Biliary papillomatosis: clinical, cholangiographic and cholangioscopic findings

BACKGROUND AND STUDY AIMS

Biliary papillomatosis (BP) is a very rare disease and its clinical features and outcome are not well known. The aims of this study were to describe the characteristic cholangiographic findings and to define the role of cholangioscopic examination in the diagnosis and treatment of this disorder.

PATIENTS AND METHODS

Nine patients (six men and three women, mean age 57 years) were diagnosed as BP among 5361 cases of endoscopic retrograde cholangiography (ERC) from 1990 to 1997 in our institution. The cholangiographic and cholangioscopic findings as well as clinical features were retrospectively analyzed.

RESULTS

ERC findings showed multiple small, round-to-ovoid filling defects in the bile duct and ductal wall irregularity in all the patients. Seven out of nine patients underwent percutaneous transhepatic cholangioscopic (PTC) examination. Additional small papillary lesions in the intrahepatic bile duct were detected by cholangioscopic examination in four patients whose ERC findings only revealed the extrahepatic lesions. Two of these four patients underwent curative resection. In these two patients, the initial surgical plan was changed from Whipple's operation to hepatico-pancratico-duodenectomy after preoperative cholangioscopic examination due to the detection of new lesions in the intrahepatic bile duct.

CONCLUSIONS

ERC findings of BP were highly characteristic. When BP is suspected by conventional imaging including ERC, preoperative percutaneous transhepatic cholangioscopic examination is, however, strongly recommended. This procedure may be beneficial to precisely determine the ductal extension of the disease, hence to decide whether or not hepatic resection is needed as well as to confirm the histology.

Expression of MUC1 and MUC2 mucins in gastric carcinomas: its relationship with the prognosis of the patients

Our previous immunohistochemical studies for the expression of MUC1 mucin antigen (which was detected by monoclonal antibody DF3) and MUC2 mucin antigen (which was detected by polyclonal antibody anti-MRP) in pancreatic and intrahepatic bile duct tumors demonstrated that invasive carcinoma with poor outcome showed a pattern of MUC1+ and MUC2- expression, whereas many of the noninvasive tumors with favorable outcome showed a pattern of MUC1- and MUC2+ expression. To clarify the relationship between the expression of these mucin antigens and the biological properties of gastric cancers, the expression of MUC1 and MUC2 mucin antigens was examined immunohistochemically in 136 patients with gastric cancer invading the submucosa or the deeper layer, and the survival of the antigen-positive and antigen-negative patient groups was compared using the Kaplan-Meier method. For MUC1 mucin expression, different glycoforms of MUC1 were examined using four monoclonal antibodies (NCL-MUC-1-CORE, DF3, MY.1E12, and HMFG-1). The patients with MUC1+ mucin antigen staining in the carcinoma showed significantly worse survival than those with MUC1- mucin antigen staining. In contrast, the patients with MUC2+ mucin antigen staining in the carcinoma showed significantly better survival than those with MUC2- mucin antigen staining. In conclusion, MUC1 antigen expression was associated with a poor outcome in patients with gastric cancer, irrespective of its glycosylation status, and MUC1 is thus considered to be a useful prognostic factor for poor outcome in patients. In contrast, MUC2 antigen expression is a prognostic factor associated with a favorable outcome in patients. In addition, combined evaluation of the MUC1 and MUC2 mucin staining is clinically useful to predict outcome in patients with gastric cancer.

A gene cluster encoding malonyl-CoA decarboxylase (MatA), malonyl-CoA synthetase (MatB) and a putative dicarboxylate carrier protein (MatC) in Rhizobium trifolii--cloning, sequencing, and expression of the enzymes in Escherichia coli

