Ina Zuber-Jerger

Alcohol dehydrogenase 1C*1 allele is a genetic marker for alcohol‐associated cancer in heavy drinkers

Chronic alcohol consumption is associated with an increased risk for upper aerodigestive tract cancer and hepatocellular carcinoma. Increased acetaldehyde production via alcohol dehydrogenase (ADH) has been implicated in the pathogenesis. The allele ADH1C*1 of ADH1C encodes for an enzyme with a high capacity to generate acetaldehyde. So far, the association between the ADH1C*1 allele and alcohol‐related cancers among heavy drinkers is controversial. ADH1C genotypes were determined by polymerase chain reaction and restriction fragment length polymorphism in a total of 818 patients with alcohol‐associated esophageal (n = 123), head and neck (n = 84) and hepatocellular cancer (n = 86) as well as in patients with alcoholic pancreatitis (n = 117), alcoholic liver cirrhosis (n = 217), combined liver cirrhosis and pancreatitis (n = 17) and in alcoholics without gastrointestinal organ damage (n = 174). The ADH1C*1 allele and genotype ADH1C*1/1 were significantly more frequent in patients with alcohol‐related cancers than that in individuals with nonmalignant alcohol‐related organ damage. Using multivariate analysis, ADH1C*1 allele frequency and rate of homozygosity were significantly associated with an increased risk for alcohol‐related cancers (p<0.001 in all instances). The odds ratio for genotype ADH1C*1/1 regarding the development of esophageal, hepatocellular and head and neck cancer were 2.93 (CI, 1.84–4.67), 3.56 (CI, 1.33–9.53) and 2.2 (CI, 1.11–4.36), respectively. The data identify genotype ADH1C*1/1 as an independent risk factor for the development of alcohol‐associated tumors among heavy drinkers, indicating a genetic predisposition of individuals carrying this genotype.

White-Light or Narrow-Band Imaging Colonoscopy in Surveillance of Ulcerative Colitis: A Prospective Multicenter Study

BACKGROUND & AIMS Early detection of neoplastic lesions is essential in patients with long-standing ulcerative colitis but the best technique of colonoscopy still is controversial. METHODS We performed a prospective multicenter study in patients with long-standing ulcerative colitis. Two colonoscopies were performed in each patient within 3 weeks to 3 months. In white-light (WL) colonoscopy, stepwise random biopsy specimens (4 biopsy specimens every 10 cm), segmental random biopsies (2 biopsy specimens in 5 segments), and targeted biopsy specimens were taken. In NBI colonoscopy, segmental and targeted biopsy specimens were taken. The sequence of WL and NBI colonoscopy was randomized. RESULTS In 36 of 159 patients enrolled (22.6%), 54 lesions with intraepithelial neoplasia (IN) were found (51 low-grade, 3 high-grade). In WL colonoscopy we found 11 IN in stepwise biopsy specimens, 4 in segmental biopsy specimens, and 15 in targeted biopsy specimens. In NBI colonoscopy 7 IN were detected in segmental biopsy specimens and 24 IN were detected in targeted biopsy specimens. Almost all IN were found with one technique alone (κ value of WL vs NBI, -0.86; P < .001). Statistically equivalent numbers of IN were found in NBI colonoscopy with targeted and segmental biopsy specimens as in WL colonoscopy with targeted and stepwise biopsy specimens, but with fewer biopsy specimens (11.9 vs 38.6 biopsy specimens, respectively; P < .001), and less withdrawal time was necessary (23 vs 13 min, respectively; P < .001). CONCLUSIONS Stepwise biopsy specimens are indispensable in WL colonoscopy. The combination of targeted and segmental biopsy specimens in the NBI technique is as sensitive as targeted together with stepwise biopsy specimens in WL colonoscopy, but requires fewer biopsy specimens and less time. The highest sensitivity should be reached by combining the WL and NBI techniques by switching between the modes.

Factors affecting cecal and ileal intubation time in colonoscopy.

