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Anamnese: Ein 41 Jahre alter Mann wurde wegen einer asymptomatischen Hyperurikamie (9,2 mg/dl) behandelt. Es wurde eine Therapie mit 300 mg Allopurinol eingeleitet. Verlauf: 4 Wochen nach Beginn der Therapie entwickelte sich ein typisches Hypersensitivitatssyndrom (AHS) mit Hautausschlag (exfoliative Blasenbildung mit Einblutungen), Fieber, Eosinophilie und akutem Leber- und Nierenversagen. Es erfolgte eine orthotope Lebertransplantation. Folgerung: Das AHS ist eine lebensgefahrliche, iatrogene Erkrankung. Bei 2 % der Behandelten treten Hautausschlage auf, die unvermittelt und nicht vorhersehbar bei 0,4 % davon in ein AHS ubergehen, das wiederum bei 14–30 % todlich verlauft. Die Diagnose ist anfangs schwierig zu stellen. In der Pathogenese werden unterschiedliche Ursachen diskutiert, wobei auch eine genetische Komponente beteiligt ist. Die Hohe der Dosierung, die Nierenfunktion und Begleitmedikationen sind von Bedeutung. Bei einer asymptomatischen Hyperurikamie ist die Verabreichung von Allopurinol nicht indiziert. Liegt eine eindeutige Indikation fur eine Allopurinol Therapie vor, so ist mit der niedrigsten Dosis (100 mg) zu beginnen, und bei Bedarf unter strengen Kontrollen die Dosis langsam zu erhohen.

Fifteen endoscopic retrograde cholangio-pancreatographies (ERCP) were performed between 1977 and 1979 in 13 children aged 2 months to 13.9 years (mean 8.9 years). All studies were done without intubation anaesthesia. Main indications were 1. acute (recurrent) biliary stasis, 2. persistent biliary stasis, 3. chronic pancreatitis, and 4. congenital malformation of the biliary system or the pancreas. Thirteen of the 15 investigations were successfully concluded. In nine cases both ductal systems were demonstrated, in two cases each either only the pancreatic or only the biliary ducts. The most frequent abnormal findings were seen in acute biliary stasis (four of five children), persistent biliary stasis (all four children) and congenital malformations (two of three children). There were no serious side effects. Except in young infants, for whom there are no properly sized instruments, ERCP in children provides no greater technical difficulties than in adults.

OBJECTIVE: Antacids are used worldwide for the treatment of acid-related conditions such as heartburn and gastro-esophageal reflux disease. The present study investigated the in vitro acid neutralization and bile acid binding capacities of hydrotalcite compared with other antacids that are available in Germany and China. It has been reported that hydrotalcite is effective in the treatment of bile reflux gastritis because of its binding capacity to bile acids. METHODS: Hydrotalcite and other preparations of antacids were tested in a comparative in vitro study. The neutralization properties were determined with static and dynamic tests (preliminary antacid test, acid neutralization capacity (ANC) test, Rossett-Rice (RR) test) and the bile acid binding test with a standardized commercial test kit (Merckotest bile acids). RESULTS: In the static and dynamic tests hydrotalcite 500 mg and some other antacids, such as magaldrate, almasilate, algedrate Mg hydroxide, Ca/Mg carbonate and calcium carbonate, demonstrated favorable ANC reflected by rapid onset and long duration of action, and high buffering capacity. In the RR test, a hydrotalcite dose of 1000 mg was able to keep the pH level above 3 for 76.9 min. The bile acid binding capacity test yielded that hydrotalcite had the highest binding potential to taurodeoxycholic acid, a lipophilic bile acid associated with cell and mucosa toxicity. CONCLUSIONS: Hydrotalcite has a rapid onset of action, a high buffering capacity and a long duration of action. In particular, hydrotalcite binds cytotoxic bile acids. These pharmacochemical properties make hydrotalcite a most suitable antacid.

