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Whipple disease is an infection caused by the bacterium Tropheryma whipplei. Due to its unspecific clinical symptoms, it is difficult to diagnose and often remains undetected for a long time. The case of a patient who presented with acute intestinal symptoms to the authors' department is reported. The diagnosis of classic Whipple disease was established. The symptoms subsided under antibiotic therapy. Complications in the form of immune reconstitution inflammatory syndrome (IRIS) occurred, requiring immunosuppressive treatment.Der Morbus Whipple ist eine durch das Bakterium Tropheryma whipplei verursachte Infektion, deren Diagnosestellung durch eine unspezifische Beschwerdesymptomatik erschwert wird und die häufig lange unerkannt bleibt. Wir berichten über einen Patienten, der sich mit neu aufgetretenen intestinalen Beschwerden in unserer Abteilung vorstellte. Es konnte die Diagnose eines klassischen Morbus Whipple gestellt werden. Unter antibiotischer Therapie wurde eine Remission der Symptomatik erreicht. Komplizierend traten Beschwerden im Sinne eines Immunrekonstitutionssyndroms (IRIS) auf, die eine immunsuppressive Behandlung erforderten.

A 44-year-old Filipino woman presented with abdominal pain and fever. Clinical examination and blood tests revealed no pathological results; however, (cross-sectional) imaging showed saccular cystic bile duct dilatation in the right liver with solid intraductal masses. Due to the clinical presentation the patient was admitted for surgical intervention with the diagnosis of Caroli disease. During the surgical procedure histopathology showed an intraductal papillary neoplasm of the bile duct (IPNB). The planned segmentetomy was extended to hemihepatectomy. IPNB is a rare entity of premalignant lesions of the bile duct system first recognized by the World Health Organization in 2010.

We report a case of a 69-year-old man who developed tetraparesis and muscular pain under the therapy of prednisolone for several months. Diagnosis was sepsis due to pyomyositis with multiple septic pulmonary staphylococcus aureus abscesses. Antibiotic therapy with piperacillin and tazobactam resulted in a decrease of the inflammatory factors and improvement of the tetraparesis. Pyomyositis, common in tropical areas, is a suppurative infection of striated muscle. Immunodeficiency has been implicated in the development of pyomyositis in temperate climates.

We report on a 48-year-old patient with Crohn's disease and left abdominal pain, who presented with hematuria and proteinuria. As reason we found a left renal vein thrombosis. This diagnosis was based on magnetic resonance imaging and doppler ultrasound. The incidence of thrombembolic complications in patients with chronic inflammatory bowel disease is increased, however renal vein thrombosis is a very rare complication of Crohn's disease. We started a conservative treatment with phenprocoumon. Thereafter the patient remained asymptomatic and the thrombus dissipated during follow-up.

Iatrogenic esophageal perforations are still a life-threatening clinical entity.We present the case reports of six patients to demonstrate different treatment options and we focus on new therapeutic strategies which have evolved in the interdisciplinary management of iatrogenic esophageal perforations. Two patients with perforations in the cervical esophagus were operated and in another patient the perforation was closed with fibrin glue. Three patients with perforations in the thoracic esophagus were treated with self-expandable plastic stents.The surgical therapy of esophageal perforations still is regarded to be the gold standard and nonadherence should only be considered based on interdisciplinary decisions in individual cases. However, positive results are increasingly being reported for conservative endoscopic treatment, particularly for thoracic perforations.

Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Due to the central anatomic localization within the liver hilum, established guidelines of oncologic surgery are difficult to apply. Resection of the hilar bifurcation alone or in combination with limited hepatic resection can be performed with low morbidity and low mortality but shows a high rate of local tumor recurrence. Usually, extended resection is required to achieve adequate safety margins. Right trisectionectomy complies best with the basic rules of oncologic surgery while allowing the maximum safety margin. The 5-year survival rates reported after right trisectionectomy range between 20% and 40% and reach 59% in selected patients. The increasing experience with living donor transplantation and recent advances in neoadjuvant tumor therapy may lead to renewed discussion of liver transplantation in hilar cholangiocarcinoma.

Photodynamic therapy (PDT) of dysplasia and early cancer of the esophagus could show good results in the potential of ablation. Unfortunately, the existing expensive and temperamental dye laser systems foiled a broad clinical use. In this pilot study, we investigated the feasibility of an inexpensive and maintenance-free diode laser system for PDT of dysplasia and early cancer in Barrett's esophagus.Eight patients with Barrett's esophagus and/or early cancer were treated. As light source we used a diode laser system with a maximum power output of 2 W and a wavelength of 633 +/- 3 nm. One patient was treated initially with Photosan-3, seven patients received 5-aminolevulinic acid.In all patients we could achieve reduction in length and/or histologically proven downgrading. In three quarters of the patients, complete eradication of adenocarcinoma could be attained. Columnar-lined metaplastic epithelium could also be completely eradicated.PDT using a diode laser system is comparably effective in Barrett's esophagus/early cancer as PDT with dye laser systems. PDT is a gentle and effective technique with little side effects.

