Extragonadal germ cell tumor presenting in a woman with systemic lupus erythematosus: a case report

Introduction

Esophageal intramural pseudodiverticulosis is a rare condition characterized by the dilatation of the submucosal glands.

Case presentation

We present a case of esophageal intramural pseudodiverticulosis in a 72-year-old Caucasian man who presented with dysphagia and with a background history of alcohol abuse. An upper gastrointestinal endoscopy of our patient showed an esophageal stricture with abnormal mucosal appearances, but no malignant cells were seen at biopsy. Appearances on a barium esophagram were pathognomonic for esophageal intramural pseudodiverticulosis.

Conclusion

We demonstrate the enduring usefulness of barium esophagography in the characterization of abnormal mucosal appearances at endoscopy.     

Percutaneous trans-splenic portal venography; applications and hazards

Trans-splenic percutaneous portavenography is a useful and relatively simple roentgen examination. Although infrequent, splenic hemorrhage and delayed splenic rupture sometimes do occur after splenic puncture. Hence the procedure should be used only with provision for immediate operation in case of hemorrhage. The method is invaluable in the demonstration of intrahepatic and extrahepatic portal obstruction, gastric and esophageal varices. With it, the size of the portasplenic veins and the degree of portal hypertension can be estimated.     

PERCUTANEOUS TRANS-SPLENIC PORTAL VENOGRAPHY—Applications and Hazards

Trans-splenic percutaneous portavenography is a useful and relatively simple roentgen examination. Although infrequent, splenic hemorrhage and delayed splenic rupture sometimes do occur after splenic puncture. Hence the procedure should be used only with provision for immediate operation in case of hemorrhage.The method is invaluable in the demonstration of intrahepatic and extrahepatic portal obstruction, gastric and esophageal varices. With it, the size of the portasplenic veins and the degree of portal hypertension can be estimated.     

Morphometry of submucous and myenteric esophagic plexus of dogs experimentally reinfected with Trypanosoma cruzi

We carried out a morphometric study of the esophagus of cross-bred dogs experimentally infected or consecutively reinfected with Trypanosoma cruzi 147 and SC-1 strains, in order to verify denervation and/or neuronal hypertrophy in the intramural plexus. The animals were sacrificed in the chronic stage, 38 months after the initial infection. Neither nests of amastigotes, nor myositis or ganglionitis, were observed in all third inferior portions of esophageal rings analyzed. No nerve cell was identified in the submucous of this organ. There was no significant difference (p>0.05) between the number, maximum diameter, perimeter, or area and volume of the nerve cells of the myenteric plexus of infected and/or reinfected dogs and of the non-infected ones. In view of these results we may conclude that the 147 and SC-1 strains have little neurotropism and do not determine denervation and/or hypertrophy in the intramural esophageal plexuses in the animals studied, independent of the reinfections.     

The differentiation of cytotoxic T lymphocytes in vitro

Summary Previous neurohistological studies have been extended to include the structures contained solely or mainly within the junctional esophageal segment which may play an important role in the sphincter mechanism. The main findings were: 1) a progressive cranio-caudal thickening of the muscularis mucosae; 2) a conspicuous thickening of the circular muscle layer; 3) abundant and close interconnections between the esophageal striated fibres and gastric smooth muscle cells; 4) presence of annulo-spiral elastic fibres coiled around bundles of striated musculature; 5) increase of the intramural nerve component, particularly Auerbach's plexus, which consisted of a continuous nervous layer containing twice as many neurocytes as found in the upper esophageal segments; 6) presence of numerous interconnected motor endplates often possessing ultraexpansional fibres and secondary endplates. The findings are discussed with emphasis on functional correlations in order to attain a unitary morpho-functional view.Abbreviations used LES lower esophageal sphincter - HPZ high pressure zone; mm: muscularis mucosae - CNS central nervous system - CCK-PZ cholecystokinin-pancreozymin Dedicated to Prof. Dr. Wolfgang Bargmann for his fundamental contributions to Comparative Morphology     

Alcohol-induced liver cirrhosis as a cause of portal hypertension

Basic data on pathomorphology and symptomatology of the alcohol-induced liver cirrhosis accompanied by portal hypertension are discussed. Respective data were compared with the group of cirrhotic patients not abusing alcohol. A high percentage of encephalopathic disorders and nearly 50% of the patients suffering from the hemorrhage from esophageal varices were the first sign of the cirrhosis in both groups. Despite hemorrhage from esophageal varices a few patients obtained surgical help preventing recurrence of the hemorrhage. Liver functional reserve, incidence of encephalopathies and the degree of liver involvement are in favour for non-alcohol cirrhosis. Inflammatory process in the liver, splenomegaly and hypersplenism were more frequent in the liver cirrhosis of non-alcohol origin.     

