spider nevi in liver cirrhosis: capiallary, microscopical and hormonal investigations. Klin Wochenschr 1988;66:298-302. 9. Rabinovitz M, Schade RR, Dindzans VJ, Belle SH, Van Thiel DH, Gavaler JS. Colonic disease in cirrhosis. An endoscopic evaluation in 412 patients. Gastroenterology 1990;99:195-9. 10. Kozarek RA, Botoman VA, Bredfeldt JE, Roach JM, Patterson DJ, Ball TJ Portal colopathy: prospective study of colonoscopy in patients with portal hypertension (PH) [Abstract). Gastroenterology 1990;98:A599.
A new twist to situs inversus To the Editor:
Figure 1. Colonoscopic view showing vascular lesion with the appearance of an arterial spider.
etiopathogenesis of GAVE and arterial spiders appear to be different. s To the best of our knowledge, no specific patterns have been described in the colonic mucosa of cirrhotic patients. In a recent report of a large series of colonoscopies in cirrhotics, a high prevalence of polyps and varices was reported. 9 Kozarek et al. 10 recently described the existence of a portal colopathy which consisted of ulcerations and telangiectasias. Our case suggests that the colonic mucosa of cirrhotic patients can exhibit microvascular abnormality as arterial spiders. Further studies should be focused on the frequence of this lesion and its eventual association with other lesions such as skin spiders and/or GAVE. Paul Cales, Jean Louis Payen, Paul Berg, Jean Pierre Pascal,
Transposition of thoracic and abdominal viscera rarely occurs. Situs inversus has been the subject of many reviews and case reports because of its rarity. Some of the gastrointestinal problems described include duodenal ulcer perforation, cholecystitis requiring cholecystectomy, liver transplantation for biliary atresia, and choledocholithiasis necessitating ERCP and papillotomy.1-4 We add a new "twist" to the situs inversus literature by reporting the placement of a bile duct endoprosthesis for relief of an obstructing bile duct stricture. A 65-year-old man with known chronic pancreatitis underwent ERCP for abdominal pain and bile duct dilation. Unlike previous reports of endoscopy in patients with situs inversus,4 we successfully intubated the duodenum with the patient lying on his left side. Cannulation of the ampulla was performed in the standard fashion. The cholangiogram was, as one would expect, in the reverse position. There was a distal common duct narrowing from chronic pancreatitis. Following a limited sphincterotomy, a 9-cm, 10 F Amster-
MD MD MD MD
Service d'Hepato-Gastroenterologle Centre Haspltalier Unlversltalre Purpan Toulouse, France
REFERENCES 1. Bean WB. The cutaneous arterial spider: a survey. Medicine 1945;24:244-331.
2. Berthelot P, Walker JG, Sherlock S, et al. Arterial changes in the lungs in cirrhosis of the liver-lung spider nevi. N Engl J Moo 1966;274:291--8. . 3. Sherlock S. Spiders and capillaries. Hepatology 1989;3:388-94.
4. Koivisto PVI. Gastric antral vascular ectasia and primary biliary cirrhosis. Endoscopy 1988;20:334. 5. Borsch G, Schafer K, Schmidt G, Menne R, TiOOjen KU. Ectasie vasculaire antrale diffuse: cause rare d'hemorragie gastrointestinale severe. Acta Endosc 1985;3:239-43. 6. Weaver GA, Alpern HD, Davis JS, Rantsey WH, Reichelderfer M. Gastrointestinal angiodysplasia associated with aortic valve disease: part of a spectrum of angiodysplasia of the gut. Gastroenterology 1979;77:1-11. 7. Van Vliet ACM, Ten Kate FJW, Dees J, Van Blankenstein M. Abnormal blood vessels of the prepyloric antrum in cirrhosis of the liver as a cause of chronic gastrointestinal bleeding. Endos- copy 1978;10:89-94. 8. Pirovino M, Linder R, Boss C, Kochli HP, Mahler F. Cutaneous
1590
Figure 1. ERCP demonstrating bile duct endoprosthesls in situs Inversus (oblique view).
GASTROINTESTINAL ENDOSCOPY
dam stent was placed (Wilson-Cook Medical Inc., WinstonSalem, N. C.) (Fig. 1). Common gastrointestinal problems may affect any person regardless of their anatomical arrangement. And even with situs inversus, therapeutic biliary endoscopy is still possible.
