Hemorrhagic shock from gastric pseudoaneurysm post-percutaneous endoscopic gastrostomy: a case report.

Percutaneous endoscopic gastrostomy (PEG) is widely used for long-term enteral nutrition in patients unable to maintain adequate oral intake. Despite advancements in PEG techniques, complications remain a concern. We report a case of a 94-year-old bedridden man who developed significant complications after PEG placement using the pull method. Initially, minor bleeding at the puncture site was managed using traction compression. However, the patient later experienced hemorrhagic shock owing to pulsatile bleeding around the gastrostomy site. Despite attempts to control the bleeding through traction and transfusions, a pseudoaneurysm adjacent to the PEG button was identified. The patient underwent successful transcatheter arterial embolization (TAE). Post-TAE, no further bleeding or hematoma was observed, and imaging confirmed the resolution of the pseudoaneurysm and hematoma. Methicillin-resistant Staphylococcus aureus (MRSA) infection was detected at the gastrostomy site, which contributed to complications. Despite successful management of the bleeding, the patient's overall condition deteriorated, and he died on postoperative day 66. This case underscores the importance of vigilant monitoring and management of PEG-related complications, particularly infections that may precipitate severe vascular events.

Persistent Nausea and Gastrointestinal Distention: A Case Report of Aerophagia.

A 43-year-old woman experienced acute nausea, diarrhea, and abdominal pain, leading her to our hospital. No relevant medical history or physical abnormalities were noted. Symptoms persisted for a month, causing weight loss and abdominal bloating. CT scans revealed distension throughout the gastrointestinal tract without stenosis. Intestinal pseudo-obstruction and aerophagia were suspected. MR enterography confirmed normal gastric and intestinal motility, diagnosing the condition as aerophagia-induced gastrointestinal distention. This case underscores the value of MR enterography in assessing intestinal motility and differentiating between intestinal pseudo-obstruction and aerophagia.

Effect of abdominal visceral fat on mortality risk in patients with severe acute pancreatitis.

BACKGROUND AND AIM: Obesity is a well-known risk factor for the development and severity of acute pancreatitis (AP), but the relationship between the abdominal visceral fat area (VFA) and mortality is unclear. We evaluated the effect of the VFA on mortality in severe AP (SAP). METHODS: This retrospective, single-center cohort study examined 119 consecutive patients with SAP from April 2009 to March 2019. The VFA at the umbilical level was assessed using computed tomography. The primary endpoint was to evaluate whether visceral obesity affects mortality in SAP. RESULTS: The median age was 63 years, and 66% of participants were male. Nine patients (7.5%) died during their hospital stay. The median body mass index (BMI) was 22.2 kg/m2, and six obese patients had a BMI of over 30 kg/m2 (5%). The median waist circumference and VFA were 85.5 cm and 112 cm2, respectively. Sixty-eight (57.1%) patients had a VFA over 100 cm2. The prognostic factor score based on the Japanese guidelines for AP management (cutoff value [COV], 4; area under the curve [AUC] = 0.869) and age [COV, 72; AUC = 0.780]) showed moderate accuracy for predicting mortality, followed by the VFA (COV, 167 cm2; AUC = 0.679). Univariate logistic analysis, but not multivariate analysis, showed that an increased VFA was associated with a significantly higher odds ratio (OR) for predicting mortality (OR: 4.38, P = 0.0406). The survival times of SAP patients with and without an increased VFA of 167 cm2 were not significantly different. CONCLUSIONS: Visceral obesity did not have a significant impact on predicting mortality in patients with SAP.

Comparison of colonoscopy after colonic diverticulitis and positive fecal immunochemical tests for the detection of colorectal neoplasia.

