Yoshio Okita

Ultrasonographic assessment of gastric motility in diabetic gastroparesis before and after attaining glycemic control.

BackgroundGlycemic control is important for maintaining gastric motility in diabetic patients, but gastric motility has not yet been studied ultrasonographically in relation to glycemic control.MethodsWe made such observations before and after establishing glycemic control in diabetic patients with gastroparesis. We studied 30 diabetic patients with upper abdominal digestive symptoms who were hospitalized for correction of poor blood sugar control and who underwent upper digestive tract endoscopy to rule out structural causes such as gastric/duodenal lesions. Gastric motility was evaluated by transabdominal ultrasonography, using a test meal, before and after attainment of glycemic control (within 3 days after admission and 3 days before discharge). Also, upper abdominal digestive symptoms present on admission and at discharge were compared.ResultsAfter glycemic control was established, contractions of the antral region were more frequent than before the attainment of control (8.93 ± 1.17/3 min vs 7.63 ± 2.22/3 min, respectively; P < 0.001). Glycemic control also significantly improved gastric emptying (before glycemic control, 49.2 ± 14.8%; after, 67.1 ± 11.5%; P < 0.001). This was also true for the motility index, concerning antral gastric contractility (before control, 2.97 ± 1.57; after, 3.75 ± 1.09; P < 0.05). Upper abdominal symptom scores were also significantly lower after attainment of control than before (0.47 ± 0.78 vs 3.17 ± 2.00, respectively; P < 0.001).ConclusionsThese findings suggest that attaining glycemic control improves gastric motility and attainments upper abdominal symptoms in diabetic patients with gastroparesis.

Low-volume continuous hemodiafiltration with nafamostat mesilate increases trypsin clearance without decreasing plasma trypsin concentration in severe acute pancreatitis.

Continuous hemodiafiltration (CHDF) has recently been used for treatment of severe acute pancreatitis. CHDF is capable of eliminating small molecules from blood, but whether trypsin can be eliminated by CHDF is not clear. In this study, elimination of trypsin-like enzyme activity (TLE) and cationic trypsin-like immunoreactivity (TLI) using low-volume CHDF was examined at the first CHDF session in eight patients with severe acute pancreatitis. CHDF was performed with a polysulfone hemofilter (membrane area, 0.7 m2) and nafamostat mesilate, a protease inhibitor and anticoagulant, at a blood flow rate of 100 ml/min and a filtration and dialysis flow rate of 10 ml/min each. Before beginning CHDF, plasma TLE was 3.41 ± 2.86 nmol/(ml·min), and TLI was 5,900 ± 9,008 ng/ml. The average plasma clearances of TLE and TLI achieved by the circuit during the 12-hour therapy were 56.7 ± 4.9 ml/min and 8.0 ± 7.2 ml/min, respectively. The average plasma clearance of TLI into the waste fluid was 2.4 ± 1.6 ml/min whereas TLE was below the measurable sensitivity. The plasma concentration of TLE and TLI remained unchanged. These results indicate that low-volume CHDF using nafamostat mesilate as an anticoagulant can increase trypsin plasma clearance. However, low-volume CHDF is not effective to eliminate the plasma trypsin concentration.

Ultrasonographic comparison of gastric motility between diabetic gastroparesis patients with and without metabolic syndrome.

Background and Aims:  Diabetic patients with poor glycemic control or long standing disease often have impaired gastric motility. Recently, metabolic factors such as blood glucose have been reported as influencing gastric motility independently of autonomic neuropathy. Many diabetic patients have metabolic syndrome, which is strongly associated with coronary and other diseases. We investigated whether metabolic syndrome influences diabetic gastroparesis patients.

VASCULAR ECTASIA OF THE COLON TREATED BY ARGON PLASMA COAGULATION : REPORT OF A CASE

A 72‐year‐old woman presented with hematochezia. Colonoscopy revealed branch‐like vasodilation in the ascending colon and chronic hemorrhage from vascular ectasia of the colon was suspected. Argon plasma coagulation was performed. After treatment, epithelialization of the lesion site was noted and her anemia improved. Vascular ectasia of the colon is recognized as the etiology of lower gastrointestinal bleeding with increasing frequency. Infrared ray electronic endoscopy is useful for determining the extent of disease and argon plasma coagulation, a new hemostatic technique, is suitable for treatment of this condition.

Usefulness and Limitations of Endoscopic Ultrasonography in Diagnosis of Adenomyomatosis of the Gallbladder

Abstract: Although endoscopic ultrasonography (EUS) is commonly used to examine lesions in the gallbladder, its ability to accurately diagnose adenomyomatosis (ADM) has not been evaluated. We compared the accuracy of EUS and various other imaging techniques in the diagnosis of ADM. Thirty‐one patients undergoing cholecystectomy after elevated lesions were found in the gallbladder by various imaging techniques were studied retrospectively. Based on histopathologic examination, the sensitivity and specificity of EUS were evaluated in ADM. The sensitivity of abdominal ultrasonography, CT and ERCP in ADM were also evaluated. Of the 11 patients diagnosed with ADM by EUS, 9 cases were confirmed histologically (81.8%). Of the 11 patients with histologic diagnosis of ADM, 9 were accurately diagnosed preoperatively by EUS (81.8%). EUS proved more reliable for diagnosis of ADM than the other imaging techniques. Important diagnostic features include preservation of the three‐layered structure of the gallbladder, wall‐thickening exceeding 3 mm, and 2 or more Rokitansky‐Aschoff sinuses occurring within a 1 cm area of the gallbladder.

