[A case of irreversible metronidazole encephalopathy during liver abscess treatment].

Metronidazole (MNZ) is a widely used drug for protozoan and anaerobic infections. The continuous use of MNZ causes various neurological symptoms, such as cerebellar ataxia, visual disturbance, vestibulocochlear symptoms, gait disturbance, dysarthria, and epileptic seizures of unknown cause, named MNZ-induced encephalopathy (MIE), in rare cases. MIE is a reversible disease that often improves within a few days of MNZ discontinuation, but irreversible neurological symptoms rarely remain. Herein, we report a case of MIE that developed during MNZ administration for a liver abscess, causing prolonged unconsciousness and death even after drug discontinuation. An 85-year-old female patient complained of fever, elevated liver enzymes, and a multifocal abscess in the right hepatic lobe, as seen on computed tomography. Percutaneous transhepatic abscess drainage and antibiotic therapy were initiated. The causative agent of the liver abscess could not be identified, thus meropenem was started, which demonstrated no inflammation improvement, thus oral MNZ was added. The inflammation recurred when MNZ was discontinued, and the patient continued taking MNZ. Vomiting, upper limb tremors, consciousness disturbance, and convulsions appeared on day 46 (total dose of MNZ 73.5mg), and the patient was hospitalized. T2-weighted, diffusion-weighted, and FLAIR head magnetic resonance imaging (MRI) revealed symmetrical abnormal high-signal areas in the cerebellar dentate nucleus, corpus callosum, cerebral white matter, and periventricular areas. MIE was diagnosed based on the patient's course and MRI images, and MNZ was discontinued. The patient continued to suffer from impaired consciousness and convulsions after MNZ discontinuation and died due to aspiration pneumonia. Suggestively, MIE development is related to long-term MNZ administration, poor nutrition, liver disease, underlying diseases (such as advanced cancer), and serious complications. A systematic review of MIE cases revealed that 4.8-5.9% of the patients demonstrated little improvement of symptoms after MNZ discontinuation, and some deaths were reported. Patients with poor prognosis were often suffering from impaired consciousness and convulsions. Furthermore, impaired consciousness was the most common residual symptom. Abnormal signals in characteristic areas, such as the dentate nucleus cerebri and corpus callosum, on head MRI are useful for MIE diagnosis, especially in patients with abnormal findings in the cerebral white matter, which is associated with a poor prognosis. We should pay close attention to the onset of MIE when MNZ is administered.

[A case of multiple duodenal gastrointestinal stromal tumors associated with neurofibromatosis type 1].

Gastrointestinal stromal tumors (GISTs) associated with von Recklinghausen's disease (neurofibromatosis type 1 [NF1]) have different pathogenesis and characteristics from common GISTs. Furthermore, no treatment strategy for this type of GIST has been established. This study presents the case of a 76-year-old man previously diagnosed with NF1 who was later diagnosed with GISTs. A resection of the horizontal leg of the duodenum was performed, and no recurrence was observed 18 months after the surgery.

Rapidly progressed large cell neuroendocrine carcinoma of the stomach with an increased serum alpha fetoprotein level: a case report.

An 82-year-old man who had multiple hepatic tumors, a gastric tumor, and ascites was referred to our hospital. On the time of our hospital visit, he had a high serum alpha fetoprotein (AFP) level of 1206 ng/mL. Upper gastrointestinal endoscopy revealed a Borrmann Type II gastric tumor approximately 40 mm in diameter in the lesser curvature of cardia, and forceps biopsy was performed. Endoscopic ultrasound fine-needle aspiration was also performed for hepatic tumor. The biopsy specimens from the gastric and hepatic tumor were diagnosed as large cell neuroendocrine carcinoma (LCNEC), containing AFP-positive cells only sporadically by immunohistochemistry. He was diagnosed with gastric LCNEC with liver metastasis. Retrospective analysis of endoscopic data obtained at 5 months ago revealed a 0-IIc lesion, approximately 10 mm in size, in the lesser curvature of cardia, the same area of the present gastric tumor. This indicated rapid growth rate of the present tumor. The patient developed jaundice 5 days after he visited our hospital. And he died 18 days after hospital admission.

