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Transnasal esophagoscopy (TNE) in the awake patient and esophagogastroduodenoscopy (EGD) in sedation are both used in the assessment of laryngopharyngeal reflux (LPR). The objective of this study was to compare these two endoscopic methods in contributing to the diagnosis of LPR.This study included 54 patients presenting with signs and symptoms suspicious for LPR, which were examined both by TNE and EGD. The contribution of each method to the diagnosis of LPR was evaluated separately and then compared with each other.In detecting LPR, TNE showed a significant higher sensitivity (94% vs. 60%) and accuracy (93% vs. 59%) than EGD, but their specificity was equal (50% each). The most common pathologic findings in both methods were a hiatal hernia (70% vs. 48%) and gaping cardia (69% vs. 24%), followed by peptic esophagitis (41% vs. 24%).The value of EGD is limited in the workup of LPR, as sedation tends to mask the subtle findings in this kind of reflux disease.

A 60-year-old female patient with longstanding left-sided ulcerative colitis presented with symptoms mimicking an acute flare and developed a colonic perforation shortly after starting steroid treatment. Following left hemicolectomy and Hartmann’s procedure, rescue treatment with infliximab was started. Within a few days, the patient developed hepatic failure. Histology and immunohistochemistry of the specimen revealed extensive necrotizing herpes simplex virus colitis, and liver biopsy demonstrated herpes simplex virus hepatitis. Sixteen days after admission, the patient died from multiorgan failure. This compelling case of severe herpes simplex virus colitis raises awareness of a rare but potentially detrimental infection in patients with inflammatory bowel disease.

Zusammenfassung. Die interventionelle Endoskopie hat im hepato-pankreatiko-biliären Bereich in den letzten Jahren eine aufregende Entwicklung durchlaufen und eine Vielzahl therapeutischer Fähigkeiten dazu gewonnen. Durch neuartige Endoskope konnte aber auch die Diagnostik verbessert werden, durch direkte Visualisierung des Gallen- und Pankreasgangsystems inklusive visuell geführter Biopsien von luminalen Läsionen. Die Therapie komplexer Gallensteine mit einer cholangioskopisch-geführten Lithotripsie ist so ebenfalls möglich. Die biliäre Dekompression bei maligner Obstruktion kann heute endosonographisch gesteuert mit sogenannten «Lumen-apposing metall stents» (LAMS) erfolgen, welche extraanatomische Verbindungen zu den Gallenwegen erlauben, ausserhalb den traditionellen, transpapillären oder perkutanen Zugängen. Mit einer endosonographisch-gesteuerten, transgastrischen Drainage kann auch bei veränderter Anatomie nach Operation ein biliärer Zugang erreicht werden. In gleicher Weise ist auch die Drainage des Pankresganges möglich. Die ERCP-basierte Radiofrequenzablation und Photodynamische Therapie ermöglicht zudem eine gezielte Lokaltherapie von Gallengangsneoplasien. Auch in der Endotherapie der chronischen Pankreatitis werden die neuen Methoden zur endoluminalen Diagnostik, Lithotripsie und transgastrischer Drainage eingesetzt. Der vorliegende Artikel gibt einen detaillierten Überblick über die modernen Behandlungsoptionen an Gallenwegen und Pankreas in der interventionellen Gastroenterologie.

Background: Despite the fast establishment of new therapeutic agents in the management of COVID-19 and large-scale vaccination campaigns since the beginning of the SARS-CoV-2 pandemic in early 2020, severe disesase-courses still represent a threat, especially to patients with risk factors. This indicates the need for alternative strategies to prevent respiratory complications like acute respiratory distress system (ARDS) associated with COVID-19. Aviptadil, a synthetic form of Human Vasoactive Intestinal Peptide, might be beneficial for COVID-19 patients at high risk of developing ARDS because of its ability to influence the regulation of exaggerated pro-inflammatory proteins and orchestrating the lung homeostasis. Aviptadil has recently been shown to considerably improve the prognosis of ARDS in COVID-19 when applied intravenously. An inhaled application of Aviptadil has the advantages of achieving a higher concentration in the lung tissue, fast onset of activity, avoiding the hepatic first-pass metabolism, and the reduction of adverse effects. The overall objective of this project is to assess the efficacy and safety of inhaled Aviptadil in patients hospitalized for COVID-19 at high risk of developing ARDS.Methods: This multicentre, placebo-controlled, double-blinded, randomized trial with 82 adult patients hospitalized for COVID-19 and at high risk for ARDS (adapted early acute lung injury score ≥ 2 points) is conducted in four public hospitals in Europe. Key exclusion criteria are mechanical ventilation and severe hemodynamic instability. Patients are randomly allocated to either inhale 67μg Aviptadil or normal saline (three times a day for 10 days), in addition to standard care, stratified by centre. The primary endpoint is time from hospitalization to clinical improvement, defined as either hospital discharge, or improvement of at least two levels on the nine-level scale for clinical status suggested by the World Health Organization (WHO)Discussion: Treatment strategies for COVID-19 are still limited. In the context of upcoming new variants of SARS-CoV-2 and possible inefficacy of the available vaccines and antibody therapies, the investigation of alternative therapy options plays a crucial role in decreasing associated mortality and improving prognosis. Due to its unique immunomodulating properties also targeting the SARS‑CoV-2 pathways, inhaled Aviptadil may have the potential to prevent ARDS in COVID-19.Trial registration: ClinicalTrials.gov, NCT04536350. Registered 02 September 2020, https://clinicaltrials.gov/ct2/show/NCT04536350

