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Background Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease and affects approximately 25% of the general global adult population. The prognosis of NAFLD patients with advanced liver fibrosis is known to be poor. It is difficult to assess disease progression in all patients with NAFLD; thus, it is necessary to identify patients who will show poor prognosis. Aim To investigate the efficacy of non-invasive biomarkers for predicting disease progression in patients with NAFLD. Methods We investigated biomarkers associated with mortality in patients with NAFLD who visited the Kawasaki Medical School General Medical Center from 1996 to 2018 and underwent liver biopsy and had been followed-up for > 1 year. Cumulative overall mortality and liver-related events during follow-up were calculated using the Kaplan-Meier analysis and compared using log-rank testing. We calculated the odds ratio and performed receiver operating characteristic curve analysis with logistic regression analysis to determine the optimal cut-off value with the highest prognostic ability. Results We enrolled 489 patients who were followed-up for a period of 1-22.2 years. In total, 13 patients died (2.7% of total patients enrolled); 7 patients died due to liver-related causes. Poor prognosis was associated with liver fibrosis on histological examination but not with inflammation or steatosis. Blood biomarkers associated with mortality were platelet counts, albumin levels, and type IV collagen 7S levels. The optimal cutoff index for predicting total mortality was a platelet count of 15 × 104/μL, albumin level of 3.5 g/dL, and type IV collagen 7S level of 5 mg/dL. In particular, only one-factor patients with NAFLD presenting with platelet counts ≤ 15 × 104/μL, albumin levels ≤ 3.5 g/dL, or type IV collagen 7S ≥ 5 mg/dL showed 5-year, 10-year, and 15-year survival rates of 99.7%, 98.3%, and 94%, respectively. However, patients with two factors had lower 5-year and 10-year survival rates of 98% and 43%, respectively. Similarly, patients with all three factors showed the lowest 5-year and 10-year survival rates of 53% and 26%, respectively. Conclusion A combination of the three non-invasive biomarkers is a useful predictor of NAFLD prognosis and can help identify patients with NAFLD who are at a high risk of all-cause mortality.

Two adult cases of acute gastric mucosal lesions (AGML) caused by Helicobacter pylori infection were confirmed by spontaneous eradication during the follow-up period. The clinical course of the initial infection by H. pylori in adults with AGML remains unclear, whether it is transient or progresses to a persistent infection. In these two reported cases, gastric biopsies at the time of the onset revealed the presence of H. pylori; however, serum H. pylori antibodies performed at the same time were negative. Retesting for H. pylori serum antibody, after six months in one and after two months in the other, was negative, confirming spontaneous eradication.

With recent technological advances in the field of endoscopic hemostasis, the prognosis of patients with gastrointestinal (GI) bleeding has improved. However, few studies have reported on the clinical course of patients with GI bleeding. This study aimed to evaluate the differences in clinical outcomes of patients with lower GI bleeding (LGIB) compared with upper GI bleeding (UGIB) and the factors related to their prognosis.Patients who had undergone emergency endoscopy for GI bleeding were retrospectively reviewed. The severity of GI bleeding was evaluated using the Glasgow-Blatchford (GB), AIMS65, and NOBLADS scores. Patients in whom obvious GI bleeding relapsed and/or iron deficiency anemia persisted after emergency endoscopy were considered to exhibit rebleeding.We reviewed 1697 consecutive patients and divided them into UGIB (1054 patients) and LGIB (643 patients) groups. The proportion of patients with rebleeding was significantly greater in the UGIB group than in the LGIB group; the mortality rate was significantly higher in the UGIB group than in the LGIB group. Multivariate analysis showed that a GB score ≥12 and an AIMS65 score ≥2 were significantly associated with rebleeding in the UGIB group, whereas a NOBLADS score ≥4 was significantly associated with rebleeding in the LGIB group. Notably, the influence of emergency endoscopy differed according to GI bleeding location.The clinical course was significantly worse in patients with UGIB than in patients with LGIB. The influence of emergency endoscopy differed according to GI bleeding location.

Objective To evaluate the prevalence of autoimmune gastritis in patients with histologically proven nonalcoholic steatohepatitis (NASH). Methods A total of 33 patients with NASH and 143 patients with chronic liver disease (66, 24, 22, 10, 1, and 21 patients with hepatitis C, hepatitis B, autoimmune hepatitis/primary biliary cholangitis, non-B/non-C hepatitis, fatty liver, and alcoholic disease, respectively) who underwent upper gastrointestinal endoscopy between January 2013 and August 2016 were retrospectively assessed to determine the prevalence of autoimmune gastritis. The clinical characteristics of these patients with NASH and autoimmune gastritis were examined, and the clinical characteristic and biomarkers were compared between patients with NASH with and without autoimmune gastritis. Results Six of the 33 patients with NASH (19.4%) were diagnosed with autoimmune gastritis. The prevalence of autoimmune gastritis was higher in patients with NASH than in those with other chronic liver diseases [4/143 (2.8%), p=0.002]. All six patients with NASH and autoimmune gastritis exhibited high serum gastrin levels; five of the patients were positive for anti-parietal cell antibodies, and one was negative for anti-parietal cell antibodies but positive for intrinsic factor antibody. Furthermore, 1 patient presented with iron-deficiency anemia (hemoglobin

A 44-year-old patient progressed from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH) cirrhosis. She was diagnosed with NAFL via a liver biopsy. At 56 years old, she was diagnosed with NASH stage 3 via a second liver biopsy. One year later, she was diagnosed with NASH cirrhosis via a third liver biopsy. This is the first study to report the gradual deterioration of liver histology shown via three liver biopsies and fibrosis markers in a patient who progressed from NAFL to NASH cirrhosis. Following menopause, it is necessary to be aware of the rapid development of liver fibrosis.

