Heinrich Josef Lübke

Prevalence of Malnutrition in Hospitalized Medical Patients: Impact of Underlying Disease

Background/Aims: Malnutrition is common among hospitalized patients. We investigated whether certain diseases predispose more frequently for malnutrition than others. Methods: Nutritional state was assessed by clinical scores, anthropometry and bioimpedance analysis in 502 consecutively admitted patients in the departments of internal medicine in two hospitals in Berlin (n = 300, university hospital; n = 202, district hospital). The prevalence of malnutrition was compared in patient groups with a different diagnosis. Results: Malnutrition was present in 24.2% of all patients. A clear association between diagnoses and malnutrition was found: the prevalence of malnutrition was significantly higher in malignant than in non-malignant diseases (50.9 vs. 21.0%, p < 0.0001). High prevalence rates >30% were observed in subgroups of patients with inflammatory bowel diseases, chronic heart failure and benign lung diseases. Patients with gastrointestinal diseases, however, were not more frequently malnourished than other medical patients (28.8 vs. 22.0%). Malnourished patients were significantly older (70.0 ± 13.6 vs. 58.3 ± 15.6 years, p < 0.0001) and had a 40% longer hospital stay (13.1 ± 8.1 vs. 9.3 ± 6.8 days, p < 0.0001) than well-nourished patients. Conclusions: Patients with malignancies, inflammatory bowel disease, chronic heart failure and benign lung diseases need special attention due to the high prevalence of malnutrition.

Anatomy of the anal sphincters: Comparison of anal endosonography to magnetic resonance imaging

PURPOSE: A recent application of endosonography in the evaluation of anal sphincter morphology has led to controversy about the possibility of precisely assessing the diameter of external and internal anal sphincter muscles. On the other hand, magnetic resonance imaging (MRI) has been proposed to allow a more detailed view of the anatomy of the pelvic floor. However, both techniques have not yet been compared directly. METHODS: Eight healthy volunteers (age range, 25–40 years; 5∶3, male∶female) participated. Anal ultrasound was performed using a 7.5-MHz rectal transducer which produced a transversal panorama display of 360, allowing an image perpendicular to the anal canal. Imaging of the diameter of the internal and external anal sphincter muscles was performed with the transducer placed in the midanal canal, and measurement was always performed by the same investigator in dorsal projection. MRI was performed using a 1.5 Tesla Magnetom (Siemens, Erlangen, Germany) to obtain sagittal and angled axial (perpendicular to the anal canal) planes for consecutive 3-mm slices which were evaluated by four independent raters. RESULTS: Muscle thickness of the sphincter muscles in dorsal projection was 1.96±0.61 mm for the internal sphincter and 6.35±1.07 mm for the external sphincter using ultrasound. It was 1.72±0.13 mm and 3.99±0.99 mm, respectively, using MRI. When both measures were compared, only the internal sphincter data correlated significantly (r=0.818,P=0.0023) between both measures. Sagittal resonance imaging of the anal canal did not allow for differentiation of both muscles at all. Differentiation among mucosa, submucosa, and internal anal sphincter is not possible with MRI but may well be performed with high-resolution ultrasound. CONCLUSION: Anal ultrasound carries the potential of becoming a routine clinical procedure for evaluation of the anal anatomy and morphology in defecation disorders, but current MRI assessment of the anal anatomy is elaborate, costly, and does not provide any further insights.

Long-term efficacy of biofeedback training for fecal incontinence

PURPOSE: Biofeedback therapy in fecal incontinence has been reported to improve continence in more than 70 percent of patients, but most studies have followed patients for less than two years. METHODS: Patients treated by biofeedback training between 1985 and 1986 were given a questionnaire in 1991, as were incontinent patients who had not entered this treatment program. All were asked for the occurrence, frequency, and severity of incontinence events in the past two weeks. Anamnestic and anorectal manometry data from the initial visit were also compared. RESULTS: Eighteen of 24 treated patients and 40 of 71 untreated patients responded. Of those treated by biofeed-back, 78 percent reported episodes of fecal incontinence as compared with 77.5 percent of those not treated by biofeedback. Severity of incontinence, however, was significantly less (P<0.02) in the treatment group (mean number of events, 0.2/day) than in those without treatment (1/day). In biofeedback-treated patients, it was identical with the frequency and severity reported immediately after therapy. No differences were found with respect to initial clinical data and anorectal manometry between both groups. CONCLUSION: Biofeedback training improves continence in patients not only during treatment and within the first two years but also for several years after therapy.

