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Whipple's disease is a systemic disorder associated with a cultivation-resistant, poorly characterized actinomycete, Tropheryma whippelii . We determined a nearly complete rRNA operon sequence of T. whippelii from specimens from 3 patients with Whipple's disease, as well as partial operon sequences from 43 patients. Variability was observed in the 16S-23S rRNA spacer sequences, leading to the description of five distinct sequence types. One specimen contained two spacer sequence types, raising the possibility of a double infection. Secondary structure models for the primary rRNA transcript and mature rRNAs revealed rare or unique features.

Beim Klippel-Trenaunay-Syndrom sind die Organe des kleinen Beckens, wie Rectum und Harnblase, selten betroffen, sie konnen in seltenen Fallen jedoch Ausgangsort fur lebensbedrohliche Blutungen werden. Wir berichten uber einen 39 jahrigen Patienten mit Klippel-Trenaunay-Syndrom der rechten unteren Extremitat und der rechten Beckenhalfte, bei dem seit Kindheit rezidivierende rectale Blutabgange bekannt sind. Zur stationaren Aufnahme zwang eine substitutionspflichtige, protrahierte rectale Blutung. Rectoskopisch zeigte sich eine vollstandig angiomatos veranderte Mucosa des Rectums und Sigmas mit Blutungsaktivitat aus mehreren Gefasconvoluten. Um einer starken intraoperativen Blutung vorzubeugen, wurde ein sequentielles Vorgehen gewahlt. Zunachst wurden die tumorversorgenden Gefase selektiv embolisiert und dann im Intervall nach 48 Std eine Rectumexstirpation unter Einbeziehung des distalen Sigmas durchgefuhrt. Bei Erhalt des Sphincterapparats wurde die Kontinenz durch eine colonpouchanale Anastomose mit protektivem Loop-Ileostoma wiederhergestellt. Der postoperative Heilungsverlauf gestaltete sich komplikationslos.

Purpose The intrahepatic “parallel channel sign” on gray-scale sonograms is generally interpreted as representing dilated bile ducts, but it may also be caused by enlargement of intrahepatic arteries. This study was performed to evaluate the incidence of misinterpretation of the parallel channel sign without color Doppler sonography and the characteristics of patients in whom misinterpretation of the parallel channel sign is likely to occur. Methods A total of 1,100 patients were examined by sonography. All patients with a parallel channel sign on gray-scale sonograms underwent color Doppler sonography. In addition, laboratory values related to cholestasis were measured. Results The parallel channel sign was observed in 57 patients (5.2%). In 35 (61%) of these patients, color Doppler sonography revealed blood flow in both lumina, indicating that the parallel channel sign was not caused by enlarged bile ducts. Eighty-six percent of this group had nonbiliary liver disease; the enlarged hepatic artery branches were associated with liver cirrhosis in 63% of this group. Color Doppler sonography confirmed that the other 22 patients (39%) had an enlarged intrahepatic bile duct. Conclusions Use of color Doppler sonography can help avoid misinterpretation of the parallel channel sign, especially in patients with nonbiliary liver disease. © 1999 John Wiley & Sons, Inc. J Clin Ultrasound 27:426–432, 1999.

Die Klassifikation entzundlicher Darmerkrankungen hat sich im Laufe des 20. Jahrhunderts kontinuierlich gewandelt. An der letzten Jahrhundertwende wurden im wesentlichen spezifisch-infektiose und unspezifische Entzundungen unterschieden. Aus der Gruppe der unspezifischen Darmentzundungen wurden dann zwei Krankheitsbilder hervorgehoben, im Jahre 1885 die „Ulcerative Colitis” und seit dem Jahre 1932 „Crohn’s Disease”. Diese beiden Erkrankungen wurden wahrend der 1970er und auch 1980er Jahre dualistisch als Chronisch-Entzundliche Darmerkrankungen (CED) zusammengefast. Inzwischen jedoch umfast der Sammelbegriff CED ein vielfaltiges Spektrum entzundlicher Darmerkrankungen mit meist definierter Atiologie. Dieser Pluralismus von CED gestattet es nicht mehr, historische Kriterien der Differentialdiagnostik anzuwenden, denn sie haben die ihnen fruher zuerkannte Spezifitat verloren. Heute gilt es, die verschiedenen chronisch-entzundlichen Darmerkrankungen (CED) mit definierter Atiologie von den idiopathischen CED abzugrenzen. Die Diagnose einer idiopathischen CU oder MC entspricht dabei letzlich einer epikritischen Ausschlusdiagnose, unter Einbezug histopathologischer und klinischer Befunde.

