Keiko Akimoto

Early effects of peppermint oil on gastric emptying: a crossover study using a continuous real-time 13C breath test (BreathID system)

BackgroundThe aim of this study was to determine whether there was a correlation between peppermint oil and gastric emptying by using a novel noninvasive technique for measuring gastric emptying with a continuous real-time 13C breath test (BreathID system, Oridion, Israel).MethodsTen healthy male volunteers participated in this randomized, two-way crossover study. The subjects were randomly assigned to receive a test meal (200 kcal per 200 ml) containing 0.64 ml of peppermint oil or the test meal alone, after fasting overnight. A 13C-acetic acid breath test was continuously performed with the BreathID system, which monitors gastric emptying, for 4 h after the administration of the test meal. Using Oridion Research Software (β version), the time for emptying of 50% of the labeled meals (T 1/2), the analog to the scintigraphy lag time for 10% emptying of the labeled meal (T lag), the gastric emptying coefficient (GEC), and the regression-estimated constants (β and κ) were calculated. The parameters between two occasions were compared using the Wilcoxon signed-rank test.ResultsAfter peppermint oil intake, the T lag and β constant were significantly decreased. No significant differences in T 1/2, GEC, or κ were observed between the two occasions.ConclusionsThe decrease in the T lag and β constant suggests acceleration of gastric emptying during the early phase. This study showed that peppermint oil enhances gastric emptying, suggesting the potential use of peppermint oil in clinical settings for patients with functional gastrointestinal disorders.

Rebleeding rate after interventional therapy directed by capsule endoscopy in patients with obscure gastrointestinal bleeding

BackgroundThe precise role of capsule endoscopy in the diagnostic algorithm of obscure gastrointestinal bleeding has yet to be determined. Despite the higher diagnostic yield of capsule endoscopy, the actual impact on clinical outcome remains poorly defined. The aim of this study was to evaluate the follow-up results of patients with obscure gastrointestinal bleeding to determine which management strategies after capsule endoscopy reduced rebleeding.MethodsAll patients in whom the cause of obscure gastrointestinal bleeding was investigated between May 2004 and March 2007 were studied retrospectively. We evaluated the clinical outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy using the rebleeding rate as the primary outcome.ResultsSeventy-seven patients with obscure gastrointestinal bleeding underwent capsule endoscopy. Capsule endoscopy identified clinically significant findings that were thought to be the sources of obscure gastrointestinal bleeding in 58.4% of the patients. The overall rebleeding rate was 36.4%. The rebleeding rate was significantly higher among patients with insignificant findings than among those with significant findings (p = 0.036). Among the patients in whom capsule endoscopy produced significant findings, the rebleeding rate of the patients who underwent therapeutic interventions was significantly lower than that in those who did not undergo intervention (9.5% vs 40.0%, p = 0.046).ConclusionFollow-up and further aggressive interventions are necessary for patients with obscure gastrointestinal bleeding and significant capsule endoscopy findings to reduce the chance of rebleeding.

Risk Factors for the Progression of Endoscopic Barrett’s Epithelium in Japan: A Multivariate Analysis Based on the Prague C & M Criteria

Purpose To determine the prevalence and progression of Barrett’s epithelium and associated risk factors in Japan. Methods The study population comprised 869 cases. Endoscopic Barrett’s epithelium was diagnosed based on the Prague C & M Criteria. The correlations of clinical factors with the prevalence and progression of endoscopic Barrett’s epithelium were examined. Results Endoscopic Barrett’s epithelium was diagnosed in 374 cases (43%), in the majority of which the diagnosis was short-segment Barrett’s esophagus. The progression of Barrett’s epithelium was identified in 47 cases. In univariate and multiple logistic regression analyses, aging, smoking habit, and erosive esophagitis were significantly associated with the prevalence of Barrett’s epithelium, whereas aging and erosive esophagitis, especially severe erosive esophagitis, were significant contributing factors to the progression of Barrett’s epithelium. Conclusions Forty-three percent of the total study population was diagnosed as having endoscopic Barrett’s epithelium. During the follow-up period, 12.6% of the cases with Barrett’s epithelium exhibited progression which was associated with aging and severe erosive esophagitis.

Rectal fecaloma: successful treatment using endoscopic removal.

