Hyperplastic gastric polyp causing progressive gastric outlet obstruction

Hyperplastic polyps represent 75 to 90% of gastric polypoid lesions. The manifestations of these unique gastric neoplasms vary, including abdominal pain, nausea, and vomiting or gastrointestinal bleeding. The vast majority of these lesions are small, asymptomatic, and found incidentally on radiologic evaluation or endoscopic examination of the upper gastrointestinal tract. Herein we describe a large, benign, pedunculated hyperplastic polyp that led to progressive gastric outlet obstruction. In addition, we provide an overview of gastric polyps and a review of the literature. Excision of gastric polyps by endoscopic or surgical means is recommended as prudent treatment to eliminate occurrence of malignant foci.     

Classification of qh regions in human chromosomes 1, 9, and 16 by C-banding

The occurrance of polyps of the uterine cervix during childhood is described which is exceedingly rare according to the literature. A pediatric gynaecological outpatient department was established two years ago and among about 600 children examined by viginoscopy, nine children with polyps of the cervix were detected. All nine girls had similar symptoms and signs. There was vaginal bleeding with malodorous discharge which could also be characteristic of a malignant tumor. The vaginal introitus was rather larger with an almost absent hymen. It is important to recognize the conditions early and to treat it. The vaginal discharge was treated. The polyp was removed and the base of the polyp was coagulated to avoid a recurrence. It can be expected that polyps of the uterine cervix in childhood will be found more often as the interest in pediatric gynaecology increases.     

Surgical hysteroscopy or hysterectomy in the treatment of benign uterine lesions. What to choose in 1998?

In the past, the treatment of benign uterine lesions required, in many instances, a hysterectomy. These days, most cases can be successfully treated by hysteroscopy. To be reliable, this technique must lead to a significant reduction in the number of hysterectomies performed for benign uterine lesions. The electroresection technique is preferred to that using the Nd-YAG laser because of its lower cost and its equivalent efficacy. By using the uterine perfusion pump device, the risk of resorption syndrome can be reduced to its minimum. Submucosal myomas < 1 cm, benign endometrial hyperplasia and adenomyosis are the commonest benign lesions treated. Dysfunctional uterine bleeding can also be treated by an endometrectomy. A preoperative workup includes a transvaginal ultrasound and a biopsy. This ensures that only benign lesions that are accessible to a hysteroscopy will be submitted to this technique and that no cases of endometrial cancer or atypical hyperplasia would be ignored. This study presents 270 cases of operative hysteroscopy with a follow-up to 4 years. 82.8% of myomatous lesions were treated with success. The results for patients with benign endometrial polyps or benign endometrial hyperplasia are also excellent with only 4.6% and 5.6% rate of secondary surgery respectively. Adenomyosis does not appear to be a good indication for hysteroscopy as only 37% of patients did not need a definitive hysterectomy. Rates of operative complications (post-operative bleeding, uterine perforation, resorption syndrome and difficulty of access) are acceptable and get less frequent as the surgeon experience increases.     

Impact of follow up letters on non-attenders for breast screening: a general practice based study

Twelve cases of tumours of the nose and sinuses misdiagnosed at the first time as nasal polyp are reported. Of them, 4 were benign and 8 malignant. The endoscopic technique is helpful to differential diagnosis of benign or malignant lesions and polyps in these areas.     

Clinical evaluation of fundic gland polyps and hyperplastic polyps

We performed a retrospective review of 477 cases of fundic gland polyps compared with 562 cases of hyperplastic polyps, which were detected endoscopically during the past 8 years between January, 1989 and December, 1996. All lesions were histologically confirmed by endoscopic biopsy or the examination of polypectomy specimens. Fundic gland polyps were more prevalent in middle aged-female, and were not associated with gastric adenomas and gastric cancers. These results suggested that the background mucosa of patients with fundic gland polyp was different from that of patients with hyperplastic polyp. Fundic gland polyps in 55 patients were followed up. No change was observed in the polyps of the about half subjects, the polyps of 12 cases (21.8%) decreased in size and number or resolved completely. Cases decreased in size and number or resolved completely were much more in fundic gland polyps than hyperplastic polyps. There were no malignant transformation of fundic gland polyps. We claimed that fundic gland polyps were benign and distinct from hyperplastic polyps which had a possibility of malignant transformation.     

