Das Reizdarmsyndrom (RDS) ist eine der häufigsten funktionellen Magen-Darm-Erkrankungen weltweit. Es betrifft etwa 10–20% der Bevölkerung in westlichen Ländern und stellt eine Herausforderung für Betroffene sowie das medizinische Fachpersonal dar. Charakteristisch für die Erkrankung sind wiederkehrende Bauchschmerzen, die mit Veränderungen des Stuhlgangs einhergehen. Die Beschwerden können sich unter anderem in Form von Durchfall, Verstopfung oder einer Mischung aus beidem äußern. Die Diagnose erfolgt nach den international anerkannten Rom-IV-Kriterien, wobei organische Ursachen ausgeschlossen werden müssen. Die Pathophysiologie des RDS ist komplex und multifaktoriell. Eine Störung der Darm-Hirn-Achse, Veränderungen der Darmflora (Mikrobiom) sowie psychische Faktoren wie Stress oder Angst spielen eine zentrale Rolle. Auch Trigger wie bestimmte Lebensmittel oder eine überstandene Darminfektion können eine Verschlechterung der Symptome auslösen. Diese Vielschichtigkeit erfordert eine individuell angepasste Betreuung der Betroffenen. In der Endoskopie kommt dem Pflegepersonal eine entscheidende Rolle zu, da die Patientinnen oft mit Angst und Unsicherheiten zur Untersuchung kommen. Neben der einfühlsamen Vorbereitung ist es wichtig, die individuellen Bedürfnisse der Patientinnen zu berücksichtigen, insbesondere im Hinblick auf die Abführlösung und den Umgang mit Schmerzen während der Untersuchung. Die interdisziplinäre Zusammenarbeit ist ein zentraler Bestandteil einer erfolgreichen Behandlung. Ärztinnen, Pflegekräfte, Ernährungsberaterinnen und Psychologinnen sollten eng zusammenarbeiten, um die körperlichen und psychischen Aspekte der Erkrankung gleichermaßen zu berücksichtigen. Eine gute Kommunikation, regelmäßige Schulungen und der Austausch zwischen den Fachbereichen tragen dazu bei, die Versorgung der Patientinnen zu verbessern. Praktische Tipps für das Pflegepersonal umfassen die empathische Betreuung während der Endoskopie, die gezielte Beratung zu Ernährung und Lebensstil sowie die Nachsorge nach der Untersuchung. Die Schulung des Pflegepersonals im Umgang mit funktionellen Darmerkrankungen und deren psychologischen Aspekten ist essenziell, um den Herausforderungen im Alltag gerecht zu werden.

Acute liver failure (ALF) is a disorder with various etiologies. Although the causes leading to this disruptive condition are well documented in published ALF cohorts, there is significant concern among patients who experience ALF with indeterminate causes, an issue requiring thorough analysis. This review aimed to analyze cohort studies on ALF with a focus on unknown causes leading to classification as indeterminate ALF. The analysis revealed that, among 67 worldwide adult and pediatric ALF cohorts, indeterminate causes of ALF ranged from 2% to 100%, with an average of 30%. Among the 13 pediatric ALF cohorts, the corresponding range was 22% to 100%, with an average of 47%, while among the 55 adult ALF cohorts, the range was 2% to 78%, with an average of 26%. The percentage values were higher in pediatric cohorts due to the higher incidence of rare genetic causes compared to adult patients. Notably, higher rates of indeterminate causes were found in cohorts studied before the availability of diagnostic serologic screening parameters and polymerase chain reaction techniques for various hepatitis virus infections. Patients with indeterminate ALF may not have received a specific treatment that, if effective, could have helped prevent liver transplantation. It is concluded that, in future cases, all efforts must be undertaken to clearly establish the cause of severe liver injury, enabling effective therapy when available and helping reduce the risk of progression to ALF and the need for liver transplantation.

