Circumferential Stricture Research Articles

Nonsteroidal anti-inflammatory drug-induced small bowel strictures (diaphragm disease) – an under-recognized cause of small bowel obstruction

BackgroundSmall bowel obstruction is a major source of morbidity and mortality that carries a significant economic burden. Recurrent small bowel obstruction may be secondary to circumferential strictures (small bowel diaphragm disease), an under-recognized entity secondary to long-term NSAID use. We aim to describe the sensitivity of preoperative CT enterography in patients with surgically treated small bowel diaphragm disease. MethodsWe retrospectively reviewed adult patients who underwent elective small bowel resection for small bowel obstruction performed by a single minimally-invasive surgeon between 2010-2023. Patient history, radiographic, endoscopic, operative, and pathology reports were reviewed for reference to NSAID use, small bowel strictures, diaphragms, and enteropathy. Exclusion criteria were prior radiation, inflammatory bowel disease, malignancy, adhesive disease, and anastomotic strictures. ResultsA total of 225 patients were identified; of those, 22 patients (10%) met inclusion criteria. The mean age was 60.7 years (range 29-78), with 15 women (68%). All patients underwent minimally invasive small bowel resection for obstruction with histopathologic evidence of stricture without evidence of transmural inflammation, granuloma, or dysplasia and confirmed NSAID use (n=22; 100%). Anemia was present in 36% (n=8). Preoperative CT or MR enterography was performed in 18 patients (82%) and stricturing was reported in 13 patients (72%). Intraoperatively, palpation identified strictures in all patients. ConclusionNSAID-induced small bowel injury is an under-recognized condition that, in severe cases, can present as small bowel obstruction. Surgeons should consider diaphragm disease in patients with obstruction and NSAID use, in which preoperative CT or MR enterography may be useful but cannot rule out disease.

Circumferential stricture segment metaplastic squamous mucosa & associated spongiofibrosis excision and urethroplasty by ventral approach with double face oral mucosal graft replacement

Circumferential stricture segment metaplastic squamous mucosa & associated spongiofibrosis excision and urethroplasty by ventral approach with double face oral mucosal graft replacement

Endoscopic characteristics of Meckel’s diverticulum in adults: a retrospective case-series from two tertiary general hospitals in China

Background To analyze the diversity in endoscopic manifestations of Meckel’s diverticulum (MD) in adults by using balloon-assisted enteroscopy (BAE) and supply more information on the application of BAE. Methods A retrospective study was carried out on adult patients diagnosed with MD by BAE in two tertiary general hospitals in China, from May 2007 to September 2021. The patients were divided into a small bowel bleeding (SBB) group and a control group according to their main symptoms. Clinical charts and endoscopic images were reviewed, analyzed, and summarized. Results Single diverticulum in the ileum and double-lumen sign were observed in all patients. The SBB group consisted of 51 patients, among which 35 cases of ulcerative lesions, 9 cases of erosive lesions, 9 cases of active bleeding/blood clots, and 4 cases of lumps inside the diverticulum were observed respectively. Majority of ulcerative lesions were inside the diverticulum (23/35). A circumferential stricture inside the diverticulum was discovered in 11 cases, and ulcerative lesions tended to occur at this structure (10/11). In the control group consisting of 15 patients, 1 case of erosive lesions at the orifice edge was observed. The percentage of patients with MD-associated ulcerative lesions was significantly higher in the SBB group than that in the control group (p < 0.001). Conclusions The endoscopic manifestations of MD in adults are extraordinarily complex and connected with the patients’ primary symptoms. The internal features of MD should be regarded as crucial observational objectives in adult patients.

Biomechanical Properties of Strictures in Crohn's Disease: Can Dynamic Contrast-Enhanced Ultrasonography and Magnetic Resonance Enterography Predict Stiffness?

