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.

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.

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.

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.

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.

[Collagen colitis: separate illness or syndrome?]. / Collageencolitis: aparte ziekte of syndroom?

Six patients with collagenous colitis are described and the literature is reviewed. Collagenous colitis is not a rare disease. Its most prominent feature is profuse watery diarrhoea. Although the endoscopic picture of the mucosa is usually normal, there is a microscopic thickening of the (subepithelial) basement membrane. For diagnostic purposes, multiple colon biopsies are warranted in patients with chronic or relapsing diarrhoea. There is no established therapy for this disease.

Can sonography diagnose acute colonic diverticulitis in patients with acute intestinal inflammation? A prospective study.

In a prospective study of 123 patients with clinical signs of acute intestinal inflammation, the sensitivity of ultrasonography in diagnosing acute colonic diverticulitis was 84.6% and the specificity 80.3%. The predictive value of a positive and a negative sonogram was 76.0% and 87.7%, respectively. Of the 52 patients with subsequently proven acute colonic diverticulitis, 44 presented sonographically with a thickened (greater than 4 mm) hypoechoic bowel wall. In 15 patients, enlarged fluid-filled bowel loops were also present. Air-containing diverticula were demonstrated in 3 patients, abscesses in 8 patients, and colovesical fistulae in 2 patients. Eight large abscesses were successfully treated without emergency surgery by percutaneous sonographically guided evacuation. The described sonographic abnormalities strongly suggest acute colonic diverticulitis, particularly when localized in the left lower abdomen.

The impact of routine admission abdominal sonography on patient care.

In a prospective study of 1000 consecutive patients, abdominal sonography added diagnostic information to that available by history and physical examination in 8.9%. The yield ranged from a high of 27.4% in patients with acute abdominal symptoms to a low of 2.7% in screening sonograms of patients without abdominal symptoms. Sonographically guided biopsy-proven diagnoses were obtained in 6.6% of the patients and were clinically not suspected in 4.4%. The percentage of false-positive and false-negative sonographic studies was 0.5% and 1.1%, respectively. Sonography shortened the duration of hospitalization in 15.3%.

Dilated abdominal paraaortic lymphatic duct: a possible pitfall in retroperitoneal US.

Three cases of dilated abdominal left paraaortic lymphatic duct are described. The diagnosis was established by means of sonography and confirmed with lymphography in all three patients. A sonographically guided puncture of the lymphatic duct was performed in one patient. Dilatation of these lymphatic ducts was possibly the consequence of previous upper abdominal surgery in two patients and a coronary bypass operation in one.

Omeprazole (40 mg) is superior to ranitidine in short-term treatment of ulcerative reflux esophagitis.

The efficacy and safety of omeprazole, 40 mg once daily for four to eight weeks of treatment, were studied in 61 patients with ulcerative reflux esophagitis. A double-blind controlled study design was used, and the patients were randomly allocated to treatment with either omeprazole 40 mg once daily or ranitidine 150 mg twice daily. Endoscopy was performed prior to inclusion into the study, after four weeks and, if unhealed, again after eight weeks. Healing of esophagitis was defined as complete disappearance of all esophageal ulcerations. Symptoms were recorded before entry, after four weeks, and again after eight weeks in unhealed patients. Fifty-one patients were included in the per-protocol analysis at day 29, and 50 patients at day 57. The healing rate after four weeks of treatment was 22 of 26 patients (85%) treated with omeprazole and 10 of 25 patients (40%) treated with ranitidine (P less than 0.001). The corresponding figures after eight weeks were 24 of 25 (96%), and 13 of 25 (52%) (P less than 0.001). These results were confirmed in the intent-to-treat analysis. Patients treated with omeprazole showed a significantly faster and more profound relief in heartburn than patients treated with ranitidine: 85% had no heartburn after four weeks of treatment with omeprazole compared to 24% in patients treated with ranitidine (P = 0.00007). The percentage of patients who were free of all reflux symptoms was significantly greater in the omeprazole-treated group as compared to the ranitidine-treated group (62% and 12% respectively; P = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary malignant melanoma of the gallbladder, metastatic to the common bile duct.

A primary malignant melanoma of the gallbladder, metastatic to the common bile duct, is reported. Both tumor sites were first visualized by abdominal sonography. The presence of the common bile duct metastasis was confirmed by endoscopic retrograde cholangiopancreatography. Histologic evidence is presented that the primary tumor did arise in the gallbladder and that the metastasis to the common bile duct most likely occurred as a consequence of mucosal implants from tumor cells that were shed in the bile.