Ulcerative colitis complicated by gastroduodenal lesions

A case of ulcerative colitis complicated with gastric and duodenal lesions is reported. The patient was a 17-year-old male who was admitted with bloody diarrhea and abdominal pain. Based on the endoscopic and histological findings of the colon, a diagnosis of ulcerative colitis was made. Upper gastrointestinal endoscopy showed multiple erosions and granular changes in the antral greater curvature of the stomach and descending portion of the duodenum. Histological examination of the stomach and duodenum revealed marked inflammatory cell infiltration and crypt abscesses. Clinically, the gastric and duodenal lesions did not respond to antiulcer drugs, but were alleviated by steroid. It was concluded that the pathogenesis of the gastric and duodenal lesions in this patient was similar to that of the colonic lesions of ulcerative colitis.     

Adrenocorticosteroid therapy and gastroduodenal lesions

Gastroduodenoscopy was performed in 25 patients with various disorders, such as liver cirrhosis, nephrotic syndrome, and ulcerative colitis, to assess the effects of corticosteroids on the stomach and duodenum. The main criterion for entry into the trial was the absence of open ulcer, healed ulcer, erosion, or bleeding from the stomach or duodenum on pretreatment endoscopy performed within 48 hours before administration of corticosteroids. Endoscopy repeated at 2 to 4 weeks disclosed gastroduodenal lesions in 11 cases (44%)and no lesion in 14 cases (56%). The gastroduodenal lesions observed in 11 cases are as follows: one gastric ulcer (4.0%), six gastric erosions (24.0%), two gastroduodenal erosions (8.0%), and two duodenal erosions (8.0%). A lack of correlation between the patients' subjective complaints and endoscopic findings indicates the unreliability of patients' complaints and the importance of endoscopy in assessing gastroduodenal lesions. There were no differences in the total and average daily doses of corticosteroid between a group with gastric and/ or duodenal lesions and a group without such lesions. Corticosteroids may produce gastroduodenal lesions, regardless of the dose.     

Endoscopic and biopsy findings of the upper digestive tract in patients with amyloidosis

Endoscopic and biopsy findings of the esophagus, stomach, duodenum, and colorectum were studied in 37 patients with amyloidosis involving the gastrointestinal tract. Endoscopic examinations revealed fine granular appearance, polypoid protrusions, erosions, ulcerations, and mucosal friability in many cases. These findings were most marked and noticed most often in the second portion of the duodenum. The frequency of amyloid deposition in the biopsy specimens was as follows; 100% in the duodenum, 95% in the stomach, 91% in the colorectum, and 72% in the esophagus. The degree of amyloid deposition in the duodenum, which was the highest of the entire gastrointestinal tract, significantly correlated with the frequency of endoscopic findings such as fine granular appearance and polypoid protrusions. Therefore, the two endoscopic findings described above are characteristic of this disease and may reflect amyloid deposition in the mucosa or submucosa of the alimentary tract. Our results indicate that for a diagnosis of amyloidosis, it is important to examine the upper gastrointestinal tract, especially the duodenum, using endoscopy and biopsy techniques.     

Alcohol-induced gastric and duodenal lesions in man.

To determine the effect of an acute dose of ethanol on the stomach and duodenum, seven alcoholic subjects with previously normal upper gastrointestinal endoscopy were reevaluated with endoscopy and directed biopsy three hours after the oral ingestion of ethanol (1 gm./kg. body weight) as a 35 gm./100 ml. solution. After ingestion of alcohol, all seven subjects had moderate to severe antral erythema and friability and two had patchy erosions and hemorrhage in the antrum and fundus of the stomach. Five of seven subjects had changes in the duodenal bulb consisting of erythema similar to that in the antrum of the stomach. Microscopically after alcohol, four of seven demonstrated focal subepithelial hemorrhage and another had frank mucosal hemorrhage in the antrum. In the duodenal bulb, four of seven subjects demonstrated focal subepithelial hemorrhage in the tips of bulbar villi and four of seven had striking infiltration of eosinophils in the subepithelial stroma. These histologic alterations were not present in prealcohol biopsies or in biopsies in two additional subjects given club soda alone or beef bouillon, or in repeat biopsies in two subjects re-endoscoped three days after the ingestion of alcohol when the endoscopic findings were again normal. It is concluded that a single dose of alcohol consistently causes macroscopic and microscopic antral and duodenal alterations.     

