A prospective, single-blind trial comparing wireless capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding

BACKGROUND: Wireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are new methods enabling diagnostic endoscopy of the entire small intestine. However, which of the two is superior is unclear. We therefore prospectively compared the clinical efficacy of CE and DBE. METHODS: We prospectively examined 32 patients with obscure gastrointestinal bleeding. CE preceded DBE by 1-7 days, and all patients underwent DBE twice, by antegrade and retrograde approaches, to evaluate the entire small intestine. Physicians evaluating the results of CE and DBE were blind to the results of the other method. We evaluated diagnosis, diagnostic yield of the two methods, and clinical outcomes. RESULTS: CE revealed abnormal findings in 29 (90.6%) of 32 patients. CE definitively or probably detected the sources of bleeding in 23 (71.9%) of the 32 patients, including angioectasias (eight), erosions (seven), ulcers (five), tumor (one), and hemorrhagic polyps (two). DBE definitely or probably detected the sources of bleeding in 21 (65.6%) of the 32 patients, including angioectasias (seven), erosions (four), ulcers (five), tumor (one), hemorrhagic polyps (two) and diverticula (two). CE yielded more abnormal findings than DBE (CE 90.6%, DBE 65.6%) (P = 0.032), although there were no significant differences in diagnostic yield between the methods. We were able to perform additional treatment or biopsy with DBE in 13 patients, including coagulation therapy (ten), endoscopic mucosal resection (one), biopsy (seven), and extraction of retained CE (two). CONCLUSIONS: Our results demonstrate the superiority of CE in detecting abnormal lesions, and the superiority of DBE in endoscopic management.     

Epidemiological study on cigar-shaped clostridia isolated in a local Japanese general hospital

Cigar-shaped clostridia such as Clostridium clostridioforme and Clostridium symbiosum have been found in serious infections such as bacteremia. In Japan, however, these strains are unrecognized as clinically significant because they are overlooked as unidentified gram-negative rods. We isolated 60 strains of cigar-shaped Clostridium spp. from 48 clinical specimens treated at our laboratory from November 2004 to September 2006. Of these, 19 (39.6%) were primary infections and 29 (60.4%) postsurgical. Primary infections included infected decubitus ulcer (7), peritonitis, intra abdominal abscess, sepsis (2 cases in each group), pyometra, Bartholin's gland abscess, and Fournier's gangrene (1 case in each group). Secondary infections included 28 cases of surgical site infection and 1 case of pyothorax. CRP in 30 cases (62.5%) exeeded 10 mg/dL. In 26 (54.2%), WBC exceeded 12,000/microL. The 60 isolated strains were as follows by 16S rRNA sequencing: Clostridium hathewayi (26.7%), C. clostridioforme (16.7%), Clostridium bolteae (18.3%), Clostridium citroniae (10%), Clostridium aldenense (8.3%), and Clostridium symbiosum (20%). In antimicrobial susceptibility, strains of C. hathe-wayi showed relatively higher MIC for cefotaxime (MIC50; 64 microg/mL, MIC90; 128 microg/mL). Three strains of C. bolteae were beta-lactamase-producing and their MICs for ampicillin exceeded 128 microg/mL.     

An autopsy case of granulocyte-colony-stimulating-factor-producing extrahepatic bile duct carcinoma

A 79-year-old man was referred to this department due to the presence of extrahepatic bile duct carcinoma with a tumor at the left chest wall. The lesion was suspected to be a metastasis of bile duct carcinoma to the left wall, however, computed tomography （CT） revealed no regional lymph node or liver metastases. In addition, cytological and pathological examinations did not show malignancy. At the time of admission, the white blood cell count was 21 460 cells/μL （neutrophils, 18 240 cells/μL） and this elevated to 106 040 before death. In addition, serum granulocyte colony-stimulating factor （G-CSF） was elevated. At 28 d after admission, the patient died. An autopsy showed a poorly differentiated adenocarcinoma with sarcomatous change, which had slightly invaded into the pancreas around the bile duct, and was found in the distal bile duct with multiple metastases to the chest wall, lung, kidney, adrenal body, liver, mesentery, vertebra and mediastinal and para-aortic lymph nodes, without locoregional lymph node and liver metastasis. The cancer cells showed positive immunohistochemical staining for anti-G-CSF antibody. This is believed to be the first report of an extrahepatic bile duct carcinoma that produces G-CSF. Since G-CSF-producing carcinoma and sarcomatous change of the biliary tract leads to poor prognosis, early diagnosis and treatment are needed. When infection is ruled out, the G-CSF in serum should be examined. In addition, examinations such as bonescintigraphy and chest CT should also be considered for distant metastasis.     

