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We herein report a patient with adult T-cell leukemia/lymphoma (ATLL) of the descending colon. A 64-year-old man was admitted to our hospital complaining of left lower abdominal pain. Endoscopic examination revealed an ulcerative tumor in the descending colon that was diagnosed as T-cell lymphoma by biopsy. Neither distant organ metastasis nor lymph node swelling was observed by radiographic examinations. Curative excision with left hemicolectomy and regional lymph node dissection was performed. Surgical sections contained ulcerative and superficially elevated lesions; these were continuous with each other. Histological examination revealed diffuse proliferation of medium-sized abnormal lymphoid cells. Immunohistochemically, these lymphoid cells were positive for UCHL-1/CD45RO and CD3 and negative for CD79a, indicating that the tumor was a primary malignant T-cell lymphoma of the descending colon. Integration of the proviral DNA of human T-lymphotropic virus type 1 (HTLV-1) was confirmed by Southern blotting analysis. [ABSTRACT FROM AUTHOR]

Purpose: We previously reported significant changes in sphincter of Oddi cyclic motility after proximal duodenal transection and anastomosis. However, the role of intrinsic myoneural continuity between the antrum and duodenum in this respect is not understood. The aim of this study was to elucidate the effects of prepyloric gastric transection on sphincter of Oddi motility in animals in the conscious state.Methods: Pressures in the bile duct, duodenum, stomach, and sphincter of Oddi and their response to an injection of cholecystokinin-octapeptide were measured in four conscious dogs, with a duodenal cannula, before and after gastric transection and anastomosis 1.5 cm proximal to the pylorus.Results: Gastric transection did not affect the initiation and propagation of the gastroduodenal migration motor complex. Biliary pressure (5.7 +/- 0.15 to 5.5 +/- 0.2 mmHg; P = 0.91), sphincter of Oddi basal pressure (10.6 +/- 0.3 to 10.7 +/- 0.2 mmHg; P = 0.97), and amplitude (26.0 +/- 1.2 to 32.9 +/- 1.7 mmHg; P = 0.304) did not change after gastric transection. Biliary pressure decreased from phase II to phase III of the duodenal migrating motor complex. Cholecystokinin-octapeptide inhibited sphincter of Oddi phasic waves before and after gastric transection.Conclusions: Intrinsic myoneural transection at the prepyloric region does not influence sphincter of Oddi cyclic motility. Preservation of pyloroduodenal myoneural continuity in pylorus-preserving gastrectomy would be beneficial to maintain normal sphincter of Oddi motility. [ABSTRACT FROM AUTHOR]

We studied the effect of the order of ward rounds on nosocomial infection in gastroenterologic surgery patients. The subjects were patients with gastrointestinal diseases admitted between September 1992 and August 1994. During the 1st year, the round proceeded indiscriminately among recovery rooms and rooms with stable patients and isolated patients with methicillin-resistant Staphylococcus aureus (MRSA). In the subsequent year, the round started in the recovery rooms and moved into the general rooms with stable patients and finally into the isolation rooms. Against the time course, piecewise linear regression analyses were made with the number of culture-positive patients and the quantities of antibiotics and disinfectants used. Of a total of 1894 strains from 264 patients, isolates of MRSA (n = 200) decreased from 150 in the 1st year to 50 in the 2nd year. The number of MRSA-positive patients showed the point of inflexion in the analysis at the change of round order, with a later decrease. The trend was similar for Candida (n = 99) and Enterococcal (n = 225) species. The amount of antibiotics was unchanged while the amount of disinfectants used decreased in the 2nd year. Thus, the round re-ordering appeared to help prevent nosocomial infection. Ward rounds for patients who have had gastroenterologic surgery should proceed from compromised hosts to stable patients, and then isolated patients. [ABSTRACT FROM AUTHOR]

