Relevance of ineffective esophageal motility and hyperactive acid sensitization in patients with gastroesophageal reflux.

BACKGROUND AND AIM: Esophageal motor abnormalities including ineffective esophageal motility (IEM) and visceral hypersensitivity have been frequently observed in patients with gastroesophageal reflux. The aim of this study was to observe the incidences of hypersensitivity to acid infusion and motor abnormalities in non-erosive reflux disease (NERD) compared with erosive esophagitis. METHODS: We performed upper GI endoscopy, an acid perfusion test and esophageal manometry on 113 NERD patients and 37 erosive esophagitis patients. RESULTS: The frequency of acid sensitization was 69.9% in NERD and 67.6% in erosive esophagitis. The frequency of esophageal motor abnormality in patients with erosive esophagitis (48.6%) was higher than in patients with NERD (25.7%, P = 0.014). The most frequent esophageal motor abnormality was IEM. The frequency of IEM was 15.9% in NERD patients, 42.9% in Los Angeles grade A, 53.8% in Los Angeles grade B and 66.7% in Los Angeles grade C esophagitis (chi(2) = 16.67, P < 0.0001). CONCLUSION: Our results suggest that no difference exists between visceral hypersensitivity in patients with NERD and those with erosive esophagitis, and that IEM occurs in NERD as well as erosive esophagitis patients. The occurrence of IEM is associated with the endoscopic severity of gastroesophageal reflux disease.

[Long-term results of endoscopic histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices--a 10-year experience].

BACKGROUND/AIMS: Gastric variceal bleeding is an infrequent but serious complication of portal hypertension. Endoscopic injection of Histoacryl (N-butyl-2-cyanoacrylate) has been approved as an effective treatment for gastric variceal bleeding. The aim of this study was to evaluate the long-term efficacy and safety of the endoscopic injection of Histoacryl for the treatment of gastric varices. METHODS: Between January 1994 and January 2005, eighty-five patients with gastric varices received endoscopic injections of Histoacryl. Among these 85 patients, 65 received the procedure within 1 week after gastric variceal bleeding, and 13 received as a prophylactic procedure. According to the Sarin classification, 32 patients were GOV1 and 53 were GOV2. Most of the varices were large (F2 or F3, 75 patients). The average volume of Histoacryl per each session was 1.43 ml. Among 85 patients, 72 patients were followed-up and the median duration was 24.5 months. RESULTS: The rate of initial hemostasis was 98.6% and recurrent bleeding occurred in 29.2% (21 of 72). When rebleeding occurred, 76.2% was within 1 year after the initial injection. Treatment failure-related mortality rate was 1.4% (1 of 85). Twenty-seven patients died, mostly due to hepatocelluar carcinoma or liver failure. Two patients experienced pulmonary embolism and one experienced splenic infarction. They recovered without specific treatment. Rebleeding rate had a tendency to increase in patients with hepatocelluar carcinoma (p=0.051) and GOV2 (p=0.061). CONCLUSIONS: Histoacryl injection therapy is a effective treatment method for gastric varices with high initial hemostasis rate and low major complications.

Effectiveness of sodium alginate as a submucosal injection material for endoscopic mucosal resection in animal.

BACKGROUND/AIMS: Although various solutions are being tested for submucosal injection during endoscopic resection, ideal solution has not been established yet. We performed an animal study to evaluate the possibility of sodium alginate as an ideal submucosal injection solution for endoscopic mucosal resection (EMR). METHODS: To compare the lesion-lifting properties of different solutions, injection was done to the submucosal layer of porcine stomach. Then the height of mucosal elevation was measured. In addition, EMR was performed after submucosal injection of sodium alginate solution in six dogs. Two were euthanized after 30 minutes of endoscopic observation while the others were euthanized after 1-4 weeks. Retrieved stomachs were examined microscopically. RESULTS: Sodium alginate and sodium hyaluronate solutions maintained longer elevation of the submucosal layer than other solutions. There was no significant difference in the height between two solutions. A clear separation of the mucosal layer from the proper muscle layer was achieved by injecting sodium alginate solution. Histological examination of EMR-induced artificial ulcers revealed no apparent tissue damage and showed normal healing process. CONCLUSIONS: Sodium alginate solution creates a sufficient submucosal fluid cushion without apparent tissue damage. It can be considered as an effective submucosal injection material.

Endoscopic Ultrasonograpic Findings of Benign Mediastinal and Abdominal Lymphadenopathy Confirmed by EUS-guided Fine Needle Aspiration.

