Ryosaku Tomiyama

Progression of diverticular colitis to ulcerative colitis.

To the Editor: Diverticular colitis, also known as segmental colitis, sigmoiditis, or endoscopic crescent fold disease, is a recently recognized entity of chronic luminal mucosal inflammation in the sigmoid colon affected by diverticula. This disease may mimic ulcerative colitis (UC) in its clinical manifestations and endoscopic and histologic appearance, but by definition, it does not involve the rectum. We report herein an unusual case of a patient who initially had diverticular colitis, which subsequently evolved into typical distal UC in an initially normal rectum. A 71-year-old man presented with lower abdominal pain and mild hematochezia with a duration of 2 months. He was not taking any antibiotics or nonsteroidal anti-inflammatory drugs. His medical history included hypertension. On examination, there was no tenderness on palpation of the abdomen. Laboratory parameters were normal. Stool culture was negative. Colonoscopy showed segmental inflammation involving the sigmoid colon with multiple diverticula (Fig. 1). Biopsies of the inflamed mucosa showed plasmacellular expansion of the lamina propria and neutrophilic cryptitis. The rectum and other segments of the colon were endoscopically and histopathological normal. A diagnosis was made of diverticular colitis of the sigmoid colon. Four months later, however, he had increasing symptoms and underwent repeated colonoscopy, which showed typical UC with characteristic rectal involvement and the lasting inflammation of the sigmoid colon. Although it was possible that the original diagnosis of this case was in fact UC with rectal sparing, histologic abnormalities are usually detectable in UC with endoscopic sparing of the rectum. Therefore, the progression of diverticular colitis to UC was diagnosed in this case. He responded well to sulfasalazine and remains asymptomatic. Although the precise pathogenesis of diverticular colitis remains unknown, mucosal prolapse, fecal stasis, relative mucosal ischemia, and mass effect by subserosal peridiverticulitis have been implicated as pathogenic factors. There have been a few reported cases of the progression of diverticular colitis to UC. These cases have suggested a certain relationship between the 2 diseases. Of interest, in the series of Pereira, 3 patients developed UC after segmental sigmoid colon resection for intractable diverticular colitis. Similar to the recent remarkable findings that appendiceal inflammation may trigger distal UC by homing of activated T-helper lymphocytes in those genetically predisposed to developing UC, diverticular colitis in the sigmoid colon may provoke inflammation in the more distal rectum. Further studies are needed to clarify whether this association is coincidental or causal. In conclusion, although very rare, diverticular colitis may precede the onset of conventional UC.

Nodular regenerative hyperplasia of the liver and Castleman's disease: potential role of interleukin-6.

A 45-year-old man presented in September 1999, with a 9-year history of weakness, fatigue, intermittent fever, and liver dysfunction. He had had muscle atrophy of the right arm due to cervical spondylosis. On examination, he was afebrile and had nontender cervical lymphadenopathy and splenomegaly. Laboratory evaluation revealed an increased erythrocyte sedimentation rate (91 mm/hr) and C-reactive protein (73.4 mg/L), with a normal white blood cell count (6.4 × 109/L). Other values were as follows—hemoglobin, 11.8 g/dL; platelet count, 17.9 × 109/L; alkaline phosphatase, 1020 IU/L (normal value [NV], 80–260); γ -glutamyl transpeptidase, 102 IU/L (NV, 10– 65)—and the rest of the liver function tests were normal. He had hyperglobulinemia: total protein was 82 g/L (NV, 67–83), of which 35 g/L was albumin, and the serum immunoglobulin showed an excess of polyclonal IgG at 29.9 g/L (NV, 8.7– 17), IgM at 2.1 g/L (NV, 0.3–1.9), and IgA at 7.36 g/L (NV, 1.1–4.1). Serum markers of viral, autoimmune, and metabolic causes of liver dysfunction were negative. A liver biopsy was performed, which showed the nodular formation displacing the normal liver parenchyma and fibrous expansion of the portal tract with chronic inflammatory infiltrate (Figure 1). These findings were consistent with NRH of the liver. Infectious diseases

A rare association of primary biliary cirrhosis and pernicious anemia

12 and the presence of anti-parietal cell antibody and anti-intrinsic factor antibody. Pernicious anemia should be regarded as a possible complication of primary biliary cirrhosis.

