A giant Brunner's gland hamartoma being treated as a pedunculated polyp: a case report

BACKGROUND

With the development and application of endoscopic technology, most pedunculated polyps can be absolutely resected with a complete specimen by hot snare polypectomy (HSP). Brunner's gland hamartoma (BGH) is a rare benign small bowel tumor. The majority of BGH measuring about 2 cm in diameter, rarely larger than 5 cm. Most patients are asymptomatic, some may present with gastrointestinal hemorrhage or intestinal obstruction. Symptomatic larger lesions leading to bleeding or obstruction should be excised either endoscopically or surgically. Whether it is safe and effective that removing a BGH measuring about 7 cm by HSP is not known.

CASE PRESENTATION

Here, we reported a rare case of a proximal duodenum pedunculated mass measuring about 7 cm which was responsible for the patient's severe anemia. we treated it as a pedunculated polyp. After being pretreated the stalk with an endoloop which was placed around the base of the mass to prevent post-polypectomy bleeding (PPB), the pedunculated BGH was removed by HSP completely. The stalk of the mass was negative. We achieved a curative resection.

CONCLUSION

It is a safe and effective for our patient to treat the pedunculated BGH measuring about 7 cm as a pedunculated polyp and remove it by HSP. And future prospective studies in larger cohorts are needed to confirm it.

Biomechanical modelling of colorectal crypt budding and fission

This paper presents a biomechanical model for the small pits, called crypts, that line the colon. A continuum approach is adopted, with the crypt epithelium modelled as a growing beam attached to the underlying lamina by cell bonds, which generate tension within the layer. These cell attachments are assumed to be viscoelastic thus allowing for cell progression along the crypt. It is shown that any combination of: an increase in net proliferation (i.e. cell production minus apoptosis), an enlargement of the proliferative compartment, an increase in the strength of the cellular attachment to the underlying lamina, or a change in the rate of cell growth or cell bonding may generate buckling of the tissue. These changes can all be generated by an activating mutation of the Wnt cascade, which is generally accepted to be the first genetic change in colorectal cancer, with subsequent deformation, budding, and crypt fission an observed feature of the adenomatous crypt.

Decreased intestinal polyp multiplicity is related to exercise mode and gender in ApcMin/+ mice

Moderate-intensity treadmill running can alter male Apc(Min/+) mouse polyp formation. This purpose of this study was to examine whether exercise mode differentially affects Apc(Min/+) mouse intestinal polyp development in male and female mice. Male and female Apc(Min/+) mice were randomly assigned to control, treadmill (18 m/min; 60 min/day; 6 days/wk), or voluntary wheel running (24-h access) groups. Nine weeks of training decreased total intestinal polyps by 29% in male treadmill runners (66 +/- 9; P = 0.038) compared with male controls (93 +/- 7). The number of large polyps (>/=1-mm diameter) were also reduced by 38% in male treadmill runners (49 +/- 6; P = 0.005) compared with male controls (79 +/- 6). Treadmill running in female Apc(Min/+) mice and wheel running in both genders did not affect polyp number or size. Spleen weight decreased in male treadmill runners (91 +/- 9 mg; P = 0.011) and wheel runners (75 +/- 6 mg; P = 0.004) compared with controls (141 +/- 13 mg). Plasma IL-6 was reduced by 96% in male treadmill runners (1.2 +/- 0.6 pg/ml) and 78% in male wheel runners (6.6 +/- 3.3 pg/ml) compared with control mice (27.9 +/- 2.8 pg/ml; P < 0.05). Female mice responded similarly with an 86% decrease in plasma IL-6 with treadmill running (3.2 +/- 1.2 pg/ml) and 90% decrease with wheel running (2.9 +/- 2.0 pg/ml) compared with control mice (21.1 +/- 5.3 pg/ml; P < 0.05). The crypt depth-to-villus height ratio in the intestine, an indirect marker of intestinal inflammation, decreased by 21 (P = 0.024) and 24% (P = 0.029), respectively, in male and female treadmill runners but not wheel runners. Physical activity-induced attenuation of intestinal polyp number and size is dependent on exercise mode and differs between genders. The modulation of systemic and intestinal inflammation may also depend on exercise mode.

Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery?

