Biomedical subjects
Publications and source records attributed to D G Sheahan.
A young girl developed painful swelling and ulceration of her lips and mouth. She had gingival hyperplasia, an anal fissure, and anal skin tags without evidence of intervening intestinal disease. A diagnosis of Crohn's disease was made. All lesions regressed with appropriate therapy. She remains asymptomatic 14 months after presentation.
A second recorded case of Waterhouse-Friderichsen syndrome, without purpura, due to Haemophilus influenzae is described. It is suggested that the absence of purpura should not preclude the diagnosis of the Waterhouse-Friderichsen syndrome due to this organism.
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To evaluate the relationship between duodenal ulcer disease and duodenitis, duodenal epithelial cell renewal was measured in mucosal biopsies by the incorporation of [3H]thymidine. When 14 patients with duodenal ulcer were compared to 13 control subjects or 7 with endoscopic duodenitis alone, the crypt size was the same in all groups. Similar to other inflammatory processes of the gastrointestinal tract, patients with endoscopic duodenitis showed increased proliferative indices including a greater number of cells incorporating [3H]thymidine. In contrast, the proliferative indices from the duodenal mucosa of patients with duodenal ulcers did not differ from a control group. In a group of 6 patients with both endoscopic duodenitis and duodenal ulcer, the [3H]thymidine incorporation was intermediate between control subjects or patients with duodenal ulcer alone and those with endoscopic duodenitis alone. When subjects were divided according to the histologic appearance of the duodenal mucosa, those having chronic duodenitis demonstrated enhanced [3H]thymidine incorporation in comparison to a control group or patients with chronic active duodenitis (polymorphonuclear leukocytes present). Although there are many possible explanations of these findings, one may speculate that duodenal ulceration does not stimulate duodenal epithelial proliferation.
Twenty-two patients with colonic arterio-venous malformations (AVM) are reported and 218 other cases in the English literature are reviewed. Of our patients, 16 (73%) underwent right hemicolectomy because of repeated episodes of rectal bleeding or iron-deficiency anemia. Ten (63%) of these patients have remained in good health with no further evidence of intestinal bleeding after surgery. In six (37%) recurrent episodes of rectal bleeding or iron deficiency anemia have gone unexplained despite thorough work-up including repeat arteriography. Our experience and that in the literature suggests: 1. Most AVM's (78%) occur in the cecum or right colon, the jejunum being the next most common site. 2. Patients with AVM's tend to be elderly with a strong history of cardiovascular disease. A potential association between aortic stenosis, intestinal bleeding, and AVM's is suggested. However, prospective studies are needed to confirm this relationship. 3. In younger patients AVM's tend to occur at atypical sites such as the small bowel. 4. Surgical removal of an AVM cannot be expected to be uniformly curative. The causes of recurrent bleeding after surgery include: incomplete resection of the initial AVM, occult AVM's missed on arteriography and left behind at surgery, and the appearance of new AVM's postoperatively. The cause of bleeding in many patients with recurrence however, remains undiagnosed despite repeat angiography.
Gastroduodenitis should be included with duodenal ulcer and gastric ulcer in the spectrum of clinical disorders that have different pathogenetic mechanisms but a similar clinical picture. Published results of a clinical, endoscopic, radiologic, and histologic study of 100 patients presenting with gastrointestinal symptoms revealed that 61% had classic and 39% had atypical manifestations of peptic ulcer disease. We could not clinically distinguish the 24 patients with ulcer crater (40% of the classic group) from the 25 patients with acute gastroduodenitis without crater (41% of the classic group). Preliminary data of a prospective study compared the treatment responses of 19 patients with gastroduodenitis and 39 patients with peptic ulcer disease. These patients were diagnosed endoscopically and restudied after treatment with a bland diet and antacids seven times per day for 8 weeks. The responses to therapy in gastroduodenitis and peptic ulcer were as follows: endoscopically, 63 and 80%, respectively; histologically, 74 and 65%, respectively; symptomatically, 47 and 65%, respectively. Preliminary data on the duodenal epithelial thymidine uptake revealed an increased proliferative index in duodenitis patients but not in patients with peptic ulcer or control subjects.
