Secondary amyloidosis of the gastrointestinal tract: an electron microscopic study.

Biopsy specimens of the gastric antrum, duodenum, and rectum from three patients with secondary amyloidosis were examined by electron microscopy in an attempt to determine the ultrastructural distribution of amyloid filaments and to identify any secondary changes in the covering mucosal epithelial cells. The characteristic amyloid filaments were seen in the walls of submucosal arterioles and mucosal capillaries deposited within the basal lamina surrounding the endothelial cells. Filaments were also sometimes seen within the muscularis mucosa. the overlying gastric and rectal epithelial cells appeared normal, but numerous curved bacilli were seen in close contact with the microvilli of the surface epithelial gastric cells. Duodenal columnar absorptive cells were vacuolated and contained prominent lysosomes. These changes are probably degenerative and may explain, at least in part, the development of malabsorption in some patients with intestinal amyloidosis.

Gastric metaplasia and Campylobacter pylori infection of duodenum in patients with chronic renal failure.

Duodenal biopsy specimens from 80 patients with chronic renal failure, who were undergoing haemodialysis, were examined by light microscopy for evidence of inflammation, gastric metaplasia, and Campylobacter pylori infection. Chronic duodenitis was present in 47 (59%) of patients, of whom only seven (9%) showed evidence of active inflammation. Gastric metaplasia was present in 50 (62.5%) of patients, yet Campylobacter pylori was identified in only two patients (2.5%). It is suggested that the duodenal environment of patients with chronic renal failure remains hostile to the growth of these organisms in spite of the presence of gastric metaplasia.

Antral Helicobacter pylori in patients with chronic renal failure.

Patients with chronic renal failure who were undergoing dialysis were recently shown to have a low prevalence of duodenal Helicobacter (Campylobacter) pylori colonisation in spite of a high incidence of gastric metaplasia. The prevalence of the organism in the gastric antrum of 50 similar patients was estimated and compared with that in a control group comprising 120 consecutive patients with no renal failure who were being investigated for a variety of symptoms and signs related to the upper alimentary tract. Seventeen of the patients with renal disease had upper gastrointestinal symptoms. The prevalence of antral H pylori was significantly less in patients with renal disease (12, 24%) than in the control group (51, 42%), but was associated with a similar active chronic inflammatory reaction with prominent lymphoid follicles. The prevalence of the bacteria in patients with renal disease was similar to that reported in normal volunteers, and was the same whether the patients had upper gastrointestinal symptoms or not. This low prevalence may be related to the wide variety of medication, including antibiotics, which these patients are prescribed during the course of their illness.

Multicentric early adenocarcinoma involving stomach and duodenum.

Six separate foci of superficial adenocarcinoma were seen in the first part of the duodenum of a 53-year-old man with a multicentric superficial adenocarcinoma of the stomach. To our knowledge, duodenal involvement in such a tumor has not been reported before. The duodenal foci were partly covered by gastric-type surface epithelium, suggesting that they might have arisen in areas of gastric metaplasia or heterotopia.

Screening for occult gastrointestinal bleeding in hospital patients.

Stools have been tested for occult gastrointestinal bleeding in 278 outpatients and 170 hospital inpatients using the Haemoccult and Haemastix methods. Seventeen outpatients (6.1%) and 42 inpatients (24%) were positive with the Haemoccult technique. Thirty-three outpatients (11.9%) and 93 inpatients (54.7%) were positive with the Haemastix test. Following investigation of the Haemoccult-positive patients, only 2 cases (3.4%) were considered false positive. However, the false positive rate with Haemastix was 22.9% which is unacceptable in a screening test. Haemoccult may be useful as a screening test for asymptomatic general practice patients, but a test of greater sensitivity is needed for hospital patients.

Chronic ulcerative jejunitis without symptoms.

A patient is presented who, in addition to subtotal villous atrophy, had superficial ulcers of the jejunum, as well as a wide band of granulation tissue deep to the crypts suggesting recurrent past ulceration. In spite of these changes she had no intestinal symptoms at the time of her presentation with reflux oesophagitis, and her only nutritional abnormality was a mild folate deficiency. Withdrawal of dietary gluten produced some improvement of the jejunal mucosa but this was not sustained on continued low-grade ingestion. She has containued to be virtually symptom-free over a 3-year period of follow-up.

