prolapsed gastric mucosa was usually that of the fundus of the stomach. In one man, spontaneous mucosal hematomas occurred after retching during the procedure. The prolapsing mucosa was followed into the stomach area during relaxation and areas of mucosal hemorrhage were identified in five patients. During observation of the gastric cardia viewed through the endoscope from within the stomach, retching sometimes occurred and usually it was mucosa of the fundus of the stomach which prolapsed into the esophagus (Fig. 2). Hiroyuki Kuwano, Masaru Morita, Masaki Mori, Hiroshi Matsuura, Keizo Sugimachi, Yukiaki Haraguchi,
MD MD MD MD MD MD
Department of Surgery /I Faculty of Medicine Kyushu University Fukuoka, Japan Sawara Hospital Fukuoka, Japan
REFERENCES 1. Callaghan J. The Boerhaave syndrome. Br J Surg 1972;59:414.
Figure 1. Prolapse of the mucosa of the gastric fundus into the left side of the esophagus viewed from within the esophagus during retching. Figure 2. Prolapse of the mucosa of the gastric fundus viewed from within the stomach during retching.
linear, longitudinal, and is located in the left posterior aspect. 2 We reported that resected specimens of the esophagus from patients with Boerhaave's syndrome showed a lack of the muscularis mucosa after the longitudinal tear of the esophagus, hence this may be one contributing factor to this entity.3 Endoscopic findings of repeated prolapse of the gastric mucosa into the esophageal lumen during retching were evident in patients presenting with epigastric pain and/or hematemesis with a precedent history of recurrent early morning retching. Shepherd et a1. 4 proposed the term "prolapse gastropathy syndrome" for such patients. We performed upper gastrointestinal tract endoscopy and observed the process of retching and vomiting during the procedure, with special attention directed to gastric mucosal prolapse. Among 1086 patients who underwent upper gastrointestinal endoscopy, retching occurred and gastric mucosal prolapse into the esophagus was observed in 20 (1.8%). During the endoscopic procedure, a tense knuckle of gastric mucosa was seen to be forcefully and repeatedly prolapsed into the distal esophageal lumen in these 20 patients (Fig. 1). This gastric mucosal prolapse was most commonly seen on the left of the esophageal lumen. Therefore, the 586
2. Enterline H, Thompson J. Motility disorders of the esophagus and spontaneous rupture of the esophagus. Pathology of the esophagus. New York: Springer-Verlag, 1984;55-71. 3. Kuwano H, Matsumata T, Adachi E, et al. Lack of muscularis mucosa and the occurrence of Boerhaave's syndrome. Am J Surg (in press). 4. Shepherd HA, Harvey J, Jackson A, Colin-Jones DG. Recunent retching with gastric mucosal prolapse. A proposed prolapse gastropathy syndrome. Digest Dis Sci 1984;29:121-8.
Barium granuloma of the rectum To the Editor: The incidence of iatrogenic rectal wall infusion of barium is unknown but appears to be very rare. We report a case of a rectal barium granuloma seen as an incidental finding on routine colonoscopy. A 38-year-old man with alternating diarrhea and constipation underwent a barium enema demonstrating a sigmoid polyp. A colonoscopy performed 3 weeks later at another institution showed a benign l-cm tubulovillous adenoma at 28 cm from the anus, which was removed endoscopically. A follow-up colonoscopy 1 year later revealed a 5-mm pale yellowish submucosal non-raised rectal lesion, with intact overlying mucosa, 8 cm from the anal verge. Biopsies showed rectal mucosa with histiocytes filled with granular material suggestive of barium. This lesion was felt likely to represent a submucosal infusion of barium during the barium enema done 1 year earlier. The patient returned 3 years later for surveillance colonoscopy and again the same 5-mm nonraised, pale submucosal lesion 8 cm from the anus was noted (Fig. 1). The lesion was again biopsied (Fig. 2) and an x-ray of the pelvis was performed to demonstrate the lesion radiographically. The first recorded case of a barium granuloma of the GASTROINTESTINAL ENDOSCOPY
tals, thus characterizing a granulomatous reaction. 7 The initial ulcerations usually heal by 8 weeks and either disappear or remain radiographically weeks later.8.9 Other later descriptions include fistulas, pedunculated or sessile lesions abscesses, masses, and proctitis with barium flecks.5.7.8.l~ The rare finding of a barium granuloma more than 2 years after barium enema has been described in two previous cases. In the patient reported by Lewis et al./ an ulcerated I-em lesion at 6 em from the anal verge was seen 2 years after barium enema. In the case of Broadfoot and Martin,a similar to ours, sigmoidoscopy 26 months after barium enema revealed a "smooth to irregular swelling covered by smooth mucosa with possible calcified tissue beneath the mucosa." It appears then that the long-term appearances of persistent barium granulomas is variable. A barium granuloma should be considered when faced with a rectal lesion after a barium enema. The diagnosis is made by biopsy, and it is best to alert the pathologist to look for barium-laden histiocytes in the rectal tissue. l l The natural history of barium granulomas, i.e., resolution, persistent ulceration, or persistent intramucosal lesion remains to be defined. Richard S. Elloway, MD Peter H. DeRidder, MD Division of Gastroenterology William Beaumont Hospital Royal Oak, Michigan
REFERENCES 1. Beddoe HL, Kay S, Kaye S. Barium granuloma of the rectum.
