Combined Endoscopic Submucosal Dissection and Snaring for the Resection of Colorectal Lesions / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic en-bloc resection of the large colorectal lesions is technically difficult. The aim of this study is to evaluate the usefulness of combined endoscopic submucosal dissection (ESD) and snare resection for treating colorectal lesions. METHODS: We enrolled 23 patients (M:F=14:9, age range: 46~76 years) with 25 colo rectal tumors that were around or above 20 mm in diameter. A combined treatment of ESD and snare resection was performed. RESULTS: The mean size of the 25 lesions was 22.6+/-8.2 mm (range: 15.0~44.0 mm). Ten lesions were laterally spreading tumors and 15 lesions were found in the rectum. On the histopathologic examination, 16 lesions were adenocarcinoma, 2 lesions were villous adenoma, 1 lesion was a villotubular adenoma, 5 lesions were tubular adenoma and 1 lesion was a hyperplastic polyp. The mean resection time was 27+/-22 min (range: 10~91 min). En bloc resection was possible for 19 lesions (76%). Of these, 18 specimens showed clear resection margins and 1 showed a positive deep resection margin. Of the 6 piecemeal resection cases, 2 showed positive lateral resection margins. Therefore, an 88% tumor free resection rate was obtained. CONCLUSIONS: Combined ESD and snare resection may be an effective and safe modality for the resection of large colorectal lesions.

Development of Early Gastric Cancer 38 Months after the Complete Remission of Helicobacter pylori Associated Gastric MALT Lymphoma / 대한소화기내시경학회지

Helicobacter pylori (H. pylori) has been etiologically linked with primary gastric mucosa-associated lymphoid tissue (MALT) lymphoma and gastric carcinoma; however, synchronous and metachronous development of these two neoplasm is a rare finding. The metachronous development of early gastric cancer following gastric MALT lymphoma is even more exceptional, and less than 10 cases have been reported on the literature. We encountered one case of early gastric cancer which occurred 38 months after the complete remission of H. pylori associated gastric MALT lymphoma. We report here on this case along with a review of the literature.

Clinical characteristics of constipation associated with diabetes mellitus / 대한내과학회지

BACKGROUND: Constipation occurs frequently in diabetes mellitus (DM). However, there are few reports that investigated the characteristics of constipation associated with DM. The purpose of this study was to evaluate the clinical features of constipation associated with DM. METHODS: Among constipated patients who visited Asan Medical Center from January 2000 to December 2004, 45 patients with DM (DM group) and 104 patients without DM (non-DM group) were included in this study. We reviewed the clinical presentation, results of anorectal manometry, colon transit time study, and defecogram. We also analyzed the response to biofeedback therapy. RESULTS: The severity of constipation symptoms before treatment was not different between DM and non-DM group. Patients with colon transit time over 56 hours were more frequent in DM group than in non-DM group (21/45, 46.7% vs. 31/104, 29.8% ; p=0.047). Among DM group, colon transit time and the duration of DM showed positive correlation (r=0.431, p=0.003). The resting anal sphincter pressure was significantly lower in DM group than in non-DM group (43.5+/-21.5 mmHg vs. 51.7+/-22.6 mmHg ; p=0.048). The results of defecography were similar between DM and non-DM group. Successful responses to biofeedback therapy were not different between DM and non-DM group (19/34, 55.9% vs. 43/79, 54.4% ; p=0.887). CONCLUSIONS: Slow transit constipation was more frequent in DM group than in non-DM group. The successful responses to biofeedback therapy appear to be similar between DM and non-DM group.

Comparison of Double Balloon Enteroscopy and Small Bowel Series for the Evaluation of Small Bowel Lesions / 대한소화기학회지

BACKGROUND/AIMS: The role of double balloon enteroscopy (DBE) is still evolving. The aim of this study was to compare the diagnostic yield of DBE with that of small bowel series (SBS). METHODS: We enrolled patients with suspected small bowel disease consecutively, and performed both DBE and SBS in all patients. RESULTS: Eighteen patients (M:F=12:6, 14-82 years) were included. Indications for small bowel evaluation were obscure gastrointestinal bleeding (10), abdominal pain (5), diarrhea (2) and abnormal CT finding (1). Of 10 obscure gastrointestinal bleeding patients, 6 showed the same findings in both studies. However, 4 showed negative findings in SBS while DBE detected erosions or ulcerations. Of 5 abdominal pain patients, 3 showed the same results in both studies. However, 2 demonstrated different results. One was suspected of early Crohn's disease in SBS, but proved to be normal in DBE, and the other was suspected of malignancy in SBS but was suspected of benign ulcers in DBE. Of 2 chronic diarrhea patients, one was diagnosed as Crohn's disease in both studies. The other was suspected of tuberculosis in SBS but diagnosed as lymphangiectasia by DBE with biopsy. One patient with jejunal wall thickening in CT proved to be normal in both DBE and SBS. There were no serious complications associated with DBE and SBS. CONCLUSIONS: DBE is better than SBS in terms of diagnostic accuracy. DBE may become an important method for the evaluation of small bowel diseases.

