Hypothesis: Mechanism of irritable bowel syndrome in inflammatory bowel disease.

Functional bowel symptoms can be occurred during remission from inflammatory bowel disease. In this case, a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet is effective for the amelioration or prevention of symptoms. However, the reason is not fully explained. This report proposes a hypothesis regarding the entire process in which inflammatory bowel disease with IBS-like symptoms (IBD-IBS) causes symptoms. A detailed process was assumed, starting from high pressure in the lumen and finally to abdominal symptoms. In this process, relationships were linked based on interactions such as ischemia, compliance, pain threshold, visceral hypersensitivity, mast cells, and permeability reported in IBD-IBS. In the process mapping, to understand the relationship between the amount of gas increased by FODMAP and ischemia, the hydrodynamic hypothesis and Ritchie's hypothesis were adapted. Ischemia in dilated intestines due to an increase in gas volume can induce excessive spasms via the mast cells and show the whole process of lowering the pain threshold. From the standpoint of the mechanism of IBD-IBS, the origin trigger may be FODMAP. Therefore, a low-FODMAP diet is recommended to relieve and prevent IBD-IBS symptoms.

Prevention of gastric cancer by Helicobacter pylori eradication: A review from Japan.

Japan introduced a Helicobacter pylori eradication therapy strategy in 2013, with the aim of decreasing the number of gastric cancer-related death, the number of new cases of gastric cancer, and associated medical costs. Five years have passed since then, but no reduction in the annual number of gastric cancer has been observed. In addition, it was suggested that the number of deaths due to gastric cancer could be reduced to 30,000 a year by 2020, but the annual death toll in 2017 remained at more than 45,000. Based on the above evidence, it was examined whether it was possible to reach the target value based on the data from the last 5 years. The number of deaths per year in 2020 is predicted to be more than 40,000, which is clearly different from the target value. Logically, the effect of the strategy might appear by 2023. However, there is a possibility that the risk of gastric cancer may increase in some populations due to the influence of proton pump inhibitors and dysbiosis in the gastric microbiome. To solve these problems, combined therapy with PPIs and aspirin for patients after H pylori eradication should be considered.

Colonic transit time and pressure based on Bernoulli's principle.

PURPOSE: Variations in the caliber of human large intestinal tract causes changes in pressure and the velocity of its contents, depending on flow volume, gravity, and density, which are all variables of Bernoulli's principle. Therefore, it was hypothesized that constipation and diarrhea can occur due to changes in the colonic transit time (CTT), according to Bernoulli's principle. In addition, it was hypothesized that high amplitude peristaltic contractions (HAPC), which are considered to be involved in defecation in healthy subjects, occur because of cecum pressure based on Bernoulli's principle. METHODS: A virtual healthy model (VHM), a virtual constipation model and a virtual diarrhea model were set up. For each model, the CTT was decided according to the length of each part of the colon, and then calculating the velocity due to the cecum inflow volume. In the VHM, the pressure change was calculated, then its consistency with HAPC was verified. RESULTS: The CTT changed according to the difference between the cecum inflow volume and the caliber of the intestinal tract, and was inversely proportional to the cecum inflow volume. Compared with VHM, the CTT was prolonged in the virtual constipation model, and shortened in the virtual diarrhea model. The calculated pressure of the VHM and the gradient of the interlocked graph were similar to that of HAPC. CONCLUSION: The CTT and HAPC can be explained by Bernoulli's principle, and constipation and diarrhea may be fundamentally influenced by flow dynamics.

Management of colon stents based on Bernoulli's principle.

BACKGROUND AND AIMS: The colonic self-expanding metal stent (SEMS) has been widely used for "bridge to surgery" and palliative therapy. However, if the spread of SEMS is insufficient, not only can a decompression effect not be obtained but also perforation and obstructive colitis can occur. The mechanism of occurrence of obstructive colitis and perforation was investigated by flow dynamics. METHODS: Bernoulli's principle was applied, assuming that the cause of inflammation and perforation represented the pressure difference in the proximal lumen and stent. The variables considered were proximal lumen diameter, stent lumen diameter, flow rate into the proximal lumen, and fluid density. To model the right colon, the proximal lumen diameter was set at 50 mm. To model the left-side colon, the proximal lumen diameter was set at 30 mm. RESULTS: For both the right colon model and the left-side colon model, the difference in pressure between the proximal lumen and the stent was less than 20 mmHg, when the diameter of the stent lumen was 14 mm or more. Both the right colon model and the left-side colon model were 30 mmHg or more at 200 mL s-1 when the stent lumen was 10 mm or less. Even with an inflow rate of 90-110 mL s-1, the pressure was 140 mmHg when the stent lumen diameter was 5 mm. CONCLUSION: In theory, in order to maintain the effectiveness of SEMS, it is necessary to keep the diameter of the stent lumen at 14 mm or more.

Logical hypothesis: Low FODMAP diet to prevent diverticulitis.

Despite little evidence for the therapeutic benefits of a high-fiber diet for diverticulitis, it is commonly recommended as part of the clinical management. The ongoing uncertainty of the cause(s) of diverticulitis confounds attempts to determine the validity of this therapy. However, the features of a high-fiber diet represent a logical contradiction for colon diverticulitis. Considering that Bernoulli's principle, by which enlarged diameter of the lumen leads to increased pressure and decreased fluid velocity, might contribute to development of the diverticulum. Thus, theoretically, prevention of high pressure in the colon would be important and adoption of a low FODMAP diet (consisting of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help prevent recurrence of diverticulitis.

