Kunihiko Aoyagi

Short-term efficacy of enteral nutrition in the treatment of active Crohn's disease: a randomized, controlled trial comparing nutrient formulas

BACKGROUNDnThe optimal dietary fat content to induce clinical remission in active Crohns disease has been the subject of controversy. We therefore performed a prospective, randomized, controlled study to compare the effects of nutrient formulas differing in the amount of medium-chain triglycerides (MCT).nnnMETHODSnThirty-six patients with active Crohns disease whose Crohns disease activity index (CDAI) was > or =150 were included in the study. A formula with 3.4 g of fat per 2000-kcal dose was used as the nutrient formula with a low-fat content (ED group), and a formula with 55.6 g of fat per 2000-kcal dose was used as the nutrient formula with a high amount of MCT (TL group).nnnRESULTSnThe rate of short-term remission induction at 6 weeks was 67% in the ED group and 72% in the TL group (p = NS). Therapy markedly reduced the high CDAI and van Hees activity index in both groups, with no significant difference in the pattern of the time-course changes. C-reactive protein levels, erythrocyte sedimentation rate, and low serum albumin and plasma prealbumin levels normalized over the course of therapy, with no significant difference between the 2 groups. The assessment of fatty acid fractions revealed that the triene/tetraene ratio began to increase at 2 weeks in the ED group. The serum levels of linoleic acid, an omega-6 fatty acid, almost always varied within the normal range during the treatment period in the TL group, but in the ED group, levels began to decrease significantly at 2 weeks. The levels of linolenic acid, an omega-3 fatty acid, decreased in both groups.nnnCONCLUSIONSnBoth nutrient formulas induced clinical remission in about two-thirds of patients. The results of the present study suggest that it is not necessary to restrict the amount of MCT when given in liquid form to patients with active Crohns disease.

Treatment of herpes simplex esophagitis in an immunocompetent patient with intravenous acyclovir: a case report and review of the literature.

A 35-yr-old, immunocompetent male was admitted complaining of severe odynophagia. He was diagnosed as having herpes simplex esophagitis and was started on intravenous acyclovir 5 mg/kg every 8 h on the day of admission. His response was dramatic. Within 24 h he was virtually asymptomatic. Acyclovir therapy in immunocompetent adults with esophagitis has been described in only a handful of cases in the literature, although the therapy is well established in immunocompromised patients. We review the English literature and discuss the efficacy of the therapy. Acyclovir therapy may be beneficial in immunocompetent patients with particularly severe odynophagia.

Seroprevalence of Helicobacter pylori infection in Nepal: Low prevalence in an isolated rural village

Objective To determine the seroprevalence of Helicobacter pylori infection in Nepal. Design H. pylori infection was identified using a specific and sensitive enzyme-linked immunosorbent assay for anti-H. pylori immunoglobulin G. Study population Serum samples were collected from 1142 inhabitants (age range 4–93 years) from two villages: Kotyang, a rural isolated village (250 men, 210 women) and Bhadrakali, a suburban village of Kathmandu (334 men, 348 women). Results The overall prevalence of H. pylori infection was 56.8%, while a significantly higher prevalence was found in the suburban village (Bhadrakali; 67.2%) than in the rural village (Kotyang; 41.5%). This difference was generally reflected by the infection rate in the 10–14-year-old age-group (Bhadrakali, 60% compared with Kotyang, 22.2%). The prevalence of infection significantly increased with age, while no significant difference was found in the prevalence of infection by gender. There was no difference in H. pylori positivity between individuals with and without upper abdominal symptoms in both villages. Conclusion There was a significant regional difference in the seroprevalence of H. pylori within Nepal, which showed lower prevalence in an isolated rural village. This difference was mainly caused by the different acquisition rate in teenagers, thus indicating that the teenage lifestyle of this particular environment seemed to be the major determinant in the acquisition of H. pylori infection in the population.