Long-Term survivor of ruptured hepatocellular carcinoma after two hepatic resections

We report here a long-term survivor of ruptured hepatocellular carcinoma (HCC). A 37-year-old Japanese man complained of sudden abdominal pain after taking an alcoholic drink. Ultrasonographic examination showed a large amount of fluid in the abdominal cavity. Emergency laparotomy was performed. A solid mass showing extrahepatic growth was present in the right lobe of the liver. No active bleeding site was detected, but the tumor was covered with old blood coagula. The tumor was covered with the greater omentum to prevent further hemorrhage. Following assessment of the extent of the tumor and of liver function, delayed hepatectomy was performed. Histological examination indicated the tumor to be HCC. Twenty-six months after initial hepatic resection, partial resection of the liver was performed again for recurrent tumor. The patient has survived without recurrence for more than 5 years. The long survival was due, we believe to the liver being non-cirrhotic, the delayed hepatic resection, and the early detection of the recurrent tumor.     

Evaluation of various imaging methods in the differential diagnosis of intraductal papillary-mucinous tumor (IPMT) of the pancreas

BACKGROUND/AIMS: IPMT (intraductal papillary-mucinous tumor) of the pancreas has unique clinicopathological characteristics. The lesions which show characteristic clinical features of IPMT exhibit a wide spectrum of histological types ranging from atypical hyperplasia to invasive cancer. Therefore, surgical treatment cannot be recommended for all patients with IPMT. It is necessary to assess the malignant potential of IPMT in individual patients in order to select an appropriate approach. The aim of this study was to evaluate the effectiveness of endoscopic ultrasonography and intraductal ultrasonography as compared with ultrasonography and computed tomography for this purpose. METHODOLOGY: Ultrasonography, computed tomography, endoscopic ultrasonography and intraductal ultrasonography were performed in 49 cases of IPMT (atypical hyperplasia 7, adenoma 23, noninvasive 7 and invasive adenocarcinoma 12). On the basis of the histopathological analysis of another 28 cases of resected IPMT specimens, criteria for differential diagnosis by imaging modalities were defined as follows: Nonneoplastic lesion (atypical hyperplasia): no wall thickening or nodule; noninvasive IPMT (adenoma and intraductal carcinoma): a nodule or wall thickening is present; and invasive IPMT with pancreatic parenchymal invasion: a mass with a heterogenous pattern or interruption of the pancreatic duct wall by the mass. RESULTS: The diagnostic accuracy rate for differentiating nonneoplastic lesion noninvasive IPMT, and invasive IPMT was 33% by ultrasonography, 38% by computed tomography, 77% by endoscopic ultrasonography, and 67% by intraductal ultrasonography. Sensitivity, specificity and accuracy rates for differentiating neoplastic and nonneoplastic IPMT by ultrasonography was 33%, 100%, 42%, by computed tomography 36%, 100%, 44%, by endoscopic ultrasonography 90%, 71%, 88%, by intraductal ultrasonography 94%, 29%, 84%, respectively. Sensitivity, specificity and accuracy rates for differentiating invasive and noninvasive IPMT by ultrasonography was 25%, 100%, 80%, by computed tomography 33%, 100%, 83%, by endoscopic ultrasonography 55%, 97%, 88%, by intraductal ultrasonography 56%, 91%, 84%, respectively. Diagnostic accuracy for invasive IPMT except minimally invasive cases by endoscopic ultrasonography and intraductal ultrasonography was 80%, based on the results of the examination which demonstrated a higher grade lesion. CONCLUSIONS: With these criteria, ultrasonography and computed tomography showed high specificity, but low sensitivity for the differential diagnosis of neoplastic/nonneoplastic and invasive/noninvasive IPMT. However, endoscopic ultrasonography and intraductal ultrasonography had high sensitivity and diagnostic accuracy for the differential diagnosis of neoplastic/nonneoplastic lesions. Combination of endoscopic ultrasonography and intraductal ultrasonography showed a high accuracy rate in the diagnosis of invasive IPMT. Thus endoscopic ultrasonography and intraductal ultrasonography contributed significantly to the choice of the treatment for IPMT.     

