Reizdarmsyndrom – Diagnostik und Therapie

Up to 25?% of gastroenterology outpatients complain of symptoms attributable to irritable bowel syndrome (IBS). A well founded diagnosis of IBS is the key to subsequent successful treatment. To safely establish a diagnosis of IBS a panel of basic investigations to carefully exclude alternative diagnoses is warranted. Once the diagnosis of IBS is established repetition of examinations, especially repeat endoscopy should be avoided in the absence of new clinical information. Medical treatment should be tailored to individual symptoms. Non-medical forms of treatment including dietary changes, exercise and alternative forms of treatment, such as hypnotherapy can be effective supportive measures in IBS.     

Asthma bronchiale – Aktuelle Diagnostik und Therapie

Bronchial asthma is a heterogeneous disease characterized by chronic airway inflammation. Different phenotypes can be distinguished based on the underlying type of inflammatory reaction (i.e. T_H2 vs. non-T_H2 cells), which is particularly important for patients with severe therapy refractive asthma, as new therapeutic strategies are directly targeted against T_H2-associated cytokines. Besides symptom control, successful asthma therapy also requires avoidance of exacerbations and fixed airflow limitation as well as the control of pharmacological side effects; therefore, early treatment with low-dose inhaled corticosteroid therapy (ICS) is required, if necessary in combination with a long-acting beta-2 agonist (LABA), preferably as fixed ICS/LABA combination. Before intensifying ICS therapy various factors, such as the inhalation technique have to be checked. Following increased dosage, controlled approaches to reduce ICS dosage again should not be forgotten in order to minimize drug side effects.     

Das intrahepatische Gallengangskarzinom – Diagnostik und Therapie

Background

Cholangiocarcinoma (CCA) is a rare, but highly aggressive malignancy of the hepatobiliary system. Only few evidence-based treatment options are available for patients who present with advanced disease.

Objectives

Diagnostic and therapeutic strategies are reviewed and discussed.

Materials and methods

The work is based on a literature search of current diagnostic and therapeutic concepts.

Results and conclusion

Despite its increasing incidence, CCA is still considered a rare malignancy. Contrast-enhanced imaging modalities, such as computed tomography and magnetic resonance imaging, serve as sensitive diagnostic tools for the detection and staging of CCA. However, due to the frequently late clinical manifestation and insufficient surveillance strategies, most CCA patients are diagnosed with locally advanced or metastatic disease, which precludes potentially curative resection. Even in R0 resected patients, overall prognosis is poor due to rapid recurrence of the disease. Therefore, adjuvant strategies are currently under investigation and there is preliminary evidence that adjuvant treatment with capecitabin may be beneficial. Palliative systemic therapy with gemcitabine and cisplatin is still considered standard of care in the unresectable patient. However, promising first results from targeted therapeutic approaches in selected patient cohorts underscore the increasing importance of early molecular diagnostics in order to offer CCA patients tailored treatment strategies. This article summarizes current treatment regimens, with an emphasis on systemic therapeutic approaches.

     

Diagnostik und Therapie des ?sophaguskarzinoms

The prognosis for patients with advanced esophageal cancer is poor. Proper risk assessment and knowledge of tumor biology may facilitate early diagnosis of adenocarcinomas and squamous cell cancer of the esophagus. New endoscopic techniques are available (e.g., (virtual) chromoendoscopy, autofluorescence, and endomicroscopy) for the early detection of cancer. Endoscopic therapy with complete resection of mucosal cancers offers long-term survival. En bloc resection combined with the removal of locoregional lymph nodes is the surgical option of choice for locally advanced cancer. In this respect, minimally invasive surgery offers the patient numerous advantages. Multimodal therapy results in better outcome for defined cancer stages and includes surgery, chemotherapy and chemoradiation. Multimodal treatment should always be individualized and requires cooperation of all subspecialties (tumor board conference). New chemotherapeutic strategies may offer improved survival but may also include new side effects. Patients with inoperable esophageal cancer also benefit from multimodal treatment.     

Perianale Hauterkrankungen – Diagnostik und Therapie

Die Gastroenterologie - Neben Blutung oder Schmerzen sind Juckreiz, Brennen und Nässen die am häufigsten geäußerten Beschwerden in der proktologischen Sprechstunde. Ein...     

Diagnostik und Therapie chronisch-entzündlicher Darmerkrankungen

Crohn’s disease and ulcerative colitis are complex, relatively uncommon diseases with a prevalence of between 1:700 and 1:1500. Thus, the diagnosis and therapy of inflammatory bowel disease is often problematic. The main diagnostic tools, including the demarcation of bacterial infections, are clinical presentation (including specific antibodies: ASCA and p-ANCA, and inflammatory markers: fecal calprotectin and procalcitonin in the serum) and imaging of the bowel. Endoscopy, but also ultrasound of the abdomen, computed tomography and magnetic resonance imaging are the diagnostic mainstays. Therapy depends on the extent and severity of the inflammation, and also on the course of the disease. Uncomplicated flaring in Crohn’s disease should only receive remission inducing therapy, whereas all patients with ulcerative colitis should also receive remission maintenance therapy. Severe flares and/or chronic active disease in both Crohn’s disease and ulcerative colitis should be treated with immunosuppressants.     

