From white points to yellow plaques: magnifying endoscopic features of duodenal lymphangiectasia

 

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The junior endoscopist is genuinely surprised when he first encounters a duodenal mucosa with whitish points ([Fig. 1]).

Fig. 1 White points and a yellow plaque (arrows) of the duodenum seen under standard mode.

This curiosity fades rapidly when a senior endoscopist points out that this finding is not specific. Furthermore, pathology reports generally have not revealed anything specific for this finding. In a recently published article in Endoscopy, Bellutti et al. characterized yellow plaques of the small bowel as representing the accumulations of lymphatic vessels that have no major pathologic significance or association with any disease [1].

Our group examined a total of 229 patients (66 men, 163 women; mean age 51.5 ± 14.3 years) using magnifying endoscopy, and identified patients with duodenal white points and yellow plaques. The study protocol has been explained in detail elsewhere [2]. Of the 229 patients, 33 (14 %; mean age 52.9 ± 13.7 years) showed white points and/or yellow plaques: 28 had white points (eight men and 20 women), three had yellow plaques (one man and two women), and two had both findings (one man and one woman). There was no difference with regard to sex, age, and levels of total cholesterol (Median: 183.5 [interquartile range: 52.5] vs. 189.0 [60.0] mg/dL), triglyceride (135.0 [81.0] vs. 117.0 [86.0] mg/dL), and albumin (4.35 [0.63] vs. 4.50 [0.40] g/dL), or to lymphocyte count (2100 [1075] vs. 2200 [900]/µL) between patients with or without white points/yellow plaques, respectively.

The magnifying endoscopic examination revealed white dots corresponding to white-tipped villi ([Fig. 2]).

Fig. 2 Under magnification white points correspond to white-tipped villi.

The number of white-tipped villi varied from scant to diffuse, and they could sometimes be found in clusters. Pathologic examination revealed dilated lacteals in eight patients ([Fig. 3]).

Fig. 3 Pathologic examination revealed dilated lacteal (#).

In eleven patients a biopsy was not taken. In the remaining patients histologic examination could not reveal any abnormality. This could probably be due to a sampling error or loss of lymphatic fluid during pathologic processing. Yellow plaques seem to be deeply located and are generally wider lesions, covered by near-normal or blunted villi. Sometimes white-tipped villi can be identified on the covering mucosa. In two patients, a characteristic white fluid exuded from the biopsy site, and lymphangiectasia was confirmed pathologically in three patients. None of our patients were suffering from symptoms of intestinal lymphangiectasia and they had no laboratory or imaging findings supportive of lymphatic obstruction.

Intestinal lymphangiectasia is characterized by dilated intestinal lacteals, resulting in lymph leakage and protein-losing enteropathy leading to hypoproteinemia, hypogammaglobulinemia, and lymphopenia. Lymphatic pathways are inadequate or obstructed. The findings of low immunoglobulins and lymphocytes help to distinguish the group from lymphatic abnormalities, in which whole lymph is lost into the bowel from a wide range of gastrointestinal disorders giving rise to protein loss. Scattered white-tipped villi, sometimes associated with white nodular lesions, are regarded as endoscopic findings. Furthermore, some authors regard these findings as pathognomonic [3], while others offer consuming a high-fat meal the night before the endoscopic procedure to induce these endoscopic findings [4]. By contrast, Femppel et al. showed that in normal individuals 4 hours after fat loading via a nasogastric tube, tiny white dots could be seen endoscopically in the duodenum [5]. Biopsies showed that these were due to a temporary dilatation of the lymph vessels in the villi filled with lipid. As our patients had no clinical or laboratory findings supporting a lymphatic disorder, we speculate that this appearance is not specific and should be regarded as normal. Furthermore, location of these white points at the tip of individual villi supports the findings of Femppel et al. Even temporary or permanent, dilated lacteals causing white-tipped villi, and also yellow plaques seem to constitute a spectrum of lymphatic organization (or disorganization) not related to any particular disease, and these lesions could not be regarded as characteristic for any lymphatic disorder unless accompanied by systemic symptoms or supportive laboratory or endoscopic findings.

Competing interests: None

References

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