Yasushi Ihama

Endoscopic and radiographic features of gastrointestinal involvement in vasculitis

Vasculitis is an inflammation of vessel walls, followed by alteration of the blood flow and damage to the dependent organ. Vasculitis can cause local or diffuse pathologic changes in the gastrointestinal (GI) tract. The variety of GI lesions includes ulcer, submucosal edema, hemorrhage, paralytic ileus, mesenteric ischemia, bowel obstruction, and life-threatening perforation.The endoscopic and radiographic features of GI involvement in vasculitisare reviewed with the emphasis on small-vessel vasculitis by presenting our typical cases, including Churg-Strauss syndrome, Henoch-Schönlein purpura, systemic lupus erythematosus, and Behçets disease. Important endoscopic features are ischemic enterocolitis and ulcer. Characteristic computed tomographic findings include bowel wall thickening with the target sign and engorgement of mesenteric vessels with comb sign. Knowledge of endoscopic and radiographic GI manifestations can help make an early diagnosis and establish treatment strategy.

Diagnosis of intestinal tuberculosis using a monoclonal antibody to Mycobacterium tuberculosis

AIM To investigate the utility of immunohistochemical (IHC) staining with an antibody to Mycobacterium tuberculosis (M. tuberculosis) for the diagnosis of intestinal tuberculosis (TB). METHODS We retrospectively identified 10 patients (4 males and 6 females; mean age = 65.1 ± 13.6 years) with intestinal TB. Clinical characteristics, including age, gender, underlying disease, and symptoms were obtained. Chest radiograph and laboratory tests, including sputum Ziehl-Neelsen (ZN) staining, M. tuberculosis culture, and sputum polymerase chain reaction (PCR) for tubercle bacilli DNA, as well as Tuberculin skin test (TST) and QuantiFERON-TB gold test (QFT), were examined. Colonoscopic records recorded on the basis of Satos classification were also reviewed, in addition to data from intestinal biopsies examined for histopathological findings, including hematoxylin and eosin staining, and ZN staining, as well as M. tuberculosis culture, and PCR for tubercle bacilli DNA. For the present study, archived formalin-fixed paraffin-embedded (FFPE) intestinal tissue samples were immunohistochemically stained using a commercially available species-specific monoclonal antibody to the 38-kDa antigen of the M. tuberculosis complex. These sections were also stained with the pan-macrophage marker CD68 antibody. RESULTS From the clinical data, we found that no patients were immunocompromised, and that the main symptoms were diarrhea and weight loss. Three patients displayed active pulmonary TB, six patients (60%) had a positive TST, and 4 patients (40%) had a positive QFT. Colonoscopic findings revealed that all patients had type 1 findings (linear ulcers in a circumferential arrangement or linear ulcers arranged circumferentially with mucosa showing multiple nodules), all of which were located in the right hemicolon and/or terminal ileum. Seven patients (70%) had concomitant healed lesions in the ileocecal area. No acid-fast bacilli were detected with ZN staining of the intestinal tissue samples, and both M. tuberculosis culture and PCR for tubercle bacilli DNA were negative in all samples. The histopathological data revealed that tuberculous granulomas were present in 4 cases (40%). IHC staining in archived FFPE samples with anti-M. tuberculosis monoclonal antibody revealed positive findings in 4 patients (40%); the same patients in which granulomas were detected by hematoxylin and eosin staining. M. tuberculosis antigens were found to be mostly intracellular, granular in pattern, and primarily located in the CD68(+) macrophages of the granulomas. CONCLUSION IHC staining with a monoclonal antibody to M. tuberculosis may be an efficient and simple diagnostic tool in addition to classic examination methods for the diagnosis of intestinal TB.

Appendiceal Orifice Inflammation in Ulcerative Colitis

A 44-year-old man was diagnosed with distal ulcerative colitis (UC) when he had hematochezia at the age of 34. He had had a few relapses on maintenance oral mesalazine. He desired a total colonoscopy in the clinical remission. Physical examination showed no abnormalities and routine laboratory tests were normal. Colonoscopy disclosed the appendiceal orifice inflammation (AOI) with reddish and friable mucosa and mucopus (Fig. 1). The remaining colorectum showed no inflammation. He remains well during the follow-up. Since Cohen et al. first coined ‘‘ulcerative appendicitis’’ [1], AOI is uncommon but has increasingly been recognized in patients of distal UC. UC classically extends proximally from the rectum without skip lesions. Isolated AOI has been more frequently observed in patients with less extensive UC and is unlikely the result of patchy improvement due to treatments. The human appendix has long been recognized as a vestigial remnant. Although the pathogenesis of UC has not been fully clarified, clinical evidence has revealed the protective role of appendicectomy on onset and severity of UC [2, 3], indicating the appendix as a priming site for UC [4]. Experimental studies of murine models have also shown that the appendix may serve a central role in antigen sampling and immunological signaling [5]. Therefore, further studies of AOI may unveil not only its clinical implication but also the immunopathogenesis of UC. References

