Oral indigo carmine for the detection of colon adenoma.

OBJECTIVES: Colonoscopy is currently considered the optimal method to detect colorectal neoplasia; however, some adenomas remain undetected. While indigo carmine staining with a dye-spray catheter has demonstrated promising results for reducing the miss rate, we investigated the oral indigo carmine method. The aim of this study was to determine whether oral indigo carmine intake before standard colonoscopy increases the adenoma (and adenocarcinoma) detection rate (ADR) or the mean number of adenomas per patient (MAP). MATERIALS AND METHODS: The oral indigo carmine method was performed from April 2018 to July 2020 in two hospitals. Data were collected in a prospective manner and compared to the conventional group whose data were collected retrospectively and consecutively from January 2016 to March 2018. All data were anonymized. RESULTS: Among the 704 patients included, colonoscopies were completely performed in 693 patients (347 in the indigo group). The ADR did not significantly differ between the groups: 42.3% vs. 40.3% (indigo vs. conventional group; odds ratio: 1.13; 95% confidence interval: 0.9-1.33, p = .33). The MAP was significantly greater in the indigo group (1.15) than that in the conventional group (0.82; p = .009). The cecal intubation rate and time to cecal intubation did not differ between the indigo and conventional group (98.6% vs. 98.3%, p = .83, and 6.2 min vs. 5.9 min, p = .39, respectively). CONCLUSION: The routine use of oral indigo carmine does not lead to a higher ADR despite the higher MAP.

Risk Factors for Aspiration Pneumonia After Endoscopic Hemostasis.

BACKGROUND: Although all types of endoscopic procedures harbor risk of aspiration, little is understood about risk factors for aspiration pneumonia developing after endoscopic hemostasis. AIMS: The present study aimed to identify risk factors for aspiration pneumonia after endoscopic hemostasis. METHODS: Charts from consecutive patients with upper gastrointestinal bleeding that had been treated by endoscopic hemostasis at a single center between January 2004 and January 2015 were retrospectively reviewed. Patient information and clinical characteristics including cause of hemorrhage, established prognostic scales, laboratory data, comorbidities, medications, duration of endoscopic hemostasis, vital signs, sedative use, and the main operator during the procedure were compared between patients who developed aspiration pneumonia and those who did not. RESULTS: Aspiration pneumonia developed in 24 (4.8%) of 504 patients after endoscopic hemostasis. Endotracheal intubation was required for three of them, and one died of the complication. Multivariate analysis revealed that age >75 years (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.5-13.6; p = 0.0073), procedural duration >30 min (OR 5.6; 95% CI 1.9-18.2; p = 0.0023), hemodialysis (OR 3.6; 95% CI 1.2-11; p = 0.024), and a history of stroke (OR 3.8; 95% CI 1-14; p = 0.041) were independent risk factors for developing aspiration pneumonia. CONCLUSIONS: Specific risk factors for aspiration pneumonia after endoscopic hemostasis were identified. Endoscopists should carefully consider aspiration pneumonia when managing older patients who are on hemodialysis, have a history of stroke, and undergo a longer procedure.

[A case report of chronic intestinal pseudo-obstruction with autoimmune autonomic ganglionopathy suspected from seropositive results for anti-ganglionic acetylcholine receptor antibody].

A 37-year-old woman who had previously been diagnosed with idiopathic chronic intestinal pseudo-obstruction (CIPO) at another hospital was admitted to our institution with severe abdominal pain. She had a history of several abdominal surgeries to treat ileus at the previous hospital, and contrast-enhanced computed tomography on admission revealed subileus without any apparent causes of obstruction. Total parenteral nutrition, a gastrointestinal prokinetic agent, and opiates reduced persistent pain;however, breakthrough pain continued. A neurologist at our hospital suggested autoimmune autonomic ganglionopathy (AAG) as a potential cause of CIPO. The patient was diagnosed with suspected AAG on the basis of seropositive results for anti-ganglionic acetylcholine receptor antibody. Intravenous immunoglobulin administration and plasma exchange were performed in combination with immunosuppressive drugs;however, her symptoms barely improved. Although percutaneous endoscopic gastrostomy and enterostomy were subsequently performed to reduce internal intestinal pressure, her pain relief was insufficient.

