Clinical usefulness of the hold-and-drag closure using the SB clip for large mucosal defects after colorectal endoscopic submucosal dissection.

BACKGROUND: Endoscopic clip closure of mucosal defects after colorectal endoscopic submucosal dissection (ESD) reduces the risk of postoperative adverse events, but achieving complete closure for large mucosal defects can be difficult. The aim of this study was to evaluate the effectiveness of the hold-and-drag closure using an SB clip compared with that of the conventional closure for mucosal defects after colorectal ESD. METHODS: Eighty-four consecutive colorectal lesions resected by ESD at the Hiroshima Asa Citizens Hospital were registered and randomly allocated to two groups (Group A: SB clip, Group B: EZ clip), and then endoscopic closures were performed. We crossed-over to the SB clip in situations where the initial closure using an EZ clip was unsuccessful in achieving complete closure. Outcomes were compared and analyzed. RESULTS: Forty-two lesions were randomly assigned to groups A and B. The complete closure rate was significantly higher in group A, especially in resected specimens with a diameter of 30 mm or more. Twelve lesions that failed complete closure in group B were changed to SB clips, and 95% of the whole of group B were successfully closed. There were no significant differences in procedural time, number of clips, and cost of clips between groups A and B. CONCLUSION: Compared with the conventional closure, the hold-and-drag closure using an SB clip is a more suitable method for complete closure, especially for large mucosal defects of 30 mm or more. Furthermore, this is a simpler and more economical compared to a zipper closure using EZ clips.

Optimal candidates for early colonoscopy in the management of acute lower gastrointestinal bleeding.

BACKGROUND AND AIM: Early colonoscopy has not shown any advantages over elective colonoscopy in reducing the risk of early rebleeding (≤ 30 days) after acute lower gastrointestinal bleeding (ALGIB). Considering the heterogeneity among patients with ALGIB, we sought to evaluate appropriate candidates for early colonoscopy. METHODS: A total of 592 patients with ALGIB were enrolled, and the clinical outcomes of early colonoscopy were investigated. Thereafter, the participants were divided into two groups: the recent bleeding group (n = 445), with hematochezia 0-6 h before hospital arrival, and non-recent bleeding group (n = 147). The clinical outcomes yielded by early colonoscopy were assessed in each group. RESULTS: The multivariate analysis including the entire population revealed that early colonoscopy (< 24 h) did not reduce the risk of early rebleeding (adjusted odds ratio [AOR], 0.88; 95% confidence interval [CI], 0.55-1.39). However, in the subgroup analysis, early colonoscopy independently reduced the risk of early rebleeding in the recent bleeding group (AOR, 0.56; 95% CI, 0.33-0.94). Moreover, a reduction in the need for radiological or surgical intervention (AOR, 0.34), transfusion (AOR, 0.62), and prolonged hospitalization (AOR, 0.42), as well as improvement in diagnostic yield (AOR, 1.78) and endoscopic treatment rates (AOR, 1.66), were observed. Early colonoscopy did not improve the outcomes of the non-recent bleeding group. CONCLUSIONS: Early colonoscopy is not required for all patients with ALGIB. However, it may be suitable for those with hematochezia 0-6 h before hospital arrival, as it reduces early rebleeding and improves clinical outcomes.

A pilot study to evaluate the effectiveness and safety of urgent endoscopy for gastroduodenal perforation.

BACKGROUND: Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan. METHODS: We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018. RESULTS: Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation. CONCLUSIONS: Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.

[Two rare cases of severe hyponatremia with consciousness disorder following bowel preparation and high fluid intake].

Symptomatic hyponatremia due to bowel preparation is extremely rare, but it can cause severe neurological symptoms and require hospitalization. We report our experience with two cases of symptomatic hyponatremia after bowel preparation. Our findings suggest that the cause of hyponatremia may be not only oral bowel cleansing agents but also high fluid intake. Adjusting the dose and pace of oral bowel cleansing agents and fluid intake;rehydration should be considered to prevent any recurrences.

Bile pigment in small-bowel water content may reflect bowel habits: a retrospective analysis of a capsule endoscopy imaging series.

