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Der Morbus Whipple ist eine durch das Bakterium Tropheryma whipplei verursachte Infektion, deren Diagnosestellung durch eine unspezifische Beschwerdesymptomatik erschwert wird und die haufig lange unerkannt bleibt. Wir berichten uber einen Patienten, der sich mit neu aufgetretenen intestinalen Beschwerden in unserer Abteilung vorstellte. Es konnte die Diagnose eines klassischen Morbus Whipple gestellt werden. Unter antibiotischer Therapie wurde eine Remission der Symptomatik erreicht. Komplizierend traten Beschwerden im Sinne eines Immunrekonstitutionssyndroms (IRIS) auf, die eine immunsuppressive Behandlung erforderten.

Whipple disease is an infection caused by the bacterium Tropheryma whipplei. Due to its unspecific clinical symptoms, it is difficult to diagnose and often remains undetected for a long time. The case of a patient who presented with acute intestinal symptoms to the authors' department is reported. The diagnosis of classic Whipple disease was established. The symptoms subsided under antibiotic therapy. Complications in the form of immune reconstitution inflammatory syndrome (IRIS) occurred, requiring immunosuppressive treatment.Der Morbus Whipple ist eine durch das Bakterium Tropheryma whipplei verursachte Infektion, deren Diagnosestellung durch eine unspezifische Beschwerdesymptomatik erschwert wird und die häufig lange unerkannt bleibt. Wir berichten über einen Patienten, der sich mit neu aufgetretenen intestinalen Beschwerden in unserer Abteilung vorstellte. Es konnte die Diagnose eines klassischen Morbus Whipple gestellt werden. Unter antibiotischer Therapie wurde eine Remission der Symptomatik erreicht. Komplizierend traten Beschwerden im Sinne eines Immunrekonstitutionssyndroms (IRIS) auf, die eine immunsuppressive Behandlung erforderten.

Eine 44-jahrige Philippinerin stellte sich mit Oberbauchschmerzen und Fieberschuben vor. Bei fehlenden laborchemischen Veranderungen zeigten (schnitt-)bildgebende Untersuchungen sackartige Gallengangserweiterungen im rechten Leberlappen mit intraduktalen soliden Anteilen. Aufgrund der Symptomatik wurde die Patientin mit Verdacht auf die Caroli-Krankheit einer operativen Therapie zugefuhrt. Hierbei ergab sich eine intraduktale papillare Neoplasie der Gallenwege (IPNB), weswegen eine geplante Bisegmentektomie auf eine Hemihepatektomie erweitert wurde. Die IPNB ist eine seltene, seit 2010 von der Weltgesundheitsorganisation anerkannte Entitat, die als Prakanzerose der Gallenwege anzusehen ist.

Der Artikel zeigt die typischen Notfall-Krankheitsbilder und gibt eine Ubersicht uber die notwendigen Zeitspannen, in denen eine spezifische Notfallendoskopie erfolgen muss.

A 44-year-old Filipino woman presented with abdominal pain and fever. Clinical examination and blood tests revealed no pathological results; however, (cross-sectional) imaging showed saccular cystic bile duct dilatation in the right liver with solid intraductal masses. Due to the clinical presentation the patient was admitted for surgical intervention with the diagnosis of Caroli disease. During the surgical procedure histopathology showed an intraductal papillary neoplasm of the bile duct (IPNB). The planned segmentetomy was extended to hemihepatectomy. IPNB is a rare entity of premalignant lesions of the bile duct system first recognized by the World Health Organization in 2010.

Wir berichten uber einen 69-jahrigen Patienten mit Tetraparese und Muskelschmerzen unter einer mehrmonatigen Prednisolontherapie. Als Ursache fand sich eine Sepsis infolge einer Pyomyositis mit septisch-pulmonalen Einschmelzungen durch Staphylococcus aureus. Unter einer antibiotischen Therapie mit Piperacillin und Tazobactam konnten eine Regredienz der initial erhohten Entzundungsparameter und eine Besserung der Tetraparese verzeichnet werden. Die Pyomyositis ist eine bakterielle Infektion der Skelettmuskulatur. Sie geht typischerweise mit einschmelzenden, abszessformigen Veranderungen einher. In den Tropen ist diese Erkrankung endemisch. Die nichttropische Form der Pyomyositis tritt am haufigsten unter Immunsuppression auf.

