Neoplasia and the coeliac syndrome in adults

Ulcerative colitis, primary sclerosing cholangitis and coeliac disease: two cases and review of the literature

The combination of ulcerative colitis, sclerosing cholangitis and coeliac disease is unusual. The two cases described here illustrate that the investigation and management of such patients can be difficult. Other diagnoses should be considered when a patient with a known pathology fails to respond to treatment. Review of the literature suggests an increased malignant potential in these patients. We conclude that patients with a combination of ulcerative colitis, sclerosing cholangitis and coeliac disease should undergo annual colonoscopic surveillance. In those with clinical deterioration and weight loss, early liver and bowel imaging should be carried out.

Thrombocytopenia with absent radii (TAR) syndrome: a new increased cellular radiosensitivity syndrome

A 70-year-old woman with congenital absence of both radii but preservation of the thumb developed a marked pancytopenia after two i.v. injections of 1 g of 5-fluorouracil (5-FU) 1 week apart. She developed bloody diarrhoea after nine fractions of 2 Gy to parallel opposed 16 x 15 cm abdominal fields. This unusual response prompted an investigation of the radiosensitivity of the patient's cells by the sensitive G2 assay of transformed lymphocytes. The radiosensitivity of the patient's lymphoblastoid line appeared to be intermediate between that of normal individuals and an ataxia telangiectasia line. The clinical response and in vitro radiosensitivity testing suggest that the thrombocytopenia with absent radii (TAR) syndrome appears to be one of the inherited impaired DNA repair syndromes and is a very newly described radiation sensitivity syndrome. The development of three separate primary cancers in this patient (small bowel, ovary and bladder) suggests there is an increased risk of neoplasia in this condition.

Atypical carcinoid tumor of the small bowel complicating celiac disease

An atypical carcinoid tumor of the small bowel in a patient with celiac disease is described. Although an increased incidence of malignancy has been observed in celiac disease, this seems to be the first report of a carcinoid tumor of the small intestine associated with this condition. Although the significance of this association is unclear, the implications with regard to gastrointestinal endocrine cell proliferation and tumor histogenesis are discussed.

Jejunal lymphoma in a patient with primary adult-onset hypogammaglobulinemia and nodular lymphoid hyperplasia of the small intestine

A patient is presented with primary adult-onset hypogammaglobulinemia and nodular lymphoid hyperplasia of the small intestine complicated by a jejunal lymphoma. The tumor was resected and was classified as a malignant diffuse histiocytic lymphoma with involvement of mesenteric lymph nodes. Gastroenterological, immunological, histological, and immunopathological studies on this case are reported. The possibility that nodular lymphoid hyperplasia of the small intestine in hypogammaglobulinemia is a premalignant condition is discussed.

The presentation of gastrointestinal lymphoma: study of a population

The clinical presentation and findings in 45 patients with lymphoma of the gastrointestinal tract occurring in an unselected population are described. Nineteen patients presented as emergencies with haemorrhage, perforation, pyloric stenosis or intestinal obstruction. Systemic symptoms, peripheral lymph node enlargement and hepatosplenomegaly were rare, and a preoperative diagnosis of lymphoma was seldom made. Endoscopy was superior to radiology in defining lesions in the stomach and duodenum. Lesions which were multicentric, or of unusual macroscopic appearance, were common in the small bowel, and these should raise the suspicion of lymphoma. Local and systemic recurrence was common, but was not always fatal. Patients with gastric lymphomas survived longer than those with intestinal disease.

Malignancy in a 19-year experience of adult celiac disease

Malignancy has developed in 10 of 93 patients with celiac disease who attended this hospital from 1959 to 1978. Four patients developed lymphoma, 5 a squamous carcinoma of the esophagus, and 1 an adenocarcinoma of the ileum. Because the majority of patients were ingesting varying amounts of gluten at the time of their follow-up no conclusion can be drawn about the possible role of a gluten-free diet in the prevention of malignancy.

Effects of cancer on nutrition: impaired organ system effects

The specific organ system effects of cancer and its treatment have been reviewed from the standpoint of nutritional impact. Nutritional impairment may occur as the result of specific organ system malfunction, and malnutrition itself may impair organ system functions in such a way as to compound these deficits. Nonmalignant, acute, and chronic illnesses resemble cancer in many ways, particularly in their ability to produce malnutrition and these organ system malfunctions. It is apparent that there is nothing particularly unique about many of these cancer states, from the standpoint of nutritional deficiency, that is not found in nonneoplastic conditions.

Intestinal lymphoma complicating dermatitis herpetiformis

A case is reported of a patient with dermatitis herpetiformis who has developed an intestinal lymphoma and a bladder carcinoma during the course of his illness. When considered in conjunction with three recently reported cases it is suggested that intestinal lymphoma may complicate the enteropathy of dermatitis herpetiformis.

