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Background Supragastric belching (SGB) may play a role in the pathophysiology of proton pump inhibitors (PPIs)-refractoriness in gastroesophageal reflux disease (GERD). SGB may be present in up to 40% of reflux symptoms in PPI-refractory GERD. Most reports on SGB have come from Western countries, and little is known about the prevalence and relevance of SGB in Asian refractory GERD patients. This study aimed at comparing the role of SGB in GERD patients in Japan and the UK. Methods We re-analyzed impedance-pH monitoring tracings from patients who were referred to tertiary centers in Japan and the UK due to PPI-refractory reflux symptoms. The prevalence of excessive SGB and the impact of SGB on reflux symptoms were compared between the two countries. Results Impedance-pH tracings from124 Japanese and 83 British patients were re-analyzed. Japanese patients were significantly younger and had smaller body mass index than the British (P P = 0.006). Logistic regression analysis showed that the geographical/cultural difference was the only factor associated with the different prevalence of SGB (odds ratio; 2.91, 95% CI 1.09–7.73, P = 0.032). SGB were related to typical reflux symptoms very rarely in Japan [0% (0–4.9)] compared to the UK [35% (0–54.1)] (P = 0.071). Conclusions The prevalence of SGB and their impact on reflux symptoms is significantly lower in Japan compared to the UK. The difference is not related to reflux parameters but might come from ethnic/cultural factors to be further characterized.

OBJECTIVE: High-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems. DESIGN: Manometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal latency (DL), and distal contractile integral (DCI) in standardized fashion. Normative thresholds were assessed using fifth and/or 95th percentile values. Chicago Classification v3.0 criteria were applied to determine motor patterns across HRM systems, study positions (upright vs supine), ages, and genders. RESULTS: Of 469 unique HRM studies (median age 28.0, range 18-79 years). 74.6% had a normal HRM pattern; none had achalasia. Ineffective esophageal motility (IEM) was the most frequent motor pattern identified (15.1% overall), followed by EGJ outflow obstruction (5.3%). Proportions with IEM were lower using stringent criteria (10.0%), especially in supine studies (7.1%-8.5%). Other motor patterns were rare (0.2%-4.1% overall) and did not vary by age or gender. DL thresholds were close to current norms across HRM systems, while IRP thresholds varied by HRM system and study position. Both fifth and 95th percentile DCI values were lower than current thresholds, both in upright and supine positions. CONCLUSIONS: Motor abnormalities are infrequent in healthy individuals and consist mainly of IEM, proportions of which are lower when using stringent criteria in the supine position. Thresholds for HRM metrics vary by HRM system and study position.

Purpose of the guidelines The primary objective of these guidelines is to provide general clinicians with information that would guide them to make informed choices of the available diagnosis/treatment strategies for esophageal cancer (intended for malignant esophageal tumors of epithelial origin, not for any other non-epithelial malignant tumors of the esophagus or metastatic esophageal malignant tumors). Furthermore, these guidelines are also intended as an aid for healthcare professionals other than the physicians, patients, and patients’ family members, to obtain an understanding of the fundamental principles of the diagnosis and treatment of esophageal cancer. These guidelines are intended to allow physicians to undertake diagnosis and treatment of esophageal cancer by sharing the information contained in the guidelines and promote mutual understanding among the healthcare professionals, patients, and their family members.

Smoking cigarettes and drinking alcoholic beverages are considered very important risk factors for adverse health effects, such as many types of cancer and cardiovascular disease. In this study, we evaluated the influence of smoking and drinking cessation on risk of esophageal cancer, by means of meta-analysis. We extracted 205 studies by conducting a systematic literature search. Thirty-five studies that estimated risk reduction following smoking cessation and 18 studies conducted following drinking cessation were identified in the literature review. Former smokers had a significantly lower summary risk ratio (RR) than current smokers [RR 0.74, 95% confidence interval (CI) 0.68–0.80]. In subgroup analysis of Japanese smokers, squamous cell carcinoma, and adenocarcinoma, RRs for former smokers versus current smokers were 0.65 (95% CI 0.51–0.83), 0.60 (95% CI 0.50–0.72), and 0.93 (95% CI 0.84–1.03), respectively. The summary RR between former alcohol drinkers and current drinkers was not significant (RR 1.09, 95% CI 0.94–1.26). In our analysis of time since drinking cessation, drinkers who had stopped consuming alcohol for 5 years or more had a significantly lower summary RR than current drinkers (RR 0.78, 95% CI 0.66–0.93). Summary RR for drinkers who stopped for 10 years or more versus current drinkers was 0.65 (95% CI 0.57–0.74). Our investigation found that smoking cessation lowers esophageal cancer incidence. We also found that esophageal cancer incidence risk could be decreased in current drinkers by cessation of alcohol consumption for 5 years or more.

