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In 14 cholecystectomized patients with recurrent attacks of pain endoscopic manometry of the c.b.d. was carried through after thorough exclusion of organic diseases. Two different conspicuous types of pressure behaviour became evident: In 8 pat. the pressure in the c. b. d. increased steadily during perfusion and finally triggered pain, identical to the spontaneous one according to localization and character. In 6 pat. even after prolonged perfusion no pain emerged and the c. b. d.-pressure remained unchanged. As the increase in c. b. d.-pressure connected with provocation of pain was reproducible, perfusion manometry in the c. b. d. seems to be a mean of delimitating and objectifying functional disturbances of the bile duct.

A survey is given on indications, results and complications of the deep duodenoscopy and endoscopic retrograde cholangiopancreaticography. The endoscopic retrograde pancreatography is indicated in the chronic forms of pancreatitis, in suspicion to cysts of the pancreas or tumours. Its results have a decisive influence on the indication to surgical procedure and on the planning of the intervention. The endoscopic retrograde cholangiography is of greatest practical significance for the differential diagnosis of the cholestatic icterus: non-obstructed bile ducts exclude an extrahepatic icterus and render a laparotomy useless. Furthermore, the endoscopic retrograde cholangiography is indicated when the demonstration of the duct is intravenously insufficient, when papillary or prepapillary narrowings are present and in the etiologically unclear syndrome of postcholecystectomy. The most dangerous complications of the endoscopic retrograde pancreatography are the acute pancreatitis and the infection of cysts. Cholangitides and septicaemias appear after the endoscopic retrograde cholangiography only in such cases when obstructions of the drainage are present.

pH was measured continuously in the lower duodenum before and 90 min after a standard meal in 15 controls and 13 patient with severe pancreatic insufficiency (PI); gastric acid secretion was unimpaired in all of them. 7 out of the 13 pat. with PI received additionally 30 ml of an A-Mg-silicate preparation (MegalacR) 45 min after the meal. Mean pH dropped after the meal from 6.9 to 6.2 in the controls and from 7.1 to 4.9 in the pat. with PI. The overall time of pH-values below 5 amounted to 0.5% of the measuring period in the controls, in PI-pat. to 35%. In pat. with PI there were additionally pH-values below 4 during 11% of the postcibal period. Antacid administration increased duodenal pH significantly but only over 15 min; this transient effect had, however, no significant influence on the overall time of the pH-values below 5 and 4. Al-Mg-silicate has obviously no relevant effect on the postcibal duodenal pH in pat. with PI and can therefore not be regarded as a means to prevent inactivation of pancreatic enzymes in the duodenum.

During the last years the endoscopic perfusion manometry developed many new recognitions about the courses of pressure and motility at the sphincter Oddi. The clinical and experimental application of the method concentrated itself to the proof of functional disturbances. Many results are contradictory and a whole series of questions is unsolved. The own investigations concentrated themselves on pressure measurements in the common bile duct in patients with removed gallbladder, in whom by comprehensive diagnostic measures no organic disease of the biliary tract could be found. Two groups of patients were compared. Patients of group 1 (n = 14) had no biliary symptoms after cholecystectomy. The patients of the second group (n = 20) continued to have biliary complaints after cholecystectomy, or they again occurred after symptom-free interval. At the beginning of the investigation the pressure in the common bile duct was the same in the two groups. In group 1 the pressure remained constant also during the manometry and the patients remained without any complaints. However, in group 2 a gradual increase of pressure and biliary complaints developed during manometry. These occurred after an average pressure increase of 8 Torr. The velocity of the increase of pressure well correlated with the intensity of the complaints. The symptoms during manometry were identical with those cited in the anamnesis. The pressure increase in the common bile duct is regarded as an expression of a functional disturbance of the sphincter of Oddi. The constant perfusion rate (1.3 ml/min) in this group of patients is sufficient as volume load, in order to detect a disturbed drainage capacity of the papilla. On its part the increase of the pressure is responsible for the evocation of the complaints.

