Z Gastroenterol 2016; 54 Mehr als 60 000 Neuerkrankungen und mehr als 25 000 Todesfälle pro Jahr sind in Deutschland dem Darmkrebs zuzuschreiben [1]. Zur Vorsorge und Früherkennung des kolorektalen Karzinoms gibt es wirksame Maßnahmen. Randomisierte Studien haben nachgewiesen, dass der Guajak fecal occult blood test (gFOBT) und die Sigmoidoskopie zu einer Senkung der KarzinomInzidenz und der Mortalität führen. Für die Koloskopie gibt es indirekte Evidenz aus Langzeit-Kohortenstudien, die eine ähnliche Wirkung nahelegen [2, 3]. Seit Einführung der Vorsorgekoloskopie 2002 in die Regelversorgung haben bisher nur rund 23 % der Anspruchsberechtigten an der FrüherkennungsKoloskopie teil genommen [4].

Einleitung: Mittels Kapselendoskopie (KE) und CT-Colonografie (CTC) können Neoplasien des Kolons identifiziert werden. Studien untersuchen den Einsatz von CTC und KE als Screeninginstrumente. Der Nutzen dieser Verfahren in der Kolonkarzinom- und Adenom-Nachsorge ist unklar.

Fragestellung: Die bayerische Kohortenstudie DiMelli untersucht die rapide steigenden Inzidenzen und möglichen Überlappungen der verschiedenen Diabetesphänotypen im Kindes- und Jugendalter.

Einleitung: Männer erkranken 4 bis 8 Jahre früher am kolorektalen Karzinom als Frauen. Leitlinien zur Früherkennung empfehlen den Start des Screenings bei beiden Geschlechtern ab dem gleichen Alter.

BACKGROUND AND STUDY AIMSData on process quality and complications of colonoscopies are sparse, especially for the screening setting. We describe process quality in routine care, estimate the incidence of acute complications, and identify risk indicators for substandard care and complications.PATIENTS AND METHODSWe analyzed data from 236 087 compulsory health insurance (CHI) members who underwent colonoscopies in 2006. Data were documented prospectively in the Electronic Colonoscopy Documentation of the Bavarian Association of CHI Physicians, a registry of outpatient colonoscopies performed in practices throughout Bavaria, Germany. It covers demographic characteristics, indications, quality indicators, macroscopic and histological findings, diagnoses, and acute complications.RESULTSColon preparation resulted in clear bowels in 76.31 % of patients, liquid residues in 22.22 %, and dirty bowels in 1.47 %. In total, 92.85 % of the examinations were performed with patients under sedation/analgesia and 97.43 % of colonoscopies were complete. Photo documentation was present for 98.87 %. Male sex, middle age, screening, satisfactory bowel preparation, and sedation/analgesia were associated with completeness. A total of 735 patients (0.31 %) suffered complications, among them 520 bleedings (0.22 %), 69 perforations (0.03 %), and 152 cardiorespiratory complications (0.06 %). Male sex, higher age, nonscreening indication, biopsies, polypectomies, and absence of sedation/analgesia were indicative of a higher bleeding risk. Perforations were also related to biopsies and polypectomies. Higher age was the only discernible risk indicator for cardiorespiratory events.CONCLUSIONSOutpatient colonoscopy is a safe procedure with a low risk of acute complications. Improving bowel preparation enhances completeness. Sedation/analgesia is conducive to both completeness and the lowering of the risk of acute complications.

INTRODUCTION:Screening colonoscopy is an effective means for early detection of colorectal carcinoma. Any exhaustive evaluation of the method must take further factors into account: epidemiology of colorectal adenomas and carcinomas in the target population, acceptance by the patients, structure, process, and outcome quality, and health economics.METHODS:The internet-based colonoscopy database of the Bavarian Association of Statutory Health Insurance Physicians (ASHIP) for the year 2006 includes data on 86.05% of all outpatient colonoscopies performed in Bavarian ASHIP patients, or a total of 245 263 documented examinations.RESULTS:The rate of participation in preventive colonoscopies was low (1.5%) and showed considerable geographical variation. The rate of detection of histologically confirmed colorectal neoplasia in symptom-free screened individuals was almost 26.0%. Some 1.3% of those screened had colorectal carcinoma. In 76.31% of the participants a completely clean gut was achieved. The incidence of bleeding, perforation, and cardiorespiratory complications was 0.22%, 0.03%, and 0.06%, respectively.DISCUSSION:The complication rate of outpatient colonoscopy is on the order of tenths of a percent, while the process quality is high. The rate of detection of colorectal adenoma and carcinoma is high and the projected benefits for public health are considerable, but the rate of participation is too low.

