Arne R. Schneider

13C-methacetin breath test shortened : 2-point-measurements after 15 minutes reliably indicate the presence of liver cirrhosis

Background and Goals The 13C-methacetin breath test (MBT) measures the activity of the cytochrome P450 dependent enzyme system and has been developed to assess the functional hepatic mass. We evaluated simple modifications of the 13C-MBT to further increase its practicability and therefore clinical acceptance. Study One hundred and four patients with different chronic liver diseases (including 35 patients with histologically proven cirrhosis) and 65 healthy controls underwent the 13C-MBT. Breath test results of 2-point measurements were compared with conventional breath test results (cumulative recovery after 30 min) and liver histology. Results The 2-point-measurement at 0 and 15 minutes (with a cut-off <14.6‰ delta over baseline) had 92.6% sensitivity and 94.1% specificity in identifying the presence of cirrhosis compared with liver histology. The 2-point-measurements at 5 and 10 minutes also provided good discrimination between cirrhotic and noncirrhotic patients. Conclusions The 13C-MBT using 2-point-measurement of breath samples at baseline and after 15 minutes reliably indicates decreased liver function in liver cirrhosis. This simplification of the 13C-MBT will increase practicability and cost efficiency, thus facilitating its clinical acceptability.

Contrast-enhanced ultrasound in the diagnosis of malignant mesenchymal liver tumors

Contrast‐enhanced ultrasound can differentiate malignant from benign hepatic tumors, but has not been studied in malignant mesenchymal liver tumors.

A Novel Line Immunoassay Based on Recombinant Virulence Factors Enables Highly Specific and Sensitive Serologic Diagnosis of Helicobacter pylori Infection

ABSTRACT Helicobacter pylori colonizes half of the worlds population, and infection can lead to ulcers, gastric cancer, and mucosa-associated lymphoid tissue (MALT) lymphoma. Serology is the only test applicable for large-scale, population-based screening, but current tests are hampered by a lack of sensitivity and/or specificity. Also, no serologic test allows the differentiation of type I and type II strains, which is important for predicting the clinical outcome. H. pylori virulence factors have been associated with disease, but direct assessment of virulence factors requires invasive methods to obtain gastric biopsy specimens. Our work aimed at the development of a highly sensitive and specific, noninvasive serologic test to detect immune responses to important H. pylori virulence factors. This line immunoassay system (recomLine) is based on recombinant proteins. For this assay, six highly immunogenic virulence factors (CagA, VacA, GroEL, gGT, HcpC, and UreA) were expressed in Escherichia coli, purified, and immobilized to nitrocellulose membranes to detect serological immune responses in patients sera. For the validation of the line assay, a cohort of 500 patients was screened, of which 290 (58.0%) were H. pylori negative and 210 (42.0%) were positive by histology. The assay showed sensitivity and specificity of 97.6% and 96.2%, respectively, compared to histology. In direct comparison to lysate blotting and enzyme-linked immunosorbent assay (ELISA), the recomLine assay had increased discriminatory power. For the assessment of individual risk for gastrointestinal disease, the test must be validated in a larger and defined patient cohort. Taking the data together, the recomLine assay provides a valuable tool for the diagnosis of H. pylori infection.

Specialized clinical cytology may improve the results of EUS (endoscopic ultrasound)-guided fine-needle aspiration (FNA) from pancreatic tumors.

Background and study aims: A variety of factors (needle type, needle passes, tumor location, cytological assessment, etc.) may influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) from pancreatic tumors. Whereas most published studies report a diagnostic accuracy of > 80 % for EUS-FNAC, the results in routine settings are often considerably lower. This retrospective study aimed to define the effect of switching microscopic assessment from a standard pathology department to a highly specialized institute of cytology. Patients and methods: A total of 63 patients underwent EUS-FNAC of solid or semisolid pancreatic masses. Specimens of the first consecutive 20 cases (Phase 1) were assessed by the local department of pathology. Then in Phase 2, involving another 43 subsequent cases, a specialized cytology laboratory examined all aspirates. All EUS-FNACs were performed in the same manner, using a 22-gauge needle. After cytological evaluation, all patients either underwent surgery or were followed up for at least 6 months. Results: Of the tumors, 56 were solid and 7 semisolid; the mean size was 30 mm. Sensitivity (sens.), specificity (spec.), positive predictive value (PPV), and negative predictive value (NPV) of EUS-FNAC were 38.5 % (95 %CI [confidence interval] 13.9 – 68.4 %), 100 % (59.0 – 100 %), 100 % (47.8 – 100 %), and 46.7 % (21.3 – 73.4 %) during Phase 1 versus 91.4 % (95 %CI 76.9 – 98.2 %), 100 % (63.1 – 100 %), 100 % (89.1 – 100 %), and 72.7 % (39.0 – 94.0 %) during Phase 2. Conclusion: These results emphasize the considerable impact of a dedicated cytological evaluation on the results of EUS-FNAC.