Strictures and abdominal pain often complicate Crohn’s disease (CD). The primary aim was to explore whether parameters obtained by preoperative contrast-enhanced (CE) ultrasonography (US) and dynamic CE MR Enterography (DCE-MRE) of strictures associates with biomechanical properties. CD patients undergoing elective small intestinal surgery were preoperatively examined with DCE-MRE and CEUS. The excised intestine was distended utilizing a pressure bag. Luminal and outer bowel wall cross-sectional areas were measured with US. The circumferential stricture stiffness (Young’s modulus E) was computed. Stiffness was associated with the initial slope of enhancement on DCE-MRE (ρ = 0.63, p = 0.007), reflecting active disease, but lacked association with CEUS parameters. For structural imaging parameters, inflammation and stricture stiffness were associated with prestenotic dilatation on US (τb = 0.43, p = 0.02) but not with MRE (τb = 0.01, p = 1.0). Strictures identified by US were stiffer, 16.8 (14.0–20.1) kPa, than those graded as no or uncertain strictures, 12.6 (10.5–15.1) kPa, p = 0.02. MRE global score (activity) was associated with E (ρ = 0.55, p = 0.018). Elastography did not correlate with circumferential stiffness. We conclude that increasing activity defined by the initial slope of enhancement on DCE-MRE and MRE global score were associated with stricture stiffness. Prestenotic dilatation on US could be a potential biomarker of CD small intestinal stricture stiffness.

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a 20-year single-center clinical and radiologic experience.

The purpose of this article is to describe clinical and imaging characteristics of confirmed cases of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE). Retrospective review of electronic medical records identified patients considered for a diagnosis CMUSE over 20-years in a single large tertiary center. Clinical data were abstracted and diagnosis was confirmed based on published criteria. Two GI radiologists reviewed CT and MR enterography (CTE/MRE) exams in consensus of confirmed patients to characterize the imaging features of CMUSE. Eight patients with confirmed CMUSE diagnosis were included for image review, and 9 CTEs and 1 MRE were analyzed. Most patients were males (75%) with a median age at diagnosis of 59.5 years (25-71) presenting with iron deficiency anemia (75%). Patients were commonly refractory (87.5%) to their first therapy, including steroids, with half being refractory to surgical intervention. Major imaging features included multiple (≥ 5; 88%; 7/8), short (< 2 cm; 100%; 8/8), circumferential (100%; 8/8) strictures with moderate wall thickening (6-9 cm), and stratified hyper enhancement (100%; 8/8) located in the ileum (100%; 8/8). Median proximal small bowel dilation was 2.95 cm (2.5-4.1 cm). No CMUSE cases demonstrated penetrating disease (e.g., abscess, fistula). CT and MR enterography are invaluable tools in the multidisciplinary diagnostic evaluation of CMUSE, a rare cause of small bowel strictures with overlapping clinical and imaging features of Crohn's disease and NSAID enteropathy.

