Superficial lesions in Crohn's disease of the small bowel

Double-contrast examinations of the small bowel were compared with operative specimens obtained within 4 weeks after X-ray evaluation of 20 patients with Crohn's disease. Objective evidence of superficial lesions was submucosal edema and superficial ulcerations observed in the operative specimens. Edema was seen radiographically in 18 of 20 patients. Superficial ulcerations were seen radiographically in 8 of 14 patients. These ulcerations were either single with edematous edges or smaller, multiple, and more uniformly spread. The diagnosis demands a high-quality technique and even then the diagnostic accuracy is not always optimal.     

Clinical analysis of primary small intestinal disease： A report of 309 cases

AIM: To evaluate the major clinical symptom, etiology, and diagnostic method in patients with primary small intestinal disease in order to improve the diagnosis. METHODS: A total of 309 cases with primary small intestinal disease were reviewed, and the major clinical symptoms, etiology, and diagnostic methods were analyzed. RESULTS: The major clinical symptoms included abdominal pain (71%), abdominal mass (14%), vomiting (10%), melaena (10%), and fever (9%). The most common disease were malignant tumor (40%). diverticulum (32%) and benign tumor (10%). Duodenal disease was involved in 36% of the patients with primary small intestinal diseases. The diagnostic rate for primary small intestinal diseases by double-contrast enteroclysis was 85.6%. CONCLUSION: Abdominal pain is the most common clinical symptom in patients with primary small intestinal disease. Malignant tumors are the most common diseases. Duodenum was the most common part involved in small intestine. Double-contrast enteroclysis was still the simplest and the most available examination method in diagnosis of primary small intestinal disease. However, more practical diagnostic method should be explored to improve the diagnostic accuracy.     

224例小肠疾病的临床分析

目的 增加对小肠疾病的认识,提高对其的诊断率并探讨检查方法。方法 观察２２４例小肠疾病患者的临床表现,分析其主要症状、病因及所采用的诊断方法。结果 小肠疾病以腹痛（５８％）,腹部包块（１８％）,发热（１７％）及便血（１２％）为主要表现：病因以恶性肿瘤为多见（３２％）,其次为憩室（２９％）,平滑肌瘤（７％）,出血,坏死性小肠炎（６％）、克隆病（４％）。小肠气钡双重造影及剖腹探查仍为目前主要的确诊手段     

Management of small hepatocellular carcinoma

In the last years the incidence of hepatocellular carcinoma (HCC) is rising in cirrhotic patients worldwide. Due the importance of early and definite diagnosis of HCC, any nodular lesion detected in patients with chronic liver disease should be considered as suspicious for HCC. The screening and surveillance programs in patients with liver diseases have increased the number of small HCC detected at an early stage, when the therapeutic options available are able to provide benefit. The introduction of new imaging techniques has improved the accuracy of characterizing these nodules. According to the EASL recommendations, contrast-enhanced computed tomography (CT), contrast enhanced ultrasound (US) and magnetic resonance (MR) with different MR-contrast agents are currently used to characterize liver lesions. Imaging guided biopsy is recommended for small nodules or in lesions without typical features (arterial hypervascularization) in at least two imaging techniques. Frequently the differential diagnosis of small nodules is complicated by discordant vascularity and recent studies have also demonstrated the presence of small hypovascular HCC at perfusional US and helical CT. At present, different treatment options can be offered to patients with diagnosis of small HCC at an early stage; percutaneous techniques, surgical resection and liver transplantation can provide benefit in properly selected patients. This review describes some critical points regarding the detection, diagnosis and therapeutic management of small nodules of HCC in cirrhotic patients.     

小肠克罗恩病的CT诊断

目的探讨CT检查对小肠克罗恩病诊断的临床应用价值。方法回顾性分析2007年1月-2010年12月在我院经手术病理证实的27例小肠克罗恩病患者的CT检查资料。图像分析项目包括小肠本身改变(如受累的部位、数目、肠壁厚度、黏膜强化、肠腔扩张和肠腔狭窄)、肠道周围病理改变(如系膜水肿、淋巴结肿大和积液等)和并发症(如蜂窝组织炎、脓肿和窦道等)等。结果 27例中,肠壁增厚、水肿、分层21例;肠腔狭窄6例;19例见小肠系膜"梳状征";淋巴结肿大7例;腹腔积液4例;小肠外脓肿2例,窦道形成1例。结论小肠克罗恩病的CT表现有一定特征性,CT检查对小肠克罗恩病的诊断具有重要临床应用价值。     

Multiple strictures in Crohn's disease of the small bowel: a benign variant

Involvement of both jejunum and ileum is uncommon in Crohn's disease of the small bowel. We report five patients with multiple strictures of the small bowel associated with one or more intervening segments of dilated bowel. A diagnosis of Crohn's disease was delayed because none of the patients experienced diarrhea. Despite the early radiologic appearance of extensive small bowel disease, only three patients have required surgery, a limited surgical resection of 65-75 cm was possible, and long-term prognosis has been favorable.     

