Showing papers in "Zeitschrift Fur Gastroenterologie in 2016"

The GALAD scoring algorithm based on AFP, AFP-L3, and DCP significantly improves detection of BCLC early stage hepatocellular carcinoma.

Abstract: Background: Hepatocellular carcinoma (HCC) is one of the leading causes of death in cirrhotic patients worldwide. The detection rate for early stage HCC remains low despite screening programs. Thus, the majority of HCC cases are detected at advanced tumor stages with limited treatment options. To facilitate earlier diagnosis, this study aims to validate the added benefit of the combination of AFP, the novel biomarkers AFP-L3, DCP, and an associated novel diagnostic algorithm called GALAD. Material and methods: Between 2007 and 2008 and from 2010 to 2012, 285 patients newly diagnosed with HCC and 402 control patients suffering from chronic liver disease were enrolled. AFP, AFP-L3, and DCP were measured using the µTASWako i30 automated immunoanalyzer. The diagnostic performance of biomarkers was measured as single parameters and in a logistic regression model. Furthermore, a diagnostic algorithm (GALAD) based on gender, age, and the biomarkers mentioned above was validated. Results: AFP, AFP-L3, and DCP showed comparable sensitivities and specifities for HCC detection. The combination of all biomarkers had the highest sensitivity with decreased specificity. In contrast, utilization of the biomarker-based GALAD score resulted in a superior specificity of 93.3 % and sensitivity of 85.6 %. In the scenario of BCLC 0/A stage HCC, the GALAD algorithm provided the highest overall AUROC with 0.9242, which was superior to any other marker combination. Conclusions: We could demonstrate in our cohort the superior detection of early stage HCC with the combined use of the respective biomarkers and in particular GALAD even in AFP-negative tumors.

Intrahepatic cholestasis of pregnancy (ICP): case report and review of the literature.

Abstract: Intrahepatic cholestasis of pregnancy (ICP) represents the most common pregnancy-related liver disease in women. Women frequently present in the third trimester with pruritus and elevated serum bile acid and/or alanine transaminase levels. Clinical symptoms quickly resolve after delivery; however, recurrence in subsequent pregnancies has to be expected. Intrahepatic cholestasis of pregnancy is associated with increased perinatal complications, such as premature delivery, meconium staining of the amniotic fluid, respiratory distress, low Apgar scores, and even stillbirth. The risk for the fetus is significantly increased with maternal serum bile acid levels above 40 µmol/L, which characterize severe ICP. An important factor for ICP development is a rise of gestational hormones leading to cholestasis in genetically predisposed women. Variants in the bile salt export pump (BSEP) and the multidrug resistance protein 3 (MDR3) are most often identified in ICP. Here, we give an overview of the current literature on ICP and present the case of a woman with recurrent severe ICP. A common BSEP polymorphism as well as a rare MDR3 mutation may underlie the development of ICP in our patient. She had a premature delivery with meconium staining of the amniotic fluid. The neonate showed signs of respiratory distress with a low Apgar score. This case emphasizes that women with severe ICP have an increased risk for perinatal complications. Furthermore, severe ICP was associated with a MDR3 mutation, which has already been described in adult patients with liver cirrhosis. Thus, ICP may unmask an underlying MDR3 defect, which may predispose to development of hepatobiliary diseases such as gallstone disease, liver fibrosis/cirrhosis, as well as hepatobiliary malignancies. Therefore, genetic testing should be considered in women with severe as well as early onset ICP. Furthermore, regular follow-up should be discussed for women with genetic variants.

D-lactic acidosis - case report and review of the literature.

Abstract: D-lactic acidosis is a rare complication that occurs mainly in patients with malabsorption due to a surgically altered gastrointestinal tract anatomy, namely in short bowel syndrome or after bariatric surgery. It is characterized by rapid development of neurological symptoms and severe metabolic acidosis, often with a high serum anion gap. Malabsorbed carbohydrates can be fermented by colonic microbiota capable of producing D-lactic acid. Routine clinical assessment of serum lactate covers only L-lactic acid; when clinical suspicion for D-lactic acidosis is high, special assays for D-lactic acid are called for. A serum level of more than 3 mmol/L of D-lactate confirms the diagnosis. Management includes correction of metabolic acidosis by intravenous bicarbonate, restriction of carbohydrates or fasting, and antibiotics to eliminate intestinal bacteria that produce D-lactic acid. We report a case of D-lactic acidosis in a patient with short bowel syndrome and review the pathophysiology of D-lactic acidosis with its biochemical and clinical features. D-lactic acidosis should be considered when patients with short bowel syndrome or other malabsorption syndromes due to an altered gastrointestinal tract anatomy present with metabolic acidosis and neurological symptoms that cannot be attributed to other causes. With the growing popularity of bariatric surgery, this metabolic derangement may be seen more frequently in the future.