A survey of pathogenesis, pathobiochemistry, pathological anatomy, clinic, diagnostics and therapy of the Zollinger-Ellison-syndrome is given. The Zollinger-Ellison-syndrome is, it is true, relatively rare, but its limitation from the usual peptic ulcer has great practical consequences. The suspicion of a Zollinger-Ellison-syndrome is aroused by therapy-resistent ulcers, which in every third person are associated with a diarrhoea, by recidivations of ulcer after gastric operations and by a large basal secretion of acid. The decisive diagnostic means is the serum gastrin determination. The only promising therapy is, as a rule, the gastrectomy.

According to current knowledge biliary (gallstone-associated) acute pancreatitis is induced by transient obstruction of the papilla by migrating gall stones. It seems, therefore, rational to remove the occluding stone as early as possible by endoscopic papillotomy (EPT). Uncontrolled studies have shown that patients with acute pancreatitis are not more endangered by EPT than those without pancreatitis and that the intervention seems to beneficially influence the course of the pancreatic disease. Early endoscopy (within 48 h), however, revealed incarcerated papillary stones only in 10% but common bile ducts free of stones in 24%. There seems to be only a small subgroup with acute biliary pancreatitis who might benefit from early EPT. This subgroup should be characterized more precisely. Early EPT indiscriminately performed in any kind of acute pancreatitis has little rational ground and is, up to now, not justified.

In 104 patients with longstanding abdominal pain of unknown origin endoscopic pancreatography was carried through after a thorough noninvasive exploration (Secretin-CCK-test included). Pancreatography revealed in 18% slight but distinct-pathological changes at the pancreatic duct system compatible with chronic pancreatitis. As the frequency of the pathological pancreatographic findings showed no correlation with duration of pain history but a significant correlation with age it is suggested that the duct changes encountered represent rather age-dependent irrelevant fibrosis of the pancreas tan clinically relevant chronic pancreatitis. Slight pathological duct changes are by themselves no proof of chronic pancreatitis because there is no possibility to discriminate between chronic pancreatitis and age-dependent fibrosis on the ground of pancreatography. ERP therefore is of little or no value in patients with otherwise insubstantial suspicion of chronic pancreatitis.

During the last years the non-surgical drainage of the bile ducts developed to an efficient treatment method and is a real enrichment in the concept of treatment of the malignant obstruction of the bile ducts. In no more radically operable carcinomas in the area of the bile ducts, the pancreas or the porta of the liver it is to be preferred to a palliative drainage operation. In case the drainage of the bile ducts shall not be used therapeutically (through-drainage), an inner drainage in form of an endoprosthesis should always be preferred. As a procedure of the 1st choice the endoscopic retrograde technique is recommended, as procedure of 2nd choice the percutaneous transhepatic technique. Benign basic diseases are more infrequently the reason for the insert of a bile duct drainage. The main indications are general inoperability in non-extractable calculi in the common bile duct. In our own cases patients could be followed up up to 3.5 years. No complications were observed. The occlusion of prostheses does apparently not play a role.

Eight male patients with compensated congestive cardiomyopathy received single 300-mg doses of intravenous quinidine by 15-min infusion. Left ventricular (LV) performance was evaluated by echocardiography at multiple points in time during the next 24 h. Quinidine kinetics and protein binding were determined from multiple serum samples drawn for up to 36 h after dosage. LV function was not impaired. Instead, quinidine transiently increased ejection fraction (mean: +39%) and rate of circumferential shortening (mean: +46%). Endsystolic and end-diastolic LV internal diameter likewise were decreased (means: -13% and -7%). Blood pressure and ventricular rate were not significantly altered. Compared to 8 healthy controls matched for age, sex, and weight, quinidine volume of distribution among patients was smaller (means: 2.27 vs 1.90 l/kg), as was total quinidine clearance (3.49 vs 2.84 ml/min/kg); however, differences were not statistically significant. Well-controlled, slow intravenous infusion of quinidine does not impair LV performance and is safe for patients with compensated congestive cardiomyopathy. However, such patients may have reduced quinidine clearance and hence require lower doses than expected based on age and weight.

