Natsuhiko Kameda

Small Bowel Injury by Low-Dose Enteric-Coated Aspirin and Treatment With Misoprostol: A Pilot Study

BACKGROUND & AIMS With capsule endoscopy, the ulcerogenic effect of low-dose enteric-coated aspirin on the small bowel and the therapeutic effect of misoprostol on intestinal injury were evaluated. METHODS Eleven patients who developed gastric ulcers while undergoing low-dose enteric-coated aspirin therapy were enrolled. They continued aspirin therapy while taking proton pump inhibitors (PPIs) for 8 weeks to heal the gastric ulcers. Then misoprostol 200 microg 4 times a day was administered instead of PPIs for 8 weeks. When the patients could not tolerate misoprostol as a result of side effects, they received another 8 weeks of PPI therapy. RESULTS Capsule endoscopy performed after 8 weeks of PPI treatment identified red spots and mucosal breaks in 100% (11/11) and 90.9% (10/11) of patients, respectively. In 7 patients who completed the study protocol, misoprostol significantly decreased the median number of red spots and mucosal breaks, with complete disappearance of mucosal breaks in 4 patients. Intestinal lesions tended not to heal in 3 patients who discontinued misoprostol. CONCLUSIONS Low-dose enteric-coated aspirin frequently damages the small intestine, and misoprostol is effective in the treatment of aspirin-induced enteropathy.

A prospective, single-blind trial comparing wireless capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding

BackgroundWireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are new methods enabling diagnostic endoscopy of the entire small intestine. However, which of the two is superior is unclear. We therefore prospectively compared the clinical efficacy of CE and DBE.MethodsWe prospectively examined 32 patients with obscure gastrointestinal bleeding. CE preceded DBE by 1–7 days, and all patients underwent DBE twice, by antegrade and retrograde approaches, to evaluate the entire small intestine. Physicians evaluating the results of CE and DBE were blind to the results of the other method. We evaluated diagnosis, diagnostic yield of the two methods, and clinical outcomes.ResultsCE revealed abnormal findings in 29 (90.6%) of 32 patients. CE definitively or probably detected the sources of bleeding in 23 (71.9%) of the 32 patients, including angioectasias (eight), erosions (seven), ulcers (five), tumor (one), and hemorrhagic polyps (two). DBE definitely or probably detected the sources of bleeding in 21 (65.6%) of the 32 patients, including angioectasias (seven), erosions (four), ulcers (five), tumor (one), hemorrhagic polyps (two) and diverticula (two). CE yielded more abnormal findings than DBE (CE 90.6%, DBE 65.6%) (P = 0.032), although there were no significant differences in diagnostic yield between the methods. We were able to perform additional treatment or biopsy with DBE in 13 patients, including coagulation therapy (ten), endoscopic mucosal resection (one), biopsy (seven), and extraction of retained CE (two).ConclusionsOur results demonstrate the superiority of CE in detecting abnormal lesions, and the superiority of DBE in endoscopic management.

Evaluation of Small Bowel Injury in Patients with Rheumatoid Arthritis by Capsule Endoscopy: Effects of Anti-Rheumatoid Arthritis Drugs

Background and Aim: The medical treatment of rheumatoid arthritis (RA) includes nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose corticosteroids, and disease-modifying antirheumatic drugs (DMARDs). We evaluated the incidence of small bowel injury in RA patients who were taking anti-RA drugs with or without concomitant NSAIDs by capsule endoscopy. Methods: A total of 28 RA patients who took low-dose corticosteroids and/or DMARDs for more than 1 year were enrolled. Results: The incidence of red spots did not differ between the 2 groups: 14 of 16 patients (87.5%) in the NSAID group and 11 of 12 patients (91.7%) in the non-NSAID group. In contrast, the incidence of mucosal breaks was significantly higher in the NSAID group than in the non-NSAID group: mucosal breaks were detected in 13 of 16 patients (81.3%) and 4 of 12 patients (33.3%) in the NSAID and non-NSAID groups, respectively. In the NSAID group, mucosal breaks developed in users of preferential cyclooxygenase-2 inhibitors at a frequency similar to that in users of traditional NSAIDs. Conclusion: Patients taking anti-RA drugs may have an increased frequency of small bowel injury regardless of NSAID use, and NSAID use may be associated with an increased incidence of severe small bowel injury.

