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Ein 63-jahriger Patient mit bekannter portaler Hypertonie wurde wegen kreislaufrelevanter gastrointestinaler Blutung mit Melana, Hamatochezie und Hamatemesis seit mehreren Tagen notfallmassig eingeliefert.

Un patient âge de 63 ans, atteint d’hypertension portale, a ete admis en raison de l’hemorragie gastro-intestinale perturbant la circulation et accompagnee de melena, hematochezie et hematemese depuis plusieurs jours.

Zusammenfassung. Der Roux-Y-Magenbypass (RYGBP) stellt weltweit die am häufigsten durchgeführte bariatrische Operation dar – innere Hernien zählen zu den wichtigsten Langzeitkomplikationen. Unser Bericht einer 30-jährigen Patientin beschreibt erstmalig einen Fall einer ischämisch bedingten Dünndarmstenose nach RYGBP. Bei der Erstvorstellung wurden eine Petersen- und eine Brolin-Hernie diagnostiziert und laparoskopisch erfolgreich verschlossen. Der minderperfundierte Dünndarmanteil erholte sich in der Folge gut. Die Zweitvorstellung folgte eine Woche darauf bei postprandialem Erbrechen aufgrund postischämischer Dünndarmstenosen. Diese wurden mittels Ballondilatation erfolgreich behandelt.

Gastric Bypass: Weight Loss with Complications Abstract. Roux-en-Y gastric bypass (RYGBP) is the most often performed bariatric operation worldwide with internal hernia as one of the main long-term complications. To our knowledge, we report the first case of post-ischemic small-bowel strictures observed after a successful operation of an internal hernia after RYGBP. During emergency surgery a Petersen and a Brolin hernia were diagnosed and repaired. The initially ischemic small intestine was recovered. However, a week later the patient presented herself again due to ischemia-induced small-bowel strictures. These were treated successfully by endoscopic balloon dilatation.Zusammenfassung. Der Roux-Y-Magenbypass (RYGBP) stellt weltweit die am häufigsten durchgeführte bariatrische Operation dar – innere Hernien zählen zu den wichtigsten Langzeitkomplikationen. Unser Bericht einer 30-jährigen Patientin beschreibt erstmalig einen Fall einer ischämisch bedingten Dünndarmstenose nach RYGBP. Bei der Erstvorstellung wurden eine Petersen- und eine Brolin-Hernie diagnostiziert und laparoskopisch erfolgreich verschlossen. Der minderperfundierte Dünndarmanteil erholte sich in der Folge gut. Die Zweitvorstellung folgte eine Woche darauf bei postprandialem Erbrechen aufgrund postischämischer Dünndarmstenosen. Diese wurden mittels Ballondilatation erfolgreich behandelt.

The histological parameters of Helicobacter pylori (H. pylori) gastritis are dependent on the virulence factor profile of the microbe, which includes the cytotoxins vacA (vacuolating cytotoxin A) and cagA (cytotoxin-associated gene A) as well as the duration of infection. The virulence factor genotypes vacA and cagA were assessed by the line probe reverse hybridization assay INNO-LiPA and correlated with the histological parameters of H. pylori infection, in particular intestinal metaplasia (IM) as well as with the patient's age. A total of 120 patients were analyzed; 47 patients with IM in the antrum and 73 control patients without this alteration. The vacA s1 cagA+ genotype (high virulence) correlated with the presence of antral IM, a more intense acute inflammation in both antrum and corpus and the formation of ulcer. The vacA m1 genotype (high virulence) correlated with a more intense acute inflammation in only the corpus as well as more prominent Russell bodies in the antrum. H. pylori strains with the vacA s2 m2 cagA- genotype (low virulence) were rarely found in these conditions (all P0.05). No correlation with the virulence status was found for the type and extent of IM, the intensity of chronic inflammation, the formation of lymphoid follicles and the microbial density. Furthermore, patients with IM were 7 years older than their counterparts without (P0.05). Finally, there was a trend for more virulent vacA s1 m1 cagA+ strains to be found in younger individuals (P0.05). The virulence genotype of the microbe is an important determinant for the severity of the gastritis and the formation of antral IM. Age is an additional factor for the development of IM.

Reliance on these meetings, encouraged in guidelines, may lead to suboptimal decisions, and they should always include an advocate of the patient, writes Franz Eigenmann

Background Jumping from heights is a readily available and lethal method of suicide. This study examined the effectiveness of a minimal structural intervention in preventing suicide jumps at a Swiss general teaching hospital. Following a series of suicide jumps out of the hospital’s windows, a metal guard rail was installed at each window of the high-rise building. Results In the 114 months prior to the installation of the metal guard rail, 10 suicides by jumping out of the hospital’s windows occurred among 119,269 inpatients. This figure was significantly reduced to 2 fatal incidents among 104,435 inpatients treated during the 78 months immediately following the installation of the rails at the hospital’s windows (χ 2 = 4.34, df = 1, p = .037). Conclusions Even a minimal structural intervention might prevent suicide jumps in a general hospital. Further work is needed to examine the effectiveness of minimal structural interventions in preventing suicide jumps.

