The regional express stops once an hour in Paulinenaue, a 1,500-inhabitant hamlet northwest of Berlin . You need a half hour train ride to the capital or a car here, where Brunhilde and Erich Ernst are now living their “second life”, as they say. The two of them also experienced firsthand what mobility means and what immobility means. After all, Erich Ernst, now 64, had progressive kidney failure tied to his armchair. Dialysis or transplantation was the alternative. But the waiting list for a donor organ was long. The couple decided to have a live transplant: in the summer of 2010, she donated one of her kidneys to him.

Endlessly long waiting lists

The subject of living donation has been gaining in importance for years, including on World Kidney Day (March 13). In 1991, only three percent of the kidneys transplanted came from living donors; in 2011 it was almost 28 percent. The reason is not only medical progress, but above all the low readiness of Germans to donate organs post-mortem, and which has recently continued to collapse: from 2012 to 2013 alone, the number of organ donors fell by a sixth to only 876. There were too many reports of bogus Allocation methods and manipulation of the waiting lists in some German clinics unsettled people.

In addition, there is the sensitive issue of brain death diagnostics. Recently, too, there were individual cases where the prescribed procedure for determining brain death had not been followed exactly. This is another reason why living donation, although formally subordinate to corpse donation as the second-best solution, is more important and, given the endlessly long waiting lists, promoted and recommended by many doctors. Family members, but also close friends, can donate for one another. Also because these organs are rejected less often and function better and longer on average than post-mortem donations, this is a real plus for most recipients.

Skepticism among kidney recipients

So for Erich Ernst: Today, three and a half years after the transplant, he is back in his armchair, but now voluntarily. He cheerfully picks up the coffee cup and tells about the fact that he can be on the road, riding a motorcycle. “I also have a mini job as a truck driver again.” The joy of being able to lead an almost normal life again can be seen in him. But with his wife’s decision, he initially had his problems.

“At the beginning I would have preferred to wait to see if there was still an organ from the donor list,” he says. He was worried about his wife – and also about their daughter. “If something had happened to my wife and me during the operation.” But dialysis, the other option, would have meant a trip to Berlin to the dialysis center three times a week. “Neither of us wanted that,” says Brunhilde Ernst energetically and lovingly nudges her husband. “No, we wanted to have the good life a little longer.” But the path to living donation posed a number of hurdles for the couple.

In the case of the Ernsts, a process of several months for living donations is set in motion: preliminary medical examinations and health checks, blood group comparisons, consultations with doctors and psychologists, and finally the mandatory visit to the ethics committee, which has to rule out the fact that commercial interests are involved. “I was asked about my motivation and was told so often that in the end I could hardly hear it,” says Brunhilde Ernst. On June 15, 2010, the two of them came under the knife in parallel. “When I was pushed out, I shouted to my husband: If everything goes well, we’ll go on a cruise.”

The two are lucky. The operation succeeds and the new kidney works promptly. But while Erich Ernst recovers quickly, his otherwise agile wife feels as if the plug has been pulled out of her. “I was very, very tired and limp. The doctors had already announced this to me, and that’s how it was: I just sat in the garden chair all summer, nothing more was possible.” Only after a joint rehab in autumn does she slowly regain strength. “I’m fine today,” she says.

“Cannibalized and exploited”

But things don’t always run so smoothly. Ralf Zietz from Morsum near Bremen donated a kidney to his seriously ill wife in the summer of 2010 and is still suffering from the consequences today. Chronic exhaustion, difficulty concentrating, and forgetfulness make it difficult for him to continue doing his job. The self-employed entrepreneur and sole earner can now only work part-time. He sees himself as a victim of a lack of medical education. “During these conversations, we only talked about the usual risks of an operation, possibly scarring problems or high blood pressure.” However, he was left in the dark that weakness and exhaustion can also be permanent. “With what I know today, I wouldn’t have the operation done again.”

While his wife is clearly better again, Zietz does not get out of the postoperative low. “I felt exploited and exploited,” he describes in an ARD film. Even today he still seems emotionally badly affected by the loss of his performance. Together with other people affected, he founded a self-help group and has since been campaigning for more information about the possible side effects of living donation. In several places in Germany, those affected have already filed lawsuits against the transplant centers – due to insufficient information.

More education for living donors

Zietz estimates the proportion of living donors who permanently suffer from the consequences of chronic fatigue due to their inadequate kidney function at around ten percent. He cites a Swiss study, which, however, has not been published in full. Zietz and his colleagues oppose the fact that their complaints are often not viewed as a neurological but a psychological illness – and in the worst case without any right to compensation.

“It is undisputed that the fatigue syndrome (chronic exhaustion syndrome) also occurs in donors, but it also occurs in healthy people. There are no serious studies that show a higher incidence in donors,” says Professor Uwe Heemann from the university hospital Munich and Chairman of the Living Donation Foundation. It is similar with depression. “Especially when living donations are unsuccessful and the organ is rejected, it can lead to depressive moods.” So far, there has been no evidence of an increased risk compared to the normal population.

