Background factors of idiopathic peptic ulcers and optimal treatment methods: a multicenter retrospective Japanese study.

This study investigated the trends in idiopathic peptic ulcers, examined the characteristics of refractory idiopathic peptic ulcer, and identified the optimal treatment. The characteristics of 309 patients with idiopathic peptic ulcer were examined. We allocated idiopathic peptic ulcers that did not heal after 8 weeks' treatment (6 weeks for duodenal ulcers) to the refractory group and those that healed within this period to the healed group. The typical risk factors for idiopathic peptic ulcer (atherosclerosis-related underlying disease or liver cirrhosis complications) were absent in 46.6% of patients. Absence of gastric mucosal atrophy (refractory group: 51.4%, healed group: 28.4%; p = 0.016), and gastric fundic gland polyps (refractory group: 17.6%, healed group: 5.9%; p = 0.045) were significantly more common in the refractory group compared to the healed group. A history of H. pylori eradication (refractory group: 85.3%, healed group: 66.0%; p = 0.016), previous H. pylori infection (i.e., gastric mucosal atrophy or history of H. pylori eradication) (refractory group: 48.5%, healed group: 80.0%; p = 0.001), and potassium-competitive acid blocker treatment (refractory group: 28.6%, healed group, 64.1%; p = 0.001) were significantly more frequent in the healed group compared to the refractory group. Thus, acid hypersecretion may be a major factor underlying the refractoriness of idiopathic peptic ulcer.

Diagnostic criteria and endoscopic and histological findings of autoimmune gastritis in Japan.

The Japanese diagnostic criteria for autoimmune gastritis (AIG) were established by the "Study Group on the establishment of diagnostic criteria for type A gastritis," which is related to a workshop associated with the Japan Gastroenterological Endoscopy Society (JGES) and the Committee of AIG Research Group (CARP). The criteria were set as follows: the cases of confirmed diagnosis are patients in whom either the endoscopic or histological findings, or both, meet the requirements for AIG and who are confirmed to be positive for gastric autoantibodies (either anti-parietal cell or anti-intrinsic factor antibodies, or both). The presentation of endoscopic findings of early-stage AIG in the diagnostic criteria was withheld owing to the need for further accumulation and characterization of endoscopic clinical data. Therefore, diagnosis of early-stage AIG only requires histological confirmation and gastric autoantibody positivity. Suspected cases are patients in whom either the endoscopic or histological findings, or both, meet only the requirements for AIG. Histological findings only meet the requirements for early stage. AIG has been underdiagnosed in the past, but our study group's newly proposed diagnostic criteria will enable a more accurate and early diagnosis of AIG. The criteria can be used to stratify patients into various high-risk groups for gastric tumors and pernicious anemia. They would allow the establishment of an appropriate surveillance system in the coming years. Nevertheless, issues such as establishing the endoscopic findings of early-stage AIG and obtaining Japanese insurance coverage for gastric autoantibody tests require attention.

Clinical characteristics and long-term prognosis of type 1 gastric neuroendocrine tumors in a large Japanese national cohort.

