Abstract:X-linked hyper IgM-syndrome caused by CD40L deficiency is a rare primary immunodeficiency. Affected male individuals who reach adulthood often develop sclerosing cholangitis. Here, we report the case of a 33-year-old patient with long-standing solitary pre-papillary bile duct stenosis but without further signs of sclerosing cholangitis, who developed distal cholangiocarcinoma. Given the increased risk of malignancy in these patients, this case highlights, that individuals with CD40L deficiency should be screened for the presence of cholangiopathy and be closely monitored for any signs of disease progression, development of hepatobiliary dysplasia or malignancy.
Abstract Dysplasia (biliary intraepithelial neoplasia-BilIN) at the cystic duct surgical margin is uncommon. However, no clear guidelines exist regarding optimal management. This study aimed to evaluate management strategies for cystic duct dysplasia (BilIN) detected at the surgical margin based on the available literature. A literature search was conducted using PubMed and Google Scholar to identify reports of dysplasia or BilIN involving the cystic duct margin in patients undergoing cholecystectomy for benign indications. Eight studies comprising 12 cases were included. High-grade dysplasia was the predominant histopathological finding. Magnetic resonance cholangiopancreatography was performed in 10 cases and revealed findings suspicious for malignancy in two. Nine of 12 patients underwent complementary procedures. Two patients had low-grade dysplasia with negative surgical margins. One patient had a missed cholangiocarcinoma located at the distal cystic duct. In nine cases, only fibrosis was observed in the cystic duct stump. No malignant transformation was reported during follow-up. Routine complementary surgery for cystic duct margin dysplasia may represent overtreatment in the absence of suspicious radiologic findings. An image-guided, selective reoperation strategy appears appropriate.
Abstract:Coffee-ground emesis in a patient with cirrhosis frequently triggers an emergency pathway for suspected variceal upper gastrointestinal bleeding (UGIB) and urgent endoscopy. However, diagnostic anchoring may delay recognition of alternative life-threatening conditions. A 68-year-old man with decompensated liver cirrhosis (Child-Pugh B), large-volume ascites, COPD GOLD grade 3 with chronic global respiratory failure developed shock and recurrent vomiting of coffee-ground material and fresh blood on a gastroenterology ward. Variceal bleeding was initially suspected. After transfer to ICU, he deteriorated with severe hypoxaemia and progressive ventilatory compromise. A markedly tense, distended abdomen prompted point-of-care ultrasound (POCUS), which demonstrated extensive pneumoperitoneum. Emergency percutaneous decompression via a standard paracentesis needle evacuated free intraperitoneal air under tension with rapid respiratory improvement. Urgent oesophagogastroduodenoscopy showed no evidence of upper gastrointestinal perforation or variceal bleeding. Computed tomography confirmed diffuse pneumoperitoneum and suggested pathology at the ileocaecal transition; surgery revealed perforation of the ascending colon with localized peritonitis. This case highlights the importance of whole-patient reassessment before emergency endoscopy, early use of POCUS when abdominal findings are discordant, and interdisciplinary crisis management. Needle decompression can be lifesaving as a bridge to definitive surgery in tension pneumoperitoneum.
Zusammenfassung Steigende Antibiotikaresistenzen (insbesondere gegen Clarithromycin und Levofloxacin) senken die Eradikationsraten bei Helicobacter (H.) pylori-Infektionen. Etablierung und Evaluierung eines mikrobiologischen Routineverfahrens zur H.-pylori-Resistenztestung am Universitätsklinikum Leipzig, um die lokale Resistenzepidemiologie zu erfassen, resistenzangepasste Eradikationstherapien zu optimieren und einen Antibiotic-Stewardship-Ansatz zu unterstützen. Prospektive monozentrische Observationsstudie mit Einschluss von Erwachsenen, Kindern und Jugendlichen. Im Rahmen ambulanter Gastroskopien gewonnene Biopsien aus Antrum und Korpus wurden mikrobiologisch kultiviert (phänotypische Resistenztestung) und mittels spezifischer PCR (molekulargenetischer Erreger- und Resistenznachweis) untersucht. Von 2017 bis 2020 wurden Biopsien von 260 Erwachsenen und 81 Kindern analysiert. Der kulturelle Nachweis gelang bei Kindern häufiger (19,8% vs. 8,8%, p=0,007); insgesamt wurden 39 H.-pylori-Stämme isoliert. Resistenzen zeigten sich gegen Metronidazol (40%), Clarithromycin (12%) und Levofloxacin (8%). Clarithromycin-Resistenzmutationen (23S-rRNA-Gen) lagen bei 5% der Erwachsenen und 16,7% der Kinder vor. Die Kultivierung dauerte 10 Tage, die Resistenztestung weitere 4 Tage. Eine systematische H.-pylori-Resistenztestung ist klinisch sinnvoll. Die routinemäßige Laboranzucht unterliegt im Alltag jedoch Limitationen und erfordert hohen Aufwand.
