Stricture Lesions Research Articles

Hepatocellular carcinoma and synchronous liver metastases from colorectal cancer in cirrhosis: A case report

A 68-year-old Caucasian man with hepatitis C virus-related cirrhosis was admitted to our Unit in February 2010 for a diagnostic evaluation of three centimetric hypoechoic focal liver lesions detected by regular surveillance ultrasound. The subsequent computer tomography (CT) led to a diagnosis of unifocal hepatocellular carcinoma (HCC) in VI hepatic segment, defined the other two nodules in the VI and VII segment as suspected metastases, and showed a luminal narrowing with marked segmental circumferential thickening of the hepatic flexure of the colon. Colonoscopy detected an ulcerated, bleeding and stricturing lesion at the hepatic flexure, which was subsequently defined as adenocarcinoma with a moderate degree of differentiation at histological examination. Finally, ultrasound-guided liver biopsy of the three focal liver lesions confirmed the diagnosis of HCC for the nodule in the VI segment, and characterized the other two lesions as metastases from colorectal cancer. The patient underwent laparotomic right hemicolectomy with removal of thirty-nine regional lymph nodes (three of them tested positive for metastasis at histological examination), and simultaneous laparotomic radio-frequency ablation of both nodule of HCC and metastases. The option of adjuvant chemotherapy was excluded because of the post-surgical onset of ascites. Abdomen CT and positron emission tomography/CT scans performed after 1, 6 and 12 mo highlighted a complete response to treatments without any radiotracer accumulation. After 18 mo, the patient died due to progressive liver failure. Our experience emphasizes the potential coexistence of two different neoplasms in a cirrhotic liver and the complexity in the proper diagnosis and management of the two tumours.

The role of adipose tissue-associated macrophages and T lymphocytes in the pathogenesis of inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders of the gastrointestinal tract that affect more than 3 million people worldwide, but the pathological etiology is still unknown. The overall purpose of our investigations was to elucidate the possibility of pathological causes of IBD, and therefore, we determined the difference of inflammatory cytokine profiles in adipose tissue macrophages (ATMs) and T lymphocytes (ATTs) obtained near active lesions of IBD; investigated whether the alteration in ATM activation induces genes involved in collagen formation; and evaluated the effects of fatty acid oxidation inhibitors on factors involved in inflammation and collagen production by ATMs in IBD. Adipose tissues (ATs) were collected near active lesions and also at the margin of resected segments of the bowel from IBD patients with ulcerative colitis (UC) and CD (n=14/group). Normal appearing ATs from control subjects (n=14) who had colon resection for adenocarcinoma were collected as far away from the cancer lesion as possible to rule out possible changes. Compared with inactive disease lesions, ATMs and ATTs from active lesions released more IL-6, IL-4 and IL-13. Treatments of cytokine IL-4 and/or IL-13 to ATMs reduced iNOS expression but increased Arg-I expression which were exacerbated when treated with T cell- and adipocyte-conditioned medium. However, fatty acid oxidation inhibitors prevented the effects of cytokines IL-4 and/or IL-13 on iNOS and Arg-I expressions. This study was the first to show the effect of IL-4 and IL-13 on collagen formation, through iNOS and Arg-I expressions, that was exacerbated in a condition that mimics in vivo condition of active lesions. Moreover, our study was the first to provide potential benefits of fatty acid oxidation inhibitors to ATMs on preventing collagen formation; thus, providing therapeutic implications for individuals with intestinal fibrosis and stricture lesions, although future study should be guaranteed to elucidate the underlying mechanisms.

Imaging of the Colon in Inflammatory Bowel Disease: Ready for Prime Time?

Endoscopy is currently considered the reference standard for the evaluation of disease activity and severity in patients with inflammatory bowel disease (IBD). However, information provided by endoscopy is limited to the mucosal surface and cannot always be complete. Cross-sectional imaging techniques are gaining acceptance for the assessment of patients with Crohn's disease (CD) and ulcerative colitis (UC). Overall diagnostic accuracy of ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of colonic lesions in patients with IBD is high. The main limitation of US is its high dependence on expertise of the examiner and the anatomic location of lesions, and its main strengths are wide availability safety and low cost. CT is highly accurate for the evaluation of patients with IBD, but due to safety issues related to radiation exposure this technique should be reserved for urgent situations in which US is not diagnostic. Technological advances in the area of MRI have allowed optimization for the assessment of patients with IBD, mainly CD. Available evidence suggests that magnetic resonance colonography (MRC) has a high diagnostic accuracy for the detection of disease activity, location, severity, and complications, particularly for penetrating and stricturing lesions, characteristic of CD. MRC can provide a valuable guidance for performing medical and surgical treatment with maximized efficacy and safety. Overall, MRI findings accurately reflect disease activity and provide reliable information for decision-making and patient care optimization.

