Atypical Acute Neuroborreliosis With Leg Paresis and Constipation

BACKGROUND/AIM

An 80-year-old male patient had complained of proximal paresis of the left leg, pain and sensory disturbances in the left abdomen, exanthema in the left lower abdomen, coprostasis, and severe abdominal pain, as well as a progressive deterioration of his general condition for weeks. The patient had already presented to three other medical centers. Colonoscopy and computed tomography of the abdomen could not explain the pronounced symptomatology. In addition, there was acute elevator paresis of the left leg and severe pruritic rash on both sides of the trunk.

CASE REPORT

At the Israelitisches Krankenhaus Hamburg (IKH), laboratory parameters of urine, stool, and blood, ultrasound, electrocardiogram, and transthoracic echocardiography diagnosis showed no abnormalities. Esophago-gastro-duodenoscopy revealed patchy erythema and moderately severe chronic low-activity Helicobacter-positive gastritis. Colonoscopically, two polyps were ablated. A neurological examination with magnetic resonance imaging and electroneurography also showed normal findings. Evidence of autoimmune or rheumatoid disease was also absent. Finally, analysis of the cerebrospinal fluid revealed a lympho-granulocytic cell count (32/3 lymphocytes, 21/3 granulocytes) and an elevated Borrelia-specific IgG index (Ai) of 20.82. This finding was confirmed by a complementary serological diagnosis, in which Borrelia-specific IgM and IgG antibodies were detected. In sum, Bannwart's syndrome was assumed to be the cause of the neurological symptoms. The 21-day borreliosis therapy included doxycycline administration and analgesia with novaminsulfone and pregabalin as needed.

CONCLUSION

A complex symptomatology of leg paresis, lower abdominal pain and sensory disturbances, exanthema, and coprostasis in combination with a long-lasting poor general condition were found to be the consequences of atypical neuroborreliosis.

[Quality management in the field of gastroenterology - Proposals of the Quality Commission of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) for Outpatient and Inpatient Quality Assurance]

The quality of the medical care depends on numerous factors that can often be influenced by the doctor itself. It is a great challenge to follow the constant scientific progress in practice. Scientific standards in gastroenterology are defined in DGVS guidelines and regularly revised. The implementation of evidence-based recommendations in practice remains challenging. On the basis of the DGVS guidelines, the Quality Commission has therefore developed a selection of quality indicators with particular relevance using standardized criteria, the broad implementation of which could contribute to improved patient care in gastroenterology.

Sustained response after remdesivir and convalescent plasma therapy in a B-cell depleted patient with protracted COVID-19

We provide detailed clinical, virological and immunological data of a B-cell depleted patient treated with obinutuzumab for follicular lymphoma with protracted COVID-19 and viremia. A sustained response was achieved after two courses of remdesivir and subsequent convalescent plasma therapy. Immunocompromised patients might require combined and prolonged antiviral treatment regimens.

Multicenter, randomized comparison of the diagnostic accuracy of 19-gauge stainless steel and nitinol-based needles for endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic masses

BACKGROUND

The use of 19-gauge (G) stainless steel needles for endoscopic ultrasound-guided fine-needle biopsy of a pancreatic mass often results in technical difficulties due to an inability to advance the relatively rigid needle out of the endoscope. More flexible nitinol-based needles might decrease such technical difficulties and thus increase diagnostic accuracy.

OBJECTIVE

In this prospective multicenter randomized single-blinded study we compared the diagnostic value of those two needle types in patients with a solid pancreatic lesion.

METHODS

Patients with a solid pancreatic mass were diagnosed with endoscopic ultrasound-guided fine-needle biopsy using one puncture with each needle in a randomized fashion. The primary endpoint was the diagnostic accuracy of each needle. Secondary endpoints included time for puncture, amount of tumour tissue obtained, and technical failure. Histological specimens were centrally reviewed by a pathologist blinded to the final needle type and final diagnosis (ClinicalTrials.gov Identifier: NCT02909530).