The Expression of TGF-beta1 in Patients with Chronic Atrophic Gastritis / 대한소화기내시경학회지

BACKGROUND/AIMS: Mucosal atrophy is defined as the loss of appropriate glands in the gastric mucosa; such a finding suggests that this malady is associated with an excessive ratio of apoptotic cells to proliferating epithelial cells. However, exactly why the genesis and progression of the atrophic changes takes place in the gastric mucosa of some, but not all of the subjects infected with H. pylori, is seldom described. TGF-beta1 (transforming growth factor-beta1) is a potent growth inhibitor in epithelial tissues, and it also induces apoptosis of epithelial cells. We evaluated its role in the pathogenesis of atrophic gastritis by analyzing the expression of TGF-beta1. METHODS: The subjects were 14 patients with chronic atrophic gastritis and 43 patients with chronic gastritis. The exclusion criteria were as follows; those patients who had a previous history of gastrectomy, PPI, H. pylori eradication, NSAIDs, stomach cancer and/or a severe bleeding tendency. Biopsy specimens were obtained from the antrum, angle and body of the stomach, respectively and we performed RT-PCR for determining the expression of TGF-beta1 mRNA with using an additional angle specimen. RESULTS: The clinical parameters were similar in both groups. The rate of H. pylori infection was also similar in both groups. The TGF-beta1 levels were significantly higher for the chronic atrophic gastritis group than for the chronic gastritis group. CONCLUSIONS: The results that the TGF-beta1 levels are significantly higher in the chronic atrophic gastritis group suggest that TGF-beta1 is associated with the development of atrophic gastritis. The apoptotic process induced by TGF-beta1 may be linked to the development of atrophic gastritis.

The Expression of Matrix Metalloproteinases (MMPs), Tissue Inhibitor of Metalloproteinases (TIMPs) and Angiogenesis in Relation to the Depth of Tumor Invasion and Lymph Node Metastasis in Submucosally Invasive Colorectal Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: Lymph node (LN) metastasis occurs in approximately 10% of patients with submucosally invasive colorectal carcinoma. This study was performed to determine the role of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs) production and microvessel formation on the LN metastasis in submucosally invasive colorectal carcinoma. METHODS: A total of forty-one subjects with surgically resected submucosally invasive colorectal carcinoma were included in this study. Immunohistochemical staining of MMP-2, MMP-9, TIMP-1, TIMP-2, and urokinase-type plasminogen activator were performed. Angiogenesis was evaluated by counting the number of microvessels in each pathologic specimen as identified by CD34 immunohistochemical staining. RESULTS: The depth of submucosal invasion was not significantly correlated with the expression of MMP-2, MMP-9, TIMP-1, TIMP-2, or urokinase-type plasminogen activator, but the microvessel count was significantly correlated with the absolute depth of invasion (r=0.312, p<0.05). Upregulation of TIMP-2 was positively correlated with adjacent lymphatic invasion (p<0.05) and increased TIMP-2 expression was correlated with LN metastasis in submucosally invasive colorectal carcinoma (p=0.088). CONCLUSIONS: These results suggest that the expression of TIMP-2 and the microvessel count may be useful parameters for considering additional surgery after endoscopic treatment of submucosally invasive colorectal carcinoma.

A Case of Gastric Emphysema with Portal Vein Emphysema associated with the Episode of Severe Vomiting / 대한소화기내시경학회지

Gastric emphysema is rare but it has a fulminant course with high mortality rate. We report a 58-year old man who visited the emergency room because of severe vomiting and nausea which had started 2 days ago. He underwent curative pylorus-preserving pancreaticoduodenectomy due to ampullary cancer 4 months ago. He was diagnosed as gastric emphysema with combined portal vein emphysema. Only with conservative treatment such as intravenous fluids infusion and decompression of the stomach by nasogastric tube, the condition of the patient slowly improved. The patient was able to discharge without surgical intervention.

