Einleitung: Die Kapselendoskopie (KE) wird zunehmend in der Diagnostik bei Erkrankungen des Dünndarms eingesetzt. Bisher liegen allerdings noch keine kontrollierten Daten zur Vorbereitung des Darmes vor.

History and admission findings: A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable.Investigations: An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT.Therapy and clinical course: Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention.Conclusion: Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.

Objective: Colonoscopy is the accepted gold standard for screening of neoplastic colorectal lesions, but the substantial miss rate remains a challenge. Computed virtual chromoendoscopy with the Fujinon intelligent colour enhancement (FICE) system is a new dyeless imaging technique that might allow higher rates of adenoma detection.Methods: This is a prospective randomised five tertiary care centre trial of colonoscopy in the FICE mode versus standard colonoscopy with targeted indigocarmine chromoscopy (control group) in consecutive patients attending for routine colonoscopy. Histopathology of detected lesions was confirmed by evaluation of endoscopic resection or biopsy specimens.Results: 871 patients were enrolled, and 764 patients (344 female, mean age 64 years) were subjected to final analysis (368 in the FICE group, 396 in the control group). In total, 236 adenomas (mean of 0.64 per case) were detected in the FICE group and 271 adenomas (mean of 0.68 per case) in the control group (p = 0.92). There was no statistically significant difference in the percentage of patients with >= 1 adenoma between the control group (35.4%) and the FICE group (35.6%) (p = 1.0). For the differential diagnosis of adenomas and non-neoplastic polyps, the sensitivity of FICE (92.7%) was comparable with that of indigocarmine (90.4%) (p = 0.44).Conclusions: At colonoscopy, adenoma detection rates are not improved by virtual chromoendoscopy with the FICE system compared with white light endoscopy with targeted indigocarmine spraying. However, FICE can effectively substitute for chromoscopy concerning the differentiation of neoplastic and non-neoplastic lesions.

Hintergrund: Die DBE hat sich bei der diagnostischen und therapeutischen tiefen Dünndarmendoskopie flächendeckend etabliert. Die SBE wurde als vereinfachte Technik der Ballonenteroskopie eingeführt.

Einleitung: Indocyaningrün (ICG) ist ein quantitativer Leberfunktionstest zur Messung der durchblutungsabhängigen Leberfunktion. MELD (model for end-stage liver disease) und Child-Pugh-Score sind als Prognoseparameter bei Patienten mit Zirrhose etabliert. Bei diesen Patienten sind Komplikationen wesentlich mit Veränderungen der Leberdurchblutung (portale Hypertension) assoziiert und durchblutungsabhängige Leberfunktionsteste könnten daher die prognostische Wertigkeit der etablierten Prognoseparameter ergänzen.

Hintergrund: Bei der Standardkoloskopie werden ca. 20% der Adenome übersehen. „Narrow band imaging“ (NBI) und „Fujinon intelligent colour enhancement“ (FICE) sind virtuelle Chromoendoskopie-Techniken, die über Verstärkung des Mukosa- und Gefäßkontrastes ohne Färbemittel Detektion und Klassifikation verbessern könnten. Mehrere kürzlich publizierte Single-Center-Studien zeigten, dass NBI im Vergleich zur Standardtechnik die Detektionsrate nicht signifikant verbessert. Die vorliegende Studie untersucht die Wertigkeit von FICE bei der Detektion und Klassifikation von Kolonläsionen. Sie ist die erste multizentrische Arbeit zur Wertigkeit der neuen virtuellen Chromoendoskopie-Techniken.

Einleitung: Bei der Standardkoloskopie werden kleine/flache Adenome häufig übersehen. Die CVC ist eine neue Bildverarbeitungstechnik, die von Fujinon als „Fujinon intelligent chromoendoscopy“ (FICE) vorgestellt wurde. Im CVC-Modus wird die spektrale Verteilung des normalen endoskopischen Bildes (Abb.1)

