GIANT GASTRIC ULCERS IN CHRONIC SPINAL CORD INJURY PATIENTS

Gastric ulcers cause significant morbidity and mortality to patients with spinal cord injuries. Case reports of three patients with gastric ulcers and chronic spinal cord injuries. Review of the medical literature using MEDLINE ranging from 1975 to 2004. We describe three cases of severe, complicated gastric ulcers in this population. Two cases involve gastric ulcers that eroded into major mesenteric arteries, leading to one fatality. One of these cases revealed a gastric ulcer that looked like a mass because of intralumenal herniation of serosal fat. Diagnosis of ulcer disease is challenging in this patient population as they often do not endorse focal symptoms. Gastroenterologists and other practitioners evaluating chronic spinal cord injury patients should be aware of the potential for giant gastric ulcers, even with benign clinical presentations.     

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.     

慢性胃病中几种胃肠激素水平的改变和意义

本文用RIA法测定352例胃镜病理诊断的胃十二指肠病患者之胃液,血清表皮生长因子（EGF），生长抑素（SS）和胃泌素（GAS）水平。结果表明，胃液EGF水平在胃癌明显升高，在消化性溃疡降低；血清SS及GAS水平在各种胃十二指肠病中均显著高于正常对照，溃疡病的血清SS和GAS水平呈负相关趋势。各种胃病血清SS水平相近，胃液SS水平胃癌显著高于良性胃病，且胃癌胃液SS显著高于其血清SS水平。幽门螺杆菌（HP）感染不影响溃疡病的血清GAS和SS水平及慢性浅表性胃炎的血清SS水平，HP感染严重时慢性萎缩性胃炎的血清SS水平显著升高。     

REFRACTORY GASTRIC ANTRAL ULCER OF UNKNOWN ETIOLOGY

We report a Helicobacter pylori‐negative patient with multiple gastric antral ulcers of unknown etiology and without a history of taking non‐steroidal anti‐inflammatory drugs (NSAIDs). The patient was a 68‐year‐old woman, and her serum gastrin and pepsinogen levels were within normal limits. The antral ulcers were refractory to treatment with a proton pump inhibitor (PPI) or an H2 receptor antagonist alone. However, since nocturnal gastric acid breakthrough was observed, both drugs were given in combination, which resulted in the healing of the ulcers.     

CHANGES IN MUCOSAL PHOSPHOLIPID‐RELATED PROTECTION IN SOME GASTRIC DISEASES

Background: Phospholipids play an important role in gastric mucosal protection. The purpose of the present study was to investigate changes in various phospholipids in the fundic and pyloric gland mucosae of patients with gastric mucosal disease. Methods: One hundred and five patients with superficial gastritis, duodenal ulcer, gastric ulcer or gastric cancer were studied. Patients underwent endoscopy to obtain biopsy specimens from both the fundic and pyloric gland mucosae. The phospholipid contents were measured by high performance liquid chromatography. Results: Total phospholipid level was significantly greater in the fundic gland mucosa than in the pyloric gland mucosa (P = 0.037), and the level in the fundic gland mucosa was high in all four gastric diseases studied. The difference was significant in patients with gastric ulcers (P = 0.0156). Total phospholipid levels were the highest in superficial gastritis, followed by duodenal ulcer, gastric ulcer and gastric cancer. In all four gastric diseases, phosphatidylserine (PS), phosphatidylethanolamine (PE), and phosphatidylcholine (PC) levels were high, while phosphatidylinositol, lysophosphatidylcholine, and sphingomyelin levels were low. The PE and PC levels were higher in the fundic gland mucosa than in the pyloric glandular mucosa, whereas the PS level was higher in the pyloric gland mucosa than in the fundic gland mucosa. Conclusions: The fundic gland mucosa has stronger phospholipid‐related protection than the pyloric gland mucosa, based on the levels of mucosal phospholipids. The main phospholipids for gastric mucosal protection are PC and PE (in the fundic gland mucosa) and PS (in the pyloric gland mucosa). Phospholipid‐related protection is strong in superficial gastritis and duodenal ulcer, but is reduced in the pyloric gland mucosa in patients with gastric ulcers, and in both gastric gland mucosae in patients with gastric cancer.     