OBJECTIVE Although laryngopharyngeal reflux (LPR) is a common condition in daily practice, no gold standard exists for its diagnosis. The objective of this study was to establish a simple and reliable scoring system for evaluating LPR consisting of both subjective and objective criteria. METHODS This retrospective study includes 124 patients presenting with symptoms of LPR. In all patients, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH monitoring (PHM) and transnasal oesophagoscopy (TNE) were performed and rated in a special scoring system. RESULTS A Horvath Score of 4-5 for severe LPR was found in 76 patients (61%), a score of 2-3 for non-severe LPR in 38 patients (31%) and a score of 0-1 for non-existing LPR in 10 patients (8%) by combining the 4 validated diagnostic methods. CONCLUSION The proposed scoring system qualifies as a simple and reliable tool for evaluating LPR in daily practice, directly impacting patient management.

Background: Treatment of Crohn’s disease (CD) patients is complex as therapy choices depend on a variety of factors, such as location and severity of inflammation, disease behavior (inflammatory, stricturing or penetrating) but also comorbidities, extra-intestinal manifestations, the patient’s age, and previous therapies. Subsequently, the choice of treatment should be tailored to the individual patient. Summary: This article gives the reader therapy algorithms as a guide through different CD scenarios to support the physician’s decision making. New compounds introduced in CD therapy in recent years justify such an update on standard approaches. Ustekinumab and vedolizumab and their positions within the treatment options are discussed. Fistulizing perianal disease and postoperative medical prophylaxis are depicted in separate chapters with own algorithms. Key Messages: In recent years, a variety of new drugs became available to treat patients with CD – especially those who are antitumor necrosis factor (TNF) experienced with ongoing inflammation. The definitive role of vedolizumab and ustekinumab is not yet fully clarified. However, with the advantage of good safety profiles over TNF-inhibitors, these drugs will be more frequently used in the near future, also as first-line biologicals, compared to TNF-inhibitors. Concerning treatment of fistulizing disease, the knowledge of the exact anatomy of the fistula is of major importance. An interdisciplinary discussion involving gastroenterologists, surgeons, and in some cases gynecologists may help to optimize the treatment plan. Regarding the postsurgical setting in CD patients, according to the very recent Cochrane Network meta-analysis, mesalazine should be at least positioned equivalent to thiopurines and TNF-inhibitors, as shown in our algorithm.

Interventional endoscopy in hepatico-pancreatico-biliary disease

BACKGROUND AND AIMS BougieCap (Ovesco Endoscopy AG, Tübingen, Germany) is a new device that allows optical and tactile feedback during stricture dilation of the upper gastrointestinal tract. We evaluated the technical feasibility, clinical efficacy, and safety of a one-time esophageal stricture dilation using BougieCap in adults with eosinophilic esophagitis (EoE). METHODS EoE patients prospectively included in the Swiss EoE Cohort were dilated with BougieCap in case of the presence of esophageal strictures (esophageal diameter ≤14 mm) and stricture-related symptoms. Symptoms were assessed before and 2 weeks after a single dilation session using the validated Eosinophilic Esophagitis Activity Index Patient Reported Outcomes (EEsAI PRO)instrument (score ranges from 0-100 points). RESULTS Fifty patients (70% male, median age 41 years, median disease duration of 4 years, 50% treated with swallowed topical corticosteroids, 10% with proton pump inhibitors, 14% with combined swallowed topical corticosteroids plus proton pump inhibitors, 14% with elimination diet, 12% without anti-eosinophil therapy) were evaluated. Endoscopic bougienage was technically successful in 100%. Median esophageal diameter increased from 12 mm (IQR 12-13) to 16 mm (IQR 16-16, p

Background and aims: Anxiety and depression are prevalent in patients with inflammatory bowel diseases (IBD), especially during IBD flares. IBD therapies can profoundly affect the mood of patients with IBD. We aimed to determine the long-term impact of anti-tumor necrosis factor (anti-TNF) and immunomodulators (IM) on anxiety and depressive symptoms in IBD patients. Methods: We compared three treatment groups with IM only (group A), anti-TNF ± IM (group B) and no such therapy (group C). Patients completed the hospital anxiety and depression scale (HADS) at 1 year, 3 years, and 5 years after start of treatment. Results: In total, 581 patients with IBD (42.9% Crohn’s disease, 57.1% ulcerative colitis/IBD unclassified) participated in this study. Effects of treatment were analyzed in a mixed effects model, with and without correction for confounders. Compared with group C, group B showed a significant treatment-related improvement in both anxiety and depressive symptoms within the first 2.5 years and also thereafter. Group A showed a significant long-term improvement of anxiety and both short-term and long-term improvement in depressive symptoms. The significance of these results was maintained after correction for confounders, including corticosteroid treatment. Additionally, both groups A and B showed a significant decrease in disease activity in the first 2.5 years after start of treatment and also thereafter. Anti-TNF and IM treatment were associated with a similarly significant decrease in anxiety and depressive symptoms over an observation period of up to 5 years. Conclusion: Besides a clear benefit for disease activity, anti-TNF and IM apparently improve the mood of patients with IBD.

