Clinical presentation and therapeutic outcome of patients with jackhammer esophagus-a multicenter cohort study in Japan.

BACKGROUND: Jackhammer esophagus (JE) is a hypercontractile esophageal motility disorder diagnosed using high-resolution manometry (HRM). We sought to determine the clinical presentation and therapeutic data of patients with JE in Japan. METHODS: The study included patients with JE, diagnosed through HRM performed for suspicious esophageal motility disorders. Demographics, esophagogastroduodenoscopy, radiology, and therapy data were collected from patient charts. RESULTS: Among the 4,412 HRM tests performed, 89 patients (61.6 ± 13.4 years; 64 males, 25 females) were diagnosed with JE (2.0%). Dysphagia was the most frequent symptom (80%), followed by chest pain (40%) and heartburn (25%). Esophagogastroduodenoscopy showed abnormal findings in 32% of patients: corkscrew/rosary beads appearance in 26%, narrowing in 11%. Eosinophilic infiltration (> 15 eosinophils/high power field) was diagnosed in 21%. Esophagography showed abnormal findings in 9% of the patients. For the initial therapy, 47 patients received medical treatment followed by peroral endoscopic myotomy (21 patients) and laparoscopic myotomy (two patients). Thirteen patients did not receive any treatment and 10 of those (77%) reported spontaneous resolution of symptoms. Patients who required invasive treatment experienced severe disability in their quality of life and greater maximal distal contractile integral than those who did not. CONCLUSIONS: HRM showed that the prevalence of JE was very low (2%). Esophagogastroduodenoscopy revealed some characteristic features of JE in patients. Some patients showed improvement of symptoms without invasive treatments. Follow-up with/without medical treatment should be considered before performing invasive treatment in patients whose distal contractile integral is relatively low and the quality of life is not impaired.

Effects of rikkunshito on quality of life in patients with gastroesophageal reflux disease refractory to proton pump inhibitor therapy.

We investigated the effects of rikkunshito, in combination with a proton pump inhibitor, on symptoms and quality of life in patients with proton pump inhibitor-refractory gastroesophageal reflux disease. The subjects were 47 patients with gastroesophageal reflux disease with residual symptoms such as heartburn following 8 weeks of proton pump inhibitor therapy. We administered these subjects rikkunshito in combination with a proton pump inhibitor for 6-8 weeks. We scored their symptoms of heartburn, fullness, abdominal discomfort, and abdominal pain, and surveyed their quality of life using the Reflux Esophagitis Symptom Questionnaire, comprising questions concerning daily activities, meals (changes in amount and favorite foods), and sleep (getting to sleep and early morning waking). Improvement was seen in all symptoms, and quality of life scores for meals and sleep also improved. These results indicate that combination therapy with rikkunshito and a proton pump inhibitor improves quality of life related to eating and sleep in patients with patients with proton pump inhibitor-refractory gastroesophageal reflux disease.

Efficacy of acotiamide in combination with esomeprazole for functional dyspepsia refractory to proton-pump inhibitor monotherapy.

Functional dyspepsia (FD) is a gastroduodenal disorder that presents as postprandial fullness, early satiation, or epigastric burning despite no evidence of a structural disease. Proton pump inhibitors (PPIs) are often the first choice for treating FD. However, some patients need additional medication because of residual symptoms despite a certain level of benefit from the PPI. For these patients, a combination of PPI and other agents has a possibly more beneficial effect than changing their medication. This study aimed to evaluate the efficacy of an initial PPI followed by combination therapy with PPI and acotiamide in FD patients with residual symptoms after an initial PPI. We enrolled 105 patients who started an initial PPI (20 mg of esomeprazole once a day). Twenty-three patients with residual symptoms received 100 mg of acotiamide, a cholinesterase inhibitor, three times a day with esomeprazole as a combination therapy for 2 weeks. The symptoms were evaluated using the modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (mFSSG). Eighteen of 23 patients (78%) achieved an overall improvement in symptoms. Almost all FD-related symptoms statistically improved after the combination therapy, with an improvement in the mFSSG score relevant to the postprandial distress syndrome and epigastric pain syndrome. The symptoms improved regardless of age, sex, and the pre-combination therapy score of the mFSSG. Our findings suggest that the combination therapy of acotiamide and PPI may be effective in selected FD patients with insufficient improvement with an initial PPI. However, well-designed trials are required to confirm the efficacy.

Endoscopic Features of Gastric Mucosa-Associated Lymphoid Tissue Lymphoma without Helicobacter pylori.

