Detection of Lymphadenopathy as a Precursor to Autoimmune Liver Diseases Before Clinical Hepatitis Became Apparent: A Report of Two Cases.

Two patients were incidentally diagnosed with intra-abdominal lymphadenopathy on imaging examinations. Although endoscopic ultrasound-guided fine needle aspiration of these areas of lymphadenopathy was performed, their causes remained undetermined. Neither patients had abnormal hepatic enzyme levels at the time lymphadenopathy was detected, but they developed hepatitis 20 months and five months later, respectively. The laboratory data and/or histopathological findings suggested primary biliary cholangitis/cirrhosis (PBC) and autoimmune hepatitis (AIH), respectively. These two patients were each started on appropriate treatment (ursodeoxycholic acid or prednisolone, respectively), their hepatitis ameliorated, and the hepatic enzyme levels recovered to within the normal ranges. These patients' clinical courses suggest that their lymphadenopathy was associated with PBC or AIH and appeared before the causative hepatitis became clinically apparent. We should consider the possibility of latent autoimmune hepatic diseases in cases with cryptogenic intra-abdominal lymphadenopathy even if there is no clinically apparent hepatitis.

Direct­acting antiviral treatment is safe and effective for chronic HCV patients with psychiatric disorders.

Although most patients with hepatitis C virus (HCV) infection have been cured since the introduction of direct-acting antiviral (DAA) treatments, whether patients with psychiatric disorders and chronic HCV infection receive benefits from DAA treatments remain unclear. The efficacy and safety of DAA treatment were compared between patients with and without psychiatric disorders. Data were retrospectively collected from medical records at the Suzuka General Hospital (Japan) between September 2014 and December 2021. The study was an observational, single-center study. Fisher's exact test, Mann-Whitney U test and Friedman's test were used for the comparisons between groups. Patients with HCV infection who had been started on DAA treatments were included. In total, 15 HCV cases with psychiatric disorders (P) and 209 HCV cases with nonpsychiatric disorders (NP) were started on DAA treatments for HCV infection. Patients in group P were younger (55±13.9 years) compared with those in group NP (68±13.0 years). A total of 12 patients (80%) in group P achieved and 188 patients (90%) in group NP achieved sustained virologic response (SVR), with no significant difference between the two groups. The remaining three patients in group P who did not achieve SVR included two drop-out cases. Regarding the laboratory data at the end of DAA treatments and SVR, there were no significant differences between the two groups. There were no cases of discontinuation or reduction of medication due to psychiatric disorders during DAA treatment. DAA treatment for HCV infection is effective, tolerable and safe for psychiatric patients, as well as patients without psychiatric disorders. Psychiatric patients with HCV infection should undergo DAA treatment to prevent progression to liver failure and/or cancer.

The safety and efficacy of Ringer's solution loading with rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: The RESOLUTION-PEP study.

Objectives: We evaluated the safety and efficacy of aggressive hydration with rectal non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods: This prospective, single-arm, multicenter trial was conducted at 12 institutions between October 2020 and August 2021. We enrolled 231 patients who had intact papillae and were scheduled to undergo ERCP. All patients were administered rectal diclofenac before ERCP. They received aggressive hydration with intravenous lactated Ringer's solution in an initial bolus of 5 ml/kg at the start of ERCP, followed by 3 ml/kg/h for 8 h after the procedure. The primary outcome was the occurrence of PEP. Secondary outcomes included PEP severity, hyperamylasemia, and adverse events. Results: The mean age of the patients was 68.8 ± 13.7 years, and 81 patients (35.1%) were 75 years or older. Thirteen patients developed PEP (5.6%, 95% confidence interval 3.0%-9.4%). There were 11 cases (4.8%) of mild pancreatitis and two cases (0.9%) of severe pancreatitis. Forty-five patients (19.5%) developed hyperamylasemia and one patient developed non-severe peripheral edema. Conclusions: Aggressive hydration combined with rectal diclofenac may be a promising strategy for the prevention of PEP. Furthermore, it is safe even for older individuals.

A Novel Scoring System to Improve the Detection Efficiency of Pancreatic Cystic Lesions in the General Population.