Sa1846 Sequential T2 Relaxometry as a Non-Invasive Assessment of Transmural Inflammation in a Murine Model of Chronically Relapsing Colitis

Background Anti-TNF therapy induces mucosal healing in patients with Crohn's disease, but the effects on transmural inflammation, stenosis and complications are largely unknown. MRI offers excellent imaging of transmural and peri-visceral lesions in Crohn's disease. Objective To assess the evolution of small bowel disease activity and complications in Crohn's disease patients treated with anti-TNF agents using serial MRI scans. Methods We performed a retrospective study of patients with Crohn's disease who had undergone serial MRI scans (T1-weighted preand post-contrast and T2-weighted sequences) while receiving anti-TNF treatment (infliximab or adalimumab). Patients were grouped as clinical responders or nonresponders based on a review of medical records. MRI scoring was performed blinded to clinical, laboratory and endoscopic data. Stricturing lesions were evaluated using simplified scoring systems of inflammation (Steward et al.) and stenosis (Fornasa et al.). Inflammation was scored using mural thickness, contrast enhancement, pattern of enhancement, mural and perimural T2 signal. At the level of stenosis, T2 signal intensity, post-contrast T1 enhancement and prestenotic dilatation was quantified. Complications were scored evaluating penetrating lesions, abscesses and/or fistulas. Results Twenty-one consecutive patients were studied (71% female) with a median age of 33 years (range 19-58 years), the median disease duration was 12 years (range 3-35 years) and the median time between initial and first follow-up MRI was 110 weeks (range 14-299 weeks). Forty-two small bowel MRI scans were evaluated in 13 clinical non-responders and 8 responders. In all patients, median inflammation scores decrease from 10 (range 6-15) on initial MRI, to 8 (range 1-13) on follow up MRI (p=0.168). In the responder group, 7/8 (86%) of the patients had reduced inflammation on follow-up MRI during anti-TNF treatment (p=0.0571). In this group the first MRI detected complicated disease in 2/8 (25%) of the patients which resolved at followup MRI. Severity of stenosis was significantly reduced between serial MRI scans (p=0.0148). In the non-responder group only 23% showed decreased inflammatory scores between serial MRI scans (non-significant). 3/13 patients had stricturing and penetrating lesions which was unchanged during the disease course as indicated by serial MRI scans. No change was seen in severity of stenosis. Conclusion A reduction in both small bowel inflammation and inflammatory stenosis on serial MRI scans correlates with clinical responses to anti-TNF treatment in Crohn's disease. Hence, anti-TNF antibodies not only produce mucosal, but also transmural healing, as well as reduction in stenosis. MRI can be used as a complementary approach to measure transmural healing in order to improve the clinical management in Crohn's disease patients.

Su1370 Prevalence of Pancreatobiliary Malignancy in Patients Presenting With Obstructive Jaundice and Biliary Stricture or Mass Lesion on CT/MRI Scans and Evaluation of EUS-FNA in Their Management

Su1370 Prevalence of Pancreatobiliary Malignancy in Patients Presenting With Obstructive Jaundice and Biliary Stricture or Mass Lesion on CT/MRI Scans and Evaluation of EUS-FNA in Their Management

Caustic esophagitis in two siblings:Munchausen syndrome by proxy

Background and aim: Recurrent corrosive esophagitis is a rare condition among children and may be due to child abuse. The Munchausen Syndrome by Proxy (MSBP) is special form of child abuse with variety of symptoms. It has challenging diagnostic process and needs a high clinical suspicion. When it is identified by physician, institutional child protection team must involve into the management of the case. Case report: We present the two siblings with recurrent esopahigitis. One of them died due to severe gastrointestinal bleeding. Other had severe esophageal stricture and oral lesions. Their mother fed both of them with caustic material at various time intervals. Both babies were treated in our hospital several times with the admission of their mother. Conclusion: This is the probably the first case report of Munchausen Syndrome by Proxy (MSBP) with caustic material ingestion of two siblings. Determining the exact cause of such cases is very difficult and physician must suspect child abuse in this situation.