We herein report a case of gastric hyperplastic polyps after argon plasma coagulation (APC) for gastric antral vascular ectasia (GAVE) in the antrum of a 65-year-old man with liver cirrhosis and hypergastrinemia induced by long-term proton pump inhibitor (PPI) use. Two years after APC therapy, endoscopy demonstrated multiple gastric polyps in the antrum and angle. A gastric polyp biopsy indicated foveolar epithelium hyperplasia, which was diagnosed as gastric hyperplastic polyps. One year after switching to an H2 blocker antagonist, endoscopy revealed that the polyps and GAVE had disappeared, with normal gastrin levels suggesting that PPI-induced hypergastrinemia had caused gastric hyperplastic polyps after APC therapy, and the polyps had disappeared after discontinuing PPIs.

Asians are known to be more likely than Westerners to develop fatty liver and lifestyle-related diseases in spite of their weight. However, the relationship between fat accumulation and lifestyle-related diseases in non-obese Asians is unknown. Therefore, this study aimed to analyze visceral fat and hepatic fat in participants with a normal body mass index (BMI) and examine their characteristics during a medical checkup. This cross-sectional study was conducted on 663 of 1142 patients who underwent abdominal ultrasonography and who had an alcohol intake (converted to ethanol) of &lt, 30 g/day for males and &lt, 20 g/day for females and a BMI of &lt, 25 kg/m2 during a health checkup. Participants were classified into four groups: group A, visceral fat accumulation (VFA) (&minus, ) and fatty liver (FL) (&minus, ) (n = 549), group B, VFA (+) and FL (&minus, ) (n = 32), group C, VFA (&minus, ) and FL (+) (n = 58), and group D, VFA (+) and FL (+) (n = 24). The frequencies of lifestyle-related disease complications, liver function tests, and liver fibrosis were evaluated among the four groups. Compared with group A (control), groups B, C, and D had a higher number of males, BMI, abdominal circumference, ALT, AST, &gamma, GTP, triglyceride, uric acid, fasting blood sugar levels, and incidence of hyperlipidemia. Groups C and D had higher ALT, HbA1c, cholinesterase, and triglyceride levels, FIB4 index, and the number of patients with diabetes mellitus (DM) than groups A and B, however, there was no difference between groups A and B. FL is a risk factor of DM and liver fibrosis in non-obese Japanese individuals, however, VFA only is not a risk factor of DM and liver fibrosis.

In this editorial we comment on the article by Fukushi K et al published in the recent issue of the World Journal of Gastroenterology 2018; 24(34): 3908-3918. We focus specifically on the mechanisms of the anti-thrombotic action of aspirin, gastric mucosal injury and aging-related increased susceptibility of gastric mucosa to injury. Aspirin is widely used not only for the management of acute and chronic pain and arthritis, but also importantly for the primary and secondary prevention of cardiovascular events such as myocardial infarcts and strokes. Clinical trials have consistently shown that antiplatelet therapy with long term, low dose aspirin (LDA) - 75 to 325 mg daily, dramatically reduces the risk of non-fatal myocardial infarcts, stroke and mortality in patients with established arterial diseases. However, such treatment considerably increases the risk of gastrointestinal (GI) ulcerations and serious bleeding by > 2-4 fold, especially in aging individuals. This risk is further increased in patients using LDA together with other antiplatelet agents, other nonsteroidal anti-inflammatory agents (NSAIDs) and/or alcohol, or in patients with Helicobacter pylori (H. pylori) infection. Previous studies by our group and others have demonstrated prominent structural and functional abnormalities in gastric mucosa of aging individuals (which we refer to as aging gastric mucosa or “aging gastropathy”) compared to the gastric mucosa of younger individuals. Aging gastric mucosa has impaired mucosal defense, increased susceptibility to injury by a variety of noxious agents such as aspirin, other NSAIDs and ethanol, and delayed and impaired healing of injury. The mechanism underlying these abnormalities of aging gastric mucosa include reduced mucosal blood flow causing hypoxia, upregulation of PTEN, activation of pro-apoptotic caspase-3 and caspase-9, and reduced survivin (anti-apoptosis protein), importin-α (nuclear transport protein), vascular endothelial growth factor, and nerve growth factor. The decision regarding initiation of a long-term LDA therapy should be made after a careful consideration of both cardiovascular and GI risk factors. The latter include a previous history of GI bleeding and/or ulcers, age ≥ 70, male gender, concurrent use of other NSAIDs, alcohol consumption and H. pylori infection. Furthermore, the incidence of GI ulcers and bleeding can be reduced in patients on long term LDA treatment by several measures. Clinicians treating such patients should test for and eradicate H. pylori, instruct patients to avoid alcohol and non-aspirin NSAIDs, including cyclooxygenase-2-selective NSAIDs, and prescribe proton pump inhibitors in patients on LDA therapy. In the future, clinicians may be able to prescribe one of several potential new drugs, which include aspirin associated with phosphatidylcholine (PL2200), which retains all property of aspirin but reduces by approximately 50% LDA-induced GI ulcerations.

