A 18-year (1983-2001) retrospective review revealed 13 cases of spontaneous esophageal rupture (Boerhaave's syndrome) including 2 of cardiopulmonary arrest (CPA). Vomiting preceded the rupture in most patients. Chief symptoms were abdominal or chest. All were sent to our hospital after visiting a nearby hospital. The rate of correct diagnosis at the first hospital was 15.4%. Although the mean time from onset to the first visit was 1.3 hour, the mean time from onset to treatment was 25.3 hours. Delayed diagnosis and treatment are obvious. Pneumomediastinum, pleural effusion, and pneumothorax in chest radiography and chest computed tomography (CT) on admission were helpful in diagnosis. Esophagography and esophagoscopy were used to confirm esophageal rupture. Ten patients undergoing emergency surgery and 1 conservative therapy survived. The 2 CPA patients died due to tension pyopneumothorax. Early diagnosis and treatment are therefore important in improving prognosis.

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Bacterial translocation has been demonstrated in animal studies, but has not been confirmed in humans because of evaluation difficulties. The translocation of some agents derived from microorganisms has also been included in the study of bacterial translocation since these mechanisms also influence various responses in the human body. New detection assays, like peptidoglycan, can now be used to detect microorganism. These assays have been used in experiments using animal models and studies examining hemorrhagic shock and alcohol ingestion. In these situations, bacterial translocation might occur in the human body either incidentally or accidentally.

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The use of enteral feeding enriched with immuneenhancing ingredients as well as the administration of certain growth factors in patients with stress have recently attracted considerable interest. These approaches to modulating the immune and inflammatory responses and thereby improving the clinical outcome are collectively known as immunonutrition. Prospective randomized clinical trails performed in the US and Europe have shown that early enteral feeding enriched with glutamine, arginine, omega-3 fatty acids and nucleotides significantly reduces infectious complications and the length of the hospital stay. Most immunonutrition strategies have been shown to modulate gut function, i.e. to prevent bacterial translocation, in animal models. Whether bacterial translocation is an important pathophysiological event in human disease or an epiphenomenon of severe disease remains debatable, but maintenance of gut barrier function may explain, at least in part, the clinical benefits of immunonutrition.

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Bacterial translocation sometimes occurs in humans and is associated with an increased incidence of septic morbidity. However, a reliable method of measuring bacterial translocation in humans has not been established. The identification of minute quantities of microbe-specific DNA is now possible using polymerase chain reaction (PCR). PCR was used to amplify genes from Escherichia coli, Bacteroides fragilis, a region of 16S ribosomal RNA found in many gram-positive and gram-negative bacteria, and Candida albicans. Bacterial and Candida albicans DNA were not detected in healthy volunteers. Enteric bacterial DNA was detected in patients who had undergone a hepatic lobectomy, and Candida albicans DNA was detected in patients immediately after the completion of an esophagectomy. Enteric bacterial and Candida albicans DNA were detected in septic patients with diagnostic findings suggestive of bacterial translocation, such as small bowel obstruction, ulcerative colitis, or supramesenteric arterial occulusion, or in those who had undergone chemotherapy for advanced colon cancer. The PCR method is more sensitive than blood cultures for detecting bacterial components in the blood of septic patients and is also a valuable tool for verifying bacterial translocation in patients who have undergone a hepatic lobectomy or esophagectomy and who do not have a defined focus of infection.

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Methicilline resistant staphylococcus aureus (MRSA) can be grown alone in a neutral culture medium but not when other kinds of bacteria are present. Under conditions where the growth of Escherichia coli (E. coli) and Bacteroides fragilis (B. fragilis) or E. coli and Escherichia faecalis (E. faecalis) are prohibited, however, the growth of MRSA increases significantly. In a rat model fed by total parenteral nutrition (TPN), MRSA was able to translocate to the small intestine when gastric acidity was suppressed. However, MRSA enteritis and diarrhea did not occur because MRSA enteritis requires a series of treatments, including the administration of antibiotics prior to and after MRSA inoculation. Bacterial translocation was confirmed using a postoperative MRSA enteritis mouse model; hepato-splenic macrophages were thought to be the front line of host protection during the initial stage of infection. Careless antibiotic administration may cause MRSA enteritis. MRSA enteritis could be a serious complication in postoperative patients with a low hepato-splenic macrophage count.

