Glomerulonephritis associated with inflammatory bowel disease. Report of a patient with chronic ulcerative colitis, sclerosing cholangitis, and acute glomerulonephritis.

We report the case of an 18-yr-old man with quiescent ulcerative colitis complicated by concomitant primary sclerosing cholangitis and rapidly progressive glomerulonephritis. Findings on immunofluorescence microscopy and electron microscopy suggested that glomerular injury occurred secondary to the deposition of circulating immune complexes. Renal disease responded to treatment with corticosteroids. A review of the literature found similar cases of glomerulonephritis and inflammatory bowel disease, but no previous association with sclerosing cholangitis has been recognized. The pertinent clinical, immunological, and pathophysiological aspects of this association are reviewed.

Periodic acid-Schiff-negative granulomatous lymphadenopathy in patients with Whipple's disease. Localization of the Whipple bacillus to noncaseating granulomas by electron microscopy.

The diagnosis of Whipple's disease in a 58-year-old man was based on the finding of periodic acid-Schiff (PAS)-positive foamy macrophages on duodenal biopsy and demonstration of the typical bacilliform bodies by electron microscopy. The patient also had generalized peripheral lymphadenopathy with lymph node biopsy showing PAS-negative noncaseating granulomas. Electron microscopic examination of the lymph node specimen demonstrated a small number of typical bacilliform bodies with localization specifically to the granulomas in the lymph node. This finding of bacilliform bodies within PAS-negative noncaseating granulomas has not been reported previously. Localization of the Whipple bacillus specifically to noncaseating granulomas suggests that some patients with the disease may manifest a delayed hypersensitivity reaction to the bacillus.

Early invasive cancer in adenomatous colonic polyps ("malignant polyps"). Evaluation of the therapeutic options by decision analysis.

The management alternatives of segmental colonic resection versus follow-up alone for colonic adenomas containing early invasive carcinoma (i.e., polypectomy resection margin free of tumor) were evaluated by decision tree analysis. Using data from the literature, the major variables influencing the decision were as follows: probability of residual disease after polypectomy, operative efficacy (defined as the chance of curing a tumor that would otherwise recur without surgery), and operative mortality. For a hypothetical patient with low operative risk (operative mortality of 0.2%), resection would yield the best outcome in terms of life expectancy as long as the probability of residual disease was greater than 0.5%. Extensive analysis of the impact of changes in assumptions about the parameters characterizing the problem showed this conclusion to be unchanging over wide ranges of operative efficacy and probability of residual disease. However, the decision to do a secondary resection in this situation was still close because surgery was only marginally justifiable on economic grounds. Observation would be preferred in patients with higher operative risk (operative mortality greater than 2%).

Early invasive carcinoma in colonic polyps. A review of the literature with emphasis on the assessment of the risk of metastasis.

The proper treatment of adenomatous colonic polyps containing small foci of invasive cancer is controversial because the metastatic potential of these lesions is not precisely known. This article critically reviews all known English language studies of this lesion. Before the introduction of colonoscopic polypectomy, the estimated incidence of metastasis from this lesion was 10.4% (based on 12 studies containing 347 polyps), with a confidence interval (95% level) of 7.4 to 14.1. The incidence of metastasis estimated from lesions removed via colonoscopic polypectomy was 10.1% (based on 13 studies containing 188 polyps), with a confidence interval of 5.9 to 14.8. Differences in the definitions of the involved lesions, study designs, and indications for resection cause problems with case selection bias and make comparison of studies difficult. These problems are discussed in detail. Most studies had broad confidence intervals for the estimated incidence of metastasis because of small sample size. The histopathologic criteria, as reflected in the literature, for considering polypectomy alone as adequate treatment for this lesion are summarized and discussed.