BACKGROUND AND AIMS:The diagnostic yield of capsule endoscopy (CE) compared with magnetic resonance imaging (MRI) in small bowel Crohn's disease is not well established. We prospectively investigated CE, MRI, and double contrast fluoroscopy in patients with suspected small bowel Crohn's disease.METHODS:Fifty two consecutive patients (39 females, 13 males) were investigated by MRI, fluoroscopy and--if bowel obstruction could be excluded--by CE. In 25, Crohn's disease was newly suspected while the diagnosis of Crohn's disease (non-small bowel) had been previously established in 27.RESULTS:Small bowel Crohn's disease was diagnosed in 41 of 52 patients (79%). CE was not accomplished in 14 patients due to bowel strictures. Of the remaining 27 patients, CE, MRI, and fluoroscopy detected small bowel Crohn's disease in 25 (93%), 21 (78%), and 7 (of 21; 33%) cases, respectively. CE was the only diagnostic tool in four patients. CE was slightly more sensitive than MRI (12 v 10 of 13 in suspected Crohn's disease and 13 v 11 of 14 in established Crohn's disease). MRI detected inflammatory conglomerates and enteric fistulae in three and two cases, respectively.CONCLUSION:CE and MRI are complementary methods for diagnosing small bowel Crohn's disease. CE is capable of detecting limited mucosal lesions that may be missed by MRI, but awareness of bowel obstruction is mandatory. In contrast, MRI is helpful in identifying transmural Crohn's disease and extraluminal lesions, and may exclude strictures.

History and clinical findings: In a 39-year-old man with increasing spasmodic epigastric pain, nausea and vomiting, varices of the esophagus and the gastric fundus were found endoscopically.Investigations: A portal vein thrombosis and a consecutive thrombosis of the splenic vein were diagnosed by colour dopplersonography and angio CT. A protein S deficiency (59%) was found to be the underlying illness.Treatment and course: The thrombosis and the resulting clinical symptoms completely resolved shortly after starting therapeutic heparinization. For six months, the patient has been without complaints or clinical symptoms.Conclusion: Hence, an isolated protein S deficiency can be the cause for a portal vein thrombosis.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Background: Data regarding the prevalence of SBP in patients with ascites or the diagnostic and therapeutic management of SBP in Germany are lacking.Patients and methods: In a multicenter study (40 hospitals), retrospective, then prospective data were collected investigating the prevalence of SBP in patients with ascites and the pertinent diagnostic and therapeutic management. In 272 prospectively entered patients with ascites (cirrhosis/malignant ascites/other: n = 227/42/ 3) a diagnostic paracentesis was performed and SBP diagnosed using the ascitic neutrophil count. History, clinical symptoms and laboratory findings were recorded and potential risk factors analysed by univariate analysis and stepwise logistic regression. SBP was treated with a standard dose of a third-generation cephalosporin.Results: In the retrospective study, SBP was diagnosed in 648 of 4,697 patients with ascites (14%). Employed diagnostic and therapeutic pathways were not effective in several hospital departments. In the prospective trial, SBP was found in 134 of 272 patients with ascites (49,3%). Frequency of symptoms was significantly different in patients either with or without SBP, as were macroscopic aspect of ascites, urine excretion and several biochemical parameters. However, their diagnostic precision was unsatisfactory. Predictive factors for SBP were previous paracentesis, endoscopic procedures and a history of abdominal pain. Treatment was effective in 83,5% of cases. Inhospital mortality was 10%.Conclusion: The prevalence of SBP in hospitalised patients with ascites in Germany is similar to that in southern Europe and USA. Symptoms alone lack sufficient diagnostic accuracy. Third-generation cephalosporin is an effective antibiotic in SBP. Pertinent diagnostic and therapeutic management calls for improvement.

Erstmals ist es durch die Kapselendoskopie (KE) nicht-invasiv möglich, Dünndarmaffektionen bei Morbus Crohn (MC) endoskopisch nachzuweisen. Die KE wird in dieser prospektiven Studie mit der MRT und dem Röntgen-Enteroklysma (EK) verglichen.

Hintergrund Die Kapselendoskopie (KE) erschließt den endoskopischen Nachweis von Dünndarmaffektionen bei Morbus Crohn (MC) der modernen Diagnostik. Sollte allerdings einer Obstruktion des Darms vorliegen, kann es zu einem operationspflichtigen Steckenbleiben der Kapsel kommen. Ein entsprechendes Risikoprofil könnte Risikopatienten für diese Komplikation identifizieren.

HISTORY AND CLINICAL FINDINGS:In a 39-year-old man with increasing spasmodic epigastric pain, nausea and vomiting, varices of the esophagus and the gastric fundus were found endoscopically.INVESTIGATIONS:A portal vein thrombosis and a consecutive thrombosis of the splenic vein were diagnosed by colour Doppler sonography and angio CT. A protein S deficiency (59 %) was found to be the underlying illness.TREATMENT AND COURSE:The thrombosis and the resulting clinical symptoms completely resolved shortly after starting therapeutic heparinization. For six months, the patient has been without complaints or clinical symptoms.CONCLUSION:Hence, an isolated protein S deficiency can be the cause for a portal vein thrombosis.

