Innere Medizin (Heidelberg, Germany)最新文献

Background: The intestinal microbiota comprises all living microorganisms in the gastrointestinal tract and is crucial for its function. Clinical observations and laboratory findings confirm a central role of the microbiota in chronic inflammatory bowel diseases (IBD). However, many mechanistic details remain unclear.

Objectives: Changes in the microbiota and the causal relationship with the pathogenesis of IBD are described and current and future diagnostic and therapeutic options are discussed.

Materials and methods: Narrative review.

Results: The intestinal microbiota is altered in composition, diversity, and function in IBD patients, but specific (universal) IBD-defining bacteria have not been identified. The healthy microbiota has numerous anti-inflammatory functions such as the production of short-chain fatty acids or competition with pathogens. In contrast, the IBD microbiota promotes inflammation through the destruction of the intestinal barrier and direct interaction with the immune system. The balance between pro- and anti-inflammatory effects of the microbiota appears to be crucial for the development of intestinal inflammation. Microbiota-based IBD diagnostics show promise but are not yet ready for clinical use. Probiotics and fecal microbiota transplantation have clinical effects, especially in ulcerative colitis, but the potential of microbiota-based therapies is far from being fully realized.

Conclusion: IBD dysbiosis remains undefined so far. It is unclear how the many parallel pro- and anti-inflammatory mechanisms contribute to IBD pathogenesis. An inadequate mechanistic understanding hinders the development of microbiota-based diagnostics and therapies.

Background: In patients with inflammatory bowel diseases (IBD), functional complaints frequently persist after the clearing of inflammation and are clinically difficult to distinguish from symptoms of inflammation. In recent years, the influence of bidirectional communication between the gut and brain on gut physiology, emotions, and behavior has been demonstrated.

Research questions: What mechanisms underlie the development of functional gastrointestinal complaints in patients with irritable bowel syndrome (IBS) and IBD? What therapeutic approaches arise from this?

Materials and methods: Narrative review.

Results: The pathogenesis of IBS involves interactions between psychosocial factors, genetics, and microbiota as well as the central and peripheral nervous systems. The interplay between stress and visceral hypersensitivity is of central importance. Therapeutically, lifestyle changes with stress reduction and exercise alongside dietary, pharmacological, and psychotherapeutic options are useful.

Discussion: The treatment of functional gastrointestinal disorders remains challenging, as pharmacological therapies are often ineffective and gut-directed psychotherapies are rarely available.

Eosinophilic esophagitis (EoE) was first described in the early 1990s. Initially a rarity, it is now the most common cause of dysphagia for solid foods in young adults. Its prevalence is estimated to be 1:2000. Mechanistically, EoE is characterized by a chronic type‑2 T‑helper cell (Th2) inflammation of the esophagus which is triggered by food allergens. It often occurs in association with other Th2-mediated diseases, such as asthma, atopic dermatitis, and chronic rhinosinusitis with nasal polyps. EoE is diagnosed based on an esophagogastroduodenoscopy with biopsies of the esophageal epithelium. The diagnosis can be established when both symptoms of esophageal dysfunction (usually dysphagia) and an eosinophilic infiltration of at least 15 eosinophils per high-power field (HPF) are present. EoE can be treated with drugs, diet, and endoscopic dilatation. In terms of diet, milk elimination appears most reasonable, particularly as first choice. Drug treatment includes proton pump inhibitors (PPI), topical steroids, and the biologic agent dupilumab. Endoscopic dilatation is effective but does not treat the underlying inflammation. Therefore, it should never be used alone, but rather as an add-on therapy. In cases where clinical suspicion of EoE is strong but no or only few eosinophils are detected in esophageal biopsies, the diagnosis of an EoE variant should be considered. This review article provides a detailed discussion of the epidemiology, clinical features, diagnosis, treatment, and variants of EoE.

