Reply to the comments on "Coffee bean sign, steel pan sign and whirl sign in sigmoid volvulus".

We thank Prof. Atamanalp and colleagues for their interest and valuable comments on our article. The authors have highlighted important considerations in the diagnosis of sigmoid volvulus (SV). We would like to respond to their comments. Firstly, although we agree with their opinion that CT, MRI, and endoscopy are more reliable diagnostic tools than plain radiography, we still emphasize that diagnostic imaging for SV is initially based on plain radiography, as recommended by the WSES consensus guidelines. Since SV is the third most common cause of colonic obstruction worldwide, the accessibility of plain radiography is crucial. Among the many plain radiographic signs of SV, Levsky et al. reported that the most sensitive signs were absence of rectal gas, followed by inverted-U appearance and coffee bean sign. Understanding these signs may lead to early detection of SV and further CT evaluation for ischemia or perforation. Despite the high value of plain radiography, there is a global tend to use CT instead from the outset. Secondly, we agree with their opinion that endoscopy is not only a therapeutic, but also a diagnostic procedure to assess mucosal viability. In addition, we believe that endoscopy is also useful in ruling out other obstructive lesions, including colorectal neoplasia and complicated sigmoid diverticular disease. In the clinical setting, endoscopy is performed after the diagnosis of SV by plain radiography or CT and serves as the first line of decompression of SV when ischemia or perforation is not suspected. Finally, we congratulate Prof. Atamanalp and colleagues for their dedicated contribution to the large-scale SV studies in Eastern Anatolia, Turkey, where SV is endemic.

Endoscopic findings of radiation ileitis.

I herein report a case of radiation ileitis. Ileocolonoscopy disclosed villous edema and multiple patchy lymphangiectasias in the terminal ileum. While observing, active bleeding occurred from the numerous telangiectasias and friable atrophic mucosa. Clinical manifestations of radiation ileitis are briefly discussed.

Duodenal nodularity with villous flattening in common variable immunodeficiency.

We herein report a case of common variable immunodeficiency (CVID). Endoscopy with biopsies disclosed duodenal nodularity with villous flattening associated with CVID. CVID-associated enteropathy is briefly discussed.

Comb sign in Crohn's disease.

We present a case of a 13-year-old boy with Crohn's disease (CD) who presented with abdominal pain and diarrhea. On examination, there was tenderness on the lower abdomen. Laboratory examinations showed elevated inflammatory parameters. A CT scan showed active inflammation of the ileum and rectosigmoid colon with the comb sign. A diagnosis of exacerbation of CD was made. The comb sign refers to hypervascularity of the mesentery with vascular dilatation, tortuosity, and wide spacing of the vasa recta that are aligned as the teeth of a comb. This sign is not always pathognomonic for CD; however, it may help identification of acute exacerbation in known CD and differentiating active CD from hypovascular disease such as lymphoma. The comb sign can be highly correlated with the endoscopic severity rather than mural thickening in CD.

Jejunal lymphangioma.

We herein report a case of jejunal lymphangioma. A CT scan showed non-enhancing cystic masses in the jejunum. Enteroscopy revealed multiple cystic swelling with whitish carpet-like villi. Histopathology disclosed dilated lymphatic channels, lined by a single layer of endothelial cells, which were positive for the lymphatic endothelial marker by the immunohistochemical staining. Clinical manifestations of intestinal lymphangioma are briefly discussed.

Transparent cap-assisted endoscopic retrieval of a sharp foreign body in the esophagus.

We herein report an 80-year-old woman who accidentally ingested a sharp foreign body. Transparent cap-assisted endoscopy disclosed an impacted press-through package (PTP) in the upper esophagus. The PTP was grasped by the forceps, inserted into the cap, and removed carefully without complication. Ingestion of sharp-pointed foreign bodies has serious risks of gastrointestinal perforation and hemorrhage; therefore, emergent endoscopic removal has been recommended. Transparent cap-assisted endoscopy is a simple, safe, and effective method with a shorter procedure time and clearer visual field compared with conventional endoscopy. We wish to emphasize that this method has advantages and a potential to be used for endoscopic retrieval of small sharp foreign bodies.

Coffee bean sign, steel pan sign, and whirl sign in sigmoid volvulus.