CRYPTOGENIC MULTIFOCAL ULCEROUS STENOSING ENTERITIS (CMUSE): A 20-YEAR SINGLE CENTER CLINICAL AND RADIOLOGIC EXPERIENCE

Abstract Background Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare illness characterized by multiple strictures and shallow ulcers of the small bowel. Even though diagnostic criteria have been described, further ellucidation is needed on therapeutic interventions and potential discriminating factors between CMUSE and other more common causes of intestinal ulcerations, including Crohn’s disease. Aim The purpose of this article is to report the clinical, CT, and MR enterography characteristics of confirmed cases of CMUSE. Materials and Methods Retrospective review of electronic medical records identified 33 patients considered for a diagnosis CMUSE. Diagnosis was confirmed if all requirements of the previously published diagnostic criteria for CMUSE were met. Patients were excluded if they had less than one year follow-up or incomplete clinical data. Two GI radiologists reviewed all CT and MR enterography (CTE/MRE) exams in consensus of confirmed patients to characterize the cross sectional imaging features. Results CMUSE was confirmed in 9 patients (27%) and 24 patients (73%) had a confirmed alternative diagnosis. Crohn’s disease (CD) (30%, n=7) and drug-induced enteropathy (30%, n=7) were the most frequent alternative. Male gender (66.7% vs. 25%, p=0.04) and clinical manifestation of anemia at presentation were more commonly observed on CMUSE-confirmed cases (66.7% vs. 4.2%, p=0.005) when compared to patients with non-CMUSE diagnosis, in which abdominal pain was the most common presenting symptom (44.5% vs 87.5%, p=0.02). Multiple (100%) and circumferential (75%) ulcers with restricted mucosal involvement (55.6%) were major features at endoscopy and pathology. Most common treatments were corticosteroids (78%) or surgical resection (55.6%), with 33% receiving biologics. Disease recurrence after first treatment occurred in the majority (88.9%) after a median time of 6 months (Table 1). 9 CTE and 1 MRE of 8 confirmed cases images were analyzed (Table 2). Major imaging features included multiple (≥ 5; 88%; 7/8), short (&amp;lt; 2 cm; 100%; 8/8) circumferential (100%;8/8) strictures with moderate wall thickening (6–9 cm), and stratified hyper enhancement (100%; 8/8) located in the ileum (100%; 8/8). Median proximal small bowel dilation was 2.95 cm (2.5–4.1 cm). Less common findings included: mesenteric adenopathy (50%; 4/8), increased mesenteric edema/ascites (38%; 3/8), mesenteric vascularity (25%; 2/8), colon inflammation (13%; 1/8), and decreased small bowel fold pattern (13%; 1/8). No patients with confirmed CMUSE cases demonstrated penetrating disease (e.g., abscess, fistula). Conclusion CMUSE is rare cause of small bowel strictures with overlapping clinical and imaging features of more common etiologies such as Crohn’s Disease and NSAID enteropathy that need to be excluded through a multidisciplinary approach to confirm the diagnosis.

