Gastrointestinal Endoscopic Biopsy Research Articles

Toxic epidermal necrolysis associated with severe cytomegalovirus infection in a patient on regular hemodialysis.

Primary illness with cytomegalovirus leads to latent infection with possible reactivations especially in the immunocompromised patients. Toxic epidermal necrolysis is an immune mediated cytotoxic reaction.A fifty years old female diabetic hypertensive patient with end stage renal disease was admitted with fever of unknown origin, constitutional symptoms, vague upper gastrointestinal symptoms and skin rash. Upper gastrointestinal endoscopic biopsy confirmed her diagnosis with cytomegalovirus esophagitis and duodenitis. Cytomegalovirus immunoglobulin M and immunoglobulin G levels were negative but polymerase chain reaction showed fulminant viremia. Biopsy of the skin rash was consistent with toxic epidermal necrolysis. Despite treatment with Ganciclovir, intravenous immunoglobulins, and granulocyte colony stimulating factor the patient’s condition rapidly deteriorated and she died due to multiorgan failure, disseminated intravascular coagulopathy and overwhelming sepsis.Probably there is a true association linking toxic epidermal necrolysis to fulminant reactivation of cytomegalovirus. The aim of this anecdote is reporting a newly recognized presentation of cytomegalovirus.

Recurrent renal cell cancer presenting as gastrointestinal bleed

We present an unusual case of renal cell cancer (RCC) which relapsed with duodenal metastasis and unveiled itself by gastrointestinal (GI) bleeding. An 80-year old Caucasian gentleman with history of renal cell cancer status post nephrectomy 11 mo previously, presented with syncope and melena. Computed tomography scan of the abdomen revealed heterogeneous soft tissue mass in the right nephrectomy bed invading the duodenum. Upper GI endoscopic biopsy confirmed the presence of recurrent renal cell cancer. However, due to extensive metastatic disease, the patient was placed on palliative chemotherapy as surgical options were ruled out. Our case report reiterates the fact that renal cell carcinoma can recur with gastrointestinal manifestations and, although a rarity, it should be considered in a patient with a history of malignancy who presents with these symptoms.

Primary intestinal lymphangiectasia diagnosed by endoscopy following the intake of a high-fat meal

Primary intestinal lymphangiectasia is a protein-losing enteropathy caused by congenital malformation or obstruction of intestinal lymphatic vessels, which lead to excessive protein loss in the intestine and malabsorption of both chylomicrons and fat-soluble vitamins [3]. It affects males and females equally and occurs mainly in children and young adults. The management of primary intestinal lymphangiectasia is difficult for the paediatric gastroenterologist because of the rarity of the disease and its variable clinical manifestations. The diagnosis is based on the typical upper gastrointestinal endoscopic findings of diffuse scattered mucosal white blebs with characteristic histological findings of abnormal lymphatic dilatation [3] and the exclusion of other acquired causes of lymphatic damage [3]. Here, we report on a girl with primary intestinal lymphangiectasia in whom the initial diagnosis based on upper gastrointestinal endoscopy and histology was uncertain. Intestinal lymphangiectasia was diagnosed by upper gastrointestinal endoscopic biopsy sampling after a high-fat

A follow up model for patients with atrophic chronic gastritis and intestinal metaplasia

Aim: To devise a follow up model for patients with gastric cancer associated lesions, such as atrophic chronic gastritis (ACG) and intestinal metaplasia (IM). Methods: Cohort study of 144 patients,...

Evaluation of 99mTc-HMPAO leukocyte scintigraphy in the investigation of pediatric inflammatory bowel disease