Objective Pancreatic cystic lesions (PCLs) are known risk factors for pancreatic cancer. Therefore, this study explored the predictors identifying PCLs in a general population and developed a scoring system to help more efficiently diagnose these entities during medical checkups. Methods We reviewed 9,369 examinees of abdominal ultrasound (AUS) during medical checkups between January 2013 and November 2019. Predictors of PCLs were identified using a multivariate logistic regression analysis, and we constructed a scoring system based on these predictors. Results PCLs were detected in 118 (1.3%). Age 50-59 years old [odds ratio (OR) 2.52, 95% confidence interval (CI) 1.18-5.35], 60-69 years old (OR 3.91, 95% CI 1.86-8.26), and ≥70 years old (OR 10.5, 95% CI 5.03-21.7) as well as abdominal pain (OR 1.85, 95% CI 1.14-3.00), alcohol consumption (OR 1.72, 95% CI 1.03-2.89), a family history of pancreatic cancer (OR 2.41, 95% CI 1.09-5.34), and pre-diabetes or diabetes (OR 1.78, 95% CI 1.05-3.00) were predictors of PCLs. The following scores were assigned according to regression coefficients: age (50-59 years old, 1 point; 60-69 years old, 1.5 points; ≥70 years old, 2.5 points); abdominal pain, 1 point, alcohol consumption, 1 point; a family history of pancreatic cancer, 1 point; and pre-diabetes, 1 point. The PCL detection rate increased with the total score: 0.2% for total score 0 point, 5.4% for ≥4.0 points. The area under the curve of the scoring system was 0.75 (95% CI 0.70-0.79). Conclusion Our scoring system allows the risk of PCLs to be determined and may help more efficiently diagnose these entities.

Gastric Foveolar-type Adenocarcinoma with Raspberry-like Appearance in a Helicobacter pylori-uninfected Stomach: A Long-term Retrospective Follow-up of 16 Years.

Esophagogastroduodenoscopy in a 58-year-old man revealed a protruding lesion measuring 6 mm in diameter in the fornix. An endoscopic biopsy of the lesion indicated well-differentiated adenocarcinoma. The lesion was resected by polypectomy. According to the Japanese histologic diagnostic criteria, we made a final diagnosis of early gastric cancer (U, Gre, 6×6 mm, Type 0-I, tub1, pT1a (M), pUl0, Ly0, V0, pHM0, pVM0). A retrospective review of the endoscopic images showed that this lesion had already been present in the images taken 16 years ago. The size and morphology of the lesion were the same as those of the first detected lesion.

The Utility of Endoscopic-Ultrasonography-Guided Tissue Acquisition for Solid Pancreatic Lesions.

Endoscopic-ultrasonography-guided tissue acquisition (EUS-TA) has been widely performed for the definitive diagnosis of solid pancreatic lesions (SPLs). As the puncture needles, puncture techniques, and sample processing methods have improved, EUS-TA has shown higher diagnostic yields and safety. Recently, several therapeutic target genomic biomarkers have been clarified in pancreatic ductal carcinoma (PDAC). Although only a small proportion of patients with PDAC can benefit from precision medicine based on gene mutations at present, precision medicine will also be further developed for SPLs as more therapeutic target genomic biomarkers are identified. Advances in next-generation sequencing (NGS) techniques enable the examination of multiple genetic mutations in limited tissue samples. EUS-TA is also useful for NGS and will play a more important role in determining treatment strategies. In this review, we describe the utility of EUS-TA for SPLs.

Ischemic hepatitis with infectious endocarditis: A case report.

A 58-year-old woman was admitted to Suzuka General Hospital with fever. She was diagnosed with infectious endocarditis based on the presence of anterior mitral leaflet vegetation on the echocardiography analysis and isolation of Pseudomonas guariconensis by blood culture. During treatment, the hepatic enzymes levels, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) were increased without any abdominal symptoms. Prolonged prothrombin time (PT) and prothrombin time international normalized ratio were observed, and acute hepatic failure was diagnosed. However, the hepatic injury resolved spontaneously with restoration of the PT value after the hepatic enzymes (AST, ALT, LDH and ALP) peaked. Diffusion-weighted imaging of hepatic magnetic resonance imaging showed diffuse high intensity of the entire liver except for part of the left lobe. The hepatic injury was diagnosed as ischemic hepatitis caused by embolization from the vegetation associated with infectious endocarditis. The recovery from hepatic ischemia was thought to be due to hepatic blood supply from extrahepatic collateral blood. After antibiotic treatment, the patient underwent resection of the vegetation on the anterior mitral valve leaflet. Hepatic artery occlusion is rare, but it may cause severe hepatic complications. During follow-up of infectious endocarditis, clinicians should be aware of the potential for whole organ ischemic damage caused by vessel occlusion, as well as hepatic ischemic damage.

Primary hepatic lymphoma diagnosed using endoscopic ultrasound-guided liver biopsy: a case report.

