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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.

Background: Management of leakages of the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be complex. New endoscopic techniques such as covered stents and over-the-scope clips (OTCs) have been developed and are valuable alternative therapeutic options to reoperation and drainage. The aim of this study was to compare the value of stents and OTCs with surgical treatment options for the therapy of anastomotic leakages after LRYGB. Methods: Results of patients who were treated surgically with reoperation, local irrigation and drain placement (n = 9) were compared with results of patients who were treated endoscopically with stent and/or OTC placement (n = 5). Success rate, length of hospital stay, mortality, number of OTC applications/stent placement and percutaneous drainage placements were analyzed. Results: Overall, 14 of 1,046 patients (1.34%) developed a leakage of their gastrojejunal anastomosis after LRYGB between 2000 and 2012. While the success rate in surgically treated patients was 88%, the endoscopic treatment using a sequential approach with stenting, OTC application and percutaneous placement of drainages resulted in a 100% closure rate. The mortality rate and length of stay were not substantially different after both treatment regimens. Conclusion: Endoscopic management of anastomotic leakages after LRYGB may constitute a valuable alternative therapeutic option to surgical reoperation and drainage placement.

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.

To date, there is no standardized treatment for esophageal perforations and leakages caused by underlying benign diseases, and it is still debated whether a conservative, endoscopic treatment or a surgical approach is preferable. However, some cases series have successfully demonstrated the feasibility of a temporary placement of self-expanding stents.All patients with benign leakages of the esophagus or gastroesophageal junction or fistulas at gastroesophageal anastomosis were collected during the past 12 years and analyzed retrospectively. The patients treated with endoscopic stenting were analyzed for sustained success, complications, time to stenting, lesion size, number of stents used, need for percutaneous drainage.Eighty-five of eight-eight patients were included in this analysis. Three patients were conservatively managed only. The success rate of stent treatment with an average of 1.3 stents was 79%. Success was highest (94%, n = 30 of 32, no complications or mortality) in iatrogenic lesions that were immediately diagnosed and treated. Spontaneous lesions, including lesions due to Boerhaave's syndrome, were healed in 73% and anastomotic leakages were closed in 71%. Fistula had a lower success rate of 43%. Use of multiple stents sequentially placed was necessary in 23% of the cases. Percutaneous drainage was necessary in 25% of all cases.Temporary stent placement for benign leakages of the esophagus is safe and seems to improve treatment success. Adjacent fluid collections should be drained percutaneously.

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 Anastomotic leak (AL) remains a major cause of morbidity in upper-GI surgery. In many centers, endoluminal vacuum drainage (EVD) has become the mainstay of therapy for AL after esophageal and gastric resections. A new idea is to use the EVD technology in a preemptive setting. In this context, we present a case series of patients that received PEVD upon completion of the anastomosis during esophago-gastric surgery. Methods Intraoperative PEVD was performed in 10 consecutive patients undergoing minimally invasive esophagectomy with cervical (n = 1) or high intrathoracic (n = 6) anastomosis, and open transhiatally extended (n = 1) or minimally invasive (n = 2) total gastrectomy. The EVD device was removed after three to six (mean 4) days, and the anastomosis was endoscopically inspected for ischemia and AL. Additional contrast radiography, computed tomography, or gastroscopy to exclude AL was performed in seven patients. Primary endpoints in this retrospective series was AL; secondary endpoints were the postoperative morbidity measured by the Clavien-Dindo (CD) classification and the comprehensive complication index (CCI), all at 30 days after surgery. Results Perioperative mortality was 0% with uneventful anastomotic healing in all patients of this series (AL rate 0%, anastomotic stenosis 0%). There were no adverse events attributable to PEVD. None of the patients experienced major morbidity (> CD grade IIIa) during the postoperative course. The median postoperative ICU and hospital stay was 1 (IQR 1-1.75) and 14 (IQR 12-16) days, respectively. Five patients (50%) developed at least one complication, mostly related to infection (2 patients) and pulmonary events (2 patients). The mean CCI at 30 days after surgery was 13.7 (range 0-39.5). Conclusion PEVD appears to be a safe procedure that may emerge as a groundbreaking technology in patients undergoing esophageal or gastric resection. Further research is needed to elucidate the true potential of this technique. Disclosure All authors have declared no conflicts of interest.

