[An autopsy case of ulcerative colitis with disseminated aspergillosis, complicated by brain hemorrhage].

An 80-year-old Japanese woman suffered multiple brain infarctions of unknown etiology during maintenance therapy of prednisolone and azathioprine for ulcerative colitis. Although a small cavity in the left lung spontaneously regressed, the patient suddenly died of massive brain hemorrhage due to disseminated aspergillosis, which was not identified until autopsy.

Endoscopic findings under narrow band imaging colonoscopy in ulcerative colitis.

Narrow band imaging (NBI) depicts distinct intramucosal vascular network and pit pattern without any use of dye technique. It is thus suggested that NBI can be used for the assessment of severity in inflammatory bowel diseases, especially in ulcerative colitis (UC). In the active UC, NBI colonoscopy depicts friability as a black area. In the inflamed granular mucosa, crypt openings and villous structure become evident through the procedure. In the inactive UC, there are two types of mucosal vascular pattern; one being composed of deep, green vessels and superficial, black vessels, and the other lacking in superficial vessels. With used of a magnifying instrument, the mildly active mucosa can be classified into the mucosa with obvious crypt openings and that with villous structure. Mucosal vascular pattern in the inactive mucosa is shown as a honeycomb-like structure or irregular, tortuous structure under magnifying NBI observation. Furthermore, such NBI findings show close correlations with histologic findings including crypt distortion, goblet cell depletion and basal plasmacytosis. Therefore, NBI colonoscopy might be of value for the precise assessment of histologic severity in mildly active and inactive UC.

Factors associated with the clinical impact of capsule endoscopy in patients with overt obscure gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: Capsule endoscopy (CE) does not necessarily identify positive findings in patients with overt obscure gastrointestinal bleeding (OGIB). We aimed to identify factors predictive of positive CE findings and those of re-bleeding after negative CE in overt OGIB. PATIENTS AND METHODS: We retrospectively analyzed 68 patients who underwent CE for overt OGIB. CE findings, therapeutic interventions, and clinical course after CE were reviewed. Clinical variables associated with positive CE findings and those associated with re-bleeding after negative CE findings were investigated. RESULTS: Positive CE finding was found in 36 (53%) patients. Marked decrease in hemoglobin value [OR; 18.8, 95% CI; 3.4-152.0] and earlier CE examination within a week after the last episode of bleeding [OR; 8.0, 95% CI; 2.2-35.9] were factors associated with positive CE findings. Nine (28%) of 32 patients with negative CE findings re-bled. Marked decrease in hemoglobin value was more frequent in patients with re-bleeding than those without (P = 0.07). CONCLUSION: Patients with massive and overt OGIB are the best candidates for CE. Earlier CE, virtually within a week, contributes to the better diagnostic yield of the procedure. Careful follow-up seems necessary for patients with massive bleeding even in cases of negative CE findings.

[A case of steroid-dependent ulcerative colitis complicated by skin infection of Mycobacterium szulgai].

We describe a case of a 47-year old Japanese man with steroid-dependent, refractory ulcerative colitis complicated by non-tuberculous mycobacterial skin infection. The patient remained in remission by combination therapy of 100mg azathioprine and 27.5mg prednisolone (total dose over 25g for three years), but developed a deep genital ulcer. Mycobacterium szulgai was confirmed by skin culture, and the ulcer became turned into a scar after oral administration of isoniazid, rifampicin, and ethanbutol.

Mucosal vascular pattern in ulcerative colitis: observations using narrow band imaging colonoscopy with special reference to histologic inflammation.

BACKGROUND AND AIM: Narrow band imaging (NBI) is a novel endoscopy system, which enables a clear visualization of the mucosal vasculature of the gastrointestinal tract. The aim of this study is to determine whether this system may be of value for assessing the disease severity in ulcerative colitis (UC). MATERIALS AND METHODS: We observed the mucosal vascular pattern (MVP) in 157 colorectal segments of 30 patients with UC using both conventional and NBI colonoscopy. The MVP was determined to be normal or distorted under conventional colonoscopy and, subsequently, to be clear or obscure under NBI colonoscopy. The histologic variables in each segment were assessed in biopsy specimen. The possible correlation between MVP and the histologic grade of inflammation was evaluated. RESULTS: The MVP under conventional colonoscopy was normal in 60 segments while it was distorted in 97 segments. In all of the former 60 segments, their MVP was clear under NBI colonoscopy. The MVP in the latter 97 segments were determined to be clear (n = 44) or obscure (n = 53) under NBI colonoscopy. Acute inflammatory cell infiltrates (26% vs. 0%, p = 0.0001), goblet cell depletion (32% vs. 5%, p = 0.0006), and basal plasmacytosis (2% vs. 21%, p = 0.006) were more frequently observed in segments with an obscure MVP than in those with a clear MVP. CONCLUSION: NBI colonoscopy may be of value for determining the grade of inflammation in patients with quiescent UC.

Bowel preparations for capsule endoscopy: a comparison between simethicone and magnesium citrate.

