Ceruloplasmin serum concentrations in a randomized population sample of 2,445 subjects

The metalloprotein ceruloplasmin has been of interest to psychiatrists for decades following early observations of elevated serum copper, and oxidase activity, in patients with schizophrenia. While immunological methods did not confirm elevated serum ceruloplasmin concentrations in schizophrenia, low serum concentrations of ceruloplasmin are typical of Wilson's disease, Menkes’ disease, and aceruloplasminemia making low ceruloplasmin an important marker of disease. Unfortunately, available normative values are of limited usefulness, the majority being derived from oxidase studies; very few immunoturbidimetric or nephelometric studies were performed on small samples, or did not account for known influencing factors. Therefore, the present study was planned to determine nephelometric ceruloplasmin serum concentrations in a large randomized population sample. 2,445 subjects between 12 and 65 years of age were randomly selected from a southern German town of 22,000 inhabitants. The mean ceruloplasmin serum concentration was 331 ± 104 mg/l. Ceruloplasmin serum concentration significantly correlated with gender and age and was higher by 23 mg/l on average in women than in men. There also were significant correlations with lipoprotein concentrations, but not with several other liver-associated features, parameters of metabolism, or markers of inflammation.

Circulating levels of miR-122 and nonalcoholic fatty liver disease in pre-pubertal obese children

OBJECTIVES

The liver-specific miR-122 was proposed as biomarker for NAFLD in adults. Here, we investigated the relationship between miR-122 levels, parameters of liver metabolism and NAFLD in pre-pubertal obese children.

METHODS

Parameters of liver metabolism (ALT, AST and GGT) of three European cohorts were included (German cohort [n = 71; age: 11.53 ± 1.29 years; BMI z-score: 2.96 ± 0.64], Italian cohort [n = 45; age: 9.60 ± 2.11 years; BMI z-score: 3.57 ± 1.16], Slovenian cohort [n = 31; age: 7.53 ± 1.47 years; BMI z-score: 3.66 ± 0.88]). MiR-122 levels and CK18 concentrations were measured in fasting blood samples. In the German and Italian cohort, the diagnosis of NAFLD and grading of NAFLD was assessed by ultrasound.

RESULTS

NAFLD was diagnosed in n = 50 patients of the German cohort (29.6%) and in n = 29 patients (72.5%) of the Italian cohort. In all three cohorts, miR-122 was positively correlated with ALT and AST as well as with CK18 concentrations. MiR-122 levels were higher in children with NAFLD compared with healthy controls.

CONCLUSIONS

MiR-122 levels in pre-pubertal obese children could be a potential biomarker for paediatric NAFLD.

Structured Reporting of Medical Findings: Evaluation of a System in Gastroenterology

A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Serumcoeruloplasmin in einer randomisierten Bevölkerungsstichprobe mit 2 445 Probanden

Die Coeruloplasmin-Serumkonzentration bezieht ihre Bedeutung für die Neuropsychiatrie aus der vermutlich ursächlichen Verknüpfung niedriger oder fehlender Werte mit Eisenstoffwechselstörungen und einer Neurodegeneration mit zerebraler Eisenakkumulation einerseits sowie aus dem Auftreten niedriger Werte bei Kupferstoffwechselstörungen mit Neurodegeneration, insbesondere M. Wilson, andererseits. Die vorliegende Untersuchung berichtet immunnephelometrische Messungen an einer randomisierten Bevölkerungsstichprobe, die im Einklang mit publizierten Werten stehen und eine Abhängigkeit der Coeruloplasmin-Serumkonzentration von Geschlecht, oraler Kontrazeption und parallel bestimmten Entzündungsparametern zeigen, darüber hinaus aber insbesondere von den Cholesterinfraktionen. Der Ausprägungsgrad dieser Abhängigkeit lässt es zweckmäßig erscheinen, diese individuellen Größen bei der Beurteilung des Serumcoeruloplasmins zu berücksichtigen.

Thyroid dysfunction and hepatic steatosis in overweight children and adolescents

BACKGROUND

Overt or subclinical hypothyroidism is a common finding in adult populations affected by non-alcoholic fatty liver disease (NAFLD). Currently, there are only sparse data available on the association of thyroid dysfunction and NAFLD in obese children and adolescents.

OBJECTIVE

The study aims to investigate the association of thyroid function test values with NAFLD and metabolic risk factors in a population of obese children and adolescents.

METHODS

A total of 332 overweight and obese children and adolescents (170 girls) aged between 10 and 19 years were analysed. Subjects underwent ultrasound examination of the liver. Thyroid function was evaluated by laboratory determination of thyroid-stimulating hormone (TSH), total triiodothyronine (T3) and total thyroxine levels. All included subjects were either euthyroid or had subclinical hypothyroidism (TSH > 4 μU mL^-1 , normal thyroxine). Further metabolic profiling included the determination of lipid status, insulin and liver function tests. Anthropometric parameters body mass index, waist and hip circumference were documented.

RESULTS

The prevalence of hepatic steatosis was 29.8%. Subjects with NAFLD had significantly higher TSH levels than those without (p = 0.0007). After dividing TSH values into quartiles, both univariate and multivariate analyses (adjusted for age, body mass index-standard deviation scores and stage of puberty) showed a significant association with hepatic steatosis (p < 0.05).

CONCLUSION

Taking possible variables into consideration, our results show that there is a significant association between hepatic steatosis and the TSH levels in obese children and adolescents. Mild thyroid dysfunction may therefore have a role in determining an unfavourable metabolic profile in obese children and adolescents.

Evaluation of Strain Elastography for Differentiation of Thyroid Nodules: Results of a Prospective DEGUM Multicenter Study

PURPOSE

Many patients with thyroid nodules are presently referred to surgery for not only therapeutic but also diagnostic purposes. The aim of noninvasive diagnostic methods is to optimize the selection of patients for surgery. Strain elastography (SE) enables the ultrasound-based determination of tissue elasticity. The aim of the present study was to evaluate the value of SE for the differentiation of thyroid nodules in a prospective multicenter study.

MATERIALS AND METHODS

The study was registered at clinicaltrials.gov and was approved by the local ethics committees of all participating centers. All patients received an ultrasound (US) of the thyroid gland including color Doppler US. In addition, all nodules were evaluated by SE (Hitachi Medical Systems) using qualitative image interpretation of color distribution (SE-ES), strain value and strain ratio.

RESULTS

Overall, 602 patients with 657 thyroid nodules (567 benign, 90 malignant) from 7 centers were included in the final analysis. The sensitivity, specificity, NPV, PPV, +LR were 21 %, 73 %, 86 %, 11 %, 0.8, respectively, for color Doppler US; 69 %, 75 %, 94 %, 30 %, 2.9, respectively, for SE-ES; 56 %, 81 %, 92 %, 32 %, 2.9, respectively, for SE-strain value; and 58 %, 78 %, 92 %, 30 %, 2.6, respectively, for SE-strain ratio. The diagnostic accuracy was 71 % for both strain value and strain ratio of nodules.

