Retrobulbar Hemodynamic Effects of Nipradilol in Normal and Normal-Tension Glaucoma Eyes

Purpose. To investigate the effects of nipradilol on retrobulbar hemodynamics. Methods. We investigated normal and normal-tension glaucoma (NTG) eyes. Topical nipradilol (one eye) and placebo eye drops (fellow eye) were instilled for 1 week in volunteers. Nipradilol was also instilled in NTG patients. Ultrasound color Doppler imaging for the posterior vessels was performed before, 2 hr, 1 week (for normal), and at 4 weeks (for NTG). Results. In normal eyes, there were significant decreases in the resistance index (RI) for the temporal short posterior ciliary arteries (PCA) at 2 hr and for the ophthalmic arteries at 1 week. There were no significant changes in the placebo-treated eyes. In the NTG eyes, there was a significant decrease in the RI for the central retinal artery, nasal, and temporal PCA at 2 hr and 4 weeks. Conclusion. Short-term observations found that nipradilol increased the ocular blood flow in normal and NTG eyes

大腸3D-CT検査(CT-colonography)における腸管外病変の検出

大腸疾患患者を対象に大腸3D-CT検査(CT-colonography)を施行し,腸管外病変の検出率,検出された腸管外病変の臨床的重要性の分類および大腸疾患の有無と腸管外病変の関係の3項目について検討した.その結果,対象者112例のうち84.8%の症例に少なくとも1つ以上の腸管外病変を認めた.また,対象例のうち33例(29.5%)にカテゴリーE4(臨床上重要な所見を有する)群に分類される腸管外病変を認めた.そして,カテゴリーE4群のうち大腸内視鏡検査で24例(72.7%)が大腸癌と,4例(12.1%,全例に対する比率:3.6%)が所見なしと診断された.これらのことから,大腸疾患およびその疑いを有する症例にCT-colonographyを施行することは,大腸疾患を有する症例はもとより内視鏡検査で所見なしと診断された症例においても,重大な腸管外病変の早期発見に有用である

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

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

川崎医科大学附属病院におけるバルーン小腸内視鏡検査の現状 : 325症例の解析結果を含めて

バルーン小腸内視鏡(balloon assisted endoscopy; BAE)は,従来困難であった小腸の検査・治療に有用な検査法である.当院では,2004年にダブルバルーン小腸内視鏡(double balloon endoscopy; DBE)を導入し,2012年6月現在,234症例(延べ325症例;シングルバルーン小腸内視鏡[single balloon endoscopy; SBE]2例を含む)経験した.症例の内訳は,男性127例,女性107例で,平均年齢は62.6歳であった.主訴は,原因不明の消化管出血(obscure gastrointestinal bleeding; OGIB)症例が143例(61.1%)と最多であった.基礎疾患は心血管障害47例(20.1%)が最多で,抗血小板・抗凝固療法を施行している症例は53例(22.6%)にみられた.経口的アプローチは325症例中158例で,経肛門的アプローチは167例,経口的,経肛門的アプローチを両方施行された症例は56例あった.病変は78例(24.0%)に検出され,その内訳は,びらん及び潰瘍性病変23例(29.5%),腫瘍性病変22例(28.2%),血管性病変21例(26.9%)であった.また,外科的切除,内視鏡的止血術等の治療を58例(74.4%)に施行した.BAE により小腸疾患の診断・治療が大きく進歩した.しかしながら,一方で手技が煩雑な点,患者の身体的侵襲も少なくなく合併症を有する点が欠点として挙げられる.そのため,各種小腸疾患の診断,治療に対しては,個々の患者の状況により,BAEとカプセル内視鏡(capsule endoscopy; CA)とを使い分けていくことが重要である.Balloon assisted endoscopy (BAE) is a novel endoscopic technique developed to investigate small bowel diseases (SBDs). BAE has been installed from 2004 in Kawasaki Medical School Hospital. Since then, 234 patients (107 female, 117 male; mean age 62.6 years) with suspected or known SBDs underwent BAE, and we have performed a total of 325 consecutive BAE procedures. The most common indication for BAE was an obscure gastrointestinal bleeding. Cardiovascular disease was the most major coexisting disease (47 patients, 20.1%), and 53 patients (22.6%) were prescribed anti-platelet and/or anticoagulant therapy. One hundred and fifty eight patients were treated BAE via the oral approach, 167 patients were performed via the anal approach, and 56 patients were treated via the dual approach. The overall diagnostic yield was 24.0% (78/325 cases). Among the 78 cases, there were 23 erosions/ulcerations, 22 tumors, 21 angiovascular lesions, and other SBDs. The subsequent treatments, such as endoscopic therapy and surgical therapy were performed following the BAE procedure in 74.4% (58/78) of cases. BAE is a useful tool that not only allows diagnostic workup of SBDs, but also makes it possible to carry out therapeutic intervention. On the other hand, we should make careful decisions of indications for BAE, because it\u27s an invasive and complex procedure and the examination requires substantial time to complete

