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Peristomal leakage, infection, and persisting fistula after tube removal are rare, but well-known complications in long-term percutaneous endoscopic gastrostomies (PEG). A standard treatment procedure is missing. This case series describes a procedure of tube removal, tailored antibiotic therapy and endoscopic closure with a gastropexy device after mechanical de-epithelialization of the fistulous tract.Three patients with infected long-standing PEG (4 to 21 years) were included. The tubes were removed endoscopically and tailored antimicrobial therapy was administered over 10 to 14 days. The persisting fistula was de-epithelialized mechanically and sutured under endoscopic control with a dedicated gastropexy device 11 to 25 days thereafter. A new PEG tube was placed in the same session on a different site. After 30 days the fistula had healed completely, and the PEG worked well in all subjects.Endoscopic sealing of a persisting fistula with a dedicated gastropexy device after thorough de-epithelialization is a promising technique that needs confirmation by larger studies.Peristomale Leckage, Infektion und persistierende Fisteln nach Entfernung einer perkutanen endoskopischen Enterostomie (PEG) sind seltene, aber wohlbekannte Langzeitkomplikationen. Eine Standardprozedur zur Behandlung ist bisher nicht etabliert. Die vorliegende Fallserie beschreibt das erfolgreiche Vorgehen von PEG-Entfernung, antibiogrammgerechter antibiotischer Therapie und endoskopischem Fistelverschluss mit einer Vorrichtung zur Gastropexie nach mechanischer Deepithelialisierung des Fisteltraktes. PRäSENTATION DER FALLSERIE : 3 Patienten mit lange bestehender PEG (4 bis 21 Jahre) und akuter Infektion wurden eingeschlossen. Der Schlauch wurde endoskopisch entfernt und eine antibiogrammgerechte antibiotische Therapie über 10 bis 14 Tage durchgeführt. 11 bis 25 Tage später wurde der persistierende Fisteltrakt mechanisch deepithelialisiert und unter endoskopischer Führung mit einer speziellen Gastropexievorrichtung zugenäht. Eine neue PEG wurde in derselben Sitzung an anderer Stelle angelegt. Nach 30 Tagen waren die zuvor persistierenden Fisteln vollständig dicht verheilt; die Gastrostomie funktionierte in allen Fällen regelrecht.Der endoskopische Verschluss einer persistierenden Gastrostomiefistel nach gründlicher Deepithelialisierung ist eine vielversprechende Technik, deren Effektivität in größeren Studien geprüft werden sollte.

Argon plasma coagulation (APC) of gastric inlet patches of the cervical esophagus (GIP) has been shown to relieve the globus sensation. This study aimed to investigate the long-term effects of APC therapy on a variety of laryngopharyngeal symptoms.Patients with laryngopharyngeal symptoms who had undergone endoscopic GIP eradication via APC therapy were eligible for a retrospective observational cohort study. Symptom relief was assessed by a five-grade scale during a structured interview. Statistical analysis included ANOVA, the chi-squared and t-test.A total of 45 patients (61.0 (52.0; 69.0) years, 26 (57.8%) female) were included after a follow-up time of 85.0 (55.3; 111.0) months. Symptoms included dysphagia (56.0%), dysphonia (51.0%), hoarseness (76.0%), the necessity of throat clearing (73.0%), globus sensation (56.0%) and heartburn (71.0%). Complete GIP eradication was achieved after one session in 25 (55.6%), repetitive sessions were needed in the remaining cases. Fourteen patients (31.1%) reported a very strong, 11 (24.4%) a strong and 8 patients (17.8%) an intermediate improvement; five patients did not benefit. The most apparent improvement was seen regarding hoarseness (from 2.6 ± 1.7 to 1.2 ± 1.3), the necessity of throat clearing (from 2.6 ± 1.7 to 1.1 ± 1.3), globus sensation (from 2.0 ± 1.9 to 0.9 ± 1.3) and heartburn (from 2.5 ± 1.8 to 1.4 ± 1.6). Adverse events included post-endoscopic pain (n = 6, 13.3%) and purulent pharyngitis (n = 2, 4.4%).The APC therapy of GIP is safe and leads to long-term relief of laryngopharyngeal symptoms in carefully selected patients.