BACKGROUND: Bowel preparation for capsule endoscopy (CE) has not been standardized. OBJECTIVE: This study aimed to compare CE images between patients prepared by simethicone and those prepared by magnesium citrate. DESIGN: Retrospective analysis of case series of our hospital from 2004 to 2007. SETTING: Single center. PATIENTS AND INTERVENTIONS: CE images of 75 patients receiving bowel preparation either by 200 mg of simethicone (n=39) or by 34 g of magnesium citrate (n=36) were retrospectively investigated. Grades of fluid transparency and mucosal invisibility by air bubbles and food residue were compared between the 2 preparations. Capsule transit time, frequency of positive findings, and interobserver variations between 2 observers were also investigated. MAIN OUTCOME MEASUREMENTS: Image quality and diagnostic yield of CE. RESULTS: Fluid transparency in the first and the third time segments of the small intestine was better in patients prepared by magnesium citrate than in those prepared by simethicone (P= .001 and P= .03, respectively). On the other hand, mucosal invisibility was not different in any part of the small intestine between the 2 groups. Neither gastric transit time nor small-bowel transit time was different between the 2 groups. The diagnostic yield of CE correlated significantly with fluid transparency (P= .04), but it did not correlate with mucosal invisibility. LIMITATIONS: Single-center retrospective study. CONCLUSION: Magnesium citrate seems to be a recommended preparation for CE compared with simethicone. The fluid transparency, rather than the mucosal invisibility, may be a factor associated with the diagnostic yield of CE.

Recombinant human granulocyte colony-stimulating factor reduces colonic epithelial cell apoptosis and ameliorates murine dextran sulfate sodium-induced colitis.

OBJECTIVE: Recombinant human granulocyte colony-stimulating factor (rhG-CSF) is a potentially effective therapy for Crohn's disease. The purpose of this study was to test the rhG-CSF in murine dextran sulfate sodium-induced colitis (DSS colitis). MATERIAL AND METHODS: Murine colitis was induced by feeding with water containing 3% DSS for 9 days. Six to 7-week-old female BALB/c mice were given rhG-CSF (100 microg/kg) or phosphate-buffered saline (PBS) subcutaneously once a day from day 0 to day 8, and the mice were sacrificed at days 3, 5, 7 and 9. Tissue specimens from the transverse colon, descending colon and rectum were obtained and stained with hematoxylin and eosin. Inflammation was scored for severity, extent, epithelial damage and crypt loss. TUNEL staining was performed to assess epithelial cell apoptosis. RESULTS: Treatment with rhG-CSF significantly attenuated body-weight loss, stool score and shortening of the colon length in comparison with treatment with PBS (p<0.01,<0.05,<0.01, respectively). Histological scores for inflammation, epithelial cell damage and crypt loss of the rectum were less severe at day 9 in the rhG-CSF group than in the PBS group (p<0.01, 0.05, 0.01, respectively). The number of TUNEL-positive cells in the rectum was smaller in the rhG-CSF group than in the PBS group (p<0.001). CONCLUSIONS: Treatment with rhG-CSF ameliorates murine DSS colitis by suppressing mucosal inflammation and epithelial damage in the rectum. The prevention of epithelial cell apoptosis seems to precede the anti-inflammatory action of rhG-CSF.

Linear mucosal defect may be characteristic of lansoprazole-associated collagenous colitis.

BACKGROUND: Although some cases of collagenous colitis have been induced by lansoprazole (LPZ), the clinicopathologic features of LPZ-associated collagenous colitis have not been elucidated. OBJECTIVE: To elucidate the clinical, endoscopic, and histopathologic features of LPZ-associated collagenous colitis. DESIGN: Retrospective case study. PATIENTS: The subjects were 13 patients with collagenous colitis diagnosed during a period from 2002 to 2007. MAIN OUTCOME MEASUREMENTS: The colonoscopic and histopathologic findings were compared retrospectively between 9 cases of LPZ use (LPZ group) and 4 cases without the use of LPZ (non-LPZ group). RESULTS: A colonoscopy revealed a linear mucosal defect more frequently in the LPZ group (7 of 9 cases [78%]) than in the non-LPZ group (0 of 4 cases [0%], P = .02). Friable mucosa was also noted in 4 patients (44%) in the LPZ group but none in the non-LPZ group. The colonoscopic finding in the non-LPZ group was either normal mucosa or nonspecific minimal abnormalities, whereas patients in the LPZ group had either a linear mucosal defect, mucosal bleeding, or both (P = .001). On histologic examination, the subepithelial collagen band was thicker in patients in the LPZ group than in those in the non-LPZ group (median 45 vs 26.3 mum). All patients in the LPZ group recovered from diarrhea after discontinuance of LPZ. LIMITATION: A small number of patients. CONCLUSIONS: Linear mucosal defects and friable mucosa may be characteristic colonoscopic findings in cases of LPZ-associated collagenous colitis.

Prevalence of non-steroidal anti-inflammatory drug-induced enteropathy determined by double-balloon endoscopy: a Japanese multicenter study.