Clinical Usefulness of Glucocorticoid Receptor beta Expression and NF-kappa B Activity in Patients with Ulcerative Colitis / 대한소화기학회지

BACKGROUND/AIMS: Glucocorticoid resistance poses a challenging clinical problem in inflammatory bowel disease because more than one fourth of patients with severe ulcerative colitis do not respond to anti-inflammatory steroids. Recently, it has been reported that glucocorticoid response is related to the expression of human glucocorticoid receptor beta (hGRbeta) and nuclear factor-kappa B (NF-kappaB) activity. The aims of this study were to clarify whether these factors may predict the responsiveness before treatment. METHODS: Total RNA was extracted from peripheral blood mononuclear cell (PBMC) and colonic mucosa in 17 patients of ulcerative colitis before steroid administration. RNA was reverse transcribed and the resulting complementary DNA was amplified using specific primers for hGR alpha and beta. Concomitantly, NF-kappaB activity in colonic mucosa was assessed by immunohistochemical stain. RESULTS: The expression of hGRbeta mRNA was detected in 10 patients (58.8%) in PBMC and 8 patients (47.1%) in colon, respectively. Operations were performed in 5 patients due to steroid unresponsiveness. Only 5 of 17 patients (29.4%) were consistent in the expression of hGRbeta between PBMC and colon. Seven of 15 patients (46.7%) showed an alteration in the expression of hGRbeta in PBMC after glucocorticoid treatment. NF-kappaB activity was found in both epithelial cell and lamina propria in 12, epithelial cell alone in 1, lamina propria alone in 1 and all negative in 3 patients, respectively. CONCLUSIONS: The expression of hGRbeta was discordant between PBMC and colon in the same patient and showed a change in the expession after the glucocorticoid treatment in nearly half. The expression of hGRbeta and colonic NF-kappaB activity patterns do not provide useful information about glucocorticoid response in patients with ulcerative colitis.

Relationship between duodenal ulcers and cagA, vacA, and iceA genotypes of Helicobacter pylori / 대한내과학회지

BACKGROUND: The aims of this study were to evaluate whether genotypes of Helicobacter pylori are different between the gastric antrum and duodenal bulb in order to assess the roles of duodenal H. pylori strains in development of duodenal ulcer. METHODS: Forty-eight H. pylori infected patients (duodenal ulcer 28, chronic gastritis 20) were included for the study. Biopsy specimens were taken separately from the antrum and duodenal bulb for the histologic examination and H. pylori culture. cagA, vacA, and iceA genotypes of H. pylori were examined by polymerase chain reaction and H. pylori DNA subtypes by random amplified polymorphic DNA (RAPD) fingerprinting. RESULTS: H. pylori genotypes were not significantly different between antrum and duodenal bulb of the duodenal ulcer and chronic gastritis. RAPD fingerprinting showed different H. pylori strains between the gastric antrum and duodenal bulb in 2 patients with duodenal ulcer. Most prevalent genotype was cagA+ vacA s1/m1 iceA1 in duodenal ulcer (15/16). CONCLUSION: The host factor or other genotypes may play the major roles in duodenal ulcerogenesis compared with H. pylori genotype itself.

Prophylactic Effect of Lactobacillus GG in Animal Colitis and Its Effect on Cytokine Secretion and Mucin Gene Expressions / 대한소화기학회지

BACKGROUND/AIMS: Lactobacillus rhamnosus GG (LGG) has been used in acute colitis treatment. However, it is unclear whether the LGG prevents chronic colitis. The aim of this study was to examine the prophylactic effect of LGG on animal colitis, cytokine secretion, and mucin gene expression. METHODS: BALB/c mice (n=64) were exposed to 5% dextran sulfate sodium (DSS) for 7 days followed by 10 days recovery period and repeatedly exposed for 4 days. Then, the mice were devided into three group; group of oral LGG adminstration throughout the recovery and repeated colitis period; PBS group of PBS administration; control group. Colon length, histologic score, tumor necrosis factor-alpha (TNF-alpha), interleukin-10 (IL-10) levels, mucin gene expressions were determined at each period. RESULTS: In acute colitis period, the LGG group showed higher levels of disease activity index (DAI), histologic score, TNF-alpha, IL-10, but shorter colon length, lower levels of mucin gene expressions than the control group. However, in repeated colitis period, the LGG group showed markedly lower levels of DAI and IL-10 but significantly longer colon length than PBS group (p<0.05). There was no difference in the mucin gene expression. CONCLUSIONS: These results suggest that LGG prevents chronic murine colitis. It may be associated with cytokine modulation and competitive inhibition of pathogenic bacteria. However, it may not be related with gene expression.

