Local ischemia causes carcinoma-like changes of the rectum.

PURPOSE: Bioptic specimens of typical cancerous changes in the rectum usually reveal signs of malignancy. Our goal was to describe the clinical feature, histologic findings, and long-term outcome of patients in whom typical findings of carcinoma of the rectum were discovered by endoscopy, but whose histologic data did not confirm the diagnosis of a malignant disease. METHODS: We conducted a retrospective review of eight patients seen in our hospital with a clinical diagnosis of colorectal cancer. RESULTS: All patients had typical macroscopic findings of colorectal cancer. Endoscopic examination was performed because of chronic gastrointestinal symptoms (tenesmus, diarrhea, hematochezia, recurrent rectal prolapses; n = 5), incidental masses detected by rectal palpation (n = 2), or acute rectal bleeding (n = 1). Instead of confirming malignancy, all histologic specimens showed typical signs of intestinal ischemia. In three patients, tumors were removed by endoscopy; the other patients received symptomatic therapy. All patients were followed for an average period of 46 months. In five patients, symptoms disappeared completely. Three patients continued to suffer from intestinal discomfort. In one case, progression of ischemic damage led to subtotal stenosis, which necessitated proctectomy. CONCLUSIONS: Our results indicate that, despite its rarity, "ischemic pseudocarcinoma" is an important differential diagnosis to cancer of the rectum. Prognosis is generally good. Only patients suffering from chronic symptoms may require surgical treatment.

Malignant biliary obstruction: clinical and histopathologic correlation after treatment with self-expanding metal prostheses.

PURPOSE: To analyze clinical and autopsy findings in patients with malignant biliary obstruction treated with biliary endoprostheses. MATERIALS AND METHODS: Stents were inserted endoscopically in nine patients and transhepatically in 50. In 24 patients, autopsy was performed; in 22 cases, histologic analysis of the area in which the stent was placed was available. RESULTS: The technical success rate was 100%, and the clinical success rate was 92%. Complications occurred in 16 patients, with one procedure-related death. The rate of severe complications was 19%, primarily due to acute cholangitis (n = 9). Mean survival time was 175 days. Stent obstruction was found in 12 patients and occurred on average 196 days after stent placement. Secondary treatment was successful in all 12 patients. Only one of 24 autopsy specimens demonstrated macroscopic nonobstructive tumor ingrowth. Histologic analysis showed that the main reaction to the stent was connective tissue formation, which never occurred before 3 months. Invasion by tumor cells was noted in only five cases. CONCLUSION: Tumor ingrowth is not a major cause of stent obstruction.

[Ischemic ulcer of stomach and duodenum: an unusual cause of a common disease]. / Ischämisches Ulkus des Magens und des Duodenums: eine ungewöhnliche Ursache bei einer alltäglichen Krankheit.

Ischemia is a rare cause of gastric and duodenal ulcers. For the present study clinical and anatomo-pathologic data from cases published so far and from twelve own patients with ischemic ulcers have been investigated. Histopathology leads to the diagnosis of an ischemic cause with great accuracy. Our results show that ischemic ulcers occur often at gastric sites unusual for a peptic ulcer, and in some cases they look macroscopically different from peptic ulcers. The most common symptom was severe gastrointestinal bleeding. Pain, typical for peptic ulcers, has only rarely been noted by patients. Lethal courses were usually due to gastrointestinal bleeding resistant to therapy. Resection of the involved gastric or duodenal segment or surgical or angiologic reconstruction of the vessels respectively are promising therapeutic means. Without therapeutic intervention very different courses have been observed, ranging from spontaneous healing to fatal gastrointestinal bleeding. The benefit of inhibitors of acid secretion is so far unclear.

Intestinal infarction after nonabdominal trauma; association with cerebral trauma.

Nonocclusive bowel infarction in nonabdominal trauma has been ascribed to periods of hypotension. However, to our knowledge only 17 cases have been reported, and hypotension was not always found. We studied the frequency and possible causes of intestinal infarction in all patients treated at our traumatologic intensive care unit from 1977 through 1986 (n = 2350). Intestinal infarction was diagnosed at the time of surgery or autopsy; patients with pre-existing vascular disease were excluded. We found 12 patients (incidence: 0.5%) of age 45 +/- 20 years (mean +/- SD). All had severe cerebral trauma [Head and Neck Abbreviated Injury Scale (AIS) score: 4-5, admission Glasgow Coma Scale (GCS) score: 6.5 +/- 3.8]. Eight patients suffered from additional injuries. The Injury Severity Score (ISS) was 27 +/- 7. All patients received ventilator assistance continuously before the diagnosis of intestinal infarction or death. The leading symptom of intestinal infarction was sepsis and multiple organ failure with abdominal distention. Five patients with favorable cerebral prognosis underwent surgery: one survived with good cerebral and gastrointestinal recovery. Four patients did not have surgery because of a poor cerebral prognosis. Three patients died of their cerebral trauma before intestinal infarction was clinically manifested. The data show that early diagnosis in ventilated patients with head injuries is extremely difficult because of the heterogenicity of this group of patients, the low frequency of the complication, and the complexity of the clinical picture. Although patients inevitably were exposed to several agents or situations associated with intestinal infarction, the ubiquitous causes were dehydration and diuretic therapy.

