Einleitung Die maligne Magenausgangsstenose kann zu einem hohen Ileus führen; ein Zustand, der mit dem Überleben des Patienten nicht vereinbar ist. Lange galten die chirurgische Gastroenterostomie (GE) oder das endoskopische Platzieren eines Metallstents in das Duodenum als gängige palliative Therapieoptionen für dieses Krankheitsbild. Die Endosonographie-gezielte GE (EUS-GE) gewinnt als wenig invasive alternative Behandlungsoption zunehmend an Bedeutung. Hierbei wird unter endosonographischer Sicht, ein vollständig beschichteter und selbstexpandierender Metallstent (Hot AXIOS™ Stent, Ø 20mm) so platziert, dass er Magen und Dünndarm verbindet. Ziel ist es, den Betroffenen durch Schaffung einer Umgehung der Magenausgangsstenose, wieder eine orale Nahrungsaufnahme zu ermöglichen.

Einleitung Obwohl IgG4 nur einen geringen Anteil der Serum-Immunglobuline ausmacht und bei immunologischen Mechanismen eine untergeordnete Rolle spielt, steigt die Prävalenz der IgG4- assoziierten Erkrankungen. Nahezu alle Organe können betroffen sein, wobei ein Befall der Speiseröhre selten auftritt. Anhand eines rezenten Falls berichten wir über die Schwierigkeiten der Diagnosestellung sowie der Therapie.

The columnar-lined mucosa at the gastroesophageal junction may contain an inflammatory infiltrate, commonly referred to as carditis (or cardia gastritis). The etiology of carditis is not entirely clear since published data are conflicting. Some authors believe it to be secondary to gastroesophageal reflux disease (GERD) and others to Helicobacter pylori gastritis. This prospective study aims at clarifying the relationship between carditis and the histological, clinical, and endoscopic findings of GERD, in a large cohort of individuals negative for H. pylori infection. Eight hundred and seventy-three individuals (477 females and 396 males, median age 53 years) participated in this study. Biopsy material was systematically sampled from above and below the gastroesophageal junction. Reflux-associated changes of the esophageal squamous epithelium were assessed according to the Esohisto consensus guidelines. Grading of carditis was performed according to the Updated Sydney System, known from the histological evaluation of gastritis. In total, 590 individuals (67.5%) had chronic carditis. Of these, 468 (53.6%) had mild chronic inflammation, with 321 individuals (68.6%) showing no or minimal changes on endoscopic examination (Los Angeles Categories N and M). The presence of chronic carditis was associated with several GERDrelated parameters of the esophageal squamous epithelium (P < 0.0001), and data retained statistical significance even when analysis was restricted to individuals with mild chronic carditis and/or endoscopically normal mucosa. Chronic carditis was also associated with the presence of intestinal metaplasia (P < 0.0001). In addition, chronic carditis had a statistically significant association with patients' symptoms of GERD (P = 0.0107). This observation remained valid for mild chronic carditis in all patients (P = 0.0038) and in those with mild chronic carditis and normal endoscopic mucosa (P = 0.0217). In conclusion, chronic carditis appears to be the immediate consequence of GERD, correlating with patients' symptoms and endoscopic diagnosis. These results are valid in individuals with nonerosive reflux disease, which indicates a higher sensitivity of histological diagnosis. Our findings may impact the routine assessment of reflux patients.

