Gallstone-containing duodenal duplication communicating with the pancreatic duct.

A 10-year-old female patient with duodenal duplication containing gallstones and communicating with the pancreatic and bile ducts is described. Although endoscopic retrograde cholangiopancreatography and computed tomography following intravenous cholangiography showed a periampullary cystic lesion, the precise relationship between the lesion and the pancreaticobiliary ductal system was not clear. After removal of the gallstones by opening the cystic lesion, a pinhole opening noticed inside was cannulated and contrast injected, demonstrating a connection between the cystic lesion and the pancreatic and bile ducts. Both the outside and inside of the lesion were lined by duodenal mucosa. Partial excision and cystoduodenostomy were performed. The imaging techniques described herein are useful for establishing the correct diagnosis and planning a surgical approach for this condition.

Mucin-producing tumor of the pancreas--intraluminal ultrasonography.

BACKGROUND/AIMS: Many patients with mucin-producing pancreatic tumor, characterized by dilatation of the pancreatic duct, are diagnosed by conventional ultrasonography in a mass ultrasonographic survey in Japan. It is a necessary and reliable method for making a precise diagnosis and for deciding on the treatment approach. Endoscopic ultrasonography (EUS) is appreciated as a useful method for precise diagnosis of pancreatic tumors. Intraductal ultrasonography (IDUS) is expected to be a new modality for the more detailed diagnosis of pancreatic tumors. METHODOLOGY: Endoscopic ultrasonography and intraductal ultrasonography were performed in 23 patients with mucin-producing pancreatic tumor. The differences in ultrasonographic findings between benign and malignant tumors were studied. RESULTS: Ultrasonographic findings of mucin-producing pancreatic tumor revealed by EUS and IDUS were: cystic lesion, mural nodule in the cystic lesion, wall thickness of the cyst, mucus echoes, and solid tumor with a mixed echo pattern. Seven out of 11 patients with mural nodule were diagnosed as carcinomas and another 4 patients had adenoma. Seven of 8 patients with mucus echoes were diagnosed as carcinoma. Three of 4 patients with solid tumor were diagnosed as invasive carcinoma. The ultrasonographic findings suggesting malignancy were: mural nodule, irregular wall thickness, mucus echoes, and solid tumor with a mixed pattern. Solid tumor indicated invasive carcinoma exclusively. CONCLUSIONS: Intraluminal ultrasonography, EUS and IDUS are very useful in making a differential diagnosis between benign and malignant tumors in mucin-producing pancreatic tumors.

Ras gene point mutations in gallbladder lesions associated with anomalous connection of pancreatobiliary ducts.

BACKGROUND/AIMS: The present study was undertaken to investigate possible changes in the K-ras oncogene in patients with gallbladder lesions (carcinoma, adenoma or hyperplasia) in relation to the presence or absence of an anomalous connection of pancreatobiliary ducts (ACPBD). METHODOLOGY: Gallbladder specimens were obtained from 44 patients with lesions that were either with or without ACPBD, and DNA samples were analyzed using PCR-SSCP. Point mutations in codons 12, 13 and 61 were analyzed by direct sequencing methods with oligonucleotide primers. RESULTS: The K-ras codon 12 was detected in 83.3% (5/6) of carcinomas the one adenoma tested and in 35.7% (5/14) of hyperplastic lesions with ACPBD, as opposed to only 36.4% (4/11) of carcinomas without ACPBD. The one case of gallbladder adenoma and 11 cases of normal gallbladder without ACPBD studied demonstrated no point mutations in the K-ras oncogene. CONCLUSIONS: Alteration of the K-ras oncogene appears to be involved in the early stages of gallbladder carcinogenesis when in association with ACPBD. The results further suggest that hyperplasia in cases with ACPBD may be a significant pre-cancerous lesion.

[Intermittent intra-arterial infusion chemotherapy using implantable reservoir for the treatment of hepatic metastasis].