Background and Purpose:The time required for a colonoscopy must be justified under economic aspects. The objective of this study was to analyze patient- and staff-related factors influencing the time for cecal and ileal intubation.Patients and Methods:A prospective study was performed on 500 consecutive patients undergoing colonoscopy in 2005. The authors analyzed patient age, gender, height, weight, surgical history, the presence of liver cirrhosis and splenomegaly, the number of children given birth, the presence of colorectal cancer and inflammatory bowel disease, the quality of bowel preparation, sedation, and the experience of the attending colonoscopist, the nurse and the team as factors of possible relevance to cecal and ileal intubation time.Results:The cecum was reached in 495/500 examinations (99%). Intubation of terminal ileum was possible in 477/500 patients (96%). Mean cecal and ileal intubation times were 10.5 ± 10.2 min and 6.4 ± 7.9 min, respectively. Time to cecal intubation was related to the experience of the endoscopist (p = 0.009), the nurse (p = 0.04) and the whole team (p = 0.002), as well as to an adequate cleaning of the bowel (p = 0.01).Conclusion:A short intubation time requires experienced staff in combination with an adequate cleaning of the bowel without reference to biological or pathologic factors except for colon-shortening surgery. The gain in examination quality by inspecting the terminal ileum comes to the cost of a prolongation of insertion time of 25–30% in experienced hands.ZusammenfassungHintergrund und Ziel:Die Vorschubzeit in das Zäkum bzw. terminale Ileum muss unter ökonomischen Gesichtspunkten so kurz wie möglich sein. Das Ziel dieser Studie war es, patienten- und personalbezogene Einflussgrößen zu untersuchen.Patienten und Methodik:500 Patienten, bei denen eine Koloskopie erforderlich war, wurden im Jahr 2005 prospektiv untersucht. Analysiert wurden patientenbezogen der Einfluss von Alter, Geschlecht, Größe, Gewicht, Voroperationen, Geburtenzahl und Vorerkrankungen (Leberzirrhose, Splenomegalie, Kolonkarzinom, chronisch-entzündliche Darmerkrankung), des Weiteren die Qualität der Vorbereitung und der Sedierung sowie personalbezogen die Erfahrung von Endoskopiker, Endoskopieschwester und untersuchendem Team im Hinblick auf die Vorschubzeit in das Zäkum und das terminale Ileum.Ergebnisse:Das Zäkum wurde in 495/500 Untersuchungen (99%) erreicht. Das terminale Ileum konnte bei 477/500 Patienten (96%) intubiert werden. Die durchschnittliche Zäkumvorschubzeit lag bei 10,5 ± 10,2 min, die durchschnittliche Ileumvorschubzeit bei 6,4 ± 7,9 min. Mit zunehmender Erfahrung von Untersucher (p = 0,009), Schwester (p = 0,04) und Team (p = 0,002) sowie bei adäquater Vorbereitung (p = 0,01) waren die Vorschubzeiten signifikant kürzer.Schlussfolgerung:Eine kurze Vorschubzeit erfordert erfahrenes Personal und eine adäquate Vorbereitung. Im Gegensatz zu anderen Studien sind patientenbezogene Faktoren von untergeordneter Bedeutung. Die verbesserte Qualität der Untersuchung bei Inspektion des terminalen Ileums bezahlt man mit einer Verlängerung der Vorschubzeit um 25–30% in erfahrenen Händen.

Complicated wireless capsule enteroscopy in a patient with Crohn's disease.

An 18-year-old male experienced a first episode of Crohns disease with inflammation of the colon, stenosis of small intestine and a fistula of the anal sphincter. After resection of the fistula and 30 cm of proximal ileum the patient remained free of symptoms under medication with azathioprine and mesalazine for 6 years. Then, blood in the stool occurred. Diagnostic work-up - gastroscopy and colonoscopy 2004 and 2006, magnetic resonance enteroclysis 2004 and 2006 and wireless capsule enteroscopy 2006 - revealed slight inflammation in the ileum but no bleeding source. The bleeding ceased, but after 2 uneventful years abdominal cramps appeared and diagnostic work-up (magnetic resonance enteroclysis, radiograph) located the capsule still in the terminal ileum proximal to an inflamed stenosis. Corticosteroids were subscribed for 4 weeks, but the capsule stayed in place. Surgery was discussed, but denied by the patient. Finally, the capsule could be taken out by double balloon enteroscopy.

