Colonoscopic observation time as a predictor of stigmata of recent hemorrhage identification in colonic diverticular hemorrhage.

OBJECTIVES: The strategy of identifying stigmata of recent hemorrhage (SRH) and treating the bleeding source is important for the prevention of rebleeding in colonic diverticular hemorrhage (CDH). However, there are few known reports on SRH identification thus far. This large multicenter study evaluated factors correlated with SRH identification, including observation time during colonoscopy. METHODS: A total of 392 CDH cases were classified into presumptive CDH (n = 276) or definitive CDH with SRH (n = 116) on the basis of colonoscopy results. Multivariate Cox proportional hazards regression was employed to identify factors correlated with SRH identification. For the endoscopic treatment, endoscopic clips (EC), endoscopic band ligation (EBL) or endoscopic detachable snare ligation (EDSL) was performed. RESULTS: Longer observation time was significantly correlated with SRH identification in multivariate analysis (OR, 10.3 [95% CI: 3.84-27.9], p<.001). Receiver operating characteristic curve (ROC) analysis of the SRH identification rate by observation time indicated a high area under the curve (AUC) (0.79), and the threshold of the observation time was calculated at 19 min using Youden's index. Moreover, the patients taken endoscopic hemostasis showed significantly lower early rebleeding rate than patients without endoscopic hemostasis (16.4% vs. 31.9%, p=.001), suggesting the importance of identifying SRH and treating the bleeding source for reducing the risk of recurrent bleeding. CONCLUSIONS: Long-observation time correlated with SRH identification in this study, in which bowel preparation and water-jet scope and cap attachment are commonly used. This is the first known study to highlight the significance of observation time in the SRH identification rates.

A case of localized colorectal wild-type ATTR amyloidosis complicated by early stage colorectal cancer and a CMV-associated ulcer during the long-term follow-up.

Gastrointestinal involvement is a rare manifestation of systemic amyloidosis, and few reports have been published on localized amyloidosis of the colon. Only one case report has been published on the long-term prognosis of localized colorectal amyloidosis, and there are no previous reports on localized colorectal ATTR amyloidosis. Here, we report an 80-year-old male with localized colorectal wild-type ATTR amyloidosis who presented with edematous mucosa with vascular changes throughout the colon. He did not exhibit any symptoms or endoscopic exacerbation for 8 years after diagnosis. However, after 8 years, he developed early stage colorectal cancer and cytomegalovirus-associated ulcer. He was treated with endoscopic submucosal dissection, which was relatively challenging due to his hemorrhagic condition and poor elevation of the submucosa caused by amyloid deposits. Since the tumor was completely resected, he will undergo regular follow-up. Our review of 20 previous cases of localized colorectal amyloidosis revealed its clinical features and long-term prognosis. Specifically, ours is the second case of a diffuse pan-colon type of colorectal localized amyloidosis, which may lead to various complications, such as colorectal cancer, over a long period of time, and thus, regular follow-up is necessary.

Case report of recurrent spontaneous tumor lysis syndrome in a patient with esophageal cancer recovered via chemotherapy.

Tumor lysis syndrome (TLS) is a life-threatening oncological emergency. Only one TLS case has been reported in patients with esophageal cancer. We report the case of a 61-year-old man with recurrent spontaneous TLS caused by esophageal cancer. He was admitted to our hospital to investigate low back pain and dysphagia. Endoscopy and computed tomography revealed esophageal cancer with multiple liver and bone metastases. He was diagnosed with laboratory TLS based on high serum uric acid and phosphorus. After intravenous fluids and allopurinol were administrated, chemotherapy with 5-fluorouracil and cisplatin was started the next day. Although he transiently developed clinical TLS, it was resolved with conservative treatment. However, mild renal dysfunction was prolonged and cisplatin was reduced in the second course. As a consequence, recurrence of spontaous TLS (sTLS) was induced at the end of the course. In the third course, docetaxel was added to the regimen, and since then the patient have not develop sTLS. To the best of our knowledge, this is the first report regarding recurrent sTLS developed on the basis of solid tumors and was successfully controlled by chemotherapy. Although TLS complications are rare in esophageal cancer, early diagnosis and the adjustment of regimen resulted in stable chemotherapy.

