Positive blood cultures growing Staphylococcus epidermidis and Propionibacterium species were considered to represent skin contaminants (15 among the 264 cultures on upper gastrointestinal endoscopy patients). DISCUSSION It is probably safe to state that upper gastrointestinal endoscopy is not associated with an increased frequency of bacteremia in the usual patient. It was thought that the trauma, especially of the pharynx, resulting from the passage of the fiberoptic 'scope, might induce bacteremia; however, this did not prove to be the case. Further work is needed to clarify the question of bacteremia after manipulation of the pancreatic ductor biliary tree because bacterial infection in an obstructed duct would appear to be a potential setting for the development of bacteremia. Colonoscopy, on the other hand, appears to carry a somewhat greater hazard of bacteremia, and special consideration to this matter is indicated when patients with valvular heart disease or those on an immunosuppressant regimen are examined. The transient nature of the bacteremia in these patients may be a reflection of the adequate removal of the bacteria by the reticuloendothelial system of the liver. Therefore, neither upper nor lower gastrointestinal endoscopy imposes an undue hazard for the average patient. Special precautions should be taken - and possibly these procedures should be avoidedin patients in whom the consequences of bacteremia might be serious.
REFERENCES 1. SLADE N: Bacteriaemia and septicaemia after urological operations. Proc R Soc Med 51:331,1958 2. COBE HM: Transitory bacteremia. Oral Surg, Oral Med & Oral Path 7:609, 1954 3. RICHARDS jH: Bacteremia following irritation of foci of infection. lAMA 99:1496, 1932 4. FELIX jE, ROSEN 5, App GR: Detection of bacteremia afterthe use of an oral irrigation device in subjects with periodontitis. Periodonto/42:785, 1971 5. LEFROCK jL, ELLIS CA, TURCHIK jB, WEINSTEIN L: Transient bacteremia associated with sigmoidoscopy. N Engl I Med 289:467,1973 6. BUCHMAN E, BERGLUND EM: Bacteremia following sigmoidoscopy. Am Heart I 60:863, 1960 7. UNTERMAN 0, MILBERG MB, KRANIS M: Evaluation of blood cultures after sigmoidoscopy. N Engl I Med 257:773,1957 8. LEFROCK jL, ELLIS CA, KLAINER AS, WEINSTEIN L: Transient bacteremia associated with barium enema. Arch Int Med 136:835, 1975 9. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNERj, YOUNG VM, WIERNIK PH: Esophagoscopy as a source of Pseudomonas aeruginosa sepsis in patients with acute leukemia: the need for sterilization of endoscopes. Gastroenterology 67:912, 1974 10. COWAN ST, STEEL Kj: Manual for the Identification of Medical Bacteria. Cambridge (England), Cambridge University Press, 1965
of special note Melanosis duodeni William M. Bisordi, MD Martin S. Kleinman, MD* University of Rochester School of Medicine and Dentistry and Gastroenterology Unit Strong Memorial Hospital Rochester, New York
The accumulation of black pigment in the colonic mucosa was first described in 1829' and has been extensively reviewed. 2 Melanin pigmentation has been classically described in the colon, but there are reports of pigment occurring in the appendix, mesenteric lymph nodes 3 , ileum', and possibly the esophagus. s We recently stud ied a patient who had the surprising finding of pigment deposition in the villi of the duodenal mucosa. A careful search of the world's literature failed to reveal a similar case. CASE REPORT A 43-year-old insulin-dependent diabetic black man with chronic renal failure was being treated by chronic dialysis at Strong Memorial Hospital. Gastroenterologic consultation was requested to evaluate intermittent episodes of abdominal pain suggestive of duodenal ulcer. At endoscopy (Olympus GIF-D2) no ulcer was seen. The duodenal bulb was friable. The folds were thickened, and a peculiar deposition of pigment in the duodenal mucosa was observed. The entire mucosa beyond the bulb in the second part of the duodenum had a "peppered" appearance. (Figure 1). Multiple biopsy specimens were taken. The esophagus and stomach were normal. The rectal mucosa showed no signs of melanosis coli by sigmoidoscopic examination. Barium contrast studies of the patient's stomach and duodenum were normal. The patient vigorously denied ingestion of cathartics such as cascara. His only medications were insulin and, occasionally, liquid aluminum hydroxide gel to lower the serum phosphate. The patient was given intensive antacid therapy with subsequent improvement of his pain. Sections of duodenal mucosa stained with hematoxylinand-eosin (Figure 1) disclosed pigment deposited in the tips of the villi. Specific staining methods confirmed this pigment as melanin. ·Reprint requests: Martin 5. Kleinman, MD, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, New York 14642.
