Acute gastroduodenal mucosal lesion

AGML (acute gastric mucosal lesion) is now recognized as one of the important causal disease for gastrointestinal bleeding. If patients have sudden onsets of epigastralgia, epigastric discomfort, vomiting, hematemesis and melena following probable causes, it seems quite reasonable to make diagnosis of AGML by endoscopy with findings of gastric erosion, hemorrhagic gastritis and gastric ulcer. There are a variety of causes for AGML such as psychological and physical stress, drugs (NSAIDs, antibiotics, adrenal corticoid steroid, anti cancer drug), alcohol, serious organ failure of liver, kidney, heart, anisakiasis and etc. There are aslso a variety of endoscopic findings of AGML such as redness, edema, erosion, ulcer, bleeding which vary quickly in a short time. In this article we describe the definition, the cause, the clinical course, the location, the diagnosis, the endoscopic findings, our cases, the treatment of AGML.     

Anisakidosis: a cause of intestinal obstruction from eating sushi

We report a case of strangulating small bowel obstruction in a 60-yr-old Japanese woman caused by anisakidosis (previously known as anisakiasis). With the increasing popularity of Japanese cuisine such as sushi in the United States, the incidence of anisakidosis is expected to increase. Intestinal anisakidosis can now be treated temporarily, but this condition may cause a serious obstruction afterwards, as evidenced by this particular case. Over 13,500 cases were reviewed in both the Japanese and English literature, and we discuss the prevention of anisakidosis without negatively altering the taste of the raw fish.     

Evaluation of a computer-mediated eating disorder intervention program

Cancer is a genetic disorder in which gene alterations are selected to provide growth advantage by oncogene activation and/or tumor suppressor gene inactivation. Even marked intra-tumor variation in the histologic pattern, which is common in gastric carcinoma, is considered a result of distinct oncogenic pathways coexisting together. The present review describes that most gastric carcinomas arise through two distinct genetic pathways: microsatellite instability targeting the mononucleotide tracts within coding regions of cancer-related genes and chromosomal deletion involving tumor suppressor genes. With regard to malignant phenotypes, microsatellite instability is associated with the intestinal histological type and chromosomal deletion is correlated with the growth pattern of gastric carcinoma. Moreover, the genetic instability would in turn lead to an increase in alterations of cancer-related genes. The corresponding cells gradually manifest diverse neoplastic properties, thus bringing about consecutive subclonal evolution of more malignant cells. We now have some dues leading to the characterization of phenotypic complexity of gastric carcinoma based on gene-inactivation mechanisms.     

Serum oncostatin M in multiple myeloma: association with prognostic factors

Strongyloides stercoralis infection is of low prevalence in Malaysia. We report an unusual case presenting primarily with gastric symptoms. The patient was a 72 years old Chinese male admitted for progressive weight loss and abdominal bloating. Gastroscopic examination revealed mucosal prepyloric elevations in the gastric mucosa. Gastric strongyloidiasis was confirmed by the presence of adult forms, as well as ova and larval rhabditiform stages of the worm in the gastric mucosal crypts. We believe that this is the first histologically documented case of gastric strongyloidiasis in Malaysia.     

Gastric acidity in a double ulcer (of the stomach and duodenum)

Gastric salt-acid secretion was studied in three comparative patient groups with gastric ulcer, endoscopically confirmed, combination of gastric and duodenal ulcers. In the patients with double localization of the ulcer (stomach and duodenum) - hyperacidity was determined after pentagastrin stimulation. Acid-salt secretion was higher than that of the patients with gastric ulcer and was close to the secretion of those with duodenal ulcer, being but with a high standard deviation, necessitates consideration to be given to each concrete case of treatment. No discrepancy in the volume of gastric secretion before meals was established, thus impugning the role of pylor stasis in the genesis of secondary gastric ulceration. The incidence of atrophic gastritis in case of gastric and double ulcer is almost identical, hence attention is paid to the duodeno-gastric reflux as an eventual cause for damaging gastric mucosa with its successive ulceration in the patients with duodenal ulcer of many years. That is the reason, drugs enhancing the resistance of gastric mucosa as well as methoclopramid intake are proposed additionally to the drugs, neutralizing or blocking the gastric acid-salt secretion.     

