Nonspecific Inflammatory Changes Research Articles

Abdominal inflammatory masses mimicking neoplasia in children—experience of two centers

Despite progress in modern imaging, some inflammatory masses are difficult to distinguish clinically from neoplastic processes. In such cases the pathology report has a great distinctive value, but even then the final diagnosis may be difficult to reach. Eight patients with abdominal tumors of inflammatory origin were treated in two institutions, the Department of Pediatric Surgery of the Medical University of Gdansk, Poland, and Helios Center of Pediatric Surgery in Berlin, Germany, during the last 10 years. Four tumors were located in the pelvis, two in the liver, and two in the colonic mesentery. Five of them were inflammatory pseudotumors (two subclassified as inflammatory fibrosarcoma), one had nonspecific inflammatory changes, one was diagnosed as idiopathic retroperitoneal fibrosis, and one was diagnosed as bacillary angiomatosis. All patients underwent surgical tumor biopsy, excisional in four and incisional in four. All but two children underwent macroscopically complete tumor excision (four primarily, two secondarily). In one case the tumor resolved with antibiotherapy. Surgery in retroperitoneal masses was often extensive and associated with significant complications because of invasive tumor growth. In conclusion, intraabdominal inflammatory lesions may closely mimic neoplasia in children. Clinical doubts result in repeated biopsies, and for this reason excisional biopsy should be preferred. In some cases, when excisional biopsy is not feasible due to invasive growth of the tumor, delayed complete mass excision should follow, despite occasional significant morbidity. The etiology and exact nature of inflammatory pseudotumors are still obscure, and it is unknown whether they represent inflammatory lesions or true neoplasia.

Temporary Intestinal Occlusion Induced by a ”Patency Capsule” in a Patient with Crohn’s Disease

A 26-year-old woman was admitted for the investigation of abdominal symptoms related to ileal Crohn's disease. The patient had been diagnosed 3 years previously with systemic sclerosis, and had been experiencing digestive complaints for 6 months. A first computed tomography (CT) scan showed ileal intestinal mucosal alterations, associated with a sclerolipomatosis and suspicion of ileal stenosis. An ileocolonoscopy was then performed and showed ulcers in the terminal ileum with nonspecific inflammatory changes found on biopsies, both suggesting the diagnosis of Crohn's disease. The patient was admitted for M2A capsule endoscopy, in order to clarify the respective roles of systemic sclerosis and Crohn's disease with regard to the symptoms and secondarily to determine the anatomical extent of the Crohn's lesions. A patency capsule was administered, for detection of intestinal stenosis before capsule endoscopy was done. At 30 hours after capsule ingestion, the patient complained of abdominal pain and nausea and experienced intestinal obstruction due to the blockage of the patency capsule in the ileal stenosis. The capsule dissolved after 76 hours and the patient then improved. After a few days, the patient underwent ileocecal resection. Pathological examination of the surgical specimen confirmed the presence of an ileal stenosis 17 cm in length. In some circumstances a patency capsule may dissolve slowly, leading to transitory intestinal obstruction requiring medical intervention. It should thus be used cautiously under clinical surveillance in patients with Crohn's disease.