Background: Tumor necrosis factor (TNF) inhibitors have improved treatment of ulcerative colitis (UC), but loss of response remains a frequent problem. The anti-TNF agent, golimumab, was approved in Switzerland for the treatment of UC in 2014. This study aims to summarize the experience of golimumab in a real-world setting in Switzerland. Methods: We analyzed real-world data from 1769 UC patients from the Swiss Inflammatory Bowel Disease Cohort (SIBDC) study and performed a chart review of golimumab-treated patients. We extracted the partial Mayo score at t0 (baseline), t1 (2–16 weeks), t2 (17–35 weeks), and t3 (36–89 weeks). The primary endpoint was clinical response at t1, defined as marked improvement in partial Mayo score and objective parameters. Clinical remission was defined as resolution of symptoms and normalization of objective parameters. Results: Our chart review included 103 UC patients with golimumab treatment (5.8% of all SIBDC UC patients); only 16 (15.5%) were anti-TNF naïve. Sixty-three patients remained on golimumab (61.2%) after 180 days, 51 (44.7%) after 365 days, and 34 (33%) after 630 days after the start of treatment. Upon golimumab treatment, the partial Mayo score decreased from 4 [interquartile range (IQR): 2–6] at t0 to 2 (IQR: 0–4) at t1, 1 (IQR: 0–3.5) at t2, and 1 (IQR: 0–3) at t3 ( p 0). The primary endpoint, clinical response at t1, could be evaluated in 52 patients and was met in 15 individuals (28.8%). Clinical remission at t1 was observed in 8 out of 52 patients (15.4%). Golimumab was generally well tolerated, one patient developed meningitis. The most frequent reasons to stop treatment were primary and secondary non-response. Conclusion: Golimumab was used in 5.8% of Swiss UC patients, mainly in biologic-experienced individuals. Golimumab treatment was associated with a sustained reduction of symptoms and clinical response in approximately 30% of patients. [ClinicalTrials.gov identifier: NCT00488631]

Zusammenfassung. Die Diagnose und auch die Überwachung von chronisch entzündlichen Darmerkrankungen ruht auf mehreren Säulen: Anamnese, körperliche Untersuchung, Laborwerte (im Blut und Stuhl), Endoskopie, Histologie und Bildgebung. Die Diagnose kann nicht anhand eines einzelnen Befundes gestellt werden. In den letzten Jahren hat sich das Therapieziel weg von klinischen Endpunkten hin zu endoskopischen und sogar histologischen Endpunkten entwickelt. Für einige dieser neuen Therapieziele existiert allerdings noch keine allgemein gültige Definition. Regelmässige Endoskopien werden von Patienten schlecht toleriert, weshalb Surrogat-Marker wie Calprotectin untersucht wurden und eine gute Korrelation mit der mukosalen Entzündungsaktivität nachgewiesen werden konnte. Entsprechend zeigte sich bei Morbus Crohn eine Algorithmus-basierte Therapiesteuerung – unter anderem basierend auf Calprotectin – einer konventionellen Therapiesteuerung überlegen. Die Überwachung der medikamentösen Therapie («Therapeutic Drug Monitoring» [TDM]) ist ein zweites Standbein des Monitoring von chronisch entzündlichen Darmerkrankungen. Mit zunehmendem Einsatz vor allem der Biologika-Therapien wurden sowohl reaktives TDM (in Patienten mit klinischem Rezidiv) als auch proaktives TDM (in Patienten in Remission / stabiler Erkrankung) untersucht und haben (teilweise) Eingang in aktuelle Richtlinien gefunden. Zukünftige Studien werden die vorgeschlagenen Therapieziele besser definieren und den Nutzen der medikamentösen Therapieüberwachung auf den Krankheitsverlauf weiter untersuchen müssen.

Very-early-onset inflammatory bowel disease (VEO-IBD) is a heterogeneous phenotype associated with a spectrum of rare Mendelian disorders. Here, we perform whole-exome-sequencing and genome-wide genotyping in 145 patients (median age-at-diagnosis of 3.5 years), in whom no Mendelian disorders were clinically suspected. In five patients we detect a primary immunodeficiency or enteropathy, with clinical consequences (XIAP, CYBA, SH2D1A, PCSK1). We also present a case study of a VEO-IBD patient with a mosaic de novo, pathogenic allele in CYBB. The mutation is present in ~70% of phagocytes and sufficient to result in defective bacterial handling but not life-threatening infections. Finally, we show that VEO-IBD patients have, on average, higher IBD polygenic risk scores than population controls (99 patients and 18,780 controls; P, Adult forms of inflammatory bowel disease (IBD) are of a polygenic nature, but paediatric and very early onset (VEO) IBD also occur as monogenic forms. Here, using whole exome sequencing, the authors explore both the monogenic and polygenic contribution to VEO-IBD and characterize a rare somatic mosaic VEO-IBD patient.

