Long esophageal stricture in Crohn's disease: a case report.

Crohn's disease of the esophagus is rare, and it is very unusual for it to be located only in the esophagus. We report a case of Crohn's disease confined to the esophagus in a 26-year-old female. The patient was admitted because of progressive dysphagia, odynophagia and weight loss. A barium-swallow examination showed an irregular narrowing of the esophagus below the level of the aortic arch which was 15 cm long, with marginal ulcers and a pseudopolypoid appearance of the mucosa; a computed tomographic scan of the thorax revealed a thickened esophageal wall. Esophagoscopy revealed an esophageal stricture 25 cm distal to the incisor teeth, 2 mm in diameter, with "punched out" ulcers and pseudopolypoid mucosa. Endobiopsy specimens showed chronic lymphocytic infiltration into the corion in the absence of neutrophils, basal-cell hyperplasia and elongation of the stromal papillae. The patient underwent an esophagectomy through a combined cervico-abdominal approach followed by a cervical esogastrostomy. The specimen was 18 cm long, the thickness of the wall was 1.7 cm with fibrosis involving all layers of the esophageal wall and a cobblestone appearance of the mucosa. A heavy lymphoplasmocytic infiltrate extended from the mucosa deep into the muscularis, fibrosis and granulomas were found transmurally. Crohn's disease of the esophagus is a rare and specific entity which can present in various ways; strictures resembling those from reflux esophagitis or a tumor are common. Diagnosis may be suggested by the presence of a chronic lymphocytic infiltrate with or without non-caseating granulomas, and no histologic evidence of chronic reflux esophagitis.

Fatal intestinal hemorrhage complicating ileal lymphoma after cyclosporine for unresponsive celiac disease.

BACKGROUND/AIMS: Unresponsive celiac disease may benefit from immunosuppressive therapy. Malignant small intestinal lymphoma is the most serious complication of celiac disease, also being noted as a complication of immunosuppressive therapy. The diagnosis of small intestinal lymphoma complicating celiac disease is notoriously difficult. Perforation is the most common complication of small intestinal lymphoma, frank hemorrhage being unusual. We report a case of massive, fatal hemorrhage from small intestinal lymphoma complicating unresponsive celiac disease treated with cyclosporine. The patient was presented with severe diarrhea and nutritional deterioration. Unresponsive celiac disease was diagnosed on the basis of clinical and histologic criteria with no response while on a gluten-free diet, corticotherapy and octreotide acetate injections. Cyclosporine therapy was advised. The patient had a remarkable clinical response. After 3 months from the start of the cyclosporine therapy, the patient returned with massive intestinal bleeding. The patient underwent emergency surgery diagnosing an enteropathy-associated lymphoma. We conclude that cyclosporine therapy for unresponsive celiac disease should be considered in select, severely ill patients only after a full-thickness biopsy of the small intestinal wall to disclose a latent super-imposed lymphoma, which course may be accelerated by immunosuppressive therapy.

[Is an esophageal transit scintigram necessary in patients with gastroesophageal reflux?]. / Este necesara scintigrama de tranzit esofagian la pacientii cu boala de reflux gastroesofagian (BRGE)?

Efficient esophageal clearance has an important defence role in the pathogenesis of the gastroesophageal reflux disease (GERD). Many GERD patients have esophageal disturbances associated with or secondary to reflux, producing delayed clearance. This delay exposes the esophageal mucosa to the reflux acid content. To determine esophageal transit we scanned the esophageal transit of a 15 ml bolus containing colloidal 300/cCi 99m Tc. The esophageal transit was calculated in seconds according to formula E.T. = T 1/2 x 5. The study included 74 GERD patients. The following investigations were carried out in all the cases: esophageal X-ray, GER scintigram, endoscopy, esophageal biopsy, Bernstein test and esophageal transit scintigram. Endoscopy revealed lesions of the esophagus (of 1st, 2nd and 3rd degree) in 39 patients, Barrett syndrome in 8 cases and normal in 27. Esophageal transit scanning was normal in 18 cases (24%), and prolonged in 56 cases (76%). Only 7 (39%) of the 18 patients with a normal transit presented lesions of the mucosa, the latter being more frequent in patients with a prolonged transit, i.e. 40 of 56 patients (71.5%). The mean value of the transit in different degrees of esophagitis (I, II, III) and Barrett syndrome were: 12.73 +/- 5.36; 13.30 +/- 7.90; 10.35 +/- 5.78; 17.25 +/- 11.17. In conclusion esophageal transit scanning is a useful test in GERD patients as it has a prognostic value. A prolonged esophageal transit is frequently associated with lesions, the more severe the slower is the transit. Moreover the test may indicate certain drugs acting upon the esophageal motor disturbances.

[Observations on 35 cases of strongyloidiasis hospitalized at a clinical digestive disease unit]. / Observatii asupra 35 cazuri de strongiloidoza internate într-un serviciu clinic de boli digestive.

After a short presentation of the etiopathogenesis of this parasitosis, the authors report their observations on 35 cases of strongyloidiasis followed in the recent years. On the basis of the epidemiologic and clinical analyses of these cases, the authors show that some data, i.e. those on the environment to which the patients belong, or their occupation, and also some clinical manifestations (clinical polymorphism) may suggest the diagnosis of strongyloidiasis in the immunosuppressed in about 30% of the cases. An associated blood eosinophilia may be a more possible for the diagnosis of strongyloidiasis. The positive diagnosis has to take into consideration, beside the repeated diet exam, the method of cultures and also jejunal biopsies, which may also verify the efficiency of the treatment recommended. The authors recommend the treatment with Mintezol and, with lower results, Vermigal and Mebendazol.

Benign gastric lymphomatosis (gastric pseudolymphoma).

The present paper reports on two cases of gastric lymphomatosis whose diagnosis could only be established by histologic examination of the operative specimen. Benign gastric lymphomatosis (BGL) is characterized by lymphoid infiltration of the gastric wall, predominant in the mucosa and sometimes in the submucosa, running a slow benign course. It must be differentiated from malignant gastric lymphomas and from inflammatory lymphoid reactions surrounding ulcers. BGL have not been treated medically to date. One of the patients initially underwent an eight months treatment with prednisone, then with prednisone and cytostatics, which resulted in clinical improvement but did not modify the pathohistologic picture. As BGL represents a precancerous state and cannot be controlled at present by any medical treatment, the surgical intervention is considered opportune.

Absorption studies in patients with parasitic infestation of the small intestine, before and after treatment.

Forty adult patients having intestinal infestation with giardia or with parasitic associations, such as giardia-strongiloides, giardia-taenia solium, were subjected to morphological explorations, iron and vitamin B12 absorption tests, steatorrhea assay and serological tests, before treatment as well as six months and one year after eradication of the infection. On admittance, jejunal morphological lesions were noted only in 15 cases especially in associated infestation, iron depletion in six patients, vitamin B12 malabsorption in five patients and steatorrhea only in two cases. After the lapse of six months and one year, respectively, all the tests ranged within normal values, and the jejunal morphological aspect improved significantly indicating the pathogenetic role of intestinal parasites in the development of selective malabsorption.