Interdisciplinary Discussion

Viszeralmedizin 2015;31:124–129 Published online: April 29, 2015

DOI: 10.1159/000382049

Colonoscopy in Acute Diverticulitis

Chair: Manfred Grossa Joachim Labenzb

Participants: Gereon Börsch c Arno Dormann d Alexander J. Eckardt e Ralf Kiesslich f

Stephan Mielke g
a Internistische
Klinik Dr. Müller, Munich, Germany,
b Innere Medizin, Jung-Stilling-Krankenhaus, Diakonie Klinikum, Siegen, Germany,
c
Gladbeck, Germany,
d
Medizinische Klinik, Krankenhaus Holweide, Kliniken der Stadt Köln gGmbH, Cologne, Germany,
e
Fachbereich Gastroenterologie und Hepatologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany,
f
Innere Medizin II: Gastroenterologie, Hepatologie und Endokrinologie, HSK – Dr. Horst Schmidt Kliniken GmbH, Wiesbaden, Germany,
g
Magen-Darm-Zentrum, Facharztzentrum Eppendorf, Hamburg, Germany

Question 1: Is there any indication to perform total An abdominal CT procedure identifying a triad of colonic di-
colonoscopy in acute diverticulitis, confirmed by verticulae, localized bowel wall thickening > 4 mm, and an increase
a positive abdominal ultrasound result and in soft tissue density within the adjacent abdominal fat is highly
accompanied by an elevated C-reactive protein sensitive (e.g. 94%) and specific (e.g. 99%) for acute colonic diver-
(CRP) value? Is it acceptable or even mandatory to ticulitis. This leads to an equally high negative predictive value (pV
perform colonoscopy when a patient does not neg) of 94% in a typical clinical 50/50 disease prevalence of acute
adequately respond to treatment? Do atypical diverticulitis versus other potential abdominal disease entities.
diagnostic imaging results in suspected diverticulitis Thus, in the absence of the above mentioned triad, or in atypical
justify colonoscopy? findings such as colonic masses, a diagnosis of acute diverticulitis
of clinical relevance would be quite unlikely. It is in these cases
Börsch: There is definitely no need for total colonoscopy in a with atypical imaging results that I would promptly and without
case of typical acute diverticulitis. Such a case would present with any reservations proceed to total colonoscopy after standard co-
ongoing left lower abdominal pain and wall tenderness of acute lonic preparation. This is justified by a very low endoscopic com-
onset, accompanied by some change of bowel habits, either consti- plication rate, especially endoscopic perforation rate, in acute co-
pation or diarrhea, and possibly by an increase of body tempera- lonic diverticulitis anyway (see question 2), all the more in a case
ture. In addition, there would be elevated inflammatory markers with highly unlikely acute diverticulitis. With negative or atypical
such as CRP, and also positive ultrasound findings of bowel wall CT findings, colonoscopy might reveal segmental bacterial or viral
thickening > 5 mm at the point of maximal tenderness, a hypo- colitis, non-occlusive colonic ischemia, Crohn’s disease, unclassi-
echoic reflection of an inflamed diverticulum, and a cap-like hy- fied colonic inflammatory bowel disease (IBD), or even segmental
perechoic peridiverticular inflammatory reaction. In such a pa- diverticular colitis, each with quite different therapeutic strategies.
tient, treatment tailored to the clinical situation will be initiated
and monitored on clinical grounds. If the response to treatment is Dormann: Diagnosing diverticulitis usually requires not only
unsatisfactory, not colonoscopy but abdominal computed tomog- clinical but also laboratory test results and diagnostic imaging with
raphy (CT) will be the next diagnostic step, or even repeat CT, if sonography and abdominal CT, but not endoscopy [1]. The totality
this procedure has already been performed initially. In all likeli- of symptoms (pain), physical examination (left-sided lower ab-
hood, any inadequate response will rather be due to some extralu- dominal pain), and laboratory values (CRP increase > 50 mg/l) is
minal disease complication, which is not, or at least rarely, view- present in more than 90% of all cases of sigmoid diverticulitis [1].
able by the strictly luminal dimension of the endoscopic procedure The compression applied in sonography, which allows the exam-
and which may possibly even be dealt with by a subsequent CT- iner to distinguish between interposed fatty tissue and intestine,
guided intervention. can allow the detection of abdominal wall inflammation and con-