We previously reported that cascade stomach was associated with reflux symptoms and esophagitis. Delayed gastric emptying has been believed to initiate transient lower esophageal sphincter relaxation (TLESR). We hypothesized that cascade stomach may be associated with frequent TLESR with delayed gastric emptying. Eleven subjects with cascade stomach and 11 subjects without cascade stomach were enrolled. Postprandial gastroesophageal manometry and gastric emptying using a continuous 13C breath system were measured simultaneously after a liquid test meal. TLESR events were counted in early period (0–60 min), late period (60–120 min), and total monitoring period. Three parameters of gastric emptying were calculated: the half emptying time, lag time, and gastric emptying coefficient. The median frequency of TLESR events in the cascade stomach and non-cascade stomach groups was 6.0 (median), 4.6 (interquartile range) vs 5.0, 3.0 in the early period, 5.0, 3.2 vs 3.0, 1.8 in the late period, and 10.0, 6.2 vs 8.0, 5.0 in the total monitoring period. TLESR events were significantly more frequent in the cascade stomach group during the late and total monitoring periods. In contrast, gastric emptying parameters showed no significant differences between the two groups. We concluded that TLESR events were significantly more frequent in persons with cascade stomach without delayed gastric emptying.

The values of the parameters in the Chicago classification measured by a high-resolution manometry (HRM) system with the Unisensor catheter (Starlet) are significantly different from those measured by the ManoScan. The contraction vigor is categorized by values of the distal contractile integral (DCI) in the Chicago classification v3.0; however, reference values of the DCI in the Starlet and the clinical impact of the different reference values in the Starlet and ManoScan on diagnosing esophageal motility disorders are not known. We evaluated data from a previous report in which ManoScan and Starlet were compared in the same subjects. The DCI values in each system were compared and reference DCI values were calculated. Moreover, diagnoses assessed by Starlet using reference values in ManoScan were compared with those using calculated reference values and those assessed by ManoScan. There was a significant positive correlation between the DCI values measured by ManoScan and those measured by Starlet (r = 0.80, p

As an increase in gastroesophageal reflux disease (GERD) has been reported in Japan, and public interest in GERD has been increasing, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009. Six years have passed since its publication, and there have been a large number of reports in Japan concerning the epidemiology, pathophysiology, treatment, and Barrett's esophagus during this period. By incorporating the contents of these reports, the guidelines were completely revised, and a new edition was published in October 2015. The revised edition consists of eight items: epidemiology, pathophysiology, diagnosis, internal treatment, surgical treatment, esophagitis after surgery of the upper gastrointestinal tract, extraesophageal symptoms, and Barrett's esophagus. This paper summarizes these guidelines, particularly the parts related to the treatment for GERD. In the present revision, aggressive proton pump inhibitor (PPI) maintenance therapy is recommended for severe erosive GERD, and on-demand therapy or continuous maintenance therapy is recommended for mild erosive GERD or PPI-responsive non-erosive GERD. Moreover, PPI-resistant GERD (insufficient symptomatic improvement and/or esophageal mucosal break persisting despite the administration of PPI at a standard dose for 8 weeks) is defined, and a standard-dose PPI twice a day, change in PPI, change in the PPI timing of dosing, addition of a prokinetic drug, addition of rikkunshito (traditional Japanese herbal medicine), and addition of histamine H2-receptor antagonist are recommended for its treatment. If no improvement is observed even after these treatments, pathophysiological evaluation with esophageal impedance-pH monitoring or esophageal manometry at an expert facility for diseases of the esophagus is recommended.

Background/Aim: We evaluated the efficacy of vonoprazan (VPZ), a novel potassium-competitive acid blocker, in patients with proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD), exhibiting continued pathological esophageal acid exposure (EAE). Methods: Despite ≥8 weeks of appropriate PPI therapy, patients with ­persistent reflux symptoms and pathological EAE times (EAETs ≥4%) were invited to switch to VPZ treatment. After an 8-week-course of once-daily VPZ (20 mg), multichannel intraluminal impedance-pH (MII-pH) monitoring was repeated to compare gastric acid exposure times (GAETs), EAETs, and other reflux parameters relative to the baseline values. Before each MII-pH study, reflux symptom severities were scored using the Gastrointestinal Symptom Rating Scale; erosive esophagitis and fasting plasma gastrin levels were also assessed. Results: From among the 124 patients undergoing MII-pH monitoring, 13 patients (median age, 69 years; females, 64%) were monitored at baseline (while on PPI therapy) and after VPZ therapy. The median GAET associated with VPZ treatment (23.8%) was less than that for PPI treatment (41.1%; p = 0.01), including both daytime and nighttime measurements. VPZ therapy resulted in better median EAET values (4.5%) than did PPI therapy (10.6%) during the 24-h monitoring period (p = 0.055). EAE normalization was achieved in 46% of VPZ-treated patients and was associated with complete gastric acid suppression (p = 0.005). After switching to VPZ, reflux symptoms (p < 0.01) and erosive esophagitis (p = 0.01) improved. Conclusion: In patients with PPI-refractory GERD, VPZ provides more potent gastric acid suppression, more effective EAE control, enhanced symptom improvement, and better esophagitis healing than PPIs.

