Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most ...common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.
This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.
The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online ( https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf ).
ZusammenfassungHintergrundSeit 2003 ist in Deutschland ein Rückgang der altersstandardisierten Erkrankungsraten des kolorektalen Karzinoms (CRC) zu beobachten. Trotzdem betrifft etwa jede achte ...Krebserkrankung das Kolon oder Rektum. Die Prognose hat sich verbessert, die relative 5‑Jahres-Überlebensrate mit Darmkrebs liegt um 65 %.MethodenDie positive Entwicklung ist vermutlich auch Folge der Vorsorgemaßnahmen der letzten 20 Jahre. Diese könnten weiter verbessert werden, da das CRC nicht nur früh entdeckt, sondern in fast allen Fällen durch die Aufdeckung noch harmloser Vorstufen vermieden werden könnte. Neben der Koloskopie sollten weitere, eventuell auch bildgebende Testverfahren erprobt und angeboten werden, die eine geringere Schwelle darstellen. Die virtuellen Verfahren der Kolographie haben nach der Studienlage ab einer Polypengröße >5 mm eine der Endoskopie vergleichbare Genauigkeit von etwa 90 %. Für die Computertomographie (CT) ist die Datenlage sehr viel umfangreicher als für die Magnetresonanztomographie (MRT).SchlussfolgerungIn Deutschland stellen die Nichtverfügbarkeit der CT-Kolographie (CTC) im Screening aus Strahlenschutzgründen und die nicht ausreichende Etablierung der MRT eine große Herausforderung dar. Jeder Radiologe sollte die Klassifikation mittels CT Colonography Reporting and Data System (C-RADS) kennen. Dabei werden die Kriterien CT-Dichte, Morphologie, Größe und Lokalisation zur Klassifikation herangezogen. Die Klassifikation nach C‑RADS erfolgt in die Kategorien C0 (inadäquate Studie), C1 (unauffällig), C2a (unklar), C2b (benigne), C3 (verdächtig) und C4 (maligne) sowie extrakolonisch E1/2 (keine klinisch bedeutsamen Befunde) E3 (vermutlich unbedeutende Befunde) und E4 (vermutlich bedeutende Befunde).
Hospital Reform Wessling, Johannes
RöFo : Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebende Verfahren
196, Številka:
3
Journal Article
AIM:To compare endoscopic retrograde cholangio-pancreatography(ERCP),intraductal ultrasound(IDUS),endosonography(EUS),endoscopic transpapillary forceps biopsies(ETP)and computed tomography(CT)with ...respect to diagnosing malignant bile duct strictures.METHODS:A patient cohort with bile duct strictures of unknown etiology was examined by ERCP and IDUS,ETP,EUS,and CT.The sensitivity,specificity,and accuracy rates of the diagnostic procedures were calculated based on the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery.For each of the diagnostic measures,the sensitivity,specificity,and accuracy rates were calculated.In all cases,the gold standard was the histopathologic staging of specimens or long-term follow-up of at least 12 mo.A comparison of the accuracy rates between the localization of strictures was performed by using the Mann-Whitney U-test and theχ2test as appropriate.A comparison of the accuracy rates between the diagnostic procedures was performed by using the McNemar’s test.Differences were considered statistically significant if P<0.05.RESULTS:A total of 234 patients(127 males,107 females,median age 64,range 20-90 years)with indeterminate bile duct strictures were included.A total of 161patients underwent operative exploration;thus,a surgical histopathological correlation was available for those patients.A total of 113 patients had malignant disease proven by surgery;in 48 patients,benign disease was surgically found.In these patients,the decision for surgical exploration was made due to the suspicion of malignant disease in multimodal diagnostics(ERCP,CT,or EUS).Fifty patients had a benign diagnosis and were followed by a surveillance protocol with a followup of at least 12 mo;the median follow-up was 34 mo.Twenty-three patients had extended malignant disease,and thus were considered palliative.A comparison of the different diagnostic tools for detecting bile duct malignancy resulted in accuracy rates of 91%(ERCP/IDUS),59%(ETP),92%(IDUS+ETP),74%(EUS),and 73%(CT),respectively.In the subgroup analysis,the accuracy rates(%,ERCP+IDUS/ETP/IDUS+ETP;EUS;CT)for each tumor entity were as follows:cholangiocellular carcinoma:92%/74%/92%/70%/79%;pancreatic carcinoma:90%/68%/90%/81%/76%;and ampullary carcinoma:88%/90%/90%/76%/76%.The detection rate of malignancy by ERCP/IDUS was superior to ETP(91%vs 59%,P<0.0001),EUS(91%vs74%,P<0.0001)and CT(91%vs 73%,P<0.0001);EUS was comparable to CT(74%vs 73%,P=0.649).When analyzing accuracy rates with regard to localization of the bile duct stenosis,the accuracy rate of EUS for proximal vs distal stenosis was significantly higher for distal stenosis(79%vs 57%,P<0.0001).CONCLUSION:ERCP/IDUS is superior to EUS and CT in providing accurate diagnoses of bile duct strictures of uncertain etiology.Multimodal diagnostics is recommended.
