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A 76-year-old woman suffered from repeated postprandial syncope of unknown cause. Computed tomography scanning revealed an enlarged hiatal hernia sac with food residues that compressed both the left atrium and inferior vena cava. As soon as the hernia cavity expanded during an upper gastrointestinal X-ray examination, she experienced a deterioration of her level of consciousness. Therefore, we diagnosed her of a swallow syncope due to left atrium compression by the huge hernia sac. The sac also compressed the inferior vena cava, and she experienced a transient elevation of her hepatobiliary enzyme level probably due to the influence of the congestive liver. Thus, clinicians should always keep this condition in mind when encountering patients with post-meal syncope.

A 19-year-old man was admitted to our hospital because of persistent fever of >38°C for 6 days and diarrhea for 4 days. Initially, he was treated for infectious enteritis, but on his second day in the hospital, the two sets of blood cultures came back positive. Cultures from the blood and stool yielded Salmonella sp. (Group O4). The patient's symptoms improved after treatment with fluoroquinolone-based antimicrobial agents for 14 days. Cases of nontyphoidal Salmonella bacteremia are rare;therefore, we reported this case with bibliographic consideration of the risk factors for Salmonella bacteremia.

A 59-year-old man was referred to our hospital for examination of intermittent abdominal pain. Computed tomography scan showed a cystic lesion adjoining the ileum, and small bowel series demonstrated a small bowel diverticulum. Double-balloon enteroscopy (DBE) revealed a diverticulum in the ileum and a soft and smooth elevated lesion with a small hole at the base of the diverticulum. Small bowel series under DBE demonstrated that the cystic lesion communicated with the diverticulum through the small hole. The diagnosis was Meckel's diverticulum and an omphalomesenteric cyst. This is the first reported case of a Meckel's diverticulum and omphalomesenteric cyst communicating through a small hole without a fibrous ligament. In addition, precise evaluation was possible by small bowel series and DBE.

Obstructive colorectal cancer accounts for 3.1-15.8% of total colorectal cancer cases, therefore it is not a rare condition. Formerly, it has been often treated with emergent operation such as colostomy or trans-anal tube decompression. Since 2012, revision of the medical payment system, it has become possible to be treated with elective operation when using endoscopic metal stent placement that enable to decompress enlarged intestine by transanal approach. This procedure provides safe elective surgery with sufficient preoperative inspection and conventional bowel preparation. We report two cases of acute large bowel obstruction due to colon cancer treated with endoscopic stent placement as a "bridge to surgery".

A 44-year-old female was referred to our hospital with a complaint of abdominal fullness. Computed tomography(CT) showed multiple liver masses and a huge ovarian tumor. Colonoscopy revealed a type 4 advanced cancer in the sigmoid colon. She was diagnosed with unresectable liver and ovarian metastases from advanced sigmoid colon cancer, for which we were obliged to select chemotherapy. As the first line, FOLFOX was applied and performed for 6 cycles, followed by FOLFOX plus bevacizumab(BV)for 5 cycles. While no deterioration of liver and ovarian metastases was observed during the course of those chemotherapy regimens, the patient developed a considerable level of acute sensorimotor neuropathic symptoms associated with oxaliplatin-induced peripheral neurotoxicity, forcing us to replace FOLFOX plus BV with FOLFIRI plus BV. Three cycles of FOLFIRI plus BV, however, turned out to be progressive disease with deterioration of liver and ovarian metastases. Since her oxaliplatin-induced neurotoxicity was improved, a regimen of FOLFOX plus BV was once again applied to her for 3 cycles, which failed to prevent her from having a progressive disease. The sequencing of K-RAS genes from the biopsy specimens of sigmoid colon cancer revealed an expression of a wild-type K-RAS. Thus, an addition of panitumumab to FOLFOX was made. Surprisingly, after 3 cycles of the chemotherapy regimen over 3 months, a significant reduction in the size of liver and ovarian metastases was observed. Her sense of abdominal fullness was apparently reduced and was even lower than what it was at admission. Panitumumab has great potential for effective treatment of patients with unresectable stage IV colorectal cancer, even after having acquired resistance to prior chemotherapy regimens.

A 74 year-old man underwent subtotal gastrectomy for advanced gastric cancer in 2000. The histological type of the cancer was signet-ring cell carcinoma, and the clinical stage was stage II (T2, N1, M0). In June 2008 the patient was referred to our hospital complaining of dysphagia. Esophageal endoscopy revealed a circular stenosis with covered with normal mucosa between the lower esophagus and the esophago-gastric junction. Histologically, samples obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) revealed signet-ring cell carcinoma. Our experience suggests that EUS-FNA was useful for the histological diagnosis of recurrence of gastric cancer.

