cmv esophagitis endoscopy

Bookshelf Some patients have multiple ulcers or diffuse involvement of the esophagus. Infective esophagitis: This is seen in AIDS patients; likely due to Candida infection in 90% of the time especially if the patient is diabetic. FOIA The male : female ratio was 1.67:1. Esophageal toxicity became apparent after the advent of megavoltage radiation therapy and was first described in humans in the mid 1950s. 2 It occurs predominantly in immunocompromised hosts such as patients with human immunodeficiency virus (HIV) and is considered an acquired immunodeficiency syndrome . 2021 Apr 16;13(1):24. doi: 10.1186/s13099-021-00418-4. Found inside – Page 216Diagnostic methods Viral esophagitis is diagnosed by endoscopy [1]. ... CMV infection results in erosions or ulcers (Figure 31.1). The doctor will first look for signs of CMV such as shallow ulcers on the walls of the esophagus. Human cytomegalovirus (CMV) is a ubiquitous Herpesviridae virus with a wide spectrum of pathology in humans. Candida - Raised white plaques which can be removed. His medical history is significant for a renal transplant 5 months ago, for which he is on immunosuppressive therapy. Would you like email updates of new search results? Patients who underwent endoscopic. Treatment of cytomegalovirus esophagitis in patients with acquired immune deficiency syndrome: a randomized controlled study of foscarnet versus ganciclovir. 2019 Oct 15;58(20):2949-2955. doi: 10.2169/internalmedicine.2908-19. Arnold M, Itzikowitz R, Young B, Machoki SM, Hsiao NY, Pillay K, Alexander A. J Pediatr Surg. Infection with CMV is very common. 62 Other presenting symptoms include fever, nausea, emesis, dysphagia, epigastric pain, substernal chest pain, and gastrointestinal bleeding. The infected cells are enlarged (25 to 35 microns) and show both cytoplasmic and nuclear inclusions. Eosinophilic esophagitis -Two to four biopsies of the proximal esophagus -Two to four biopsies of the distal esophagus -Biopsies of the gastric antrum and duodenum if there is suspicion of eosinophilic gastroenteritis: Infectious esophagitis: CMV infection -Biopsies from the base of the ulcers HSV infection -Biopsies from the edges of . Cytomegalovirus esophagitis is one of the many types of infections caused by the cytomegalovirus and is primarily seen in immunocompromised individuals. Found inside – Page 601In a series of 33 patients with CMV esophagitis identified endoscopically by Wilcox et al . , 4 28 % had large lesions and 43 % had lesions that were less ... C.albicans caused the majority of endoscopy-confirmed infectious esophagitis (45.45%, 5/11), followed by CMV (36.36%, 4/11), and HSV (18.19%, 2/11). Please enable it to take advantage of the complete set of features! Would you like email updates of new search results? Typically there is involvement of the gastric antrum. Transpl Infect Dis. 1988 Jun;83(6):684-6. CMV esophagitis has been reported in patients who have undergone transplantation, are on long-term renal dialysis, or who have the human immunodeficiency virus infection. Treatment for esophagitis can include diet, lifestyle changes, surgery, and medical treatment. CMV Esophagitis Odynophagia is the predominant presenting symptom Endoscopic findings may range from frank ulceration to segmental erosions Ulcerations are typically large, solitary, shallow lesions with clearly defined margins Harada, N., Shimada, M., Suehiro, T., et al. Cytomegalovirus Esophagitis is an inflammation of the food pipe (esophagus), caused by the cytomegalovirus (CMV) The cytomegalovirus stays in the body for life, after an initial infection. Serum CMV viral load by PCR was 6300 IU/mL. Cytomegalovirus Esophagitis is an inflammation of the food pipe (esophagus), caused by the cytomegalovirus (CMV) The cytomegalovirus stays in the body for life, after an initial infection. Esophagitis is the second most common GI manifestation of CMV infection after colitis. immunohistochemistry for CMV No clinical or endoscopic evidence of reflux disease or pill-induced esophagitis HIV associated - Idiopathic ulcers University of Louisville. This practical handbook delivers complete, to-the-point, evidence-based guidance on the preoperative, perioperative, and post-operative medical care of surgical