Scott H. Saul

The Effect of a Pectin-Supplemented Elemental Diet on Intestinal Adaptation to Massive Small Bowel Resection

The effect of a pectin-supplemented elemental diet on intestinal adaptation to massive small bowel resection in the rat was investigated in this study. Sixty adult Sprague-Dawley rats underwent placement of a feeding gastrostomy and swivel apparatus. Control animals (N = 16) were then returned to their cages while the remaining animals underwent an 80% small bowel resection and anastomosis (resected, N = 44). Postoperatively, animals were randomly assigned to receive either a fat- and fiber-free elemental diet (no pectin) or the same diet supplemented with 2% pectin (pectin). After 8 days of full strength diet, samples of jejunum, ileum, and colon were obtained for analysis. The weights per unit length of the ileum and colon were significantly greater in the resected pectin group than either the resected no pectin or pectin control groups. Mucosal parameters (unit weight, DNA, RNA, and protein content) were significantly increased in the jejunum and ileum of both the resected pectin and resected no pectin...

Barrett's metaplasia and adenocarcinoma of the esophagus in scleroderma

Gastroesophageal reflux is well documented in scleroderma, but the complications of Barretts metaplasia and adenocarcinoma are not well described. The records of 75 patients with scleroderma seen over a four-year period at the Hospital of the University of Pennsylvania were retrospectively reviewed to determine the prevalence of Barretts metaplasia and adenocarcinoma of the esophagus and to identify clinical, manometric, laboratory, or radiographic criteria that might predict the presence of these lesions. Twenty-four of these patients underwent endoscopy. In this group, the prevalence of Barretts metaplasia was 37 percent (nine patients) and adenocarcinoma was also present in two of these patients. The patients with and without Barretts metaplasia were similar in age (range, 22 to 64 compared with 28 to 79, respectively), sex (six of nine compared with 12 of 15 female, respectively), frequency of esophageal motility disorders, presence of proximal skin involvement, digital ulceration, and pulmonary involvement as measured by diffusion capacity. Barretts metaplasia was diagnosed on the basis of double-contrast esophagographic results in only one of eight patients with Barretts metaplasia so-studied. Patients with Barretts metaplasia tended to have longer duration of heartburn (90 +/- 40 months compared with 11 +/- 35 months) and dysphagia (39 +/- 22 months compared with 7 +/- 3 months). Patients with Barretts metaplasia also tended to have greater impairment of lower esophageal sphincter pressure either at end-expiration (4.0 +/- 2.1 compared with 6.1 +/- 1.8 mm Hg) or mid-respiration (13.0 +/- 3.0 compared with 16.9 +/- 2.5 mm Hg). Using chi-square analysis, however, none of these differences reached statistical significance. Discrimination did occur on the basis of the presence of the CREST (calcinosis, Raynauds phenomenon, esophageal manifestations of scleroderma, sclerodactyly, and telangiectasis) variant (55 percent compared with 7 percent, p less than 0.01), a duration of dysphagia of more than five months (p less than 0.03), and mid-respiratory lower esophageal sphincter pressure of less than 10 mm Hg (p less than 0.05). It is suggested that: Barretts metaplasia of the esophagus occurs in one third of patients with scleroderma; clinical, manometric, laboratory, and radiographic features are poor predictors of the presence of Barretts metaplasia; patients with CREST syndrome, prolonged dysphagia, or a very low lower esophageal sphincter pressure may have an increased risk for the development of metaplasia; patients with scleroderma and Barretts metaplasia have an increased risk of complications such as stricture or adenocarcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

The immunohistochemistry of gastrointestinal stromal tumors. Evidence supporting an origin from smooth muscle.

To study the histogenesis of gastrointestinal stromal tumors, 79 cases were evaluated for desmin (DES), vimentin (VIM), and S-100 protein immunoreactivity by the avidin-biotin immunoperoxidase procedure on paraffin- embedded, Bouins-fixed tissue sections. All tumors showed weak vimentin positivity. Trapped nonneoplastic smooth muscle and nerve twigs were often noted, particularly at the tumor periphery. Significant tumor S-100 positivity was not identified in our series. Similarly, glial fibrillary acidic protein (GFAP) immunoreactivity (performed in 11 desmin-negative tumors) was not detected within either gastrointestinal stromal tumors or enteric glial cells. Fifty-three percent (53%) of all gastrointestinal stromal tumors (GIST) displayed positive tumor cell desmin immunoreactivity. All 10 esophageal and all four colorectal tumors were diffusely desmin positive and unequivocal smooth muscle lesions. In contrast, only 17 of 37 (46%) benign and six of nine (67%) malignant gastric tumors were desmin positive. Similarly, four of 10 (40%) benign and one of nine (11%) malignant small-bowel tumors expressed desmin. Several gastric neoplasms with prominent nuclear palisading resembling schwannian Antoni A regions were nonetheless desmin positive. Epithelioid gastric tumors were more frequently desmin positive than nonepithelioid tumors; however, this positivity did not attain statistical significance. Two gastrointestinal stromal tumors that were desmin negative in paraffin-embedded material had detectable antigen in frozen sections. Gastric and small-bowel tumors measuring less than 3 cm were significantly more often desmin positive than those 3 cm or greater. We conclude that the method of fixation, tissue preparation, and immunostaining may significantly affect the expression of desmin. Although the histogenesis of gastrointestinal stromal tumors remains controversial, most of these tumors show evidence of smooth muscle differentiation.

