Azathioprine induced serious portal hypertension: a case series of three IBD patients and review of the literature.

We report 3 male IBD patients (2 Crohn's Disease, 1 Ulcerative Colitis) developing thrombocytopenia and splenomegaly on azathioprine treatment. All patients were diagnosed with significant portal hypertension due to histological proven nodular regenerative hyperplasia (NRH) of the liver. In two of three patients, liver function tests remained completely normal. In addition we provide a short literature review of azathioprine induced NRH covering etiology, imaging, pathology, prognosis and treatment.

Abrikossoff cell tumor of the oesophagus: a case report and review of the literature.

Abrikossoff tumours or granular cell tumours are rare and usually benign tumours. The oesophagus is a rare location (0.001% of all tumours). The macroscopic appearance is typical (yellow, firm, well circumscribed submucosal neoplasm-like with reduced vascular patterns) but due to the rarity of this lesion, it can be mistaken with other similar lesions. This is the report of a case of a 47-year-old female with a granular cell tumour of the distal oesophagus. In this case, the Abrikossoff tumour is clinically, radiologically en histologically benign. According to the fact that there is low evidence in the literature for removing such Lesions in patient without symptoms, it was decided to be conservative. In this paper we discuss the case with review of the Literature with emphasis on the diagnosis, evaluation and management.

CT colonography with fecal tagging after incomplete colonoscopy.

The objective of this study was to evaluate dietary fecal tagging (FT) as a cleansing method prior to CT colonography (CTC) in patients with incomplete conventional colonoscopy (CC). After written informed consent was obtained, 24 patients had standard colonoscopic preparation (ScCl), and 25 patients had FT as cleansing method. Segmental distention, fluid levels, fecal residues, tagged appearance of fluid levels, and residual stool were evaluated. Mann-Whitney U test was used to test for significant differences between FT and ScCl groups. Compared with ScCl, FT improved distention (p=0.001), reduced the amount of fluid (p=0.043), but suffered from residual stool (p=0.046). A clear correlation was found between distention and fluid. No differences were found in stool size between FT and ScCl. FT showed a good labeling of fecal residues, and acceptable labeling of fluid levels. Compared with ScCl, FT reduces fluid, favors distention, but suffers from fecal residues. The tagged nature of these residues, however, allows differentiation from polyps.

Acute torsion and necrosis of the greater omentum herniated into a foramen of Morgagni.

Computed tomography is mandatory in the investigation of the acute abdomen and can provide the physician with crucial information to decide whether the patient should be treated surgically or conservatively. An unusual cause of acute abdomen is presented. Computed tomography suggested the diagnosis of omental torsion and necrosis. At surgery, the greater omentum and part of the transverse colon were incarcerated in a small diaphragmatic hernia of the Morgagni type.

Hypertrophic lymphocytic gastritis with a gastric carcinoma.

Lymphocytic gastritis is a recently described gastric inflammation, characterized by an increased intraepithelial lymphocytic infiltrate mainly composed of T-lymphocytes. Endoscopically it correlates mainly with diffuse varioliform gastritis. Ménétrier's disease is a hypertrophic gastropathy with enlarged gastric folds. The histological picture is that of foveolar hyperplasia and glandular cysts of the mucosa. A few small series of lymphocytic gastritis with microscopic and endoscopic features of Ménétrier's disease have been published previously. We describe a similar case associated with a gastric adenocarcinoma.

Ultrasound-guided puncture of the gallbladder for acute cholecystitis.

We performed a US-guided aspiration of the gallbladder in 27 patients with an acute cholecystitis and severe concurrent disease, not responding to IV antibiotics and supportive therapy. Twenty six of the 27 patients improved after the procedure. One patient died 7 days after the procedure due to multi organ failure; in the others immediate surgery could be avoided. Three patients experienced local pain after the procedure; no other puncture related complications were encountered. Long-term results (mean follow up 18 months; range 2-36 months) were excellent in 20/26 survivors with no biliary complications or need for elective cholecystectomy. Six of the 26 patients needed subsequent cholecystectomy for relapse or incomplete cure.

[Herpetic esophagitis in 5 immunocompetent patients]. / Herpetische oesofagitis bij 5 immuuncompetente patiënten.

In five immunocompetent patients, 3 of whom were moderately ill, herpes simplex virus (HSV) oesophagitis was diagnosed. HSV oesophagitis is a frequent infection in immunocompromised hosts. Nevertheless the English medical literature (Medline) contains at least 33 cases of HSV oesophagitis in immunocompetent persons over the period 1983 to 1993. Odynophagia, dysphagia and chest pain are common symptoms. Endoscopy is necessary for diagnosis: brush cytology, biopsy for histology and viral culture are the tools for identification of herpes simplex as the cause of the oesophagitis. HSV oesophagitis in an immunocompetent patient is an acute but self-limiting disease. Nevertheless acyclovir per os or intravenously may be recommended if started early after onset of symptoms.