Fecalomas are hard, laminated masses that sometimes contain calcification and are usually located in the sigmoid colon or rectum. Complications of fecalomas include constipation, ulceration, bleeding and perforation of the colon. Treatments include laxatives, enemas, rectal evacuation, surgical colotomy (which is required in patients with short-segment Hirschsprung disease), and endoscopic removal – as in the present patient. Impaired anorectal function arising from diabetic neuropathy may have caused the fecaloma in present patient. Dear Sir, A 78-year-old woman, who had been monitored because of diabetes mellitus for several decades, complained of constipation for 1 week. An abdominal X-ray examination showed that feces had filled the descending and sigmoid colon. An abdominal computed tomography examination showed an impacted fecal ball with calcification, 5 cm in size, in her rectum. We diagnosed her as having a fecaloma in her rectum. A colonoscopy revealed the rectal fecaloma to be black, smooth and ball-like in appearance ( fig. 1 ). The fecaloma was successfully removed endoscopically. Published online: September 20, 2007

Colocutaneous fistula after percutaneous endoscopic gastrostomy.

In conclusion, we have reported a patient who developed a colocutaneous fistula after the insertion of a PEG. Colocutaneous fistula is a rare but important complication of PEG. Dear Sir, Percutaneous endoscopic gastrostomy (PEG) was first introduced by Gauderer et al. [1] in 1979 for enteral feeding. Since then, PEG has become a widely accepted method because of its safety and convenience. As this procedure becomes more common, however, numerous complications have been described. A 74-year-old man with a cerebral infarction and Parkinson disease had a PEG tube inserted at our hospital. The procedure was uneventful and the PEG functioned normally. Six months after the PEG insertion, he was admitted to our hospital because fecal material was observed in the gastrostomy tube. A gastrografin study revealed that the tube had been mispositioned in the colon ( fig. 1 ). Colocutaneous fistula was diagnosed. Colocutaneous fistula, which is a rare complication of PEG [2] , is thought to be formed during the insertion of the original PEG tube when the colon becomes interposed between the stomach and the abdominal wall. The fistula initially functions normally and can remain asymptomatic for several months. The transverse colon is often tightly compressed but not completely obstructed, enabling feces and flatus to pass. Such colocutaneous fistulas often remain asymptomatic until the tube is exchanged; in the present case, however, the patient exhibited symptoms prior to the replacement of the gastrostomy tube. Published online: June 26, 2007

Usefulness of transnasal ultrathin endoscopy for the placement of a postpyloric decompression tube.

Dear Sir, A 69-year-old man who had received an operation for prostate carcinoma 1 week previously complained of abdominal pain and vomiting. Abdominal X-ray revealed a dilated jejunum, and we diagnosed him as having ileus. Insertion of a postpyloric decompression tube was necessary. An ultrathin endoscope (GIFN260, outer diameter: 4.9 mm; Olympus) was inserted via the nasal cavity and was used to suction gastric fluids and to advance a guidewire into the duodenum ( fig. 1 ). After withdrawal of the endoscope, a decompression tube was inserted over the guidewire under fluoroscopic guidance. Postpyloric tubes are now commonly placed under fluoroscopic guidance. However, this procedure requires a longer fluoroscopy time than endoscopy-assisted placements. Transnasal endoscopy can reduce the time required for postpyloric tube intubation for the suctioning of gastric f luids and the advancement of guidewires into the duodenum. Moreover, traditional oral endoscopy methods require oronasal transfer techniques, but transnasal endoscopy can be used to place the postpyloric decompression tube direct ly. We have confirmed the validity of transnasal ultrathin endoscopy for the placement of postpyloric decompression tubes. Published online: September 7, 2007

Recovery of a misinserted gastrostomy tube during replacement: effectiveness of gastropexy using a 'Funada style' kit.

reported the efficacy of gastropexy using a ‘Funada style’ kit [1, 2] . Our patient, with a misinserted gastrostomy tube, was successfully treated during replacement using the gastropexy technique. Dear Sir, Percutaneous endoscopic gastrostomy (PEG) is a widely accepted method of providing long-term nutrition. However, as this procedure becomes more common for nutritional support, numerous complications have been described. We describe a case in which a gastrostomy tube was misinserted during tube replacement; endoscopic gastropexy successfully prevented peritonitis in this patient. A 65-year-old man was admitted for replacement of a gastrostomy tube, which had been inserted after an operation for neck cancer. Following tube replacement, a gastrografin study was performed through the gastrostomy tube; this study revealed that the tube had been misinserted. We immediately fixed the gastric wall to the abdominal wall using the gastropexy technique ( fig. 1 ). The patient showed no symptoms suggesting peritonitis. Gastropexy involves a technique in which the anterior gastric wall is non-surgically sutured to the abdominal wall. The procedure is often performed prior to the placement of a tube, and some studies have Published online: August 8, 2007

