松本 吏弘

Although biologics are important inflammatory bowel disease therapies, loss of response (LOR) remains problematic. We evaluated LOR to biologics in our Crohn disease (CD) patients receiving biologics. Of 137 biologic-treated CD patients, 68 continuously receiving the same biologic type for at least 1 year were divided into 2 groups: infliximab (IFX) (n= 39) and adalimumab (ADA) (n= 29). Clinical courses were compared at biologic introduction and at 1 year. Both groups were retrospectively analyzed for LOR at and beyond 1 year after biologic introduction (study endpoint). Patients were then divided into LOR and non-LOR groups to identify factors predicting LOR. At 1 year after biologic introduction, decreases in CD activity index were 94 +/- 105 in the IFX and 102 +/- 89 in the ADA group, not significantly different. Blood test data did not differ between these groups. LOR occurred in 14 IFX and 5 ADA group patients. Event-free rates at 5 years after biologic introduction were 62% in the IFX and 61% in the ADA group. Patients achieving clinical remission 1 year after biologic introduction accounted for 69% of the IFX and 90% of the ADA group, while respective rates of secondary LOR at 5 years were 32% and 26%. C-reactive protein (CRP) at biologic introduction (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.04-2.06; P=. 02) and age at CD onset (OR, 1.1; 95% CI, 1.01-1.20; P=. 03) predicted LOR. As to IFX and ADA efficacies after 1 year of administration, there were no significant differences in event-free rates for the 5 years after biologic introduction or the secondary LOR rate. CRP at biologic introduction and age at CD onset predicted LOR.

There have been few reports regarding the improvement of hyperammonemic hepatic encephalopathy after the extirpation of a large uterine leiomyoma. We present a case of a 53-year-old postmenopausal woman who experienced a clouding of consciousness. She had been suffering from mild hepatitis and a large uterine leiomyoma. On admission, she had experienced constipation for seven days and exhibited a high serum ammonia level (251 g/dL). She was diagnosed with liver cirrhosis as a result of autoimmune hepatitis, combined with Sjogren's syndrome. A total hysterectomy was performed 29 days after admission. Severe diarrhea lasted for three days after surgery. By the sixth postoperative day, the patient's consciousness level had normalized and her serum ammonia level had fallen to 47 g/dL. Although the true mechanism of hyperammonemia in this case is unclear, we speculate that organic constipation following chronic obstruction of the colon might have played a role in the development of the condition.

31歳女性。大動脈炎症候群の治療中に、血便を認め当センターに入院した。下部消化管内視鏡検査にて、終末回腸に縦走潰瘍を認め、小腸型クローン病と診断した。寛解導入療法として、栄養療法とメサラジン製剤の内服に加え、生物学的製剤アダリムマブを投与した。寛解を得た後、プレドニゾロン・メトトレキセートの減量を行ったが、両疾患とも再燃・悪化なく経過している。両疾患の合併は稀であり、本邦からの報告例が19例、国外からの報告例を加えると55例に過ぎない。発症の順序に規則性は認めない。今回貴重な症例を経験したので、文献的考察を加え、報告する。(著者抄録)

Diversion colitis is a benign inflammatory process that occurs in any part of the large bowel excluded from the fecal stream by a diverting colostomy. While most of the patients with diversion colitis usually are asymptomatic, a minority has abdominal pain and rectal discharge of blood or mucus. A 65-year-old Japanese man was diagnosed as having diversion colitis with ulcerative colitis at 4 months after subtotal colectomy. Corticosteroid and mesalazine enemas were started nonsynchronously. A proctoscopy after 2 months showed no response. Prednisolone injections were started at 1.0 mg/kg daily, but the mucosal inflammation still failed to improve. A combined mesalazine 1 g plus prednisolone sodium phosphate 20 mg enema was started once daily. The rectal bleeding and endoscopic findings improved. Finally proctectomy and ileal pouch-anal anastomosis were successfully performed. A combined mesalazine plus corticosteroid enema may be effective in patients with diversion colitis associated with ulcerative colitis.

