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Background Patients with liver cirrhosis often suffer from complications such as ascites, gastrointestinal bleeding, and infections, resulting in impaired quality of life. Frequently, the close relatives of patients also suffer from a lower quality of life in chronic diseases. In recent years, acute-to-chronic liver failure has been defined as a separate entity with high mortality. Often several organs are affected which makes intensive care therapy necessary. Little is known about the influence of acute-on-chronic-liver failure (ACLF) on the quality of life of patients and the psychosocial burden on close relatives. Aim The purpose of this prospective study is to investigate the influence of decompensated liver cirrhosis and the onset of ACLF of the patient’s’ quality of life and the psychosocial burden of close relatives. Method In this non – randomized prospective cohort study a total of 63 patients with acute decompensation of liver cirrhosis and hospital admission were enrolled in the study. To assess the quality of life of patients, the disease specific CLDQ questionnaire was assessed. In addition. Quality of life and psychosocial burden of first degree relatives was measured using the generic SF-36 questionnaire as well as the Zarit Burden Score. Results 21 of the 63 patients suffered from ACLF. Patients with ACLF showed a lower quality of life in terms of worries compared to patients with only decompensated liver cirrhosis (3,57 ± 1,17 vs. 4,48 ± 1,27; p value: 0,008) and increased systemic symptoms (3,29 ± 1,19 vs. 4,48 ± 1,58; p value: 0,004). The univariate analysis confirmed the link between the existence of an ACLF and the concerns of patients. (p value: 0,001). The organ failure score was significantly associated with overall CLDQ scores, especially with worries and systemic symptoms of patients. Interestingly the psychosocial burden and quality of life of close relative correlates with patient’s quality of life and was influenced by the onset of an acute-on-chronic liver failure. Conclusion Patients with decompensated liver cirrhosis suffer from impaired quality of life. In particular, patients with ACLF have a significantly reduced quality of life. The extent of the psychosocial burden on close relative correlates with poor quality of life in patients with decompensated liver disease and is influenced by the existence of ACLF.

BACKGROUND: Hepatorenal syndrome (HRS) is associated with a poor prognosis. In HRS type 1, loss of renal function is rapidly progressive, while HRS type 2 is characterised by chronic ascites and more moderately elevated renal parameters. While treatment with terlipressin/albumin is well established in type 1, its effectiveness in chronic HRS is less clear. OBJECTIVE: The aim of this study was to evaluate the effectiveness of terlipressin/albumin treatment in patients with HRS type 2. METHODS: All patients with a first episode of HRS between April 2013 and February 2016 were included in this observational study. Relevant clinical and laboratory parameters were recorded and patients were followed. RESULTS: A total of 106 patients with HRS were included. With terlipressin therapy reversal of HRS types 1 and 2 was achieved in 48% and 46% of patients (p = 0.84) with relapse rates of 8% vs 50% (p = 0.001). Overall survival (OS) and survival free of liver transplantation (LTx) were similar in HRS types 1 and 2 (p = 0.69; p = 0.64). In multivariate analysis response to treatment was independently associated with better OS in HRS type 2, in addition to established risk factors such as lower Model for End-Stage Liver Disease score, absence of hepatic encephalopathy and eligibility for LTx. CONCLUSION: A terlipressin treatment course seems to be justified in selected patients with HRS type 2, especially in countries and settings with long transplant waiting lists. In addition treatment response might also help to identify HRS type 2 patients with a more favourable outcome.

Diagnosis of covert hepatic encephalopathy (CHE) is time consuming in clinical practice. Recently, a new diagnostic tool - the simplified Animal Naming Test (S-ANT1) - was presented with promising results in an Italian cohort. The aim of the present study was to validate S-ANT1 in a cohort of cirrhotic patients from a German tertiary referral centre.143 cirrhotic patients and 37 healthy controls were enrolled. Hepatic encephalopathy (HE) grade 1 (HE1) was clinically diagnosed according to the West-Haven Criteria. Critical flicker frequency and Psychometric Hepatic Encephalopathy Score were used to detect minimal HE (MHE). All participants were additionally examined by S-ANT1.58 (40.6%) patients presented with CHE (40 MHE, 18 HE1). S-ANT1 was lowest in patients with HE1, followed by patients with MHE, patients without CHE, and healthy controls, respectively (each p 0.05). Naming20 animals discriminated best between patients with and without CHE in ROC analysis (with Youden's index). With a cut-off value of ≥23 mentioned animal names further testing for CHE could be avoided in 38.5% of patients with a negative predictive value of 84%.S-ANT1 may become an important first screening tool for the assessment of CHE in clinical practice.

