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ZusammenfassungDie COVID-19-Pandemie ist ein weltweiter Ausbruch von neu aufgetretenen Infektionen mit dem SARS-CoV-2-Virus, von denen weltweit derzeit mehr als 10.670.000 Menschen erkrankt sind bzw. waren. In Deutschland leiden ca. 450.000 Patienten an einer chronisch entzündlichen Darmerkrankung; diese Patienten benötigen in der Regel eine kontinuierliche und kompetente Betreuung. Vor dem Hintergrund eines rasch zunehmenden Wissenszuwachses haben 68 Experten, die die derzeit gültigen Leitlinien der DGVS zum Morbus Crohn und zur Colitis ulcerosa erstellt haben, im Rahmen einer virtuellen Konferenz aktuelle und praxisnahe Empfehlungen formuliert, um die Versorgung von CED-Patienten zu verbessern. Diese adressieren das Infektionsrisiko einschließlich des Risikos für besondere Gruppen, den möglichen Verlauf der Erkrankung und die Konsequenzen für die medikamentöse und die operative Therapie der Grunderkrankung sowie allgemeine Maßnahmen zur Infektionsprävention und adjuvante Präventions- und Therapiemöglichkeiten.

Die laparoskopische restaurative Proktokolektomie mit ileopouchanaler Anastomose (IPAA) stellt eine kurative Behandlungsoption der therapierefraktaren Colitis ulcerosa (CU) dar. Das zweizeitige Vorgehen mit Anlage eines doppellaufigen, protektiven Ileostomas ist die haufigste gewahlte Variante. Ziel des chirurgischen Eingriffs ist die komplette Entfernung des Kolons und Rektums mit gleichzeitiger Wiederherstellung der gastrointestinalen Kontinuitat und Erhalt der Kontinenzfunktion. Die langfristige Lebensqualitat nach laparoskopischer Proktokolektomie mit IPAA ist gut und vergleichbar mit der einer gesunden Vergleichspopulation. Anhand eines Operationsvideos, welches online zur Verfugung steht, wird die Operationstechnik detailliert dargestellt.

Restorative proctocolectomy with an ileoanal pouch anastomosis (IAPA) is the surgical therapy of choice for patients with refractory ulcerative colitis and/or associated (pre)neoplastic lesions. It is predominantly performed laparoscopically. Reconstruction with a J‑pouch is the most frequently applied variant due to the ideal combination of technical simplicity and good long-term results. In the present review, potential postoperative pouch complications, their risk factors, diagnostics and surgical management, as well as mid-term and long-term quality of life after pouch construction are differentially presented based on the current literature.

Objective: The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. Background: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity. Methods: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions. Result: The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)-pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri) pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical. Conclusions: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Im Jahr 1998 wurde der erste TNF-Blocker in den USA und ein Jahr spater auch in Deutschland zugelassen. Die Therapie mit TNF-Blockern hat die Therapiemoglichkeiten von Patienten mit chronisch-entzundlichen Erkrankungen in Rheumatologie, Dermatologie und Gastroenterologie deutlich erweitert. Es ist aber nicht immer moglich, durch systemisch applizierte TNF-Blocker eine lokale klinische Besserung der jeweiligen Grundkrankheit zu erreichen. Daher gab es in den letzten Jahren vielfaltige Ansatze einer topischen Therapie mit TNF-Blockern. Das wichtigste Ziel dieser off-label-Anwendungen ist die Applikation einer groseren Menge des TNF-Blockers im entzundeten Gewebe, als dies mit einer systemischen Therapie erreichbar ware. Diese Ubersicht gibt einen Uberblick uber die Vielfalt der bislang erfolgten topischen Therapieversuche mit TNF-Blockern.

