Publications by authors named "Christoph Schlag"

36 Publications

Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

Endoscopy 2021 Jul 26. Epub 2021 Jul 26.

Department of Gastroenterology and Hepatology, University Hospitals Leuven, and TARGID, KU Leuven, Leuven, Belgium.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2: Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee's procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3: Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4: The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.
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http://dx.doi.org/10.1055/a-1537-8999DOI Listing
July 2021

Development of a core outcome set for therapeutic studies in eosinophilic esophagitis (COREOS).

J Allergy Clin Immunol 2021 Jul 6. Epub 2021 Jul 6.

Inform Diagnostics, Irving, Tex; Department of Pathology, Baylor College of Medicine, Houston, Tex.

Background: End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments.

Objective: We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE.

Methods: Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists.

Results: The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life.

Conclusions: This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis.
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http://dx.doi.org/10.1016/j.jaci.2021.07.001DOI Listing
July 2021

[Treatment of eosinophilic esophagitis - advancements and perspectives].

Z Gastroenterol 2021 Aug 22;59(8):869-878. Epub 2021 Jun 22.

Klinik für Gastroenterologie, KRH Klinikum Siloah, Hannover.

In recent years significant progress has been made in the treatment of eosinophilic esophagitis (EoE), especially in the area of topical corticosteroids. Novel EoE-specific formulations have been developed and first approvals have been obtained for induction and maintenance of remission in adult EoE patients with the orodispersible budesonide tablet in Germany and other European and non-EU countries. A novel budesonide oral suspension is currently under priority review by the FDA for first approval in the U.S. In contrast, the scientific evidence on the efficacy of proton pump inhibitors remains limited. Moreover, new biologicals have been identified which showed promising results in phase 2 trials and are now being studied in phase 3. This article aims to summarize and discuss recent advances and perspectives in the treatment of EoE.
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http://dx.doi.org/10.1055/a-1429-4192DOI Listing
August 2021

Endoscopic Diagnosis of Bouveret Syndrome.

Case Rep Gastroenterol 2020 Sep-Dec;14(3):683-686. Epub 2020 Dec 14.

Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.

Bouveret syndrome is a form of gallstone ileus and a rare complication of chole(cysto)lithiasis. It describes gastric outlet obstruction secondary to an impacted gallstone. Here, we report a case of an 82-year-old female patient with gastric outlet obstruction and penetration of gallstones into the duodenal bulb on endoscopic imaging. Based on these findings Bouveret syndrome was diagnosed and confirmed by computed tomography.
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http://dx.doi.org/10.1159/000510162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772864PMC
December 2020

Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience.

Surg Endosc 2021 Jan 4. Epub 2021 Jan 4.

Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Akademisches Lehrkrankenhaus der TU München, Achdorferweg 3, 84036, Landshut, Germany.

Background: In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era.

Patients And Methods: Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed.

Results: At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease.

Conclusion: In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.
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http://dx.doi.org/10.1007/s00464-020-08191-2DOI Listing
January 2021

Treatment of eosinophlic esophagitis with swallowed topical corticosteroids.

World J Gastroenterol 2020 Sep;26(36):5395-5407

Klinikum rechts der Isar der Technischen Universität München, Klinik und Poliklinik für Innere Medizin II, Munich 81675, Germany.

Eosinophilic esophagitis (EoE) is an emerging chronic local immune-mediated disease of the esophagus. Beside proton pump inhibitors and food-restriction-diets swallowed topical corticosteroids (STC) can be offered as a first line therapy according to current guidelines. This review describes the background and practical management of STCs in EoE. So far, mainly asthma inhalers containing either budesonide or fluticasone have been administered to the esophagus by swallowing these medications "off label". Recently esophagus-targeted formulations of topical steroids have been developed showing clinicopathological response rates up to 85% - an orodispersible tablet of budesonide has been approved as the first "in label" medication for EoE in Europe in June 2018. Whereas it was shown that disease remission induction of EoE by STCs is highly effective, there is still a lack of data regarding long-term and maintenance therapy. However, current studies on STC maintenance therapy add some movement into the game.
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http://dx.doi.org/10.3748/wjg.v26.i36.5395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520613PMC
September 2020

Aspergillus fumigatus cholangitis in a patient with cholangiocarcinoma: case report and review of the literature.

Infection 2021 Feb 29;49(1):159-164. Epub 2020 Aug 29.

School of Medicine, Department of Medicine II, Technical University of Munich, University Hospital Rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.

Aspergillus spp. cholangitis is an uncommon presentation of invasive aspergillosis. Only few cases are described in the literature affecting severely immunocompromised patients or patients following biliary surgery. Especially, invasive aspergillosis in non-haematological patients is associated with high mortality rates, caused by atypical presentations, which is associated with a delay in diagnosis and therapy. We report a 72-year-old man with primary diagnosis of cholangiocarcinoma and stent implantation by endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression who developed severe cholangitis with invasive aspergillosis. The patient had no history of prior hospitalisation, no immunosuppressive therapy and no preceding biliary surgery. Furthermore, in this exceptional case of extrapulmonary aspergillosis, there were no signs of pulmonary involvement. From the literature review, only three cases of Aspergillus cholangitis could be identified. Clinical manifestations of invasive aspergillosis can be variable and classical risk factors such as immunosuppression are not mandatorily present. Clinical awareness of these rare cases is of vital importance for initiation of correct therapy.
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http://dx.doi.org/10.1007/s15010-020-01487-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851102PMC
February 2021

Budesonide Orodispersible Tablets Maintain Remission in a Randomized, Placebo-Controlled Trial of Patients With Eosinophilic Esophagitis.