Phenotypic change and accumulation of smooth muscle cells in strictures in Crohn’s disease: relevance to local angiotensin II system

Intestinal stricture lesions in Crohn's disease are characterized as submucosal fibromuscular accumulation. There has been a controversy about whether the fibrogenic cells in stricture lesions in Crohn's disease originate from a smooth muscle cell or a fibroblast lineage. In the present study, we aimed to elucidate: (1) the origin of the fibrogenic cells in stricture lesions; and (2) the roles of the local angiotensin II system, including mast cell chymase, in stricture formation. Methanol-Carnoy's-fixed colonic tissues, obtained from the stricture sites of 18 patients with Crohn's disease, were analyzed by immunostaining for vimentin, smooth muscle actin (1A4 and CGA7), angiotensin II type-1 receptor, angiotensin II-converting enzyme, and mast cell tryptase and chymase. As controls, unaffected (normal) portions of 11 colonic tumor specimens were also investigated. Submucosal fibromuscular accumulation was seen in every stricture lesion. The majority of mesenchymal cells accumulated in the stricture lesions were moderately differentiated intestinal smooth muscle cells [vimentin(+), 1A4(+), and CGA7(+)]. Moreover, occasional intestinal smooth muscle cells in the muscular layers, adjacent to the site of the submucosal fibromuscular response, showed distinct positivity for vimentin, indicating phenotypic modulation toward an immature, or dedifferentiated state. These smooth muscle cells accumulated in the stricture lesions were positive for angiotensin II type-1 receptor. Abundant chymase-positive mast cells were distributed in these lesions. These results suggest that the proliferation and migration of moderately differentiated intestinal smooth muscle cells from the muscular layers are the major pathological mechanisms in stricture formation in Crohn's disease, and the angiotensin II system is involved in this process.

PTH-001 “Prophylactic” placement of self-expandable metal stent in colorectal cancer prior to obstruction: is this of any value?

<h3>Introduction</h3> Colorectal cancer (CRC) is one of the most prevalent malignancies in the world and is the second most common cancer cause of death in the UK. Colonic obstruction is usually a late presentation of CRC and is more characteristic of an advanced and incurable lesion. 40% of CRC present as a surgical emergency with either obstruction or perforation. Emergency presentation is associated with a poorer outcome. Colonic stents are a routine part of management of CRC, being used for palliation and as a “bridge to surgery“ for patients presenting with bowel obstruction thus minimising morbidity and mortality. It can be argued that the tighter the CRC stricture the more difficult the process of placement of colonic stent. For this reason, it has been suggested by some that “prophylactic” stent placement in the palliation of CRC patients who have stricturing but not yet obstruction may be an appropriate step in management. This may reduce failure rate of stent placement during obstruction and thus prevent emergency surgical decompression. <h3>Methods</h3> To aim was to assess the number of patients presenting with a stricturing CRC tumour that subsequently obstructs. This was a retrospective analysis was performed on consecutive patients with CRC during 2006–2007, presenting with a stricture as identified on colonoscopy and deemed for palliation following a multidisciplinary assessment. An analysis of whether or not these patients subsequently developed obstruction was performed. Data were obtained from the Unisoft endoscopy software and a database of patients with CRC. <h3>Results</h3> 17 patients (9 males, mean age of 78 (52 to 96 years)), were found to have a malignant stricturing lesion at colonoscopy and had palliative treatment. Four patients presented with obstruction as part of their symptom complex and underwent successful colonic stent placement. One patient underwent a defunctioning stoma operation for bowel obstruction 1 month following diagnosis. In the 12 cases (70%) that were not stented, none re-presented with bowel obstruction. 16 /17 patients died from causes unrelated to bowel obstruction, with all dying within 18 months due to disease progression and chemotherapy related complications. One patient who initially presented with obstructive symptoms and was subsequently stented is still alive to date. <h3>Conclusion</h3> The majority (70%) of CRC presenting with stricturing at colonoscopy do not require treatment for obstruction (ie, stenting or operation) and seem to die from disease progression prior to occurrence of clinical obstruction. “Prophylactic” stent placement to prevent obstruction, when CRC presents with a stricturing lesion is not suggested by this study.

