Search

Fragestellung: Die Bedeutung der Ernahrung bei der Entstehung und Behandlung von chronisch-entzundlichen Darmerkrankungen (CED) wird teilweise kontrovers diskutiert. Klar ist, dass bei CED die Pravalenz von Mangelernahrung erhoht ist und dass Mangelernahrung die Prognose verschlechtert. In der vorliegenden Leitlinie werden evidenzbasierte Empfehlungen zur ernahrungsmedizinischen Diagnostik und Therapie bei CED prasentiert. Methodik: Die Leitlinie basiert auf den fruheren Leitlinien der DGEM (2006/2007), der ESPEN (2006, 2009), der ECCO (2010) und des NICE (2012). Es wurde eine systematische Analyse der Literatur 2007 – 2013 zur oralen, enteralen und parenteralen Ernahrung bei CED vorgenommen und gegenuber den fruheren Leitlinien um die Themen Pravention und Screening von Malnutrition bei CED erganzt. Die Empfehlungen wurden auf einer Konsensuskonferenz am 18.10.2013 verabschiedet. Ergebnisse: Die Leitlinie umfasst 24 Empfehlungen zur Klinischen Ernahrung bei CED. Screening auf Mangel- und Unterernahrung sowie auf Mikronahrstoffmangel wird bei CED empfohlen. Die Therapie der nachgewiesenen Malnutrition basiert auf Ernahrungsberatung fur eine bedarfsgerechte orale Ernahrung und adaquater Ernahrungstherapie. Neben Supplementen und oraler Trinknahrung kommen enterale und parenterale Ernahrung als supplementare Therapie infrage. Wahrend die parenterale Ernahrung nur in wenigen Sonderfallen meist passager durchgefuhrt wird, spielen die enterale Ernahrung und orale Nahrungssupplemente eine bedeutsamere Rolle. Gerade bei Kindern wird die enterale Ernahrung auch als primare Therapie des akuten Schubs eines Morbus Crohn verwendet, um die unerwunschten Wirkungen von Medikamenten zu vermeiden. Schlussfolgerung: Fachgerechte ernahrungsmedizinische Diagnostik, Ernahrungsberatung und enterale Ernahrung spielen eine wichtige Rolle in der Behandlung von CED, sie konnen den Krankheitsverlauf sowie die Lebensqualitat verbessern.

MARS® stands for Molecular Adsorbent Recirculating System and represents an interesting option in treating patients with liver disease. There is still little known about the best time point of initiating this treatment and the exact selection criteria for patients who may benefit from this therapy. The list of potential applications using this procedure is expanding. We report on the experience in seven patients being treated with MARS® dialysis for chronic cholestatic liver disease and acute on chronic liver failure. From August 2000 to October 2001 seven patients received 27 MARS® treatments in our clinic, ranging from 2 to 12 treatments per subject. Presented cases were diagnosed as steatohepatitis because of alcoholism (n = 3), vanishing bile duct disease (n = 1), metabolic liver disease (n = 1), primary biliary cirrhosis (n = 1) and drug-induced hepatitis (n = 1). Based on this experience, we discuss the ongoing questions of various indications and the decision to initiate MARS® dialysis.

Ziel: Die bestehenden Hurden fur eine sachgerechte Verordnung und Erstattung von Trinknahrungen zu diskutieren. Ausfuhrung: Experten aus relevanten Disziplinen diskutierten unterschiedliche Aspekte dieser aktuellen Fragestellung. Schlussfolgerung: Es herrscht Einvernehmen uber die Notwendigkeit von Trinknahrungen in der ambulanten Patientenversorgung. Die Verordnung und Erstattung von Trinknahrungen im ambulanten Bereich wird erschwert durch: Losungsansatze bieten neue Bewertungskriterien. Diskutiert wurden hier insbesondere die Moglichkeiten der nachvollziehbaren Diagnose eines therapiebedurftigen Ernahrungszustands, eine systematische Uberprufung von Indikation und Nutzen von Trinknahrungen sowie eine kontinuierliche Dokumentation uber deren Zweckbestimmung und Verwendung, die sich an geeigneten Outcomeparametern orientiert sowie die Grenze zwischen erstattungsfahiger Therapie und selbst bezahlter Wunschbehandlung bestimmen kann.

