Yasushi Akita

Primary small cell carcinoma of the stomach.

Abstract  We report on an 80‐year‐old man with primary gastric small cell carcinoma (SmCC). He was admitted to hospital with hematemesis. An upper gastrointestinal examination revealed an irregularly ulcerated tumor, 60 mm in diameter, on the lesser curvature of the stomach body extending to the cardia. An endoscopic biopsy revealed a solid proliferation of intermediate‐sized tumor cells with hyperchromatic nuclei and scanty cytoplasm. Immunohistochemically, the neoplastic cells were positive for neuron‐specific enolase and chromogranin A, but negative for carcinoembryonic antigen. No tumor was detected on examination of the chest. Therefore, primary gastric SmCC was diagnosed preoperatively. To date, only 38 cases of primary gastric SmCC, including our case, have been reported. By using endoscopic biopsy, approximately two‐thirds of cases have been diagnosed incorrectly. In the reported cases of gastric SmCC, the endoscopic findings frequently indicated a submucosal tumor. Gastric SmCC is clinically aggressive and has an extremely poor prognosis, even when discovered at an early stage. Most patients with gastric SmCC die within 1 year of diagnosis. Although a standard treatment for gastric SmCC has not been established, intensive chemotherapy should be considered to promote long‐term survival. We believe that careful examination, including immunohistochemical investigation, is necessary for determining the therapeutic strategy whenever gastric SmCC is suspected during endoscopy.

Seroprevalence of immunoglobulin G antibodies against Helicobacter pylori among endoscopy personnel in Japan.

BACKGROUND The seroprevalence of immunoglobulin G antibodies against Helicobacter pylori in endoscopy personnel was determined to investigate whether gastrointestinal endoscopists and endoscopy nurses in Japan are at an increased risk for H. pylori infection and to clarify risk factors for H. pylori infection during endoscopy. METHODS One hundred twenty-one gastrointestinal endoscopists and endoscopy nurses provided personal information, including their observance of infection-control measures, by means of self-administered questionnaire. One hundred one age-matched healthy individuals undergoing routine physical examinations served as controls. Serum samples from each subject were examined with enzyme-linked immunosorbent assay for the presence of IgG antibodies against H. pylori. RESULTS Among younger subjects (< 40 years old), endoscopists and endoscopy nurses had higher seropositive rates than did control subjects (p < 0.05). Among older subjects (> or = 40 years old), the seropositive rate did not differ between endoscopy personnel and control subjects (p = 0.2174). However, among older seropositive subjects, endoscopy personnel had significantly higher antibody titers than did control subjects (p < 0.01). Older seropositive endoscopists performed significantly more examinations per month than did their seronegative colleagues (p < 0.05). Furthermore, younger seropositive endoscopy nurses performed significantly more examinations per month than did seronegative nurses (p < 0.05). CONCLUSIONS Gastrointestinal endoscopists and endoscopy nurses in Japan are at high risk for H. pylori infection. The risk of H. pylori infection is correlated with the frequency of endoscopic examinations, especially in older gastrointestinal endoscopists and younger endoscopy nurses.

Surgical treatment of Cronkhite-Canada syndrome associated with protein-losing enteropathy: report of a case.

PURPOSE: The case of a patient with Cronkhite-Canada syndrome, who developed a protein-losing enteropathy, is reported. METHODS: After localization of the protein-losing region, a right colectomy was performed. RESULTS: Hypoproteinemia and ectodermal changes improved postoperatively. CONCLUSIONS: Surgery is an effective treatment for protein-losing enteropathy in Cronkhite-Canada syndrome. Ectodermal changes improve after correcting malnutrition.

Relationship between Helicobacter pylori infection and histologic features of gastritis in biopsy specimens in gastroduodenal diseases, including evaluation of diagnosis by polymerase chain reaction assay.

Abstract: We investigated the relationship between Helicobacter pylori infection and the histologic features of gastritis in gastroduodenal disease, and evaluated the diagnostic usefulness of the polymerase chain reaction (PCR) assay for the detection of H. pylori before and after eradication therapy. Endoscopic biopsy specimens from 81 patients with gastroduodenal disease were examined for the presence of H. pylori by culture and histologic examination. Histologic features of gastritis were classified according to the updated Sydney System, and results of the PCR assay were compared with those of histologic examination, using histologic scores. The density of H. pylori was significantly correlated with polymorphonuclear neutrophil activity and chronic inflammation. These findings suggest that the grades of infiltration of polymorphonuclear neutrophil cells and chronic inflammatory cells correspond to the density of H. pylori infection assessed by the updated Sydney System. Patients with positive results on PCR assay and negative results on histologic examination may have a low density of H. pylori because of severe atrophy in the gastric mucosa. Differences in results for the PCR assay and histologic examination were found in 2 of 12 patients in the detection of H. pylori after eradication therapy. According to the results of the PCR assay and histologic features before and after eradication, the gastric tissue-based PCR assay for H. pylori after eradication may be too sensitive to judge successful eradication of H. pylori.

