At the 45th Annual Congress of the Japanese Society for Abdominal Emergency Medicine held in Tokyo in 2009,I gave a lecture titled “Ulcerative Colitis” focusing on : the (1)epidemiology, (2)diverse medical treatments available, (3)progress in surgical treatment, and (4)importance of co-operation among the medical and paramedical staff in the management of ulcerative colitis. Ulcerative colitis used to be a rarely encountered condition in Japan, however, its incidence has gradually increased, and the estimated number of cases in 2007 was 90,000. Treatment with mesalazine, salazosulfapyridine, and prednisolone was common until 15 years ago, however, recent trends reveal a greater reliance on immunosuppressive agents such as azathiopurine, 6-mercaptopurine, cyclosporine A and tacrolimus, as well as leukocytapheresis. The indications for surgery are not clear, and postoperative management is difficult. While there have been no improvements in the fundamental surgical procedure, the percentage of elective operations and of one-stage restorative proctocolectomy has been increasing. Finally, I emphasized the importance of co-operation among the doctors, nurses and other paramedical staff in the management of patients with ulcerative colitis.

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The aim of this study was to evaluate the complications of endoscopic submucosal dissection (ESD) in patients with superficial gastric neoplasias. Two hundred and fifty patients with 269 lesions due to early gastric cancer or gastric adenoma were enrolled ; 187 lesions were in patients under 75 years of age (younger group) and 82 were in patients of 75 years of age or older (elderly group). The mean size of lesions in the elderly group (17.0mm) was significantly larger than that in the younger group (14.0mm). The mean time of the ESD procedure in the elderly group (58.2minutes) was significantly longer than that in the younger group (47.2minutes). Bleeding after ESD occurred in 15 lesions out of 269 (5.6%), the mean size of which was significantly larger (20.4mm) than lesions which had no bleeding (14.5mm). Lesions in the upper third, middle, and lower portion occurred in 2 of 31 lesions (6.5%), 3 of 105 lesions (2.9%) and 10 of 133 lesions (7.5%). The rate of bleeding after ESD in the elderly group (2.6%) was significantly lower than that in the younger group (8.0%). Perforation occurred in two patients (0.7%), who were both in the younger group. Fever after ESD occurred in 2 patients and severe bradycardia during ESD occurred in one patient. ESD thus seems to be safe for patients with superficial gastric neoplasias if their general condition and comorbid illness is carefully managed not only during, but also before and after ESD.

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【Objective】To identify the prognostic factors in patients with colorectal perforation and investigate the indications and efficacy of endotoxin adsorption therapy (hereinafter, PMX-DHP). 【Subjects and methods】The subjects studied were 54 patients with colorectal perforation treated at our hospital during the 5-year period from April 2003 through March 2008. Nine preoperative factors and 6 postoperative factors were identified and subjected to statistical analysis. 【Results】Based on the results of the multivariate analysis, 4 factors independently related to poor prognosis were identified, as follows: (1) preoperative shock index ≥1.1; (2) systolic blood pressure immediately after surgery &le80 mmHg; (3) absolute need for nor-adrelanine therapy after surgery; (4) decrease of the platelet count on the day after the surgery ≥40%. All the patients who died fulfilled at least 2 of the 4 aforementioned factors. 【Discussion】PMX-DHP is considered for patients with the most serious colorectal perforation. Presence of at least 2 of the 4 poor prognostic factors mentioned above is considered as an indication for commencing PMX-DHP.

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For the safe and effective treatment of esophageal varices with endoscopic injection sclerotherapy, the lesion was hemodynamically classified based on an anatomical analysis of the collateral circulation by multi-detector-row computed tomography (MD-CT). Forty-nine patients with esophageal varices having a blood supply from the left gastric vein (LGV) served as the subjects of this study. Following a hemodynamic study based on MD-CT, a 3D-CT (three-dimensional computed tomography) image was produced for the collateral circulation. The hemodynamics of the para-esophageal vein (PEV) were classified into the following 3 types : type I, without PEV ; type II, PEV that had developed with its diameter being equal to or less than the diameter of the esophageal varix ; and type III, where the PEV had a diameter greater than the esophageal varix. Thirteen, 20 and 16 cases accounted for types I, II and III, respectively. In 18 cases, postoperative complications or recurrences were seen in the perforating veins. For treatment, embolization must be extended to the root of the LGV in type I ; in types II and III, embolization up to where the LGV branches off will suffice. In type III, in particular, an excess of sclerosing agent may be injected unless the site where LGV branches is visualized. This type represents the hemodynamics state that requires the closest attention. Hemodynamic classification based on the PEV is highly useful in formulating safe and effective therapeutic strategies.

