GOALS:The present survey from the Italian Society of Digestive Endoscopy (SIED-Società Italiana di Endoscopia Digestiva) was aimed at reporting infection control practice and outcomes at Digestive Endoscopy Units in a high-incidence area.BACKGROUND:Lombardy was the Italian region with the highest coronavirus disease-2019 (COVID-19) prevalence, at the end of March 2020 accounting for 20% of all worldwide deaths. Joint Gastro-Intestinal societies released recommendations for Endoscopy Units to reduce the risk of the contagion. However, there are few data from high-prevalence areas on adherence to these recommendations and on their efficacy.METHODS:A survey was designed by the Lombardy section of SIED to analyze (a) changes in activity and organization, (b) adherence to recommendations, (c) rate of health care professionals' (HCP) infection during the COVID-19 outbreak.RESULTS:In total, 35/61 invited centers (57.4%) participated; most modified activities were according to recommendations and had filtering face piece 2/filtering face piece 3 and water-repellent gowns available, but few had negative-pressure rooms or provided telephonic follow-up; 15% of HCPs called in sick and 6% had confirmed COVID-19. There was a trend (P=0.07) toward different confirmed COVID-19 rates among endoscopists (7.9%), nurses (6.6%), intermediate-care technicians (3.4%), and administrative personnel (2.2%). There was no correlation between the rate of sick HCPs and COVID-19 incidence in the provinces and personal protective equipment availability and use, whereas an inverse correlation with hospital volume was found.CONCLUSIONS:Adherence to recommendations was rather good, though a minority were able to follow all recommendations. Confirmed COVID-19 seemed higher among endoscopists and nurses, suggesting that activities in the endoscopy rooms are at considerable viral spread risk.

A 73-year-old Caucasian woman was referred by her GP to the local dermatology service in order to remove a 1.5 cm nodular brownish lesion on her left leg. Pathologic exam revealed diffuse sheets of medium to large sized tumor cells with moderate nuclear pleomorphism limited to dermal-hypodermal layers and immunohistochemistry confirmed the melanocycic nature of this proliferation (positivity for S100 protein, patchy expression of MART1 and HMB45—Fig. 1a), prompting pathologists to consider this lesion as a metastatic melanoma of unknown origin. Extensive investigations performed to detect the primitive tumor excluded the presence of skin, ocular and oral lesions as well as regional or superficial lymphoadenopathies. A 18F-fluorodeoxyglucose PET/CT scan showed an abnormal uptake in the proximal jejunum and a subsequent enteroscopy revealed a big polypoid mass with central brownish depression protruding into the jejunal lumen (Fig. 2). Histology revealed a neoplastic proliferation of epithelioid, focally pigmented cells, identical to those identified in the subcutaneous metastasis and immunohistochemical cells profile was quite similar to that observed in the skin lesion (Fig. 1b), making sure a diagnosis of primary malignant jejunal melanoma. Intestinal resection followed by chemotherapy was considered but, after a second 18F-FDG PET/CT performed two months later and showing cardiac metastasis, the patient refused any aggressive treatment and deceased 4 months later. Fig. 2 View Large Image Figure Viewer Download Hi-res image

DIS 5.4.0 DTD YGAST60423 proof 1 July 2016 10:34 am ce Gastro 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 Question: A 58-yearold man with unremarkable past medical history presented at the emergency department of our hospital for lowgrade fever and dull right lower abdominal pain. On arrival, his abdomen was mildly tender and his body temperature 38.2 C; routine laboratory tests showed leukocytosis (12.7 10/L; 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 normal range, 3.5-10.5 10/L) and increased level of C-reactive protein (2.6 mg/dL; normal range, 0-1). A plain abdominal radiograph was normal; abdominal ultrasonography (US) revealed a moderate thickening of the ileal walls in the right iliac fossa. Empiric ciprofloxacin-based antibiotic therapy was started and the patient was admitted to the gastroenterology ward for further evaluation. As an initial approach, US of the bowel was performed; it revealed, both on longitudinal and crosssectional images, a hypoechoic lesion (10.8 19.8 mm) originating from the inner layers of the terminal ileum (mucosa and submucosa), highly vascularized on Doppler US, conditioning bowel stricture, without significant retrodilation of the ileal lumen (Figure A). Subsequent colonoscopy showed a normal appearance of the entire colonicmucosa but failed to give further information owing to unsuccessful intubation of the ileocecal valve, which was deformed and untraversable. The patient underwent computed tomographic (CT) enterography that confirmed the presence of the highly vascularized solid lesion in the terminal ileum, about 8 cm before the ileocecal valve (Figure B). Multiple abdominal lymphadenopathies were also discovered on CT scanning, as well as swelling of both the adrenal glands and vertebral osteolytic lesions at L4 and L3; a chest CT scan revealed multiple pathologic lymphadenopathies in the mediastinum as well. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.E 100 101 102 103 104 105 106 Conflicts of interest The authors disclose no conflicts.