BACKGROUND Minimal hepatic encephalopathy (HE) and HE grade 1 (HE1) according to the West Haven criteria have recently been grouped as one entity named-covert HE- (CHE). Data regarding the impact of CHE on health-related quality of life (HRQoL) and sleep quality are controversial. AIM First, to determine whether CHE affects HRQoL and sleep quality of cirrhotic patients and second, whether minimal HE (MHE) and HE1 affect HRQoL and sleep quality to a comparable extent. METHODS A total of 145 consecutive cirrhotic patients were enrolled. HE1 was diagnosed clinically according to the West Haven criteria. Critical flicker frequency and the Psychometric Hepatic Encephalopathy Score were used to detect MHE. Chronic Liver Disease Questionnaire (CLDQ) was used to assess HRQoL and Pittsburgh Sleep Quality Index (PSQI) was applied to assess sleep quality. RESULTS Covert HE was detected in 59 (40.7%) patients (MHE: n = 40; HE1: n = 19). Multivariate analysis identified CHE (P

Zusammenfassung Hintergrund Leberwerterhöhungen stellen in der Hausarztpraxis eine häufige Zufallsdiagnose dar. Bislang fehlt ein evidenzbasierter, strukturierter Diagnosealgorithmus zur Einordnung und Bewertung erhöhter Leberwerte, insbesondere im Hinblick auf die Früherkennung von Patienten mit erhöhtem Risiko für eine Leberfibrose oder Leberzirrhose. Dementsprechend stellt der Umgang mit erhöhten Leberwerten, welche im Rahmen einer allgemeinen Blutuntersuchung auffallen, eine diagnostische Herausforderung dar, die stark vom jeweiligen Arzt abhängt. Methoden Mittels schriftlicher Befragung wurden zwischen März und Juni 2017 insgesamt 391 Hausärzte in Rheinland-Pfalz und im Saarland zum Vorgehen bei Leberwerterhöhungen befragt. Schwerpunkte waren Verhalten und Strategien bei der Abklärung (unklar) erhöhter Leberwerte sowie die Identifizierung von Herausforderungen und Fortbildungsinteressen. Neben der deskriptiven Analyse kam eine Faktorenanalyse zum Einsatz. Ergebnisse Die nicht-anlassbezogene Bestimmung von Leberwerten wie γ-GT, AST und ALT wird in der hausärztlichen Praxis häufig durchgeführt. Für die bestimmten leberassoziierten Laborwerte zeigen sich stark unterschiedliche Cluster. Im Fall erhöhter Leberwerte präferiert eine Mehrheit der Hausärzte grundsätzlich ein kontrolliertes Zuwarten (58 %). In Ermangelung eines feststehenden Behandlungspfads treten im Praxisalltag Herausforderungen auf, die sich auf das kontrollierte Zuwarten, die Zusammenarbeit mit gastroenterologischen Fachärzten sowie die Orientierung an vorgegebenen Laborwertportfolios beziehen. Schlussfolgerung Neben der Einführung eines evidenzbasierten Algorithmus ist über eine Optimierung im Informationsfluss zwischen Haus- und Fachärzten nachzudenken. Der Ausbau von themenbezogenen Schulungs- und Fortbildungsformaten für Hausärzte wäre begrüßenswert.

Nonerosive reflux disease (NERD) is commonly diagnosed in patients with symptoms of reflux. The aim of the present study was to determine whether high-definition endoscopy (HD) plus equipped with the iScan function or chromoendoscopy with Lugol's solution might permit the differentiation of NERD patients from those without reflux symptoms, proven by targeted biopsies of endoscopic lesions. A total of 100 patients without regular intake of proton pump inhibitors and with a normal conventional upper endoscopy were prospectively divided into NERD patients and controls. A second upper endoscopy was performed using HD+ with additional iScan function and then Lugol's solution was applied. Biopsy specimens were taken from the gastroesophageal junction in all patients. A total of 65 patients with reflux symptoms and 27 controls were included. HD(+) endoscopy with iScan revealed subtle mucosal breaks in 52 patients; the subsequent biopsies confirmed esophagitis in all cases. After Lugol's solution, 58 patients showed mucosal breaks. Sensitivity for the iScan procedure was 82.5%, whereas that for Lugol's solution was 92.06%. Excellent positive predictive values of 100% and 98.3%, respectively, were noted. The present study suggests that the majority of patients with NERD and typical symptoms of reflux disease can be identified by iScan or Lugol's chromoendoscopy as minimal erosive reflux disease (ERD) patients.

