Einleitung: Die kollagene Kolitis (KK) gehört zur den mikroskopischen Kolitiden. Sie ist gekennzeichnet durch chronische, wässrige Diarrhoen und histologisch durch den Nachweis eines subepithelialen Kollagenbandes sowie einer lymphoplasmazellulären Infiltration der Tunica propria. Die Einfluss der KK auf die Lebensqualität ist bisher nicht untersucht worden.

Hintergrund: Es gibt widersprüchliche Daten bezüglich der Frage, ob und inwieweit die Refluxsymptomatik bei Patienten mit Barrett-Ösopahgus (BE) und Patienten mit unkomplizierter Refluxösophagitis.

Hintergrund: Die kollagene Kolitis gehort zu der Gruppe der mikroskopischen Kolitiden. Sie sind chronisch entzundliche Darmerkrankungen mit wassriger Diarrho und meist chronisch rezidivierendem Verlauf. Die Diagnose wird histologisch anhand eines verdickten subepithelialen Kollagenbandes gestellt. Aufgrund antiinflammatorischer Eigenschaften wurde Boswellia-serrata-Extrakt (BSE) schon bei verschiedenen entzundlichen Erkrankungen z.B. Asthma bronchiale, chronischer Polyarthritis und chronisch entzundlichen Erkrankungen eingesetzt. Ziel der Untersuchung: Wir untersuchten den Effekt von BSE auf die Symptome, Lebensqualitat und Histologie bei Patienten mit kollagener Kolitis in einem randomisierten, placebokontrollierten, doppelblinden Studiendesign. Patienten und Methoden: Patienten mit chronischer Diarrho (>5/Tag) und histologisch nachgewiesener kollagener Kolitis wurden fur 6 Wochen randomisiert entweder mit BSE (3×400mg oral/Tag) oder Placebo behandelt. Der Pathologe war bezuglich der Therapie verblindet. Die Symptome und Lebensqualitat wurden anhand standardisierter Fragebogen und dem SF-36 erfasst. Patienten der Placebogruppe mit persistierender Diarrho erhielten eine Cross-over BSE-Therapie. Ergebnisse: 31 Patienten (mittleres Alter 59 Jahr, 26 Frauen) wurden randomisiert, 25 Patienten sind fur die Per-Protokoll-Analyse auswertbar. Vier Patienten wurden wegen Protokollverletzung ausgeschlossen, ein Patient brach die Therapie wegen einer infektiosen Enteritis ab. Nach 6 Wochen Therapie waren 63,3% der BSE-Gruppe und 26,7% der Placebogruppe in klinischer Remission (Stuhlfrequenz <3/Tag) (p=0,04). 5 von 7 Patienten der Placebogruppe, die eine Cross-over BSE-Therapie erhielten, waren nach weiteren 6 Wochen in klinischer Remission. Diskussion: Die orale Therapie mit BSE ist effektiv und sicher bei Patienten mit kollagener Kolitis. BSE stellt somit eine weitere therapeutische Option bei kollagener Kolitis dar.

Summary Background: Budesonide (Entocort) is effective for the treatment of collagenous colitis. Aim: To assess the long‐term outcome of patients after induction of clinical remission by budesonide treatment. Methods: Fifty‐one patients with chronic diarrhoea and histologically proven collagenous colitis were enrolled in randomized, placebo‐controlled crossover trial using budesonide 9 mg daily for 6 weeks. Patients in clinical remission after either initial or crossover budesonide treatment were followed using standardized questionaires. Clinical relapse was defined as five or more loose stools/day for at least 4 consecutive days. Results: A total of 33 patients achieved clinical remission (85% per‐protocol). During a median follow‐up of 16 months, clinical relapse occurred in 20 patients (61%), after a median time of 2 weeks (range: 1–104, mean: 10 weeks). Patient age <60 years was identified as a significant risk factor for clinical relapse (OR = 7.4, P = 0.048). Budesonide was used for treatment of clinical relapse in 80% of patients achieving clinical response in all of them. Conclusions: Budesonide is effective in the treatment of collagenous colitis. Clinical relapses may occur in a considerable number of patients, particularly in those <60 years. Treatment of clinical relapse with budesonide appears to be an effective option.