Background: Pressure ulcers are a common complication in patients with spinal cord injury. The role of faecal diversion to support anus-near ulcer healing is under debate and its impact on the microbial colonisation pattern is unclear. The aim was to evaluate the primary microbial colonisation and secondary infection depending on the presence of a pre-existing diverting stoma and investigate the effect on the wound healing. Methods: A total of 120 spinal cord injured patients who had undergone surgery of an anus-near decubitus stage 3 or 4 were included in a retrospective matched-pair cohort study. Matching was realised according to age, gender, body mass index and general condition. Results: The most common species in both groups was Staphylococcus aureus (45.0 %). The only significantly different primary colonisation affected Escherichia coli, that was found in the stoma patients less often (18.3 and 43.3 %, p < 0.01). A secondary microbial colonisation occurred in 15.8 % and was equally distributed, except for Enterococcus spp. that was present only in the stoma group (6.7 %, p < 0.05). The time to complete cure took longer in the stoma group (78.5 versus 57.0 days, p < 0.05) and was associated with a larger ulcer size (25 versus 16 cm2, p < 0.01). After correction for the ulcers’ size, there was no association to outcome parameters such as overall success, healing time or adverse events. Conclusion: The presence of a diverting stoma alters the microbial flora of an anus-near decubitus slightly without impact on the healing process.

Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality. The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy. Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively. Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed. Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.

Study DesignRetrospective cohort study including spinal cord injured patients with anus-near pressure ulcers.ObjectiveThe primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined.SettingUniversity hospital with a spinal cord injury unit.MethodsA total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis.ResultsThe severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days,p = 0.02). The age (regression coefficientb = 0.41,p = 0.02), the ASA classification (b = 16.04,p = 0.001) and the stage of the ulcers (b = 19.65,p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = −18.19,p = 0.03) and the stage of the ulcers (b = 21.62,p = 0.001) were the only predictors of delayed wound healing.ConclusionThe presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.

Zusammenfassung Einleitung Der Einfluss einer SARS-CoV-2-Infektion auf chronisch entzündliche Darmerkrankungen (CED) ist bislang nicht gut charakterisiert, und es ist unklar, ob diese eine Anpassung der immunsuppressiven Therapie erfordert. Methodik Für die retrospektive Dokumentation klinischer Parameter und Veränderungen einer immunsuppressiven Therapie von mit SARS-CoV-2 infizierten CED-Patienten wurde ein nationales Melderegister etabliert. Ergebnisse Insgesamt wurden nur 3 von 185 CED-Patienten (1,6 %) wegen abdomineller Symptome auf eine SARS-CoV-2-Infektion getestet. Im COVID-19-Krankheitsverlauf entwickelten 43,5 % Durchfall, abdominelle Schmerzen oder Hämatochezie (Hospitalisierungsrisiko mit vs. ohne abdominelle Symptome: 20,0 % vs. 10,6 %, p Diskussion Bei mit SARS-CoV-2 infizierten CED-Patienten traten häufig neue abdominelle Symptome bei Infektion auf. Diese führten aber nur selten zur SARS-CoV-2-Testung. Eine hohe CED-Aktivität zum Zeitpunkt des SARS-CoV-2-Nachweises war mit einem erhöhten Hospitalisierungsrisiko assoziiert.

Zusammenfassung Hintergrund In der Abrechnungssystematik der deutschen Krankenhäuser (G-DRG-System) sind endoskopische Leistungen in der Kostenstellengruppe 8 gesondert ausgewiesen. Für die interne Leistungsverrechnung oder die Erstattung externer Anbieter werden häufig noch wenig aktuelle oder unvollständige Kataloge wie DKG-NT oder GOÄ verwendet. Wir haben die Kosten endoskopischer Leistungen im DRG-System ermittelt. Methodik Zur Erfassung endoskopischer Leistungen wurden der DGVS von 74 Kalkulationskrankenhäusern des Instituts für das Entgeltsystem im Krankenhaus (InEK) die kompletten gastroenterologischen Kostendatensätze (2011 – 2015; § 21 KHEntgG) anonymisiert überlassen (4873 809 Falldatensätze). Aus Fällen mit nur genau einer Endoskopie (n = 274 186) wurden die mittleren Kosten für 46 endoskopische Leistungsgruppen aus 5 Jahren ermittelt. Ergebnisse Es wurden belastbare Kostenwerte errechnet mit einer Spanne, die von 230,56 € für die Gastroskopie (n = 144 666), über die einfache Koloskopie (276,23 €, n = 32 294) bis zur ERCP mit Papillotomie und Kunststoffstenteinlage (844,07 €, n = 10 150) oder zur ERCP mit Einlage eines selbstexpandierenden Metallgitterstents (1602,37 €, n = 967) reichte. Höhere Kosten für Universitätsklinika fanden sich vor allem bei komplexen Leistungen. Diskussion Der Kostenkatalog endoskopischer Leistungen, der anhand der § 21 KHEntgG Datensätze von 74 Kalkulationskrankenhäusern des InEK errechnet wurde, erlaubt erstmals eine Abschätzung von realen Endoskopiekosten im Krankenhaus. Die höheren Kosten in Universitätsklinika sind am ehesten durch einen „referral bias“ für komplexe Fälle und Eingriffe im Nacht- und Notdienst zu erklären. Für 46 endoskopische Leistungsgruppen ist jetzt eine sachgerechtere Zuordnung der Kosten im DRG-System möglich. Im internationalen Vergleich sind die Kosten der Endoskopie in deutschen Krankenhäusern niedrig, was entweder in höherer Effizienz, geringerer Personalausstattung oder unvollständiger Kostendokumentation begründet ist.