Background Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. Objective To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. Design Randomized controlled study. Setting University Hospital of Zurich, Switzerland. Patients Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. Main Outcome Measurements Success rates of endoscopic placement of enteral feeding tubes. Results A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument ( P Limitations In rare cases, the randomization list could not be followed correctly. Conclusions This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

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.

BACKGROUND AND STUDY AIM The correct placement of an enteral feeding tube in the duodenum in critically ill patients is usually controlled radiographically. However, a direct bedside method that obviates the need for exposure to radiation would be preferable. The aim of this study was to demonstrate the usefulness of bedside sonographic position control for placing enteral feeding tubes in critically ill patients. PATIENTS AND METHODS After placement of the enteral feeding tube, the position of the tip was determined using bedside transabdominal ultrasound. Native ultrasound was enhanced by injection of air bubbles into the feeding tube. The tube was regarded as being correctly positioned when the tube was visualized within the second or third parts of the duodenum. Plain abdominal radiographs with contrast served as the gold standard test. RESULTS A total of 76 consecutive examinations were analyzed. In 12 patients, access to the upper abdominal wall was not possible because of open wounds; in another 13 patients who had undergone extensive abdominal surgery, the duodenum could not be identified and so no conclusion could be reached regarding the position of the tube. In 51/76 patients (67 %) ultrasound identified the duodenum and it was possible to determine the position of the tube (46 true positives and 2 true negatives); the position was incorrectly diagnosed in three patients. The sensitivity was 96 % (95 %CI 87 % - 98 %) and the specificity was 50 % (95 %CI 36 % - 65 %), with a positive predictive value of 94 %. CONCLUSIONS Bedside sonographic control of the positioning of enteral feeding tubes is very sensitive and can be a valuable alternative to radiological control, especially in patients without open abdominal wounds, external installations, or extensive abdominal surgery.

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.

Since its introduction by Gauderer et al. in 1980, PEG has become the most widespread method of establishing enteral access. Although this technique is safe, there are well-known early and late complications. Immediate complications are a consequence of the endoscopic procedure itself and include respiratory distress, cardiac events, and esophageal injuries, e.g., perforation. During the procedure, insertion of the needle or the PEG tube may injure tissue interposed between the stomach wall and the skin. For example, damage to the colon after PEG placement has been described. The present report describes two cases of liver injury as an early complication of the PEG procedure.

Die wichtigsten Untersuchungstechniken der Gastroenterologie nebst der Schichtbildgebung sind die Sonographie und Endoskopie.

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.

In der Abklarung von Bauchschmerzen und Cholestase wird nach einer transabdominellen Ultraschallunter­suchung fast immer eine Schichtbildgebung wie Compu­tertomographie oder Magnetresonanztomographie durch­gefuhrt. Je nach Konstellation und hohem Verdacht wird anschliessend noch eine flexible obere Endosono­graphie angeschlossen. Wird dabei ein fokaler Befund gefunden, muss bis zur definitiven Klarung mittels Zytologie, Histologie oder gar chirurgischer Resektion von einem malignen Tumor ausgegangen werden. Als Diagnose finden sich dann in absteigender Haufigkeit Adenokarzinome, neuroendokrine Tumoren, Metasta­sen, Lymphome oder ein solider pseudopapillarer Tumor. Analog erwartet man bei einer symptomatischen oder asymptomatischen intra­ oder extrahepatischen Cho­lestase ein gewisses Spektrum an bekannten Erkran­kungen, je nach Kontext oder Begleiterkrankungen. Differentialdiagnostisch werden die Choledocholithia­sis, eine primar oder sekundar sklerosierende Cholan­gitis oder Tumoren der Gallenwege und/oder des Pan­kreaskopfes vermutet und entsprechend gesucht.Eine wenig bekannte neuere Entitat ist eine autoim­mune Erkrankung der Gallenwege und des Pankreas bzw. des Pankreasgangs. In der Literatur werden diese Erkrankungen zurzeit am haufigsten als IgG4­assozi­ierte Cholangitis bzw. Autoimmunpankreatitis zitiert. Ob es sich um zwei verschiedene Erkrankungen oder um eine jeweilige Variante bzw. Subgruppe einer einzi­gen Entitat handelt, ist noch nicht abschliessend geklart.Die Diagnosestellung ist von hoher klinischer Relevanz, da es sich um benigne Erkrankungen mit meist eindruck­lichem Therapieansprechen auf systemische Kortiko­steroide handelt.Exemplarisch mochten wir nun je einen Fall aus unse­rem klinischen Alltag vorstellen, um auf diese Differen­tialdiagnose zu sensibilisieren. Fall 1Ein 67­jahriger Schweizer wurde wegen Fieber und Schut telfrost zugewiesen. Die Anamnese ergab einen Status nach Cholezystektomie, eine Colitis ulcerosa in klinischer Remission und eine primar sklerosierende Cholangitis (PSC). Wegen Letzterer wurden ambulant wiederholt Antibiotika verordnet und bei Stenose in der Hepatikusgabel eine Ballondilatation mit Drain­Einlage durchgefuhrt. Die Strikturen lagen am Hilus und seriell im Ductus hepatocholedochus (Abb. 1