Solitary rectal ulcer syndrome: Its clinical and pathological underdiagnosis

ABSTRACTReports of solitary rectal ulcer syndrome (SRUS) from the United States are rare. A retrospective analysis of biopsy specimens over a period of 5 years yielded 12 patients who fulfilled the histopathologic criteria for this disorder. The clinicopathologic features of patients in this series are similar to those previously reported; the majority presented with solitary ulcerated or polypoid lesions located 4–18 cm from the anal margin. The initial clinical diagnosis was never SRUS; carcinoma and inflammatory bowel disease were considered most likely in one and three cases, respectively. Three patients had mucosal prolapse. Solitary rectal ulcer syndrome was the initial pathologic diagnosis in only four patients (33%). We conclude that SRUS is frequently underdiagnosed both clinically and pathologically in this country. The pathologist might be the first to suggest this diagnosis to the clinician by recognizing its characteristic histopathologic features.

Barrett's esophagus in scleroderma: Increased prevalence and radiographic findings

Ten of 27 patients (37%) with scleroderma who underwent endoscopy at our hospital between 1980 and 1984 for symptoms of reflux esophagitis had biopsy-proven Barretts esophagus. Two of those 10 patients had esophageal adenocarcinomas. In a blinded review of esophagrams (all but 2 using double-contrast technique) from 16 of the 27 patients, only 1 patient was thought to be at high risk for Barretts esophagus due to a high esophageal stricture with an adjacent reticular pattern of the mucosa. The latter patient had biopsy-proven Barretts mucosa. Eight patients were thought to be at moderate risk for Barretts esophagus due to reflux esophagitis and/or distal strictures in 6 and polypoid intraluminal masses in 2. Three of the 6 patients with esophagitis and/or strictures had Barretts esophagus, and both patients with masses had adenocarcinomas arising in Barretts mucosa. Finally, 7 patients who had no esophagitis or strictures were thought to be at low risk for Barretts esophagus. None of those 7 had histologic evidence of Barretts mucosa. Thus, the major value of double-contrast esophagography is its ability to classify patients into high-, moderate-, and low-risk for Barretts esophagus to determine the relative need for endoscopy and biopsy in these patients.

Gastric small lymphocytic proliferation with immunoglobulin gene rearrangement in pseudolymphoma versus lymphoma

The nature of gastric infiltrates consisting primarily of benign-appearing small lymphocytes is at present a controversial issue. Earlier reports of gastric lymphoma developing in gastric pseudolymphoma and more recent immunohistochemical studies demonstrating monoclonal B-cell populations in pseudolymphoma suggest that at least some cases represent low-grade lymphomas or clonal precursor lesions that may develop into lymphoma. Observations of a small lymphocytic infiltrate arising in the region of a gastric ulcer that lacked definitive morphologic evidence of malignancy (lymphoma) but was clearly a monoclonal B-cell proliferation by immunohistochemical and gene rearrangement studies support the notion that some gastric lymphoproliferative lesions that histologically have been called pseudolymphomas may include one or more clonal lymphoid expansions. A histopathologic/molecular model suggesting a potential pathway for the development of morphologically recognizable lymphoma from benign-appearing small lymphocytic infiltrates is presented, and the concept that for a variety of lymphoid proliferations clonality and malignancy may not be synonymous is discussed.

Benign Pneumoperitoneum in a Patient with Celiac Sprue

A patient with celiac sprue was found to have an asymptomatic pneumoperitoneum. Prompt recognition that the pneumoperitoneum was due to pneumatosis cystoides intestinalis prevented unnecessary surgical intervention. Severe mucosal disease of the small intestine can be associated with an asymptomatic pneumoperitoneum.

Solitary rectal ulcer syndrome: A radiologic diagnosis?

The solitary rectal ulcer syndrome (SRUS) is an uncommon condition in which a solitary area of discrete ulceration is typically found on the anterior wall of the rectum. Between 1981 and 1983, we collected 8 pathologically proven cases of SRUS in which barium enema examinations had been performed (7 double-contrast, 1 single-contrast). Seven patients had rectal bleeding. On the original x-ray report, 4 cases were thought to be normal, but the pathologic tissue had been removed endoscopically in 2 of these cases prior to the radiologic study. The other 4 cases were thought to be abnormal, although the specific diagnosis of SRUS was not suggested in any case. In a blinded rereading of these 8 cases randomly interspersed with 29 other non-SRUS cases, however, the films were interpreted in light of recent radiologic experience with this condition. The same 4 cases were still thought to be normal. In the remaining 4 cases, barium enemas revealed thickened, edematous valves of Houston (3 cases) and a submucosal mass adjacent to the anal verge (1 case). The diagnosis of SRUS was suggested in all 4 cases with only 1 false-positive diagnosis due to a rectal stricture in a patient with endometriosis. Although barium enemas may be normal in patients with SRUS, the presence of thickened, edematous valves of Houston, particularly in a young patient with rectal bleeding, should suggest this condition.

Biopsy Diagnosis of the Digestive Tract

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