CONCLUSION

SE as an additional ultrasound tool improves the value of ultrasound for the work-up of thyroid nodules. It might reduce diagnostic surgery of thyroid nodules in the future.

Comparison of Two High-End Ultrasound Systems for Contrast-Enhanced Ultrasound Quantification of Mural Microvascularity in Crohn's Disease

PURPOSE

To verify the reproducibility of contrast-enhanced ultrasound (CEUS) quantification results of two different high-end ultrasound systems and to evaluate the clinical utility of the method in patients with Crohn's disease (CD).

MATERIALS AND METHODS

18 patients with histologically confirmed CD (36.8 % women, 63.2 % men; mean age 43.7 ± 14.1 years) and wall segments thicker than 5 mm were recruited. CEUS quantification and conventional ultrasound investigation were performed under standardized settings using Toshiba Aplio500 and Siemens Acuson S3000 high-end ultrasound systems. CEUS was performed at a low mechanical index of 0.1 after bolus application of 4.8 ml of SonoVue(®) contrast medium. The recorded DICOM clips were quantified using VueBox(®) (version 4.3) calculating 11 quantitative parameters. Subsequently, CEUS quantification and conventional ultrasound results were analyzed.

RESULTS

Correlation of quantitative parameters between the Aplio500 and AcusonS3000 systems for peak enhancement (PE), rise time (RT), wash-in-rate (WiR) and quality of fit (QOF) yielded significance levels of p < 0.05 and p < 0.0001 for wash-in-wash-out area under the curve (WiWoAUC). Spearman rank test showed moderate levels of correlation for PE, RT, WiR and QOF (r = 0.5, 0.49, 0.49 and 0.5 respectively), and high correlation for WiWoAUC (r = 0.89) between the two ultrasound systems.

CONCLUSION

Due to multiple uncontrollable affecting factors, the method of CEUS quantification by VueBox in the intestine cannot be recommended for device-independent multicenter studies. Therefore we suggest to use identical ultrasound systems and probes as well as to establish adequate reference ROIS, like a AIF-ROI.

A Nonclassical Monocyte Phenotype in Peripheral Blood is Associated with Nonalcoholic Fatty Liver Disease: A Report from an EMIL Subcohort

Nonalcoholic fatty liver disease (NAFLD) as the prototypic hepatic manifestation of metabolic syndrome is an independent risk factor for cardiovascular disease. Our study was designed to investigate the association between NAFLD and alteration in monocyte subsets as hallmark of cardiovascular disease. Seventy-three "Echinococcus Multilocularis and other medical diseases in Leutkirch" (EMIL) population-based cohort participants (mean observation period 11 years) were selected to study their monocyte phenotype by multiparameter flow cytometry. NAFLD was diagnosed using standard ultrasound based criteria excluding other causes of fatty liver disease. Three monocyte subsets ("classical" CD14++ CD16-, "intermediate" CD14++  CD16+, "nonclassical" CD14+CD16++  monocytes), and surface markers (CD36 and CD9) were determined. Classical risk markers covering inflammatory and dysmetabolic characters were also determined. Forty-three out of 73 subjects revealed a stable clinical phenotype, namely 17 subjects revealed NAFLD, whereas 26 subjects showed no fatty liver disease. Compared to the nonfatty liver group, the nonclassical monocyte fraction (p=0.049), total monocyte fraction and count were increased in NAFLD probands (p=0.028, and 0.035, respectively), while classical monocyte fraction (p=0.034) was decreased. Total monocyte fraction, nonclassical monocyte fraction, and waist circumstance were independent risk factors for NAFLD. The nonclassical monocyte fraction and classical monocyte fraction were significantly correlated with waist-to-hip ratio. This pilot long-term follow-up study suggests that nonclassical monocyte fraction and total monocyte fraction might have potential as a prognostic and modifiable biomarker in NFALD patients. This novel marker set might therefore be of interest to monitor druggable inflammatory pathways in individuals with hepatic manifestation of the metabolic syndrome.

Caliber of the common bile duct: effect of cholecystectomy and other factors in a ultrasonographic study of 8534 patients

OBJECTIVE

The objective of the present study was to analyze the effects of different factors impacting the caliber of the common bile duct (CBD) and a comparison of maximum extrahepatic bile duct caliber in patients with and without a history of cholecystectomy.

MATERIAL AND METHODS

A retrospective data analysis was undertaken of 8534 patients (4480 females; 4054 males; average age: 59.2±18.0 years) with sonographic documentation of bile duct caliber. Maximum intra- and extrahepatic bile duct diameters were studied. The normal maximum diameter of the extrahepatic bile duct was defined as 7 mm. In patients who had undergone prior cholecystectomy, a maximum bile duct diameter<10 mm was considered normal.

RESULTS

The average maximum diameter of the CBD amounted to 5.3±3.0 mm for the overall collective. In patients who had undergone prior cholecystectomy, maximum CBD diameters in the normal range (<7 mm) were documented in 55%, while larger diameters (>7 mm) were observed in 45%. In the collective of patients without prior cholecystectomy, CBD diameters in the normal range (<7 mm) were found in 81%, with larger diameters observed in only 18.4% of patients. In both subgroups, there was a significant association between age and bile duct diameter (for those with prior cholecystectomy, p=0.0003; without prior cholecystectomy, p<0.0001). No statistically significant influence on CBD diameter was observed for either prior cholecystectomy (p=0.2116) or time interval since cholecystectomy (p=0.3537). Females, both with and without a history of prior cholecystectomy, showed a 1.4-1.5-fold higher risk of exhibiting a CBD diameter>7 mm (for those with prior cholecystectomy, p=0.0485; without prior cholecystectomy, p<0.001).

CONCLUSIONS

Our data show a positive correlation between age and CBD diameter. There was no statistically significant relationship between CBD diameter and prior cholecystectomy, postoperative interval and BMI.

Sonographically measured suprailiac adipose tissue is a useful predictor of non-alcoholic fatty liver disease in obese children and adolescents

OBJECTIVE

The objective of the present study was to identify ultrasonographic and anthropometric parameters that are highly associated with the presence of non-alcoholic fatty liver disease (NAFLD) in overweight children and adolescents.

METHODS

A total of 447 overweight children and adolescents (body mass index, 32.4 ± 5.2 kg m(-2) ; mean age, 14.2 ± 1.9 years; range 10.1-20.3 years) were analysed. Subjects underwent ultrasound examination of the liver as well as ultrasonographic measurement of the amount of adipose tissue overlying the biceps brachii and triceps brachii muscles, and of subscapular, suprailiac and abdominal subcutaneous adipose tissue and intra-abdominal depth. Anthropometric parameters such as body mass index, waist and hip circumference were documented.

