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Aim: The aim of this paper is to describe the imaging pattern of focal nodular hyperplasia (FNH) by 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET). Methods: Eight consecutive asymptomatic patients with histologic proof of FNH underwent 18F-FDG PET imaging. The lesions were found incidentally. The 18F-FDG PET imaging was performed with a dedicated PET tomograph after intravenous injection of 300–370 MBq 18F-FDG. The 18F-FDG accumulation in the lesions was (semi)quantified by calculating the standardized uptake value (SUV) and SUV has been corrected for the lean body mass (LBM). Eight patients with liver metastases spread from melanoma (n=2) and colorectal carcinoma (n=6) served as controls. The size of the FNH lesions and of the control group ranged from 2.0 to 8.5 cm (mean 4.83 cm±2.37) and from 1.5 to 6 cm (mean 3.28±1.52), respectively. Results: While in malignant liver lesions the accumulation of 18F-FDG was significantly increased, all FNH lesions showed normal or even decreased accumulation of 18F-FDG. In FNH lesions, SUV ranged between 1.5 and 2.6 (mean 2.12±0.38), whereas all liver metastases showed an increased SUV ranging between 6.20 and 16.00 (mean 10.07±3.79). The SUV corrected for LMB (SUVLBM) was similar to the SUV and ranged between 0.9 and 2.2 (mean 1.81±0.41) for FNH and between 5.9 and 16.3 (mean 9.15±4.03), respectively. Conclusion: In contrast to liver metastases, there is no increased glucose metabolism in FNH in vivo. The imaging feature of FNH by 18F-FDG-PET imaging is not specific for FNH; however, it may be helpful to differentiate FNH from liver metastases in cancer patients if radiological methods are not diagnostic.

Summary Background On the basis of promising data on the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (F18-FDG) whole body positron emission tomography (WB-FDG-PET) in the staging of patients with lymphoma, we initiated a pilot series to evaluate the role of WB-FDG-PET in the staging of extranodal B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type. Patients and methods We examined ten consecutive patients with histologically-verified MALT-type lymphomas of various origin before initiation of therapy. Nine patients had low-grade lymphomas (five cases of gastric lymphoma, two patients with lymphoma arising in the lung, one parotid and one lacrimal gland lymphoma, while one patient had a high-grade gastric lymphoma arising from a low-grade background. Two patients had stage El, seven had stage EII disease, and one presented with stage EIII. WB-FDG-PET scans were performed 40 min following the injection of 300–380 MBq of F18-FDG. The PET scans were correlated with extensive conventional staging including ophthalmologic investigation, otolaryngologic examination, gastroscopy, endosonography, enteroclysis, colonoscopy, CT of thorax and abdomen, and bone marrow biopsy. Results WB-FDG-PET documented no lymphoma in any of the 10 patients studied, as no focal tracer uptake was demonstrated in either gastric or extragastric lesions or in involved lymph nodes, irrespective of histologic grading. In three patients the scan showed a false negative result with respect to the MALT lesions but showed focal tracer uptake indicating tumor spread, which, however, was ruled out by further follow-up and biopsy, respectively, and was thus rated false positive. Due to these results, the study was discontinued prematurely after the first ten patients. Conclusions These discouraging results indicated that WB-FDG-PET is not useful for staging and follow-up of MALT-type lymphoma, and should therefore not be included in the clinical decision making process.

A 51-year-old male patient presented with characteristic radiologic features of Crohn’s disease in the terminal ileum plus a large tumorous lesion in the right lower abdomen. Because of rapid crescent symptoms of bowel obstruction, the patient underwent surgery revealing a high-risk gastrointestinal stromal tumor (GIST) of the terminal ileum within an area of Crohn’s ileitis. Whereas the association of chronic inflammatory bowel disease (IBD) and gastrointestinal adenocarcinoma is well known, other primary intestinal tumors are rare in these patients, particularly at the time of onset of clinical symptoms. This is the 3rd patient reported in the literature with a sarcoma complicating IBD, and in fact, the first description of the coincidence of Crohn’s disease and GIST. Though the present case is likely to be a mere coincidence of two pathologically distinct entities (without any potential causal relationship), it should remind one of the possibility of small bowel ‘Crohn’s carcinoma’ in patients with a sudden change in symptomatology as well as in those in whom intestinal obstruction fails to resolve with adequate therapy.

