Reply to Gonen et al.

We enjoyed reading the study by Gonen et al. In a previous study we had characterized sporadic lymphangiectasias of the small bowel using double balloon enteroscopy [1]. Gonen et al. went further and also characterized white dots and yellow plaques of the duodenum incidentally found during upper endoscopy [2]. Their study contributes to the morphological description of these generally benign lesions. One interesting novelty of their study was the utilization of magnification endoscopy. The findings in this study underline our previous observations, both with respect to the incidence (14 % vs. 13 % in our investigation), as well as to their appearance independently from serum lipid levels. It would have been interesting also for this study to have inspected the whole small bowel, going beyond the duodenum, as the incidence of the lymphangiectasias described would have been higher.

In contrast to our study, most lymphangiectasias described in the present letter have the appearance of white dots, as demonstrated in [Fig. 1] [2].

Fig. 1 Multiple white dots corresponding to minute lymphangiectasias in a patient with Whipple’s disease. Note the ring-like structures. In Whipple’s disease, lymphangiectasias are engorged, with cellular and lymphatic invasion by bacteria and bacterial debris.

It may be speculated that these white dots in some conditions are converging to larger lesions, forming the so-called ”yellow plaques.” The comment regarding the inconspicuousness of histological findings in the major part of investigated individuals is partially in line with our data, where in 25 % of taken biopsies no lymphangectasia could be demonstrated. Because of the submucosal localization of lymphangiectasias, the biopsy forceps is sometimes not able to grasp enough tissue to reach the region of interest. However, we would like to emphasize that lymphangiectasias can also be found in pathologic conditions such as lymphoma, neuroendocrine tumors, and Whipple’s disease ([Fig. 1] and [2]) [3].

Fig. 2 Small-bowel biopsies of a patient with Whipple’s diseases. Note the periodic acid Schiff (PAS)-positive stain. These formations represent clusters of bacteria and debris phagocytized by macrophages, which in turn become very large and irregular (”foamy macrophages”).

If such a condition is suspected, then multiple biopsies and specific stains for pathogens or flow cytometry should be taken.

Competing interests: None

References

• 1 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
• 2 Gonen C, Sarioglu S, Akpinar H, Simsek I. From white points to yellow plaques: magnifying endoscopic features of duodenal lymphangiectasia.  Endoscopy. 2009;  in press
• 3 Mönkemüller K, Fry L C, von Arnim U. et al . Whipple’s disease: an endoscopic and histologic study.  Digestion. 2008;  77 161-165