RESULTS

The prevalence of NAFLD was 27.1%; it was significantly associated with the above-cited anthropometric parameters (P < 0.001). Ultrasonographic findings identified a significant association between NAFLD and the amount of subscapular, suprailiac and abdominal subcutaneous adipose tissue (P < 0.001) as well as between NAFLD and intra-abdominal depth (P < 0.001). Stepwise logistic regression analysis showed only intra-abdominal depth for both gender and the deposit of subcutaneous suprailiac adipose tissue in females to be independent predictors of NAFLD.

CONCLUSIONS

In overweight children and adolescents, we identified intra-abdominal depth for both gender and the ultrasonographically easily determined subcutaneous suprailiac adipose tissue in females as independent predictor of NAFLD.

Influence of plasma cortisol and other laboratory parameters on nonalcoholic Fatty liver disease

The objective of the present study was to analyse the association between the plasma cortisol concentration and nonalcoholic fatty liver disease (NAFLD). A total of 1 326 subjects (age 18-65 years) were examined in the context of an epidemiological study of a population-based random sample. Medical history and anthropometric data of 662 women and 664 men were documented. In addition, laboratory examinations were performed and the fat concentration of the liver was estimated by ultrasound examination. Mean cortisol concentration in plasma was 260.4±156.8 nmol/l for women and 295.8±161.2 nmol/l for men. NAFLD was identified in 17.7% in women and 35.1% in men. Plasma cortisol concentration showed no association with the existence of NAFLD. NAFLD correlated positive with age, body-mass index (BMI), waist-to-hip-ratio (WHR), alanine aminotransferase (ALT), and triglycerides. The present study failed to establish any association of plasma cortisol concentrations and NAFLD.

Determination of vitality of liver lesions by alveolar echinococcosis

Objective of our study is qualitative and quantitative comparison of contrast enhanced ultrasound (CEUS) and 18F-FDG PETCT in monitoring hepatic alveolar echinococcosis (HAE). Parasitic liver lesions were examined regarding number, size, morphology, vascularization and metabolic activity. Patients, methods: 36 patients with medicallytreated HAE were included in this prospective clinical study. Abdominal ultrasound and CEUS were carried out using ultrasound contrast amplifier SonoVue®. As part of monitoring, patients were examined by 18F-FDG-PET-CT. Quantitative analysis of CEUS was performed using the Software Vue- Box™ Quantification Toolbox. Maximum contrast enhancement in lesions peak enhancement (PE) was used as parameter. For quantification of 18F-FDG PET-CT, maximum Standardized Uptake Value (SUVmax) of lesions was specified and statistically compared with PE. Results: 18F-FDG uptake in parasitic liver lesions was diagnosed by 18F-FDG PET-CT in 32 of 36 patients. Vascularization of liver lesions was detected by CEUS in 22 of 32 FDG-positive patients with sensitivity of 69% and specificity of 100%. Mean maximum diameter of lesions was 69.5mm in CEUS and 63.7mm in B-scan ultrasound (p < 0.0001). No significant correlation was found between SUVmax and PE (p = 0.8879). Conclusion: In comparison to FDG PET-CT, the gold standard for detecting viable lesions by depicting metabolism, CEUS detects viable lesions with high specificity and moderate sensitivity by showing vascularization. CEUS must be regarded as an important tool in monitoring HAE. Dimensions of parasitic lesions are displayed more precisely through CEUS than in B-scan. With currently available methods, CEUS quantification has no benefit in monitoring HAE lesions in daily clinical practice.

Associations of fatty liver disease and other factors affecting serum SHBG concentrations: a population based study on 1657 subjects

Sex hormone binding globulin (SHBG) is a glycoprotein expressed predominantly in the hepatocytes. It regulates the transport of sex steroid hormones in the blood stream to their target tissues. The expression of the SHBG gene is subject to multifactorial regulation including hormonal, metabolic, and nutritional aspects. Against this background, we investigated the effect of fatty liver and metabolic syndrome, together with other parameters, on serum SHBG concentrations in a population-based cohort in Germany. This cross-sectional study included 870 women and 787 men (average age 42.3±12.8 years), who underwent ultrasound screening for fatty liver in addition to providing a complete medical history and undergoing physical and laboratory examination. Fatty liver was diagnosed on ultrasound criteria in 159 women (18.3%) and 287 men (36.5%). Fatty liver was shown to exert a significant influence on serum SHBG concentrations in men and in premenopausal women. Men with grade 1 fatty liver had a 1.96-fold increased risk (95%-confidence interval=1.28-3.02; p=0.0022) and postmenopausal women with grade 1 fatty liver a 2.4-fold risk (95%-confidence interval=1.11-5.27; p=0.0267) for low SHBG concentrations. Among metabolic parameters, HDL-C represented as affecting factor in men (p=0.0058) and premenopausal women (p=0.0002), while cholesterol only showed an association in premenopausal women (p=0.0439) and triglyceride in postmenopausal women (p=0.0436). No association of concentrations of SHBG and metabolic syndrome was observed. Age, BMI and waist-to-hip ratio also influence the SHBG concentration. Based on these findings, we conclude that fat accumulation in the liver influences SHBG concentrations in men and premenopausal women.

[Ultrasonographically guided biopsy procedures: current practice in hospitals with established departments of gastroenterology]

OBJECTIVE

Ultrasonographically guided adominal biopsies are a frequent daily procedure in German hospitals. There are, however, few guidelines or recommendations for these common procedures. The oive of the current study was to assess current practice with respect to ultrasonographically guided biopsy procedures in a survey of hospitals with established departments of gastroenterology or with over 500 beds.

MATERIAL AND METHOD

A questionnaire addressing the preparation for, procedure during, and post-interventional monitoring following ultrasonographically guided biopsies was mailed to 349 German hospitals. The response rate was 51 % (n = 177).

RESULTS

Establishment of an intravenous access is standard in 51.2 % (88/172) of the hospitals. Sedation analgesia is standard in 19.1 % (33/173) of the hospitals and is an option in a further 60.1 % (104/173). Local anesthesia is performed in 84.8 % (145/171) of the hospitals. A dedicated transducer for targeted biopsy is used in 40.6 % (81/176) of the hospitals, while 29.5 % (52/176) use a separate biopsy bracket attached to the probe. In 80.6 % (141/175) of the hospitals, a minimum platelet count of 50,000/µL is required. A minimum of 50 % is used as limit for quick in 86.5 % (147/170) of the hospitals. A value of 1 - 1.5 for the international normalized ratio (INR) is most commonly used in the hospitals. A partial thromboplastin time (PTT) between 28 and 50 sec. is used as the upper limit. Interruption of anticoagulants is handled in a very heterogeneous manner. Postinterventional monitoring following biopsy in ambulatory patients ranges from two to 24 hours.

