Gastric lesions in secondary syphilis

endoscopy. It would be impossible to duplicate this resource and effort in any other format! THE A/S/G/E Endoscopic Guidelines are, by no means, completed. New guidelines are always in the "works." Guideline refinement is an on going process. In the future, new or updated endoscopic guidelines will appear at periodic intervals in the Society's publication, Gastrointestinal Endoscopy. The will now be readily available as a reference source to all who need them. The endoscopic guidelines reflect our concern and dedication to excellence in all aspects of gastrointestinal endoscopy. The fruits of countless manhours of work, critique, and redrafting are coming to bear and will benefit our patients, the medical community, and our membership. After all, isn't that what a legacy is all about?

a 50-year-old Malay man, had recurrent melena and concomitant weight loss and anorexia of 6 months' duration. On endoscopy, there was a polypoid mass with ulceration of the ampullary region of the second part of the duodenum. In 39 examinations (26.5%), the findings were normal. The majority of referrals were from other medical units and private centers. With some, there were delays of a week or longer between the bleeding episode and endoscopy. Thus, acute lesions would have resolved completely by then. In no case was there difficulty in diagnosis because of active bleeding or blood clot. Thein-Htut, MB,BS(Rangoon), FRCP(Edin) Madhav V. Kudva, MB,BS(Malaya), MRCP(UK), MRCPI Kuala Lumpur, Malaysia

Gastric xanthoma To the Editor:

Letters to the Editor Upper gastrointestinal bleeding in Kuala Lumpur, Malaysia To the Editor: We have reviewed referrals for upper gastrointestinal bleeding (hematemesis and/or melena) to our "open access" endoscopy service for the period, April 1985 to December 1986 (Table 1). These comprised about 10% of the total number of endoscopies. Gastric erosions were the most common cause of bleeding, probably related to self-medication with over the counter analgesics and the frequent use of indigenous medicinal preparations containing salicylates and even corticosteroids. Gastric and duodenal ulcers were equally common causes. We have noted this similar prevalence in endoscopies for uncomplicated peptic ulcers. All malignancies were confirmed by endoscopic biopsy. Of the three patients with gastric carcinoma, one, a 51-yearold Indian man with a large prepyloric malignant ulcer also had extensive esophageal varices due to advanced liver cirrhosis. The patient with carcinoma of the head of pancreas, Table 1. Upper gastrointestinal endoscopies: April 1985 to December 1986-

a

Findings

No.

Gastric erosions Gastric ulcers Duodenal ulcers Both gastric and duodenal ulcers Esophageal varices Esophageal varices and gastric ulcers Carcinoma stomach (one with varices) Carcinoma head of pancreas Mallory-Weiss tears Normal

33 26 25

Total = 1477; indication: bleeding, 147.

VOLUME 34, NO.4, 1988

4

11 3 3 1 2 39

We read the article of Kunze et aI.' with interest and would like to report our experience with the endoscopic observation on gastric xanthoma. Among the total of 7699 cases of endoscopic practice during the previous 2 years, we could diagnose 65 cases of gastric xanthoma endoscopically. The incidence of 0.8% in our reports is similar to other endoscopic series. 2 , 3 It is well known that the presence of gastric xanthoma has no correlation with serum lipid level. 2 ,4 Unfortunately, in our recent review on the endoscopy charts, serum lipid level (Table 1) was recorded only in 10 cases of biopsy-confirmed gastric xanthoma. We briefly describe the endoscopic and biochemical findings of those 10 cases. Woo Joong Kim, MD Kyu Sung Rim, MD Department of Gastroenterology Hallym University Seoul, Korea

REFERENCES 1. Kunze KC, Baum RA, Nasrallah SM. Gastric xanthoma. Gastrointest Endosc 1987;33:114-5, 2. Kemeya S, Nakamura S, Mizutani K, et al. Xanthoma in the stomach. Gastrointest Endose 1963;5:37-41. 3. Terruzzi V, Minoli G, Butti GC, Rossini A. Gastric lipid islands in the gastric stump and in non-operated stomach. Endoscopy 1980;12:58-62. 4. Mast A, Elewaut A, Mortier G, et al. Gastric xanthoma. Am J GastroenteroI1976;65:311-7.