Intermittent intra-arterial infusion chemotherapy using implantable reservoir was performed for hepatic metastases and the therapeutic effects were evaluated. We treated 21 patients with hepatic metastases of gastric cancer in 8 cases, rectal cancer in 6 cases, colon cancer in 5 cases and breast cancer in 2 cases. The reduction rate of the tumor diameter as seen by CT scan was used as a criteria for antitumor effectiveness. Only 1 case was PR, for an efficacy rate of 5%. Changes in serum CEA level were related to antitumor effectiveness.

[Extracorporeal shock wave lithotripsy (ESWL) for common bile duct stones].

We treated twenty-three patients with common bile duct stones (12 female, 11 male, mean age: 67.1 years) by Extracorporeal Shock Wave Lithotripsy (ESWL). The stones were focused by ultrasonic or choledochographic localization. The twenty-three patients received 53 ESWL treatments consisting of mean 2357 shocks per treatment at mean 18 kV. We performed ESWL in five cases with endoscopically unextractable common bile duct stones after endoscopic sphincterotomy (EST). In these cases, ESWL permitted stone disintegration and successful endoscopic extraction of the fragments. We performed ESWL in eighteen cases with common bile duct stones without EST. In fifteen of the eighteen cases (83%), fragmentation was achieved. The stone fragments were spontaneously discharged in ten cases (56%) after a median of 4 days following ESWL. In five cases, adjutant endoscopic procedures were performed. The complete fragmentation and the clearance rate for stones of diameter of less than 10 mm were higher than that for stones of diameter of more than 11 mm. In the cases with the stones of diameter of more than 10 mm, there is a very strong possibility that complete clearance is achieved by ESWL alone. No correlation was obtained for the effective results according to pretreatment number of stones. In eight of thirteen cases (62%) with gall bladder stones, complete clearance was achieved without EST. ESWL without EST can be thought as a rational treatment for preserving the function of papilla of Vater in the case of cholecysto-choledocholithiasis.

[The effects of synthetic protease inhibitor on motility of the human duodenal papilla].

We studied the effects of synthetic protease inhibitors on the motility of the human duodenal papilla. Before and after the intravenous administration of gabexate mesilate (GM) or nafamostat mesilate (NM), the duodenal papillary pressure was measured with a catheter tip pressure transducer under duodenoscopy. GM was administered to fourteen subjects at 1 and 3 mg/kg/h. The peak pressure and the basal pressure were dose-dependently reduced by GM, but the frequency did not change. The blood CCK concentration was not changed after GM administration. NM was administered to twelve subjects at 0.3 mg/kg/h. Both the papillary pressure and the frequency were not changed by NM. GM inhibited the papillary motility, but NM had no consistent effect on the papillary motility.

[Evaluation of chemotherapy for gastric cancer by endoscopic ultrasonography].

We judged the efficacy of chemotherapy using endoscopic ultrasonography (EUS) in 26 cases of gastric cancer. Treatment efficacy was evaluated according to the General Rules for the Gastric Cancer Study, based on the reduction of the largest cross-sectional area of the tumor. A reduction of over 50% was rated as U-PR and a reduction of -25-50% was rated as U-NC. Our findings showed U-PR in 11 cases and U-NC in 15 cases. Three cases initially considered to be NC according to the rules were judged to be U-PR based on EUS findings. Marked therapeutic efficacy in these 3 cases was demonstrated clinically and this was confirmed by EUS findings. Generalized Wilcoxon test showed a significant difference in the cumulative survival rate between U-PR and U-NC cases (p < 0.05). EUS provides an objective means of evaluating the efficacy of chemotherapy in gastric cancer patients, including those with lesions that cannot be evaluated by the General Rules for the Gastric Cancer Study.

[A study of the influence of gastric acid on the extension of regenerative epithelium of gastric ulcer].

