[Clinicopathological features of hemorrhagic gastrointestinal stromal tumor].

In order to demonstrate the bleeding risk factors of GIST (gastrointestinal stromal tumor), we retrospectively investigated clinicopathological features between hemorrhagic (H group, 24 cases) and nonhemorrhagic GIST (NH group, 30 cases). In addition, we investigated features between the E group (6 cases) necessitating TAE (trans-catheter arterial embolization) and NE group (other 48 cases). Whereas H group partly includes high-risk grade GIST with chronic bleeding, meanwhile the E group (reflecting acute bleeding) is characterized by a highly enhanced mass with ulceration, comprising of smaller low-risk grade GIST. Amongst the 29 cases for forceps biopsy, which were 6 cases (21%) including one of E group, needed be hospitalized for postbiopsy bleeding. Acute bleeding in GIST may not be associated with malignant transformation. Postbiopsy bleeding or massive hemorrhage can also be encountered particularly in highly enhanced GIST with ulceration, even with a small and low-risk grade.

A case of Turner syndrome (46XXp-/45X) complicated with Crohn's disease after hormone therapy.

A 19-year-old woman, who had been receiving hormone replacement therapy for 13 months before the diagnosis of mosaic Turner syndrome (46XXp-/45X), developed Crohn's colitis and erythema nodosum of the lower legs. Colonoscopy revealed an anal fistula and the presence of deep longitudinal ulcers with cobblestoning in the colorectum. Therapy with prednisolone and adalimumab was effective for the intestinal and skin lesions. To date, all seven case reports of Turner syndrome in Japan have also developed Crohn's disease after hormone therapy, suggesting a possible association of sex hormones in the pathogenesis.

[Clinical features and pathophysiology of acute esophageal mucosal lesion].

Acute esophageal mucosal lesions (AEMLs) are categorized into black esophagitis (type B) and non-black esophagitis (type NB) on endoscopy. To clarify the distinct pathophysiology, we compared the clinical features and hematological findings at onset among 17 patients with type B esophagitis and 6 patients with type NB esophagitis. In type B esophagitis, time to endoscopy after onset was significantly shorter, and blood levels of lactate, urea nitrogen, creatinine, and glucose were higher than in type NB esophagitis. However, there were no significant intergroup differences in the incidences of other predisposing factors, such as diabetic ketoacidosis or esophageal hernias. These findings suggest that AEMLs are caused by acid reflux and peripheral vascular insufficiency, the latter being more associated with type B esophagitis by its etiology. In addition, blood lactate may indicate the severity of AEML, leading to black esophagitis.

[An autopsy case of ulcerative colitis with disseminated aspergillosis, complicated by brain hemorrhage].

An 80-year-old Japanese woman suffered multiple brain infarctions of unknown etiology during maintenance therapy of prednisolone and azathioprine for ulcerative colitis. Although a small cavity in the left lung spontaneously regressed, the patient suddenly died of massive brain hemorrhage due to disseminated aspergillosis, which was not identified until autopsy.

Colonic diverticular bleeding: precise localization and successful management by a combination of CT angiography and interventional radiology.

We report a case of 50-year-old man with relapsing severe colonic diverticular bleeding. The patient required total blood transfusion of 14 units, despite fasting for bowel rest. Repeated CT, colonoscopy, and angiography could not determine the accurate bleeding site. Superselective arterial embolization could be finally achieved by precise localization on CT immediately after superior mesenteric arteriography.

[Bacillus cereus bacteremia in Crohn's disease with multiple ileal stricture on maintenance azathioprine therapy].

We describe a case of 36-year-old Japanese man with Crohn's disease, complicated by Bacillus cereus bacteremia on maintenance azathioprine therapy. Although anti-microbial agents were ineffective, the patient became well immediately after a partial resection of the ileum with multiple severe stenosis.

[A case of steroid-dependent ulcerative colitis complicated by skin infection of Mycobacterium szulgai].

We describe a case of a 47-year old Japanese man with steroid-dependent, refractory ulcerative colitis complicated by non-tuberculous mycobacterial skin infection. The patient remained in remission by combination therapy of 100mg azathioprine and 27.5mg prednisolone (total dose over 25g for three years), but developed a deep genital ulcer. Mycobacterium szulgai was confirmed by skin culture, and the ulcer became turned into a scar after oral administration of isoniazid, rifampicin, and ethanbutol.

[Case of gastric cancer with isolated brain metastasis successfully managed by gamma knife radiotherapy and chemotherapy].

We describe a 51-year-old man case of a huge gastric cancer with an initial presentation of isolated brain metastasis. The patient was successfully managed by gamma knife radiotherapy, followed by chemotherapy using 5-fluorouracil and cisplatin. He has continued oral administration of TS-1 on an outpatient basis with disease free survival for more than one year.

Endoscopic and histological diagnosis on upper gastrointestinal cancer screening.

BACKGROUND/AIMS: Screening endoscopy for upper gastrointestinal cancer has come into wide use in Japan. We aim to clarify the limitation of its endoscopic diagnosis and contribution of histological biopsy on routine endoscopy. METHODOLOGY: For consecutive 1184 patients (696 men and 488 women, average age of 57 years) undergoing routine esophagogastroduodenoscopy, we prospectively evaluated endoscopic diagnosis with regard to grade of malignancy (definitely cancer, E5; probably cancer, E4; dysplasia/adenoma or indeterminate malignant, E3; probably benign, E2; and definitely benign, E1). Histological grade was defined as H5 (cancer), H4 (probably cancer), H3 (dysplasia/ adenoma or indeterminate malignant), H2 (probably benign), and H1 (definitely benign) in 267 patients undergoing endoscopic forceps biopsy. We analyzed the accuracy of endoscopic and histological biopsy diagnosis. RESULTS: Incidence of neoplastic lesions including H3, H4, and H5 was 0% in E1 (0/978), 2% in E2 (3/132), 19% in E3 (6/31), 33% in E4 (3/9), and 100% in E5 lesions (34/34). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of endoscopic diagnosis for these neoplastic lesions were 94%, 97%, 58%, 99%, and 97%, respectively. CONCLUSIONS: Better awareness of its endoscopic features and appropriate endoscopic biopsy is essential in the diagnosis of upper gastrointestinal cancer on screening endoscopy.

