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BACKGROUND: TREATMEN The contribution of eosinophilic esophagitis (EoE) to refractory gastroesophageal reflux disease (GERD) remains unknown. When EoE and GERD overlap, the clinical, endoscopic and histological findings are nonspecific and cannot be used to distinguish between the two disorders. Limited data are available on this topic, and the interaction between EoE and GERD is a matter of debate. AIM: We have conducted a prospective study of adult patients with refractory GERD to evaluate the overlap of reflux and EoE. METHODS: Between July 2006 and June 2008, we consecutively and prospectively enrolled 130 male and female patients aged 18 to 70 years old who experienced persistent heartburn and/or regurgitation more than twice a week over the last 30 days while undergoing at least six consecutive weeks of omeprazole treatment (at least 40 mg once a day). The patients underwent an upper digestive endoscopy with esophageal biopsy, and intraepithelial eosinophils were counted after hematoxylin/eosin staining. The diagnosis of EoE was based on the presence of 20 or more eosinophils per high-power field (eo/HPF) in esophageal biopsies. RESULTS: Among the 103 studied patients, 79 (76.7%) were females. The patients had a mean age of 45.5 years and a median age of 47 years. Endoscopy was normal in 83.5% of patients, and erosive esophagitis was found in 12.6%. Only one patient presented lesions suggestive of EoE. Histological examination revealed >;20 eo/HPF in this patient. CONCLUSION: Our results demonstrated a low prevalence of EoE among patients with refractory GERD undergoing omeprazole treatment.

Hyperplastic gastric polyps are often found at GI endoscopy and are not considered premalignant lesions, although some cases of malignancy have been reported. Neuroendocrine tumors, conversely, are rare and account for approximately 1% to 2% of gastric polyps. Both hyperplastic gastric polyps and neuroendocrine tumors are related to gastric atrophy. The case of a hyperplastic polyp with multifocal areas of adenocarcinoma within the polyp associated to multiple gastric neuroendocrine tumors is reported.

Dysplasia and esophageal adenocarcinoma may arise in patients with Barrett's esophagus after fundoplication esophageal pH monitoring showing no acid in esophagus. This suggests the need to develop methodology to evaluate the occurrence of ultra-distal reflux (1cm above the LES). The objective of the study was to compare acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the LES and in the intrasphincteric region. Eleven patients with Barrett's esophagus after Nissen fundoplication with no clinical, endoscopic and radiologic evidence of reflux were selected. Four-channel pH monitoring took place: channel A, 5cm above the upper border of the LES; channel B, 1cm above the LES; channel C, intrasphincteric; channel D, intragastric. The results of channels A, B and C were compared. There was significant increase in number of reflux episodes and a higher fraction of time with pH4.0 in channel B compared to channel A. There was significant decrease in fraction of time with pH4.0 in channel B compared to channel C. Two cases of esophageal adenocarcinoma were diagnosed in the studied patients. The region 1cm above the upper border of the LES is more exposed to acid than the region 5cm above the upper border of the LES, although this exposure occurred in reduced levels. The region 1cm above the upper border of the LES is less exposed to acid than the intrasphincteric region.

Background and Study Aims: Intraoperative changes in circulatory hemodynamics and autonomic nervous activity were evaluated in 33 patients with cholelithiasis who underwent laparoscopic cholecystectomy. Patients and Methods: Of these patients,18 were treated using a pneumoperitoneum (group G) and 15 using the abdominal wall-lifting method (group WL). Their ECG, blood pressure, arterial oxygen saturation, and expiratory carbon dioxide partial pressure were monitored. Autonomic nervous function was evaluated by spectral analysis of the heart rate. Results: Mean blood pressure increased significantly in group G during surgery, but did not vary in group WL during any stage of surgery. The high-frequency (HF) power, an index of parasympathetic activity, decreased significantly in group G after pneumoperitoneum. However, the HF power did not decrease significantly in group WL. The LF/HF ratio, an index of sympathetic activity, increased significantly in group G after pneumoperitoneum, but did not vary in group WL. In addition, the incidence of ventricular or supraventricular arrhythmias and the severity of the arrhythmias as determined by Lown's classification were higher in group G than in group WL. These findings suggest that intraoperative changes in autonomic nervous activity, due to increased intra-abdominal pressure, were smaller in patients undergoing laparoscopic cholecystectomy using the abdominal wall-lifting method than in those undergoing laparoscopic cholecystectomy using pneumoperitoneum. The results also demonstrated that hemodynamic changes were smaller in patients undergoing the abdominal wall-lifting method than in those undergoing pneumoperitoneum. Conclusions: It was concluded that hemodynamics should be carefully monitored during pneumoperitoneum, and that the abdominal wall-lifting approach in laparoscopic cholecystectomy is a method worthy of consideration for elderly patients or those with cardiopulmonary complications.

