A retrospective study was conducted into technetium-99m sestamibi imaging of primary hyperparathyroidism to determine the accuracy of identification and localization of parathyroid pathology. Of 56 patients studied, 48 had full preoperative scan data, operative data and pathological results analysed. Overall scan accuracy was 96 per cent. For single gland pathology (adenoma) imaging had a sensitivity of 97 per cent, a specificity of 100 per cent and a positive predictive value of 100 per cent. For single gland disease the side was correctly identified in 100 per cent of cases and the site in 94 per cent, but the respective values were only 82 and 79 per cent for multiple gland pathology. Technetium-99m sestamibi imaging is highly sensitive and accurate for primary hyperparathyroidism, with sufficient positive predictive value and accuracy in single gland disease to allow scan-directed unilateral neck exploration.

Only smoking has been confirmed as a significant adverse risk factor for recurrence. Evidence for differing recurrence rates in fibrostenosing disease and perforating disease is inconclusive, but such a classification along with the endoscopic findings of recurrence may have a place in the analysis of therapeutic trials. Minimal resectional surgery with clearing of only macroscopic disease seems to be justified, with no clear benefits from different anastomotic techniques. Recent trials offer encouraging evidence of the usefulness of 5-aminosalicylic acid, particularly higher-dose regimens started early after resection, although the long-term benefits are uncertain. The oral steroid, budesonide, offers a potent treatment with minimal side-effects, but evidence of its prevention of recurrence is presently weak.

The relationship between the gross connective tissue and in¯ammatory changes in ileal Crohn's disease remains unclear. This study investigated 20 patients undergoing ileal resection for Crohn's disease and 20 normal controls. The specimens were blocked in 1 cm serial sections and fully examined, including fresh morphometry and documentation of a range of pathological features. Pathological features of disease showed uniform distributions within affected segments, although specimens showed different patterns and severity of af¯iction. Serosal fat wrapping (FW) was present in all cases and was signi®cantly greater than normals [mean 63.5% (SD 27.8) vs. 21.0% (6.4), p<0.001], as was mesenteric thickening (MTh) [mean 18.0 mm (SD 11.1) vs. 5.9 mm (2.2), p<0.001]. The extent of FW correlated signi®cantly with the degree of acute and chronic in¯ammation (r s =0.32 and 0.23 respectively, p<0.01), particularly the extent of transmural in¯ammation in the form of lymphoid aggregates (r s =0.35, p<0.01). MTh did not correlate with any features studied. These ®ndings support the hypothesis that serosal connective tissue changes in Crohn's disease are related to the local effects of underlying chronic in¯ammatory in®ltrates. Full thickness, radial samples from a grossly affected area are representative of the histopathological features present in a diseased segment as a whole.

No abstract

Although the inflammatory pathology of Crohn's disease is manifestly its most important attribute, the connective tissue changes are important in the genesis of the more chronic features of the disease, and yet these have received little attention from clinicians, pathologists, and scientists. Fat-wrapping appears to be pathognomonic of Crohn's disease, and is an important marker of disease for surgeons. There is evidence of a complex interplay between the effector inflammatory cells of Crohn's disease and adipocytes, hyperplasia of which results in fat-wrapping. Pathologically, this is exhibited in the close relationship between the transmural inflammation that is so characteristic of Crohn's disease and fat-wrapping. Fibrosis and muscularization are also important components of the chronic changes of intestinal Crohn's disease. Neuronal and vascular changes make up the remaining connective tissue changes: these constitute a distinctive feature, and are even specific for Crohn's disease. For pathologists, the combination of these connective changes will allow a diagnosis of chronic 'burnt-out' Crohn's disease, even in the absence of its highly characteristic inflammatory features. The connective tissue changes of Crohn's disease form an important part of its long-term pathology. They deserve more attention from clinicians, diagnostic pathologists and researchers alike.