Coronary segmental responses to acetylcholine in patients with hypercholesterolemia

We investigated coronary segmental response to intracoronary acetylcholine (ACh) in 19 patients with hypercholesterolemia and 18 patients with normal cholesterol levels. All patients had atypical and chest pain and angiographically normal coronary arteries. After baseline angiography, ACh (3 and 30 micrograms/min) was infused into the left coronary artery, followed by infusion of nitroglycerin. Percent changes in diameter of the proximal, middle, and distal segments of the left coronary arteries were measured by quantitative angiography. In the normocholesterolemic group, 3 micrograms/min of ACh produced significant coronary vasodilation in the distal segments (+8.2 +/- 2.6%, p < 0.005), while 30 micrograms/min did not cause any changes. In the hypercholesterolemic group, 30 micrograms/min of ACh caused significant coronary vasoconstriction in the middle and distal segments (-7.2 +/- 1.9% and -6.2 +/- 1.9%, p < 0.001 and p < 0.01, respectively), while 3 micrograms/min caused no changes. In each group, vasodilator responses to nitroglycerin in the middle and distal segments were significantly greater than those in the proximal segments (p < 0.001). Our results suggest that impaired endothelial function may be evaluated more effectively in the distal coronary segments in patients in the early stage of epicardial coronary atherosclerosis attributable to hypercholesterolemia.

Nucleotide sequence of a major satellite DNA element isolated from a saltwater fish Sillago japonica

A member of satellite repetitive DNA was isolated and sequenced from a saltwater fish Sillago japonica (Percoidei). This sequence consists of several oligo-dA/dT tracts and two inverted repeats which resemble each other. Dot blot hybridization analysis using a satellite DNA clone pSJ2 among the species in the suborder Percoidei revealed that the pSJ2 sequence was amplified at least after the family Sillaginidae had been derived.

Brain single photon emission computed tomography imaging in Landau-Kleffner syndrome

Five right-handed children with Landau-Kleffner syndrome (LKS) who had disease onset between the ages of 3 and 9 years were studied with EEG and single-photon emission computed tomography (SPECT) before and, in four cases, after 6 months of corticosteroid treatment. EEG findings included both focal and generalized spikes as well as spike-wave discharges with bilateral temporal predominance. These increased markedly during sleep in 1 child, and continuous spike-and-wave complexes appeared during slow-wave sleep in another patient. Neuropsychological testing demonstrated verbal auditory agnosia. Magnetic resonance imaging (MRI) was performed in 4 children and was normal. Brain SPECT imaging demonstrated abnormal perfusion in the left temporal lobe in all patients. The response to corticosteroid therapy was mixed. Our findings reinforce the concept that LKS is a functional disease affecting the language-dominant brain areas. We conclude that SPECT imaging may be of diagnostic assistance in the evaluation of this syndrome of unknown etiology.

A tyrosine kinase-like molecule is localized in the nuclear membrane of neurons: hippocampal behavior under stress

Protein tyrosine kinases play important roles in the development of the mammalian nervous system during embryogenesis and in the maintenance of function of the adult brain. Using a semi-nested PCR technique based on a short amino acid motif of protein tyrosine kinases, we isolated a human genomic DNA encoding a peptide whose sequence was related to known mammalian protein tyrosine kinases. The expression was examined by Northern blot analysis, and transcripts were detected almost exclusively in the brain. The corresponding cDNA was sequenced, and it was revealed that the gene designated as byk coded for a receptor-like molecule with a motif of protein tyrosine kinase. Immunohistochemical analysis demonstrated that the Byk protein was expressed in neurons and was located in the nuclear envelope. To understand the physiological significance of the Byk protein, we investigated the behavior of this molecule in the hippocampus after ischemia. Byk-like immunoreactivity disappeared from the neurons in the fields CA1 through CA3 and the dentate gyrus of the hippocampus following 20 min of ischemia. After recirculation of blood flow, neurons in the CA3 field and the dentate gyrus re-expressed Byk-like antigen but CA1 neurons did not. Interestingly, Byk-like immunoreactivity was detected in microglial cells and astrocytes in the CA1 field that were activated after ischemia. Byk could be a new tool to study the neuron-glia and glia-glia interactions.

Significance of free prostate-specific antigen and gamma-seminoprotein in the screening of prostate cancer

BACKGROUND

Since free prostate-specific antigen (PSA) and gamma-seminoprotein (gamma-SM) recognize similar epitope(s) of PSA, the significance of serum-free PSA and gamma-SM in the early detection of prostate cancer was compared.