Background: Patients with proton pump inhibitor (PPI)-resistant nonerosive reflux disease (NERD) include subgroups that have markedly different pathophysiology. This study aimed to clarify the pathophysiology of NERD by esophageal manometry with 24-hour esophageal impedance and pH monitoring. Methods: Eighteen consecutive outpatients referred to our expert center for functional gastrointestinal motility with suspected PPI-resistant NERD were enrolled. Manometry was performed to detect esophageal motility disorders. Subsequently, 24-hour esophageal impedance and pH monitoring was done while patients were on PPI therapy. Results: Manometry revealed 1 case of achalasia, 1 case of nutcracker esophagus and 3 cases of diffuse esophageal spasm. Three patients had ineffective esophageal motility, with impedance and pH monitoring being performed in 2 of them. Esophageal acid exposure (%time pH Conclusion: A substantial percentage (28%) of patients with suspected PPI-resistant NERD had primary esophageal motility disorders. Both nonacidic reflux and weakly acidic reflux are important contributors to the symptoms of patients with PPI-resistant NERD. Esophageal manometry is required to exclude motility disorders, while 24-hour esophageal impedance and pH monitoring is invaluable for assessing symptom-reflux associations and the indications for fundoplication in patients with suspected PPI-resistant NERD.

Hepatitis B virus (HBV) reactivation has been increasingly recognized in patients receiving chemotherapy and immunosuppressive therapy; however, the prevalence of HBV infection and rate of HBV screening in patients with rheumatic diseases remains unclear. In this study, we aimed to assess the prevalence of HBV infection and fulminant HBV hepatitis in patients with rheumatic diseases. We also investigated the rate of HBV screening before immunosuppressive therapy in patients with rheumatic diseases. A retrospective questionnaire survey was conducted in the North-east area (Tohoku) of Japan. Questionnaires, comprising 6 questions, were sent to 318 rheumatologists in May 2010, and responses were gathered until June 2011. In total, 71 rheumatologists (22.3%) responded to the survey. We enrolled 7,650 patients with rheumatoid arthritis (RA) and 1,031 patients with systemic lupus erythematosus (SLE). When limited to institutes at which almost all (≥ 90%) patients were tested for HBV serology, 1.1% (40/3,580) patients with RA and 0.3% (3/1,128) patients with SLE were positive for hepatitis B surface antigen (HBsAg), and 25.2% (177/703) patients with RA and 13.7% (34/248) patients with SLE were positive for hepatitis B core antibody (HBcAb). About one-third of rheumatologists did not check HBsAg and more than half did not check hepatitis B surface antibody (HBsAb) or HBcAb at all before therapy. Fulminant HBV hepatitis was observed in 1 RA patient who was current HBV carrier. In conclusion, the prevalence of HBV infection is high in patients with RA and SLE. HBV screening before immunosuppressive therapy should be strictly performed.

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

We recently demonstrated that cascade stomach detected by barium studies was correlated with upper gastrointestinal symptoms. We developed a new endoscopic classification of cascade stomach and examined its relationship with reflux esophagitis. Study 1: the classification (grades 0–3) was based on detecting a ridge that runs from the cardia toward the anterior wall crossing the greater curvature. Inter-observer variation was evaluated by kappa statistics when ten experienced endoscopists used this classification three times each. Study 2: in 710 consecutive subjects (500 men and 210 women) undergoing endoscopic screening, the grade of cascade stomach and incidence of reflux esophagitis were compared. In study 1, the kappa values at the third assessment were 0.85, 0.58, 0.50, and 0.78 for each grade, respectively, while overall agreement was 0.68. In study 2, the incidence of reflux esophagitis in men was 20 % in grade 0, 17 % in grade 1, 25 % in grade 2, and 30 % in grade 3, showing significant differences. Among women, the incidence of reflux esophagitis in each grade was 9, 3, 6, and 35 %, respectively, also showing significant differences. Multivariate analysis showed that independent risk factors for reflux esophagitis were cascade stomach (odds ratio = 2.20), body mass index, and hiatus hernia in men, as well as cascade stomach (odds ratio = 9.01) and smoking tobacco in women. This endoscopic classification of cascade stomach showed acceptable inter-observer variation. Cascade stomach is a risk factor for reflux esophagitis.

