Efficacy of ramosetron in the treatment of male patients with irritable bowel syndrome with diarrhea: a multicenter, randomized clinical trial, compared with mebeverine

BACKGROUND

The 5-HT(3) receptor antagonists are known to be effective for the treatment of diarrhea-predominant irritable bowel syndrome (IBS), but not widely used yet. The aim of this study was to compare the efficacy and safety of ramosetron, a 5-HT(3) receptor antagonist, and mebeverine in male patients with IBS with diarrhea (IBS-D).

METHODS

This study was performed in a multicenter, randomized, open-label design. Data of 343 male patients with IBS-D who were randomized to either a 4-week treatment of ramosetron 5μg once daily or a 4-week treatment of mebeverine 135 mg three times daily were analyzed by the intent-to-treat analysis. The primary efficacy parameter was the proportion of patients with adequate relief of IBS symptoms at the last week of treatment. The secondary endpoints were changes in each symptom score and the safety profiles.

KEY RESULTS

The responder rates for global IBS symptoms, abdominal pain/discomfort and abnormal bowel habits in the ramosetron and mebeverine groups significantly increased during the treatment period. The severity scores of abdominal pain/discomfort and urgency, the stool form score, and the stool frequency in both treatment arms were significantly reduced, compared with the baselines. There were no significant differences in the responder rates (37%vs 38% on ITT analysis) and adverse event profiles between the ramosetron and mebeverine groups. Neither severe constipation nor ischemic colitis was reported by ramosetron-treated patients.

CONCLUSIONS & INFERENCES

Ramosetron 5μg once daily is as effective as mebeverine three times daily in male patients with IBS-D.

Interobserver reliability in the endoscopic diagnosis and grading of Barrett's esophagus: an Asian multinational study

BACKGROUND AND STUDY AIM

The establishment of precise and valid diagnostic criteria is important for any disease. We determined the interobserver reliability in the endoscopic diagnosis and grading of Barrett's esophagus.

PATIENTS AND METHODS

Video clips of endoscopy in 21 patients with/without Barrett's esophagus were used for training (n = 3) and for diagnosis/grading (n = 18) of Barrett's esophagus by endoscopists from seven hospitals in Asia. Barrett's esophagus was graded using the Prague C & M Criteria whereby the circumferential extent of the Barrett's segment (C value), maximum extent of Barrett's segment (M value), location of the gastroesophageal junction, and location of the diaphragmatic hiatus were scored. The intraclass correlation coefficients (ICC) were calculated as a measure of interobserver reliability.

RESULTS

A total of 34 endoscopists participated. ICC values for the scores of the C value, M value, location of the gastroesophageal junction, and location of the diaphragmatic hiatus were: 0.92 (95 % confidence interval [CI] 0.88 - 0.97), 0.94 (95 %CI 0.90 - 0.98), 0.86 (95 %CI 0.78 - 0.94), and 0.81 (95 %CI 0.71 - 0.92), respectively, indicating excellent interobserver agreement. The differences in region/country, endoscopists' experience, case volume of participating centers, or primary practice type had no significant effect on the reliability. The ICC values for recognition of Barrett's esophagus of > or = 1 cm were 0.90 (95 %CI 0.80 - 1.00) and 0.92 (95 %CI 0.87 - 0.98) for the C and M values, respectively, whereas the corresponding ICC values for Barrett's segment of < 1 cm were 0.18 (95 %CI 0.03 - 0.32) and 0.21 (95 %CI 0.00 - 0.51), respectively.

CONCLUSIONS

Despite the uncommon occurrence of Barrett's esophagus in Asia, our endoscopists exhibited excellent agreement in the endoscopic diagnosis and grading of Barrett's esophagus using the Prague C & M Criteria. However, in view of the low interobserver reliability in recognizing Barrett's segments of < 1 cm, future studies in Asia should take this into account when selecting the study population.

Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding

BACKGROUND

Intestinal bleeding in patients with typhoid fever usually occurs in the ileum. However, endoscopic findings in such patients are not well established. We examined the colonoscopic manifestations of intestinal lesions with bleeding in patients with typhoid fever.

PATIENTS AND METHODS

The colonoscopic findings of seven patients who presented with haematochezia due to typhoid fever were reviewed retrospectively. Typhoid fever was diagnosed when the Salmonella typhi was isolated or when the Widal test showed strongly positive reactions.

RESULTS

Clinical data and colonoscopic findings were reviewed in seven patients (four men and three women with an average age of 42 years). The most commonly involved area was the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%). Left colon was intact in all cases. The most common colonoscopic finding was multiple variable-sized punched-out ulcers with slightly elevated margin, as found in five patients. In two patients, only several oedematous hyperaemic mucosal patches with haemorrhagic spots or shallow erosions were seen. Active bleeding was noticed only in one patient, who received endoscopic haemostasis twice. The remaining six patients were treated by conservative treatment including antibiotic therapy. There was no complication during or after the colonoscopic examination.

CONCLUSIONS

Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations.

Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding

BACKGROUND

Intestinal bleeding in patients with typhoid fever usually occurs in the ileum. However, endoscopic findings in such patients are not well established. We examined the colonoscopic manifestations of intestinal lesions with bleeding in patients with typhoid fever.