Ultrasound assessment of schistosomiasis.

Abstract: In 2000, the World Health Organization (WHO) issued an ultrasound field protocol for assessing the morbidity due to Schistosoma (S.) haematobium and S. mansoni. The experience with this classification has recently been reviewed systematically. The WHO protocol was well accepted worldwide. Here we review the use of ultrasound to assess the morbidity due to schistosomiasis with emphasis on easy, quick, and reproducible ways that can be used in the field. Findings obtained with high-end ultrasound scanners in the hospital setting that might eventually have applications in the field are also described.

Duplex sonography of the mesenteric vessels--a critical evaluation of inter-observer variability.

Abstract: Introduction: The number of publications concerning mesenteric Doppler sonography (mesDS) is immense and does not correlate with the frequency of its use in clinical practice. This is astonishing since it provides real time blood flow (perfusion) information without side effects. Despite uncontrollable parameters like the technical limitations in some situations the optimization of (possibly) controllable parameters like standardization, production of normal values and reduction of the investigator variability by evaluating stable parameters could change the situation. Patients and methods: 10 investigators experienced in abdominal sonography (“DEGUM-Seminarleiter”) performed mesenteric Doppler sonography in 5 healthy subjects with 5 different machines. Results: The portal vein at the confluence and the common hepatic artery provide a significant portion of investigations with intromission angles of more than 60°. Values of diameter, resistance index and pulsatility index of the celiac trunc could be obtained with inter-observer variability values below 25 %. The proper and the common hepatic artery show no differences in inter-observer variability values, whereas the intrahepatic measure point of the portal vein showed a higher reproducibility. Discussion: We define frame conditions for future mesenteric Doppler studies: the portal vein should be investigated at the intrahepatic measure point. Pathophysiological studies should refrain from velocity parameters except in the case of larger vessels running in a straight course towards the probe.

Durable remission under dual HER2 blockade with Trastuzumab and Pertuzumab in a patient with metastatic gallbladder cancer

Abstract: Gallbladder cancer represents a rare but dismal disease. The only curative option is complete surgical resection, though patients often develop recurrent disease. In patients with advanced biliary tract cancer, the combination of cisplatin and gemcitabine showed a benefit in overall survival compared to gemcitabine alone. However, there is no standardized second-line regimen after treatment failure. We report on a young patient with early recurrence of a gallbladder cancer with cutaneous and peritoneal metastases. Upon identification of an ERBB2 gene amplification within the NCT MASTER (Molecularly Aided Stratification for Tumor Eradication Research) exome sequencing program with resulting overexpression of HER2 in the tumors cells, the patient received a targeted therapy with the HER2 antibodies pertuzumab and trastuzumab in combination with nab-paclitaxel, which led to a durable remission for more than one year. This case report underlines the potential of molecularly aided personalized targeted therapy for patients with biliary tract cancer and the need for respective clinical trials.

Percutaneous sclerotherapy of liver and renal cysts, comments on the EFSUMB guidelines

Abstract: Cystic lesions in the liver and kidneys are common incidental findings. They are generally benign and require no treatment. They can appear sporadically or as part of a syndrome, and are characterised by their anechoic structure and posterior enhancement in ultrasound imaging. Increased size, haemorrhage or infection of a cyst can lead to development of symptoms. Along with surgical options and laparoscopic cyst fenestration, ultrasound-guided sclerotherapy of symptomatic cysts represents an effective and safe minimally invasive treatment option.

"Miniguts" from plucked human hair meet Crohn's disease.