Combined Removal of Stones with Resection of Concurrent Pathologic Ureter May Be a Preferred Treatment for Impacted Ureteral Stones with Stricture Lesions

We investigated ureteral lesions associated with impacted stones and compared the long-term outcomes after ureteroscopic lithotripsy (URSL) with a holmium laser with open ureterolithotomy, resection of concurrent pathologic ureter, and ureteroureterostomy (OUU) for patients with impacted ureteral stone. Between January 2004 and December 2007, 86 patients with impacted ureteral stones were treated with URSL (61) or OUU (25) because of tortuous ureter or failed access to stones. The stone size, location, impaction, ureteral lesions, and long-term outcomes were recorded. Mean stone size for the URSL group and the OUU group was 11.8 +/- 2.6 mm and 15.3 +/- 4.2 mm, respectively (P = 0.078). The impaction duration was 8.5 +/- 1.1 months for the URSL group and 17.2 +/- 3.8 months for the OUU group (P < 0.001). Endoscopic observation revealed two types of ureteral lesions that were defined as villous or polypoid protrusion (type 1) and edematous hemispheric lesions (type 2). Stone-free rates for the URSL group and the OUU group were 91.8% and 100%, respectively (P = 0.140). URSL was associated with a higher incidence of stricture (26.2% v 4.0%; P = 0.019) and worse recovery of hydronephrosis (P < 0.001). Stricture occurred more frequently in patients with type II lesions in the URSL group (P = 0.022). Stone recurrence for the URSL group and the OUU group were 13.1% and 4%, respectively (P = 0.210). Chronically impacted stones are frequently associated with ureteral polyp or stricture lesions. Our results reveal that combined removal of stones with resection of the pathologic ureter may achieve better long-term outcomes for patients with impacted stones with stricture lesions.

Does the behavior of Crohnʼs disease change over time?

Does the behavior of Crohnʼs disease change over time?

Correlation of magnetic resonance enteroclysis (MRE) and wireless capsule endoscopy (CE) in the diagnosis of small bowel lesions in Crohnʼs disease

The aim was to evaluate and compare the diagnostic performance of magnetic resonance enteroclysis (MRE) and wireless video capsule endoscopy (CE) in detecting and classifying small bowel Crohn's disease (CD) proximal to the terminal ileum. Nineteen patients with histologically proven CD (M:F = 13:6; mean 34 years, range 17-65) were prospectively included in the study when presenting with clinical signs suggesting stricturing or inflammatory lesions of CD in the proximal small bowel. All patients underwent MRE with an infusion technique and were then admitted to CE. As for the presence or absence of pathology, results of MRE and CE were in total agreement for 44/52 (85%) evaluated segments. In judging lesion severity, MRE and CE yielded identical results in 29/52 (56%) segments. MRE underestimated pathology in 7/52 (14%) segments and revealed more severe pathology in 6/52 (12%) segments. CE identified subtle (n = 7) or severe (n = 2) mucosal pathology while MRE was normal. CE entirely missed severe inflammatory mural changes depicted in MRE in 1/52 (2%) segments. MRE and CE show good correlation in the detection and localization of inflammatory bowel disease. As for disease activity, MRE is inferior in the detection of superficial mucosal disease but reliably discloses the presence of severe inflammatory changes within the bowel wall and beyond, which may be underestimated from the endoscopic aspect of the mucosal surface. MRE helps to rule out severe stenoses that should be referred for immediate surgical intervention. In conclusion, both modalities are complementary and MRE should be used in more severe cases of Crohn's disease and in patients who might have involvement beyond the mucosa of the small bowel.