[Complete recovery obtained with combined S-1 + CDDP therapy in a patient with multiple lung metastases from esophageal cancer].

PURPOSE: There are numerous reports on the subject of effectiveness in radio-chemotherapy with regard to esophageal cancer, suggesting especially the combination therapy of 5-FU + CDDP aimed for recovery. Treatment becomes difficult when distal metastases appear during an adjuvant therapy followed by surgery. Our report here is a case in which a complete recovery was obtained after changing to S-1, a prodrug of 5-FU, in response to multiple lung metastases which appeared during the combined 5-FU + CDDP therapy followed by surgery for esophageal cancer. CASE: The patient was a 71-year-old male. Endoscopy during a physical examination showed a Type 1 tumor 27-30 cm from the anterior teeth. Detailed tests provided a preoperative diagnosis of esophageal cancer: Ut Type 1, T2-T3, N2, MO, IMO. A right thoracolaparotomic subtotal esophagectomy and retrosternal reconstruction were performed. Pathological findings showed well-differentiated squamous cell carcinoma, pT1b (sm), pN1 (106-rec R), pStage II. Postoperative combination of 5-FU + CDDP (day 1-5, 5-FU 500 mg; CDDP 10 mg/body) was started. Because of the appearance of multiple lung metastases after the completion of 3 courses, 2 courses of S-1 + CDDP (S-1 120 mg/body day 1-14; CDDP 5 mg/body day 1-5, day 8-12) were performed. After completing the chemotherapy, CT revealed the resolution of the lung metastases and complete recovery was diagnosed. Following this, a treatment with S-1 alone was continued until the appearance of bone metastases at which time radiotherapy was performed. The treatment is currently ongoing and no recurrence of the lung metastases has been shown. CONCLUSION: There have been numerous reports of the combination of S-1 + CDDP in esophageal cancer for NAC or in inoperable cases. However, our report suggests that this method may be effective in cases of recurrence or distal metastases.

Introducer method of percutaneous endoscopic cecostomy and antegrade continence enema by use of the Chait Trapdoor cecostomy catheter in patients with adult neurogenic bowel.

BACKGROUND: Previous reports on percutaneous endoscopic cecostomy (PEC) for the delivery of antegrade continence enema (ACE) in adults have been presented in the form of case reports. Heretofore the tubes used in the pull method of PEC have been thick bolster catheters. The author performed PEC by using the introducer method (IM) with 10 F Chait Trapdoor cecostomy catheters (CTCC) in adult cases. OBJECTIVE: Report author experience with a new method of PEC in adults. DESIGN: Case series. SETTING: Single institution in Japan. PATIENTS: Five patients with bowel obstruction and 15 patients with chronic severe constipation. INTERVENTIONS: The interventions were the pull method or IM of PEC and drainage or ACE. In 5 cases, PEC was performed by the pull method with the use of an 18 F to 24 F bolster catheter for decompression of dilated intestine. In 15 patients with chronic constipation, PEC was performed with the IM method using a balloon catheter (11 F or 15 F) and CTCC. ACE was performed every other day. RESULTS: PEC was successful and effective (decompression and evacuation) in all patients. In patients with IM of PEC, 5 patients were placed with a 15 F balloon catheter and 10 patients were placed with an 11 F balloon catheter. Immediate bleeding occurred in 1 case. Balloon rupture occurred during the first month or on average at the 1 month period. Nine of 10 patients who had the 11 F catheters were changed to CTCC. The advantages of CTCC were prevention of accidental balloon rupture, decreased leakage and granulation tissue, and ease of exchange compared with bolster catheter. LIMITATIONS: Retrospective, single-institution. CONCLUSIONS: PEC with IM is a safe and useful method. CTCC is advantageous on a long-term basis for ACE.

Does flexible small-diameter colonoscope reduce insertion pain during colonoscopy?

AIM:It is well known that colonoscopy can be difficult due to abdominal pain induced during colonoscope insertion, if sedative agents are not given. Recently, an extra-flexible, small-diameter colonoscope (CF-SV, Olympus Inc.Japan) was developed in order to improve safety and comfort. The aim of this study was to access the usefulness of the CF-SV.METHODS:One hundred patients undergoing sigmoidoscopy were recruited and colonoscopy was performed by one experienced colonoscopist. First, a routine type colonoscope (CF-230I) was inserted into the colon without sedation. When the patient complained of abdominal pain (even if mild), the scope was not advanced further and was withdrawn after the anatomic location of its tip was determined fluoroscopically. Then, the CF-SV was inserted until it reached the cecun or the site where abdominal pain occurred. Previous abdominal surgery and abdominal disease were considered as unfavorable factors (UF) and the relationship between abdominal pain and UF, age and gender were investigated.Furthermore, the colonic insertion pressures in 36 patients with abdominal pain were measured with a force gauge.RESULTS:Thirty-four cases (34%) felt no pain with the CF-230I and successful pancolon-oscopies to the cecum were performed. Sixty-six cases (66%) complained of abdominal pain. The procedure was painless for 47% of men and 24% of women, respectively. The CF-230I scope failed to reach the sigmoid-descending colon junctions in 59 (89.4%) of the 66 patients complaining of abdominal pain. However, CF-SV reached proximal area in 94.9% of those who failed with CF-230I. The median pressure for pain-inducing was 700g/cm(2).CONCLUSION:Unsedated patients with UF were prone to complain of pain when the standard type CF-230I scope was used. The newly developed extra-flexible CF-SV is useful for the aged and for those with UF or being prone to suffer from abdominal pain. Sedative agents may be unnecessary if this new type of colonoscope is used.