Endoscopy in the diagnosis of gastrointestinal Mycobacterium avium-intracellulare infection

Two cases of mycobacterium avium-intracellulare (MAI) infection in association with acquired immunodeficiency syndrome (AIDS) are presented to highlight the distinctive upper gastrointestinal endoscopic appearances: 2 X 4 mm diameter, white nodules with intervening erythema and hemorrhagic erosions covered the mucosa of the second part of the duodenum. Histological evaluation of these nodules revealed diffuse expansion of the lamina propria by macrophages that contained numerous intracellular and extracellular acid-fast organisms. We conclude that endoscopy with endoscopic biopsy may represent the most rapid and sensitive diagnostic tool available in this disease.     

Impact of Helicobacter pylori infection on histological changes in non-erosive reflux disease

AIM: The evidence for an association between Helicobacter pylori (H pylori) and gastroesophageal reflux disease, either in non- erosive (NERD) or erosive esophagitis (ERD) remains uncertain. The available data on the histological changes in NERD and the effect on H pylori infection on them are elusive. The aim of this study therefore was to prospectively evaluate the histological findings and the impact of H pylori infection on a group of symptomatic patients with NERD. METHODS: Fifty consecutive patients were prospectively evaluated for symptoms compatible with GORD. In all cases, routine endoscopy and lugol directed biopsies were performed and assessed histologically in a blinded manner. RESULTS: The overall prevalence of H pylori infection was 70%. Twenty-nine patients out of 50 (58%) were NERD patients. No statistical significance was observed between the H pylori status and NERD. The remaining 21 (42%) were diagnosed as follows: 13 (26%), 6 (12%), 2(4%) with esophagitis grade A, B and C respectively. A statistically significant correlation was observed between the H pylori+ and esophagitis grade A, as well as between H pylori- and grade B. Biopsies from 2 patients were not included because of insufficient materials. Histologically, a basal zone hyperplasia was found in 47 (97.91%) patients, alterations of glycogen content in 47 (97.91%), papillae elongation in 33 (68.75%), blood vessels dilatation in 35(72.91%), chronic inflammation in 21 (43.75%), infiltration with eosinophils, neutophils and T-lymphocytes in 4 (8.33%), 6 (12.5%) and 39 (81.25%) respectively. No correlation was observed between the H pylori status and the histological parameters studied either in NERD or GERD. CONCLUSION: Histological assessment can not differentiate symptomatic patients with erosive versus non-erosive reflux disease. Moreover, H pylori infection may not act as an important factor in patients with NERD.     

Schistosomal colonic disease.

This study evaluates 216 patients with schistosomal colonic disease, diagnosed by endoscopic biopsies at the Armed Forces Hospital, Riyadh. The colonoscopic appearance was suggestive of schistosomiasis in 98 of these patients (45.37%), Schistosoma mansoni ova in stool was detected in only 24 of these 216 patients (11.11%). The most common histopathological finding in colonic biopsies of these patients was Schistosoma mansoni ova in the colonic mucosa with no or mild inflammatory cells infiltrates. These findings correlate with the endoscopic appearances in most patients. The most common symptoms were abdominal pain or distention in 84 patients (38.88%). Sixty five patients (30.09%) had hepatosplenic schistosomiasis. Eight patients had schistosomal polyps and two patients had colonic malignancy in which no association between their malignancy and Schistosoma mansoni infection was established. After antischistosomal treatment follow up, sigmoidoscopy was normal in 28 patients who previously had abnormal endoscopic appearances. Colonoscopic examination is valuable in colonic schistosomiasis as it can show characteristic colonic lesions and colonic biopsies are diagnostic and correlates with histological findings.     

