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BACKGROUND & AIMS: Little is known about cholestasis, including its most severe variant secondary sclerosing cholangitis (SSC), in critically ill patients with coronavirus disease 19 (COVID-19). In this study, we analysed the occurrence of cholestatic liver injury and SSC, including clinical, serological, radiological and histopathological findings. METHODS: We conducted a retrospective single-centre analysis of all consecutive patients admitted to the intensive care unit (ICU) as a result of severe COVID-19 at the University Hospital Zurich to describe cholestatic injury in these patients. The findings were compared to a retrospective cohort of patients with severe influenza A. RESULTS: A total of 34 patients with severe COVID-19 admitted to the ICU were included. Of these, 14 patients (41%) had no cholestasis (group 0), 11 patients (32%, group 1) developed mild and 9 patients (27%, group 2) severe cholestasis. Patients in group 2 had a more complicated disease course indicated by significantly longer ICU stay (median 51 days, IQR 25-86.5) than the other groups (group 0: median 9.5 days, IQR 3.8-18.3, P = .001; and group 1: median 16 days, IQR 8-30, P

To compare the diagnostic accuracy of texture analysis (TA)–derived parameters combined with machine learning (ML) of non-contrast-enhanced T1w and T2w fat-saturated (fs) images with MR elastography (MRE) for liver fibrosis quantification. In this IRB-approved prospective study, liver MRIs of participants with suspected chronic liver disease who underwent liver biopsy between August 2015 and May 2018 were analyzed. Two readers blinded to clinical and histopathological findings performed TA. The participants were categorized into no or low-stage (0–2) and high-stage (3–4) fibrosis groups. Confusion matrices were calculated using a support vector machine combined with principal component analysis. The diagnostic accuracy of ML-based TA of liver fibrosis and MRE was assessed by area under the receiver operating characteristic curves (AUC). Histopathology served as reference standard. A total of 62 consecutive participants (40 men; mean age ± standard deviation, 48 ± 13 years) were included. The accuracy of TA and ML on T1w was 85.7% (95% confidence interval [CI] 63.7–97.0) and 61.9% (95% CI 38.4–81.9) on T2w fs for classification of liver fibrosis into low-stage and high-stage fibrosis. The AUC for TA on T1w was similar to MRE (0.82 [95% CI 0.59–0.95] vs. 0.92 [95% CI 0.71–0.99], p = 0.41), while the AUC for T2w fs was significantly lower compared to MRE (0.57 [95% CI 0.34–0.78] vs. 0.92 [95% CI 0.71–0.99], p = 0.008). Our results suggest that liver fibrosis can be quantified with TA-derived parameters of T1w when combined with a ML algorithm with similar accuracy compared to MRE. • Liver fibrosis can be categorized into low-stage fibrosis (0–2) and high-stage fibrosis (3–4) using texture analysis–derived parameters of T1-weighted images with a machine learning approach. • For the differentiation of low-stage fibrosis and high-stage fibrosis, the diagnostic accuracy of texture analysis on T1-weighted images combined with a machine learning algorithm is similar compared to MR elastography.

Immune checkpoint inhibitors have revolutionized the treatment of various cancers but are notorious for their potential to cause severe side effects. While most side effects occur during ongoing therapy, an increasing number of reports of late onset have emerged. It is also not yet clear how long side effects can last. Resolution is achieved under symptomatic therapy, but the side effects may persist latently. We present a patient case with recurrence of colitis after closure of an ileostomy over 1 year after discontinuation of immune checkpoint inhibitor therapy with nivolumab and ipilimumab. To the best of our knowledge, no other case with severe colitis still lasting after more than a year of suspension of therapy has yet been reported.Lay abstract Checkpoint inhibitors have revolutionized therapy for suitable cancers. However, they can cause side effects that are reminiscent of autoimmune diseases. While most adverse effects occur during ongoing therapy, there are increasing reports of late-onset adverse effects after discontinuation of therapy and of long-lasting adverse effects after discontinuation of treatment, which may remain latent even if symptom relief could be achieved by immunosuppression. We present a patient case with reappearance of a severe inflammation of the large bowel (colitis) after closure of an ostomy over 1 year after withdrawal of immune checkpoint inhibitor therapy. To the best of our knowledge, no other case with severe colitis still lasting after more than a year of suspension of therapy has yet been reported.

