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Stents and prostheses in the hepatobiliary system are visible by ultrasound examination and can be checked for their function. The reappearance of mechanical cholestasis, stent dislocation or formation of sludge on the stent tip is signs of stent dysfunction. Graduation of the biliary obstruction can help to find the best time for changing the stent. After intervention hematoma, abscess, intraabdominal fluid or gas may occur and can be diagnosed by ultrasound. Tumor stenosis in the gastrointestinal tract can be treated by self expandable metallic stents. Ultrasound helps to localize the stent in the correct position and to observe the reduction of occlusive ileus. Percutaneous and gastrointestinal drainage of pancreatic cysts, necrosis and abscesses are often controlled by ultrasound to evaluate size, echogenicity and localized pain. Many procedures and interventions in gastroenterology can be monitored by an experienced ultrasound examiner in an effective and inexpensive manner.

Due to the specialisation of esophageal surgery a significant reduction of post-surgical mortality was possible during the last few decades. Nevertheless a high complication rate of about 30% remains even in the hands of experienced surgeons. Anastomotic leakage has an incidence between 5 and 30% leading to serious postoperative morbidity. With a broad range of conservative and endoscopic therapeutic methods there is encouraging progress in shortening the time to closure of the leakage and reducing the risk of severe systemic complications such as sepsis or malnutrition. If conservative therapy fails, re-surgery remains as an ultima-ratio option.

Hintergrund: Die Videokapsel-Endoskopie ermoglicht inzwischen die Darstellung des gesamten Dunndarmes. Bisher war dieser nur teilweise mit der Push-Enteroskopie einsehbar oder es war der Einsatz radiologischer bzw. kernspintomographischer Untersuchungsmethoden zu seiner Darstellung erforderlich. Ziele der Studie: 1) Quantifizierung der diagnostischen Ausbeute der Kapselendoskopie bei UGIB oder UEMA unter den Bedingungen des klinischen Alltages; 2) Vergleich der diagnostischen Ausbeute von Kapselendoskopie, Push-Enteroskopie und radiologischer Untersuchungsmethoden bei diesen beiden Fragestellungen; 3) Klarung der Frage, ob die Kapselendoskopie bei einer dieser beiden Fragestellungen diagnostisch erfolgreicher ist. Patienten und Methoden: Bei 41 Pat. mit UGIB oder UEMA wurde eine Kapselendoskopie (M2ATM, Given Imaging) nach einer Osophagogastroduodenoskopie und Koloskopie durchgefuhrt. Bei 24 dieser Pat. erfolgte eine Push-Enteroskopie und bei 25 dieser Pat. eine radiologische Darstellung des Dunndarmes (konventionelle oder CT-gestutzte Sellink-Untersuchung). 14 Frauen und 27 Manner wurden untersucht; ihr Durchschnittsalter betrug 61±15 (SD) Jahre. Ergebnisse: Bei 27/41 Pat. (66%) zeigte die Kapselendoskopie pathologische Befunde der Dunndarmschleimhaut. Die gestellten Diagnosen umfassten Ulzera bei 9 Pat., Teleangiektasien bei 10 Pat., Ulzera kombiniert mit Teleangiektasien bei 2 Pat., eine akute Blutungen bei 1 Pat. und Schleimhauterytheme (Entzundung) bei 5 Pat.. Bei 9/15 Pat.(60%) with UEMA und bei 18/26 Pat. (69%) mit UGIB zeigte die Kapselendoskopie pathologische Befunde. Dieser Unterschied war nicht signifikant (p=0.73, Fisher Exact Test). 2 Pat. wurden operiert; bei einem dieser 2 Pat. zeigte die intraoperativ durchgefuhrte Enteroskopie eine Blutungsquelle auserhalb des Dunndarmes. Die Kapselendoskopie konnte neue Befunde bei 20/27 untersuchten Pat.(74%) nachweisen; bei 7/27 Pat.(26%) konnte die Kapselendoskopie aufzeigen, dass sich bei der Osophagogastroduodenoskopie und Koloskopie nachgewiesenen pathologischen Befunde sich weiter in den Dunndarm hinein erstreckten. Die radiologische Untersuchung konnte nur einen pathologischen Befund namlich ein Aortenaneurysma nachweisen; dieser Befund wurde als nicht ursachlich fur die intestinale Blutung gesehen. Die Push-Enteroskopie war bei einem Pat. nicht moglich, so dass hier nur die Ergebnisse von 24 Pat. verfugbar waren. Die Push-Enteroskopie entdeckte 5 Lasionen im Jejunum; alle diese 5 Pat. litten an einer UGIB. Diese pathologischen Befund waren bei allen 5 Pat. auch in der Kapselendoskopie nachweisbar. Daruberhinaus entdeckte aber die Kapselendoskopie bei 10 Pat. pathologische Befunde im Dunndarm, die der Push-Enteroskopie entgingen. Schlussfolgerungen: Die Kapselendoskopie entdeckt eine grose Zahl pathologischer Befunde bei der unklaren gastrointestinalen Blutung (UGIB) und der unklaren Eisenmangelanamie (UEMA). Operative Konsequenzen resultieren aber aus diesen Befunden nur selten. Die diagnostische Ausbeute der Kapselendoskopie ist bei der UGIB und der UEMA ahnlich gros. Die radiologische Bildgebung brachte in der vorliegenden Studie keinen wesentlichen Zugewinn bei diesen beiden klinischen Fragestellungen. Die Push-Enteroskopie erbrachte ein Drittel der diagnostischen Ausbeute der Kapselendoskopie. Dennoch erscheint es gerechtfertigt, sie speziell bei der UGIB an die erste Stelle des diagnostischen Algorithmus setzen.