Although gastric mucosa-associated lymphoid tissue (MALT) lymphoma without Helicobacter pylori (HP) has increased recently, a specific endoscopic classification has not been established; its endoscopic characteristics have not been investigated. In this study, we retrospectively investigated gastric MALT lymphoma without HP in our hospital and assessed differences in the endoscopic findings according to HP infection status. Fifty-seven patients with gastric MALT lymphoma Lugano stage I, diagnosed between January 2013 and March 2023, were divided into three groups (currently HP infected, previously infected, and uninfected), wherein their endoscopic findings were evaluated. Furthermore, the superficial type, as per the classification of Sano et al., was independently subdivided based on the endoscopic differential diagnoses, as follows: atrophic gastritis-like, angiodysplasia-like, superficial gastritis-like, and undifferentiated carcinoma-like. Compared with the currently infected group, the HP-uninfected group tended to have more small lesions without erosion and more discolored, undifferentiated carcinoma-like depressed lesions. In addition, the positive rate of the tree-like appearance (TLA) and ballooning characteristics of gastric MALT lymphoma in magnified findings was lower in the HP-uninfected group. In patients without HP infection, MALT lymphoma should be excluded, even in the absence of suspicious magnifying findings such as TLA or ballooning.

Endoscopic Image 2 Hours after PuraStat® Application: A Case of Achieving Hemostasis Using PuraStat® for Postgastric Lesion Biopsy Bleeding after Hemostatic Clips Failed.

PuraStat® (3D Matrix, Tokyo, Japan) is a novel, self-assembling peptide hemostatic hydrogel that can be used endoscopically. Hemostasis can be physically obtained by covering bleeding points; however, there are no reports of how long PuraStat remains in the upper gastrointestinal tract. Herein, we report a case wherein esophagogastroduodenoscopy (EGD) was performed 2 hours after PuraStat application. A 73-year-old man underwent EGD for evaluation of lesions in the posterior wall of the stomach. A biopsy was then performed on the gastric lesions; however, massive bleeding occurred. A hemostatic clip was used to stop bleeding but failed; primary hemostasis was obtained by applying PuraStat. EGD performed 2 hours later to determine whether the patient could be discharged revealed that the white-turning PuraStat gel remained firmly in the applied area, confirming complete hemostasis. PuraStat is a hemostatic agent capable of physical hemostasis that reliably remains in the stomach even after a few hours of use and, thus, may replace some conventional hemostasis methods.

A case of gastric antral vascular ectasia in which PuraStat, a novel self-assembling peptide hemostatic hydrogel, was effective.

Gastric antral vascular ectasia (GAVE) is a gastric hemorrhagic disease associated with chronic liver disease. Argon plasma coagulation is widely used to control gastrointestinal bleeding due to GAVE. Although argon plasma coagulation is a relatively safe endoscopic procedure, it is not suitable in some cases, such as in patients with pacemakers. We report a case of GAVE in which PuraStat, a novel self-assembling peptide hemostatic hydrogel, was effective. The patient was a 55-year-old man who had undergone Fontan surgery for tricuspid regurgitation more than 20 years prior. He developed hepatic cirrhosis as a complication following Fontan surgery. During upper gastrointestinal endoscopy to examine the cause of the progression of anemia and black stool, bleeding from GAVE was observed; PuraStat was applied to stop the bleeding. Postoperatively, the black stool disappeared, and his hemoglobin levels improved. Upper gastrointestinal endoscopy was performed 13 days after the surgery; the density of the capillaries in the antrum was significantly decreased, and a clear trend toward disappearance was observed. Therefore, the application of PuraStat may be useful in the treatment of GAVE.

Characteristics, Outcomes, and Risk Factors for Upper Gastrointestinal Bleeding in Inpatients - A Comparison with Outpatients.

Objective The study objectives were to clarify the clinical findings and the causes of intractability and mortality of upper gastrointestinal (UGI) bleeding in inpatients. Methods The patients were divided into Inpatient (Ip) and Outpatient (Op) onset groups, and their characteristics, clinical and bleeding data, and outcomes were compared. Patients Our study included 375 patients who developed UGI bleeding during hospitalization or were admitted after being diagnosed with UGI bleeding in an outpatient setting from January 1, 2015, to June 30, 2020. Results The Ip group had worse general condition; increased percentages of comorbidities; and more common use of proton pump inhibitor, anti-coagulant, and steroid than the Op group. Compared with the Op group, the Ip group had lower serum albumin levels and platelet counts at the onset of bleeding, whereas rebleeding, mortality, and bleeding-related death rates were higher. Multivariate analysis of the Ip group revealed that the risks of rebleeding included endoscopic high-risk stigmata, maintenance dialysis, and duodenal bleeding, whereas the risks of mortality were gastric ulcer and a Charlson Comorbidity Index update score of ≥3. Conclusion UGI bleeding in the Ip group was associated with higher rebleeding and mortality rates. Because of their poor general health condition, the pathology of UGI bleeding in these patients may differ from that of patients with common UGI bleeding. A different approach for the care and prevention of UGI bleeding in inpatients is required.