[Squamous esophageal papillomas]. / Squameuze slokdarmpapillomen.

In three patients, two women of 37 and 58 and a man of 68 years, a papillomatous lesion was incidentally detected in the distal part of the oesophagus. Microscopically a squamous papilloma was seen with parakeratosis and in two patients poikilocytosis, indicating an infection with human papilloma virus (HPV). The lesions were removed endoscopically, in one patient with laser photocoagulation. Squamous papillomas of the oesophagus are benign tumours with a very low incidence. The pathogenesis still remains unclear. Some authors suggest local irritation as a possible mechanism. On the other hand there is growing evidence of an aetiological role of HPV. In several studies the presence of viral antigen or DNA has been demonstrated. These papillomas may undergo malignant transformation, which means that they are best removed preventively.

Provocation tests versus 24-h pH and pressure measurements.

The diagnosis of the oesophageal origin of non-cardiac chest pain is still a matter of controversy. This review discusses the diagnostic accuracy of oesophageal provocation tests, such as acid perfusion, edrophonium and balloon distension, in comparison with 24-h intra-oesophageal pH and pressure recordings. It also discusses how these various tests relate to known underlying mechanisms of oesophageal chest pain: acid reflux, oesophageal dysmotility or a combination of both.

How well can quantitative 24-hour intraesophageal pH monitoring distinguish various degrees of reflux disease?

Twenty-four normal subjects and 64 symptomatic patients with various degrees of reflux disease (24 with reflux symptoms without esophagitis and 21 with mild and 19 with severe esophagitis) underwent quantitative 24-hr intraesophageal pH monitoring. Various reflux parameters during supine, interprandial, and postprandial periods were examined by binary logistic regression and by CART analysis to determine the sensitivity and specificity to separate the various groups of subjects and patients. The distinction was excellent between asymptomatic controls and patients with severe erosive esophagitis (sensitivity and specificity both 100% by logistic regression and 95% and 88%, respectively, by CART), but discrimination was poor when asymptomatic controls were compared to symptomatic patients without esophagitis (71% and 79% by logistic regression and 75% and 92% by CART), which is the most important indication for pH recording in clinical practice. A 3-hr postprandial pH recording was inadequate to distinguish the various groups. The acidity of the reflux episodes during the night appeared to be a crucial factor in the development of severe erosive esophagitis. The duration of esophageal acid exposure was another important factor in the development of reflux lesions.

Lymphocytic gastritis. Clinical and endoscopic presentation and long-term follow-up.

Lymphocytic gastritis is a histopathological entity corresponding with diffuse varioliform gastritis but also with other gastroscopic findings. Eighteen patients were followed over a mean period of 25 months. The symptoms, the endoscopic and histopathological abnormalities remained unchanged in the majority of the cases. Conventional peptic ulcer therapy failed to control symptoms or to normalize endoscopic alterations. Helicobacter pylori did not seem to play a role in the pathophysiology. Lymphocytic duodenitis was found in four patients. The relationship between lymphocytic gastritis, Ménétrier's disease and coeliac disease has further to be elucidated.

Ultrasonographic diagnosis of hepatobiliary ascariasis.

Eight cases of hepatobiliary invasion of Ascaris lumbricoides into the hepatobiliary tract are presented. In the presence of nonspecific symptoms and biochemical test results, the diagnosis was made in seven patients by sonography. In the remaining patient, in whom the adult roundworm was not visible on sonography owing to the presence of aerobilia, the diagnosis was made at ERCP. Sonography revealed typical tubular, echogenic, filling defects along the long axis of a dilated common bile duct, sometimes exhibiting slow movements and containing a central sonolucent line. Repeated sonographic examinations accurately predicted treatment success.

Ultrasound-guided puncture of the gallbladder for acute cholecystitis.

In 18 high-risk patients with acute cholecystitis and severe concurrent disease, we aspirated the gallbladder by using a percutaneous technique under ultrasound guidance. 17 of the 18 improved after aspiration, the only complication being local pain in 2. 13 of the 17 who improved remained free from biliary infections during a mean follow-up period of 14 months. 4 had an uncomplicated cholecystectomy 6-10 weeks later for recurrent cholecystitis. Percutaneous transhepatic gallbladder aspiration is a safe and effective procedure in critically ill patients with acute cholecystitis.

Ischemic colitis in a patient with Crohn's disease taking an oral contraceptive and an ergotamine alkaloid.