INTRODUCTION Despite enormous efforts during the past decades, pancreatic adenocarcinoma (PAC) remains one of the most deleterious cancer entities. A useful biomarker for early detection or prognosis of PAC does not yet exist. The goal of our study was the characterization of β6-integrin (ITGB6) as a novel serum tumor marker for refined diagnosis and prognosis of PAC. Serum ITGB6 levels were analyzed in 3 independent PAC cohorts consisting of retrospectively and prospectively collected serum and/or (metastatic) PAC tissue specimens. METHODS Using 2 independent cohorts, we measured serum ITGB6 concentrations in 10 chronic pancreatitis patients, 10 controls, as well as in 27 (cohort 1) and 24 (cohort 2) patients with PAC, respectively. In these patients, we investigated whether ITGB6 serum levels correlate with known clinical and prognostic markers for PAC and whether they might differ between patients with PAC or benign inflammatory diseases of the pancreas. RESULTS We found that elevated serum ITGB6 levels (≥0.100 ng/mL) in patients suffering from metastasizing PAC presented an unfavorable prognostic outcome. By correlating the ITGB6 tissue expression in primary and metastatic PAC with clinical parameters, we found that positive ITGB6 expression in the tumor tissue is linked to increased serum ITGB6 levels in nonmetastatic PAC and correlates with carbohydrate antigen 19-9 and clinical outcome. DISCUSSION Our findings suggest that ITGB6 might serve as a novel serum biomarker for early diagnosis and prognosis of PAC. Given the limited specificity and sensitivity of currently used carbohydrate antigen 19-9-based assays, ITGB6 may have the potential to improve the diagnostic accuracy for PAC.

Checkpoint inhibitor-induced side effects such as diarrhea and colitis occur in up to 30% of patients. We present a case of recurrent episodes of checkpoint inhibitor-induced colitis and subsequent Fournier gangrene that resolved after ileostomy formation. Once the Fournier gangrene and colitis had resolved, the ileostomy was reversed. However, within only 4 days, another serious flare-up of colitis occurred, necessitating emergent re-formation of the ileostomy. Expertise in the management of side effects of immune checkpoint inhibitor therapy is currently limited. Although most side effects are mild to moderate and transient, a minority of patients suffer from life-threatening complications, such as colitis. The creation of an ileostomy might be a valid treatment option in severe or recurrent colitis due to immune checkpoint inhibitor therapy. Intestinal diversion surgery may be useful if conservative treatment has failed, similar to other forms of immune-mediated intestinal inflammation.

Background/Aims: Among the severe immune-related adverse events (irAEs) that occur with immune checkpoint inhibitor (ICI) therapy, colitis is the most frequent one. This study aimed at describing the experience from the largest gastroenterology unit in Switzerland with immune checkpoint inhibitor-associated colitis (ICIAC), its clinical presentation, management, and outcomes. Methods: We performed a retrospective review of patients who were referred for the evaluation of ICIAC between January 2011 and October 2018 to the Division of Gastroenterology and Hepatology, University Hospital Zurich. Results: Thirty-three patients with immune-related colitis grade 3 or 4 met the inclusion criteria and were analyzed in detail: All patients had diarrhea, 64% had abdominal pain, 42% had bloody stool, 27% had emesis, and 18% developed fever. In total, 33% were successfully treated with corticosteroids alone; 66% were steroid-refractory and treated with infliximab or vedolizumab. Two of these patients developed severe complications requiring surgery. All patients reached complete remission of ICIAC and its symptoms. At colonoscopy, ulcerations were seen in 37% of steroid-refractory versus 63% of steroid-responsive cases. Deep histological ulcerations invading the submucosa were only present in steroid-refractory cases. Conclusion: ICIAC is a severe irAE which frequently requires high-dose steroids and a close follow-up due to deleterious complications. The detection of histologically diagnosed deep ulcerations may predict a steroid-refractory course and may warrant early application of infliximab. However, larger studies are required to confirm our findings.

