Second‐look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: A meta‐analysis

Background and Aims: In the management of peptic ulcer bleeding, the benefits of second‐look endoscopic treatment with thermal coagulation or injections in controlling recurrent bleeding is unsure. This study set out to compare efficacy of routine second‐look endoscopy with treatment using either thermal coagulation or injections versus single endoscopy by pooling data from published work. Methods: Full publications in the English‐language published work as well as abstracts in major international conferences were searched over the past 10 years, and six trials fulfilling the search criteria were found. Outcome measurements included: (i) recurrent bleeding; (ii) requirement of surgical intervention; and (iii) mortality. We examined heterogeneity of trials and pooled the effects by meta‐analysis. The quality of studies was graded according to the prospective randomization, methods of patient allocation, the list of exclusion criteria, outcome definitions and the predefined salvage procedures for uncontrolled bleeding. Results: Among 998 patients recruited in these five randomized trials, 119 received routine second‐look endoscopy with thermal coagulation, and 374 received second‐look with endoscopic injection and 505 had single endoscopic therapy. Less recurrent bleeding was reported after thermal coagulation (4.2%) than single endoscopy (15.7%) (relative risk [RR] = 0.29; 95% confidence interval [CI] = 0.11–0.73), but no reduction was reported for the requirement of surgical intervention and all‐cause mortality. Injection therapy did not reduce re‐bleeding (17.6%) when compared to single endoscopy (20.8%; RR = 0.85; 95% CI = 0.63–1.14), requirement for surgery and mortality. Conclusion: Routine second‐look endoscopy with thermal coagulation, but not injection therapy, reduced recurrent peptic ulcer bleeding. There is no proven benefit in reducing surgical intervention and overall mortality.     

Acute kidney failure and nutrition]

Acute renal failure (ARF) is characterized by a persistently high mortality rate, mainly in prerenal, postaggressive forms. Nutritional perturbations are related to the metabolic response to stress, ie mainly an elevation of the basal caloric expenditure and a marked proteic hypercatabolism, and to specific consequences of the loss of renal function. Identification of characteristic metabolic patterns and of their mediators, leading to a nutritional support adjusted to the elevated demand rather than to the impairment of renal excretion faculties, may improve the prognosis. Benefits of such a nutritional support may be restricted to hypercatabolic forms of ARF in the intensive care unit, provided extrarenal failures are reversible.     

CT morphometry for calcaneal fractures and comparison of the Zwipp and Sanders classifications

AIM: The aim of the study is to correlate the CT-morphological changes of fractured calcaneus and the classifications of Zwipp and Sanders with the clinical outcome. METHOD: In a retrospective clinical study, the preoperative CT scans of 75 calcaneal fractures were analysed. The morphometry of the fractures was determined by measuring height, length diameter and calcaneo-cuboidal angle in comparison to the intact contralateral side. At a mean of 38 months after trauma 44 patients were clinically followed-up. The data of CT image morphometry were correlated with the severity of fracture classified by Zwipp or Sanders as well as with the functional outcome. RESULTS: There was a good correlation between the fracture classifications and the morphometric data. Both fracture classifying systems have a predictive impact for functional outcome. The more exacting and accurate Zwipp classification considers the most important cofactors like involvement of the calcaneo-cuboidal joint, soft tissue damage, additional fractures etc. The Sanders classification is easier to use during clinical routine. CONCLUSION: The Zwipp classification includes more relevant cofactors (fracture of the calcaneo-cuboidal-joint, soft tissue swelling, etc.) and presents a higher correlation to the choice of therapy. Both classification systems present a prognostic impact concerning the clinical outcome.     

Coronary artery aneurysm and type-A aortic dissection demonstrated by retrospectively ECG-gated multislice spiral CT

The case of a 40-year-old male patient with a coronary aneurysm of the proximal left descending artery (LAD) combined with circumferential type-A dissection of the ascending aorta is reported. Computed tomography angiography of the coronary arteries was performed using multislice spiral computed tomography (MSCT) with retrospective ECG gating. Anatomical relations of the LAD aneurysm as well as the origin of the left coronary artery from the false lumen of the dissection were well depicted for planning of the surgical intervention using this new noninvasive imaging modality.     

Hepatic derangement following N‐Acetylcysteine enemas in an infant with cystic fibrosis

We discuss an infant with MI secondary to cystic fibrosis, who was managed surgically by a double barrel ileostomy for mid – small bowel atresia and developed severe faecal impaction in the post – operative period. The faecal impaction was treated successfully with oral NAC and 0.2% NAC contrast enemas. The patient's liver function tests revealed a dramatic increase in transaminases and bilirubin contemporaneous with the administration of the enemas. The levels showed a spontaneous improvement after discontinuation. This is only the second reported case of hepatotoxicity secondary to NAC enemas in the literature. While our experience offers modest support for the use of NAC, its efficacy is not yet proven and paediatric surgeons using NAC in the enema form need to closely monitor liver function contemporaneous with this agent's administration and adjust their treatment accordingly.     