SummaryBackgroundFaecal microbiota transplantation is an experimental approach for the treatment of patients with ulcerative colitis. Although there is growing evidence that faecal microbiota transplantation is effective in this disease, factors affecting its response are unknown.AimsTo establish a faecal microbiota transplantation treatment protocol in ulcerative colitis patients, and to investigate which patient or donor factors are responsible for the treatment success.MethodsThis is an open controlled trial of repeated faecal microbiota transplantation after antibiotic pre‐treatment (FMT‐group, n = 17) vs antibiotic pre‐treatment only (AB‐group, n = 10) in 27 therapy refractory ulcerative colitis patients over 90 days. Faecal samples of donors and patients were analysed by 16SrRNA gene‐based microbiota analysis.ResultsIn the FMT‐group, 10/17 (59%) of patients showed a response and 4/17 (24%) a remission to faecal microbiota transplantation. Response to faecal microbiota transplantation was mainly influenced by the taxonomic composition of the donor's microbiota. Stool of donors with a high bacterial richness (observed species remission 946 ± 93 vs no response 797 ± 181 at 15367 rps) and a high relative abundance of Akkermansia muciniphila (3.3 ± 3.1% vs 0.1 ± 0.2%), unclassified Ruminococcaceae (13.8 ± 5.0% vs 7.5 ± 3.7%), and Ruminococcus spp. (4.9 ± 3.5% vs 1.0 ± 0.7%) were more likely to induce remission. In contrast antibiotic treatment alone (AB‐group) was poorly tolerated, probably because of a sustained decrease of intestinal microbial richness.ConclusionsThe taxonomic composition of the donor's intestinal microbiota is a major factor influencing the efficacy of faecal microbiota transplantation in ulcerative colitis patients. The design of specific microbial preparation might lead to new treatments for ulcerative colitis.

Einleitung: Der gastro-ösophageale Übergang (EGJ) besteht aus dem unteren Ösophagussphinkter sowie den Zwerchfellschenkel und dient dem Schutz der Speiseröhre vor saurem Mageninhalt. Seine Funktion wird mittels Druckmessung ermittelt. Da Bauchatmung im Gegensatz zur Brustatmung stärker das Zwerchfell involviert, war das Ziel dieser kontrollierten prospektiven Studie, die Druckveränderungen des EGJ während Brust-, Bauch- sowie Bauchatmung mit erhöhtem Atemwiderstand mittels Ösophagusmanometrie zu evaluieren.

Einleitung: Infektionen mit Clostridium difficile (CDI) können fulminant verlaufen und sind in dieser Situation mit eine hohen Mortalität assoziiert. Hohe Leukozytenzahlen (> 20 000), Alter > 75, Hypoalbuminämie, Organversagen, septischer Schock und Peritonitis sind Hinweise für fulminante Verläufe. Die fäkale Mikrobiota Transplantation (FMT) ist eine etablierte Therapie bei rezidivierenden CDI, die Rolle bei schweren Verläufen als Alternative zur totalen Kolektomie, der Therapie bei Versagen der medikamentösen CDI Behandlung, ist bis dato nicht gesichert.

Traditionally, Helicobacter infection is considered to be the most common cause of gastritis. Our study aimed to evaluate the significance of endoscopic diagnoses of gastritis in relation to histological findings, paying special attention to the aetiology of disease.

Untreated severe kyphoscoliosis is rarely observed nowadays. In affected patients dislocation of inner organs with functional impairment may occur [1] [2]. We present the unusual case of a patient with severe kyphoscoliosis who developed extensive esophageal ulceration.

chronic gastrointestinal bleeding. Colo− noscopy showed a longitudinal ulcer ex− tending from the ascending to the trans− verse colon (l" Fig. 1 a). Biopsies taken from the ulcer ruled out malignancy and inflammatory bowel disease. Despite ex− tensive diagnostic workup, including an− giography and CT scan, the cause of the ulcer remained unclear. The patient de− nied taking nonsteroidal anti−inflamma− tory drugs (NSAIDs). The patient received empiric treatment with antibiotics, ste− roids, and mesalamine (5−aminosalicylic acid, 5−ASA), but the ulcer persisted for 6 months on repeated endoscopy. During this period the patient required the trans− fusion of 17 units of red blood cells. Re− peated gastrointestinal hemorrhage fi− nally prompted right hemicolectomy. The resection specimen showed a 23−cm− long antimesenteric ulcer of the ascend− ing and transverse colon with a maxi− mum width of 3 cm (l" Fig. 1 b). Histolo− gical analysis disclosed chronic ulcera− tion with reactive epithelial changes (l" Fig. 1 c). Three months later the pa− tient again presented with lower gastro− intestinal bleeding. Colonoscopy showed a new longitudinal ulcer in the descend− ing colon and additional smaller ulcers in the ileum (l" Fig. 1 d). Despite repeated denial regarding NSAID intake, diclofenac and its metabolites were detected in the patient’s urine by high−performance li− quid chromatography. In the face of these results, the patient finally admitted to chronic NSAID consumption. NSAID−induced ulcers in the colon are usually reported as ring−like ulcers with the formation of diaphragms, or as well− circumscribed single or multiple flat ul− cers, especially in the right colon and around the ileocecal valve [1]. The unu− sual longitudinal appearance of the pres− ented ulcer has previously been referred to as “colon single−stripe sign” and is thought to be related to ischemia [2]. The occurrence of the colon single−stripe sign in a patient with chronic NSAID intake and the antimesenteric location of the mucosal defect support the concept that NSAID−related colonic ulcers may be caused by local ischemic injury due to lib− eration of vasoconstrictive metabolites and/or vascular spasms [3].