Background Drug toxicity is a common and even serious problem in the gastrointestinal tract that is thought to be caused by a broad spectrum of agents. Although withdrawal of the causative agent would cure the disease knowledge is scarce and mostly derives from case reports and series. Aim To investigate potential triggers of drug-induced colitis (DiC). Methods We conducted a retrospective, observational case control study. Patients were assigned to DiC or one of two age- and gender-matched control groups (non-inflammatory controls and inflammatory colitis of another cause) based on histopathological findings. Histopathology was reassessed in a subset of patients (28 DiC with atherosclerosis, DiC without atherosclerosis and ischaemic colitis each) for validation purposes. Medical history was collected from the electronic database and patient records. Statistical analysis included chi-squared test, t-test, logistic and multivariate regression models. Results Drug-induced colitis was detected in 211 endoscopically sampled biopsy specimens of the colon mucosa (7% of all screened colonoscopic biopsy samples); a total of 633 patients were included equally matched throughout the three groups (291 males, mean age: 62.1 ± 16.1 years). In the univariate analysis, DiC was associated with diuretics, dihydropyridines, glycosides, ASS, platelet aggregation inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), statins and fibrates, and with atherosclerosis, particularly coronary heart disease, and hyperlipoproteinaemia. Echocardiographic parameters did not show substantial differences. In the multivariate analysis only fibrates [odds ratio (OR) = 9.1], NSAIDs (OR = 6.7) and atherosclerosis (OR = 2.1) proved to be associated with DiC. Both DiC reassessment groups presented milder inflammation than ischaemic colitis. The DiC patients with atherosclerosis exhibited histological features from both DiC without atherosclerosis and ischaemic colitis. Conclusion Several drugs indicated for the treatment of cardiovascular and related diseases are associated with DiC. Atherosclerosis and microcirculatory disturbances seem to play an important pathogenetic role.

BackgroundPropofol is recommended for sedation in gastrointestinal endoscopy (GE), but preliminary data suggest addictive potentials.ObjectiveThe objective of this article is to evaluate the frequency of predominantly euphoric reaction after GE and patients’ subsequent reminiscences.MethodsEighty-two patients undergoing elective GE under propofol sedation were enrolled in a prospective observational study. The grade of anxiety, expectation or relief about the examination’s result and affective state in terms of cheerfulness, relaxation, activation, sedation and anxiety were surveyed using a numeric rating scale (1 to 10) immediately before (t1), after GE (t2) and seven days (t3) later. Statistics: hierarchical cluster analysis, heat map, χ2 test and paired t test.ResultsMean propofol dosage was 264 ± 120 mg. Two clusters of mood changes emerged (t1 vs. t2). One (n = 46, 56.1%) was characterized by an unease reaction pattern with equal values regarding cheerfulness, relaxation and anxiety, while relaxation...