Background and Aim: The Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) is the standard questionnaire used in Japan for the diagnosis of gastroesophageal reflux disease (GERD) and assessment of the response to treatment. We modified the FSSG in order to assess dyspepsia symptoms, and evaluated the modified questionnaire. Methods: We modified the FSSG by adding two questions on interdigestive and postprandial epigastric pain. We then assessed the modified FSSG with 100 new untreated symptomatic patients presenting to hospital and in 200 subjects undergoing health checks. Endoscopic assessment of the esophagogastric junction was performed according to the modified Los Angeles classification with addition of Grade N (normal appearance) and Grade M (minimal change). Endoscopic images were assessed by five experienced endoscopists blinded to the questionnaire results. Results: The 100 new patients included 16 with erosive GERD (>Grade A), 12 with peptic ulcer, and two with gastric cancer. Among the 70 patients with no evidence of organic disease, the modified FSSG diagnosed functional dyspepsia (FD) in 41 and non-erosive gastric disease (NERD) in 29. A significant difference was seen in the dyspepsia score between patients with FD and NERD. Subjects with endoscopic GERD undergoing health checks had significantly higher scores for all symptoms, reflux symptoms, and dyspeptic symptoms on the modified FSSG. Conclusion: The modified FSSG can clearly distinguish FD from NERD, and is useful for the assessment of dyspeptic symptoms.

Objective. To know the characteristics of endoscopic laryngeal and pharyngeal abnormalities in Japanese patients with laryngopharyngeal reflux symptoms (LPRS).Methods. A total of 146 endoscopic images of the larynx and pharynx (60 pairs for the rabeprazole group and 13 pairs for the control group) were presented to 15 otolaryngologists blinded to patient information and were scored according to several variables potentially associated with laryngopharyngeal reflux. The median value of the 15 scores for each item from each image was obtained. The mean pretreatment scores of each item and total score were assessed in both rabeprazole and control groups. In the rabeprazole group, the endoscopic findings before and after the 4-week treatment with rabeprazole were compared. Changes between corresponding duration in the control group were also evaluated.Results. The median and mean pretreatment total score was 3 and 3.02, respectively, from the 73 patients with LPRS. No significant differences were observed before and after treatment in either the rabeprazole or control groups for any item or total score. In 24 patients with a high pretreatment score (total score ≥ 4) from the rabeprazole group, significant decreases in scores for “thick endolaryngeal mucous” (0.54 to 0.17,P=0.017) and total (4.77 to 3.58,P=0.0003) were observed after the 4-week treatment.

a Department of Gastroenterology, Gunma University Hospital, Address: 3-39-15 Showamachi, Maebashi, Gunma 371-8511, Japan b Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Address: 3-39-15 Showamachi, Maebashi, Gunma 371-8511, Japan c Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Address: 3-39-22 Showamachi, Maebashi, Gunma 371-8511, Japan Available online 2 June 2014

Analyses of selected cases suggest that immunosuppressive treatment could reduce proteinuria and delay the progression of immunoglobulin A nephropathy (IgAN). The aim of this study was to examine the long-term effectiveness of this therapy on the clinical course of IgAN. We also examined the relationship between the efficacy of the treatment and the suppression of the serum immunoglobulin level. Eighteen patients who were observed for more than 2 years after prednisolone and cyclophosphamide therapy were enrolled in this study. Their clinical and laboratory characteristics were recorded for 2–18 years (mean 7.8 ± 5.7 years). Of the 18 patients, 13 had remission of proteinuria. We observed the subsequent development of proteinuria in four patients. Fourteen patients had remission of hematuria, with five patients experiencing subsequent relapse of hematuria. The mean time from the treatment to the relapse of proteinuria or hematuria was 5.8 years. Serum immunoglobulins were suppressed by the combination therapy. Serum IgG and IgM recovered 6 months after the treatment, whilst the suppression of serum IgA lasted for 4 years. We found a positive correlation between the serum IgA level and the degree of proteinuria. This study indicates that long-term follow-up is essential in order to prove the long-term benefit of immunosuppressive therapy in patients with IgAN. Careful monitoring of the serum IgA level may be useful in the follow-up of patients with IgAN, especially when they are treated with immunosuppressive agents.