METHODS

A prospective clinical trial was conducted on 701 male volunteers, age 50 years or older. Free PSA (Tandem-R free PSA, Hybritech) and gamma-SM (gamma-SM, Chugai) levels were determined, and biopsies were performed if the PSA (Tandem-R, Hybritech) level was > 4 ng/ml, or if digital rectal examination (DRE) was suspicious.

RESULTS

One hundred and eighty-seven men (27%) had either a PSA level > 4 ng/ml or a suspicious DRE. Of 116 biopsies performed, cancer was detected in 13 (1.9%, 13/701). Receiver-operating characteristic analysis of free PSA to PSA ratio (free PSA ratio, %) and gamma-SM to PSA ratio (gamma-SM ratio), to differentiate normal biopsy findings from cancer, showed that the optimal values were 12% and 0.38, respectively. Positive predictive value for cancer was 24% (12 cancers/50 biopsies) for PSA alone, 42% (8/19) for the combination of PSA and DRE, 45.5% (10/22) for the combination of PSA and gamma-SM ratio, and 50% (10/20) for the combination of PSA and free PSA ratio. Regression analysis showed that gamma-SM highly correlated with free PSA, but that the analytical detection limit of gamma-SM was 1 ng/ml, significantly higher than that of free PSA.

CONCLUSIONS

Free PSA determination might effectively eliminate unnecessary biopsies in subjects with PSA > 4 ng/ml, and gamma-SM might provide a complementary index to free PSA, but its validity should be further studied in other settings, such as after radical prostatectomy or during endocrine treatment.

Optimal conditions for collection of blood samples for assay of alpha 2-macroglobulin-trypsin complex-like substance (MTLS)

We have developed an enzyme-linked immunosorbent assay (ELISA) for the specific quantification of alpha 2-macroglobulin-trypsin complex-like substance (MTLS). To exclude artifacts in measured values of MTLS, the conditions for collection of blood samples are critical. In the present study, we have determined the optimal conditions for blood collection and investigated the role of MTLS as a clinical tool for diagnosis in pancreatitis. Results obtained are as follows: (1) MTLS levels of all sera were more than 10-fold higher than the corresponding plasma; (2) MTLS levels of heparinized plasma were the lowest among plasma with three anticoagulants (sodium citrate, sodium EDTA and heparin); (3) some kinds of blood collection tubes containing heparin were not suitable for the sampling; (4) MTLS values of plasma obtained by blood collection tubes containing Trasylol and sodium EDTA were demonstrated more stable and lower than those obtained by heparin tubes; and (5) under these conditions, we can exclude elevation of MTLS values caused by inappropriate blood sampling and find the time course of the elevation reflecting clinical course of a patient with acute pancreatitis and a patient after endoscopic retrograde cholangiopancreatography (ERCP). The optimal conditions for collection of blood samples were as follows. Blood sampling should be performed by blood collection tubes containing Trasylol (50 microliters/ml blood) and sodium EDTA (1.5 mg/ml blood). The samples were immediately stored at 4 degrees C and centrifuged at 3,000 rpm for 15 min. The plasma were stored in plastic tubes at 4 degrees C until assayed.

Methylation status of Sillago japonica satellite DNA examined by bisulfite modification

A member of Sillago japonica satellite DNA contained internal subrepeats in its 174 bp unit. S. Japonica genomic DNA isolated from liver tissue was subjected to bisulfite modification, and the DNA sequences of about 40 bp flanked by both subrepeats were amplified by polymerase chain reaction (PCR). This protocol, combination of bisulfite reaction and PCR, converts cytosines in the genomic DNA to thymines in the amplified DNA, whereas 5-methylcytosines in the genomic DNA remain as cytosines. Sequence analysis of the amplified DNA fragments revealed that most of the cytosine residues at CpG were methylated in this region.

