A Case of Lupus Enteritis in Which Multiple Colorectal Ulcers Were the Only Signs of Relapse.

The patient was a 62-year-old woman. She had been treated for systemic lupus erythematosus (SLE) for 15 years and had a stable clinical course with cyclosporine, prednisolone, and ticlopidine. She experienced anal pain, diarrhea, and bloody stools for four months. Colonoscopy showed scattered large and small punchedout ulcers in the colon and deep longitudinal ulcers in the sigmoid colon. Blood test results indicated low SLE activity. Culture of mucosal biopsy did not reveal any findings. Computed tomography showed intestinal membrane arteriovenous dilatation (comb sign), therefore lupus enteritis was suspected. After initiating endoxan pulse therapy, symptoms improved rapidly. Disappearance of ulcers was confirmed by endoscopic images.

Analysis of Comorbidity for Patients with Pancreatic Cysts in Medical Checkup Screening.

OBJECTIVES: We investigated whether there is a difference in the frequency of comorbidity between patients with pancreatic cysts and those without pancreatic cysts by abdominal ultrasonography in patients undergoing medical checkup screening. METHODS: The subjects were 6,627 patients who underwent abdominal ultrasonography at Tokai University Hachioji Hospital's Health Screening Center between April 2019 and March 2020. RESULTS: Of the total 6,627 patients, 158 (2.4%) were pointed out to have pancreatic cysts. Multivariate analysis revealed that the related factors were female sex, age 60 years or older, diabetes, lung cancer, and uterine/ovarian cancer. CONCLUSION: Unlike pancreatic cancer, pancreatic cysts are more common in women. In addition, it is known that pancreatic cysts have a high complication rate of cancers of other organs; lung cancer and uterine/ovarian cancer were identified as high-risk factors in this study.

Antiviral Therapy for Patients Chronically Infected with Hepatis C Virus at Tokai University Hospital.

OBJECTIVE: Hepatitis C virus (HCV) was identified in 1989. In 2020, three decades after HCV identification, three researchers won the Nobel Prize in Physiology or Medicine for the discovery of this virus. In 1992, three years after the discovery, interferon (IFN) was launched as the first anti-HCV therapy in Japan; however, the efficacy of IFN therapy was far from acceptable due to severe adverse effects. The advent of IFN-free direct-acting antivirals (DAAs) in 2014 dramatically improved the outcomes of antiviral treatment without serious adverse effects. In this study, we aimed to summarize anti-HCV therapy at the Tokai University Hospital. METHODS: We identified patients who underwent anti-HCV therapy by searching medical records from January 1992 to December 2020, analyzed their background, and compared safety and efficacy among treatments. RESULTS: A total of 1777 treatments were given to 1299 patients. The sustained virologic response rate has dramatically increased over the past 30 years, with only 7% for IFN monotherapy and 95% or higher for recent IFN-free DAA therapies. CONCLUSIONS: We documented the results of anti-HCV therapy at the Tokai University Hospital. In the 30 years since the discovery of HCV, surprisingly successful progress has been accomplished in the anti-HCV treatment.

Primary Sclerosing Cholangitis Complicated with Aphthoid Colitis Difficult to Diagnose from IgG4-Related Sclerosing Cholangitis.

A 19-year-old man visited our hospital because of diarrhea and blood and liver dysfunction. Magnetic and endoscopic retrograde cholangiography revealed diffuse narrowing of the common biliary tract and intrahepatic biliary tract. A biopsy specimen from the narrowed area of the common biliary tract revealed IgG4-related sclerosing cholangitis (IgG4-SC). Colonoscopy showed multiple aphthoid colitis. He was treated with corticosteroids, and the levels of hepatobiliary enzymes, IgG, and IgG4 gradually decreased. This is an extremely rare case of colitis in which the patient had a phenotype of sclerosing cholangitis similar to IgG4-SC, which was finally diagnosed as primary sclerosing cholangitis.

A potential pathogenic association between periodontal disease and Crohn's disease.