Hemodynamics in the colonic mucosa of rats with dextran sulfate-induced colitis in the early phase.

We investigated hemodynamics in the colonic mucosa of rats with experimental colitis induced by the administration of dextran sulfate sodium (DSS). As parameters of hemodynamics, we determined the indices of mucosal hemoglobin concentration (IHb) and mucosal oxygen saturation (ISO2), measured by reflectance spectrophotometry, and an index of colonic mucosal blood flow (Flow), measured by laser-Doppler flowmetry. In the ascending colon, each parameter was measured by a combination of these methods after 1, 3, 5, 7, and 10 days of DSS administration. Histopathological examination was also performed. IHb in the DSS group increased with time; on the 7th day, the value was 126.9±8.32, while that in the control group was 85.0±4.14, IHb in the DSS group being significantly increased (P<0.02). ISO2 in the DSS group was lower than that in the control group, and on the 7th day, was significantly lower in the DSS group (25.7±1.34) than in the control group (33.4±1.77) (P<0.01). No changes in Flow were observed in either the DSS or the control group during the administration period, and no significant difference in Flow was found between the two groups. On histopathological examination, we observed a time-dependent increase in the infiltration of inflammatory cells in the ascending colon of rats treated with DSS, but changes such as erosion and ulceration were not found in the superficial layer of the mucosa. No histopathological changes were found in the control animals. In the early phase of the experimental colitis, hemodynamic alterations in the colonic mucosa were already present at the time the slight histopathological changes developed. These observations seemed to indicate the involvement of hemodynamic alterations in the subsequent tissue injury.

The influence of feeding on gastric acid suppression in Helicobacter pylori-positive patients treated with a proton pump inhibitor or an H2-receptor antagonist after bleeding from a gastric ulcer.

Background. This study investigated the influence of feeding on gastric acid suppression in Helicobacter pylori-positive patients treated with intravenous infusions of proton pump inhibitors (PPIs) or with H2-receptor antagonists (H2-RAs) after bleeding from a gastric ulcer. Methods. Forty-nine H. pylori-positive patients with bleeding gastric ulcers (44 men and 5 women) were divided into four groups: one group received an H2-RA while fasting, one group received an H2-RA while eating regularly, one group received a PPI while fasting, and one group received a PPI while eating regularly. Intragastric pH was monitored during fasting and nonfasting to calculate the pH 3 and pH 4 holding times and the mean pH. Results. During a 24-h fast, the pH 3 and pH 4 holding times and the mean pH were significantly higher in patients administered omeprazole (PPI; 93.2 ± 9.2%, 90.6 ± 11.1%, and 6.9 ± 0.6, respectively) than in those administered ranitidine (H2-RA; 61.0 ± 27.5%, 55.8 ± 29.1%, and 4.8 ± 1.3, respectively; P < 0.001 for all). Results were similar during feeding (PPI meal, 98.9 ± 2.6%, 98.3 ± 3.7%, and 6.9 ± 0.3; H2-RA meal, 59.8 ± 17.6%, 49.7 ± 18.0%, and 4.3 ± 0.7, respectively; P < 0.001 for all). In addition, the pH 3 and pH 4 holding times and the mean pH in the H2-RA meal group were not significantly lower than those in the H2-RA group (P = 0.999, P = 0.865, and P = 0.687, respectively). The values in the PPI and PPI meal groups were similar (P = 0.872, P = 0.777, and P > 0.999, respectively). Conclusions. Gastric acid suppression during the administration of an H2-RA or a PPI soon after the cessation of gastric bleeding was scarcely affected by feeding. It may well be that H. pylori-positive patients with bleeding gastric ulcer can resume a regular diet and return to work soon after bleeding ceases.

