Ileal mucosa-associated lymphoid tissue lymphoma showing several ulcer scars detected using double-balloon endoscopy

Severe Cryptogenic Multifocal Ulcerous Stenosing Enteritis. A Report of Three Cases and Review of the Literature

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare condition characterised by chronic or relapsing moderate ileous episodes resulting from multiple small intestinal strictures, multiple shallow ulcers of the small bowel and favourable therapeutical effect of glucocorticosteroids. The aim of this paper was to evaluate three cases of CMUSE diagnosed within 10 years at a tertiary gastroenterology centre. Three females (35, 50, 60 years) were presented with colicky pain, repeated moderate ileous episodes and weight loss. Multiple fibrous strictures and ulcers of the small bowel were found. All three patients responded to glucocorticosteroid treatment. Tandem tight jejunal stenoses were dilated endoscopically by means of double balloon enteroscopy. In conclusion, CMUSE should always be considered when chronic moderate ileous episodes and multiple small intestinal strictures and ulcers of uncertain aetiology are found. Double balloon enteroscopy enables precise diagnostic work, possible endoscopic treatment of stenoses, may obviate the need for surgery and prevent excessive small bowel resections.

Decreased numbers of vascular networks and irregular vessels on narrow-band imaging are useful findings for distinguishing intestinal lymphoma from lymphoid hyperplasia

BACKGROUND

No method for sufficiently making the differential diagnosis of intestinal lymphoma resembling lymphoid hyperplasia (LH) on endoscopy has yet been established.

OBJECTIVE

The aim of this study was to evaluate the usefulness of narrow-band imaging (NBI) in diagnosing intestinal lymphoma.

DESIGN

Prospective study.

SETTING

Single-center study.

PATIENTS

Sixty-one patients with primary or systemic lymphoma were enrolled in this study.

INTERVENTIONS

The terminal ileum and entire colon were observed by using conventional endoscopy. NBI was subsequently performed when small polypoid lesions were detected. A decrease in the number of vascular networks (DVNs) and the presence of irregular vessels on the surface of the epithelia were defined as characteristic findings of intestinal lymphoma. The diagnostic accuracy of these 2 findings in distinguishing intestinal lymphoma from LH was examined.

MAIN OUTCOME MEASUREMENTS

The ability to use NBI to distinguish intestinal lymphoma from LH.

RESULTS

Two hundred ninety-four small polypoid lesions, including 59 lymphomas and 235 LH lesions, were detected. The rates of detecting DVNs and the presence of irregular vessels were significantly higher in the lymphoma samples (81.4% and 62.7%) than in the LH samples (25.5% and 4.7%). Based on these findings, the diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values for differentiating intestinal lymphoma from LH were 88.8%, 62.7%, 95.3%, 77.1%, and 91.1%, respectively, which are significantly higher than those of conventional endoscopy.

LIMITATIONS

Single-center study.

CONCLUSION

DVNs and the presence of irregular vessels on NBI are thus considered to be useful findings for differentiating intestinal lymphoma from benign LH.

Cryptogenic multifocal ulcerous stenosing enteritis: a review of the literature

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is an extremely rare illness characterised by chronic or relapsing subileus status resulting from multiple small intestinal fibrous strictures and multiple shallow ulcers of the small bowel. The etiology is unknown and pathogenesis is not fully understood. Therapy with systemic glucocorticosteroids is the treatment of choice. However, most patients develop corticosteroid dependence. Deep enteroscopy enables precise diagnostic work, possible endoscopic treatment of stenoses; may obviate the need for surgery and prevent excessive small bowel resections.

Double-balloon enteroscopy versus magnetic resonance enteroclysis in diagnosing suspected small-bowel Crohn's disease: results of a pilot study

OBJECTIVE

Small-bowel manifestations are common complications in Crohn's disease (CD) but can often be underestimated because of diagnostic limitations. Double-balloon enteroscopy (DBE) is a new endoscopic method that provides complete visualization and biopsy sampling of the small bowel with potential implications for diagnosis and therapy. The purpose of this study was to compare the diagnostic yield of DBE and magnetic resonance enteroclysis (MRE) in patients suspected of having small-bowel CD.

MATERIAL AND METHODS

Ten patients were consecutively selected and included in the study. In all patients a DBE of the small bowel was performed, the endoscopist being unaware of the radiological findings. Evaluation criteria included the presence of pathology, localization, degree, and extension of affection according to predefined morphologic criteria. Samples for histopathological investigation were taken in all patients with abnormal mucosa.

RESULTS

In 50% of the patients (5 out of 10) with suspected small-bowel CD, DBE revealed pathological results. Here, in four patients, CD was verified histologically. A new diagnosis had to be established in one patient diagnosed for malignant lymphoma. The medical management had to change in five patients. In two patients, both DBE and MRE showed no pathological results; in three patients, superficial lesions were identified by MRE, whereas DBE was normal.