Background: In contrast to former clinical trials concerning the ablation of non-neoplastic Barrett's epithelium (BE), Schulz et al. (Gastrointest Endosc, 2000) obtained a complete squamous regeneration after argon plasma coagulation (APC) in 98,6% of treated patients. The aim of this prospective study was to evaluate for the first time the effectiveness of APC at a high power setting for the ablation of BE in a multicenter trial. Methods: In 8 study centers, 60 patients (mean age 57, range 27-77; 47 male, 13 female) with endoscopic and histologically proven non-neoplastic BE (length of BE 1-8 cm) were recruited for treatment by APC in combination with esomeprazole. After baseline documentation by video endoscopy (VE) plus chromoendoscopy with 0,5% methylene blue (MB) and four quadrant biopsies (4QB) including the gastroesophageal transition zone, BE was treated by repeated APC using a power setting of 90 W; the number of APC sessions was restricted depending on the length of BE. During the treatment period, all patients received esomeprazole 80 mg daily; 2 weeks after completion of treatment the esomeprazole dose was reduced to 20 mg on demand daily or adapted to the result of 24 h pH monitoring. Endoscopic examinations including VE, chromoendoscopy with MB, and 4QB depending on pretreatment length of BE were performed 3 weeks, 6 and 12 months after completion of treatment. The effect of ablation was classified either as complete remission (CR; complete macroscopic and microscopic regression of BE), partial remission (macroscopic regression more than 50% depending on pretreatment length of BE) or minor response (macroscopic regression of BE less than 50%). Results: 51/60 recruited patients were treated within the study. 3 patients were lost for follow-up (FU) after complications had occurred. In 37 of 48 patients (77%) CR was achieved after a mean FU of 14 months (range 12-32). To achieve complete ablation of BE (mean length 3,6 cm), a mean of 2,6 APC sessions (range 1-5) were used. Transient complications (chest pain, fever) were noted in 9/51 patients (17,6%). Major complications (stricture formation, bleeding, perforation) occurred in 5/51 patients (9,8%). Conclusions: The fact that esophageal cancer incidence rate in non-neoplastic BE is low and the goal of ablation treatment namely complete ablation of BE is not reached in all patients together with the risk for morbidity due to ablation does not justify APC for ablation of non-neoplastic BE.

Einleitung: Entgegen vorherigen Erfahrungen mit endoskopischen Verfahren zur Ablation von Barrettschleimhaut beschrieb die Arbeitsgruppe von Schulz et al. (GE 2000) eine 99% komplette Ablation mittels Argon-Plasma-Koagulation (APC). Im Rahmen einer Multicenterstudie sollte nun überprüft werden, ob die vermutlich durch Anwendung einer hohen Energiestufe erreichte Ablationsrate nachvollzogen werden kann.

