小林 隆

Chronic pancreatitis is progressive and irreversible, leading to digestive and absorptive disorders by destruction of the exocrine pancreas and to diabetes mellitus by destruction of the endocrine pancreas. When complications such as pancreatolithiasis and pseudocyst occur, elevated pancreatic ductal pressure exacerbates pain and induces other complications, worsening the patient's general condition. Combined treatment with extracorporeal shock-wave lithotripsy and endoscopic lithotripsy is a useful, minimally invasive, first-line treatment approach that can preserve pancreatic exocrine function. Pancreatic duct stenosis elevates intraductal pressure and favor both pancreatolithiasis and pseudocyst formation, making effective treatment vitally important. Endoscopic treatment of benign pancreatic duct stenosis stenting frequently decreases pain in chronic pancreatitis. Importantly, stenosis of the main pancreatic duct increases risk of stone recurrence after treatment of pancreatolithiasis. Recently, good results were reported in treating pancreatic duct stricture with a fully covered self-expandable metallic stent, which shows promise for preventing stone recurrence after lithotripsy in patients with pancreatic stricture. Chronic pancreatitis has many complications including pancreatic carcinoma, pancreatic atrophy, and loss of exocrine and endocrine function, as well as frequent recurrence of stones after treatment of pancreatolithiasis. As early treatment of chronic pancreatitis is essential, the new concept of early chronic pancreatitis, including characteristics findings in endoscopic ultrasonograms, is presented.

A 62-year-old man was referred to our hospital after ultrasonographic mass screening detected a pancreatic cyst that proved to be an intraductal papillary mucinous neoplasm. Computed tomography additionally demonstrated air in the main pancreatic duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography delineated a filling defect in the main pancreatic duct in the body of the pancreas. The sphincter of Oddi was open. The main pancreatic duct was dilated by viscous mucin air in the duct was attributed to consequent dysfunction of the sphincter. Laboratory findings included no significant abnormality. The patient has remained asymptomatic during follow-up. Of 25 previously reported cases with air in the duct, only 1 involved an intraductal papillary mucinous neoplasm. © Springer 2013.

今回我々は検診で発見され, 手術を行った胆嚢ポリープについて検討した。対象は当院で超音波検査により胆嚢ポリープと診断された2,152例中, 検診で発見され経過観察中に増大を認め手術した増大後手術群9例および発見時に手術した即時手術群7例であった。増大後手術群は平均径12.9mm, 増大速度が平均2.6mm/年で病理組織所見はコレステロールポリープ7例, 乳頭状過形成1例, 管状腺腫1例であった。即時手術群は平均径13.1mmで, 病理組織所見はコレステロールポリープ5例, 炎症性ポリープ1例, 腺腫内癌1例であった。増大後手術群と比較して即時手術群は発見時の径が有意に大きく, 単発例が有意に多かった。内部エコーは増大後手術群では実質様・等エコーを示すものが多く, 即時手術群では小嚢胞様構造を示すものが多かった。実質様・等エコーを示す胆嚢ポリープが増大した場合には腺腫あるいは腺腫内癌を考慮する必要がある。

1999年から3年間に行った注腸検査1,040例のうち大腸憩室は373例(35.9%)に認められた.大腸憩室は年齢とともに増加し,右側結腸では40歳代まで急激に増加したが,左側結腸では年齢とともに次第に増加し,右側結腸とほぼ同率になった.大腸出血性疾患557例のうち大腸憩室出血は55例で,出血部位は左側結腸40例,活動性出血を認めた例は7例,治療は外科手術1例,塞栓術1例,内視鏡的止血術5例であった.便秘症は56.4%,内服薬はLDAを含む抗血栓薬が43.6%,LDAを服用した者が27.3%,NSAIDsが25.5%であった.大腸憩室炎に伴う穿孔に対して治療を行った14例はS状結腸に最も多く発生し,内服薬はNSAIDs 5例,便秘薬5例,LDA 2例であった.(著者抄録)

