Endoscopic Aspects of Gastric Syphilis

Introduction. Considered as a rare event, gastric syphilis (GS) is reported as an organic form of involvement. Low incidence of GS emphasizes the importance of histopathological analysis. Objective. We aim to characterize GS endoscopic aspects in an immunocompetent patient. Case Report. A 23-year-old man presented with epigastric pain associated with nausea, anorexia, generalized malaise and 11 kg weight loss that started 1 month prior to his clinical consultation. Physical examination was normal except for mild abdominal tenderness in epigastrium. Endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions. Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes. Syphilis serologies were positive for VDRL and Treponema pallidum reagents. Immunohistochemical tests were positive for Treponema pallidum and CD138. The patient was treated with penicillin, leading to resolution of his clinical complaints and endoscopic findings. Conclusion. Diagnosis suspicion of GS is important in view of its nonspecific presentation. Patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis

Diagnosis of superficial esophageal squamous cell carcinoma in patients with head and neck cancer by probe-based confocal laser endomicroscopy

Introdução: Os programas de vigilância endoscópica de pacientes com câncer de cabeça e pescoço são capazes de detectar carcinoma escamocelular sincrônico ou metacrônico em até 15% de pacientes. Tanto a cromoendoscopia com solução de Lugol, quanto a cromoscopia digital com narrow-band imaging popularizaram-se como ferramentas endoscópicas para aprimoramento diagnóstico da mucosa esofágica. Entretanto, são identificadas, frequentemente, múltiplas lesões não neoplásicas secundárias ao intenso processo inflamatório crônico, fundamentado no conceito de \"cancerização de campo\", particularmente naqueles pacientes com histórico de consumo prolongado e excessivo de álcool. Sendo assim, lesões suspeitas à cromoendoscopia não correspondem necessariamente à neoplasia, o que explica a alta incidência de lesões falso-positivas. Consequentemente, são métodos que ainda requerem biópsias tradicionais para confirmação histológica. O cenário ideal para a vigilância endoscópica desses pacientes seria a possibilidade de visualizar in vivo a estrutura celular da mucosa esofágica, com imagens microscópicas em tempo real, além de auxiliar nas biópsias direcionadas e orientar ressecção endoscópica, otimizando-se, assim, o atendimento ao paciente. A técnica da endomicroscopia confocal a laser com sonda pode proporcionar esses recursos, pois permite a aquisição de imagens ultramagnificadas de 1.000 vezes, em tempo real, in vivo, a nível celular e microvascular. Objetivo: Avaliar acurácia da endomicroscopia confocal no diagnóstico diferencial de lesões esofágicas não neoplásicas e neoplásicas Lugol negativas em pacientes com câncer de cabeça e pescoço sob vigilância endoscópica. Pacientes e métodos: Foram incluídos, prospectivamente, 27 pacientes com câncer de cabeça e pescoço tratados que apresentaram lesões esofágicas Lugol negativas durante a vigilância endoscópica. Após investigação com auxílio da endomicroscopia confocal, foram realizadas biópsias ou ressecção endoscópica das lesões estudadas, para confirmação histológica. As biópsias foram examinadas por um patologista sênior que desconhecia os resultados da endomicroscopia confocal (com cegamento). Resultados: A média de idade dos pacientes foi de 59 anos (DP 8,8) e 70,4% eram do sexo masculino. Todos os pacientes eram tabagistas, 22 deles (81,5%) com histórico de consumo de álcool. As localizações de câncer de cabeça e pescoço foram: cavidade oral (n = 13), laringe (n = 10) e faringe (n = 4). Trinta e sete lesões esofágicas Lugol negativas detectadas em 27 pacientes foram analisadas. Os diagnósticos finais foram carcinoma escamocelular em 17 pacientes e lesões benignas em 20 pacientes. A sensibilidade, especificidade e acurácia da endomicroscopia confocal para diagnóstico histológico de carcinoma escamocelular esofágico em pacientes com câncer de cabeça e pescoço prévio corresponderam a 94,1%, 90,0% e 91,9%, respectivamente. Conclusão: A endomicroscopia confocal apresentou elevada acurácia diagnóstica no exame