The role of capsule endoscopy in small bowel Crohn's disease

Video capsule endoscopy is an invaluable tool for examining the small bowel. It is non-invasive and generally well tolerated, however its role in the assessment of the severity and extent of small bowel Crohn's disease has not, to date, been adequately evaluated.MethodsAll capsule endoscopies performed over a two year period in a tertiary referral centre in subjects with known or suspected Crohn's disease were reviewed.ResultsTwenty-six capsule endoscopy studies in total were included. These were performed in 15 cases of known Crohn's disease, 5 cases of suspected Crohn's disease, 3 cases of endoscopically diagnosed non-specific terminal ileal inflammation and finally 3 post colectomy cases of indeterminant being considered for IPAA formation. Ten patients known to have small bowel Crohn's disease were prospectively recruited; of 3 with normal small bowel follow through or CT exams, one had an abnormal capsule endoscopy. The other 7 patients had small bowel follow through or abdominal CT scans consistent with small bowel Crohn's disease; additional mucosal abnormalities were detected by capsule endoscopy in 6 cases with capsule retention in the stomach in one. Of 5 with colonic Crohn's disease normal small bowel imaging corresponded with normal capsule endoscopy in all but one. A diagnosis of Crohn's disease was made in 2 out of 5 cases of suspected Crohn's disease on the basis of the capsule endoscopy findings. Three patients with non-specific acute terminal ileal inflammation at ileocolonoscopy were confirmed to have ongoing inflammation. The capsule was retained in four subjects beyond 24 h.ConclusionCapsule endoscopy more accurately determines the severity and extent of the Crohn's disease in the small bowel than traditional imaging modalities.     

Adenocarcinoma as a complication of small bowel Crohn's disease

Carcinoma is a recognized but rare complication of small bowel Crohn's disease. This case series emphasizes the importance of considering this diagnosis in patients with small bowel Crohn's disease. We report three cases in which patients were treated for presumed exacerbations of Crohn's, but were subsequently found to have underlying small bowel adenocarcinoma. This case series will demonstrate the need for the surgical assessment of patients with long-standing symptomatic Crohn's disease that fails to settle with conservative management.     

Application of capsule endoscopy in small intestine diseases: analysis of 28 cases in Kaohsiung Medical University Hospital

Capsule endoscopy (CE) is used to diagnose small intestine disease. Many studies have shown a better lesion detection rate in obscure gastrointestinal (GI) bleeding than with other surveyed techniques. Our study investigates the diagnostic value of CE in patients with suspicious small intestine diseases. Between October 2004 and January 2006, patients who had suspected small intestine disease underwent CE in Kaohsiung Medical University Hospital. Presenting symptoms included obscure GI bleeding, abdominal pain, diarrhea, microcytic anemia, and other indications. CE results were analyzed as a proportion of total lesion detection rate and also with regard to obscure GI bleeding and abdominal pain for analysis. A total of 28 patients, including 12 males and 16 females, were enrolled for CE examination. Overall, small intestine lesions were detected in 20 cases (71.4%), with negative findings in eight cases. For obscure GI bleeding, the total lesion detection rate was 85.7% (12 of 14 patients) but the diagnostic rate was only 35.7% (five of 14 cases). In patients with abdominal pain, four of seven (57.1%) had small intestine lesions. In conclusion, CE survey has a good lesion detection rate for small intestine disease, especially for patients with obscure GI bleeding, and is helpful in the diagnosis of unexplained abdominal pain.     

