Novel score for prediction of malignant bile duct obstruction based on biochemical and clinical markers

BACKGROUND

Early differentiation of malignant from benign bile duct obstruction is of utmost importance.

AIM

To identify biochemical and clinical predictors for malignancy in patients with bile duct obstruction, and establish a predictive model by combining pre-treatment patient characteristics. A web-based application was developed for easy assessment of malignant bile duct probability (www.pmal-score.org).

METHODS

One thousand hundred and thirty-five patients [median age 66 (52-75) years, 53% male] with bile duct obstruction of various aetiologies were retrospectively evaluated at our tertiary referral centre. Multivariate logistic regression analysis identified factors as independently significant for malignant bile duct obstruction. A predictive risk score was established using ROC analysis and applied to an external validation cohort of 101 patients.

RESULTS

Three hundred and ninety-four patients had malignant bile duct obstruction proven by surgery, while in 741 patients benign obstruction was observed. Multivariate analysis identified various clinical factors to be predictive for malignancy. On the basis of eight predictors, a risk score for malignancy was developed [X = 0.025 * [age] + 1.239 * [1 if weight loss, otherwise 0] - 0.235 * [1 if pain, otherwise 0] + 0.649 * [1 if diabetes, otherwise 0] + 0.896 * [1 if jaundice, otherwise 0] + 0.109 * [bilirubin] + 0.0007 * [γ-GT] + 0.0003 * [AP] - 4.374]: A significant correlation between the predicted malignancy and the actual malignancy was found by ROC (AUC: 0.862; 95% CI 0.838-0.886, P < 0.0001).

CONCLUSIONS

This predictive risk score estimates the risk of malignancy in patients with bile duct obstruction, and it seems to be very accurate. A better prediction enables both earlier diagnosis of malignant obstructive disease and improved management of patients with bile duct obstruction, which may result in reduced morbidity and mortality.

Contrast-enhanced ultrasound (CEUS) in hepatic lymphoma: retrospective evaluation in 38 cases

PURPOSE

Description of contrast-enhanced ultrasound (CEUS) patterns of hepatic lymphoma.

MATERIALS AND METHODS

Over a period of 6 years and 1 month from January 2006 to January 2012, n = 38 patients with histological or clinically apparent hepatic lymphoma were studied by means of CEUS prior to B-mode imaging.

RESULTS

Using B-mode imaging, lesions were hypoechoic in n = 37 (97.4 %) cases, while a focal lymphoma lesion was echo-rich in 1 case (2.6 %). For comparison, with CEUS, a hyperenhanced signal during the arterial phase was observed in n = 9 (23.7 %), an isoenhanced signal in n = 17 (44.7 %) and a hypoenhanced signal in n = 12 (31.6 %) cases. During the portal phase n = 2 (5.3 %) lesions were isoenhanced and n = 36 (94.7 %) were hypoenhanced followed by a hypoenhancement in n = 38 (100 %) cases in the late phase.

CONCLUSION

Lymphomas of the liver can cause different contrast accumulation in the arterial phase of CEUS. Furthermore, a clear differentiation from other malignant liver lesions such as metastases is crucial as different contrast accumulation in the arterial phase of CEUS is observed. In the late phase, hepatic lymphomas lead to a hypoenhancement in CEUS, also known as a "wash-out" phenomenon. In conclusion, CEUS is helpful to differentiate hepatic lesions by means of evaluating the malignancy or benignancy. In this regard, the application of CEUS can help to find the right diagnosis. A final discrimination between malignant liver lesions, such as liver lymphomas, metastasis or HCC, remains impossible.

Prospective evaluation of duodenogastroesophageal reflux in gastroesophageal reflux disease patients refractory to proton pump inhibitor therapy

BACKGROUND

Duodenogastroesophageal reflux (DGER) is considered an independent risk factor for complicated reflux disease (gastroesophageal reflux disease; GERD). However, the role of DGER in GERD patients refractory to proton pump inhibitors (PPI) remains poorly understood.

