Tadahiko Fuchigami

Endoscopic and biopsy findings of the upper digestive tract in patients with amyloidosis

Endoscopic and biopsy findings of the esophagus, stomach, duodenum, and colorectum were studied in 37 patients with amyloidosis involving the gastrointestinal tract. Endoscopic examinations revealed fine granular appearance, polypoid protrusions, erosions, ulcerations, and mucosal friability in many cases. These findings were most marked and noticed most often in the second portion of the duodenum. The frequency of amyloid deposition in the biopsy specimens was as follows; 100% in the duodenum, 95% in the stomach, 91% in the colorectum, and 72% in the esophagus. The degree of amyloid deposition in the duodenum, which was the highest of the entire gastrointestinal tract, significantly correlated with the frequency of endoscopic findings such as fine granular appearance and polypoid protrusions. Therefore, the two endoscopic findings described above are characteristic of this disease and may reflect amyloid deposition in the mucosa or submucosa of the alimentary tract. Our results indicate that for a diagnosis of amyloidosis, it is important to examine the upper gastrointestinal tract, especially the duodenum, using endoscopy and biopsy techniques.

Changes in Helicobacter pylori status in patients with rheumatoid arthritis under non‐steroidal anti‐inflammatory drugs

Background: The role of Helicobacter pylori infection in rheumatoid arthritis (RA) patients during treatment with non‐steroidal anti‐inflammatory drugs (NSAID) is still unclear. Methods: By means of endoscopy and biopsy, gastroduodenal lesions and H. pylori status were repeatedly examined in 88 RA patients at intervals ranging from 26 to 49 months. Histology and culture were applied to determine H. pylori status. Serial changes in gastroduodenal lesions and histologic score for mucosal atrophy were compared among groups classified by initial and second H. pylori status. Results: There were 28 patients with continuously positive H. pylori infection (CP group), 33 patients with continuously negative H. pylori infection (CN group), 7 patients in whom H. pylori status became negative (PN group), and 20 patients in whom H. pylori status could not be determined (UD group). Age, duration and species of NSAID, disease activity of RA, gastroprotective drugs applied and the prevalence of gastroduodenal mucosal lesions were not different among the groups at either the initial or the second examination. In the PN group, the score for mucosal atrophy at the second examination was significantly lower than at the initial examination, whereas no difference was found for the CP, CN and UD groups. Overall, histologic score for mucosal atrophy was higher in H. pylori‐positive patients than in H. pylori‐negative patients at both initial and second examination. Conclusions: In RA patients using NSAIDs, H. pylori infection may not affect the course of gastroduodenal lesions and activity of RA, but the infection contributes to mucosal atrophy.

Postoperative recurrence in patients with intestinal Behçet's disease

PURPOSE: The postoperative course of intestinal Behçets disease was studied in nine patients who had undergone a total of 15 operations due to intestinal ulcers. METHODS: These patients were followed up for an average of 6.0 years (range, 1 year, 3 months to 13 years, 10 months) after each operation and they were repeatedly examined by double-contrast radiography and/or colonofiberscopy. RESULTS: Recurrence of intestinal ulcers was observed in 12 (80 percent) of the 15 surgical cases. The incidence (50 percent) of postoperative recurrence in six cases in which intraoperative endoscopy revealed no abnormality in the retained intestine was lower than that (100 percent) in nine cases without this examination. Recurrent intestinal lesions in most cases were demonstrated as multiple aphthoid ulcers in the ileum near the ileocolectomy, or as one or two deep ulcers at the ileocolectomy site. The recurrent ulcers were successfully treated by various medical therapies, but the effectiveness of these therapies was only temporary. CONCLUSION: In the case of this disease, intraoperative endoscopy may be useful for preventing postoperative recurrence and periodic follow-up examination with radiography and endoscopy should be performed, even after surgery.

Helicobacter pylori and mucosal atrophy in patients with gastric cancer: a special study regarding the methods for detecting Helicobacter pylori.

We assessed the sensitivities of several methodsfor detecting Helicobacter pylori (culture, histology,rapid urease test, and serology), and evaluated the H.pylori positivity considering the degree of atrophy in the background mucosa in 202 gastriccancer patients and 101 controls. The positivity of H.pylori determined by culture (81%) was significantlyhigher than that determined by serology (62%) in gastric cancer patients (P < 0.001). Thepositivities of H. pylori determined by biopsy and/orserology in intestinal (84%) and diffuse (95%) types ofgastric cancer were higher than that observed in controls (54%) (P < 0.001).Intestinal-type gastric cancer tended to occur in theatrophic mucosa, in which H. pylori positivity was notdifferent from that in controls after adjusting for thedegree of atrophy, whereas diffuse-type gastric cancerwas observed more often in the nonatrophic mucosa, inwhich H. pylori positivity was higher than that incontrols even after adjusting for the degree ofatrophy.