With the advent of endoscopic full-thickness resection (EFTR), small subepithelial tumors (SETs) became easily resectable both in upper and lower gastrointestinal tract. Several studies have suggested that complete resection of SETs is achievable in the vast majority of cases and severe complications occur only rarely [1]. Whereas technical success in the case of mucosal or submucosal lesions is easy to accomplish, for tumors arising from the muscularis propria, an R0 resection is more difficult to achieve by EFTR [1]. Grasping these lesions with the Twin Grasper may lead to tenting of the mucosa and submucosa, which in turn leads to incomplete removal of the SET. To overcome this technical problem, we herein present the feasibility of EFTR using a tissue-retracting helix device that was originally designed as part of the OverStitch endoscopic suturing system (Apollo Endosurgery Inc., Austin, Texas, USA). We describe the case of a 75-year-old patient who was referred for removal of an incidental SET in the proximal gastric corpus. Endosonography suggested a small gastrointestinal stromal tumor (GIST) ([Fig. 1]). After the lesion had been marked ([Fig. 2 a]), the gastroduodenal EFTR device (Ovesco, Tubingen, Germany) was mounted onto the endoscope and the helix device was advanced through the working channel. Once the endoscope was centered over the lesion, it was gradually punctured with the helix; the device was then manually rotated (like a corkscrew), resulting in tissue approximation. After this “fixation” procedure, it was easy to retract the lesion into the cap using gentle suction. The SET was then resected in the usual fashion, with adequate closure of the resection site ([Fig. 2 b]; [Video 1]). The resected specimen ([Fig. 3]) was shown histologically to be a completely resected leiomyoma.

The worldwide number of performed bariatric surgeries is increasing continuously, whereas laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are conducted most frequently. Alongside with the usual post-operative and metabolic complications, luminal complications such as anastomotic bleeding, ulceration, leakage, fistula formation, enlargement and stenosis of the anastomosis may occur. Evolution of interventional endoscopy frequently allows endoscopic management of complications, avoiding surgical interventions in most cases. Here, we review the various luminal complications after bariatric surgery with a focus on their endoscopic management.

INTRODUCTION The accuracy of preoperative lymph-node staging in patients with adenocarcinoma of the esophagogastric junction (AEG) or gastric cancer (GC) is low. The aim of this study was to assess the accuracy of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (PET-CT) for lymph-node staging in patients with AEG or GC, with or without neoadjuvant treatment. PATIENTS AND METHODS 221 consecutive patients with GC (n = 88) or AEG (n = 133) were evaluated. Initial staging included endoscopic ultrasound (EUS), multidetector spiral CT (MDCT) and PET-CT. PET-CT was performed for restaging in patients after neoadjuvant treatment (n = 94). Systematic lymphadenectomy was routinely performed with histopathological assessment of individual mediastinal and abdominal lymph-node stations. Preoperative staging from EUS, MDCT, and PET-CT was correlated with histopathological results. RESULTS PET-CT showed a high specificity (91%) and positive predictive value (89%) for the preoperative detection of lymph-node metastases. In comparison, EUS was more sensitive (73% versus 50%, P

Summary Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien–Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0–26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.

Anastomotic leakages or staple line defects after Roux-en-Y gastric bypass (RYGB) and primary laparoscopic sleeve gastrectomy (LSG), respectively, with consecutive bariatric revisional surgery are associated with relevant morbidity and mortality rates. Endoscopic vacuum therapy (EVT) with or without stent-over-sponge (SOS) has been shown to be a promising therapy in foregut wall defects of various etiologies and may therefore be applied in the treatment of postbariatric leaks. We report the results of six consecutive patients treated with EVT (83% in combination with SOS) for early postoperative leakages in close proximity to the esophagogastric junction (EGJ) after LSG (n = 2) and RYGB (n = 4) from May 2016 to May2018. All patients (2/6 male, median age 51 years, median BMI 44.2 kg/m2) were treated successfully without further signs of persisting leakage at the last gastroscopy. The lesions’ size ranged from 0.5 cm2 to 9 cm2, and the leaks were connected to large (max. 225 cm2) abscess cavities in 80% of the cases. Median duration of treatment (= EVT in situ) was 23.5 days (range, 7–89). The number of endoscopic interventions ranged from 1 to 24 (median, n = 7), with a median duration between vacuum sponge replacements of 4 days. EVT is an effective and safe treatment for staple line defects or anastomotic leakage after bariatric surgeries and can therefore be adopted for the treatment of midgut wall defects. Further studies with a greater number of patients comparing surgical drainage alone or in combination with EVT versus EVT alone are needed.