PATIENTS AND METHODS

The colonoscopic findings of seven patients who presented with haematochezia due to typhoid fever were reviewed retrospectively. Typhoid fever was diagnosed when the Salmonella typhi was isolated or when the Widal test showed strongly positive reactions.

RESULTS

Clinical data and colonoscopic findings were reviewed in seven patients (four men and three women with an average age of 42 years). The most commonly involved area was the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%). Left colon was intact in all cases. The most common colonoscopic finding was multiple variable-sized punched-out ulcers with slightly elevated margin, as found in five patients. In two patients, only several oedematous hyperaemic mucosal patches with haemorrhagic spots or shallow erosions were seen. Active bleeding was noticed only in one patient, who received endoscopic haemostasis twice. The remaining six patients were treated by conservative treatment including antibiotic therapy. There was no complication during or after the colonoscopic examination.

CONCLUSIONS

Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations.

Increased risk of peristomal wound infection after percutaneous endoscopic gastrostomy in patients with diabetes mellitus

BACKGROUND

Results of prospective studies on the effect of prophylactic antibiotics before percutaneous endoscopic gastrostomy are conflicting. Factors for increased risk of peristomal wound infection have not been clearly identified.

AIM

To evaluate the incidence of complications of percutaneous endoscopic gastrostomy and to determine the predictors of wound infection.

PATIENTS AND METHODS

Percutaneous endoscopic gastrostomy was performed on 134 patients in different disease groups between January 1996 and June 2000. Medical records were carefully reviewed for demographic data, indications for percutaneous endoscopic gastrostomy, use of prophylactic antibiotics, complications and comorbid conditions predisposing to wound infection.

RESULTS

Of 134 patients, 22 (16.4%) developed complications after percutaneous endoscopic gastrostomy Wound infection, the most common complication, occurred in 19 patients (14.2%) and Pseudomonas aeruginosa was the most frequently isolated microorganism. In univariate analysis, non-malignant disease and diabetes mellitus were significantly associated with peristomal wound infection after percutaneous endoscopic gastrostomy. In multivariate analysis, only diabetes mellitus was an independent risk factor for the development of peristomal wound infection after percutaneous endoscopic gastrostomy (p = 0.035)

CONCLUSIONS

Patients with diabetes mellitus have a higher risk of peristomal wound infection after percutaneous endoscopic gastrostomy.

Long-term stress and Helicobacter pylori infection independently induce gastric mucosal lesions in C57BL/6 mice

BACKGROUND

Long-term psychological stresses may have a role in the pathogenesis of peptic ulcer. However, the interaction between stress and Helicobacter pylori infection in the development of peptic ulcer is not established. The aim of this study was to elucidate the roles of long-term stress and H. pylori infection in the development of gastric mucosal lesions in mice.

METHODS

The Sydney strain (SS1) of H. pylori was inoculated into the stomach of C57BL/J6 mice. Twelve weeks later, mice with or without H. pylori infection were exposed to long-term repeated water-immersion-restraint stress (WIRS) for 12 h per day, 3 times per week, for 8 weeks. Gastric mucosal lesions were evaluated both macroscopically (ulcer index) and microscopically (Updated Sydney System).

RESULTS

The long-term WIRS induced mild inflammation, oedema, interstitial haemorrhage and superficial erosions in the stomach of mice both with and without H. pylori infection. The degree of mucosal inflammation or atrophy in H. pylori-infected mice was not influenced by the stress. In the mice without H. pylori infection, the ulcer index of the stressed mice was greater than that of non-stressed mice (1.66 +/- 0.39 versus 0.17 +/- 0.08, P = 0.007). In the mice with H. pylori infection, the ulcer index (mean +/- s(x)) of the stressed mice was also greater than that of non-stressed mice (2.31 +/- 0.59 versus 0.64 +/- 0.22, P = 0.027).

CONCLUSIONS

The present study showed that long-term stress can induce gastric mucosal inflammation and erosions, and this effect may occur independently of H. pylori infection.

The effect of sildenafil on lower esophageal sphincter and body motility in normal male adults

OBJECTIVE

Sildenafil relaxes smooth muscle by blocking type 5 phosphodiesterase, which destroys nitric oxide-stimulated cyclic guanosine monophosphate. The aim of this study is to investigate the change of lower esophageal sphincter (LES) and body motility with the lapse of time after sildenafil infusion in normal male adults.

METHODS

After basal esophageal manometry in eight healthy male adult volunteers, we infused a 50-mg tablet of sildenafil dissolved in water in the stomach through the manometry catheter and observed the changes of LES and body motility with the lapse of time. We randomized the study population into two groups, and esophageal manometry was repeated in LES and body sequence in four volunteers and in body and LES sequence in the other four volunteers immediately after sildenafil infusion.

RESULTS

LES resting pressure significantly decreased after sildenafil infusion. The body peristaltic amplitude gradually decreased and eventually disappeared, and the latency increased significantly after sildenafil infusion in both the proximal and distal esophagus.

