We report here the case of a 78-year-old man who developed a recurrence of an adenocarcinoma, 15 months after initial endoscopic mucosal resection (EMR) of adenocarcinoma arising from short-segment Barrett’s esophagus. The recurrent adenocarcinoma had the appearance of a submucosal tumor and was found in an area of squamous epithelium. The new lesion was resected by EMR and the patient has had no further recurrences for 32 months. In the initial endoscopic examination, a red area of short-segment Barrett’s esophagus was detected (Figure [1]). The patient underwent examination by magnifying endoscopy and an irregularly round pit and abnormal capillaries were revealed as a cancerous area. The pathological diagnosis was adenocarcinoma. EMR was performed in February 2001. Histological investigation of the proximal edge of the tumor revealed slight submucosal invasion and squamous epithelium covering the carcinoma: the proximal margin of the resected tissue was defined as carcinoma-negative. The diameter of the cancer was 10 mm. Fifteen months after EMR, endoscopic examination revealed a submucosal tumor-like lesion with a nodular appearance in the area of squamous epithelium proximal to the original site of the tumor (Figure [2 a]). Two biopsy specimens taken from this area showed adenocarcinoma covered by squamous epithelium. This lesion was resected by EMR and was found to be a well-differentiated adenocarcinoma, 1.5 mm in diameter, located in the lamina propria and covered with squamous epithelium (Figure [2 b]). Endoscopic examination was repeated after the second EMR and no residual or recurrent lesion has been found at the latest follow-up examination in January 2005, 32 months after the second EMR. Recently, adenocarcinoma arising from Barrett’s esophagus has been treated by EMR [1] [2] [3] [4] [5]. Giovannini et al. [5] reported that out of 21 patients whose tumor resection by EMR was initially classified as complete, two patients later presented with local recurrence and underwent further treament by EMR. Follow-up endoscopic surveillance for tumor recurrence is necessary after initial EMR treament, because EMR has the potential to become a complete therapy in terms of long-term survival of patients with this disease.
Urinary tract infections (UTIs) caused by urease-producing bacteria are known to cause hyperammonemia; however, non-urease-producing bacteria can also cause it. This report describes a case of an 87-year-old woman who developed hyperammonemia and impaired consciousness resulting from a UTI caused by the non-urease-producing bacterium, Actinotignum schaalii (A. schaalii). On admission, the patient presented with urinary retention, hyperammonemia (281 μg/dL), and alkaline urine (pH 8.5). Gram staining of urine revealed the presence of gram-positive bacilli with coryneform morphology, which was suggestive of A. schaalii or Corynebacterium, with some being urease-producing bacteria. After bladder decompression through catheterization, the patient's level of consciousness improved within 30 minutes, and the ammonia level normalized. The patient's condition stabilized after ceftriaxone treatment, and she was discharged after nine days. This case demonstrated that non-producing bacteria can cause hyperammonemia and may acquire urease activity within an infected environment. In cases of hyperammonemia associated with obstructive urinary tract disorders, it is necessary to consider both urease-producing and non-urease-producing bacteria. Further, upon identification of a gram-positive bacillus, it is important to select an appropriate antimicrobial agent.
A 54-year-old female was accidentally diagnosed as having bronchoesophageal fistula by upper gastrointestinal series, who had been taken with a fit of coughing frequently since the age of 15 and recent years when she took water, especially soda pops. The fistula was found to connect with the B6 branch of the right bronchus from middle part of the esophagus. The fistula was surgically resected. After the operation clinical symptoms remarkably disappeared. The lumen of the fistula was covered with striated squamous epithelium and surrounded by the muscularis mucosae. There was no infiltration of inflammatory cells nor any adhering lymph nodes, so this case was concluded to be congenital.This disease is relatively rare. Only 94 cases have been reported in the Japanese literarure, including this case.