A 34-year-old man presented to our GI clinic with chronic cough. Coughing episodes exacerbated on days of bagpipe playing and the morning after. Methacholine testing revealed airway hyperreactivity. Allergic bronchopulmonary aspergillosis could be excluded; CT scan of the chest was without pathological findings. Also bronchoscopy with bronchoalveolar lavage (BAL) and mucosal biopsy failed to reveal a pulmonary aetiology of the cough. Minor findings in BAL were an elevated number of macrophages and bacteria representative of the oral flora. A trial with inhalative budesonide and formoterol and consecutively 8 weeks of proton pump inhibitor …

Zusammenfassung. Die Ultraschall-Elastografie visualisiert und misst die Elastizität von Gewebe. Abhängig von der jeweilig verwendeten Methode gibt es im Wesentlichen vier Typen der Elastografie: Strain-Elastografie (SE), Transiente Elastografie (TE), Acoustic Radiation Force Impulse Imaging (ARFI) und Shear-Wave-Elastografie (SWE). Da pathologisch verändertes Gewebe meistens eine niedrigere Elastizität aufweist als gesundes, kann die Ultraschall-Elastografie zur initalen Diagnostik und zur Verlaufskontrolle von Erkrankungen wie Leberfibrose und -zirrhose, zur ergänzenden Diagnostik bei suspekten Brustbefunden, Schilddrüsenknoten, Prostatakarzinom und vielen weiteren Organerkrankungen verwendet werden. Zum aktuellen Zeitpunkt kann die Ultraschall-Elastografie noch keine standardisierten Diagnostik-Verfahren ersetzen, diese aber sinnvoll ergänzen.

A 74-year-old woman with extensive lichen planus mucosae (LPM) developed stenotic esophagitis that was refractory to intravenous glucocorticosteroids. Esophageal dilatations to 14 mm width were repeatedly performed without any lasting effect. After introducing oral apremilast, she experienced complete clinical remission within the first 4 weeks of treatment. Control esophagoscopy confirmed a marked recovery of the esophageal mucosa with no recurrence of the former stenosis. Our observation is in line with the case series of Paul et al. [J Am Acad Dermatol 2013;68: 255–261] who first reported on the benefit of apremilast in patients with extensive LPM. Ideally, the effectiveness of apremilast in LPM should be studied in a randomized controlled trial.

Background and study aims Endoluminal vacuum therapy (EVT) has evolved as a promising option for endoscopic treatment of foregut wall injuries in addition to the classic closure techniques using clips or stents. To improve vacuum force and maintain esophageal passage, we combined endosponge treatment with a partially covered self-expandable metal stent (stent-over-sponge; SOS). Patients and methods Twelve patients with infected upper gastrointestinal wall defects were treated with the SOS technique. Results Indications for SOS were anastomotic leakage after surgery (n = 11) and chronic foregut fistula (n = 1). SOS treatment was used as a first-line treatment in seven patients with a success rate of 71.4 % (5/7) and as a second-line treatment after failed previous EVT treatment in five patients (success rate 80 %; 4/5). Overall, SOS treatment was successful in 75 % of patients (9/12). No severe adverse events occurred. Conclusion SOS is an effective method to treat severely infected foregut wall defects in patients where EVT has failed, and also as a first-line treatment. Comparative prospective studies are needed to confirm our preliminary results.

