Detailed features of palisade vessels as a marker of the esophageal mucosa revealed by magnifying endoscopy with narrow band imaging.

The palisade vessels present at the distal end of the esophagus are considered to be a landmark of the esophagogastric junction and indispensable for diagnosis of columnar-lined esophagus on the basis of the Japanese criteria. Here we clarified the features of normal palisade vessels at the esophagogastric junction using magnifying endoscopy. We prospectively studied palisade vessels in 15 patients undergoing upper gastrointestinal endoscopy using a GIF-H260Z instrument (Olympus Medical Systems Co., Tokyo, Japan). All views of the palisade vessels were obtained at the maximum magnification power in the narrow band imaging mode. We divided the area in which palisade vessels were present into three sections: the area from the squamocolumnar junction (SCJ) to about 1 cm orad within the esophagus (Section 1); the area between sections 1 and 3 (Section 2); and the area from the upper limit of the palisade vessels to about 1 cm distal within the esophagus (Section 3). In each section, we analyzed the vessel density, caliber of the palisade vessels, and their branching pattern. The vessel density in Sections 1, 2, and 3 was 9.1 ± 2.1, 8.0 ± 2.6, and 3.3 ± 1.3 per high-power field (mean ± standard deviation [SD]), respectively, and the differences were significant between Sections 1 and 2 (P= 0.0086) and between Sections 2 and 3 (P < 0.0001). The palisade vessel caliber in Sections 1, 2, and 3 was 127.6 ± 52.4 µm, 149.6 ± 58.6 µm, and 199.5 ± 75.1 µm (mean ± SD), respectively, and the differences between Sections 1 and 2, and between Sections 2 and 3, were significant (P < 0.0001). With regard to branching form, the frequency of branching was highest in Section 1, and the 'normal Y' shape was observed more frequently than in Sections 2 and 3. Toward the oral side, the frequency of branching diminished, and the frequency of the 'upside down Y' shape increased. The differences in branching form were significant among the three sections (P < 0.0001). These results indicate that the density of palisade vessels is highest near the SCJ, and that towards their upper limit they gradually become more confluent and show an increase of thickness. Within a limited area near the SCJ, observations of branching form suggest that palisade vessels merge abruptly on the distal side. We have demonstrated that palisade vessels are a useful marker for endoscopic recognition of the lower esophagus.

Unsedated transnasal ultrathin esophagogastroduodenoscopy may provide better diagnostic performance in gastroesophageal reflux disease.

Transnasal ultrathin esophagogastroduodenoscopy (N-EGD) with less gagging reflexes under non-sedation is likely suitable for the diagnosis of gastroesophageal reflux disease (GERD), however, N-EGD might have drawbacks, including its low image resolution. Limited information is available regarding the diagnosability of N-EGD for GERD. We compared the utility and gagging reflexes of three different endoscopies, including N-EGD, ultrathin transoral EGD (UTO-EGD) and conventional oral EGD (CO-EGD), in the diagnosis of GERD. We performed screening endoscopy in 1580 patients (N-EGD n=727, UTO-EGD n=599, CO-EGD n=254) and compared the frequency distributions of the severity of reflux esophagitis, hiatus hernia, and Barrett's epithelium to estimate the diagnostic performance of each endoscopy. We also analyzed patients' tolerability of endoscopy by the subjective evaluation of gagging reflexes. In the diagnosis of reflux esophagitis and Barrett's epithelium, there was no significant difference in the frequency distributions of the severity of the diseases among three EGDs. However, the incidence of Barrett's epithelium was higher than that in the previous nationwide survey of GERD in Japan. The evaluated size of hiatus hernia was smaller in N-EGD than in two other peroral endoscopies. The size of hiatus hernia correlated significantly with severity of gagging reflexes that was also lowest when diagnosed with N-EGD. N-EGD had an equivalent performance in the diagnosis of reflux esophagitis and Barrett's epithelium compared with CO-EGD. Enlargement of hiatus hernia induced by gagging reflexes was minimal in N-EGD, resulting in its better performance in the diagnosis of Barrett's epithelium.

Peptic ulcer recurrence during maintenance therapy with H2-receptor antagonist following first-line therapy with proton pump inhibitor.

We investigated the peptic ulcer recurrence rates during maintenance therapy with H2-receptor antagonists (H2RAs) following first-line therapy with a proton pump inhibitor (PPI). Patients with gastric ulcer (GU) or duodenal ulcer (DU) were enrolled in this study; 583 eligible patients (GU, 325; DU, 258) were administered lansoprazole (30 mg/day for 8 weeks for GU, and the same dosage for 6 weeks for DU) as first-line therapy, and a half dose of H2RA as maintenance therapy for 12 months. Endoscopic photographs were taken before administration and after 8 (GU) and 6 (DU) weeks of lansoprazole administration. Ulcer stage was evaluated using the classification of Sakita and Miwa. Endoscopic examinations were performed 6 months or 12 months after the start of maintenance therapy or when a recurrence was suspected because of the appearance of subjective symptoms. The healing rates for GU and DU patients after completion of lansoprazole therapy were 79% in both groups, while the S2-stage healing rates were 18% and 31%, respectively. At 1 year after the start of maintenance therapy, the recurrence rates were 25% for GU and 39% for DU patients. In DU patients, the recurrence rates from S1-stage and S2-stage were 49% and 20%, respectively (P = 0.004), but no significant difference was found between these rates in GU patients. The recurrence rates in H. pylori-positive patients before lansoprazole administration were 27% for GU and 43% for DU patients. We concluded that the maintenance therapy with a half-dose of H2RA following PPI therapy was insufficient to prevent recurrences of GU and DU.