Abstract
Background and study aims
Due to demographic transition, neurogenic dysphagia has become an increasingly recognized problem. Patients suffering from dysphagia often get caught between ...different clinical disciplines. In this study, we implemented a defined examination protocol for evaluating the whole swallowing process by functional endoscopy. Special focus was put on the esophageal phase of swallowing.
Patients and methods
This prospective observational multidisciplinary study evaluated 31 consecutive patients with suspected neurogenic dysphagia by transnasal access applying an ultrathin video endoscope. Thirty-one patients with gastroesophageal reflux symptoms were used as a control group. We applied a modified approach including standardized endoscopic positions to compare our findings with fiberoptic endoscopic evaluation of swallowing and high-resolution manometry. The primary outcome measure was feasibility of functional endoscopy. Secondary outcome measures were adverse events (AEs), tolerability, and pathologic endoscopic findings.
Results
Functional endoscopy was successfully performed in all patients. No AEs were recorded. A variety of disorders were documented by functional endoscopy: incomplete or delayed closure of the upper esophageal sphincter in retroflex view, clearance disturbance of tubular esophagus, esophageal hyperperistalsis, and hypomotility. Analysis of results obtained with the diagnostic tools showed some discrepancies.
Conclusions
By interdisciplinary cooperation with additional assessment of the esophageal phase of deglutition using the innovative method of functional endoscopy, the diagnosis of neurogenic disorders including dysphagia may be significantly improved, leading to a better clinical understanding of complex dysfunctional patterns. To the best of our knowledge, this is the first study to show that a retroflex view of the ultrathin video endoscope within the esophagus can be safely performed. NCT01995929
The aim of this study was to determine whether individually tailored protocols for the injection of contrast medium (CM) result in higher and more homogeneous vascular attenuation throughout the ...coronary arteries at coronary CT angiography compared with conventional injection protocols using fixed injection parameters. Of 120 patients included in the study, 80 patients were randomized into two groups. Group 1 received 80 mL of CM at 6 mL/s. For group 2 injection parameters were individually adjusted to patient weight, the duration of CT data acquisition, and attenuation parameters following a test bolus. In the control group (group 3) the volume of CM was adjusted to the duration of CT data acquisition and injected at 5 mL/s. Attenuation was measured in the proximal, middle, and distal right coronary artery (RCA), in the proximal and middle left anterior descending artery (LAD), and in cranial and caudal sections of both ventricles. Patient parameters, scan delay, and scan duration did not differ significantly between the groups. Mean CM volume was 82.5 mL (flow rate 5.1 mL/s) in group 2 and 73.5 mL in group 3. Attenuation in both RCA and LAD was significantly higher for group 2 vs. group 3 (RCA: 414.9(±49.9)–396.1(±52.1) HU vs. 366.0(±64.3)–341.6(±72.5) HU; LAD: 398.9(±48.6)–364.6(±44.6) HU vs. 356.3(±69.5)–323.0(±67.2) HU). For group 1 vs. group 2 only attenuation in the distal RCA differed significantly: 396.1(±52.1) vs. 370.7(±70.5) HU. Individually tailored CM injection protocols yield higher attenuation, especially in the distal segments of the coronary vessels, compared with injection protocols using fixed injection parameters.