AIM: Hypertrophied anal papillae and fibrous anal polyps are not given due importance in the proctology practice. They are mostly ignored being considered as normal structures. The present study was aimed to demonstrate that hypertrophied anal papillae and fibrous anal polyps could cause symptoms to the patients and that they should be removed in treatment of patients with chronic fissure in anus.

METHODS: Two groups of patients were studied. A hundred patients were studied in group A in which the associated fibrous polyp or papillae were removed by radio frequency surgical device after a lateral subcutaneous sphincterotomy for relieving the sphincter spasm. Another group of a hundred patients who also had papillae or fibrous polyps, were treated by lateral sphincterotomy alone. They were followed up for one year.

RESULTS: Eighty-nine percent patients from group A expressed their satisfaction with the treatment in comparison to only 64% from group B who underwent sphincterotomy alone with the papillae or anal polyps left untreated. Group A patients showed a marked reduction with regard to pain and irritation during defecation (P = 0.0011), pricking or foreign body sensation in the anus (P = 0.0006) and pruritus or wetness around the anal verge (P = 0.0008).

CONCLUSION: Hypertrophied anal papillae and fibrous anal polyps should be removed during treatment of chronic anal fissure. This would add to effectiveness and completeness of the procedure.

A case of Cronkhite-Canada syndrome whose major complaint, taste disturbance, was improved by zinc therapy

A patient whose major complaint was taste disturbance and who was diagnosed as having Cronkhite-Canada syndrome was prescribed zinc sulfate. Improvement in taste disturbance was noted after 3 weeks of treatment, followed by gradual improvement in skin and gastrointestinal symptoms. Cronkhite-Canada syndrome can be considered a zinc-deficiency disorder caused by gastrointestinal polyposis.

Germline mutations in BMPR1A/ALK3 cause a subset of cases of juvenile polyposis syndrome and of Cowden and Bannayan-Riley-Ruvalcaba syndromes

Juvenile polyposis syndrome (JPS) is an inherited hamartomatous-polyposis syndrome with a risk for colon cancer. JPS is a clinical diagnosis by exclusion, and, before susceptibility genes were identified, JPS could easily be confused with other inherited hamartoma syndromes, such as Bannayan-Riley-Ruvalcaba syndrome (BRRS) and Cowden syndrome (CS). Germline mutations of MADH4 (SMAD4) have been described in a variable number of probands with JPS. A series of familial and isolated European probands without MADH4 mutations were analyzed for germline mutations in BMPR1A, a member of the transforming growth-factor beta-receptor superfamily, upstream from the SMAD pathway. Overall, 10 (38%) probands were found to have germline BMPR1A mutations, 8 of which resulted in truncated receptors and 2 of which resulted in missense alterations (C124R and C376Y). Almost all available component tumors from mutation-positive cases showed loss of heterozygosity (LOH) in the BMPR1A region, whereas those from mutation-negative cases did not. One proband with CS/CS-like phenotype was also found to have a germline BMPR1A missense mutation (A338D). Thus, germline BMPR1A mutations cause a significant proportion of cases of JPS and might define a small subset of cases of CS/BRRS with specific colonic phenotype.

Adult T-cell leukemia with multiple lymphomatous polyposis of the gastrointestinal tract

A rare case of adult T-cell leukemia (ATL) in which multiple lymphomatous polyposis (MLP) was revealed throughout the entire gastrointestinal tract is reported here. The polypectomy specimens taken from the rectum revealed infiltration of neoplastic T-cells, the integration of HTLV-1 proviral DNA, and increased CD4 (OKT4) and CD25 (IL-2R) cells. The analysis of surface markers of the lymphocytes from polypoid lesions may be useful for elucidating cell tropism and homing properties in the gastrointestinal tract. Although MLP has always been associated with B-cell lymphoma in the Western world, it is important for clinicians and pathologists to be aware that MLP may be caused by the infiltration of ATL cells.