Abstract: Human pluripotent stem cells represent a powerful tool to study human embryonic development and disease but also open up novel strategies for cell replacement therapies. Their capacity to give rise to every cell type of the human body, meanwhile, enables researchers to generate high yields of mesodermal, ectodermal, but also endodermal-derived tissues such as hepatic, pancreatic, or intestinal cells. Another progress in the field came with the advent of 3-dimensional culture conditions, so-called organoids, which facilitate maturation of stem cells and in turn more faithfully recapitulate human tissue architecture. While several studies reported the derivation of organoid cultures from adult intestinal tissue, the derivation of intestinal organoids derived from plucked human hair of Crohn’s disease patients has not been reported. The current research project reports such successful generation and characterization of induced pluripotent stem cells (iPSCs) derived from hair sheet keratinocyte cultures of a patient with Crohn's disease. Stepwise differentiation along the intestinal lineage showed no differences in intermediate stages such as definitive endoderm formation. We also directed the patterned primitive gut tube toward intestinal organoids resembling the cellular architecture of human “miniguts”. As expected from current pathophysiological knowledge on Crohn's disease, there were no obvious morphological differences in the “miniguts” derived from healthy control and diseased patient-induced pluripotent stem cells. Taken together, our platform will enable for detailed and complementary phenotyping of the pathophysiology of Crohn’s disease in a novel disease-in-a-dish format.

Perspectives of immunotherapy in hepatocellular carcinoma (HCC).

Abstract: Immunotherapy is considered a new treatment option for many tumor entities, as decades of research into cancer immunotherapy have recently yielded promising results. Indeed, impressive clinical results of checkpoint blockade inhibitors in malignant melanoma and non-small cell lung cancer indicate the therapeutic potential of tumor-specific immune restoration. Over the years, different immunotherapeutic approaches have been evaluated for the treatment of hepatocellular carcinoma (HCC) with some respectable results. In this review article, we will summarize the key studies of the past 30 years and will elucidate in which direction the dynamic field of HCC immunotherapy is currently moving.

Clinical value of imaging for lymph nodes evaluation with particular emphasis on ultrasonography

Abstract: Enlarged or irregular lymph nodes (LNs) are clinical and imaging findings in a large variety of malignant and non-malignant diseases. A comprehensive diagnostic work up is usually necessary in order to differentiate the benign or the malignant nature of the altered LNs. The diagnosis has to be made using all clinical information and, if necessary, assessed LNs need to be biopsied and further, histologically or microbiologically characterized. However, imaging techniques, and particularly ultrasonography (US), are essential on the way to the final diagnosis, from initial detection and characterization to follow-up of biopsy guidance. Computed-tomography (CT) and/or magnetic resonance imaging (MRI) are of great value for oncological diseases staging and treatment monitoring. Imaging techniques are helpful in distinguishing between benign and malignant LNs disease as well as between LNs metastases and lymphoma in most cases. Furthermore, imaging can define the extent and distribution of malignant diseases. It may assist, through the use of particular techniques such as elastography, to identify the most suspicious LN to be biopsied and to guide targeted biopsies from the most suspicious areas. It also serves as the main tool for the evaluation of treatment response in malignant diseases. The quality of LNs imaging has remarkably improved in recent years. New methods, such as contrast-enhanced ultrasonography (CEUS), elastography, positron emission tomography (PET)/PET-CT, as well as diffusion weighted imaging (DWI) in MRI, have already led to substantial changes in clinical practice. This review describes the most recent imaging techniques for LNs assessment, and their particular clinical value, with a special emphasis on the role of US techniques. Strengths and weaknesses of different imaging tools are discussed comprehensively, highlighting the importance of a corroborative attitude for successful management of each particular case.

Determinants and frequency of irritable bowel syndrome in a German sample

Abstract: Background: To date there is no study that has estimated the prevalence of irritable bowel syndrome (IBS) in Germany according to the current Rome III criteria The aim of the present study was to investigate the prevalence of IBS in a non-clinical German sample Furthermore, we investigated the association of IBS with socio-demographic and psychological risk factors Methods: Baseline data from a prospective cohort study were analysed, including the IBS Module of the Rome III Diagnostic Questionnaires and validated psychometric scales including the Patient Health Questionnaire-15 (PHQ-15), the Big Five Inventory (BFI), the Perceived Stress Questionnaire (PSQ-5), and the Whiteley-Index (WI-7) The study population was compared to the German general population to appraise its representativeness Multivariate logistic regression analyses were performed to identify possible risk factors associated with IBS Results: Between January 2011 and September 2012, 2419 persons participated (female 540 %, mean age 374 ± 149 years) According to the Rome III criteria, 401 participants (166 %) suffered from IBS Five predictors were independently associated with IBS: previous traveller’s diarrhoea infection (OR = 176; 95 % CI = 134 to 231), higher somatic symptom burden (OR = 115; 95 % CI = 107 to 123), increased level of hypochondriasis (OR = 204; 95 % CI = 154 to 270), increased vulnerability to diarrhoea under stress (OR = 388; 95 % CI = 321 to 468) and perceived stress (OR = 143; 95 % CI = 104 to 199) Conclusions: Our analyses yielded a relatively high IBS prevalence estimate, compared to studies published more than ten years ago This might partially be explained by the fact that the time criterion of the Rome III criteria (at least 3 days/month in last 3 months) is more inclusive compared to the time criterion of the Rome II criteria (at least 12 weeks, which need not be consecutive, in the preceding 12 months)