OBJECTIVE: Capsule endoscopy has shown that non-steroidal anti-inflammatory drugs (NSAIDs) can damage the small intestine. The aim of this study was to determine the prevalence of NSAIDs enteropathy in subjects indicated for double-balloon endoscopy (DBE). MATERIAL AND METHODS: The Japanese Study Group for Double-Balloon Endoscopy (JSG-DBE) established a database for the practical use of DBE in the Japanese population during a 2-year period from 2004 to 2005. Using this database, we identified subjects who had been taking NSAIDs within a month prior to DBE (NSAIDs group) and those free from NSAIDs use (control group). The clinical background and DBE findings were compared between the two groups. RESULTS: Among 1035 patients registered in the JSG-DBE database, 61 subjects were classified as the NSAIDs group and 600 served as the control group. Patients in the NSAIDs group were older (62+/-18 versus 51+/-19 years, p<0.0001) and gastrointestinal bleeding was a more frequent indication for DBE (79% versus 44%, p<0.001) compared with in the control group. Non-specific mucosal breaks were detected by DBE in 31 patients in the NSAIDs group (51%) and 29 patients in the control group (5%, p <0.0001). Aspirin was less frequently prescribed and cardiovascular disease was a less frequent indication for NSAIDs use in patients with mucosal breaks than in those without breaks. CONCLUSIONS: In the cases indicated for enteroscopy, NSAIDs enteropathy occurred in half of the patients taking NSAIDs. Aspirin seems to be less harmful to the small intestine than other NSAIDs.

Magnifying colonoscopy with narrow band imaging system for the diagnosis of dysplasia in ulcerative colitis: a pilot study.

BACKGROUND: Narrow-band imaging (NBI) is a novel illumination technology for endoscopy that enhances vasculature of the GI tract. OBJECTIVE: The aim was to elucidate whether NBI colonoscopy can identify dysplasia in patients with ulcerative colitis (UC). DESIGN: Cross-sectional study of eligible patients. SETTING: Single center. PATIENTS: 46 patients with UC. INTERVENTIONS: Apparently flat mucosa at each segment and visible protruding lesions were observed by magnifying NBI colonoscopy. The surface structure was classified into honeycomb-like, villous, or tortuous pattern. The grade of dysplasia was determined in the specimens obtained from protrusions and from flat mucosa. MAIN OUTCOME MEASUREMENTS: The positive predictive value of conventional and NBI colonoscopy for the diagnosis of dysplasia. RESULTS: A total of 296 sites (20 protruding lesions and 276 flat areas) were examined by NBI colonoscopy. The surface pattern was determined to be honeycomb like in 161 sites, villous in 85 sites, and tortuous in 50 sites. Five dysplastic lesions were detected in 3 patients. A patient had 3 dysplastic lesions and the other 2 had a dysplastic lesion each. The positive rate of dysplasia was higher in protrusions (2/20 sites, 10%) than in flat mucosa (3/276 sites, 1.1%, P = .038; however, correction for the multiple testing of data removes this significance). When the surface pattern was taken into account, the rate of positive dysplasia was higher in the tortuous pattern (4/50 sites, 8%) than in the honeycomb-like or villous patterns (1/246 sites, 0.4%, P = .003). LIMITATIONS: Uncontrolled study. CONCLUSIONS: The tortuous pattern determined by NBI colonoscopy may be a clue for the identification of dysplasia during surveillance for UC.

Colonic obstruction due to giant inflammatory polyposis in a patient with ulcerative colitis.

A 32-year-old Japanese woman with a 14-month history of ulcerative colitis (UC), pancolitis type, was referred to our institution, because of abdominal distention. Plain abdominal X-ray and computed tomography (CT) showed marked dilatation of the right side of the colon. The patient was treated by immediate total colectomy, with the diagnosis of toxic megacolon. Macroscopically, there was a constricting lesion with giant polyposis in the middle part of the transverse colon. Histologically, there was transmural inflammation with a thickened proper muscular layer overlaid by inflammatory polyposis. This case suggests that giant polyposis in UC patients may result in severe stenosis and that such a condition should not be misinterpreted as toxic megacolon or as colitic cancer.

Analysis of mucosal regeneration and the expression profile of heat shock protein 70 in the isolated small bowel segment.

To investigate the mechanisms underlying the regeneration of the denervated small bowel segment from ischemic injury, we examined the heat shock protein 70 (HSP70) expression profile and compared it to the histopathological and proliferative changes seen in an isolated bowel segment using a rabbit model. Two weeks following the small bowel segment transplantation to the subcutaneous space, the vascular pedicle was sectioned. Next, the rabbits were divided into three groups based on the collection time of the isolated bowel segment (3, 7, and 14 days for Groups A, B, and C, respectively). The unsectioned small bowel segment was utilized as a control for each group. Histological studies showed that no experimental group recovered from mucosal injury. The bromodeoxyuridine labeling index showed that the more severe mucosal injury group had the highest bromodeoxyuridine incorporation. In the experimental groups, HSP70 immunoreactivity was intensely seen in the regenerating epithelial cells and inflammatory cells. In the control mucosa, HSP70 immunoreactivity was weakly seen in the subepithelial stromal tissue, crypt cells and not in epithelial cells. The present study shows that the isolated bowel segment requires longer periods for regeneration from ischemic injury and HSP70 may play an important role during the regeneration process.