Pseudocyst of the pancreas is sometimes difficult to distinguish from mucinous cystic neoplasm of the pancreas. A 37-year-old asymptomatic Japanese man was diagnosed with hypertension. He had a 20-years history of habitual drinking of alcohol, but no history of pancreatitis or abdominal trauma. During examinations to ascertain the cause of hypertension, ultrasonography and computed tomography incidentally demonstrated a huge cyst in the head of the pancreas. Laboratory data were within normal limits, including serum levels of amylase, carcinoembryonic antigen, and carbohydrate antigen 19-9. Imaging studies showed a huge unilocular cyst, measuring 7 cm, in the head-to-body of the pancreas, and two small unilocular cysts, measuring 1.4 and 1.5 cm, in the tail and head of the pancreas, respectively. A mural nodule was suspected in the largest cyst. Endoscopic retrograde cholangiopancreatography demonstrated communication of the main pancreatic duct with the two small cysts in the head and tail of the pancreas but not with the huge cyst. There were no ductal changes suggesting chronic pancreatitis. Laparotomy was performed under the tentative diagnosis of potentially malignant mucinous cystic neoplasms of the pancreas. However, inflammatory adhesion was dense around the pancreas and the mural nodule suspected preoperatively was found to be sludge aggregates in a pseudocyst. The diagnosis of an intraoperative frozen section of the cyst wall was pseudocyst of the pancreas. Cystojejunostomy was performed. We report this case because the preoperative diagnosis was mucinous cystic neoplasm of the pancreas, but the diagnosis changed with careful intraoperative examinations, to pseudocyst of the pancreas. We discuss the differential diagnosis of the two conditions. [ABSTRACT FROM AUTHOR]

An inflammatory polyp of the gallbladder is a rare variant of benign gallbladder polyp. Differentiation between an inflammatory polyp and polypoid gallbladder carcinoma is difficult when the polyp is more than 1 cm in diameter. We report a rare case of a large inflammatory polyp of the gallbladder masquerading as gallbladder carcinoma in a 37-year-old Japanese woman who was incidentally diagnosed with a large gallbladder polyp, measuring 1 cm in diameter, by ultrasonography. She was asymptomatic and physical examination was unremarkable. Abdominal ultrasonography and endoscopic ultrasonography revealed three polypoid lesions in the gallbladder. One lesion was an isoechoic polyp, measuring 15 x 8 mm, showing a nodular surface and located in the fundus of the gallbladder. The other two lesions were hyperechoic polyps, measuring 5 x 5 mm, in the body of the gallbladder. Computed tomography and magnetic resonance imaging revealed marked enhancement of the largest polypoid lesion by dynamic study, and no lymph node enlargement was noted. Endoscopic retrograde cholangiography revealed a 12 x 8 mm polyp with an irregular surface in the fundus of the gallbladder. Superselective angiography of the cystic artery revealed neovascularity and a tumor stain in the fundus of the gallbladder. Cholecystectomy with lymph node dissection was performed. Intraoperative frozen section diagnosis of the largest polyp was an inflammatory polyp of the gallbladder. The other two polyps were cholesterol polyps. Inflammatory polyp should be considered as a differential diagnosis of hypervascular gallbladder polyps that measure more than 1 cm in diameter. [ABSTRACT FROM AUTHOR]

Cholelithiasis is known to occur in 15%-24.5% of proctocolectomized patients. However, the clinical features and chemical analysis of gallstones in these patients have not been reported. We describe two cases of cholelithiasis that developed in patients after proctocolectomy with ileoanal anastomosis. These patients had a high output of watery stools and more frequent bowel movements than the average for Japanese patients with ileoanal anastomosis. The chemical composition of the resected gallstones was 93.0% cholesterol and 80.9%, respectively, in the two patients, indicating that cholesterol gallstones are formed in patients with ileoanal anastomosis after proctocolectomy. [ABSTRACT FROM AUTHOR]