Background and study aims The relationship between acute colonic diverticulitis and colorectal cancer (CRC) is unclear, but colonoscopy is recommended to exclude malignancy. We compared the detection rates for colorectal neoplasia in patients with colonic diverticulitis and asymptomatic patients who had positive fecal immunochemical tests (FITs). Patients and methods In total, 282 patients with acute colonic diverticulitis were hospitalized in our hospital from February 2011 to December 2019. Of them, 143 patients with diverticulitis and 1819 with positive FITs patients during the same period underwent colonoscopy without a prior colonoscopy within 5 years. We retrospectively compared these patients in terms of the invasive CRC rate, advanced neoplasia detection rate (ANDR), adenoma detection rate (ADR), and polyp detection rate (PDR). Results Compared to the diverticulitis group, the FIT-positive group had a significantly higher CRC rate (0 vs 2.7 %, P  = 0.0061), ANDR (5.6 vs. 14.0 %, P  = 0.0017), ADR (19.6 vs. 53.2 %, P  < .0001), and PDR (44.1 vs. 91.0 %, P  < .0001). Using 1:1 propensity score matching based on age and sex, we obtained 276 matched patients in both groups. After matching, no difference was found in the CRC rate (0 vs 0.7 %) or ANDR (5.8 vs 7.3 %) between groups, but the ADR and PDR were significantly higher in the FIT-positive group (20.3 vs 43.5 %, P  < .0001; 45.7 % vs 86.2 %, P  < .0001). Conclusion Patients with acute diverticulitis had lower ADRs and PDRs than patients with positive FITs.

Radiation exposure dose of fluoroscopy-guided gastrointestinal procedures: A single-center retrospective study.

Background and study aims Fluoroscopy-guided gastrointestinal procedures (FGPs) are increasingly common. However, the radiation exposure (RE) to patients undergoing FGPs is still unclear. We examined the actual RE of FGPs. Patients and methods This retrospective, single-center cohort study included consecutive FGPs, including endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasound (EUS), enteral stenting, balloon-assisted enteroscopy, tube placement, endoscopic injection sclerotherapy (EIS), esophageal balloon dilatation and repositioning for sigmoid volvulus, from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm 2 ), and fluoroscopy time (FT, min) for each procedure. Results In total, 3831 patients were enrolled. Overall, 2778 ERCPs were performed. The median AK, DAP, and FT were as follows: ERCP: 109 mGy, 13.3 Gycm 2 and 10.0 min; self-expandable enteral stenting (SEMS): 62 mGy, 12.4 Gycm 2 and 10.4 min; tube placement: 40 mGy, 13.8 Gycm 2 and 11.1 min; balloon-assisted enteroscopy: 43 mGy, 22.4 Gycm 2 and 18.2 min; EUS cyst drainage (EUS-CD): 96 mGy, 18.3 Gycm 2 and 10.4 min; EIS: 36 mGy, 8.1 Gycm 2 and 4.4 min; esophageal balloon dilatation: 9 mGy, 2.2 Gycm 2 and 1.8 min; and repositioning for sigmoid volvulus: 7 mGy, 4.7 Gycm 2 and 1.6 min. Conclusion This large series reporting actual RE doses of various FGPs could serve as a reference for future prospective studies.

A Triple-Drug Blister-Packaged Drug with Vonoprazan Improves First-Line Eradication of Helicobacter pylori in Elderly Patients: A Retrospective Propensity Score-Matched Cohort Study.

BACKGROUND: A blister-packaged drug might be useful to enhance the eradication of Helicobacter pylori. We investigated the effect of a blister-packaged drug for H. pylori eradication. METHODS: We treated 1,758 patients with H. pylori infections and evaluated the successful eradication rate in patients who underwent first-line eradication between January 2013 and May 2018. Treatments included a conventional proton pump inhibitor (PPI) blister-packaged drug containing lansoprazole or rabeprazole with clarithromycin (CAM) and amoxicillin (AC), vonoprazan (VPZ) with CAM and AC in a separate tablet, or a VPZ blister-packaged drug (VONOSAP) containing VPZ with CAM and AC, with all drugs given twice daily for 7 days. RESULTS: Finally, we evaluated 1,263 patients (conventional PPI: n = 644, VPZ: n = 326, and VONOSAP: n = 293). The overall successful eradication rates were 71.9% in the conventional PPI group, 90.2% in the VPZ group, and 92.2% in the VONOSAP group. There was a significantly lower eradication rate in the PPI group than in the VPZ and VONOSAP (p < 0.00001, p < 0.0001) groups, but there was no significant difference between the VPZ and VONOSAP groups (p = 0.4006). We enrolled a total of 256 age- and gender-matched patients in the VPZ and VONOSAP groups, and both groups had successful eradication rates of approximately 90% (89.8 vs. 90.4%, respectively, p = 0.7641). After analyzing the subgroup of patients older than 75 years, there was a significant treatment benefit of VONOSAP but not of VPZ in elderly patients (EPs). CONCLUSION: Triple-drug blister-packaged drugs including VPZ may improve the first-line eradication of H. pylori in EPs.

