[A large symptomatic gastric leiomyoma. A case report and considerations of the treatment possibilities]. / Grosso leiomioma gastrico sintomatico. Descrizione di un caso e considerazioni sulle possibilità di trattamento.

The authors describe the case of a female patient affected with large symptomatic gastric leiomyoma, six centimeters in diameter, who presented to clinical observation referring gastric pain and melena. The first gastroscopy showed massive bleeding from a submucosal gastric lesion. The lesion was not endoscopically resectable and the injective endoscopic treatment of bleeding failed. The patient was surgically treated with laparotomic excision of the leiomyoma. She was back home in ten days. The authors describe this case to discuss the possibility to resect large gastric leiomyomas using endoscopic resection indeed surgical approach. They also enhance the validity of surgical treatment for its safety and radical approach to large lesions.

[Barrett's esophagus: characteristics and evaluation of risk of malignancy]. / Esofago di Barrett: caratteristiche e valutazione del rischio di malignità.

Barrett's esophagus (B.E.) is defined the replacement of the distal malpighian epithelium of the esophagus by a columnar type epithelium which is considered a precancerous condition. Its aetiology is supposed to derive from the damage induced by esophagitis. We recognize three endoscopic aspects of columnar replacement: flames or tongues of columnar epithelium in continuity to the gastric mucosa (I type), irregular cuff with malpighian islets (II type), complete circumferential cuff with displaced Z line (III type). The evolution of this epithelium into cancer is still debated (prevalence from 0 to 46%), but seems to be particularly elevated in presence of incomplete intestinal metaplasia (I.M.) in which the development of dysplasia is more frequent. The endoscopic examination is essential in the diagnosis and follow-up of B.E. Endoscopy permits other methodological approaches such as histological, chemical, ultrastructural examination aiming to obtain good results in the study of prevalence and incidence of esophagitis, B.E. and adenocarcinoma. It is also possible to perform functional examination. Many Authors joined international protocols to study B.E. in order to obtain uniform data about this condition. A second point of interest is represented by the evaluation of the efficacy of medical treatment to reduce the extension of Barrett's metaplasia and to control the esophagitis. Finally it is possible to detect fluorescence in the dysplastic tissues by laser irradiation using hematoporphyrin derivative and to evaluate their non surgical treatment with photodynamic therapy.

Gastric histology and function tests in Italian patients with dermatitis herpetiformis.

Gastric mucosal histology and function were evaluated in 57 Italian subjects with dermatitis herpetiformis (DH), by means of multiple endoscopic biopsies, gastrin and pepsinogen I (Pg I) serum levels, and parietal cell antibodies (PCA). One hundred and forty-nine patients with nonulcer dyspepsia served as reference population for the prevalence of atrophic gastritis of the body. Seventeen DH patients (30%) and 23 controls (15.4%) showed atrophic gastritis of the body mucosa (p less than 0.05). Nine of the DH patients with atrophic gastritis of the body also had atrophic changes in the antrum. Six patients, all with severe atrophic gastritis, had high gastrin levels and PCA; five of these six also had low Pg I levels. We found an increased prevalence of abnormal indirect function tests among patients with atrophic gastritis is due to the younger age of the patients in our series. Thus, atrophic gastritis can be detected early on a histologic basis, but functional impairment occurs later, as the mucosal damage increases in severity.

Eradication of esophageal varices by endoscopic sclerotherapy: how much is enough?

To clarify if complete eradication of varices from the lower esophagus by endoscopic sclerotherapy is really essential to prevent rebleeding, or if reduction of varices below a certain size can be considered a sufficient result, we compared the fate of 72 patients in whom sclerotherapy was stopped after one of the following endoscopic endpoints was reached: complete eradication (15 patients, group 1), partial eradication with residual small white varices (32 patients, group 2), and partial eradication with residual small blue varices (25 patients, group 3). The incidence of variceal recurrences and recurrent bleeding over a median follow-up of 17 months after stopping sclerotherapy did not differ significantly in the three groups. Analysis of the time course of variceal recurrences showed that the recurrence-free interval was almost identical in group 1 and group 2 patients (13 and 14 months, respectively). Group 3 patients had a shorter recurrence-free interval (8.3 months), but the difference was not statistically significant. We conclude that sclerotherapy can be stopped safely when either complete eradication or reduction of varices to small white columns is obtained.

Prevalence of duodenal and jejunal lesions in dermatitis herpetiformis.

Sixty-eight patients with dermatitis herpetiformis underwent jejunal suction biopsies and/or multiple endoscopic duodenal biopsies to evaluate the incidence of small bowel mucosal atrophy and to compare the diagnostic yield of the two methods. Small bowel function tests were also performed to evaluate the extent of functional impairment. Small bowel lesions were observed in 89.4% of jejunal suction biopsies and in 100% of endoscopic duodenal biopsies. Of the 10 patients who underwent both procedures, one had lesions only in the duodenum, one had more severe lesions in the duodenum than in the jejunum, while the remaining 8 patients showed identical lesions at both sites. The 1-h blood d-xylose test after a dose of 5 g proved more sensitive than xylosuria or serum folic acid assay in detecting subclinical malabsorption. Finally, histological features of gluten-sensitive enteropathy can be found in nearly 100% of patients with dermatitis herpetiformis. Upper gastrointestinal endoscopy with duodenal biopsies is at least as sensitive as jejunal suction biopsy in assessing small bowel involvement in dermatitis herpetiformis.