A 57-year old woman underwent lung transplantation for non-specific interstitial pneumonia. Primary graft dysfunction was diagnosed requiring continued use of extracorporeal membrane oxygenation (ECMO). Within three days she developed recurring hemothoraces requiring two surgical evacuations. After ECMO removal a series of complications occurred within four months: femoral thrombosis, persisting tachycardic atrial fibrillation, pneumopericardium with an esophagopericardial fistula and purulent pericarditis, septic shock, multiorgan failure and intracerebral hemorrhage with ventricular involvement requiring external ventricular drainage. Interdisciplinary management coordinated by the intensive care specialist, transplant surgeon and pulmonologist with various interventions by the respective specialists followed by intensive physical rehabilitation allowed for discharge home on day 235 post transplant. Subsequently quality of life was considered good by the patient and family. Keywords: Lung transplantation, Esophagopericardial fistula, Intracranial hemorrhage, Complications, Treatment

Biliary complications following liver transplantations, with leaks and bile duct strictures being the most common ones, are greatly feared. Portobiliary fistulas are rare, but may cause potentially life-threatening complications. The presented case shows the first successful treatment of a portobiliary fistula by an endoscopically deployed fully covered self-expandable metal stent after liver transplantation. In accordance to the already established use in refractory bile leaks, we believe that fully covered self-expandable metal stent is a safe and efficient treatment option for portobiliary fistula.

Acute esophageal variceal bleeding in patients with portal hypertension remains a complication with a high mortality today. In cases refractory to standard therapy including endoscopic band ligation and pharmacological therapy, traditionally balloon tamponade has been used as salvage therapy. However, these techniques show several important limitations. Self-expanding metal stents (SEMS) have been proposed as an alternative rescue treatment. The use of variceal stenting in 7 patients with a total of 9 bleeding episodes in three different Swiss hospitals is demonstrated. While immediate bleeding control is achieved in a high percentage of cases, the 5-day and 6-week mortality rate remain high. Mortality is strongly influenced by the severity of the underlying liver disease. Accordingly, our data represent a high-risk patient collective. Thanks to their safety and easy handling, SEMS are an interesting alternative to balloon tamponade as a bridging intervention to definitive therapy including the pre-hospital setting.

Over-the-scope-clips (OTSC®) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC® treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC® closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC® closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC® closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC® was achieved in all patients with no immediate or long-term complications. OTSC® is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities.

Background and Study Aims: The role of cyst cytology to diagnose mediastinal duplication cysts remains controversial. Since endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of duplication cysts has been considered as safe so far, there are only a few case reports of infections following FNA. Case Summary: We report a case series of all patients at our institution undergoing EUS evaluation for suspected mediastinal duplication cysts (n = 5) in the last 15 years. The mediastinal lesion in 4 patients did not feature typical EUS features for duplication cysts, wherefore we did perform EUS-guided FNA in order to rule out malignancy. In 3 out of 4 patients, a duplication cyst was confirmed. The fourth lesion turned out to be a sarcoma. All 4 patients developed severe FNA-induced cyst infection causing mediastinitis and the need for surgical debridement. Despite an immediate review of the FNA by the on-site cytopathologist with establishing the diagnosis of a duplication cyst, peri-interventional broad-spectrum antibiotics could not prevent severe infections of the lesions. Conclusions: Given the potentially high rate of infectious complications, we advocate a very restrictive indication for diagnostic FNA in mediastinal masses. Yet, in unclear cases, FNA might be indispensable despite the potential adverse events in order to rule out hypoechogenic, mediastinal malignancy.

A new approach for the treatment of complicated anastomotic leaks following esophageal resections by combining vacuum-assisted therapy with covered self-expanding stents is reported. This is not an approach for a simple leak but a rescue maneuver for complex uncontained leaks. It is known that anastomotic leakages particularly situated in the chest can be successfully treated with endoscopically placed self-expanding stents with/without additional drainage. If this approach fails, reoperation with substantial morbidity is frequently necessary. Two complicated anastomotic leakages refractory to stenting alone were successfully treated with the combination of an endo-sponge-assisted device covered by a self-expanding metallic stent. If stent therapy fails or the perianastomotic abscess cavity is large and complex to drain from outside, the endoscopic two-modality approach can be considered.

