Reply to S. Rana

Reply to S. Rana

We appreciate the comments of Rana et al. and share their interest in this novel topic. As they mention, often multiple white or yellow plaques are found in patients undergoing capsule endoscopy and/or double-balloon enteroscopy of the small bowel for a broad range of indications. A recent study by Fenkel et al. confirms the findings of Rana et al. In their retrospective analysis of all capsule endoscopy studies performed at an urban academic medical center during a 2-year period, the presence of lymphangiectasias was evaluated and an overall prevalence of 22.9 % determined [1]. In a statistical evaluation by logistic regression analysis Fenkel et al. established a significant association of this finding with African-American ethnicity. The clinical significance of this finding so far remains unknown.

As described by Rana et al., most lymphangiectasias are benign and do not necessitate further work-up. This is supported by the findings of our study, as none of our patients had an underlying small bowel or systemic disease which could have explained an alteration of small-bowel lymphatic drainage [2]. However, there are some conditions that do necessitate further work-up of small-bowel lymphangiectasias, as derangement of the small-bowel lymphatic system can occur secondary to localized, infiltrative, or systemic processes [2] [3]. Diffuse or patchy lymphangiectasias suggestive of lymphatic drainage obstruction in patients should prompt an intensive search for diseases such as amyloidosis, tuberculosis, Whipple’s disease, lymphoma, and primary intestinal lymphangiectasia ([Fig. 1]).

Fig. 1 Lymphangiectasias involving the terminal ileum in a patient with primary intestinal lymphangiectasia. Note the diffuse enlargement of the villi, which are filled with lymph. The mucosa appears edematous and cobblestoned, giving a “lizard skin” impression.

Currently, we are investigating the subpopulations of lymphocytes which populate these lesions. We believe that, like Peyer’s patches, these lymphangiectasias may play a role in the immunological homeostasis of the small bowel.

Competing interests: None

References

• 1 Fenkel J M, Goldberg E M, Grasso M A. et al . Lymphangiectasia is more common in African-Americans by wireless capsule endoscopy.  Gastrointest Endosc. 2007;  65 AB182
• 2 Bellutti M, Mönkemüller K, Fry L C. et al . Characterization of yellow plaques found in the small bowel during double-balloon enteroscopy.  Endoscopy. 2007;  39 1059-1063
• 3 Cammarota G, Cianci R, Gasbarrini G. High-resolution magnifying video endoscopy in primary intestinal lymphangiectasia: a new role for endoscopy?.  Endoscopy.. 2005;  37 607