Contribution of Capsule Endoscopy Early in a Bleeding Episode to Treatment of Small Bowel Angioectasia: A Case Report.

Background: Recent advances in endoscopic devices such as small bowel capsule endoscopy and balloon-assisted endoscopy have improved the level of medical care for small bowel bleeding. However, treating small bowel angioectasia remains challenging because repeated intermittent bleeding can occur from the multiple minute lesions (about 1 mm in size) that develop in a synchronous and metachronous manner. Here, we report a case of small bowel angioectasia in which capsule endoscopy performed early in a bleeding episode contributed to treatment. Case Summary: A 66-year-old man with suspected small bowel bleeding underwent small bowel capsule endoscopy and balloon-assisted endoscopy with argon plasma coagulation hemostasis for a small intestinal angioectasia. Because small bowel bleeding recurred intermittently after the treatment, small bowel capsule endoscopy and balloon-assisted endoscopy were repeated when there was no bleeding, but no abnormalities were found. Subsequent small bowel capsule endoscopy during a bleeding episode revealed bloody intestinal fluid in the proximal small intestine. Peroral balloon-assisted endoscopy was performed 2 days after SBCE for detailed observation of the small intestinal mucosa at the suspected bleeding site, and there a 1-mm Dieulafoy's lesion with no active bleeding was identified. We performed argon plasma coagulation, and no bleeding was observed thereafter. Conclusions: Small bowel capsule endoscopy immediately after bleeding onset can identify the bleeding source of multiple minute lesions in small bowel angioectasia.

Real-time computer-aided diagnosis of diminutive rectosigmoid polyps using an auto-fluorescence imaging system and novel color intensity analysis software.

Objectives: An endoscopic technique that provides ≥90% negative predictive value (NPV) for differentiating neoplastic polyps is needed for the management of diminutive (≤5 mm) rectosigmoid polyps. This study aimed to assess whether a newly developed software can achieve ≥90% NPV for differentiating rectosigmoid diminutive polyps based on the green-to-red (G/R) ratio, obtained by dividing the green color tone intensity by the red color tone intensity on autofluorescence imaging (AFI). Methods: From December 2017 to May 2018, consecutive patients with known polyps who were scheduled for endoscopic treatment at our institution were prospectively recruited. All colorectal diminutive polyps were differentiated by computer-aided diagnosis using autofluorescence imaging (CAD-AFI) using a novel software-based automatic color intensity analysis; subsequent diagnosis was made by endoscopists based on trimodal imaging endoscopy (TME), which combines AFI, white-light imaging (WLI) and magnifying narrow-band imaging (M-NBI) findings. Thereafter, all polyps were removed endoscopically, and the histopathological diagnosis was evaluated. Results: Ninety-five patients with 258 diminutive rectosigmoid polyps and 171 diminutive non-rectosigmoid polyps were enrolled. Regarding diminutive rectosigmoid polyps, the NPV for differentiating neoplastic polyps was 93.4% (184/197) [95% confidence interval (CI), 89.0%-96.4%] with CAD-AFI and 94.9% (185/195) (95% CI, 90.8%-97.5%) with TME. The accuracy, sensitivity, specificity, and positive predictive value for differentiating diminutive rectosigmoid neoplastic polyps by CAD-AFI were 91.5%, 80.0%, 95.3% and 85.2%, respectively. Conclusions: Real-time CAD-AFI was effective for differentiating diminutive rectosigmoid polyps. This objective technology, which does not require extensive training or endoscopic expertise, can contribute to the effective management of diminutive rectosigmoid polyps.

Effectiveness of color intensity analysis using updated autofluorescence imaging systems for serrated lesions.