Background: Chronic constipation is a risk factor of inadequate bowel preparation for colonoscopy; however, no large clinical trials have been performed in this subgroup of patients. Aims: To compare bowel cleansing efficacy, tolerability and acceptability of 2-L polyethylene-glycolcitrate- simethicone (PEG-CS) plus 2-day bisacodyl (reinforced regimen) vs. 4-L PEG in patients with chronic constipation undergoing colonoscopy.Methods: Randomized, observer-blind, parallel group study. Adult outpatients undergoing colonoscopy were randomly allocated to 2-L PEG-CS/bisacodyl or 4-L PEG, taken as split regimens before colonoscopy. Quality of bowel preparation was assessed by the Ottawa Bowel Cleansing Scale (OBCS). The amount of foam/bubble interfering with colonic visualization was also measured.Results: 400 patients were enrolled. There was no significant difference in successful cleansing (OBCS score <= 6): 80.2% in the 2-L PEG-CS/bisacodyl vs. 81.4% in the 4-L PEG group. Significantly more patients taking 2L PEG-CS/bisacodyl showed no or minimal foam/bubbles in all colonic segments (80% vs. 63%; p < 0.001). 2-L PEG-CS/bisacodyl was significantly more acceptable for ease of administration (p < 0.001), willingness to repeat (p < 0.001) and showed better compliance (p = 0.002).Conclusion: Split 2-L PEG-CS plus bisacodyl was not superior to split 4-L PEG for colonoscopy bowel cleansing in patients with chronic constipation; however, it performed better than the standard regimen in terms of colonic mucosa visualization, patient acceptance and compliance. (C) 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background: Colorectal cancer screening may reduce disease-related mortality by early-stage detection of cancers.Aims: To study the effect of a single immunochemical faecal occult blood test (i-FOBt) screening round on reduction in colorectal cancer-related-mortality among average risk subjects.Methods: Comparison of 5-year mortality rates in 3 cohorts from a Northern Italian province: (1) colorectal cancers detected at the 1st biennial round of a mass-screening programme targeting 50-69 years old subjects, (2) non-screening cancers symptomatically diagnosed during the same time period, and (3) cancers detected in the pre-screening biennium. Multivariate analyses were performed with the Cox regression model including tumour node metastasis (TNM) stage at diagnosis, anatomical distribution of cancers, age at diagnosis, gender and patient group. Kaplan-Meyer survival estimates and log-rank test for equality of survivor functions were calculated.Results: Stage distribution significantly differed between screening and non-screening colorectal cancers: 73% of screen-detected colorectal cancers were stages I and II versus 43% and 40% of non-screening and pre-screening colorectal cancers. Cumulative 5-year mortality rate was significantly lower in screening compared to non-screening or pre-screening colorectal cancers patients (19% versus 37% and 41%, p < 0.001).Conclusions: Colorectal cancers were detected at earlier stages in i-FOBT-positive subjects in comparison with non-screening patients; colorectal cancers found at screening had a significantly improved 5-year survival. (C) 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:Adequate bowel preparation prior to colonic diagnostic procedures is essential to ensure adequate visualisation.SCOPE:This consensus aims to provide guidance as to the appropriate use of bowel preparation for a range of defined clinical circumstances. A consensus group from across Europe was convened and met to discuss appropriate bowel preparation. The use of polyethylene glycol (PEG), sodium picosulphate and sodium phosphate (NaP), together with other agents, prokinetics and simethicone, in colonoscopy and small bowel video capsule endoscopy were considered. A systematic review of the literature was carried out and additional unpublished data was obtained from the members of the consensus group where required. Recommendations were graded according to the level of evidence.FINDINGS:PEG-based regimens are recommended first line for both procedures, since their use is supported by good efficacy and safety data. Sodium-picosulphate-based regimens are recommended second line as their cleansing efficacy appears less than PEG-based regimens. NaP is not recommended for bowel cleansing due to the potential for renal damage and other adverse events. However, the use of NaP is acceptable in patients in whom PEG or sodium picosulphate is ineffective or not tolerated. NaP should not be used in patients with chronic kidney disease, pre-existing electrolyte disturbances, congestive heart failure, cirrhosis or a history of hypertension. The timing of the dose, dietary restrictions, use in special patient groups and recording of the quality of bowel preparation are also considered for patients undergoing colonoscopy. During the development of the guidelines the European Society of Gastrointestinal Endoscopy (ESGE) issued guidance on bowel preparation for colonoscopy. The ESGE guidelines and these consensus guidelines share many recommendations; differences between the guidelines are reviewed.CONCLUSION:The use of bowel preparation should be tailored to the individual patient and their specific clinical circumstances.

