說(shuō)明教案講稿cle全文inflammatory cloacogenic diagnostic features by confocal endomicroscopy

1、Brief Reportsmore likely, because calcium carbonate crystals were noted here with only mild changes of chronic pancreatitis.4. Elta GH. Sphincter of Oddi dysfunction and bile duct microlithiasisin acute idiopathic pancreatitis. World J Gastroenterol 2008;14: 1023-6.5. Harada H, Takeda M, Yabeum H, e

2、t al. Calcium concentration in human pure pancreatic juice in chronic pancreatitis. J Gastroenterol 1980;15: 355-61.6. Sarles H, Augustine P, Laugier R, et al. Pancreatic lesions and modifica- tions of pancreatic juice in tropical chronic pancreatitis (tropical calcific diabetes). Dig Dis Sci 1994;3

3、9:1337-44.DISCLOSUREAll authors disd no final relationships rele-vant to this publication.REFERENCESDepartments of Gastroenterology (J.A.J., E.G.S., A.C.), Clinical Pathology(S.C.), Christian Medical College, Vellore, Tamil Nadu, India.Reprint requests: Professor Ashok Chacko, Department of Gastroen

4、terology, Christian Medical College, Vellore, Tamil Nadu, India.Copyright 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00doi:10.1016/j.gie.2008.05.0121. Catalano MF, Lahoti S, Geenen JE, et al. Prospective evaluation of endo-scopic ultrasonography, endoscopic retrograde

5、pancreaticography, and secretin test in the diagnosis of chronic pancreatitis. Gastrointest Endosc 1998;48:11-7.2. Axon AT, Classen M, Cotton PB, et al. Pancreaticography in chronic pan- creatitis: international definitions. Gut 1984;25:1107-12.3. Levy MJ, Geenen JE. Idiopathic acute recurrent pancr

6、eatitis. Am J Gastroenterol 2001;96:2540-55.Inflammatory cloacogenic polyp: diagnostic features by confocal endomicroscopySilvia Sanduleanu, MD, PhD, Ann Driessen, MD, PhD, Wim Hameeteman, MD, PhD, Wim van Gemert, MD, PhD, Adriaan de Brune, MD, PhD, Ad Masclee, MD, PhDMaastricht, The NetherlandsInfl

7、ammatory cloacogenic polyps (ICPs), first described in 1981,1 are relatively rare lesions of the anal transitional zone. It is presently thought that ICPs are regenerative changes of the rectal mucosa caused by recurrent pro- lapse.2,3 These polyps arise in association with various con- ditions (eg,

8、 internal hemorrhoids, diverticulosis, colorectal tumors, and Crohns disease) in which mucosal injury is the underlying pathogenic mechanism.3 Most cases of ICP are benign, although occasionally malignancy has been reported.ICPs may share clinical presentation and endoscopic appearance with malignan

9、t colorectal polyps. During conventional endoscopy, distinction is not possible, and histopathologic examination is mandatory. If the histol- ogy shows no malignancy, the question of sampling er- ror arises. Repeated endoscopy with multiple biopsies is then required, and this results in delay of dia

10、gnosis and treatment.Confocal laser endomicroscopy (CLE) is a combination technique in which real-time histology can be generated during endoscopy.4,5 This procedure allows thorough examination of large mucosal areas. Targeted biopsy speci-We present a patient with an ICP and focus on the diag- nost

11、ic features of these polyps by histologic examination and real-time confocal endomicroscopy.CASE REPORTA 52-year-old man was referred to our endoscopy unit because of recurrent hematochezia and mucus discharge. There was a long history of internal hemorrhoids. Family history revealed several cases o

12、f colorectal cancer, fulfilling the Amsterdam II criteria. Results of the physical examina- tion were negative except for the rectal examination, which showed a circumferential, mobile, soft mass at the top of the finger. The hemoglobin level and serum ferritin levels were normal.Results of colonosc

13、opy up into the cecum were nor- mal. Rectal retroflexion revealed a large rectal mass above the anorectal junction with circumferential, exophytic aspect and hyperemic mucosa with shallow ulcerations, suggestive of rectal carcinoma (Fig. 1A). Several biopsy specimens were taken, and these indicated

14、mucosal re- generative changes compatible with an inflammatory clo- acogenic polyp (Fig. 2A and B). No signs of malignancymens can be taken fromareas, thereby increasingdiagnostic accuracy and reducing the risk of sampling error.Volume 69, No. 3 : Part 1 of 2 : 2009 GASTROINTESTINAL ENDOSCOPY 595Bri

15、ef ReportsFigure 1. A, Inflammatory cloacogenic polyp: endoscopic appearance. Rectal retroflection revealed a large circumferential mass just above the dentateline with exophytic aspect and shallow ulcerations, miing a rectal carcinoma. B, Inflammatory cloacogenic polyp by MRI of the pelvis. Large r