In recent years, cases of elderly-onset ulcerative colitis (UC) have been increasing in number and are currently reported to account for 10-15% of all cases of UC. Although the treatment of UC is essentially similar between older and younger patients, evidence of the therapeutic efficacy of tacrolimus in elderly-onset UC patients is still limited. Herein, we report our attempt to induce remission using tacrolimus in three patients with elderly-onset UC. A 75-year-old Japanese woman, a 71-year-old Japanese man and a 76-year-old Japanese woman with severe elderly-onset UC of the pancolitis type were treated with tacrolimus. Although all three patients showed response to the drug, the eventual outcome was poor in the first patient, who developed toxic megacolon, underwent surgery, and suffered from recurrent infections and hemorrhage after the surgery. However, clinical remission was successfully achieved in the second and third patient. Tacrolimus shows some indication of effectiveness in the treatment of elderly-onset UC. However, in elderly-onset UC patients, it is necessary to keep in mind the higher risk of adverse effects of medical therapy and postoperative complications because of the high comorbidity rates. Moreover, in situations where surgery needs to be considered, it is important to ensure appropriate timing of the surgery.

We report a case of an elderly man who developed myositis of the deltoid muscle 8 days after influenza vaccination. Adverse reactions to influenza vaccine are generally immediate reactions. However, delayed-type hypersensitivity reactions, although rare, can occur after routine influenza vaccination.

A one-week eradication therapy of <i>Helicobacter pylori</i> using metronidazole, clarithromycin, and omeprazole is generally considered a well-tolerated therapy with minor side effects. We report a 66-year-old male patient who developed diarrhea few days after the treatment, and <i>Clostridium difficile</i> toxin was detected in his stool. Although this is a rare complication, it can sometimes o

Background: Familial Mediterranean fever is a hereditary autoinflammatory disease, mainly characterized by periodic fever and serositis. The level of awareness about familial Mediterranean fever is far from sufficient, and it is assumed that there may be many patients with this disease who are under observation without an accurate diagnosis. Case presentation: A 30-year-old Japanese man presented to us with a few years' history of recurrent episodes of fever, abdominal pain and diarrhea. He often visited a hospital when the attacks occurred however, acute enteritis was diagnosed each time, and the symptoms resolved spontaneously within a few days. When he noticed a shortening of the interval between the attacks, he visited the hospital again. Upper endoscopy and colonoscopy performed at this hospital revealed no significant abnormal findings. He was then referred to our hospital under the suspicion of a small intestinal disease. Abdominal computed tomography revealed wall thickening and increased density of the mesenteric adipose tissue in the jejunum, which led us to suspect Crohn's disease. Oral double-balloon enteroscopy was performed because this revealed only mild mucosal edema in the jejunum, Crohn's disease was considered to be highly improbable. Based on the patient's clinical course, we suspected familial Mediterranean fever. As the Livneh criteria for familial Mediterranean fever were satisfied, the patient was started on oral colchicine for the purpose of diagnostic treatment. A definitive diagnosis of familial Mediterranean fever was then made based on the detection of a mutation of the Mediterranean fever gene. A marked reduction in the frequency of attacks was observed in response to colchicine treatment. Conclusions: Although Crohn's disease may be considered first in the differential diagnosis of young patients presenting with periodic fever, abdominal pain and diarrhea, the possibility of familial Mediterranean fever should also be borne in mind.

AIM: To determine an appropriate compartmentalization of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for duodenal tumors. METHODS: Forty-six duodenal lesions (excluding papillary lesions) from 44 patients with duodenal tumors treated endoscopically between 2005 and 2013 were divided into the ESD and EMR groups for retrospective comparison and analysis. RESULTS: The mean age was 65 +/- 9 years (35-79 years). There were 24 lesions from men and 22 from women. The lesions consisted of 6 early cancers, 31 adenomas and 9 neuroendocrine tumors. Lesion location was the duodenal bulb in 15 cases and the descending part of the duodenum in 31 cases. The most common macroscopic morphology was elevated type in 21 cases (45.6%). Mean tumor diameter was 11.9 +/- 9.7 mm (3-60 mm). Treatment procedure was ESD (15 cases) vs EMR (31 cases). The examined parameters in the ESD vs EMR groups were as follows: mean tumor diameter, 12.9 +/- 14.3 mm (3-60 mm) vs 11.4 +/- 6.7 mm (4-25 mm); en bloc resection rate, 86.7% vs 83.9%; complete resection rate, 86.7% vs 74.2%; procedure time, 86.5 +/- 63.1 min (15-217 min) vs 13.2 +/- 17.0 min (2-89 min) (P < 0.0001); intraprocedural perforation, 3 cases vs none (P = 0.0300); delayed perforation, none in either group; postprocedural bleeding, 1 case vs none; mean postoperative length of hospitalization, 8.2 +/- 2.9 d (5-16 d) vs 6.1 +/- 2.0 d (2-12 d) (P = 0.0067); recurrence, none vs 1 case (occurring at 7 mo postoperatively). CONCLUSION: ESD was associated with a longer procedure time and a higher incidence of intraprocedural perforation; EMR was associated with a lower rate of complete resection. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