The donor’s fate is unpredictable

What Heemann sees as well as the community of interests around Zietz are problems with insurance. “The new transplant law has brought us a big step forward in terms of donor protection, but there are still questions about its concrete implementation. Are chronic fatigue or high blood pressure a possible, foreseeable consequence? And: does the accident insurance pay? Not?”

Brunhilde Ernst has had similar experiences. “I always mess with my health insurance company – for example when they don’t want to reimburse the travel expenses to Berlin for my aftercare because the clerks don’t know about the new law.” Ernst also came to the conclusion from her experiences that it makes sense to exchange ideas with those affected and to support them – she is networked nationwide in a self-help group. “At the time I would have liked to be able to speak to one or the other donor beforehand and hear about their experiences. Many now turn to us when they are in the decision-making phase.”

Living Donation – A Moral Question?

The Berlin psychologist Merve Winter is also interested in this phase – from a professional point of view. She assesses possible donors and accompanies them in the decision-making process at a university clinic. “There is definitely a moral imperative to living donations. And women often comply particularly quickly,” she sums up. In fact, 60 percent of living donors in Germany are women. 

Winter notes that not all potential donors are really clear about their motives. Feelings of guilt, misunderstood altruism, the desire to generate gratitude in the recipient – a lot can play a role here. “In addition to the many positive aspects that it brings with it, living organ donation is still a psychological and physical challenge and an unreasonable burden for those affected, especially for the donors,” emphasizes Winter in a study. She therefore advocates giving ambivalent feelings more space in advance and not simply suppressing them.

The transplant doctor Andreas Pascher from the Virchow-Klinikum of the Berlin Charité knows this ambivalent attitude of many potential donors, who are torn between fears and the desire to help. “About a tenth of those willing to donate are turned down for such psychosocial reasons,” he says. A study on the progress of living liver donations, co-authored by Pascher, sums up: “Most living liver donations show a positive postoperative course.” However, the decision-making process prior to the intervention should not be accelerated and the medical follow-up care of the donors should be supplemented by discussions. 

“I was terrified for him”

As the recipient of a partial liver donation from her father, Claudia Schneider from the Heilbronn area also experienced this emotional rollercoaster ride. “I was terrified for him and at first didn’t want to accept the donation. But he said: ‘If I don’t help you now and you die, then I can no longer live afterwards.’ He made his will and clarified everything. But when I woke up from the operating room everything went well. Even if my father had problems with his scar for a long time – today his liver has completely grown back, he is healthy. And our relationship is still more intimate than before. ” She laughs happily. “I stroke my new liver every day. This is something really big for me.” Nevertheless, she would not recommend such a step to anyone who asks her for advice. 

Claudia Schneider has just celebrated her milestone birthday at the age of 42 – her 10th with a new liver. The Zietz family fights their way back to life. And the Ernsts from Paulinenaue? They went on their big cruise.

There are three broad groups of disorders that are also the most common reasons for going to a psychotherapist: first, anxiety, second, depression, and third, addictions. To treat such disorders, psychotherapies have proven to be effective and promising. Eating disorders, sexual dysfunction, schizophrenia and bipolar disorders are sometimes more difficult to treat, says Jürgen Margraf, President of the German Society for Psychology. V. (DGPs). “For patients with schizophrenia or bipolar disorder, medication in combination with psychotherapy can therefore be useful.”

What happens in the therapy session

If someone seeks a psychotherapist, they will have the problem explained to them in an initial consultation. Within a maximum of five test sessions, the patient and therapist can then find out whether “the chemistry is right” between them. During these preliminary discussions, the therapist will make a diagnosis and explain whether treatment is necessary. He then submits an application to the cash registers. The approval for psychotherapy then also includes the number of hours. Only then does the therapy really begin. The scope of treatment depends on the mental illness and the severity of the disorder. In behavior therapy, short therapy lasting a total of 25 hours is usually sufficient.

“The health insurance companies take on two forms of therapy, behavioral therapy and psychodynamic therapies, including psychoanalysis,” says Margraf. “These forms of therapy have been scientifically recognized for a long time.” The regulations of the private insurance companies are different, so that those with private insurance should ask directly. The statutory health insurances only pay 100 percent of the costs if the therapist has a license to practice medicine and diagnoses a mental disorder with an illness value. These disorders are for example phobias, panic attacks, depression or compulsions. The therapist makes the diagnosis in the trial sessions.

Success rate is 80 percent

Behavioral therapy is the method of choice, says Margraf, especially for anxiety and depression – and thus for the most common disorders. In the case of anorexia and chronic pain, on the other hand, behavior therapy is generally less successful. Behavioral therapy focuses on current problems, but also on current strengths, and tries to change behavior. It is about how patients classify and evaluate information. The aim is to reinterpret situations with the help of the therapist and to practice healthier behavior. The motto here: Everything that has been learned can be unlearned again. Behavioral therapists do not want to look into the past, into childhood – but into the future. “The success rates are good.

