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The various efficient methods available for bowel preparation prior to colonoscopy differ in patient acceptance. Combining the laxative sodium picosulfate with hyperosmotic magnesium citrate, used in this study in the formulation CitraFleet(®), allows the uptake of the purgative substances as a solution of low volume. This observational study with 737 patients evaluated efficacy of bowel preparation, potential side or adverse effects and patient acceptance of this medicinal product when used by resident physicians in Germany.Colon cleansing with CitraFleet(®) was considered very good to sufficient in 95.2 % of the patients and inadequate in only 4.8 %. In 75 % of the colonoscopies, bowel preparation was rated very good or good. Compared to the standard regimen of two portions taken the day before endoscopy, cleaning efficacy was better when patients received one of the doses on the morning of the day of colonoscopy. The quality of bowel preparation was rated lower by gastroenterologists without any prior experience with sodium picosulfate/magnesium citrate. The overall assessment of the colon cleansing procedure by the 76 participating physicians was very positive and patient acceptance was also very high which can be considered a clear advantage over alternative methods. Efficacy of colon cleansing with CitraFleet(®) was not substantially affected by typical deviations from the recommended standard procedure, emphasizing the robustness of the method. Only one of the patients reported a mild adverse effect potentially caused by the cleansing agents., (© Georg Thieme Verlag KG Stuttgart · New York.)

Chronic pancreatitis is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganization of the pancreas leads to a progressive exocrine and endocrine pancreatic insufficiency. In addition, characteristic complications arise, such as pseudocysts, pancreatic duct obstructions, duodenal obstruction, vascular complications, obstruction of the bile ducts, malnutrition and pain syndrome. Pain presents as the main symptom of patients with chronic pancreatitis. Chronic pancreatitis is a risk factor for pancreatic carcinoma. Chronic pancreatitis significantly reduces the quality of life and the life expectancy of affected patients. These guidelines were researched and compiled by 74 representatives from 11 learned societies and their intention is to serve evidence-based professional training as well as continuing education. On this basis they shall improve the medical care of affected patients in both the inpatient and outpatient sector. Chronic pancreatitis requires an adequate diagnostic workup and systematic management, given its severity, frequency, chronicity, and negative impact on the quality of life and life expectancy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Non cardiac chest pain (NCCP) are recurrent angina pectoris like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70 % and may be detected in this order at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life in NCCP is comparable, partially even higher compared to cardiac chest pain. Reasons for psychological strain are symptom recurrence in app. 50 %, nonspecific diagnosis with resulting uncertainty and insufficient integration of other medical disciplines in diagnostic work-up. Managing of patients with NCCP has to be interdisciplinary because non cardiac causes of chest pain may be found frequently. Especially gastroenterological expertise is required because in 50 - 60 % of cases gastroesophageal reflux disease (GERD), in 15 - 18 % hypercontractile esophageal motility disorders with nutcracker, jackhammer esophagus or distal esophageal spasmus or achalasia and in 32 - 35 % other esophageal alterations (e. g. infectious esophageal inflammation, drug-induced ulcer, rings, webs, eosinophilic esophagitis) as cause of chest pain may be detected. This implicates that regular interdisciplinary round wards and management of chest pain units are mandatory., (© Georg Thieme Verlag KG Stuttgart · New York.)