16、ectalmass (diameter 42 mm, length 10 mm), without signs of local invasion or lymphadenopathy.Figure 2. Corresponding histologic appearance of an inflammatory cloacogenic polyp. A, Overview of the inflammatory cloacogenic polyp, character-ized by an eroded surface and irregular hyperplastic crypts (H

17、&E, orig. mag. 2). B,of the inflammatory polyp, with elongated crypts and in-creased cellularity of the stroma due to inflammation (downward arrow). Numerous bundles of muscles fibers are seen in the stroma (upward arrow) (H&E, orig. mag. 20).were found. Because proctoscopy 3 years before showed int

18、ernal hemorrhoids only, we could not exclude an in- terval cancer in this patient, with increased family risk for colorectal cancer. For this reason, a second endoscopy was performed. On this occasion a confocal endomicro-scope (EC-3870CIFK; Pentax, Tokyo, Japan) was used. Large mucosal areas of the

19、 rectal tumor were carefully ex- amined after administration of 5 mL fluorescein 10%. Real-time histology was obtained, and targeted mucosal biopsy specimens were taken. Confocal endomicroscopy596 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 3 : Part 1 of 2 : 2009Brief ReportsFigure 3. CLE images of an

20、 inflammatory cloacogenic polyp. A-D, During in vivo CLE using fluorescein 10% as a contrast agent, mild vascular abnor- malities and mild alterations of the crypt architecture with slight depletion of goblet cells point toward the benign nature of the lesion. Additionally, some specific features fo

21、r an ICP were found: hyperplastic, elongated, or branch-like crypts (C and E, arrows); increased stromal component due to both splaying and extension of muscle fibers vertically upward into the lamina propria (F, arrow); and prominent inflammatory infiltrate (D, arrow). These findings were consisten

22、tly present in all mucosal areas examined.showed minor alterations of the crypt architecture and a vascular pattern with increased stromal component, pointing toward a benign lesion (Fig. 3 A-F). Magnetic res- onance imaging (MRI) of the pelvis confirmed a large rec- tal mass (diameter 42 mm, length

23、 10 mm), with no signs of local invasion or lymphadenopathy (Fig. 1B). Local sur- gical resection was performed with complete removal of the rectal mass.DISCUSSIONThis report emphasizes the potential additional value of CLE in the differential diagnosis between benign (inflamma- tory) andmalignantco

24、lorectal polyps (rectal carcinoma) dur- ing ongoing endoscopy. This technique allows scanning of large mucosal areas, with subsequent targeted sampling of mucosa, thereby reducing the risk of sampling error.Volume 69, No. 3 : Part 1 of 2 : 2009 GASTROINTESTINAL ENDOSCOPY 597Brief ReportsFigure 3 (co

25、ntinued)The following features evidenced by both CLE and con- ventional histopathologic examination were suggestive of a benign polyp: (1) mild disturbance of the crypt architec- ture with slight depletion of goblet cells (as opposed to rectal carcinoma, in which completely distorted crypts with a l

26、oss of goblet cells are found); and (2) minor vascu- lar abnormalities (as opposed to rectal carcinoma, in which completely altered vascular pattern with leakage of fluorescein into the surrounding tissue occurs).4 Addi- tionally, specific features of an ICP were observed: (1) hyperplastic crypts, w

27、ith an elongated, branch-like appear- ance3; and (2) an increased stromal component due to splaying and extension of muscle fibers vertically upward into the lamina propria,3 as well as to inflammatory infil- trate with lymphocytes, plasma cells, and eosinophilic granulocytes.CLE in patients with be

28、nign colorectal polyps, such asICPs, may significantly improve the clinicohistopathologic evaluation and prevent diagnostic and therapeutic delay. CLE may also have a role in the follow-up of these patients. Ultimately, the surgical approach will be influenced as well. As opposed to malignant tumors

29、, ICPs are usually easy to re- move by local excision, and more extensive surgery is rarelyDISCLOSUREAll authors disd no final relationships rele-vant to this publication.Abbreviations: CLE, confocal laser endomicroscopy; ICP, inflammatory cloacogenic polyp; MRI, magnetic resonance imaging.REFERENCE

30、S1. Lobert PF, Appelman HD. Inflammatory cloacogenic polyp: a uniqueinflam-matory lesion of the anal transitional zone. Am J Surg Pathol 1981;5:761-6.2. Saul SH. Inflammatory cloacogenic polyp: relationship to solitary rectal ulcer syndrome/mucosal prolapse and other bowel disorders. Hum Pathol 1987

31、;18:1120-5.3. Tendler DA, Aboudola S, Zacks JF, et al. Prolapsing mucosal polyps: an unrecognized form of colonic polypda clinicopathological study in 15 cases. Am J Gastroenterol 2002;97:370-6.4. Kiesslich R, Burg J, Vieth M, et al. Confocal laser endomicroscopy for diagnosing intraepithelial neoplasias and colorectal cancer in vivo. Gastroenterol 2004;127:707-13.5. Hurlstone DP, Tiffin N, Brown SR, et al. In vivo confocal laser scanning chromo-endomicroscopy of colorectal neoplasia: changing the techno- logical paradigm.