Gastric intramural hematoma and hemoperitoneum in a captive northern fur seal

A 16-yr-old adult male northern fur seal (Callorhinus ursinus) was found dead in its outdoor pool in November 1995. The animal was maintained at Mystic Aquarium (Mystic, Connecticut, USA) from March 1980 to November 1995. Gross necropsy findings included hemoperitoneum and locally extensive gastric intramural hemorrhage that involved the posterior fundic, antral, and pyloric regions and extended into the duodenum. The gastric mural thickening grossly resembled hemangioma, and the gastric serosa was ruptured at the site of maximal mural expansion. In histologic sections of the stomach, a cribiform network of fibrin, which encompassed numerous variably-sized aggregates of closely packed erythrocytes, markedly expanded the submucosa. No vascular endothelium was identified in serial histologic sections of the expanded gastric submucosa stained with hematoxylin and eosin or immunohistochemically with antibodies to vimentin and Factor VIII-related antigen, establishing an absence of hemangioma. Carstairs' and Weigert's histochemical stains confirmed that the framework expanding the submucosa was fibrin. Although the appearance of the gastric wall resembled hemangioma, a population of neoplastic endothelial cells was not identified within the submucosal expansion of hemorrhage and fibrin, and microscopic evidence was most consistent with the diagnosis of gastric intramural hematoma. This lesion is a rare pathologic event that has not been reported in marine mammals, but one that should be included in diagnostic considerations of hemoperitoneum and gastric mural expansion.     

终末期肾病患者合并胃食管反流病的临床研究进展

胃食管反流病(GERD)是最常见的食管疾病之一。多项研究表明,终末期肾病(ERSD)患者GERD的患病率高于普通人群。目前对于ERSD患者特别是血液透析患者GERD的症状特点及严重程度的研究较少。ESRD患者常并发或伴发糖尿病、高血压等,而糖尿病神经病变可影响胃排空功能,钙拮抗剂和硝酸酯类药物可影响LES舒张功能。透析相关淀粉样变通过影响食管蠕动、食管下段括约肌张力和胃排空影响GERD的发生。ERSD患者中,相当比例的患者全身状况不佳,行胃镜风险较高,常常应用标准化量表或质子泵抑制剂诊断试验评估患者症状性GERD患病情况。ESRD及透析患者GERD的知晓率仍较低,部分患者自行服用碳酸氢钠等非一线药物控制症状。理论上对于ESRD及透析患者伴随的GERD进行早期诊断和治疗可能提高患者生活质量,并减少水钠摄入,改善血压及透析间期体重增加,降低心血管事件风险,具体的临床获益仍有待进一步研究证实。     

Biomechanical, morphological and zero-stress state characterization of jugular vein remodeling in arteriovenous fistulas for hemodialysis

While the role of hemodynamic variables on the development of intimal hyperplasia in arteriovenous fistulas for hemodialysis has been examined, less is known about the intramural biomechanical factors. In this study, arteriovenous fistulas were created by implantation of e-PTFE grafts between carotid artery and jugular vein in healthy pigs. In vivo recordings exhibited a three-fold pressure and flow elevation in grafted veins after fistula creation, remaining so until sacrifice. The chief morphological observation in grafted vessels was wall thickening at two weeks, serving to restore intramural stresses to homeostatic levels, and a less marked internal diameter enlargement, gradually normalizing intimal shear after four weeks. The residual strains and opening angle, specifying the zero-stress configuration, increased with differences reaching significance at twelve weeks. Association with histomorphological findings on intima, media and adventitia growth disclosed a correlation between intimal hyperplasia and opening angle increase. Elastin and cellular contents diminished opposite to collagen content, most differences occurring within the first four weeks after grafting. Inflation/extension testing showed that post-fistula the vein wall became progressively thicker and stiffer, lacking restoration of compliance to baseline levels. The present data may further our understanding of the dynamics of venous biomechanical remodeling under pressure and flow-overload conditions.     