Plasma alpha 2-macroglobulin-trypsin complexlike substance (MTLS) in pancreatic disease

alpha 2-macroglobulin-trypsin complexlike substance (MTLS) was determined in plasma of pancreatic and nonpancreatic diseases using a two-step enzyme immunoassay to study the diagnostic and pathophysiological significance of MTLS. Plasma levels of MTLS in acute pancreatitis (mean +/- SD = 265.6 +/- 346.2 ng/ ml, n = 9), calcified chronic pancreatitis (128.6 +/- 257.4, n = 13), and noncalcified chronic pancreatitis (13.5 +/- 12.5, n = 10) were significantly higher than that in controls (3.6 +/- 1.8, n = 81). In other diseases such as gastric cancer, hepatoma, diabetes mellitus, and gallstones, MTLS values were not different from those of control. Plasma MTLS values showed low correlation with serum trypsin, elastase 1, pancreatic amylase, lipase, and pancreatic secretory trypsin inhibitor (PSTI). The elevation of plasma MTLS values in acute pancreatitis suggests that plasma MTLS levels reflect that protease is inappropriately activated in pancreatic acinar cell and released into the circulation and that the determination of MTLS can be useful for diagnosis and pathophysiology of acute pancreatitis and chronic pancreatitis.

Genetic change in transforming growth factor beta (TGF-beta) receptor type I gene correlates with insensitivity to TGF-beta 1 in human prostate cancer cells

Transforming growth factor beta 1 (TGF-beta 1), a potential regulator of growth of prostate cancer cells, exerts its effects through interaction with membrane receptors. In the present study, an attempt was made to establish a correlation between TGF-beta 1 sensitivity and TGF-beta receptor expression in three prostate cancer cell lines (PC3, DU145, and LNCaP). In a dose-dependent manner, TGF-beta 1 inhibited the proliferation of PC3 and DU145 cells but not LNCaP cells. Since TGF-beta signals through a heteromeric complex composed of TGF-beta receptors type II and type I, the expression of these receptors was investigated by Western blot analysis and reverse transcriptase-PCR. These studies demonstrated that all three prostate cancer cell lines express type II receptor. In contrast, type I receptor was detected only in the TGF-beta 1-sensitive PC3 and DU145 cells but not in the TGF-beta 1-insensitive LNCaP cells. To investigate the possibility that the undetectable expression of type I receptor in LNCaP cells is due to a change in the respective gene, Southern blot analysis was performed. The result demonstrated that there was a genetic change in type I receptor gene in these cells. Subsequently, when LNCaP cells were transiently transfected with T beta R-I cDNA, sensitivity to TGF-beta 1 was restored. These observations indicate that LNCaP cells contain a defective T beta R-I gene which rendered these cells insensitive to the action of TGF-beta 1.

[A case of superior vena cava syndrome treated with combination radiation and CRE (CBDCA and VP-16) therapy]

Carboplatin and etoposide were reported to be excellent radiation sensitizers. We encountered a patient with SVC syndrome due to lung cancer who was successfully treated by combination carboplatin, etoposide and hyperfractionation radiotherapy. A 72-year-old man was admitted to our hospital because of remarkable face edema. Computed tomography revealed a huge lung tumor and compressed SVC due to tumor growth. Acute tumor regression was essential for this case. We performed combination chemotherapy and radiation. The regime consisted of CBDCA 300 mg (day 1 1 hr drip infusion) and etoposide 50 mg/day for 21 days by oral administration. Two daily fractionations of 1.4 Gy were delivered 5 days-a-week, with a 4 h interval between fractions (total dose 49.8 Gy). Complete response of huge tumor was attained in this case. The major side effect associated with the therapy was myelosuppression. The patient's quality of life has been remarkably improved with this therapy.

Surgical control of akinesia in Parkinson's disease

Posteroventral pallidotomy (PVP) was carried out in 86 patients with Parkinson's disease, who presented marked bradykinesia, freezing of gait and postural defect associated with rigidity and tremor in 82 patients (bradykinesia type), and similar gait and postural problems with minimum signs of rigidity and tremor in 4 (pure akinesia type). The stereotactic coordinates of Leksell's device were calculated from MRI and conventional ventriculography. The final target was defined by microelectrode techniques in the basal ganglia. The microrecording study revealed a very high background activity in the internal pallidum in patients of the bradykinetic type, however, a much lower pallidal activity in patients of the pure akinesia type. Fifty-eight patients underwent unilateral PVP, and 28 underwent bilateral surgery. Following PVP, rigidity tremor and poor reciprocal movements were significantly improved especially in the contralateral extremities. The most dramatic findings were the reversal of akinetic symptoms and wearing-off phenomena. The patients were followed up for 3-30 months (mean = 8) after surgery. Of the 82 bradykinesia type patients, good result were obtained in 48 (58%), fair results in 26 (32%), and minor improvement or no change in 8 (10%). In all the 4 patients of the pure akinesia type, recurrence of the akinetic symptoms occurred after a temporal improvement lasting a few days to 3 month after surgery. There was worst dysarthria in 3 patients, hemiparesis in 1 and partial motor aphasia in 1. The visual field problem was not complicated in any patients. These findings suggest that akinetic symptoms in PD are implicated in overactive pallidal outputs with putative GABAergic modulator by excessively inhibiting pedunculopontine nucleus activity (midbrain locomotor and posture regions) as well as thalamic activity. Partial interruption of the pallidal efferents eliminates the akinetic symptoms by disinhibitory effects on the target structures. The pathology of PD of the pure akinesia type is supposedly in the brainstem and should be excluded from indication of pallidotomy.