Wir berichten uber eine 48-jahrige Patientin mit bekanntem M. Crohn und linksseitigen abdominellen Schmerzen sowie einer neu aufgetretenen Hamaturie und Proteinurie. Als Ursache fand sich eine linksseitige Nierenvenenthrombose. Diese konnte durch eine Magnetresonanzangiographie gesichert werden. Trotz erhohter Inzidenz thrombembolischer Ereignisse bei Patienten mit chronisch entzundlichen Darmerkrankungen ist eine Nierenvenenthrombose eine sehr seltene Komplikation. Wir begannen eine orale Antikoagulation mit Phenprocoumon. Hierunter wurde die Patientin beschwerdefrei, und der Thrombus zeigte sich in der Verlaufskontrolle komplett regredient.

Biliare Komplikationen treten in bis zu 30% aller Lebertransplantationen auf. Gallelecks lassen sich sehr erfolgreich mittels vorubergehender endoskopischer Stenteinlage therapieren. Eine gefurchtete Komplikation ist die Thrombose der A. hepatica, die haufig zu Gallenwegsnekrosen mit konsekutiven Leberabszessen und Sepsis fuhren kann. Gallenwegsstenosen konnen an der Anastomose (Anastomosenstenosen, AS) oder im Hilus- und/oder intrahepatischen Bereich als Ischemic Type Biliary Lesions (ITBL) auftreten. AS lassen sich mit hoher Erfolgsrate mit einer Kombination aus Ballondilatation und Endoprotheseneinlage behandeln. Bei den ITBL ist die Datenlage weniger eindeutig, eine wiederholte Ballondilatation scheint aber auch erfolgreich und kann zumindest eine erforderliche Retransplantation deutlich hinauszogern. Erste Daten zeigen, dass auch die sehr anspruchsvollen Anastomosenstenosen nach Leberlebendtransplantation mit gutem Erfolg endoskopisch therapiert werden konnen.

Hintergrund Die iatrogene Osophagusperforation ist noch immer ein potenziell lebensbedrohliches Krankheitsbild.

Fluorescence-based diagnostic techniques are an evolving field in the staging of hepatologic and gastroenterologic malignancies. The method aims at improved accuracy in the detection of locoregional and distant metastases. In hepatocellular carcinoma, detection of metastases is of utmost importance, because advanced tumors preclude curative surgical therapy. We present here our first experience of fluorescence-based diagnostic laparoscopy in a patient with hepatocellular carcinoma. We performed diagnostic laparoscopy in a 76-year-old woman who presented with a tumor of the liver and increased serum levels of alpha-fetoprotein. For photosensitization, 5-aminolevulinic acid (20 mg/kg bodyweight, p.o.) was used 6 hours prior to laparoscopy, which was performed with a prograde 0 degree telescope suitable for fluorescence-based laparoscopy. The D-Light AF system was used as a light source. Laparoscopy was carried out according to common guidelines in the white-light as in the blue-light mode. The main tumor and the satellite metastases clearly showed intense fluorescence compared with unaffected liver parenchyma and other abdominal organs. Fluorescence-based laparoscopy identified several small metastases which had been missed during conventional white-light illumination. Hepatocellular carcinoma was confirmed by the histological examination of several biopsies drawn from suspicious areas. Fluorescence-based laparoscopy provided additional information in the staging of hepatocellular carcinoma. The technique can further improve diagnostic accuracy in the staging of hepatocellular carcinoma, particularly in patients potentially suitable for partial liver resection or transplantation.

We report on a 48-year-old patient with Crohn's disease and left abdominal pain, who presented with hematuria and proteinuria. As reason we found a left renal vein thrombosis. This diagnosis was based on magnetic resonance imaging and doppler ultrasound. The incidence of thrombembolic complications in patients with chronic inflammatory bowel disease is increased, however renal vein thrombosis is a very rare complication of Crohn's disease. We started a conservative treatment with phenprocoumon. Thereafter the patient remained asymptomatic and the thrombus dissipated during follow-up.

Iatrogenic esophageal perforations are still a life-threatening clinical entity.We present the case reports of six patients to demonstrate different treatment options and we focus on new therapeutic strategies which have evolved in the interdisciplinary management of iatrogenic esophageal perforations. Two patients with perforations in the cervical esophagus were operated and in another patient the perforation was closed with fibrin glue. Three patients with perforations in the thoracic esophagus were treated with self-expandable plastic stents.The surgical therapy of esophageal perforations still is regarded to be the gold standard and nonadherence should only be considered based on interdisciplinary decisions in individual cases. However, positive results are increasingly being reported for conservative endoscopic treatment, particularly for thoracic perforations.

Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Due to the central anatomic localization within the liver hilum, established guidelines of oncologic surgery are difficult to apply. Resection of the hilar bifurcation alone or in combination with limited hepatic resection can be performed with low morbidity and low mortality but shows a high rate of local tumor recurrence. Usually, extended resection is required to achieve adequate safety margins. Right trisectionectomy complies best with the basic rules of oncologic surgery while allowing the maximum safety margin. The 5-year survival rates reported after right trisectionectomy range between 20% and 40% and reach 59% in selected patients. The increasing experience with living donor transplantation and recent advances in neoadjuvant tumor therapy may lead to renewed discussion of liver transplantation in hilar cholangiocarcinoma.

Die invasiven gastroenterologischen Untersuchungs- und Therapiemethoden sind relativ sichere Verfahren. Komplikationen — mit z. T. desastrosen Folgen — treten dennoch auf. Die Kenntnis der Risiken endoskopischer Eingriffe ist essenziell fur deren Vermeidung und Management.

Photodynamic therapy (PDT) of dysplasia and early cancer of the esophagus could show good results in the potential of ablation. Unfortunately, the existing expensive and temperamental dye laser systems foiled a broad clinical use. In this pilot study, we investigated the feasibility of an inexpensive and maintenance-free diode laser system for PDT of dysplasia and early cancer in Barrett's esophagus.Eight patients with Barrett's esophagus and/or early cancer were treated. As light source we used a diode laser system with a maximum power output of 2 W and a wavelength of 633 +/- 3 nm. One patient was treated initially with Photosan-3, seven patients received 5-aminolevulinic acid.In all patients we could achieve reduction in length and/or histologically proven downgrading. In three quarters of the patients, complete eradication of adenocarcinoma could be attained. Columnar-lined metaplastic epithelium could also be completely eradicated.PDT using a diode laser system is comparably effective in Barrett's esophagus/early cancer as PDT with dye laser systems. PDT is a gentle and effective technique with little side effects.

This study was performed to assess the role of additional diagnostic laparoscopy in the preoperative staging of patients with gastric cancer and pancreatic cancer prior to intended curative surgery. Furthermore patients with ascites of unknown origin were evaluated. 127 patients with primary solid abdominal tumors were eligible for evaluation; of those 66 patients had a gastric cancer and 61 a pancreatic cancer. Patients without histologically proven metastases proceeded to laparotomy. Ascites of unknown origin was the indication for performing a diagnostic laparoscopy in 23 patients. Metastases were detectable laparoscopically in 13 of 66 patients (20%) with gastric cancer. Intraoperatively metastases were evident in further 7 cases. In 14 of 61 patients (23%) with pancreatic cancer metastases were detected by laparoscopy and in further 5 patients intraoperatively. A peritoneal carcinosis was diagnosed laparoscopically in 17 of 23 patients with ascites of unknown origin. Preoperative staging by additional diagnostic laparoscopy proved effective in patients with gastric- and pancreatic cancer.

Prognosis of pancreatic cancer and bile duct cancer is extraordinary poor. Despite of the improvement in diagnostic procedures and the development of more radical resectional procedures prolongation of survival could not have been achieved yet. At the time of diagnosis only 20-30% of patients are suitable for resection, thus the value of non resectional methods for palliation has to be determined. Despite of numerous efforts to increase the local radiation dosage by means of distinguished radiation techniques none of these procedures could achieve an unequivocal prolongation of survival. After promising preliminary results of intraoperative radiotherapy (IORT) in pancreatic cancer following studies could not show a survival benefit for IORT allone or in combination with extracorporal radiotherapy (EBRT). EBRT is indicated at best for local pain control and is limited by the high radiation sensitivity of the adjacent organs. Intracorporal radiotherapy or brachytherapy with iridium 129-labelled wires leeds to local, intraluminal tumour control, but has also no influence on survival time. Up to now, photodynamic therapy (PDT) of pancreatic cancer must be characterized as highly experimental. But PDT can contribute to local tumour control. Preliminary data of photodynamic therapy in bile duct cancer show good results concerning reduction of cholestasis, improvement of life quality and even prolongation of survival time. The value of these preliminary results is being proved at present in controlled studies in comparison to mere endoprosthetic supply at a few centers.

