Safety and efficacy of endoscopic balloon dilation for treatment of Crohn's disease strictures.

BACKGROUND AND STUDY AIMS: Strictures are a substantial cause of morbidity in patients with Crohn's disease. Endoscopic balloon dilation is a therapeutic option in limited strictures to avoid intestinal surgery, although there have been few reports regarding the long-term outcome. PATIENTS AND METHODS: Balloon dilation was scheduled for 46 patients (26 women, 20 men; median age 34) with Crohn's-associated symptomatic and radiographically confirmed intestinal stenosis. The study plan envisaged up to four consecutive treatments within the first 2 months until relief of symptoms, and thereafter dilations depending on clinical requirements. RESULTS: Dilation was not possible in seven of the 46 patients (15 %), due to technical problems (n = 2), internal fistulas (n = 3), or absence of a stenosis (n = 2). Thirty-nine patients received at least one treatment. The site of obstruction was the ileocolonic anastomosis in 23 of the 39 patients (59 %) and surgically untreated areas in 16 patients (41 %). After the initial dilation series (median 1, interquartile range 1-2), strictures were traversed in 37 of the 39 patients (95 %). During a median follow-up period of 21 months (range 3-98 months), 24 of the 39 patients (62 %) underwent a repeat intervention, including 12 (31 %) with repeat dilation, 11 (28 %) with surgical resection, and one patient who received an intestinal stent. The cumulative percentages of patients without a repeat intervention or surgery at 6, 12, 24, and 36 months were 68 %, 48 %, 36 %, and 31 %, and 97 %, 91 %, 84 % and 75 %, respectively. Two perforations and one case of severe bleeding were seen in the 73 dilation procedures (4 %) performed. CONCLUSIONS: Endoscopic balloon dilation is a safe and effective method that allows surgery to be avoided in approximately 75 % of patients with Crohn's-associated short intestinal strictures. However, recurrent symptoms frequently make it necessary to repeat the procedure.

Liver penetration by a duodenal ulcer in a young woman.

Liver penetration is a rare but serious complication of peptic ulcer disease. We report a case of a 33-year-old woman who took large doses of nonsteroidal antiinflammatory drugs and developed a giant duodenal ulcer that penetrated into her liver. The diagnosis was based on histologic examination of endoscopic biopsies. She was initially treated with a proton pump inhibitor, but, within 5 weeks, she developed a symptomatic postbulbar stricture that required surgical correction. We also review 11 other reported cases of endoscopically and histologically diagnosed peptic ulcer penetration into the liver.

Rectal sequelae after conformal radiotherapy of prostate cancer: dose-volume histograms as predictive factors.

PURPOSE: To identify clinically relevant parameters predictive of late rectal bleeding derived from cumulative dose-volume histograms (DVHs) of the rectum after conformal radiotherapy of prostate cancer. MATERIALS AND METHODS: One hundred and nine patients treated with 3D conformal radiotherapy between 1/1994 and 1/1996 for localized prostate cancer (clinical stage T1-T3) were available for analysis. All patients received a total dose of 66 Gy/2 Gy per fraction (specified at the International Commission on Radiation Units and Measurements ICRU reference point). DVHs of the contoured rectum were analyzed by defining the absolute (aV) and relative (rV) rectum volume that received more than 30% (V30), 50% (V50), 70% (V70), 80% (V80), 90% (V90) and 100% (V100) of the prescribed dose. Additionally, a new aspect of DVH analysis was investigated by calculation of the area under the DVH-curve between several dose levels (area under the curve (AUC)-DVH). DVH-variables were correlated with radiation side effects evaluated in 3-6 months intervals and graded according to the EORTC/RTOG score. The median follow-up was 30 months (12-60 months). RESULTS: Univariate and multivariate stepwise Cox-Regression analysis including age, PTV, rectum size, rV100, rV90, rV80, rV70, rV50 rV30 and aV30 to aV100 were calculated. Late rectal bleeding (EORTC/RTOG grade 2) was significantly correlated with the percentage of rectum volume receiving > or = 90% of the prescribed dose (rV90) (P = 0.007) and inversely correlated in a significant way with the size of contoured rectum (P = 0.006) in multivariate analysis. In our series, a proportion of the rectum volume > or = 57% were included in the 90%-isodose (rV90 > or = 57%) in one half of the patients, with an actuarial incidence of 31% of late rectal bleeding at 3 years. In the other half of the patients, when rV90 < 57%, the 3-year actuarial incidence was 11% (P < 0.03). CONCLUSION: Our data demonstrate a dose-volume relationship at the reference dose of 60 Gy ( approximately 90% of the prescribed dose) with respect to late rectal toxicity. The rV90 seems to be the most useful and easily obtained parameter when comparing treatment plans to evaluate the risk of rectal morbidity.

