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Murat
Alper, Olcay K Belenli, Selma Çukur, Kamuran A Aksoy, Mazlume
Suna, Department of Pathology, Medical School of Düzce, Abant
Izzet Baysal University, Turkey
Yusuf Akcan, Department of Gastroenterology, Medical School
of Düzce, Abant Izzet Baysal University, Turkey
Correspondence to: Assistant Professor. Dr. Murat Alper, Düzce
T1p Fakültesi Patoloji ABD, Konuralp/Düzce 81650, Turkey.
muratalper@tusdata.com
Fax: +90-212-5311616
Received: 2003-08-02
Accepted: 2003-10-22
Abstract
Microvesicular pneumatosis intestinalis, also called "pseudolipomatosis"
for resembling fatty infiltration, is characterized by the presence
of small gas voids in the gastrointestinal wall, especially in
mucosa. These voids are not lined with epithelia. There are few
reported cases about colon, duodenum and skin. Because there is only
one case report about pseudolipomatosis in the stomach, we
re-evaluated 909 endoscopic biopsies taken from gastric corpus to
check the presence of pseudolipomatosis. We determined
pseudolipomatosis foci in 3 percent (n=27) of biopsies. In
two cases there were pseudolipomatosis foci in endoscopic biopsies
having otherwise normal histologic findings, while there were
pseudolipomatosis foci in endoscopic biopsies of 25 patients with
gastritis. H pylori was found in 85 % of biopsies having
pseudolipomatosis foci. In this study, we presented some
histopathologic characteristics of pseudolipomatosis seen in gastric
mucosa.
Alper
M, Akcan Y, Belenli OK, ?ukur S, Aksoy KA, Suna M. Gastric
pseudolipomatosis, usual or unusual? Re-evaluation of 909 endoscopic
gastric biopsies. World J Gastroenterol
2003; 9(12): 2846-2848
http://www.wjgnet.com/1007-9327/9/2846.asp
INTRODUCTION
Microvesicular pneumatosis intestinalis which is also called
"pseudolipomatosis" for resembling fatty infiltration, is
characterized by the presence of small gas voids in the
gastrointestinal wall, especially in mucosa[1]. These gas
voids are not lined with epithelial cells. Since we came across only
one letter about gastric mucosa while searching literature for our
previous case report, in which we presented a case of
pseudolipomatosis in the stomach, duodenum and colon, although
recently in gastrointestinal system pseudolipomatosis was defined
particularly in the colon, duodenum and skin, we investigated
endoscopic biopsies with regard to pseudolipomatosis[1-8].
MATERIALS
AND METHODS
In this study, 909 endoscopic gastric biopsies were investigated
at the Department of Pathology of Düzce Medical Faculty Abant ízzet
Baysal University, between December 1998 and June 2003. Biopsies
taken from the corpus for various reasons other than cancer were
included in this study. Biopsies were fixed in 10 % formaldehyde and
subjected to automatic tissue follow-up procedures. We re-examined
the 4-5 micron thick samples stained with hematoxylene eosin and
modified Giemsa by a light microscope. When pseudolipomatosis was
found, the presence and grade of inflammation, the presence of
intestinal metaplasia, and the presence and concentration of H
pylori were determined. The absence of inflammation was designated
as (0), and the presence of inflammation was classified as mild (1),
moderate (2) and severe (3). The absence of H pylori was designated
as (0), and the presence was classified as scarce (1), moderate (2)
and diffuse (3). Intestinal metaplasia was evaluated as present or
absent, and atrophy as present or absent, if present as mild,
moderate or severe. Three hundred and sixty-four (40 %) subjects
were female and 545 (60 %) were male. The ages of patients ranged
between 19 and 78 years with a mean of 46 years.
RESULTS
Pseudolipomatosis was found in 27 of 909 re-evaluated cases. Of
these 27 patients, 15 were male and 12 were female. Male patients
were between 28 and 56 years old, with a mean of 39 years, female
patients were aged between 22 and 65 years, with a mean of 41 years.