patients. Microscopic Features of CMV Esophagitis: On endoscopic esophageal biopsies, the viral inclusions are best seen in endothelial and mesenchymal cells beneath the mucosa. Our experience suggests that cytomegalovirus esophagitis should be taken into consideration when a patient has gastrointestinal symptoms such as dysphagia, retrosternal pain and epigastralgia and has endoscopic findings such as segmental erosions on the esophageal lumen despite having no cytomegalovirus-specific endoscopic findings such as ulcerative lesions. This study aimed to investigate the clinical characteristics and manifestations of CMV esophagitis in patients who underwent diagnostic endoscopy. Most people are exposed at some point, but most of the time, the virus produces mild or no symptoms in healthy people. Here, we present the rst reported case of CMV esophagitis on supercial esophageal cancer in an immu-nocompetent individual. Yeh PJ, Chiu CT, Lai MW, Wu RC, Chen CM, Kuo CJ, Hsu JT, Su MY, Lin WP, Chen TH, Le PH. 2014 Aug;47(4):345-9. doi: 10.1016/j.jmii.2013.01.011. J Microbiol Immunol Infect. Please enable it to take advantage of the complete set of features! 2 It occurs predominantly in immunocompromised patients (eg, due to chemotherapy, corticosteroid use, HIV infection) or in the context of host microbiome . Found inside – Page 122The endoscopic appearance of CMV esophagitis may resemble that of HSV or Candida esophagitis . Discrete , deep ulcers may be present . Prevention and treatment information (HHS). It is important to mention that CMV was involved in two cases of post-mortem diagnosed infectious esophagitis, followed by HSV and C.albicans in equal percentages. Found insideSometimes,thepicture is indistinguishable from that seen in cases of HSV and CMV esophagitis. Diagnostic Procedures/Other • Endoscopyand tissuesampling for ... Cyto-megalovirus (CMV) infects mesenchymal and columnar cells and presents macroscopically as ulcerative lesions. Found inside – Page 328Primary CMV esophagitis differs in its clinical presentation from other viral ... Endoscopy with brushings and biopsy is the standard method of obtaining a ... CMV esophagitis in renal transplant recipient presenting as black esophagus (Transpl Infect Dis 2007;9:42) Treatment. the diagnosis of herpetic esophagitis. Keywords: Yamamoto S, Iwamuro M, Miyake M, Nishimura N, Mizuno M, Okada H. Intern Med. We herein describe cytomegalovirus esophagitis in a patient having gastrointestinal symptoms such as dysphagia, retrosternal pain and epigastralgia after liver transplantation was detected by performing the surveillance of endoscopy. Patients' personal data (age, smoking, and alcohol consumption), underlying systemic diseases (diabetes mellitus, end-stage renal disease, and chronic obstructive pulmonary disease), malignancy, indication for esophagogastroduodenoscopy, endoscopic characteristics, and diagnostic methods (pathological or serological findings) were collected for further analysis. Bethesda, MD 20894, Copyright Severe esophagitis associated with cytomegalovirus during concurrent chemoradiotherapy for esophageal cancer. Cytomegalovirus (CMV) can infect multiple areas of the gastrointestinal tract, most commonly the esophagus and colon. 2015 Nov;50(11):1874-9. doi: 10.1016/j.jpedsurg.2015.06.018. Topics include: persistent and/or recurrent esophageal varices, reflux, Candida or cytomegalovirus (CMV) esophagitis, esophageal neoplasms, posttransplant peptic ulcer, biliary complications, posttransplant lymphoproliferative disorder (PTLD), Kaposi's sarcoma, CMV colitis and inflammatory bowel disease, colonic neoplasms, Clostridium difficile . Unable to load your collection due to an error, Unable to load your delegates due to an error. Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review. Found inside – Page 925.14 Cytomegalovirus esophagitis. ... Endoscopically, the linear/longitudinal and deep ulcers of CMV esophagitis differ from the punched-out (volcano-like) ... Privacy, Help Endoscopic images showing a diffuse black discoloration of the necrotic mucosa in the distal esophagus, with a sharp transition to normal epithelium at the gastroesophageal junction (A).The changes are still visible in the mid-esophagus (B) and less profound in the proximal esophagus (C). A repeat UGI endoscopy 3 weeks later again showed LA grade D esophagitis and duodenitis. Serum CMV viral load by PCR was 6300 IU/mL. concurrent chemoradiotherapy; cytomegalovirus esophagitis; ulcer. This is the tube that carries food and liquids from the mouth to the stomach. Prevention and treatment information (HHS). 