Objective To evaluate 99mTc-HMPAO leukocyte scintigraphy as an investigation for inflammatory bowel disease (IBD).Study design Scintigraphy was performed in 95 children undergoing investigation for IBD in a tertiary Gastroenterology Department. Diagnosis was based on conventional investigations including small bowel barium contrast radiology (BCR), upper gastrointestinal endoscopy (UGIE), colonoscopy, and endoscopic biopsy (the “gold standards”). IBD was confirmed in 73 (57 Crohn's disease; 10 ulcerative colitis; 6 indeterminate colitis) and excluded in 22 (controls). Scintigraphy was (1) evaluated as a screening test, (2) compared with individual conventional tests, (3) assessed for each gut segment.Results Screening test: sensitivity 0.75 (95% CI, 0.63-0.85), specificity 0.82 (95% CI, 0.59-0.94), PPV 0.93, NPV 0.5. Comparison with BCR: sensitivity 0.87 (95% CI, 0.72-0.96), specificity 0.57 (95% CI, 0.39-0.73), PPV 0.69, NPV 0.2. Comparison with UGIE: specificity 0.9 (95% CI, 0.79-0.96), NPV 0.13 (sensitivity and PPV unavailable). Comparison with colonoscopy: sensitivity 0.57 (95% CI, 0.41-0.73), specificity 0.71 (95% CI, 0.54-0.85), PPV 0.71, NPV 0.42. Comparison with biopsies paralleled that with endoscopy. False negatives were especially common (NPV≤0.2) in the proximal gut.Conclusions99mTc-HMPAO leukocyte scintigraphy should not be relied on as a screening test for IBD because false egative results are common. This method is especially unreliable at detecting disease in the proximal gut.

Upper gastrointestinal mucosal disease in pediatric Crohn disease and ulcerative colitis: a blinded, controlled study.

Upper gastrointestinal endoscopic biopsies often show histologic abnormalities in Crohn disease. Consequently, it has been proposed that routine endoscopy could help to distinguish Crohn disease from ulcerative colitis. Surprisingly, however, recent case reports and an uncontrolled study suggested that similar abnormalities may occur in ulcerative colitis. Therefore, a blinded, controlled study was performed. Esophageal, gastric antral, and duodenal biopsies from children with Crohn disease (n = 28) and ulcerative colitis (n = 14) were compared with those from controls undergoing endoscopy for suspected reflux esophagitis (n = 22). Two pathologists, unaware of patient identity and diagnosis, agreed on a consensus report. Severity of inflammation was scored semiquantitatively. Helicobacter pylori colonization was an exclusion criterion. Inflammation was reported as follows: esophagitis: controls 91%; Crohn disease: 72%; ulcerative colitis: 50%; gastritis: controls: 27%; Crohn disease: 92% (P < 0.001); ulcerative colitis: 69%; duodenitis: controls: 9%; Crohn disease: 33%; ulcerative colitis: 23%. In Crohn disease, granulomas were noted in 40% of patients (P = 0.001). Duodenal cryptitis was noted in 26% of patients with Crohn disease but not ulcerative colitis. In one patient with ulcerative colitis, neutrophilic infiltration of gastric glands was seen. Abnormalities seen in Crohn disease and ulcerative colitis included gastroduodenal ulceration (Crohn disease, 7%; ulcerative colitis, 8%), villus atrophy (Crohn disease, 11%; ulcerative colitis, 15%), and increased intraepithelial lymphocytes (Crohn disease, 15%; ulcerative colitis, 31% [P < 0.05]). None of these abnormalities was noted in the controls. Although the presence of granulomas can support a diagnosis of Crohn disease, severe inflammation and other abnormalities occur in the proximal gastrointestinal tract in Crohn disease and ulcerative colitis.

Upper Gastrointestinal Mucosal Disease in Pediatric Crohn Disease and Ulcerative Colitis: A Blinded, Controlled Study