Ganglioneuromas are neuroectodermal tumors that are found in diverse anatomic sites, but they are very uncommon in the colon. We observed a patient with partial colonic obstruction whose roentgenogram had a napkin-ring construction that was thought to be carcinoma. On resection, pathologic examination showed a ganglioneuroma. Mesenchymal neoplasms of various histologic types occur thoughout the gastrointestinal tract. Neurogenic tumors are not uncommon in Von Recklinghausen's neurofibromatosis and multiple mucosal neuroma syndrome, but solitary lesions unassociated with these conditions are rare. To our knowledge, this complication in the colon is only the second such reported case. We believe that this case is noteworthy because of its clinical and roentgenographic resemblance to carcinoma.
To evaluate the frequency and type of gastroduodenal mucosal inflammatory changes in patients with symptomatic acid peptic disease and nonulcer dyspepsia, 100 patients with gastrointestinal symptoms indicative of acid peptic disease or dyspepsia and 10 control subjects were clinically evaluated and underwent radiographic, endoscopic, and biopsy studies of the stomach and duodenum. Clinical evaluation revealed that of the 100 patients, 61% had classic and 39% had atypical manifestations of acid peptic (ulcer) disease. Endoscopic and histologic evaluation revealed that 25 patients had peptic ulcer craters, 86-90% of whom had associated gastroduodenitis. Thirty-nine patients had acute and 20 patients had chronic gastroduodenitis without ulcer crater. Twelve symptomatic patients had no histologic changes in the gastroduodenal mucosa. Two of the ten control subjects had mild gastritis. In the 61% of the patients with classic manifestations of peptic ulcer disease, we could not clinically distinguish the 24 patients with craters, (40% of the classic group) from the 25 patients with acute gastroduodenitis without craters (41% of the classic group). As a result of this study of our group of patients, we believe that gastroduodenitis can be symptomatic and may present with the same manifestations as peptic ulcer crater. Further study will be required to determine whether gastroduodenitis is an independent entity or part of the spectrum of acid peptic (ulcer) disease.
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Radiation therapy directed at the abdomen may damage the digestive tract, the type and extent of injury depending on the dose of the radiation and the radiation sensitivity of the gut. Characteristic early changes are manifest in the mucosa of the gut: for later ulceration, changes in the collagen tissues and particularly in the vascular channels occur. This paper describes and characterizes injuries to the esophagus, stomach, small intestine and colon. It emphasizes the importance of recognizing radiation-induced damage to the gut which may occur early or late after radiation.
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A patient with a lifelong history of asthma and hay fever was investigated because of symptoms of esophageal spasm. Esophageal biopsies revealed elongated papillae and basal zone hyperplasia of the epithelial layer with eosinophilic infiltration of the lamina propria and muscularis mucosae. There was no evidence of reflux. Small bowel biopsies revealed a flat mucosal pattern with absent or blunted villi, tall columar surface epithelium, and eosinophilic infiltration of the lamina propria. He did not respond to a gluten-free diet. This patient is thought to have eosinophilic gatroenteritis with esophageal involvement, the first such case reported.
The accuracy of colonoscopic biopsies in predicting the histological diagnosis of colonic polyps removed at colonoscopy or at laparotomy was studied. Forty-two patients were colonoscoped before the removal of 50 polyps. A single fractional biopsy was obtained from each lesion with the standard endoscopic biopsy forceps and was compared to the final histological diagnosis of each excised lesion. Thirteen (26%) of the singular fractional biopsies did not demonstrate the significant histological features of the excised polyps. These tiny biopsies do not adequately represent the entire polyp. Moreover, the 2- to 3-mm size of the biopsy does not permit the study of the central submucosal area of the polyp stalk, the critical area for assessing invasive malignancy. Histological examination of a completely excised polyp is essential for accurate diagnosis and appropriate therapy.
