Linear Ulcers Research Articles

A GASTROCOLIC FISTULA DUE TO GASTRIC ULCER-A CASE REPORT-

A 50-year-old male was admitted to the hospital because of diarrhea, vomiting and body weight loss. Upper GI examination revealed protrusion at the posterior wall of the gastric angle, and the barium leaked from this to the colon. Endoscopic examination showed protruded colonic mucosa, and a fiberscope could be inserted to the colon. Flow of barium from the transverse colon into the stomach was observed by barium enema. It was concluded that gastrocolic fistula had been made by penetration of gastric ulcer. The patient was operated on. During surgery the shortened mesocolon transversum and dilated stomach were observed. The tranverse colon adhered to the posterior wall of the stomach. Billroth I partial gastrectomy and partial resection of the transverse colon were done. The resected specimen showed an open ulcer in the anterior wall, the protruded colonic mucosa of posterior wall and a linear ulcer scar between the both. Most of gastrocolic fistulas have been reported as a complication of malignant tumor or stomal ulcer after gastrojejunostomy. The clinical cases due to gastric ulcer are rarely encountered.

Gastric motility and ischemic changes in occurrence of linear ulcer formation induced by restraint-water immersion stress in rat

The pathogenesis of linear ulceration induced by restraint water-immersion (RWI) was investigated in view of gastric motility and early ischemic changes. After three hours of restraint-water immersion stress, the cross-sectioned gastric body was prepared for light microscopy. Most lesions (90.8%) were present in the mucosal folds projecting toward the cavity. Wedge-shaped degeneration in the crest of the folds was recognized as an ischemic lesion followed by hemorrhagic ulceration. Compressed arterioles were frequently encountered in the muscularis mucosae and circular muscle. Generally, mucosal folds appear merely with the reduction of gastric content, and run along with the elevation of the circular muscle as an anatomical structure, becoming tall and steep after RWI. Marked enhancement of contraction, observed with a strain gauge force transducer, was induced by RWI. This enhancement was suppressed by papaverine HCl pretreatment in accordance with suppression of the fold-related mucosal lesion even after 150 mM HCl perfusion into the stomach. In conclusion, gastric motility appears to play an important role in the pathogenesis of linear ulceration by causing ischemic change along the folds.

Severe Reflux Esophagitis After Vertical Banded Gastroplasty for Treatment of Morbid Obesity

Herein we describe two patients with medically refractory, severe reflux esophagitis after vertical banded gastroplasty for morbid obesity. Neither patient had symptoms of reflux preoperatively. Both patients underwent conversion to a vertical Roux-en-Y gastric bypass, an operation that prevents acid and peptic reflux and maintains a weight-reducing anatomy. Symptoms of gastroesophageal reflux are common (they occur in approximately 38% of patients) after vertical banded gastroplasty has been performed. Patients with unusually severe reflux may require operative management.

An endoscopic study of antibiotic-associated hemorrhagic colitis.

Colonoscopy was performed on acute stage within 72 hours from onset in 48 patients with antibiotic-associated hemorrhagic colitis (AAHC). From our observations we have developed a new endoscopic classification of AAHC and investigated the incidence of each finding in further detail. We have classified in principle the endoscopic findings of the 48 subjects into two groups: major and minor ones respectively. Category of major findings were: 1) diffuse mucosal hemorrhage (100%); 2) spotty mucosal hemorrhage (100%), and 3) linear mucosal hemorrhage (22.9%), while minor findings were: 1) irregular ulcers in 10.4%; 2) aphthoid ulcers in 6.3%, and 3) linear erosions or ulcers in 4%. Minor findings were ulcers or erosions present over the hemorrhagic mucosa associated with the moderate degree of inflammation. A histopathologic study of colon biopsy specimens from 24 patients with AAHC showed hemorrhage and inflammatory cell infiltration in the lamina propria mucosae varying from mild to moderate in extent. It was concluded that AAHC was a colonic mucosal hemorrhagic disease caused by the destruction of mucosal vessels from unknown causes and in this disease mild to moderate inflammation was partially followed by ulceration over the edematous and hemorrhagic mucosa of the colon.