BACKGROUND: Pigmented bile salts darken the small-bowel lumen and are present with bile acid, which is involved in the development of bowel habits. The small-bowel water content (SBWC) in the ileum could represent the colonic environment, but no studies have focused on this feature. However, measurement of crude SBWC can be challenging because of the technical difficulty of the endoscopic approach without preparation. Our aim was to evaluate optically active bile pigments in the SBWC of patients with abnormal bowel habits using capsule endoscopy (CE) to investigate the impact of bile acid on bowel habits. METHODS: The study population included 37 constipated patients, 20 patients with diarrhea, and 77 patients with normal bowel habits who underwent CE between January 2015 and May 2018. Patients with secondary abnormal bowel habits were excluded. In addition to conventional imaging, we used flexible spectral imaging color enhancement (FICE) setting 1 imaging, in which the effects of bile pigments on color are suppressed. Intergroup color differences of SBWC in the ileum (ΔE) were evaluated from conventional and FICE setting 1 images. Color values were assessed using the CIE L*a*b* color space. Differences in SBWC lightness (black to white, range 0-100) were also evaluated. RESULTS: The ΔE values from the comparison of conventional images between patients with constipation and with normal bowel habits and between patients with diarrhea and with normal bowel habits were 12.4 and 11.2, respectively. These values decreased to 4.4 and 3.3, respectively, when FICE setting 1 images were evaluated. Patients with constipation and diarrhea had significantly brighter (34.4 versus 27.6, P < .0001) and darker (19.6 versus 27.6, P < .0001) SBWC lightness, respectively, than patients with normal bowel habits. The FICE setting 1 images did not reveal significant differences in SBWC lightness between those with constipation and with normal bowel habits (44.1 versus 43.5, P = .83) or between those with diarrhea and with normal bowel habits (39.1 versus 43.5, P = .20). CONCLUSIONS: Differences in SBWC color and darkness in the ileum appear to be attributable to bile pigments. Therefore, bile pigments in SBWC may reflect bowel habits.

Management and risk factors for incomplete resection associated with jumbo forceps polypectomy for diminutive colorectal polyps: a single-institution retrospective study.

BACKGROUND: Cold forceps polypectomy is simple and widely used in clinical practice. However, there are concerns about the risk of incomplete resection using this technique. In recent years, it has been reported that polypectomy with jumbo forceps (JF) is an effective treatment modality for diminutive polyps (DPs) because JF are able to remove large tissue samples with the combined advantage of a higher complete histological resection rate for DPs than standard forceps. To our knowledge, no studies have evaluated the risk factors for incomplete resection when polypectomy with JF is performed for DPs. METHODS: From among 1129 DPs resected using JF at Hiroshima City Asa Citizens Hospital between November 2015 and December 2016, we retrospectively evaluated the clinical outcomes of 999 tumors with known histopathology and investigated the relationship between incomplete resection and clinicopathological factors. RESULTS: Most lesions [985 (87%)] were low-grade dysplasia and 14 (1%) were high-grade dysplasia. The en bloc resection rate was 92% (918/999) and the histological en bloc resection rate was 78% (777/999). Multivariate analysis showed that the significant independent predictors of incomplete resection were tumor size ≥ 4 mm [odds ratio (OR) 3.8; 95% confidence interval (CI) 2.65-5.37; p < 0.01], non-tangential direction of forceps in relation to the tumor (OR 1.73; 95% CI 1.21-2.45; p < 0.01), and lack of muscularis mucosae in the pathological specimen (OR 15.7; 95% CI 9.16-27.7; p < 0.01). CONCLUSIONS: This study identified significant independent predictors of incomplete resection of DPs which may be helpful when planning polypectomy with JF.

[A case of ruptured posterior superior pancreaticoduodenal artery aneurysm successfully treated by emergency transcatheter embolization].