Colonoscopic polypectomy

The colonoscopic management of 86 patients with polypoid lesions of bleeding from the colon of intermittent nature is discussed. There were 145 polyps found in 85 of these patients. Adenomatous polyps occurring in the sigmoid colon above the reach of the standard sigmoidoscope was the most common finding and pathological diagnosis. Adenocarcinoma of the colon occurred in two patients and invasive carcinoma of a polyp was found in three other patients. Five other patients had polyps that demonstrated a carcinoma in situ. The definitive treatment of these complicated polyps is outlined. The importance of barium enema examination on follow-up of polyp and carcinoma patients and on patients with polyps found at standard sigmoidoscopy is stressed. The possibility of colonoscopic follow-up in lieu of colectomy and ileoproctostomy is suggested for patients with multiple polyps of the colon who do not belong to the familial polyposis group.     

CT colonography with three-dimensional problem solving for detection of colonic polyps

OBJECTIVE: We performed CT colonography in patients referred for conventional colonoscopy, interpreted the axial images, and used commercially available software to reconstruct endoluminal perspective views to differentiate polyps from folds. SUBJECTS AND METHODS: We prospectively examined 44 patients (27 men and 17 women; mean age, 58 years old) with CT colonography by interpreting the axial images and using three-dimensional rendering for problem solving only. The CT scans were interpreted by two radiologists who were unaware of patients' histories as revealed by colonoscopic findings. The findings on colonography were compared with those of conventional colonoscopy to determine sensitivity, specificity, time spent on interpretation, and confidence of interpretation. RESULTS: Colonoscopy showed normal findings in 28 patients and 22 polyps in the remaining 16 patients. Six polyps were 8 mm or larger, three were 5-7 mm, and 13 were 5 mm or smaller. The findings of the two observers revealed an overall sensitivity of 50% and 38%, respectively, and a specificity of 93% and 86%, respectively. Sensitivity for polyps larger than 8 mm was 83% and specificity was 100% for both observers. The average amount of time spent on interpretation was 28 min 30 sec (range, 14-65 min). Both observers used the endoluminal view for differentiating folds from polyps in 23 (52%) of 44 patients, which had only minimal impact on interpretation time. CONCLUSION: CT colonography can be performed and the images interpreted using currently available hardware and software by initially using the axial images to search for polyps of significant size. Endoluminal views should be used only when necessary to help distinguish normal folds from fixed raised lesions that are suggestive of polyps.     

Which colonic polyps should be excised endoscopically?

A review of 464 consecutive polypoid lesions of the colon reveals that virtually all pedunculated polyps and over 80% of 218 sessile polyps were removed colonoscopically. Although size or location of the lesions occasionally precludes colonoscopic excision, the endoscopic appearance of a sessile polyp is the most important factor in deciding upon the method of excision. In gneeral, smooth, soft, nonulcerated sessile lesions of all sizes were excised endoscopically, while approximately half of the larger (2-6 cm) firm, irregular-surfaced, benign sessile lesions, and all ulcerated or malignant sessile lesions required laparotomy for proper management. All polypoid lesions should be viewed endoscopically before deciding the method of excision, regardless of their size, location, or general appearnce by barium enema. Experience with endoscopic morphology and snare electrocautery technics was most important, since more than 85% of all polypoid lesions in this consecutive series were removed endoscopically.     

Adenosarcoma of the uterine cervix presenting as a cervical polyp

A case of adenosarcoma arising from the uterine cervix of a 55-year-old female who complained of vaginal discharge is reported. A polyp, 6 x 2 x 1.5 cm in size, identified in the cervical canal was clinically diagnosed as benign cervical polyp and resected. Histologically, the polyp was composed of benign epithelial components and sarcomatous stroma wherein periglandular hypercellularity and some mitoses including atypical ones were noted. Immunohistochemically, stromal cells were positive for muscle-type actins, desmin and estrogen receptor. Adenosarcoma is a rare, biphasic tumor of the uterus and usually presents as a polypoid mass in the endometrial cavity. When they arise from the cervix, adenosarcomas may be confused with benign cervical polyps clinically and pathologically. As the former often recurs, microscopic differentiation is crucial for further treatment.     

Nasal polyps in children

The inflammatory nasal polyp is the most common benign or malignant nasal mass seen in children. Nasal polyps in the pediatric population appear to occur as inflammatory responses to bacterial infections. In 33% of the patients with polyps whom we studied, antral choanal polyps were noted, and in 20% of the patients the polyps were unilateral but not antral choanal. In 18% of the patients the polyps were bilateral and in an additional 29% they occurred bilaterally in association with cystic fibrosis. History of an allergy is infrequently associated with nasal polyps; allergies are potentially major contributing factors to nasal polyps only in patients without cystic fibrosis whose nasal polyps are bilateral. Patients with antral choanal polyps are most successfully managed by simultaneous Caldwell-Luc antrostomy and polypectomy. Sixty percent of patients with nasal polyps and cystic fibrosis are adequately managed with a single intranasal polypectomy. Simultaneous sinus surgery and polypectomy should be considered for all patients with recurrent polyps and for all patients with clinical or radiographic evidence of significant sinusitis. Complications, including epistaxis and intranasal synechia, occurred in 3% of the 170 surgical procedures performed.     

