A patient with obstructive jaundice due to bleeding in the common bile duct after ultrasound-guided liver biopsy

A-63-year-old man was referred to our hospital for interferon therapy to treat chronic hepatitis C. The patient complained of right upper abdominal pain 1 hour after the ultrasound-guided liver biopsy. Bleeding in the gallbladder and the common bile duct were found on emergency CT. Obstructive jaundice due to the common bile duct hematoma was diagnosed, and endoscopic retrograde cholangiopancreatography(ERCP) was performed, and a filling defect thought to be a hematoma was seen in the bile duct on cholangiography. The hematoma in the bile duct was extracted after endoscopic sphincteroyomy.

Tetracycline, metronidazole and amoxicillin-metronidazole combinations in proton pump inhibitor-based triple therapies are equally effective as alternative therapies against Helicobacter pylori infection

BACKGROUND

A proton pump inhibitor (PPI)-based triple therapy with clarithromycin (CAM) and amoxicillin (AMPC) is now a standard regimen for Helicobacter pylori (HP) eradication in Japan. However, the CAM-resistant rate has increased recently and alternative therapies are sorely needed. Therefore the aim of the present study was to evaluate the effectiveness and safety of the PPI-tetracycline (TC)-metronidazole (MNZ) regimen (the PTM regimen) as an alternative therapy in comparison with the PPI-AMPC-MNZ (PAM) regimen.

METHODS

Sixty-four HP-positive patients visiting the HP-eradication clinic in Tokai University Hospital from July 1998 to March 2003 were treated with either PTM or PAM as alternative therapies. The HP eradication was assessed by urea breath test (UBT), HP stool antigen test, or HP culture method more than 2 months after completion of the treatments. The drug resistances against CAM, AMPC, TC, and MNZ were assessed by the agar dilution method.

RESULTS

Fifty-six patients (26 PTM and 30 PAM) completed medication and evaluation of the eradication. The eradication rates of PTM were 82.8% (24/29) and 92.3% (24/26), while those of PAM were 74.3% (26/35) and 89.7% (26/29) by intention-to-treat and per-protocol analysis, respectively. The differences between the regimens were not statistically significant. There were no severe adverse effects observed in either of the regimens. The drug-resistance analyses showed 15 CAM- and one MNZ-resistant cases but no TC or AMPC resistance in the available 25 samples.

CONCLUSION

The PTM and PAM regimens were equally effective and safe as alternative HP eradication therapies. And PTM would be particularly useful in penicillin allergy cases.

A case of ileocolic intussusception from renal cell carcinoma

We report a case of ileal metastasis of renal cell carcinoma (RCC) in a 58-year-old male. The patient had a history of radical nephrectomy for a right RCC, and 2 years later underwent bilateral partial pneumonectomy for metastatic disease of the lung. A period of 1 year after the partial pneumonectomy, he developed bloody stools. Colonoscopy revealed an ileocolic intussusception caused by a polypoid tumor in the ileum, and the tumor was observed to be protruding into the ascending colon. The histological features of the tumor biopsy specimen confirmed the diagnosis of metastatic RCC. Metastasis of RCC in the small bowel is a rare disease clinically. To our knowledge, this is the first reported case with ileal metastasis of RCC, which has been definitively diagnosed by colonoscopy.

[Age-related clinical features in ischemic colitis]

Ischemic colitis has been considered to have relatively high prevalence in the elderly population with underlying vascular disorder such as hypertension. However, this disease has been recently reported increased in the young population so that it is not necessarily limited to the aged. The aim of the present study was to elucidate the characteristics of age-related clinical features in ischemic colitis. The subjects consisted of 30 patients with ischemic colitis admitted to our hospital during the last 5 years. They were divided into the aged group more than 65 years old and the young group aged 65 or less. As a result, there were no significant differences in symptoms, resulted serological examination, endoscopic findings, and treatment period. Lesion sites were more extended in the aged group. Concerning underlying disease and etiologic factors, the vascular factor was important in the aged group, while the peristaltic factor, especially constipation was important in the young group. Ten of the 30 patients had habitual constipation, and the aged group had a high percentage of paralytic constipation, while the young group had a high rate of spastic constipation. Many patients with paralytic constipation had a history of underlying diseases and laparotomy, while the patients with spastic constipation did not have such a history. Therefore, it is presumed that the spastic type of constipation is an etiologic factor in ischemic colitis.