The objective of this follow-up study was to assess the long-term outcome of patients with infected necrotizing pancreatitis treated with percutaneous catheter drainage and necrosectomy.Nine patients (median age 44 years, range 19-69) with infected pancreatic necrosis and catheter drainage for initial treatment were evaluated after a median follow-up of 30 months (range 15-52) with respect to quality of life (pain, diarrhea, fat intolerance), morphology and endocrine and exocrine pancreatic function.At follow-up all 9 patients (100%) were in good general condition with respect to quality of life. Only 2/9 (22%) patients had moderate to marked changes in computed tomography. There was mild to moderate exocrine dysfunction in 5/8 (63%) patients, 2/8 (25%) patients had a severe restriction of the exocrine pancreatic function; in one patient the serum pancreoaryl test was normal. An oral glucose tolerance test was performed in 6/9 patients, with a normal result in 3/6 (50%) patients. 2/6 (33%) patients had an impaired oral glucose tolerance test with metabolic pathogenesis. One patient with diabetes in the oral glucose tolerance test had a preexisting type II diabetes requiring insulin therapy since the onset of acute pancreatitis. In 3/9 (33%) patients an oral glucose tolerance test was not performed due to known preexisting diabetes.Percutaneous drainage of infected necrotizing pancreatitis has given good long-term results with regard to quality of life, endocrine and exocrine pancreatic function and may be an alternative to surgical treatment.

The growing data about new endoscopic therapies for gastroesophageal reflux disease (GERD) seem to indicate that these techniques might be effective at least in a part of patients suffering from GERD. However, up to now it is not clear which technique is the best. Randomized studies comparing the different techniques with each other and especially with surgical antireflux procedures (laparoscopic fundoplication) are needed. In addition, more data proving the long term effectiveness of these new techniques are necessary.

Possible approaches to improve the diagnostic and therapeutic effects of 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PPIX) are the esterification of ALA for enhanced uptake and the choice of wavelength for irradiation. The human colonic cell lines HT29 [G2] and CCD18 (fibroblasts) were incubated with 0.6 mM ALA, ALA-hexylester or -benzylester respectively, and for further assays with hypotaurine, in addition. PPIX-accumulation was analyzed by flow cytometry and fluorescence spectroscopy. PPIX formation kinetics were continuously recorded. Incubated cells were irradiated with an incoherent light source lambda = 400-700 nm or lambda = 590-700 nm, respectively. After PDT treatment, clonogenicity assays were performed to determine cell viability. Esterification leads to increased PPIX-accumulation, decreased time for production of detectable amounts of PPIX as well as increased response to PDT. Tumor specificity is always maintained or exceeds values for ALA alone. ALA enters the cells via beta transporter whereas esters by passive diffusion. Altering irradiation wavelengths showed the independence of wavelength rather than light dose. Results emphasize the role of heme metabolism for generating tumor specificity rather than the process of ALA-uptake, an important detail for future clinical application.