[Endoscopic classification of reflux esophagitis].

A new endoscopic classification of reflux esophagitis was proposed in Los Angeles in 1994(LA classification). A mucosal break was defined as 'an area of slough or an area of erythema with a discrete lined demarcation from the adjacent or normal looking mucosa'. Reflux esophagitis is divided into four grades according to the severity of its mucosal break. We can find a minimal change during endoscopy which is not a mucosal break but is histologically or chromographically reflux esophagitis. I think Los Angeles classification must include the minimal change and I propose a modification of LA classification which includes the minimal change as grade M and the esophagus without any minimal change and mucosal break as grade N.

Duodenal somatostatinoma: a case report and review of 31 cases with special reference to the relationship between tumor size and metastasis.

Somatostatinomas are rare functioning neoplasms usually arising in the pancreas and duodenum. We report a case of somatostatinoma in a 42-year-old male with neither neurofibromatosis nor somatostatinoma syndrome. A large tumor in the descending duodenum had given rise to multiple lymph node metastases. An additional 31 duodenal somatostatinoma cases were also reviewed. Most originated in the descending part of the duodenum, with the ampulla and peri-ampullary area as the most common sites (60%). Frequent manifestations were abdominal pain (25%), jaundice (25%), or cholelithiasis (19%), the latter two reflecting obstruction of the bile duct by tumors. Only two cases showed a possible somatostatinoma syndrome (6%). The tumors with metastases, lymph nodes (10) and liver (2), were significantly larger than average than those without (2.91 +/- 1.49 cm vs 1.36 +/- 0.71 cm, P < 0.05). With a cut-off point of 2.0 cm, diagnostic accuracy for metastasis was 77.78% with 87.50% specificity and 63.64% sensitivity. The smallest tumor with metastases was 0.8 cm and the largest without metastases was 3.0 cm. These results indicate that duodenal somatostatinomas are malignant by nature and the risk of metastasis significantly increases with tumors larger than 2.0 cm.

Significance of anaerobic preincubation of Helicobacter pylori for measuring metronidazole susceptibility by the Etest.

The Etest is widely used for measuring the susceptibility of Helicobacter pylori to metronidazole. By using 55 H. pylori isolates from 55 patients and a standard H. pylori strain, NCTC11637, we compared metronidazole susceptibility results obtained from the Etest with or without anaerobic preincubation to those obtained from the agar dilution method. Mueller Hinton agar plates supplemented with 5% horse blood were used for both methods. For the Etest, plates were incubated for 72 hr at 35 C under microaerophilic conditions after 0-, 4- or 24-hr periods of anaerobic preincubation. For the agar dilution method, the plates were incubated at the same microaerophilic conditions as those for the Etest. Without anaerobic preincubation for the Etest, 39 of the 56 (70%) H. pylori isolates were categorized as resistant to metronidazole (minimal inhibitory concentration>8 mg/liter), whereas only one of the 56 (1.8%) isolates was resistant according to the agar dilution method. The resistant and susceptible agreement rate was 32%. Four-hour anaerobic preincubation did not alter the readings of the Etest significantly. However, when the Etest was performed with 24-hr anaerobic preincubation, the number of isolates categorized as resistant was reduced to six (11%), improving the agreement rate to 91%. For measuring the metronidazole susceptibility of H. pylori by the Etest, 24-hr anaerobic preincubation is necessary to agree with the results obtained by the agar dilution test.

[A gastrointestinal radiographic study of 18 patients with esophageal adenocarcinoma arising from Barrett's epithelium].

Gastrointestinal radiographs were reviewed with pathological correlation in 18 patients with histologically proven esophageal adenocarcinoma arising from Barrett's epithelium. Comparison was also made with postoperative radiographs of resected esophageal specimens from 3 of the patients. Esophageal carcinoma could be observed in the gastrointestinal radiographs in 17 of the 18 patients. In 14 of the 17, the classification based on the gastrointestinal radiographs was consistent with the gross classification. In 10 of the 18 patients, rough mucosa was seen on gastrointestinal radiographs in the same area in which Barrett's epithelium was observed in the histopathological specimens. Sliding esophageal hiatus hernia was present in 12 of the 18 patients, a relatively high incidence. Regular granular or reticular shadows were observed on the mucosal surface of the esophagus on the postoperative radiographs of 3 patients. It is believed that a diagnosis of Barrett's epithelium can be made from gastrointestinal radiographs if these mucosal patterns are present. Although a definitive diagnosis of Barrett's epithelium based on upper gastrointestinal radiographs is considered difficult, the presence of rough mucosa in the esophagus around the carcinoma in combination with esophageal hiatus hernia are suggestive of esophageal adenocarcinoma arising from Barrett's epithelium.