BACKGROUND: Because of the rarity of primary hepatic lymphomas, diagnosis of this disease entity may often be difficult, and performing a liver biopsy is the only way to establish a definitive diagnosis. Recently, endoscopic ultrasound-guided liver biopsy has emerged as a safe technique for obtaining liver tissue. However, there is no report on the use of endoscopic ultrasound-guided liver biopsy for diagnosing primary hepatic lymphomas. CASE PRESENTATION: An 85-year-old Asian man was admitted to our hospital because of multiple liver lesions without any identifiable primary tumor or extrahepatic lymphadenopathy. Serum tumor markers, including alpha-fetoprotein, were in the normal range. We provisionally diagnosed the patient with a cancer of unknown primary origin with liver metastases. An endoscopic ultrasound-guided fine needle liver biopsy of the tumor in the left lobe of the liver was performed using a transgastric approach, and histology revealed a primary hepatic lymphoma of a diffuse large B-cell lymphoma type. CONCLUSIONS: Primary hepatic lymphomas are quite rare, and diagnosis is often difficult without performing a biopsy. Endoscopic ultrasound-guided liver biopsy is a useful diagnostic modality even in such cases.

Early stage clear cell adenocarcinoma coexisting with tubular adenoma and adenoma with clear cell change in the colon.

Primary clear cell adenocarcinoma (CCA) of the colorectum is rare. We report a case of a 57-year-old man with early-stage CCA with conventional tubular adenoma and tubular adenoma with clear cell change in the transverse colon, diagnosed with image-enhanced endoscopy. The tumor was then treated with endoscopic submucosal dissection. The endoscopic findings characteristic of clear cell adenoma/adenocarcinoma could not be identified. Therefore, similar diagnostic tools as for conventional colorectal adenoma/cancer were considered. The pathogenesis of the clear cell change was unknown, but it might appear with the progression of the malignancy.

The spontaneous clearance of hepatitis E virus (HEV) and emergence of HEV antibodies in a transfusion-transmitted chronic hepatitis E case after completion of chemotherapy for acute myeloid leukemia.

A 64-year-old woman was infected with hepatitis E virus (HEV) during chemotherapy for leukemia. By retrospective analyses of stored serum from the blood products and the patient, the source of the infection was determined to be platelet concentration (PC) transfused during chemotherapy. The partial nucleotide sequence of the HEV strain isolated from the donated PC and that from the patient's sera was identical and was subgenotype 3b. Clinical indicators such as alanine aminotransferase, HEV RNA titer, and anti-HEV antibodies in the serum were investigated from the beginning of the infection until 1 year after the termination of HEV infection. HEV RNA had propagated over 6 months and then cleared spontaneously after the completion of chemotherapy. Anti-HEV antibodies appeared in the serum just before the clearance of HEV RNA. Interestingly, HEV RNA was detected in the patient's urine, spinal fluid, and saliva. The HEV RNA titers in those samples were much lower than in the serum and feces. No renal, neurological, or salivary gland disorders appeared during the follow-up. We observed virological and biochemical progress and cure of transfusion-transmitted chronic hepatitis E in the patient despite an immunosuppressive status during and after chemotherapy against hematological malignancy.

Hepatic Injury without Granulomatous Formation Associated with Intravesical Bacillus Calmette-Guérin Therapy.

A 74-year-old man developed hepatic injury after intravesical Bacillus Calmette-Guérin (BCG) therapy for bladder carcinoma. Although hepatitis-associated disseminated BCG was suspected, granulomatous formations were undetectable. The hepatic injury was considered to have resulted from an allergic reaction to BCG therapy because a histopathological assessment revealed enlarged portal areas with eosinophils and neutrophils. The hepatic injury was resolved by prednisolone. This case suggested that hepatic injury associated with BCG therapy might be due to an allergic mechanism unrelated to disseminated BCG disease. A liver biopsy is needed to confirm the histopathological findings of hepatic injury after BCG therapy in order to differentiate allergic hepatic injury from infectious hepatic injury.

Early stage clear cell adenocarcinoma of the colon examined in detail with image-enhanced endoscopy: a case report.

Primary clear cell adenocarcinoma (CCA) of the colorectum is a rare tumor. We report on a 48-year-old man with early stage CCA in the descending colon who underwent detailed examination with image-enhanced endoscopy, such as magnifying endoscopy with narrow-band imaging and crystal violet staining. The tumor was treated successfully with endoscopic mucosal resection at our hospital.

Gastric adenocarcinoma coexisting with a reddish semipedunculated polyp arising from Helicobacter pylori-negative normal gastric mucosa: a report of two cases.

