鸡内金化学成分和药理作用研究

鸡内金是家鸡的砂囊内壁,就是鸡的内胃膜,具有健胃消食、涩精止遗、通淋化石等功效,用于呕吐、腹泻、小儿囤积、遗尿、遗精、石滴痛、胆道忧郁症等疾病,临床应用广泛。鸡内金的营养成分主要包括蛋白质、多糖、氨基酸和微量元素,具有抗氧化、改善血糖血脂水平和血液流变学参数以及改善肠胃功能等药理作用。作为一种常用药,它的炮制方法颇多,因此产生的功效也不同,主要有生用、炒制、醋制等方法。

Quantitative ultrastucture analysis of neuroendocrine cells of gastric mucosa on normal and pathological conditions

AIMS To study the quantitative ultrastucture of neu- roendocrine cells of gastric mucosa on normal anc pathological conditions including the duodenal ulcer (DU) and Zollinger-Ellison syndrome (ZES). METHODS The neuroendocrine cells of the gastric mucosa of eight normal subjects,six patients with DU and five patients with ZES were quantitatively investi- gated with electro microscope and ultrastructure image analyzer. RESULTS The volume density of neuroendocrine cells in DU was 1.3% and 0.8% (vs 1.6% and 0.9%,P>0.05) in gastric antrum and corpus respectively. In antrum,G cells was of 65% (P< 0.05),D cells decreased in cell density (3% vs 9.5%) and in number of cell per unit area (P<0.01). In corpus,the cell density of ECL cells increased (49% vs 30%,P<0.05);D cells and EC cells decreasec (2% P<0.01 and 4% P<0.05,respectively),and the number of D cell per unit area markedly decreased. In ZES,D cells in corpus decreased in cell density (4% vs 22%,P<0.01) and P cells also decreased (11% vs 24%,P<0.05). The density of ECL cells increased (65% vs 30%,P<0.01). CONCLUSIONS In DU and ZES,both the number and type of NE cells present some changes. Incresed gastrin in DU and ZES patients may be caused by the decrease of D cells and somatostatin secretion.

Treatment of over 20 mm gastric cancer by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM： To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife （IT-ESD） for the treatment of patients with over 20 mm early gastric cancer （EGC）. METHODS： A total of 112 patients with over 10 mm EGC were treated with IT-ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 5 year period from January 2002 to December 2006, including 40 patients with over 20 mm EGC. We compared patient backgrounds, the one-piece resection rate, complete resection （CR） rate, operation time, bleeding rate, perforation rate between patients with over 20 mm EGC [over 20 mm group （21-40 ram）] and the remaining patients （under 20 mm group）. RESULTS： We found no significant difference in the rate of underlying cardiopulmonary disease （over 20 mm group vs under 20 mm group, 5.0% vs 5.6%）, one- piece resection rate （95% vs 96%）, CR rate （85% vs 89%）, operation time （72.3 rain vs 66.5 rain）, bleeding rate （50 vs 4.2%）, and perforation rate （0% vs 1.4%） between the 2 groups. Three patients in each group had submucosal invasion and two in each groups underwent additional surgery. CONCLUSION： There was no significant difference in the outcome resulting from IT-ESD between the 2 groups. Our study proves that IT-ESD is a feasible treatment for patients with over 20 mm mucosal gastric cancer although the long-term outcome should be evaluated in the future.

Endoscopic resection of superficial gastrointestinal tumors

Therapeutic endoscopy plays a major role in the management of gastrointestinal (GI) neoplasia. Its indications can be generalized into four broad categories; to remove or obliterate neoplastic lesion, to palliate malignant obstruction, or to treat bleeding. Only endoscopic resection allows complete histological staging of the cancer, which is critical as it allows stratification and refinement for further treatment. Although other endoscopic techniques, such as ablation therapy, may also cure early GI cancer, they can not provide a definitive pathological specimen. Early stage lesions reveal low frequency of lymph node metastasis which allows for less invasive treatments and thereby improving the quality of life when compared to surgery. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are now accepted worldwide as treatment modalities for early cancers of the GI tract.

