Das Zenker-Divertikel ist eine seltene, aber klinisch relevante Erkrankung, die vorwiegend bei älteren Patienten auftritt. Die Behandlungsoptionen reichen von traditionellen, offen-chirurgischen Eingriffen bis hin zu modernen endoskopischen und submukosalen Tunnelungstechniken wie Z‑POEM und POES. Die Wahl der Behandlungsmethode hängt von mehreren Faktoren ab, darunter die Größe des Divertikels, die Symptome und den Komorbiditäten des Patienten. Die flexiblen endoskopischen Therapien sind weniger invasiv und mit einer kürzeren Erholungszeit verbunden als chirurgische Optionen, weisen jedoch eine höhere Rezidivrate auf.

Zusammenfassung Die Artifizielle Intelligenz (AI) wird oft als Zukunftsmusik abgetan – dabei verändert sie bereits zum jetzigen Zeitpunkt die Gegenwart vieler Gastroenterolog/innen. Die beiden prominentesten Beispiele sind der Einsatz einer AI im Bereich der Polypendetektion bei der Vorsorgekoloskopie und die Veränderungen, die die Verwendung von ChatGPT im Bereich der Administration und Patientenversorgung mit sich bringt. In vielen anderen Bereichen wie der Diagnostik des Barrettkarzinomes oder bei der Klassifizierung von Pankreaszysten wird die AI in Zukunft die diagnostischen Fähigkeiten von Gastroenterolog/innen verbessern. Offene Fragen bleiben in Bezug auf die Sichtweise des Patienten auf den Einsatz dieser neuen Techniken und den Einsatz der AI in der Ausbildung und Lehre.

A 55-year-old female patient with longstanding Crohn's disease (CD) treated with anti-TNF antibodies presented with abdominal pain and diarrhea for 3 months. Her past medical history showed ileocecal resection 20 years ago and two surgeries due to stenosis of the ileocecal anastomosis. Slight elevation of CRP and dilated and thickened small bowel loops on transabdominal ultrasound were observed. Steroids were started with little symptom improvement. A CT scan showed a stenotic anastomosis with a 4 cm prestenotic radiodense structure. Colonoscopy revealed a stone behind a passable stenosis in the right colon. As the patient had undergone surgery before, the stone was treated with electrohydraulic lithotripsy (EHL) (Walz® Germany) twice and removed via a net. The stenotic anastomosis was treated using balloon dilatation with resolution of symptoms. Stone analysis revealed the consistence of 10% calcium oxalate monohydrate and 90% calcium oxalate dihydrate. A diagnosis of primary enterolithiasis was made. Enterolithiasis is a rare finding (prevalence of 0.3%–10%) and classified into primary and secondary types. Real primary enterocoliths are caused by stasis of chyme due to intestinal diverticula, tumors, or surgically altered anatomy mostly forming under the alkaline conditions in the ileum and have been described in CD.1, 2 False primary enterocoliths (bezoars) form in the gastrointestinal tract from insoluble foreign substances. Secondary enterocoliths form outside the colon (gallbladder, kidney) and migrate via fistulas. Treatment of primary enterocoliths >2 cm is mostly surgical, and our case is the first in the literature to describe the application of EHL on a primary enterocolith (Figure 1).3, 4 Large enterocolith in the right lower quadrant seen on CT. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Zusammenfassung Komplementärmedizinische Therapien werden von Patienten mit gastrointestinalen Beschwerden, insbesondere bei Patienten mit Reizdarmsyndrom („irritable bowel syndrome“, IBS) und bei Patienten mit chronisch-entzündlichen Darmerkrankungen (CED), häufig verwendet. Im Gegensatz zum großen Interesse der Patienten ist das Wissen über solche Therapien bei vielen Gastroenterologen, wahrscheinlich bedingt durch die eher schwache Datenlage, meistens gering. In diesem Übersichtsartikel möchten wir die wichtigsten phytotherapeutischen Therapiemöglichkeiten bei IBS und CED beleuchten und versuchen, einen Überblick über die Datenlage von Bewegungstherapien, Yoga und Akupunktur in der Therapie von gastrointestinalen Krankheiten zu geben.