Factors influencing bowel function after ileal pouch-anal anastomosis

Seventeen patients were studied 3-31 months (median 6.4 months) after mucosal proctectomy and ileal pouch-anal anastomosis for ulcerative colitis (n = 15) or adenomatous polyposis (n = 2). Seven had a triplicated pouch, and ten a duplicated pouch. Clinical bowel function was determined by detailed questionnaire, and correlations sought between clinical end-points such as frequency of defaecation, urgency of defaecation and continence, and the results of laboratory investigations, comprising anal manometry, capacity and compliance of the pouch, completeness of emptying, faecal bacteriology and mucosal inflammation. Frequency of defaecation was found to be inversely correlated with both the capacity (rs = -0.66, P less than 0.01) and the compliance (rs = -0.53, P less than 0.05) of the pouch. Patients who could postpone defaecation for greater than 30 min had higher anal squeeze pressures (P less than 0.05) than patients who had greater urgency of defaecation. Patients with perfect anal continence had higher resting anal pressure (P less than 0.05) and emptied the pouch more completely (P less than 0.01) than patients who experienced minor leakage. The faecal flora of the pouches showed a greater predominance of anaerobes (P less than 0.01) and increased numbers of bacteroides (P less than 0.01) compared with the faecal flora of ileostomies, but the changes in the flora did not correlate with any aspect of bowel function. The best clinical results (i.e. perfect continence, low frequency of defaecation and little urgency) were associated with high anal pressure and with large volume, high compliance and complete emptying of the pouch. The completeness of emptying was similar for both designs of pouch, but the capacity and compliance of triplicated pouches were greater than the capacity and compliance of duplicated J pouches (P less than 0.05), and this was associated with a better clinical result in the triplicated pouches.

Comparison of the function of triplicated and duplicated pelvic ileal reservoirs after mucosal proctectomy and ileo-anal anastomosis for ulcerative colitis and adenomatous polyposis

Among 39 consecutive patients who underwent colectomy, mucosal proctectomy and ileo-anal anastomosis, a triplicated pelvic ileal pouch was constructed in 17, and a duplicated pouch in 22 patients. There was no mortality, but complications such as anastomotic dehiscence and pelvic sepsis led to removal of the pouch in seven patients (18 per cent). The functioning of the pouch and anal sphincter was assessed in 31 patients 6 months, and in 22 patients 12 months after closure of the diverting ileostomy. By 6 months, all patients were either completely continent or experienced only minor leakage and defaecation could be deferred for more than 15 min by 81 per cent of patients and flatus distinguished from faeces by 90 per cent of patients. No significant differences between triplicated and duplicated pouches were discernible at 6 months. At 12 months defaecation was significantly less frequent (P less than 0.05) in patients with triplicated pouches (median, 5 times in 24 h) than in patients with duplicated pouches (7 times in 24 h). All patients with triplicated pouches and all except one with duplicated pouches were able to defaecate spontaneously, without needing to intubate the reservoir. Thus, provided the early postoperative problems can be overcome, most patients achieve good anal function after mucosal proctectomy combined with a pelvic ileal reservoir. No evidence was found in this study that the functional results of duplicated pouches were superior to those of triplicated pouches; in fact, the triplicated pouches proved to be slightly superior.

The role of bile acids in colonic carcinogenesis

Several line of evidence suggest that bile acids may be implicated in the pathogenesis of colonic cancer. A high consumption of fat and animal protein and a low dietary intake of fiber have been shown to be related to the incidence of colonic cancer. From these epidemiologic observations the hypothesis was proposed that the correlation between diet and colon cancer might be explained by the involvement of bile acids. Populations at a high risk of developing cancer were shown to have an increased excretion both of total and bacterially modified bile acids in their feces. Animal studies demonstrated a cocarcinogenic effect of bile acids and experimental diets containing large amounts of fat did not only induce an increased bile acid excretion but also an enhanced tumor formation in the colon. Furthermore, microbial in vitro tests showed a comutagenic activity of secondary bile acids. However, case control studies comparing the fecal bile acid excretion pattern in colonic cancer patients and control subjects failed to show such a clear relationship, which might be explained by rather similar dietary habits within one population and individual differences in sensitivity to environmental factors contributing to the tumor development. Cholecystectomy, leading to an increased exposure of bile acids to the intestinal microflora, has been suggested as a predisposing factor for the development of colonic cancer, but the results of experimental and epidemiologic studies so far are rather inconsistent.(ABSTRACT TRUNCATED AT 250 WORDS)

A new technique for ileoanal and coloanal anastomosis

The following report includes a description of the technical details of a new surgical method for the total removal of the rectum while preserving the anal sphincter function. Seventeen patients including 11 patients with rectal carcinoma, two with diffuse polyposis involving the rectum, three with ulcerative colitis, and one with Crohn's disease of the colon and rectum have undergone operation by this method in the last 4 years. Clinical follow-up (mean 22 months) of these patients has demonstrated normal and continence for feces and gas. Postoperative manometric and electromyographic studies have also shown adequate sphincteric function. This method could be carried out either on patients in whom the total removal of the rectum is indicated or in patients with previous ileostomy or colostomy and a remaining rectal stump unsuitable for direct anastomosis.

