COVID-19 und Gastroenterologie

Die COVID-19-Pandemie hat die Welt verändert. Diese Ausgabe der Zeitschrift "Die Gastroenterologie" legt ihren Fokus auf die Auswirkungen von COVID-19 auf die Gastroenterologie und die Hepatologie. K. Schütte und C. Schulz geben einen Überblick über die gastroenterologischen Aspekte der COVID-19-Pandemie. Ein signifikanter Teil von PatientInnen mit SARSCoV-2-Infektion berichtet über gastrointestinale Symptome. So zeigt eine jüngere prospektive multizentrische Studie, in die wegen COVID-19 hospitalisierte PatientInnen eingeschlossen wurden, eine Anorexie bei 49,8%, Diarrhö bei 39,4%, Übelkeit und Erbrechen bei 27,4% und abdominelle Schmerzen bei 20,7% der PatientInnen zum Zeitpunkt der stationären Aufnahme [1]. Die AutorInnen besprechen darüber hinaus die sektorenübergreifend signifikanten Auswirkungen der COVID-19-Pandemie auf die Versorgungsstrukturen in der Gastroenterologie. Neben den Herausforderungen für die Aufrechterhaltung einer guten medizinischen Versorgung aller PatientInnen sehen die AutorInnen zukünftige Herausforderungen insbesondere darin, die Tätigkeit im Gesundheitssystem durch strukturelle, inhaltliche und psychologische Unterstützung der AkteurInnen attraktiv zu halten und auch unter den Umständen einer Pandemie eine qualitativ hochwertige Ausbildung im pflegerischen und ärztlichen Bereich sicherzustellen. Mit diesen Herausforderungen und Folgen spezifisch für die Endoskopie und das Endoskopiepersonal beschäftigt sich der Beitrag von P. Mester, A. Kandulski et al. Endoskopische Untersuchungen des oberen Gastrointestinaltrakts können als aerosolgenerierende Prozeduren eingeordnet werden. Die Verwendung von persönlicher Schutzausrüstung („personal protective equipment“, PPE) als infektionspräventive Maßnahme in der Endoskopie ist effektiv und wahrscheinlich in ihrer Wirksamkeit höher einzuschätzen als präendoskopische Teststrategien. Die AutorInnen zeigen, dass die Präventionsstrategien während der Pandemie erfolgreich und die Infektionsraten des Personals in der Endoskopie durch die eingeleiteten nun evidenzbasierten Maßnahmen sehr gering waren

Flooding Induced Seismicity in the Ruhr Area – a geomechanics numerical modelling approach

The Ruhr region is characterized by centuries of coal mining at depths reaching more than 1000 meters. After the closure of the last mines, their controlled flooding started. The Floodrisk project investigates ground uplift, stress changes due to pore pressure changes and the reactivation potential of faults to explain induced seismicity. We focused on monitoring the eastern Ruhr area and are investigating in detail the relationship between mine water rise, tectonic stress and induced seismicity in the Haus Aden drainage area. In the region of the former "Bergwerk Ost", which had the highest seismicity in the Ruhr area during active mining, the RUB has installed a network of up to 30 short-period seismic stations. Continuous monitoring of seismicity and mine water levels is available for this region from the active mining phase through the post-mining phase to flooding. The temporal evolution of the mine water level after the pumps were shut down in mid-2019 shows a strong correlation with the temporal evolution of the observed microseismicity. Over 2200 induced events have been located since the beginning of flooding, showing spatial clustering. A comparison of the mine galleries, which today serve as the main underground waterways, with the localizations of the events shows that most of the events occur about 300 m below the main pillars located between the longwall panels. This study provides a compilation of the regional stress state in the eastern Ruhr area based on the mine measurements, which were re-evaluated to derive the regional stress component and compared with stress orientations from independent sources (information on stresses in deep boreholes and earthquake focal mechanisms). The spatial distribution of stress orientations in the Ruhr region shows a rather homogeneous stress pattern with only very few locations where stress orientations differ significantly from the average. Based on the geometry of the pillars, shafts and longwall panels, a generic numerical FE-model was developed using the compiled stress data for model calibration. The results indicate increased vertical stresses within and below the pillars as a result of stress arching. The horizontal stress changes are minor, thus differential stress increases in the vicinity of the event localization

