Follow-up of hot biopsy forceps treatment of diminutive colonic polyps.

Although the hot biopsy technique is widely used to treat diminutive colon polyps, there is concern over its efficacy and safety. Our study involved 39 patients undergoing routine colonoscopy in whom 62 diminutive polyps were found in the rectosigmoid. These lesions were treated with hot biopsy forceps in the standard manner. Flexible sigmoidoscopy was repeated 1 and 2 weeks later with the original treatment sites being identified. Eleven of the 62 sites (17%) revealed persistent viable polyp remnants, indicating incomplete treatment. In terms of safety, there were no clinical complications in this small study and most post-biopsy ulcers were healed by 2 weeks. This study shows that the hot biopsy technique may be unreliable in eradicating diminutive colon polyps.     

Clinical Vignette Delayed ("Blow-out") Perforation of Sigmoid Following Diagnostic Colonoscopy

A case has been described in which perforation of the sigmoid colon occurred three days following simple diagnostic colonoscopic examination. The desirability is indicated for including the possibility of this occurrence in the informed eonsent. Administration of stool softener and use of low-residue diet for several days following diagnostic and therapeutic colonoscopy may be of value in averting the occurrence of this catastrophe.     

Should hot biopsy forceps be abandoned for polypectomy of diminutive colorectal polyps?

Standardized approach to polypectomy of diminutive colorectal polyps(DCPs) is lacking since cold biopsy forceps have been associated with high levels of recurrence, hot biopsy forceps are considered inadequate and risky and cold snaring is currently under investigation for its efficacy and safety. This has led to confusion and a gap in clinical practice. This article discusses the usefulness and contemporary practical applicability of hot biopsy forceps and provides wellintentioned criticism of the new European guidelines for the treatment of DCPs. Diminutive colorectal polyps are a source of frustration for the endoscopist since their small size is accompanied by a considerable risk of premalignant neoplasia and a small but nonnegligible risk of advanced neoplasia and even cancer. Since the proportion of diminutive colorectal polyps is substantial and exceeds that of larger polyps, their effective removal poses a considerable workload and a therapeutic challenge. During the last decade, the introduction of cold snaring to routine endoscopy practice has attempted to overcome the use of prior techniques, such as hot biopsy forceps. It is important to recognize that with the exception of endoscopic methods that are obviously unsafe and inadequate to serve their purpose, all other interventional endoscopic methods are operator-dependent in the sense that specific expertise and training are obligatory for the success of any therapeutic intervention. Since relevant publications on hot biopsy forceps are still in favor of its careful use, as it has not yet demonstrated inferiority compared with newer techniques, it would be prudent for any medical practitioner to evaluate the available tools and judge any new proposed technique based on the evidence before it is adopted.     

Surgical management of colonic diverticulosis with massive hemorrhage by subtotal colectomy

Summary Two cases of colonic diverticulosis with massive hemorrhage are reported. After re-establishment of blood volume and completion of initial diagnostic procedures, when bleeding continued, a subtotal colectomy was performed without exhaustive attempts to localize the bleeding site. The outcome was successful and advantages of the method employed have been discussed.     

Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication

BACKGROUND/AIMS: Delayed massive arterial hemorrhage from the operating field occurs in 1-4% of cases after pancreaticoduodenectomy, with a mortality rate up to 50%. The purpose of this study was to define diagnostic and treatment methodologies to maximize survival. METHODOLOGY: Between 1990 and 1999, 84 pancreaticoduodenectomies were performed for periampullary and pancreatic head cancer. After surgery, massive bleeding occurred in two patients (2.3%), 30 and 8 days after resection, respectively. RESULTS: Pancreatic leak and disruption of the pancreaticojejunostomy were reported in both cases. Bleeding was controlled by suture ligation of the stump of the gastroduodenal artery. Completion pancreatectomy and a new pancreaticojejunostomy were respectively performed. Hemorrhage recurred in both cases from a ruptured pseudoaneurysm of the hepatic artery, requiring re-exploration and surgical ligation. The first patient died of re-bleeding despite completion pancreatectomy, the other survived after oversewing the residual pancreatic stump at re-exploration. CONCLUSIONS: Early diagnosis and management of pancreatic leak represents the only means to prevent a delayed massive arterial hemorrhage. Transarterial embolization or surgical ligation of the hepatic artery proximal to the celiac axis represents the procedure of choice to control the bleeding. Taking down the pancreatic anastomosis and oversewing the pancreatic stump is safe and effective. Extensive drainage of the operating field should always be associated to prevent multisystem organ failure.     

Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage

Varices of the entire colon are very rare. This rare cause of massive lower gastrointestinal hemorrhage is almost invariably associated with cirrhosis of the liver and consequent hypertension or portal venous obstruction. We report about a patient with massive lower gastrointestinal bleeding from extensive colonic varices. Despite extensive investigation and a follow-up of 3 years, the etiology of the colonic varices could not be determined. Only a few cases of apparent idiopathic (familial or non-familial) colonic varices have been described. Recognition of this abnormality is important, however, because colonic varices may be the cause of recurrent, frequently massive lower gastrointestinal hemorrhage. A misleading endoscopic diagnosis can lead to inappropriate biopsies, resulting in major bleeding.     

The atopic eczema/dermatitis syndrome. Epidemiology, natural course, and immunology of the IgE-associated ("extrinsic") and the nonallergic ("intrinsic") AEDS.

According to the position paper from the EAACI nomenclature task force, the term "Atopic eczema/dermatitis syndrome" (AEDS) should be used as the "umbrella" term to cover the different subtypes of atopic dermatitis (AD). The new nomenclature (AEDS) underlines the fact that AD is not one, single disease, but rather an aggregation of several diseases with certain clinical characteristics in common. The so-called "intrinsic" type of AD (now termed nonallergic AEDS) fulfills the most commonly used diagnostic criteria for AD. These patients have no associated respiratory diseases, such as bronchial asthma or allergic rhinitis, show normal total serum IgE levels, no specific IgE, and negative skin-prick tests to aeroallergens or foods. Immunologic differences between the IgE-associated type of AD and the nonallergic type can be found in the cell and cytokine pattern in peripheral blood and in the affected skin, and also by phenotyping characterization of epidermal dendritic cells. The current explanation of this distinction is based on differences in genetics and/or environmental conditions. The classification into an allergic, IgE-associated (AAEDS) and a nonallergic type (NAAEDS) at each stage of life, i.e., infancy, childhood, teenage, and adult, is essential for the allergological management of patients as to allergen avoidance, secondary allergy prevention, and immunotherapy. The risk of an "atopy march" is significantly lower in children with the non-IgE-associated type.     

Clinical, biochemical and pathological features of low-renin ("primary") hyperaldosteronism

The clinical and biochemical findings in 136 patients with low-renin (“primary”) hyperaldosteronism are described. A pathological diagnosis was made in 82 cases and a unilateral adrenocortical adenoma was found in 62. However, a tumor was not identified in 17, the adrenal glands then usually showing hyperplasia of the zona glomerulosa, often with nodular changes. The adrenal lesion in a further three cases proved fifficult to classify.Patients with an adrenocortical adenoma were significantly younger than those in whom a tumor was not found. The female/male ratio was greater than 2:1 in the adenoma group, but no sex difference was observed in the group without tumor. Vascular complications of hypertension occurred in 23 per cent and there was histologic evidence of malignant-phase hypertension in four. It is concluded that this condition is not a benign form of hypertension.Biochemical abnormalities were more marked among patients with an adrenocortical adenoma, compared with those in whom a tumor was not found. Mean plasma concentrations of aldosterone, sodium and tCO₂, and mean exchangeable sodium were significantly higher, while plasma potassium and renin concentrations and mean exchangeable potassium were significantly lower. Although plasma aldosterone was above normal at least once in all, levels were often only intermittently raised. Hypokalemia occurred in all patients with a proved adenoma and was usually persistent. Among patients in whom a tumor was not found, hypokalemia was less severe and usually intermittent, while plasma potassium was persistently normal in three of 17 patients in this group.In addition to the aldosterone excess, plasma deoxycorticosterone was raised in 13 of 26 patients, plasma corticosterone was marginally raised in two and plasma 18-OH-DOC in four of 15. There was a significant inverse correlation between plasma renin concentration and age in the non-adenoma group but not among patients with an aldosterone-producing adenoma. Weak positive correlations were observed in the adenoma group between total exchangeable sodium and both systolic and diastolic blood pressure and between exchangeable sodium and plasma aldosterone concentrations. Such correlations were not seen in the non-tumor group. The hypertension may have a different basis in these two groups.     

