Susumu Ishihara

Extensive atrophic gastritis increases intraduodenal hydrogen gas

Objective. Gastric acid plays an important part in the prevention of bacterial colonization of the gastrointestinal tract. If these bacteria have an ability of hydrogen (H2) fermentation, intraluminal H2 gas might be detected. We attempted to measure the intraluminal H2 concentrations to determine the bacterial overgrowth in the gastrointestinal tract. Patients and methods. Studies were performed in 647 consecutive patients undergoing upper endoscopy. At the time of endoscopic examination, we intubated the stomach and the descending part of the duodenum without inflation by air, and 20 mL of intraluminal gas samples of both sites was collected through the biopsy channel. Intraluminal H2 concentrations were measured by gas chromatography. Results. Intragastric and intraduodenal H2 gas was detected in 566 (87.5%) and 524 (81.0%) patients, respectively. The mean values of intragastric and intraduodenal H2 gas were 8.5 ± 15.9 and 13.2 ± 58.0 ppm, respectively. The intraduodenal H2 level was increased with the progression of atrophic gastritis, whereas the intragastric H2 level was the highest in patients without atrophic gastritis. Conclusions. The intraduodenal hydrogen levels were increased with the progression of atrophic gastritis. It is likely that the influence of hypochlorhydria on bacterial overgrowth in the proximal small intestine is more pronounced, compared to that in the stomach.

Salivary gland scintigraphy in gastro-esophageal reflux disease

Abstract.Gastro-esophageal reflux disease (GERD) is associated with a decreased salivary flow as well as gastric acid production. This study therefore aimed to investigate functional disorders of salivary glands in patients with GERD.Methods:Thirty-one consecutive patients with GERD underwent salivary gland scintigraphy.Results:If the results defined the optimal cutoff point for determining the decreased salivary secretion as 51 % in parotid glands and 36 % in submandibular glands, a decreased salivary secretion of right parotid gland, left parotid gland, right submandibular gland, and left submandibular gland was found in 39 %, 32 %, 36 %, and 58 %, respectively. Overall, salivary function disorder of at least one major salivary gland was found in 24 patients (78 %) with GERD. There was no difference in the incidence of impaired salivary function between GERD patients with and without erosive esophagitis. Salivary gland function was more frequently diminished than expected in GERD. We concluded that the presence of impaired salivary gland function was considered to be one of risk factors for developing GERD symptoms.

Clinicoradiological changes of brain NK/T cell lymphoma manifesting pure akinesia: a case report

BackgroundPure akinesia (PA) is a distinct form of parkinsonism characterized by freezing phenomena. Little is known about brain tumor-associated PA. We highlight the clinicoradiological changes in a patient with PA and central nervous system (CNS) metastases of natural killer/T-cell lymphoma (NKTL).Case presentationA 68-year-old man with stage IVB extranodal NKTL developed a gait disturbance. Neurological examination of his gait revealed freezing, start hesitation, short step, forward flexion posture, festination and postural instability. Mild facial hypomimia and micrographia were observed. There was no rigidity or tremor in any of the four extremities. Brain magnetic resonance imaging (MRI) displayed T2-hyperintense lesions in the dorsal brainstem, cerebellum and periventricular white matter. Diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) revealed hyperintensity in these regions. Cerebrospinal fluid cytology revealed CD56-positive cells on immunohistochemical staining. The patients neurological deficits did not respond to L-dopa treatment and intrathecal administration of methotrexate (MTX). Two weeks later, he displayed confusion and generalized convulsions. T2-hyperintense lesions spread to the basal ganglia and the infratentorial regions. Gadolinium enhancement was observed in the cerebellum and frontal subcortex. DWI and the ADC revealed diffusion-restricted lesions in the middle cerebellar peduncles, left internal capsules and cerebral white matter. MTX pulse therapy and intrathecal administration of cytosine arabinoside and MTX were performed. Two months later, his ambulatory state was normalized. Brain MRI also revealed marked alleviation of the infratentorial and supratentorial lesions.ConclusionsThe clinicoradiological profile of our patient suggested that dorsal ponto-mesencephalic lesions could contribute to the pathogenesis of PA. Physicians should pay more attention to striking CNS seeding of metastatic NKTL. MTX pulse therapy had an excellent effect in improving serious symptoms and brain lesions in our patient.