Summary Background: There is no standard therapy for the treatment of patients with nonresectable biliary tract carcinomas who face a particularly di

A survival analysis in 16 patients with unresectable hepatocellular carcinoma (HCC) undergoing transcatheter arterial embolization (TAE) using a combination of lipiodol and N-butyl-2-cyanoacrylate (5:1) was performed in a retrospective study.A combination of lipiodol and N-butyl-2-cyanoacrylate (5:1) was used for TAE. All patients had disease compatible with Okuda stages I and II.Twenty-four embolizations were done; five patients had more than one embolization. Median alpha-fetoprotein levels declined from 116 to 48.6 ng/ml. A median of 0.3 ml cyanoacrylate was administered per patient. Median survival was 8.5 months (range 2-49 months). After a median follow-up of 4 years, 12 patients have died (75%). Okuda stage I and II patients had a median survival time of 34.4 and 5.5 months respectively. Few side effects (19%) were seen.We conclude that the TAE procedure used [lipiodol and N-butyl-2-cyanoacrylate (5:1)] is safe and produced only few side effects, thus constituting a valuable therapeutic option for patients with Okuda stage I and II HCC.

Nitric oxide (NO) has been implicated in various aspects of physiological regulation in the gastrointestinal tract. Hence, measurement of luminal NO concentrations is of interest for studying physiological and pathophysiological alterations in NO generation; however, at present, no reliable measurement techniques are available. Here we describe novel approaches for measurement of NO concentrations directly in the gas phase of the stomach and colon in healthy subjects and patients. Studies were conducted in young healthy volunteers (n = 13), intensive care patients (n = 8) and patients undergoing gastroscopy (n = 8) or colonoscopy (n = 8). NO concentrations were measured by chemolumininescence detection in air obtained through a nasogastric tube, after inflation into the stomach of a defined volume of air, or directly in the air suctioned from the endoscope. The mean NO concentration obtained from the stomach of healthy volunteers studied under baseline conditions was 18.0 +/- 2.8 (SEM) p.p.m. Day-to-day reproducibility of NO measurements was high. Tube feeding with a nitrite- and nitrate-free feeding solution left gastric NO concentrations unchanged, but standardized bicycle exercise caused an approximately 30% decrease in NO levels. NO concentrations in intensive care patients were approximately 2 log cycles lower than in healthy volunteers. NO levels in the colon were similar to those in the stomach. We have described two readily applicable techniques for direct, uncontaminated measurement of NO concentrations in the lumen of the gastrointestinal tract. Our finding of a striking reduction in gastric NO concentrations in intensive care patients requires further study.

OBJECTIVE: Controversial data exist on the effect of obesity and weight reduction on surface electrocardiographic parameters. The purpose of this study was to analyze electrocardiograms of obese children in the course of short-term weight reduction. DESIGN: Prospective trial over a period of three weeks with a conventional low calorie diet containing a mean of 525±109 kcal. SUBJECTS: Thirty-three children, 17 girls and 16 boys with a mean age of 12.2±1.7 y and an overweight of 25.4–102%, mean 54.2±15.6%. MEASUREMENTS: Before the onset of therapy and thereafter, body weight, blood chemistry and 12 lead electrocardiographic evaluations were performed. RESULTS: The mean loss of body weight was 5.7±1.6 kg resulting in a mean decrease in overweight of 13.5±3.4%. Blood chemistry analyses revealed no significant changes except for cholesterol, triglycerides and uric acid. All electrocardiograms were within normal limits, however, a change in the electrocardiographic pattern was noted after weight loss. Heart rate (84±14 vs 64±11 beats per min, P

For evaluating pancreaticobiliary stenoses during endoscopic retrograde cholangiopancreatography (ERCP) tissue sampling techniques may be important. Brush cytology and forceps biopsy during ERCP are two potential, but so far only incompletely evaluated, tools for the diagnosis of malignant biliary or pancreatic stenoses.Between 1992 and 1995 we acquired 133 cytologic and/or histologic samples from 119 patients who underwent ERCP because of biliary duct stenoses. Sixteen patients had to be excluded from the study due to insufficient follow-up information. After papillotomy, brush cytology was performed in 65 cases (63 patients), and forceps biopsy in 119 cases (106 patients under fluoroscopic guidance. Both methods were applied in combination 51 times (48 patients). The nature of the stenoses was confirmed by surgery, autopsy, or by the subsequent clinical course.The sensitivity was 46.7% for brush cytology and 64.9% for forceps biopsy. The combined application of both methods resulted in superior sensitivity (70.4%). Specificity was 100% for all methods.These numbers lead us to recommend a combined and more frequent application of brush cytology and forceps biopsy of bile duct stenoses to enhance the diagnostic yield whenever substantial influence on therapy can be expected.