Distribution of inflammation and atrophy in the stomach of Helicobacter pylori-positive and -negative patients with chronic gastritis.

OBJECTIVES: To investigate the extent of inflammation and atrophy in the stomach of Helicobacter pylori-positive and -negative patients with chronic gastritis. METHODS: Endoscopy with biopsies from the lesser curvatures of the antrum, angulus, middle body, and the greater curvature of the middle body of the stomach was performed in 59 patients with histologically confirmed chronic gastritis. The extent of atrophic gastritis was assessed endoscopically as well histologically. H. pylori status was assessed by histology as well as enzyme-linked immunosorbent assay. The histological severity of chronic and acute inflammation, glandular atrophy, and intestinal metaplasia was assessed according to the Sydney system. RESULTS: In H. pylori-positive patients, H. pylori was evenly distributed throughout the stomach when the extent of atrophic gastritis was limited to the antrum and the lesser curvature of the body, but disappeared from the antrum of patients with more extensive atrophic gastritis. The severity of acute and chronic inflammation at the greater curvature of the body increased with the extension of atrophic gastritis. In H. pylori-negative patients, the severity of chronic inflammation at the greater curvature of the body was significantly higher in patients with extensive atrophic gastritis than in those with a lesser extent of atrophic gastritis. CONCLUSION: At the greater curvature of the body, the development of atrophy is closely associated with the increase in the severity of inflammation, which is more marked in H. pylori-positive patients.

Effects of lansoprazole on mucosal regeneration in patients with gastric ulcers: evaluation using an electronic endoscope with a magnifying function.

When healing of gastric ulcers is observed using an electronic endoscope with a magnifying function, five types of regenerated mucosa can be distinguished. The membranous type appears first at the ulcer margin and is followed by the spindle-shaped and palisade-shaped regenerated mucosae that plays an important role in ulcer healing. These two types change into the cobblestone-shaped and the basically normal structure, which have an important relation to the maturity of ulcer healing. In observation of gastric ulcer healing in 10 patients who received lansoprazole 30 mg (L group) or in 12 patients who received famotidine 20 mg b.i.d. (F group), the spindle- and palisade-shaped mucosae were significantly more developed in the L group than in the F group after 4 weeks (p < 0.05). On the other hand, after 8 weeks, the development of these two types of mucosa was less extensive in the L group than in the F group, because these two types had changed into cobblestone-shaped and basically normal structure in the L group. In conclusion, treatment with lansoprazole resulted in more rapid ulcer healing and maturation of regenerated mucosa than did treatment with famotidine in this study.

Mucosal regeneration of gastric ulcer confirmed by electronic endoscopy.

We studied the detailed surface structure and changes in the regenerated mucosa during the course of healing of recurrent gastric ulcers treated with lansoprazole or famotidine, using a magnifying electronic endoscope (videoendoscope) and a dye contrast method. The detailed patterns of regenerated mucosa were classified into five types: membranous, spindle-shaped, palisade-shaped, cobblestone-shaped, and almost normal structure. Initially, the membranous regenerated mucosa appears at the ulcer margin and grows into the spindle- and palisade-shaped regenerated mucosa. These latter types of mucosa change gradually into the cobblestone-shaped type, which finally develops into an almost normal structure. Lansoprazole appeared to bring about more rapid growth and changes of the regenerated mucosa than famotidine, although the difference was not statistically significant. We suggest that it is useful, in the assessment of gastric ulcer therapy, to observe the detailed patterns of the regenerated mucosa during the healing process using a magnifying electronic endoscope.

The effect of CV-3988 and CV-6209 on the acute gastric erosions of rats due to water-immersion and restraint stress.

CV-3988 and CV-6209 inhibited gastric erosions in rats due to water-immersion and restraint stress in a dose-dependent manner. The above inhibitory effects of CV-3988 were observed in the presence of indomethacin, which may indicate that the inhibition is not prostaglandin dependent. The studies indicate that platelet-activating factor may be involved in the formation of erosions in rats under water-immersion and restraint stress.

Remarkable regression of malignant paraganglioma in the retroperitoneum and neck after chemotherapy: report of a case and a review of the literature.

The present communication describes a patient with paraganglioma found in the retroperitoneum and neck. She was treated with the combination chemotherapy employing cyclophosphamide, doxorubicin, and cisplatin (CAP therapy), and resulted in remarkable regression of the tumor in size. We reviewed the literature about the therapy of paraganglioma and the nature of retroperitoneal paraganglioma in relation with this case.