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Image of the month answer
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CORRESPONDENCE
they have experienced excellent quality-of-life outcomes as well. 6 In view of these facts, and our experience, we would recommend that EUS/SBD be included in diagnostic algorithms (as were EUS and bile drainage in the second edition of Rome II8), for unexplained upper abdominal pain in patients with intact gallbladders. JAMES E. DILL BOBBIE DILL
Georgia GastroenterologyGroup Savannah, Georgia 1. Amaral J, Xiao Z, Chert Q, Yu P, Biancani P, Behar J. Gallbladder muscle dysfunction in patients with chronic acalculous disease. Gastroenterology 2 0 0 1 ; 1 2 0 : 5 0 6 - 5 1 1 . 2. Mulholland MW. Progress in understanding acalculous gallbladder disease. Gastroenterology 2 0 0 1 ; 1 2 0 : 5 7 0 - 5 7 2 . 3. Dill JE, Hill J, Callis L, Berkhouse L, Evans P, Martin D, Palmer ST. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis-Diagnoses and outcomes. Endoscopy 1 9 9 5 ; 2 7 : 4 2 4 - 4 2 7 . 4. Khosla R, Singh A, Marshall JB. Does cholecystectomy alleviate symptoms in patients with acalculous biliary-type pain and abnormal gallbladder ejection fraction (abstr)? Gastroenterology 1996; 110:A461. 5. Dahan P, Amouyal P, et al. Is endoscopic ultrasonography (EUS) helpful in patients with suspicion of complicated gallstones and normal ultrasonography (US) (abstr)? Gastroenterology 1993;104: A358. 6. Dill JE, Dill BP. Quality of life outcomes following endoscopic ultrasound for dyspepsia/unexplained upper abdominal pain. Acta Endoscopica 2000;30:231-235. 7. Dill JE. Endosonography/bile drainage combination for difficult-todiagnose gallbladder disease. J Laparoendosc Adv Surg Tech 1998;vol 8. 8. Corazziari E. Rome I1. Functional gastrointestinal disorders: Diagnosis, pathophysiology, and treatment. In: Drossman D, ed. A multinational consensus, 2nd ed. 4 4 9 - 4 7 6 . doi:10.1053/gast.2001.30127
GASTROENTEROLOGY Vol. 121, No. 6
Comments on Experimental Use of Intravenous Cyclosporine (CsA) Alone to Treat Severe Ulcerative Colitis Dear Sir: We would like to comment on the article of Dr. Rutgeerts et al. 1 describing the experimental use of intravenous cyclosporine (CsA) alone to treat severe ulcerative colitis. In 1992 we believe we were the first to suggest that CsA can be effective in severe ulcerative colitis without the need for synergy with high-dose steroids, 2 but we did not embark in the endeavor to demonstrate that CsA "can stand alone" to this goal. In our opinion, the reader of Dr. Rutgeert's paper is at risk of gathering the message that CsA may easily become a first-line drug for ulcerative colitis. Firstly, cost-benefit issues, an obviously relevant matter, were just superficially addressed by Dr. Rutgeerts; secondly, with an expected rate of response to steroids exceeding 50%, like the other so-called autoimmune diseases, ulcerative colitis remains a steroidsensitive disorder by definition,3 and first-line treatment using a drug like CsA raises an array of ethical questions. G.C. ACTIS
Department of Gastroenterology OspedaleMolinette Torino, Italy 1. D'Haens G, kemmens L, Geboes K, Vandeputte L, Van Acker F, Mortlemans L, Peeters M, Vermeire S, Pennincky F, Nevens F, Hiele M, Rutgeerts P. Intravenous cyclosporine versus intravenous corticosteroids as single therapy for severe attacks of ulcerative colitis. Gastroenterology 2 0 0 1 ; 1 2 0 : 1 3 2 3 - 1 3 2 9 . 2. Actis GC, Ottobrelli A, Pera A, et al. Continuously infused cyclosporin at low-dose to avoid emergency colectomy in acute attacks of ulcerative colitis. J Clin Gastroenterol 1993;17:10-13. 3. Investigator's Brochure: Sandimmun NEORAL in systemic lupus erythematosus. Novartis Data Files. doi:10.1053/gast.2001.30129