The clinical value of Haemoccult and Fecatwin in the detection of colorectal neoplasia in hospital and general practice patients.

Four hundred and fifty asymptomatic general practice patients and 330 hospital inpatients had their stools tested for occult blood with the Haemoccult and Fecatwin methods. In general practice, 9/64 (14%) of patients with a positive result had a colonic neoplasm (three carcinomas, one Dukes' Stage A, two Dukes' Stage C, six adenomas) and in hospital 12/142 patients (8%) were found to have colonic tumours, (nine carcinomas, two Dukes' Stage A, two Dukes' Stage B, five Dukes' Stage C and three adenomas). The overall detection rates for colonic neoplasia were 2% in general practice and 3.4% in hospital. In 2 years of follow-up, none of the general practice patients have presented with colonic symptoms. Two hospital patients with colonic carcinomas produced negative tests with both methods. Out of the total of 21 colonic neoplasms, nine were detected by Fecatwin alone, but this trend in favour of the more sensitive test did not reach the 5% level of statistical significance. In contrast, the number of false positive results were significantly greater with Fecatwin than Haemoccult. From our data it would appear that the Fecatwin method warrants assessment in a full controlled trial of its value as a population screening test for colonic cancer.

Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management.

Seventeen patients with chronic obscure gastrointestinal bleeding presenting over a 5-year period are described. While representing only 6 per cent of the total number of admissions due to gastrointestinal haemorrhage they required a disproportionate amount of medical attention, including 67 admissions, 73 radiological and 56 endoscopic procedures and transfusion of a total of 198 units of blood. The diagnoses included 5 cases of recurrent acute upper gastrointestinal erosions, 7 small bowel abnormalities and 4 colonic lesions, with 1 patient undiagnosed. Eight arteriovenous malformations (AVM) were demonstrated angiographically and one Meckel's diverticulum identified by a 99Tcm pertechnetate scan. There were 5 cases in which laparotomy yielded the final diagnosis and in one of these peroperative endoscopy of the small bowel was required. On the basis of our experience and a review of other series, a logical plan of investigation is described for such difficult cases.

The incidence of amyloidosis complicating inflammatory bowel disease. A prospective survey of 177 patients.

Three cases of secondary amyloidosis are reported, two in patients who had unequivocal Crohn's disease and one in whom the clinical course was that of Crohn's disease, but with histologic findings that were more suggestive of ulcerative colitis. All had evidence of renal failure. A prospective study of 177 patients with inflammatory bowel disease of greater than five years' duration was carried out in an attempt to establish the incidence of secondary amyloidosis, using rectal biopsy and simple renal function tests. No new cases were found. Neither was there evidence of renal failure due to other conditions. In the absence of renal dysfunction, a search for secondary amyloidosis probably is not justified.

Metastatic spindle-cell renal carcinoma presenting as multiple intestinal polyps.

A 75-year-old woman presented with rapidly progressive intestinal and general symptoms including diarrhea, melena, weight loss, back pain, and lassitude. Endoscopy revealed multiple intestinal polyps which, microscopically, consisted of metastatic tumor deposits composed predominantly of spindle-shaped tumor cells. The primary tumor, a mixed spindle-cell and clear-cell carcinoma, was later identified in the kidney at autopsy. The patient had a cholecystectomy 13 years previously.

Ferritin and lysozyme distribution in normal and abnormal duodenal mucosae.

The distribution of ferritin and lysozyme in 19 normal and abnormal duodenal biopsies was studied by an immunoperoxidase technique. The abnormal biopsies included cases of chronic duodenitis with gastric metaplasia, gastric heterotopia, villous atrophy, and a case of hemochromatosis. Ferritin is demonstrated in duodenal absorptive cells, with the staining being most intense in the hemochromatosis case. It was absent in duodenal cells showing gastric metaplasia and in the surface epithelial cells of most biopsies with villous atrophy and gastric heterotopia. Lysozyme-positive mononuclear inflammatory cells were markedly increased in all abnormal biopsies. Not all lysozyme-positive cells were ferritin positive. The latter were especially abundant in areas with gastric metaplasia. It is suggested that this abundance may be related to passive diffusion of intestinal contents, particularly iron, through the metaplastic areas, and consequently there may be a relationship between the presence of duodenal gastric metaplasia and uncontrolled iron absorption.