CONCLUSIONS

In selected patients with suspected small-bowel lesions, DBE is a promising tool in the diagnostic work-up and provides the advantage of biopsy sampling. In contrast, non-invasive MRE delivers excellent information about extraluminal pathology associated with CD. Both MRE and DBE have the potential to become diagnostic standards that complement each other in patients with suspected complex small-bowel CD.

Usefulness of EUS with double-balloon enteroscopy for diagnosis of small-bowel diseases

BACKGROUND

Until recently, EUS of the small bowel has been performed only in limited regions because of difficulties in endoscopically approaching the small bowel. Double-balloon enteroscopy (DBE) now permits investigation of the entire small bowel.

OBJECTIVE

To evaluate the usefulness of EUS with DBE for diagnosis of small-bowel diseases.

DESIGN

Pilot study.

SETTING

All patients were examined at Hiroshima University Hospital.

PATIENTS

EUS with DBE was performed in 20 consecutively analyzed patients (14 men, 6 women; mean age, 47.6 +/- 3.8 years). DBE was performed to investigate obscure GI bleeding (n = 12), small-bowel diseases suggested by other modalities (n = 7), recurring ileus (n = 1), or follow-up (n = 1).

INTERVENTIONS

Endoscopic biopsies were performed as clinically indicated.

MAIN OUTCOME MEASUREMENTS

EUS image quality for various types of small-bowel diseases and comparison with abdominal US.

RESULT

Protruding lesions were detected in 7 examinations, ulcerative lesions in 7, and no abnormalities in 7. EUS could be performed in 20 of 21 examinations. These images were adequately detailed evaluations and with more detail than US images in 16 examinations.

LIMITATION

Small nonblinded study.

CONCLUSIONS

EUS with DBE offers high-resolution cross-sections of small-bowel lesions and may contribute to the diagnosis of small-bowel diseases.

Cytogenetic and clinicopathological characterization by fluorescence in situ hybridization on paraffin-embedded tissue sections of twenty-six cases with malignant lymphoma of small intestine

OBJECTIVE

In small intestinal malignant lymphoma (SIML), the correlation between specific chromosomal abnormalities and clinicopathological features remains unclear. The aim of this study was to determine the frequency of chromosomal translocations involving the BCL1, BCL2, c-MYC, BCL6 and MALT1 genes by using fluorescence in situ hybridization directly on paraffin-embedded tissue sections (tissue-FISH).

MATERIAL AND METHODS

Twenty-six cases diagnosed as having SIML between 1996 and 2003 were the subjects of the clinicopathological investigation conducted in this study. Tissue-FISH was performed with specific probes on paraffin-embedded tissue sections as described previously.

RESULTS

The primary site was frequently located at the duodenum (9 cases, 35%). In accordance with the World Health Organization classification, 14 (53%) cases were diagnosed as having diffuse large B-cell lymphoma (DLBCL) and 6 (23%) as marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT). Macroscopically, DLBCL and MALT lymphoma displayed various macroscopic features. Cytogenetically, IGH-BCL2 translocation was detected in 3 (21%) out of 14 DLBCL cases, but in none of the MALT lymphomas. BCL6 translocation was detected in 5 (35%) of 14 DLBCL cases and in 1 (17%) of 6 MALT lymphoma cases (17%). API2-MALT1 translocation was detected in 1 (7%) of 14 DLBCL cases and in 1 (17%) of 6 MALT lymphoma cases.

CONCLUSIONS

The duodenum was preferentially involved in SIML. DLBCL and MALT lymphoma showed various macroscopic features. Tissue-FISH analysis disclosed that DLBCL is cytogenetically heterogeneous. Furthermore, our study validated tissue-FISH as an additional promising diagnostic tool for detecting specific chromosomal translocations in NHL.

Double-balloon endoscopy for the diagnosis and treatment of small intestinal disease

Evaluation of the small bowel has long been hampered because of its long and multiple complex loop configurations. Yamamoto et al have developed a new method of inserting an endoscope, known as the double-balloon method of enteroscopy, the Fujinon double-balloon endoscopy system being specialised for this application. Two types of endoscope are currently available for this technique. The EN-450 P5 is a thin endoscope for regular use, whereas the EN-450 T5 is a therapeutic double-balloon endoscope with a larger accessory channel of 2.8mm in diameter. Double-balloon endoscopy enables visualisation of the entire small bowel and also allows for interventional therapy in the small intestine. This method can be used either from an oral or an anal insertion. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, haemostasis, balloon dilatation, stent placement, polypectomy and endoscopic mucosal resection, to be performed. In our large study series, it was demonstrated that double-balloon endoscopy permitted exploration of the small intestine with the high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.

