis, AIDS-related enteritis, neutropenic colitis, cystic fibrosis, celiac sprue, vasculitis, benign and malignant tumors of the intestine, amyloidosis, ischemic colitis, and radiogenic enteritis. Ultrasonography may display the transformation of the intestinal wall from normal to pathological states both in inflammatory and neoplastic disease. Besides demonstrating the transmural aspect of inflammation it also shows the mesenteric reaction as well as complications such as fistula, abscesses, stenosis, or ileus. Furthermore, in some diseases intestinal ultrasonography may serve as a diagnostic clue if typical patterns of the bowel wall and impaired peristalsis can be demonstrated. This may lead to an important reduction of invasive and expensive procedures. Ultrasonography is of definite help in the follow-up of inflammatory changes of the bowel wall and primarily diagnostic with respect of other entities (e.g., penicillin-induced segmental hemorrhagic colitis). A sonographic differential diagnosis of diseases of the bowel wall on a purely morphological basis, however, is difficult and rather the exception than the rule. The information gained by ultrasonography regarding intestinal disease, however, is as important and valid as e.g., in case of focal lesions of the liver.

Endoscopic injection of botulinum toxin for biliary sphincter of Oddi dysfunction

BACKGROUND AND STUDY AIMS

Endoscopic sphincterotomy is not without risks, and is also ineffective in about half of patients with type III sphincter of Oddi dysfunction (SOD), i.e. those without clinical evidence of biliary obstruction (normal liver tests, normal bile duct diameter, and regular drainage time at endoscopic retrograde cholangiography). The present study therefore investigated the efficacy and safety of endoscopic botulinum toxin (BTX) injection into the papilla of Vater, and analyzed whether the symptomatic response to BTX injection might be a predictor of outcome for endoscopic sphincterotomy.

PATIENTS AND METHODS

Twenty-two patients who had undergone cholecystectomy and had manometrically confirmed type III SOD were enrolled during a three-year study period. All patients received treatment with an endoscopic single-shot injection of 100 mouse units of BTX into the papilla of Vater. Initial symptomatic responses were analyzed six weeks later. If the BTX injection had been ineffective, or if biliary symptoms recurred after initial benefit during the follow-up period, endoscopic manometry and endoscopic sphincterotomy were performed. All patients then received further prospective clinical follow-up examinations.

RESULTS

With the exception of one patient with mild pancreatitis (4.5%), no side effects were observed after endoscopic BTX injection. Six weeks after BTX injection, 12 SOD patients (55%) were symptom-free, but ten patients (45%) were not. However five of these ten SOD patients who did not experience symptomatic benefit from BTX injection had normal basal sphincter of Oddi pressures (< 40 mmHg) at this time, and none of these five patients was free of complaints after subsequent endoscopic sphincterotomy. Two of the remaining five patients with sustained sphincter hypertension after BTX injection benefitted from endoscopic sphincterotomy. Eleven of the 12 SOD patients who had initially responded to BTX injection developed recurrent symptoms after a median period of six months. Manometry revealed sphincter hypertension in all 11 cases, and all patients became free of complaints again after endoscopic sphincterotomy during a median follow-up of a further 15 months. Overall, 11 of the 12 patients who responded to BTX injection, versus two of the ten patients who did not gain pain relief after BTX injection, later benefitted from endoscopic sphincterotomy (p < 0.01).

CONCLUSIONS

Endoscopic injection of botulinum toxin into the papilla of Vater is a safe procedure and provides short-term relief of symptoms in half of patients with type III SOD. Our results also indicate that the clinical response to BTX injection can predict whether SOD patients will gain long-term benefit from endoscopic sphincterotomy.

Risk of gastrointestinal bleeding associated with Helicobacter pylori infection in patients with hemophilia or von Willebrand's syndrome

BACKGROUND

Many episodes of bleeding in the upper gastrointestinal tract are caused by Helicobacter pylori infection. Because these episodes present a life-threatening complication in patients with bleeding disorders, we prospectively investigated the prevalence of H. pylori infection in patients with hemophilia A or B and with the von Willebrand syndrome.