The psychodynamic approaches go back to Freud and his students. They assume that the current problem is based on repressed feelings and memories. Using dream interpretations or free associations, the patient should get access to these emotions. “The symptom is traced back to a conflict from the past.”

Other approaches such as systemic therapy, body and art therapies are not (yet) adopted by the health insurances, but they achieve success in many cases. Especially as a supplement in holistic therapy concepts.

• The pathogen Toxoplasma gondii attacks the nerve tissue in the brain.
• This apparently leads to outbursts of anger in infected people.
• Animal studies have shown that the parasite can actually control mice remotely.

A traffic hooligan, pushing, honking or scolding may not be able to do anything for his outrageous behavior – his brain could simply be controlled by others. Parasites of the species Toxoplasma gondii may have nested in it and are now causing neuronal chaos.

At least this is what a study carried out by psychiatrists at the University of Chicago suggests on patients who have been noticed by aggressive behavior and sudden outbursts of anger. The work appears in the journal “Journal of Clinical Psychiatry”.

Twice as many outbursts of anger among infected people

It was found that people who had several seizures in succession were more than twice as likely to be infected by the pathogen as healthy people who had no psychiatric diagnosis.

The unicellular organism, one of the so-called protozoa, occurs worldwide and is widespread in the population. According to the Berlin Robert Koch Institute, 50 percent of Germans carry it in their bodies or have at least come into contact with it.

In the group of people over 50, the level of contamination is around 70 percent. It affects up to 16 million people in the United States, more than the country’s schizophrenia sufferers and those with bipolar disorder combined.

The pathogen usually affects cats

The actual host of the parasite is cats , which excrete it with their feces. People can get infected through smear infections, but also through contaminated water and the consumption of raw meat.

The infection usually proceeds without symptoms, but occasionally toxoplasmosis occurs, which is accompanied by flu-like symptoms. If women become infected during pregnancy, there is a risk of miscarriage.

Toxoplasma gondii affects the nervous tissue

Previous research found that Toxoplasma gondii affects nerve tissue in the brain and is associated with diseases such as schizophrenia , bipolar disorder, and suicidal ideation.

The Chicago scientists built on this. They examined 358 US citizens as test persons, one third of whom suffered from “pathological irascibility” (the technical term for the sudden attacks of aggression), another third from other mental disorders. The latter served as a control group to differentiate the irascibility from other ailments. The test subjects in the remaining third were mentally healthy.

In fact, blood analyzes and other tests showed that twice as many irascible patients had come into contact with the parasite than healthy subjects. The rates of the mentally ill group lay in between.

Sick people were much more aggressive

But the impulse control disorder – it was measured according to a point system – was much more pronounced in the irascible than in the other two groups, whose subjects hardly differed.

Overall, test subjects who tested positive in all groups were found to be significantly more aggressive and impulsive than those with a negative test result.

“Our work suggests that latent infections with Toxoplasma gondii can change brain chemistry in such a way that the likelihood of aggressive behavior increases,” explains study leader Emil Coccaro. “But we don’t know whether this connection is causal, because not everyone with a positive test result gets tantrums.”

Further studies are needed to find out. “A correlation is not yet a cause, above all it cannot be deduced from the fact that people should get rid of their cats,” adds Coccaro’s colleague Royce Lee, a co-author of the study. “We don’t yet understand the underlying mechanisms.”

This could be an inflammatory response in the body’s response to the infection, or it could be a direct modulation of the brain by the parasite. But a paradoxical reversal of the cause is also conceivable, Lee continues: Aggressive people could keep more cats or eat raw meat.

Further investigations will follow

Now the Chicago researchers want to investigate the connection between toxoplasmosis, aggressive behavior and pathological irascibility. They hope that this will provide further knowledge about the condition that will lead to new diagnostic and therapeutic methods. “We have to conduct experimental studies to see whether treating a latent infection reduces aggressiveness,” says lead author Coccaro. “Then it might prove sensible to fight toxoplasmosis first in irascible patients.”   

Several studies in recent years have shown that Toxoplasma gondii can actually change behavior.

The pathogen reprograms mouse brains

If the parasite attacks mice, it makes them forget their fear of cats so that they no longer flee from their enemy. Occasionally, infected rodents even run up to cats, attracted by the smell of their urine.

It seems like the mice are about to be eaten. This is exactly what the parasite wants to achieve, because it can reproduce sexually only in the cat’s intestine, so rodents are only intermediate hosts for it.

In 2015, scientists at the Indiana School of Medicine discovered how the pathogen reprograms the mouse brain: Apparently it modifies certain brain cells, namely the so-called star cells (astrocytes).

They help to supply the nerve cells with nutrients from the blood and generally maintain the physiological balance in the brain. In infected mice, certain proteins in the astrocytes were changed compared to the cells of healthy animals.