Background Current EASL/AASLD guidelines recommend treatment of covert hepatic encephalopathy (HE) only in symptomatic patients, for example, in those with impaired quality of life or with affected driving abilities. Goals Because testing for impaired quality of life is time consuming, the aim of the present study was to identify simple clinical predictors for poor quality of life in patients with covert HE (CHE). Study In total, 139 cirrhotic in- and outpatients without a history of overt hepatic encephalopathy were enrolled. Diagnosis of HE grade 1 (HE1) was diagnosed clinically according to the West-Haven Criteria. Critical flicker frequency and the Psychometric Hepatic Encephalopathy Score were used to detect minimal HE (MHE). Chronic Liver Disease Questionnaire was used to assess health-related quality of life (HrQoL). Results CHE was detected in 51 (36.7%) patients. Multivariate analysis identified a history of falls in the previous year (P=0.003) and female gender (P=0.030) as independent predictors of reduced HRQoL in patients with CHE. Comparison of patients with and without a history of falls revealed relevant differences in the subdomains-abdominal symptoms, fatigue, systemic symptoms, emotional functions and worries. Conclusions A history of falls and female gender are associated with impaired HRQoL in patients with CHE. These data indicate that a history of falls should be considered as a treatment indication in patients with CHE to improve HRQoL and ultimately prognosis.

Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments. All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding. In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9 %) presented with suspected GI bleeding, and 165 patients (58 %) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21 %). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation of suspected GI bleeding (79 % of patients with MTS priority levels 1 or 2, 53 % in level 3 patients, and 40 % in levels 4 or 5 patients; p = 0.024). The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding. Eine gastrointestinale Blutung ist eine der häufigsten gastroenterologischen Verdachtsdiagnosen in einer Notaufnahme. Obwohl diverse Scores zur Einschätzung der schwere einer gastrointestinalen Blutung existieren, kann die primäre notfallmedizinische Einschätzung dieser Patienten dennoch herausfordernd sein. Das Manchester Triage System (MTS) ist ein validierter Score, der für Patienten unabhängig von diagnostischen Befunden zur Triage bei der initialen Aufnahme in einer Notaufnahme von nicht ärztlichem Personal angewandt wird. Alle Akten von gastroenterologischen Patienten die zwischen Januar 2014 und Dezember 2014 in unserer Notaufnahme eines Maximalversorgers behandelt wurden, wurden retrospektiv analysiert. Das Ziel unserer retrospektiven Analyse war es zu untersuchen, ob die Anwendung des MTS mit der endoskopischen Diagnostik und dem Befund einer aktiven gastrointestinalen Blutung korreliert. Insgesamt wurden 5689 Patienten in einem Jahr mit einer gastrointestinalen Symptomatik in unserer Notaufnahme behandelt. Bei 284 Patienten (4,9 %) wurde eine gastrointestinale Blutung vermutet. 165 Patienten (58 %) erhielten akut oder im Verlauf eine endoskopische Diagnostik. Dabei war eine endoskopische Intervention bei 34 Patienten (21 %) notwendig. Patienten die in höheren MTS Notfallkategorien klassifiziert waren, zeigten höhere Raten an endoskopisch bestätigten gastrointestinalen Blutungen. (79 % mit MTS Level 1 oder 2, 53 % in Level 3 und 40 % in Level 4 oder 5; p = 0,024). Das MTS ist ein etabliertes Triage System in Notaufnahmen. Es kann angenommen werden, dass dieses einfach zu bedienende System auch das Potential hat, klinische Entscheidungen für eine Notfallendoskopie bei Patienten mit dem Verdacht auf eine gastrointestinale Blutung zu unterstützen.