Oral conditions are relatively common in patients with inflammatory bowel disease (IBD). However, the contribution of oral maladies to gut inflammation remains unexplored. Here, we investigated the effect of periodontitis on disease phenotypes of patients with IBD. In all, 60 patients with IBD (42 with ulcerative colitis [UC] and 18 with Crohn's disease [CD]) and 45 healthy controls (HCs) without IBD were recruited for this clinical investigation. The effects of incipient periodontitis on the oral and gut microbiome as well as IBD characteristics were examined. In addition, patients were prospectively monitored for up to 12 months after enrollment. We found that, in both patients with UC and those with CD, the gut microbiome was significantly more similar to the oral microbiome than in HCs, suggesting that ectopic gut colonization by oral bacteria is increased in patients with IBD. Incipient periodontitis did not further enhance gut colonization by oral bacteria. The presence of incipient periodontitis did not significantly affect the clinical outcomes of patients with UC and CD. However, the short CD activity index increased in patients with CD with incipient periodontitis but declined or was unchanged during the study period in patients without periodontitis. Thus, early periodontitis may associate with worse clinically symptoms in some patients with CD.

Posterior reversible encephalopathy syndrome (PRES) caused by chemotherapy containing S-1 against diffuse type gastric cancer.

A 23-year-old woman who complained of abdominal distension and anorexia was referred to our hospital. Computed tomography showed ascites, a huge hepatic tumor and ovarian tumor. Gastroscopy revealed type 4 gastric cancer and biopsy examination showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. We diagnosed her with stage IV advanced gastric adenocarcinoma. She received the chemotherapy with S-1 and CDDP regimen. After two courses, this regimen was changed to the SOX (S-1 + OHP) regimen because of acute kidney injury. After one course of the SOX regimen, she developed general muscle cramp. Magnetic resonance imaging showed a 15 mm, round, high-intensity signal at the parietal lobe on T2-weighted images. She was hospitalized for with the suspicion of brain metastasis. Anticonvulsants improved her muscle cramp, but she had consciousness disturbance on the 9th hospital day. T2WI showed high-intensity signals within the cerebral white matter at both sides of the occipital lobe. We suspected leukoencephalopathy caused by S-1 and discontinued the SOX regimen. We also treated her hypertension and hyponatremia. Her consciousness disturbance improved in several days, and the T2WI finding was markedly improved on the 20th hospital day. We diagnosed her with posterior reversible encephalopathy syndrome caused by chemotherapy containing S-1.

A Case of Rare Cutaneous Metastasis from Advanced Pancreatic Cancer.

A 71-year-old woman presented to a nearby hospital with an occipital scalp ulcer with exudate. Thoracoabdominal enhanced computed tomography (CT) was performed due to suspected cancer. The imaging results showed tumors in the pancreatic tail and at multiple sites in the lung, whereupon she was referred to our hospital for further investigation. Histological analysis of the occipital scalp ulcer and the pancreatic tumor led to the diagnosis of pancreatic adenocarcinoma with cutaneous metastasis and multiple lung metastases. Combination chemotherapy (gemcitabine and nab-paclitaxel) was started, and about 4 months later the patient experienced right lower back pain. Abdominal CT showed partial sclerosis of the right iliac bone and multiple spinal lesions, which were diagnosed as multiple bone metastases. Narcotic analgesia was started for the right lower back pain. Since then, FOLFIRINOX has been introduced as second-line chemotherapy against tumor growth, and treatment has been ongoing for 10 months since the initial chemotherapy. Pancreatic cancer is a rapidly growing cancer and can show early metastasis to other organs, lymph node metastasis, and peritoneal dissemination; therefore, the prognosis of pancreatic cancer is very poor. Cutaneous metastasis from pancreatic cancer is rare, and only a few cases have been reported. Here, we report an unusual case of pancreatic adenocarcinoma with cutaneous metastasis and multiple lung and bone metastases.