Chemotherapy with MACOP-B and VACOP-B for intermediate- and high-grade non-Hodgkin's lymphoma: clinical results and analysis of prognostic factors.

Eighty-three previously untreated patients with aggressive non-Hodgkin's lymphomas were treated with either MACOP-B (23 patients) or VACOP-B (60 patients) as originally described by Klimo and Conners [1, 2]. Their median age was 46 years. Thirty-seven patients had stage I or II and 46 stage III or IV disease. The tumor histopathology was reviewed in all cases. Sixty-five patients had intermediate grade and 18 high-grade non-Hodgkin's lymphomas according to the International Working Formulation. The rate of complete response was 74% for MACOP-B and 76% for VACOP-B. At the time of analysis the duration of follow-up was 50 months for the MACOP-B and 22 months for the VACOP-B group. The actuarial three-year progression-free survival was 35 +/- 10% for the MACOP-B group, 48 +/- 11% for the VACOP-B group, and 46 +/- 7% for all patients. Treatment mortality was 6%. A univariate and a multivariate analysis of selected pretreatment parameters and of regimen demonstrated that stage III or IV, high-grade lymphoma, and elevated serum LDH, but not the type of regimen, are significantly associated with poor progression-free survival in our patient population.

[Mycobacterium malmoense infection of the flexor tendon sheath]. / Mycobacterium malmoense-Infektion der Beugesehnenscheiden.

Infections of the tendon sheath caused by non-tuberculous mycobacteria are well known. So far, only one case involving Mycobacterium malmoense has been reported. The authors report of a 73-year old patient having undergone carpal tunnel release. In spite of granulomatous inflammation of the flexor tendon sheaths, there was no biopsy cultured for acid-fast bacteria. One year later, symptoms recurred and synovialectomy was repeated. In spite of macroscopic appearance of the synovialis and histological studies, a specific diagnosis was not yet made. Two weeks later, acid-fast bacteria, identified as M. malmoense were cultured in the BACTEC vial. Because specific treatment was not initiated, a further recurrence developed five months later, necessitating further surgery with synovialectomy. Properly treated with Rifampin and Ethambutal for twelve months, the patient has remained asymptomatic for the following two years.

[Angiosarcoma in a mastectomy scar following irradiation]. / Angiosarkom in Mastektomienarbe nach Bestrahlung.

A 74-year-old patient who had undergone radical mastectomy and postoperative radiotherapy for invasive ductal mammary carcinoma developed an angiosarcoma in the radiotherapy field without associated lymphedema. The latency time was 178 months after the first and 82 months after the second radiotherapy. The total radiation-dose was 54 Gy. Only a few such cases have so far been described. These tumors are often multifocal and their prognosis is poor. Better known are angiosarcomas appearing after radical mastectomy as a consequence of chronic lymphedema, which are known as Stewart-Treves-syndrome.

[Risk of malignancies in celiac disease--a retrospective study]. / Malignomrisiko bei Zöliakie--eine retrospektive Studie.

A review of 52 patients with celiac disease showed the development of malignant tumors in eight cases (15%). The following malignomas were diagnosed: one malignant lymphoma, one multiple myeloma, one rhabdomyosarcoma, one carcinoma of the uterus, one carcinoma of the sigmoid colon and three adenocarcinomas of the small bowel. Patients with tumors showed significantly lower hemoglobin, lower serum albumin, and higher sedimentation rates than patients without tumors. The possibility of underlying malignoma must always be considered in all patients with newly diagnosed coeliac disease and in patients where symptoms of a known celiac disease change without alteration of the prescribed diet.

[Adenocarcinoma of the small intestine in celiac disease. Case report and literature review]. / Das Adenokarzinom des Dünndarms bei Zöliakie. Kasuistik und Literaturübersicht.

We describe three patients with celiac disease complicated by adenocarcinoma of the small intestine, and summarize the 36 cases of this association that have been reported. Retrospectively we found an increased risk (relative risk 25-250) of developing adenocarcinoma of the small intestine in patients with celiac disease in the region of Winterthur (north-east Switzerland). We therefore suggest that celiac disease be considered a premalignant condition not only for malignant lymphoma and gastrointestinal tumors, but also for adenocarcinoma of the small intestine. Synchronous or metachronous development of carcinoma in one of our patients and in two cases reported in the literature offer further evidence that celiac disease is a premalignant condition for adenocarcinoma of the small bowel. In several patients celiac disease was diagnosed only after diagnosis of the carcinoma. With regard to asymptomatic or subclinical celiac disease, it seems justifiable to search for possible underlying celiac disease in all patients with established diagnosis of adenocarcinoma of the small intestine.

[Segmental hemorrhagic colitis following amoxicillin therapy]. / Segmentale, hämorrhagische Kolitis nach Amoxicillin-Therapie.

