Objectives Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size. Designs A cute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre. Results A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis. Conclusions T his large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients.

ZusammenfassungDie seit Langem eingesetzten Pankreasstents migrieren zu 7,5 % nach distal, zu 5,2 % nach proximal. Trotz verschiedener Möglichkeiten und Instrumente die nach proximal migrierten Stents zu bergen, gelingt dies nur in ca. 80 % der Fälle. Aufgrund der Folgeschäden und Risiken durch den verbleibenden Stent im Pankreasgang im Sinne einer chronischen Pankreatitis mit konsekutiver OP-Indikation bzw. mit erhöhtem Karzinomrisiko, rieten wir unserem Patienten, in Anbetracht der heute überschaubaren perioperativen Risiken, zur operativen Bergung.

Das Gallensteinleiden zählt zu den häufigsten Erkrankungen in Deutschland. Die unkomplizierte symptomatische Cholelithiasis wird elektiv mittels laparoskopischer Cholezystektomie behandelt. Bei komplizierten Verläufen etwa mit Cholezystitis, Cholestase, Cholangitis, Sepsis oder biliärer Pankreatitis ist rasches Handeln essenziell, um vital bedrohliche Folgen zu vermeiden. In der Vorgehensweise gibt es einige aktuelle Neuerungen.

Hintergrund/Einleitung: Als Palliation maliger Gallengangsobstruktionen hat sich die endoskopische Stenteinlage etabliert. Obwohl diverse Studien einen Vorteil von Metallstents gegenüber Plastikstents zeigten, ist ihr Einsatz durch hohe Kosten limitiert. Auch Modifikationen von Plastikstents lieferten bislang keine besseren Ergebnisse.

A 63-year-old man presented with massive diarrhea and weight loss. This was preceded by nonspecific symptoms for three years, which resembled sarcoidosis. By duodenal biopsy, the diagnosis of Whipples disease was confirmed. Antibiotic treatment resulted in rapid and complete disappearance of signs and symptoms.

Objective. The identification of CARD15 as a susceptibility gene for Crohn's disease (CD) offers new possibilities for patient classification and risk assessment. The purpose of this study was to carry out a CARD15 sequence analysis in a large single-center IBD cohort and to investigate the impact of different genotypes on disease phenotypes. Material and methods. A total of 445 unrelated patients with IBD (68.1% CD, 28.5% ulcerative colitis (UC), 3.4% indeterminate colitis (IC)) were included in the study. Clinical data were recorded by detailed questionnaire and analysis of the charts. CARD15 variants (R702W, G908R, 1007fs (frameshift)) were identified by DNA sequence analysis. Results. CARD15 variants were found in 142 inflammatory bowel disease (IBD) patients (31.9%) including 120 CD patients (39.6%). In CD, the presence of two CARD15 variants was associated with ileal disease (p=0.008 versus wild-type (wt); OR 4.04; 95% CI 1.36–11.96) and a fibrostenotic phenotype (p=0.002 versus wt; OR 5.47; 95% CI 1.61–18.58). Subgroup analysis of 19 patients (4.3%) homozygous for the CARD15 variant 1007fs (3020ins C) revealed an association with onset of CD at an early age (p=0.014 versus wt), ileal involvement (p=0.001), and intestinal stenoses in all patients (p=0.001) frequently requiring surgery (73.7%; p=0.093). Of these patients 78.6% developed re-stenoses after surgical resection; 52.6% of the homozygotes were diagnosed as having entero-enteral fistulas. Conclusions. Patients homozygous for the 1007fs mutation had an early disease onset with long-segment ileal stenoses and entero-enteral fistulas. They frequently needed surgical intervention and had a high risk of re-stenosis. Genotyping therefore appears to be an important diagnostic tool in identifying severely affected patients requiring individualized treatment strategies at an early stage of the disease.

In recent years, laparascopic cholecystectomy has been the treatment of choice for patients with symptomatic gallbladder stones. At present, non-surgical alternatives are considered in highly selec...

AIM: To study the role of the intracellular receptor domain of gp130 in human inflammatory bowel disease (IBD).METHODS: We amplified and sequenced the complete exon 17 of the human gp130 gene in 146 patients with IBD. According to clinical and histopathological signs,the 146 patients with IBD were classified as having Crohn's disease (n = 73) or ulcerative colitis (n = 63),or as indeterminate status (n = 10).RESULTS: No mutations in exon 17 of the gp130 gene could be detected in any of the 146 patients with IBD examined.CONCLUSION: There is no evidence that mutations in exon 17 of the gp130 gene are involved in the pathogenesis of human IBD.