Background and Study Aims: Self-expandable metallic covered stents (SEMS) are widely used for the palliation of esophageal cancer. In the long term, a drawback of these stents is the occurrence of nontumoral occlusion at their proximal or distal parts. New self-expanding plastic stents (SEPS) may combine the advantages of SEMS with those of previously used plastic stents. Our aim was to study prospectively the implantation of such stents in a series of patients with fairly long life expectancy, focusing on safety, feasibility and long-term effectiveness.Patients and Methods: Between June 1999 and December 2000, in a prospective cohort study, 33 patients were treated with Polyflex stents for palliation of esophageal stenoses, and were followed up until death. The inclusion criteria demanded the presence of a nonresectable or nonoperable, histologically proven, malignant stricture of the esophagus causing significant dysphagia.Results: Stent insertion was successful in all cases. The mean duration of follow-up of the patients was 149.7 days (range 25 469). A complete follow-up until death was documented for all patients (n = 33). During the entire follow-up, no stent occlusion was observed which was caused by either nontumoral or tumoral ingrowth, or by nontumoral overgrowth. Stent occlusions were caused only by tumoral overgrowth, and occurred at a rate of 12.1% (n = 4). The stent migration rate was 6.0% (n = 2), and the re-intervention rate overall was 21.1% (n = 7).Conclusions: These results show that SEPS are effective for the palliation of dysphagia in patients with esophageal malignancies. The immediate results are similar to those observed with SEMS, and the observed low rate of late obstruction suggests that their long-term efficacy might be superior to that of SEMS. This device warrants evaluation in a controlled prospective trial.

We report the case of a 39-year-old German women who suffered from chronic inflammatory bowel disease which had not been exactly classified for 6 years. In the course of the disease she developed recurrent iritis, nodular skleritis, oral and genital ulcer, erythema nodosum and axillary folliculitis. For the first time retrosternal pain occurred. Endoscopy of the upper gastrointestinal tract showed mid esophageal ulcer formation. Colonoscopy demonstrated ulcerative colitis with no involvement of rectal mucosa. Histologically a cutaneous vasculitis in the lower limb was seen and diagnosis of Adamantiades-Behçet disease with marked gastrointestinal involvement and rare manifestation in the esophagus was established. A therapy with prednisolone, azathioprine and mesalazine was started. Under this regimen stomatitis, esophagitis and cutaneous vasculitis resolved, while the colitis showed partial remission now for up to one year.

We report the case of a 39-year-old German women who suffered from chronic inflammatory bowel disease which had not been exactly classified for 6 years. In the course of the disease she developed recurrent iritis, nodular skleritis, oral and genital ulcer, erythema nodosum and axillary folliculitis. For the first time retrosternal pain occurred. Endoscopy of the upper gastrointestinal tract showed mid esophageal ulcer formation. Colonoscopy demonstrated ulcerative colitis with no involvement of rectal mucosa. Histologically a cutanous vasculitis in the lower limb was seen and diagnosis of Adamantiades-Behget disease with marked gastrointestinal involvement and rare manifestation in the esophagus was established. A therapy with prednisolone, azathioprine and mesalazine was started. Under this regimen stomatitis, esophagitis and cutanous vasculitis resolved, while the colitis showed partial remission now for up to one year.

The use of self-expandable metallic stents (SEMS) is an established palliative treatment of malignant stenosis in the gastrointestinal tract. There is wide experience with the palliation of malignant esophageal obstruction and fistulae, but the application of stents in benign stenosis is rarely reported and exclusively deals with obstruction of the esophagus. No data has been available for benign gastric outlet and rectosigmoid obstruction until now. For the first time we report about 4 cases, in which we temporarily implanted a SEMS (Ultraflex(R) stent, Boston Scientific Microvasive(R)) in benign stenosis of the pylorus or rectosigmoid between 09.97-07.98. The indications for stent implantation were failure of established dilatation therapy and/or refusal of surgical treatment, and/or surgical high-risk patients. Our idea was to prolong the duration of the dilatation by interim implantation (range 8 days - 12 weeks) of a SEMS. There where no peri-interventional complications or dislocations. In one case endoscopic removal was not possible, peranal surgical approach allowed the removal of the stent. During follow-up (range 34-39 months) 2 patients needed one bougienage directly after stent removal. Endoscopic examinations showed no recurrence of any stenosis in all patients. We conclude that interim application of SEMS in benign stenosis of the gastrointestinal tract may be a possible therapeutic tool in selected patients. Further trials with greater numbers of patients dealing with the questions of duration of stay of SEMS and choice of stent type are needed.