Hintergrund und Fragestellung | Das hepatorenale Syndrom (HRS) ist eine schwere, potenziell reversible Komplikation bei Patienten mit Leberzirrhose. Unbehandelt ist die Prognose sehr schlecht. Fur eine Behandlung mit Terlipressin in Kombination mit Humanalbumin wurde in mehreren randomisiert-kontrollierten Studien eine Verbesserung der Nierenfunktion demonstriert, der Einfluss dieser Therapie auf die Gesamtprognose bleibt allerdings unklar. Im Rahmen der vorliegenden Observations-Studie sollte der Effekt einer Terlipressin-Behandlung bei HRS auf Nierenfunktion, Gesamtuberleben sowie dialyse- und transplantationsfreiem Uberleben untersucht werden. Patienten und Methodik | Uber einen Zeitraum von 12 Monaten wurden in unserem Zentrum alle Patienten mit HRS und Terlipressin-Therapie prospektiv erfasst. Klinisch relevante Parameter, Therapiecharakteristika, Ansprechen, Gesamtuberleben, Dialyseeinleitung und Lebertransplantation (LTx) wurden ausgewertet. Ergebnisse | Insgesamt wurden 57 Patienten uber einen medianen Zeitraum von 65 Tagen prospektiv beobachtet. Bei der Mehrzahl der Patienten lag ein fortgeschrittenes Zirrhose-Stadium vor (Child-Pugh C: 46; 81 %). Die kumulative Terlipressin-Dosis bzw. -Behandlungsdauer betrug im Median 20 mg bzw. 5 Tage. Ein komplettes oder partielles Ansprechen auf Terlipressin im Sinne einer HRS-Ruckbildung wurde in 29 bzw. 3 von 57 Patienten beobachtet (51 %; 5 %). Patienten mit Terlipressin-Ansprechen zeigten mit einem medianen Gesamtuberleben von 167 vs. 27 Tagen bzw. einem dialyse- und LTx-freiem Uberleben von 81 vs. 4 Tagen eine signifikant bessere Gesamtprognose als Patienten mit Nicht-Ansprechen. In einer uni- und multivariaten Analyse war eine hohe Ausgangs-Serum-Bilirubin-Konzentration mit dem Nicht-Ansprechen assoziiert. Folgerung | Terlipressin in Kombination mit Humanalbumin ist eine effektive Therapie beim HRS. Das Terlipressin-Ansprechen ist dabei mit einem signifikanten Uberlebensvorteil assoziiert.

Hintergrund und Fragestellung: Die Leberzirrhose entsteht als Komplikation und Endstadium chronischer Lebererkrankungen. Der klinische Verlauf ist wesentlich von der Atiologie der Grunderkrankung und den begleitenden Risikofaktoren abhangig. Wir haben Atiologie, klinischen Verlauf und Therapie von Patienten mit Leberzirrhose an unserem Zentrum analysiert, um Risikofaktoren fur Infektionen zu identifizieren. Methodik: Nach standardisierter Erfassung ambulanter Patienten erfolgte eine retrospektive Auswertung uber 20 Monaten (Juli 2012 – Februar 2014). Zugrunde lagen die Daten von 236 Patienten (159 Manner, 77 Frauen, medianes Alter 57,0 [22–81] Jahre). Zwei Subgruppen wurden gesondert auf Infektionen (A) und Komplikationen (B) untersucht. Ergebnisse: Als haufige Ursachen wurden Alkoholkonsum (52 %), chronische Hepatitis C (28 %) oder B (14 %) und nichtalkoholische Steatohepatitis (NASH; 6 %) festgestellt. Zum Zeitpunkt der ersten Vorstellung befanden sich 55 % der Patienten im Stadium A nach Child-Turcotte-Pugh (CTP); 30 % waren bereits im Stadium B und 15 % im Stadium C. Erfasste Komplikationen der Gruppe B waren wie folgt verteilt: 14 % Pleuraergusse, 18 % hepatorenales Syndrom, 25 % hepatische Enzephalopathie, 49 % Aszites, 60 % Osophagusvarizen. Nach klinischen Kriterien konnte bei 16 % der Patienten der Gruppe A eine Infektion festgestellt werden, allerdings gelang nur bei 8 von 21 dieser Patienten ein Erregernachweis. Ein erhohtes Risiko fur Infektionen konnte in der multivariaten Analyse (p = 0,046, OR 3,607) lediglich fur Aszites gezeigt werden. Folgerung : Trotz verbesserter Therapieoptionen waren in unserem Zentrum Virushepatitiden weiterhin eine haufige Ursache der Leberzirrhose. Daneben sind alkoholbedingte Leberzirrhosen von zentraler Bedeutung. Zu den Hauptkomplikationen zahlen Infektionen und Folgen der portalen Hypertension.