A 25-year-old man was admitted with the chief complaints of right flank pain, watery diarrhea, and fever. Blood tests revealed high levels of inflammatory markers, and infectious enteritis was diagnosed. A stool culture obtained on admission revealed no growth of any significant pathogens. Conservative therapy was undertaken with fasting and fluid replacement. On day 2 of admission, the fever resolved, the frequency of defecation reduced, the right flank pain began to subside, and the white blood cell count started to decrease. On hospital day 4, the frequency of diarrhea decreased to approximately 5 times per day, and the right flank pain resolved. However, the patient developed epigastric pain and increased blood levels of the pancreatic enzymes. Abdominal computed tomography revealed mild pancreatic enlargement. Acute pancreatitis was diagnosed, and conservative therapy with fasting and fluid replacement was continued. A day later, the blood levels of the pancreatic enzymes peaked out. On hospital day 7, the patient passed stools with fresh blood, and Campylobacter jejuni/coli was detected by culture. Lower gastrointestinal endoscopy performed on hospital day 8 revealed diffuse aphthae extending from the terminal ileum to the entire colon. Based on the findings, pancreatitis associated with Campylobacter enteritis was diagnosed. In the present case, a possible mechanism of onset of pancreatitis was invasion of the pancreatic duct by Campylobacter and the host immune responses to Campylobacter. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

ObjectiveWe investigated factors that may affect hospitalization and surgery in patients presenting with aggravation of ulcerative colitis (UC).Materials and methodsThis study included 222 UC patients who had visited our hospital regularly since 2000 (127 men, 95 women; mean age at onset, 3416 years). We divided the patients into groups according to whether or not they were hospitalized for aggravation of UC (hospitalized group, n=75; nonhospitalized group, n=147), compared the clinical features and clinical courses between the two groups, and also analyzed the cumulative rates of surgery. Then, only the 75 patients of the hospitalized group were divided into two groups for a subanalysis (colectomy group, n=25; noncolectomy group, n=50).ResultsIn the hospitalized group, the rates of use of steroids and thiopurine immunomodulators were significantly higher, and the rates of concurrent cytomegalovirus (CMV) infection and surgery for UC aggravation were also significantly higher. Multivariate analysis identified CMV infection [odds ratio (OR), 8.2; 95% confidence interval (CI), 1.91-35.33; P=0.0047] and steroid use (OR, 4.4; 95% CI, 1.30-14.93; P=0.0170) as risk factors for hospitalization because of UC aggravation. Moreover, the cumulative rate of surgery was significantly higher in the hospitalized group (P<0.0001). Multivariate analysis as part of the subanalysis identified the use of thiopurine immunomodulators as a factor for avoidance of surgery (OR, 0.2; 95% CI, 0.08-0.67; P=0.0072).ConclusionConcurrent CMV infection was associated with an eight-fold increase in the risk of hospitalization for UC aggravation. In contrast, maintenance therapy with thiopurine immunomodulators reduced the risk of surgery by 80%.

Although endoscopic screening has become more common in recent years, its efficacy in reducing the mortality from gastric cancer has not yet been demonstrated. We carried out a case-control study to evaluate the efficacy of endoscopic screening in Kamigoto town, Kamigoto Island. The case group consisted of 13 patients who died of gastric cancer between 2000 and 2008, and ten controls per patient, ie. a total of 130 controls, were extracted as the control group. To clarify the relationship between participation in endoscopic screening and gastric cancer mortality, the odds ratio of death from gastric cancer in participants vs. nonparticipants of screening was calculated. The odds ratio of death from gastric cancer in participants of endoscopic screening vs. nonparticipants was 0.206 (95 % CI, 0.044-0.965 p = 0.0449). Participation in endoscopic screening within the previous 5 years decreased the risk of death from gastric cancer by 79 %. Implementation of endoscopic screening was associated with a significant reduction in mortality from gastric cancer in the small island town. © 2013 Indian Society of Gastroenterology.