A man in his 40s with no remarkable past medical history was referred to our hospital with acute exacerbation of nonspecific epigastric pain by another hospital on the morning of the day of presentation. Though vital signs were stable, tenderness and guarding were observed over the entire abdomen. Contrast-enhanced computed tomography (CT) revealed a giant retroperitoneal hematoma due to a ruptured aneurysm close to the superior mesenteric artery. Emergency angiography of the superior mesenteric artery detected a ruptured 2-mm pseudoaneurysm of the posterior superior pancreaticoduodenal artery, for which embolization was immediately performed. The postoperative course was good, with the patient complaining only of transient abdominal pain due to exclusion of the hematoma on hospital day 6. His clinical symptoms disappeared with conservative treatment, and the patient was discharged on hospital day 18. Complete occlusion of the aneurysm and reduction of the hematoma was confirmed on follow-up CT. Pancreaticoduodenal artery aneurysm is an uncommon visceral artery aneurysm, and ruptured aneurysms typically result in fatal hemorrhage and high mortality. We herein report a case of ruptured aneurysm of the posterior pancreaticoduodenal artery where emergency transcatheter arterial embolization was able to save the patient's life. We also review 116 cases of pancreaticoduodenal artery aneurysm reported in Japanese literature.

Arteriosclerosis Is a Major Predictor of Small Bowel Vascular Lesions.

BACKGROUND: Most studies have focused on evaluating the association between the presence of small bowel vascular lesions (SBVLs) and patients' comorbidities. AIMS: We sought to uncover a more fundamental indicator that may predict the presence of SBVLs by considering atherosclerosis qualitatively and quantitatively. METHODS: We enrolled 79 consecutive patients with obscure gastrointestinal bleeding who had undergone computed tomography (CT) and capsule endoscopy or double-balloon endoscopy from January 2015 to June 2017. The SBVL frequency, type, and location, and the relationship between the presence of SBVLs and the patients' clinical characteristics were evaluated. Arterial wall calcification was assessed on unenhanced CT images, and a modified Agatston scoring system was used to determine the abdominal aorta calcium scores. RESULTS: Of the 27 (34%) patients with SBVLs, 15 (19%) had type 1a, 12 (15%) had type 1b, and 2 (3%) had type 2a SBVLs. Most of the lesions were located in the jejunum. Cardiovascular disease (P = .017), chronic kidney disease (P = .025), and arteriosclerosis (P = .0036) were associated with the presence of SBVLs. Subsequent multivariate analysis revealed that arteriosclerosis (odds ratio [OR] 7.29; 95% confidence interval [CI] 1.13-143.9) and superior mesenteric artery calcification (OR 16.3; 95% CI 3.64-118.6) were independent predictors of the presence of SBVLs. The modified Agatston score was significantly higher in SBVL cases than in non-SBVL cases (6384 vs. 2666, P = .0023). CONCLUSIONS: Arteriosclerosis, especially increased superior mesenteric artery calcification, is associated with an increased likelihood of SBVLs.

Percutaneous transhepatic sclerotherapy for recurrent bleeding ileal varices diagnosed by capsule endoscopy and computed tomography during percutaneous transhepatic venography.

We report a case of acute uncontrolled gastrointestinal bleeding in a patient with liver cirrhosis. A 64-year-old man was admitted to our hospital for further investigation of blood in stools. Preliminary examination by computed tomography (CT) as well as upper and lower endoscopy could not detect the bleeding source. Exploratory laparotomy was considered difficult due to potential easy bleeding and adhesions caused by past abdominal surgery. The hemoglobin level was normalized by blood transfusion. Capsule endoscopy (CE) identified ileal varices. The top of these ileal varices was red, prompting their identification as the source of bleeding. Percutaneous transhepatic venography (PTV) confirmed the presence of many varices in the branch of the superior mesenteric vein, although the bleeding source could not be identified. CT during PTV identified varices protruding into the ileal lumen, which were managed subsequently by percutaneous transhepatic sclerotherapy (PTS). The procedure stopped the bleeding completely. CE proved less invasive and effective in detecting obscure gastrointestinal bleeding. CT during PTV followed by PTS is suitable for diagnosis and treatment of bleeding varices in patients with portal hypertension.

A Rare Case of Delayed Perigastric Abscess after Curative Resection of Early Gastric Cancer by Uncomplicated Endoscopic Submucosal Dissection: Successful Treatment with Endoscopic Ultrasound-guided Drainage.