ABSTRACTBackgroundUpper gastrointestinal endoscopic biopsies often show histologic abnormalities in Crohn disease. Consequently, it has been proposed that routine endoscopy could help to distinguish Crohn disease from ulcerative colitis. Surprisingly, however, recent case reports and an uncontrolled study suggested that similar abnormalities may occur in ulcerative colitis. Therefore, a blinded, controlled study was performed.MethodsEsophageal, gastric antral, and duodenal biopsies from children with Crohn disease (n = 28) and ulcerative colitis (n = 14) were compared with those from controls undergoing endoscopy for suspected reflux esophagitis (n = 22). Two pathologists, unaware of patient identity and diagnosis, agreed on a consensus report. Severity of inflammation was scored semiquantitatively. Helicobacter pylori colonization was an exclusion criterion.ResultsInflammation was reported as follows: esophagitis: controls 91%; Crohn disease: 72%; ulcerative colitis: 50%; gastritis: controls: 27%; Crohn disease: 92% (P &lt; 0.001); ulcerative colitis: 69%; duodenitis: controls: 9%; Crohn disease: 33%; ulcerative colitis: 23%. In Crohn disease, granulomas were noted in 40% of patients (P = 0.001). Duodenal cryptitis was noted in 26% of patients with Crohn disease but not ulcerative colitis. In one patient with ulcerative colitis, neutrophilic infiltration of gastric glands was seen. Abnormalities seen in Crohn disease and ulcerative colitis included gastroduodenal ulceration (Crohn disease, 7%; ulcerative colitis, 8%), villus atrophy (Crohn disease, 11%; ulcerative colitis, 15%), and increased intraepithelial lymphocytes (Crohn disease, 15%; ulcerative colitis, 31% [P &lt; 0.05]). None of these abnormalities was noted in the controls.ConclusionAlthough the presence of granulomas can support a diagnosis of Crohn disease, severe inflammation and other abnormalities occur in the proximal gastrointestinal tract in Crohn disease and ulcerative colitis.

Atlas of Gastrointestinal Endoscopy and Endoscopic Biopsies

By Theresa S. Emory, Herschel A. Carpenter, Christopher J. Gostout, and Leslie H. Sobin, 455 pp, with illus, Washington, DC, Armed Forces Institute of Pathology, 2000.This new textbook can serve as a practical working reference for both gastroenterologists and pathologists. As stated by the authors in the preface, “the aim of the atlas is to facilitate clinicopathologic correlative diagnosis and enhance effective interaction between gastroenterologists and pathologists.” This textbook achieves that goal.The textbook is arranged in 4 parts (esophagus, stomach, small intestine, and large intestine); each part is introduced with the endoscopic examination and normal histology. Each disease entity is discussed in a concise manner, describing the morphology, endoscopic features, clinical features, and the differential diagnosis, followed by appropriate photographs. The writing style is matter-of-fact and to the point. Most importantly, the authors do not pretend that an exact diagnosis can be rendered all the time, and in those instances, they stress the importance of the clinicopathologic correlation and formulating a differential diagnosis. Every photograph is provided with a complete description. The presentation balances the endoscopic findings and the histologic findings, so that neither the gastroenterologist nor the pathologist will feel shortchanged. The text is well written, succinct, and easy to read, allowing the book to be used when needed, such as during sign-out or even as a guide for teaching in lectures or conferences.The atlas contains more than 1000 photographs of both endoscopic and histologic findings. The photographs are clear and focused, with the endoscopic findings placed near the histologic findings; thus, the images are essentially seen side by side. In addition to photographs illustrating both the healthy stomach and injuries to the stomach, tables and diagrams are used. A table is also used in the section on the large intestine to describe histologic features and their associated etiologies in the various patterns of injury. Tables are not used in the sections for the esophagus and the small intestine.A list of additional references are given in Appendix 1 for further reading. For those interested, a standardized format for final pathology reports used at one of the authors' institutions is presented in Appendix 2.This work is an essential textbook for both gastroenterologists and surgical pathologists. Whether one is in practice or in training, the Atlas of Gastrointestinal Endoscopy and Endoscopic Biopsies by Drs Emory, Carpenter, Gostout, and Sobin should be an excellent guide for physicians interested in diseases of the gastrointestinal tract.

Necrosis of the gastrointestinal tract in uremic patients as a result of sodium polystyrene sulfonate (Kayexalate) in sorbitol: an underrecognized condition.

Sodium polystyrene sulfonate (Kayexalate) in sorbitol given as an enema or orally to treat hyperkalemia has been reported to induce intestinal necrosis in uremic patients. We studied the clinical and pathologic features of 15 patients in whom Kayexalate crystals were observed in specimens from gastrointestinal surgical resections (n = 9) or endoscopic biopsies (n = 7). Oral or nasogastric tube administration of Kayexalate in sorbitol was documented in 10 patients. Among 12 patients with colorectal specimens, necrosis was observed in nine patients (75%), represented by seven of eight surgical resection specimens and three of five endoscopic biopsy specimens. No other cause of colorectal necrosis apart from Kayexalate in sorbitol was apparent in seven patients, and four also had necrosis of the small intestine. Four patients with colonic necrosis in their initial resection specimen developed progressive necrosis of the small intestine or rectum, and five patients (56%) had fatal outcome within 1 day to 6 weeks. Kayexalate crystals were observed in upper gastrointestinal tract specimens from four patients, including one with hemorrhagic gastritis. Our findings provide additional evidence that Kayexalate in sorbitol administered orally or by nasogastric tube can produce necrosis in the gastrointestinal tract.