Current status of endoscopic submucosal dissection for the management of early gastric cancer:A Korean perspective

The early diagnosis of gastric cancer allows patients and physicians to pursue the option of endoscopic resection,which is significantly less invasive than conventional surgical resection.In Korea,the use of endoscopic submucosal dissection(ESD) has been increasing,and many reports on ESD have been published.In addition,Korean gastroenterologists from several hospitals performing ESD have conducted formal meetings to discuss useful information regarding ESD.Here,we discuss the Korean experience with ESD,including outcomes and prospects of endoscopic treatments.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue.Treatment of heterotopic pancreas may include expectant observation,endoscopic resection or surgery.The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection(EMR) for resection of heterotopic pancreas of the stomach.Two patients(both female,mean age 32 years) were referred for management of gastric subepithelial tumors.Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa.Band ligation-assisted EMR was performed in both cases without complications.Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa.Margins were free of pancreatic tissue.Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Endoscopic ultrasonographic appearance of gastric emphysema

Emphysematous gastritis (or phlegmonous gastritis) and gastric emphysema (or gastric pneumatosis) are variations of conditions associated with the presence of intramural air in the stomach. The presence of air in the gastric wall is a very rare clinical condition, associated with bacterial infection, increased intragastric pressure from gastric outlet obstruction, gastric mucosal disruption or air dissection from the mediastinum. In adults, this can occur in the setting of instrumentation-related injury, gastric outlet obstruction by gastric, duodenal or pancreatic malignancies or bowel ischemia. Here we describe a case of gastric emphysema related to repeated biliary stenting and partial duodenal obstruction in a patient with inoperable periampullary cancer, and provide the first description of the endoscopic ultrasonographic findings of gastric emphysema in the literature. In our case, endoscopic ultrasound showed a band of bright echogenicity arising from the submucosa layer, representing air in the gastric wall.

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea

Endoscopic treatment,such as endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD),has been established as one of the treatment options for selected cases with early gastric cancer(EGC).Most studies on this topic have been carried out by researchers in Japan.Recently,the experience in EMR/ESD for EGC outside Japan is increasingly reported.In Korea,gastric cancer is the most common malignant disease,and the second leading cause of cancer death.Currently,EMR for EGC is widely performed in many centers in Korea.Early results with a shortterm follow-up period are very promising in Korea.Thecomplete resection rate of EMR was 37.8%-94.3%,and that of ESD was 77.4%-93.1%.In this review,we will provide an overview of the outcomes of endoscopic treatments in Korea.

Effects of ranitidine for exercise induced gastric mucosal changes and bleeding

AIM： To evaluate the effect of ranitidine on gastric mucosal changes and on GI bleeding in long distance runhers. METHODS： Twenty-four long distance runners （M： 16, F： 8, age： 18.2＋ 1.5 years） participated in this study. A symptom questionnaire, stool hemoccult test, and upper gastrointestinal （GI） endoscopy were performed on the subjects prior to the study. The subjects took oral ranitidine （150 mg, b.i.d.） for two weeks. The upper GI endoscopy and stool Hemoccult tests were repeated after the treatment. RESULTS： Twenty-two of the 24 runners had at least one upper G1 mucosal lesion before the medication. The Endoscopic improvements were seen in eleven of the 14 cases of erosive gastritis and four of the 5 cases of esophagitis. Six subjects were Heine occult positive prior to the study, but only one was positive after the medication. CONCLUSION： Gastric mucosal lesions and GI bleeding in long distance runners seem to be associated to acidrelated factors mediated by the high level of regular running. Ranitidine seems to be and effective prophylaxis to prevent gastric mucosal lesions and GI bleeding.

Relationship between p-catenin expression and epithelial cell proliferation in gastric mucosa with intestinal metaplasia

