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大腸浸潤をきたした成人T細胞性白血病(ATL)の5症例を経験した.男性4例,女性1例で,平均58歳であった.病型は急性型が3例,リンパ腫型が2例であった.大腸浸潤の画像所見は,多発隆起性病変が4例,びまん浸潤型が1例であった.いずれも胃や小腸への浸潤も合併しており,4か月から1年9か月後に死亡した.自験5例を含む本邦報告31例の臨床的検討でも,大腸浸潤は多発する隆起性病変が18例,多発性潰瘍・びらんが5例と病変が多発するものが大半を占め,びまん浸潤型は6例のみであった.96%に胃や小腸への浸潤をきたしており,予後は平均7か月と不良であった.消化管の検索はATLの病態把握に有用と思われた.

A rare case of malignant lymphoma of the stomach after treatment for hepatocellular carcinoma (HCC) is reported. A 72-year old man presented with a large mass on the right hypochondrium, which was diagnosed as HCC associated with chronic hepatitis C with cirrhosis. The inoperable tumor was treated conservatively with cisplatin, etoposide, carboplatin, and Lipiodol infused into the hepatic artery, together with transcatheter arterial embolization. The patient presented 38 months later with features suggestive of gastric ulceration. Endoscopy and histological examination of biopsy material confirmed the presence of malignant lymphoma of the stomach. He ultimately died as a result of hepatic failure. The clinical presentation suggests that gastric lymphoma was possibly related to the lymphotropic effect of hepatitis C virus (HCV) and exacerbated by intraarterial injection of the cytotoxic drugs.

A case of Hippocratic digital associated with secondary hypertrophic osteoarthropathy complicating Crohn's disease in a 29 year old Japanese male is reported. Hippocratic digital, or finger clubbing, complicating inflammatory bowel disease has been frequently reported in the Western hemisphere. However, its association with secondary hypertrophic osteoarthropathy has been very rarely found in that disease. In Japan, Hippocratic digital has not been described previously. With regard to the pathogenesis of Hippocratic digital and secondary hypertrophic osteoarthropathy, the theory that both entities belong to the same pathological spectrum and that megakaryocytes or platelet clumps may play the most important role, is discussed.

We experienced two cases of cecal granular cell tumor. The site of occurrence and diagnosis are discussed in relation to the literature on granular cell tumor of the large intestine. Most granular cell tumors of the large intestine tend to remain constant in size, showing the morphology of a submucosal tumor. Endoscopic excision was considered a useful diagnostic procedure. S-100 protein was positive in most cases, supporting the hypothesis that the tumor is derived from Schwann cells.

A total of 44 patients with long-standing ulcerative colitis were studied to elucidate changes over time in colonoscopic and histological inflammatory activity. More than two years of symptomatic remission without melena or bloody diarrhea was achieved in 63.6% (28/44). All patients underwent total colonoscopic examinations. Compared with findings of the previously involved area, 70.5% (31/44) showed a reduction or disappearance of the inflammatory area on endoscopic and histological examinations; however, the rectal inflammation disappeared in 31.8% (14/44) of patients. Moreover, it became apparent that the remaining active inflammatory area tended to show discontinuous spread with patchy inflammatory foci. Thus, the mucosal inflammation in long-standing ulcerative colitis may be characterized by a reduction in both extent and degree.

A case of Borrmann type IV colorectal adenocarcinoma detected as a complication of long-standing ulcerative colitis is reported. Barium enema and colonoscopy disclosed a stenotic area associated with a tumoral mass and a flat elevated lesion in the rectosigmoid region and a submucosal tumor-like lesion in the rectum. Total colectomy was performed and histological studies, demonstrated a moderately differentiated adenocarcinoma accompanied by high- and low-grade dysplasia. DNA ploidy pattern analysis showed aneuploidy in the adenocarcinoma and high-grade dysplasia, but diploidy in the normal and atrophic mucosa and in low-grade dysplasia. DNA aneuploid content was associated with the presence of colorectal carcinoma complicating ulcerative colitis, indicating that DNA content studies should be included in screening programs to detect early colorectal carcinoma following this disease, as a complementary study to histological assessment.