A 41 year old patient started treatment with 300 mg/d allopurinol for asymptomatic hyperuricaemia (9,2 mg/dl).4 weeks later he developed exfoliative skin lesions with haemorrhage, fever, eosinophilia and acute liver and renal failure, typical for an allopurinol hypersensitivity syndrome (AHS).An orthotopic liver-transplantation was performed.The AHS is a serious iatrogenic disease. 2 % of the treated patients develop a skin rash. 0,4 % of these patients experience suddenly and unforeseen a severe hypersensitivity with a mortality of 14-30 %. An early diagnosis is often very difficult. In the pathogenesis different causes are discussed. A hereditary component is involved. Of essential importance is the amount of the starting dose, the kidney function and concomitant drugs. In an asymptomatic hyperuricaemia the application of allopurinol is not indicated. If strong indications are present, the allopurinol therapy has to start with the lowest dose (100 mg/d). If required this dose should be increased under consequent supervision only.

Prostaglandin E2 (PGE2) plays an important role in the inhibition of gastric acid production and exerts cytoprotective action. The in vitro and in vivo effect of magaldrate, an aluminum containing antacid, on PGE2 synthesis in the gastric mucosa was investigated.In the first part of the study, magaldrate was added to a suspension of isolated gastric mucosal cells. In the second part, the antacid gel was applied to the gastric mucosa during gastroscopy and biopsies were taken from the same site 5 and 10 min later.The antacid significantly stimulated PGE2 release from the suspension of isolated gastric cells in vitro. The biopsies obtained after the application of magaldrate showed an increased PGE2 production compared to specimens obtained before.The data suggest that in addition to its neutralizing capacity as an antacid, magaldrate contributes to the cytoprotective activity of the mucosa by stimulating endogenous PGE2 synthesis.

To compare the efficacy of ranitidine (CAS66357-35-5, Sostril) in combination with clarithromycin (CAS 81103-11-9, Cyllind) against H. pylori, a controlled randomized double-blind study was carried out. Fourty duodenal ulcer patients were treated either with ranitidine 150 mg b.i.d. and clarithromycin 500 mg q.i.d. (20 patients, group 1) or ranitidine 300 mg q.i.d. and clarithromycin 500 mg q.i.d. (20 patients, group 2) for 14 days. Both treatment groups received an additional treatment with ranitidine 300 mg daily for another 14 days. Endoscopy 6 weeks after the beginning of the trial showed complete ulcer healing in all patients. The control of H. pylori status done by CLO (Campylobacter-like organism) test and histology yielded an eradication rate of 84% (group 2) and 61% (group 1) in patients with duodenal ulcer disease treated with ranitidine and clarithromycin. Whether higher suppression of gastric acidity with a higher dose of ranitidine in combination with the antibiotic clarithromycin presents clear advantages in eradication of H. pylori should be investigated in further studies.

The mucosal barrier in the stomach is complete only when the mucous layer has become saturated with bicarbonate. The latter arises as a waste product, as it were, of acid production in the parietal cell, but is then actively secreted via the surface epithelial cells and tight junctions. If the acid secretion is inhibited by means of drugs, the bicarbonate concentration also decreases. This situation probably occurs only when the bicarbonate batteries in the mucous layer and the surface epithelial cells have become "discharged" after a period of about 24 hours, which indicates an intermittent, non-maximum block. In the region between the surface epithelial cells and the mucous layer, Helicobacter pylori has its ecological niche. As studies with, for example, ranitidine nocte, amoxycillin and metronidazole have shown, a 12 hour alternation between acid secretion inhibition and the physiological buildup of the gastric mucosal barrier appears to promote the eradication of Helicobacter pylori. Hypotheses about the role of sudden ammonia production on the part of the pathogen and on the regulation of bicarbonate and acid production in humans underscore these findings.

