骨髓移植术后急性肠道移植物抗宿主病内镜及病理学诊断研究

目的评价内镜和病理学诊断在急性肠道移植物抗宿主病(GVHD)中的作用。方法回顾性总结和分析2001—2005年北京大学人民医院血液病学研究所临床已确诊的23例急性肠道GVHD患者的内镜及病理学资料。结果内镜下表现可分为:黏膜大致正常、血管纹理模糊或消失、弥漫性黏膜充血、水肿和脆性增加,重者出现糜烂、溃疡,甚至黏膜脱落或出血;病理学表现提示:隐窝上皮细胞凋亡、缺失,隐窝结构破坏,上皮和黏膜固有层不同程度的淋巴细胞浸润。结论内镜和病理学检查可以用于急性肠道GVHD的诊断,尤其是内镜在急性肠道GVHD的早期诊断方面具有重要作用,同时结合病理学检查最终确立诊断。     

骨髓移植术后急性移植物抗宿主病的肠镜及病理表现

目的 探讨非亲缘异基因骨髓移植术后出现肠道症状的急性移植物抗宿主病(GVHD)患者的结肠镜、病理特征及治疗情况.方法 分析总结4例急性GVHD中、重度肠道受损患者的内镜病理资料.结果 4例患者分别于移植后的21～57 d发生不同程度肠道黏膜受损所致的腹痛、腹泻等症状,肠镜和活检病理示肠黏膜允血水肿或上皮层坏死脱落,肠腔正常结构消失,直、结肠多发性溃疡,见较多淋巴细胞和浆细胞浸润,未见巨细胞病毒(CMV)包涵体和巨细胞,诊断为急性GVHD.予以糖皮质激素等治疗,1例治疗无效死亡,其余得到有效控制.结论 非亲缘异基因骨髓移植后发生急性GVHD的肠道受损,诊断有赖于肠镜和活检病理,据此及时正确治疗后多能得到有效控制.     

同种异基因骨髓移植中控制移植物抗宿主病和保留移植物抗白血病的新策略

同种异基因骨髓移植(allo-BMT)对白血病的治疗效果已得到广泛承认，然而移植物抗宿主病(GVHD)和白血病复发是移植成功的两个主要障碍。积累的研究已证明异基因骨髓移植物中的T淋巴细胞是GVHD重要效应细胞，同时具有移植物抗白血病(GVL)、抗感染和预防宿主抗移植物效     

警惕输血相关性移植物抗宿主病

警惕输血相关性移植物抗宿主病陈志哲临床医生熟知异基因骨髓移植并发的移植物抗宿主病，但对输血而引起的移植物抗宿主病相对地了解较少，这种输血相关性移植物抗宿主病（ＴＡ－ＧＶＨＤ）发病急、病死率高，而且容易漏诊。由于输血疗法（包括成分输血）在临床上的应用很...     

一氧化氮在骨髓移植中的作用研究进展

移植物抗宿主病的发生与骨髓移植后长期和严重的免疫功能缺陷有关,这些都导致了术后致病率和致死性的增加。伴随异基因骨髓移植产生的移植物抗白血病效应可以大大提高我们治疗难治性恶性疾病的能力。探索一氧化氮在骨髓移植中的作用对于拓展恶性疾病治疗的新领域有着重要意义。     

内镜及病理对胃肠道淀粉样变的诊断意义

目的 探讨淀粉样变的胃镜、肠镜表现特点以及粘膜活组织检查对其诊断的价值。方法 分析内镜诊断的10例淀粉样变患者资料（男5例，女5例），分别总结胃镜、肠镜表现及其活组织检查特点。结果 胃肠道淀粉样变患者的临床症状包括腹痛、便血或黑便、腹胀、慢性腹泻。5例接受胃镜检查的患者中，3例发现淀粉样变，阳性病变包括溃疡、结节、粘膜剥脱、瘢痕，还有1例患者在外观正常处取材确诊。8例接受肠镜检查的患者中，均发现淀粉样变，阳性病变包括息肉、溃疡、粘膜剥脱、结节不平及粘膜充血、水肿等。结论 胃肠道是淀粉样变的好发部位之一，内镜检查可发现病变，其粘膜活组织检查具有重要的诊断价值。     

