A case report of severe ulcerative colitis with mediastinal and subcutaneous emphysema.

A 17-year-old boy developed prominent mediastinal and subcutaneous emphysema while receiving treatment with 5-aminosalicylic acid (5-ASA) and oral corticosteroids for severe ulcerative colitis. We ruled out infection and initiated oral administration of tacrolimus, after which both the underlying disease and mediastinal and subcutaneous emphysema improved. However, he continued to experience repeated bouts of ulcerative colitis, so we ultimately opted for surgical intervention. Although mediastinal and subcutaneous emphysema is rare, it is one of the known extra-intestinal complications and can be particularly concerning. In this patient, mediastinal and subcutaneous emphysema might have been caused by the vulnerability of pulmonary alveolar walls to steroid medication and the increase of pulmonary alveolar pressure with abdominal pain and breath holding. Here, we report a case of inflammatory bowel disease with mediastinal and subcutaneous emphysema, along with a review of the literature.

Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection.

Delayed perforation after duodenal endoscopic submucosal dissection (ESD) occurs at a high rate because the duodenal wall is very thin and the artificial ulcer after resection is exposed to bile and pancreatic juice. We investigated the application of the combination of a polyglycolic acid (PGA) sheet and fibrin glue. PGA sheets comprise materials widely used in surgery for absorbable thread. Fibrin glue is a heated blood product and is used for hemostasis during operations. We developed a combined method using both materials. We have used this method in two cases. One case involved an elevated lesion located in the lower duodenal angle of the duodenum. The other involved an elevated lesion in the second portion of the duodenum. About 1 week after ESD, the PGA sheets remained covering the ulcer and delayed perforation did not occur. We were able to easily carry out this method for several parts of the duodenum. This method may be helpful for the prevention of delayed perforation after duodenal ESD.

Multicenter study of endoscopic mucosal resection using 0.13% hyaluronic acid solution of colorectal polyps less than 20 mm in size.

PURPOSE: Endoscopic mucosal resection (EMR) of colorectal polyps should be curative and safe. This study aimed to determine the efficacy and safety of colorectal EMR using 0.13% hyaluronic acid (HA) solution. METHODS: This was a single-armed multicenter prospective open trial conducted at 11 Japanese institutions. Lesion characteristics and various measures of clinical outcome, including en bloc resection, histopathologically complete resection, and postoperative bleeding were analyzed for 624 consecutive patients who underwent EMR of colorectal polyps at ≤20 mm in size from August 2010 to September 2011. RESULTS: En bloc and complete resection were achieved in 93.3 and 78.3% of 624 lesions. The median EMR procedure time was 2.1 ± 1.5 min. The rates of postoperative bleeding and perforation were 1.1 and 0%. The rate of en bloc resection was higher for polyps at 5-10 mm than for polyps at 11-20 mm (95.1 vs. 85.1%; P < 0.001) and was higher for protruding polyps than for superficial polyps (94.5 vs. 87.1%; P < 0.05). The rate of en bloc resection was also higher for polyps in the left-side colon than for those in the right-side colon or rectum (96.7 vs. 91.6 vs. 90.8%; P < 0.05). Multivariate analysis showed that polyp at 11-20 mm in size and location not on the left-side colon was significantly independent risk factors for failure of en bloc resection. CONCLUSION: EMR using 0.13% HA of colorectal polyps less than 20 mm in size had high rates of en bloc and complete resection and few complications.

The first case of SMARCA4-deficient sarcoma of stomach.

SMARCA4-deficient sarcoma was first reported in the chest and recently in the uterus, but not in the stomach. Here, we present a patient diagnosed with SMARCA4-deficient sarcoma of the stomach, using histochemistry. An emergency operation was performed due to perforation of the tumor. However, one month after the operation, two nodes recurred, and six cycles of combination chemotherapy consisting of adriamycin and ifosfamide were administered. The combination chemotherapy showed a remarkable effect, and complete remission was achieved. The patient was alive without recurrence after 48-month follow-up. SMARCA4-deficient sarcoma is an exceedingly rare tumor with an extremely poor therapeutic response to anticancer drugs. Herein, we present the first case of SMARCA4-deficient sarcoma of the stomach, where a complete response to chemotherapy was achieved.