Figure 1. Endoscopic view of a 3-year-old rectal barium granuloma. The lesion was non-raised, pale white, and 5 mm across. Figure 2. Biopsy specimen from the intramucosal barium lesion shown in Figure 1 showing rectal mucosa with histiocytes (arrows) filled with barium (H & E; original magnification x250).
rectum was in 1954, and it had the appearance of a pedunculated tumor. l Lewis et al. 2 found at least 35 cases in the world literature in his 1975 review. By 1986 there were less than 45 cases in the English literature. 3• 4 These previous cases report on lesions that differ endoscopically from that of our patient. The reason for this appears to be the time the lesion was viewed after barium enema, and the nature of the iatrogenic infusion. Animal studies have been inconsistent, but the injection of unsterile barium usually creates a classic ulceration of the bowel wall covered by slough and surrounded by indurated elevated borders, and overhanging ragged mucosa. 5 This typical early appearance was either not seen or missed in our case 3 weeks after barium enema. Such a finding is consistent with previous reports of the relatively inert and non-toxic effect of small amounts of barium on body tissues. 5 The fact that most barium granulomas of the rectum occur within 8 em of the anal verge strongly suggests that insertion of the enema tip probably lacerates the rectal wall to some degree, and barium is able to enter the deeper tissues. 6 An inflammatory reaction ensues with a collection of cells (fibroblasts, multinucleated giant cells, macrophages, and lymphocytes) around the intracytoplasmic barium sulfate crysVOLUME 37, NO.5, 1991
JAMA 1954;154:747-9. 2. Lewis JW, Kerstein MD, Koss N. Barium granuloma of the rectum: an uncommon complication of barium enema. Ann Surg 1975;181:418-23. 3. Broadfoot E, Martin G. Barium granuloma of the rectum. Aust RadioI1977;21:50-2. 4. Arlow FL, D'Angelo DM. Barium granuloma mimicking rectal carcinoma. Henry Ford Hosp Med J 1986;34:213-4. 5. Gaston EA. Barium granuloma ofthe rectum. Dis Colon Rectum 1969;12:241-7. 6. Gardiner H, Roscoe EM. Barium peritonitis a new therapeutic approach. Am J Surg 1973;125:350-2. 7. Rand AA. Barium granuloma ofthe rectum. Dis Colon Rectum 1966;9:20-32. 8. Carney JA, Stephens DH. Intramural barium (barium granuloma) of colon and rectum. Gastroenterology 1973;65:316-20. 9. Carter RW. Barium granuloma of the rectum: a complication of diagnostic barium enema examinations. AJR 1963;89:880-2. 10. Weitzner S, Law DH. Barium granuloma of the rectum. Dig Dis 1972;17:17-22. 11. Saliero JV, Costa Santos C. Barium "granuloma" ofthe rectum a light and electron microscopic analysis. J Submicrosc Cytol 1983;15:1089-94.