A gene cluster consisting of three consecutive genes, matABC, was isolated using a probe prepared from amino acid sequence information of Rhizobium trifolii malonyl-CoA synthetase, and was subsequently sequenced. The sequences of matA and matB were overlapped by four base pairs, whereas the intergenic region between matB and matC had 95 base pairs. The upstream region contained DNA sequences which are typical for an Escherichia coli sigma70 promoter, and no other open reading frame was found within 400 bp downstream of matC. The ribosome-binding sites were found 7 to 12 base pairs upstream of each gene. MatA gene encoded a polypeptide of 462 amino acid residues, with deduced molecular mass of 51414 Da. A glutathione-S-transferase-MatA fusion protein has been purified and MatA was shown to have an intrinsic malonyl-CoA decarboxylase activity (Km = 0.47 mM; Vmax = 52 micromol x min(-1) x mg(-1)). MatB encoded a polypeptide of 504 amino acid residues with deduced molecular mass of 54612 Da. MatB was also purified from E. coli transformant carrying the gene cluster. The enzyme was essentially indistinguishable from the wild-type malonyl-CoA synthetase of R. trifolii by the criteria of polyacrylamide gel electrophoresis and biochemical properties. MatC encoded a 46453-Da protein with a high content of hydrophobic residues. The deduced amino acid sequences of matC showed identity to some extent with anaerobic C4-dicarboxylate carrier proteins from E. coli (25%) and Haemophilus influenzae (17%). MatC protein appears to be an integral membrane protein that could function as a malonate carrier. The formation of acetyl-CoA and malonyl-CoA from malonate was confirmed by thin-layer chromatographic analysis. These results strongly suggest that the gene cluster encodes proteins involved in the malonate-metabolizing system, malonate-->malonyl-CoA-->acetyl-CoA, in R. trifolii and that the metabolic pathway in the malonate-rich clover nodule might play an important role in symbiosis.

Steroid acne vs. Pityrosporum folliculitis: the incidence of Pityrosporum ovale and the effect of antifungal drugs in steroid acne

BACKGROUND

Steroid acne is a folliculitis that can result from systemic or topical administration of steroid, and has been described as showing a similar clinical picture to Pityrosporum folliculitis, but there have been few reports about the incidence of Pityrosporum ovale and the effect of antimycotic drugs in steroid acne and other acneiform eruptions. Our purpose was to describe the association between steroid acne and P. ovale, and to confirm the superior efficacy of oral antifungal drugs over anti-acne drugs in the treatment of steroid acne.

METHODS

The history, clinical features direct microscopy, histopathologic analysis, and therapeutic results of 125 cases with steroid acne or other acneiform eruptions were described and compared.

RESULTS

Over 80% of patients with acneiform eruption receiving systemic steroid revealed significant numbers of P. ovale in the lesional follicle. Furthermore, oral antifungal drug (itraconazole) showed significantly better clinical and mycologic effects than any other group of medications used in this study.

CONCLUSIONS

Steroid acne and other acneiform eruptions showing discrete follicular papules and/or pustules localized to the upper trunk and acneiform facial skin lesions associated with multiple acneiform lesions on the body in the summer period should be suspected as Pityrosporum folliculitis. In addition, oral antifungal drugs recommended for Pityrosporum folliculitis; however, it will require a larger case-control study to confirm the superiority of antifungal therapy over anti-acne treatment.

Expression of Tcf-1 mRNA and surface TCR-CD3 complexes are reduced during apoptosis of T cells

When a T cell hybridoma, 70.7, was treated with a Ca2+ ionophore (A23187), apoptotic cell death was induced. Interestingly, we observed that the expression of Tcf-1, a T cell-specific transcription factor, mRNA was reduced by approximately 5-fold in the A23187-treated apoptotic cells compared to an ethanol-treated control. The hybridoma cells, however, did not display such a reduced expression of Tcf-1 mRNA upon treatment with buthionine sulfoxide, which is known to induce a necrosis-like cell death. When another T cell hybridoma, KMIs-8.3.5, was treated with A23187 and phorbol myristate acetate, which leads to activation-induced apoptosis, Tcf-1 expression was again greatly reduced. However, a mutant line (KCIT1-8.5) derived from KMIs-8.3.5, which produces IL-2 upon activation and is resistant to apoptosis, did not show such reduction in Tcf-1 expression. We also showed that the reduced expression level of CD3epsilon mRNA and surface TCR-CD3 complex in apoptotic T cells is caused by the reduced expression of Tcf-1. When 70.7 cells were transfected with a plasmid DNA pSVtcf-1, in which Tcf-1 gene expression is driven by the SV40 promoter, such reduction of the Tcf-1 mRNA and the surface expression of the TCR-CD3 complex were not observed upon apoptosis induction. Our results suggest that the reduced expression of Tcf-1 is specific for the apoptotic, but not for the activating, process of T cells and is also responsible for the reduced surface expression of the TCR-CD3 in apoptotic T cells.