WIRELESS CAPSULE ENDOSCOPY IN CLINICAL PRACTICE

Large multi-center clinical trials have demonstrated the utility of Wireless Video Capsule Endoscopy (WCE), in the detection of small bowel pathology. How practical and useful is WCE in a GI practice? Methods: 138 patients were referred for WCE between January 2003 and June 2004. 80 patients were studied. The group was 60% (48) female, 40% (32) male; average age 58 (range 11–86). All patients underwent EGD and Colonoscopy, most Ileoscopy and Small bowel series, all within 1 year prior to their study. All studies were reviewed by 4 independent readers. Results: 48 patients had Obscure GI blood loss (30 occult; 18 overt); 13 had Indeterminate Colitis; 9 had diarrhea and abdominal pain; 10 had suspected small bowel polyposis. Reading times: 40 to 80 minutes. Average Small bowel transit was (SBT) 245 minutes. The capsule reached the cecum in 91% of the cases. 3 patients had markedly prolonged SBT (all with diffuse small bowel Crohn's). In 1 patient, the capsule was retained (to date-4 months; diagnosis-Crohn's). Small bowel pathology was detected in 80% of the patients. Vascular Ectasias were detected in 29 patients, Small bowel ulcers were detected in 26 patients; the diagnostic yield for obscure occult bleeding was 56.6%, and for obscure overt was 66.6%. 18 definite sites of bleeding were detected. 3 patients appeared to have active bleeding (1 from VE, 2 from gastric erosions). In 11 patients, findings were consistent with Crohn's disease. 8 patients had findings consistent with Celiac Sprue (one in the setting of Crohn's). 10 patients had findings attributed to NSAID use. 13 patients had non-specific inflammatory changes. 1 patient had numerous small bowel polyps (diagnosed Gardner's syndrome). 3 studies were non-diagnostic secondary to gastric retention of the capsule. These findings prompted a change in medical management in 70%. 10 patients underwent small bowel enteroscopy for cauterization or biopsy. 1 patient had a right colectomy with ileal resection secondary to bleeding VE. Conclusion: WCE maintained a high diagnostic yield in clinical practice. WCE was practical, and led to significant therapeutic gain.

Histiocytic sarcoma with fatal duodenal ulcers

Histiocytic sarcoma is an uncommon neoplasm of mature histiocytes with very poor outcome. We report an autopsy case of a true histiocytic sarcoma with characteristic symptoms of so-called “malignant histiocytosis of the intestine”. The liver and spleen were enlarged, with remarkable tumor cell infiltration in the hepatic sinusoids and splenic sinuses. Tumor cells aggregated to form sporadic nodular lesions in the liver, which often showed coagulative necrosis. Infarcted lesions also occurred at the splenic subcapsular area. In addition, tumor cell infiltration was noted in the sinuses of bone marrow and lymph node. Tumor cells often demonstrated moderate pleomorphism with multinucleated giant cells. They were positive for CD68 and negative for T- and B-cell lineage markers, megakaryocytic markers, and CD30. Various examinations were done to rule out infection-associated hemophagocytic syndrome, and the absence of infectious diseases was revealed. Thus, the diagnosis of histiocytic sarcoma was made. Apart from these lesions, multiple ulcerations, some with fatal perforation, were found in the esophagus and duodenum. They showed only non-specific inflammatory changes without tumor cell involvement. The ulcers probably derived from ischemic condition through an embolic process caused by tumor cell infiltration elsewhere in the blood vessels at the periphery of the ulcers.

Severe colitis after administration of UFT chemotherapy for temporal bone carcinoma

UFT (Uftoral®), a blend of uracil and Tegafur, is an antitumour agent for oral administration that is presumed to maintain the concentration of 5-fluorouracil (5-FU) in tumour tissue. As a result of increased use of high-dose 5FUbased chemotherapy for various solid tumours, complicated drug-induced colitis is more frequently observed. Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme in the catabolism of 5-FU and its deficiency is responsible for the severe toxicities encountered in cancer patients receiving 5-FU. The authors present the case of a patient with locally advanced temporal bone carcinoma who developed haematochezia during a course of chemotherapy with UFT. Colonoscopy of the patient showed bleeding petechia-like lesions and superficial inflammatory exudate, whilst histology revealed non-specific inflammatory changes of the colon mucosa. As the haematochezia improved with supportive treatment, neutropenia complicated the clinical picture. This patient developed life-threatening UFT toxicity without an exon-14 DPD gene mutation.

Nonspecific Ulcers of the Colon

Nonspecific colonic ulcers (NSCUs) are rare and potentially life-threatening lesions of unknown etiology; the diagnosis is based on histologic findings showing nonspecific inflammatory changes. The condition's variable symptoms can include nonspecific abdominal discomfort, gastrointestinal bleeding, perforation, and peritonitis. Radiologic imaging can be helpful in locating the lesions, but colonoscopy facilitates early definitive diagnosis and aggressive treatment. The potential of NSCUs to recur is currently unknown, and morbidity rates remain high. Long-term colonoscopic follow-up may improve the prognosis.