Gastric lesions in secondary syphilis To the Editor: Syphilis of the stomach is an uncommon condition. Only rarely have the treponema been isolated from involved tissue.' The following case represents a rare form of syphilis with biopsy-proven gastric involvement causing severe symptoms during the second stage. A 23-year-old unmarried man presented with a 4-week history of acute epigastric pain (not relieved by any drug), anorexia, vomiting of coffee-ground material, and weight 437

Table 1. Endoscopic and biochemical findings Age

Sex

39

F

Antrum

65

F

Antrum

43

F

High body

50

M

Middle body

56 31

F M

Low body Low body

56 51

M M

Low body Low body

52 40

M M

Antrum Antrum

Location

Associated finding Chronic superficial gastritis Chronic superficial gastritis Chronic superficial gastritis Chronic superficial gastritis Gastric polyp Chronic superficial gastritis Duodenal ulcer Chronic superficial gastritis Gastric ulcer Reflux gastritis

Total cholesterol" (mg/dl)

Triglyceride" (mg/dl)

186

97

194

68

136

106

199

79

194 200

80 198

143 168

105 112

162 135

117 100

" Reference range (total cholesterol, 150 to 250; triglyceride, 20 to 160).

Figure 2. Spirochete in gastric mucosa (Warthin-Starry stain, X1800).

Figure 1. Syphilitic gastropathy: endoscopic findings.

loss. Four months prior to admission, 1 week after a sexual contact, the patient noted an ulceration on the penis, which healed spontaneously after 10 days. Two months later he noted progressive alopecia and erythema all over the body (rubeola). Physical examination revealed a poorly nourished man in distress. The inguinal nodes were slightly enlarged, and abdominal examination showed epigastric tenderness. The only significant laboratory findings were a positive 438

TPHA with a titer of 1:10240, positive VDRL, and FTAABS. Gastointestinal x-ray examination was unsatisfactory because the patient vomited the barium. Gastroscopy revealed an infiltrating intramural lesion compatible with the diagnosis of lymphoma. In the midbody of the stomach, there were giant gastric folds, partially compressible with insufflation of air, hemorragic ulcerations, and erosions with marked friability (Fig. 1). Biopsy of representative gastric lesions revealed dense infiltration of the mucosa by mononuclear cells (Fig. 2). Warthin-Starry stain showed the spirochetes in some biopsy fragments, and immunofluorescent studies for Treponema pallidum were positive. The patient subsequently received 1.2 million units of GASTROINTESTINAL ENDOSCOPY

long-acting penicillin intramuscularly, 12 times in a month for 3 months. His gastrointestinal symptoms markedly improved. After he received a total of 28.8 million units of penicillin, gastroscopy revealed healing with residual moderate hyperemia. Repeat of the biopsy of the body showed only a moderate infiltrate. Warthin-Starry stain was negative for spirochetes and immunofluorescent studies were negative for Treponema pallidum. The first cases of gastric syphilis were described by Andral (1834).2 Chiari3 also described gastric syphilis during the tertiary period of the disease. Wile,4 Stokes,5 and Luria6 described gastric illness during the secondary period: these cases were always nonspecific gastritis. Our case is a rare type of pseudoneoplastic gastric syphilis involving the gastric body, while the majority of other cases reported have involved the antrum. Criteria usually considered essential for the diagnosis of gastric syphilis are: (a) untreated syphilis, (b) a roentgenographic or endoscopic lesion, (c) presence of gastric symptoms, (d) inability to alleviate these symptoms or effect any improvement in the anatomical defect by orthodox management without luetic therapy, and (e) symptomatic relief with disappearance of the anatomical lesions after intensive specific therapy.? Our case meets all of these criteria. The gastroscopic findings of an infiltrating lesion with giant folds, hemorrhagic ulcerations, and serpiginous erosions with a mucosa markedly friable and edematous is consistent with the reported endoscopic findings in carcinoma-like gastric syphilis.8-I4 Biopsies of the body lesions in our case showed alteration of the mucosa characterized by cellular infiltration with plasma cells, granulocytes, and perivascular changes of proliferative endarteritis: these lesions, although non-specific, are compatible with reported pathologic findings in syphilitic gastritis. '5 Endoscopic and bioptic abnormalities, in combination with positive TPHA, VDRL, and FTA-ABS tests suggest gastric lues. This diagnosis was confirmed by complete healing following penicillin therapy and by demonstrating spirochetes in gastric mucosa with the Warthin-Starry stain. As this stain is not entirely satisfactory'6 because it is technically difficult, immunofluorescent techniques specific for Treponema pallidum were carried out and found to be positive. M. Bottari, D. Melina, P. Napoli, S. Pallio, A. Puglisi, D. Villari,