BACKGROUND AND AIM: We previously reported the effectiveness of color intensity analysis using autofluorescence imaging (AFI) for differentiating colorectal neoplastic lesions from non-neoplastic lesions. However, the ability of AFI systems for differentiating serrated lesions has not been evaluated. In the present study, we assessed the effectiveness of color intensity analysis using updated AFI systems for evaluating serrated lesions. METHODS: We retrospectively reviewed the data for 48 consecutive patients with 87 serrated lesions that were examined using updated AFI systems and resected at Jikei University Hospital. The mean green/red (G/R) ratio, which is obtained by dividing the mean green color intensities by the mean red color intensities, was calculated for each serrated lesion and compared between hyperplastic polyps, sessile serrated adenomas/polyps (SSA/P) with cytological dysplasia, and SSA/P without cytological dysplasia. We also assessed the area under the receiver operating characteristic curve (AUC) for determining SSA/P (both with and without cytological dysplasia) and SSA/P with cytological dysplasia. RESULTS: The AUC for determining SSA/P was 0.68; however, the AUC for determining SSA/P with cytological dysplasia was 0.97. With a cut-off for the G/R ratio of <0.93, the sensitivity, specificity, positive predictive value, and negative predictive value for SSA/P with cytological dysplasia were 95.5%, 91.0%, 77.8%, and 98.3%, respectively. CONCLUSION: Color intensity analysis of serrated lesions using updated AFI systems could effectively distinguish SSA/P with cytological dysplasia from hyperplastic polyps and SSA/P without cytological dysplasia.

Significance of P53-Binding Protein 1 as a Novel Molecular Histological Marker for Hypopharyngeal Squamous Neoplasms.

The DNA damage response protein p53-binding protein 1 (53BP1) accumulates and forms foci at double-strand DNA breaks, indicating the extent of DNA instability. However, the potential role of 53BP1 as a molecular biomarker for hypopharyngeal squamous cell carcinoma (HPSCC) diagnosis remains unknown. Here, we evaluated the potential of immunofluorescence-based analysis of 53BP1 expression to differentiate the histology of hypopharyngeal neoplasms. A total of 125 lesions from 39 surgically or endoscopically resected specimens from patients with HPSCC was histologically evaluated. 53BP1 expression in the nucleus was examined using immunofluorescence. The number of 53BP1 nuclear foci increased with the progression from non-tumorous to low-grade dysplasia, high-grade dysplasia, and squamous cell carcinoma. Unstable 53BP1 expression served as an independent factor for distinguishing lesions that required intervention. Colocalization of 53BP1 foci in proliferating cells, as assessed by Ki67, was increased in tumors ≥ 1000 µm in depth compared to those <1000 µm in depth at the tumor surface. Hence, the expression patterns of nuclear 53BP1 foci were associated with the progression of hypopharyngeal neoplasms. These findings suggest that 53BP1 could serve as an ancillary marker to support histological diagnosis and predict the factors that influence prognosis in patients with HPSCC.

Visualization of colorectal neoplasia by a second-generation autofluorescence imaging system.

OBJECTIVE: Autofluorescence imaging (AFI) systems may allow better visualization of colorectal neoplasia than conventional methods. However, this is difficult to demonstrate objectively. Recently, a second-generation AFI system with a noise-reduction algorithm was developed. We aimed to objectively evaluate the visualization of colorectal neoplasia by using a second-generation AFI system and software to calculate the color-contrast index. MATERIAL AND METHODS: We retrospectively reviewed 53 consecutive colorectal neoplasias examined using the second-generation AFI system. Color-contrast indices between the colorectal lesions and the surrounding normal mucosa in the WLI, AFI and NBI images were calculated. The WLI, AFI, NBI and CE images were also evaluated by endoscopists using questionnaire-based visualization scores. RESULTS: The color-contrast index seen in the AFI images (33.74 ± 9.20) was significantly higher than that in either the WLI (11.14 ± 6.14) or NBI images (11.72 ± 7.12). There was no significant difference between the color-contrast indices of the WLI and NBI images. The mean AFI image visualization score (6.7 ± 1.8) was significantly higher than that of WLI (6.0 ± 1.7), and tended to be higher than that of the NBI images (6.1 ± 1.6) when assessed by less-experienced endoscopists. CONCLUSIONS: This study objectively demonstrates that compared to WLI and NBI, the second-generation AFI system enables superior visualization of colorectal neoplasms. The visualization scores were higher for the AFI images when evaluated by less-experienced endoscopists. These results indicate that the second-generation AFI system may aid less-experienced endoscopists in the detection of colorectal neoplasia.

Magnifying endoscopy combined with narrow band imaging may help to predict neoplasia coexisting with gastric hyperplastic polyps.