To study the influence of gastric acid on the extension of the regenerative epithelium, 26 patients (28 ulcers) of gastric ulcer were examined by the stereo video-endoscope being able to measure the length and 24-hours intragastric pH monitoring. Extending speeds of the regenerative epithelium were measured from the time the regenerative epithelium of the ulcer was observed till the last examination, but which was limited 8 weeks after the first observation of the regenerative epithelium. The relationship was not observed between the extending speeds and the stages (A2-H1, H1-H2, H2-S1) of the ulcer. For 21 ulcers followed up by the stereo video-endoscope from active stage, the extending speed of the regenerative epithelium and the pH 3 holding time in a day were significantly correlated (r = 0.51, p = 0.014), and the same relationship (r = 0.56, p = 0.008) were observed in the nighttime. It was confirmed that the gastric acid regulated strongly the extending speed of regenerative epithelium of gastric ulcer. The intragastric circumstance of the low acid secretion induced by the antacid-drugs was considered to accelerate the extension of regenerative gastric epithelium.

[Comparative study of extracorporeal shock wave lithotripsy (ESWL) between spark gap system and piezoelectric system].

We have analyzed the results of the treatment given on 170 cases of cholecystolithiasis, using two different systems of ESWL: Spark Gap System (hereinafter SGS) and Piezoelectric System (hereinafter PES). 1) In the total cases, there were no significant differences in the fragmentation rate between the two systems. PES was, however, superior to SGS in terms of the complete stone free rate. On the other hand, SGS was superior to PES in terms of the average fragmentation rate. 2) We have classified cholecystolithiasis into 4 groups, combining CT and US. PES showed superiority in the ESWL Group 1 (seeming Pure Cholesterol Stone) and Group 2 (seemingly Mixed Stone) in terms of stone free rate. SGS showed superiority in ESWL Group 3 (seemingly Combination Stone) and Group 4 (seemingly Pigment Stone) in terms of fragmentation effect. 3) We have gained good results from both of the system according to Munich Criteria Modified. 4) Concerning the failures of fragmentation and insufficient stone free, further study shall be required to determine whether fragmentation should be repeated, the case should be handled as "beyond adaptability", or the two-system-combined therapy should be applied.

[Diagnosis of the wall-thickened lesions of the gallbladder with dynamic MRI].

We studied 32 patients with the thickened lesions of the wall of the gallbladder by using dynamic MRI. We tried the differential diagnosis of gallbladder lesions according to the time intensity curve (TIC) and enhanced pattern. TIC of carcinoma was elevated more seeply from plain to arterial phase than the inflammatory diseases. The Inflammatory diseases were keeping three-layer structures of the wall of the gallbladder, but gallbladder carcinoma destroys the wall-structure. We could diagnose as direct liver invasion of the carcinoma clearly. We could exactly diagnose adenomyomatosis in dynamic MRI by small low intensity spots within the wall of the gallbladder. In the patients with gall stones, the wall of the gallbladder were more clearly observed in dynamic MRI compared with US and EUS.

[Studies of gastric acid secretion and gastric mucosal change after Helicobacter pylori eradication--the short and long-term observation].

We studied the gastric acid secretion and the histological findings of gastric mucosa in 48 patients with peptic ulcer before and after successful Helicobacter pylori (H. pylori) eradication. The pH of fasting gastric juice significantly decreased from 2.46 to 1.65 four weeks after eradication (p < 0.001). The factors such as disease, atrophic border, inflammatory cell involvement and histological atrophy were analyzed by logistic regression. Only the atrophic border was a significant and independent factor to convert the acidity after eradication, and the pH of gastric juice prominently decreased in the patients with widespread atrophic mucosal area. In the 24-hour intragastric pH monitoring, the pH3 holding time overnight remarkably decreased from 54.1% to 22.3% after eradication (p < 0.005). In the long follow-up of 17 patients (the mean follow-up period was 15.2 months), the pH of gastric juice kept a lower titer of 1.66. The mean atrophic scores in the upper body reduced from 1.5 to 0.9 (p < 0.05). In addition to the functional recovery of parietal cells after eradication, it was considered that the histological improvement of atrophy in oxyntic mucosa was associated with the recovery of pH.