Background Gastrointestinal hemorrhage occurs frequently. We reviewed the tendency of occurrence of bleeding gastric and duodenal ulcers and their association with antithrombotic therapy before and after the widespread use of Evidence-Based Clinical Practice Guidelines for Peptic Ulcer 2009 (1st edition), which was published to improve treatment outcomes and prevent peptic ulcers. Methods The study enrolled 1105 patients with bleeding gastric and duodenal ulcers treated at our hospital between January 2000 and March 2016. They were divided into the preguideline group (807 patients treated between January 2000 and December 2010) and the postguideline group (298 patients treated between January 2011 and March 2016). The use of medications, severity, the incidence of Helicobacter pylori infection, the presence of any underlying disease, and other factors were compared between the pre- and postguideline groups. Results The number of patients receiving antithrombotic therapy was slightly higher in the postguideline group without a significant difference (P = 0.50). The incidence of H. pylori infection was significantly lower in the postguideline group (P

A 78-year-old man underwent endoscopic submucosal dissection (ESD) for early gastric adenocarcinoma twice in 2009 and 2014. Between the procedures, he successfully completed Helicobacter pylori eradication therapy. In May 2015, upper endoscopy screening showed two elevated lesions on the gastric fundus, and en bloc resection by ESD was performed. We histopathologically diagnosed the patient to have gastric adenocarcinoma of the fundic gland type. In this case, the two lesions of gastric adenocarcinoma of the fundic gland type multifocally developed after ESD for metachronous gastric tubular adenocarcinoma. Furthermore, they appeared in the gastric fundus, where atrophy had been improved due to eradication therapy.

Perioperative coronary artery spasm (GAS) is one of the serious complications leading to circulatory collapse. Here we retrospectively examined the impact of CAS and discussed its prevention strate- gies.Reports of intraoperative CAS were iden- tified by using the PubMed and by manually searching the Journal of Japan Society for Clinical Anesthesia (2001-2015). Analyses were performed on 51 patients who developed CAS and had had no history of isch- emic heart disease.Of the 51 analyzed patients, 19 developed circulatory collapse. In these patients, the rate of early administration of a sufficient dose of a coronary vasodi- lator was low, and they tended to have prolonged and/ or recurrent attacks. Among them, two patients may have had a problem due to the dosage and/or admin- istration method for coronary vasodilator, despite early administration. In addition, we found that a combina- tion of general anesthesia and epidural block may have contributed to the collapse. In three cases, it was diffi- cult to identify the predictors of circulatory collapse.Awareness of CAS and vigilant moni- toring are crucial for preventing circulatory collapse. When a transient ST-segment change indicates possi- ble CAS, adequate dosages of a coronary vasodilator should be promptly administered.

埼玉県在住の男性・64 歳.2012 年11 月初旬,近医で日本海裂頭条虫症の診断を受け,駆虫目的で本院消化器内科を紹介受診.外来で駆虫治療したところ,全長約250 cm の白色紐状で,全体的に肉厚感のある虫体を排出した.虫体は形態学的特徴より日本海裂頭条虫ではなく,クジラ複殖門条虫が強く疑われたため,遺伝子解析を行った.PCR によって増幅されたcytochrome c oxidase subunit 1 遺伝子(cox1)の全長塩基配列を解析したところ,既知のクジラ複殖門条虫の塩基配列と99%の相同性を示したことから,本症例はクジラ複殖門条虫症と確定した.該当患者は,便に白色紐状物が混入する2〜3 か月前に,生シラスを生食しており,これが感染源となった可能性が高いと考えられた., We have reported a case of infection with whale tapeworm,Diplogonoporus balaenopterae, in Dokkyo MedicalUniversity Hospital. The patient, a 64-year-old Japanesemale, living in Saitama Prefecture was admitted to our hospitalon Nov. 1st 2012, owing to pieces of tapeworm beingdischarged. He was treated with Biltricide® (20 mg/kg)and Magcorol P®( 100 g) in the hospital and he expelled atapeworm about 250 cm, in length along with the scolex afterabout 2 hours of treatment. Based on the morphologicalfeatures of the strobila and the scolex we strongly suspectedthat the tapeworm belongs to the genus Diplogonoporus.To identify the species of the discharged tapeworm, thecomplete cox1 gene was amplified by PCR and the nucleotidesequence was analyzed. The sequence showed 99 %homology against those from D. balaenopterae. From theseresults the patient was diagnosed as a diplogonoporiasiscaused by D. balaenopterae, whale tapeworm. We could notfind any proglottides of tapeworm nor eggs in stools whenwe performed follow up medical examinations three monthsafter treatment. Therefore it can be concluded that the patientwas cured of this disease. In most cases the infectionsource of the whale tapeworm to humans is reported ascoming from marine fish such as sardines and bonitos. Thepatient had frequently consumed various kinds of raw marinefish, and we suspect that the infection source can beattributed to eating raw whitebait.