METHODS

Seventy patients (54 men, 16 women, ages 40 +/- 11 years) and 100 age-related volunteers (63 men, 37 women, ages 39 +/- 9 years) were tested for H. pylori infection using the 13C urea breath test. Fifty-four patients with hemophilia and 16 patients with von Willebrand syndrome participated.

RESULTS

Thirty-three (33%) of the controls and 24 (34.3%) of the patients showed positive 13C urea breath tests (p = .97). Nineteen (35.2%) patients with hemophilia and 5 (31.3%) patients with von Willebrand syndrome were positive for H. pylori. History of dyspeptic symptoms (28% vs. 26%) were not different in patients and controls (p = .91). Gastric ulcers (20% vs. 5%) and duodenal ulcers (7% vs. 5%) were diagnosed more often in patients with bleeding disorders. Fourteen of the patients (20%), but none of the controls had a history of gastrointestinal bleeding (p < .001).

CONCLUSIONS

The rate of H. pylori infection and dyspepsia in patients with bleeding disorders is similar to the prevalence in the normal population. Due to increased bleeding complications, H. pylori screening and therapy appears mandatory in patients with bleeding disorders.

[Structure and quality of German-language gastroscopy information forms from the patients' viewpoint]

Information about procedure and risks is prerequisite for obtaining informed consent for endoscopy. This prospective and randomized investigation evaluated (i) the extent of patients' information needs and (ii) the formal quality (language, ease of understanding, length, figures etc.) of three information forms concerning upper CI-endoscopy issued in 1995 by DIOmed (1), perimed compliance (2), and PERIMED-spitta (3) as judged by the patients. (iii) Outcome quality was investigated as the influence of these forms on understanding why and how endoscopy was performed as well as the influence on feeling threatened. Furthermore patients' anxiety was assessed by using Spielberger's state-trait anxiety inventory (STAI). 218 patients completed the investigation (n = 73; 70; 75, respectively). 60% claimed the need for a detailed explanation of the planned endoscopy and 48% said they wanted exhaustive informations about potential complications and risks. The three forms (length 819, 771, 1,245 words) were entirely read by 87%, 89% and 82% of the patients. Positive language, adequate length (69%, 69%, 71%) and adequate layout were evenly attributed to the three forms. A high impact of the figures for understanding was found more frequently (48%, 46%, 35%) with (1) and (2) and language war regarded easy by 57%, 54% and 44%, respectively. Flesh's reading ease score, however, proved a sophisticated niveau of language with all three forms. The indication for endoscopy (37%, 49%, 56%) and explanation of performance (43%, 43%, 63%) was superior with (3). This form also reduced anxiety as judged by STAI-means, overall STAI-changes, and relevant changes (> or = 5 points). Form (2) increased patients' anxiety.

CONCLUSION

While the formal quality of all information forms is appreciated by patients both their reading ease score and figures should be improved. A significant reduction of anxiety can be achieved by appropriate selection of the information material.

Sonographic detection of focal changes in the liver hilus in patients receiving corticosteroid therapy

OBJECTIVE

While diffuse deposition of fat may occur with corticosteroid (CS) administration both in the liver and in other organs, comparatively little is known about focal changes in the liver under corticosteroid medication. Therefore, we evaluated pattern and extent of focal hepatic steatosis by ultrasound (US) in patients receiving corticosteroids.

SUBJECTS AND METHODS

93 patients with known inflammatory bowel disease (IBD) received corticosteroids during a period of at least six weeks prior to the ultrasound examination and 28 IBD-patients had no corticosteroids within the last three years. 13 additional patients received corticosteroids for other reasons than IBD for > 1 year. 80 healthy volunteers served as controls. Focal changes of the liver as assessed by high resolution ultrasound (Acuson 128, 3.5 and 5 MHz) were defined as areas of brighter echogenicity compared to the general aspect of the liver. The size of the hyperechoic areas was documented (photoprint).

RESULTS

40/93 IBD-patients with corticosteroids (43%) had definite areas of brighter echos in the hilus region of the liver. In IBD-patients without corticosteroids only one patient showed a focal brighter echogenicity, whereas in the non-IBD group with corticosteroids 8/13 had focal lesions (62%). In the control group only four healthy subjects showed brighter areas (5%).