CONCLUSION

Our survey shows relevant differences in preparation, execution and postinterventional monitoring in ultrasonographically guided biopsy procedures as routinely performed in German hospitals. There seems to be a need for a guideline standardising ultrasonographically guided biopsy procedures.

Non-fatal and fatal liver failure associated with valproic acid

Little is known about hepatotoxicity associated with valproic acid (VPA), a widely used substance in neuropsychiatry.All reported cases to the German Federal Institute for Drugs and Medical Devices between 1993 and 2009 of VPA-induced serious hepatic side effects were evaluated.A total of 132 cases of serious VPA-associated liver failure were identified. Approximately one third (34.8%) occurred under VPA monotherapy, while the majority was seen with VPA plus co-medication, most frequently antiepileptics (34.8%) and benzodiazepines (16.7%). A subgroup of 34 cases (25.8%) had a fatal outcome, the largest number reported to date. Of these, 32.4% were under VPA monotherapy and 67.6% under VPA plus concomitant medication. Within the study period a significant increase in the total number of reported cases and the subgroup of fatal cases was found.This first pharmacovigilance study of VPA-associated liver failure indicates a higher rate of non-fatal and fatal liver failure when VPA is given with co-medication as compared to monotherapy. However, co-medication per se does not increase the risk of fatalities.

Reference values and early determinants of intra-abdominal fat mass in primary school children

BACKGROUND

Intra-abdominal fat (IAF) is a valuable predictor of cardiovascular morbidity. However, neither reference values nor determinants are known in children.

METHODS

IAF was assessed as sonographically measured intra-abdominal depth in 1,046 children [median age 7.6 years, interquartile range (IQR) 7.2-7.9; 54% boys] of the URMEL-ICE study.

RESULTS

The intraclass correlation coefficient for intraobserver agreement was 0.93. The median IAF showed a significant gender difference (boys: 54.6 mm, IQR 50.1-59.3, vs. girls: 51.7 mm, IQR 46.3-56.4; p < 0.001). Age- and gender-specific centiles were generated. IAF showed a positive correlation to systolic blood pressure [regression coefficient (β) = 0.24 mm Hg/mm; p < 0.001] and a negative correlation to HDL cholesterol (β = -0.01 mmol/l/mm; p < 0.001). IAF showed a positive association with increased paternal and maternal BMI (β = 0.28 mm/kg/m(2) and 0.27 mm/kg/m(2); p < 0.001), increased weight gain in the first 2 years of life (β = 3.04 mm; p < 0.001), and maternal smoking during pregnancy (β = 2.4 mm; p = 0.001). Increased parental education was negatively associated with IAF (maternal: β = -0.65 mm/degree; p = 0.004, and paternal: β = -0.61 mm/degree; p = 0.002).

CONCLUSION

Sonography was a reliable tool to estimate IAF. Factors influencing IAF included rapid infant weight gain, smoking during pregnancy, and parental BMI and education. Since IAF showed an association with cardiovascular risk factors even in prepubertal children, it might become a valuable predictor of cardiovascular vulnerability.

[Research activity in abdominal ultrasonography in German university departments of gastroenterology - comparison between 1999 and 2009]

AIM

The aim of this study was to generate an overview of the current research situation in abdominal ultrasonography conducted by gasteroenterology departments of German university hospitals and to compare this situation with data from 1999.

METHODS

A survey was sent to all 36 German university hospitals encompassing information on research topics, number of research projects and publications, grants, and support by manufacturers of ultrasonography units. The response rate was 86 %.

RESULTS

74 % of gastroenterological departments had 113 ongoing research projects during the enquiry period - on average 3.6 projects per departement. Of these projects 43 % were clinical research, 11 % technical studies, 13 % various topics and 33 % studies with ultrasound contrast enhancers. Ten years ago 80 % of gastroenterological departments had research projects - on average 3.5 projects per department. There was no significant difference in the number of publications between the two enquiry periods. The percentage of publications in English had increased considerably from 57 % (1999) to 78 % (2009). Regarding scientific grants there was no relevant difference during the observed time spans. A total of 32 % (1999: 26 %) of departments receive external funding in addition to their regular budgets. Forty-five percent (1999: 31 %) receive support from manufacturers in the form of hard- and software for application studies.

CONCLUSION

Regrettably the research situation in abdominal ultrasonography has not improved considerably during the observed time span. As already stated in 1999, the urgent need for improved research funding for what is the most widely applied image modality still remains an ongoing concern.

[Gallbladder polyps: prevalence and risk factors]

PURPOSE

The objective of the present study was to investigate the prevalence of gallbladder polyps and possible risk factors in a random population sample of an urban population.

MATERIAL AND METHODS

A total of 2099 subjects (1072 women, 1027 men; aged 19 - 65 years, mean age 42.1 (SD ± 12.8 years) were prospectively examined using ultrasound, a standardized questionnaire and laboratory studies.

RESULTS

Gallbladder polyps were identified in 6.1 % (128 / 2099) of all subjects (women: 6.1 % [63 / 1027]); men: 6.1 % [65 / 1072]). Solitary polyps were found in 52.4 % (65 / 124), two polyps in 16.1 % (20 / 124), three polyps in 6.5 % (8 / 124), several polyps in 22.6 % (28 / 124) and multiple polyps in 2.4 % (3 / 124) of subjects. The mean polyp diameter was 4.7 mm (SD ± 2.2; range 2 - 20 mm). The polyp diameter was ≤ 7 mm in 94.5 % of subjects. The polyps were described as pedunculate in 82.3 % (102 / 124). The polyps were broad-based in 11.3 % of subjects (14 / 124; men: 18 % women: 4.8 %). The polyps were homogeneously echogenic in 100 % of cases and with irregular contours in only one male subject. Multiple logistic regression failed to demonstrate an influence on the increased occurrence of gallbladder polyps for the risk factors of male sex, age, body-mass index (BMI), alcohol, nicotine or caffeine consumption or diabetes mellitus.

CONCLUSION

The prevalence of gallbladder polyps reported in the present study (6.1 %) is higher than figures previously published for populations in Germany or Europe. The majority of polyps were pedunculate and solitary. A typical risk factor profile for gallbladder polyps could not be identified in the present population sample.