ObjectiveTo evaluate the efficacy of endoscopic and radiographic screening for gastric cancer. DesignA retrospective cohort study. SettingCommunity in an isolated island. ParticipantsThe study involved 186 patients (131 men, 55 women) diagnosed with gastric cancer between 2000 and 2005. InterventionsEndoscopic and radiographic screening. Main outcome measurementsThe odds ratio of death from gastric cancer in participants versus non-participants of screening, the cumulative survival rate of the gastric cancer patients. ResultsThe odds ratio of death from gastric cancer in the participants versus non-participants of screening was 0.091 (95% confidence interval (CI) 0.027-0.308; P<0.0001). The cumulative survival rate of the gastric cancer patients in the screening group was higher than that in the non-screening group (P<0.0001). In the endoscopic screening district, the odds ratio of death from gastric cancer among the participants versus non-participants of endoscopic screening was 0.117 (95% CI 0.013-1.056; P=0.0525), while in the radiographic screening district, it was 0.086 (95% CI 0.020-0.376; P<0.0001). The cumulative survival rates were higher in both the screening groups as compared with the non-screening group (endoscopy, P=0.0302; radiography, P=0.0012). ConclusionThe results suggest that both radiographic and endoscopic screening may prevent gastric cancer deaths.

We examined the pathologies, treatment characteristics, and clinical course of elderly ulcerative colitis (UC) patients. Among 222 UC patients (127 men, 95 women; average age, 34 +/- A 16 years), we selected 109 with UC diagnosed between 20 and 39 years of age (young adult group) and 23 diagnosed at a parts per thousand yen60 years of age (elderly group). Moreover, 12 patients diagnosed between 60 and 64 years of age (late-onset group) and 6 patients aged a parts per thousand yen60 years diagnosed under 50 years old (long-standing group) were also extracted for sub-analysis. The clinical characteristics and course were compared among the groups. The average age at onset was 29 +/- A 6 years in the young adult group and 66 +/- A 5 years in the elderly group. The frequency of immunomodulator or steroid use did not differ between the two groups. The comorbidity rate was 14.7 % in the young adult group and 69.6 % in the elderly group (P < .0001). Seven patients (58.3 %) in the late-onset UC group and none of the patients in the long-standing UC group were on steroid treatment. None of the patients in the long-standing UC group required hospitalization/surgery for UC exacerbation, while 3 (25.0 %) and 2 patients (16.7 %) in the late-onset group required hospitalization and surgery, respectively. The comorbidity rate was significantly higher in the elderly group. Treatments did not differ significantly between the young adult and elderly groups. Therefore, it appears that the inflammation tends to subside with age in elderly patients with long-standing UC.

The indications for endoscopic submucosal dissection (ESD) for duodenal tumors have not yet been established. We reviewed our experience of ESD performed for duodenal tumors. We analyzed the data of a total of 13 patients with 14 duodenal lesions (excluding papillary lesions) comprising 2 early cancers, 5 adenomas, and 7 neuroendocrine tumors, who were treated by ESD between 2005 and 2011. The mean tumor diameter was 12.7 +/- 14.8 mm. En bloc resection was achieved in 85.7% of the cases. The procedure time was 89.1 +/- 64.6 minutes. Intraoperative perforation occurred in three cases. The mean length of postoperative hospitalization was 8.4 +/- 2.4 days. Because ESD for duodenal lesions was associated with a higher incidence of perforation than ESD for lesions in other locations (stomach, esophagus, and colon) reported previously, its use for duodenal lesions should be considered with caution.

症例は50歳の女性．繰り返す膵炎と心窩部痛の精査目的に当院紹介．造影CT，USで腫瘍や膵管・胆管拡張は認めなかったが，胆道シンチグラフィにて十二指腸への胆汁排泄遅延を認めた．入院時血液検査所見（無症状時）では肝胆道系，膵酵素，IgG4値の異常は認めなかった．ERCP所見は胆管挿管困難にてprecut施行後に胆管造影・IDUS実施したが器質的閉塞は認めなかった．主乳頭からは膵管像得られず，副乳頭からの膵管造影で背側膵管のみ造影された．膵炎の原因は膵管癒合不全と診断し，副膵管口切開術を施行した．また，biliary typeの十二指腸乳頭括約筋機能不全（SOD）も合併していると診断し，乳頭括約筋切開術も同時に施行した．その後，内視鏡的乳頭バルーン拡張術の追加を要したが，以後は膵炎の再燃も認めず自覚症状も改善している．膵管癒合不全を伴ったSODの報告は稀であり若干の文献的考察を加えて報告する．<br>

