Fumiaki Kitahara

Ultrasonographic evidence of association of polyps and stones with gallbladder cancer

Objective:The purpose of this study was to evaluate the level of gallbladder cancer risk associated with polyps and stones of the gallbladder by ultrasound examinations.Methods:We investigated abdominal ultrasonographic findings for gallstones and polyps of the gallbladder and the relationship of these findings to malignancy in 194,767 asymptomatic participants in health screening examinations.Results:Gallstones were detected in 7,985 participants (4.1%), at a prevalence of 5.3% in male and 4.5% in female participants. The prevalence was highest in the participants’ seventh decade, followed by the sixth and the fifth decades, in both male and female participants. Polyps were found in 10,926 (5.6%), at a prevalence of 6.9% in the male and 4.5% in the female participants. In the male participants, prevalence was highest in the fourth decade, followed by the third and the fifth decades, whereas in the female participants it was highest in the fifth decade, followed by the fourth and third. High prevalence of polyps ≥10 mm in diameter was found in the fifth to seventh decades in both sexes. Nineteen participants (0.01%) were diagnosed as having gallbladder cancer, and many of them were in the sixth or seventh decade in both sexes. Patients with stones showed a higher prevalence of gallbladder cancer. This difference was shown to be statistically significant by age-adjusted analysis (p < 0.01). The age distribution of the participants with polyps ≥10 mm in diameter was correlated with that of patients diagnosed with gallbladder cancer. Furthermore, polyp incidence was significantly related to cancer by statistical analysis (p < 0.01).Conclusion:These results suggest an association between gallstone or polyp of the gallbladder and increased risk of malignancy, implying that an etiological association may also exist.

Severe atrophic gastritis with Helicobacter pylori infection and gastric cancer

Background. We conducted a case-control study to evaluate whether patients with severe gastric atrophy (indicated by serum pepsinogen concentration) have a high risk of gastric cancer. Methods. At the time of diagnosis of gastric cancer, sera from 301 patients (cases) and 602 sex- and age-matched cancer-free individuals (controls) were tested for the presence of anti-Helicobacter pylori IgG antibody (HM-CAP enzyme-linked immunoassay [ELISA] kit; Kyowa Medix, Tokyo, Japan) and serum pepsinogen (PG) levels (PG I and II Riabead Kits; Dainabot, Tokyo, Japan). We defined positivity for pepsinogen a pepsinogen I concentration of less than 70 ng/mL and a PG I/II ratio of less than 3.0. We categorized the subjects according to serum pepsinogen levels and anti-Helicobacter pylori IgG antibody, creating four categories. Results. Of the 301 cancer cases, 177 had positive serum pepsinogen levels, and 172 were positive for anti-Helicobacter pylori IgG antibody. The category in which subjects had positive serum pepsinogen levels and were negative for anti-Helicobacter pylori IgG antibody had the highest proportion (76.9%) of individuals with gastric cancer and the highest odds ratio (4.20) of the four categories. The odds ratios were 2.55 (95% confidence interval; 1.92–3.88) for positive serum pepsinogen levels and 0.93 (95% confidence interval; 0.63–1.27) for positive anti-Helicobacter pylori IgG antibody. Conclusion. These results suggest that patients with positive serum pepsinogen levels who are negative for IgG antibody to Helicobacter pylori, constitute a high-risk group for gastric cancer. Helicobacter pylori infection is associated with the development of gastric cancer by providing a suitable environment i.e., severe gastric atrophy, for carcinogenesis of the gastric mucosa.

Immunological Rapid Urease Test for Detecting Helicobacter pylori: Comparative Study of Biopsy Specimens and Gastric Mucus

Abstract: A variety of reliable methods are available for the detection of H. pylori during upper gastrointestinal endoscopy. We evaluated the clinical utility of an analyzer for H. pylori urease composed of a solid‐phase tip coated with a monoclonal antibody against H. pylori urease and ion‐sensitive field effect transistor‐based pH sensor system. Samples of both gastric mucus and gastric mucosal specimens were collected and the results from this system were compared. Sensitivity and specificity were 97% and 100% for mucus samples and 92% and 97% for mucosal specimens in the present system; compared to 95% and 96% for histological examination, 92% and 100% for bacteriological test, and 89% and 100% for rapid urease test, respectively. These results confirmed that the present system had high clinical sensitivity and specificity, especially for testing of mucus samples. This method has the advantage of requiring only one sample per patient because mucus can be collected from a broad area of the stomach lumen by stroking the mucosal surface with a brush. (Dig Endosc 1999; 11: 42–46)

