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Background and Objective: The aim of this study was to evaluate the diagnostic and therapeutic consequences arising from abnormal ultrasound findings in a multidisciplinary setting in the University of Regensburg Clinical Centre., Patients and Methods: The results of 1162 randomly selected ultrasound examinations (on 671 males and 491 females) from a total of 14,301 at an interdisciplinary ultrasound unit were analysed. The investigators recorded the findings in a routinely used standardized manner. The records and discharge reports of each patient were then evaluated with regard to the diagnostic and therapeutic consequences of the findings., Results: There were 1843 abnormal findings in 901 patients. In 114 patients (6.2 %) no adequate diagnostic measures had been undertaken or recommended at discharge, but the reasons for the decisions taken could not be judged (value 4). 72.1 % of all patients were recruited from departments of internal medicine. However, the highest percentage of findings without adequate consequences were found to be in patients of the departments of oral and maxillofacial surgery, dermatology and nuclear medicine., Conclusion: The number of ultrasound examinations that had been done without adequate consequences was comparatively low at 6.2 %. But perhaps this number can be further reduced by improved wording of the examination reports.

History and Clinical Findings: A 52-year-old man with liver cirrhosis and ascites, hepatorenal syndrome and severe pancytopenia was admitted to hospital for treatment and consideration for future liver transplantation., Investigations: Laboratory tests revealed severe leukocytopenia and thrombocytopenia, which had persisted after otherwise successful treatment of spontaneous bacterial peritonitis and a hepatorenal syndrome. There was no evidence of a toxic cause such as drugs or alcohol nor of an underlying haematologic disease. The most likely diagnosis was hypersplenism., Diagnosis, Therapy and Clinical Course: Because of the high risk of a splenectomy it was decided to perform a partial splenic arterial embolization. Both leukocyte and thrombocyte counts rose after the intervention and continued to stay within normal range. This made it possible to discharge the patient from inpatient treatment until he was admitted again for a subsequently successful liver transplantation., Conclusions: Partial splenic artery embolization can be successfully used to treat severe leukocytopenia and thrombocytopenia in patients with liver cirrhosis and hypersplenism.

History: A 52-year-old woman with chronic anaemia presented with recurrent epistaxis, telangiectasias and haemangiomas, suggesting the presence of hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber disease). Moreover, previous investigations had also shown multiple polyps of the stomach., Investigations: A severe microcytic iron deficiency anaemia in combination with hepatic haemangiomas and duodenal angio-dysplasia were detected. Gastrointestinal endoscopy revealed multiple juvenile polyps in the gastric fundus and body, indicating the diagnosis of hereditary haemorrhagic telangiectasia in combination with juvenile polyposis., Therapy and Course: A gastrectomy was performed because of recurrent gastrointestinal bleeding and the malignant potential of juvenile gastric polyposis. Histopathology confirmed the diagnosis and did not reveal any malignancy., Conclusion: The association of hereditary haemorrhagic telangiectasia and juvenile polyposis, as seen in this patient, has been reported repeatedly. A diagnosis of one of the described entities should initiate the screening for evidence of the other one to prevent (life-threatening) complications.