© 2015 S. Karger GmbH, Freiburg Prof. Dr. med. Dr. rer. biol. hum. Manfred Gross
1662–6664/15/0312–0124$39.50/0 Internistische Klinik Dr. Müller
Fax +49 761 4 52 07 14 Am Isarkanal 36, 81379 München, Germany
Information@Karger.com Accessible online at: gross@muellerklinik.de
www.karger.com www.karger.com/vim
firm the diagnosis. When an abscess is suspected, a drain can be Question 2: What is your estimate of the risk of
placed immediately. Supplementary CT can detect especially extra- colonic perforation when total colonoscopy is
luminal structures (mainly air when perforation is suspected) and performed in acute diverticulitis?
is also to be used as a method providing objective evidence in com-
plicated procedures. Drainage of interposed abscesses can also be Börsch: It has to be kept in mind that, in principle, acute colonic
performed. Major diagnostic criteria in imaging procedures are diverticulitis is caused by micro- or macroscopic colonic diverticu-
wall thickening, pericolic blurring in the fatty tissue, and detection lar perforation. The clinical course is then determined by the speed,
of the inflamed diverticular area. The results can be improved by extent, and quality of the spontaneous biologic repair, or any lack
rectal contrast agent administration. The sensitivity and specificity thereof. Thus, the diagnosis of acute diverticulitis implies the pres-
for ultrasound alone are 92 and 90%, respectively, and thus are ence or recent occurrence of a micro- or macroscopic colonic per-
usually sufficient for diagnosis in uncomplicated clinical courses. foration. From this pathogenetic pathway, a very high complica-
The use of CT after inconclusive ultrasound findings can increase tion rate due to an increase of intraluminal pressure by colono-
the sensitivity and specificity to 94 and 99%, respectively [2, 3]. scopic air insufflation has been deduced and admonished in every
Magnetic resonance imaging is available as a more recent method. relevant textbook or atlas of endoscopy or colonoscopy. This, how-
The results are still unclear and the method should not be used for ever, has never been substantiated by sound scientific facts. In my
routine diagnosis [4]. Endoscopy is not indicated in the acute personal colonoscopic experience stretching over more than 40
phase [5]. This is based on the theory that a concealed perforation years, with far more than a thousand cases of colonoscopy in acute
can be converted to a free perforation by air insufflation; moreover, diverticulitis, the risk of colonoscopy-induced acute abdomen by
the examination is impeded by edema and possibly residual con- perforation is in the range of around 1/1,000. In a formal retro-
tamination. Colonoscopy is generally performed 4–6 weeks after spective analysis of 210 own cases with a final diagnosis of acute
the acute event to rule out malignancy. There is no increased risk colonic diverticulitis, of which 155 had been submitted to total co-
of malignancy developing after diverticulitis [1]. In therapy failure lonoscopy, 13 of whom (i.e. 8.4%) even had a small amount of peri-
or atypical imaging, endoscopic clarification should be performed luminal gas as detected by CT, a free perforation was not observed.
to rule out further differential diagnoses besides malignancy, in- There was only a single case in which a deterioration of the clinical
cluding other inflammatory etiology (viral, bacterial, IBD) or vas- course, though without acute abdomen, as due to a diagnostic co-
cular reasons (ischemic colitis). In these cases it is often helpful to lonoscopy, could not be completely excluded, even though a causal
perform only sigmoidoscopy and, if the findings are clear, to re- relationship was unlikely [7]. The group of Bar-Meir [8] found one
frain from high colonoscopy in the acute episode [1, 6]. Colon bar- free colonic perforation after colonoscopy in a group of 40 patients
ium enema, an often chosen alternative, should no longer be used investigated prospectively. In a second cohort of 39 patients lack-
for the diagnosis of diverticulitis because of the radiation exposure ing any accumulation of pericolonic gas, no complication was
[6]. observed.
Also, bland diverticulae by themselves do not show any propen-
Eckardt: Patients with a typical clinical presentation of divertic- sity to perforate during colonoscopy. Thus, the colonic perforation
ulitis, which is supported by clinical and laboratory findings, rate did not differ in patients with or without diverticulae [9]. Fi-
should not undergo unnecessary colonoscopy in the acute setting nally, when applying increasing intraluminal pressure thresholds
to avoid discomfort and the risk of perforation. However, in the by intracolonic air insufflation, the colonic serosa and mucosa will
setting of an atypical presentation, such as poor response to treat- tear open well before diverticulae will rupture [10].
ment, iron deficiency, or weight loss, careful sigmoidoscopy or co- In summary, the exact rate of free perforations after colonos-
lonoscopy should be performed, and alternative diagnoses should copy in acute diverticulitis is unknown. However, it is by all means
be sought [5]. much lower than generally anticipated. My personal estimate
places the rate between 1 and 5 per thousand procedures, maybe
Kiesslich: Colonoscopy during the acute phase of diverticulitis is slightly higher than the perforation rate of screening endoscopies,
not recommended by the experts. The diagnostic algorithm should thought to be somewhere between 0,1 and 1 per thousand.
include: patient with typical symptoms and laboratory findings –
abdominal ultrasound – CT scan of the abdomen. Colonoscopy Dormann: Colonoscopy makes it possible to determine the
should be performed 4–6 weeks after the acute phase. cause of abdominal complaints and is the suitable method for
lower gastrointestinal bleeding or to rule out a tumor. Besides de-
Miehlke: In the situation of a clinically established diagnosis of tecting diverticula, colonoscopy can be performed for differentia-
acute diverticulitis (typical ultrasound, elevated CRP), I do not see tion of mucosal inflammatory or polypoid lesions [6]. Colonos-
any need or benefit of a complete colonoscopy. If the diverticulitis copy is not required to diagnose acute diverticulitis.
does not resolve by conservative treatment, I would perform a CT Opinions diverge regarding the safety of colonoscopy in acute
scan to rule out perforation or abscess. If the CT scan is inconclu- illness. 1.9% of 54 diverticulitis patients suffered perforation from
sive or reveals any other unclear finding, I would proceed to colo- colonoscopy. The colonoscopies were early elective procedures
noscopy if the clinical condition of the patient allows doing so. done at between 4 and 12 days (median 5.8 days). The rate of com-