CONCLUSION

Bright focal areas in the liver hilus occur in > 40% of IBD-patients during corticosteroid medication. This phenomenon occurs in IBD-patients as frequently and as intense as in other patients with longstanding corticosteroid therapy. There is a hilar area of the liver with typical size and location which reacts to corticosteroid administration with hyperechoic reflexes at ultrasound investigation. This is important to know when it comes to the differential diagnosis of focal changes.

Density of gastric Helicobacter pylori colonization is not associated with occurrence of dyspeptic symptoms

In most studies, the prevalence of Helicobacter pylori infection in patients with dyspeptic symptoms does not clearly differ from the prevalence in asymptomatic controls. However, the degree of H. pylori colonization might play a role for the occurrence and severity of dyspeptic symptoms. Between August 1993 and July 1994, we screened 1500 apparently healthy volunteers (1036 men, 464 women, 42 +/- 12 years) for H. pylori infection using the [13C] urea breath test. The noninvasive urea breath test enables a semiquantitative assessment of the extent of H. pylori colonization in the stomach. Of the 1500 volunteers, 526 (35.1%) complained of occasional or frequent dyspeptic symptoms. No difference was observed in the H. pylori prevalence between asymptomatic subjects (35.5%) and those with dyspeptic symptoms (35.9%; P > 0.95). A high density of H. pylori colonization in the gastric mucosa was not associated with a higher frequency of dyspepsia (P > 0.80). According to these findings, an eradication therapy on the basis of dyspeptic symptoms alone cannot be recommended as H. pylori is not a proven etiology of dyspepsia.

Endoscopy is not a risk factor for Helicobacter pylori infection--but medical practice is

BACKGROUND

Previous studies have suggested an increased risk for Helicobacter pylori infection in physicians who perform UGI endoscopy because of exposure to potentially infectious gastric secretions. Therefore, the H. pylori infection status of the endoscopy staff was compared with the H. pylori prevalence of medical staff without endoscopy experience and control subjects who had no contact with patients.

METHODS

The noninvasive 13C-urea breath test was performed in 2108 volunteers: 1460 physicians (mean age 44 +/- 12 years), 235 nurses (33 +/- 10 years), and 413 control subjects (43 +/- 12 years) who were not working in clinical medicine. All subjects completed a questionnaire concerning the weekly frequency of gastroscopies and the duration of endoscopic experience.

RESULTS

Overall, 37.4% of the physicians and 35.3% of the nurses, but only 27.1% of the control subjects were infected. H. pylori infection was not significantly different between endoscopy-performing (37.8%; n = 1091) and general medical staff (35.9%; n = 604). Neither the frequency of gastroscopies nor the duration of endoscopy practice correlated with H. pylori status. With respect to the age distribution; however, a statistically significant higher prevalence of H. pylori was observed in physicians and nurses compared with the 413 control subjects without patient contact (p < 0.01).

CONCLUSION

UGI endoscopy is not a risk factor for H. pylori infection, but medical practice slightly raises H. pylori acquisition.

Ultrasound studies of the intestinal wall in patients with cystic fibrosis

BACKGROUND

In 1994, first published reports described cystic fibrosis patients who experienced a then unknown complication-ileocecal and colonic stenoses with submucosal proliferation requiring surgical intervention. To investigate a suspected correlation between increased intestinal wall diameter and high doses of pancreatic enzymes, we carried out a prospective study in our CF-outpatient clinic.

METHODS

By ultrasound analysis we measured the intestinal wall diameter in 201 patients. One hundred ninety-three patients treated with pancreatic enzymes had pancreatic insufficiency. Eight patients showed normal pancreatic function, seven of them had never been treated with pancreatic enzymes. The control group included 12 healthy children. Measuring points were the distal ileum, cecum, ascending, and descending colon. Measurements were made by the longitudinal and cross sectional cut. The following aspects of the patients' history were recorded (a) current type of pancreatic enzyme medication; (b) total dosage per day (with reference to lipase units); (c) duration of therapy with standard-strength pancreatic enzyme (SSPE) preparations (< or = 10,000 lipase units per capsule) and HSPE preparations (> or = 20,000 lipase units per capsule); (d) gastrointestinal complication (distal intestinal obstruction syndrome, meconium ileus, abdominal surgery, intussusception), diabetes mellitus, and hepatobiliary complications.