Notch信号通路在急性移植物抗宿主病中的作用

目的:分析异基因造血干细胞移植后患者Notch1的表达,了解Notch1信号通路与急性移植物抗宿主病发生、发展的关系。方法:采集54例异基因造血干细胞移植后患者外周血,同期采集26例自体造血干细胞移植患者和10例正常志愿者外周血标本作为对照,检测Notch1和Hes-1 mRNA的表达,分析其与急性移植物抗宿主病的关系。结果:异基因造血干细胞移植患者Notch1和Hes-1 mRNA表达较自体造血干细胞移植患者和正常志愿者高(P0.05),其中急性移植物抗宿主病患者Notch1 mRNA表达明显高于非急性移植物抗宿主病患者、自体造血干细胞移植患者及正常志愿者(P0.05)。Notch1 mRNA的表达与急性移植物抗宿主病总体分度呈正相关,急性移植物抗宿主病越严重,Notch1 mRNA的表达越高(P0.05)。结论:Notch1信号参与调节急性移植物抗宿主病;Notch1及其靶基因的表达与急性移植物抗宿主病的严重程度密切相关。     

淋病双球菌性直肠结肠炎的诊断

目的 总结淋病双球菌性直肠、结肠炎的临床、内镜特征，以提示消化科医师对此疾病的注意。方法 回顾经内傍晚诊断的6例淋病双球菌性直肠、结肠炎患者资料，归纳分析其临床、内镜下表现及病理学、细菌学检查结果。结果 淋病双球菌性直肠、结肠炎患者多以肛门搔痒、烧灼感及腹泻为主诉。肠镜下直肠及乙状结肠粘膜均有不同程度水肿、充血，表面附有较多粘液，3例附有脓性分泌物，2例有散在片状出血点及局灶性糜烂及浅表溃疡。病理学检查4例呈慢性炎症改变，2例呈灶性糜烂、坏死，形成浅表溃疡。分泌物涂片革兰氏染色4例阳性，6例均培养出淋病双球菌。结论 淋病双球菌性直肠、结肠炎内镜下无特异性改变，但严重者可见有较多脓性分泌物，分泌物涂片革兰氏染色有诊断价值，培养阳性率最高。     

炎症性肠病的诊治经验

多年来我国对炎症性肠病 (IBD)的治疗一直沿用西方国家推荐的治疗方法 ,近年来又有很多治疗经验的报道 ,值得我们借鉴[1 3 ] 。关于IBD的诊断 ,仍依靠病史、体检、肠镜及黏膜病理、X线小肠造影和常规实验室检查 ,最近还有胶囊内镜协助小肠克罗恩病 (CD)的诊断。抗中性粒细胞胞质抗体的阳性率在欧美溃疡性结肠炎 (UC)患者可高达 70 %～ 80 % ,但在中国却只有 16 %～ 2 6 % [4,5] ,这说明欧美研究的结果不完全适用于中国人。目前鉴别UC和结肠CD在国内基本上还是依赖肠镜 :UC的结肠黏膜有弥漫性充血、水肿、糜烂、假性息肉等病变 ,溃疡…     

非亲缘和亲缘供者异基因骨髓转植治疗骨髓增生异常综合征

目的 评估非亲缘和亲缘供者异基因骨髓移植治疗骨髓增生异常综合征（ＭＤＳ）的临床疗效。方法 对７２例ＭＤＳ－难治性贫血、ＭＤＳ－原始细胞增多伴转化型患者分别进行非新缘和亲缘供髓的异基因骨髓移植术。２例均为男性,年龄１７和２０岁。预处理为马利兰和环磷酰胺化疗方案。以霉酚酸酯加环孢素Ａ和短程氨甲蝶呤预防移植物抗宿主病,低剂量肝素和前列腺素Ｅ１脂质微球预防肝静脉阻塞病。结果 ２例患者骨髓移植后的中性粒细胞     

Endoscopic diagnosis of gastrointestinal graft-versus-host disease

AIM：To evaluate the diagnostic value of endoscopy in patients with gastrointestinal graft-versus-host disease （GI GVHD）. METHODS：We identified 8 patients with GI GVHD following allogeneic hematopoietic stem cell trans-plantation （HSCT）. GVHD was defined histologically as the presence of gland apoptosis, not explained by other inflammatory or infectious etiologies. RESULTS：The symptoms of GI GVHD included anorexia, nausea, vomiting, watery diarrhea, abdominal pain, GI bleeding, etc. Upper endoscopic appearance varied from subtle mucosal edema, hyperemia, erythema to obvious erosion. Colonoscopic examination showed diffuse edema, hyperemia, patchy erosion, scattered ulcer, sloughing and active bleeding. Histological changes in GI GVHD included apoptosis of crypt epithelial cells, dropout of crypts, and lymphocytic infiltration in epithelium and lamina propria. The involvement of stomach and rectocolon varied from diffuse to focal. CONCLUSION：Endoscopy may play a significant role in early diagnosis of GI GVHD patients following allogeneic HSCT, and histologic examination of gastrointestinal biopsies is needed to confirm the final diagnosis.     