RESULTS

Out of 46 prospectively recruited patients, central pathological examination was available for 41. Diagnostic accuracy for the two needles combined was 87.8%. Diagnostic accuracy was 66% and 68% using the stainless steel- and nitinol-based needle respectively. Time spent for puncturing was 137 ± 61 s (mean ± standard deviation) for the stainless steel and 111 ± 53 s for the nitinol-based needle (p = 0.037). Technical failure occurred in three (6.5%) cases using the stainless steel- and in none using the nitinol-based needle.

CONCLUSIONS

Usage of a nitinol-based 19-G needle failed to present a significant superior accuracy compared with a stainless steel needle in endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic lesions.

Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study

OBJECTIVE

Percutaneous biliary interventions (PBIs) can be associated with a high patient radiation dose, which can be reduced when national diagnostic reference levels (DRLs) are kept in mind. The aim of this multicentre study was to investigate patient radiation exposure in different percutaneous biliary interventions, in order to recommend national DRLs.

METHODS

A questionnaire asking for the dose area product (DAP) and the fluoroscopy time (FT) in different PBIs with ultrasound- or fluoroscopy-guided bile duct punctures was sent to 200 advanced care hospitals. Recommended national DRLs are set at the 75th percentile of all DAPs.

RESULTS

Twenty-three facilities (9 interventional radiology depts. and 14 gastroenterology depts.) returned the questionnaire (12%). Five hundred sixty-five PBIs with 19 different interventions were included in the analysis. DAPs (range 4-21,510 cGy·cm2) and FTs (range 0.07-180.33 min) varied substantially depending on the centre and type of PBI. The DAPs of initial PBIs were significantly (p < 0.0001) higher (median 2162 cGy·cm2) than those of follow-up PBIs (median 464 cGy·cm2). There was no significant difference between initial PBIs with ultrasound-guided bile duct puncture (2162 cGy·cm2) and initial PBIs with fluoroscopy-guided bile duct puncture (2132 cGy·cm2) (p = 0.85). FT varied substantially (0.07-180.33 min).

CONCLUSIONS

DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. PBI with US-guided bile duct puncture did not reduce DAP, when compared to PBI with fluoroscopy-guided bile duct puncture. National DRLs of 4300 cGy·cm2 for initial PBIs and 1400 cGy·cm2 for follow-up PBIs are recommended.

KEY POINTS

• DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. • PBI with US-guided bile duct puncture did not reduce DAP when compared to PBI with fluoroscopy-guided bile duct puncture. • DRLs of 4300 cGy·cm2for initial PBIs (establishing a transhepatic tract) and 1400 cGy·cm2for follow-up PBIs (transhepatic tract already established) are recommended.

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

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.

The impact of technical and clinical factors on fecal microbiota transfer outcomes for the treatment of recurrent Clostridioides difficile infections in Germany

Introduction

Fecal microbiota transfer (FMT) is highly effective in the treatment and prevention of recurrent Clostridioides difficile infection (rCDI) with cure rates of about 80% after a single treatment. Nevertheless, the reasons for failure in the remaining 20% remain largely elusive. The aim of the present study was to investigate different potential clinical predictors of response to FMT in Germany.

Methods

Information was extracted from the MicroTrans Registry (NCT02681068), a retrospective observational multicenter study, collecting data from patients undergoing FMT for recurrent or refractory CDI in Germany. We performed binary logistic regression with the following covariates: age, gender, ribotype 027, Eastern Co-operative Oncology Group score, immunosuppression, preparation for FMT by use of proton pump inhibitor, antimotility agents and bowel lavage, previous recurrences, severity of CDI, antibiotic induction treatment, fresh or frozen FMT preparation, and route of application.

Results

Treatment response was achieved in 191/240 evaluable cases (79.6%) at day 30 (D30) post FMT and 78.1% at day 90 (D90) post FMT. Assessment of clinical predictors for FMT failure by forward and confirmatory backward-stepwise regression analysis yielded higher age as an independent predictor of FMT failure (p = 0.001; OR 1.060; 95%CI 1.025-1.097).

Conclusion

FMT in Germany is associated with high cure rates at D30 and D90. No specific pre-treatment, preparation or application strategy had an impact on FMT success. Only higher age was identified as an independent risk factor for treatment failure. Based on these and external findings, future studies should focus on the assessment of microbiota and microbiota-associated metabolites as factors determining FMT success.