Concomitant colitis associated with primary sclerosing cholangitis.

Between 1985 and 2001, seven Japanese patients (four males and three females) were diagnosed as having primary sclerosing cholangitis (PSC) in our hospital. All seven patients received total colonoscopy with distal ileoscopy. All four male patients were diagnosed as having colitis by colonoscopy, while none of the three female patients had colitis. The four patients with colitis did not have any symptoms attributable to colitis, such as diarrhea or hematochezia. In three of the four patients, unclassified colitis was the most suitable diagnosis, because there were no typical findings of ulcerative colitis or Crohn's disease. The remaining patient was diagnosed as having eosinophilic colitis. By colonoscopic visualization, the right-sided colon, including the terminal ileum, was mainly involved, but the lesions were not severe. The main findings were redness, erosion, stenosis, and insufficiency of haustral formation. Histologically, these lesions were nonspecific inflammatory changes in the three patients with unclassified colitis. In the patient with eosinophilic colitis, remarkable infiltration of eosinophils was observed. Thus, unclassified colitis appeared to be the main complication in these patients with PSC. Males predominated in regard to concomitant colitis, and they had no symptoms of the colitis. Colonoscopic examination revealed that the lesions were not severe. The main lesions were found in the right-sided colon, with nonspecific inflammatory changes. These results suggest that colonoscopic surveillance of patients with PSC should be performed even if they do not have any colitis symptoms.

New strategies for prevention and treatment of graft-versus-host disease and for induction of graft-versus-leukemia effects.

Graft-versus-host disease (GVHD) continues to be a problem in allogeneic hemopoietic stem cell transplantation; however, our understanding of the basic pathophysiology of GVHD has improved. Although not all data obtained from murine or other animal models can be extrapolated to the clinic, there are leads that deserve to be pursued. The skin, intestinal tract, and liver are the 3 major target organs of GVHD and share the feature of presenting a barrier to the "environment" of the host. There is evidence that the damage inflicted to these organs, the epithelial and endothelial cells in particular, by the conditioning regimen causes a release of various cytokines and a penetration of endotoxin into the systemic circulation. According to these observations, the nonimmunologic aspects of GVHD have been likened to an inflammatory process. If this characterization is valid, blocking these nonspecific inflammatory changes would ameliorate GVHD without interfering with the graft-versus-leukemia (GVL) reaction. In fact, one study has shown a substantial amelioration of GVHD with a molecule that directly blocks endotoxin. Clinical data also suggest that patients with organ dysfunction early after transplantation that is presumed to be treatment related may benefit from preemptive interventions aimed at controlling GVHD. Furthermore, there is growing evidence that the mechanisms involved in GVHD may differ from organ to organ (for example, Fas/Fas-ligand interactions in the liver versus tumor necrosis factor alpha/receptor interactions in the intestinal tract), and from a therapeutic point of view, the time of onset of clinical GVHD may be important in choosing the appropriate therapy. Thus, combinations of interventions chosen and timed appropriately may be more effective in preventing and managing GVHD than are the standard across-the-board approaches that have been used so far. Such a strategy may also be successful in maintaining a GVL effect and possibly in incorporating direct antileukemic therapy, such as the use of cytotoxic T-cells directed at minor histocompatibility antigens, without increasing the risk of GVHD. The development of nonmyeloablative conditioning regimens and the observations on GVHD kinetics and the progression or eradication of leukemia with that strategy are likely to add new insights into how one can optimally combine various modalities to achieve engraftment, prevent GVHD, and at the same time maintain a GVL effect.