Helicobacter pylori infection is associated with chronic gastritis, peptic ulceration, and gastric carcinoma. The potential role of CD95-mediated apoptosis was investigated in a panel of gastric biopsies obtained from patients with H. pylori-associated chronic gastritis (n = 29) and with noninfected normal mucosa (n = 10). Immunohistochemistry revealed increased CD95 receptor expression in epithelial and lamina propria cells in chronic gastritis. By in situ hybridization, CD95 ligand mRNA was absent or low in normal mucosa but expressed at high levels in lamina propria lymphocytes and, unexpectedly, in epithelial cells in chronic gastritis. Apoptotic cells were rare in normal mucosa but were observed regularly in chronic gastritis in close proximity to CD95 ligand mRNA expression throughout the epithelial and lamina propria cells. In a functional analysis gastric epithelial cell lines were incubated with supernatants of H. pylori. Treatment with the cytotoxic isolate H. pylori 60190 but not with the noncytotoxic isolate Tx30a upregulated CD95 in up to 50% of gastric epithelial cells and induced apoptosis in these cells. H. pylori-induced apoptosis was partially prevented by blocking CD95, demonstrating the functional role of the CD95 system. These findings suggest that H. pylori-associated chronic gastritis involves apoptosis of gastric epithelial cells by activation of the CD95 receptor and ligand system.

Die Atiologie von Karzinomen, die als Spatkomplikation im Rahmen chronisch entzundlicher Darmerkrankungen entstehen, ist weitgehend ungeklart. Man darf aber davon ausgehen, das die gesteigerte Epithelproliferation bei der Reparation entzundlicher und ulzeroser Lasionen das spontane Auftreten genetisch bedingter Veranderungen begunstigt. Auch wird die malignomfordernde Nebenwirkung immunsuppressiver Therapie sowohl innerhalb als auch auserhalb des Darmtrakts unterstellt, was allerdings retrospektiv fur Azathioprin nicht nachgewiesen werden konnte. In der vorliegenden Arbeit wird uber Epidemiologie, Risikofaktoren, Atiologie, Pathogenese, Lokalisation und Morphologie von kolorektalen Karzinomen referiert. Die daraus resultierenden Empfehlungen fur die Krebsfruherkennung sind besonders wichtig. Wenn auch die tatsachliche Inzidenz Colitis-assoziierter Karzinome in den letzten 2 Jahrzehnten nicht rucklaufig ist, werden diese heutzutage jedoch in fruheren und noch limitierten Tumorstadien diagnostiziert und therapiert, was zu einer signifikanten Verbesserung der 5-Jahres-Uberlebensrate gefuhrt hat.

BACKGROUND & AIMS: Diagnostic procedures in Whipple's disease usually focus on the intestine, but symptomatic central nervous system involvement is a major threat for patients. The aim of this study was to determine the diagnostic value of cerebrospinal fluid (CSF) analysis. METHODS: A total of 39 CSF samples and 2 brain biopsy specimens that were obtained from 24 patients with Whipple's disease at various intervals after diagnosis were examined. Five patients presented with neurological symptoms, 3 of them as relapses after therapy. Thirty-two CSF samples were examined by polymerase chain reaction for Tropheryma whippelli and 20 CSF samples by cytology. Brain biopsy specimens were examined histologically. RESULTS: Positive results were obtained in 4 of 5 patients (80%) with neurological symptoms, in 7 of 10 patients (70%) without neurological symptoms examined before therapy, and in 3 of 11 patients (27%) without neurological symptoms studied during or after therapy. Conversion from positive to negative was observed in 4 patients after antibiotic treatment. CONCLUSIONS: Testing of CSF in Whipple's disease yields a high rate of positive results, even in patients without neurological symptoms. Examination of CSF is therefore potentially useful for initial staging and for monitoring of the efficiency of therapy. (Gastroenterology 1997 Aug;113(2):434-41)

