宮原 良二

OBJECTIVES: Pancreatic cystic (PC) lesions are not necessarily rare, and it is important to diagnose whether PC lesions are neoplastic such as intraductal papillary mucinous neoplasm (IPMN) because of its malignant potential. Reports on PC lesions in hemodialysis (HD) patients are remarkably limited. The aim of this study was to clarify the prevalence and characteristics of PC lesions in HD patients. METHODS: We reviewed 1012 consecutive HD patients and 11,100 patients (controls) without renal disease who underwent transabdominal ultrasonography between January 2003 and December 2005. Patients' sex ratio (female-to-male) was less, and the age was older in HD patients. Clinical findings of these patients were examined. RESULTS: The prevalence both of PC lesions and IPMNs was significantly higher in HD patients than in controls (9.3% vs 1.3% and 2.8% vs 0.2%, P < 0.0001). The incidence of IPMNs in HD patients with PC lesions was higher than that in controls with PC lesions (29.8% vs 17.0%, P = 0.021). Multivariate logistic regression analysis revealed that the odds ratios of PC lesions and IPMNs were 6.38 (95% confidence interval, 4.82-8.45) and 9.39 (95% confidence interval, 5.36-16.49) in HD patients compared with controls. CONCLUSION: The prevalence of PC lesions in HD patients is higher, and HD patients with PC lesions have high prevalence of IPMNs.

小腸用カプセル内視鏡(VCE)を施行した131症例を対象に、VCEによる大腸画像を撮影し、VCE以前に施行していた大腸スコープ所見と比較して得られる特徴について検討した。対象のVCE検査の契機は、原因不明の消化管出血;87例・小腸腫瘍検査;21例・慢性下痢症又は腹痛;13例・蛋白漏出性胃腸症;9例・クローン病疑い;1例であった。VCEが予定された131例中10例ではポリエチレングリコール/電解質洗浄溶液(PEG)で、10例ではクエン酸マグネシウム(MgC)68gを含む水1.8Lで前処理を受けており、残る111例は絶食のみを行った。当日患者はレコーダーを朝8時に接続されたVCEを嚥下し、2時間後に水分、4時間後に食事が許可され、レコーダーは9時間後に取り外され、VCE所見は経験のある内視鏡専門医2名によって評価された。被検者は絶食群・PEG群・MgC群の3群に分けられ、各群の性・年齢・体重と腹部手術の既往歴には有意差は認めなかった。その結果、VCEの消化管通過はPEG群で平均胃通過時間(GTT)は他群より長く、大腸への検査時間到達率はPEG群で低く、その理由は下部回腸の大量の洗浄液貯留と考えられた。GTTと小腸通過時間(SBTT)は3群間で有意差を認めず、検査時間内のVCEの体外排出は全体で5.3%、絶食群で5.4%、前処理群で5.0%であった。本研究において腸洗浄は大腸を通して迅速な通過には大きな効果を及ぼさず、VCEが終了した時点の大腸の部位は上行又は横行結腸が多く、癌と炎症性腸疾患のスクリーニングに不可欠な直腸・S状結腸部へのアクセスは僅かに6.9%(9/131例)であった。

BACKGROUND/AIMS: Matrix metalloproteinases (MMPs) are endopeptidases which perform important functions in extracellular matrix remodeling, cell proliferation, and inflammatory processes. Here, we compared MMP-3 levels with those of tissue inhibitor of metalloproteinases (TIMP)-1 and several inflammatory cytokines in gastric ulcer (GU) patients. METHODS: This study enrolled 50 patients with GU and 6 with functional dyspepsia (FD). Samples of gastric mucosa from the antrum and the ulcer site were harvested from GU patients and of antral mucosa alone from FD patients during upper gastrointestinal endoscopy. Mucosal biopsy tissues were cultured for 24 h, and the culture supernatant was measured for levels of MMP-3, TIMP-1, IL-1beta, IL-6, and IL-8. RESULTS: All GU patients were positive for Helicobacter pylori, while all FD patients were negative. Antral levels of TIMP-1, IL-1beta, IL-6, and IL-8 were significantly higher in GU than FD patients. Further, MMP-3 levels were significantly higher in GU patients at the ulcer site than in the antrum, and had a significantly positive correlation with TIMP-1, IL-1beta, IL-6, and IL-8. CONCLUSION: MMP-3 levels were significantly higher at the ulcer site than in the antrum, suggesting that MMP-3 may perform an important function in gastric ulcer healing.

