Kenji Mukawa

Characteristic pancreatic duct appearance in autoimmune chronic pancreatitis: A case report and review of the Japanese literature

We report a case demonstrating the progressive narrowing of the pancreatic duct, which is presumed to be characteristic of autoimmune pancreatitis, and we review the 37 cases of chronic pancreatitis in which autoimmunity was suggested as an etiological factor in the Japanese literature. A 55-year-old man presented with abdominal discomfort, jaundice, and diffuse swelling of the pancreas on ultrasonography. Serial endoscopic retrograde pancreatography demonstrated the progression of an irregular narrowing of the main pancreatic duct forming diffusely over the course of 2 months. Because the patient had hyperglobulinemia and tested positive for autoantibodies, he was diagnosed as a case of autoimmune chronic pancreatitis. Steroid therapy was carried out with excellent success.

Comparing the treatment outcomes of endoscopic papillary dilation and endoscopic sphincterotomy for removal of bile duct stones

To compare the clinical usefulness of endoscopic papillary dilation (EPD) and endoscopic sphincterotomy (EST) for removal of bile duct stones, 110 patients with stones up to 15 mm in diameter and less than 10 in number were randomly treated with either EPD (55 patients) or EST (55 patients). The patients were followed up for a median period of 23 months and endoscopic manometry with the administration of morphine was carried out in 17 patients who were observed more than 12 months after the procedures to evaluate the post‐procedure papillary function. Duct clearance was achieved in 51 EPD (92.7%) and 54 EST patients (98.1%, not significantly different). Forty EPD (78.4%) and 51 EST patients (94.4%) achieved duct clearance in the initial procedure (P = 0.02). Early complications occurred in one EPD (2.0%) and in three EST patients (5.6%, P = 0.62). Complications during the follow‐up period occurred in two EPD and eight EST patients. Recurrence of bile duct stones was observed in two EPD and three EST patients (P = 0.98). Acute cholecystitis was observed in one EPD and five EST patients (P = 0.06) and among patients with gall‐bladder stones in situ, the rate of acute cholecystitis after EPD was significantly lower than that after EST (P = 0.03). Endoscopic manometry showed the existence of a choledochoduodenal pressure gradient only after EPD, while papillary contractile function was observed after both procedures. In conclusion, both EPD and EST are safe therapeutic modalities, although EPD is more clinically effective in decreasing the risk of acute cholecystitis in patients with gall‐bladder stones in situ and in preserving post‐procedure papillary function.

Reduced expression of p53 and cyclin A in intraductal mucin-hypersecreting neoplasm of the pancreas compared with usual pancreatic ductal adenocarcinoma

OBJECTIVE:Intraductal mucin-hypersecreting neoplasm (IMHN) of the pancreas, a slow-growing malignancy with a favorable prognosis, is distinctly categorized from the high-grade malignancy of the more common ductal adenocarcinoma. The aim of the present study was to clarify the molecular differences underlying the biological differences between IMHN and ductal adenocarcinoma of the pancreas.METHODS:The expression of p53 and cyclin A in IMHN was compared with that in ductal adenocarcinoma of the pancreas immunohistochemically.RESULTS:In IMHN, the incidence of p53 and cyclin A ascertained by positive nuclear staining was significantly lower than that in ductal adenocarcinoma. Furthermore, in ductal adenocarcinoma, p53 and cyclin A are topographically coexpressed.CONCLUSIONS:These results suggest that the overexpression of p53 and cyclin A plays a role in the tumorigenesis of pancreatic ductal adenocarcinoma, and sparse expression of both antigens in IMHN may partly contribute to its low-grade malignant characteristics.

