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Squamous cell metaplasia without dysplasia of the colonic mucosa in ulcerative colitis
oncretions in the main pancreatic duct. 9 Incomplete lancreas divisum, in which the ventral and dorsal luct communicate through secondary branches de.pite their separate development, is a very unusual lbnormality that may offer a radiologic image similar 10 :0 that of our case. The treatment of cases similar ;0 this should be individualized. Our patient and a ;imilar case previously reported9 were successfully ~reated by pancreatojejunostomy.
4. 5. 6. 7. 8.
REFERENCES 1. Sarles H. Etiopathogenesis and definition of chronic pancrea-
titis. Dig Dis Sci 1986;31:91S-107S. 2. Bernarde P, Belghiti J, Athovel M, Mallardo N, Breil P, Fekete F. Historie naturelle de la pancreatite chronique: etude de 120 cases. Gastroenterol Clin Bioi 1983;7:8-13. 3. Tasso F, Stemmelin M, Sarles H, Clop J. Comparative morpho-
Squamous cell metaplasia without dysplasia of the colonic mucosa in ulcerative colitis Takashi Maruoka, MD Kaori Hasegawa, MD Kou Nagasako, MD
There have been only a few reports of squamous cell metaplasia l - 4 or squamous cell carcinoma 1 ,2.5,6 of the colon associated with ulcerative colitis. We encountered a patient with squamous cell metaplasia and long-standing ulcerative colitis. The lesion was noted endoscopically as a pinkish white area with a clearly demarcated border. Lugol stain and biopsies demonstrated the lesion to be composed of squamous epithelium.
9.
10.
metric study of the human pancreas in its normal state and in primary chronic calcifying pancreatitis. Biomedicine 1973;18:134-44. Gyr KE, Singer MV, Sarles H. Pancreatitis: concepts and classification. Excerpta Med Int Congress Series 1984. Nakamura K, Sarles H, Payan H. Three-dimensional reconstruction of the pancreatic ducts in chronic pancreatitis. Gastroenterology 1972;62:942-9. Gilinski NH, Lewis JW, Flueck JA, Fried AM. Annular pancreas associated with diffuse chronic pancreatitis. Am J GastroenteroI1987;82:661-4. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980;21:105-14. Bretagne JF, Darnault P, Raoul JL, et al. Calcifying pancreatitis of a congenital short pancreas. Am J Gastroenterol 1987;82:1314-7. Noda A, Hamano H, Shibata T, et al. Chronic pancreatitis at early age of onset presenting interesting findings through endoscopic retrograde pancreatography and chemical analysis of nonopaque pancreatic concretion. Dig Dis Sci 1987;32:433-40. Tulassay Z, Papp J. Diagnostic aspects of incomplete pancreas divisum. Gastrointest Endosc 1986;31:428.
contraction or decrease in size of the lumen, and pseudopolyps were not observed. All biopsies showed changes consistent with ulcerative colitis, including inflammatory cells in a mucosa of reduced height with rather shallow crypts, sometimes not reaching the muscularis mucosae. There was also a marked decrease in the number of glands and intensive capillary congestion. All changes were typical of active ulcerative colitis. Barium enemas showed involvement of the left colon with
CASE REPORT A 19-year-old man with symptoms of fulminating ulcerative colitis, including diarrhea and bloody stool, was seen in January 1973. Colonoscopy at that time showed a friable and inflamed mucosa. Barium enema showed involvement of the left colon with irregular mucosa and loss of haustration. No cobblestone appearance or skip lesions were present. The patient was hospitalized for 8 months and was treated with supportive measures including steroids and sulfasalazine. Between 1974 and 1986, the patient had frequent exacerbations of the disease, requiring hospitalization in 1974, 1985, and 1986. Colonoscopy, with biopsy, performed during these periods showed an edematous, granular mucosa that bled easily. The normal vascular pattern was absent. There was no evident From the Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan. Reprint requests: Takashi Maruoka, MD, HonmaHospital, 3-4-20, Nakamachi, Sakata City, Yamagata, Japan. VOLUME 36, NO.1, 1990
Figure 1. Colonoscopic picture. A well-circumscribed whitish area is noted surrounded by healed colitic mucosa. 65
Figure 3. Biopsy from the whitish area showing a mature squamous cell epithelium.