This study was performed to assess the role of additional diagnostic laparoscopy in the preoperative staging of patients with gastric cancer and pancreatic cancer prior to intended curative surgery. Furthermore patients with ascites of unknown origin were evaluated. 127 patients with primary solid abdominal tumors were eligible for evaluation; of those 66 patients had a gastric cancer and 61 a pancreatic cancer. Patients without histologically proven metastases proceeded to laparotomy. Ascites of unknown origin was the indication for performing a diagnostic laparoscopy in 23 patients. Metastases were detectable laparoscopically in 13 of 66 patients (20%) with gastric cancer. Intraoperatively metastases were evident in further 7 cases. In 14 of 61 patients (23%) with pancreatic cancer metastases were detected by laparoscopy and in further 5 patients intraoperatively. A peritoneal carcinosis was diagnosed laparoscopically in 17 of 23 patients with ascites of unknown origin. Preoperative staging by additional diagnostic laparoscopy proved effective in patients with gastric- and pancreatic cancer.

Prognosis of pancreatic cancer and bile duct cancer is extraordinary poor. Despite of the improvement in diagnostic procedures and the development of more radical resectional procedures prolongation of survival could not have been achieved yet. At the time of diagnosis only 20-30% of patients are suitable for resection, thus the value of non resectional methods for palliation has to be determined. Despite of numerous efforts to increase the local radiation dosage by means of distinguished radiation techniques none of these procedures could achieve an unequivocal prolongation of survival. After promising preliminary results of intraoperative radiotherapy (IORT) in pancreatic cancer following studies could not show a survival benefit for IORT allone or in combination with extracorporal radiotherapy (EBRT). EBRT is indicated at best for local pain control and is limited by the high radiation sensitivity of the adjacent organs. Intracorporal radiotherapy or brachytherapy with iridium 129-labelled wires leeds to local, intraluminal tumour control, but has also no influence on survival time. Up to now, photodynamic therapy (PDT) of pancreatic cancer must be characterized as highly experimental. But PDT can contribute to local tumour control. Preliminary data of photodynamic therapy in bile duct cancer show good results concerning reduction of cholestasis, improvement of life quality and even prolongation of survival time. The value of these preliminary results is being proved at present in controlled studies in comparison to mere endoprosthetic supply at a few centers.

The trends and developments in endoscopy of the coming years are many-sided. Improved fiber-optics and invention of computer technology lead to smaller endoscopes with higher resolution. Electronic image processing makes three dimensional measurement or presentation of objects possible. In endosonography a trend to miniaturization is also obvious. Advances in molecular biology and imaging procedures will strengthen the importance of endoscopy in the future. Moreover a differentiated use of new laser technologies will improve the possibilities of endoscopic diagnosis and therapy. The use of electronic diagnostic documentation systems will contribute to a standardized nomenclature and to a quality-improvement of documentation in the near future. The utilization of modern electronic communication systems will facilitate intra- and interdisciplinary exchange of information.

Minimal invasive methods compete with surgical treatment in the therapy of complications after cholecystectomy. We demonstrate our results of endoscopic therapy. 52 patients with postoperative complications (39 stenoses, 5 leakages, 6 stenoses and leakages, 2 complete obliterations of bile duct) were treated by transpapillary or transhepatic biliary drainage over a time period of 12 months. In 73% of patients who completed the therapy protocol successful treatment was possible. In 4 cases a restenosis occurred. 4 patients underwent surgical treatment. We think endoscopic management is the therapy of first choice for postoperative biliary complications. Biliary stricture should be dilatated for 12 months by biliary endoprosthesis, leakage can be drained for shorter time periods.

Since the establishing of laser technology in gastroenterology there has been a change in the indications for laser therapy and numerous new laser systems have been introduced in basic and clinical research. First the argon laser and later on the Nd:YAG laser were used mainly for bleeding peptic lesions, today emphasis is on palliative desobliteration of advanced esophageal and rectosigmoidal carcinoma. Moreover, in selected cases it is used for curative ablation of early carcinoma and dysplasia. A new field of application is photocoagulation of the "watermelon stomach". Despite of promising ablation results the erbium:YAG and holmium:YAG laser became not yet established in gastroenterology. Also the KTP laser is rarely used e.g. for treatment of telangiectasia. Difficult bile duct stones can be highly effective fragmented intracorporally by means of laser lithotripsy; an automatic stone-tissue discrimination system avoids uncontrolled injury of the bile ducts. The hitherto experimental interstitial laser therapy of primary and secondary liver malignancies shows excellent results, but online monitoring of the expansion of the necrosis is still a problem. Thermal probes, MRT technology and duplex sonography are under current evaluation. Photodynamic therapy (PDT) is now, after numerous pilot studies, investigated with larger numbers of patients. First results show a marked effectiveness in ablation of dysplasia and mucosal carcinoma. The photosensitizer 5-aminolaevulinic acid seems to be particularly effective for ablation of Barrett's mucosa and m-THPC for treatment of local carcinoma. Palliative PDT of bile duct cancer may help to avoid repeated endoprosthetic treatment. The possibilities and limitations of light induced fluorescence diagnostics of severe dysplasia and carcinoma in situ is now being evaluated intensively. This method might in future facilitate the endoscopic diagnosis of dysplasia in Barrett's esophagus and chronic inflammatory bowel disease.