Zusammenfassung: Funktionelle Dyspepsie (FD) und Reizdarm-Syndrom (RDS), zwei häufige gastro-intestinale Entitäten mit überlappenden Symptomen, sollten nach den Rom-IV-Kriterien diagnostiziert werden. Dabei handelt es sich um eines oder mehrere der folgenden Symptome: bei FD um postprandiales Völlegefühl, frühes Sättigungsgefühl, Schmerzen oder Brennen epigastral; bei RDS um rezidivierende abdominale Schmerzen jeweils assoziiert mit Defäkation, Veränderungen der Stuhlfrequenz oder der Stuhlform. Zum Ausschluss struktureller Krankheiten ist auf Alarmsymptome zu achten. Für die Therapie bewährt sich bei beiden Krankheiten ein Stufenschema. Stufe 1: Arzt-Patienten-Gespräch mit Erläuterung von Diagnose und Prognose sowie Klärung der Therapieziele; Optimierung des Lebensstils; Einsatz von Phytotherapeutika; Stufe 2: Symptomorientierte Medikamente: bei FD Protonenpumpenhemmer bzw. Prokinetika; bei RDS Spasmolytika, Sekretagoga, Laxanzien, Gallensäurebinder, Antidiarrhoika, Antibiotika, Probiotika; Stufe. 3: viszerale Analgetika (Antidepressiva).

Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice Abstract: Functional dyspepsia (FD) and irritable bowel syndrome (IBS), two common gastrointestinal entities with overlapping symptoms, should be diagnosed according to Rome IV criteria. This includes one or more of the following symptoms: in FD, postprandial fullness, early satiation, epigastric pain or burning; in IBS, recurrent abdominal pain associated with defecation, change in frequency of stool or form of stool. To exclude structural diseases, attention should be paid to alarm symptoms. As far as treatment is concerned, a stepwise scheme proves to be effective for both diseases. Step 1: doctor-patient discussion with explanation of diagnosis and prognosis as well as clarification of therapy goals; lifestyle adaptations; use of phytotherapeutics; step 2: symptom-oriented medication: for FD, PPIs or prokinetics; for IBS, antispasmodics, secretagogues, laxatives, bile acid sequestrants, antidiarrheals, antibiotics, probiotics; step 3: visceral analgesics (antidepressants).

OBJECTIVES:In critically ill patients, correct placement of enteral feeding tubes is usually controlled by X-ray. A bedside method without radiation exposure would be preferable. This study aimed to demonstrate the feasibility and value of endoscopic position control for enteral feeding tubes by transnasal re-endoscopy.METHODS:A total of 120 consecutive examinations in critically ill patients were analyzed. Immediately after transnasal endoscopic placement of a feeding tube, the correct position was determined by re-endoscopy. In cases of incorrect position, replacement was performed instantly until the correct position was achieved. Abdominal X-ray with contrast was performed thereafter and served as the gold standard.RESULTS:In 95 patients (79%), endoscopic control showed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (one attempt in 22 patients, two attempts in 3 patients). Radiological control showed correct position in 118 patients (98%). In two cases, the feeding tube was displaced in the meantime. The sensitivity and positive predictive value of endoscopic position control was 100% (95% confidence interval, CI; 97-100%) and 98% (95% CI; 94-99%), respectively. The cost savings per case ranged from $281 to $302, depending on different cost assumptions.CONCLUSIONS:Endoscopic position control of enteral feeding tubes by re-endoscopy is feasible, very accurate, leads to a high rate of successful feeding tube placements, and has the potential of substantial cost-savings.

Background. Combined fluorine 18-flu-orodeoxyglucose-positron emission tomography-CT imaging has been shown to be of good diagnostic value in the preoperative evaluation of patients with colorectal cancer and liver metastases. The adjunctive use of intraoperative sonography (IOUS) may have a limited impact on treatment selection in these patients.Purpose. To compare the diagnostic performance of preoperative positron emission tomography (PET)-CT alone and PET-CT combined with IOUS in the evaluation of patients who are considered for curative resection of hepatic metastases from colorectal carcinoma.Materials and Methods. Patients with colorectal cancer who underwent resection of hepatic metastases and preoperative PET-CT (with or without contrast-enhanced CT) and IOUS were identified. The performance of the imaging techniques was evaluated through review of the radiologic reports, correlation with surgical and histopathologic findings, and clinical follow-up.Results. Thirty-one patients (mean age, 63.5 years [range, 53-82 years]) were analyzed. Fifteen patients had received preoperative chemotherapy. The mean interval between PET-CT and IOUS was 22.6 days (range, 1-56 days). In 4 cases, neither PIET-CT nor IOUS correctly diagnosed the liver metastases. in all 31 patients, the sensitivity of PET-CT alone and PET-CT combined with IOUS was 63% (95% Cl 44-80%) predictive value was 81% and 89%, respectively. In patients without preoperative chemotherapy (n = 16), the sensitivity of PET-CT alone and PET-CT combined with IOUS was 77% (95% Cl 49-94%) and 100% (95% Cl 79-100%), respectively. In 11 cases (35%), IOUS altered the surgical strategy.Conclusion. In patients with colorectal carcinoma and potentially resectable liver metastases on preoperative PET-CT, IOUS can provide additional information that may alter decision making with regard to surgical technique. (c) 2007 Wiley Periodicals, Inc.