Microwave ablation of hepatic tumors with a third generation system: loco‑regional efficacy in a prospective cohort study with intermediate term follow-up

Abstract: Purpose: To evaluate the safety and intermediate-term efficacy of percutaneous microwave ablation (MWA) in primary and secondary liver tumors using a third generation MWA device, under ultrasound guidance. Patients and methods: Sixty-two patients (median age 74 years, 73 % males) with 69 liver tumors were enrolled in this prospective observational study. Forty-seven patients (76 %) had hepatocellular carcinoma (HCC) and 15 (24 %) metastases. Median follow-up was 3.6 years. Results: Median tumor diameter at contrast enhanced computed tomography was 23 mm (I–III quartiles, 18 – 31 mm). All procedures were performed percutaneously using a 2.45 GHz generator. Median ablation time was 10 minutes (I–III quartiles, 10 – 14 minutes). A single percutaneous antenna insertion was performed for 56/69 (81 %) of the tumors. Technical success was obtained in all tumors. Primary efficacy at 24 hours was achieved in 68/69 (99 %) tumors. The overall one-year cumulative local tumor progression rate was 15.1 % (95 % CI, 7.7 – 24.8 %) with no significant difference between HCC and metastases (p = 0.26). There was one procedure-related mortality (1.6 %) and one major bleeding (1.6 %). Conclusion: Microwave ablation is a valid option for thermal ablation of HCC and liver metastases with comparable complication rate to other local ablative procedures.

Patients with ultrasound diagnosis of hepatic steatosis are at high metabolic risk.

Abstract: Background and aims: Hepatic steatosis is the basis of non-alcoholic fatty liver disease (NALFD). Mere fat accumulation within hepatocytes is considered the mild form of NAFLD, but can progress in some patients to advanced steatohepatitis (NASH), which may lead to fibrosis, cirrhosis or hepatocellular carcinoma. However, even hepatic steatosis alone may be a risk factor for cardiovascular disease (CVD). Patients and methods: In the present real life study 106 patients from the outpatient clinic of the Department for Gastroenterology and Hepatology with either NAFLD (n = 60) or other typical diagnoses (n = 46) were included. Ultrasound examination identified 77 patients with hepatic steatosis. Liver enzymes, lipid profile, surrogate cell death markers, and adiponectin were determined. Transient elastography (Fibroscan®) and bioelectrical impedance analysis (BIA) were performed. Results: Mean patient age was 46 years (23 - 62) for non-NAFLD and 53 years (18 - 71) for the NAFLD group. ALT and AST did not differ significantly between the two groups. Adiponectin and HDL were significantly lower in NAFLD (p < 0.05) and BIA profiles showed higher fat and fat free mass. Non-NAFLD patients with steatosis also exhibited an adverse metabolic profile. Overall steatosis was associated with factors of metabolic syndrome (MS) and CVD. Prevalence of CVD and factors of MS hint to steatosis as an early event for these conditions. Conclusion: Patients with steatosis are at higher cardiovascular and metabolic risk without differences in transaminases levels compared to those without steatosis. Steatosis diagnosed by ultrasound needs to rise attention for further metabolic alterations including CVD.

Empfehlungen zur antiviralen Therapie der chronischen Hepatitis C bei Patienten auf der Warteliste und nach Transplantation

Abstract: Mit der Zulassung der neuen direkt antiviral wirksamen Substanzen (DAA) wurden die Therapiemoglichkeiten der chronischen Hepatitis C-Virus(HCV)-Infektion bei Patienten vor und nach Lebertransplantation (LTx) durch effektive, interferonfreie und nebenwirkungsarme Kombinationstherapien deutlich erweitert. Da bislang nur wenige Daten zu Patienten mit hohergradig eingeschrankter Leberfunktion sowie nach LTx vorliegen, ist die klinische Erfahrung mit einer DAA-basierten HCV-Behandlung in diesen speziellen Patientenpopulationen limitiert. Die nachstehenden Empfehlungen zur Therapie der Hepatitis C im Rahmen der LTx wurden in einer Expertenrunde als Stellungnahme erarbeitet und geben den Kenntnisstand der recherchierten Literatur, verfugbaren Fachinformationen sowie klinischen Erfahrungen der beteiligten Autoren wieder. Sie sollen hinsichtlich der Entscheidungsfindung bei antiviraler Therapie vor und nach LTx als Orientierungshilfe dienen.