A 22-year-old woman developed transient left-sided ischemic colitis with submucosal oedema and bleeding, six weeks after an uneventful right hemicolectomy for Crohn's disease. The thrombogenic properties of the contraceptive pill and the concomitant use of an ergotamine alkaloid were thought to be the cause of this complication in a patient at risk. An increase of procoagulant activity and underlying vascular injury has been described in Crohn's disease.

PIP: In Belgium, physicians at Heilig Hart Kliniek in Roeselare removed half of the colon of a 22-year-old woman suffering from obstructing Crohn's disease of the terminal ileum. 2 weeks after leaving the hospital she had diarrhea and abdominal cramps and neither fecal culture nor Clostridium difficile toxin were positive. 2 weeks later she experienced the same symptoms, but the diarrhea was now profuse watery diarrhea mixed with blood. The physicians performed a biopsy of the colonic segment at both ends of the left colon which revealed signs of ischemic colitis (obvious congestion, acute extravasation of blood, and focal desquamation of epithelial cells). So they ordered parenteral feeding for 24 hours, after which she had no more symptoms. She began oral feeding with no complications. When the physicians learned that after discharge she began using the combined oral contraceptive (OC) Trinovum and 2.5 mg dihydroergotaminemesilate to treat migraine, they told her to stop taking the ergotamine alkaloid and recommended that she not use the OC. She agreed to stop using the migraine medication but started using the OC again. 4 months after the biopsy she no longer has side effects. The woman had multiple risk factors of ischemic colitis development: OC use and use of an ergotamine alkaloid. The potentially vasoconstrictory and thrombogenic factors may have irritated underlying vascular injury and the tendency of focal mesenteric thrombosis which is often present in people with Crohn's disease. Therefore, the physicians deducted that OC use and use of ergotamine alkaloid were responsible for the ischemia. In conclusion, ergotamine alkaloid use in association with OC use is contraindicated in women who have predisposing factors, e.g., thrombogenic disease or coagulation abnormalities.

Prospective study on prevalence of esophageal chest pain in patients referred on an elective basis to a cardiac unit for suspected myocardial ischemia.

The prevalence of esophageal chest pain was studied prospectively in patients referred on an elective basis to a cardiac unit for suspected myocardial ischemia. A group of 248 consecutive patients without previously documented heart disease was admitted for elective diagnostic coronary angiography. The clinical history classified 185 patients as having anginal pain and the coronary angiogram was normal in 48 of them. In 37 of these 48 patients full esophageal testing was performed including 24-hr intraesophageal pH and pressure recordings with indication of chest pain episodes as well as a number of esophageal provocation tests, ie, acid perfusion, edrophonium stimulation, balloon distension, and ergonovine stimulation, all performed under continuous esophageal manometric and electrocardiographic monitoring. In 19 of these 37 patients, the familiar chest pain could be reproduced by esophageal provocative testing without ischemic ST-T segment alterations; six of these 19 patients had also a positive 24-hr pH and pressure recording. These data strongly suggest an esophageal origin of chest pain in half the patients with typical angina and a normal coronary angiogram.

Detection of colorectal cancer by routine ultrasound.

In 95 consecutive patients with proven colonic carcinoma, the tumor was detected by routine sonography in only half of the patients. However, in 22 out of 23 tumors of the right colon, a correct diagnosis was suggested by sonography (sensitivity 95.5%). Although not suitable as a first choice screening procedure for colorectal cancer, routine abdominal ultrasound can detect even non-suspected colonic tumors, especially in the ascending colon. Since the specificity of ultrasound is probably low, diagnosis must be confirmed by X-ray and/or endoscopy.

Ambulatory 24 hour intraoesophageal pH and pressure recordings v provocation tests in the diagnosis of chest pain of oesophageal origin.

Fifty patients with non-cardiac chest pain underwent 24 hour intraoesophageal pH and pressure recording and provocation tests to determine the relative value of both techniques in establishing the oesophageal origin of the chest pain. Twenty six patients (52%) had at least one positive provocation test: the acid perfusion test was positive related in 18 patients (36%), the edrophonium test in 16 patients (32%), the vasopressin test in five patients (10%), and the balloon distension test (performed in only 20 patients) in one (5%). The 24 hour pH and pressure recording correlated spontaneous chest pain attacks with abnormal motility or gastro-oesophageal reflux in 19 patients (38%). Fourteen of these patients also had at least one positive provocation test. Therefore, 24 hour pH and pressure recordings are only slightly better than a set of provocation tests in identifying the oesophagus as the cause of chest pain (10% diagnostic gain). In the case of oesophageal chest pain, however, 24 hour recording appeared to be the only way to identify the nature of the underlying oesophageal abnormality that caused the spontaneous pain attacks--for example, gastro-oesophageal reflux, motility disorders, or irritability of the oesophagus.