IBS20.02 Airway Stenosis

Tracheal stenosis is suspected in individuals with risk factors presenting with signs and symptoms of airway narrowing. The condition may be suspected based on spirometry with a flow-volume loop and CT imaging of the neck and chest but fiberoptic bronchoscopy is required to confirm the presence and severity of tracheal stenosis. The symptoms of tracheal stenosis are similar to those of other conditions so it is important to carefully evaluate patients history. The symptoms of tracheal stenosis typically are wheezing, coughing or shortness of breath, cornage, upper respiratory infections, asthma that doesn’t respond to treatment. Benign tracheal stenoses are more commonly the result of an injury to the trachea due to prolonged intubation or tracheostomy but also Infections (tuberculosis), autoimmune disorders such as Granulomatosis with polyangiitisand amyloidosis or radiation therapy to the neck or chest. The morphological classification of airway stenosis includes granulomas, pseudoglottic stenosis, and “true stenosis” divided into web-like and complex stenoses. Web-like stenoses are circumferential strictures of the trachea involving the mucosa of a short segment (maximum 1 cm long)without any damage to the cartilages. Complex stenosesare sleeve strictures of the trachea more than 1 cm long, often associated with various degrees of cartilage involvement, malacia and inflammation. Several treatment options that can be used for tracheal stenosis depending on the cause, location and severity of the tracheal narrowing. Resection and anastomosis of the involved tract of the trachea is the gold standard treatment. Interventional Pulmonology (IP) offers minimally invasive techniques. Some IP treatment options can provide immediate relief but are considered temporary solutions, while others can provide a better long-term solution. Short-term treatment options for the condition include laser surgery and mechanical dilation with rigid scopes.Treatment options that are generally considered to work long term include stenting and tracheal reconstruction when only a short portion of the trachea is involved. Choice of procedure depends on the exact location and extent of the stenosis, but also on patient age and comorbidities.The most common treatment options for tracheal stenosis include: In 2007 Cavaliere et al. published the results of Laser Assisted Mechanical Dilation in 113 post-intubation tracheal stenosesTab 1Patient carachterstics Therapeutic bronchoscopies were performed using rigid bronchoscopes (Efer, Dumon-Harrel type; FR) and general anesthesia.Endoscopic treatment was based on the use of three main techniques: laser photo-resection (multiple radial incisions), gentle dilation and removable silicon stents.SexAge(Y)Cause of stenosisType of stenosisM 4750±21 (12-84)Intubation 38Tracheotomy 35Web-like 13Complex 60 Open table in a new tab View Large Image Figure ViewerDownload Hi-res image Download (PPT) Most web-like stenoses were successfully treated with Laser Assisted Mechanical Dilation (LAMD) alone; among complex stenoses LAMD was sufficient to treat 13 patients (22%), whereas 47 patients (78%) required stent placement: 22 had their stent removed after one year and did not require any further therapy, 13 inoperable patients required permanent stent and 12 were referred to surgery after failure of multiple endoscopic treatments. No permanent complications secondary to endoscopic treatment were observed. Forty-eight patients (66%) obtained a stable, good result with the endoscopic procedure, 13 (18%) required a permanent stent while 12 patients (16%) were referred to surgery. These authors indicate that bronchoscopic treatment of post-intubation tracheal stenoses can be considered a safe first-line therapy, leaving some selected cases and the relapsing stenosis for surgical resection. 1.Shapshay SM, Beamis JF, Jr, Hybels RL, Bohigian RK. Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann Otol Rhinol Laryngol. 1987;96:661–664. 2. Bacon JL, Patterson CM, Madden BP. Indications and interventional options for non-resectable tracheal stenosis. J Thorac Dis. 2014;6:258–70. 3. Galluccio G, Lucantoni G, Battistoni P, Paone G, Batzella S, Lucifora V et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009;35:429–33. 4. Murgu SD, Colt HG, Mukai D, Brenner M. Multimodal imaging guidance for laser ablation in tracheal stenosis. Laryngoscope. 2010;120:1840–6. 5. Cavaliere S, Bezzi M, Toninelli C, Foccoli P Management of post-intubation tracheal stenoses using the endoscopic approach. Follow-up of 73consecutive patients over a four-year period. Monaldi arch Chest Dis 2007 Jun; 67(2):73-80

Use of Axios Stent to Relieve Short Malignancy Stricture

Pancreatic cancer is a leading cause of malignant strictures in the upper gastrointestinal tract, caused by a head of the pancreas mass abutting the duodenum. Often, these tumors are not responsive to chemotherapy or radiation leading to supportive care with gastric decompression via endoscopic stenting or operative bypass to relieve obstruction. The lumen-apposing self-expandable metal stent (LASEMS), which is often used to drain pancreatic fluid collections, may serve as a safe and effective option to stent short strictures from pancreatic malignancy. Axios stents, with their short and flared ends, create an anastomotic conduit between two lumens, allowing short strictures to be bypassed. These stents have lumen-apposing and dual anchoring capabilities. The unique design allows for robust pseudocyst drainage and for the passage of an endoscope with a lower risk of stent migration due to anchoring. The ease of deployment and retrieval serves as an advantage over uncovered and partially-covered stents. We present a patient with history of duodenal cancer and recurrent bleeds in which an Axios stent was used to relieve a malignant duodenal stricture. A 57 year old male presented with 4-5 months of decreased oral intake, weight loss, and coffee ground emesis. Endoscopy revealed a near complete, circumferential stricture between the first and second portion of the duodenum, consistent with malignancy (Figure 1). An Axios LASEMS was advanced over a guidewire, across the duodenal stricture (Figure 2). Ampullary exclusion was confirmed endoscopically and patency was confirmed fluoroscopically. An argon plasma coagulation catheter was used to fenestrate the proximal plastic covering of the stent to allow improved mucosal adhesion and was further secured using an over the scope clip (Figure 3).1426_A.tif Figure 1: Near complete, circumferential stricture between the first and second portion of the duodenum1426_B.tif Figure 2: Advancement of a guidewire over the stricture1426_C.tif Figure 3: Axios stent with an over scope clip; argon plasma coagulation catheter was used to fenestrate the proximal plastic covering of the stentSeveral studies have described the use of LASEMS for the management of benign gastrointestinal strictures. The majority of patients who underwent stenting for benign strictures failed prior therapy. Stricture recurrence was seen in those with prior endoscopic balloon dilation or stricturoplasty, and prior placement of covered SEMS had led to migration. In our literature review we were unable to find a case in which Axios stents were used to relieve malignant duodenal strictures. We demonstrated the feasibility and potential safety and efficacy of LASEMS for management of various types of gastrointestinal strictures.

