Histological characteristics of gastric mucosa prior to Helicobacter pylori eradication may predict gastric cancer.

OBJECTIVE: Although Helicobacter pylori (H. pylori) eradication has been shown to inhibit gastric cancer, it does not completely suppress it. Therefore, risk factors of gastric cancer development following H. pylori eradication were examined. MATERIAL AND METHODS: A total of 2355 patients (1501 males and 824 females) underwent successful eradication of H. pylori. Endoscopic atrophy, histological gastritis, atrophy, intestinal metaplasia (IM), and operative link for gastritis assessment (OLGA) staging were subsequently evaluated. RESULTS: Following eradication, 33/2355 patients (25 males and 8 females) developed gastric cancer. Compared to a nongastric cancer group that was matched according to gender and age, the incidence of endoscopic atrophy (3.52 ± 1.45 vs. 4.85 ± 1.18, p < 0.001), histological atrophy at the greater curvature of the antrum (1.42 ± 0.80 vs. 1.95 ± 0.86, p = 0.0059), inflammation (2.05 ± 0.59 vs. 2.33 ± 0.66, p = 0.031), IM at the greater curvature of the corpus (0.06 ± 0.30 vs. 0.24 ± 0.54, p = 0.029), the ratio of OLGA-stage 0-II/III, IV (13/8 vs. 55/11, p = 0.038) were significantly higher for the gastric cancer group. Multivariate analysis also showed the highest odds ratio (6.26, 95% confidence interval or CI, 1.28-30.60, p = 0.023) for IM at the greater curvature of the corpus. CONCLUSIONS: Severe endoscopical atrophy, OLGA staging, histological atrophy at the antrum, inflammation, and particularly IM at the corpus, were identified as risk factors for gastric cancer development following H. pylori eradication. Therefore, eradication should be performed before these predictors develop.

Evaluation of selective cyclooxygenase-2 inhibitor-induced small bowel injury: randomized cross-over study compared with loxoprofen in healthy subjects.

AIM: Non-steroidal anti-inflammatory drugs have the potential to injure the mucosa of the upper digestive tract and small bowel, whereas celecoxib (a selective cyclooxygenase-2 inhibitor) has less influence on the entire digestive tract mucosa. The present study was conducted to compare the extents of small bowel mucosal injury induced by celecoxib and loxoprofen (the most frequently used non-steroidal anti-inflammatory drugs in Japan). METHODS: Ten healthy adult males were given celecoxib (200 mg/day, Group C) and loxoprofen (180 mg/day, Group L) in a cross-over design for 14 days, and the influence of each drug on small bowel mucosa was evaluated by comparing pre- and post-treatment capsule endoscopy findings. We measured the percentage of patients with small bowel mucosal injury following administration of these drugs as primary endpoint. Additionally, mean number of small bowel mucosal injuries per subject was analyzed as secondary endpoint. RESULTS: The percentage of subjects experiencing small bowel mucosal injury as primary endpoint was 10% in Group C and 70% in Group L after treatment. This magnitude of the difference of between Group C and Group L was statistically significant (P = 0.031). The number of small bowel mucosal injuries as secondary endpoint differed significantly between the two groups, and the influence of celecoxib on small bowel injury was less than that of loxoprofen. CONCLUSION: These results indicate that celecoxib has less influence on small bowel mucosa than loxoprofen and can be used safely.

Helicobacter pylori eradication improves gastric atrophy and intestinal metaplasia in long-term observation.

