Loss of duodenal folds allows diagnosis of unsuspected coeliac disease

We report three patients with coeliac disease who presented without the classic features of malabsorption and who underwent biopsy and were diagnosed only because of the endoscopic finding of the disappearance of Kerckring's folds in the descending duodenum. This sign constitutes a new and valid aid for the identification of patients with otherwise unsuspected coeliac disease.

Assessment of portal hypertension by endoscopic ultrasonography

Endoscopic ultrasonography (EUS) was performed in 40 patients with portal hypertension (PH) and in 48 control subjects. The azygous, splenic, mesenteric, and portal veins were displayed in both groups. However, esophageal and gastric varices, periesophageal and perigastric collateral veins, and submucosal gastric venules were displayed only in patients with portal hypertension. EUS was inferior to endoscopy in detecting and grading esophageal varices (p less than 0.0005), but EUS was superior in the detection of varices in the fundus of the stomach (p less than 0.0005). Detection of periesophageal veins by EUS increased with increasing diameter of esophageal varices at endoscopy (57% in grade 1, 89% in grade 2, and 100% in grade 3), and there was a direct correlation between endoscopic grade and the diameter of the periesophageal collateral veins at EUS. The diameter of the azygous vein by EUS at its distal and proximal margins was significantly greater in patients with PH (p less than 0.001); the EUS diameter of the azygous vein was significantly larger with variceal grade 2 compared with grade 1 (p less than 0.02 and p less than 0.01, respectively). In portal hypertensive gastropathy, endoscopic and EUS detection were coincident. No correlation was found between the presence of portal hypertensive gastropathy, endoscopic grade of esophageal varices, and detection of gastric varices at EUS.

Assessment of portal hypertension by endoscopic ultrasonography

Endoscopic ultrasonography (EUS) was performed in 40 patients with portal hypertension (PH) and in 48 control subjects. The azygous, splenic, mesenteric, and portal veins were displayed in both groups. However, esophageal and gastric varices, periesophageal and perigastric collateral veins, and submucosal gastric venules were displayed only in patients with portal hypertension. EUS was inferior to endoscopy in detecting and grading esophageal varices (p less than 0.0005), but EUS was superior in the detection of varices in the fundus of the stomach (p less than 0.0005). Detection of periesophageal veins by EUS increased with increasing diameter of esophageal varices at endoscopy (57% in grade 1, 89% in grade 2, and 100% in grade 3), and there was a direct correlation between endoscopic grade and the diameter of the periesophageal collateral veins at EUS. The diameter of the azygous vein by EUS at its distal and proximal margins was significantly greater in patients with PH (p less than 0.001); the EUS diameter of the azygous vein was significantly larger with variceal grade 2 compared with grade 1 (p less than 0.02 and p less than 0.01, respectively). In portal hypertensive gastropathy, endoscopic and EUS detection were coincident. No correlation was found between the presence of portal hypertensive gastropathy, endoscopic grade of esophageal varices, and detection of gastric varices at EUS.

Endoscopic ultrasonography in the diagnosis of gastric submucosal tumor

Endoscopic ultrasonography contributed to a correct diagnosis in 24 of 25 patients with gastric submucosal tumor, including 10 extrinsic compressions and 14 intraparietal growths. Leiomyoma and lipoma were easily recognized. In one case, an unusual group of gastric varices was clearly differentiated from a pedunculated polyp prior to polypectomy. In gastric submucosal tumors, endoscopic ultrasonography can greatly reduce the need for aggressive and risky biopsy techniques or exploratory laparotomy.

Endoscopic demonstration of loss of duodenal folds in the diagnosis of celiac disease

Among 873 patients undergoing upper gastrointestinal endoscopy for various reasons over a two-year period, four had a loss of Kerckring's folds in the descending duodenum. Endoscopic duodenal biopsy in all four patients revealed subtotal villous atrophy due to celiac disease. We undertook a prospective study to evaluate the extent to which this finding predicted celiac disease in 65 consecutive patients referred for intestinal biopsy. Duodenal folds were absent or markedly decreased in 15 of 17 patients with subtotal villous atrophy and in 8 of 48 patients with partial villous atrophy or normal duodenal mucosa, giving a sensitivity of 88 percent and a specificity of 83 percent for this endoscopic finding with respect to celiac disease. We recommend that all patients undergoing upper gastrointestinal endoscopy be examined for the loss or reduction of duodenal folds and, should this be found, that the examination include duodenal biopsy. The value of this procedure as an aid in the diagnosis of celiac disease should be particularly great in patients with minimal, transient, or unrelated symptoms.