AIM： To investigate β-catenin expression in patients with intestinal metaplasia, and to look for a possible relationship between β-catenin expression and either epithelial proliferation values or Helicobacter pylori （ H pylori） infection.METHODS： Twenty patients with complete type intestinal metaplasia were studied. β-Catenin expression and epithelial cell proliferation in antral mucosa were assessed using an immunohistochemical analysis. H pylori infection was detected by histology and a rapid urease test.RESULTS： Reduced β-catenin expression on the surface of metaplastic cells was detected in 13 （65%） out of 20 patients. Moreover, in eight （40%） patients intranuclear expression of β-catenin was found. When patients were analyzed according to H pylori infection, the prevalence of both β-catenin reduction at the cell surface and its intranuclear localization did not significantly differ between infected and uninfected patients. Cell proliferation was higher in patients with intranuclear β-catenin expression as compared to the remaining patients, although the difference failed to reach the statistical significance （36±8.9 vs 27.2±11.4, P= 0.06）. On the contrary, a similar cell proliferation value was observed between patients with reduced expression of β-catenin on cell surface and those with a normal expression （28.1±11.8 vs 26.1±8.8, P= 0.7）.H pylori infection significantly increased cell proliferation （33.3±10.2% vs 24.6±7.4% , respectively, P= 0.04）.CONCLUSION： Both cell surface reduction and intranuclear accumulation of β-catenin were detected in intestinal metaplasia. The intranuclear localization of β-catenin increases cell proliferation. H pylori infection does not seem to play a direct role in β-catenin alterations, whilst it significantly increases cell proliferation.

Endoscopic mucosal resection of early gastric cancer: Experiences in Korea

Endoscopic mucosal resection （EMR） has been established as one of the treatment options for early gastric cancer （EGC）. However, there are many uncertain areas such as indications of EIR, best treatment methods, management of complications and follow-up methods after the procedure. Host studies on this topic have been carried out by researchers in Japan. In Korea, gastric cancer is the most common malignant disease, and the second leading cause of cancer death. In these days, EIR for EGC is widely performed in many centers in Korea. In this review, we will provide an overview of the bechniques and outcomes of EIR in Korea.

Management of the complications of endoscopic submucosal dissection

Endoscopic submucosal dissection(ESD) is currently widely accepted as a standard treatment option for early gastrointestinal neoplasms in Korea.However,ESD has technical difficulties and a longer procedure time than conventional endoscopic resection.So it may have a higher risk of complications than conventional endoscopic resection techniques.We,the ESD study group of Korean Society of Gastrointestinal Endoscopy,have experienced many complications,mostly treated by endoscopic or conservative management.Here,we introduce and share our experiences for managementof post ESD complications and review published papers on the topic.

Endoscopic submucosal dissection for early gastric cancer:Quo vadis?

The diagnosis of early gastric cancer(EGC) is of great interest because its endoscopic and surgical treatment presents the best chance for a cure.With technical development,endoscopic submucosal dissection(ESD) has been widely performed for the curative treatment of EGC in Korea.Multinational studies of ESD for EGC will be the next missions that overcome these limitations and global guidelines will be processed for ESD for EGC.

Dehiscence following successful endoscopic closure of gastric perforation during endoscopic submucosal dissection

Gastric perforation is one of the most serious complications that can occur during endoscopic submucosal dissection(ESD).In terms of the treatment of such perforations,we previously reported that perforations immediately observed and successfully closed with endoclips during endoscopic resection could be managed conservatively.We now report the first case in our medical facility of a gastric perforation during ESD that was ineffectively treated conservatively even after successful endoscopic closure.In December 2006,we performed ESD on a recurrent early gastric cancer in an 81-year-old man with a medical history of laparotomy for cholelithiasis.A perforation occurred during ESD that was immediately observed and successfully closed with endoclips so that ESD could be continued resulting in an en-bloc resection.Intensive conservative management was conducted following ESD,however,an endoscopic examination five days after ESD revealed dehiscence of the perforation requiring an emergency laparotomy.

Gastric intramural hematoma accompanied by severe epigastric pain and hematemesis after endoscopic mucosal resection

Gastric intramural hematoma is a rare injury of the stomach,and is most often seen in patients with underlying disease.Such injury following endoscopic therapy is even rarer,and there are no universally accepted guidelines for its treatment.In this case report,we describe a gastric intramural hematoma which occurred within 6 h of endoscopic mucosal resection(EMR).Past medical history of this patient was negative,and laboratory examinations revealed normal coagulation profiles and platelet count.Following EMR,the patient experienced severe epigastric pain and vomited 150 mL of gastric contents which were bright red in color.Subsequent emergency endoscopy showed a 4 cm × 5 cm diverticulum-like defect in the anterior gastric antrum wall and a 4 cm × 8 cm intramural hematoma adjacent to the endoscopic submucosal dissection lesion.Following unsatisfactory temporary conservative management,the patient was treated surgically and made a complete recovery.Retrospectively,one possible reason for the patient's condition is that the arterioles in the submucosa or muscularis may have been damaged during deep and massive submucosal injection.Thus,endoscopists should be aware of this potential complication and improve the level of surgery,especially the skills required for submucosal injection.