Chronic duodenitis with gastric metaplasia: electron microscopic study including comparison with normal.

Duodenal biopsies from 11 patients with non-ulcer dyspepsia were examined by electron microscopy. Chronic duodenitis with gastric metaplasia was seen in samples from four patients, and areas of normal-looking duodenal mucosa were present in nine. The metaplastic cells were similar to those previously described in association with duodenal ulcers. They usually showed marked morphological differences from the normal duodenal absorptive cells. The microvilli were distorted and reduced in number, the glycocalyx was ill-defined, the cytoplasm filled with mucous globules and the intercellular spaces, in some areas, were widened and contained acute and chronic inflammatory cells.

The endoscopically abnormal duodenum in patients with dyspepsia: biopsy findings in 60 cases.

Biopsies from 60 patients with dyspepsia and endoscopically abnormal first part of duodenum were examined. The main endoscopic findings were duodenitis (35 cases), chronic ulceration (eight) and abnormal mucosal patterns (17). The latter included mucosal atrophy, thickening, irregularity, nodularity and polypoid formation. The main histological findings were duodenitis (40), gastric metaplasia (42) and gastric heterotopia (seven). The first two were commonly seen together. Heterotopia was not associated with inflammation. Good correlation existed between endoscopic and histological findings.

Duodenal ultrastructure in patients with chronic renal failure with a comment on the incidence of Campylobacter pylori infection.

This study was aimed at identifying ultrastructural abnormalities that may be present in the duodenum of patients with chronic renal failure who were undergoing hemodialysis and that may have an effect on the normal absorptive function of the duodenum. Duodenal biopsy specimens from ten patients and four controls were examined. Light microscopy showed gastric metaplasia in eight patients and in none of the controls. The main electron microscopic findings were related to the metaplastic changes, with abundant mucous globules and abnormal microvilli being seen in the affected columnar cells. Prominent lysosomes and wide intercellular spaces were seen in some areas. Goblet and enterochromaffin cells appeared to be normal. Some of the reported abnormal duodenal absorptive functions may be related to the ultrastructural abnormalities seen in the microvilli and the apical parts of the columnar cells. Because of the known association between gastric metaplasia and colonization of the duodenum with Campylobacter pylori, we looked for these organisms in our cases. Light microscopy demonstrated these bacteria in only one of the eight duodenal biopsy specimens with gastric metaplasia. Particles, probably representing degenerated bacteria, were seen by electron microscopy in most of the examined specimens, however, suggesting that the duodenum of these patients remains hostile to the growth of these organisms.

Carcinoembryonic antigen in patients suffering from ulcerative proctocolitis.

Carcinoembryonic antigen (CEA) has been measured by radioimmunoassay in samples obtained from all patients suffering from ulcerative proctocolitis and seen within a four-month period. The characteristics of this group of patients have been compared with reported epidemiological studies in this disease, and have been found to have a similar sex ratio and age of onset, but a more limited disease. Among 59 patients, 11 were found to have elevated circulating CEA values. One of the 11 had a colonic carcinoma and another was pregnant. Excluding these two patients, an overall prevalence of elevated CEA levels of 17.5% was found. The prevelance in ulcerative proctitis was 7.1%, and in colitis was 19.9%. The patients in whom elelvated plasma CEA values were found were compared with the remaining patients in relation to factors known to be associated with an increased propensity for the development of colorectal carcinoma complicating ulcerative colitis. There was no difference in mean age of the patients at disease onset, nor was there any difference in disease duration, extent, and control. A significant correlation was found between elevated plasma CEA levels and the severity of the initial attack. One patient with premalignant changes in the rectal mucosa had consistently normal concentrations of plasma CEA. There was no significant correlation between elevated plasma CEA values and disease activity. The mean age of the two groups of patients was similar. No carcinoma has manifested in any patient during follow-up periods of at least 18 months.