Colonoscopy in Acute Diverticulitis Viszeralmedizin 2015;31:124–129 125

plete examinations of 81.7% was markedly lower than in an elective endoscope, e.g. puncture with a biopsy forceps. Also, vi) a luminal
situation [11]. In another study on early (in the first 10 days) versus stenosis untypical of IBD or colonic ischemia can be a sign of acute
later (after 6 weeks) colonoscopy in CT-confirmed diverticulitis diverticulitis.
there was neither an increased rate of perforations nor a diagnostic Nevertheless, acute diverticulitis is primarily a periluminal dis-
gain [6, 12]. There may possibly be a benefit for atypical courses ease. Therefore, endoscopic failure to detect luminal inflammatory
with persistent complaints after 1 week of antibiotic therapy or a changes does not exclude the presence of acute diverticulitis. In
recurrence within 2 months. A relevant diagnosis, e.g. adenocarci- our series, we saw normal endoscopic findings in 22 of 114 patients
nomas or causes of the perforation, was obtained in 17% of these in whom typical CT criteria nevertheless and reliably established
cases [13]. acute diverticulitis. However, a miss rate of not visualizing an in-
In summary, because of the limited data the rate of perforations flamed diverticulum has to be reckoned with.
cannot be reliably determined in an early elective procedure; how-
ever, an additional benefit of an early examination is not observed. Dormann: Inflammatory changes of diverticula in endoscopy
An early elective control should therefore be performed after 4–6 appear in about 0.8% of colonoscopies without acute diverticulitis
weeks [6]. In individual cases (e.g. for an uncharacteristic clinical being present [5]. Significant luminal changes are secondary in the
picture or course) colonoscopy can be performed in acute diver- pathogenesis of diverticulitis as the disease begins with the pene-
ticulitis if a concealed perforation and abscess formation is ruled tration of bacteria deep inside a diverticulum. The main complica-
out by CT. tions (phlegmones, microperforation, fistula, abscess) lie deeper
inside the tissue or are periluminal. Consequently, (extraluminal)
Eckardt: There is a lack of sufficient data on the risk of endo- diverticulitis, which can only be detected by imaging, can also be
scopic perforation in the setting of acute diverticulitis. However, present in the case of a negative colonoscopy (see question 1).
considering that a microperforation in a diverticulum is a likely
pathomechanism of diverticulitis, the risk of macroperforation by Eckardt: Because colonoscopy has historically not been used in
mechanical manipulation or air insufflation must be considered. the setting of acute diverticulitis, the literature on endoscopic as-
There is only one study reporting a perforation risk of 1.9% [11]. pects is scarce. Diverticula are common and so are inflammatory
Special attention must be paid to older patients with concomitant appearances around them. One study suggests that inflammatory
steroid use, as these carry a high risk of perforation. changes in diverticulitis directly affect the diverticular orifice
(fig. 1, 2), whereas segmental colitis in association with diverticulo-
Kiesslich: There is no evidence for an increased risk of perfora- sis (SCAD) primarily affects the interdiverticular mucosa (fig.  3)
tion during complete colonoscopy in the presence of acute diver- [14]. ‘Normal’ endoscopy makes diverticulitis unlikely, but not im-
ticulitis. However, pathogenesis of acute diverticulitis includes mi- possible, as it is primarily an extraluminal disease.
croperforation of the colonic wall. Thus, colonoscopy is not rec-
ommended in patients with known acute diverticulitis. If acute di-
verticulitis is found by accident, colonoscopy can be completed
without any additional requirements.