[The studies of extracorporeal shock wave lithotripsy (ESWL) for pancreatic ductal stones].

30 patients with main pancreatic duct stones were treated by ESWL. In 18 of 22 patients who had not previously undergone endoscopic pancreatic sphincterotomy (EPST) or endoscopic sphincterotomy (EST), the stone fragments disappeared after ESWL. The fragments were removed endoscopically in the remaining 4 cases. Complete clearance was achieved in 8 cases with endoscopically unextractable stones by ESWL. After the ESWL procedure, absolute relief from pain was reported by in 19 of 22 patients with abdominal complaints. Serum amylase levels decreased significantly, and dilatation of the main pancreatic duct (MPD) was reduced. In the medium-term follow-up period, pancreatic exocrine function and endocrine function had a possibility to be preserved. One case of pancreatic cancer and one case of an intraductal papillary tumor of the pancreas were found, indicating that careful observation is necessary even after complete removal of pancreatic stones. In cases of Santorini duct dominant, multiple stones, or stricture of the MPD, ESWL should be combined with EPST and endoscopic stenting for preventing recurrence of acute pancreatitis and pancreatic stones. In conclusion, ESWL is the first choice of treatment for pancreatolithiasis and useful procedure and the limited complications.

[Application of ultrasound method for hemorrhagic digestive disease].

Ultrasonography for the digestive diseases are consisted of abdominal ultrasonography (US), endoscopic ultrasonography (EUS) and color Doppler endoscopic ultrasonography (CDEUS). These play a supplementary role in comparison with the roentgenography and endoscopy. The information of the ultrasonography is different from these examinations. By US the collateral shunts of esophago-gastric varices are observed. EUS is useful for diagnosis of the properties of esophago-gastric varices and judgement of effects of treatment for these varices, gastric ulcer and vessels in ulcer base and hemorrhagic bowel diseases. CDEUS can show blood streams of esophago-gastric varices and hemorrhagic ulcer.

[A case of extramedullary hematopoiesis (EH) in thalassemia].

A 37-year-old woman with diagnosis of thalassemia intermedia was admitted because of mild dyspnea and edema of her lower extremities. CT scan revealed solid soft tissue masses with a well-defined anterior border, located at the costovertebral angles bilaterally. EH was diagnosed without further investigation and a biopsy was avoided.

Three-dimensional intraductal ultrasonography: preliminary results of a new technique for the diagnosis of diseases of the pancreatobiliary system.

BACKGROUND AND STUDY AIMS: Intraductal ultrasonography (IDUS) is a useful method for the diagnosis of pancreatobiliary diseases, but the images obtained using the presently available ultrasonic probes are limited by their two-dimensional nature and are sometimes difficult to interpret. The possible application of three-dimensional intraductal ultrasonography (3 D-IDUS) to facilitate the diagnosis of pancreatobiliary disease was therefore studied using a newly developed system. PATIENTS AND METHODS: 3 D-IDUS of the biliary system was performed on 26 patients with benign (n = 100) or malignant pancreatobiliary diseases (n = 16), via percutaneous transhepatic or peroral approaches. Three-dimensional diagnoses were made using both radial and linear images generated on the monitor of this system along with a comparison with conventional IDUS (2 D-IDUS) findings. RESULTS: The courses of vessels surrounding the bile duct could be easily imaged in all cases, and accurate assessment of tumor extension and the relationship with surrounding organs could be achieved for all the malignancies. In four of six cases of bile duct cancers the whole outline of the tumor could be visualized so that the tumor volumes could be measured. CONCLUSIONS: These preliminary results of 3 D-IDUS in the pancreatobiliary system, the first to be reported in the English literature, indicate that this new system has clear advantages over the 2 D-IDUS approach for diagnostic purposes. Further technical improvements can be expected which will ensure a clinical role for 3 D-IDUS.