Errors in fluid management can lead to significant morbidity in children. We conducted an experimental animal study to determine the margin of safety in accidental hyperinfusion of different glucose and electrolyte containing solutions.Fifteen piglets [bodyweight 12.1 (sd 2.0) kg] were randomly assigned to receive either 100 ml kg⁻¹ of balanced electrolyte solution with glucose 1% (BS-G1), hypotonic electrolyte solution with glucose 5% (HE-G5), or glucose 40% solution (G40) over 1 h. Blood electrolytes, glucose, and osmolality and intracranial pressure (ICP) were measured before, during, and after fluid administration.Hyperinfusion of BS-G1 led to moderate hyperglycaemia [baseline 3.4 (sd 1.3) mmol litre⁻¹, study end 12.6 (1.8) mmol litre⁻¹], but no other relevant pathophysiological alterations. Hyperinfusion of HE-G5 produced marked hyperglycaemia [baseline 3.9 (1.2) mmol litre⁻¹, study end 48.6 (4.3) mmol litre⁻¹, P0.05] and hyponatraemia [baseline 136.4 (1.3) mmol litre(-1), study end 119.6 (2.1) mmol litre⁻¹, P0.05], whereas osmolality remained stable during the course of the study. Hyperinfusion of G40 induced acute hyperglycaemic/hyperosmolar decompensation with an extreme decrease in serum electrolytes [e.g. sodium baseline 138 (1.1) mmol litre⁻¹, 30 min 87.8 (6.4) mmol litre⁻¹, P0.01], leading to cardiac arrest after infusion of 50-75 ml kg⁻¹. ICP remained within a physiological range in all groups.In an animal model of accidental hyperinfusion, BS-G1 showed the widest margin of safety and can therefore be expected to enhance patient safety in perioperative fluid management in children; HE-G5 proved significantly less safe; and G40 was found to be outright hazardous.

Nutritional concepts in acute pancreatitis are undergoing a rapid change. An early start of nutrition via nasojejunal tubes is about to replace parenteral nutrition. Yesterday it was believed that the pancreas had to be put at rest. Thus, stimulation of pancreatic secretion by enteral nutrition was believed to be detrimental. However, on comparing the results of enteral with those of parenteral nutrition, the pancreatic infection rates, rate of surgical interventions, days of hospital stay, and costs are found to be significantly reduced. Whether or not enteral nutrition decreases mortality has not been clearly proven. Pancreatitis is associated with the risk of paralytic ileus. Thus, data suggesting that one does not have to feed via a nasojejunal tube but rather via an easier to place nasogastric tube, are provocative. Numerous questions still have to be answered such as composition of tube diet, nutrition in mild to moderate pancreatitis, ways to reduce pain and composition of diet when oral refeeding is started. The nutrition of tomorrow may implicate immunonutrition. There are only a few small studies suggesting beneficial effects by supplementation of tube feeding with MCT/LCT triglycerides, glutamine, arginin, omega-3-fatty acids, nucleotides. So far, these supplements have failed to show efficacy for clinically relevant endpoints. In an recently published study, prebiotics were associated with a high complication rate. In this review, we summarise the current knowledge on nutrition in acute pancreatitis and discuss future developments.

Malignome des Gastrointestinaltrakts stellen zusammengenommen die haufigste krebsbedingte Todesursache in Deutschland dar. Die Morbiditat durch diese Erkrankungen ist erheblich. Trotz der Fortschritte in der chirurgischen und medikamentosen Therapie gastrointestinaler Malignome besteht im fortgeschrittenen Stadium in der Regel keine Heilungsmoglichkeit mehr. Praventionsmasnahmen und Screening konnen die Letalitat durch diese Karzinome senken. Vermeidung von Ubergewicht bzw. Gewichtsabnahme sowie Nikotinkarenz sind effektive vorbeugende Masnahmen bei Osophagus-, Pankreas- und kolorektalem Karzinom. Behandlung von Infektionen durch Hepatitisviren und Helicobacter pylori schutzt vor hepatozellularem Karzinom bzw. Magenkarzinom. Das beste Beispiel fur eine wirksame Vorsorgeuntersuchung ist die Koloskopie. Durch die Koloskopie konnen kolorektale Adenome und Karzinome fruhzeitig entdeckt, Adenome als Prakanzerosen endoskopisch in gleicher Sitzung entfernt werden. Der Einsatz einfacher Praventionsstrategien und effizienter Vorsorgemasnahmen bei gastrointestinalen Malignomen wird im vorliegenden Beitrag praxisnah erlautert.

