Cancfidiasis after cimetidine therapy - Gastrointestinal Endoscopy

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These pa- tients are prone to synchronous or metachronous tumors.3. , 4. For this reason ... Biopsy after vital staining showed esophageal dys- plastic changesĀ ...
stones in man using a pulsed neodymium-YAG laser. Endoscopy 1986; 18:144-5. 19. Nishioka NS, Levins PC, Murray SC, Parrish JA, Anderson RR. Fragmentation of biliary calculi with tunable dye laser. Gastroenterology 1987;93:250-5. 20. Cotton PB, Forbes A, Leung JWC, Dineen L. Endoscopic stenting for long-term treatment of large bile stones: 2- to 5year follow-up. Gastrointest Endosc 1987;33:411-2.

Letters to the Ed itor

Candidiasis after cimetidine therapy

A panendoscopic approach with vital staining for tumors of the upper aerodigestive tract

To the Editor:

To the Editor: Recently, you published a report on in vivo staining of the esophageal mucosa as an aid for the detection of Barrett's esophagus.1 Other papers have been published in the last few months regarding vital staining as a means of early detection of esophageal dysplastic changes. 2 We would like to point out a panendoscopic approach to patients affected by a neoplasia of the upper aerodigestive tract. These patients are prone to synchronous or metachronous tumors. 3 , 4 For this reason we are doing a cooperative study including all patients referred to the hospital for tracheal, bronchial, maxillofacial, or esophageal tumors. All patients are submitted to esophagogastroduodenoscopy and bronchoscopy, and in each case vital staining is performed in the esophagus with toluidine blue 1 % and for the bronchial mucosa by methylene blue 1%. Bronchial staining is time consuming and sometimes not well tolerated by the patients, whereas esophageal staining is quick and much more readily accepted. Biopsy after vital staining showed esophageal dysplastic changes (including second and third degree esophagitis) in 16 of 40 cases (40%) and in 6 of 11 cases (54%) for the bronchial mucosa. We did not find false positive staining in the esophagus, but edema and inflammation were positively stained in the bronchial mucosa in five patients. Although the study is still on going and the number of patients is small, we believe that this panendoscopic approach is reasonable in this type of patient for the early discovery of dysplasia or neoplastic changes of the upper aerodigestive tract. s Sandro Contini, Gian Franco Consigli, Francesco Di Leece, Angelo Casalini, Matteo Chiapasco, Giorgio Ferrari,

MD MD MD MD MD MD

Istituto di Patologia Speciale Chirurgica UniversitiJ di Parma Parma, Italy

REFERENCES

1. Chobanian SJ, Cattan EL, Winters C, et al. In vivo staining with toluidine blue as an adjunct to the endoscopic detection of VOLUME 34, NO.3, 1988

Barrett's esophagus. Gastrointest Endosc 1987;33:99-101. 2. Nishizawa M, Okada T, Hosoi T, Makino T. Detecting early esophageal cancers, with special reference to the intraepithelial stage. Endoscopy 1984;16:92-4. 3. Chavy A, Zimmerman P, Kac J, Zummer K. L'endoscopie oesophagienne chez les malades atteints d'un cancer de la sphere ORL et d'un cancer de l'oesophage. Indications, techniques et resultats. J Fr Otorhinolaryngol 1982;31:500-4. 4. Yellin A, Hill RL, Benfield JR. Bronchogenic carcinoma associated with upper aerodigestive cancers. J Thorac Cardiovasc Surg 1984;91:674-83. 5. Atkins JP, Keane WM, Young KA, Rowe LD, Value of panendoscopy in determination of second primary cancer. Arch OtolaryngoI1984;110:533-4.

Minoli et aI., in a recent study/ have concluded that invasive candidiasis does not complicate short-term cimetidine treatment of duodenal ulcer. They have based these conclusions or the results of biopsy samples taken from the ulcer edge on the healed tissue. We have also recently studied the effect of cimetidine on gastric candidiasis in patients with duodenal ulcer, and our findings are in contrast to those of Minoli et al.1 Twenty patients with duodenal ulcer were treated with cimetidine (1.0 g/day) for 4 weeks, and gastric aspirates were drawn at the beginning and end of the study. There was a significant elevation of gastric pH after therapy with cimetidine. Whereas only three (15%) of the 20 patients had demonstrated pseudohyphae before the treatment, eight (40%) patients showed this invasive form at the end of the therapy. There was also a significant increase in the number of organisms grown on culture after the treatment. In four of the 20 patients the ulcers did not heal, and in three of them there was appearance of pseudohyphae in the gastric aspirates at 4 weeks. There are reports incriminating cimetidine in the causation of Candida peritonitis 2 and Candida septicemia.3 More pertinent to our study are the reports of Candida invasion causing nonhealing of gastric and duodenal ulcers. 4 - 6 Our study suggests that treatment with cimetidine leads to an increased incidence of invasive candidiasis. Minoli et aI,! based their conclusions on the histology of biopsy specimens. Only 23 of the 99 patients had an active ulcer at 4 weeks and 11 at 8 weeks, from which a biopsy could have yielded tissue for examination for Candida. Even for the 23 ulcers still active at 4 weeks, half seemed to be in the process of healing. There is no mention of the size of ulcer at different intervals. Healing or healed scarred tissue is not expected to show replicating fungal elements. We believe that cimetidine leads to an increased incidence of gastric candidiasis and in some patients duodenal candidiasis as well. The latter may be responsible for nonhealing of some of the ulcers. R. Kochhar, S. Singh, P. Talwar, S. K. Mehta,