[Ultrasound artifacts and their diagnostic significance in internal medicine and gastroenterology - Part 1: B-mode artifacts].

Abstract: Artifacts in ultrasonographic diagnostics are a result of the physical properties of the ultrasound waves and are caused by interaction of the ultrasound waves with biological structures and tissues and with foreign bodies. On the one hand, they may be distracting and may lead to misdiagnosis. On the other hand, they may be diagnostically helpful. Ultrasound imaging suffers from artifacts, because in reality, parameters assumed to be constant values, such as sound speed, sound rectilinear propagation, attenuation, etc., are often different from the actual parameters. Moreover, inadequate device settings may cause artifacts. Profound knowledge of the causes, avoidance, and interpretation of artifacts is a necessary precondition for correct clinical appraisal of ultrasound images. Part 1 of this review comments on the physics of artifacts and describes the most important B-mode artifacts. Pitfalls, as well as diagnostic chances resulting from B-mode artifacts, are discussed.

Treatment of fulminant acute Hepatitis B with nucles(t)id analogues is safe and does not lead to secondary chronification of Hepatitis B.

Abstract: Background: Acute hepatitis B virus (HBV) infection is still a major cause of acute liver failure (ALF), necessitating a high rate of emergency liver transplantation (LTx). Acute infection is followed by high viral replication rates leading to hepatocyte death and, ultimately, ALF. The objective of treating HBV-induced ALF thus is to eliminate, or significantly suppress, HBV replication and therefore reduce cell death and support regeneration. Objective: In this retrospective study, we want to evaluate the timing, the safety, and the long-term virological outcome of this approach. Methods/results: In this study, we included 32 patients (16 female and 16 males; median age 39.5 years) with ALF due to hepatitis B, who were transferred to the university hospital Essen, Germany between January 2009 and December 2013. Before treatment, transaminases were highly elevated, bilirubin was increased, and elevated international normalized ratio (INR) revealed impaired liver function. HBV-DNA and HBsAg were positive. All 32 patients received oral antiviral treatment (3 lamivudine, 21 entecavir, and 8 tenofovir) between 1 day and 4 months after diagnosis of acute hepatitis B. One patient died, 2 were transplanted, one died shortly after LTx the other patient survived after LTx. These 3 patients received treatment in a state of advanced liver failure, and 1 patient 4 months after initial diagnosis of hepatitis B. Twenty-nine patients survived without LTx. Five patients were discharged without further follow-up. All 24 remaining patients became HBV-DNA negative in median of 100 days. Twenty-two patients were followed further, and all patients lost their HBsAg in median of 108 days. Sixteen of the 22 patients experienced a seroconversion to anti-HBs in median of 137 days. Four patients who were followed for 1 more year after HBsAg did not develop anti-HBs. None of the patients developed chronic hepatitis B. Conclusion: Immediate treatment of HBV-induced ALF with nucleos(t)id-analogues (NUCs) appears save and prevents LTx and death, and there is no indication for increased chronicity.

Die verschwundene Lebermetastase – Neues Einsatzgebiet für die computerassistierte 3D-navigierte laparoskopische Leberesektion?

