Double contrast is the best radiological technique for the detection of small esophageal cancer. Gastrografin is indicated when a blind mediastinal fistula is suspected; in cases of choking or suspicion of a fistula with the airways, a low osmotic hydrosoluble Iodium compound must be used. Conventional radiology and endoscopy are complementary techniques for the detection of esophageal cancer, as some lesions may be missed or misinterpreted by both. The need for endoscopic biopsy being incontestable for diagnostic confirmation and characterization, radiology presents some advantages over classic esophagoscopy for preoperative and the general pretherapeutic staging of esophageal carcinoma: assessment of topographical relation with the surrounding organs is possible and with the upper esophageal sphincter is easier; appreciation of tumoral extension along the longitudinal axis (tumor length, gastric invasion) remains mostly possible even in cases of severe stenosis; tumoral extension along the transverse axis (kinking, fistula) may be evaluated; detection of a second tumor or concomitant pathology distally from a stenosing tumor is mostly possible; moreover radiology is important before starting radiotherapy; and finally, previous radiology may reduce the (small) risk of endoscopic perforation. Radiology is indispensable or indicated in the posttherapeutic follow-up of esophageal carcinoma, as well after surgery as after endoscopic interventions, radiotherapy or chemotherapy.
Earlier studies regarding possible primary immune disturbances participating in the pathogenesis of Crohn's disease yielded conflicting results. Peripheral blood lymphocyte subsets and lymphocyte proliferative responses to five soluble recall antigens and to the polyclonal stimulator phythaemagglutinin were therefore measured in 17 patients with active Crohn's disease, before and six months after surgical resection of the inflamed intestine and in 16 healthy controls. Lymphocyte proliferation in response to all five recall antigens was significantly lower in patients than in controls. No significant differences with controls were detected after surgery. Addition of indomethacin to phythaemagglutinin stimulated lymphocyte cultures had a stronger proliferation enhancing effect in patients than in controls, resulting in comparable proliferative responses in both groups. When both indomethacin and prostaglandin E2 were added, inhibition of reactivity by prostaglandin E2 was stronger in patients' cultures. This suggests a higher sensitivity to inflammatory prostaglandins in Crohn's disease. The degree of lymphocyte stimulation by antigens correlated positively with the percentage of circulating memory T cells (CD 45 RA-). The percentage of activated (HLA-DR+) CD8 cells was higher in patients than in controls. The CD4/CD8 ratio, which was not significantly different between patients and controls, correlated significantly with disease activity and characteristics, even in the postoperative phase. These findings suggest that immune abnormalities in Crohn's disease fluctuate with and are probably secondary to inflammatory activity.
SummaryA case of a female patient with unilateral localized granulomatous peritonitis due to ectopic localization of Enterobius vermicularis is Presented. The diagnosis was made because of vaginal bleeding at the laparotomy.The pathology is described. Infrequent occurrence of symptoms associated with ectopic oxyuriasis is emphasized.
Objective: To assess the value of adding ileoscopy with biopsy to colonoscopy, hence increasing the indications for ileoscopy in patients presenting with symptoms of inflammatory bowel disease. Methods: Two hundred fifty-seven patients with persistent diarrhea and 43 patients with sporadic colonic polyps were studied prospectively. The final diagnosis based on clinical and follow-up data, the histology of multiple ileal biopsies, and endoscopic findings were analyzed. Results: Endoscopic lesions of the terminal ileum were found in 123 of 300 patients. In the 43 patients with colonic polyps, no ileal lesions were seen. Ileal disease without colonic involvement was present in 44 of 123 patients. Microscopic lesions of the ileum were present in 125 of 300, or in 125 of 257 (49%) with symptoms of diarrhea. Two of these had a normal endoscopy. Thirteen patients had a diffuse colitis and 11 had a predominantly left-sided colitis, both originally suggestive of ulcerative colitis. Crohn's disease was diagnosed in 88 patients and infectious disease in 17. Ileal biopsies were essential for the diagnosis in 15 patients and were contributive in 53. Granulomas, solitary giant cells, pseudopyloric gland metaplasia, eosinophils, and a disturbed villous architecture were the most important lesions observed in Crohn's disease and were contributive for this diagnosis. Conclusions: Ileoscopy with biopsy is useful in carefully selected patients presenting with symptoms of inflammatory bowel disease. The main indications are diagnosis of isolated ileal disease in the presence of a normal colon and differential diagnosis in patients with pancolitis and predominantly left-sided colitis. Multiple biopsy specimens show definite pathology in almost half of the patients.
