Intestinal tuberculosis: a diagnostic challenge.

OBJECTIVE: To describe characteristics, presentation, time to diagnosis and diagnostic findings of patients with intestinal tuberculosis (ITB) in a low-burden country. METHOD: Retrospective study of 61 consecutive ITB patients diagnosed between 2008 and 2014 at a large East London hospital. RESULTS: Forty of sixty-one patients were male. Mean age was 34.6 years. 93% of patients were born abroad, mostly from TB-endemic areas (Indian subcontinent: 88%, Africa: 9%). 25% had concomitant pulmonary TB. Median time from symptom onset to ITB diagnosis was 13 weeks (IQR 3-26 weeks). Ten patients were initially treated for IBD, although patients had ITB. The main sites of ITB involvement were the ileocaecum (44%) or small bowel (34%). Five patients had isolated perianal disease. Colonoscopy confirmed a diagnosis of ITB in 77% of those performed. 42 of 61 patients had a diagnosis of ITB confirmed on positive histology and/or microbiology. CONCLUSION: Diagnosis of ITB is often delayed, which may result in significant morbidity. ITB should be excluded in patients with abdominal complaints who come from TB-endemic areas to establish prompt diagnosis and treatment. Diagnosis is challenging but aided by axial imaging, colonoscopy and tissue biopsy for TB culture and histology.

Regionally dependent neuromuscular functions of motilin and 5-HT4 receptors in human isolated esophageal body and gastric fundus.

BACKGROUND: Motilin agonists promote human gastric motility and cholinergic activity, but excitatory and inhibitory actions are reported in the esophagus. The effect of 5-HT4 agonists in esophagus is also unclear. Perhaps the use of drugs with additional actions explains the variation. The aim, therefore, was to examine how motilin and prucalopride, selective motilin and 5-HT4 receptor agonists, modulate neuromuscular functions in human esophagus and gastric fundus. METHODS: Electrical field stimulation (EFS) evoked nerve-mediated contractions of circular and longitudinal muscle from human esophageal body and circular muscle from gastric fundus. KEY RESULTS: In esophageal circular muscle EFS evoked brief contraction, followed by another contraction on termination of EFS, each prevented by atropine. Nitric oxide synthase inhibition facilitated contraction during EFS and the overall contraction became monophasic. In esophagus longitudinal muscle and gastric fundus, EFS evoked cholinergically mediated, monophasic contractions, attenuated by simultaneous nitrergic activation. Motilin (100-300 nM) reduced esophagus circular muscle contractions during EFS, unaffected by L-NAME or apamin. Motilin 300 nM also reduced EFS-evoked contractions of longitudinal muscle. Similar concentrations of motilin facilitated cholinergic activity in the fundus and increased baseline muscle tension. Prucalopride facilitated EFS-evoked contractions in esophagus (tested at 30 µM) and fundus (0.1-30 µM). CONCLUSIONS & INFERENCES: Selective motilin and 5-HT4 agonists have different, region-dependent abilities to modulate human esophageal and stomach neuromuscular activity, exemplified by weak inhibition (motilin) or excitation (5-HT4) in esophageal body and excitation for both in stomach. In different patients with motility dysfunctions, motilin and 5-HT4 agonists may reduce gastro-esophageal reflux in different ways.

Human in vivo cellular response to a cross-linked acellular collagen implant.

BACKGROUND: Hernia surgery, in particular parastomal hernia mesh repair and new techniques for hernia prevention, require novel biomaterials that avoid fibrosis and potential bowel erosion, while retaining adequate strength for their intended purpose. The aim was to evaluate the human host response to an acellular porcine-derived cross-linked collagen implant. METHODS: In a prospective pilot study on prevention of parastomal herniation, 15 patients undergoing loop stoma formation had an implant placed within the anterior abdominal wall. Histopathology and immunohistochemistry were performed to analyse the implant qualitatively and, where appropriate, quantitatively for biocompatibility, degradation, cellular infiltration, neo-extracellular matrix (ECM) formation and neovascularization. RESULTS: At a median of 7 (range 1-8) months, 12 of 15 patients had stoma reversal and 11 implant biopsies were obtained. In biopsies from ten of the 11 patients all responses were limited to the periphery of the implant and native pores. There was a minimal inflammatory response and minimal degradation of the implant. Fibroblastic and neovascular infiltration were noted, as was matrix metalloproteinase 1 activity with organized deposition of host collagen, fibronectin and laminin. CONCLUSION: The collagen implant demonstrated excellent biocompatibility and resistance to degradation in most patients. However, fibrovascular in-growth and ECM deposition were limited. This implant has excellent potential for soft tissue reinforcement.

A review of post-trachelectomy isthmic and vaginal smear cytology.

Currently in the UK cervical cancer has a peak incidence in women aged 35-39. Fertility-conserving surgical treatment by radical trachelectomy is established in the management of early disease. This study aimed at establishing the value of cytology in follow-up after trachelectomy. The cytological features of isthmic-vaginal smears post-trachelectomy for cervical cancer are presented together with a discussion of relevant clinical issues. One hundred and ninety seven smears from 32 women were reviewed. Two of the 32 patients developed pelvic recurrences. In both cases recurrence was detected cytologically long before development of a clinical or radiological abnormality. There is, however, a potential for overcall due to the presence of endometrial cells. These were present in large numbers and varying configurations in 58% of smears and led to a false positive report of malignancy in 2% of smears. The rate of referral for a cytologist opinion was significantly higher in smears containing endometrial cells (26%) than those without (13%). While all smears contained squamous cells, 41% contained squamous cells only and it is proposed that such smears should be reported as unsatisfactory in the first 2 years after surgery and negative thereafter, although the absence of glandular cells should be recorded. When an abnormality is reported, smear review and multidisciplinary discussion may avoid unnecessary investigations.

Fibrous histiocytoma of tendon sheath of the hand.

The hand is not uncommonly afflicted by Fibrous histiocytoma/Giant Cell tumour of tendon sheath, an enigmatic and loosely-defined clinical entity only occasionally entering into the literature. The 26 cases in this clinico-pathologic review were obtained by a computerised search of histological files at the Dept. of Pathology, UCHG. Twice as many of these were female, more often in their fourth decade of life. The condition has a propensity for the long digits, more often the volar aspect and roughly evenly distibuted over each of the joints. Resection of these neoplasia is tedious due to it's propensity to grow between local anatomical structures contributing to a high recurrence rate. Interestingly it rarely figures in guesses at pre-operative diagnosis although the second commonest cause of a benign superficial hand mass after ganglion. We suggest that if this condition is suspected, referral to a specialist hand surgeon in the first instance is wise.