Comparison between intraluminal multiple electric impedance measurement and manometry in the human oesophagus.

Abstract Conventional oesophageal manometry and intraluminal electrical impedance measurement were simultaneously applied in eight healthy volunteers to study the effect of wet and semisolid bolus viscosities on oesophageal motility and bolus transit. Contraction front velocity measured by electrical impedance and manometry were identical for wet and semisolid swallows and highly associated. Bolus front velocity as measured by electrical impedance was significantly faster than contraction front velocity in both wet and semisolid swallows. Bolus front velocity during semisolid swallows was significantly slower compared to wet swallows. It is concluded that intraluminal electrical impedance measurement is a reliable technique to detect oesophageal motility as well as to differentiate between transit of wet and semisolid bolus consistencies.

Age and sex and anorectal manometry in incontinence.

Although the prevalence of fecal incontinence is greater in women compared with men and in elderly subjects compared with younger subjects, data regarding the influence of age and sex on anorectal performance in continent and incontinent patients are conflicting. The authors, therefore, investigated age-and gender-related changes in anal resting and squeeze pressure as well as in sphincter relaxation after rectal balloon distention in 75 patients with fecal incontinence of different pathogenesis and in 99 continent patients by multichannel anorectal manometry. As a group, incontinent patients usually exhibit lower pressure profiles than do continent patients regardless of age and gender; however, both the resting pressure of the internal anal sphincter and the voluntary contractile pressure of the external anal sphincter are decreased with age, and both are lowered in women compared with men. Sphincter relaxation and perception of gastrointestinal events are not altered in incontinent patients, and they are not different between men and women or between elderly and younger patients.

Up and down the spinal cord: afferent and efferent innervation of the human external anal sphincter

Afferent and efferent pathways from the anal canal to the external anal sphincter muscle have been investigated in healthy volunteers by means of scalprecorded somatosensory‐evoked potentials following electrical stimulation within the anal canal and by means of motor‐evoked potentials recorded from the external anal sphincter muscle following transcranial magneto‐electrical stimulation of the motor cortex. Control recordings were obtained following posterior tibial‐nerve stimulation on the one hand and recordings form the anterior tibial muscle on the other hand. Latencies of both somatosensory‐evoked potentials following anal stimulation and motor‐evoked potentials recorded from the external anal sphincter were similar to those of the tibial muscle/nerve despite a longer distance. This may be due to slower conduction of the sensory and motor pathways from and to the pelvic floor in comparison to those pathways innervating the limbs, or to the fact that pelvic floor pathways comprise a larger number of neurons and synapses as has been shown in the motor pathways to the pelvic floor in animals.

The effect of trospium chloride on oesophageal motility

Trospium chloride is a muscarinergic antagonist acting on oesophageal smooth muscle and on ganglionic and/or myenteric neurons. The effect of this drug on oesophageal motility was tested in 16 healthy male subjects in a double‐blind randomized cross‐over examination of trospium chloride or placebo following phentolamine or placebo application. Each subject underwent two separate investigations at least one week apart. Trospium chloride was effective in the oesophagus to reduce contractile activity (amplitude and duration of peristalsis) in all parts of the oesophageal body, and this effect was not blocked by phentolamine. Its potent action and its minor side‐effects appear to be promising for clinical use in patients with motility disorders such as the hypercontractile oesophagus.

Effect of topical anaesthesia on oesophageal sensory and motor function in healthy subjects

Abstract Oesophageal hyperalgesia was demonstrated in the non‐cardiac chest pain syndrome and suggests an altered perception of visceral stimuli in these patients. Data on oesophageal sensory function and its pharmacological manipulation, however, are fragmentary.