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In severe acute pancreatitis, endotoxemia and/or the infection of the pancreas and/or prepancreatic necrosis are thought to derive from the translocation of bacteria from the gut. Bacterial translocation has been reported to occur in conditions with reduced gut integrity, an impairment of systemic and gut immunity, or bacterial overgrowth. In acute pancreatitis, bacterial overgrowth resueting from paralytic ileus has been reported. In addition, we have noted an impairment of systemic and gut immunity as a result of lymphocyte apoptosis and an increase in gut permeability from apoptosis of the intestinal epithelial cells in experimental pancreatitis. In fact, the inhibition of caspases, which are key enzymes for the induction of apoptosis, ameliorated endotoxemia via the maintenance of systemic and gut immunity and gut integrity.

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Bacterial translocation (BT) has recently gained attention as an important factor in the onset and deterioration of multiple organ failure (MOF). The morbidity of clinically identified BT in MOF patients was 10.5%, and the survival rate of MOF patients with BT was significantly lower than in MOF patients without BT in our study. Although an early clinical diagnosis of BT is difficult to achieve, the ratio of the interleukin-6 (IL-6) level in the pulmonary arterial blood and the arterial blood (PA/A) as measured using a rapid chemiluminescent enzyme immunoassay (CLEIA) system could be a new diagnostic tool for the early diagnosis of BT. Selective digestive decontamination (SDD) has been widely applied and evaluated as a countermeasure against BT. We performed SDD and early enteral nutrition (EN) in patients with MOF. SDD and EN reduced the infection rate after ICU admission and improved the survival rate of MOF patients with infections complications. Since BT plays an important role in the pathophysiology of MOF, early diagnosis and the early application of SDD and EN are important for the management of patients with a high risk of BT.

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A 50-year-old woman found to have pneumatosis cystoides of the small intestine was seen for abdominal distension and appetite loss. Despite prominent distension, no muscle guarding or tenderness in the abdomen was noted. Plain chest X-ray showed a large amount of free air under the diaphragma and an image resembling a bunch of grapes in the upper quadrant. Plain abdominal X-ray showed dilation of the small intestine and multiple niveau. Upper abdominal computed tomography (CT) (lung fenestration) showed a stranded appearance within the air collection. Emergency surgery conducted due to suspected perforation of the intestinum tanue under laparotomy showed large amounts of free air and serous ascites in Winslow's pouch. A cystic emphysematous mass was comfirmed in the small intestine wall. From these intraoparative findings, we diagnosed this case as pneumatosis cystoides intestinalis (PCI) resulting in free air. We partially resected the small intestine. The mucosa of the resected specimen showed no abnormal findings but a cystic emphysematous mass about 10cm in diameter in the subserosal layer. The woman was discharged on postoparative day 21.

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An 80-year-old woman with an epigastric mass note 1 or 2 years previously and admitted for epigastric pain was found to have a 10×10×6cm soft elastic mass palpated in the upper abdomen. No operative scar was seen computed tomograply (CT) showed a defect of the linea alba and protrusion of the transverse colon. Laparotomy done under a diagnosis of epigastric hernia revealed a hernia of the transverse colon and omentum without necrotic change, so we reduced the colon and closed the hernia after excising the sac. The postoperative course was uneventful and no signs of recurrence have been noted in lyear 11 months. We review 62 cumulative cases reported in the Japanese literature.

