Anne Lavergne

Colonoscopy of acute colitis. A safe and reliable tool for assessment of severity.

Complications that might lead to surgery in severe attacks of ulcerative colitis have been found to be correlated with the depth of colonic ulcerations as measured by pathological examination of colectomy specimens. In order to evaluate the value of colonoscopy for the assessment of colonic ulcerations, we have reviewed the clinical, biological, colonoscopic, and anatomical findings in 85 consecutive patients with attacks of ulcerative colitis involving at least the rectosigmoid and part of the descending colon, seen in our center between 1981 and 1989. All had colonoscopy performed by a senior endoscopist at entry. Extensive deep colonic ulcerations were diagnosed in 46 of them, and moderate endoscopic colitis in 39. No complication related to colonoscopy occurred except for one colonic dilatation. Forty-three of the 46 patients with severe endoscopic colitis were operated upon: 38 of them failed to improve with high-dose corticosteroids and five had a toxic megacolon. Extensive ulcerations reaching at least the circular muscle layer were found at pathological examination of colectomy specimen in 42 of the 43 patients. Conversely, 30 of 39 patients with moderate endoscopic colitis went into clinical remission with medical treatment, and only nine patients needed further surgery because of medical treatment failure. Six of these nine patients underwent another colonoscopy prior to colectomy, and all six showed features of severe endoscopic colitis. Deep ulcerations reaching the circular muscle layer were found at pathological examination in five of these six patients and in one additional patient whose colonoscopy had been performed 21 days before colectomy. We conclude that, in expert hands, colonoscopy is safe and accurately selects patients with high risk of surgical complications who need early surgery in case of failure of medical treatment.

Ileal pouch/anal anastomosis for Crohn's disease.

BACKGROUNDnPatients with Crohns disease (CD) are not commonly considered as candidates for ileal pouch/anal anastomosis (IPAA). This approach has been avoided because of the poor results observed, retrospectively, in patients with an initial diagnosis of ulcerative colitis who were found to have CD on examination of the resected specimen. However, in 1985, we decided to investigate an alternative to coloproctectomy with definitive end-ileostomy by a prospective study of IPAA for selected patients with CD.nnnMETHODSnBetween 1985 and 1992, 31 patients with CD, but with no evidence of anoperineal or small-bowel disease, were recruited to our study. They comprised 15 men and 16 women whose mean age was 36 years (SD 14; range 16-72). All CD patients underwent IPAA. The short-term and long-term functional results of this procedure were compared with those of 71 ulcerative colitis patients who also underwent IPAA during the same period in our unit. Mean follow-up was 59 (SD 25) months.nnnFINDINGSnNo significant differences were observed between patients with CD and ulcerative colitis in the postoperative complication rate. Of the 31 CD patients, six (19%) experienced specific complications 9 months to 6 years after surgery: three had pouch-perineal fistulas, which required pouch excision in two cases; one had a pouch-vaginal fistula that was treated by gracilis muscle interposition; and one had an extrasphincteric abscess, which was treated surgically. Two patients (6%), one of whom was treated for an extrasphincteric abscess, experienced CD recurrence on the reservoir, and were treated successfully with azathioprine. At 5-year follow-up, there were no significant differences between patients with CD and ulcerative colitis in stool frequency (5.0 [2.0] vs 4.7 [1.4] per day; p=0.68), continence, gas/stool discrimination, leak or need for protective pads, and sexual activity.nnnINTERPRETATIONnOur results show that in selected cases of CD without anoperineal or small-bowel manifestations, IPPA can be recommended as an alternative to coloprotectomy with definitive end-ileostomy, when rectal resection is essential.