Despite the increasing use of carbon dioxide for endoscopies during the last years, ambient air is still used. The amount of air depends on several factors such as examination time, presumable diameter of the endoscope channel and of course active use of air by the operator. Although endoscopic complications due to ambient air in the gastrointestinal (GI) tract are a rare observation and mostly described in the colon, we report five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer. Due to insufflation of inadequate amounts of air through the endoscope channel, all patients deteriorated in circulation and ventilation. Two rumenocenteses and consecutively three laparotomies had to be performed in three patients. In the other two, gastroscopies had to be stopped for an emergency computed tomography. All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air. Therefore in emergency situations, endoscopies should be performed with either submersion, low air flow pumps or even better by the use of carbon dioxide.

Background/Aims: To identify the number and potential causes of unnecessary diagnostic procedures in a cohort of patients with autoimmune pancreatitis (AIP). Methods: All AIP cases at our centre between April 2006 and April 2013 were collected and followed up. Diagnosis was established by the International Consensus Diagnostic Criteria (ICDC). Demographic, clinical, radiological, serological data, the number of diagnostic procedures and the reason for referral were recorded. Possible risk factors for a delayed diagnosis of AIP were analysed. Results: A total of 29 patients (median age 60 years; 22 males and 7 females) were diagnosed with AIP using ICDC. Twenty-five patients were diagnosed with definite, 2 with possible type 1 AIP and 2 with type 2 AIP. In 29 patients, 50 ERCPs and 18 EUS were carried out; based on ICDC recommendations, a total of 20 ERCPs and 4 EUS were unnecessary diagnostic procedures. Eight patients (23.0%) were referred for unnecessary surgery. Jaundice was shown to be a significant risk factor for unnecessary endoscopic investigations (OR 11.00, 95% CI 1.14-106.43, p = 0.04). Conclusion: Diagnosis of AIP still remains a challenge. Patients with jaundice are at particular risk of being subjected to unnecessary endoscopic procedures. Use of ICDC would help avoid unnecessary examinations or even major surgeries at times.

Optimal endoscopic treatment of gastric varices is still not standardized nowadays. Actively bleeding varices may prohibit a successful endoscopic injection therapy of Histoacryl® (N-butyl-2-cyanoacrylate). Since 2006, we have treated gastric varices by standardized endoscopic ultrasound (EUS) guided Histoacryl injection therapy without severe adverse events.We present a large single-center cohort over 7 years with a standardized EUS-guided sclerotherapy of all patients with gastric varices. Application was controlled by fluoroscopy to immediately detect any glue embolization. Only perforating veins located within the gastric wall were treated. In the follow up, we repeated this treatment until varices were eradicated.Utmost patients (36 of 40) were treated during or within 24 h of active bleeding. About 32.5% of patients were treated while visible bleeding. Histoacryl injection was always technically successful and only two patients suffered a minor complication. Acute bleeding was stopped in all patients. About 15% (6 of 40) of patients needed an alternative rescue treatment in the longer course. Three patients got a transjugular portosystemic shunt and another three underwent an orthotopic liver transplantation. Mean long-term survival of 60 months was excellent.Active bleeding of gastric varices can be treated successfully without the necessity of gastric rinsing with EUS-guided injection of Histoacryl.

Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a hemostatic agent recently introduced for the management of upper gastrointestinal bleeding (GIB). To date, there is little experience with this fairly new hemostatic tool. The aim of this case series was to reflect the use and effectiveness of Hemospray as a treatment option in GIB in everyday clinical practice at two tertiary referral centers. Consecutive patients (n = 16) with active GIB of various origins were treated with Hemospray. The rate of successful initial hemostasis was 93.75 % (15 /16; salvage therapy 92.85 % [13/14]; monotherapy 100 % [2 /2]). The rebleeding rate within 7 days was 12.5 % (2/16). One patient, in whom interventional radiology also failed, had to undergo surgery as salvage therapy. The effectiveness of Hemospray in the management of GIB in various clinical situations is promising. Future multicenter randomized prospective trials for clearly defined bleeding situations are needed for greater generalizability of case series findings.