Autoimmune Chronic Pancreatitis

Autoimmune pancreatitis (AIP) is a unique form of chronic pancreatitis that is characterized by swelling of the pancreas, narrowing of the main pancreatic duct (MPD), elevation of serum gamma globulin, or immunoglobulin G or presence of autoantibody, lymphoplasmacytic infiltration and dense fibrosis on histopathology. It is responsive to steroid therapy. The incidence of AIP can reach 5-6% of chronic pancreatitis. It can present as obstructive jaundice, body weight loss, and pancreas head mass mimicking pancreatic cancer. The recognition of AIP can avoid major surgery such as pancreatic resection. From May 2003 to July 2007, a total of 5 cases of AIP were reviewed retrospectively. The diagnosis was made on imaging study, serology, steroid response and/or histology if surgery was carried out. There were 2 male and 3 female patients, with a mean age of 61 (39-75) years. Atypical AIP was found in the first case and typical AIP in the remaining 4. The presenting clinical pictures were mild epigastric pain, obstructive jaundice, and loss of body weight in 4 cases, with associated autoimmune disease in 1. Diffuse or long segmental enlargement of the pancreas without peripancreatic fat infiltration was found in all patients except 1 who only had focal pancreatic head enlargement. Distal common bile duct (CBD) stricture was seen in 4 cases and the median CBD stricture length was 1.2 (0.5-2.5) cm. Multiple narrowing of the whole MPD was seen in 2 cases, focal narrowing of the MPD in 2 and long segmental narrowing of the MPD in 1. Serum immunoglobulin G tests were done in 4 cases and were elevated in all. Antinuclear antibody was positive in 3. The first case was operated on after a preoperative diagnosis of suspicious pancreatic head tumor. The subsequent 3 cases were diagnosed correctly as AIP. The last case presented with distal CBD stricture and hypoechoic lesion in the pancreas head on endoscopic ultrasound, with only borderline pancreatic enlargement on computed tomography, and he was operated on. Retrospective endoscopic retrograde pancreatogram review revealed MPD narrowing in the pancreatic body. Endoscopic retrograde brush cytology was performed and was negative for malignancy in 3 cases. Steroid therapy was given in 3 and was responsive, but there were 2 recurrences. AIP should be a differential diagnosis in distal CBD stricture and pancreatic head mass when the patient has: (1) diffuse or long segmental enlargement of the pancreas without peripancreatic fat infiltration, with multiple narrowing of the MPD without much upstream dilatation, or narrowing of the MPD not corresponding to the region of CBD stricture; and (2) abnormal immunoserologic tests.

Diagnosis and treatment of small-bowel stricture by double balloon endoscopy

The source of small-bowel stricture is often difficult to diagnose due to the difficulty of placing an endoscope into the small bowel. It has recently become possible to examine the entire small bowel and perform balloon dilatation for stricture by means of double balloon endoscopy (DBE). To identify clinical features of small-bowel stricture and determine the validity of balloon dilatation as a treatment option. Retrospective multicenter study. Researchers at 7 institutions affiliated with the DBE Working Group. One hundred seventy-nine patients with stricture among a total of 1035 patients who underwent DBE at the 7 institutions. Surgical treatment or balloon dilatation was performed as clinically indicated. Ability to detect stricture lesions by DBE, types of lesions, locations of small-bowel strictures, details of strictures, treatments for strictures, and outcomes of balloon dilatation for strictures associated with inflammatory disease. The total number of patients with strictures was 179. Lesions were detected within the small bowel in 156 patients. Inflammatory disease was the most common (n = 87) in patients with small-bowel stricture, and the ileum was the most common site of the inflammatory disease. Crohn's disease was the most common of the inflammatory diseases (n = 57). Balloon dilatations were performed in 31 patients with inflammatory disease, and long-term success was achieved in 22 patients. The number of patients treated by balloon dilatation was small. DBE appears to be useful for the detection as well as treatment of small-bowel lesions.

Clinical outcome of patients examined by capsule endoscopy for suspected small bowel Crohn's disease

Background Capsule endoscopy has a greater diagnostic yield than radiology for detecting subtle inflammatory changes of the small bowel mucosa, but the clinical significance of these abnormalities is still uncertain because of the lack of long-term follow-ups. Aim and methods To verify the accuracy of capsule endoscopy in a cohort of patients with suspected Crohn's disease of the small bowel, taking as ‘gold standard’ the final diagnosis made after a long follow-up. From April 2002 to March 2005, we enrolled and examined by capsule endoscopy 27 consecutive patients with abdominal pain and diarrhea lasting more than 3 months and at least one of the following: anaemia, weight loss, fever, extra-intestinal manifestation(s) of inflammatory bowel disease. All patients already had an unremarkable pan-endoscopy, serology for celiac disease and intestinal radiology inconclusive for small bowel abnormality. On the basis of capsule endoscopy findings, patients were distributed in three groups; Group A had severe stricturing lesions requiring surgery; Group B, moderate inflammatory lesions further investigated invasively; Group C, minimal inflammatory changes or normal findings, clinically observed every 3 months (median 21 months, range 15–29). Results Small bowel inflammatory lesions were found in 16 of the 27 patients (diagnostic yield 59%). Three had surgery (Group A) and Crohn's disease was confirmed in two; the remainder had ileal adenocarcinoma in a pathological context of chronic inflammation. Crohn's disease was histologically confirmed in four of the five patients in Group B. Group C comprised 19 patients; Crohn's disease was confirmed in seven out of eight with positive capsule endoscopy, while only one of the patients with normal findings later developed overt ileal Crohn's disease. Sensitivity, specificity, positive and negative likelihood ratio were, respectively, 93%, 84%, 5.8 and 0.08. Assuming a 50% pre-test probability of disease, capsule endoscopy gave a post-test probability of 85%. Conclusions In our selected cohort, capsule endoscopy was highly sensitive in detecting small bowel inflammatory changes, enhancing by nearly 35% the pre-test probability of structural small bowel disease. Focal erythema and luminal debris may limit the specificity of capsule endoscopy.