A 72-year-old man had undergone uncomplicated endoscopic submucosal dissection (ESD) with en bloc resection of a localized 20-mm IIc lesion in the anterior wall of the gastric angle. Twenty-eight days later, he was re-admitted with epigastric pain of one-week duration. Contrast-enhanced computed tomography (CT) revealed a 60-mm mass bordered by viscera; repeat endoscopy confirmed a smooth elevated submucosal tumor at the greater curvature on the oral side of the post-ESD ulcer. We diagnosed him with a perigastric abscess as a complication of ESD and performed endoscopic ultrasound-guided drainage. Subsequently, the symptoms and blood inflammatory parameters improved, and follow-up CT showed the disappearance of the abscess.

Step-clipping method can improve the detectability of the target lesion in colonic diverticular bleeding.

Background and study aims Despite the information regarding extravasation from contrast-enhanced computed tomography (CECT), the detectability of the target diverticulum by colonoscopy remains unsatisfactory in colonic diverticular bleeding (CDB). The lack of common signs recognizable on CT and endoscopic images makes it difficult to set a region of interest; however, this can be overcome with the "step-clipping" method, a strategic marking technique for revealing the target. We aimed to investigate the clinical performance of the step-clipping method in patients with CDB. Patients and methods Eighty-seven patients diagnosed with CDB with extravasation using CECT who underwent colonoscopy between August 2007 and February 2020 were included. Patients were divided into two categories: the traditional group (those who underwent colonoscopy from August 2007 to May 2017, n = 54) and the step-clipping group (those who underwent colonoscopy from June 2017 to February 2020, n = 33). Results The detection rate for the responsible diverticulum was significantly higher in the step-clipping group than in the traditional group (94 % vs 63 %; P  = .0013). The step-clipping group had a shorter average search time during colonoscopy (9.6 vs 40.5 minutes; P  < .0001) and lower re-bleeding rate after the initial colonoscopy (6 % vs 26 %; P  = .02) than the traditional group, which facilitated earlier hospital discharge (5.4 vs 6.8 days; P  = .027). Conclusions Colonoscopy using the step-clipping method can improve the detectability of the target lesion within a shorter time, thus leading to lower re-bleeding rates and earlier hospital discharge.

Combined stimulation with Poly(I:C), TNF-alpha and Th2 cytokines induces TARC production by human fibroblasts from the nose, bronchioles and lungs.

BACKGROUND: Th2 cells trigger allergic diseases in the respiratory tract. However, the mechanisms that cause Th2 cell infiltration remain unclear. Viral infections exacerbate allergic diseases in the respiratory tract. Thymus- and activation-regulated chemokine (TARC) recruits Th2 cells to sites of inflammation. Resident fibroblasts are thought to contribute to inflammatory cell infiltration through chemokine production. We compared the abilities of nasal, bronchiolar and lung fibroblasts to produce TARC. METHODS: Expression of TARC mRNA was evaluated by real-time RT-PCR, while the amount of TARC in supernatants was measured by ELISA. RESULTS: Costimulation with TNF-alpha and Th2 cytokines (IL-4, IL-13) or with poly(I:C) and Th2 cytokines (IL-4, IL-13) induced TARC production by nasal (polyp and normal) fibroblasts. Costimulation with TNF-alpha and Th2 cytokines (IL-4, IL-13) also induced TARC production by both bronchiolar and lung fibroblasts, but costimulation with poly(I:C) and Th2 cytokines (IL-4, IL-13) caused no induction. Combined exposure of cells to poly(I:C), TNF-alpha and Th2 cytokines (IL-4, IL-13) resulted in substantial production of TARC by nasal and lung fibroblasts, but much less by bronchiolar fibroblasts. CONCLUSIONS: TARC is directly inducible in diverse fibroblast populations from the respiratory tract (nose, bronchioles and lungs), but the mechanisms and levels of TARC production differ. Fibroblasts in the respiratory tract may contribute to Th2 cell infiltration and viral-induced exacerbation of allergic diseases, such as allergic sinusitis, asthma and allergic lung inflammation.

Nasal polyp fibroblasts produce MIP-3alpha in response to toll-like receptor ligands and cytokine stimulation.