Gastrointestinal bleeding after cold biopsy

Cold biopsy of the gastric mucosa is useful in many gastroduodenal disorders. Antral biopsies are done with increasing frequency to confirm Helicobacter pylori infection and to determine the type and content of gastritis. Gastrointestinal bleeding after gastric cold biopsy is rare. We report two patients who developed melena after cold biopsy of the gastric antrum. Repeat gastroscopies excluded lesions other than the biopsied sites as the source of bleeding. Colonoscopies in both cases did not reveal any evidence of lower GI bleed. Relevant medications include amlodipine, in case 1, and brufen, which was used in case 2 but discontinued before biopsy. Literature review has shown the rarity of clinically significant hemorrhage resulting from gastric cold biopsy. Nevertheless, all patients undergoing gastroscopy should be informed of this potential complication.     

Multidrug-resistant tuberculosis. 4. Treatment and prognosis of multidrug-resistant tuberculosis

Mucinous gastric carcinoma is a rare pathologic subtype of gastric adenocarcinoma. Whether the mucin behaves aggressively as in mucinous colorectal carcinoma is still controversial. Most mucinous gastric carcinomas are diagnosed from surgical specimens. The mucinous gastric carcinoma in this case report was discovered preoperatively according to its characteristic presentation. An upper gastrointestinal endoscopic examination showed a round protruding tumor of greater than 4 cm in size on the mid-body of the stomach; it had an uneven, friable and shiny surface. The surface was coated with a sticky layer of mucin-like substance, which persisted even after the aspiration of the gastric juice. Endoscopic ultrasonography (EUS) revealed a large heterogeneous hyperechoic tumor mass, originating from the mucosal and submucosal layers, on the body of the stomach. The mass was covered with a thick layer of hypoechoic amorphous substance. Hence, a mucin-producing tumor was suspected. Subsequent surgical biopsy proved the mass to be a moderately differentiated mucinous adenocarcinoma. This case illustrates the first endoscopic ultrasonographic report of an intraluminal mucin pool as a hypoechoic substance, which is quite different from the hyperechoic presentation of intramural mucin lakes. In preoperative evaluation, EUS is not only important for determining the depth of tumor invasion, but it is also useful in differentiating mucinous gastric carcinoma from nonmucinous gastric carcinoma.     

Assembly of Atlantic cod (Gadus morhua) brain microtubules at different temperatures: dependency of microtubule-associated proteins is relative to temperature

Isolated cod (Gadus morhua) brain microtubules were found to have a broad temperature interval for assembly. In contrast to mammalian microtubules they assembled even at as low temperatures as 14 degrees C. Evidence was found that temperature alters the dependency of microtubule-associated proteins (MAPs) for assembly. The assembly was MAPs-dependent at low, but not at higher temperatures. Assembly at +18 degrees C was inhibited by both NaCl and estramustine phosphate. These compounds are well known to inhibit the binding of MAPs to tubulin. At higher temperatures there was no MAPs dependency for assembly, despite that MAPs bound to the microtubules. Cow MAPs had the same effect as cod MAPs, suggesting that despite differences in MAP composition, the effect is not caused by the unusual composition of cod MAPs. The results therefore suggest that these differences in MAPs dependency are due to intrinsic properties of cod tubulin or tubulin-to-tubulin interactions. Small temperature-induced conformational changes of tubulin and a slight enrichment of acetylated and detyrosinated tubulin in microtubules assembled at +30 degrees C as compared to +15 degrees C, were observed. The ability to alter the assembly stimulating effect of MAPs may be important for the cell to regulate microtubule dynamics and stability. In addition, changes in tubulin conformation and composition of tubulin isoforms may reflect adaptations for microtubule assembly at low temperatures.     

