含糖酸化鉄注射液の長期投与でFGF23関連低リン血症性骨軟化症を来たしたクローン病の１例

症例は50歳代，男性．クローン病で２年前に右半結腸切除術，小腸部分切除を施行．術後に他院にてアダリムマブを導入され，クローン病は臨床的寛解の状態であった．４か月前より下肢を中心とした疼痛が出現した．アダリムマブによる薬剤起因性ループスあるいは腸炎性関節炎を疑い，２か月前よりアダリムマブ投与を中止し，プレドニゾロンの内服を開始するも改善を認めなかった．血液検査にて，低リン血症と高アルカリフォスファターゼ血症を認め，精査治療目的で当院に紹介入院となった．骨塩定量検査にて骨密度の低下を，骨シンチグラフィーで疼痛を認める骨への多発取り込みを認め，骨軟化症と診断した．血清のfibroblast growth factor 23（FGF23）が175pg/ml と高値であり，入院前まで定期的に使用されていた含糖酸化鉄注射液による，FGF23関連低リン血症性骨軟化症と診断した．含糖酸化鉄注射液投与を中止し，リン製剤とビタミンD 製剤の投与を開始したところ，徐々に低リン血症と高アルカリフォスファターゼ血症の改善を認めた．その後の経過は良好で，FGF23値は徐々に低下を示し，下肢を中心とした疼痛は軽快し，退院した．長期的に含糖酸化鉄注射液を投与する場合は，FGF23関連低リン血症の早期発見のため，血中リン濃度を定期的に測定する必要がある．The case is a man in his 50s. He underwent operations of right half colon resection and small intestine segmental resection due to Crohn’s disease two years ago. After surgery, Adalimumab was introduced in other hospital, and he was a state of the clinical remission in Crohn’s disease. The sharp pain mainly on lower limbs develops from four months ago. We doubted drug origin-related lupus with Adalimumab or enteritis-related joint pain. Therefore, we stopped Adalimumab injection and started internal use of the prednisolone, however the symptoms did not improve and had continued for two months.Laboratory test showed hypophosphatemia and hyperphosphatasemia and then he was transported to our hospital. Bone mineral quantity showed bone salt decrease and bone scan showed increased uptakes in multiple bones. Fibroblast growth factor23 (FGF23) of the serum was high (175pg/ml), and we diagnosed him FGF23-mediated hypophosphatemic osteomalasia induced by prolonged administration of saccharated ferric acid.Saccharated ferric acid has regularly been used until hospitalization. After stopping the ferric acid injection, and taking phosphorus and vitamin D, hypophosphatemia and hyperphosphatasemia was gradually improved. FGF23 level gradually reduced, and the sharp pain mainly on lower limbs was relieved, and it became a discharge. Regular measurement of serum phosphorus concentration is necessary for early detection of the FGF23-related hypophosphatemia in patients with long term use of saccharated ferric acid

内視鏡的ドレナージが有効であった胃壁膿瘍を合併した胃迷入膵の１例

　症例は30歳代女性．３日前から心窩部痛が出現し，徐々に増悪してきたため当院を受診した．血液検査でWBC 15,120/μl，CRP 2.95mg/dl と炎症反応上昇を認め，腹部超音波検査で胃幽門前庭部前壁に約3.5cm の粘膜下腫瘍様隆起を認めた．腫瘍内部はechogenic particles の混在する液体の貯留を認めた．腹部造影CT 検査では，胃前庭部から胃体部前壁にリング状の造影効果を伴う著明な壁肥厚を認めた．以上より胃壁膿瘍と診断した．胃前庭部前壁の弾性硬のやや発赤した粘膜下腫瘍様隆起に対して，超音波内視鏡下穿刺術（EUS-FNA）を行った．粘稠な白色液体の流出を認め，膿瘍を示唆する所見であった．絶食・点滴・抗生剤投与による保存的加療を施行後，速やかに腹部症状は消失し，EUS-FNA 施行後５日目に退院した．４か月後，病変は上部内視鏡検査で頂部に陥凹を有する腫瘍に形態変化を認め，さらに縮小傾向であった．また，腹部超音波検査では粘膜下層内に約５mm 大の嚢胞性領域とそれに接する約４mm 大の境界不明瞭な低エコー域，不整な固有筋層の肥厚を認め，胃迷入膵の所見であった．以上より，胃壁膿瘍を合併した胃迷入膵と診断した．現在，再発なく当科で経過観察中である．胃壁膿瘍を合併した胃迷入膵の報告は非常に稀であり，貴重な症例と考えられた．　Here, we report a case of gastric wall abscess in aberrant pancreas. A 30-yearold woman visited our hospital for epigastric pain. Routine hematological examination showed increased white blood cell count and biochemical tests revealed elevated C reactive protein levels. Abdominal ultrasound revealed a submucosal tumor that appeared as a hypoechoic heterogenous mass in the stomach. Abdominal computed tomography revealed a thickened gastric wall with a low-density area. This mass was diagnosed as a gastric wall abscess, which was treated with endoscopic ultrasound-guided fine needle aspiration and conservative therapy with antibiotics. The patient’s pain resolved after the treatment. Four months after the episode, follow-up examinations showed that the submucosal tumor had changed to a small submucosal mass with depression. This lesion was diagnosed as an aberrant pancreas. Thus, the final diagnosis was a gastric wall abscess in the aberrant pancreas. This patient was followed up for one year following this episode with no incidence of recurrence