Objective: To assess the process quality of colonoscopies and identify factors associated with substandard quality in a large outpatient series. Rationale: The importance of colonoscopy for prevention of colorectal carcinoma is rising. Maximum effectiveness and safety require adherence to international standards such as the 2006 ASGE quality indicators. Studies report results on particular quality aspects. There exists no report on the simultaneous findings for an extensive panel of indicators. Patients and methods: Since January 2006, outpatient colonoscopies performed by Compulsory Health Insurance Physicians in Bavaria, Germany are documented via online access to a central database. As of September 2006, 145,401 examinations have been recorded (110,658 curative or tumor aftercare, 34,743 screening). The database covers demographic characteristics, colonoscopy indications, process quality indicators, macroscopic and histological findings, diagnosis, acute complications, and further diagnostic and therapeutic recommendations. Results: Colon preparation achieved a clean bowel in 110.648 of the 145,401 patients (76.1%, 95% CI 75.9-76.3), liquid residues were present in 32,479 (22.3%, 95% CI 22.1-22.6), a dirty bowel in 2,274 cases (1.6%, 95% CI 1.5-1.6). The vast majority of examinations was undertaken under sedation/analgesia (n = 134,655; 92.6%, 95% CI 92.5-92.8). 141,425 colonoscopies reached cecum or ileum (97.3%, 95% CI 97.2-97.4), only 3,976 examinations were incomplete. Photo documentation was present in 99.0% (95% CI 99.0-99.1). Reasons for incomplete examinations were given as follows: adhesions (n = 512, 12.9% of incomplete colonoscopies, 95% CI 11.9-14.0), impassable stenosis (n = 506, 12.7%, 95% CI 11.7-13.8), long and curved colon (n = 284, 7.1%, 95% CI 6.4-8.0), complications (n = 50, 1.3%, 95% CI 0.9-1.7); no reason was specified in 1,361 cases (34.2%, 95% CI 32.8-35.7). Logistic regression analysis revealed a higher risk for incomplete colonoscopies in older patients (OR 1.02 per year, 95% CI 1.01-1.02), insufficient bowel preparation (OR 13.62; 95% CI 12.27-15.12) or liquid residues (OR 1.16; 95% CI 1.08-1.26), and in curative colonoscopies (OR 2.05, 95% CI 1.87-2.24). Male (OR 0.786, 95% CI 0.74-0.84) and sedated patients (OR 0.40, 95% CI 0.37-0.44) were more likely to have a complete colonoscopy. Conclusions: For the first time, we report findings for a large range of process quality indicators for outpatient colonoscopies. They may serve as a benchmark for comparisons with other programs. Sedation and thorough bowel cleansing are modifiable factors conducive to the completeness of colonoscopies.

Introduction: Since the start of the German colonoscopy screening program for Compulsory Health Insurance (CHI) members in October 2002, documentation has been paper-bound, and digitization has proved error-prone. Moreover, carcinoma stages were not documented in many cases, because of the time lag (weeks or even months) between the initial colonoscopy and the receipt of the hospital discharge letter after an operation. Data on curative colono-scopies (80% of all outpatient colonoscopies) were not recorded. To resolve these problems, the Association of CHI Physicians in Bavaria (KVB) introduced a central database for docu-mentation of preventive and curative colonoscopies via online access in the beginning of 2006. Setting: The physicians document colonoscopies via web portal, secured by login and SSL encryption. For data protection, storage of patient data is pseudonymous. Inbuilt plausibility checks improve data quality. The content of the existing Germany-wide documentation was largely adopted and supplemented by data on indication in case of curative colonoscopies. Workflow benefits from the electronic form. For example, carcinoma stages are collected on a separate form, which is created automatically as soon as a relevant diagnosis is entered. In-formation on cancer stages is merged with examination data later on. The documenting physi-cians have access to online feedback reports comparing statistics of their colonoscopies to the average of all documented examinations. Epidemiological evaluation of these data allows studying questions in health care services research. Results: Currently, 430 physicians are documenting via the portal. This covers 80% of the outpatient colonoscopies in a population of 12 million people. As of November 2006, 150,000 documentations on curative and 46,000 on screening colonoscopies have been submitted. Data quality improved substantially compared to the paper based documentation. For exam-ple, the percentage of surveyed carcinoma stages increased from 5-10% to 70% (values with-out subsequent inquiries by telephone). Conclusions: Online documentation via web portal has proved technically feasible, secure, and comfortable. Pseudonymity protects the privacy rights of the patients. The feedback re-ports with their informative and educative intentions are well accepted by the participating physicians. Therefore, besides benchmarking, the portal offers a reliable basis for health care services research.