Image of the Month Answer: Malignant lymphomatous polyposis A n s w e r to the Image o f the Month Question (page 1274): These endoscopic photographs show malignant lymphomatous polyposis (MLP). Lymphomatous polyposis is an u n c o m m o n presentation of primary gastrointestinal or gastrointestinal predominant lymphoma. As in the case presented, MLP is generally mantle cell lymphoma, a low-grade non-Hodgkin's, B-cell lymphoma. Rare cases of mucosa-associated lymphoid tissue lymphoma and T-cell lymphoma presenting as MLP have been reported. There is some evidence that mantle cell lymphoma manifesting as MLP is separated from nodal mantle cell lymphoma by virtue of the presence of integren ot4137, which may mediate lymphocyte homing to the intestinal mucosa. MLP has been described in the stomach, small intestine, large intestine, and rectum. An individual patient may have diffuse involvement or an isolated area affected. At the time of diagnosis, up to one third of patients with MLP will have extraintestinal disease. Patients may present with abdominal pain, diarrhea, gastrointestinal bleeding, gastrointestinal obstruction, intusseption, or systemic symptoms such as fever, weight loss, and fatigue. The differential diagnosis of multiple colonic polyps includes adenomatous and hamartomatous polyposis syndromes. As noted in our patient, the appearance of the mucosa overlying the lymphomatous polyps is often normal as opposed to that seen in adenomas. Response to conventional chemotherapy is generally poor, with a median survival of less than 3 years. Recent trials indicate that high-dose radiochemotherapy with stem cell transplantati0n may improve prognosis. In the patient presented, the excised Cervical lymph node also showed features consistent with mantle cell lymphoma. He was referred to the oncology service for further management. For submission instructions, please see the Gastroenterology w e b s i t e (http://www.gastrojournal.org).
CORRESPONDENCE
they have experienced excellent quality-of-life outcomes as well. 6 In view of these facts, and our experience, we would recommend that EUS/SBD be included in diagnostic algorithms (as were EUS and bile drainage in the second edition of Rome II8), for unexplained upper abdominal pain in patients with intact gallbladders. JAMES E. DILL BOBBIE DILL
Georgia GastroenterologyGroup Savannah, Georgia 1. Amaral J, Xiao Z, Chert Q, Yu P, Biancani P, Behar J. Gallbladder muscle dysfunction in patients with chronic acalculous disease. Gastroenterology 2 0 0 1 ; 1 2 0 : 5 0 6 - 5 1 1 . 2. Mulholland MW. Progress in understanding acalculous gallbladder disease. Gastroenterology 2 0 0 1 ; 1 2 0 : 5 7 0 - 5 7 2 . 3. Dill JE, Hill J, Callis L, Berkhouse L, Evans P, Martin D, Palmer ST. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis-Diagnoses and outcomes. Endoscopy 1 9 9 5 ; 2 7 : 4 2 4 - 4 2 7 . 4. Khosla R, Singh A, Marshall JB. Does cholecystectomy alleviate symptoms in patients with acalculous biliary-type pain and abnormal gallbladder ejection fraction (abstr)? Gastroenterology 1996; 110:A461. 5. Dahan P, Amouyal P, et al. Is endoscopic ultrasonography (EUS) helpful in patients with suspicion of complicated gallstones and normal ultrasonography (US) (abstr)? Gastroenterology 1993;104: A358. 6. Dill JE, Dill BP. Quality of life outcomes following endoscopic ultrasound for dyspepsia/unexplained upper abdominal pain. Acta Endoscopica 2000;30:231-235. 7. Dill JE. Endosonography/bile drainage combination for difficult-todiagnose gallbladder disease. J Laparoendosc Adv Surg Tech 1998;vol 8. 8. Corazziari E. Rome I1. Functional gastrointestinal disorders: Diagnosis, pathophysiology, and treatment. In: Drossman D, ed. A multinational consensus, 2nd ed. 4 4 9 - 4 7 6 . doi:10.1053/gast.2001.30127