Endoscopic biopsy diagnosis of acute gastrointestinal graft-versus-host disease: rectosigmoid biopsies are more sensitive than upper gastrointestinal biopsies

OBJECTIVES: The diagnosis of gastrointestinal (GI) graft- versus -host disease (GVHD) is based upon histologic findings in endoscopic mucosal biopsy specimens. The portion of the GI tract with the highest diagnostic yield is a topic of debate. Our aim was to evaluate the sensitivity of simultaneous biopsy of the stomach, duodenum, and rectosigmoid in establishing the diagnosis of GI GVHD.
METHODS: We identified 112 patients who had simultaneous endoscopic biopsies of the stomach, duodenum, and rectosigmoid within the first 100 days following allogeneic hematopoietic stem cell transplantation (HSCT). GVHD was defined histologically as the presence of gland apoptosis, not explained by other inflammatory or infectious etiologies. The patient was diagnosed with GI GVHD if at least one biopsy site was positive.
RESULTS: Overall, 81% of the patients had GI GVHD. Of these, 66% had involvement at all three biopsy sites. Rectosigmoid biopsies had the highest sensitivity, specificity, positive predictive value, and negative predictive value for diagnosing GI GVHD, at 95.6%, 100%, 100%, and 84%, respectively. The sensitivities of gastric and duodenal biopsies were 72.5% ( P < 0.0001 vs rectosigmoid) and 79.2% ( P = 0.0018), respectively. The negative predictive values of gastric and duodenal biopsies were 45.6% ( P = 0.0039 vs rectosigmoid) and 52.5% ( P = 0.0205), respectively. Rectosigmoid biopsies had a higher sensitivity and negative predictive value than biopsies at other sites whether the patient presented with diarrhea or nausea/vomiting. No association between the degree of mucosal injury and the presence of GVHD was found at any site.
CONCLUSIONS: Biopsy of the rectosigmoid is the single best test for diagnosing GI GVHD.     

Endoscopic and histologic diagnosis of intestinal graft-versus-host disease after marrow transplantation

BACKGROUND: Gastrointestinal graft-versus-host disease after allogeneic hematopoietic cell transplantation presents a range of upper gastrointestinal endoscopic and histologic abnormalities. Recognition of these sometimes subtle abnormalities is critical for directing specific therapy. METHODS: Endoscopic and histologic abnormalities in 10 patients with gastrointestinal graft-versus-host disease are reviewed to detail the spectrum of findings. RESULTS: The endoscopic appearance of the stomach and duodenum varies from subtle mucosal erythema and edema to frank ulceration and mucosal slough. Histologic findings include crypt epithelial cell apoptosis and dropout, crypt destruction, and variable lymphocytic infiltration of the epithelium and lamina propria. The involvement may vary from diffuse and uniform to focal, with either the stomach or the duodenum appearing much more involved. CONCLUSIONS: Endoscopic evaluation of the stomach and duodenum and histologic evaluation of biopsies of the gastric antrum can be used to diagnose gastrointestinal graft-versus-host disease. The gross appearance of the mucosa and the histology of gastric biopsies are mutually complementary. However, both the endoscopic evaluation and the histology of the upper gut can underestimate the severity of acute graft-versus-host disease elsewhere in the intestine unless extensive mucosal sloughing is seen.     

Endoscopic cryotherapy for the treatment of bleeding mucosal vascular lesions of the GI tract: a pilot study

BACKGROUND: Thermal therapy is the cornerstone of endoscopic treatment of bleeding mucosal lesions of the GI tract. However, there is a 20% failure rate and contact devices may be cumbersome in the treatment of large bleeding areas. A pilot study was conducted to evaluate the safety and efficacy of endoscopic cryotherapy for bleeding mucosal vascular lesions. METHODS: Patients with recurrent bleeding from diffuse mucosal vascular lesions were treated with cryotherapy and had endoscopic and clinical follow-up. RESULTS: Twenty-six patients with gastric and duodenal arteriovenous malformations (n = 7), watermelon stomach (n = 7), radiation-induced gastritis (n = 5), and radiation-induced proctitis (n = 7) were treated with mean of 3.4 (1.6) sessions. The best results were achieved in patients with radiation-induced proctitis, with cessation of bleeding in all 7 patients. Cryotherapy was also effective in patients with multiple arteriovenous malformations (86%) and watermelon stomach (71%). It was less effective in patients with radiation-induced damage to stomach and duodenum, although all patients in this group were debilitated because of disseminated malignancy. CONCLUSIONS: Cryotherapy is a safe and effective treatment for bleeding from diffuse mucosal lesions of the GI tract. Bleeding from radiation-induced proctitis and multiple arteriovenous malformations is particularly responsive to endoscopic cryotherapy.     