Eosinophilic Cholecystitis Associated with Eosinophilic Granulomatosis with Polyangiitis.

We report a case of eosinophilic cholecystitis associated with eosinophilic granulomatosis with polyangiitis (EGPA) complicated by cerebral hemorrhage. A 60-year-old man presented to a local hospital with a diagnosis of acute cholecystitis, with persistent fever and epigastric pain for 2 weeks. His symptoms persisted despite 3-week hospitalization; therefore, he was transferred to our hospital for further evaluation. Laboratory investigations upon admission showed white blood cells 26,300/µL and significant eosinophilia (eosinophils 61%). Abdominal computed tomography revealed no gallbladder enlargement but a circumferentially edematous gallbladder wall. Additional blood test results were negative for antineutrophil cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies; however, immunoglobulin (Ig)G and IgE levels were high at 1,953 mg/dL and 3,040/IU/mL, respectively. He improved following endoscopic transnasal gallbladder drainage for cholecystitis and was diagnosed with EGPA and received corticosteroid and immunosuppressant combination therapy. The eosinophil count decreased immediately after treatment, and abdominal pain and numbness resolved. He returned with left-sided suboccipital hemorrhage likely attributed to EGPA 6 months after discharge. EGPA is characterized by inflammation of small blood vessels and clinically manifests with an allergic presentation of bronchial asthma, as well as renal dysfunction, interstitial pneumonia, enteritis, and cerebral hemorrhage. Few reports have described cholecystitis as a presenting symptom of EGPA. We report a rare case of such a presentation with added considerations.

An Autopsy Case of Anaplastic Pancreatic Ductal Carcinoma (Spindle Cell Type) Multiple Onset in the Pancreas.

This is a case of a 75-year-old man who was diagnosed with anaplastic pancreatic ductal carcinoma (spindle cell type). His image findings showed pancreatic head cysts and pancreatic head, body, and tail tumors respectively. EUS-FNA was performed to the pancreatic head and pancreatic body tumors, and the same high atypical type cells suspected of cancer were obtained from either specimen, and finally total pancreatectomy was performed. On the specimen, there were 4 lesions in the pancreas; histology showed that the same anaplastic pancreatic ductal carcinoma (spindle cell type) was obtained from the pancreatic head cyst and the pancreatic tumors.

An autopsy case of primary extranodal NK/T cell lymphoma (extranodal NK/T-cell lymphoma) of the bile duct.

We reported the case of a 50-year-old man diagnosed with extrinsic NK/T-cell lymphoma. He was initially diagnosed with locally advanced unresected pancreatic duct carcinoma and was treated with combination chemotherapy using gemcitabine and nabpaclitaxel. One month after treatment, he developed bleeding. Upper gastrointestinal endoscopy showed a deep ulcer lesion from the duodenal bulb to the inner wall of the descending section that was not observed before treatment. Coil embolization was performed, but the necrotic area widened after treatment; the patient died of disseminated intravascular coagulation after 1 week. Autopsy showed a soft white-tone lesion that extended from the ulcer wall to the gallbladder wall and around the intrahepatic bile duct. Lesions were also found in the spleen, lungs, kidney, and bone marrow, and immunohistochemistry confirmed extrinsic NK/T-cell lymphoma (extranodal NK/T-cell lymphoma, nasal type). In conclusion, histological diagnosis of NK/T-cell lymphoma is difficult at an early stage, and the clinical course often shows rapid tumor progression, particularly bleeding in the digestive organs or widespread perforation and penetration. NK/T-cell lymphoma should be ruled out in patients with bile duct and pancreatic tumors in whom tissue diagnosis via biopsy cannot be performed.

Current status of portal vein thrombosis in Japan: Results of a questionnaire survey by the Japan Society for Portal Hypertension.