Diagnosis and treatment of a patient with gallstone ileus

Background A 79-year-old white woman presented with upper abdominal pain. She had a history of rheumatoid arthritis since she was 19 years old, which was treated with prednisolone, leflunomide, diclofenac and pantoprazole. She also had factor VII deficiency. The patient had been hospitalized 2 months previously with sepsis presumed to be due to urinary infection, and was treated with antibiotics. Sonography at this time revealed a gallbladder with a monstrous thick wall and stones, and the first differential diagnosis was cholecystitis. Cholecystectomy was planned after amelioration of the patients general state, but her general state worsened.Investigations Sonography, endoscopy of the upper and lower intestine, and CT scan.Diagnosis Biliodigestive fistula and gallstone ileus.Management Enterolithotomy, stenting, endoscopic retrograde cholangiopancreatography, and surgery.

A new grading system to evaluate the risk of endoscopic retrograde cholangiopancreatography.

BackgroundThe aim of our study was to develop a system to grade the risk of the procedures summarized under the term endoscopic retrograde cholangiopancreatography (ERCP).MethodsIn a controlled prospective study, we evaluated the early complications of ERCP in 526 consecutive patients at a single endoscopy center in a defined period. The relation between endoscopic procedures and related complications was analyzed for significance. A grading system based on significant risk factors and clinical implications was developed.ResultsOf the ERCP procedures, 29% were diagnostic and 71% therapeutic. A total of 45 complications occurred in 42 patients: pancreatitis (2%), perforation (1%), cardiorespiratory problems (0.6%), stent-related complications (0.5%), leakages (1.5%), and bleeding (3%). A native papilla was a significant risk factor for the development of complications (P = 0.046). On the basis of these findings, we defined five groups of ERCP-related complications: nonnative papillae with either diagnostic (A) or therapeutic interventions (B); native papillae with diagnostic (C) or therapeutic (D) interventions; and special therapeutic interventions (E). Complication rates differed significantly between individual groups, A versus D (P = 0.013), A versus E (P = 0.010), B versus D (P = 0.005), and B versus E (P = 0.003), as well as between A/B and C/D (P = 0.003).ConclusionsA grading system based on differentiating between native and nonnative papillae and diagnostic versus therapeutic procedures demonstrated significantly different complication rates. This grading system has the potential to predict the risk of ERCP-related complications.

Akute obere gastrointestinale Blutung nach Koronarintervention bei akutem Myokardinfarkt

ZusammenfassungAnamnese und klinischer Befund:Ein 73-jähriger Patient wurde bei NSTEMI (Nicht-ST-Hebungsinfarkt) notfallmäßig koronarangiographiert und mit einem medikamentenbeschichteten Koronarstent (DES [„drug-eluting stent“]) versorgt. 12 h postinterventionell kam es unter einer dreifachen Thrombozytenaggregationshemmung zu einer gastrointestinalen Blutung mit Absetzen von großen Mengen dunklen Bluts und einem Hämoglobin-( Hb-)Abfall von 15,3 auf 9,7 g/dl.Untersuchungen:Im Aufnahmelaborbefund waren erhöhte Herzenzyme, positives Troponin und erhöhte Entzündungsparameter auffällig. Koronarangiographisch zeigte sich bei bekannter koronarer Herzkrankheit und Z.n. Stentimplantation in den R. interventricularis anterior und R. circumflexus der Stent im R. circumflexus proximal verschlossen. Es erfolgten eine Ballondilatation und bei einer In-Stent-Restenose die Implantation eines DES. Im Rahmen der Blutungsquellensuche fand sich gastroskopisch eine 2,5 cm große, nekrotisch zerfallende tumorähnliche Formation mit Sickerblutung, welche nach Unterspritzung mit Adrenalin sistierte. Histologisch ergab sich kein Hinweis auf Malignität.Therapie und Verlauf:Unter hochdosierter Protonenpumpenblockertherapie, kalkulierter Keimeradikation mit Amoxicillin und Clarithromycin und NSAR-Karenz (nichtsteroidale Antirheumatika) stabilisierte sich der Hb-Wert bei 9,7 g/dl, so dass weder eine Erythrozytensubstitution noch das Pausieren der dualen Thrombozytenaggregationshemmung notwendig waren. In einer Kontrollgastroskopie zeigte sich der initial endoskopisch malignitätsverdächtige Befund als ein kleines, oberflächliches, sich in Abheilung befindliches Restulkus.Schlussfolgerung:Blutungskomplikationen nach Stentimplantation schaffen eine Dilemmasituation, in der die Risiken eines hämorrhagischen Schocks bei Fortführung der Thrombozytenaggregationshemmung und einer akuten Stentthrombose bei Absetzen der Thrombozytenaggregationshemmung sowohl individuell als auch leitliniengerecht gegeneinander abgewogen werden müssen.AbstractHistory and Admission Findings:A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl.Investigations:Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy.Treatment and Course:With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer.Conclusion:Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.HISTORY AND ADMISSION FINDINGS A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl. INVESTIGATIONS Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy. TREATMENT AND COURSE With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer. CONCLUSION Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.