胃粘膜相关淋巴组织淋巴瘤的内镜下表现

目的 胃粘膜相关淋巴组织淋巴瘤（ＭＡＬＴ淋巴瘤）的内镜特征。方法 对１９例胃ＭＡＬＴ淋巴瘤患者的临床资料进行回顾分析。结果 胃ＭＡＬＴ淋巴瘤的内镜下表现呈多样性改变。病变主胃体最多（７８．９％），主要病变形态包括溃疡（６３．２％）、肿块（１５．８％）、浸润病变（１５．８％）及糜烂（５．３％）。大多数２（７３．７％）有较典型的恶性征象，但少数可无典型恶性征象，甚至仅表现为一般的炎症及糜烂。本组病例内     

Campylobacter pyloridis in the upper gastrointestinal tract: a Brazilian study

The successful isolation of C. pyloridis from human gastric mucosa has renewed interest in these bacteria and their role as a causative agent for gastritis, and possible causal relationship between chronic gastritis and peptic ulceration. To determine the incidence of C. pyloridis in gastric biopsies we studied 51 consecutive Brazilian patients with a wide range of alimentary disorders presenting for endoscopy. At least three biopsies were taken from each site: antrum, any ulcer or cancer. Microbiological and histological studies were performed to identify the bacteria. The organism was found in 40/51 (78%) of patients. These was a close correlation between culture (100%), Gram (90%) and Gimenez staining (80%) in identifying the bacteria. All C. pyloridis positive patients had histological evidence of antral chronic gastritis (active or quiescent) even if the endoscopic appearance looked normal. All peptic ulcer patients (n = 17) showed C. pyloridis in the antrum. In the duodenum the bacteria were mainly seen in gastric type of mucosa. Our findings support the hypothesis that C. pyloridis is etiologically related to gastritis and possibly peptic ulceration.     

Clinical results of observation of the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope

Background and Aim: Esophagogastroduodenoscopy through the oral cavity of patients who have undergone percutaneous endoscopic gastrostomy (PEG) causes some distress and puts these patients at risk of aspiration pneumonia. The aim of this study was to evaluate results for the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope. Methods: The study subjects were 43 patients, who underwent exchange of a PEG button or tube, 20‐French or more in diameter. After PEG buttons or tubes were extracted from the gastrostomy tract, an ultrathin endoscope was inserted through the gastrostomy tract. The stomach and the duodenal bulb were observed and the esophagus was observed in retrograde passage. A new PEG button or tube was then inserted. The rate of successful insertion into the esophagus and duodenal bulb, the observation of the gastrostomy site in retroversion in the stomach, and the endoscopic findings were analyzed. Results: Ninety‐nine examinations were carried out. The esophagus could be observed in 95 (96.0%), the duodenum in 92 (92.9%) and the gastrostomy site in the stomach in all. Gastric polyps were detected in four patients, gastric erosions in two, reflux esophagitis in two, polypoid lesion at the gastrostomy tract in two, gastric ulcer scar in one, duodenal ulcer scar in one, early gastric cancer in one and recurrent esophageal cancer in one. Neither discomfort nor complications occurred during transgastrostomic endoscopy. Conclusions: Observation of the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope during a gastrostomy button or tube replacement may be useful and safe.     

The diagnostic value of endoscopic terminal ileum biopsies

OBJECTIVES: Biopsy of the terminal ileum (TI) is commonly performed during colonoscopy. The primary utility of this is to diagnose or rule out Crohn's disease in patients with symptoms and/or radiographic findings suggesting this diagnosis. We see many such biopsies in our gastrointestinal pathology service and have been impressed by the subjectively low yield of TI biopsies. Therefore, we studied this to obtain objective data. METHODS: We retrospectively reviewed 414 consecutive patients with terminal ileal biopsies. Histologic parameters evaluated were primarily those changes diagnostic of chronic inflammation or its sequelae. Histologic findings were then compared with the indication(s) and endoscopic findings. RESULTS: The TI was histologically normal in 82% and endoscopically normal in 81% with most endoscopic abnormals having "ileitis" (13%). Known or strongly suspected inflammatory bowel disease was the most common indication (38%) with Crohn's disease accounting for 20% and ulcerative colitis 16% followed by diarrhea (33%), anemia/hematochezia (15%), abdominal pain (6%), and abnormal imaging (5%). Diagnostic yield varied, with indication and endoscopic findings being highest with known suspected Crohn's disease (40%), abnormal imaging (32%), and with endoscopic "ileitis" (84%) or ulcers/erosions (69%). CONCLUSIONS: Diagnostic yield of TI biopsy varied with indication and endoscopic findings. Our study indicates that biopsy is of greatest value in patients undergoing endoscopy for known or strongly suspected Crohn's disease, or with an abnormal imaging study of the TI. Biopsy of endoscopically normal mucosa is unlikely to yield diagnostically useful information, and is not encouraged as routine. However, when "ileitis," ulcers, or erosions are identified, biopsies can be very helpful.     