AIM: To investigate the current status of portal vein thrombosis (PVT) in Japan, the Clinical Research Committee of the Japan Society of Portal Hypertension undertook a questionnaire survey. METHODS: A questionnaire survey of 539 cases of PVT over the previous 10 years was carried out at institutions affiliated with the Board of Trustees of the Japan Society of Portal Hypertension. RESULTS: The most frequent underlying etiology of PVT was liver cirrhosis in 75.3% of patients. Other causes included inflammatory diseases of the hepatobiliary system and the pancreas, malignant tumors, and hematologic diseases. The most frequent site was the main trunk of the portal vein (MPV) in 70.5%, and complete obstruction of the MPV was present in 11.5%. Among the medications for PVT, danaparoid was given to 45.8%, warfarin to 26.2%, heparin to 17.3%, and anti-thrombin III to 16.9%. Observation of the course was practiced in 22.4%. Factors contributing to therapeutic efficacy were implementation of various medications, thrombi localized to either the right or left portal vein only, non-complete obstruction of the MPV and Child-Pugh class A liver function. A survival analysis showed that the prognosis was favorable with PVT disappearance regardless of treatment. CONCLUSION: The questionnaire survey showed the current status of PVT in Japan. Any appropriate medication should be given to a patient with PVT when PVT is recognized. It is necessary to compile a large amount of information and reach a consensus on safe and highly effective management of PVT.

Treatment of a Case of Ulcerative Colitis with Sacroiliitis Using Granulocyte and Monocyte Adsorption Apheresis.

In Japan, sacroiliitis is a very rare extraintestinal manifestation in patients with ulcerative colitis (UC), and it typically presents with intestinal symptoms. Radiography is used for diagnosis, and reveals erosions, sclerosis, and ankylosis, but magnetic resonance imaging is more useful for early detection. The treatment of spondyloarthropathy such as sacroiliitis and spondylitis includes physiotherapy, nonsteroidal anti-inflammatory drugs, sulfasalazine, and immunomodulators. In patients intolerant or cases refractory to these treatments, anti-tumor necrosis factor agents are recommended. Granulocyte and monocyte adsorption (GMA) apheresis was developed in Japan in the 1980s, and is currently used widely in clinical practice for UC patients. Unlike conventional medication, GMA apheresis has no serious adverse effects. We present the first report of a UC patient with sacroiliitis, who responded well to GMA therapy. GMA apheresis may be considered a new treatment option for UC-associated spondyloarthropathy that is refractory or tolerant to conventional treatment.

Feasibility and Safety of Repeated Transarterial Chemoembolization Using Miriplatin-Lipiodol Suspension for Hepatocellular Carcinoma.

AIM: To retrospectively evaluate the feasibility and safety of repeated transarterial chemoembolization (TACE) three or more times using miriplatin-lipiodol (M-LPD) suspension (repeated M-LPD TACE) for hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Sixteen patients who underwent repeated M-LPD TACE were examined. Total dose of miriplatin, lipiodol and porous gelatin sponge particles and adverse events of the first and last M-LPD TACE were evaluated. RESULTS: The mean±standard deviation (SD) of the total number of M-LPD TACE per patient was 3.7±1.1. The mean±SD dose of total miriplatin, lipiodol and porous gelatin sponge particles per patient was 303±103 mg, 21±7.3 ml and 84±57 mg, respectively. There were no significant differences in any adverse events between the first and last M-LPD TACE. CONCLUSION: Repeated M-LPD TACE for HCC is feasible and safe in selected patients.

Balloon-occluded retrograde transvenous obliteration using a new microballoon for gastric varices.

We here present a case involving a complicated type of gastric fundal varices treated by balloon-occluded retrograde transvenous obliteration. A newly developed 1.8-Fr tip coaxial microballoon catheter was successfully advanced into narrow and tortuous varices, and a sclerosant could be infused in a reasonable manner, avoiding reflux into collaterals. Divided injections of sclerosant were performed over two days, via a microballoon catheter that remained inserted overnight with balloon inflation, and the sclerosant could be infused sufficiently in the entirety of the varices. The varices were completely thrombosed and prominently reduced.