Curettage vs. hysteroscopic resection

The aim of the present study was to evaluate the therapeutic efficacy of curettage vs hysteroscopic resection in the treatment of endometrial polyps. A group of 25 patients were examined and during surgery underwent diagnostic hysteroscopy, curettage of the uterine cavity, control hysteroscopy and resectoscopy in the event of residual polyps. Thirteen cases revealed the total persistence of the polyp after curettage and in 6 cases the polyp was only partially removed; the polyp was detached but not removed from the uterine cavity in 4 cases and the polyp was fully removed using the curette in only 2 cases. The considerable limits of curettage which emerge from this study appear to be linked to three main factors: the localization, nature and size of endometrial polyps. Curettage may therefore now be considered a method which has been surpassed in not only diagnostic but also therapeutic terms by hysteroscopic techniques.     

Enteroscopy valuable in obscure small bowel disease. Chances are good to discover curable conditions

Indications for enteroscopic examination of the proximal small bowel are expanding, above all in cases of gastro-intestinal bleeding of obscure origin. Of 66 patients examined enteroscopy revealed new and unforeseen diagnoses in about half of them, such as angiodysplasia and erosions (15 per cent of cases each). Former as well as ongoing bleeding was treated with electro cautery, bicap. In four cases the need for blood transfusion ceased. Ulcers, neoplasia and varices were also diagnosed. 16 out of 36 pathologic lesions were located within reach of an ordinary gastroscope, in spite of the patients being selected through repeated normal upper and lower endoscopic examinations. This emphasises the need for better quality assurance in routine endoscopic examinations.     

Central nervous system (CNS) involvement in SLE. The diagnostic role of antibodies to neuronal antigens

Dysplasia in inflammatory bowel disease (IBD) is categorized as either flat or associated with a raised lesion or mass (dysplasia-associated lesion or mass [DALM]). One specific subtype of a dysplasia-associated lesion or mass consists of isolated discrete nodules or polyps that are difficult to distinguish from sporadic adenomas. Because the clinical management of these two lesions is different, we performed this study to (1) evaluate the clinical presentation, pathologic features, and natural history of polypoid dysplastic lesions and sporadic adenomas in patients with IBD and (2) determine whether there are clinical, endoscopic, or pathologic findings useful in differentiating between these two lesions. The morphologic features of 89 benign polypoid epithelial neoplasms from 59 patients with IBD (51 with ulcerative colitis, 8 with Crohn's colitis) were evaluated and correlated with the clinical, endoscopic, and follow-up data. In a separate analysis, patients were categorized arbitrarily as having (1) a probable sporadic adenoma if the polypoid epithelial neoplasm was not located within areas of histologically proven colitis, (2) a probable IBD-associated polypoid dysplasia if the lesion developed within an area of colitis, and associated flat dysplasia or an adenocarcinoma was detected during follow-up evaluation or (3) an indeterminate polyp, which was seen in the remainder of the cases. The clinical, endoscopic, and histologic data were compared among these three patient and polyp subgroups. There were 35 males and 24 females (median age, 57 years; range, 27-85 years). Median duration of disease was 10 years. Forty-nine percent of the patients had pancolitis; 66% had histologically active disease at the time of presentation. Nearly 70% of patients had only one polyp; the majority occurred in either the left colon or the rectum (66%). Most polyps were described as a sessile nodule, whereas only 7 (7.8%) were pedunculated. Polyps ranged from 2 mm to 50 mm (median, 5 mm); most had a tubular architecture (84.3%) and contained low-grade dysplasia (64%). In addition, most polyps had mildly increased lamina propria and intraepithelial neutrophilic and mononuclear inflammation. At follow-up evaluation (40 patients; median follow-up time, 13 months; range, 1-78 months), a further neoplastic lesion developed in 20%; low-grade flat dysplasia was seen in 5 (12.5%), and adenocarcinoma developed in 3 (7.5%). However, dysplasia or adenocarcinoma did not develop in the patients who had polyps located outside of areas of histologically proven colitis. In addition, at least one more benign polypoid epithelial neoplasm developed in 15 of 40 patients (37.5%). Patients with probable IBD-associated polypoid dysplasia had a statistically significant (p < 0.05), longer disease duration than patients with probable sporadic adenoma. A statistically significant, higher proportion of polyps with tubullovillous or villous architecture, an admixture of normal and dysplastic epithelium at the surface of the polyps, and increased lamina propria mononuclear inflammation was noted in probable IBD-associated polypoid dysplastic lesions compared with those considered to be sporadic adenomas. Several clinical and pathologic features may be useful to help categorize a polypoid dysplastic lesion as a sporadic adenoma or an IBD-related neoplasm in a patient with IBD. This distinction is important because the natural history of these two lesions (as shown by the results of this study) and their subsequent management are quite different.     