The direct effect of glucagon on human parietal cell function in vitro was tested by measuring adenylate cyclase (AC) activity and H+ production in homogenates of human gastric mucosa obtained during surgery or at biopsy. Cells isolated from mucosa obtained during surgery showed an increase in AC with histamine and glucagon. In parietal cell enriched fractions (75%) glucagon and histamine stimulated AC much more effectively than in parietal cell depleted fractions (15% and 7%). In contrast, glucagon did not affect basal or histamine stimulated 14C amino pyrine uptake. In homogenates of mucosal biopsy specimens 2 X 10(-7) mol/l glucagon enhanced AC activity by 76% (corpus) and 20% (antrum). In the same homogenates 10(-4) mol/l histamine caused a stimulation by 161% (corpus) and 38% (antrum). In fundic biopsy specimens glucagon displayed a biphasic concentration response curve with an increase at 10(-10) mol/l (46% above basal AC activity) and a maximum at 2 X 10(-7) mol/l (97%). Histamine elicited the maximal response (192%) at 10(-3) mol/l. Increasing histamine and glucagon concentrations caused additive stimulation of AC. Ranitidine did not change AC in response to glucagon but abolished the effect of histamine. Data suggest that the glucagon action is mediated by separate (glucagon?) receptors. As H+ production was not affected by glucagon, the coexistence of two AC systems in the human parietal cell is postulated: One that is activated via histamine H2-receptors and which stimulated H+ production; another that is activated by glucagon and is directed towards other, possibly metabolic effects.

Die Wirkung von Ipratropiumbromid und Propanthelinbromid per os auf die basale und auf die durch Pentagastrin und Insulin-Hypoglykamie stimulierte Magensekretion wurde im intraindividuellen Vergleich im Doppelblindverfahren untersucht. Die Dosis und die Wirkungszeit wurden variiert. Zusatzlich wurde die Anticholinergikawirkung mit der von Oxacepam auf die basale und auf die durch Pentagastrin stimulierte Magensekretion verglichen. Ipratropiumbromid hat einen starker inhibitorischen Effekt auf die basale, Pentagastrin und Hypoglykamie stimulierte Sekretion als Propanthelinbromid. Das Wirkungsmaximum auf die basale Sekretion tritt erst nach 450 min ein, wahrend die Wirkung auf die durch Pentagastrin stimulierte Sekretion eine kurzzeitigere ist. Die Wirkung konnte nur bei einer Anticholinergikadosis von 30 mg beobachtet werden. Oxacepam scheint eher einen steigernden Effekt auf die durch Pentagastrin stimulierte Magensekretion zu besitzen, der durch Ipratropiumbromid vollstandig kompensiert werden kann. Eine Kombination Ipratropiumbromid+Oxacepam hat gegenuber Ipratropiumbromid allein keine starkere Wirkung. Aufgrund der Ergebnisse wird ein Angriffspunkt fur Anticholinergika direkt an der Belegzelle diskutiert.

A choledochocele with obstruction to outflow from the biliary and pancreatic duct systems was diagnosed by endoscopic retrograde cholangio-pancreatography in a 67-year-old man with radiating upper-abdominal pain and constantly elevated gamma-glutamyl transferase. After distension of the choledochocele with contrast medium a papillotome was introduced across the papilla and the choledochocele was split open. There were no complications and flow from both systems became normal. The symptoms disappeared and the patient required neither anaesthesia nor an abdominal operation.

The problem of the disinfection of fibre endoscopes is to achieve a good efficiency together with easy handling. There is not yet a disinfectant which shows a sufficient germicidal effect after a short time of contact with the fibre endoscope and which is harmless to the patient and medical staff. This paper deals with a two-stage disinfecting procedure in which the instrument undergoes a short intermediate disinfection using polyvidoneiodine (Betaisodona) between two investigations and a main disinfection at the end of a series of investigations using glutardialdehyde (Cidex). The measures lead to a sufficient reduction of the number of germs. The importance of the disinfection of all parts of the endoscopes, especially the channels and the accessories (water bottles etc.) is pointed out.