ZusammenfassungNach der Rückkehr aus dem Urlaub wurde ein 55-jähriger Patient mit Teerstuhl und hämorrhagischem Schock im Zugabteil eines InterCity der Deutschen Bahn notfallmedizinisch versorgt und in ein Krankenhaus der Maximalversorgung eingeliefert. Hier erfolgte zunächst die weitere notfallmedizinische Behandlung, in deren Rahmen in der internistischen Notaufnahme in interdisziplinärer Zusammenarbeit eine Stabilisierung der Hämodynamik sowie die Sicherung der Atemwege und Atemfunktion erfolgten. Anschließend wurde eine Notfall-Endoskopie des oberen Gastrointestinaltrakts durchgeführt. Ursächlich für das hämorrhagische Schockgeschehen war eine arteriell spritzende, endoskopisch nicht zu stillende Blutung im Duodenum. Die definitive Blutungsstillung gelingt schließlich im Rahmen einer notfallmäßigen Laparatomie. Durch ein an die Versorgung traumatologischer Patienten angelehntes, aber für gastroenterologische Patienten mit Schockgeschehen nicht regelhaft vorhandenes Schockraum-Management konnte im vorliegenden Falle eines hochgradig instabilen Patienten durch die spontane Übernahme von etablierten Algorithmen aus der interdisziplinären Versorgung von Trauma-Patienten eine adäquate Kreislaufstabilisierung sowie Blutungskontrolle erreicht werden. Auch wenn ein Großteil der oberen gastrointestinalen Blutungen spontan sistieren, sollte wie für hier berichtete internistische Notfälle mit hämorrhagischem Schockgeschehen eine notfallmedizinische Versorgung nach Algorithmen entwickelt und implementiert werden. Am vorliegenden Fall wird ein mögliches beispielhaftes Vorgehen diskutiert sowie ein Vorschlag für ein mögliches Schockraum-Protokoll für diese Patientengruppe entwickelt.

Background: Hepatocellular carcinoma (HCC) is the most deadly complication of all major chronic liver diseases. Since early detection is the most significant determinant of overall survival, intense screening is of major importance. Methods: This overview is based on a systematic review of the available literature on HCC screening and surveillance in the PubMed database. Results: Over the last decades, major etiological risk factors were identified and the population at highest risk for the development of HCC was clearly defined. Screening in these patients has been repeatedly demonstrated to detect early tumor stages and to be cost-effective. Therefore, screening is recommended by all current guidelines and usually comprises a bi-annual ultrasound examination in Western countries. In some Asian countries biomarkers are also used; however, their efficiency for Western HCCs remains to be determined. The detection of lesions >1 cm during routine screening requires subsequent confirmation of HCC. The diagnosis can be accurately established by modern imaging techniques, i.e. computed tomography or magnetic resonance imaging, in the majority of patients. In ambiguous cases and if radiological criteria are not met by two imaging techniques, biopsies remain the gold standard for diagnosis. Furthermore, histology is of key importance for the development of new diagnostic and predictive biomarkers. Conclusion: Screening and detection algorithms for patients at risk for HCC are effective and should be rigorously implemented in clinical routine.

IgG4-related disease has gained increased attention worldwide. While the initial focus was on autoimmune pancreatitis which was first described in Asian populations and turned out to be of relevance in Western populations too, the scope has recently broadened towards a notion of a multi-systemic disease with very diverse manifestations such as autoimmune pancreatitis, IgG4-related sclerosing cholangitis (IgG4-SC), retroperitoneal fibrosis and tubulointerstitial nephritis. IgG4-SC (also known as IgG4-associated cholangitis, IAC) represents a rare but clinically challenging differential diagnosis in patients with obstructive jaundice and proximal extra- or intrahepatic biliary strictures which can be mistaken for cholangiocarcinoma (CC). We present the case of a 79-year-old male patient who presented with obstructive jaundice and biliary strictures at the hepatic duct bifurcation without any evidence for autoimmune pancreatitis and without elevation of serum IgG4-concentrations who underwent hemihepatectomy for suspected CC. However, on histological examination of the resection specimen CC could not be confirmed. It was only after several episodes of obstructive jaundice had reoccurred that the diagnosis of IgG4-SC could be established by reexamination of the surgical specimen which showed extensive infiltration with IgG4-positive plasma cells. Appropriate medical treatment with steroids and azathioprine led to complete remission of the disease. Early recognition of IgG4-SC can save patients from potential harmful and unnecessary surgical interventions. Here we describe the clinical features of this rare case of IgG4-SC with extensive liver tissue infiltration with IgG4-positive cells but without elevated serum IgG4 concentration or evidence of autoimmune pancreatitis. We describe diagnostic criteria for IgG4-SC and review recent insights in pathophysiology and treatment options.