Comparative study of CA242 and CA19-9 in chronic pancreatitis

CA242 has been proved to be useful in the diagnosis of pancreatic cancer. The aim of the present study was to clarify the mechanisms contributing to the high specificity of CA242 as compared with CA19-9 resulting from scarce serum elevation of this antigen in patients with chronic pancreatitis by correlating serum levels and endoscopic retrograde choledocho-pancreatography (ERCP) findings and by immunohistochemical analysis. Serum CA19-9 levels were significantly elevated in patients with calcification and with main pancreatic duct (MPD) stenosis or obstruction. On the other hand, serum CA242 levels showed no significant elevation in patients with such factors. Even though such pathological conditions were considered to lead to the stagnation of pancreatic juice, serum CA242 levels seemed to be less affected than serum CA19-9 levels. Immunohistochemical studies of chronic pancreatitis tissues revealed that CA242 was expressed less frequently and less intensely than CA19-9, and the difference in expression was more prominent in the centroacinar cells and terminal ductules. From the results of the present study, it is conceivable that CA242 is less influenced by the stagnation of the pancreatic juice than CA19-9 because of the low levels of expression in ductal systems, which results in the release of this antigen into the circulation in lower amounts than that of CA19-9.

Case report: Pneumatosis cystoides intestinalis associated with post-surgical bowel anastomosis: a report of three cases and review of the Japanese literature.

We report three cases of pneumatosis cystoides intestinalis (PCI) occurring in association with post‐surgical bowel anastomosis. A 74‐year‐old man, a 58‐year‐old woman, and a 62‐year‐old woman were found to have PCI at the colonic side of a bowel anastomosis at 4 years, 3 years and 1 year after operation, respectively, for right colon carcinoma, although all were asymptomatic. They all had a positive anti‐nuclear antibody test and had received postoperative cancer chemotherapy. The clinical features of 123 cases of PCI reported in Japan between 1981 and 1995 were also reviewed. On the basis of the present and previous cases, we propose that post‐surgical anastomosis, cancer chemotherapy, and predisposition to collagen vascular disease might be responsible for the damage to intestinal mucosa that leads to the development of PCI.

Endoscopic pancreatic sphincter balloon dilation for effective retrieval of pancreatic duct stone

To facilitate pancreatic stone retrieval, four patients with chronic pancreatitis and pancreatic stones underwent endoscopic pancreatic sphincter balloon dilation (EPSBD) rather than pancreatic sphincterotomy. Extracorporeal shock wave lithotripsy combined with endoscopic removal was carried out in three patients. Stone removal following EPSBD was completely successful in all four patients. Patients showed no severe complications during the dilation procedure. In one patient, to prevent pancreatitis, an endoscopic nasopancreatic drain was placed for 1 week after EPSBD. Compared with pancreatic sphincterotomy, EPSBD can be performed safely in patients with chronic pancreatitis to assist in the extraction of pancreatic duct stones. Use of the EPSBD procedure in cases of chronic pancreatitis provides a useful approach to improve endoscopic clearance of pancreatic duct stones.

Caroli's disease in three siblings

SummaryThree sisters with cystic dilatation of the intrahepatic bile ducts (Caroli’s disease) are reported. The index case, a 41-year-old woman with remittent high fever and right upper quadrant abdominal pain, was diagnosed as Caroli’s disease with hepatic lithiasis and cholangitis based on findings of ultrasonography, computed tomography and endoscopie retrograde cholangiography. Her two older sisters were also examined and found to have the same disease without clinical symptoms. Their symptoms, locations of the dilated ducts and complications all varied. The hereditary mode of Caroli’s disease in 13 families (32 cases) reported in the world literature including our study was examined. While Caroli’s disease is thought to be an autosomal recessive disease, a conclusion on the hereditary mode of transmission could not be made in this study because of an insufficient investigation of family members, especially the parents.

CASE REPORT: A case of primary ileal carcinoma in a young woman and a review of the Japanese literature

We report a case of primary ileal carcinoma in a young woman, which was diagnosed definitively before operation. A 29‐year‐old woman presented with abdominal pain, diarrhoea and bloody stools. Colonoscopic and radiographic studies revealed that there was a 7.5 × 7 cm tumour (well‐differentiated adenocarcinoma) at the terminal ileum, forming an ulcerated lesion at the centre. The tumour had invaded the caecum, the right urinary tract, the right ovary and a portion of the sigmoid colon. Fifty‐three cases of primary ileal carcinoma were reported in Japan between 1982 and 1994 and their clinical features are reviewed herein.