Growth hormone-releasing hormone augments voltage-gated Na+ current in cultured rat pituitary cells

The effect of human growth hormone-releasing hormone (hGHRH), a potent stimulator of adenylate cyclase in somatotrophs on the voltage-gated sodium current was determined by perforated patch clamp of cultured rat somatotrophs The amplitude of the voltage-gated sodium current was augmented by 65.3 +/- 20.6% (mean +/- SE, n = 7) by 10 nM hGHRH. This augmentation was reversibly blocked by 10 microM H-89 a specific inhibitor for adenosine 3',5'-cyclic monophosphate (cAMP)-dependent protein kinase. The membrane-permeant analogue of cAMP, dibutyryl cAMP (5 mM), also augmented the voltage-gated sodium current by 39.6 +/- 7.4% (n = 10). There were no effects of hGHRH or dibutyryl cAMP on steady-state inactivation of the sodium current. In contrast, in the whole cell configuration of patch clamp, no augmentation of the sodium current was observed by hGHRH or by the membrane-permeant analogue of cAMP. These results suggest that hGHRH augments the peak amplitude of the voltage-gated sodium current in rat somatotrophs via phosphorylation by cAMP-dependent protein kinase. For this augmentation, the intracellular environment must be kept relatively intact.

Immunohistochemical detection of coagulation factor XIIIa in postmortem human brain tissue

Blood coagulation factor XIII is responsible for stabilizing fibrin clots by catalyzing the formation of covalent bonds between lysine amino groups and glutamine carboxyl groups. A smaller form of factor XIII called factor XIIIa (FXIIIa) occurs intracellularly in platelets, monocytes and peripheral macrophages. Using a specific antibody to FXIIIa, we detected this molecule immunohistochemically in a subpopulation of reactive microglia and macrophages in a number of neurological disease states. These included Alzheimer's disease and other degenerative disorders. FXIIIa was also detected in capillaries and some leukocytes in both control and neurologically diseased tissue. FXIIIa is known to cross-link a variety of proteins in addition to fibrin. Its occurrence in some reactive microglia suggests a possible role in the fundamental pathology.

Immunohistochemical investigation of tau-positive structures in the cerebral cortex of patients with progressive supranuclear palsy

We have investigated tau-positive structures immunohistochemically in the cerebral cortex of patients with progressive supranuclear palsy (PSP). In addition to neurofibrillary tangles, a variety of tau-positive structures occur. They are particularly abundant in the precentral gyrus and other frontal cortices. Double immunostaining has demonstrated that coil-like structures (coiled bodies) are located in the oligodendroglial cell bodies. Three forms of tau-positive astrocytic inclusions are discerned: those with tuft-like profiles, thorn-like structures, and concentric clusters of short stubby fibers. The concentric clusters of tau-positive fibers are present in some, but not all, PSP brains. They appear to be identical to 'astrocytic plaques' previously reported in patients with corticobasal degeneration (CBD). PSP and CBD might share a common pathological background which causes abnormal accumulation of tau protein in neurons and glial cells of neuroectodermal origin.

Two family G xylanase genes from Chaetomium gracile and their expression in Aspergillus nidulans

With oligonucleotides based on the amino-terminal and internal amino-acid sequences of a xylanase, two xylanase genes, cgxA and cgxB, were isolated and sequenced from Chaetomium gracile wild and mutant strains. Each gene isolated from both strains was essentially the same as far as nucleotide sequences were compared. The mature CgXA and CgXB xylanases comprise 189 and 211 amino acids, respectively, and share 68.5% homology. The CgXA was found to be the major enzyme in the mutant strain. Comparison of these amino-acid sequences with xylanase sequences from other origins showed that they have a high degree of identity to the family G xylanases. The cgxA and cgxB genes were introduced into Aspergillus nidulans and found to be expressed with their own promoters.