Usefulness of Non-Magnifying Narrow-Band Imaging in Screening of Early Esophageal Squamous Cell Carcinoma: A Prospective Comparative Study Using Propensity Score Matching

OBJECTIVES:The usefulness of non-magnifying endoscopy with narrow-band imaging (NBI; NM-NBI) in the screening of early esophageal squamous cell carcinoma (SCC) and high-grade intraepithelial neoplasia (HGIN) remains unclear. Here, we aimed to compare NM-NBI and chromoendoscopy with iodine staining (CE-Iodine) in terms of the diagnostic performance, and to evaluate the usefulness of NM-NBI in detecting early esophageal SCC.METHODS:We prospectively enrolled 202 consecutive patients (male/female=180/22; median age, 67 years) with high-risk factors for esophageal SCC. All patients received endoscopic examination with NM-NBI and CE-Iodine to screen for early esophageal SCC or HGIN. We conducted the examinations sequentially, and calculated the accuracy, sensitivity, and specificity through a per-lesion-based analysis. A propensity score matching analysis was performed to reduce the effects of selection bias, and we compared the respective outcomes according to NM-NBI and CE-Iodine after matching.RESULTS:The accuracy, sensitivity, and specificity of NM-NBI were 77.0, 88.3, and 75.2%, respectively, and those for unstained areas by CE-Iodine were 68.0, 94.2, and 64.0, respectively. The accuracy and specificity of NM-NBI were superior to those of CE-Iodine (P=0.03 and P=0.01, respectively). However, the sensitivity did not significantly differ between NM-NBI and CE-Iodine (P=0.67). The accuracy and specificity of NM-NBI before matching were superior to those of CE-Iodine after matching (P=0.04 and P=0.03).CONCLUSIONS:NM-NBI was useful and reliable for the diagnosis of esophageal SCC and can be a promising screening strategy for early esophageal SCC.

Predictive Factors of Worsening of Esophageal Varices After Balloon-Occluded Retrograde Transvenous Obliteration in Patients With Gastric Varices

OBJECTIVES:Although balloon-occluded retrograde transvenous obliteration (B-RTO) is useful for management of gastric varices, worsening of esophageal varices (EV) is the most important complication of B-RTO. The predictive factors of worsening of EV have not been evaluated in detail. This study was designed to evaluate the role of endoscopic color Doppler ultrasonography (ECDUS) in the detection of possible risk factors for worsening of EV after B-RTO.METHODS:A total of 39 cirrhotic patients with high-risk gastric varices successfully treated by B-RTO were included in this study. All patients underwent ECDUS before B-RTO to measure hemodynamic parameters of gastric varices and regular endoscopic follow-up after B-RTO to detect worsening of EV. The risk factors were analyzed by Coxs proportional hazards regression.RESULTS:Worsening of EV was found in 24 (61.5%) patients. The presence of esophageal varices before B-RTO and a lower degree of liver dysfunction (Child-Pugh class B) were statistically independent risk factors for worsening of EV after B-RTO (hazard ratio, HR, 5.81, 95% confidence interval, CI, 1.71–19.77 and HR 2.92, 95% CI: 1.21–7, respectively). High resistance index (≥0.24), measured by ECDUS, is also an independent risk factor for worsening of EV after B-RTO (HR 4.06, 95% CI: 1.14–14.38) and increase in resistance index is associated with worsening of EV (P for trend=0.028).CONCLUSIONS:The presence of EV, higher Child-Pugh class, and higher resistance index assessed by ECDUS before B-RTO were significant risk factors for worsening of EV after B-RTO.

Feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with gastroesophageal reflux disease: first report from Asia