Barrett's esophagus is a major complication of gastroesophageal reflux disease and is associated with 30-125 fold increased risk of developing carcinoma. Because of the rising incidence of esophageal adenocarcinoma the malignant potential of Barrett's esophagus has been generally recognized. The definition of Barrett's esophagus has evolved over the last decades. It is now accepted that "Long-Barrett-Segment" (LBS) is used when intestinal-type epithelium, characterized by the presence of goblet cells, is detected in the distal esophagus3 cm in length. The term "Short-Barrett-Segment" (SBS) is defined by intestinal metaplasia detection3 cm in length in the distal esophagus. Recently, there has been focus on microscopic Barrett's esophagus, so called "Ultra-Short-Barrett's esophagus", with histological evidence of intestinal metaplasia without endoscopic appearance. The most significant predictor of the risk of malignancy in patients with Barrett's esophagus is the presence of dysplasia. Guidelines for surveillance are based on the diagnosis of dysplastic lesions. New methods (e. g. Methylene blue staining, endoscopic fluorescence detection, OCT) to improve the recognition of Barrett's esophagus and especially enhance the detection of premalignant and malignant lesions are under evaluation. So far, the standard biopsy protocol for patients with LBS includes biopsies in the 4 quadrants every 1-2 cm, whereas the appropriate surveillance intervals are dependent on the grade of dysplasia. Whether surveillance in patients with SBS has to be similar to that in patients with LBS is unclear and needs further evaluation.

Barrett's esophagus is a complication of gastroesophageal reflux disease (GERD) characterized by specialized columnar epithelium that contains goblet cells and replaces the squamous epithelium of the distal esophagus. It is found in about 10% of patients with symptomatic reflux disease and more importantly has been associated with the development of esophageal cancer. Adenocarcinoma arises from dysplasia, which is usually not visible during routine endoscopy, therefore extensive random sampling of the entire Barrett's segment should be performed with biopsies in the 4 quadrants every 1 to 2 cm and of any macroscopic abnormality.We report the history of a 60-year-old man who was admitted to hospital because of an ulcer in Barrett's esophagus not healing despite conservative treatment. He has suffered from gastroesophageal reflux disease for more than 30 years and an antireflux surgical procedure had not resulted in regression of Barrett's esophagus. However, close surveillance could not reveal any dysplastic or malignant lesion. Endoscopic fluorescence detection (EFD) after sensitization with 30 mg/kg 5-aminolevulinic acid (5-ALA) in this patient demonstrated a selective red fluorescence in a macroscopically normal appearing area near the already known ulcer. Biopsies from this fluorescent area showed an adenocarcinoma. Esophagectomy confirmed the presence of intramucosal adenocarcinoma without lymph node metastases.

The detection of gastrointestinal dysplasia is an unresolved problem. Fluorescence detection of these premalignancies after exogenous application of 5-aminolevulinic acid, which is converted to protoporphyrin IX and accumulates selectively in tumors, is an interesting approach. Illumination with light of appropriate wavelength allows the discrimination and detection of gastrointestinal neoplasia either by spectroscopy or fluorescence endoscopy because of a typical red fluorescence of protoporphyrin IX. Surveillance of patients with Barrett's esophagus and ulcerative colitis might benefit from this new technique.

Fluorescence endoscopy is a new technique which allows a better endoscopic detection of nonvisible or difficult detectable malignant or premalignant lesions. Exogenously applied sensitizers accumulate selectively in malignant lesions and induce fluorescence after illumination with light of adequate wavelength. However, also endogenous fluorophores, different located in malignant or benign lesions, induce a different autofluorescence in these tissues. Meanwhile fluorescence endoscopy is a widely spread technique in urology using 5-aminolevulinic acid sensitization. In gastroenterology this technique seems promising in the detection of early cancers or dysplasia in patients with Barrett's esophagus or ulcerative colitis. This paper describes the current status and future development of fluorescence endoscopy in gastroenterology.

A 65-year-old woman was admitted to another hospital with suspected status asthmaticus. While there was progressive respiratory failure, the chest X-ray showed bilateral congestion and infiltration with widened mediastinum and cardiomegaly. The patient was transferred to the authors' hospital after two days on ventilatory support because of suspected left-ventricular failure and pulmonary congestion with pneumonia. 30 years previously she had undergone a myotomy for achalasia.Imaging of the oesophagus with water-soluble contrast medium, computed tomography of the thorax and gastroscopy revealed a siphon-like megaoesophagus (which had been misinterpreted radiologically as cardiomegaly) with a slightly open lower oesophageal sphincter. The pulmonary symptoms were thought to be due to aspiration pneumonia.As there were no other reasonable treatment options a transmediastinal oesophageal resection with gastric pull-through and collar anastomosis was performed.In long-standing achalasia a megaoesophagus can develop despite previous myotomy. It should be included in the differential diagnosis of radiologically demonstrated mediastinal enlargement.