History and Admission Findings: A 51-year-old woman was admitted because of relapsing episodes of fever and leg ulcers for 14 years. In addition, she had polyserositis, polyarthralgias and polyarthritides, renal failure with proteinuria and elevation of gamma-GT and alkaline phosphatase. The patient was in a reduced general condition and cachectic nutritional state. She had slight scleral icterus, the liver being palpable 5 cm under the costal margin, edema of the lower limbs and two ulcers at the right foot., Investigations: Laboratory examinations revealed leukocytosis, anemia, elevation of cholestasis and inflammation parameters as well as renal failure. During a 24 hour collection period, a significant proteinuria was demonstrated. Immunoserologically, an ANA titer of 1:100 and a positive rheumatoid factor were found, ANCAs and AMAs were negative. On ultrasound, both kidneys exhibited a blurred pelvic parenchymal border. Thyroid ultrasound demonstrated parenchymal changes consistent with Hashimoto's disease. Ultrasound of the wrist revealed extensive arthritis with tendovaginitis. A renal biopsy revealed mesangioproliferative glomerulonephritis., Diagnosis, Therapy and Clinical Course: Due to serologically persistent cholestasis, a liver biopsy was performed which, together with negative AMAs, revealed the diagnosis of an autoimmune cholangitis (AIC; AMA-negative primary-biliary cirrhosis (PBC)). In addition, the patient presented with rheumatoid arthritis, polyserositis, IgA glomerulonephritis, vasculitic leg ulcers and Hashimoto's thyreoiditis which were interpreted as extra-hepatic manifestations of the AIC. After initiation of high dosage corticosteroid therapy, rapid healing of the leg ulcers occurred. Therapy of the AIC consisted in ursodeoxycholic acid., Conclusion: The multitude of associated immunological phenomena in this patient resulted in a delay of the diagnosis. A AIC/PBC, however, should, always be considered in case of cholestasis.

History and Admission Findings: During a routine check-up, a 37-year-old woman was found to have elevated levels of serum gamma-glutamyl transferase (gamma GTP) and IgA- and IgM-antibodies. One of the patient's brothers had died at the age of six from acute liver failure. We found a palpably enlarged liver with normal consistency and no particular helpful laboratory results., Investigations: The abdominal ultrasound and computed tomography (CT) showed segmental and saccular dilatations of the biliary tract, hepatofugal flow in the portal vein, multiple collateral vessels as well as a mild splenomegaly. Histopathology revealed fibrotic liver parenchyma, a dilatated and branched biliary tract lined by cubical epithelium., Course: Gastroscopy showed lowgrade esophageal varices. Seventeen months after the initial presentation there were no significant changes of the laboratory tests or the ultrasound., Conclusions: The defective remodelling of the ductal plate ("ductal plate malformation") is associated with dysplasia of the biliary tract. Depending on the localisation of the lesions within the biliary tract and whether it is a more cystic or more fibrotic component, there are different malformations caused by ductal plate malformation. We diagnosed congenital hepatic fibrosis, because of the atypical age of presentation, it could be the "adult form" of congenital liver fibrosis.

Objective: We investigated the value of abdominal ultrasound screening of abdominal foci in patients with benign diseases of the skin., Patients and Methods: The data of 151 patients (age (mean) 56,6 years; male n = 79, female n = 72) from the department of dermatology were retrospectively analysed. The patients were sent for ultrasound evaluation of abdominal foci as cause of benign diseases of the skin., Results: In these 151 patients 3 potential foci were found (2 yen suspicion of a liver tumor, 1 yen thickened bowel wall). The liver tumors could not be confirmed by computed tomography, in the patient with a thickened bowel wall, a Crohńs disease was newly diagnosed. Abdominal ultrasound led to clinically relevant findings in fewer than 1 % of cases. We diagnosed 142 abnormal findings, mostly without clinical relevance. These abnormal findings caused follow-up examinations in 30 of the cases (19 computed tomographies; 2 magnetic resonance tomographies)., Conclusion: Abdominal ultrasound does not seem useful in the primary screening of patients with benign diseases of the skin. Perhaps a more restrictive and selective use of ultrasound could be valuable.

History and Admission Findings: A seventy-seven year-old woman with an unclear tumor of the liver suffered from recurrent hypoglycemia and was therefore admitted to our hospital. As diabetes mellitus, hyperinsulinism and reactive forms of hypoglycemia could be excluded, the presumptive diagnosis was non-islet-cell tumor hypoglycemia (NICTH)., Investigations: Postprandial glucose levels were normal. Fasting glucose levels were 30 - 50 mg/dl. Plasma insulin-like growth factor (IGF)-I was below the normal range, IGF-II was not elevated, although 34 % of plasma IGF-II was present as "big"-IGF-II. IGF-binding protein (IGFBP)-2 was extremely elevated, whereas IGFBP-3 was within the normal range. Histological examinations of the tumor revealed a hemangiopericytoma of the liver., Treatment and Course: : After a 2-month treatment with steroids and an experimental antiangiogenetic therapy, the glucose metabolism became stable. The tumour did not grow. Simultaneously, plasma IGF-II and "big"-IGF-II remained constant and plasma IGF-I level improved slightly. IGFBP-2, which is presumable produced by the tumor, increased, IGFBP-3 fell below the normal range., Conclusion: NICTH is a rare but important differential diagnosis of recurrent hypoglycemia. The tumor derived IGF-II has a higher than normal molecular weight ("big"-IGF-II) and shows different interactions with binding proteins, thus resulting in an increased bioavailability. An increased glucose uptake in different tissues as well as inhibition of hepatic gluconeogenesis and lipolysis lead to severe hypoglycemia. If surgical therapy of the tumor is not possible, symptomatic treatment with steroids may represent an effective alternative to control severe hypoglycemia.