The Clinical Entity of Orofacial Crohn's Disease

The clinical features, treatment and outcome of 29 patients with oral Crohn's disease seen over a 6-year period have been reviewed. Findings on clinical examination included labial swelling (19 patients), buccal mucosal cobblestoning (11), linear ulceration (11), lumps (five), and mucosal tags (two). Eleven patients had multiple features. Eight patients developed symptoms within the first decade of life and nine patients had symptoms for more than 4 years before diagnosis; the mean age at diagnosis was 30 (range 6-78) years. Fourteen of these patients (48 per cent) have Crohn's disease elsewhere in the alimentary tract, and in nine patients the oral disease predated the development or detection of Crohn's disease at other sites. Eight patients (25 per cent) have required no specific therapy for their oral disease and 12 have been treated with systemic corticosteroids of whom three are steroid-dependent. No other pharmacological approach to treatment has been successful and elimination diets, tried by five patients, had no effect. Oral Crohn's disease has a characteristic naked-eye appearance, may be the first or only manifestation of Crohn's disease and usually improves with oral corticosteroid treatment.

Umbilical cord ulceration and intestinal atresia: A new association?

In three fetuses, congenital intestinal atresia was associated with linear ulcerations of the umbilical cord. In two cases, hemorrhage was seen from the cord ulcer. Both fetuses required emergency cesarean section for fetal distress and were born anemic. The third fetus was mildly hydropic, attributed to hemorrhage, and was stillborn. The mechanism of the association could not be determined. These cases suggest a risk of prenatal umbilical cord hemorrhage in infants with intestinal atresia.

Acute gastric mucosal injury induced by toxins from Tityus serrulatus scorpion venom: a novel experimental model in the rat

The effect of a partially purified fraction (T 1) and toxin γ purified from Tityus serrulatus scorpion venom, on gastric mucosa were investigated in anesthetized rats. The animals were injected i.v. with the T 1 fraction (37.5 μg/100g) or with saline and 60 min later were sacrificed and the stomachs resected. The gastric juice was measured and stereoscopic examination of the stomachs made. In animals injected with the T 1 fraction there was an increase in volume, acidity and pepsin output of rat stomach. The T 1 fraction also induced acute gastric injuries in the glandular mucosa, consisting of circular or linear ulcers, and punctiform lesions. Intravenous injection of 20 μg/100 g of a pure toxin obtained from Tityus serrulatus scorpion venom (toxin γ) also induced similar lesions in the rat stomach. Our data indicate that the injection of T 1 fraction or toxin γ are good models to induce acute gastric ulcers in a short period of time in anesthetized rats.

Necrotizing Duodenitis—A Stress-Associated Lesion?

We report three cases of stress ulceration exhibiting primarily mucosal abnormalities of the duodenum with duodenal ulceration and linear ulcerations on the duodenal folds which is unique in our experience. We hypothesize that vascular insufficiency during low flow states decreases the ability of mucosa to buffer back-diffused hydrogen ion, leading to mucosal injury and ulceration. The duodenal folds receive an end-arteriole supply and are thus affected before other areas of the duodenum. Given the degree of necrosis associated with these lesions on pathological examination, we have chosen the term necrotizing duodenitis to describe the lesions observed.

Colitis presenting with linear ulcer and redness with special referrence to comparison of ischemic and acte hemorrhagic colitis

Colitis presenting with linear ulcer and redness with special referrence to comparison of ischemic and acte hemorrhagic colitis

Radiation-induced esophageal cancer: A case report and a review of the literature

A 63 year old woman who had been irradiated for thyroid carcinoma at 36 years of age developed a cervico-esophageal stricture, the biopsy specimens from which revealed squamous cell carcinoma. Total esophagectomy was performed and a small linear ulcer was found in the resected specimen. Histological examination revealed moderately differentiated squamous cell carcinoma with severe fibrosis around the tumor, indicating radiation-induced cervical esophageal cancer. The characteristics of radiation-induced esophageal cancers described in the literature are reviewed in context of the present case.