Introduction: Preceding investigations of quality of hygiene of endoscope disinfection showed a failure in 50%(1) to 60%(2) in ambulatory settings. Mandatory hygiene control and certification for ambulatory endoscopy centers were introduced thereafter. The comparison of microbiological testing results before and after the introduction of hygiene controls are presented.Methods: In the first study (1) all ambulatory endoscopy centers (aec) were invited to participate in a hygiene control study, voluntarily. In the following study(2) all endoscopists applying for reimbursement of colonoscopy had to have undergo a hygiene control, performed by authorised microbiological laboratories as in (1) . Methods of endoscope reprocessing (automatically-chemo-thermal (act), semi-automatically (sa) and manually (m)) were documented. Microbiological specimens were taken from distal end, working channel, air-water channel of the endoscopes after reprocessing and the water rinse system. Identification of bacterial count > 10 CFU/ml and/or culture of E. coli, Enterobacter (EB), Enterococci (E), P. aeruginosa (PA) or other non fermenting gram- rods (NFG) in the endoscope channel flushing fluid were considered as failures.Results: In the (1) study 1271 endoscopes (52% gastroscopes (g), 40% colonoscopies (c), 7% duodenoscopes (d)) in 577 endoscopy centers were investigated. Bacterial contamination after disinfection were shown in 75% (498/661), 74% (n=380/513) and 55% (n=54/97) of g, c and d tested, respectively. In the (2) study 1170 endoscopes (45% g, 57% c, 7% d) of 592 aecs were investigated. 79/1170 (6,7%) endoscopes (6% (n=31/494) g, 9% (n=47/519) c, 1,2% (1/81) d) showed bacterial contamination. Comparing to the preceding results, the contamination of g (75% vs 6%), c (74% vs 9%) and d (55% vs 1,2%) decreased clearly . The methods for reprocessing applied differed (act 25% vs 56,6%, sa 21% vs 16,7%, m 53% vs 26.6%) between study 1 and 2. Different rates of successful reprocessing of endoscopes (84% vs 97% act, 60% vs 81% sa, 56% vs 87% m) were shown as well. Conclusion: The introduction of a mandatory hygiene control measurement may have caused an increasing implementation of act reprocessing. Consequently the failure rates decreased clearly. In order to avoid the risk of nosocomial infection by gi endoscopes it is advisable to implement mandatory hygiene control. (1)L. Bader, G. Blumenstock, B. Birkner et al. Z Gastroenterol 2002;40:157 (2) Birkner B, G. Blumenstock, A Munte et al. JCHAO. Chicago, Oct 2003.

Entsprechend dem Allparteienbeschluss soll bis Ende 2005 das Mammographie-screening flächendeckend in Deutschland eingeführt werden. Gleichzeitig wird und wurde seitens der Politik immer gefordert, das dezentrale Gesundheitssystem zu respektieren.

A 46-year-old woman with a histologically, immunoserologically and biochemically confirmed chronic destructive non-suppurative cholangitis in the stage of incipient primary biliary cirrhosis developed an erosive, hemorrhagic cholangitis of obscure etiology with massive life-threatening bleeding from the biliary tracts. Hemobilia could be diagnosed endoscopically and confirmed by exploratory laparotomy. Postoperatively the biliary tracts were washed out with Tachostyptan, Ugurol and Trasylol through a T drain. The bleeding stopped within 48 hours and has not recurred since.

Von 7000 untersuchten Blut- und Plasmaspendern konnte bei 95 das Australia-Antigen im Serum nachgewiesen werden. Alle 95 AuAg-positiven Spender wurden auf das Vorliegen einer Leberkrankheit klinisch und laborchemisch untersucht. 62 von diesen 95 Antigenträgern konnten einer Leberbiopsie mit feingeweblicher Untersuchung zugeführt werden. Nur 13 (=21 %) dieser 62 Spender waren histologisch lebergesund. Bei 10 (=16 %) bestand eine floride Hepatitis, bei 9 (14 %) lag eine chronisch persistierende Hepatitis vor und bei 18 (=29 %) konnten Restveränderungen nach durchgemachter bzw. im Abklingen befindlicher Hepatitis gefunden werden. Somit konnten bei insgesamt 69 % dieser 62 bioptisch untersuchten AuAg-positiven Blutspender feingewebliche Zeichen einer in Gang befindlichen oder in Rückbildung begriffenen Hepatitis objektiviert werden. 30 % dieser Gruppe boten laborchemisch keinerlei Hinweis auf das Vorliegen einer Leberkrankheit, bei den übrigen 70 % bestanden in Abhängigkeit vom Schädigungsausmaß der Leber diskrete bis eindeutige Laborveränderungen, die diagnostisch verwertbar waren. Bei den Spendern mit florider oder persistierender Hepatitis wurde der Krankheitsverlauf über einen Zeitraum von 12–18 Monaten klinisch und biochemisch überwacht und z.T. durch Mehrfachbiopsien auch histologisch verfolgt. Bei einem Teil der Plasmaspender war der Heilverlauf in Abhängigkeit von der Häufigkeit des vorausgegangenen Plasmaentzuges verzögert. Ursächlich wird ein induziertes Immundefizit diskutiert.