Figure 1. Endoscopic photograph of the first portion of the duodenum (left). Note the peppered appearance of the duodenal mucosa. The bleeding was caused by biopsy. In this hematoxylin-and-eosin section (40x) of the duodenal mucosa (right), the arrow points to a collection of pigment just below the epithelial surface. VOLUME 23, NO.1, 1976
37
DISCUSSION Careful review of the literature has failed to reveal an example of melanin staining of the duodenum on surgical, postmortem, or endoscopic evaluation. Pigment deposition in the rectum has been associated with the ingestion of cathartics of the anthracine type and is thought to be related to fecal stasis. The pa'tient herein described denied the use of cathartics or the ingestion of unusual foods or home remedies. The melanin pigment in the duodenal mucosa was clearly extracellular, collecting in clumps below the epithelial surface. The cause and clinical significance of this unusual finding remains obscure.
REFERENCES 1. CRUVEILHEIR j: Cancer avec melanose. In Anatomic Patho/ogique du Corps Humain, ). B. Bailliere (ed.), Paris, 1829. p. 6 2. WITIOESCH IH, JACKMAN RI, McDONALD jR: Melanosi coli: general
review and a study of 887 cases. J Dis Colon Rectum 1: 172, 1958 a pathological study. Its experimental production in monkeys. J Med Sci 6:654, 1940 4. WON KH, RAMCHAND 5: Melanosis of the ileum: case report and electron microscopic study. Am J Dig Dis 15:57, 1940 5. ANDREJAUKAS G: Rare cases of esophagitis with melanosis. Medicine 18:13, 1937
3. RODEN B: Melanosis coli -
~:
Adenocarcinoma occurring in a hyperplastic gastric polyp Removal by electrosurgical polypectomy
John P. Papp, MD* Department of Internal Medicine Michigan State University and Blodgett Memorial Hospital Grand Rapids, Michigan
Julian I. Joseph, MD Department of Pathology Mary's Hospital Grand Rapids, Michigan
Polyps of the stomach are rare.'-2 They may be benign or malignant tumors, hyperplastic (regenerative), or composed of ectopic tissue. Hyperplastic polyps occur from 3 to 8 times more commonly than adenomatous polyps. Although the frequency of associated malignancy has been reported to vary from 8% to 28%, malignancy occurring in a hyperplastic polyp is said not to occur. 3- 4 This report descri bes partial gastric outlet obstruction due to a hyperplastic polyp. After removal by endoscopic electrosurgery, it was found that the polyp was partially composed of an adenocarcinoma without invasion into the stalk. CASE REPORT An 8S-year-old woman had had midepigastric pain and vomiting for 4 weeks before admission. Emesis occurred 60 to 120 minutes after eating and relieved the midepigastric pain. Solid food increased her pain. She had lost 10 pounds. Physical examination revealed tenderness to palpation of the midepigastric area. A succussion splash was present. The extent of liver dullness was 11 cm. There were no abdominal masses. The hemoglobin was 12.S g, and the bematocrit was 40%. An electrocardiogram showed first degree A-V block. Upper gastrointestinal barium radiography revealed a polyp extending from the distal antrum through the pylorus into the duodenal bu Ib (Figure 1a). Gastroscopy with the Olympus GIF endoscope showed severe superficial gastritis throughout the stomach. A 1 cm stalk was seen to protrude into the duodenal bulb through the pylorus. The polyp stalk was grasped by biopsy forcep, and the polyp head was brought into the antrum. The polyp was snared, and the stalk was transected at setting 7 of the Cameron-Miller electrocoagulation unit. The polyp was resnared and withdrawn with the endoscope applying constant suction. The external appearance was lobulated (Figure 1b). The stalk was light yellow and measured 0.8 cm. The main portion of the polyp was light brown. On microscopic exam'Reprint requests: John P. Papp, MD, 2500 Oakwood Drive SE, Grand Rapids, Michigan 49506.