We experienced two cases of adenocarcinoma coexisting with a hyperplastic polyp arising from Helicobacter pylori-negative normal gastric mucosa. The first case was of a 59-year-old man. Esophagogastroduodenoscopy revealed a protruding lesion measuring 4 mm in diameter on the greater curvature of the middle gastric body. The second case was of a 47-year-old man. Esophagogastroduodenoscopy showed a protruding lesion measuring 5 mm located at the greater curvature of the upper gastric body. The absence of atrophic changes in the entire gastric mucosa was confirmed endoscopically in both cases. Multiple H. pylori tests were all negative. Endoscopically, these protruding lesions appeared as reddish, semipedunculated polyps. Hyperplastic polyps were suspected based on white light endoscopic findings. Magnified endoscopy with narrow band imaging could not predict the coexistence of cancer. However, histopathological examination of the resected specimen revealed focal cancer at the surface of the gastric hyperplastic polyps. Considering the possibility that cancer may be coexisting in polyps, when reddish polyps are detected in H. pylori-negative normal gastric mucosa, it is important to perform a biopsy, or a careful follow-up endoscopy.

Usefulness of Endoscopic Transpapillary Tissue Sampling for Malignant Biliary Strictures and Predictive Factors of Diagnostic Accuracy.

BACKGROUND/AIMS: It is sometimes difficult to distinguish between malignant and benign biliary strictures using imaging studies alone, and pathological diagnosis is necessary. The aim of this study was to determine the usefulness of endoscopic transpapillary tissue sampling and factors predictive of diagnostic accuracy. METHODS: From April 2008 to December 2014, 136 patients underwent endoscopic transpapillary tissue sampling for malignant biliary strictures. The cytological and histological findings were reported as negative, suspicious, or positive. Suspicious and positive findings were defined as pathologically positive. RESULTS: The sensitivity was 65.0% for forceps biopsy, 49.5% for brush cytology, 46.2% for bile aspiration cytology, and 21.9% for endoscopic nasobiliary drainage cytology. The combination of these procedures improved the sensitivity (72.8%). Endoscopic transpapillary tissue sampling was more sensitive for lesions of biliary origin (91.4%) than for extrabiliary lesions (66.3%). In surgical cases, the sensitivity for tumors with an infiltrative growth pattern (53.3%) was significantly lower than for a tumor with an expanding or intermediate growth pattern (87.5%). CONCLUSIONS: Combining procedures can improve diagnostic accuracy. It may be possible to predict the sensitivity of endoscopic transpapillary tissue sampling by evaluating the etiology and tumor growth pattern using preoperative imaging studies.

[Case of protein plug in the pancreatic duct mimicking pancreatic cancer concomitant with branch-type intraductal papillary mucinous neoplasm].

A 65-year-old male was referred to our hospital 2 years ago for a multilocular cyst accompanied with a protein plug in the pancreas tail. He was diagnosed as having branch duct-type intraductal papillary mucinous neoplasm and was followed-up. Two years later, endoscopic ultrasonography revealed a hypoechoic lesion, 10mm in diameter, near the cyst-like lesion. Finally, he was diagnosed with small pancreatic adenocarcinoma concomitant with intraductal papillary mucinous neoplasm and underwent radical distal pancreatectomy with splenectomy. Resected specimen revealed that the protein plug in the main pancreatic duct had caused distal pancreatic duct dilatation, resembling a multilocular cyst and pancreatic duct stenosis with inflammatory changes and fibrosis around the pancreatic parenchyma. Here, we report a rare case of protein plugs in the pancreatic duct mimicking pancreatic cancer concomitant with branch-type intraductal papillary mucinous neoplasm.

A case of diminished pericardial effusion after treatment of a giant hepatic cyst.

A 75-year-old woman was discovered to have a pericardial effusion when she was admitted to our hospital because of a giant hepatic cyst. We could not detect the cause of the effusion and diagnosed idiopathic pericardial effusion. The patient underwent transcutaneous drainage of the hepatic cyst and an injection of antibiotics. There was no communication between the pericardial effusion and the hepatic cyst. Although the hepatic cyst was reduced in size, the pericardial effusion showed no remarkable change immediately after treatment; however, 5 months later, the pericardial effusion was found to be diminished. The pericardial effusion might have been caused by the physical pressure of the giant hepatic cyst and disturbance in the balance between the production and reabsorption of the pericardial fluid. When we experience a huge hepatic cyst, we should take into account its influence against the surrounding organs, including the intrapleural space.

Hemostasis by esophageal stent placement for management of esophageal tumor bleeding:a case report.