Wilson disease, a well-established genetic disorder characterized by impaired copper excretion and toxic copper accumulation in the liver, has clear clinical presentations and diagnostic criteria. However, the metabolic and molecular pathways leading to liver injury - a critical hallmark of the disease - remain largely cryptic and require new analytical approaches to elucidate underlying mechanisms. In Wilson disease, supraphysiological and toxic amounts of hepatic copper arise due to genetically reduced biliary excretion. Interestingly, hepatic iron accumulation of unknown etiology is also observed. Both metals contribute to the production of reactive oxygen species (ROS), including singlet oxygen, superoxide anions, and highly disruptive hydroxyl radicals generated via the Haber-Weiss and Fenton reactions. Historically, liver injury has been attributed to copper-induced toxicity (cuproptosis) without sufficient consideration of ROS involvement, neglecting the significant ROS burden in hepatic tissue. A revised concept of cuproptosis incorporates ROS, particularly hydroxyl radicals, which convert copper ions into reactive intermediates such as copper peroxyl, copper hydroperoxyl, and copper superoxyl species. These intermediates induce mitochondrial oxidative stress by covalently binding to mitochondrial constituents including lipoylated dihydrolipoamide S-acetyltransferase (DLAT), leading to its aggregation and triggering regulated cell death via cuproptosis. Thus, copper ions must first be converted into reactive intermediates to initiate cuproptosis effectively. Furthermore, singlet oxygen and superoxide anion hydroxyl radicals generated by hepatic iron ions may promote regulated cell death via ferroptosis. This process involves the accumulation of lipid peroxides derived from polyunsaturated fatty acids in mitochondrial membranes, with malondialdehyde (MDA) serving as a diagnostic marker. Consequences include enhanced mitochondrial membrane rigidity, disruption of plasma membrane integrity, and ultimately cell death. This mechanistic pathway requires the activity of iron-dependent enzymes such as lipoxygenases, ferroptosis suppressor protein 1, glutathione peroxidase 4, dihydroorotate dehydrogenase, and lysosomal iron release from ferritin stores. To sum up, the definition of cuproptosis requires refinement to incorporate its mechanistic dependence on ROS, and its quantitative contribution to liver injury should be reassessed alongside hepatic iron and ferroptosis.

Drug-induced autoimmune hepatitis (DIAIH) is a relatively new subtype of idiosyncratic drug-induced liver injury (iDILI), but the features of DIAIH have been variably described due to the inhomogeneity of assessed study cohorts. The aim of this analysis is to harmonize DIAIH cohorts by unifying causality assessments, which may help characterize the features of DIAIH. Methods: Published reports of DIAIH cases were evaluated for the causality assessment methods used to verify the diagnosis of DIAIH. This disorder consists of two parts, i.e., the iDILI part and the autoimmune (AIH) part, whereby each part needs a specific diagnostic algorithm. The validated and scoring Roussel Uclaf Causality Assessment (RUCAM) is privileged for assessing the iDILI part, and the validated, simplified AIH score is the perfect choice for evaluating the AIH part. The analysis of DIAIH publications revealed that 12/20 reports (60%) presented cases assessed by both the RUCAM and the simplified AIH score, providing 49 drugs and drug combinations as causative drugs in up to 25 cases of DIAIH. Serum alanine aminotransferase activities of up to 3489 UL and high titers of autoimmune parameters such as anti-nuclear antibodies, anti-smooth-muscle antibodies, and soluble liver antigen antibodies supported DIAIH diagnosis. In contrast, 4/20 reports (20%) applied only RUCAM, and 2/20 reports (10%) used only the simplified AIH score; these 6 reports therefore provided insufficient criteria for a valid DIAIH diagnosis. Moreover, 2/20 reports (10%) did not use any causality algorithm, providing elusive features of DIAIH. While DIAIH is clearly restricted to drugs as responsible agents, this term is erroneously used to refer to disease induced by non-drugs such as herbs, green tea, dimethoate (an organophosphate insecticide), dietary supplements, biologics, herbal remedies, different viruses, and bacteria, as well as vaccines. For diseases induced by these agents, a better term could be, for instance, non-drug-induced autoimmune hepatitis. Drug cessation and immunotherapy with corticosteroids and azathioprine comprise the treatment of choice. The characteristics of DIAIH can best be described if both the RUCAM and the simplified AIH score are used concomitantly.

