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The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.

Although NSAID-induced colonopathy characterised by erosions, ulcers, strictures and diaphragms has been known for quite some time, it is not infrequently misinterpreted endoscopically and histologically as Crohn's disease. This is exemplified by the present case history of a 39-year-old man with bloody diarrhoea and a stenosis in the transverse colon that was histologically interpreted as "consistent with Crohn's disease". Treatment with glucocorticoids, however, merely gave rise to adverse reactions. After surgical treatment of the stenosis, the episodes of bloody diarrhoea persisted, and endoscopy continued to reveal erosions and ulcers in the transverse colon. Changing treatment to azathioprine also failed to produce any positive response, merely causing side effects. Subsequent evaluation of the histological specimens by a consultant pathologist turned up the tentative diagnosis of NSAID-induced colonopathy. An analysis of the patient's medical history revealed that he was suffering from Bechterew's disease, for which he had long been taking diclofenac. This case history is a good example of the fact that NSAID-induced enterocolopathy is still too poorly recognised among internists, gastroenterologists and pathologists, and, on the basis of the discontinuous endoscopic and histological findings, is often misinterpreted as Crohn's disease.

Multiple biopsies from the lower duodenum were obtained during endoscopy of 171 patients with dyspepsia, diarrhoea and/or suspected malabsorption. Histological evidence of lambliasis was obtained in six (3.5%). Antibiotic treatment with metronidazole, 250 mg two or three times daily for seven to 11 days (which had to be repeated in two cases), improved symptoms in four. In most of the patients "functional upper-abdominal symptoms" had been diagnosed after extensive examinations. In case of unclear upper-abdominal symptoms, chronic or chronic-recurrent diarrhoea and/or malabsorption lambliasis should be considered and histological examination of the duodenal mucosa undertaken.

In an experiment testing the resorption of Poly-l-lactate in the back muscles of Cara rats a foreign body sarcoma occurred in two rats. 20 months after implantation of a body of high molecular weight poly-l-lactate a malignant fibrous histiocytoma developed in one rat. A soft tissue tumor, which was classified according to the immune-histiochemical analysis as a neurogenic sarcoma, developed 23 months after the implantation of a body of injection-casted poly-l-lactate of high molecular weight in a second rat.

The gastrointestinal wall can be separated into 5 layers by means of ultrasonic endoscopy and also by external ultrasound when using a probe of 5 Mhz. We studied the relationship between these echographic layers and the real anatomical structures by means of in-vitro examination of surgical specimens. The anatomical layers were separated in these specimens step by step. We found that the first and the fifth hyperechoic layers are border echos. The 2. (inner echopoor layer), the 3. (middle echogenic layer) and the 4. (outer echopoor layer) correspond to the mucosa, the submucosa and the muscularis propria, respectively. In so far, the differentiation between early cancer and advanced cancer of the stomach should be possible by endoscopic ultrasonography.

Groove pancreatitis is a special type of segmental pancreatitis. Its morphological aspects with participation of the peripheral dorsal and cranial parts of the pancreatic head, the pancreatic soft tissue, and the duodenal wall with frequent narrowing of the distal common bile duct and suprapapillar stenosis of the duodenum can be detected by means of sonography. If this type of seqmental pancreatitis is known, the suspicion of a carcinoma of the pancreatic head can be removed.

Biophysical restoration or rehabilitation measures of land have demonstrated to be effective in many scientific projects and small-scale environmental experiments. However circumstances such as poverty, weak policies, or inefficient scientific knowledge transmission can hinder the effective upscaling of land restoration and the long term maintenance of proven sustainable use of soil and water. This may be especially worrisome in lands with harsh environmental conditions. This review covers recent efforts in landscape restoration and rehabilitation with a functional perspective aiming to simultaneously achieve ecosystem sustainability, economic efficiency, and social wellbeing. Water management and rehabilitation of ecosystem services in croplands, rangelands, forests, and coastlands are reviewed. The joint analysis of such diverse ecosystems provides a wide perspective to determine: (i) multifaceted impacts on biophysical and socio-economic factors; and (ii) elements influencing effective upscaling of sustainable land management practices. One conclusion can be highlighted: voluntary adoption is based on different pillars, i.e. external material and economic support, and spread of success information at the local scale to demonstrate the multidimensional benefits of sustainable land management. For the successful upscaling of land management, more attention must be paid to the social system from the first involvement stage, up to the long term maintenance. © 2016 by the authors.