Mucosal vacuolation was characterized by empty spaces, 30-250 micron
in diameter, associated with neither fibrosis/sclerosis nor a
lymphocytic infiltrate. There was no evidence of true adipocyte
differentiation, vascular markers, e.g. S-100 protein, F-VIII and
F-XIII were negative. Vacuoles were found in different parts of the
mucosa, although they could be seen beneath epithelia, in a few
cases they were detected within muscularis mucosa as well (Figures
1-2). Twenty five of the patients with pseudolipomatosis had
gastritis. Of these patients 23 were H pylori positive. Among the H
pylori positive patients, five had scarce, ten had moderate, and
eight had diffuse bacteria. Among the 25 patients with gastritis, 5
had mild, 13 had moderate, and 7 had severe chronic inflammation. In
8 cases with gastritis, intestinal metaplasia was encountered. In
all the cases with metaplasia goblet cells and in 4 cases Paneth
cells were noticed. Two cases of gastritis had severe atrophy, and
one case had mild atrophy. Four patients with gastritis had prior
endoscopy for gastric complaints. The previous biopsy results were H
pylori gastritis with severe inflammatory activity in three cases,
and H pylori gastritis with moderate inflammatory activity in one
case. Pseudolipomatosis was not found in previous endoscopic gastric
biopsies of these four patients. However, in one of these patients,
pseudolipomatosis was detected in duodenal and colonic biopsies[8].
Two other patients had undergone colonoscopy while being searched
for malignancy. In samples taken from the colon pseudolipomatosis
was not detected.
The
patients who were H pylori positive were given a course of treatment
for H pylori eradication composed of lansoprazol 30 mg daily for 15
days, clarithromycin bid 500 mg and amoxicilin bid 1 000 mg for 10
days. One month later control biopsies were performed for 5 patients
whose complaints were not fully resolved. We found that in two of
them pseudolipomatosis continued while in the other three biopsies
pseudolipomatosis was not found. In those cases in which
pseudolipomatosis continued, we noticed that although H pylori was
decreased, it was not completely eradicated, and in the other three
patients we saw that H pylori was eradicated and the gastritis
continued though decreased. Control biopsies were not performed for
the remaining patients. In two patients with pseudolipomatosis, a
45-year-old female and a 39-year-old man, biopsies taken for
non-specific abdominal pain showed no H pylori, inflammation or
metaplasia. In these patients no pathologic finding except mild
edema could be demonstrated. These patients had no previous
endoscopies. Vacuoles were seen in small foci in lamina propria, and
were considered as pseudolipomatosis.
Figure
1 Presence of
many vacuoles beneath epithelium in gastric mucosa (H & E ×200).
Figure 2
Presence of many vacuoles in muscularis mucosa and lamina
propria as well (H & E ×200).
DISCUSSION
Mucosal pseudolipomatosis is a recently described endoscopic
finding, most likely caused by intramucosal air. Because of their
gross and microscopical similarity to fat, however, the term "pseudolipomatosis"
is proposed. Although the etiopathogenesis of pseudolipomatosis is
not so clear yet, some probable causes of it in the colon, duodenum
and skin have been mentioned[1-8]. We could find only one
case-report about gastric pseudolipomatosis except our one[6].
For this reason we searched how often pseudolipomatosis, yet its
rate in colon increased contionusly, was found in gastric mucosa.
Pneumatosis
coli is a rare condition characterized by multiple gas-filled cysts
within the bowel wall. Mechanical, bacterial and biochemical
theories have been availabe to explain the pathogenesis of
pneumatosis in the colon[5]. Pneumatosis cyctoides
intestinalis has been reported to be present together with other
conditions such as pseudomembranous enterocolitis, necrotizing
enterocolitis, bowel infarction, chronic obstructive pulmonary
disease, intestinal obstruction, collagen vascular diseases (scleroderma,
dermatomyositis, mixed connective tissue disease), systemic
amyloidosis and iatrogenic conditions (after surgery or endoscopy),
late-stage AIDS with cryptosporidial diarrhea, and Crohn's disease[5].