Nosologic and anatomy pathological study of flat adenoma and associated lesions

Flat adenomas can be dysplastic from onset, whereas for polyps the risk of malignant transformation increases over time and with the size of the polyp. A dominant autosomal syndrome characterized by the development of flat adenomas has been reported. In a retrospective study of operative specimens from high-risk patients who had surgery for colorectal cancer, the author found that flat adenomas, which had been overlooked at initial evaluation, were a potentially useful phenotype. The mucosa adjacent to the flat adenomas showed hyperplasia and increased proliferation reminiscent of the morphologic abnormalities in aberrant crypts described by Pretlow; the latter have been found to occur rapidly in rats exposed to carcinogens and have also been demonstrated in patients at high risk for colon cancer. Aberrant crypt abnormalities and flat adenomas may be premalignant lesions.     

Modified duodenum-preserving resection of the head of the pancreas

A modified procedure of duodenum-preserving resection of the head of the pancreas was used in treating three patients with benign lesions in the head of the pancreas. Compared with Beger's procedure, the modified procedure was simpler, and pancreaticojejunostomy on duodenal side was not necessary because of less remaining pancreas attached to the conjunction of the pancreatobiliary duct. The patients, recovered and ate food from 4 to 6 days after operation without symptoms of duodenal obstruction. The patient's digestive function was normal, and the pre- and postoperative pancreatic endocrine function was almost identical. This procedure can be used as the first-choice surgical procedure for benign lesions in the head of the pancreas. Problems in how to protect blood supply of the duodenum were also discussed.     

Are endoscopic measurements of colonic polyps reliable?

Many clinical studies of colorectal adenomatous polyps rely on endoscopic estimation of polyp size. To examine the reliability of such measurements, we conducted a study using artificial polyps in an endoscopy teaching model. Eight experienced endoscopists estimated the size of 13 polyps in two separate sessions 2 wk apart. Endoscopic estimates of polyp size tended to be significantly lower than the true polyp size for all polyps and all endoscopists at both sessions. We also found a statistically significant difference in the magnitude of the underestimation between the first and second session (p < 0.0001). At the first session, polyps tended to be estimated at 64% of their true size, and at the second session, the estimates tended to be at 77% of the actual polyp size. We estimate the magnitude of the variation in polyp measurements due to individual polyps, endoscopist, and examination session, and discuss the impact these sources of variation have in planning of clinical trials.     

A prospective evaluation of the safety and efficacy of methohexital in the emergency department

OBJECTIVE: Knowledge of a possible correlation between distal polyps found at screening sigmoidoscopy and proximal colonic lesions is important for deciding whether to perform total colonoscopy or not. PATIENTS: A prospective analysis of 2439 consecutive patients with colorectal polyps. Of these, 304 were asymptomatic subjects who underwent complete colonoscopy for screening and were found to have adenomatous or hyperplastic polyps in the distal colorectum. RESULTS: Ten (15%) out of 65 patients with distal hyperplastic polyps only and 86 (36%) out of 239 with distal adenomatous polyps were found to have adenomatous polyps in the proximal colon as well (P < 0.001). The frequency of synchronous proximal adenomas in patients with small (< or = 5 mm) or large distal adenomas (> 5 mm) was comparable (37% and 35%, respectively). However, patients with small distal adenomas had significantly smaller proximal adenomas (P = 0.004) containing less villous component (P = 0.017) than those with large distal adenomas. Neither the patient's age nor the presence of multiple distal adenomas increased the prevalence of proximal adenomas. CONCLUSION: Hyperplastic polyps found on rectosigmoidoscopy do not indicate a need for a complete colorectal examination, as 15% of patients with distal hyperplastic polyps will have proximal adenomatous polyps, a figure that is comparable with that of asymptomatic patients having no distal polyps, either hyperplastic or adenomatous. When only small distal adenomas are found at screening sigmoidoscopy in asymptomatic persons the decision to do a total colonoscopy should be based on individual considerations, as in such cases only small polyps are to be expected in the proximal colon.     

