Schweizerische Rundschau fur Medizin Praxis = Revue suisse de medecine Praxis最新文献

Application of pancreatic digestive enzymes is indicated in cases of a quantitatively decreased exogenous secretion or an asynchronous secretion of enzymes with regard to the duodenal passage of chyme. A clear indication for therapy is a proven steatorrhea, a relative indication loss weight of and/or uncharacteristic abdominal discomfort in patients with proven pancreatic disease, i.e. chronic pancreatitis. Uncharacteristic abdominal discomfort alone, which is regarded as a consequence of 'maldigestion' without proven pancreatic disease, is not an indication for therapy. To prevent a destruction of exogenously applied lipase by gastric acid and to enable a synchronous gastroduodenal passage of the enzymes together with food, acid-protected micropellets or -tablets with an ideal diameter around 1.4 mm containing high amounts of lipase are requested. In cases of anacidity i.e. gastrectomy or type-A gastritis, lipase rich 'conventional' enzymes applied as granulate are sufficient. Combinations (pancreatic enzymes with bile acids) or fungal lipases have either more side effects (diarrhea) or are less efficient when compared to porcine enzymes. Acid-resistant microbial lipases may be useful in the near future. Application of pure proteases or pancreatic enzymes with high concentrations of proteases as treatment of pain in chronic pancreatitis ('negative feedback regulation') are a rather expensive form of treatment when compared to analgetics and are probably ineffective.

Acute and chronic pseudocysts differ. Chronic pseudocysts develop during the evolution of chronic pancreatitis unrelated to a specific bout of clinically recognizable acute pancreatitis. Acute pseudocysts arise in conjunction with an episode of acute pancreatitis. Whereas until recently surgical therapy has been the standard treatment for acute (or chronic) pancreatic pseudocysts, a range of nonsurgical options has been developed. The most important nonsurgical treatment of all is to watch and wait. Pseudocysts following acute pancreatitis should be observed when they are truly asymptomatic and less than or equal to 6 cm in diameter and left alone if not increasing in size. Only if after a six-week observation period pancreatic pseudocysts increase in diameter and become symptomatic, percutaneous needle aspiration, catheter drainage or an endoscopic drainage procedure (cystogastrostomy/cystoduodenostomy) or ultimately operative drainage procedure should be considered. Antibiotic therapy should be considered for all patients presenting with pancreatic necrosis. They should be treated with drugs administered intravenously at the maximum recommended dose as early as possible after onset of symptoms, continued throughout at least the first two weeks of the disease. Moreover, they should be treated alone and/or in combination with antibiotics that are active against gram-negative organisms of intestinal origin, commonly isolated in necrotic tissue, pseudocysts and infected pancreatic abscesses, and that are capable of penetrating into the pancreatic juice and necrotic tissue (e.g. mezlocillin, cephalosporin, metronidazole). Removal of pancreatic stones and pancreatic stenosis by endoscopic procedures in the treatment of pain in patients with chronic pancreatitis is still not an established and generally accepted treatment. Controlled trials to validate stenting and ESWL in chronic pancreatitis are needed.

In about 95% of patients with acute cholecystitis the cystic duct is obstructed by a gall stone. The imprisoned bile salts have a toxic action on the gall bladder wall. Acute cholecystitis is liable to be confused with other causes of sudden pain and tenderness in the right hypochondrium. Below the diaphragm, acute retrocecal appendicitis, intestinal obstruction, a perforated peptic ulcer or acute pancreatitis may be confusing factors; however, the gall bladder remains shrunken, fibrotic, full of stones and nonfunctioning. Recurrent acute cholecystitis may follow, but there may be surprisingly long clinically silent periods. The treatment of choice is elective cholecystectomy. General measures include bed rest, intravenous fluids, a light diet and relief of pain with pethidine and buscopan. Antibiotics are given to treat septicemia and prevent peritonitis and empyema. During the first 24 h., 30% of the gall bladder cultures are positive. This rises to 80% after 72 h. Common infecting organisms are Escherichia coli, Streptococcus faecalis and Klebsiella, often in combination. Anaerobes are present, if sought, and are usually found with aerobes. They include Bacteroides and Clostridia. Antibiotic(s) should have a spectrum to cover the colonic type micro-organisms which are usually found with infection of the biliary tree. The choice depends upon the clinical picture. A broad-spectrum penicillin or a cephalosporin is usually adequate for the stable patient with pain and mild fever. The severely septicemic patient is better treated with a combination of ureidopenicillin (mezlocillin or piperacillin) and metronidazole.