Gastroenterology 2020 11 25;159(5):1672-1685.e5. Epub 2020 Jul 25.

Department of Health Services Research, Durham University, Durham, UK.

Background & Aims: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder. Swallowed topical-acting corticosteroids are effective in bringing active EoE into remission. However, it is not clear whether these drugs are effective for long-term maintenance of remission.

Methods: We performed a double-blind trial to compare the efficacy and safety of 2 dosages of a budesonide orodispersible tablet (BOT) vs placebo in maintaining remission of EoE. Maintenance of remission was defined as absence of clinical and histologic relapse and no premature withdrawal for any reason. Two hundred and four adults with EoE in clinical and histologic remission, from 29 European study sites, were randomly assigned to groups given BOT 0.5 mg twice daily (n = 68), BOT 1.0 mg twice daily (n = 68), or placebo twice daily (n = 68) for up to 48 weeks.

Results: At end of treatment, 73.5% of patients receiving BOT 0.5 mg twice daily and 75% receiving BOT 1.0 mg twice daily were in persistent remission compared with 4.4% of patients in the placebo group (P < .001 for both comparisons of BOT with placebo). Median time to relapse in the placebo group was 87 days. The frequency of adverse events was similar in the BOT and placebo groups. Morning serum levels of cortisol were in the normal range at baseline and did not significantly change during treatment. Four patients receiving BOT developed asymptomatic, low serum levels of cortisol. Clinically manifested candidiasis was suspected in 16.2% of patients in the BOT 0.5 mg group and in 11.8% of patients in the BOT 1.0 mg group; all infections resolved with treatment.

Conclusions: In a phase 3 trial, up to 48 weeks of treatment with BOT (0.5 mg or 1.0 mg twice daily) was superior to placebo in maintaining remission of EoE. Both dosages were equally effective and well tolerated. EudraCT number; 2014-001485-99; ClinicalTrials.gov number, NCT02434029.
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http://dx.doi.org/10.1053/j.gastro.2020.07.039DOI Listing
November 2020

Implementing cell-free DNA of pancreatic cancer patient-derived organoids for personalized oncology.

JCI Insight 2020 08 6;5(15). Epub 2020 Aug 6.

Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.

One of the major challenges in using pancreatic cancer patient-derived organoids (PDOs) in precision oncology is the time from biopsy to functional characterization. This is particularly true for endoscopic ultrasound-guided fine-needle aspiration biopsies, typically resulting in specimens with limited tumor cell yield. Here, we tested conditioned media of individual PDOs for cell-free DNA to detect driver mutations already early on during the expansion process to accelerate the genetic characterization of PDOs as well as subsequent functional testing. Importantly, genetic alterations detected in the PDO supernatant, collected as early as 72 hours after biopsy, recapitulate the mutational profile of the primary tumor, indicating suitability of this approach to subject PDOs to drug testing in a reduced time frame. In addition, we demonstrated that this workflow was practicable, even in patients for whom the amount of tumor material was not sufficient for molecular characterization by established means. Together, our findings demonstrate that generating PDOs from very limited biopsy material permits molecular profiling and drug testing. With our approach, this can be achieved in a rapid and feasible fashion with broad implications in clinical practice.
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http://dx.doi.org/10.1172/jci.insight.137809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455062PMC
August 2020

Body surface and body core temperatures and their associations to haemodynamics: The BOSTON-I-study: Validation of a thermodilution catheter (PiCCO) to measure body core temperature and comparison of body surface temperatures to thermodilutionderived Cardiac Index.

Math Biosci Eng 2019 11;17(2):1132-1146

Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, D-81675 München, Germany.

Assessment of peripheral perfusion and comparison of surface and body core temperature (BST; BCT) are diagnostic cornerstones of critical care. Infrared non-contact thermometers facilitate the accurate measurement of BST. Additionally, a corrected measurement of BST on the forehead provides an estimate of BCT (BCT_Forehead). In clinical routine BCT is measured by ear thermometers (BCT_Ear). The PiCCO-device (PiCCO: Pulse contour analysis) provides thermodilution-derived Cardiac Index (CI_TD) using an arterial catheter with a thermistor tip in the distal aorta. Therefore, the PiCCO-catheter might be used for BCT-measurement (BCT_PiCCO) in addition to CI-measurement. To the best of our knowledge, BCT_PiCCO has not been validated compared to standard techniques of BCT-measurement including measurement of urinary bladder temperature (BCT_Bladder). Therefore, we compared BCT_PiCCO to BCT_Ear and BCT_Bladder in 52 patients equipped with the PiCCO-device (Pulsion; Germany). Furthermore, this setting allowed to compare different BSTs and their differences to BCT with CI_TD. BCT_PiCCO, BCT_Ear (ThermoScan; Braun), BCT_Bladder (UROSID; ASID BONZ), BCT_Forehead and BSTs (Thermofocus; Tecnimed) were measured four times within 24h. BSTs were determined on the great toe, finger pad and forearm. Immediately afterwards TPTD was performed to obtain CI_TD. 32 (62%) male, 20 (38%) female patients; APACHE-II 23.8 ±8.3. Bland-Altman-analysis demonstrated low bias and percentage error (PE) values for the comparisons of BCT_PiCCO vs. BCT_Bladder (bias 0.05 ±0.27° Celsius; PE = 1.4%), BCT_PiCCO vs. BCT_Ear (bias 0.08 ±0.38° Celsius; PE = 2.0%) and BCT_Ear vs. BCT_Bladder (bias 0.04 ±0.42° Celsius; PE = 2.2). While BCT_PiCCO, BCT_Ear and BCT_Bladder can be considered interchangeable, Bland-Altman-analyses of BCT_Forehead vs. BCT_PiCCO (bias =-0.63 ±0.75° Celsius; PE = 3.9%) Celsisus, BCT_Ear (bias = -0.58 ±0.68° Celsius; PE = 3.6%) and BCT_Bladder (bias = -0.55 ±0.74° Celsius; PE = 3.9%) demonstrate a substantial underestimation of BCT by BCT_Forehead. BSTs and differences between BCT and BST (DCST) significantly correlated with CI_TD with r-values between 0.230 and 0.307 and p-values between 0.002 and p < 0.001. The strongest association with CI_TD was found for BST_forearm (r = 0.307; p < 0.001). In a multivariate analysis regarding CI_TD and including biometric data, BSTs and and their differences to core-temperatures (DCST), only higher temperatures on the forearm and the great toe, young age, low height and male gender were independently associated with CI_TD. The estimate of CI based on this model (CI_estimated) correlated with CI_TD (r = 0.594; p < 0.001). CI_estimated provided large ROC-areas under the curve (AUC) regarding the critical thresholds of CI_TD ≤ 2.5 L/min/m (AUC = 0.862) and CI_TD ≥ 5.0 L/min/m (AUC = 0.782). 1.) BCT_PiCCO, BCT_Ear and BCT_Bladder are interchangeable. 2.) BCT_Forehead significantly underestimates BCT by about 0.5° Celsius. 3.) All measured BSTs and DCSTs were significantly associated with CI_TD. 4.) CI_estimated is promising, in particular for the prediction of critical thresholds of CI.
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http://dx.doi.org/10.3934/mbe.2020059DOI Listing
November 2019

