DEVELOPMENT OF SPORADIC GASTRIC FUNDIC GLAND POLYP AFTER ERADICATION OF HELICOBACTER PYLORI

The pathogenesis of sporadic gastric fundic gland polyps (FGP) without familial adenomatous polyposis remains unclear. However, development of FGP is associated with normal gastric mucosa without Helicobacter pylori infection. We report two cases of FGP newly developed after successful eradication therapy of H. pylori infection. H. pylori‐associated gastric ulcers occurred in the two patients; H. pylori eradication was performed in the patients and was successful. The patients have not received medication of long‐term proton pump inhibitors. Follow‐up gastrointestinal endoscopy demonstrated a FGP in the fundus of the stomach of each patient after eradication therapy. Regression of sporadic FGP can be observed to coincide with the acquisition of H. pylori infection. Conversely, the present cases demonstrated that the curing of H. pylori infection could lead to the development of FGP.     

儿童幽门螺杆菌感染与上胃肠道疾病

我们对153例因胃肠道症状接受胃镜检查的连续患儿进行前瞻性活检组织学、尿素酶试验及血清学检查,探讨幽门螺杆菌(HP)感染和上胃肠道疾病关系,并和成人及健康儿童对照。结果显示,消化性溃疡患儿HP感染率15/22(68％),明显高于功能性消化不良29/130(22％),而后者和健康儿童62/181(34％)无显著差异,提示HP和消化性溃疡相关,但与症状无关。儿童HP相关性胃炎内镜无特异性征象,组织学多集中在胃窦部,炎症细胞浸润和活动较明显。     

RECENT PROGRESS IN ENDOSCOPY‐BASED DIAGNOSIS OF HELICOBACTER PYLORI INFECTION

Numerous invasive and non‐invasive tests are available in the detection of Helicobacter pylori. Endoscopy‐based tests that include rapid urease test, histological examination and culture are important generally in the assessment of H. pylori status before eradication therapy. Recently, several new endoscopy‐based diagnostic methods have been developed aiming at rapid and accurate detection of the organisms. It would be possible to diagnose H. pylori infection in treated patients by using these new highly sensitive tests. Although the diagnosis of H. pylori infection itself is possible by using non‐invasive diagnostic tests, endoscopy‐based tests provide not only the diagnosis of the organisms, but also the exclusive information such as treatment indications and the susceptibility for the antimicrobial drugs. Recently, new triple therapy including clarithromycin has been widely performed in Japan. Along with an increase in the prevalence of the antibiotic‐resistant strains, culture may become a more important diagnostic method in the future. The inappropriate application of the tests may increase the potential risk of the misdiagnosis and the treatment failures. The diagnostic method should be selected by taking into account the circumstances in which a diagnosis is to be performed.     

CONCURRENT GASTRIC AND COLONIC LOW‐GRADE MUCOSA‐ASSOCIATED LYMPHOID TISSUE LYMPHOMATA IN A PATIENT WITHOUT HELICOBACTER PYLORI INFECTION

Mucosa‐associated lymphoid tissue (MALT) lymphomata observed simultaneously in the stomach and colon are rare. We report concurrent gastric and colonic low‐grade MALT lymphomata that originated from the same clone in a 58‐year‐old Japanese man without Helicobacter pylori infection. Endoscopy showed multiple erosive lesions in the gastric body and antrum, and a single flat elevation with an irregular margin in the sigmoid colon. Histopathological findings of both lesions suggested low‐grade MALT lymphoma. Lymphoepithelial lesions were evident in the gastric lesions, but not in the colonic lesion. Southern blot analysis of lymphoma cells revealed the same immunoglobulin heavy‐chain rearrangement pattern. The chromosomal translocation t(11;18)(q21;q21) was also observed. After six courses of cyclophosphamide, doxorubicin, vincristine and predonisolone, the gastric lesions disappeared endoscopically, while the colonic lesion persisted. A sigmoidectomy was consequently performed. The chromosomal translocation may be related to the pathogenesis of the present MALT lymphoma case without H. pylori infection. It is interesting that the gastric and colonic lesions differed in response to treatment and in their endoscopic and histologic features, despite having the same origin.     