Effects of Helicobacter pylori vacuolating cytotoxin on primary cultures of human gastric epithelial cells.

Many Helicobacter pylori strains produce a cytotoxin that induces cytoplasmic vacuolation in various types of eukaryotic cells. In contrast with the marked cell vacuolation that occurs in vitro in response to this cytotoxin, comparatively little epithelial vacuolation has been observed in the gastric mucosa of H pylori infected persons. Experiments were performed to determine the susceptibility of human gastric epithelial cells in vitro to H pylori vacuolating cytotoxin activity. Human gastric epithelial cells, harvested from upper gastrointestinal endoscopic biopsy specimens, were incubated overnight with broth culture supernatants from either a wild type cytotoxin producing (tox+) H pylori strain or an isogenic mutant strain that lacks cytotoxin activity. Prominent cytoplasmic vacuolation occurred in response to tox+ supernatant, but not supernatant from the isogenic mutant strain. Primary human gastric epithelial cells were significantly more sensitive to H pylori vacuolating cytotoxin activity than were either HeLa or AGS cells. Exposure of human gastric epithelial cells to high concentrations of tox+ supernatant for 48 hours caused lethal cell injury. These studies indicate that primary human gastric epithelial cells are highly sensitive to H pylori vacuolating cytotoxin activity.

The Endoscopic Appearance of Severe Intestinal Mycobacterium Avium Complex Infection As a Coarsely Granular Mucosa Due to Massive Infiltration and Expansion of Intestinal Villi Without Mucosal Exudation

Although Mycobacterium avium complex (MAC) is the most common opportunistic pathogen at postmortem in patients with AIDS, many cases are not recognized premortem. A patient with advanced AIDS had diarrhea, fecal occult blood, and iron deficiency anemia. Esophagogastroduodenoscopy showed an extensive coarsely granular mucosa, resistant to endoscopic irrigation and brushing, in the descending duodenum. Histologic analysis of duodenal biopsies confirmed expansion of intestinal villi due to massive villar infiltration by acid-fast bacilli and no mucosal exudation. An absence of mucosal exudation is consistent with an attenuated local immunologic response in advanced AIDS. MAC was isolated from mycobacterial culture of duodenal biopsies. The currently reported endoscopic appearance of intestinal MAC can aid in diagnosis by alerting the endoscopist to send biopsies for mycobacterial stains and cultures when MAC infection is suggested by this endoscopic appearance. However, even in the absence of endoscopically evident lesions, gastrointestinal endoscopic biopsy is appropriate to exclude occult opportunistic pathogens in an AIDS patient with wasting or significant gastrointestinal complaints. The currently reported pathologic findings show that villar engorgement and hypertrophy is a sufficient explanation for the granular endoscopic appearance of intestinal MAC and that mucosal exudation is not required to produce this appearance.