Goals: To investigate whether there is a relationship between hiatus hernia (HH) and kyphosis or obesity in elderly Japanese persons. Background: The causes of HH in the elderly are unclear. Study: We enrolled 147 consecutive patients aged over 50 years in this study. Endoscopic assessment of the size of HH was performed by using a modified Makuuchi classification with grades from 1 (no HH) to 4 ( > 3 cm). The gastroesophageal flap valve (GEFV) was also graded from I to IV. Kyphosis was evaluated from a lateral photograph by measuring the modified Cobb angle (CA) and calculating the kyphosis index (KI). Body mass index (BMI) was used to evaluate obesity. Results: In women, there were significant differences of both the CA (analysis of variance, P < 0.0001) and KI (Kruskal-Wallis test, P < 0.01) between each grade of HH. Differences of the CA (P

ワイヤレス式pHモニタリング法，インピーダンス・モニタリング法の登場により，GERDの病態に対する理解は大きく変わろうとしている。近年，Bravo pHモニタリング・システムを用いた報告が増えつつあり，その正常値も確立されようとしている。これらの報告により，従来のカテーテル法には限界があることがはっきりと示されれば，Bravoシステムは，pHモニタリングの新しいスタンダードとなる可能性がある。一方，インピーダンス法の登場によりnon-acidic refluxとgas refluxが捉えられるようになり，GERはもはや酸逆流のみでなく非酸逆流を含めた概念となった。GERDの食道および食道外症状はpHモニタリングでは捉えられないweakly acidic refluxやgas refluxに関連している可能性がある。pH・インピーダンス・モニタリングは，すべてのタイプの逆流を高い感度で捉える唯一の測定法である。

SUMMARY Background There have been many reports about the relationship between reflux oesophagitis and obesity, but not the metabolic syndrome. Aim To review upper gastrointestinal endoscopic findings and screening data obtained in healthy subjects, and assess relations between reflux oesophagitis and features of the metabolic syndrome. Methods In 3599 men and 1560 women, the prevalence of reflux oesophagitis was assessed in relation to the age, body mass index, blood pressure, triglycerides and fasting blood glucose. Logistic regression analysis was used to calculate odds ratio for risk factors. Results The overall prevalence of reflux oesophagitis was 4%, and it increased with age in women. Prevalence of reflux oesophagitis increased significantly with an increase of body mass index, blood pressure, triglycerides and fasting blood glucose. On multivariate analysis, male sex (odds ratio: 2.5; 95% confidence interval: 1.6‐3.8), obesity (1.9; 1.4‐2.5), hyperglycaemia (1.7; 1.2‐2.4) and hypertension (1.5; 1.1‐2.1) were independent risk factors for reflux oesophagitis. Among both men and women, those with reflux oesophagitis were significantly more likely to have two or more of these risk factors than non-reflux oesophagitis subjects. Conclusions Components of the metabolic syndrome are associated with the occurrence of reflux oesophagitis. Therefore, some risk factors may be common to reflux oesophagitis and the metabolic syndrome.

It has been reported that proton pump inhibitors are more effective than H2 receptor antagonists in patients with functional dyspepsia. Dyspeptic symptoms that respond to proton pump inhibitors are classified as acid-related dyspepsia. A new questionnaire for assessing gastroesophageal reflux disease (GERD), the Frequency Scale for Symptoms of GERD, covers the 12 most common symptoms of GERD patients. A quantitative assessment of the changes of reflux symptoms and acid-related dyspepsia was made in GERD patients receiving proton pump inhibitor therapy. Sixty-eight GERD patients receiving proton pump inhibitor therapy completed the questionnaire before and after treatment for 8 weeks. There is a significant positive correlation between reflux symptoms and acid-related dyspepsia before and after therapy (r = 0.569 and r = 0.569; both P's < 0.001) and acid-related dyspepsia in patients with both nonerosive and erosive GERD. We conclude that GERD patients suffer not only from reflux symptoms, but also from acid-related dyspepsia, and proton pump inhibitors improve both types of symptoms.

Detection rate, influence of recording site, and subject posture for impedance monitoring of pharyngeal reflux of gastric contents remain unknown. We evaluated the ability of the impedance sensor for detection of various volumes of intrapharyngeal infusate at two sites and in two subject positions.Nineteen healthy subjects were studied using concurrent videoendoscopic, manometric, impedance, and pH recording.Detection rate of simulated pharyngeal reflux events ranged between 87% and 100% for 1-4 mL. Detection rate for 0.1-1 mL volumes in the upright position was significantly higher (78-85%) when the impedance sensor was located at the proximal margin of the upper esophageal sphincter (UES) compared to 2 cm proximally (38-68%) (P0.001). With the sensor at 2 cm above the UES, the average detection rate for all volumes in the upright position was significantly less (P0.001) compared to the supine position (48%vs 84%). There was substantial variability in the magnitude of impedance changes induced by different infusates.Impedance sensors can detect as small a volume as 0.1 mL and combined with a pH sensor can detect acidic and nonacidic liquid and mist reflux events. Sensor placement at the proximal margin of the UES yields the highest detection rate irrespective of subject posture compared to placement 2 cm proximally. Depending on the volume of refluxate and location of the impedance sensor, a substantial minority of simulated reflux events can be missed.