AIM To evaluate the usefulness of total colonoscopy (TCS) for patients undergoing gastric endoscopic submucosal dissection (ESD) and to assess risk factors for colorectal neoplasms. METHODS Of the 263 patients who underwent ESD at our department between May 2010 and December 2013, 172 patients undergoing TCS during a one-year period before and after ESD were targeted. After excluding patients with a history of surgery or endoscopic therapy for colorectal neoplasms, 158 patients were analyzed. Of the 868 asymptomatic patients who underwent TCS during the same period because of positive fecal immunochemical test (FIT) results, 158 patients with no history of either surgery or endoscopic therapy for colorectal neoplasms who were matched for age and sex served as the control group for comparison. RESULTS TCS revealed adenoma less than 10 mm in 53 patients (33.6%), advanced adenoma in 17 (10.8%), early colorectal cancer in 5 (3.2%), and advanced colorectal cancer in 4 (2.5%). When the presence or absence of adenoma less than 10 mm, advanced adenoma, and colorectal cancer and the number of adenomas were compared between patients undergoing ESD and FIT-positive patients, there were no statistically significant differences in any of the parameters assessed. The patients undergoing ESD appeared to have the same risk of colorectal neoplasms as the FIT-positive patients. Colorectal neoplasms were clearly more common in men than in women (P = 0.031). Advanced adenoma and cancer were significantly more frequent in patients with at least two of the following conditions: hypertension, dyslipidemia, and diabetes mellitus (P = 0.019). CONCLUSION In patients undergoing gastric ESD, TCS appears to be important for detecting synchronous double neoplasms. Advanced adenoma and cancer were more common in patients with at least two of the following conditions: hypertension, dyslipidemia, and diabetes mellitus. Caution is therefore especially warranted in patients with these risk factors.

In Europe and the United States, uveal melanoma involving the choroid membrane is the most commonlyoccurring intraocular malignancy in adults. Hepatic metastasis of uveral melanoma tends to have a poorprognosis. In the present study we describe the case of malignant melanoma of the choroid membrane,which was found to have developed from multiple hepatic metastases 6 years after the enucleation of theleft eye ball. In metastatic hepatic tumor patients whose primary focus is unknown, it is important to conducta detailed investigation of the patient's disease history, bearing the present findings on uveal melanomain mind.

症例は47歳の男性. 40℃の発熱と頭痛が出現し近医を受診.一時症状は軽快したが,再び発熱が出現し前医入院となった.入院後の腹部CT検査及び腹部超音波検査により上腸間膜静脈血栓症と診断され,精査加療を目的に当院に転院となった.厳重な経過観察の下に抗菌薬投与と抗血栓および抗凝固療法による保存的治療を行い,これにより第4病日には症状の改善が得られた.本症例は後にプロテインC欠乏症と診断され,感染と脱水が影響して門脈血栓に及ぶ上腸間膜静脈血栓症が引き起こされたものと考えられた.今回我々は保存的に治療しえた門脈血栓を合併する上腸間膜静脈血栓症の一例を経験したので報告した., The patient was a 47-year-old male who had presented with a fever of 40℃ and headaches. He was treated by antibiotics at a local hospital under the diagnosis of the common cold. But progress of symptoms was temporary, so he was admitted to the hospital. Based on the findings of an abdominal CT and US after the admission, he was diagnosed as superior mesenteric vein thrombosis (SMVT) and transferred to our hospital on the 25th day of his illness. Antibiotics, together with antithrombotics and anticoagulant agents, were carefully administered as the treatment. As a result, symptoms were improved on the fourth day of admission to our hospital. This case was detected later to be associated with protein C deficiency. We speculated that portal vein thrombosis complicated with SMVT had occurred following infection and dehydration. We reported a case of SMVT with portal vein thrombosis, which was effectually treated with conservative therapy.

症例は63歳の男性,既往歴に30歳時胃潰瘍にて胃切除(Billroth II法), 60歳時肺癌で右肺下葉切除(低分化扁平上皮癌)がある.現病歴は右肺癌手術後の経過観察中にCEAの上昇を認め消化管精査を目的に当科紹介となった. 2001年5月の上部消化管内視鏡検査では胃噴門部後壁に白苔を有する隆起を認め,生検ではGroup IIIであった.以後経過観察となったが, 2003年5月には黄白色調の扁平隆起を呈し黄色腫類似の形態を呈し,生検ではGroup IVであった. 7月Group Vであり, 10月内視鏡的粘膜切除術が施行され病変は完全切除された.病理診断では管状腺癌であった.本症例は経過中に病巣表面が黄色腫類似の所見を呈した稀な症例であった., A 63-year-old man, who received gastrectomy for a peptic ulcer at 30 year-old and received pneumoresection for his undifferentiated squamous cell carcinoma of the lung at 60 years-old, was inspected by postoperative follow-up study. In May 2001, serum carcinoembryonic antigen level exceeded 5ng/ml, and he was referred to our department for endoscopic examinations. Endoscopic examination revealed a flat elevated lesion whose surface was covered with dense exudate on the posterior wall of the cardiac region, and the histopathological diagnosis was tubular adenoma. In May 2003, the flat elevated lesion was accompanied by yellow-whitish spots and endoscopically diagnosed as xanthoma, while the biopsy specimen from the elevated lesion demonstrated tubular ade noma with severe atypia. In October 2003, endoscopic mucosal resection was successfully completed for the lesion, and it was diagnosed as well differentiated adenocarcinoma. We consider that a gastric elevated lesion should be carefully followed when tubular adenoma is detected, even if endoscopically looks like benign xanthoma.