The task now is to find out whether this mechanism can change not only the character of mice, but also that of humans.

The passion for coffee is great in Germany . Germans prefer to drink espresso, cappuccino and latte macchiato rather than beer or mineral water. But for many, the guilty conscience tarnishes the pleasure, because coffee is suspected of being harmful to health. However, numerous studies have come to a different conclusion.

Udo Pollmer, food chemist and scientific director of the European Institute for Food and Nutritional Sciences (EULE), Munich, also gave the infusion of the ground coffee beans good marks. Coffee fans shouldn’t expect too much either, because, as is usually the case with food, the study results are contradictory.

Does Coffee Raise Cholesterol?

Coffee, as beans or powder, contains substances similar to fat, especially the terpenes Cafesol and Kawheol. “So to conclude that coffee raises cholesterol levels is nonsense. After all, there are no greasy eyes floating on the coffee, ”says food chemist Udo Pollmer. So far, studies have shown no long-term influence of coffee on blood cholesterol.

Does coffee increase the risk of a heart attack?

“For years there have been warnings about the harmful effects of coffee on cardiovascular diseases . However, this cannot be scientifically proven, ”says expert Udo Pollmer.

A study on more than 128,000 men and women showed that even more than six cups a day did not have a negative impact on the risk of heart attack. “There is even increasing evidence that coffee reduces the risk of heart attacks,” explains the scientist. A meta-analysis later came to the same conclusion.

Does coffee rob the body of fluids?

“Coffee contributes to the supply of fluids because it consists of almost 100 percent water,” says Udo Pollmer. Coffee has a slight diuretic effect, which is generally positive. The water balance of our body is not negatively influenced by the slightly diuretic effect of coffee, because the body can counter-regulate. Habitual coffee drinkers, however, no longer feel the diuretic effect at all, because their bodies get completely used to it.

Does coffee protect against cancer?

“So far, it is certain that coffee does not increase the risk of cancer,” says food expert Pollmer. Countless studies have examined the influence of coffee on various types of cancer.

According to Pollmer, it is now accepted that coffee protects the liver. Accordingly, the liver cancer rates in coffee drinkers are apparently falling. The exact reason for this is not yet known

Nevertheless, the expert advises: If you can’t tolerate coffee, you shouldn’t drink it because of its positive health aspects. In addition, based on research, it cannot be concluded that it is only the bean drink that protects against cancer. “There is much speculation about the influence of diet on cancer risk. The connections are probably much less than assumed, because the development of tumors is very complex and cannot be traced back to just one food, ”says the scientist.

Does Caffeine Increase Blood Pressure?

“Drinking coffee regularly does not increase blood pressure in the long term,” says the food expert. This is confirmed by a study of more than 155,000 women . Coffee has only a weak, short-term effect on blood pressure, if at all.

Does coffee prevent diabetes?

Coffee protects against diabetes, according to a study from Finland. Researchers from the country with the highest coffee consumption worldwide examined more than 14,000 women and men. The result: three to four cups reduce the risk of getting sick by almost 30 percent, ten cups reduce the risk for women by as much as 79 percent and for men by 55 percent.

“A number of other studies confirm the results of this study. On average, the data show that coffee halves the risk of diabetes, so that scientists now assume a protective effect. However, an effect can only be statistically proven from two to three cups a day and has so far only been proven for people who like coffee, ”says Udo Pollmer.

Is coffee addicting?

If you are used to coffee, you can experience slight withdrawal symptoms if you do not take the usual dose of caffeine. “Strong coffee drinkers react with headaches that disappear after about two days,” says food expert Udo Pollmer.

This is often the case on weekends, when coffee consumers forego their usual office decoration or when they drink a caffeine-free variety.

Nevertheless, coffee is not referred to as an addiction, because the dose does not have to be constantly increased as with a classic addiction.

Ever since sugar fell into disrepute as a health hazard, the food industry has had a problem. Because the nutrient is a perfect flavor carrier. Even hearty products like pizza or herring salad don’t taste good without sugar. Manufacturers of finished products have come up with a few tricks to lure consumers with the “little sugar” selling point.

The magazine “Öko-Test” looked at the tricks that the food industry uses to hide sugar. In addition, a laboratory tested 34 foods for their sugar content – with surprising results. Because who would think that

• Herring salad (Lysell Schwedenhappen) offers more sugar than salt ,
• Currywurst contains the equivalent of eight sugar cubes ,
• Pizza (Dr. Oetker Tradizionale Speciale) contains seven different sweetening ingredients ,
• in coleslaw Zucker (Nadler) to second place in the list of ingredients creates
• Ready coffee ( Rewe Best Choice Cappuccino with no added sugar ) brings a total of 30 sugar cubes ,
• Ketchup (good & cheap curry spice ketchup) with the equivalent of 110 pieces of sugar per bottle consists of 40 percent sugar ,
• Almost a third of a milk slice consists of sweetening ingredients, but that is “only” two pieces of sugar .