Background. Barrett’s oesophagus embodies the risk of malignant transformation. High-grade intraepithelial neoplasia and early cancer in Barrett’s oesophagus are often discrete or macroscopically occult lesions and show a patchy distribution and therefore, directed biopsies in combination with four-quadrant random biopsies are the gold standard for surveillance. Aims. The aim of this prospective study was to compare methylene blue staining and random biopsies in patients with early Barrett’s neoplasia. Patients and methods. Eighty-six patients (mean age 65 ± 8 years) with histologically proven but macroscopically in evident high-grade intraepithelial neoplasia (n = 17) or early cancer in Barrett’s oesophagus (n = 69) on HR-endoscopy with all together 98 lesions, were included. In the first step, four-quadrant random biopsies were taken during routine endoscopy (group I). In a second step, staining was performed with a 0.5% solution of methylene blue with a spray catheter. Biopsies of focal areas with decreased stain, heterogeneity of stain or absence stain were taken (group II). Results. In 75/86 patients, high-grade intraepithelial neoplasia or early cancer in Barrett’s oesophagus could be diagnosed in the methylene blue group while 56 patients were determined in the random biopsies group (P = 0.053). High-grade intraepithelial neoplasia or early cancer was diagnosed in significantly more methylene blue-directed biopsies (80.9% versus 26.4%, P < 0.005) and also significantly more lesions could be identified in the methylene blue group (96/98; 98%) while in the random biopsies group only 58/98 lesions (59%) could be localised (P < 0.05). When methylene blue was used (1217 versus 562, P < 0.0001), the average number of specimens taken with methylene blue per patient was about half of that with random biopsy (6.5 versus 14.1, P < 0.0001). Conclusions. Chromoendoscopy with methylene blue diagnosed significantly more patients and lesions with intraepithelial neoplasia or early cancer in Barrett’s oesophagus compared to random biopsies. In addition, significantly less biopsies were needed with methylene blue compared to random biopsies. The use of methylene blue-directed biopsies appears to improve the detection of intraepithelial neoplasia and early cancer in Barrett’s oesophagus. © 2006 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Dieulafoy's lesion was described in 1896 by the French pathologist Georges D. Dieulafoy as a vascular malformation in the stomach. Although usually found in the stomach, the lesion may occur anywhere within the gastrointestinal tract and can cause severe hemorrhage. There is no sex or age predilection. The diagnosis is established endoscopically, and the current therapy of choice is endoscopic hemoclipping. Only rarely is the diagnosis confirmed histologically. We report the case of an elderly female patient who, while hospitalised for a slipped intervertebral disc, presented with lower gastrointestinal bleeding. The source of the bleeding was suspected to be in the right colon by endoscopy. Renewed massive bleeding necessitated surgical treatment with resection of the right hemicolon. The histological work-up of the resected specimen identified a 350-micron large tortuous submucosal artery that had eroded.

Since the rediscovery of spiral-shaped gastric bacteria in 1983 by Warren and Marshal numerous detailed facts have enlarged our knowledge base for a better understanding of gastritis. The WHO classified Helicobacter as a class 1 carcinogen. Helicobacter plays a role in many diseases of the upper GI tract (gastric and duodenal ulcer, MALT lymphoma, and gastric cancer). Knowledge of the interaction between bacterium and host led to an improvement of the diagnosis of gastritis. Unfortunately endoscopy, histology, and patient's symptoms do not correlate with each other. Therefore, gastritis is a purely histological diagnosis. A histological diagnosis always needs to be accompanied by an etiological cause of the inflammation. Only when this information is given a clinical consequence can be drawn from a histological diagnosis. In Germany the so-called ABCD scheme of gastritis is widely used (A: autoimmune gastritis, B: bacterial gastritis, C: chemical reactive gastritis, D: other forms of gastritis). At least two antrum and two corpus biopsies (matrix diagnostics) are necessary to reach representative tissue with an acceptable probability. If less than these four (minimal standard) biopsies are taken, the histological diagnosis will remain uncertain.

