Rectal mucosal dysplasia in Crohn's disease.

Serial sections of 812 rectal biopsy specimens from 356 Crohn's disease patients were analysed for mucosal epithelial dysplasia. Dysplasia was found in 18 patients (5%), with four showing dysplasia on repeat biopsy specimen. In these 22 biopsy specimens the dysplasia was mild in 13, moderate in nine, and severe in none. Subsequently, three patients (17%) developed neoplasms including carcinoma in two and an adenomatous polyp in one. In colectomy specimens which showed dysplasia, significantly more dysplastic changes were found in seven patients who underwent colonic resection than in 10 others who underwent operation but had no prior dysplasia (p less than 0.001). Thirteen patients still have their rectum in situ and remain at risk of developing colonic cancer. Four carcinomas developed in patients with Crohn's disease who did not have dysplasia on rectal biopsy specimen.

Renal pathology of essential hypertension.

Microscopic analysis of over 2,000 renal biopsies taken at surgical sympathectomy operations has been correlated with blood pressures in essential hypertension. Statistically significant relationships exist between the average diastolic pressure and the degree of afferent renal arteriolar thickening and narrowing. Postoperative prognosis was favorable with all but the most severe and diffuse arteriolar sclerosis, and vascular fibrinoid necrosis did not affect survival. Juxtaglomerular cell hyperplasia and inferred renin hypersecretion were significantly involved in the kidney biopsies of essential hypertension. Diabetic juxtaglomerular cell atrophy and sclerosis reduced this component of hypertension. After age 80, kidneys at autopsy showed no evident relation between arteriolar lesions and hypertension.

Metastatic potential of gastric leiomyosarcoma.

Metastatic and lethal gastric leiomyosarcoma in 12 of 30 surgically treated cases was found most closely correlated with larger size tumors. A highly statistically significant correlation (p less than 0.0001) between tumor diameter and success or failure of surgical extirpation was demonstrated for the total of 241 gastric leiomyosarcomas in the present series and collected from the literature. Six other gross and microscopic attributes analyzed, including mitotic counts, did not provide equally useful prognostic indications. Inadequate sampling may be responsible for lack of correlation between histological criteria and tumor progression.

Clinicopathologic diagnosis of mycoplasma endometritis.

Chronic endometritis and its association with cervical colonization by Ureaplasma urealyticum was investigated in a group of 28 infertile patients treated for infertility problems. Twenty had positive cervical cultures for U. urealyticum and eight had negative cultures. There was focal chronic endometritis in 11 of the endometrial biopsies of the 20 cases with positive mycoplasma cultures. Ten of these biopsies were in the secretory phase, and one was in proliferative phase. No case with a negative culture showed endometritis.

On the renal basis for essential hypertension: nephron heterogeneity with discordant renin secretion and sodium excretion causing a hypertensive vasoconstriction-volume relationship.

We propose herein that there are two functionally abnormal nephron populations in essential hypertension: (1) a group of ischemic nephrons with impaired sodium excretion which chronically hypersecrete renin. Numerically, these ischemic nephrons comprise a minor subgroup since most patients with essential hypertension exhibit no overt evidence of renal insufficiency. (2) In reaction to this, a more numerous group of normal nephrons appears in adaptive hypernatriuresis. They have an increased distal sodium supply and consequently, a chronically suppressed renin secretion. One difference between patients with renovascular hypertension and those with essential hypertension is the intermingling of these two populations of nephrons. In our hypothesis, the adapting hyperfiltering normal nephrons accomplish the hypernatriuresis in response to saline infusion, that is characteristic of all essential hypertension. However, the unsuppressed secretion of renin, that arises from the ischemic nephron population attenuates this compensatory natriuresis in the following ways: (1) by inappropriately acting on the hyperfiltering nephrons to enhance proximal tubular sodium reabsorption; (2) by activating TGF-mediated afferent constriction in these nephrons, and (3) simultaneously, the reactive secretion of renin from ischemic nephrons is diluted by non-participation of the adapting hypernatriuretic nephrons so that plasma renin settles at a level which is insufficient to fully compensate GFR in the ischemic nephrons. These adaptive responses provide a basis for the observation that the inhibition of renin activity with converting enzyme inhibitors in essential hypertension increases renal blood flow and sodium excretion. They also explain why converting enzyme inhibitors can effectively reduce blood pressure, even when renin levels are not absolutely elevated, since any circulating renin imposed upon the adapting hypernatriuretic nephrons inappropriately impairs their sodium excretion. In addition, the theory explains why basal renin secretion is either not suppressed or inadequately suppressed in patients with essential hypertension. As a result, whole kidney homeostatic function is compromised because individual nephrons are responding to their individual stimuli to fulfil their individual need, rather than acting in concert with other nephrons. The net effect of this uncoordinated response is to shift total renal function so that systemic arterial hypertension is sustained by abnormal sodium retention for the inappropriately high plasma renin level, or vice versa.(ABSTRACT TRUNCATED AT 400 WORDS)

Recurrent and metastatic pulmonary fibrous histiocytoma/plasma cell granuloma in a child.

