Intraparietal esophageal leiomyomas diagnosed by endoscopic ultrasound-guided fine-needle aspiration cytology: Cytological and immunocytochemical features in two cases.

Endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) has proven to be of significant value as a diagnostic method for the evaluation of esophageal mesenchymal tumors, such as true leiomyomas. Utilizing the cell block procedure, the present study reports the diagnostic approach of EUS-FNAC in two patients affected by this lesion, describing the cytological and immunocytochemical findings. Spindle-shaped elements with elongated nuclei were appreciable; moreover, the cytoplasmatic immunohistochemical positivity for smooth muscle actin and desmin strongly supported the diagnosis of leiomyoma when also taking into account the constant negativity for CD34, CD117 and S100. The differential diagnosis between spindle cell mesenchymal tumors and leiomyomas, and the clinico-therapeutic management of the latter are also discussed in the study.

Gastrointestinal stromal tumours of the stomach: Cytological and immunocytochemical diagnostic features of two cases diagnosed by endoscopic ultrasound-guided fine needle aspiration.

The present study reports the diagnostic utility of endoscopic ultrasound-guided fine needle aspiration (EUS-FNAC) in two patients affected by gastrointestinal stromal tumours (GISTs) of the stomach. Clinically, the patients demonstrated skin pallor, melena, gastric discomfort and pain that had lasted three days or weeks. The cytological findings are discussed; these were strongly supported by immunocytochemical procedures that were performed on cell blocks and further confirmed following post-surgical histopathological examination. The crucial aim of GIST management is to determine a correct diagnosis in early-phase disease in order to realize an adequate curative surgical resection before the tumour becomes unresectable or metastatic. Moreover, a correct pre-surgical differential diagnosis of GISTs from other mesenchymal neoplasms may be easily made by EUS-FNAC, supported by cytological and immunocytochemical features.

Endoscopic resection as a safe and effective technique for treatment of pedunculated and non-pedunculated benign-appearing colorectal neoplasms measuring 40 mm or more in size.

AIM: The aim of this paper was to evaluate the outcome of endoscopic resection (ER) for pedunculated and non-pedunculated colorectal neoplasms exceeding 4 cm in size. METHODS: All patients with a colorectal neoplasms measuring 4 cm or more, who underwent ER at our institution between January 1996 and December 2008 were included in the study. RESULTS: In the study period, 67 ERs were carried out in 67 patients with a mean (±SD) age of 72±11 years. The mean neoplasms size was 48.2±12.5 mm. There were 32 sessile, 26 flat and 9 pedunculated neoplasms. The most frequent location (49.3%) was rectum. No perforation occurred, there were 4 procedural and 2 delayed bleeding, treated endoscopically, and 3 cases of transmural burn syndrome, managed conservatively. Pathologic examination showed 18 low-grade dysplasia, 43 high-grade dysplasia, 3 intramucosal and 3 invasive cancer. The most frequent type of neoplasm was villous adenoma (76.1%). The presence of malignancy was related to villous histology (P=0.005) and to age ≥ 80 of patients (P=0.04). RESULTS: During endoscopic follow-up (49.4± 26.3 months) recurrence was found in 25.8% of lesions (11 sessile and 4 flat), always treated endoscopically. Recurrence was more likely in patients with lesions larger than 60 mm (P=0.04). The three patients with invasive cancer did not undergo surgery, because of advanced age and/or severe extracolonic diseases. During follow-up no local recurrence or metastasis was found. CONCLUSION: ER is a safe and effective procedure for removing benign appearing very large colorectal neoplasms.

Endoscopic mucosal resection for large and giant sessile and flat colorectal polyps: a single-center experience with long-term follow-up.

BACKGROUND AND STUDY AIMS: This study examines efficacy, outcome, and complications of endoscopic mucosal resection (EMR) for large (> or = 20 mm) and giant (> or = 40 mm) sessile and flat colorectal polyps. PATIENTS AND METHODS: All EMRs carried out at our institution over a 9-year period, for large and giant sessile and flat colorectal polyps with an intensive and regular follow-up were evaluated. The rate of en bloc and piecemeal resection, complications, and recurrence were analyzed. RESULTS: A total of 148 polyps were resected in 148 patients. There were 113 large polyps (76.3 %) with a mean size of 25 +/- 4.7 mm (range 20 - 39 mm) and 35 giant polyps (23.7 %) with a mean size of 48.8 +/- 12.5 mm (range 40 - 100 mm). The most frequent location was the rectum, occurring in 43.2 %. All lesions were removed in a single session. En bloc resection was performed in 65 cases (43.9 %) and piecemeal in 83 (56.1 %). Procedural bleeding occurred in 13 EMRs (8.8 %), and one case of early and one case of delayed bleeding also occurred. There were two cases of postpolypectomy syndrome and one case of perforation. Malignancy (intramucosal and invasive cancer) was mostly present in polyps with sessile shape ( P = 0.0013). Follow-up colonoscopy was performed in 142 patients for a mean of 29.8 months. Recurrence was observed in 6/142 (4.2 %) patients and was found more in patients with giant polyps ( P = 0.014). CONCLUSIONS: In our experience EMR is a simple and safe procedure for removing large and giant sessile and flat colorectal polyps, and is associated with a very low risk of complication and local recurrence.