Minimal chronic inactive gastritis is regularly observed in routine histopathology. Presently, it is not clear whether this type of gastritis should be regarded as a histopathological entity or a normal variant. The similarity to lesions observed after H.pylori eradication prompted us to look for an association between minimal chronic inactive gastritis and status post H.pylori eradication. In a prospective study of 110 consecutive patients undergoing upper gastrointestinal endoscopy, at least two mucosal biopsies were taken from the gastric antrum and body. Gastritis was classified according to the Sydney System. Antibodies to H.pylori were determined serologically by immunofluorescence test, ELISA, and complement binding reaction. A status post eradication of H.pylori was revealed by medical history and/or positive serology; H.pylori gastritis was found in 39.1%, reactive gastritis in 12.7%, and minimal chronic inactive gastritis in 29.1%. In 19.1% a combination of reactive/ minimal chronic gastritis was diagnosed according to morphology. Status post eradication was observed significantly more often in cases with minimal chronic inactive gastritis (43.8%) than in cases with reactive gastritis (7.1%, p < 0.004). Furthermore, positive ELISA and/or status after eradication was found in 50% of the cases with minimal chronic inactive gastritis (p < 0.005 vs reactive gastritis), in 42.9% of the cases with mixed reactive/chronic inactive gastritis (p < 0.03 vs reactive gastritis), and in 7.1% of the cases with reactive gastritis. Lymphoid aggregates, considered another sign of former H.pylori presence, were found significantly more often in minimal chronic inactive gastritis than in reactive gastritis (50% versus 7.1%, p < 0.005). Minimal chronic inactive gastritis is significantly associated with both positive H.pylori serology and status post eradication and is, therefore, an indicator of pre-existing H.pylori gastritis.

Background: Serum carbohydrate deficient transferrin is a marker of chronic alcohol consumption; it increases above normal in healthy individuals after a daily alcohol intake of more than 60 g/d for more than 2 weeks. The influence of liver disease itself on carbohydrates deficient transferrin levels has not been sufficiently established. Methods: We investigated serum levels of carbohydrate deficient transferrin in 196 consecutive patients admitted to our Gastroenterology and Hepatology Unit and correlated this parameter with the patients' statements about alcohol intake during the previous 2 weeks and with other markers of chronic alcohol consumption. Results: In our patient population, carbohydrate deficient transferrin had the best overall performance with respect to sensitivity (88%), specificity (82%), and negative predictive value (98%), as compared to other markers, although specificity was much lower than previously reported in patients without liver disease. In the group of patients with liver disease, sensitivity and specificity were 90% and 73%, respectively, and in patients without liver disease, 80% and 88%. The negative predictive value was excellent (96% for patients with liver disease and 99% for patients without liver disease). Conclusions: Thus, in a patient with a negative interview for chronic alcohol abuse and normal carbohydrate deficient transferrin level, alcohol is unlikely to be the cause of liver disease, and further investigations to establish the etiology of liver disease are warranted. An increased carbohydrate deficient transferrin level, however, cannot be regarded as reliable evidence for chronic alcohol abuse in patients with liver disease.

Elevated concentrations of lipopolysaccharide have been found in serum of patients with severe parenchymal liver disease and its toxic effect is thought to involved in hemodynamic disturbances seen in cirrhosis. A soluble form of the receptor (sCD14) for lipopolysaccharide is present in serum and is released by stimulated macrophages, indicating macrophage activation. We investigated sCD14 serum levels and in vitro production by lipopolysaccharide stimulated peripheral blood monocytes in patients with various liver diseases. In acute viral hepatitis serum sCD14 levels were significantly higher during the first 2 weeks after onset of jaundice (n=11; 3.6 +/- 0.9 microg /ml (mean +/- SD)) than in healthy control individuals (n=52; 2.5 +/- 0.7 microg/ml; p

