Reflux esophagitis and Helicobacter pylori infection in patients with scleroderma.

OBJECTIVE: This study aimed to evaluate the possible effects of Helicobacter pylori (H. pylori) infection in reflux esophagitis with scleroderma. PATIENTS AND METHODS: There were a total of 138 patients with scleroderma in our hospital between October 1998 and June 2005. Among these patients, 64 consecutive patients of scleroderma, who did not receive medication for gastrointestinal diseases, underwent endoscopy after informed consent. H. pylori was examined using an H. pylori IgG ELISA. The endoscopists graded esophageal mucosal breaks according to the Los Angeles Classification of Esophagitis. RESULTS: Among the 64 patients, 37 patients (57.8%) were positive for H. pylori infection. Reflux esophagitis was observed in 10 of 37 H. pylori-positive patients and in 19 of 27 H. pylori-negative patients. Significantly fewer H. pylori-infected patients had reflux esophagitis than H. pylori-negative patients (p<0.01). The odds ratio for H. pylori infection and reflux esophagitis was 0.16 (95%CI; 0.052-0.47). CONCLUSION: These findings suggest an important role for H. pylori infection in reflux esophagitis with scleroderma.

[A case of relapsed ischemic colitis with colon cast-like stripped mucosa].

An 82-year-old woman who had 5 relapses of ischemic colitis was admitted with sudden lower abdominal pain. Colonoscopic examination performed on the 2nd day revealed colon cast-like stripped colonic mucosa in the lower portion of the descending colon. She was treated conservatively. After 2 weeks, ischemic colitis healed, with slight residual stenosis. Most reports of colon cast indicated that colon cast was caused by abdominal aneurysm, operation, or external wound. The only predisposing conditions in this case were arteriosclerosis of abdominal aorta and chronic constipation. Arteriosclerosis and chronic constipation might be the important risk factors of ischemic colitis with colon cast and relapsing of ischemic colitis.

[A case of Crohn's disease successfully treated with infliximab without steroid].

A 39-year-old man diagnosed as Crohn's disease suffered steroid induced psycosis during treatment for Crohn's disease on July 2001. He was admitted on May 2002, because of progressing high fever, abdominal pain and diarrhea. He was treated with infriximab (5mg/kg) together with mesalazine without steroid. The treatment induced rapid improvement of systematic symptoms together with laboratory data and colonoscopic findings. He kept remission for more than 10 months after a single administration of infliximab (5mg/kg). The case is suggestive of wider indication of infliximab for Crohn' s disease.

Role of Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use in bleeding peptic ulcers in Japan.

BACKGROUND: Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) are well-known major causes of peptic ulcers. This study aimed to characterize the features of bleeding peptic ulcers in Japan. METHODS: This prospective study evaluated 116 patients revealed to have bleeding peptic ulcers from January 2000 to December 2002. RESULTS: Eighty-eight of the 116 patients (75.9%) had H. pylori infection. Seventy (60.3%) patients were positive for H. pylori with no history of NSAID use (group A), and 18 (15.5%) were positive for H. pylori with a history of NSAID use (group B). Among the H. pylori-negative patients, 15 (12.9%) were associated with NSAID use (group C). Thirteen (11.2%) patients had no H. pylori infection or history of NSAID use (group D). Among the 33 patients with a history of NSAID use, 11 were on-demand NSAID users and 14 took daily low-dose aspirin. The patients in groups B and C were significantly older that those in groups A and D, and they more frequently had coexisting diseases compared with group A. In group D, 11 patients had atrophic changes revealed by endoscopic examination, suggesting a past H. pylori infection, and these atrophic changes remained at the time of bleeding. Many of the patients in group D had serious comorbidity. Compared with healthy control subjects, the concentrations of both phosphatidylcholine and phosphatidylethanolamine were significantly decreased in the antral gastric mucosa in all patient groups. CONCLUSIONS: NSAID use contributed to bleeding ulcers in 28.4% of patients; thus, low-dose aspirin or on-demand NSAID use may cause bleeding ulcers. There were only two (1.7%) confirmed cases of H. pylori-negative, non-NSAID ulcers.