BACKGROUND AND AIM: Helicobacter pylori has been shown to cause atrophic gastritis and intestinal metaplasia (IM), both of which are precancerous lesions. To clarify the mechanism by which H. pylori eradication prevents gastric cancer, we monitored atrophy and IM improvement in gastric mucosa over a long period after H. pylori eradication. METHODS: We monitored 118 patients (72 males, 46 females; mean age 61.3 ± 5.1 years) for a mean of 8.6 years (range 5-13) after successful H. pylori eradication. Biopsy specimens were taken from the greater curvatures of the antrum (A2) and the corpus (B2). RESULTS: Atrophy was significantly decreased in patients with successful H. pylori eradication, both at A2 (from 1.60 ± 0.09 to 1.02 ± 0.08; p < 0.001) and B2 (from 0.71 ± 0.10 to 0.02 ± 0.02; p < 0.001), and IM score was significantly decreased at B2 (from 0.17 ± 0.12 to 0.00 ± 0.00; p < 0.05), but not at A2 (from 0.60 ± 0.11 to 0.43 ± 0.09; p = NS). In patients without successful eradication, however, there were no differences in scores over time. Before eradication, IM score was significantly higher in males than in females, both at A2 (0.81 ± 0.12 vs. 0.25 ± 0.10; p < 0.05) and B2 (0.32 ± 0.08 vs. 0.07 ± 0.04; p < 0.05). CONCLUSION: We were able to monitor the gastric mucosa for a mean of 8.6 years after H. pylori eradication, the longest period reported to date. Significant improvements in gastric atrophy and IM after H. pylori eradication may decrease the risk of gastric cancer.

An outbreak of Paragonimus westermani infection among Cambodian technical intern trainees in Japan, exhibiting various extrapulmonary lesions.

We encountered an outbreak of paragonimiasis among Cambodian technical intern trainees (TITs) at a food-processing factory in Fukuoka, Japan. The patients were 20-28 years old, seven females and two males, who had been in Japan for one to four years. All of them had consumed raw or undercooked Japanese mitten crab they purchased at a local grocery store near their training place. CT images showed multiple lesions not only in the lungs but in the extrapulmonary organs as well, such as subcutaneous tissues, abdominal muscles, and mesentery, in most of the patients. Their medical records indicated that all of them acquired infection in Japan, not in Cambodia. Diagnosis was made serologically and the patients were treated with praziquantel successfully. Foreign workers and TITs are increasing in Japan so rapidly, that food borne-infections, including paragonimiasis, should be considered in people from developing countries who have exotic dietary habits.

The efficacy of diffusion-weighted imaging for the detection and evaluation of acute pancreatitis.

BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) is a new magnetic resonance imaging (MRI) technique that evaluates the random motion of water molecules in biological tissues. The clinical utility of DWI has been established for acute stroke and brain tumors. Recent technical advancements in MRI have enabled DWI for the body and several studies have revealed the efficacy of DWI for detecting various diseases. This study documents the efficacy of DWI for the evaluation of acute pancreatitis. METHODOLOGY: MRI was performed with sequences including T1-weighted, T2-weighted, diffusion-weighted imaging, MR cholangiopancreatography (MRCP) and computed tomography (CT) examinations on 11 patients with mild acute pancreatitis. MRI examinations were performed using 1.5-T imager (Toshiba, Otawara, Japan). Two experienced radiologists evaluated the presence or absence of acute pancreatitis, complications and the cause of acute pancreatitis on the MRI and CT images. RESULTS: There were no differences between the DWI and the CT images regarding their abilities to detect acute pancreatitis. However, DWI could detect acute pancreatitis more clearly than CT without enhancing material. The DWI findings were consistent with the clinical findings, the results of chemical analyses and the CT findings. Furthermore, DWI could detect pancreatic cancer causing acute pancreatitis and MR cholangiopancreatography (MRCP) could detect choledocholithiasis and pancreas divisum causing acute pancreatitis. CONCLUSIONS: DWI can be a powerful tool for the evaluation and follow-up of acute pancreatitis.

The efficacy of diffusion-weighted imaging for the detection of colorectal cancer.

BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) is a new magnetic resonance (MR) imaging technique that evaluates the diffusion of water molecules. Its clinical usefulness in the acute stage of cerebral infraction has been established. Recent technical developments have enabled DWI for human body and the usefulness of DWI for detecting malignant tumors such as liver, kidney, ovary, and breast tumors has been reported. This study documents cases of colorectal cancer detected by DWI and discusses the efficacy of DWI for the evaluation of colorectal cancer. METHODOLOGY: DWI, computed tomography (CT) and colonoscopy examinations were performed on 18 patients with colorectal cancer. MRI examinations were performed using a 1.5-T imager (Toshiba, Otawara, Japan). The signal intensity was measured in a series of DWI and the apparent diffusion coefficient (ADC) values were calculated in order to differentiate the cancers from normal tissues. Two experienced radiologists evaluated the depth of tumor invasion into the colorectal wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on DWI and CT images according to the TNM classification system. TNM staging of each tumor was compared with the pathologic and surgical findings. RESULTS: There were no differences between the DWI and the CT images regarding their abilities to detect early colorectal cancer. However, DWI could detect advanced colorectal cancer and liver metastasis more sensitivity, or accurately than CT with no enhancing material. In one patient who did not undergo a surgical resection, a follow up DWI showed peritoneal seeding and bone metastasis. CONCLUSION: Although DWI has a difficulty to detect early colorectal cancer, DWI has the potential to be clinically effective for the evaluation of preoperative TNM staging and the postoperative follow-up of colorectal cancer.

Usefulness of diffusion-weighted imaging (DWI) for the detection of pancreatic cancer: 4 case reports.

The clinical utility of diffusion-weighted magnetic resonance imaging (DWI) was originally established for acute stroke; however, recent studies suggest that DWI may be more sensitive and specific for the detection and staging of malignant tumors than either computed tomography (CT) or ultrasonography (US). We herein present 4 cases of pancreatic cancer that were detected by DWI and subsequently discuss the efficacy of DWI for the diagnosis pancreatic cancer. We performed both DWI and dynamic CT examinations on 4 patients with pancreatic cancer. MR examinations were performed with a 1.5-T imager (Toshiba). We measured the signal intensity in a series of DWI images and calculated the apparent diffusion coefficient (ADC) values to differentiate the tumors from normal tissue, inflammation, or another lesion. Two radiologists analyzed the DWI and CT images, and the evaluation of the primary tumor (T), regional lymph nodes (N), and distant metastatic disease (M) was conducted according to the TMN classification system. There were no differences between the DWI and the CT images regarding their abilities to detect advanced pancreatic cancer. However, DWI displayed superior ability in detecting early stage tumors and evaluating the degree of tumor invasion. DWI has the potential to be clinically effective in the detection of early pancreatic cancer, and DWI can be a powerful tool for the evaluation of pancreatic cancer.

The usefulness of diffusion-weighted imaging (DWI) for the detection of gastric cancer.

BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) is already utilized in the important clinical diagnosis of brain ischemia and also for differentiating brain abscesses from metastatic brain tumors. Recent technical developments make DWI of the body feasible. Several studies have revealed the usefulness of DWI for the diagnosis of liver, ovary, parotid gland, kidney, and breast tumors. We herein present cases of gastric cancer detected by DWI and discuss the efficacy of DWI for the diagnosis of gastric cancer. METHODOLOGY: We performed DWI, enhanced computed tomography (CT) and endoscopic examinations on 15 patients with gastric cancer. MR examinations were performed using the 1.5-T imager (Toshiba). We measured the signal intensity in a series of DWI images and calculated the apparent diffusion coefficient (ADC) values in order to differentiate the tumors from normal tissues and inflammations. Two experienced radiologists evaluated the depth of tumor invasion into the gastric wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on DWI and CT images according to the TMN classification system. TMN staging of each tumor was compared with the pathologic and surgical findings. RESULTS: There were no differences between the DWI and the CT images regarding their abilities to detect advanced gastric cancer. However, DWI could detect peritoneal dissemination, liver metastasis, lymph nodes metastasis without any enhancement material more clearly than CT. CONCLUSIONS: DWI is therefore considered to have the potential to be clinically effective for the evaluation of preoperative TMN staging of gastric cancer.

Diffusion-weighted imaging is a feasible method for screening colorectal cancer: report of a case.