CONCLUSIONS

These data support that nitric oxide mediates LES relaxation and the timing of esophageal peristalsis. In the future, sildenafil can be tried in some esophageal motor disorders, which have defects in nitric oxide neuromuscular communication.

Interaction between cyclooxygenase-2 and inducible nitric oxide synthase in gastric cancer

BACKGROUND

Chronic expression of cylcooygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) may play an important role in gastric carcinogenesis. Thus, the purpose of our study was to assess the expression of COX-2 and iNOS messenger RNA (mRNA) in gastric cancer and to investigate the correlation between the expression of COX-2 and iNOS mRNA in these patients.

STUDY

Twenty-three gastric carcinoma specimens and accompanying adjacent specimens were obtained from surgical resection. The expression of COX-2 and iNOS were examined by comparative reverse transcription polymerase chain reaction.

RESULTS

Cylcooygenase-2 and iNOS mRNA were significantly higher in gastric cancer tissues than in adjacent normal tissues. There was significant correlation between the levels of COX-2 and iNOS mRNA in carcinoma tissues. However, there was no significant correlation between the level of COX-2 or iNOS mRNA expression and several clinicopathologic parameters in these patients.

CONCLUSION

The expression of COX-2 and iNOS may be one of the factors that contribute to gastric carcinogenesis.

Role of autonomic dysfunction in patients with functional dyspepsia

BACKGROUND

The role of autonomic dysfunction in patients with functional dyspepsia is not completely understood.

AIMS

1. to prospectively assess abnormalities of autonomic function in patients with functional dyspepsia, 2. to assess whether autonomic dysfunction in these patients is associated with a. visceral hypersensitivity or b. delayed gastric emptying or c. severity of dyspeptic symptoms.

PATIENTS

A series of 28 patients with functional dyspepsia and 14 healthy volunteers without gastrointestinal symptoms were studied.

METHODS

All patients and controls were submitted to a battery of five standard cardiovascular autonomic reflex tests, dyspeptic questionnaire, gastric barostat tests and gastric emptying tests.

RESULTS

1. Autonomic function tests showed that both sympathetic and parasympathetic scores of dyspeptic patients were significantly higher than in controls; 2. visceral hypersensitivity was confirmed in dyspeptics in response to proximal gastric distension, demonstrating lower pain threshold; 3. delayed gastric emptying occurred more frequently in patients with functional dyspepsia than in controls; 4. epigastric pain and epigastric burning were significantly more prevalent in patients with definite evidence of autonomic dysfunction; 5. No significant association was found between presence of autonomic dysfunction and presence of visceral hypersensitivity or presence of delayed gastric emptying in patients with functional dyspepsia.

CONCLUSIONS

We concluded that a possible role of autonomic dysfunction in eliciting dyspeptic symptoms could not be determined from alterations in visceral hypersensitivity or delayed gastric emptying. Autonomic dysfunction might not be the major explanation for symptoms associated with functional dyspepsia.

Risk factors suggesting malignant transformation of gastric adenoma: univariate and multivariate analysis

BACKGROUND AND STUDY AIMS

Since gastric adenomas are precancerous lesions, polypectomy is necessary. However, there have been no reports suggesting factors capable of predicting malignant transformation of gastric adenomas removed by endoscopic snare polypectomy (ESP) or endoscopic mucosal resection (EMR) in Korea, a country in which gastric cancer is a major problem. The aim of this paper was to elucidate the risk factors suggesting malignant transformation of gastric adenomas removed by ESP or EMR at our center.

PATIENTS AND METHODS

Between November 1994 and June 1999, 118 gastric adenomas diagnosed on the basis of endoscopy and histological examinations of the forceps biopsy specimens obtained were treated by ESP or EMR at our department. Factors capable of predicting malignancy were searched for in the endoscopy reports, still photographs, and histopathological findings.

RESULTS

Eight of the 118 adenomas ultimately proved to have malignant foci. In the univariate analysis, four of the variables studied--location, histological type, surface redness, and degree of dysplasia--had a statistically significant relationship with malignant transformation. In the multivariate analysis, only the degree of dysplasia had a statistically significant relationship with malignant transformation.

CONCLUSIONS

These results suggest that a diagnosis of high-grade dysplasia in forceps biopsy material should be considered an absolute indication for ESP or EMR.

Malignant esophagogastric junction obstruction: palliative treatment with an antireflux valve stent

The authors assessed the efficacy of an antireflux valve stent in the palliation of malignant esophagogastric junction (EGJ) obstruction after in vitro testing of the stent. Seventeen patients with inoperable malignant EGJ obstruction were treated. Antireflux valves, made of three polyurethane leaflets, were attached to the distal part of the stent to prevent reflux. When the flow rate of normal saline was 100 mL/sec in the forward direction, the valve fully opened at a pressure of 10 mm Hg. When the flow rate of normal saline was 0.35 mL/sec in the backward direction, the valve nearly completely closed at a pressure of 10 mm Hg. Stent placement was successful in all patients without complications. The median dysphagia score decreased significantly, from 3.0 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food) (P < .0005). No patients experienced reflux symptoms. There was one case of stent migration. A valve stent that can prevent major reflux is an effective device for the palliation of malignant EGJ obstruction.