The sonographic appearance of the normal gastric wall: an in vitro study

In order to evaluate the real number and anatomical correspondence of the ultrasonographically recognizable layers within the gastric wall, we used a high frequency (7.5 MHz) rotating transducer to examine five surgical specimens of the stomach suspended in a water bath. Five layers were always clearly distinguishable within the gastric wall, whose thickness was 3-6 mm. Fine needles and lancets were localized at the level of the 3rd hyperechoic layer when inserted in the submucosa and in the 4th hypoechoic layer when inserted in the muscolaris propria. Thin echogenic bands were always displayed on both sides of other homogeneous tissues (spleen, myometrium) suspended in water. On the basis of these findings and also taking in account the physical laws of ultrasound interactions with tissues, we conclude that the 1st and the 5th hyperechoic layers are partially generated by ultrasound reflection at the interface liquid/wall. The 2nd hypoechoic layer corresponds to the deepest part of the mucosa; the 3rd hyperechoic to the submucosa and the submucosa/muscularis propria interface and the 4th hypoechoic layer to the muscularis propria.

Problems and variations in the interpretation of the ultrasound feature of the normal upper and lower GI tract wall

The aim of this study was to define the various ultrasound appearances of the normal upper and lower GI tract wall and to discuss current interpretations of the relationship between each echographic layer with the real anatomical structures. We studied a total of 70 patients by means of endoscopic ultrasonography and examined in vitro some surgical specimens of the normal stomach, colon and rectum. We found a 'five layer' structure at the level of the esophageal and gastric wall. This pattern was not recognized in the duodenum during the in vivo study. Our experimental results support the hypothesis that the first and fifth hyperechoic layers of the gastric wall are partially generated by ultrasound reflection at the interface liquid/wall and that the second hypoechoic layer corresponds to the deepest part of the mucosa. Important variations in the thickness of each layer were found in different conditions during in vivo studies. The fourth hypoechoic layer becomes very thin after water distension of the stomach. The in vitro investigation of the specimen of normal colon and rectum showed some different features. At this level it is sometimes possible to distinguish a separate very thin hypoechoic layer in the deepest part of the second layer, probably corresponding to the muscularis mucosae. The muscular layer is sharply divided into two distinct layers related to the circular and longitudinal muscular coats.

Anatomical aspects in ultrasonic endoscopy for the stomach

Gastric wall structure cannot be visualized neither by conventional ultrasonography nor by endoscopy alone. Using a newly developed ultrasonic endoscope (Olympus GF- UM1 / EUM1 Prototype III) twenty-two patients were examined with the stomach filled with 300-500 cc of de- aired water. Ultrasonographic appearance of the normal gastric wall consists of four layers of different echogenicity. The first inner layer, echogenic, seems to correspond to the mucosa and the submucosa, the 2nd echopoor to the muscularis propria, the 3rd echogenic to the serosa and the 4th echopoor to the subserosal-fat. For a complete exploration of the gastric cavity, starting with the scope near the pylorus and withdrawing it until the fundic region, four positions have been standardized. In the first, the antral region is explored, in the 2nd the antrum and the gastric body, in the 3rd the body and antrum and in the 4th position body and fundic region are visualized. For a satisfactory examination a good filling of the stomach must be achieved; problems in interpretation may arise when the gastric wall is not well distended or when peristaltic waves are present. Promising findings have been obtained in 3 cases of cancer involvement of the stomach. No complications were encountered during this study.

Ultrasonographic findings in portal hypertension: correlation with the presence and size of oesophageal varices

This study assesses the usefulness of ultrasonography in the diagnosis of portal hypertension. Several ultrasonographic signs were correlated with the presence and size of oesophageal varices detected by endoscopy in 32 patients suffering from alcoholic liver cirrhosis. Ultrasonography is proposed as a simpler and earlier method for screening of portal hypertension than endoscopy.

Sensitivity of endoscopic retrograde pancreatography in chronic pancreatitis

This study examines the value of endoscopic pancreatography in chronic pancreatitis. With the cooperation of nine departments in Italy, the authors examined the pancreatograms of 1179 patients with chronic pancreatitis. The pancreatograms were abnormal in 80·6 per cent. There were difficulties in distinguishing between cancer and pancreatitis in 11·3 per cent, and difficulty in deciding whether the radiographs were normal or slightly abnormal in 6·8 per cent. The ability of pancreatography to diagnose chronic pancreatitis increased with the duration of the disease, reaching 92·3 per cent in those patients who had had chronic pancreatitis for 5 or more years. However, the failure to obtain a pancreatogram increased as calcification increased. A good correlation between abnormalities of the pancreatogram and of the pancreatic function tests was demonstrated.

An evaluation of endoscopic retrograde pancreatography (ERP) in chronic and relapsing acute pancreatitis

The results of ERP carried out in a series of cases of established and suspected chronic and acute relapsing pancreatitis are presented. Radiological findings are divided into major and minor alterations of the pancreatic secretory system. X-ray findings are easy to interprete in chronic pancreatitis with major alterations. Minor anomalies of the pancreas are difficult to interprete in the absence of supporting evidence. Biliary tract involvement is useful for diagnosis of chronic pancreatitis.

[Eosinophilic gastroenteritis. Report of a clinical case]

An unusual case of eosinophilic gastroenteritis is described, together with its differential diagnosis from allergic enteropathy. Numerous biopsies and other instrumental examinations pointed to small intestine as the only site and eosinophilic enteritis as a suitable classification. Disappearance of the clinical symptoms was obtained with corticosteroid management in the space of 6 months.