The effect of peptide YY on contractility, acetylcholine release and noradrenaline release was examined in the isolated guinea-pig colon, and findings were compared with those for neuropeptide Y. Peptide YY and neuropeptide Y inhibited the twitch contractions mediated by the stimulation of cholinergic neurons. Peptide YY, neuropeptide Y, [Leu31,Pro34]neuropeptide Y and neuropeptide Y-(13–36) inhibited the electrically stimulated release of acetylcholine. Neuropeptide Y, but not peptide YY, inhibited the high K+-stimulated tetrodotoxin-resistant release of acetylcholine, while the inhibitory effect of neuropeptide Y disappeared after treatment with yohimbine. Neuropeptide Y, but not peptide YY or neuropeptide Y analogues, evoked the release of noradrenaline. After desensitization to the effects of neuropeptide Y, peptide YY inhibited electrically stimulated acetylcholine release. Thus, peptide YY inhibits acetylcholine release through stimulation of a receptor, distinct from the site of action of neuropeptide Y, located on cholinergic neurons as well as the neuropeptide Y Y1 and Y2 receptors in the guinea-pig colon. Neuropeptide Y inhibits acetylcholine release due to the noradrenaline release mediated by stimulation of a receptor distinct from neuropeptide Y Y1 and Y2 receptors, located on adrenergic neurons.

Primary malignant fibrous histiocytoma seldom occurs in the alimentary tract. This report documents a case in which a 50-year-old man presented with abdominal fullness and anorexia, together with inflammatory reactions such as fever, leukocytosis, an elevated erythrocyte sedimentation rate and positive CRP. Radiologic and endoscopic studies revealed a large mass in the ascending colon. The histology of the resected tumor revealed inflammatory malignant fibrous histiocytoma, a histologic subtype which is rare among not only soft tissue fibrous but also as gastrointestinal histiocytomas. The inflammatory reactions disappeared following resection of the tumor. Although we suspected that the tumor produced granulocyte colony-stimulating factor because of the slightly elevated serum level and the characteristics of the tumor histology, an immunohistochemical study failed to show the G-CSF production by the tumor cells.

A 75-year-old man was diagnosed as having a sessile tumor measuring 1.4 x 1.0 cm in size in the duodenal bulb after upper gastroduodenal series. The biopsy specimens revealed a proliferation of the adenomatous glands showing an acinar structure with papillary infolding; type III mucus, which is characteristic of Brunner's glands. Antral glands and mucus neck cells of the fundic glands were also observed in the adenomatous glands by concanavalin A staining. Thus, it was clear that the tumor had originated from the Brunner's glands. Three years and four months later, the sessile tumor had developed into a fungating ulcerated tumor via a polypoid form. The biopsy specimens revealed a papillary adenocarcinoma with foci of undifferentiated carcinoma. Retrospectively, the adenomatous glands in the biopsy taken from the sessile tumor should have been regarded as low grade carcinoma. Therefore, we propose that when a polyp or tumor shows an increase in size or change in macroscopic appearance, surgery should be considered.

The Cronkhite-Canada syndrome was diagnosed in a 62 year-old male in whom the gastrointestinal polyposis and ectodermal change disappeared after treatment with corticosteroids and albumin infusions. The major pathophysiologv of this syndrome is gastrointestinal polyposis. The polyps were examined in detail using a magnifying endoscope and then by spraying methylene blue onto the mucosa. It was shown that the polyps were formed by groups of intestinal glands each dilated by hyperaemia and oedema. Destruction of the dilated glands and opening of a pit at the central region were also observed. These changes were associated with secretion from the pit and it is suggested that this is the mechanism for the protein leakage. Angiographic studies confirmed our previous finding that the coeliac and mesenteric arteries are dilated in the Cronkhite-Canada syndrome but a follow-up study showed that this is reversible once the mucosal lesions have resolved in response to treatment.