Ureteritis Cystica Presenting as a Retractile Ureteral Polyp

An 82-year-old woman presented with asymptomatic microhematuria and mild stress incontinence. Physical examination revealed an atrophic vagina and a small cystocele. Ultrasound showed bilateral small echogenic foci in each kidney, consistent with nephrolithiasis. Urinalysis demonstrated 3 red blood cells per high power field. Cystoscopy revealed a 5 ml. retractile polyp protruding from the left ureteral orifice (fig. 1). Cystoscopy and biopsy with the patient under anesthesia showed the polyp to have a long stalk extending from the left ureteral orifice. The tumor was resected and the stalk was electrocauterized. Retrograde pyelograms following resection demonstrated no ureteropelvic filling defect. Histological analysis revealed ureteritis cystica with focal squamous metaplasia (fig. 2). The submucosa contained focal nonspecific inflammatory infiltrate, edematous changes and focal collections of macrophages.

Polymyalgia rheumatica (PMR): clinical, laboratory, and immunofluorescence studies in 13 patients

Thirteen elderly patients with polymyalgia rheumatica (PMR) are presented. The clinical and laboratory findings suggest that many progressive symptoms are due to the non-specific inflammatory changes in various organs of the body, especially in muscles and joints. An immunofluorescence study of muscle biopsy specimens revealed IgG, IgA, and fibrinogen deposits in the perifascicular area of the perimysium. This finding suggests that immune complexes play a role in the pathogenesis of this condition and that the pathophysiology of PMR is an interstitial inflammatory process. We think that the inflammatory findings affecting the interstitial tissue of muscles in the immunofluorescence study are relatively specific to PMR, and will be affected by steroid treatment.

GASTRIC PATCH PYELOPLASTY: DEVELOPMENT OF AN ANIMAL MODEL TO PRODUCE UPPER TRACT URINARY ACIDIFICATION FOR TREATING STRUVITE URINARY CALCULI

Struvite calculi form in an alkaline environment created by urease producing uropathogens. We developed a viable upper tract urinary acidification model by performing gastric patch pyeloplasty in the rabbit. This model produces urinary acidification sufficient for the treatment and prevention of struvite renal calculi. We evaluated the physiological, metabolic and surgical outcomes. gastric segment was harvested based on branches of the left gastro-epiploic artery. The flap was folded along the transverse axis and the adjacent edges were closed. The mouth of this reconfigured pouch provided optimal dimensions for anastomosis with the diminutive renal pelvis. Half of the rabbits were treated with internal stenting and H-2 blockade. Urinary pH was assessed by weekly cage collection and direct collection from the cannulated ureters. Urine culture was done, and serum gastrin and electrolytes were assessed at regular intervals. The rabbits were sacrificed at 3 to 26 weeks. Histological examination was routinely performed. A total of 15 rabbits were available for complete assessment. Sustained urinary acidification was produced in 7 animals (47%) with a mean pH decrease of 2.27. In another 2 rabbits (13%) the urine was initially acidic but subsequently became alkaline due to ureteral obstruction. Electrolytes and gastrin were unchanged in these rabbits and urine culture was positive in 2. Histological testing revealed nonspecific inflammatory changes of the renal pelvis. Anastomotic complications were the most common surgical complication and the most common cause of failed acidification. The cohort treated without stents and H-2 blockade was at significantly greater risk for anastomotic leakage. Gastric patch pyeloplasty may significantly increase urinary acidity in the rabbit model without altering the serum electrolyte balance or gastrin level. The procedure utilizes common techniques of reconstructive urology and may be possible with laparoscopy. Further study is required to assess the in vivo effect of this procedure for treating and preventing upper tract struvite calculi.

Spontaneous late rupture of orthotopic detubularized ileal neobladders: report of five cases

Objectives. To report five spontaneous ruptures in 4 patients. Spontaneous late rupture of orthotopic ileal bladder replacements is a rare complication of continent urinary diversion. Methods. Four recurrence-free patients aged 36 to 68 years experienced apparently spontaneous rupture of continent orthotopic ileal bladder replacement 3 months to 3 years after curative radical cystectomy and urinary diversion for invasive bladder cancer. Ileal bladder rupture occurred twice in 1 patient with an interval of 9 months. Results. All 4 patients had had a good result from their diversion procedure and had reported complete day and nighttime continence before the spontaneous rupture. The spontaneous rupture was evidently caused by overdistension of the ileal neobladder in four of five instances. In addition to overdistension, a second factor such as minor blunt abdominal trauma or urethral occlusion was identifiable in two instances. The rupture occurred in the right upper corner of the ileal bladder in four of five instances and led to acute and severe abdominal pain. Cystography was done in three instances, but was diagnostic in only 2 cases. The histologic examination of the excised bladder wall margins revealed nonspecific inflammatory changes in 3 cases. Open surgical drainage and repair was successfully undertaken in all cases. Conclusions. The circumstances of the cases described suggest that late spontaneous rupture of an orthotopic ileal bladder replacement is not related to the surgical technique but rather to factors of patient compliance and medical management.