Objective:It is unclear whether small bowel visibility in video capsule endoscopy (VCE) is enhanced by the use of bowel preparation in addition to pre-procedural fasting. The objective of this study was to clarify this issue by means of a systematic review of the literature and meta-analysis.Methods:Randomised controlled trials comparing the use of laxative bowel preparation with fasting alone were identified using a literature search. Categorical measures of treatment efficacy were extracted from qualifying studies and pooled using random-effects meta-analyses. Primary analysis compared any bowel preparation with fasting alone; subsidiary analyses assessed diagnostic yield and results for each regimen.Results:Eight studies were identified, using either polyethylene glycol (PEG) or sodium phosphate (NaP) based regimens. No qualifying studies were identified using other laxatives. Study quality was sufficiently high to warrant meta-analysis. Use of any form of bowel preparation yielded significantly better visibility than fasting alone (OR = 2.31; 95% CI = 1.46-3.63; p<0.0001). Similar results were seen for diagnostic yield (OR = 1.88; 95% CI = 1.24-2.84; p = 0.023). When sub-analysed according to the treatment used, PEG-based regimens showed benefit (OR = 3.11; 95% CI = 1.96-4.94; p<0.0001), while NaP-based regimens yielded no significant difference from fasting alone (OR = 1.32; 95% CI = 0.59-2.96; p<0.0001).Limitations:The study did not consider results from retrospective studies, nor those which did not give a categorical measure of efficacy. The impact of prokinetic and other adjunctive treatments was not considered. The results are only relevant to the most commonly used video capsule, as data for newer alternative devices have not yet been published.Conclusion:Based on the results of this analysis, the use of bowel preparation alongside fasting is recommended for VCE. PEG-based regimens offer a clear advantage in these patients, while the currently available evidence base does not support the use of NaP. For VCE, lower volume PEG appears to be as efficacious as higher volumes traditionally used for colonoscopy preparation.

Introduction Colonoscopy workload for endoscopy services in Western countries is increasing markedly because of the implementation of faecal occult blood-based mass screening programmes against colorectal cancer (CRC). We therefore explored the possibility of using a combination of faecal tests to prioritize the access to colonoscopy with criteria other than symptoms and/or time of referral. Aims and methods We tested a combination of faecal tests [immunochemical faecal occult blood test (i-FOBT), M2-PK, calprotectin] as markers for advanced neoplasia in a selected series of patients requiring colonoscopy for the suspicion of CRC. All the tests were performed in a 1-day stool sample of patients aged 50–80 years, without any dietary restriction, before colonoscopy. Results A total of 280 patients’ stool single samples were analysed. Forty-seven patients had CRC and 85 patients had one or more advanced adenoma(s) at colonoscopy/histology. CRCs were associated with a highly significant increase (P<0.001) in faecal tumour M2-PK (mean 24.2 kU/l), which correlated with Dukes’ staging. For CRC detection, i-FOBT was the test with the highest specificity and positive predictive value (0.89 and 0.53), whereas M2-PK had the highest sensitivity and negative predictive value (0.87 and 0.96). Calprotectin showed performance similar to M2-PK in terms of sensitivity and negative predictive value (0.93), but had lower specificity (0.39). The best combination of tests to predict the risk of CRC in this series was i-FOBT+M2-PK, as in patients showing positivity to both markers, the risk of cancer was as high as 79%. Conclusion The combination of i-FOBT and M2-PK is a sensitive tool in clinical practice for the appropriate management of waiting lists for colonoscopy, as it allows the classification of patients into different degrees of priority for investigation, according to their foreseeable risk of CRC.