Esophageal perforation by fish bone ingestion

Y M j M A 59-year-old man presented with odynophagia and severe retrosternal pain following a fish (snapper) meal. Physical examination was unremarkable. A CT of the chest disclosed a radiodense linear foreign body that measured 3 cm in length and that perforated the esophagus (A, arrow) but was not associated with the great vessels. EGD showed fish bones that were penetrating the upper esophageal wall (B). The bones were removed with a standard biopsy forceps. Quinolone antibiotics were prescribed for a brief time, and

Pneumatosis intestinalis and hepatic portal venous gas in Crohn's disease.

Dear Sir, A 44-year-old man with a 16-year history of ileal-colonic Crohns disease (CD) presented with acute onset severe abdominal pain and vomiting. On examination, he was febrile and a distended and generalized tender abdomen was noted with signs of peritoneal irritation. Laboratory tests revealed increased white blood cell count of 12,500/mm3. The other laboratory values were within normal range. Computed tomography (CT) scan disclosed pneumoperitoneum and dilated loops of the small …

The Sigmoid Colon of Ulcerative Colitis

A 70-year-old man with a 20-year history of ulcerative colitis was referred to our emergency unit for haematochezia of 2 weeks’ duration. Physical examination showed localized tenderness in the left lower quadrant without rebound. Plain abdominal radiography showed the sigmoid colon with foreshortening and a loss of haustra (Fig. 1, arrowheads), indicating active ulcerative colitis. His condition got worse despite intensive medical treatments, and he thus underwent total colectomy and end ileostomy with uneventful recovery. Although recent imaging studies have shown progress for assessing intestinal diseases, the plain abdominal radiograph is still crucial for evaluating the severity of ulcerative colitis, especially toxic megacolon, a wellknown life-threatening complication. Potential exacerbating factors of ulcerative colitis include colonoscopy and barium enema. In addition to toxic megacolon, we highlight that the tubular appearance on plain abdominal radiographs is quite helpful for assessing the activity of ulcerative colitis in emergency situations.

Gastrointestinal: The shell sign of Crohn's disease

In medicine, a sign is usually a marker or indicator of the presence of a particular disease. Many signs are related to findings on clinical examination. However, some signs refer to changes on radiological or other investigations. In relation to Crohn’s disease, a number of signs have been described that may assist with the interpretation of barium studies. The most well-known sign is the “string sign”. This refers to a stricture of the terminal ileum that typically extends to the ileocecal valve. The sign can be caused by a fibrotic stricture of the terminal ileum or by ileal inflammation, edema and spasm. A second sign in Crohn’s disease is the “cobblestone sign” or cobblestone appearance. With this sign, there are residual islands of intact mucosa between a series of longitudinal and transverse ulcers. The sign usually indicates active inflammation of moderate or greater severity. Less well-known signs include the “ram’s horn sign” and the “star sign”. The former refers to funnel-shaped narrowing of the gastric antrum that occurs in gastric Crohn’s disease while the latter can be created by multiple internal fistulas, fissures and sinuses. In the images shown below, we highlight another common finding in Crohn’s disease that we have called the “shell sign”. The sign is illustrated by barium studies in two different patients with ileal Crohn’s disease. The image in Figure 1 was from a 25-year-old man who was investigated because of a 3-month history of diarrhea and lower abdominal pain. The single-contrast image of the jejunum shows shortening along the mesenteric border with multiple pseudodiverticula-like sacculations on the antimesenteric border. Colonoscopy revealed multiple longitudinal ulcers throughout the colon. Figure 2 shows a double-contrast barium image in a 31-year-old man with known Crohn’s disease. Again, there is shortening of the ileum on the mesenteric border with sacculation on the antimesenteric border. This radiological feature resembles a shell. The sign is caused by the predilection of Crohn’s ulcers for the mesenteric border of the bowel. Ulceration can then be followed by fibrosis and shortening such that there are sacculations on the antimesenteric border. Although comparative studies are needed, the sign may be pathognomonic of Crohn’s disease and could be helpful in excluding other small bowel disorders such as intestinal tuberculosis and small bowel neoplasms.

