Surgery in (pre)malignant celiac disease

AIM: To report the outcome of surgery in patients with (pre)malignant conditions of celiac disease (CD) and the impact on survival.

METHODS: A total of 40 patients with (pre)malignant conditions of CD, ulcerative jejunitis (n = 5) and enteropathy associated T-cell lymphoma (EATL) (n = 35), who underwent surgery between 2002 and 2013 were retrospectively evaluated. Data on indications, operative procedure, post-operative morbidity and mortality, adjuvant therapy and overall survival (OS) were collected. Eleven patients with EATL who underwent chemotherapy without resection were included as a control group for survival analysis. Patients were followed-up every three months during the first year and at 6-mo intervals thereafter.

RESULTS: Mean age at resection was 62 years. The majority of patients (63%) underwent elective laparotomy. Functional stenosis (n = 13) and perforation (n = 12) were the major indications for surgery. In 70% of patients radical resection was performed. Early postoperative complications, mainly due to leakage or sepsis, occurred in 14/40 (35%) of patients. Eight patients required reoperation. More patients who underwent resection in the acute setting (n = 3, 20%) died compared to patients treated in the elective setting. With a median follow-up of 20 mo, seven patients (18%) required reoperation due to long-term complications. Significantly more patients who underwent acute surgery could not be treated with adjuvant chemotherapy. Patients who first underwent surgical resection showed significantly better OS than patients who received chemotherapy without resection.

CONCLUSION: Although the complication rate is high, the preferred first step of treatment in (pre)malignant CD consists of local resection as early as possible to improve survival.

Surgical aspects of celiac disease

Celiac disease, characterized by intestinal inflammation and malabsorption, occurs in 1 per cent of the population and is often undiagnosed. These patients are at increased risk for surgical procedures resulting from symptoms, associated intestinal disorders, and malignancy. Our aim was to determine the incidence and outcome of abdominal operations in patients with celiac disease. Records of 512 adult patients with celiac disease evaluated over a 22-year period were reviewed. Operations were classified as related or unrelated to celiac disease. One hundred eighty-eight (36%) of 512 patients underwent abdominal operations. One hundred twenty-seven (68%) of the 188 patients had unrelated procedures. Sixty-one (32%) had operations considered related to celiac disease. Twenty-six (43%) of 61 with related procedures were diagnosed preoperatively. Procedures were performed for pain, obstruction, motility disorders, and malignancy. Six patients had recurrent pancreatitis. Seven patients underwent liver transplantation. Thirty-five (57%) related procedures led to the diagnosis of celiac disease including "unmasking" (n = 25) and diagnostic findings (n = 10). One-third of patients with celiac disease undergo abdominal operations of which one-third are related to celiac disease. Operations are related to complications of celiac disease and often lead to the initial diagnosis.

Hematopoietic stem cell transplantation for non-malignant gastrointestinal diseases

Both, autologous and allogeneic hematopoietic stem cell transplantation (HSCT) can be used to cure or ameliorate a variety of malignant and non-malignant diseases. The rationale behind this strategy is based on the concept of immunoablation using high-dose chemotherapy, with subsequent regeneration of naive T-lymphocytes derived from reinfused hematopoietic progenitor cells. In addition, the use of HSCT allows for the administration of high-dose chemotherapy (whether or not combined with immunomodulating agents such as antithymocyte globulin) resulting in a prompt remission in therapy-refractory patients. This review gives an update of the major areas of successful uses of HSCT in non-malignant gastrointestinal disorders. A Medline search has been conducted and all relevant published data were analyzed. HSCT has been proved successful in treating refractory Crohn’s disease (CD). Patients with refractory celiac disease type II and a high risk of developing enteropathy associated T-cell lymphoma have shown promising improvement. Data concerning HSCT and mesenchymal SCT in end-stage chronic liver diseases are encouraging. In refractory autoimmune gastrointestinal diseases high-dose chemotherapy followed by HSCT seems feasible and safe and might result in long-term improvement of disease activity. Mesenchymal SCT for a selected group of CD is promising and may represent a significant therapeutic alternative in treating fistulas in CD.

