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Aim: To evaluate prospectively the accuracy of preoperative high-frequency (20 MHz) probe ultrasonography (HFPUS) for detecting invasive cancer in patients referred for esophagectomy because of an endoscopic biopsy diagnosis of high-grade dysplasia (HGD) or intramucosal carcinoma (ICA) in Barrett's esophagus (BE)., Patients and Methods: Nine consecutive male patients (median age of 69 yr) who were referred for esophagectomy for HGD or ICA in BE agreed to participate. We performed conventional upper gastrointestinal endoscopy followed by HFPUS using a through-the-scope ultrasound probe (20 MHz), and we compared our preoperative findings with the pathologist's findings in the resected esophageal specimens., Results: There was complete agreement between the postoperative pathological findings and the preoperative HFPUS findings in only 4 of the 9 patients. HFPUS resulted in two false-negative diagnoses of esophageal cancer (both had T1 lesions in the resected specimens), one false-positive diagnosis of esophageal cancer, and two errors in tumor staging (1 understaged, 1 overstaged)., Conclusions: HFPUS has limited accuracy for identifying invasive cancer in patients found to have HGD or IMC in BE. Pending further refinements in technology, clinical management decisions in such patients should not be based solely on the results of HFPUS.

Objectives: Scattered eosinophils in the distal esophagus traditionally provide the hallmark for peptic esophagitis, but the upper limit of eosinophils and the longitudinal extent of peptic inflammation along the esophagus are unknown. Recently, adults and children with upper intestinal symptoms and >20 eosinophils/high-power field (eos/HPF) have been given the diagnosis of allergic esophagitis. Standardized diagnostic criteria for allergic esophagitis are lacking and the isolated finding of large numbers of eosinophils in the squamous epithelium has been used as the defining feature. We cared for three patients with symptoms and endoscopic features of esophagitis with >20 eos/HPF in their esophageal mucosa. Symptoms, endoscopic features, and histologic findings resolved after 2 months of proton pump inhibitor (PPI) treatment. The aim of this case series is to demonstrate that features thought to be consistent with a diagnosis of allergic esophagitis are also observed in peptic esophagitis., Methods: A retrospective chart review of three patients with esophagitis (>20 eos/HPF) whose symptoms and eosinophilia resolved with PPI treatment was performed. Esophageal biopsies were reviewed in a blinded manner by one pathologist., Results: Patients (aged 14, 25, and 5 yr) presented with dysphagia, food impaction, and vomiting. Endoscopic features included white exudates and linear furrows. None of the patients received antiallergic treatments or dietary eliminations prior to endoscopy. Following treatment with PPIs alone, all patients became asymptomatic and endoscopic findings reverted to normal. In all three patients, pre- and post-PPI treatment eosinophil numbers/HPF decreased to normal/near normal (37 to 1, 21 to 3, and 52 to 0 eosinophils/HPF in patients 1, 2, and 3, respectively)., Conclusion: Large numbers of eosinophils can be seen in peptic esophagitis. This histologic finding must be interpreted in the context of the clinical setting in which it is obtained.

Objective: There are no endoscopic features that distinguish intestinal metaplasia of the cardia (CIM) from the normal cardia. Biopsy specimens are therefore randomly obtained from normal-appearing mucosa with significant potential sampling errors. Enhanced magnification endoscopy involves the combined use of magnification endoscopy with acetic acid instillation. This study assessed the value of enhanced magnification endoscopy in detecting CIM., Methods: Patients undergoing elective upper endoscopy were invited to participate in the study. Patients were included if the squamocolumnar junction and the esophagogastric junction were judged to be at the same level. Enhanced magnification endoscopy was performed with 3% acetic acid instillation. Standard endoscopy was followed by magnification endoscopy and repeated after acetic acid spraying. Surface patterns were characterized before and after acetic acid spraying. The observed surface patterns were compared with histological results obtained from a single targeted biopsy specimen of each pattern., Results: The overall prevalence of CIM was 34.8% (86/247 patients). After excluding 52 patients because of endoscopic evidence of Barrett's esophagus, 195 patients were eligible for participation in the study. In the study group, CIM was detected in 86 patients (44.1%) in targeted biopsy samples. No dysplasia was identified. Enhanced magnification endoscopy detected four different patterns of the mucosal surface: I) round pits, II) reticular, III) villous, and IV) ridged. The yields of detection of intestinal metaplasia according to endoscopic patterns were I) 0%, II) 5.3% (odds ratio = 0.05), III) 57.7% (odds ratio = 7.5, p = 0.0001), and IV) 95.8% (odds ratio = 42.8, p = 0.0001)., Conclusions: CIM is more common than previously reported. Enhanced magnification endoscopy identifies two characteristic endoscopic patterns, villous (pattern III) and ridged (pattern IV), with outstanding clarity and resolution that correlate with histological identification of CIM with a single targeted biopsy sample. Enhanced magnification endoscopy will permit longitudinal studies of an entity that can be identified endoscopically.

Objective: The factors that influence the decision to do an adequate evaluation for a positive test for fecal occult blood in a middle-aged or elderly patient are largely unknown. Our study was undertaken to determine whether factors such as the number of positive Hemoccult II card windows, age, gender, family history of colon cancer, the patient's concern that he or she might have colon cancer, or history of rectal bleeding influence the evaluation performed., Method: A mass screening program for colon cancer was performed using unrehydrated Hemoccult II cards in the Boston area., Results: Among the 23,593 Hemoccult II cards returned to Beth Israel Deaconess Medical Center, cards from 1,112 patients (4.7%) were found to be positive for one or more of the six possible card windows. Ninety percent, or 940 patients, over 40 yr of age had follow-up information available. As the number of positive windows increased from one to four, there was a significant trend (p < 0.001) for the adequacy of the evaluation to increase. Family history (p = 0.044) and a patient's worry that he or she might have colon cancer (p = 0.003) significantly improved a patient's chance for an adequate evaluation., Conclusions: Hemoccult testing is not followed by an adequate evaluation in a significant proportion of patients. Our study points out for the first time that the number of positive Hemoccult windows significantly influences the decision-making.

A case of barbiturate-induced submassive hepatic necrosis is presented and the literature is reviewed. The patient's clinical presentation, histologic features on liver biopsy and favorable course after stopping the drug suggest that barbiturates can be added to the list of agents which can cause submassive hepatic necrosis.

Patients with distal ulcerative colitis may be refractory to standard drug therapy. 5-Aminosalicylate, the active moiety of sulfasalazine, is effective topically in new onset distal colitis. Six patients with distal colitis unresponsive to sulfasalazine and corticosteroids had a prompt and dramatic response to the administration of 5-aminosalicylate enemas with clinical, sigmoidoscopic, and histological improvement. Topical 5-aminosalicylate should be a useful addition to the current available therapies for some patients with refractory distal ulcerative colitis.