RANITIDINE IN THE TREATMENT OF GASTRIC AND DUODENAL ULCERS ASSOCIATED WITH NON-STEROIDAL ANTI INFLAMMATORY DRUGS

To assess the effect of 4 weeks' therapy with ranitidine 150mg twice daily on the healing of symptomatic NSAID associatedgastric and duodenal ulcers, 149 arthritic patients were randomlyallocated to one of three treatment groups: ranitidine withNSAID continued, ranitidine with NSAID discontinued, and placebowith NSAID discontinued. The healing frequency in patients withgastric ulceration was 67, 68 and 47%, and in those with duodenalulceration 61, 81 and 42%, respectively. Only the differencebetween the duodenal ulcer healing rates for ranitidine withNSAID discontinued and placebo was statistically significant(P=0.02). Healing rates were uninfluenced by gender, age, smokinghabits, alcohol consumption, ulcer frequency or size, arthriticdisease, or participating country. KEY WORDS: Non-steroidal anti-inflammatory drug-associated ulcers, Ulcer healing, Ranitidine     

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.     

ACCURACY OF ENDOSCOPIC DIAGNOSIS OF HELICOBACTER PYLORI IN PATIENTS WITH HEMORRHAGIC PEPTIC ULCERS

Background: Recent progress in Helicobacter pylori eradication has resulted in dramatic improvements in the incidence of peptic ulcers and decreased rates of ulcer relapse. Because bleeding is an important complication of ulcer diseases, accurate diagnosis of H. pylori infection is necessary. Methods: We studied the efficacy of diagnostic methods to detect H. pylori in hemorrhagic peptic ulcer patients. A total of 59 patients who had received emergency endoscopy because of symptoms such as hematemesis, melena or tarry stool, were examined. Endoscopic methods of H. pylori diagnosis (culture, histological assessment and rapid urease test) and serum anti‐H. pylori assays were used in the hemorrhagic peptic ulcer group and the control group. Results: The percentage of endoscopically determined H. pylori‐negative patients was significantly higher in the hemorrhagic ulcer group than the control group (P < 0.05). Out of the endoscopically determined H. pylori‐negative patients in the hemorrhagic ulcer group, 78.9% were serologically H. pylori‐positive. Conclusion: Endoscopic methods are not sufficient for the diagnosis of H. pylori infection in hemorrhagic ulcer patients. Therefore, serum anti‐H. pylori assessment should also be performed for such patients.     

THE HEALING PROCESS OF GASTRIC ARTIFICIAL ULCERS AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: Due to the remarkable progress of endoscopic resection techniques, endoscopic submucosal dissection (ESD) has been widely performed for larger mucosal tumors that would result in large arti?cial ulcers. The healing process of peptic ulcers has been previously studied in detail; however, no precise investigation for arti?cial ulcers after ESD has been reported. To con?rm the validity of the treatment from the aspect of wound healing, we aimed to clarify the healing process of large gastric arti?cial ulcers after ESD. Methods: Seventy patients with gastric mucosal tumors treated by ESD were enrolled. The size, location and time of scar formation of the ulcers were reviewed using endoscopic pictures taken from the same view and angle. Follow‐up endoscopy was performed at 1, 4, 8 and 12 weeks after ESD. For postoperative medication, all patients received normal doses of proton pump inhibitors and sucralfate for 8 weeks. Results: The average size of the resected specimen was 34.7 mm (20–90 mm). Irrespective of ulcer size and location, all of the cases healed up to scarring stages within 8 weeks. Conclusions: Gastric arti?cial ulcers after ESD healed within 8 weeks regardless of size and location using normal doses of medication as peptic ulcers. The fact that even giant ulcers after ESD heal within 8 weeks could be helpful information for candidates for ESD and for postoperative management of patients after ESD.     