Localization and in vitro mutagenesis of the active site in the Saccharomyces cerevisiae mRNA capping enzyme

The yeast mRNA capping enzyme is composed of 52 (alpha) and 80 kDa (beta) polypeptides, which are responsible for its mRNA guanylyltransferase and RNA 5'-triphosphatase activities, respectively. We isolated the gene encoding the alpha subunit (CEG1) and showed that CEG1 is essential for yeast cell growth [Shibagaki et al., (1992) J. Biol. Chem. 267, 9521-9528]. In this study, CEG1 was expressed in Escherichia coli and the alpha subunit protein was purified to near homogeneity. A [32P]GMP-bound tryptic peptide derived from the recombinant enzyme-[32P]GMP covalent reaction intermediate was converted to a [32P]phosphoryl-peptide through periodate oxidation followed by beta-elimination. Hydrolysis of the [32P]phosphoryl-peptide with alkali resulted in [32P]N epsilon-phospholysine as the only phosphoamino acid, indicating that GMP in the enzyme-GMP complex is bound to a lysine residue via a phosphoamide linkage. Microsequencing of the [32P]GMP-peptide showed that the GMP binding site was located in the region between amino acids 60 and 75, which contained an internal trypsin-resistant lysine at position 70. CEG1 was subjected to site-directed mutagenesis and the mutant proteins were expressed in E. coli. Substitution of His or Ile for Lys70 entirely abolished the enzyme-GMP formation activity, and this mutation was lethal to yeast in vivo, supporting the notion that the active site in the alpha subunit is located at Lys70. Replacement of Lys70 with Arg reduced the ability to form the enzyme-GMP complex; however, yeast cells bearing this allele were not viable. A series of mutations, including 8 amino acid replacements and 3 insertions, near the active site (Lys70-Thr-Asp-Gly motif) were also introduced and the mutant polypeptides were examined for catalytic activity in vitro as well as yeast cell viability in vivo. There was a good correlation between the in vitro and in vivo functions of the mutant proteins, except when Asp72 was replaced with Glu, which allowed formation of the enzyme-GMP complex but failed to support cell growth. The results with Lys70 to Arg and Asp72 to Glu substitutions indicated that guanylyltransfer to RNA and/or additional roles besides cap formation per se are impaired in these mutant proteins.

Parvocellular and magnocellular contributions to visual evoked potentials in humans: stimulation with chromatic and achromatic gratings and apparent motion

Psychophysical evidence suggests that two major parallel pathways, the parvocellular (P) and the magnocellular (M) pathways, exist in humans. We herein report that responses specific to the P and M systems can be recorded in human visual evoked potentials (VEPs) by using the appropriate stimuli. The onset of isoluminant chromatic (red-green) and high contrast achromatic sinusoidal gratings were used for stimulating the P-system. A chromatic stimulation evoked a characteristic negative wave (N1) with peak latencies around 120 msec. The amplitude showed an inverse U-shaped function as a function of spatial frequency with a peak at 2 c/deg. In contrast, VEPs to achromatic (black-white) gratings showed different spatial frequency characteristics with a peak at 5.3 c/deg. By varying the luminous intensity ratio between the red and green gratings, N1 was found to reach a maximum during isoluminant stimulation. An apparent motion display was used for stimulating the M-system. The speed of alternation (i.e., the interstimulus interval (ISI)) was varied to record both the transient and steady-state VEPs. Transient VEPs showed triphasic waves with the major positive peak (P1) at around 120 ms. Steady-state VEPs were quasi-sinusoidal waveforms, depending on the ISI, and were quite stable across all subjects. There was a also high correlation between the motion threshold and the VEP amplitude. The above observations indicate that characteristic potentials may distinguish between these two parallel visual systems in humans. Thus, the combined use of isoluminant color and high contrast achromatic gratings and an apparent motion display is considered to be useful for evaluating both systems electrophysiologically.