Platelet-derived thromboxane A2 decreases microvascular perfusion after arterial repair

Previous work suggests that cod liver oil helps to protect the microcirculation from the consequence of thromboembolic events. The possibility that altered synthesis of thromboxane A2 accounts for the protective effects seen with cod liver oil was investigated in the present study. This was done using the combined thromboxane A2 synthetase inhibitor and thromboxane A2-prostaglandin H2 receptor blocker R68070 (Ridogrel). A standardized microvascular injury was inflicted on the right iliac artery of the rat to generate emboli. The downstream cremaster muscle was used to visualize the passage of the ensuing emboli and to assess the effects of this arterial injury on capillary perfusion and arteriole diameters. The number of visible emboli was not changed by either cod liver oil diet or Ridogrel administration. However, capillary perfusion was preserved by using cod liver oil (n = 7) and was significantly increased by using Ridogrel (n = 7) in comparison with untreated controls (n = 7) in which capillary perfusion was decreased because of the emboli. The administration of Ridogrel to cod liver oil-treated animals (n = 7) provided no additive benefit. The percentage change in A-2 vessel diameters in cod liver oil-treated (n = 7) animals was no different from the control group (n = 7). Ridogrel (n = 7), on the other hand, produced a significant increase in A-3 vessel (n = 21) diameters, but its effects were comparatively less in the cod liver oil-treated animals (n = 7). The formation of platelet aggregates (emboli) appears relatively independent of thromboxane A2 in the rat. Ridogrel is very effective in protecting the microcirculation, and these effects appear to be mediated by A-3 vasodilatation, which, therefore, is at least partially thromboxane A2-dependent. The positive effects of cod liver oil may be mediated by a mechanism that reduces thromboxane A2 synthesis, but further studies are necessary.     

Gastrointestinal complications associated with intramuscular ketorolac tromethamine therapy in the elderly

OBJECTIVE: To report 3 cases of gastrointestinal (GI) complications associated with the use of intramuscular ketorolac tromethamine therapy in elderly patients. CASE SUMMARIES: In case 1, an 88-year-old woman was taken to surgery for the management of an acute abdomen and repair of a 2+ cm perforated prepyloric gastric ulcer. The patient had received a total 16 doses of ketorolac 30 mg im. The patient died after surgery from complications associated with bacterial and candidal sepsis, as well as acute renal failure. In case 2, an 80-year-old woman with no known history of GI problems developed a prepyloric gastric ulcer, which perforated and penetrated into the pancreas after the patient received 13 doses of ketorolac 30 mg im. The patient died from complications associated with candidal sepsis, peritonitis, and cardiopulmonary collapse. In case 3, an 85-year-old man with a history of a gastric ulcer developed GI bleeding after receiving a total of 9 doses of ketorolac 30 mg im. The bleeding was stabilized and the patient was discharged 12 days later in stable condition. DISCUSSION: Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug with potent analgesic properties. We report 3 cases of GI complications associated with intramuscular ketorolac therapy in the elderly. A temporal relationship was established with the development of gastric ulceration in 2 patients and the recurrence of a gastric ulcer in the third patient. CONCLUSIONS: We recommend that the manufacturer's guidelines be followed when ketorolac is used in elderly patients, and the drug should not be used in patients with a history of gastric ulcer disease. The use of misoprostol may be warranted as prophylactic therapy in high-risk patients who are receiving ketorolac.     

Esophageal intramural metastasis from an adenocarcinoma of the gastric cardia: report of a case

We report herein the rare case of a 65-year-old man found to have esophageal intramural metastasis from cancer of the gastric cardia. Endoscopic examination initially revealed an infiltrating ulcerative tumor of the gastric cardia involving the esophagogastric junction, as well as a submucosal tumor of the lower esophagus. A total thoracic esophagogastrectomy with lower mediastinal lymphadenectomy was performed, and the resected specimen demonstrated that both the cardia and esophageal tumors were adenocarcinomas with the same cellular differentiation. As lymphatic invasion and metastases to the paracardial and mediastinal lymph nodes were observed, the esophageal submucosal tumor was considered to be an intramural metastasis from the carcinoma of the gastric cardia resulting from extensive lymphatic spread. The patient died of recurrent disease 9 months after the resection. This case report serves to demonstrate that intramural metastasis may be a local indicator of the systemic spread of disease in patients with gastric carcinoma, as it is in esophageal carcinoma.     