Optical coherence tomography in inflammatory bowel disease: prospective evaluation of 35 patients.

PURPOSE: Optical coherence tomography is a technique using infrared light in tissues of the gastrointestinal tract and human colon affected by inflammatory diseases. We evaluated whether there are specific patterns of optical coherence tomography for inflammatory bowel disease and compared the technique performance to the histology. METHODS: Optical coherence tomography was performed in 35 patients (18 men; 31 ulcerative colitis, 4 Crohn's disease). The images were obtained from affected and normal colon at endoscopy. Two biopsies of the sites visualized were taken. Two endoscopists scored the images, and two pathologists, blind to the endoscopy and optical coherence tomography, performed the histologic evaluation. RESULTS: Three optical coherence tomography patterns were identified: 1) mucosal backscattering alteration, 2) delimited dark areas, and 3) layered colonic wall. Compared with the histology, mucosal backscattering alteration was the most effective in recognizing the disease in patients (P = 0.007 in colon segments affected, and P < 0.001 in normal segments). The sensitivity and specificity have been 100 and 78 percent, respectively. CONCLUSIONS: The in vivo optical coherence tomography correctly detected inflammatory bowel disease features in affected and apparently normal colon, and allowed to discriminate patterns for active ulcerative colitis and Crohn's disease.

Gastro-intestinal permeability is increased in patients with limited systemic sclerosis.

OBJECTIVE: to evaluate gastro-intestinal (GI) permeability in patients with limited systemic sclerosis (LSS) at baseline and after oral acetylsalicylic acid (ASA). METHODS: 13 patients with LSS and 10 controls were studied. Baseline GI permeability was assessed with orally administered sucrose, mannitol, and lactulose. Gastric lesions and Helicobacter status were investigated by endoscopy. In 5 patients and 6 controls (with normal baseline permeability) the GI permeability response was assessed after oral ASA. RESULTS: compared with controls, gastric (p<0.05) and intestinal (p<0.02) permeability was higher in LSS patients, at baseline. After oral ASA gastric permeability (sucrose) increased in both groups (controls: 186%, LSS: 265%), whereas the lactulose/mannitol ratio raised significantly only in LSS (+31% and +148%; p<0.05 vs controls). CONCLUSIONS: baseline permeability is altered in LSS; the exaggerated response of the small intestine to ASA may represent a genetically determined or a disease-related dysfunction of the mucosal barrier.

Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection?

Our aims were to develop a noninvasive predictive tool to identify cirrhotic patients with esophageal varices and to evaluate whether portal Doppler ultrasonographic parameters may improve the value of other predictors. One hundred forty-three consecutive compensated cirrhotic patients underwent upper gastrointestinal endoscopy. Fourteen clinical, biochemical, ultrasonographic, and Doppler ultrasonographic parameters of each patient were also recorded. Esophageal varices were detected in 63 of the 143 patients examined (44%; 95% confidence interval [CI] 36.2-52.6). Medium and large esophageal varices were observed in 28 subjects (44%; 95% CI 31.4-58.4). Using stepwise logistic regression, presence of esophageal varices was independently predicted by prothrombin activity less than 70% (odds ratio [OR]: 5.83; 95% CI: 2.6-12.8), ultrasonographic portal vein diameter greater than 13 mm (OR: 2.92; 95% CI: 1.3-6.4), and platelet count less than 100 x 10(9)/L (OR: 2.83; 95% CI: 1.27-6.28). Variables included in the model were used to generate a simple incremental rule to evaluate each individual patient. The discriminating ability of the prediction rule was relevant (area under the curve: 0.80) and did not change by replacing ultrasonographic portal vein diameter with congestion index of portal vein. We concluded that compensated cirrhotic patients should be screened by upper gastrointestinal endoscopy when prothrombin activity less than 70%, platelet count less than 100 x 10(9)/L, and ultrasonographic portal vein diameter greater than 13 mm are observed, whereas those without any of these predictors should not undergo endoscopy. The contribution provided by portal Doppler ultrasonographic parameters does not appear of practical utility.