Clinical Characteristics at Diagnosis and Course of Korean Patients with Crohn's Disease / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the clinical characteristics and course of Korean patients with Crohn's disease (CD). METHODS: A total of 113 patients who were newly diagnosed as having CD at the Asan Medical Center between October 1989 and December 2001 were included. RESULTS: The male to female ratio was 1.9:1 and the mean age at diagnosis was 24.2 +/- 7.8 years. The disease location was the small bowel in 19.5%, the large bowel in 11.5%, and the both small and large bowels in 69.0% of the patients. Empirical anti-tuberculous medications were administered to 53 cases (46.9%). Major complications of CD were intestinal obstruction (25.7%) and perianal fistula (42.5%). The cumulative remission rate was 75.7% at 1 year and 80.7% at 3 years from diagnosis. The cumulative relapse rate was 30.7% at 1 year and 53.0% at 3 years from remission. The cumulative operation rate was 11.5% at 1 year and 13.1% at 3 years from diagnosis. CONCLUSIONS: There are no differences in the remission and recurrence rates between Korean and Western patients with CD. Although the cumulative operation rate seems to be lower in Korea than in Western countries, the cause of the difference is uncertain. Further studies are needed to determine the characteristics of CD in Korea.

Two Cases of Intussusception Occurring through the Stoma after Gastric Surgery / 대한소화기내시경학회지

Intussusception is a rare but potentially serious complication of gastric surgery, and 6 cases have been reported in Korea. Diagnosis can be made by endoscopy, upper gastrointestinal series or computed tomography, but it needs a high index of suspicion for diagnosis. Early diagnosis and prompt surgical intervention is mandatory to avoid mortality. We report two cases of intussusception occurring through the stoma after gastric surgery. A 58-year-old woman presented with epigastric pain and vomiting followed by hematemesis, 30 years after gastrojejunostomy for pyloric obstruction caused by duodenal ulcer. Endoscopy showed jejunogastric intussusception and CT scan was compatible with the diagnosis. She was managed by segmental resection and anastomosis of the jejunum. Another 60-year-old man presented with epigastric pain and hematemesis, 7 years after total gastrectomy with a Roux-en-Y anastomosis for advanced gastric cancer. He was diagnosed as having chronic type jejunal intussusception by endoscopy and CT scan, and intussusception was resolved spontaneously.

A Gastric Hyperplastic Polyp with Intramucosal Adenocarcinoma / 대한소화기내시경학회지

Adenomatous polyps have been well known to be premalignant, but it is still controversial how to treat and follow them up. Up to date, endoscopic resection has been the choice of treatment, particularly exceeding 2 cm, though there is no concensus on the indications for the excision of hyperplastic polyps. The incidence of malignant tissue found in hyperplastic polyps has been reported to be less than 3%, which is considerably lower than the incidence of greater than 6% reported in adenomas. There have been few reports of hyperplastic polyps in which malignant changes developed during endoscopic surveillance. We report a case of hyperplastic gastric polyp with intramucosal, well-differentiated adenocarcinoma with reviewing references.

Clinical Characteristics of Patients with Chronic Constipation after Radical Hysterectomy or Delivery / 대한소화기학회지

BACKGROUND/AIMS: This study was aimed to analyze the clinical characteristics of patients who developed constipation after radical hysterectomy or delivery and to investigate the results of biofeedback therapy for these patients. METHODS: Thirty-five chronic constipation patients with radical hysterectomy (radical hysterectomy group), 27 chronic constipation patients with delivery (delivery group) and 27 constipation patients with no history of hysterectomy or delivery (control group) were included. Clinical characteristics of these patients, including the results of biofeedback therapy, were analyzed. RESULTS: The delivery group showed higher rates of pelvic floor dyssynergia than the control group (14/27, 52% vs. 6/27, 22%; p<0.05). The prevalence of slow transit constipation was lower in the radical hysterectomy group and delivery group than in the control group (7/35, 20% and 5/27, 19% vs. 12/27, 44%; p<0.05). The prevalence of anatomical abnormalities was not different between the groups. The radical hysterectomy group showed higher rate of obstructive sensation and the delivery group showed higher rate of hard stool and digital maneuvers. The biofeedback therapy was effective in 10 out of 12 patients (91%) among the radical hysterectomy and delivery group. CONCLUSIONS: Radical hysterectomy and delivery seem to induce functional constipation, which may be caused by anorectal dysfunction such as pelvic floor dyssynergia. The biofeedback treatment was effective in functional constipation after radical hysterectomy or delivery.