Intestinal and extraintestinal complications of Crohn's disease: Predictors and cumulative probability of complications

Of 238 patients with Crohns disease seen at our clinics from April 1973 to August 1988, 203 patients were selected for this study, since they fulfilled the following criteria: they had been followed up for more than 6 months as outpatients or had been treated as inpatients for more than 1 month. They were studied to elucidate: (a) the different types and indidence of various complications, (b) the factors related to complications present at the time of diagnosis, (c) predictors of new complications arising after diagnosis, and (d) the cumulative incidence of complications occurring during the course of the disease from the times of onset and diagnosis. Of the intestinal complications, perianal fistula was most common (33%), followed by strictures with dilatations of the proximal bowel (21%), and internal fistula (14%). Of the extraintestinal complications, menstrual disturbance was the most common (18% of the female patients), followed by arthritis (10%), and aphthous stomatitis (10%). As for the factors influencing complications present at the time of diagnosis, the pattern of bowel involvement was significantly correlated with the presence of intestinal stricuture, while the erythrocyte sedimentation rate was significantly correlated with the presence of perianal fistula. A significant predictor of new complications arising after diagnosis was the general well-beling of patients at the time of diagnosis. Patients who, at diagnosis, already have complications such as stricture, absominal abscess, internal or external fistula, massive hemorrhage, and free perforation or anal lesions are more likely to develop new complications in addition to those present at diagnosis, compared with patients without any complications at diagnosis (P=0.055).

Endoscopic findings in Yersinia enterocolitica enterocolitis

The endoscopic findings in the colon and terminal ileum in eight cases of Yersinia enterocolitica enterocolitis infection were studied. The diagnosis was based on the isolation of Y. enterocolitica in the feces and/or elevated serum antibody titers to the organism. Total colonoscopy was performed between 7 and 38 days (mean, 24 days) after the onset of symptoms. In all patients, the terminal ileum was affected, followed by frequent involvement of the ileocecal valve and the cecum, and less frequently, the ascending colon. In the terminal ileum, round or oval elevations with or without ulcers were detected. Small ulcers were detected on the ileocecal valve and in the cecum. These findings were observed even 4 to 5 weeks after the onset of symptoms, suggesting a relatively long course for this disease.

Hypophosphatemia induced by intravenous administration of saccharated iron oxide

SummaryForty milligrams saccharated iron oxide1 was given intravenously, daily, to nine iron-deficient patients with moderate to severe anemia. During the 14–42 days of treatment, levels of serum inorganic phosphorus (Pi) decreased significantly and in a stepwise manner (before vs 1 week,P<0.005; 1 week vs 2 weeks,P<0.01). Seven of the nine patients became hypophosphatemic within 2 weeks and the other two within 4 weeks. In parallel with the decline in serum Pi, the phosphate clearance increased and tubular reabsorption of phosphate decreased. Reversion to normal levels was delayed in patients treated for the longer period.

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.

Jejunal endoscopy using a long duodenofiberscope

Consistently good results have been reported using this treatment.S This endoscopic ligating device is a modification and extension of the widely practiced hemorrhoid banding technique. With a standard flexible fiberoptic gastroscope, precise elastic band ligation of targets in the esophagus and stomach is possible. Superficial lesions such as varices, vascular malformations, and acute ulcers and erosions would appear to be suitable candidates for elastic band ligation. Penetrating ulcers and those with significant surrounding inflammatory response are not, however, likely to be pliable enough to be drawn into the banding chamber. Preliminary experience in the canine suggests that results similar to those obtained using elastic band ligation in the lower gastrointestinal tract may be achievable. In the normal canine esophagus and stomach, adequate amounts of mucosal and submucosal tissue can be drawn into the ligating device to effect secure entrapment and ligation. The fate of entrapped tissue and length of time required for band dislodgment and tissue slough will require further investiga-

Endoscopic evaluation of gastric inflammatory fibroid polyp

Clinical and endoscopic manifestations of 18 gastric inflammatory fibroid polyps (IFP) in 16 patients who underwent endoscopic or surgical removal were retrospectively analyzed. All of the lesions were located within the pyloric antrum, and the sizes varied from 0.8 to 7.0 cm. On endoscopy, six polyps which measured 1.0 cm or less uniformly seemed to be sessile or intramural tumors, whereas four of the nine polyps between 1.1 and 2.0 cm in size were additionally accompanied by a central depression. The remaining three, which measured more than 2.0 cm, showed characteristic polypoid growth with ulcerations. Three polyps more than 1.0 cm in size occasionally prolapsed into the duodenal bulb. Three patients with these prolapsing polyps and two with polyps accompanied by ulcerations experienced abdominal pain, nausea, or severe anemia. Two polyps (11%) were precisely diagnosed as IFP by means of conventional forceps biopsy. Histological examinations revealed that all of the polyps proliferated within the submucosa. Therefore, this type of polyp may be subject to endoscopic removal to enable a precise diagnosis and treatment.