Endoscopy in Dyspeptic Patients: Is Gastric Mucosal Biopsy Useful?

Should dyspeptic patients coming to endoscopy with "normal" findings also be biopsied? To assess this, we studied the sensitivity and specificity of endoscopic examination compared with histology, microscopic evidence of Helicobacter pylori, CP-TEST, culture, and serum IgG and IgA antibody titers to H. pylori to determine whether endoscopy and antral biopsies really are useful. One hundred seven consecutive dyspeptic patients (mean age 43 yr) were entered. Four antral biopsies were taken routinely for evaluation by histology, microscopy, CP-TEST, and culture. Serum IgG and IgA antibody levels were measured in all patients. Of symptoms, postprandial bloating was statistically more common in H. on-positive than in negative patients. Endoscopy had the poorest sensitivity (37.1 %) and specificity (53.3%). Patients with normal endoscopic appearances but histologically confirmed gastritis had significantly higher IgG and IgA titers than the patients normal by both endoscopy and histology and without evidence of H. pylori. This study has shown that endoscopy is unhelpful in dyspeptic patients if endoscopic biopsies are not routinely taken.     

Correlation of endoscopy and histology in the gastroesophageal mucosa in children: are routine biopsies justified?

Guidelines for obtaining biopsies during endoscopy in children are needed. The endoscopic evaluation may be considered deficient on many occasions if not accompanied by a histopathologic evaluation. A retrospective review of our endoscopic records and biopsies was undertaken to determine the correlation of the visualized endoscopic appearance and the histopathologic findings in the upper gastrointestinal (GI) tract in children. Over a 1-year period, 204 patients, all of whom had esophageal biopsies and 59 of whom had gastric biopsies as well, were evaluated by an upper GI endoscopy. Endoscopic findings included erythema, granularity, abnormal vascular pattern, friability, erosions, plaques, ulceration, and strictures. Histologic evaluation of biopsies was undertaken by one pathologist according to the presence of and type of cellular infiltrate and cellular morphologic abnormalities in the mucosa and submucosa where available. In this study, the correlation of endoscopic appearance with histology was rather limited in both the esophagus and the gastric mucosa. Low specificity and sensitivity of endoscopy in both locations (41% and 81% for the esophagus; and 43% and 86% for the gastric mucosa, respectively) illustrated the discrepancy. The overall accuracy of endoscopic evaluation in matching the histologic diagnosis was not more than two out of three (63.8%). No single endoscopic finding had a reliable correlation with histologic diagnosis but some had higher predictive value than others. Of the multiple indications for endoscopy in children, recurrent abdominal pain had the least diagnostic yield. Endoscopic appearance correlates poorly with histologic diagnosis in the gastroesophageal mucosa in children. Regardless of the appearance of the mucosa, routine biopsy during upper GI endoscopy in children should be encouraged.     