小肠克罗恩病的特征分析

目的通过对小肠克罗恩病患者的临床特点分析,加深对小肠克罗恩病的认识,提高早期诊断水平,减少误诊率。方法对1992年1月～2006年12月期间在我院住院病历中符合克罗恩病的116例患者的临床特点进行回顾性分析。结果小肠克罗恩病24例（20．69％）,青壮年好发,首次确诊时间比其他类型克罗恩病患者更长。其临床主要表现为腹痛20例（83．33％）,便秘8例（33．3％）,腹泻6例（25％）,便血6例（25％）,消瘦14例（58．3％）,贫血8例（33．3％）,发热7例（29．2％）,手术18例（75％）。结论小肠克罗恩病临床表现多样化,诊断困难。小肠钡灌检查可作为小肠克罗恩病的有效筛查手段。     

Plasma calcitonin as a marker of disease activity in patients with small cell carcinoma of the lung

To evaluate the usefulness of plasma calcitonin as an index of tumor burden and disease activity, we undertook a prospective study of serial calcitonin measurements in a group of patients with small cell carcinoma of the lung from diagnosis throughout a period of intensive therapy. Plasma calcitonin was significantly elevated in 84% of patients with extensive small cell carcinoma of the lung and was not elevated in patients with limited disease at the time of diagnosis. The elevated values fell significantly in response to chemotherapy and radiation therapy, and reflected regression of followable disease and improvement in clinical status. A significant correlation existed between plasma calcitonin and extent of disease. Relapse was generally associated with an increase in elevated plasma calcitonin levels, and calcitonin appeared to reflect tumor burden. The serial measurement of plasma calcitonin is useful in the management of the patient with small cell carcinoma of the lung.     

Non-operative management of small cell carcinoma of esophagus

Primary small cell carcinoma of the esophagus (SmCC) is an uncommon aggressive tumor characterized by early systemic dissemination and poor prognosis, regardless of the methods of treatment. The optimal treatment strategy remains uncertain. A retrospective study was conducted to review the results of non-operative treatment for patients with limited and metastatic esophageal SmCC. Between 1993 and 2003, 10 patients were diagnosed to have primary esophageal SmCC in our institution. Six of them had disseminated diseases, whereas the other four had limited disease upon diagnosis. All patients were managed non-operatively by either chemotherapy and/or radiotherapy. The overall median survival was 8 months (range, 2-62 months). The survival was 4-62 months for patients with limited disease, whereas it was 2-10 months for patients with disseminated disease at initial diagnosis. In summary, the current study demonstrated satisfactory palliation could be achieved with chemo-radiation for patients with limited disease; however, the ultimate role of primary chemo-radiation for esophageal SmCC must await results from randomized trials.     

双气囊内镜与多层螺旋CT小肠造影在小肠克罗恩病诊断中的作用

目的 研究双气囊内镜(DBE)和多层螺旋CT小肠造影(MSCTE)在小肠克罗恩病(CD)诊断中的价值.方法 对71例临床疑似小肠CD患者分别进行DBE和MSCTE检查并作出诊断.结合病理及临床随访结果,比较两种方法在小肠CD诊断、判断病变范围、活动性和并发症等方面的能力.结果 DBE与MSCTE对小肠CD确诊率相似,两者间差异无统计学意义(χ2=2.29,P>0.05).前者阳性似然比为22.5,阴性似然比为0.022;后者阳性似然比为1.6,阴性似然比为0.240.两种检查方法对于无-轻度管腔狭窄者判断的一致性明显高于中-重度管腔狭窄者(χ2=11.298,P=0.001).DBE与MSCTE对疾病活动性判断的一致性为95.8%.结论 DBE可能是确诊小肠CD的首选方法,与MSCTE联合应用有利于诊断和评价小肠CD患者的病情.     

Magnetic resonance imaging evaluation of small intestinal Crohn's disease

Imaging evaluation in patients with Crohn's disease is based on morphological abnormalities, traditionally disclosed by barium studies including conventional enteroclysis, and more recently by cross-sectional imaging. A major prerequisite for optimal image quality and a more confident diagnosis is the adequate luminal distension of the bowel, which is usually achieved by administering an intraluminal contrast agent through a nasojejunal catheter. Magnetic resonance enteroclysis is a new technique that combines the advantages of volume challenge with state-of-the-art ultrafast pulse sequences, resulting in an excellent demonstration of the anatomy of the small bowel. Magnetic resonance enteroclysis compares favourably with conventional enteroclysis in detecting, localising and assessing the extent of involved small bowel segments. Luminal narrowing and extramural manifestations or complications of the disease can also be accurately assessed by the technique. Imaging features including the presence of deep ulcers, extensive wall thickening and mesenteric lymph nodes exhibiting marked gadolinium enhancement correlate strongly with disease activity. Although the clinical utility of magnetic resonance enteroclysis in Crohn's disease has been widely recognised, its routine application is currently limited to academic centres. Its clinical indications may include follow-up studies of known disease, the classification of Crohn's disease subtypes, an estimation of disease activity and a determination of the extramucosal extent and spread of the disease process.     