Background and Aims: Small bowel visualisation is a complex diagnostic approach, but mandatory for risk stratification and stage-adjusted therapy in Crohn's disease. Current guidelines favour transabdominal ultrasound and small bowel MRI as methods of choice, although their clinical impact in daily practice remains controversial. The aim of this study was to evaluate the diagnostic benefit of small bowel MRI in Crohn’s disease according to Montreal Classification, in routine practice. Methods: Patients who underwent MR-enterography [MRE] or MR-enteroclysis [MRY] were included in a retrospective single-centre study. MRI findings were correlated with results from clinical work-up and evaluated in terms of [1] diagnostic yield, [2] significant additional information, and [3] alterations in the assessment of disease behaviour and location according to Montreal Classification. Results: A total of 347 small bowel MRI examinations were analysed [MRE: 49 / MRY: 298]. MRI had an average sensitivity/specificity of 82.5% and 99.9% [positive predictive value: 99.8% / negative predictive value: 91.1%] respectively. In every second patient, new relevant diagnostic information was provided. Incorporation of the MRI results caused significant shifts in Montreal Classification, specifically higher L-levels [+21.2%; p < 0.05] and higher B-levels: [+24.6%; p < 0.05]. Conclusions: Even in routine practice, small bowel MRI is a powerful and reliable technique in small bowel work-up. Since MRE and MRY presented high diagnostic yields, often detected significant additional information, and significantly caused shifts in Montreal Classification, both techniques are confirmed to be excellent tools in diagnosing and monitoring Crohn’s disease in its daily course.

Background and aimsApparent aspiration is a notable adverse event during gastrointestinal endoscopy under sedation (GIES), but data about inapparent aspiration are scarce. Generally, particularly older patients are at higher risk of suffering from adverse events.ObjectiveThe objective of this article is to determine the risk of pneumonia, lower respiratory tract infection (LRI) and systemic inflammatory activation after GIES, especially in patients of at least 65 years.MethodsThe retrospective case-control study included 250 patients undergoing GIES and assigned age-, gender- and time of performance-matched controls without invasive procedure or sedation (ratio 1:1).ResultsOn day 3 patients of advanced age presented with both pneumonia and LRI more often (2.6 vs. 0.0%, p = 0.041 and 7.8 vs. 2.5%, p = 0.034, respectively). In general, several inflammatory parameters increased significantly after GIES (i.e. white blood cell count (increase of ≥ 25%) 18.6 vs. 6.9%, p ConclusionsPatients of advanced age carry an increased risk of pneumonia and LRI after GIES. Patients are generally more likely to feature inflammation and to receive antibiotic treatment.

Background and aim: The prevalence of cervical heterotopic gastric mucosa (HGM) of the proximal oesophagus differs widely between studies, perhaps due to examination conditions during endoscopy. In this study we aimed to determine whether narrow band imaging (NBI) or high definition (HD) imaging improves detection of HGM. Possible factors of influence for HGM detection, in particular setting (position, timing, in-/out-patient), examination time and sedation parameters, were analysed. Methods: Retrospective analysis of 641 consecutive patients who underwent an oesophagogastroduodenoscopy (EGD) by the same, substantially experienced endoscopist between June 2011 and August 2013. The type of endoscope was randomly assigned to patients. Results: A total of 85 patients showed HGM with an overall prevalence of 13.3 %. The detection rate in the HD-NBI group was 18/127 (14.2 %) and in the HD white light (HDWL) group, 15/104 (14.4 %, p = 0.957). The detection rate between standard definition white light (SDWL) endoscopy (52/410, 12.7 %) and HD endoscopy did not differ significantly (33/231, 14.3 %, p = 0.566). Setting, sedation dosage and examination times were equally distributed between study groups. The indication of dysphagia (11.8 % vs. 2.4 % with p = 0.000, respectively) and dyspepsia (19.1 % vs. 10.8 %, p = 0.047, respectively) occurred significantly more often in HGM patients than in the control group. There was no difference in the detection rate depending on HGM size. Conclusions: The prevalence of HGM in the upper EGD is high and does not differ significantly between the study groups of SDWL, HDWL and HD-NBI under equivalent conditions.