Ein 32-jahriger Patient stellte sich aufgrund von akutem Brechdurchfall in unserem Klinikum vor. Leichtere Durchfalle, gelegentlich auch mit Blutbeimengungen bestanden bereits seit mehreren Jahren. Zum Zeitpunkt der Vorstellung war der Patient auserdem anurisch. Nach Ausschluss eines pra- und postrenalen Nierenversagens erfolgte eine Nierenbiopsie. Die histologische Aufarbeitung der Nierenbiopsie zeigte Veranderungen, die auf ein hamolytisch-uramisches Syndrom hinweisen. Fur eine Glomerulonephritis im Rahmen einer Vaskulitis gab es keinen Anhalt. Als Ursache fur den Durchfall und die Erregereintrittspforte ist bei typischer Bildgebung auch ohne histologischen Nachweis ein M. Crohn anzusehen. Wir berichteten damit erstmals von einem hamolytisch-uramischen Syndrom als Erstmanifestation eines M. Crohn.

BACKGROUND AND OBJECTIVE Sudden cardiac death is a leading cause of death. In Germany, only 10% of patients will survive reanimation. The prognosis is mainly determined by the first-aid skills of accidental witnesses. METHODS The reaction of 1007 German-speaking adults (462 males, 545 females, median age 39 years) was investigated in an emergency scenario with symptoms of sudden cardiac death in an acquaintance. Afterwards a self-assessment of their first-aid skills, such as cardiac compression and mouth-to-mouth ventilation was made. RESULTS 94% of the interviewees would call professional aid at once. Diagnostic skills, as searching for pulse or checking for breath would be done by 26 and 21%, respectively. The most frequently mentioned therapeutic skill was positioning the victim in stable lateral position (37%), but very less frequently cardiac compression (6%) and mouth-to-mouth resuscitation (10%). When asked, 51 (81%) of those interviewed regarded their skills in cardiac compression and mouth-to-mouth resuscitation as adequate. To some extent there were differences in favor of young people and those from East Germany. CONCLUSION These representative data suggest that (a) ABC-like first-aid rules are largely unknown among the population; (b) the value of a stable lateral position is overestimated and (c) first-aid skills of elderly persons are worst. A significant improvement of first-aid skills of the German population is mandatory in order to improve in future the outcome of sudden cardiac death.

Summary. The understanding of the pathogenesis of chronic pancreatitis is limited. Several theories (i. e. obstruction hypothesis) were suggested in the past but could not be confirmed by experimental data. As a formal description of the course of the disease, the necrosis-fibrosis concept seems to be very attractive. According to this theory, there is no significant difference in the pathogenesis of acute and chronic pancreatitis. A major step was the identification of mutations of the cationic trypsinogen, the secretory trypsin inhibitor (SPINK 1) and the cystic-fibrosis protein (CFTR) in some patients. Investigation of these mutations may significantly contribute to a better understanding of the pathogenesis of chronic pancreatitis.

Pyoderma gangrenosum is the most severe of all cutaneous extraintestinal manifestations seen in inflammatory bowel diseases. One subtype—parastomal pyoderma gangrenosum—is a rare complication of surgery and a particularly demanding task for surgeons, dermatologists, wound care specialists and gastroenterologists. Glucocorticoids and cyclosporine have been mainstays of systemic treatment for pyoderma gangrenosum, although increasing evidence supports the use of biologic therapies, such as tumor necrosis factor inhibitors [1, 2]. Currently no guideline for the treatment of pyoderma gangrenosum exists. Recently, we reported the rapid improvement of refractory pyoderma gangrenosum of the lower limb after topical application of an infliximab gel in a young woman with ulcerative colitis [3]. The refractory course of parastomal pyoderma gangrenosum in a woman with Crohn’s disease stimulated us to investigate topical infliximab therapy. The patient was diagnosed with Crohn’s disease at age 32. Within the first years, she developed several extraintestinal manifestations such as polyarthritis, erythema nodosa and anemia. At initial presentation in our practice in September 2010, she complained of fever and severe abdominal pain which was caused by a large abdominal wall abscess due to a colonic stenosis with a fistula to the abdominal wall. Immediate surgery with partial colonic resection and colostomy was necessary. The patient’s postoperative course was uneventful and she continued azathioprin. A complex rectovaginal fistula was detected during follow-up, which precluded rapid stoma closure. We therefore started infliximab infusions 6 weeks after surgery. In May 2012, when the patient was 48 years old, she detected a small parastomal lesion; histology revealed pyoderma gangrenosum. There was no change after application of topical glucocorticoids. However, the patient reported a marked improvement of pyoderma gangrenosum activity within 10 days after every infliximab infusion but worsening within the next weeks. Dose escalation to 10 mg/kg every 4 weeks did not improve healing, and the patient observed enlargement and bleeding from the lesion. Adalimumab, clobetasol-propionat, gentamycin, topical tacrolimus and several other topic applications were without success, and we continued infliximab infusions with a temporal improvement after infusion. The findings of high tumor necrosis factor concentrations in wound fluid and the success of topical infliximab gel application in chronic venous leg ulcers [4] were rationales for an individual attempt to treat the pyoderma gangrenosum with freshly made infliximab gel as reported recently [3]. However, this gel was difficult to fix aside the stoma bag and did not improve the clinical appearance of the parastomal pyoderma gangrenosum after 3 weeks. Due to the improvement of the pyoderma gangrenosum after infliximab infusion, we suggested a fan-shaped sublesional injection of 100 mg infliximab (dissolved in 10 mL of saline) under the lesion, which caused only slight pain during injection. This was repeated weekly for 3 weeks, but did not result in any improvement after 12-month follow-up (Fig. 1). Sublesional infliximab injection does not seem to be a successful option for patients with parastomal pyoderma gangrenosum. In contrast to pyoderma gangrenosum of leg or face skin, different pathogeneses of sites that are in continuity with the bowel—like parastomal pyoderma N. Teich (&) Internistische Gemeinschaftspraxis fur Verdauungs-und Stoffwechselkrankheiten, Nordstr. 21, 04105 Leipzig, Germany e-mail: teich@igvs.de