New Year's silent killer in Japan: Undigested mochi.

Swallowed rice cake (mochi) without chewing retained in the stomach intactly. We successfully treated the hardened mochi without surgery. Eye-catching images showed as many as 10 intact mochi in the stomach and endoscopic crushing procedure.

Fifty-millimeter abscess in the ileum caused by perforation from anisakiasis successfully treated with conservative therapy without drainage.

Intestinal anisakiasis is not only a rare but also a difficult to diagnose parasitic disease. The symptoms are not specific and are often severe and abrupt; therefore, patients are sometimes diagnosed as having surgical abdomen. The clinical imaging findings are remarkable, including ascites, enteritis, ileus, eosinophilic granuloma and sometimes perforation. We experienced a case of intestinal anisakiasis diagnosed on the basis of the Anisakis-specific immunoglobulin A level from paired sera and treated successfully with conservative therapy, although ileum perforation was complicated by a 50-mm abscess. Even the large abscess could be treated without drainage in thiscase.

Risk of colonic diverticular rebleeding according to endoscopic appearance.

BACKGROUND AND STUDY AIMS: Re-commencement of bleeding (rebleeding) of colonic diverticula after endoscopic hemostasis is a clinical problem. This study aimed to examine whether endoscopic visibility of colonic diverticular bleeding affects the risk of rebleeding after endoscopic hemostasis. PATIENTS AND METHODS: We performed a retrospective review of endoscopic images and medical charts of patients with colonic diverticular bleeding who underwent endoscopic hemostasis. Endoscopic visibility was classified into two types according to visibility of the source of bleeding; source invisibility due to bleeding or attached hematin (type 1), or endoscopically visible responsive vessels (type 2). Rebleeding rates within one year after initial hemostasis were examined. RESULTS: Of 93 patients with successful endoscopic hemostasis, 38 (41 %) showed type 1 visibility, while the remaining presented type 2. All patients received hemostasis with clipping, rebleeding developed in 20 patients (22 %). Type 1 visibility was more likely to be observed in patients with rebleeding (65 % vs. 34 %, P  = 0.013). Multivariate analysis revealed that after endoscopic hemostasis, type 1 visibility (invisible source) was the only independent risk factor for colonic diverticular rebleeding (odds ratio, 3.05; 95 % confidence interval, 1.03 - 9.59, P  = 0.044). Kaplan-Meier curve showed the cumulative incidence of rebleeding was significantly higher in patients with type 1 visibility than those with type 2 visibility ( P  = 0.0033, log-rank test). CONCLUSION: Hemostasis by clipping for colonic diverticular bleeding without definite observation of the source of bleeding may not be sufficiently effective. Other hemostatic methods, including band ligation, should be considered when the source of bleeding is unclear.

Superior Mesenteric Artery Syndrome May Be Overlooked in Women with Functional Dyspepsia.

Objective Superior mesenteric artery (SMA) syndrome is characterized by the compression of the third segment of the duodenum between the SMA and aorta, resulting in duodenal obstruction. Because the symptoms of the syndrome are similar to those of functional dyspepsia (FD), this study aimed to examine whether or not patients with SMA syndrome were present among those diagnosed with FD. Methods Patients with an FD diagnosis underwent measurement of the angle and distance between the SMA and aorta by ultrasonography or computed tomography. Patients with an angle of ≤22° or with a distance of ≤8 mm between the SMA and aorta were diagnosed with SMA syndrome. Bacterial culture of the duodenal aspirate was also performed. Results Of the 46 FD patients, 5 (11%) met the criteria. All 5 were women with a body mass index significantly lower than the remaining 41 patients (18.7 vs. 24.0 kg/m2, p=0.003). In addition, all 5 patients had 105/mL or more bacteria in the duodenum. The symptoms of these five patients were treated through dietary and postprandial posture counselling with or without medication. Conclusion Patients with SMA syndrome were observed among underweight women diagnosed with FD. Their symptoms may be associated with bacterial overgrowth.

