Gastric Angle Research Articles

Post-ESD endoscopy for prevention of delayed bleeding

Objective To evaluate a second endoscopy for prevention of delayed bleeding after ESD. Methods Data of 67 patients with gastric epithelial neoplasms undergoing ESD from May to November 2011 were reviewed. The median age was 63 （31 ± 84） years. All patients were followed up by endoscopy on the first and the third day after ESD. Results Of 67 lesions, 5 were located at eardia, 6 at gastric body, 3 at fundus, 35 at antrum, 16 at gastric angle, and 2 at residual stomach. The mean maximum diameter of the lesions was 3.73 ±1.24 （2.0 ± 7.0 ）em. There were no intraoperative complications. Post-ESD de- layed bleeding was detected by endoscopy in 6 （9.0%） patients, with 5 on the third day and 1 on the fourth day. Forrest grading showed 2 cases of ] b, and 4 of 11 b. All 6 cases were cured by endoscopy. The inci- dence of postoperative bleeding was far more than that evaluated based on the patients＇ clinical manifestations only. But therapeutic effect and safety were the same according to the follow-up results. Conclusion Incidence of post-ESD bleeding is high, but there are no symptoms or severe consequences, so a second endoscopy after gastric ESD may contribute little to the prevention of delayed bleeding. Key words: Endoscopic submueosal dissection; Postoperative complications; Postoperative hemorrhage

No.3リンパ節転移を伴った横行結腸癌胃浸潤の1例

No.3リンパ節転移を伴った横行結腸癌胃浸潤の1例

Retroperitoneal Fibrosis in a Patient with Gastric Cancer Manifested by Lower Extremity Edema and Hydrocele

Herein we report a 57-year-old man with lower extremity edema and swelling in the scrotum who was found to have a periaortic soft tissue mass and hydronephrosis by computed tomography. With the most plausible diagnosis of retroperitoneal fibrosis, corticosteroid therapy was initiated; however, it did not improve his symptoms. Upper gastroscopy performed on day 20 post admission showed ulcerative regions with an irregular border and fusion of thickened rugae at the gastric angle; the diagnosis of gastric adenocarcinoma was confirmed histologically. It is important to always be aware of unrecognized malignancies that are accompanied by retroperitoneal fibrosis.

A case of lymphomatoid gastropathy: An indolent CD56-positive atypical gastric lymphoid proliferation, mimicking aggressive NK/T cell lymphomas

Lymphomatoid gastropathy (LyGa) is a new evolving pathological entity that has been introduced recently. It is designated to describe CD56-positive atypical gastric lymphoid proliferation, mimicking NK/T cell lymphomas, that shows an indolent clinical course with spontaneous regression. We here present our experience with one new case diagnosed and treated in our hospital. An annual upper endoscopic check-up of a 50-year-old male with an unremarkable past history revealed a small reddish lesion on the posterior wall of the gastric angle. Endoscopic biopsy showed atypical cells of NK-cell lineage expressing CD56, CD16, CD3, perforin, and TIA-1, but not CD4, CD5, and CD8. Epstein–Barr virus encoded RNA was negative. The lesion regressed spontaneously after one month without treatment, but recurred two years later in a different site of the stomach with spontaneous regression again one month later. The recurrence of lymphomatoid gastropathy is very rare and should be diagnosed carefully to distinguish it from the aggressive lymphoma.

Neuroendocrine Tumor of Unknown Primary Accompanied with Stomach Adenocarcinoma

A 67 year old male at a regular checkup underwent esophagogastroduodenoscopy. On performing esophagogastroduodenoscopy, a lesion about 1.2 cm depressed was noted at the gastric angle. The pathology of the biopsy specimen revealed a well-differentiated adenocarcinoma. On performing an abdominal computed tomography (CT) scan & positron emission tomography-computed tomography (PET-CT) scan, no definite evidence of gastric wall thickening or mass lesion was found. However, lymph node enlargement was found in the left gastric and prepancreatic spaces. This patient underwent laparoscopic assisted distal gastrectomy and D2 lymph node dissection. On final examination, it was found out that the tumor had invaded the mucosal layer. The lymph node was a metastasized large cell neuroendocrine carcinoma with an unknown primary site. The patient refused chemotherapy. He opted to undergo a close follow-up. At the postoperative month 27, he had a focal hypermetabolic lesion in the left lobe of the liver that suggested metastasis on PET-CT scan. He refused to undergo an operation. He underwent a radiofrequency ablation.

