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Zwischen 20 % und 40 % der Bevolkerung weisen chronische Oberbauchschmerzen, haufig in Kombination mit anderen dyspeptischen Beschwerden auf. Bei Patienten, die deswegen zum Arzt gehen, sind die Symptome in etwa der Halfte der Falle auf eine organisch fassbare Erkrankung zuruckzufuhren, wahrend die anderen Patienten unter funktionellen Beschwerden leiden. Fur die Diagnosestellung einer funktionellen Dyspepsie sollten aktuell die Rom III-Kriterien verwandt werden. Sie fordern epigastrische Schmerzen / Brennen, unangenehmes postprandiales Vollegefuhl und / oder fruhes Sattigungsgefuhl mit Beschwerdebeginn vor mindestens 6 Monaten, auserdem den hinlanglichen Ausschluss einer die Symptome erklarenden organischen Erkrankung. Hierfur ist auch die Durchfuhrung einer Osophagogastroduodenoskopie vorgesehen. Zusatzlich wird von Experten die Untersuchung von Routinelaborparametern und eine Abdomensonografie empfohlen. Nur bei jungen Patienten mit typischer und masiger Symptomatik, die zudem keine Alarmsymptome aufweisen, kann ohne apparative Diagnostik und somit ohne Diagnosesicherung eine probatorische Therapie erwogen werden. Sprechen die Beschwerden innerhalb von 4 Wochen nicht (gut) an, sollte auch bei jungen Patienten eine weiterfuhrende Diagnostik erfolgen. Die therapeutischen Moglichkeiten bei funktioneller Dyspepsie sind limitiert. Sie umfassen die klare Diagnosevermittlung, die Identifikation und Berucksichtigung von Trigger- bzw. lindernden Faktoren und den Einsatz bestimmter Medikamente, insbesondere bestimmter Phytotherapeutika, von Sauresekretionshemmern und / oder Prokinetika.

Anamnese und klinischer Befund: Eine 43-jahrige, aus Ghana stammende Patientin stellte sich mit wahrend eines Langstreckenfluges aufgetretenen heftigen linksseitigen Oberbauchschmerzen vor. In der korperlichen Untersuchung fiel ein deutlicher Druckschmerz im linken Oberbauch und Flanke auf. Es bestunden keine Vorerkrankungen, eine regelmasige Medikation wurde verneint. Untersuchungen, Diagnose: Im Labor fanden sich die Konstellation einer hamolytischen Anamie und erhohte Entzundungsparameter. Der „dicke Tropfen" war unauffallig. Sonographisch war die Milz mit 14 × 5 cm vergrosert und erschien sehr inhomogen mit ausgedehnten, diffus verteilten echoarmen Arealen in Hilusnahe. Die sonographischen Befunde wurden als ausgedehnte Milzinfarzierung gewertet. Aufgrund der anamnestischen Angabe eines Langstreckenfluges bei Symptombeginn und der erhobenen Befunde einer hamolytischen Anamie und ausgedehnten Milzinfarzierung wurde primar eine vasookklusive Krise mit Hamolyse vermutet. Die molekulargenetische Diagnostik erbrachte den Nachweis einer HbSC-Sichelzellkrankheit und heterozygoten Alpha-Thalassamie. Therapie und Verlauf: Die Patientin war unter Infusion von kristalloider Infusionslosung im Verlauf beschwerdefrei. Bei Milzinfarzierung wurde prophylaktisch mit Cefuroxim behandelt. Eine Impfung gegen Pneumokokken, Meningokokken und Haemophilus influenzae B wurde empfohlen. Folgerungen: Eine milde Hypoxie und Dehydratation wahrend eines Langstreckenfluges konnen Ausloser von Sichelzellkrisen sein und in Einzelfallen sogar zur Erstdiagnose dieser Erkrankung fuhren. Bei der HbSC-Sichelzellkrankheit konnen Komplikationen wie bei der „klassischen“ HbSS-Sichelzellkrankheit auftreten. Die HbSC-Sichelzellkrankheit sollte jedoch als eigenstandige Erkrankung mit spezifischem klinischem Erscheinungsbild und nicht als milde Variante der HbSS-Sichelzellkrankheit betrachtet werden. Milzinfarkte im Rahmen einer Sichelzellkrise konnen in der Kontrastmittelsonographie anders aussehen als typische arterielle thromboembolische Infarkte.