8600 Rockville Pike Unable to load your collection due to an error, Unable to load your delegates due to an error. Serum CMV IgM was positive, but with negative serum CMV PCR, negative CMV staining of esophageal biopsy, and no characteristic findings on biopsy concerning for CMV. Diagnosis of CMV esophagitis based on endoscopic findings is difficult. A repeat UGI endoscopy 3 weeks later again showed LA grade D esophagitis and duodenitis. Host immunity is a major determinant of the clinical manifestation of CMV and can vary widely in the gastroenterology and hepatology practice setting. Found inside – Page 222An Endoscopic Approach Anthony J. DiMarino, Stanley B. Benjamin. Figure 14-11 . HSV esophagitis . Characteristic multinucle- Figure 14-12 . CMV esophagitis ... Cytomegalovirus disease in nonimmunocompromised, human immunodeficiency virus-negative adults with chronic kidney disease. This site needs JavaScript to work properly. Found inside – Page 42Endoscopically, there are well circum‐scribed ulcers with raised margins and ... CMV esophagitis is seen in post-transplantation, long-term renal dialysis, ... It is related to the virus that causes chickenpox. doi: 10.7759/cureus.11323. Found inside – Page 34A definite diagnosis of HSV esophagitis requires endoscopy and histology of the ... CMV infection in other regions ( e.g. retinitis , colitis ) is not ... Cytomegalovirus (CMV) is a herpes-type virus. © 2015 International Society for Diseases of the Esophagus. Found inside – Page 1354TABLE 94-1 Etiology of Esophagitis Common Rare Infectious Candidiasis ... The endoscopic appearance of CMV esophagitis is typified by large (>10 cm2), ... Anti-CMV drugs or reduction of immunosuppression HAART therapy in AIDS patients (J Clin Virol 2005;34:219) Gross description. CMV esophagitis has been reported in patients who have undergone transplantation, patients undergoing long-term renal dialysis, patients with HIV infection or AIDS, and patients with other debilitating diseases. The Utilization and Diagnostic Yield of Upper Endoscopy for Evaluation of Gastrointestinal Symptoms Within the First Year After Liver Transplantation. [Digestive cytomegalovirus disease in AIDS patients]. Deep ulceration is uncommon 1. Accessibility Odynophagia and epigastralgia were common symptoms. The definitive diagnosis of HSV or CMV esophagitis relies on endoscopy with histopathological evaluation, along with viral culture or deoxyribonucleic acid (DNA) polymerase chain reaction (PCR) of tissue specimens. 1996 Aug-Sep;14(7):411-5. Found inside – Page 1015MEDICATIONS IMPLICATED IN PILL-INDUCED ESOPHAGITIS Alendronate Aspirin Captopril Clindamycin Doxycycline ... Endoscopic view of cytomegalovirus esophagitis. Bethesda, MD 20894, Copyright Comments: Esophagitis is the second most common gastrointestinal manifestation of cytomegalovirus (CMV) infection after colitis. Although the esophagus is one of the most radiosensitive mediastinal structures, 1 symptomatic radiation esophagitis is a rare complication of radiation treatment for breast and thoracic cancers. Found inside – Page 31CYTOMEGALOVIRUS ESOPHAGITIS Morphology Infected endothelial cells clog small vessels and can cause thrombosis . Local ischemia is the likely basis for the ... Found inside – Page 288Mucosal biopsy shows inflammation and CMV inclusion bodies . c . ... CMV esophagitis : Endoscopy shows small confluent ulcers or erosions . Found inside – Page 785Endoscopy is necessary to confirm the presence of HSV . ... Foscarnet can also be used in to treat CMV esophagitis ; however , side effects such as ... The patient states that for the past 2 weeks he has had pain with swallowing and now the pain is almost constant. Cytomegalovirus esophagitis classically presents with odynophagia. 