Objective: This prospective clinical study investigated whether the relatively simple and cost-effective ultrasonography of the inferior vena cava (IVC) represents a valid clinical tool to assess the effectiveness of diuretic therapy in patients with chronic congestive heart failure (CHF)., Methods: Measurement of the resting and inspiratory diameter of the VCI repeatedly during diuretic therapy in 23 consecutive patients (11 women, 70 +/- 10 years) with CHF and comparing the results to the daily measured body weight and serum creatinine in these patients. Results were compared with the IVC diameter obtained in 33 healthy controls (16 women, 42 +/- 15 years). In addition, the IVC collapse index was calculated to assess inspiratory movements of the IVC in patients on day 1 and 10 of therapy., Results: The IVC diameter at rest was 2.4 +/- 0.6 cm and decreased to 2.0 +/- 0.7 cm at inspiration, which was significantly greater than in healthy controls (1.4 +/- 0.4 cm at rest and 1.05 +/- 0.5 cm at inspiration; p = 0.008 and p = 0.01, respectively). The IVC diameter decreased continuously and significantly (p < 0.003) from day 1 to day 10 during diuretic therapy without a concomitant rise in serum creatinine. At beginning of therapy, the collapse-index of the IVC was significantly greater in patients than in controls. However, after 10 days of therapy this index reached similar values to those observed in controls., Conclusion: Ultrasonographic measurements of IVC diameter and inspiratory movements are a quantifiable and reliable approach to assess the hypervolemia associated with CHF. Normalization of inspiratory IVC collapse movement correlates with successful diuretic therapy and can be reliably used for bedside assessment and monitoring treatment in CHF patients.

Background: Almost all patients in departments of internal medicine routinely undergo abdominal ultrasound examination in which liver changes indicating hepatic steatosis are often detected. The aim of this study was to assess the occurrence of pathological oral glucose tolerance, manifest diabetes mellitus and other changes indicative of a metabolic syndrome in patients with sonographic signs of hepatic steatosis., Patients and Methods: 577 patients were examined during a period of 6 months: 90 patients fulfilled the inclusion criteria., Results: Among the 90 patients with echodense liver who were included in the study (42 female, 48 male) 36 patients presented with previous diagnosis of diabetes mellitus (40%). The oral glucose tolerance test was impaired in 19 patients (21%) and in four patients with manifest diabetes mellitus (4%). Among patients with echodense liver a high percentage presented with obesity and impaired fat metabolism., Conclusions: The large number of patients with an impaired oral glucose tolerance test converting to manifest diabetes, as well as the large number of patients with manifest disorders of fat metabolism suggest that screening for diabetes should be performed in patients who present with sonographic signs of hepatic steatosis.

History and Admission Findings: A 26-year-old woman, for 3 years known to have systemic lupus erythematodes (SLE), was admitted because of fever, muscle and joint pains as well as nausea and vomiting. Maintenance therapy of 50 mg azathioprine, three times daily, had been stopped by the patient several weeks earlier. Physical examination was unremarkable except for pale skin and mucosae as well as pain on pressure over muscle groups of the upper arms and thighs and paravertebrally., Diagnosis, Treatment and Course: Laboratory tests showed a pancytopenia with a decrease of the haemoglobin level of 3.0 g/dl. The differential diagnosis included an acute exacerbation of SLE, toxic damage to the bone-marrow by azathioprine or a viral infection involving the bone-marrow. Serological tests and the further course confirmed an acute paravirus B19 infection as the cause., Conclusion: Paravirus B19 infection should be included in the differential diagnosis when an acute exacerbation of SLE is suspected.