Many names for the desired taste “sweet”

As syrup, sweet whey, malt, honey, fructose, dextrose or agave syrup, the sweetening substances are also used in the tested spreads, breakfast cereals, smoothies, yoghurts, sauces and savory salads and add up to generous amounts of sugar.

To find the hidden sugars, you need to know the tricks the food industry uses to disguise the sweet stuff in their products:

Trick number 1: Instead of simply adding “sugar”, manufacturers often add glucose-fructose syrup, Detrose and sweet whey powder. In the list of ingredients, the sweeteners do not end up at the top, but in places 3, 5 and 9. 

Trick number 2: “Natural sweetness”, “fruit sweetness” – that sounds healthy, but it is also nothing more than a mixture of fructose and glucose and is therefore qualitatively equivalent to ordinary table sugar.

Trick number 3 : Everyone knows the terms sugar or syrup. But maltodextrin, oligofructose or dextrose? Anyone who wants to recognize sugar in any form has to learn many chemical terms.

Trick number 4 : “Less sweet” – this statement on a food does not necessarily mean that sugar has been saved, but that the product contains 30 percent less sweetener than a comparable food.

Trick number 5 : The smaller a manufacturer measures the portion quantity, the lower the proportion of the food in the total daily amount of sugar. So the content of sugar, but also fat, salt and calories are subtracted.

And how does the consumer find their way through this thicket of tricks? The experts from “Öko-Test” give two simple tips :

1. On the list of ingredients, look out for terms that end with “-ose”. All of this is cute.
2. To see the total sugar content, it is helpful to take a look at the nutritional value table.

Stomach cancer is not uncommon, with around 15,000 new cases per year on the list of carcinomas. 9,300 men and 5,600 women are affected. The cause of the gender difference is currently unknown.

Stomach cancer is not one of the most common cancers, but the chances of survival are not good. Two thirds ultimately die of the tumor disease. “We have to assume that three out of four patients will only be diagnosed in a locally extended or even metastatic situation,” reports Michael Stahl, head of the Clinic for Internal Oncology at the Evangelical Clinics Essen-Mitte (KEM).

This late diagnosis means that three quarters of the patients have a poor prognosis and cannot be cured with an operation alone, summarizes the oncologist, who is among other things the author responsible for the German guideline for the diagnosis and treatment of esophageal cancer and a member of the lead group of the Working Group on Internal Oncology for carcinomas of the stomach and esophagus.

Cause of stomach cancer unknown, but there are risk factors

“The only good relative risk factor for stomach cancer is the stomach germ Helicobacter pylori,” explains the expert. That would be risk factor number 1.

However, around a quarter of Germans are infected with this bacterium, but only a fraction of them develop gastric cancer. Why they get sick is not yet fully understood, just as much is still unknown about the causes of stomach cancer.

There is also evidence that smoking increases the risk. And what about alcohol? “However, there is no meaningful evidence that alcohol also increases the risk of stomach cancer,” adds the oncologist. However, it can lead to gastric mucosal inflammation, i.e. gastritis, up to and including gastric ulcer.

Chronic gastric mucosal inflammation and reflux disease could in turn increase the risk of gastric cancer at the junction with the esophagus.

Stomach cancer can also develop from previous operations on the stomach.

The reflux of bile is also considered a risk factor. This danger arises from being very overweight.

And on the subject of obesity and nutrition: Scientists assume that a one-sided diet with a lot of processed meat products, heavily salted, but also smoked and grilled foods promote stomach cancer – keyword nitrosamines, which are known to be carcinogenic. Rotten and moldy foods pose a general health risk, also with regard to stomach cancer.

Stomach cancer with certain genetic changes

In addition, there are genetic components in the development of gastric cancer: first-degree relatives (children, siblings) of patients with gastric cancer have an increased risk – that is, when the father, mother or sibling are ill. In addition, stomach cancer can occur if a certain form of colon cancer is already present (hereditary colorectal cancer) or breast cancer.

These are patients with changes in their genetic makeup, for example what is known as microsatellite instability (MSI). You are at an increased risk of various types of cancer, including cancer of the stomach and intestines. “Doctors should keep this in mind if a patient has a colon cancer with microsatellite instability , or if there are several carcinomas in the family,” emphasizes the oncologist from Essen.

However, all of these are only possible risk factors. “Of most patients who fall ill, we don’t know why, because none of these risk factors apply to them,” summarizes Michael Stahl.

Look out for these warning signs

In addition to this fact, there is the second difficulty in gastric cancer – the late diagnosis. This is because the symptoms are rather unspecific, affecting the stomach, but are often dismissed as harmless everyday complaints. Early signs can be:

• Feeling full, pressure in the stomach
• general upper abdominal discomfort
• Eructation
• nausea
• Vomit
• Flatulence
• Loss of appetite

“Anyone who has one or more of these complaints for more than three weeks should have them checked out by a doctor,” advises Michael Stahl.