Two cases of intravascular lymphoma (IVL) were diagnosed by endoscopic biopsy. Both patients were admitted to our hospital with a fever of an unknown origin. An elevated serum level of soluble interleukin-2 receptor antibody suggested IVL. An upper gastrointestinal endoscopy was performed. A biopsy of both the reddened and normal gastroduodenal mucosa (Case 1) and a biopsy of a gastric antral ulcer, multiple polyploid lesions resembling submucosal tumors in the duodenum, and the patient's normal mucosa (Case 2) revealed vascular infiltration by CD20-positive atypical lymphocytes, confirming the diagnosis of IVL. The performance of a gastrointestinal biopsy for suspected IVL is important, even if there are no visible endoscopic abnormalities.

Oxalate concentration in forage plants is important, because it results mineral deficiency in ruminants. Data on oxalate concentration in forage plants in conjunction with cutting and uncutting conditions throughout the growing period are limited. This study was aimed to investigate the changes in oxalate and some mineral concentrations of setaria (Setaria sphacelata). The plants were harvested at different stages (vegetative, boot, pre-flowering, flowering and seed) of maturity and at about 50 cm in length of regrowth (second to sixth cuttings) for evaluation of soluble oxalate, insoluble oxalate and some mineral concentrations. Soluble oxalate and total oxalate concentrations, as well as mineral concentrations, decreased with advancing maturity. Both oxalate concentrations (soluble or insoluble) were higher in leaf compared to stem. Soluble oxalate and total oxalate concentrations of regrowth were the highest at third cutting and lowest at sixth cutting. Insoluble oxalate concentration of regrowth was almost similar in all cuttings, except for the sixth cutting. The highest concentrations of potassium, sodium and magnesium of regrowth were observed at third cutting, while the highest concentration of calcium was observed at sixth cutting. A relationship between oxalate and mineral concentrations was partially observed. Results suggest that cutting materials of setaria from June to October could achieve oxalate levels that are toxic to ruminants.

It is known that the prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients is high. Although an endoscopic diagnosis of GERD based on the established Los Angeles (LA) classification requires the detection of erosive mucosal breaks, there are patients with GERD who have prominent erythema of the esophageal membrane without erosive mucosal breaks. Non-erosive mucosal change denotes the minimal change of the discoloring type of reflux esophagitis. This study was undertaken to determine the prevalence of GERD in asthmatic patients using the LA classification with the inclusion of minimal change, compared to the prevalence determined using the established LA classification without minimal change. The presence of GERD in asthmatic patients (n = 78), non-asthmatic disease control patients (n = 56), and healthy subjects (n = 150) was evaluated by endoscopic examination. The frequency of GERD in asthmatic patients based on the LA classification with minimal change was higher (54/78, 69.2%) than in asthmatic patients based on the LA classification without minimal change (37/78, 47.4%) (p < 0.05). The prevalence of GERD in asthmatic patients (69.2%) was higher than that in disease control patients (17/56, 30.4%) and healthy subjects (27/150, 18.0%) based on the LA classification with minimum change. These data indicate that asthmatic patients have a high frequency of GERD. In addition, without the inclusion of minimum change to the diagnosis of GERD, the prevalence of GERD appears to be underestimated in asthmatic patients. Therefore, physicians should carefully observe asthmatic patients with minimal change on endoscopy.

To determine the optimal air stimulus intensity and duration for elicitation of the laryngo–upper esophageal sphincter (UES) contractile reflex, we studied 37 healthy volunteers 20 to 81 years of age. A sleeve device monitored the UES pressure. For laryngeal stimulation, we used an air stimulator unit (Pentax AP-4000) that incorporated a nasolaryngeal endoscope. The arytenoids and interarytenoid areas were stimulated at least three times by three different stimuli: 6–mm Hg air pulse with 50-ms duration, 10–mm Hg air pulse with 50-ms duration, and 6–mm Hg air pulse with 2-second duration. Of 1,165 air stimulations, 1,041 resulted in mucosal deflections. Of these, 451 resulted in an abrupt increase in UES pressure. The response/deflection ratio for 6–mm Hg stimulation with 2-second duration was significantly higher than those for air pulses with 50-ms duration (p < .001). We conclude that although the laryngo-UES contractile reflex can be elicited by an air pulse with 50-ms duration, this ultrashort stimulation is not reliable. Using longer-duration pulses (at least 2 seconds) improves the reliability of elicitation of the laryngo-UES contractile reflex.