Surgical indication in Schistosomiasis mansoni portal hypertension: follow-up from 1985 to 2001

The study had the objective to evaluate the benefits of surgical indication for portal hypertension in schistosomiasis patients followed from 1985 to 2001. Schistosoma mansoni eggs were confirmed by at least six stool examinations or rectal biopsy. Clinical examination, abdominal ultrasonography, and digestive endoscopy confirmed the diagnosis of esophageal varices. A hundred and two patients, 61.3% male (14-53 years old) were studied. Digestive hemorrhage, hypersplenism, left hypochondrial pain, abdominal discomfort, and hypogonadism were, in a decreasing order, the major signs and symptoms determining surgical indication. Among the surgical techniques employed, either splenectomy associated to splenorenal anastomosis or azigoportal desvascularization, esophageal gastric descompression and esophageal sclerosis were used. Follow-up of patients revealed that, independent on the technique utilized, a 9.9% of death occurred, caused mainly by digestive hemorrhage due to the persistence of post-treatment varices. The authors emphasize the benefits of elective surgical indication allowing a normal active life.     

Should right ventricle dilatation during exercise have clinical implications in patients with chronic thromboembolic pulmonary hypertension? Case report

Background

The occurrence of pulmonary artery obstruction in the course of acute aortic dissection is an unusual complication. The mechanism implicated is the rupture of the outer layer of the aorta and the subsequent hemorrhage into the adventitia of the pulmonary artery that causes its wall thickening and, at times, produces extrinsic obstruction of the vessel. There are no reports of this complication in acute intramural hematoma.

Case presentation

An 87-year-old woman was admitted to the hospital in shock after having had severe chest pain followed by syncope. An urgent transesophageal echocardiogram revealed the presence of acute intramural hematoma, no evidence of aortic dissection, severe pericardial effusion with cardiac tamponade, and periaortic hematoma that involved the pulmonary artery generating circumferential wall thickening of its trunk and right branch with no evidence of flow obstruction. Urgent surgery was performed but the patient died in the operating room. The post mortem examination, in the operating room, confirmed that there was an extensive hematoma around the aorta and beneath the adventitial layer of the pulmonary artery, with no evidence of flow obstruction.

Conclusion

This is the first time that this rare complication is reported in the scenario of acute intramural hematoma and with the transesophageal echocardiogram as the diagnostic tool.     

Pharmacological characterization of lower esophageal sphincter relaxation induced by swallowing, vagal efferent nerve stimulation, and esophageal distention.

To characterize the neural pathways involved in lower esophageal sphincter relaxation, intraluminal pressures from the lower esophageal sphincter of the opossum were monitored during swallowing, vagal efferent nerve stimulation, and intraluminal balloon distention in the presence and absence of pharmacologic antagonism of putative neurotransmitters. The combination of atropine, hexamethonium, and 5-methoxydimethyltryptamine, which is known to block ganglionic transmission in the vagal inhibitory pathway to the lower esophageal sphincter, significantly antagonized LES relaxation induced by both swallowing and vagal stimulation, but did not affect the LES relaxation induced by balloon distention. Administration of the nitric oxide synthase inhibitor N omega nitro-L-arginine methyl ester, on the other hand, markedly inhibited LES relaxation induced by vagal stimulation, swallowing, and balloon distention, and this effect was reversed by administration of the nitric oxide synthase substrate L-arginine. These studies indicate that the distension-induced intramural pathway mediating LES relaxation does not involve ganglionic transmission similar to that of the vagal inhibitory pathway to the LES. However, the LES relaxation induced by all forms of stimuli appears to depend on nitric oxide as a final mediator.     

Gastritis of the Herniated Stomach in Patients with Esophageal Hiatus Hernia

Seven illustrative cases of gastritis of the herniated stomach in patients with sliding esophageal hiatus hernia are reported. Five had superficial gastritis (three mild, one moderate and one severe); two had atrophic gastritis. Gastritis was present in two patients whose mucosa appeared normal at esophagoscopy. Interstitial hemorrhage into the lamina propria was present in four of the seven biopsy specimens. The possibility that interstitial hemorrhage may be related to the development of gastric erosions is considered. The pathogenesis of this form of gastritis is discussed.     