Hintergrund: In der Abrechnungssystematik der Deutschen Krankenhauser (G-DRG-System) sind endoskopische Leistungen weder vollstandig noch kostengerecht abgebildet. Hauptursache ist eine Zuordnung der Personalkosten aufgrund veralteter Leistungskataloge sowie das Fehlen einer verpflichtenden Zeiterfassung der Personalbindung. Methodik: Zur Erstellung eines zeitgemasen Leistungskatalogs wurden der DGVS von 50 Kalkulationskrankenhausern des Instituts fur das Entgeltsystem im Krankenhaus (InEK) die kompletten gastroenterologischen Kostendatensatze (2011 – 2013; § 21,4 KHEntgG) anonymisiert uberlassen (2499 900 Falldatensatze) und aus diesen alle Operationen und Prozedurenschlussel (OPS) endoskopischer Leistungen in Leistungsgruppen (z. B. Koloskopie mit Biopsie/Koloskopie mit Stenteinlage) klassifiziert. Eine Expertengruppe ordnete die Leistungsgruppen nach Fallschwere und wies ihnen geschatzte Personalbindungszeiten zu. Von Juni bis November 2014 wurde der Leistungskatalog an 119 Krankenhausern mittels exakter Personalzeiterfassung in der Endoskopie validiert (38 288 Prozeduren). Ergebnisse: Dieses 3-stufige Vorgehen hat, in enger Abstimmung mit dem InEK, die Erstellung eines zeitgemasen Leistungskatalogs mit 97 Einzelleistungsgruppen ermoglicht, der uber 99 % aller durchgefuhrten endoskopischen Prozeduren abdeckt und diese anhand der gemessenen arztlichen Personalbindung gewichtet. Wahrend in der Vergangenheit eine diagnostische Koloskopie im Vergleich zur Osophagogastroduodenoskopie (Standardwert 1,0) ein Relativgewicht von 1,13 aufwies, wird der Personalaufwand im Leistungskatalog sachgerechter mit 2,16 abgebildet. Bei der diagnostischen ERCP andert sich das Relativgewicht von 1,7 auf 3,62. Leistungen mit hoher Personalbindung, die bisher nicht erfasst wurden, werden jetzt sachgerecht abgebildet (z. B. ESD im Magen 16,74). Diskussion: Der neue, in Zusammenarbeit von uber hundert Krankenhausern validierte Leistungskatalog bildet endoskopische Prozeduren in der Gastroenterologie nahezu vollstandig ab und weist diesen validierte Relativkostengewichte zu. Der Einsatz des Leistungskatalogs wird vom InEK als Ersatz fur veraltete GOA-, DKG-NT- und Hauskataloge empfohlen und wird, bis zum flachendeckenden Einsatz der Zeiterfassung in der Endoskopie, wesentlich zu einer sachgerechteren Zuordnung der Kosten im deutschen DRG-System beitragen.

AIM To identify a set of contributors, and weight and rank them on a pathophysiological basis. METHODS Patients who have undergone a lactulose or glucose hydrogen breath test to rule out small intestinal bacterial overgrowth (SIBO) for various clinical symptoms, including diarrhoea, weight loss, abdominal pain, cramping or bloating, were seen as eligible for inclusion in a retrospective single-centre study. Clinical data such as co-morbidities, medication, laboratory parameters and other possible risk factors have been identified from the electronic data system. Cases lacking or with substantially incomplete clinical data were excluded from the analysis. Suspected contributors were summarised under four different pathophysiological pathways (impaired gastric acid barrier, impaired intestinal clearance, immunosuppression and miscellaneous factors including thyroid gland variables) and investigated using the χ2 test, Student’s t-test and logistic regression models. RESULTS A total of 1809 patients who had undergone hydrogen breath testing were analysed. Impairment of the gastric acid barrier (gastrectomy, odds ratio: OR = 3.5, PPI therapy OR = 1.4), impairment of intestinal clearance (any resecting gastric surgery OR = 2.6, any colonic resection OR = 1.9, stenosis OR = 3.4, gastroparesis OR = 3.4, neuropathy 2.2), immunological factors (any drug-induced immunosuppression OR = 1.8), altered thyroid gland metabolism (hypothyroidism OR = 2.6, levothyroxine therapy OR = 3.0) and diabetes mellitus (OR = 1.9) were associated significantly to SIBO. Any abdominal surgery, ileocecal resection, vagotomy or IgA-deficiency did not have any influence, and a history of appendectomy decreased the risk of SIBO. Multivariate analysis revealed gastric surgery, stenoses, medical immunosuppression and levothyroxine to be the strongest predictors. Levothyroxine therapy was the strongest contributor in a simplified model (OR = 3.0). CONCLUSION The most important contributors for the development of SIBO in ascending order are immunosuppression, impairment of intestinal clearance and levothyroxine use, but they do not sufficiently explain its emergence.

Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome. In this article, we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall, using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock. Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.