Bladder preservation in adult classic exstrophy: early results of four patients

Objectives. To report our experience with the treatment of classic exstrophy of the bladder in a small series of adult patients using ileocystoplasty, bladder neck reconstruction, and abdominal wall closure with flaps. The presentation of exstrophy of the bladder in adulthood is rare. The problems encountered include difficulty in abdominal closure, malignant potential, and upper tract dysfunction. The treatment of choice has been cystectomy with urinary diversion in all reported cases. Methods. We treated 4 adult male patients with classic exstrophy of the bladder and complete epispadias. They had not received any previous treatment. Multiple random bladder biopsies revealed nonspecific inflammatory changes with focal areas of keratinization. Three patients were treated in two stages. The first stage included ileocystoplasty, bladder neck reconstruction, and abdominal wall closure with the use of flaps. The epispadias was repaired in the second stage. In 1 patient, the reconstruction was completed in a single stage. Results. All patients were continent at the last follow-up visit, with three using self-catheterization and one voiding spontaneously. The renal parameters and ultrasound scans were normal at a follow-up of 2 to 48 months. Cystoscopy performed at 6 months postoperatively revealed normal-looking mucosa in 2 patients and mild inflammation in 1 patient. Three patients were satisfied with the cosmetic results and one complained of the small size of his penis. All patients were evaluated by psychiatrists and revealed anxiety disorders preoperatively. After surgery, all demonstrated improved social interaction. Conclusions. Vesical preservation with primary reconstruction of bladder exstrophy in adults is safe and feasible in the absence of significant histologic changes in the bladder mucosa. Abdominal closure can be achieved without difficulty with the use of transposition flaps. However, these patients require strict follow-up to detect malignant transformation at an early stage.

Estudio de las uretritis masculinas mediante la tinción de Papanicolaou

Sexual pathogens, cell types and morphologic alterations of urethral epithelial cells were investigated by means of the Papanicolaou smear in 110 heterosexual men. Seventy-five patients with urethritis were included: 17 (22.6%) with gonococcal urethritis (GU) and 58 (77.3%) with non-gonococcal urethritis (NGU). Thirty-five males without symptoms or signs of urethritis comprised the control group. An increase in epithelial cell dissociation was observed in patients with urethritis. Non-specific inflammatory changes were statistically more common in patients with urethritis than in controls, and more severe in GU (65%) than in NGU (15.5%). Nuclear atypia was a common finding (43.5%) in infections due to C. trachomatis. Mucus was associated with the presence of urethritis although no differences regarding etiology were found. No polimorphonuclear neutrophils were observed in the exudate of three patients (5%) with NGU. There was a statistically significant presence of lymphocytes in patients with urethritis, particularly in GU (45%), more frequent than in NGU (15.5%). Erythrocytes were also significantly more frequent in urethritis, with a greater proportion in GU (94%) than in NGU (64%). Plasma cells, eosinophils, and histiocytes were only observed in a few patients with urethritis. The Papanicolaou smear had a sensitivity of 47% and a specificity of 90% in Chlamydia trachomatis infections.