[Intraoperative ultrasound duplex scanning in the diagnosis and assessment of results of surgical treatment of patients with celiac compression syndrome]

The authors have performed an analysis of main indicators of celiac duplex scanning in 180 patients with celiac compression syndrome before operation, during decompression and at the postoperative period. All the patients underwent surgical celiac trunk decompression. The indicators of the intraoperative celiac duplex scanning (stenosis degree, linear peak systolic circulation rate) of the celiac trunk shower hemodynamic reliable stenosis and were sufficiently different from preoperative findings. The stenosis degree and linear peak systolic circulation rate were less during intraoperative examination than before the operation. Intraoperative, duplex canning allowed compressive stenosis of the seliac trunk to be differentatied in some patients from intravasal one (atherosclerosis and arteritis), and its adequate decompression to be performed. When performing the celiac trunk decompression it is thought to be necessary to fulfill its intraoperative ultrasound duplex scanning before and after elimination of the compression.

[Adenocarcinoma of the small intestines complicating coeliac disease in an adult: case report]

Coeliac disease is an auto-immune disease due to gluten intolerance. One per cent of the European population is concerned. This small bowel adenocarcinoma is rare and concerns less than 5% of the digestive neoplasias. However the frequency of this rare cancer is higher in presence of coeliac disease. We are reporting the case of a 67-years-old woman whose coeliac disease has been complicated 5 years thereafter by a jejunal adenocarcinoma. The latter was found during an etiology search for iron deficiency anemia.

Aplastic anaemia in association with coeliac disease: a series of three cases

We report a series of three patients in whom the diagnoses of aplastic anaemia (AA) and coeliac disease were made concurrently. Haematological manifestations of coeliac disease are well described but this is the first report to suggest an association with aplastic anaemia. 'Silent/atypical coeliac disease', in the absence of gastrointestinal symptoms, is increasingly recognised and patients may present with generalised symptoms, such as malaise and fatigue, which are easily attributable to AA. Immunosuppressive therapy for AA could modulate the course of celiac disease. We recommend clinicians should be vigilant for signs of coeliac disease in patients with AA.

[Double-balloon enteroscopy for the diagnosis and treatment of patients with unexplained gastrointestinal blood loss]

In 3 patients, 2 women aged 56 and 57 and a 65-year-old man, who presented with overt and occult gastrointestinal bleeding, no focus of the bleeding could be found during gastroscopy and colonoscopy. The patients were then examined and treated by double-balloon enteroscopy (DBE). DBE is a relatively new endoscopic technique that allows high-resolution visualisation of the entire small intestine with full endoscopic instrumentation. The 56-year-old woman had coeliac disease and an enteropathy-associated T-cell lymphoma with stenoses over approximately 150 cm of bowel length. She was given chemotherapy and responded well. The 57-year-old woman suffered from Rendu-Osler-Weber syndrome with multiple angiodysplasias in the small intestine. She was treated 5 times with argon plasma coagulation during DBE, for more than 40 angiodysplasias, and thereafter no longer needed blood transfusions. The 65-year-old man had a history of recurrent melanoma. During DBE, multiple metastases of a melanoma in the small intestine were found and tattooed. The tumours were later surgically excised, with no further metastases in the following 2 years. DBE has proven to be a good diagnostic and therapeutic tool in the management of small intestinal diseases.

Autologous hematopoietic stem cell transplantation in refractory celiac disease with aberrant T cells

Autologous hematopoietic stem cell transplantation (ASCT) is an increasingly accepted treatment for refractory autoimmune diseases. Refractory celiac disease with aberrant T cells (RCD type II) is unresponsive to available therapies and carries a high risk of transition into enteropathy associated T-cell lymphoma (EATL). This study reports on the feasibility, safety, and efficacy of ASCT in patients with RCD type II. Thirteen patients with RCD type II were evaluated. Seven patients (4 men, 3 women, mean age 61.5 years [range, 51-69 years]) underwent transplantation. After conditioning with fludarabine and melphalan, ASCT was performed. Patients were monitored for response, adverse effects, and hematopoietic reconstitution. All 7 patients completed the mobilization and leukapheresis procedures successfully and subsequently underwent conditioning and transplantation. Engraftment occurred in all patients. No major nonhematologic toxicity or transplantation-related mortality was observed. There was a significant reduction in the aberrant T cells in duodenal biopsies associated with improvement in clinical well-being and normalization of hematologic and biochemical markers (mean follow-up, 15.5 months; range, 7-30 months). One patient died 8 months after transplantation from progressive neuroceliac disease. These preliminary results showed that high-dose chemotherapy followed by ASCT seems feasible and safe and might result in long-term improvement of patients with RCD type II whose condition did not respond promptly to available drugs.