OBJECTIVES: Optimal management of type 1 gastric neuroendocrine tumors (T1-GNETs) remains unknown, with few reports on their long-term prognosis. This study investigated the clinical characteristics and long-term prognosis of T1-GNETs. METHODS: We reviewed the medical records of patients diagnosed with T1-GNET during 1991-2019 at 40 institutions in Japan. RESULTS: Among 172 patients, endoscopic resection (ER), endoscopic surveillance, and surgery were performed in 84, 61, and 27, respectively, including 27, 77, and 2 patients with pT1a-M, pT1b-SM, and pT2 tumors, respectively. The median tumor diameter was 5 (range 0.8-55) mm. Four (2.9%) patients had lymph node metastasis (LNM); none had liver metastasis. LNM rates were significantly higher in tumors with lymphovascular invasion (LVI) (15.8%; 3/19) than in those without (1.1%; 1/92) (P = 0.016). For tumors <10 mm, LVI and LNM rates were 18.4% (14/76) and 2.2% (2/90), respectively, which were not significantly different from those of tumors 10-20 mm (LVI 13.3%; 2/15, P = 0.211; and LNM 0%; 0/17, P = 1.0). However, these rates were significantly lower than those of tumors >20 mm (LVI 60%; 3/5, P = 0.021; and LNM 40%; 2/5, P = 0.039). No tumor recurrence or cause-specific death occurred during the median follow-up of 10.1 (1-25) years. The 10-year overall survival rate was 97%. CONCLUSIONS: Type 1 gastric neuroendocrine tumors showed indolent nature and favorable long-term prognoses. LVI could be useful in indicating the need for additional treatments. ER for risk prediction of LNM should be considered for tumors <10 mm and may be feasible for tumors 10-20 mm. TRIAL REGISTRATION: The study protocol was registered in the University Hospital Medical Information Network (UMIN) under the identifier UMIN000029927.

Endoscopic features and clinical importance of autoimmune gastritis.

Autoimmune gastritis (AIG) is a special type of chronic gastritis characterized by autoimmune disorders caused by cellular immunity, resulting in the destruction of parietal cells and production of antiparietal cell antibodies. Endoscopic findings of AIG are mainly characterized by corpus-dominant advanced atrophy. The antral area is generally considered to have no or mild atrophy; however, there are cases wherein the gastric mucosa is red or faded due to past infection with Helicobacter pylori or bile reflux. Currently, there are no diagnostic criteria for AIG in Japan, and it is important to make a diagnosis based on the presence of gastric autoantibodies and characteristic endoscopic and histological findings. AIG is associated with gastric cancer, neuroendocrine tumors (NETs), and other autoimmune diseases, such as thyroid diseases, anemia, and neurological symptoms due to impaired absorption of iron and vitamin B12 , and thus requires systemic treatment. The significance of diagnosing AIG is to include patients as a high-risk group for the development of gastric cancer and gastric NETs, provide an opportunity to detect autoimmune endocrine diseases, and initiate therapeutic intervention before anemia and neurological symptoms develop. It is important to pay close attention to the occurrence of AIG comorbidities not only at the time of AIG diagnosis but also during follow-up after detection.

Gastric epithelial neoplasm of fundic-gland mucosa lineage: proposal for a new classification in association with gastric adenocarcinoma of fundic-gland type.

BACKGROUND: Gastric adenocarcinoma of fundic-gland type (GA-FG) is a rare variant of gastric neoplasia. However, the etiology, classification, and clinicopathological features of gastric epithelial neoplasm of fundic-gland mucosa lineage (GEN-FGML; generic term of GA-FG related neoplasm) are not fully elucidated. We performed a large, multicenter, retrospective study to establish a new classification and clarify the clinicopathological features of GEN-FGML. METHODS: One hundred GEN-FGML lesions in 94 patients were collected from 35 institutions between 2008 and 2019. We designed a new histopathological classification of GEN-FGML using immunohistochemical analysis and analyzed via clinicopathological, immunohistochemical, and genetic evaluation. RESULTS: GEN-FGML was classified into 3 major types; oxyntic gland adenoma (OGA), GA-FG, and gastric adenocarcinoma of fundic-gland mucosa type (GA-FGM). In addition, GA-FGM was classified into 3 subtypes; Type 1 (organized with exposure type), Type 2 (disorganized with exposure type), and Type 3 (disorganized with non-exposure type). OGA and GA-FG demonstrated low-grade epithelial neoplasm, and GA-FGM should be categorized as an aggressive variant of GEN-FGML that demonstrated high-grade epithelial neoplasm (Type 2 > 1, 3). The frequent presence of GNAS mutation was a characteristic genetic feature of GEN-FGML (7/34, 20.6%; OGA 1/3, 33.3%; GA-FG 3/24, 12.5%; GA-FGM 3/7, 42.9%) in mutation analysis using next-generation sequencing. CONCLUSIONS: We have established a new histopathological classification of GEN-FGML and propose a new lineage of gastric epithelial neoplasm that harbors recurrent GNAS mutation. This classification will be useful to estimate the malignant potential of GEN-FGML and establish an appropriate standard therapeutic approach.