Late Gastrointestinal Bleeding and Protein Loss after Distal Small-Bowel Resection in Infancy

Four children who underwent extensive small-bowel resection in infancy developed recurrent iron deficiency anemia due to gastrointestinal bleeding between 4 and 12 years later. The initial resections were required for multiple ileal atresia (n = 2) and gastroschisis (n = 2). Three patients have had melena and one had persistently guaiac-positive stools. Three patients had protein-losing enteropathy, and in one there was persistent hypoalbuminemia. Colonoscopy identified circumferential ulcerative lesions at the surgical anastomosis (n = 2) and at laparotomy another patient had well-defined linear ulcers close to the surgical anastomosis. Histology demonstrated focal ulceration with chronic inflammation, but did not show granulomata, crypt abscesses, or malignancy. Multiple imaging procedures and gastroduodenoscopy failed to identify an alternative bleeding source. Medical therapy including iron, antacids, sucralfate, H2 antagonists, and cholestyramine was ineffective. Two patients have undergone anastomotic resection. One experienced symptomatic recurrence 4 months after surgery. Repeat colonoscopy found ulceration at the new anastomosis with similar histology. The other patient remains asymptomatic 7 months postsurgery. Recurrent gastrointestinal hemorrhage due to anastomotic ulceration, of unknown etiology, appears to be a late complication of small-bowel resection in infancy.

Late Gastrointestinal Bleeding and Protein Loss after Distal Small‐Bowel Resection in Infancy

Four children who underwent extensive small‐bowel resection in infancy developed recurrent iron deficiency anemia due to gastrointestinal bleeding between 4 and 12 years later. The initial resections were required for multiple ileal atresia (n = 2) and gastroschisis (n = 2). Three patients have had melena and one had persistently guaiac‐positive stools. Three patients had protein‐losing enteropathy, and in one there was persistent hypoalbuminemia. Colonoscopy identified circumferential ulcerative lesions at the surgical anastomosis (n = 2) and at laparotomy another patient had well‐defined linear ulcers close to the surgical anatomosis. Histology demonstrated focal ulceration with chronic inflammation, but did not show granulomata, crypt abcesses, or malignancy. Multiple imaging procedures and gastroduodenoscopy failed to identify an alternative bleeding source. Medical therapy including iron, antacids, sucralfate, H2 antagonists, and cholestyramine was ineffective. Two patients have undergone anastomotic resection. One experienced symptomatic recurrence 4 months after surgery. Repeat colonoscopy found ulceration at the new anatomosis with similar histology. The other patient remains asymptomatic 7 months postsurgery. Recurrent gastrointestinal hemorrhage due to anastomotic ulceration, of unknown etiology, appears to be a late complication of small‐bowel resection in infancy.

Outcome of "indeterminant" colitis following ileal pouch-anal anastomosis.

To establish whether patients with indeterminant colitis (patients with ulcerative colitis whose surgical specimens also show features of Crohn's colitis) have an adverse outcome after ileal pouch-anal anastomosis (IPAA), the authors reviewed the pathologic reports and postoperative status of 514 consecutive patients who underwent IPAA for chronic ulcerative colitis (CUC). Twenty-five patients (5 percent) had features of indeterminant colitis (IC), including unusual distribution of inflammation, deep linear ulcers, neural proliferation, transmural inflammation, fissures, creeping fat, and retention of goblet-cell population. The clinical and functional outcome of these 25 IC patients was compared with that of the remaining 489 CUC patients. The mean follow-up was 38 +/- 18 months. No significant differences in complication rates, pouch function, incidence of "pouchitis," or requirement for pouch excision were detected in the two groups at follow-up. Although the authors are continuing to perform IPAA on patients with IC, a better definition of the IC patient and a more objective, prospective analysis of outcome of IC following IPAA is required before confident and specific treatment policies can be recommended.

Oesophageal symptoms, their causes, treatment, and prognosis in patients with the acquired immunodeficiency syndrome.