Liver transplantation (LT) can be the only option for patients with acute liver failure (ALF) where medical approaches are ineffective. Causes of ALF are multiple and commonly easily detectable, but uncertainty remained on the role of drug-induced liver injury (DILI) within the published ALF cohorts. Therefore, an analysis was undertaken to clarify which drugs may have caused the DILI and how the diagnosis of the liver injury was established. Using the PubMed database and Google Science, the search term of acute liver failure combined with drugs provided 36 publications of ALF cohorts, which included 21,709 DILI cases. Whereas non-drug causes were detectable by specific diagnostic biomarkers, the diagnosis of DILI among the ALF cohorts was neglected, as evidenced by the lacking use of a validated diagnostic algorithm like the Roussel Uclaf Causality Assessment Method (RUCAM), best qualified to verify causality for individual drugs or combined drugs. This lack of firm diagnosis leads to a long list of drugs with highly questionable causality of suspected DILI, prevents calculation of incidence or prevalence data of DILI among ALF cohorts, and cannot help find an appropriate therapy for selected cases of drug-induced autoimmune hepatitis (DIAIH) or overdosed N-acetyl-para-aminophenol (APAP) also known as paracetamol, aiming to prevent LT. Under discussion is also the high rate of indeterminate cases of up to 78% among the published cohorts, which confounds any quantitative approach in this setting. In conclusion, there is much room for improvement in future ALF cohorts, requiring the application of validated tools.

BACKGROUND:Endoscopic procedures are a notable source of medical waste, contributing significantly to environmental pollution. Prior studies report 0.5-3.0 kg of waste per procedure-compared with just 1.2 kg of household waste generated per person per day in Germany. OBJECTIVE:To quantify endoscopic waste in hospitals and outpatient settings, assess its impact on the healthcare system and identify strategies for reduction. DESIGN:This prospective, multicentre, observational study was conducted over 4 weeks in two tertiary hospitals and two gastroenterology offices. Waste from 2275 patients across 2889 procedures was collected, sorted, weighed and categorised for recyclability. National waste generation from GI endoscopy was estimated using published insurance data. RESULTS:The average waste per procedure was 1119 g (hospitals: 1167 g; offices: 1094 g). Office-based procedures produced significantly less waste than their hospital counterparts-by 51% for oesophagogastroduodenoscopy (EGD), 50% for colonoscopy, 47% for combined procedures and 69% for sigmoidoscopy (all p<0.001). Performing consecutive procedures reduced waste by up to 39% for EGD and colonoscopy, and 33% for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. Switching from single-use to reusable gowns could reduce personal protective equipment waste by 54%. Overall, 23% of waste was potentially recyclable. Nationally, GI endoscopy generates an estimated 8024 tonnes of waste annually-equivalent to the yearly household waste of 18 533 German citizens. CONCLUSION:The waste generated by endoscopy per year in Germany rivals that of a small town. Adopting targeted waste reduction strategies-focusing on prevention, reduction, reuse, recycling and recovery-can substantially mitigate the environmental footprint of endoscopic practice. TRIAL REGISTRATION NUMBER:NCT05921136.