This study was performed to assess the role of additional diagnostic laparoscopy in the preoperative staging of patients with adenocarcinoma of the esophagus, gastric cancer and pancreatic cancer prior to intended curative surgery. 89 patients with primary solid abdominal tumors were eligible for evaluation; of those 49 patients had a gastric cancer, 33 a pancreatic cancer and seven an adenocarcinoma of the esophagus. Patients without histologically proven metastases proceeded to laparotomy. Metastases were detectable laparoscopically in nine of 49 patients (18.4%) with gastric cancer (peritoneum n = 5, omentum n = 2, liver n = 2). Intraoperatively metastases were evident in further five cases (liver n = 3, peritoneum n = 2). In eleven of 33 patients (33%) with pancreatic cancer metastases were detected by laparoscopy (liver n = 6, peritoneum n = 2, liver and peritoneum n = 3) and in further four patients intraoperatively (liver n = 2, peritoneum n = 2). One of seven patients with an adenocarcinoma of the esophagus had liver metastases detected by laparoscopy. Intraoperatively no metastases were evident in those patients. Laparotomies were avoidable in 21 of the 89 patients (23.6%) who had a diagnostic laparoscopy prior to intended curative resection. Preoperative staging by additional diagnostic laparoscopy proved effective in patients with gastric and pancreatic cancer.

The trends and developments in endoscopy of the coming years are many-sided. Improved fiber-optics and invention of computer technology lead to smaller endoscopes with higher resolution. Electronic image processing makes three dimensional measurement or presentation of objects possible. In endosonography a trend to miniaturization is also obvious. Advances in molecular biology and imaging procedures will strengthen the importance of endoscopy in the future. Moreover a differentiated use of new laser technologies will improve the possibilities of endoscopic diagnosis and therapy. The use of electronic diagnostic documentation systems will contribute to a standardized nomenclature and to a quality-improvement of documentation in the near future. The utilization of modern electronic communication systems will facilitate intra- and interdisciplinary exchange of information.

Minimal invasive methods compete with surgical treatment in the therapy of complications after cholecystectomy. We demonstrate our results of endoscopic therapy. 52 patients with postoperative complications (39 stenoses, 5 leakages, 6 stenoses and leakages, 2 complete obliterations of bile duct) were treated by transpapillary or transhepatic biliary drainage over a time period of 12 months. In 73% of patients who completed the therapy protocol successful treatment was possible. In 4 cases a restenosis occurred. 4 patients underwent surgical treatment. We think endoscopic management is the therapy of first choice for postoperative biliary complications. Biliary stricture should be dilatated for 12 months by biliary endoprosthesis, leakage can be drained for shorter time periods.

Since the establishing of laser technology in gastroenterology there has been a change in the indications for laser therapy and numerous new laser systems have been introduced in basic and clinical research. First the argon laser and later on the Nd:YAG laser were used mainly for bleeding peptic lesions, today emphasis is on palliative desobliteration of advanced esophageal and rectosigmoidal carcinoma. Moreover, in selected cases it is used for curative ablation of early carcinoma and dysplasia. A new field of application is photocoagulation of the "watermelon stomach". Despite of promising ablation results the erbium:YAG and holmium:YAG laser became not yet established in gastroenterology. Also the KTP laser is rarely used e.g. for treatment of telangiectasia. Difficult bile duct stones can be highly effective fragmented intracorporally by means of laser lithotripsy; an automatic stone-tissue discrimination system avoids uncontrolled injury of the bile ducts. The hitherto experimental interstitial laser therapy of primary and secondary liver malignancies shows excellent results, but online monitoring of the expansion of the necrosis is still a problem. Thermal probes, MRT technology and duplex sonography are under current evaluation. Photodynamic therapy (PDT) is now, after numerous pilot studies, investigated with larger numbers of patients. First results show a marked effectiveness in ablation of dysplasia and mucosal carcinoma. The photosensitizer 5-aminolaevulinic acid seems to be particularly effective for ablation of Barrett's mucosa and m-THPC for treatment of local carcinoma. Palliative PDT of bile duct cancer may help to avoid repeated endoprosthetic treatment. The possibilities and limitations of light induced fluorescence diagnostics of severe dysplasia and carcinoma in situ is now being evaluated intensively. This method might in future facilitate the endoscopic diagnosis of dysplasia in Barrett's esophagus and chronic inflammatory bowel disease.

In the early beginning of laser angioplasty the free laser beam of a continuous wave argon laser (488-514 nm) was used [1,2] for the recanalization of peripheral arteries. Uncontrollable thermal effects and the risk of damage and perforation of the vessel wall due to the penetration depth of the laser beam into the tissue stimulated further developments.