History and Admission Findings: A 69-year-old man, a known carrier of hepatitis B virus (HBV) after blood transfusion, developed increasingly severe jaundice with high transaminase levels after receiving steroids in high doses. Significant preceding conditions included chronic obstructive pulmonary disease, coronary heart disease, ulcerative colitis in remission and diabetes mellitus. On admission he was jaundiced and experienced pain on pressure below the right costal margin., Investigations: Serology demonstrated reactivated hepatitis B with an increase of the HBV-DNA concentration in serum, as well as seroconversion with HBe antigen, anti-HBc-IgM antibodies and absence of anti-HBe antibodies., Diagnosis, Treatment and Course: The history and serological findings indicated reactivation of the hepatitis B by the steroid treatment. Progressive liver failure developed. A marked reduction of virus particles in the blood occurred after a therapeutic trial with the nucleoside analog lamivudine, but the patient died of liver failure 30 days after admission., Conclusion: Steroids should be given to known hepatitis B carriers only if strictly indicated, because of the danger of acute deterioration of liver functions by reactivation of the disease with possibly fatal consequences. If steroids are administered, liver functions and serological hepatitis markers should be closely monitored so that any necessary treatment can be quickly initiated.

History and Clinical Findings: A 63-year-old man was hospitalized because of his worsening general condition and weight loss. Physical examination revealed marked thoracic kyphosis with impaired mobility of his back and restricted walking because of pain in the right hip. He also had other bone pains., Investigations: Serum calcium was reduced (1.60 mmol/l) and there was generalized bone demineralization. Subsequently an increased parathormone (PTH) level was noted (499.0 ng/l) as well as markedly increased activity of enzymes involved in bone metabolism, decreased renal excretion of phosphates (4.76 mmol/24 h) and multiple pathological fractures., Treatment and Course: The listed abnormalities indicated the diagnosis of pseudohypoparathyroidism (PHP), type 1 b. After treatment had been started with vitamin D (calcitriol 2 x 0.25 micrograms/d) and calcium (calcium gluconate, 3 x 500 mg/d), the levels of calcium, PTH and enzymes in bone metabolism gradually became normal. A cataract operation had to be performed because of calcification of the lens., Conclusion: The level of PTH should be determined in patients with extensive bone demineralization and hypocalcaemia. If PTH is raised, PHP should be included in the differential diagnosis. Normalization of serum calcium by calcium substitution and vitamin D administration will normalize PTH and improve mineralization of the skeleton. In this way the debilitating effects of osteodystrophia cystica generalisata (OCG) (Engel von Recklinghausen syndrome) can be prevented. Also, the consequences of extraosseous calcification, such as extrapyramidal symptoms of calcification of the brain-stem ganglia can be avoided if treated in time.

History: A 65-year-old woman was admitted to another hospital with suspected status asthmaticus. While there was progressive respiratory failure, the chest X-ray showed bilateral congestion and infiltration with widened mediastinum and cardiomegaly. The patient was transferred to the authors' hospital after two days on ventilatory support because of suspected left-ventricular failure and pulmonary congestion with pneumonia. 30 years previously she had undergone a myotomy for achalasia., Investigations: Imaging of the oesophagus with water-soluble contrast medium, computed tomography of the thorax and gastroscopy revealed a siphon-like megaoesophagus (which had been misinterpreted radiologically as cardiomegaly) with a slightly open lower oesophageal sphincter. The pulmonary symptoms were thought to be due to aspiration pneumonia., Treatment and Course: As there were no other reasonable treatment options a transmediastinal oesophageal resection with gastric pull-through and collar anastomosis was performed., Conclusion: In long-standing achalasia a megaoesophagus can develop despite previous myotomy. It should be included in the differential diagnosis of radiologically demonstrated mediastinal enlargement.