Evaluation of solitary and scattered esophageal varices according to infrared endoscopy and endoscopic ultrasonography

Background and Aim:  The aim of this study was to clarify the etiology and clinical significance of solitary and scattered esophageal varices by evaluating their hemodynamics and other characteristics using infrared endoscopy and endoscopic ultrasonography.

7234 Usefulness of three-dimensional expression by endoscopic ultrasonography in the diagnosis of gastric cancer invasion.

Objective: Many studies have reported the usefulness of endoscopic ultrasonography (EUS) in the diagnosis of gastric cancer invasion. However, the diagnostic capacity of EUS should be further improved. In this study, we examined the usefulness of three-dimensional expression by EUS in the diagnosis of gastric cancer invasion. Subjects and Methods: In 54 gastric cancer lesions that were histologically diagnosed after April 1995 by EUS using an ultrasonic miniprobe in our department, the rate of accurately diagnosing invasion was compared between period A and period B. The period between April 1995 and October 1996, when examination of threedimensional expression was started at our department, was regarded as period A (35 lesions) , while the period from October 1996 to date was regarded as period B (19 lesions). Furthermore, the usefulness of threedimensional expression was examined in l9 lesions during period B. In the three-dimensional expression, we pulled ultrasonic miniprobe out at definite speed manually, and recorded the images on VTR.We connected VTR output to images processing equipment (IndigO 2 , Silicon Graphics), and compressed each tomographic image (30 frame/sec) by EUS by Motion JPEG method. We selected necessary frames from the images, and converted them into volume data by the three-dimensional image processing software (Medical Design Composer 1.0) which we developed. We determined arbitrary cross sections and the external form on volume data, and observed the lesions spatially. Result: The rate of accurate diagnosis of invasion by EUS was 77.8% (42/54) , overall. Percentages were 74.3% (26/35: T1-m 71.4%, T1-sm 83.3%, T2-pm 50%) during period A and 84.2% (6/19: T1-m 87.5%, T1-sm 66.7%) during period B. During period B, the whole lesion was scanned in each direction for three-dimensional expression. Furthermore, more detailed examination could be performed by expressing random cross sections from three-dimensional data, improving the diagnostic capacity of this procedure. In 8 of 19 patients, superficial expression was possible. In these lesions, the rate of accurately diagnosed invasion was 100% (8/8). Although these patients were selected based on lesion size and the absence of the influence of heart beats, it was suggested that three-dimensional expression contributes to improving the diagnosis of invasion. Conclusion: Three-dimensional expression of EUS findings in patients with gastric cancer may improve the diagnosis of invasion.

7128 Three-dimensional ct pancreatography (3d-ctp) of pancreatic diseases.

Background: Endoscopic retrograde pancreatograpy (ERP) is common techniques used for the diagnosis of pancreatic diseases. However, conventional ERP under fluoroscopy (c-ERP) provides only two-dimensional projection images of the pancreatic ducts. Recent advances in the volumetric CT enable us to get whole pancreatic deta. CT images provide better tissue characterization than fluoloscopy images and ability to create 3D images from its data. Using volumetric CT technique with ERP is thought to be able to provide additional information. Aims: The present study was undertaken to assess the usefulness of 3D-CTP in the diagnosis of pancreatic diseases. Methods: The subjects of this study were 22 patients with pancreatic disease (5 with pancreatic cancer, 5 with chronic pancreatitis and 12 with pancreatic cystic disease). After c-ERP with balloon-catheter, 3D-CTP was performed with volumetric CT within a single brethhold period. Several 3D images per a case were made with the method of shaded surface display(SSD), multiplanar reconstruction (MPR) and maximum intensity projection (MIP) from CT data. Results: Images with SSD and MIP allowed us to realize the pancreatic ducts three dimensionally. The main pancreatic duct (MPD) was visualized three dimensionaly, but the side branches were not enough (see table).Images with MPR provide good visualization of both the pancreatic duct and its parenchyma. In the case of pancreatic cyst, the communication between the cyst and MPD was detected with 3D-CTP. In the case of mutin producing tumor, papillary intraductal tumor was detected more clearly. In the case of pancreatic cancer, dilated pancreatic ducts proximal to the stenosis were observed by 3D-CTP, which could not be visualized by c-ERP, with advantage of contrast resolution of CT. Conclusion: 3D-CTP provides three dimensional images of pancreatic ducts and its parenchyma. It provides additional information about the pancreatic pathologies to c-ERP. 3D-CTP with c-ERP seems to be applicable to simulation for the surgery. The accuracy and clinical usefulness of 3D-CTP will elevated by using improved devices under optimal condition.

A Case of a Giant Lipoma of the Duodenal Bulb

We describe a 58‐year‐old male whose major complaint was epigastric pain. A pediculate mass located in the anterior wall of the duodenal bulb and extending into the descending portion of the duodenum was noted on endoscopy of the upper digestive tract. The mass nearly completely occupied the duodenal lumen and was covered by normal mucosa with a tiny ulcer. Ultrasound endoscopy showed a nearly homogeneous hyperechoic pattern localized in the submucosa, and abdominal CT showed fatty density, suggesting a lipoma. The mass was resected by laparotomy, because it was large and extended to near the duodenal papillae. The tumor measured 55X35X30 mm and was histologically confirmed to be a lipoma which had originated in the submucosa. Giant duodenal lipomas more than 50 mm in maximum diameter have only been reported in 5 cases in Japan including our present case and 9 cases abroad, but some differences were observed in the description of the Japanese cases versus the non‐Japanese cases, such as the fact that the non‐Japanses cases often presented with severe symptoms such as bloody stools and intussusception.