Hypocalcemia <7.5 mg/dl: early predictive marker for multisystem organ failure in severe acute necrotizing pancreatitis, proposed by the study analyzing post-ERCP pancreatitis

TO THE EDITOR: E. coli O157:H7 is a major cause of diarrheal illness, and hemorrhagic colitis induced by this organism was initially described in 1983 (1). Healthy cattle are a major reservoir for the organism; however, it has also been isolated from a variety of other animals (2). Acquisition of the organism by ingestion of contaminated, undercooked ground beef is the most notorious route of transmission, although infection through ingestion of contaminated apple cider, unpasteurized apple juice and milk, lamb, venison jerky, salami, and some vegetables have also been reported (3). Waterborne outbreaks are less common. Person-to-person transmission of this bacterium appears to be aided by a low infectious dose (4). Human infection with E. coli O157:H7 is more common in the summer months, and seasonal shedding of the organism, which may be contributory, has been documented to occur in animals (2). Recently, a large outbreak of E. coli O157:H7 infection, presumably involving.1,000 persons, occurred in northeastern New York. Primary cases, many of whom were seen at our hospital, attended a county fair. It was ultimately proven that the outbreak was waterborne. The pathogenic E. coli were isolated from a water well located on the fairgrounds. Multiple factors appear to have contributed to the situation. A summer drought occurred and was followed by heavy rainfall, which caused surface flooding over a shallow, recently dug well. The well was presumably contaminated by manure in surface runoff from a nearby cattle pasture that was located adjacent to the fairgrounds. It has been speculated that well contamination was facilitated by permeable fill dirt, which had been placed around the new well pipping. Water from this well was used by multiple vendors to make beverages and ice. Two weeks after the outbreak began, approximately 1,000 persons reported diarrhea ( ;108,000 persons attended the fair), and stool cultures documentedE. coli O157:H7 from 116 persons (5). Two patients died with associated hemolytic uremic syndrome. Much of the fairgrounds were supplied by chlorinated water; however, water from the shallow well, which was incriminated, was unchlorinated, and cultures subsequently yielded high coliform counts. The State Public Health Laboratory performed elegant PCR assays, which demonstrated E. coli O157:H7 in the water from the implicated well. Pulsed-field gel electrophoresis showed similar DNA “fingerprints” in E. coli isolates in water samples from the incriminated well, the water distribution system, and patients (5). This largeE. coli O157:H7 outbreak highlights that this infection may cause devastating illness, and acquisition of this infection by ingestion of contaminated water may occur. Before this public health disaster, New York State law did not mandate the privately owned fair’s well water to be chlorinated. The New York State Health Commissioner subsequently has signed an order that requires disinfection and monitoring of drinking water at all state fairgrounds with private water supplies.

A Case of Pneumatosis Cystoides Intestinalis Associated with Trichlor-oethylene Developing Typical Features during the Follow-up of Undetermined Sigmoid Lesions

Abstract: A 64‐year‐old male lens grinder with a 43‐year history of occupational exposure to trichloroethylene (TCE) visited Shinshu University Hospital in December 1988 complaining of distention of the lower abdomen. A barium enema study and endoscopic examination showed rosary‐like semilunar folds and edematous mucosa of undetermined etiology in the sigmoid colon. Three months later, the patient visited the hospital again complaining of blood in the stool. An endoscopic examination performed at this time revealed numerous broad‐based, smooth‐surfaced, protruding lesions in the sigmoid colon. A diagnosis of pneumatosis cystoides intestinalis (PCI) associated with TCE was made. After 4‐days treatment with 50% oxygen given by inhalation, the patients symptoms were completely relieved, and a colonoscopy revealed no evidence of PCI. He returned to his job at the factory which involved dealing with TCE and because of adequate ventilation and a shorter work‐day he has been free of recurrence during a year follow‐up period. The finding of rosary‐like semilunar folds, as demonstrated by the initial endoscopic and barium enema studies in our patient, is a peculiar one in the incipient stage of PCI.