A 78-year-old man with hepatocellular carcinoma treated by chemoembolization and percutaneous ethanol injection was admitted to our hospital because of acute abdomen. The CT scan showed biliary fistula caused by hepatocellular carcinoma protruding from S3. Endoscopic retrograde cholangiopancreatography showed disruption of an intrahepatic duct and the main pancreatic duct, and contrast agent leaked into the peritoneal cavity from each duct Omental panniculitis with biliary fistula and pancreatic fistula was diagnosed. The symptoms improved by endoscopic nasobiliary drainage and endoscopic pancreatic stenting. On the 13th day after admission, we added endoscopic nasopancreatic drainage because his abdominal pain had been exacerbated by pancreatic juice leakage. Omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula is extremely rare. Endoscopic transpapillary pancreaticobiliary drainage was effective for omental panniculitis in this case.

食道粘膜下腫瘍（SMT）は良性腫瘍が大部分を占め，悪性は稀とされている．しかし，画像所見のみでは良悪性の鑑別が困難な場合もあり，組織型により治療方針も異なるため組織診断を得ることが必要である．今回，われわれは30mmの食道SMTに対して超音波内視鏡下穿刺吸引生検術（EUS-FNAB）を試みたが，組織量が不十分で確定診断に至らず，粘膜切開後直視下生検にて確定診断が得られた症例を経験した．EUS-FNABはSMTに対する組織診断法の第一選択であるが，EUS-FNABにより十分な組織が得られない場合には，本法を試みてよいと思われた．

【目的】高齢者胃がん内視鏡検診の有効性について検討した。<BR>【方法】1984年から2004年までに長崎県上五島病院にて胃癌と診断され, 診断時に65歳以上であった116症例を対象とした。65-79歳を高齢者, 80歳以上を超高齢者と定義し, 検診群および非検診群の2群において治療内容, 病期分類を比較評価し, さらに生命予後について解析を行った。<BR>【成績】検診群で有意にEMR症例(p=.0041), StageI症例(p<.0001)が多く, 手術不能症例が少数であった(p=.0144)。高齢者群の胃癌の5年生存率は, 検診群88.9％, 非検診群57.9％と検診群において有意に高く(p=.0002), 超高齢者群の胃癌5年生存率は, 非検診群42.7％であり, 検診群では観察期間中の胃癌死はみられなかった。 <BR>【結論】高齢者群, 超高齢者群ともに検診群において, 早期胃癌の占める割合が高く, 5年生存率も有意に高かった。

60歳女性．突然ショック状態となり，造影CTにて脾臓および転移性肝腫瘍からの腹腔内出血と診断した．同部位に対するTAEにて血行動態は安定したが，第13病日死亡した．剖検にて腹膜播種，肝・肺・リンパ節転移をともなう脾原発血管肉腫と診断した．本疾患は原発臓器のみならず転移巣からも出血をともなうことがあり，TAEが出血性ショックに対する一時止血に有用であったと考えられ，本邦報告42例の検討とともに報告する．<br>

【目的】胃内視鏡検診による胃癌死亡率減少効果について検討した。<BR>【方法】Ｘ線検診群1,425例, 内視鏡検診群2,264例, 検診未受診群6,284例に3区分し, 性別, 年齢をマッチングさせた3群を2008年12月まで追跡した。胃癌死をエンドポイントとした場合の3群それぞれの累積生存率を算出し解析を行い, 検診内容別の死亡に対するハザード比を求めた。<BR>【成績】胃癌発症者40例(Ｘ線群18例, 内視鏡群12例, 未受診群10例)において胃癌死した症例はＸ線群1例, 内視鏡群1例, 未受診群8例であった。累積生存率は, Ｘ線群と内視鏡群では有意差はみられなかったが, これら2群と未受診群においては有意に未受診群の生存率が低い結果となった(p=.0073)。未受診群は内視鏡群よりも8倍胃癌死亡の危険が高かった(p=.0499)。<BR>【結論】内視鏡検診は胃癌死亡率減少効果を認め, Ｘ線検診に劣っていない可能性が示唆された。