The liver is one of the most common sites for metastatic disease. It is sometimes difficult to detect the primary site. We describe herein the feasibility of diffusion-weighted imaging (DWI) for searching primary site of liver metastases. A 93-year-old male patient presented to us with the chief complaints of hematochezia. Ultrasonography (US) and computed tomography (CT) showed multiple masses in the liver. However, these examinations revealed no primary tumor. DWI showed bright signal mass in the rectum. Furthermore, the apparent diffusion coefficient (ADC) map in that area was depicted as a low ADC value. A histopathological analysis demonstrated the tumor to be moderately differentiated adenocarcinoma. We consider that DWI is a feasible method for screening colorectal cancer, especially for unknown primary site cancers.

Chronic myelogenous leukemia that occurred two years after the diagnosis of adult Still's disease.

A 25-year-old Japanese man was diagnosed with steroid-resistant Adult Still's Disease (ASD) in August 2000. No evidence of chronic myelogenous leukemia (CML) had been found during admissions in 2000 and 2001. In August 2002, he was diagnosed with CML with a peripheral white blood count of 69,940/microl and positivity for Philadelphia chromosome and BCR/ABL fusion gene on bone marrow aspiration. No case of CML was reported to develop from ASD. Because a diagnosis of ASD is based on the exclusion of other diseases, we must be cognizant of the possibility of the development of concurrent diseases.

Efficacy of rebamipide for low-dose aspirin-related gastrointestinal symptoms.

Gastrointestinal symptoms are a problematic issue for patients who take low-dose aspirin for long time. We conducted a pilot study to investigate the efficacy of combination therapy with proton pump inhibitor and rebamipide. This was a prospective, randomized, double-blind, placebo-controlled cross-over study. All the subjects received aspirin 100 mg and omeprazole 20 mg. The subjects were divided into two groups and received either rebamipide 300 mg or placebo, which was prescribed for 4 weeks. The subjects were instructed to record their gastrointestinal symptom rating scale before the study and 1 and 4 weeks after beginning the protocol. These scores of the groups were compared before and after the treatment to evaluate the severity of their symptoms and the number of symptom items present in each group. For the subjects receiving rebamipide, the total prevalence of lower gastrointestinal symptoms was significantly different from the placebo group (p=0.0093) at week 4. No troublesome symptoms were observed in the rebamipide group. Inconclusion, the administration of rebamipide prevented the occurrence of troublesome symptoms, especially lower gastrointestinal symptoms, in patients taking aspirin and omeprazole. Rebamipide is a candidate drug for combination therapy with proton pump inhibitors to prevent low-dose aspirin-induced gastrointestinal symptoms.

Ten-year prospective follow-up of histological changes at five points on the gastric mucosa as recommended by the updated Sydney system after Helicobacter pylori eradication.

BACKGROUND: Atrophic gastritis and intestinal metaplasia (IM) are well known as precancerous lesions of gastric cancer. The present study evaluated the gastric mucosa for 10 years after H. pylori eradication at five points of the stomach as recommended by the updated Sydney system to clarify the relationship between H. pylori eradication and gastric cancer prevention. METHODS: Among the comprised 373 patients, 323 were H. pylori-positive while 50 patients were H. pylori-negative. Patients with successful eradication underwent follow-up endoscopic examination every year. Biopsy specimens were taken from five points of the stomach, as recommended by the updated Sydney system, and were evaluated for the degree of gastritis prospectively. RESULTS: Two hundred ninety-four out of the 323 H. pylori-positive patients successfully achieved eradication. Of the 197 patients on whom five-point biopsy was performed, the courses of 30 patients were able to be observed every year for 10 years after successful eradication. Inflammation, activity, and atrophy score at all five points were significantly reduced half a year to 6 years after eradication. IM scores fluctuated intensely up and down during all observation periods; however, IM score of the lesser curvature of the corpus continued decreasing gradually and showed a significant decrease 6 years after (0.97 ± 0.09 to 0.42 ± 0.17, P < 0.05). CONCLUSION: In 10 years after H. pylori eradication, atrophy at all sites and IM in the lesser curvature of the corpus gradually and significantly decreased. These results suggest that the improvement of gastric atrophy and IM might have association with the reduction of gastric cancer occurrence.