Successful treatment of esophageal perforation with a removable self-expanding plastic stent

OBJECTIVE:The Cliny PEG 13 has been available since 1999 for clinical use in the modified introducer technique in combination with endoscopically controlled gastropexy. Data on indication, insertion technique and safety have not yet been reported in the literature. METHODS:During the time period from January 1999 to June 2000, from a total of 457 patients receiving a PEG 27 (5.9%) subjects, in whom the insertion of a PEG by means of pull-through technique was impossible or only in combination with an intervention e.g. bougienage were included in this prospective study. Each patient received a Cliny PEG 13 by means of introducer technique with endoscopically controlled double gastropexy. Tumor patients with severe stenosis made up more than 90% of the cases. The insertion and 30 day follow-up were performed using a standardized protocol. Method-related and unrelated complications were recorded. RESULTS:PEG insertion was successful in all patients without additional intervention. We did not see any method-related complications. The peri-interventional local infection rate was 3.7%. One patient died during the 30-day follow-up period as a result of progression of the underlying disease. No further complications occurred in long term follow-up. CONCLUSIONS:Our results show that the Cliny PEG 13 is a safe technique and an alternative to other methods and surgical procedures in patients in whom a PEG was not applicable by means of the pull-through technique. Larger case numbers and the use in other patient collectives will have to prove these initial results.

OBJECTIVE:To determine the efficacy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG) as a part of a standardized regimen.METHODS:An open prospective randomised multicenter study in 216 patients. 106 received ceftriaxone 1 g i.v. 30 min preinterventionally and 110 no study medication. A standardized protocol was followed for PEG preparation, insertion, and aftercare; all patients received a 15 French gastrostomy tube. Follow-up of local and systemic infection and clinical course was continued to postintervention day 10. An aggregate erythema and exudation score > 3 or the presence of pus was taken as indicative of peristomal infection. The pharmacoeconomics of antibiotic use were also examined.RESULTS:In no-prophylaxis patients, wound infection rates were 23.6% on day 4 and 24.5% on day 10 vs. 7.6% (p < 0.05) and 11.4% (p < 0.05), respectively, in prophylaxis patients. Results were disproportionally better in tumor patients in comparison with neurological patients. Patients systemic infection rates were 11.8% vs. 1.9% in noprophylaxis vs. prophylaxis (p < 0.05), and overall infection rates 36.3% vs. 13.3%, respectively (p < 0.05). Pneumonia was more frequent in patients with underlying neurological disease and reduced in the prophylaxis group. Antibiotic and application costs were similar in both groups (p = 0.400).CONCLUSIONS:Single-dose ceftriaxone 1 g is a effective prophylaxis against local and systemic infection after PEG and should be a part of a standard regimen.

Malignant gastric outlet obstructions are commonly present in an advanced tumor stage. Surgery and other therapy options are often accompanied with substantial problems and reduced quality of life. We therefore investigated the endoscopic palliation with self-expandable metallic stents. This report documents the clinical benefit of new stent systems.During a period of eleven months we implanted eleven self-expandable metallic stents (one Ultraflex Esophageal Stent/five Ultraflex Duodenal Diamond Stents/five Enteral Wallstents) in eight patients with malignant gastric outlet stenoses (five female/three male, average age 66 years, range 42-85 years). The procedure was performed under analgosedation and in seven cases on an outpatient bases.The stenosis could be dilated in all cases without complications, allowing semi-liquid oral feeding at the procedure day. Three patients needed a second stent in the follow-up. Stent dislocation appeared in one case after one month - the stent protruded per vias naturales. The stent struts broke in two patients after one and four months post stent implantation. A new stent could be inserted without complications in both cases.The used products enabled a fast and precise positioning of the metallic stent in malignant gastric outlet stenosis. We experienced some problems with the Ultraflex Duodenal Diamond Stent. This didn't occur with the Enteral Wallstent. Additionally with the Enteral Wallstent we could solve the diamond stent complications. Due to the small diameter (10 French) the Enteral Wallstent system can be positioned wire guided in the stenosis through the working channel of the endoscope. Stent release is performed fluoroscopically and with the use of endoscopic guidance retaining the instrument in the stomach. In our point of view, this metallic stent is an optimal device for the palliative treatment of malignant gastric outlet obstructions.