Neutropenic enteritis (NE) or enterocolitis (NEC) is a rare, but potentially life-threatening side effect of neutropenia-inducing chemotherapy agents. Generally, its occurrence is attributed to leukemia-associated chemotherapies. Two cases of NE have been reported after the appliance of pemetrexed for treatment of non-small cell lung cancers. To our knowledge, NE has never been reported due to treatment with pemetrexed for malignant pleural mesothelioma (MPM). We present a case of MPM in a 77-year-old male suffering from severe NE one week after the seventeenth cycle of pemetrexed in the course of maintenance therapy for MPM, which could be treated successfully with antibiotic coverage and supportive measures. Concomitantly the patient showed a severe hyperpigmentation of his entire integument sparing the palms of both hands and the soles of his feet. After exclusion of alternative causes of skin hyperpigmentation, a pemetrexed-induced cutaneous hyperpigmentation was assumed according to two previous case reports. A combination of both pemetrexed-induced side effects in one patient has not been reported to date.

Background: Therapy-resistant lichen planus (LP) can be a challenging condition for dermatologists. There are some case reports about successful treatments with alitretinoin of cutaneous and oral, but not of esophageal LP. Objective: We present the unique case of a patient with cutaneous, oral and esophageal LP which was refractory to classical treatment options (topical clobetasol propionate and pimecrolimus, intramuscular triamcinolone acetonide); because of systemic side effects the patient did not tolerate systemic acitretin dosed up to 25 mg daily. Methods: Oral alitretinoin was used at a dose of 30 mg daily. Results: Both oral and skin changes as well as dysphagia completely resolved within 4 weeks without any severe side effects and the drug was used for 6 months. No papules, intraoral striae or dysphagia recurred during the 6 months of treatment. After 4 months the patient relapsed with mucosal patches so that a second cycle was initiated for 6 months where oral LP lesions resolved after 4 weeks also (with sporadic mild headache). Conclusion: Further studies are needed to better understand the impact of alitretinoin in LP. Our observation suggests alitretinoin as a new, well-tolerated treatment option for esophageal LP after failed response to conventional treatments.

Acute gastrointestinal bleeding represents a common medical emergency. We report the rare case of acute upper gastrointestinal bleeding caused by varices in the gastric fundus secondary to splenic duplication. Splenic duplication has been only rarely reported in the literature, and no case so far has described the associated complication of gastrointestinal bleeding, caused by venous drainage of the upper spleen via varices in the gastric fundus. We describe the imaging findings from endoscopy, endosonography, computed tomography (CT), flat-panel CT, and angiography in this rare condition and illustrate the effective role of intra-arterial embolization.

Obscure gastrointestinal bleeding can lead to extensive diagnostic work-up, as well as repeated episodes of hospitalizations with significant morbidity. Patients with a previous small-bowel anastomosis seem to be prone to varices at this site, even in the absence of portal hypertension. We report here five cases with varices of this type. All the anastomoses in these patients were reached using overtube-assisted single- or double-balloon enteroscopy. The bleeding varices were treated by injecting N-butyl-2-cyanoacrylate (Histoacryl). Bleeding was stopped in all five patients without any adverse events, requiring one session in four patients and a second session in one patient.

With increasingly advanced therapeutic endoscopic procedures and more complex gastrointestinal surgery, endoscopists are more often confronted with perforations, fistulas, and anastomotic leakages for which nonsurgical closure is desired. The over-the-scope clip (OTSC) is a novel endoscopic tool for consideration in such situations. We treated seven patients (age range 35 – 83 years; five men, two women), three with colonic perforation, one with perforation of the stomach, and three with anastomotic leakage after gastrointestinal surgery. Follow-up was at least 74 days. Eight OTSCs were deployed. In all but one patient closure of the perforation was demonstrated. Further surgery was avoided in four of the seven patients. The OTSC is a system that is easy to handle and safe. It seems to be ideally suited to use for a relatively small (iatrogenic) perforation, where a single clip can be released with carbon dioxide insufflation. Anastomosis leakage and larger dehiscence can also be treated to avoid further surgery, but the utility in this situation needs to be defined in the future.