Appendectomy as a Risk Factor for Bacteremic Biliary Tract Infection Caused by Antibiotic-Resistant Pathogens.

BACKGROUND/AIMS: Recent evidence has suggested that appendix plays a pivotal role in the development and preservation of intestinal immune system. The aim of this study is to examine whether prior appendectomy is associated with an increased risk for the development of antibiotic-resistant bacteria in bacteremia from biliary tract infection (BTI). METHODS: Charts from 174 consecutive cases of bacteremia derived from BTI were retrospectively reviewed. Using multivariate analysis, independent risk factors for development of antibiotic-resistant bacteria were identified among the clinical parameters, including a history of appendectomy. RESULTS: In total, 221 bacteria strains were identified from 174 BTI events. Of those, 42 antibiotic-resistant bacteria were identified in 34 patients. Multivariate analysis revealed that prior appendectomy (Odds ratio (OR), 3.02; 95% confidence interval (CI), 1.15-7.87; p = 0.026), antibiotic use within the preceding three months (OR, 3.06; 95% CI, 1.26-7.64; p = 0.013), and bilioenteric anastomosis or sphincterotomy (OR, 3.77; 95% CI, 1.51-9.66; p = 0.0046) were independent risk factors for antibiotic-resistant bacteria. CONCLUSIONS: Prior appendectomy was an independent risk factor for the development of antibiotic-resistant bacteria in bacteremia from BTI.

Efficacy of tolvaptan in patients with refractory ascites in a clinical setting.

AIM: To elucidate the efficacies of tolvaptan (TLV) as a treatment for refractory ascites compared with conventional treatment. METHODS: We retrospectively enrolled 120 refractory ascites patients between January 1, 2009 and September 31, 2014. Sixty patients were treated with oral TLV at a starting dose of 3.75 mg/d in addition to sodium restriction (> 7 g/d), albumin infusion (10-20 g/wk), and standard diuretic therapy (20-60 mg/d furosemide and 25-50 mg/d spironolactone) and 60 patients with large volume paracentesis in addition to sodium restriction (less than 7 g/d), albumin infusion (10-20 g/wk), and standard diuretic therapy (20-120 mg/d furosemide and 25-150 mg/d spironolactone). Patient demographics and laboratory data, including liver function, were not matched due to the small number of patients. Continuous variables were analyzed by unpaired t-test or paired t-test. Fisher's exact test was applied in cases comparing two nominal variables. We analyzed factors affecting clinical outcomes using receiver operating characteristic curves and multivariate regression analysis. We also used multivariate Cox's proportional hazard regression analysis to elucidate the risk factors that contributed to the increased incidence of ascites. RESULTS: TLV was effective in 38 (63.3%) patients. The best cut-off values for urine output and reduced urine osmolality as measures of refractory ascites improvement were > 1800 mL within the first 24 h and > 30%, respectively. Multivariate regression analysis indicated that > 25% reduced urine osmolality [odds ratio (OR) = 20.7; P < 0.01] and positive hepatitis C viral antibodies (OR = 5.93; P = 0.05) were positively correlated with an improvement of refractory ascites, while the total bilirubin level per 1.0 mg/dL (OR = 0.57; P = 0.02) was negatively correlated with improvement. In comparing the TLV group and controls, only the serum sodium level was significantly lower in the TLV group (133 mEq/L vs 136 mEq/L; P = 0.02). However, there were no significant differences in the other parameters between the two groups. The cumulative incidence rate was significantly higher in the control group with a median incidence time of 30 d in the TLV group and 20 d in the control group (P = 0.01). Cox hazard proportional multivariate analysis indicated that the use of TLV (OR = 0.58; P < 0.01), uncontrolled liver neoplasms (OR = 1.92; P < 0.01), total bilirubin level per 1.0 mg/dL (OR = 1.10; P < 0.01), and higher sodium level per 1.0 mEq/L (OR = 0.94; P < 0.01) were independent factors that contributed to incidence. CONCLUSION: Administration of TLV results in better control of refractory ascites and reduced the incidence of additional invasive procedures or hospitalization compared with conventional ascites treatments.