Dysphagia associated with gastroesophageal reflux disease is improved by proton pump inhibitor.

This study aimed to determine whether dysphagia associated with gastroesophageal reflux disease was effectively treated with rabeprazole, a proton pump inhibitor. Sixty-eight outpatients with gastroesophageal reflux-associated dysphagia were enrolled in this study. Endoscopic esophagitis was confirmed in 52 of 68 subjects. The proton pump inhibitor rabeprazole was administered at 20 mg daily for 8 weeks. Rabeprazole was administered for a further 6 months to 16 subjects whose dysphagia was improved (10 mg/day) and 5 of these underwent 24-hr esophageal pH monitoring before and after treatment. Dysphagia was completely resolved in 40 of 68 subjects, which were categorized in Group I. Dysphagia improved partially in 20 subjects and was unchanged in 8 subjects. These 28 subjects were categorized into Group II. Comparison was made between Group I and Group II and multivariate analysis demonstrated that the only factor that correlated with the effect of rabeprazole on dysphagia was "improvement in heartburn symptoms." There were no relapses of symptoms during the 6-month follow-up period, and pH monitoring showed sustained suppression of acid secretion. The results indicate that rabeprazole is effective in the treatment of dysphagia associated with gastroesophageal reflux disease. We were, however, unable to elicit any factors that could predict the therapeutic effect of rabeprazole before commencing treatment.

Evaluation of endoscopic hemostasis with metallic hemoclips for bleeding gastric ulcer: comparison with endoscopic injection of absolute ethanol in a prospective, randomized study.

OBJECTIVE: Although metallic hemoclips have been used for hemostasis of bleeding ulcer, there have been few prospective trials to evaluate their efficacy. In this study, a prospective, randomized trial was performed to evaluate endoscopic hemoclipping for bleeding gastric ulcer in comparison with endoscopic injection of absolute ethanol. METHODS: During the period 1995-1998, 126 gastric ulcer patients with bleeding or nonbleeding visible vessel were considered for entry. They were randomly assigned to one of three groups: endoscopic hemostasis performed with injection of absolute ethanol (group I, n = 42), hemoclipping (group II, n = 42), and a combination of the two methods (group III, n = 42). RESULTS: The permanent hemostatic rate was 85.7% in group I, 90.5% in group II, and 92.9% in group III. The mean volume of blood transfusion was 313 +/- 77 ml in group I, 274 +/- 54 ml in group II, and 163 +/- 42 ml in group III, which was significantly less than in groups I or II (p < 0.05). No patients required emergency surgery. Five patients died within a month after initial hemostasis as a result of unrelated conditions. CONCLUSIONS: Endoscopic hemostasis with hemoclips for bleeding gastric ulcer was as effective and safe as that with injection of absolute ethanol, and a combination of ethanol injection and hemoclips did not result in a great advantage over the two individual procedures.

Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips.

BACKGROUND: The number of complications associated with use of EMR for early-stage gastric cancer, including perforation, has increased with the increasing use of this procedure. Endoscopic clip application was performed in patients who sustained a perforation as a result of EMR for gastric neoplasm. PATIENTS AND METHODS: Seven patients who underwent endoscopic application of metallic clips to close perforations were studied. The omental patch method was applied in one case with a large perforation. OBSERVATIONS: In all patients, endoscopic clip application successfully closed the perforation of the stomach, which occurred after EMR. No patient required laparotomy. CONCLUSIONS: The technique of endoscopic clip application might be useful for treatment of patients who sustain a perforation caused by EMR.

Endoscopic injection sclerotherapy for esophageal varices in cirrhotic patients without hepatocellular carcinoma: a comparison of longterm survival between prophylactic therapy and emergency therapy.

