During colonoscopies, clinicians often find feces accumulated in the colonic diverticula. We hypothesized that these feces and potential changes in fecal microbial communities contribute to colon diverticulitis. The aim of this study was to investigate potential changes in the fecal microbiota in symptomatic uncomplicated diverticular disease by terminal restriction fragment length polymorphism (T-RFLP) analyses of fecal microbiota from patients with colonic diverticula, and stool samples. Materials: Fifteen patients with colon diverticulum and 28 healthy volunteers were enrolled. The fecal samples were classified as follows: Group I, feces from a healthy individual; Group II, feces in colonic diverticula obtained during colonoscopy; Group III, feces from the natural defecation of Group II patients. Methods: Fecal microbiota profiles were evaluated by T-RFLP analysis. Results: T-RF patterns of fecal microbiota were divided into three clusters. Most Group I samples were included in clusters A and B, whereas most Group II samples were included in cluster C. Operational taxonomic units of 657 bp (p < 0.05) and 955 bp (p < 0.01) differed in abundance between patients with colon diverticulum and healthy individuals. Conclusions: T-RFLP analyses revealed that the fecal microbial communities in patients with diverticular disease differed from those of healthy individuals, particularly for the operational taxonomic units of 657 and 955 bp. Changes in the fecal microbiota, including Lactobacillales and Clostridium subcluster XIVa, may play a role in diverticular disease.

a b s t r a c tBackground: Neurally mediated syncope (NMS) is a disorder of autonomic nervous system (ANS) regulation. Orthostatic stress is one of the most common causative factors seen in clinical practice. Analysis of heart rate variability (HRV) is a non-invasive method that is used to assess ANS regulation. In this study, we investigated the pathophysiology of NMS using HRV in our emergency department. Methods: The subjects were 19 patients (age 25.8 ± 6.2 years old) who presented with NMS and 20 healthy individuals (age 26.6 ± 2.7 years old) who served as controls. HRV was measured in supine, sitting and standing positions. Heart rate (HR), low frequency (LF 0.04-0.15 Hz), high frequency (HF N 0.15 Hz), and coefficient of variation of the R-R interval (CVRR) were determined. Results: LF and HF in the supine position were significantly lower in the patients with NMS (p b 0.05). HR was higher in all positions in patients with NMS than in healthy individuals (p b 0.05). CVRR in the supine position was lower in the patients with NMS (p b 0.001), and it was significantly lower in patients who were positive in an orthostatic test (p = 0.0017). Area under the curve was calculated to be 0.824, and at the cutoff value of 4.997 of CVRR in supine, the sensitivity and the specificity were 78.9% and 85.0%. Conclusion: The sympathetic and parasympathetic nervous systems were both suppressed in patients with NMS. In post-syncope, parasympathetic withdrawal, rather than sympathetic reactivation, was responsible for the increased HR after syncope. CVRR may serve as a new clinical biomarker in the emergency department.

Background Spontaneous esophageal rupture, or Boerhaave syndrome, is a fatal disorder caused by an elevated esophageal pressure owing to forceful vomiting. Patients with Boerhaave syndrome often present with chest pain, dyspnea, and shock. We report on two patients of Boerhaave syndrome with different severities that was triggered by excessive alcohol consumption and was diagnosed immediately in the emergency room. Case presentation The patient in case 1 complained of severe chest pain and nausea and vomited on arrival at the hospital. He was subsequently diagnosed with Boerhaave syndrome coupled with mediastinitis using computed tomography (CT) and esophagogram. An emergency operation was successfully performed, in which a 3-cm tear was found on the left posterior wall of the distal esophagus. The patient subsequently had anastomotic leakage but was discharged 41 days later. The patient in case 2 complained of severe chest pain, nausea, vomiting, and hematemesis on arrival. He was suggested of having Boerhaave syndrome without mediastinitis on CT. The symptoms gradually disappeared after conservative treatment. Upper gastrointestinal endoscopy performed on the ninth day revealed a scar on the left wall of the distal esophagus. The patient was discharged 11 days later. In addition to the varying severity between the cases, the patient in case 2 was initially considered to have Mallory–Weiss syndrome. Conclusion Owing to similar histories and symptoms, Boerhaave syndrome and Mallory–Weiss syndrome must be accurately distinguished by emergency clinicians. CT can be a useful modality to detect any severity of Boerhaave syndrome and also offers the possibility to distinguish Boerhaave syndrome from Mallory–Weiss syndrome.

