A patient with Cronkhite-Canada syndrome, myxedema and muscle atrophy

A case of Cronkhite-Canada syndrome is presented. The patient had alopecia, onychodystrophy and gastrointestinal polyposis, mainly in the stomach and duodenum, with transient diarrhea and hypoproteinemia. Marked atrophy and weakness of the shoulder girdle muscles due to myopathy were also present. In addition she had primary hypothyroidism. The outcome of the disease is usually fatal within months, but so far our patient is alive four years after the onset of symptoms. The pathological changes, pathophysiology, symptoms, course and treatment of this rare disorder of unknown etiology are discussed.

[Ileal intussusception due to a voluminous inflammatory fibroid polyp. A case report and review of the literature]

An inflammatory fibroid polyp is a rare benign submucosal lesion frequently located in the gastric antrum but it may be found anywhere in the gastrointestinal tract with maximal incidence in the fifth and sixth decades of life. The main histological characteristics are diffuse inflammatory infiltrate with eosinophils, high vascularisation and a myofibroblastic component. Its localisation in the small bowel can cause intestinal invagination in adults, a condition, that occurs most frequently in childhood where, however, it is generally not related to a pathological lesion. The diagnosis may often be delayed because of its non-specific symptoms and most cases are diagnosed at emergency laparotomy, although CT scans can furnish useful preoperative information. In the majority of cases, the treatment of choice is surgical resection. Reduction performed prior to resection proves controversial in patients with colic intussusception because of the high incidence of malignancy. We report a case of a 37-year-old man who had undergone emergency surgery for acute ileum intussusception associated with a voluminous inflammatory fibroid polyp. The case described emphasises that patients with bowel obstruction pose a complex and difficult challenge to surgeons as regards the choice of the correct diagnostic work-up and optimal therapeutic management.

Ileal inflammatory fibroid polyp causing ileocolic intussusception

Inflammatory Fibroid Polyp (IFP) is an extremely rare tumour involving the gastrointestinal tract (GI) and especially the stomach and small bowel. It presents either as a solitary large or sessile lesion arising from the submucosa and despite a large size and sometimes infiltrating growth, the tumour is always benign and has a good prognosis. Histogenesis remains unknown and controversial. We report an ileal case presenting classically and typically with ileocolic intussusception. Diagnosis was made preoperatively with abdominal mdCT. The polyp itself does not have noteworthy radiological signs but must be included in the large essentially histological differential diagnosis of GI tumours.

Small bowel intussusception secondary to inflammatory fibroid polyp of the ileum: report of a case

Inflammatory fibroid polyps are rare benign lesions of uncertain origin, that may occur in many different locations in the gastrointestinal tract, the gastric antrum being the most common site, followed by the small bowel. These lesions can cause abdominal pain, gastrointestinal bleeding, intestinal obstruction or intussusception. In the case of a gastric inflammatory fibroid polyp in the presence of Helicobacter Pylori infection, the patient can benefit from pharmacological eradication of Helicobacter Pylori. In case of an intestinal inflammatory fibroid polyp causing acute abdomen, the treatment is surgical. In this paper we report a case of an adult male patient with ileal intussusception due to an inflammatory fibroid polyp. A 62-year-old male patient presenting with acute abdomen underwent an exploratory laparotomy. At surgery an ileal tumour 15 cm from the ileocecal valve causing ileoileal intussusception was found. The intussuscepted segment was resected and an end-to-end anastomosis was carried out. The postoperative period was uneventful and the patient was discharged 5 days after the surgery. After 6 months, he is doing well and back to normal life. Even if inflammatory fibroid polyps are benign lesions, surgical treatment is the only solution when they present with intestinal intussusception. Preoperative diagnosis of inflammatory fibroid polyps is often difficult, and confirmation can only be obtained by histological and immunohistochemical examination. Since they can mimic malignant stromal lesions, the differential diagnosis must be done very carefully.

True adrenal mesothelial cyst in a patient with flank pain and hematuria: a case report

True mesothelial (epithelial) cysts in the adrenal gland are rare lesions. They represent 9% of adrenal cysts and are much less common than vascular adrenal cysts. We report a case of a true adrenal mesothelial cyst in a patient with flank pain and hematuria that was diagnosed on imaging as a renal cyst. Immunohistochemical studies were performed to investigate the nature of the cyst lining. The positive immunostains for calretinin and WT-1 lend support to the postulate of Medeiros et al nearly 20 years ago of a mesothelial origin for these cysts. The clinical presentation and salient radiologic and pathologic features are described.