Rectal mucosal hemodynamics, evaluated by reflectance spectrophotometry, in patients with chronic hepatitis

Abstract: To evaluate rectal mucosal hemodynamics in patients with chronic hepatitis, we employed reflectance spectrophotometry and examined the results in relation to the presence and severity of chronic hepatitis. Twenty-six patients with histologically diagnosed chronic hepatitis and 21 controls were examined for rectal vascular findings by endoscopy. Indices (I) of rectal mucosal oxygen saturation (ISO2) and rectal mucosal hemoglobin (IHb) concentration were measured. To minimize the effects of systemic anemia, the IHb was divided by blood Hb concentration, giving the rectal index for Hb (RHb). The relationship between rectal mucosal hemodynamics and the histological grade of chronic hepatitis was studied. Rectal vascular lesions were observed in three patients with chronic hepatitis (11.5%). The RHb in patients with chronic hepatitis was significantly higher than that in the controls (5.74 ± 0.71 and 4.82 ± 1.12, respectively; P < 0.01). There was no significant difference in ISO2 levels (44.23 ± 5.84 and 41.94 ± 4.91, respectively). No significant correlation was observed between rectal mucosal hemodynamics and the histological severity of chronic hepatitis, although rectal mucosal hemodynamics changed in patients with chronic hepatitis. Early vascular changes were observed in the rectal mucosa of patients with chronic hepatitis.

Malignant Paraganglioma of the Stomach

Abstract: We report a case of malignant paraganglioma of the stomach. A gastric endoscopic examination on a 67‐year‐old female, performed for follow‐up purposes, revealed an irregularly elevated lesion with a central ulcer on the lesser curvature of the lower body. The lesion showed characteristics of both an epithelial tumor and a submucosal tumor by endoscopy and radiography. The biopsy specimen suggested that the lesion was a malignant poorly differentiated tumor. On abdominal ultrasonography and computed tomography, several space occupying lesions were found in both lobes of the liver. Therefore, this case was diagnosed as having an advanced gastric cancer with liver metastases and underwent distal gastrectomy. Postoperatively, a final diagnosis of gastric paraganglioma was made by histological and immunohistochemical findings (positive for Grimelius, neuron specific enolase and other stains). These findings also revealed lymph node metastases. To date, only seven cases of gastric paraganglioma have been reported. Furthermore, two cases of malignant gastric paraganglioma have also been described in the literature. This is the first case of malignant gastric paraganglioma evaluated in detail by endoscopic and radiographic examinations.

6957 Evaluation of usefulness of endoscopic ultrasonography for diagnosis of villous tumors.

Background: Villous tumors are potentially or substantially malignant lesions. A detailed examination of this tumor is important for determining therapeutic strategy. We used to frequently observe a peculiar finding in villous tumors during endoscopic ultrasonography (EUS). The study of villous tumor based on EUS is not enough performed, although reports of usefulness of EUS for pretherapeutic staging of colorectal cancer have increased. Aim of this study is to clarify the characteristics of EUS findings of villous tumors. Methods: We performed EUS for 52 lesions histologically diagnosed as mucosal lesion (adenoma and intramucosal cancer) or submucosal cancer at Showa University Hospital from 1993 to 1999. The instrument used for EUS is the CF-UM200 with a 7.5 MHz radial-scan transducer (Olympus Optical Co.Ltd., Tokyo, Japan). These lesions were histologically classified into three categories: non-villous type; 24 cases (less than 25% of villous component), tubulovillous type; 21 cases (25-75% of villous component) and villous type; 7 cases (more than 75% of villous component). In this study, both tubulovillous type and villous type were defined as villous tumor. We compared EUS findings with histologic findings of the lesions. Results: By EUS, the non-villous tumor was demonstrated as a hypoechoic mass and its echo level was intermediate between the third hyperechoic layer and the fourth hypoechoic layer of colorectal wall. The echo-pattern of villous tumor contained multiple cystic area. The incidence of this echo-pattern was significantly different between villous tumors (18/28; 64%) and non-villous tumors (5/24; 21%)(p=0.0211). In the further investigation, cystic area was diffusely distributed in 7/7 (100%) of villous type and 5/21 (24%) of tubulovillous type (p=0.0007). But, there was no diffuse distribution in non-villous type. The depth of invasion was correctly determined by EUS as follows: mucosal lesion; 58% of villous tumors and 80% of non-villous tumors, submucosal cancers; 50% of villous tumors and 78% of non-villous tumors, respectively. Conclusions: EUS is useful for the diagnosis of villous tumors, however it is difficult to determine the depth of invasion of villous tumor by only EUS.