Milestone in gastrointestinal endoscopy: double-balloon enteroscopy of the small bowel

The small bowel (SB) has been largely bypassed by flexible endoscopy because of inaccessibility. Push enteroscopy is now in the past, with recent innovations now making visualization of the SB possible. Wireless capsule endoscopy (CE) and double-balloon endoscopy (DBE) have been introduced. In this review, we focus on the diagnostic and therapeutic modalities of DBE, which may be a suitable replacement for push enteroscopy, preoperative endoscopy and to some extent of SB fall-through and CT scan. DBE is a new method of endoscopy developed and described by Yamamoto et al. in Jichi, Japan, in cooperation with Fujinon. Introduced to the market in 2003, it is possible with this endoscope to observe the entire SB in steps of 20-40 cm. Measuring the depth of insertion is also possible. Obscure gastrointestinal bleeding can be explained and treated in the majority of cases. Biopsy sampling, hemostasis, polypectomy, dilatation and tattoo are possible in the SB. Guidelines for FAB and Peutz-Jeghers syndrome will probably be reviewed in the next few years. The safety and efficacy of DBE have been demonstrated. DBE improves SB disease management and can substitute for more complex investigations. Additional data will come to light in years to come. Combining DBE with CE, CT/MRI enteroclysis in a new era for SB work-up and treatment is the likely future.

Clinicopathological features of primary small intestinal lymphoma: analysis of 23 cases

AIM: To summarize the clinicopathologic features of the small intestinal lymphoma.

METHODS: The clinical data, including the initial symptoms or signs, involved locations, histological subtypes, and complications, of 23 patients pathologically diagnosed with small intestinal lymphoma were retrospectively analyzed.

RESULTS: The initial symptoms or signs included abdominal pain (13 cases, 56.5%), abdominal mass (6 cases, 26.1%), melena or hematochezia (2 cases, 8.7%), diarrhea (1 cases, 4.3%), and constipation (1 cases, 4.3%). Five patients had B-symptom. The involved locations were ileocecum (7 cases, 30.4%), jejunum (7 cases, 30.4%), ileum (6 cases, 26.1%), and duodenum (1 cases, 4.3%). Multiple involvements appeared in 2 cases (8.7%). Hodgkin's lymphoma was not found in all the patients. Of the 23 cases, 19 were B-cell origin (82.6%) and 4 were T-cell origin (17.4%). For histological subtypes, 13 cases (56.5%) were diagnosed with diffuse large B cell lymphoma, 6 cases (26.1%) with B-cell MALT lymphoma, 3 cases (13.0%) with diffuse T-cell lymphoma, and 1 cases (4.3%) with enteropathy-associated T cell lymphoma.

CONCLUSION: Abdominal pain is the most common symptom for small intestinal lymphoma, and the most frequently involved location is ileocecum and jejunum. B-cell origin covers a larger percent. Diffuse large B cell non-Hodgkin's lymphoma is commonly occurred in terms of histological classification.

Double-balloon endoscopy

PURPOSE OF REVIEW

Our strategy for small intestinal diseases has dramatically been brushed up with a novel technique, double-balloon endoscopy, which exhibits extremely better insertability and maneuverability compared with conventional methods. Double-balloon endoscopy has a potential to change radically the approach for the small intestinal diseases in the future. In this article, the publications on double-balloon endoscope will be reviewed.

RECENT FINDINGS

A double-balloon endoscope can be inserted into deeper portions of the small intestine via both oral and anal approaches, and allows endoscopic observation as well as treatment for the entire small intestine without general anesthesia. Reports have been made on this method's safety and low frequency of complication: it is very useful for diagnosis and treatment of small intestinal diseases, including small intestinal bleeding, small intestinal tumor, stenosis of small intestine, and polyposis syndrome.

SUMMARY

The development of double-balloon endoscopy enabled observation and treatment in the entire small intestine. The double-balloon endoscopy has a potential to be a standard of enteroscopy by replacing conventional push enteroscopy and intraoperative enteroscopy. In the near future, the double-balloon endoscopy, together with the capsule endoscopy, will be essential modalities for the management of small intestinal diseases.

Enteroscopy

Wireless capsule endoscopy and double-balloon endoscopy are new methods of enteroscopy that have been introduced in recent years. Wireless capsule endoscopy is an epoch-making examination method that makes possible an endoscopic imaging examination of the entire small intestine without discomfort and without confining patients to a medical facility. Although it is expected to be useful as an initial examination for finding diseases of the small intestine, it cannot be used for biopsy or treatment. One risk associated with the capsule endoscopy technique is entrapment by strictures. Double-balloon endoscopy is based on a new insertion technique in which two balloons, one at the distal end of the endoscope and the other at the distal end of an overtube, are operated in combination, and the endoscope is inserted while simultaneously shortening the intestine. It can be inserted through either the mouth or the anus, allowing the observation of the entire gastrointestinal tract. It features excellent maneuverability even in the distal small intestine, and enables back-and-forth observation, biopsy, and endoscopic treatment at any given site. These two new enteroscopy techniques are expected to lead to innovations in how diseases of the small intestine are approached.