[Eosinophilic Esophagitis Update: New Guidelines of the European Study Group EUREOS].

Laryngorhinootologie 2019 Nov 18;98(11):764-775. Epub 2019 Nov 18.

Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg.

Eosinophilic esophagitis is now considered to be a frequent chronic esophageal disease and is one of the most common causes for dysphagia and bolus obstruction in children and adults. The increasing significance and new scientific insights in this disorder required an update of currently existing guidelines. Therefore, the European Study Group of Eosinophilic Esophagitis (EUREOS) has elaborated new guidelines for the management of eosinophilic esophagitis, based on a systematic literature search and, for the first time, using the GRADE methodology (Grading of Recommendations Assessment, Development, and Evaluation). The aim of the present article is to summarize and comment on new developments and clinical recommendations of this guideline to further increase the awareness for this relevant esophageal disease.
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http://dx.doi.org/10.1055/a-0960-6553DOI Listing
November 2019

Post-neoadjuvant cellular dissociation grading based on tumour budding and cell nest size is associated with therapy response and survival in oesophageal squamous cell carcinoma.

Br J Cancer 2019 12 6;121(12):1050-1057. Epub 2019 Nov 6.

Institute of Pathology, Technical University Munich, Munich, Germany.

Background: Cellular Dissociation Grade (CDG) composed of tumour budding and cell nest size has been shown to independently predict prognosis in pre-therapeutic biopsies and primary resections of oesophageal squamous cell carcinoma (ESCC). Here, we aimed to evaluate the prognostic impact of CDG in ESCC after neoadjuvant therapy.

Methods: We evaluated cell nest size and tumour budding activity in 122 post-neoadjuvant ESCC resections, correlated the results with tumour regression groups and patient survival and compared the results with data from primary resected cases as well as pre-therapeutic biopsies.

Results: CDG remained stable when results from pre-therapeutic biopsies and post-therapeutic resections from the same patient were compared. CDG was associated with therapy response and a strong predictor of overall, disease-specific (DSS) and disease-free (DFS) survival in univariate analysis and-besides metastasis-remained the only significant survival predictor for DSS and DFS in multivariate analysis. Multivariate DFS hazard ratios reached 3.3 for CDG-G2 and 4.9 for CDG-G3 neoplasms compared with CDG-G1 carcinomas (p = 0.016).

Conclusions: CDG is the only morphology-based grading algorithm published to date, which in concert with regression grading, is able to contribute relevant prognostic information in the post-neoadjuvant setting of ESCC.
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http://dx.doi.org/10.1038/s41416-019-0623-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964693PMC
December 2019

Clinical management of eosinophilic esophagitis - a nationwide survey among gastroenterologists in Germany.

Z Gastroenterol 2019 Jun 6;57(6):745-752. Epub 2019 Jun 6.

Internal Medicine, Jung-Stilling-Hospital, Siegen.

Background:  Eosinophilic esophagitis (EoE) is an increasingly recognized immune-mediated esophageal disease and a common cause for dysphagia and food bolus obstruction. The aim of this study was to evaluate the current clinical management of EoE among adult gastroenterologists in Germany.

Methods:  We performed a cross-sectional study of 1393 adult gastroenterologists using a questionnaire containing 22 questions to general, diagnostic, and therapeutic aspects of EoE. The self-administered online survey was conducted between November 2017 and February 2018. Data capture and analysis was performed using SurveyMonkey.

Results:  The overall responder rate was 29.6 %. More than half of the responders (54.9 %) felt to observe a significant increase of EoE patients. The EREFS score was mostly either unknown (44.3 %) or not routinely used (52.2 %). If EoE was suspected, most responders obtained multiple esophageal biopsies (n = 3 - 4: 35.7 %; n > 4: 61.6 %). The preferred primary treatment was proton pump inhibitors (PPI) in 37.2 % and topical steroids in 35.0 % of responders. PPI regimens were highly diverse, with only half of responders using high-dose PPI regimens. Allergy testing was often initiated (always 25.4 %, sometimes 48.9 %). The most common dietary therapy was 6-food elimination diet (52 %), followed by allergy test-directed diets (16 %) and 2-food elimination diet (16.5 %). The majority of responders indicated a need for long-term treatment (i. e., 23 % of responders in > 50 % their patients and 47.7 % of responders in 25 - 50 % of their patients).