Clinical significance of enlarged perihepatic lymph nodes in chronic hepatitis B

GOALS

To evaluate the clinical significance of enlarged perihepatic lymph nodes in patients with chronic hepatitis B.

BACKGROUND

Enlargement of perihepatic lymph node is a common finding during ultrasonography in patients with chronic hepatitis. Its relation with liver histology and viremia was reported in chronic hepatitis C, but little has been known about its clinical significance in chronic hepatitis B.

STUDY

We evaluated the clinical significance of perihepatic lymphadenopathy in chronic hepatitis B. In 50 patients with biopsy-proven chronic hepatitis B and 15 healthy controls, the perihepatic lymph node volume was evaluated by ultrasonography and its possible correlation with biochemical tests, hepatitis activity index, and hepatitis B viremia was investigated.

RESULTS

Perihepatic lymph node was detected in 48 of 50 patients with chronic hepatitis B (volume = 3.4 +/- 2.4 mL) and in two of 15 controls (0.4 mL and 0.6 mL). In chronic hepatitis B, lymph node volume showed a significant correlation with serum aspartate transaminase (r = 0.66), alanine transaminase (r = 0.63), gamma-glutamyl-transpeptidase (r = 0.53), histologic activity index (r = 0.59), and necroinflammatory score (r = 0.59; p < 0.05 for all), but not with fibrosis score and serum hepatitis B viremia.

CONCLUSIONS

Enlarged perihepatic lymph nodes in chronic hepatitis B can be a good indicator for histologic and biochemical inflammatory activity of the liver, but not for viremia.

Lipiodol accumulation in focal peliosis hepatis with sinusoidal dilatation

Peliosis hepatis is a rare benign condition that is histologically characterized by multiple cystic blood-filled spaces in the liver. Although the cause is unknown, the condition occurs in association with several diseases or medications. We report a patient who was found to have a lesion with lipiodol accumulation in the liver 2 months after its intraarterial injection. The lesion was diagnosed and treated as a small hepatocellular carcinoma. However, subsequent right hepatic lobectomy and histologic examination confirmed the diagnosis of focal peliosis hepatis.

Inducible nitric oxide synthase expression in gastroduodenal diseases infected with Helicobacter pylori

BACKGROUND

Nitric oxide (NO) is synthesized enzymatically from L-arginine by NO synthase, which is measured by inducible NO synthase (iNOS). Helicobacter pylori (H. pylori) infection produces a state of chronic immunostimulation in the gastric epithelium. Infection with cagA+ H. pylori has greater degree of gastric inflammation and epithelial cell damage. Therefore, we compared the levels of iNOS in patients with H. pylori infection in relation to cagA status and H. pylori-related disease.

MATERIALS AND METHODS

One hundred and seven patients, including 51 patients with gastric cancer, 12 patients with gastric ulcer, 18 patients with duodenal ulcer and 26 patients with chronic gastritis, were enrolled in this study. Biopsies from the antrum and body were obtained for histologic examination, culture and reverse transcriptionase-PCR (RT-PCR) for detection of iNOS gene expression. The presence of H. pylori was confirmed by Giemsa staining or culture and the gene expression of cagA in H. pylori isolates was confirmed by PCR.

RESULTS

H. pylori infection was detected in 70.1% (75/107) and cagA was detected in 84.8% (28/33). iNOS expression was detected in 49.5% (53/107) and there was no significant difference in iNOS expression according to H. pylori infection nor the cagA status in the gastroduodenal diseases. However, iNOS expression was more frequently detected in gastric cancer than the other H. pylori-related diseases (64.7% vs. 35.7%, p <.05).

CONCLUSION

Although NO was thought be involved in the gastric carcinogenesis, the level of NO production was not related to H. pylori infection or cagA status.

An increased rectal maximum tolerable volume and long anal canal are associated with poor short-term response to biofeedback therapy for patients with anismus with decreased bowel frequency and normal colonic transit time

PURPOSE

Biofeedback is an effective therapy for a majority of patients with anismus. However, a significant proportion of patients still failed to respond to biofeedback, and little has been known about the factors that predict response to biofeedback. We evaluated the factors associated with poor response to biofeedback.

METHODS

Biofeedback therapy was offered to 45 patients with anismus with decreased bowel frequency (less than three times per week) and normal colonic transit time. Any differences in demographics, symptoms, and parameters of anorectal physiologic tests were sought between responders (in whom bowel frequency increased up to three times or more per week after biofeedback) and nonresponders (in whom bowel frequency remained less than three times per week).

RESULTS

Thirty-one patients (68.9 percent) responded to biofeedback and 14 patients (31.1 percent) did not. Anal canal length was longer in nonresponders than in responders (4.53 +/- 0.5 vs. 4.08 +/- 0.56 cm; P = 0.02), and rectal maximum tolerable volume was larger in nonresponders than in responders. (361 +/- 87 vs. 302 +/- 69 ml; P = 0.02). Anal canal length and rectal maximum tolerable volume showed significant differences between responders and nonresponders on multivariate analysis (P = 0.027 and P = 0.034, respectively).