Miehlke: The risk for perforation during colonoscopy in the set-

ting of acute diverticulitis is probably low, but may depend on the
stage of the disease. To my knowledge, the scientific evidence is Fig. 1. Severe inflam-
scarce and limited to retrospective single-center series reporting matory changes di-
rectly surrounding a
perforation rates between 0 and 2%.
diverticulum with
edema and relative ste-
nosis, suggesting diver-
Question 3: Are there typical endoscopic signs of ticulitis.
acute diverticulitis? Does the lack of such signs
exclude acute diverticulitis?

Börsch: There are typical and even disease-specific luminal en-

doscopic findings which may be seen in just one diverticulum or
several of them. Among these are i) reddening and swelling around
diverticulae, ii) a fibrinous or putrid slough covering a diverticu- Fig. 2. Mild inflam-
matory changes di-
lum or surrounding it, iii) a putrid secretion from the base of a pre-
rectly surrounding a
sumed diverticulum, or iv) from a peridiverticular mass protruding diverticulum as an in-
into the colonic lumen and representing extraluminal abscess for- cidental finding during
mation, or v) induction of such secretion by manipulation via the routine colonoscopy.

126 Viszeralmedizin 2015;31:124–129 Gross/Labenz/Börsch/Dormann/Eckardt/

Kiesslich/Mielke
 moidoscopy is therefore electively dispensable; the decision ‘colo-
noscopy or no endoscopy’ should be taken.