Photodynamic therapy (PDT) produces localized necrosis with light after prior administration of a photosensitizing drug. As PDT lesions in the gastrointestinal tract heal well, the technique is suitable for repeated endoscopic use. In this study we used PDT to treat benign and malignant gastrointestinal tumors in esophagus, duodenum and rectum in 22 patients, who refused or were not suitable for surgery. Patients were sensitized with 0.15 mg/kg of body weight with mesotetrahydroxyphenylchlorin i.v. m-THPc (2 patients), with 2.0 mg/kg Photofrin i.v. (4 patients) or 60 mg/kg 5-aminolevulinic acid orally ALA (which is converted in vivo to active derivate protoporphyrin IX-PRIX) in fractionated doses (16 patients). Laser treatment was performed 2 days after Photofrin, 2 and 4 days after mTHPc and 4 hours after ALA, using a metal vapour laser (628 nm, 50-150 J/cm2 for ALA and Photofrin, 650 nm and 10-15 J/cm2 for mTHPc). Using ALA, the necrosis was only superficial (up to 1.8 mm depth). Four patients treated with Photofrin showed deeper necrosis, in one case of 8 mm colon cancer complete response, in three cases 1-1.5 cm adenomatous polyps involving the ampulla Vateri 50% longer term reduction in size-seen endoscopically. Two patients with rectal villous adenomas treated with mTHPc showed 60-80% reduction in size (observed endoscopically) within few days after PDT, with better effects for treatment carried out 4 rather than 2 days after the sensitization. In all patients the healing was without any complications. Photofrin and mTHPc work better, but cause cutaneous photosensitivity lasting 12 and 5 weeks, respectively. Better results with ALA are possible when using higher drug doses or modified light dosimetry. PDT is a promising treatment for small localized tumors in patients unsuitable for surgery, but further work is required to optimize the treatment conditions.

Endoscopic diagnosis of gastrointestinal precancerous and cancerous lesions is difficult, often even impossible. This study was undertaken to find out whether premalignant or suspected malignant tumors can be diagnosed by preceding sensitization with 5-aminolaevulinic acid (ALA), which in tumors is transformed in increased amounts into photosensitizing protoporphyrin IX, the latter being recognized by its characteristic red fluorescence on exposure to blue light.20 patients with known mild or moderately severe dysplasias (Barrett's esophagus, n = 8; colorectal adenoma, n = 3; ulcerative colitis n = 2, and gastric polyps or mucosal changes suspicious of malignancy, n = 5. Two patients with squamous-cell carcinoma, who after radio- and chemotherapy were endoscopically free of tumor, were sensitized with different concentrations of ALA (orally: 5-30 mg/kg; or locally: 3 g in 100 ml 0.9% NaCl). Photodynamic diagnosis (PDD) took place 4-8 h after oral and ca. 1-2 h after local sensitization with blue light (D-light, Storz, Tuttlingen, Germany).Definite red fluorescence with demonstration of dysplasia was found in three of four patients with Barrett's esophagus. Biopies from nonfluorescent areas were free of dysplasia. Two gastric adenomas (10 mg/kg ALA with high-grade dysplasia were definitively endoscopically by their red fluorescence. In one patient mild dysplasia was found in a non-fluorescent area after radio- and chemotherapy of an esophageal carcinoma. Dysplasias were also seen in the rectal biopsy after local applications.PDD makes it possible for the first time to visualize precancerous lesions of the gastrointestinal tract after preceding ALA sensitization. PDD is a highly promising method for monitoring patients with gastrointestinal disease and an increased risk of cancer, and for clarifying the diagnosis of mucosal changes suspicious of malignancy.