Protein-losing gastroenteropathy and gastric polyps: successful treatment by Helicobacter pylori eradication.

day, and he was diagnosed as having protein-losing gastroenteropathy. We tried H. pylori eradication therapy for reduction of the polyps. After 1 month, an urea breath test revealed that H. pylori had been eradicated from his stomach. Two months after H. pylori eradication therapy, endoscopic examination showed that the gastric polyps were smaller in size. His body weight increased, and the serum total protein level also increased to 5.8 g/dl and the albumin concentration to 3.8 g/dl. We succeeded in treating protein-losing gastroenteropathy associated with gastric hyperplastic polyps by H. pylori eradication. Dear Sir, Protein-losing gastroenteropathy is a disease associated with excessive loss of plasma protein into the gastrointestinal tract and is caused by a wide variety of disorders. A 71-year-old man was admitted to our hospital for edema and body weight loss. His serum total protein level was 4.2 g/dl, and the albumin concentration was 2.6 g/dl. Endoscopy of the upper gastrointestinal tract showed a lot of reddish pedunculated polyps, measuring 5–20 mm in diameter, in gastric body and antrum ( fig. 1 ). Histological investigation of biopsy specimens revealed hyperplastic changes, and Helicobacter pylori was confirmed. His 1 -antitrypsin clearance was 120 ml/ Published online: May 18, 2007

Argon plasma coagulation for a bleeding gastrointestinal stromal tumor.

doscopic hemostasis ( fig. 1 ). Following the procedure, laparoscopic surgery was performed, and the pathological diagnosis was GIST. APC in endoscopy was first described in 1986 and became a major treatment of choice for gastrointestinal hemorrhage in superficial lesions such as gastric antral vascular ectasia, red veins in the esophagus, and angiodysplasia. Our case showed steady bleeding from the top of the GIST, but the vessel responsible for the bleeding could not be identified. We confirm the validity of APC for the treatment of a bleeding GIST. Dear Sir, A gastrointestinal stromal tumor (GIST) occurs submucosally in the stomach and endoscopically represents an unusual cause of upper gastrointestinal bleeding. Endoscopic hemostasis has sometimes proved to be difficult in bleeding GISTs. A 65-year-old woman was admitted to our hospital complaining of tarry stools. A subsequent endoscopic examination revealed that there was a submucosal tumor in the lower body of the stomach. Endoscopy revealed hemorrhage from ulceration. Argon plasma coagulation (APC) was performed, resulting in successful enPublished online: August 6, 2007

Gastric surgery is not a risk factor for erosive esophagitis or Barrett's esophagus

Abstract Objective. The role of gastric acid reflux is difficult to separate from that of pancreatic-biliary reflux in the pathogenesis of erosive esophagitis (EE) and Barretts esophagus (BE). Gastric surgery patients provide a good model for both significant pancreatic-biliary reflux and marked gastric acid inhibition. We assessed the risk of EE and BE after distal gastrectomy in a case-controlled study. Material and methods. One hundred and sixty patients (121 men, 39 women; median age 68 years; range 32–86 years) with distal gastrectomies (Billroth-I) and 160 sex- and age-matched controls with intact stomachs were enrolled. The presence of EE and BE were diagnosed based on the Los Angeles Classification and the Prague C & M Criteria, respectively. A conditional logistic regression model with adjustments for potential confounding factors was used to assess the associations. Results. According to the multivariate analyses, patients with distal gastrectomies tended to have inverse associations with the risks of EE and BE, and the inverse association with the risk of BE reached a significant level. Conclusions. Distal gastrectomy is not a risk factor for the development of EE and BE. This lack of a positive association between distal gastrectomy and EE and BE may suggest that pancreatic-biliary reflux with a limited amount of acid is not sufficient to damage the esophageal mucosa.