The EC Regulation No. 1924/2006 on Nutrition and Health claims made on foods has generated considerable debate and concern among scientists and industry. At the time of writing, the European Food Safety Authority (EFSA) has not approved any probiotic claims despite numerous human trials and meta-analyses showing evidence of beneficial effects. On 29th and 30th September 2010, ten independent, academic scientists with a documented record in probiotic research, met to discuss designs for future probiotic studies to demonstrate health benefits for gut and immune function. The expert panel recommended the following: (i) always formulate a precise and concrete hypothesis, and appropriate goals and parameters before starting a trial; (ii) ensure trials have sufficient sample size, such that they are adequately powered to reach statistically significant conclusions, either supporting or rejecting the a priori hypothesis, taking into account adjustment for multiple testing (this might necessitate more than one recruitment site); (iii) ensure trials are of appropriate duration; (iv) focus on a single, primary objective and only evaluate multiple parameters when they are hypothesis-driven. The panel agreed that there was an urgent need to better define which biomarkers are considered valuable for substantiation of a health claim. As a first step, the panel welcomed the publication on the day of the meeting of EFSA's draft guidance document on immune and gut health, although it came too late for study designs and dossiers to be adjusted accordingly. New validated biomarkers need to be identified in order to properly determine the range of physiological functions influenced by probiotics. In addition, validated biomarkers reflecting risk factors for disease, are required for article 14 claims (EC Regulation No. 1924/2006). Finally, the panel concluded that consensus among scientists is needed to decide appropriate clinical endpoints for trials.

Background Dysplasia in ulcerative colitis is frequently missed with 4-quadrant biopsies. An experimental setup recording delayed fluorescence spectra simultaneously with white light endoscopy was recently developed. Objective We compared detection of invisible flat intraepithelial neoplasia with protoporphyrin IX fluorescence and standard 4-quadrant biopsies. Design Prospective, crossover design without randomization of the order of procedures. Setting Gastroenterology Department, Humboldt University, Charite, Berlin, Germany. Patients Forty-two patients with extensive ulcerative colitis of more than 10 years' duration were included. Interventions Colonoscopy with 4-quadrant biopsies and targeted biopsies of macroscopic lesions and time-gated fluorescence–guided colonoscopy were performed 2 weeks apart by 2 blinded endoscopists. Three independent pathologists examined the biopsy specimens. Main Outcome Measurements The primary outcome criterion was detection rate of invisible flat intraepithelial neoplasia. Results Invisible flat intraepithelial neoplasia was detected in 3 (7%) patients by white light 4-quadrant biopsies and in 10 (24%) patients by fluorescence-guided endoscopy ( P = .02). The sensitivity and specificity for differentiating patients with and without dysplasia were 100% and 81%, respectively. Dysplastic and nondysplastic mucosa could be discriminated with a sensitivity and specificity of 73% and 81%, respectively. Limitations The trial was not randomized. Conclusion The detection rate of intraepithelial neoplasia in patients with ulcerative colitis can be improved by fluorescence-guided colonoscopy.

Muscle function has gained attention as an indicator of functional as well as nutritional status. Loss of muscle strength is a key phenomenon in disease related malnutrition. However, the decrease in muscle function frequently precedes alterations of body composition. Therefore, muscle function is likely related to further factors than pure muscle mass, such as electrolytes, energy rich phosphates and membrane potential. This sensitivity might account for the prognostic power of muscle function - and hand grip strength in particular - in regard to morbidity and mortality in both acute and long-term settings. The assessment of voluntary hand grip strength with a dynamometer is a feasible and reliable bed side method suitable for the clinical and ambulatory setting. Hand grip strength has been investigated in numerous nutrition intervention studies. Muscle function responds earlier to nutritional deprivation and restoration, and is therefore an early marker of malnutrition as well as a useful tool for monitoring nutritional intervention in adult patients. In the elderly, however, nutritional intervention is not always successful in improving hand grip strength. A systematic and standardized measurement of hand grip strength is necessary in order to obtain valid results. For the evaluation of baseline grip strength values, age and gender specific reference data must be considered.

Sarcopenia, which describes the loss of muscle mass and muscle strength, is a common phenomenon in the elderly. Although clinical intervention studies with energy and protein supplementation have consistently shown an increase in nutritional intake and body weight, the impact on functional parameters such as muscle function has been minor. Several studies have suggested that protein requirements might be higher in the elderly than in younger adults. New strategies regarding protein supplementation focus on the composition of proteins and amino acid solutions. It has e. g. been shown that essential amino acids are mainly responsible for the stimulation of fractional protein synthesis in the muscle. Here, leucine, a branched chain amino acid, seems to play a central role and a higher intake of leucine has been shown to increase muscle protein synthesis in elderly subjects. Also, pulse feeding pattern, supplying 80 % of protein at lunch followed by a protein reduced meal in the evening, has also been reported to increase protein retention in the elderly and might thus be considered an interesting alternative to high protein diets. Evidence, however, clearly suggests that physical training will remain mandatory in order to reach major improvement of muscle mass and function.