OBJECTIVES:Mucosal healing has been proposed as an important sign of the efficacy of medical treatment of inflammatory bowel disease; however, direct evidence in ulcerative colitis (UC) is scarce. We evaluated the usefulness of colonoscopy and bowel ultrasound (US) as indexes of response to short-term therapy and as predictors of subsequent outcome in UC. METHODS:A total of 83 patients with moderate-to-severe UC were recruited; endoscopic and US severity was graded 0-3 at entry according to validated scores. Of the recruited patients, 74, who were clinically responsive to steroids, were followed up with repeated colonoscopy and bowel US at 3, 9, and 15 months from recruitment. Concordance between clinical, endoscopic, and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of clinical, endoscopic, and US scores measured at 3 and 9 months on the development of endoscopic UC relapse within 15 months. RESULTS:A variable concordance was found over time between endoscopic and clinical score (weighted kappa between 0.38 and 0.95), with high and consistent concordance between endoscopic and US scores (weighted kappa between 0.76 and 0.90). On logistic regression analysis, moderate-to-severe endoscopic and US scores at 3 months were associated with a high risk of endoscopic activity at 15 months (odds ratio (OR): 5.2; 95% confidence interval (CI): 1.6-17.6 and OR: 9.1; 95% CI: 2.5-33.5, respectively). CONCLUSIONS:Bowel US may be used as a surrogate of colonoscopy in assessing the short-term response of severe forms of UC to therapy. Both US score and endoscopic score after 3 months of steroid therapy predict outcome of disease at 15 months.

Worldwide diagnoses of bowel cancer approximate an estimated one million new cases per year, comprising 9% of all cancer cases, and this has continued to increase over the last 25 years. With the association between cancer risk and increasing age, together with the suggestion that by 2015 there will be a 22% increase in the proportion of the population aged over 65 years and a 50% increase in the proportion of people aged over 80 years, there is likely to be a significant increase in the demand on cancer services throughout Europe and the rest of the world. This article discusses the current state of bowel cancer screening within Europe.

The risk for gallstones (GD) in inflammatory bowel diseases and the factors responsible for this complication have not been well established. We studied the incidence of GD in a cohort of Crohn's disease (CD) and ulcerative colitis (UC) patients and investigated the related risk factors. A case-controlled study was carried out. The study population included 634 inflammatory bowel disease (IBD) patients (429 CD, 205 UC) and 634 age-matched, sex-matched, and body mass index (BMI)-matched controls free of GD at enrollment, who were followed for a mean of 7.2 years (range, 5-11 years).The incidence of GD was calculated by dividing the number of events per person-years of follow-up. Multivariatc analysis was used to discriminate among the impact of different variables on the risk of developing GD. The incidence rates of GD were 14-35/1,000 persons/year in CD as compared with 7.75 in matched controls (P = 0.0 12) and 7.48/ 1000 persons/year in UC patients as compared with 6.06 in matched-controls (P = 0.38). lleo-colonic CD location (OR, 2.14), disease duration > 15years (OR, 4.26), > 3 clinical recurrences (OR, 8.07), ileal resection > 30 cm (OR, 7.03), > 3 hospitalizations (OR, 20.7), multiple TPN treatments (OR, 8.07), and long hospital stay (OR, 24.8) were significantly related to GD in CD patients. Conclusion: Only CD patients have a significantly higher risk of developing GD than well-matched hospital controls. Site of disease at diagnosis, lifetime surgery, extent of ileal resections, number of clinical recurrences, TPN, and the frequency and duration of hospitalizations are independently associated with GD.