Zygomycosis (Mucor- and Entomophtoramycosis) of the gastrointestinal tract is rare compared to other mycoses in the gastrointestinal area. The infection occurs mainly in immunosuppressed patients but rare cases concerning immunocompetent persons are also documented. Zygomycosis occurs in the gastrointestine primarily or due to disseminated disease. We report on a 48-year-old female alcohol-addicted patient who underwent gastric biopsies. The biopsy results showed invasive zygomycosis. Shortly thereafter, the patient died of sepsis. The second case presented here is a 15-year-old female patient with recurrent vomiting. Histological and immunohistochemical analysis of duodenal biopsy specimens revealed fungi of the class Zygomycetes. In addition, histological and/or microbiological examination demonstrated the presence of Candida in both cases.Zygomycosis of the gastrointestinal tract can have an aggressive course, making it important to know the morphological characteristics of the disease to facilitate early diagnosis and therapy. This is all the more important because the cultivation of fungi, as in our cases, is not always successful.

We report on a 22-year-old man with dysphagia and repeated bolus impaction in the esophagus for 10 years. Bolus impactions were frequently mobilised using an endoscope. At endoscopy, esophagitis IV degrees was described. After treatment with omeprazol there was no improvement. The patient was submitted to our hospital for fundoplication. pH-metry demonstrated an increased reflux. At endoscopy of the esophagus, we found red stripes which did not show the typical appearance of erosions. Manometry and X-ray films of the esophagus did not reveal any pathological findings. In combination with anamnesis, symptoms, and endoscopy, the diagnosis of eosinophilic esophagitis was documented by histology. After administration of oral corticosteroids a rapid improvement of the clinical symptoms was observed. The diagnosis of eosinophilic esophagitis should be kept in mind in patients with chronic symptoms of gastroesophageal reflux persisting despite medical therapy, pathological pH-metry and repeated bolus impactions.

Background and aim: Evidence exists for the pathogenic role of the enteric flora in inflammatory bowel disease. Probiotics contain living microorganisms which exert health effects on the host. We compared the efficacy in maintaining remission of the probiotic preparation Escherichia coli Nissle 1917 and established therapy with mesalazine in patients with ulcerative colitis. Patients and methods: In total, 327 patients were recruited and assigned to a double blind, double dummy trial to receive either the probiotic drug 200 mg once daily (n = 162) or mesalazine 500 mg three times daily (n = 165). The study lasted for 12 months and patients were assessed by clinical and endoscopic activity indices (Rachmilewitz) as well as by histology. The primary aim of the study was to confirm equivalent efficacy of the two drugs in the prevention of relapses. Results: The per protocol analysis revealed relapses in 40/110 (36.4%) patients in the E coli Nissle 1917 group and 38/112 (33.9%) in the mesalazine group (significant equivalence p = 0.003). Subgroup analyses showed no differences between the treatment groups in terms of duration and localisation of disease or pretrial treatment. Safety profile and tolerability were very good for both groups and were not different. Conclusions: The probiotic drug E coli Nissle 1917 shows efficacy and safety in maintaining remission equivalent to the gold standard mesalazine in patients with ulcerative colitis. The effectiveness of probiotic treatment further underlines the pathogenetic significance of the enteric flora.

Case Report: A 72-year-old female patient with known neurofibromatosis type 1 was admitted to the hospital with symptomatic anaemia and a history of melaena. Upper and lower endoscopy did not show any signs of bleeding. Ultrasound and computed tomography revealed an abdominal mass. The histological analysis of a US-guided puncture showed a mesenchymal tumour with spindle-shaped appearance. Laparotomy revealed two jejunal tumours which could be classified as gastrointestinal stromal tumours (GIST) by immunohistochemistry. Conclusion: Patients with neurofibromatosis type 1 have an increased risk of developing gastrointestinal tumours including rare types such as GIST. Because the localisation in the small intestine by conventional endoscopy can be difficult, further diagnostic means such as ultrasound, computed tomography or possibly capsule endoscopy should be considered.