4178 Background: Barrett esophagus is the precursor of most esophageal adenocarcinomas. Dysplasia or intraepithelial neoplasia (IEN) is the first step in the sequence which can be recognized with routine morphology in endoscopic biopsies. This diagnosis is however difficult in biopsies with high interobserver variability for low-grade IEN. To solve this diagnostic challenge, immunohistochemistry for p53, a tumor-supressor marker, has been proposed. The features which are useful for assessment of p53-immunoreactivity (p53+) and their clinical and pathogenetic implications are still unclear. Aim: To evaluate the relationship between p53+ and morphological changes and Ki-67-positivity (Ki-67+), a proliferation marker, in Barrett mucosa. Methods: Histology and immunohistochemistry (p53, clone DO-7;Ki-67, clone Mib-1) was performed on 20 operation specimens (short segment Barrett n=10, long n=10) (M/F 3, 66±10 yr) (IEN: low grade n=3, high grade n=3, adenocarcinoma: in situ n=2, T1 n=12; 100% of lesions p53+). p53+ in non-tumoral Barrett mucosa (focal i.e. one or more foci of positive glands vs. diffuse) and its localization (surface epithelium vs. basis of crypts) was analyzed in function of architectural and cytological features of IEN (nuclear enlargement, pseudostratification, maturation). Results: p53+ was detected in 90% of cases (focal: 45%; diffuse: 45%). Diffuse p53+ correlates with carcinoma. Five cases did contain 1 or 2 p53+ foci, 4 cases 4 up to 22 foci. No association was found with architectural abnormalities. A significant difference (p<0.0001)was observed in nuclear enlargement (18% vs. 53%), pseudostratification (11% vs. 79%) and absence of maturation of the epithelium (8% vs. 59%). Focal p53+ was associated with clear-cut morphological IEN in 17% of foci, with a significant lower sensitivity (20% vs. 80%), specificity (27% vs. 73%) and diagnostic accuracy (24% vs 76%) than diffuse p53+ (p<0.0001). Ki-67+ did not improve the diagnostic accuracy. p53+ surface epithelium equals IEN. Conclusion: p53+ was found in two patterns (focal vs. diffuse), whereby the latter correlates to morphological IEN and the former may be indicative of early changes which are not yet detectable by routine morphology. No significant financial relationships to disclose.
Vasculitis, defined as a non-infectious inflammatory disorder of blood vessels, can affect vessels of any type in any organ. The gastrointestinal (GI) tract may thus also be involved. In systemic disorders as mixed connective tissue disease (MCTD) and systemic lupus erythematodes (SLE), patients may present with symptoms of gastrointestinal disfunction such as motility disorders, caused by alterations in the connective tissue. True vasculitis however also occurs in the GI tract. Severe, occlusive damage often leads to ischemia that may result in ulceration and perforation. Non-occlusive vascular disease may lead to vascular leakage resulting in oedema and haemorrhage. Those patients often present with diarrhoea or symptoms of bleeding. GI involvement is frequent in Henoch-Schönlein purpura and also often noted in polyarteritis nodosa (PAN), microscopic polyangiitis, Wegener's syndrome and Churg-Strauss syndrome. Furthermore, GI vasculitis has also been described in giant cell arteritis, Takayasu's disease, Buerger's disease and leucocytoclastic vasculitides as essential mixed cryoglubulinemia, lupus vasculitis, rheumatoid disease, MCTD, drug-induced vasculitis and Behçet's disease. The diagnosis and classification of vasculitis relies upon a combination of clinical, serological, haematological, radiological and histological findings. Establishing a precise diagnosis can be difficult but is important because treatment and prognosis can be highly variable.