Two independent families with strongly suspected hereditary diffuse gastric cancer based on the probands' endoscopic findings.

Hereditary diffuse gastric cancer (HDGC) is the most famous of hereditary gastric cancer syndromes with an autosomal dominant inheritance pattern, and its diagnosis can be made by identifying a pathogenic germline variant in CDH1. We report two independent families that were strongly suspected of having HDGC based on endoscopic findings (multiple tiny, pale areas) obtained in the probands; the probands were pathologically diagnosed as having signet ring cell carcinoma (SRCC) and were genetically confirmed to have a pathogenic CDH1 germline variant. Although the updated International Gastric Cancer Linkage Consortium (IGCLC)'s clinical guidelines for HDGC (2015) state that screening/surveillance endoscopy should be performed (Cambridge protocol), the endoscopic findings obtained in the two presently reported families suggest that pale areas should be suspected as indicating the presence of SRCCs, and biopsies should be performed in addition to obtaining a precise family history in cases suspected of having HDGC.

Clinical and endoscopic characteristics of eosinophilic esophagitis in Japan: a case-control study.

BACKGROUND: Eosinophilic esophagitis (EoE) is an allergy-associated clinicopathologic condition gaining an increasing amount of recognition in various areas of the world. While the clinical definition and characteristics may differ depending on country and region, sufficient studies have not yet been performed in Japan. OBJECTIVE: To assess the prevalence of EoE among the Japanese population and the clinical features associated with the disease. METHODS: Endoscopic data from January 2012 to October 2018 was gathered from 9 Japanese clinical institutes. EoE, defined as esophageal mucosal eosinophilia of at least 15 eosinophils per high-power field, was determined based on esophageal biopsies. Clinical and endoscopic patterns in the cases with EoE were investigated and compared with 186 age- and sex-matched controls. RESULTS: From 130,013 upper endoscopic examinations, 66 cases of EoE were identified (0.051%; mean age, 45.2 years [range, 7-79 years]; 45 males). Twenty-five patients (37.9%) with EoE were diagnosed by endoscopy during a medical check-up. Patients with EoE had more symptoms (69.7% vs. 10.8%, p < 0.01) such as dysphagia and food impaction, and more allergies (65.2% vs. 23.7%, p < 0.01) compared with the controls. The prevalence of atrophic gastritis was lower in EoE patients than in the controls (20.0% vs. 33.3%, p < 0.05). CONCLUSION: The prevalence of EoE in the Japanese population was 0.051% which was comparable with previous reports in Japan. History of allergies and the absence of atrophic gastritis were associated with EoE.

Multicenter study of autoimmune gastritis in Japan: Clinical and endoscopic characteristics.

BACKGROUND AND AIM: In Japan, the prevalence of autoimmune gastritis (AIG) is assumed to be very low. With the recent rapid decrease in Helicobacter pylori (Hp) prevalence, reports on AIG are increasing. This multicenter registry study aimed to clarify the characteristics of AIG, especially its endoscopic appearance. METHODS: A total of 245 patients with AIG from 11 institutions in Japan from January 2010 to October 2016 were included, and their clinical and endoscopic findings were evaluated. RESULTS: Mean age was 67.2 ± 11.4 years, and 63.7% of the participants were women. The most common approach to diagnose AIG was endoscopic examination. Repeated incorrect treatment for Hp infection, due to a false-positive result in 13 C-urea breath test, ranked third among the basis for diagnosis of AIG. Associated gastric lesions were type 1 neuroendocrine tumor (11.4%), adenocarcinoma (9.8%), and hyperplastic polyps (21.1%). Corpus pan-atrophy was the most common appearance (90.1%); however, remnant oxyntic mucosa was found in 31.5% of the patients (flat, localized type, 48.6%). Sticky adherent dense mucus and scattered minute whitish protrusions were also observed in approximately 30% of the patients. Despite the prevailing presumption of the antral mucosa remaining normal, 42.3% of the patients presented with various extents of atrophy, and patchy redness and circular wrinkle-like patterns were both observed in approximately 20% of the patients. CONCLUSIONS: The present study showed some prominent clinical characteristics and endoscopic findings of AIG. We believe that our study will facilitate the diagnosis of potential AIG.