RESULTS

The intestinal wall diameter in patients receiving HSPE therapy was greater (with prominent submucosal layer) than that in patients receiving SSPE therapy or in patients with pancreatic sufficiency. Healthy subjects had the smallest intestinal wall diameter. There was no correlation between patient history and increased intestinal wall thickness.

CONCLUSIONS

Ultrasound detects characteristic ileocecal wall lesions in the majority of cystic fibrosis patients on pancreatic enzymes. These lesions may lead to significantly increased ileocecal wall thickness, which is correlated but not restricted to HSPE.

[Breath tests in intestinal diseases and functional gastrointestinal diagnosis]

Among the numerous breath tests described for gastroenterological applications, breath hydrogen (H2) tests have emerged during the past two decades as a most sensitive, reliable and feasible method for detecting carbohydrate malabsorption and maldigestion (e. g. lactose maldigestion). Hence they are regarded time honored standards of contemporary gastroenterological function tests. For the diagnosis of the small bowel bacterial overgrowth syndrome the glucose H2 breath test is a feasible tool with moderate sensitivity (approximately 65%), which, however, is not higher with alternative breath test (e. g. the 1 g 14C-D-xylose breath test). Measuring mouth-to-caecum-transit time by the breath H2 response after lactulose is more of scientific interest than clinically informative. Breath tests making use of 14C labeled substrates (usually 5 to 10 microCi) bear a rather low calculated radiation hazard and are thus in routine use in some countries, e. g. in Scandinavia, but they are abandoned in others. At least, however, radioactive 14C breath tests are (partially) dispensible, as these restrictions do not apply for the stable isotope 13C breath tests which are nonradioactive and thus devoid of any radiation hazard. For the purpose of gastroenterological function testing the 13C urea breath test for the detection of Helicobacter pylori infection, quantitative studies of gastric emptying with 13C-acetate or 13C-octanoate and quantitative liver function tests have gained diagnostic use while 13C-breath tests assessing intestinal absorption or exocrine pancreatic function have been found less effective than the respective alternatives, or too expensive. Both, H2-breath tests and 13CO2-breath tests are clinically important, diagnostic methods with well delineated indications in gastroenterology.

[Do ultrasound parameters allow diagnosis of biliary sphincter of Oddi dysfunction?]

A noninvasive test to prove sphincter of Oddi dysfunction is desired, because endoscopic manometry is technically demanding and not without risks.

METHODS

40 consecutive patients (n = 20 patients with, and n = 20 patients without enzymatic cholestasis) with suspected SOD were investigated both by ultrasonography (US; 3.5 MHz) and by endoscopic manometry. SOD was suspected at US if the extrahepatic bile duct diameter was > or = 9 mm and a further increase (at least > 0.5 mm) was observed after intravenous ceruletide (0.3 micrograms/kg b.w.). SOD was verified manometrically by a sphincter of Oddi basal pressure > or = 40 mmHg. Endoscopic sphincterotomy was performed if SOD was diagnosed by manometry. Thereafter, all patients were enrolled in a prospective follow-up (median: one year).

RESULTS

At US SOD was suspected in eleven of 20 patients with cholestasis. SOD was confirmed manometrically in all of them but also in two further patients (13 of 20 patients with proven SOD). After EST twelve of 13 patients remained free from biliary symptoms. In the 20 patients without cholestasis SOD was suspected at US in five patients only. However, endoscopic manometry revealed SOD in eleven of 20 patients and proved sonographically presumed SOD in only three of five patients. After EST only three of eleven patients remained asymptomatic during follow-up (p < 0.05 vs. patients with cholestasis). Clinically important side effects were not observed after ceruletide administration, whereas postmanometry pancreatitis was observed in three of 40 patients.

CONCLUSION

In patients with recurrent symptoms after cholecystectomy and enzymatic cholestasis SOD was reliably diagnosed by ultrasonography (sensitivity: 85%, specificity: 100%), and this finding may guide endoscopic sphincterotomy.