The spectrum of GI strongyloidiasis: an endoscopic-pathologic study

BACKGROUND: The aim of this study was a detailed endoscopic-pathologic assessment of patients with various forms of GI strongyloidiasis. METHODS: Six patients with a diagnosis of GI strongyloidiasis who underwent endoscopic evaluation during a 3-year period (January 1998-January 2001) were included. Published information was reviewed in detail, focusing on the endoscopic features and the diagnostic approach to this parasitosis. OBSERVATIONS: Strongyloidiasis has a broad range of endoscopic features. In the duodenum, the findings included edema, brown discoloration of the mucosa, erythematous spots, subepithelial hemorrhages, and megaduodenum. In the colon, the findings included loss of vascular pattern, edema, aphthous ulcers, erosions, serpiginous ulcerations, and xanthoma-like lesions, and, in the stomach, thickened folds and mucosal erosions. A histopathologic diagnosis of strongyloidiasis was made in all cases. CONCLUSIONS: Strongyloidiasis can involve any segment of the GI tract. EGD with procurement of biopsy specimens from the duodenum was the most accurate method of diagnosis in this case series.     

High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of high-frequency probe EUS (HFPE)-assisted endoscopic mucosal resection in the management of submucosal tumors of the GI tract. METHODS: HFPE-assisted endoscopic mucosal resection was attempted in 28 patients with submucosal tumors less than 2 cm in diameter. HFPE was performed with a 20-MHz "through-the-scope" probe. Saline solution was injected into the submucosa. After confirming detachment of the lesion from the muscularis propria by repeat HFPE, endoscopic mucosal resection was performed with a lift-and-cut or endoscopic mucosal resection cap technique. Follow-up endoscopy was performed in all patients. RESULTS: Submucosal tumors from the following areas were included: esophagus 3, stomach 4, duodenum 3, and colon 18. The submucosal tumors were located in the upper third (n = 3), middle third (n = 18), and lower third (n = 7) of the submucosa. Twenty-one submucosal tumors were removed by the lift-and-cut technique and 6 by the cap method. One patient required surgical resection after unsuccessful endoscopic mucosal resection. The origin and depth of penetration of all lesions was accurately depicted by HFPE. Median tumor diameter was 9 mm (range 3-20 mm). Resection was successful and complete in 93% of the cases. There were no immediate postprocedure complications (exact 95% CI [0%, 12.3%]). During a median follow-up of 21.5 months (range 2-74 months) no recurrence was found. CONCLUSIONS: HFPE-assisted endoscopic mucosal resection is safe and effective for the management of selected submucosal tumors of the GI tract. A management algorithm based on endoscopic and HFPE findings is proposed.     

Endoscopic appearance of AIDS-related gastrointestinal lymphoma with c-MYC rearrangements: Case report and literature review

Acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL) remains the main cause of AIDS-related deaths in the highly active anti-retroviral therapy (HAART) era. Recently, rearrangement of MYC is associated with poor prognosis in patients with diffuse large B-cell lymphoma. Here, we report a rare case of gastrointestinal (GI)-ARL with MYC rearrangements and coinfected with Epstein-Barr virus (EBV) infection presenting with various endoscopic findings. A 38-yearold homosexual man who presented with anemia and was diagnosed with an human immunodeficiency virus infection for the first time. GI endoscopy revealed multiple dish-like lesions, ulcerations, bloody spots, nodular masses with active bleeding in the stomach, erythematous flat lesions in the duodenum, and multiple nodular masses in the colon and rectum. Magnified endoscopy with narrow band imaging showed a honeycomb-like pattern without irregular microvessels in the dish-like lesions of the stomach. Biopsy specimens from the stomach, duodenum, colon, and rectum revealed diffuse large B-cell lymphoma concomitant with EBV infection that was detected by high tissue EBV-polymerase chain reaction levels and Epstein-Barr virus small RNAs in situ hybridization. Fluorescence in situ hybridization analysis revealed a fusion between the immunoglobulin heavy chain (IgH) and c-MYC genes, but not between the IgH and BCL2 loci. After 1-mo of treatment with HAART and R-CHOP, endoscopic appearance improved remarkably, and the histological features of the biopsy specimens revealed no evidence of lymphoma. However, he died from multiple organ failure on the 139 th day after diagnosis. The cause of his poor outcome may be related to MYC rearrangement. The GI tract involvement in ARL is rarely reported, and its endoscopic findings are various and may be different from those in non-AIDS GI lymphoma; thus, we also conducted a literature review of GI-ARL cases.     

