BACKGROUND Barrett esophagus predisposes individuals to esophageal carcinoma, which develops from intermediate stages of tissue dysplasia primarily in the vicinity of the gastroesophageal junction. Understanding the cellular and molecular events in the progression of Barrett esophagus to adenocarcinoma may contribute to its early diagnosis and treatment. Mutation and overexpression of the tumor suppressor p53 have previously been observed in Barrett high grade dysplasia and adenocarcinoma. The expression of the cyclin‐dependent kinase (CdK) inhibitor p21 can be up‐regulated by p53, resulting in the down‐regulation of cell division at the G1/S‐phase transition. The current study examined the correlation between the expression of p21 and p53 by quantifying their levels during the progression of dysplasia and adenocarcinoma in Barrett esophageal tissues. METHODS Barrett esophageal tissue samples that were negative or indefinite for dysplasia, contained dysplasia, and contained adenocarcinoma were examined by immunohistochemistry. Paraffin embedded sections of lining and glandular epithelia were adsorbed with primary murine antibodies against human p21 or p53 followed by horseradish peroxidase secondary antibody. An immunoreactivity score for each primary antibody and section was obtained by multiplying a staining intensity factor by the percent of positively stained cells. RESULTS Nuclear p21 expression was detectable immunohistochemically in Barrett esophagus that was negative for dysplasia, but it was significantly elevated (P ≤ 0.05) in tissues scored as indefinite for dysplasia, positive for low grade or high grade dysplasia, and positive for adenocarcinoma. Importantly, p53 expression did not parallel p21 expression. p53 levels were low in the early stages of Barrett dysplasia and were increased in high grade dysplasia and adenocarcinoma. There were no differences in p21 or p53 levels between glandular and lining epithelia in Barrett tissue throughout the histologic stages of neoplastic progression evaluated in this study. CONCLUSIONS p21 expression in Barrett tissue scored as indefinite for dysplasia or low grade dysplasia was significantly elevated relative to p53 expression. Elevated levels of p21 were also observed in high grade dysplasia and adenocarcinoma, in which they do not appear to be effective in down‐regulating cell division. Analysis of p21 and p53 expression may aid in the evaluation of tissue abnormalities in Barrett esophagus. Cancer 1999;86:756–63. © 1999 American Cancer Society.

Histoplasmosis is the most common endemic mycosis in the United States. Symptomatic gastrointestinal histoplasmosis is a rare entity. We report a case of isolated intestinal histoplasmosis that manifested as severe lower gastrointestinal bleeding in a renal transplant patient. The patient developed hematochezia, and colonoscopy showed diffuse, extensive areas of cratered, ulcerated mucosa in the entire colon. Biopsy showed prominent mucosal and submucosal infiltrate of plump histiocytes containing intracytoplasmic yeast forms morphologically compatible with florid histoplasmosis.

INTRODUCTION: The American Gastroenterology Association (AGA) Bridges to Excellence (BTE) Inflammatory Bowel Disease (IBD) Care Recognition program encourages clinicians to develop a superior quality of care in the management of IBD. The compliance to AGA quality metrics has been historically low in general gastroenterology (GI) clinics. We evaluated adherence to BTE measures in the care of IBD patients seen at a tertiary care hospital gastroenterology fellows' clinic, and developed a provider-friendly template to further increase compliance. METHODS: Patients with diagnosis of IBD (Crohn's disease (CD), Ulcerative Colitis (UC), or indeterminate colitis (IC)) were identified in the gastroenterology continuity clinic using ICD-9 and ICD-10 codes at the University of Oklahoma Health Sciences Center, Gastroenterology fellow's clinic. Baseline patient characteristics and 8 BTE measures were recorded. Based on compliance with quality metrics, a simple, provider-friendly template was added to GI initial and return clinic notes. Overall adherence to BTE measures and average scores as per the AGA 100 point scale were evaluated and compared pre- and post-intervention. RESULTS: 50 patients were seen in GI fellows' clinic over 6-month period in the pre-intervention phase, and 35 were seen in the post-intervention phase. Baseline characteristics for both groups were similar. Overall adherence to BTE measures was 54%, and average BTE score was 58.8 (3 star) in the pre-intervention phase. Overall adherence to BTE measures was 42.4%, and average BTE score was 53 (3 star) (P > 0.05) in the post-intervention phase. On sub-group analysis, it was found that only half of the patients had had the intervention implemented for their care (18/35). Sub-group analysis of patients where template was implemented, adherence to BTE measures was 98.4% and average BTE score was 98.5 (5 star) (P = 0.02). When compared to the group of patients where template was not used, the overall adherence was 42.4%, and average BTE score of 53 (3 star). This was found to be statistically insignificant when compared to pre-intervention group (P = 0.60). CONCLUSION: The care for IBD patients continues to be a multi-disciplinary, complex approach. Using template increased compliance to vaccination and tobacco screening/counselling in our cohort. Using a provider-friendly template may improve compliance with AGA quality metrics for the care of IBD patients in outpatient settings.

Severe gastrointestinal bleeding (GIB) secondary to jejunal diverticulosis (JD) is very rare. Delay in establishing a diagnosis is common and GIB from JD is associated with significant morbidity and mortality. We report an illustrative case diagnosed by push enteroscopy and managed with surgery.

Chilaiditi’s sign is a rare radiological anomaly of hepato-diaphragmatic interposition of the bowel. We report a case of Chilaiditi’s sign associated with acute colonic pseudo-obstruction.A 90-year-old male was admitted for hypertensive emergency. His physical examination showed a distended abdomen, decreased bowel sounds, and right upper quadrant tenderness. A chest radiograph demonstrated marked elevation of the right diaphragm and interposition of the hepatic flexure of the colon between the diaphragm and the liver, along with marked gaseous distension up to 9 cm in the ascending colon without any small bowel distension. The patient was managed conservatively with bowel rest, stool softeners, enemas, and intravenous (IV) hydration. The patient improved clinically with resolution of colonic distension.Chilaiditi's sign and Chilaiditi syndrome are rare entities and therefore are often misdiagnosed and mismanaged. Awareness of the radiological sign, the syndrome itself, and the association with acute colonic pseudo-obstruction is important for all care providers so that they can opt for more conservative management strategies instead of unnecessary interventions including surgeries.