Background Some patients complain that eating lettuce, gives them gas and abdominal distention. Our aim was to determine to what extent the patients' assertion is sustained by evidence. Methods An in vitro study measured the amount of gas produced during the process of fermentation by a preparation of human colonic microbiota (n = 3) of predigested lettuce, as compared to beans, a high gas‐releasing substrate, to meat, a low gas‐releasing substrate, and to a nutrient‐free negative control. A clinical study in patients complaining of abdominal distention after eating lettuce (n = 12) measured the amount of intestinal gas and the morphometric configuration of the abdominal cavity in abdominal CT scans during an episode of lettuce‐induced distension as compared to basal conditions. Key Results Gas production by microbiota fermentation of lettuce in vitro was similar to that of meat (P = .44), lower than that of beans (by 78 ± 15%; P, In some patients lettuce produces abdominal distension, which is not related to gas, but rather to an uncontrolled reaction of the abdominal muscles and the diaphragm. Hence, learning to control the abdominal muscles may prevent distension with no need of dietary restrictions.

Background: Laryngopharyngeal reflux (LPR) can display a variety of symptoms, and upper endoscopy is occasionally used for its investigation. The aim of the present study was to determine the value of transnasal esophagoscopy (TNE) in the workup of LPR. Methods: In 200 consecutive patients with suspected LPR, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH-monitoring (PHM) and transnasal esophagoscopy (TNE) were carried out and rated according to the Horvath Score. Results: In the investigation of LPR, TNE showed a sensitivity, specificity and accuracy of 96%, 85% and 95%, respectively. The most common pathologic TNE findings in LPR patients were an insufficient cardia, hiatal hernia, lymphoid follicles and visible reflux. Conclusions: TNE is a supportive method in the workup of LPR, which can display the underlying pathology and directly affect therapeutic decisions.

Background: Laryngopharyngeal reflux (LPR) is a prevalent disorder. The aim of the present retrospective cohort study was to evaluate oropharyngeal pH-monitoring using a novel scoring system for LPR. Methods: In a total of 180 consecutive patients with possible LPR, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH-monitoring and transnasal esophagoscopy were carried out for further investigation. Results: In our series, 99 (55%) patients had severe LPR, 29 (16%) cases presented with moderate and 23 (13%) with mild severity, 9 (5%) subjects revealed neutral values, and 7 (4%) individuals were alkaline, while 13 (7%) patients had no LPR. In detecting LPR, the sensitivity, specificity and accuracy of oropharyngeal pH-monitoring was 95%, 93% and 94%, respectively. Conclusion: Oropharyngeal pH-monitoring is a reliable tool in the assessment of LPR, but the pH graphs have to be precisely analyzed and interpreted in context with other validated diagnostic tests.

Background: Patient care in ulcerative colitis (UC) remains challenging despite an array of established treatment options and emerging new therapies. The management of UC therapy should be guided by the endoscopic extent of inflammation, disease severity, and prognostic factors of poor outcome. Complete remission, defined as durable symptomatic and endoscopic remission without corticosteroid therapy, is the desired treatment goal. Summary: This review focuses on treatment recommendations for different clinical scenarios in moderate-to-severe UC: Active UC of any extent not responding to aminosalicylates, steroid-dependent UC, steroid-refractory UC, immunomodulator-refractory UC, and acute severe UC. Comprehensive treatment algorithms for daily clinical practice were developed based on published guidelines and current literature. Key Messages: While current treatment options including a number of biologicals and small molecules have evolved UC treatment to achieve sustained remission in a majority of patients, upcoming treatment options with different molecular pathways and different modes of actions will further increase the need for personalized medicine.

Background & Aims Inflammatory bowel disease (IBD) scoring systems combine patient-reported data with physicians’ observations to determine patient outcomes, but these systems are believed to have limitations. We used real-world data from a large IBD cohort in Switzerland to compare results between patients and healthcare professionals from scoring systems for Crohn’s disease (CD) and ulcerative colitis (UC). Methods We collected data from the Swiss IBD cohort, beginning in 2006, using 2453 reports for 1385 patients (52% female, 58% with CD). During office visits, physicians asked patients about signs and symptoms and recorded their answers (health care professional-reported outcomes). On a later date, patients received a questionnaire at home (independently of the medical visit), complete it, and sent it back to the data center. Patients also completed the short form 36 and IBD quality of life (QoL) questionnaires. We calculated Cohen’s kappa (κ) statistics to assess the level of agreement in scores between patients and health care professionals (Δt between reports collected less than 2 months apart). We used Spearman correlation coefficients (ρ) to compare general well-being (GWB) and QoL scores determined by patients vs health care professionals. Our primary aim was to investigate the overall and individual level of agreement on signs and symptoms reported by health care professionals vs patients. Results The best level of agreement (although moderate) was observed for number of stools last week in patients with CD (κ = 0.47), and nocturnal diarrhea in patients with UC (κ = 0.52). Agreement was low on level of abdominal pain (κ = 0.31 for patients with CD and κ = 0.37 for patients with UC) and GWB (κ = 0.23 for patients with CD and κ = 0.26 for patients with UC). Patients reported less severe abdominal pain and worse GWB (CD) or better GWB (UC) than that determined by health care professionals. Patient self-rated GWB correlated with IBD quality of life (ρ = 0.68 for patients with CD and ρ = 0.70 for patients with UC) and SF-36 physical scores (ρ = 0.55 for patients with CD and ρ = 0.60 for patients with UC); there was no correlation between health care professional-rated GWB and QoL. Conclusions In a comparison of patient vs health care provider-reported outcomes in a Swiss IBD cohort, we found that health care professionals seem to misinterpret patients’ complaints. Patients self-rated GWB correlated with QoL scores, indicating that reporting GWB in a single question is possible and relevant, but can vary based on how the data are collected.