Serial intestinal endoscopic examinations of patients with persistent diarrhea after allo-SCT

Gastrointestinal (GI) GVHD after allo-SCT is diagnosed on the basis of symptoms and findings in endoscopic mucosal biopsy specimens. However, GI symptoms often persist despite treatment and whether a second endoscopy may be helpful in determining the most suitable therapy is not established. We identified 31 patients with persistent diarrhea who underwent more than one endoscopic study. All cases underwent serial microbiological stool analysis and CMV-detecting assays on serum and biopsies. Of the 31 initial GI biopsies, 20 (64.5%) were classified as GVHD, two (6.5%) as GVHD with CMV, four (13%) as non-CMV infection, and five (16%) as normal or unspecific. The second GI biopsies were diagnostic of GVHD in nine cases (29%), GVHD simultaneously with CMV infection in four (13%), regenerative changes post-GVHD in five (16%), CMV infection in four (13%), and normal or unspecific in nine (29%). In 22 of the 31 patients (71%), the histological findings of the second/third endoscopic biopsies differed from the findings of the first endoscopy and led to a therapy change in 77%. In conclusion, serial GI endoscopies are of reliable diagnostic value and can impact on therapeutic decision-making for patients with persistent diarrhea after allo-SCT.     

Prospective endoscopic evaluation for gastrointestinal graft-versus-host disease: determination of the best diagnostic approach

The best endoscopic diagnostic strategy for gastrointestinal (GI) graft-versus-host disease (GVHD) is unknown. Over a 48-month period, all patients with unexplained diarrhea at risk for acute gastrointestinal GVHD were prospectively identified. Acute GVHD was defined as symptoms and histologic evidence of GVHD occurring within 100 days of transplant or donor lymphocyte infusion (DLI). Colonoscopy was performed with multiple biopsies of the ileum, right colon and rectosigmoid colon. Next, upper endoscopy with duodenal and random gastric biopsies of both antrum and body were performed. All biopsies were evaluated for GVHD by an experienced GI pathologist. Over the study period, 24 patients (mean age 37 years; 62.5% male) were evaluated. The median time from transplantation or DLI was 30.5 days. The biopsy site with the highest yield was the distal colon (82%). A combination of upper endoscopy with sigmoidoscopy and colonoscopy with ileal biopsies were equivalent ( approximately 94%). In patients with diarrhea at risk for GVHD, biopsies of the distal colon had the highest diagnostic yield suggesting the importance of sigmoidoscopy and biopsy. Colonoscopy and ileoscopy or flexible sigmoidoscopy plus upper endoscopy had the highest diagnostic yields.     

腹型过敏性紫癜的临床及内镜表现

目的 总结腹型过敏性紫癜的临床和内镜特点,以加强对此病的认识。方法 对1994 年1月以来收治的197名过敏性紫癜患者病例资料进行回顾性分析,其中81名为腹型紫癜。19例次 接受了胃镜或肠镜检查。结果 腹型紫癜占紫癜病例的41.1％,其中51例(63.0％)在发病前1-3 周有明确诱因。21例以消化道症状首发,其消化道症状可早于皮损1-40 d出现。74例(91.4％)出 现腹痛,37例(45.7％)表现为消化道出血。内镜表现为胃肠道黏膜弥漫性充血水肿,广泛多发的出 血点、红斑、糜烂、溃疡,小肠病变较重。胃肠道黏膜组织病理学表现为黏膜及黏膜下层中到大量中性 粒细胞浸润、小血管壁纤维素性坏死、灶性出血、糜烂和溃疡。患者的内镜和临床病理表现的范围和 严重程度与消化道症状的程度一致。结论 41.1％的紫癜患者表现为腹型过敏性紫癜,腹型紫癜中 25.9％以消化道症状为首发。小肠病变程度重于胃或结肠。其典型的临床和内镜表现对早期诊断有 一定帮助。