Comparison of double balloon enteroscopy and small bowel series for the evaluation of small bowel lesions]

BACKGROUND/AIMS: The role of double balloon enteroscopy (DBE) is still evolving. The aim of this study was to compare the diagnostic yield of DBE with that of small bowel series (SBS). METHODS: We enrolled patients with suspected small bowel disease consecutively, and performed both DBE and SBS in all patients. RESULTS: Eighteen patients (M:F=12:6, 14-82 years) were included. Indications for small bowel evaluation were obscure gastrointestinal bleeding (10), abdominal pain (5), diarrhea (2) and abnormal CT finding (1). Of 10 obscure gastrointestinal bleeding patients, 6 showed the same findings in both studies. However, 4 showed negative findings in SBS while DBE detected erosions or ulcerations. Of 5 abdominal pain patients, 3 showed the same results in both studies. However, 2 demonstrated different results. One was suspected of early Crohn's disease in SBS, but proved to be normal in DBE, and the other was suspected of malignancy in SBS but was suspected of benign ulcers in DBE. Of 2 chronic diarrhea patients, one was diagnosed as Crohn's disease in both studies. The other was suspected of tuberculosis in SBS but diagnosed as lymphangiectasia by DBE with biopsy. One patient with jejunal wall thickening in CT proved to be normal in both DBE and SBS. There were no serious complications associated with DBE and SBS. CONCLUSIONS: DBE is better than SBS in terms of diagnostic accuracy. DBE may become an important method for the evaluation of small bowel diseases.     

Impact of the small bowel study on patient management

Medical records of 528 consecutive patients who had a peroral small bowel examination or enteroclysis were reviewed. Clinical indications, efficacy of the small bowel examinations, and patient outcome were correlated to determine the impact of the small bowel examination on patient management. The most frequent indications were abdominal pain (19%), diarrhea (15%), obstruction (12%), bleeding (11%), postsurgical evaluation (10%), and assessment of Crohn's disease (8%). Two thirds of the studies (67%) were normal, and 33% of the examinations were abnormal, with similar results in all age groups. Small bowel obstruction (13%), miscellaneous results primarily including diffuse small bowel diseases (7%), adhesions (6%), and Crohn's disease (5%) were the most common abnormalities detected. The effects of small bowel studies on patient management were exclusion of serious pathology (67%), diagnosis that changed therapy (32%), and incidental findings (1%). Small bowel enteroclysis had a higher yield of positive examinations than the peroral small bowel examination, most likely due to patient selection.     

Videocapsule endoscopy versus barium contrast studies for the diagnosis of Crohn's disease recurrence involving the small intestine

OBJECTIVES: Historically, suspected Crohn's disease (CD) has been evaluated with small bowel follow-through (SBFT) or enteroclysis (equally accurate). This study was undertaken to determine the accuracy of videocapsule endoscopy (VCE) in the diagnosis of CD relative to SBFT and clinical/laboratory indices of CD activity. Previous investigations have used VCE for the diagnosis of suspected CD in patients presenting with a variety of gastrointestinal symptoms. This is the first study to evaluate the occurrence of active disease in patients with known CD. METHODS: Thirty subjects (22 female, 8 male, aged 36.9 +/- 14.2 yr); all with prior CD diagnosis made on the basis of standard criteria (5.5 +/- 6.5 yr prior to study), in whom recurrent CD was suspected based on abdominal pain, diarrhea, anemia, and/or arthralgias. Subjects were studied in a prospective, blinded evaluation of VCE versus SBFT. SBFT was performed first; those with stricture and proximal bowel dilation were excluded from further study. For SBFT, studies were graded as grade 0 (normal), grade 1 (minimal nodularity, ulcerations, normal luminal diameter, < 5 cm involved), grade 2 (more extensive ulcers, minimal luminal narrowing, 5-10 cm involved), or grade 3 (fistula, skip areas, extensive ulceration, >10 cm involved). VCE was performed within 1 wk of SBFT. Serum was obtained for ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein), stool was obtained for alpha-1 antitrypsin, and the Harvey Bradshaw index of CD severity was calculated. VCE (digitalized video) was graded as grade 0 (normal), grade 1 (erythema, isolated villi loss), grade 2 (erosion, no ulcer), or grade 3 (ulcers, spontaneous bleeding, and/or stricture). RESULTS: Twelve patients were excluded for small bowel obstruction. VCE and SBFT scores highly correlated (r = 0.65; p= 0.001). Active CD was visualized in 21 of 30 patients with videocapsule endoscopy and in 20 of 30 patients with SBFT. Complete agreement occurred in 13 of 30 studies; 13 of 17 studies differed by one grade. SBFT found mucosal disease in 20 of 30 patients and VCE found mucosal disease in 21 of 30 patients. VCE found mucosal disease in 6 patients (5 in grade 1, 1 in grade 3) with normal SBFT. SBFT showed CD in 5 patients (all grade 1) with normal VCE. Neither VCE nor SBFT scores correlated with biological or clinical indices. Patient satisfaction was superior for VCE. CONCLUSIONS: VCE and SBFT are complementary for the diagnosis of CD. SBFT may be required to detect strictures as the videocapsule may not pass. However, some strictures may also be missed with SBFT. VCE is less invasive, less time-consuming for the patient than SBFT, and avoids radiation exposure, although reading time is greater for the gastroenterologist than the radiologist. Given that patients with clinically suspected CD recurrence may not have active disease, unnecessary and potentially harmful empiric therapy is not warranted without imaging.     

