Early colorectal cancer in a flat adenoma.

A 56-year-old man presented with intermittent rectal bleeding of six months' duration. Colonoscopy revealed three left colon polyps, one of which harbored adenocarcinoma. Endoscopic mucosal resection (band-assisted colonoscopic polypectomy) was successful. Endoscopic ultrasonography did not demonstrate any local or regional spread; however, abdominal computed tomography (CT) scan raised suspicion of an isolated metastasis to the liver. The patient's mother had recently died from metastatic colorectal cancer. When presented with the options of no surgery, postendoscopic mucosal resection, and CT-directed needle biopsy of the suspected isolated metastasis to the liver versus segmental resection of the flat adenoma site and wedge resection of the liver lesion for the maximum chance of a surgical cure, the patient opted for the surgical approach. Histopathology revealed no evidence of malignancy in the rectosigmoid colon, pericolonic lymph, or liver specimen. Awareness of increased risk of early cancer in flat adenomas with central depression is important because prompt recognition can lead to curative therapy.

Endoscopic hemorrhoidal ligation: preliminary clinical experience.

BACKGROUND: Endoscopic hemorrhoidal ligation may provide an alternative to surgical treatment of internal hemorrhoids. This study assessed the safety and efficacy of endoscopic elastic band ligation for bleeding internal hemorrhoids. METHODS: Endoscopic hemorrhoid ligation was performed in 20 adult patients who had chronic rectal bleeding attributed to internal hemorrhoids. Elastic band ligation was accomplished using a ligating device attached to the end of a video endoscope. Repeat endoscopy was done 3 weeks after the initial procedure. RESULTS: Seventy band ligations were performed during 23 separate sessions. Post-therapy endoscopy showed reduction of hemorrhoidal size by at least one grade in 19 of 20 patients (95%). Bleeding resolved in 19 of 20 patients (95%) in 5.4 months (mean) of follow-up; 18 of 20 (90%) required only one banding session. No major complications (perforation, secondary bleeding, deep ulceration) occurred in this small group. CONCLUSIONS: Preliminary data indicates that endoscopic hemorrhoidal ligation is a safe and effective technique for treating internal hemorrhoids. It holds promise as an important technique for successfully treating and possibly eradicating symptomatic internal hemorrhoids.

Jejunal adenocarcinoma presenting as iron deficiency in a young man.

A 30-year-old man presented with iron deficiency anemia and occult blood in his stools. Both upper and lower gastrointestinal tract endoscopy were initially unrevealing. This case illustrates the importance of small bowel follow through/enteroclysis supplemented by endoscopic examination and biopsy for adenocarcinoma of the proximal jejunum.

Cost analysis for procedure comparisons.

Using the methodology of activity-based costing as a conceptual framework, the authors present the potential cost reduction of a new office routine and a medical procedure. The costs of a new instrument for colorectal cancer screening and a new surveying and follow-up of at-risk patients show that time and relevant costs in the G.I Clinic and G.I Endoscopy Lab were significantly reduced.

Simultaneous M-mode echoesophagram and manometry in the sheep esophagus.

We report the simultaneous measurement of esophageal wall layer thickness and intraluminal pressure in the sheep esophagus using a miniature suction device incorporating a high-frequency ultrasound transducer and a manometry system. Transnasal placement of the device into the distal esophagus of a conscious sheep allowed observation of 133 swallowing events during three trials, each lasting from 45 to 60 minutes. In a fourth trial, 11 sequential dry and 23 sequential wet swallows were compared. Maximum manometric pressure, esophageal wall layer thickness, and duration of contraction were measured. All swallowing events produced simultaneous increases in intraluminal pressure and esophageal wall thickness. Mean maximal pressures were lower for dry swallows (18 +/- 2.1 mm Hg) than wet swallows (22 +/- 3.0 mm Hg) (p < .01). Thickness of the inner (circular) muscle layer increased above baseline by 124% for dry swallows and 161% for wet swallows (p < .01). We conclude that thickening of the esophageal inner (circular) muscle layer may be important in the generation of intraluminal esophageal pressure in the sheep esophagus.

Gallbladder wall thickening: an in vitro sonographic study with histologic correlation.

RATIONALE AND OBJECTIVES: We compared histologic sections with in vitro sonographic images for 40 resected gallbladder specimens to correlate the histopathologic processes with the sonographic appearance of the gallbladder wall. METHODS: In vitro sonographic images and histologic specimens were obtained by use of a specimen container with a micropositioner. An 8.5-MHz transducer and a scalpel were attached to the micropositioner to obtain the sonographic image and the histologic section. The sonographic images were analyzed for wall thickness and the number and echo texture of the visualized layers and then were correlated with the histologic sections. Each histologic specimen was interpreted as being normal or showing mild, chronic, acute, or gangrenous cholecystitis. RESULTS: One to four sonographic layers were observed in the gallbladder wall specimens. The number of wall layers was fairly evenly distributed among the different types of gallbladder wall inflammation. One to three sonographic layers were observed for most of the different types. In nearly all instances, the findings were attributable to either similar pathologic processes in two or more histologic layers or different pathologic processes in a single histologic layer. The gallbladder wall measured less than or equal to 3 mm in 89% of gallbladders with normal or mild inflammation, greater than 3-6 mm in 71% of cases of chronic cholecystitis, greater than 3 mm in 83% of cases of acute cholecystitis, and greater than 6 mm in 50% of cases of gangrenous cholecystitis. CONCLUSIONS: The sonographic layers in the inflamed gallbladder wall are determined by the pathologic changes present rather than by the normal histologic boundaries. However, because of the overlap of pathologic changes, we cannot predict the type of gallbladder wall pathology on the basis of the sonographic appearance. We found a trend toward gallbladder wall thickening for severely inflamed gallbladder walls.

Changes in esophageal wall layers during motility: measurements with a new miniature ultrasound suction device.

We have developed a miniaturized ultrasound device that attaches to the gastrointestinal mucosa by suction and produces high-resolution (+/- 0.1 mm) images of the layers of the intestinal wall. The esophageal wall layers in a single sheep were measured during 20 occlusive contractions observed with simultaneous endoscopy, which revealed thickening of the inner circular muscle layer from 1.2 +/- 0.2 mm to 2.2 +/- 0.4 mm (p < 0.01), and during 20 dilations demonstrating thinning of the full thickness of the esophageal wall from 3.6 +/- 0.3 mm to 2.9 +/- 0.3 mm (p < 0.01). Safety experiments performed in two canine stomachs demonstrated no erosions or ulceration at any level of suction. Our investigations indicate that the M-mode suction ultrasound device can safely assess changes occurring in the layers of the esophageal wall during contractions and dilations and should be evaluated for the study of human intestinal motility.

Apudoma of the pancreas: benign or malignant?

A middle-aged, obese, black woman complained of abdominal pain and tenderness in the left upper quadrant. An abdominal computerized tomographic (CT) scan revealed an encapsulated cystic mass in the tail region of the pancreas. Selective angiography confirmed mass and hypervascularity, definite encapsulation, and lack of capsular invasion. The diagnostic value of the CT scan, angiography, and special staining in classifying the excised pancreatic mass as an apudoma is discussed. Malignancy was excluded by the lack of capsular-vascular invasion and the absence of metastases. Nonfunctional status was determined by lack of hormone hypersecretion.