Monitoring pancreatin supplementation in cystic fibrosis patients with the 13C-Hiolein breath test: evidence for normalized fat assimilation with high dose pancreatin therapy

BACKGROUND

13C-Hiolein is a randomly 13C-labeled mixture of long chain triglycerides synthesized by algae.

METHODS

Because the 13C-Hiolein breath test is a suitable noninvasive tool to detect and monitor pancreatic steatorrhea, we used this new breath test for monitoring the effect of enzyme replacement therapy with an acid resistant enteric coated polydisperse pancreatin preparation (1.500 U/kg d) in children with cystic fibrosis.

RESULTS

Administration of 1.5 mg/kg 13-C-Hiolein together with a physiological mixed meal (1.5 g/kg rice cookies, containing 25% fat and 37% starch) resulted in significantly higher breath 13CO2/12CO2 ratios in controls than in cystic fibrosis children (maximal delta over baseline responses (DOBmax) 39.2 +/- 18.1% vs. 13.1 +/-13.9%; p < 0.001). With pancreatin, DOBmax in the cystic fibrosis patients responses returned completely to normal (39.2 +/- 29.2% DOBmax). A breath hydrogen increase indicating the malassimilation of starch was noticed in one patient with severe pancreatic insufficiency only.

CONCLUSION

In contrast to fecal fat analysis, the 13C-Hiolein breath test reflects postprandial fat assimilation immediately after a given, labeled meal. Monitoring the oxidative fate of physiological test meal with a stable isotope breath test, this study shows that fat assimilation in cystic fibrosis patients can be normalized with high dose pancreatin.

Causes and management of recurrent biliary pain after successful nonoperative gallstone treatment

OBJECTIVE

To evaluate the frequency and causes of recurrent biliary colic after successful extracorporeal shock wave lithotripsy of gallstones.

METHODS

Follow-up of 77 patients for 2 yr (median) after complete gallstone clearance by lithotripsy and adjuvant oral litholysis. All patients with recurrent biliary colic were examined thoroughly (laboratory data, ultrasonography, gastroscopy); the examination included gallbladder motility testing. If the patients suffered from additional gastrointestinal complaints, further symptom-guided investigations (pH-metry, lactose absorption study, enteroclysis, colonic transit time, colonoscopy) were performed. Patients without documented gallstone recurrence underwent ERCP and sphincter of Oddi manometry. Cholecystectomy was advised for patients in whom gallstones recurred, and patients with sphincter of Oddi dysfunction underwent endoscopic sphincterotomy. If other gastrointestinal disorders were diagnosed, appropriate treatment was initiated.

RESULTS

Twenty-seven patients (35%) experienced biliary colic during follow-up. Gallstone recurrence was documented in 17 patients, and 16 of the patients who underwent cholecystectomy became symptom-free again (follow-up: 12 months). Gallbladder hypomotility was revealed in seven of the 17 patients with gallstone recurrence compared to none of the 10 patients without gallstone recurrence (p < 0.05). Microlithiasis was not detected in bile samples from the patients whose gallstones did not recur. Sphincter of Oddi dysfunction was found in four patients, and sphincterotomy cured all of them (follow-up: 9 months). Two of the remaining six patients had functional gastrointestinal disorders (reflux, constipation) and became asymptomatic after specific treatment.

CONCLUSIONS

Biliary colic often recurs after successful gallstone lithotripsy. Recurrent gallbladder stones are the main cause, but another cause is sphincter of Oddi dysfunction. Neither gallbladder hypomotility nor microlithiasis seems to cause biliary symptoms in patients without recurrence of gallstones.

Exocrine pancreatic insufficiency: accuracy and clinical value of the uniformly labelled 13C-Hiolein breath test

BACKGROUND AND AIMS

The 13C-Hiolein breath test (98% [U-13C] labelled long chain triglyceride mixture (highly labelled triolein) was evaluated as a non-invasive, non-radioactive test for exocrine pancreatic insufficiency. Accuracy and clinical validity were examined with reference to both the secretin pancreozymin test and faecal fat analysis.

METHODS

A secretin pancreozymin test and faecal fat analysis were performed in 46 patients, 30 with exocrine pancreatic insufficiency and 16 with normal pancreatic function. In all of these patients and in seven healthy volunteers (controls), a 13C-Hiolein breath test was performed using 2 mg/kg [U-13C] labelled Hiolein with a standard risk snack (1.5 g/kg; 25% fat). 13CO2/12CO2 enrichment in the exhaled breath was measured by isotope ratio mass spectrometry.