[The role of ceruloplasmin in the differential diagnosis of neuropsychiatric disorders]

The blue copper protein ceruloplasmin has been of interest to psychiatrists for decades following Heilmeyer's observation of elevated serum copper levels in schizophrenic patients. Immunoturbidimetry, however, does not yield elevated serum ceruloplasmin concentrations in schizophrenia while ceruloplasmin-related oxidase activity appears to be elevated in patients with schizophrenia and reduced in patients with Alzheimer's disease. Low serum concentrations of immuno-turbidimetrically measured ceruloplasmin, and of oxidase activity, are typical of Wilson's disease, Menkes' disease, and aceruloplasminemia, three familial neurodegenerative disorders of pronounced variability, with regard to both genotype and phenotype. Especially patients with Wilson's disease may exhibit behavioural symptoms only over a long period. Heterozygous carriers of Wilson's disease and aceruloplasminaemia may have low serum ceruloplasmin concentrations; they will not develop somatic symptoms, but the significance of these carrier states, or of "hypoceruloplasminaemia", with regard to mental disorders is unknown.

Contrast-enhanced ultrasound (CEUS) for the characterization of focal liver lesions in clinical practice (DEGUM Multicenter Trial): CEUS vs. MRI--a prospective comparison in 269 patients

PURPOSE

The aim of this prospective multicenter study was to assess the diagnostic role of CEUS in the diagnosis of newly discovered focal liver lesions in clinical practice. One important aspect is the comparison of CEUS with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

From 05 / 2004 to 12 / 2006, standardized CEUS was performed prospectively on 1349 patients with focal liver lesions that had been newly detected by fundamental ultrasound in order to determine tumor differentiation and tumor entity. 269 patients had a standardized MRI after CEUS. In typical liver hemangioma and focal nodular hyperplasia (FNH), the definitive diagnosis was based on the MRI as the "diagnostic gold standard" and on clinical evidence and additional follow-up (subgroup A) or on histology (subgroup B). 262 patients met the diagnostic standard that had been set.

RESULTS

In the subcollective (n = 262), the tumor differentiation (malignant or benign) of CEUS and MRI was concordant in 225 cases (85.9%), and the assessment of tumor entity in 204 cases (77.9%). In subgroup A (n = 180), concordant results for tumor differentiation were obtained in 169 (93.2%) and for tumor entity in 160 (88.9%) cases. Liver hemangiomas (n = 122) and FNH (n = 43) were most frequent. Subgroup B (n = 82) comprised mainly malignant liver lesions (n = 55), with only a few of hemangiomas (n = 8) or FNH (n = 5). Tumor differentiation was concordant in 56 (68.3%) and tumor entity in 44 cases (53.7%). There were no statistically proven differences between CEUS and MRI.

CONCLUSION

CEUS and MRI are of equal value for the differentiation and specification of newly discovered liver tumors in clinical practice. CEUS and MRI are extremely reliable for the differentiation of benign and malignant lesions, the diagnosis of liver hemangiomas and FNH. The characterization of metastases and HCC is also very reliable.

Gallstone prevalence and risk factors for gallstone disease in an urban population of children and adolescents

BACKGROUND

At present only a few sonography-based studies have assessed gallstone prevalence and associated risk factors in children and adolescents in randomly selected urban population samples. The aim of the present study was to analyze the prevalence of cholecystolithiasis and associated risk factors in children and adolescents.

METHODS

From a randomly selected urban population sample a total of 307 children and adolescents (157 girls, 150 boys; age 12 - 18 years, mean age 15.1 +/- 2.0 years) were studied using ultrasonography, standardized questionnaires and blood samples.

RESULTS

Three adolescents (one girl, two boys), corresponding to a prevalence of 1.0 %, showed gallstones. One 14-year-old girl and one 17-year-old boy were overweight using Cole's classification. A positive family history and female gender could not be confirmed as risk factors.

CONCLUSION

Obesity appears to be a risk factor in the development of gallstones in childhood and adolescence.

Comparison of panorama ultrasonography, conventional B-mode ultrasonography, and computed tomography for measuring liver size

PURPOSE

The objective of the present study is to compare the utility of extended field-of-view ultrasonography and conventional B-mode ultrasonography for determining liver size.

MATERIALS AND METHODS

The liver size in the medioclavicular line (MCL) was determined in 104 inpatients (females: n = 47; males: n = 57) using both ultrasound methods (Philips HDI 5000). The liver size measured in computed tomography (CT; MX 8000 IDT, Philips) served as the gold standard. The body mass index (BMI), ultrasound scanning conditions, and hepatomegaly identified by CT were evaluated as possible factors affecting the measurement accuracy of the sonographic methods.

RESULTS

The standard deviation of the differences between the measured pairs of values shows less dispersion in B-mode ultrasonography (18.7 mm) than panorama ultrasonography (20.8 mm). The mean value of differences between the measured pairs (bias) in the ultrasonographic methods compared to CT is considerably higher in panorama sonography (15.3 mm; SD = 20.8) than in B-mode ultrasonography (0.27 mm; SD = 18.7). A paired t-test of the mean values shows a significant difference between the ultrasonographic methods (p < 0.0001). In diagnosing or excluding hepatomegaly, B-mode sonography is consistent with CT findings in 84 (80.8 %) of 104 patients and panorama ultrasonography is consistent with CT findings in 77 (74.0 %) of 104 patients. Ultrasonographic methods show moderate agreement with each other (Kappa = 0.4265). Higher BMI and limited scanning conditions lead to an increase in the mean difference of measured pairs of values (bias) as well as to an increase in standard deviation of the differences (dispersion).

CONCLUSION

The determination of liver size in the medioclavicular line using panorama ultrasonography often leads to the false-positive diagnosis of hepatomegaly. Therefore, the method should not be recommended for routine diagnostic scans. In cases of significant hepatomegaly, however, panorama ultrasonography offers superior visualization compared to conventional B-mode ultrasonography.

Prevalence and risk factors of focal sparing in hepatic steatosis

PURPOSE

The prevalence, localization and potential risk factors for focal sparing were prospectively assessed in subjects with sonographically detectable hepatic steatosis as part of a population-based cross-sectional study.

MATERIALS AND METHODS

A total of 1,624 persons (n = 906 women; n = 718 men) were evaluated using ultrasonography, laboratory testing and a standardized questionnaire. The following were excluded from the analysis: subjects with reported alcohol consumption > 40 g/day (males) or > 20 g/day (females), those with known chronic hepatitis B or C infection, elevated serum transaminases (AST: m > 44 U/l, f > 33 U/l; ALT: m > 45 U/l, f > 35 U/l) and prior right nephrectomy.

RESULTS

The prevalence of focal sparing in patients with hepatic steatosis (grade I) was 25.6 % for men and 13.0 % for women. In patients with grade II/III disease, the prevalence was 70.9 % for men and 77.6 % for women. The most common site of focal sparing was in segment IV. The average diameter was 22.3 mm (range 7 - 84 mm). No correlation was found for postulated risk "age" (p = 0.09) or "status post cholecystectomy" (p = 0.09). Male sex (p = 0.02) and metabolic syndrome (odds ratio, 2.1; 95 % confidence interval, 1.1 - 4.1; p = 0.02) were confirmed as risk factors.