Funktionsprufungen globaler Natur, zum Beispiel Leistungsprufungen an einem Ergometer oder Funktionsprufungen bestimmter Organsysteme oder Funktionskreise, etwa der Atmung, des Herz-Kreislauf-Systems, der Nieren oder der Entgiftungskapazitat der Leber werden im Rahmen arztlicher Begutachtungen durchgefuhrt, um eingehendere und sicherere diagnostische Aufschlusse zu gewinnen als sie die Anamnese, die subjektiven Beschwerden, der korperliche Untersuchungsbefund und die Ergebnisse technischer Untersuchungen primar vermitteln. Die Ergebnisse solcher Funktionsanalysen sollen also besonders grose Aussagesicherheit haben, denn sie sollen helfen, die gutachterliche Beurteilung zu verbessern und so sicher wie irgend moglich zu gestalten.

Traumen durch stumpfe oder penetrierende Verletzungen der gastrointestinalen Hohlorgane (Magen, Duodenum, Dunndarm, Pankreas, Kolon) konnen zur Organperforation und/oder Blutung mit der Notwendigkeit der zeitnahen chirurgischen Intervention fuhren. Bei Ingestion starker Sauren oder Laugen stehen Verletzungen des Osophagus im Vordergrund; Nekrosen bis hin zur Perforation des Magens sind jedoch moglich. Traumatische Verletzungen des Pankreas bedurfen eines interdisziplinaren Vorgehens (Endoskopie, Chirurgie). Der Grad der Schadigung orientiert sich am dauerhaften Funktionsverlust (Kurzdarmsyndrom, Anus praeter, endokrine/exokrine Pankreasinsuffizienz).

Gastrointestinal bleeding from small-bowel varices is a rare and difficult to treat complication of portal hypertension. We describe the case of a 79-year-old female patient with recurrent severe hemorrhage from small-bowel varices 30 years after a complicated cholecystectomy. When double balloon enteroscopy was unsuccessful to reach the site of bleeding, a rendezvous approach was favored with intraoperative endoscopy. Active bleeding from varices within a biliodigestive anastomosis was found and controlled by endoscopic injection of cyanoacrylate. Intraoperative endoscopy should be considered in the case of life-threatening gastrointestinal hemorrhage that is not accessible by conventional endoscopy.

Einleitung: Die stationare Aufnahme des 71-jahrigen mannlichen Patienten erfolgte aufgrund einer exazerbierten COPD. Im Verlauf kam es bei schon kurz zuvor ambulant begonnener Medikation mit Irenat und Thiamazol bei latenter Hyperthyreose bei multifokaler Autonomie zu einem schweren Steven-Johnson-Syndrom mit Beteiligung enoraler Schleimhaute, uretraler Schleimhaut, intestinaler Schleimhaute sowie grosflachige Lasionen der gesamten Korperoberflache, in dessen Verlauf der Patient intensivpflichtig wurde. Unter Steroidstostherapie protahierte Befundbesserung. Im Verlauf kam es zur Ausbildung eines akuten Abdomens mit lokalem Peritonismus. Ziele: Nach CT-morphologischer Diagnostik einer Dunndarmperforation explorative Laparotomie mit Nachweis groser Mengen freier Flussigkeit intrababdominell und Ubernahung des Defektes. Im Verlauf rezidivierende Hb-Abfalle, in deren Folge mehrzeitige GAstroskopien notig wurden zur Blutstillung. Methodik: Gastroskopien mit gastroskopischen Clipapplikationen. Ergebnis: Nach mehrzeitigen Gastroskopien mit teils sichtbaren Gefassstumpfen im Bereich der duodenoduodenalen Anastomose und derer Clippung konnten im Verlauf stabile Hb-Werte erreicht werden. Unter hoch doisierter PPI Therapie stabile Verhaltnisse auch bei Kontrollen bei im Verlauf unauffalligen Schleimhautbefunden des gesamten endoskopisch eingesehenen Intestinums. Im Verlauf Entlassung des vollstandig genesenen Patienten ohne persistierende Defekte an den betroffenen Haut- und Schleimhautarealen. Zudem Ausstellung eines Warnpasses zur Vermeidung potentiell auslosender Substanzen, hier Irenat, Thiamazol und, bei nicht sicherem Ausschlu0, Metamizol. Schlussfolgerung: Steven-Johnson-Syndrom bei schweren Verlaufen auch mit intestinaler Manifestation und dadurch komplikativem Verlauf, regelmassige endoskopische Kontrollen der Lokalbefunde mit endoskopischer Therapie als Weg der Wahl zur Vermeidung von Re-Laparotomien.

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.