Do not treat persistent stomach problems with acid blockers on your own initiative

However, many sufferers do not take these symptoms seriously and try to alleviate them first with self-medication – wasting valuable time on early cancer therapy and thus a high chance of recovery.

They resort to gastric acid blockers that are available over the counter or prescribed by doctors. The pain will actually go away. “Cancer itself does not cause the pain at the beginning of the disease, rather the mucous membrane defect it causes is irritated by stomach acid – and that triggers the pain,” explains the expert.

This pain disappears when the stomach acid is blocked because it no longer irritates the mucous membrane. The cancer growth is not influenced by this, the tumor can spread undisturbed.

The most important diagnostic tool – gastroscopy

The oncologist therefore urgently recommends that the complaints be clarified by a quality-assured endoscopy, i.e. in a gastroenterological practice that carries out these examinations on a daily basis or in an appropriate center.

The gastroscopy only takes a few minutes, the doctor can not only check the condition of the esophagus and stomach up to the duodenum, but can also test whether Helicobacter is present and possibly take additional tissue samples.

Usually no tumor is discovered, but rather the germ in the stomach or an enlargement or displacement of the area between the stomach and esophagus (hernia), which can lead to reflux. A change in diet can help here or medication may be necessary. Sometimes, however, the doctor finds stomach cancer, “and more and more often in the transition area to the esophagus,” reports the expert from the practice.

The reason for this is that there are more and more people who are very overweight. “Being overweight puts pressure on the abdominal cavity, which is why bile acids and stomach acid flow back into the transition area to the esophagus, which is not designed for frequent contact with these acids and is therefore damaged,” says Michael Stahl, summarizing the chain of reactions.

Small bowel cancer accounts for up to five percent of all bowel cancers; around 2,600 men and women were diagnosed with small bowel cancer in 2016, compared with around 60,000 colon cancer. “It is important to classify a carcinoma on the one hand by localization, i.e. in the case of bowel cancer, small or colon cancer, but also differentiate it on the basis of its biological characteristics,” reports Ulrich Graeven, chief physician at the Clinic for Hematology, Oncology and Gastroenterology at Maria Hilf Mönchengladbach Hospital.

Cancer of the small intestine is usually biologically very different from cancer of the colon

While colon cancer is usually adeno tumors, i.e. growths of the mucous membrane, this affects only a small fraction of small bowel cancer. The most common forms of small bowel cancer, depending on the cells that cause the disease, are:

• Neuroendocrine tumors (NET) with around 50 percent, they arise from hormone-producing cells
• Gastrointestinal stromal tumors (GIST) make up about ten percent, these tumors originate from the connective tissue in the gastrointestinal tract.

The differing biological characteristics of the two types of colon cancer, colon and small bowel cancer, “make these two diseases so fundamentally different, even though both affect the bowel,” explains the oncologist.

Causes of small bowel cancer and why it is less common than colon cancer

It is still largely unknown what triggers the cells in the small intestine to no longer act normally, but to degenerate and multiply in an uncontrolled manner. It is assumed that there is a connection with pollutants in food that come into contact with the small intestine during passage and can thus influence its cells.

It is well known that the small intestine connects directly to the stomach. This first section of the three-part small intestine is called the duodenum, followed by the jejunum and the ileum. In addition to transporting the chyme to the large intestine, the task of the five-meter-long small intestine is to break down certain food components and release them into the blood. The most important of these are carbohydrates, which are processed into various sugars, fat, but also vitamins and trace elements.

The chyme is still thin in this section of the intestine and is therefore transported on quickly. The contact time with the intestinal wall is much shorter than later in the large intestine, “which could explain why colon cancer is much more common than small intestine cancer,” the gastroenterologist explains the possible background. In addition, the mucous membrane in the small intestine is less susceptible to certain factors such as pollutants than that in the large intestine.

Risk factor hereditary diseases

However, there is also a familial willingness to develop small bowel cancer: Hereditary polyposis syndromes such as familial adenomatous polyposis (FAP) and Lynch syndrome. Genetically, a large number of polyps develop in the large intestine, sometimes also in the small intestine. These are adenocarcinomas, but they are very rare in the small intestine compared to NET and GIST.

Small bowel tumors associated with FAP are usually only discovered when polyps have been detected in the large intestine. In the course of further diagnosis of the familial predisposition, these rare small bowel carcinomas are also identified.

Small bowel cancer symptoms

Small bowel cancer usually grows rather slowly. Frequently, signs only appear when the disease has progressed and the tumor is taking up space. Depending on you can

• Bleeding,
• Stomach pain,
• nausea
• Constipation or diarrhea

occur. If the tumor is large, it can even block the intestines (ileus). The intestinal obstruction manifests itself through massive pain, it is always a medical emergency that is life-threatening and must be treated immediately.

Small bowel cancer prognosis varies

Small bowel cancer is usually only discovered at an advanced stage. In more than 70 percent of the cases, the cancer is only diagnosed in stage three or four, i.e. later than is the case with this common colon cancer – again the comparison with colon cancer.

