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Epinephrine local injection is a hemostatic procedure used in active diverticular bleeding that elicits vasoconstriction and tamponade effects. We compared the additional benefit of combination therapy with HSE-C (hypertonic saline epinephrine injection with clipping) to clipping monotherapy. Retrospective data on diverticular bleeding between 2011 and 2016 was reviewed. Those with an active bleeding source confirmed by colonoscopy (excluding non-bleeding vessels and adherent clots) who received either HSE-C or clipping were evaluated. Endpoints were rates of successful primary hemostasis, recurrent bleeding, and surgical intervention during hospitalization. A total of 320 patients with diverticular bleeding were evaluated, on which either HSE-C (n = 35) or clipping monotherapy (n = 18) was performed. Rates of successful primary hemostasis (91.4% vs. 66.7%, p = 0.048) and direct placement of endoclips (60.0% vs. 16.7%, p = 0.004) were significantly higher in the HSE-C group. Although not statistically significant, the HSE-C group had a higher rate of early rebleeding (18.8% vs. 8.3%, p = 0.653), while no difference was seen in the number of patients requiring surgery (11.4% vs. 5.5%, p = 0.651). HSE-C is associated with a higher rate of successful primary hemostasis for severe active diverticular bleeding but has no significant difference in reducing early recurrent bleeding or the number of patients requiring surgery, suggesting that hemostatic effects may be temporary.

A previously healthy 89-year-old man was admitted to our hospital with right upper quadrant pain and mild fever. A diagnosis of cholangitis was suspected based on the patient's physical findings and imaging features. Although he received treatment typical for cholangitis, he suddenly died of shock for unknown reasons two months after disease onset. An autopsy revealed a ruptured hepatic artery aneurysm, which had caused lethal intra-abdominal bleeding. In addition, systemic necrotizing vasculitis of small- and medium-sized arteries was detected, and polyarteritis nodosa (PAN) was diagnosed after the autopsy. Biliary symptoms as the initial manifestation of PAN are extremely rare.

A 79-year-old woman with colon cancer and multiple liver metastases was admitted to our hospital for systemic chemotherapy. She underwent first cycle of modified FOLFOX6 chemotherapy. She was confused on treatment day 5. Blood test revealed her serum ammonia level to be 121 microg/dl. We diagnosed 5-fluorouracil (5FU)-induced hyperammonemia. Conservative treatment resulted in improvement of metal status. The reason for hyperammonemia after administration of 5FU was the excess production of ammonium from metabolites of 5FU.

The Dornier MPL9000 lithotriptor was originally equipped with an ultrasound guiding system. Recently an optional fluoroscopic guiding system was developed to overcome the known disadvantages of the ultrasound system and to exploit the merits of both systems by using them in combination. Herein, we examined the effectiveness and safety of this new optional system. From December 1990 to February 1991, we treated 41 patients with upper urinary tract stones with MPL9000 using the optional fluoroscopic system. Treatments were judged as effective if the patients were stone-free or the residual fragments were smaller than 4mm in diameter. The overall effectiveness rates at one month after the treatment were 54.5% for renal stones and 76.9% for ureter stones respectively. At three months after the treatment the effectiveness rate for renal stones was 83.3%, and that for ureter stones 95.5%. The changes in the laboratory data after the treatment were alight and caused no clinical problems. Complications during and after the treatment were also minor and tolerable. MPL9000 was sufficiently effective and safe in the treatment of upper urinary tract stones when it was used the new optional fluoroscopic system instead of the original ultrasonic guiding system.

Recently several authors have observed tissue damages in ESWL treated kidneys, such as interstitial hemorrhage and edema, cavitation of renal tubular cells and vascular spasms. Examination using renal scintigraphy suggested that these damages could cause a decrease of renal blood flow in the treated kidney. Trying to confirm and further investigate this possibility, we studied on changes of renal blood flow velocity using ultrasound color doppler method in 23 consecutive patients with renal stones who underwent ESWL. The studies were conducted before, immediately after and 1 week after an ESWL treatment. Results were as follows; renal blood flow velocity decreased significantly in the area exposed to shock were immediately after the treatment and returned to the pretreatment levels after 1 week. The changes were not significant in the non-exposed area. In parallel with this decrease of renal blood flow velocity, significant increases of resistive index, pulsatility index and significant decreases of ratio were observed. These parameters calculated by measuring of renal blood flow velocity are known to well correlate with parenchymal vascular resistance. We speculate that these changes in renal parenchymal blood flow velocity are triggered by the tissue damages caused by the exposure to shock wave. The recovery of renal blood flow velocity may depend on the recovery of the tissue damages. Ultrasound color doppler method may make it possible to monitor the recovery of tissue damages induced by shock wave and may provide us with an useful information to determine when to repeat ESWL if needed.