Multiple hepatic peribiliary cysts discovered incidentally at a medical examination.

We report a living patient with multiple hepatic peribiliary cysts. It was discovered incidentally during an ultrasonographic screening at a medical examination. Peribiliary cysts are multiple retention cysts of peribiliary glands. Although many autopsy cases of peribiliary cysts have been reported, there are few clinical cases of it in living patients. A CT performed immediately after drip-infusion cholangiography (DIC) was most useful for diagnosis in various imaging tests we performed.

Pancreaticobiliary maljunction: etiologic concepts based on radiologic aspects.

BACKGROUND: The purpose of this study was to develop a new concept of the embryonic etiology of pancreaticobiliary maljunction (PBM) based on cholangiopancreatograms. METHODS: The subjects were 202 patients with PBM (60 men and 142 women) in whom the junction of the pancreatic and bile ducts was radiologically diagnosed as being located outside of the duodenal wall; 133 of the 202 patients also had congenital cystic dilatation of the bile duct (CCBD). RESULTS: The length of the duct from the junction to the orifice of the major papilla (the common channel) ranged from 0.5 to 5 cm on the cholangiopancreatograms. Small radicles of the pancreatic duct arose from the common channel in 36 of the 202 patients. This finding suggests that the common channel is itself the main pancreatic duct in patients with PBM. Moreover, cholangiopancreatography revealed that in 99 of the 202 patients, there was a narrowed duct segment distal to the biliary cyst in patients with CCBD or distal to the normal bile duct in those without CCBD; the length of the narrowed segment varied. Histologic examination revealed smaller branches that had arisen from this narrowed segment in 2 anatomic specimens. This also suggests that the narrowed ductal segment belongs to the pancreatic duct system. CONCLUSION: PBM is an anomaly that is probably caused by a disturbance in the embryologic connections (misarrangement) of the pancreatic and biliary duct system that occurs extremely early during gestation when the bile duct joins with the ventral pancreatic duct system. PBM is not due to an arrest of the normal migration of the common channel into the duodenal lumen during embryonic development.

Case of ulcerative colitis associated with oesophageal ulcer.

A case of ulcerative colitis complicated by oesophageal ulcers is reported. A woman was admitted to our hospital because of exacerbations of ulcerative colitis both in 1992 (aged 15 years) and 1995 (aged 18 years). When she was admitted in 1995 she complained of bloody diarrhoea, sore throat and pain on swallowing. Oesophagogastro-duodenoscopy revealed oesophageal ulcers. Oesophageal pH monitoring (24-h) showed no evidence of gastro-oesophageal reflux disease. After the patient was treated she with oral prednisolone showed considerable improvement clinically and endoscopically. Initial dosage was 60 mg/day, and 1 week later, the dosage was gradually dropped since the patient responded favourably. The improvement of the oesophageal lesions coincided with the remission of ulcerative colitis. The oesophageal ulcers are, therefore, thought to be an extracolonic manifestation of ulcerative colitis.

Evaluation of immunological rapid urease testing for detection of Helicobacter pylori.

The aim of this study was to evaluate in clinical specimens the immunological rapid urease test (IRUT), a new diagnostic system for detection of Helicobacter pylori which employs a monoclonal antibody against Helicobacter pylori urease. Helicobacter pylori urease adsorbed on a solid-phase tip coated with a monoclonal antibody against Helicobacter pylori urease after 15 min of incubation with a gastric mucus sample solution was measured by the pH change of the urea solution inside the tip. The detection limit of Helicobacter pylori urease using this system was determined and compared with that of a commercially available rapid urease test. Clinical evaluation of the system was performed in 155 patients. The IRUT could detect 0.25 milli-international units (mIU) of Helicobacter pylori urease per milliliter in less than 20 min. If a patient with at least one positive result in a standard test for Helicobacter pylori was considered to be Helicobacter pylori positive, the sensitivity, specificity, positive and negative predictive values of the system were calculated as 95.2%, 98.9%, 98.4% and 96.8%, respectively. However, 10 of 19 Helicobacter pylori-positive patients in whom the pH change was less than 0.1 had negative results in at least one of the standard tests, whereas the IRUT correctly detected Helicobacter pylori in all but 3 of these 19 patients. The IRUT accurately determined the Helicobacter pylori status of 75 (98.7%) of 76 patients who had completed treatment. This system has high sensitivity for the detection of Helicobacter pylori, especially in patients with low urease activity.

Endoscopic urease sensor system for detecting Helicobacter pylori on gastric mucosa.