Diagnostic value of porphobilin staining of gastric mucus for primary pathological duodenogastric reflux

Objective To study the diagnostic value of porphobilin staining of gastric mucus for pfimalt pathologic duodenogastrie reflux （DCR）. Methods A total of 58 DCR patients diagnosed from Janualy, 2007 to April, 2008 were recruited to the study as DGR group, and 21 healthy volunteers as control. All subjects underwent 24-hour intragastric bilimbin monitor and gastroscopy. Bilirubin absorption value of 0. 25 and median reflux time of 23.60% were taken as thresholds to differentiate low reflux group （ reflux time 〈23.60% ） and high reflux group （ reflux time≥23.60% ）. Porphobilin staining of gastric mucosa was quantitatively analyzed. Results Deposition of porphobilin in mucosa of gastric antrum, gastric angle and gastric body in primary pathologi DGR group was significantly higher than those in healthy group （P 〈 0. 05 ）. The occurrence of atrophic and intestinal metaplasia of gastric antrum in high reflux group was significantly higher than that of low reflux group （ P 〈 0. 05 ）. Deposition of porphobilin in mueosa of gastric antrum, gastric angle and gastric body in high reflux group was significantly higher than that of low reflux group （ P 〈 0. 05 ）. The New Sydney system pathological scores of gastric antrum and angle of high reflux group was higher than that of low reflux group （P 〈 0. 05 ）. The deposition uf porphobilin in mueosa of gastric antrum and gastric angle was positively correlated with New Sydney system pathological seores in primary pathological DC, R group （ r = 0. 59, P = 0. 041 and r = 0. 73, P = 0. 038）. Conclusion Porphobilin staining of mucosa in gastric antrum can reflect the severity of bile reflux, and is positively correlated with the extent of gastric mucosal lesion, which may be helpful in diagnosis of primary pathological DGR. Key words: Duodenogastric reflux; Gastric mucosa; Porphobilin staining

Three Cases of Synchronous Laparoscopic Resection for Gastric and Colonic Cancer

Case 1 was an 84-year-old female who suffered from a superficial elevated lesion within depressed area (0 IIc+IIa) from the lesser curvature to the posterior wall at the middle corpus of the stomach and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. Case 2 was a 70-year-old male who suffered from a superficial depressed lesion (0 IIc) at the lesser curvature of the gastric angle and a superficial elevated lesion (0 IIa) at the cecum. Case 3 was a 58-year-old male who suffered from a superficial depressed lesion (0 IIc) from the lesser curvature to the posterior wall at the middle corpus of the stomach, and an elevated lesion (type 1) and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. In 3 cases, we first inserted 5 or 6 trocars and performed laparoscopic distal gastrectomy with groups 1 and 2 lymph node dissection according to the Japanese Classification of Gastric Carcinoma. Subsequently, in case 1, 1 additional port was inserted at the right lower quadrant for sigmoidectomy; in case 2, two trocars were added for ileocecal resection; and in case 3, one additional port was inserted at the median hypogastric region for sigmoidectomy. In cases 1 and 2, Billroth II reconstruction was performed using a laparoscopic linear stapling device (endo-GIA) and, in case 3, Roux-en-Y reconstruction was performed using endo-GIA, after distal gastrectomy. The double stapling technique using a conventional circular stapling device was performed after pulling out the specimen from the paraumbilical port after colectomy in case 1, whereas an end-to-end triangular suture using endo-GIA was used extracorporeally through the paraumbilical port in case 2 and the median hypogastric port in case 3. The operative durations of cases 1, 2, and 3 were 315, 340, and 495 minutes and the amounts of blood loss were 80, 300, and 440 mL, respectively. Except for the need to retain the drain until the tenth postoperative day because of serous discharge in case 1, no postoperative complications occurred. The postoperative commencement of oral feeding was on the fifth day in case 1 and on the third day in cases 2 and 3. All cases made a quick recovery and they were discharged from hospital on the nineteenth, thirteenth, and tenth day after operation, respectively. Double cancer patients with gastric and colonic carcinomas were thought to be very suitable for laparoscopic surgery because by avoiding a total median skin incision, there is less wound pain and quicker postoperation recovery.