Infection with Helicobacter pylori is associatedwith the development of gastric cancer. To study whetherthe infection with H. pylori strains expressing thevacuolating cytotoxin (VacA) and/or thecytotoxin-associated protein (CagA) is associated with an increasedrisk of developing gastric adenocarcinoma, sera of 90patients with gastric cancer and 90 matched controlswith cardiovascular diseases were investigated for the presence of antibodies to VacA and CagA byimmunoblot. Although no significant difference in theoverall H. pylori seropositivity was found betweencancer patients and controls, antibodies against VacA or CagA were significantly more frequent incancer patients than in control subjects. Seventyfive(97.4%) of 77 H. pylori-positive patients in the cancergroup, but only 60 (84.5%) of 71 H. pylori-positive control patients had antibodies against eitherVacA or CagA (χ2 6.63; relative risk,2.00; 95% confidence interval, 1.18–3.39; P =0.01). The presence of antibodies against VacA or CagAalone was also associated with an increased cancer risk (92.2%vs 80.3%; χ2 = 5.30; relative risk, 1.74;95% confidence interval, 1.08–2.78; P = 0.021, forVacA; and 87.0% vs 74.6%; χ2 4.90;relative risk, 1.61; 95% confidence interval, 1.06–2.45; P =0.037, for CagA). The relative risk for gastric cancerwas mainly elevated in patients under 65 years, but notin patients at or over 65 years. There is evidence that infection with VacA- or CagA-producing H.pylori strains increases the risk of developing gastriccancer, especially in younger patients.

Familial adenomatous polyposis (FAP) and idiopathic ulcerative colitis are both mucosal diseases that bear a significant risk of developing colorectal cancer. As a consequence, their surgical treatment is currently widely performed by restorative proctocolectomy with pelvic ileal pouch-anal anastomosis (IPAA). Herein we report a new case of cancer after IPAA that developed in a 33-year-old woman with FAP. Pouch-anal cancer was diagnosed 8 years after restorative proctocolectomy, including anorectal mucosectomy, for FAP with manifest cancer in the sigmoid colon. This case observation reemphasizes that the risk of cancer for FAP patients persists as long as any rectal mucosa remains after IPAA surgery.

BACKGROUND & AIMS: The uncultured Whipple's disease bacterium (Tropheryma whippelii) was characterized in 1991-1992 by polymerase chain reaction (PCR) and sequencing of the bacterial 16S ribosomal RNA gene. The aim of this study was to develop a PCR assay for diagnostic purposes. METHODS: Modified primers for PCR and a specific probe for hybridization were designed. The specificity of this PCR assay was tested using 37 bacterial control strains and intestinal biopsy samples from 16 patients without Whipple's disease. The sensitivity was tested in 88 intestinal biopsy samples from 35 patients with Whipple's disease. RESULTS: PCR and hybridization were negative in all 37 bacterial controls and in all 16 patients without Whipple's disease. Before therapy, DNA of T. whippelii was detected in all 30 patients with Whipple's disease from whom formalin-fixed biopsy material was available, whereas Bouin-fixed material was negative. During and after treatment, PCR was negative in 23 of the 24 patients who were followed up. Generally, conversion to negative occurred within 1 year. Despite negative intestinal PCR, symptomatic cerebral Whipple's disease appeared in 3 patients. CONCLUSIONS: This PCR assay is specific and sensitive and is applicable as a diagnostic test. However, PCR from intestinal biopsy samples seems less helpful for monitoring the effect of treatment. (Gastroenterology 1996 Jun;110(6):1735-43)

