Ichiro Yoshikawa

Variable stiffness colonoscopes are associated with less pain during colonoscopy in unsedated patients

OBJECTIVES:Application of a new variable stiffness colonoscope (VSC) is expected to control loop formation and to lessen patient discomfort. The aim of this prospective study was to compare the efficacy of VSC with a conventional colonoscope (CC) in unsedated colonoscopy, based on the experience of examiners.METHODS:Four-hundred sixty-seven patients were randomly assigned to undergo colonoscopy with either VSC or CC by an endoscopist, including experienced and less-experienced examiners. The percentages of completed procedure and time to cecal intubation were recorded. Patients were asked to rate pain on a 5-point pain score.RESULTS:The percentages of completed procedure with VSC and CC were 98% and 95%, respectively, by less-experienced hands, and 99% and 98%, respectively, by experienced hands. Time for cecal intubation with VSC and CC was 15.7 and 18.5 min, respectively, by less-experienced hands, and 9.8 and 10.6 min, respectively, by experienced hands. A significantly lower mean pain score was noted in VSC patients compared with CC patients, irrespective of experience of the examiner. The percent of patients rating the procedure as moderately or severely painful was significantly lower with VSC than with CC, both in less-experienced (19% vs 40%; p < 0.01) and experienced hands (15% vs 26%; p < 0.05).CONCLUSIONS:Our results indicated that VSC allows favorable examination compared with CC regarding completeness, time to cecal intubation, and comfort of patients undergoing unsedated colonoscopy, irrespective of the examiners experience. These features suggest VSC as the preferred colonoscope for patients undergoing unsedated colonoscopy.

Effects of endoscopic variceal ligation on portal hypertensive gastropathy and gastric mucosal blood flow

Objective:Portal hypertensive gastropathy (PHG) has been recognized recently as a potential cause of upper gastrointestinal tract bleeding and is associated with a change in gastric hemodynamic indices in cirrhotic patients with portal hypertension. Endoscopic variceal ligation (EVL) is the treatment of choice for esophageal varices. We investigated the early effect of EVL on PHG and gastric mucosal blood flow (GMBF).Methods:We examined 35 cirrhotic patients who were treated by EVL. PHG was evaluated endoscopically and GMBF was measured by laser Doppler flowmetry before and 1 or 2 wk after EVL.Results:After EVL, only two patients (5.7%) developed severe PHG, 6 (17.1%) developed mild PHG, and 27 (77.1%) showed no change in endoscopic appearance of PHG. In those patients who developed PHG, EVL significantly decreased GMBF at the corpus (p < .05). However, no significant changes of GMBF at the corpus were noted after EVL in those patients who had no worsening of endoscopic features. EVL had no effect on GMBF at the antrum in any patients.Conclusions:Endoscopic variceal ligation is safe and does not lead, at least within 1–2 wk, to worsening of gastropathy in most cases. Our finding that gastropathy developed in the presence of reduced GMBF may suggest that PHG develops as a result of congestion caused by blockade of gastric blood drainage rather than by hyperemia.

Asymptomatic amebic colitis in a homosexual man

ABSTRACTWe describe case of a 75-yr-old Japanese homosexual man who was diagnosed as having amebic colitis. The present case is unique in that invasive amebiasis has occurred in a homosexual man, because Entamoeba histolytica in homosexual patients is considered to be a nonpathogenic and commensal organism in western countries, and that the patient has not complained of any gastrointestinal symptoms associated with minute colonic lesion of an isolated cecal ulcer. This report indicates that the absence of gastrointestinal symptoms does not rule out invasive amebiasis. Therefore, once the ameba is identified in stool specimens, even in homosexual men, it is important to differentiate pathogenic from nonpathogenic species irrespective of whether the patient is symptomatic, and to treat the patient infected with pathogenic species. By means of this strategy, we can prevent pathogenic ameba from spreading in the community.

EMR of upper GI lesions when using a novel soft, irrigation, prelooped hood

BACKGROUND EMR with a cap-fitted endoscope, including a soft, prelooped hood, is a useful, effective, and safe technique. One problem with this method, however, is that the lesion cannot always be kept in the center of the cap because the procedure is performed blindly after aspiration. A soft, prelooped hood with attached irrigation tube was developed. The usefulness of this device for EMR of upper-GI intramucosal cancers was evaluated. METHODS The end-hood piece was fabricated by drilling a side hole in the cap portion of a conventional soft, prelooped hood and then attaching an irrigation tube with glue to the exterior surface of the hole. The fabricated transparent hood was placed at the tip of an endoscope, and aspiration mucosectomy under irrigation was performed in 15 patients with upper-GI intramucosal cancer. When the field of view at the aspiration site was obscured by oozing blood, the site was irrigated. RESULTS A satisfactory view was obtained of all lesions. The mean diameter of specimens was 24.5 mm (interquartile range: 15-35). The proportion of en bloc resected lesions was 86.7% (13/15). Bleeding was the only complication (4/15; 26.7%) and was controlled by using endoscopic hemostatic techniques under irrigation. CONCLUSIONS EMR when using the soft, prelooped hood with irrigation tube is effective and safe for intramucosal cancers 20 mm or less in diameter.