Amoebiasis Presenting as Acute Appendicitis.

We report a case of amoebic appendicitis without colitis symptoms. Acute appendicitis is commonly encountered by gastroenterologists in their daily practice. The number of cases of amoebiasis increases annually in Japan, and is thought to be associated with an increase in sexually transmitted disease or travel to endemic areas. However, acute amoebic appendicitis is rare and the prognosis is very poor compared to nonamoebic appendicitis. In our case, appendectomy was performed immediately after onset, and the patient was discharged without complications. It is difficult to differentiate between amoebic and nonamoebic appendicitis preoperatively, and the possibility of amoebic appendicitis should be kept in mind.

Combination therapy using PSE and TIO ameliorates hepatic encephalopathy due to intrahepatic portosystemic venous shunt in idiopathic portal hypertension.

A 64-year-old woman treated for anemia and ascites exhibited hepatic encephalopathy. Abdominal ultrasonography and computed tomography (CT) showed communication between the portal vein and the middle hepatic vein, indicating an intrahepatic portosystemic venous shunt (PSS). Since hepatic encephalopathy of the patient was resistant to medical treatment, interventional radiology was performed for the treatment of shunt obliteration. Hepatic venography showed anastomosis between the hepatic vein branches, supporting the diagnosis of idiopathic portal hypertension (IPH). To minimize the increase in portal vein pressure after shunt obliteration, partial splenic artery embolization (PSE) was first performed to reduce portal vein blood flow. Transileocolic venous obliteration (TIO) was then performed, and intrahepatic PSS was successfully obliterated using coils with n-butyl-2-cyanoacrylate (NBCA). In the present case, hepatic encephalopathy due to intrahepatic PSS in the patient with IPH was successfully treated by combination therapy using PSE and TIO.

Colonic High-grade Tubular Adenomas Associated with Schistosoma japonicum.

We reported a case of sigmoid colonic high grade tubular adenomas associated with deposited ova of Schistosoma japonicum. A 76-year-old Japanese man was referred to our colonoscopy due to a positive fecal occult blood test. He had a medical history of schistosomiasis japonica. The colonoscopy revealed that there were two sigmoid colon polyps, approximately 8 mm in diameter. These were removed by endoscopic mucosal resection (EMR). Pathological examination revealed high grade tubular adenomas and deposited some ova of Schistosoma japonicum with severe fibrotic change and granuloma formation in the submucosal layer. Colonic schistosomiasis is a probable independent risk factor for the development of colorectal carcinogenesis.

Balloon-occluded arterial stump pressure before balloon-occluded transarterial chemoembolization.

OBJECTIVE: To evaluate balloon-occluded arterial stump pressure (BOASP), which is responsible for effective balloon-occluded transarterial chemoembolization (B-TACE), at each hepatic arterial level before B-TACE using a 1.8-French tip microballoon catheter for unresectable hepatocellular carcinoma (HCC). MATERIAL AND METHODS: The BOASP at various embolization portions was retrospectively investigated. "Selective" and "non-targeted" BOASP was defined as the BOASP at the subsegmental or segmental artery and the lobar artery, respectively. RESULTS: The measurement of the BOASP was carried out in 87 arteries in 47 patients. BOASP > 64 mmHg was revealed in the caudate lobe artery (A1) and the left medial segmental (A4), right anterior superior segmental (A8), anterior segmental, right and left hepatic arteries. Significant difference was noted in the incidence of BOASP above 64 mmHg between "non-targeted" and "selective" BOASP (p = 0.01). "Non-targeted" BOASP was significantly greater than "selective" BOASP (p = 0.0147). In addition, the BOASP in A1, 4, 8 and the anterior segmental arteries were significantly greater than in the other subsegmental and segmental arteries (p = 0.0007). CONCLUSION: "Non-targeted" B-TACE should be avoided to perform effective B-TACE and "selective" B-TACE at A1, 4, 8 and the anterior segmental arteries may become less effective than at the other segmental or subsegmental arteries.