[The 486th case: chronic diarrhea and orthostatic hypotension].

A 57-year-old man was admitted to hospital with diarrhea for 10 months and dizziness for 4 months. The patient had 1-2 liters watery stool per day, without pyogenic blood or abnormality in gastroenteroscopy examination. The level of hemoglobin and albumin was generally normal, and fasting test was positive. At the same time, he was accompanied with hyperalgesia of lower limbs and orthostatic hypotension. After the discussion of multiple disciplinary teams, the patient was diagnosed with amyloidosis by sural nerve biopsy, myocardial MRI, and the assays of urine immunoelectrophoresis and serum free light chain. Light chain amyloidosis was confirmed after excluded the diagnosis of familial amyloidosis. The patient was improved after courses of chemotherapy with melphalan and dexamethasone.

[The colonoscopic characteristics of colorectal endometriosis: a single-centered retrospective study].

Objective: To reinforce the awareness of colorectal endometriosis (EM) in colonoscopy examination. Methods: Patients diagnosed as colorectal EM at Peking Union Medical College Hospital between February 2002 and February 2017 were enrolled in this study. The clinical characteristics and endoscopic features of EM lesions were summarized and compared between pathologically positive group and negative group. Results: A total of 34 cases were included with average age of (38.3±8.9) years old. All EM lesions located within rectum and sigmoid colon. The endoscopic lesions manifested as protrusion in 21 cases (61.8%) and protrusion-depression in 13 cases (38.2%), local stenosis in 8 cases (23.5%); erosive surface in 33 cases (97.1%) with local spontaneous hemorrhage in 4 cases (11.8%); nodal surface in 23 cases (67.6%), and lymphangiectasis base in 9 cases (26.4%). Endoscopic biopsy specimens were obtained in all cases with average 3 (2, 4) pieces. Positive results were found only in 4 patients (11.8%) with 3 endometriosis and one (endometrial) adenosarcoma. Compared with negative group, spontaneous hemorrhage was more frequent in positive group (2/4 vs. 2/30, P=0.013). Mean biopsy sample number was significantly larger in positive group (5 vs. 3, P=0.004). Conclusions: Colorectal endometriosis is mostly located within rectosigmoid region. Endoscopic features mainly include protrusion or protrusion-depression lesions with erosive and nodular surface, or local stenosis. Spontaneous hemorrhage under colonoscopy yields higher positive rate for biopsy, thus increasing biopsy sample numbers may improve pathology results.

[The clinical characteristics of patients with monomorphic epitheliotropic intestinal T-cell lymphoma characterized by minor endoscopic abnormalities].

Objective: To clarify the clinical features of monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) with minor endoscopic abnormalities. Methods: The clinical data of 6 patients with MEITL characterized by minor endoscopic abnormalities in Peking Union Medical College Hospital from 2012 to 2016 were retrospectively analyzed, including clinical manifestations, endoscopic, pathological features, medications and prognosis. Results: Five out of 6 patients were male, with an average age of 61.2 years old. The median disease duration was 4.5 months. All patients initially presented with diarrhea without specific findings for serologic testing. CT enterography showed continuous intestinal lesions, including symmetric thickening of the bowel wall, abnormal hyperenhancement of mucosal surface and lymphadenopathy. Endoscopic appearances were only mildly abnormal, including mucosal swelling, atrophy of villus, mosaic sign and shallow ulcers. Histopathologic findings revealed massive small to medium sized T lymphocytes infiltration with positive expression of CD(3) and CD(8). Chemotherapy and palliative treatment were administrated after diagnosis. Conclusions: Clinical presentations of MEITL are non-specific with minor endoscopic abnormalities. Therefore, biopsy is indispensable for patients with a relatively normal endoscopic result.

[The efficacy of cyclosporine A as salvage therapy for severe active ulcerative colitis refractory to glucocorticoid].

Objective: To clarify the efficacy and safety of cyclosporine A (CsA) as salvage therapy in patients with severe active ulcerative colitis (UC) and refractory to steroids. Methods: A total of 24 severe active UC patients refractory to steroids and hospitalized from 2006 to 2012, were retrospectively enrolled.Data including demographic features, clinical manifestations, laboratory tests and medications were collected. Results: CsA was effective in 15(62.5%) patients, who did not receive colectomy during 12-week administration. This regimen was tolerable in most patients.Twelve (50.0%) patients reported 16 adverse events, but only one patient withdrew CsA due to intolerance.The rates of adverse events in initial intravenous CsA including 4 mg·kg(-1)·d(-1,) 3 mg·kg(-1)·d(-1) and 2 mg·kg(-1)·d(-1) were 2/2, 9/17 and 1/5 respectively.Responders had higher white blood cell count compared with non-responders (P= 0.045). Conclusions: CsA could be an effective alternative regimen to colectomy in severe active UC patients who are refractory to steroids.