Physicians in internal medicine are exposed to high levels of stress. Conditions of chronic emotional fatigue and burnout are widespread. Resilience, the ability to cope with difficult situations and to adapt to adverse circumstances, is essential. Resilient physicians remain calm, make clear decisions and are in a position to support the collegial environment as well as to requisition and utilize support themselves. Resilience can be described at a biological level and is influenced by biological mechanisms, such as the hypothalamic-pituitary-adrenal axis; , even resilience of patients should be more strongly considered in internal medicine. Resilient patients can cope better with the stress due to the disease and sequelae of the treatment, which not only facilitates the healing and regeneration process but also strengthens the adaptability to altered life situations in the case of newly occurring health challenges. Interventions that activate the individual coping strategies and social support can positively influence the course of chronic diseases. A high level of resilience contributes to the quality of patient care. In addition to biological factors, this is based particularly on psychological and social factors and can be specifically promoted and trained.

In patients with chronic inflammatory bowel disease (IBD), endoscopic techniques (including capsule techniques and balloon enteroscopy for the small intestine), ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are primarily used as often complementary imaging techniques. Radiation exposure needs to be kept in mind when using CT and conventional X‑ray-techniques. Therefore, most importantly, ultrasound and MRI have changed the routine diagnostics of intestinal diseases. US, CT and MRI not only assess the lumen but, similarly importantly, also the wall and the surrounding structures of the gastrointestinal tract. Furthermore, functional processes can be visualized and provide important information about passage and perfusion, which is mainly true for real-time ultrasound. CT and MRI are usually carried out with the use of contrast agents as contrast-enhanced CT (CECT) and contrast-enhanced MRI (CEMRI). Ultrasound is performed conventionally or with intravascular (CEUS) and/or extravascular intracavitary contrast agent application (icCEUS). This article provides an overview of the current significance of the mentioned imaging procedures in patients with IBD and discusses the typical indications.

Testosterone is a natural hormone which is an essential factor to maintain the physical and emotional well-being in men, regardless of age. Male hypogonadism is an endocrinal condition of testosterone deficiency with the potential to cause multiple physical complaints and psychosocial problems. The condition can be of primary (due to testicular injury), secondary (due to diseases of the hypothalamus or pituitary gland) or functional nature (due to comorbidities, such as inflammatory diseases, obesity, type 2 diabetes mellitus). Testosterone deficiency causes problems of a sexual nature, promotes metabolic disequilibrium and can impair physical abilities (reduction in muscle mass, increase in fat mass). In addition, in the condition of hypogonadism depression, osteoporosis and/or anemia often develop. A testosterone replacement therapy should not be initiated in cases of a desire to have children, unclear processes of the prostate glands or mammary glands or an elevated hematocrit value. The diagnosis as well as treatment and monitoring of the treatment should follow the international guidelines and then a clear improvement in the abovenamed complaints can be expected. Particularly functional hypogonadism, which is mostly but not exclusively diagnosed in older men, always requires treatment of the underlying comorbidity prior to starting testosterone administration.

Background: In chronic inflammatory bowel diseases (IBD), severe flares are characterized by intense inflammatory activity and a high disease burden for patients. Treatment addresses both short-term goals (e.g., symptom reduction, prevention of complications) and long-term goals (sustained clinical steroid-free remission and healing of inflammatory lesions, known as "mucosal healing").

Objective of the study: To present evidence-based, targeted diagnostics and stepwise treatment of severe flares in Crohn's disease (CD) and ulcerative colitis (UC), in order to prevent complications, including mortality, and to achieve rapid remission.

Materials and methods: Selective literature review, including German and European guidelines for the treatment of severe flares.

Results and discussion: After ruling out complications (e.g., infections, strictures, abscesses, toxic megacolon), based on a structured assessment of disease severity, intravenous steroid therapy is indicated in severe acute flares for both CD and UC, which should lead to improvement within the first 72 h. If no improvement occurs, medical therapy must be intensified. Various therapeutics, including biologics targeting tumor necrosis factor (TNF)-α, α₄ß₇ integrins, interleukin (IL)-12/23 or IL-23, as well as Janus kinase (JAK) inhibitors, sphingosine 1‑phosphate receptor (S1PR) modulators, and calcineurin inhibitors, are available today, but there is no clear algorithm preferring one drug for CD or UC. Instead, treatment should be selected based on approvals, the patient's medical history, prior treatment, risk profile, and potential complications. Surgical options must always be considered as part of close interdisciplinary care.