The survival rates for small bowel cancer are therefore somewhat lower. “The decisive factor, however, is always the type of cancer of the small intestine,” explains the expert. If a GIST or NET is detected early, the chances of survival are very good. If, on the other hand, it is adenocarcinoma, which is also usually discovered later, the prognosis is not quite as favorable.

Diagnosis of small bowel cancer

The classic examination methods of gastroscopy and colonoscopy only cover the upper or lower part of the small intestine, “the almost five meters in between are not reached with these examination techniques,” explains the expert.

Imaging methods such as magnetic resonance tomography (MRT) or computed tomography (CT) are only used if there are symptoms and suspicion of this intestinal tumor. Capsule endoscopy, which shows images from the small intestine, also provides information.

Only when these examinations reveal an abnormality is it possible to specifically mirror the small intestine. “However, this is very time-consuming and cannot be used as a preventive check-up – also because these intestinal tumors are very rare,” emphasizes Ulrich Graeven.

Small intestinal cancer therapies – surgery and its consequences

Overall, the following applies to the various small intestinal tumors: If possible, an operation should be performed. “If the tumor is limited, parts of the small intestine can usually be removed without any problems,” explains the oncologist in more detail.

A stoma, i.e. an artificial anus, is therefore usually not necessary. However, it is crucial which part of the small intestine is missing and which functions it had, which trace elements and vitamins it passed on to the body. This deficiency must then be compensated for through appropriate nutrition or medication.

Treatment for small bowel cancer varies depending on the type of tumor

Parts of the removed tumor are examined histologically. For the therapy plan it is crucial whether it is NET, GIST or the rare familial adenocarcinoma in the small intestine. “A generally applicable therapy scheme for small bowel cancer is not possible because there is not just one small bowel cancer, but different ones, it always depends on its type,” emphasizes the oncologist.

Accordingly, there are many different therapy options. If a gastrointestinal stromal tumor (GIST) has metastasized, for example, there are very good drugs for further treatment. “This is not the classic chemotherapy, but we use so-called tyrosine kinase inhibitors, with very good results,” reports the expert. These are inhibitors, such as imitanib, that can block certain signaling pathways within the cells. They are sometimes also used before an operation to reduce the size of a tumor that is too large and therefore inoperable, or after an operation to avoid a relapse.

If the cancer of the small intestine is a neuroendocrine tumor (NET), however, surgery is often the only treatment required. The NET is further subdivided with regard to the need for drug therapy, taking into account its growth rate. This subdivision of the NET is also of crucial importance for the therapy planning of metastatic NET.

Ademocarcinoma of the small intestine is treated on the basis of the results from the treatment of large intestine tumors.

Small bowel cancer prevention

Targeted prevention against these rare tumors is hardly possible – apart from the well-known rules for a healthy life, i.e. without smoking, with a sensible diet, extensive alcohol restriction and sufficient exercise. Because little is known about the possible causes of small bowel cancer, they cannot be influenced.

However, there is an important tip from the expert for everyone in whose families there are genetically determined polyps in the large intestine: Remember to not only limit the preventive measures to the large intestine, but also to extend it to the small intestine. Although this is provided for in the relevant colorectal cancer screening and follow-up programs, it must not be overlooked.

Biliary cancer, with around 5500 new cases per year, is one of the rare forms of cancer, but it is particularly risky. According to popular opinion, the tumor causes almost no early symptoms and is therefore usually only recognized late when an operation is no longer possible and the tumor has already metastasized.

Biliary cancer – important: inside or outside the liver

The fact is, however, that the colloquial term biliary cancer, medically cholangiocarcinoma (CCA), covers different forms. There is gallbladder cancer, which forms in the gallbladder, which in turn is embedded in the liver.

Secondly, a carcinoma can form in the bile ducts, which are not only located within the liver and direct the bile to storage in the gallbladder, but also away from the gallbladder, which lead the bile to the small intestine.

“Depending on the localization, we differentiate between intra- and extrahepatic carcinoma, that is, those that develop inside or outside the liver,” explains Arndt Vogel, spokesman for the “Hepatobiliary Tumors” working group of the Internal Oncology Working Group (AIO) and head of the Visceral Oncological Center Hannover Medical School (MHH).

The risk of developing cholangiocarcinoma increases with age. Overall, the incidence of intrahepatic carcinomas is increasing, while that of extrahepatic carcinomas decreases somewhat.

Risk factors for biliary cancer

An exception in connection with cholangiocarcinoma is Southeast Asia, especially countries like Thailand. This cancer often occurs there because certain parasites can inflame the biliary tract. Chronic inflammation plays an important role in the development of biliary cancer.