Possible neoplastic transformation within gastric hyperplastic polyp

A total of 263 gastric hyperplastic polyps, which had been removed endoscopically from 202 patients, were clinicopathologically analyzed. Among these polyps, there were nine polyps with neoplastic components (3.4%), corresponding to adenoma in five lesions and mucosal adenocarcinoma in four lesions. Comparing the neoplastic transformed polyps with the pure hyperplastic polyps, there was no significant difference according to age, gender, location, gross appearance, or size. However, the transformed polyps which were located in the lower third of the stomach were larger in size (mean, 20.8 mm) and were more likely to be found among older patients (mean, 75.8 years) than were the pure hyperplastic polyps (mean size and age: 14.5 mm and 61.8 years). These results may indicate the possibility of a different carcinogenesis belonging to gastric hyperplastic polyps by location, and this finding seems to be significant in the application of endoscopic polypectomy.

Calcitonin gene-related peptide affords gastric mucosal protection by activating potassium channel in Wistar rat

BACKGROUND & AIMSnCalcitonin gene-related peptide (CGRP) protects the gastric mucosa against injurious stimuli in various experimental models. The underlying mechanism could be the increase in gastric mucosal blood flow (GMBF). A number of endogenous vasodilators exert their effects through the activation of adenosine triphosphate (ATP)-sensitive potassium (KATP) channels on vascular smooth muscle. The present experiments were performed to elucidate whether CGRP increases GMBF through the activation of KATP channels and whether the channels are involved in the protection by CGRP of gastric mucosa.nnnMETHODSnGMBF was determined by the hydrogen-clearance technique in male Wistar rats. Mucosal lesions were produced by intragastric superfusion with 0.15N HCland 15% ethanol for 40 minutes. Effects of an agonist (Y-26763, intra-arterially) and an inhibitor (glibenclamide, intravenously) of KATP channels were tested.nnnRESULTSnY-26763 increased GMBF, which was abolished by glibenclamide, and a CGRP-induced increase in GMBF was attenuated by glibenclamide. Macroscopic and microscopic lesions were exacerbated by human CGRP-(8-37) (a CGRP-1 receptor antagonist; intra-arterially) and glibenclamide but were ameliorated by exogenous CGRP (intra-arterially).nnnCONCLUSIONSnCGRP protects the gastric mucosa against ulcerogenic stimuli, at least in part, through the activation of KATP channels in rats.

Rapidly growing esophageal leiomyosarcoma: case report and review of the literature

We evaluated a 72-year-old woman who was experiencing dysphagia. Esophageal leiomyosarcoma was diagnosed by barium meal study, upper gastrointestinal endoscopy, endoscopic ultrasonography (EUS), by computed tomography (CT). A barium meal study and esophagoscopy performed 3 months before the diagnosis of esophageal leiomyosarcoma showed no abnormalities. Therefore, the tumor appeared to have grown rapidly during the 3-month period.

Intraoperative enteroscopy detects more lesions but is not predictive of postoperative recurrence in Crohn's disease.

BackgroundThe aim of this investigation was to elucidate the clinical value of intraoperative enteroscopy (IOE) for Crohn’s disease, and to determine the value of IOE in predicting recurrent disease.MethodsIn this study 27 patients requiring surgery were examined by both preoperative radiography and IOE. The findings obtained by these procedures in the remnant small intestine were compared. In 19 patients, the clinical course and colonoscopic or radiographic findings after surgery were analyzed.ResultsIntestinal lesions were identified in 23 patients by IOE, and in 19 patients by radiography. Longitudinal ulcers were equivalently detected by IOE (63%) and radiography (56%), whereas small ulcers and inflammatory polyps were less frequently detected by radiography than by IOE (37% vs 74% and 19% vs 33%, respectively). Neither the presence nor the distribution of IOE findings was related to postoperative recurrence.ConclusionsWhereas IOE demonstrates small intestinal lesions in detail, the procedure alone cannot predict postoperative recurrence in Crohn’s disease.