We describe the clinicopathological features of six patients, two with rheumatoid arthritis and four with osteoarthritis, in whom intake of sustained-release diclofenac for one or more years was associated with ulceration and or stricture of the ascending colon. All were referred for further evaluation of anemia and changes in bowel habits. Three had chronic watery diarrhea, one suffered from progressive constipation and subsequently needed a right hemicolectomy because of complete intestinal obstruction. In five patients, colonoscopy revealed single to multiple semilunar ulcers, predominantly localized on the crest of the haustra of the ascending colon. In five of six cases the lumen was narrowed, from slight accentuation of the haustrum to almost pinhole-like concentric stenosis. All except one patient had multiple diaphragm-like strictures. The macroscopic and microscopic appearances closely resembled those of similar lesions previously described in the terminal ileum in patients treated with nonsteroidal anti-inflammatory drugs. It appears that the slow-release form of a nonsteroidal anti-inflammatory drug, such as sustained-release diclofenac, predisposes to manifestations of such lesions in the ascending colon.

To retrospectively compare the dynamic contrast enhancement of the small bowel segments with and without active Crohn's disease at 3D MR enterography (MRE).Thirteen patients (five men, eight women; mean age 41.2 years; range 29-56) were imaged on a 1.5-T MR scanner (Sonata, Siemens Medical) with standard MR sequences after having ingested 1000 ml of a 3% mannitol solution. Subsequently, high resolution 3D gradient-echo (volumetric interpolated breath-hold examination=VIBE) data sets were obtained pre-contrast and 20-40s, 60-80s, and 120-140 s after i.v. Gd-DOTA administration (0.2 mmol/kg). Signal enhancement was measured on single slices both in normal and histologically confirmed (12/13) inflamed small bowel wall segments as well as in the aorta, the psoas muscle, and the background to calculate signal-to-noise (SNR) and contrast-to-noise ratios (CNR).Small bowel wall enhancement was significantly higher (p0.05) in inflamed compared to normal segments at 20-40s (SNR inflamed: 58.7+/-33.8 vs normal: 36.0+/-19.8; p=0.048; CNR inflamed: 34.8+/-23.4 vs normal: 16.3+/-11.2; p=0.017) and at 60-80s (SNR: 60.3+/-25.1 vs 41.9+/-20.0; p=0.049; CNR: 34.9+/-15.1 vs 19.3+/-13.2; p=0.01) after i.v. contrast administration, respectively. Even at 120-140 s CNR was still increased in inflamed segments (33.7+/-16.0 vs 18.1+/-13.2; p=0.04), while differences in SNR did not attain statistical significance (63.0+/-26.2 vs 45.3+/-23.3; p=0.15).In active Crohn's disease, histologically confirmed inflamed small bowel wall segments demonstrate a significantly increased early uptake of gadolinium on 3D VIBE sequences compared to normal small bowel segments.

Forty-one patients underwent nonsurgical removal of postoperatively retained bile duct stones in two nonrandomized groups. The endoscopic-retrograde technique was used in 21 patients, and succeeded in 19. The percutaneous approach through the T-tube tract was used in 22 patients, including the two in whom endoscopic stone removal had failed, and was successful in 21 patients. Individual preferences and prior history introduced a selection bias against the percutaneous technique. Auxiliary extracorporeal shockwave lithotripsy (ESWL) was used in 2 patients whose stones could not be fragmented mechanically by the percutaneous basket technique. ESWL was successful in one patient but failed in the second. Because endoscopy had also failed in this case, the patient subsequently underwent repeat surgery. Procedure-related complications were minor with both techniques and were readily treated by conservative measures. We conclude that both the retrograde and the percutaneous approaches are effective and safe. The endoscopic approach appears convenient because there is no need to await maturation of the percutaneous tract, but sphincterotomy carries a small but distinctive risk. Because the percutaneous approach uses an existing tract, is only minimally invasive and leaves the sphincter of Oddi intact, it is preferable in those patients who have T-tubes of approapriate size and position in place.

Aim First, to assess the clarithromycin resistance (Cla(R)) rate 1) in patients with persistent Helicobacter pylori (H. pylori) infection after eradication,2) in patients with untreated infection and 3) in patients with successful status post eradication. Second, to evaluate the techniques sequencing and line probe hybridisation INNO-LipA for resolution of uniform and mixed populations in archival gastric biopsy samples. Methods The genomic 2142/43 23s rRNA mutations of the 50S ribosomal subunit conferring Cla(R) were detected by PCR-based assays. Results A total of 130 patients were investigated. Out of 21 patients of a first series with persistent infection after eradication, 19 (90%; CI (95%): 67-99%) exhibited point mutations at position 2142/43. In the second series of untreated patients, primary resistance was observed in 8 out of 93 patients (9%; CI: 4-16%). In a third series of 16 successfully eradicated patients, pure wild type populations (WT; for loci 2142/43) without any minimal mutated part were found (resistance rate 0%; CI: 0-21%). Further, in all 24 biopsies with uniform mutated and in 8 of 11 biopsies with mixed populations the two molecular biological methods yielded concordant results (100%; CI: 86-100% and 73%; CI: 39-94%, respectively). Conclusion In the Baden region of Switzerland, most clarithromycin resistant H. pylori strains harbour mutations at position 2142/43. The primary resistance rate is below 10%. Mixed populations, even with minor mutated part, cannot become successfully eradicated. The two investigated techniques are equally valid for resolution of uniform mutated or mixed H. pylori populations in archival biopsy material.