[Suspected malignant cancer of the pancreas associated with pseudo-invasive duodenal hamartomas in a patient with Peutz-Jeghers syndrome]

A 29-year-old man with a previously known Peutz-Jeghers syndrome (PJS) was admitted for epigastric pain, emesis and weight loss due to both intestinal intussusception causing bowel obstruction and obstructive pancreatitis. The patient had cholestasis with an enlarged common bile duct on imaging. Because duodenal and/or pancreatic cancer was suspected due to weight loss, the pancreatic and bile duct obstruction, and the increased risk of small intestine and pancreatic adenocarcinoma in patients with PSJ, a pancreatoduodenectomy was performed. Pathological examination revealed a duodenal polyp with epithelial misplacement invading the ampulla and compressing the main bile duct. Twenty months after surgery, there was no relapse of symptoms or cholestasis. This is the first case showing a direct role of pseudo-invasive duodenal harmatomas in the development of biliary obstruction and chronic obstructive pancreatitis.

[Colorectal polyps]

BACKGROUND

Colorectal polyps are common, but there is a large geographical variation--and Norway has one of the highest incidences. There is circumstantial evidence that most cancers develop from polyps; so detection, eradication and follow-up stategies for polyps are important. The article provides an update on these topics.

MATERIAL AND METHODS

The article is based on the authors' own research and clinical experience, and on literature retrieved through a non-systematic search of Pubmed.

RESULTS AND INTERPRETATION

Classification of polyps is based on morphology and histology, and the risk of malignancy depends on both. Colonoscopy is the primary method for detection of polyps; biopsies can be taken and treatment initiated during the procedure. CT colography (virtual colonoscopy) may be on the verge of becoming a diagnostic tool. Pedunculated polyps are usually removed by endoscopical snare resection, which is sufficient even when cancer has developed in the head of the polyp. Large sessile polyps, with considerable risk of malignancy, may be removed by transanal endoscopic microsurgery in the rectum, while surgical localised resection will often be required in the colon. Between these extremes, many polyps may be removed by more advanced endoscopic techniques, and at times with supplementary ablation.

[Inflammatory cloacogenic polyp]

INTRODUCTION

Cloacogenic Polyps are characterized by the presence of inflammatory lesions in the lower rectum, and the anal transition zone. The polyps can prolaps; this is due to the malfunction of the internal anal sphincter; and the smooth muscle that covers the rectum. This is the result of the chronic inflammatory process. The lesions are more common in women during the third and fourth decade of life, however lesion have been described in 10 and 83 year olds. 85% lesions are located above the anal border and predominantly in the anterior lateral wall. The polyps vary in size from 3-4 cm in diameter, and have a sessile appearance.

CASE REPORT

10-year-old female presents with a 3-month history of irregular abdominal pain, with occasional vomiting, constipation, and occasional diarrhea.

CONCLUSIONS

This entity of colon polyps is somewhat rare, and is seen in young adults; however its presence in infancy requires that we think of this entity when we formulate our differential diagnosis. Due to the character of the lesions, this entity could be confused with colorectal malignant tumors. All children and infants with a rectal mass, and blood in their stools should get a biopsy sent for histopathology. This technique can aid in analyzing the origin of the lesion.

[Distal hyperplastic polyps as a marker for advanced neoplasm of the proximal colon. Our experience]

BACKGROUND AND AIM

While, several studies indicate that there is an association between proximal and distal colorectal adenomas, no agreement seems to be between the presence of distal hyperplastic polyps and proximal neoplasia. The aim of this study was to investigate, retrospectively, the possible correlation between the distal hyperplastic polyps and proximal colorectal neoplasia.

MATERIALS AND METHODS

In our GI Unit, from 1st February 2006 to 24 November 2006, we performed 142 polypectomy. Patients were 36 females and 80 males, with a median age of 66 years [range: 38-87 years]. All of the polpys were resected during colonoscopy and sent for histological study. Chi-square test was used for statistical analysis. A probability value of P< or =0.05 was considered to be statistically significant.

RESULTS

Histological study showed the following results: 33 hyperplastic polyps (8 F, 21 M; median age 63 years), 100 adenomas (26 F, 61 M; median age 67 years) and 2 inflammatory polpys (2 F, 0 M; median age 71 years). The rectal localization was associated with a significantly higher frequency of hyperplastic polyps (63.6% vs 23.5%), OR: 5.688 (95% C.I. 2.445-13.230) (p<0.0001). Five hyperplastic polyps of the rectum were associated with 5 adenomas located 1 in the rectum, 2 in the sigmoid colon, and 1 in the descendens colon and 1 in the ascendens colon. While, 5 adenomas were associated with 5 adenocarcinoma.