Several small studies have indicated an impaired cell mediated immune response as a possible cause for the delayed elimination of the bacteria in Whipple's disease. A specific defect, however, has not been defined. We examined the expression of cell surface molecules and mitogenic responses of peripheral blood mononuclear cells in 27 patients with Whipple's disease at different disease stages by indirect immunofluorescence and by measurement of [3H]thymidine incorporation, respectively. E-rosette formation and cutaneous reaction to seven recall antigens were determined. Matched healthy donors served as controls. We found a significantly reduced number of cells expressing the complement receptor 3 αchain (=CD11b) in all patients. In florid disease, the number of activated cells (in particular CD58 positive cells) was increased and CD4/CD8 ratios were diminished. Proliferation to phytohemagglutinin and to sheep red blood cells was reduced at all stages of the disease. Serum of control persons reversed this decreased responsiveness especially in patients with active disease. Skin reaction was hypoergic in all patients. Determination of CD58 positive cells increased in patients with active disease may be useful to define the activity of the disease and the duration necessary for treatment. Transient inhibiting serum activities may impair the CD2/CD58 interaction. The reduction of cells expressing CD11b, the decreased proliferation, and the cutaneous hypoergy indicate a persisting defect of cell mediated immunity in vivo and in vitro. These defects may contribute to the impaired ability of patients with Whipple's disease to eliminate bacteria.

The RRR-alpha-tocopherol (vitamin E) content in plasma from 46 patients with liver diseases and 23 healthy controls was determined by high performance liquid chromatography and electrochemical detection. Patients were divided into three groups: alcoholic liver diseases (n = 17; group A), hemochromatosis (n = 17; group B) and Wilson's disease (n = 12; group C). Lipid-standardized alpha-tocopherol levels were determined to neutralize differences due to hyperlipemia. The ratio of serum vitamin E to serum lipids (cholesterol, triglycerides, phospholipids) was highest in healthy controls and in patients in group A with cirrhosis and normal transaminases and bilirubin. Patients in group A with acute or chronic ethanol intoxication and high bilirubin levels had a 37% lower lipid-standardized vitamin E level than controls. Patients in group B with hemochromatosis, showing high serum iron (180 micrograms/dl), a low free iron binding capacity (8 mumol/l) and high ferritin-levels (450 micrograms/l), had a 34% lower vitamin E/lipid ratio than healthy controls. No significant lowering of the vitamin E/lipid ratio was observed in the other patients in group B. A significant decrease (37%) in the vitamin E/lipid ratio was only detectable in patients with Wilson's disease (group C) showing high free serum copper (10 micrograms/dl). The data support a role for free radicals in the pathogenesis of active liver diseases.

Due to their adjuvant effect and their ability to chaperone tumor-associated peptides, heat shock proteins constitute a potent alarm signal for the immune system and can lead to activation of anti-tumor T-cell immunity. Radiofrequency ablation has been reported to induce heat shock protein expression especially that of heat shock protein 70 in sublethally damaged tumor cells. In this study, we evaluated the release of heat shock protein 70 into the serum of cancer-bearing patients directly after radiofrequency ablation. Sera of 22 patients undergoing radiofrequency ablation for the treatment of primary and secondary malignancies of the liver, kidney, and lung, as well as control sera of 20 patients undergoing diagnostic liver biopsy were analyzed using a manufactured heat shock protein 70 ELISA. A significant increase in serum levels of heat shock protein 70 was detectable in the patient cohort 1 day after radiofrequency ablation. More than a twofold increase was observed in nine out of 22 patients, which tended to correlate with favorable clinical outcome. No patient of the control group revealed a comparable increase. Radiofrequency ablation can lead to a release of heat shock protein 70 into the serum, which is transiently detectable 1 day after treatment. Elevated heat shock protein 70 serum levels may constitute a biomarker for favorable clinical outcome.

The authors describe an atypical case of Kawasaki disease in a 9-month-old girl who presented with fever, coronary artery aneurysms, and acquired ischemic stricture of the proximal jejunum. Histology of the surgical specimen was consistent with mesenteric vasculitis. The infant had only some of the typical clinical signs of Kawasaki disease, suggesting that an atypical or incomplete form of the disease was present. To the best of the authors' knowledge this is only the third case to be reported of incomplete Kawasaki disease associated with ischemic bowel stricture. J Pediatr Surg 36:648-650. Copyright © 2001 by W.B. Saunders Company.