1-beta-D-Arabinofuranosylcytosine (ara-C) is used empirically at a low, conventional, or high dose. Ara-C therapy may be optimal if it is directed by the clinical pharmacokinetics of the intracellular active metabolite of ara-C, 1-beta-D-arabinofuranosylcytosine 5'-triphosphate (ara-CTP). However, ara-CTP has seldom been monitored during low- and conventional-dose ara-C therapies because detection methods were insufficiently sensitive. Here, with the use of our newly established method (Cancer Res., 56, 1800 -- 1804 (1996)), ara-CTP was monitored in leukemic cells from acute myelogenous leukemia patients receiving low- or conventional-dose ara-C [subcutaneous ara-C administration (10 mg / m(2) ) (3 patients), continuous ara-C infusion (20 or 70 mg / m(2) / 24 h) (7 patients), 2-h ara-C infusion (70 mg / m(2) ) (4 patients), and 2-h infusion of N(4)-behenoyl-1-beta-D-arabinofuranosylcytosine, a deaminase-resistant ara-C derivative (70 mg / m(2) ) (6 patients)]. Ara-CTP could be determined at levels under 1 microM. There was a close correlation between the elimination half-life values of the plasma ara-C and the intracellular ara-CTP. The presence of ara-C in the plasma was important to maintain ara-CTP. The continuous ara-C and the 2-h N(4)-behenoyl-1-beta-D-arabinofuranosylcytosine infusions maintained ara-CTP and the plasma ara-C longer than the subcutaneous ara-C or the 2-h ara-C infusion. They also afforded relatively higher ara-CTP concentrations, and consequently produced ara-CTP more efficiently than the 2-h ara-C infusion. Different administration methods produced different quantities of ara-CTP even at the same dose.

We describe a patient with highly refractory malignant lymphoma who died of hepatic tumor rupture following treatment with irinotecan (CPT-11). This 60-year-old man with non-Hodgkin's lymphoma (diffuse large B-cell lymphoma) demonstrated disease recurrence in the liver and the vertebrae following high-dose chemotherapy and autologous hematopoietic stem cell transfusion. He was treated with CPT-11 at a dose of one third of the conventional dose used for non-Hodgkin's lymphoma in Japan. The tumor in the liver markedly decreased in size but then ruptured. Although pathologic hepatic tumor rupture is a rare complication in patients with malignant lymphoma of the liver, this case demonstrates that hepatic tumor rupture may occur in refractory malignant lymphomas that reveal extensive degradation by this new, effective salvage therapy.

The purpose of the study is to clarify the manifestation of the ciliary body after retinal photocoagulation for diabetic retinopathy.Ultrasound biomicroscopy (UBM) was applied to obtain the tomographic features of the anterior ocular segment.Twenty-one eyes of 17 consecutive patients with diabetic retinopathy were included in this study.These eyes were treated by panretinal photocoagulation divided in four sessions. In the first session, the nasal quadrant of the fundus was treated with argon or dye (590 nm) laser totaling 208 to 331 spots per eye.The eyes were examined by UBM before, immediately after, 3, and 7 days after the first session of photocoagulation.Three days after photocoagulation, ciliochoroidal detachment was observed in 19 eyes (90%). The detachment was present along the whole circumference. The ciliary detachment was most prominent in the pars plana in 19 eyes and extended to the pars plicata in 9 eyes. It spontaneously had disappeared 7 days after photocoagulation.Ciliochoroidal detachment was a very frequent feature after sector photocoagulation in diabetic eyes. Although this complication was asymptomatic and transient so far, this potential hazard merits due attention in the planning of panretinal photocoagulation in diabetic eyes.