COVID-19 und Lebererkrankungen

Bis zu 53 % der PatientInnen mit Coronavirus Disease 2019 (COVID-19) weisen eine hepatische Beteiligung auf. Durch die Expression der Hauptzielstruktur für „severe acute respiratory syndrome coronavirus type 2“ (SARS-CoV-2), des Angiotensin-converting-Enzym-2(ACE2)-Rezeptors, auch auf Cholangiozyten, sinusoidalen Endothelzellen und Hepatozyten kann es zu einer direkten Schädigung der Leber kommen. Ferner spielt eine indirekte (nicht durch Rezeptoren vermittelte) Schädigung der Leber im Rahmen von COVID-19 durch eine schwere systemische Inflammation mit Zytokinsturm, hepatischen Thrombosen und einer systemischen Hypoxie eine wichtige Rolle. Bei COVID-19 gelten Leberwerte als wichtige Prädiktoren für die Prognose der PatientInnen. Wichtig ist es hierbei Differenzialdiagnosen für die Leberwerterhöhung, wie andere Virusinfektionen, medikamentös-toxisch induzierte Leberschädigung sowie autoimmune, metabolische und andere Lebererkrankungen, abzuklären. Von hoher klinischer Relevanz für die Behandlung kritisch kranker PatientInnen auf der Intensivstation ist das Krankheitsbild der „secondary sclerosing cholangitis in critically ill patients“ (SSC-CIP). Hierfür sind unter anderem hochdosierte Katecholamine, eine Beatmung mit hohem positivem endexspiratorischem Druck (PEEP) und die extrakorporale Membranoxygenierung (ECMO) Risikofaktoren. Eine frühe Diagnose dieser Erkrankung und Behandlung mittels interventioneller endoskopischer retrograder Cholangiographie (ERC) ist hierbei von entscheidender Bedeutung. Auch sollte eine Lebertransplantation evaluiert werden. Bei einer COVID-19-Erkrankung treten Fälle mit SSC, sog. COVID-SSC, auf. Die COVID-SSC und die SSC-CIP sind im klinischen Phänotyp, Risikofaktoren, Prognose und transplantatfreien Überleben vergleichbar. PatientInnen mit vorbestehender Lebererkrankung haben kein erhöhtes Risiko für eine Infektion mit SARS-CoV‑2, erkranken jedoch schwerer an COVID-19 als PatientInnen ohne Lebervorerkrankungen. Bei PatientInnen mit einer vorbestehenden Leberzirrhose kann eine SARS-CoV-2-Infektion ein akut-auf-chronisches Leberversagen (ACLF) induzieren. Hierbei handelt es sich um ein Krankheitsbild mit einer sehr hohen Mortalität, das im Rahmen einer intensivmedizinischen Behandlung therapiert werden muss. ---------------------------------------------------- In patients with coronavirus disease 2019 (COVID-19), hepatic involvement occurs in up to 53% of all cases. Via the primary target for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), the angiotensin-converting enzyme 2 (ACE2) receptor, expressed on cholangiocytes, sinusoidal endothelial cells, and hepatocytes, direct damage to the liver may occur. Furthermore, indirect (= not receptor-mediated) damage to the liver plays a crucial role in the context of COVID-19 due to severe systemic inflammation with cytokine storm, hepatic thrombosis, and systemic hypoxia. In COVID-19, liver enzymes are considered significant predictors of outcome. Thus, it is essential to rule out other causes of liver enzyme elevation, such as other viral infections, drug-induced liver injury, and metabolic, autoimmune and other liver diseases. Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is highly relevant in treating critically ill patients in the intensive care unit (ICU). Risk factors for SSC-CIP include high doses of catecholamines, high positive end-expiratory pressure (PEEP), and extracorporeal membrane oxygenation (ECMO) therapy. Early recognition of this disease and treatment by endoscopic retrograde cholangiography (ERC) is crucial. Furthermore, liver transplantation should be evaluated. Some patients with COVID-19 are diagnosed with SSC, which is termed COVID-19-associated SSC. COVID-19-associated SSC and SSC-CIP are comparable with regard to clinical phenotype, risk factors, prognosis, and graft-free survival. Patients with pre-existing liver disease are not at increased risk for infection with SARS-CoV‑2 but show more severe clinical courses of COVID-19 than patients without pre-existing liver disease. Patients with pre-existing liver cirrhosis may develop acute-on-chronic liver failure (ACLF) upon infection with SARS-CoV‑2. ACLF has a high mortality rate, which must be treated in the ICU

Implementing an interprofessional point-of-care ultrasound protocol for dyspneic patients in an emergency department as a blended learning concept—Feasibility of Employing Thoracic Ultrasound in Shortness of Breath