38
FIGURE 1 (a) A polypoid lesion contrasted by barium is seen in the duodenal bulb. (b) A brown, lobulated polyp measuring 2.5 cmf x 2 cm is seen arising from a light yellow stalk. (c) Carcinomatous involvement ofa hyperplastic polyp is seen (H & Ex 55). (d) Invasion of the stroma of the hyperplastic polyp by signet cell carcinoma (H & Ex 430). GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. SLADE N: Bacteriaemia and septicaemia after urological operations. Proc R Soc Med 51:331,1958 2. COBE HM: Transitory bacteremia. Oral Surg, Oral Med & Oral Path 7:609, 1954 3. RICHARDS jH: Bacteremia following irritation of foci of infection. lAMA 99:1496, 1932 4. FELIX jE, ROSEN 5, App GR: Detection of bacteremia afterthe use of an oral irrigation device in subjects with periodontitis. Periodonto/42:785, 1971 5. LEFROCK jL, ELLIS CA, TURCHIK jB, WEINSTEIN L: Transient bacteremia associated with sigmoidoscopy. N Engl I Med 289:467,1973 6. BUCHMAN E, BERGLUND EM: Bacteremia following sigmoidoscopy. Am Heart I 60:863, 1960 7. UNTERMAN 0, MILBERG MB, KRANIS M: Evaluation of blood cultures after sigmoidoscopy. N Engl I Med 257:773,1957 8. LEFROCK jL, ELLIS CA, KLAINER AS, WEINSTEIN L: Transient bacteremia associated with barium enema. Arch Int Med 136:835, 1975 9. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNERj, YOUNG VM, WIERNIK PH: Esophagoscopy as a source of Pseudomonas aeruginosa sepsis in patients with acute leukemia: the need for sterilization of endoscopes. Gastroenterology 67:912, 1974 10. COWAN ST, STEEL Kj: Manual for the Identification of Medical Bacteria. Cambridge (England), Cambridge University Press, 1965
of special note Melanosis duodeni William M. Bisordi, MD Martin S. Kleinman, MD* University of Rochester School of Medicine and Dentistry and Gastroenterology Unit Strong Memorial Hospital Rochester, New York
The accumulation of black pigment in the colonic mucosa was first described in 1829' and has been extensively reviewed. 2 Melanin pigmentation has been classically described in the colon, but there are reports of pigment occurring in the appendix, mesenteric lymph nodes 3 , ileum', and possibly the esophagus. s We recently stud ied a patient who had the surprising finding of pigment deposition in the villi of the duodenal mucosa. A careful search of the world's literature failed to reveal a similar case. CASE REPORT A 43-year-old insulin-dependent diabetic black man with chronic renal failure was being treated by chronic dialysis at Strong Memorial Hospital. Gastroenterologic consultation was requested to evaluate intermittent episodes of abdominal pain suggestive of duodenal ulcer. At endoscopy (Olympus GIF-D2) no ulcer was seen. The duodenal bulb was friable. The folds were thickened, and a peculiar deposition of pigment in the duodenal mucosa was observed. The entire mucosa beyond the bulb in the second part of the duodenum had a "peppered" appearance. (Figure 1). Multiple biopsy specimens were taken. The esophagus and stomach were normal. The rectal mucosa showed no signs of melanosis coli by sigmoidoscopic examination. Barium contrast studies of the patient's stomach and duodenum were normal. The patient vigorously denied ingestion of cathartics such as cascara. His only medications were insulin and, occasionally, liquid aluminum hydroxide gel to lower the serum phosphate. The patient was given intensive antacid therapy with subsequent improvement of his pain. Sections of duodenal mucosa stained with hematoxylinand-eosin (Figure 1) disclosed pigment deposited in the tips of the villi. Specific staining methods confirmed this pigment as melanin. ·Reprint requests: Martin 5. Kleinman, MD, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, New York 14642.
