Risk Management for Gastrointestinal Endoscopy in Elderly Patients: Questionnaire for Patients Undergoing Gastrointestinal Endoscopy

More elderly patients now undergo gastrointestinal endoscopy following recent advances in endoscopic techniques. In this study, we conducted a high-risk survey of endoscopies in Japan, using a questionnaire administered prior to upper gastrointestinal tract endoscopy (UGITE), and identified anticholinergic agents and glucagon preparations as high-risk premedication. We also evaluated the cardiovascular effects of anticholinergic agents and glucagon through measurements of plasma levels of human atrial natriuretic peptide (hANP) and human brain natriuretic peptide (hBNP). The subjects were 1480 patients who underwent UGITE. Nurses administered a pre-endoscopy questionnaire, questioning subjects regarding heart disease, hypertension, glaucoma, and urinary difficulties as risk factors for anticholinergic agents, and Diabetes mellitus as a risk factor for glucagon preparations. Evaluation of subjects divided into under 65 and over 65 age groups revealed that in subjects aged 65 and over, risk factors for anticholinergic agents were significantly more high than those for glucagon. Analysis of the cardiovascular effects of anticholinergic agents and glucagon, in the elderly patients showed that hANP levels were significantly higher following administration of anticholinergic agents, but the change was not significant for glucagon premedication. Taking a detailed history before UGITE with the aid of a questionnaire at the same time as informed consent is obtained, is extremely useful in terms of risk management and selection of the appropriate premedication

Prevention of NSAID-Induced Small Intestinal Mucosal Injury: Prophylactic Potential of Lansoprazole

Non-steroidal anti-inflammatory drugs (NSAIDs), which are used for the treatment of several inflammatory disorders including rheumatoid arthritis, are well known to cause gastroduodenal mucosal lesions as an adverse effect. Recently, the serious problem of NSAID-induced small intestinal damage has become a topic of great interest to gastroenterologists, since capsule endoscopy and double-balloon enteroscopy are available for the detection of small intestinal lesions. Such lesions have been of great concern in clinical settings, and their treatment and prevention must be devised as soon as possible. Proton pump inhibitors (PPI), such as lansoprazole and omeprazole, show a potent anti-secretory effect. PPIs also have a gastroprotective effect, independent of their anti-secretory actions, which is probably mediated by inhibition of neutrophil functions as well as antioxidant actions. Administration of lansoprazole reduced the severity of the intestinal lesions in a dose-dependent manner, but omeprazole had no effect. The amount of heme oxygenase-1 (HO-1) protein in the intestinal mucosa was significantly increased by lansoprazole, but not by omeprazole. These results suggest that lansoprazole, but not omeprazole, ameliorates indomethacin-induced small intestinal ulceration through upregulation of HO-1/carbon monoxide. Therefore, lansoprazole may be useful for preventing the adverse effects of NSAIDs not only in the stomach but also in the small intestine

Thymoma-associated Graft-versus-Host Disease-like Erythroderma

We report a 40-year-old woman with recurrent thymoma associated with myasthenia gravis, in whom an unusual form of erythroderma developed. A histological examination revealed a graft-versus-host disease (GVHD)-like reaction. After high-dose steroid therapy, the metastatic thymoma lesion in the abdominal cavity was reduced in size from 9.5 × 6 × 7.5 cm to 4 × 3 × 1 cm in diameter. Nevertheless, the GVHD-like erythroderma become aggravated, her condition worsened, and the patient finally suffered from respiratory failure and died of sepsis. A GVHD-like reaction may be a rare presentation of thymoma-associated immunological disorders such as myasthenia gravis or pure red cell aplasia. Herein, we discuss the present case and review pertinent reports of thymoma cases associated with GVHD

Combined treatment with dipeptidyl peptidase 4 (DPP4) inhibitor sitagliptin and elemental diets reduced indomethacin-induced intestinal injury in rats via the increase of mucosal glucagon-like peptide-2 concentration.

The gut incretin glucagon-like peptide-1 (GLP-1) and the intestinotropic hormone GLP-2 are released from enteroendocrine L cells in response to ingested nutrients. Treatment with an exogenous GLP-2 analogue increases intestinal villous mass and prevents intestinal injury. Since GLP-2 is rapidly degraded by dipeptidyl peptidase 4 (DPP4), DPP4 inhibition may be an effective treatment for intestinal ulcers. We measured mRNA expression and DPP enzymatic activity in intestinal segments. Mucosal DPP activity and GLP concentrations were measured after administration of the DPP4 inhibitor sitagliptin (STG). Small intestinal ulcers were induced by indomethacin (IM) injection. STG was given before IM treatment, or orally administered after IM treatment with or without an elemental diet (ED). DPP4 mRNA expression and enzymatic activity were high in the jejunum and ileum. STG dose-dependently suppressed ileal mucosal enzyme activity. Treatment with STG prior to IM reduced small intestinal ulcer scores. Combined treatment with STG and ED accelerated intestinal ulcer healing, accompanied by increased mucosal GLP-2 concentrations. The reduction of ulcers by ED and STG was reversed by co-administration of the GLP-2 receptor antagonist. DPP4 inhibition combined with luminal nutrients, which up-regulate mucosal concentrations of GLP-2, may be an effective therapy for the treatment of small intestinal ulcers