In 62 cadaver-donor-allograft recipients we observed 11 times gastrointestinal complications 7 times (11%) an ulcer or an erosion of the mucous membrane could be secured gastroscopically. The therapeutic remedy of choice seems to be the well-timed 2/3-resection after Billroth II, since a too long hesitation increases the number of complications, has a negative influence on the choice of the intervention and increases the lethality.

Defects of the ANF system in cirrhosis have not been demonstrated in terms of absolute deficiency of plasma levels or by evidence of major abnormalities of processing in patients with cirrhosis. In the present study, the responsiveness of the ANF system to acute volume stimulation by water immersion and the diuretic and natriuretic effects of ANF infusion were examined. Stimulation of ANF release by 1-h immersion was significantly blunted in ten cirrhotic patients with ascites (increase of plasma ANF by 46 +/- 18%), whereas 11 cirrhotics without ascites showed a 104 +/- 16% increase, similar to the 117 +/- 29% stimulation in 25 healthy controls. Immersion increased urinary volume by 3.6 +/- 0.6/2.0 +/- 0.8/0.7 +/- 0.4 ml/min and urinary sodium excretion by 146 +/- 38/75 +/- 43/43 +/- 19 mumol/min in controls/cirrhotics without/cirrhotics with ascites. Infusion of ANF for 30 min prompted an increase in diuresis and natriuresis in seven cirrhotic patients, which was less marked in patients with ascites, as compared to patients without ascites. Thus, the stimulus response coupling for ANF may be impaired in patients with cirrhosis and ascites.

By histological examination of the exocrine pancreas a triphasic reaction was proven in 46 rats of a wistar strain 1 hour up to 8 weeks after a transduodenal intraductal instillation of an alcoholic amino acid solution (Ethibloc). The first phase, due to both the incorporated substance by itself and an acutely increased intraductal pressure, consists in an interstitial edema with transition into a perilobular pancreatitis, a cytotoxic damage of the acinar and ductal epithelium with focal necrosis of parenchyma and fat-tissue, a sialangiitis and foreign body granulomas. In a second phase, produced by the occlusion of the duct system, a cystofibrosis of the lobuli developed within 7 to 14 days after a preceding hyperplasia and ectasia of intercalated ducts and an atrophy of acini. In a third phase of pancreas injury, starting at the 14th day of experiment, in non-atrophied lobuli a progressive intralobular, supposed autoimmunological, pancreatitis developed. Changes in the activity of serum lipase and -amylase correlated strongly with the morphological findings. The results suggest that at last a nearly complete burnout of the normal rat pancreas is possible by duct occlusion. But for the clinical application the danger of provocation of an acute relapse of chronic pancreatitis might be given by the presence of a secreting parenchyma.

In 36 patients with ulcer without Zollinger-Ellison-syndrome (25 patients with recurrent duodenal ulcer, 11 with an ulcus pepticum jejuni after B II-resection of the stomach) and 2 patients suffering from ulcus pepticum jejuni with an ascertained gastrinoma the secretion of acid was compared after stimulation of pentagstrin (6 mug/kg) and calcium (4 mg Ca++/kg/h). The secretion of hydrochloric acid was statistically significantly stimulated in all patients suffering from ulcer by the hypercalcaemia (increase of the serum calcium concentration from 5.0 +/- 0.3 mval/1 to 6.2 +/- 0.8 mval/1). But in patients suffering from ulcer with gastrinoma the stimulatory effect was larger than in such patients without autonomous source of gastrin: the calcium-stimulated secretion of hydrochloric acid was on the average in cases of duodenal ulcer 40% (2 to 68%), in the ulcera peptica jejuni 47% (17 to 75%), in the 4 comparative examinations of the two patients with Zollinger-Ellison-syndrome, however, always more than 100% (106 to 177%) of the pentagastrin-stimulated peak secretion. The comparative test of the pentagastrin and calcium-stimulated secretion of hydrochloric acid could be a help for the proof of autonomous places of the formation of gastrin.