We examined the vitreous of 37 eyes of 31 patients with macular holes of various stages. There was no posterior vitreous detachment (PVD) in 18 of 18 impending and 19 of 20 newly formed macular holes. In newly formed macular holes, the operculum was located either at the level of or immediately anterior to the retinal surface. The gel component of the vitreous was always separated from the posterior fundus by intervening liquefied lacuna, simulating PVD. However, the cortical vitreous was located posterior to the liquefied lacuna and remained attached to the retina. PVD failed to develop in all of 15 eyes during the follow-up period of 3 months after formation of a macular hole. The incidence of PVD increased in the eyes with macular holes lasting for 1 year or longer. In our present series, PVD in its classical sense did not contribute to the pathogenesis of macular holes as it developed after formation of the latter. Instead, a subtle anterior displacement of vitreous cortex strictly confined to the area of the fovea seemed to trigger the development of idiopathic macular holes.

Up to now, surgery was the only possible treatment for choledochoduodenal fistulas, which are seen more often in Japan than in Europe. This paper presents the value and effect of endoscopic fistulotomy (EFT) as an alternative treatment in those cases. Parapapillary choledochoduodenal fistulas are abserved usually on the longitudinal fold of the papilla or on its oral side. The papillotome is inserted into the common bile duct through the orifice of the duodenal papilla, then the wall between its orifice and the fistula is cut to open widely the distal portion of the choledochus. EFT was performed successfully in 7 cases. The procedure led to a wide open stoma of the distal common bile duct with free bile outflow. Residual stones, a common occurrence in cases of parapapillary choledochoduodenal fistulas, may pass spontaneously after EFT or can be removed with a basket catheter. In cases of parapapillary choledochoduodenal fistula, EFT is a reliable method, especially in high-risk patients, and an alternative to surgical treatment.

The authors experienced one case of malignant melanoma of the superior palpebral conjunctiva and the inferior palpebral skin, originating from benign acquired melanosis of the bulbar conjunctiva which developed in a 48-year-old man. Orbital exenteration including superior and inferior palpebrae was performed, and the removed tissue was examined by light and electron microscopy. In the temporal bulbar conjunctiva, melanocytes containing abundant fine melanin granules proliferated over almost the whole area of the epithelial layer. Cellular atypia and karyomitosis were not observed. The basement membrane remained intact with no proliferation of melanocytes in the substantia propria. However, in the perivascular area, in addition to the moderately prominent infiltration by lymphocytes and plasma cells, infiltration by melanophages was observed relatively frequently. Based on these findings, it was confirmed that the primary lesion of the bulbar conjunctiva was an acquired melanosis of Stage IB as classified by Zimmerman. The black nodular tumors of the superior palpebral conjunctiva and inferior palpebral skin consisted of melanoma cells showing markedly prominent cellular and nuclear atypia. The nuclei showed indentations in the membrane with electron-lucent karyoplasm, each having one nucleolus. The cytoplasm contained many round or elongated melanosomes in various developmental stages, with sizes of about 0.7 micron. Scattered among melanoma cells were a number of melanophages which had phagocytized many melanosomes at various stages of maturity.(ABSTRACT TRUNCATED AT 250 WORDS)

An eye with moderate simple diabetic retinopathy in a 47-year-old man was enucleated for rubeotic glaucoma of 2 months' duration and was subjected to histopathological and ultrastructural studies. Particular attention was paid to the structure of the retinal surface as examined by scanning electron microscopy. Six normal eyes and 2 eyes with long-standing central retinal vein occlusion served as the control. The inner retinal surface in normal eyes with posterior vitreous detachment appeared as a smooth, continuous sheet seen by scanning electron microscopy. No cell-like structure was detected on the retinal surface. In the eye with simple diabetic retinopathy, on the other hand, numerous spherical cells with pseudopodic protrusions were observed throughout the retinal surface which were identified as macrophages in light, scanning and transmission electron microscopic studies. The macrophages were particularly dense and were arranged in circinate pattern corresponding to circinate lesions within the retina. The macrophages were also densely populated in retinal areas with hard exudates. In areas adjacent to the macrophages, the inner retinal surface lost its smooth and continuous structure. The matrix in the inner limiting membrane disappeared in such areas so that a coarse network of filaments lay bare on the retinal surface. These findings indicate that the inner retinal surface would be pathologically altered in simple diabetic retinopathy, particularly where hard exudates are located.