Background Esophageal full-thickness wall repair is an important but unsolved issue in endoscopy. It is unknown how well endoscopic clip closure (ECC) and endoscopic closure with suturing (ECS) perform compared with the criterion standard of thoracoscopic closure (TC). Objective Comparison of technical success, feasibility, long-term patency, complications, and histological quality of the different closure techniques (ECC, ECS, TC) for esophageal perforations. Design Comparative animal study. Setting Approved animal facility. Subjects Eighteen pigs. Interventions Eighteen pigs were randomized, 6 each into 3 groups (ECC, ECS, TC). After endoscopic wall incision and mediastinoscopy, closure was performed by using 1 of the 3 techniques. After 8 to 12 weeks, pre-euthanasia endoscopic, necropsy, histological, and morphometric analyses were performed. Main Outcome Measurement Long-term survival and histological quality of the repair. Results The closure of the esophageal incisions was successful in all pigs. On days 2 and 6, 1 animal died of mediastinitis, 1 in the ECS group because of reflux of gastric contents into the mediastinum before the repair and 1 in the TC group because of leakage of the sutured closure ( P = 1.0). No strictures were seen on prenecropsy endoscopy. At necropsy, 1 mediastinal abscess was found in an ECS animal ( P = 1.0). Minor complications included periesophageal adhesions and reactive lymph nodes in 3 of 6 (ECC group) and 5 of 6 (TC and ECS groups). Histology showed muscle layer defects up to 12 mm in width and 21 mm in length, with a trend toward smaller defect size of width and length in the ECS group of animals. Limitations Animal study of limited size. Conclusions Overall, ECS and ECC performed similarly to TC. ECS showed the smallest histological defects in the long-term repair.

Tenascin is a fibroblast product and extracellular matrix protein probably excerting a fibronectinantagonizing role. Tenascin is broadly distributed interstitially during embryogenesis but restricted to a small range of structures in normal adult tissues. Using tenascin antibodies and an indirect immunoperoxidase method, normal colon, colitis, colon adenomas, and colorectal carcinomas were examined for tissue distribution of tenascin. Normal mucosa displayed a sparce meshwork of microfibrillar tenascin in the lamina propria. The basement membrane was tenascin negative at the bottom of the crypt and developed into a positive band steadily broadening towards the mucosal surface. In colitis, this polarity was effaced; the basement membrane was a broad tenascin-positive band nearly throughout while interstitial tenascin was moderately increased. Loss of polarity in tenascin content of the basement membrane was a constant feature of adenomas, inconsistently paralleled by structural alterations in surface qualities and continuity of tenascin pattern of the basement membrane. These were most pronounced in carcinomas, where this interface was often discontinuous and had a rough surface; in addition, interstitial tenascin was considerably increased. In carcinomas, the rough surface aspect of the tenascin pattern of the basement membrane was correlated with presence of lymph node metastases (P = 0.04). It is concluded that alterations in tenascin pattern and content reflect complex disturbances in the interaction of inflamed/neoplastic colon epithelium and underlying matrix, leading to an organoid induction of tenascin in the inflammatory context and to induction together with structural abnormalities in neoplasia.