Does immunohistochemical staining have a clinical impact in early gastric cancer conducted endoscopic submucosal dissection?

AIM: To evaluate clinicopathologic parameters and the clinical significance related lymphovascular invasion (LVI) by immunohistochemical staining (IHCS) in endoscopic submucosal dissection (ESD). METHODS: Between May 2005 and May 2010, a total of 348 lesions from 321 patients (mean age 63 ± 10 years, men 74.6%) with early gastric cancer (EGC) who met indication criteria after ESD were analyzed retrospectively. The 348 lesions were divided into the absolute (n = 100, differentiated mucosal cancer without ulcer ≤ 20 mm) and expanded (n = 248) indica-tion groups after ESD. The 248 lesions were divided into four subgroups according to the expanded ESD indication. The presence of LVI was determined by factor Ⅷ-related antigen and D2-40 assessment. We compared LVI IHCS-negative group with LVI IHCSpositive in each group. RESULTS: LVI by hematoxylin-eosin staining (HES) and IHCS were all negative in the absolute group, while was observed in only the expanded groups. The positive rate of LVI by IHCS was higher than that of LVI by HES (n = 1, 0.4% vs n = 11, 4.4%, P = 0.044). LVI IHCS-positivity was observed when the cancer invaded to the mucosa 3 (M3) or submucosa 1 (SM1) levels, with a predominance of 63.6% in the subgroup that included only SM1 cancer (P < 0.01). In a univariate analysis, M3 or SM1 invasion by the tumor was significantly associated with a higher rate of LVI by IHCS, but no factor was significant in a multivariate analysis. There were no cases of tumor recurrence or metastasis during the median 26 mo follow-up. CONCLUSION: EGCs of the absolute group are immunohistochemically stable. The presence of LVI may be carefully examined by IHCS in an ESD expanded indication group with an invasion depth of M3 or greater.

Endoscopic scoring of late gastrointestinal mucosal damage after adjuvant radiochemotherapy

AIM： To evaluate late effects of chemoradiation on gastrointestinal mucosa with an endoscopic scoring system and compare it to a clinical scoring system. METHODS： Twenty-four patients going to receive chemoradiation after gastric surgery underwent endoscopy four wk after surgery and one year after the chemoradiation finished. Upper gastrointestinal findings were recorded according to a system proposed by World Organisation for Digestive Endoscopy （OMED） and clinical scoring was done with RTOG-EORTC radiation morbidity scoring systems. RESULTS： There was no significant endoscopic difference in gastric and intestinal mucosa after chemoradiation （P 〉 0.05） and there was no association between endoscopic scores and clinical scores. Endoscopic changes were minimal. CONCLUSION： Late effects after chemoradiation in operated patients with gastric cancers can be evaluated with an endoscopic scoring system objectively and this system is superior to clinical scoring systems.

Comparison between air and carbon dioxide insufflation in the endoscopic submucosal excavation of gastrointestinal stromal tumors