We propose a model for use with ordinal spatial data arising from field assessments of the grazing and trampling impact by animals on vegetation, and study the predictive performance of the model on partial surveys. We employ a mixed effects model, including a term for spatial correlation, which assumes a continuous underlying scale of grazing impact, and where the classification into discrete categories is made via cut-points. We analyse two classes of data: full census data and sample data drawn from the full census. In the latter case, we show that the estimation of nonsampled data improves as the spatial information included within the model increases.

The increasing use of endoscopic resection for curative treatment of early oesophageal cancers requires accurate staging before therapy. In a prospective blinded trial, we compared staging of early oesophageal carcinoma using high resolution endoscopy (HR-E) with staging using high resolution endosonography (HR-EUS).A total of 100 patients (89 men, 11 women; mean age 63.9 (10.8) years (range 31-91)) with a suspicion of early oesophageal adenocarcinoma (n = 81) or squamous cell carcinoma (n = 19) were enrolled in the study. After endoscopic staging with high resolution video endoscopy by two experienced endoscopists, HR-EUS was performed by an experienced endosonographer who was blinded to the endoscopic assessment. Results of the staging examinations were correlated with the histology of the resected tumours.Overall rates for accuracy of the endoscopic and endosonographic staging were 83.4% and 79.6%, respectively. Sensitivity for mucosal tumours (n = 68) was more than 90% (EUS 91.2%, endoscopy 94.1%) while sensitivity for submucosal tumours (n = 25) was lower, at 48% for EUS and 56% for endoscopic staging. A combination of the two techniques increased the sensitivity for submucosal tumours to 60%. Submucosal tumours in the tubular oesophagus were significantly better staged with HR-EUS than submucosal tumours close to the oesophagogastric junction (10/11 v 2/14; p0.001). Tumours infiltrating the second and third submucosal layers were also more correctly diagnosed than tumours with slight infiltration of the first submucosal layer (sm1).The overall diagnostic accuracy of both HR-E and HR-EUS with a 20 MHz miniprobe in early oesophageal cancer was high (approximately 80%), with no significant differences between the two techniques. HR-E and HR-EUS provide a high level of diagnostic accuracy for mucosal tumours and submucosal tumours located in the tubular part of the oesophagus. With submucosal tumours located at the oesophagogastric junction or with infiltration of the first third of the submucosa however, the diagnostic accuracy of both techniques is not yet satisfactory.

Introduction: Dilatation of intercellular spaces of the esophageal squamous epithelium has been suggested as a marker of early acid reflux-induced damage. This change is a potentially useful addition to histomorphological changes that represent so called minimal endoscopic lesions. We have assessed dilatation of intercellular spaces with regard to: (1) interobserver variability, and (2) whether the incidence of this varies between ‘red streaks’ and the adjacent normal looking squamous epithelium. Methods: Esophageal biopsies from 44 patients with chronic gastro-esophageal reflux (GERD) were evaluated. At endoscopy, these patients had one or more red streaks on the tops of the mucosal folds in the distal esophagus. Biopsies were taken from the red streaks and from the normal-appearing mucosa 1 cm lateral to the red streaks. Biopsies were assessed in a blinded fashion by two independent pathologists (MV & RF). Criteria for assessing intercellular space dilatation were evaluated and agreed on prior to the study. Results: Good interobserver agreement was recorded (kappa = 0.82 at the streaks and 0.77 for the control tissues) for absence/presence of intercellular space dilatation. Red streak and control biopsies differed significantly (p = 0.0001), with respect to presence of dilated intercellular spaces, with 90.5 % of the former demonstrating this as present compared to 56.1% in the controls. Conclusion: This study supports the concept that esophageal mucosal minimal changes due to reflux is localised and that dilatation of intercellular spaces is an early sign of reflux-induced epithelial damage. The low interobserver variability in the assessment of intercellular space dilatation suggests that this may be a useful variable for assessment of early signs of acid-reflux induced damage to the squamous epithelium of the esophagus by use of light microscopy.