A child had a pulmonary plasma cell granuloma/fibrous histiocytoma that recurred after lobectomy in 1952 and required pneumonectomy in 1953, at which time it extended into the mediastinum at the pulmonary hilus. A metastatic nodule was removed from within the diaphragmatic musculature. The long-term favorable outcome suggests a good prognosis after adequate surgical therapy. The possible relationship of fibrous histiocytoma/plasma cell granuloma to modified measles is discussed.

Kidney pathology in endemic nephropathy.

Histopathologic analysis was made of kidneys from seven cases of typical endemic nephropathy and five cases of probable endemic nephropathy or upper urinary tract carcinoma from Yugoslavia. Glomeruli usually had an increased mesangial matrix and abnormal lobulation, sometimes with vacuolar degeneration. Particularly the straight ascending, descending and Henle loop tubules showed increased epithelial degeneration and regeneration. A network of interstitial scars and a subcapsular stratum of notable cortical degeneration contributed to severe renal atrophy. Unusual intrarenal vein thickening with or without obliteration was notable. Reactive glomerular, Bowman's epithelial and convoluted tubular alterations were ascribed to a filtered toxic material with carcinogenic properties which was considered eventually responsible for renal atrophy, fibrosis and some attributes of an autoimmune reaction.

3-D reconstruction of endometrial carcinoma in situ.

Reconstructions in 3-D of 4 of 18 endometrial carcinoma in situ specimens demonstrated a simple branching tubular pattern, distinctively different from atypical adenomatous hyperplasia and invasive endometrial adenocarcinoma. A clonal origin of carcinoma in situ was suggested.

Sigmoidoscopy and biopsy in surveillance for cancer in ulcerative colitis.

Surveillance has become an established concept to find dysplasia as a premalignant lesion in ulcerative colitis. Since the advent of colonoscopy and the access of the entire colon to biopsy, utilization of the rigid sigmoidoscope and rectal biopsies has been markedly reduced. We have reviewed 940 rectal biopsies obtained from 360 patients with ulcerative colitis of various extent and duration to determine the yield of dysplasia and assess the value of this procedure. The rectal biopsies had been performed for a variety of reasons in the course of clinical management of ulcerative colitis in addition to surveillance. Dysplasia was found in 10.8% of the patients--higher than has been demonstrated by colonoscopy. In four of the 39 patients with dysplasia a carcinoma coexisted (2) or developed subsequently (2). In no instance did dysplasia serve to warrant the colectomy that disclosed the carcinoma, but earlier discovery of the dysplasia or more intense surveillance once it had been found might have led to earlier discovery of the carcinoma. The yield of dysplasia was greater in those with onset of ulcerative colitis in childhood. In more than half, including 71% of patients with onset in childhood, the dysplasia was found before they had the disease for 9 years. Surveillance, therefore, should begin earlier in young patients with ulcerative colitis. Sigmoidoscopic biopsies do not substitute for colonoscopic biopsies in a surveillance program. Nevertheless, the ease of obtaining rectal biopsies, the relatively large yield of dysplasia, and the need for frequent sigmoidoscopy in the clinical management of ulcerative colitis all warrant a high priority role for rectal biopsies to supplement that of colonoscopic biopsies.

Neuroendocrine carcinoma of lung associated with bradycardia and episodic cardiac asystole.

A neuroendocrine carcinoma of the lung associated with bradycardia and episodic cardiac asystole is reported. Cardiac dysfunction may have been caused by a hormonal factor produced by a carcinoma developing in the pulmonary neuroepithelial bodies because the bradycardia and periods of asystole disappeared after pneumonectomy, only to return months later when pleural metastatic tumor developed. No neoplastic involvement of the heart was present. Implications of a cholinesterase isoenzyme involvement in the cardiac dysfunction are discussed.

Alimentary tract biopsy lesions in the acquired immune deficiency syndrome.

The surgical pathology of the alimentary tract complications of the acquired immune deficiency syndrome (AIDS) is described and illustrated by a review of one year's material accessioned at a New York Community Hospital. Cytomegalovirus, Cryptosporidium and Mycobacterium avium-intracellulare were particularly notable among diverse opportunistic infectious agents. Visceral Kaposi's sarcoma and malignant lymphomas were the principal malignancies recognized, and their occurrence in young men should alert clinicians to the possibility of AIDS.

The fate of the rectal segment after diversion of the fecal stream in Crohn's disease: its implications for surgical management.