BACKGROUND AND PURPOSE: The role of duodenogastroesophageal reflux (DGER) in gastroesophageal reflux disease (GERD) remains controversial. Few studies of reflux have compared patients with an intact stomach to those without intact stomach after gastroesophageal surgery. This study aimed to investigate differences of the refluxate between patients with and without prior gastroesophageal surgery and to assess the role of DGER in GERD. METHODS: One hundred patients (34% with reflux symptoms) were divided into four groups: 23 with an intact stomach, and 27, 42, and 8 with esophagectomy followed by gastric tube reconstruction, distal gastrectomy, and total gastrectomy, respectively. Reflux symptoms were evaluated, and endoscopy and simultaneous 24-h monitoring of esophageal pH and bilirubin were performed. RESULTS: Of 44 patients with increased DGER but without increased acid reflux, three had severe reflux esophagitis and seven had Barrett's esophagus. DGER was most frequent under weakly acidic conditions in the intact stomach, esophagectomy, and distal gastrectomy groups. Pure acid reflux and DGER at any pH were elevated in GERD patients with an intact stomach, while weakly acidic and alkaline DGER were elevated in GERD patients after gastrectomy. Esophagectomy patients had reflux with the combined characteristics of those in the intact stomach and gastrectomy groups. Weakly acidic or alkaline DGER was correlated with symptoms and esophageal mucosal changes in gastrectomy patients. CONCLUSION: The refluxate causing GERD differed between patients with and without prior gastroesophageal surgery. Weakly acidic or alkaline DGER may cause both symptoms and esophageal mucosal damage.

AIM: The aim of the present study was to use video capsule endoscopy (VCE) to objectively evaluate bowel movements in patients with irritable bowel syndrome (IBS) compared with healthy volunteers. METHODS: Subjects were nine healthy volunteers (group A) and five IBS patients (group B) whose VCE reached the cecum within the examination time. As the darkest component in an image of VCE is the lumen, we regarded real movements of the intestine observed in the images as the changes of luminal movement, and analyzed them. We trimmed the luminal edge, counted pixels in the lumen and the low brightness area (LBA), of all VCE images and compared them between the groups. RESULTS: There was no difference in the frequency observed in the LBA corresponding to the luminal area between the groups. As for the average volume of the LBA found in an image, it was 1702 pixels in healthy persons versus 305 in IBS patients (P = 0.21) and in healthy persons it tends to be larger. We drew a graph of LBA by time-course. A periodic change in the volume of LBA was found in eight of nine (88.9%) healthy persons over time, but in only two of five (40.0%) IBS patients (P = 0.62). Using endoscopy, a difference in the bowel movement between groups A and B could be evaluated objectively. CONCLUSION: The present study presents the possibility of a new technique to evaluate functional bowel disorders objectively using an endoscopic procedure.

BACKGROUND AND AIMS: Little information is available regarding the prevention and treatment of small intestinal mucosal injuries caused by non-steroidal anti-inflammatory drugs (NSAIDs). We planned a pilot study to investigate the protective effects of geranylgeranylacetone (GGA) against NSAID-induced small intestinal injuries using video capsule endoscopy (VCE). SUBJECTS AND METHODS: Ten healthy male volunteers took oral GGA 300 mg/day (regimen A) or placebo (regimen B) in addition to diclofenac 75 mg/day + rabeprazole 20 mg/day for 7 days. We conducted a cross-over trial of regimens A and B with a 2-week washout period. All subjects underwent VCE before and after each administration period, and were evaluated for NSAID-induced gastric and small intestinal mucosal lesions. RESULTS: The number of mucosal lesions (erosions, ulcers and a red spot with possible bleeding) detected in both stomach and small bowel changed between prior to and immediately after administration period, with significantly fewer lesions for regimen A after administration period (mean +/- SD A:B = 2.6 +/- 3.2:9.5 +/- 8.5; p = 0.027). CONCLUSIONS: Combination therapy with GGA and rabeprazole reduced the incidence of gastroenteropathy induced by 1-week administration of diclofenac. Our findings suggest this therapy as a candidate for protecting patients on long-term NSAID therapy.

BACKGROUND AND AIM: In Japan, screening examination with photofluorography is widely performed to reduce the mortality due to gastric cancer. The possibility of a future decline in gastric cancer cases and changes in its characteristics is suggested. The aim of this study was to examine the usefulness of direct radiology as a general health screening technique and the historical changes of gastric cancer in Japan. METHODS: This study involved 936 patients with gastric cancer whose carcinomas were detected by direct radiology as part of a general health screening at the Aichi Prefectural Center for Health Care from 1970 to 2000. We studied the prevalence of gastric carcinoma, its prognosis, differences between the two histological types of carcinoma and historical changes. RESULTS: The age-adjusted cancer detection rate slightly decreased. Comparing two histological types, diffuse-type carcinoma cases relatively increased. Intestinal-type carcinomas increased in the lower portion of the stomach, whereas diffuse-type increased in the upper portion. The 5-year survival rate was 92.7% for intestinal-type carcinoma and 84.8% for diffuse-type. Diffuse-type carcinomas were further progressed than intestinal-type when detected by direct radiology; however, detection of diffuse-type improved, so the percentage of early gastric cancer of diffuse type significantly increased, and the survival rate significantly improved, from 70.4% to 90.5%. CONCLUSION: The prevalence of gastric cancer has been decreasing, but the proportion of diffuse-type carcinoma localized in the upper portion of the stomach has been increasing in Japan.