Hypophosphatemia predicts a failure to recover from adefovir-related renal injury after dose reduction in lamivudine-resistant hepatitis B patients.

AIM: In chronic hepatitis B patients receiving 10 mg adefovir, dose reduction is recommended when renal injury appears. However, recovery is not always achieved and markers that recommend switching to another antiviral agent are unknown. We investigated adefovir-related renal injury, recovery after dose reduction, and their predictors. METHODS: The renal injury in 77 chronic hepatitis B patients receiving 10 mg adefovir and recovery after dose reduction to alternate day administration in those with adefovir-related renal injury were assessed. The predictors for >20% estimated glomerular filtration rate (eGFR) decline following treatment with 10 mg adefovir and for >20% eGFR recovery after dose reduction were investigated. RESULTS: The adefovir dose was reduced in 26 patients (34%) at 59 ± 30 (mean ± standard deviation) months of 10 mg adefovir treatment because of decreases in eGFR (cumulative incidence 27%), serum phosphorus (9%), and uric acid (16%) levels, and increases in alkaline phosphatase (20%), bone type alkaline phosphatase (18%), urinary α1-microglobulin (18%), and urinary N-acetyl-ß-D-glucosaminidase (18%) levels. The only significant predictor for >20% eGFR decline was age ≥50 years at the start of 10 mg adefovir treatment. The cumulative eGFR recovery rate was 42% at 42 ± 27 months after dose reduction, and ≥2.5 mg/dL serum phosphorus level at dose reduction was the only significant predictor for >20% eGFR recovery after dose reduction. CONCLUSION: Patients aged ≥50 years are predisposed to adefovir-related renal injury and switching to another antiviral agent rather than adefovir dose reduction is recommended when hypophosphatemia is observed.

The Ulcerative Colitis Endoscopic Index of Severity More Accurately Reflects Clinical Outcomes and Long-term Prognosis than the Mayo Endoscopic Score.

BACKGROUND AND AIMS: The Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and the Mayo endoscopic score (Mayo ES) are used to evaluate ulcerative colitis (UC) severity. This study compared UCEIS and the Mayo ES for evaluating UC severity and outcomes in patients undergoing remission induction during routine clinical practice with the aim of predicting medium- to long-term prognosis. METHODS: Forty-one UC patients who received colonoscopy before and after tacrolimus remission induction therapy were included. An index of clinical activity and endoscopic findings scored by both the UCEIS and the Mayo ES were determined. Changes in UCEIS and Mayo ES before and after induction therapy were compared. RESULTS: The mean UCEIS improved from 6.2±0.9 to 3.4±2.1 (p < 0.001). Based on the UCEIS, a significant reduction was reached in both the response and the remission groups. In contrast, the Mayo ES did not reflect a significant change in the response group. The discrepancy appeared to be due to ulcers becoming smaller and shallower during the early stages of mucosal healing; the Mayo ES seems to miss these early changes. In other words, whereas the UCEIS indicates improvements when ulcers shrink, the Mayo ES does not distinguish deep ulcers from shallow ulcers and is 3 (severe UC) for both deep and shallow ulcers. Additionally, better UCEIS strata after induction therapy were associated with lower incidences of colectomy (p = 0.0001) or relapse (p = 0.0008). CONCLUSIONS: The UCEIS accurately reflects clinical outcomes and predicts the medium- to long-term prognosis in UC patients undergoing induction therapy. These findings should support decision-making in clinical practice settings.

Characteristics of Colonic Diverticulitis and Factors Associated With Complications: A Japanese Multicenter, Retrospective, Cross-Sectional Study.