BACKGROUND:Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. OBJECTIVE:To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. DESIGN:Randomized controlled study. SETTING:University Hospital of Zurich, Switzerland. PATIENTS:Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. MAIN OUTCOME MEASUREMENTS:Success rates of endoscopic placement of enteral feeding tubes. RESULTS:A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument (P < .0001). LIMITATIONS:In rare cases, the randomization list could not be followed correctly. CONCLUSIONS:This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

Background: Examination of the colon and consequent removal of polyps is usually accomplished during withdrawal of the endoscope. By this strategy, polyps seen on the way up may be difficult to relocate and be missed on the way down. Consequently, it may not be possible to remove all polyps. Aim: To demonstrate that removing all visible polyps both on the way up and down misses less polyps than removing polyps only on the way down. Methods: Patients scheduled for regular colonoscopy were asked for informed consent and included if at least one polyp was detected. According to a randomization list, polyps were removed both on the way up and down (group A) or only on the way down (group B). Results: To date, a total of 153 patients (75 women, age 59.6, range 32-84) were included (group A: 72; group B: 81). Total mean procedure times were equal in both groups (25.9 and 26.0 minutes, resp.). Mean intubation time was 11.3 min in group A and 8.5 min in group B (p < 0.01). Mean withdrawal time was 11.5 min in group A and 14.3 min in group B (p < 0.01). Per procedure, equal numbers of polyps were detected in both groups (2.49 and 2.64, resp.). In group A, totally 61 polyps were removed on the way up and 118 polyps on the way down. In group B, totally 56 polyps were seen on the way up and 208 polyps removed on the way down. In 6 patients (7.4%) of group B, polyps seen on the way up have been missed on the way down (average size 3.7 mm). Conclusions: This ongoing study demonstrates that the rate of missed polyps can be reduced by removing polyps both on the way up and down.

Background and Aim: Contamination of endoscopy suites with bacteria during procedures is of concern particularly through droplets during handling of biopsy specimens. It has been advocated that suctioning while removing the biopsy forceps could help to reduce potentially hazardous bioaerosols. The aim of the present study was to evaluate the efficacy of air suctioning during removal of the biopsy forceps. Materials and Methods: Airborne bacteria were collected by an impactor air-sampler (MAS-100). Fifty liters of air were collected continuously for 30 seconds at a 30 cm distance from the colonoscope suction channel. Room air samples were taken in the endoscopy suite in the morning prior to the beginning of the endoscopy program, during colonoscopy with a sham biopsy in the descending colon with and without suctioning and at the end of the procedure day. Standard 90 mm Petri dishes containing a selective medium for gram-positive cocci (CNA blood agar) were used with the impaction sampler and colony forming units/m3 (cfu) were determined. Results: Measurements were performed at fifty consecutive colonoscopies. Prior to the beginning of the endoscopy program, the bioaerosol burden in the colonoscopy suite reached a mean of 4.2 cfu/m3. During colonoscopies performed without suctioning at biopsy the bioaerosol burden increased to 29.4 cfu/m3 whereas this burden increased only to 15.1 cfu/m3 when the suctioning was applied during removal of the biopsy forceps. The difference in bioaerosol burden between suctioning and no suctioning was highly significant (p < 0.0005). At the end of the procedure day the airborne bacteria count dropped to 15.6 cfu/m3. The analysis of the colonies on the CNA blood agar identified predominantly enterococci. Staphylococci spp. and other gram-positive bacteria were rarely isolated. Conclusion: The present study indicates that the bioaerosol burden during handling of biopsy specimens is not neglectable but can be reduced by the simple habit of applying suctioning during acquisition of biopsies. This practice might be an important infection-control measure during gastrointestinal endoscopies.