ZusammenfassungDas Thema Klimaschutz, Ökologie und CO2-Neutralität wird seit Jahren in der Gesellschaft intensiv und zunehmend diskutiert. Auch in Krankenhäusern und anderen medizinischen Einrichtungen nimmt dies einen immer höheren Stellenwert ein. Der Gesundheitssektor ist für 5,6% aller deutschlandweiten CO2-Emissionen verantwortlich, insbesondere durch den hohen Energieverbrauch und den anfallenden Müll von 6kg pro Patient und Tag. Der folgende Beitrag fasst die Möglichkeiten zusammen, die die Endoskopie als Beitrag zur ökologischen Nachhaltigkeit zu leisten vermag. Ein besonderer Focus liegt auf den heute schon einfach umzusetzenden Maßnahmen.

Aims Waste is a relevant contributor of environmental pollution, as besides the direct consequences of landscape and water pollution, large amounts of greenhouse gases are also produced during incineration.The aim of the present study was to obtain a picture of the amount of waste generated and its composition during endoscopic examinations in order to be able to calculate the recycling potential for Germany's gastrointestinal endoscopy landscape.To the best of our knowledge, this is the first study worldwide to look at the amount of waste generated in the office-based sector.

Aims Single-use devices and equipment have been widely adopted in flexible endoscopy and currently almost all reusable accessories are abandoned due to hygiene, medico-legal and economic reasons. During the last 10 years also single-use endoscopes were deployed in the clinical routine, mainly in bronchoscopy and recently for duodenoscopy (ERCP) and gastroscopy to eliminate the risk of cross-contamination. A complete recycling of these scopes can reduce the ecological burden and may lead to a greener endoscopy. We evaluated the recycling process of single-use duodenoscope (aScope Duodeno; Ambu A/S, Denmark) in routine clinical practice.

Background Computer-aided detection (CADe) has been developed to improve detection during colonoscopy. After initial reports of high efficacy, there has been an increasing recognition of variability in the effectiveness of CADe systems. The aim of this study was to evaluate a CADe system in a varied colonoscopy population. Methods A multicenter, randomized trial was conducted at seven hospitals (both university and non-university) in Europe and Canada. Participants referred for diagnostic, non-immunochemical fecal occult blood test (iFOBT) screening, or surveillance colonoscopy were randomized (1:1) to undergo CADe-assisted or conventional colonoscopy by experienced endoscopists. Participants with insufficient bowel preparation were excluded from the analysis. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included adenomas per colonoscopy (APC) and sessile serrated lesions (SSLs) per colonoscopy. Results 581 participants were enrolled, of whom 497 were included in the final analysis: 250 in the CADe arm and 247 in the conventional colonoscopy arm. The indication was surveillance in 202/497 colonoscopies (40.6 %), diagnostic in 199/497 (40.0 %), and non-iFOBT screening in 96/497 (19.3 %). Overall, ADR (38.4 % vs. 37.7 %; P = 0.43) and APC (0.66 vs. 0.66; P = 0.97) were similar between CADe and conventional colonoscopy. SSLs per colonoscopy was increased (0.30 vs. 0.19; P = 0.049) in the CADe arm vs. the conventional colonoscopy arm. Conclusions In this study conducted by experienced endoscopists, CADe did not result in a statistically significant increase in ADR. However, the ADR of our control group substantially surpassed our sample size assumptions, increasing the risk of an underpowered trial.