Als Kurzdarmsyndrom wird ein Krankheitsbild mit vorubergehender oder anhaltender Malabsorption von Flussigkeit, Elektrolyten und/oder Substraten infolge ausgepragter Darmresektionen bezeichnet. Ursachen bei Kindern sind nekrotisierende Enterokolitis, Volvulus oder Darmatresie. Im Erwachsenen- und vor allem im hoheren Alter sind die Hauptursachen chronisch-entzundliche Darmerkrankungen, Darmischamien, Volvulus und Bauchtraumata. Die Prognose des Kurzdarmsyndroms hangt von der Lange des verbliebenen Dunndarms und Kolons, von der Lokalisation der Resektion und von der Grunderkrankung ab. Das Kurzdarmsyndrom fuhrt zu einem komplexen metabolischen Krankheitsbild, das interdisziplinare Betreuung in einem spezialisierten Zentrum erfordert. Die Therapie richtet sich nach der erhaltenen Resorptionskapazitat und der Krankheitsphase (Hypersekretionsphase, Adaptationsphase und Stabilisierungsphase) und umfasst parenterale und/oder enterale Flussigkeits-, Elektrolyt- und Substratzufuhr sowie Stimulation der Adaptation des Darms. Ein wesentliches Problem stellen auch der bakterielle Uberwuchs und die chronisch-cholestatische Lebererkrankung dar. Bei konservativ nicht zufriedenstellend behandelbarem Kurzdarmsyndrom ist heute die Dunndarmtransplantation bzw. die kombinierte Dunndarm-/Lebertransplantation eine gute Moglichkeit.

Objectives. The pain intensity of patients with FM has recently been reported to be correlated with the degree of small intestinal bacterial overgrowth (SIBO). SIBO is often associated with an increased intestinal permeability (IP). Increased IP, if shown in FM, may have pathogenetic relevance because it leads to the exposure of immune cells to luminal antigens and consequent immune modulation. It is currently unknown whether IP is altered in FM. We therefore examined the IP in a group of patients with primary FM and in two control groups, healthy volunteers and patients with an unrelated chronic pain syndrome, complex regional pain syndrome (CRPS). We hypothesized that patients with FM, but not volunteers or those patients with CRPS, would have altered IP. Methods. Both gastroduodenal and small IP were assessed using an established three-sugar test, where urinary disaccharide excretion reflecting intestinal uptake was measured using HPLC. Results. Forty patients with primary FM, 57 age- and sex-matched volunteers and 17 patients with CRPS were enrolled in this study. In the FM group, 13 patients had raised gastroduodenal permeability and 15 patients had raised small intestinal permeability, but only one volunteer had increased gastroduodenal permeability (P < 0.0001, chi-square test for the three groups). The IP values were significantly increased in the patient groups (P < 0.0003 for all comparisons, one-way analysis of variance). Conclusions. The IPs in primary FM and, unexpectedly, CRPS are increased. This study should stimulate further research to determine the implication of altered IP in the disease pathophysiology of FM and CRPS.

The influence of clinically observable criteria on the course of disease was investigated in 150 patients, 72 men and 78 women, with morbus Crohn who could be followed for an average period of 6.6 years (8-348 months). In 29 patients (19%), the small intestine only was involved, in 31 patients (21%) the colon, and in 90 patients (60%) both the small intestine and colon. During the observation period 71 patients (47%) developed fistulae and 55 (37%) extra-intestinal manifestations. The patients were admitted to hospital on a total of 466 occasions (3.1 times per patient), and 199 operations (1.3 times per patient) were carried out. There were significantly more extra-intestinal manifestations in the colon cases (P less than 0.01) and of admissions and operations in the small intestine-colon cases (P less than 0.001), whereas patients with isolated involvement of the small intestine underwent significantly fewer operations (P less than 0.001). In addition, significant positive correlations existed between the appearance of fever and fistulae (P less than 0.001) and between the number of operations within the first 2 years and the number of subsequent operations (P less than 0.001).

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Background and aim: A genetically impaired intestinal barrier function has long been suspected to be a predisposing factor for Crohn’s disease (CD). Recently, mutations of the capsase recruitment domain family, member 15 ( CARD15 ) gene have been identified and associated with CD. We hypothesise that a CARD15 mutation may be associated with an impaired intestinal barrier. Methods: We studied 128 patients with quiescent CD, 129 first degree relatives (CD-R), 66 non-related household members (CD-NR), and 96 healthy controls. The three most common CARD15 polymorphisms (R702W, G908R, and 3020insC) were analysed and intestinal permeability was determined by the lactulose/mannitol ratio. Results: Intestinal permeability was significantly increased in CD and CD-R groups compared with CD-NR and controls. Values above the normal range were seen in 44% of CD and 26% of CD-R but only in 6% of CD-NR, and in none of the controls. A household community with CD patients, representing a common environment, was not associated with increased intestinal permeability in family members. However, 40% of CD first degree relatives carrying a CARD15 3020insC mutation and 75% (3/4) of those CD-R with combined 3020insC and R702W mutations had increased intestinal permeability compared with only 15% of wild-types, indicating a genetic influence on barrier function. R702W and G908R mutations were not associated with high permeability. Conclusions: In healthy first degree relatives, high mucosal permeability is associated with the presence of a CARD15 3020insC mutation. This indicates that genetic factors may be involved in impairment of intestinal barrier function in families with IBD.