Gastric carcinoma resected 95 months after being diagnosed: report of a case

It is usually assumed that patients with gastric carcinoma will almost certainly die within 5 years if they do not receive treatment. We report herein a rare case of curative gastrectomy being performed 95 months after gastric carcinoma was diagnosed. A 37-year-old Japanese man had an upper gastrointestinal endoscopy with biopsy which revealed moderately differentiated adenocarcinoma of the stomach. This was diagnosed as type IIc early gastric carcinoma with ulceration but he refused surgery. At 45 years of age, 95 months later, he presented to our hospital with melena, at which time lesions in an identical location had enlarged to Borrmann type 3 advanced gastric carcinoma. Thus, a total gastrectomy with regional lymph node dissection was performed. Although there was no liver or peritoneal metastasis, the regional lymph nodes were involved; however, the patient recovered well and is still alive without any further recurrence roughly 4 years postoperatively. The natural history of gastric carcinoma and the malignant cycle are discussed following the presentation of this case.     

Polychlorinated diphenyl ethers, dibenzo-P-dioxins and dibenzofurans in Finnish human tissues compared to environmental samples

Finnish human samples from the Helsinki area and Arctic cod samples from Vestertana Fjord (Norway) were analyzed for polychlorinated diphenyl ethers (PCDE) and 2,3,7,8-chloro substituted dibenzo-p-dioxins (PCDD) and dibenzofurans (PCDF). The PCDE, PCDD and PCDF contents in human and animal samples from Finland and elsewhere were briefly reviewed. PCDEs were non-detectable in human liver and testis, but some PCDE congeners were identified in human adipose tissue and fat of boiled Arctic cod liver composite. The contents of PCDEs in Finnish human samples were similar to those reported in the literature for human tissues from North America. The estimated concentrations of PCDEs 99, 147 + 153 (coeluting) and 206 ranged between 2 and 8 ng/g lipid weight (lw) in one Finnish human adipose tissue. The concentrations of PCDE congeners identified in the cod liver fat were between 0.4 and 5 ng/g lw. Of toxic PCDDs and PCDFs, hepta- and octa-CDDs dominated in human. The concentrations of PCDD and PCDF congeners varied from < 2 to 7700 pg/g lw in human. In Arctic cod samples analyzed (muscle tissues of an air dried cod and cod liver fat), 2,3,7,8-tetra-CDF was nearly the only congener of PCDD/PCDFs detected.     

Massive gastrointestinal bleeding from Meckel''s diverticulum in a 91-year-old man

Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal (GI) tract, complications in adults are rare, especially in the elderly. Intestinal obstruction is the most common complication in the adult, and inflammation mimicking acute appendicitis may also occur. Lower GI bleeding as a result of Meckel's diverticulum with ectopic gastric mucosa is distinctly unusual among the elderly, with most previous case reports involving patients under the age of 40. The case we report involved a 91-year-old man with massive lower GI hemorrhage found to be due to a Meckel's diverticulum with ectopic gastric mucosa.     

Combined microwave-assisted extraction and gel permeation chromatography for the determination of chlorinated hydrocarbons in seal blubber and cod livers

A fast and effective sample clean-up procedure for the quantitation of chlorinated hydrocarbons in seal blubber and cod livers is presented. Lipophilic sample ingredients are extracted by application of microwave energy. Microwave-assisted extraction (MAE) was performed with ethyl acetate and cyclohexane as solvent. Without exchange of the solvent, the organochlorine compounds are separated from matrix coextractives by gel permeation chromatography. Traces of matrix remainders were separated on deactivated silica prior to GC/ECD analysis. In this study we focused on quantification of PCB 153, PCB 138, PCB 180, HCB, and p,p'-DDE. In seal blubber, the recovery rates for these organochlorines were > 90% for the complete sample clean-up procedure. The standard deviation of the overall-method was within 5%. MAE of cod livers required softer conditions. After optimization of the MAE the organochlorine levels in cod liver were almost identical with those determined with another independent clean-up method.     