Wilson disease is a genetic disorder of the liver characterized by excess accumulation of copper, which is found ubiquitously on earth and normally enters the human body in small amounts via the food chain. Many interesting disease details were published on the mechanistic steps, such as the generation of reactive oxygen species (ROS) and cuproptosis causing a copper dependent cell death. In the liver of patients with Wilson disease, also, increased iron deposits were found that may lead to iron-related ferroptosis responsible for phospholipid peroxidation within membranes of subcellular organelles. All topics are covered in this review article, in addition to the diagnostic and therapeutic issues of Wilson disease. Excess Cu2+ primarily leads to the generation of reactive oxygen species (ROS), as evidenced by early experimental studies exemplified with the detection of hydroxyl radical formation using the electron spin resonance (ESR) spin-trapping method. The generation of ROS products follows the principles of the Haber–Weiss reaction and the subsequent Fenton reaction leading to copper-related cuproptosis, and is thereby closely connected with ROS. Copper accumulation in the liver is due to impaired biliary excretion of copper caused by the inheritable malfunctioning or missing ATP7B protein. As a result, disturbed cellular homeostasis of copper prevails within the liver. Released from the liver cells due to limited storage capacity, the toxic copper enters the circulation and arrives at other organs, causing local accumulation and cell injury. This explains why copper injures not only the liver, but also the brain, kidneys, eyes, heart, muscles, and bones, explaining the multifaceted clinical features of Wilson disease. Among these are depression, psychosis, dysarthria, ataxia, writing problems, dysphagia, renal tubular dysfunction, Kayser–Fleischer corneal rings, cardiomyopathy, cardiac arrhythmias, rhabdomyolysis, osteoporosis, osteomalacia, arthritis, and arthralgia. In addition, Coombs-negative hemolytic anemia is a key feature of Wilson disease with undetectable serum haptoglobin. The modified Leipzig Scoring System helps diagnose Wilson disease. Patients with Wilson disease are well-treated first-line with copper chelators like D-penicillamine that facilitate the removal of circulating copper bound to albumin and increase in urinary copper excretion. Early chelation therapy improves prognosis. Liver transplantation is an option viewed as ultima ratio in end-stage liver disease with untreatable complications or acute liver failure. Liver transplantation finally may thus be a life-saving approach and curative treatment of the disease by replacing the hepatic gene mutation. In conclusion, Wilson disease is a multifaceted genetic disease representing a molecular and clinical challenge.

Climate protection, ecology and CO2 neutrality have been discussed intensively and increasingly in society for years. This is also becoming increasingly important in hospitals and other medical facilities. The health care sector is responsible for 5.6% of all CO2 emissions in Germany, particularly due to high energy consumption and a daily waste production of 6kg per patient. The following article summarizes the options for endoscopy to contribute to ecological sustainability, with a special focus on measures that can be easily implemented today.

ZusammenfassungMedizin im Klimawandel – ein beherrschendes Thema in den letzten 3 Jahren, nicht nur wegen der direkten medizinischen Folgen auf Krankheitsgeschehen und Gesundheitserhaltung, sondern insbesondere auch wegen der ökologischen und ökonomischen Konsequenzen. Auch in stationären und ambulanten Versorgungsstrukturen nimmt dies inzwischen einen breiten Raum ein. Der deutsche Ärztetag hat sich im November 2021 dem Ziel der Klimaneutralität bis zum Jahr 2030 verschrieben. Ein überaus ambitioniertes Ziel, ist der Gesundheitssektor doch für 5,6% aller deutschlandweiten CO2-Emissionen verantwortlich, insbesondere durch den hohen Energieverbrauch und den anfallenden Müll von 6 kg/Tag pro Patient. Dabei sind heute die Endoskopie-Abteilungen neben OP und Intensivstationen die drittgrößten Müllverursacher in den Kliniken. Den größten Einfluss und das höchste Potential zu mehr Nachhaltigkeit und Ressourcenschonung in der Endoskopie ist jedoch eine strengere Indikationsstellung mit Vermeidung überflüssiger Endoskopien und Zweituntersuchungen. Dies macht circa 25% aller endoskopischen Leistungen aus, die durch eine „choose wisely“-Strategie sofort vermeidbar wären und damit unmittelbar zu einer signifikanten Reduktion des CO2-Ausstoßes und besserer Klimabilanz führen würde. Die ESGE (European Society of Gastrointestinal Endoscopy) proklamiert in ihrem aktuellen Positionspapier die strikte Befolgung evidenzbasierter Leitlinienempfehlungen zur Indikation mit Supervision und Auditierung durch Fachgesellschaften und Sozialversicherungsträger. Die Einführung eines Bonus-Malus-Prinzips kann diesen sinnvollen Prozess beschleunigen.