Diagnostik und Therapie differenzierter Schilddrüsenkarzinome

Zum Thema Rund 95% der Malignome der Schilddrüse liegen in Form von epithelialen Schilddrüsenkarzinomen vor, die überwiegende Zahl hiervon als differenzierte Karzinome. Damit sind sie die h?ufigsten malignen Tumore des endokrinen Systems. Der Pathomechanismus des Schilddrüsenkarzinoms ist weiterhin ungekl?rt, obwohl Risikofaktoren und famili?re Dispositionen bekannt sind. Bei famili?ren Formen kann hier die molekulargenetische Diagnostik zielführend sein. Obwohl Schilddrüsenkarzinome h?ufig erst in sp?ten Stadien symptomatisch werden, ist die Prognose aufgrund guter therapeutischer M?glichkeiten doch relativ günstig. Der vorliegende Beitrag fasst die aktuellen Standards in Diagnostik, Therapie und Nachsorge der unterschiedlichen Formen des differenzierten Schilddrüsenkarzinoms zusammen und gibt dabei Hinweise auf m?gliche zukünftige Entwicklungen.     

Diagnostik und Therapie der chronischen Myokardischämie

In patients with chronic coronary artery disease different therapeutic strategies, such as optimal medical therapy, revascularization by percutaneous coronary intervention or coronary artery bypass grafting have been shown to improve the prognosis and symptoms and yield proven superiority over other treatment strategies in different patient populations. Thus, individual assessment of cardiac function and structure is of paramount importance to choose the optimal therapeutic strategy and subsequently improve patient prognosis. In this setting cardiac magnetic resonance imaging (CMR) has been shown to provide important diagnostic information. Myocardial ischemia can be detected by either perfusion stress CMR demonstrating perfusion deficits indicative of hemodynamically relevant coronary artery stenosis or dobutamin stress CMR for objectifying wall motion abnormalities during stress. Both techniques are superior to single photon emission computerized tomography and stress echocardiography in specific patient populations. Myocardial viability can be assessed by means of end-diastolic wall thickness or delayed enhancement imaging which allows quantification of the transmural extent of scarring. Furthermore, low-dose dobutamin stress CMR can detect a contractile reserve. Delayed enhancement imaging leads to accurate results due to its high resolution, can be performed at rest requiring no stress within a short time period and is easy to analyze. Thus this technique can be recommended as the favored technique to assess myocardial viability. In the following article the CMR techniques for ischemia and viability testing will be presented and their role in diagnosis and therapy of chronic myocardial ischemia will be discussed.     

Duktales Adenokarzinom des Pankreas – Entstehung,Diagnostik, Therapie

Die Gastroenterologie - Nach 5 Jahren leben nur noch 8–9?% der Patienten mit einem duktalen Adenokarzinom des Pankreas (?pancreatic ductal adenocarcinoma“ [PDAC])....     

Hybridbildgebung in Diagnostik und Therapie der chronischen Myokardischämie

Clinical studies have consistently shown that there is only a very weak correlation between the angiographically determined severity of coronary artery disease (CAD) and disturbance of regional coronary perfusion. On the other hand, the results of randomized trials with a fractional flow reserve (FFR)-guided coronary intervention (DEFER, FAME I, FAME II) showed that it is not the angiographically determined morphological severity of coronary artery disease but the functional severity determined by FFR that is critical for prognosis and the indications for revascularization. A non-invasive method combining the morphological image of the coronary anatomy with functional imaging of myocardial ischemia is therefore particularly desirable. An obvious solution is the combination of coronary computed tomography angiography (CCTA) with a functional procedure, such as perfusion positron emission tomography (PET), perfusion single photon emission computed tomography (SPECT) or perfusion magnetic resonance imaging (MRI). This can be performed with fusion imaging or with hybrid imaging using PET-CT or SPECT-CT. First trial results with PET CCTA and SPECT CCTA carried out as cardiac hybrid imaging on a 64 slice CT showed a major effect to be a decrease in the number of false positive results, significantly increasing the specificity of CCTA and SPECT. Although the results are promising, due to the previously high costs, low availability and the additional radiation exposure, current data is not yet sufficient to give clear recommendations for the use of hybrid imaging in patients with a low to intermediate risk of CAD. Ongoing prospective studies such as the SPARC or EVINCI trials will bring further clarification here.     