Eckardt: Sigmoidoscopy should be considered when atypical

features are present (see question 1). In my opinion, endoscopy has
no role in the drainage of intramural abscesses in the setting of
diverticulitis.
Fig. 3. Mild patchy
erythema on the mu-
Kiesslich: Sigmoidoscopy is not recommended (as colonoscopy).
cosal folds between
diverticula (SCAD).
Miehlke: In my opinion, a sigmoidoscopy also has no place in
the primary diagnostic workup of acute diverticulitis, for the same
Kiesslich: Diverticulitis is an extraluminal disease. Thus, colo- reasons already mentioned. I would consider this procedure only
noscopy of the inner wall of the colon cannot exclude diverticulitis. in unclear situations if a complete colonoscopy is not feasible.
However, ‘classical’ mucosal findings are pus, reddishness, and in-
tramural abscess.
Question 5: Why should a colonoscopy be performed
Miehlke: I would consider erythema and edema of the peridiver- after an episode of acute diverticulitis? After which
ticular mucosa and putrid secretion out of the diverticula as typical time interval should it be performed? How do prior
signs of acute diverticulitis. However, theses endoscopic findings colonoscopies influence your decision, e.g., if a
may also occur in patients without clinical symptoms. In contrast, patient had screening endoscopy 3 years ago
an unremarkable colonoscopy may not definitely rule out acute showing diverticula but no polyps or tumor?
diverticulitis since inflammatory manifestations could be extralu-
minal or intramural. Börsch: Given that any symptoms have completely reverted to
normal, acute colonic diverticulitis by itself is not a valid indica-
tion for subsequent colonoscopy. The large body of scientific evi-
Question 4: Would sigmoidoscopy be of value dence, with several important papers having been published in
when acute diverticulitis is suspected? After all, 2014/2015, may best be summarized to the extent that the yield of
interesting or clinically relevant incidental findings advanced colonic neoplasia, adenomatous polyps, or hyperplastic
such as intramural abscesses may be found and polyps in this cohort is roughly equivalent to that detected on
drained. screening asymptomatic average-risk individuals. In such once
again asymptomatic cases, colonoscopy should be regarded as a
Börsch: The presumed risk of endoscopy in acute diverticulitis, screening endoscopy which could safely be performed 4–6 weeks
low as it may be, arises from an increase in luminal pressure possi- after the acute episode, or at the proper time interval after a previ-
bly causing a ‘blow-out’ free perforation of the colonic wall at the ous screening. In the specific patient mentioned here, endoscopy
site of an inflamed diverticulum. Any endoscopy in an inflamed could reasonably be delayed for another 7 years. Incidentally, any
bowel, especially in acute diverticulitis, is a ‘difficult’ procedure not episode of diverticulitis might be utilized to remind patients
suitable for the endoscopic novice. Even so, the amount of air in- within a specific age range of the merit of colonic cancer screen-
sufflation sufficient to adequately visualize the luminal inflamma- ing, and, if previously not done, to offer arrangements for such a
tion during sigmoidoscopy will in all likelihood give rise to equiva- procedure.
lent luminal pressure thresholds as would be induced by total colo- These suggestions certainly apply to typical left-sided ‘Western-
noscopy after standard bowel preparation, which can also be used type’ diverticulitis with complete resolution of symptoms after 4–6
advantageously to effectively deflate the colon on retraction. weeks, and thus to the vast majority of our local patients. Whether
Thus, there is no indication for routine sigmoidoscopy in the right-sided, proximal ‘Asian-type’ diverticulitis would necessitate
setting of acute colonic diverticulitis. When an endoscopic proce- other strategies remains to be elucidated.
dure is warranted as described in question 1, total colonoscopy However, in patients still symptomatic 4–6 weeks after an epi-
after standard bowel preparation should be the procedure of sode of acute diverticulitis, endoscopy should definitely be offered
choice. Incidental findings of therapeutic value for the manage- and performed to look for luminal complications, rule out other
ment of the current disease episode are quite unlikely and do not disease entities, or, last but not least, serve as a base for a diagnosis
justify the very low, but presumably not negligible, endoscopic of post-diverticulitis irritable bowel syndrome.
risk.
Dormann: Colonoscopy is recommended after a conservatively
Dormann: For diagnostic colonoscopy in acute diverticulitis treated acute diverticulitis and before a sigmoid resection [6]. It
please consult question 2 and the indications discussed there. Sig- serves to clarify the differential diagnosis of conditions with a sim-