BACKGROUND AND STUDY AIM: Although focal cancer occasionally coexists with gastric hyperplastic polyps, previous studies have reported that white light endoscopy (WLE) and biopsy sampling cannot effectively predict the coexistence of cancer. The aim of this study was to elucidate efficacious predictors for cancer coexistence. PATIENTS AND METHODS: This retrospective single academic center study analyzed consecutive patients with gastric polyps diagnosed as hyperplastic before endoscopic resection. Using an image catalog of WLE and magnifying endoscopy combined with narrow band imaging (ME-NBI) performed as part of the preresection work-up, three endoscopists independently assessed the coexistence of cancer and the presence of predefined ME-NBI findings in the microvasculature (MV) and fine mucosal structure (FMS). RESULTS: Twelve of 64 gastric polyps (19%) resected from 51 patients enrolled in the study showed the coexistence of neoplasia. Polyps with coexisting neoplasia were significantly larger than those without (22.6 ± 10.1 vs. 15.5 ± 7.7 mm, respectively). Multivariate analysis of factors significantly associated with the coexistence of neoplasia identified lesion size and three specific endoscopic findings, that is, WLE diagnosis of cancer coexistence, ME-NBI findings of abnormal MV and micrification (size reduction) of the FMS. Combining lesion size (≥20 mm) and ME-NBI findings of FMS micrification had a diagnostic accuracy of 100% sensitivity and 58% specificity for coexisting neoplasia. However, combinations of WLE diagnosis and any other criteria could not achieve a diagnostic sensitivity of 100%. CONCLUSION: ME-NBI enhances the prediction of cancer coexistence in gastric hyperplastic polyps, with lesion size (≥20 mm) and FMS micrification the most effective predictive findings.

Five cases of endoscopically noted esophageal stenosis due to abnormal aortic angiogenesis.

Right aortic arch is caused by a malformation of the aorta while Kommerell's diverticulum is a saccular aneurysm arising at the origin of the subclavian artery. Both diseases are caused by malformations during embryonic development and can subsequently cause compression of the esophagus and trachea due to abnormal arterial migration. Here, we report five cases of esophageal stenosis due to aortic angiogenesis anomalies. Three of the five cases had aortic running abnormalities, noted on computed tomography (CT). However, until it was observed for the first time, esophageal stricture was not recognized as an esophagogastroduodenoscopy (EGD) finding due to the lack of knowledge of diseases such as Kommerell's diverticulum even when EGD was performed during regular follow-up after treatment for esophageal cancer or other conditions. Symptoms include dysphagia and dyspnea due to stenosis of the esophagus and trachea, however, regardless of symptomatic presentation, the presence of esophageal stenosis on EGD should be considered as an effect of aortic travel abnormality or Kommerell's diverticulum. Although there have been no reports of Kommerell's diverticulum rupture due to endoscopic manipulation, gastroenterologists should consider the possibility of Kommerell's diverticulum during clinical decision making.

Megaesophagus and Megaduodenum Found Incidentally on a Routine Chest Radiograph During a Health Examination.

Chronic idiopathic intestinal pseudo-obstruction (CIIP) caused by impaired intestinal peristalsis leads to intestinal obstructive symptoms. A 20-year-old man had marked esophageal dilatation that was found incidentally on chest radiography during a health examination. Chest/abdominal contrast-enhanced computed tomography and endoscopy showed marked esophageal and duodenal dilatation without mechanical obstruction. Upper gastrointestinal series and high-resolution esophageal manometry revealed absent peristalsis in the dilated part. CIIP was suspected in the patient's father, suggesting familial CIIP. The patient likely had signs of pre-onset CIIP. This is the first case of suspected CIIP in which detailed gastrointestinal tract examinations were performed before symptoms appeared.

Mesalazine formulation intolerance due to suspected excipient allergy in the treatment of ulcerative colitis: a case report.

Mesalazine formulations are essential for treating ulcerative colitis (UC), and intolerance to these formulations complicates the treatment of this condition. Some cases of mesalazine formulation intolerance are caused by the excipients rather than the active ingredient mesalazine. Therefore, mesalazine administration can be continued in such cases by changing the mesalazine formulation. This report describes a case of intolerance to mesalazine in which UC was effectively treated by switching mesalazine formulations. A drug-induced lymphocyte stimulation test suggested that allergy to the additive povidone was the cause of mesalazine formulation intolerance. This is the first case study to identify an additive that caused mesalazine formulation intolerance.