Biliary obstruction caused by intrabiliary transplantation from hepatocellular carcinoma

A rare autopsy case of hepatocellular carcinoma (HCC) presenting as extrahepatic bile duct obstruction is reported. A 54-year-old man who had been treated at another hospital for obstructive jaundice was referred to our hospital and admitted on March 1, 1998, because of progressive jaundice. On hospital day 94, he died of bleeding esophageal varices. At autopsy, a bile duct tumor, measuring 3.0 x 3.5 cm and adhering to the wall of the left hepatic duct, occluded the common hepatic duct at the hilus. A tumor measuring 2.0 x 2.0 cm was found in the parenchyma of the left liver lobe. The parenchymal tumor was not continuous with the extrahepatic bile duct tumor. Histologically, the bile duct tumor and the parenchymal tumor of the left lobe were diagnosed as HCC. The bile duct tumor was attached to the mucosa of the bile duct with a thin stalk. No invasive growth into the submucosa was observed. The tumor may have been an intrabiliary transplantation from the HCC in the left lobe via the bile duct.

Varioliform gastritis and duodenitis associated with protein-losing gastroenteropathy, treated with omeprazole

A 44-year-old female with varioliform gastritis and duodenitis had gastrointestinal protein loss revealed by111indium chloride scintigraphy. Treatment with omeprazole, a proton pump inhibitor, for 2 months, followed by famotidine, resulted in clinical improvement with resolution of the gastroduodenal lesions and protein loss. Colonization of the stomach withHelicobacter pylori was found before and after the treatment. The results in this patient suggest that omeprazole can be of value for the treatment of varioliform gastritis associated with protein-losing gastroenteropathy. The role ofHelicobacter pylori in the pathogenesis of this disease is unclear.

Endoscopic mucosal resection for early gastric cancer : comparison of two modifications of the cap method

BACKGROUND AND STUDY AIM Endoscopic mucosal resection using a cap (EMR-C) is an established method for curative resection of early neoplastic lesions; prelooping of the snare may however be difficult and lead to imprecise resection. We therefore compared two modifications of the conventional technique using outer snare placement with an accessory channel in a prospective, nonrandomized study. PATIENTS AND METHODS Between October 2004 and March 2007, 54 patients (men 37, women 17; mean age 71 years) underwent EMR. One method involved an internally retained snare (IRS) cap, with a fixed prelooped snare inside the cap; the other method used an externally guided snare (EGS) cap with the snare guided over an oblique cap. The main outcome parameters were specimen size, en bloc resection, and complications. RESULTS There was no difference between use of the IRS and EGS cap methods in relation to specimen size (27.6 vs. 27.1 mm), or rates of en bloc resection (88.9 % vs. 83.3 %); only one perforation occurred, and this was in the EGS group. CONCLUSION Both techniques appeared to provide similar efficacy, the inner rim of the IRS cap stabilizes aspiration of the lesion compared with the EGS cap that does not have it.