In a prospective study of 154 AIDS patients, 48 (31%) complained of pain on swallowing both liquids and solids and 32 (21%) of these also had dysphagia. While candidiasis was the most common cause of symptoms (26 patients), discrete ulceration of the oesophagus occurred in 12 instances in 10 patients (four cytomegalovirus, four herpes simplex virus, three aphthous ulcer, one peptic ulcer). One patient had a diffuse oesophagitis caused by Mycobacterium avium intracellulare. No cause was found for the oesophageal symptoms in four patients. Kaposi's sarcoma (KS) was found in seven patients associated with other pathology in four. All 26 patients with oesophageal candidiasis only, also had oral involvement. All the patients with herpes simplex virus (four) and aphthous ulcers (three) had obvious perioral involvement. Three of the four patients with cytomegalovirus ulceration had evidence of disease elsewhere (colon or retina). All patients with Kaposi's sarcoma lesions had skin and buccal cavity involvement. The cause of oesophageal disease was usually obvious at endoscopy. The appearance of candidiasis was typical and the various ulcerating lesions also had different macroscopic configurations. Cytomegalovirus infection produced deep linear ulcers in the distal oesophagus, herpes simplex oesophagitis is similar in appearance to the typical perioral lesions of fluid filled vesicles. Diagnostic radiology was not helpful in most patients. In nine of 17 patients with candidiasis, the barium swallow examination performed within 24 hours of presentation was normal. In only three of seven patients with oesophageal ulceration (three cytomegalovirus, two herpes simplex virus, one aphthous, one peptic) was there evidence of an abnormality. Treatment produces symptomatic relief. All patients with candidiasis responded to ketoconazole, the four with herpes simplex virus to acyclovir and one of three with aphthous ulceration had a dramatic response to thalidomide. The three patients with cytomegalovirus infection who were treated with foscarnet had a prolonged remission of symptoms. The overall prognosis of patients with oesophageal symptoms is poor, with an average survival time from a definitive diagnosis of five months (range one to 13).

A CASE OF JEJUNAL DIVERTICULOSIS WITH MASSIVE MELENA

A case of jejunal diverticulosis with massive melena, of which bleeding point was locally diagnosed by preoperative angiography, is reported. A 52-year-old male with the complaint of massive melena was admitted in pre-shock state. As anemia was not improved by conservative therapy and selective superior mesenteric angiogram revealed a bleeding lesion in the jejunum, emergency operation was performed. Two diverticula were recognized at the mesenteric border of the jejunum about 50cm and 130cm below the ligament of Treitz. Both of them were bilocular, and linear ulcers were found at their septums. A stump of artery was exposed in the ulcer of oral side diverticulum and the source of the bleeding was found macroscopically. Histopathologically a linear ulcer and ruptured artery at the bottom of the ulcer were shown and the additional discussion was made from a point of clinical surgery.

TEN-YEAR STATISTICS OF SURGICAL TREATMENT OF PEPTIC ULCERS AT OUR DEPARTMENT

Possible changes in surgical treatment of peptic ulcers at the Kobe University Hospital (First Dept. of Surgery) over the past ten years were explored, dividing the 10 years into the first (1978-1982) and second (1983-1987) periods. The number of hospitalized peptic ulcer cases and the number of surgically treated peptic ulcer cases fel by 50% from the first to the second period. The decrease was particularly marked in duodenal ulcer cases (in comparison with ulcers of the other sites) and intractable ulcer cases (in comparison with ulcers of the other features). The percentage of patients who underwent urgent operation was 37.3% in the first period, which fell to 28.6% in the second period. The number of surgically treated intractable ulcer cases showed a 69.2% reduction in the second period compared to the first period. However, the percentage of cases whose excised specimen was rated as representing giant ulcer, linear ulcer, or U1 IV was higher in the second period than in the first period. Stenosis was found in 7 cases in the first period and 3 cases in the second period. The percentage of hemorrhagic ulcer cases who received conservative treatment or pallilative operation became higher in the second period than in the first period, while the percentage of hemorrhagic ulcer cases who underwent urgent operation decreased from 65.2% in the first period to 33.3% in the second period. In hemorrhagic ulcer cases, the death rate during or after uregent operation rose from 28.7% (first period) to 40.0% (second period). Perforated ulcer was found in 7 cases in the first period and 1 case in the second period. Of these 8 cases, 4 died (3 in the first period and 1 in the second period). Death rate was particularly high in elderly patients who had no history of ulcer and in patients who received surgery 12 hours or more after perforation.