Three cases of Asymptomatic Gastric Anisakiasis during health check-ups

　本邦での胃アニサキス症の報告例は多く，健康診断（以下：健診）や人間ドック診療において偶然発見される無症候性の胃アニサキス症の報告例も散見される．我々は，当施設の人間ドックで発見された胃アニサキス症３例を経験したので報告する．症例は58歳女性，66歳男性，73歳男性．自覚症状は全例で無症状であった．診断時期は12月から２月の冬季で，全例で検査数日前に鯖，イカ等の魚介類の生ものの摂食歴があった．血液検査所見では，白血球数は全例で正常範囲であり， CRP は２例で軽度の上昇を認めた（0.02 mg/dl，0.41 mg/dl，0.91 mg/dl）．好酸球数は２例で前回値より軽度の上昇を認めた（181/μl から322/μl，379/μl から540/μl）．胃内視鏡所見については，穿入部の発赤，浮腫，びらんを全例で認め，２例で非萎縮粘膜領域に虫体が穿入していた．背景胃粘膜所見は「胃炎の京都分類」で評価すると１例が萎縮やびまん性発赤等の所見のないH. pylori未感染胃相当であり，２例は除菌後の症例（木村・竹本分類：C2 type）であった．過去の報告例と同様，当院で診断した３症例は，全例が無症状で発見され，２例で好酸球数の上昇が認められた．健診・人間ドック診療において胃アニサキス症を検査前に強く疑うことは困難であるが，この疾患を念頭に入れ，無症状であっても十分な問診や内視鏡観察を行うことが重要である．　There are several reports of gastric anisakiasis, and some reports of asymptomatic gastric anisakiasis observed during health check-ups in Japan. We are reporting three cases of gastric anisakis found in health check-up in our hospital. These cases presented in a 58-year-old woman, a 66-year-old man, and a 73-year-old man. All the three cases were asymptomatic in nature. All the cases were observed during the winter season from December to February. The patients consumed fish such as mackerel, tuna, and squid before the examination. White Blood Cell (WBC) counts on blood tests was stable in all cases, whereas two cases exhibited a slight increase in C-reactive Protein (CRP) levels (0.41 mg/dl, 0.91 mg/ dl). Eosinophil count were slightly higher than the previous values in two cases (from 181/μl to 322/μl, and 379/μl to 540/μl). Endoscopic findings in the area invaded by the parasite showed redness, edema, and swelling. In addition to this, parasites penetrated the non-atrophic mucosal area in two cases. According to evaluation by the“Kyoto classification of gastritis”, one case was non-H. pylori infected stomach and 2 cases were post-eradication. All cases depicted asymptomatic gastric anisakiasis in our institutions and two cases indicated an increase in the eosinophil count. Even if it is asymptomatic, the eosinophil count may increase due to the effects of gastric anisakiasis. It is challenging to diagnose gastric anisakiasis before the examination in health check-ups. However, it is imperative to pay attention to this disease and to opt for endoscopic evaluations despite the absence of symptoms

Linked Color Imaging for Stomach

Image-enhanced endoscopy (IEE) plays an important role in the detection and further examination of gastritis and early gastric cancer (EGC). Linked color imaging (LCI) is also useful for detecting and evaluating gastritis, gastric intestinal metaplasia as a pre-cancerous lesion, and EGC. LCI provides a clear excellent endoscopic view of the atrophic border and the demarcation line under various conditions of gastritis. We could recognize gastritis as the lesions of the diffuse redness to purple color area with LCI. On the other hand, EGCs are recognized as the lesions of the orange-red, orange, or orange-white color area in the lesion of the purple color area, which is the surround atrophic mucosa with LCI. With further prospective randomized studies, we will be able to evaluate the diagnosis ability for EGC by IEE, and it will be necessary to evaluate the role of WLI/IEE and the additional effects of the diagnostic ability by adding IEE to WLI in future

Linked Color Imaging for Stomach

Image-enhanced endoscopy (IEE) plays an important role in the detection and further examination of gastritis and early gastric cancer (EGC). Linked color imaging (LCI) is also useful for detecting and evaluating gastritis, gastric intestinal metaplasia as a pre-cancerous lesion, and EGC. LCI provides a clear excellent endoscopic view of the atrophic border and the demarcation line under various conditions of gastritis. We could recognize gastritis as the lesions of the diffuse redness to purple color area with LCI. On the other hand, EGCs are recognized as the lesions of the orange-red, orange, or orange-white color area in the lesion of the purple color area, which is the surround atrophic mucosa with LCI. With further prospective randomized studies, we will be able to evaluate the diagnosis ability for EGC by IEE, and it will be necessary to evaluate the role of WLI/IEE and the additional effects of the diagnostic ability by adding IEE to WLI in future

Effect of Long-term Administration of Ammonia Water on Rat Gastric Mucosa —Combined Effect of Gastric Mucosal Protective Agents

We focused on the fact that ammonia induces gastric mucosal damage by Helicobacter pylori, and investigated the effect of ammonia water administration in two kinds of concentration of rat gastric mucosa, by allowing rats free access to ammonia water for 6 weeks. No atrophy developed in the rat gastric mucosa and mucus was maintained in the low concentration group of 0.02% ammonia water, while atrophy was observed in the antral mucosa after 4 weeks and in the body mucosa after 6 weeks of administration in the high concentration group of 0.1% ammonia water. The course of atrophy was similar to that of human atrophic gastritis due to H. pylori infection. Furthermore, both superficial and deep mucus significantly decreased. On the contrary, coadministration of geranylgeranylacetone (GGA), one of gastric mucosal protective agents, inhibited decrease in gastric mucus as well as gastric mucosal atrophy in the 0.1% ammonia water group. In that way, myeloperoxidase (MPO) activity, which is an index of tissue disorders in gastric mucosa, and lipid peroxidation (LPO) activity were significantly increased due to access to ammonia water, while GGA suppressed these activities. It was suggested that gastric mucus may act as a radical scavenger to prevent gastric mucosal damage by ammonia