CONCLUSION

Sonographic evidence of focal sparing in subjects with hepatic steatosis is associated with an increased risk for metabolic syndrome and may be an easily obtained diagnostic criterion in routine clinical settings.

Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions - prospective comparison in clinical practice: CEUS vs. CT (DEGUM multicenter trial). Parts of this manuscript were presented at the Ultrasound Dreiländertreffen 2008, Davos

AIM

The aim of our study was to evaluate the diagnostic value of Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions in a prospective multi-center study in clinical practice. For this purpose CEUS was compared with the spiral-CT (SCT), the standard radiological method.

MATERIAL AND METHODS

1349 patients with unclear liver lesions after fundamental ultrasound diagnostics including color doppler analysis were examined with standardized CEUS (pulse inversion method, mechanical index < 0.4) from May 2004 to December 2006 in 14 hospitals in a prospective study. The enhancement of contrast medium in the liver tumors was analyzed according to known tumor-specific vascular patterns, using standardized documentation and analysis methods for the differentiation of tumor differentiation (malign or benign) and tumor specification (entity). A subcollective of 267 patients was additionally examined by standardized SCT method. Final diagnosis was based on histology, SCT or MRI in typical findings of liver hemangioma and FNH and on proved clinical data and additional follow up.

RESULTS

The subcollective of 267 patients was divided in two subgroups. In 109 of these patients (subgroup A) there was no histological verification, diagnoses based on clear SCT-findings in 79 cases of hemangioma or FNH, as well as in 20 cases with a clear clinical diagnosis. 6 cases (5.5 %) remained unclear. In this subgroup the assessment of tumor differentiation was concordant with CEUS in 90 cases, discordant in 19 cases and the assessment of tumor specification was concordant in 82 and and discordant in 27 cases. In 158 patients (subgroup B) a histological finding was also present, only in 4 cases no definitive tumor diagnosis was achieved. In this subgroup assessment of tumor differentiation with CEUS and SCT was concordant in 124 cases and discordant in 30 cases (CEUS/SCT: sensitivity 94.0 / 90.7 %, specificity 83.0 / 81.5 %, PPV 91.6 / 91.5 %, NPV 87.5 / 80.0 %, accuracy 90.3 / 87.8 %). Tumor specification matched in 103cases and were different in 51 cases (CEUS/SCT: sensitivity 95.3 / 90.6 %, specificity 83.7 / 81.6 %, PPV 92.7 / 91.4 %, NPV 89.1 / 80.0 %, accuracy 91.6 / 87.7 %). A statistically significant difference could not be established. The analysis of particular tumor specification showed a statistically non significant slight advantage in tumor differentiation for CEUS in the case of hemangioma, FNH, HCC and metastases.

CONCLUSION

In a multi-center approach under routine clinical conditions, this prospective study demonstrates CEUS to be of equal rank to the CT-scan in regard to the assessment of tumor differentiation and specification. No statistically significant differences could be established. CEUS should be employed before computed tomography is performed for the differentiation of liver tumors, because radiation exposure and invasive biopsies can be avoided in veritable numbers of cases, when precise clinical evaluation of the findings is implemented.

Comparison of sonographically measured bowel wall vascularity, histology, and disease activity in Crohn's disease

The purposes of this study was to provide a retrospective comparison of semiquantitatively measured bowel wall vascularity by power Doppler sonography, endoscopic-histopathological biopsy findings, and disease activity in patients with confirmed Crohn's disease. Thirty-two out of 1,332 patients with histologically confirmed Crohn's disease (18 female, 14 male; mean age 38.8 years) met the inclusion criteria: ileocolonoscopy with biopsy and power Doppler sonographic determination of bowel wall vascularity with assessment of disease activity within a period of 5 days. Sonographic determination of bowel wall vascularity was based on a semiquantitative score. Endoscopic bowel wall biopsy specimens were assessed using a self-developed inflammation score and the disease activity was calculated using Crohn's disease activity index (CDAI). A significant association (p < 0.05) was shown for results of histology and bowel wall vascularity in the terminal ileum (kappa = 0.66; sensitivity 95%; specificity 69%). There was no observed association between CDAI and histology, although there was an association between CDAI and bowel wall vascularity (sensitivity 82%). Increased bowel wall vascularity in the terminal ileum measured by power Doppler ultrasound reflects inflammatory activity in histologically examined bowel wall. Power Doppler ultrasound may be able to monitor activity changes of the bowel wall determined by pharmaceutical treatment.

Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice (DEGUM multicenter trial)

PURPOSE

To evaluate the diagnostic benefit of contrast-enhanced ultrasound for the differential diagnosis of liver tumors in clinical practice.

MATERIALS AND METHODS

From May 2004 to December 2006 1349 patients (male 677, female 672) with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by contrast-enhanced ultrasound using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). The Tumor status was assessed based on the vascularity pattern and contrast enhancement seen in focal lesions during the arterial, portal, and late phase. The diagnosis established after contrast-enhanced ultrasound was compared to histology (> 75% cases) or in some cases to CT or MRI.

RESULTS

The final diagnosis of hepatic tumors included 573 benign hepatic tumors (hemangiomas n = 242, focal nodular hyperplasia n = 170, hepatocellular adenoma n = 19, other benign lesions n = 142) and 755 malignant hepatic tumors (metastases n = 383, hepatocellular carcinoma n = 279, other malignant lesions n= 93). The overall diagnostic accuracy of contrast-enhanced ultrasound in comparison to the correct final diagnosis based on the combined gold standard was 90.3%. Contrast-enhanced ultrasound was able to correctly assess 723/755 malignant lesions (sensitivity 95.8%) and 476/573 benign lesions (specificity 83.1%). The positive predictive value of contrast-enhanced ultrasound for the diagnosis of a malignant tumor was 95.4% and the negative predictive value of contrast-enhanced ultrasound was 95.7%.

CONCLUSION

Contrast-enhanced ultrasound clearly improves the differential diagnosis of hepatic tumors and is very helpful in clinical practice when B-scan or power Doppler morphological criteria are missing.