Porro, Gabriele Bianchi; Parente, FabrizioEditor(s): Porro, Gabriele Bianchi; Parente, Fabrizio Author Information

During the last two decades the general availability of high resolution ultrasound has greatly improved the diagnostic potential of ultrasound in the assessment of inflammatory bowel disease (IBD). This technique has proved to be useful as a screening imaging modality in patients with symptoms or clinical signs that strongly indicate an inflammatory bowel disorder as well as for assessing the anatomical extension of Crohn's disease (CD) lesions at primary diagnosis. Another important indication is the follow-up of patients who are already known to have CD. Here, the technique may play a key role in the detection of luminal and mesentery complications or for the evaluation of disease extension during a clinical flare-up of both CD and ulcerative colitis. By contrast, the role of bowel ultrasound in the assessment of disease activity is limited so far, even though colour Doppler flow imaging may, perhaps, help to differentiate inflammatory from fibrotic intestinal strictures. New ultrasound technologies, such as those using oral and intravenous contrast agents, will probably further increase the diagnostic capability of ultrasound in this context, thus radically changing the diagnostic approach to IBD in the near future.

AIMTo prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODSAll patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTSStudy population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSIONEndoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Question: An 18-year-old man presented to the emergency department because of a 48-hour history of abdominal pain, nausea, and fever. Prior medical history was unremarkable. On examination, he appeared uncomfortable, febrile (39.2°C), with stable vital signs. No oral lesions or abnormal lymph node enlargement was found. The abdomen was slightly distended with active bowel sounds in all 4 quadrants; on palpation, there was diffuse tenderness without guarding or rebound, and a deep painful mass was found in the right iliaca fossa. Digital rectal examination was notable for brown stool that tested negative for blood. The white blood cell count was 12,500/mm3 (normal 5000–10,000/mm3) with 86% neutrophils. C-reactive protein was 5.5 mg/dL (0–1 mg/dL), and erythrocyte sedimentation rate was 52 mm/h (1–7 mm/h). Serum electrolytes, biochemical tests of renal and liver function, and coagulation tests were within normal limits. Chest radiograph on admission was normal, whereas plain radiographs of the abdomen revealed some air levels in the small intestine. Abdominal ultrasound (US) demonstrated marked bowel wall thickening of the terminal ileum and cecum, with an hypoechoic echopattern and fibrofatty proliferation of the surrounding mesentery. Figure A shows the symmetric thickening of the terminal ileal walls at longitudinal (left) and transverse (right) US section. Stool studies performed during hospitalization, including cultures and analyses for ova and parasites (3 samples), were negative as well as were blood cultures and testing for human immunodeficiency virus (HIV). Small bowel enema revealed significant disease of the terminal ileum with narrowing of the lumen but no obstruction. Figure B shows the radiograph of the patient with loss of the normal mucosal pattern and with a cobblestoned appearance of the terminal ileum. Colonoscopy disclosed a normal colon apart from multiple nodules with scattered shallow ulcers in the cecum and a deformation of the ileocecal valve, which could not be traversed by the endoscope. Multiple biopsy specimens were taken from the cecum.What is the most likely diagnosis?Look on page 368 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Image of the Month. View Large Image Figure ViewerDownload Hi-res image Download (PPT)Answer to the Image of the Month Question (page 8): Ileocecal Burkitt’s LymphomaThe patient had an ileocecal Burkitt’s lymphoma. Histopathologic evaluation of cecal biopsy specimens disclosed sheets of monotonous round cells diffusely infiltrating the lamina propria between intestinal glands with interspersed “starry sky” macrophages typical of Burkitt’s lymphoma (Figure C; H&E, original magnification 600×). The germinal center origin of neoplastic B-cell lymphocytes was demonstrated at immunohistochemical staining (Figure D, panel a; IHC for CD10, immunoperoxidase stain, original magnification 600×) as well as their high (>99%) proliferative rate (Figure D, panel b; IHC for Ki67, immunoperoxidase stain, original magnification 400×).Non HIV-associated Burkitt’s lymphoma is a highly aggressive malignant monoclonal B-cell lymphoma that presents in either an endemic form, observed in Africa, or a sporadic form; despite being a quite rare neoplasm (2–3 cases per million/per year), the sporadic form accounts for most of childhood gastrointestinal lymphomas observed in Western countries.1Takahashi H. Hansmann M.