MD MD MD MD

Departments of Gastroenterology and Medical Microbiology Postgraduate Institute of Medical Education and Research Chandigarh, India

283

REFERENCES 1. Minoli G, Terruzzi V, Butti GC, et a1. Invasive candidiasis does not complicate short-term cimetidine treatment of duodenal ulcer. Gastrointest Endosc 1987;3:227-8. 2. Stark FR, Ninos N, Hutton J, Katz R, Butler M. Candida peritonitis and cimetidine. Lancet 1978;2:744. 3. Triger DR, Goepel JR, Slater DN, Underwood JCE. Systemic candidiasis complicating acute hepatic failure in patients treated with cimetidine. Lancet 1981;2:837-8. 4. Neeman A, Avidor I, Kedish U. Candida infection of benign gastric ulcers in aged patients. Am J GastroenteroI1981;75:2113.

5. Roy A, McCallum RW. Candidiasis of the duodenum: the role of continuous cimetidine therapy. Gastrointest Endose 1984;30:47-8. 6. Thomas E, Reddy KR. Nonhealing duodenal ulceration due to candida. J Clin Gastroenterol 1983;5:55-8.

Safe coagulation of diminutive polyps To the Editor: Recent reports of perforations of the colon associated with the hot biopsy forceps have questioned the safety of the monopolar coagulating forceps of sessile polyps less than 5 mm in size. The necessity of removing these polyps is no longer in debate, however. These facts leave the management of these diminutive polyps in question. Two recent advances in thermal coagulation of gastrointestinal bleeding have emerged: bipolar coagulation and heat probe coagulation. Both of these methods eliminate the risk of sparking. The depth of coagulation and speed of heating are regulated by both of these units so that there is no potential for acute tissue erosion. In the experimental animal, coagulation does not extend to the muscularis. A ground plate is not used, eliminating the patient from becoming part of the electrical arc. To date, 32 polyps less than 0.5 em have been treated in 25 patients using these methods. Fifteen polyps were destroyed with the bipolar device and 17 with the heat probe. The technique is simple. When the polyp is encountered during a colonoscopy, an adequate biopsy is obtained by the cold forceps. The bipolar probe or heat probe is then inserted through the biopsy channel, and the polyp is coagulated. Approximately three I-sec pulses of 50 watts are used with the bipolar probe or 30 to 60 joules using the heater probe. To date, there have been no complications, and repeat visualization at 6 months reveals no recurrence of persistence of the polyps. These findings suggest that this method may be safer for the management of colonic polyps less than 0.5 em in size. John J. O'Connor, MD Washington, DC

Accuracy of estimation of colon polyp size To the Editor: The risk of adenocarcinoma in .colon polyps is closely related to the size of the polyp. The endoscopic estimation of size may be more readily available in the chart, and it may be the only estimation if the polyp was not retrieved (or retrieved in a fragmented state). Anecdotically, many 284

Table 1. Classification of 100 polyps according to risk as measured by pathologist and estimated by colonoscopist

Estimated value per colonoscopist Low risk

Measured value per pathologist Low

risk 50

Medium risk High risk

5 0

Medium risk

High risk

8 29 1

0 3 4

endoscopists complain of poor accuracy in estimation of apparent polyp size. We reviewed our experience with the size estimation on the colonoscopy note compared to the size measured by the pathologist. The reports including the l!lst 100 polyps removed by loop electrocautery for which pathology reports were available were examined. The greatest dimensions of the polyps as estimated by the colonoscopists and measured by the pathologists were compared. The pathologists' measurements were accepted as the "gold standard." Polyps less than 1 em were classified as low risk for malignancy, those from 1 to and including 2 em were considered medium risk, and those greater than 2 em were considered high risk. Our data are expressed in Table 1 according to these classifications. The estimated value was always within one risk class of the measured value, and 83% of the time the risk class was the same. Analyzed another way, the estimated value was within 2 mm of the measured value 79% and within 3 mm 88% of the time. Only 6% of the estimated values underestimated the relative risk of malignancy. As can be seen from the above data, visual estimation of size is reasonably accurate. The measured value is preferable, but if it is not available, the estimated value can be used with some degree of confidence. Mark A. Riner, Robert A. Rankin, Ralph T. Guild III, Don J. Kastens,

MD

MD MD MD

Digestive Diseases and Nutrition Section The University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Transanal excision of rectal villous adenomas To the Editor: Just as surgeons accustomed to traditional procedures have had to become acquainted with endoscopic alternatives (colonoscopic polypectomy being the most obvious but endoscopic biliary surgery another), so also the nonsurgeon endoscopist needs to be familiar with simple traditional surgical procedures that may still be useful, appropriate, and even superior. A case in point is the villous adenoma of the rectum. Every colorectal surgeon and general surgeon experienced in rectal procedures knows that a broad, flat papillary lesion of the rectum may be easily excised, especially if it is close GASTROINTESTINAL ENDOSCOPY