A rare case of ulcerative colitis in a patient who developed acute ischemic colitis associated with Takayasu arteritis.

Intestinal ischemia is a rare complication of Takayasu arteritis (TAK), which often requires colectomy. We report the case of a 27 year-old man with ulcerative colitis (UC), who was admitted to our hospital due to abdominal pain. Computed tomography revealed an edematous wall of the ascending colon with ascites and a thickened aortic wall with mild stenosis of the superior mesenteric artery (SMA), suggesting large vessel vasculitis, especially TAK. Colonoscopy revealed acute ischemic colitis associated with mild stenosis of the SMA caused by TAK, but there was no worsening of UC. The patient was successfully treated with conservative therapy.

5-aminosalicylate-intolerant patients are at increased risk of colectomy for ulcerative colitis.

BACKGROUND: Although 5-aminosalicylate (5-ASA) is the therapy of first choice in ulcerative colitis (UC), some patients cannot tolerate it because of side effects. Previous reports have not investigated whether 5-ASA intolerance is associated with the risk of colectomy. AIM: To investigate the associations between 5-ASA tolerance and colectomy among UC patients METHODS: The data of UC patients who visited any of three hospitals during 2014-2018 in and around Tokyo, Japan, were retrospectively obtained from the medical records. Patients were categorized as (a) tolerant to any 5-ASA compounds ("tolerant to 5-ASA") and (b) patients who were intolerant to one or more 5-ASA compounds leading to refrainment from their further use ("intolerant to 5-ASA"). The association between 5-ASA tolerance and colectomy was examined by Cox proportional hazards model adjusted for sex, age, smoking and extent of colitis. RESULTS: Of 1788 patients, 1684 were "tolerant to 5-ASA" while 104 were "intolerant to 5-ASA". Colectomy was performed in 43 (2.6%) of the patients tolerant to 5-ASA and 12 (11.5%) of the patients intolerant to 5-ASA. After adjusting for all covariates, the risk of undergoing colectomy was higher in the "intolerant to 5-ASA" group than in the "tolerant to 5-ASA" group (hazard ratio: 4.92; 95% confidence interval: 2.58-9.38). CONCLUSION: Patients in whom 5-ASA was discontinued due to intolerance had a higher risk of undergoing colectomy than patients tolerant to their first, second or third 5-ASA compounds.

Self-expandable Metal Stent as a Bridge to Surgery for Colorectal Cancer: Safety and Oncological Outcomes.

BACKGROUND/AIM: Self-expandable metal stent (SEMS) as a bridge to surgery (BTS) for obstructive colorectal cancer (CRC) raises concerns regarding the short-term as well as oncological outcome. The present study aimed to investigate the safety of SEMS placement and risk factors of worse short-term and oncological outcomes as BTS. PATIENTS AND METHODS: Twenty-four patients with obstructive CRC who underwent SEMS placement as BTS were included. Success rate of SEMS placement and 2-year relapse-free survival (RFS) rates in stage II/III BTS patients were assessed. RESULTS: Technical and clinical success rates for SEMS placement were 100% and 87.5%, respectively. In Multivariate analyses, longer tumour length, longer interval to surgery, and angular positioning were risk factors related with the complication of stent placement. Two-year RFS rates were significantly higher in the no-complication than in the complication group (100% vs. 75%, log-rank test, p<0.01). CONCLUSION: A long tumour length, long interval between SEMS insertion and surgery, and angular positioning of the SEMS were identified as risk factors for SEMS-related complications. Moreover, SEMS insertion and/or surgery complications were associated with worse oncological outcome in CRC patients.

[A case of gastric neuroendocrine carcinoma with liver metastasis and portal vein invasion successfully treated by S-1 and cisplatin chemotherapy].

A 66-year-old man presented with anemia. Endoscopy revealed an elevated lesion with ulceration in the posterior wall of the lesser curvature of the lower gastric body. Endoscopic biopsy demonstrated pathological diagnosis, neuroendocrine carcinoma. A computed tomography scan showed liver metastasis and portal vein invasion. We started chemotherapy with S-1 and cisplatin. After six courses of treatment over seven months, partial response was assessed. We are continuing this chemotherapy now.