The National Cancer Programme of the German Federal Administration aims to assess the present status of the national fight against cancer in Germany. Experts in their field have analysed the present target-performance comparison in different working groups dealing with topics from cancer prevention to follow-up and have developed recommendations as to how improvements in the various fields of cancer care may be achieved and mainly how these imrpovements may be implemented in day-to-day cancer care. The working group "Advancement of Colon Cancer Screening, Early Detection and Prevention" proposes the establishment of regulatory proposals for a nationwide, population-based, postal invitational process and, according to Pilot-Projects in Bavaria and Baden-Wuerttemberg, to evaluate the essential recommendations in data protection, logistics, documentation and financing. There are already several programmes in preparation--for example, the Saarland Offensive, based on the results of the KolosSal-Study., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: APC is a thermal coagulation technique that uses ionized argon to transmit high-frequency electrical current, contact-free, to tissue. Precise APC is one of the new modes and is characterized by a small and distinctive energy input, higher reproducibility of tissue effects which is almost independent of the probe distance. The aim of the study was the evaluation of precise APC in patients with bleeding angiodysplasia's in the cecum or the small bowel., Aim/methods: Patients (pts.) with bleeding angiodysplasia of the cecum or small bowel were prospectively enrolled. Effectivity and safety of APC was assessed by evaluating the local coagulation effect, number of rebleedings and transfusions and complications (perforation, infection)., Results: There were 50 males and 44 females, median age 65.5 ± 8.5 years. 58 pts. (62 %) had lesions in the small bowel, 28 pts. (30 %) lesions in the cecum and 8 pts. (8 %) lesions in small bowel and cecum. All 234 visible lesions in 94 pts. were coagulated successfully. There was no perforation, active bleeding and tissue carbonization after the procedure. Re-bleeding was recognized in 18 pts. (19 %) after a mean follow-up of 6.1 months and new lesions in the same area were seen in 15 / 18 pts (16 %)., Conclusion: In a historical comparison to forced or pulsed APC, precise APC may be a more appropriate option for the treatment of bleeding angiodysplasia's in critical locations like the cecum or small bowel. The coagulation effect seems to be comparable and due to its better depth control we assume a better safety, especially in preventing perforations., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Today, endoscopic resection is a standard procedure for the resection of colonic polyps. Before the establishment of endoscopic techniques, the surgical approach was a clearly preferred method for removal of polyps with a size larger than three centimeters. The safety and effectiveness concerning endoscopic resections of colorectal polyps also with a size of more than 3 cm have been demonstrated in numerous studies., Patients and Methods: Data from 165 patients (age: 68 +/- 10.4 years) harboring 167 polyps with a minimum diameter of 3 cm were retrospectively evaluated. Objects of interest were macroscopic morphology and histopathology of the polyps, their localization in the colon, the modality of endoscopic resection and follow-up. In those cases with macroscopic signs of malignancy the patients were excluded., Results: Successful endoscopic resections were obtained in 72.5 %. Therefrom, resection in the piecemeal-technique was necessary in 73.6 %. Recurrence polyps after endoscopic complete resections occurred in 26.3 % after a mean follow-up of 16 +/- 12.5 months. We registered a complication rate of 19.2 %. Relevant bleeding and perforation were registered as early complications in 18.6 %. We observed no intervention-related mortality., Conclusion: Endoscopic mucosal resection is a safe and efficient method even for removing giant colorectal polyps. Controls are recommended at defined intervals for detecting polyp recurrence.

Colorectal cancer is the most common cancer in Germany. The LebensBlicke foundation and it's supporting alliance have or many years, like others, been pushing information campaigns abour early detection measures and their chances for the general population. With the aid of the institute for public opinion research in Allensbach a representative cross-sectional investigation about the state of knowledge, opinions and attitudes concerning this topic was carried out. Surprisingly, it was demonstrated that an information deficit no longer exists and that especially people of older age are concerned about this topic. It is also remarkable that more than 40 % of the individuals over 50 years of age have had a colonoscopy at least once in their lifetime, that there is still a lack of knowledge in terms of familiy and genetic risk factors and that a doctor's recommendation is the most important driving factor to choose to undertake preventive measures. The data of this investigation will of course influence not only the work of the foundation in the next years, but should also be of major importance for medical societies and last not least for the politicians who control the health system.

In future, the profile of gastroenterology in Germany - as in other countries - will change. New achievements such as capsule endoscopy, aero-scopes and advanced CT and MRI technology and others will become alternatives to conventional endoscopy. Additional emphasis in clinical and outpatient gastroenterology is shifted towards gastrointestinal oncology, dietetics, nutrition and metabolism and in the clinical setting onto infectious diseases, endocrinology/diabetology, intensive care medicine, emergency service and geriatric medicine. The German Confederation of Gastroenterology (BVGD) initiated two Germany-wide surveys on the current diagnostic and therapeutic spectrum in hospitals and out-patient facilities to achieve a base for future discussions regarding the development of gastroenterology. The number of gastroenterologists working in hospitals and in out-patient facilities has been analysed as well as the number of examinations passed successfully during the last few years in the speciality "gastroenterology". The results of this survey offer a valid basis for continuing discussions as to how gastroenterology should develop in Germany.