[Long-term endoscopic follow-up for peptic ulcer patients after eradication of H. pylori; comparison with the maintainance therapy by H2-blocker]

This study was aimed to clarify the endoscopic findings and the decline of serum IgG titer after successful eradication of H. pylori in long-term (from 2 to 7 years). Forty-six H. pylori-positive peptic ulcer (22 GU and 26 DU) cases were eradicated with antimicrobial therapy. Sixty-nine non-eradicated DU cases who received maintainance therapy with H2-blocker were control group. Biopsy urease test (BUT) and culturing was performed to diagnose the H. pylori infection. Anti-H. pylori IgG titer (EIA) were also measured in some cases, pre and 6, 12, 24 months after the eradication. In 3 cases, H. pylori were recrudescent and only in a case, DU recurred during 5 years after eradication. Meanwhile, in 55% of control cases, DU were recurred during same periods. In 62% of eradicated cases, serum IgG-antibody to H. pylori declined below the cut-off level during 2 years after eradication. It was certified that eradication therapy against H. pylori prevents ulcer recurrence for long time, and re-rise of serum IgG titer to H. pylori might predict a recrudescence of infection.

The effect of Helicobacter pylori on gastric acid secretion by isolated parietal cells from a guinea pig. Association with production of vacuolating toxin by H. pylori

BACKGROUND

One of the features of Helicobacter pylori infection in the human stomach seems to be disordered gastric acid secretion. The effect of vacuolating toxin (VT) produced by H. pylori on gastric acid secretion was examined.

METHODS

VT(+)(toxigenic) and VT(-)(nontoxigenic) strains of H. pylori were cultured in brucella broth. The culture supernatant was added to isolated parietal cells, and acid secretion and intracellular adenosine 3'5'-cyclic phosphate (cAMP) and Ca2+ levels were measured with the 14C-aminopyrine (14C-AP) method, with 125I radioimmunoassay (RIA), and with the fura-2 fluorescence method, respectively.

RESULTS

In the VT(+) strain a considerable inhibitory effect on 14C-AP accumulation was observed. However, the VT(-) strain had no significant effect on intracellular c-AMP and Ca2+.

CONCLUSIONS

The VT(+) strain of H. pylori has an inhibitory effect on gastric acid secretion, whereas the VT(-) strain does not. This inhibitory effect was not associated with the response of second messengers. It is speculated that VT produced by H. pylori has a direct action on H(+)-K+ adenosine triphosphatase in parietal cells.

Aberrant insulinoma of the duodenal bulb

A rare insulin-immunoreactive neuroendocrine tumor of the duodenum in a 54 year old male is reported. The incidentally identified tumor was located on the anterior free wall of the duodenal bulb and measured approximately 6 mm in diameter. Uncomplicated endoscopic resection of the tumor was carried out. The lesion exhibited classic histologic features of insulinoma of the beta-islet cell type with stromal amyloid deposition. In addition to positive reactivities of chromogranin A, neuron-specific enolase, synaptophysin, Leu 7 (CD57), cystatin C, CA15-3 and cytokeratin, the non-argyrophilic tumor cells were strongly immunoreactive for insulin and C-peptide. The stromal amyloid was clearly labeled for amylin. A few cells were stained for somatostatin, whereas other hormones were negative. Interestingly, a few isolated insulin-positive cells were identified in the non-neoplastic duodenal mucosa in the proximity of the tumor. Immunoelectron microscopy using paraffin sections disclosed insulin-immunoreactive secretory granules in the cytoplasm. The patient exhibited no signs or symptoms of hypoglycemia. Serum insulin levels were not measured prior to resection. No tumors were demonstrated in the pancreas. Magnetic resonance imaging revealed a 1 cm asymptomatic pituitary mass, in association with moderately elevated serum prolactin levels. The patient is currently being followed up in the outpatient clinic.