Background: Pancreatobiliary reflux (PBR) can occur in individuals without pancreaticobiliary maljunction. The aim of this study was to elucidate the incidence of PBR in individuals with a normal pancreaticobiliary junction and its impact on the biliary tree., Methods: Data were prospectively collected from 15 centers on 420 patients with a morphologically normal pancreaticobiliary junction who had undergone bile sampling and measurement of the biliary amylase level. We investigated the incidence and predictive factors for high biliary amylase levels (HBAL), as well as the relationship of HBAL with biliary malignancy., Results: Twenty-three patients (5.5%) showed HBAL (≥10,000 IU/L). Univariate analysis showed that risk factors for the elevation of biliary amylase levels were the existence of a relatively long common channel (≥5 mm), acute pancreatitis, and papillitis. Multivariate analysis revealed that only the existence of a relatively long common channel was a significant factor for PBR. Biliary amylase levels in patients with a relatively long common channel were significantly higher than in patients without a long common channel (12,333 vs. 2,070 IU/L, P = 0.001). The incidence of HBAL (P < 0.001), as well as the overall biliary amylase levels (P = 0.007) were significantly higher in patients with gallbladder cancer than in those without gallbladder cancer., Conclusions: The PBR was frequently observed in individuals with a relatively long common channel. Patients showing HBAL with normal pancreaticobiliary junction are at high risk for gallbladder cancer.

We herein report a patient with adult T-cell leukemia/lymphoma (ATLL) of the descending colon. A 64-year-old man was admitted to our hospital complaining of left lower abdominal pain. Endoscopic examination revealed an ulcerative tumor in the descending colon that was diagnosed as T-cell lymphoma by biopsy. Neither distant organ metastasis nor lymph node swelling was observed by radiographic examinations. Curative excision with left hemicolectomy and regional lymph node dissection was performed. Surgical sections contained ulcerative and superficially elevated lesions; these were continuous with each other. Histological examination revealed diffuse proliferation of medium-sized abnormal lymphoid cells. Immunohistochemically, these lymphoid cells were positive for UCHL-1/CD45RO and CD3 and negative for CD79a, indicating that the tumor was a primary malignant T-cell lymphoma of the descending colon. Integration of the proviral DNA of human T-lymphotropic virus type 1 (HTLV-1) was confirmed by Southern blotting analysis.

We herein report a 64-year-old Japanese woman with cystadenocarcinoma of the liver without mesenchymal stroma which had been followed up by imagings for 12 years. A small round cyst grew from 1cm to 4 cm in diameter during 10 years. Thereafter, solid components were first detected in the unilocular cystic mass, which showed very rapid growth. Extended right lobectomy with right caudate lobectomy was performed. The histopathological diagnosis was cystadenocarcinoma of the liver without mesenchymal stroma. In this communication, we describe the progressive morphologic changes, shown on imagings, from a benign hepatic cyst to cystadenocarcinoma of the liver without mesenchymal stroma, and we briefly discuss the carcinogenesis of cystadenocarcinoma of the liver.

Autoimmune pancreatitis is a rare type of pancreatitis that is characterized by diffuse swelling of the pancreas and irregular stenosis of the pancreatic ductal system ("sclerosing" pantreatitis), caused by autoimmune processes. Previous reports have shown the complete form of the disease, but very few have presented follow-up imagings from the beginning to the complete form. We, herein, report a case of autoimmune pancreatitis starting as a localized form. A-56-year-old Japanese man developed obstructive jaundice. Ultrasonography showed a hypoechoic mass in the head of the pancreas, and endoscopic retrograde pancreatography (ERP) showed localized stenosis of the pancreatic duct in the head of the pancreas. Computed tomography (CT) showed enlargement, with a capsule-like rim, in the head of the pancreas. Internal biliary tube drainage was performed to relieve the obstructive jaundice. The patient was followed-up under the tentative diagnosis of localized "mass-forming" pancreatitis. Four months after the drainage, CT showed diffuse swelling of the pancreas, with a capsule-like rim, and ERP demonstrated diffuse irregular narrowing of the pancreatic duct. Glucose intolerance was noted for the first time. Steroid was given as a diagnostic treatment for autoimmune pancreatitis. Two months after initiation of the steroid treatment, the ERP findings were normal, and CT showed a normal pancreas. The biliary tube was removed, and the glucose intolerance was subsequently alleviated. To summarize, we report a case of autoimmune pancreatitis starting as localized "mass-forming" pancreatitis with a peripheral rim on imagings. It is very important to be well aware of the presence of the localized form of autoimmune pancreatitis.