METHODS

85 patients with clinical reflux symptoms and a history of ineffective response to PPIs were enrolled in the study. Patients with elevated reflux measurement (pH and/or Bilitec measurement; n = 47) received pantoprazole 80 mg for 8 weeks. Clinical outcome was defined as response (≤2 symptoms/week) or nonresponse (≥3 symptoms/week).

RESULTS

Of the 47 patients with elevated reflux measurement, 30 were classified as responders and 17 as nonresponders. Treatment with pantoprazole resulted in a significant reduction of acidic reflux in both PPI responders and PPI nonresponders. In contrast, DGER was only significantly reduced in the PPI responder group (22.8 ± 22.8 vs. 6.6 ± 10.8%; p < 0.05) but not in the PPI nonresponder group (24.5 ± 18.6 vs. 22.2 ± 12.7%; p > 0.05).

CONCLUSIONS

The presented study firstly describes that nonresponsiveness to PPI is associated with a limited effect of PPIs on reducing DGER. Thus, persistent DGER may play a key role in mediating reflux symptoms refractory to high-dose PPIs.

Combined lung-sound and reflux-monitoring: a pilot study of a novel approach to detect nocturnal respiratory symptoms in gastro-oesophageal reflux disease

BACKGROUND

Increased prevalence of respiratory symptoms has been commonly reported in patients with gastro-oesophageal reflux disease (GERD).

AIM

To introduce a novel Lung-Sound-Monitoring device that allows simultaneous measurement of both nocturnal respiratory symptoms and episodes of acidic and biliary refluxes.

METHODS

Nocturnal respiratory symptoms (coughing and wheezing) were continuously recorded in 20 healthy subjects and 30 reflux patients with respiratory symptoms in parallel to combined pH-monitoring and Bilitec measurement.

RESULTS

Analysis could be completed in 20 healthy subjects and in 25 patients with reflux. A clear temporal correlation to reflux phases was detected in 49% of coughing and 41% of wheezing events, respectively. Moreover, 89% of the coughing and 100% of the wheezing events succeeded reflux episodes. Finally, the technique was capable of assessing a statistically significant difference between patients and controls regarding the occurrence of these symptoms.

CONCLUSIONS

Our pilot study establishes the Lung-Sound-Monitoring system as a unique tool to measure objectively the temporal correlation between gastroesophageal reflux and the appearance of respiratory symptoms. It represents a useful technique to identify patients with respiratory symptoms due to reflux, and therefore allows one to determine and quantify the impact of therapeutic interventions such as antireflux therapy on respiratory symptoms.

Contrast-enhanced ultrasound pattern of splenic metastases - a retrospective study in 32 patients

PURPOSE

To characterize the pattern of contrast-enhanced ultrasonography (CEUS) in splenic metastases compared to standard B-mode ultrasonography.

MATERIALS AND METHODS

Between January 2004 and March 2009, about 50,000 abdominal ultrasound examinations were performed, and n = 279 (< 0.6 %) of focal splenic lesions were detected of which n = 32 (11.5 %) were highly suggestive for splenic metastases of various solid tumors. The number of lesions, size, echogenicity, rim appearance, presence of halo sign and necrosis were recorded via B-mode sonography. Contrast enhancement was determined in the arterial phase (5 - 30 sec) and parenchymal phase (3 - 5 min). B-mode sonography and CEUS were compared in terms of the visibility of splenic metastases. All data was evaluated retrospectively.

RESULTS

On B-mode sonography lesions were solitary n = 18 (56 %), multiple n = 14 (44 %), < 2 cm n = 11 (34 %), > or = 2 cm n = 21 (66 %), hypoechoic n = 14 (44 %), isoechoic n = 12 (38 %) and hyperechoic n = 6 (19 %), with regular rim appearance n = 27 (84 %), and with irregular rim appearance n = 5 (16 %). During the arterial phase CEUS lesions were hypoechoic n = 21 (66 %), isoechoic n = 2 (6 %), hyperechoic n = 1 (3 %) and complex n = 8 (25 %). During the parenchymal phase lesions were hypoechoic n = 24 (75 %) and complex n = 8 (25 %). CEUS provided improved visualization of splenic metastases in n = 12 (38 %) cases.