Ein 31-jahriger Patient stellte sich mit chronischem Husten und Thoraxschmerzen vor. Radiologisch zeigte sich eine suspekte pulmonale Raumforderung. Es erfolgte eine chirurgische Segmentresektion. Histopathologisch wurde ein Abszess bei thorakaler Aktinomykose diagnostiziert. 3 Monate spater trat ein Aktinomykoserezidiv der Thoraxwand auf, und Penicillin wurde i.v. verabreicht. 5 Monate spater, unter fortgesetzter antibiotischer Therapie, wurden Thoraxwandabszess und -fistel diagnostiziert. Ein Monat nach Abszessdranage und erneuter i.v. antibiotischer Therapie war der Patient beschwerdefrei, ebenso wahrend der sich anschliesenden Nachbeobachtungszeit uber 10 Monate.

Gastroparesis is a common but challenging disorder which can be idiopathic or induced by a variety of underlying diseases, most frequently by diabetes, or post-surgical conditions of the upper abdomen. Clinicians must also consider rare causes of gastric motor dysfunction, such as collagen vascular disorders and paraneoplastic syndromes. Here we present the case of a patient with severe gastroparesis, who was admitted to our hospital for vomiting and weight loss of 25 kg within four months. Endoscopy showed a dilated fluid-filled stomach without peristalsis but no obstruction. High titres of anti-Hu antibodies were detected in patient's serum, supporting the diagnosis of severe paraneoplastic gastroparesis with chronic intestinal pseudo-obstruction. Fine-needle aspiration of suspicious mediastinal lymph nodes guided by endoscopic ultrasound revealed lymphatic metastases of a small-cell lung carcinoma. Jejunal tube feeding and chemotherapy with carboplatin and etoposide were initiated. Paraneoplastic gastrointestinal dysmotility is rare, however, clinicians should consider this differential diagnosis in otherwise unexplained gastrointestinal motor dysfunction. The pathophysiology of paraneoplastic gastroparesis, the diagnostic relevance of anti-Hu antibodies as well as therapeutic options are discussed.

Liver cirrhosis develops as a terminal complication of chronic liver disease. The clinical course is determined by the underlying etiology and the accompanying risk factors, which are influenced by the geographic and cultural background.A total of 236 patients (159 men, 77 women, median age 57 [22-81] years) were included for retrospective analysis between July 2012 and February 2014 using standardized questionnaires during an outpatient visit at a hepatology clinic.The most common etiologies of liver cirrhosis were related to alcohol consumption (52 %), chronic hepatitis C (28 %) or hepatitis B (14 %) infection and NASH (nonalcoholic steatohepatitis, 6 %). At the time of presentation 55 % patients had compensated cirrhosis corresponding to Child-Turcotte-Pugh (CTP) stage A, while 45 % were in a decompensated stage (30 % CTP B and 15 % CTP C). Subgroups were analyzed for the incidence of complications and the emergence of infections. Most frequently esophageal varices (60 %) and ascites (49 %) were observed, followed by pleural effusion (14 %), hepatic encephalopathy (25 %) or hepatorenal syndrome (18 %). 16 % of patients exhibited infection based on clinical criteria. An infective agent was isolated in 38 % of all cases with infection and of those 50 % were gram positive bacteria. In multivariate analysis only the presence of ascites was an independent risk factor for infection.Despite improved medical therapies for viral hepatitis, these were the most frequent causes of liver cirrhosis, closely followed by alcoholic cirrhosis. The observed complications included bacterial infection and complication related to portal hypertension.

