![]() ![]() Symptomatic patients were further divided according to their final diagnosis into organic and functional bowel disorders the latter subset was stratified into IBS, chronic functional diarrhoea and chronic constipation. NLH cases were divided into two groups: asymptomatic subjects (a-NLH), who underwent colonoscopy for colorectal cancer screening or family history of colorectal cancer and symptomatic patients (s-NLH), in which colonoscopy was prescribed for IBS-type symptoms (abdominal pain and/or altered bowel habits in the absence of alarm signs or symptoms) or suspected IBD. We selected all cases showing lesions compatible with NLH, for which biopsies from multiple sites (ileum, ascending, transverse, sigmoid colon, and rectum) were taken. We evaluated all colonoscopies performed by a single endoscopist (ACP) from January 2012 to January 2015, at the Endoscopy Unit of the State Hospital of San Marino Republic. Based on this clinical observation, the aim of the present study is to evaluate the prevalence of NLH in adults undergoing colonoscopy in San Marino Republic, and its association with known diseases. ![]() Most of the NLH cases that we have found in our daily practice, underwent colonoscopy for irritable bowel syndrome (IBS)-type symptoms, or suspected IBD, while a minority of them was asymptomatic. In 2010, Krauss et al evaluated the significance of lymphoid hyperplasia in the lower gastrointestinal tract in a cohort of consecutive adult patients and concluded that the presence of colonic NLH is not rare and it may represent a mucosal response to antigenic stimulation, like allergens or pathogens. Kagueyama et al, demonstrated that 39% of adult patients with chronic diarrhoea and a normal colonoscopy had NLH at histological examination of serial biopsies taken from the terminal ileum, ascending colon and rectum. Indeed, NLH frequency in adults might be largely underestimated because it is hard to recognize at WL endoscopy. Published literature includes case reports and small series of patients whether this relates to endoscopy underreporting or to the true rarity of the condition is unclear. NLH can mimic familial polyposis and it has been reported in association with inflammatory bowel disease (IBD), celiac disease (CeD), lymphoma, dysgammaglobulinemia, Ehlers-Danlos syndrome, diversion colitis and food allergies.Īdult NLH is considered a rare finding. In adults, NLH can be asymptomatic, or more rarely presents with gastrointestinal symptoms, like abdominal pain, chronic diarrhoea, and bleeding. However, there have been reports of NLH in children associated with refractory constipation, viral infection, juvenile idiopathic arthritis, connective tissue disease, immunodeficiency, cow’s milk protein hypersensitivity, familial mediterranean fever, and the so-called “autistic enterocolitis”. NLH is commonly seen in the terminal ileum and colon during paediatric endoscopies, and it has been classically considered a paraphysiologic phenomenon in children. Little is known about the epidemiology, pathogenesis, and clinical implications of NLH. Sometimes NLH had a reddish outline, the so-called “red ring sign” (RRS), due to hypervascularization at the base of the follicles, associated with granulocyte infiltrate. When biopsied, these areas always corresponded to clusters of ≤ 10 lymphoid nodules, composed of hyperplastic benign lymphoid tissue, named “nodular lymphoid hyperplasia” (NLH). In our daily practice, we have noted that some patients undergoing colonoscopy showed multiple slightly raised whitish areas, usually < 5 mm in diameter, closely spaced, difficult to see at WL endoscopy and easier to recognize with NBI. Among such techniques, narrow band imaging (NBI) uses optical filters in front of the light source, to narrow the wavelength of the projected light, to enable visualization of micro-vessel morphological changes and to enhance the visibility of both neoplastic and inflammatory mucosal lesions. In the last years, the introduction of advanced imaging techniques has ameliorated the characterization of mucosal lesions and has permitted to detect minimal mucosal changes that might be missed with standard white-light (WL) colonoscopy. However, there are conditions in which symptomatic patients might have a normal colon appearance on colonoscopy, although their intestinal mucosa shows signs of microscopic inflammation at histological examination. Colonoscopy allows direct visualization of the mucosa of the lower gastrointestinal tract and it is a useful tool to investigate symptoms of lower bowel diseases. ![]()
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