原发性胃恶性淋巴瘤与幽门螺杆菌感染的相关性初探

为了探讨原发性胃恶性淋巴瘤（ＰＧＭＬ）与幽门螺杆菌（Ｈｐ）感染的相关性，收集３９例ＰＧＭＬ与２２例淋巴性胃炎、３２例Ｈｐ无关疾病的胃粘膜作病例对照研究；Ｈｐ感染的确定采用改良的Ｇｉｅｍｓａ染色；ＰＧＭＬ的分类结合组织学和免疫组化染色。结果：ＰＧＭＬ组Ｈｐ检出率为８７．１８％，显著高于对照的６３．６４％及５３．１３％（Ｐ＜０．００５）。粘膜相关淋巴样组织（ＭＡＬＴ）来源的淋巴瘤占９２．３１％，Ｈｐ检出率达８６．１１％，瘤周慢性活动性胃炎及淋巴滤泡检出率分别为８４．６２％及５６．４１％。组织学检测的初步结论为：胃Ｂ细胞ＭＡＬＴ淋巴瘤与Ｈｐ感染相关。     

NODULAR GASTRITIS WITH HELICOBACTER PYLORI INFECTION IS STRONGLY ASSOCIATED WITH DIFFUSE‐TYPE GASTRIC CANCER IN YOUNG PATIENTS

Background: Nodular gastritis (NG), a particular type of gastritis, is now defined as antral nodularity. Recent studies have shown that NG is strongly associated with Helicobacter pylori infection, and we recently showed that it may be associated with diffuse‐type gastric cancer of the corpus. We retrospectively investigated the relation between NG and gastric cancer in patients aged 29 years or less. Patients and Methods: The study group comprised 150 patients (48 males, 102 females; mean age, 27.7 years) who were endoscopically diagnosed with NG and were less than 29 years of age; 3939 sex‐ and age‐matched patients without NG who were H. pylori‐positive served as the control group (1184 males, 2755 females; mean age, 27.5 years). We estimated the risk of gastric cancer development in patients with NG relative to that of patients without NG. Results: The prevalence of gastric cancer was significantly higher in patients with NG than in the control patients (7/150; 4.7% vs 3/3939; 0.08%, P < 0.001). The odds ratio for the risk of gastric cancer in patients with NG was found to be 64.2 (95% confidence interval; 16.4–250.9). The seven cases of gastric cancer with NG showed the same characteristics: all were diagnosed histologically as the diffuse type and were located in the corpus with H. pylori infection. Conclusion: NG with H. pylori infection is strongly associated with diffuse‐type gastric cancer of the corpus in young patients.     

GASTRIC FUNDIC VARICES: HEMODYNAMICS AND NON‐SURGICAL TREATMENT

The hemodynamics and non‐surgical treatment of gastric fundic varices (FV) are reviewed. FV are more frequently supplied by the short and posterior gastric veins than esophageal varices (EV), and are formed mostly by large spontaneous shunts in which the gastric or splenic vein is continuous with the left renal vein via the inferior phrenic veins and the suprarenal vein (so‐called gastric‐renal shunt). Concomitant collaterals such as EV, para‐esophageal vein, and para‐umbilical vein were also observed in nearly 60% of FV. Endoscopic injection sclerotherapy (EIS) with Histoacryl is thought to be the most approved treatment for hemorrhage from FV, but repeated treatment for residual FV and care for ensuing hepatic failure are required. Balloon‐occluded retrograde transvenous obliteration (B‐RTO) is a notable interventional radiological procedure specially developed for the elective or prophylactic treatment of FV. If the procedure is technically successful, long‐term eradication of treated FV is found in most patients without recurrence. B‐RTO includes another significance, obliteration of the unified portal‐systemic shunt. Follow‐up abdominal CT scan revealed a high incidence of long‐term obliteration of the gastric‐renal shunt after B‐RTO. Benefits such as elevation of serum albumin, improvement in 15‐min retention rate of indocyanine green, decrease in blood ammonia levels, and improvement of encephalopathy are sometimes observed.     