We describe an intestinal perforation in a football player who had been hit with the knee in the abdomen. Perforation of the small bowel, following blunt abdominal trauma, is relatively rare. Its most frequent cause is a deceleration trauma, usually from a traffic accident. Clinical signs are frequently discrete and nonspecific. The most frequent symptom is abdominal pain. Lack of bowel sounds is reported in 64% oft the cases. Enteric lesions should be suspected in the presence of a corresponding history (deceleration trauma) and of other pathologies (fractures of vertebrae and/or pelvis). Sonography and computed tomography are rarely helpful. Delayed perforations have been described, necessitating prolonged observation for 48 to 72 h. after painful abdominal trauma. Repeated examinations are essential to rule out enteric perforation. Initially, less than 50% of the cases show free air, thus limiting the usefulness of thoracic and abdominal radiography. Mortality reaches 30%. This rate is adversely affected by concomitant lesions in other organs and by delay (more than 10 h.) in diagnosis. When laparotomy has been delayed and peritonitis is present, antibiotic treatment should be started immediately during surgical intervention (cephalosporin, aminoglycoside, metronidazole). Postoperative complications include septicaemia, wound infection and, rarely, enterocutaneous fistulae.

Several articles covering treatment of mammary carcinoma in situ and invading mammary cancer have been published recently. This article delivers a short description of the clinical picture and the treatment of a noninvasive tumor as well as of the mainly conservative primary treatment of invasive carcinoma in common use since 20 years. Systemic adjuvant treatment is discussed in the context of results from a meta-analysis publishes two years ago in 'Lancet'. Finally, various directives for the execution of an adjuvant treatment are given that are offered today outside of a study protocol.

The topic of patient compliance is presented synoptically in a three-part review. In this first part the definition as well as the methods for the measurement of compliance are treated. Patient compliance is a problem that concerns every physician and patient. The phenomenon is not new and is the term for an old central problem of cooperation between physician and patient. Compliance is the intention to follow a medical advice. Noncompliance is common, occurs in all kinds of diseases and is expensive. There are several methods of different accuracy that allow to assess the extent of compliance or noncompliance, respectively. Direct and indirect procedures are distinguished. Questionnaires offered to patients, 'pill-counting', 'appointment-keeping' as well as registration of drug effects represent indirect methods. The direct approach includes measurement of drugs or metabolites in urine or serum. The next issues feature on factors determining compliance, interactions between physician and patient as well as methods for the determination of compliance.

The life expectancy of patients with inoperable esophageal neoplasms is very limited. Therefore, palliative strategies should be immediately effective in relieving dysphagia. The efficiency of different methods so far available for palliation is discussed. In inoperable localized cancers, combined chemotherapy and radiation therapy are more effective than irradiation alone. Patients with more advanced carcinomas will benefit from the development of self-expanding metal stents. These stents can be placed quickly, are safe and show low morbidity rates.

In patients with acute pancreatitis, ultrasound is used to clarify the etiology of biliary pancreatitis by diagnosis of cholelithiasis and to follow up pancreatic fluid collection in pseudocyst development. CT ist the imaging modality of choice in clinically severe pancreatitis of patients representing diagnostic dilemmas or failing responds to conservative therapy and in patients with suspected complications. The radiologic diagnosis in chronic pancreatitis is primarily based on ultrasonography, CT and ERCP. ERCP is the most accurate method for diagnosis of pancreatic ductal changes. Screening for pancreatic neoplasms is accomplished by ultrasonography, while CT is used for detection, diagnosis and staging. Magnetic resonance tomography has proved to be equal to CT. The highest diagnostic accuracy for detection of small neoplasms and for local staging is achieved by endoscopic ultrasonography.