ABSTRACT We investigated whether a novel monoclonal stool antigen test for detection of Helicobacter pylori performs with the same accuracy as the 13 C-urea breath test (UBT) for adult outpatients in the setting of a private office. The two tests showed identical levels of sensitivity when used to identify H. pylori -infected patients before and after eradication therapy.

Extracorporeal shock-wave lithotripsy has been introduced as a novel nonsurgical therapy for gallstone disease. To substantiate the initial results, more than 400 patients with biliary calculi have been treated. In selected patients with gallbladder stones, complete clearance of all stone fragments can be expected within 1 year in about 80%. In patients with bile-duct stones not amenable to endoscopic measures, sufficient stone fragmentation by extracorporeal shock waves was achieved in about 80%. Extracorporeal shock-wave lithotripsy is a safe and efficient therapy for selected patients with gallbladder calculi. For patients with bile-duct stones not amenable to endoscopic measures it offers a nonsurgical alternative.

All patients underwent four tissue biopsies for histology and one tissue biopsy for each urease test (CLO and Pronto), during the gastroscopy.Results were examined at 30-rain intervals for 2 consecutive hours.The two test results are presented below.Pronto and CLO sensitivity at 120 rain was 79 % and 76 % respectzvely, in patients under no antisecretory therapy and no upper GI truck hemorrhage.We found a linear correlation between the histology grading and Pronto graded chromatic index, regarding the stomach mucosal colonization density of Hp.[ Y= -0,12 +0,8SX (F1,101 = 104 p< 0,0001)].Conclusions:Both test results were comparable at two hours.However Pronto test surpasses CLO, because it becomes positive in 48% of patients at 30 rain, offering a sooner diagnosis, even with a single biopsy specimen.Additionally, Pronto correlates the chromatic grading with the stomach mucosal colonization density by Hp reliably, providing to clinicians a clear idea of what to be expected in the forthcoming histology.Last but not least, Pronto net price is remarkably lower than that of CLO.

Background: Steroids comprise the standard therapy for acute severe ulcerative colitis Therapeutic alternatives for patmms in whom steroids would usually be contraindicated are rare. Drugs such as cyclosporine and tacrolimus have a considerable risk of nephrotoxicity, and immunosuppressams, such as azathioprine have a delayed onset of effectivity. The chimene monoclonal antibody to tumor necrosis factor alpha, lnfliximab, seems to be effective in the treatment of steroid-refractory ulcerative colitis. We, therefore, evaluated whether Infliximab can achieve remission in non steroid refractory patients with acute severe ulcerative pancolitis in a randomized, prednisolone-controlled pilot trial over 3 months. Methods: Patients were elegible if they had acute severe disease with a modified Truelove and Wilts activity score of more than ten for at least two weeks and if they were currently not receiving immunomodulators or more than 10 mg prednisolone per day. Patients were randomly assigned to receive either infliximab or high dose predinsolone with a 50% likelyhood for each. They received either three intravenous infusions of lnfhximab at 5 rag/ kg body weight, at 0, 2 and 6 weeks (group A) or prednisolone 1.5mg/kg body weight, daily for two weeks, followed by lmg/kg for one week, followed by a tapering regimen with a weekly reduction of 5mg (group B). Therapy success was defined as clinical response in terms of a decrease of more than 5 points from baseline score and to less than 10 points total after 3 as well as after 13 weeks. Results: 13 patients (8 women, 5 men) were randomized (6 for group A and 7 for group B). The median baseline activity scores were 13.5 (12 to 18) in group A and 14.0 (11 to 18) in group B. Five of six patients in group A and six of seven patients in group B showed therapy success after three as well as after 13 weeks. One patient in group A showed no response at all and one patient in group B relapsed after eleven weeks. No significant complications or side effects were observed. Conclusion: Infliximab seems to be as effective as high dose prednisolone in the treatment of acute severe ulcerative colitis. The obtained data call for larger controlled trials.

