Diffuse Esophageal Narrowing in Eosinophilic Esophagitis: A Barium Contrast Study.

BACKGROUND: Patients with eosinophilic esophagitis (EoE) present with mechanical type dysphagia. Barium esophagrams occasionally demonstrate focal strictures or multiple concentric rings. Diffuse narrowing has also been reported but may be difficult to recognize because of lack of normative data. AIM: The aim of this study is to assess esophageal diameters at multiple sites in healthy controls in comparison with EoE patients. METHODS: A standardized barium swallow was performed in 22 healthy male volunteers without esophageal symptoms and compared with 10 untreated EoE patients. A radiopaque ruler attached at the subject's back was used to measure maximal esophageal diameter at three esophageal sites by a blinded observer. Peak intraepithelial eosinophil counts and Mayo Dysphagia Questionnaire scores were correlated to esophageal diameters in EoE patients. RESULTS: Two of 10 EoE patients had areas of focal narrowing on barium Xray. Esophageal diameters were significantly less at all three esophageal sites in EoE patients compared with controls. Using a total esophageal diameter score (i.e., sum of the three diameters) to establish the 95th percentile for minimal diameter in controls, four of 10 EoE patients fell below the normal range. There was no significant correlation between esophageal diameters, peak eosinophil counts and any of the Mayo Dysphagia Questionnaire severity scores. CONCLUSION: Patients with EoE have a diffusely narrow esophagus in comparison to healthy controls, and this abnormality may not be appreciated without using appropriate normative data.

Multiple squamous hyperplastic-fibrous inflammatory polyps of the oesophagus: a new feature of eosinophilic oesophagitis?

This report describes the unusual case of a 12-year-old boy with multiple polyps in the oesophagus and concurrent eosinophilic oesophagitis (EoE). Polyps were of a fibrous-inflammatory composition featuring eosinophils, mast cells, hyperplastic epithelium and fibrosis, which are all features described with EoE. EoE is an increasingly recognised clinicopathological disorder characterised by large numbers of eosinophils infiltrating the oesophageal mucosa. Polyps in the oesophagus are rare, have not previously been associated with EoE, and may represent a new feature of the disease.

Liver biopsies for chronic hepatitis C: should nonultrasound-guided biopsies be abandoned?

BACKGROUND/OBJECTIVE: Liver biopsy has been the gold standard for grading and staging chronic hepatitis C virus (HCV)- mediated liver injury. Traditionally, this has been performed by trained practitioners using a nonimage-guided percutaneous technique at the bedside. Recent literature suggests an expanding role for radiologists in obtaining biopsies using an ultrasound (US)-guided technique. The present study was undertaken study to determine if the two techniques produced liver biopsy specimens of similar quality and hypothesized that at our institution, non-US-guided percutaneous liver biopsies for HCV would be of higher quality than US-guided specimens. METHODS: Liver biopsies from 100 patients with chronic HCV infection (50 consecutive US-guided and 50 consecutive non-US-guided), were retrospectively identified using a hospital histopathology database. All original biopsy slides were coded and prospectively reanalyzed by a single hepatopathologist who was blinded to the technique used in obtaining the biopsy. Additionally, all liver biopsies for chronic HCV infection completed at the centre from 1998 to 2007 were identified and the technique used was recorded. Biopsy quality was determined primarily by the number of complete portal tracts (CPTs) identifiable in the slides. The total length of specimen and the degree of fragmentation were secondary outcome measures. RESULTS: There was a slight difference observed between the US-guided and non-US-guided groups in mean age (46.3 years versus 42.5 years, respectively; P=0.018) but no differences in sex, presence of cirrhosis, bilirubin, creatinine, international normalized ratio, and grade or stage of disease. Biopsies obtained using the US-guided technique produced higher quality specimens than the non-US-guided technique based on our primary outcome of number of CPTs in the biopsy (11.8 versus 7.4; P<0.001). US-guided specimens also were longer (24.4 mm versus 19.7 mm; P=0.001), had less fragmentation (P=0.016), and a higher overall histopathological quality assessment (P=0.026) than the non-US-guided biopsies. However, there was no significant difference between the two groups in the ability to grade and stage the disease (96% US-guided versus 90% in non-US-guided (P=0.20). Over a 10-year period, 763 biopsies for chronic HCV infection were identified with an obvious trend toward the increased use of US-guided technique observed at 2% in 1998 to 85% in 2007. CONCLUSIONS: US-guided liver biopsies for chronic HCV are the most common method of obtaining specimens at the Kingston General Hospital, Kingston, Ontario, and are of higher quality than non-US-guided specimens. However, there is no significant difference in the two techniques in the ability to grade and stage chronic HCV.