AIM:To evaluate the safety and efficacy of CO2 insufflation compared with air insufflation in the endoscopic submucosal excavation(ESE) of gastrointestinal stromal tumors.METHODS:Sixty patients were randomized to undergo endoscopic submucosal excavation,with the CO2 group(n = 30) and the air group(n = 30) undergoingCO2 insufflation and air insufflation in the ESE,respectively.The end-tidal CO2 level(pETCO2) was observed at 4 time points:at the beginning of ESE,at total removal of the tumors,at completed wound management,and 10 min after ESE.Additionally,the patients' experience of pain at 1,3,6 and 24 h after the examination was registered using a visual analog scale(VAS).RESULTS:Both the CO2 group and air group were similar in mean age,sex,body mass index(all P > 0.05).There were no significant differences in PetCO2 values before and after the procedure(P > 0.05).However,the pain scores after the ESE at different time points in the CO2 group decreased significantly compared with the air group(1 h:21.2 ± 3.4 vs 61.5 ± 1.7;3 h:8.5 ± 0.7 vs 42.9 ± 1.3;6 h:4.4 ± 1.6 vs 27.6 ± 1.2;24 h:2.3 ± 0.4 vs 21.4 ± 0.7,P < 0.05).Meanwhile,the percentage of VAS scores of 0 in the CO2 group after 1,3,6 and 24 h was significantly higher than that in the air group(60.7 ± 1.4 vs 18.9 ± 1.5,81.5 ± 2.3 vs 20.6 ± 1.2,89.2 ± 0.7 vs 36.8 ± 0.9,91.3 ± 0.8 vs 63.8 ± 1.3,respectively,P < 0.05).Moreover,the condition of the CO2 group was better than that of the air group with respect to anal exsufflation.CONCLUSION:Insufflation of CO2 in the ESE of gastrointestinal stromal tumors will not cause CO2 retention and it may significantly reduce the level of pain,thus it is safe and effective.

Duodenal intraepithelial T lymphocytes in patients with functional dyspepsia

AIM： To quantify the intraepithelial lymphocytes （IELs） and to document the membrane expression of CD4, CD8, TCRγδ and adhesion and/or activation-associated molecules （CD103, CD28, CD44, CD69, HLA-DR, CD95/ Fas） in the duodenal mucosa of patients with functional dyspepsia （FD） in order to provide arguments for an immunological process in FD. METHODS： Twenty-six FD patients according to Rome Ⅱ criteria （20 were H pylori negative） were studied and compared to 12 healthy adults. IELs were isolated from five duodenal biopsy samples, then quantified by microscopy and flow cytometry while the membrane phenotypes were determined by cytofluorometry. RESULTS： Duodenal histological examination was normal. In H pylori negative patients, the number of IELs was not different from that in healthy controls. Median percentage expression of CD4, CD8, or TCRy8 and CD103, CD44, CD28, CD69 on CD3＋ IELs, among the adhesion/activation associated molecules tested, was not different from that in healthy controls. In contrast, the median percentage expression of CD95/ Fas [22 （9-65） vs 45 （19-88）, P = 0.03] and HLADR expressing CD3＋ IELs [4 （0-30） vs 13 （4-42）, P = 0.04] was significantly lower in the H pylori negative FD group than in healthy controls, respectively. The number of IELs was significantly greater in H pylori positive FD patients than in healthy controls [median ratio for 100 enterocytes 27.5 （6.7-62.5） vs 10.8 （3-33.3）, P = 0.02] due to a higher number of CD8＋ CD3＋ IELs. CONCLUSION： In H pylori negative FD patients, the phenotypic characterization of IELs suggests that we cannot exclude a role of IELs in FD.

Endoscopic diagnosis of Barrett's esophagus

The Prague C and M Criteria have been developed for the objective endoscopic diagnosis of Barrett's esophagus(BE).BE arises between the squamocolumnar junction and the gastroesophageal junction at the proximal margin of the gastric folds.In this study,we reported that 43.0% of the subjects examined were diagnosed with BE based on the Prague C and M Criteria.Previous criticism by John Dent proposed that our data should be considered invalid because the prevalence of BE reported in our study was extraordinarily high and discordant with previous studies.Dent predicted that the position of the gastroesophageal junction in our study was judged to be lower than the actual position due to the effacement of the proximal ends of the gastric folds because of the routine use of a high degree of air distension during typical Japanese endoscopic examinations.The endoscopic evaluation of the superior gastric folds is certainly influenced by the degree of air distension of the esophagus.However,in our study,the proximal limit of the gastric mucosal folds was prospectively imaged while the oesophagus was minimally insufflated.Then,under a high level of air distension,the distal ends of the palisade-shaped longitudinal vessels were imaged because they are more easily observed when distended.In the majority of patients,the distal ends of the palisade-shaped longitudinal vessels correspond to the proximal limit of the gastric mucosal folds.Our endoscopic evaluation was appropriately performed according to the Prague C and M Criteria.We suspect that the high prevalence of BE in our study may be due to the inclusion of ultrashort-segment BE,which defines BE with an affected mucosal length under 5 mm,in our positive results.