CONCLUSIONS

This study showed that a long anal canal and increased rectal maximum tolerable volume are associated with poor short-term response to biofeedback for patients with anismus with decreased bowel frequency and normal colonic transit time.

Incidence and prevalence of ulcerative colitis in the Songpa-Kangdong District, Seoul, Korea, 1986-1997

BACKGROUND AND AIMS

Ulcerative colitis (UC) is regarded as a rare disease in developing countries, but accurate data are generally lacking. We performed the present study to evaluate the incidence and prevalence of UC in Korea.

METHODS

A retrospective study was performed from 1986 to 1997 in the Songpa-Kangdong district of Seoul, Korea. To recruit UC patients as completely as possible, multiple information sources including all medical facilities in the study area and three referral centres located nearby, but outside the study area were used. The incidence and prevalence rates were adjusted using the 1997 Korean population statistics.

RESULTS

During the study period, a total of 94 incident cases were identified, for an adjusted mean annual incidence rate of 0.68 per 100,000 inhabitants. On 31 December 1997, 91 patients with UC lived in the study area, giving an adjusted prevalence rate of 7.57 per 100,000 inhabitants. By using the Poisson regression analysis, the annual incidence rate increased significantly from 0.20 per 100,000 inhabitants in 1986-1988 to 1.23 per 100,000 inhabitants in 1995-1997 (P < 0.005). Patient age at diagnosis, the interval from onset of symptoms to diagnosis, and the disease extent at diagnosis were fairly constant throughout the study period.

CONCLUSIONS

The incidence and prevalence of UC in our study area are still low compared with those of Western countries, but the incidence rate is steadily increasing.

Hypotonic swelling increases L-type calcium current in smooth muscle cells of the human stomach

The purpose of the present study was to characterize the Ca2+ channels in smooth muscle cells from human stomach and to examine the effects of osmotic swelling on the channel activity. Ca2+ channel current with either Ca2+ or Ba2+ as charge carrier was recorded from freshly isolated smooth muscle cells using the conventional whole-cell patch clamp technique. The degree of cell swelling as a result of hypotonic challenge was monitored using a video image analysis system. The changes in intracellular Ca2+ concentration ([Ca2+]i) were measured by microfluorimetry. The pharmacological and voltage activation profile suggests a typical dihydropyridine-sensitive L-type Ca2+ current. Cell swelling, induced by hypotonic challenge, enhanced the amplitude of currents through L-type Ca2+ channels without significant effects on steady-state voltage dependency. After treatment with the L-type Ca2+ channel agonist Bay K 8644 (0.1-2 microM), no further significant increase in calcium channel current or corresponding [Ca2+]i transients were provoked by the swelling. The above results demonstrated that the presence of L-type Ca2+ current in smooth muscle cells of the human stomach and the augmentation of the current are closely associated with the volume increase resulting from hypotonic swelling.

Evaluation of individual symptoms cannot predict presence of gastric hypersensitivity in functional dyspepsia

Recently, the concept of gastric hypersensitivity was introduced as an important factor in the pathophysiology of functional dyspepsia (FD), but it is unclear which symptoms can predict the presence of gastric hypersensitivity. Therefore, we evaluated the relationship between common symptoms of FD and various parameters measured by gastric barostat in FD patients. Gastric barostat tests were performed in 64 FD patients and 20 healthy control subjects without gastrointestinal symptoms. Individual symptoms such as early satiety, postprandial fullness, sense of delayed emptying, nausea, vomiting, and epigastric soreness were collected and graded as mild to severe. Basal tone, gastric compliance, and postprandial receptive relaxation were similar in controls and patients, the threshold of abdominal discomfort was lower in FD patients than in controls (8.9 +/- 3.6 mm Hg and 14.5 +/- 3.7 mm Hg, respectively, P < 0.05). However, there were no significant differences in the threshold of abdominal discomfort according to the severity of individual symptoms. In conclusion, a simple evaluation of individual symptoms could not predict the presence of gastric hypersensitivity.

Muscarinic receptors controlling the carbachol-activated nonselective cationic current in guinea pig gastric smooth muscle cells

Muscarinic receptor subtypes controlling the nonselective cationic current in response to carbachol (ICCh) were studied in circular smooth muscle cells of the guinea pig gastric antrum using putative muscarinic agonists and antagonists. Both oxotremorine-M (an M2-selective agonist) and CCh dose-dependently activated the cationic current with EC50 values of 0.21 +/- 0.01 microm and 0.97 +/- 0.06 microM, respectively. In contrast, pilocarpine and McN-A 343 (an M1-selective and a putative M4 agonist) were weak partial agonists. In response to 10/microM CCh, 4-DAMP, methoctramine and pirenzepine dose-dependently inhibited ICCh and had IC50 values of 1.91 +/- 0.2 nM, 0.46 +/- 0.07 microM and 8.33 +/- 0.4 microM, respectively. 4-DAMP, methoctramine and pirenzepine shifted the concentration-response curves of ICCh to the right without significantly reducing the maximal current. Values of the apparent dissociation constant pA2 obtained from Schild plot analysis were 9.24, 7.72 and 6.62 for 4-DAMP, methoctramine and pirenzepine, respectively. Also, pertussis toxin completely blocked ICCh generation. These results suggest that the M2-subtype plays a crucial role in the activation of the ICCh, and a block of the M3-subtype reduces the sensitivity of the M2-mediated response with no significant reduction of maximum response.