Faecal calprotectin correlates with histological and clinical activity in inflammatory bowel disease. Gastrointestinal bleeding might also increase faecal calprotectin levels, erroneously implying intestinal inflammation; however, this possibility has not been systematically assessed.Sixteen healthy volunteers without gastrointestinal disease and normal faecal calprotectin baseline values ingested their own blood twice, either by drinking or via nasogastric tube. Quantities of 100 ml and 300 ml blood were ingested in a randomised order, with a 28-day wash-out period. Faecal calprotectin, faecal occult blood test, and the occurrence of melaena were assessed. Faecal calprotectin ≥ 50 µg/g was considered elevated.Melaena was reported by all healthy volunteers after 300 ml and by 11/15 healthy volunteers (71%) after 100 ml blood ingestion. One day after ingestion of 300 ml blood, 8/16 faecal calprotectin tests were positive compared to 1/16 at baseline (Ingestion of blood resulted in an increase in faecal calprotectin-positive tests. Gastrointestinal bleeding should be considered as a potential cause of mild faecal calprotectin elevation 50 µg/g; however, increased faecal calprotectin above 250-300 µg/g, the established cut-off for relevant intestinal inflammation in patients with inflammatory bowel disease, is rare.

Background: The knowledge about risk factors for the onset of uveitis manifestations in patients with inflammatory bowel disease (IBD) is still limited. Here, we aimed to provide an overview of the clinical factors associated with the onset of uveitis in the Swiss IBD Cohort Study (SIBDCS). Methods: We included epidemiological and clinical data from 1840 patients with Crohn’s disease (CD) and 1426 patients with ulcerative colitis (UC) followed up in the SIBDCS between 2006 and 2018. Associations between disease characteristics and uveitis were assessed in univariate and multivariate analyses. Results: Overall, we identified 285 patients with uveitis. Uveitis was more frequent in patients with CD (11.1%; 205 of 1635) than UC (5.6%; 80 of 1346; odds ratio 2.11, p Conclusions: Our data demonstrate that uveitis in IBD occurs more often in CD as well as in women and is associated with a more severe disease course. This might guide physicians’ awareness in at-risk patients to the presence of uveitis extraintestinal manifestations and help to improve patient care.

Patienten mit Morbus Crohn weisen bei der Erstvorstellung bereits in 20 – 30 % perianale Läsionen auf, meist Abszesse und Fisteln. Die Diagnose einer Fistel kann meist klinisch gestellt werden. Die weitere Abklärung sollte mittels Magnetresonanztomographie oder analer Endosonographie erfolgen wobei eine genaue präoperative Bildgebung die Rezidivrate deutlich reduziert. Einfache, unkomplizierte Fisteln können primär medikamentös mit Antibiotika therapiert werden. Bei komplexen Fisteln bietet eine kombinierte medikamentös-chirurgische Therapie in der Regel die optimale Behandlung. Die alleinige chirurgische Behandlung von komplexen perianalen Fisteln ist selten kurativ und von einer erheblichen Morbidität begleitet, wohingegen die alleinige medikamentöse Therapie aufgrund der Rezidivrate und der hohen Therapiekosten Nachteile aufweist. Bei hohen transsphinktären, suprasphinktären oder extrasphinktären Fisteln werden zudem Immunsuppresiva oder anti-TNF alpha Blocker eingesetzt. Ein kompletter, andauernder Fistelverschluss wird dabei in 30 – 50 % erreicht. Ein Viertel aller Patienten mit perianalem Morbus Crohn bedürfen im Laufe ihrer Erkrankung einer chirurgischen Behandlung. Die Fistelspaltung ist das häufigste Verfahren und wird bei subkutanen und kurzen intersphinktären Fisteln angewandt. Transsphinktäre oder intersphinktäre Fisteln sollten hingegen nicht gespalten werden. Die Seton-Einlage kann dabei als primäre Therapie oder als Vorbereitung für ein definitives chirurgisches Verfahren eingesetzt werden. Als minimalinvasives chirurgisches Verfahren wird der anale Fistelzapfen eingesetzt. Obwohl die Rezidivrate hoch ist, kann das Verfahren aufgrund der geringen Inkontinenzgefahr und der Einfachheit des operativen Eingriffs als Therapie empfohlen werden. Als Standartverfahren gilt die Fistelexzision mit Deckung der inneren Fistelöffnung durch einen Mukosa-Verschiebelappen. Damit kann auch bei komplexer Fistulierung oft eine Remission erreicht werden. Fissuren, Ulzerationen, Strikturen stellen nicht-fistulierende perianale Läsionen des Morbus Crohn dar.

BACKGROUND: We previously showed that abdominal distension in patients with functional gut disorders is due to a paradoxical diaphragmatic contraction without major increment in intraabdominal volume. Our aim was to characterize the pattern of gas retention and the abdomino-thoracic mechanics associated with abdominal distension in patients with intestinal dysmotility. METHODS: In 15 patients with manometrically proven intestinal dysmotility, two abdominal CT scans were performed: one during basal conditions and other during an episode of severe abdominal distension. In 15 gender- and age-matched healthy controls, a basal scan was performed. KEY RESULTS: In basal conditions, patients exhibited more abdominal gas than healthy subjects, particularly in the small bowel, and the volume significantly increased during an episode of distension. During episodes of abdominal distension, the increase in abdominal content was associated with increased girth and antero-posterior abdominal diameter, as well as a cephalic displacement of the diaphragm, which reduced the height of the lung. The consequent reduction in the air volume of the lung was attenuated by an increase in the antero-posterior diameter of the chest. CONCLUSIONS & INFERENCES: Abdominal distension in patients with severe intestinal dysfunction is related to marked pooling of gut contents, particularly in the small bowel. This increase in content is accommodated within the abdominal cavity by a global and coordinated abdomino-phreno-thoracic response, involving an accommodative ascent of the diaphragm and a compensatory expansion of the chest wall.