Advanced distal colonic lesions as predictors of advanced lesions in the proximal colon.

The characteristics of adenomas found during sigmoidoscopy have been suggested to predict synchronous adenomas in the proximal colon. Our aim was to examine whether the presence and characteristics of distal colonic lesions are associated with the presence and characteristics of lesions in the proximal colon. We performed a university hospital based case-control study with 3,268 consecutive subjects who received colonoscopy between January 1992 and December 1995. Subjects who had a history of colonic polyps, inflammatory bowel disease, intestinal resection, or had a contraindication against biopsies were excluded. Number size, and histologic characteristics of polyps in the distal and proximal colon were recorded. Advanced lesions were defined as neoplastic lesions with 1 or more of the following features: 1) > or = 1 cm diameter, and/or 2) villous histology, and/or 3) severe dysplasia or carcinoma, and/or 4) > or = 3 lesions. We found that 439 patients had neoplastic lesions in the distal colon only (61.3% with advanced lesions), 198 patients had lesions in the proximal colon only (55.1% advanced), and 197 had lesions in both the distal colon (74.6% advanced) and the proximal colon (55.8% advanced). Distal lesions were significantly more often advanced in patients with synchronous proximal lesions compared with patients with lesions in the distal colon only (odds ratio: 1.9; 95% confidence interval [CI]: 1.3-2.8; p < 0.001). The odds ratios for finding any neoplastic lesion in the proximal colon and an advanced proximal lesion, respectively, were 3.7 (2.6-5.3) (p < 0.001) and 2.2 (1.3-3.7) (p < 0.01) when a nonadvanced lesion was found in the distal colon, and 6.8 (5.3-8.7) (p < 0.001) and 6.7 (4.9-9.0) (p < 0.001) when an advanced lesion was found in the distal colon. Logistic regression analysis revealed number of distal polyps and villous histology as independent predictors of advanced lesions in the proximal colon; size and severe dysplasia were not independent predictors. In conclusion, characteristics of neoplastic lesions in the distal colon predict the presence and characteristics of lesions in the proximal colon.

Endoscopic scoring of late rectal mucosal damage after conformal radiotherapy for prostatic carcinoma.

PURPOSE: To describe rectal mucosal damage in an endoscopic study after conformal radiotherapy of prostate cancer and to correlate this with clinical outcome. MATERIALS AND METHODS: Flexible rectosigmoidoscopy was performed on 44 patients who voluntarily accepted the examination. The median follow-up was 29 months (20-41 months) after 3-D-planned conformal radiotherapy of prostate cancer (66 Gy at the ICRU Reference point, 2 Gy per fraction). To enable a systematic topographic description of endoscopic findings the rectum was divided into four sections. Additionally we differentiated between anterior, posterior, right and left lateral rectal wall. Due to the lack of an existing valid graduation system for radiation induced proctitis, we introduced a six-scaled rectoscopy score for describing and reporting endoscopic findings based on the standardization of the endoscopic terminology published by the ESGE (European Society for Gastrointestinal Endoscopy). Endoscopic findings were compared to the EORTC/RTOG morbidity score. In addition, since 3-D dose distribution of organs at risks was available, a correlation could be made between the location of the rectal lesions and the absorbed dose at that level. RESULTS: In general, endoscopic findings increased from the proximal rectum to the anorectal transition, as well as from the posterior to the anterior rectum wall. Telangiectasia grade 1 and 2 were observed at the whole circumference, only telangiectasia grade 3 were limited to the high dose region at the anterior rectum wall. Similar results were found for congested mucosa (reddening and edematous mucosa). Correlation with symptoms, 7/9 patients who suffered from intermittent rectal bleeding (EORTC/RTOG grade 2) had multiple telangiectasia grade 2-3 and/or congested mucosa grade 3 and microulcerations. However, the same extent of mucosal damage (rectoscopy score 2-3) was found in seven out of 35 patients who have never developed a period of macroscopic rectal bleeding. CONCLUSION: Rectoscopy offers the possibility of detecting signs of tissue dysfunction below the level of subjective symptoms. Systematic analytic examinations such as rectoscopy, in addition to clinical examinations, as already foreseen in the LENT-SOMA-score, will be necessary due to the fact that even telangiectatic lesions have been observed for asymptomatic patients. For the opportunity of sharing and comparing data collected from endoscopy after radiotherapy a graduation system as proposed based on a standardisation of the endoscopic terminology will be necessary.