Types of medical lasers

The knowledge about different types of lasers and their potential use in medicine is presented. A very rapid development of laser technology in the world imposes a need for up-to-date information about the characteristics of different laser instruments. Without this kind of information it would be difficult to keep in touch with the latest developments in the world's technology. Different types of lasers have different indication range in the medical practice. An inquiry into the fundamental principles of lasers physics is an important prerequisite for successful application of this technology in medicine. Laser as a surgical knife has shown certain advantages over scalpel, electrocautery and cryosurgery, as the laser surgery is a noncontact method, bloodless, precise, with better visualization, minimal postoperative edema, painless healing, without complications. Although laser cannot entirely replace conventional surgical instruments, it is still the instrument of choice for treatment of numerous pathological conditions. The carbon dioxide laser is a highly precise, bloodless light scalpel used for incising and excising tissues and sealing small blood vessels. The infrared beam at 10,600 nm wavelength is absorbed by water and tissue destruction is due to the instantaneous vaporization at relatively low temperature of 100 degrees C. The beam seals blood vessels of up to 0.5 mm in diameter and if the beam is defocused, larger vessels may be controlled. The beam also seals lymphatics, possibly reducing the spread of tumour cells by this route, and seals nerve endings: there is no incidence of neuroma formation. Carbon dioxide laser has shown a great efficiency in otorhinolaryngology, in maxillo-facial surgery and plastic surgery, in urology and gynecology. Provides true "no touch" surgery, and is used increasingly in neurosurgery for the precise atraumatic removal of tissue and for creation of precise lesions for the control of pain. The carbon dioxide laser beam cannot, at present, be transmitted via a flexible fibre, although a number of fibres are being investigated. Delivery of laser energy to microscope, colposcope or handpiece is via an articulated arm which is a hollow tube with mirrors at the articulations. The argon laser produces blue-green coherent light at a number of wavelengts but 80% of the energy is at wavelengths of 488 and 514 nm. This laser was first used in ophtalmology to treat diabetic retinopathy through, and without damage to, the clear anterior parts of the eye. The argon laser is used for blood vessel coagulation but can be used to perform slow, thermal tissue destruction at higher power levels. Argon laser is most commonly used in ophthalmology for otological micro-surgery, particularly in the treatment of otosclerosis and tympanosclerosis. Very good results have been achieved in the argon laser treatment of gastrointestinal bleeding ulcers, vascular lesions and polyps. Dermatology is another field where argon laser has shown great efficiency: hemangyomas, telangiectasias, tattoos, small benign and malignant tumours are amenable to argon laser treatment. In neurosurgery it is used to control both normal and abnormal blood vessels but at present much work on treatment of arteriovenous malformations and aneurysms is experimental. Both the argon laser energy can be transmitted via flexible fibre optic delivery system which can then be attached to an operating microscope, slit lamp, endoscope delivery fibre or handpiece. The Neodymium-YAG laser is used both for tissue destruction with good haemostasis and for the control of normal and abnormal blood vessels. This laser produces infrared coherent light at 1060 nm wavelength, which is deeply absorbed in the tissues without colour or tissue specificity. Neodymium-YAG laser is mostly used in tracheobronchial, gastrointestinal and urologic pathology in the treatment of stenoses, granulomas, benign tumours, and for reduction of malignant tumours. (ABSTRACT TRUN     

Pharyngeal dermoids ("hairy polyps") as accessory auricles

The purpose of this study is to clarify the origin and nature of so-called hairy polyps or dermoids of the pharynx, which are often thought to be a variant of pharyngeal teratoma. For this purpose, a case is reported of a dermoid polyp involving the middle ear of an infant, the features of multiple examples of pharyngeal dermoid polyps and teratomas received for consultation by the Armed Forces Institute of Pathology are examined, and selected pertinent reports from the literature are reviewed. All three means are used to support the conclusion that these lesions are choristomatous developmental anomalies arising from the first branchial cleft area and that they essentially represent heterotopic accessory "ears" (auricles) without the growth potential of a teratoma.     

Long pedunculated colonic polyp composed of mucosa and submucosa: proposal of a new entity, colonic muco-submucosal elongated polyp

We encountered 15 patients with colonic polyps showing histologic features that did not belong to any of the known categories. All polyps were elongated and drumstick-shaped, with lengths of 12 to 160 (mean, 29 mm) mm. Histologically, the polyps were covered with normal mucosa and consisted of edematous, loose, fibrous, connective tissues and dense, fibrous submucosal layers, often showing dilation of blood vessels and lymphatics. Although the mechanism of generation of such polyps remains unknown, their elongation may be caused by intestinal motion. Because this kind of polyp has not been described previously outside Japan, we here introduce a new type of polyp, which we have proposed calling the colonic muco-submucosal elongated polyp.