In 15 patients with acute pancreatitis caused by biliary disease endoscopic sphincterotomy was performed after diagnostic ERCP. All patients had a history of symptoms pointing to long-standing biliary disease, such as typical right-sided upper abdominal pain, signs of biliary stasis, and jaundice. An impacted solitary ampullar stone was demonstrated in eight patients while in seven several stones were found in the biliary tract. In one patient pancreaticogram also revealed a gall-stone which had slipped in Wirsung's duct. After endoscopic sphincterotomy and extraction of stone rapid and marked improvement occurred in all 15 patients and the biochemical abnormalities were restored towards normal. All patients became pain-free immediately after the procedure. The markedly raised levels of serum-alpha-amylase (mean of 21 700 U/l immediately before the procedure) fell tonormal values within 48 hours (400--3000 U/l). Endoscopic sphincterotomy is thus an alternative to early operation in acute pancreatitis of biliary origin.

In a prospective study, gastroscopy and biopsies from the gastric antrum and body were undertaken in 100 consecutive patients (67 women, 33 men; mean age 58.6 [11-90] years) with unknown Helicobacter pylori status. None had been on any bacteria-suppressing drugs. Main indications for gastroscopy were upper abdominal pain, dyspepsia, emesis and anaemia of unknown cause. The macroscopic criteria for the diagnosis of H. pylori gastritis were the presence of at least one of the following signs: (1) chronic antral erosions; (2) goose-pimple-like appearance of the antral mucosa; (3) spotty erythema in the antrum; (4) complex changes of the antral mucosa with both bizarre reddening and pale areas; and (5) increased areolar markings and diffuse or fine-spotty erythema in the mucosa of the body of the stomach. Four biopsies each from the antrum and body were examined with the urease quick-test, microscopically as smears, specific culture and histology as reference methods. 60 patients had H. pylori gastritis, recognized macroscopically in 59 (sensitivity 98.3%). A false-positive diagnosis was made in 10 of 40 H. pylori-negative patients (specificity 75%). The positive predictive value of macroscopic diagnosis was 85.5%, the negative predictive value 96.8%.

Coeliac plexus nerve block by alcohol through a percutaneously introduced, ultrasonically guided, small needle was performed in 36 patients with severe chronic upper-abdominal pains, 32 of them with malignant and four with benign disease. In 11 patients there was lasting, in eight transitory freedom from the pain, while in five other patients there was a definite diminution of pain, and the use of analgesics and especially opiates was discontinued or at least markedly reduced. Body-weight increased in 14 patients. In a woman with chronic pancreatic pain who had several previous operations alcohol injection triggered off an acute attack of pancreatitis which ended fatally.

Intermittent jaundice and recurrent colicky upper abdominal pain in two patients, aged 46 and 48 years, were found by endoscopy to be due to an adenoma of the papilla of Vater. Transduodenal local excision with papilloplasty made both patients free of symptoms.

A 39-year-old man was hospitalized because of a 5-week history of feeling very ill, with fever up to 39 degrees C and nonspecific upper abdominal pain. He looked very pale and his spleen was painful on palpation. There was a blood eosinophilia of over 50% and computed tomography demonstrated hypodense areas in the liver, suggesting a parasitic infection with liver involvement. An ELISA factor of over 100 and the finding of liver fluke eggs in bile confirmed the diagnosis of Fasciola hepatica infection, which was probably acquired by eating wild watercress when visiting in the Allgau. A fasciola infection was also proven in his 37-year-old sister who for some time had complained of colicky right-sided upper abdominal pain, her 40-year-old husband with similar symptoms and their 10-year-old daughter. All four were successfully treated for two days with 10 mg/kg triclabendazole daily by mouth. Persons eating raw vegetables and salads of wild-growing plants are at risk of being infected with Fasciola hepatica.