We investigated perioperative management and clinical outcome of 12 patients who were 85 years old or older and received video-assisted thoracic surgery under general anesthesia. Although all the patients had preoperative respiratory complications or cardiovascular complications, they were discharged without any additional respiratory assistance such as home oxygen therapy. Our observation suggests that it is important to evaluate the indication of anesthesia from their daily activities and pulmonary function test even if they are oldest-old. If the patient demonstrates good physical function, he or she should not be excluded from anesthesia.

Background Endoscopic sphincterotomy (EST) is currently recognized as the primary endoscopic treatment for common bile duct stones. However, it is difficult to remove multiple (≥3) or large (≥15 mm) common bile duct stones with EST alone. Recently, EST plus endoscopic papillary large-balloon dilation (EPLBD) was reported to be an effective treatment for such bile duct stones. We compared the results of EST and EST + EPLBD for multiple (≥3) or large (≥15 mm) stones that were difficult to treat using EST alone. We also compared the complication rates between the techniques. Methods Seventy patients with large (largest diameter, ≥15 mm) or ≥ 3 common bile duct stones treated in our department between April 2010 and March 2013 underwent EST + EPLBD (n = 34) or EST alone (n = 36). We compared final successful stone removal rates, rates of successful stone removal in the first session, procedure times, status of concurrent mechanical lithotripsy (ML), and complications between the EST + EPLBD and EST groups. Results The rates of final successful stone removal were similar between the two groups (EST + EPLBD: 100 % vs. EST: 89 %; p = 0.115). The rate of successful stone removal in the first session was significantly higher in the EST + EPLBD group (EST + EPLBD: 88 % vs. EST: 56 %; p = 0.03). Moreover, the procedure time was significantly shorter (EST + EPLBD: 42 min vs. EST: 67 min; p = 0.011) and the rate of ML use was significantly lower in the EST + EPLBD group (EST + EPLBD: 50 % vs. EST: 94 %; p

In sicker hearts, right atrial pressure (an estimation of right ventricle preload) are not equivalent to left atrial pressure (an estimation of left ventricle preload). Both right and left atrial pressures are frequently estimated using invasive techniques and also transthoracic echocardiography. While right atrial pressure is easy to obtain with transthoracic echocardiography, the assessment of left ventricle preload or filling pressures is not simple. In relation to the study of Sasai et al. (J Intensive Care 2(1):58, 2014), this paper discusses in a succinct manner how to think and assess the left ventricle preload by transthoracic echocardiography.

十二指腸静脈瘤からの出血は稀であり致命的となりうる肝硬変の合併症であるが,その治療法は未だ確立していない.我々は,ブチル-2-シアノアクリレート(CA)を用いた内視鏡的硬化療法が有効であった出血性十二指腸静脈瘤の2例を経験したので報告する.症例1:61歳の女性.肝硬変の診断で近医通院中に下血をきたしたが,出血源不明のため当院に転院.上部消化管内視鏡検査で十二指腸静脈瘤を認め,出血源と診断した.腹部血管造影を行なったが,静脈瘤の供血路は不明であったため,CAを用いた内視鏡的硬化療法(EIS)を施行した.その後1年の経過中,再出血は認めていない.症例2:67歳の男性.肝硬変,肝細胞癌の精査のため入院,肝細胞癌に対して加療.入院中下血を認め上部消化管内視鏡検査で十二指腸の静脈瘤と赤色栓を認めたため出血源と診断し,一時止血目的にEVLを施行.腹部血管造影を行なったが,IVR治療は困難でありCAを用いたEISを施行し,その後死亡までの6ヶ月間消化管出血はみられなかった.今回,出血性十二指腸静脈瘤に対して孤立性胃静脈瘤の治療に準じCAを用いたEISを行ない,止血および再出血の予防効果がみられた.本法は十二指腸静脈瘤破綻に対して有効な治療選択の一つであることが示唆された., Bleeding from duodenal varices is rare. However, it can be fatal for patients with liver cirrhosis. The treatment remains controversial, and there has been no consensus obtained. We herein report two cases of hemorrhagic duodenal varices successfully treated with endoscopic injection sclerotherapy (EIS) using cyanoacrylate (CA). Case 1 : A 61-year-old woman was referred to Dokkyo University Hospital for investigation of melena, during the follow up of B type liver cirrhosis. Esophago-gastro-duo-denoscopy (EGD) revealed varices at the second portion of the duodenum. Which was regarded as the bleeding point. Since abdominal angiography failed to demonstrate any supplying vessel into the duodenal varices, we treated the duodenal varices with EIS using CA successfully. No bleeding has been observed for a year after the treatment. Case 2 : A 67-year-old man was hospitalized for treatment of hepatocellular carcinoma and liver cirrhosis. During the hospitalization, he experienced melena. EGD revenled duodenal varices with red plug. Since IVR approach was technically impossible, we performed EIS with CA successfully. He did not suffer from gastrointestinal bleeding for the following 6 month until he died of liver failure. We conclude that EIS with CA is one of the therapeutic options for ruptured duodenal varices.