AIM: The aim of our study was to evaluate the diagnostic value of Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions in a prospective multi-center study in clinical practice. For this purpose CEUS was compared with the spiral-CT (SCT), the standard radiological method. MATERIAL AND METHODS: 1349 patients with unclear liver lesions after fundamental ultrasound diagnostics including color doppler analysis were examined with standardized CEUS (pulse inversion method, mechanical index < 0.4) from May 2004 to December 2006 in 14 hospitals in a prospective study. The enhancement of contrast medium in the liver tumors was analyzed according to known tumor-specific vascular patterns, using standardized documentation and analysis methods for the differentiation of tumor differentiation (malign or benign) and tumor specification (entity). A subcollective of 267 patients was additionally examined by standardized SCT method. Final diagnosis was based on histology, SCT or MRI in typical findings of liver hemangioma and FNH and on proved clinical data and additional follow up. RESULTS: The subcollective of 267 patients was divided in two subgroups. In 109 of these patients (subgroup A) there was no histological verification, diagnoses based on clear SCT-findings in 79 cases of hemangioma or FNH, as well as in 20 cases with a clear clinical diagnosis. 6 cases (5.5 %) remained unclear. In this subgroup the assessment of tumor differentiation was concordant with CEUS in 90 cases, discordant in 19 cases and the assessment of tumor specification was concordant in 82 and and discordant in 27 cases. In 158 patients (subgroup B) a histological finding was also present, only in 4 cases no definitive tumor diagnosis was achieved. In this subgroup assessment of tumor differentiation with CEUS and SCT was concordant in 124 cases and discordant in 30 cases (CEUS/SCT: sensitivity 94.0 / 90.7 %, specificity 83.0 / 81.5 %, PPV 91.6 / 91.5 %, NPV 87.5 / 80.0 %, accuracy 90.3 / 87.8 %). Tumor specification matched in 103cases and were different in 51 cases (CEUS/SCT: sensitivity 95.3 / 90.6 %, specificity 83.7 / 81.6 %, PPV 92.7 / 91.4 %, NPV 89.1 / 80.0 %, accuracy 91.6 / 87.7 %). A statistically significant difference could not be established. The analysis of particular tumor specification showed a statistically non significant slight advantage in tumor differentiation for CEUS in the case of hemangioma, FNH, HCC and metastases. CONCLUSION: In a multi-center approach under routine clinical conditions, this prospective study demonstrates CEUS to be of equal rank to the CT-scan in regard to the assessment of tumor differentiation and specification. No statistically significant differences could be established. CEUS should be employed before computed tomography is performed for the differentiation of liver tumors, because radiation exposure and invasive biopsies can be avoided in veritable numbers of cases, when precise clinical evaluation of the findings is implemented.

Purpose. The aim of the study was to investigate the ability of contrast-enhanced sonography (CEUS) with the contrast agent SonoVue to differentiate between benign and malignant focal liver lesions. Methods. In a prospective study, we examined 317 patients (204 males, 113 females, aged 59 ± 12 years) with focal liver lesions detected by B-mode gray-scale sonography. After intravenous injection of 1.2 mL SonoVue, the liver was examined continuously for 3 minutes using low-MI sonography with contrast-specific software. Final diagnosis was established by histopathology, CT, MRI, or HIDA-scintigraphy. Results. Two hundred nine patients had malignant focal lesions, including 107 hepatocellular carcinomas, 70 metastases, 26 cholangiocellular carcinomas, and 6 other types of malignancy. One hundred eight patients had benign focal lesions, including 30 regenerative nodules, 30 hemangiomas, 13 cases of focal nodular hyperplasia, 12 abscesses, 8 cases of necrosis, 7 cases of focal steatosis areas, and 8 other benign lesions. Hypoenhancement or no enhancement in the late phase was found in 91% of the malignant lesions but in only 37% of the benign lesions (p < 0.001, sensitivity = 64%, specificity = 93%). Hyperenhancement in the late phase was found in 20% of the benign lesions but in none of the malignant lesions (p < 0.001, sensitivity = 21%, specificity = 100%). Hyperenhancement in the early phase with diffuse complete enhancement was found in 30% of the patients with malignant lesions but in only 2% of the patients with benign lesions (p < 0.001, sensitivity = 30%, specificity = 98%). CEUS had a sensitivity of 90%, a specificity of 99%, and an accuracy of 89% in the diagnosis of malignant liver lesions. Conclusion. CEUS is helpful in the differentiation between benign and malignant focal liver lesions. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2010