-L. Primary gastrointestinal lymphoma in childhood (up to 18 years of age). A morphological, immunohistochemical and clinical study.Cancer Res Clin Oncol. 1990; 116: 190-196Crossref PubMed Scopus (18) Google Scholar It commonly presents in the abdomen, often involving the distal ileum, cecum and mesentery, or both, in contrast to the endemic form, which is virtually always associated with Epstein-Barr virus infection and mainly involves the jaw, orbit, paraspinal regions, and gonads.2Bethel C. Bhattacharyya N. Hutchinson C. Ruymann F. Cooney D. Alimentary tract malignancy in children.J Pediatr Surg. 1997; 32: 1004-1009Abstract Full Text PDF PubMed Scopus (96) Google Scholar Clinical presentation of sporadic forms usually includes recurrent abdominal pain, anorexia, weight loss, abdominal mass, and bowel obstruction, whereas an acute abdomen, as described in this case, is far less frequent.3DiSario J.A. Burt R.W. Vargas H. McWhorter W.P. Small bowel cancer epidemiological and clinical characteristics from a population-based registry.Am J Gastroenterol. 1994; 89: 699-701PubMed Google ScholarBowel US, barium enteroclysis, and endoscopy are helpful in determining the site of the lesion but are not diagnostic for lymphoma because features are nonspecific (as in our case where they included ulcers, nodules, and polyps) and indistinguishable from those occurring in inflammatory or infectious conditions (such as Crohn’s disease or intestinal tuberculosis).Burkitt’s lymphoma is rapidly fatal without treatment, but it usually responds well to the institution of aggressive chemotherapy, which is currently tailored to the amount of disease (localized versus disseminated disease). Intensive combination chemotherapy, such as intravenous cyclophosphamide, vincristine, doxorubicin, methotrexate with cytarabine intrathecal prophylaxis (CODOX-M) alternated with IVAC (intravenous ifosfamide, etoposide, and cytarabine), in 3–4 cycles produces a satisfactory response in 60%–80% of low-risk patients (i.e., those with localized disease, as the patient presented here) with a high chance of long-term survival.4Bishop P.C. Rao V.K. Wilson W.H. Burkitt’s lymphoma molecular pathogenesis and treatment.Cancer Invest. 2000; 18: 574-583Crossref PubMed Scopus (71) Google Scholar View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Question: An 18-year-old man presented to the emergency department because of a 48-hour history of abdominal pain, nausea, and fever. Prior medical history was unremarkable. On examination, he appeared uncomfortable, febrile (39.2°C), with stable vital signs. No oral lesions or abnormal lymph node enlargement was found. The abdomen was slightly distended with active bowel sounds in all 4 quadrants; on palpation, there was diffuse tenderness without guarding or rebound, and a deep painful mass was found in the right iliaca fossa. Digital rectal examination was notable for brown stool that tested negative for blood. The white blood cell count was 12,500/mm3 (normal 5000–10,000/mm3) with 86% neutrophils. C-reactive protein was 5.5 mg/dL (0–1 mg/dL), and erythrocyte sedimentation rate was 52 mm/h (1–7 mm/h). Serum electrolytes, biochemical tests of renal and liver function, and coagulation tests were within normal limits. Chest radiograph on admission was normal, whereas plain radiographs of the abdomen revealed some air levels in the small intestine. Abdominal ultrasound (US) demonstrated marked bowel wall thickening of the terminal ileum and cecum, with an hypoechoic echopattern and fibrofatty proliferation of the surrounding mesentery. Figure A shows the symmetric thickening of the terminal ileal walls at longitudinal (left) and transverse (right) US section. Stool studies performed during hospitalization, including cultures and analyses