We examined the recurrence of gastric mucosal lesions in rats after a single treatment with compound 48/80 (C48/80), a mast cell degranulator. During the period of 0.5 h to 24 h after treatment with C 48/80 (0.75 mg/kg, i.p.), an apparent recurrence of gastric mucosal lesions was found 18 and 24 h after the lesion formation, progression, and recovery occurred during the period of 12 h. Gastric mucosal blood flow showed the maximum reduction at 0.5, 16, and 22 h after treatment followed by the maximum recovery of the decrease at 12, 20, and 24 h, respectively. Gastric mucosal myeloperoxide and xanthine oxidase activities and lipid peroxide content showed the maximum increase at 3, 18, and 24 11 after treatment. Gastric mucosal superoxide dismutase activity unchanged after treatment and gastric mucosal catalase activity decreased only at 24 h. Gastric mucosal Se-glutathione peroxidase activity and vitamin E. ascorbic acid, and hexosamine contents showed their maximum decrease at 3, 18, and 24 11 after treatment. Gastric mucosal nonprotein SH content showed the maximum decrease at 0.5, 16, and 22 11 after treatment. Serum histamine and serotonin concentrations increased rapidly after treatment but the increases in serum histamine and serotonin concentrations diminished completely until 12 and 14 h, respectively. These results indicate that lesions recur repeatedly accompanied with an ischemia-reperfusion-like change in blood flow, inflammation, and disruption of antioxidant defense systems in the gastric mucosa of rats in no relation to released histamine and serotonin after a single C48/80 treatment.

Inflammatory bowel disease is a multifactorial disease. Oxidative stress has been thought to be one of etiologic factor for inflammatory bowel disease. The genes superoxide dismutase (SOD2) and NAD(P)H:quinone oxidoreductase 1 (NQO1) are involved in inflammation and oxidative stress. The purpose of the present case-control study with 134 patients with ulcerative colitis (UC) and 125 healthy controls was to determine whether polymorphisms of these genes, the NQO1 C609T and the SOD2 Ala-9Val, are associated with the risk of UC and influence the clinical characteristics. These polymorphisms were examined by polymerase chain reaction-restriction fragment length polymorphisms and direct sequencing. In patients showing steroid resistance, the number with the NQO1 T/T genotype was significantly higher than other genotypes (odds ratio 9.45, 95% confidence interval 2.46-41.6, p = 0.002). In the patients whose onset of UC was age 20 years or younger, more patients had SOD2 T/T genotype than the other genotypes (odds ratio 6.46, 95% confidence interval 0.82-51.0). No association between these polymorphisms and UC risk was apparent. The NQO1 C609T polymorphism may influence steroid resistance of UC patients, while the SOD2 Ala-9Val polymorphism may influence age of onset of UC. Oxidative stress may influence the clinical features of UC.

高齢化社会を迎え心疾患や脳血管疾患が増加し、その予防や治療目的で抗凝固薬や抗血小板薬が用いられる機会が多くなり、これらの薬剤は時に消化管出血の原因となることが危惧される。今回、高齢者における食道出血性病変について81症例(Mallory-Weiss症候群20例・逆流性食道炎37例・食道潰瘍15例、うち42例が65歳以上の高齢者)を対象に抗凝固薬・抗血小板薬との関連性について検討した。その結果、抗凝固薬或いは抗血小板薬を処方されていたのは14例(28.6%)で全例高齢者であり、出血によりヘモグロビンが10g/dl以下をきたしていたのはこの14例で、4例に対しては輸血を要し、またこの14例は1例を除き何らかの心疾患や脳血管疾患の既往を有していた。以上より、これらの薬剤投与中には消化管出血の可能性があることを患者・家族に説明して注意を促すことが必要と考えられた。

症例は66歳の男性、46歳時に先天性胆道拡張症にて分流手術が行われた。その後、当院外科で経過観察されていたが、肝内結石による肝膿瘍を発症したため当科に転科となった。PTCS下に切石を行ったところ、右肝管に赤色調で大きさ7mm大の結節状の隆起性病変を認めた。同部位からの生検にて中分化型腺癌を認めた。既往歴にB型慢性肝炎があり、肝予備能が低下していたため手術を断念し、remote After Loading System(以下RALS)による腔内照射を行った。しかしながら、腫瘍の縮小が得られず、マイクロ波凝固療法を実施したところ、比較的良好な局所制御が得られた。先天性胆道拡張症では術後においても胆道癌発生の危険性があり、長期にわたる経過観察が必要である。肝内結石を発症した本症では、PTCSが胆管癌の早期診断に有用であった。(著者抄録)