Background Combined fluorine 18-fluorodeoxyglucose–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 PET-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% CI 44–80%) and 93% (95% CI 78–98%), respectively; the positive 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% CI 49–94%) and 100% (95% CI 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. © 2007 Wiley Periodicals, Inc. J Clin Ultrasound, 2008

We describe a case of cerebral aspergillosis which was successfully treated with a combination of caspofungin and voriconazole. The patient remains in remission 18 months after stopping antifungal treatment. We discuss primary and salvage therapy of invasive aspergillosis with focus on cerebral involvement. Since historical data showed a fatal outcome in most cases, amphotericin B does not cross the blood brain barrier while voriconazole does, we chose a combination of voriconazole plus caspofungin as primary therapy.

BACKGROUND Perihepatic lymph node enlargement (LNE) is often present in patients with chronic hepatitis C (CHC) and correlates with the degree of inflammation, as well as the stage of fibrosis of the liver. LNE at sites distant from the liver hilum, however, is not a common feature of chronic hepatitis but may occur during antiviral therapy as we report here. OBJECTIVES The aim of this study was to examine the frequency and aetiology of LNE at sites distant from the liver hilum in patients with chronic hepatitis C during combination therapy with pegylated interferon alpha and ribavirin. METHODS The charts of all patients undergoing therapy with PEG and RIBA for CHC at our institution from January 2002 to April 2003 were reviewed for those who developed de novo LNE at sites distant from the liver hilum. RESULTS In total, 8/217 patients (3.7%) or 5/125 patients treated within clinical trials (4.0%) were recorded to have developed de novo LNE during antiviral therapy. CONCLUSION LNE at various sites distant from the liver hilum was observed in up to 4% of our patients during treatment of CHC with PEG and RIBA. While being reactive in nature and resolving upon cessation of therapy in the majority of patients de novo LNE may be due to serious disease and warrants further investigations.

Introduction Hepatologists and internists often encounter patients with unexplained high serum ferritin concentration. After exclusion of hereditary hemochromatosis and hemosiderosis, rare disorders like hereditary hyperferritinemia cataract syndrome should be considered in the differential diagnosis. This autosomal dominant syndrome, that typically presents with juvenile bilateral cataracts, was first described in 1995 and has an increasing number of recognized molecular defects within a regulatory region of the L-ferritin gene (FTL). Case presentation Two patients (32 and 49-year-old Caucasian men) from our ambulatory clinic were suspected as having this syndrome and a genetic analysis was performed. In both patients, sequencing of the FTL 5' region showed previously described mutations within the iron responsive element (FTL c.33 C > A and FTL c.32G > C). Conclusion Hereditary hyperferritinemia cataract syndrome should be considered in all patients with unexplained hyperferritinemia without signs of iron overload, particularly those with juvenile bilateral cataracts. Liver biopsy and phlebotomy should be avoided in this disorder.

Introduction Liver cirrhosis is a common disease with many known complications. Cirrhosis represents a clinical spectrum, ranging from asymptomatic liver disease to hepatic decompensation. Manifestations of hepatic decompensation include variceal bleeding, ascites, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension and hepatocellular carcinoma. There are reports about infarcted regenerative nodules in cirrhotic livers after gastrointestinal hemorrhage. Case presentation We report three Caucasian patients (one female and two male patients; ages: 52, 54 and 60 years) with decompensated liver cirrhosis, who showed newly infarcted regenerative nodules at necropsy. Two of them suffered from gastric variceal bleeding. Histopathology showed extensive infarction in all three cases. Hemorrhage and inflammatory changes were also observed around the infarcted regenerative nodules. Conclusion These patients showed focal liver lesions, to be considered in the differential diagnosis of cirrhotic livers. Infarcted regenerative nodules may be underdiagnosed in patients with decompensation of cirrhosis. In order to differentiate these lesions from malignant tumors, serial imaging seems to be helpful. However, the main differential diagnosis should be an abscess. It is important to know the wide spectrum of image appearances of these lesions. Hypotension can lead to a reduction of portal and arterial liver flow. Since variceal bleeding or septic shock can induce hypotension - as observed in our patients - we conclude that this leads to infarction of such nodules.