RESUMEN

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and a mucosal inflammatory process with increased subepithelial collagen band on colonic biopsy. This disorder occurs primarily in females, and the etiology is unknown. We report the atypical presentation of collagenous colitis in two older-aged men following prolonged use of nonsteroidal antiinflammatory agents and short-term use of antibiotics. Although one patient had colonic pseudomembranes, neither patient had microbiological evidence of C. difficile toxin or infection. A variety of medications were initially given to these patients without resolution of diarrhea. Only after the diagnosis of collagenous colitis was made and antiinflammatory drugs directed at the colitis given did the diarrhea abate. These cases illustrate an unusual presentation of collagenous colitis with possible implications for pathogenesis.

Asunto(s)

RESUMEN

Although the reported complication rate of endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is low, patients often experience abdominal pain postprocedure. When pain persists, or fever and leukocytosis develop, a procedure-related complication should be suspected. The authors reviewed a series of 36 patients referred to computed tomography (CT) for evaluation of possible complications following ERCP with sphincterotomy. Initial CT scans were obtained within 24 h in 19 patients, and during the second to seventh day in the remainder. Complications detected by CT included acute pancreatitis (23), duodenal perforation (11), retroperitoneal dissection of air (4), pneumoperitoneum (4), and development of retroperitoneal abscess (4). Eight patients had normal CT scans except for air and contrast material in the biliary tree. The severity and extent of injury were readily assessed by CT, and response to therapy effectively monitored by serial CT examinations. Thirty-one cases (31 of 36) were successfully managed conservatively with antibiotics, intravenous hydration, and restriction of oral intake. Four patients required surgical intervention for drainage of a retroperitoneal abscess (3) or a pseudocyst (1). A fifth patient required intensive care resuscitation for septic shock. We conclude that CT is the study of choice for evaluating the patient with suspected complication following ERCP and sphincterotomy.

Asunto(s)

RESUMEN

The diagnosis, differentiation, and management of severe pancreaticoduodenal complications occurring after therapeutic endoscopic sphincterotomy and related procedures on the ampulla of Vater were reviewed for 254 patients. Five patients had duodenal (peri-Vaterian) perforation and six patients had clinically significant pancreatitis. Most patients were not suspected of having a significant complication the night of the procedure despite abdominal pain. Computer tomography proved to be the most accurate test for establishing the existence of a significant complication. A periduodenal collection of fluid (abscess) without significant pancreatic enlargement was the predominant complication in patients with duodenal perforation. In patients who had pancreatitis after peri-Vaterian procedures, generalized pancreatic enlargement and peripancreatic edema were most prominent. Four of the five patients with duodenal perforation required surgical drainage; all recovered. In contrast, four of the six patients with pancreatitis had medical therapy. One patient with pancreatitis died after multiple pancreatitic debridements were done. A second patient with pancreatitis who underwent exploration eventually recovered. Pancreaticoduodenal complications after therapeutic endoscopic sphincterotomy and related procedures are difficult to diagnose early; they should be suspected early and approached aggressively to limit morbidity and death.

Asunto(s)

RESUMEN

The pathogenesis of juvenile polyps of the colon was studied in a patient with multiple juvenile polyposis who underwent proctocolectomy for rectal carcinoma and antrectomy for associated polyps of the stomach. Numerous polyps up to 3 cm in diameter were present predominantly in the cecum and rectum, and in addition there was an adenocarcinoma in the rectum. Microscopically there were five categories of lesions: 1) Hyperplastic epithelial foci and small hyperplastic polyps; 2) Typical Juvenile polyps; 3) Juvenile polyps with focal adenomatous epithelium; 4) Adenomas; and 5) and adenocarcinoma. The five categories could represent a pathogenetic sequence, beginning with epithelial hyperplasia, leading to small hyperplastic polyps which become inflamed and enlarge, forming juvenile polyps. Focal adenomatous areas which develop in some juvenile polyps might give rise to adenomas and in turn lead to carcinoma. Although juvenile polyps are generally not considered to be premalignant lesions, this case demonstrates that neoplastic changes may occur in juvenile polyps in certain individuals, and raises the possibility that these may on occasion give rise to carcinoma.