Das Cronkhite-Canada-Syndrom ist eine seltene nichtneoplastische Polypose-Erkrankung des gesamten Darmrohrs, kompliziert durch lebensbedrohlichen Eiweissverlust. Insgesamt wurden seit der Erstbeschreibung 1955 weltweit mehr als 400 Fälle berichtet. Die Ursache und Pathogenese liegen im Unklaren. Ein 71jähriger Patient präsentierte sich nach mehrwöchiger Diarrhoe mit einem Serumalbumin von 1,9g/dl und einem Serumgesamteiweiss von 3,8g/dl. Die klinische Untersuchung zeigte deutliche Unterschenkelödeme. Weiters konnten auch die für Cronkhite-Canada-Syndrom typischen Hautveränderungen (periaurikuläre Alopezie, Finger- und Zehennagelveränderungen, Hyperpigmentierung) gefunden werden.

Pharyngoesophageal gastric acid reflux is thought to initiate chronic posterior laryngitis. The gold standard for measuring gastric reflux is dual-channel 24-hour pH monitoring. This is a time-consuming, inconvenient, expensive method that is not available in all areas. New therapeutic regimes that make use of proton pump inhibitors (PPIs) have proven to be therapeutically efficient for control of acid reflux. Twenty-four consecutive patients with chronic voice disorders and signs of posterior laryngitis were selected for therapy. Twenty-four hour pH monitoring was performed independently before the therapy. The trial therapy consisted of all patients receiving pantoprazole, 40 mg once daily for 6 weeks. Immediately following the therapy a statistically significant (p < 0.05) improvement was observed in all patients. This improvement was analyzed retrospectively by comparison with the results of 24-hour pH monitoring. In 71% of the patients the 24-hour pH-monitoring gave a positive result showing a high number of patients with extraesophageal reflux in our study group. Patients with positive results of pH-monitoring responded in a statistically significant manner (p < 0.05) to the pantoprazole therapy, whereas those patients without detected reflux did not. A 3-month follow-up of the patients with a positive result of the pH-monitoring confirmed the improvement. No patients reported adverse effects. A 6-week treatment with pantoprazole can be clinically justified. It helps to save time and reduce costs, allows for selection of reflux-negative patients for alternative therapy, and may prevent inadequate treatment of patients with false-negative pH monitoring. Twenty-four hour pH monitoring is still recommended for patients unresponsive to this trial therapy.

A subglottic tophaceous deposition of urate crystals is a rare finding. We report on a case of a male Caucasian who had a moderate dysphonia without any further laryngeal symptoms. The laryngoscopy revealed a hemispheric lesion on the left subglottic region. An excision biopsy was performed, and the histopathological examination of the dissected specimen showed a tophus. Diagnostic and therapeutic strategies are discussed.

The aim of this study was to investigate whether patients with chronic posterior laryngitis and symptoms of gastro-pharyngeal reflux benefit from a six-week therapy with pantoprozole. Twenty-nine out-patients with voice disorders (case history of at least two months) and simultaneous symptoms of gastro-pharyngeal reflux were recruited for this study. At the entry to the study a symptom questionnaire and a video-laryngo/stroboscopy were completed. The symptom questionnaire and the video-laryngo/stroboscopy were repeated after the six weeks of therapy with pantoprazole 40 mg once a day and again six weeks and three months after this follow-up, during which time the patient was without therapy. Hoarseness, globus pharyngeus, sore throat, heartburn, and coughing were the symptoms which showed a significant (p < 0.05) recovery at the follow-ups (mean of hoarseness index: 7.28 to 0.92; mean of globus pharyngeus index: 3.14 to 0.58; mean of heartburn index: 2.86 to 0.5; mean of cough index: 1.72 to 0.25; mean of throat soreness index: 1.72 to 0.15). Laryngoscopy scores of the posterior laryngeal region, the glottic and the supraglottic region showed statistically significant improvement (p < 0.05) after the treatment with pantoprazole. The therapeutic effect exceeded the drug administration until the last follow-up (after three months). The medication was tolerated without side-effects in all patients. A primary (ex juvantibus) therapy with proton pump inhibitors seems to be a therapeutic option for patients with long-lasting chronic inflammation of the larynx not responding to common therapy. In this case a six-week course of treatment has been shown to be sufficient.