Long peptic strictures of the esophagus due to reflux esophagitis: a case report.

BackgroundMost of benign esophageal strictures caused by gastroesophageal reflux are short segments and can be treated by an endoscopic dilatation, but cases of long-segment stenosis requiring an esophagectomy are rare.Case presentationA 62-year-old woman had undergone emergency surgery for a giant ovarian tumor rupture at another hospital. A duodenal perforation occurred after surgery but improved with conservative treatment. She had undergone long-term nasogastric tube placement for 4 months because she was on a mechanical ventilator and did not receive proton pump inhibitors (PPIs). Thereafter, the patient experienced dysphagia. An esophagogastroduodenoscopy (EGD) revealed circumferential reflux esophagitis (grade D) and a stricture located 25 to 40 cm from the incisor teeth. She received medical treatment with fasting and PPIs. The second EGD revealed that the reflux esophagitis had improved somewhat, but that the esophageal stricture had worsened. Thereafter, balloon dilatation was attempted, but the stricture did not improve and she was referred to our hospital. Finally, she was diagnosed as having a benign esophageal stricture caused by reflux esophagitis. She underwent a thoracoscopic esophagectomy with gastric tube reconstruction through the antethoracic route. Her postoperative course was uneventful. Pathologically, a circumferential stricture with white scar formation and no malignant cells were observed.ConclusionsWe experienced a rare case requiring esophagectomy for long-segment stenosis caused by reflux esophagitis. It is suggested that the possibility of esophageal stricture needs to be kept in mind when treating GERD patients with long-term nasogastric tube placement.

Lichen Planus: Esophageal Involvement

Case Presentation: A 71-year-old white female with a past medical history of gastroesophageal reflux disease presented with intermittent dysphagia to solid food and odynophagia that had been progressing for the past few months. She also reported unintentional weight loss. Patient has history of erosive lichen planus that was causing ulcers in her oropharynx three years ago and it was treated with topical steroids. All her initial laboratory tests were normal, this includes CBC, BAMP, LFTs. Barium sallow was performed and showed narrowing in the proximal one-third of the esophagus. Subsequent upper endoscopy revealed ulcerated circumferential stricture in the proximal esophagus just 2 cm below the cricopharyngeal muscle. Upper endoscopy also showed moderate mid and distal esophageal strictures (Figure. 1). Esophageal biopsies were consistent with acute erosive esophagitis with lymphocytic predominance and with minimal eosinophils. Based on the presence of oral lichen planus, our patient's endoscopic apperance and the biopsy findings, the patient was diagnosed with esophageal lichen planus. She had undergone multiple esophageal dilatations since the initial presentation. She had also received a course of systemic steroids. On follow-up, the patient was clinically stable and had denied worsening of her symptoms.Figure 1Discussion: Lichen planus is a common idiopathic disorder involving skin, nail, and mucosal membranes. It is characterized by immune response attacking an antigen in the basal cells of squamous epithelium. Esophageal lichen planus is a relatively rare condition and the prevalence is unknown. The diagnosis can be challenging due to the subtle clinical findings and lack of characteristic histologic features. Esophageal lichen planus usually affects the upper and mid esophagus; in addition, it often spares the gastroesophageal junction when compared to reflux esophagitis. The history of oral lichen planus, endoscopic images and site of esophageal involvement are very helpful in differentiating between the latter two entities. Esophageal lichen planus has a tendency to be chronic disease with the potential risk of malignancy. Topical and oral steroids are the mainstay of treatment but to date there are no wellestablished guidelines. Conclusions: Oropharyngeal lichen planus is a chronic disease that can lead to recurrent esophageal stricture. Endoscopic findings and pathology may not be specific; however, clinicians should be aware of this entity and appropriate referrals should be made as patients might need repeated interventions to have a relief in their symptoms.