First results of endoscopic papillotomy and biliary drainage in patients with Billroth II gastrectomy are presented. For endoscopic papillotomy and removal of gall stones a home-made papillotomy and a side viewing endoscopy were used. The technique for biliary drainage in patients with Billroth II gastrectomy and normal stomach is identical.

The deep duodenoscopy serves for the endoscopico-bioptic clarification of radiologically unclear findings distally from the bulb (niches, sockets, stenoses) and of the positional relations between diverticulum and papilla. As a rule, it is connected with an endoscopic retrograde cholangiopancreaticography (ERCP). The endoscopic retrograde pancreaticography is indicated in relapsing chronic pancreatitis for proving or excluding of changes needing operation which are taken into consideration as partial factors of the relapsing course as well as in suspicion to a local pancreatitis complication and carcinoma of the pancreas. The endoscopic retrograde cholangiography is a decisive aid for the differentiation of the cholostatic icterus. It improves the diagnostics of complaints after operative interventions at the system of the biliary ducts, facilitates the diagnosis of the papillary stenosis and is indicated in insufficient conventional contrasting the biliary ducts. The complications (pancreatitis, cholangitis, cystic infection) have become rare with increasing experience. Contraindications are the florid pancreatitis and cholangitis.

The most important requirement for satisfactory transperitoneal dialysis is faultless functioning of the Tenckhoff catheter. Suddenly occurring functional disturbances are often caused by wrong positioning and by envelopment of the catheter by tissue, which require surgical correction. A technique for successfully locating and replacing a transperitoneal catheter by means of an operation laparoscope is described.

A survey of the modern importance of the secretion test of the stomach for diagnostics and differential diagnostics of the gastroduodenal ulcer, for an individualising surgery of the stomach and for the testing of the success in vagotomy is given. In the epoch of the fibre endoscopy the secretion test can scarcely still contribute to the diagnostics of ulcer, but it is now as ever important as screening method for the differentiation of the Zollinger-Ellison-syndrome. The decision on the size of an individual surgical intervention for the treatment of the peptic ulcer should also be based on the result of the secretion test. The usual control of the success of vagotomy by means of the insulin test has its problems.

Plasma concentrations of 5-(2-chlorophenyl)-7-ethyl-1,3-dihydro-1-methyl-2H-thieno[2,3-e][1,4]diazepin-2 -one (clotiazepam, CTZ, Trecalmo), a thienodiazepine anti-anxiety agent, and two of its metabolites (hydroxy- and desmethyl-clotiazepam) are reliably quantified by electron capture GLC. After addition of diazepam as internal standard, 1-ml plasma samples are extracted with benzene-isoamyl alcohol (98.5:1.5). The organic extract is evaporated to dryness, reconstituted, and directly chromatographed using a 3% SP-2250 liquid phase at 260 degrees C. Sensitivity limits are 1-3 ng of each of the 3 compounds per ml of plasma. The method is applicable to clinical pharmacokinetic studies in humans. After p.o. ingestion of a single 5-mg dose of clotiazepam by three healthy volunteers the drug was rapidly absorbed. Values of elimination half-life were 6.5, 7.0, and 17.8 h, respectively. The two metabolites appeared and disappeared approximately in parallel with the parent compound. Clotiazepam was more than 99% bound to plasma protein.