Abstract: Einleitung: Mit den Verbesserungen der Chemo- und Antikorpertherapien von kolorektalen Lebermetastasen finden sich im klinischen Alltag zunehmend komplette bildgebende Remissionen. Histologisch lassen sich jedoch oft noch vitale Tumorzellen nachweisen, sodass die betroffenen Stellen reseziert werden sollten. Haufig stellt jedoch intraoperativ die Lokalisierung der „verschwundenen“ Lebermetastasen (VLM) eine grose Herausforderung dar, insbesondere beim laparoskopischen Vorgehen. Wir beschreiben den ersten Fall einer laparoskopischen computerassistierten 3D-navigierten Resektion einer VLM. Fallbericht: Ein 60-jahriger Patient mit einer synchronen Lebermetastase (Segment IVb) eines Sigmakarzinoms (T4 N1 M1) wurde uns nach laparoskopischer Sigmaresektion und systemischer Chemotherapie (12 Zyklen FOLFIRI/Panitumumab) zur Leberresektion zugewiesen. Diese Lebermetastase war aktuell weder computertomografisch noch sonografisch eindeutig darstellbar. Es wurde eine CT-basierte 3D-Rekonstruktion der Leber durchgefuhrt, wobei die initiale Grose der Metastase (vor Chemotherapie) in das aktuelle CT projiziert wurde. Anhand dieser Fusionsbilder erfolgte die computerassistierte 3D-navigierte laparoskopische Leberresektion. Intraoperativ war die Metastase ebenfalls sonografisch nicht sicher darstellbar. Am aufgeschnittenen Resektat bestatigte sich die Metastase. Der postoperative Verlauf war komplikationslos. Histologisch fanden sich in der noch 0,5 cm grosen Metastase uberwiegend vitale Tumorzellen (Regressionsgrad 4 n. Rubbia-Brandt). Der Sicherheitsabstand betrug 7 mm. Schlussfolgerung: Die computerassistierte 3D-Navigation ermoglichte eine sichere, onkologische Leberresektion einer „verschwundenen“ Lebermetastase nach Chemotherapie. Dieses Verfahren war aufgrund der eingeschrankten Haptik der laparoskopischen Technik besonders hilfreich. Weitere Arbeiten sind notig, um den Nutzen der computerassistierten 3D-navigierten Leberchirurgie zu verifizieren.

[Ultrasound artifacts and their diagnostic significance in internal medicine and gastroenterology - part 2: color and spectral Doppler artifacts].

Abstract: Artefakte (Bildfehler) in der Sonografie entstehen durch Interaktion der Ultraschallwellen mit den biologischen Strukturen und Geweben sowie mit Fremdkorpern wahrend ihrer Ausbreitung im Korper. Ihre Bedeutung ist ambivalent. Einerseits konnen sie diagnostisch genutzt werden, andererseits konnen sie erheblich storen oder fehlerhafte Interpretationen begunstigen. Kenntnisse uber die Entstehung, Vermeidung und Interpretation von Artefakten sind elementare Voraussetzung fur die korrekte klinische Befundung von Ultraschallbildern. Nachdem im ersten Teil der Ubersicht physikalische Grundlagen von Artefakten und die wichtigsten Artefakte in der B-Mode-Sonografie dargestellt worden sind, fokussiert Teil 2 auf die klinisch relevanten Artefakte der Doppler- und Farbduplexsonografie. Diskutiert werden die daraus resultierenden Interpretationsprobleme und Fehlerquellen, aber auch die diagnostische Nutzbarkeit von Farbdopplerartefakten.

Comorbidity in acute pancreatitis relates to organ failure but not to local complications.

Abstract: Objective: Organ failure and local complications contribute to morbidity and mortality in acute pancreatitis. Comorbidity is known to be related to organ failure. The impact of comorbidity on local complications has not yet been delineated. Moreover, it is not clear if the outcome of first-attacks and acute-on-chronic episodes, respectively, differs from outcome in all episodes. Methods: Consecutive cases of confirmed acute pancreatitis in a four-year period were reviewed. Charlson comorbidity index (CCI), complications (organ failure and local complications), disease severity (according to the revised Atlanta Classification), need for intensive care, and mortality were derived from the charts. Results: A total of 391 episodes of acute pancreatitis were included. Patients with organ failure were significantly older (P Conclusions: Comorbidity and age clearly are contributors to organ failure and mortality. Local complications occur independently of age and concomitant diseases. The overall complication rate is not significantly influenced by preceding inflammation of the pancreas. To further improve care in patients with acute pancreatitis special attention should be given to old and multi-morbid patients.