The Warren Shunt in Treating Bleeding Esophageal Varices

In patients who have impaired hepatic reserve, the Warren shunt has been proposed as an effective operation because it decompresses the esophageal varices without disturbing portal perfusion of the liver. However, early reports of high operative mortality and technical difficulties have impeded acceptance of the procedure.The operation was done in a series of 17 patients. All patients in whom elective variceal decompression with a patent splenic vein was required and without clinical ascites were candidates for this operation. Follow-up ranged from 2 to 48 months. Six patients had alcoholic cirrhosis, two had primary biliary cirrhosis and seven had postnecrotic cirrhosis; in two the cause of the liver disease was unknown. Five patients were categorized as Child''s class A, nine as class B and three as class C. No intraoperative or early postoperative deaths owing to hemorrhage occurred. However, there was one death two weeks postoperatively from pulmonary sepsis and one death five weeks postoperatively due to antigen-positive hepatitis. Two patients died from hepatic failure six weeks and five months after operation, respectively; in the first of these, chronic active hepatitis was diagnosed at the time of operation. In one patient hemorrhage recurred and transfusion was required. Although ascites, which eventually resolved, developed in eight patients after operation, the results in 76 percent of patients have been good without new episodes of hemorrhage or encephalopathy. We conclude that the Warren shunt is a safe and effective elective operation for the treatment of patients in whom hemorrhage from esophageal varices has occurred.     

Comparative stereometric study of the intramural arterial bed of the human myocardium using injection and non-injection methods]

Comparative sterometric study of intramural arterial bed of the left ventricle wall of 20 injected and 30 non-injected hearts of practically health adults aged from 24 to 27 years (after violent death) was conducted. The volumetric density index of intramural arterial bed(Vv) of the myocardium of the left ventricle wall was on the average 9 times less in case of non-injected hearts than in the injected ones. The Vv was the greastest in the middle type of the coronary circulation of the heart. The non-linear dependence between the Vv and the age was revealed. The Vv decreased with the increase of the heart weight. With the equal indices of the heart weight the Vv was significantly higher in females than in males. The non-injection sterometric method used for the study of the inorganic arterial bed simplifies and objectifies the estimation of the state of myocardial blood supply and can be used in anatomopathological practice.     

Risk and Prognosis of Bloodstream Infections among Patients on Chronic Hemodialysis: A Population-Based Cohort Study

Background and Objectives

Infections are common complications among patients on chronic hemodialysis. This population-based cohort study aims to estimate risk and case fatality of bloodstream infection among chronic hemodialysis patients.

Methods

In this population-based cohort study we identified residents with end-stage renal disease in Central and North Jutland, Denmark who had hemodialysis as first renal replacement therapy (hemodialysis patients) during 1995–2010. For each hemodialysis patient, we sampled 19 persons from the general population matched on age, gender, and municipality. Information on positive blood cultures was obtained from regional microbiology databases. All persons were observed from cohort entry until first episode of bloodstream infection, emigration, death, or end of hemodialysis treatment, whichever came first. Incidence-rates and incidence-rate ratios were computed and risk factors for bloodstream infection assessed by Poisson regression. Case fatality was compared by Cox regression.

Results

Among 1792 hemodialysis patients and 33 618 matched population controls, we identified 461 and 1126 first episodes of bloodstream infection, respectively. Incidence rates of first episode of bloodstream infection were 13.7 (95% confidence interval (CI), 12.5–15.0) per 100 person-years among hemodialysis patients and 0.53 (95% CI, 0.50–0.56) per 100 person-years among population controls. In hemodialysis patients, the most common causative microorganisms were Staphylococcus aureus (43.8%) and Escherichia coli (12.6%). The 30-day case fatality was similar among hemodialysis patients and population controls 16% (95% CI, 13%–20%) vs. 18% (95% CI, 15%–20%).

Conclusions

Hemodialysis patients have extraordinary high risk of bloodstream infection while short-term case fatality following is similar to that of population controls.     

Achalasia in a sixty-four-year-old man.