Pancreas divisum is an embryologic anomaly of the pancreas that is characterized by a lack of fusion of the dorsal and ventral pancreatic ducts. It is rarely associated with pancreatic neoplasms. We report herein a rare association of pancreas divisum and serous cystadenoma of the pancreas. A 46-year-old Japanese woman presented with epigastralgia. Ultrasonography, computed tomography (CT) and magnetic resonance cholangiopancreatography revealed a multilocular cystic mass, measuring 7 cm in diameter, with a central stellate scar, in the body and tail of the pancreas. Angiography demonstrated a relatively hypervascular mass, suppressing the splenic vein. No arterial encasement was evident. Endoscopic retrograde pancreatography through the major papilla demonstrated only the duct of Wirsung; cannulation into the minor papilla was unsuccessful. In addition, CT showed a mildly dilated main pancreatic duct draining into the minor papilla. Distal pancreatectomy and splenectomy were performed, with the tentative diagnosis being serous cystic neoplasm of the pancreas, possibly malignant, and pancreas divisum. The cut surface of the resected specimen had a honeycomb-like appearance and the specimen consisted of multiple cysts of various sizes. Histopathological examination showed multiple cysts lined by a single layer of flat or cuboidal epithelial cells with glycogen in the cytoplasm. There was no evidence of malignancy. The histopathological diagnosis was serous cystadenoma of the pancreas. To the best of our knowledge, only three cases of serous cystadenoma of the pancreas associated with pancreas divisum have been reported. We report the fourth case of such an association, and briefly review the literature.

Background: Early gastric stasis is a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD). However, few reports have addressed this phenomenon in relation to the type of gastrointestinal reconstruction. We compared gastrointestinal motility and gastric juice output after two different types of gastrointestinal reconstruction following PPPD, end-to-side duodenojejunostomy after pancreaticojejunostomy and hepaticojejunostomy (group 1) and end-to-end duodenojejunostomy before pancreaticojejunostomy and hepaticojejunostomy (group 2)., Method: In a total of 25 patients, 10 in group 1 and 15 in group 2, who underwent PPPD, manometry was repeated to assess gastric and jejunal motility until the first occurrence of phase III activity of gastric cyclic motor activity (CMA). The plasma level of motilin was measured in each phase of the gastric CMA and compared between the two groups. The daily volume of gastric juice output through a gastrostomy tube was also recorded for comparison., Result: There was no significant difference in the time period for recovery of gastric phase III activity and gastric juice output between the two groups. However, abnormal contractions with an increased basal pressure appeared frequently in the afferent jejunal loop only in group 1. The plasma motilin level after PPPD showed no apparent cyclic change even after the recovery of gastric phase III in either group., Conclusion: Gastrointestinal reconstructive procedures have almost no effect on the recovery of gastric CMA. The plasma motilin concentration does not play a major role in the recovery of gastric CMA in the early postoperative period after PPPD.

We report a 74-year-old Japanese woman with a spontaneously vanishing pseudocyst in the remnant pancreas after pylorus-preserving pancreatoduodenectomy for intraductal papillary-mucinous adenoma of the pancreas. A cystic lesion appeared in the remnant pancreas 6 months after the operation and had disappeared 3 months later. When a cystic lesion is encountered in the remnant pancreas after pancreatectomy for mucin-hypersecreting tumor of the pancreas, pseudocyst, as well as recurrence, should be considered in the differential diagnosis. Additional resection would likely cause considerable morbidity, with loss of endocrine and exocrine functions.