A 47-year man was hospitalized to our hospital because of consciousness disturbance. He had been abnormally fond of soy bean products since childhood. His plasma levels of ammonia and citrulline were elevated, and we suspected of adult-onset type II citrullinemia (CTLN2). Gene examination demonstrated abnormality in the SLC25A13 gene, confirming CTLN2. Serum levels of hepatobiliary enzymes were increased and his liver biopsy revealed nonalcoholic steatohepatitis. Although we considered that living donor liver transplantation was suitable for the treatment, unfortunately, there was no appropriate donor candidate in his family. He has received conservative treatments, showing a symptom-free course.

We performed a small phlebotomy (50 ml) intermittently just before intravenous injection of glycyrrhizin (GL) in eight patients with chronic hepatitis C and continued this therapy until their serum ferritin levels dropped below 20 ng/ml without any changes of GL dosage. No patients had complications but one patient holded treatment according to their wishing. In seven patients who completed this therapy, the average amount of phlebotomized blood was 1221 +/- 1055 ml, their serum ferritin value significantly fell from 253 +/- 233 ng/ml to 18+/-5 ng/ml (p=0.038). Serum ALT levels also significantly decreased from 74 +/- 22 IU/L to 41 +/- 12 IU/L (p=0.001). Small intermittent phlebotomies before GL injection may be a effective treatment for hepatitis C.

A 42-year-old woman with chronic hepatitis C has visited our hospital since October 2003. Liver biopsy revealed chronic hepatitis (A1/F1) . Therapy was initiated with interferon (IFN) alpha-2b and ribavirin in February 2004. Two months later, the patient developed left facial weakness. Laboratory findings showed cryoglobulinemia and abnormal thyroid function without any evidence of other viral infections. Idiopathic peripheral facial nerve palsy was diagnosed. IFN was discontinued at week 9 of therapy, but she obtained sustained virological response and her symptoms resolved at 6 month after the withdrawal.

A 73-year-old man was admitted with fever and abnormal liver function test. After admission, his fever persisted in spite of administrating a variety of antibiotics. He was diagnosed as acute Q fever on the basis of a high titer of IgM antibodies against phase II Coxiella burneti. His fever resolved after starting minocycline, but biliary enzymes continued to be elevated. Transbronchial lung biopsy and percutaneous liver biopsy revealed caseating granulomas and Mycobacterium tuberculosis was detected by culture. Miliary tuberculosis was diagnosed and his biliary enzymes declined after starting therapy with antituberculous drugs. This report of miliary tuberculosis complicating acute Q fever is a valuable and unprecedented case.

We report a case of N 3 gastric cancer successfully treated by TS-1 followed by curative resection. The patient was a 64-year-old male. Gastrointestinal endoscopic examination showed advanced gastric cancer. Examination by computed tomography revealed gastric cancer and swollen para-aortic lymph nodes. This patient was treated by neoadjuvant chemotherapy with oral administration of TS-1 (120 mg/day, day 1-28 with 2 weeks rest). After 3 courses of TS-1, the primary lesion and swollen lymph nodes were remarkably reduced. This chemotherapy enabled pancreatoduodenectomy with D 3 lymph node dissection in curative resection. The pathological diagnosis was por, pT 2, pMP and pap, pT 1, pSM 2, pPM(-), pDM(-), pN 1, pStage II and curability A. This neoadjuvant chemotherapy regimen seems to be an effective and promising therapy for patients with advanced gastric cancer.

We report the case of an 80-year-old man given a diagnosis of pancreatic intraductal papillary-mucinous carcinoma (IPMC) and early gastric cancer. He refused surgery, therefore endoscopic mucosal resection (EMR) for gastric cancer and careful observation were performed. Penetration of the IPMC to the stomach was observed 3 months later. Ten months after the initial diagnosis, he was found to have a splenic abscess and was subsequently treated by antibiotics and percutaneous drainage, and a fistula between the IPMC and the splenic abscess was observed. We suppose IPMC penetration to the spleen and bacterial transmission from the stomach through the fistula caused the splenic abscess. While IPMC is recognized as a low-grade malignancy, some cases of invasive carcinoma with fistulation to adjacent organs have been reported. To the best of our knowledge, this is the first case of IPMC associated with splenic abscess due to pancreatosplenic fistula.

Liver biopsy interpretation remains the gold standard for diagnosis of NASH. It also permits determination of disease severity and may provide insight into prognosis. The histopathologic criteria for NASH generally include the presence of hepatic steatosis, lobular inflammation, and hepatocyte ballooning degeneration. The system proposed by Brunt remains the best known and most frequently used method for the grading and staging of NASH. Recently a histologic scoring system (NAFLD activity score (NAS)) has been proposed that can assist in diagnosis of NAFLD and may be useful for assessing the response to therapy. In our hospital, informed consent about liver biopsy was obtained from 65(56%) of 116 consecutive NAFLD patients with elevated ALT levels: 35% (23/65) had NASH, 59% (38/65) had simple steatosis, and 6% (4/65) had normal liver histology. Sampling variability continues to be a limitation of liver biopsy in staging NASH.