History and Clinical Findings: A 26-year-old man was admitted urgently because of breathing-related pain in the left thorax. This pain had started 3 months before, but had at first improved spontaneously. He had lost 13 kg during those weeks and had no recollection of any injury. Physical examination was unremarkable except for slight pain on upper-abdominal pressure and a palpably enlarged spleen., Investigations: All laboratory tests were normal, including the Quick value (100%), partial thromboplastin time (38 sec) and hemoglobin (14.2 g/dl). Chest radiogram showed a high left diaphragm. Abdominal sonography revealed a 12 x 10 cm moderately echogenic tumour in the spleen, extending from the splenic hilus to the upper splenic pole. Contrast-enhanced computed tomography demonstrated a hypodense tumour from which 300 ml of old blood were removed by needle puncture. Biopsy of the wall of the haematoma revealed pseudocystic transformation., Treatment and Course: The pseudocyst again filled with blood in a few days. A drain was inserted and remained for 32 days. Six installations of alcohol achieved complete obliteration of the cystic haematoma, which did not recur., Conclusion: Splenic haematoma should be considered in the differential diagnosis of pain in the lower left thorax, even in the absence of a history of injury. Sonographically such a haematoma my imitate a solid tumor. Obliteration of the cavity by alcohol installation can be a successful alternative to surgical treatment.

Basic Problem and Objective: Endoscopic diagnosis of gastrointestinal precancerous and cancerous lesions is difficult, often even impossible. This study was undertaken to find out whether premalignant or suspected malignant tumors can be diagnosed by preceding sensitization with 5-aminolaevulinic acid (ALA), which in tumors is transformed in increased amounts into photosensitizing protoporphyrin IX, the latter being recognized by its characteristic red fluorescence on exposure to blue light., Patients and Methods: 20 patients with known mild or moderately severe dysplasias (Barrett's esophagus, n = 8; colorectal adenoma, n = 3; ulcerative colitis n = 2, and gastric polyps or mucosal changes suspicious of malignancy, n = 5. Two patients with squamous-cell carcinoma, who after radio- and chemotherapy were endoscopically free of tumor, were sensitized with different concentrations of ALA (orally: 5-30 mg/kg; or locally: 3 g in 100 ml 0.9% NaCl). Photodynamic diagnosis (PDD) took place 4-8 h after oral and ca. 1-2 h after local sensitization with blue light (D-light, Storz, Tuttlingen, Germany)., Results: Definite red fluorescence with demonstration of dysplasia was found in three of four patients with Barrett's esophagus. Biopies from nonfluorescent areas were free of dysplasia. Two gastric adenomas (10 mg/kg ALA with high-grade dysplasia were definitively endoscopically by their red fluorescence. In one patient mild dysplasia was found in a non-fluorescent area after radio- and chemotherapy of an esophageal carcinoma. Dysplasias were also seen in the rectal biopsy after local applications., Conclusions: PDD makes it possible for the first time to visualize precancerous lesions of the gastrointestinal tract after preceding ALA sensitization. PDD is a highly promising method for monitoring patients with gastrointestinal disease and an increased risk of cancer, and for clarifying the diagnosis of mucosal changes suspicious of malignancy.

Objective: To analyse retrospectively the results of CT (computed tomography)-guided gastrostomy or gastroenterostomy where an endoscopic procedure was not possible or had failed., Patients and Methods: Between August 1993 and March 1997, CT-guided gastrostomy (n = 50) or gastroenterostomy (n = 8) was performed in 58 patients (mean age 56 +/- 6 years; 51 males, 7 females). An endoscopic or fluoroscopic method had been contraindicated in 52 and had failed in 6 patients., Results: Technical success was achieved in all patients. Three patients needed intravenous sedation. There were no procedure related complications requiring treatment. Three patients had a mild infection at the site of the skin puncture., Conclusion: CT-guided gastrostomy or gastroenterostomy is a safe and simple procedure which provides a minimally invasive alternative also in patients with contraindications to the established percutaneous method.