Breath hydrogen excretion after oral administration of xylose to cats

ABSTRACTMaximum breath hydrogen excretion after the oral administration of xylose to 11 healthy cats ranged from 0.13 ml/hour to 0.47 ml/hour, with a mean of 0.18 ml/hour. After oral administration of xylose, breath hydrogen excretion in five cats with chronic diarrhoea and, or, vomiting was significantly different (P&lt;0.001) compared with healthy cats. Increased breath hydrogen excretion occurred before xylose was given and at all measurement times after its administration to the sick cats (P&lt;0.05), indicating carbohydrate malassimilation. In four sick cats, large increases in breath hydrogen excretion occurred, with maximum values ranging from 1.21 to 1.56 ml/hour, but in one cat the maximum value was only 0.28 ml/hour. Plasma xylose concentrations in cats with chronic diarrhoea and, or, vomiting were not significantly different from healthy cats (P&gt;0.05) and thus did not demonstrate carbohydrate malassimilation. A hiatus hernia was seen on radiographic views of the thorax and abdomen of one cat with chronic vomiting. Inflammatory bowel disease was found in three of the five sick cats after upper gastrointestinal endoscopic examination and mucosal biopsy. Clostridium species were isolated in increased numbers from the cats with chronic diarrhoea and, or, vomiting (P&lt;0.005), after quantitative bacterial culture of small intestinal fluid specimens obtained endoscopically. Clostridium species were isolated from all five cats with chronic diarrhoea and, or, vomiting but from only one of eight healthy cats. However, whether a specific bacterial pathogen caused the increased breath hydrogen excretion found in these cats could not be determined from this study.

Whipple’s disease: endoscopic aspects before and after therapy

This report describes the utility and the advantages of endoscopy in diagnosing and following the course of Whipple's disease. Sixteen patients, diagnosed over a period of 22 years, were identified via pathology records and retrospectively reviewed. Five patients were diagnosed before 1980 by means of peroral suction biopsy of the small intestine. The 11 patients diagnosed after 1980 all had upper gastrointestinal endoscopy and endoscopic small intestinal biopsies. Gross endoscopic lesions were observed in 9 of the 11 patients and disappeared in 5 of 6 treated patients at 6 months. These lesions include erosions, yellow plaques, and a pale yellow shaggy mucosa. The latter two lesions are macroscopically suggestive of Whipple's disease. After endoscopic "healing," periodic acid-Schiff-positive macrophages remained present in the endoscopic biopsies for years. The patients were followed for a median period of 4 years and 5 months. All patients were treated with antibiotics (eight tetracycline alone, four tetracycline + streptomycin + penicillin, and four trimethoprim). Five patients (four of the tetracycline alone group, none of the trimethoprim group) relapsed 2 to 11 years after the initial treatment.

Biopsy pathology of the gastrointestinal tract in human immunodeficiency virus-associated disease: a 5 year experience in Zürich.

Patients with human immunodeficiency virus (HIV)-associated disease are subject to a wide variety of unusual opportunistic infections and to the development of malignant tumours. These complications frequently manifest themselves within the gastrointestinal tract and endoscopic biopsies may contribute to their diagnosis. The results of 63 such biopsies from 28 patients are reviewed in this study. The diagnoses made included: upper gastrointestinal tract candidiasis (n = 6); cytomegalovirus infection of large intestine (n = 2); cryptosporidiosis (n = 1); spirochaetosis (n = 2); Kaposi's sarcoma (n = 4); malignant lymphoma (n = 3); and anal carcinoma (n = 2). Many of the specimens also showed inflammatory changes with no demonstrable aetiological agent. No specific pattern could be recognized for HIV infection per se.

The ultrastructural localisation of De-Nol (colloidal tripotassium dicitrato-bismuthate--TDB) in the upper gastrointestinal tract of man and rodents following oral and instrumental administration.

In the presence of hydrochloric acid, tripotassium dicitrato-bismuthate forms a particulate precipitate which is electron dense. In upper gastrointestinal tract endoscopic biopsies, following a single oral dose, precipitate was detected between superficial oesophageal epithelial cells and also lining lipid droplets within oesophageal cells. The precipitate does not appear to penetrate the thick mucus barrier in the normal stomach but reaches the epithelial cell surface in the duodenum and proximal jejunum. Small particles of bismuth complex are endocytosed by the enterocyte and enter multivesicular bodies. A similar series of events was observed in rodents and an approximate time course for adsorption and endocytosis was estimated.

Biopsy appearances easily mistaken for malignancy in gastrointestinal endoscopy.

A series of 10 cases is described which were characterized by the occurrence, in gastrointestinal endoscopic biopsies, of benign lesions which bore a close resemblance to malignancy. In three cases an erroneous diagnosis of carcinoma was made and major resections were performed unnecessarily. The lesions fall into two histological types, one of which is seen only in gastric biopsies and the other at any level of the gastrointestinal tract. The histopathology of these lesions is described in detail.