RECENT PROGRESS IN ENDOSCOPY-BASED DIAGNOSIS OF HELICOBACTER PYLORI INFECTION

Numerous invasive and non‐invasive tests are available in the detection of Helicobacter pylori. Endoscopy‐based tests that include rapid urease test, histological examination and culture are important generally in the assessment of H. pylori status before eradication therapy. Recently, several new endoscopy‐based diagnostic methods have been developed aiming at rapid and accurate detection of the organisms. It would be possible to diagnose H. pylori infection in treated patients by using these new highly sensitive tests. Although the diagnosis of H. pylori infection itself is possible by using non‐invasive diagnostic tests, endoscopy‐based tests provide not only the diagnosis of the organisms, but also the exclusive information such as treatment indications and the susceptibility for the antimicrobial drugs. Recently, new triple therapy including clarithromycin has been widely performed in Japan. Along with an increase in the prevalence of the antibiotic‐resistant strains, culture may become a more important diagnostic method in the future. The inappropriate application of the tests may increase the potential risk of the misdiagnosis and the treatment failures. The diagnostic method should be selected by taking into account the circumstances in which a diagnosis is to be performed.

Endosonographic criteria for assessment of the depth of duodenal invasion in carcinoma of the papilla of Vater

Background: Imaging criteria by endosonography for assessment of the depth of duodenal invasion of carcinoma of the papilla of Vater (papilla carcinoma) have not been established.

4708 Immunological rapid urease test-a new diagnostic system for detecting helicobacter pylori-.

Introduction: New diagnostic methods have been developed aiming at sensitive, specific and rapid detection of H. pylori. We established a new diagnostic system using a monoclonal antibody against H. pylori urease and pH sensor. Aim: To evaluate the sensitivity, specificity, positive predictive value and negative predictive value of the present system and to determine the calibration curve and detection limits the system. Methods: H. pylori urease adsorbed on a solid-phase tip coated with a monoclonal antibody against H. pylori urease after 15 min of incubation with a gastric mucus sample solution was measured by the pH change of the urea solution inside the tip.The detection limit of H. pylori urease using this system was determined and compared with that of the CLO test. Clinical evaluation of the system was performed in 155 patients. Histological examination, CLO test and culture were used as the standard tests. Results:The present system could detect 0.25 mIU/ml of H. pylori urease in less than 20 min. The sensitivity of the present system is superior to that of the CLO test by about two orders of magnitude. If a patient with at least one positive result in a standard test for H. pylori was considered to be positive, the sensitivity, specificity, positive predictive value and negative predictive value of the system were calculated as 95.2%, 98.9%, 98.4% and 96.8%, respectively.The present system had a significantly higher rate of determining the correct diagnosis than the CLO test and histological examination (McNemars test, p=0.023 and p=0.027, respectively). However, ten of 19 H. pylori -positive cases with the pH change less than 0.1 were negative for at least one of the standard tests, whereas the present system could detect H. pylori correctly in all but for three of these 19 cases. The present system accurately determined H. pylori status in 75 of 76 patients (98.7% ) who had completed treatment. Conclusions: Immunological rapid urease test makes it possible to detect H. pylori within 20 min, and gives very high sensitivity and specificity, especially in the patients with low urease activity.

Factors That Delay Transit Time of Wireless Capsule Endoscopy

Factors That Delay Transit Time of Wireless Capsule Endoscopy Simon Chan, Gary Chen, Mary Kalpakian, Clifford Quan, Mary Lee Henderson, Tam Tran, Pedram Enayati, Gareth Dulai, Ian Arnott, Fumiaki Kitahara, J. Gornbein, Rome Jutabha Background: Factors that delay capsule endoscopy gastric transit (GT) and small bowel transit times (SBT) are important to consider because prolonged transit time may lead to incomplete small bowel examination. Methods: We performed a retrospective analysis of 25 patients who underwent capsule endoscopy from 12/ 02-07/03 for obscure GI bleeding to determine if certain pre-existing conditions delay capsule transit times. Patients with delayed GT and SBT were compared to patients with normal transit times. Delayed GT was defined as greater than two standard deviations above the mean. Delayed SBT was defined as the capsule not reaching the cecum in the setting of normal gastric transit time. Independent risk factors that could delay transit (e.g. prior abdominal surgery, diabetes, hypothyroidism, chronic narcotic use, diverticulosis) were evaluated and compared. Results: For patients with normal GT (n=21), the mean time was 34 minutes (range 6-64 minutes). In contrast, the mean GT for patients with delayed gastric transit (n=4) was 231 minutes (range 170-390 minutes). Two patients had gastric retention during the entire 8 hour recording time (multiple abdominal surgeries involving the upper abdomen); the other two had poorly controlled diabetes and hypothyroidism. These risk factors were absent in patients with normal GT. The mean SBT was 221 minutes (range 95 to 380 minutes) in the normal patients (n=15); 2 of these patients had prior abdominal surgery. The capsule did not reach the colon in six patients thus SBT could not be calculated. Pre-existing conditions in this group included intraor extra-luminal small bowel pathology (post-op adhesions/strictures requiring surgical lysis-3, intra-luminal masses-2, or radiation enteritis/stricture-1). The capsule eventually passed spontaneously in 5/6 patients; one patient required surgery for a high grade stenosis. Of note, small bowel X-rays performed prior to capsule endoscopy on 5/5 of these patients did not demonstrate intra-luminal narrowing or masses. Conclusions: 1) Delayed capsule GT is associated with prior upper abdominal surgery and active endocrinological disturbances. 2) Patients with delayed SBT had a prior history of intra-abdominal adhesions/strictures requiring surgery or intra-luminal masses. 3) Small bowel follow through X-rays do not adequately assess the risk of delayed SBT. Multi-variate analyses with larger sample size are needed to confirm these preliminary results and better define independent risk factors for delayed capsule transit.