Akute Hypermagnesiamie hemmt die basale als auch die durch Calcium, Pentagastrin und Gastrin stimulierte Sauresekretion des menschlichen Magens. An 12 Probanden wurde bei 14 quantitativen Magensekretionsanalysen der Einflus akuter Hypermagnesiamie auf die durch Methylxanthine (Theophyllin) intracellular stimulierte Sauresekretion und auf die Elektrolyt- und Pepsinogensekretion untersucht. Magnesium hemmt die Sekretion von H+, Cl−, K+- und Na+-Ionen und von Pepsinogen. Die Konzentration der Cl−-und Na+-Ionen und des Pepsins blieben statistisch unverandert. Die Konzentration der H+-Ionen nahm dagegen in der funften 15 min-Portion signifikant zu und die der K+-Ionen in der achten 15 min-Portion signifikant ab. Die moglichen Angriffspunkte des Magnesiums in der Stimulationsreihe: first messenger — target tissue — second messenger werden diskutiert.

An 20 Probanden wurde die Wirkung von Methyl-Xanthine (Theophyllin) auf die Magensekretion untersucht. Die Saure-, Elektrolyt-und Pepsinogensekretion nahm signifikant zu. Bei 16 dieser Probanden wurde zusatzlich Glucagon infundiert. Es kam dabei in allen erwahnten Parametern zu einer Hemmung der Magensekretion bis unter den Basalwert. Die moglichen Hypothesen der Angriffspunkte des Glucagons innerhalb der Stimulationsreihe: first messenger — target tissue — second messenger werden diskutiert.

Der Einflus von intravenosen Aldosteron-Infusionen auf die durch Pentagastrin-Infusionen submaximal stimulierte Magensekretion wurde an 14 mannlichen Probanden untersucht. Eine akute Erhohung des Aldosteronspiegels im Blut veranderte die Sauresekretion nicht. Lediglich die Kalium-Ionen-Konzentration und die Menge der in der Zeiteinheit sezernierten Kalium-Ionen nahm signifikant ab. Dieser Abfall ist jedoch regelmasig bei Magensekretions-analysen zu beobachten und nicht als Aldosteroneffekt zu bewerten. Inwiefern chronische Aldosterongaben die Magensekretion des Menschen beeinflussen, bedarf weiterer Untersuchungen.

In 127 Fallen wurde gezielt wahrend der Gastroskopie aus Antrum, Korpus und nach Inversion aus der Kardia insgesamt 762 Gewebspartikel entnommen und ihr Entzundungsgrad histologisch ermittelt. Die Verteilung der Gastritisstadien in den einzelnen Magenregionen wurde statistisch mit demx 2-Test untersucht. Die Entzundung nimmt vom Antrum zur Kardia hin ab. Die Kopplung der Entzundungsgrade ist zwischen Antrum und Korpus lockerer als zwischen Korpus und Kardia. Bei Feststellung einer Entzundung im Kardiabereich ist eine Gastritis im ganzen Magen wahrscheinlich. Eine isolierte Entzundung ist dagegen im Antrum haufig.

Serum vitamin B12 concentration, parietal cell antibodies (PCA), peak acid output vitamin B12 resorption capacity were determined in 76 patients (age 23 to 82 years). Gastroscopy was performed on all of these patients; guided biopsy was taken from 70 of them. No influence of the inflammatory changes in the gastric mucosa, sex or the presence of PCA on the serum vitamin B12 concentration were demonstrable in our patients, who all revealed a vitamin B12 resorption in the normal range. In particular we were unable to confirm the observation of Döscherholmen et al. (5) of a fall in serum vitamin B12 concentration with increasing age or decreasing PAO. Hence the estimation of the serum vitamin B12 concentration cannot be used as a screening test for selecting those patients suffering from chronic atrophic gastritis and achlorhydria, who should be monitored by gastroscopy and biopsy because of an increased risk of gastric cancer.