[Crohn's ileocolitis with initially superimposed cytomegalovirus infection, resembling intestinal tuberculosis].

We describe a case of 41-year-old Japanese man with Crohn's ileocolitis and cytomegalovirus infection, confirmed by histology of ileal ulcers. Although his colonoscopic and radiological features resembled those of intestinal tuberculosis, granulomas of typical Crohn's disease were evident on histology of biopsy specimens taken from the duodenum and colon. The lesions remain unchanged even after 1.5 years by oral administration of salazosulphapyridine 3g daily.

An autopsy case of Merkel cell carcinoma presenting aggressive intraabdominal metastasis and duodenal obstruction.

A 85-year-old Japanese woman was urgently admitted to our hospital complaining of vomiting 20 months after the initial diagnosis of Merkel cell carcinoma on the right eyelid. The patient died of a huge intra-abdominal mass with complete obstruction of the distal duodenum two months later. On autopsy, the mass measuring 18 x 12 x 5 cm in size was histologically diagnosed as metastatic Merkel cell carcinoma and directly invaded the stomach, pancreas, and distal duodenum.

Late-onset life threatening hemorrhage of omeprazole-resistant duodenal ulcer managed by interventional radiology: report of a case.

A 67-year-old diabetic man was emergently hospitalized in our department because of a huge duodenal ulcer without visible vessels. Despite of intravenous administration of 40 mg omeprazole and fasting with intravenous nutritional support, endoscopically unmanageable massive bleeding occurred on the 8th hospital day. Emergent angiography showed extravasation of contrast media from a duodenal branch of the proper hepatic artery, and superselective arterial embolization was successfully achieved. The patient recovered from the hemorrhagic shock and underwent subsequent successful surgery. Analysis of CYP2C19 enzyme genotype indicated the patient was a homozygous extensive metabolizer, considered a poor responder for omeprazole treatment.

Probe EUS for the diagnosis of invasion depth in superficial esophageal cancer: a comparison between a jelly-filled method and a water-filled balloon method.

BACKGROUND AND OBJECTIVE: Diagnostic accuracy of probe EUS depends on the constant maintenance of luminal medium for acoustic coupling. This study compared the accuracy of probe EUS by a jelly-filled method (EUS-J) and by a water-filled balloon method (EUS-W) for the assessment of invasion depth in superficial esophageal cancer. DESIGN AND SETTING: A prospective, single-center study. PATIENTS: Forty superficial esophageal cancers in 38 patients. INTERVENTIONS: Patients were alternately assigned to EUS-J or EUS-W. The depth of invasion was classified into epithelium or lamina propria mucosae (D1), muscularis mucosae or superficial layer of the submucosa (D2), and deep portion of the submucosa (D3). Depiction rate, interobserver variation between 2 observers, and accuracy for the determination of invasion depth were compared between EUS-J and EUS-W. MAIN OUTCOME MEASUREMENTS AND RESULTS: Eighteen cancers were examined by EUS-J, and 22 cancers were examined by EUS-W. The actual depth of invasion was D1 in 21 cancers, D2 in 9 cancers, and D3 in 10 cancers. Depiction rate (94.4% vs 77.2%, P = .14) and interobserver agreement of EUS determination (82.3% vs 58.8%, P = .13) was higher in EUS-J than in EUS-W. The overall accuracy for the diagnosis of invasion depth was 77.8% in EUS-J and 59.1% in EUS-W (P = .18). The sensitivity for the diagnosis of D1 cancer was significantly higher in EUS-J than in EUS-W (100% vs 50%, P = .03), while the specificity was not different between the 2 procedures (81.8% vs 87.5%). CONCLUSIONS: EUS-J is superior to EUS-W for the assessment of invasion depth in superficial esophageal cancer, especially for intramucosal cancer.

Preventive effect of nutritional therapy against postoperative recurrence of Crohn disease, with reference to findings determined by intra-operative enteroscopy.

OBJECTIVE: The aim of this study was to elucidate the predictive value of intra-operative enteroscopy (IOE) and the effect of enteral nutrition (EN) with regard to the postoperative recurrence of Crohn disease (CD). MATERIAL AND METHODS: Forty patients requiring surgery for severe intestinal complications of CD were examined by IOE, and the severity of the remnant small intestine was determined. Patients were subclassified into either an EN group (>1,200 kcal/day) or a non-EN group (<1,200 kcal/day) according to the amount of daily EN intake after surgery. Contributions of IOE findings and EN to postoperative recurrence were analysed retrospectively. RESULTS: IOE identified intestinal lesions in 39 patients and active intestinal lesions in 24 patients. The cumulative rate of postoperative recurrence was significantly higher in patients with cobblestone appearance confirmed by IOE (p=0.006). However, other active intestinal lesions were not related to postoperative recurrence. EN reduced the cumulative rate of postoperative recurrence (p=0.017), especially in patients with penetrating type (p=0.005), in patients who did not have colitis (p=0.051) and in patients who did not have active intestinal lesions confirmed by IOE (p=0.02). CONCLUSIONS: EN is a prophylactic that prevents the postoperative recurrence of small intestinal CD. Patients with the penetrating type of CD, and those who do not have active lesions in the small intestine according to IOE, are candidates for EN after surgery.