Advanced imaging and visualization in gastrointestinal disorders

Advanced medical imaging and visualization has a strong impact on research and clinical decision making in gastroenterology. The aim of this paper is to show how imaging and visualization can disclose structural and functional abnormalities of the gastrointestinal (GI) tract. Imaging methods such as ultrasonography, magnetic resonance imaging (MRI), endoscopy, endosonography, and elastography will be outlined and visualization with Virtual Reality and haptic methods. Ultrasonography is a versatile method that can be used to evaluate antral contractility, gastric emptying, transpyloric flow, gastric configuration, intragastric distribution of meals, gastric accommodation and strain measurement of the gastric wall. Advanced methods for endoscopic ultrasound, three-dimensional (3D) ultrasound, and tissue Doppler (Strain Rate Imaging) provide detailed information of the GI tract. Food hypersensitivity reactions including gastrointestinal reactions due to food allergy can be visualized by ultrasonography and MRI. Development of multi-parametric and multi-modal imaging may increase diagnostic benefits and facilitate fusion of diagnostic and therapeutic imaging in the future.     

Breathing exercises with vagal biofeedback may benefit patients with functional dyspepsia

OBJECTIVE: Many patients with functional dyspepsia (FD) have postprandial symptoms, impaired gastric accommodation and low vagal tone. The aim of this study was to improve vagal tone, and thereby also drinking capacity, intragastric volume and quality of life, using breathing exercises with vagal biofeedback. MATERIAL AND METHODS: Forty FD patients were randomized to either a biofeedback group or a control group. The patients received similar information and care. Patients in the biofeedback group were trained in breathing exercises, 6 breaths/min, 5 min each day for 4 weeks, using specially designed software for vagal biofeedback. Effect variables included maximal drinking capacity using a drink test (Toro clear meat soup 100 ml/min), intragastric volume at maximal drinking capacity, respiratory sinus arrhythmia (RSA), skin conductance (SC) and dyspepsia-related quality of life scores. RESULTS: Drinking capacity and quality of life improved significantly more in the biofeedback group than in the control group (p=0.02 and p=0.01) without any significant change in baseline autonomic activity (RSA and SC) or intragastric volume. After the treatment period, RSA during breathing exercises was significantly correlated to drinking capacity (r=0.6, p=0.008). CONCLUSIONS: Breathing exercises with vagal biofeedback increased drinking capacity and improved quality of life in FD patients, but did not improve baseline vagal tone.     

Stiff person syndrome associated with lower motor neuron disease and infiltration of cytotoxic T cells in the spinal cord

We present a 67-year-old non-diabetic male who presented with muscle cramps, paresis, atrophy and fasciculations in the left leg, followed by rapidly progressive muscle stiffness and superimposed spasms which subsequently also affected the right leg and the trunk. GAD65 autoantibodies were elevated in serum and CSF, compatible with systemic and intrathecal synthesis of oligoclonal and high-avidity autoantibodies, and GAD65 specific T cells were clonally expanded in the CSF. The patient did not respond to GABAergic and immunomodulatory treatment or plasma exchange, and died from respiratory failure after 18 months. Autopsy revealed unilateral axonal swelling, chromatolysis and vacuolisation of anterior horn cells of the lower spinal cord, accompanied by microglia proliferation and discrete infiltration of CD8+ cytotoxic T cells. No CD4+ T helper cells, B cells or complement deposition were detected. To our knowledge, this is the first report of stiff person syndrome with lower motor signs restricted to a lower limb, and also the first attempt to characterize the infiltrating T cells. The finding of CD8+ cytotoxic T cells in the absence of B cells in the inflamed area of the spinal cord suggests that the intrathecal synthesis of GAD65 autoantibodies takes place in areas of the CNS not strictly related to the clinically relevant lesions.     

Sonography of the small intestine

In the last two decades, there has been substantial development in the diagnostic possibilities for examining the small intestine. Compared with computerized tomography, magnetic resonance imaging, capsule endoscopy and double-balloon endoscopy, ultrasonography has the advantage of being cheap, portable, flexible and user- and patient-friendly, while at the same time providing the clinician with image data of high temporal and spatial resolution. The method has limitations with penetration in obesity and with intestinal air impairing image quality. The flexibility ultrasonography offers the examiner also implies that a systematic approach during scanning is needed. This paper reviews the basic scanning techniques and new modalities such as contrast-enhanced ultrasound, elastography, strain rate imaging, hydrosonography, allergosonography, endoscopic sonography and nutritional imaging, and the literature on disease-specific findings in the small intestine. Some of these methods have shown clinical benefit, while others are under research and development to establish their role in the diagnostic repertoire. However, along with improved overall image quality of new ultrasound scanners, these methods have enabled more anatomical and physiological changes in the small intestine to be observed. Accordingly, ultrasound of the small intestine is an attractive clinical tool to study patients with a range of diseases.     