Asunto(s)

RESUMEN

Pseudomembranous colitis (PMC) is an infrequent but serious complication of oral and intravenous antibiotic therapy. Twelve patients with antibiotic-associated PMC, documented by sigmoidoscopy and rectal biopsy, were treated with cholestyramine resin. The mean time from the institution of therapy to cessation of diarrhea was 2.1 days. The response interval bore no relationship to the time symptoms were present prior to therapy. Complete resolution of sigmoidoscopic and histologic evidence of PMC usually accompanied or followed cessation of diarrhea. Obstipation was reported in 5 of 12 patients as a side effect of cholestyramine treatment. Therapy should be continued for up to five days after cessation of diarrhea to prevent recurrence of active PMC. Cholestyramine resin is shown to be an effective treatment for antibiotic-associated PMC.

Asunto(s)

Asunto(s)

RESUMEN

In families with one of the Mendelian hereditary polyposes, one can predict the proportion of patients at risk and thus obtain a denominator against which colonoscopy, barium enema, and fecal occult blood can be validated. Colonoscopy is more sensitive than barium enema. There were 42 positive colonoscopies, 12 positive barium enemas, both being positive in 10 of these. There were 141 negative enemas, 133 negative colonscopies, and 118 negative for both. Occult blood was positive in 30% of patients with polyposis, five to seven times more frequently than in those without evident polyposis. Colonoscopy detected polyposis in 30% of the progeny of affected people. The shortfall, compared with the 50% expected under the Mendelian hypothesis, is readily explained by removal of affected cases from the study by surgery or death from cancer.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Duodenoscopic examination of a patient with Whipple's disease revealed that the duodenal mucosa appeared to be partially covered with a yellow-white material. On closer inspection, however, this was found to consist of enlarged villi interspersed with normal-looking mucosa. Histologically these enlarged white villi were shown to contain a heavy accumulation of lipid and typical PAS positive macrophages. The duodenal mucosa was endoscopically normal and histologically showed only a few PAS positive macrophages one year after instituting antibiotic therapy.

Asunto(s)

RESUMEN

This is a study of 11 cases of duodenal tumors encountered in 1200 consecutive duodenoscopic examinations over a 34-month period at The Johns Hopkins Hospital. Of these tumors, 4 were benign and 7 malignant. Endoscopic removal of 2 benign tumors was accomplished without morbidity and obviated the necessity for transabdominal surgery. The 2 other benign tumors were a probable lipoma and a benign polyp, and did not require surgical intervention. In 6 of the 7 patients with malignant lesions, the indication for performing duodenoscopy was an abnormal roentgenographic study. In each case, direct visualization of the abnormal area, together with biopsy and cytologic brushing, provided a definitive diagnosis of malignant disease and helped plan the therapeutic course. In the seventh patient, a primary adenocarcinoma at the duodenojejunal junction was found on endoscopic examination, after all other available diagnostic studies to find the cause of persistent gastrointestinal bleeding had been exhausted. Although duodenal tumors are not common, they were encountered in 1 of every 100 duodenoscopies at a referral center. With increasing use of fiberoptic endoscopy, such tumors will undoubtedly be seen with increasing frequency. In our experience, endoscopy has proved to be a safe and reliable method of distinguishing between benign and malignant duodenal neoplasms and of assistance in planning subsequent management.

Asunto(s)

RESUMEN

Acute intercurrent CMV colitis developed in a patient with UC who was receiving prednisone. CMV infection was suggested by light and electron microscopic study of a rectal biopsy taken during the acute episode and was confirmed by serology done nine months later. The microscopic studies of plastic-embedded tissues demonstrated that infected cells were concentrated in a subendothelial location and were presumably macrophages. Epithelial and endothelial cells were not involved. Steroid therapy and the inflammation and repair process (granulartion tissue) of active UC may have predisposed the present patient to CMV colitis. CMV infection has been reported to be more common in patients with UC than in the general population. Detection of CMV colitis in patients with UC could be of special importance since alteration of immunosuppressive therapy may be indicated.

Asunto(s)

RESUMEN

Two patients with diarrhea and pseudomembranous colitis associated with lincomycin hydrochloride monohydrate and clindamycin phosphate therapy were treated with cholestyramine resin, with prompt remission of symptoms.

Asunto(s)

RESUMEN

In four patients, septic complications developed following endoscopic retrograde cholangiopancreatography which required surgical intervention. The pathogenesis involves stasis in the pancreatic or biliary tree, but the source of infection is unclear. Prompt recognition and early surgical intervention should decrease the seriousness of these complications.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)