Background: Little is known about the similarities and differences in the clogging process of biliary and pancreatic stents. The aim of the study was to elucidate this process using scanning electron microscopy., Materials and Methods: Scanning electron microscopy was performed in a consecutive series of 18 biliary and 10 pancreatic endoprostheses. The indication for stenting in the 18 patients (13 men, 5 women) with biliary stents was malignancy (n = 11), benign bile duct stenosis (n = 5), and biliary obstruction by bile duct stones (n = 2). The indication for stenting in the 10 patients (8 men, 2 women) with pancreatic stents was chronic pancreatitis with or without stenosis of the pancreatic duct., Results: The scanning electron microscopy study revealed a quite uniform pattern of the clogging material in biliary and pancreatic stents. The clogging material seemed to adhere to the inner stent surface by numerous tiny threads. The clogging material itself was also stabilized by tiny threads., Conclusions: The occurrence of the tiny threads constitutes the central point in the clogging process in biliary and pancreatic stents. Inhibiting the formation of these threads or at least preventing adhesion to the inner stent surface might be the best option to improve stent patency.

This guideline provides evidence-based key recommendations for diagnosis and therapy of gallstones and upgrades version 2000. It was developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, external comparative quality assurance and patient support groups under the auspices of the German Society for Digestive and Metabolic Diseases and the German Society for Surgery of the Alimentary Tract. The guideline used structural S3 consensus-based methodology and includes statements on clinical practice, prevention, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone diseases.

Background: Endoscopic screening for Barrett's esophagus is an accepted base for surveillance strategies of Barrett's esophagus; data on the natural history of erosive gastroesophageal reflux disease (ERD) are sparse. Therefore, we performed a prospective long-term follow-up examination of the course of ERD to confirm the recommendation of a once-in-lifetime endoscopy as a screening programme for Barrett's esophagus., Methods: Patients not older than 60 years with reflux symptoms and a first time diagnosis of ERD or Barrett's esophagus at the time of inclusion were identified. Patients were followed up by a further upper GI endoscopy after at least 5 years. They were interviewed about clinical symptoms and medication use., Results: One hundred and thirty-five patients were included. Follow-up data were obtained for 115 patients. Seventy-one patients (22 female, 49 male, average age: 48.3 years; range: 22-60 years) remained in the programme, 37 patients died from unrelated diseases within the follow-up period (mostly due to cardiovascluar diseases). Seven patients were excluded because of missing videoendoscopy. The average follow-up period was 78.3 (range: 60-85) months. During this time, 76 % of the patients received medical therapy. Only three patients (4.5 %) showed progression of erosive lesions, whereas two patients developed a short-segment Barrett's esophagus without intraepithealial neoplasia. These 5 patients received no medical therapy., Conclusions: Progression of ERD is an unlikely event. Once-in-lifetime endoscopy is an adequate screening tool that may serve as a basis for a Barrett's esophagus surveillance program.

Introduction: It is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis (FAP) are at greater risk for small bowel neoplasia. We therefore conducted a study to determine the frequency of small bowel polyps in patients with non-papillary duodenal adenomas using capsule endoscopy for small bowel examination., Patients and Methods: 14 patients (8 women, 6 men; mean age 67 +/- 10 years; range: 49 - 77 years) with non-papillary duodenal adenomas without FAP were included. All patients underwent wireless capsule endoscopy. The results were compared with an age- and sex-matched cohort of patients undergoing capsule endoscopy for suspected small bowel disease., Results: Overall, 15 polyps ranging between 1 and 8 mm in diameter were detected in eight patients of the study group, whereas no polyps could be identified in the control group. Natural excretion of the capsule within 24 hours was always reported and no complications were reported by any of the patients. Other pathological findings were multiple angiodysplasias in two patients of the study group. In the control group capsule endoscopy detected angiodysplasias in 5 patients with the indication obscure gastrointestinal bleeding, and inflammatory lesions in 2 patients with suspected Crohn's disease., Conclusions: Based on the results of this prospective study, the frequency of small bowel polyps in patients with duodenal adenomas without familial adenomatous polyposis appears to be increased compared with a control group undergoing capsule endoscopy for other reasons. In none of the patients was the management altered. Follow-up data of these patients will be needed.