Histological findings after routine biopsy at the gastro-oesophageal junction.

OBJECTIVE: Endoscopy with biopsy is an important diagnostic procedure in patients with gastro-oesophageal reflux disease. However, it is still unclear whether histological findings such as intestinal metaplasia, squamous epithelial hyperplasia, and carditis should have an impact on patient management, and whether routine biopsies at the gastro-oesophageal junction should be taken. DESIGN: Patients undergoing routine gastroscopy for various indications were biopsied twice just below, directly at, and right above the gastro-oesophageal junction. METHODS: Clinical symptoms, endoscopic oesophagitis, and histopathologies such as carditis, reflux disease, and intestinal metaplasia were determined and graded. RESULTS: Epithelial hyperplasia suggestive of reflux disease (63%), chronic carditis (94%), active carditis (40%), foveolar hyperplasia (75%), and intestinal metaplasia (14%) were frequently observed. For patients with a normal appearing Z-line, there was a weak correlation of intestinal metaplasia at the cardia with intestinal metaplasia in the stomach (Spearman's R = 0.2, P = 0.008), but no correlation with either chronic or active carditis, or with epithelial hyperplasia in the oesophagus. There was no correlation between H. pylori status or symptoms of reflux disease with epithelial hyperplasia. The severity of chronic and active carditis was closely correlated with H. pylori status (R = 0.37, P < 0.00001). The median time for gastroscopy in 30 control patients was 4.6 min, while endoscopy with additional biopsies at the gastro-oesophageal junction took a median of 8 min (U-test, P < 0.00001). CONCLUSIONS: Intestinal metaplasia at the gastro-oesophageal junction was encountered too frequently to warrant regular follow-up in a surveillance programme. Correlation of epithelial hyperplasia with symptoms of reflux disease is poor. We propose that routine biopsy at the gastro-oesophageal junction is not warranted until an impact on patient management can be demonstrated.

Successful symptomatic management of a patient with Ménétrier's disease with long-term antibiotic treatment.

We present the case of a 79-year-old female patient with criteria typical for Ménétrier's disease, i.e. enlargement of the gastric folds due to foveolar hyperplasia associated with severe protein-loss along with epigastric pain, nausea, vomiting and weight loss. Gastrin levels were within the normal range, but elevated Helicobacter pylori antibody titers (83 microg/ml) were indicative of a recent infection. Histologic examination of a gastric polyp, which was removed in toto, revealed the presence of early gastric cancer of the mucosal type. After initiation of antibiotic treatment with clarithromycin (3 x 250 mg/day) and metronidazole (2 x 500 mg/day) in combination with lansoprazole (30 mg/day), the patient's condition improved rapidly along with abrogation of protein loss. Under maintenance treatment as indicated above, the patient has been free of symptoms now for a period of more than 2 years. On repetitive endoscopic follow-up, there was no change in gastric mucosa morphology either endoscopically or histologically, and also no evidence of recurrence of a malignant lesion. We conclude that this therapeutic regimen represented an effective alternative to surgical intervention in this patient and should be considered in similar cases.

Transient and long-term feeding by means of percutaneous endoscopic gastrostomy in neurological rehabilitation.

