Jun Tanabe

A CASE OF DIFFUSE‐TYPE EARLY GASTRIC CANCER WITH NODULAR GASTRITIS

A 39‐year‐old woman was referred to Osaka Police Hospital and admitted for surgical treatment of gastric cancer. Barium upper gastrointestinal study and endoscopic examination showed a 3.0 × 3.0 cm depressed lesion in the greater curvature of the middle corpus. An unusual miliary pattern resembling ‘goose flesh’ was observed endoscopically in the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma, and specimens from the antrum showed many lymphoid follicles with a germinal center. Rapid urease test and histological tests (Giemsa stain) for Helicobacter pylori were both positive. Early gastric cancer with nodular gastritis (NG) was diagnosed and a partial gastrectomy was performed. Histological examination of the resected specimen showed a stage I tumor consisting mainly of signet‐ring cell carcinoma restricted to the mucosa. Postoperatively H. pylori eradication therapy was performed and proved to be successful. One year after eradication therapy, endoscopy with biopsy showed no recurrence of gastric cancer and the remarkable regression of antral NG.

Massive gastrointestinal bleeding in a patient with polyarteritis nodosa

To the Editor: There have been a few reports about muscle toxicity induced by omeprazole. We would like to report a case of rhabdomyolysis associated with the intravenous administration of omeprazole. A 56-year-old Japanese man visited Tokyo Metropolitan Police Hospital with an episode of nausea and dizziness that had begun the previous evening. He had been diagnosed as suffering from arrhythmia at the age of 51, and was a heavy drinker. Physical examination was unremarkable. Clinical investigations revealed anemia (hemoglobin [Hb], 10.8g/dl); leukocytosis (WBC, 11 900/ μl); and hyperlipidemia, (triglyceride [TG], 169mg/dl). Renal and liver functions were within normal limits. After being admitted, he presented with massive hematemesis due to Mallory-Weiss syndrome. Esophageal and gastric hemorrhage was treated with endoscopic clipping and intravenous omeprazole, 20mg twice a day. The patient generally improved, but his serum creatine phosphokinase level gradually became elevated. On his fifth day in hospital, it rose to 3856IU/l (normal range, 43–272IU/l), while his serum myoglobin level was 467ng/ml (normal range, 65ng/ml). Physical and neurological examination results were unremarkable. Creatine kinase isoenzyme showed a 0.5% MB fraction, and serum myosin light chain I and cardiac troponin T levels were within normal limits. Electrocardiogram results and thyroid function were normal. After withdrawal of omeprazole, the laboratory data improved within 5 days. The patient was discharged on the fifteenth hospital day, and a follow-up examination showed that he was doing well 6 months later. Although our patient’s physical findings were negative for rhabdomyolysis, these laboratory findings usually indicate rhabdomyolysis due to destruction of skeletal muscle.1 There are a few scattered reports of muscle toxicity with marked elevation of serum creatine phosphokinase2,3 induced by omeprazole taken orally. The exact mechanism is not known, but we should be aware of possible side effects associated with the intravenous administration of omeprazole.

SUCCESSFUL ENDOSCOPIC HEMOSTASIS OF RECTAL DIEULAFOY's ULCER BY CLIPPING: AGING MAY BE A FACTOR

Dieulafoys ulcer is a rare form of gastrointestinal bleeding. Although the original descriptions and early reports were of lesions in the proximal stomach, similar lesions have subsequently been reported in the esophagus, duodenum, jejunum, colon and rectum. A 55‐year‐old man was admitted to hospital for a sudden acute headache. On admission he was conscious, and had severe occipitalgia due to a subarachnoid hemorrhage demonstrated on computed tomography. On the fifteenth hospitalization day, he passed fresh blood together with stool, followed by several further episodes of massive hematochezia. Although no lesion was found by gastroduodenoscopy, colonoscopy revealed fresh blood and clots in the rectum. No obvious source of hemorrhage could be identified until careful irrigation revealed pulsatile bleeding from a protuberant vessel (2 mm in size) in the rectum 5 cm from the anal verge. The patient underwent an endoscopic hemostasis in which the pulsatile vessel was easily sutured with seven clips. The patient did not have another episode of bleeding. The finding of Dieulafoys ulcer in the elderly‐patient group suggests that sclerotic changes to the artery may be associated with this type of rectal ulcer.

Schistosoma japonicum showing flat colon polyp appearance.

Commentary Anatomy of the splanchnic circulation is highly individualized, but in general, the middle colic artery is a branch of the superior mesenteric artery and divides into the right branch, which anastomoses with the right colic artery, and the left branch, which anastomoses with the left colic artery, which is itself a branch of the inferior mesenteric artery. Aneurysms and pseudoaneurysms of the splanchnic vessels are not common, especially involving the superior and inferior mesenteric arteries. Causes include infection, inflammation, degeneration, and, as in the present case, trauma. Management of pseudoaneurysms has broadened over the last decade and includes resection, endovascular stenting, transcatheter embolization, and, as was done in this patient, transendoscopic clipping. Ralph Waldo Emerson advised that to hit the mark one needs to aim above the mark. Philosophy is different from vascular surgery, however, and when tying or clipping bleeding vessels, the mark is the mark and the aim must be true. Lawrence J. Brandt, MD Associate Editor for Focal Points

A case of collagenous gastritis resembling nodular gastritis in endoscopic appearance

Abstract A 25-year-old Japanese female was referred to our clinic for the investigation of moderate iron-deficiency anemia and epigastralgia. Endoscopic examination showed diffuse mucosal nodules in the gastric body resembling nodular gastritis, but this pattern was not observed in the antrum. Histology of the gastric biopsies taken from the gastric body showed mild atrophic mucosa with chronic active inflammation. Some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen. Four years later, the patient showed no clinical symptoms and signs. A follow-up endoscopic examination showed similar findings, which mimicked pseudopolyposis or a cobblestone-like appearance. The biopsy specimens from the depressed mucosa between the nodules revealed a thickened subepithelial collagen band with no improvement, which led to a diagnosis of collagenous gastritis. Treatment with oral administration of proton-pump inhibitors and histamine-2-receptor antagonists had proved ineffective. To make a correct diagnosis of collagenous gastritis, we should determine the characteristic endoscopic findings and take biopsies from the depressed mucosa between the nodules.

NEW TYPE OF CASSETTE FOR BIOPSY SAMPLES

Background:  Biopsy samples may be erroneously mixed up during endoscopic examination. Although the conventional cassette which we previously reported was opaque before the fixation, it was not hard to confirm biopsy specimens in the cassette after closing the cover because the cover of conventional cassettes used resin which was not resistant against alcohol and xylene, resulting in non‐transparent resin.