多排螺旋计算机断层成像技术小肠造影对小肠疾病的诊断价值

目的评价多排螺旋计算机断层成像技术小肠造影（MSCTE）对诊断小肠疾病的诊断价值。方法98例疑为小肠病变的患者行MSCTE检查，观察受试者对MSCTE的耐受性以及有无并发症，观察分析不同病变的MSCTE表现，并以手术病理结果或小肠捕管造影、内镜和（或）活检病理的综合诊断结果为金标准来判断MSCTE对小肠病变的诊断价值。结果所有受试者均顺利完成MSCTE，未发现并发症。其中2例为小肠捕管造影失败而改行MSCTE。MSCTE诊断小肠病变总的灵敏度为96．5％（83／86），MSCTE结果与最后临床诊断符合率为90．8％（89／98）。结论MSCTE是一种简便易行、能多方位、全景式显示小肠的方法，对多种小肠疾病有较高的诊断价值。     

Solitary Metastatic Malignant Melanoma of the Small Intestine: Findings Obtained during Intraoperative Enteroscopy

Abstract: A 59-year-old male with an established diagnosis of malignant melanoma of the nasal cavity plus multiple pulmonary metastases was referred to our hospital because of abdominal pain and vomiting. Double-contrast study of the small intestine revealed a filling defect in the middle of the ileum. lntraoperative enteroscopy revealed that the ileal tumor was ulcerated, and that it was covered by ileal mucosa of normal appearance. Because no other lesions were identified within the intestine, the ileal segment with the tumor was surgically removed. The tumor was diagnosed as malignant melanoma with a histology similar to that of nasal mass. The patient has survived for the subsequent 13 months, during which no gastrointestinal symptoms recurred. Our case suggests that metastasis should be included in the differential diagnosis of a single small intestinal tumor. (Dig Endose 1999; 11: 47–51)     

The usefulness of routine small bowel biopsies in evaluation of iron deficiency anemia

BACKGROUND: Iron deficiency anemia (IDA) may be the sole manifestation of celiac disease. The role of routine small bowel biopsies obtained during endoscopy in the evaluation of IDA is unclear. This study assessed the usefulness of routine small bowel biopsies in patients presenting with IDA. STUDY: Evaluation of 103 consecutive patients with IDA undergoing panendoscopy with routine small bowel biopsies was performed. All patients had a diagnosis of IDA with either a ferritin less than 15 microg/L or iron saturation less than 8%. Celiac disease was defined as total or partial villous atrophy with intraepithelial lymphocytosis, histologically, and a clinical response to gluten free diet. Gastrointestinal symptoms were recorded. RESULTS: Nine patients (8.7%) were diagnosed with celiac disease. Of these patients, endoscopic lesions potentially responsible for IDA were found in 33%. We found no statistically significant difference when comparing reports of diarrhea, weight loss, abdominal pain, nausea or vomiting, aspirin or NSAID use, or menopausal status with celiac disease status. CONCLUSIONS: Routine small bowel biopsies to evaluate for celiac disease are indicated in the evaluation of patients with IDA. The finding of endoscopic lesions that may otherwise explain IDA should not preclude small bowel biopsy.