症例54歳，男性．50歳時に肝機能障害を指摘されたが，膵炎発作の既往なし．嗜好歴は，缶ビール2本/日，焼酎水割5～6杯/日．<br> 心窩部痛を主訴に近医受診．血液検査，腹部CTにて急性膵炎と診断され当院へ救急搬送となった．当院で施行した腹部CT所見で，膵管癒合不全，十二指腸副乳頭部での膵石嵌頓が疑われたため，同日緊急内視鏡検査を施行した．副乳頭からの造影にて尾部膵管までの背側膵管が独立して認められ，背側膵管は拡張し，内部に陰影欠損を認めた．内視鏡的副乳頭切開術後，経鼻膵管ドレナージを施行した．保存的治療で膵炎，背側膵管拡張は軽快し，陰影欠損は消失した．経過良好にて第36病日に退院し，16ヵ月後の現在まで膵炎の再発を認めていない．<br> 膵管癒合不全において，膵石が副乳頭に嵌頓し慢性背側膵炎が増悪する例は稀であり，内視鏡的副乳頭切開術が膵炎の重症化を予防するうえで有効であったので報告する．<br>

腹膜透析患者の大腸内視鏡検査・処置後には腹膜炎等の致死的な偶発症が生じる可能性がある．医療の進歩によって，透析患者の長期予後が期待されるようになり，今後腹膜透析患者に対する内視鏡検査件数の増加が予想される．今回，我々は腹膜透析患者における大腸粘膜切除術を2例経験したので，内視鏡時の注意点を含めて報告する．

症例は52歳女性。45歳時に膵管非癒合による急性膵炎の既往あり。心窩部痛にて当院救急搬送され，急性膵炎と診断された。軽快後，膵管非癒合の精査目的にERPを施行した。経副乳頭的に行った圧測定で，膵管内圧上昇と副乳頭部で括約筋様収縮波を認めた。副乳頭切開を施行し，その後膵炎の再発はない。経副乳頭的内圧測定は膵管非癒合による再発性膵炎に対して，副乳頭切開を行う際の指標として有用である可能性が考えられた。

症例は78歳，女性。主訴は貧血，食後腹痛。NSAIDs小腸潰瘍を疑われ当科に転院。カプセル内視鏡にて空腸に狭窄病変を指摘され，経口的ダブルバルーン小腸内視鏡にて空腸に2箇所の膜様狭窄を認め，径8mmのバルーン拡張を施行。NSAIDs関連性小腸潰瘍による瘢痕狭窄と診断した。食上げ中に腹痛の再燃を認め，2度目のDB小腸内視鏡にて径13mmまでの拡張を行った。その後症状の再燃みられず軽快退院となった。

症例は35歳男性。クローン病にてS状結腸に狭窄あり，狭窄部切除術後infliximabを投与開始した。Infliximab投与後，腸管狭窄が出現したためバルーン拡張術を試みたが，狭窄長が長く屈曲していたため穿孔の危険性が高く，手術に至った。Infliximab投与後に腸管狭窄が出現した症例を経験したので報告する。

The patient was a 78-year-old male who had been found to have multiple hepatic cysts and renal cysts at 68 years of age. Because multiple hepatic cysts and a solid mass in some of the cysts were observed on a follow-up CT scan in December 2007, he was referred to our department for a thorough examination and treatment in March 2008. Abdominal ultrasonography showed multiple cysts in both lobes of the liver, and papillary protruding masses were observed in a cyst in S3 of the left lobe and a cyst in S7 of the right lobe. Abdominal CT showed a soft-tissue-density mass associated with weak contrast enhancement in the cyst at both sites. An FDG-PET study showed no abnormal accumulation in the liver. It was impossible to identify any communication between either of the two cysts and the bile duct by ERCP or MRCP. Cystic tumors were strongly suspected, and partial hepatectomy was performed. Histopathological examination revealed that the solid portion observed in part of a multilocular cystoma was vascular connective tissue that had the thickened cyst wall, while the portion that was thought to be a cystic protruding lesion was a thrombotic mass caused by intracystic hemorrhage, part of which had become organized, and there was no evidence of adenoma or cancer. Since cases of simultaneous multiple hepatic cysts with intracystic hemorrhage and a tendency to enlarge are extremely rare, we report here the case together with a brief discussion based on the literature. © 2010 The Japan Society of Hepatology.