CHANGES IN THE PATTERN OF INTRACTABLE ULCERS FOLLOWING THE DEVELOPMENT OF CIMETIDINE, IN RELATON TO SURGERY

Patients with peptic ulcers admitted to the First Department of Surgery, Kobe University School of Medicine, during the past ten years were divided into a first half group and a second half group, corresponding to the development of cimetidine, and changes in the pattern of intractable ulcers were studied retrospectively.In the second half group, both the number of admissions and the number of operations decreased by 50%, but the rate of surgery, about 70%, was unchanged. In the second half, the rate of surgery for hemorrhage was reduced slightly, but the rate of surgery for intractability increased slightly.The backgrounds and morphological features of intractable ulcer patients were investigated, and the age, the rate of complications and gastric analysis were not different in the two groups but the percentage of women increased in the second half and the past history of ulcer dropped from 87% to 55%. Morphologically the rates of giant ulcers, 2 cm or larger, linear ulcers 3 cm or longer, and ulcers with deep UI IV increased, while multiple ulcers decreased from 57.5% to 25%.

Clinical and Radiological Study of Gastric Linear Ulcers, with Emphasis on Those in the Gastric Body and Cardiac Portion

1968年10月より1979年12月までの間に順天堂大学消化器内科で検査し, 胃切除を施行した線状潰瘍71例74病変の, 臨床的事項・検査所見・病理学的所見を検討した. 特に, 体部・噴門部の線状潰瘍30例32病変の, X線検査所見上の変形の解析を行った. 非綿状潰瘍切除例に比較すると, 線状潰瘍例の病悩期間は平均6.9年と長く, 切除理由には難治・再発, 吐・下血が多かった. 線状潰瘍例中でも, 5年以上の病悩期間のある症例の潰瘍は, 病悩期間3-6カ月の症例より潰瘍の長さが有意に長かった. 経過観察例では, 55例中13例 (23.6%) が無症状で潰瘍が悪化した. 同じく13例に症状の再燃があり, 12例に潰瘍の再燃を認めた. 経過検査は2-4カ月ごとに行うべきであろう. 癌合併・併存率は, 線状・非線状とも約24%であった. 二重造影による体部・噴門部の線状溝描出率は, 初回X線検査では75.0%, 術前精密検査では100%であった. 体部・噴門部線状潰瘍による胃変形の種類と強さは, 潰瘍と小弯との関係と長さにより異なる. 小弯と交わる線状潰瘍で長さ30-35mmでは, 小弯に軽微な変形が出没する. 35-45mmでは小弯の弱い変形が恒存する. 42mm以上で大弯への影響が現われ, 大弯変形が出没する. 45mm以上で小弯にU字型変形が恒存し, 病変の92.9%で大弯の弯入も恒存し, 全体変形としてB型を呈する. B型を呈する病変では, 潰瘍の長さと切除胃の横巾の比は0.33より大であった. 小弯と交わらない線状潰瘍では, 弯側から10mm以内では変形が強く恒存し, 10-20mmでは変形が動く. 変形を利用すると, 体部・噴門部線状潰瘍のX線正診率は術前で12.5%改善し, 見直しで96.9%である. 以上により, 内視鏡検査を超える正診率の改善をもたらした.

Multiple linear ulcers on the dorsum of the tongue in a patient with Waldenstrom’s macroglobulinemia

An unusual clinical presentation of an eosinophilic ulcer of the tongue has been described. This lesion is seen most often in the fourth to sixth decades of life and has been shown to have a strong predilection for males. The etiology is unknown although trauma has been implicated by several investigators. Because of the clinical resemblance of eosinophilic ulcer to carcinoma, biopsy examination is recommended. After the diagnosis is made, conservative management is most appropriate.

Severe Diarrhea in a Patient With AIDS

To the Editor.— The recent publication by Green et al1of two cases of acquired immunodeficiency syndrome (AIDS), in which the presenting features mimicked Crohn's disease, prompts us to report a similar case. Report of a Case.— A 46-year-old homosexual Frenchman, with multiple sexual partners, was admitted to the hospital because of diarrhea and fever. Stool examination revealedGardia lamblia, Endolimax nana, andPseudolimax butchilii, but noSalmonella, Shigella, and Campylobacter. Colonoscopy showed disseminated superficial linear or irregular ulcerations predominantly in the left colon. Pathological study of distal ileal and colonic biopsy specimens showed a mild inflammatory infiltration of the lamina propria by plasma cells, polymorphs and macrophages, rare signs of cryptitis, and colonic erosions. Neither ileal villous atrophy nor pathogens were observed. (A basophil body at the basal area of an enterocyte could have been a Coccidia, ofIsospora bellitype, but this finding was not confirmed by