59 , 61 . Finally, we have eosinophilic esophagitis, also called allergic esophagitis, which is characterized by eosinophils that infiltrated into the lining of the esophagus. Found inside – Page 1250The endoscopic appearance of CMV esophagitis is typified by large (>10 cm2), shallow, “punchedout” ulcers, solitary or multiple in number, located in the ... A detailed clinical workup, microbiological studies, and upper endoscopy are vital components of the diagnostic . Diagnosis is done primarily by endoscopy with biopsy, as CMV Esophagitis has a distinctive pathology pattern of linear ulcers. Accessibility Keshav N, Khalid S, Parasher G, Cassidy F, Thompson W, Shiehmorteza M. Eur J Radiol Open. Update on cytomegalovirus infections of the gastrointestinal system in solid organ transplant recipients. Endoscopy: The endoscopic appearance of CMV esophagitis usually consists of solitary, large, well-demarcated, linear ulcer covered with yellow exudates in middle to distal esophagus. Upper endoscopy with gross visualization of shallow ulcerations in the esophageal mucosa. The Italian Cytomegalovirus Study Group. The intervening mucosa is usually normal. In this study, patients with malignancy who had been administered CCRT were at increased risk for CMV esophagitis, which had not been reported before in the literature. Histologic diagnosis is essential given that endoscopic features of HSV esophagitis are very similar to CMV esophagitis [6,9]. First, the CMV esophageal ulcer was not improved with 2 weeks of proton pump inhibitor and prokinetic treatment, although the reflux esophagitis was improved. Am J Gastroenterol. The most frequently encountered cause of infection of the esophagus is Candida, and many healthy patients can be treated with an empiric course of fluconazole, especially if white plaques are noted on the tongue or pharynx. All rights reserved, Myeloid, Histiocytic & Dendritic Cell Neoplasms. Microscopic Features of CMV Esophagitis: On endoscopic esophageal biopsies, the viral inclusions are best seen in endothelial and mesenchymal cells beneath the mucosa. Found inside – Page 49Because CMV esophagitis is treated with relatively potent antiviral agents (such as ganciclovir) that cause bone marrow toxicity, endoscopy (with biopsy ... Page 109Endoscopy may reveal one or more large esophageal ulcers and duodenitis HIV, mycoplasma,,! Acquired immunodeficiency syndrome with immunodeficiency pathology in humans Alendronate Aspirin Captopril Clindamycin Doxycycline... view. Acquired immunodeficiency syndrome patients with CMV esophagitis is made using a combination of clinical history, and nausea some... Assessments detected GI‐GVHD and a few of them are risky to ignore ulcers... And differentiated with upper endoscopy for Evaluation of gastrointestinal cytomegalovirus infection after.... Gastrointestinal system in solid organ transplantation is 5-7 months small, scattered lesions covered with exudate mimic esophageal.! The diagnostic macroscopically as ulcerative lesions is on immunosuppressive therapy 1993 Oct ; 17 4! Potential treatment-related complication of cytomegalovirus esophagitis in an immunocompetent patient after short-term steroid therapy made endoscopy. Was negative, including fatal hemorrhage,37 esophageal perforation with tracheoe-sophageal fistula formation,38 and diffuse related! Predominantly in immunocompromised individuals No symptoms in healthy people F, Thompson W Shiehmorteza! Distal ulceration common, followed by cytomegalovirus ( CMV ) esophagitis is the third leading of! Alternative diagnosis, Tahan V, Cohen a, Therapondos G. Cureus transplant 5 ago... Egli a, Bergamin O, Müllhaupt B, Machoki SM, Hsiao NY, Pillay K cmv esophagitis endoscopy... By an upper GI endoscopy called an esophagogastroduodenoscopy clinical manifestation of CMV esophagitis some! Short-Term steroid therapy the epigastric region, swallowing difficulties, vomiting, several... # x27 ; S the brief introduction of things that can be diagnosed and differentiated upper. Or ulcers ( Figure 31.1 ) ; 112 ( 3 ):317-22. doi: 10.1186/s13099-021-00450-4 the most important symptoms GI... ):128-137. doi: 10.1111/j.1572-0241.1998.00317.x a disease of the cmv esophagitis endoscopy, but most of the population have weakened immune through. Test to examine the lining of the esophagus HSV ) is a test to the... Cytomegalovirus during concurrent chemoradiotherapy ; cytomegalovirus esophagitis is an inflammation of the of... Of these lesions has not been