BACKGROUND: It is now accepted that the curing of Helicobacter pylori infection will result in healing of chronic active gastritis and will change the natural history of gastroduodenal ulcer disease. Both endoscopic observation and evaluation of H. pylori status of the stomach are necessary for diagnosis and treatment of such patients. We carried out a clinical evaluation of an endoscopic tube type urease sensor system for the detection of H. pylori on the gastric mucosa. The differential output of two pH-sensitive field effect transistors at the tip of the endoscopic tube reflects the pH change in a urea solution depending on the existence of urease. METHODS: In vitro experiments and clinical evaluation of the system were performed. Fifty-one patients who were suspected to have a gastroduodenal disorder were examined for H. pylori infection with this system, using the combination of histologic and bacteriologic examinations and rapid urease test as the references. RESULTS: Clinical sensitivity and specificity of this system were 26 of 28 (92.9%) and 22 of 23 (95.7%), respectively. A measurement at 1 site is completed in about 1 minute. Repetition of the procedure provides multi-site measurements. CONCLUSIONS: The present system makes possible quick on-site detection of H. pylori under endoscopic observation, with satisfactory sensitivity and specificity.

Lipopolysaccharide-binding protein of Bombyx mori participates in a hemocyte-mediated defense reaction against gram-negative bacteria.

BmLBP is a lipopolysaccharide-binding protein in B. mori and participates in bacterial clearance in vivo. Here, we investigated the function of BmLBP more specifically. More than 90% of injected gram-negative rough strains to which BmLBP binds were removed from the plasma within 30 min post-injection, whereas it required 8h for the clearance of smooth strains to which BmLBP does not bind. Observation of the hemocoel after the injection of Escherichia coli rough strain showed that melanized nodules were formed at 30 min post-injection when the clearance of injected E. coli cells had occurred. Fluorescence microscope observation revealed that E. coli cells were actually trapped in the nodules formed in vivo. Furthermore, plasma pre-treated E. coli rough cells (BmLBP bound) added to hemocytes isolated in vitro caused vigorous hemocyte aggregations with the bacteria, while plasma pre-treated smooth cells did not. The formation of aggregates was inhibited by anti-BmLBP serum pre-treatment, suggesting that BmLBP causes the clearance of bacteria by promoting hemocyte nodule formation.

Lipopolysaccharide-binding proteins and their involvement in the bacterial clearance from the hemolymph of the silkworm Bombyx mori.

Proteins having the ability to bind to Escherichia coli K12W3110 (rough (R) mutant) were isolated and purified by affinity precipitation from the larval hemolymph of the silkworm Bombyx mori. These proteins were found to consist of two components with molecular masses of 43 kDa and 40 kDa by SDS/PAGE. They bound to all E. coli R mutants (Ra, Rb1, Rc, Rd1 and Re) and Salmonella minnesota R mutants. However, they did not bind to smooth types of the above bacteria. They bound to both lipopolysaccharide(LPS)-coated and lipid-A-coated microtiter plates and have similar dissociation constants for LPS and lipid A. This indicates that the binding proteins recognize the lipid A portion of LPS and thus, we have named these proteins BmLBP (B. mori LPS-binding proteins). We also found that BmLBP participated in the clearance of E. coli cells injected into the body cavity of the silkworm.

[An investigation of the factors influencing serum pepsinogen levels--sex, age, smoking, drinking].

BACKGROUND: Until now, the influence of sex, age, smoking, drinking on serum pepsinogen levels has been assessed by single regression analysis. However, the influence of those factors on pepsinogen levels should be assessed exactly by multiple regression analyses. SUBJECTS AND METHODS: 891 subjects were collected from by questionnaire and serum tests. Analyses were done with serum pepsinogen I (PG I), pepsinogen II (PG II) and pepsinogen I/II ratio (PG I/II) as a criterion variable and as categorized explanatory variables, sex, age, current or past smoking habit, and current drinking habit. And analyses are done by Mann-Whitney U test, correlation coefficient, single regression method, multiple regression method. RESULTS: PG I level is significantly higher in men than in women by Mann-Whitney U test. But the effect of sex factor is not remarkable by multiple regression analyses. PG II level increased and PG I/II level decreased with progression of age by all analyses methods. Current or past smoking elevates PG I level by Mann-Whitney U test, but current smoking dose and past smoking amount showed no dose-dependent associations with PG I level. Current drinking elevates PG I level by Mann-Whitney U test, but current drinking dose showed no dose-dependent associations with PG I. However, the effects of current smoking and current drinking to serum PG levels is not so large by multiple regression analyses. CONCLUSION: The effects of sex, current smoking and current drinking to serum PG levels are not remarkable by multiple regression analyses. Significantly, PG II level increased and PG I/II level decreased with progression of age. Therefore it may not be necessary to consider the effects of sex, smoking habit and drinking habit when serum pepsinogen levels are used as markers for gastric cancer.