FGF9-induced proliferative response to eosinophilic inflammation in oesophagitis.

BACKGROUND: Oesophagitis is characterised by basal cell hyperplasia and activated eosinophils, which release mediators including major basic protein (MBP). MBP and its mimetic polyarginine activate the calcium sensing receptor (CaSR) on oesophageal epithelium. Fibroblast growth factor 9 (FGF9) is implicated in epithelial homeostasis and proliferative response to injury, but has not been characterised in the oesophagus. OBJECTIVE: To characterise FGF9 in oesophageal epithelium and oesophagitis, as the result of MBP activation of the CaSR. METHODS: Human oesophageal epithelial cells (HET-1A) were used to compare affects of calcium, polyarginine and MBP-peptide on FGF9. HET-1A were transfected with interfering RNA (siRNA(CaSR)). FGF9, FGF receptors 2 and 3, bone morphogenetic protein (BMP)-2, BMP-4 and noggin mRNA expression were detected by reverse transcriptase polymerase chain reaction. FGF9 was measured from HET-1A and from normal, gastro-oesophageal reflux and eosinophilic oesophagitis (EoE) patient biopsies using ELISA and immunohistochemistry. HET-1A proliferation was studied using bromodeoxyuridine and MTT. RESULTS: FGF9 was secreted by HET-1A cells treated with polyarginine and MBP-peptide, but not calcium. This effect was abrogated by siRNA(CaSR). FGF9 receptor mRNA was present. HET-1A cells proliferated following rhFGF9, but not MBP-peptide treatment, and rhFGF9 altered transcription of downstream proliferation-related genes (noggin, BMP-2 and BMP-4). FGF9 was increased in biopsies from patients with eosinophilic oesophagitis, which correlated with basal hyperplasia. CONCLUSION: Eosinophil-released MBP acts on the CaSR to increase FGF9 in oesophageal epithelial cells, leading to proliferation. Increased FGF9 is found in biopsies of EoE patients and may play a role in the pathogenesis of oesophagitis.

Fatal hemorrhage from a gastroaortic fistula secondary to gastric ulceration associated with Nissen fundoplication and nonsteroidal anti-inflammatory drug use.

Acute gastrointestinal hemorrhage from a gastroaortic fistula in the gastric fundoplication pouch is a rare complication of Nissen fundoplication. The present case reports a gastroaortic fistula secondary to gastric ulceration associated with prior Nissen fundoplication and nonsteroidal anti-inflammatory drug use. A 55-year-old man presented with massive hematemesis and died of exsanguination during emergency laparotomy. Recognition of factors that predispose a patient to gastric ulceration after fundoplication, including nonsteroidal anti-inflammatory drug use, is critical to arouse the high index of suspicion required to diagnose and manage this life-threatening complication.

Ulcerative colitis of the appendix ('ulcerative appendicitis') mimicking acute appendicitis.

Appendiceal involvement in ulcerative colitis may occur in the setting of either diffuse or distal disease, and is usually diagnosed incidentally at the time of proctocolectomy. The present patient had a rare case of 'ulcerative appendicitis' occurring on a background of clinically quiescent ulcerative colitis, and presented with the signs and symptoms of acute appendicitis.

Histologic staging in malignant melanoma: cross-sectional area revisited.

