Clinical significance of duodenal lymphangiectasia incidentally found during routine upper gastrointestinal endoscopy

Video capsule endoscopy findings in dogs with chronic enteropathy and in healthy dogs

BACKGROUND

Video capsule endoscopy is a noninvasive technique for evaluation of the gastrointestinal tract.

OBJECTIVE

To investigate the safety of using the video capsule ALICAM in dogs with chronic enteropathy (CE) >10 kg, and to compare macroscopic gastrointestinal morphology between CE dogs and healthy controls (HC).

ANIMALS

Fifteen CE dogs and 15 similarly breed, age and body weight matched HC.

METHODS

All dogs underwent a clinical work up including blood analyses, fecal samples, abdominal ultrasonographic examination, and blood pressure measurement. The dogs were withheld from food for 16 hours before and 8 hours after they PO received an ALICAM. All recordings were quality assessed, and blindly evaluated by 2 trained observers.

RESULTS

The median age of CE dogs and HC was 3.3 (interquartile range [IQR] 2.5-5.9) years and 4.7 (IQR 3.3-5.6) years, respectively. The median body weight in the CE dogs and HC was 25.9 (IQR 20.6-30.9) kg, and 29 (IQR 16.2-30.5) kg, respectively. Complete recordings of the gastrointestinal tract were obtained from all dogs without complications. No significant differences were found between groups regarding number of abnormalities such as irregular mucosa, erythema, nonbleeding erosions, bleeding erosions, and dilated lacteals, as well as severity and extent of the abnormalities.

CONCLUSIONS AND CLINICAL IMPORTANCE

The use of ALICAM for evaluation of the gastrointestinal tract in CE dogs and HC seems safe and feasible regarding gastrointestinal transit and macroscopic morphology assessment in dogs >10 kg. Abnormalities were found in similar proportions in CE dogs and HC.

Intestinal lymphangiectasia: Understanding the bigger picture

Intestinal lymphangiectasia (IL) is characterized by the dilation of intestinal lymphatic vessels, which can rupture and cause loss of lymph into the intestine. Due to the high content of proteins, lipoproteins, and lymphocytes in the intestinal lymph, loss of lymph might result in hypoproteinemia, hypoalbuminemia, hypogammaglobulinemia, and lymphocytopenia. In addition, there may be a depletion of minerals, lipids, and fat-soluble vitamins. IL can be primary due to inherent malfunctioning of the lymphatic system, or secondly, a result of various factors that may hinder lymphatic drainage either directly or indirectly. This condition has emerged as a subject of significant clinical interest. Given that the intestinal lymphatic system plays an important role in the body's fluid homeostasis, adaptive immunity, nutrient and drug absorption, intestinal transport, and systemic metabolism, its dysfunction may have wider implications. Although primary IL is rare, with varied clinical features, complications, treatment response, and outcomes, secondary IL is more common than previously believed. The definitive diagnosis of IL requires endoscopic demonstration of whitish villi (which frequently resemble snowflakes) and histological confirmation of dilated lacteals in the small intestinal mucosa. Treatment of IL is challenging and involves dietary modifications, managing underlying medical conditions, and using medications such as sirolimus and octreotide. Recognizing its prevalence and diverse etiology is crucial for targeted management of this challenging medical condition. This article provides a comprehensive exploration of the clinical implications associated with IL. In addition, it offers valuable insights into critical knowledge gaps in the existing diagnostic and management landscape.

Polypoid Lymphangiectasia in the Sigmoid Colon: A Case Report of a Rare Entity

Intestinal polypoid lymphangiectasia is an uncommon disorder involving an improperly formed enteric lymphatic system. It is characterized by lymphatic vessel dilatation with impaired drainage or obstruction of the lymph from the intestine. In this report, we present a case of a 73-year-old male patient with chronic intermittent left lower quadrant abdominal pain for one year who was found to have a sigmoid colon polyp on a colonoscopy. Upon microscopic examination, the polyp revealed dilated lymphatic vessels staining strongly for D2-40 (lymphatic vessel marker), supporting the diagnosis of polypoid lymphangiectasia. Intestinal lymphangiectasia has a broad differential diagnosis, warranting histopathological examination for a definitive diagnosis.--------------.

Therapeutic Banding for Bleeding Duodenal Lymphangiectasias: A Novel Approach

With endoscopic advancements, the number of detected intestinal lymphangiectasias has been on the rise. They are generally considered benign and incidental; occasionally, these lesions carry complications, and best management options need to be established. Bleeding intestinal lymphangiectasias should be considered a rare cause in the differential diagnosis for gastrointestinal bleeding. References in the literature primarily indicate surgical treatment in these situations. In this study, we report an uncommon case of a man with esophageal adenocarcinoma who developed acute gastrointestinal bleeding from duodenal lymphangiectasias that were successfully banded.