Diverting the fecal stream has been considered to benefit the course of Crohn's disease. Clinical signs and symptoms have not, however, been distinguished previously from the objective inflammatory changes in the distal segment. We reviewed the course of 16 consecutive patients with Crohn's disease in whom sigmoidoscopy showed normal mucosa at the time of diversion and who underwent an ileostomy or colostomy, the rectal segment being left in place. As early as 3 months after diversion, all 16 patients showed progressive friability, ulceration, and exudation in the retained rectum. Stricture occurred in four and lead to abdominoperineal resection in three. Four of eight patients with only moderate inflammation on sigmoidoscopy underwent reanastomosis which was followed by a return to a normal-appearing rectal mucosa. The rectal segment inflammed after diversion rarely shows the histological characteristics of Crohn's disease when resected. This leads us to suspect that the disorder of nonspecific "diversion colitis" might account for this phenomenon entirely, or at least it may accelerate the Crohn's disease process. Continuity of the intestinal tract should be maintained in the course of Crohn's disease surgery if feasible. If a diversion is clinically warranted, reanastomosis should be considered as early as possible despite progressive inflammation of the rectal mucosa.

Proctitis after fecal diversion in Crohn's disease and its elimination with reanastomosis: implications for surgical management. Report of four cases.

Diverting the fecal stream has been considered to affect the course of Crohn's disease favorably. Adverse effects on the distal segment have not previously been distinguished from clinical signs and symptoms. The course of four patients with Crohn's disease who underwent fecal diversion with an in situ rectum were observed in whom sigmoidoscopy was initially normal at the time of the diversion, became distinctly abnormal during the year after the diversion, and then returned to normal within 3 mo following reestablishment of intestinal continuity. The entity of nonspecific diversion proctitis might account for this phenomenon independently or by accelerating the Crohn's disease process. The inflammation present was nonspecific and did not show the stigmata of Crohn's disease. Continuity of the intestinal tract should be maintained in the course of Crohn's disease surgery if feasible. If a diversion is clinically warranted, reanastomosis should be considered as early as possible despite evidence of inflammation in the rectal mucosa.

Acute renal failure following poisonous snakebite.

This study describes acute renal failure (ARF) following snakebite in humans and the effects of viperide venoms on the renal structure and function in subhuman primates. ARF developed in 45 of 157 patients with a history of snakebite admitted to the hospitals of the Postgraduate Medical Institute, Chandigarh, India. They were studied clinically, hematologically, and in 35 cases, for renal histopathology. All 45 were treated with antibiotics, and 8 received anti-snake venom. Ten cases had bilateral renal cortical necrosis (BRCN), eight of whom died; less severe acute tubular lesions (ATL) occurred in 23 patients, four of whom died (P less than .001). Sepsis was significantly more common with BRCN than ATL (P less than .05). No statistical difference was found between these groups in bleeding incidence, disseminated intravascular coagulation (DIC), hemolysis, or hypotension. Monkeys given lethal doses of viperide venom developed hypotensive shock, DIC, and hemolysis, with significantly reduced serum complement, and died within 24 hours. However, no renal functional changes or lesions were found. Monkeys given sublethal doses of viperide venom showed a significant increase in serum creatinine levels after 48 hours, and renal lesions were observed in a majority of animals. In conclusion, ARF in snakebite victims appears to be multifactorial in origin. Although hypotension, hemolysis, and DIC are likely to be important pathogenetic factors, a direct cytotoxic effect of the venom on the kidney in producing ARF cannot be excluded.

Chronic aortitis following furosemide therapy.

A significant increase in histopathologic nonspecific chronic aortitis was found when 100 autopsy specimens from 1965 were compared with series from 1974 and 1980. The chronic aortitis was correlated with furosemide diuretic administration during the last hospitalization. Furosemide is albumin bound, produces vasodilation, and is suspected of having induced a subclinical haptenic immunologic reaction in about one third of those treated.

Response to drug therapy in Crohn's disease: evaluation by rectal biopsy and mucosal cell counts.

Improvement in Crohn's disease after drug therapy was evaluated in 38 patients with evidence of rectal disease at sigmoidoscopy in whom the rectum later appeared normal. Rectal biopsies taken before and after therapy were examined histopathologically. Cell counts of the lamina propria connective tissue cells were used to evaluate mucosal changes. The drugs apparently responsible for conversion of the rectal mocosal appearance to normal were sulfasalazine, prednisone, and 6-mercaptopurine. There was complete healing histologically in 24 patients (63%). In the other 14, healing was incomplete as evidenced by microscopic chronic inflammation, microgranulomas, or occasional lymphangiectasia. There were both complete and incomplete responses to all three drugs, but the total numbers were too small to identify significant therapeutic differences. Cell counts confirmed the elimination of acute inflammation. Despite drug therapy, histological evidence of activity persisted in one-third of the patients in whom the appearance of the rectum became normal.

Pheochromocytoma producing immunoreactive ACTH with Cushing's syndrome.

A 42-year-old female with clinical and endocrine indications of Cushing's syndrome, as well as periodic hypertension and increased urinary catecholamines and their metabolites, benefitted from removal of a pheochromocytoma. Adrenocortical hyperplasia was present. Electron microscopy showed catecholamine-type granules in the tumor cells; in addition, immunoreactive ACTH, leu-enkephalin, somatostatin, and serotonin were identified. Such studies were performed for the first time in this unusual condition.