Gagliardi et al. detected mucosal pseudolipomatosis foci in
colon of 5 cases among 25 pneumatosis coli patients in their study[5].
Micropneumatosis was reported to be caused by disinfectant hydrogen
peroxide solution[3]. It might also be a result of
colonoscopy application and usually disappeared three weeks after
the procedure[4]. Commercially available endoscope
disinfecting hydrogen peroxide solution could cause
the unique form of colitis referred as pseudolipomatosis[3].
It was also reported in asymptomatic patients as an air pressure-
related colonoscopy complication[4]. Mucosal
pseudolipomatosis of the colon is an infrequent condition that
occurs mainly in elderly males, usually involves the left colon, and
is manifested clinically by passage of blood per rectum. Colonoscopy
showed solitary or multiple whitish-yellowish plaques, which were
localized or involved several segments[1]. Superficial
dermal vacuoles resembling fatty infiltration of the skin have also
been reported as pseudolipomatosis cutis[2]. Dermal
vacuoles likely represent an artifact of tissue fixation or
processing and are unrelated to the underlying pathologic process.
Trottor et al. suggested the name pseudolipomatosis cutis,
analogous to insufflation-induced colonic vacuolation, to
distinguish this phenomenon from true dermal fatty infiltration and
to emphasize its incidental, likely artifactual nature[2].
As in colon and duodenum, histologic studies in the stomach
demonstrated microscopic cavities in mucosa, measuring 20 to 300
micron in diameter. Histochemical stains showed that these cavities
contained no lipids, suggesting that they were filled with gas. In
the study of Gagliardi et al, 14 patients were treated with
antidiarrhoeals and anti-inflammatory drugs, improvement was
detected in 9 cases. There was a high recurrence rate, but with
further courses of continued therapy remission was achieved in five
patients. According to Gagliardi et al, the associations of
pneumatosis coli with psychiatric disorders and mucosal
pseudolipomatosis were new and of possible pathogenetic[5].
In our study, 23 out of 27 patients had H pylori. In our
previous case report, one patient was diagnosed as micropneumatosis
on the first and second colonoscopy specimens at a four week
interval[8]. After another four weeks during the first half of H
pylori gastritis treatment of the patient, colonoscopy was repeated
for the third time, and micropneumatosis foci were not observed on
pathological sections. In the present study, when control biopsy was
performed one month later for 5 patients whose complaints were not
resolved it was noticed that pseudolipomatosis continued in two of
them while pseudolipomatosis was not seen in the other three in
control biopsies. In those cases with persistent pseudolipomatosis,
it was noticed that although H pylori was decreased, it was not
completely eradicated, and in the other three patients it was seen
that H pylori was eradicated and the gastritis findings were
decreased. It is also possible that the control endoscopic biopsies
may be taken from sites that are free of pseudolipomatosis. Since
the conditions of some patients improved after the eradication
therapy for H pylori, this finding implicates that H pylori may be
one of the causative factors for micropneumatosis and pneumatosis
cyctoides intestinalis. It can also be speculated that
micropneumatosis grows with time and may lead to pneumatosis
cyctoides intestinalis. The fact that micropneumatosis foci are also
reported in most pneumatosis cyctoides intestinalis cases is
supportive for this suggestion. The pseudolipomatosis type changes
seen in mucosal biopsies should not be ignored by just considering
them as artifacts. We think that, in order to determine the
etiopathogenesis and significance of gastric mucosal
pseudolipomatosis, more case reports are required.
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Indian J Gastroenterol 2003 (in
press)
Edited
by Wang
XL
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PubMed