Fecal calprotectin and lactoferrin are sensitive markers of mucosal inflammation. We compared three different assays in their ability to identify patients with organic intestinal disease.In a post-hoc analysis of a prospective study, we examined 405 unselected patients with abdominal complaints referred for endoscopy to the University Hospital Basel, Switzerland. Calprotectin (EK-CAL, Bühlmann Laboratories, Switzerland; PhiCal, Calpro AS, Norway) and lactoferrin (IBD-Scan, Techlab, USA) were measured using enzyme-linked immunosorbent assays. The presence of a clinically significant endoscopic finding was the primary endpoint of the study. Final diagnoses were adjudicated blinded to calprotectin values.The prevalence of organic intestinal disease was 35.3%. Receiver operating characteristics analysis calculated an area under the curve (AUC) for EK-CAL of 0.918, which was significantly better than for PhiCal (AUC 0.842, P0.001) and IBD-Scan (AUC 0.830, P=0.003) to identify patients with organic intestinal disease. Overall test accuracy was 88.1% for EK-CAL, 83.7% for PhiCal, and 81.3% for IBD-Scan. Optimal cut-off value calculated for PhiCal and IBD-Scan were lower than recommended by the manufacturer.Monoclonal testing of calprotectin is superior to both polyclonal calprotectin testing and fecal lactoferrin in identifying symptomatic patients with organic intestinal disease.

This is the peer reviewed version of the following article: Bendezú, R. A., Barba, E., Burri, E., Cisternas, D., Accarino, A., Quiroga, S., Monclus, E., Navazo, I., Malagelada, J.-R. and Azpiroz, F. (2016), Colonic content in health and its relation to functional gut symptoms. Neurogastroenterol. Motil., 28: 849–854, which has been published in final form at [doi:10.1111/nmo.12782]. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving Gut content may be determinant in the generation of digestive symptoms, particularly in patients with impaired gut function and hypersensitivity. Since the relation of intraluminal gas to symptoms is only partial, we hypothesized that non-gaseous component may play a decisive role. Methods: Abdominal computed tomography scans were evaluated in healthy subjects during fasting and after a meal (n = 15) and in patients with functional gut disorders during basal conditions (when they were feeling well) and during an episode of abdominal distension (n = 15). Colonic content and distribution were measured by an original analysis program. Key results: In healthy subjects both gaseous (87 ± 24 mL) and non-gaseous colonic content (714 ± 34 mL) were uniformly distributed along the colon. In the early postprandial period gas volume increased (by 46 ± 23 mL), but non-gaseous content did not, although a partial caudad displacement from the descending to the pelvic colon was observed. No differences in colonic content were detected between patients and healthy subjects. Symptoms were associated with discrete increments in gas volume. However, no consistent differences in non-gaseous content were detected in patients between asymptomatic periods and during episodes of abdominal distension. Conclusions & inferences: In patients with functional gut disorders, abdominal distension is not related to changes in non-gaseous colonic content. Hence, other factors, such as intestinal hypersensitivity and poor tolerance of small increases in luminal gas may be involved.

Background & Aims We examined the relationship between symptoms of depression and anxiety and clinical recurrence of inflammatory bowel disease (IBD) in a large patient cohort. We considered the progression of depression and anxiety over time. Methods We collected clinical and treatment data on 2007 adult participants of the Swiss IBD study (56% with Crohn's disease [CD], 48% male) performed in Switzerland from 2006 through 2015. Depression and anxiety symptoms were quantified by using the Hospital Anxiety and Depression Scale. The relationship between depression and anxiety scores and clinical recurrence was analyzed by using survival-time techniques. Results We found a significant association between symptoms of depression and clinical recurrence over time (for all patients with IBD, P = .000001; for subjects with CD, P = .0007; for subjects with ulcerative colitis, P = .005). There was also a significant relationship between symptoms of anxiety and clinical recurrence over time in all subjects with IBD ( P = .0014) and in subjects with CD ( P = .031) but not ulcerative colitis ( P = .066). Conclusions In an analysis of a large cohort of subjects with IBD, we found a significant association between symptoms of depression or anxiety and clinical recurrence. Patients with IBD should therefore be screened for clinically relevant levels of depression and anxiety and referred to psychologists or psychiatrists for further evaluation and treatment.

BurriE,HochholzerK,ArenjaN,Martin-Bras- chlerH,KaestnerL,GekelerH,HatziisaakT,Buttiker M, Fraulin A, Potocki M, Breidthardt T, Reichlin T, SocratesT,TwerenboldR,MuellerC (UniversityHos- pitalBasel,Basel;UniversityHospital,Basel,Switzer- land).B-typenatriureticpeptideintheevaluationand management of dyspnoea in primary care. J Intern Med 2012; 272:504-513. Objectives. The rapid and accurate diagnosis of heart failureinprimary careisamajorunmetclinicalneed. We evaluated the additional use of B-type natriuretic peptide(BNP)levels. Design.Arandomizedcontrolledtrial.