7154 Clinical significance of non-neoplastic lesions of the ampulla of vater.

Background: Non-neoplastic conditions of the ampulla of Vater are poorly understood. Our purpose was to investigate non-neoplastic lesions of the ampulla of Vater in relation to past medical history and findings at presentation. Method: Medical records of patients with biopsies of the ampulla of Vater revealing non-neoplastic histopathology in a 5-year period were reviewed after identification from review of our pathology database. Biopsies were reviewed blindly and categorized as “inflammatory”, “reactive, consistent with a site of healing ulcer”, and “acute ulcer”. Results: The mean age of patients was 59 years. Of a total of 26 cases - 14 were male. 11 specimens had nonspecific inflammatory changes, 11 were consistent with a site of healing ulcer, and 4 revealed acute ulceration. Of 14 patients without a history of instrumentation, 5 (36%) showed nonspecific inflammation, 8 (57%) showed changes consistent with a site of healing ulcer, 1 (7%) had acute ulceration. In this subgroup, 9 (64%) had clinical and/or radiographic evidence of biliary obstruction, 6 (43%) had a history of pancreatitis, 5 (36%) had elevated bilirubin and/or alkaline phosphatase, and 3 (21%) had elevated amylase and/or lipase. Twelve of 26 patients (46%) had a recent history of instrumentation in the ampulla of Vater. Nine (75%) of these had either inflammation or changes consistent with site of healing ulcer; 3 (11%) had acute ulceration. No correlation with NSAID use was found. Discussion: This study reveals that a history of instrumentation of the ampullary region is the single most common clinical parameter in patients with non-neoplastic lesions of the ampulla. However, over 50% of patients in this study had no history of instrumentation. Obstructive biliary disease is the common clinical parameter in this subgroup occurring in 9 of 14 patients. Pancreatitis is the second most significant clinical parameter occurring in 6 of 14 patients (43%). Patients with noniatrogenic causes of ampullary inflammation commonly present with obstructive biliary disease or pancreatitis.

Incidence of preputial lichen sclerosus in adults: Histologic study of circumcision specimens

Background: Narrowing of the prepuce in men is poorly documented, and the causes are often unknown, except in the case of clinical infections or skin diseases such as lichen sclerosus (LS). Objective: We conducted a histologic study of circumcision specimens with phimosis or paraphimosis. Methods: This prospective study included 43 men with contraction referred for circumcision. Results: LS was present in 32% of cases, but only 12% of these cases of LS had not been diagnosed before circumcision. In 31% of cases the histologic findings were normal. Subacute nonspecific inflammatory changes were diagnosed in 37% of all cases, and secondary narrowing of the prepuce in 62% of cases. It is probable that this histologic modification of the preputial mucosa is involved in narrowing of the prepuce. Conclusion: Phimosis in young adults is usually not associated with LS (only 14%). In contrast, most older patients had secondary phimosis caused by progressive LS (40%) or subacute nonspecific inflammatory changes (40%). Although all cases of phimosis in men should be treated by complete circumcision to prevent penile cancer, paraphimosis associated with preputial dyspareunia, with the exception of cases associated with LS, can be treated by corrective surgery. (J Am Acad Dermatol 1999;41:923-6.)

The Pathology of Interstitial Lung Disease in Nylon Flock Workers

Flocking is a widely used industrial process in which short lengths of synthetic fibers are applied to backing fabric to produce plush material. In response to an apparent outbreak of interstitial lung disease in flock workers, the Centers for Disease Control hosted a clinical-pathological workshop to identify the defining characteristics of the disease and possible etiologic agents. Six pathologists reviewed 15 biopsies of 15 cases (out of a clinical caseload of 20 patients) and assessed the pattern, extent and degree of pulmonary inflammation, fibrosis, and other changes. A consensus clinical-pathologic diagnosis was reached for each patient and correlated with clinical and radiologic findings. Four of eight open lung biopsies and one of seven closed (transbronchial) lung biopsies demonstrated a characteristic pattern to which the descriptive terminology lymphocytic bronchiolitis and peribronchiolitis with lymphoid hyperplasia was applied. The other biopsies showed nonspecific inflammatory changes, airspace organization, and diffuse alveolar damage. One open lung biopsy demonstrated respiratory bronchiolitis with lymphoid hyperplasia. None of the lung biopsies showed more than mild interstitial fibrosis and no granulomas were identified. The consensus of the workshop was that lymphocytic bronchiolitis and peribronchiolitis with lymphoid hyperplasia was a characteristic and distinctive pattern of injury in the flock workers' lung biopsies. Although the etiology of this disease remains undefined at present, the injury pattern and environmental studies suggest a chronic immunologic response to inhaled material.