Gastric gastrointestinal stromal tumor with predominant cystic formation diagnosed by endoscopic ultrasound-fine needle aspiration.

A 69-year-old woman who had no symptoms was found to have an intraperitoneal tumor on abdominal ultrasonography in a medical checkup. Thereafter, she was referred to our hospital for a further detailed examination. Contrast-enhanced computed tomography revealed a thin-walled cystic tumor with a diameter of 8 cm and with a hypervascular solid masses in the cystic wall, along with intraperitoneal multiple nodules. The cystic tumor was contiguous with the stomach wall. For solid mass of cystic lesions, endoscopic ultrasound-fine needle aspiration was performed transgastrically with a 25-gauge Franseen needle. Pathologically, the cells in the tumor were spindle shaped with atypical nucleus and were positive for c-kit, CD34, and smooth muscle actin. The tumor was diagnosed as gastrointestinal stromal tumor (GIST). With the diagnosis of gastric GIST with peritoneal dissemination, imatinib chemotherapy was initiated.

Efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: A single-center retrospective study.

Objective: This study aimed to assess the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with an Eastern Cooperative Oncology Group performance status (ECOG-PS) score of 3 or 4. Patients and Methods: We reviewed the data of 287 patients with native papillae who underwent therapeutic ERCP for biliary disease at our hospital between October 2016 and October 2018. The patients were divided into two groups; those with an ECOG-PS score of 3 or 4 (group A; n=78) and those with an ECOG-PS score of 0-2 (group B; n=209). Results: The rate of technical success was not significantly different between the two groups (95% versus 89%, P=0.13). Although the occurrence rate of overall adverse events (10% versus 11%, P=0.95) was not significantly different between the groups, the occurrence rates of aspiration pneumonia (3.8% versus 0%, P=0.0044) and heart failure (2.6% versus 0%, P=0.020) were significantly higher in group A. Conclusion: The rates of technical success and overall adverse events did not significantly differ between patients with an ECOG-PS score of 3 or 4 and those with a score of 0-2; however, aspiration pneumonia and heart failure were more likely to occur among patients with an ECOG-PS score of 3 or 4.

Spontaneous rectus sheath hematoma associated with warfarin administration: a case report.

Objectives: Rectus sheath hematoma (RSH) can result from bleeding into the rectus abdominis muscle or a direct muscular tear; nontraumatic spontaneous RSH is a rare condition. Here, we report a case of spontaneous RSH associated with warfarin administration for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Patient: An 87-year-old woman was referred to our hospital because of abdominal pain, nausea, and vomiting for 3 days. She was receiving warfarin for treating CTEPH. She had a bulging and hard lower abdomen with ecchymosis. Moreover, the bulging portion was highly tender, and a positive Carnett's sign was also observed. She reported no history of abdominal trauma. Abdominal computed tomography (CT) scan revealed right RSH. Results: She was diagnosed with spontaneous RSH and admitted to our hospital. Warfarin was antagonized with an intravenous injection of vitamin K; hemostatic agents were intravenously administered. Gradually, her abdominal pain improved. She was finally discharged 12 days after the admission. Abdominal CT scan performed 17 days after the discharge revealed a reduction in the size of RSH. Conclusion: Despite not having a history of trauma, it is necessary to consider the possibility of RSH for patients receiving warfarin and complaining of abdominal pain.

Gallstone ileus with spontaneous evacuation: A case report.

A 65-year-old man was referred to our hospital for abdominal pain. He had a history of enterotomy with stone extraction for gallstone ileus. On abdominal computed tomography, a stone measuring 32 × 28 mm lodged in the jejunum was identified. He was diagnosed with gallstone ileus and treated using a nasal ileus tube. Four days after admission, computed tomography showed that the stone had passed into the rectum. The gallstone was spontaneously evacuated on the same day. A fistula with the gallbladder was found in the duodenal bulb. The patient's condition improved, and he was discharged 9 days after admission.