Akute obere gastrointestinale Blutung nach Koronarintervention bei akutem Myokardinfarkt@@@Acute Upper Gastrointestinal Bleeding after Coronary Intervention in Acute Myocardial Infarction

ZusammenfassungAnamnese und klinischer Befund:Ein 73-jähriger Patient wurde bei NSTEMI (Nicht-ST-Hebungsinfarkt) notfallmäßig koronarangiographiert und mit einem medikamentenbeschichteten Koronarstent (DES [„drug-eluting stent“]) versorgt. 12 h postinterventionell kam es unter einer dreifachen Thrombozytenaggregationshemmung zu einer gastrointestinalen Blutung mit Absetzen von großen Mengen dunklen Bluts und einem Hämoglobin-( Hb-)Abfall von 15,3 auf 9,7 g/dl.Untersuchungen:Im Aufnahmelaborbefund waren erhöhte Herzenzyme, positives Troponin und erhöhte Entzündungsparameter auffällig. Koronarangiographisch zeigte sich bei bekannter koronarer Herzkrankheit und Z.n. Stentimplantation in den R. interventricularis anterior und R. circumflexus der Stent im R. circumflexus proximal verschlossen. Es erfolgten eine Ballondilatation und bei einer In-Stent-Restenose die Implantation eines DES. Im Rahmen der Blutungsquellensuche fand sich gastroskopisch eine 2,5 cm große, nekrotisch zerfallende tumorähnliche Formation mit Sickerblutung, welche nach Unterspritzung mit Adrenalin sistierte. Histologisch ergab sich kein Hinweis auf Malignität.Therapie und Verlauf:Unter hochdosierter Protonenpumpenblockertherapie, kalkulierter Keimeradikation mit Amoxicillin und Clarithromycin und NSAR-Karenz (nichtsteroidale Antirheumatika) stabilisierte sich der Hb-Wert bei 9,7 g/dl, so dass weder eine Erythrozytensubstitution noch das Pausieren der dualen Thrombozytenaggregationshemmung notwendig waren. In einer Kontrollgastroskopie zeigte sich der initial endoskopisch malignitätsverdächtige Befund als ein kleines, oberflächliches, sich in Abheilung befindliches Restulkus.Schlussfolgerung:Blutungskomplikationen nach Stentimplantation schaffen eine Dilemmasituation, in der die Risiken eines hämorrhagischen Schocks bei Fortführung der Thrombozytenaggregationshemmung und einer akuten Stentthrombose bei Absetzen der Thrombozytenaggregationshemmung sowohl individuell als auch leitliniengerecht gegeneinander abgewogen werden müssen.AbstractHistory and Admission Findings:A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl.Investigations:Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy.Treatment and Course:With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer.Conclusion:Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.HISTORY AND ADMISSION FINDINGS A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl. INVESTIGATIONS Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy. TREATMENT AND COURSE With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer. CONCLUSION Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.