Subcapsular hematoma as a complication of acute pyelonephritis: a case report

A case of subcapsular hematoma, a rare complication of acute pyelonephritis (APN) is described. A 60-year-old diabetic woman was admitted with a 3 day history of fever and left flank pain due to acute pyelonephritis. On the third day in hospital, left flank pain worsened despite use of antibiotics available for the treatments of APN and hemoglobin rapidly decreased from 11.1 to 7.9 g/dL. Ultrasonography and abdominal CT showed left subcapsular hematoma. Renal angiography demonstrated an ovoid avascular zone between the capsular artery and parenchyme of the left kidney with no evidence of tumors or vascular abnormalities, such as arteriovenous malformation or fistula. Subsequent percutaneous drainage of this subcapsular hematoma was performed and showed old blood-colored drainage. Hereby, the possibility of subcapsular renal hematoma in the course of acute pyelonephritis is stressed as a rare complication.

Degradation of acharan sulfate and heparin by Bacteroides stercoris HJ-15, a human intestinal bacterium

When glycosaminoglycan (GAG)-degrading enzymes were measured in normal human stool suspensions, all 5 tested different stools degraded titrable heparin and acharan sulfate. GAG-degrading bacteria were screened from the isolates of human stools. Among them, HJ-15 had the most potent activities of heparinases (GAGs-degrading enzymes). However, HJ-15 produced the enzyme even if in the media without heparin. Acharan sulfate lyase was induced by acharan sulfate and heparin. Heparinase production was also induced by these GAGs. These enzymes, acharan sulfate lyase and heparinase, were produced in exponential and stationary phase of HJ-15 growth, respectively. Optimal pHs of the acharan sulfate lyase and heparinase activities were 7.2 and 7.5, respectively. The biochemical properties of HJ-15 was similar to those of B. stercoris. However, difference from B. stercoris was utilization of raffinose. This HJ-15 also degraded chondroitin sulfates A and C.

Isolation and identification of chondroitin sulfates from the mud snail

Chondroitin sulfates were isolated from the mud snail. For the quantitative analysis of enzymatic digestion products of isolated chondroitin sulfates, strong anion exchange-high performance liquid chromatography (SAX-HPLC) was performed. By the action of chondroitinase ABC, three unsaturated disaccharides 2-acetamide-2-deoxy-3-O-(beta-D-gluco-4-enepyranosyluronic acid)-D-galactose (delta Di-OS), 2-acetamide-2-deoxy-3-O-(beta-D-gluco-4-enepyranosyluronic acid)-6-O-sulfo-D-galactose (delta Di-6S) and 2-acetamide-2-deoxy-3-O-(beta-D-gluco-4-enepyranosyluronic acid)-4-O-sulfo-D-galactose (delta Di-4S) were produced from the mud snail chondroitin sulfates. The analysis showed that relative proportion of delta Di-OS/delta Di-6S/delta Di-4S was 58.7/3.1/38.2. The immunomodulating activity of chondroitin sulfate was examined by cell proliferation assay and these results suggest that it might be a immunosuppressant.

Routine biliary sphincterotomy may not be indispensable for endoscopic pancreatic sphincterotomy

BACKGROUND AND STUDY AIMS

It is generally accepted that biliary sphincterotomy is mandatory to avoid possible cholestasis and infection due to edema after pancreatic sphincterotomy. However, biliary sphincterotomy is an invasive procedure and the above claim on dual sphincterotomy has not been proven by a prospective randomized study. The aim of our study was to determine whether cholangitis develops more frequently when the patients have not undergone concomitant biliary sphincterotomy during the endoscopic pancreatic sphincterotomy.