The clinical pathology characteristic of 42 example early time stomach cancer

Objective To observe early gastric endoscopy, clinical and pathological features of the pathological diagnosis. Methods 42 cases of early gastric cancer of clinical, endoscopic and pathological features was observed, C-erbB2, P53, Ki-67 expression were detected by immunohistochemical sp method. Results The results of early gastric cancer had no specific, mainly abdominal pain and bloating discomfort, some weight loss loss of appetite, vomiting blood in the stool, etc. , endoscopy showed erosive flat major, 23 cases (54. 8% )protruded in 17 cases (40. 5% ), lesions up to 29 cases of gastric area, gastric angle in 5 cases, 6 cases of gastric body and gastric cardia in 2 patients. Organization type: tubular adenocarcinoma, 24 cases,2 cases of mucinous adenocarcinoma, signet ring cell carcinoma in 7 cases, 9 cases of poorly differentiated adenocarcinoma, 15 cases associated with intestinal metaplasia, dysplasia in 14 cases. Mucosal carcinoma in 26 patients, submucosa in 16 cases, 6 cases with lymph node metastasis. C-erbB-2 expression accounted for 16. 7%(7/42) , Ki-67 expression accounted for 38. 1% (16/42), P53 expression accounted for 30. 9% (13/42).Conclusion The clinical manifestations of early gastric cancer is hidden, non-specific, not enough to cause attention to patients and clinicians. High risk of gastric cancer patients with gastroscopy active on a regular basis to improve the detection rate of early gastric cancer is the key to the early diagnosis of gastric cancer. C-erbB-2 expression is related to lymph node metastasis. Factors of early gastric cancer is a multi-step interaction of multiple genes and more complex process. Key words: Clinical pathology; Early the stomach cancer; Gastrosscope; Immunohistochemical

Focus on small lesion of alpha-fetoprotein producing gastric cancer

Dear Editor: Alpha-fetoprotein (AFP) remains a clinically meaningful instrument for diagnosis of hepatocellular carcinoma (HCC). We meet a female patient with AFP-producing gastric cancer (AFP-GC) accompanied with gallbladder adenomyosis; she was misdiagnosed with gallbladder cancer in the beginning. A 50-year-old woman complained of abdominal distension and fatigue for 3 months. She underwent an ultrasonographic examination and was diagnosed with adenomyomatosis of the gallbladder. Also, she underwent a gastroscopy with biopsies and was diagnosed with ulcer of gastric cardia (0.7×0.5 cm) accompanied with Helicobacter pylori infection; so she accepted quadruple therapy. Her serum AFP level (43.8 ng/ml) was slightly higher than the reference value. As the AFP was positive, associated with adenomyomatosis of gallbladder, she came to our hospital for further diagnosis. Abdominal computerized tomography showed adenomyomatosis of the gallbladder. However, AFP level (74.3 ng/ml) was higher than the previous level. Based on the above results, she decided to accept laparoscopic cholecystectomy, and pathology confirmed adenomyomatosis of gallbladder. Unfortunately, after quadruple therapy and cholecystectomy, she still felt abdominal distension and fatigue. Gastroscopy was performed and showed that gastric angle ulcer did not heal, and pathology confirmed carcinoma of gastric cardia. Simultaneously, AFP level (96.4 ng/ml) was obviously higher than the previous two tests. She accepted gastrectomy surgery, and fortunately, there was no peripheral lymphnode malignant metastasis. After six courses of chemotherapy, AFP level (4.5 ng/ml) returned to normal. Alpha-fetoprotein (AFP) is a serum protein, which is synthesized by fetal liver, yolk sac cells, and fetal gastrointestinal cells. Actually, AFP is evaluated as it is one of most important serum marker for early stage HCC, clinically. AFP-GC has an aggressive behavior with the lymphatic system, is hematogenous, and metastasizes into the liver at an early stage. After cholecystectomy, if we did not follow up the AFP levels of the patient, she could be misdiagnosed or liver metastasis could have occurred when she came to hospital again. Due to poor prognosis of AFP-GC, clinicians need to pay more attention to the diagnosis. When we encountered patients with elevated AFP, we need to focus on AFP-GC except HCC.