Eine impaktierte „Wiener Semmel“ im Ösophagus – Erstmanifestation einer eosinophilen Ösophagitis bei einem 17-jährigen Patienten

A 17-year-old patient was transferred to the emergency room with an impacted food bolus by colleagues from the Department of Otorhinolaryngology. The examination of ear, nose and throat revealed significant amounts of saliva in both recessus piriformis, a radiologic examination of the esophagus showed a foreign body with a diameter of 1.6 cm in the region of the transitional zone of esophagus and stomach with a support level of the contrast medium. Clinical examination and laboratory tests showed no abnormalities. An emergency gastroscopy was performed. The foreign body, already evident in the barium swallow, was found in the distal esophagus. The foreign body was identified as a food bolus and gently advanced into the stomach with the aid of the gastroscope. In the stomach further food residues were detected and the examination was aborted because of increased risk of aspiration. On the next day, an elective gastroscopy was performed. Several biopsies were obtained from the esophagus because eosinophilic esophagitis (EE) was suspected due to clinical symptoms. Histological work-up showed a significant amount of eosinophilic granulocytes (> 15 eosinophils/HPF, 400 x) and reactive changes in the distal esophagus. Therefore, EE was diagnosed. Fluticasone therapy led to amelioration of symptoms and there was no evidence of recurring bolus impaction during follow-up.ZusammenfassungEin 17-jähriger Patient wurde aufgrund eines impaktierten Nahrungsbolus von den Kollegen der Hals-Nasen-Ohren-Klinik in der internistischen Notaufnahme vorgestellt. Die HNO-ärztliche Untersuchung zeigte deutliche Speichelseen in beiden Recessus piriformes, die radiologische Untersuchung des Ösophagus ergab einen 1,6 cm messenden Fremdkörper im Bereich des ösophagogastralen Übergangs mit einem proximalen Kontrastmittelspiegel.In der klinischen Untersuchung und der Laborchemie fanden sich keinerlei Auffälligkeiten. Es folgte die Durchführung einer Notfallösophagogastroskopie. Hier zeigte sich der in der Breischluckuntersuchung nachgewiesene Fremdköper im Bereich des gastroösophagealen Übergangs. Der als Nahrungsbolus identifizierte Fremdkörper wurde mittels Gastroskop vorsichtig in den Magen vorgeschoben. Im Magen befanden sich weitere Nahrungsreste, so dass die Untersuchung bei Aspirationsgefahr abgebrochen wurde. In einer am Folgetag elektiv durchgeführten Gastroskopie wurden aus dem Ösophagus Stufenbiopsien bei klinischem V.a. eosinophile Ösophagitis (EÖ) entnommen. Die histologische Aufarbeitung ergab eine deutliche Eosinophilie (> 15 Eosinophile/HPF bei 400facher Vergrößerung) und reaktive Veränderungen im distalen Ösophagus. Somit wurde die Diagnose einer EÖ gestellt. Eine Therapie mit Fluticason führte zu einer deutlichen Symptombesserung, erneute Bolusimpaktionen traten im Verlauf nicht mehr auf.AbstractA 17-year-old patient was transferred to the emergency room with an impacted food bolus by colleagues from the Department of Otorhinolaryngology. The examination of ear, nose and throat revealed significant amounts of saliva in both recessus piriformes, a radiologic examination of the esophagus showed a foreign body with a diameter of 1.6 cm in the region of the transitional zone of esophagus and stomach with a support level of the contrast medium.Clinical examination and laboratory tests showed no abnormalities. An emergency gastroscopy was performed. The foreign body, already evident in the barium swallow, was found in the distal esophagus. The foreign body was identified as a food bolus and gently advanced into the stomach with the aid of the gastroscope. In the stomach further food residues were detected and the examination was aborted because of increased risk of aspiration. On the next day, an elective gastroscopy was performed. Several biopsies were obtained from the esophagus because eosinophilic esophagitis (EE) was suspected due to clinical symptoms. Histological work-up showed a significant amount of eosinophilic granulocytes (> 15 eosinophils/HPF, 400×) and reactive changes in the distal esophagus. Therefore, EE was diagnosed. Fluticasone therapy led to amelioration of symptoms and there was no evidence of recurring bolus impaction during follow-up.

[Impaction of a "sausage bread" in the esophagus--first manifestation of an eosinophilic esophagitis in a 17-year-old patient].