Hintergrund: Colorectale Carcinome sind gut bekanntermasen eine mogliche langfristige Konsequenz einer Colitis ulcerosa (CU). Sie entstesthen bei etwa 10–15% der CU Patienten. Das Risiko fur ein CU associziiertes Carcinom im Ileum, entweder im terminalen Ileum oder einem Ileum-Pouch, ist weit weniger gut charakterisiert. Methoden und Patienten: Wir analysierten eine Serie von 652 konsekutiven CU Patienten, welche zwischen 1984 und 2005 operiert wurden. Deren Operationsprarate des Dickdarms und Ileums wurden umfangreich histopathologisch untersucht (Median: 18 Paraffinblocke je Colectomie), speziell im Hinblick auf Dysplasien und Carcinome. Ergebnisse: Bei insgesamt 69 CU Patienten wurde ein colorektales Adenocarcinom diagnostiziert (Pravalenz in unserer Serie: 11%). Bei vier CU Patienten (2Manner, 2 frauen; Alter 28–49 Jahre) lag ein Adenocarcinom des Ileums vor (Pravalenz: 0,6%). Ein Patient (#1) hatte ein primares Carcinoma im terminalen Ileum als Komplikation seiner CU mit retrograder Anschlussileitis; synchron hatte er multifokale Dysplasien in Colon, dort jedoch kein Carcinom. Bei drei Patienten (#2, #3, #4) entstand ein Carcinom in einem Ileum-Pouch. Zwei von ihnen hatten eine Anamnese von fruherer Dysplasie im Rektum, bei beiden trat das Carcinom 3–4 Jahre nach restaurativer Proktocolektomie an der Ileum-Pouch-Analen Anastomose auf, und einer (#3) hatte ein weiteres Carcinom im Corpus des J Pouch. Ein Patient (#4) hatte ein Adenocarcinom an der Anastomose eines omega-formigen Ileumpouches zu einem kurzen Rest des Rektums, 10 Jahre nach seiner restaurativen Colektomie. Diskussion: Das Risiko fur ein CU assoziiertes intestinales Carcinom reicht uber das Colon und Rektum hinaus – auch in das Ileum hinein. Disponierend ist dafur ist eine Retrograde Anschlussilieits. Das Vorliegen eines Dysplasie im Rektum scheint ein Risikoindikator fur die spatere Entwicklung eines Ileumcarcinoms im Pouch zu sein.

Pulmonary tumor thrombotic microangiopathy is characterized by fibrocellular intimal proliferation of small pulmonary arteries and arterioles in patients with metastatic carcinoma. Its morphologic features, including precursor lesions, were studied in 21 patients diagnosed in 630 consecutive autopsy cases with carcinoma (3.3%). Nineteen of 21 patients had adenocarcinoma and 11 of these 19 patients had gastric carcinoma. The pathogenetic events start with microscopic tumor cell embolism. Tumor emboli do not occlude affected vessels but induce both local activation of coagulation and fibrocellular intimal proliferation, which lead into stenosis or occlusion. Hemodynamically, an increase in vascular resistance results in pulmonary hypertension. In three patients, metastatic carcinoma was unknown before death, and the condition was diagnosed as pulmonary hypertension of unknown origin. Thus, pulmonary tumor thrombotic microangiopathy should be considered in the differential diagnosis of primary pulmonary hypertension, particularly in patients with well-known carcinoma who develop acute or subacute cor pulmonale.

BACKGROUND AND STUDY AIMS: Natural orifice transluminal endoscopic surgery (NOTES) within the peritoneal cavity is rapidly evolving, using transgastric, transcolonic, or transvaginal access. There is little experience with transesophageal NOTES access to the mediastinum. This prospective long-term animal survival study was performed to explore the feasibility and safety of transesophageal intrathoracic procedures including minor surgery. MATERIAL AND METHODS: Nine pigs were used for acute (n = 2) and up to 6-week survival studies (n = 7), followed by autopsy and histological investigation. The esophageal incision site was chosen using EUS; this was followed by endoscopic mediastinoscopy and therapeutic procedures such as mediastinal lymph node removal, saline injection into myocardium, and pericardial fenestration. The wall was closed using a suturing system or endoscopic clips. RESULTS: No acute complications were recorded with respect to mediastinal structures, pericardium, cardiac rhythm, or circulatory parameters. Removal of small mediastinal lymph nodes (n = 2) was feasible, but proved to be difficult. Other procedures, specifically at the heart were all successfully performed. Endoscopy after 4 - 6 weeks showed a well-healed esophageal incision. Autopsy with histology revealed no signs of mediastinitis, infection, bleeding, or pericarditis. The esophageal scar was found to be well healed in all cases, but with a muscular gap where clip closure had been used. CONCLUSIONS: Transmural esophageal incision and endoscopic partial mediastinoscopy including therapeutic procedures on the heart or mediastinum proved feasible in long-term survival animal studies. Clip closure of the defect was effective, but did not close the esophageal muscle layer. Other means such as endoscopic suturing appear to be preferable.

