Felice R. Zwas

Colonic mucosal abnormalities associated with oral sodium phosphate solution

BACKGROUND Oral sodium phosphate (NaP) is increasingly used as a colonic cleansing agent for colonoscopy. It has been shown to be efficacious, well-tolerated, and safe. Mucosal abnormalities associated with NaP have recently been described. We carried out this controlled study to assess whether bowel cleansing preparations commonly used in colonoscopy are associated with colonic mucosal changes that may mimic inflammatory bowel disease (IBD). METHOD All patients undergoing colonoscopy from January 1994 to June 1994 were considered for the study. Patients with history or symptoms suggestive of IBD were excluded. Patients were randomized to receive polyethylene glycol-based lavage (PEG-ELS) or NaP solution as their bowel cleansing preparation. Two gastroenterologists performing the colonoscopies were blinded to the type of preparation. Any mucosal abnormalities were noted and photographic documentation and biopsy specimens were taken. RESULTS Ninety-seven patients were studied, 44 receiving PEG-ELS and 53 receiving NaP. Both groups were similar with regard to sex, age, and indication for colonoscopy. Fourteen patients were found to have nonspecific aphthoid-like erosions similar in appearance to Crohns disease. These lesions, however, were not friable and biopsy results were not compatible with IBD. This mucosal abnormality was found in 13 patients who received NaP (24.5%) and only 1 patient who received PEG-ELS (2.3%). CONCLUSION Nonspecific aphthoid-like mucosal lesions occur frequently in patients who received NaP for colonoscopy preparation. These lesions are endoscopically similar to those seen in Crohns disease. Because of the potential for misinterpretation of these lesions, we do not recommend the use of NaP as a colonic cleansing preparation for patients with chronic diarrhea or in whom the diagnosis of IBD is suspected.

Detection by scanning electron microscopy of a distinctive esophageal surface cell at the junction of squamous and Barrett's epithelium

Metaplastic columnar epithelium replaces the normal squamous epithelium in Barretts esophagus. We characterized the surface epithelial cells of the junction between squamous and Barretts epithelium using scanning electron microscopy and light microscopy. In four biopsy specimens from the squamous-Barretts junction in three patients, we found a distinctive cell type having features intermediate between those of squamous and columnar epithelium. Its distinguishing characteristic is the presence on its surface of two disparate structures not normally present on the same cell in the gastrointestinal tract: microvilli (a scanning electron microscopy feature of glandular epithelium) and intercellular ridges (a scanning electron microscopy feature of squamous mucosa). The surface characteristics of this newly recognized cell were strikingly similar to those of cells found in the transformation zone of the uterine cervix, an area in which squamous epithelium physiologically replaces columnar epithelium. We also examined 28 biopsies of the gastroesophageal junction area from 14 patients with and without a history of heartburn but with no evidence of Barretts esophagus. None of these biosies showed the distinctive cell. We hypothesize that this distinctive cell represents an intermediate step in either the development or the healing of Barretts epithelium, during which surface characteristics of two different cell types, columnar and squamous, coexist on the same cell.

Endometriosis. An important condition in clinical gastroenterology.

Endometriosis, a condition defined by the presence of ectopic endometrium, is a disorder of increasing incidence and a significant cause of gastroenterologic distress in young women. Although clinical manifestations vary considerably depending upon the anatomic extent of disease, characteristic abdominal complaints and typical physical findings continue to be associated with misdiagnosis and delayed recognition of gastrointestinal involvement. The authors of this paper review the medical literature concerning endometriosis of the digestive tract--emphasizing modes of presentation, risk factors, diagnostic testing, complications, and therapy. Greater familiarity with the disease and heightened awareness of its sequellae are needed and prerequisite to improved medical management.

Prospective evaluation of multilayered epithelium in Barrett's esophagus

OBJECTIVE:We recently identified a distinctive type of multilayered epithelium in two patients with Barretts esophagus, which shows morphological characteristics of both squamous and columnar epithelium. This study was performed to prospectively evaluate the prevalence of multilayered epithelium in patients with Barretts esophagus.METHODS:Mucosal biopsies were obtained from the squamocolumnar junction (Z-line) of 58 patients with endoscopic evidence of esophageal columnar epithelium and from the gastroesophageal junction in 21 patients without endoscopic evidence of esophageal columnar epithelium. Specimens were evaluated for the presence of multilayered epithelium and goblet cells.RESULTS:Twenty-four of 58 (41%) of the patients with endoscopic evidence of esophageal columnar epithelium had multilayered epithelium compared with only one of 21 patients (5%) in the control group (p = 0.005). Of the 58 patients in the study group, 43 had goblet cell metaplasia and 15 did not (p < 0.001). Only patients with goblet cell metaplasia had multilayered epithelium. Shorter lengths of columnar epithelium were noted in the 24 patients with goblet cells and multilayered epithelium compared with the 19 patients with goblet cells and no multilayered epithelium (p < 0.05).CONCLUSIONS:Multilayered epithelium is strongly associated with goblet cell metaplasia in patients with endoscopic evidence of esophageal columnar epithelium. These data support the hypothesis that multilayered epithelium may represent a transitional stage in the development of Barretts esophagus.

Abnormal liver enyzmes in outpatients with eating disorders

OBJECTIVE This study was undertaken to screen a large series of outpatients with anorexia or bulimia for liver enzyme abnormalities, examining their frequency and their clinical correlates. METHOD Eight hundred seventy-nine eating-disordered outpatients presenting at a suburban clinic constituted the subject population. Serum glutamic oxalacetic transaminase, serum glutamic pyruvate transaminase, and gamma glutamyl transpeptidase (SGOT, SGPT, and GGTP, respectively) were drawn at intake. Medical charts were reviewed to obtain further clinical data on all patients with an enzyme elevation. RESULTS Liver enzymes were abnormally high in 36 patients (4.1%). Elevated SGPT was the most frequent enzyme abnormality and was correlated with lower current and past weight and body mass index (BMI). DISCUSSION Hepatic dysfunction in eating-disordered outpatients is neither specific nor common. Low weight alone can cause liver damage, yet elevated liver chemistries in patients with anorexia and especially bulima are often not due to their eating disorder.

Multilayered epithelium may be found in patients with Barrett's epithelium and dysplasia or adenocarcinoma

To determine if multilayered epithelium (MLE) is a useful prognostic indicator for a benign natural history of Barrett’s epithelium, we evaluated endoscopic biopsies from patients with Barrett’s epithelium without and with dysplasia and/or adenocarcinoma and from non-Barretts controls for the presence of MLE. MLE was found in 6% of non-Barretts controls, 30% of Barrett’s patients with no dysplasia, and 14% of Barretts patients with dysplasia and/or adenocarcinoma. MLE was significantly associated with shorter lengths of Barrett’s epithelium in both Barrett’s groups. Three of 5 photodynamic therapy patients were noted to develop MLE after therapy. MLE may be found in patients with dysplasia and/or adenocarcinoma and after photodynamic therapy; its presence is not useful as a prognostic indicator for a more benign course of Barrett’s. This study confirms that MLE is significantly associated with shorter lengths of Barrett’s epithelium.