Comparison of the Ability of Artificial-Intelligence-Based Computer-Aided Detection (CAD) Systems and Endoscopists to Detect Colorectal Neoplastic Lesions on Endoscopy Video.

Artificial-intelligence-based computer-aided diagnosis (CAD) systems have developed remarkably in recent years. These systems can help increase the adenoma detection rate (ADR), an important quality indicator in colonoscopies. While there have been many still-image-based studies on the usefulness of CAD, few have reported on its usefulness using actual clinical videos. However, no studies have compared the CAD group and control groups using the exact same case videos. This study aimed to determine whether CAD or endoscopists were superior in identifying colorectal neoplastic lesions in videos. In this study, we examined 34 lesions from 21 cases. CAD performed better than four of the six endoscopists (three experts and three beginners), including all the beginners. The time to lesion detection with beginners and experts was 2.147 ± 1.118 s and 1.394 ± 0.805 s, respectively, with significant differences between beginners and experts (p < 0.001) and between beginners and CAD (both p < 0.001). The time to lesion detection was significantly shorter for experts and CAD than for beginners. No significant difference was found between experts and CAD (p = 1.000). CAD could be useful as a diagnostic support tool for beginners to bridge the experience gap with experts.

Endoscopic Features of Autoimmune Gastritis: Focus on Typical Images and Early Images.

Autoimmune gastritis (AIG) is chronic atrophic gastritis caused by an autoimmune mechanism of unknown etiology and presents with various pathological conditions by causing an achlorhydria state through parietal cell damage. The most characteristic endoscopic finding in AIG is advanced corpus-dominant mucosal atrophy. A recent study that examined several cases in Japan revealed the presence of endoscopic features other than corpus-dominant advanced atrophy. Remnants of oxyntic mucosa and sticky adherent dense mucus were found in ≥30% of cases, and hyperplastic polyps were found in ≥20% of cases. In image-enhanced endoscopy (IEE), white globe appearance (WGA) was observed in 32% of AIG cases. Additionally, some reports have stated that the findings in AIG cases using IEE showed cast-off skin appearance (CSA) and foveola type mucosa; however, a consensus is yet to be achieved. These endoscopic results were found in cases of advanced-stage AIG. There have been few reports concerning early-stage AIG cases. In these few reports, all of the cases were pathologically diagnosed as early AIG. In all of the cases, the pathological findings almost always showed neither parietal cell destruction nor atrophy. Endoscopic findings such as "mosaic pattern with slight swelling of the areae gastricae", "diffuse reddened and edematous gastric fundic gland mucosa", and "pseudopolyp-like nodules" may be common characteristics of early images. In such early cases, high antibody titers, no atrophic changes, and few clinical abnormal findings were shown. Endoscopists are expected to update their knowledge regarding AIG diagnosis with the evolution of imaging equipment.

Young gastric cancer patient with high CA19-9 complicated by Trousseau syndrome.

A 47-year-old Japanese woman presented with epigastric discomfort and anorexia. Upper endoscopy showed type 4 advanced gastric cancer in the gastric antrum with stenosis of the pyloric portion. Abdominopelvic CT revealed peritoneal dissemination, and stage IV advanced gastric cancer was diagnosed. Laparoscopic gastrojejunostomy and enterostomy were performed. Trousseau syndrome occurred 7 days post-surgery. Despite appropriate treatment, the patient developed a pulmonary embolism 13 days later and died 18 days post-surgery. Even in young cancer patients without lifestyle disease complications, it is important to pay attention to Trousseau syndrome as part of cancer management.

A case of early autoimmune gastritis with characteristic endoscopic findings.