Endoscopy altered the practice of gastroenterology by providing nonoperative access to the gastrointestinal (GI) tract and the pancreaticobiliary system. The detection of microscopic and biochemical changes within the mucosa and submucosa, however, has remained beyond the realm of routine endoscopy. Distinguishing hyperplastic from neoplastic polyps, differentiating malignant from benign ulcers, and detecting mucosal dysplasia in patients with inflammatory bowel disease or Barrett’s esophagus (BE) remains within the purview of the GI pathologist. In particular, endoscopic detection of dysplasia relies on the recognition of visible lesions (e.g., adenomatous polyps, dysplasia-associated lesion, or mass), or random sampling of tissue (biopsy). Endoscopy alone can neither reliably detect regions of invisible or flat dysplasia nor distinguish dysplasia from nondysplastic changes within visible lesions. Histological examination of the excised material is required to diagnose and locate dysplasia. Random biopsy techniques are subject to sampling errors and increased risk because of long procedure time and multiple biopsy sites. In patients with inflammatory bowel disease, it has been estimated that a total of 33 and 56 biopsy specimens are required for a 90 and 95% confidence to detect dysplasia or carcinoma (1).

Background: Air contamination of procedure rooms with enteric bacteria is of concern. As a consequence, high power air conditioning systems were installed in many units. To date, there is no data quantifying the amount of air contamination in procedure rooms. Aim: To demonstrate that there is a significant air contamination with bacteria in procedure rooms of a GI unit depending on the type of procedures performed. Methods: Two hundred liters of air were sampled continuously for 2 minutes in three different procedure rooms (colonoscopy, upper endoscopy, abdominal ultrasound). The procedure rooms were equipped with a high power air conditioning system. Airborne bacteria were collected by an impactor air-sampler (MAS-100) that exposed the aspirated air directly to standard Petri dishes (sheep blood). The samplings were performed before the first procedure started (7 am), during daytime (11 am), and late after the last procedure before cleaning (5 pm). At each Petri dish, colony forming units per m3 (cfu/m3) were counted. Results: Measurements were performed on 5 consecutive days. The results (mean values) are displayed in the table below. There is a significant increase of bacterial air contamination during daytime (p = 0.005). The colonoscopy room is during daytime more contaminated than the other two procedure rooms (p = 0.05). The analysis of the colonies identified predominantly enterococci and micrococci. Conclusions: The present study indicates that the highest bacterial contamination occurs predominantly during daytime and in the colonoscopy room. The clinical significance of air contamination by enteric bacteria in procedure rooms needs to be determined. Tabled 1 Colonoscopy room Upper endoscopy room Ultrasound room 7 am 4.2 4.8 12.2 11 am 81.8 59.4 42.6 5 pm 28.0 40.4 38.4 Data are presented in colony forming units per m3 (cfu/m3) Open table in a new tab Data are presented in colony forming units per m3 (cfu/m3)

Background: In critically ill patients, correct placement of enteral feeding tubes is usually ascertained radiologically. Transnasal re-endoscopy may represent a quick and reliable method to verify tube position and make radiation exposure unnecessary. Aim: To study the feasibility and value of endoscopic position verification of enteral feeding tubes by transnasal re-endoscopy. Methods: Immediately after transnasal endoscopic placement of an enteral feeding tube, correct position was determined by re-endoscopy through the opposite nasal passage. In case of incorrect position, re-placement was undertaken until correct position was achieved. Plain abdominal x-ray after tube perfusion with a contrast medium served as gold standard. Results: A total of 120 consecutive examinations (79 men, median age 56 years, range 17-88) were analyzed. In 95 patients (79%), endoscopic ascertainment confirmed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (1 and 2 attempts in 22 and 3 patients, respectively). The average additional time spent on endoscopic control and repositioning when indicated was 3.1 minutes (1-22 minutes). Eventually, radiologic comparison showed correct position in 118 patients (98%) whereas in 2 cases, the feeding tube got displaced in the meantime. The estimated cost-savings per case were approximately 350 USD. Conclusions: Endoscopic position ascertainment of enteral feeding tubes by re-endoscopy is feasible and very accurate, leads to a high rate of successful feeding tube placements, and has the potential for substantial cost-savings.