A retrospective endoscopic study of 11 patients with intestinal lipomas was conducted. The patients included 2 with duodenal—, 2 with small intestinal—, and 7 with large intestinal lipomas. Endoscopically, in addition to features common to all submucosal tumors, lipomas often present characteristic findings including a yellowish surface color and softness of the tumor. The yellowish color was noticed in the 6 patients whose tumors were 10 mm and more in size. In the 2 patients with lipomas in the small intestine, the yellowish color was diminished by hemorrhages, inflammation and fibromusculosis in the lamina propria mucosa due to mechanical irritations such as peristalsis and intussusception. Thus, the appearance of the yellow color was related to the size of the tumors and the histological changes in the overlying mucosa. Endoscopic palpation with biopsy forceps aids in making a diagnosis of lipomas; and the cushion sign was noticed in 3 of 4 patients who underwent the palpation. The naked fat sign is pathognornonic but was observed in only 1 patient with a duodenal lipoma, in which the fat tissue was exposed by denuding the mucosa with the biopsy forceps. Scopic biopsies revealed lipomas in 3 patients. Careful observation of the color and palpation during the endoscopic examination are important for making a correct diagnosis and avoiding the unnecessary resection of lesions.

63例のクロン病患者を対象に外科的あるいは内科的治療後の経過を臨床的要因をもとに検討した.外科的切除例は24例38.1%,保存的治療症例は39例61.9%であった.手術後の再燃はあっても2回目以上の手術例は著明に減少し,病勢は鎮まりquality of lifeは悪くなかった.保存的治療症例39例中3年以上の炎症持続症例が22例56.4%,逆に3年以上の緩解持続症例が9例23.1%にあった.前者に小腸・大腸炎型が多く,炎症反応が強い傾向にあった.後者には小腸炎型が多い傾向にあったが,初診時の血清鉄値が前者に比べ統計学的に有意に高い値であった.以上のことからクローン病は極めて難治で進行性の疾患であるが,なかには無治療で長期間緩解状態が持続していたり,治癒したと判断できる症例があることが明瞭になった.これらの症例では血清鉄値の低下が軽度であり,血清鉄値は病勢や重症度により鋭敏に影響を受け,長期管理の方針と予後の予測に役立つ因子と考えられた。

再発を繰り返した回盲部単純性潰瘍の1例を経験した.症例は55歳, 男性.右下腹部痛を主訴として来院した.小腸X線検査と大腸内視鏡検査では, 回盲部に周堤を伴う潰瘍が見られた.回盲部-上行結腸切除術が行われたが, 回盲部には下掘れ性の漿膜に達する潰瘍があり, 終末回腸には5個の随伴潰瘍が見られた.組織学的には非特異性の潰瘍であった.約1年後, 回腸-横行結腸吻合部に瘻孔が出現し, 吻合部切除を受けた.摘出標本では吻合部と回腸に7個の非特異性潰瘍と潰瘍瘢痕が見られた.その6カ月後に口腔内アフタが出現し, 1年後に再び回腸-横行結腸吻合部に潰瘍が再発した。現在, プレドニンの経口投与で経過を観察中であるが, 臨床所見は, 一進一退の状態である.ベーチェット病の腸病変と回盲部の単純性潰瘍は肉眼的, 組織学的に近似しており, ベーチェット病と同様に単純性潰瘍でも吻合部での潰瘍の再発が特徴であるので, 十分な経過観察が必要である.

One-hundred twelve hyperplastic polyps were analyzed. The aim was to study their malignant transformation. Among them, four hyperplastic polyps harbored adenocarcinoma; two were from our own institution (1.8%). The majority were pedunculated and located in the antrum with an average of 14.5 mm in diameter. The four polyps bore well-differentiated adenocarcinoma. Dysplasia and intestinal metaplasia were detected in two and three polyps, respectively. The cancer and dysplastic foci shared the same type of neutral and acid mucosubstances. p53 oncoprotein was positive in three cancer foci and in the dysplastic areas, and nucleolar organizer region counts were higher in the cancer foci. In conclusion, hyperplastic polyps have malignant potential. Such possibility increases in polyps larger than 14.5 mm. In our cases, the carcinoma foci may have arisen from dysplastic areas. Once the neoplastic changes occur, the cancer cells proliferate and behave as other adenocarcinomas of the stomach.