In 28 patients of a neurological rehabilitation unit of a hospital the use of enteral nutrition via percutaneous endoscopic gastrostomy (PEG) tubes was reviewed. During a total observation period of 5,172 days no life-threatening complications occurred. Minor complications were observed in 12 patients (43%) in the first 2 weeks after the insertion and in 5 patients (18%) afterwards. The nutritional status stabilized in all subjects. Transient PEG feeding was performed in 11 patients (39%) with a mean duration of 150 days. We conclude that hesitation in the application of PEG feeding in neurological rehabilitation should be abandoned. The timing and monitoring of PEG feeding in patients undergoing neurological rehabilitation for acute remitting neurological disorders is discussed.

Conflicting results of ileoscopy and small bowel double-contrast barium examination in patients with Crohn's disease.

BACKGROUND AND STUDY AIMS: Ileoscopy has become a routine procedure for the diagnosis of Crohn's disease of the terminal ileum. The aim of this study was to compare the diagnostic accuracy of small bowel barium examination with that of ileoscopy. PATIENTS AND METHODS: In a retrospective study the two methods were compared in 55 patients with Crohn's disease. First, routine radiology reports and second, reevaluation of the small bowel barium study by gastrointestinal radiologists with scoring of examination quality were compared with the results of ileoscopy. RESULTS: Using routine radiology reports, 66% sensitivity and 82% specificity were reached for inflammatory changes of the terminal ileum by small bowel barium study. Sensitivity and specificity increased to 68% and 91% with double reading by experienced radiologists. Disagreement between endoscopic and radiologic results changed from 31% to 27% and were mainly because of false-negative barium studies. Sensitivity and specificity of barium studies were influenced by the quality of the examination with a sensitivity of 91% and specificity of 100% when the quality was good. CONCLUSIONS: In patients in whom the terminal ileum is successfully intubated, ileoscopy is superior to barium examination in the evaluation of Crohn's disease of the terminal ileum. Results of the barium study were strongly influenced by the quality of the examination.

Gastroduodenal permeability in Crohn's disease.

BACKGROUND: Gastric permeability was prospectively investigated by determination of sucrose excretion in 100 patients with Crohn's disease. Results were compared with histological findings and the lactulose-mannitol ratio as a measure of intestinal permeability. METHODS: All subjects underwent oesophagogastroduodenoscopy with biopsies of all investigated parts. Thirty-two Helicobacter pylori-positive patients were excluded from further analyses. RESULTS: Gastroduodenal permeability was significantly higher in patients with Crohn's disease than in control subjects (P < 0.00001). Sucrose excretion alone did not predict microscopic inflammation of the upper gastrointestinal tract. Increased gastroduodenal permeability with a concomitant rise in intestinal permeability predicted histological upper gastrointestinal involvement of Crohn's disease with a likelihood of 86%. The negative predictive value was 43%. CONCLUSION: In parallel with findings in the small intestine, gastroduodenal permeability is increased in a high proportion of patients with Crohn's disease. In patients with an increased lactulose-mannitol ratio, elevated sucrose excretion is highly predictive of histological gastroduodenal involvement.

Establishment of primary cultures from human colonic tissue during tumor progression: vitamin-D responses and vitamin-D-receptor expression.

Primary cultures derived from pre-cancerous and cancerous human colon tissue are essential for understanding normal and abnormal growth function in the large intestine. Here presented are (i) the methodology for routine establishment of primary cultures of normal, adenoma- and carcinoma-derived cells, and (ii) data for the apparently protective role of vitamin-D compounds in colon carcinogenesis. The steroid hormone 1,25-dihydroxyvitamin D3 and some non-hypercalcemic analogs reduce the high mitotic rate of adenoma cells to that of normal colonocytes. After vitamin-D treatment, tumor cells are less proliferative and differentiation is enhanced. Primary-colon-cancer cultures display a mosaic pattern of vitamin-D-receptor expression, at the mRNA level and at the protein level, with varying intensity of expression in positive cells. This suggests that, in human colorectal tumors in vivo, a large fraction of cells will respond to genomic action of vitamin-D compounds.

The relationship between juxtapapillary duodenal diverticula and biliary stone disease.