RESULTS

In patients with pancreatic steatorrhoea the 13CO2 response was below the 95% confidence interval of 13CO2 exhalation in the controls. These responses were also diminished (p < 0.001) compared with patients with impaired lipase output but normal fat excretion and with disease as well as healthy controls. There was a linear correlation between stimulated lipase output and the ratio of lipase output/13CO2 response (r = 0.95). Among the 40 patients in whom direct pancreatic function testing was clinically indicated, the sensitivity of the 13C-Hiolein test for detecting steatorrhoea was 91.7%, with a specificity of 85.7%.

CONCLUSIONS

In patients with pancreatic disease the 13C-Hiolein breath test reflects impaired lipase output and indicates decompensated lipolysis. The 13C-Hiolein breath test is a convenient alternative to faecal fat analysis.

Diagnostic intervals for recognizing celiac disease

The aim of this retrospective study was to determine the time intervals between the onset of symptoms and diagnosis of celiac disease on the basis of a questionnaire that was published in the journal of the German Celiac Society (Verbandszeitschrift der Deutschen Zöliakie-Gesellschaft). 408 adult patients in whom the diagnosis of celiac disease was made after the age of 15 responded to the questionnaire. The time interval between the onset of symptoms and diagnosis (total diagnostic interval) was 5.4 (median) and 10.1 +/- 12.3 (mean +/- SD) years, interval-1 (time interval between the onset of symptoms and the first visit to a doctor) was 0.4 (median) and 2.2 +/- 6.6 (mean +/- SD) years, and interval-2 (time interval between the first visit to a doctor and the diagnosis) was 3.9 (median) and 8.0 +/- 10.4 (mean +/- SD) years. The time intervals shortened only a little over the years. At all times, interval-2 was significantly longer than interval-1. There were no differences between female (n = 328) and male (n = 80) patients and between the age groups. Furthermore, none of the gastrointestinal and non-gastrointestinal symptoms had had a distinct influence on all diagnostic intervals and also the fact that other family members having the disease did not shorten any of the intervals. In summary, the diagnostic intervals for recognizing celiac disease are still unacceptably long. More public awareness work has to be done so that patients can recognize their symptoms and doctors especially can suspect celiac disease sooner and perform the necessary diagnostic procedures when patients present with suggestive symptoms.

[Esophagus and anorectal motility in patients with dysfunction of Oddi's sphincter]

Esophageal and anorectal motility have not been systematically evaluated in patients with sphincter of Oddi dysfunction (SOD). We have investigated 8 consecutive patients (6 females, 52.5 +/- 9.5 y) with type I-SOD (according to the Milwaukee-classification), 12 patients (9 females, 50.4 +/- 12.3 y) with type III-SOD, and 20 healthy volunteers (15 females, 48.5 +/- 15.2 y) by means of a standardized questionnaire for esophageal and anorectal symptoms, esophageal manometry, colonic transit time evaluation, and anorectal manometry. Symptom-scores did not differ significantly between type-I and type III-SOD-patients, respectively. Furthermore, there were no relevant differences of the symptom-scores of the SOD-patients vs. healthy subjects. However, the lower esophageal sphincter pressure (LESP) was significantly higher in patients with type I-SOD (26.8 +/- 7.4 mmHg) than in both, type III-SOD-patients (20.3 +/- 4.0 mmHg, p < 0.05) and healthy subjects (18.6 +/- 3.5 mmHg, p < 0.001), respectively. Mean colonic transit time did not differ significantly between both groups of patients (type I-SOD, 27.9 +/- 21.4 h, vs. type III-SOD, 28.5 +/- 15.1 h, p < 0.05). The anal sphincter resting pressure (ARP) was significantly higher in patients with type I-SOD (90.8 +/- 15.5 mmHg) than in healthy subjects (74.1 +/- 10.3, p < 0.01), but did not differ significantly from that in patients with type III-SOD (82.1 +/- 11.5 mmHg, p = 0.17). Computer-assisted "beat-to-beat"-evaluation showed an abnormal heart rate variability in 3/8 patients with type I-SOD. These results give evidence for a systemic involvement of the lower esophageal and the anal sphincter in patients with type I-SOD, which does not occur in patients with type III-SOD.