Efficacy of a novel auto-fluorescence imaging system with computer-assisted color analysis for assessment of colorectal lesions.

AIM: To evaluate the efficacy of computer-assisted color analysis of colorectal lesions using a novel auto-fluorescence imaging (AFI) system to distinguish neoplastic lesions from non-neoplastic lesions and to predict the depth of invasion. METHODS: From January 2013 to April 2013, consecutive patients with known polyps greater than 5 mm in size who were scheduled to undergo endoscopic treatment at The Jikei University Hospital were prospectively recruited for this study. All lesions were evaluated using a novel AFI system, and color-tone sampling was performed in a region of interest determined from narrow band imaging or from chromoendoscopy findings without magnification. The green/red (G/R) ratio for each lesion on the AFI images was calculated automatically using a computer-assisted color analysis system that permits real-time color analysis during endoscopic procedures. RESULTS: A total of 88 patients with 163 lesions were enrolled in this study. There were significant differences in the G/R ratios of hyperplastic polyps (non-neoplastic lesions), adenoma/intramucosal cancer/submucosal (SM) superficial cancer, and SM deep cancer (P < 0.0001). The mean ± SD G/R ratios were 0.984 ± 0.118 in hyperplastic polyps and 0.827 ± 0.081 in neoplastic lesions. The G/R ratios of hyperplastic polyps were significantly higher than those of neoplastic lesions (P < 0.001). When a G/R ratio cut-off value of > 0.89 was applied to determine non-neoplastic lesions, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 83.9%, 82.6%, 53.1%, 95.6% and 82.8%, respectively. For neoplastic lesions, the mean G/R ratio was 0.834 ± 0.080 in adenoma/intramucosal cancer/SM superficial cancer and 0.746 ± 0.045 in SM deep cancer. The G/R ratio of adenoma/intramucosal cancer/SM superficial cancer was significantly higher than that of SM deep cancer (P < 0.01). When a G/R ratio cut-off value of < 0.77 was applied to distinguish SM deep cancers, the sensitivity, specificity, PPV, NPV, and accuracy were 80.0%, 84.4%, 29.6%, 98.1% and 84.1%, respectively. CONCLUSION: The novel AFI system with color analysis was effective in distinguishing non-neoplastic lesions from neoplastic lesions and might allow determination of the depth of invasion.

Computer-aided diagnosis of neoplastic colorectal lesions using 'real-time' numerical color analysis during autofluorescence endoscopy.

OBJECTIVE: Differentiating non-neoplastic colorectal lesions from neoplastic lesions during screening colonoscopies is essential to reduce the unnecessary treatment of non-neoplastic lesions. The present study was conducted to verify the diagnostic yields of the computer-aided diagnostic system that enables 'real-time' color analysis of colorectal lesions when applied to autofluorescence endoscopy (AFE). PATIENTS AND METHODS: Consecutive patients who were scheduled to undergo a therapeutic colonoscopy in our department were enrolled in this study. The encountered lesions were evaluated in AFE and color-tone sampling was performed. Lesions with green/red (G/R) ratios less than 1.01 were judged to be neoplastic and those with G/R ratios of at least 1.01 were considered to be non-neoplastic. All lesions greater than 5 mm were endoscopically removed and lesions less than 5 mm were biopsied. RESULTS: During the study period, a total of 32 patients with 102 colorectal lesions were evaluated with AFE. The mean G/R ratio for all neoplastic lesions was 0.86 [95% confidence interval (CI), 0.63-1.01], which was significantly lower than the mean G/R ratio for non-neoplastic lesions (1.12; 95% CI, 0.98-1.26; P<0.001). The mean G/R ratios were 1.36 (95% CI, 1.21-1.57) in normal mucosa, 1.12 (95% CI, 0.98-1.26) in hyperplastic lesions, 0.88 (95% CI, 0.69-1.02) in adenomas, and 0.61 (95% CI, 0.54-0.73) in intramucosal cancers. A G/R ratio cutoff value of 1.01 was applied for discriminating between neoplastic lesions and non-neoplastic lesions, and yielded sensitivity, specificity, positive and negative predictive values of 94.2, 88.9, 95.6, and 85.2%, respectively. CONCLUSION: This diagnostic tool may lead to the reduction of unnecessary treatments for non-neoplastic lesions.