In a double-blind trial 16 persons with gastric ulcer and 35 with duodenal ulcer were treated as out-patients with 1200 mg proglumide daily or 1320 mg magnesium tricilicate daily (as an "active placebo") for four weeks. The ulcers were assessed by endoscopy before and after treatment. The gastric ulcers disappeared in 75% of patients receiving proglumide (six of eight subjects) but in only 25% of those on the placebo (two of eight). There was no significant effect of proglumide on duodenal ulcers (17 in the proglumide and 18 in the placebo groups). Proglumide failed to affect either basal or maximally stimulated acid secretion, nor was there any change in the serum gastrin level. There were no side effects during proglumide administration. This underlines its therapeutic value in the treatment of gastric ulcer, in comparison with cimetidine or carbenoxolone.

Intestinale Gasansammlungen beeinflussen die abdominelle Sonographie ungunstig und lassen bei starkem Meteorismus oft nur eine eingeschrankte Beurteilung zu. Da die Schallwellenwiderstande von Luft und Weichteilen stark differieren, kommt es beim Auftreffen des Schalls auf Luftansammlungen zu Totalreflexionen, so das die dahinterliegenden Strukturen nicht dargestellt werden konnen. Wahrend sich grosere Luftblasen mit ihrer umschriebenen Schallausloschung weniger storend bemerkbar machen, fuhren kleinere Luftblaschen aufgrund der Vielfalt der durch sie bewirkten akustischen Artefakte zu einer groseren Beeintrachtigung der sonographischen Untersuchung [4].

Die klinische Erfahrung zeigt, das funktionelle Storungen im Gastroin-testinaltrakt selten isoliert auftreten und unvorhersehbar ineinander ubergehen konnen [1–4]. Haufig zugleich auftretende vegetative Stigmata wie Hypotonie, labile Hypertonie, Herzklopfen und -stolpern, Konzentrationsschwache und Geschmacksanderungen, fuhren in der Regel zu einer Polypragmasie, die sich in ein definierbares therapeutisches Sukzessivschema nicht einordnen last. Zudem erlauben unsere derzeitigen diagnostischen Moglichkeiten nicht sicher genug festzulegen, ab wann eine funktionelle Storung nicht mehr funktionell ist, und ob hinzugetretene organische Veranderungen durch die funktionellen Storungen hervorgerufen wurden [6].

Jede Zeit hat ihren Schmerztyp. Der Schmerztyp des technischen Zeitalters ist der schizothyme Leptosom. Starke, erklarbare Schmerzen werden gut unterdruckt, leichte, aber unerklarbare Schmerzen verstarkt. Dies trifft auch fur die funktionellen Oberbauchbeschwerden zu. Ihre Haufigkeit nimmt in der Praxis (uber 40%) und in der Klinik (vorwiegend in der Rekonvaleszenzphase) zu. Das Spektrum der Schmerzempfindungen ist gros: 93% Druck im Oberbauch, 90% Vollegefuhl nach kleinen Mahlzeiten, 90% Ubelkeit, 80% Leibschmerzen, 60% Brennen im Epigastrium und 56% Erbrechen (n = 7834 ambulante Patienten. Alter: 10 bis 86 Jahre).

Fifteen endoscopic retrograde cholangio-pancreatographies (ERCP) were performed between 1977 and 1979 in 13 children aged 2 months to 13.9 years (mean 8.9 years). All studies were done without intubation anaesthesia. Main indications were 1. acute (recurrent) biliary stasis, 2. persistent biliary stasis, 3. chronic pancreatitis, and 4. congenital malformation of the biliary system or the pancreas. Thirteen of the 15 investigations were successfully concluded. In nine cases both ductal systems were demonstrated, in two cases each either only the pancreatic or only the biliary ducts. The most frequent abnormal findings were seen in acute biliary stasis (four of five children), persistent biliary stasis (all four children) and congenital malformations (two of three children). There were no serious side effects. Except in young infants, for whom there are no properly sized instruments, ERCP in children provides no greater technical difficulties than in adults.