Hintergrund und Fragestellung: Das hepatorenale Syndrom (HRS) ist eine schwere Komplikation bei Patienten mit Leberzirrhose. Der unbehandelte Verlauf ist mit einer sehr schlechten Prognose assoziiert. Fur die Behandlung mit Terlipressin in Kombination mit Humanalbumin konnte in mehreren randomisiert-kontrollierten Studien (RCTs) eine Verbesserung der Nierenfunktion demonstriert werden, der Einfluss auf die Gesamtprognose bleibt allerdings unklar. Im Rahmen der vorliegenden Observations-Studie sollte der Effekt einer Terlipressin-Behandlung bei Patienten mit HRS auf Nierenfunktion, Gesamtuberleben und dialysefreies Uberleben untersucht werden. Patienten und Methodik: Uber einen Zeitraum von 12 Monaten wurden in unserem Zentrum alle Patienten mit HRS und Terlipressin-Therapie beobachtet. Klinisch relevante Parameter, Therapiecharakteristika, Ansprechen, Gesamtuberleben und dialysefreies Uberleben wurden prospektiv erfasst. Ergebnisse: Insgesamt wurden 57 Patienten uber einen medianen Zeitraum von 65 Tagen beobachtet. Bei der Mehrzahl der Patienten lag ein fortgeschrittenes Zirrhose-Stadium zugrunde (Child-Pugh C: 46; 81%). Die kumulative Terlipressin-Dosis bzw. -Behandlungsdauer betrug im Median 20 mg bzw. 5 Tage. Ein komplettes oder partielles Ansprechen auf Terlipressin im Sinne einer HRS-Ruckbildung wurde in 29 bzw. 3 von 57 Patienten beobachtet (51%; 5%). Patienten mit Terlipressin-Ansprechen zeigten mit einem medianen Gesamtuberleben von 167 vs. 27 Tagen bzw. einem dialysefreies Uberleben von 82 vs. 4 Tagen eine signifikant bessere Gesamtprognose als Patienten mit Nicht-Ansprechen. In einer univariaten Analyse war das Nicht-Ansprechen mit einer hohen Ausgangs-Bilirubin-Konzentration assoziiert. Folgerung: Terlipressin in Kombination mit Humanalbumin ist eine effektive Therapie beim HRS. Das Terlipressin-Ansprechen ist dabei mit einem deutlichen Uberlebensvorteil assoziiert.

Upon returning from holidays, a 55-year-old patient presenting with melena and haemorrhagic shock was admitted to a University hospital after receiving first emergency medical care in a German InterCity train. In an interdisciplinary effort, haemodynamics were stabilised and the airway and respiratory function were secured. Under emergency care conditions the patient then underwent an emergency upper GI endoscopy where a spurting arterial upper gastrointestinal bleeding (Forrest 1a) was found. While the bleeding could not be controlled with endoscopic techniques, definitive haemostasis was achieved with a surgical laparotomy. While not commonly established for patients with severe GI bleeding, by spontaneous implementation of an interdisciplinary trauma room approach following established trauma algorithms the team was able to achieve stabilisation of vital functions and final control of bleeding in this highly unstable patient. Although the majority of upper gastrointestinal bleedings spontaneously cease, emergency care algorithms should be developed and implemented for patients with severe gastrointestinal bleedings in shock. Following the case vignette, we discuss a potential approach and develop an exemplary protocol for shock room management in this patient subgroup.

GOALS AND BACKGROUND Hepatocellular carcinoma in non-hepatitis B virus endemic areas is rare in patients younger than 40 years of age. The aim of this study was to characterize young patients in a large German cohort in comparison with older patients with regard to underlying liver disease, clinical management, and survival. STUDY We analyzed the clinical data and medical records of 1108 consecutive patients with confirmed hepatocellular carcinoma. Twenty-five patients (2%) were younger than 40 years of age. We compared this subgroup with patients older than 40 years of age. RESULTS Underlying chronic liver disease was less common in young patients and detectable in only 56% of patients. Fibrolamellar carcinoma was more frequent in young versus old patients (20% vs. 0.7%; P

Background Impact of patient and tumour baseline characteristics on the overall survival is not well characterized in patients with advanced hepatocellular carcinoma (HCC) treated with sorafenib. Aims/methods Univariate/multivariate analyses were conducted to identify retrospectively the impact of baseline characteristics on the survival of 110 patients with advanced HCC treated with sorafenib. Results Median survival of the whole cohort was 6.7 months, median survival in Child-Pugh A, B, C patients was 10.5, 6.1 and 3.0 months and median survival of patients with Barcelona Clinic Liver Cancer (BCLC) stage C/D was 6.8/2.6 months. Presence of ascites, presence of macrovascular invasion and BCLC stage D (mainly determined by Child-Pugh C status and Eastern Cooperative Oncology Group Performance Status > 2) remained independent prognostic factors for the survival on multivariate analysis. Particularly, the presence of macrovascular invasion significantly influenced survival both in patients with liver cirrhosis Child-Pugh A and Child-Pugh B. Conclusion Well maintained liver function and performance status are prerequisites for sorafenib treatment in patients with advanced HCC. Our findings do not support routine clinical use of sorafenib in Child-Pugh B patients. Evaluation of ascites and particularly macrovascular invasion might help to identify patients more likely to benefit from sorafenib treatment.