A CASE OF EARLY GASTRIC CANCER ACCOMPANIED BY DIEULAFOY ULCER IN A YOUNG WOMAN

A case of early gastric carcinoma accompanied by Dieulafoy ulcer is presented. The patient, a 26‐year‐old female, visited our emergency room with chief complaints of massive hematemesis and tarry stool. The initial endoscopic examination revealed a superficial depressed lesion with a faded color accompanied by a tiny ulcer with converging folds at the anterior wall of the middle gastric body. Although no active bleeding vessel was found at that time, the patient was admitted to our hospital for further check‐ups and treatment. On the 6th hospital day, she developed massive hematemesis resulting in shock. Urgent endoscopy, this time, disclosed an exposed bleeding vessel at the small ulcer floor previously mentioned, and endoscopic hemostasis was achieved. Since, however, a biopsy at initial examination from the surrounding depressed area proved carcinoma, a partial distal gastrectomy was subsequently carried out. Histological examination of the resected specimen confirmed the diagnosis of carcinoma limited to the mucosa and submucosa along with findings consistent with Dieulafoy ulcer. This is a rare case of combination of early cancer and Dieulafoy ulcer particularly in such a young patient. A review of the literature is also presented.     

CASE REPORT OF TRICHOBEZOAR CAUSING GASTRIC PERFORATION

A 17‐year‐old girl with trichophagia (hair eating) habits was admitted to our hospital because of severe acute epigastralgia in June 1997. Abdominal computed tomography showed free air in the abdominal cavity and a heterogeneous mass in the stomach and the duodenum. A perforation on the anterior wall of the lower gastric body was found by urgent laparoscopic surgery and thus a laparoscopic omental patch repair was performed. Endoscopic examination after the operation revealed a large trichobezoar and gastric ulcers. An attempt made by us to extract the bezoar by endoscopy using a flexible outer‐tube was unsuccessful. The gastric ulcer relapsed in November 1997. Another attempt was made to extract the bezoar with laparoscopic instrumentation using a percutaneous gastrostomy port associated with oral gastroendoscopy. Only the part of the bezoar in the duodenum was extracted, and multiple superficial ulcers and erosions in the second part of the duodenum were found. Removal of the entire bezoar in the stomach required surgical gastrostomy. An endoscopic examination after the operation revealed healing of the gastric ulcer and duodenal erosions. Gastric perforation due to trichobezoar is a rare complication. Since the attempt to remove the trichobezoar in a minimally invasive manner failed, a surgical gastrostomy was required.     

ANALYSIS OF PROGNOSTIC FACTORS IN PATIENTS WITH GASTRIC VARICES AFTER ENDOSCOPIC TREATMENT

Background: The prognostic factors, including gastric variceal bleeding itself, in patients with gastric varices (GV) after endoscopic treatment remain unclear. The aim of this study was to analyze prognostic factors in patients with GV after endoscopic treatment as well as to evaluate safety and efficacy of our endoscopic treatment. Patients and Methods: This study enrolled 115 patients who underwent endoscopic treatment for GV between October 1988 and December 2003 using cyanoacrylate and 5% ethanolamine oleate. Successful hemostasis, recurrence rates, rebleeding rates, survival rates, complications and prognostic factors after the treatment were retrospectively reviewed. Results: Treatment sessions for GV were performed 3.4 ± 2.5 times. All cases, including 14 emergency cases, were treated successfully. The cumulative recurrence rates at 1, 3 and 5 years after the treatment were 7.0%, 15.6% and 20.0%, respectively, and the cumulative rebleeding rates at 1, 3 and 5 years were 3.5%, 8.7% and 14.8%, respectively. The overall survival rates were 78.3%, 63.7% and 51.5% at 1, 3 and 5 years, respectively. Grade B or C in Child–Pugh classification, emergency or elective cases, and association with hepatocellular carcinoma were identified as significant negative prognostic factors after endoscopic treatment by multivariate analysis. Although several complications were observed, there was no mortality. Conclusions: Grade B or C in Child–Pugh classification, emergency or elective situation, and association with hepatocellular carcinoma are negative prognostic factors after endoscopic treatment.     