Figure 2. Lugol staining. The lesion alone was stained in dark brown.
irregular mucosa and loss of haustra, but not progressive narrowing or shortening of the colon. Steroids given systemically and locally were effective. His clinical condition was good and there were no extraintestinal manifestations except urolithiases in 1978. A follow-up colonoscopy with biopsies was performed in 1988 two years after his last hospitalization. The colonoscopy showed healed ulcerative colitis from the rectum to the transverse colon. In the lower sigmoid colon 25 cm from the anal verge, there was a thin whitish area occupying two thirds of the luminal circumference (Fig. 1). It was clearly distinguished from the surrounding mucosa and the margin was distinct. The endoscopic appearance strongly suggested that the lesion was squamous epithelium, which was confirmed with a positive Lugol strain (Fig. 2), and biopsies showing a matured squamous cell metaplasia without dysplasia (Fig. 3). Fourteen other biopsies from the rectum to the transverse colon showed healed ulcerative colitis without epithelial dysplasia. DISCUSSION
There have been several reports of squamous cell metaplasia and squamous cell carcinoma of the colorectal mucosa in ulcerative colitis. 1- 6 In 1988 Adamsen et al. 4 reported a case of squamous cell metaplasia with severe dysplasia of the colonic mucosa in ulcerative colitis. They emphasized that squamous cell metaplasia in the colonic mucosa alone in ulcerative
66
colitis had not been reported before. However, they did not identify endoscopic characteristics of the lesions. Biopsies from a stricture in the sigmoid colon revealed highly differentiated squamous cell metaplasia' and in the transverse colon, squamous epithelium with dysplastic large nuclei and prominent nucleoli. Our case appears to be the first report of squamous cell metaplasia of the colon which includes a description of the endoscopic appearance. The etiology of squamous cell metaplasia is not known, but it has not been reported to occur in the normal colon. There are only a few reports of squamous cell metaplasia, and these relate to long-standing ulcerative colitis l - 4 as in our case.
REFERENCES 1. Zirkin RM, McCord DL. Squamous carcinoma of the rectum: 2.
3. 4.
5.
report of a case complicating chronic ulcerative colitis. Dis Colon Rectum 1963;6:370-3. Hohm WH, Jackman RJ. Squamous cell carcinoma of the rectum complicating ulcerative colitis: report of two cases. Mayo Clin Proc 1964;39:249-51. Otto HF, Gebberts JO. Precancerous epithelial dysplasia in ulcerative colitis: histological possibility for the early diagnosis of colitis carcinoma. Virchows Arch [A) 1978;377:259-76. Adamsen S, Ostberg G, Norry C. Squamous-cell metaplasia with severe dysplasia of the colonic mucosa in ulcerative colitis: Report of a case. Dis Colon Rectum 1988;31:558-62. Michelassi F, Mishlove LA, Stipia F, Block GE. Squamous-cell carcinoma of the colon: experience at the University Chicago, review of the literature, report of two cases. Dis Colon Rectum
1988;31:229-35. 6. Michelassi F, Montag AG, Block GE. Adenosquamous-cell car-
cinoma in ulcerative colitis: report of a case. Dis Colon Rectum 1988;31:323-6.
GASTROINTESTINAL ENDOSCOPY
4. 5. 6. 7. 8.
REFERENCES 1. Sarles H. Etiopathogenesis and definition of chronic pancrea-
titis. Dig Dis Sci 1986;31:91S-107S. 2. Bernarde P, Belghiti J, Athovel M, Mallardo N, Breil P, Fekete F. Historie naturelle de la pancreatite chronique: etude de 120 cases. Gastroenterol Clin Bioi 1983;7:8-13. 3. Tasso F, Stemmelin M, Sarles H, Clop J. Comparative morpho-
Squamous cell metaplasia without dysplasia of the colonic mucosa in ulcerative colitis Takashi Maruoka, MD Kaori Hasegawa, MD Kou Nagasako, MD
There have been only a few reports of squamous cell metaplasia l - 4 or squamous cell carcinoma 1 ,2.5,6 of the colon associated with ulcerative colitis. We encountered a patient with squamous cell metaplasia and long-standing ulcerative colitis. The lesion was noted endoscopically as a pinkish white area with a clearly demarcated border. Lugol stain and biopsies demonstrated the lesion to be composed of squamous epithelium.
9.
10.
metric study of the human pancreas in its normal state and in primary chronic calcifying pancreatitis. Biomedicine 1973;18:134-44. Gyr KE, Singer MV, Sarles H. Pancreatitis: concepts and classification. Excerpta Med Int Congress Series 1984. Nakamura K, Sarles H, Payan H. Three-dimensional reconstruction of the pancreatic ducts in chronic pancreatitis. Gastroenterology 1972;62:942-9. Gilinski NH, Lewis JW, Flueck JA, Fried AM. Annular pancreas associated with diffuse chronic pancreatitis. Am J GastroenteroI1987;82:661-4. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980;21:105-14. Bretagne JF, Darnault P, Raoul JL, et al. Calcifying pancreatitis of a congenital short pancreas. Am J Gastroenterol 1987;82:1314-7. Noda A, Hamano H, Shibata T, et al. Chronic pancreatitis at early age of onset presenting interesting findings through endoscopic retrograde pancreatography and chemical analysis of nonopaque pancreatic concretion. Dig Dis Sci 1987;32:433-40. Tulassay Z, Papp J. Diagnostic aspects of incomplete pancreas divisum. Gastrointest Endosc 1986;31:428.