Endoscopy and endoscopic ultrasonography for heterotopic pancreas in upper gastrointestinal tract

Objective To study the characteristics of heterotopic pancreas （HP） in upper gastrointestinal tract （UGIT） under endoscopy and endoscopic sonography （EUS）, and its endoscopic manage- ments. Methods Data of 67 patients with pathologically confirmed HP in our hospital from March 2004 to November 2009, including clinical and endoscopic manifestations and sequelae after endoscopic resection, were retrospectively studied. Results Heterotopic pancreas were most commonly found as a single lesion in gastric antrum （62/67, 92. 5% ） and in gastric angle and duodenum as well, which were characterized by protrusion, with intact mucous membrane and centrally umbilicated. Of the 67 patients, 59 underwent EUS before endoscopic resection. Findings were heterogeneous and mixed echogenic lesions with indistinct borders involving both the second and third layers of the gastrointestinal wall, sometimes even involving the first and fourth layers. Most lesions （n = 60） were removed by endoscopic mucosal resection （EMR） , with basal res- idues in 25 eases, in which fourth layer involvement was observed in 23 cases （92. 0% ）. Delayed bleeding occurred in 1 case at 3rd day after the procedure, and no other complications were observed. Complete re- moval was achieved in 8 cases （including one receiving EMR previously） with endoscopic submucosal dis- section （ESD） , and there was no such severe complications as perforation. Postoperative pathological exami- nations revealed that the consistent rate of preoperative diagnosis with EUS was 91.5% （54/59）. Conclu- sion Endoscopy combined with EUS is critical in diagnosis of HP in UGIT. EMR, especially with cap assistance, is the best method for those without involvement of muscularis propria, while ESD or endoscopic surveillance is a better alternative for those with 4th layer involvement. Key words: Pancreatic diseases ; Endoscopic uhrasonography ; EMR ; ESD

Rejuvenation of atrophic gastritis in the elderly

See article in J. Gastroenterol. Hepatol. 2010; 25: 544–547

Distal Cholangiocarcinoma with Gastric Metastasis Mimicking Early Gastric Cancer

We report an unusual case of distal cholangiocarcinoma with gastric metastasis mimicking early gastric cancer. A 67-year-old woman presented with a 4-month history of abdominal pain after eating. Computed tomography showed a malignant tumor of the common bile duct located just above the intrapancreatic segment, and endoscopy revealed a 2-cm, flat, elevated lesion with convergence of the surrounding folds, situated at the gastric angle. Based on the endoscopic biopsy results, an adenocarcinoma, thought to be an early gastric cancer, was diagnosed. The patient underwent Whipples's operation. Histopathological findings showed that the adenocarcinomatous tissue was clearly demarcated and infiltrated the gastric mucosa and submucosa, leaving the gastric superficial mucosa intact. Both tumors showed similar pathological features and were positive for cytokeratin (CK)-19 and CK-7. These finding suggest distal cholangiocarcinoma with gastric metastasis.

Useful DNA typing using AmpFlSTR ® Identifiler ® Kit for formaldehyde-fixed paraffin-embedded (FFPE) tissues in early gastric cancer patient with lymph node metastasis

After distal gastrectomy in a patient with early gastric cancer, 27 regional lymph nodes around the stomach were evaluated for the existence of metastasis. There was a 0IIa+IIc type tumor 2.0 x1.5 cm in size in the gastric angle of the lesser curvature according to the Japanese Classification of Gastric Carcinoma (JCGC). Histologically, the lesion extended no deeper than the muscularis mucosae. The cancer stage was so early that no metastasis was expected to occur but a lymph node with metastasis was found in one lymph node along the common anterior hepatic artery (station No.8a). This histological type was a little different from that of a primary tumor. The doctor began to suspect that the lymph node with metastasis might have been from another patient by mistake. Therefore, DNA typing using the AmpFlSTR Identifiler kit was performed in formaldehyde-fixed paraffin-embedded (FFPE) tissues: 2 parts of gastric mucosa without cancer, one part of gastric mucosa with cancer, 4 lymph nodes without metastasis, and the lymph node station No.8a with metastasis. STR typing was successful in 6~14 STR loci and amelogenin gene, and the detected STR type was the same in all samples. Compared with the STR type using DNA from the patient's blood, the lymph node station No.8a was from the same patient. The lymph node with metastasis turned out to be not from another patient. Therefore, we suggest that DNA typing using the AmpFlSTR Identifiler Kit for FFPE samples is useful in such clinical cases.