In patients with a space-occupying lesion of the pancreas at first a primary ductal adenocarcinoma is considered as the cause. Other tumours or metastases are assumed to occur very rarely. Therapy and prognosis of other pancreas tumours differ from therapy and prognosis of a primary ductal adenocarcinoma. We therefore examined the question of how frequently a space-occupying lesion of the pancreas was not due to a ductal adenocarcinoma in our case materials. Retrospectively 70 patients who had undergone a percutaneous puncture of a space-occupying mass of the pancreas under ultrasonographic control were included in the study (34 women, 36 men). In 62 patients a clear histological diagnosis was possible on the basis of the biopsy. In 53 cases (76 %) a primary adenocarcinoma of the pancreas could be diagnosed. In 5 patients (7 %) these masses turned out to be metastases of a previously known malignant tumour disease (2 x mammary carcinoma, 2 x gastric carcinoma, 1 x sigmoid carcinoma). Other tumours could be detected in 4 cases (6 %) including a tuberculoma, an endocrine tumour, a fusocellular sarcoma with partial neurogenic differentiation and a large-cell and pleomorphic-cell anaplastic, partly sarcomatoid carcinoma. In patients with a space-occupying lesion of the pancreas, tumours other than a ductal adenocarcinoma are not rare. In particular, in cases of a previously known malignant tumour disease a space-occupying lesion of the pancreas can also turn out to be a metastasis. Every other individual tumour entity is rare. Other tumour entities at large, however, are found in daily routine. The preoperative biopsy of space-occupying lesions of the pancreas, therefore, still has a clinical importance for the further therapy planning.

Background: Endoscopic stenting with self-expanding metal stents (SEMS) has proved to be an efficient palliative endoscopic therapy option in treating malignant dysphagia. Different types of SEMS have been examined previously in small randomized clinical trials., Methods: A total of 150 consecutive patients (from 1/1995-1/2004; 35 females, 115 males) with a median age of 66 years (range 43-94 years) were evaluated. Three different types of SEMS were examined: Group A: Gianturco Z Stent n = 59 pts.; Gruppe B: Ultraflex Stent n = 49 pts.; Gruppe C: Flamingo Wallstent n = 42 pts.). Dysphagia was categorized into grade 0 (no dysphagia) to grade 4 (total obstruction)., Results: Stent insertion was successfully evaluated in 55/59 (93 %) of the patients in group A, in 47/49 (96 %) of the patients in group B and in 40/42 (95 %) of the patients in group C (p = 0.78). After stent insertion, a reduction in the dysphagia score from 2.77 to 0.99 was observed in group A, from 2.58 to 0.72 in group B and from 2.62 to 0.81 in group C (p = 0.37). The median time to dysphagia recurrence was 78 days in group A, 90 days in group B and 70 days in group C (p = 0.45). The median overall survival time was 96 days in group A, 118 days in group B and 108 days in group C (p = 0.18). The incidence of high grade complications was 34 % in group A, 16 % in group B and 17 % in group C (p = 0.04)., Conclusions: The 3 types of SEMS examined in this study showed similar efficacies in treating malignant dysphagia. However, the major complication rate of the Gianturco Z stent was significantly higher when compared to the complication rate of the Ultraflex stent and the Flamingo Wallstent.

During the past years several endoscopic and interventional techniques have been developed for the treatment of bile duct strictures and have had a strong impact on therapeutic regimens. Benign stenoses of the bile duct are mainly caused by cholecystectomy or liver resection or by inflammatory diseases. Insertion of an endoprosthesis insertion or balloon dilation is clinically successful in 60 to 90 % of these patients and will result in adequate opening of the stricture. To date, only bile duct stenosis in chronic pancreatitis are not improved satisfactorily by endoscopy. The insertion of an endoprosthesis is a cornerstone in the treatment of malignant obstructive jaundice in patients with cancer. Several comparative studies have demonstrated the advantages of self-expanding metal stents (SEMS) over plastic prostheses in terms of patency. A selective use of SEMS is mandatory, as the costs for SEMS are high and many patients with malignant jaundice will die with their first plastic prosthesis in situ without stent occlusion. In patients with hilar cholangiocarcinoma, the combination of photodynamic therapy and endoprosthesis insertion might result in a survival advantage. The use of bioabsorbable stent materials or coating of the stent with antiproliferative drugs will improve the treatment results in the future.

Background: The superiority of laparoscopy with guided biopsy over biopsy alone is established. It is still uncertain if this is also true for midi-/ and mini-laparoscopy., Aim: The aim of this study was to determine the diagnostic gain of laparoscopic-guided biopsy for standard laparoscopy and the use of midi-/mini-laparoscopies. Characteristics of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis., Methods: In a consecutive series of 425 patients clinical, laparoscopic and histological findings were investigated. The length and fragmentation of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis., Results: The sensitivity of laparoscopy in the diagnosis of cirrhosis was 96 %, that of histology 68 %. The sensitivity of histology alone was especially low in macronodular cirrhosis. The sensitivity of both laparoscopy and histology improved from Child A to C. When cirrhosis was apparent, liver biopsies were shorter and more frequently fragmented. However, the diagnosis of cirrhosis was independent of these parameters., Conclusion: Mini-laparoscopy may replace standard laparoscopy and appears to be superior compared with histology alone.