A rare case of adult T-cell leukemia (ATL) in which multiple lymphomatous polyposis (MLP) was revealed throughout the entire gastrointestinal tract is reported here. The polypectomy specimens taken from the rectum revealed infiltration of neoplastic T-cells, the integration of HTLV-1 proviral DNA, and increased CD4 (OKT4) and CD25 (IL-2R) cells. The analysis of surface markers of the lymphocytes from polypoid lesions may be useful for elucidating cell tropism and homing properties in the gastrointestinal tract. Although MLP has always been associated with B-cell lymphoma in the Western world, it is important for clinicians and pathologists to be aware that MLP may be caused by the infiltration of ATL cells.

Background: A polypectomy was performed on a 68-year-old woman who had three gastric hyperplastic polyps. A focal signet ring cell carcinoma was discovered in one of the polyps, which was 2.2 cm in diameter and was located in the antrum. Methods: To study the carcinoma's phenotypic expression, special mucin histochemical stainings were performed. Results: The carcinoma infiltrated only into the mucosa. Intestinal metaplasia was scant. In the neoplasm neutral and foveolar mucin was predominant over acid mucin. The surrounding hyperplastic foveolar epithelium showed positivity for neutral mucin, and the intestinal metaplasia foci for acid mucin. Conclusions: This neoplasm has a mixed composition of mucins and shares histochemical characteristics with the surrounding hyperplastic foveolar epithelium.

Using polymerase chain reaction and single strand conformation polymorphism assay, we examined genetic alterations of p53 and K-ras genes in multiple lesions of colorectal cancers that developed in three patients with ulcerative colitis. p53 gene mutations were found in two lesions and a K-ms gene mutation at codon 12 was found only in one. Neither was found in non-cancerous lesions. The results indicate that mutation of both genes may not be so frequent among Japanese patients. They were found only in very few cancerous lesions of each patient. Therefore, it is possible that the oncogenic process in each lesion is a consequence of rather independent events. Our preliminary results suggest the potential usefulness of CD44 variant forms as markers for dysplastic and cancerous tissues in ulcerative colitis.

A 47-year-old man was admitted with appendicitis, and appendectomy was performed. On microscopic examination of the resected specimen, the presence of goblet cell carcinoid in the tip of appendix was revealed. This tumor showed an aggressive nature with perineural and vascular invasion around the appendiceal serosa. The tumor was composed of two main cell populations: mucin-producing (goblet cell type) and silver-positive cells (endocrine differentiation). Additionally, a few cells were also positive for serotonin and lysozyme, but negative for gastrin and ACTH. These findings suggest that goblet cell carcinoid share some functional and histologic characteristics with carcinoid tumors and adenocarcinomas, although it is a distinct entity.(Internal Medicine 33: 422-426, 1994)

Six cases of type A gastritis associated with multiple carcinoids and/or endocrine cell micronests (ECM) in the atrophic fundic mucosa were examined light microscopically, immunohistochemically, and ultrastructurally. The ECM and carcinoids were mainly composed of enterochromaffin-like (ECL) cells. The cells were hyperplastic only in the atrophic fundic glands and pseudopyloric glands, but not in the intestinal metaplastic gland. It is suggested that the development of both the ECM and the carcinoids is highly related to the atrophic change of the fundic mucosa and a trophic action of subsequently raised serum gastrin in type A gastritis and that the both lesions arise from the pseudopyloric glands or atrophic fundic glands. In addition, the definition of neoplastic ECM (microcarcinoid) of the stomach was made with comparative study on both the cases with ECM and multiple carcinoids and the cases with ECM alone.

"Worm-eaten" appearance (WEA) is a fine lesion of Crohn's disease observed in apparently normal rectal mucosa by magnifying endoscopy. Magnifying endoscopy has now been performed following application of methylene blue on 37 occasions in 27 patients with Crohn's disease, and the occurrence of WEA was reviewed in relation to the duration and extent of disease. The frequency of WEA was 75% in patients with a history of less than five years and 77% in those who had had the disease for more than five years. In the active stage, the frequency was 85% and 100% respectively, and the degree of WEA also increased. The detection rate of granulomata in regions of WEA was 53% when the clinical history was less than five years and 33% when five years or more. In active disease, granulomata were found in 70% and 67% respectively. The large intestine other than the rectum was reviewed in eight patients with ileitis. WEA and granulomata were observed throughout the large intestine including the cecum, especially when the ileal disease was active.