Aortic Valve Rheumatoid Nodules Producing Clinical Aortic Regurgitation and A Review of the Literature

The majority of cardiac involvement in rheumatoid arthritis (RA) is an incidental finding at postmortem, as less than 3% of patients with RA have clinical cardiac signs or symptoms. Most cardiac involvement in RA involves the pericardium and has been known since Charcot first described an RA patient with pericarditis in 1881. Cardiac involvement takes two different forms: non-specific inflammatory changes and specific granuloma formation. Specific rheumatoid nodules in the heart are an infrequent complication of RA. This is the first case report of a surgically excised heart valve with rheumatoid nodules. A 74-year-old RA patient with a high seropositive rheumatoid factor presented with severe aortic regurgitation and underwent a valve replacement. The native aortic valve showed significant stenosis with multiple, classic rheumatoid nodules. Cardiovas Pathol 1999;8: 333–338

Colonic tuberculosis: clinical features, endoscopic appearance and management.

Although rare in the West, colonic tuberculosis is not an uncommon disease in developing countries. However, the clinical manifestations and radiological appearance of the disease are non-specific. In recent years, colonoscopy has been found to be very useful in diagnosing patients with colonic tuberculosis. Clinical features, colonoscopic findings, histology and response to treatment were recorded in 50 patients with colonic tuberculosis. Abdominal pain, fever, anorexia, weight loss and diarrhoea were the common symptoms. The colonoscopic features consisted of ulcers (92%), nodules (88%), deformed caecum and ileocecal valve (42%), strictures (25%), multiple fibrous bands (8%) and polypoid lesions (6%). Segmental tuberculosis and lesions simulating carcinoma were seen in 22 and 16% of patients, respectively. Histological examination of the colonic biopsy specimens showed well-formed, non-caseating granulomas in 18%, collection of loosely arranged epithelioid cells in 40% and chronic non-specific inflammatory changes in 42% of the patients. Six patients needed surgical intervention. The other 44 patients responded well to anti-tuberculous therapy and became asymptomatic. It is concluded that colonoscopy is a useful method for diagnosing colonic tuberculosis. It is suggested that if the clinical picture and colonoscopic appearance are suggestive of tuberculosis and target biopsies reveal non-caseating granulomas, a collection of loosely arranged epithelioid cells, or even non-specific changes, then a therapeutic trial of anti-tuberculous drugs should be given and continued if there is clinical improvement.

Exhaled nitric oxide in human lung transplantation. A noninvasive marker of acute rejection.

Acute allograft rejection in animals and humans has been associated with increased nitric oxide production in the graft. Exhaled nitric oxide (ENO) measurement is a noninvasive method of assessing inflammation in airway diseases, e.g., asthma, which might be applicable to lung transplant recipients. Over 12 months, ENO of lower respiratory origin was measured in 108 lung transplant recipients with a mean time after transplant of 1,083 d. ENO (mean +/- SEM; ppb) in stable patients (19.5 +/- 1.1; p < 0.001) was not different from that of healthy controls (23.8 +/- 3.2). ENO was significantly higher in episodes of clinical acute rejection (51.1 +/- 6.3) compared with stable patients but not elevated in bronchiolitis obliterans syndrome (18.6 +/- 1.5) or pulmonary infection (25.9 +/- 4.0). A retrospective analysis of bronchoscopy findings and concurrent ENO (n = 99) showed that ENO did not vary according to histological findings (normal, acute rejection grade I, nonspecific inflammatory change) or with a positive BAL culture. ENO was not correlated with differential lymphocyte and neutrophil counts. ENO appears to be a valid marker of clinical acute rejection in human lung transplantation as distinct from infection or bronchiolitis obliterans. Furthermore, bronchoscopic findings in the absence of a clinical illness were not associated with a rise in ENO.