Wolfgang F. Caspary

Retroperitoneal endoscopic debridement for infected peripancreatic necrosis

Standard management of infected peripancreatic necrosis consists of open surgical debridement and lavage--a traumatic intervention with substantial morbidity and mortality. As an alternative and novel approach with minimum invasiveness, we present fenestration of the gastric wall and debridement of infected necrosis by direct retroperitoneal endoscopy. In three patients, this strategy led to rapid clinical improvement and no serious complications. Transgastric endoscopic therapy may be a less traumatic alternative to surgery and should be further assessed in prospective studies.

Physiology and pathophysiology of intestinal absorption.

Final digestion and absorption of carbohydrates (CHO) occur after intraluminal hydrolysis by pancreatic alpha-amylase at the surface of the mucosal membrane in close relationship between disaccharide hydrolysis and the glucalogue carrier system. In general, Na(+)-dependent transport is the rate-limiting step of CHO absorption. The rate of absorption is determined by mode of ingestion, chemical composition of the meal, gastric emptying, pancreatic digestion, intestinal digestion and absorption, and intestinal motility. A delay of absorption of CHO may be achieved by dietary fibers, alpha-amylase inhibitors, or alpha-glucosidase inhibitors. Final protein digestion is achieved by a dual mechanism: intact peptide absorption with subsequent intracellular hydrolysis to free amino acids (AA) and membrane hydrolysis of peptides followed by absorption of free AA. More complex is the mechanism of lipid absorption: emulsification, lipolysis, micellar formation, membrane translocation, intracellular resynthesis, chylomicron formation, and lymphatic drainage. The most critical steps in lipid digestion are lipolysis and micellar formation.

The [13C]acetate breath test accurately reflects gastric emptying of liquids in both liquid and semisolid test meals

BACKGROUND/AIMS The current standard for gastric emptying studies are radioactive isotope methods. [13C]breath tests have been developed as a nonradioactive alternative. The aim of this study was to validate a [13C]acetate breath test as a measure of gastric emptying of the liquid phase both in liquid and semisolid test meals by simultaneous radioscintigraphy. METHODS Thirty-five patients with dyspeptic symptoms and 20 healthy volunteers were tested using a semisolid oatmeal or a liquid test meal. Both test meals were labeled by 150 mg sodium [13C]acetate and (in patients) by 45 MBq 99mTc-albumin colloid. Half-time of gastric emptying was calculated after curve fitting of the 13C exhalation to a modified power exponential function. 99mTc-albumin emptying was measured by conventional radioscintigraphy. RESULTS The half-emptying times for the [13C]acetate breath test closely correlated to those measured by radioscintigraphy both for semisolids (r = 0.87) and liquids (r = 0.95). The time of maximum 13CO2 exhalation was itself a reliable parameter compared with the half-emptying times obtained by scintigraphy (r = 0.85 for semisolids; r = 0.94 for liquids). CONCLUSIONS The [13C]acetate breath test is a reliable and noninvasive tool for the analysis of gastric emptying rates of liquid phases without radiation exposure.

Bioelectrical impedance analysis as a predictor of survival in patients with human immunodeficiency virus infection.

In patients with AIDS, short-term survival has been related to body weight, body composition, and serum nutritional parameters, but their prognostic impact at earlier stages of the HIV infection is not known. With an individual follow-up period of 1,000 days, we investigated the prognostic relevance of electrical tissue conductivity [resistance R, reactance Xc, phase angle alpha, extracellular mass (ECM), body cell mass (BCM)] measured by bioelectrical impedance analysis, of the CD4+ cell count, and of serum parameters indicating malnutrition in 75 HIV-infected male patients at Walter Reed stages 3-5. After initial recording, 29 patients (38.7%) died from AIDS during this period. Among 12 parameters estimated with a semiparametric Cox regression model adjusted for therapy (pentamidine, azidothymidine), the phase angle alpha (parameter estimate: -1.043, 95% confidence interval of -0.61 to -1.47; p < or = 0.0001), the ECM/BCM ratio, Xc, BCM, serum cholesterol, number of CD4+ cells, and serum albumin had significant prognostic influence on survival, whereas age, body weight, body mass index, resistance, serum protein, and serum triglycerides did not. In a model with four covariates (CD4+ cells, phase angle, pentamidine, azidothymidine), the prognostic impact of the CD4+ cell count (parameter estimate: -0.549) was lower compared with the phase angle alpha (parameter estimate: -0.799; p < or = 0.0001) and did not gain statistical significance (p = 0.0626). The phase angle alpha was the best single predictive factor for survival among all 12 parameters (comparison of the respective Cox models with the likelihood ratio test).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study