Significant atrophic gastritis in the fundic gland region is a well-known endoscopic finding observed in autoimmune gastritis (AIG). The endoscopic features of early AIG have not been reported. Iron deficiency, vitamin B12 deficiency, anemia, or neurological symptoms may not be observed in the early stages of AIG, and it may thus be difficult to diagnose early AIG based on clinical findings. We treated a 50-year-old Japanese female whose condition was suspected to be early AIG. The endoscopic findings showed normal gastric pyloric gland mucosa, and diffuse reddened and edematous gastric fundic gland mucosa. Pathologically, local infiltration of lymphocytes and decrease of parietal cells was present in a deep part of the gastric fundic gland mucosa. Blood tests showed that the titer of parietal cell antibody (PCA) was 1:320 and the gastrin level was 820 pg/ml. We determined that the patient had AIG because she also had Hashimoto's disease, the PCA titer was high, the serum gastrin level was slightly increased, and inflammation was observed only in the gastric body on the endoscopic images. To the best of our knowledge, this is the first case report of endoscopic findings that suggest early AIG, before atrophic changes were observed.

Two cases of accidental ingestion of a press-through package (PTP) sheet, diagnosed by tomosynthesis prior to endoscopy.

The accidental ingestion of a press-through package (PTP) sheet is associated with the risk of gastrointestinal injury and puncture. When pain occurs in the laryngeal pharynx, the PTP may already be stuck in the upper esophageal region, and urgent endoscopic treatment is necessary. A plain chest X-ray image should be performed first to identify the ingested PTP, but this was not successful in the present two patients. As a next step, a CT scan (which involves high radiation exposure) is commonly used. In our patients (a 76-year-old woman and a 59-year-old man), tomosynthesis was used to confirm the presence and location of a PTP sheet as a pre-endoscopic diagnosis. With tomosynthesis, the level of radiation exposure was reduced to approx. 1/10 of that of simple CT; the imaging time is also shorter at ~ 5 s. Tomosynthesis can be performed at approx. 1/3-1/4 the cost of simple CT. The usefulness of tomosynthesis as a pre-endoscopic diagnostic tool was demonstrated in our patients, and its further utilization is expected.

Symptoms and Upper Gastrointestinal Mucosal Injury Associated with Bisphosphonate Therapy.

Objective The incidence of osteoporosis is increasing with the rapid aging of the Japanese population. Bisphosphonates are first-line agents used for the treatment of osteoporosis, but they can cause upper gastrointestinal mucosal injury. This study investigated symptoms and upper gastrointestinal mucosal injury associated with oral bisphosphonates. Methods Symptoms were evaluated using the F-scale questionnaire, and esophageal mucosal injury and gastroduodenal ulceration were assessed by endoscopy. Patients were stratified by the type of bisphosphonate (alendronate, risedronate, or minodronate), treatment schedule (once weekly or every four weeks), and the concomitant use of other medications [antithrombotic agents, nonsteroidal anti-inflammatory drugs (NSAIDs), or acid suppressants]. Patients The subjects included 221 patients treated with oral bisphosphonates for at least one month. Results The median F-scale total score was 4 (0-34), reflux score was 2 (0-20), and the mean dyspepsia score was 2 (0-16). Endoscopy showed esophageal mucosal injury of Grade A or worse (Los Angeles classification) in 22/221 patients (10.0%) and gastroduodenal ulcers in 9 patients (4.1%). The dyspepsia score in patients who took minodronate every four weeks was significantly lower (p<0.05) in comparison to patients who took other bisphosphonates. The dyspepsia score was significantly higher (p<0.05) and mucosal injury was significantly more frequent in patients who also used antithrombotic agents and NSAIDs. Conclusion Symptoms and upper gastrointestinal mucosal damage were not necessarily frequent or severe in patients treated with bisphosphonates. However, the concomitant use of bisphosphonates with antithrombotic agents and NSAIDs increased both symptoms and mucosal injury. The symptoms were milder in patients using minodronate once monthly.

Long-term follow up of esophageal varices after balloon-occluded retrograde transvenous obliteration for gastric varices.