Inverted sigmoid diverticulum: a misleading polyp To the Editor: Inverted sigmoid diverticula are polyp-like lesions which may confuse endoscopists. We encountered two cases of such lesions. In the first one, diagnosis was made after a sigmoidectomy, and in the second one after an inadvertent endoscopic removal. The first patient was a 45-year-old man. He complained 587
MD MD MD MD MD MD
Department of Surgery /I Faculty of Medicine Kyushu University Fukuoka, Japan Sawara Hospital Fukuoka, Japan
REFERENCES 1. Callaghan J. The Boerhaave syndrome. Br J Surg 1972;59:414.
Figure 1. Prolapse of the mucosa of the gastric fundus into the left side of the esophagus viewed from within the esophagus during retching. Figure 2. Prolapse of the mucosa of the gastric fundus viewed from within the stomach during retching.
linear, longitudinal, and is located in the left posterior aspect. 2 We reported that resected specimens of the esophagus from patients with Boerhaave's syndrome showed a lack of the muscularis mucosa after the longitudinal tear of the esophagus, hence this may be one contributing factor to this entity.3 Endoscopic findings of repeated prolapse of the gastric mucosa into the esophageal lumen during retching were evident in patients presenting with epigastric pain and/or hematemesis with a precedent history of recurrent early morning retching. Shepherd et a1. 4 proposed the term "prolapse gastropathy syndrome" for such patients. We performed upper gastrointestinal tract endoscopy and observed the process of retching and vomiting during the procedure, with special attention directed to gastric mucosal prolapse. Among 1086 patients who underwent upper gastrointestinal endoscopy, retching occurred and gastric mucosal prolapse into the esophagus was observed in 20 (1.8%). During the endoscopic procedure, a tense knuckle of gastric mucosa was seen to be forcefully and repeatedly prolapsed into the distal esophageal lumen in these 20 patients (Fig. 1). This gastric mucosal prolapse was most commonly seen on the left of the esophageal lumen. Therefore, the 586
2. Enterline H, Thompson J. Motility disorders of the esophagus and spontaneous rupture of the esophagus. Pathology of the esophagus. New York: Springer-Verlag, 1984;55-71. 3. Kuwano H, Matsumata T, Adachi E, et al. Lack of muscularis mucosa and the occurrence of Boerhaave's syndrome. Am J Surg (in press). 4. Shepherd HA, Harvey J, Jackson A, Colin-Jones DG. Recunent retching with gastric mucosal prolapse. A proposed prolapse gastropathy syndrome. Digest Dis Sci 1984;29:121-8.
Barium granuloma of the rectum To the Editor: The incidence of iatrogenic rectal wall infusion of barium is unknown but appears to be very rare. We report a case of a rectal barium granuloma seen as an incidental finding on routine colonoscopy. A 38-year-old man with alternating diarrhea and constipation underwent a barium enema demonstrating a sigmoid polyp. A colonoscopy performed 3 weeks later at another institution showed a benign l-cm tubulovillous adenoma at 28 cm from the anus, which was removed endoscopically. A follow-up colonoscopy 1 year later revealed a 5-mm pale yellowish submucosal non-raised rectal lesion, with intact overlying mucosa, 8 cm from the anal verge. Biopsies showed rectal mucosa with histiocytes filled with granular material suggestive of barium. This lesion was felt likely to represent a submucosal infusion of barium during the barium enema done 1 year earlier. The patient returned 3 years later for surveillance colonoscopy and again the same 5-mm nonraised, pale submucosal lesion 8 cm from the anus was noted (Fig. 1). The lesion was again biopsied (Fig. 2) and an x-ray of the pelvis was performed to demonstrate the lesion radiographically. The first recorded case of a barium granuloma of the GASTROINTESTINAL ENDOSCOPY
tals, thus characterizing a granulomatous reaction. 7 The initial ulcerations usually heal by 8 weeks and either disappear or remain radiographically weeks later.8.9 Other later descriptions include fistulas, pedunculated or sessile lesions abscesses, masses, and proctitis with barium flecks.5.7.8.l~ The rare finding of a barium granuloma more than 2 years after barium enema has been described in two previous cases. In the patient reported by Lewis et al./ an ulcerated I-em lesion at 6 em from the anal verge was seen 2 years after barium enema. In the case of Broadfoot and Martin,a similar to ours, sigmoidoscopy 26 months after barium enema revealed a "smooth to irregular swelling covered by smooth mucosa with possible calcified tissue beneath the mucosa." It appears then that the long-term appearances of persistent barium granulomas is variable. A barium granuloma should be considered when faced with a rectal lesion after a barium enema. The diagnosis is made by biopsy, and it is best to alert the pathologist to look for barium-laden histiocytes in the rectal tissue. l l The natural history of barium granulomas, i.e., resolution, persistent ulceration, or persistent intramucosal lesion remains to be defined. Richard S. Elloway, MD Peter H. DeRidder, MD Division of Gastroenterology William Beaumont Hospital Royal Oak, Michigan
REFERENCES 1. Beddoe HL, Kay S, Kaye S. Barium granuloma of the rectum.
