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Endoscopic diverticulectomy in the sigmoid colon
with biopsy forceps reveals dimpling, which is not found with true polyps. Polypectomy of an inverted diverticulum may result in perforation of the colon. REFERENCES 1. WHITE AF, OH KS, WEBER AL, JAMES AE: Radiologic manifestations
of Meckel's diverticulum. Am J Roentgenol 118:86, 1973 2. DALINKA MK, WUNDER jK: Meckel's diverticulum and its com-
plications, with emphasis on roentgen demonstration. Radiology 106:295, 1973 3. FREENY PC, WALKER IH: Inverted diverticula of the gastrointestinal tract. Gastrointest Radiol 4:57, 1979
Figure 2. Colonoscopy showing an inverted diverticulum.
Endoscopic diverticulectomy in the sigmoid colon Bernard M. Schuman, MD
An inadvertent endoscopic diverticulectomy of an inverted colonic diverticulum was performed. This procedure is not recommended and can be avoided by eliciting the radiating fold pillow sign.' CASE REPORT A 43-year-old woman was seen in December 1973 for left lower quadrant abdominal pain. A barium enema demonstrated several diverticula of the sigmoid colon. Because of persistent symptoms, colonoscopy was done as an outpatient and several sessile polyps were observed. A biopsy was taken and the histological diagnosis was adenoma. Because of the possibility that multiple polypectomy might be necessary, hospital admission was advised. Cotonoscopy was carried out to the splenic flexure. In the proximal to midsigmoid, several projections were identified which were considered to be submucosal rather than mucosal and appeared to vary in prominence with the distension and contractility of the bowel. Two of these lesions were biopsied and a third, which was the larger one, was removed in toto by snare electrocoagulation (Fig. 1). There was no evidence of bleeding or excessive electrocoagulation at the time. Diverticula were also identified.
From the Department of Gastroenterology, Henry Ford Hospital, Detroit, Michigan. Reprint requests: Bernard M. Schuman, MD, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, Michigan 48202. VOLUME 28, NO.3, 1982
Figure 1. Polypoid structure at lower left corner of photograph before polypectomy.
Figure 2. The "polyp" unmasked as a diverticulum. 189
The larger specimen measured 9 mm in diameter and on microscopic examination showed colonic mucosa with a large number of capillaries and a few chronic inflammatory cells. Submucosal tissue was lined by a concentric muscular layer, and the finding was consistent with that of a diverticulum (Fig. 2). Upon learning the pathological report, the endoscopist immediately telephoned the patient to determine the present state of her health. There had been no untoward result from the colonoscopy, and the patient had not experienced abdominal pain, fever, or alteration of bowel habit.
Endoscopic appearances of duodenitis due to strongyloidiasis M. F. Bone, BSc, MBCP, DCH I. M. Chesner, MRCP R. Oliver, MB, ChB P. Asquith, MD, FRCP
Chronic infestation of the upper gastrointestinal tract with the larvae of Strongyloides stercora/is is frequently associated with dyspepsia. 1 The diagnosis can readily be made by duodenal aspiration and biopsy.2 In this condition the barium appearances of the duodenum are well recognized and may even be diagnostic. 3 However, endoscopic findings are less well documented. We present a case of severe hypertrophic duodenitis seen on endoscopy due to S. stercora/is infection which completely resolved on treatment with thiabendazole. CASE REPORT A 47-year-old Jamaican bus driver who had lived in Eng-
land for the last 13 years had been well, except for intermittent attacks of dyspepsia that were controlled with proprietary antacids. He was a nonsmoker and took no alcohol. In September 1980 he was admitted to the hospital with a 4day history of vomiting and diarrhea. He was dehydrated with slight, generalized abdominal tenderness. Sa/monella typhimurium was isolated from a stool specimen, but no ova or parasites were seen. He was treated with intravenous saline and recovered rapidly; stool cultures were negative prior to discharge from the hospital 1 week later. On review in the clinic, he complained of severe burning epigastric pain, nausea, and weight loss. Barium studies revealed considerable spasm at the pyloric antrum with gross deformity of the duodenal loop and possible antral and postbulbal ulceration (Fig. 1). Endoscopy revealed a healed ulcer on the posterior aspect of the lesser curve of the stomach. The duodenal cap was markedly deformed, but there was no active ulceration. The lumen of the second part of the duodenum was nearly obliterated by gross inflammation and hypertrophy of the From the Alastair Fraser and John Squire Metabolic and Clinical Research Unit, East Birmingham Hospital, Birmingham, England. Reprint requests: Dr. M. F. Bone, East Birmingham Hospital, Bordes/ey Green East, Birmingham, B9 5ST, England.