Ischemic Colitis Associated With Paclitaxel and Carboplatin Chemotherapy

TO THE EDITOR: Combination chemotherapy regimens including paclitaxel have been widely used for standard treatment of many solid tumors. Reported adverse effects on the gastrointestinal tract in paclitaxel-containing chemotherapy regimens are pseudomembranous colitis (1) and gastrointestinal necrosis (2). We describe a case of ischemic colitis (IC) after chemotherapy with paclitaxel and carboplatin. Endoscopic findings of IC are documented. The patient was a 68-yr-old Japanese woman who had been operated on for left upper lobectomy for squamous cell lung cancer. Thirty-seven days after the operation (on day 1), the patient was treated for lymph node metastasis with 135 mg/body of paclitaxel and 240 mg/body of carboplatin at the surgery department of our university hospital. On day 3, she had bloody watery diarrhea five times, with upper abdominal pain, although she had no constipation, fever, nausea, or vomiting. She also had no mucositis or abdominal tenderness. The white blood cell count was increased (15,600/mm), but the C-reactive protein level was normal. On day 5, the patient was consulted at the internal medicine department. Although she had no diarrhea, both white blood cell count and C-reactive protein levels were increased (12,600/mm and 5.3 mg/100 ml, respectively). Colonoscopy showed acute colitis on the right side of the transverse colon. Annular colonic mucosa was hemorrhagic with superficial ulceration (Fig. 1A). It also showed longitudinal ulcerations on the anal side of the hemorrhage with ulceration (Fig. 1B). A pseudomembrane was not detected. A pathological examination of the biopsy specimens showed a mild acute inflammatory infiltration and mild edema with regenerative epithelium, together with a necrotic slough in the colonic mucosa. Stool cultures were normal flora. From these findings, we diagnosed the patient with IC caused by chemotherapy. The patient received total parental nutrition from day 5 to day 14. On day 9, both white blood cell count and C-reactive protein levels returned to normal. On day 14, a barium study showed mild stenosis with ulceration on the right side of the transverse colon indicating healing stage of IC. On day 37, colonoscopy showed a scar on the right side of the transverse colon. Chemotherapy reagents have been implicated in three patterns of necrotizing colitis—pseudomembranous colitis, neutropenic enterocolitis, and IC (3). Pseudomembranous colitis is the common disease after chemotherapy including paclitaxel (1). Several cases of neutropenic enterocolitis after taxane (paclitaxel and docetaxel)-containing chemotherapy have been reported (4–6). Although IC typically develops in people who are otherwise healthy (7), it can also develop after anticancer chemotherapy (3). Ibrahim et al. (4) reported a case of IC as pancolitis after chemotherapy with docetaxel and cyclophosphamide for liver metastasis from breast cancer. Seewaldt et al. (2) also observed and reviewed paclitaxel-associated gastrointestinal necrosis. They postulated that gastrointestinal necrosis is the result of a direct taxane-based effect on the gastrointestinal epithelium (2), although a synergistic interaction between compromised bowel and taxan-induced mitotic arrest is also suggested. Only a single brief report about paclitaxel-associated IC is available. Daniele et al. (8) reported a case of transient mild IC after chemotherapy with paclitaxel and carboplatin for liver metastasis from a neuroendocrine tumor of unknown origin. Colonoscopy is the preferred diagnostic examination for many kinds of colitis because it is more sensitive in diagnosing mucosal abnormalities, and tissue biopsy can be obtained (7). Diarrhea is a common complication of cancer chemotherapy, whereas bloody diarrhea is rare. Therefore, colonoscopy is also important for diagnosis and prompt therapy after chemotherapy with bloody diarrhea (9). Be-

Pericardiac metastasis from advanced gastric cancer

A 64-year-old man complaining of anterior chest pain, weight loss, and neck tumors was found to have advanced gastric cancer with pleuritis carcinomatosa and multiple lymph node and bone metastases. The patient was treated with combination chemotherapy consisting of mitomycin C (MMC), tegafur (UFT), and lentinan, and then with MMC and 5-fluorouracil (5FU) instillation into the pleural spaces after pleural drainage. With these treatments, the primary tumors and cancerous ulcers of the stomach improved markedly, and the lymph node enlargement and pleural effusion disappeared completely. Afterwards pericardiac metastasis complicated by cardiac tamponade occurred, but repeated pericardiocentesis and administration of MMC into the pericardiac cavity effectively eliminated the effusion. These treatments appeared potentially useful for advanced gastric cancer with generalized metastases including pericardiac involvement. However, the patient died of cardiac tamponade with massive pericardiac bleeding, probably due to the repeated pericardiocentesis and/or the administration of anticancer drugs.

Infliximab treatment in a patient with Crohn’s disease on haemodialysis

A 33-year-old man with a 15-year history of CD, first diagnosed in 1991, underwent an ileal resection the same year. In 1997 he developed marked proteinuria (2 g ⁄ day) that gradually worsened so that haemodialysis was required by 2002. Secondary amyloidosis was diagnosed in 1997. The patient underwent a second small bowel resection in June 2003. Between 2000 and 2003, the Crohn’s disease activity index (CDAI) was always more than 300, despite treatment with steroids and immunosuppressants. The use of infliximab was discussed with the patient and, as a result, this drug was given from August 2003, at a dose of 5 mg ⁄ kg, at 0, 2 and 6 weeks, and then every 8 weeks thereafter. Following initiation of infliximab, a dramatic improvement the patient’s disease was observed, as evidenced by both clinical and laboratory parameters, without impairment in renal function. The CDAI fell below 150. After approximately 5 years of infliximab treatment, the patient has remained in clinical remission with no adverse effects.