Achalasia is an esophageal motility disorder characterized by increased lower esophageal sphincter pressure and absence of peristalsis in the lower esophagus. Patients typically present with complaints of progressive difficulty swallowing over a period of several years. Diagnosis is confirmed by esophageal manometry. Complications of achalasia include esophagitis, aspiration and possibly an increased risk of esophageal carcinoma. Medical treatment options include pneumatic dilatation, esophageal bougienage, nitrates, calcium channel blockers and botulinum toxin injections. The primary method of surgical treatment is the Heller myotomy, in which longitudinal incisions are made in the muscle fibers of the lower esophageal sphincter to reduce sphincter pressure. Frequently, a fundoplication is performed in addition to the myotomy to decrease the likelihood of development of gastroesophageal reflux. In recent years, the Heller myotomy has been performed both thoracoscopically and laparoscopically. An additional development has been the placement of an endoscope in the esophagus to provide transillumination during surgery; intraoperative endoscopy allows improved assessment of the depth of myotomy incisions and reduces the risk of esophageal perforation. The case report below describes a 64-year-old-man with achalasia who presented with persistent dysphagia despite multiple attempts at medical treatment. A laparoscopic Heller myotomy with Toupet fundoplication was performed with subsequent eradication of symptoms. A discussion of the epidemiology, etiology, clinical presentation, diagnosis and treatment of achalasia follows the case report.     

Esophageal tuberculosis. Endoscopic cytology as a diagnostic tool

OBJECTIVE: To study the utility of endoscopic cytology in the diagnosis of esophageal tuberculosis in clinically unsuspected cases. STUDY DESIGN: During a period of four years, endoscopic cytology of esophageal lesions was performed on 228 patients. In eight (3.5%) the cytologic diagnosis of esophageal tuberculosis was suggested on smears. Upon endoscopic examination, the sites of involvement were mid esophagus (five cases), upper esophagus (two cases) and lower esophagus (one case). Linear ulcer was seen in six cases; growth and narrowing of the lumen were seen in one case each. Endoscopic brush smears in seven cases and fine needle aspiration cytology smear in one case were collected. Air-dried smears stained by Giemsa stain were reviewed for detailed cytologic assessment. RESULTS: Smears showed well-defined granulomas with necrosis in five cases and granulomas without necrosis in three. Cytologic evidence of concurrent poorly differentiated squamous cell carcinoma was observed in one case. Tubercle bacilli were demonstrated in five cases. Endoscopic biopsy showed granulomas in three cases and tubercle bacilli in one case. In six cases there was no clinical or radiologic evidence of tuberculosis at other sites, thereby suggesting the possibility of primary esophageal tuberculosis. The remaining two cases had a past history of tuberculosis; one presented with cervical lymphadenopathy and one mediastinal lymphadenopathy. All patients received antitubercular treatment, and the patient with concurrent malignancy also received radiotherapy. All but one of the patients who succumbed to aspiration pneumonia responded to treatment. CONCLUSION: Endoscopic cytology is a useful modality in the diagnosis of esophageal tuberculosis in clinically unsuspected cases.     

Prevalence of human papilloma virus in esophageal carcinomas: a polymerase chain reaction-based study

Objectives: Human papilloma virus (HPV) has been repeatedly found in esophageal carcinoma tissues. However, detection rates of HPV DNA in these tumors have varied markedly. Differences in detection methods, sample types and geographic regions of the sample origin have been suggested as potential causes of this discrepancy. This study was undertaken to analyze the prevalence of HPV in esophageal carcinoma. Study Design: HPV L1 DNA was evaluated in a total of 49 esophageal carcinoma samples, including 44 cases of squamous cell carcinoma (SCC) and 5 cases of adenocarcinoma. Seventeen control samples of esophageal brushings were also analyzed. The HPV L1 fragment was detected using MY09/MY11 primers. Results: In test samples, 17/49 (34.7%) were positive for HPV L1 and, in comparison, none of the control samples were positive. HPV DNA was identified in 17/37 (46%) cases of non-keratinizing SCC and was not identified in any case of esophageal keratinizing SCC and adenocarcinoma. Conclusion: This study defines a significant association of HPV with esophageal non-keratinizing SCC. Our findings raise the possibility that HPV is involved in esophageal carcinogenesis, especially the non-keratinizing type of SCC. Further investigation with a larger sample size over broader geographic areas may be warranted.     

Tuberculosis; recent trends in infection,disease and deaths in California

Although fewer patients with tuberculosis are reported in a far advanced stage of the disease than ever before, the proportion of persons dying of tuberculosis whose disease had not previously been diagnosed appears to be increasing. The average length of sanatorium treatment, and the intramural case fatality rates have not shown much decrease. Tuberculosis mortality rates fall during economic depressions and rise with business booms. Epidemics of influenza do not always increase tuberculosis death rates. Common claims to the contrary are not sustained by recent California data.