Background: Capsule endoscopy is a new imaging method for visualization of the entire small bowel. However, no standardized protocol for bowel preparation for capsule endoscopy has been evaluated.Methods: Capsule endoscopy was performed in 36 consecutive patients, all of whom fasted for 12 hours before ingestion of the capsule. Before capsule endoscopy, 18 patients received 80 mg simethicone and 18 had no supplemental medication for bowel preparation. Two observers, both experienced endoscopists, independently reviewed the examinations in a single-blinded and randomly assigned fashion. Mucosal visibility and intraluminal gas bubbles were assessed and graded by both observers.Results: Bowel preparation with simethicone resulted in significantly better visibility because of fewer intraluminal bubbles (p<0.01). Interobserver agreement was excellent (r greater than or equal to 0.8; k 0.78: 95% CI[0.57, 0.98]). No adverse effect of simethicone was observed.Conclusions: Simethicone may be added to the routine preparation for capsule endoscopy to improve the visibility of small bowel mucosa.

BACKGROUND:Data regarding the prevalence of SBP in patients with ascites or the diagnostic and therapeutic management of SBP in Germany are lacking.PATIENTS AND METHODS:In a multicenter study (40 hospitals), retrospective, then prospective data were collected investigating the prevalence of SBP in patients with ascites and the pertinent diagnostic and therapeutic management. In 272 prospectively entered patients with ascites (cirrhosis/malignant ascites/other: n = 227/42/3) a diagnostic paracentesis was performed and SBP diagnosed using the ascitic neutrophil count. History, clinical symptoms and laboratory findings were recorded and potential risk factors analysed by univariate analysis and stepwise logistic regression. SBP was treated with a standard dose of a third-generation cephalosporin.RESULTS:In the retrospective study, SBP was diagnosed in 648 of 4,697 patients with ascites (14 %). Employed diagnostic and therapeutic pathways were not effective in several hospital departments. In the prospective trial, SBP was found in 134 of 272 patients with ascites (49,3 %). Frequency of symptoms was significantly different in patients either with or without SBP, as were macroscopic aspect of ascites, urine excretion and several biochemical parameters. However, their diagnostic precision was unsatisfactory. Predictive factors for SBP were previous paracentesis, endoscopic procedures and a history of abdominal pain. Treatment was effective in 83,5 % of cases. Inhospital mortality was 10 %.CONCLUSION:The prevalence of SBP in hospitalised patients with ascites in Germany is similar to that in southern Europe and USA. Symptoms alone lack sufficient diagnostic accuracy. Third-generation cephalosporin is an effective antibiotic in SBP. Pertinent diagnostic and therapeutic management calls for improvement.

BACKGROUND:Homocysteine metabolism may be impaired in chronic liver disease, possibly contributing to fibrogenesis and disease complications.OBJECTIVE:The goal was to investigate the prevalence and determinants of basal and postprandial hyperhomocysteinemia in patients with chronic liver disease and after orthotopic liver transplantation (OLT).DESIGN:This was a cross-sectional study of 323 patients with chronic liver disease (93 with hepatitis, 8 with fatty liver, 168 with cirrhosis, and 54 after OLT) and 25 healthy control subjects. Portohepatovenous gradients of total homocysteine (tHcy) and methionine and postload methionine and tHcy kinetics before and after 10 d of supplementation with folate plus vitamin B-6 were investigated in subgroups.RESULTS:Basal hyperhomocysteinemia was observed in all patient groups (34% of patients with hepatitis, 50% with fatty liver, 54% with cirrhosis, and 52% after OLT). It was more frequently seen in patients with elevated plasma creatinine concentrations and at advanced stages of liver disease. Mean plasma folate was normal in patients with liver disease, but vitamin B-12 was elevated in cirrhosis and vitamin B-6 was low after OLT. There were significant negative associations between tHcy and folic acid or vitamin B-12 concentrations in control subjects and in patients with hepatitis and after OLT. No systematic association between portohepatovenous differences in tHcy and methionine concentrations was found. Cirrhosis was accompanied by impaired methionine clearance. After vitamin supplementation, the area under the tHcy curve improved in cirrhosis at nearly unchanged basal tHcy concentrations.CONCLUSIONS:Basal hyperhomocysteinemia is seen in approximately 50% of patients with cirrhosis and after OLT. Basal tHcy concentrations do not change significantly after supplementation with folate and vitamin B-6, but postprandial Hcy metabolism improves.