Conclusions:  Among gastroenterologists in Germany, substantial variation in the adherence to published EoE guidelines appears to exist. This indicates the need for intensified education and national guidelines in order to optimize and harmonize the clinical management of EoE patients.
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http://dx.doi.org/10.1055/a-0885-1963DOI Listing
June 2019

Magnetic resonance cholangiopancreatography at 3 Tesla: Image quality comparison between 3D compressed sensing and 2D single-shot acquisitions.

Eur J Radiol 2019 Jun 15;115:53-58. Epub 2019 Apr 15.

Institute for Diagnostic and Interventional Radiology, Faculty of Medicine of the Technical University Munich, Ismaninger Straße 22, D-81675 Munich, Germany. Electronic address:

Objectives: To compare the image quality between compressed sensing (CS) 3D-magnetic resonance cholangiopancreatography (MRCP) using respiratory-triggered (RT) and breath-hold (BH) acquisitions and 2D single-shot breath-hold (SSBH) MRCP at 3 T MRI.

Methods: 53 datasets were retrospectively assessed. 3D-MRCP with CS (RT-CS10, BH-CS24) and 2D-SSBH MRCP were acquired. Overall image quality, blurring/motion artifacts and discernibility of the pancreaticobiliary tree (PBT) structures were scored on a 4-point scale by 2 radiologists. The contrast ratio between the common bile duct and its adjacent tissue was measured by region-of-interest (ROI) analysis. Signal intensity increase at the boundaries of the ducts was quantified by line profiles to objectively characterize blurring and motion artifacts.

Results: Total scan duration was 17 s for BH-CS24, 1m12 s for 2D-SSBH and 3m48 s for RT-CS10. Images acquired with CS were consistently rated superior in terms of image quality, background suppression, blurring and discernibility of PBT structures compared to 2D-SSBH images. RT-CS10 was superior to BH-CS24 for all ratings except for blurring. Objective analysis yielded the highest contrast ratio for RT-CS10 (0.91 ± 0.04) followed by BH-C24 (0.88 ± 0.05) and 2D-SSBH (0.85 ± 0.06); one-way ANOVA P < 0.0001. The line-profile slope through the CBD was significantly higher in BH-CS24 (37.91 ± 6.38% of maximum intensity/mm) compared to RT-CS10 (29.46 ± 8.17% of maximum intensity/mm) and on par with 2D-SSBH (35.8 ± 12.30% of maximum intensity/mm); one-way-ANOVA P = 0.017.

Conclusion: CS allows acquisition of volumetric image data with improved image quality compared to SSBH. CS24 yields substantial gains in acquisition speed while robust towards artifacts, enabling diagnostic image quality with a single breath-hold acquisition.
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http://dx.doi.org/10.1016/j.ejrad.2019.04.002DOI Listing
June 2019

Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial.

Gastroenterology 2019 07 26;157(1):74-86.e15. Epub 2019 Mar 26.

Swiss EoE Research Group, Olten, Switzerland.

Background & Aims: Swallowed topical-acting corticosteroids are recommended as first-line therapy for eosinophilic esophagitis (EoE). Asthma medications not optimized for esophageal delivery are sometimes effective, although given off-label. We performed a randomized, placebo-controlled trial to assess the effectiveness and tolerability of a budesonide orodispersible tablet (BOT), which allows the drug to be delivered to the esophagus in adults with active EoE.

Methods: We performed a double-blind, parallel study of 88 adults with active EoE in Europe. Patients were randomly assigned to groups that received BOT (1 mg twice daily; n = 59) or placebo (n = 29) for 6 weeks. The primary end point was complete remission, based on clinical and histologic factors, including dysphagia and odynophagia severity ≤2 on a scale of 0-10 on each of the 7 days before the end of the double-blind phase and a peak eosinophil count <5 eosinophils/high power field. Patients who did not achieve complete remission at the end of the 6-week double-blind phase were offered 6 weeks of open-label treatment with BOT (1 mg twice daily).

Results: At 6 weeks, 58% of patients given BOT were in complete remission compared with no patients given placebo (P < .0001). The secondary end point of histologic remission was achieved by 93% of patients given BOT vs no patients given placebo (P < .0001). After 12 weeks, 85% of patients had achieved remission. Six-week and 12-week BOT administration were safe and well tolerated; 5% of patients who received BOT developed symptomatic, mild candida, which was easily treated with an oral antifungal agent.

Conclusions: In a randomized trial of adults with active EoE, we found that budesonide oral tablets were significantly more effective than placebo in inducing clinical and histologic remission. Eudra-CT number 2014-001485-99; ClinicalTrials.gov ID NCT02434029.
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http://dx.doi.org/10.1053/j.gastro.2019.03.025DOI Listing
July 2019

IgG4 is Elevated in Eosinophilic Esophagitis but Not in Gastroesophageal Reflux Disease Patients.

J Clin Gastroenterol 2020 01;54(1):43-49

2nd Clinical Department for Internal Medicine.

Background: For eosinophilic esophagitis (EoE) recently an association with immunoglobulin (Ig)G4 rather than IgE has been reported. Gastroesophageal reflux disease (GERD) is the most important differential diagnosis of EoE. We compared esophageal IgG4 plasma cell infiltration and serum IgG4 levels of EoE patients (before and after budesonide therapy) with GERD patients.