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We report a case of recurrent pancreatic pseudocyst treated by endoscopic cystogastrostomy 4 year after conservative treatment for pancreatic injury. A 24-year-old woman seen for low back pain had a history of pancreatic injury 4 years earlier involving complete disruption (III a) of the main pancreatic duct symptoms were amelisrated by conservative treatment with somatostatin and the woman was followed up regularly as an outpatient. Abdominal computed tomography (CT) and ultrasonography (US) showed a pseudocyst 6×5cm in diameter in the body and tail of the pancreas, yielding a diagnosis of recurrent pseudocyst of the pancreas. After admission, the patient was managed by stopping oral intake and starting intravenous infusion, but the pseudocyst showed no change in size. We conducted endoscopic pancreatic cystogastrostomy in the third week of hospitalization. On postoperative day 7, the patient was discharged with an indwelling transgastric pancreatic pseudocyst drainage tube, removed 2 months later. The subsequent outcome has been favorable with no complications. No signs of recurrence were noted 15 months after tube removal.

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A 74-year-old man with abdominal pain from the previous morning and admitted the following day was found in Abdominal X-ray to have an ileal obstruction pattern and, on computed tomography (CT), a double target sign with a central low-density area, indicating ileum-to-ileum intussesception. Surgical examination showed invagination 40cm oral to the terminal ileum. Upon manual reduction, a well-circum scribed pedicled tumor was palpated interminally, necessitating partial resection of the ileum and tumor. The resected specimen was a 7cm black polyp. Histological examination indicated Meckel's diverticulum accompanied by hemorrhagic necrosis. Ectopic pancreatic tissue was found in the diverticulum, classifying it as Heinrich II.

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We present a case of gallbladder torsion associated with gallbladder cancer diagonosed postoperatively. An 83-year-old woman admitted with right upper abdominal pain was found in abdominal sonography and computed tomography to have a small amount of ascites and a gallbladder with remarked swelling and wall thickness in the neck, but no stones in the cystic duct. Emergency surgery conducted under a diagnosis of acute cholecystitis showed acute gangrenous cholecystitis and 540° clockwise torsion of the cystic duct, necessitating detorsion and cholecystectomy. The postoperative histological diagnosis was stage II gallblad der cancer. Because gallbladder torsion with cancer occurs in both bile peritonitis and peritonitis car cinomatosa, early diagnosis and surgery are vital to patient suvival, especially in the elderly gallbladder torsion.

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A 68-year-old man admitted to a nearby hospital for exacerbated rheumatoid arthritis 1 month earlier suffered melena when the steroid dose was gradually increased. Hemorrhage from the ascending colon diverticulum was diagnosed and endoscopic hemostasis conducted. An IVH catheter was inserted via the right femoral vein, and hyperalimentation and blood transfusion were started. Four days later, right lower abdominal pain occurred and the patient was referred to our department. Localized tenderness was noted in the right rectus abdominis muscle, but not fever or peritoneal irritation signs. WBC was 18, 100/μ/ and CRP was 0.47mg/dl. Ultrasonography showed a heterogenous internal echo and a lens-like right rectus abdominis muscle. Computed tomography imaged gas and a foreign body within the rectus sheath, suggesting hematoma or abscess in the rectus abdominis muscle and necessitating surgery. An IVH catheter was found to have strayed into the rectus sheath. This rare case involved an IVH catheter inserted via the right femoral vein reaching the inferior epigastric vein, puncturing the vessel and causing necrosis of the rectus abdominis muscle.

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Gallbladder torsion is relatively rare and occasionally undiagnosed preoperatively. A 77-year-old woman seen for right lower abdominal distension and fever, who had been treated for cerebral infarction and atrial fibrillation at an other hospital, was found in computed tomography (CT) and magnetic resonance imaging (MRI) to have an interrupted cystic duct, downward deviation of the gallbladder, and a cystic lesion with fluid collection that was surrounded by a thick wall at the iliocecum. She was diagnosed with gallbladder torsion, necessitating emergency surgery. The gallbladder was twisted 270 degrees counterclockwise, and cholecystectomy was done. Postoperative recovery was uneventful.

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A 57-year-old man admitted for increasing upper abdominal pain 3 days after falling down stairs was found in abdominal radiography and computed tomography (CT) to have a thickened gastric wall and free air in the peritoneal cavity, suggesting traumatic stomach rupture. Non surgical treatment by administering H2-blocker and total parenteral nutrition was chosen because peritonitis was localized and vital signs were stable. Ten days later, the initial diagnosis was confirmed by endoscopy showing a rupture at the lesser curveture of the mid corpus. Intraabdominal abscess formation was complicated and treated successfully by percutaneous drainage. Healing of the perforated site was observed endoscopy and oral intake restarted 12 days after admission. The man was discharged 93 days admission. Traumatic gastric rupture can thus be managed by non surgical treatment in certain situations, although most patients undergo emergency surgery.