Impact of time from diagnosis to chemotherapy in advanced gastric cancer: A Propensity Score Matching Study to Balance Prognostic Factors.

BACKGROUND: It is unclear whether treatment delay affects the clinical outcomes of chemotherapy in advanced gastric cancer (A-GC). AIM: To assess whether treatment delay affects the clinical outcomes of chemotherapy in A-GC. METHODS: This single-center retrospective study examined consecutive patients with A-GC between April 2012 and July 2018. In total, 110 patients with stage IV A-GC who underwent chemotherapy were enrolled. We defined the wait time (WT) as the interval between diagnosis and chemotherapy initiation. We evaluated the influence of WT on overall survival (OS). RESULTS: The mean OS was 303 d. The median WT was 17 d. We divided the patients into early and elective WT groups, with a 2-wk cutoff point. There were 46 and 64 patients in the early and elective WT groups, respectively. Compared with the elective WT group, the early WT group had significantly lower albumin (Alb) levels and higher neutrophil/lymphocyte ratios and C-reactive protein (CRP) levels but not a lower performance status. The elective WT group underwent more combination chemotherapy than did the early WT group. OS was different between the two groups (230 d vs 340 d, respectively). Multivariate analysis revealed that higher CRP levels, lower Alb levels and monotherapy were significantly related to a poor prognosis. To minimize potential selection bias, patients in the elective WT group were 1:1 propensity score matched with patients in the early WT group; no significant difference in OS was found (303 d vs 311 d, respectively, log-rank P = 0.9832). CONCLUSION: A longer WT in patients with A-GC does not appear to be associated with a worse prognosis.

Nivolumab Induces Sustained Liver Injury in a Patient with Malignant Melanoma.

A 42-year-old man was diagnosed with cStage IIIb malignant melanoma and underwent resection. After interferon-beta therapy, 18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) showed multiple lung metastases, and he received nivolumab (2 mg/kg) every 3 weeks, resulting in a total of 17 cycles. After treatment, 18F-FDG PET/CT showed a significant decrease in the size of the metastases, but he had a Grade 4 alanine aminotransferase (ALT) elevation. Liver histology revealed drug-induced liver damage. Therefore, we performed steroid half-pulse therapy followed by oral methylprednisolone, but his ALT level did not completely recover to the normal range even after five months. We herein report a case with specific, sustained liver injury induced by nivolumab as an immune-related adverse events.

Selective and potent inhibitors of human 20alpha-hydroxysteroid dehydrogenase (AKR1C1) that metabolizes neurosteroids derived from progesterone.

Neuroactive steroids, such as 3alpha,5alpha-tetrahydroprogesterone (3alpha,5alpha-THP) and 3alpha,5alpha-tetrahydrodeoxycorticosterone have been shown to be synthesized from progesterone in animal brains. Comparison of kinetic constants for the neuroactive steroids and their precursors among four human 3(20)alpha-hydroxysteroid dehydrogenases (AKR1C1-AKR1C4) suggests that AKR1C1 and AKR1C2 are involved in the catabolism and synthesis, respectively, of the neuroactive steroids in the human brain. In our efforts to identify agents that would specifically inhibit the two enzymes, benzbromarone and 3',3",5',5"-tetrabromophenolphthalein were found to be relatively selective and potent inhibitors of AKR1C1. Kinetic analyses in the oxidoreduction catalyzed by AKR1C1 in the presence of the inhibitors suggest that the inhibitors bind to the enzyme-NADP(H) complex (K(i)=0.7 nM) in the ordered bi-bi pathway, including an isomerization step. The inhibitors effectively also decreased the reduction of 3alpha,5alpha-THP to its 20alpha-hydroxy metabolite in HepG2 cells treated with ethacrynic acid.