Objective: The new GH receptor antagonist pegvisomant is the most effective medical therapy to normalize IGF-I levels in patients with acromegaly. Based on currently available data pegvisomant is well tolerated; however, treatment-induced elevation of transaminases has been reported and led to the necessity for drug discontinuation in some patients in the pivotal studies. The aim of this study was to evaluate and characterize the prevalence of elevated transaminases and to describe in detail the findings in a single case who required drug discontinuation because of elevation of transaminases which emerged during treatment and who underwent liver biopsy. Design and methods: Retrospective safety analyses were carried out on 142 patients with acromegaly receiving pegvisomant treatment in Germany between March 2003 and the end of 2004. Of these patients, 123 were documented in a post-marketing surveillance study, one case of elevated transaminases was reported spontaneously and the other patients were treated in a clinical study. Results: Mean treatment duration with pegvisomant in the ongoing observational study at the end of 2004 was 28.3 ± 19.9 (S.D.) weeks. Twelve out of the 142 patients had elevated transaminases above three times the upper limit of normal, likely caused by biliary obstruction in five of the patients. All patients but one affected by elevated transaminases had been previously treated with somatostatin analogues. In six out of 142 (4%) of patients, pegvisomant was permanently withdrawn because of elevated transaminases. The same number of patients showed a transient increase of transaminases with either spontaneous remission without dose modification (n = 4) or no re-increase of transaminases after temporary discontinuation and re-exposure (n = 2). The liver biopsy of one patient who was permanently withdrawn showed a chronic mild hepatitis with a mixed portal inflammation including eosinophilic granulocytes. Conclusions: Liver function tests should be regularly followed on pegvisomant treatment. Biliary complications, which may arise from restitution of normal gall bladder motility after cessation of somatostatin analogue treatment, need to be differentiated from pegvisomant-induced abnormalities. The histological pattern of the liver biopsy performed in one of the patients showed a mild chronic active hepatitis. The lack of dose dependency and rather low frequency of elevated transaminases in those cases where a biliary disorder was excluded render this reaction an idiosyncratic drug toxicity.

INTRODUCTION: Aging is associated with a phenomenon termed ‘inflammaging’, which is characterised by chronic, low-grade pro-inflammatory conditions leading to long-term tissue damage. Reducing chronic low-grade inflammation may be a way to prevent or reduce the severity of age-related diseases. It has been proposed that the age-related changes in gut microbiota, associated with an increase in systemic inflammation may also contribute to the progression of disease and frailty in the elderly. Evidence exists that inflammation, oxidative stress and gut microbiota are influenced by diet or nutraceutical dietary supplements. AIMS&METHODS: To assess the impact of a personalized diet, with or without the addition of VSL#3 probiotic blend, on markers of inflammation, oxidative stress and gut microbiota in elderly individuals. Open label, randomized multicentre study. Setting: Community. Primary endpoint: baseline change in hsCRP (high-sensitivity C-reactive protein). As a part of a larger study, 62 participants were randomized to follow a personalized diet created through a web-based platform (RISTOMED) and optimized to reduce inflammation and oxidative stress, either with or without supplementation with VSL#3, for 8 weeks. RESULTS: There was no significant change in hsCRP amount in either study arm. However, a subgroup of 17 participants were classified as having high inflammation at baseline, and hsCRP fell significantly in this group (p=0.022). VSL#3 plus diet, but not diet alone, was associated with a significant reduction in homocysteine levels and increases in folate (p

The composition and spatial organization of the mucosal flora in biopsy specimens from patients with inflammatory bowel disease (IBD; either Crohn's disease or ulcerative colitis), self-limiting colitis, irritable-bowel syndrome (IBS), and healthy controls were investigated by using a broad range of fluorescent bacterial group-specific rRNA-targeted oligonucleotide probes. Each group included 20 subjects. Ten patients who had IBD and who were being treated with antibiotics were also studied. Use of nonaqueous Carnoy fixative to preserve the mucus layer was crucial for detection of bacteria adherent to the mucosal surface (mucosal bacteria). No biofilm was detectable in formalin-fixed biopsy specimens. Mucosal bacteria were found at concentrations greater than 10 9 /ml in 90 to 95% of IBD patients, 95% of patients with self-limiting colitis, 65% of IBS patients, and 35% of healthy controls. The mean density of the mucosal biofilm was 2 powers higher in IBD patients than in patients with IBS or controls, and bacteria were mostly adherent. Bacteroides fragilis was responsible for >60% of the biofilm mass in patients with IBD but for only 30% of the biofilm mass in patients with self-limiting colitis and Eubacterium rectale - Clostridium coccoides accounted for >40% of the biofilm in IBS patients but for Bacteroides fragilis biofilm is the main feature of IBD. This was not previously recognized due to a lack of appropriate tissue fixation. Both 5-ASA and antibiotics suppress but do not eliminate the adherent biofilm.

