Gender Differences in Patients with Gastric Adenocarcinoma.

Background: Gastric cancer (GC) epidemiology and outcomes vary by gender. Methods: We reviewed 18,436 GC patients from 2008 to 2018 and looked for gender differences in clinical characteristics and survival. Results: The gender proportion was 71% male and 29% female. Males had a significantly (p < 0.001) higher proportion of differentiated GC (66.3%) and a lower proportion of undifferentiated GC (26.3%). Diagnosis through medical check-ups was more common in males (30.0% vs. 26.4%, p < 0.001). Clinical staging revealed 54.6% of males and 52.9% of females had localized disease without lymph node metastasis (LNM), while distant metastasis occurred in 17.4% of males and 16.9% of females (p < 0.001). Kaplan-Meier survival curves indicated females had a significantly higher overall survival (p = 0.0018). The survival advantage for females was evident in the early stages, with a significant difference in localized disease without LNM (p < 0.001) and localized disease with LNM (p = 0.0026, log-rank test) but not in the advanced stages. Multivariate Cox regression analysis showed a significantly reduced mortality risk in females (p < 0.001). Conclusions: Significant gender differences exist with regard to pathological type, presentation, clinical stage, and overall survival. These findings suggest gender-specific strategies for screening, diagnosis, and treatment.

A new grading assessment of eosinophilic esophagitis using red dichromatic imaging: a pilot study.

BACKGROUND AND AIMS: The endoscopic reference score using white-light imaging (WLI) is utilized for objectively evaluating the severity of findings in patients with eosinophilic esophagitis. A novel image-enhanced endoscopy technique, red dichromatic imaging (RDI), can visualize deeper vessels in the GI tract, which may assess edema more precisely than WLI. METHODS: A total of 21 consecutive patients with eosinophilic esophagitis were prospectively evaluated. Patients were categorized according to 3 grades based on the visibility of vessels with RDI. Clinical features, such as peak eosinophil counts and presence of symptoms, were reviewed. RESULTS: There were 10 patients with RDI Grade 0/1 and 11 patients with RDI Grade 2. Peak eosinophil counts and the prevalence of heartburn were significantly higher in patients with RDI Grade 2 than in patients with RDI Grade 0/1. CONCLUSIONS: The severity of eosinophilic infiltration could be predicted more precisely using RDI than by evaluations with WLI.

Background factors of idiopathic peptic ulcers and optimal treatment methods: a multicenter retrospective Japanese study.

This study investigated the trends in idiopathic peptic ulcers, examined the characteristics of refractory idiopathic peptic ulcer, and identified the optimal treatment. The characteristics of 309 patients with idiopathic peptic ulcer were examined. We allocated idiopathic peptic ulcers that did not heal after 8 weeks' treatment (6 weeks for duodenal ulcers) to the refractory group and those that healed within this period to the healed group. The typical risk factors for idiopathic peptic ulcer (atherosclerosis-related underlying disease or liver cirrhosis complications) were absent in 46.6% of patients. Absence of gastric mucosal atrophy (refractory group: 51.4%, healed group: 28.4%; p = 0.016), and gastric fundic gland polyps (refractory group: 17.6%, healed group: 5.9%; p = 0.045) were significantly more common in the refractory group compared to the healed group. A history of H. pylori eradication (refractory group: 85.3%, healed group: 66.0%; p = 0.016), previous H. pylori infection (i.e., gastric mucosal atrophy or history of H. pylori eradication) (refractory group: 48.5%, healed group: 80.0%; p = 0.001), and potassium-competitive acid blocker treatment (refractory group: 28.6%, healed group, 64.1%; p = 0.001) were significantly more frequent in the healed group compared to the refractory group. Thus, acid hypersecretion may be a major factor underlying the refractoriness of idiopathic peptic ulcer.

Validation of red dichromatic imaging score (RDI score) to evaluate the severity of ulcerative colitis.