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Isolated gastric varices can result in massive hemorrhage and lead to death or secondary liver failure. Therefore, gastric varices are treated not only in emergency cases but also prophylactically. Endoscopic injection sclerotherapy (EIS) and interventional radiology including balloon-occluded retrograde transvenous obliteration (B-RTO) are performed to eradicate gastric varices, and good results have been reported. In emergency case, EIS can stop bleeding from gastric varices using histoacryl or α-cyanoacrylate monomer (CA). In addition, in prophylactic case, EIS using the EO/ET/CA method can eradicate gastric variceal lumens completely. We discuss herein the endoscopic treatment methods and examinations needed to select treatment methods. In addition, EIS using CA is explained in detail.

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With regard to esophageal varices, the preferred treatment for bleeding gastric varices remains controversial and empiric. Endoscopic cyanoacrylate injection for bleeding gastric varices has been widely applied and has been reported to achieve hemostasis in more than 90% of patients with acute gastric variceal bleeding. However, reports of severe complications related to embolization in the brain, lung, portal vein and spleen have raised concerns about the safety of tissue adhesive agent injection. Nine admissions for bleeding gastric varices were treated with endoscopic hemoclipping at Showa University Fujigaoka Hospital, Yokohama, Japan. When spurting gastric variceal bleeding or fibrin clots on the gastric varices were encountered, hemoclips were applied. Endoscopic hemoclipping resulted in hemostasis for gastric variceal bleeding in all nine cases, and there was no instance of immediate post-clipping hemostatic failure. In general, hemoclipping is easy to perform, thus, this procedure is available to endoscopists who are not familiar with injection methods for variceal bleeding.

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The clinical usefulness of assessing the hemodynamic response to drug therapy as prophylaxis against variceal rebleeding is unknown. We conducted an open-labeled, uncontrolled pilot trial in which the hemodynamic response to pharmacological treatment was used to guide therapy in secondary prophylaxis to prevent variceal bleeding. Eighteen patients with acute variceal bleeding underwent a hepatic venous pressure gradient (HVPG) measurement after the episode. Treatment was initiated with the oral angiotensin II type 1 receptor blocker Olmesartan, and a second HVPG was measured 14 days later. Responder patients (≥20% decrease in HVPG from baseline) were maintained on drugs, nonresponders (<20%) had banding ligation added to the drugs. Six patients were classified as responders (33.3%) ; 12 as non responders (66.7%) with the addition of banding. We compared the 18 patients with 247 retrospective control patients who had only received endoscopic variceal therapy without drug therapy. There was no significant difference with respect to baseline characteristics including age, sex, etiologies of cirrhosis, hepatic function. The non-rebleeding rate was not statistically significantly different at 1 and 3 years (93% vs. 95%, and 78% vs. 83%, respectively). In conclusion, using the hemodynamic response to pharmacological treatment to guide therapy in secondary prophylaxis to prevent variceal bleeding is feasible and effectively protects patients from rebleeding.

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Ascites develops in patients with cirrhosis because of the development of portal hypertension in concert with splanchic vasodilatation, renal sodium retention, and active renal vasoconstriction. The quality of life (QOL) of patients with refractory ascites is markedly compromised, and these patients are frequently admitted to the hospital for recurrence of tense ascites, renal failure, infection, or other related morbidities. Approximately 50% of these patients die within 12 months. A number of approaches have been taken in the management of patients with refractory ascites, including peritoneovenous shunts (PVS), repeated large volume paracentesis (LVP), and transjugular intrahepatic portosystemic shunt (TIPS). In the TIPS groups, the percentage of patients who showed improvement in their ascites was 49% while in the LVP groups improvement was seen in 90% of patients. The average survival at 2 years of follow-up was 60% for patients allocated to TIPS and 15～30% for patients allocated to LVP or PVS, respectively. Several controlled studies have suggested that patients who underwent TIPS for refractory ascites experienced improved QOL.