Point-of-care ultrasound (POCUS) in Norwegian general practice

Objective: To assess the use of point-of-care ultrasound (POCUS) in Norwegian general practice.Design: Retrospective register study based on general practitioners’ (GPs’) reimbursement claims.Setting: Norwegian general practice excluding out-of-hours clinics in 2009, 2012 and 2016.Subjects: GPs who scanned patients for a given set of symptoms and medical conditions.Main outcome measures: Number and characteristics of GPs performing POCUS. Number and type of scans carried out.Results: The number of scanning GPs increased from 479 in 2009 to 2078 in 2016. The number of registered scans increased from 8962 to 55921. In 2016, approximately 30% of Norwegian GPs sent at least one reimbursement claim for POCUS. Seven out of 10 GPs did not scan every month. The gender distribution of scanning GPs was equal to that of the total GP population. Male GPs scanned four times more frequent than female GPs. Specialist in family medicine scanned twice as much as non-specialist. The use of POCUS among GPs in different counties varied from 31.6 to 198.5 per 10,000 citizens.Conclusions: The number of Norwegian GPs using POCUS and the number of scans have increased substantially from 2009 to 2016. The use of the various scans, based on the use of reimbursement claims, have evolved differently. The reasons for this are not known. The low number of scans carried out by most GPs raises a concern when it comes to the quality of the performed scans.

KEY POINTS

• 30% of Norwegian general practitioners (GPs) used point-of-care ultrasound (POCUS) in 2016.
• The use of POCUS increased six-fold from 2009 to 2016.
• Three out of four scanning GPs performed less than 10 scans annually.
• Male GPs performed 80% of the claimed scans.

     

Adrenal hemorrhage versus testicular torsion — a diagnostic dilemma in the neonate

Three boys aged 2–3 days were admitted to the Pediatric Surgical Clinic on suspicion of testicular torsion. One of the boys had a scrotal mass that on surgical exploration was shown to be a hematoma within the processus vaginalis beside a normal testis. An immediate laparotomy revealed an adrenal hemorrhage with rupture into the peritoneal cavity. Two further patients in whom a bluish discoloration of one hemiscrotum and groin had appeared postnatally were examined by ultrasound, which revealed a right-sided suprarenal mass. It is concluded that a scrotal mass or hematoma in the neonate may be the only symptom of an adrenal hemorrhage. When a scrotal mass is found an intra-abdominal hemorrhage into an inguinal hernia should be considered and if possible ultrasonographically examined before surgical exploration is performed on the suspicion of testicular torsion or tumor. Furthermore, a scrotal or inguinal hematoma should lead to an ultrasound examination of the retroperitoneal organs, especially of the adrenal glands. Offprint requests to: B. Karpe     

Kettil Bruun Society for Social and Epidemiological Research on Alcohol

The Kettil Bruun Society for Social and Epidemiological Research on Alcohol (KBS) was established in 1987 and is an independent organization open to all scientists working on problems related to social and epidemiological research on alcohol. The aim of the Society is to promote social and epidemiological research which fosters a comparative understanding of the social aspects of alcohol use and alcohol problems. In line with this the Society also aims at promoting a spirit of international collaboration. The Kettil Bruun Society is based on individual membership and, by 2003, has 197 fully paid-up members, representing 34 different countries over five continents. The main activities include an annual meeting as well as thematic meetings. In these meetings, discussions are emphasized by having precirculated papers and assigned discussants. The KBS also serves as a basis for organizing international collaborative projects. Project meetings or work-shops are often organized around the annual meetings, and the projects tend to run over several years. The Society's primary influence is through the mutual influence of its members on each others' thinking, the work of the projects that KBS sponsors and the influence its members have collectively on the development of the field.     

Co-occurrence of Epstein-Barr virus infection and ascites in sarcoidosis

We present a young woman with a rare association of Epstein-Barr virus (EBV) infection, sarcoidosis and massive ascites. The temporal relationship between the EBV infection and ascites strongly suggests a pathophysiological relationship, and other causes of ascites were not identified. The prognosis of ascites is excellent in acute EBV infection.     

Uroflowmetry with simultaneous electromyography versus voiding video cystourethrography

OBJECTIVES: Urethral dysfunction may lead to a deterioration of kidney function and be life-threatening. A thorough diagnosis of the pathophysiology is consequently vital to ensure the correct treatment is given. MATERIAL AND METHODS: In this study, 34 adult patients suspected of a urethral etiology giving rise to urinary retention, urgency or chronic lower urinary tract infections were investigated by uroflowmetry with simultaneous electromyography and voiding video cystourethrography. CONCLUSIONS: Both methods proved to be essential for an accurate assessment of the pathological state.