The esophagogastric polyp-fold complex

A polyp-fold complex at the gastroesophageal junction is a rare finding. We made this diagnosis in a 51-year-old man who presented with abdominal discomfort after an episode of protracted vomiting. The esophagogastric polyp-fold complex is not always associated with reflux esophagitis, as was originally proposed.

Patterns of mucus secretion in the colonic epithelium in familial polyposis

Patterns of mucus secretion were investigated, by histochemical methods, in 24 colectomy specimens resected for familial polyposis coli. In this pre-malignant condition, mucus secretion contained an increased proportion of sialomucins as compared with normal colonic mucosa where sulphomucins predominate. These mucin changes (a) were more extensive in the left colon than in the right; (b) although consistently present in the mucosa adjacent to carcinomas, independent of their site, and around large polyps, they were also seen in patches of mucosa distant from the neoplastic growth; (c) they were more marked in the non-involved mucosa from patients who had developed carcinoma than in the non-cancer group. It was not possible to relate the type of mucin secreted and the degree of dysplasia. Similar alterations in mucus secretion have been previously described in colonic mucosa harbouring carcinoma both in humans and experimentally in rats, suggesting a relationship between altered glycoprotein synthesis and malignancy. The present results add further evidence to this hypothesis.

Histogenesis of adenomatous polyps in the human large intestine

Detailed histologic analyses have been performed in 75, minute, colorectal polyps from familial polyposis patients. All polyps were composed of typical adenomatous tissue, with, in addition, some normal-looking glands still to be found among the neoplastic elements. Bifurcating glands were not observed, and branching patterns were present in 27% of the polyps only. In 86% of the lesions, the number of gland openings along the polyp surface was larger than the number of gland bases observed along the muscularis mucosae. This difference increased with polyp size (r = 0.9043). Those data, together with previous radioautographic observations, suggest that formation of new adenomatous glands mainly results from an infolding of the surface epithelium between normal, preexisting glands. This mechanism sharply contrasts with villous polyps in which papillary projections arise upwards from the mucosal surface.

Early proliferative changes in intestinal cells

Early lesions in the colonic mucosa of humans and rodents are characterized by similar proliferative changes within their epithelial cell population. Progressive phases of abnormal cell development appear during the evolution of neoplastic transformation in colonic cells of rodents exposed to chemical carcinogens and in humans highly susceptible to gastrointestinal cancer. Identification and classification by phenotype of cells of these individuals at increased risk for colon cancer are leading to new methods to improve the detection and diagnosis of neoplasia in high risk individuals and families. An analytical system of precise numerical definitions is aiding an approach to modify the evolution of advanced stages of neoplasia.

The precursor tissue of ordinary large bowel cancer

Hyperplastic polyps are 10 times as common as adenomas and must be distinguished from them since they are unrelated as a precursor tissue to either adenomas or carcinomas. Only adenomas are relevant to the development of the common moderately and well-differentiated large bowel cancer. Depending on three related factors (increasing size, a sessile rather than pedunculated mode of growth, and a villous rather than tubular microscopic architecture), one may find minute (1 to 2-mm) or microcancer with increasing frequency in adenomas. However, despite unlimited opportunity to do so, minute or microcancer has not been observed in normal mucosa, i.e., unassociated with adenomatous tissue. The same findings obtain in familial polyposis. In this condition, in grossly normal areas of mucosa, adenomas (but not carcinomas) as small as one or two crypts have been found. Direct one-step transformation from normal crypt cells to cancer, without formation of adenomatous epithelium, does not seem to be the usual pathway.

Primary tumours of the small intestine

Tumours of the small intestine are not common. It is essential that an early diagnosis be made so that curative surgery can be carried out and the patient survive. The various clinical presentations and methods of investigation are discussed in order to create an awareness of this type of tumour. The methods of treatment are considered and also the prognosis of malignant growths, which, although poor, compares favourably with that of cancer of the stomach. The relative rarity of these tumours is probably due to the rapid passage of intestinal contents through the small bowel as compared with the stomach or colon.