Background: Upper oesophagogastroduodenoscopy is considered to be the gold standard for upper gastrointestinal disease assessment, but is currently seldom used in epidemiological studies. One concern is that the procedure may bias sampling among volunteers in a general adult population. The aim of this study was to explore whether the procedure affects symptom reporting. Methods: A random sample of 3000 adults aged 20-81 years (mean age 50.4), from two Swedish municipalities (n = 21,610) was surveyed using a validated postal questionnaire (the Abdominal Symptom Questionnaire) assessing gastrointestinal symptoms. A subsample of the responders was invited, in random order, to undergo an upper endoscopy and repeated symptom reporting using the same questionnaire, as well as a serology test for Helicobacter pylori. Results: The response rate to the initial questionnaire was 74.2% and the participation rate for those eligible for the upper endoscopy was 73.3% (n = 1001, mean age 54.0 years, 48.8% male). No maj...

In den letzten Jahrzehnten hat sich die endoskopische Polypektomie kolorektaler Adenome gegenuber chirurgischen Verfahren durchgesetzt. Dies gilt auch fur die kolorektalen Adenokarzinome mit Invasion der Submukosa (pT1). Es stellt sich die Frage, bei welcher Befundkonstellation primar eine chirurgische Therapie anzustreben ist. Ein sehr gutes Mas ist die Wahrscheinlichkeit von Lympknotenmetastasen, die es gegen das Operationsrisiko abzuwagen gilt.

Die sehr seltene intestinale Spirochatose wird immer dann diagnostiziert, wenn in den Biopsaten aus einer endoskopisch normalen kolorektalen Schleimhaut ein basophiler Saum zwischen den Mikrovilli des Deckepithels der kolorektalen Schleimhaut nachzuweisen ist. Die bakteriologische Klassifikation der in Spezialfarbungen (z. B. Warthin-Starry-Versilberung) und elektronenmikroskopisch nachweisbaren Bakterien ist immer noch unklar. Umstritten ist auch noch, ob es sich bei dieser Spirochatenbesiedlung um pathogene Keime handelt. Gegen die Pathogenitat spricht, dass histologisch keine entzundliche Reaktion nachzuweisen ist. Auch die Symptomatik der Patienten mit intestinaler Spirochatose lasst keine Aussage zu der Frage zu, ob es sich um eine pathogene oder apathogene Kolonisation der kolorektalen Schleimhaut handelt. Einige Studien scheinen aber zu belegen, dass die Spirochatose Ursache fur Symptome wie Diarrhoen, Obstipation und abdominale Schmerzen sein konnten. Fur diese pathogene Bedeutung spricht auch, dass diese Symptome nach erfolgreicher Therapie mit Metronidazol verschwinden konnen. Die histologische Diagnose ist leicht zu stellen, wenn man bei scheinbar normalem histologischen Befund der kolorektalen Schleimhaut an die Moglichkeit der Spirochatose denkt und gezielt nach dem basophilen Saum im Deckepithel der kolorektalen Schleimhaut sucht.

Background/Aims: Helicobacter pylori gastritis is a risk factor for the development of gastric cancer. The results of several studies indicate that gastric adenomas, which are considered premalignant lesions, may also be associated with H pylori gastritis. However, it is not clear whether there are different patterns of gastritis in these patients compared with patients with gastric cancer or patients with H pylori gastritis alone. Therefore, this study was designed to investigate the patterns of gastritis in these three groups of patients. Methods: The histological features of gastric mucosa at a distance from the tumour were analysed prospectively in 118 patients with gastric adenoma (mean age, 71.8; female to male ratio, 6 : 4). In addition, for every patient with H pylori associated gastric adenoma an age and sex matched control patient with either H pylori associated early gastric cancer of the intestinal type or H pylori gastritis only was investigated. Results: Only 60 patients (50.9%) with gastric adenoma were infected with H pylori . In the remaining patients, complete atrophic gastritis predominated. In those patients with adenoma and H pylori infection, the gastritis was similar to that seen in patients with early gastric cancer (median score, 2 for activity and degree of gastritis in the antrum and corpus); intestinal metaplasia was common to both groups. These two groups differed significantly from patients with H pylori gastritis only (median grade and activity of gastritis, 1 in antrum and corpus), in whom intestinal metaplasia was rare. Conclusions: It appears that gastric adenomas and gastric intestinal cancer arise by analogous mechanisms. However, owing to severe atrophic gastritis and a lower incidence of H pylori , adenomas do not appear to be definite precursor lesions for gastric cancer.