OBJECTIVE: To assess the relationship between juxtapapillary duodenal diverticula (JDD) and common bile duct stones and biliary stone disease in general. DESIGN: A retrospective study. METHODS: We analysed 1115 patients who underwent consecutive endoscopic retrograde cholangiopancreatography examinations. The patients were subdivided into three groups: the first group (group I; n = 482) had no biliary stone disease, the second one (group II; n = 329) had common bile duct stones, and the third group (group III; n = 304) had biliary stone disease of the gallbladder but without evidence of common bile duct stones. Additionally, the patients were subdivided into age groups of < 50, 50-59, 60-69, 70-79, and > or = 80 years of age. Logistic regression was applied for statistical analysis. RESULTS: Juxtapapillary duodenal diverticula were diagnosed in 111 (10.0%) patients. The incidence of JDD was 6.9% in group I, 14.3% in group II and 10.2% in group III. Age was the most dominant influence factor for JDD, common bile duct stones, and biliary stone disease (P < 0.0001). Sex was also a factor, female patients having a higher risk for common bile duct stones (P = 0.01) and biliary stone disease (P < 0.0001). After adjustment for age and sex, JDD was found to have a noticeable, but not statistically significant (P = 0.073), influence on common bile duct stones and no influence on biliary stone disease (P = 0.15). CONCLUSION: Our data support only moderately the existence of a relationship, which had been conjectured in a part of the literature, between JDD and common bile duct stones. No noticeable influence on biliary stone disease was found.

Focally enhanced gastritis: a frequent type of gastritis in patients with Crohn's disease.

BACKGROUND & AIMS: Gastric histology is not well studied in patients with Crohn's disease. The aim of this study was to analyze the histological appearance of gastric mucosa in patients with Crohn's disease. METHODS: In a prospective study, biopsy specimens taken from the antrum and body of 75 patients with known Crohn's disease of the large and/or small bowel and 200 Crohn's disease-free controls were evaluated by histology and immunohistochemistry. RESULTS: Helicobacter pylori-associated gastritis was found in 25 patients with Crohn's disease (33.3%) and 78 controls (39%). In H. pylori-negative patients with Crohn's disease, a characteristic type of gastritis was found in antral biopsy specimens of 36 patients (48%) and in body biopsy specimens of 18 patients (24%). It was characterized by a focal infiltration of CD3+ lymphocytes, CD68R+ histiocytes, and, in 80% of cases, of granulocytes. Granulomas were found in 11 patients. Overall, granulomas and/or focally enhanced gastritis were observed in 76% of H. pylori-negative patients with Crohn's disease and in 0.8% of controls. There were no correlations between the occurrence of focally enhanced gastritis and clinical and laboratory findings. CONCLUSIONS: Focally enhanced gastritis is common in Crohn's disease. Its recognition should guide the clinician into further investigations in patients not yet known to have Crohn's disease.

Gastric mucormycosis due to Rhizopus oryzae in a renal transplant recipient.

Gastric mucormycosis is a rare disease with a reported fatal outcome of 98%. Manifestations range from colonization of peptic ulcers to infiltrative disease with vascular invasion and dissemination. In our renal transplant patient a deep gastric ulceration infected with Rhizopus oryzae (class Zygomycetes), which is known to be an agent of mucormycosis, was diagnosed in the early posttransplant period after antirejection therapy. The infection was successfully managed with amphotericin B and omeprazole.

Minimal chronic inactive gastritis: indicator of pre-existing helicobacter pylori gastritis?

Minimal chronic inactive gastritis is regularly observed in routine histopathology. Presently, it is not clear whether this type of gastritis should be regarded as a histopathological entity or a normal variant. The similarity to lesions observed after H.pylori eradication prompted us to look for an association between minimal chronic inactive gastritis and status post H.pylori eradication. In a prospective study of 110 consecutive patients undergoing upper gastrointestinal endoscopy, at least two mucosal biopsies were taken from the gastric antrum and body. Gastritis was classified according to the Sydney System. Antibodies to H.pylori were determined serologically by immunofluorescence test, ELISA, and complement binding reaction. A status post eradication of H.pylori was revealed by medical history and/or positive serology; H.pylori gastritis was found in 39.1%, reactive gastritis in 12.7%, and minimal chronic inactive gastritis in 29.1%. In 19.1% a combination of reactive/ minimal chronic gastritis was diagnosed according to morphology. Status post eradication was observed significantly more often in cases with minimal chronic inactive gastritis (43.8%) than in cases with reactive gastritis (7.1%, p < 0.004). Furthermore, positive ELISA and/or status after eradication was found in 50% of the cases with minimal chronic inactive gastritis (p < 0.005 vs reactive gastritis), in 42.9% of the cases with mixed reactive/chronic inactive gastritis (p < 0.03 vs reactive gastritis), and in 7.1% of the cases with reactive gastritis. Lymphoid aggregates, considered another sign of former H.pylori presence, were found significantly more often in minimal chronic inactive gastritis than in reactive gastritis (50% versus 7.1%, p < 0.005). Minimal chronic inactive gastritis is significantly associated with both positive H.pylori serology and status post eradication and is, therefore, an indicator of pre-existing H.pylori gastritis.