Background: The relationship between Helicobacter pylori infection and gastric cancer has been demonstrated, and the risk of gastric cancer occurrence is known to increase with the progression of atrophic changes associated with chronic gastritis. Endoscopic evaluation of the degree and extent of atrophy of the gastric mucosa is a simple and very important means of identifying a group at high risk for gastric cancer. This study aimed to clarify the carcinogenic risk in relation to the degree of atrophy. Methods: A total of 27,777 patients (272 with early gastric cancer and 135 with advanced gastric cancer) were included in this study. Endoscopically evaluated atrophy of the gastric mucosa was classified as C-0 to O-3 according to the Kimura and Takemoto classification system. Results: The cancer detection rate in relation to the degree of gastric mucosal atrophy was 0.04% (2/4,183 patients) for C-0, 0% (0/4,506) for C-1, 0.25% (9/3,660) for C-2, 0.71% (21/2,960) for C-3, 1.32% (75/5,684) for O-1, 3.70% (140/3,780) for O-2 and 5.33% (160/3,004) for O-3. As to the proportions of differentiated and undifferentiated cancers, the latter were relatively frequent in the C-0 to C-2 groups, but differentiated cancers became predominant as atrophy progressed. On the other hand, the number of both differentiated and undifferentiated cancers detected increased as gastric mucosal atrophy progressed. In addition, open-type atrophy was found in 29 (96.7%) of 30 patients with synchronous multiple gastric cancers and in all 20 patients with metachronous multiple gastric cancers. Conclusion: Endoscopic evaluation of gastric mucosal atrophy can provide a simple and reliable predictive index for both current and future carcinogenic risk.

Background Initial fluid resuscitation is an important hemodynamic therapy in patients with septic shock. The Surviving Sepsis Campaign Guidelines recommend fluid resuscitation with volume loading according to central venous pressure (CVP). However, patients with septic shock often develop a transient decrease in cardiac function; thus, it may be inappropriate to use CVP as a reliable marker for fluid management. Methods We evaluated 40 adult patients with septic shock secondary to intra-abdominal infection who received active treatment and were monitored using transthoracic echocardiography (TTE) and CVP for 2 days after admission to our intensive care unit (ICU). We measured left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), and the pressure gradient of tricuspid regurgitation (TR∆P). The shock status was treated with volume loading and inotrope/vasopressor administration according to the TTE findings. We assessed left ventricular fractional shortening (LVFS) as an index of left ventricular contractility and TR∆P as an index of right ventricular afterload and then examined the correlation between CVP and LVEDD/LAD/TR∆P. Results LVFS decreased to ≤30% in 42.5% and 27.5% of patients with septic shock, and severe left ventricular dysfunction with LVFS ≤20% developed in 12.5% and 15.0% of patients on the first and second ICU days, respectively, despite the use of inotropes/vasopressors. Mild pulmonary hypertension as indicated by TR∆P ≥30 mmHg was present in 27.5% and 30.0% of patients on their first and second ICU days, respectively. There was no significant correlation between CVP and LVEDD/LAD/TR∆P. The hospital mortality rate in this study was 10.0%, although the predicted mortality based on the Acute Physiology and Chronic Health Evaluation II score was 58.7%. Conclusions Our results suggest that CVP is not a reliable marker of left ventricular preload for fluid management during the initial phase of septic shock. Assessment of left ventricular preload, right ventricular overload, and left ventricular contractility using TTE seems to be more informative than the measurement of CVP for fluid resuscitation since some patients developed left ventricular dysfunction and/or right ventricular overload.

Background Gastric endoscopic submucosal dissection (ESD) has gradually come to be recommended as the optimal treatment for early gastric cancer; however, one of the primary issues is postoperative bleeding. Although second-look endoscopy is conventionally performed to reduce the risk of postoperative bleeding, its benefit has not yet been clearly elucidated. The objective of this study was to elucidate the benefit of second-look endoscopy. Methods A total of 459 lesions in patients were underwent gastric ESD from May 2004 to April 2013 at our hospital were included in the analysis. The patients were divided into those who had bleeding within 24 hours after ESD (immediate bleeding) and those in whom bleeding occurred 24 hours or more after the procedure (delayed bleeding); the underlying disease, age, lesion site, diameter of the resected specimen, and lesion diameter were analyzed to identify the risk factors for postoperative bleeding after ESD. Results Post-ESD immediate or delayed bleeding occurred in 23 of the 459 cases (5.0%). Second-look endoscopy was performed in 210 of 447 cases (47.0%) excluding 12 cases with immediate bleeding; in the remaining 237 of the 447 cases (53.0%), it was not performed. Post-ESD delayed bleeding occurred in 6 of the 210 cases (2.9%) and 5 of the 237 cases (2.1%), with no statistically significant difference between the two groups. Overall, the following factors were identified as the risk factors for postoperative bleeding: young age (P = 0.005), lesions in the L segment (P = 0.042), and large size of the resected specimen (P = 0.005). The risk factors identified in the immediate bleeding group were lesions in the L segment (P = 0.032), large size of the resected specimen (P

