AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points
A rare benign esophageal lesion
An 83-year-old man with asymptomatic iron deficiency anemia was referred for an EGD procedure. Esophagoscopy showed a well-demarcated, shiny, and slightly elevated lattice-like lesion in the mid-esophagus (A–C). Biopsy specimens (D) taken from the esophageal lesion and stained with hematoxylin and eosin showed hyperkeratosis and parakeratotic squamous epithelium with no koilocytosis. The appearance was that of squamous papillomatosis, a rare lesion in Western populations. Although the human papillomavirus has been implicated, no viral particles were detected in this case. No further follow-up is planned.
DISCLOSURE
www.giejournal.org
Volume 80, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 731
All authors disclosed no financial relationships relevant to this article. Rohit Sinha, MBBS, MRCP (Edin) PgDip (London), Department of Gastroenterology, James Cook University Hospital, Middlesborough, United Kingdom, Ursula Earl, BMedSci, MBChB, FRCPath, Department of Histopathology, James Cook University Hospital, Middlesborough, United Kingdom, Arvind Ramadas, MBBS, MRCP (UK), Mike Bramble, MBChB, MD, FRCP (Edin), FRCP (London),
At the Focal Point
Department of Gastroenterology, James Cook University Hospital, Middlesborough, United Kingdom
http://dx.doi.org/10.1016/j.gie.2014.05.306
Commentary Papillomas are seen in many medical specialties, although, with exception of dermatology (common skin wart) and perhaps gynecology (genital warts and squamous papillomatosis of the vulvar vestibule and introitus), these lesions are not very common: ENT and pulmonary (laryngeal/recurrent respiratory papillomatosis), ophthalmology (conjunctival papilloma), gastroenterology (esophageal papilloma), and proctology (anal condylomata acuminata, Buschke-Lowenstein lesion). Although some lesions are clearly associated with human papillomavirus (HPV), causation by HPV in others is controversial. For the gastroenterologist/endoscopist, papillomas are uncommon growths that are usually incidental. In Western populations, most are solitary lesions found in the distal esophagus of middle-aged men and are believed to be a hyper-regenerative response of the mucosa to chemical or mechanical irritation, such as gastroesophageal reflux. In Japan, however, where there is a high incidence of chronic gastritis and reflux esophagitis is not seen to the same extent as in other populations, papillomas more frequently are seen in younger women, are mid-esophageal, and have a higher relative frequency of HPV causation. Esophageal papillomas are classified microscopically into 3 types based on the predominant shape of the lesion: exophytic, endophytic, and spiked; their histologic characteristics are an acanthotic stratified squamous epithelium, intraepithelial capillary loops, and koilocytosis (from the Greek word koilos meaning a hollow cell), which refers to a cell with a perinuclear “halo” surrounded by a rim of cytoplasm that is associated with HPV infection. To what extent HPV infection contributes to esophageal papilloma is controversial, with a reported range of 0% to 64%. In this case, we have another variation on the theme: a nonpolypoid lattice-work pattern. The term lattice, regardless of whether referring to framework, a small opening in a window, or a crystallographic pattern, connotes a crossing of parallel lines with another series at a diagonal angle, forming a network with openings between the lines. The precise explanation of the latticework pattern of this papillomatous lesion is unclear, and its cause is unknown. See the pattern, recognize it for what it is, and realize that nothing is as mysterious as something clearly seen. Lawrence J. Brandt, MD Associate Editor for Focal Points
A tale of 2 capsules: retained capsule diagnosed by capsule endoscopy A 39-year-old man with familial adenomatous polyposis and a history of total colectomy with ileoanal anastomosis was referred for videocapsule endoscopy (VCE) to define the burden of small-bowel polyposis. He had undergone VCE 6 months earlier at an outside facility, the report of which was unavailable. In addition to mild small-bowel polyposis, images retrieved by the current capsule showed a retained capsule device in association with a stricture (A). A plain X-ray film of the abdomen performed 2 weeks later confirmed the presence of 2 retained capsules (B). Upon per anal enteroscopy with a pediatric colonoscope, a moderately severe stricture (lumen about 7–8 mm) was encountered at about 40 cm from the anal verge. The 2 capsule devices were identified through the stenotic lumen (C). The stricture was balloon dilated by use of a multisized through-the-scope balloon to 12 mm, and both capsules were able to be retrieved with a retrieval net (D). A surgical
732 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 4 : 2014
staple was seen at the proximal aspect of the stricture, suggesting that the patient had previously undergone smallbowel resection as well. This was confirmed from a review of additional medical records obtained after the endoscopy. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Sumanth R. Daram, MD, Division of Gastroenterology and Hepatology, Medical College of Georgia/Georgia Regents University, Augusta, Georgia, USA, Rajesh N. Keswani, MD, Srinadh Komanduri, MD, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA http://dx.doi.org/10.1016/j.gie.2014.06.022
www.giejournal.org
A rare benign esophageal lesion
An 83-year-old man with asymptomatic iron deficiency anemia was referred for an EGD procedure. Esophagoscopy showed a well-demarcated, shiny, and slightly elevated lattice-like lesion in the mid-esophagus (A–C). Biopsy specimens (D) taken from the esophageal lesion and stained with hematoxylin and eosin showed hyperkeratosis and parakeratotic squamous epithelium with no koilocytosis. The appearance was that of squamous papillomatosis, a rare lesion in Western populations. Although the human papillomavirus has been implicated, no viral particles were detected in this case. No further follow-up is planned.