BACKGROUND: Little is known about the epidemiology of diverticulitis in Japan. Additional information is needed about its clinical characteristics and the factors associated with complications of diverticulitis. OBJECTIVE: This study was designed to determine the clinical characteristics of diverticulitis and factors associated with its complications in Japanese patients. DESIGN: This was a retrospective, multicenter, large-scale, cross-sectional study. SETTINGS: All of the consecutive patients in 21 Japanese hospitals with a final diagnosis of acute colonic diverticulitis were included in this study. PATIENTS: A total of 1112 patients, including 658 men and 454 women, with a mean age of 54.8 years, who were diagnosed by CT and/or ultrasonography between January 2006 and May 2011, were included in this study. INTERVENTIONS: Data on medical history, investigations, treatments, and prognosis were collected using a standard form to create a dedicated database. MAIN OUTCOME MEASURES: Clarification of the clinical characteristics of Japanese patients with acute diverticulitis was the main outcome measured. RESULTS: Diverticulitis was detected mainly in men and women aged 40 to 60 years. Although diverticulitis more frequently affected the right colon (70.1%), diverticulitis of the left colon was significantly more frequent (61.0%) in elderly patients. Of the 1112 patients with diverticulitis, 179 (16.1%) developed complications, including abscess formation, perforation, stenosis, and/or fistula, some of which required surgical treatment, such as drainage or colonic resection. The duration of hospitalization (24.1 ± 19.5 days) and mortality rate (2.8%) were significantly higher in patients with versus without complications. Factors associated with complications were fever (>38.5°C), involvement of the left colon, higher age, and delayed diagnosis. LIMITATIONS: Limitations included the nonconsideration of diverticulitis treatment, the effect of dietary fiber, and the retrospective design of the study. CONCLUSIONS: Complications were more frequent in elderly men with left-sided diverticulitis, although diverticulitis was more common in middle-aged people and on the right side of the colon. Factors associated with complications were fever, site of involvement, older age, and longer time until diagnosis.

Myxoid epithelioid gastrointestinal stromal tumor harboring an unreported PDGFRA mutation: report of a case and review of the literature.

Activating mutations of platelet-derived growth factor receptor α (PDGFRA) are detected in a significant proportion of gastrointestinal stromal tumors (GISTs), in addition to the more frequent mutation in c-kit. GISTs with PDGFRA mutations have been found to have several characteristic morphological features, sometimes allowing to discriminate them from GISTs with c-kit mutations. Among these, epithelioid morphology in tumor cells and tumor-infiltrating mast cells are powerful predictors of PDGFRA mutations. Although myxoid stroma by itself is not so much a reliable predictor of PDGFRA mutation, myxoid stroma in conjunction with epithelioid morphology in tumor cells is a powerful predictor of mutations in this gene. GISTs showing either weak or negative immunoreactivity for c-kit and epithelioid cells with myxoid stroma are called myxoid epithelioid GISTs, which typically show PDGFRA mutation. Herein, we presented a case of a 59-year-old woman with myxoid epithelioid GIST of the stomach. A unique finding in this case was eosinophil infiltration, probably more numerous than mast cells; mast cell infiltration is known to be usually found in myxoid epithelioid GIST. The existence of a similar mechanism in eosinophil and mast cell recruitment via tumor-producing stem cell factor is speculated. Mutational analyses revealed a PDGFRA exon 18 mutation: D842_H845del, D846N. Combined deletion and substitution mutation has been reported in rare instances, but to the best of our knowledge, D846N has not been documented.

Intraductal papillary neoplasm of the bile duct, gastric type, arising in the intrapancreatic common bile duct could progress to colloid carcinoma: report of a case.

