Baishideng Publishing Group Inc, 8226 Regency Drive, Pleasanton, CA 94588, USA. Erythematous, Annular, Scaling Patches on the Skin. Pityriasis rosea begins with a herald patch that can appear as an. The most common initial sign is a 2- to 10-cm salmon-colored patch or plaque known as the herald patch. The herald patch is present 40–76% of the time. Salmon patch on the glabella of a newborn. WebMD does not provide medical advice, diagnosis or treatment. Clinical Challenge: Widespread Salmon-Colored Patches. A 68-year-old man is referred to a podiatry clinic for evaluation and treatment of a nail condition manifested. Bilateral Papulosquamous Lesions. Salmon-colored patch with a collarette of fine scale inside the well-demarcated border (herald patch); generalized. World Journal of Gastrointestinal Endoscopy. INTRODUCTIONEctopic gastric mucosa (EGM) can occur in the fore- , mid- and hindgut and, conceivably, at any of their derivatives. The origin of EGM is either heterotopic (congenital) or metaplastic (acquired). The reported incidence of EGM in the endoscopic literature ranges from 0. Heterotopic gastric mucosa (HGM) patches are congenital gastrointestinal abnormalities and have been reported to occur anywhere along the gastrointestinal tract from mouth to anus. At endoscopy, the HGM appears as a mainly flat or slightly raised, well circumscribed red- orange salmon- colored patch. This is mainly a solitary patch but can be multiple measuring from a few millimeters to several centimeters. Complications of HGM patches include dysphagia, upper gastrointestinal bleeding. Interestingly, HGM in the duodenum may also manifest as dyspepsia. Fistula diagnosis was made during investigation of relapsing episodes of acute dyspnea and upper abdominal discomfort during the previous six months. The patient’s family history was unremarkable except that his father was treated for tuberculosis twenty years previously. The patient was diagnosed with allergic rhinitis and mushroom allergy; he never smoked and rarely drank alcohol. For the last twenty years the patient had suffered from relapsing episodes of lower respiratory tract infections which were treated with antibiotics and one year ago he underwent coronary artery stenting. Almost all Goffin’s Cockatoos have a pink or salmon-colored patch near their cheeks, which gives them the appearance of blushing. Like other Cockatoos. Salmon patch a salmon-colored nevus flammeus usually found over the eyelids, between the eyes, or on the forehead. It is the most common vascular lesion of infancy. The round orange patches are hemorrhagic infarctions on the peripheral retinal surface. They are caused by sickling occlusion of arterioles. Doctor insights on: Salmon Patches Share. Salmon patch is the name given to a group of birth marks in babies. The patient had previously been investigated for these acute dyspnea episodes and, as cardiologic and other routine evaluations were negative, he was started on bronchodilators and antibiotics without subsequent improvement. As his symptoms persisted, the patient developed stress- related sleeping disturbances and panic disorder and was followed up by a psychiatrist. After some weeks the patient consulted a gastroenterologist. As he could not tolerate endoscopy he underwent baium follow through which revealed an esophagobronchial fistula tract (Figure 1) and he was referred for further investigation and treatment. Figure 1 Barium follow through of the esophagus revealing the esophago- bronchial fistula. On admission clinical examination was negative. The patient was on antidepressants, beta- blockers, clopidogrel, aspirin and simvastatin. Laboratory tests revealed nothing. Serum angiotensin converting enzyme was within normal limits. Mantoux was 1. 8 mm at 4. Differential diagnosis included congenital fistula, active or latent tuberculosis, granulomatous diseases, neoplasia and possible blind trauma. Trauma probability was immediately excluded as the patient had never had any kind of endoscopy or history of complicated esophageal foreign body ingestion. Congenital fistula was improbable as the patient had been free of symptoms until twenty years of age. Thorax high resolution computed tomography showed infiltrations in the right lobe in contact with the mediastinum but not of lymph nodes and Tc- 9. Upper gastrointestinal endoscopy was performed with deep sedation. In the mid esophagus at 2. Figures 2. A and B). A small gastro- esophageal hernia extended from 4. Barrett’s esophagus. In the stomach there was mild gastritis with some erosions and biopsies were taken. The first and second part of the duodenum was normal. Bronchoscopy including cytology, PCR and cultures for mycobacterium tuberculosis and other pathogens were negative. Figure 2 Endoscopic view of the proximal opening (open and closed) of the esophago- bronchial fistula caused by heterotopic