A questionnaire survey was conducted in September 2000 to clarify the actual state and problems inherent to the care of patients with amyotrophic lateral sclerosis (ALS). The subjects were members of a patients' association, and 176 members answered the questionnaire (response rate. 64.9%). Patients being taken care of at home accounted for 76.7% of those who answered the questionnaire and those under mechanical ventilation (MV) at home for 40.3% of respondents. Compared with the results of the same survey administered by the patients' association in 1992 and 1996, the figures showed an increase of the patients being taken care of at home. Of the subjects who were receiving domiciliary services under the long-term care insurance system introduced in April 2000, those who considered the services had improved under the new system accounted for 44.2% of the respondents, and those who thought the services had worsened for 25.0%. The latter percentage included a greater number of patients under MV or who were using an aspirator and those with overworked caregivers. Moreover, the burden for the caregiver did not necessarily decrease when the patient was admitted to hospital, because attendance by the caregiver or additional costs for services were required. The new insurance system is thus considered to be inadequate and unsatisfactory for seriously disabled people, such as patients with ALS.

A 69-year-old man attempted suicide by abdominal penetrating injury and taking sulfonyl acid. After a laparotomic drainage operation, corrosive esophageal stenosis occurred. Esophageal bougienage was not effective. An expandable metallic stent (GIANTURCO-ROCHE Z stent, Cook Bloomington U.S.A.) was inserted aiming to achieve temporary oral diet and nutritional improvement. But diet did not improve sufficiently because of the awareness of the prosthesis, severe hiccup, uncontrolled regurgitation esophagitis and restenosis caused by intraluminal mucosal growth. After 4 months of insertion, an esophago-bronchial fistula was produced by the wire of EMS. An operation became necessary for this complication. No data exist on the long-term use of the EMS and it is not suitable for benign esophageal stenosis. Unavoidably if the palliative treatment of endoprosthesis is necessary for benign esophageal stenosis such as corrosive esophageal stenosis, a removable esophageal tube prosthesis is preferable.

A 50-year-old man was admitted to our hospital for the evaluation of hypocalcemia and the treatment of diabetes mellitus. Seven months before admission, he sometimes felt thirst and polyuria, and 4 months before admission, he went to a doctor to check his blood glucose and was diagnosed as having diabetes mellitus which had suddenly developed. At that time he was treated with sulfonylurea, but his diabetic control was very poor. At the time of admission to our hospital, the patient's serum calcium (Ca) level was 5.7 mg/dl, phosphorus (P) 5.0 mg/dl, and fasting blood glucose 308 mg/dl, but urinary ketone bodies were not detected. High sensitive assay of parathyroid hormone (HS-PTH), intact PTH and C-terminus PTH concentrations were under the level of detection. TSH level was slightly high (6.1 mu U/ml) with positive antimicrosomal and antithyroglobulin antibodies but thyroid hormone levels were within normal limits. TRH test showed over-response of TSH. Based on Ellsworth-Howard test, we made the diagnosis of idiopathic hypoparathyroidism associated with primary hypothyroidism and diabetes mellitus. He was treated with insulin twice a day and reached good control, and he was also administered 1 alpha-OH-D3 and calcium lactate resulting in an increase of serum Ca level after 2 weeks. These findings suggest that this case may be a polyglandular autoimmune (PGA) syndrome type 1 reported by Neufeld, which is very rare in Japan. The type of diabetes mellitus of this case is controversial. It is, however, necessary to pay attention to the decrease of the patient's insulin-secreting activity because autoimmune disorders are accompanied by this case.

Plasma concentrations of alpha-atrial natriuretic peptide (alpha-ANP), antidiuretic hormone (ADH) and aldosterone (ALDS) were determined by radioimmunoassay in 9 patients undergoing aortocoronary bypass grafting under high dose fentanyl (94.4 micrograms.kg-1) anesthesia. These three levels in pre-anesthetic period (control values) were within normal ranges suggesting the absence of congestion and dehydration. Although these values changed significantly after sternotomy, they all increased at the termination of cardiopulmonary bypass (CPB) reaching 2.5 fold in alpha-ANP, 27.7 fold in ADH and 2.4 fold in ALDS as compared with control (P less than 0.05). Present results indicate that high dose fentanyl anesthesia cannot suppress ADH and ALDS level during CPB as was previously demonstrated and the observed rise in alpha-ANP level is considered to be inadequate not only for diuresis but also for vascular dilatation. Administration of alpha-ANP to ameliorate circulatory insufficiency after CPB should probably be considered.

Conradi's syndrome is a rare hereditary disease characterized by punctate epiphyseal calcifications. The symptoms include short stature, typical facies with hypertelorism, saddle nose, short neck, tracheal stenosis and scoliosis. The deformities of airway and thoracic cage are expected to bring about ventilatory failure during anesthesia and operation. Although there has been a brief report of a death of a child with this syndrome during induction of anesthesia, we cannot find any other report concerning the perioperative respiratory management. This is a report on a girl with Conradi's disease who developed respiratory problems due possibly to gastric aspiration during ophthalmic surgery under general anesthesia. Several anesthetic problems raised by this case are discussed.