Background: Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis., Case Report: A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice., Conclusion: In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.

Background: Different noninvasive and invasive techniques are available for the detection of abdominal metastases in pancreatic carcinoma. Since small hepatic or peritoneal metastases are a crucial problem which precludes resection, accurate detection is mandatory. We compared laparoscopic staging of abdominal metastases in adenocarcinoma of the pancreas with MRI., Methods: 55 patients with pancreatic adenocarcinoma had been screened and 49 entered the retrospective study. All patients had undergone MRI of the upper abdomen with concomitant MR-cholangiopancreatography (MRCP) and diagnostic laparoscopy under conscious sedation. Patients without histologic proof of abdominal metastases underwent laparotomy., Results: In 6/10 patients, metastases were correctly detected by laparoscopy, yielding a sensitivity of 60% and a specificity of 92%.MRI predicted metastases in 6/10 patients with 60% sensitivity and 100% specificity. Laparoscopy showed metastases in 3 patients that were missed by MRI, but failed to identify metastases in 3 of 6 patients with metastases on MRI. Though only one patient showed previously undetected metastases during laparotomy, 3 patients with abdominal metastases underwent unnecessary laparotomy due to a lack of histologic proof of malignancy., Conclusions: Whereas diagnostic laparoscopy is sensitive for the detection of small metastases and offers histologic verification, intrahepatic alterations are not detectable by sole visual inspection.MRI may compensate for this deficiency, but histologic proof of malignancy may be problematic. To date, no definite decision in favor of one of the presented procedures for the staging of abdominal metastases can be given.

Background: Symptomatic common bile duct strictures are frequently seen in the course of severe chronic pancreatitis with a reported incidence of 10-30%. The exact role of endoscopic stenting with metal prostheses as definitive treatment has not yet been clearly defined., Methods: Six patients with symptomatic distal common bile duct stricture in the setting of chronic pancreatitis were treated with a self-expandable metal stent in an attempt to achieve permanent drainage. All cases were approached non-operatively and underwent prior unsuccessful treatment with plastic prostheses., Results: The patients received a self-expandable metal Wall stent after a median follow-up of 14 months of plastic stenting. The median follow-up time was 58 months and the stents remained open for a median time of 20 months, respectively. Overall, in 2 of 6 cases the metal stent therapy was successful while 4 of 6 patients required additional endoscopic procedures., Conclusions: Self-expandable metal stents could be useful and adequate in patients who suffer from symptomatic obstructive jaundice due to chronic pancreatitis. However, they provide acceptable dilation of the common bile duct for only a limited period of time. Overall, endoscopic stenting with self-expandable metal stents seems to be an advantageous treatment only for a subgroup of patients who are unfavorable candidates for surgical drainage. To clarify the role of the endoscopic approach, prospective trials with homogeneous and larger patient numbers are necessarily in the future.

Background: Wireless capsule endoscopy is a new method enabling non-invasive diagnostic endoscopy of the entire small intestine. In this study we prospectively examined the diagnostic precision of capsule endoscopy compared with push enteroscopy in patients with occult gastrointestinal bleeding., Methods: Between July 2001 and October 2002 we examined 48 patients with suspected disorders of the small intestine using capsule endoscopy. 33 patients with obscure bleeding (19 men, 14 women, mean age 58 +/- 23 years) were prospectively examined using capsule endoscopy and push enteroscopy., Results: On average, the patients had been suffering from chronic gastrointestinal bleeding for 30 +/- 36 (1-120) months. The lowest haemoglobin level was 6.5 +/- 1.6 g/dl (2.3-9.6) and on average 9 +/- 10 (0-50) blood units were transfused. Each patient underwent 4 +/- 2 (1-10) hospitalisations, with a mean 9 +/- 4 (5-17) diagnostic procedures before capsule endoscopy was used. Definitive bleeding sites were diagnosed by push enteroscopy in 7 patients (angiodysplasia [n = 5], ulcers [n = 1], multiple jejunal diverticula [n = 1]). Capsule endoscopy showed a bleeding source in 25 cases (76 %) (angiodysplasias [n = 15], Meckel's diverticulum [n = 1], ulcers [n = 7], ileum diverticulosis [n = 1], B-cell lymphoma [n = 1]). Push enteroscopy localised an additional bleeding source in comparison with capsule endoscopy (multiple jejunal diverticula) in one patient. Both methods of examination were safe and showed no complications., Discussion: The present study shows that capsule endoscopy had the highest diagnostic yield and was superior to push enteroscopy in patients with chronic gastrointestinal bleeding. By using the capsule at an early stage the subsequent therapeutic procedure could be considerably shortened and diagnostic processes could possibly be optimised.