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We present a case of synchronous double cancer of the stomach and colon treated by single-stage resection and stent placement for a colonic obstruction. A 70-year-old man with severe pulmonary emphysema admitted for abdominal pain and constipation was found to have tumors in the stomach and transeverse colon. Abdominal X-ray revealed ileus. We diagnosed colonic obstruction due to the colon tumor and emplaced a stent, which relieved abdominal pain and constipation. We diagnosed synchronous double cancer of the stomach and colon, necessitating simultaneou total gastrectomy and lefthhemicolectomy. The postoperative course was uneventful and the patient remains in good health and recurrence-free. Preoperative stent placement for colonic obstruction is thus useful in selected patients with malignat tumors because it is minimally invasive and avoids multiple surgery.

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A78-year-old man admitted for upper abdominal pain, general fatigue, and severe anemia was found in upper gastrointestinal endoscopy to have a type III tumor at the greater curvature of the middle to lower gastric corpus, diagnosed by biopsy as malignant lymphoma. Surgery showed copious ascites; numerous cementations on Douglas' pouch, peritoneum, and diaphragm; and bead-like enlargement of lymph nodes in the mesentery; making the case non-resectable. Chemotherapy (CHOP: cyclophosphamide, doxorubicin, vincristine, and predonisolone) was initiated after surgery. Gastric perforation due to tumor necrosis occurred on day 3, causing peritonitis, requiring omental patch closure of the perforation and gastrotomy. Peritoneal metastasis disappeared. Gastroscopic examination on postoperative day 50 showed epithelization of the packed area and marked tumor shrinkage. Abdominal fluid cytology was negative. Chemotherapy was continued, and remission achieved. Therapeutic results for tumor perforation during chemotherapy are extremely poor, but in this case, surgery for gastric perforation-induced peritonitis saved the patient's life.

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A 51-year-old man seen for abdominal pain and fullness was found in abdominal computed tomography (CT) to have portal venous gas and intestinal pneumatosis. We conducted emergency laparotomy due to panperitonitis. Operative findings showed perforation of a gangrenous appendicitis and dilation of the small intestine, but us bowel necrosis. We conducted appendectomy and cecostomy. This is the third case of portal venous gas caused by acute appendicitis reported in the Japanese literature.

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A 66-year-old man admitted for left upper abdominal pain and vomiting was found to have a mildly distended abdomen and hyperactive bowel sounds. Plain abdominal X-ray revealed marked gaseous dilation of the small intestine. Ultrasonography and plain computed tomograhy (CT) showed a marked distended intestine, pneumobilia, and a stone in the atrophic gallbladder. Upper gastrointestinal tract series by long intestinal tube showed complete obstruction of the upper small intestine. Thin-section CT at the obstructed site showed an impacted gallstone. In open abdominal surgery, an obstructive 40 × 35 mm gallstone at the jejunum was removed. The billirubin stone consisted mainly of billirubin calcium, stearin acid calcium, and cholesterol, without carbonic calcium.

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An erroneously swallowed clasp denture whose clasp had lodged deep in the submuosa of the cervical esophagus just below the entrance to the esophagus could not be removed by fiberscopy and hard esophagoscopy, necessitating emergency surgery. We detail the case and review of the literature. A 60-year-old man erroneously swallowed a clasp denture when taking oral medicine on September 21, 2001. The following day, he was admitted for treatment of pain on the right side of the neck on swallowing. Upper gastrointestinal fiberscopy showed a claps denture lodged in the right esophageal wall immediately subjacent to the pharyngoesophageal junction. An attempt to grasp the denture with forceps failed, as did hard esophagoscopy under general anesthesia. After emergency surgery, the man improved progressively following the operation and was discharged on hospital day 14.

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