Methods: Prospectively collected serum samples of 17 EoE patients before and after 8 weeks of therapy with budesonide (1 mg BID) were analyzed for total and antigen-specific IgG4 and IgE levels. Also, immunohistochemical analysis of total and IgG4-positive plasma cells was performed on esophageal biopsies of these patients. In total, 14 GERD patients without histologic proof of eosinophilic infiltration were taken as a control group.

Results: Total IgG4 serum levels in EoE patients were significantly higher than in GERD patients (121.0 vs. 71.2 mg/dL; P=0.038) and decreased under budesonide therapy (121.0 vs. 104.2 mg/dL; P=0.019). IgE levels did not differ significantly between all groups. In EoE patients also a high number of esophageal IgG4-positive plasma cells was detected and significantly reduced under therapy (29.1 vs. 0.1 IgG4-positive cells; P<0.001). In GERD patients no relevant esophageal plasma cell infiltration could be seen.

Conclusions: In EoE patients elevated systemic IgG4 serum levels compared with GERD patients can be seen and decrease under topical steroid therapy. Also, local IgG4 plasma cells expression is high in EoE, but not in GERD patients and normalize under therapy. These findings are further proof for a possible association of EoE with IgG4.
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http://dx.doi.org/10.1097/MCG.0000000000001154DOI Listing
January 2020

Angioectasias in the elderly: Interpreting the data by Pérez-Cuadrado Robles et al.

United European Gastroenterol J 2018 Jun 7;6(5):792-793. Epub 2018 Jun 7.

Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.

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http://dx.doi.org/10.1177/2050640618779674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6068785PMC
June 2018

Predictors and characteristics of angioectasias in patients with obscure gastrointestinal bleeding identified by video capsule endoscopy.

United European Gastroenterol J 2017 Dec 7;5(8):1129-1135. Epub 2017 Apr 7.

Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.

Background: In obscure gastrointestinal bleeding, angioectasias are common findings in video capsule endoscopy (VCE).

Objective: The objective of this study was to identify predictors and characteristics of small bowel angioectasias.

Methods: Video capsule examinations between 1 July 2001 and 31 July 2011 were retrospectively reviewed. Patients with obscure gastrointestinal bleeding were identified, and those with small bowel angioectasia were compared with patients without a definite bleeding source. Univariate and multivariable statistical analyses for possible predictors of small bowel angioectasia were performed.

Results: From a total of 717 video capsule examinations, 512 patients with obscure gastrointestinal bleeding were identified. Positive findings were reported in 350 patients (68.4%) and angioectasias were documented in 153 of these patients (43.7%). These angioectasias were mostly located in the proximal small intestine ( = 86, 56.6%). Patients' age >65 years (odds ratio (OR) 2.15, 95% confidence interval (CI) 1.36-3.38,  = .001) and overt bleeding type (OR 1.89, 95% CI 1.22-2.94,  = .004) were identified as significant independent predictors of small bowel angioectasia.

Conclusion: Angioectasias are the most common finding in VCE in patients with obscure gastrointestinal bleeding. They are mostly located in the proximal small bowel and are associated with higher age and an overt bleeding type.
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http://dx.doi.org/10.1177/2050640617704366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721981PMC
December 2017

[Eosinophilic Esophagitis Update: New Guidelines of the European Study Group EUREOS].

Z Gastroenterol 2018 02 9;56(2):139-150. Epub 2017 Nov 9.

Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Germany.

Eosinophilic esophagitis is now considered to be a frequent chronic esophageal disease and is one of the most common causes for dysphagia and bolus obstruction in children and adults. The increasing significance and new scientific insights in this disorder required an update of currently existing guidelines. Therefore, the European Study Group of Eosinophilic Esophagitis (EUREOS) has elaborated new guidelines for the management of eosinophilic esophagitis, based on a systematic literature search and, for the first time, using the GRADE methodology (Grading of Recommendations Assessment, Development, and Evaluation). The aim of the present article is to summarize and comment on new developments and clinical recommendations of this guideline to further increase the awareness for this relevant esophageal disease.
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http://dx.doi.org/10.1055/s-0043-121349DOI Listing
February 2018

Endoscopic ultrasound-guided tissue sampling of small subepithelial tumors of the upper gastrointestinal tract with a 22-gauge core biopsy needle.

Endosc Int Open 2017 Mar;5(3):E165-E171

II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.

 The optimal approach to small subepithelial tumors (SETs) of the upper gastrointestinal tract remains inconclusive. The aim of this study was to evaluate endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for less invasive tissue sampling of small SETs of the upper gastrointestinal tract.  In this prospective observational study patients with small ( ≤ 3 cm) SETs of the upper gastrointestinal tract were eligible and underwent EUS-FNB with a 22-gauge core biopsy needle. The main outcome measure was the diagnostic yield. The number of obtained core biopsies was also assessed.  Twenty patients were included. The mean SET size was 16 mm (range 10 - 27 mm). EUS-FNB was technically feasible in all cases and no complications were observed. The diagnostic yield was 75 %. Core biopsy specimens were obtained in only 25 % of cases.  EUS-FNB with a 22-gauge core biopsy needle of small SETs can achieve a definite diagnosis in the majority of cases. However, because core samples cannot regularly be obtained, EUS-FNB seems not to be convincingly superior to standard EUS-FNA in this setting.
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http://dx.doi.org/10.1055/s-0042-119948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5348295PMC
March 2017

Cap Assisted Upper Endoscopy for Examination of the Major Duodenal Papilla: A Randomized, Blinded, Controlled Crossover Study (CAPPA Study).