CONCLUSIONS

Guidelines from the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy do not recommend colonoscopy for patients with distal hyperplastic polyps. Also our study is in keeping with the data of the literature and it confirmed that rectal localization is associated with a higher prevalence of hyperplastic polyps.

Bleeding Jejunal Dieulafoy Pseudopolyp: Capsule Endoscopic Detection and Laparoscopic-Assisted Resection

In this paper, we report a case of bleeding solitary jejunal Dieulafoy pseudopolyp that was detected on capsule endoscopy and treated with a laparoscopic-assisted transumbilical polypectomy procedure. This case illustrates an innovative, tailored application of minimal invasive techniques in the management of a relatively uncommon lesion. To our knowledge, this is the first case report of the combination of capsule endoscopy and laparoscopic-assisted transumbilical resection for a bleeding jejunal Dieulafoy pseudopolyp in children.

Café au lait macules and juvénile polyps

Several hereditary and nonhereditary gastrointestinal tract polyposis syndromes exhibit extra-intestinal manifestations, including cutaneous findings. However, a lack of information exists regarding cutaneous features of juvenile polyposis. Our objective was to document the prevalence of cutaneous hyperpigmented lesions in children with juvenile polyposis coli or juvenile polyposis coli and their first degree relatives.Children seen in the gastroenterology practice at The Children's Hospital in Denver, Colorado with polyps (juvenile polyposis coli, sporadic juvenile polyps, and familial adenomatous polyposis coli) and their first degree relatives were invited to participate in the study. A comprehensive skin examination was performed on those who consented to participate. We found that 8 of 14 patients (eight with juvenile polyposis coli, four with juvenile polyposis, and two with familial adenomatous polyposis coli) had at least one café-au-lait macule, compared with three of 27 relatives (p=0.003).The prevalence of at least one café-au-lait macule in our patients (8/14 or 57.1%, CI: 28.9–82.3%) was significantly higher than the general population prevalence of 28.5% (p=0.023). However, if the two patients with familial adenomatous polyposis coli were excluded, the comparison with the general population prevalence did not reach statistical significance (p=0.095). The prevalence of multiple cafe´-au-lait macules in our patients (4/14 or 28.6%; CI:8.4–58.1%) was significantly higher than the general population prevalence of 5.2% (p ¼ 0.005). A notable finding was the presence of multiple café -au-lait macules in 4 of 12 juvenile polyposis coli/juvenile polyposis patients.Two patients with juvenile polyposis coli also had lentigines. In this selected case series, we observed single or multiple café-au-lait macules in a high proportion of children with the three types of polyps. Further studies are needed to assess a possible common pathway for hamartomatous polypsand café-au-lait macules.

Rectal bleeding in children: endoscopic evaluation revisited

OBJECTIVES

Rectal bleeding is an alarming event both for the child and parents. It is hypothesized that colonoscopy instead of sigmoidoscopy and adding esophago-gastro-duodenoscopy in case of accompanying complaints, improves the diagnostic accuracy in children with prolonged rectal bleeding.

STUDY DESIGN

All pediatric patients undergoing colonoscopy because of prolonged rectal bleeding over an 8-year period at the Emma Children's Hospital/Academic Medical Centre were reviewed. Patient demographics, clinical features, number and extent of endoscopic examinations and the endoscopic and histopathological findings were assessed.

RESULTS

A total of 147 colonoscopies were performed in 137 pediatric patients (63 boys) because of prolonged rectal bleeding. Inflammatory bowel disease and polyp(s) were the most prevalent diagnoses. In 72% of patients diagnosed as Crohn's disease, focal, chronically active gastritis was seen on histology, giving support to the diagnosis Crohn's disease. In 22% of the cases polyps would have been missed in the case where only sigmoidoscopy was performed. No complications after endoscopic intervention were seen.

CONCLUSIONS

Colonoscopy is the investigation of choice in children with prolonged rectal bleeding. In patients presenting with accompanying complaints such as abdominal pain or diarrhea, it is advisable to perform ileocolonoscopy combined with esophago-gastro-duodenoscopy. This combines a high diagnostic yield with a safe procedure.

Radio-guided resection of non-palpable rectal carcinoma following polypectomy

Due to widespread use of screening procedures for colorectal cancer, an increasing number of colorectal malignancies is diagnosed at an early stage. A special subgroup of these patients has polyp carcinoma, which can be diagnosed with histological examination of the removed specimen. In such cases the exact intraoperative localization of the non-palpable lesion is a greater challenge than resection itself. In our case report, radio-labeled colloid was used to identify non-palpable rectal carcinoma after polypectomy in a high risk patient. Using a navigator device, the submucosal injected colloid was detected on the surface of the bowel determining the proper resection level. The proper resection level was double checked with metal clips and by histology. Radio-guided technique may be a preferable method to identify non-palpable colon lesions before surgical treatment.