Diagnostik und Therapie gastrointestinaler Funktionsstörungen bei Diabetes mellitus

Gastrointestinal functional disturbances frequently cause abdominal symptoms in patients with diabetes mellitus and have been shown to impair the quality of life. Autonomic neuropathy is an important pathomechanism but other disturbances affecting the enteric nervous system, interstitial cells of Cajal (ICC), smooth muscle cells, release of insulin and other regulatory peptide hormones and glucose homeostasis also contribute to the pathogenesis. Diagnostic procedures should start with exclusion of infectious and structural diseases by laboratory investigations, endoscopy, abdominal sonography and/or radiological methods. If the diagnosis remains unclear individual parameters decide whether a therapeutic trial can be started or whether functional diagnostic procedures are needed for further clarification. Optimization of blood glucose control is generally of importance but frequently difficult to achieve due to interactions between gastrointestinal dysfunction and blood glucose control. Apart from this, symptom-oriented therapy is usually performed as established for patients without diabetes. Moreover, diabetes-associated functional disturbances, particularly those affecting the proximal gastrointestinal tract, may cause few symptoms but may still impair blood glucose and therefore need therapy. In this article the diabetes-associated diseases dysphagia, reflux disease, gastropathy, exocrine pancreatic insufficiency, gallbladder dysfunction, diarrhea, constipation and stool incontinence are discussed with respect to the diagnostic procedures and therapy     

Neue Möglichkeiten der Diagnostik und Therapie der Perikarditis

Pericarditis is an inflammatory disorder of the pericardium with or without an associated pericardial effusion. The diagnosis is based on the clinical manifestations and typical ECG changes. Echocardiography is essential to reveal the size of the pericardial effusion and to determine its hemodynamic significance. The precise etiology of pericarditis may be established by pericardiocentesis, pericardioscopy and targeted biopsy and consecutive pericardial fluid and biopsy analysis by molecular biology, cytology, microbiology and immunological techniques. Non steroidal anti-inflammatory drugs and/or colchicine are the mainstay of anti-inflammatory treatment of pericarditis. Systemic corticoid treatment should be restricted to patients with associated autoimmune disorder, relapsing pericarditis and as a complementary therapy in tuberculous pericarditis. In autoreactive pericarditis intrapericardial instillation of triamcinolone is effective with few side effects. In malignant pericarditis the intrapericardial administration of cisplatin prevents early recurrences.     

Kulturnegative Endokarditis: Ätiologie, Diagnostik, Management und Therapie

BACKGROUND: Culture-negative endocarditis is a diagnostic challenge with variable clinical presentation and protean manifestations. ETIOLOGY AND DIAGNOSIS: The two main causes why endocarditis may be culture-negative are 1. antibiotic treatment prior to obtaining blood cultures, and 2. the presence of fastidious microorganisms with limited or no capacity to grow in routine blood cultures (Table 1). If initial blood cultures remain negative for 48-72 hours, these cultures should be incubated for at least an additional 2-4 weeks. Moreover, subcultures should be plated onto chocolate agar and incubated in an atmosphere of increased CO2 environment to facilitate recovery of fastidious bacteria. Additional techniques for identification of a causative organism include serologic tests and DNA/RNA-based molecular techniques. If the patient is clinically stable, the clinician can wait until culture results from initial samples are known before deciding upon either administering an empiric antibiotic therapy or obtaining further blood cultures. Certain predisposing patient characteristics or epidemiologic exposures may be associated with particular causative microorganisms in culture-negative endocarditis. In the absence of positive blood cultures echocardiography is a crucial tool in the diagnosis and management of culture-negative endocarditis which provides the basis for the visualization of endocarditis-associated cardiac lesions. In this context, transesophageal echocardiography is associated with a significantly higher sensitivity in the detection of vegetations and perivalvular complications and is, therefore, considered the diagnostic imaging method of choice in the diagnosis of culture-negative endocarditis. The Duke criteria have been shown to have a high accuracy in the diagnosis of culture-negative endocarditis. In this context global clinical judgment demonstrated a comparable sensitivity but a lower specificity. Main differential diagnoses include diseases which can mimic the clinical endocarditis syndrome as well as the echocardiographic pattern of culture-negative endocarditis, especially 1. nonbacterial thrombotic endocarditis and 2. valvular sclerosis in the presence of systemic infection (Table 2). TREATMENT: The selection of a particular antibiotic regimen in a suspected case of culture-negative endocarditis depends on demographics (e.g., age or geographic area), epidemiologic history (e.g., animal exposures, drug-use history, alcohol abuse, homelessness) and clinical characteristics which may be suggestive of an etiologic organism.     

Osteonekrosen bei Morbus Adamantiades-Behçet: Diagnostik,Therapie und Verlauf

AIM: The aim of this study is to review the data of skeletal manifestations of Beh?et's disease (BD, Morbus Adamantiades- Beh?et, silk road disease), which is clinically diagnosed by dermatological, neurological and ophthalmological symptoms. This paper demonstrates the diagnostic and therapeutic difficulties in the management of osteonecrosis and recurrent arthritis associated with BD. Arthrogenic symptoms are a well-recognized feature of the syndrome but low in incidence. METHOD: A literature review served as the database to show the characteristics of osseous and articular manifestations in Beh?et's disease. Furthermore, we present a 25-year clinical follow up of a patient with BD and multiple osteonecrosis. RESULTS/CONCLUSIONS: Chronic or intermittent joint pain should lead the physician to include BD into the differential diagnosis especially if there are findings of cutaneous ulcerations, ophthalmological inflammations or neurological symptoms. For detection of osteonecrosis at an early stage, which would allow for successful treatment, MRI scans of at least the symptomatic joints are recommended.