PATIENTS AND METHODS

From January 1990 to November 1997, 60 patients (38 men, 22 women, age range 19-45 years) with non-alcoholic chronic calcifying pancreatitis were prospectively enrolled. The patients with jaundice (bilirubin > or = 3 mg/dl), cholangitis, or parenchymal liver disease were excluded. The patients were randomly subjected either to dual sphincterotomy (group I, n = 30) or to pancreatic sphincterotomy alone (group II, n = 30). Groups I and II were further classified as IA (or IIA) and IB (or IIB), according to the level of serum alkaline phosphatase (sALP) and the diameter of the common bile duct (CBD). Group IA (or IIA) was defined when abnormal in both sALP (> or = 2 times the upper limit of normal) and CBD diameter (> or = 12 mm), whereas group IB (or IIB) was defined when normal, or solely abnormal in sALP or CBD diameter.

RESULTS

As a complication after sphincterotomy, pancreatitis developed in one of eight patients (12.5%) in group IA, whereas cholangitis occurred in one of 22 (4.5%) and hemorrhage in one of 22 (4.5%) cases in group IB. By contrast, in group IIA, the cholangitis developed in 56% (five of nine patients), which was significantly more frequent than in any other groups (P < 0.05). Hemorrhage (one of 21, 4.8%) and pancreatitis (one of 21, 4.8%) occurred in group IIB.

CONCLUSIONS

Our results suggest that dual sphincterotomy may be indicated only in patients who have both dilated choledochus and elevated alkaline phosphatase in chronic pancreatitis. Routine biliary sphincterotomy may not be indispensable for pancreatic sphincterotomy.

Identification of oxidized low density lipoprotein in human renal biopsies

BACKGROUND

Intraglomerular lipid deposition is frequently observed in routine renal biopsies, and it has been suggested that lipid peroxidation of low density lipoprotein (LDL) may be implicated in the pathogenesis of progressive glomerulosclerosis. We have examined whether oxidized LDL (Ox-LDL) is present in the glomeruli of patients with renal disease and whether intrinsic human glomerular cells express NADPH-oxidase (a superoxide-generating enzyme found in professional phagocytes).

METHODS

Immunocytochemical study was performed on 939 renal biopsy specimens, using monoclonal antibodies (mAbs) OL-10, 48 and 449, and polyclonal antibody against human apolipoprotein (apo) B. Mouse mAb OL-10 recognizes malondialdehyde (MDA)-modified peptide epitope, and mAbs 48 and 449 react with alpha and beta subunits of cytochrome b558, an essential component of NADPH-oxidase.

RESULTS

Sixty-two (6.6%) of the 939 patients with renal disease exhibited a staining for MDA-altered protein or Ox-LDL in the glomeruli, mainly in the sclerotic segments or mesangial areas. Group 1 patients with heavy Ox-LDL deposition mainly in the sclerotic segments showed a higher frequency of renal insufficiency and heavy proteinuria and a greater degree of glomerulosclerosis, compared to those in group 2 with mesangial Ox-LDL staining. The distribution of MDA protein epitopes, in general, paralleled the deposition of apo B epitopes. Immunoelectron microscopy of ultrathin frozen sections showed the presence of immunogold particles for mAbs 48 and 449 in the cytoplasm of resident glomerular cells of both normal and diseased kidneys. When immunoblotted with mAb OL-10, one band from the IgA nephropathy and focal segmental glomerulosclerosis groups at approximately 260 kD was labeled, whereas immunostaining of normal control samples revealed no staining.

CONCLUSIONS

These results indicate that Ox-LDL is present mainly in the lesions of glomerulosclerosis and mesangial areas in human renal biopsies. They also suggest that patients with heavy Ox-LDL accumulation in the sclerotic segments of glomeruli have more advanced renal disease than those with mesangial Ox-LDL and that resident glomerular cells generate cytochrome b558, the potential of which may not suffice to induce peroxidation of LDL in the diseased glomeruli.