Serum bile acids in patients with hepatopulmonary syndrome

Abstract: Fragestellung Das hepatopulmonale Syndrom (HPS) ist eine Storung der arteriellen Oxygenierung, welche bei bis zu 30 % der Patienten mit Leberzirrhose auftritt und mit deutlich erhohter Sterblichkeit einhergeht. Ikterus und cholestatische Dysfunktion sind von zentraler pathogenetischer Rolle in akuter als auch chronischer Lebererkrankung. Ziel Deshalb war es Ziel dieser Studie den Stellenwert der Serum-Gallensauren bei Patienten mit HPS zu untersuchen. Methodik 74 Patienten mit Leberzirrhose wurden in diese Studie eingeschlossen. Cholestasemarker, Gesamt- als auch individuelle Gallensauren wurden bestimmt und alle Patienten auf das Vorhandensein von HPS gescreent. 26 Patienten (35 %) erfullten die Kriterien fur HPS. Ergebnisse Serum-Gallensauren waren signifikant hoher bei Patienten mit HPS im Vergleich zu denen ohne (mediane Gesamt-Gallensauren 83,5 μmol/l, IQR 43,1 – 148,9 vs. 26,9 μmol/l, 11 – 75,6; p Schlussfolgerung Serum-Gallensauren sind mit dem Vorhandensein von HPS assoziiert und korrelieren mit dem Schweregrad der Butgasaustauschstorung. Zukunftige Studien sollten den Stellenwert der Gallensauren bei HPS sowie den Einfluss einer direkten Regulation des Gallensaure-Metabolismus untersuchen. Background Hepatopulmonary syndrome (HPS) occurs in 20 – 30 % of patients with cirrhosis and is associated with increased mortality. Cholestasis and accumulation of bile acids (BAs) play a major role in chronic liver disease. Aim We aimed to evaluate the clinical role of serum BAs in patients with HPS. Methods Seventy-four patients with cirrhosis were included in this prospective study. Marker for cholestasis as total and individual serum BAs, bilirubin, alkaline phosphatase (AP), and gamma-glutamyl transpeptidase (GGT) were analyzed in patients screened for HPS. Criteria of HPS were fulfilled in 26 patients (35 %). Results In contrast to AP and GGT, bilirubin and serum BAs were significantly elevated in patients with HPS (median total BAs in HPS 83.5 μmol/L, IQR 43.1 – 148.9 vs. no HPS 26.9 μmol/L, 11 – 75.6; p Conclusion BA retention is associated with HPS and gas exchange abnormalities. Future studies should assess whether modulation of BAs signaling may impact the course of HPS.

Endoscopic ultrasound-guided drainage of abdominal fluid collections after pancreatic surgery: Efficacy and long-term follow-up.

Abstract: Background/Purpose: Endoscopic ultrasound-guided drainage (EUS-GD) of postoperative abdominal fluid collections (POFC) following pancreatic surgery is used as an alternative or complement to percutaneous drainage (PD) procedure. The present single-center retrospective study evaluates its efficacy and safety. Method: We included consecutive cases with POFC treated by EUS-GD between September 2009 and November 2014 in our department. Technical success, long-term clinical success, recurrence rate and need for surgery were analyzed. Results: 24 procedures in 20 patients (95 % after pancreatic resection) were assessed. Indications for surgery included tumors/lesions located in the pancreas (15/20), chronic pancreatitis (3/20) and duodenal adenoma not completely resectable endoscopically (2/20). EUS-GD was performed within a median of 30 days (IQR: 8.25) for a median fluid collection size of 72.5 mm (IQR: 46.25), requiring a mean of 1.2 sessions with placement of a mean of 2.1 plastic stents (7 Fr/10 Fr) per patient for a mean of 89 days (IQR: 127). Microbiology of aspirated fluid revealed positive cultures in 13 patients, mostly polymicrobial, isolated positive for fungal and 3 multidrug-resistant gram negative (MRGN) in 4 cases. An additional transpapillary drainage was inserted in 1/20 patients. 4/20 patients received PD, mostly before EUS-GD. Technical and clinical success was achieved in 20/20 (100 %) and 18/20 (90 %) patients, respectively, while 2 patients required re-operation. During follow-up (median 630 days after stent removal, range: 45 – 2160), recurrence occurred in 1/18 (5.5 %) patient that was referred for surgery. No death or severe adverse events were noted. Conclusion: EUS-GD is an effective, minimally invasive and safe method for therapy of POFC after pancreatic surgery offering long-term remission in about 95 % of cases.

Endoscopic therapy for infected pancreatic necrosis using fully covered self-expandable metal stents: combination of transluminal necrosectomy, transluminal and percutaneous drainage

Abstract: Background/Aims: Endoscopic transluminal therapy has become the standard of care as a less invasive alternative to surgery. In a retrospective case series of two tertiary referral centers we report on an individualized concept combining EUS-guided drainage with self-expanding metal stents, direct transluminal debridement und percutaneous drainage. Methods: We treated 13 patients with infected pancreatic necrosis. Initially in all patients an EUS-guided drainage with plastic stents was performed under antibiotic protection (transduodenal: 2, transgastral: 11). After clinical consolidation (after 9.6 ± 9.4 days) a covered self-expanding metal stent (Niti-S, Taewoong medical Co., Seoul, Korea) was inserted by performing direct endoscopic necrosectomy in 2.9 ± 1.7 sessions through the stent. In cases of disrupted duct syndromes a pancreatic plastic stent was inserted (5 of 13 patients). In 5 of 13 cases additional percutaneous drainage was applied because of extended necrosis. In one patient percutaneous endoscopic drainage using the percutaneous access was needed. Results: A sustained clinical success was achieved in 12 of 13 cases (CRP before therapy 23.5 ± 14.4 mg/L, after 3.1 ± 2.6 mg/lL). Discharge occurred after 2.5 ± 22.4 days. The self-expanding metal stent was extracted after 82.5 ± 56.6 days. Mean follow up was 8.5 ± 5.9 months. Conclusion: Our concept of combining transluminal drainage, direct endoscopic necrosectomy and percutaneuos drainage offers a safe and reliable alternative to surgery, even in case of extended necrosis.