gastric mucosa. Furthermore, the mucosa was covered by tall, columnar foveolar epithelium, which at the edges merged with the adjacent esophageal stratified squamous epithelium. Goblet cells were not identified. There was no evidence of dysplasia. Microorganisms with the morphological characteristics of Helicobacter pylori were not observed with Giemsa special stain (Figures 3. A and B). Figure 3 Heterotopic gastric mucosa in middle esophagus. At the lamina propria cardiac and fundic- type glands are evident (H& E, . Helicobacter pylori micro- organisms were observed with Giemsa special stain. We decided on a non- surgical therapeutic endoscopic procedure. During upper gastrointestinal endoscopy performed by one of us (E. V. T), a sclerotherapy catheter was inserted through which 1 m. L of ready to use synthetic surgical glue (Glubran 2, GEM Srl, Viareggio Italy) closed the fistula opening with excellent results (Figures 4. A and B). The patient is completely asymptomatic at 6 mo follow up. Figure 4 Gastrograffin follow through 1 mo after endoscopic therapy of esophago- bronchial fistula with glue. DISCUSSIONTo the best of our knowledge this is the first case of esophago- broncheal fistula due to HGM in the esophagus and the second case ever reported on esophageal fistula related to HGM. The other case reported on a 5. In fact, HGM patches have been associated with a broad spectrum of symptoms such as ulceration, bleeding, perforation and malignant transformations. If asymptomatic the clinical importance of esophageal HGM patches is debatable. Although pertechnetate scintigraphy (Tc- 9. Traditionally, esophageal HGM is considered a distinct entity from Barrett’s esophagus. The presence of specialized columnar epithelium characterized by acid mucin- containing goblet cells has been accepted as diagnostic of Barrett’s esophagus. The American College of Gastroenterology and its Practice Parameters Committee provided a definition of Barrett’s esophagus as a change in the esophageal epithelium of any length that can be recognized at endoscopy and is confirmed by biopsy to have intestinal metaplasia. A healing process of the lower esophagus in response to injury from gastric reflux is believed to be its primary etiology. Of interest, immunohistological studies suggested a similarity between Barrett epithelium and HGM patch. These studies have shown that Barrett epithelium and HGM have the same mucin core protein expression and cytokeratin pattern (cytokeratins 7 and 2. However, in the study of Borhan- Manesh et al. On the other hand, it is possible that occasional cases of Barrett's mucosa at the distal end of the esophagus are nothing but the failure of the squamous epithelium to carpet the area resulting in Barrett’s epithelium. However, the 1. 0 cm distance of HGM from the gastro- esophageal junction and the absence of concomitant Barrett’s lesions exclude this probability in our patient. Furthermore, histological changes of the squamous epithelium distally adjacent to the HGM area in our patient did not show changes consistent with reflux esophagitis. Despite the fact that the HGM patch in this patient was Helicobacter pylori negative, we cannot exclude the probability that Helicobacter pylori causing chronic gastritis in our patient may also have previously colonized the HGM patch contributing to ulcerogenesis and subsequent fistula formation. We decided to treat our patient using a technique similar to that applied in the previous fistula case. The adhesive was selectively applied into the fistula track via a 1. Four days later, a further 2 m. L of fibrin adhesive was selectively instilled into the fistula opening. Treatment of symptomatic HGM is necessary in order to relieve symptoms and to further prevent the development of other complications. Efficient treatment can be successfully offered with the use of proton pump inhibitors. If appropriate and when medical therapy fails to promote regression of symptoms, transcervical or endoscopic biopsy and/or excision are warranted. Endoscopic laser ablation is an acceptable treatment modality because of the rarity of malignant transformation. However, if a small focus of malignancy is suspected, complete local excision with narrow margins is the treatment of choice in order to exclude further progression. Mucosectomy of the patch aided with chromoendoscopy with 0. In general, small in size and length, well- defined, non- inflamed fistula with no concomitant regional abscess can be treated with glue. In conclusion, we presented herein an exceptional case of symptomatic esophageal gastric heterotopia with esophago- bronchial fistula formation. We have discussed pathophysiological and diagnostic issues and have described the endoscopic therapy which should be the treatment of first choice in such cases.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
November 2017
Categories |