GASTROENTEROLOGY Vol. 121, No. 6
Comments on Experimental Use of Intravenous Cyclosporine (CsA) Alone to Treat Severe Ulcerative Colitis Dear Sir: We would like to comment on the article of Dr. Rutgeerts et al. 1 describing the experimental use of intravenous cyclosporine (CsA) alone to treat severe ulcerative colitis. In 1992 we believe we were the first to suggest that CsA can be effective in severe ulcerative colitis without the need for synergy with high-dose steroids, 2 but we did not embark in the endeavor to demonstrate that CsA "can stand alone" to this goal. In our opinion, the reader of Dr. Rutgeert's paper is at risk of gathering the message that CsA may easily become a first-line drug for ulcerative colitis. Firstly, cost-benefit issues, an obviously relevant matter, were just superficially addressed by Dr. Rutgeerts; secondly, with an expected rate of response to steroids exceeding 50%, like the other so-called autoimmune diseases, ulcerative colitis remains a steroidsensitive disorder by definition,3 and first-line treatment using a drug like CsA raises an array of ethical questions. G.C. ACTIS
Department of Gastroenterology OspedaleMolinette Torino, Italy 1. D'Haens G, kemmens L, Geboes K, Vandeputte L, Van Acker F, Mortlemans L, Peeters M, Vermeire S, Pennincky F, Nevens F, Hiele M, Rutgeerts P. Intravenous cyclosporine versus intravenous corticosteroids as single therapy for severe attacks of ulcerative colitis. Gastroenterology 2 0 0 1 ; 1 2 0 : 1 3 2 3 - 1 3 2 9 . 2. Actis GC, Ottobrelli A, Pera A, et al. Continuously infused cyclosporin at low-dose to avoid emergency colectomy in acute attacks of ulcerative colitis. J Clin Gastroenterol 1993;17:10-13. 3. Investigator's Brochure: Sandimmun NEORAL in systemic lupus erythematosus. Novartis Data Files. doi:10.1053/gast.2001.30129
Image of the Month Answer: Malignant lymphomatous polyposis A n s w e r to the Image o f the Month Question (page 1274): These endoscopic photographs show malignant lymphomatous polyposis (MLP). Lymphomatous polyposis is an u n c o m m o n presentation of primary gastrointestinal or gastrointestinal predominant lymphoma. As in the case presented, MLP is generally mantle cell lymphoma, a low-grade non-Hodgkin's, B-cell lymphoma. Rare cases of mucosa-associated lymphoid tissue lymphoma and T-cell lymphoma presenting as MLP have been reported. There is some evidence that mantle cell lymphoma manifesting as MLP is separated from nodal mantle cell lymphoma by virtue of the presence of integren ot4137, which may mediate lymphocyte homing to the intestinal mucosa. MLP has been described in the stomach, small intestine, large intestine, and rectum. An individual patient may have diffuse involvement or an isolated area affected. At the time of diagnosis, up to one third of patients with MLP will have extraintestinal disease. Patients may present with abdominal pain, diarrhea, gastrointestinal bleeding, gastrointestinal obstruction, intusseption, or systemic symptoms such as fever, weight loss, and fatigue. The differential diagnosis of multiple colonic polyps includes adenomatous and hamartomatous polyposis syndromes. As noted in our patient, the appearance of the mucosa overlying the lymphomatous polyps is often normal as opposed to that seen in adenomas. Response to conventional chemotherapy is generally poor, with a median survival of less than 3 years. Recent trials indicate that high-dose radiochemotherapy with stem cell transplantati0n may improve prognosis. In the patient presented, the excised Cervical lymph node also showed features consistent with mantle cell lymphoma. He was referred to the oncology service for further management. For submission instructions, please see the Gastroenterology w e b s i t e (http://www.gastrojournal.org).