Colonoscopy in Acute Diverticulitis Viszeralmedizin 2015;31:124–129 127

ilar clinical presentation and to rule out adenoma or malignancy. Question 6: How do you react when a (screening)
The value of capsule endoscopy has not been proved for this indi- endoscopy reveals the unexpected endoscopic find-
cation, especially as there is always the risk of capsule retention. In ings of acute diverticulitis? Under what conditions
205 patients with CT-supported confirmation of diverticulitis, en- is it necessary to discontinue the investigation, and
doscopy showed adenomas with >50% advanced neoplasias in when should it be completed?
only 9.3% of patients [15]. The rate of adenomas and carcinomas
is lower compared to data of screening colonoscopies. In 100 pa- Börsch: The detection of endoscopic signs of acute diverticulitis
tients, at least one polyp was detected in 32% of cases, an advanced in a screening situation is well known to every experienced en-
adenoma was found in only one case, and in no patient was malig- doscopist and may be expected about once in 100 colonoscopies
nancy detected by colonoscopy 4–6 weeks after the end of the hos- (e.g. 0.8% of 2,566 consecutive colonoscopies performed by Ghorai
pital treatment for acute diverticulitis [5]. Colonoscopy is there- et al. [12]). However, the underlying inflammation is hardly ever
fore not associated with an elevated incidence of malignancy after clinically severe or due to complicated diverticulitis, given that a
diverticulitis [16]. A systematic literature search by Sai et al. [17] screening situation implies an asymptomatic patient. Also, the vast
in order to detect a colon carcinoma up to 24 weeks after CT diag- majority of such patients do not need treatment.
nosis of diverticulitis identified ten studies with 771 documented This clearly is a low-risk state, roughly equivalent to a colonic
patients. The rate of identified colorectal carcinomas was 2.1% screening situation. The merit of completing the procedure far out-
(95% confidence interval 1.2–3.2%) and thus above the expected weighs the potential risk.
prevalence (0.68%) in US citizens >55 years. A recommendation
for complete colonoscopy in patients >55 years with clinically Dormann: Inflammatory changes of diverticula in endoscopy
overt diverticular disease and without a colonoscopy <5 years pre- occur in about 0.8% of colonoscopies without acute diverticulitis
viously appears justified [6]. A colonoscopy <5 years previously being present [6]. Generally, the examination can be performed
without evidence of neoplasia primarily indicates no new exami- without problems if there is no pronounced lumen obstruction. If
nation and should only be indicated when there is a risk constella- there is a significant stenosis, it may be necessary to switch to a
tion (e.g. familial history, doubtful previous examination (e.g. smaller device or discontinue the examination and repeat it subse-
contamination)). quently. The present day use of endoscopes with diameters of 5
mm usually allows the examinations to be terminated or at least
Eckardt: Recent studies have shown that the risk of neoplasia is the stenotic region to be determined in almost all patients. If this is
low in the setting of uncomplicated diverticulitis [18, 19]. There- not possible, the examination should be discontinued and repeated
fore, colonoscopy should primarily be performed after resolution electively in the interval [16].
of complicated diverticulitis or in cases of suspicious radiologic
findings, warning signs (such as anemia), a protracted clinical Eckardt: Whether colonoscopy should be completed in the case
course, and if age-appropriate screening is necessary. Such an ap- of an incidental finding of acute diverticulitis depends on the se-
proach avoids an unnecessary colonoscopy in a patient who has verity of the endoscopic findings and symptoms. My practice is to
had a thorough exam within the past 3 years. continue colonoscopy with little air insufflation (I prefer water im-
mersion in this setting [20]) as long as the patient does not com-
Kiesslich: Colonoscopy is recommended by all experts after the plain of major discomfort, and advancement of the endoscope is
acute phase of diverticulitis has passed. Rationale for colonoscopy possible without difficulty.
is the risk of colon cancer, which could be the underlying cause of
abdominal symptoms. Kiesslich: The prevalence of asymptomatic diverticulitis is about
However, the largest study on this topic could not confirm a 0.8%. Complete colonoscopy is possible without an increased risk
substantially increased cancer risk. Thus, complete colonoscopy of complication. However, if a stenotic area appears the risks and
should be recommended for screening purposes only. Colonos- benefits of complete colonoscopy should be individually specified
copy is not necessary if a screening or diagnostic colonoscopy was and advanced endoscopic techniques could be used (e.g. use of
already performed within the last 3–5 years. small-caliber endoscopes, CO2 insufflation, etc.).

Miehlke: After the first episode of an acute diverticulitis I would Miehlke: This certainly depends on the severity of the endo-
definitely recommend a full colonoscopy 4–6 weeks later to deter- scopic manifestation. If the endoscopic findings are mild to moder-
mine the extension of diverticulosis and to rule out neoplastic le- ate and if there is no significant stenosis of the sigmoid lumen I
sions. I would also recommend a full colonoscopy after an acute would aim to perform complete colonoscopy. In all other cases I
diverticulitis in patients with established diverticulosis if the last would stop the procedure, initiate or continue conservative treat-
colonoscopy was done more than 3 years ago, especially if the qual- ment, and repeat colonoscopy after resolution of the acute episode.
ity of this procedure was unclear.

128 Viszeralmedizin 2015;31:124–129 Gross/Labenz/Börsch/Dormann/Eckardt/

Kiesslich/Mielke
 Participants

Prof. Dr. med. Gereon Börsch

Chefarzt Emeritus/Facharzt für Innere Medizin & Gastroenterologie
Heinrich-Krahn-Straße 17, 45964 Gladbeck, Germany
g.boersch@t-online.de

Prof. Dr. med. Arno J. Dormann

Medizinische Klinik
Krankenhaus Holweide, Kliniken der Stadt Köln gGmbH
Neufelder Straße 32, 51067 Köln, Germany
DormannA@kliniken-koeln.de

PD Dr. med. Alexander J. Eckardt

Fachbereich Gastroenterologie und Hepatologie
DKD Helios Klinik Wiesbaden
Aukammallee 33, 65191 Wiesbaden, Germany
alexander.eckardt@helios-kliniken.de

Prof. Dr. med. Ralf Kiesslich

Innere Medizin II: Gastroenterologie, Hepatologie und Endokrinologie
HSK – Dr. Horst Schmidt Kliniken GmbH
Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
ralf.kiesslich@helios-kliniken.de

Prof. Dr. med. Stephan Miehlke

Magen-Darm-Zentrum
Facharztzentrum Eppendorf
Eppendorfer Landstraße 42, 20249 Hamburg, Germany
prof.miehlke@mdz-hamburg.de

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