Service de Pathologie Digestive Hopital d'lnstruction des Armees BEGIN St. Mande, France
Richard G. Mitchell, MD John H. Gilliam III, MD Robert M. Kerr, MD
1. Chi PS, Adams WE. Benign tumors of the esophagus. Arch Surg 1950;60:92-101.
Bowman Gray School of Medicine Gastroenterology Winston-Salem, North Carolina
REFERENCES 1. Ghandi DM, Warty PP, Pinto AC, Shetty SV. Perforated
duodenal ulcer with dextrocardia with situs inversus. J Postgrad Med 1986;31:45-6. 2. McFarland SB. Situs inversus with cholelithiasis: a case report. J Tenn Med Assoc 1989;82:69-70. 3. Raynor SC, Wood RP, Spanta AD, Shaw BW. Liver transplantation in a patient with abdominal situs inversus. Transplantation 1988;45:661-3. 4. Nordback I, Airo I. ERCP and endoscopic papillotomy in complete situs inversus. Gastrointes Endosc 1988;34:150.
Spontaneous partial elimination of a carcinoma of the esophagus
G. Grandpierre, MD J. Vindrios, MD
REFERENCES 2. Tannen NL. Tumors of the esophagus. Edinburg: Churchill Livingstone, 1961. 3. Stout AP, and Lattes R. Tumors of the esophagus. Section V. Fasicle 20. Atlas of tumor pathology. Washington DC: Armed Forces Institute of Pathology, 1957. 4. Allen MS, Talbot WHo Sudden death due to regurgitation of a pedunculated esophageal lipoma. J Thorac Cardiovasc Surg 1967;54:756-8.
5. Cochet B, Hohl P, Sans M, Cox IN. Asphyxia caused by laryngeal impaction of an esophageal polyp. Arch Otolaryngol 1980;106:176-8.
Abstracts ENDOSCOPY AROUND THE WORLD
Editor for Abstracts, James Barthel, MD
To the Editor: Pedunculated tumors of the esophagus are rare, and malignant tumors even rarer. We present an unusual case of pedunculated carcinoma of the esophagus. A 36-year-old man presented with weight loss, fever, and dysphagia. He had a history of heavy alcohol and tobacco use. Fiberoptic esophagoscopy showed a pedunculated tumor of the middle part of the esophagus obstructing the lumen; three biopsies were taken and showed only necrotic tissue and intense inflammation. The patient noticed a marked and sudden improvement of his dysphagia 13 days after the initial endoscopy. A second endoscopy showed the disappearance of the bulk of the tumor, with a remaining small nodule and esophageal infiltration. Biopsies of the lesion were consistent with well-differentiated epidermoid carcinoma. The disappearance of the tumor mass was radiologically confirmed by barium x-ray study. The patient underwent a thoraco-abdominal esophagectomy with an esophagogastric anastomosis and pyloroplasty. One year later he died from diffuse metastatic disease of the lungs, liver, and skin. Three points should be emphasized: (1) Pedunculated tumors of the esophagus represent 0.5 to 1% of esophageal tumors. They have a polypoid appearance and are almost always benign.! (2) Benign or malignant, these tumors are usually of mesenchymal origin, 2 but a particular form of a carcinoma, that may be pedunculated, contains fusiform cells giving a "pseudo-sarcoma" appearance. 3 (3) Spontaneous loss of a polypoid tumor is very rare, but dramatic complications were reported with asphyxiation following regurgitation,4.5 Thus, endoscopic removal is useful to confirm benign histology and to prevent mechanical complications. B. Vergeau, MD C. MoUnie, MD
VOLUME 37, NO.5, 1991
Panel of Reviewers Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt David R. Cave Sarkis J. Chobanian Kenneth A. Forde Lionello Gandolfi David Y. Graham Richard H. Hunt Richard A. Kozarek
Glenn A. Lehman Finlay Macrae Zdenek Maratka Steven A. McClave Mark H. Mellow Giorgio Minoli Ben Novis John F. Reinus Walter L. Trudeau Richard A. Wright
Small bowel enteroscopy and intraoperative enteroscopy for obscure gastrointestinal bleeding LEWIS BS, WENGER JS, WAYE JD Am J GastroenteroI1991;86:171-4
This study retrospectively evaluated 23 patients with obscure gastrointestinal bleeding who underwent small bowel enteroscopy (SBE) and subsequent intraoperative enteroscopy (IOE). All patients had gastrointestinal blood loss averaging 2 years in duration, an average transfusion requirement of 27 units and negative workup including colonoscopy, upper endoscopy, gastrointestinal series, and barium enema. SBE was performed transnasally with the Olympus SIFSW small bowel enteroscope (Gastrointest Endosc 1987;33:435-8) and IOE was performed with an adult pediatric colonoscope during exploratory laparotomy. The average time span between enteroscopy and intraoperative endoscopy was 96.5 days (range, 2 days to 19 months). 591
A new twist to situs inversus To the Editor:
Figure 1. Colonoscopic view showing vascular lesion with the appearance of an arterial spider.
