Leber, Magen, Darm最新文献

The choice of the appropriate endoscopic procedure for treating a malignant esophageal obstruction depends on the tumor localisation, the tumor configuration, on specific patient data and last but not least on the technical possibilities of the hospital involved. Successfully performed is the mechanical dilatation, the tube insertion and stent implantation, the laser therapy, the argon plasma coagulation and the local sclerotherapy. The procedures differ in rate of complication, long term palliation and the improvement of dysphagia. In a case discussion we demonstrate that in the wide range of disease and patient specific facts that have to be dealt with, only the combined use of different endoscopic procedures will lead to the best results.

The case of a 74-year-old male patient with a watermelon stomach (GAVE-syndrome: gastric antral vascular ectasia) is reported. The superficial annual mucosa showed the characteristic picture of ectatic capillaries, some of them plugged with fibrin thrombi. Anemia due to chronic blood loss had developed in our patient. The vascular lesions of the antral mucosa were treated endoscopically in three sessions with an argon-plasma-coagulation (APC). Three months after completion of therapy the vascular changes of the antral mucosa had resolved almost completely. In addition no further blood loss had occurred. Many treatment modalities of the watermelon stomach abnormality exist. Nowadays, vaporization of the vascular lesions with the Neodym-Yag laser has widely replaced surgical treatment. The argon-plasma-coagulation uses instead of laser energy conduction of electric energy by ionized argon gas (plasma), which produces coagulation necrosis of tissues. The potential advantages of the argon-plasma-coagulation lie in the limited deep penetration, which reduces the risk of perforation and the symmetric spread of the coagulation effects in the surrounding mucosa. These properties make the argon plasma-coagulation a promising tool for the endoscopic therapy of mucosal lesions of the GI-tract. Further attractive is the low cost of the argon-plasma-coagulation equipment compared with laser devices.

With the less invasive techniques for complications regarding chronic pancreatitis, such as tubular choledochostenosis, the endoscopic transpapillary bile drainage therapy by means of endoprosthesis has undergone an enlargement of its indications range. Blocked and dislocated prostheses, however, further raise the already existing possibility of septic complications. With 15 out of 43 patients undergoing medium-term endodrainage treatment, we observed different resulting conditions of chronic cholestasis, such as abscess-forming cholangitis, hepatic abscesses, retroperitoneal phlegmon and sepsis up to biliary cirrhosis. Thus, in the case of chronic pancreatitis we still regard choledochostenosis- which, due to scarring, is mostly fixed-as a primary indication for operation.

Tumours of the small intestine differ from gastric or colonic neoplasms because of their low incidence rate and the occurrence of histologic entities rarely seen in other gastrointestinal locations. In our institution 67 patients with small intestinal tumours were treated through 1960 to 1991, including 19 carcinomas, 15 carcinoids, 13 sarcomas and 7 lymphomas. In patients with symptomatic disease, the correct diagnosis was achieved preoperatively in 43%. Small bowel enema and CT were the most effective diagnostic procedures. Emergency laparotomy was necessary in 44%. The rate of curative tumour resections rose from 23% during 1960-1983 to 67% during 1984-1991.

In the treatment of gastrointestinal motility disorders 3 prokinetic agents are principally available. They are differentiated from their pharmacological mode of action, their clinical efficacy and tolerability. Metroclopramide is an antidopaminergic benzamide with mainly antiemetic effects and minor prokinetic efficacy in the GI-Tract. Domperidon is a pure dopaminantagonist. It accelerates gastric emptying but has less effect on bowel motility. Cisapride stimulates indirect the secretion of acetylcholine and acts via 5 HT-receptors selective at the plexus myentericus. These pharmacological differences have clinical relevance: metoclopramide and domperidon could not consistently prove efficacy in functional dyspepsia and GORD. In addition the data in other indications are rare. Only cisapride has shown significant responder rates in controlled studies in the treatment of gastrointestinal motility disorders particularly in long term treatment. As concerns tolerability cisapride presents a progress by its selective mode of action in contrast to the agents crossing the blood-brain-barrier.

Pancreatic pseudocysts with mediastinal extension are a rare clinical entity. The pseudocysts traverse the diaphragma by way of the esophageal hiatus or by erosion directly through the diaphragma. Although the predominant clinical manifestations are related to the chest, proper management should include laparotomy and cystenteric anastomoses. In some cases the mediastinal components rapidly disappear without any specifically treatment.

We report on a young african women, who had a severe anemia due to iron deficiency. By colonoscopy we found as cause a late stage of intestinal schistosomiasis. On this occasion we agree to the pathophysiology, the epidemiology, the symptomatology, the diagnosis and the therapy of this disease.

In 17 patients (8 men, 9 women; mean age 61.5 years) with problematic bile-duct stones (papilla endoscopically inaccessible, residual bile-duct stones after recent laparoscopic cholecystectomy or age below 25 years) the chances of successful treatment by ESWL without sphincterotomy were examined. In 15 patients with solitary stones measuring up to 14 mm "pulverization-ESWL" produced complete freedom from stones after spontaneous migration of fragments through the intact papilla. Only two patients with two ductal stones measuring up to 15 mm still had residual fragments in the bile duct after treatment. The ideal stone for ESWL without sphincterotomy is thus the solitary bile-duct stone measuring up to 14 mm. Before performing a high-risk sphincterotomy, before re-operation and in young patients one should therefore always examine whether ESWL without sphincterotomy is indicated.