Kunihiko Kimoto

Pancreatic arteriovenous malformation with pancreatitis involving a pancreatico-venous fistula.

SummaryAn arteriovenous malformation of the pancreas is a very rare disease, but its presentation is distinct and unique. In this report, we describe a patient who presented with this malformation which was localized in the tail of pancreas and demonstrated by abnormal angiography findings. The patient was a 60-year-old male with severe left hypochondralgia. Angiography revealed an increased blood volume in the tail of the pancreas with arteriovenous shunting. Secondary pancreatitis caused by the arteriovenous malformation was suspected by abnormal laboratory data, and confirmed by histology from the resected tail of the pancreas. This is a very rare report in which pancreatic arteriovenous malformation involving a pancreaticovenous fistula was confirmed by endoscopic retrograde cholangiopancreatography (ERCP).

Triple Therapy with Omeprazole, Amoxicillin and Clarithromycin Is Effective against Helicobacter Pylori Infection in Gastric Ulcer Patients as well as in Duodenal Ulcer Patients

Background/Aims: There have been few reliable published studies permitting assessment of therapeutic regimens for Helicobacter pylori infection in gastric ulcer (GU) patients. The aim of the present study was to evaluate the efficacy of omeprazole-based dual and triple therapy regimens, both including clarithromycin, for the cure of H. pylori infection in active GU and duodenal ulcer (DU) patients. The study was conducted in Japan, a country in which GU is more prevalent than DU. Methods: Two hundred and thirty-four consecutive peptic ulcer patients (GU: n = 124; DU: n = 103; GDU: n = 7) suffering from H. pylori infection were randomly treated with either omeprazole 20 mg b.i.d. + amoxicillin 500 mg q.i.d. + clarithromycin 400 mg b.i.d. (OAC) or with omeprazole 20 mg b.i.d. + clarithromycin 400 mg b.i.d. (OC) for 14 days. H. pylori infection was evaluated by histology and culture from antral and corpus biopsies 6 weeks after completing antimicrobial therapy. Results: Follow-up data were available in 202 patients. The cure rates of H. pylori infection in GU patients were 83.9% (47/56) with OAC and 59.2% (29/49) with OC. Corresponding rates in DU patients were 91.5% (43/47) and 70.5% (31/44), respectively. The cure rates with OAC were significantly higher than those with OC (p < 0.001, χ2 test). The cure rates in GU patients were lower than those in DU patients for both regimens, but these differences were not statistically significant. Side effects were generally mild and did not interfere with compliance. One patient in the OAC group and 2 patients in the OC group complained of severe side effects that led to therapy discontinuation. Conclusions: Triple therapy with omeprazole, amoxicillin and clarithromycin is a safe and effective regimen for the cure of H. pylori infection in GU patients as well as in DU patients. We recommend this triple regimen as a first-line treatment in all patients with peptic ulcers associated with H. pylori infection in Japan.

G-Cell population and serum gastrin response to cimetidine-oxo test meal in relation to histopathological alterations in resected stomachs from patients with peptic ulcer disease

SummaryThe relationship between histopathological alterations and G-cell population in the stomach was studied in 14 resected stomachs from patients with chronic peptic ulcer disease (6 with duodenal ulcer and 8 with gastric ulcer). G-cells were identified by indirect immunoperoxidase method. When atrophy was graded three steps (0, 1, 2), the average grade of DU and GU was 0.23 and 0.89, respectively. There was a significant correlation (r=-0.871, p<0.005) between atrophic grade and G-cell population in each stomach. The mean occupation rate with intestinal metaplasia was 0.9% in DU and 35.8% in GU. There was no correlation between total pyloric area and G-cell population, however residual pyloric area excluding intestinal metaplasia correlated significantly with G-cell population (r=0.557, p<0.05). There was a significant difference in the mean G-cell population which were 26.5 millions in DU and 8.9 millions in GU. The mean integrated gastrin response to Cimetidine-OXO test meal were 559±236 pg/ml in DU and 216±124 pg/ml in GU, and there was significant correlation (r=0.889, p<0.005) between G-cell population and integrated gastrin response. The average age of both groups, however, was 27.7 in DU and 52.8 in GU, so that these differences of G-cell population and functional G-cell mass in both groups might originate in the histopathological alterations accompanying with the aging.

Dynamic aspects of gastric emptying in patients with peptic ulcer according to ulcer stages.

The pattern and the time of gastric emptying were investigated in 38 patients with peptic ulcer and 7 healthy volunteers using the double-sampling method. The pattern of gastric emptying assumed the following three attitudes, that is, exponential (44%), quadratic (29%) and unclassified (27%) pattern. These patterns appeared to depend on the distance from the gastric angle to the pyloric ring measured from X-ray pictures in the upright position. There was no significant difference in the gastric emptying time in patients with peptic ulcer according to its site. During follow-up observations of the same case, the gastric emptying time had a tendency to shorten in patients with duodenal ulcer while it showed no definite variation in patients with gastric ulcer.