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

当院における便潜血陽性者に対する大腸CT(CTコロノグラフィー)検査の有用性:大腸がん検診への導入と課題

大腸がん検診におけるスクリーニング検査としての大腸CT(CT colonography: CTC)検査の有用性を検討するために,当院における便潜血陽性者に対するCTCと大腸内視鏡検査の精度比較を行った.2009年7月から2014年1月までに川崎医科大学附属病院で施行されたCTC検査673件中,スクリーニング目的で行われた411件の中で便潜血陽性者に対して行われた183名を対象とした.全例CTC検査と同日に全大腸内視鏡検査も行った.対象とする病変は内視鏡観察あるいは病理組織学的に腺腫,がんと診断されたものとした.CTCの前処置は,経口腸管洗浄剤に水溶性造影剤による標識(タギング)を付けて行った.CT装置は16列Multi-slice CT(MSCT),腸管拡張は自動炭酸ガス注入器を使用した.CTC読影は,まず仮想内視鏡(3D)で行い,後に多断面再構成像(Multi-planar reconstruction: MPR 像(2D))を行う3D primary 法で行った.183名(男性98名,女性85名,年齢40～86歳,平均年齢62.1歳±0.8歳)のうち,病変を認めなかったのは87名(47.5%)であり,病変を認めたのは96名(53%)であった.総病変数は191個であり,うち6mm以上の病変は77個(40%)で,そのうち10mm以上のものは46個(24%)であった.大腸癌は25例(全病変中13%)で,うち腺腫内癌16例(全病変中8%)であった.側方発育型腫瘍は8例(4%)(大きさ平均17mm)であった.病変のうち,内視鏡的切除が行われたものは34病変であり,手術が行われたものは22病変であった.病変形態別による描出率は隆起型病変80%で,平坦型病変65%であった.病変サイズ別の精度は10mm以上の病変(n=46)で感度96%,陽性適中率98%であり,6mm以上の病変(n=77)で感度83%,陽性適中率79%であった.CTCは便潜血陽性者において良好な精度を示し,大腸がんスクリーニング法としての可能性がある.The purpose of this study was to estimate the sensitivity and specificity of CT colonography (CTC) for colorectal cancer screeing following positive fecal occult blood test (FOBT) in Japan. To compare detection rates of colorectal cancer and adenoma between CTC and optical total colonoscopy (TCS). This study included 183 patients with positive result of FOBT in Japanese colorectal cancer screening program. The patients had both CTC and TCS on the same day. 96 patients (53%) had colorectal lesions, on the other hand 87 patients had no lesions. The total number of lesions was 191, including 77 lesions 6 mm in maximum diameter and larger, including 46 lesions 10 mm and larger

Reduction of butyric acid-producing bacteria in the ileal mucosa-associated microbiota is associated with the history of abdominal surgery in patients with Crohn’s disease

ABSTRACTFecal microbiota is a significant factor determining the cause, course, and prognosis of Crohn’s disease (CD). However, the factors affecting mucosa-associated microbiota (MAM) remain unclear. This retrospective study examined the differences in ileal MAM between CD patients and healthy controls and investigated the factors affecting MAM in CD patients to clarify potential therapeutic targets. Ileal MAM was obtained using brush forceps during endoscopic examination from 23 healthy controls and 32 CD patients (most were in remission). The samples’ microbiota was profiled using the Illumina MiSeq platform. Compared to controls, CD patients had significantly reduced α-diversity in the ileum and a difference in β-diversity. The abundance of butyric acid-producing bacteria in the ileal MAM was significantly lower in CD patients with a history of abdominal surgery than in those without. Because butyric acid is a major energy source in the intestinal epithelium, its metabolism via β-oxidation increases oxygen consumption in epithelial cells, reducing oxygen concentration in the intestinal lumen and increasing the abundance of obligate anaerobic bacteria. The suppression of obligate anaerobes in CD patients caused an overgrowth of facultative anaerobes. Summarily, reducing the abundance of butyric acid-producing bacteria in the ileal MAM may play an important role in CD pathophysiology