The etiologic role of gastric hypersensitivity in functional dyspepsia in Korea

To evaluate the role of gastric hypersensitivity and the relationship between gastric hypersensitivity and delayed gastric emptying in Korean functional dyspepsia (FD) patients, the authors performed gastric barostat and gastric emptying scintigraphy in 64 FD patients and compared these results with those of control subjects. Basal tones and gastric compliance were similar in control subjects and patients. However, threshold of abdominal discomfort was lower in FD patients than in control subjects (8.9 +/- 3.6 mmHg and 14.5 +/- 3.7 mmHg respectively; p < 0.05). Twenty-four of 64 patients (37.5%) experienced abdominal discomfort at a pressure less than 7 mmHg above minimal distending pressure (corresponding to the 95th percentile of normal values). Half time of solid-phase gastric emptying in patients and control subjects was not significantly different. Twenty-three of 64 patients (35.9%) had delayed gastric emptying compared with control subjects (normal ranges were mean +/- two standard deviations in control subjects). Thresholds of abdominal discomfort were not significantly different in patients with and without delayed gastric emptying (9.3 +/- 4.0 mL/mmHg vs. 8.6 +/- 3.3 mL/mmHg). There were also no significant differences in the proportion of patients with delayed gastric emptying between patients with and without gastric hypersensitivity. In conclusion, gastric hypersensitivity plays an important role in FD, and the presence of gastric hypersensitivity was not related to the presence of delayed gastric emptying.

Lack of association of Helicobacter pylori infection with gastric hypersensitivity or delayed gastric emptying in functional dyspepsia

OBJECTIVE

We evaluated the relationship between Helicobacter pylori (H. pylori) infection and gastric sensitivity to distention or gastric emptying rate to define the role of H. pylori in the pathogenesis of functional dyspepsia.

METHODS

Gastric barostat, gastric emptying scintigraphy, and 13C urea breath test were performed in 34 consecutive patients with functional dyspepsia.

RESULTS

Between H. pylori-positive and -negative patients with functional dyspepsia, there were no significant differences in basal tone (57.2 +/- 15.0 ml vs 66.8 +/- 18.3 ml), compliance (41.0 +/- 11.2 ml/mm Hg vs 38.2 +/- 11.8 ml/mm Hg), threshold of first sense (3.6 +/- 2.7 mm Hg vs 2.3 +/- 1.5 mm Hg), threshold of abdominal discomfort (9.4 +/- 4.0 mm Hg vs 7.3 +/- 1.9 mm Hg), and postprandial receptive relaxation (115.4 +/- 89.7 ml vs 99.0 +/- 88.7 ml), measured by gastric barostat. Half gastric emptying time (88.6 +/- 24.5 min vs 91.4 +/- 21.6 min) and retention rate at 120 min (32.8 +/- 17.8% vs 41.9 +/- 20.1%) were also similar between the two groups.

CONCLUSION

H. pylori infection was not associated with gastric hypersensitivity to distention or delayed gastric emptying.

Role of hyperinsulinemia and glucose intolerance in the pathogenesis of nonalcoholic fatty liver in patients with normal body weight

OBJECTIVES

The pathogenesis of nonalcoholic fatty liver in non-obese persons is poorly understood. We aimed to elucidate whether hyperinsulinemia and glucose intolerance are associated with development of fatty liver in patients with normal body weight.

METHODS

Forty-seven patients with fatty liver were divided into non-obese (n = 25) and obese groups (n = 22) according to age adjusted body mass index. Inclusion criteria were as follows: (1) elevated transaminase levels during more than 3 months of follow up period, (2) no detectable HBsAg or anti-HCV in the serum, (3) alcohol consumption less than 40 gm/week, (4) no use of potential hepatotoxic drugs within 3 months and (4) sonographic evidence of fatty liver(moderate to severe degree). Baseline insulin levels and oral glucose tolerance test using 75gm of glucose were performed and the results were compared in each group of patients.

RESULTS

Mean baseline insulin levels were elevated in both groups above the reference value, 9.3 +/- 3.5 microU/L in non-obese group and 9.9 +/- 3.5 microU/L in obese group (p = 0.26). Seventeen of non-obese patients (68%) had elevated basal insulin level and 16 of obese patients (73%) had elevated basal insulin level (p = 0.39). In oral glucose tolerance test, there was no difference in glucose level between non-obese and obese groups from O minute to 180 minutes (p > 0.05). Eleven patients from the non-obese group (44%) and 8 patients from the obese group (36%) had either impaired glucose tolerance or diabetes (p = 0.29).

CONCLUSION

Our data suggest that hyperinsulinemia and glucose intolerance may play a role in the pathogenesis of fatty liver in patients with normal body weight as well as in patients with obesity.