Objective Colonoscopy is the accepted gold standard for screening of neoplastic colorectal lesions, but the substantial miss rate remains a challenge. Computed virtual chromoendoscopy with the Fujinon intelligent colour enhancement (FICE) system is a new dyeless imaging technique that might allow higher rates of adenoma detection. Setting and Patients: This is a prospective randomized five tertiary care center trial of colonoscopy withdrawal in the FICE mode versus standard colonoscopy with targeted indigocarmine chromoscopy (control group) in consecutive patients attending for routine colonoscopy. Histopathology of detected lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. Results: A total of 871 patients were enrolled and 764 patients (344 female, mean age 64 years) were subjected to final analysis (368 in the FICE-group, 396 in the control group). In total, 236 adenomas (0.64 per case) were detected in the FICE group and 271 adenomas (0.68 per case) in the control group (p = 0.92). There was no statistically significant difference in the percent of patients with ≥ 1 adenoma between the control group (35.4 %) and FICE group (35.6 %) (p = 1.0). For the differential diagnosis of adenomas and non-neoplastic polyps, the sensitivity of FICE (92.7%) was comparable to that of indigocarmine (90.4 %) (p = 0.44). Conclusions: At colonoscopy adenoma detection rates are not improved by virtual chromoendoscopy with the FICE system compared to white light endoscopy with targeted indigocarmine spraying. However, FICE can effectively substitute for chromoscopy in the determination of real-time histology.

A 31-year-old patient presented with chronic cough and thoracic pain. A pulmonary mass was seen on chest x-ray, and pulmonary segmental resection was done. Histopathologically, a pulmonary abscess cavity due to actinomycosis was found. Three months later, recurrence of actinomycosis at the thoracic wall was observed. Antibiotic therapy with penicillin was administered. Five months later, with the patient receiving continued antibiotic therapy, a thoracic wall abscess and fistula was diagnosed. Four weeks after abscess drainage and repeat intravenous antibiotic therapy, the patient was symptom-free and had remained symptom-free at 10 months of follow-up.

BACKGROUND AND STUDY AIMS: For surveillance of Barrett’s esophagus random stepwise four-quadrant biopsy (4QB) is recommended for detecting macroscopically occult neoplasias. Thorough performance of the systematic protocol is commonly hampered by poor visibility due to oozing from biopsy sites. Topical application of dilute epinephrine may prevent bleeding by vasoconstriction of superficial microvessels and might therefore enable ”dry biopsy” sampling. The aim of this study was to examine the safety and efficacy of spraying dilute epinephrine for optimal 4QB mapping of Barrett’s esophagus. PATIENTS AND METHODS: In this prospective, double-blind trial 40 patients with known long segment Barrett’s esophagus were randomly allocated to undergo spraying with either dilute epinephrine (1 : 20 000) (epinephrine group; n = 20) or saline (control group; n = 20) before 4QB sampling. During endoscopies patients received continuous monitoring of vital parameters. Endoscopists blinded to randomization assessed visibility scores during biopsy sampling. Additionally, electronically stored images of the Barrett’s esophagus segment after 4QB sampling were evaluated by blinded assessors. RESULTS: The mean length of Barrett’s segments was 5.5 ± 1.8 cm and the mean number of 4QBs was 12.5 ± 3.6 with no statistically significant differences between control and epinephrine groups. Epinephrine spraying did not affect patients’ vital parameters. Visualization ratings by endoscopists on site and by the assessors of the stored images were significantly better in the epinephrine compared with the control group ( P < 0.05). Moreover, epinephrine spraying reduced the time for 4QB sampling ( P = 0.015) and the mean number of saline flushes needed to maintain visibility ( P = 0.0003). CONCLUSIONS: The novel “dry biopsy” technique with spraying of dilute epinephrine is safe, and facilitates thorough performance of systematic 4QB mapping of Barrett’s esophagus by improvement of visibility.