胃癌自然人群幽门螺杆菌感染的血清流行病学调查

于１９９２年１２月～１９９３年２月在胃癌高、中、低发区以家庭为为单位进行幽门螺杆菌感染的血清流行病学调查。结果：在胃癌高、中、低发区ＨＰ阳性率分别为５９．４％、５５．９％３３．５％；平均抗体水平为２．３０＋０．４９、２．０４±０．４７、１．８４±０．４６（－χ±ｓ）。高发区的感染率及抗体水平均明显高于低发区（Ρ＜０．０５、Ρ＜０．０１），且感染的年龄早。ＨＰ感染率与胃癌死亡率的高低呈平行趋势。说明ＨＰ感染可能与胃癌有关。     

改良式聚合酶链反应检测幽门螺杆菌

为建立一种检测幽门螺杆菌感染的最佳方法，用尿苷酶抗污染聚合酶链反应（改良式ＰＣＲ）检测幽门螺杆菌，并与组织病理学检查、尿素酶试验、酶联免疫吸附试验及细菌培养相比较。共９５例病人５种方法的检出率分别为８３．１％，７８．９％，７０．５％，６６．３％，４２．１％。２项检查阳性即判断为阳性，否则为阴性。９５例病人中有７９例阳性，１６例阴性。ＰＣＲ方法的敏感性、特异性、阳性预测值及阴性预测值分别为：９７．５％，８７．５％，９７．５％，８７．５％，明显优于其它检查方法。改良后的ＰＣＲ方法为其从单纯的科研方法转为临床应用作了尝试。     

用支气管镜诊断免疫缺陷合并肺感染性疾病进展

用支气管镜诊断免疫缺陷合并肺感染性疾病进展任少华综述　胡华成审校免疫缺陷患者极易发生各种肺部感染，积极防治这些肺部并发症能够提高患者的生存期。纤维支气管镜（ＦＯＢ）是检查各种肺部感染性疾病的重要工具之一。本文就ＦＯＢ在诊断免疫缺陷患者肺部感染方面的应...     

MAGNIFYING ENDOSCOPIC FINDINGS OF THE SURFACE STRUCTURE OF NON‐CANCEROUS MUCOSA SURROUNDING DIFFERENTIATED AND UNDIFFERENTIATED GASTRIC CARCINOMA

Background: Several reports have described the usefulness of magnifying endoscopy in observing the surface structure in gastric neoplasia. The aim of the present study was to evaluate the characteristics of the surface structure of non‐cancerous mucosa surrounding gastric cancer. Methods: Sixty Japanese patients with early gastric cancer were enrolled in this study. We observed the non‐cancerous gastric mucosa surrounding gastric carcinoma by magnifying endoscopy and classified the magnified view into four patterns: (A) dotted; (B) short‐linear; (C) striped; and (D) granular, according to Sakaki's classification. Results: All patients were diagnosed as having Helicobacter pylori infection, and histological evaluation revealed 46 types of differentiated and 14 types of undifferentiated‐type gastric carcinomas. There were significant differences in the gender, age and endoscopic‐atrophic‐border scale between patients with these two types. In all, the surface structure at 240 points (4 points each in 60 patients) of non‐cancerous mucosa was observed by magnifying endoscopy. The prevalences of the surface patterns of the mucosa surrounding differentiated carcinoma were: A, 1.1%; B, 8.1%; C, 28.3%; D, 62.5%, and those of the mucosa surrounding undifferentiated carcinoma were: A, 8.9%; B, 73.2%; C, 14.3%; D, 3.6%. There were significant differences in the surface structure of the non‐cancerous mucosa surrounding differentiated and undifferentiated gastric carcinoma. Conclusion: The microsurface structure of the gastric mucosa surrounding gastric cancer lesions differed between patients with differentiated and undifferentiated gastric cancer. These findings are expected to be useful for the early detection of gastric carcinoma lesions or for the determination of extensions of carcinoma lesions.     