Dose-response of omeprazole combined with amoxycillin on duodenal ulcer healing and eradication of Helicobacter pylori

BACKGROUND

Combination therapy using omeprazole and amoxycillin can cure Helicobacter pylori infection, but data are controversial concerning the efficacy of this regimen. The present study investigated varying doses of omeprazole combined with a standard amoxycillin dose on duodenal ulcer healing and eradication of H. pylori, in order to find an optimal dose regimen.

METHODS

H. pylori-positive out-patients (n = 231) with duodenal ulcers were treated randomly and double-blind with either omeprazole 20, 40 or 80 mg b.d. plus amoxycillin 1 g b.d. for 14 days. Patients with an unhealed ulcer after this therapy took omeprazole 20 mg o.m. for another month.

RESULTS

After 2 weeks, ulcer healing rates in the three treatment groups were not statistically different (85, 82 and 93%, respectively). Treatment with omeprazole 80 mg b.d. was significantly better in curing H. pylori infection (eradication rate 69%) than treatment with omeprazole 20 and 40 mg b.d. (47 and 53%).

CONCLUSIONS

Combination of either omeprazole 20 or 40 mg b.d. plus amoxycillin 1 g b.d., is not sufficiently effective to be recommended as an anti-H. pylori therapy. Omeprazole 80 mg b.d. combined with amoxycillin is more efficient and well tolerated, but better treatment options now exist to cure H. pylori infection.

Nondispersive isotope-selective infrared spectroscopy: a new analytical method for 13C-urea breath tests

BACKGROUND

Currently, stable isotope techniques in breath tests using 13C-labeled substrates are limited to a few centers equipped with expensive and complex isotope ratio mass spectrometry (IRMS). Although breath samples can be mailed to these centers, widespread application of 13C breath tests would be more feasible with a cheaper and more practicable analysis system at hand.

METHODS

We therefore tested the newly developed nondispersive isotope-selective infrared spectrometer (NDIRS) with reference to IRMS in a clinical setting comparing the results of both techniques in 538 consecutive 13C-urea breath tests performed for the detection of Helicobacter pylori infection.

RESULTS

With NDIRS five false-positive and three false-negative results were observed; that is, the sensitivity of NDIRS was 98.3%, and the specificity was 98.6%. The delta over base-line values of both devices correlated linearly (Y = 0.87 +/- 0.01 X + 0.29 +/- 1.5; r = 0.95; p < 0.0001; n = 538).

CONCLUSIONS

When running this large number of breath tests in 3 days, the NDIRS proved to be a reliable, stable, and easy-to-operate analytical tool, which is well qualified for gastroenterologic application in the diagnostic routine. Both the price and the easy handling of NDIRS will facilitate the widespread use of the noninvasive stable isotope technique for 13C breath tests.

Immunoreactive elastase I: clinical evaluation of a new noninvasive test of pancreatic function

We have evaluated the diagnostic value of the fecal elastase test in comparison with the secretin-pancreozymin test in the diagnosis of exocrine pancreatic insufficiency. Pancreatic elastase was measured immunologically. Immunoreactive elastase activity in spot stools from controls ranged from 136 to 4440 microgram/g; 95% of all values were within 175 to 1500 microgram/g. The elastase assay CVs ranged from 3.3% to 6.3% (intraassay) and from 4.1% to 10.2% (interassay). The output of elastase correlated well with those of amylase, lipase, and trypsin, yielding respective correlation coefficients of 0.83, 0.82, and 0.84 in controls and 0.86, 0.91, and 0.91 in patients with impaired pancreatic function. In contrast to fecal chymotrypsin, the test results were unaffected by pancreatic enzyme replacement therapy. These results indicate that fecal immunoreactive elastase may be recommended as a new, noninvasive tubeless test of pancreatic function.

Do patients with sphincter of Oddi dysfunction benefit from endoscopic sphincterotomy? A 5-year prospective trial

OBJECTIVES

To assess the incidence of elevated sphincter of Oddi baseline pressure and the response to endoscopic sphincterotomy in patients with suspected sphincter of Oddi dysfunction.