The abdomen normally accommodates intra-abdominal volume increments. Patients complaining of abdominal distension exhibit abnormal accommodation of colonic gas loads (defective contraction and excessive protrusion of the anterior wall). However, abdominal imaging demonstrated diaphragmatic descent during spontaneous episodes of bloating in patients with functional gut disorders. We aimed to establish the role of the diaphragm in abdominal distension.In 20 patients complaining of abdominal bloating and 15 healthy subjects, we increased the volume of the abdominal cavity with a colonic gas load, while measuring abdominal girth and electromyographic activity of the anterior abdominal muscles and of the diaphragm.In healthy subjects, the colonic gas load increased girth, relaxed the diaphragm, and increased anterior wall tone. With the same gas load, patients developed significantly more abdominal distension; this was associated with paradoxical contraction of the diaphragm and relaxation of the internal oblique muscle.In this experimental provocation model, abnormal accommodation of the diaphragm is involved in abdominal distension.

Suspicion of inflammatory bowel disease should be raised in any patient with chronic or recurrent abdominal pain and diarrhoea. However, symptoms of inflammatory bowel disease (IBD) overlap with functional gastrointestinal disorders and those patients may not need endoscopy. Currently, colonoscopy with multiple biopsies is considered the gold standard to establish the diagnosis of IBD. Unfortunately, patient selection for endoscopy based on symptoms is not reliable. The use of guideli-nes of appropriateness for endoscopy yields significantly more significant findings but the selection criteria suffer from low specificity. Calprotectin is a calcium binding protein of neutrophil granulocytes that correlates well with neutrophil infiltration of the intestinal mucosa when measured in faeces. In the last decade, a large body of evi-dence on the diagnostic value of faecal calprotectin has accumulated and measurement of calprotectin in faeces has been suggested as a surrogate marker of intestinal inflammation. Testing of faecal calprotectin has been highly useful to distinguish organic from functional intestinal disorders in pati-ents with abdominal complaints. Additionally, faecal calprotectin has reliably identified colonic inflam-mation in patients with suspected IBD. The use of this inexpensive and widely available test in the evaluation and risk stratification in patients with abdominal complaints is likely to increase in the futu-re.

L’anamnese et la laryngoscopie seules sont peu fiables pour justifier un traitement probatoire par inhibiteurs de la pompe a protons (IPP). Un reflux laryngo-pharynge doit plutot etre objective a l’aide d’une pH-metrie oropharyngee.

Anamnese und Laryngoskopie allein sind wenig verlasslich, um damit eine probato­rische PPI-Therapie zu rechtfertigen. Vielmehr sollte ein laryngopharyngealer Reflux durch oropharyngeale pH-Metrie objektiviert werden.

Crohn’s disease and ulcerative colitis are characterized by periods of symptomatic relapse and remission. Diagnosis and assessment of inflammatory bowel disease has so far been based on clinical evaluation, serum parameters, radiology and endoscopy. Faecal markers such as calprotectin or lactoferrin have emerged as new diagnostic tools to detect and monitor intestinal inflammation. This review focuses on their potential clinical applications and limitations in the management of inflammatory bowel disease.

Measurement of faecal calprotectin concentration is increasingly used to assess disease activity in patients with IBD. Lasson et al. have now demonstrated that calprotectin concentrations in faeces of patients with mild or moderate left-sided or extensive ulcerative colitis vary considerably and have questioned the long-term stability of calprotectin when stored at room temperature.

BACKGROUND & AIMS: In patients with functional gut disorders, abdominal distension has been associated with descent of the diaphragm and protrusion of the anterior abdominal wall. We investigated mechanisms of abdominal distension in these patients. METHODS: We performed a prospective study of 45 patients (42 women, 24-71 years old) with functional intestinal disorders (27 with irritable bowel syndrome with constipation, 15 with functional bloating, and 3 with irritable bowel syndrome with alternating bowel habits) and discrete episodes of visible abdominal distension. Subjects were assessed by abdominothoracic computed tomography (n = 39) and electromyography (EMG) of the abdominothoracic wall (n = 32) during basal conditions (without abdominal distension) and during episodes of severe abdominal distension. Fifteen patients received a median of 2 sessions (range, 1-3 sessions) of EMG-guided, respiratory-targeted biofeedback treatment; 11 received 1 control session before treatment. RESULTS: Episodes of abdominal distension were associated with diaphragm contraction (19% +/- 3% increase in EMG score and 12 +/- 2 mm descent; P < .001 vs basal values) and intercostal contraction (14% +/- 3% increase in EMG scores and 6 +/- 1 mm increase in thoracic antero-posterior diameter; P < .001 vs basal values). They were also associated with increases in lung volume (501 +/- 93 mL; P < .001 vs basal value) and anterior abdominal wall protrusion (32 +/- 3 mm increase in girth; P < .001 vs basal). Biofeedback treatment, but not control sessions, reduced the activity of the intercostal muscles (by 19% +/- 2%) and the diaphragm (by 18% +/- 4%), activated the internal oblique muscles (by 52% +/- 13%), and reduced girth (by 25 +/- 3 mm) (P

Abdominal discomfort including pain, bloating and diarrhea is common. It often arises from functional gastrointestinal disorders but may indicate inflammatory bowel disease (IBD). Calprotectin is an abundant neutrophil protein that is released during inflammation. When measured in feces, it can be used to differentiate between non-organic and inflammatory intestinal disorders, especially to identify IBD. Fecal calprotectin might also be useful to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse. The use of fecal calprotectin has been investigated in a number of gastrointestinal disorders other than IBD, for example, as screening test for colorectal cancer but the available data are limited. This article summarizes the current literature on the use of fecal calprotectin in clinical practice.