Zusammenfassung Die Artifizielle Intelligenz (AI) wird oft als Zukunftsmusik abgetan – dabei verändert sie bereits zum jetzigen Zeitpunkt die Gegenwart vieler Gastroenterolog/innen. Die beiden prominentesten Beispiele sind der Einsatz einer AI im Bereich der Polypendetektion bei der Vorsorgekoloskopie und die Veränderungen, die die Verwendung von ChatGPT im Bereich der Administration und Patientenversorgung mit sich bringt. In vielen anderen Bereichen wie der Diagnostik des Barrettkarzinomes oder bei der Klassifizierung von Pankreaszysten wird die AI in Zukunft die diagnostischen Fähigkeiten von Gastroenterolog/innen verbessern. Offene Fragen bleiben in Bezug auf die Sichtweise des Patienten auf den Einsatz dieser neuen Techniken und den Einsatz der AI in der Ausbildung und Lehre.

The recognition of dominantly inherited micro-satellite instable (MSI) cancers caused by pathogenic variants in one of the four mismatch repair ( MMR ) genes MSH2, MLH1, MSH6 and PMS2 has modified our understanding of carcinogenesis. Inherited loss of function variants in each of these MMR genes cause four dominantly inherited cancer syndromes with different penetrance and expressivities: the four Lynch syndromes. No person has an “average sex “or a pathogenic variant in an “average Lynch syndrome gene” and results that are not stratified by gene and sex will be valid for no one. Carcinogenesis may be a linear process from increased cellular division to localized cancer to metastasis. In addition, in the Lynch syndromes (LS) we now recognize a dynamic balance between two stochastic processes: MSI producing abnormal cells, and the host’s adaptive immune system’s ability to remove them. The latter may explain why colonoscopy surveillance does not reduce the incidence of colorectal cancer in LS, while it may improve the prognosis. Most early onset colon, endometrial and ovarian cancers in LS are now cured and most cancer related deaths are after subsequent cancers in other organs. Aspirin reduces the incidence of colorectal and other cancers in LS. Immunotherapy increases the host immune system’s capability to destroy MSI cancers. Colonoscopy surveillance, aspirin prevention and immunotherapy represent major steps forward in personalized precision medicine to prevent and cure inherited MSI cancer.

Aims Hybrid FTRD has been described as an effective approach for large lesions in the duodenum and colorectum with non-lifting sign, as FTRD technique is limited by lesion size. Here we describe results of different hybrid FTRD approaches in a cohort of 40 patients.

Helicobacter pylori (H.p.) stellt trotz abnehmender Prävalenz weiterhin ein relevantes gesundheitliches Problem dar und ist in erster Linie für die Entstehung von Magen- und Duodenalulzera, dem Magenkarzinom und dem MALT-Lymphom („mucosa-associated lymphoid tissue lymphoma“) verantwortlich. Daneben sollte H.p. bei einer Reihe weiterer Diagnosen oder Risikokonstellationen gesucht und eradiziert werden. Auch ein prophylaktisches Screening bei Gesunden wird erstmals in deutschen Leitlinien empfohlen. Die bisherige Behandlung aus einer Kombination von zwei Antibiotika und Säurehemmung mit Protonenpumpeninhibitoren (PPI) muss wegen der hohen Resistenzrate angepasst werden. Neu sollte in den meisten Fällen als Erstlinientherapie eine Bismuth-Quadrupeltherapie oder eine Nicht-Bismuth-Quadrupeltherapie eingesetzt werden. Das Ziel ist es, bei 90

Gastroenterologists frequently face the dilemma of how to choose among different management options. To develop a tool of medical decision analysis that helps choosing between competing management options of interventional endoscopy and surgery. Carcinoma-in-situ of the esophagus, large colonic polyps, and ampullary adenoma serve as three examples for disorders being managed by both techniques. A threshold analysis using a decision tree was modeled to compare the costs and utility values associated with managing the three examples. If the expected healing or success rate of interventional endoscopy exceeds a threshold calculated as the ratio of endoscopy costs over surgery costs, endoscopy becomes the preferred management option. A low threshold speaks in favor of endoscopic intervention as initial management strategy. If the decision in favor of surgery is focused exclusively on preventing death from a given disease, surgical intervention may seem to provide the best treatment option. However, interventional endoscopy becomes a viable alternative, if the comparison is based on a broader perspective that includes adverse events and long-term disability, as well as the healthcare costs of both procedures. For carcinoma-in-situ of the esophagus, the threshold for the expected success rate is 24

Introduction Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill(R) acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. Material and methods Sixty-one consecutive patients in whom the HemoPill(R) had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. Results The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. Conclusion HemoPill(R)-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.