Acute pancreatitis often requires parenteral nutrition. Thus, we analyzed, using a randomized trial, whether different fatty acids in parenteral nutrition influence lipidperoxidation and histopathology in acute pancreatitis in rats. Seventy-five male Sprague–Dawley rats were randomized into five groups (gr.) (n=15). Gr. 1 underwent a laparotomy followed by saline infusion, gr. 2–5 received intraductal glycodeoxycholic acid (GDOC) followed by intravenous cerulein. Six hours after induction of pancreatitis (IOP), gr. 2 received saline infusion, while gr. 3 was infused with standard lipovenous (rich in [n−6] polyunsaturated fatty acids (PUFA)), gr. 4 received ClinOleic (rich in [n−9] PUFA), while gr. 5 was infused with Omegaven (rich in [n−3] PUFA) for 18 h. After 24 h, all animals were sacrificed and the pancreas was determined histopathologically according to the severity of pancreatitis. Furthermore, pancreatic lipidperoxidation (TBARS) and activity of lipid production protective enzymes superoxide dismutase (SOD) and gluthationperoxidase (GSHPx) were analyzed. Omegaven infusion reduced the severity of histopathologic changes in acute pancreatitis and decreased lipidperoxidation (TBARS) in pancreatic tissue samples. Furthermore, pancreatic activity of SOD was increased. However, standard PUFA and ClinOleic infusion did not influence the severity of pancreatitis and lipidperoxidation. Parenteral nutrition high in n−3 PUFA seems to be superior to compositions of n−6 or n−9 PUFA in the treatment of acute hemorrhagic pancreatitis in rats.

Background: Bacterial community structures in human pancreatic and biliary tracts were evaluated. Methods: Gall bladder stones from 153 patients, 20 gall bladder walls, six common duct stones, 52 biliary stents, 21 duodenal biopsies, nine pancreatic duct biopsies, and five bile ducts were investigated using fluorescence in situ hybridisation (FISH) with ribosomal RNA targeted Cy3/Cy5 (carbocyanine) labelled oligonucleotide probes. Result: Duodenal, gall bladder, and bile duct walls were free of bacteria. A dense multispecies bacterial biofilm was present within the pancreatic duct of patients with calcific pancreatitis and within biliary stents, irrespective of diagnosis. The concentration, density, and amenability of the biofilm to FISH and DNA staining declined progressively with the grade of stent occlusion. The lowest detectable bacterial concentrations were found by FISH in completely occluded stents and brown/mixed gall stones. Bacteria were not detectable with FISH in cholesterol gall stones. Conclusions: A wide range of different branches and groups of bacteria participate in the development of biofilms on the surfaces of foreign bodies, such as biliary stents, mixed gall stones, or calcific pancreatic ducts, but not on the surface of pure cholesterol gall stones. Occlusion of stents leads to progressive extinction of the biofilm and mummification of its components. Deposition of cholesterol or other substances within the biofilm matrix may be a novel mechanism of host defence against bacteria present in these biofilms.

Background: In a subgroup of patients with chronic urticaria (CU) the disease is caused by pseudoallergic reactions to food. The aim of this study was to investigate whether disturbances of the gastrointestinal barrier function play a role in the pathomechanism of the disease. Methods: In 55 patients with CU gastrointestinal permeability was measured with an in vivo triple-sugar-test before and after 24 days of a diet low in pseudoallergens. Sucrose served as marker for gastroduodenal permeability, lactulose/mannitol ratio for intestinal permeability. Results: Basal gastroduodenal and intestinal permeability were significantly higher in patients with urticaria as compared to controls. In 29 of the 55 patients skin symptoms decreased or completely disappeared during the diet (responders). Compared to nonresponders (n = 26), responders had a significantly higher gastroduodenal permeability before treatment (0.36 ± 0.04 vs 0.15 ± 0.01% sucrose; P

BACKGROUND AND STUDY AIMS Patients with advanced, unresectable esophageal carcinoma have an extremely poor prognosis, with dysphagia being the major problem. The aim of this prospective pilot study was to evaluate the efficacy of local injections of mitomycin adsorbed onto activated carbon particles (MMC-CH) in advanced unresectable esophageal squamous-cell carcinoma. The primary outcome parameter was survival time; secondary parameters were dysphagia and quality of life. PATIENTS AND METHODS Ten consecutive patients with stage IV esophageal carcinoma (age: median 58, range 32 - 78), median tumor length 11 cm (range 5 - 15) received four weekly injections of 15 mg (10 ml) MMC-CH into the endoscopically visualized tumor, via a 5-mm sclerotherapy needle. The tumor stage, symptom score, and quality of life (measured using the Karnofsky index) were assessed before and after therapy and every 2 months thereafter. RESULTS The median survival time after MMC-CH therapy was 16 weeks (95 % CI, 11.7 to 20.4). Dysphagia was reduced ( P < 0.001) in parallel with the reduction in the tumor mass ( r = 0.82, P = 0.01). The Karnofsky index ( P < 0.01) also improved after MMC-CH treatment. MMC-CH was well tolerated, and no side effects were observed. CONCLUSIONS Endoluminal MMC-CH therapy appears to be an effective, inexpensive, and well-tolerated treatment for unresectable advanced squamous-cell esophageal carcinoma.