Deterioration of duodenal lymphangiectasia after radiotherapy for gastric MALT lymphoma

A 68-year-old Japanese woman underwent radiotherapy for gastric lymphoma. Although lymphangiectasia was sparsely observed in the second portion of the duodenum before radiotherapy, the number of pinpoint white spots obviously increased after the treatment. Although the duodenal lymphangiectasia gradually progressed, the patient had no features of protein-losing enteropathy. This case highlights the importance of endoscopic observation of the duodenum after irradiation to the abdomen as radiotherapy may secondarily cause intestinal lymphangiectasia.

Lymphangiomatous Lesions of the Gastrointestinal Tract: A Clinicopathologic Study and Comparison Between Adults and Children

OBJECTIVES

Lymphangiomatous lesions involving the gastrointestinal (GI) tract remain incompletely characterized, and their clinical and histopathologic features have not been systematically evaluated. The distinction between a primary lymphatic malformation (lymphangioma) and a dilation of existing lymphatics (lymphangiectasia) is of clinical significance, since lymphangiectasia may occur in the setting of lymphatic obstruction due to an unsampled malignancy. We describe clinical and morphologic features of lymphangiomas of the GI tract in adult and pediatric populations and contrast them with lymphangiectasia.

METHODS

We performed a retrospective review of adult and pediatric lymphangiomas and lymphangiectasia involving the GI tract.

RESULTS

Thirty-six cases of lymphangioma and lymphangiectasia were retrieved, and clinical presentation and histologic features were compared. Lymphangiomas had distinct clinical presentations in adults and children, with adult lesions being more frequently asymptomatic and more frequently involving the superficial mucosal layers of the GI tract. Microscopically, lymphangiomas mostly consisted of confluent dilated spaces with a smooth muscle component. This appearance differed from lymphangiectasia, which lacked a complete distinct endothelial or smooth muscle lining and diffusely involved the mucosa and submucosa.

CONCLUSIONS

Morphologic features of GI tract lymphangiomas can be reliably distinguished from lymphangiectasia by clinical and pathologic characteristics.

Behçet disease and protein-losing enteropathy due to intestinal lymphangiectasia

We report an unusual case of a patient with Behçet's disease that developed protein-losing enteropathy due to intestinal lymphangiectasia.

Intestinal lymphangiectasis and lipidosis in rats following subchronic exposure to indole-3-carbinol via oral gavage

To investigate the toxicity and carcinogenic potential of indole-3-carbinol (I3C), the National Toxicology Program has conducted 13-week subchronic studies in Fisher 344 rats and B6C3F1 mice, and chronic 2-year bioassays in Sprague-Dawley rats and B6C3F1 mice. While the chronic study results are not yet available, subchronic study results and short-term special evaluations of interim sacrifices in the 2-year rat bioassay are presented. F344 rats were orally gavaged ≤300 mg I3C/kg body weight 5 days a week for 13 weeks. Rats treated with ≥150 mg/kg demonstrated a dose-related dilation of lymphatics (lymphangiectasis) of the duodenum, jejunum, and mesenteric lymph nodes. Material within dilated lacteals stained positively for Oil Red O and Sudan Black, consistent with lipid. Electron microscopic evaluation confirmed extracellular lipid accumulation within the villar lamina propria, lacteals, and within villar macrophages. Analyses of hepatic and pulmonary CYP1A enzymes demonstrated dose-dependent I3C induction of CYP1A1 and 1A2. B6C3F1 mice orally gavaged ≤250 mg I3C/kg body weight did not demonstrate histopathological changes; however, hepatic CYP induction was similar to that in rats. The histopathologic changes of intestinal lymphangiectasis and lipidosis in this study share similarities with intestinal lymphangiectasia as observed in humans and dogs. However, the resultant clinical spectrum of protein-losing enteropathy was not present.

The endoscopic course of scattered white spots in the descending duodenum: a prospective study

AIM

Scattered white spots (SWSs) in the descending duodenum are an uncommon finding of upper gastrointestinal system endoscopy (UGSE). Intestinal lymphangiectasia, chronic nonspecific duodenitis and giardiasis are associated with a SWS appearance. The aim of this study was to determine the frequency of SWS during routine endoscopy, as well as to evaluate the effect of treatment on this finding.

MATERIALS AND METHODS

Patients undergoing UGSE with a SWS appearance in the descending duodenum were included prospectively. Appearance of SWSs was graded endoscopically based on density, after which patients were divided into two groups; group 1 (treated group) and group 2 (untreated group). Patients with Helicobacter pylori infection were given eradication therapy, whereas a diet was recommended to patients with intestinal lymphangiectasia. Proton pump inhibitors were initiated for patients with H. pylori negative gastritis. All patients were re-evaluated three months after therapy for the presence of any changes in the SWS appearance.

RESULTS

SWSs were observed in 97 (3.2%) out of 3010 patients. This appearance was most commonly associated with chronic non-specific duodenitis followed by intestinal lymphangiectasia. While in the untreated group no statistically significant change in SWS appearance was observed, the decrease in endoscopic grade seen in the treated group was statistically significant (p<0.001).