Jejunojejunal intussusception caused by an inflammatory fibroid polyp. Case report and review of the literature

Inflammatory fibroid polyps (IFPs) are rare benign submucosal growth of the gastrointestinal tract. The exact pathogenesis is still not well known. Clinical symptoms are variable. Physical exam and laboratory tests are helpful in establishing the diagnosis ; however, microscopic examination of the resected lesions is required to confirm the diagnosis of IFPs. Surgical resection of the lesion remains the primary therapy. Jejunojejunal intussusception secondary to IFPs in particular has only rarely been reported. We have reviewed all documented cases and added a new one to the literature. In this paper, we examine pertinent pathologic, epidemiologic, clinical, diagnostic, and therapeutic characteristics of this clinical entity.

Hyperplastic polyps of the duodenum: an unusual histological finding

A 58-year-old man underwent upper gastrointestinal surveillance endoscopy for Barrett's oesophagus. This showed a possible gastric ulcer, although histological examination was normal. Follow-up endoscopy showed white ridges in the distal duodenum and these were subjected to biopsy. Histological examination of the biopsy specimens showed polypoid duodenal mucosa showing features similar to those of a hyperplastic polyp of the colon. In addition, the mucosal surface was focally of gastric surface type. The features were interpreted overall as most likely to represent an unusual form of regenerative change in the setting of previous chronic inflammatory mucosal damage. The case is presented as an unusual histological phenomenon at this site; it would be important not to overdiagnose neoplasia in this situation.

Resection of over 290 polyps during emergency surgery for four intussusceptions with Peutz-Jeghers syndrome: Report of a case

A 41-year-old male patient with aggravated epigastralgia and nausea was admitted to Central Aizu General Hospital in February 1997. His past history showed a colonic polyp and anemia in the fourth decade. The patient looked healthy, but showed abdominal distension and tenderness, and pigmented lips. A plain abdominal X-ray revealed a dilation of the small intestine with niveau. Computed tomography disclosed multiple target signs. An emergency laparotomy clarified four intussusceptions of the small intestine with numerous polyps. Three were successfully reduced, while one jejunal intussusception was resected. Due to a fear of recurrence, a total of over 290 polyps were removed. His illness was diagnosed to be Peutz-Jeghers syndrome with a histology of hamartomatous polyps. He thereafter did well for 6 years, when he underwent an ileal resection for another intussusception caused by a newly grown lipoma. He was able to retain his job, but anemia and hypoproteinemia due to the proliferation of polyps necessitated treatments at the outpatient clinic. In May 2005, he underwent a third emergency laparotomy for an intussusception, followed by a resection of the ileum and 54 polyps. Since then he has been able to lead a normal life.

Feasibility of double-balloon enteroscopy-assisted chromoendoscopy of the small bowel in patients with familial adenomatous polyposis

BACKGROUND AND STUDY AIMS

Patients with familial adenomatous polyposis (FAP) are at increased risk of developing duodenal and jejunal adenocarcinomas. The aim of this study was to assess the usefulness of double-balloon enteroscopy- (DBE-) assisted chromoendoscopy for the detection and characterization of small-bowel polyps in patients with FAP.

PATIENTS AND METHODS

We performed a prospective evaluation of patients with clinically and genetically proved FAP who were enrolled in an endoscopic surveillance program. DBE was performed using a Fujinon intestinoscope (FN 450P 5/20; Fujinon Corp., Omiya, Japan), and chromoendoscopy was performed using indigo carmine. The severity of small bowel polyposis was based on the Spigelman-Saurin classification.

RESULTS

Nine patients underwent DBE-assisted chromoendoscopy. Small-bowel polyps (including papillary adenomas) were detected in seven patients (88 %). The mean depth of small-bowel insertion was 180 cm (range 120-320 cm). The mean Spigelman-Saurin score was 4.6 (range 0-8). Jejunal polyps were detected in six patients (67 %). Chromoendoscopy aided in the detection of additional polyps in two patients. In one patient the polyps were flat and only visible with chromoendoscopy (biopsy confirmed these to be adenomas). Jejunal polyps and advanced neoplasms were more frequent in patients with APC gene mutations in exon 15. The following endoscopic therapies were performed: polypectomy (n = 1), duodenal mucosectomy (n = 1), and ablation therapy with argon plasma coagulation (n = 2).

CONCLUSIONS

DBE was found to be a helpful method for the evaluation of small-bowel polyps in patients with FAP. DBE-assisted chromoendoscopy was of further assistance for the detection of jejunal polyps.