BACKGROUND/AIMS: Distinguishing benign and malignant lymph nodes by the findings of endoscopic ultrasonography (EUS) is still controversial. We tried to evaluate EUS findings of benign mediastinal and abdominal lymphadenopathy (BLAP) confirmed by EUS-guided fine needle aspiration (FNA). METHODS: A total of 37 patients with enlarged mediastinal or abdominal lymph nodes (diameter >/=1 cm) were enrolled and EUS-FNA was performed. Final diagnosis was based on FNA cytology and follow up imaging studies (CT scans or EUS). RESULTS: Thirteen patients were confirmed to have BLAP by EUS-FNA. Causes of BLAP were as follows; (i) extrapulmonary tuberculosis in six cases including patients with postoperative states due to cervical cancer and advanced gastric cancer, (ii) Kikuchi disease in one case, (iii) hypereosinophilic syndrome in one case, (iv) reactive hyperplasia in five cases including patients with postoperative states due to thyroid cancer, lung cancer, and EGC with ESD. EUS findings of BLAP revealed that median lymph node size was 24.7 mm. Lymph nodes were oval or round shaped in 9 cases, sharp borders in 9 cases, hypoechoic echo pattern in 7 cases, heterogenous internal echo pattern in 7 cases. Other findings included internal septation, calcification, multiplicity, attachment to the gastrointestinal tract wall, and conglomeration. CONCLUSIONS: EUS findings of BLAP were not different from those of malignant lymphadenopathy previously reported in other studies.

[The expression of p53, p16, cyclin D1 in esophageal squamous cell carcinoma and esophageal dysplasia].

BACKGROUNDS/AIMS: p53 is known to play a central role in sensing and signaling for the growth arrest and apoptosis in cells with DNA damage. Mutation of p53 is a frequent event in esophageal squamous cell carcinoma (ESCC). p16 protein binds to cyclin dependent kinase 4 (CDK4) inhibiting the ability of CDK4 to interact with cyclin D1, and stimulates the passage through the G1 phase of cell cycle. We observed the expression patterns and frequencies of p53, p16, and cyclin D1 in esophageal dysplasia and in esophageal squamous cell carcinomas. METHODS: In 15 patients of ESCC, 5 patients of esophageal dysplasia and 5 volunteers with normal esophagus, tissue specimens were taken from esophageal lesions during the operation or endoscopic examination. We used specific monoclonal antibodies for p53 protein, p16(INK4 ) protein and cyclin D1. Immunoreactivity was scored. RESULTS: Mean age of all groups was 66 years old (range 47-93) and men to women ratio was 19:1. p53 mutation was observed in 87% (13/15) of ESCC, in 80% (4/5) of esophageal dysplasia, in 0% (0/5) of normal mucosa (p=0.001). p16 expression was seen in 40% (2/5) of esophageal dysplasia, 27% (4/15) of ESCC and 100% (5/5) of normal mucosa (p=0.016). Cyclin D1 expression was not significantly different among 20% (1/5) of esophageal dysplasia, 53% (8/15) of ESCC and 20% (1/5) of normal mucosa. Either the expression of p53 mutation or the loss of p16 occurred in 80% (4/5) of esophageal dysplasia and in 93% (14/15) of ESCC. CONCLUSIONS: The expression of p53 mutation and the loss of p16 might play a central role in the pathogenesis of esophageal squamous cell carcinoma (ESCC), and contribute to the development of precancerous lesion such as dysplasia. In addition, there is a possibility that the mutations of p53 and p16 silencing would be the early events in ESCC development.

Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy: a Korean multicenter study.

OBJECTIVE: Capsule endoscopy (CE) is approved for the evaluation of obscure gastrointestinal (GI) bleeding and its use has increased in the assessment of patients with various small-bowel disorders. The yield of CE for indications of disorders other than GI bleeding is not yet well described. The aim of the present study was to determine in which subgroup of patients with unexplained abdominal pain, CE would be a helpful evaluation tool. MATERIAL AND METHODS: The results of CE in 110 patients (70 M, 40 F, mean age 50.8+/-14.1 years) with unexplained abdominal pain from 12 tertiary referral centers between September 2002 and September 2004 were retrospectively analyzed. RESULTS: The visualization of the small bowel to the cecum was successfully carried out in 69.1% of the patients. Nineteen out of the 110 cases revealed positive findings that explained the symptoms of the patient (diagnostic yield=17.3%). Diagnosis included small-bowel stricture (5), Crohn's disease (3), small-bowel tumor (2), radiation-induced enteritis (1), NSAID-induced enteropathy (1), ischemic ileitis (1), diffuse lymphangiectasia (1), and significant erosion or ulceration (5). By univariate logistic regression analysis, the positive findings of CE were significantly associated with weight loss (odds ratio (OR), 11.9; 95% CI [2.0, 70.6]), elevated erythrocyte sedimentation rate (ESR) (>20 mm/h) (OR, 11.5; 95% CI (1.9, 69.5)), elevated C-reactive protein (CRP) (>or=0.4 mg/dL) (OR, 5.0; 95% CI (1.6, 15.9)), and hypoalbuminemia (albumin<3 g/dL) (OR, 23.1; 95% CI (2.4, 223.1)). Using a multivariate analysis, weight loss was found to be a significant risk factor for positive findings of CE (OR, 18.6; 95% CI (1.6, 222.4), p=0.02). CONCLUSIONS: The results of this study suggest that CE can be helpful in patients suffering from abdominal pain that cannot be explained by established examinations, if the pain is accompanied by weight loss.

