Colonoscopic classification of internal hemorrhoids: Usefulness in endoscopic band ligation

Background:  Bleeding is one of the main symptoms of internal hemorrhoids. However, the conventional Goligher's classification of internal hemorrhoids does not consider the severity of bleeding. We intended to establish a useful method for evaluating internal hemorrhoids using a colonoscope that reflected the severity of the symptoms.
Methods:  Using a colonoscope in the retroflexed and forward viewing position, 104 patients with symptomatic internal hemorrhoids were evaluated based on the criteria of range, form and red color signs (RCS). Range was determined by the circumferential distribution of internal hemorrhoids and scaled from 0 to 4. Form was determined by size and scaled from 0 to 2. The presence of RCS was also evaluated. Symptoms were determined by interview and scaled from 0 to 3. Patients were treated by endoscopic band ligation (EBL) and were examined endoscopically before and 4 weeks after the treatment.
Results:  Before the treatment, range, form and RCS were significantly correlated to bleeding ( P <  0.01), and form was significantly correlated to prolapse ( P <  0.05). The endoscopic classification scores at 4 weeks after EBL improved significantly (range from 3.25 ± 0.05–0.56 ± 0.08 [ P <  0.01] and form from 2.81 ± 0.04–0.56 ± 0.07 P <  0.01).
Conclusion:  The new endoscopic classification of internal hemorrhoids proved to be closely correlated to symptoms, particularly bleeding, and thus highly useful in evaluating the effectiveness of the treatment.     

Pulmonary surfactant proteins and lipids as modulators of inflammation and innate immunity

Objectives: The pulmonary surfactant system of the human lung consists of unique lipids and proteins that contribute to the biophysical and innate immune properties of the organ. Surfactant protein A (SP‐A) is an oligomeric protein consisting of 18 protomers with collagen and lectin–like domains that recognizes glycoconjugates, lipids and protein determinants on both host cells and invading microorganisms. The authors examined the interaction of SP‐A with Mycoplasma pneumoniae and the influence of the protein upon the innate immune response to the bacteria. Methodology: The authors quantified SP‐A interaction with bacteria using ELISA, and identified the major surface ligand by thin layer chromatography, HPLC and mass spectrometry. The inflammatory response of human and rat macrophages was measured by quantifying tumour necrosis factor‐α secretion using ELISA, and nitric oxide production. Results: SP‐A bound the bacteria with high affinity and enhanced the inflammatory response of human and rat macrophages to the organism and its membranes. Analysis of the interaction of SP‐A with the bacteria revealed that the major ligand was a phospholipid. The lipid ligand was purified by a combination of thin layer and HPLC, and identified by mass spectrometry. The mass spectrometry demonstrated that the SP‐A reactive lipid consisted of several disaturated molecular species of phosphatidylglycerol (PtdGro). Additional experiments were performed to determine if disaturated PtdGro was capable of interfering with the action of SP‐A as an inhibitor of bacterial lipopolysaccharide‐induced inflammatory mediator production by macrophages. The disaturated PtdGro failed to alter the anti‐inflammatory action of SP‐A but unexpectedly these same studies revealed that unsaturated PtdGro can modify the host response to lipopolysaccharide. Conclusions: These findings reveal that both the lipids and proteins of pulmonary surfactant play a role in regulating the host response to invading microorganisms.     

Relationship between severity and symptoms of reflux oesophagitis in elderly patients in Japan

Since information concerning reflux oesophagitis in the elderly is limited, particularly in Japan, the severity and symptomatic profiles of reflux oesophagitis in elderly patients were investigated. One hundred and nineteen patients with reflux oesophagitis found among 2278 endoscopy cases between 1993 and 1996 were investigated in this study. The patients were divided into two groups, elderly and non-elderly. The severity of reflux oesophagitis was estimated by the Los Angeles classification. The presence or absence of typical symptoms (heartburn and regurgitation) was determined by interview. Reflux oesophagitis was not only more frequently found in the elderly group, but was more severe than in the non-elderly. Although the degree of manifestation of typical symptoms was similar between the elderly and the non-elderly with high-grade oesophagitis, the elderly patients with mild reflux oesophagitis were less symptomatic than the non-elderly. Mild reflux oesophagitis in the elderly may be missed due to its rarity of typical reflux symptoms and a substantial number of elderly persons might have subclinical reflux oesophagitis.     

Detection of Helicobacter pylori Gene by Means of Immunomagnetic Separation-Based Polymerase Chain Reaction in Feces

Background: Detection of Helicobacter pylori is usually performed by culture, polymerase chain reaction (PCR), histology, or urease test on gastric biopsy samples. Although methods based on feces are non-invasive, their sensitivity has been relatively low. In this study, to improve its sensitivity, immunomagnetic separation (IMS) was used as a pre-PCR step for direct detection of H. pylori in feces. Methods: Fresh fecal samples were taken from 72 patients attending for endoscopy. Of these, 57 patients had a positive H. pylori status according to the results of culture, histology, and PCR on gastric biopsy samples. Anti-H. pylori antibody-sensitized immunomagnetic beads were used to concentrate the bacteria. PCR was then performed to detect the H. pylori urease A-encoding gene. Results: Of the 57 H. pylori-positive patients, 35 (61.4%) had positive fecal samples by IMS-based PCR method. None of the 15 H. pylori-negative patients had positive fecal samples. The sensitivity of this method was 61.4%, and the specificity 100.0%. Conclusions: This study confirms that non-invasive diagnosis of H. pylori infection could be made from feces by using IMS-based PCR.     