The aim of this study was to assess the applicability and accuracy of the modified serum pancreolauryl test (sPLT) in patients with chronic pancreatitis (cP).We compared the results of a modified serum pancreolauryl test to morphological changes as detected by endoscopic retrograde pancreatography (ERP) in 60 patients with a history suggesting chronic pancreatitis were compared. Serum fluorescein was measured 30, 60, 120, 150, 180 and 240 minutes after the ingestion of fluoresceindilaureat, a standardized breakfast, and i.v. administration of secretin (1 U/kg) and metoclopramide (10 mg). Furthermore, the results of sPLT and ERP were compared to the findings on abdominal ultrasonography.Forty of 60 patients suffered from cP according to ERP criteria. With a fluorescein cut-off point of 4.5 micrograms/ml, sPLT reached a sensitivity of 68% and a specificity of 50%. According to the ROC curve, the optimal cut-off point was at a fluorescein level of 4.1 micrograms/ml; however, predictive accuracy was only slightly improved at this point. In the subgroup of patients with advanced pancreatic duct changes (n = 23), however, sPLT reached a sensitivity of 87% with 16 patients showing a peak fluorescein concentration below 2.5 micrograms/ml.Like other indirect pancreatic function tests, modified sPLT provides good recognition of patients with advanced cP but poor identification of patients with mild or moderate cP, leading to an unsatisfying overall performance of the test.

If transillumination is not possible, percutaneous endoscopic gastrostomy (PEG) is contraindicated. In these cases the stomach had so far to be punctured directly during radiological monitoring. A new method is described which combines endoscopy and computed tomography (CT) for performing a percutaneous endoscopic gastrostomy.Among 189 patients who were to have the procedure there were eleven (nine men, two women) in whom transillumination was not possible. After endoscopic insufflation of air PEG was done under CT guidance, using the common pull-through technique.The combined method was successful in ten of the eleven patients without complication. In one patient with hepatomegaly and interposition of the transverse colon PEG was not possible even with CT guidance.The combined endoscopic-radiological method is practicable and safe in cases in which transillumination is not possible. There are several advantages compared with direct puncturing: The common pull-through technique can be used; radiological exposure is low and other clinically relevant findings may be revealed by the endoscopy.

We report a rare case of a 52 year old patient with multiple gastric wall abscesses. In 1987 a selective proximal vagotomy was performed. Because of non-specific gastric symptoms in 1993 an endoscopy and an endoscopic ultrasound was performed at another hospital which resulted in the likely diagnosis of multiple leiomyomas. Three months later a control endosonography showed three well demarcated submucosal tumors, partly echo-genic, but with an inhomogeneous echo-pattern. A laparotomy and histological examination of the submucosal gastric tumors revealed multiple gastric abscesses with granulomas after selective proximal vagotomy. Difficulties in the differential diagnosis of submucosal gastric tumors arising from this case are demonstrated and discussed.

5-Aminolaevulinic acid (ALA) is a promising agent for photodynamic therapy (PDT) sensitization as it can be given orally and only causes skin photosensitivity for 1-2 days. In fluorescence and photodynamic studies 26 patients with benign and malignant gastrointestinal tumors were given 30-60 mg ALA orally (single or divided doses) and biopsies were taken of tumor and normal tissue at 1-24 hours for fluorescence microscopy. With 30 mg/kg, highest protoporphyrin IX (PPIX) levels were seen in esophagus, duodenum and less in colon, but without tumor selectivity. Better tumor selectivity was seen in colon after 60 mg/kg (5:1). Six patients had transient rises in transaminases and five mild nausea. Sixteen patients were later treated (after further ALA) with red light (628 nm, bare or diffuser fibre, 50-100 J at 50 mW at each site). All but two showed subsequent necrosis, but only 0.5-1.5 mm of depth. PDT with ALA is simple, safe and promising for tumors in the gastrointestinal tract. Modification of treatment parameters may make it suitable for larger lesions.

We report on a case of an 85-year-old man with dysphagia who suffered from a stenosing esophageal adenocarcinoma that could not be treated by surgery. The tumor demonstrated circumferential growth and extended from 14 to 22 cm from the incisors. There were no esophago-tracheal fistulas. The stenosis could be negotiated with the endoscope. Under fluoroscopic guidance, a self-expanding Strecker stent was placed in the stenosed area with no prior dilatation. After releasing the stent an x-ray revealed a twisted and wrinkled stent which had expanded to only half of its maximum diameter. The patient's symptoms had not improved. Four days later dysphagia resolved when the stent spontaneously corrected its position and was found to be maximally expanded. On the basis of this observation it may be concluded that, at least in some cases, self-correction of an initially unsatisfactory positioning of a Strecker stent may be expected, even after four days.