Background:Solitary fibrous tumours (SFTs) are rare mesenchymal neoplasms that may cause insulin-independent hypoglycaemia (Doege-Potter-syndrome). Although surgical resection is the standard treatment, non-surgical options may be required for elderly or multimorbid patients. Case Presentation:An 82-year-old woman presented with severe nocturnal hypoglycaemia (<40mg/dl) and progressive weakness. Imaging revealed a large hypervascular retroperitoneal mass. Laboratory findings showed low insulin and C-peptide levels with an IGF-II/IGF-I ratio of 9.3, indicating paraneoplastic hypoglycaemia. Biopsy demonstrated low-grade malignant SFT with STAT6 and CD34 positivity. Because of advanced age and comorbidities, dexamethasone (8mg/day) was initiated, followed by two selective transarterial embolizations over 6 months. Hypoglycaemia resolved rapidly, allowing dexamethasone reducing to 1.5mg/day. At 9-month follow-up, only rare hypoglycaemic episodes remained and were managed with regular meals and low-dose dexamethasone. Conclusion:Combined glucocorticoid therapy and selective embolization may provide sustained glycaemic control in elderly patients with retroperitoneal SFT and Doege-Potter syndrome when surgery is not feasible.
Abstract:This review critically analyses a systematic review with a network meta-analysis (NMA) on the effectiveness of endoscopic interventions for gastroparesis by Eckhardt et al. (Eckhardt D, et al. BJS 2025;112. DOI: 10.1093/bjs/znaf183) is critically analysed in the light of the literature. The results show that, by restricting the network exclusively to interventional procedures - G-POEM, pyloroplasty, GES and botulinum toxin injection - drug-based and dietary therapies were not taken into account, even though these constitute first-line treatment in most consensus guidelines; furthermore, the aggregation of heterogeneous outcome measures and the predominance of non-randomised retrospective studies with often inadequately controlled participant selection further undermine confidence in the ultimately proposed ranking of treatment approaches. Due to the complex pathophysiology, patient selection and the differentiation between gastroparesis and functional dyspepsia are essential for the success of endoscopic treatment.
Background:Colorectal cancer (CRC) is a leading cause of cancer-related morbidity and mortality. Physicians serve as role models for preventive care, yet data on CRC screening uptake among German visceral medicine specialists are scarce. Methods:An anonymous, questionnaire-based cross-sectional survey was conducted among participants of the Visceral Medicine 2021 Congress in Leipzig. Physicians reported sociodemographics, personal colonoscopy participation and lifestyle factors. Descriptive and inferential analyses were performed. Results:Of 369 physicians included, 54.4% had undergone a colonoscopy. Among those aged ≥ 50 years (n = 177), 81.9% had participated, three-quarters within the CRC screening program. Notably, 28.9% of physicians < 50 years had already undergone colonoscopy, mainly for screening purposes. Outpatient physicians were significantly more likely to have undergone colonoscopy, independent of age and sex. Medical specialty was not significantly associated with participation. Conclusions:Visceral medicine physicians show higher CRC screening participation than the general population. Lower participation among hospital-based physicians suggests structural disparities warranting further investigation.
Kurzfassung In der gastroenterologischen Endoskopie wurden erhebliche Fortschritte erreicht, die sie vielfach zur Therapie der ersten Wahl hat werden lassen. Mehrere Leitlinien und Publikationen der DGVS machen Vorgaben zur Qualität der Endoskopie, Mindestzahlen zum Kompetenzerwerb und Kompetenzerhalt sind bislang aber nur partiell adressiert. Daher haben wir Vorschläge für Mindestzahlen für fortgeschrittene endoskopische Prozeduren und zur Implantation eines TIPS erarbeitet. Wenn möglich folgen sie vorliegender Evidenz, ansonsten der Erfahrung der Autorinnen und Autoren. Vorausgesetzt werden Kompetenzen in der diagnostischen Gastroskopie und Koloskopie inklusive einfacher Prozeduren sowie eine strukturierte Weiterbildung durch erfahrene Trainer. Auch ex-vivo Modelle können eingerechnet werden. Wir schlagen zum Kompetenzerwerb 70 Endoskopische Mukosaresektionen von Polypen >2cm (schwache Evidenz), 60 Endoskopische Submukosadissektionen (moderate Evidenz), 15 Vollwandresektionen (keine Evidenz), 200 ERCPs (gute Evidenz), 225 Endosonographien (schwache Evidenz), 50 endoskopische Blutstillungen (schwache Evidenz) und 25 POEM (für ESD erfahrene Endoskopiker) vor. Für TIPS-Anlagen schlagen wir 20 pro Jahr pro Zentrum vor (gute Evidenz). Keine Basis für eine gesonderte Empfehlung sehen wir beim Stenting und bei Verschlusstechniken. Eine breite Implementierung dieser Vorgaben kann zu einer Verbesserung der Versorgungsqualität führen und ist Voraussetzung zur Bildung endoskopischer Zentren.