The Usefulness of Colonoscopic Biopsy in the Diagnosis of Intestinal Tuberculosis and Pattern of Concomitant Extra-intestinal Tuberculosis / 대한소화기학회지

BACKGROUND/AIMS: Intestinal tuberculosis can be difficult to diagnose because it may mimic many other intestinal diseases. The aim of this study was to evaluate the diagnostic yield of colonoscopic biopsy and frequency of concomittent extra-intestinal tuberculosis in intestinal tuberculosis. METHODS: The medical records of 225 consecutive patients with intestinal tuberculosis (81 men, 144 women; mean age 40.6 yrs) were analyzed retrospectively. RESULTS: Histological examination of colonoscopic biopsy specimens revealed granulomas in 163 (72.4%) of the 225 patients. However, caseous necrosis was found in only 25 (11.1%) patients, and acid-fast bacilli (AFB) were noted in 39 (17.3%) of the 225 patients. Mycobacterium tuberculosis was isolated from the culture of biopsy specimens in 52 (29.3%) of 177 patients. Eighty-four patients (37.3%) had concomitant extra-intestinal tuberculosis and 67 (29.8%) showed active pulmonary tuberculosis. Histological examination of the biopsy specimens enabled the diagnosis of intestinal tuberculosis by the presence of either caseating granulomas or AFB in 52 (23.1%) patients. Combination of histological examination and Mycobacterium culture established the diagnosis in 87 (38.7%) patients. Before getting the result of Mycobacterium culture, the diagnosis could be made, by either histological examination or the presence of extra-intestinal tuberculosis in 107 (47.6%) patients. Combination of caseating granulomas, AFB staining, Mycobacterium culture, and the presence of extra-intestinal tuberculosis resulted in the diagnosis in 126 (56.0%) patients. CONCLUSIONS: To increase the diagnostic yield, AFB staining and Mycobacterium culture should be routinely performed on biopsy specimens in addition to routine histological examination for caseating granulomas.

A Case of Enteropathy-associated T-cell Lymphoma Presenting with Recurrent Hematochezia / 대한소화기학회지

Enteropathy-associated T-cell lymphoma (EATL) is an unusual primary gastrointestinal lymphoma, particularly associated with celiac sprue. This tumor usually affects the jejunum and grossly presents as multiple circumferential ulcers without the formation of definite tumor masses. Moreover, mesenteric lymph nodes are commonly involved. The patients have typically suffered from abdominal pain, diarrhea, or weight loss whereas some patients may manifest with nonspecific symptoms for a period of years or an acute emergency of perforation, obstruction, or hemorrhage. The clinical course of EATL is very unfavorable and the prognosis is poor. Both celiac sprue and EATL are very rare diseases in Asia, except India and Middle East. We report a 60-year-old male diagnosed as having EATL after segmental small bowel resection, who presented with recurrent gastrointestinal bleeding.

A Case of Multiple Gastric Carcinoids Associated with Chronic Atrophic Gastritis and Hypergastrinemia / 대한소화기내시경학회지

Gastric carcinoid tumors are so rare that they constitute less than 1% of total primary gastric tumors. They are classified into 3 types: (1) gastric carcionoid associated with chronic atrophic gastritis (type I), (2) gastric carcinoids associated with Zollinger-Ellison syndrome (ZES) or multiple endocrine neoplasm (MEN) type 1 (type II), and (3) sporadic gastric carcinoid (type III). A 55-year-old man underwent a medical check-up. Five polypoid masses were incidentally detected in the cardia, fundus and midbody whose size ranged from 0.5 cm to 1.6 cm in diameter. Tumor cells were strongly positive for cytokeratin, synaptophysin and chromogranin staining. Biopsies from the body and fundus showed severe atrophy. Fasting serum gastrin level was highly increased, 1,098 pg/mL. There was, however, no evidence of the presence of ZES or MEN type 1. The patient underwent total gastrectomy for complete resection and has remained free of any complications with normal serum gastrin level.