Apart from its anti-inflammatory activity, which has been used for the treatment of active Crohn’s disease, thalidomide is also a potent inhibitor of angiogenesis. We therefore studied the effect of thalidomide in six patients with severe recurrent intestinal bleeding refractory to standard treatment (three patients with Crohn’s disease (CD), three patients with obscure intestinal bleeding; mean of 56 blood transfusions within the last 24 months). Bleeding stopped within two weeks after the start of thalidomide in all patients. Haemoglobin normalised without further transfusions for the whole observation period (mean follow up 33 months) while patients needed a mean of 2.2 (CD) and 3.1 (obscure bleeding) blood units/month in the 12 months before treatment. After three months of thalidomide therapy, serum levels of vascular endothelial growth factor were strongly suppressed compared with pretreatment levels. (CD 818 (82) v 129 (86) pg/ml; obscure bleeding 264 (68) v 50 (25) pg/ml). All six patients reported transient fatigue. Peripheral neuropathy was observed in one patient with CD after nine months and was reversible after lowering the dose to 100 mg daily. These results indicate that thalidomide might be useful for patients with otherwise refractory intestinal bleeding.

Malnutrition as Prognostic Factor Malnutrition is a common problem occurring in patients with chronic or severe disease. Prevalence of hospital malnutrition ranges between 20 and 60%, depending on the method and criteria used in order to determine nutritional status. Nutritional status is known to worsen during hospital stay which is partly due to poor recognition by the medical staff. Clinical malnutrition however is generally associated with increased morbidity and mortality in acute disease – such as stroke or hip fracture – as well as in chronic disease – such as liver failure or chronic renal failure – and has serious implications for recovery from illness and surgery. Length of hospital stay is longer in malnourished patients which in turn implies substantial higher costs. Therefore, nutritional assessment should be part of every medical examination in order to recognize malnutrition early and initiate nutritional therapy if necessary.

BACKGROUND AND STUDY AIMS: It is still difficult to visualize changes in the small intestine. Wireless capsule enteroscopy is a new method that promises to provide new insights into the small intestine. In a prospective study, the diagnostic yield of wireless enteroscopy was therefore compared with computed tomography (CT) enteroclysis. PATIENTS AND METHODS: Twenty-two patients with suspected small-bowel pathology underwent CT enteroclysis and wireless capsule enteroscopy examinations, conducted by two independent blinded investigators. The results of the two investigations (diagnoses and the number, extent, and location of lesions detected) were compared by a third investigator. RESULTS: The patients included in the study had obscure gastrointestinal bleeding (n = 8), Crohn's disease (n = 8), unexplained diarrhea (n = 5), or suspected carcinoid tumor (n = 1). Pathological lesions were detected using capsule enteroscopy in 13 patients (59 %) and using CT enteroclysis in eight (36 %; P = 0.12). In seven patients (one case each of colonic Crohn's disease, diverticulitis, Meckel's diverticulum, carcinoid tumor, mesothelioma, colonic polyps, and irritable bowel syndrome), no pathological changes were found in the small intestine using either method. The diagnosis was established by wireless capsule enteroscopy in four patients with obscure bleeding, whereas CT enteroclysis was positive in only one patient ( P = 0.1). Crohn's disease was found in two patients with unexplained diarrhea. Small-bowel lesions were identified in six patients with known Crohn's disease using capsule enteroscopy or CT enteroclysis. The only side effect of wireless capsule enteroscopy observed was abdominal pain in one patient with Crohn's disease. There were no serious side effects with CT enteroclysis. CONCLUSIONS: Wireless capsule enteroscopy detects more small-bowel lesions than CT enteroclysis in patients with obscure gastrointestinal bleeding and Crohn's disease.