Am J Gastroenterol 2017 05 14;112(5):725-733. Epub 2017 Mar 14.

II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität Mìnchen, Munich, Germany.

Objective: Examination of major duodenal papilla (MDP) by standard forward-viewing esophagogastroduodenoscopy (S-EGD) is limited. Cap assisted esophagogastroduodenoscopy (CA-EGD) utilizes a cap fitted to the tip of the endoscope that can depress the mucosal folds and thus might improve visualization of MDP. The aim of this study was to compare CA-EGD to S-EGD for complete examination of the MDP.

Methods: Prospective, randomized, blinded, controlled crossover study. Subjects scheduled for elective EGD were randomized to undergo S-EGD (group A) or CA-EGD (group B) before undergoing a second examination by the alternate method. Images of the MDP were evaluated by three blinded multicenter-experts. Our primary outcome measure was complete examination of the papilla. Secondary outcome measures were duration and overall diagnostic yield.

Results: A total of 101 patients were randomized and completed the study. Complete examination of MDP was achieved in 98 patients using CA-EGD compared to 24 patients using S-EGD (97 vs. 24%, P<0.001). Median duration from intubation of the esophagus until localization of the MDP was shorter with CA-EGD (46. vs. 96 s., P<0.001). In group A, 11 extra lesions and 12 additional incidental findings were detected by secondary CA-EGD, whereas neither were detected by secondary S-EGD in group B (22 vs. 0% and 24 vs. 0%, P<0.001 and P<0.001).

Conclusion: CA-EGD enabled complete examination of MDP in almost all cases compared to a low success rate of S-EGD. CA-EGD detected a significant amount of lesions and incidental findings when added to S-EGD. CA-EGD is a safe and effective method for examination of MDP.
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http://dx.doi.org/10.1038/ajg.2017.47DOI Listing
May 2017

Magnetic endoscope imaging for routine colonoscopy: impact on propofol dosage and patient safety - a randomized trial.

Endoscopy 2016 Oct 21;48(10):916-22. Epub 2016 Jul 21.

II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.

Background And Study Aim: The use of magnetic endoscope imaging (MEI) has been previously shown to facilitate colonoscopy procedures. We aimed to evaluate the benefits of MEI in terms of reduction in propofol dosage in patients undergoing routine colonoscopy.

Methods: We conducted a randomized prospective trial in a university hospital in Germany. Endoscopists were randomly assigned 1:1 to use MEI during colonoscopy (MEI arm) or to conduct colonoscopy without the use of MEI (standard arm). The desired level of sedation was conscious sedation as assessed using the Observer's Assessment of Alertness and Sedation scores. After complete recovery, patient satisfaction was assessed using a numeric rating scale (NRS) ranging from 1 to 10 points. The primary outcome was total propofol dosage. Secondary outcome measures were patient satisfaction, patients' cooperation, and complication rates, as well as cecal intubation time and adenoma detection.

Results: Among 334 randomized patients, no severe adverse events were observed. Median propofol dosage was significantly lower in the MEI arm compared with the standard arm (150 mg vs. 180 mg; P = 0.04). Deep sedation was observed in 7.8 % of patients in the MEI group and 3.6 % in the standard arm (P = 0.10). Patient satisfaction scores were higher in the MEI arm compared with standard procedures (9.0 vs. 8.5; P = 0.04). No significant differences in patients' cooperation, cecal intubation time, and adenoma detection were observed between the study arms.

Conclusion: The use of MEI may be useful in reducing propofol dosage for colonoscopy and improving patient satisfaction.ClinicalTrials.gov identifier: NCT02121704.
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http://dx.doi.org/10.1055/s-0042-110933DOI Listing
October 2016

Capnographic monitoring of midazolam and propofol sedation during ERCP: a randomized controlled study (EndoBreath Study).

Endoscopy 2016 Jan 28;48(1):42-50. Epub 2015 Sep 28.

Medizinische Klinik, KRH Klinikum Agnes Karll, Laatzen, Germany.

Background And Study Aims: This was to determine whether intervention based on additional capnographic monitoring reduces the incidence of hypoxemia during midazolam and propofol sedation for endoscopic retrograde cholangiopancreatography (ERCP).

Methods: Patients (American Society of Anesthesiologists [ASA] I – IV) scheduled for ERCP under midazolam and propofol sedation were randomly assigned to a control arm with standard monitoring or an interventional arm with additional capnographic monitoring. In both arms detection of apnea prompted withholding of propofol administration, stimulation of the patient, insertion of a nasopharyngeal tube, or further measures. The primary study end point was incidence of hypoxemia (oxygen saturation [Sao 2] below 90 %); secondary end points included occurrences of severe hypoxemia (Sao 2 ≤ 85 %), bradycardia, and hypotension, and sedation quality (patient cooperation and satisfaction).

Results: 242 patients were enrolled at three German endoscopy centers. Intention-to-treat analysis revealed no significant reduction in hypoxemia incidence in the capnography arm compared with the standard arm (38.0 % vs. 44.4 %, P = 0.314). Apnea was more frequently detected in the capnography arm (64.5 % vs. 6.0 %, P < 0.001). There were no differences regarding rates of bradycardia and hypotension. Per-protocol analysis showed lower incidence of hypoxemia in the capnography arm compared with the standard arm (31.5 % vs. 44.8 %, P = 0.048). There was one death related to sedation in the standard arm. Sedation quality was similar in the two groups.