GASTROBILIARY FISTULA FROM A GIANT GASTRIC ULCER

Gastrobiliary fistula arising from a gastric ulcer is yet unreported. Biliary lithiasis with its secondary complications is the commonest cause of enterobiliary fistulas. Enterobiliary fistulas are commonly identified incidentally and their discovery can complicate management, especially when identified intraoperatively. Penetration into contiguous organs occurs more frequently with giant (≥3 cm) gastric ulcers.     

ENDOSCOPIC COAGULATION THERAPY IS USEFUL FOR IMPROVING ENCEPHALOPATHY IN CIRRHOTIC PATIENTS WITH GASTRIC ANTRAL VASCULAR ECTASIA

Background: Gastric antral vascular ectasia (GAVE) is an uncommon but treatable cause of chronic gastrointestinal bleeding often associated with severe cirrhosis. Efficacy of endoscopic treatment is well known; however, long‐term outcome after endoscopic treatment is not clear. Methods: We studied 16 cases of GAVE patients with liver cirrhosis that were endoscopically treated using heater probe unit or argon plasma coagulator. Endoscopic finding of GAVE and clinical finding of hepatic encephalopathy in particular was evaluated after endoscopic therapy. Results: After endoscopic ablation therapy, mucosal vascular lesion of GAVE and rebleeding occurred in four patients during follow up; however, re‐treatment was effective and long‐term hemostasis was achieved. Moreover, a case report herein revealed the effectiveness of endoscopic therapy on hepatic encephalopathy of GAVE patients with cirrhosis. In the follow‐up study of 13 patients of GAVE with cirrhosis that suffered from encephalopathy, the coma level of nine patients was improved after endoscopic therapy. Conclusion: Endoscopic treatment, such as heater probe coagulation and argon plasma coagulation therapy, are effective and useful for long‐term follow up. Also, the beneficial effect of endoscopic therapy on hepatic encephalopathy for GAVE with cirrhosis encourages us to find and treat the mucosal lesion intensively to improve the quality of life of such patients.     

良性胃体大弯溃疡的临床特点

在３３６６６例胃镜检查中，发现良性胃体大弯溃疡３９例，检出率为０．１２％，占消化性溃疡总数的０．９１％，占胃溃疡总数的２．０５％。男女之比为５．５：１。青年患者中良性大弯溃疡多于同期受胃镜检查的其它非大弯消化性质疡。良性胃体大弯溃疡同时伴有其它部位溃疡者比例偏高。良性胃体大弯溃疡一般较小并且大多形态不规则，由于解剖关系，无论Ｘ线或内镜检查均易漏诊，应当引起临床医师的高度重视。     

溃疡病患者血浆、胃液和胃窦十二指肠粘膜组织神经降压素含量及试餐影响的研究

应用放免法测定了２０名正常人、１８例胃溃疡（ＧＵ）和３１例十二指肠溃疡（ＤＵ）患者的血浆（空腹和餐后）、胃液和胃十二指肠粘膜组织的神经降压素（ＮＴ）含量。结果发现，正常人血浆ＮＴ含量较高，胃液较少，胃窦和十二指肠粘膜组织含量相近；胃液中ＮＴ可能来源于胃粘膜Ｎ细胞的直接分泌和血液弥散；试餐刺激后３０分钟血浆ＮＴ含量无明显变化。ＧＵ和ＤＵ患者血浆、胃液和胃窦、十二指肠粘膜ＮＴ含量明显减少，由此引起胃十二指肠粘膜所受侵袭因素增强、防御机能减退，使ＧＵ和ＤＵ易于发生发展，且部分复合性溃疡可能来源于ＤＵ．     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.