History and Clinical Findings: No cause had been found for chronic diarrhoea in a 57-year-old man. Up to 15 watery stools daily had been without relation to food intake and without blood admixture. But muscular cramps had developed, especially in the legs. The patient had a history of recurrent peptic ulcers for which a selective proximal vagotomy had been performed 13 years ago. Physical examination was unremarkable., Investigations: Alkaline phosphatase activity (182 U/l) and C-reactive protein (9.3 mg/l) were slightly raised; serum iron was 42 micrograms/dl, while all other routine laboratory tests, including protein electrophoresis, blood picture and differential count were within normal limits. Gastroscopy revealed ulcerative duodenitis, gastritis with erosions and numerous ulcers and reflux oesophagitis, grade III-IV. Endosonography showed enlarged gastric mucosal relief as sign of foveolar hyperplasia and a ca. 4 x 3 cm tumour next to the duodenal bulb. Gastrin level was 7537 pg/ml (normal < 150 pg/ml). Computed tomography and somatostatin receptor scintigraphy confirmed the site and size of the gastrinoma., Treatment and Course: Treatment with omeprazole (40 mg three times daily) slightly improved the symptoms. The tumour was excised a week after diagnosis. The patient has been symptom-free since then., Conclusion: Chronic diarrhoea of unknown aetiology can be caused by an endocrine tumour; endosonography can often provide information on the diagnosis and location of such a tumour.

History and Clinical Findings: About 10 weeks before admission to hospital a 73-year-old woman developed a fever of up to 40 degrees C for three days. She then had subfebrile temperature for several weeks with some rises to 39 degrees C. She was known to have type II a diabetes mellitus and pulmonary silicosis, having worked in a porcelain and ceramic factory for many years. Before admission her cerebral functions were rapidly deteriorating, especially short-term memory. This was followed by increasing paraplegia of the legs with inability to walk. She finally had urinary and faecal incontinence and swallowing difficulties with tendency to aspiration, which necessitated hospitalisation., Investigations: Both lactate dehydrogenase (339 U/l) and C-reactive protein (112 mg/l) were elevated; the platelet count was low (73000/microliters). Cerebrospinal fluid was unremarkable, as was computed tomography of the skull. But magnetic resonance imaging revealed multiple spotty lesions with low contrast-medium uptake throughout the brain, pointing to a disseminated bacterial or mycotic infection. 3 days later the chest-ray showed small nodular soft shadows in the lungs, and lung functions had decreased. Mycobacteria were found in the urine and liver biopsy showed granulomatous hepatitis, establishing the diagnosis of miliary tuberculosis in the presence of silicosis., Treatment and Course: Tuberculostatic treatment was instituted with four drugs (pyrazinamide, ethambutol, isoniazid and streptomycin. After 6 weeks the patient was again able to walk and continent of urine during the day. All cerebral functions gradually improved., Conclusion: Miliary tuberculosis should be included in the differential diagnosis of ill-defined feverish disease, especially in the elderly.

Background and Objective: If transillumination is not possible, percutaneous endoscopic gastrostomy (PEG) is contraindicated. In these cases the stomach had so far to be punctured directly during radiological monitoring. A new method is described which combines endoscopy and computed tomography (CT) for performing a percutaneous endoscopic gastrostomy., Patients and Methods: Among 189 patients who were to have the procedure there were eleven (nine men, two women) in whom transillumination was not possible. After endoscopic insufflation of air PEG was done under CT guidance, using the common pull-through technique., Results: The combined method was successful in ten of the eleven patients without complication. In one patient with hepatomegaly and interposition of the transverse colon PEG was not possible even with CT guidance., Conclusions: The combined endoscopic-radiological method is practicable and safe in cases in which transillumination is not possible. There are several advantages compared with direct puncturing: The common pull-through technique can be used; radiological exposure is low and other clinically relevant findings may be revealed by the endoscopy.