Intraductal papillary neoplasm of the bile duct (IPNB) exists in a pathway of multistep-carcinogenesis toward cholangiocarcinoma. Four subtypes are observed in IPNB, pancreatobiliary type, intestinal type, gastric type, and oncocytic type, similarly to the corresponding disease in the pancreas, intraductal papillary mucinous neoplasm (IPMN). IPNB can present with or without macroscopically visible mucin secretion. IPNB usually progresses to tubular adenocarcinoma. However, there are a limited number of well-described cases of gastric-type IPNB progressing not to tubular adenocarcinoma but to colloid carcinoma. Herein, we present a case of an 82-year-old female patient with gastric-type IPNB in the intrapancreatic common bile duct without macroscopically visible mucin secretion, which progressed to colloid carcinoma. As IPNB, especially without visible mucin secretion, is considered to be a heterogeneous group of diseases, such an unexpected association could occur.

Xanthogranulomatous gastritis associated with actinomycosis: report of a case presenting as a large submucosal mass.

Xanthogranulomatous gastritis (XGG) is a rarely encountered condition, and its causative mechanism is still unclear. Given that some types of xanthogranulomatous inflammation (XGI) are associated with pathogens, infection should be considered as a possible cause of XGG. Herein, we report a case of an 86-year-old woman presenting with a large, bleeding lesion resembling a submucosal tumor. Distal gastrectomy was performed, and the surgically resected specimen revealed a mass measuring 6 × 4.5 × 3 cm and appearing yellowish on the cut surface. Histopathological examination revealed a few Actinomyces "sulfur granules" and cellular composition characteristic of XGI, supporting a diagnosis of XGG associated with actinomycosis. Gastric actinomycosis is a rare condition and has not previously been reported in association with XGG, although rare cases of XGI associated with actinomycosis have been documented in other organs.

Tacrolimus for remission induction in ulcerative colitis: Mayo endoscopic subscore 0 and 1 predict long-term prognosis.

BACKGROUND: Tacrolimus has shown efficacy in patients with ulcerative colitis. AIMS: To evaluate the efficacy of tacrolimus as remission induction therapy and assess medium to long-term outcomes in patients who achieve remission. METHODS: Forty-four ulcerative colitis patients who were treated with tacrolimus in three institutes during 2009-2013 were retrospectively reviewed. Short-term efficacy was based on the clinical activity index and the Mayo endoscopic subscores. Clinical activity index≤4 meant clinical remission, while Mayo endoscopic subscore 0 or 1 meant mucosal healing. Medium to long-term prognosis was based on relapse free survival in relation to the Mayo endoscopic subscore and duration of tacrolimus therapy in patients who achieved remission. RESULTS: At 12 weeks, clinical remission was achieved in 29 of 44 patients (65.9%). Thirty-two patients received endoscopic evaluations, and mucosal healing rate was 43.8%. Among patients with clinical remission, mucosal healing rate was 60.9%. Relapse-free survival at 6, 12, and 24 months were 66%, 56%, and 50%, respectively, and was higher in patients on long-term tacrolimus (over 4 months, P=0.03), and patients with better endoscopic subscore (P=0.009). CONCLUSIONS: Mucosal healing observed within 12 weeks or after a longer duration of tacrolimus therapy was associated with significantly better remission maintenance time.

Successful transarterial embolization for recurrent pseudoaneurysm of the right hepatic artery with acute cholecystitis.

Pseudoaneurysm of the right hepatic artery is an extremely rare complication of acute cholecystitis. We report a patient with a right hepatic artery pseudoaneurysm associated with acute cholecystitis who was treated successfully by transarterial embolization. We also review the literature on right hepatic artery pseudoaneurysm secondary to acute cholecystitis. A 50-year-old male visited Fujieda General Municipal Hospital with an episode of sudden headache. He was diagnosed with a subarachnoid hemorrhage and treated successfully by microcoil embolization on hospital day 4. On hospital day 54, he developed fever and right upper quadrant tenderness. Abdominal ultrasonography revealed acute cholecystitis, while color Doppler imaging showed a low-echogenic mass with a pulsatile wave pattern inside the gallbladder. Contrast-enhanced computed tomography (CE-CT) demonstrated a pseudoaneurysm in the gallbladder, and angiography disclosed a right hepatic artery pseudoaneurysm. Selective transarterial embolization (TAE) was then performed using a steel coil. Abdominal pain and fever continued after TAE, with CE-CT showing re-bleeding from the previous pseudoaneurysm. Selective angiography identified extravasation at the same place as the previous pseudoaneurysm from the posterior superior pancreaticoduodenal artery and the inferior pancreaticoduodenal artery via the epicholedochal arterial plexus. TAE was performed resulting in successful occlusion of the pseudoaneurysm.

