Spire Manchester Hospital

As discussed in part 1 of this series, gallbladder mucocele is defined as a build-up of immobile mucus within the gallbladder that can result in extrahepatic biliary obstruction, pressure necrosis of the gallbladder wall and, ultimately, rupture. Although many gallbladder mucoceles are discovered during abdominal ultrasonography while screening for other diseases, patients with mature gallbladder mucoceles or gallbladder rupture can present as an emergency. Medical management with hepatoprotectants, choleretics, antibiotics and suitable diet can be attempted in certain cases, but cholecystectomy remains the gold standard treatment option. If an underlying cause is detected (such as an endocrinopathy), this should be treated accordingly. Mortality rates following gallbladder removal vary from 16–40%. A high mortality rate has been associated with septic bile peritonitis, hyperadrenocorticism and/or pancreatitis as a concurrent disease.

Over the last half century, radiotherapy has been established as a very effective treatment modality for solid tumours. Large numbers of patients owe their lives to this treatment; however, radiotherapy is not without a price. When applied to the pelvic organs, radiotherapy carries potential serious complications, including in the small and large bowels. This article describes the magnitude of the clinical and social problems of radiation bowel disease, presents the histopathological features, and puts these features in the clinical context of the condition. The article will not address prevention and management for radiation bowel disease nor complications outside the gastrointestinal tract.

In rectal cancer patients, the stage of the disease, local spread and distant metastases status drive the treatment decisions to be made. Histopathology remains the gold standard, but preoperative staging, particularly magnetic resonance imaging (MRI), is pivotal for defining surgical planes and finding patients who could potentially benefit from preoperative regimes. Unfortunately, due to a lack of awareness, expertise and practise the quality of rectal cancer MRI and histopathology reporting varies among centres. This paper highlights the most important and frequently occurring radiological and histopathological discrepancies/mistakes to be aware of.

Malignant colorectal polyps (MCRP) have become a major challenge in the field of coloproctology from diagnosis to full treatment. One important facet of the challenge is the histopathological staging of the lesion and identifying various prognostic parameters. The primary aim of this study was to find the interobserver variation amongst 4 experienced gastrointestinal pathologists when assessing important parameters and staging systems (Haggitt, Kikuchi and Ueno) in MCRPs. Four experienced gastrointestinal pathologists independently assessed 56 cases of MCRP, and each pathologist completed a pro forma for each case. The results were collated and statistically analysed. There was a significant variation in the assessments using the various published staging systems agreed upon on important prognostic parameters. None of the staging systems used is suitable for all polyp types or has good reproducibility. There is an urgent need to make pathologists' assessment of MCRPs easier and more reproducible.

Interest has increased in CDX2 gene expression in oesophageal non-goblet-cell columnar metaplasia as recent investigations indicate such metaplasia possesses neoplastic potential. This study aims to assess expression of the transcription factor CDX2 specifically in non-goblet-cell cardia and fundic oesophageal metaplastic tissue, and to compare the location of CDX2 expression in non-goblet-cell specimens to that in goblet-cell specimens. A total of 43 patient specimens (20 fundic-type metaplasia, 42 cardia-type metaplasia and 18 intestinal metaplasia goblet cellpositive) were examined in this study. These were selected over six months from a patient database using the systematised nomenclature of human and veterinary medicine coding system (SNOMED). CDX2 was detected in patient specimens with an anti-CDX2 mouse monoclonal antibody. The types of mucosa in each specimen were confirmed by haematoxylin and eosin (H&E) staining. Fundic specimens were consistently CDX2-negative (0%). CDX2 expression was distinct in 55% of cardia and 100% of intestinal cases. Nearly all cardia-positive cases displayed focal expression (95.5%) and all intestinal cases displayed diffuse distribution of expression. Almost all cardia-and intestinal-positive specimens demonstrated epithelial expression (95.5% and 100%, respectively). The percentage of cardia-positive specimens with deep tissue expression was lower than in intestinal specimens (31.8% vs. 94.4%, respectively). This study confirms CDX2 as an early marker for Barrett’s oesophagus in the absence of goblet cells as expression was noted in cardia metaplasia. CDX2 appears to induce the transformation of the normal oesophageal mucosa to cardia type, which then differentiates to an intestinal type under the influence of gastro-oesophageal reflux disease.

Recent studies have suggested that segmental ablation is the treatment of choice for patients with ingrowing toenails and that the success rate is 96%. This procedure has been common practice among chiropodists for 20 years, usually using phenol in the United Kingdom, and sodium hydroxide in the United States. However, there has been little critical evaluation of the relative merits of the two chemicals, of the period of chemical application, or of the duration of post-operative pain and healing time. We therefore embarked upon a number of controlled prospective studies to examine these questions. A prospective study of 422 procedures for patients with ingrowing toenails (onychocryptosis) shows that good results are achieved by segmental chemical ablation performed by chiropodists in 91% of cases. The average period of post-operative pain is 3.6 days. Similar results are obtained using either 80% phenol or 10% sodium hydroxide. We believe that segmental chemical ablation by a chiropodist is the treatment of choice for the typical patient with an ingrowing toe nail.