AN ENDOSCOPIC AND MAGNIFYING ENDOSCOPIC STUDY OF ESOPHAGEAL CARDIAC GLAND: WHAT ROLE DOES ESOPHAGEAL CARDIAC GLAND PLAY AT THE ESOPHAGO‐GASTRIC JUNCTION?

The purpose of this study was to ascertain whether areas of yellow elevated change in the distal squamous epithelium represent esophageal cardiac gland and to further assess the features of the exposed esophageal cardiac gland in the magnified view. In addition, the relationship between the columnar‐lined esophagus, gastro‐esophageal reflux disease (GERD), reflux esophagitis, and H. pylori infection was also assessed. Fifty patients (28 men, 22 women; median age 61 years) underwent elective upper GI endoscopy. The distal margin of the squamo‐columnar junction was observed to ascertain whether a yellow elevated lesion was present. When such a lesion was observed, this area was studied using magnifying endoscopy with acetic acid and a biopsy specimen was taken. Furthermore, biopsy specimens of the cardia, antrum, and body were taken for biopsy specimen to check for the presence of carditis, gastritis, and H. pylori. Of 38 patients showing the yellow elevated change, all showed exposed columnar epithelium and 30 patients proved to have esophageal cardiac gland tissue in biopsy specimens. Of 31 patients with H. pylori infection, all had carditis and the yellow elevated lesion. Of 19 patients with a H. pylori‐negative normal stomach, none had carditis and seven patients had the yellow elevated change which was ascertained to be esophageal cardia by biopsy. The yellow elevated change at the distal squamo‐columnar junction was revealed to be esophageal cardiac gland and exposed esophageal cardiac gland was visible in all cases by magnifying endoscopy with acetic acid.     

PREDICTIVE VALUE OF ENDOSCOPY AND ENDOSCOPIC ULTRASONOGRAPHY FOR REGRESSION OF GASTRIC DIFFUSE LARGE B‐CELL LYMPHOMAS AFTER HELICOBACTER PYLORI ERADICATION

Background: Some gastric diffuse large B‐cell lymphomas have been reported to regress completely after the successful eradication of Helicobacter pylori. The aim of this study was to investigate the clinical characteristics of gastric diffuse large B‐cell lymphomas without any detectable mucosa‐associated lymphoid tissue (MALT) lymphoma that went into complete remission after successful H. pylori eradication. Patients and Methods: We examined the effect of H. pylori eradication in 15 H. pylori‐positive gastric diffuse large B‐cell lymphoma patients without any evidence of an associated MALT lymphoma (clinical stage I by the Lugano classification) by endoscopic examination including biopsies, endoscopic ultrasonography, computed tomography, and bone marrow aspiration. Results: H. pylori eradication was successful in all the patients and complete remission was achieved in four patients whose clinical stage was I. By endoscopic examination, these gastric lesions appeared to be superficial. The depth by endoscopic ultrasonography was restricted to the mucosa in two patients and to the shallow portion of the submucosa in the other two patients. All four patients remained in complete remission for 7–100 months. Conclusion: In gastric diffuse large B‐cell lymphomas without a concomitant MALT lymphoma but associated with H. pylori infection, only superficial cases and lesions limited to the shallow portion of the submucosa regressed completely after successful H. pylori eradication. The endoscopic appearance and the rating of the depth of invasion by endosonography are both valuable for predicting the efficacy of H. pylori eradication in treating gastric diffuse large B‐cell lymphomas.     

IS HELICOBACTER PYLORI‐INDUCED ENLARGED FOLD GASTRITIS A HIGH‐RISK FACTOR FOR GASTRIC CARCINOMA?