Background Spontaneous esophageal rupture, or Boerhaave syndrome, is a fatal disorder caused by an elevated esophageal pressure derived from forceful vomiting, and subsequent presentation of chest pain, dyspnea, and shock. Case presentation: We present two cases of Boerhaave syndrome that were both triggered by excessive alcohol consumption and quickly detected in the emergency room. The first patient complained of severe chest pain, nausea, and vomited on his arrival: he was diagnosed with Boerhaave syndrome complicated with mediastinitis from the computed tomography (CT) and esophagogram findings. An emergency operation was successfully performed, where a 3-cm tear was found on the left-posterior wall of the distal esophagus. The patient subsequently suffered from anastomotic leakage but was discharged 41 days later. The second patient reported severe chest pain, nausea, vomiting, and hematemesis on his arrival: he was suspected of having Boerhaave syndrome without mediastinitis based on the CT findings. The symptoms gradually disappeared after a conservative treatment. Upper gastrointestinal endoscopy performed on the 9th day revealed a scar on the left wall of the distal esophagus. The patient was discharged 11 days later. In addition to the varying severity between the cases, the second patient was also differently diagnosed with Mallory-Weiss syndrome. Conclusion Emergency clinicians must accurately distinguish Boerhaave syndrome from Mallory-Weiss syndrome as they both have similar history and symptoms. CT can be a valuable and useful modality to detect any severity of Boerhaave syndrome.

Background: Spontaneous esophageal rupture, or Boerhaave syndrome, is a fatal disorder caused by an elevated esophageal pressure owing to forceful vomiting. Patients with Boerhaave syndrome often present with chest pain, dyspnea, and shock. We report on two patients of Boerhaave syndrome with different severities that was triggered by excessive alcohol consumption and was diagnosed immediately in the emergency room.Case presentation: The patient in case 1 complained of severe chest pain and nausea and vomited on arrival at the hospital. He was subsequently diagnosed with Boerhaave syndrome coupled with mediastinitis using computed tomography (CT) and esophagogram. An emergency operation was successfully performed, in which a 3-cm tear was found on the left-posterior wall of the distal esophagus. The patient subsequently had anastomotic leakage but was discharged 41 days later. The patient in case 2 complained of severe chest pain, nausea, vomiting, and hematemesis on arrival. He was suggested of having Boerhaave syndrome without mediastinitis on CT. The symptoms gradually disappeared after conservative treatment. Upper gastrointestinal endoscopy performed on the ninth day revealed a scar on the left wall of the distal esophagus. The patient was discharged 11 days later. In addition to the varying severity between the cases, the patient in case 2 was initially considered to have Mallory–Weiss syndrome.Conclusion: Owing to similar histories and symptoms, Boerhaave syndrome and Mallory–Weiss syndrome must be accurately distinguished by emergency clinicians. CT can be a useful modality to detect any severity of Boerhaave syndrome and also offers the possibility to distinguish Boerhaave syndrome from Mallory–Weiss syndrome.

Patient: Female, 76-year-old Final Diagnosis: Drug induced hypoprothrombinemia Symptoms: Abdominal pain • fever • loss of appetite Medication: — Clinical Procedure: Blood tests • CT scan Specialty: Infectious Diseases Objective: Unusual clinical course Background: Cefmetazole (CMZ), containing an N -methyl-tetrazole-thiol (NMTT) side chain, is a therapeutic option for diverticulitis in Japan. Cephems containing an NMTT, a methyl-thiadiazol, and a thiadiazolethiol side chain are known to induce coagulation disorders. Case Report: A 76-year-old woman developed hypoprothrombinemia after receiving oral levofloxacin (LVFX) 250 mg q24h for 2 days followed by intravenous CMZ 2 g q8h for sigmoid diverticulitis. On day 5 of CMZ administration (after 12 doses in total), black stool was observed. On the following day (after 14 doses), prothrombin time (PT) prolongation was noted; PT and international normalized ratio (INR) were 37.1 s and 2.47, respectively. We diagnosed the patient with hypoprothrombinemia because of vitamin K deficiency caused by markedly elevated protein levels induced by vitamin K absence or antagonist-II on day 6 of CMZ administration. Intravenous vitamin K administration and CMZ cessation rapidly restored PT and led to the disappearance of black stool. Conclusions: The causes of vitamin K deficiency were considered to be an impaired vitamin K cycle due to CMZ and decreased vitamin K intake because of malnutrition. These findings are consistent with CMZ’s reported adverse effects. Decreased vitamin K production due to alterations in the gut bacterial flora by LVFX and CMZ was also postulated as a cause. If a bleeding tendency is noted during diverticulitis treatment with NMTT-containing cephems, switching to intravenous quinolones or carbapenems is recommended. It remains unclear how this reaction can be avoided; however, prudent monitoring of bleeding signs and PT-INR is recommended.