BACKGROUND AND OBJECTIVE In view of numerous sequelae of a Helicobacter pylori (H.p.) infection and sparse epidemiological data on the infectious status of children and juveniles, a cross-sectional study was undertaken in schools of the Aschaffenburg area. Data were recorded on the number of H.p. infections in pupils aged 14-20 years, the possible influence of various socio-economic factors, and a possible association of the infection with upper abdominal symptoms. SUBJECTS AND METHODS In 540 pupils of grade 2 (aged 7-9 years: primary school, n = 183) grade 7 (aged 11-15: primary and secondary schools, n = 177) and grade 12 (aged 16-20 years: vocational or grammar school: n = 180), the presence of H.p. was elucidated with the 13C-urea breath test. An anonymous questionnaire was used to ascertain socio-economic status and any symptoms. RESULTS In 51 of the 540 pupils (9.4%) the test for H.p. was positive. The infectious state increased with age, but there was no significant difference between the various age groups. Ethnically German pupils were less often infected (7.1%) than those of foreign origin (28.2%). The number of persons in a household correlated with the H.p. status. Upper abdominal symptoms were more frequently reported by infected children and juveniles and were an independent risk factor for H.p. infection. CONCLUSION This study highlights the importance of socio-economic factors and the possible association of upper abdominal pain with H.p infection.

Acute pancreatitis with severe belt-like upper abdominal pain developed within 1-4 weeks of starting medication in three patients (29-year-old man with ulcerative colitis; 43-year-old woman and 22-year-old woman with Crohn's disease) treated, for the first time, with 5-aminosalicylic acid (mesalazine), 500 mg three times daily. Concentrations of lipase initially were 545, 1182 and 3000 U/l, and of amylase 243, 449 and 129 U/l, respectively. Symptoms receded within a few hours after the drug had been discontinued, enzyme levels returning to normal in the course of the next 2-3 weeks. On repeating the drug in two of the patients, in lower dosage, the pancreatitis recurred within a few days. These observations support the view that 5-aminosalicylic acid can cause acute pancreatitis, perhaps as an allergic reaction.

In 6 patients with upper abdominal pain of unknown origin presenting with pancreas divisum, the pressure in the pancreatic duct was measured via the minor papilla into which in these patients the main part of the pancreatic duct system drains. For comparison intraductal manometry via the major papilla (papilla of Vater) was performed in 8 patients with normal pancreatic duct system. The pressure in the pancreatic duct of the control group was 10.5 +/- 0.9 (8-14) mm Hg, whereas in the patients with pancreas divisum it was 23.7 +/- 1.3 (20-28) mm Hg. The results demonstrate that in patients with pancreas divisum intraductal pressure may be largely increased even in the fasting state.

Die 33-jahrige Patientin stellte sich mit Oberbauchbeschwerden vor. Laborchemisch bestand eine leichtgradige Anamie und eine diskrete, isolierte γGT-Erhohung (AFP normwertig). Sonographisch wurden multiple knotige Lasionen in der Leber nachgewiesen, daher wurde eine MRT mit Kontrastmittel-Gabe durchgefuhrt. Die MRT-Schnittbildgebung zeigt einen pathologischen Befund.

Rupture of the spleen occurred in two patients (a man of 32 and a girl of 16 years) with serologically proven infectious mononucleosis. No history of trauma as a cause of the rupture could be elicited in either patient, despite intensive questioning. Abdominal symptoms were left-sided upper abdominal pain radiating into the left shoulder (Kehr's sign). The suspected diagnosis was confirmed by ultrasound demonstration of free abdominal fluid and abnormal splenic structure. Splenectomy had to be performed in both patients.

In seven patients with chronic renal failure in an advanced stage 17 episodes of upper abdominal pain, hypertension, vomiting and (in some of them) coma occurred during peritoneal dialysis with sorbitol-containing dialysate. The signs recurred in some of the patients but did not when glucose-containing dialysate of otherwise identical composition was used. Very high levels of sorbitol in CSF and serum were measured in the comatose patients. The precipitating factor is probably a reduced metabolic breakdown of sorbitol in renal failure with preferential intracellular deposition of sorbitol and subsequent cellular oedema. To avoid this dangerous reaction it is necessary to use glucose instead of sorbitol in peritoneal dialysates, despite the technical problems of sterilisation. Where this is not possible, glucose should be added in order to reduce the sorbitol concentration in the dialysate to less than 15g/l.