Background and Aims : To determine the optimal treatment of superficial carcinoma of the thoracic esophagus, we retrospectively analyzed the site and prevalence of lymph node metastases in three-field dissection specimens removed during radical esophagectomy.Methods : We reviewed the medical charts and surgical and histopathological reports of 34 patients with superficial carcinoma of the thoracic esophagus, who were treated with esophagectomy and three-field lymph node dissection.Results : Lymph node metastases were found in 14 of 34 patients (41%). None of five cases with tumor invasion of only the pEP or pLPM had lymph node metastases. However, the prevalence of lymph node metastases from tumors that invaded the pMM or pSM was 22% and 60%, respectively. Even when the cancer was located in the lower esophagus, the prevalence of cervical lymph node metastases was 20%. Two of three (67%) patients had cervical lymph node metastases even when there were no metastases in mediastinal nodes (“jumping lymph node metastases”). The 5-year survival rates in patients with and without lymph node metastases were 83% and 100%, respectively.Conclusions : A radical esophagectomy with three-field lymph node dissection should be performed on patients who have superficial carcinoma of the thoracic esophagus that invades the pMM or deeper.

During maintenance proton pump inhibitor (PPI) therapy, patients with gastroesophageal reflux disease (GERD) sometimes complain of upper gastrointestinal symptoms.To evaluate upper gastrointestinal symptoms in patients on maintenance PPI therapy for erosive GERD or non-erosive reflux disease (NERD) without endoscopic mucosal breaks by using a new questionnaire.At Gunma University Hospital over a 12-month period during 2011-2012, we enrolled 30 consecutive patients with erosive GERD and 46 patients with NERD. All patients had been on maintenance PPI therapy for more than 1 year. We used the modified frequency scale for the symptoms of GERD (mFSSG) questionnaire to assess upper gastrointestinal symptoms. We also asked patients about their satisfaction with maintenance therapy and whether they wished to change their current PPI.The NERD patients had significantly higher symptom scores than the erosive GERD patients. There was no difference in the treatment satisfaction rate between patients with erosive GERD and NERD, but more patients with NERD wanted to change their PPI therapy. There was no difference in the mFSSG score between NERD patients who wished to change their current PPI therapy and those who were satisfied with it.During maintenance PPI therapy, upper gastrointestinal symptoms were more severe in NERD patients than in patients with erosive GERD. NERD patients often wished to change their PPI therapy, but this was not dependent on the severity of their upper GI symptoms.

Background Recently reported normal values for esophageal motility obtained by high-resolution manometry (HRM) using a system with a Unisensor catheter were significantly different from those obtained by the ManoScan®, which could result in a wrong diagnosis. To clarify whether these differences were due to system or subject differences, we compared the manometric parameter values between ManoScan and a new system with a Unisensor catheter (Starlet) in the same subjects. Methods A total of 103 volunteers without any symptoms related to esophageal motility disorders were recruited. Esophageal HRM was performed using both the ManoScan and the Starlet in all subjects. Data from the ManoScan were analyzed using ManoView, and data from the Starlet were analyzed by a program with e-sleeve function. Integrated relaxation pressure, distal contractile integral, contractile front velocity (CFV), intrabolus pressure, and distal latency were calculated by both analyzing programs, and the values of these parameters were compared between the two systems by a signed rank test. Key Results Data from a total of 97 participants were analyzed. The values of all parameters, except CFV, measured by the Starlet were significantly higher than those obtained by the ManoScan (p

It is known that there is a close relationshipbetween serum motilin fluctuation and the initiation ofgastric interdigestive migrating complexes (IMC) (1).The administration of synthetic motilin initiates IMC (2), and antimotilin serum blocks theinitiation of IMC (3). Erythromycin has recently beenshown to be a motilin-receptor agonist (4), and motilinreceptors have been found in the human stomach (5). At present motilin is considered to initiateIMC through both the vagal cholinergic pathway anddirect stimulation of smooth muscle. From the clinicalpoint of view, Labo et al (6) and our group (7) recently reported on the relationship between a lowmotilin concentration and disturbance of IMC in patientswith dyspepsia. On the other hand, little is known aboutthe effect of an abnormally high motilin concentration on gastroduodenal motility. We have found threeoutpatients in our clinic at Gunma University Hospitalwith duodenal ulcer or duodenitis who had disturbedinitiation of IMC despite an abnormally high plasma motilin concentration.