In the clarification of circumscribed processes in stomach and duodenal bulb radiodiagnostics and endoscopy supplement themselves in an ideal way. The endoscopy seems to have advantages in recognition and explanation of findings on the cardial and subcardial parts of the stomach as well as on the operated stomach. Deformation of the duodenal bulb and changes of the post-stenotic parts can be better judged radiologically. The complete healing of an ulcer is exactly recognisable only by means of endoscopy. Linear ulcers are often not to be seen in radiodiagnostics. With the help of the aimed biopsy the decision on benignity or malignity of the ulcerating process has become easier. Every radiologically not certainly explainable findings and every discrepancy between X-ray picture and complaints of the patients should bring about an endoscopic examination.

Inoculation of the right hind paw with Mycobacterium butyricum rapidly led to swelling and inflammation. The afflicted limb showed an enhanced sensitivity to noxious pressure (hyperalgesia) and a reduced sensitivity to noxious heat 24 h following treatment. Both naloxone and MR 2266 (which has greater activity at kappa-opioid receptors) further increased the sensitivity to pressure (that is, potentiated the hyperalgesia) but did not affect the response to heat. They did not affect the response of the uninflamed paw. At 1 week, only MR 2266 was effective. At both 24 h and 1 week, the inflamed paw showed pronounced supersensitivity to the antinociceptive action of morphine against noxious pressure. At both 24 h and (to a greater extent) 1 week, a rise in levels of immunoreactive (ir)-dynorphin (DYN) was seen in the ipsilateral dorsal horn of the lumbar spinal cord. There was no alteration in the contralateral dorsal horn or in either ventral horn. Furthermore, levels of ir-met-enkephalin (ME) and ir-leu-enkephalin (LE) were unaffected. There was no difference in the density of mu-, delta- or kappa-binding sites in any part of the lumbar cord, at either 24 h or 1 week, between ipsilateral and contralateral tissue. By 3 and 5 weeks postinoculation, the symptoms had spread to the contralateral hind limb and ir-DYN was elevated in the contralateral dorsal horn and the ipsilateral ventral horn. At 5 weeks, levels of ir-ME and ir-LE also were increased in the ipsilateral and contralateral dorsal horns, but not in the contralateral ventral horn. Furthermore, levels of ir-DYN were increased in the cervico-thoracic spinal cord, and rats displayed adrenal hypertrophy and a rise in plasma levels of ir-beta-endorphin (beta-EP). These data indicate: (1) Peripheral inflammation localized to a single limb selectively modifies levels of ir-DYN in ipsilateral dorsal horn. The effect is specific to DYN as compared to ME and LE. The density of mu-, delta-, or kappa-receptors in the lumbar spinal cord is unmodified. (2) The altered response to opioid agonists and antagonists shown by rats with an inflamed limb may be selective to the injured tissue. (3) Alterations in opioid systems associated with unilateral hind limb inflammation may not be exclusively chronic in nature: they appear very rapidly (within 24 h) of the induction of pain. With time, the contralateral limb becomes affected and, eventually, the effects resemble those seen with generalized polyarthritis.

A survey is given of the present state of the ERCP in the diagnostics of the chronic pancreatitis. The ERCP is not suited for the proof of early changes in the chronic pancreatitis; it does not allow an exclusion diagnosis. The value of the ERCP in the chronic pancreatitis consists in the fact to render the indication to operation by the proof changes which should be operated on, or to precise it, respectively, and to prevent unnecessary test laparotomies. For this reason the ERCP is indicated above all in the ascertained chronically relapsing pancreatitis and in the persistence of symptoms after an acute inflammatory attack. The most comprehensive information about the morphologic state of the pancreas is got by the combination of the ERCP with methods which reflect the size and the external form of the organ and give evidence concerning the structural changes (sonography, computer tomography).

Continuous pH measurements were undertaken on 15 patients for the study of gastrooesophageal reflux during 12 hours after ingestion of test meals of protein, fat and carbohydrate. During 4 hours reflux has been increased by the different diets to similar extents.