Gastroesophageal reflux diseases: The relationship between the hospital anxiety and depression scale and its severity

[Aim] Gastroesophageal reflux diseases(GERD) is a clinical entity in which refluxing gastric contents produce symptoms, and impairs the quality of life. Patients with GERD tend to be have impaired feeling of well-being and functional status, yet the impact of GERD on quality of life including emotional functioning has not carefully studied. We examined whether GERD and its severity were related to anxiety and depression as assessed by the hospital anxiety and depression (HAD) scale. [Methods] We studied 97 patients who visited our department with reflux symptom. Inclusion criteria was primary symptom of heartburn without other organic diseases. A control group compromised 106 patients referred to our department without symptom. All patients completed self report HAD questionnaires and GERD symptom questionnaires including the grading of GERD symptom. GERD patients were asked whether their daily activities were interrupted because of GERD symptom, and were asked to rate their overall health related quality of life as excellent, good, or poor. [Results] The GERD patients gave higher HAD scores than the normal group(anxiety score: mean 5.44 vs. 3.59, depression score: mean 5.30 vs. 3.69, p < 0.01). The severer the GERD symptom was, the higher HAD score tended to be(mean anxiety score: excellent 3.59, good 6.97, poor 6.22, mean depression score: excellent 4.23, good 5.71, poor 7.66). There was a significant correlation between HAD score and GERD severity(anxiety: r=0.328, p < 0.01, depression: r=0.320, p < 0.01). [Conclusion] This study confirms that anxiety and depression scores are higher in patients with GERD symptom than in controls. The severity of GERD symptom has close relationship to the mental health. This research was made possible by grant from Astra Japan.

Evolution of endoscopic sphincterotomy

Endoscopic sphincterotomy (EST) is a non-surgical treatment for residual or relapsing common bile duct stones in patients with a history of cholecystectomy and/or choledochotomy. Indications for its use have gradually expanded and now include removal of choledochal stones prior to cholecystectomy and removal of large bile duct stones not originally considered suitable for endoscopic removal. EST is used world wide and it now plays an indispensable role in transpapillary diagnostic and therapeutic procedures such as insertion of thin caliber endoscopes into the biliopancreatic system and inserstion of endoprostheses for malignant biliary obstruction. However, some, doubts have been voiced about the extension of indications for EST. The problem of loss of function of the duodenal papilla, for example, is controversial. We summarize the circumstances surrounding the development of EST, the controversies that have occurred in the process of expanding EST indications, and the history of overcoming the technological problems with transpapillary endoscopic procedures. The importance of conducting well-controlled clinical trials to determine the usefulness of new techniques is discussed.

A Case of Acute Organoaxial Gastric Volvulus Treated by Endoscopic Reduction and Fixation with the Use of Percutaneous Endoscopic Gastrostomy Device

Abstract: Acute organoaxial gastric volvulus with paraesophageal hernia was detected by upper gastrointestinal endoscopy in a 75‐year‐old female patient. Endoscopic reduction of gastric volvulus was initially performed and a nasogastric tube was inserted into the jejunum. The introduction of oral intake resulted in vomiting and a barium meal study suggested recurrence of gastric volvulus. Endoscopic reduction was then performed, and a percutaneous endoscopic gastrostomy tube was inserted to anchor the stomach to the anterior abdominal wall. The tube was removed 15 weeks later, and the patient has remained asymptomatic to date.

Estimation of serum acid proteases at pH 1.8 and pH 3.5 in patients with duodenal ulcer, gastric ulcer and gastric carcinoma

SummaryUsing a simple hemoglobin method on the basis of Anson-Mirsky’s method, acid protease levels in serum were measured at pH 1.8 (pepsin) and pH 3.5 (gastricsin) in 18 healthy controls and 14 patients with duodenal ulcer, 19 patients with gastric ulcer and 18 patients with gastric cancer.Though acid protease acitvity in pH 1.8 in duodenal ulcer has a tendency to show a little higher level than healthy controls, there is no significant differences in acid protease levels between controls and each of three diseases.

1) Early radiological diagnosis of linitis plastica type of carcinoma of the stomach

For this study 110 cases of gastric ca rc inoma which had been opera ted upon in the per iod of 10 years from 1965 to 1974 at the Cancer Ins t i tu te Hospital . Of these, 48 cases are linitis plast ica type of carc inoma and in 62 cases (32 cases of early carc inoma and 30 cases of advanced carc inoma) the lesion are su r rounded completely in the fundic gland mucosa. Primary site of linitis plastica The pr imary site of linitis plastica was defined as single depressed lesion such as I Ic which was located within the range of cancerous infi l t rat ion It was identified in 29 of 48 cases (60%) of linitis plastica and in 17 of those 29 cases in which the entire operated mater ia l was sectioned serially for the pathological examina t ion the mucosal details sur rounding the p r imary focus could be studied macroscopically. O f these, the p r imary site of 12 cases was sur rounded completely in the fundic g land mucosa and the p r imary site of 5 cases was in the in termedia te zone, more than hal f port ion of it being included in the fundic gland mucosa. Early radiological diagnosis of linitis plastica Generally, the fundic gland mucosa corresponds to the area where mucosal folds pa t t e rn seems to be p rominen t radinlogically. F-line was defined in the supine double contras t rad iography as a border between the area where the mucosal folds pa t t e rn is lacking and the area where the mucosal folds pa t t e rn is p rominen t . I t is most impor tan t in the early radiological diagnosis of linitis plast ica to detect an early depressed carc inoma which is located within the grea ter curvature aspect of Fline.