Zusammenfassung: Vaskulär-gastroenterologische Notfälle zählen zu den häufigen Krankheitsbildern auf internistischen und chirurgischen Notfallstationen. Die klinischen Konsequenzen reichen von trivialen bis zu lebensbedrohlichen Situationen. Nur eine frühzeitige Erkennung der Symptomenkomplexe und die Anwendung der adäquaten diagnostischen Mittel führen zur korrekten Diagnosestellung mit nachfolgend - möglicherweise lebensrettender - Therapie. Um die hohen Mortalitätsraten der akuten Mesenterialischämien (50%), aortoenterischen Fisteln (30-40%), Aneurysmen viszeraler Arterien (10-100%) sowie des Budd-Chiari-Syndroms weiter senken zu können, gewinnen neue Strategien mit endovaskulärem Therapieansatz zunehmend an Bedeutung und ersetzen teilweise über viele Jahrzehnte etablierte Diagnose- und Therapiealgorithmen. Diese Übersichtsarbeit soll einen Überblick über aktuelle Diagnostik- und Therapiekonzepte häufiger vaskulär-gastroenterologischer Notfälle verschaffen

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.

Background: Newer techniques such as mucosal resection, submucosal dissection and risky polypectomy will probably lead to increasing numbers of iatrogenic perforations. Reliable immediate closure of these lesions would increase safety and acceptance of the interventions. Methods: All acute directly observed perforations during diagnostic or therapeutic endoscopy were treated by the application of an over-the-scope clip. All consecutive patients from 2009 to August 2011 were followed in our tertiary referral center. The main outcome was technically successful closure of the perforation during endoscopy with a subsequent clinical observation for 24 h. Results: During the observation period, acute perforation occurred in 14 patients. All but 1 patient had technically successful treatment. Due to persistent abdominal pain, 3 patients had to be sent to the theater for laparoscopic evaluation after colon perforation. These 3 lesions were proven to be sealed and no resection of the colon was indicated. One patient with gastric adenocarcinoma had to be resected subtotally following endoscopic mucosal resection. Hospital stay ranged from 2 to 21 days. Conclusion: Directly observed perforations up to 30 mm diameter during endoscopy should be treated by deploying an over-the-scope clip. Endoscopists should be encouraged to be trained and to use over-the-scope clips in the stomach, duodenum and colon.

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.