Gastrointestinal: Rectal Dieulafoy lesion

A Dieulafoy lesion is a term that is used to describe gastrointestinal bleeding caused by rupture of an exposed submucosal artery associated with a minute mucosal defect. The lesion was originally described by Dr Gallard in 1884 and was subsequently characterized by a French surgeon, Georges Dieulafoy, in 1898. Bleeding from Dieulafoy lesions can occur at any age but is most common in elderly men. The typical site of bleeding is the proximal stomach, usually within 6 cm of the cardio-esophageal junction, but bleeding has been described in a variety of other sites including the esophagus, small bowel and large bowel. Most patients present with intermittent and severe bleeding over several days. When bleeding seems likely to be arising from the large bowel, the initial investigation could be either colonoscopy or mesenteric arteriography. The latter is more likely with torrential bleeding. At colonoscopy, techniques that have been used to control bleeding include epinephrine injections, cauterization, clipping and band ligation. The patient illustrated below was a 76-year-old man who presented with massive rectal bleeding. His medical history included bladder cancer, cecal cancer and a previous cerebral infarct. After resuscitation and a blood transfusion, urgent colonoscopy was performed without bowel preparation. A large amount of fresh blood and clots were noted within the bowel lumen and a bleeding point was not identified. Seven days later, colonoscopy was repeated after a further episode of bleeding. Careful inspection revealed an exposed vessel without surrounding ulceration in the distal rectum consistent with a Dieulafoy lesion (Fig. 1). The vessel was ligated with a single elastic band (Fig. 2). Thereafter, bleeding settled and a follow-up colonoscopy showed that the lesion had healed with scar formation. Although rare, Dieulafoy lesions need to be considered in the differential diagnosis of major rectal bleeding, particularly as they are often suitable for endoscopic therapy.

Chronic intermittent vomiting after scoliosis surgery

A 12 year old girl presented with an 18 month history of intermittent postprandial vomiting …

Elevated Carbohydrate Antigen 19-9 Caused by Early Colon Cancer Treated with Endoscopic Mucosal Resection

Carbohydrate antigen 19-9 (CA 19-9) is one of the tumor markers associated with colorectal carcinomas (CRCs). In the early stage of CRC, serum levels of CA 19-9 are usually normal and early colon cancers presenting highly elevated serum CA 19-9 level are rare. We herein describe a case of early colon cancer strongly expressing CA 19-9 and successfully treated with endoscopic mucosal resection (EMR). The serum CA 19-9 level decreased markedly after treatment. Literature on the value of CA 19-9 in colonic neoplasms is briefly reviewed.

An unusual cause of polyposis

A 50 year old woman presented with progressive snoring of two months’ duration. She denied fever, fatigue, or abdominal pain. On examination, a pharyngeal mass …

Bamboo trees in the stomach

A 46 year old man presented with general fatigue and abdominal discomfort. He had a surgical history of ileal perforation at the age of 40 years. …

Gastrointestinal: Aphthous lesions to overt Crohn's disease

The word aphthous is derived from the Greek word aptha and can be translated as an inflamed spot. The terms aphthous ulcers and aphthous lesions were initially used to describe small superficial ulcers in the mouth but were subsequently used to describe small ulcers in any part of the gastrointestinal tract. Although aphthous lesions have been regarded as early features of Crohn’s disease, they may occur in a variety of other clinical settings including infectious enterocolitis. In Crohn’s disease of the small bowel, aphthous lesions typically occur over Peyer’s patches while in the large bowel, lesions frequently occur over lymphoid aggregates. As the disease progresses, aphthous lesions can enlarge and coalesce, initially forming stellate ulcers and subsequently forming deeper longitudinal and transverse linear ulcers. Islands of mucosa not affected by ulceration can create a cobblestone appearance. The typical endoscopic appearance of an aphthous lesion is a superficial ulcer, 1–5 mm in diameter, with surrounding erythema. Although progression of Crohn’s disease is widely believed to follow the above pattern, radiological documentation of progression is uncommon. The patient illustrated below was a 13-year-old boy who presented with anorectal fistulas. Blood tests revealed mild anemia with an elevated erythrocyte sedimentation rate and C-reactive protein. A double-contrast barium enema study (Fig. 1) showed (Æ) a small number of aphthous lesions in the ascending colon. He was treated with an elemental diet. After an interval of 21 months, he began to lose weight and developed an intermittent fever. A repeat barium enema X-ray (Fig. 2) showed abnormalities in the ascending colon and transverse colon with narrow areas, eccentric rigidity, nodularity and longitudinal ulcers. The appearance was typical of Crohn’s disease.

A calcified caecal mass

A 64 year old woman with a history of Bentall operation and maintenance haemodialysis due to multiple myeloma presented with a positive faecal occult …