BACKGROUND: Red dichromatic imaging (RDI) is a new imaging technology that has been closely correlated with the activity index of ulcerative colitis (UC). Although the RDI score has been developed no study has validated a correlation between the RDI score and the activity index of UC. Therefore, this study aims to validate the RDI score prospectively. METHODS: A total of 34 patients with UC in whom colonoscopy was scheduled between May 2019 and October 2021 at our hospital were enrolled prospectively. MES, UCEIS, RDI scores, and Nancy index were evaluated in a blinded fashion. We evaluated the correlation between RDI and WLI scores using still images with histology. RESULTS: We analyzed 191 sites of colorectum. RDI score showed the positive correlation with UCEIS (r = 0.74 P < 0.0001) and MES (r = 0.78 P < 0.0001). RDI score also showed the positive correlation with Nancy index (r = 0.63 P < 0.0001). RDI score was more strongly correlated with Nancy index than UCEIS (r = 0.51) and MES (r = 0.48). CONCLUSIONS: When comparing still images of RDI and WLI scores, we showed RDI had a higher correlation to histology than WLI. CLINICAL TRIAL ID: The University Hospital Medical Information Network (UMIN000041750).

Efficacy of using red dichromatic imaging throughout endoscopic submucosal dissection procedure.

BACKGROUND: Management of bleeding during endoscopic submucosal dissection (ESD) is critical. Red Dichromatic Imaging (RDI), a novel image-enhanced endoscopy technology, has been reported to improve the visibility of deep vessels and bleeding source compared to white light imaging (WLI). We hypothesized that using RDI during the entire cutting process (full time RDI ESD: FTR-ESD), higher R0 resection rate, shorter procedure time and fewer complications could be achieved. Therefore, the aims of the present study were to investigate the efficacy and safety of FTR-ESD. METHODS: This retrospective observational study included a total of 82 consecutive patients who underwent ESD by a single expert endoscopist for 40 esophageal, 17 gastric and 25 colorectal cancers at our institution from January 2018 to March 2021. The clinicopathological data were collected from patients' medical records and the treatment outcomes were analyzed according to the treatment phase (early; 57 WLI-ESD and late; 25 FTR-ESD). RESULTS: The median of the greatest diameter of resected specimen was 40.0 mm. The median procedure time was relatively shorter in the FTR-ESD group (35 min) than in the WLI-ESD group (40 min), but the difference was not statistically significant (p = 0.34). The median dissection speed in the FTR-ESD group (27.23 mm2/min) was significantly faster than that in the WLI-ESD group (20.94 mm2/min) (p = 0.025). The dissection speed was not different among different organs. A multivariate analysis revealed that tumor size (more than 30 mm) and FTR-ESD were significant independent factors contributing to faster dissection speed (p < 0.05). There were no significant differences in the rates of en bloc resection, HM0, VM0 or occurrence of adverse events between WLI-ESD and FTR-ESD. CONCLUSIONS: FTR-ESD significantly increases the dissection speed compared to WLI-ESD. FTR-ESD can be performed safely and therapeutic outcomes in FTR-ESD are comparable with WLI-ESD. A further multicenter prospective study is warranted to confirm our results.

[Ulcerative colitis complicated by pyoderma gangrenosum and multiple aseptic abscesses].