Breath Hydrogen Gas Concentration Linked to Intestinal Gas Distribution and Malabsorption in Patients with Small-bowel Pseudo-obstruction

Summary Background The patient with colonic obstruction may frequently have bacterial overgrowth and increased breath hydrogen (H2) levels because the bacterium can contact with food residues for longer time. We experienced two cases with intestinal obstruction whose breath H2 concentrations were measured continuously. Case 1 A 70-year-old woman with small bowel obstruction was treated with a gastric tube. When small bowel gas decreased and colonic gas was demonstrated on the plain abdominal radiograph, the breath H2 concentration increased to 6 ppm and reduced again shortly. Case 2 A 41-year-old man with functional small bowel obstruction after surgical treatment was treated with intravenous administration of erythromycin. Although the plain abdominal radiograph demonstrated a decrease of small-bowel gas, the breath H2 gas kept the low level. After a clear-liquid meal was supplied, fasting breath H2 concentration increased rapidly to 22 ppm and gradually decreased to 9 ppm despite the fact that the intestinal gas was unchanged on X-ray. A rapid increase of breath H2 concentration may reflect the movement of small bowel contents to the colon in patients with small-bowel pseudo-obstruction or malabsorption following diet progression. Conclusions Change in breath H2 concentration had a close association with distribution and movement of intestinal gas.

Breath hydrogen and methane levels in a patient with volvulus of the sigmoid colon

Volvulus of the large bowel is the third most common cause of colonic obstruction. A patient with colonic obstruction or delayed small intestinal transit may frequently have bacterial overgrowth and increased breath hydrogen (H(2)) and/or methane (CH(4)) excretion because the bacterium can contact with food residues for a longer time. A 39 year old woman attended our hospital with complaints of abdominal pain and distension. This patients abdominal radiograph showed an inverted U-shaped shadow. The fasting breath CH(4) level was 26 ppm. An endoscopic procedure was immediately carried out with suspected sigmoid colon volvulus, and detorsion was achieved. There was resolution of the sigmoid volvulus after colonoscopy, and breath CH(4) concentration in the next morning decreased to 10 ppm. A liquid meal was supplied at noon on the second hospital day. The breath CH(4) concentration increased markedly to 38 ppm at 18:00 although she had no abdominal symptoms. This value peaked at 42 ppm at 18:00 on the third hospital day and was gradually reduced to 20 ppm the next day. The breath H(2) concentration value kept a low level during fasting and increased markedly to 51 ppm the next day after a liquid meal was supplied. The next morning, fasting breath H(2) concentration rapidly decreased to 6 ppm. This suggests that changes in breath H(2) levels may reflect transient malabsorption after a liquid test meal is supplied. In conclusion, breath H(2) and CH(4) analysis may be another tool for evaluating the intestinal circumstances.