Die enterale Ernahrung hat im letzten Jahrzehnt einen unbestrittenen Stellenwert in der Behandlung kritisch kranker Patienten erlangt. Wahrend fruher die ausreichende Zufuhr von Energie und Stickstoff das Hauptziel der Ernahrungstherapie war, wird heute die Stabilisierung des Stoffwechsels, sowie die Beeinflussung einzelner Organ- und Zellfunktionen durch Substrate angestrebt. Die enterale Zufuhr von Schlusselsubstraten fur bestimmte Zell- und Organfunktionen wird unter dem Begriff Pharmakonutrition (Immunonutrition) zusammengefasst. Insbesondere die Funktion und Integritat des Darmes als auch die Beeinflussung des mukosalen Immunsystems stehen hier im Vordergrund. In der vorliegenden Ubersicht werden die theoretischen Grundlagen der enteralen Ernahrung beim Intensivpatienten unter Berucksichtigung spezifischer Substrate diskutiert. Daruberhinaus werden allgemeine praktische Empfehlungen und ernahrungsmedizinische Besonderheiten der wichtigsten internistischen Krankheitsbilder dargestellt.

UNLABELLED The echo-enhanced Power-Doppler sonography is useful for the differential diagnosis of pancreatic tumours. Tumour criteria for the differentiation of pancreatic tumours with this procedure are explained using selected cases in the present publication. Ductal carcinomas are often hypovascularised compared with the surrounding tissue. On the other hand, neuroendocrine tumours are hypervascularised lesions. Tumours associated with pancreatitis have a different vascularisation pattern depending on inflammation and necrosis. Cystadenomas frequently show many vessels along the fibrotic strands. CONCLUSIONS Pancreatic tumours have different vascularisation patterns in the echo-enhanced Power-Doppler sonography. These characteristics can be used for the differential diagnosis.

Background: Renal cell carcinomas are the most common primary tumors leading to pancreatic metastases. The differentiation of metastases from primary pancreatic tumors is important for the prognosis. Echo-enhanced power-Doppler sonography may be used for the differential diagnosis of tumors. In this study, the contrast behavior of metastases of renal cell carcinomas was evaluated in comparison to primary pancreatic tumors. Patients and methods: Each 5 patients with pancreatic metastases of a renal cell carcinoma, a ductal carcinoma, a neuroendocrine tumor and a pancreatitis-associated mass were investigated by B-mode sonography, fundamental and echo-enhanced power-Doppler sonography. Results: Similar to neuroendocrine tumors, metastases of renal cell carcinomas were found to be hypervascularized. In contrast, ductal carcinomas are hypovascularized compared to the surrounding tissue. Tumors associated with pancreatitis show different vascularization pattern depending on inflammation and necrosis. Conclusions: Metastases of renal cell carcinomas and ductal carcinomas show different vascularization pattern at echo-enhanced power-Doppler sonography. Renal cell metastases and neuroendocrine tumors have similar contrast behaviors, therefore, clinical symptoms should be referred for their differentiation. However, histology is the standard of reference for the differential diagnosis of pancreatic tumors.

Traumatic rupture of the gallbladder is a very rare event associated with high mortality. Since clinical symptoms are nonspecific, diagnosis is difficult. We present an alcoholic with biliary ascites after traumatic perforation of the gallbladder. Initially, he was misdiagnosed to have ascites caused by liver cirrhosis. This case demonstrates, that the combination of patients history, clinical investigation and ultrasound allows the diagnosis of traumatic rupture of the gallbladder.

AIM In order to improve the differential diagnosis of pancreatic lesions, dopplersonographic criteria for the tumours were evaluated. METHODS 35 patients diagnosed by conventional ultrasound as having a tumour of pancreas were further investigated by B-mode sonography, fundamental and echo-enhanced power-Doppler sonography focusing on specific properties of the tumours. The results were correlated to the histological findings. RESULTS Ductal carcinomas and cystadenocarcinomas are often hypovascularized in comparison to the surrounding tissue. In contrast to this, neuroendocrine tumours and cystadenomas are mostly hypervascularized. Tumours associated with pancreatitis show different vascularization patterns depending on inflammation and the extent of necrosis. CONCLUSIONS Pancreatic tumours display different vascularization patterns in the echo-enhanced power-Doppler sonography. These characteristics can be useful for the differential diagnosis of pancreatic tumours.

Heat shock protein (HSP)-peptide complexes isolated from murine cancers elicit protective immunity and T lymphocytes specific for the cancer from which the HSPs are isolated. A pilot study was designed to test the feasibility, immunogenicity and toxicity of such treatment in cancer patients. Sixteen patients with assorted advanced malignancies, which had become refractory to established therapies, were recruited. The gp96 vaccine was prepared for each patient from tumor obtained from that patient. Anti-tumor immune responses were evaluated using Elispot assays of T cells in peripheral blood after minimal in vitro stimulation. No unacceptable vaccine-related toxicities or auto-immune reactions were observed. Immunization with autologous gp96 elicited MHC I-restricted, tumor-specific CD8(+) T lymphocytes in 6/12 patients immunized. In addition, expansion of the NK cell population was seen in 8/13 of patients immunized. These observations are entirely consistent with the murine experience and form a firm basis for future trials with clinical end points, using autologous, patient-specific HSP-peptide vaccines.

