Endoscopic Findings of Protein-Losing Enteropathy Michio Tanaka 1 , Tadayoshi Takemoto 2 1The Third Department of Internal Medicine, Toyama Medical and Pharmaceutical University 2The First Department of Internal Medicine, Yamaguchi University, School of Medicine pp.759-772
Published Date 1985/7/25
DOI https://doi.org/10.11477/mf.1403109906
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 Protein-losing enteropathy is a rather rare abnormal state of the intestinal tract. In Japan, 125 cases with protein-losing enteropathy have been reported in the past 15 years. And small intestinal diseases were found in 118 cases out of 125. The most frequent small intestinal disease combined with proteinlosing enteropathy was intestinal lymphangiectasia (63 cases).

 Endoscopic findings of intestinal lymphangiectasia were first reported by us in 1974 (Case 1 in Table 1) 1).“Scattered white spot”, “white villus”(Fig. 1a) and color change at the villous tip (Fig. 1b) were noticed in the duodenal mucosa. Oozing of the chyle-like fluid was also observed after rubbing the mucosal surface endoscopically (Fig. 1c). Such findings were not recognized in the jejunum (Fig. 1d) and ileum. Dissecting microscopic and histological examination of biopsy specimens obtained from the duodenum was done. Partial defects of the villous tip were noticed under the dissecting microscope (Fig. 2a). This shape was very similar to that of villi observed by endoscopy (Fig. 1b). Scanning electron micrography revealed that the epithelial layer of the villus tip was exfoliated and the lamina propria mucosae was exposed (Fig. 3a and b). Histological studies including transmission electron microscopic examination revealed dilated central lacteal, extruded epithelial layer at villous tip (Fig. 4a), lipid droplets in the absorptive epithelial cell and intracellular space (Fig. 4b), dilatation of intracellular space, closure of tight junction (Fig. 5a) and protein-like substance and chylomicron-like substance in the dilated intracellular space (Fig. 5b).

 After that first case report, we carried out endoscopic examination of the duodenum, jejunum and ileum in five cases with protein-losing enteropathy (Case 2~6 in Table 1). These five cases had the small intestinal diseases of lymphangiectasia (Fig. 6a~d), ileal erosions (Fig. 7a), Crohn's disease, malignant lymphoma (Fig. 7b and c) or thoracic duct occlusion with duodenal elevated lesion (Fig. 7d). It was very difficult to presume the relationship between endoscopic findings and the phenomenon of proteinlosing. For instance, in some cases without proteinlosing enteropathy,“scattered white spot”and“white villus”in the small intestine were as widely distributed as in cases with protein-losing enteropathy combined with intestinal lymphangiectasia (Fig. 8).

 In Japan, small intestinal endoscopic findings have been reported in 26 cases with protein-losing enteropathy (Table 2). But most of these cases have been examined endoscopically within the limits to the duodenum and upper part of the jejunum.

 We have succeeded in making“scattered white spot”by means of experimental blockage of rat's mesenteric lymph vessel (Fig. 10). Marked dilated villous lacteal filled with chylomicron was the characteristic of the histologic appearance of “scattered white spot”. The distribution of “scattered white spot” in rats (Fig. 9) suggests that endoscopic examination of intestinal lymphangiectasia should be done in all parts of the small intestine.

 In summary, we reported endoscopic findings of six cases with protein-losing enteropathy in this paper. It was not easy to presume the relationship between endoscopic findings and the phenomenon of protein-losing. We expect that endoscopic examination will play an important role in the study on protein-losing enteropathy.

Copyright © 1985, Igaku-Shoin Ltd. All rights reserved.


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