Substrate specificity of human 3(20)alpha-hydroxysteroid dehydrogenase for neurosteroids and its inhibition by benzodiazepines.

In this report, we compared kinetic constants and products in the reduction of the neurosteroids, 3alpha,5alpha-tetrahydroprogesterone (3alpha,5alpha THP) and 3alpha,5alpha-tetrahydrodeoxycorticosterone (3alpha,5alpha-THDOC), and their precursors, 5alpha-dihydroprogesterone (5alpha-DHP), 5alpha-dihydrodeoxycorticosterone (5alpha-DHDOC) and progesterone, by three isoenzymes (AKR1C1, AKR1C2 and AKR1C3) of human 3alpha-hydroxysteroid dehydrogenase. AKR1C1 efficiently reduced 3alpha,5alpha-THP, 5alpha-DHP and progesterone to their 20alpha-hydroxy metabolites, and slowly converted 5alpha-DHDOC to 3alpha,5alpha-THDOC. AKR1C2 exhibited low 20-ketoreductase activity for 3alpha,5alpha-THP and moderate 3-ketoreductase activity for 5alpha-DHP and 5alpha-DHDOC. 3alpha,5alpha-THDOC was not reduced by the two isoenzymes. No significant activity for the steroids was detected with AKR1C3. The results suggest that AKR1C2 is involved in the neurosteroid synthesis, but AKR1C1 decreases the neurosteroid concentrations in human brain by inactivating 3alpha,5alpha-THP and eliminating the precursors from the synthetic pathways. In addition, we found that the several benzodiazepines inhibited the three isoenzymes noncompetitively with respect to the substrate. Although cloxazolam was a potent and specific inhibitor of AKR1C3, diazepam, estazolam, flunitrazepam, medazepam and nitrazepam, that inhibited AKR1C1 and AKR1C2, may influence the neurosteroid metabolism.

Molecular characterization of two monkey dihydrodiol dehydrogenases.

Japanese monkey liver contains multiple forms of dihydrodiol dehydrogenase with 3(20)alpha-hydroxysteroid dehydrogenase activity. Here we have purified the major and minor forms (DD1 and DD4) of the enzyme from Cynomolgus monkey liver, and isolated cDNA species for the two enzyme forms by reverse transcription-PCR. The cDNAs encoded proteins comprising of 323 amino acids, in which the sequence identity between DD1 and DD4 was 83%. The sequences deduced from the cDNAs for DD1 and DD4 perfectly matched the partial sequences of peptides derived from the respective enzymes. We also isolated the cDNAs for DD1 and DD4 of Japanese monkey liver, which had almost identical amino acid sequences with those of the respective enzymes of Cynomolgus monkey liver. The monkey DD1s and DD4s showed the highest sequence identity (94%) with AKR1C1 and AKR1C4, respectively, of four isoenzymes of human 3(20)alpha-hydroxysteroid dehydrogenase, which belongs to the aldo-keto reductase family. The substrate specificity and inhibitor sensitivity of the purified recombinant Cynomolgu monkey DD1 and Japanese monkey DD4 were also essentially identical to those of the recombinant AKR1C1 and AKR1C4, respectively, indicating that DD1 and DD4 are homologues of human AKR1C1 and AKR1C4, respectively. The mRNA for DD1 was detected only in liver, kidney, intestine and adrenal gland among Japanese monkey tissues, and that for DD4 was expressed in liver and kidney. These tissue distribution patterns differ from those of human AKR1C1 and AKR1C4, which are expressed ubiquitously and liver-specific, respectively. In addition, no mRNA for an enzyme corresponding to another isoenzyme (AKR1C2) of the human enzyme was detected in livers of the two monkey strains. The results suggest a difference in the metabolism of steroids and xenobiotics mediated by 3(20)alpha-hydroxysteroid dehydrogenase isoenzymes between monkeys and humans.