Eosinophilic esophagitis in 29 pediatric patients

BACKGROUND: Eosinophilic esophagitis is a recently described entity with esophageal symptoms like gastroesophageal reflux disease and significant esophageal eosinophilic infiltration. AIM: To present our clinical series of 29 children with eosinophilic esophagitis, describing the clinical and diagnostic features, treatment and outcome. METHODS: We describe 29 patients (22 boys), 1-18 years-old, with 20 eosinophils per high-power field in esophageal biopsy specimens and absence of eosinophilic inflammation in the stomach and duodenum. Evaluation of the clinical, endoscopic and histologic findings, treatment and outcome was undertaken. RESULTS: The most common presenting symptoms included vomiting in 15 patients (52%) and abdominal pain in 11 patients (38%). Children under the age of 4 years presented with feeding disorder and failure to thrive. Patients between 5 and 8 years of age presented commonly with abdominal pain or symptoms that may be associated with reflux (heartburn and/or vomiting). Patients over the age of 8 presented most often with abdominal pain, dysphagia and occasional food impaction. Endoscopic features included vertical furrowing in 14 patients (48%), whitish papules in 12 (41%), corrugated rings in 2 patients (7%) and esophageal erosions in 3 patients (10%). In seven patients endoscopy was normal (24%). Treatment included swallowed fluticasone propionate in 19 patients and restriction diet in 7 patients. Patients who returned for follow-up had either improvement or remission of symptoms. After treatment, endoscopic biopsies were repeated in 11 patients, and a significant decrease in esophageal eosinophil counts was observed. CONCLUSIONS: The diagnosis of eosinophilic esophagitis must be considered when symptoms of reflux do not respond to conventional treatment. Upper gastrointestinal endoscopy must be complemented by a detailed analysis of histologic findings and eosinophil counts.     

The Los Angeles and Savary–Miller systems for grading esophagitis: utilization and correlation with histology

The aim of the study is to determine the proportion of patients who have esophageal biopsy specimens taken for an endoscopic diagnosis of reflux esophagitis in which an endoscopic grade of esophagitis (Los Angeles [LA] or Savary–Miller [SM]) is communicated to the pathologist, and to evaluate the correlation between those endoscopic grades and histopathologic findings. We searched the database of Caris Diagnostics (a large, gastrointestinal pathology practice that receives specimens from community‐based endoscopy centers), and extracted data from all patients who had an endoscopy with esophageal biopsies submitted in a 12‐month period. There were esophageal biopsy specimens from 49 480 patients obtained during 58 986 endoscopies. The LA grade was provided in 5513 cases (27.9% of 19 778 with endoscopic esophagitis); the SM grade was stated in only 2416 cases (12.2%). A histopathologic diagnosis of erosive or ulcerative esophagitis was made significantly less often in LA grade A patients (3.2%) than in those with LA grades C (20.0%) and D (23.3%); erosive or ulcerative esophagitis was found in only 1.4% of patients with SM grade I and in 35.5% of cases with grade IV. Endoscopists who biopsy the esophagus of patients with reflux esophagitis usually do not communicate the grade of esophagitis to the pathologist. Although both the LA and SM grading systems are based on the presence of esophageal mucosal breaks (erosions or ulcers), in practice such breaks are documented in only a minority of esophageal biopsy specimens taken from patients with reflux esophagitis of any grade.     

Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease

Two hundred and twenty patients with symptoms suggestive of pathologic gastroesophageal reflux were investigated to elucidate the ability of symptoms and endoscopic findings in establishing a diagnosis of reflux disease as measured by ambulatory 24-h pH-monitoring. Daily occurrence of heartburn or acid regurgitation had positive predictive values of 59% and 66%, respectively. pH-monitoring showed pathologic reflux in 75% of patients with esophageal mucosal erosions. Endoscopic erythema of the distal esophagus predicted reflux disease in only 53%. Symptom registration during ambulatory 24-h pH-monitoring showed that about half of the symptomatic events reported by patients with pathologic reflux occurred within 5 min of a reflux episode. The corresponding figure for patients with normal pH-monitoring was less than 20%. We conclude that it is difficult to establish a diagnosis of gastroesophageal reflux disease by patient history alone, that erythema at endoscopy correlates poorly with pathologic reflux, and that reflux disease may be present even with normal endoscopy findings.     