Diagnostic et surveillance de leiomyomes œsophagiens et gastriques par ultrasonographie endoscopique (USE)

RésuméDe 1991 à 1994 nous avons investigué par endoscopie et ultrasonographie endoscopique (USE) 39 patients (19 hommes et 20 femmes — limite d’âge: 39–85 ans).Les examens de surveillance ont été réalisés après un intervalle de 6 à 24 mois chez 10 patients. La majorité des malades était asymptomatique.La dysphagie a été observée chez seulement 8 patients, la douleur rétrosternale chez deux malades et une hémorragie gastro-intestinale dans 8 cas.L’échoendoscopie a révélé des images comportant une structure hypoéchogène, homogène, à bords réguliers prenant son origine au niveau de la tunique musculaire. Les dimensions des leiomyomes variaient de 0,9 × 0,4 à 7,7 × 6,0 cm. Les examens de surveillance ont révélé un accroissement des dimensions du leiomyome dans un seul cas, après un intervalle de 12 mois. Nous n’avons constaté aucune corrélation entre les symptômes cliniques et les dimensions du leiomyome. Une intervention chirurgicale a été pratiquée dans 6 cas. Chez 5 malades, le diagnostic endoscopique et échoendoscopique du leiomyome a été confirmé à la fois par la chirurgie et l’examen histopathologique. Néanmoins, dans un cas opéré, le diagnostic de leiomyome n’a pas été confirmé et l’examen histologique a révélé un kyste bronchogénique.En conclusion, le leiomyome de l’œsophage et de l’estomac peuvent être détectés de façon efficace par échoendoscopie et ces lésions expriment une faible tendance à la croissance. Pour cette raison il nous semble suffisant de contrôler les leiomyomes non compliqués après un intervalle de temps de 24 mois.SummaryFrom 1991 to 1994 we investigated 39 patients (19 men, 39–85 years old) with leiomyomas of the esophagus and stomach by endoscopy and by endoscopic ultrasonography (EUS). Follow-up investigations after 6 to 24 months were performed in 10 patients. The majority of patients was without specific symptoms. Dysphagia occurred in only 8 patients, retrosternal pain in 2 patients, and gastrointestinal bleeding in 8 patients. Endoscopic ultrasonography revealed hypoechoic, homogeneous and regular bordered structures that originated from the muscularis propria. The size of the leiomyomas ranged between 0.9 × 0.4 and 7.7 × 6.0 cm, respectively. Follow-up investigation revealed significant increase in size in only one patient after a period of 12 months. No correlation between clinical symptoms and size of the leiomyomas could be obtained. Surgery was performed in 6 patients. In 5 cases, endoscopic and endosonographic diagnosis of leiomyoma was confirmed by surgery and histology, respectively. However, in one patient surgery did not confirm esophageal leiomyomas but revealed a bronchial cycst. It is concluded that leiomyoma of the esophagus and stomach can be detected reliably by EUS and show a low tendency of growth. Therefore, it appears to be sufficient to control uncomplicated leiomyomas after a period of 24 months.

Exsudative Enteropathie beim Klippel-Trenaunay-Syndrom

SummaryThe triad of the Klippel-Trénaunay Syndrome consists of varicose veins, “port-wine” haemangioma of the skin and bone and soft-tissue hypertrophy with a different extension. Often an obstruction of lymphatic vessels and lymphoedema accompany the syndrome. We observed for the first time a patient with an impressive Klippel-Trénaunay-Syndrome in combination with a symptomatic exsudative enteropathy.In spite of a regular intravenous protein substitution for many years, this patient had develloped a monstrous elephantiasis of the lower extremities. A lymphography demonstrated a blockade of the lymph flow at the height of the middle paraaortic lymph nodes. The cysterna chyli and the Ductus thoracicus were not visualised. The measurement of51Cr-labelled albumin excretion in the stool for two days after the intravenous injection of 3.07 MBq51Cr showed an excretion of 17.9% of the total dose, which means an elevated gastrointestinal protein-loss. However, intestinal lymphangiectasia was not seen on histologic examination of bioptic material of duodenal and jejunal mucosa.These results show that the Klippel-Trénaunay Syndrome may be accompanied by a protein-loosing enteropathy due to obstruction of the gastrointestinal lymph flow. As the intestinal lymphangiectasia may occur locally, it is not always demonstrable directly on pathologic examination of biopsies.