Gastritis associated with Epstein-Barr virus infection.

Infectious mononucleosis is a self-limiting clinical syndrome caused by primary Epstein-Barr virus (EBV) infection. EBV-associated gastritis, however, has rarely been documented. We report a case of a 17-year-old woman who presented with fever, sore throat, and epigastric pain. Upper endoscopy revealed diffuse granular mucosae and elevated lesions in the stomach. Histologically, the biopsied mucosa was infiltrated by numerous atypical lymphocytes. From clinical, histopathologic, immunohistochemical, and in situ hybridization analyses, we diagnosed EBV-associated gastritis. Her symptoms spontaneously resolved, and follow-up endoscopy revealed improvement and no atypical lymphocytes. To prevent misdiagnosis and unnecessary treatment, the possibility of EBV-associated gastritis should be considered.

Cap polyposis (CP) which relapsed after remission by avoiding straining at defecation, and was cured by Helicobacter pylori eradication therapy.

A 52-year-old woman was diagnosed with cap polyposis (CP) with characteristic clinical, endoscopic, and histological features. By avoiding straining at defecation, her symptoms improved temporarily, however recrudesced. She was diagnosed with Helicobacter pylori (H. pylori) infection, and received eradication therapy successfully. After this eradication therapy, her symptoms and colonoscopic findings recovered completely. Only two reports in the English language literature have discussed the relationship between CP and eradication therapy for H. pylori, all patients achieved complete recovery. We recommend H. pylori testing for all cases of CP and H. pylori eradication therapy if necessary.

Acute pancreatitis successfully diagnosed by diffusion-weighted imaging: a case report.

Diffusion-weighted imaging (DWI) is an established diagnostic method of acute stroke. The latest advances in magnetic resonance imaging (MRI) technology have greatly expanded the utility of DWI in the examination of various organs. Recent studies have revealed the usefulness of DWI for imaging of the liver, kidney, ovary, and breast. We report a patient with acute pancreatitis detected by DWI and discussed the efficacy of DWI in diagnosing acute pancreatitis. A 50-year old man presented with a primary complaint of abdominal pain. We performed both DWI and computed tomography (CT) for this patient. The signal intensity in a series of DWI was measured and the apparent diffusion coefficient (ADC) values were calculated to differentiate inflammation from normal tissue. Two experienced radiologists evaluated the grade of acute pancreatitis by comparing the CT findings. Initially, the pancreas and multiple ascites around the pancreas produced a bright signal and ADC values were reduced on DWI. As the inflammation decreased, the bright signal faded to an iso-signal and the ADC values returned to their normal level. There was no difference in the abilities of DWI and CT images to detect acute pancreatitis. However, our case indicates that DWI can evaluate the manifestations of acute pancreatitis using no enhancement material and has the potential to replace CT as a primary diagnostic strategy for acute pancreatitis.

[A case of amyopathic dermatomyositis with systemic sclerosis sine scleroderma presenting abnormal vermiculation].

A 24-year-old Japanese woman was admitted to our hospital in January 2000 with daily diarrhea, abdominal distention, and abdominal pain. Raynaud's phenomenon with erythroderma desquamativum eruptions had been found in 1992. In 1999, small intestinal transillumination showed dilation of the second and third portion of the duodenum. She was diagnosed as amyopathic dermatomyositis because of Gottron's sign despite not having symptoms of myositis, normal serum CPK levels and no histological abnormality by muscle biopsy. In addition, the patient was diagnosed as systemic sclerosis sine scleroderma because Raynaud's phenomenon, leukoma and gastrointestinal dilation were present. Also, antinuclear antibody and anti centromere antibody were positive and anti Scl-70 antibody was dull-positive, despite the absence of scleroderma, extreme edema, and bone resorption. Careful, long term observation will be required because of the splanchnopathy in youth and the complications of systemic sclerosis.