Figure 1. Endoscopic view of a 3-year-old rectal barium granuloma. The lesion was non-raised, pale white, and 5 mm across. Figure 2. Biopsy specimen from the intramucosal barium lesion shown in Figure 1 showing rectal mucosa with histiocytes (arrows) filled with barium (H & E; original magnification x250).
rectum was in 1954, and it had the appearance of a pedunculated tumor. l Lewis et al. 2 found at least 35 cases in the world literature in his 1975 review. By 1986 there were less than 45 cases in the English literature. 3• 4 These previous cases report on lesions that differ endoscopically from that of our patient. The reason for this appears to be the time the lesion was viewed after barium enema, and the nature of the iatrogenic infusion. Animal studies have been inconsistent, but the injection of unsterile barium usually creates a classic ulceration of the bowel wall covered by slough and surrounded by indurated elevated borders, and overhanging ragged mucosa. 5 This typical early appearance was either not seen or missed in our case 3 weeks after barium enema. Such a finding is consistent with previous reports of the relatively inert and non-toxic effect of small amounts of barium on body tissues. 5 The fact that most barium granulomas of the rectum occur within 8 em of the anal verge strongly suggests that insertion of the enema tip probably lacerates the rectal wall to some degree, and barium is able to enter the deeper tissues. 6 An inflammatory reaction ensues with a collection of cells (fibroblasts, multinucleated giant cells, macrophages, and lymphocytes) around the intracytoplasmic barium sulfate crysVOLUME 37, NO.5, 1991
JAMA 1954;154:747-9. 2. Lewis JW, Kerstein MD, Koss N. Barium granuloma of the rectum: an uncommon complication of barium enema. Ann Surg 1975;181:418-23. 3. Broadfoot E, Martin G. Barium granuloma of the rectum. Aust RadioI1977;21:50-2. 4. Arlow FL, D'Angelo DM. Barium granuloma mimicking rectal carcinoma. Henry Ford Hosp Med J 1986;34:213-4. 5. Gaston EA. Barium granuloma ofthe rectum. Dis Colon Rectum 1969;12:241-7. 6. Gardiner H, Roscoe EM. Barium peritonitis a new therapeutic approach. Am J Surg 1973;125:350-2. 7. Rand AA. Barium granuloma ofthe rectum. Dis Colon Rectum 1966;9:20-32. 8. Carney JA, Stephens DH. Intramural barium (barium granuloma) of colon and rectum. Gastroenterology 1973;65:316-20. 9. Carter RW. Barium granuloma of the rectum: a complication of diagnostic barium enema examinations. AJR 1963;89:880-2. 10. Weitzner S, Law DH. Barium granuloma of the rectum. Dig Dis 1972;17:17-22. 11. Saliero JV, Costa Santos C. Barium "granuloma" ofthe rectum a light and electron microscopic analysis. J Submicrosc Cytol 1983;15:1089-94.
Inverted sigmoid diverticulum: a misleading polyp To the Editor: Inverted sigmoid diverticula are polyp-like lesions which may confuse endoscopists. We encountered two cases of such lesions. In the first one, diagnosis was made after a sigmoidectomy, and in the second one after an inadvertent endoscopic removal. The first patient was a 45-year-old man. He complained 587