Kolorektale Karzinome gehören in Deutschland mit ca. 64 000 Neuerkrankungen und
26 000 Todesfällen pro Jahr zu den häufigsten malignen Tumoren. Etwa 55% dieser
Tumoren entstehen dabei im Rektum. Zur ...bestmöglichen medizinischen Versorgung
ist die richtige Bestimmung des lokalen Tumorstadiums unerlässlich. Dieser
Artikel gibt einen Überblick über die richtige Durchführung und die
entscheidenden Bewertungskriterien einer MRT beim Rektumkarzinom.
The purpose of this study was to assess the effect of dose reduction and the potential of noise reduction filters on image quality and the detection of liver lesions using MSCT. Twenty-nine patients ...with a total of 40 liver lesions underwent 16-slice CT (120 kV; 180 mAs). Virtual noise was added to CT raw datasets simulating effective mAs levels of 155, 130, 105, 80, 55, 30 and 10 mAs. All datasets were post-processed with an edge-preserving noise-reduction filter (ANR-3D), yielding a total of 15 datasets per patient. Ten radiologists performed independent evaluations of image quality, the presence of liver lesions and diagnostic confidence. Quantitative noise and contrast-to-noise ratios (CNR) were obtained. Superior image quality (P < 0.02), reduction of image noise (P < 0.001) and the increase of lesion-to-liver CNR (P < 0.001) were observed in images processed with the ANR-3D filter. Sensitivity for lesion detection remained unchanged down to 105 mAs (CTDI(w) 6.6 mGy) without filter and 80 mAs (CTDI(w) 5.1 mGy) with ANR-3D. Confidence was rated significantly higher for datasets reconstructed with ANR-3D. The use of a noise-reducing, but edge-preserving filter (ANR-3D) is a promising option to reduce further the radiation dose in liver CT.
Since 2003, a decline in the age-standardized incidence rates of colorectal cancer (CRC) has been observed in Germany. Nonetheless, one in eight cancer cases still affects the colon or rectum. The ...prognosis has improved, with the relative 5‑year survival rate for CRC being approximately 65%.
This positive trend is probably a result of preventive measures introduced over the last 20 years. This could be further improved, however, as CRC can not only be detected early but in almost all cases also prevented through the identification of benign precursors. Less than half of all eligible individuals participate in screening via colonoscopy. This implies that further, possibly even imaging, screening test methods should be explored and offered. Studies have reported that virtual colonography techniques have a comparable accuracy to endoscopy of about 90% for polyp sizes larger than 5 mm. The data for computed tomography (CT) is more extensive than for magnetic resonance imaging (MRI).
Significant challenges are posed however by the fact that in Germany CT colonography (CTC) is not considered a viable screening option due to radiation protection concerns, and MRI screening is not an established screening method. Radiologists should be familiar with classification using the CT Colonography Reporting and Data System (C-RADS), which uses criteria such as CT density, morphology, size, and location for classification. C‑RADS classification follows the categories: C0 (inadequate study), C1 (normal), C2a (indeterminate), C2b (benign), C3 (suspicious), and C4 (malignant), as well as extracolonic categories E1/2 (no clinically significant findings), E3 (likely insignificant findings), and E4 (likely significant findings).
Beim Morbus Crohn kommt der MRT bei Diagnose, Verlauf und Therapie eine große Bedeutung zu. Dabei sind gemeinsame Befundungsstandards für die MRT (und den Darmultraschall) eine wichtige
Voraussetzung ...für die Zusammenarbeit von Gastroenterologen, Radiologen und Chirurgen. Die wesentlichen Standards sind in diesem Beitrag zusammengefasst.
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