Conclusion: Intention-to-treat analysis showed hypoxemia incidence was not significantly lower in the additional capnography arm compared with standard monitoring. Additional capnographic monitoring of ventilatory activity resulted in improved detection of apnea.
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http://dx.doi.org/10.1055/s-0034-1393117DOI Listing
January 2016

Patient position and hypoxemia during propofol sedation for colonoscopy: a randomized trial.

Endoscopy 2015 Dec 30;47(12):1159-66. Epub 2015 Jun 30.

II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.

Aim: To evaluate the benefits of the left lateral position in avoiding hypoxemic events in patients undergoing colonoscopy.

Methods: We conducted a randomized, prospective, controlled trial at two study sites in Germany. Patients undergoing colonoscopy under propofol sedation were randomized to either the supine or left lateral position. The primary outcome was oxygen desaturation (SaO2<90%). Secondary outcome measures were apneic events, hypotension, patient satisfaction, propofol dosage, cecal intubation time, and adenoma detection.

Results: A total of 412 patients were randomized 1:1 to undergo colonoscopy in the supine or left lateral position. No severe adverse events were observed in either group. Intention-to-treat analysis revealed no significant difference in the frequency of desaturation in the left lateral arm compared with the supine arm (6.8% vs. 12.1%; P=0.064). Patients in the left lateral arm showed lower apnea rates (9.4% vs. 16.2%; P= .040), but had more episodes of hypotension (12.3% vs. 2.9%; P<0.001). The frequency of repositioning was higher in the left lateral group. No significant differences were observed in patient satisfaction and cooperation, propofol dosage, or adenoma detection rate. Patients who were repositioned to facilitate endoscope passage were excluded from per-protocol analysis. The incidence of hypoxemia was lower for the left lateral than for the supine group in per-protocol analysis (1.8% vs. 11.2%; P=0.003).

Conclusion: The positioning of patients in the left lateral position during propofol sedation for colonoscopy results in lower desaturation rates provided the position can be maintained throughout endoscopy. ClinicalTrials.gov NCT02001792.
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http://dx.doi.org/10.1055/s-0034-1392329DOI Listing
December 2015

A randomised, double-blind trial comparing budesonide formulations and dosages for short-term treatment of eosinophilic oesophagitis.

Gut 2016 Mar 19;65(3):390-9. Epub 2015 Mar 19.

Swiss EoE Research Network, Olten, Switzerland.

Objective: To investigate the efficacy and safety of two different budesonide formulations (effervescent tablet for orodispersible use (BET) and viscous suspension (BVS)) with different daily dosages for short-term treatment of eosinophilic oesophagitis (EoE).

Design: Adults with active EoE (n=76) randomly received 14 days' treatment with either BET 2×1 mg/day (BET1, n=19) or BET 2×2 mg/day (BET2, n=19), or BVS 2×5 mL (0.4 mg/mL)/day (BVS, n=19) or placebo (n=19) in a double-blind, double-dummy fashion, with a 2-week follow-up. Primary end point was histological remission (mean of <16 eosinophils/mm(2 )hpf). Secondary end points included endoscopy score, dysphagia score, drug safety and patient's preference for drug formulation.

Results: Histological remission occurred in 100%, 94.7% and 94.7% of budesonide (BET1, BET2, BVS, respectively) and in 0% of placebo recipients (p<0.0001). The improvement in total endoscopic intensity score was significantly higher in the three budesonide groups compared with placebo. Dysphagia improved in all groups at the end of treatment; however, improvement of dysphagia persisted only in those treated with BET1 (p=0.0196 vs placebo). There were no serious adverse events. Local fungal infection (stained fungi) occurred in two patients of each budesonide group (10.5%). The effervescent tablet was preferred by 80% of patients.

Conclusions: BET or BVS was highly effective and safe for short-term treatment of EoE. The 1 mg (twice daily) dosage was equally effective as the 2 mg twice daily dosage. The majority of patients preferred the effervescent tablet formulation.

Clinicaltrialsgov Number: NCT02280616; EudraCT number, 2009-016692-29.
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http://dx.doi.org/10.1136/gutjnl-2014-308815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4789829PMC
March 2016

New aspects in the pathomechanism and diagnosis of the laryngopharyngeal reflux-clinical impact of laryngeal proton pumps and pharyngeal pH metry in extraesophageal gastroesophageal reflux disease.

World J Gastroenterol 2015 Jan;21(3):982-7

Valentin Becker, Romina Drabner, Simone Graf, Christoph Schlag, Simon Nennstiel, Roland M Schmid, Dieter Saur, Monther Bajbouj, II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, 81675 München, Germany.

Aim: To determine the laryngeal H+K+-ATPase and pharyngeal pH in patients with laryngopharyngeal reflux (LPR)-symptoms as well as to assess the symptom scores during PPI therapy.

Methods: Endoscopy was performed to exclude neoplasia and to collect biopsies from the posterior cricoid area (immunohistochemistry and PCR analysis). Immunohistochemical staining was performed with monoclonal mouse antibodies against human H+K+-ATPase. Quantitative real-time RT-PCR for each of the H+K+-ATPase subunits was performed. The pH values were assessed in the aerosolized environment of the oropharynx (DxpH Catheter) and compared to a subsequently applied combined pH/MII measurement.

Results: Twenty patients with LPR symptoms were included. In only one patient, the laryngeal H+K+-ATPase was verified by immunohistochemical staining. In another patient, real-time RT-PCR for each H+K+-ATPase subunit was positive. Fourteen out of twenty patients had pathological results in DxpH, and 6/20 patients had pathological results in pH/MII. Four patients had pathological results in both functional tests. Nine out of twenty patients responded to PPIs.