[The revised version of standard terminology in gastroenterological endoscopy - result of a consensus project of the german society for gastroenterology, digestive and metabolic diseases]

A uniform and comprehensive terminology is essential in the correct documentation of diagnostic or therapeutic endoscopic procedure. In the German-speaking world, the standard terminology available so far is based on a previous version published in 1999. Therefore, the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) has undergone a comprehensive revision and re-structuring of the terminology. This appeared mandatory due to various changes, new diagnoses and new endoscopic procedures. The suggestions drawn up by individual working groups were approved by consensus and are now available as an online document (https://doi.org/10.1055/s-0043-121167) for modifying current software systems. In order to ensure an up-to-date documentation in the future, it was decided that annual updates will be performed by the DGVS to check respective software packages for modifications and new contents.

Consensus report: faecal microbiota transfer - clinical applications and procedures

BACKGROUND

Faecal microbiota transplantation or transfer (FMT) aims at replacing or reinforcing the gut microbiota of a patient with the microbiota from a healthy donor. Not many controlled or randomised studies have been published evaluating the use of FMT for other diseases than Clostridium difficile infection, making it difficult for clinicians to decide on a suitable indication.

AIM

To provide an expert consensus on current clinical indications, applications and methodological aspects of FMT.

METHODS

Well-acknowledged experts from various countries in Europe have contributed to this article. After literature review, consensus has been achieved by repetitive circulation of the statements and the full manuscript among all authors with intermittent adaptation to comments (using a modified Delphi process). Levels of evidence and agreement were rated according to the GRADE system. Consensus was defined a priori as agreement by at least 75% of the authors.

RESULTS

Key recommendations include the use of FMT in recurrent C. difficile infection characterised by at least two previous standard treatments without persistent cure, as well as its consideration in severe and severe-complicated C. difficile infection as an alternative to total colectomy in case of early failure of antimicrobial therapy. FMT in inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS) and metabolic syndrome should only be performed in research settings.

CONCLUSIONS

Faecal microbiota transplantation or transfer is a promising treatment for a variety of diseases in which the intestinal microbiota is disturbed. For indications other than C. difficile infection, more evidence is needed before more concrete recommendations can be made.

Sensitivity and specificity of an abbreviated (13)C-mixed triglyceride breath test for measurement of pancreatic exocrine function

BACKGROUND

A modified (13)C-mixed triglyceride breath test ((13)C -MTGT) detects moderate pancreatic exocrine insufficiency noninvasively and reliably, but it requires prolonged breath sampling (6 hours (hr)).

OBJECTIVE

We aimed to investigate whether (13)C -MTGT can be abbreviated, to optimize clinical usability.

METHODS

We analyzed the (13)C-MTGT of 200 consecutive patients, retrospectively. Cumulative 1-5 hr (13)C-exhalation values were compared with the standard parameter (6-hr cumulative (13)C-exhalation). We determined the sensitivity and specificity of shortened breath sampling periods, by comparison with the normal values from 10 healthy volunteers, whom also underwent a secretin test to quantitate pancreatic secretion. Moreover, we evaluated the influence of gastric emptying (GE), using a (13)C-octanoic acid breath test in a subset (N = 117).

RESULTS

The 1-5 hr cumulative (13)C-exhalation tests correlated highly and significantly with the standard parameter (p < 0.0001). Sensitivity for detection of impaired lipolysis was high (≥77%), but the specificity was low (≥38%) for the early measurements. Both parameters were high after 4 hrs (88% and 94%, respectively) and 5 hrs (98% and 91%, respectively). Multivariate linear correlation analysis confirmed that GE strongly influenced early postprandial (13)C-exhalation during the (13)C-MTGT.

CONCLUSION

Shortening of the (13)C -MTGT from 6 to 4 hrs of duration was associated with similar diagnostic accuracy, yet increased clinical usability. The influence of GE on early postprandial results of the (13)C-MTGT precluded further abbreviation of the test.