Low-grade gastric MALT lymphoma and helicobacter heilmannii (Gastrospirillum hominis

We report the fourth case of low-grade gastric MALT lymphoma associated to Helicobacter heilmannii. This spiral organism may be present in the gastric mucosa of animals where it is non pathogenic while, in humans, its presence is always associated with chronic gastritis. In this case, Helicobacter heilmannii was observed in the absence of Helicobacter pylori. Regression of endoscopic and histological lesions after Helicobacter heilmannii eradication suggests its role in gastric lymphoma. This observation underlines the need for searching for Helicobacter heilmannii by careful histological examination, in the absence of Helicobacter pylori, and the importance of its eradication in the treatment of gastric lymphoma.     

Leiomyosarcoma of the stomach

A case of gastric leiomyosarcoma (primary maliganant mesenchymal neoplasia of non-lymphoblastic origin) personally observed, is presented. The pathological anatomy, aetiopathogensis, symptomatology and diagnosis of this disease are described as well as the surgical treatment of the case.     

Diabetic muscle infarction: a difficult diagnosis suggested by magnetic resonance imaging

Malignant pericardial effusion is an uncommon disorder and is usually caused by far advanced lung cancer, breast cancer, lymphoma and leukaemia. Pericardial effusion in recurrent gastric cancer has been reported in only three patients. We report the case of a 53-year-old male with sudden onset of dyspnoea, pericardial effusion and cardiac tamponade and the unexpected and the asymptomatic concurrence of gastric cancer. Recurrent haemorrhagic pericardial effusion with physical signs of cardiac tamponade as the initial and only clinical manifestation of gastric cancer has not been described previously.     

Gastric re-resection in emergency

BACKGROUND/AIMS: We reviewed a consecutive series of patients with acute complications following gastric resection, in order to evaluate the role of gastric re-resection as the operation of choice in emergency. METHODOLOGY: Records of 90 patients with acute complications following gastric resection observed from January 1991 to January 1996 were retrospectively analyzed. RESULTS: Hemorrhagic events occurred in the vast majority of cases (87), either as acute complications after a long time since surgery (78 cases) or as early postoperative complications (9). Among late acute complications, three cases were related to bleeding cancer of the gastric stump. Anastomotic obstructions presenting as acute complications occurred in 3 cases. Emergency surgery was indicated in three cases of acute obstruction, in 1 case of bleeding cancer of the gastric stump, in 9 (12%) out of the 75 remaining late acute hemorrhagic complications and in 1 (11%) out of 9 early hemorrhagic complications. Completion gastrectomy was chosen in the one case of bleeding cancer of the gastric stump with indication for emergency surgery. Gastric re-resection was performed in 11 cases: 9 for hemorrhagic complications and 2 for obstructive acute complications. In two cases, one for hemorrhage and one for occlusion, other surgical procedures were carried out. CONCLUSIONS: Gastric re-resection can represent the most suitable operation in acute complications following gastric resection.     

Localization of human midisatellite and macrosatellite DNA sequences on chromosomes 1 and X in the great apes

We report the case of a 38-year-old man who, 2 weeks after a laparoscopic Nissen fundoplication, was referred to our Unit because of acute wrap herniation and intrathoracic gastric perforation. Although both of these complications have already been described, this is the first case in which they have occurred simultaneously and not as an immediate consequence of the operation. Intraoperative findings suggested that diaphragmatic crura had not been reapproximated and that the gastric wrap had not been fixed to them. This observation and the fact that immediately after hospital discharge the patient had sustained intense physical efforts can explain acute wrap herniation. Placement of full-thickness sutures may account for gastric perforation. These pathogenetic determinants and their preventive measures are discussed in the light of a review of the literature.