It is now a generally accepted fact that Helicobacter pylori is an important cause of gastric carcinoma. The International Agency for Research on Cancer classified H. pylori as a group 1 carcinogen. We previously reported that H. pylori‐positive subjects had enlarged folds (fold width = 5 mm); that is, ‘enlarged fold gastritis’. Helicobacter pylori‐induced enlarged fold gastritis is accompanied by a massive infiltration of inflammatory cells, profound production of interleukin‐1β (IL‐1β) and hepatocyte growth factor (HGF), which decrease gastric acid secretion and increase the proliferation rate of the gastric epithelial cells. In addition, there is increased mutagenicity of gastric juice, and mucosal 8‐hydroxydeoxyguanosine (8‐OhdG) levels. Fold width improves and these factors recover to within a normal range with the eradication of H. pylori. The odds ratio for gastric carcinoma and the prevalence of diffuse‐type early gastric carcinoma in the body region increased with an increase in fold width. Therefore, enlarged fold gastritis may be a major risk factor for gastric carcinoma among H. pylori‐infected people. We propose that H. pylori‐infected persons with enlarged fold gastritis are a potential population for the prevention of gastric carcinoma via the use of antibiotics.     

Helicobacter pylori‐negative gastric cancer: Characteristics and endoscopic findings

Helicobacter pylori (H. pylori) leads to chronic gastritis and eventually causes gastric cancer. The prevalence of H. pylori infection is gradually decreasing with improvement of living conditions and eradication therapy. However, some reports have described cases of H. pylori‐negative gastric cancers (HpNGC), and the prevalence was 0.42–5.4% of all gastric cancers. Diagnostic criteria of HpNGC vary among the different reports; thus, they have not yet been definitively established. We recommend negative findings in two or more methods that include endoscopic or pathological findings or serum pepsinogen test, and negative urease breath test or serum immunoglobulin G test and no eradication history the minimum criteria for diagnosis of HpNGC. The etiology of gastric cancers, excluding H. pylori infection, is known to be associated with several factors including lifestyle, viral infection, autoimmune disorder and germline mutations, but the main causal factor of HpNGC is still unclear. Regarding the characteristics of HpNGC, the undifferentiated type (UD‐type) is more frequent than the differentiated type (D‐type). The UD‐type is mainly signet ring‐cell carcinoma that presents as a discolored lesion in the lower or middle part of the stomach in relatively young patients. The gross type is flat or depressed. The D‐type is mainly gastric adenocarcinoma of the fundic gland type that presents as a submucosal tumor‐like or flat or depressed lesion in the middle and upper part of the stomach in relatively older patients. Early detection of HpNGC enables minimally invasive treatment which preserves the patient's quality of life. Endoscopists should fully understand the characteristics and endoscopic findings of HpNGC.     

CAN DENTAL TREATMENT BE THE INFECTION ROUTE OF H. PYLORI TRANSMISSION IN ADULTS? THREE CASES OF ACUTE GASTRIC MUCOSAL LESIONS AFTER DENTAL TREATMENT

Acute gastric mucosal lesions (AGML) comprise a typical clinical entity in patients with acute gastritis, which is characterized by severe erosion, hemorrhage, and ulceration. It is thought that most Helicobacter pylori (H. pylori) infections are established during childhood through human‐to‐human contact. Initial H. pylori infection in an adult is rare, and the transmission route is unknown. The first patient was a 27‐year‐old woman whose chief complaint was epigastric pain. She underwent dental treatment for 30 min and developed sudden epigastric pain 6 h after the treatment. Endoscopic examination revealed multiple hemorrhagic erosions in the antrum. Rapid urease test and histology for H. pylori were positive, but serum anti‐H. pylori IgG antibody was negative at the onset. Serology and urea breath test were positive for H. pylori 2 months after the dental treatment. The second and third patients were diagnosed as having AGML 2 and 4 days after dental treatment, respectively. Culture for H. pylori was positive and serology was negative at the onset, but serology showed seroconversion 2 months after the dental treatment in both patients. These findings indicate that dental treatment is a possible route for H. pylori infection in patients with AGML.