Effects of aging on serum levels of lipid molecular species as determined by lipidomics analysis in Japanese men and women

Abstract Background Aging is known to be associated with increased risk of lipid disorders related to the development of type 2 diabetes. Recent evidence revealed that change of lipid molecule species in blood is associated with the risk of type 2 diabetes. However, changes in lipid molecular species induced by aging are still unknown. We assessed the effects of age on the serum levels of lipid molecular species as determined by lipidomics analysis. Methods Serum samples were collected from ten elderly men (71.7 ± 0.5 years old) and women (70.2 ± 1.0 years old), ten young men (23.9 ± 0.4 years old), and women (23.9 ± 0.7 years old). Serum levels of lipid molecular species were determined by liquid chromatography mass spectrometry-based lipidomics analysis. Results Our mass spectrometry analysis revealed increases in the levels of multiple triacylglycerol molecular species in the serum of elderly men and women. Moreover, serum levels of total ester-linked phosphatidylcholine (PC) and phosphatidylethanolamine (PE) were increased by aging. In contrast, serum levels of specific ether-linked PC and PE molecular species were lower in elderly individuals than in young individuals. Conclusions Our finding indicates that specific lipid molecular species, such as ether- and ester- linked phospholipids, may be selectively altered by aging

食道アカラシアの治療 : バルーン拡張術の有効性に関する検討（第２報）

原著論文Regular Articlejournal articl

食道アカラシアの治療 : バルーン拡張術の有効性に関する検討（第２報）

食道アカラシアは食道運動障害を呈する疾患で，良性疾患ではあるものの，QOL を大きく障害し，食道癌の発生リスクともなるため，適切な診断治療が重要である．一般的に，治療は内視鏡的治療や外科的治療が行われる．以前，我々は内視鏡的バルーン拡張術（pneumatic dilation:PD）を行った16例の食道アカラシアについて，PD の有効性に関する因子を検討し報告した．近年，新たな食道運動障害の診断基準（Chicago 分類）も策定されたことも踏まえ，アカラシア症例36例での検討を行ったため第２報として報告する．対象は当院で食道アカラシアと診断し加療した36例で，うち27例（男性８例，女性19例，平均年齢51.0±16.5歳）にPD を行った．対象をPD有効例と無効例とに群分けし，その２群間で患者背景，QOL，High-resolution manometry（ HRM）所見，治療前後でのHRM 所見の差異について検討を行った．結果はPD 有効例は19例（70.4%）であった．有効群と無効群との比較を行うと，無効群で女性が多い傾向にあった（p=0.06）．HRM所見では有効例でChicago 分類typeⅡアカラシアが有意に多く認められた（p=0.04）．また，治療前後のHRM 所見の差異については，有効例で治療前後の下部食道括約筋（lower esophageal sphincter: LES）圧変化率が有意に大きかった．以上より，Chicago 分類typeⅡのアカラシアではPD の有効性が高く，また１度PD を行った症例でもLESP 変化率が大きい症例では有効性が高いことが示された．Achalasia is a disease presenting with esophageal motor disorder. Although this disease is benign, appropriate diagnosis and treatment are important, because it greatly impairs quality of life (QOL) and is a risk for the development of esophageal cancer. In general, endoscopic or surgical treatment is used. In our previous report, we investigated factors related to the efficacy of pneumatic dilation (PD) in 16 patients with esophageal achalasia who underwent PD. In this second report, based on recently established new diagnostic criteria for esophageal motility disorders (Chicago classification), we investigated 36 cases of achalasia. The study involved 36 patients who were diagnosed with esophageal achalasia and received treatment in our hospital and, of these, 27 (8 males and 19 females with a mean age of 51.0 ± 16.5 years) underwent PD. The subjects were divided into PD effective and ineffective groups, and patient characteristics, QOL, high-resolution manometry (HRM) findings and differences in HRM findings before and after treatment were compared between the two groups. As a result, PD was effective in 19 patients (70.4%). The comparison between the effective and ineffective groups showed that the proportion of patients classified into the ineffective group tended to be higher in females (p = 0.06). HRM findings revealed that type Ⅱ achalasia defined by the Chicago classification was significantly more common in the effective group (p = 0.04). In addition, the comparison of differences in HRM findings before and after treatment showed that the rate of change in lower esophageal sphincter pressure (LESP) before and after treatment was significantly greater in the effective group. The above results indicated that PD is highly effective in type Ⅱ achalasia defined by the Chicago classification and in patients with a high rate of change in LESP who underwent PD once