contraction or decrease in size of the lumen, and pseudopolyps were not observed. All biopsies showed changes consistent with ulcerative colitis, including inflammatory cells in a mucosa of reduced height with rather shallow crypts, sometimes not reaching the muscularis mucosae. There was also a marked decrease in the number of glands and intensive capillary congestion. All changes were typical of active ulcerative colitis. Barium enemas showed involvement of the left colon with
CASE REPORT A 19-year-old man with symptoms of fulminating ulcerative colitis, including diarrhea and bloody stool, was seen in January 1973. Colonoscopy at that time showed a friable and inflamed mucosa. Barium enema showed involvement of the left colon with irregular mucosa and loss of haustration. No cobblestone appearance or skip lesions were present. The patient was hospitalized for 8 months and was treated with supportive measures including steroids and sulfasalazine. Between 1974 and 1986, the patient had frequent exacerbations of the disease, requiring hospitalization in 1974, 1985, and 1986. Colonoscopy, with biopsy, performed during these periods showed an edematous, granular mucosa that bled easily. The normal vascular pattern was absent. There was no evident From the Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan. Reprint requests: Takashi Maruoka, MD, HonmaHospital, 3-4-20, Nakamachi, Sakata City, Yamagata, Japan. VOLUME 36, NO.1, 1990
Figure 1. Colonoscopic picture. A well-circumscribed whitish area is noted surrounded by healed colitic mucosa. 65
Figure 3. Biopsy from the whitish area showing a mature squamous cell epithelium.
Figure 2. Lugol staining. The lesion alone was stained in dark brown.
irregular mucosa and loss of haustra, but not progressive narrowing or shortening of the colon. Steroids given systemically and locally were effective. His clinical condition was good and there were no extraintestinal manifestations except urolithiases in 1978. A follow-up colonoscopy with biopsies was performed in 1988 two years after his last hospitalization. The colonoscopy showed healed ulcerative colitis from the rectum to the transverse colon. In the lower sigmoid colon 25 cm from the anal verge, there was a thin whitish area occupying two thirds of the luminal circumference (Fig. 1). It was clearly distinguished from the surrounding mucosa and the margin was distinct. The endoscopic appearance strongly suggested that the lesion was squamous epithelium, which was confirmed with a positive Lugol strain (Fig. 2), and biopsies showing a matured squamous cell metaplasia without dysplasia (Fig. 3). Fourteen other biopsies from the rectum to the transverse colon showed healed ulcerative colitis without epithelial dysplasia. DISCUSSION
There have been several reports of squamous cell metaplasia and squamous cell carcinoma of the colorectal mucosa in ulcerative colitis. 1- 6 In 1988 Adamsen et al. 4 reported a case of squamous cell metaplasia with severe dysplasia of the colonic mucosa in ulcerative colitis. They emphasized that squamous cell metaplasia in the colonic mucosa alone in ulcerative
66
colitis had not been reported before. However, they did not identify endoscopic characteristics of the lesions. Biopsies from a stricture in the sigmoid colon revealed highly differentiated squamous cell metaplasia' and in the transverse colon, squamous epithelium with dysplastic large nuclei and prominent nucleoli. Our case appears to be the first report of squamous cell metaplasia of the colon which includes a description of the endoscopic appearance. The etiology of squamous cell metaplasia is not known, but it has not been reported to occur in the normal colon. There are only a few reports of squamous cell metaplasia, and these relate to long-standing ulcerative colitis l - 4 as in our case.
REFERENCES 1. Zirkin RM, McCord DL. Squamous carcinoma of the rectum: 2.
3. 4.
5.
report of a case complicating chronic ulcerative colitis. Dis Colon Rectum 1963;6:370-3. Hohm WH, Jackman RJ. Squamous cell carcinoma of the rectum complicating ulcerative colitis: report of two cases. Mayo Clin Proc 1964;39:249-51. Otto HF, Gebberts JO. Precancerous epithelial dysplasia in ulcerative colitis: histological possibility for the early diagnosis of colitis carcinoma. Virchows Arch [A) 1978;377:259-76. Adamsen S, Ostberg G, Norry C. Squamous-cell metaplasia with severe dysplasia of the colonic mucosa in ulcerative colitis: Report of a case. Dis Colon Rectum 1988;31:558-62. Michelassi F, Mishlove LA, Stipia F, Block GE. Squamous-cell carcinoma of the colon: experience at the University Chicago, review of the literature, report of two cases. Dis Colon Rectum
1988;31:229-35. 6. Michelassi F, Montag AG, Block GE. Adenosquamous-cell car-
cinoma in ulcerative colitis: report of a case. Dis Colon Rectum 1988;31:323-6.
GASTROINTESTINAL ENDOSCOPY