BACKGROUND AND OBJECTIVES: Tumor thickness is considered the single most important predictor of survival in clinically localized malignant melanoma. A recent study found tumor volume a more sensitive predictor of survival than thickness. Volume measurement, however, is complicated, time consuming, and based on biologically imprecise mathematical models of tumor configuration. This report compares the prognostic power of cross-sectional area (CSA), a simpler measurement than volume, with tumor thickness. METHODS: Forty-five patients with clinically localized malignant melanoma and a minimum 5-year follow-up post excision with negative resection margins were retrospectively followed for disease recurrence or death. Digitalized histologic images of each tumor were made from the original pathology slides and stored on a compact disc. Maximum tumor thickness and CSA were calculated for each primary melanoma using an image analysis program and compared for predictive accuracy of 5-year survival. RESULTS: CSA was positively correlated with maximum tumor thickness (r = 0.76). Both measures had a similar predictive accuracy for survival. Patients with melanomas less than 8 mm2 had superior 5-year (94%) and disease-free survival rates (78%) compared to patients with melanomas exceeding 8 mm2 (5-year survival, 62%; 5-year disease-free survival, 23%). CONCLUSIONS: CSA is an easily calculated measurement that is as predictive for 5-year survival as is Breslow's thickness. Prospective assessment of CSA is warranted.

Primary adenocarcinoma in an enterocutaneous fistula associated with Crohn's disease.

Increasing numbers of intestinal adenocarcinomas in patients with Crohn's disease have been reported, but the strength of this association still needs to be elucidated. Adenocarcinoma has also been documented in different types of fistulous tracts associated with Crohn's disease. The first case of well-differentiated mucinous adenocarcinoma involving only enterocutaneous fistulae is reported in a patient with long-standing Crohn's disease complicated by persistent abdominal wall fistulous tracts. The malignant lesion arose from neoplastic transformation of columnar epithelium lining portions of the fistulae occurring as a result of either re-epithelialization of these inflammatory tracts or mural implantation of mucosal tissue secondary to prior ulceration. The patient has remained disease-free eight years after surgical resection of the tumour. Even though intestinal carcinoma is not as strongly associated with Crohn's disease as with ulcerative colitis, intestinal carcinoma should be considered in the setting of long-standing disease, previous intestinal exclusion surgeries and complications such as enterocutaneous or other types of fistulous tracts. The prognosis of such patients may be excellent with early diagnosis and treatment.

Fatal light aircraft accidents in Ontario: a five year study.

Fatal civil aviation crashes in Ontario from 1985 to 1989 were studied. Data regarding accident circumstances, injury patterns and medical factors (disease, alcohol/drugs) which could have contributed to accident causation was obtained from a review of the files of the Chief Coroner for Ontario in Toronto and the aviation occurrence reports of the Transportation Safety Board of Canada. Forty-seven crashes involving mainly general aviation type aircraft but also 2 gyroplanes, 2 ultralights and a glider were reviewed. About half occurred during the cruise phase of the flight. Seventy (40 pilots; 30 passengers) of the 98 occupants died. The bodies of 68 victims were recovered; 63 were dead at the scene and 5 survived up to ten hours after impact. Multiple trauma killed about half of all the victims (n = 34); 29% (n = 20) drowned; 16% (n = 11) and 3% (n = 2) died of head/neck injuries and coronary disease respectively. Neck trauma was observed mostly in pilots and was the most frequent major blunt trauma injury in drowning victims. Passengers sustained relatively more craniofacial fractures and abdominal/retroperitoneal trauma. Pilot error was the most frequent cause of crashes (55%; 26/47 impacts) followed by mechanical failure (15%; 7/47) and adverse weather/environmental conditions (11%; 5/47). Coronary artery disease incapacitated two pilots (4% of crashes) and ethanol intoxication was implicated in two other accidents. Other drugs did not appear to be a definite factor in accident causation.

Human orthotopic small intestine transplantation: radiologic assessment.

The authors describe the postoperative anatomy and review the radiologic examinations of five patients who underwent orthotopic small intestine or combined orthotopic liver and small intestine transplantation. Mucosal thickening of the transplanted intestine was demonstrated on the first postoperative contrast material-enhanced images and was due to submucosal edema. This resolved within 2 weeks in the long-term survivors. Bowel peristalsis appeared normal as early as 31 days after transplantation. Contrast-enhanced examinations of the intestine were useful to exclude surgical complications such as anastomotic leaks or strictures, but were insensitive for biopsy-proved cytomegalovirus enteritis or rejection.