Desmoid tumors in familial adenomatous polyposis/Gardner's syndrome

To clarify the clinical risk of desmoid tumors developing in familial adenomatous polyposis, we reviewed the cases of 49 Japanese patients diagnosed with familial adenomatous polyposis at our institute. In six patients who manifested desmoid tumors at a mean age of 31 years, we reviewed the clinical features and compared various phenotypic manifestations with those in the 43 patients without desmoid tumors. During the observation periods (mean, 6.5 years), two of six patients with desmoid tumors died because of the tumors, which measured > 10 cm in diameter at the initial diagnosis, whereas the remaining four patients with desmoid tumors < 5 cm did not experience complications. The patients with desmoid tumors tended to be women (5 of 6 vs. 17 of 43; p = 0.05) and more frequently had gastric fundic gland polyposis (5 of 6 vs. 17 of 43; p = 0.05) than did the patients without desmoid tumors. There were no apparent differences in other clinical manifestations, including the incidences of colonic polyposis, gastroduodenal adenomas, and extraintestinal tumors. Desmoid tumors can be serious complication in patients with familial adenomatous polyposis. There may be some association in the genesis of desmoid tumors and gastric fundic gland polyposis.

Recurrence of Helicobacter pylori infection and the long-term outcome of peptic ulcer after successful eradication in Japan.

&NA; Recurrence of peptic ulcer after successful eradication of Helicobacter pylori is closely associated with reinfection. The aim of this study was to examine the recurrence of peptic ulcer and reinfection with H. pylori after successful eradication. To eradicate H. pylori infection, patients with active peptic ulcer disease were assigned to two treatment groups depending on the year of their enrollment (AM group and OAMR group). Patients in the AM group received 400 mg of cimetidine twice per day, 300 mg of amoxicillin three times per day, and 250 mg of metronidazole three times per day for 2 weeks. Patients in the OAMR group received 20 mg of omeprazole once per day, 500 mg of amoxicillin granules three times per day, 250 mg of metronidazole three times per day, and 150 mg of roxithromycin twice per day for 1 week. After endoscopy verified ulcer scarring and successful eradication of H. pylori infection, study patients were followed up monthly and did not undergo acid‐suppressive therapy. Endoscopy was performed at 6‐month intervals for the 1st year. After the 1st year, follow‐up endoscopies were performed annually. In total, 107 patients with peptic ulcer (duodenal ulcer [DU], 65; gastric ulcer [GU], 42) were followed up for a mean period of approximately 2 years. Recurrence of infection occurred in 10 (9.3%) of 107 patients (AM group, 9; OAMR group, 1) after 210 patient‐years of follow‐up; the recurrence rate was 4.8% per patient‐year. Recurrence of H. pylori infection was significantly higher in the AM group (23.1%) than in the OAMR group (1.5%). H. pylori infection recurred in two patients 6 months after eradication therapy, in seven 1 year after, and in one 2 years after. Thereafter, no further cases of H. pylori recurrence were observed. During follow‐up periods, seven cases of ulcer recurrence were observed (DU, 4; GU, 3). The rate of peptic ulcer recurrence within 2 years after eradication therapy was significantly higher than that after more than 2 years. Four cases of ulcer recurrence (DU, 3; GU, 1) also had recurrence of H. pylori infection. One recurrent case of DU without reinfection was associated with nonsteroidal anti‐inflammatory drugs. The remaining two cases of GU recurred without H. pylori reinfection. In conclusion, peptic ulcer recurrence rarely occurred (3 [2.9%] of 103) in patients cured of H. pylori infection. Reinfection after apparent successful eradication was rarely noted when a powerful therapeutic regimen in eradication was used. Therefore, to eradicate H. pylori, a highly effective therapeutic regimen should always be used.

Can quinolones cause hemorrhagic colitis of late onset? Report of three cases.

PURPOSE: This study was undertaken to demonstrate that quinolones may cause acute colitis resembling penicillin-induced hemorrhagic colitis. METHODS: We reviewed the medical records of patients with acute colitis in our institutes. Twenty-eight patients with acute hemorrhagic colitis in which no pathogenic microorganisms were identified were the subjects of this study. Pseudomembranous colitis caused byClostridium difficile was excluded. Ulcerative colitis, Crohns disease, and radiation proctocolitis were also excluded. RESULTS: Among these patients, 25 had a history of recent administration of penicillin derivatives. The remaining three patients had never been given any penicillin derivatives, but had ingested quinolones approximately four weeks before the developing colitis had been identified.Klebsiella oxytoca was also isolated in these three patients. CONCLUSIONS: Quinolones may cause acute hemorrhagic colitis. The time interval from antibiotic ingestion to onset of the condition may be much longer in quinolones than in penicillin derivatives.