BACKGROUND: This study aimed to determine whether prophylactic endoscopic injection sclerotherapy prolonged survival in patients with esophageal varices complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy. METHODS: The subjects included 160 patients suffering from esophageal varices complicated by liver cirrhosis without hepatocellular carcinoma. Sixty-eight patients underwent emergency therapy for bleeding varices and the remaining 92 patients underwent prophylactic sclerotherapy. All subjects continued to receive therapy until the varices disappeared. RESULTS: Five-year survival was significantly better in the prophylactic group compared with the emergency group. During the 5-year observation period, 20 of the 68 patients in the emergency group experienced rebleeding and 5 patients died as a result of rebleeding. These rates were significantly higher than those in the prophylactic group (1 of 9 patients with bleeding died among the 92 prophylactic sclerotherapy patients). Multivariate analysis showed that prophylactic therapy and Child's C hepatic function were significant factors for 5-year survival. CONCLUSIONS: Prophylactic sclerotherapy for esophageal varices might be more effective in prolonging longterm survival of patients complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy.

Characteristics of gastroesophageal reflux disease in Japan: increased prevalence in elderly women.

The aim of this study was to examine the characteristics of gastroesophageal reflux disease in Japan. We evaluated the correlation between clinical symptoms and endoscopic findings in an age- and sex-specific manner. This study included 6010 Japanese subjects who had not received medication or undergone laparotomy for gastrointestinal disease. All subjects were questioned in regard to clinical symptoms by paramedical personnel before endoscopic examination. Esophageal mucosal breaks were evaluated according to the Los Angeles Classification of Esophagitis. The ratio of subjects with each complaint to all subjects is as follows: heartburn, 27.0%; dysphagia, 16.9%; odynophagia, 19.2%; acid regurgitation, 7.1%. The proportion of each grade was grade A, 9.6%; grade B, 4.6%; and grade C + D, 2.0%. The most common related symptom for endoscopic esophagitis among these four symptoms was heartburn (odds ration, 2.5), although about 40% of subjects with severe esophagitis of grade C or D did not complain of heartburn. Regarding odynophagia, acid regurgitation, and dysphagia, odds ratios were about 1.0. The age-related ratio of esophagitis and severe disease with grades C and D increased in women over 60 years of age. An age-related slouched position was related to the increased esophagitis in these elderly women. Male subjects whose body mass index was more than 25 tended to show a greater prevalence in the age group 30-50 years. The prevalence of hiatal herniation increased in an age-related manner. These data indicate the characteristics of esophagitis in Japan are as follows: (1) the prevalence of reflux esophagitis is about 15% and most of these cases are grade A or B; and (2) the prevalence of severe esophagitis increases in older women, who do not always complain of clinical symptoms.

Normalization of phospholipids concentration of the gastric mucosa was observed in patients with peptic ulcer after eradication of Helicobacter pylori.

BACKGROUND: Phospholipids concentration in the gastric mucosa decreased in patients with Helicobacter pylori infection. The aim of this study is to examine the effects of eradication of H. pylori on decreasing the phospholipids concentration in the gastric mucosa in patients with gastric or duodenal ulcer. MATERIALS AND METHODS: Phospholipids (phosphatidylcholine, phosphatidylethanolamine, and sphingonomyeline) were measured in biopsy specimens from the antrum and corpus using thin-layer chromatography. In H. pylori positive patients with gastric ulcer (n = 26) and duodenal ulcer (n = 13), and H. pylori negative controls (n = 20), the biopsy specimens were obtained before and 3 months after eradication. Eradication was performed using lansoprazole, amoxycillin, and clarithromycin. RESULTS: Compared with the H. pylori negative control group, the concentrations of phosphatidylcholine and phosphatidylethanolamine decreased significantly in the gastric ulcer group in both antrum and corpus mucosa, and in the duodenal ulcer group in antrum mucosa. This decrease returned to the control level after eradication. CONCLUSIONS: This study demonstrates that the eradication of H. pylori in patients with peptic ulcer normalized the decrease of phosphatidylcholine and phosphatidylethanolamine in the gastric mucosa.