New endoscopic classification of cascade stomach, a risk factor for reflux esophagitis.

BACKGROUND: We recently demonstrated that cascade stomach detected by barium studies was correlated with upper gastrointestinal symptoms. We developed a new endoscopic classification of cascade stomach and examined its relationship with reflux esophagitis. METHODS: Study 1: the classification (grades 0-3) was based on detecting a ridge that runs from the cardia toward the anterior wall crossing the greater curvature. Inter-observer variation was evaluated by kappa statistics when ten experienced endoscopists used this classification three times each. Study 2: in 710 consecutive subjects (500 men and 210 women) undergoing endoscopic screening, the grade of cascade stomach and incidence of reflux esophagitis were compared. RESULTS: In study 1, the kappa values at the third assessment were 0.85, 0.58, 0.50, and 0.78 for each grade, respectively, while overall agreement was 0.68. In study 2, the incidence of reflux esophagitis in men was 20 % in grade 0, 17 % in grade 1, 25 % in grade 2, and 30 % in grade 3, showing significant differences. Among women, the incidence of reflux esophagitis in each grade was 9, 3, 6, and 35 %, respectively, also showing significant differences. Multivariate analysis showed that independent risk factors for reflux esophagitis were cascade stomach (odds ratio = 2.20), body mass index, and hiatus hernia in men, as well as cascade stomach (odds ratio = 9.01) and smoking tobacco in women. CONCLUSIONS: This endoscopic classification of cascade stomach showed acceptable inter-observer variation. Cascade stomach is a risk factor for reflux esophagitis.

A prospective randomized controlled trial of AJG522 versus standard PEG+E as bowel preparation for colonoscopy.

Polyethylene glycol- (PEG-) based bowel preparations for colonoscopies are often poorly tolerated due to the large volumes of fluid intake required. We compared low-volume "modified" PEG + ascorbic acid (AJG522) with standard PEG with electrolytes (PEG+E) in addition to a stimulant laxative and an agent to improve bowel function for the bowel cleansing before colonoscopy to evaluate its efficacy, safety, and acceptability. Outpatients scheduled to undergo colonoscopy were randomized to receive either AJG522 or PEG+E. Bowel cleansing conditions were assessed via macroscopic fecal findings by blinded and independent investigators. A survey of the patients' feedback regarding the preparation was conducted by questionnaire. Successful cleansing was achieved in all cases, except for 4 cases in the PEG+E group, at 3 hours after taking the preparation. The fecal properties were significantly clearer in the AJG522 group than in the PEG+E group at 2 hours after taking each preparation (P=0.013). Although the total liquid volume of the bowel preparation was not reduced, the AJG522 preparation could significantly reduce the required volume of the preparation (P<0.0001). Moreover, the patients in the AJG522 group had better acceptability (P=0.010). There were no significant differences in the safety profiles between groups (UMIN000013892).

More severe upper gastrointestinal symptoms associated with non-erosive reflux disease than with erosive gastroesophageal reflux disease during maintenance proton pump inhibitor therapy.

BACKGROUND: During maintenance proton pump inhibitor (PPI) therapy, patients with gastroesophageal reflux disease (GERD) sometimes complain of upper gastrointestinal symptoms. AIM: To evaluate upper gastrointestinal symptoms in patients on maintenance PPI therapy for erosive GERD or non-erosive reflux disease (NERD) without endoscopic mucosal breaks by using a new questionnaire. METHODS: At Gunma University Hospital over a 12-month period during 2011-2012, we enrolled 30 consecutive patients with erosive GERD and 46 patients with NERD. All patients had been on maintenance PPI therapy for more than 1 year. We used the modified frequency scale for the symptoms of GERD (mFSSG) questionnaire to assess upper gastrointestinal symptoms. We also asked patients about their satisfaction with maintenance therapy and whether they wished to change their current PPI. RESULTS: The NERD patients had significantly higher symptom scores than the erosive GERD patients. There was no difference in the treatment satisfaction rate between patients with erosive GERD and NERD, but more patients with NERD wanted to change their PPI therapy. There was no difference in the mFSSG score between NERD patients who wished to change their current PPI therapy and those who were satisfied with it. CONCLUSIONS: During maintenance PPI therapy, upper gastrointestinal symptoms were more severe in NERD patients than in patients with erosive GERD. NERD patients often wished to change their PPI therapy, but this was not dependent on the severity of their upper GI symptoms.

Carbon dioxide insufflation reduces the discomfort due to colonoscopy as objectively analyzed by salivary stress markers.