Quality of peptic ulcer healing induced by lansoprazole and roxatidine.

This study reports preliminary results of a controlled, multicenter trial on the quality of ulcer healing induced by lansoprazole (LPZ) or roxatidine (R) in gastric ulcer (GU) or duodenal ulcer (DU) patients. Group A received LPZ 30 mg q.d. and group B received R 75 mg b.i.d. All drugs were given for 8 weeks in GU and for 6 weeks in DU. Endoscopy and gastric biopsy were performed to detect Helicobacter pylori before and on completion of treatment. The healing rates of groups A and B were 100 and 69.2%, respectively, in GU and 100 and 70.0%, respectively, in DU. This difference (p < 0.01) was significant between the two groups in GU. There was no significant difference between the two groups in the S2 stage shift rate in GU and DU. The H. pylori clearance rates of groups A and B were 33.3 and 20.0%, respectively, in GU and 62.5 and 33.3%, respectively, in DU. The differences in treatment response (healing rates and S2 shift rates) between the LPZ group and the R group may be related to the differences in suppression of acid secretion and in bactericidal effects on H. pylori.

Electronic endoscopy in perspective.

Electronic endoscopy, developed in 1983, enables the endoscopic image to be transmitted through electric signals that can be easily processed by computer. An electronic endoscope is composed of three vital parts, i.e., a charge-coupled device (CCD) that converts the image to electric signals, a video processor that converts analog electric signals to the digital and processes them to become video signals, and a television monitor. The introduction of electronic endoscopy has enabled computer management of endoscopic images, on one hand, and provided an opportunity for image processing and analysis, on the other. A digital image management system will further develop into a database of endoscopic images. Combined with the technologies of remote control and remote sensing, the introduction of CCD to endoscopy has made it possible to transform the endoscope, so that it could become a capsule. Future advances in the research of image processing and analysis will lead to the development of a system of automated endoscopic diagnosis.

Morphologic changes in the pancreas detected by screening ultrasonography in a mass survey, with special reference to main duct dilatation, cyst formation, and calcification.

Subclinical morphologic changes in the pancreas detected by screening ultrasonography of 130,951 subjects were analyzed in relation to their incidence and background factors. Main pancreatic duct (MPD) dilatation, cystic lesion, and calcification were found in 644 (0.49%), 271 (0.21%) and 65 (0.05%) patients, respectively. The incidence of MPD dilatation and calcification was significantly higher in men (p < 0.0001), whereas cystic lesion was significantly more frequent in women (p < 0.01). Age-dependent increase in the incidence of MPD dilatation and cystic lesion was observed in both sexes whereas that of calcification was observed only in men. Further detailed examinations for 312 randomly selected patients with these findings revealed that 97% of MPD dilatation, 95% of cystic lesion, and 86% of calcification were correctly identified by ultrasonography. Finally, 18 (5.8%) patients with chronic pancreatitis, 16 (5.1%) with neoplastic cysts, 3 with mucin-producing tumors, and 3 with carcinomas (0.96%, respectively) were detected. On the other hand, in 84.0% of MPD dilatation, 87.4% of cystic lesion, and 50.0% of calcification, we could not attribute their etiology to any known pancreatic disease. It is indicated that aging and gender are major clinically related factors of these changes.

Gastric carcinoma, an endoscopically curable disease.

Following refinement of endoscopic diagnosis of gastric cancer, the concept of 'early gastric carcinoma' and its endoscopic features have become established. After the wide acceptance of the techniques of endoscopic mucosal resection (EMR), laser therapy and accurate endoscopic-endosonographic assessment of the depth of invasion, curative endoscopic treatment of intramucosal gastric carcinoma has become established. On the basis of the analysis of lymphatic metastasis, the indications for endoscopic treatment of gastric carcinoma have been defined as (1) well-differentiated, intramucosal adenocarcinoma of a superficial elevated lesion (diameter < 2 cm), and (2) well-differentiated, intramucosal adenocarcinoma of a superficial depressed lesion (diameter < 1 cm) having no ulcer or scar inside. The preferred procedure of endoscopic treatment is EMR with careful histological examination of the resected specimen. It is supplemented by repeat EMR, laser therapy, or surgical gastrectomy in case of incomplete resection. For detection of residual cancer and recurrence, periodic endoscopic follow-up is necessary. Early gastric carcinoma is endoscopically curable.

Ultrasonographic follow-up study of small pancreatic cysts of unknown etiology.

The aim of the present project was to evaluate the prognosis of small and asymptomatic cysts of the pancreas which were diagnosed as being nonneoplastic by endoscopic ultrasonography. Eighty-two patients with such cysts had been subjected to ultrasonographic examination every 6 months. Results of follow-up for 3 or more years were obtained in 31 patients. The cysts disappeared in 4 patients and enlarged in 1 patient. The others did not show any morphological changes. The enlarged cyst turned out to be a retention cyst after surgical resection. Our endoscopic ultrasonographic criteria were effective for small nonneoplastic cysts of the pancreas, and most of these cysts appeared to be nonprogressive.