BACKGROUND Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The short-acting anesthetic propofol offers certain potential advantages for endoscopic procedures, but controlled studies proving its superiority over benzodiazepines for ERCP are lacking. METHODS During a 6-month period 198 consecutive patients undergoing routine ERCP randomly received either midazolam (n = 98) or propofol (n = 99) for sedation. Vital signs (heart rate, blood pressure, oxygen saturation) were continuously monitored and procedure-related parameters, the recovery time and quality (recovery score) as well as the patients cooperation and tolerance of the procedure (visual analog scales) were prospectively assessed. RESULTS Patients receiving propofol or midazolam were well matched with respect to demographic and clinical data, ERCP findings, and the performance of associated procedures. Propofol caused a more rapid onset of sedation than midazolam (p < 0.01). Clinically relevant changes in vital signs were observed at comparable frequencies with temporary oxygen desaturation occurring (< 85 %) in 6 patients in the propofol group and 4 patients receiving midazolam (not significant). However, an episode of apnea had to be managed by mask ventilation via an ambu bag (lasting 8 minutes) in one of the patients receiving propofol sedation. Mean recovery times as well as the recovery scores were significantly shorter with propofol (p < 0. 01). Propofol provided significantly better patient cooperation than midazolam ( p < 0.01), but procedure tolerability was rated the same by both groups of patients (not significant). CONCLUSIONS Intravenous sedation with propofol for ERCP is (1) more effective than sedation with midazolam, (2) safe under adequate patient monitoring, and (3) associated with a faster postprocedure recovery.

Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: a prospective, randomized study

Adequate patient sedation is mandatory for most interventional endoscopic procedures. Recent anaesthesiologic studies indicates that propofol and midazolam act synergistically in combination and therefore may be superior to sedation with propofol alone in terms of sedation efficacy, recovery and costs (due to a presumed lower total dose of propofol needed).

New Immunoassay in Stool Provides an Accurate Noninvasive Diagnostic Method for Helicobacter pylori Screening in Children

Objective. The noninvasive13C-urea breath test (UBT) is a reliable diagnostic method for detection of Helicobacter pylori infection in children, and it avoids invasive gastrointestinal endoscopy. In this study, we compared a noninvasive, newly developed fecal H pylori antigen test with the UBT. Methodology. One hundred sixty-two children (76 girls and 86 boys) were tested for H pylori infection using the UBT and a new antigen test in stool samples. The H pylori stool test is based on a sandwich enzyme immunoassay with antigen detection. Results. Twenty-four of the children (14.8%) with dyspepsia tested positive for H pylori according to the breath test results. In 22 of the 24 patients, H pyloriantigen could be detected in the stool (sensitivity: 91.6%). Of 138 patients with negative UBT results, 136 were H pylori-negative in the stool test (specificity: 98.6%). Conclusions. The new, noninvasive, low-cost H pylori antigen test in stool can replace the UBT for detection of H pylori infection in children with comparable reliability and accuracy.

Predictors of reduced health‐related quality of life in adults with coeliac disease

Background  Data available on predictors of reduced health‐related quality of life in coeliac disease are not consistent.

Pneumatic dilation in achalasia with a low-compliance balloon: results of a 5-year prospective evaluation

To evaluate long-term efficacy and side effects after pneumatic dilation with low-compliance balloons, 40 patients with achalasia were prospectively studied during a 5-year period. All patients were investigated before, 4-6 weeks after, and at 28 +/- 15 months (final visit) after pneumatic dilation. Additionally, 12 patients underwent 24-hour esophageal pH-metry before and 26 +/- 14 months after dilation. Initial symptomatic success was obtained in 35 of 40 patients (87.5%). The remaining five and another seven patients with recurrent dysphagia underwent a second dilation, and two of these patients finally underwent esophagomyotomy. Effective dilation was reflected by a significant decrease of the symptom scores (p < 0.01) and an increase of the gastric cardia diameter both at 4-6 weeks after dilation and at the final visit (p < 0.01). Dilation reduced the lower esophageal sphincter pressure from 28.3 +/- 0.8 mmHg to 16.4 +/- 6.4 mmHg at the 4-6 weeks exam and to 14.7 +/- 5.5 mmHg at the final visit, respectively (p < 0.01). Neither the diameter of the esophageal body nor the motility of the tubular esophagus was affected by pneumatic. Esophageal pH-metry showed an increase of the number and duration of reflux episodes (pH < 4) after dilation (p < 0.05), whereas only one patient reported heartburn and another asymptomatic patient revealed esophagitis I0 at endoscopy. Therefore, pneumatic dilation with low compliance balloons proved to be safe and long lasting treatment of achalasia. Although prolonged esophageal acid exposure was measurable after dilation, clinically relevant gastroesophageal reflux occurred in only 5% (n = 2).

13C-methacetin breath test as liver function test in patients with chronic hepatitis C virus infection.

Background : The 13C‐methacetin breath test enables the quantitative evaluation of the cytochrome P450‐dependent liver function.