Malignant lymphoma and Schistosoma japonica infection

Schistosoma japonica invades the human body through the skin with Oncomelania nosophora, an intermediate host, and adult schistosoma inhabit and lay eggs in the mesenteric and portal veins. Because of the extinction of Oncomelania nosophora in Japan, all new patients with acute schistosomiasis have become infected abroad. We report a case of malignant lymphoma with coexisting S. japonica infection. This 72-year-old man, who had experienced general malaise for one month, presented to our hospital with abdominal pain, distention and vomiting. He had cervical lymphadenopathy, conjunctival pallor, scleral icterus and abdominal distention caused by ileus. The liver and spleen were palpable 5 and 4 cm, respectively, below the costal margin. Single 1-cm inguinal lymph nodes were palpable bilaterally. Abnormal test results on admission were: haemoglobin concentration 104 g/l, platelet count 46 · 10/l, total protein 53 g/l, albumin 29 g/l, bilirubin 205 lmol/l, glutamic oxaloacetic transaminase 121 IU/l, lactate dehydrogenase 2460 IU/l. Biopsy of cervical lymph nodes showed nonHodgkin lymphoma (diffuse large B cell). Abdominal echography showed many hypoechoic areas in the spleen. Liver biopsy showed lymphoma and eggs of S. japonica (right and left, *1 Schistosoma japonicum egg, *2 infiltrating lymphoma cells). The clinicopathological stage was IVB. The patient did not undergo chemotherapy due to a worsening general condition and abdominal cavity bleeding of unknown origin; he died approximately one month after admission. Schistosomiasis occurs in Japan, China and the Philippines. Schistosoma eggs are most frequently found in the mucosal and submucosal layers of the colon, caecum and sigmoid colon, in that order. It is hypothesized that the relationship between S. japonica and cancer has much in common with that between Helicobacter pylori and mucosa-associated lymphoid tissue lymphoma, and that between Epstein–Barr virus and empyema-related lymphoma, in that the mechanisms of chronic inflammation act as cancer-promoting factors. In this case, lymphoma cells proliferated around egg-emboli in Glisson’s capsule and portal vein branches, suggesting a close relationship between the infection and the lymphoma.

P42. Multiple neoplasms consist of lung cancer and hematological malignancies.

Background The lung cancer is a cancer of the most in Japan and first place in cause of death. Lung cancer still has poor prognosis with cure only in early clinical stage. Recently, new anti-cancer agent and molecular target agents are increased but clinical outcomes are not satisfied. We report that we reviewed 39 cases of multiple neoplasms with lung cancer and the hematological malignancies.

Multiple neoplasms including hematological malignancies in elderly

Introduction.– Chronic myelogeneous leukemia (CML) is, so called, stem cell leukemia. There was a major change in CML treatment last two decades. Now CML therapy strategy gets special medicine, tyrosine kinase inhibitor. This special medicine brings good prognosis and good general condition. So we report a review of elderly CML cases. Methods.– From 2003 to 2012, we intended for 229 patients whom suffered from hematological malignancies. Sixty-five years old or older, 15 cases in thatdiagnosedCMLand15patientswere followed up until death or until December 2012. And we studied about age, gender, diagnosises, prognosis, and cause of death. Result.– From 2003 to 2012, CML patients are 39 cases in that 65years or over years patients are 15 cases. Gender is male 8 cases, female 7 cases, median age is 70 years. Clinical phase are chronic phase, and the chance to diagnosis were medical health check. 14 cases received imatinib therapyand1casewasbest supporting care because patient did not want to treat because he needed his own time. Imatinib therapy is 400mg/day po, and almost all patients are outer ward. Side effects aremainly edema, neutropenia and pain of lower limb, but all side effects was undercontrolable by medicine. Clinical outcome is that achieved complete remission is in 13 cases out of 15 cases. One case was remission failure, 1 case was best supporting care.Median overall survival time is 27months (ranged 10–122 months). Key conclusion.–Treatment inCML ishopeful in elderly, it is possible to treat the same as adult.

Nizatidine Improves Impaired Salivary Secretion in GERD

During esophageal acid clearance, salivation plays an important role in defending the esophageal mucosa. Nizatidine, a histamine H2 receptor antagonist, inhibits acetylcholine esterase, with a resultant increase in acetylcholine. We experienced a patient with gastroesophageal reflux disease (GERD) and impaired salivary secretion who has been successfully treated with nizatidine. Case report A 63-year-old female visited our hospital with complaints of heartburn and continuous laryngeal discomfort. Saliva scintigraphy was performed to evaluate the salivary function. Washout ratio was decreased to be 25%–40% in individual salivary gland. After the treatment with nizatidine, salivary scintigraphy demonstrated the increased washout ratios. The values of both parotid glands increased up to 90%, whereas those of submandibular glands improved to be around a normal range. GERD symptoms disappeared completely after treatment. In conclusion, nizatidine may be one of therapeutic options for low salivary excretion.

DIFFUSE WHITE DEPOSITS OF THE DUODENUM MAY SUGGEST DELAYED GLUCOSE ABSORPTION

Background:  The aim of the present study was to evaluate the relationship between white deposits observed in the duodenum and malabsorption of nutrients.