Antimicrobial activity and postantibiotic effect of flurithromycin against Helicobacter pylori strains.

The minimal inhibitory concentrations (MIC) of flurithromycin on 49 clinical isolates of Helicobacter pylori was investigated. The MICs were determined using an agar dilution technique. Flurithromycin inhibited the growth of H. pylori strains with MIC(50) and MIC(90) values of 0.156 and 0.625 mg/l, respectively. The postantibiotic effects (PAE) were studied on ten strains, by exposure of the bacteria to flurithromycin at five and ten times MIC for 1 or 2 h. Regrowth was determined by measuring the viable counts after drug removal by a 10(3) dilution procedure. All PAEs increased as a function of concentration and time of exposure. The mean duration of PAEs varied between 1.5 and 6 h. These data are encouraging since macrolides play a key role in the clinical treatment of H. pylori infections, and the strong PAE caused by flurithromycin may contribute to the in vivo efficacy of this drug.

Gastric permeability to sucrose is increased in portal hypertensive gastropathy.

BACKGROUND: Portal hypertensive gastropathy (PHG) is frequently found among patients with hepatic cirrhosis and at present the only way to detect and follow PHG is via endoscopy. OBJECTIVE: To assess gastric and intestinal permeability and investigate its relationship to endoscopic findings and indices of portal hypertension and hepatic function. DESIGN AND METHODS: Thirty-one non-diabetic patients with hepatic cirrhosis and PHG (PHG+) were studied and compared with 17 cirrhotic patients without PHG (PHG-). All patients underwent endoscopy for the assessment of PHG and Helicobacter pylori status, ultrasound determination of the diameters of spleen and portal vein, and, subsequently, an oral load of sucrose, lactulose, and mannitol. Sugar concentrations were determined in 6-h urine specimens and expressed as a percentage of the orally administered dose or as lactulose/mannitol ratio. RESULTS: The urinary sucrose excretion was significantly elevated in patients with PHG compared to those without (PHG+, 0.20% +/- 0.03; PHG-, 0.07% +/- 0.01; P< 0.001). No difference was found for the small intestinal probes lactulose and mannitol. Gastric sucrose permeability correlated positively with the endoscopic lesion score (P < 0.001), but not with other parameters of portal hypertension or hepatic function. H. pylori status did not influence gastric permeability. The sensitivity of this test reached 100% for PHG scores > 2. CONCLUSIONS: Gastric permeability to sucrose is increased in patients with PHG, independently of the presence of H. pylori. Sucrose permeability may be useful for the follow-up of patients with PHG.

[Endoscopy in non-neoplastic cholestasis]. / L'endoscopia nella colestasi non neoplastica.

The role of endoscopic treatment of cholestasis is well codified as an alternative or adjuvant therapy to surgery, particularly in those cases where non malignant cause has been identified. Non-neoplastic cholestasis therefore benefits very substantially from endoscopic treatment in a context where the traditional surgical approach presents limitations in terms of morbidity and mortality. It should be borne in mind, however, that the two approaches are strictly complementary for the correct management of these patients.

[Benign esophageal stenosis: role of endoscopic therapy]. / Le stenosi esofagee benigne: ruolo della terapia endoscopica.

The authors report on their experience over a period of three years with the endoscopic treatment of benign oesophageal stenosis utilising the endoscopic balloon dilatation (EBD) technique or Savary-Gilliard cylindrical-conical dilators. They evaluate the results of the therapy with clinical and endoscopic follow-up at six-monthly intervals. The treatment proved effective, with total remission of dysphagia symptoms in approximately 95% of patients and with a low risk of complications.

[Digestive hemorrhage in portal hypertension: role of sclerotherapy]. / Le emorragie digestive da ipertensione portale: ruolo della scleroterapia.

Haemorrhage is perhaps the most terrible complication of portal hypertension whatever is the etiopathology. The authors point out how sclerotherapy of the varices is either a prophylaxis and a therapeutic procedure with a low rate of local and systemic complications. Even if they are supported by good results in personal experience, the authors notice as important is to tailor the treatment for each patient.

[Preoperative staging of colorectal neoplasms: importance of the echo-endoscopy]. / La stadiazione pre-operatoria delle neoplasie colo-rettali: importanza dell'ecoendoscopia.