BackgroundIn recent years, various endoscopic treatments have become available to treat gastroesophageal reflux disease (GERD) in Western countries. The Stretta procedure, which uses radiofrequency energy, is one type of safe and effective endoluminal treatment for GERD. However, the feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with GERD, who differ from Western peoples in their physiological characteristics, are not known. In 2006, we imported a Stretta system from the United States and investigated important clinical aspects of the system in Japanese patients with GERD.MethodsThis study was an open-label trial that enrolled patients with GERD who desired to undergo the Stretta procedure. Heartburn scores, medication use, overall satisfaction with the procedure, and adverse events were evaluated.ResultsNine patients received the Stretta treatment between February and September 2006. Esophagogastroduodenoscopy just after treatment revealed a remarkable reduction in the expansion of the gastric cardia and small erosions in all patients. At 3 or 6 months after treatment, heartburn scores were significantly improved compared with pretreatment scores (5.0 ± 1.7 pretreatment vs. 0.7 ± 1.4 posttreatment, P = 0.007). In six of nine patients (66.7%), treatment significantly (P = 0.009) decreased medication use. There were no major adverse events. All patients were satisfied with this treatment.ConclusionsThe Stretta procedure safely reduced GERD symptoms and decreased medication use in Japanese patients with GERD. This treatment may thus be very useful for such patients, and it is hoped that a nationwide trial will be undertaken in Japan to obtain more extensive data.

Secondary aortoduodenal fistula caused on the suture line of the wrapping

To the Editor: Aortoenteric fistula (AEF) can cause fatal intestinal bleeding. Of all reported cases of AEF, 90% are known to be secondary to aortic surgery. Primary AEF is defined as a communication between the native aorta and the intestinal tract, and is a very rare lesion. Secondary AEF, however, is well known as a serious complication of abdominal aortic aneurysm (AAA) surgery. Secondary AEF has been classified into three types based on its morphology and each type has definitive clinical features. Nevertheless, all types of secondary AEF are fatal without surgical treatment. Most patients die of arterial bleeding, even if successfully diagnosed. This letter describes an autopsy case of secondary AEF, in which the fistula occurred on the suture line of the wrapping. The morphological type of this fistula is not included in the previous classification system. A Japanese man in his 70s complained of melena persisting for 13 days. His past history included mild diabetes mellitus, rheumatoid arthritis, arteriosclerosis obliterans and gastric ulcer. He had also had undergone graft replacement of an AAA 13 years earlier at another hospital. His health was under good control without medication before his last admission. Fourteen days before he was referred to Osaka City University Hospital, he was admitted to a local hospital complaining of melena. Emergency upper gastrointestinal (GI) endoscopy and colonoscopy could not detect any active bleeding site in the esophagus, stomach or colon. Due to persistent intestinal bleeding the patient was referred to Osaka City University Hospital for further investigation. On physical examination at admission, respiratory and heart sounds were normal, blood pressure was 124/60 mmHg, pulse 70 b.p.m. and regular. Laboratory tests indicated a lower level of hemoglobin (8.7 g/dL) and hematocrit (29.6%). He did not show any symptoms of infection. On capsule endoscopy and double balloon endoscopy there were no signs indicating either intestinal bleeding or the origin of bleeding. Four days after admission he developed hypovolemic shock following an episode of melena with back pain. Emergency colonoscopy showed multiple diverticulae and coagula in the ascending colon. He was treated with clipping for these colonic diverticulae to rule out bleeding from these sites. At this time there was no apparent bleeding in the transverse colon or ileum. Six days and 7 days after admission, colonoscopy and repeat abdominal arteriography (AAG) were respectively performed, but neither examination could identify the origin of intestinal bleeding. Communication between the aorta and intestine was not detected. After these examinations he vomited blood. Therefore, a second upper GI endoscopy and third AAG were performed, which showed that the duodenum was full of fresh blood, but physicians could not identify the site of bleeding. Despite intensive care for hypovolemic shock, he died 7 days after admission. During admission 30 units of packed red cells had been transfused. An autopsy was performed approximately 12.5 h after death. The body was 162 cm in height and weighed 62.6 kg. The stomach and intestine contained an estimated 1300 mL of blood. An area of adhesion measuring 2 ¥ 1.5 cm was noted between the third portion of the duodenum and the abdominal aorta. In this area there was an AEF measuring 2 mm in diameter. The aorta side of this fistula opened to a space between the graft and the native aneurysm wall, 5 mm distal from the proximal suture line (Fig. 1). The nonbifurcated graft was wrapped with aneurysm wall showing macroscopic suture lines on the proximal and distal sides that were firmly attached. The graft measuring 20 mm in diameter ¥ 90 mm length had shortened to 70 mm in length. The graft did not show dilation. The bilateral renal artery 30 mm proximal from the proximal suture line did not show either stenosis or dissection. The mucosal surface of the duodenum continuous with the fistula was intact. There was no diverticulum of the duodenum. The heart weighed 390 g and showed mild left hypertrophy. The coronary artery demonstrated arteriosclerosis, but there was no obstructive lesion. Ascites (100 mL) was yellowish and clear. Pleural effusion (left 50 mL; right 50 mL) was yellowish and clear. The bilateral kidneys showed severe arteriosclerotic nephrosclerosis. There were multiple colonic diverticulae in the ascending colon. Otherwise, we could not find tumor or ulcer in the large intestine. We incised the adhesion between the duodenum and aorta, and sliced the abdominal aorta horizontally into 3 mm sections, then embedded these in paraffin and stained the specimens with HE, Azan-Mallory, Elastica van Gieson with Alcian blue, and phosphotungstic acid hematoxylin (PTAH). The duodenal mucosa and muscular layer became continuous with the intimal layer of the aorta, forming the fistula (Fig. 2). Adjacent to this fistula, the cleft of the suture thread was confirmed. Thrombus in the fistula was fresh and sealed the lumen. There were scant intimal cells on the surface of thrombus. In the space between the graft composed of circular fibers and the aneurysm wall, there was multi-layered Pathology International 2009; 59: 598–600 doi:10.1111/j.1440-1827.2009.02414.x