Recent advances in capsule endoscopy: development of maneuverable capsules

One important disadvantage of modern capsule endoscopy is its lack of maneuverability. Thus, clinically available systems depend on transportation by spontaneous gastrointestinal motility. Even in subjects with normal motility, transit time for different intestinal segments may vary considerably, and relevant segments may be passed too quickly. This probably explains why approximately 10% of all pathologies are overlooked during small bowel investigations. Moreover, without maneuverable capsule endoscopes, the large inner surface of the stomach cannot be investigated properly. The most advanced approaches, which try to develop maneuverable systems for targeted inspection of the GI tract, use magnetic fields for steering of a videocapsule with magnetic inclusions. With such systems, preliminary clinical studies have already been performed. Other projects try to develop biologically inspired steering mechanisms such as capsules that can move on legs or they use electrical stimulation of the intestinal wall in order to induce contractions for propulsion of the videocapsule.

Inspection of the human stomach using remote-controlled capsule endoscopy: a feasibility study in healthy volunteers (with videos)

BACKGROUND

Remote control of capsule endoscopes might allow reliable inspection of the human stomach.

OBJECTIVE

To assess the safety and efficacy of manipulation of a modified capsule endoscope with magnetic material (magnetic maneuverable capsule [MMC]) in the human stomach by using a handheld external magnet.

DESIGN

Open clinical trial.

SETTING

Academic hospital.

PATIENTS

Ten healthy volunteers.

INTERVENTIONS

Subjects swallowed the MMC and sherbet powder for gastric distention. An external magnetic paddle (EMP-2) was used to manipulate the MMC within the stomach. MMC responsiveness was evaluated on a screen showing the MMC film in real time.

MAIN OUTCOME MEASUREMENTS

Safety and tolerability (questionnaire), gastric residence time of the MMC, its responsiveness to the EMP-2, area of gastric mucosa visualized.

RESULTS

There were no adverse events. The MMC was always clearly attracted by the EMP-2 and responded to its movements. It remained in the stomach for 39 ± 24 minutes. In 7 subjects, both the cardia and the pylorus were inspected and 75% or more of the gastric mucosa was visualized (≥50% in all of the remaining subjects). A learning curve was clearly recognizable (identification of MMC localization, intended movements).

LIMITATIONS

Small amounts of fluid blocked the view of apical parts of the fundus; gastric distention was not sufficient to flatten all gastric folds.

CONCLUSIONS

Remote control of the MMC in the stomach of healthy volunteers using a handheld magnet is safe and feasible. Responsiveness of the MMC was excellent, and visualization of the gastric mucosa was good, although not yet complete, in the majority of subjects. The system appeared to be clinically valuable and should be developed further. (

CLINICAL TRIAL REGISTRATION NUMBER

DE/CA05/2009031008.).

S3-guideline "helicobacter pylori and gastroduodenal ulcer disease" of the German society for digestive and metabolic diseases (DGVS) in cooperation with the German society for hygiene and microbiology, society for pediatric gastroenterology and nutrition e. V., German society for rheumatology, AWMF-registration-no. 021 / 001

This guideline updates a prior consensus recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) from 1996. It was developed by an interdisciplinary cooperation with representatives of the German Society for Hygiene and Microbiology, the Society for Pediatric Gastroenterology and Nutrition (GPGE), and the German Society for Rheumatology. The guideline is methodologically based on recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) for providing a systematic evidence-based S 3 level consensus guideline and has also implemented grading criteria according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) process. Clinical applicability of study results as well as specifics for Germany in terms of epidemiology, antibiotic resistance status, diagnostics, and therapy were taken into account.

[S3-guideline "Helicobacter pylori and gastroduodenal ulcer disease"]

This guideline updates a prior concensus recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) from 1996. It was developed by an interdisciplinary cooperation with representatives of the German Society for Microbiology, the Society for Pediatric Gastroenterology and Nutrition (GPGE) and the German Society for Rheumatology. The guideline is methodologically based on recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) for providing a systematic evidence-based consensus guideline of S 3 level and has also implemented grading criteria according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). Clinical applicability of study results as well as specifics for Germany in terms of epidemiology, antibiotic resistance status, diagnostics and therapy were taken into account.