Pancreatic mucinous cystadenoma associated with celiac disease and polycystic kidneys. Case report and short review of the literature

We report a case of giant benign pancreatic mucinous cystadenoma in a 19-year-old woman with celiac disease and polycystic kidneys. She presented with a history of moderate episodic left flank pain evolving for a few weeks before becoming acute the night before her admission. We provide radiological and histological material and a short review of the literature.

[Problems of differential diagnosis of lymphoma and celiac disease. A case report]

An association between celiac disease and non-Hodgkin's lymphoma of the small intestine has been recognized for many years. Coeliac disease is characterized by an enteropathy sensitive to gluten, malabsorption of food and partial or total villous atrophy. Also malignant lymphoma may present with malabsorption and mucosal lesion similar to that found in coeliac patients. The diagnosis of lymphoma in coeliac patients can be extremely difficult because the presenting symptoms and histological lesion are similar, but the presence of a cluster of symptoms such as abdominal pain malabsorption, weight loss in patients older than 40 years with a history of poorly responsive coeliac disease should raise a suspicion of malignancy. We present a case of 55 year-old man with malignant lymphoma and coeliac disease surgically treated in our Institute for intestinal obstruction.

Small bowel biopsy in Swedish paediatric clinics

The capsule technique for small bowel biopsy performed at Swedish paediatric clinics was evaluated using two questionnaires in 1990 and 1993, respectively. Replies were received from all 45 centres which together perform approximately 2300 biopsies per year. Clotting function tests prior to biopsy were carried out in 42% of the centres. The biopsies were performed under intubation anaesthesia in 13% of the centres. The most striking difference between the answers to the two questionnaires was the mode of sedation. The use of intravenous sedatives increased from 40% of the centres in the first questionnaire to 59% in the second one. The use of the oral, rectal and intramuscular routes decreased correspondingly. The most frequently used drugs for intravenous sedation were benzodiazepines, in the first questionnaire diazepam and in the second one midazolam. The failure rate was approximately 5%. In the first questionnaire, no complication was encountered. In the second questionnaire, three cases of intramural duodenal haematoma were reported, one of which led to pancreatitis. We conclude that by focusing on questions of sedation these rather simple questionnaires may have resulted in more effective sedation of children undergoing small bowel biopsy.

[Ulcerative jejunitis: a complication of celiac disease]

We report the case of a 57-year-old woman with celiac disease of long standing, who developed episodes of intestinal obstruction during two months. They were misdiagnosed as intestinal obstructions caused by adhesions. The barium meal and follow-through examination disclosed several jejunal stenoses. Therefore, the patient underwent early surgery where an intestinal resection was carried out. The histological examination showed the presence of benign ulcers at the stenoses. After surgery, the patient began to gain weight and her nutritional state improved remarkably.

[Eosinophilia as the leading symptom of highly malignant enteropathy-associated T-cell lymphoma]

A 39 year old man had been suffering from chronic bowel symptoms of changing intensity. At the age of 37 the diagnosis of nontropical sprue was made. After institution of a gluten free diet the patient improved, but soon diarrhea started again. In the examination of peripheral blood smear, bone marrow and small intestinal mucosal biopsies a dominant eosinophilia was found. Since several attacks of abdominal colics and finally an acute abdomen occurred, a laparotomy was indicated. This operative intervention showed a perforation of the intestine and tumors in the bowel wall as well as numerous lymphomas spread over the whole mesentery. The histological examination of both the small intestine resect and the lymphomas proved the diagnosis of a highly malignant Non Hodgkin lymphoma (middle and large cell pleomorphic T-cell lymphoma with transition into a large cell anaplastic lymphoma [ki-1 lymphoma]). The patient received a chemotherapy with COEP but died 4 weeks after the surgery.

[When and why a celiac patient could be subjected to surgical intervention]

The authors report the case of a three year old patient who presented with coeliac disease simulating an Hirschsprung's (constipation and megacolon). She underwent surgery many times and this was due to an initial diagnosis of aganglionic megacolon. Moreover the relationship between constipation and megacolon is discussed and some pathogenetic interpretations of megacolon, a common observation in patient with coeliac disease, are presented.