A 66-year-old man presented with abdominal distension. A plain radiograph showed the coffee bean sign, suggesting sigmoid volvulus (SV). The CT scans disclosed the steel pan sign, the whirl sign, and the beak-shaped transition point, confirming SV. He improved with colonoscopic decompression and detorsion. Characteristic radiographic signs of SV are briefly discussed.

Hepatocellular Carcinoma in a Patient With Crohn's Disease.

A 44-year-old woman with a 26-year history of Crohn's disease (CD) presented with intermittent fever, vomiting, and watery diarrhea. Her medication included an elemental diet, mesalazine, and infliximab. Liver profile and viral hepatitis markers were normal. Computed tomography scans showed a hepatic tumor by chance. Serum tumor markers disclosed elevated protein induced by vitamin K absence-II. With a diagnosis of hepatocellular carcinoma (HCC), she underwent a hepatic resection of the tumor, revealing well-to-moderately differentiated HCC. The nontumor region of the liver disclosed the absence of cirrhosis or other diseases. Here, the development of HCC in CD without underlying liver diseases is discussed with a review of the literature.

Image of the month: Target the bugs: Strongyloides stercoralis hyperinfection.

A 74-year-old woman carrying the human T-lymphotropic virus type-1 (HTLV-1) presented with abdominal pain and vomiting. Computed tomography and microscopic analysis of the gastroduodenal drainage fluid made a diagnosis of paralytic ileus due to Strongyloides stercoralis hyperinfection with underlying HTLV-1 infection. Strongyloidiasis should be included in the differential diagnosis for paralytic ileus in patients who have lived in or migrated from the endemic regions.

Whipple disease mimicking inflammatory bowel disease.

Whipple disease is a systemic chronic infection caused by Tropheryma whipplei. Although chronic diarrhea is a common gastrointestinal symptom, diagnosis is often difficult because there are no specific endoscopic findings, and the pathogen is not detectable by stool culture. We present a female patient with Whipple disease who developed chronic bloody diarrhea and growth retardation at the age of 4 years. Colonoscopy showed a mildly edematous terminal ileum and marked erythema without vascular patterns throughout the sigmoid colon and rectum. Subsequently, a primary diagnosis of ulcerative colitis was made. Histopathological analysis of the terminal ileum showed the presence of foamy macrophages filled with periodic acidSchiff-positive particles. Polymerase chain reaction using DNA from a terminal ileum biopsy sample amplified a fragment of 16S rRNA from T. whipplei. Antibiotic treatment relieved the patient's symptoms. There was no evidence of immunodeficiency in the present case. Since Whipple disease worsens after anti-tumor necrosis factor inhibitor therapy, considering this infection in the differential diagnosis may be important in patients with inflammatory bowel disease, especially before initiation of immunotherapy.

Elective staged proctocolectomy and living donor liver transplantation for colon cancer with sclerosing cholangitis-related ulcerative colitis: a case report.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a well-known complication of ulcerative colitis (UC), but it is rare to encounter patients requiring both living donor liver transplantation (LDLT) and proctocolectomy. We report a case of elective two-stage surgery involving proctocolectomy performed after LDLT for a patient with early colon cancer concurrent with PSC-related UC. To our knowledge, this is the first report of concurrent cancer successfully treated with both LDLT and proctocolectomy. CASE PRESENTATION: A 32-year-old Japanese man with colon cancer associated with UC underwent restorative proctocolectomy at 3 months after living donor liver transplantation (LDLT) for PSC. He was diagnosed with PSC and UC when he was a teenager. Conservative therapy was initiated to treat both PSC and UC. He had experienced recurrent cholangitis for years; therefore, a biliary stent was placed endoscopically. However, his liver function progressively deteriorated. Colonoscopic surveillance revealed early colon cancer; hence, surgical treatment was considered. PSC progressed to cirrhosis and portal hypertension; hence, LDLT was performed before restorative proctocolectomy. Three months after LDLT, we performed restorative proctocolectomy with ileal pouch-anal anastomosis. The postoperative course was uneventful. The patient was well, with good liver and bowel functions and without tumor recurrence, more than 1 year after proctocolectomy. CONCLUSIONS: With strict patient selection and careful patient management and follow-up, elective proctocolectomy may be performed safely and effectively after LDLT for concurrent early colon cancer with PSC-related UC. There are no previous reports of the use of both LDLT and proctocolectomy for the successful treatment of PSC-related UC and concurrent cancer.