There have been numerous reports that mucinous cystadenoma of the pancreas can transform to mucinous cystadenocarcinoma after cystenterostomy, but few authors have reported morphological changes long after cystenterostomy for mucinous cystadenoma. A 41-year-old Japanese woman had undergone cystgastrostomy at a nearby hospital 11 years before undergoing the treatment reported here. The preoperative diagnosis at the time of cystgastrostomy was a pancreatic cyst. At laparotomy a cyst, measuring 10cm in diameter, was found in the body and tail of the pancreas. The histopathological diagnosis of the cyst wall was mucinous cystadenoma of mild dysplasia. Computed tomography 10 years after the cystgastrostomy showed that the cyst had decreased in diameter from 10 cm to 5cm. Gastroscopy showed a scar at the cystgastrostomy site in the stomach. A complete resection of the mucinous cystadenoma was done, 11 years after the cystgastrostomy, because of the malignant potential. The resected specimen showed mucinous cystadenoma of mild dysplasia with structural and cellular atypia similar to that in the previous specimen. There was no malignant change. The patient was discharged after an uneventful postoperative course and no recurrence has been evident for 6 months to date. This case showed imaging and histopathological evidence of the slow-growing nature of mucinous cystadenoma of the pancreas.

To examine the initial step of brown pigment gallstone formation, sterile human gallbladder bile samples were incubated with or without beta-glucuronidase in vitro. Enhanced bilirubin deconjugation achieved by adding beta-glucuronidase significantly accelerated the formation of a precipitate that contained bilirubin (28.2 +/- 3.8% of dry weight), cholesterol (14.3 +/- 5.2%), free fatty acids (12.0 +/- 1.3%), and glycoprotein (10.0 +/- 6.7%). Both the composition and scanning electron microscopic appearance of the precipitate were similar to these features in brown pigment gallstones. The cholesterol saturation index and nucleation time in the supernatant did not change with various incubation periods. The weight ratios of bilirubin to cholesterol in the precipitates correlated with those in bile (r = 0.76; P = 0.017). Gel chromatography of the precipitate showed high molecular weight glycoprotein to be the major constituent. Bilirubin, cholesterol, fatty acids, and mucin were found to coprecipitate in accordance with bilirubin deconjugation, which process may play an important role in an early stage of the formation of brown pigment gallstones.

A 30-year-old man with multiseptate gallbladder, a very rare congenital anomaly, is presented. His presenting symptom was epigastric pain. A hypoplastic gallbladder with multiple septa was demonstrated by ultrasonography and endoscopic retrograde cholangiography. An injection of cerulein reproduced pain, and simultaneous biliary manometry and scintigraphy showed impairment of gallbladder filling and emptying. Laparoscopic cholecystectomy resulted in complete relief of the pain. Biliary manometry and scintigraphy are useful to determine the operative indication in a symptomatic patient with this entity.

To investigate the effects of pravastatin and ursodeoxycholic acid (UDCA) on cholesterol and bile acid metabolism in humans, 41 patients with cholesterol gallstone disease were allocated to four groups and treated with pravastatin (20 mg/day), UDCA (600 mg/day), both pravastatin and UDCA, or neither drug (control) for 1-2 weeks prior to elective cholecystectomy. Cholesterol 7 alpha-hydroxylase activity and serum levels of total 7 alpha-hydroxycholesterol were significantly increased by pravastatin and unaffected by UDCA. 3-Hydroxy-3-methylglutaryl coenzyme A reductase activity was markedly increased by pravastatin and decreased by UDCA. UDCA significantly decreased biliary cholesterol concentration and the cholesterol saturation index and prolonged the nucleation time; however, pravastatin alone had little effect on biliary lithogenicity. Serum total and low-density lipoprotein (LDL)-cholesterol levels were reduced most by the combined administration of pravastatin and UDCA. In conclusion, at a dose of 20 mg/day, pravastatin increased bile acid synthesis but did not decrease biliary lithogenicity. UDCA had no significant effect on bile acid synthesis, but markedly decreased biliary lithogenicity.