Wireless capsule endoscopy is a new diagnostic procedure to detect diseases of the small bowel, in particular in patients with obscure gastrointestinal bleeding. We report on a 76-year-old patient who presented at our hospital with signs of gastrointestinal bleeding and hypochromic anaemia. Bidirectional endoscopy, push enteroscopy, angiography as well as small bowel barium enema rendered no pathologic findings. Wireless capsule endoscopy demonstrated a polypous space in the cantral area of the small bowel. Subsequent intraoperative endoscopy revealed a subtotal stenosing tumour of the upper jejunum which was resected. Based on the histology a high-grade B-Cell lymphoma was diagnosed. The postoperative staging examinations did not indicate any further extranodal involvement.

Unlabelled: A non-invasive diagnostic modality for differential diagnosis and detection of complications in inflammatory bowel disease (IBD) is desirable as alternative to invasive and troublesome endoscopy and conventional radiological methods., Methods: 51 patients suspicious of inflammatory bowel disease (bloody diarrhoea, symptoms of stenosis, abdominal pain) were investigated consecutively according to a standardised protocol by magnetic resonance tomography (MRI). Also, endoscopy was performed dependent on clinical presentation. MRI findings were compared to clinical follow-up, percutaneous ultrasonography (US), endoscopy, and surgical findings., Results: MRI confirmed diagnosis of Crohn's disease (CD) in more than 90 % of cases. In case of distinct lesions, all of these were detected by MRI in the small bowel and colon. Discreet inflammatory lesions were not seen regularly. Numerous findings in endoscopically inaccessible bowel segments were described by MRI, extraintestinal lesions (conglomerate, abscess, fistulae) were detected accurately. Altogether, MRI was superior to abdominal ultrasonography., Conclusion: In patients with distinct inflammatory bowel disease, and in detection of complications (abscess, fistulae), MRI appears as versatile, non-invasive and accurate diagnostic instrument with therapeutical consequence. Endoscopy remains method of first choice for detection of discreet lesions and for histopathological diagnosis.

Objective: The treatment of advanced rectal cancer is still a challenge. We analysed the short-term success, treatment-related complications and the long-term outcome after laser palliation for rectal cancer., Methods: Over a ten-years period eighty-three consecutive patients (median age 81 (46-94) yrs; 43 female) were treated mainly for obstructive symptoms or tumour bleeding. Laser palliation was performed using a Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG) laser., Results: The immediate overall-success rate was 96.4 % (80 of 83 patients) and only one female received a diverting colostomy because of an inaccessible high-grade rectal stenosis, initially. During follow-up, eight additional patients had to undergo surgery on their rectal cancer because of treatment failures (most of them recurrent obstruction) or complications (long-term success rate: 86.7 % (72 of 83 pts.)). The median survival period was nine months. Patients treated for obstruction had more treatment sessions and had a higher rate of surgical palliation in comparison to those pts. therapied for bleeding. Major complications were seen in three patients (3.6 %). One patient died after rectal perforation following bougienage before laser treatment (overall mortality: 1.2 %)., Conclusion: Laser therapy is effective for the palliation of advanced rectal cancer with a high short-term and long-term success rate and only few complications. Laser treatment therefore is still a valuable alternative to newer endoscopic techniques and surgery.

In general, hyperplastic polyps of the stomach are regarded as benign lesions. Still there is the chance to find carcinomas within them as documented in this case report. This finding can be interpreted as an incidental appearance. At the moment there are no standardized guidelines regarding diagnostics and therapy of gastric hyperplastic polyps. Referring to a short review of the literature endoscopic snare polypectomy seems to be a reasonable therapeutic option of hyperplastic polyps with a size of 0.5-1 cm. Although it is possible to determine the histology by forceps biopsy, it is possible to be misled by missing areas of focal carcinomas. Complications after polypectomy are rare and often no further intervention is needed. A further point for polypectomy is the fact that surfaces of hyperplastic polyps are eroded in about 90 % and therefore there is the risk of bleeding, chronic anaemia and positive stool tests for occult blood.