DISCLOSURE
www.giejournal.org
Volume 80, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 731
All authors disclosed no financial relationships relevant to this article. Rohit Sinha, MBBS, MRCP (Edin) PgDip (London), Department of Gastroenterology, James Cook University Hospital, Middlesborough, United Kingdom, Ursula Earl, BMedSci, MBChB, FRCPath, Department of Histopathology, James Cook University Hospital, Middlesborough, United Kingdom, Arvind Ramadas, MBBS, MRCP (UK), Mike Bramble, MBChB, MD, FRCP (Edin), FRCP (London),
At the Focal Point
Department of Gastroenterology, James Cook University Hospital, Middlesborough, United Kingdom
http://dx.doi.org/10.1016/j.gie.2014.05.306
Commentary Papillomas are seen in many medical specialties, although, with exception of dermatology (common skin wart) and perhaps gynecology (genital warts and squamous papillomatosis of the vulvar vestibule and introitus), these lesions are not very common: ENT and pulmonary (laryngeal/recurrent respiratory papillomatosis), ophthalmology (conjunctival papilloma), gastroenterology (esophageal papilloma), and proctology (anal condylomata acuminata, Buschke-Lowenstein lesion). Although some lesions are clearly associated with human papillomavirus (HPV), causation by HPV in others is controversial. For the gastroenterologist/endoscopist, papillomas are uncommon growths that are usually incidental. In Western populations, most are solitary lesions found in the distal esophagus of middle-aged men and are believed to be a hyper-regenerative response of the mucosa to chemical or mechanical irritation, such as gastroesophageal reflux. In Japan, however, where there is a high incidence of chronic gastritis and reflux esophagitis is not seen to the same extent as in other populations, papillomas more frequently are seen in younger women, are mid-esophageal, and have a higher relative frequency of HPV causation. Esophageal papillomas are classified microscopically into 3 types based on the predominant shape of the lesion: exophytic, endophytic, and spiked; their histologic characteristics are an acanthotic stratified squamous epithelium, intraepithelial capillary loops, and koilocytosis (from the Greek word koilos meaning a hollow cell), which refers to a cell with a perinuclear “halo” surrounded by a rim of cytoplasm that is associated with HPV infection. To what extent HPV infection contributes to esophageal papilloma is controversial, with a reported range of 0% to 64%. In this case, we have another variation on the theme: a nonpolypoid lattice-work pattern. The term lattice, regardless of whether referring to framework, a small opening in a window, or a crystallographic pattern, connotes a crossing of parallel lines with another series at a diagonal angle, forming a network with openings between the lines. The precise explanation of the latticework pattern of this papillomatous lesion is unclear, and its cause is unknown. See the pattern, recognize it for what it is, and realize that nothing is as mysterious as something clearly seen. Lawrence J. Brandt, MD Associate Editor for Focal Points
A tale of 2 capsules: retained capsule diagnosed by capsule endoscopy A 39-year-old man with familial adenomatous polyposis and a history of total colectomy with ileoanal anastomosis was referred for videocapsule endoscopy (VCE) to define the burden of small-bowel polyposis. He had undergone VCE 6 months earlier at an outside facility, the report of which was unavailable. In addition to mild small-bowel polyposis, images retrieved by the current capsule showed a retained capsule device in association with a stricture (A). A plain X-ray film of the abdomen performed 2 weeks later confirmed the presence of 2 retained capsules (B). Upon per anal enteroscopy with a pediatric colonoscope, a moderately severe stricture (lumen about 7–8 mm) was encountered at about 40 cm from the anal verge. The 2 capsule devices were identified through the stenotic lumen (C). The stricture was balloon dilated by use of a multisized through-the-scope balloon to 12 mm, and both capsules were able to be retrieved with a retrieval net (D). A surgical
732 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 4 : 2014
staple was seen at the proximal aspect of the stricture, suggesting that the patient had previously undergone smallbowel resection as well. This was confirmed from a review of additional medical records obtained after the endoscopy. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Sumanth R. Daram, MD, Division of Gastroenterology and Hepatology, Medical College of Georgia/Georgia Regents University, Augusta, Georgia, USA, Rajesh N. Keswani, MD, Srinadh Komanduri, MD, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA http://dx.doi.org/10.1016/j.gie.2014.06.022
www.giejournal.org