Crohn's Disease Initially Suggested by Minute Esophageal Erosions—Report of a Case

A 19–year-old woman visited our hospital complaining of fever and epigastral-gia. Upper gastrointestinal endoscopy showed minute discrete erosions surrounded by elevated mucosa about one millimeter in diameter in the esophagus and aphthoid erosions in the stomach. Biopsy samples obtained from the esophagus showed non-caseating epitheloid granulomas, suggesting Crohn's disease. Colonoscopy showed a small erosion in the cecum adjacent to the vermiform appendix and biopsy showed non-caseating epitheloid granulomas and Crohn's disease was diagnosed. In hospital, she was treated with elemental diet and 5–aminosalicyclic acid. Clinical symptoms disappeared rapidly and laboratory data became normal. We thus report a rare case of early-stage Crohn's disease initially indicated by biopsy of minute esophageal erosions. (Dig Endosc 1999; 11: 255–258)     

Estimation of the Chemosensitizing Activity of Modulators of Multi-drug Resistance via Combined Simultaneous Analysis of Sigmoidal Dose-Response Curves

The potency of modulators which re-establish sensitivity of resistant tumour cells to cytotoxic drugs is not usually described by ED50 values, even though such values are needed for comparison of modulator activity. Various methods are reported for the determination of ED50 values of propafenone-type modulators of multi-drug resistance in cytotoxicity assays. Best results were obtained by using a combined simultaneous analysis of dose-response curve families. This approach enables calculation of statistically highly significant ED50 values without any data reduction directly from the original data points obtained in daunomycin cytotoxicity assays. The method also enables extrapolation of the ED50 values of compounds with low activity or poor solubility, or both.     

The side‐effects and efficacy of leflunomide in Japanese patients with rheumatoid arthritis

Aims: To investigate the efficacy and safety of leflunomide, including the side‐effects, we assessed 84 rheumatoid arthritis (RA) patients who received leflunomide treatment. Methods: We analyzed the C‐reactive protein (CRP), white blood cell count (WBC), KL‐6, and visual analogue scale (VAS) scores, modified Stanford Health Assessment Questionnaire (MHAQ) score, American Rheumatism Association score (ACR20 and ACR50) within a time course after treatment with leflunomide. We treated 84 RA patients, 12 male and 72 female from 28 to 81‐years‐old, with an average age of 63.5 years. The patients were divided into three groups: a group consisting of 38 patients who received 100 mg/day of leflunomide for 3 days followed by 20 mg/day thereafter; a second group of 11 patients who received a no‐loading dose of 10 mg/day; and a third group of 35 patients who received a no loading dose of 20 mg/day. Results: The 50% decrease of CRP seen in 2 weeks was 52% of the total of 84 patients. The WBC score did not change significantly after the medication was given. The KL‐6 score did not change significantly, either. The VAS pain score improved 4 weeks later, and then further improved 8 weeks later. Therefore, RA patients using leflunomide obtained pain relief 4 weeks after commencing medication. The MHAQ score did not change significantly until 8 weeks after the patients started the medication. ACR20 was 62% and ACR50 was 38% at 8 weeks after treatment. The side‐effects of leflunomide observed in our patients were rash, respiratory infection, diarrhea, nausea, alopecia, muscle pain, headache, dizziness and general fatigue. Twenty‐three out of 84 patients experienced side‐effects (27%), and 48/84 (57%) experienced withdrawal. In our hospital, there were no patients who developed severe interstitial pneumonia (IP) or who died after taking leflunomide; however, the incidence of side‐effects of the 100 mg/day loading dose (42.1%) was 2.5 times higher than in the patients who received 20 mg/day (17.1%) of a no‐loading dose. Conclusion: Because of this, it is possible that a 100 mg/day loading dose is a relatively high risk dose in terms of causing side‐effects, especially for severely ill RA patients with a high CRP level.     

Evaluation of Endoscopic Resection of Gastric Tumors Following Local Injections of HSE (Hypertonic Saline-Epinephrine Solution)

Abstract: The Endoscopic resection of gastric tumors following local injections of hypertonic saline-epinephrine solution (ERHSE) was performed on 72 lesions (69 patients) of gastric tumors at Yoyogi Hospital etc. from March, 1983, to December, 1989. These included 40 cases of adenoma, 31 cases of carcinoma, and one carcinoid tumor. The average length of the major axis of the endoscopically resected tumors was 12 ± 9 mm. The curative rate at the first attempt was 94% (64 of 68 lesions). The curative rate of the final procedure was 99% (67 of 68 lesions). This excluded 4 lesions in 3 patients in whom a follow-up examination was not possible. There was no relationship found between the final cure rate and the form and location of the lesions. Fifty four lesions were resected with one session of snare cautery; the average length of their major axis was 9 ± 6mm. The resection of 18 lesions was done piecemeal, and the average length of their major axis was 20 ± 10mm. A statistical significance was noted between the size of the lesions which could be resected with one session of snare cautery and those treated by the piecemeal method, but no difference was noted in the location of lesions for the two groups. The indication for ERHSE was assessed in accordance with the cases that resulted in piecemeal resection, those in which the first ERHSE left residual tumor tissues, and those with perforation. ERHSE could be performed with difficulty on lesions which were (1) on the sharply bending gasric wall, (2) observed only tangentially, (3) inadequately observed. These lesions were situated on the gastric fornix, cardia, and their vicinities, the gastric angulus, posterior wall and greater curvature of the gastric body, and anterior wall and lesser curvature of the middle to the upper gastric body.