AIM: Because the procedure of balloon-occluded retrograde transvenous obliteration (B-RTO) causes extensive thrombosis of the major shunt that connects the spleen and gastric/renal venous systems, an increase in portal pressure is unavoidable. The aim of the present study was to assess the long-term outcome of B-RTO, including changes in esophageal varices. METHODS: B-RTO was conducted in 22 patients with gastric varices, who were divided according to the severity of esophageal varices at baseline; there were no esophageal varices (n = 7), F(1) varices (n = 11), and F(2) varices (n = 4). The outcome measures included the development/worsening of esophageal varices after B-RTO and survival rates. RESULTS: The cumulative bleeding-free probability for all 22 patients at 3 years after B-RTO was 100%. The overall 3-year survival was 94.4%. Seven patients who had no esophageal varices prior to B-RTO did not develop any after the procedure. Seven (63.6%) of the 11 patients with stage F(1) esophageal varices prior to B-RTO showed no changes in the varices after B-RTO, while two patients progressed to F(2) varices and two developed F(3) varices. The cumulative treatment-free probability of the esophageal varices at 24 months after B-RTO was 100% for patients without esophageal varices at baseline, 80.8% for patients with pre-existing F(1) varices, and 75% for those with pre-existing F(2) varices. CONCLUSION: Although the B-RTO procedure is considered useful for the treatment of gastric varices, changes in hemodynamics due to obliteration of this major shunt must be taken into account and observed closely.

Prevalence of esophagogastric varices in patients with non-alcoholic steatohepatitis.

AIM: In non-alcoholic steatohepatitis (NASH), fibrosis begins around the central veins, as also happens with alcoholic liver disease, so the symptoms of portal hypertension may be due to central vein occlusion. The aim of this study was to define the prevalence of esophagogastric varices and the clinical outcome after endoscopic treatment in NASH patients with severe fibrosis. METHODS: The subjects were 72 patients with clinicopathologically confirmed NASH who had bridging fibrosis (F3) or cirrhosis (F4) determined by the examination of liver biopsy specimens, and who underwent upper gastrointestinal endoscopy. The prevalence and pattern of endoscopically detected varices at the time of liver biopsy were evaluated. The results of NASH patients (n = 11) with endoscopically treated esophageal varices were compared to those with alcoholic (n = 67) and hepatitis C virus-associated cirrhosis (n = 152). RESULTS: Esophagogastric varices were detected in 34 out of the 72 (47.2%) patients; esophageal varices in 25 (34.7%) and gastric varices in nine (12.5%), while six of these patients had variceal bleeding. In NASH patients, the cumulative recurrence-free probability at 24 months after endoscopic treatment was 63.6%, the bleeding-free probability was 90.9%, and the 5-year survival was 100%. Only one out 11 patients died of liver failure at 70 months after treatment. CONCLUSION: About half of NASH patients with severe fibrosis had esophagogastric varices. The clinical status and course of the varices do not necessarily improve after endoscopic treatment. NASH patients with esophagogastric varices need to be followed up carefully, like patients with other chronic liver diseases.

Clinical and Endoscopic Features of Undifferentiated Gastric Cancer in Patients with Severe Atrophic Gastritis.

OBJECTIVE: Differentiated gastric cancer generally develops in the atrophic gastric mucosa, although undifferentiated cancer is sometimes encountered in patients with severe atrophic gastritis. We characterized the endoscopic features of undifferentiated gastric cancer in patients with severe atrophic gastritis. METHODS: Stage IA early gastric cancer was diagnosed in 501 patients who were admitted to our hospital between April 2003 and March 2012. The endoscopic and pathological findings were compared among 29 patients with undifferentiated cancer and severe atrophic gastritis, 104 patients with undifferentiated cancer and mild/moderate atrophic gastritis and 223 patients with well-differentiated cancer and severe atrophic gastritis. Endoscopic atrophic gastritis was classified according to the Kimura-Takemoto classification as no gastritis, C-1 and C-2 (mild), C-3 and O-1 (moderate) or O-2 and O-3 (severe). RESULTS: The tumors were larger and showed deeper mural invasion in the patients with undifferentiated cancer and severe atrophic gastritis than in those with well-differentiated cancer and severe gastritis or undifferentiated cancer and mild/moderate gastritis. On endoscopy, undifferentiated cancer associated with severe gastritis was often red in color. CONCLUSION: It is often difficult to diagnose early undifferentiated gastric cancer, especially in patients with severe atrophic gastritis. The present study characterized the important endoscopic features of such tumors.

A case of solid pseudopapillary neoplasm of the pancreas presenting with left-sided extrahepatic portal hypertension.

A 53-year-old woman was referred to our hospital for management of gastric varices that ran transversely across the greater curvature of the gastric body, detected during routine upper gastrointestinal endoscopy. CT identified a low-density calcified mass near the tail of the pancreas and the splenic hilum. Based on the results of radiographic and pathological investigations, the tumor was diagnosed as solid pseudopapillary neoplasm (SPN), and the gastric varices were considered to have developed secondary to occlusion of the splenic vein by the tumor mass. This is a rare case of SPN associated with splenic vein occlusion and left-sided extrahepatic portal hypertension.