NSAID enteropathy: appearance at CT and MR enterography in the age of multi-modality imaging and treatment.

CT and MR enterography and capsule endoscopy are increasingly used as routine diagnostic tests for patients with potential small bowel disorders and obscure gastrointestinal bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used drugs that disrupt prostaglandin synthesis and result in a variety of localized complications within the small bowel ranging from ulcer formation to characteristic circumferential strictures, or diaphragms. NSAID enteropathy encompasses this spectrum of acute and chronic inflammatory sequelae, and is associated with typical findings at capsule endoscopy and surgery. Herein we review the typical clinical presentation of NSAID enteropathy, in addition to its endoscopic appearances, focusing on imaging findings at cross-sectional enterography. Multiple, short-segment strictures are the hallmarks of imaging diagnosis. Strictures may have minimal hyperenhancement or wall thickening, but these findings are typically symmetric and circumferential with respect to the bowel lumen. Multifocal Crohn's strictures, and occasionally radiation-induced strictures or adhesions, will mimic NSAID diaphragms. Multi-phase or multi-sequence imaging at CT and MR enterography increase diagnostic confidence in stricture presence. Strategies for subsequent workup and therapy after enterography are also discussed. Given the frequent use of NSAIDs and typical appearance of these strictures, knowledge of characteristic imaging findings can be particularly useful when evaluating patients with anemia and recurrent small bowel obstruction.

Exploring signet-ring cells in pregnant female.

Primary signet-ring cell carcinoma (SRCC) of the colon and rectum are rare form, which present at an advanced stage and have poor prognosis. Different treatment policies of SRCC during different gestational age of pregnancy are explored from the literature. A 26-year-old young pregnant female with 10-week gestation presented with constipation and blood in stools and on per rectal examination a tender circumferential stricture was present 2 cm above the anal verge. Magnetic resonant imaging (MRI) pelvis of the patient revealed rectal thickening, the biopsy of which revealed characteristic appearance of "linitis plastica" and diagnosed as poorly differentiated adenocarcinoma with signet ring morphology with wide spread positivity for cytokeratin & p53. With this diagnosis, patient underwent medical termination of pregnancy (MTP). SRCC of the colon comprises about only 1% of all cases of colon cancer. When compared with other types of adenocarcinoma, patients with SRCC in the colon are younger and more likely to experience lymph node metastasis. Its incidence in pregnancy is estimated to be less than 0.1%. Certainly, any pregnant patient who reports rectal bleeding or has hemoccult positive stool on examination deserves careful evaluation to rule out cancer. The complex treatment of colorectal cancer in pregnancy is based on the gestational age of the fetus, tumor stage and need for emergent vs. elective management.

Development of novel treatment with a bioabsorbable esophageal patch for benign esophageal stricture.