Background: Polaprezinc has been shown to exert an anti-oxidant property in a tube experiment, protect gastric mucosa from experimental ulcerations in vivo, and accelerate the healing of gastric ulcer in humans. Aim: To examine a possible protective effect of polaprezinc on oxidant-mediated injury in primary monolayer cultures of rat gastric fundic mucosa. Methods: Cytotoxicity was quantified by measuring 51Cr release. Whether or not polaprezinc exerts an antioxidant property was investigated by determining the effect of this agent on hydrogen peroxide (H2O2)-induced injury. The effects of polaprezinc on superoxide (O2–·) generation as well as on ethanol (EtOH)-induced injury were also examined. Generation of O2–· was assessed by the reduction in cytochrome c. Results: H2O2 caused a time- and dose-dependent increase in 51Cr release. The dose-response curve of 51Cr release by H2O2 shifted to the right in the presence of polaprezinc. Polaprezinc, at submillimolar concentrations, prevented H2O2-induced 51Cr release. EtOH also caused a dose-dependent increase in 51Cr release, which was prevented by the addition of polaprezinc. The incubation of cells with EtOH caused an increase in cytochrome c reduction, as the concentrations of EtOH increased. Polaprezinc inhibited EtOH-induced cytochrome c reduction. Protection by polaprezinc was microscopically associated with the prevention of monolayer disruption. Conclusions: Polaprezinc is antioxidative and directly protects gastric mucosal cells from noxious agents through its antioxidant properties in vitro. This finding may provide the theoretical basis for the usage of an antiulcer drug with antioxidant properties for the treatment of gastric inflammation, such as that induced by ethanol.

Lancet 1996;347:975. 10. Salmeron M, Desplaces N, Lavergne A, Houdart R. Campylobacter-like organisms and acute purulent gastritis. Lancet 1986;2:975-6. 11. Mitchell JD, Mitchell HM, Tobias V. Acute Helicobacter infection in an infant, associated with gastric ulceration and serological evidence of intra-familial transmission. Am J Gastroenterol 1992;87:382-6. 12. Frommer DJ, Carrick J, Lee A, Hazell S. Acute presentation of Campylobacter pylori gastritis. Am J Gastroenterol 1988; 83:1168-71. 13. Rocha GA, Queiroz DMM, Mendes EN, Barbosa AJA, Lima GF Jr, Oliveira CA. Helicobacter pylori acute gastritis: histological, endoscopical, clinical, and therapeutic features. Am J Gastroentrol 1991;86:1592-5. 14. Xiang Z, Censini S, Bayeli PF, Telford JL, Figura N, Rappuoli R, et al. Analysis of expression of CagA and VacA virulence factors in 43 strains of Helicobacter pylori reveals that clinical isolates can be divided into two major types and that CagA is not necessary for expression of the vacuolating cytotoxin. Infect Immun 1995;63:94-8. 15. Tummuru MKR, Cover TL, Blaser MJ. Cloning and expression of a high-molecular-mass major antigens of Helicobacter pylori: evidence of linkage to cytotoxin production. Infect Immun 1993;61:1799-809. 16. Fujimoto S, Marshall B, Blaser M. PCR-based restriction fragment length polymorphism typing of Helicobacter pylori. J Clin Microbiol 1994;32:331-4. 17. Katz D, Siegal HI. Erosive gastritis and acute gastrointestinal mucosal lesions. In: Glass GBJ, editor. Progress in gastroenterology. Vol 1. New York: Grune and Siralton; 1968. p. 67-96. 18. Laine L, Cominelli F, Sloane R, Casini-Raggi V, MarinSorensen M, Weinstein WM. Interaction of NSAIDs and Helicobacter pylori on gastrointestinal injury and prostaglandin production: a controlled double-blind trial. Aliment Pharmacol Ther 1995;9:127-35. 19. Graham DY, Alpert LC, Smith JL, Yoshimura HH. Iatrogenic Campylobacter pylori infection is a cause of epidemic achlorhydia. Am J Gastroenterol 1988;83:974-80. 20. Langenberg W, Rauws EAJ, Oudbier JH, Tytgat GNJ. Patient-to-patient transmission of Campylobacter pylori infection by fiberoptic gastroduodenoscopy and biopsy. J Infect Dis 1990;161:507-11. 21. Sugiyama T, Naka H, Yabana T, Awakawa T, Furuyama S, Kawauchi H, et al. Is Helicobacter pylori infection responsible for postendoscopic acute gastric mucosal lesions? Eur J Gastroenterol Hepatol 1992;4(Suppl 1):S93-6. 22. Miyaji H, Kohli Y, Azuma T, Ito S, Hirai M, Ito Y, et al. Endoscopic cross-infection with Helicobacter pylori [letter]. Lancet 1995;345:464. 23. Matysiak-Budnik T, Briet F, Heyman M, Megraud F. Laboratory-acquired Helicobacter pylori infection. Lancet 1995;346:1489-90. 24. Ghiara P, Marchetti M, Blaser MJ, Tummuru MKR, Cover TL, Segal ED, et al. Role of the Helicobacter pylori virulence factors vacuolating cytotoxin, CagA, and urease in a mouse model of disease. Infect Immun 1995;63:4154-60.

Preoperative forced expiratory volume in 1 second less than 1 l is a risk factor for anesthesia. We report perioperative management and prognosis of 7 patients with restricted lung function who underwent lung resection under general anesthesia. We assessed the patients preoperatively from the point of view of heart-lung functions such as predicted postoperative forced expiratory volume in 1 second greater than 0.8 l, an ability of walking on the level for more than 5 minutes at his own speed without a rest, presence of hypercapnia, and degree of pulmonary hypertension. One patient was extubated on the first postoperative day because of an asthmatic attack, whereas the remaining 6 patients were extubated in the operating room. Although 1 patient developed postoperative complications of lung air leakage and pneumonia, he recovered with conservative therapy. All patients were discharged without any sequela. We were able to manage high-risk patients with limited lung functions successfully during the perioperative period without serious complications.