Primary upper small-intestinal lymphomal A report of 40 cases fron Iran

Primary upper small-intestinal lymphoma (PUSIL) has now been recognized as a distinct clinical entity with a distinct geographic distribution. Herewith are presented 40 cases of PUSIL seen at Pahlavi University Hospitals in Southern Iran. The investigation reveals the lymphoma to be predominantly a disease of those under 30 and males; the major complaints and physical findings point to an intraabdominal disease. An exception has been clubbing and osteoarthropathy. Special features of PUSIL include: (1) protein loss into the gastrointestinal tract leading to hypoalbuminemia and edema; (2) an antibiotic-responsive diarrhea and steatorrhea; and (3) an associated abnormal heavy-chain protein. The study further stresses the importance of peroral small-intestinal biopsy and the pathologic features of this condition.

Adenocarcinoma of the jejunum associated with nontropical sprue

A patient with a thirty-year history of celiac disease, developed malabsorption and ultimately intestinal obstruction. He failed to respond to a strict gluten-free diet, steroids, and antibiotics. Postmorten examination revealed primary adenocarcinoma of the small bowel. The relationship between adenocarcinoma of the jejunum and celiac disease is reviewed.

Neglected coeliac disease

A review has been carried out of patients diagnosed as having coeliac disease some years previously and subsequently lost to follow-up. Most were unaware of the need for continuing treatment and had returned to a normal diet. The resulting morbidity was slight, although one patient had died of a small-bowel lymphoma. If untreated coeliac disease is indeed a pre-malignant condition, then it is suggested that there must be a large population at risk, with no motivation to return to treatment other than the risk of malignancy itself.

Necropsy studies on adult coeliac disease

The distribution of mucosal changes in adult coeliac disease have been studied in 24 cases within four hours of death. There were six patients on a normal diet who showed flat mucosa in the jejunum, convolutions in the middle third, and digitate villi in the terminal ileum. A more extensive distribution of flat mucosa and convolutions involving most of the small intestine was noted in one case. Eighteen patients had been treated with a gluten-free diet and 11 had responded well clinically and histologically. No evidence of flat mucosa was discovery at necropsy in six of these. Attention is drawn to the high incidence of malignancy in this series (13 out of 24 cases). Other complications of adult coeliac disease are discussed briefly.

Coeliac disease during the teenage period: the value of serial serum folate estimations

A group of teenage coeliac patients has been followed at three monthly intervals in the Outpatient Department to assess their progress and also to monitor their ability to maintain a gluten-free diet. After a follow-up period of four to six years a detailed reassessment was carried out in hospital on 10 patients, only five of whom had persevered with a gluten-free diet. The jejunal mucosal histology of those patients who did not persist with a gluten-free diet remained ;flat' although these patients appeared to have remitted clinically. Those subjects who did persist with a gluten-free regime had a normal or near normal mucosal histology. It was difficult on the basis of clinical, haematological, or biochemical criteria to separate the two groups. The best single assessment of whether these patients were maintaining a gluten-free diet was serial serum folate estimations. It is often extremely difficult to say whether teenage coeliac patients are keeping to their diet unless repeated jejunal biopsies are obtained, and this study suggests that serial serum folate estimations can act as a reasonable criterion of whether subjects are maintaining a gluten-free regime.

Coeliac disease and small bowel carcinoma

Small bowel carcinoma can occur in association with villous atrophy in the jejunum. In most reported cases there is doubt as to which of these represents the primary lesion. These cases are reviewed here. A further case is reported in which a carcinoma developed in a patient known to be suffering from coeliac disease for some years, although he was not on a gluten-free diet for the time preceding the diagnosis of carcinoma. On dietary restriction he remains well at 2-year follow-up. Possible aetiological factors are discussed.

Immunoglobulins and dietary protein antibodies in childhood coeliac disease

Twenty-four children with coeliac disease were compared with a control group, comprising 17 children with a variety of gastroenterological disorders, with respect to serum immunoglobulins and dietary protein antibodies. Elevated levels of IgA and abnormally low levels of IgM were demonstrated in one third of the coeliac patients. Antibodies to at least one of eight dietary proteins were found in 50% of coeliac children. Three children with raised levels of serum IgA and two with deficient IgM were re-examined after varying periods on a gluten-free diet. Antibodies to dietary proteins had waned and immunoglobulin levels returned to normal in all cases. The raised IgA was considered to have resulted from an extensive immunological response to antigens of dietary origin which had entered through the abnormal gut mucosa. It is suggested that IgM deficiency was due to specific inhibition of IgM synthesis by dietary components which had also entered through the mucosa.

Recurrent benign ileal ulcer occurring with the coeliac syndrome

Images