190
DISCUSSION Nonpedunculated polyps in the setting of diverticulosis must be carefully studied before biopsy or polypectomy to be certain that the polypoid structure is not an inverted diverticulum. It may be the better part of valor to leave untouched a small polyp that has diverticula as neighbors. REFERENCE The detection of an inverted diverticulum by colonoscopy. Gastrointest Endosc 28:188, 1982
1. SHAH AN, MAZZA BR:
mucosa. Several biopsies were taken of the friable, hyperemic mucosa. Histological examination of the duodenal biopsies revealed focal villous atrophy, inflammatory cell infiltration of the lamina propria, and many filarial and rhabditiform larvae characteristic of S. stercoralis (Fig. 2). A rectal biopsy also revealed helminthic material surrounded by eosinophils, and stool examination now showed large numbers of filarial S. stercora/is. Treatment with three courses of thiabendazole at monthly intervals eventually led to the patient's complete clinical recovery and eradication of filariae from the stool. Repeat endoscopy and biopsy showed a normal appearance of the duodenum and resolution of the previous histological changes.
DISCUSSION The frequent occurrence of abdominal pain in strongyloidiasis is well recognized 1 ; indeed, in one early study peptic ulceration was the most common presentation in such patients,. Dyspepsia may be due to 4 actual peptic ulceration of the stomach or duodenum. Duodenitis is probably much more common, with radiological appearances of duodenal dilation or rigidity and swollen mucosal folds. 5 In endemic areas these appearances may be diagnostic3 but in nonendemic areas the abdominal complications of this disease are not readily appreciated. As a consequence of population migration and the long period of infectivity, sporadic cases of hyperinfection will be seen. An important setting for strongyloidiasis hyperinfection in nonendemic areas is in the clinical situation of im6 mune suppression by systemic disease or drugs. Failure to recognize the disease with upper small gut obstruction leads to a high mortality rate. A spectrum of small bowel pathology from mild catarrhal appearances to a severe ulcerative and fibrotic enteritis has been described on laparotomy specimens; however, the endoscopic appearances of the duodenum in this condition have not previously been described in detail. Since endoscopy is becoming the prime investigative procedure for abdominal pain in many centers, it will be increasingly important to recognize this specific form of duodenitis. In fact, the endoscopic appearance, as revealed in our patient, mirrors that seen radiologically. Mucosal hypertrophy, inflammation, and microulceration occur to such a GASTROINTESTINAL ENDOSCOPY
of Meckel's diverticulum. Am J Roentgenol 118:86, 1973 2. DALINKA MK, WUNDER jK: Meckel's diverticulum and its com-
plications, with emphasis on roentgen demonstration. Radiology 106:295, 1973 3. FREENY PC, WALKER IH: Inverted diverticula of the gastrointestinal tract. Gastrointest Radiol 4:57, 1979
Figure 2. Colonoscopy showing an inverted diverticulum.
Endoscopic diverticulectomy in the sigmoid colon Bernard M. Schuman, MD
An inadvertent endoscopic diverticulectomy of an inverted colonic diverticulum was performed. This procedure is not recommended and can be avoided by eliciting the radiating fold pillow sign.' CASE REPORT A 43-year-old woman was seen in December 1973 for left lower quadrant abdominal pain. A barium enema demonstrated several diverticula of the sigmoid colon. Because of persistent symptoms, colonoscopy was done as an outpatient and several sessile polyps were observed. A biopsy was taken and the histological diagnosis was adenoma. Because of the possibility that multiple polypectomy might be necessary, hospital admission was advised. Cotonoscopy was carried out to the splenic flexure. In the proximal to midsigmoid, several projections were identified which were considered to be submucosal rather than mucosal and appeared to vary in prominence with the distension and contractility of the bowel. Two of these lesions were biopsied and a third, which was the larger one, was removed in toto by snare electrocoagulation (Fig. 1). There was no evidence of bleeding or excessive electrocoagulation at the time. Diverticula were also identified.
From the Department of Gastroenterology, Henry Ford Hospital, Detroit, Michigan. Reprint requests: Bernard M. Schuman, MD, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, Michigan 48202. VOLUME 28, NO.3, 1982
Figure 1. Polypoid structure at lower left corner of photograph before polypectomy.
Figure 2. The "polyp" unmasked as a diverticulum. 189
The larger specimen measured 9 mm in diameter and on microscopic examination showed colonic mucosa with a large number of capillaries and a few chronic inflammatory cells. Submucosal tissue was lined by a concentric muscular layer, and the finding was consistent with that of a diverticulum (Fig. 2). Upon learning the pathological report, the endoscopist immediately telephoned the patient to determine the present state of her health. There had been no untoward result from the colonoscopy, and the patient had not experienced abdominal pain, fever, or alteration of bowel habit.