A woman in her 30s was diagnosed with ulcerative colitis (UC) 4 years ago and treated with tacrolimus, azathioprine, and prednisolone 5mg (PSL). Skin ulcers appeared on the right lower leg during the course of treatment, diagnosed as pyoderma gangrenosum (PG). The patient initially improved with an increased PSL and infliximab dose, but then developed multiple skin ulcers and folliculitis throughout her body. She was transferred to our hospital for PG exacerbation treatment. She developed fever after transfer and contrast-enhanced computed tomography showed multiple abscesses in the lungs and kidneys. PSL was decreased and infliximab was discontinued. Antibiotic therapy and granulocyte/monocyte apheresis (GMA) were started. Fever persisted even after antibiotic treatment, and her general condition did not improve. A right renal abscess puncture was performed. Pus was sterile. A sterile abscess associated with PG was suspected. The PSL dose was increased to 1mg/kg and infliximab restarted. Thereafter, the patient's general condition improved, and both lung and renal abscesses contracted. Skin ulcer epithelialization was also observed. Abdominal symptoms were mild during the course of the disease, and colonoscopy showed only a localized ulcerative lesion in the rectum. The patient was later transferred to the department of dermatology at our hospital for PG treatment. Aseptic abscesses are caused by neutrophil infiltration without infection and have been reported to be associated with neutrophilic dermatosis and inflammatory bowel disease. UC-associated aseptic abscess is rare. This is only the sixth case in Japan. Aseptic abscesses can occur in various sites, including subcutaneous and deep organs, but this is the first kidney abscess case. In previous reports, PSL, infliximab, colchicine, and infliximab+GMA were used for aseptic abscesses associated with UC. They all showed abscess reduction. Aseptic abscesses associated with PG should be considered if abscess lesions occur during the course of UC, and a treatment strategy including enhanced immunosuppression should be considered.

The role of endoscopy in the management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a common disease that may cause a huge economic burden. Endoscopy is performed not only to rule out other organic diseases but also to diagnose reflux esophagitis or Barrett's esophagus. Non-erosive GERD (non-erosive reflux disease [NERD]) is called endoscopy-negative GERD; however, GERD-related findings could be obtained through histological assessment, image-enhanced endoscopy, and new endoscopic modalities in patients with NERD. Moreover, endoscopy is useful to stratify the risk for the development of GERD. In addition, endoscopic treatments have been developed. These techniques could significantly improve patients' quality of life as well as symptoms.

Endoscopic tissue shielding with polyglycolic acid sheet, fibrin glue, and endoclip for perforation during balloon dilation for esophageal stricture after endoscopic submucosal dissection.

Esophageal endoscopic submucosal dissection can cause esophageal strictures. Endoscopic balloon dilation is the standard treatment for esophageal strictures, but has complications, including perforation, and sometimes requires surgery. We report a case of perforation during endoscopic balloon dilation for esophageal stricture secondary to esophageal submucosal dissection that was successfully treated conservatively. A 66-year-old man with superficial carcinoma in the upper thoracic esophagus underwent circumferential endoscopic submucosal dissection with local steroid injections. Endoscopic balloon dilation was performed weekly for esophageal stricture. However, during the sixth procedure, an attempt to increase the size of the balloon to 13.5 mm resulted in perforation. The patient was treated conservatively using polyglycolic acid sheet with fibrin glue at the perforation site, which was fixed using an endoclip. However, the esophageal stricture persisted after the perforation was closed and Endoscopic balloon dilation was carefully repeated twice weekly up to a maximum of 17 mm, and the endoscope was able to pass through, and associated symptoms improved. This report indicates that endoscopic tissue shielding using polyglycolic acid sheet with fibrin glue and endoclip to correct perforation, followed by additional endoscopic balloon dilation, is an alternative to surgery.

New endoscopic classification of cascade stomach, a risk factor for reflux esophagitis.