The A. A., after having confirmed how the timely diagnosis of cancer of the Sigma-Rectum section is the result a complicated and articulate diagnostic iter, describe the advantages of using the ultrasonography-endoscopy. Therefore they relate their experience, comparing the outcome of this research with that of the TC images and above all with the histo-pathological surveys on the removed sechions. They conclude affirming that a higher percentage of the diagnostic care is a clear evolution in the correct pre-operating stage of these neoplasias.

[Giant fibrovascular polyp of the esophagus]. / Su di un caso di polipo fibrovascolare gigante dell'esofago.

Fibrovascular polyps of the oesophagus are rare tumor-like lesions characterized by development of the peduncolated intraluminal masses that can reach gigantic size and may have spectacular clinical presentation including regurgitation of a fleshy mass into the mouth and can lead to sudden death for occlusion of the larynx. Starting from a case observed and successfully treated by transoral resection we review the clinical radiographic and pathological findings of benign oesophageal tumor that requires surgical removal because of the progressive nature of the symptoms and the small, just known, risk of sudden death. The approach depends on the pedicule site.

[Morphological variations of the human gastric mucosa after omeprazole treatment: a scanning electron microscopic study]. / Variazioni morfologiche della mucosa gastrica umana dopo trattamento con omeprazolo: studio al microscopio elettronico a scansione.

Numerous studies have been performed on the effects of omeprazole, a powerful inhibitor of gastric acid secretion, on the various morphotypes of oxyntic mucosa, whilst scant attention has been paid to modifications induced by this drug on surface epithelial mucosa. The authors carried out a SEM study on bioptic fragments removed at gastric level from 15 patients receiving omeprazole treatment for duodenal ulcer and/or reflux esophagitis, but apparently free from lesions to the mucosa of the body of the stomach. Biopsies were performed before the start, after two months and after seven-ten months of treatment. The results of basal biopsies showed an hypersecretive trend in surface epithelial cells, with frequent dissolution of the apical plasmalemma and emptying of cell bodies. After two months of treatment the hypersecretive phenomena regressed, whereas the mucosa appeared hypertrophic and presented typical cell polymorphism in some areas. After seventeen months of treatment the mucosa showed normal characteristics, except in one case in which there was a trend towards atrophy. In conclusion, the authors attribute the hypertrophic-dysplastic modifications observed after medium-term treatment to hypergastrinemia, secondary to treatment, and suggest careful morphological control follow-up during the course of treatment so as to obtain an early diagnosis of a possible deviation towards intestinal metaplasia.

Gastric infection by Helicobacter pylori and antral gastritis in hyperglycemic obese and in diabetic subjects.

The aim of this work was to ascertain if diabetes and obesity can affect gastric colonization by Helicobacter pylori. 59 hospitalized subjects with dyspepsia and endoscopic antral gastritis were selected. They were divided into three groups: I) 13 patients with normal body weight and without disease other than gastritis (control group); II) 15 patients with essential obesity of whom 10 had impaired glucose tolerance (IGT); III) 31 patients with type II diabetes mellitus, of whom 14 were obese. Three gastric biopsies were obtained from each patient for histologic examination and H. pylori detection by means of rapid urea test, culture and histological evidence of Helicobacter-Like Organisms (HLO). Age, sex, blood glucose, cholesterol, triglycerides, HDL-cholesterol, basal gastrine, duration of illness, body weight were statistically analysed. Differences between the three groups were not statistically significant. There was a higher prevalence of H. pylori infection both in obese and in diabetic patients with respect to control subjects. Prevalence became still higher in obese patients with impaired glucose tolerance. Among the three tests used for the detection of H. pylori, culture and rapid urea were reliable and specific, while the histologic test was highly sensitive but barely specific. Our data suggest that both obesity and type II diabetes may be associated with an increased incidence of H. pylori-colonization. This could be related to the reduced gastric motility observed in both pathologies and chemical changes in gastric mucosa following non-enzymatic glycosylation processes.

Upper gastrointestinal endoscopy can be a reliable screening tool for celiac sprue in adults.

In our study, we evaluated whether the combination of two endoscopic abnormalities in the duodenum (the "mosaic" appearance and loss of duodenal folds) is significantly associated with duodenal villous atrophy secondary to celiac sprue in adults. Fourteen patients referred for esophagogastroduodenoscopy for suspected celiac sprue and 146 for suspected peptic disease were enrolled in the study. At least one of the two endoscopic duodenal abnormalities was observed in all 10 untreated celiac patients but in only one of the dyspeptic patients. The sensitivity and specificity were 100 and 99.3%, with positive and negative predictive value of 90.9 and 100%, respectively. Such good results suggest that duodenal endoscopy can be a screening procedure for celiac sprue in patients who are undergoing endoscopy for other reasons.