Looking for endoscopic features of cytomegalovirus colitis: a study of 187 patients with active ulcerative colitis, positive and negative for cytomegalovirus.

BACKGROUND: Cytomegalovirus (CMV) is frequently detected in ulcerative colitis (UC) lesions of steroid-refractory patients. This has led to the suspicion that CMV might cause colitis and steroid refractoriness. METHODS: During 2003 and 2011, 187 consecutive patients were divided into group I (n = 105), corticosteroid-free and thiopurine-free in the past 6 months, and group II (n = 82), all corticosteroid refractory. The combination of serum CMV immunoglobulin (Ig)M, CMV IgG, CMV antigenemia (Ag), and real-time polymerase chain reaction assays were performed to identify CMV(+) patients. RESULTS: In group I, 79 patients were CMV IgG(+) and 26 patients were CMV IgG(-) and CMV IgM(-). In group II, 61 patients were CMV IgG(+), 1 CMV IgM(+), and 20 CMV IgG(-) and CMV IgM(-). All CMV IgG(+) patients were screened for CMV Ag. In group I, 6 of the 79 CMV IgG(+) patients were CMV Ag(+). In group II, 27 patients were CMV Ag(+). Colonoscopy was performed in all patients before screening for CMV. Similar colonoscopic features including punched out ulcers, geographic ulcers, and irregular ulcers were found in both CMV(+) and CMV(-) patients, without any striking difference between the 2 groups. CONCLUSIONS: CMV reactivation might be encouraged by immunosuppressive drugs, like corticosteroids, immunomodulators, and therefore, patients with UC are at a high risk of CMV reactivation, potentially exacerbating UC. However, this study of 187 patients, CMV(+) and CMV(-), could not find colonoscopic features unique to CMV, except that CMV might be one factor for steroid refractoriness, and UC exacerbation.

A new paradigm in ulcerative colitis: regulatory T cells are key factor which induces/exacerbates UC through an immune imbalance.

Leukocytapheresis (LCAP) appears to remove or inactivate inflammatory cells and to reset immunological responses, resulting to cure responders of ulcerative colitis (UC). The changes of T cell subsets were investigated in UC patients treated with LCAP. Levels of T cell subsets in peripheral blood before and after LCAP were analysed by flow cytometric analysis. Of 20 UC patients, 13 (65%) achieved remission and 2 (10%) showed the improvement of UC symptoms. Ratios of some T cell subtypes such as regulatory T (Treg) cells and memory T cells to CD4(+) T cells changed significantly only in responders. Especially, ratio of resting Treg/CD4(+) T cells was significantly increased after the first LCAP session, and then one of activated Treg/CD4(+) T cells was increased after 2 week. This may lead to the development of a new UC paradigm in which an imbalance in Treg cell subsets triggers the onset and/or exacerbation of UC.

[Esophageal involvement in a case of eosinophilic gastroenteritis].

A 43-year-old woman presented with severe diarrhea and vomiting in addition to abdominal distension and dysphagia which had persisted for a month. Endoscopic biopsies revealed a significant eosinophilic infiltration in the mucosal layer of the esophagus, duodenum and ileum, yielding a diagnosis of eosinophilic gastroenteritis (EG) with esophageal involvement. The endoscopic examination of esophageal lesion in this case showed linear fissures and concentric rings, both of which are characteristic findings observed in eosinophilic esophagitis (EE). This suggests that these characteristic endoscopic findings in EE can also be applied to the results of endoscopic examinations for esophageal involvement in EG.