Figure 1. Endoscopic photograph of the first portion of the duodenum (left). Note the peppered appearance of the duodenal mucosa. The bleeding was caused by biopsy. In this hematoxylin-and-eosin section (40x) of the duodenal mucosa (right), the arrow points to a collection of pigment just below the epithelial surface. VOLUME 23, NO.1, 1976
37
DISCUSSION Careful review of the literature has failed to reveal an example of melanin staining of the duodenum on surgical, postmortem, or endoscopic evaluation. Pigment deposition in the rectum has been associated with the ingestion of cathartics of the anthracine type and is thought to be related to fecal stasis. The pa'tient herein described denied the use of cathartics or the ingestion of unusual foods or home remedies. The melanin pigment in the duodenal mucosa was clearly extracellular, collecting in clumps below the epithelial surface. The cause and clinical significance of this unusual finding remains obscure.
REFERENCES 1. CRUVEILHEIR j: Cancer avec melanose. In Anatomic Patho/ogique du Corps Humain, ). B. Bailliere (ed.), Paris, 1829. p. 6 2. WITIOESCH IH, JACKMAN RI, McDONALD jR: Melanosi coli: general
review and a study of 887 cases. J Dis Colon Rectum 1: 172, 1958 a pathological study. Its experimental production in monkeys. J Med Sci 6:654, 1940 4. WON KH, RAMCHAND 5: Melanosis of the ileum: case report and electron microscopic study. Am J Dig Dis 15:57, 1940 5. ANDREJAUKAS G: Rare cases of esophagitis with melanosis. Medicine 18:13, 1937
3. RODEN B: Melanosis coli -
~:
Adenocarcinoma occurring in a hyperplastic gastric polyp Removal by electrosurgical polypectomy
John P. Papp, MD* Department of Internal Medicine Michigan State University and Blodgett Memorial Hospital Grand Rapids, Michigan
Julian I. Joseph, MD Department of Pathology Mary's Hospital Grand Rapids, Michigan
Polyps of the stomach are rare.'-2 They may be benign or malignant tumors, hyperplastic (regenerative), or composed of ectopic tissue. Hyperplastic polyps occur from 3 to 8 times more commonly than adenomatous polyps. Although the frequency of associated malignancy has been reported to vary from 8% to 28%, malignancy occurring in a hyperplastic polyp is said not to occur. 3- 4 This report descri bes partial gastric outlet obstruction due to a hyperplastic polyp. After removal by endoscopic electrosurgery, it was found that the polyp was partially composed of an adenocarcinoma without invasion into the stalk. CASE REPORT An 8S-year-old woman had had midepigastric pain and vomiting for 4 weeks before admission. Emesis occurred 60 to 120 minutes after eating and relieved the midepigastric pain. Solid food increased her pain. She had lost 10 pounds. Physical examination revealed tenderness to palpation of the midepigastric area. A succussion splash was present. The extent of liver dullness was 11 cm. There were no abdominal masses. The hemoglobin was 12.S g, and the bematocrit was 40%. An electrocardiogram showed first degree A-V block. Upper gastrointestinal barium radiography revealed a polyp extending from the distal antrum through the pylorus into the duodenal bu Ib (Figure 1a). Gastroscopy with the Olympus GIF endoscope showed severe superficial gastritis throughout the stomach. A 1 cm stalk was seen to protrude into the duodenal bulb through the pylorus. The polyp stalk was grasped by biopsy forcep, and the polyp head was brought into the antrum. The polyp was snared, and the stalk was transected at setting 7 of the Cameron-Miller electrocoagulation unit. The polyp was resnared and withdrawn with the endoscope applying constant suction. The external appearance was lobulated (Figure 1b). The stalk was light yellow and measured 0.8 cm. The main portion of the polyp was light brown. On microscopic exam'Reprint requests: John P. Papp, MD, 2500 Oakwood Drive SE, Grand Rapids, Michigan 49506.
38
FIGURE 1 (a) A polypoid lesion contrasted by barium is seen in the duodenal bulb. (b) A brown, lobulated polyp measuring 2.5 cmf x 2 cm is seen arising from a light yellow stalk. (c) Carcinomatous involvement ofa hyperplastic polyp is seen (H & Ex 55). (d) Invasion of the stroma of the hyperplastic polyp by signet cell carcinoma (H & Ex 430). GASTROINTESTINAL ENDOSCOPY