Rate-dependent changes in atrial action potential duration after short- duration rapid atrial pacing in humans.

The effect of rapid atrial pacing on the rate adaptation of the atrial action potential duration was studied in humans. The right atrial monophasic action potential (RAMAP) of 5 patients was recorded before and after 30 min of rapid atrial pacing. The pacing cycle length (CL) was 146 +/- 9 ms, the shortest duration at which 1:1 capture was possible. The RAMAP duration at 90% repolarization (RMAPD) was measured. CL-dependent changes in RAMAPD (CL 600 ms-CL 300 ms) before and after rapid atrial pacing were 51.8 +/- 10.7 ms and 30.8 +/- 7.6 ms (p < 0.05), respectively.     

Unusual radiological findings of Fasciola hepatica infection with huge cystic and multilocular lesions

This report describes a case of hepatic phase Fasciola hepatica infection presenting huge and multilocular lesions. The unique radiological findings mimicked hydatid diseases and also cystic liver neoplasm. Fascioliasis should be included in the differential diagnosis for cystic liver diseases.     

Inheritability of atherosclerosis and the role of lipoproteins as risk factors in the development of atherosclerosis in WHHL rabbits: risk factors related to coronary atherosclerosis are different from those related to aortic atherosclerosis.

Inheritability of atherosclerosis and the influences of serum lipids on atherosclerosis were examined by following its progression in selectively bred WHHL rabbits. Our studies indicate (1) coronary atherosclerosis is clearly inherited from parents by offspring whereas inheritability of aortic atherosclerosis is uncertain; (2) coronary stenosis is positively correlated to serum cholesterol level, although the correlation coefficient is markedly low: in contrast, no relationship between serum lipid levels and aortic atherosclerosis was observed; (3) cholesterol-rich VLDL showed atherogenicity in aorta, but not in coronary arteries; (4) an unknown lipoprotein detected by 3.6% polyacrylamide gel electrophoresis was related to coronary atherosclerosis, although no relationship between the unknown lipoprotein and aortic atherosclerosis was observed. These findings suggest that there are two types of genetic factors involved in atherosclerosis, one of which is unique to coronary atherosclerosis whereas the other is related to only aortic atherosclerosis.     

Noninvasive assessment of left and right ventricular filling in myocardial infarction with a two-dimensional Doppler echocardiographic method

Inflow characteristics of left and right ventricular filling were assessed in 40 patients with myocardial infarction and in 10 normal subjects by pulsed Doppler echocardiography. Patients with myocardial infarction were subdivided into four groups, focusing on the involvement of right ventricular and septal branches of the coronary arteries. Group I consisted of 11 patients with anterior infarction who showed an obstructive lesion of the proximal left anterior descending branch involving the first septal perforator with a patent right coronary artery. Group II consisted of 10 patients with inferior infarction who showed an obstructive lesion of the proximal right coronary artery involving the right ventricular branch. Group III consisted of 12 patients with both anterior and inferior infarction who showed obstructive lesions of both the proximal left anterior descending branch and the right coronary artery involving the right ventricular branch. Group IV consisted of seven patients with lateral infarction who showed an obstructive lesion of the diagonal branch or branches of the circumflex coronary artery with a patent left anterior descending branch and right coronary artery. Three measurements were performed from the transmitral and transtricuspidal inflow velocity patterns to assess the left and right ventricular diastolic behaviors. These measurements were: acceleration half-time, deceleration half-time of early diastolic rapid inflow, and the ratio of the peak velocity of early diastolic rapid inflow to that of the late diastolic inflow due to the atrial contraction. Impaired diastolic filling of the left ventricle compensated by enhanced left atrial contraction was observed in patients with myocardial infarction from groups I, II, III and IV.(ABSTRACT TRUNCATED AT 250 WORDS)