A case of sporadic Echinococcus granulosus infection originating from Southern Germany

A 67-year-old woman with cystic echinococcosis (CE) is presented. She had complained of upper abdominal discomfort due to large hepatic cysts. These cysts showed no typical infrastructure characteristic for CE and she had never left the rural areas of southern Germany. Most remarkably, this area is highly endemic for alveolar echinococcosis, caused by Echinococcus multilocularis, but only sporadic cases of CE have been described. Due to the discrepancy between positive Echinococcus serology, atypical morphology and residency in an area non-endemic for Echinococcus granulosus, diagnostic puncture was performed with albendazole coverage. Puncture was complicated by anaphylaxis, from which the patient recovered without sequelae. The diagnosis of CE was highly likely due to the combination of positive serology with post puncture anaphylaxis, increasing antibody titers and eosinophilia. Retrospectively, the cysts had initially corresponded to the WHO stage CE 1. The patient was treated with albendazole for 15 weeks. Under treatment, the parasitic membrane detached from the cyst wall, revealing characteristic morphology for CE, now corresponding to the WHO stage CE 3. The patient remained asymptomatic during follow-up visits.

Comparison of contrast-enhanced power Doppler ultrasound (Levovist) and computed tomography in alveolar echinococcosis

BACKGROUND

To date, no study has compared unenhanced and contrast-enhanced (Levovist) power Doppler ultrasound with three-phase helical computed tomography (CT) for the analysis of the vascularization of hepatic lesions in patients who have alveolar echinococcosis.

METHODS

Fifteen patients (11 female and four male; average age, 45.8 years) with confirmed Echinococcus multilocularis infection underwent unenhanced and contrast-enhanced (Levovist) power Doppler ultrasound (2- to 5-MHz transducer head) and three-phase helical CT. The largest identified lesion in each patient was studied.

RESULTS

CT visualized vascularization peripheral or central to the largest echinococcal lesions in 11 of 15 patients. Vascularization in the area of the echinococcal lesions was not visualized by unenhanced or contrast-enhanced power Doppler ultrasound in any of the 15 patients studied.

CONCLUSION

Three-phase helical CT visualizes the vascularization associated with Echinococcus multilocularis lesions in the liver. Neither unenhanced nor contrast-enhanced ultrasound in power mode is suitable for this application.

[Intestinal wall vascularisation in Crohn's disease]

BACKGROUND AND AIMS

In a pilot study the semi-quantitative classification of intestinal wall vascularisation as proposed by Limberg was evaluated.

PATIENTS AND METHODS

20 patients with confirmed Crohn's disease and clinical activity (10 male, 10 female, mean age 30.0 +/- 7.72 years, range 21 - 49 years, mean time since onset of disease 4.6 years, range 0 - 15 years) were included. CDAI, CRP, ESR, and the blood count were evaluated. Two and six weeks after inclusion into the study these examinations were repeated. All patients were treated with anti-inflammatory drugs. The intestinal wall thickness was measured with ultrasound. The vascularisation following the Limberg classification and the number of blood vessels per square centimetre were assessed in the power-Doppler mode.

RESULTS

The mean length of bowel segments with increased wall thickness (> 3 mm) at the beginning of the study was 20.3 cm (range 5 - 50 cm), the mean intestinal wall diameter 5.9 mm (range 4 - 9 mm). The mean density of blood vessels in the power-Doppler mode was 3.8 vessels/cm (2) (range 0 - 8 vessels/cm (2)), the median of Limberg levels was 2 (range 1 - 4). The density of blood vessels per cm (2) well correlated with the Limberg classification throughout the study (r = 0.2 at start; r = 0.94 at 1st follow-up; r = 0.91 at 2nd follow-up).

CONCLUSION

The classification for measuring intestinal wall vascularisation semi-quantitatively (as proposed by Limberg) proved to be easily applicable in routine sonography. Besides the measurement of intestinal wall thickness, activity indices, clinical and laboratory parameters, it may constitute an additional means for evaluation of disease activity.

Type II diabetes mellitus and impaired glucose regulation in Caucasian children and adolescents with obesity living in Germany

BACKGROUND

Recent studies reported an increased prevalence of type II diabetes mellitus in obese children and adolescents, especially in specific ethnic subgroups. The aim of this study was to determine the prevalence of type II diabetes mellitus and impaired glucose regulation in a large group of Caucasian children and adolescents with obesity living in Germany.

PATIENTS AND METHODS

A total of 520 subjects (237 boys, 283 girls) (mean age: 14.0+/-2.0 y (range 8.9-20.4 y)) with a BMI>97th percentile, BMI-SDS: 2.7+/-0.5 (range 1.9-4.6), who were consecutively admitted to an in-patient obesity unit participated in the study. A 2-h oral glucose tolerance test (1.75 mg of glucose per kilogram of body weight) was performed before entering a weight-loss program and capillary blood glucose concentrations were measured. Patients were categorized into normal glucose regulation, impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and diabetes. In addition, fasting venous blood was taken to determine the circulating insulin, C-peptide and lipids. Insulin resistance was estimated by homeostatic model assessment.

RESULTS

Type II diabetes was present in 1.5% (n=8) of the patients, two patients were admitted with already diagnosed type II diabetes and six patients were identified with yet unknown diabetes. IFG was detected in 3.7% (n=19) and IGT in 2.1% (n=11) of the patients. All together, in 6.7% (n=35) (95% confidence interval: 4.7-9.2%) of the patients, impaired glucose regulation (IFG, IGT) or diabetes was identified. These patients had a higher BMI-SDS, higher levels of fasting insulin and C-peptide and a higher insulin resistance index than the patients with normal glucose regulation. Risk factors for the occurrence of impaired glucose regulation were a BMI-SDS>2.5 as well as a positive parents' history for diabetes.

CONCLUSIONS

This is the first report on the prevalence of type II diabetes in a large cohort of Caucasian children and adolescents with obesity living in Europe. Impaired glucose regulation and type II diabetes were present in a substantial proportion of the patients studied. Screening for diabetes in severely obese children and adolescents (BMI-SDS>2.5) is therefore recommended. Patients identified with impaired glucose regulation need specific treatment programs in order to prevent progression to diabetes.

[Quantifying the inflammatory activity in Crohn's disease using CE dynamic MRI]

PURPOSE

Evaluation of dynamic contrast enhanced MRI in patients with Crohn's disease to assess local inflammatory activity.

MATERIAL AND METHODS

Prospective study of 13 patients with histologically proven Crohn's disease. Axial and coronal slices were acquired by a 1.5 T MR (Magnetom Vision, Siemens, Germany): T1 flash 2 D (TR 72.5 ms, TE 4.1 ms), T2 (TR 2730 ms, TE 138 ms), turbo-flash sequences T1 (TR 94.2 ms, TE 4.1 ms) post contrast media fat saturated (Magnevist, 0.2 ml/kg, flow 4 ml/s). In area of maximal thickening of terminal ileal wall, axial dynamic T1 sequences (TR 11 ms, TE 4.2 ms) were acquired every 1.5 s post contrast media application for a total duration of 1 min. Contrast uptake was subjectively measured by semiquantitative score and computed assisted ROI evaluation. MR parameters were correlated with CDAI (Crohn's disease activity index) and SAI (severe activity index).