BACKGROUND AND OBJECTIVEA high operative mortality, diffuse local tumor growth and abnormal wound healing are significant risk factors in the palliative surgical treatment of gastric outlet obstruction caused by a malignant tumor. This study was undertaken to evaluate the use of self-expanding metal stents as an alternative.PATIENTS AND METHODSOver a period of 33 months, nine previously unoperated patients (three women, six men; mean age 71.4 [66-76] years) with gastric outlet obstruction by a malignant tumor underwent endoscopic implantation of an uncoated self-expanding nitinol Ultraflex stent. The stent's length was 7 and 10 cm, respectively, the length of the carrier catheter was 92 cm. The stent was implanted after balloon dilatation of the stenosis and marking the distal tumor margin with lipiodol injected over a guide-wire under fluoroscopic control.RESULTSThe implantation was successful in only two of the first five patients, but after modifying the method of stent release in three of the four subsequent patients. All patients reported an improved quality of life. One patient died after 10 days of the underlying malignancy. There were no complications associated with the implantation.CONCLUSIONSInsertion of a self-expanding metal stent can provide palliation in patients with inoperable gastric outlet stenosis due to malignant tumour. The number of successful implantations can probably be increased by optimizing some of the devices used, for example by lengthening the carrier catheter.

Objective: The aim of this study was to determine the efficacy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG). Methods: An open prospective, randomised, multicenter study was conducted in 141 patients; 72 received ceftriaxone 1 g i.v. 30 min preintervention, and 69 received no study medication. A standardized protocol was followed for PEG preparation, insertion, and aftercare; all patients received a 15-Fr gastrostomy tube. Follow-up of local and systemic infection and clinical course was continued to postintervention day 10. An aggregate erythema and exudation score >3 or the presence of pus was taken as indicative of peristomal infection. The pharmacoeconomics of antibiotic use were also examined. Results: In no-prophylaxis patients, wound infection rates were 25% on day 4 and 26.4% on day 10, versus 10.1% (p= 0.03) and 14.5% (p= 0.10), respectively, in prophylaxis patients. Results were disproportionally better in tumor patients: systemic infection rates were 16.7%versus 5.8% in no-prophylaxis versus prophylaxis patients (p= 0.045), and overall infection rates 38.9%versus 17.4%, respectively (p= 0.046). Pneumonia was more frequent in patients with underlying neurological disease. Antibiotic costs were the same in both groups (p= 0.792). Conclusions: Single dose ceftriaxone 1 g is an effective prophylaxis against local and systemic infection after PEG.

Gemcitabine is a new cytidine analogue for the treatment of solid tumours including pancreatic cancer and non-small-cell lung cancer (NSCLC). 1 Burris HA III Moore MJ Andersen J et al. Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial.. J Clin Oncol. 1997; 15: 2403-2413 PubMed Google Scholar , 2 Thatcher N Hopwood P Anderson H Improving quality of life in patients with non-small cell lung cancer: research experience with gemcitabine. Eur J Cancer. 1997; 33: S8-S13 Summary Full Text PDF PubMed Google Scholar Toxicity appears to be mild, with myelosuppression, raised liver enzymes, and an influenza-like syndrome as the most reported side-effects. 3 Green MR Gemcitabine safety overview. Semin Oncol. 1996; 23: 32-35 PubMed Google Scholar Renal failure and neurotoxicity are rarely seen. Neuropathy presenting as paresthesia occurs in less than 6% of people treated. We report on a patient who developed autonomic neuropathy while on gemcitabine for NSCLC.