The quality of reprocessing gastroscopes, colonoscopes and duodenoscopes in daily routine of 25 endoscopy departments in hospitals and 30 doctors with their own practices was evaluated by microbiological testing in the HYGEA interventional study. In 2 test periods, endoscopes ready for use in patients were found contaminated at high rates (period 1: 49 % of 152 endoscopes; period 2: 39 % of 154 endoscopes). Culture of bacterial fecal flora (E. coli, coliform enterobacteriaceae, enterococci) was interpreted indicating failure of cleaning procedure and disinfection of endoscopes. Detection of Pseudomonas spp. (especially P. aeruginosa) and other non-fermenting rods - indicating microbially insufficient final rinsing and incomplete drying of the endoscope or a contaminated flushing equipment for the air/water-channel - pointed out endoscope recontamination during reprocessing or afterwards. Cause for complaint was found in more than 50 % of endoscopy facilities tested (period 2: 5 in hospitals, 25 practices). Reprocessing endoscopes in fully automatic chemo-thermally decontaminating washer-disinfectors with disinfection of final rinsing water led to much better results than manual or semi-automatic procedures (failure rate of endoscopy facilities in period 2 : 3 of 28 with fully automatic, 8 of 12 with manual, 9 of 15 with semi-automatic reprocessing). The study results give evidence for the following recommendations: 1. Manual brushing of all accessible endoscope channels has to be performed even before further automatic reprocessing; 2. For final endoscope rinsing, water or aqua dest. should only be used disinfected or sterile-filtered; 3. Endoscopes have to be dried thoroughly using compressed air prior to storage; 4. Bottle and tube for air/water-channel flushing have to be reprocessed daily by disinfection or sterilization, and in use, the bottle have to be filled exclusively with sterile water. The HYGEA study shows that microbiological testing of endoscopes is useful for detection of insufficient reprocessing and should be performed for quality assurance in doctors' practices, too. The study put recommendations for reprocessing procedures in more concrete terms.

Niemann-Pick disease type C is an inborn error of metabolism that affects lipid degradation and storage. Hepatosplenomegaly and progressive neurological symptoms are the main clinical features. We present a case of an adult-onset type of Niemann-Pick disease in a 33-year-old woman who initially presented with dysarthria. At first, laboratory findings suggested Wilson's disease. Laparoscopy showed macroscopic signs of liver cirrhosis and histology did not confirm Wilson's disease. After bone marrow biopsy showed characteristic sea-blue histiocytes, Niemann-Pick disease was suspected and confirmed by filipin stain of cultured fibroblasts. Though rarely encountered, lipid storage disease should be suspected especially in younger patients with organomegaly and progressive signs of neurologic disease.

Incarceration of a pancreatic stone fragment in the distal pancreatic duct after ESWL-therapy.A partial or total absence of stones in pancreaticolithiasis therapy can be reached by using ESWL. We report on a patient who happened to get an incarceration of a fragment in the distal pancreatic duct after having been treated by ESWL without a previous sphincterotomy to the ductus Wirsungianus. This emphasizes the recommendation to carry out a papillotomy of the pancreatic main duct before applying ESWL to pancreatic stones.

Ascariasis is the most common intestinal helminthiasis worldwide. Heavily infected individuals are prone to develop bowel obstruction or perforation as well as biliary disease. Nevertheless, the presence of roundworms in the biliary tree outside endemic areas is very uncommon. The migration of these worms to the biliary system can cause biliary colic, pancreatitis, or even acute suppurative cholangitis with hepatic abscesses and septicemia. We report here on 2 infants with 14 and 15 months and a 9-year-old boy who suffered from massive biliary ascariasis and who presented with acute suppurative cholangitis. All cases were successfully treated by endoscopic retrograde cholangiopancreatography with worm extraction and adjuvant medical therapy. Physicians should be aware of ascariasis in patients with pancreatobiliary symptoms who have traveled to endemic areas or in immigrants from these areas.