[Associations of sigmoid colon mucosal mast cells with bowel symptoms and psychological status in patients with irritable bowel syndrome with diarrhea].

OBJECTIVE: To investigate the bowel symptoms and psychological status of patients with irritable bowel syndrome (IBS) with diarrhea (IBS-D), and to verify whether sigmoid colon mucosal mast cells (MCs) and their activation have effect on the symptoms and psychological status of IBS-D patients. METHODS: Patients meeting Rome Ⅲ diagnostic and subtyping criteria of IBS-D who visited the outpatient clinic of gastroenterology of Peking Union Medical College Hospital were consecutively enrolled between July 2009 and June 2012. IBS symptoms questionnaire was completed using face-to-face interview, and Hamilton Anxiety Scale (HAMA)/ Hamilton Depression Scale (HAMD) were administrated to evaluate psychological status, both by well-trained investigators. Mast cell tryptase monoclonal antibody was used for immunohistochemical staining to detect MCs and degranulated MCs in mucosal biopsy of sigmoid colon. MCs and degranulated MCs were blindly counted by a senior pathologist, and presented as number of cells in high power field (HPF) and percentage of activated MCs. Correlation analysis was performed using Spearman rank correlation analysis. RESULTS: Ninety-seven patients with IBS-D were enrolled in this study, with mean age of (44±11) years. 70.10%(68 cases) of the IBS-D patients had comorbid anxiety and/or depression. The median total numbers of MCs, activated MCs, and percentage of activated MCs in sigmoid mucosa were 11.60 (7.09)/HPF, 2.00 (1.40) /HPF, and 17.50% (10.90%), respectively. Patients having abdominal pain/discomfort before bowel movement "every day with intermediate to high severity" had significantly larger numbers of total MCs in sigmoid colon compared with those with pain or discomfort "not every day and mild" [13.80(4.85)vs 7.60(5.90)/HPF, P=0.019]; the patient having "frequent" urge to have a bowel movement and mushy stools showed significantly higher percentage of activated MCs in sigmoid colon mucosa compared to those having the symptoms "some of the time" [18.75%(9.12%) vs 14.50%(13.14%), P=0.031; 21.33%(7.43%)vs 11.51%(10.65%)vs 18.42%(8.61%), P=0.030]. There was a positive correlation between the bowel movement during IBS-D onset and the percentage of activated MCs (r=0.221, P=0.030). There were no statistically significant differences in the total number of MCs and percentage of activated MCs between the patients with anxiety/depression and those without anxiety/depression (P=0.255, P=0.315). Scores of HAMA and HAMD were found not correlated with either total MCs number or percentage of activated MCs in sigmoid colon mucosa(all P>0.05). CONCLUSIONS: The majority of IBS-D patients had comorbid anxiety and/or depression. The total number and activation status of MCs in sigmoid colon mucosa might be related with some intestinal symptoms in IBS-D patients. Psychological disorders might influence the pathogenesis and regression of IBS-D through brain-gut axis other than MCs in sigmoid colon mucosa.

Neurogastroenterology of tegaserod (HTF 919) in the submucosal division of the guinea-pig and human enteric nervous system.

Actions of the 5-HT(4) serotonergic receptor partial agonist, tegaserod, were investigated on mucosal secretion in the guinea-pig and human small intestine and on electrophysiological behaviour of secretomotor neurons in the guinea-pig small intestinal submucosal plexus. Expression of 5-HT(4) receptor protein and immunohistochemical localization of the 5-HT(4) receptor in the submucosal plexus in relation to expression and localization of choline acetyltransferase and the vesicular acetylcholine (ACh) transporter were determined for the enteric nervous system of human and guinea-pig small intestine. Immunoreactivity for the 5-HT(4) receptor was expressed as ring-like fluorescence surrounding the perimeter of the neuronal cell bodies and co-localized with the vesicular ACh transporter. Exposure of mucosal/submucosal preparations to tegaserod in Ussing chambers evoked increases in mucosal secretion reflected by stimulation of short-circuit current. Stimulation of secretion had a relative high EC(50) of 28.1 +/- 1.3 mumol L(-1), was resistant to neural blockade and appeared to be a direct action on the secretory epithelium. Tegaserod acted at presynaptic 5-HT(4) receptors to facilitate the release of ACh at nicotinic synapses on secretomotor neurons in the submucosal plexus. The 5-HT(2B) receptor subtype was not involved in actions at nicotinic synapses or stimulation of secretion.