Clinical Factors Associated with Response to Biofeedback Therapy for Patients with Chronic Constipation / 대한소화기학회지

BACKGROUND/AIMS: Biofeedback therapy has been widely used for the treatment of constipated patients. However, there are only a few reports about the clinical factors that can predict the effectiveness of biofeedback therapy. The aim of this study was to evaluate prognostic factors before the initiation of biofeedback treatment in constipated patients. METHODS: Biofeedback treatment was performed in 114 patients with constipation. After classifying the patients into two groups, responder and non-responder by subjective and objective parameters, univariate and multivariate analysis were performed to evaluate the factors associated with effectiveness of biofeedback therapy. RESULTS: Eighty-five patients (74.6%) responded to biofeedback therapy. Pre-treatment balloon expulsion test, paradoxical contraction on manometry, defecation index and anal residual pressure during straining were the factors that influenced the results of biofeedback treatment. On multivariate analysis, defecation index (odds ratio=67.5, p<0.05) and paradoxical contraction on manometry (odds ratio=0.053, p<0.05) were the factors that showed significant difference between the responders and non-responders. CONCLUSIONS: This study suggests that several pre-treatment prognostic factors are associated with response to biofeedback for the constipated patients. Using prognostic factors, we may be able to evaluate the patterns of pelvic floor dysfunction and responsiveness of biofeedback therapy for the patients with constipation.

A Case of Solitary Rectal Ulcer Syndrome with Characteristic Findings of Evacuation and Magnetic Resonance (MR) Defecography / 대한소화관운동학회지

Solitary rectal ulcer syndrome is an uncommon, chronic benign condition characterized by rectal bleeding, the passage of mucus, tenesmus and excessive straining during defecation. Occasionally, solitary rectal ulcer syndrome has been reported to be associated with defecation disorder such as pelvic floor dyssynergia, rectal intussusception and rectal prolapse. However, it is ambiguous how these associated defecation disorders contribute to make the rectal ulcer. We report a case of solitary rectal ulcer syndrome suggesting the pathophysiology of rectal ulcer by typical findings of evacuation defecography and MR defecography. A 40-year-old man presented with lower abdominal pain, rectal bleeding, passage of mucus and tenesmus intermittently for the past 4 years. Colonoscopy showed a large geographic and circumferential ulcer at the 10 cm distance from the anal verge. A biopsy revealed fibromuscular proliferation of laminar propria, hyperplasia of crypt and focal superficial ulceration. Finally, he was diagnosed as solitary rectal ulcer syndrome. Evacuation defecography showed paradoxical movement of puborectal sling and unusual invagination of rectal walls during defecation. In addition, rectum showed spastic movement and anterior rectal wall directly merged into posterior rectal wall making a kissing appearance. The invagination of the rectum at evacuation defecography proved to be the rectal wall thickening at MR defecography. After 9 sessions of biofeedback therapy, his defecation symptoms improved. However, ulcer was still observed without interval change.

Diagnosis of Cowden's Disease Based on Gastrointestinal Manifestations / 대한소화기내시경학회지

BACKGROUND/AIMS: Cowden's disease is an autosomal dominant hereditary disease characterized by the various hamartomatous and neoplastic lesions of multiple organs. We analyzed gastrointestinal manifestations of 5 cases of Cowden's disease and suggest several findings which are helpful to gastroenterologists for the early diagnosis. METHODS: The clinical characteristics of 5 unrelated patients with Cowden's disease were evaluated. Four patients were male, one patient was female, and their ages at the time diagnosis ranged from 17 to 49 years. All patients had the pathognomonic mucocutaneous lesions and thyroid nodules. RESULTS: In all patients, the esophagus was affected by acanthosis. In 4 patients, the stomach was affected by numerous variable sized polyps. In 4 patients, the duodenum was involved by several polyps. In 4 patients, the entire small bowel and in one patients, only the terminal ileum was affected by numerous polyps. In all patients, the colon, especially the sigmoid colon and rectum, showed numerous variable sized polyps. Family history was positive for stomach cancer in two patients. CONCLUSIONS: Cowden's disease should be considered in patients with esophageal acanthosis among patients with colonic polyposis, although the mucocutaneous lesions, unfamiliar to gastroenterolgists, are pathognomonic criteria for the diagnosis.