Granulocytic sarcoma of the jejunum: a rare cause of small bowel obstruction

We report the case of a 40-yr-old man presenting with symptoms of small bowel obstruction. Small bowel x-rays revealed a stricture of the mid-jejunum. Push enteroscopy found a polypoid mass at 1 meter of the ligament of Treitz. Histopathological examination of the biopsy and surgical specimens showed a diffuse infiltrate of the mucosa made of medium to large cells, which were stained on immunohistochemistery by the leucocyte marker CD45 and the histiocyte/monocyte marker CD68 but were negative for the B and T cell markers. Cytological examination of the ascitic fluid revealed many myelobasts with cytoplasmic Auer rods and positive myeloperoxidase staining. There was no evidence of blood or bone marrow involvement suggestive of acute leukemia or myeloproliferative disorders. These findings were consistent with the diagnosis of preleukemic granulocytic sarcoma (or chloroma). Chemotherapy led to complete remission, but 21 months later the patient developed an acute myeloid leukemia. He died from arpergillus pneumonitis, 10 months after bone marrow allograft. Preleukemic granulocytic sarcoma of the small bowel is a rare condition and its diagnosis is usually not easy, requiring histochemical or immunohistochemical studies. Most cases have progressed to acute myeloid leukemia.

Primary gastric peripheral T-cell malignant lymphoma with helper/inducer phenotype. First case report with a complete histological ultrastructural and immunochemical study

Primary gastrointestinal T‐cell malignant lymphomas (T‐ML) are very rare. In this case report we describe a primary gastric tumor with local lymph node involvement. On the basis of histologic, immunohistochemical, and electron microscopic studies, the authors classified this tumor as a pleomorphic T‐ML, large cell variant with peripheral helper/inducer T‐cell phenotype (Leul/CD5+, Leu4/CD3+, Leu5/CD2+, Leu9/CD7+, and Leu3/CD4+). The extreme pleomorphism of lymphoma cells, the numerous giant cells, and the presence of tumor nodules with two or three concentric layers were the three striking morphologic features of our case. Tumor cells showed an inconstant but true positive staining with anti‐LeuM1/CD15 and LeuM3/CD14 antibodies. Vimentin positivity could be related to the presence of intermediate filaments at ultrastructural level. Neuron‐specific enolase reactivity was a peculiar but unexplained feature. Furthermore, the positivity of the surface markers Ki‐1/CD30, anti‐Tac/CD25 and HLA‐DR, and the nuclear marker Ki‐67 suggested an activation state and a high proliferative activity of the tumor cells. This study emphasizes the usefulness of combined pathologic methods in order to rule out other diagnoses such as undifferentiated carcinoma, malignant melanoma, malignant histiocytosis, B‐cell lymphoma and interdigitating reticulum cells sarcoma, in view of an extremely polymorph tumor proliferation. This is apparently the first completely documented case report of a primary gastric pleomorphic T‐ML of peripheral T‐cell origin.

Neuron-specific enolase and malignant lymphomas (23 cases)

The immunoreactivity of polyclonal antiserum to neuron-specific enolase (NSE) has been investigated. Twenty-three cases of malignant lymphoma (ML) were studied and compared with previously published reports. In our study 11 out of 23 cases showed strong or weak NSE positivity; any type of ML could be positive or negative even among B or T cell ML. This study indicated that polyclonal NSE is not a specific marker; it might be an inconstant marker of ML with no apparent correlation between reactivity and morphology or phenotype.

Vascular evolution of single-layer end-on colonic anastomosis

One hundred eighty left colonic single-layer end-on anastomoses performed on 90 rats by microsurgical techniques, using polydioxanone monofilament absorbable sutures, were examined histopathologically and microangiographically at nine different times, from two to 180 days. There was no anastomotic leakage. The vascular state after suturing and the evolution of the neovascularization are described. The neovascularization appeared to follow the same process of evolution as tissue restoration. It began early, was greatest on the seventh day, and diminished thereafter. When granulation tissue was narrow, the anastomoses were barely hypervascular, the neovascularization assured by submucosal plexus. A voluminous granulation tissue was hypervascular, had a slower evolution, and neovascularization was then assured above all by the peritoneal formations adherent to the suture.