BACKGROUND—Lymphoma of the mucosa associated lymphoid tissue (MALT) arising in the stomach has been shown to be related to Helicobacter pylori infection, and total regression of gastric lymphoma after successful eradication of H pylori has consistently been reported. MALT-type lymphoma at other localisations, however, has to our knowledge not been linked to H pylori, and eradication of the bacteria has not been studied for management of such lymphomas. PATIENT/METHOD—A 67 year old man was diagnosed with MALT-type lymphoma simultaneously involving the stomach and the colon descendens. In addition to the presence of MALT-type lymphoma, H pylori associated chronic gastritis was diagnosed, and treatment with clarithromycin, metronidazole, and omeprazole was initiated, resulting in its successful eradication. RESULTS—Follow up performed four months later showed regression of the colonic manifestation, whereas the gastric lymphoma did not respond to antibiotic treatment, as assessed by regular follow up for 14 months, in spite of its restriction to mucosa and submucosa. The patient was therefore treated with oral cyclophosphamide (100 mg a day) resulting in partial remission after seven months of continuous treatment. Because of the presence of residual lymphoma, additional irradiation was performed, which led to complete remission of the gastric lymphoma. The patient remains in complete remission 40 months after diagnosis and 26 months after initiation of treatment. CONCLUSION—In the case of concurrent gastric and intestinal low grade MALT-type lymphoma, H pylori eradication may cause regression of the intestinal lesion. Keywords: mucosa associated lymphoid tissue; colon; Helicobacter pylori eradication; lymphoma

Serum levels and production of soluble CD8 and soluble CD4 antigens by peripheral blood mononuclear cells were determined in patients with alcoholic cirrhosis and acute or chronic viral hepatitis. Patients with chronic viral hepatitis had significantly increased soluble CD8 serum levels (n = 18; 734 +/- 143 U/ml) (mean +/- SD) compared to healthy controls (n = 80; 312 +/- 141 U/ml; p0.001) and patients with alcoholic cirrhosis (n = 12; 505 +/- 256 U/ml; p = 0.006), whose soluble CD8 concentrations were also higher than controls (p0.001). In contrast, soluble CD4 antigen serum levels were similar in all groups. In addition, patients with chronic hepatitis showed an increased production of soluble CD8, but not soluble CD4, after mitogenic stimulation of their peripheral blood mononuclear cells compared to controls or patients with alcoholic cirrhosis. Patients with acute viral hepatitis, studied within the first 2 weeks after onset of jaundice, showed markedly elevated serum concentrations of soluble CD8 (n = 4; 807 +/- 379 U/ml; p0.001 vs. controls), but not soluble CD4. In addition, nine patients with chronic hepatitis C were studied during and after treatment with alpha interferon. Soluble CD8 serum concentrations of six treatment responders were not found to be different from the low levels seen in controls, whereas three non-responders had increased soluble CD8 levels which were similar to levels in untreated patients with chronic hepatitis C. After interferon-alpha therapy ended, a significant elevation of soluble CD8 serum concentrations was observed in four relapsing patients, which paralleled the serum ALT increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Self expanding metal endoprostheses for biliary drainage have been designed to increase stent patency compared to plastic endoprostheses. The new Diamond® Stent (Boston Scientific Corp., USA), an uncovered self expanding metal endoprosthesis made from nitinol, is supposed to increase stent patency further more due to an improved stent design. The ESGE Research Comittee therefore initiated this prospective, mulitcenter study. Since April 1997 111 patients (53 males and 58 females; mean age 72 years, range 34 - 88ys.) were treated with 119 stents. The reasons for bile - duct obstruction were pancreatic cancer in 62 patients, bile duct cancer in 23 patient, hilar lymph nodes in 12 patients, cancer of the gallbladder in 8 patients and others in 6 patients. The site of obstruction was the distal third in 56%, the middle third in 31% and the proximal third of the main bile duct in 13%. Insertion was successful in 109 patients (98%). In 2 patients early reintervention was necessary due to insufficient stent expansion. During initial ERCP 3 stents had to be removed immediately, 2 of those did not open correctly, 1 was placed too far in the duodenum. No clinical complications due to the implantation procedure were observed. The mean follow up period is now 195 days (2 - 897). 84 patients (76%) died up to now. 30 day mortality is 15% (17 of 108). In 24 patients (22%) an occlusion of the Diamond®-Stent was observed after a mean period of 205 days. Median stent patency is 355 days and median survival is 174 days. After metal stent occlusion all patients were successfully treated with plastic endoprostheses. Stent occlusion occurred due to tumor-ingrowth or -overgrowth in 86% and due to sludge in 14%. Stent patency did not differ in patients with proximal or distal stenoses. Median patency in patients with distant metastases (n=54) was 201 days with a median survival of 93 days, whereas in patients without distant metastases (n=57) median patency was 367 days and median survival was 230 days. Cost analysis and evaluation of life quality (SF 36) are still pending. These results for biliary drainage of malignant jaundice with the Diamond®-Stent in a multicenter prospective setting compare favourably with other biliary metal stents. Metastases had a negative impact on stent patency whereas the site of the stenoses did not influence the performance of the stents.