We report on three young females complaining of bloody diarrhea of acute onset due to hemorrhagic colitis associated with oral amoxicillin therapy. The bloody diarrhea with abdominal cramps began 4 to 6 days after starting the treatment. Right colon was involved in two patients, and the descending and sigmoid colon in the other. Stool cultures and search for Cl. difficile toxins were repeatedly negative. Biopsy revealed marked mucosal hemorrhage (2/3), erosions (2/3) and thrombosed vessels (2/6). Symptoms rapidly resolved after 2 to 6 days. Extensive allergic evaluation in one patient did not reveal a hypersensitivity reaction. A literature review reveals another 31 patients with this characteristic form of colitis associated with ampicillin or amoxicillin therapy.

[Colorectal carcinoma following radiotherapy of gynecological carcinoma]. / Das kolorektale Karzinom nach Radiotherapie von gynäkologischen Karzinomen.

To assess the risk of radiation-induced cancer of the colon we studied 196 patients with a history of radiation treatment for cancer of the female genital system. After a median follow-up of 12.4 years (range 10-15 years) corresponding to 1172 patient-years, 94 (48%) patients were still alive. 84 (89%) of these patients were evaluated for a second primary cancer to the colon. In 38 (45%) colonoscopic examination was performed. 3 patients were found to have a second primary cancer to the colon compared with 0.32 expected (relative risk 9.3) on the basis of rates from the Zürich Tumor Registry. Due to partial long-term survival, patient non-compliance and non-feasibility of colonoscopic examination, only one fourth of all patients initially treated by radiotherapy for cancers of the female genital system were suitable for colon screening. For these high risk women, colorectal tumor screening should be integrated into a gynecologic tumor follow-up.

Acute ischaemic colitis in a female long distance runner.

A 34 year old female long distance runner is reported with bloody diarrhoea. Colonoscopy revealed patchy haemorrhagic mucosal lesions throughout the colon. The most extensive lesions were found in the sigmoid colon. Histologic examination disclosed mucosal haemorrhage, dilated capillaries, patchy fibrosis and superficial erosions. Additional findings in this patient were haemorrhagic gastritis, microscopic haematuria and rhabdomyolysis. The only medication taken by the patient was oral contraceptives. We conclude that ischaemic colitis is one of the possible mechanisms leading to gastrointestinal blood loss in competitive runners.

Angiodysplasia of the colon: an expression of occlusive vascular disease.

We performed a prospective case control study and found among 306 patients, in whom a complete colonoscopy was done, 19 patients (6%) with angiodysplasia of the colon. These patients were significantly older than control subjects (p less than 0.05). Nine patients (47%) with angiodysplasia had no bleeding and were identified incidentally by colonoscopy performed for other indications. To clarify the possible role of underlying occlusive arterial diseases we compared the 19 patients with angiodysplasia with a control group, matched for sex and age, in whom a complete colonoscopy did not reveal a vascular anomaly. An increased incidence of cardiovascular diseases was found (p less than 0.001). Risk factors for cardiovascular diseases were significantly associated with angiodysplasia (p less than 0.05). These data support the contention that these acquired vascular lesions might result from chronic submucosal arteriovenous shunting secondary to mucosal ischemia due to underlying occlusive arterial diseases.

[Ischemic-granulomatous colitis: a new differential diagnosis from Crohn's colitis?]. / Ischämisch-granulomatöse Kolitis: eine neue Differentialdiagnose zur Crohn-Kolitis?

In patients with inflammatory bowel disease the presence of epitheloid cell granuloma is considered to be the most reliable single criterion for the presence of Crohn's disease. We report on 6 patients (5 female, 1 male, mean age 73.5 years) with acute onset of inflammatory bowel disease, in whom the presence of epitheloid cell granuloma led to the diagnosis of Crohn's disease. However, concomitant major bleeding (4/6), absence of small intestinal involvement, and absence of extraintestinal manifestations suggested the presence of ischemic colitis. Histologic findings including thrombosed vessels (6/6), mucosal (5/6) and submucosal (3/4) hemorrhage, and mucosal (3/6) and submucosal (3/4) fibrosis supported this diagnosis. A review of the literature suggests that many clinical features of assumed Crohn's disease in elderly patients are atypical and would be most consistent with an ischemic pathogenesis: rarity of fistula, low recurrence rate, low rate of small intestinal involvement and extra-intestinal manifestations, and increased incidence of major colonic bleeding would best fit with an ischemic pathogenesis in at least some of these patients. We suggest that in elderly patients with "Crohn's colitis", even in the presence of epitheloid cell granuloma, an ischemic etiology should be considered.

[Actinomycosis of the colon: clinical, endoscopic, serological and therapeutic aspects]. / Aktinomykose des Kolons: klinische, endoskopische, serologische und therapeutische Aspekte.

The case of a 73-year-old woman with extensive abdominal actinomycosis is reported. It appears to be the first case of abdominal actinomycosis in which endoscopic and serologic investigations have been performed before and after medical therapy. Ultrasonography, CT scan and surgical exploration revealed an extensive inflammatory tumor of the sigmoid colon involving the urinary bladder and uterus. Histologic examination revealed typical sulfur granules. Longterm highdose therapy with penicillin was performed.