The pathogenesis of alcohol-induced chronic pancreatitis is still not completely understood. One discusses alcohol-induced fatty degeneration of pancreatic acinar cells, disturbances in ethanol detoxification, reduced synthesis of lithostathines, changes in duct permeability, a pressure increase of the papilla of Vater, generation of free radicals, etc. Hereditary chronic pancreatitis (HCP) is a rare form of early-onset chronic pancreatitis. With the exception of the young age at diagnosis and a slower progression, the clinical course, morphological features, and laboratory findings of HCP do not differ from those of patients with alcoholic chronic pancreatitis. Mutations in the PRSS1 gene, encoding cationic trypsinogen, play a causative role in chronic pancreatitis. It has been shown that the PRSS1 mutations increase autocatalytic conversion of trypsinogen to active trypsin, and thus probably cause premature, intrapancreatic trypsinogen activation disturbing the intrapancreatic balance of proteases and their inhibitors. Other genes, such as the anionic trypsinogen (PRSS2), the serine protease inhibitor, Kazal type 1 (SPINK1), and the cystic fibrosis transmembrane conductance regulator (CFTR) have been found to be associated with chronic pancreatitis (idiopathic and hereditary) as well. The findings in HCP highlight that the protease trypsin seems to play a major role in pathogenesis of chronic pancreatitis.

A 64-year-old man was admitted to our hospital to clarify the aetiology of two delirious episodes which occurred in February and May 2006. Past …

Ulcerative colitis (UC) has traditionally been considered to be an inflammatory disease limited to the colonic mucosa. However, since it has been shown that UC is frequently accompanied by various extraintestinal disorders, there is increasing evidence that UC may also manifest in the nervous system. The following review focuses particularly on these possible manifestations of UC, both in the peripheral (PNS), and in the central nervous system (CNS). A systematic literature search according to the MEDLINE database was performed for this purpose. Although a reliable differentiation may clinically not always be possible, three major pathogenic entities can be differentiated: (i) cerebrovascular disease as a consequence of thrombosis and thromboembolism; (ii) systemic and cerebral vasculitis; (iii) probably immune mediated neuropathy and cerebral demyelination. With the exception of thromboembolism and sensorineural hearing loss, evidence for a causal relationship relies merely on single case reports or retrospective case series. Considering the CNS-manifestations, similarities between UC-associated disorders of the white matter and acute disseminated encephalomyelitis (ADEM) are obvious. Epileptic seizures, unspecified encephalopathies and confusional states are most likely epiphenomena that have to be regarded symptomatic rather than as own entities. A prospective study on the neurologic aspects of UC would be very welcome.

17551 Background: Adjuvant trastuzumab, recommended for HER2-positive early stage breast cancer, is associated with asymptomatic drop in left ventricular ejection fraction (LVEF) in 10–15% of patie...