CONCLUSION

CEUS of splenic metastases is characterized by reduced contrast enhancement in both the arterial and the parenchymal phase in most cases. Moreover, CEUS improved the visualization of splenic metastases in about 40 % of cases in comparison to standard B-mode sonography.

[Nocturnal long-term monitoring of lung sounds in patients with gastro-oesophageal reflux disease]

Gastro-oesophageal reflux disease (GERD) is one of the most common clinical conditions in the developed countries. Particular interest in pulmonary manifestations of this disease has arisen over the last few years. Although the high coincidence between reflux and chronic cough is unquestioned, the proof of a causal correlation is still lacking. In this paper we present the Marburger Lung-Sound-Monitoring as a new method for the detection of nocturnal respiratory symptoms such as cough, wheezing and throat clearing and their temporal correlation with reflux. This method will in future allow us to precisely record and to evaluate the extent and duration of reflux events and their correlation with respiratory symptoms.

Increased Duodeno-Gastro-Esophageal Reflux (DGER) in symptomatic GERD patients with a history of cholecystectomy

BACKGROUND

Duodenal-Gastro-Esophageal Reflux (DGER) represents an independent risk factor for the development of complicated Gastro-esophageal-reflux-disease (GERD) and Barrett's esophagus. Clinical and epidemiological data suggest a potential association between cholecystectomy (CCE) and augmented bile reflux.

METHODS

132 patients (67 women, 65 men, median age 55) with typical symptoms of GERD were enrolled in the study and divided in cholecystectomized (CCE-group: n = 107) and non- cholecystectomized (nCCE-group: n = 25) patients. Standardized clinical work-up of patients included combined esophageal 24 h pH-measurement and Bilitec 2000 esophageal manometry and upper endoscopy.

RESULTS

In the statistical analysis no differences between the cholecystectomized group (CCE-group, n = 25) and the patients without cholecystectomy (nCCE-group, n = 107) could be observed in quantity or quality of reflux symptoms. Furthermore, neither acid reflux nor severity of inflammation and frequency of Barrett's esophagus significantly differed between the nCCE and CCE-group. However, the percentage of patients with pathological DGER were significantly higher in the CCE-group as compared to the nCCE-group (76 vs. 55 %, p < 0.01). Moreover, the CCE-group revealed significant higher levels of pathological DGER compared to the nCCE-group (15.5 % +/- 14.1 vs. 8.6 % +/- 15.4; p < 0.05).

CONCLUSION

To conclude, our data provide first evidence of elevated DGER after CCE in patients with typical clinical symptoms of GERD using the Bilitec device. Both the frequency and the extent of DGER was significantly increased in the CCE-group. Prospective studies are urgently needed to elucidate the impact of CCE on DGER in patients with clinical symptoms of a reflux disease.

Echo-rich and echo-poor periportal cuffing: pole position for inflammatory bowel diseases

PURPOSE

To determine the prevalence of echo-rich and echo-poor periportal cuffing in patients from a German tertiary referral hospital and correlate ultrasonographic findings with clinical data.

MATERIALS AND METHODS

From April 2002 till April 2008 about 10 500 abdominal examinations were performed by a single physician in our interdisciplinary ultrasound unit. During this time, n = 100 patients (62 male/ 38 female) with periportal cuffing of the liver were detected qualifying for the retrospective study design. Echomorphology of periportal cuffing was evaluated and clinical diagnoses of the underlying diseases were clustered in four main groups: Liver diseases, haematological diseases, bowel diseases and others. Furthermore, liver function tests and body mass index were determined.