Wireless Capsule Endoscopy and Double-Balloon Enteroscopy in Japanese Patients with Obscure Gastrointestinal Bleeding

Wireless Capsule Endoscopy and Double-Balloon Enteroscopy in Japanese Patients with Obscure Gastrointestinal Bleeding Masatsugu Shiba, Kazuhide Higuchi, Natsuhiko Kameda, Kaori Kadouchi, Hirohisa Machida, Kazuki Yamamori, Hirotoshi Okazaki, Masaki Hamaguchi, Tomoko Wada, Yoshio Jinnno, Eiji Sasaki, Kenji Watanabe, Kazunari Tominaga, Toshio Watanabe, Yasuhiro Fujiwara, Shirou Nakamura, Nobuhide Oshitani, Tetsuo Aeakawa Background: Capsule endoscopy has demonstrated its clinical utility in the evaluation of small bowel pathology in several Western studies and increasingly being used in the investigation of obscure gastrointestinal bleeding. Double-balloon enteroscopy is emerging as another interesting alternative or complementary method. We aimed to evaluate the clinical utility of capsule endoscopy and compare the usefulness of double-balloon enteroscopy with capsule endoscopy. Patiens and Methods: From March 2004 through October 2004, we examined by CE 26 patients with complained of obscure GI bleeding and between June 2004 and October 2004, we used double-balloon enteroscopy on 14 patients and retrospectively evaluated the usefulness of double-balloon enteroscopy compared with capsule endoscopy. All patients had undergone non-diagnostic EGD, colonoscopy, and barium contrast radiography of the small bowel. Results: M2A capsule endoscopy disclosed abnormal small bowel findings in 23 (88%) out of 26 patients. Sixteen of them had significant pathological findings explaining their clinical disorders. Diagnostic yield was therefore 58% (15 of 26 patients). Definite bleeding sites diagnosed by capsule endoscopy in 15 patients included angiodysplasia (4), small-bowel erosion (8), small-bowel ulcer (1) small-bowel tumors (2). Double-balloon enteroscopy detected the definite sources of bleeding in 11 (79%) of the 14 patients. Patients with definite bleeding sources included small-bowel erosion (4), small-bowel ulcer (4) small-bowel tumors (2), angiodysplasias (1), small-bowel polyp (1), small-bowel hemorrhagic polyp (1) and not detectable (1). Double-balloon enteroscopy localized an additional bleeding source in comparison with capsule endoscopy in 4 patients. On the other hand, capsule endoscopy localized an additional bleeding source in comparison with double-balloon enteroscopy in 2 patients. Capsule endoscopy was well tolerated by all patients. One patient had a complication of capsule retention due to stricture of ileum. Conclusions: Many of the bleeding sources recognized by both imaging methods were small-bowel erosions or small-bowel ulcers in this study; although angiodysplasia was most popular bleeding source of obscure gastrointestinal bleeding in several Western studies. Double-balloon enteroscopy resulted in more positive findings than capsule endoscopy, although there is no significant difference in both imaging methods.