RESULTS

Contrast uptake in the intestinal wall occurred after 18.5 s (range: 3.0 - 28.0), contrast upslope until plateau phase lasted for 16.1 s (range: 8.0 - 50.0). Maximum contrast enhancement into the bowel wall was 266 % (105 - 450 %) of baseline. After maximum contrast uptake, we observed a plateau phase in all cases for the total duration of measurement. A significant correlation existed for maximum contrast uptake to CDAI (r = 0.591; p = 0.033), for beginning of contrast upslope to the time until plateau phase (r = 0.822; p = 0.001), and for the time until plateau phase to CDAI (r = 0.562; p = 0.046). CDAI was on average 108, median 106; SAI was on average 114, median 115. SAI correlated significantly to CDAI (r = 0.874). Maximum contrast uptake, beginning of contrast upslope, and time until plateau phase were independent to creeping fat, local lymphadenitis, laboratory parameters, temperature, body mass index, heart frequency and systolic blood pressure.

CONCLUSION

Dynamic MRI enables to quantify local inflammatory activity of bowel wall in patients with Crohn's disease. Larger studies are necessary to establish this method in clinical routine.

[Comparison of conventional enteroclysis, intestinal ultrasound and MRI-enteroclysis for determining changes in the small intestine and complications in patients with Crohn's disease]

BACKGROUND

Enteroclysis, intestinal wall ultrasound (IWU) and abdominal magnetic resonance imaging (MRI) are three established methods in the diagnosis of Crohn's disease (CD). To date, however, the three methods have not been compared in one patient collective.

AIMS

The present prospective study compared the relative performance of IWU, MRI and enteroclysis in determining the extent of disease involvement and intestinal complications in patients with CD both at initial diagnosis and during follow-up.

PATIENTS AND METHODS

Included in the present study were 48 patients with confirmed CD (age: 19-66 years) examined with all three methods between August 1999 and December 2000. IWU was performed in B-mode with a 4-7 MHz convex transducer head and a 5-12 MHz linear transducer head by an experienced examiner. At MRI, T1 and T2 weighted sequenced (Flash 2D before and after intravenous application of gadolinium DTPA or TSE) were acquired in coronal and transverse planes. Enteroclysis was performed using conventional biphasic technique. Interpretation was conducted on the basis of a standardized catalogue of findings.

RESULTS

Changes in bowel segments consistent with inflammation were identified in 41 of 48 patients. All three methods returned equivalent findings with regard to the length of inflamed bowel segments (IWU, range: 3-25 cm, mean: 12 cm; MRI, range: 3-25 cm, mean: 10 cm; enteroclysis, range: 3-30 cm, mean: 11 cm) and wall thickness (IWU, range: 4-10 mm, mean: 7 mm; MRI, range: 5-10 mm, mean: 7 mm; of nine patients with stenotic change, five were correctly diagnosed with IWU (sensitivity, 55.6%; specificity, 97.4%), four with MRI (sensitivity, 44.4%; specificity, 100%) and six with enteroclysis (sensitivity, 66.7%; specificity, 100%). Fistulae were correctly identified in five patients with IWU (sensitivity, 55.6%; specificity, 97.4%), in four with MRI (sensitivity, 44.4%; specificity, 100%) and in six with enteroclysis (sensitivity, 66.7%; specificity, 100 %) of a total of nine patients with confirmed fistula formation. Abscesses were correctly identified in five patients with IWU (specificity, 66.7%; specificity, 100%), in five with MRI (sensitivity, 83.3%; specificity, 100%) and in no patients with enteroclysis (sensitivity, 0%; specificity, 100%) in six patients with abscesses.

CONCLUSION

Both IWU and MRI identify extent, severity and intestinal complications with adequate diagnostic accuracy in patients with CD. Both techniques possess the potential for replacing enteroclysis in the work-up of CD. Enteroclysis should be reserved for the work-up of complex fistula systems.

Therapy of osteoporosis in patients with Crohn's disease: a randomized study comparing sodium fluoride and ibandronate

BACKGROUND

Osteoporosis is a frequent complication in Crohn's disease. Although the efficacy of both sodium fluoride and aminobisphosphonates in postmenopausal osteoporosis has been investigated in long-term therapy studies, no long-term results are available regarding the effect of these agents in the management of osteoporosis in patients with Crohn's disease.

METHODS

Eighty-four patients with Crohn's disease and pathological bone mineral density findings were randomized to receive either vitamin D3 (1000 IU) and calcium citrate (800 mg) daily (group A) or sodium fluoride (25 mg b.d., group B) or intravenous ibandronate (1 mg every 3 months, group C) in addition to daily calcium/vitamin D substitution. On admission to the study and after 12 and 27 months, patients underwent dual-energy X-ray absorptiometry and radiological examination of the spine.

RESULTS

Sixty-eight patients completed the 1-year observation period and were available for the intention-to-treat analysis. No new vertebral fractures were diagnosed. In group A, lumbar bone density increased by 2.6% (P = 0.066, N.S.), in group B by 5.7% (P = 0.003) and in group C by 5.4% (P = 0.003). Therapy with sodium fluoride was associated with an increase in osteocalcin (N.S.), whereas administration of ibandronate was associated with a decrease in the resorption parameter, carboxy-terminal cross-linked type-I collagen telopeptide (P < 0.05). Both sodium fluoride and ibandronate resulted in significant decreases in the serum concentration of osteoprotegerin after 9 months (P < 0.001).

CONCLUSIONS

The findings of the present study show that both sodium fluoride and ibandronate are effective in combination with calcium and vitamin D substitution in the management of osteopenia and osteoporosis in patients with Crohn's disease. Both agents are safe and well tolerated, and induce continuous increases in lumbar bone density.

Long-term seropositivity against Echinococcus multilocularis in an epidemiological follow-up study in southwestern Germany (Römerstein)

BACKGROUND

Out of 2,560 participants in an epidemiological survey of alveolar echinococcosis (AE) performed in 1996 in southwestern Germany, 47 participants had tested seropositive in one of two crude antigen screening ELISAs and were inconspicuous on hepatic ultrasound.

PATIENTS AND METHODS

Out of these 47 seroreactors, 36 attended a follow-up examination 30 months after the primary examination, including ultrasound and serology with various Echinococcus multilocularis-specific antigens.

RESULTS

No lesion suspicious for AE was detected in any participant. Serology showed only minor changes as compared to the earlier results.

CONCLUSION

Persistent seropositivity without detectable hepatic lesions could be interpreted as an early sign of sonographically not yet detectable AE, immunity to E. multilocularis or unspecific serological reactivity. For seropositive and clinically inconspicuous inhabitants of areas endemic for AE follow-up examinations at intervals of 2-3 years seem to be adequate.