Life Style Factors Influencing Serum Pepsinogen Levels in Healthy Japanese: A Prospective Study

Background : Gastric cancer mass screening using serum pepsinogen has been recognized and several advantages of this methods over photofluorography have been shown by previous study. Aims : To determine the factors influence the serum pepsinogen levels in healthy subjects. Subjects & Methods : One thousand and one hundred fourteen subjects who were screened for gastric cancer as part of a periodic health check. Blood samples were taken after fasting and stored below –20 ° C, until pepsinogen levels were assayed. Results : The subjects consist of 338 males (mean age 52.6+14.0) and 776 females (mean age 49.0+11.9). Age ranges from 19 to 81 years. The overall prevalence of chronic atrophic gastritis using a criterion PG I £ 70 hg/ml and PG I/II ratio £ 3.0 was 21.99 % in 1996 and 23.97 % in 2000. Bivariate analysis revealed a significant association between age, more salt consumption, fish favorable over meat and less than three time meal intake covariates with the lowering of PG I/II ratio. Smoking, drinking, BMI, weight and gender did not affect the changes of PG I/II ratio. Conclusion : Age and more salt consumption covariates have a strongest association with the decreased of PG I/II by multivariate analysis. Keywords : pepsinogen, dietary, drinking, smoking, atrophic gastritis

Diagnosis of multiple submucosal cysts of the stomach by endoscopic ultrasonography

The association of multiple submucosal cysts (MSC) of the stomach with gastric carcinoma has attracted clinical and pathological attention. The aim of the present study was to evaluate the diagnostic ability of endoscopic ultrasonography (EUS) for MSC and to investigate the relationship between MSC and gastric carcinoma.

3433 Gallbladder wall layer displayed by mr endoscopy.

Introduction: Imaging of gallbladder wall layers is almost performed by endoscopic ultrasonography. Standard magnetic resonance (MR) imaging of gallbladder by body and surface coils often inadequately depict extension into the gallbladder wall. Endocavitary coils have been developed to help solve this problem. Aims: To investigate MR endoscopic imaging of gallbladder wall layer compared to histopathologic appearance. Methods: We used an MR endoscope, type XGIF-MR30, developed by the Olympus Optical Co. Ltd. (Tokyo, Japan), with a 3-cm-long receive-only coil embedded in its tip. All imaging is currently performed on a 1.5-T system (Signa 5.6; GE Yokogawa Medical Systems, Tokyo, Japan). Patients were sedated intravenously in a standard fashion, and anticholinergic agent is administered intravenously to minimize gut motility and spasm. The tip of the MR endoscope was placed in the duodenal bulb. Then, axial MR examinations were performed in the following sequences: T1-weighted imaging, fast-spin-echo T2-weighted imaging, MRCP imaging, and gadolinium enhanced spin-echo T1-weighted imaging. Supplemental sagittal or coronal images were obtained, depending on lesion morphology and the patients clinical stability. We performed endoscopic examinations with this endoscope in 10 subjects, seven subjects with control and three subjects with gallbladder cancer. The study was accepted by the Ethics Committee of the institutions, and every participating patient gave an informed consent. Results: In the control subjects, we identified three tissue layers in the normal gallbladder. The mucosa and submucosa were depicted as the first layer with high intensity imaging, muscularis propria corresponded to the second layer with low intensity, and subserosa and serosa consisted the third layer with high intensity. On the basis of these findings by MR endoscopy, gallbladder tumors were identified and staged in all patients: subserosa invasion in all patients. A good histopathologic correlation was obtained. Conclusion: We are investigating the optimal combination of a phased-array surface coil with the endoscopic coil to improve signal-to-noise ratio in our images. We believe that there are important potential advantages with this technique in staging gallbladder cancer and in planning patient treatment.