DESIGN

A 5-year prospective clinical trial.

METHODS

One-hundred and eight patients with recurrent biliary-type pain after cholecystectomy were enrolled. After thorough investigation, 35 patients with suspected type II sphincter of Oddi dysfunction (SOD) and another 29 type III patients remained for further investigation. Both groups were similar with respect to demographic data and severity of pain. Biliary manometry was performed in all except three patients in either group. Endoscopic sphincterotomy was performed in all patients with abnormal sphincter of Oddi baseline pressure (> 40 mmHg). All patients were clinically re-evaluated after 4-6 weeks, and thereafter the sphincterotomized patients were followed for a median period of 2.5 years.

RESULTS

An abnormal sphincter of Oddi baseline pressure was found in 62.5% of the type II patients and in 50% of the patients with suspected type III SOD (P = 0.66). At the 4-6 week follow-up none of those patients without abnormal manometry, but 70% of the patients with type II SOD, and 39% of the type III SOD patients, respectively, reported subjective benefit after sphincterotomy (P = 0.13 type II vs. type III). However, after a median follow-up of 2.5 years, sustained symptomatic improvement after sphincterotomy was found in 60% of the type II patients, but only in 8% of the patients with type III SOD (P < 0.01).

CONCLUSION

Disregarding a lack of difference in the incidence of abnormal sphincter of Oddi baseline pressure between type II and type III SOD, the Geenen-Hogan classification helps to predict the clinical outcome after endoscopic sphincterotomy.

Quantification of fecal carbohydrates by near-infrared reflectance analysis

Established methods for quantitative analysis of fecal carbohydrates (CHO) are time consuming, require unpopular sample handling, and are therefore rarely performed. The aim of this study was to evaluate the efficiency, validity, and practicability of near-infrared reflectance analysis (NIRA), compared with standard methods for measurement of fecal CHO. Excretion of fecal CHO was cross- validated spectrophotometrically with the anthrone method. Fecal CHO concentrations ranged form 2.7 to 24.5 g/kg wet weight. Methods comparison showed linear regression over the entire range of diagnostic relevance with a correlation coefficient of 0.869 (S(y/x) +/- 0.31). Repeated measurements from the same stool collections obviated the need for homogenization. These results indicate that NIRA may be a new, reliable, and accurate test in the diagnosis of CHO malabsorption.

Effect of endoscopic sphincterotomy on sphincter of Oddi manometry results in patients with or without papillary stenosis

Patients with fibrotic papillary stenosis (PS) are at high risk for sphincter of Oddi-re-stenosis after endoscopic sphincterotomy (ES). Therefore, a prospective trial was conducted to assess the acute and long-term effects of ES on sphincter of Oddi motor function in patients with papillary stenosis. The immediate effects of ES were studies by endoscopic manometry in 12 patients with PS, and in 15 patients with common bile duct stones (CBDS, control group). Furthermore, after a median follow-up of 15 months, 11 from those 12 patients with papillary stenosis were reinvestigated with ERCP and manometry. Complete ES (defined by a common bile duct pressure and a basal sphincter of Oddi-pressure (BSOP) < 5 mm Hg) was achieved in 13/15 CBDS-patients, but only in 3/12 patients with PS (p<0.01), although sphincterotomy was extended to the maximal length as judged endoscopically. Four patients with PS had a residual BSOP > 20 mm Hg. However, all patients with PS became symptom-free immediately after ES. The phasic sphincter motility was not affected significantly different in both groups of patients (p = 0.25). Those patients with a residual BSOP > 20 mm Hg after ES developed sphincter of Oddi-re-stenosis during the follow-up (3 patients) or revealed re-stenosis at the control examination after follow-up (1 patient). After the follow-up manometrically defined complete sphincterotomy was furtheron demonstrable in only 2/11 patients with papillary stenosis. In conclusion, ES revealed a decreased efficacy to eliminate the sphincter of Oddi motor function in a substantial number of patients with papillary stenosis. This may explain the remarkably high rate of sphincter of Oddi-re-stenosis after sphincterotomy in these patients.