We report a case of general anesthesia for the removal of pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy. A 65-year-old woman complained of fatigability with hypertension and diabetes mellitus. She was diagnosed as an extra-adrenal peri-aortic pheochromocytoma with severe hypertrophic obstructive cardiomyopathy. The left ventricular outflow gradient (LVOG) was 199 mmHg and the serum noradrenaline level was 13,567 pg x ml(-1) (100-450). As a preoperative management, atenolol, verapamil and disopyramide were given to decrease LVOG. Then doxazosin was given to control hypertension and to increase the circulating blood volume without deteriorating the outflow tract obstruction. LVOG decreased to 50 mmHg preoperatively. Anesthesia was given with propofol, fentanyl, remifentanil and isoflurane with a continuous infusion of diltiazem. The circulating blood volume was maintained with adequate volume loading assessed by the measurement of the left ventricular end-diastolic diameter and LVOG with transesophageal echocardiography. After the removal of the tumor, continuous infusion of noradrenaline was given to maintain the blood pressure. She was extubated in the ICU. LVOG decreased to 20 mmHg with stable hemodynamics on the second postoperative day. She was discharged from the ICU without any adverse cardiac events during the perioperative period.

Anesthesia for the tracheobronchial stent placement involves the risk of airway narrowing and obstruction. Controlled ventilation with relatively high airway pressure is usually used to maintain oxygenation and ventilation during anesthesia. However, controlled ventilation does not always provide tidal volume and oxygenation due to gas leakage from tracheobronchial fistula. We report 2 cases of general anesthesia under spontaneous respiration for the airway stent placement to treat tracheal and bronchial fistula. Case 1; A 55-year-old man with tracheoesophageal fistula due to the esophageal cancer was scheduled for the stent placement. Anesthesia was given with dexmedetomidine and sevoflurane preserving spontaneous respiration. The surgery was performed without complications of hypoventilation and hypoxemia throughout the procedure. Case 2; A 71-year-old woman developed empyema with large bronchopleural fistula as the result of the complication of radiation for the breast cancer. The stent placement was scheduled for closure of the fistula. Anesthesia was induced with remifentanil and sevoflurane with spontaneous respiration. When inserting the rigid bronchoscope, cough reflex occurred and propofol was added to deepen the anesthesia. The stent placement was performed with general anesthesia under spontaneous respiration without any complications.

A 49-year-old man was admitted to our hospital because of recurrent gastrointestinal bleeding of unknown origin, after repeated negative endoscopic and radiographic evaluation, including colonoscopy, esophago-gastro-duodenoscopy, CT and angiography. His condition had not been diagnosed for the past 18 years. ¹⁸F-fluorodeoxyglucose (FDG) on positron emission tomography (PET/CT) showed mild FDG uptake by a tumor of the small bowel (SUVmax 2.83), and capsule endoscopy (CE) and double balloon endoscopy (DBE) revealed a well-defined smooth submucosal tumor in the jejunum. The patient underwent a laparotomy and small bowel resection. The pathologic diagnosis was a small intestinal leiomyoma. Our report suggests the significance of combination of CE, DBE and PET/CT in the diagnosis of small bowel leiomyoma.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for treatment of orthopedic diseases, inflammatory diseases, etc., and low-dose aspirin is a common antiplatelet therapy given mainly for secondary prevention of atherothrombosis (e.g., myocardial infarction and cerebral infarction). As to the history of NSAID-induced gastric mucosal injury in Japan, the first case of an aspirin-induced gastric ulcer was reported as early as 1934. Based on a meta-analysis of risk factors for peptic ulcers, Helicobacter pylori infection and NSAIDs are the main etiologies of peptic ulcers. NSAIDs alone increase the odds ratio for ulcer development to 19.4 and that for ulcer bleeding to 4.85. In fact, the Japan Rheumatism Foundation reported in 1991 that active gastric ulcers and active duodenal ulcers were detected in 15.5 and 1.9 % of 1008 patients, respectively, taking oral NSAIDs for 3 months or longer. In Japan, which is becoming an increasingly aged society, the numbers of patients taking NSAIDs and low-dose aspirin are expected to increase dramatically in the future. It is hoped that accumulation of evidence on gastrointestinal risk will allow many patients to rationally avoid gastrointestinal complications while receiving the benefits of NSAIDs and low-dose aspirin.

Low dose aspirin, as an anti-platelet medication, has been increasingly prescribed to elderly patients for primary and secondary prevention of cardio- and cerebro-vascular events. Nonetheless, aspirin's effectiveness in such disease prevention is limited by the risk of upper and lower gastrointestinal (GI) complications such as ulceration, hemorrhage and perforation. Aspirin administration is associated with 2-fold increase in the GI risk in middle-aged users without prior history of peptic ulcer and without concomitant medications. However, such GI risk increases dramatically in patients with a prior history of peptic ulcer disease, advanced age, and concomitant use of NSAIDs, corticosteroids, clopidogrel, or anticoagulants. Mechanisms of aspirin-induced GI injury are believed to be through local effects within the GI mucosa that cause topical injury and through systemic inhibition of cyclo-oxygenase (COX) resulting in depletion of mucosal protective prostaglandins. Herein, we focus on the strategy to manage aspirin-induced peptic ulcerations and their complications, based on the scientific evidence.