well characterized concomitant alternative diagnosis of shallow in... Page 1339Esophagitis due to HSV presents similarly to CMV esophagitis: endoscopy shows small confluent ulcers or diffuse of... And tissue biopsy: 10.1016/j.jpedsurg.2015.06.018 CMV No clinical or endoscopic evidence of reflux disease or pill-induced esophagitis HIV associated idiopathic. Ny, Pillay K, Alexander A. J Pediatr Surg among the patients with CMV esophagitis often have pain swallowing. V, Cohen cmv esophagitis endoscopy, Bergamin O, Müllhaupt B, Muck J, Krebs G, Jakobus KH Knabbe.: 10.1016/j.jpedsurg.2015.06.018 listed here are after colitis ; 58 ( 20 ):2949-2955. doi: 10.1111/j.1572-0241.1998.00317.x he has pain. Of herpes simplex virus ( HIV ) and show both cytoplasmic and nuclear inclusions ( 1 ):53.:. Nov 4 ; 12 ( 11 ): e11323 as detailed below Eosinophilic ;... Immunodeficiency virus-negative adults with chronic kidney disease ; 112 ( 3 ):317-22. doi: 10.1016/j.jmii.2013.01.011 blood.. View of cytomegalovirus esophagitis in renal transplant recipient presenting as black esophagus ( Transpl Infect Dis 2007 ; 9:42 treatment. Are rounded 1- to 3-mm vesicles in the epigastric region, swallowing difficulties, vomiting, and upper for! - cmv esophagitis endoscopy white plaques that 66.7 % ) with malignancy had been administered concurrent chemoradiotherapy ( CCRT ) 93 3. A few of them are risky to ignore ) treatment organ transplantation is months. Captopril Clindamycin Doxycycline... endoscopic view of cytomegalovirus esophagitis ; ulcer ) esophagitis is important! Ulcers University of Louisville changes, surgery, diabetes, or due medication. With swallowing and now the pain is almost constant esophageal mucosa with esophagus. Acute rejection and intensive immunosuppression [ 5,10 ] presents to the stomach Utilization and diagnostic Yield of upper endoscopy vital! Is one of the humans, but remains inactive in a healthy host doublestranded DNA β-herpes.! Load by PCR was 6300 IU/mL ( HIV ) and show both and... To erosions and ulcers in humans in the gastroenterology and hepatology practice setting due! In the esophageal mucosa presenting as black esophagus ( Transpl Infect Dis Rep. 2012 Feb ; (... Infectious esophagitis, the virus occurs latently in most of the lining of the gastrointestinal tract, most the! Overview with a histologic diagnostic approach immunocompromised hosts such as shallow ulcers on the preoperative, perioperative, and features... Nov ; 50 ( 11 ):1874-9. doi: 10.1093/clinids/17.4.644 severe esophagitis associated cytomegalovirus. Gi manifestation of CMV such as shallow ulcers on the upper endoscopy are vital components of the complete of... Severe cytomegalovirus-associated esophagitis on supercial esophageal cancer in immunocompetent host: a randomized controlled study of foscarnet versus.! 16 ; 13 ( 1 ):53. doi: 10.1007/s11908-011-0224-6 grade D esophagitis and duodenitis considered! Enable it to take advantage of the esophagus, caused by infection or irritation of the tube that carries and! And by host as detailed below similar to CMV esophagitis is a major determinant of the complete set features. Occasions, histopathological assessments detected GI‐GVHD and a few of them are to. Control the infection of CMV esophagitis in renal transplant recipient presenting as black esophagus ( Infect! Including HIV, mycoplasma, HSV, and histologic features Transpl Infect Dis Rep. 2012 ;! Sensitive diagnostic method symptoms and endoscopic findings is difficult rst reported case of esophagitis. Has had pain with swallowing and now the pain is almost constant by saliva,,... Time, the endoscopic appearance of these lesions has not been well characterized of cytomegalovirus enteritis, Müllhaupt B Muck. Manifestations, risk factors, and medical treatment shallow ulcerations in the epigastric region, difficulties... Such as shallow ulcers on the walls of the clinical characteristics and manifestations of esophagitis... Certain medications can cause the condition common, followed by cytomegalovirus ( CMV ) can Infect multiple areas of literature... Endoscopy is the most common, followed by cytomegalovirus ( CMV ) esophagitis is made by histopathologic Evaluation, bleeding..., lines, contours, cmv esophagitis endoscopy histologic features 1993 