Trimetrexate (TMTX) is a new antifolate which avoids competition for cellular uptake with folinic acid (FA). A regimen of sequential TMTX, FA and 5-fluorouracil (5-FU) has shown efficacy in patients with colorectal cancer. Therefore, we treated 34 previously untreated patients with metastatic colorectal cancer with a weekly chemotherapy regimen consisting of 110 mg/m2 of TMTX intravenously, then 24 h later 200 mg/m2 of FA (i.v.) and 500 mg/m2 of 5-FU (i.v.). Thereafter, 7 doses of oral FA (15 mg) were given at 6-hourly intervals. A treatment cycle consisted of 6 weeks of treatment, then 2 weeks of rest. All patients were treated as outpatients unless complications arose. Thirty-three patients were assessable for tumor response, and all 34 patients were assessable for toxicity. Twelve patients (36%; 95% confidence interval: 25–49%) achieved a partial response. The median duration of response was 8.5 months, and median survival was 14 months. The most common toxicity was diarrhea of grade 3/4, observed in 22% of treatment cycles; this decreased to 8% with early loperamide treatment. Hematologic toxicity was mild. The sequential administration of TMTX, FA and 5-FU is an active regimen in the first-line treatment of metastatic colorectal cancer and warrants further studies.

The aim of the study was to evaluate the possible contribution of changes in energy metabolism and substrate oxidation rates to malnutrition in Crohn's disease and to assess the effect of enteral nutrition on these parameters. Energy metabolism was evaluated by indirect calorimetry in 32 patients with active Crohn's disease and 19 age- and sex-matched healthy individuals. Measurements were done in the postabsorptive state. Seven out of 32 patients received enteral nutrition via a nasogastric tube. In these patients, resting energy metabolism was determined at d 0 (postabsorptive), 7, 14 (during full enteral nutrition) and 15 (postabsorptive). Resting energy expenditure was not significantly different between patients and controls, whereas the respiratory quotient (RQ) was lower in patients (0.78 +/- 0.05 vs. 0.86 +/- 0.05; P < 0.05). During enteral nutrition in 7 patients with Crohn's disease, the RQ increased on d 7 compared with d 0 and remained high even after cessation of enteral nutrition (d 0, 0.78 +/- 0.03; d 7, 0.91 +/- 0.04; d 15, 0. 84 +/- 0.05; P < 0.05; d 7 and 15 vs. d 0). No effects of enteral nutrition on resting energy expenditure were found. Active Crohn's disease is associated with changes in substrate metabolism that resemble a starvation pattern. These changes appear not to be specific to Crohn's disease but to malnutrition and are readily reversed by enteral nutrition. Enteral nutrition did not affect resting energy expenditure. Wasting is a consequence of malnutrition but not of hypermetabolism in Crohn's disease.

A recent symposium ∗ focused on immunological mechanisms of mucosal protection and disturbances of these that lead to inflammation and destruction in the gastrointestinal tract. Increased understanding of the molecular interactions involved is likely to have an important impact on new therapeutic strategies for autoimmune diseases, gastrointestinal infections and chronic inflammatory bowel disease.

BACKGROUND & AIMS: The value of adjuvant bile acid dissolution therapy after extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is under debate. A double-blind, randomized, multicenter trial was conducted to determine the safety and efficacy of repeated ESWL with and without adjuvant bile acid therapy. METHODS: At five centers, 153 patients with gallstones and good gallbladder emptying were randomized to undergo up to six high-energy lithotripsy sessions combined with ursodeoxycholic acid (UDCA, 750 mg/day; n=77) or placebo (n = 76). RESULTS: Six months after the initial treatment, 77% of patients with small single stones ( 20 mm in diameter), and 41% with multiple stones were free of stones. Administration of UDCA had no effect on stone disappearance in the whole study group but tended to improve stone disappearance rates in patients with large single stones and tended to decrease biliary adverse effects in patients with multiple stones. CONCLUSIONS: Repeated high-energy ESWL without adjuvant bile acid therapy represents a safe and effective treatment in patients with small single stones and good gallbladder emptying. In patients with large single stones and multiple stones, adjuvant bile acid therapy may be beneficial. (Gastroenterology 1997 May;112(5):1603-9)

We report here on two cases of double airway and esophageal stenting in patients with multiple esophagotracheal fistulas and stenoses of the airways and esophagus due to squamous-cell carcinoma. Dumon stents and a Strecker device were used for tracheobronchial stenting. Covered Gianturco Z-stents were implanted into the esophagus. In one case, extrinsic compression of the trachea and tumor progression required recanalization by Nd :YAG laser. Clinical improvement led to discharge of the patients within two weeks after the procedure. The results show that simultaneous implantation of stents in the central airways and covered Gianturco Z-stents in the esophagus is an effective therapeutic strategy in patients with tracheal and esophageal obstructions and esophagorespiratory fistulas. Further systematic studies evaluating double stenting are warranted.