Fecal Primary Bile Acids and Serum Cholesterol Are Associated with Colorectal Adenomas

In order to identify biomarkers of colorectal tumors, 20 subjects with colorectal adenomas were compared with 20 controls as regards fecal parameters (pH, short-chain fatty acids, bile acids, and sterols), blood parameters (bile acids, cholesterol, triglycerides, glycemia and insulinemia), and rectal cell proliferation. Variables were compared by unconditional logistic regression, controlling for gender. There were significant and positive associations between risk of adenoma and total fecal primary bile acids and serum cholesterol, with odds ratios for the third versus first tertile = 9.4 ( P for trend = 0.03) and 8.6 (P for trend = 0.04), respectively. There was a trend towards an increased triglycerides level in adenoma subjects compared with controls (P = 0.08). These three parameters correlated with cell proliferation, although cell proliferation itself was not significantly associated with adenomas. In conclusion, these results suggest that fecal primary bile acids and serum cholesterol are markers of early events of colorectal carcinogenesis.

Idiopathic chronic watery diarrhea from excluded rectosigmoid with goblet cell hyperplasia cured by restoration of large bowel continuity.

SummaryA 73-year-old woman developed abnormal electrolyte and water loss from an excluded rectosigmoid segment after surgical treatment of a volvulus of the sigmoid colon. Rectal discharges lasted almost for a year, until it spontaneously resolved after restoration of large bowel continuity. Despite extensive investigation, including endoscopic, radiologic, microscopic, bacteriologic and parasitic examinations, no satisfactory explanation of the diarrhea could be found. The histologic pattern of the excluded segment showed a striking increase in mucosal thickness and in number and height of goblet cells. These abnormalities disappeared after closure of the colostomy. Electrolyte composition of the rectal fluid, which contained 134 mmol potassium and 22 mmol sodium per liter was remarkable and similar to that of normal stool water and anal discharges of patients with ulcerative proctitis.

Histological, Immunohistochemical, Ultrastructural and Biochemical Study of Human Gastric Composite Tumor: Expression of the Serotonin-2B Receptor by the Neuroendocrine Component

AbstractWe report a case of a human gastric composite tumor occurring seven years after a partial gastrectomy for a low grade B cell MALT lymphoma. Histological examination of the tumor revealed two intimately intermingled components:1.A moderately to poorly differentiated tubulo-acinar adenocarcinoma with signetring cells; and2.Isolated or clustered small neuroendocrine cells without atypia expressing chromogranin A, somatostatin and/or glucagon, serotonin (5-HT) and, the 5-HT2B receptors. In addition to immunohistochemical detection, the presence of 5-HT2B receptors was shown pharmacologically through [125l]-DOI binding.n Since 5-HT2B receptors have been demonstrated to have autocrine functions and, mitogenic and transforming properties, these results suggest a role of 5-HT in neuroendocrine malignant transformation. On the other hand, the expression of somatostatin and the detection by reverse transcriptase polymerase chain reaction (RT-PCR) of somatostatin receptor subtypes 2, 3, and 5, which have been shown to be involved in tumor regression, might account for the long evolution of this case (>5 yr). This case illustrates the importance of local humoral modulation in tumor growth. Moreover, ultrastructural results favor a unique origin of the tumor cells from one amphicrine cell type.

Polydioxanone in digestive surgery: An experimental study

An experimental study was carried out to analyze the reaction of polydioxanone suture. Two hundred ten single layer colonic anastomoses were performed in rats and histopathologically studied at nine different times between the 2nd and 180th postoperative days. Eighteen of 105 abdominal wound closures were studied in the same way between the 7th and 90th days. Polydioxanone was resorbed slowly in approximately 6 months with minimum inflammation. We believe that polydioxanone is actually the suture material of choice for all biliary and biliodigestive sutures.