Conclusion: The laryngeal H+K+-ATPase can only be sporadically detected in patients with LPR symptoms and is unlikely to cause the LPR symptoms. Alternative hypotheses for the pathomechanism are needed. The role of pharyngeal pH-metry remains unclear and its use can only be recommended for patients in a research study setting.
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http://dx.doi.org/10.3748/wjg.v21.i3.982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299353PMC
January 2015

Magnetic endoscope imaging in single-balloon enteroscopy.

Dig Endosc 2015 May 19;27(4):465-470. Epub 2015 Jan 19.

II. Medical Department, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.

Background And Aim: Magnetic endoscope imaging (MEI) provides continuous viewing of the position of the endoscope on a monitor without using X-ray and has already been established for colonoscopy. The aim of the present study was to evaluate a new MEI probe for enteroscopy.

Methods: In this prospective feasibility study, consecutive patients received single-balloon enteroscopy guided by the new MEI probe. Fluoroscopy was also used in all examinations. MEI images were compared to fluoroscopy images with respect to concordance of loop configuration by two independent observers after the examinations. Main outcome measurement was the rate of concordant MEI and fluoroscopy images with respect to loop configuration.

Results: In all 10 patients, single-balloon enteroscopy with MEI was carried out without any adverse events or technical difficulties. Concordance of MEI and fluoroscopy images was seen in 36/38 images (95%; 95% CI, 82-99%) by both observers. Overall agreement between the two observers was 95% (κ = 0.47, 95% CI, -0.04-1).

Conclusion: The use of MEI in single-balloon enteroscopy is safe and feasible. Detection and control of loops can be accurately achieved.
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http://dx.doi.org/10.1111/den.12415DOI Listing
May 2015

Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results.

Gastrointest Endosc 2015 Apr;81(4):889-95

Background: In mid-GI bleeding, video capsule endoscopy (VCE) shows the best diagnostic yield for ongoing overt bleeding. To date, the utility of VCE in acute severe GI bleeding has been analyzed rarely.

Objective: To evaluate the impact of VCE when performed on patients with acute severe GI bleeding immediately after an initial negative upper endoscopy result.

Design: Prospective study.

Setting: Tertiary-care center.

Patients: Patients with melena, dark-red or maroon stool, hemodynamic instability, drop of hemoglobin level ≥2 g/dL/day, and/or need of transfusion ≥2 units of packed red blood cells per day were included.

Interventions: After a negative upper endoscopy result, emergency VCE was performed by immediate endoscopic placement of the video capsule into the duodenum.

Main Outcome Measurements: Rate of patients in whom emergency VCE correctly guided further diagnostic and therapeutic procedures.

Results: Upper endoscopy showed the source of bleeding in 68 of 88 patients (77%). In the remaining 20 patients (23%), emergency VCE was performed, which was feasible in 19 of 20 patients (95%; 95% confidence interval [CI], 75%-99%). Emergency VCE correctly guided further diagnostic and therapeutic procedures in 17 of 20 patients (85%; 95% CI, 62%-97%) and showed a diagnostic yield of 75% (95% CI, 51%-91%).

Limitations: Single-center study, small sample size.

Conclusion: In patients with acute severe GI bleeding and negative upper endoscopy results, emergency VCE can be useful for the immediate detection of the bleeding site and is able to guide further therapy. (Clinical trial registration number: NCT01584869.)
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http://dx.doi.org/10.1016/j.gie.2014.09.035DOI Listing
April 2015

Small bowel pleomorphic liposarcoma: a rare cause of gastrointestinal bleeding.

Case Rep Gastrointest Med 2014 4;2014:391871. Epub 2014 Aug 4.

II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany.

In this case report we present a 60-year-old male patient with overt midgastrointestinal bleeding of a primary ileal pleomorphic liposarcoma diagnosed by video capsule endoscopy (VCE). Clinical work-up for final diagnosis and the pathological background of this uncommon tumorous entity of the small bowel will be discussed in this paper.
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http://dx.doi.org/10.1155/2014/391871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137735PMC
August 2014

Endosonography For Right-sided and Acute Upper Intestinal Misery: the EFRAIM study: A prospective, randomized, controlled, blinded study.

United European Gastroenterol J 2013 Oct;1(5):329-34

Technischen Universität München, München, Germany.

Background: Acute upper abdominal pain is a frequent symptom leading to hospital admission.

Objective: To determine whether a primary intra- and extraluminal diagnostic approach enabled by endoscopic ultrasound is as effective as a conventional diagnostic algorithm of transabdominal ultrasound followed by oesophagogastroduodenoscopy.

Methods: A total of 240 patients who presented with acute right-sided and/or upper abdominal pain were prospectively recruited. Exclusion criteria were chronic pain, malignancy, prior abdominal surgery, bleeding, peritonitis, and elevated liver enzymes or lipase as defined 3-times higher than upper reference value. All patients underwent first transabdominal ultrasound and were then randomized (1 : 1) to either endoscopy followed by endoscopic ultrasound or vice versa. Patients and respective examiners were blinded to prior findings.

Results: A total of 223 patients were included. Endoscopic ultrasound provided a higher diagnostic yield than the combination of transabdominal ultrasound and endoscopy (62.3 vs. 50.7%; p = 0.001). For mucosal/intraluminal lesions, we observed a very good agreement between both endoscopic modalities (kappa 0.89). The agreement for pancreatic and biliary causes was good between both ultrasound modalities (kappa 0.66).

Conclusions: Due to its high diagnostic yield, endoscopic ultrasound as a primary diagnostic modality appears to be a valuable option in patients with acute upper abdominal pain.
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http://dx.doi.org/10.1177/2050640613498589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040764PMC
October 2013
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