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This study was performed to investigate the results of long-term treatment with a transjugular intrahepatic portosystemic shunt (TIPS) to determine the indications for this treatment. The study subjects comprised 20 patients who had undergone TIPS between 1993 and 2007. TIPS was performed for refractory ascites in 13 patients, refractory varices in 5, and refractory pleural effusion and PHG in 1 patient each. A shunt was placed between the hepatic vein and the portal vein branch. The portal vein pressure after TIPS was significantly reduced. Encephalopathy was observed in 10 patients, but it was controllable. The efficacy rate of TIPS for ascites was 84.6%, and pleural effusion completely disappeared following TIPS. Refractory varices showed negative red color signs. Shunt malfunction was found in 9 patients (45.0%), with a patency rate of 68.8% at 1 year and 50.4% at 3 years. The survival rate was 72.2% at 1 year, 46.8% at 3 years, and 18.7% at 5 years. The prognoses of alcoholic cirrhotic patients were good. On the other hand, the prognoses of patients with viral cirrhosis and those with preoperative total bilirubin values of more than 2.5 mg/dL were poor, and the causes of death included hepatic failure in 13 patients and hemobilia in 1 patient. Accordingly, TIPS is favorably applied for treatment of alcoholic cirrhosis, but it should be performed with caution for the treatment of viral cirrhosis and severe hepatic impairment. Although the incidence of shunt malfunction is high, the malfunction is recoverable, and its early detection is important.

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The aim of this study was to analyze the effect of liver transplantation on portosystemic collaterals in patients with hypersplenism. Between December 2001 and February 2007, 462 adult patients underwent orthotopic liver transplantations (OLTX) at our institution, in whom CT or MRI information was reviewed retrospectively. Fifty-five patients with hypersplenism were included in this study. We evaluated spleen volume and collateral vessels before and after OLTX. Spleen volume decreased from 827±463mL to 662±376mL after OLTX (P<0.01). A spontaneous spleno-renal shunt (SRS) was observed in 19 patients (35%). SRS was not detected postoperatively in 3 cases ; size decreased in 7 cases, was unchanged in 6 cases, and increased in 3 cases. The development of esophagogastric varices (EGV) and/or para-esophageal veins (PEV) was observed on preoperative CT or MRI in 27 patients (49%). These vessels were not detected postoperatively in 8 patients ; size decreased in 14 and was unchanged in 5 patients. Portosystemic collaterals improved but did not disappear after OLTX in many cases.

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We report herein on a rare complication of a secondary aortoenteric fistula at the colon after reconstruction of an abdominal aortic aneurysm. A 74-year-old man had undergone Y-shaped graft replacement for an abdominal aortic aneurysm 8 years previously and an operation for a perforated gastric ulcer 2 years previously. He was admitted with melena in September 2008. Although colonoscopy identified the probable origin of the bleeding as an elevated lesion detected at the sigmoid colon, we could not obtain the patient's his family's consent for operation. He was admitted with melena again in October 2008, and this time we performed a surgical procedure with their consent. Laparotomy revealed adhesion between the sigmoid colon and the retroperitoneum. When sigmoid colon was opened, a prosthetic graft was found at the base of the granulation tissue. A secondary aortoenteric fistula was diagnosed between the anastomotic site of the right graft limb and the sigmoid colon, and removal of the contaminated right graft limb was performed. The sigmoid colon was exteriorized. The patient's ostoperative course was uneventful and he was initially discharged, but hemorrhage from a pseudoaneurysm at the anastomotic site of the right iliac artery occurred in December 2008. We thus performed a right axillobifemoral bypass and removal of the Y-shaped graft.

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A 63-year-old male with sudden abdominal pain went to a hospital and a superior mesenteric artery (SMA) embolism was suspected based on abdominal CT findings. The patient was brought to our hospital in good general condition but with tenderness in the lower abdominal region. Blood chemistry revealed a high lactic acid value at 31.3 mg/dL. CT revealed that there was no embolism in the SMA, a poorly enhanced area was observed in parts of the ileum, and the mesentery was edematous. Based on these findings, our diagnosis was non-occlusive mesenteric ischemia (NOMI). The angiographic findings resembled those on CT. No improvement of the arterial narrowing was achieved following injection of papaverine hydrocholoride, but the abdominal pain improved markedly. CT just after this exam revealed improvement in the ischemic changes of the ileum, and the lactic acid levels returned to normal. Based on these findings we believed that no necrosis existed in the small intestine. Angiography 48 hrs after the continuous infusion of papaverine hydrocholoride demonstrated improvement of the narrowing of the ileal arteries. The patient's course was uneventful after this and he was discharged on the 13th hospital day.