etiopathogenesis of GAVE and arterial spiders appear to be different. s To the best of our knowledge, no specific patterns have been described in the colonic mucosa of cirrhotic patients. In a recent report of a large series of colonoscopies in cirrhotics, a high prevalence of polyps and varices was reported. 9 Kozarek et al. 10 recently described the existence of a portal colopathy which consisted of ulcerations and telangiectasias. Our case suggests that the colonic mucosa of cirrhotic patients can exhibit microvascular abnormality as arterial spiders. Further studies should be focused on the frequence of this lesion and its eventual association with other lesions such as skin spiders and/or GAVE. Paul Cales, Jean Louis Payen, Paul Berg, Jean Pierre Pascal,
Transposition of thoracic and abdominal viscera rarely occurs. Situs inversus has been the subject of many reviews and case reports because of its rarity. Some of the gastrointestinal problems described include duodenal ulcer perforation, cholecystitis requiring cholecystectomy, liver transplantation for biliary atresia, and choledocholithiasis necessitating ERCP and papillotomy.1-4 We add a new "twist" to the situs inversus literature by reporting the placement of a bile duct endoprosthesis for relief of an obstructing bile duct stricture. A 65-year-old man with known chronic pancreatitis underwent ERCP for abdominal pain and bile duct dilation. Unlike previous reports of endoscopy in patients with situs inversus,4 we successfully intubated the duodenum with the patient lying on his left side. Cannulation of the ampulla was performed in the standard fashion. The cholangiogram was, as one would expect, in the reverse position. There was a distal common duct narrowing from chronic pancreatitis. Following a limited sphincterotomy, a 9-cm, 10 F Amster-
MD MD MD MD
Service d'Hepato-Gastroenterologle Centre Haspltalier Unlversltalre Purpan Toulouse, France
REFERENCES 1. Bean WB. The cutaneous arterial spider: a survey. Medicine 1945;24:244-331.
2. Berthelot P, Walker JG, Sherlock S, et al. Arterial changes in the lungs in cirrhosis of the liver-lung spider nevi. N Engl J Moo 1966;274:291--8. . 3. Sherlock S. Spiders and capillaries. Hepatology 1989;3:388-94.
4. Koivisto PVI. Gastric antral vascular ectasia and primary biliary cirrhosis. Endoscopy 1988;20:334. 5. Borsch G, Schafer K, Schmidt G, Menne R, TiOOjen KU. Ectasie vasculaire antrale diffuse: cause rare d'hemorragie gastrointestinale severe. Acta Endosc 1985;3:239-43. 6. Weaver GA, Alpern HD, Davis JS, Rantsey WH, Reichelderfer M. Gastrointestinal angiodysplasia associated with aortic valve disease: part of a spectrum of angiodysplasia of the gut. Gastroenterology 1979;77:1-11. 7. Van Vliet ACM, Ten Kate FJW, Dees J, Van Blankenstein M. Abnormal blood vessels of the prepyloric antrum in cirrhosis of the liver as a cause of chronic gastrointestinal bleeding. Endos- copy 1978;10:89-94. 8. Pirovino M, Linder R, Boss C, Kochli HP, Mahler F. Cutaneous
1590
Figure 1. ERCP demonstrating bile duct endoprosthesls in situs Inversus (oblique view).
GASTROINTESTINAL ENDOSCOPY
dam stent was placed (Wilson-Cook Medical Inc., WinstonSalem, N. C.) (Fig. 1). Common gastrointestinal problems may affect any person regardless of their anatomical arrangement. And even with situs inversus, therapeutic biliary endoscopy is still possible.