Small bowel tuberculosis is sometimes encountered in oriental countries, and because its symptoms are vague and present a nonspecific pattern, confirmative diagnosis is difficult to achieve. In 2001, two new innovative endoscopic techniques for the small bowel, video capsule endoscopy and double balloon enteroscopy, were introduced, thus advancing the diagnostic technology for small bowel disorders. Our asymptomatic patient with small bowel tuberculosis was diagnosed definitively using the combination of video capsule endoscopy and double balloon enteroscopy. The number of such cases will increase when those procedures become more widely used. At present, the endoscopic view of small bowel tuberculosis is difficult to differentiate from Crohn's disease and drug-induced enteropathy, but from now on it will be possible to distinguish them utilizing endoscopic and fluoroscopic images. On the basis of the characteristics of small bowel tuberculosis with its endoscopic images, referring to our case report and previous literature, we report a topical diagnostic procedure, the combination of video capsule endoscopy and double balloon enteroscopy.

早期胃癌症例132病変を対象とし、胃癌の深達度診断における拡大観察の意義について検討した。1)粘膜構造が保たれたsmall regular patternではM癌が多く、構造が破壊されたlack of visible structureではSM癌が多かった。2)未分化癌においてはlack of visible structureを示すM癌も多く認められた。また、微小血管所見に着目した場合、fine network patternでは分化型癌が多く、corkscrew patternでは未分化型癌が多く見られた。3)深達に関してはfine network patternではM癌が多く見られた。一方、caliber variationが見られた場合には有意にSM癌が多かく、未分化型癌では全てSM癌であった。

Background and study aims: Advances in endoscopy have led to imaging of the details of the gastric mucosa, but the histological diagnosis usually has to be confirmed by endoscopic biopsy. A method of confocal endomicroscopy that has recently been developed allows the observation of living cells in vivo. Several investigators have reported that the technique is of value, but there have as yet been no studies describing its application in gastric cancer. Patients and methods: Twenty-seven patients with early gastric cancer underwent confocal endomicroscopy (Pentax EG3870CIK; Pentax, Tokyo,japan). After intravenous administration of fluorescein sodium, confocal images obtained from the normal mucosa and from cancerous lesions were interpreted by two pathologists independently and compared with the histological findings, including CD34 immunostaining of biopsy specimens or resected specimens from the same sites. Results: Fluorescein yielded high-quality confocal images of the gastric mucosa; if cancer could be targeted (59%) images were mostly graded good. The images corresponded to the hematoxylin-eosin staining of transverse sections of specimens from the same sites. In the results for the interpretation by the two pathologists, the accuracy for the diagnosis of gastric cancer was 94.2% (pathologist A), and 96.2% (pathologist B), respectively. The accuracy decreased substantially when poor images and inaccessible lesions were included. Conclusions: Confocal endomicroscopy is useful in the diagnosis of gastric cancer but good quality images cannot always be obtained. In the future, it may allow virtual biopsy and help reduce unnecessary biopsies.

OBJECTIVE: The purpose of our investigation was to determine the usefulness of digital radiography (DR) for diagnosing the depth of invasion of esophageal carcinoma. METHODS: We evaluated 59 patients with esophageal carcinomas who underwent DR. During continuous DR in tangential views, the most distended image of the esophagus was chosen. Percent esophageal stenosis (PES) was based on the diameter across the lesion of maximal narrowing and the average of the normal oral and anal side diameters. The maximal thickness of the tumor was measured on sequentially prepared specimens. We evaluated whether the percent of esophageal stenosis correlated with the maximal thickness of the tumor on histologic findings. Receiver-operating characteristic (ROC) curves were constructed to establish the cut-off level for PES in diagnosing the depth of tumor invasion. Accuracies for the depth of the invasion were calculated based on PES using DR. For the accuracy rate, DR was compared with endoscopy and endoscopic ultrasonography (EUS). RESULTS: There was a close correlation between PES and pathological thickness of the tumor. PES values (mean+/-S.D.) were 2.45+/-0.75% in Tis and T1a tumors, 13.3+/-10.9% in T1b tumors, 35.2+/-11.1% in T2 tumors, 55.2+/-18.1% in T3 tumors, and 86.1+/-7.5% in T4 tumors. Using the ROC analysis, 12.5, 37.5, and 44.4% were the highest cut-off values of PES for differentiating < or =T1a, < or =T1b, and < or =T2 tumors. Regarding T staging, 45 (76%) of 59 lesions were staged correctly with EUS, whereas 47 (80%) were staged correctly with DR. CONCLUSION: DR is useful for diagnosing the depth of the invasion because esophageal stenosis calculated using DR is an objective index of tumor infiltration. The accuracy rate of the depth of invasion with DR was as good as that of EUS.