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A 65-year-old man was admitted with abdominal pain and fever. Ileocecal inflammation was identified at that hospital, and the patient was referred to our hospital. We recognized umbilicus and right lower quadrant tenderness. Multidetector-row computed tomograph (MD-CT) showed a 34×28mm low density area at the right lower quadrant and a high density spot inside the inflammatory tumor. During our preliminary examination the patient reported that he had eaten fish before the symptoms appeared. Based on which our diagnoses was an abdominal abscess caused by a fish bone which had perforated the abdominal cavity. Conservative treatment failed to elicit an improvement, so we performed an appendectomy and drainage. Intraoperatively, a perforation was seen with a piece of fish bone at the tip of the appendix. We recognized that this bone was at the core of abscess. In the case of intestinal damage by aspiration, there is no specific symptom. In this case diagnosis was enabled by the combination of careful history-taking and the MD-CT findings.

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We report herein on a case of hemorrhage from a duodenal diverticulum treated with a pylorus preserving pancreaticoduodenectomy. A 78-year-old woman presented with hematemesis. Gastrointestinal endoscopy revealed a dark red agger with bleeding at the second duodenal segment, right orally to the papilla. The bleeding persisted even after electrocoagulation. Since abdominal angiography showed extravasation at the branch of posterior superior pancreaticoduodenal artery, transarterial embolization was performed, but anemic deterioration was observed. Computed tomography examination identified bleeding from a neoplasm-like lesion around the major duodenal papilla or at pancreatic head. The patient underwent a pylorus-preserving pancreaticoduodenectomy. The postoperative histologic examination revealed diverticulitis of the second duodenal segment with erosion, ulcer and granulation. This was regarded as the source of the bleeding. Recently most cases of bleeding duodenal diverticula have been treated with endoscopic therapy. Nevertheless we should recognize the presence of a few cases of bleeding duodenal diverticula which cannot be treated successfully with conservative therapy and resemble neoplasm-like lesions owing to their inflammatory granulation.

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We report a case of type III pancreatic injury successfully treated with a pancreatogastrostomy. A 36-year-old woman was caught between a cow and a fence, and had a bruise on her abdomen. She was admitted to our hospital with pancreatic injury diagnosed with abdominal computed tomography (CT). CT revealed a complete transection of the pancreas and emergency surgery was performed. Laparotomy showed a complete pancreatic transection including the main pancreatic duct at the right border of the superior mesenteric vein. The oral stump of the main pancreatic duct was closed with ligations and the pancreatic stump with 3-0 silk interrupted sutures. The distal pancreas was preserved and the stump was anastomosed to the stomach to preserve pancreatic function. The patient's postoperative course was uneventful except for a transient fever at the beginning of oral intake. The blood glucose level remained normal, and exocrine pancreatic function was been preserved at one year after discharge. It is considered that a distal pancreatogastrostomy is a suitable procedure for type III pancreatic injury from the standpoint of preserving pancreatic function.

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A 71-year-old man attended the ER in our hospital with severe lower abdominal pain and, under the diagnosis of acute enteritis, was followed up conservatively. Two days later, he was admitted to our hospital for regular hemodialysis, at which time his symptoms had persisted. Abdominal computed tomography (CT) revealed free air and we diagnosed perforated peritonitis. We started conservative therapy because the abdominal pain did not become worse. Five days after admission, no major change was seen in his symptoms and follow-up CT showed a pericecal abscess. We performed percutaneous drainage of the pericecal abscess and the patient's symptom improved immediately. Six months later, we performed a total colonoscopy and follow-up CT. We found cecal diverticula without inflammation and the cecal abscess had disappeared.

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We report herein on the successful treatment of an anorectal impalement injury that reached the chest cavity. A 52-year-old male construction site worker fell from a height onto a reinforcing bar that entered his body through the anus. The rebar was removed at the site without emergency transportation or a rescue request. When he reached our hospital he was fully conscious and only complained of pain. A thoracoabdominal computed tomography scan revealed left hemopneumothorax and a small amount of ascites. He underwent emergency surgery under general anesthesia. During the laparotomy, part of the rectum was observed to be damaged ; we repaired this damage and reconstructed an artificial sigmoid anus with double orifices. Furthermore, mesenteric, gastric, and diaphragmatic damage were detected via an intraperitoneal examination. During thoracotomy, following the abdominal injury repair, hemorrhagic pleural effusion including saburra and damage to the lingula of the left lung were observed ; therefore, we inferred that the rebar had also pierced the lung via the abdominal cavity. The heart and major blood vessels were not damaged. After surgery, 5-day intensive treatment was required ; however, the patient showed satisfactory progress and was discharged from the hospital on day 21 post-surgery.