Urinary albumin excretion rate and puberty in non-diabetic children and adolescents

Slightly elevated urinary albumin excretion rate (microalbuminuria) is a marker of early diabetic nephropathy, but it is unclear if the established definition of microalbuminuria (20–200 μg/min) is correct for children and adolescents. We investigated the albumin excretion rate, albumin/creatinine ratio and urinary albumin concentration in 150 healthy schoolchildren and adolescents to (a) obtain a reference value for albumin excretion rate, (b) relate albumin excretion to pubertal stages and (c) evaluate albumin/creatinine ratio and morning albumin concentration as screening methods for elevatcd albumin excretion rate. Albumin concentration was measured by immunoturbidimetry in timed overnight urine samples. The albumin excretion showed a skewed distribution (geometric mean 3.2 μg/min, 95 percentile 15.1 μg/min). In girls, a peak in the albumin excretion rate was found at the pubertal stage 4 (Tanner) and in boys at stage 5. Albumin/creatinine ratio of 2.5 mg/mmol as a scrccning level for elevatcd albumin cxcrction (15 μg/min) showed a high positivc (0.88) and negative (0.99) predictive value.     

Fortbildung Coloproctology Obstipation—Wie helfe ich dem Patienten?

Eine 73-jährige Patientin stellt sich wiederholt mit kolikartigen abdominellen Schmerzen in der Praxis vor. Die Lokalisation der Schmerzen sei sehr wechselnd. Zusätzlich berichtet die Patientin über eine erhebliche Blähungsneigung und zeitweise Umfangszunahme des Leibes. Die Beschwerden treten ausschließlich tagsüber auf, der Nachtschlaf werde durch diese Beschwerden nicht beeinflusst. Das Körpergewicht sei in den letzten Monaten konstant gewesen. Auf genaues Nachfragen gibt die Patientin weiterhin an, dass sie etwa zwei bis drei Stuhlentleerungen pro Woche habe. Der Stuhl sei überwiegend sehr hart, und die Darmentleerung bereite immer große Schwierigkeiten. Manchmal habe sie das Gefühl, dass der Darm nach dem Stuhlgang nicht vollständig entleert sei. Außer einem ACE-Hemmer zur Therapie eines seit langer Zeit bekannten arteriellen Hypertonus besteht keine Dauermedikation.In der zu Beginn geschilderten Kasuistik wird das klassische Bild einer chronischen Obstipation beschrieben. Abgegrenzt werden muss das Krankheitsbild von einer Defäkationsstörung, die bei einer Frau in diesem Alter als Folge eines inneren Rektumprolapses vorliegen könnte. Funktionsproktoskopie und Defäkographie sind wesentliche diagnostische Maßnahmen, die zu einer Klärung führen können. Bei der weiteren Vorgehensweise muss nun geklärt werden, ob Alarmsymptome bestehen, die eine weitere diagnostische Abklärung notwendig machen. Ist dies nicht der Fall, kann auf eine aufwendige Diagnostik verzichtet werden. Bevor therapeutische Maßnahmen eingeleitet werden, muss mittels einer detaillierten Anamnese nach möglichen Ursachen gesucht werden. Es ist insbesondere wichtig, Obstipationen als Nebenwirkung einer medikamentösen Therapie aufzudecken, da in diesen Fällen vor einer medikamentösen Therapie der Obstipation geklärt werden sollte, ob die obstipierenden Medikamente reduziert oder abgesetzt werden können. Im nächsten Schritt sollten ein Diabetes mellitus und eine Hypothyreose ausgeschlossen werden. Finden sich keine Hinweise für eine chronische Obstipation als Folge einer medikamentösen Therapie oder metabolischer Störungen, kann eine radiologische Bestimmung der Kolontransitzeit die Diagnose eines verlangsamten Kolontransits bestätigen. Zur Therapie der chronischen Obstipation stehen mehrere Medikamentengruppen zur Verfügung. Bevorzugt sollten gegenwärtig insbesondere bei älteren Menschen synthetische Osmotika eingesetzt werden. Unabhängig von Alarmsymptomen ist der Patientin jedoch eine Dickdarmkrebsprävention entsprechend den aktuellen Richtlinien zu empfehlen, falls diese bislang nicht konsequent durchgeführt worden ist.