for ova and parasites (3 samples), were negative as well as were blood cultures and testing for human immunodeficiency virus (HIV). Small bowel enema revealed significant disease of the terminal ileum with narrowing of the lumen but no obstruction. Figure B shows the radiograph of the patient with loss of the normal mucosal pattern and with a cobblestoned appearance of the terminal ileum. Colonoscopy disclosed a normal colon apart from multiple nodules with scattered shallow ulcers in the cecum and a deformation of the ileocecal valve, which could not be traversed by the endoscope. Multiple biopsy specimens were taken from the cecum. What is the most likely diagnosis? Look on page 368 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Image of the Month. Answer to the Image of the Month Question (page 8): Ileocecal Burkitt’s LymphomaThe patient had an ileocecal Burkitt’s lymphoma. Histopathologic evaluation of cecal biopsy specimens disclosed sheets of monotonous round cells diffusely infiltrating the lamina propria between intestinal glands with interspersed “starry sky” macrophages typical of Burkitt’s lymphoma (Figure C; H&E, original magnification 600×). The germinal center origin of neoplastic B-cell lymphocytes was demonstrated at immunohistochemical staining (Figure D, panel a; IHC for CD10, immunoperoxidase stain, original magnification 600×) as well as their high (>99%) proliferative rate (Figure D, panel b; IHC for Ki67, immunoperoxidase stain, original magnification 400×).Non HIV-associated Burkitt’s lymphoma is a highly aggressive malignant monoclonal B-cell lymphoma that presents in either an endemic form, observed in Africa, or a sporadic form; despite being a quite rare neoplasm (2–3 cases per million/per year), the sporadic form accounts for most of childhood gastrointestinal lymphomas observed in Western countries.1Takahashi H. Hansmann M.-L. Primary gastrointestinal lymphoma in childhood (up to 18 years of age). A morphological, immunohistochemical and clinical study.Cancer Res Clin Oncol. 1990; 116: 190-196Crossref PubMed Scopus (18) Google Scholar It commonly presents in the abdomen, often involving the distal ileum, cecum and mesentery, or both, in contrast to the endemic form, which is virtually always associated with Epstein-Barr virus infection and mainly involves the jaw, orbit, paraspinal regions, and gonads.2Bethel C. Bhattacharyya N. Hutchinson C. Ruymann F. Cooney D. Alimentary tract malignancy in children.J Pediatr Surg. 1997; 32: 1004-1009Abstract Full Text PDF PubMed Scopus (96) Google Scholar Clinical presentation of sporadic forms usually includes recurrent abdominal pain, anorexia, weight loss, abdominal mass, and bowel obstruction, whereas an acute abdomen, as described in this case, is far less frequent.3DiSario J.A. Burt R.W. Vargas H. McWhorter W.P. Small bowel cancer epidemiological and clinical characteristics from a population-based registry.Am J Gastroenterol. 1994; 89: 699-701PubMed Google ScholarBowel US, barium enteroclysis, and endoscopy are helpful in determining the site of the lesion but are not diagnostic for lymphoma because features are nonspecific (as in our case where they included ulcers, nodules, and polyps) and indistinguishable from those occurring in inflammatory or infectious conditions (such as Crohn’s disease or intestinal tuberculosis).Burkitt’s lymphoma is rapidly fatal without treatment, but it usually responds well to the institution of aggressive chemotherapy, which is currently tailored to the amount of disease (localized versus disseminated disease). Intensive combination chemotherapy, such as intravenous cyclophosphamide, vincristine, doxorubicin, methotrexate with cytarabine intrathecal prophylaxis (CODOX-M) alternated with IVAC (intravenous ifosfamide, etoposide, and cytarabine), in 3–4 cycles produces a satisfactory response in 60%–80% of low-risk patients (i.e., those with localized disease, as the patient presented here) with a high chance of long-term survival.4Bishop P.C. Rao V.K. Wilson W.H. Burkitt’s lymphoma molecular pathogenesis and treatment.Cancer Invest. 