SUPERFICIALLY ELEVATED‐TYPE SERRATED HYPERPLASTIC LESION OF THE STOMACH WITH MINUTE ADENOCARCINOMA

We report a case of gastric serrated hyperplastic lesion with minute adenocarcinoma. A 65-year-old Japanese man underwent endoscopic submucosal dissection to the superficially elevated-type (0-IIa) lesion located at the lesser curvature of the gastric angle. Histological observation revealed hyperplastic change of foveolar epithelium with serrated glandular structure as well as a minute tubular adenocarcinoma component. Immunohistochemically, the lesion demonstrated gastrointestinal, predominantly gastric, phenotype (MUC5AC++, MUC6+, MUC2+, CD10-). Positive p53 immunoreactivity was detected in the carcinoma component of the lesion with a point mutation (G877T; R209I) of the gene and microsatellite instability of the BAT-RII locus; however, immunoreactivity of the mismatch repair gene product hMLH1 was well preserved in the cancer as well as in the hyperplastic lesion. The hyperplastic lesion with serrated glandular pattern would be a precancerous lesion of adenocarcinoma of the stomach.

Angleplasty in gastric tube reconstruction after esophagectomy

Anastomotic leakage after radical esophagectomy is mostly caused by the hypoxia and high tension at the esophagogastric anastomotic site. Here, we introduce a new surgical technique, 'Angleplasty,' to enable the tensionless anastomosis at a highly oxygenic site of gastric conduit. In short, the seromuscular layer is cut for a perpendicular direction against a lesser curvature at a gastric angle and the gastric wall is carefully divided between the muscular and submucosal layers for longitudinal direction for 4-5 cm in length. Then, the wound is closed with seromuscular sutures for longitudinal direction. With this maneuver, the lesser curvature of the gastric roll is significantly elongated and the anastomosis site of the gastric conduit can be moved more distal on the greater curvature of the stomach where it is expected to receive more oxygen supply. This technique takes only several minutes, but provides highly favorable conditions for esophagogastric anastomosis and thus is clinically useful to reduce the risk of anastomotic leakage after esophagectomy.

Endoscopic analysis of ulcer at the gastric angle in Yan’an area: a report of 208 cases

Endoscopic analysis of ulcer at the gastric angle in Yan’an area: a report of 208 cases

Two rare cases of node-positive differentiated gastric cancer despite their infiltration to sm1, their small size, and lack of lymphatic invasion into the submucosal layer

Early gastric cancer without lymph node metastasis has been reported after the analysis of many cases, and a consensus has been reached about this condition. We report two cases of node-positive differentiated sm1 gastric cancer without lymphatic invasion into the submucosal layer. Case 1 was a 73-year-old man who underwent EMR for 0-IIc early gastric cancer (EGC) on the gastric angle, with a histological diagnosis of tub1. Pathological examination revealed a 0-IIc lesion that was 12 mm in size and sm1 in invasion depth without lymphatic-vascular invasion. However, the infiltration in the submucosal layer was relatively wide. The patient subsequently underwent distal gastrectomy with D2 lymph node dissection. Pathological examination revealed level 2 lymph node metastasis. Case 2 was a 62-year-old woman who underwent ER for a 0-I+IIc-type EGC on the greater curvature of the antrum, with a histological diagnosis of tub1. Pathological examination revealed a 0-I+IIc-type lesion that was 15 mm in size and sm1 in depth. Lymphatic invasions in the muscularis mucosa were found, but none were seen in the submucosal layer. Two years later, follow-up computed tomography (CT) showed a lymph node swelling in the infrapyloric region. Distal gastrectomy with D2 dissection was then performed, and pathological examination revealed level 1 lymph node metastasis. Although the lesions in both patients satisfied the criteria of Gotoda et al. for minimal risk of nodal involvement, lymph node metastasis was observed in these patients. Curative surgery with lymph node dissection is thus required in patients with wide infiltration of the submucosal layer or lymphatic invasion in the muscularis mucosa.

Localization of the Focal Gastric Lesion on Abdominal MDCT: The Importance of the Right and Left Gastric Arteries and Gastroepiploic Arteries

Purpose: To identify the importance of the right and left gastric arteries, as well as the gastroepiploic arteries, for the localization of focal gastric lesions from axial images of abdominal MDCTs. Materials and Methods: Axial image interpretations from abdominal MDCTs were performed to diagnose the location of focal gastric lesions. The interpretations were performed on 72 patients retrospectively by two radiologists who were blinded from the endoscopic and surgical results by consensus at two different time intervals. No information was provided to the observers, who were asked to determine the precise location of the focal gastric lesion, for the first interpretation. Next, the observers were informed that the right and left gastric arteries, as well as the gastroepiploic arteries, are on the lesser and greater curvature, respectively. Moreover, the gastric angle is on the course of the right and left gastric arteries. One week later, the second interpretation was performed using the same subjects and methods as the first interpretation. The diagnostic accuracy of each interpretation was comparatively evaluated. Results: The diagnostic accuracy of the first and second interpretations was 52.8% (38/72) and 98.6% (71/72), respectively (p