Delayed hemorrhage from hepatic artery after ultrasoundguided percutaneous liver biopsy： A case report

Percutaneous liver biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases. Pseudoaneurysm of hepatic artery is an unusual complication after ultrasound-guided percutaneous liver biopsy. Delayed hemorrhage occurs much less frequently. We report a case of pseudoaneurysm of the hepatic artery of a 46-year-old man who was admitted for abdominal pain after 4 d of liver biopsy. The bleeding was controlled initially by angiographic embolization. However, recurrent bleeding could not be controlled by repeat angiography, and the patient died 4 d after admission from multiorgan failure. The admittedly rare possibility of delayed hemorrhage should be considered whenever a liver biopsy is performed.     

Comparison of acute rejection in sensitized ("domino") and unsensitized donor hearts following heterotopic transplantation

Right cervical heart transplantation was performed in 18 mongrel dogs. Three experimental groups (6 dogs in each) were set up. Group I and II dogs received unsensitized donor hearts, while Group III dogs received the potentially sensitized native hearts of Group I and II dogs, following final rejection episodes in those animals. We call the transplantation of a native heart out of a previous recipient "domino" transplantation. Immunosuppression consisted of standard triple-drug therapy in all dogs. Groups II and III received, additionally, high-dose steroids during acute rejection episodes. The donor hearts were assessed daily via transmural biventricular biopsy (graded according to Billingham's criteria), and these results were compared with results of daily cytoimmunologic monitoring (n=259 for activation-index), used as a noninvasive method. Supplementally, antimyosin scintigraphy (n=25, heart-to-lung ratio) was employed for rejection diagnosis. The rejection type was determined by calculating T-cell/B-cell ratios with the aid of fluorescein-conjugated monoclonal antibodies. The invasive data consisted of 587 transmyocardial biopsy results, which were used to establish the rejection kinetics. In the domino grafts of Group III, acute rejection had an earlier onset (an average of 3.2 days) and was permanent, despite repeated cortisonepulse therapy. In contrast, acute rejection followed a biphasic course in Group II (average rejection-free interval, 6.8 days) and was non-uniform in Group I (onset after an average of 5.7 days). Cytoimmunologic monitoring corresponded significantly (p < 0.001) with daily histologic findings in Groups I and II, but not with those in Group III (domino grafts). The T-cell/B-cell ratio increased in Groups I and II (to an average of 3.9), as would be expected during acute cellular rejection. In contrast, the T-cell/B-cell ratio decreased in Group III (to an average of 1.1). The heart-to-lung ratio, as determined by antimyosin scintigraphy, accurately revealed the various stages of acute rejection in all groups (p < 0.001). We conclude that the native heart appears to become sensitized during acute rejection episodes of a heterotopically transplanted heart. Cytoimmunologic monitoring and calculation of T-cell/B-cell ratios support this conclusion. In addition, we conclude that cyto-immunologic monitoring and antimyosin scintigraphy are highly specific and sensitive tools for diagnosis of cellular rejection.     

Establishment of a colonic polyp registry in Rhode Island

A colonic adenomatous polyp registry (PR) has been organized at the Roger Williams Medical Center whose main functions are to prevent the occurrence of colorectal cancer (CRC) in the enrollees, to provide a population of subjects for epidemiological and interventional studies, and to provide educational, including dietary, information to subjects and physicians. One hundred fou and 202 patients with polyps, originally retrieved from the hospital pathology files, were enrolled in the 1984 and 1987 cohorts, respectively, of whom about 90% were followed for at least three years after polypectomy. Three carcinomas, all Dukes A, were found in the right colonin the follow-up period. New polyps identified in the first three years after polypectomy were generally small tubular adenomas with a greater predilection for the right colon than was found for the index polyps. Risk factors for new polyps included history of previous polyps and, probably, multiple index polyps. The use of colonoscopy for postopolypectomy surveillance increased between 1984 and 1987. About 25% of the subjects in, each cohort were either lost to follow-up or received no endoscopic suveillance. On the other hand, some of those who were followed were probably subjected to excessive numbers of procedures. Defects in the PR include inadequacy of personal and family history data, and steady loss of patients during the three to six years after polypectomy. Despite the small size and limited resources of our hospital, its colonic polyp registry has already provided information that may help in the management of patients with this premalignant condition. The more widespread use of securely funded polyp registries would probably reduce the incidence of metachronous CRC in that population and would have significant epidemiological and educational functions.