The following risk factors come into play in the western industrialized nations, but they are also closely related to inflammation:

• Primary sclerosing cholangitis, an inflammation of the bile ducts that mostly affects men.
• Cysts in the bile and bile ducts, including Caroli’s syndrome; they increase the risk of biliary cancer.
• Smoking, because the substances in smoke are known to be carcinogenic, are not only excreted via the kidneys and urine, but are also collected, processed and passed on in the bile.
• Gallstones; However, only when they cause problems, i.e. inflame the bile, do they promote the development of cancer.

Gallstones and biliary cancer

Around ten percent of Germans are said to have gallstones, and the risk increases with age. “But very few of those affected develop cholangiocarcinoma. This cancer is very rare, ”says the medicine professor reassuringly.

The gallbladder should only be removed if the stones cause problems, i.e. colic and inflammation.

Symptoms appear differently late, but are similar

The signs of gallbladder inflammation caused by stones are somewhat similar to those of cholangiocarcinoma (CCA).

So biliary cancer can cause the following signs:

• Jaundice (jaundice)
• nausea
• Vomit
• Pain in the left upper abdomen.

The location of the carcinoma is crucial for the stage at which symptoms appear:

• Intrahepatic carcinoma triggers these clear signs quite late, “because the liver doesn’t hurt when a tumor grows there,” explains the expert.
• Extrahepatic carcinoma, on the other hand, usually quickly means that the bile can no longer flow into the intestine. Bile congestion and jaundice are relatively early signs of this form of cancer.

That is why bile duct cancer that grows outside of the liver is usually diagnosed earlier – but it is difficult to operate because of its often complicated location next to blood vessels and does not make the generally difficult situation with cholangiocarcinoma easier, the oncologist limits the associated high expectations.

Diagnosis of cancer of the gallbladder and bile ducts

Doctors use cross-sectional image diagnostics such as MRI and CT. “This allows the suspicion to be clarified and the staging, i.e. stage and spread, to be identified,” explains Vogel.

The histological examination provides additional details about the tumor, whereby the samples in gallbladder cancer are relatively easy to obtain. However, this is more difficult with extrahepatic tumors because the biliary tract is often narrow and winding. The examination is carried out through an endoscope, the method here is called endoscopic retrograde cholangiopancreatography (ERCP examination).

Are there any less invasive methods? Ultrasound, carried out endoscopically from the inside through the stomach or from the outside, can also be informative, says the cancer specialist. However, the methods of first choice are MRI and CT.

Treatment of biliary cancer – surgery not always possible

If the suspicion has been confirmed and the results of the examination enable a classification of the tumor, the goal is to remove the carcinoma surgically. “However, as already described, this is sometimes difficult due to the location of the tumors,” reports Vogel. However, the surgical techniques have improved significantly in recent years.

The standard treatment for patients with advanced tumors is chemotherapy, with a combination of gemcitabine and cisplatin.

In a palliative situation, i.e. to increase survival time and / or to improve quality of life, local therapies such as selective internal radiotherapy (SIRT, radioembolization) are currently used in clinical studies . Radioactive microspheres are guided to the tumor via an inguinal catheter, its cells are destroyed and healthy tissue is spared. The first results show that for some patients many months can be gained with this.

The prognosis for biliary cancer is poor …

Despite all these possibilities, few patients can be cured. Even if the tumor could be completely removed in the healthy, the recurrence rate is still relatively high. “60 to 80 percent of the tumors come back,” reports Vogel. Because the tumors spread very early.

… but with the therapy “a small revolution is emerging”

This is the bad news. In fact, these prospects could improve in the future. The oncologist says: “Because a small revolution is taking place here at the moment.” The interest of pharmaceutical companies in this rare cancer has increased significantly, and intensive work is being carried out on the development of new drugs.

The reason for this change is the fact that it has been discovered that numerous genetic changes occur in these tumors and thus allow a molecular, i.e. targeted therapy. There have been many studies on this topic for a few years now.

Two developments are particularly promising:

1. Inhibitors against IDH1 mutations , from which patients with a corresponding cholangiocarcinoma can clearly benefit.

2. Inhibitors against FGFR2 , fusions, MSI, NTRK and others.

“There are currently a number of very promising active ingredients in the test that have the various genetic changes as a starting point,” reports the oncologist. How much these new therapies could improve the treatment of biliary cancer becomes clear when one realizes that 40 to 50 percent of all these tumors, especially intrahepatic ones, show such genetic changes and are therefore suitable for targeted, molecular therapy.

Prevention Of Bile Cancer – Quit Smoking!

It will be some time, however, before the new therapies are available to all patients. Until then, it is still true that biliary cancer is difficult to treat and the prognosis is unfavorable.

This makes prevention all the more important. To what extent can everyone prevent this tumor – apart from the advice not to smoke, which is so important with regard to many other diseases? Above all, the expert has one recommendation:

Get gallstones cleared up if they’re causing problems. However, this does not mean that everyone who has gallstones should be afraid: Gallstones are considered to be risk factors for gallbladder cancer, but only one percent of all gallstone carriers develop this tumor.