A 67-year-old male was diagnosed with advanced esophageal cancer. A computed tomography scan showed multiple intra-abdominal lymphadenopathies. Because the tumor was thought to be unresectable, we initiated chemotherapy. Twelve months later, the patient was admitted to our hospital because of hematemesis. Gastroduodenoscopy revealed oozing bleeding from the esophageal tumor. Hemostasis was not achieved with conservative treatment, and frequent blood transfusions were required. Endoscopic hemostasis was difficult to achieve because of the malignant esophageal stenosis. To treat the malignant esophageal stricture and esophageal tumor bleeding, we attempted to insert an esophageal covered self-expandable metallic stent. After the procedure, hemostasis was achieved by mechanical tamponade. Here we report a rare case of esophageal tumor bleeding that was managed with mechanical tamponade using an esophageal covered self-expandable metallic stent.

An impacted minor papilla stone in a patient with pancreas divisum that caused acute exacerbation of chronic pancreatitis: a case report.

A 75-year-old woman with epigastric pain was admitted to our emergency department. She was diagnosed with an acute exacerbation of chronic pancreatitis based on the results of blood tests and abdominal computed tomography (CT). The abdominal CT and magnetic resonance cholangiopancreatography revealed pancreas divisum. Abdominal CT also showed a stone in the minor papilla, with impaction of the stone being the most likely cause of the acute episode. Therefore, endoscopic sphincterotomy of the minor papilla and endoscopic naso-pancreatic duct drainage were performed to remove the stone and decrease the internal pressure of the pancreatic duct. These procedures improved the patient's clinical status. The naso-pancreatic drainage tube was removed, and her pancreatitis has not recurred. Herein, we report a rare case of an impacted minor papilla stone in a patient with pancreas divisum that caused an acute exacerbation of chronic pancreatitis.

No Benefit of Oral Diclofenac on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

BACKGROUND: Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a serious complication. Rectal diclofenac (100 mg) has been shown to reduce the incidence of pancreatitis; however, this dosage form is unavailable in several countries. AIMS: We aimed to investigate the preventive effect of oral diclofenac on pancreatitis after ERCP in a multicenter, randomized, prospective, placebo-controlled, double-blind trial. METHODS: Patients undergoing a first ERCP in seven high-volume centers between July 2012 and August 2014 were considered eligible. Participants were administered oral diclofenac (50 mg) or placebo before and after ERCP. The primary endpoint was the incidence of pancreatitis. A subgroup analysis was performed for patients at high or low risk of pancreatitis. Secondary endpoints were pancreatic enzyme levels (amylase and lipase). RESULTS: We initially enrolled 430 patients (216 in the diclofenac and 214 in the placebo group), and 23 were excluded after randomization. The overall incidence of pancreatitis was 9.8 % (20/205) and 9.4 % (19/202) in the diclofenac and placebo groups, respectively (p = 0.90). The incidence of pancreatitis was 20.3 % (13/64) and 21.3 % (13/61) in patients at high risk of pancreatitis (p = 0.78) and 5.0 % (7/141) and 4.3 % (6/141) in patients at low risk of pancreatitis in the diclofenac and placebo groups (p = 0.94), respectively. There were no significant differences in serum amylase and lipase levels between the two groups before and 24 h after ERCP. CONCLUSIONS: Oral administration of diclofenac before and after ERCP showed no benefit in the prevention of pancreatitis. CLINICAL TRIALS REGISTRY NO: UMIN000008109.

[Acute obstructive suppurative pancreatic ductitis after endoscopic retrograde cholangiopancreatography in a patient with carcinoma of the pancreatic head:a case report].

An 85-year-old woman with jaundice was referred to our hospital where she was diagnosed with obstructive jaundice due to carcinoma of the pancreatic head based on blood tests and abdominal computed tomography (CT). We performed endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage, but 5 days after the procedure, she complained of epigastric pain. Laboratory data revealed an elevated white blood cell count and a high serum amylase concentration. Follow-up CT 6 days after the ERCP revealed that the main pancreatic duct diameter had increased since the time of admission. Therefore, ERCP was performed for pancreatic ductal drainage. Purulent pancreatic juice was drained by endoscopic placement of a nasopancreatic drainage tube in the main pancreatic duct, resulting in marked alleviation of clinical symptoms;however, after removal of the tube, the abdominal pain recurred. Subsequent endoscopic placement of a pancreatic stent improved her clinical status once again. Herein, we report this rare case of acute obstructive suppurative pancreatic ductitis in a patient with carcinoma of the pancreatic head.