Introduction: Laparoscopy plays an essential role in the diagnosis of hepatic diseases. During the past few years, minilaparoscopy (ML) has increasingly emerged as an alternative diagnostic method in this field. We hereby present the preliminary results of a randomized trial comparing ML with conventional laparoscopy (CL)., Patients and Methods: 92 with suspected hepatic disease were randomized either to undergo CL (n = 47) or ML (n = 45). For CL, we used a Hopkins-laparoscope (Ø 11 mm, Storz, Tuttlingen) and ML was performed with a 1.9 mm small-diameter optic (Wolf, Knittlingen)., Results: Laparoscopy with simultaneous liver biopsy could successfully be performed in 88/92 patients. ML could be performed in a significantly shorter time than CL (25 vs. 28 min, p < 0.05). Liver cirrhosis was diagnosed by laparoscopy in a similar proportion of patients (70% in CL, 56% in ML). In 76% of cases, histology confirmed macroscopic signs of liver cirrhosis. Cirrhosis was found in one patient of each group solely by histologic examination of biopsy specimens. The number of bleeding complications during CL equaled the proportion of hemorrhagias in the ML-group., Discussion: In the workup of hepatic disease, ML is a diagnostic tool comparable with CL. The fact that ML can be performed in significantly shorter time and seems subjectively less invasive might be an argument for a better acceptance by patients.

Accurate staging of pancreatic malignancy is essential to properly plan appropriate therapy. The purpose of preoperative staging of intraabdominal malignancies is to identify patients in whom malignancies are unresectable and therefore would not be candidates for curative surgery. Routine preoperative evaluation of intraabdominal malignancies typically include abdominal helical computed tomographic (CT) scanning and/or ultrafast magnetic resonance (MR) imaging. In fact both investigations are considered mandatory for intraabdominal malignancies. But despite modern techniques a significant number of false negative results occur (more than 20%). This has led to the investigation of additional staging modalities to better identify patients with unresectable disease. In this purpose we present the case of a patient with pancreatic carcinoma. After preoperative imaging (ultrasound, endosonography and MRI) there was no evidence for metastatic disease (uT3uN1). He underwent laparoscopy and a hepatic lesion was detected, histologically consistent with a liver metastasis. In this patient an unnecessary laparotomy could be avoided. In conclusion laparoscopy is an important tool in the staging of intraabdominal malignancy for patients with locally advanced disease without signs of tumor spread in CT or MRT. It is a relatively simple, well-tolerated and safe procedure and decreases the rate of unnecessary laparotomies. It should be considered in all patients with pancreatic malignancy in whom laparotomy is planned, either to establish the diagnosis or before an attempt at curative resection.

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.

Background: In patients with Iron Deficiency Anemia (IDA) occult gastrointestinal bleeding is generally investigated by bidirectional endoscopy. The aim of our study was to examine the long-term follow-up of patients with IDA where the sources of bleeding couldn't be detected despite close endoscopic and radiologic examination of the GI tract., Methods: Based on the endoscopic data base we examined consecutive patients who were referred for gastrointestinal endoscopy due to IDA with a negative endoscopic (upper GI endoscopy and colonoscopy) evaluation. Further diagnostic work up (repeated endoscopy of the upper and lower GI tract by an experienced investigator, small bowel enteroclysis, push enteroscopy, proctoscopy, intraoperative enteroscopy, angiography, scintigraphic examinations) was recorded. The eligible patients were divided into 2 groups: Group 1 (no identification of the source of bleeding in the GI tract); group 2 (source of gastrointestinal blood loss was found). Long-term follow-up was performed by telephone interview with patients and/or with their general practitioner., Results: 79 patients (mean age 58.8 years [17-83, 44] female) with IDA met the inclusion criteria. In 42 patients (53%) the endoscopic and radiographic evaluation was unable to find the source of gastrointestinal blood loss. 29 of these patients (69%) showed a resolved anemia after a mean follow-up of 48 months (18 months-5 years). 10 patients had a mild anemia, 3 required blood transfusions. In group one Helicobacter pylori infection was significantly more prevalent in comparison with group 2 (57% vs. 38%, p = 0.032)., Conclusion: Based on our data, the prognosis of IDA with negative endoscopy is favorable. The pathogenic role of Helicobacter pylori infection should be evaluated in further studies.

In many gastroenterological departments, the push-enteroscopy has become a well-established method to investigate the small bowel. Compared to the sonde-enteroscopy, this method has the advantage of offering the opportunity to intervene (e.g., taking biopsies, polypectomy, electrocoagulation) since the push-enteroscope has a working channel. The main indication for an endoscopic procedure is still the search for intestinal sources of bleeding after more frequent sources in the gastrointestinal tract have been ruled out. Other diagnostic and therapeutic indications are less frequent. In this overview we will first describe the procedure. Then we will review the most recent diagnostic and therapeutic aspects of the push-enteroscopy and compare it to other procedures.