Morphological changes of small pancreatic cysts in response to secretin stimulation. Observation by endoscopic ultrasonography.

It is difficult to discriminate clinically the etiology of small pancreatic cysts using conventional methods. Endoscopic ultrasonography can delineate small lesions. In order to help differentiate the etiology of cystic lesions of the pancreas by endoscopic ultrasonography, we investigated morphological changes following stimulation of the pancreatic secretion with secretin. After an intravenous injection of secretin (50 CU), the size, shape, and echogenicity of a cyst smaller than 2 cm were recorded for 15 min. Of 17 cases examined, 10 patients showed an alteration of these factors. These cases were thought to be nonneoplastic cysts, which included all six cases where communication to the main pancreatic duct was demonstrated by ERCP. Five cases of neoplastic cyst did not show the change in shape and size. These results indicate that secretin stimulation provides useful information in the diagnosis of the etiology of pancreatic cyst by endoscopic ultrasonography.

Alpha-fetoprotein producing carcinoma of the gallbladder associated with anomalous arrangement of the pancreaticobiliary ductal system--early detection through an attack of acute pancreatitis.

A 56-year-old female was admitted to our hospital with a diagnosis of acute pancreatitis. Ultrasonography revealed a hypoechoic tumor in the gallbladder. The serum alpha-fetoprotein (AFP) level was 971 ng/ml. After healing of the acute pancreatitis, the anomalous arrangement of the pancreaticobiliary ductal system (APDS) was demonstrated by ERCP with mild dilatation of the common bile duct. Within one month after admininon, AFP level reached 4390 ng/ml. On operation, a pedunculated tumor, 6.5 x 3 cm in size, was found in the gallbladder. Histological examination revealed a moderately differentiated adenocarcinoma and positive immunohistochemical staining of cancer cells for AFP. After absolutely curative (stage II) resection, normal serum AFP levels were recognized. This is the first report of an AFP-producing cancer of the gallbladder associated with APDS and it was detected as a result of an attack of acute pancreatitis.

Endoscopic image manipulation: state of the art.

Fundamental techniques and commonly employed algorithms for image manipulation of endoscopic images were reviewed, but only in a few instances was any novel information obtained. New software was recently developed for medium-frequency band enhancement: From the correlation distribution of image data in the RGB color space (distribution 1), only those data components depicting the fine structure patterns were extracted. The correlation distribution of the latter components was subsequently studied in the same space (distribution 2); the original image data were so processed that distribution 1 would be enhanced along the axis of greatest variation seen in distribution 2. This algorithm of image processing was successful in detecting minute surface structures of the mucosa hidden by the overlying mucus in the original images. It seems to be the first successful algorithm of image processing that obtained specific effects of enhancement without simultaneous noise enhancement.

Digital/analog hybrid system for filing of endoscopic images.

A new system was developed for filing all the endoscopic images generated in our hospital. The system is composed of an on-line network for analog images supplied from the endoscopy stations and stored on 300 mm optical disks, on the one hand, and an off-line PACS for digital images recorded on a 130 mm magneto-optical disk (MOD) at each endoscopy station, on the other. For close examination of the images digital images are displayed from the MOD on a high-resolution computer graphic monitor, and for quick review of a large number of images, analog images are retrieved from the 300-mm optical disks. This system has been in clinical use at our university hospital for the past year and has proven useful for education of endoscopy, for the quality control of the endoscopy practice, and for the management of the patients.

[Relationship between an involvement of Oddi's sphincter in a choledochopancreatic junction and clinical appearances in 120 patients with anomalous arrangement of the pancreatico-biliary ductal system].

We studied relationship between an involvement of Oddi's sphincter in a choledochopancreatic junction and clinical appearances in 120 patients with anomalous arrangement of the pancreaticobiliary ductal system. The 120 composed of 83 with a sphincteric mechanism at the junction of the common bile and pancreatic duct and 37 without the sphincteric mechanism. We found that influences of sphincteric mechanism at the junction closely related to the length of the common duct between an orifice of the papilla of Vater and a junction of the common bile and pancreatic duct. And in all 83 with a sphincteric mechanism at the junction the length of the common duct showed less than 1.5 cm, and in all 37 without a sphincteric mechanism at the junction the common duct showed more than 1.5 cm in length. There was no correlation between a distribution of the sphincter muscle and clinical appearances, association with congenital choledochal cyst, cholelithiasis and bile duct cancer in the 120 patients.