History and Findings: A 45-year-old woman sustained an ankle fracture in an accident. At examination she was found to have marked pallor of skin and mucosae. There was no hint for melaena or haematemesis., Investigations: Biochemical tests showed marked iron deficiency anaemia (haemoglobin 7.5 g/dl) and raised serum bilirubin and C-reactive protein levels (1.94 mg/dl and 85.2 mg/l, respectively). Abdominal sonography revealed a cystic space-occupying mass (8 x 4.5 cm) projecting onto the gallbladder, interpreted as a choledochal cyst of unknown origins without bleeding. After treatment of the ankle fracture an endoscopic retrograde cholangiopancreatography was performed. This showed a large cyst of the choledochal duct into which the cystic and choledochal ducts entered, without evidence of tumour or haematoma. There was also a 1 cm prepapillary common choledochal and Wirsung duct., Treatment and Course: With these findings, the diagnosis of a congenital choledochal cyst (type Ia of Todani) could be made. After healing of the ankle fracture the cyst was removed and a Roux Y-anastomosis created. The cystic tissue was benign. At follow-up 6 months later the patient was symptom-free and no longer anaemic., Conclusions: Congenital choledochal cysts are very rare in Europeans. The symptom-free course with anaemia and no manifestation until adulthood is also very unusual.

Hypophosphataemic osteomalacia occurred in a 38-year-old woman. The leading clinical symptom was severe bone pain. X-ray studies demonstrated fractures of the iliac crest and pubic and ischiadic bone, as well as Looser's zones and demineralization of the skeleton. Computerized densitometry of the bone revealed a 31% reduction of hydroxyapatite. Histological evaluation showed nearly absence of osteoclasts and extensive demineralisation of the bone. Hypophosphataemia (0.48 mmol/l), increased urinary phosphate clearance (36 ml/min), reduced renal-tubular reabsorption for phosphate (73%) and increased alkaline phosphatase (355 U/l) were present. Parathyroid hormone and 1,25-dihydroxyvitamin D were normal. No inborn errors, disturbances of the calcium metabolism or paraneoplastic signs could be detected. Defective renal tubular reabsorption of phosphate is likely to be the underlying cause of the disease. Phosphate supplementation and intermittent vitamin D administration remains the therapy of choice.

In 502 patients, length, thickness and width of the spleen as well its location with respect to the ipsilateral kidney were determined by means of ultrasonography, and a relationship was established with the incidence of diseases accompanied by enlargement of the spleen. A significant correlation to the incidence of such diseases was found only with respect to spleen thickness. The probability of a corresponding disease was 80% for a spleen thickness of 5 cm, 90% for 6 cm and 100% for more than 7 cm. A comparison between palpation and ultrasonography supported the fact that enlargement of the spleen can, in many cases, not be ascertained by palpation, but that palpation findings are indeed positive in splenic enlargement of minor degree. The most suitable parameter for ultrasonographic detection of splenomegaly is thus spleen thickness, for which a limit value of 5 cm should be assumed. If the spleen is found to exceed this value, further examinations are indicated to clarify the underlying disease.

The accuracy of ultrasonography in the detection of liver metastases was studied in 245 patients. Sensitivity, specificity and positive and negative accuracy were defined and calculated. Taking into account only metastases more than 15 mm in diameter, sensitivity was 75.5%, positive accuracy was even higher at 83.0%. Specificity and negative accuracy were above 90%. The results are largely dependent on the type of primary tumour. Sensitivity for metastases of a bronchial or gastric carcinoma was about 50%. The results indicate that a positive ultrasound finding generally need not be checked by other methods, while a negative result, especially in certain types of tumour, is by no means sufficient to exclude metastases.

Complications occurred in 29 of 37 patients after ascites retransfusion (n = 16) or introduction of a peritoneovenous shunt (n = 21). Blood clotting disturbances, that could either be successfully treated with drugs or which led to interruption of the reinfusion, appeared in 38%. Estimation of plasminogen proved to be of reliable prognostic value thus enabling prophylactic measures to be taken. Post-operatively 14 patients had transient fever not requiring specific treatment. Local fibrinolysis or shunt revision was successful in three patients with shunt thromboses. According to our experience most complications can be avoided by prophylactic and therapeutic measures.