A choledochocele with obstruction to outflow from the biliary and pancreatic duct systems was diagnosed by endoscopic retrograde cholangio-pancreatography in a 67-year-old man with radiating upper-abdominal pain and constantly elevated gamma-glutamyl transferase. After distension of the choledochocele with contrast medium a papillotome was introduced across the papilla and the choledochocele was split open. There were no complications and flow from both systems became normal. The symptoms disappeared and the patient required neither anaesthesia nor an abdominal operation.

In terms of a short review indications and applications of infusion therapy in gastroenterology (concerning vomiting, fistulas, diarrhea, ileus and peritonitis) are discussed. It is pointed out that in cases of water and electrolyte deficiency a rigid regimen is not reasonable. If possible a balance should be obtained. Parenteral nutrition is applied in obstructions of the upper gastrointestinal tract and in maldigestion and malabsorption.

After the short review of the pathogenesis, diagnosis and therapy for congenital intrahepatic cysts of the bile-duct (morbus Caroli), reference was made to the diagnostic significance of liver scintigraphy on the basis of two casuistic reports. Liver scintigraphy permits an exact localization of intrahepatic cysts as well as information regarding the course of the hepatopathy connected with morbus Caroli. In addition, 131-J-bromsulfon scintigraphy of the liver is a simple method for controlling the patency of the bile ducts. Our observations tend to indicate that preoperative and postoperative scintigraphic controls of the liver are practical for this disease.

Activation of adenylate cyclase (AC) by PGE2, histamine and gastrointestinal hormones was studied in parietal cell-free gastric biopsy specimens from the corpus of patients with proven high gastrin achlorhydria. PGE2, somatostatin, VIP, pentagastrin and secretin activated AC in a concentration-dependent manner both in normal and in atrophic mucosa. Histamine activated AC only in normal gastric mucosa, being entirely ineffective in mucosa devoid of parietal cells. The results indicate that histamine-sensitive AC disappears in patients with achlorhydria, probably due to their loss of parietal cells. Enzyme activity in response to somatostatin, VIP, pentagastrin, secretin and PGE2 remains unchanged in these patients indicating AC localization in nonparietal cells, e.g. chief or mucous cells.

Die intramurale Pseuodivertikulose des Osophagus wurde erstmals 1960 beschrieben [7] und bisher sind etwa 32 Falle dieser seltenen Erkrankung in der Literatur bekannt geworden. Atiologie und Pathogenese der intramuralen Pseudodivertikulose des Osophagus sind noch weitgehend ungeklart.

The effect of orally administered ipratropiumbromide and propanthelinbromide on the basic gastric secretion as well as on the gastric secretion stimulated by pentagastrin or hypoglycemia due to application of insulin was tested intraindividually in a double blind comparative study. Drug dosage and time after the drug effect was measured varied. In addition the anticholinergic effect of ipratropiumbromide on the basic as well as on the gastric secretion stimulated by pentagastrin was compared to that of oxacepam. The inhibitory effect of ipratropiumbromide on the basic gastric secretion as well as on the secretion stimulated by pentagastrin and hypoglycemia is more pronounced than that of propanthelinbromid. The effect on the basic secretion reached its peak 450 min after drug application whereas the maximal effect on pentagastrin stimulated secretion showed earlier. The effect described was only seen with a dose of the anticholinergic drug of at least 30 mg. A combination of ipratropiumbromide+oxacepam has no effect stronger than ipratropiumbromide alone. On the contrary, it rather seems to have an augementative effect on pentagastrin stimulated gastric secretion that may be compensated completely by ipratropiumbromide. On the basic of these results a direct influence of anticholinergic substances on the parietal cell is discussed.