[The relationship between ineffective esophageal motility and gastro-esophageal reflux disease].

BACKGROUND/AIMS: Ineffective esophageal motility (IEM) is a distinct manometric entity characterized by a hypocontractile esophagus. Recently, IEM replaced the nonspecific esophageal motility disorder (NEMD), and its associations with gastro-esophageal reflux disease (GERD) and respiratory symptoms are well known. We evaluated the relationship of IEM with GERD, and the diagnostic value of IEM for GERD. METHODS: We retrospectively analyzed recent 3-year (Jan. 1998-Sep. 2002) datas of esophageal manometry, acid perfusion test and simultaneous 24 hr-ambulatory pH-metry with manometry studies in 270 consecutive patients with esophageal and/or GERD symptoms. The prevalence of IEM in GERD group and non-GERD group, and the variables of pH-metry and manometry among esophageal motility disorders were compared. In addition, the sensitivity, specificity, positive predictive value, negative predictive value of IEM, esophageal symptom, and acid perfusion test for GERD were calculated. RESULTS: There was no significant difference in IEM prevalence rate between GERD group and non-GERD group. In addition, there was no significant difference in GERD prevalence rate and esophageal acid clearance in variety of motility disorder groups. Total percent time of pH <4 in IEM group did not show any difference when compared with other groups except in the achalasia group. In regard of diagnostic value to detect GERD, all positive results showed high specificity (97%) in IEM with esophageal symptom and positive acid perfusion test. CONCLUSIONS: The diagnosis of IEM using esophageal manometry in patients with various esophageal symptoms does not strongly suggest on association with GERD. However, IEM with concomitant esophageal symptoms and positive acid perfusion test has diagnostic values for GERD.

Usefulness of three-dimensional, multidetector row CT (virtual gastroscopy and multiplanar reconstruction) in the evaluation of gastric cancer: a comparison with conventional endoscopy, EUS, and histopathology.

BACKGROUND: The aim of this study was to assess the role of three-dimensional multidetector row CT for detection, precise localization, and staging of gastric cancer by comparison with conventional endoscopy, EUS, and histopathology. METHODS: Sixty-three patients with gastric cancer (31 early stage, 32 advanced) were evaluated by EGD with biopsies, EUS, and three-dimensional multidetector row CT between January 2003 to August 2003. Three-dimensional multidetector row CT findings were analyzed by a single radiologist blinded to the endoscopic findings. Among 63 patients, the findings were confirmed in 48 at surgery or by EMR. In the remaining cases, the findings were confirmed by EGD and biopsy specimen. The accuracy of three-dimensional multidetector row CT for detection, localization, and staging of gastric cancer was determined, compared with endoscopy, EUS, and histopathology. RESULTS: Among the 63 patients, there were 67 gastric cancers. The overall accuracy of three-dimensional multidetector row CT for detection of gastric lesions was 94% (63/67), with accuracies of 96.7% (30/31) and 100% (32/32) for detection of, respectively, early and advanced stage gastric cancer. The overall accuracy, sensitivity, and specificity for EUS and three-dimensional multidetector row CT in the pre-operative determination of depth of invasion (T stage) were, respectively, 87.5%, 82.4%, and 96%; and 83.3%, 69.1%, and 94.4%. The accuracy, sensitivity, and specificity of EUS and three-dimensional multidetector row CT for lymph node staging was, respectively, 79.1%, 57%, and 89.5%; and 75%, 57.4%, and 89.3%. CONCLUSIONS: Three-dimensional multidetector row CT, along with virtual gastroscopy is a promising method for pre-operative evaluation of gastric cancer.

A spontaneously ruptured gastric stromal tumor with cystic degeneration presenting as hemoperitoneum: a case report.

We report a case of a 38-yr-old man with a spontaneously ruptured gastric stromal tumor presenting as hemoperitoneum in outpatient clinic. He visited our hospital with generalized abdominal pain after abdominal CT scan for the evaluation of the asymptomatic palpable abdominal mass. Repeated abdominal CT scan showed a size decrement of cystic mass compared with the previous abdominal CT scan, and newly developed fluid collection in the left paracolic gutter. An emergency laparotomy revealed a ruptured gastric stromal tumor with bloody fluid in the peritoneal cavity. Immunohistochemical examination revealed positive reactivity to C-kit protein and CD34. The patient presented with hemoperitoneum due to spontaneous rupture of the tumor, which is an extremely rare complication.