A 17-year-old patient was transferred to the emergency room with an impacted food bolus by colleagues from the Department of Otorhinolaryngology. The examination of ear, nose and throat revealed significant amounts of saliva in both recessus piriformis, a radiologic examination of the esophagus showed a foreign body with a diameter of 1.6 cm in the region of the transitional zone of esophagus and stomach with a support level of the contrast medium. Clinical examination and laboratory tests showed no abnormalities. An emergency gastroscopy was performed. The foreign body, already evident in the barium swallow, was found in the distal esophagus. The foreign body was identified as a food bolus and gently advanced into the stomach with the aid of the gastroscope. In the stomach further food residues were detected and the examination was aborted because of increased risk of aspiration. On the next day, an elective gastroscopy was performed. Several biopsies were obtained from the esophagus because eosinophilic esophagitis (EE) was suspected due to clinical symptoms. Histological work-up showed a significant amount of eosinophilic granulocytes (> 15 eosinophils/HPF, 400 x) and reactive changes in the distal esophagus. Therefore, EE was diagnosed. Fluticasone therapy led to amelioration of symptoms and there was no evidence of recurring bolus impaction during follow-up.ZusammenfassungEin 17-jähriger Patient wurde aufgrund eines impaktierten Nahrungsbolus von den Kollegen der Hals-Nasen-Ohren-Klinik in der internistischen Notaufnahme vorgestellt. Die HNO-ärztliche Untersuchung zeigte deutliche Speichelseen in beiden Recessus piriformes, die radiologische Untersuchung des Ösophagus ergab einen 1,6 cm messenden Fremdkörper im Bereich des ösophagogastralen Übergangs mit einem proximalen Kontrastmittelspiegel.In der klinischen Untersuchung und der Laborchemie fanden sich keinerlei Auffälligkeiten. Es folgte die Durchführung einer Notfallösophagogastroskopie. Hier zeigte sich der in der Breischluckuntersuchung nachgewiesene Fremdköper im Bereich des gastroösophagealen Übergangs. Der als Nahrungsbolus identifizierte Fremdkörper wurde mittels Gastroskop vorsichtig in den Magen vorgeschoben. Im Magen befanden sich weitere Nahrungsreste, so dass die Untersuchung bei Aspirationsgefahr abgebrochen wurde. In einer am Folgetag elektiv durchgeführten Gastroskopie wurden aus dem Ösophagus Stufenbiopsien bei klinischem V.a. eosinophile Ösophagitis (EÖ) entnommen. Die histologische Aufarbeitung ergab eine deutliche Eosinophilie (> 15 Eosinophile/HPF bei 400facher Vergrößerung) und reaktive Veränderungen im distalen Ösophagus. Somit wurde die Diagnose einer EÖ gestellt. Eine Therapie mit Fluticason führte zu einer deutlichen Symptombesserung, erneute Bolusimpaktionen traten im Verlauf nicht mehr auf.AbstractA 17-year-old patient was transferred to the emergency room with an impacted food bolus by colleagues from the Department of Otorhinolaryngology. The examination of ear, nose and throat revealed significant amounts of saliva in both recessus piriformes, a radiologic examination of the esophagus showed a foreign body with a diameter of 1.6 cm in the region of the transitional zone of esophagus and stomach with a support level of the contrast medium.Clinical examination and laboratory tests showed no abnormalities. An emergency gastroscopy was performed. The foreign body, already evident in the barium swallow, was found in the distal esophagus. The foreign body was identified as a food bolus and gently advanced into the stomach with the aid of the gastroscope. In the stomach further food residues were detected and the examination was aborted because of increased risk of aspiration. On the next day, an elective gastroscopy was performed. Several biopsies were obtained from the esophagus because eosinophilic esophagitis (EE) was suspected due to clinical symptoms. Histological work-up showed a significant amount of eosinophilic granulocytes (> 15 eosinophils/HPF, 400×) and reactive changes in the distal esophagus. Therefore, EE was diagnosed. Fluticasone therapy led to amelioration of symptoms and there was no evidence of recurring bolus impaction during follow-up.