MD MD MD MD MD MD

Istituto di Medicina Interna Servizio di Endoscopia Digestiva Istituto di Anatomia Patologica (2 0 Cattedra) Istituto di Dermatologica Policlinico University of Messina Messina, Italy

REFERENCES 1. Sachar DB, Klein RS, et al. Erosive syphilitic gastritis: darkfield and immunofluorescent diagnosis from biopsy specimens. Ann Intern Med 1974;80:512-5. 2. Andral P. Cliniques 1834;2:201.

VOLUME 34, NO.5, 1988

3. Chiari H. Gastric syphilis. Felschrift Rudolf Virchows 1891;2:297. 4. Wile UJ. Syphilis of the stomach. Arch Dermatol Syphilol 1920;1:543. 5. Stokes JH. Modern clinical syphilis. 1st ed. Philadelphia: WB Saunders 1926:734-67. 6. Luria R. Syphilitische und Syphilogene Magenkrankungen (Gastrolues). 1st ed. Berlin: S. Karger, 1929:21-48. 7. Bockus H. Chronic infections of the stomach, granulomas of the stomach and duodenum, foreign bodies. Gastroenterology. 2nd ed. Philadelphia: WB Saunders, 1963:835-56. 8. Sexton RL, Dunkley RE, Kreglow AF. Gastroscopic study of 100 cases of early syphilis. Trans Am Ther Soc 19371938;37:73-7. 9. Reynolds FW. Gastic lesions associated with early syphilis. Am J Syph 1942;26:218-26. 10. Swartz IR. Gastroscopic observations in secondary syphilis. Gastroenterology 1948;10:227-30. 11. Patterson CO, Rouse MO. Description of gastroscopic appearance of luetic gastic lesions in late acquired syphilis. Gastroenterology 1948;10:474-85. 12. Colli A, Gonzales VS. Lue neoplastiforme dello stomaco. Arch Ital Mal Appl Dig 1951;17:358-75. 13. Ninfo G, Manganiello A. Su di un caso di pseudo tumore luetico dello stomaco. Chir ltaI1963;15:89-101. 14. llyn II. Carcinoma-like affection ofthe stomach in early syphilis. Klin Med (Mosk) 1979;57:36-40. 15. Williams C, Kimmelstiel P. Syphilis ofthe stomach. J Am Med Assoc 1940;115:578-82. 16. Beckman JW, Schuman BM. Antral gastritis and ulceration in a patient with secondary syphilis. Gastrointest Endosc 1986;32:355-6.

The endoscopic localization of a gastrinoma in the afferent loop of a gastrojejunostomy To the Editor: Your readers may be interested in the case of a patient with a duodenal wall gastrin-producing endocrine tumor and a 17-year history of ulcer disease, including a 12-year remission after surgery, because the tumor was diagnosed endoscopically by retrograde exploration of the afferent loop of a gastrojejunostomy.

A 45-year-old alcoholic male presented with severe epigastric pain and melena for 3 days. Partial gastrectomy and gastrojejunostomy had been performed in 1968 for complications of peptic ulcer disease. The patient remained asymptomatic until 1980, when he required hospitalization for recurrent upper gastrointestinal bleeding. During the next 2 years episodes of bleeding recurred, prompting a left transthoracic vagotomy in 1983. The severity of the patient's disease state was attributed to the effects of chronic alcoholism. In the emergency room the vital signs were stable. Nasogastric lavage was negative for blood. Abdominal examination was remarkable for a midline surgical scar, epigastric and left upper quadrant tenderness, a liver span of 12 cm by percussion, and active bowel sounds. The stool was black and Hemoccult positive. There were no stigmata of chronic liver disease. The hematocrit was 13% and the albumin was 2.6 gldl. Other routine laboratory data, including coagulation studies, were normal. The patient was transfused with packed red blood cells and given intravenous 439