Faculty Bibliography

BACKGROUND: Collagenous colitis is characterized by collagen deposition in the superficial colonic mucosa, beneath the surface epithelium, resulting in chronic nonbloody diarrhea of variable severity. The mucosa generally appears endoscopically normal. METHODS: We report the occurrence of distinctive linear mucosal tears, unassociated with trauma, in 4 patients during diagnostic colonoscopy. The patients' tissue specimens were examined histologically, and clinical courses were recorded. OBSERVATIONS: Recognition of linear 'fractures' was followed in 3 patients by colonic perforation. One patient required colectomy. Severe collagenous colitis was present in all. The resection specimen contained shallow linear ulcers overlying fibrotic submucosa, with pneumatosis and acute peritonitis. CONCLUSIONS: We theorize that the stiffness of the colon in areas of collagenous colitis with submucosal fibrosis makes it susceptible to linear 'fractures' during colonoscopic air insufflation with subsequent transmural air dissection. We urge extreme caution if this lesion is recognized at colonoscopy and recommend aborting the examination and obtaining plain radiographs to detect free intraperitoneal air

Spontaneous intramural hematoma of the esophagus (SIHE) is a rare condition usually affecting middle-aged or elderly women. It presents as acute substernal or epigastric pain, typically accompanied by dysphagia or hematemesis. SIHE is not usually associated with vomiting, and is therefore clearly distinguished from emetogenic esophageal disorders, such as the Mallory-Weiss lesion and the Boerhaave syndrome. The diagnosis has traditionally been made by barium esophagram. Therapy is conservative; a favorable prognosis is the rule. The pathogenesis is in dispute. We present a case of SIHE without a discernible mucosal breach, suggesting a primary intramural bleed as the initiating event. We document the utility of computed tomographic scan and magnetic resonance imaging in the diagnosis of SIHE

Three cases of isolated granulomatous disease of the stomach are reported. Other granulomatous diseases were ruled out on the basis of clinical and histological studies. These cases differ from those previously described in having only mucosal granulomas which were discovered as incidental findings in stomachs removed for peptic ulcers. Perigastric lymph node involvement by granulomas was present in one of three cases

Gastrointestinal bleeding in aortic stenosis is an uncommon condition but when present it is often undiagnosed. The usual radiological proceedures fail to demonstrate the source of bleeding. Mesenteric angiography, however, will identify the lesion. The lesion is usually a vascular malformation located in the right colon. The angiodysplasia may also occur in other parts of the gastrointestinal tract. We have encountered five patients with aortic stenosis who had multiple massive hemorrhages of the lower gastrointestinal tract who defied diagnosis by the conventional methods. Mesenteric angiography, however, disclosed the orgin of the bleeding. In four patients vascular malformations were found in the right colon and one in the jejunum. Right hemicolectomy and partial jejunectomy resulted in a cure in all

Retrograde endoscopic cholangiography is an effective means of evaluating the biliary ductal system. It can provide a nonoperative modality for diagnosing PSC and for assessing the effects of therapeutic interventions on the diameter of the bile ducts.