[Benchmarking in gastrointestinal endoscopy]

Quality and costs of endoscopic procedures in gastroenterology have recently come into focus of professionals and patients alike. The project presented here combines benchmarking of indicators of quality and simultaneous assessment of costs in departments of endoscopy. In all 9400 examinations from 14 departments were analysed. First and most obvious results are presented: the machine-readable data sheet was filled out correctly in 95 % (compulsory data fields); endoscopy costs differed by factor two for diagnostic gastroscopy and by factor five for therapeutic ERCP; in some departments a polypectomy was performed in up to every second diagnostic colonoscopy while in others polypectomy occurred only in 10 % in some departments patient monitoring like pulse oxymetry was used only in half of the procedures. Interpretation of the data requires further validation by resumption of the project to obtain more data from possibly more departments.

Pancreatic acinar cell carcinoma with excessive alpha-fetoprotein expression

We report a case of acinar cell carcinoma of the pancreas associated with excessively elevated levels of serum alpha-fetoprotein (>32,000 ng/ml). Abdominal computed tomography scan revealed a large pancreatic mass with infiltration of the splenic artery. Because of inoperability, palliative combination chemotherapy with gemcitabine and mitomycin C was administered. This regimen was associated with clinical improvement and dramatic decreases in both tumor size and serum alpha-fetoprotein. However, the patient died 7 months later from acute severe cardiac failure.

The patient with slightly elevated pancreatic enzymes and abdominal complaints

Abdominal complaints in combination with slightly elevated serum pancreatic enzymes represent a classical clinical challenge. These symptoms may be due to coincidental unrelated harmless disorders, benign pancreatic alterations which are fairly easily treatable such as mild acute pancreatitis or uncomplicated chronic pancreatitis. However, serious, often insidious diseases such as pancreatic tumours may also present with this constellation as their first signs. Diagnostic procedures need to be stratified according to acuteness and severity of symptoms. While patients with acute onset of symptoms and severe complaints need immediate and combined laboratory and imaging investigations to allow adequate therapy, chronic and mild complaints usually justify a stepwise diagnostic approach consecutively using abdominal ultrasound, CT/MRI and endoscopic ultrasound as imaging procedures and reserving ERCP for cases which remain unclear or in which interventional therapy is needed. Diagnosis and follow-up are often particularly demanding in patients with cystic tumours of the pancreas. In chronic pancreatitis patients pain therapy and adequate control of pancreatic exocrine insufficiency may pose major problems. Patients with refractory pain may ultimately require surgical intervention. Another important indication for surgery in chronic pancreatitis is suspicion of cancer that cannot be ruled out by dedicated diagnostic procedures. This also applies to cystic tumours of the pancreas, which have a high risk of malignant transformation or may even already represent pancreatic cancer at the time of diagnosis.

Do elevated plasma vasoactive intestinal polypeptide (VIP) levels cause small intestinal motor disturbances in humans?

Increased VIP plasma levels cause severe secretory diarrhea. Moreover, VIP is a major regulator of human intestinal motility. We hypothesized that VIP-mediated intestinal motility disturbances contribute to symptoms in elevated plasma VIP. Ten healthy volunteers were intubated twice with an orojejunal multilumen tube for duodenal manometry, jejunal perfusion of electrolyte and marker solution, and aspiration 10 and 40 cm more distally. All subjects randomly received intravenous infusion of saline and 300 pmol/kg x hr VIP for 5 hr. Results showed that VIP but not saline infusion induced netjejunal sodium secretion, watery diarrhea, and cardiovascular effects (P < 0.04). VIP did not alter intestinal motor activity or the mean duration of the interdigestive motility cycle or of phases I and II but nearly halved the duration of phase III (P = 0.0002). We conclude that increased plasma VIP markedly shortens human phase III activity without influencing other motility parameters. Hence, it is unlikely that VIP-mediated small intestinal motor disturbances cause symptoms in VIPOMA. Yet VIP may contribute to terminate phase III motility.