A case of ischemic colitis associated with pheochromocytoma

A 40-year-old woman was admitted because of abdominal pain and diarrhea. She sometimes experienced paroxysmal hypertension, sweating, headache, and palpitation. Sigmoidoscopic findings showed well-demarcated diffuse mucosal edema, hyperemia, and easy touch bleeding from distal descending colon up to the splenic flexure area. Barium x-ray showed loss of haustral marking, thumb printing appearance, and diffuse luminal stenosis in the transverse, descending, and sigmoid colon. On the abdominal computed tomogram, a 3.8-cm sized well-enhanced right adrenal mass was incidentally found. Twenty-four hour urinary excretion of vanillyl mandelic acid, norepinephrine, and normetanephrine were increased. Iodine131 metaiodobenzylguanidine scan showed hot uptake on the right adrenal gland compatible with pheochromocytoma. Exploratory laparotomy was done under the impression of ischemic colitis associated with pheochromocytoma. Adrenalectomy and resection of the stenotic left colon were performed. After surgery, pain subsided, blood pressure fell gradually, blood sugar and catecholamine level became normal, and bowel habit returned to normal.

Primary T-cell lymphoma of the colon

A 40-year-old woman had been diagnosed with Crohns disease in September 1994, but later examinations revealed a primary T-cell lymphoma of the colon. Colonoscopic and histological examination showed ulcerative lesions simulating Crohns disease involving the entire colon and the terminal ileum, and she was first diagnosed as having Crohns disease. Differential therapeutic strategies, including corticosteroid, had improved the symptoms which were dominated by abdominal pain. When she visited our institute in April 1995, she presented with bloody stool twice a day, 7 kg weight loss in a period of six months and a slightly painful abdomen. Colonoscopic finding showed geographic ulceration on the entire colon, especially rectum and terminal ileum. The histologic examination of specimens from colonoscopic biopsy showed primary peripheral T-cell lymphoma of the colon. Any dense lymphocyte infiltrates seen in the biopsy specimens obtained from lesions simulating ulcerative colitis or Crohns disease should be assessed to exclude intestinal lymphoma.

Hypersensitivity to acid in ulcer-like functional dyspepsia

OBJECTIVES

The mechanism of pain sensation in patients with ulcer-like functional dyspepsia is unclear and there are no guidelines for its treatment. Whilst much research and many pharmacological treatments have provided symptomatic relief of ulcer-like functional dyspepsia through control of acid secretion, the role of acid in ulcer-like functional dyspepsia is unknown. We carried out this study to investigate the role of hypersensitivity to acid in the sensation of pain in ulcer-like functional dyspepsia by direct administration of acid into stomach.

METHODS

Twelve patients with ulcer-like functional dyspepsia (5 male, 7 female, mean age 41.0 years old, 7 with mild chronic superficial gastritis, 2 with metaplastic gastritis and 3 with normal endoscopic findings) and seven healthy control subjects (3 male, 4 female, mean age 36.0 years old, 7 with normal endoscopic findings) participated in the study. After overnight fasting, a nasogastric sump tube was inserted and its tip was positioned in the antrum under fluoroscopic guidance. Normal saline or 0.1N hydrochloric acid was administered in random and single blind cross over fashion. The test was considered positive only if similar pain developed-similar to that experienced by the patient under nonstudy condition- during the administration.

RESULTS

Five patients (41.7%) developed pain with 0.1N hydrochloric acid administration, but none with normal saline (p < 0.05). None of the healthy controls developed pain upon administration of 0.1N hydrochloric acid or normal saline.

CONCLUSION

We suggest that acid hypersensitivity plays a role in the sensation of pain in ulcer-like functional dyspepsia.

The role of mucosal biopsy in the diagnosis of chronic diarrhea: value of multiple biopsies when colonoscopic finding is normal or nonspecific

OBJECTIVES

There are controversies about taking routine mucosal biopsy when the gross colonoscopic finding is normal. This study was conducted to determine the frequency of clinically important histological abnormalities, prospectively, in chronic diarrhea patients with grossly normal or nonspecific colonoscopic findings.

METHODS

One hundred and eighteen patients suffering from nonbloody diarrhea with average frequency of more than two times a day for more than 4 weeks were included. Multiple biopsies (cecum, ascending colon, mid-transverse colon, descending colon, sigmoid colon and rectum) were taken during colonoscopic examinations and each biopsy specimen was reviewed by one pathologist after H&E and Masson-trichrome staining.

RESULTS

Clinically significant abnormalities (2 collagenous colitis, 1 lymphocytic colitis, 1 eosinophilic enterocolitis, 1 ulcerative colitis and 4 melanosis coli) were observed in 9 patients (7.6%). Sixteen cases (13.6%) of borderline histological abnormalities were observed (8 cases of possible collagenous colitis and 8 cases showing some features of lymphocytic colitis). Ninety two cases (78.8%) showed nonspecific inflammation only.

CONCLUSION

Clinically important histological lesions can exist in significant percentage in spite of normal or nonspecific colonoscopic findings, which can justify routine mucosal biopsy in the evaluation of chronic diarrhea patients. The clinical significance of borderline histological abnormalities needs to be determined by careful follow-up studies.