Background: In animal models ursodeoxycholic acid (UDCA) showed a chemoprotective effect against colon cancer. To explain this, a reduced proliferation of the colorectal mucosal proliferation was suggested. We, therefore, examined the influence of UDCA on the proliferation of normal colorectal mucosa in humans. Methods: Following endoscopic polypectomy, 20 patients with colorectal adenomas were randomized to receive either UDCA (750 mg/day, n = 10, group A) or placebo (n = 10, group B) for 6 months in a double-blinded way. Colorectal biopsies were sampled before and at the end of the medication by total colonoscopy. Colorectal mucosal proliferation was measured by FACScan analysis of propidium iodine labeling. Serum was sampled, and serum bile acids were analyzed by gas chromatography. Results: The proliferation rates at the end of the study were similar in both groups (median 15.4%; range 12.0–20.9 in group A; median 16.0%, 14.0–20.2 in group B, p = 0.41). Serum lithocholic acid levels at the end of the study were significantly higher in group A (1.3 µmol/l, 0.9–1.8) than in group B (0.7 µmol/l, 0–1.7, p < 0.02), whereas serum deoxycholic acid levels were similar in both groups. Conclusions: In this study, UDCA treatment for 6 months does not seem to induce changes in the proliferative behavior of the colorectal mucosa in patients with adenomas. It seems likely that a putative chemopreventive effect of UDCA in humans is not exerted by a reduction of the colorectal proliferation.

Background. It has been reported that treatment with proton pump inhibitors (PPI) leads to partial elimination and suppression of Helicobacter pylori. In theory; since acid is known to denature immunoglobulins, this antibacterial activity of PPI may be due to a reduction in the acid output favouring humoral immunity.Materials and methods. We analysed prospectively fasting gastric juice in 54 consecutive patients attending upper endoscopy for pH and levels of IgG, IgA and IgM. In addition, two antral and two corpus biopsies were obtained and histologically examined for the presence of H. pylori.Results. 41/54 patients were infected with H. pylori. Immunoglobulines in the gastric juice of these patients were found in 25/41 (IgG), 27/41 (IgA), and 29/41 (IgM) patients. There was a highly significant difference in the gastric pH when H. pylori infected patients with measurable IgG, IgA, or IgM were compared with those in whom no immunoglobulines were found (median pH: 6 vs. 2 in each group; p <.001)Conclusions. There is a close correlation between a high gastric pH and the presence of IgG, IgA, and IgM antibodies. Hence, it may be speculated that the efficacy of humoral immunity following H. pylori infection depends on a high pH such as resulting from PPI treatment.

PURPOSE:Early detection of pancreatic cancer using molecular markers may improve outcome. Mutations of the ki-ras oncogene are detected in 70% to 90% of pancreatic adenocarcinomas. A prospective, partially blinded, multicenter diagnostic trial was performed to test the sensitivity and specificity of the ki-ras polymerase chain reaction (PCR) analysis of pancreatic juice and bile specimens.PATIENTS AND METHODS:Specimens of pancreatic juice and bile were collected from 532 consecutive patients. Mutations in codon 12 of the ki-ras gene were identified by two independent enrichment PCRs and confirmed by direct sequencing.RESULTS:One hundred seventy-four of 532 patients were excluded from the final analysis (reasons: no amplifiable DNA, no specimen or only duodenal juice sent, lost to follow-up). Sixty-three of 358 patients had ductal pancreatic cancer. In 24 (38.1%) of 63 patients, a mutated ki-ras gene was identified in pancreatic juice and/or bile. Ki-ras mutations were found in four (8%) of 50 cases of chronic pancreatitis, in 10 (18.7%) of 53 cases of other malignancies of the pancreaticobiliary tree, and in 14 (7.3%) of 192 cases of benign diseases or normal findings. Sensitivity and specificity of the ki-ras PCR analysis for the detection of pancreatic cancer was 38.1% and 90.5%, respectively.CONCLUSION:In this prospective trial performed in nonselected patients, mutations of the ki-ras gene were detected in 38.1% of cases with pancreatic cancer. This test in its present form is not appropriate to confirm or screen for pancreatic cancer. More sensitive and/or quantitative PCR tests may improve the molecular diagnosis of pancreatic cancer.

With the continuous increase in network capacities, video transmissions in medicine are becoming an effective tool for second-opinion diagnosis, archiving and teaching environments. This study investigates video compression delay times and transmission impairments for different compression formats and describes the resulting picture qualities. For the evaluation, endoscopic video sequences were produced with different compression formats and bandwidth requirements. In a second step, an impairment tool was used to introduce error rates to the video material to simulate network behavior. A group of medical experts evaluated the video sequences, rating the visibility of errors, artifacts, sharpness, overall picture quality and suitability for medical diagnosis. The results clearly establish lower bounds for picture quality deteriorated by compression and network impairments, and introduce limits for medical assessments.