Using a large animal model, we examined whether circumferential stricture after esophageal endoscopic submucosal dissection (ESD) can be treated by grafting a bioabsorbable esophageal patch. Circumferential ESD was performed on the thoracic esophagus in pigs (n = 6) to create a stricture, for which one of the following interventions was performed: (1) the stricture site was longitudinally incised, and an artificial esophageal wall (AEW) was grafted after placing a bioabsorbable stent (AEW patch group, n = 3); (2) endoscopic balloon dilation (EBD) was performed every other week after stricture development (EBD group, n = 3). In both groups, esophageal fluoroscopy was performed 8 weeks after the interventions, and the esophagus was excised for histological examination of the patched site. In the AEW patch group, esophageal fluoroscopy revealed favorable passage through the patched site. Histologically, the mucosal epithelium and lamina propria had regenerated as in the normal area. In the EBD group, the circumferential stricture site showed marked thickening, and there were hypertrophic scars associated with epithelial defects on the luminal surface. Histologically, defects of the mucosal epithelium and full-thickness proliferation of connective tissue were observed. AEW patch grafting was suggested to be a potentially novel treatment strategy for post-ESD esophageal circumferential stricture.

Verrucous Squamous Carcinoma of the Esophagus Successfully Diagnosed by Endoscopic Mucosal Resecion: A Case Report

A 62-year-old male with a history of type 2 diabetes mellitus and alcoholic liver disease presented with dysphagia, heartburn, and appetite loss. He had lost 10 kg weight within 1 month. The patient gave a history of excessive alcohol intake and a smoking habit of 60 cigarettes per day for 40 years. Upper gastroenteroscopy revealed a wartlike, whitish, protruding mass with circumferential stricture at a point 35 cm from the incisor down to the cardia. Although esophageal cancer was suspected, repeated biopsies of the mass revealed no malignant findings. Concurrent esophageal candidiasis was treated with an antifungal drug. Increased esophageal stricture made food intake impossible; therefore, total parenteral nutrition was initiated. Endoscopic mucosal resection revealed highly keratinized, well-differentiated squamous cell carcinoma with invasion into the submucosa. A diagnosis of verrucous squamous carcinoma was confirmed. Subtotal esophageal resection and esophagostomy was performed with video assistance. Postoperative pathological findings were compatible with the diagnosis of verrucous squamous carcinoma, which is known to be a slow-growing tumor that rarely metastasizes to lymph nodes or distant organs. However, verrucous squamous carcinoma is rarely diagnosed by endoscopic biopsy. Moreover, endoscopic mucosal resection or surgery should be considered in cases when endoscopic examination fails to confirm the diagnosis of carcinoma and if the lesion presents some characteristics of verrucous squamous carcinoma.

Special diaphragm-like strictures of small bowel unrelated to non-steroidal anti-inflammatory drugs

To summarize clinical, endoscopic, radiologic and pathologic features of special diaphragm-like strictures found in small bowel, with no patient use of non-steroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2009, 5 cases (2 men and 3 women, with a mean age of 41.6 years) were diagnosed as having diaphragm-like strictures of small bowel on imaging, operation and pathology. All the patients denied the use of NSAIDs. The clinical, endoscopic, radiologic and pathologic findings in these 5 patients were retrospectively reviewed from the hospital database. Images of capsule endoscopy (CE) and small bowel follow-through (SBFT) obtained in 3 and 3 patients, respectively, and images of double-balloon enteroscopy and computed tomography enterography (CTE) obtained in all 5 patients were available for review. All patients presented with long-term (2-16 years) symptoms of gastrointestinal bleeding and varying degrees of anemia. There was only one stricture in four cases and three lesions in one case, and all the lesions were located in the middle or distal segment of ileum. Circumferential stricture was shown in the small bowel in three cases in the CE image, but the capsule was retained in the small bowel of 2 patients. Routine abdomen computed tomography scan showed no other abnormal results except gallstones in one patient. The lesions were shown as circumferential strictures accompanied by dilated small bowel loops in the small bowel on the images of CTE (in all 5 cases), SBFT (in 2 cases) and double-balloon enteroscopy (in all cases). On microscopy, a chronic inflammatory infiltrate and circumferential diaphragm were found in all lesions. Diaphragm-like strictures of small bowel might be a special consequence of unclear damaging insults to the intestine, having similar clinical, endoscopic, radiologic and pathologic features.