European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria have been developed to increase diagnostic yield, but their predictive value is limited. We investigated the incremental diagnostic value of faecal calprotectin to EPAGE criteria.In a post-hoc analysis of a prospective study, EPAGE criteria were applied to 298 of 575 (51.8%) patients who had undergone esophagogastroduodenoscopy (EGD), colonoscopy or both for abdominal complaints at the Division of GastroenterologyHepatology at the University Hospital Basel in Switzerland. Faecal calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. Final endoscopic diagnoses were blinded to calprotectin values.Of 149 EGDs and 224 colonoscopies, 17.6% and 14.7% respectively were judged inappropriate by EPAGE criteria. Appropriate or uncertain indications revealed more endoscopic findings in both EGD (46.3% vs. 23.1%, P = 0.049) and colonoscopy (23.6% vs. 6.1%, P = 0.041) than inappropriate indications. Median calprotectin levels were higher (81.5 μg/g, interquartile range 26-175, vs. 10 μg/g, IQR 10-22, P0.001) and testing was more often positive (50 μg/g) in patients with endoscopic findings, both in EGD (58.2% vs. 33.0%, P = 0.005) and in colonoscopy (57.3% vs. 7.4%, P0.001). The use of faecal calprotectin in addition to EPAGE criteria improved the risk reclassification of patients by endoscopic findings. The calculated net reclassification index was 37.8% (P = 0.002) for EGD and 110.9% (P0.001) for colonoscopy, thus improving diagnostic yield to 56.8% and 70.2%, respectively.The use of faecal calprotectin in addition to EPAGE criteria improved diagnostic yield in patients with abdominal complaints.

Background: Non-invasive monitoring of inflammatory bowel disease is an unmet clinical need as patients in clinical remission may have residual mucosal inflammation preceding clinical relapse. Aims: We aimed to assess the value of fecal calprotectin and standardized clinical activity scoring to monitor disease activity in ulcerative colitis under medical treatment. Methods: Forty-one patients with ulcerative colitis were included in a prospective observational study. Medical treatment was guided by clinical judgement of treating physicians. Fecal calprotectin and the clinical activity index (CAI) were measured blinded to treating physicians every 2months until the end of follow-up. Twenty-six patients received colonoscopy for clinical reason. Results: As defined by the CAI, patients were in clinical remission (63.4%), having mild (26.8%) or moderate (11.2%) disease activity. Of those in clinical remission (CAI≤4), 86.4% showed residual endoscopic activity (Mayo Score ≥1). Calprotectin levels were higher in endoscopically active disease (779.0 vs 331.5μg/g, P=0.034) and calprotectin testing identified more patients with endoscopic disease activity (86.4%) than the CAI (45.5%, P=0.034). Medical treatment was escalated in 90.2% during the study. Values of the CAI and calprotectin correlated with therapy escalation (OR 3.94 and 3.22, respectively). Only for calprotectin, changes between two measurements were related to intensified medical treatment (OR 1.39). Conclusion: Fecal calprotectin was similarly useful to the CAI to monitor disease activity of ulcerative colitis during medical treatment but identified endoscopic disease activity far more reliably. Changes of calprotectin values between measurements might indicate clinical relapse earlier than the CAI.

Patients with irritable bowel syndrome and abdominal bloating exhibit abnormal responses of the abdominal wall to colonic gas loads. We hypothesised that in patients with postprandial bloating, ingestion of a meal triggers comparable abdominal wall dyssynergia. Our aim was to characterise abdominal accommodation to a meal in patients with postprandial bloating.A test meal (0.8 kcal/ml nutrients plus 27 g/litre polyethylenglycol 4000) was administered at 50 ml/min as long as tolerated in 10 patients with postprandial bloating (fulfilling Rome III criteria for postprandial distress syndrome) and 12 healthy subjects, while electromyographic (EMG) responses of the anterior wall (upper and lower rectus, external and internal oblique via bipolar surface electrodes) and the diaphragm (via six ring electrodes over an oesophageal tube in the hiatus) were measured. Means +/- SD were calculated.Healthy subjects tolerated a meal volume of 913±308 ml; normal abdominal wall accommodation to the meal consisted of diaphragmatic relaxation (EMG activity decreased by 15±6%) and a compensatory contraction (25±9% increase) of the upper abdominal wall muscles (upper rectus and external oblique), with no changes in the lower anterior muscles (lower rectus and internal oblique). Patients tolerated lower volume loads (604±310 ml; p=0.030 vs healthy subjects) and developed a paradoxical response, that is, diaphragmatic contraction (14±3% EMG increment; p0.01 vs healthy subjects) and upper anterior wall relaxation (9±4% inhibition; p0.01 vs healthy subjects).In functional dyspepsia, postprandial abdominal distension is produced by an abnormal viscerosomatic response to meal ingestion that alters normal abdominal accommodation.