症例 : 43歳, 男性.主訴 : 発熱.近医にて貧血の経過観察中, 発熱出現し肺野異常陰影を指摘され, 精査加療目的に当科入院.発熱, 呼吸困難, 汎血球減少, 巨大肝脾腫, 両肺野の多発性腫瘤陰影を認めたが表在リンパ節は触知しなかった.胸腔鏡下肺生検にてリンパ腫様肉芽腫症と診断された.CHOP療法を開始も1クール終了時, 肺腫瘤影増大し無効と判断, MCNU-CHOP療法を開始した.肺腫瘤影はCT上1クール終了時36.8%, 2クール終了時には7.9%まで縮小した.また, その後の検討で本例は血管中心性B細胞性リンパ腫に一致し, 病変部にEpstein-Barrウイルスが証明された.本症は, 肺に血管中心性に多様な免疫細胞の浸潤を来す稀な疾患であり, 治療法も確立されていない.本症例はCHOP療法を早期に無効と判断し, MCNU-CHOP療法に変更して改善をみた一例であり, 本症に対する治療法確立に有用と考えられる.

According to the 2006 Montreal globally acceptable definition and classification of gastroesophageal reflux disease (GERD), this condition develops when the reflux of gastric contents causes symptoms or complications (Vakil et al., 2006). Because reflux esophagitis is defined as occurring when reflux of gastric acid into the esophagus causes mucosal breaks, erosions and/or ulcers, this condition requires endoscopic diagnosis. Non-erosive reflux disease (NERD) is defined by occurrence of reflux symptoms in patients without any endoscopic mucosal breaks. Thus, NERD includes prominent erythema without clear demarcation or whitish cloudiness of the lower esophageal mucosa obscuring the longitudinal blood vessels, which used to be known as the "discoloring" type of reflux esophagitis in Japan. In the present study, we characterized the symptoms and pathophysiology of patients with minimal change esophagitis (MC esophagitis), who had prominent erythema and whitish cloudiness of the esophageal mucosa.

The endoscopic ultrasonography findings at the lower esophageal sphincter (LES) were compared in patients with reflux esophagitis and esophageal achalasia to clarify the differences in wall structure between these diseases. In reflux esophagitis, the esophageal wall was hypertrophied at the LES and featured both irregularity and interruption of the submucosa, muscularis propria, and adventitia. In achalasia, there was generalized hypertrophy of the esophageal wall at the LES including the mucosa, submucosa, muscularis propria and adventitia but for each layer the normal 5-layer structure was visualized well. Thus achalasia and reflux esophagitis both featured hypertrophy at the LES, but the detailed findings were quite different. This difference was thought to arise from the presence of inflammation in reflux esophagitis and no inflammation in achalasia.

Objective Gastroptosis is recognized by its characteristic appearance on barium studies. The present prospective study assessed the relationship between gastroptosis and dyspeptic symptoms. Methods Japanese subjects underwent health screening, and gastroptosis was diagnosed by barium studies. Consecutive subjects (500 women and 167 men) with gastroptosis were identified and the same number of age-matched subjects without gastroptosis were selected as controls. Dyspepsia was classified as reflux-like (heartburn and belching), dysmotility-like (bloating and fullness), or ulcer-like dyspepsia (epigastralgia) based on the Rome II criteria. Results Body mass index was significantly lower in women with gastroptosis than in controls [19.7±1.83 (SD) vs. 23.4±3.70, p

A 22-year-old man was unable to belch. He could sense intraesophageal gas, but had no chest pain. An upper gastrointestinal X-ray series and endoscopic examination showed no abnormalities. Esophageal manometry showed normal relaxation of both the upper and lower esophageal sphincters with primary peristalsis during deglutition. However, bolus injection of air into the middle esophagus failed to initiate the belch reflex.

Avoiding oxidative stress in the airways is important for the treatment of respiratory disease associated with gastroesophageal reflux disease (GERD). It is often difficult to decide whether GERD is causing airway inflammation or whether an airway disease is complicated by GERD. Measurement of exhaled breath condensate (EBC) is performed by cooling and collecting the airway lining fluid contained in exhaled air. A decrease of pH and an increase of the 8-isoprostane concentration in EBC have been observed in patients with mild to moderate asthma accompanied by GERD. There are still problems to be overcome before EBC can be used clinically, but pH and 8-isoprostane may be promising objective markers of airway inflammation due to GERD. The disease concept and diagnosis of GERD are constantly advancing, including the development of impedance methods. It is expected that treatment will be based on the latest diagnostic knowledge of GERD associated with respiratory disease and on monitoring of airway inflammation.