Pylephlebitis is a serious condition with significant morbidity and mortality which can complicate intraabdominal infection occurring in the region drained by the SMV and portal vein. The diagnosis requires the demonstration of portal vein thrombosis accompanied by bacteremia in a febrile patient. Both CT scan and transabdominal US have been used to demonstrate thrombus in the venous structures. This is the first report of EUS detected pylephlebitis in a situation where standard imaging techniques were suggestive of another diagnosis.

Screening and surveillance can prevent gastrointestinal cancer by detecting precursor lesions of cancer, but in many cases dysplasia is invisible to the eye of the endoscopist. Therefore, surveillance in these situations requires extensive random biopsies and histologic examination of the excised tissue for dysplasia. This biopsy strategy may overlook areas of dysplasia and is limited by sampling errors. Spectroscopic methods have the potential to overcome these limitations by rapidly and safely evaluating wide regions of tissue for dysplasia without required excision of the tissue. Spectroscopy can objectively quantify the color and brightness of light and uses this information to detect changes within the mucosa that are too subtle to be appreciated by the naked eye. Most spectroscopic techniques are initially developed and tested with optical fiber probes. These probes have several advantages including ease of passage through the accessory channel of standard diagnostic endoscopes and highly predictable geometry between fibers that provide the source of light and those that deliver collected light to the detector. These factors make point probes highly suitable for research and technology development; however, they are limited by the small surface area they examine at the tip of the probe.

Benign mediastinal cysts, which account for approximately 20% of mediastinal masses, may be diagnostic challenges. Information regarding the use of EUS and EUS-guided FNA in this setting is limited. The aim of this study was to demonstrate the value and potential risks of EUS and EUS-FNA in the diagnosis of mediastinal foregut cysts.The EUS database of a single tertiary referral center was reviewed for the diagnosis of benign mediastinal cysts. Twenty patients were identified who underwent 23 EUS examinations for suspected mediastinal cysts (n = 4), for follow-up of a known cyst (n = 3), or for a mediastinal mass of unknown origin (n = 16).In 19 patients, the definite diagnosis of a mediastinal cyst was established by EUS. Twelve cysts appeared anechoic, 6 were hypoechoic, and one anechoic cyst contained small echoic foci. CT (n = 17) or magnetic resonance imaging (n = 1) was performed in 18 cases; only 4 of these were diagnostic of a cyst. In 3 cases, the cyst contents were aspirated by EUS-FNA. In a fourth case, a solid-appearing duplication cyst, misdiagnosed by EUS, was sampled with FNA and core biopsy. This patient developed severe sepsis secondary to mediastinitis 4 days later. Thoracotomy revealed an infected bronchogenic cyst.EUS provides a minimally invasive approach to the diagnosis of benign mediastinal cysts and may be more accurate than CT or other imaging modalities. Aspiration of suspected cysts should be undertaken with caution, given the risk of infection.

Background. Computed tomography (CT) is the most common method of staging lung cancer. We have previously shown endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) to be highly accurate in staging patients with nonsmall cell lung cancer (NSCLC) who have enlarged mediastinal lymph nodes on CT scan. In this study we report the accuracy and yield of EUS-FNA in staging patients without enlarged mediastinal lymph nodes by CT. Methods. Patients with NSCLC and CT scan showing no enlarged mediastinal lymph nodes (> 1 cm for all nodes except > 1.2 cm for subcarinal) in the mediastinum underwent EUS. Fine needle aspiration was performed on at least one lymph node, if present, in the upper mediastinum, aortopulmonary window, subcarinal, and periesophagus regions. Each specimen was evaluated with on-site cytopathology and confirmed with complete cytopathologic examination.Results. Sixty-nine patients without enlarged mediastinal lymph nodes were evaluated. Endoscopic ultrasound detected malignant mediastinal lymph nodes in 14 of 69 patients as well as other advanced (American joint Committee on Cancer [AjCC] stage III/IV) in 3 others (1 left adrenal, and 2 with mediastinal invasion of tumor) for a total of 17 of 69 (25%, 95% confidence interval: 16% to 34%) patients. Eleven additional patients were found to have advanced disease by bronchoscopy (2), mediastinoscopy (2), and thoracotomy with mediastinal lymph node dissection (7). The sensitivity of EUS for advanced mediastinal disease was 61% (49% to 75%), and the specificity was 98% (95% to 100%).Conclusions. Endoscopic ultrasound guided fine needle aspiration can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost one of four patients who have no evidence of mediastinal disease on CT scan. In addition to previously reported results in patients with enlarged lymph nodes on CT, these data suggest that all potentially operable patients with nonmetastatic NSCLC may benefit from EUS staging.