SPLANCHNIC ARTERIAL BLOOD FLOW IS SIGNIFICANTLY INFLUENCED BY BREATHING—ASSESSMENT BY DUPLEX-DOPPLER ULTRASOUND

Duplex ultrasound is established for the assessment of mesenteric ischemia but potential influences of breathing on mesenteric arterial blood velocity have not been investigated so far. In 100 patients without abdominal diseases (39 men; age 59.4 ± 18.0 years), peak systolic (PSV), end diastolic velocity (EDV) and resistance index (RI) were assessed in the celiac trunk (CT) and the superior mesenteric artery (SMA) by Doppler ultrasound during expiration and deep inspiration. Expiratory PSVs in the CT and the SMA (153.4 ± 42.5 and 145.3 ± 39.5 cm/s) were significantly higher than inspiratory velocities (135.4 ± 36.8 and 131.9 ± 42.2 cm/s, p < 0.0001 and p = 0.0002), with expiratory PSVs exceeding inspiratory PSVs in more than 75% of patients. The mean percentage of PSV-variation was 21.5% ± 15.3% and 24.6% ± 19.1%, respectively. The study demonstrates that breathing may exert considerable periodic effects on splanchnic arterial hemodynamics. We, therefore, recommend that to prevent an underestimation of arterial stenosis, mesenteric Doppler ultrasound should be performed during expiration.

Validation of a Novel Immunoline Assay for Patient Stratification according to Virulence of the Infecting Helicobacter pylori Strain and Eradication Status

Helicobacter pylori infection shows a worldwide prevalence of around 50%. However, only a minority of infected individuals develop clinical symptoms or diseases. The presence of H. pylori virulence factors, such as CagA and VacA, has been associated with disease development, but assessment of virulence factor presence requires gastric biopsies. Here, we evaluate the H. pylori recomLine test for risk stratification of infected patients by comparing the test score and immune recognition of type I or type II strains defined by the virulence factors CagA, VacA, GroEL, UreA, HcpC, and gGT with patients disease status according to histology. Moreover, the immune responses of eradicated individuals from two different populations were analysed. Their immune response frequencies and intensities against all antigens except CagA declined below the detection limit. CagA was particularly long lasting in both independent populations. An isolated CagA band often represents past eradication with a likelihood of 88.7%. In addition, a high recomLine score was significantly associated with high-grade gastritis, atrophy, intestinal metaplasia, and gastric cancer. Thus, the recomLine is a sensitive and specific noninvasive test for detecting serum responses against H. pylori in actively infected and eradicated individuals. Moreover, it allows stratifying patients according to their disease state.

Radiofrequency ablation-associated necrosis of the hepatic duct confluence: re-establishing biliary continuity with percutaneous cholangiographic-peroral cholangioscopic rendezvous (with videos)

been described for kidney resection, lymphadenectomy, and adrenal gland resection in animal models.3,4 A hybrid transaginal retroperitoneoscopic nephrectomy in a human was ecently reported.5 Here, we report the first case of transrectal rainage of a retroperitoneal para-aortic abscess after failure f percutaneous drainage. With advantages like avoidance of eneral anaesthesia in critically ill patients and relative ease f access in patients with previous abdominal surgery, the ransrectal retroperitoneoscopic route can be of value, espeially in such difficult clinical settings. EUS guidance can be f help in localizing the abscess if the draining point of the bscess is not visualized during endoscopy. A risk-benefit Figure 2. Para-aortic abscess, perirenal extension.