SonoVue and Levovist (SH U 508A) are both ultrasound contrast agents, which are helpful in characterization and detection of malignant liver lesions. This study was performed to compare both contrast agents according to the capability to diagnose hepatocellular carcinoma (HCC).In a prospective study, 65 patients with histologically proven hepatocellular carcinoma (HCC) were examined with both, Levovist and SonoVue. In all patients HCC lesions had been detected by B-mode sonography before the study start. After injection of 2.4 ml SonoVue i. v., the liver was examined continuously for up to three minutes using "low MI"-pulse inversion sonography. For the Levovist-examinations 2.5 g Levovist were injected i. v. After a delay of at least 2.5 minutes without scanning, the liver was examined with three different scans using "high-MI"-pulse-inversion sonography.The examination was technically sufficient in 98% after SonoVue-injection and in 92% after Levovist-injection (n. s.). Comparison of the results was performed for the 60/65 patients (61 lesions), in which both methods were technically sufficient. After SonoVue-injection contrast-enhancement in the arterial phase was found in 79% (48/61) of the lesions. Demarcation of the HCC-lesion in the late phase was found in 89% of the SonoVue-examinations and in 98% of the Levovist-examinations (p0.05). Early SonoVue-enhancement and/or demarcation in SonoVue late-phase was found in 93% of the HCC-lesions (n. s. compared to Levovist-late phase).Levovist-late phase has a higher sensitivity in predicting lesion dignity of HCC-lesions compared to SonoVue-late phase, but not compared to combination of SonoVue-early phase and late phase.

Cardiac involvement in Whipple's disease is well established. However, clinical consequences beside antibiotic therapy have rarely been reported. Our observation of a middle-aged man with increasing dyspnea, fatigue, chest pain, and dizziness leading to admission to a cardiology department demonstrates that cardiac symptoms may represent the main symptoms in patients with Whipple's disease. The diagnosis was not made prior to upper endoscopy, performed because of diarrhea, and revealed Whipple's agent now classified as Tropheryma whippelii, which is a PAS-positive rod-shaped bacterium in the macrophages of the intestinal lamina propria. The aortic valve was replaced after the intestinal symptoms were resolved by antibiotic treatment reducing the number of infectious agents in the duodenal mucosa. Histological analysis of the aortic valve demonstrated the presence of PAS-positive rod shaped material as the most likely cause of aortic insufficiency. Five months after valve replacement, the patient had completely recovered from intestinal and cardiac symptoms. Still under antibiotic treatment 16 months later, no more PAS-positive macrophages were detectable in the intestinal mucosa.

The diagnosis of ischemic injury by B-mode-sonography is difficult in many cases. Aim of the pilot-study was to evaluate whether additional examination with the ultrasound contrast agent SonoVue could improve the sonographic diagnosis of ischemic injury.In a prospective study, intra-abdominal organs (n = 12) with ischemic lesions found by CT-scan were examined. All ischemic organs were examined by native B-mode-sonography and after injection of 1.2 ml SonoVue i. v. The SonoVue-examinations were performed using the CPS-software (Siemens, Erlangen).Native B-mode-sonography detected demarcation of ischemic lesions in only 7 of the 12 organs. In contrast, SonoVue-enhanced sonography diagnosed ischemic lesions in all organs. In one patient with renal infarction, however, the ischemic lesion found by SonoVue-enhanced sonography was smaller compared with the CT-scan. The diagnosis "compatible with ischemia" as cause for the abnormalities in B-mode sonography was described in only 3 out of 12 organs, and none of the organs were classified as "definite diagnosis of ischemia". In contrast, the diagnosis "definite diagnosis of ischemia" was made in 10 of the 12 organs when examined with SonoVue-enhanced sonography. In two further patients, the lesion was classified as "compatible with ischemia". In these patients, the diagnosis of ischemia was verified by CT-scan, due to the accompanying subtotal splenic infarction and a partial thrombosis of the coeliac trunc.It became evident that SonoVue-enhanced sonography was more sensitive in the diagnosis of ischemic injury than native B-mode sonography.