BACKGROUND: We recently demonstrated that cascade stomach detected by barium studies was correlated with upper gastrointestinal symptoms. We developed a new endoscopic classification of cascade stomach and examined its relationship with reflux esophagitis. METHODS: Study 1: the classification (grades 0-3) was based on detecting a ridge that runs from the cardia toward the anterior wall crossing the greater curvature. Inter-observer variation was evaluated by kappa statistics when ten experienced endoscopists used this classification three times each. Study 2: in 710 consecutive subjects (500 men and 210 women) undergoing endoscopic screening, the grade of cascade stomach and incidence of reflux esophagitis were compared. RESULTS: In study 1, the kappa values at the third assessment were 0.85, 0.58, 0.50, and 0.78 for each grade, respectively, while overall agreement was 0.68. In study 2, the incidence of reflux esophagitis in men was 20 % in grade 0, 17 % in grade 1, 25 % in grade 2, and 30 % in grade 3, showing significant differences. Among women, the incidence of reflux esophagitis in each grade was 9, 3, 6, and 35 %, respectively, also showing significant differences. Multivariate analysis showed that independent risk factors for reflux esophagitis were cascade stomach (odds ratio = 2.20), body mass index, and hiatus hernia in men, as well as cascade stomach (odds ratio = 9.01) and smoking tobacco in women. CONCLUSIONS: This endoscopic classification of cascade stomach showed acceptable inter-observer variation. Cascade stomach is a risk factor for reflux esophagitis.

More severe upper gastrointestinal symptoms associated with non-erosive reflux disease than with erosive gastroesophageal reflux disease during maintenance proton pump inhibitor therapy.

BACKGROUND: During maintenance proton pump inhibitor (PPI) therapy, patients with gastroesophageal reflux disease (GERD) sometimes complain of upper gastrointestinal symptoms. AIM: To evaluate upper gastrointestinal symptoms in patients on maintenance PPI therapy for erosive GERD or non-erosive reflux disease (NERD) without endoscopic mucosal breaks by using a new questionnaire. METHODS: At Gunma University Hospital over a 12-month period during 2011-2012, we enrolled 30 consecutive patients with erosive GERD and 46 patients with NERD. All patients had been on maintenance PPI therapy for more than 1 year. We used the modified frequency scale for the symptoms of GERD (mFSSG) questionnaire to assess upper gastrointestinal symptoms. We also asked patients about their satisfaction with maintenance therapy and whether they wished to change their current PPI. RESULTS: The NERD patients had significantly higher symptom scores than the erosive GERD patients. There was no difference in the treatment satisfaction rate between patients with erosive GERD and NERD, but more patients with NERD wanted to change their PPI therapy. There was no difference in the mFSSG score between NERD patients who wished to change their current PPI therapy and those who were satisfied with it. CONCLUSIONS: During maintenance PPI therapy, upper gastrointestinal symptoms were more severe in NERD patients than in patients with erosive GERD. NERD patients often wished to change their PPI therapy, but this was not dependent on the severity of their upper GI symptoms.

Development and evaluation of a modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease to distinguish functional dyspepsia from non-erosive reflux disease.

BACKGROUND AND AIM: The Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) is the standard questionnaire used in Japan for the diagnosis of gastroesophageal reflux disease (GERD) and assessment of the response to treatment. We modified the FSSG in order to assess dyspepsia symptoms, and evaluated the modified questionnaire. METHODS: We modified the FSSG by adding two questions on interdigestive and postprandial epigastric pain. We then assessed the modified FSSG with 100 new untreated symptomatic patients presenting to hospital and in 200 subjects undergoing health checks. Endoscopic assessment of the esophagogastric junction was performed according to the modified Los Angeles classification with addition of Grade N (normal appearance) and Grade M (minimal change). Endoscopic images were assessed by five experienced endoscopists blinded to the questionnaire results. RESULTS: The 100 new patients included 16 with erosive GERD (>Grade A), 12 with peptic ulcer, and two with gastric cancer. Among the 70 patients with no evidence of organic disease, the modified FSSG diagnosed functional dyspepsia (FD) in 41 and non-erosive gastric disease (NERD) in 29. A significant difference was seen in the dyspepsia score between patients with FD and NERD. Subjects with endoscopic GERD undergoing health checks had significantly higher scores for all symptoms, reflux symptoms, and dyspeptic symptoms on the modified FSSG. CONCLUSION: The modified FSSG can clearly distinguish FD from NERD, and is useful for the assessment of dyspeptic symptoms.