The etiology and clinical characteristics of mesenteric adenitis in Korean adults

This study is aimed at investigating the etiology and clinical characteristics of mesenteric adenitis in Korean adults, prospectively. Clinical manifestations of fifteen patients who presented with the acute onset of right lower quadrant pain and sonographically enlarged mesenteric lymph nodes and normal appendix were evaluated. For etiologic diagnosis, stool culture, serologic test for Epstein-Barr virus, and Widal test were performed. Colonoscopy with mucosal biopsies and microbial tissue cultures were performed in 12 of 15 patients. Of fifteen patients 6 were male and the average age was 29.9 (17 approximately 41) years. Associated symptoms were diarrhea (80%), fever (73%), nausea and vomiting (27%). Right lower quadrant tenderness was observed in all cases but rebound tenderness was observed only in 26.7% of the cases. Etiology was identified in 7 cases (47%): 2 Yersinia enterocolitica infection, 2 non-typhoidal Salmonella infection, 2 tuberculosis, and 1 typhoid fever. In colonoscopic examination, signs of active inflammation were observed in 9 cases (75%) and inactive or normal findings in 3 cases (25%). All of our patients, except for the patients with tuberculosis and typhoid fever who needed specific antibiotic therapy, improved spontaneously without using antibiotics. In conclusion, the etiology of mesenteric adenitis in Korean adults seems to be different from that of western countries. Furthermore, mesenteric adenitis in Korean adults is a clinical syndrome, frequently found in a relatively young age group, which improves spontaneously unless specific anti-microbial agents are indicated by microbiological tests, such as tuberculosis or typhoid fever.

Acute pancreatitis complicating pregnancy in a patient with co-existing choledochal cyst

Choledochal cyst, although more common in females than in males, has only rarely been encountered in association with pregnancy. A 29-year-old nulliparous woman at 32nd week gestation was diagnosed as acute pancreatitis with co-existing type l choledochal cyst. Resection of the choledochal cyst was performed and a Roux-en-Y hepatico-jeunostomy was carried out to provide biliary drainage. Although the preferred management of a choledochal cyst is excision and Roux-en Y reconstruction, this may have to be deferred until after delivery, depending on gestational age, because of the risk of fetal mortality and maternal morbidity that is associated with this procedure.

Intracellular Ca2+ oscillations in vascular smooth muscle cells

We monitored caffeine- and histamine-induced [Ca2+]i oscillations by patch-clamp whole-cell recordings of K(Ca)-current in single smooth muscle cells of rabbit cerebral (basilar) artery. Superfusion of caffeine (1 mM) or histamine (1-3 microM) induced periodic oscillations of large whole-cell K-current with fairly uniform amplitudes and intervals. Repetitive activations of the large-conductance K(Ca)-channels were recorded in the cell-attached patch mode. Inclusion of heparin (3 mg/ml) in the pipette solution failed to inhibit the oscillations caused by caffeine treatment, but blocked histamine-evoked oscillations. Ryanodine (1-10 microM) abolished both caffeine- and histamine-induced oscillations. Removal of extracellular Ca2+, but not verapamil or Cd2+, abolished the caffeine-induced oscillations, and the changes in the oscillatory frequency closely reflected the altered Ca2+ influx rate. These results indicate that in smooth muscle cells of the rabbit cerebral artery, ryanodine-sensitive Ca(2+)-induced Ca2+ release (CICR) pools play key roles for the generation of the [Ca2+]i oscillations.

Temporal changes in the clinical type or diagnosis of Behçet's colitis in patients with aphthoid or punched-out colonic ulcerations

The intestinal lesion of Behçet's colitis shows aphthoid or punched-out ulceration. However, the diagnosis of Behçet's colitis should be based on the presence of other stigmata of Behçet's syndrome, since these morphological characteristics are not pathognomonic by themselves. Furthermore, the stigmata of Behçet's syndrome could appear simultaneously or separately with intervals of several months to years. Besides, when a physician first meets patients with intestinal ulcerations of aphthoid or punched-out shape, if they do not have any stigma of Behçet's syndrome, the physician has some difficulty in making a diagnosis of Behçet's colitis. The purpose of this retrospective study was to investigate the followings: 1) The upgrade in clinical type of Behçet's colitis with the advance of time. 2) What portion of the patients with aphthoid or punched-out ulcerations, but without any other clinical feature of Behçet's syndrome, could be diagnosed as Behçet's colitis with the advance of time? During the mean follow-up period of 38.2 months, 4 (22.2%) out of 18 patients with Behçet's colitis upgraded their clinical types. In the nonspecific ileocolitis group, who had no major stigma of Behçet's syndrome on their initial visit, 3 (30%) out of 10 patients were subsequently diagnosed as Behçet's colitis during the mean follow-up period of 33.3 months. From these results, we could conclude that in possible or suspicious cases of Behçet's colitis, a more confident diagnosis could be made by close observations for new developments of major stigma of Behçet's syndrome. Even in cases of nonspecific ileocolitis, the diagnosis of Behçet's colitis could be made in a significant number of cases as time goes by.