The effect of cyclosporin was evaluated in six patients with severe ulcerative colitis not responding to at least 8 days of standard therapy with intravenous corticosteroids. Cyclosporin (5-7.5 mg/kg/day intravenously) was added while steroid therapy was continued. Five of 6 patients responded after a mean of 7 days and colectomy was not necessary. After 4 weeks three patients achieved clinical remission or had mild symptoms and were weaned from cyclosporin and corticosteroids without exacerbation within the next 7-15 months. Two patients improved and they were put on oral cyclosporin. One of them relapsed after 2 weeks and then responded to high dose corticosteroids. This patient is doing well at 8 months of followup on azathioprine and steroids. One patient stopped oral cyclosporin after 3 months abruptly and then had a relapse. He subsequently improved while refusing any medical therapy. Side effects of cyclosporin occurred in 2 patients but were mild and self limited and did not necessitate discontinuation of the drug. Cyclosporin appears to be effective in a large portion of patients with severe ulcerative colitis who failed to improve on corticosteroids and in whom colectomy would otherwise be considered.

Eighty-eight endoscopists (mean age 41 years, range 29-76 years) and a control group of 100 persons of similar ages were investigated for the prevalence of antibodies (ABs) to Helicobacter pylori, using a quantitative enzyme-linked immunosorbent assay (ELISA) to IgG, two semiquantitative re ELISAs to IgG and IgA, and a latex test to IgG and IgM antibodies. The prevalence of antibodies to H. pylori in endoscopists was 48 % (quantitative ELISA), 56 % (semiquantitative ELISA to IgG), 62 % (lates test), and 57 % by combined evaluation of semiquantitative ELISAS to IgG and IgA. The respective numbers in the control group were 47 %, 48 %, 48 % and 51 %. None of the differences was significant. In both groups, endoscopists and controls, there was a significantly higher H. pylori positivity in older subjects compared to younger persons, but there was no difference between the two groups. The prevalence of ABs was independent to the number of endoscopies previously performed, and independent of protective measures taken, such as wearing gloves during the procedures. Antibody titers as measured with quantitative ELISA showed a positive correlation with the length of time the subject had been active as an endoscopist, but no correlation with the total number of endoscopies performed. In conclusion,,the prevalence of ABs to H. pylori in endoscopists follows the age-dependent pattern known from the general population. The regular performance of gastrointestinal endoscopies poses no additional risk of infection with H. pylori in Austria.

Objective: To point out the importance of spontaneous bacterial peritonitis which is now diagnosed in 18-27% of patients hospitalized with cirrhosis of the liver and ascites and the mortality of which is very high and may approach 100% if it remains undiagnosed or if treatment is delayed. Diagnosis: The protein concentration of ascitic fluid can identify patients at high risk, particularly if it is below 1g/dl. The polymorphonuclear cell (PMN) count of the ascitic fluid is most important. PMN counts of more than 250 cells/mu-l are diagnostic in the presence of a positive bacterial culture. Without positive culture 500 PMNs per mu-l are considered to be diagnostic. Differentiating the spontaneous form from secondary bacterial peritonitis is essential because the appropriate treatment for the latter is surgical. Management and treatment: Cefotaxime or a combination of amoxycillin and clavulanic acid appear equally effective for the treatment of spontaneous bacterial peritonitis with over 80% success rate. Selective intestinal decontamination may be useful in some patients. Patients who were already candidates should be considered for prompt liver transplantation as soon as they have recovered from spontaneous bacterial peritonitis. Conclusion: The possibility of spontaneous bacterial peritonitis should be considered in every case of cirrhosis of the liver, since early diagnosis and prompt treatment are essential for the patient's survival.