Sedation with dexmedetomidine hydrochloride during endoscopic submucosal dissection of gastric cancer.

AIM: Although the treatment of early gastric cancer with endoscopic submucosal dissection (ESD) has been widely carried out, a standardized method of sedation for ESD has not been established. The purpose of the present study was to evaluate the efficacy and safety of sedation with dexmedetomidine (DEX). METHODS: We conducted a randomized study involving 90 patients with gastric tumors who were intended to be treated with ESD. The patients were sedated either with DEX (i.v. infusion of 3.0 µg/kg per h over 5 min followed by continuous infusion at 0.4 µg/kg per h [n = 30]), propofol (PF [n = 30]), or midazolam (MDZ [n = 30]). In all groups, 1 mg MDZ was added i.v. as needed. RESULTS: En bloc resection of the gastric tumor was achieved in 88 (98%) patients. None of the DEX-sedated patients showed a significant reduction of the oxygen saturation level. The percentage of patients who showed body movement in the DEX group was significantly lower than those in the PF and MDZ groups, and the mean dose of additional MDZ in the DEX group was significantly smaller than that in the MDZ group. The rate of effective sedation was significantly higher in the DEX group compared with the MDZ or PF group. The mean length of ESD in the DEX group was 65 min, which was significantly shorter than in the other two groups. No DEX-sedated patient developed major surgical complications. CONCLUSIONS: Sedation with DEX is effective and safe for patients with gastric tumors who are undergoing ESD.

[A case of probable autoimmune hepatitis from which the persistence of hepatitis A IgM antibody, and the improvement was pathologically obtained by ursodeoxycholic acid medication].

We present a 68 years old woman who was referred to our department due to impaired liver function. Hepatitis A IgM antibody and anti-nuclear antibody were positive, IgG, and gamma-globulin were elevated. Percutaneous liver biopsy was performed and autoimmune hepatitis was suspected pathologically. Oral administration of ursodeoxycholic acid was started and liver function was normalized three months later. The improvement of a hepatitis image was examined by percutaneous liver biopsy one year later. Although hepatitis A IgM antibody was positive throughout the course, hepatitis A virusemia was not considered the cause of persistent positive hepatitis A. IgM antibody could not be clarified. There was a possibility of a non-specific reaction and abnormalities in antibody production control were considered possible. We present this case and discuss the previous literature.

alpha-Phenyl-N-tert-butylnitrone provides protection from dextran sulfate sodium-induced colitis in mice.

Nuclear factor-kappaB (NF-kappaB)-dependent up-regulation of inflammatory cytokines and inducible nitric oxide (iNOS) occurs in inflammatory bowel disease. We investigated the effect of alpha-phenylN-tert-butylnitrone (PBN), a spin-trapping agent that inhibits NF-kappaB activity, on dextran sulfate sodium (DSS)-induced colonic mucosal injury and inflammation in mice. Acute colitis was induced with DSS in female BALB/c mice receiving 0, 0.3, 3, and 30 mg/kg i.p. PBN daily. Colonic mucosal inflammation was evaluated biochemically and histologically. Nitric oxide was evaluated as luminal nitrite/nitrite concentration by the Griess reaction and as immunoreactive nitrotyrosine in mucosal cells. Mucosal tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) were determined by immunoassay. Colonic mRNA expression for iNOS, TNF-alpha, and IFN-gamma was measured by reverse transcription-polymerase chain reaction, and NF-kappaB activation was evaluated by electrophoretic mobility shift assay. After DSS administration, mice showed increased luminal nitrite/nitrate, mucosal TNF-alpha and IFN-gamma, and mRNA for iNOS and these cytokines, in addition to decreased colonic length and increased inflammatory score, luminal hemoglobin, and colonic myeloperoxidase activity. PBN inhibited increases in luminal nitric oxide production, nitrotyrosine immunoreactivity, and mucosal TNF-alpha and IFN-gamma. Colonic iNOS, TNF-alpha, and IFN-gamma mRNA were suppressed by PBN, as was a DSS-induced increase in colonic NF-kappaB DNA-binding activity. NF-kappaB is essential to DSS-induced colitis, suggesting molecular approach targeting of NF-kappaB for treatment of inflammatory bowel disease.