Quantitative and qualitative usefulness of rebamipide in eradication regimen of Helicobacter pylori

The aim of the present study was to determine the efficacy of a new combination regimen including antioxidant, proton pump inhibitor, and antibiotics against Helicobacter pylori and to document the changes of oxidative stress and cytokines involved in H. pylori-associated gastritis. From each of 57 patients with endoscopically diagnosed gastric and/or duodenal ulcers associated with H. pylori infection, five gastric antral biopsy specimens were taken for the diagnosis of H. pylori and for experimental measures. The patients were then treated either with lansoprozole 30 mg + amoxicillin 1.5 g (LA group; 21 patients) or lansoprazole 30 mg + amoxicillin 1.5 g + rebamipide 300 mg (LAM group; 36 patients) for two weeks. Four weeks after the initiation of treatment, the patients were endoscoped again and biopsy specimens were obtained. Mucosal malondialdehyde (MDA) levels; myeloperoxidase (MPO) activities; superoxide dismutase; catalase; glutathione peroxidase; cytokines IL-1, IL-6, TNF-alpha; and chemokines IL-8, GRO-alpha, RANTES (regulated on activation normal T expressed and secreted) were measured. Using paraffin-embedded tissue sections, in situ terminal deoxyribonucleotide transferase (TdT) -mediated dUTP nick end labeling (TUNEL) for apoptosis and immunohistochemical staining for inducible nitric oxide synthase (iNOS) were performed. Two weeks of treatment with the LA regimen resulted in 57.4% eradication rates of H. pylori, whereas two weeks of treatment with the LAM regimen resulted in 75.0% eradication rates. Eradication rates between these two groups were statistically significantly different (P < 0.05). Mucosal MDA levels and MPO activities were significantly lower in the LAM group than the LA group. Mucosal levels of cytokines IL-1, IL-6, and TNF-alpha and of chemokines IL-8, GRO-alpha, and RANTES were all significantly decreased after the treatment of H. pylori, especially in the LAM-treated group. The apoptotic index and iNOS score were significantly reduced after the eradication of H. pylori. The addition of the antioxidative drug rebamipide to the eradication regimen against H. pylori has quantitative and qualitative advantages such as either augmenting the eradication rates of H. pylori or decreasing oxidative stress and cytokines levels generated by H. pylori infection.

Ballooning of the papilla during contrast injection: the semaphore of a choledochocele

BACKGROUND

Choledochocele is a rare abnormality involving the intramural segment of the common bile duct. ERCP is essential to demonstrate a choledochocele. The aim of this study was to investigate the duodenoscopic and cholangiographic findings during ERCP.

METHODS

Over a 4-year period, 17 symptomatic patients (8 men, 9 women; age range 45 to 83 years) were identified as having choledochoceles. The diagnosis of choledochocele was made by both duodenoscopic and cholangiographic findings.

RESULTS

As a characteristic duodenoscopic finding, the enlarged bulging papilla was noted in 8 patients (47%), whereas a normal-appearing papilla was noted in 9 patients (53%) before the injection of contrast media. However, in all 17 patients progressive enlargement or ballooning of the papilla was noted during contrast injection. The maximum diameter of the choledochocele, determined by cholangiography, was significantly larger (19 +/-4 mm) in patients with initially bulging papilla than in those with normal-appearing papilla (9+/-3 mm) (p < 0.05).

CONCLUSIONS

Ballooning of the papilla during contrast injection may be a specific duodenoscopic finding for choledochocele. To avoid missing the diagnosis of a choledochocele, especially when it is small, it is important to watch the papilla carefully during contrast injection.