症例は67歳男性。上行結腸に60mmのIp様のSMTを認め，粘膜下脂肪腫と診断した。2チャンネルスコープを用い，留置スネアで基部を絞扼し，33mmスネアにてpolypectomyを実施した。短時間に一括切除可能であったが，術後に軽度のair leakを認めた。脂肪腫の内視鏡治療に際しては，病変の形状により完全切除にこだわらずリスクを考慮した治療法を選択すべきである。

自己免疫性膵炎の治療中に肝門部胆管狭窄を認め，胆管癌との鑑別に苦慮した自己免疫性胆管炎の1例を経験した。症例は65歳男性，自己免疫性膵炎に対しステロイドを漸減中に胆道系酵素が上昇し，腹部超音波検査・腹部CTで右肝内胆管の拡張及び肝門部に腫瘤様陰影を認めた。胆管ブラシ細胞診，胆汁細胞診では悪性所見は見られなかった。ステロイドを増量し2週間後には肝門部の胆管狭窄は改善し，その後腫瘤影も消失した。

症例は71歳，パーキンソン病で治療中の女性。朝食後，内服薬4TをPTP包装のまま誤飲，咽頭痛が持続するため，救急車で来院した。異物摘出目的に緊急内視鏡施行，食道内に2個，胃内に2個のPTPおよびLm，F2，Cb，Rc sign陽性の食道静脈瘤を認めた。EVL用オーバーチューブ挿入後，スコープに先端フードを装着し，把持鉗子で把持し，慎重な操作の下，4個のPTPを摘出した。食道胃接合部付近では十分に送気することにより噴門を開大し，出血させることなく摘出可能であった。

症例は23歳女性。腹腔内腫瘍の精査目的に当センター紹介となる。右上腹部を中心に10cm大の弾性硬・表面平滑な腫瘤を触知し，腹部CT上，腫瘤は膵頭部付近に存在し表面平滑で造影効果を伴う被膜を有した。確定診断目的にEUS-FNA施行，細胞診で血管間質を伴い，乳頭状構造を呈し結合性の低下した細胞集団を認め，solid-pseudopapillay tumorと診断，膵頭十二指腸切除術が施行された。EUS-FNAは膵由来の腫瘍が疑われる病変の確定診断に有用であり，治療法決定に役立つものと考えられた。

症例は60歳，男性。主訴は左下腹部痛。前医で施行された腹部CTにて小腸腫瘍が疑われ，当科紹介入院となった。経口ダブルバルーン（DB）小腸内視鏡にて回腸に全周性狭窄を認めた。生検では確定診断が得られず，腹腔鏡下小腸部分切除術を施行。病理組織学所見にてMALTリンパ腫と診断した。今回我々は，回腸MALTリンパ腫をDB小腸内視鏡にて確認しえたので報告する。

Background. The rate of human T lymphotropic virus type 1 (HTLV-1) positivity among residents of Kamigoto, Japan, is extremely high (15%). Although the rate of Helicobacter pylori positivity in Kamigoto is almost the same as that in other areas of Japan, the incidence of gastric cancer in Kamigoto is lower. This study examined whether HTLV-1 infection affects H. pylori infection and the development of gastric cancer. Methods. The study involved 5686 patients &gt 40 years of age who provided serum specimens for HTLV-1 antibody testing during 1989-1992. A total of 1812 patients underwent gastric endoscopy during the follow-up period. Of these, 497 were HTLV-1 seropositive. Data for these patients were compared with those for 497 HTLV-1-seronegative control patients matched for age, sex, and follow-up duration. We followed these groups until 2003 and determined the cumulative incidence rate of gastric cancer. Results. The rate of H. pylori positivity was 61.7% in the HTLV-1-positive group and 71.6% in the HTLV-1-negative group (P = .07). Fourteen HTLV-1-positive patients (2.8%) had gastric cancer, compared with 35 patients (7.0%) in the HTLV-1-negative group (odds ratio, 0.38 95% confidence interval, 0.21- 0.70 P = .0028). Conclusion. HTLV-1 infection likely reduces the risk of H. pylori infection and proliferation and, thereby, the risk of gastric cancer. © 2008 by the Infectious Diseases Society of America. All rights reserved.

AIM: To attempt rectal administration of rebamipide in the treatment of ischemic colitis patients with ulcers, and evaluate its effects. METHODS: We compared 9 ischemic colitis patients (2 men, 7 women) with ulcers treated by bowel rest only from 2000 to 2005 (conventional therapy group), with 6 patients (2 men, 4 women) treated by rebamipide enema therapy in 2006 (rebamipide enema therapy group) and analyzed the mean duration of fasting and hospitalization, degree of ulcer healing, and decrease in WBC count for the two groups. RESULTS: The mean duration of fasting and hospitalization were 2.7 +/- 1.8 d and 9.2 +/- 1.5 d in the rebamipide group and 7.9 +/- 4.1 d and 17.9 +/- 6.8 d in the control group, respectively, and significantly reduced in the rebamipide group (t = -2.915; P = 0.0121 and t = -3.054; P = 0.0092). As for the degree of ulcer healing at 7 d after admission, the ulcer score was reduced by 3.5 +/- 0.5 (points) in the rebamipide group and 2.8 +/- 0.5 (points) in the control group (t = 1.975; P = 0.0797), while the decrease in WBC count was 120.0 +/- 55.8 (x 10(2) /mu L) in the rebampide group and 85.9 +/- (x 10(2)/mu L) in the control group (t = 1.006; P = 0.3360). CONCLUSION: In left-sided ischemic colitis patients with ulcers, rebamipide enema therapy significantly reduced the duration of fasting and hospitalization, recommending its use as a new and effective therapeutic alternative.(C) 2008 The WJG Press. All rights reserved.