Synchronous adenocarcinoma and carcinoid tumor of the terminal ileum in a Crohn's disease patient

BackgroundSeveral malignancies have been described in association with inflammatory bowel diseases, the most common being adenocarcinoma. Carcinoid tumor and Crohn disease has also been previously reported, however the coexistence of both neoplasms is quite rare and the clinical diagnosis is very difficult. Here we report what we believe to be the fourth case of a mixed adenocarcinoid tumor coexisting with Crohn's disease.Case reportThe patient presented with clinical and radiological features of intestinal obstruction. Laparotomy showed a stricturing lesion in the last 6 cm of the terminal ileum with proximal dilation. Only the histology of the resected surgical specimen proved the presence of a mixed adenocarcinoid tumor involving the terminal ileum.ConclusionCarcinoid tumor should be suspected in elderly patients with Crohn's disease presenting with intestinal obstruction and laparotomy should be considered to exclude malignancy.

Technical Modification of the Double-balloon Endoscopy to Access to the Proximal Side of the Stenosis in the Distal Colon

Stricture in the colon is one of the complications associated with various kinds of disease including inflammatory bowel disease, tumor invasion, ischemic colitis, and colonic diverticulosis. Inability of endoscopic insertion beyond the stricture is a considerable problem in these patients. Double-balloon endoscopy (Fujinon EN-450P5/20, Fuji Photo Optical Co., Ltd., Omiya, Japan) is a new system of endoscopy which enables endoscopic scrutiny of the entire small bowel. We have applied this system in a patient with a narrowing segment in the colon and succeeded in reaching to the proximal side of the stricture from oral approach through the entire small bowel. A 45-year-old man was referred to our hospital because of chronic diarrhea and abdominal fullness. A contrast study of the colon taken at the nearby practitioner revealed a severe stricture lesion from the descending colon to the recto-sigmoid colon. He required emergent hospitalization because of the bowel obstruction before we started scrutiny. Decompression with an ileus tube after the hospitalization relieved his clinical symptoms. Colonoscopy showed a stenotic lesion at the recto-sigmoid colon and further endoscopic insertion was hampered. In order to explore the oral side of the stenosis, we used double-balloon endoscopy with a new modified insertion technique. Initially the proximal end of the ileus-tube was cut off and the insertion route was changed to begin from the mouth. After the insertion of the guide wire through the ileus tube, an overtube with a balloon was inserted with the assist of both the guide-wire and ileus tube, both of which in turn were removed after the insertion of the overtube. The overtube balloon was inflated to fix the overtube tip at the terminal ileum. Finally, an enteroscope was inserted through the overtube. These procedures enabled the insertion of the endoscope to the ileum end from oral approach. The endoscope was further inserted into the colon by way of the ileocecal valve and we have succeeded in reaching to the proximal side of the colonic stricture. Cancer was observed in the descending colon along with inflammatory changes and ulcerations. Pathological findings confirmed the diagnosis of colitic cancer associated with ulcerative colitis and total colectomy was performed. In conclusion, we diagnosed a case of colitic cancer with ulcerative colitis by inserting the endoscope to the proximal side of the stricture in the colon from oral approach by using the modified double-balloon endoscopy.