Mutations of the STK11 gene in sporadic gastric carcinoma

Gastric carcinoma may occur sporadically or in association with hereditary diseases, such as Peutz-Jehgers syndrome (PJS). The PJS gene (named STK11 or LKB1) was mapped to 19p13.3 and recently cloned. Germ-line mutations of the gene have been detected in familial PJS patients and are predicted to predispose STK11 carriers to the development of a wide range of gastrointestinal and other neoplasms. To elucidate the etiological role of the STK11 gene in sporadic gastric carcinoma tumorigenesis, we analyzed 28 gastric carcinomas (22 of intestinal type and 6 of diffuse type) for STK11 gene mutations. STK11 gene mutations were detected in 3 of 28 gastric carcinomas but were not seen in the corresponding germ-line DNA sequence. In one tumor, a missense mutation, C-to-T transition, was detected at codon 324 resulting in proline to leucine substitution; in the other two, silent mutations were detected at codons 106 and 350, respectively. While these results suggest that somatic STK11 mutations are not common in sporadic gastric carcinomas, they may occur in a subset of these tumors.

Association of periampullary diverticula with primary choledocholithiasis but not with secondary choledocholithiasis

BACKGROUND AND STUDY AIMS

Several endoscopic studies have reported an association between periampullary diverticula and biliary calculi, but the results are inconsistent when the anatomic site of the stones is considered. The aims of our study are to evaluate the association between periampullary diverticula and gallstones according to their site and to clarify the origin of the common bile duct stones by analyzing their composition.

PATIENTS AND METHODS

During a period of 10 months, 611 of 632 consecutive patients having endoscopic retrograde cholangiopancreatography (ERCP) were prospectively enrolled. The data about periampullary diverticula and gallstones were analyzed according to the site of the stones. The stones were initially grouped on the basis of their gross morphology and cross-sectional appearance, and finally analyzed by quantitative infrared spectroscopy.

RESULTS

Diverticula were found in 165 of 611 cases (27%) and the incidence increased with age (p<0.01). The incidence of gallbladder or common bile duct stones was higher in patients with periampullary diverticula (73/165,44%) than without (130/446,29%) (p<0.01). Considering the site of the gallstones, this significance was found only in patients with common bile duct stones not associated with gallbladder stones (p<0.001). Of the 40 who had gallstones only in the common bile duct, 32 gave a history of cholecystectomy more than two years previously and had been free of symptoms postoperatively, and on analysis most of the stones (30/36,83%) were brown pigment stones. These therefore were assumed to be primary common bile duct stones. The common bile duct stones with associated gallbladder stones were identical to their paired gallbladder stones in gross and cross-sectional appearance and chemical composition. They were assumed to be secondary common bile duct stones and the difference in the incidence of calculi according to the presence of diverticula was not significant.

CONCLUSION

The incidence of gallstones was significantly higher in periampullary diverticula, and when the site and the origin of the gallstones was considered the association between diverticula and gallstones was significant in patients with primary common bile duct stones but not with the secondary ones.

Evaluation of articular cartilage thickness of the humeral head and the glenoid fossa by MR arthrography: anatomic correlation in cadavers

OBJECTIVE

To evaluate the accuracy of MR arthrography in determining the thickness of articular cartilage of the humeral head and glenoid fossa.

DESIGN AND PATIENTS

MR arthrography of the glenohumeral joint was performed in 17 cadaveric shoulders. Articular cartilage thickness was measured on the MR arthrographic images and corresponding anatomic sections.

RESULTS

The correlation coefficients for MR arthrographic measurement versus anatomic measurement of the cartilage thickness were 0.7324 and 0.8757 for humeral head and glenoid fossa, respectively. With regard to the humeral head, there was a tendency to overestimate regions of thin cartilage and underestimate regions of thick cartilage. This tendency was not found in the assessment of glenoid cartilage. The mean of the absolute value of MR-anatomic differences was similar on the glenoid side (0.27 mm) and the humeral side (0.29 mm). The accuracy of measurement was significantly better on the glenoid side (Fisher's r-to-Z transformation: Z=5.21, P=0.000001).

CONCLUSION

MR arthrography causes a moderate degree of error in the naked-eye measurement of the cartilage of the glenohumeral joint. The accuracy is higher on the glenoid side than on the humeral side.