Garlic extracts have been shown to decrease drug exposure for saquinavir, a P-glycoprotein and cytochrome P450 3A4 substrate. In order to explore the underlying mechanisms and to study the effects of garlic on pre-systemic drug elimination, healthy volunteers were administered garlic extract for 21 days. Prior to and at the end of this period, expression of duodenal P-glycoprotein and cytochrome P450 3A4 protein were assayed and normalized to villin, while hepatic cytochrome P450 3A4 function and simvastatin, pravastatin and saquinavir pharmacokinetics were also evaluated. Ingestion of garlic extract increased expression of duodenal P-glycoprotein to 131% (95% CI, 105-163%), without increasing the expression of cytochrome P450 3A4 which amounted to 87% (95% CI, 67-112%), relative to baseline in both cases. For the erythromycin breath test performed, the average result was 96% (95% CI, 83-112%). Ingestion of garlic extract had no effect on drug and metabolite AUCs following a single dose of simvastatin or pravastatin, although the average area under the plasma concentration curve (AUC) of saquinavir decreased to 85% (95% CI, 66-109%), and changes in intestinal P-glycoprotein expression negatively correlated with this change. In conclusion, garlic extract induces intestinal expression of P-glycoprotein independent of cytochrome P450 3A4 in human intestine and liver.

BACKGROUND AND STUDY AIMS: Bacterial contamination of endoscopy suites is of concern; however studies evaluating bacterial aerosols are lacking. We aimed to determine the effectiveness of air suctioning during removal of biopsy forceps in reducing bacterial air contamination. PATIENTS AND METHODS: This was a prospective single-blinded trial involving 50 patients who were undergoing elective nontherapeutic colonoscopy. During colonoscopy, endoscopists removed the biopsy forceps first without and then with suctioning following contact with the sigmoid mucosa. A total of 50 L of air was collected continuously for 30 seconds at 30-cm distance from the biopsy channel valve of the colonoscope, with time starting at forceps removal. Airborne bacteria were collected by an impactor air sampler (MAS-100). Standard Petri dishes with CNA blood agar were used to culture Gram-positive bacteria. Main outcome measure was the bacterial load in endoscopy room air. RESULTS: At the beginning and end of the daily colonoscopy program, the median (and interquartile [IQR] range) bioaerosol burden was 4 colony forming units (CFU)/m (3) (IQR 3 - 6) and 16 CFU/m (3) (IQR 13 - 18), respectively. Air suctioning during removal of the biopsy forceps reduced the bioaerosol burden from a median of 14 CFU/m (3) (IQR 11 - 29) to a median of 7 CFU/m (3) (IQR 4 - 16) ( P = 0.0001). Predominantly enterococci were identified on the agar plates. CONCLUSION: The bacterial aerosol burden during handling of biopsy forceps can be reduced by applying air suction while removing the forceps. This simple method may reduce transmission of infectious agents during gastrointestinal endoscopies.

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

BACKGROUND AND STUDY AIM: Capsule endoscopy is widely used for diagnosis of small-bowel disease; however, the impact of capsule endoscopy on clinical management remains uncertain. We conducted a prospective study of the impact capsule endoscopy on clinical management decisions in 128 patients with suspected small-bowel pathology. METHODS: Prior to performing each procedure the gastroenterologist predicted the findings of capsule endoscopy and further management based on the clinical history and previous investigations. This prediction was compared with the actual results of capsule endoscopy and the following investigative and therapeutic management. RESULTS: The actual findings of capsule endoscopy and the further management were consistent with clinical prediction in 93/128 patients (73 %) and, irrespective of capsule endoscopy findings, no further procedures were required in 80 % of these patients. In 13 patients (10 %), gastric or colonic pathology was discovered that had not been detected on prior gastroscopy or colonoscopy. Thus, capsule endoscopy findings in the small bowel changed clinical management in 22 patients (17 %). In 4 patients, positive findings on capsule endoscopy that had not been predicted by the examiner prompted referral for abdominal surgery. Conversely, planned surgery was canceled in four other patients. CONCLUSION: In this series of patients referred for capsule endoscopy, small-bowel findings and appropriate clinical management were predicted on clinical grounds alone in approximately three-quarters of patients. Repetition of standard upper and lower endoscopy may be useful in many patients prior to small-bowel imaging. Referral for capsule endoscopy should take into account whether the findings will impact on clinical management; however, capsule endoscopy is mandatory in patients in whom surgery for small-bowel bleeding is intended.

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.