A critical assessment of the current status of non-erosive reflux disease

Non-erosive reflux disease (NERD) has assumed increasing prominence in studies of gastroesophageal reflux disease (GERD), but it remains a challenge to define NERD precisely and to define its place in the investigation and treatment of GERD. Most simply, NERD may be defined as GERD in an individual who has no evidence of erosions at endoscopy. Unfortunately, the characteristic symptoms of GERD--heartburn and regurgitation--are insufficient to identify all GERD patients and, hence, the diagnosis of NERD is hampered by the lack of clear criteria for the symptomatic diagnosis of GERD. The diagnosis of NERD is hampered further by limited interobserver agreement on the endoscopic diagnosis of erosive esophagitis and by the fact that endoscopy is often performed soon after patients have discontinued therapy. Improvements in endoscopic technology will increase the likelihood of identifying small erosions or other reflux-related lesions; however, this will increase the proportion of patients considered to have erosive esophagitis without defining precisely what constitutes NERD. It is important to recognize that NERD is but one manifestation of GERD and that it, like other manifestations of GERD, is associated with a marked diminution in patients' quality of life. However, this recognition apart, there seems to be little practical benefit or understanding to be gained in clinical practice or clinical research from considering NERD as a distinct entity or from studying NERD patients in isolation. Advances in understanding the pathogenesis of GERD and its symptoms may be better served by categorizing GERD with respect to the spectrum of its histologic, functional, endoscopic and symptomatic manifestations rather than by studying NERD, a manifestation that is characterized solely by the absence of esophageal erosions.     

经内镜切除消化道黏膜下肿瘤

目的 探讨内镜切除消化道黏膜下肿瘤(SMT)的疗效、安全性以及切除前内镜超声检查(EUS)的价值。方法 SMT71例中食管36例，胃29例，十二指肠和直肠各3例，64例(90．1％)治疗前行EUS检查。SMT大小6～20mm，平均14．2mm。55例用双活检管道内镜行黏膜切除术(EMR)，把持钳剥离SMT后，将其切除；6例先用圈套器在SMT基底部勒紧，再注入生理盐水，切除SMT；10例≤10mm的用透明帽吸引法切除。结果 71例SMT中68例(95．8％)内镜下完全切除；2例(1例异位胰腺、1例胃平滑肌瘤)病变残留(4周时胃镜发现)；l例直肠平滑肌瘤，未能切除改行外科手术。67例平均随访18．7个月未见复发。组织学诊断平滑肌瘤51例(71．8％)，颗粒细胞瘤、纤维瘤、异位胰腺、脂肪瘤、间质瘤和类癌共15例(21．1％)，5例(7．0％)间叶肿瘤未做免疫染色，不能确定组织来源。并发症：9例局部少量出血，1例胃间质瘤切除后胃穿孔。结论 内镜切除SMT是一种较安全、有效的方法，并可获得组织学诊断，EUS对内镜治疔SMT选择适应证有重要的价值。     

Endoscopic appearance of GERD: Putative role of cell proliferation

BACKGROUND: Erosive esophagitis is a frequent endoscopic feature in patients with gastro-oesophageal reflux disease. However, most of patients with heartburn/regurgitation have a non-erosive reflux disease. The reason for this heterogeneous impact of gastro-oesophageal reflux disease on oesophageal mucosa is unknown to date. AIM: To evaluate the cell proliferation status of oesophageal epithelium in both healthy normal subjects and patients with gastro-oesophageal reflux disease with or without erosions. MATERIALS AND METHODS: All the subjects underwent endoscopy and biopsies were taken at 5 cm from the squamo-columnar junction. Specimens were analysed both at histology and at transmission electron microscopy. Cell proliferation was evaluated by MIB1 immunostaining. Of the 85 subjects were studied, 10 were healthy controls with normal pH-testing and macroscopical, histological and ultrastructural patterns; 37 were patients with erosive esophagitis, and 38 patients with non-erosive reflux disease. RESULTS: At histology, of the 37 patients affected by erosive esophagitis, 30 had normal mucosa and 7 showed mild oesophagitis. One patient with non-erosive reflux disease showed signs of oesophagitis at histology. At TEM, all patients with gastro-oesophageal reflux disease had ultrastructural patterns of damage i.e. dilations of intercellular spaces (DIS), and all controls had a normal ultrastructural pattern. The mean (+/-SD) MIB1-LI values of normal subjects and non-erosive reflux disease and erosive oesophagitis patients were 62.2% (+/-9.1), 29.7% (+/-7.2) and 16.2% (+/-5.2), respectively; there were significant differences among the three groups (p<0.001). CONCLUSIONS: Oesophageal mucosa of patients with reflux symptoms presents a decrease in MIB1 immunostaining of 50% and 25% in non-erosive reflux disease and erosive esophagitis patients with respect to normal subjects.