OBJECTIVE: Dendritic cells (DCs) play important roles in the development and perpetuation of immune responses. DCs are present in upper airway diseases such as chronic rhinosinusitis with nasal polyps. However, the mechanisms of how DCs migrate into the upper airway mucosa during upper airway inflammatory diseases remains unclear. Macrophage inflammatory protein-3alpha (MIP-3alpha) is known to be a migratory factor for immature DCs. There have been very few reports regarding cells producing this chemokine in the airways. To investigate this, we stimulated fibroblasts cultured from the nasal polyps with various toll-like receptor (TLR) ligands, which are derived from microorganisms, and IL-beta1 and TNF-alpha, which are proinflammatory cytokines, and analyzed their ability to produce MIP-3alpha. METHODS: Fibroblast lines were established from nasal polyps and stimulated with TLR2, 3, 4, 5, 7/8 and 9 ligands, IL-beta1 and TNF-alpha. MIP-3alpha mRNA expression in nasal polyp fibroblasts (NPF) was evaluated by real-time RT-PCR and the protein levels of MIP-3alpha in the supernatants of stimulated NPF was measured by ELISA. RESULTS: Stimulation with TLR2, 3, 4 and 5 ligands, IL-beta1 and TNF-alpha, induced MIP-3alpha gene expression and protein production in the cultured NPF This response was dose- and time-dependent. CONCLUSION: NPF possibly play an important role in the recruitment of DCs in upper airway diseases such as chronic rhinosinusitis with nasal polyps through the production of MIP-3alpha.

A duodenal follicular lymphoma associated with the lesion mimicking MALT lymphoma in terminal ileum and Bauhin valve.

This is a case report of a 66-year-old woman who consulted us with a 1-week history of postprandial epigastric discomfort and dyspepsia. Upper and lower gastrointestinal endoscopy and double-balloon enteroscopy revealed lesions in three parts: a swelling with a shallow depression in the ampulla of Vater, flat and rough nodules in the jejunum, and a mixture of lymphoid polyposis and rough surface of follicular lymphoma of the terminal ileum and Bauhin valve. The histological, immunophenotypic, and molecular findings of the duodenal lesion confirmed the diagnosis of follicular lymphoma. We initially diagnosed the ileal lesion as MALT lymphoma immunohistochemically. However, Southern blot hybridization analysis for immunoglobulin heavy chain gene rearrangement showed identical monoclonal bands in both the duodenal and ileal lesions. The molecular cytogenetic studies were also positive for the 14;18 translocation in both lesions. Therefore, the true diagnosis of this ileal lesion should be a follicular lymphoma with marginal zone differentiation. Primary follicular lymphomas of gastrointestinal tract were suggested to have intermediate features between nodal follicular lymphoma and MALT lymphoma. This case is an important clue to prove the similarity of follicular lymphoma of gastrointestinal tract to MALT lymphoma and will be crucial in considering the therapeutic strategy.

Food-Induced Duodenal Obstruction Successfully Reopened by Endoscopic Treatment.

Duodenal obstruction is a rare event that is unlikely to be treated endoscopically. Herein, we describe the case of a 75-year-old woman who presented with vomiting and was diagnosed with food-induced duodenal obstruction. Impacted food was fragmented and removed by double-balloon enteroscopy, and the duodenal tract was reopened without any adverse events. Follow-up capsule endoscopy was performed one month after treatment to determine the obstruction etiology and it revealed a remarkably delayed passage of the capsule through the duodenum and excessive amounts of floating food residue in the third portion of the duodenum. Obstruction recurrence was not observed six months after endoscopic treatment. In conclusion, in our case, endoscopic treatment of duodenal obstruction prevented the unnecessary performance of surgery, suggesting its clinical utility for this condition.

Successful Endoscopic Sclerotherapy Using Polidocanol for Small Bowel Hemangioma.

Small-bowel hemangiomas are a possible source of gastrointestinal bleeding for which there is no established treatment approach. In this report, we describe the case of a 58-year-old woman who presented with hematochezia and who was diagnosed with small bowel hemangioma. She was successfully treated using endoscopic sclerotherapy. Initial capsule endoscopy revealed bleeding in the ileum. Subsequent double-balloon enteroscopy showed a 2-cm, bluish-purple, ileal submucosal tumor with an overlying protrusion. The lesion was responsible for the hematochezia and was treated with intralesional injection of polidocanol. The hematochezia completely resolved and at 4 months after sclerotherapy, the size of the lesion was significantly reduced.