Vitamin D receptor and cytokeratin expression may be progression indicators in human colon cancer.

Epidemiological data suggest the protective role of vitamin D against the development of colorectal carcinoma in man. This could be due to the anti-mitogenic effect of the steroid hormone on human colon carcinoma cells which is mediated by a specific nuclear vitamin D receptor (VDR). Western blot analysis showed that VDR expression increases during the transition from normal mucosa to polyps and later to pT3 tumors. In later stages, however, VDR is dramatically reduced. Cytokeratin 20, which was monitored as a differentiation marker, decreases in parallel with advancing proliferation and disappears from "normal" mucosa adjacent to later stage carcinoma. Interestingly, VDR density was conspicuously higher in all tumors tested when compared to adjacent "normal" tissue. This suggest that, up to a certain degree of dedifferentiation, malignant colonocytes can upregulate the VDR, probably as a counteractive measure in response to tumor cell growth, but that this ability is finally lost in highly undifferentiated carcinoma cells.

Three-dimensional spiral CT cholangiography in patients with suspected obstructive biliary disease: comparison with endoscopic retrograde cholangiography.

PURPOSE: To evaluate the diagnostic potential of spiral computed tomography (CT) performed after the administration of cholangiographic contrast material (spiral CT cholangiography) in patients with suspected obstructive biliary disease. MATERIALS AND METHODS: After infusion of meglumine iodoxamate, 29 patients underwent upper abdominal spiral CT with subsequent three-dimensional rendering of the biliary tract. In 27 patients, the presence, site, and extent of biliary obstruction were compared with that at endoscopic retrograde cholangiography (ERC). RESULTS: Spiral CT cholangiography correctly depicted biliary obstruction in 14 of 27 patients, with no false-positive or false-negative cases. In one patient, the precise length of a common bile duct stenosis could not be assessed with spiral CT cholangiography. ERC demonstrated intrahepatic ductal stenoses more clearly in two patients. In two patients with hilar cholangiocarcinomas, spiral CT cholangiography depicted undrained areas not seen with ERC. CONCLUSION: Spiral CT cholangiography allows accurate assessment of the biliary system in patients with suspected obstructive biliary disease.

Dental and periodontal disease in patients with cirrhosis--role of etiology of liver disease.

BACKGROUND/AIMS: Bacterial infections are frequent complications in patients with cirrhosis, especially in alcoholics. A potential source of infection may be dental foci. The aim of the study was to assess the role of cirrhosis and chronic alcoholism in the development of dental or periodontal disease. METHODS: Dental and periodontal examinations were performed prospectively in 97 patients with cirrhosis (alcoholic: 64, nonalcoholic: 33), in 68 alcoholics without cirrhosis and in 71 healthy subjects (subdivided into age groups: 21-30, 31-40, 41-50, and 51-60 years). RESULTS: Measures of oral hygiene (p < 0.01), dental care (p < 0.001), and periodontal parameters were worse and the number of teeth requiring treatment (p < 0.001) was higher in alcoholics with or without cirrhosis than in healthy subjects and nonalcoholic patients with cirrhosis. Alcoholics had a lower total number of teeth than patients without alcohol abuse and healthy controls (p < 0.05). The dental and periodontal status of patients with nonalcoholic cirrhosis did not differ from the control group. The severity and duration of liver disease had no influence on dental and peridontal disease. CONCLUSION: The presence of cirrhosis itself, therefore, is not a predisposing factor for dental and periodontal diseases. In alcoholics, these diseases appear to be caused primarily by bad oral hygiene and poor dental care.