Through a survey 751 patients, in whom an endoscopic papillotomy (EPT) had been tried, were registered to the end of 1981. EPT was technically successful in 695 cases (92,5%). Control investigations were available for 650 patients, the aim of therapy being achieved in 594 cases (91,4%). The main indication was choledocholithiasis, 90,2%--among them 10% with gallbladder in situ--followed by benign papillary stenosis without stones (5,9%), carcinoma of the Vaterian papilla (3,2%) and rare indications such as ascaridiasis, choledochocele and stones of the pancreatic duct (0,7%). 53 patients suffered from more serious complications (7,6%), 18 had to be operated on (2,6%), and 7 patients died due to EPT (1%). The results are in agreement with those of other statistics from various countries.

Urgent laparoscopy was carried out in 684 patients because of acute abdominal pains. Laparoscopic diagnoses have been compared with the clinical tentative diagnoses on one hand and with the operative or final clinical diagnosis on the other hand. The referring diagnoses were in 20% "acute abdomen" without an attempt to uncriminating a particular organ, the clinical tentative diagnosis turned out to be wrong in 40% regarding the inspected a cause of abdominal pains. Laparoscopic diagnoses compared with operative findings proved to be wrong in 10 out of 296 cases but only in 2 out of these 10 patients the indication of operation remained incertain. In 1 out of 388 patients conservatively treated according to the laparoscopic finding, the further clinical course forced to operate upon, i. e. to change the diagnosis fundamentally. The high diagnostic reliability of urgent laparoscopy in patients with an "acute abdomen" decisively contributed to diminishing the number of explorative laparotomies and advancing indicated operations.

A survey is given on the present state of experience with Cimetidine. Cimetidine significantly promotes healing of duodenal and gastric ulcers; this effect is especially significant in countries with low spontaneous ulcer healing. Prophylactically administered Cimetidine is the only drug capable of decisively lowering the recurrence rate of duodenal ulcers. In certain cases, Cimetidine long-term treatment therefore seems to compete with elective gastric operations. However apart from the operative risk surgery of the stomach (especially selective gastric vagotomy) still provides certain advantages. Controlled long-term trials are still required in order to come to a clear-cut delimitation between the indications for Cimetidine prophylaxis and elective operation. Furthermore prophylaxis with Cimetidine prevents gastric bleeding from erosions in stress-patients. Even in Zollinger-Ellison-syndrome Cimetidine enables ulcers to heal and patients to reach operability. In patients with operable gastrinomas the long-term treatment with Cimetidine seems to replace palliative total gastrectomy by curative resection of the tumour.

12 patients were treated with endoscopic transpapillary biliary endoprosthesis. The indication for biliary drainage was malignant obstructive jaundice in 10 and benign obstructive jaundice in 2 cases. The effectiveness of drainage is indicated by the disappearance of jaundice. The lifetime of the endoprosthesis was maximal 4 months and the survival of the tumor patients maximal 6 months. If the endoprosthesis is occluded replacement by a new one is necessary. Nonsurgical biliary drainage is an alternative method to palliative operation and should be preferred in general inoperability and in patients with irresectable tumors.

A procedure to collect pure pancreatic juice endoscopically is described which allows an instant estimation of the protein content of the secretion by measuring its absorption at 280 nm. By this the kinetics of protein secretion can already be read from a curve during the collecting procedure, thus avoiding a multitude of small fractions otherwise necessary. Timing and size of the samples are adjusted individually according to the course of protein secretion and not to a rigid regimen. The method described is especially apt to investigations of pancreatic proteins and substances the secretion of which parallels that of protein; e. g. trypsinogen, calcium and zinc, however not sodium and potassium.

The pathological stereotypies frequently observed among severely mentally retarded and autistic persons are highly rhythmical in nature. Most attempts to quantify such behavior, however, have not analyzed stereotypy in terms of its cyclical properties. In the present paper we have detailed a method for electronically transducing stereotyped body-rocking and analyzing its frequency and amplitude characteristics with a standard polygraph and microprocessor. The relationship between stereotyped body-rocking and cardiac activity was also described using time-series analysis. The method described should provide a sensitive index of various experimental manipulations and treatment effects.