Background. The rate of human T lymphotropic virus type 1 (HTLV-1) positivity among residents of Kamigoto, Japan, is extremely high (15%). Although the rate of Helicobacter pylori positivity in Kamigoto is almost the same as that in other areas of Japan, the incidence of gastric cancer in Kamigoto is lower. This study examined whether HTLV-1 infection affects H. pylori infection and the development of gastric cancer. Methods. The study involved 5686 patients &gt; 40 years of age who provided serum specimens for HTLV-1 antibody testing during 1989-1992. A total of 1812 patients underwent gastric endoscopy during the follow-up period. Of these, 497 were HTLV-1 seropositive. Data for these patients were compared with those for 497 HTLV-1-seronegative control patients matched for age, sex, and follow-up duration. We followed these groups until 2003 and determined the cumulative incidence rate of gastric cancer. Results. The rate of H. pylori positivity was 61.7% in the HTLV-1-positive group and 71.6% in the HTLV-1 negative group (P = .07). Fourteen HTLV-1-positive patients (2.8%) had gastric cancer, compared with 35 patients (7.0%) in the HTLV-1-negative group (odds ratio, 0.38; 95% confidence interval, 0.21-0.70; P = .0028). Conclusion. HTLV-1 infection likely reduces the risk of H. pylori infection and proliferation and, thereby, the risk of gastric cancer.

AIM: To examine how the introduction of endoscopy to gastric cancer screening affected survival prognosis in a regional population. METHODS: The subjects comprised 4261 residents of Kamigoto, Nagasaki Prefecture, who underwent gastric X-ray examination for gastric cancer screening from 1991 to 1995, and all 7178 residents who underwent endoscopic examination for the same purpose from 1996 to 2003. The analysis evaluated trends in age-adjusted gastric cancer mortality rates and standard mortality ratios (SMRs) among the Kamigoto residents. RESULTS: According to demographic statistics, the 1995 and 2000 age-adjusted gastric cancer mortality rates in Nagasaki Prefecture (per 100000 population) were 42.6 and 37.3 for males and 18.6 and 16.0 for females, while the corresponding rates in Kamigoto before and after the introduction of endoscopic screening were respectively 51.9 and 28.0, and 26.6 and 6.9. The data obtained in this study were divided into those for two periods, 1990-1996 and 1997-2006, and SMRs were calculated separately for males and females. For the first period, the SMR was 1.04 (95% CI 0.50-1.58) for males and 1.54 (95% CI 0.71-2.38) for females, while for the second period the SMR was 0.71 (95% CI 0.33-1.10) for males and 0.62 (95% CI 0.19-1.05) for females. CONCLUSION: Following the introduction of endoscopic examination, gastric cancer death rates decreased in Kamigoto. (c) 2007 WJG. All rights reserved.

AIM: To investigate the relationship among the presence of ulcer lesions, underlying disease, and clinical course in patients with ischemic colitis. METHODS: The subjects were 41 patients (10 male and 31 female; mean age 70 years) with ischemic colitis who were admitted to and received treatment in our hospital from 2000 to 2006. We compared their characteristics and analyzed the mean lengths of admission and fasting for 9 patients with ulcer lesions (ulcer group) and 32 without (non-ulcer group). RESULTS: The groups with presence and absence of ulcer differed significantly only in white blood cell (WBC) count. Lengths of fasting and admission were 7.9 d and 17.9 d for the ulcer group and 4.4 d and 10.7 d for the non-ulcer group, respectively, and significantly longer in the ulcer group (P = 0.0057 and 0.0001). There was no correlation between presence of ulcer and presence of underlying diseases. CONCLUSION: Lengths of fasting and admission were significantly longer in patients with ischemic colitis with ulcer than for those without ulcer. (C) 2007 The WJG Press. All rights reserved.