CONCLUSION

The prevalence of SWSs during routine UGSE was 3.2%, with this finding being more commonly associated with chronic non-specific duodenitis and intestinal lymphangiectasia. Treatment of the underlying causes, including H. pylori eradication, proton pump inhibitors and diet decreased the density of the SWSs.

Intestinal lymphangiectasia in adults

Intestinal lymphangiectasia in the adult may be characterized as a disorder with dilated intestinal lacteals causing loss of lymph into the lumen of the small intestine and resultant hypoproteinemia, hypogammaglobulinemia, hypoalbuminemia and reduced number of circulating lymphocytes or lymphopenia. Most often, intestinal lymphangiectasia has been recorded in children, often in neonates, usually with other congenital abnormalities but initial definition in adults including the elderly has become increasingly more common. Shared clinical features with the pediatric population such as bilateral lower limb edema, sometimes with lymphedema, pleural effusion and chylous ascites may occur but these reflect the severe end of the clinical spectrum. In some, diarrhea occurs with steatorrhea along with increased fecal loss of protein, reflected in increased fecal alpha-1-antitrypsin levels, while others may present with iron deficiency anemia, sometimes associated with occult small intestinal bleeding. Most lymphangiectasia in adults detected in recent years, however, appears to have few or no clinical features of malabsorption. Diagnosis remains dependent on endoscopic changes confirmed by small bowel biopsy showing histological evidence of intestinal lymphangiectasia. In some, video capsule endoscopy and enteroscopy have revealed more extensive changes along the length of the small intestine. A critical diagnostic element in adults with lymphangiectasia is the exclusion of entities (e.g. malignancies including lymphoma) that might lead to obstruction of the lymphatic system and “secondary” changes in the small bowel biopsy. In addition, occult infectious (e.g. Whipple’s disease from Tropheryma whipplei) or inflammatory disorders (e.g. Crohn’s disease) may also present with profound changes in intestinal permeability and protein-losing enteropathy that also require exclusion. Conversely, rare B-cell type lymphomas have also been described even decades following initial diagnosis of intestinal lymphangiectasia. Treatment has been historically defined to include a low fat diet with medium-chain triglyceride supplementation that leads to portal venous rather than lacteal uptake. A number of other pharmacological measures have been reported or proposed but these are largely anecdotal. Finally, rare reports of localized surgical resection of involved areas of small intestine have been described but follow-up in these cases is often limited.

Small bowel lymphangiectasia and angiodysplasia: a positive association; novel clinical marker or shared pathophysiology?

INTRODUCTION

Small bowel angiodysplasia accounts for 30 to 40% of cases of obscure gastrointestinal bleeding and is associated with significant morbidity and mortality. Identifying lesions can be difficult. Small bowel capsule endoscopy (SBCE) is a significant advance on earlier diagnostic techniques. The cause of angiodysplasia is unknown and the natural history poorly understood. Many lesions are thought to arise from a degenerative process associated with ageing, local vascular anomalies, and tissue hypoxia. Nonpathologic lymphangiectasias are commonly seen throughout the small bowel and are considered a normal finding.

AIMS

To determine whether there is an association between lymphangiectasias, angiodysplasia, and atherosclerosis related conditions.

METHODS

Relevant information was collected from a dedicated SBCE database. Logistic regression analysis was used to examine associations between angiodysplasia, lymphangiectasia, patient demographics, and comorbidity.

RESULTS

In all, 180 patients underwent SBCE during the study period, 46 (25%) had angiodysplasia and 47 (26%) lymphangiectasia. Lymphangiectasia were seen in 24 (52%) of 46 with angiodysplasia, in 16 (19%) of 84 with obscure gastrointestinal bleeding without angiodysplasia and in 7 (14%) of 50 without gastrointestinal bleeding. Logistic regression analysis confirmed a strong positive association between angiodysplasia and lymphangiectasia; odds ratio 4.42, P<0.003. Angiodysplasias were also associated with increasing age; odds ratio 1.1. There was no correlation with any other patient characteristic.

CONCLUSIONS

Lymphangiectasia are strongly associated with the presence of small intestinal angiodysplasia and may represent a useful clinical marker for this condition. Angiodysplasia are also associated with increasing age. Conditions associated with systemic atherosclerosis did not increase the risk of angiodysplasia.

Diagnostic value of intraoperative endoscopic examination in patients with intestinal lymphangiectasia: an analysis of 6 cases

AIM: To assess the diagnostic value of intraoperative endoscopic examination in patients with intestinal lymphangiectasia (IL).

METHODS: Six patients with IL and protein-losing enteropathy underwent intraoperative endoscopic examination during the study. Intraoperative endoscopic examination was performed via an intestinal incision to locate the site of lymph fluid leakage.

RESULTS: Endoscopic findings included white fluid in the intestinal lumen, multiple scattered white spots, and white and swollen villi in all the 6 patients, polyps in 3 patients, and mucosal erosion in 2 patients. After subserosal injection of methylene blue, the sites of lymph fluid leakage were successfully located in 5 patients (83.3%).

CONCLUSION: Endoscopic examination is a very important diagnostic test for patients with IL, especially for locating the site of lymph fluid leakage.