Esophageal perforations are potentially life threatening conditions associated with high mortality. The two main diagnostic modalities are endoscopy and CT. Important criteria are the presence of a contained or free rupture and the time elapsed between perforation and diagnosis (more or < 24 h). Evidence levels for diagnostic and treatment modalities are low due to a lack of prospective and randomized trials and are mainly dependent on local expertise. There is a tendency towards minimally invasive procedures as endoscopic placement of covered stents or more recently endoluminal vacuum-assisted treatment. Patients should be transferred to high volume centers for esophageal surgery whenever possible to improve outcomes of this rare and dangerous condition.

For any decision in favor of performing an endoscopic procedure, its expected benefit should exceed its expected cost. Otherwise, one should not do the endoscopy. The choice between two options against, or in favor of, endoscopy is based on the underlying cost– benefit relationship. Occasionally, situations arise when, besides these two options, the endoscopist faces yet a third option of ‘‘willful ignorance.’’ Rather than focusing on the potential benefit of endoscopy, the physician (or the patient) may, a priori, decide to remain ignorant of any of its potential outcomes. For instance, an abdominal computer tomography (CT) scan in an asymptomatic 85-year-old man with serious comorbid conditions reveals the incidental findings of a pancreatic head mass. Instead of subjecting the patient to further testing with endoscopic ultrasound and fine needle aspiration (EUS with FNA) or endoscopic retrograde cholangio-pancreatography (ERCP), the patient and his family decide against any additional diagnostic workup. Such decisions are relatively simple if the procedure is risky with few, if any, beneficial consequences. The choice between competing options may become more complex and difficult to make if the procedural costs are less prohibitive and the diagnostic knowledge obtained through endoscopy comprises a mixture of beneficial, as well as harmful, aspects. The aim of the present article is to present an intuitive decision tool that would be applicable in clinical practice to resolve such diagnostic dilemmas without involving complex mathematical analysis.

Background: Inflammatory bowel disease (IBD) needs early interventions and an individual specialist–patient relationship. Distance from a tertiary IBD center might affect patient’s disease course and outcome. We investigated whether the patient-to-specialist distance has an impact on the disease course using the well-defined patient collective of the Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS). Methods: Patient’s home address at diagnosis (postal zip code) was extracted from the SIBDCS database. Distance between each zip code and the nearest located IBD specialist center was calculated and classified into the following three sections based on proximity: <10 km (group 1); 10–35 km (group 2); >35 km (group 3). Results: Our study included in total 408 IBD patients [234 Crohn’s disease (CD), 154 ulcerative colitis (UC), 20 IBD unclassified (IBDU)]. Median age was lowest in group 2 at diagnosis (G1: 28 years; G2: 21 years, G3: 26 years, p < 0.01). The diagnostic delay did not differ between groups. CD patients in group 1 were treated more often with anti-tumor necrosis factor (TNF) agents (72% versus 56%, p = 0.04) and 5-aminosalicylates (44% versus 28%, p = 0.04) than in group 3. UC/IBDU patients in group 1 were treated more often with corticosteroids than patients in group 3 (83% versus 58%, p < 0.01). The occurrence of IBD-related surgeries did not differ between groups. Conclusions: Patient-to-specialist distance might affect drug treatment. However, disease course and the need for IBD-related surgery does not seem to be associated with a longer distance to specialist care in Switzerland.

Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.

Une patiente s’est présentée au service des urgences en raison de fortes douleurs rétrosternales. La patiente a indiqué prendre un antibiotique en raison de la suspicion d’un érythème migrant suite à une piqûre de tique.