DIFFERENTIAL DIAGNOSIS OF INTESTINAL BEHCET'S DISEASE and CROHN'S DISEASE BY COLONOSCOPIC FINDINGS

Both Crohn's disease and intestinal Behçet's disease can cause nonspecific ulcerative lesion in any part of the intestine. The differential diagnosis between these two diseases is often difficult due to lack of pathognomic findings. The aims of this study were to investigate the colonoscopic findings and to find valuable parameters in differentiation between Crohn's disease and Behçet's disease.Methods From August 1989 to June 2000, 183 patients were diagnosed as Crohn's disease (82) or intestinal Behçet's disease (101). We evaluated endoscopic features of 170 patients (100 patients with Intestinal Behçet's disease and 70 patients with Crohn's disease) who had ulcerative lesions on colonoscopy. Classification and regression tree method was used for the differentiation of two diseases by colonoscopic findings.Results The distribution of lesions was divided into 3 types; focal (single or multiple), segmental, and diffuse. Most (93%) of the lesions in intestinal Behçet's disease distributed focally, in contrast many (70%) of the lesions in Crohn's disease showed segmental or diffuse distribution. The shape of ulcer was commonly round/oval (68%) or irregular (24%) in intestinal Behçet's disease while longitudinal (49%) or irregular (30%) in Crohn's disease. The ulcer in intestinal Behçet's disease tended to deeper, and more discrete than that in Crohn's disease. Stricture, inflammatory polyp, and perianal lesion were more common in Crohn's disease. Statistically these characteristics could make a tree structured classification rule as follows (Hit ratio: 91.9%).Round/oval Intestinal Behçet's diseaseUlcer Irregular Focal distribution Intestinal Behçet's diseaseSegmental or diffuse distribution Crohn's diseaseLongitudinal Crohn's diseaseConclusion The shape of ulcer and distribution of lesions were the two most distinguishable endoscopic features. Round/oval ulcer was the characteristics in intestinal Behçet's disease, and longitudinal ulcer was that in Crohn's disease. When the ulcer was irregular, focal distribution suggested intestinal Behçet's disease, while segmental or diffuse distribution suggested Crohn's disease.

シートベルト損傷による遅発性小腸狭窄の１例

We report a case of post-traumatic delayed stricture of the small bowel. An 11-year-old girl wearing a 2-point seat belt while riding as a passenger in a car was injured. Her demonstrable injuries were an L3 Chance fracture and contused seat belt scar in the lower abdomen. Symptoms of bowel obstruction began 9 days after the injury but then improved. On the 21st day, symptoms of bowel obstruction worsened rapidly, necessitating surgery. Four annular stricture lesions were revealed. Three were resected and one was treated conservatively. Mesenteric injury was slight. Histological findings were Ul-IV and no ischemic change. The time elapsed from the injury to the appearance of these symptoms was approximately 12 days. Laparotomy is important in considering resection. The main causes of this disease are circulatory disorders and inflammatory adhesions, but in our case the source was an organic change in the curative course of small bowel injury.

Upper intestinal and biliary tract endoprosthesis

The endoscopic insertion of an endoprosthesis is now a standard procedure in the ultimate palliation of malignant obstructing upper gastrointestinal and biliary malignancy. The commercially available prostheses and introducing devices are adequate for the majority of upper intestinal cancers. For some stricturing lesions, especially when associated with fistula formation, individual adaptation of a tygon prosthesis with extra widening rings is often necessary. Nd: Yag laser vaporisation of mainly exophytic cancerous tissue is mainly indicated for those circumstances which are less amenable to prosthesis insertion such as total luminal obstruction, noncircumferential tumorous involvement, polypoid cancers, excessively necrotic and chronically bleeding tumors, lesions extending within 2 cm of the upper esophageal sphincter, markedly angulated cancers of the cardia with almost horizontal tube positioning and cancerous overgrowth occluding the funnel opening. Overall successful insertion occurs in over 90% of patients. Main complications are perforation 5-8% and early or late dislocation. The procedure related mortality fluctuates around 2 to 4%. Overall results with laser application are roughly comparable. The dysphagia free intervall after laser is only around 6 weeks for the majority of the patients. Transpapillary insertion of a straight Amsterdam-type prosthesis rapidly became a standard procedure for palliation of malignant jaundice. For many patients with pancreatic cancer this endoscopic approach competes favorably with corresponding surgical palliative alternatives. Disappearance of jaundice is to be expected in the vast majority of the patients. The only major unsolved problem remains late clogging with biliary sludge which necessitates insertion of new prostheses. Most problematic to breach are bifurcation tumors. Cholangitis is a major complication if one does not succeed at the first attempt to drain both liver lobes.