A Rare Cause of Dysphagia

Question: A 76-year-old woman presented with new onset of dysphagia to solid food for 3 weeks. Her past medical history included breast cancer diagnosed 10 years earlier with metastases to the ovaries and pleural cavity 6 years ago. Upper endoscopy showed a circumferential stricture with ulcerated mucosa at 25 cm from the incisors (Figure A). The mucosal biopsies only showed squamous cells with mild reactive changes. Endoscopic ultrasound (EUS) showed diffuse thickening of all layers of the esophageal wall up to 6 mm (normal, <3 mm) in the narrowed portion of the esophagus, indicating an infiltrative process (Figure B).

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Endoscopic palliation of malignant dysphagia: a challenging task in inoperable oesophageal cancer

BackgroundThe main goal when managing patients with inoperable oesophageal cancer is to restore and maintain their oral nutrition. The aim of the present study was to assess the value of endoscopic palliation of dysphagia in patients with oesophageal cancer, who either due to advanced stage of the disease or co-morbidity are not suitable for surgery.Patients and methodsAll the endoscopic palliative procedures performed over a 5-year period in our unit were retrospectively reviewed. Dilatation and insertion of self-expandable metal stents (SEMS) were mainly used for tight circumferential strictures whilst ablation with Nd-YAG laser was used for exophytic lesions. All procedures were performed under sedation.ResultsOverall 249 palliative procedures were performed in 59 men and 40 women, with a median age of 73 years (range 35 – 93). The median number of sessions per patient was 2 (range 1 – 13 sessions). Palliation involved laser ablation alone in 24%, stent insertion alone in 22% and dilatation alone in 13% of the patients. In 41% of the patients, a combination of the above palliative techniques was applied. A total of 45 SEMS were inserted. One third of the patients did not receive any other palliative treatment, whilst the rest received chemotherapy, radiotherapy or chemoradiotherapy. Swallowing was maintained in all patients up to death. Four oesophageal perforations were encountered; two were fatal whilst the other two were successfully treated with covered stent insertion and conservative treatment. The median survival from diagnosis was 10.5 months (range 0.5–83 months) and the median survival from 1st palliation was 5 months (range 0.5–68.5 months).ConclusionEndoscopic interventions are effective and relatively safe palliative modalities for patients with oesophageal cancer. It is possible to adequately palliate almost all cases of malignant dysphagia. This is achieved by expertise in combination treatment.

Urethral stricture associated with malacoplakia: a case report and review of the literature

A 68-year-old man presented with obstructive and irritative lower urinary tract symptoms and microscopic hematuria. Cystourethroscopy showed a circumferential stricture in the bulbar urethra that bled easily on contact. Biopsy revealed malacoplakia. There was also focal nonspecific cystitis. The patient improved symptomatically, but the microscopic hematuria persisted. Follow-up biopsies showed persistent urethral malacoplakia and stricture. Malacoplakia of the male urethra is exceptionally rare, this being the second reported case.

A CASE OF ISCHEMIC COLITIS OCCURRED AS ILEUS 19 MONTHS AFTER REPAIR FOR AN ABDOMINAL AORTIC ANEURYSM

A 66-year-old woman was admitted to the hospital for low abdominal pain and vomiting in July 1998. She had undergone graft repair for abdominal aortic aneurysm in February 1997. Colonoscopy and a barium enema study revealed a whole circumferential stricture of the sigmoid colon. She was treated conservatively for two months, but her symptoms did not disappear. Therefore, low anterior resection was performed in September 1998. On histological examination, the specimen showed necrosis and fibrosis with ischemic colitis, but no malignant change. Thereafter, her right thigh was amputated for necrosis due to arteriosclerosis obliterans in December 1998, and she was discharged from the hospital subsequently. We report this case together with a review of the literature.