Abstract:A 19-year-old female presented with recurrent upper abdominal pain, pruritus, and jaundice. Imaging and endoscopic evaluation revealed a high-grade biliary stricture in the hilum and left hepatic bile duct with a tumor-like lesion. Repeated brush and fluoroscopic guided biopsies failed to yield a definitive diagnosis. Using SpyGlass DS single-operator cholangioscopy, targeted biopsies were obtained, indicating a benign mesenchymal neoplasm. Due to persistent cholestasis and suspected malignancy, left hemihepatectomy was performed. Final histopathology revealed an inflammatory fibroid polyp of the intrahepatic bile duct - a previously undocumented localization. The patient recovered fully after surgery. This case highlights that inflammatory fibroid polyps can present as biliary tumors and underscores the diagnostic value of SpyGlass DS cholangioscopy in evaluating indeterminate biliary strictures.
Background and study aims:Video capsule endoscopy (VCE) is an established approach for small bowel (SB) examination. In 2022, the European Society of Gastrointestinal Endoscopy (ESGE) updated its guideline on VCE use. However, little is known about guideline implementation in daily clinical practice. Methods:Between June and August 2025, we performed a nationwide online survey on VCE use in Germany. A questionnaire was distributed to gastroenterologists in Germany performing VCE in in- or outpatient settings. Results:The main indications for VCE were SB bleeding and iron deficiency anaemia. In 2024, most physicians (48.2%, 82/170) performed 10 to 30 VCE procedures, mainly using the Pillcam system. In patients with active SB bleeding VCE was performed promptly. For elective cases, the waiting time for VCE was typically no more than two weeks (86 %, 141/164). Results:Nearly all participants (99.4%, 156/157) used laxatives for bowel preparation. VCE interpretation is time-intensive, with most participants (34.8%, 55/158) requiring 31 to 45 minutes per case. Overall, participants considered VCE to be a valuable diagnostic tool; however, reimbursement was widely perceived as inadequate. Conclusion:This first nationwide study on the use of VCE in Germany shows that VCE remains a niche diagnostic tool with relatively few procedures per centre. Despite time-intensive interpretation and perceived inadequate reimbursement waiting times are generally short.
Abstract:Metabolic dysfunction-associated steatotic liver disease (MASLD) has undergone a major conceptual shift from a steatosis-centred condition to a disease spectrum, in which advanced fibrosis is the major prognostic determinant. It affects up to one-third of the adult population but remains asymptomatic in the majority of patients. Therefore, the efficient identification of at-risk individuals is a central clinical task. Non-invasive tests increasingly complement histological staging and are embedded in sequential diagnostic algorithms. In particular, FIB-4, as a first-line screening tool followed by vibration-controlled transient elastography for liver stiffness assessment, has been adopted by expert recommendations and clinical guidelines. Abstract:These non-invasive tests have proven relevance to clinical endpoints beyond risk stratification and indications for MASLD-specific therapy. However, dynamic changes and their prognostic implications during treatment require further prospective evaluation. This review summarizes the current diagnostic strategies for MASLD and discusses their implementation in the German healthcare context.
Background:The intrathoracic herniation of the pancreas is extremely rare 1 2 3. A review of the literature identified only 37 cases reported since 1981 unrelated to prior esophagectomy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35. Symptoms may be absent, nevertheless cholestasis or acute pancreatitis can occur and so three subtypes can be classified 3. Case Series:We report three cases of intrathoracic pancreatic herniation associated with Type IV hiatal hernia. One patient showed elevated cholestasis. None developed acute pancreatitis. Two patients underwent surgery, one was treated conservatively. Literature review and discussion:Hiatal hernias are often asymptomatic but may cause thoracic, or gastrointestinal symptoms 9. Surgery indication and timing remain controversial 1 2 36 37. Intrathoracic pancreatic herniation is rare and technically challenging, especially the pancreatic repositioning 1 2 3 34. Cholestasis or pancreatitis has been reported mainly in cases involving herniation of the pancreatic body and tail. Based on the clinical presentation, three subtypes can be defined 3 19. We analyzed the published cases and our own, classifying them by the herniated pancreatic portion and corresponding subtype. Conclusion:None of our patients developed acute pancreatitis, regardless of the herniated pancreatic portion. Given the rarity, individualized management and continued case reporting are essential to improve understanding and guide optimal treatment.
Background:Esophageal adenocarcinoma in patients with liver cirrhosis and portal hypertension presents significant treatment challenges. This case highlights a multidisciplinary approach involving transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic submucosal dissection (ESD) for tumor resection. Case Presentation:A 60-year-old male with newly diagnosed liver cirrhosis was referred for routine esophagogastroduodenoscopy (EGD) to screen for esophageal varices. Endoscopy revealed an exophytic lesion in the distal esophagus (Paris 0-Ip) over a column of varices, and biopsy confirmed adenocarcinoma. Following a multidisciplinary tumor board discussion, the patient underwent TIPS to reduce portal hypertension, allowing for a safer endoscopic resection. Intervention:After successful TIPS implantation and a significant reduction in portal pressure, ESD was performed. The tumor was removed en bloc, and histopathological examination confirmed curative resection with negative margins and no lymphovascular invasion. Conclusion:This case demonstrates the successful management of early-stage esophageal adenocarcinoma in a cirrhotic patient with severe portal hypertension using a combination of TIPS and ESD. It underscores the importance of a multidisciplinary strategy in managing complex cases.