How Strong Construction Toy Magnets Are! A Gastro‐Gastro‐Duodenal Fistula Formation

Children like to play with many kinds of magnetic construction toys, and their size and shape make them easy to swallow. They can cause serious complications such as intestinal obstruction, perforation, and fistula formation when multiple magnets are ingested (1–3). Ingestion accidents can occur frequently in young children, especially those with developmental disabilities (1,3). We introduce an extremely unusual case involving the ingestion of multiple construction toy magnets that formed a gastro-gastro-duodenal fistula formation without bowel perforation. A 12-y-old boy with autism presented to the emergency department after vomiting for 4 d. On clinical examination he was afebrile and had no abdominal distension or peritoneal irritation. An abdominal x-ray demonstrated that the multiple radiopaque bar objects arranged in multiple tandem structures were found in the stomach (Fig. 1A). The exact time of the ingestion could not be ascertained because the ingestion was not witnessed and the patient was nonverbal. On showing the x-ray to his parents, they recognized the foreign bodies as parts of a magnetic educational construction toy, and they recalled that 22 rods had disappeared from the toy box. An esophagogastroduodenoscopy (EGD) was performed under general anesthesia. After repeated EGD with a polypectomy snare, 17 of 22 rods were removed from the stomach. Then it was noticed that 1 rod was deeply embedded in the fundic wall of the gastric angle (Fig. 1B), and its distal end was found in the antral side across the gastric angle. In the antrum this embedded rod was being attracted by another magnetic rod, which had passed through the prepyloric antral wall into the duodenum (Fig. 1C). Hence, these 2 connected magnets had caused the formation of a gastro-gastro-duodenal penetration. This tandem complex of 2 magnets was connected with another tandem complex of 3 pieces, forming a “T” shape, in the duodenal bulb (Fig. 1C). A surgery consult was obtained for suspected bowel perforation despite the lack of free air on the x-ray. An operation or EGD removal was scheduled after a further evaluation of the risk of perforation or bleeding. However, an abdominal x-ray taken the next day revealed that the remaining 5 rods were located in the descending colon (Fig. 1D); there was no sign of peritoneal irritation on physical examination and no sign of perforation by radiographic and ultrasonographic evaluations. The patient was treated with a proton pump inhibitor for 14 d, and a follow-up EGD showed that the fistulas in the stomach and duodenum had completely healed.FIG. 1: A, An assemblage of multiple radiopaque bar objects in the stomach. B, A magnetic rod is deeply embedded in the fundic wall, and (C) this protrudes across the gastric angle and attracts another rod in the antrum. This antral rod also penetrates the prepyloric antral wall into the duodenum. D, Five magnetic rods in the descending colon. F indicates fundic wall; A, antral wall; P, pyloric ring.In the present case, the pressure exerted on the respective walls of the bowel because of magnetic attraction and the pressure of gastroduodenal peristalsis probably led to local pressure necrosis and perforation with attracted rods, which dramatically demonstrates the strength of construction toy magnets. After 17 pieces had been endoscopically removed, the remaining magnets appeared to lose the ability to resist gastroduodenal peristalsis, and were probably dislodged from their embedded positions in gastric and duodenal walls. Fortunately, the lesions that had developed in the stomach and duodenum healed without perforation or bleeding. We suggest that warning labels concerning the unique dangers of ingesting magnetic toys be implemented on all packaging.

A case of gastric ulcer induced by cytomegarovirus infection during maintenance therapy with prednisolone and azathioprine for autoimmune hepatitis

A patients, 51 years old female had been treated with prednisolone (7.5mg/day) and azathioprin (50mg/day) for autoimmune hepatitis. She had been also treated for duodenal ulcer with famotidine. High grade fever continued for 20 days without the evidence of bacterial infection and blood examination showed high titer of cytomegarovirus (CMV) IgG antibody and CMV antigenemia. After the discontinuation of azathioprine, her body temperature become normal and cytomegarovirus antigenemia disappeared. Endoscopic examination revealed an ulcer at the gastric angle, and gastric erosions on the fornix and the greater curvature. CMV inclusion bodies were recognized in the biopsies from the ulcer edge. CMV was not detected from former gastric biopsy samples which were taken for the examination of Helicobactor pylori. CMV disappeared in biopsy samples with the improvement of gastric ulcer. The clinical course and histopathological findings suggested gastric ulcer was induced by CMV infection.