Service de Pathologie Digestive Hopital d'lnstruction des Armees BEGIN St. Mande, France
Richard G. Mitchell, MD John H. Gilliam III, MD Robert M. Kerr, MD
1. Chi PS, Adams WE. Benign tumors of the esophagus. Arch Surg 1950;60:92-101.
Bowman Gray School of Medicine Gastroenterology Winston-Salem, North Carolina
REFERENCES 1. Ghandi DM, Warty PP, Pinto AC, Shetty SV. Perforated
duodenal ulcer with dextrocardia with situs inversus. J Postgrad Med 1986;31:45-6. 2. McFarland SB. Situs inversus with cholelithiasis: a case report. J Tenn Med Assoc 1989;82:69-70. 3. Raynor SC, Wood RP, Spanta AD, Shaw BW. Liver transplantation in a patient with abdominal situs inversus. Transplantation 1988;45:661-3. 4. Nordback I, Airo I. ERCP and endoscopic papillotomy in complete situs inversus. Gastrointes Endosc 1988;34:150.
Spontaneous partial elimination of a carcinoma of the esophagus
G. Grandpierre, MD J. Vindrios, MD
REFERENCES 2. Tannen NL. Tumors of the esophagus. Edinburg: Churchill Livingstone, 1961. 3. Stout AP, and Lattes R. Tumors of the esophagus. Section V. Fasicle 20. Atlas of tumor pathology. Washington DC: Armed Forces Institute of Pathology, 1957. 4. Allen MS, Talbot WHo Sudden death due to regurgitation of a pedunculated esophageal lipoma. J Thorac Cardiovasc Surg 1967;54:756-8.
5. Cochet B, Hohl P, Sans M, Cox IN. Asphyxia caused by laryngeal impaction of an esophageal polyp. Arch Otolaryngol 1980;106:176-8.
Abstracts ENDOSCOPY AROUND THE WORLD
Editor for Abstracts, James Barthel, MD
To the Editor: Pedunculated tumors of the esophagus are rare, and malignant tumors even rarer. We present an unusual case of pedunculated carcinoma of the esophagus. A 36-year-old man presented with weight loss, fever, and dysphagia. He had a history of heavy alcohol and tobacco use. Fiberoptic esophagoscopy showed a pedunculated tumor of the middle part of the esophagus obstructing the lumen; three biopsies were taken and showed only necrotic tissue and intense inflammation. The patient noticed a marked and sudden improvement of his dysphagia 13 days after the initial endoscopy. A second endoscopy showed the disappearance of the bulk of the tumor, with a remaining small nodule and esophageal infiltration. Biopsies of the lesion were consistent with well-differentiated epidermoid carcinoma. The disappearance of the tumor mass was radiologically confirmed by barium x-ray study. The patient underwent a thoraco-abdominal esophagectomy with an esophagogastric anastomosis and pyloroplasty. One year later he died from diffuse metastatic disease of the lungs, liver, and skin. Three points should be emphasized: (1) Pedunculated tumors of the esophagus represent 0.5 to 1% of esophageal tumors. They have a polypoid appearance and are almost always benign.! (2) Benign or malignant, these tumors are usually of mesenchymal origin, 2 but a particular form of a carcinoma, that may be pedunculated, contains fusiform cells giving a "pseudo-sarcoma" appearance. 3 (3) Spontaneous loss of a polypoid tumor is very rare, but dramatic complications were reported with asphyxiation following regurgitation,4.5 Thus, endoscopic removal is useful to confirm benign histology and to prevent mechanical complications. B. Vergeau, MD C. MoUnie, MD
VOLUME 37, NO.5, 1991
Panel of Reviewers Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt David R. Cave Sarkis J. Chobanian Kenneth A. Forde Lionello Gandolfi David Y. Graham Richard H. Hunt Richard A. Kozarek
Glenn A. Lehman Finlay Macrae Zdenek Maratka Steven A. McClave Mark H. Mellow Giorgio Minoli Ben Novis John F. Reinus Walter L. Trudeau Richard A. Wright
Small bowel enteroscopy and intraoperative enteroscopy for obscure gastrointestinal bleeding LEWIS BS, WENGER JS, WAYE JD Am J GastroenteroI1991;86:171-4
This study retrospectively evaluated 23 patients with obscure gastrointestinal bleeding who underwent small bowel enteroscopy (SBE) and subsequent intraoperative enteroscopy (IOE). All patients had gastrointestinal blood loss averaging 2 years in duration, an average transfusion requirement of 27 units and negative workup including colonoscopy, upper endoscopy, gastrointestinal series, and barium enema. SBE was performed transnasally with the Olympus SIFSW small bowel enteroscope (Gastrointest Endosc 1987;33:435-8) and IOE was performed with an adult pediatric colonoscope during exploratory laparotomy. The average time span between enteroscopy and intraoperative endoscopy was 96.5 days (range, 2 days to 19 months). 591