ObjectiveDyspnea is a common symptom in the Emergency Department, with a wide variety of differential diagnoses. Previous research has demonstrated the diagnostic accuracy of Point-of-Care Ultrasound (POCUS) in this field of interest. Our goal was to better establish sonography in our emergency department with a practicable and time effective method. Therefore, we implemented a sonography protocol in an interprofessional emergency team using blended learning as a modern didactic approach and evaluated the learning and teaching success. We named the study FETUS, which stands for “Feasibility of Employing Thoracic Ultrasound in Shortness of Breath.”MethodsA demonstration of the POCUS protocol was given, followed by individual supervision during clinical routine. A written manual, a pocket card, and further materials for personal training supplemented the training. A post-training questionnaire measured several parameters regarding the training, e.g., subjective skill-acquisition or media use.Results32 medical and nursing staff participated in this study, 14 of whom completed the questionnaire. All training modalities offered were well received. A pre-post comparison of subjective sonographic competence shows a significant increase in both medical and nursing staff.The other items surveyed also indicate the success of the intervention undertaken.ConclusionThe use of different media as a blended learning approach can support the implementation of new measures in the ongoing working routine within an interprofessional team

Transient hypoglycemia as a rare cause of recurring transient loss of consciousness: a case report

Background Syncopes and transient loss of consciousness affect a large number of patients. Determining the underlying mechanism of a syncope is key to effectively treating and preventing future events. However, given the broad differential diagnosis of transient loss of consciousness, it can be challenging to determine the exact etiology. Case presentation This case presents a 42-year-old Caucasian female patient with recurrent transient loss of consciousness due to a hitherto undiagnosed impaired glucose tolerance and hyperinsulinism. The patient had been thoroughly tested for all typical causes of syncope without finding any causal explanation. An oral glucose tolerance test confirmed rapidly dropping blood glucose levels associated with rapidly fading consciousness as the underlying cause of transient loss of consciousness. Further diagnostic workup revealed that the patient suffered from impaired glucose tolerance and subsequent hyperinsulinism without overt diabetes mellitus. Nutritional counseling including reduction of glucose intake and frequently eating smaller meal portions led to a significant reduction in the frequency of transient loss of consciousness and overall improvement in quality of life. Conclusions The current European Society of Cardiology (ESC) guideline on syncope does not list hypoglycemia as a cause of transient loss of consciousness. However, this case report stresses that metabolic dysregulation can indeed lead to self-limited transient loss of consciousness. Thus, in the case of recurrent syncope with an unclear underlying mechanism, physicians should consider transient hypoglycemia and metabolic workup as a possible differential diagnosis

Leitsymptom Hämatemesis

Eine 62-jährige Patientin wurde notfallmäßig bei Hämatemesis, arterieller Hypotonie, Anämie und hämodynamischer Instabilität auf unsere Intensivstation aufgenommen. Bekannt war eine AL-Amyloidose mit kardialer Beteiligung und Omentuminfiltration. Im Rahmen dieser erhielt die Patientin 6 Tage vor dem Ereignis den zweiten Zyklus Chemotherapie mit Daratumumab und Cyclophosphamid, Bortezomib und Dexamethason. In der Medikation fanden sich Acetylsalicylsäure (ASS) und Apixaban bei Zustand nach akuter Beinischämie links. In der Notaufnahme trat eine weitere akute Hämatemesisepisode mit einem konsekutiven Hämoglobinabfall auf. Zur hämodynamischen Stabilisierung und zur notfallmäßigen endoskopischen Untersuchung und Blutstillung erfolgte die Verlegung auf unsere Intensivstation

Urinary chemerin as a potential biomarker for inflammatory bowel disease

Purpose: Systemic levels of the adipokine chemerin are elevated in different inflammatory conditions such as inflammatory bowel disease (IBD). In IBD, chemerin protein expression in colon mucosa is induced and serum chemerin levels are increased. Aim of this study was to identify chemerin protein in human feces and/or urine and to evaluate a possible association with IBD activity. Materials and methods: Feces and urine of 40 patients with IBD and the respective sera of 34 patients were collected. Chemerin levels were analyzed by immunoblot in feces and urine samples. In addition, enzyme-linked immunosorbent assay (ELISA) was used to measure chemerin in all urine, feces and serum samples of the patients and in urine of 17 healthy controls. Results: Chemerin was not detectable in 80% of the human feces samples by ELISA. Chemerin in human urine was detected by immunoblot and ELISA. Compared to serum levels, urinary concentration was about 6,000-fold lower. Urinary chemerin did not differ between patients with ulcerative colitis (n = 15) and Crohn’s disease (n = 25). Urinary chemerin was not related to its serum levels, did not correlate with serum C-reactive protein level and negatively correlated with serum creatinine. Of note, urinary chemerin of patients with a fecal calprotectin > 500 μg/g was significantly higher compared to patients with lower calprotectin levels and compared to healthy controls. Serum creatinine did not differ between the patient groups. Conclusion: Urinary chemerin might present a novel non-invasive biomarker for monitoring IBD severity and clinical course