BACKGROUND: Carbon dioxide (CO2) insufflation has been shown to reduce the procedure-related pain and discomfort during colonoscopy. However, the effects of CO2 insufflation on the improvement of participant's stress had not been objectively analyzed. METHODS: Using a randomized, double-blinded design, 100 consecutive patients undergoing colonoscopy were assigned to have their examination performed with either CO2 or air insufflation. Patients completed a questionnaire to grade their discomfort using a visual analogue scale (VAS). The salivary alpha-amylase (SAA) level was also measured at these times as a marker of stress. RESULTS: The total VAS score did not show any statistically significant differences between the CO2 and air insufflation groups. However, the VAS score for abdominal fullness significantly decreased in the CO2 insufflation group in comparison to the air insufflation group in the patients who had a longer examination. The titer of the maximum SAA was significantly increased by colonoscopy (P <0.01). CO2 insufflation significantly reduced the total SAA after the colonoscopy in comparison with air insufflation (P < 0.05). The examination time and SAA tended to have a positive relationship in the air insuflation group. However, no such relationship was observed in the CO2 insufflation group. CONCLUSIONS: CO2 insufflation significantly reduced the post-examination discomfort, as indicated by a salivary stress marker. The use of CO, rather than air insufflation reduced the patients' stress and may contribute to better acceptance of colonoscopy. The usefulness of CO2 insufflation was more prominent when a longer examination was necessary.

Functional gastrointestinal disorders in adolescents and quality of school life.

BACKGROUND AND AIM: The prevalence of functional gastrointestinal disorders (FGID) in adolescents and their relationship to quality of school life (QOSL) are not fully understood. This study investigated the relationship between FGID and QOSL. METHODS: Adolescents (10-17 years) were recruited from 40 schools. FGID diagnoses were based on the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version (QPGS-RIII). QOSL was evaluated by a questionnaire and calculated as the QOSL score. RESULTS: Five hundred and fifty-two of the 3976 students (13.9%) met the FGID criteria for one or more diagnoses according to the QPGS-RIII: 12.3% met the criteria for one, 1.5% for two or more. Irritable bowel syndrome (IBS) was the most common diagnosis (5.9%) followed by functional abdominal pain (3.1%). The prevalence of FGID was significantly higher in the female students in comparison to male students (P < 0.01). The prevalence of FGID was 9.5% in elementary school, 15.4% in junior high school, 26.0% in high school students, respectively. The prevalence of FGID was significantly increased with age (P < 0.01). The QOSL score of the patients with FGID was 10.9 ± 4.5 and that without FGID was 8.2 ± 2.8, respectively. The QOSL score of the patients with FGID was significantly worse than those without FGID (P < 0.01). The QOSL scores with IBS, aerophagia, and cyclic vomiting syndrome were significantly worse among the FGID (P < 0.01). CONCLUSIONS: The prevalence of FGID in adolescents was relatively high. The presences of FGID worsen the QOSL score. Medical intervention and/or counseling are needed for such students to improve the QOSL.

Analysis of colonoscopic perforations at a local clinic and a tertiary hospital.

AIM: To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic. METHODS: A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared. RESULTS: A total of 10  826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32  148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24  361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained. CONCLUSION: It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.

[A survival case of hepatocellular carcinoma with splenic metastasis: metachronous rupture at the liver primary and splenic metastatic lesion].

A 78-year-old man was referred to our hospital in March 2003 for rupture of hepatocellular carcinoma (HCC). Hemostasis was obtained by emergency angiography. In December 2004, metastasis to the right lung appeared and right lower lobectomy was carried out. In October 2005, a splenic metastatic lesion ruptured and hemostasis was obtained by emergency partial splenic embolization (PSE). Since viable remnants of the splenic tumor were suspected by CT, splenectomy was subsequently performed. He has been followed up in the outpatient clinic without recurrence. This is a markedly rare case of HCC in which, metachronous rupture primary and metastatic lesions, the patient was saved.

Acute thrombocytopenia associated with preexisting ulcerative colitis successfully treated with colectomy.

We report a case of successfully treated acute thrombocytopenia associated with preexisting ulcerative colitis (UC). The patient had typical symptoms of UC, and colonoscopy showed pancolitis. During treatment with sulfasalazopyridine (SASP) and steroids, thrombocytopenia was observed. Despite the cessation of drugs, severe thrombocytopenia was noted. Immune thrombocytopenic purpura (ITP) was suspected based on a normal bone marrow megakaryocyte count, positive autoantibody to platelet membrane antigen, and the absence of splenomegaly. Medical treatment, including increased dosage of steroids, failed to control UC and acute thrombocytopenia in this patient. Moreover, acute severe pancreatitis developed and abdominal computed tomography showed toxic megacolon. Platelet count recovered after urgent total colectomy without splenectomy. When patients with UC develop thrombocytopenia, particularly in the presence of extensive and significant colonic inflammation, a diagnosis of ITP should be considered. In such patients, preexisting UC might be involved in the immunological causal mechanism of ITP. In this situation, colectomy might cure both UC and resistant thrombocytopenia. Steroid-refractory and life-threatening UC complicated by thrombocytopenia presumably caused by ITP is therefore a possible indication for colectomy.