Accelerated cell turnover has been held responsible for the basal zone thickening of the esophageal squamous mucosa of patients with reflux esophagitis. We have studied the in vitro proliferative activity of the basal zone in suction biopsy specimens obtained from normal subjects, from patients with medically treated esophagitis, and from patients who had previously undergone anterior fundoplication. In patients with severe esophagitis, the basal zone showed a significantly elevated [3H]thymidine labeling index in contrast to that of mild esophagitis patients and that of normal subjects. When esophagitis was associated with mucosal lesions at endoscopy, the labeling index was higher than that seen in esophagitis patients without endoscopic abnormalities. Significantly increased thymidine labeling was found only in patients with the most severe changes of papillary length or basal layer thickening. We therefore conclude that there is an increased basal zone uptake of [3H]thymidine in severe esophagitis which suggests increased cell turnover as the mechanism for basal zone hyperplasia. Present techniques for measuring mucosal uptake of [3H]thymidine, however, do not permit the distinction of mild degrees of esophagitis from normal epithelium.
Two histochemical sequential staining techniques, Alcian blue-PAS (AB-PAS) and high-iron-diamine-Alcian blue (HID-AB), which differentiate neutral from sulfated and non-sulfated acid mucosubstances, were applied to sections from the gastrointestinal tract of eleven mammalian species, including man, to study patterns of distribution of gastrointestinal epithelial mucosubstances. The application of these techniques under uniform laboratory conditions enabled a detailed description of epithelial mucosubstances throughout the gastrointestinal tract relative to location in each species as well as a comparison of their distribution among various species. The results showed that all of the 11 species studied had a distinctly different distribution of epithelial mucosubstances throughout the entire gastrointestinal tract. These differences were most obvious in the stomach and duodenum. In each species, neutral mucosubstances were most evident in the stomach and acid mucosubstances in the intestines, with sulfomucins most prominent in the large bowel. Acid mucosubstances were noted in Paneth cell granules of rodent species only. These histochemical observations make available a uniform comparative basis for the normal distribution of mammalian gastrointestinal mucosubstances which should facilitate their study in diverse pathological conditions.
The sensitivity and specificity of each of five esophageal tests used in the diagnosis of reflux esophagitis were compared with those of six combinations of two tests, one indicating esophagitis and the other indicating sphincter incompetence. The esophageal tests were performed in patients with reflux symptoms, chest pain, and esophagitis without reflux symptoms. Control data were obtained from normal subjects (negative control) and duodenal ulcer patients (positive control). The results indicate that the acid infusion test and esophageal biopsy combined with esophageal pH study after HC1 have similar sensitivity and greater specificity than any test alone. In normal subjects, the cumulative incidence of abnormalities with esophageal tests alone was 30%, but with combinations of two tests it was only 5%. The use of criteria (simultaneous esophagitis and sphincter incompetence) which establish the diagnosis of reflux esophagitis helps to resolve conflicting results obtained with single tests. The most sensitive and specific test combination for the diagnosis of reflux esophagitis appears to be esophageal biopsy with esophageal pH study after HC1.
A somewhat obese, 40-year old female presented with a classic history of gallbladder disease and a peripheral eosinophilia of 14% without an allergic history. A nonvisualizing oral cholecystogram was followed by an uneventful cholecystectomy. Pathological examination revealed a calculus in the cystic duct and a pure transmural eosinophilic infiltrate of the gallbladder wall. Postoperatively the peripheral eosinophilia returned to normal. Biopsies of the small bowel one year later showed focal mucosal eosinophilia when the patient had recurrent abdominal pain, diarrhea and peripheral eosinophilia. Eosinophilic cholecystitis may represent a descrete entity in search of an etiology or involvement of the biliary tract by eosinophilic gastroenteritis.