A recurrent case of spontaneous mediastinal emphysema

The first case of spontaneous mediastinal emphysema was reported by Hamman et al. in 1939. It is a rare condition that primarily occurs in young adults. In many instances, spontaneous mediastinal emphysema is caused by yelling, shouting or active exercise, but the cause is often unknown. It is rare for cases of spontaneous mediastinal emphysema to recur. Recently, we experienced a recurrent case of spontaneous mediastinal emphysema in a patient with a duodenal ulcer. Vomiting appeared to be the cause of the recurrence in our patient. Of the 58 patients with spontaneous mediastinal emphysema who have been reported in Japan so far, recurrences were documented only in our patient and two others.

Eradication of Helicobacter pylori with lansoprazole, amoxicillin, and plaunotol in duodenal ulcer patients

Helicobacter pylori eradication therapy combining amoxicillin (AMPC), plaunotol (PL), and a proton pump inhibitor (PPI) was examined as an alternative to triple therapy, which has a high rate of side effects and low patient compliance. Thirty-two H. pylori-positive patients (24 men, 8 women) with duodenal ulcers were examined. The diagnosis of H. pylori infection was made by the urease test on specimens biopsied from two sites in the stomach. Simultaneously, the IgG antibody against H. pylori was measured by the EIA method. The therapeutic regimen was lansoprazole (LPZ) 30 mg q.d. (6 weeks) and AMPC 1,500 mg t.i.d. (2 weeks) plus PL320 mg b.i.d. (6 weeks). The rate of ulcer healing was judged endoscopically after 6 weeks. Cases that become urease-negative after the cessation of the therapy were defined as having achieved clearance, and those negative after 1 month as eradication. Within 6 weeks, 31 of 32 patients had healed ulcers. All patients were H. pylori antibody-positive before therapy. The clearance rate was 71.9% (23/32) and the eradication rate was 45.8% (11/24). Adverse effects were observed only in one case. We conclude that combination therapy with LPZ, AMPC, and PL has a high therapeutic effect on ulcer healing and moderate effectiveness for eradication of H. pylori.

Studies on hindered phenols and analogues. 1. Hypolipidemic and hypoglycemic agents with ability to inhibit lipid peroxidation

A series of hindered phenols were investigated as hypolipidemic and/or hypoglycemic agents with ability to inhibit lipid peroxidation. 1,3-Benzoxathioles (9 and 22), phenoxypentanoic acid (34), phenoxypentanol (35a), phenoxynonanol (35b), phenylchloropropionic acid having a chromanyl group (25), and a thiazolidine compound (27) derived from 25, all having a hindered phenol group, were prepared and examined. Compound 27 showed the expected biological properties in vivo and in vitro without any liver weight increase. Biological activities of the analogous thiazolidine compounds, 43-58, were compared. Thus, (+/-)-5-[4-[(6-hydroxy-2,5,7,8-tetramethylchroman-2-yl)methoxy]- benzyl]-2,4-thiazolidinedione (27) (CS-045) was found to have all of our expected properties and was selected as a candidate for further development as a hypoglycemic and hypolipidemic agent.

Fumarate reductase in the control of heme biosynthesis

A drug-induced stimulation of heme biosynthesis in mouse liver was accompanied by altered fumarate metabolism. In liver homogenate, fumarate 1,4-C(14) was incorporated, via succinate and succinyl coenzyme A, into heme at an accelerated rate. This pathway of fumarate utilization was inhibited by acetoacetate but not by beta-hydroxybutyrate. Fumarate reduction to succinate required reduced nicotinamide adenine dinucleotide. The enzyme fumarate reductase is suggested as a link between terminal oxidation and cellular control of the heme biosynthetic pathway.