[Diagnosis related groups (DRG)--current significance in gastroenterology]

Prospective payment systems using the diagnosis related groups (DRG) payment mechanism have been introduced in many countries all over the world. In June 2000 the Australian Refined Diagnosis Related Groups System (AR-DRG) was chosen as the model which will be introduced in 2003 as the control instrument for the hospital dependent public health system in Germany. Background and possible implications for gastroenterologists and hepatologists are discussed.

[Cystic lesions of the pancreas]

Most cystic lesions of the pancreas are pseudocysts caused by acute or chronic pancreatitis. Congenital cysts are rare and may occur in congenital syndromes like von Hippel-Lindau syndrome. Cystic tumors of the pancreas may be difficult to distinguish clinically; however, because of their malignant potential, in particular in cases of mucinous types, diagnostic verification is crucial. Hence, in all cases of cystic lesions of the pancreas, which are not a sequela of an etiological confirmed acute or chronic pancreatitis, a cystic neoplasm must be ruled out. Differential diagnosis may be difficult even with ultrasonography, computertomography, endoscopic retrograde cholangiopancreatography and serum analyses; endoscopic ultrasound, magnetic resonance tomography and analysis of the cyst content may be of particular value. The therapeutic approach for pseudocysts is now well established and guided by symptoms and complications. If a cystic neoplasm is suspected, surgical resection of the complete lesion is warranted.

CONCLUSION

The most important differential diagnosis in all cystic lesions of the pancreas with atypical presentation includes a cystic neoplasm. Therefore complete resection is indicated whenever the suspicion cannot be ruled out.

[Patient with right-sided epigastric pain and "negative" ultrasound]

In most cases pain in the right upper abdominal quadrant is of biliary origin. Diseases of the biliary system are often visualized by ultrasonography; however, a negative test does not rule out a biliary cause. Moreover, a number of several non-biliary diseases have to be considered. Patient history, physical examination and laboratory findings determine the further diagnostic approach and include radiologic (i.e. CT/scintigraphy) and/or endoscopic (upper GI endoscopy, ERCP) examinations. In difficult diagnostic situations specialized diagnostic tools may be indicated (e.g. manometry in suspected dysfunction sphincter of the Oddi.

[Treatment of radiotherapy-induced gastroparesis with erythromycin]

HISTORY

A 75-year-old woman who had undergone a hysterectomy with adnexectomy followed by radiotherapy for endometrial carcinoma complained of postprandial nausea with vomiting after eating solid foods and of cramp-like abdominal pain, but her appetite was good. She had lost 25 kg in weight over 13 months.

EXAMINATION

Physical examination, laboratory tests, radiology and gastroscopy were unremarkable. Gastric scintigraphy showed abnormally prolonged emptying.

TREATMENT AND COURSE

Nausea and vomiting stopped at once after erythromycin (a motilin agonist) had been administered. It was at first given intravenously after meals (50 mg three times daily for 5 days), then orally for 10 weeks (250 mg three times daily before meals). Subsequent examination revealed normal gastric emptying. The symptoms did not recur after erythromycin had been discontinued.

CONCLUSION

Erythromycin is an effective drug against gastroparesis caused by radiotherapy, because it acts even when the enteric nerves are damaged.

DNA diagnosis of fatal fructose intolerance from archival tissue

Hereditary fructose intolerance is a recessively-transmitted disorder of metabolism caused by deficiency of aldolase B in the liver, intestine and kidney, that responds favourably to an exclusion diet. The occurrence of fatal hepatorenal failure in a 16-year-old girl, who had received infusions of fructose and sorbitol during minor surgery, led us to suspect that she had suffered from hereditary fructose intolerance. Molecular analysis of leucocyte DNA obtained from her brother who had had a long-standing aversion to fruit and sugar, showed two previously unknown mutations in the aldolase B gene. An initiation codon mutation, M-1T, was inherited from the father, whereas Y203X, inherited from the mother, is a nonsense mutation that replaces a tyrosine codon by the ochre termination signal. The only source of genomic DNA from the index case was a fixed fragment of necrotic liver that had been obtained by needle aspiration postmortem and was embedded in paraffin wax. Analysis of aldolase B genes in this sample by procedures based on the polymerase chain reaction (PCR) confirmed the presence of both mutations in the proposita, the diagnosis of hereditary fructose intolerance, and the cause of death.