Molecular biological and quantitative abnormalities of ADP/ATP carrier protein in cardiomyopathic hamsters

The adenine nucleotide translocator or ADP/ATP carrier protein (AAC) is an integral protein present in the inner mitochondrial membrane, which performs the exchange of cytoplasmic and intramitochondrial ADP and ATP. The myocardial AAC content was studied in J-2-N cardiomyopathic hamsters. The AAC content was found to be significantly decreased in J-2-N hamsters. For molecular biological analysis, hamster AAC (T1 isoenzyme) cDNA was cloned by the plaque hybridization method. This AAC cDNA hybridized specifically with AAC mRNA, so RNA dot-blot hybridization was performed. The highest AAC mRNA level was observed in control hamsters followed by J-2-N hamsters with mild myocardial damage, J-2-N hamsters with severe myocardial damage and Bio 14-6 cardiomyopathic hamsters. These results suggest that a decreased AAC content may contribute to the pathogenesis of cardiomyopathy and that a decrease of AAC mRNA levels may explain the abnormalities of AAC in J-2-N cardiomyopathic hamsters.

Ki-1 (CD30) positive anaplastic large cell lymphoma of T-cell phenotype developing in association with long-standing tuberculous pyothorax: report of a case with detection of Epstein-Barr virus genome in the tumor cells

We report a case of CD30 positive anaplastic large cell lymphoma of T-cell phenotype developing in association with long-standing tuberculous pyothorax. Phenotypic analysis showed CD1a-, CD2+, CD3+, CD4+, CD5-, CD8-, CD10-, CD19-, CD20 +/-, CD21-, CD25-, CD56-, T-cell receptor (TCR) alpha/beta antigens-, and HLA-DR+ phenotype. Neither rearrangement of TCR beta and gamma chain genes or of immunoglobulin heavy chain gene was detected in DNA extract from fresh material. The lymphoma cells were also shown to express the latent membrane protein-1 and the Epstein-Barr virus (EBV)-encoded nuclear antigen-2 by immunohistochemistry and EBV-encoded small RNAs by in situ hybridization.

Three-channeled aortic dissection

A 68-year-old woman in whom a thoracic aortic dissection (DeBakey type III) had been followed up for 6 years was admitted to our hospital with a complaint of chest pain. A graft replacement of the descending thoracic aorta was performed. A communication between the second and third channels was detected intraoperatively. Nine cases of three-channeled aortic dissection whose third dissection existed within the outer wall of the second one were previously reported, and 4 of them had a communication between the two false channels.

Effects of quisqualic acid on the corneal and intraretinal direct-current electroretinogram and on the standing potential of the rabbit eye

Quisqualic acid, an excitatory amino acid agonist, has been shown to stimulate inositol phosphate production in the rabbit retina. Inositol trisphosphate serves as a second messenger and increases intracellular calcium. We investigated the influence of quisqualic acid on the direct-current electroretinogram and on the standing potential of the rabbit eye. After unilateral vitrectomy, the corneal direct-current electroretinogram and the standing potential were recorded from both eyes of albino rabbits during simultaneous unilateral intravitreal perfusion with quisqualic acid alternating with control solution. The contralateral eye was used as a control. Intravitreal perfusion with 100-microM and 200-microM quisqualic acid elevated the standing potential significantly. This elevation was accompanied by a significant increase in c-wave amplitude and a significant decrease in b-wave amplitude. Quisqualic acid at 200-microM concentration decreased the a-wave amplitude also. In vivo intraretinal recordings showed that intravitreal perfusion with quisqualic acid at 200-microM concentration significantly increased the retinal pigment epithelial component of the c-wave. We conclude that quisqualic acid influences the direct-current electroretinogram and the standing potential apparently through its action on the retinal pigment epithelium. A possible mode of action is increased production of inositol trisphosphate, followed by an increase in intracellular release of calcium ions and an increase in basal chloride conductance. The decrease in a- and b-wave amplitudes indicates direct effects of quisqualic acid also on the neural retina.

[A case of Lemmel's syndrome caused by a large diverticular enterolith at the peripapillary portion of the duodenum]

A 93-year-old woman admitted because of epigastralgia. Cholelithiasis, obstructive jaundice, acute suppurative cholangitis and acute pancreatitis were diagnosed on blood chemistry and ultrasonography on admission. We performed emergency PTCD. A calculus 4 cm in diameter was detected at the papilla of Vater and marked dilatation of the common bile duct and pancreatic duct. ESWL was performed because of her age and because endoscopical operation seemed to be difficult. After lithotripsy, PTC and endoscopy demonstrated a diverticulum at the peripapillary portion of the duodenum. Based on analysis of PTC result before and after ESWL, we diagnosed this case as Lemmel's syndrome (obstructive jaundice, acute suppurative cholangitis and acute pancreatitis) caused by a large diverticular enterolith at the peripapillary portion of the duodenum. ESWL treatment of aged patient with an enterolith is safe.