histológico em tempo real de lesões esofágicas Lugol negativas em pacientes com câncer de cabeça e pescoço.Background and Aims: The endoscopic surveillance programs of patients with head and neck cancer detect synchronous or metachronous esophageal squamous cell carcinoma in up to 15% of patients. Both chromoendoscopy with Lugol\'s solution and narrow-band imaging have been popularized as endoscopic tools for the diagnostic improvement of the esophageal mucosa. However, multiple non-neoplastic lesions are frequently identified secondary to the intense chronic inflammatory process, based on the field cancerization concept, especially in patients with a history of chronic and excessive alcohol consumption. Therefore, all suspicious lesions detected by chromoendoscopy do not necessarily correspond to neoplasia, which explains the high incidence of false-positive lesions. For that reason, these are methods that still require traditional biopsies to confirm the diagnosis. The ideal scenario for endoscopic surveillance of these patients would be able to visualize in vivo the cellular structure of the esophageal mucosa, with microscopic images in real-time, in addition to getting guidance for targeted biopsies and endoscopic resection, thereby optimizing patient care. The probe-based confocal laser endomicroscopy technique may provide these features, as it allows the acquisition of in vivo real-time 1.000-fold ultra-magnifying imaging at the cellular and microvascular level. Aim: This study aims to evaluate the accuracy of confocal endomicroscopy for the differential diagnosis of non-neoplastic and neoplastic Lugol-unstained esophageal lesions in patients with head and neck cancer. Methods: Twenty-seven patients with head and neck cancer who presented Lugol-unstained esophageal lesions at endoscopic surveillance were prospectively included. After an investigation by confocal endomicroscopy, subsequent biopsy or endoscopic resection of the lesions was performed for histological confirmation. The biopsies were examined by a senior pathologist who was unaware of the confocal endomicroscopy findings (blinded). Results: The patients\' mean age was 59 years (SD 8.8) and 70.4% were men. All patients were smokers, 22 of them (81.5%) had a history of alcohol consumption. The locations of head and neck cancer were oral cavity (n= 13), larynx (n= 10), and pharynx (n= 4). Thirty-seven esophageal lesions detected in 27 patients were studied. The final diagnoses were squamous cell carcinoma in 17 patients, and benign lesions in 20 patients. The sensitivity, specificity, and accuracy of confocal endomicroscopy for the histologic diagnosis of esophageal squamous cell carcinoma in patients with head and neck cancer were 94.1%, 90.0%, and 91.9%, respectively. Conclusion: The confocal endomicroscopy was highly accurate for the real-time histology of Lugol-unstained esophageal lesions in patients with head and neck cancer

Esophageal Intramural Pseudodiverticulosis: A Rare Endoscopic Finding

A 76-year-old woman, presenting with a 4-year history of progressive dysphagia, was submitted to endoscopic examination. The upper endoscopy revealed a proximal esophageal stricture and inflammatory mucosa associated with multiples small orifices in the esophageal wall, some of them fulfilled with white spots suggestive of fungal infection. This was a typical endoscopic finding of esophageal intramural pseudodiverticulosis, a benign and rare condition, related to chronic esophagitis and others comorbid states, such as gastroesophageal reflux disease or infectious esophagitis, diabetes mellitus, alcohol consumption, and achalasia. Dysphagia is the predominant symptom and can be accompanied by esophageal stricture in 80% to 90% of patients. The pathogenesis is unknown, and as the pseudodiverticulosis is an intramural finding, endoscopy biopsies are inconclusive. The main histological finding is dilation of the submucosal glands excretory ducts, probably obstructed by inflammatory cells. The treatment consists in management of the underlying diseases and symptoms relief. In this particular case, the patient was submitted to antifungal drugs followed by endoscopic dilation with thermoplastic bougies, with satisfactory improvement of dysphagia