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The patient was an 81-year-old women who was diagnosed as having adenocarcinoma of the left lower lobe of the lung (cT3N2M1 Stage IV) in April 2008. She was followed up without any treatment, because she rejected chemotherapy. In June, she was admitted for radiation therapy for right acetabular metastasis. Lower abdominal pain suddenly occurred 14 days after admission. Abdominal computed tomography examination showed free air in the abdominal cavity. She was diagnosed as having perforating peritonitis and underwent an emergency operation. During the operation, a perforated ileum was observed, and partial resection of the intestine was performed. The pathologic diagnosis of the resected specimen was metastasis of lung cancer to the small intestine. She was able to eat after the operation, however, the pulmonary lesion progressed, the patient's general condition deteriorated, and the patient died on the 81st postoperative day. Metastasis to the small intestine from lung cancer is rare, and the prognosis of peritonitis due to perforated intestinal metastasis from lung cancer is poor. It should however be considered when progressive abdominal symptoms are observed in patients with lung cancer.

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An 85 year-old female was referred to our care for treatment of abdominal pain and fever not resolving following an inpatient course of 6 days. On arrival, she had severe generalized abdominal pain with guarding. Abdominal CT showed a massive ileocecal lesion and abscess with cavitation, as well as free air adjacent to the liver. We diagnosed peritonitis due to cecal perforation and performed emergency surgery. Upon opening the abdomen, a discolored mass was observed in the small intestine which yielded an abundance of purulent white discharge during dissection. We excised the structures forming the abscess, resecting approximately 2 m of bowel including the ileocecal region in the process. Macroscopic findings included significant thickening of the cecal wall as a solid white mass with the lumen being relatively preserved. A large perforation was found near the base of the appendix. The appendix itself could not be identified. Microscopic findings included polymorphic atypical cell growth extending from the lamina propria, infiltrating beyond the intestinal wall. Immunohistochemical analysis led to the diagnosis of diffuse large B cell lymphoma. The patient made a transient recovery following surgery but died 117 days later.

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Blunt injury to the renal artery occurs infrequently. A 61-year-old male had an approximately 8 m fall in his factory workplace and presented at our emergency room. Simple X-ray and computed tomography (CT) revealed mild contusion of the lung and liver, right rib fracture, right radius fracture, pelvic fracture and right femur fracture. Enhanced CT scan showed a lack of contrast in the right kidney. Angiography revealed that the main right renal artery was occluded. A laparotomy was performed for revascularization of the right renal artery. We had to remove the patient's right kidney, however, because of advanced congestion. Pneumonia occurred and ventilatory support was needed. He was discharged 100 days after the accident. Our review of the literature found that nonoperative management should be considered in patients with unilateral renal artery injury who are hemodynamically stable.

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A 14-year-old boy was admitted for abdominal pain. He had no history of laparotomy. Plain X-ray of the abdomen showed a dilated small intestine, and abdominal computed tomography (CT) showed a whirl shaped mass involving the small bowel and mesentery around the superior mesenteric artery. The patient was diagnosed as having volvulus of the small intestine and underwent emergency surgery. The small intestine was found to be twisted and rotated about 270°C clockwise by mesenteric torsion. Because of the absence of malrotation and other predisposing anatomical abnormalities, we diagnosed primary volvulus of the small intestine. Necrosis of the small bowel was not present, so only reduction of the torsion was performed. The patient's course was favorable. Acute abdomen in childhood presents a diagnostic challenge, especially an intestinal obstruction in the absence of a history of laparotomy. An abdominal CT scan provides useful information for diagnosing volvulus of the small intestine.

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Emphysematous cystitis and emphysematous pyelonephritis are relatively rare urinary tract infections with gas collection. It is very rare that both can develop at the same time. We describe a case of emphysematous cystitis occurring together with emphysematous pyelonephritis. A 78-year-old man undergoing stroke rehabilitation in our hospital presented with gross hematuria and fever. As computed tomography revealed a characteristic gas collection in the right renal pelvis and the bladder, we diagnosed emphysematous cystitis with emphysematous pyelonephritis. His condition gradually improved with administration of antibiotics and ureteral catheter drainage. In Japan, there are five reports of emphysematous cystitis with emphysematous pyelonephritis including our case, and all of them were accompanied with hydronephrosis or ureteral dilation. In one case, cystoscopy showed that vesical emphysema occluded the ureteral orifice. Based on these findings, it is supposed that occlusion of the ureteral orifice by vesical emphysema induces hydronephrosis and emphysematous pyelonephritis. The upper urinary tract should therefore be checked in any case of emphysematous cystitis.

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