Endoscopic appearances of duodenitis due to strongyloidiasis M. F. Bone, BSc, MBCP, DCH I. M. Chesner, MRCP R. Oliver, MB, ChB P. Asquith, MD, FRCP
Chronic infestation of the upper gastrointestinal tract with the larvae of Strongyloides stercora/is is frequently associated with dyspepsia. 1 The diagnosis can readily be made by duodenal aspiration and biopsy.2 In this condition the barium appearances of the duodenum are well recognized and may even be diagnostic. 3 However, endoscopic findings are less well documented. We present a case of severe hypertrophic duodenitis seen on endoscopy due to S. stercora/is infection which completely resolved on treatment with thiabendazole. CASE REPORT A 47-year-old Jamaican bus driver who had lived in Eng-
land for the last 13 years had been well, except for intermittent attacks of dyspepsia that were controlled with proprietary antacids. He was a nonsmoker and took no alcohol. In September 1980 he was admitted to the hospital with a 4day history of vomiting and diarrhea. He was dehydrated with slight, generalized abdominal tenderness. Sa/monella typhimurium was isolated from a stool specimen, but no ova or parasites were seen. He was treated with intravenous saline and recovered rapidly; stool cultures were negative prior to discharge from the hospital 1 week later. On review in the clinic, he complained of severe burning epigastric pain, nausea, and weight loss. Barium studies revealed considerable spasm at the pyloric antrum with gross deformity of the duodenal loop and possible antral and postbulbal ulceration (Fig. 1). Endoscopy revealed a healed ulcer on the posterior aspect of the lesser curve of the stomach. The duodenal cap was markedly deformed, but there was no active ulceration. The lumen of the second part of the duodenum was nearly obliterated by gross inflammation and hypertrophy of the From the Alastair Fraser and John Squire Metabolic and Clinical Research Unit, East Birmingham Hospital, Birmingham, England. Reprint requests: Dr. M. F. Bone, East Birmingham Hospital, Bordes/ey Green East, Birmingham, B9 5ST, England.
190
DISCUSSION Nonpedunculated polyps in the setting of diverticulosis must be carefully studied before biopsy or polypectomy to be certain that the polypoid structure is not an inverted diverticulum. It may be the better part of valor to leave untouched a small polyp that has diverticula as neighbors. REFERENCE The detection of an inverted diverticulum by colonoscopy. Gastrointest Endosc 28:188, 1982
1. SHAH AN, MAZZA BR:
mucosa. Several biopsies were taken of the friable, hyperemic mucosa. Histological examination of the duodenal biopsies revealed focal villous atrophy, inflammatory cell infiltration of the lamina propria, and many filarial and rhabditiform larvae characteristic of S. stercoralis (Fig. 2). A rectal biopsy also revealed helminthic material surrounded by eosinophils, and stool examination now showed large numbers of filarial S. stercora/is. Treatment with three courses of thiabendazole at monthly intervals eventually led to the patient's complete clinical recovery and eradication of filariae from the stool. Repeat endoscopy and biopsy showed a normal appearance of the duodenum and resolution of the previous histological changes.
DISCUSSION The frequent occurrence of abdominal pain in strongyloidiasis is well recognized 1 ; indeed, in one early study peptic ulceration was the most common presentation in such patients,. Dyspepsia may be due to 4 actual peptic ulceration of the stomach or duodenum. Duodenitis is probably much more common, with radiological appearances of duodenal dilation or rigidity and swollen mucosal folds. 5 In endemic areas these appearances may be diagnostic3 but in nonendemic areas the abdominal complications of this disease are not readily appreciated. As a consequence of population migration and the long period of infectivity, sporadic cases of hyperinfection will be seen. An important setting for strongyloidiasis hyperinfection in nonendemic areas is in the clinical situation of im6 mune suppression by systemic disease or drugs. Failure to recognize the disease with upper small gut obstruction leads to a high mortality rate. A spectrum of small bowel pathology from mild catarrhal appearances to a severe ulcerative and fibrotic enteritis has been described on laparotomy specimens; however, the endoscopic appearances of the duodenum in this condition have not previously been described in detail. Since endoscopy is becoming the prime investigative procedure for abdominal pain in many centers, it will be increasingly important to recognize this specific form of duodenitis. In fact, the endoscopic appearance, as revealed in our patient, mirrors that seen radiologically. Mucosal hypertrophy, inflammation, and microulceration occur to such a GASTROINTESTINAL ENDOSCOPY