Kosten endoskopischer Leistungen der Gastroenterologie im deutschen DRG-System – 5-Jahres-Kostendatenanalyse des DGVS-Projekts

Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

Echosignalverstärkte Sonographie-gesteuerte Feinnadelpunktion bei unklaren Lebertumoren

Hintergrund/Einleitung: Die echosignalverstarkte Sonographie verbessert sowohl die Detektion als auch die Charakterisierung von Lebertumoren. Im Gegensatz zu den meisten benignen Tumoren lassen sich in der leberspezifischen Spatphase maligne von benignen Raumforderungen der Leber durch fehlende Kontrastierung differenzieren. Insbesondere bei grosen, inhomogenen Raumforderungen der Leber oder multiplen Raumforderungen mutmaslich unterschiedlicher Genese kann die Lokalisation eines Areals fur die Gewinnung einer reprasentativen sonographisch-gesteuerten Biopsie schwierig sein. Zielsetzung: Ziel dieser Arbeit war es den Einsatz von Signalverstarkern zur Lokalisation einer reprasentativen Punktionstelle bei ausgedehnten bzw. multiplen Lebertumoren unterschiedlicher Echogenitat zu untersuchen. Material und Methoden: Es wurden sechs konsekutive Patienten mit ausgedehnter Infiltration der Leber durch histologisch gesicherte benigne Veranderungen untersucht. Die Patienten wurden nativ und nach Gabe der Echosignalverstarker SonoVue™ (4,8ml, Bracco, Mailand) und Levovist® (4g, Schering, Berlin) mittels Phaseninversionstechnik untersucht. In Abhangigkeit dieser Ergebnisse erfolgte erneut die sonographisch-gesteuerte Punktion. Ergebnisse: Erst durch die echosignalverstarkte Sonographie konnten folgende histologisch gesicherte Tumorentitaten differenziert werden: Patientin 1: FNH und Hamangiom → Angiosarkom. Patientin 2: histologisch gesicherte und uber >3 Jahre vorbekannte Adenome → hepatozellulares Karzinom (HCC) an differenter Lokalisation. Patient 3: Hamangiom → T-Zell-Lymphom. Patienten 4: Nodular regenerative Hyperplasie → HCC. Patient 5: FNH → Klarzellsarkommetastase. Schlussfolgerung: Der Einsatz von Echosignalverstarkern erlaubt die bessere Charakterisierung von unklaren Lebertumoren. Insbesondere bei grosen, inhomogenen Lasionen ist eine verbesserte Lokalisation eines Areals fur die Gewinnung einer reprasentativen sonographisch-gesteuerten Biopsie moglich.

7007 Minilaparoscopy versus conventional diagnostic laparoscopy in chronic liver disease - preliminary results of a prospective trial.

Introduction: Minilaparoscopy (ML) increasingly establishes in the diagnosis of liver disease. We hereby present our results of a prospective study comparing ML and conventional laparoscopy (CL) in the diagnostic workup of patients with liver disease. Patients and methods: 96 patients were randomized either to undergo CL (n = 47) or ML (n = 49) for the diagnosis of suspected liver disease. Conventional laparoscopy was performed with a 11mm-standard Storz laparoscope (Storz, Tuttlingen, Germany) according to previously published guidelines. For minilaparoscopy we used a 1,9 mm-minioptic (Richard Wolf GmbH, Knittlingen, Germany). In all cases, we attempted to obtain a liver biopsy. Results: Laparoscopy could successfully be performed in 92/96 (96%) patients with simultaneous biopsies of the liver. Compared to CL, ML could be performed in a significantly shorter period of time (27,6 min vs.25,1 min, p≤.0,05). In four cases (1 CL and 3 ML), postoperative adhesions prevented sufficient inspection of the liver and in one further patient the technique was switched from CL to ML for the same reason. Minor, self-limiting bleeding after biopsy was observed during 7 examinations with either technique, 2 patients in the ML-group (liver cirrhosis stage Child-Pugh C with ascites) required surgery for uncontrollable bleeding. The patients` subjective perception of the examination was comparable in both groups. Macroscopic and microscopic findings equaled in both groups: During CL and ML, macroscopic signs of cirrhosis were found in 33/47 (70%) and 26/49 (53%) patients, respectively. Histological confirmation of these findings could be obtained in 76% and 77%, respectively. On the other hand, liver cirrhosis was diagnosed by histology in 1/14 (7%) and 1/23 (4%) patients without macroscopic signs of cirrhosis. Discussion: The diagnostic gain of laparoscopy with minioptics in the workup of liver disease seems to be comparable with the results obtained by CL. An advantage is a lower degree of invasiveness and a shorter examination time in ML.