RESULTS

The mean age of the patients was 57.06 years (SD +/- 19.47). Mean body-mass-index was 24.76 kg/m (2) (SD +/- 4.28). Periportal cuffing was echo-poor in n = 9 (9 %) and echo-rich in n = 91 (91 %). Echo-poor periportal cuffing was significantly more often associated with malignant diseases as compared to echo-rich periportal cuffing (78 vs. 36 %) (p < 0.025). Liver diseases (n = 33) were malign n = 10 (10 %), autoimmune n = 8 (8 %), infectious n = 8 (8 %) and cholestatic n = 7 (7 %). Bowel diseases (n = 34) originated from the upper gastrointestinal tract n = 7 (7 %), lower gastrointestinal tract n = 21 (21 %) and the pancreas n = 6 (6 %). Haematological disorders (n = 15, 15 %) were chronic myeloproliferative n = 2 (2 %), lymphoma n = 8 (8 %), leukemia n = 4 (4 %) and miscellaneous n = 1 (1 %). Other diseases accounted for 18 (18 %) of cases. Aspartat-aminotrasferase (AST) and alanin-aminotransferase (ALT) were elevated in 39 patients (40 %) and 34 patients (35 %), respectively. Total bilirubin was elevated in 35 patients (36 %). Alkaline phosphatase (AP) was detected above normal range in 49 patients (50 %) whereas g-glutamyl-transferase was elevated in 58 patients (59 %).

CONCLUSION

Periportal cuffing of the liver is an extremely rare ultrasonographic phenomenon with a prevalence of approximately 0.95 % in our unit. Echo-rich periportal cuffing occurs more frequently than echo-poor periportal cuffing. The majority of echo-poor periportal cuffing is associated with malignant disorders, in particular haematological diseases, whereas echo-rich periportal cuffing is most frequently seen in inflammatory bowel disease patients.

[Reflux-associated nutcracker oesophagus in a 49-year-old patient with non-cardiac chest pain (NCCP)]

A 49-year-old woman was admitted to our department because of intermittent left-sided chest pain for the past 2 years. The patient reported an increasing frequency and duration of the symptoms which were independent from food intake, medication or physical exercises. A cardiac cause of the chest pain was excluded before admittance to our hospital. The initially performed upper endoscopy revealed a small oesophageal hiatal hernia but no signs of acute or chronic inflammation. Basal oesophageal manometry and pH monitoring confirmed the presence of a nutcracker oesophagus, defined by high-amplitude contractions of the distal oesophagus, in combination with a gastro-oesophageal reflux disease. The patient was treated with high-dose pantoprazole for 8 weeks before re-examination. Interestingly, the symptoms completely disappeared upon medication and the relief of the chest pain was accompanied by normalisation of the nutcracker oesophagus pattern. Thus, our observation provides evidence for a causative role of acid reflux in the pathophysiology of the nutcracker oesophagus and, in addition, suggests that effective acid suppression might be a useful therapeutic tool to deal with this painful motility disorder of the oesophagus.

Claudin-4: a new target for pancreatic cancer treatment using Clostridium perfringens enterotoxin

BACKGROUND & AIMS

Recently, several members of the claudin family have been identified as integral constituents of tight junctions. Using expression profiling, we previously found claudin-4 to be overexpressed in pancreatic cancer. Because claudin-4 has been described as a receptor for the cytotoxic Clostridium perfringens enterotoxin (CPE), we investigated the effect of CPE on pancreatic cancer cells.

METHODS

Expression of claudin-4 was analyzed by Northern blots. In vitro toxicity of CPE was determined by trypan blue exclusion and the (86)Rb-release assay. The in vivo effect of CPE was studied in claudin-4-expressing nude mouse xenografts of the Panc-1 cell line.

RESULTS

Expression analyses showed that claudin-4 was overexpressed in most pancreatic cancer tissues and cell lines and several other gastrointestinal tumors. CPE led to an acute dose-dependent cytotoxic effect, restricted to claudin-4-expressing cells and dependent on claudin-4 expression levels. Furthermore, transforming growth factor beta was identified as a negative modulator of both claudin-4 expression and susceptibility to CPE. In vivo, intratumoral injections of CPE in Panc-1 xenografts led to large areas of tumor cell necrosis and significant reduction of tumor growth.

CONCLUSIONS

Our findings suggest that targeting claudin-4-expressing tumors with CPE represents a promising new treatment modality for pancreatic cancer and other solid tumors.