Ultrasonography for acute appendicitis - the way it looks today.

Abstract: 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.

Yellow fever vaccination during treatment with infliximab in a patient with ulcerative colitis: A case report.

Abstract: We report the case of a 59-year-old patient who accidentally underwent live vaccination against yellow fever during continuous treatment with the TNF-α-antibody (AB) infliximab for ulcerative colitis. The clinical course showed fever of short duration and elevation of liver enzymes without further clinical complications. Yellow fever viremia was not detectable and protective antibodies were developed. A primary vaccination against yellow fever under infliximab has not been reported in the literature before, although vaccination is an important topic in IBD. Live vaccinations, like Stamaril® against yellow fever, are contraindicated during TNF-α-AB treatment. Treatment regimens containing TNF-α-AB are of growing importance, not only in gastroenterology, but also in rheumatology and dermatology. We discuss this topic by presenting our case and reviewing the current literature.

Ultrasonography in acute diverticulitis - credit where credit is due.

Abstract: Diagnosing diverticulitis implies physical and laboratory examination, cross-sectional imaging (computed tomography [CT] or ultrasonography [US]), and a classification of the type of diverticular disease. This article illustrates the role of ultrasonography in view of the recently published Guidelines on diverticular disease of the Consensus Conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV). The focus is to foster both sensitivity for pictorial analysis and improving practical accomplishments of US in diverticulitis. Based on the German classification of diverticular disease (CDD), characteristic features of each type of diverticulitis are presented and commented along with possible differential diagnoses. In the literature qualified US is equipotent to qualified CT. US is frequently effective for the diagnosis and unsurpassed resolution enables detailed imaging thereby allowing one to differentiate and stratify the relevant types of diverticular disease according to the new classification. This educational review is a guided tour through the different facettes of diverticulitis on ultrasonography thereby expanding and multiplying individual competence to more users. With expert performance, US is in the pole position for diagnosing diverticulitis, however, this does come with the price of responsibility and requires transfer of advanced standards and performance in the broad.

Improvement in advanced pancreatic cancer survival with novel chemotherapeutic strategies - experience of a community based hospital.

Abstract: Background: New chemotherapeutic strategies for locally advanced or metastatic pancreatic ductal adenocarcinoma (PDAC) have been shown to improve survival in randomized clinical trials. Little is known about the use of such chemotherapies and their benefit in community-based hospitals. This retrospective study analyzes the overall survival of these patients under “real life conditions” before and after the introduction of FOLFIRINOX in 2011. Methods: We retrospectively identified consecutive patients with PDAC who were treated at our hospital from 2011 to June 2014 (2011+ cohort) and 2004 to 2010 (historical cohort). Patients were included if PDAC was diagnosed in a locally advanced or metastatic state and at least 1 cycle of chemotherapy was given. Survival was assessed until April 2016. Patients with FOLFIRINOX were further analyzed regarding drug administration and side effects. Results: 128 patients met the inclusion criteria. Of the 74 patients in the historical cohort, 62 patients received Gemcitabine. Of the 54 patients diagnosed between 2011 and June 2014, 28 patients received FOLFIRINOX and 22 Gemcitabine as the first-line chemotherapy. Only 34 % of the patients in the historical cohort received a second-line chemotherapy in comparison to 69 % in the 2011+ cohort. Median overall survival (OS) showed a survival of 13.1 months (95 % CI; 11.6 – 14.5) for the 2011+ cohort compared to 9.6 months (95 % CI; 6.1 – 13.1) in the historical group. Conclusion: This study shows a marked improvement in survival of patients diagnosed with locally advanced or metastatic PDAC in a community-based hospital during the past 4 years. The most likely reasons are the use of new polychemotherapies like FOLFIRINOX and the use of second-line chemotherapy.