Efficacy of transcatheter arterial chemoembolization followed by sorafenib for intermediate/advanced hepatocellular carcinoma in patients in Japan: a retrospective analysis.

BACKGROUND: Sorafenib might prevent hepatocellular carcinoma (HCC) recurrence caused by the promotion of neoangiogenesis after transarterial chemoembolization (TACE). OBJECTIVES: To evaluate the efficacy and safety of TACE followed by sorafenib for treating advanced HCC. PATIENTS AND METHODS: We retrospectively analyzed 95 advanced HCC patients treated with TACE between July 2008 and December 2012 at our institution. Twenty-four patients received TACE followed by sorafenib within 14 days (S-TACE) and 71 received TACE alone. Progression-free survival (PFS) and cumulative survival from the time of non-responsiveness to TACE were compared between groups and predictive factors for PFS were analyzed. RESULTS: The median patient age was 72.2 years and 74 patients were male (77.9 %). Although median tumor size was similar between groups, the mean tumor number was significantly higher in the S-TACE versus TACE-alone group (16 vs. 8, P = 0.04). The number of prior treatments was significantly higher in the S-TACE group. Other baseline variables were similar. There were two severe adverse events in the S-TACE group and none in the TACE-alone group. Median PFS (189 vs. 106 days, P = 0.02) and median overall survival time (861 vs. 467 days, P = 0.01) from the time of non-responsiveness to TACE were significantly longer with S-TACE than TACE alone. Adjusting for significant factors in univariate analysis, multivariate analysis indicated that sorafenib administration, tumor size, and alanine transaminase were independent predictors of PFS. CONCLUSION: TACE followed by sorafenib significantly improved PFS and survival in patients with advanced HCC unresponsive to TACE.

Persistent monoarthritis of the temporomandibular joint region enhances nocifensive behavior and lumbar spinal Fos expression after noxious stimulation to the hindpaw in rats.

Effects of persistent temporomandibular joint (TMJ) inflammation on nociceptive responses of remote bodily areas of the rat were investigated. Monoarthritis of the TMJ region was evoked by the injection of complete Freund's adjuvant (CFA) into the left TMJ region. Rats without injection of CFA into the TMJ region served as controls (non-CFA group). Time spent on licking behavior evoked by the injection of formalin into the left hindpaw and withdrawal thresholds of mechanical stimulation to both sides of the hindpaw were measured during TMJ inflammation for 3 weeks. Furthermore, expression of Fos protein in the lumbar dorsal horn was immunohistochemically investigated following the injection of formalin into the hindpaw during TMJ inflammation. Formalin-evoked nocifensive behavioral activities were significantly enhanced at 10 and 14 days after CFA injection in the late phase, while the withdrawal threshold to mechanical stimulation was significantly decreased bilaterally at 8, 10 and 14 days after CFA injection. Both formalin-evoked licking behavior and mechanical withdrawal thresholds to bilateral hindpaw at 21 days after CFA injection were similar to those in the non-CFA group. The number of Fos-positive neurons in the lumbar dorsal horn ipsilateral to the formalin injection at 1 and 7 days after CFA injection into the TMJ were similar to those in the non-CFA group; however, those were significantly increased in the laminae I-II and V-VI of the lumbar dorsal horn at 14 days after CFA injection. TMJ inflammation for 7 and 14 days alone produced a small number of Fos-expressing neurons in the lumbar dorsal horn. These results provide evidence that persistent unilateral inflammation of the TMJ region causes an increase in behavioral hyperalgesia of the hindpaw, which is attributed to the modulation of neural activities, in part, in the lumbar dorsal horn, likely mediated by supraspinal neural mechanisms.