2000; 18: 574-583Crossref PubMed Scopus (71) Google Scholar View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient had an ileocecal Burkitt’s lymphoma. Histopathologic evaluation of cecal biopsy specimens disclosed sheets of monotonous round cells diffusely infiltrating the lamina propria between intestinal glands with interspersed “starry sky” macrophages typical of Burkitt’s lymphoma (Figure C; H&E, original magnification 600×). The germinal center origin of neoplastic B-cell lymphocytes was demonstrated at immunohistochemical staining (Figure D, panel a; IHC for CD10, immunoperoxidase stain, original magnification 600×) as well as their high (>99%) proliferative rate (Figure D, panel b; IHC for Ki67, immunoperoxidase stain, original magnification 400×). Non HIV-associated Burkitt’s lymphoma is a highly aggressive malignant monoclonal B-cell lymphoma that presents in either an endemic form, observed in Africa, or a sporadic form; despite being a quite rare neoplasm (2–3 cases per million/per year), the sporadic form accounts for most of childhood gastrointestinal lymphomas observed in Western countries.1Takahashi H. Hansmann M.-L. Primary gastrointestinal lymphoma in childhood (up to 18 years of age). A morphological, immunohistochemical and clinical study.Cancer Res Clin Oncol. 1990; 116: 190-196Crossref PubMed Scopus (18) Google Scholar It commonly presents in the abdomen, often involving the distal ileum, cecum and mesentery, or both, in contrast to the endemic form, which is virtually always associated with Epstein-Barr virus infection and mainly involves the jaw, orbit, paraspinal regions, and gonads.2Bethel C. Bhattacharyya N. Hutchinson C. Ruymann F. Cooney D. Alimentary tract malignancy in children.J Pediatr Surg. 1997; 32: 1004-1009Abstract Full Text PDF PubMed Scopus (96) Google Scholar Clinical presentation of sporadic forms usually includes recurrent abdominal pain, anorexia, weight loss, abdominal mass, and bowel obstruction, whereas an acute abdomen, as described in this case, is far less frequent.3DiSario J.A. Burt R.W. Vargas H. McWhorter W.P. Small bowel cancer epidemiological and clinical characteristics from a population-based registry.Am J Gastroenterol. 1994; 89: 699-701PubMed Google Scholar Bowel US, barium enteroclysis, and endoscopy are helpful in determining the site of the lesion but are not diagnostic for lymphoma because features are nonspecific (as in our case where they included ulcers, nodules, and polyps) and indistinguishable from those occurring in inflammatory or infectious conditions (such as Crohn’s disease or intestinal tuberculosis). Burkitt’s lymphoma is rapidly fatal without treatment, but it usually responds well to the institution of aggressive chemotherapy, which is currently tailored to the amount of disease (localized versus disseminated disease). Intensive combination chemotherapy, such as intravenous cyclophosphamide, vincristine, doxorubicin, methotrexate with cytarabine intrathecal prophylaxis (CODOX-M) alternated with IVAC (intravenous ifosfamide, etoposide, and cytarabine), in 3–4 cycles produces a satisfactory response in 60%–80% of low-risk patients (i.e., those with localized disease, as the patient presented here) with a high chance of long-term survival.4Bishop P.C. Rao V.K. Wilson W.H. Burkitt’s lymphoma molecular pathogenesis and treatment.Cancer Invest. 2000; 18: 574-583Crossref PubMed Scopus (71) Google Scholar

Technological advancement of ultrasound (US) equipments and understanding of bowel appearances with high resolution US during the last decade has led to consideration of this imaging procedure as an important tool for inflammatory bowel diseases assessment. In particular, Crohn's disease (CD) for its pathologic characteristics (that is, inflammatory infiltration of the entire bowel wall with possible extension to the surrounding mesentery) is the disease entity which has mainly taken advantage from this non-invasive, radiation-free technique. Beside correctly defining anatomic location and extension of CD lesions within the bowel in the majority of cases, US also shows perigut abnormalities and may demonstrate complications such as fistulas and abscesses. With the help of Power Doppler function, some additional information may be obtained about the local activity of the disease which is particularly useful in the presence of strictures. New US technologies (such as those using intravenous bolus contrast agents or oral nonabsorbable anechoic solutions) may further improve diagnostic capability of US in this context, thus probably revolutioning the diagnostic approach to this disease in the near future, particularly during follow-up in CD of the small bowel.