Education and imaging. Gastrointestinal: the shell sign of Crohn's disease.

In medicine, a sign is usually a marker or indicator of the presence of a particular disease. Many signs are related to findings on clinical examination. However, some signs refer to changes on radiological or other investigations. In relation to Crohn’s disease, a number of signs have been described that may assist with the interpretation of barium studies. The most well-known sign is the “string sign”. This refers to a stricture of the terminal ileum that typically extends to the ileocecal valve. The sign can be caused by a fibrotic stricture of the terminal ileum or by ileal inflammation, edema and spasm. A second sign in Crohn’s disease is the “cobblestone sign” or cobblestone appearance. With this sign, there are residual islands of intact mucosa between a series of longitudinal and transverse ulcers. The sign usually indicates active inflammation of moderate or greater severity. Less well-known signs include the “ram’s horn sign” and the “star sign”. The former refers to funnel-shaped narrowing of the gastric antrum that occurs in gastric Crohn’s disease while the latter can be created by multiple internal fistulas, fissures and sinuses. In the images shown below, we highlight another common finding in Crohn’s disease that we have called the “shell sign”. The sign is illustrated by barium studies in two different patients with ileal Crohn’s disease. The image in Figure 1 was from a 25-year-old man who was investigated because of a 3-month history of diarrhea and lower abdominal pain. The single-contrast image of the jejunum shows shortening along the mesenteric border with multiple pseudodiverticula-like sacculations on the antimesenteric border. Colonoscopy revealed multiple longitudinal ulcers throughout the colon. Figure 2 shows a double-contrast barium image in a 31-year-old man with known Crohn’s disease. Again, there is shortening of the ileum on the mesenteric border with sacculation on the antimesenteric border. This radiological feature resembles a shell. The sign is caused by the predilection of Crohn’s ulcers for the mesenteric border of the bowel. Ulceration can then be followed by fibrosis and shortening such that there are sacculations on the antimesenteric border. Although comparative studies are needed, the sign may be pathognomonic of Crohn’s disease and could be helpful in excluding other small bowel disorders such as intestinal tuberculosis and small bowel neoplasms.

Gastrointestinal: The shell sign of Crohn's disease: Education and Imaging

In medicine, a sign is usually a marker or indicator of the presence of a particular disease. Many signs are related to findings on clinical examination. However, some signs refer to changes on radiological or other investigations. In relation to Crohn’s disease, a number of signs have been described that may assist with the interpretation of barium studies. The most well-known sign is the “string sign”. This refers to a stricture of the terminal ileum that typically extends to the ileocecal valve. The sign can be caused by a fibrotic stricture of the terminal ileum or by ileal inflammation, edema and spasm. A second sign in Crohn’s disease is the “cobblestone sign” or cobblestone appearance. With this sign, there are residual islands of intact mucosa between a series of longitudinal and transverse ulcers. The sign usually indicates active inflammation of moderate or greater severity. Less well-known signs include the “ram’s horn sign” and the “star sign”. The former refers to funnel-shaped narrowing of the gastric antrum that occurs in gastric Crohn’s disease while the latter can be created by multiple internal fistulas, fissures and sinuses. In the images shown below, we highlight another common finding in Crohn’s disease that we have called the “shell sign”. The sign is illustrated by barium studies in two different patients with ileal Crohn’s disease. The image in Figure 1 was from a 25-year-old man who was investigated because of a 3-month history of diarrhea and lower abdominal pain. The single-contrast image of the jejunum shows shortening along the mesenteric border with multiple pseudodiverticula-like sacculations on the antimesenteric border. Colonoscopy revealed multiple longitudinal ulcers throughout the colon. Figure 2 shows a double-contrast barium image in a 31-year-old man with known Crohn’s disease. Again, there is shortening of the ileum on the mesenteric border with sacculation on the antimesenteric border. This radiological feature resembles a shell. The sign is caused by the predilection of Crohn’s ulcers for the mesenteric border of the bowel. Ulceration can then be followed by fibrosis and shortening such that there are sacculations on the antimesenteric border. Although comparative studies are needed, the sign may be pathognomonic of Crohn’s disease and could be helpful in excluding other small bowel disorders such as intestinal tuberculosis and small bowel neoplasms.