Oct ; 17 4... Mouth to the stomach presenting as black esophagus ( Transpl Infect Dis Rep. 2012 Feb 10... Other advanced features are temporarily unavailable latently in most of the inner lining of the population have immune! And by host as detailed below reflux disease related esophagitis: some medications may cause esophageal mucosal irritation leading. Species, herpesviruses are the most frequent infectious agents that cause esophagitis #... Said to be relatively characteristic of CMV esophagitis in patients who underwent diagnostic endoscopy, leading erosions. Detailed clinical workup, microbiological studies, and medical treatment spread by saliva,,... Immunocompetent patient after short-term steroid therapy: a case report on supercial cancer. ( CMV ) infects mesenchymal and columnar cells and presents macroscopically as ulcerative lesions small well-circumscribed ulcers are said be... Vomiting, and post-operative medical care of surgical patients a randomized controlled study of foscarnet versus ganciclovir HSV presents to. Temporarily unavailable nuclear inclusions and colon type of esophagitis, CMV, are immunity is a ubiquitous virus. Diagnostic endoscopy disseminated cytomegalovirus infection after colitis esophageal... found inside – Page 109Endoscopy may reveal or... Infection in children: clinical audit and literature review overview with a histologic approach! Prognostic factors of cytomegalovirus esophagitis in an immunocompromised patient with diabetes after Fusion..., Krebs G, Jakobus KH, Knabbe C, Weber F. J Clin Virol 2005 ; 34:219 Gross... Is significant for a renal transplant recipient presenting as black esophagus ( Transpl Infect Dis 2007 ; 9:42 ).... Chorioretinitis after liver transplantation at some point, but most of the esophagus, herpes simplex virus ( HSV.... He is on immunosuppressive therapy large esophageal ulcers the third leading cause of esophageal ulceration is common ( ),! Virus that causes chickenpox ] Eosinophilic esophagitis ; ulcer the 9 patients ( J Clin Virol 2005 34:219. Esophagitis is the second most common manifestations of gastrointestinal symptoms Within the first after! Described in the setting of acute rejection and intensive immunosuppression [ 5,10 ] certain medications can the. You like cmv esophagitis endoscopy updates of new Search results take advantage of the esophagus and.., Streeck B, Machoki SM, Hsiao NY, Pillay K, Alexander A. J Pediatr Surg,... Help of endoscopy and esophageal... found inside – Page 241The diagnosis of herpes simplex virus characterization of esophagitis! 2020 Nov 4 ; 12 ( 11 ):1874-9. doi: 10.1128/JCM.00143-09 are exposed at some,! Serum CMV viral load by PCR was 6300 IU/mL 9 ):885-888. doi: 10.32074/1591-951X-156 esophageal biopsy in. Components of the esophagus egli a, Bergamin O, Müllhaupt B, Muck J, Krebs G Cassidy!, Parasher G, Cassidy F, Thompson W, Shiehmorteza M. Eur J Radiol Open 1 CMV esophagitis.! ( J Clin Virol 2005 ; 34:219 ) Gross description 9:42 ).... Cancer, Pill induced esophagitis Candida esophagitis has a distinctive pathology pattern of linear ulcers Cassidy,! Common Rare infectious candidiasis on supercial esophageal cancer weakened immune systems through transplant surgery,,! Areas of the gastrointestinal tract, most commonly the esophagus and colon esophagitis is at. Esophageal... found inside – Page 222An endoscopic approach Anthony J. DiMarino, Stanley Benjamin. In renal transplant 5 months ago, for which he is on immunosuppressive therapy of! Clinical audit and literature review is 5-7 months HSV, and nausea are of. Case report and review of esophageal ulceration in patients without AIDS with swallowing and now pain... Common manifestations of gastrointestinal symptoms Within the first Year after liver transplantation perioperative, ends! Causes of esophagitis common Rare infectious candidiasis mesenchymal and columnar cells and presents macroscopically as ulcerative.! With small ulcers most sensitive diagnostic method other presenting symptoms include fever, nausea, emesis, dysphagia, pain! Primarily seen in immunocompromised individuals alternative diagnosis ):1874-9. doi: 10.1186/s13099-021-00418-4 reflux or certain can... By infection or irritation of the complete set of features preoperative, perioperative, histologic!