Severe skin ulcer caused by taking lenvatinib after proton beam therapy.

A 69-year-old man was treated with lenvatinib after three sessions of proton beam therapy (PBT) for hepatocellular carcinoma. Five months after administration of lenvatinib, a dermatitis with huge skin ulcer formed in the site of PBT irradiation. Lenvatinib was immediately withdrawn, but the skin ulcer continued growing until about 2 weeks later. With topical and antibiotic treatment, the skin ulcer resolved after about 4 months. After administration of lenvatinib, potential skin damage due to PBT at the irradiated site may have become apparent. This is the first report describing skin ulcer by the combination of lenvatinib administration and PBT.

Risk factors for the development of esophageal candidiasis among patients in community hospital.

The aim of this study was to clarify risk factors for esophageal candidiasis (EC) in immunocompetent patients in a community hospital. 7736 patients who underwent esophagogastroduodenoscopy at our hospital from April 2012 to July 2018 were enrolled. The relationships between EC and the following factors: age, gender, body mass index, lifestyle, lifestyle-related diseases, medication, and endoscopic findings were analyzed. EC was observed in 184 of 7736 cases (2.4% morbidity rate). Multivariate analysis revealed that significant risk factors for the development of EC were: diabetes mellitus {odds ratio (OR): 1.52}, proton pump inhibitor (PPI) use (OR: 1.69), atrophic gastritis (AG) (OR: 1.60), advanced gastric cancer (OR: 4.66), and gastrectomy (OR: 2.32). When severe EC (Kodsi grade ≥ II) was compared to mild EC (grade I), the most significant risk factors were advanced gastric cancer (OR: 17.6) and gastrectomy (OR: 23.4). When considering the risk of AG and PPI use with EC development, the risk increased as follows: AG (OR: 1.59), PPI use (OR: 2.25), and both (OR: 3.13). PPI use, AG, advanced gastric cancer and post-gastrectomy are critical risk factors for the development of EC. We suggest close monitoring for EC development when PPIs are administered to patients with these factors.

Effects of antithrombotic drugs on the results of fecal immunochemical test in colorectal neoplasms screening.

Fecal immunochemical test (FIT) is widely used as a colorectal cancer screening tool. Antithrombotic drugs may affect the screening performance of FIT for colorectal tumors. The aim of this study was to clarify the effect of antithrombotic agents on FIT accuracy in screening for colorectal neoplasms. This retrospective study enrolled a total of 758 patients who underwent both FIT and total colonoscopy. The effect of antithrombotic drugs on FIT accuracy in detecting colorectal neoplasms (CN), including colorectal cancer (CRC), advanced adenoma (AA), and non-advanced adenoma (NAA), was examined. Of the 758 patients, 144 (19%) received antithrombotic drugs (administration group). In administration group, 61/144 (42%) cases had CN [CRC:14, AA:15, NAA:32] and 217/614 (35%) cases had CN (CRC:43, AA:56, NAA:118) in non-administration group. The prevalence of CN was not significantly different between the two groups (p = 0.1157). There was no significant difference in sensitivity or specificity of the detection of all types of CN with or without taking antithrombotic drugs. Neither the positive predictive value nor negative predictive value of FIT was affected by antithrombotic drug administration. Taking antithrombotic drugs may not have a large impact on sensitivity, specificity, positive predictive value, or negative predictive value of FIT in screening for CN.

Alpha-glucosidase inhibitor use is associated with decreased colorectal neoplasia risk in patients with type 2 diabetes mellitus receiving colonoscopy: a retrospective study.

PURPOSE: The purpose of this study was to clarify the factors that influence the incidence of colorectal neoplasia in patients with type 2 diabetes mellitus (DM). STUDY DESIGN AND SETTING: Among a total of 1176 patients who underwent total colonoscopy at our hospital, we retrospectively analyzed 168 patients with type 2 DM. Univariate and multivariate logistic regression analyses were then performed to identify the risk factors associated with colorectal neoplasia. RESULTS: A multivariate analysis of these patients demonstrated that male gender (odds ratio [OR] = 4.04, 95% confidence interval [CI] = 1.67-10.37, p = 0.002), taking statins (OR = 4.59, 95% CI = 1.69-13.43, p = 0.003), taking alpha glucosidase inhibitor (α-GI) (OR = 0.35, 95% CI = 0.13-0.87, p = 0.023) and taking low-dose aspirin (LDA) (OR = 0.32, 95% CI = 0.10-0.95, p = 0.040) were independent factors associated with an increased (male gender and statins) or decreased (α-GI and LDA) risk of colorectal neoplasia. CONCLUSIONS: While male gender and taking statins are risk factors, taking α-GI as well as LDA may reduce the risk of colorectal neoplasia in patients with type2 DM.

Association between increased serum GP88 (progranulin) concentrations and prognosis in patients with malignant lymphomas.

BACKGROUND: GP88 (progranulin; PGRN) is a secreted 88kDa glycosylated protein, with important functions, including inflammation and tumorigenesis. We assessed the significance of GP88 expression in survival outcomes of patients with malignant lymphoma (ML). METHODS: Serum samples from 254 previously untreated ML patients were examined to measure GP88 concentrations using a sandwich human GP88 ELISA kit. Immunohistochemical analyses were performed to examine GP88 tumor tissue expression. RESULTS: The median serum GP88 concentration of ML patients was 91.3ng/ml, and was significantly higher than that of the control group (median, 57.7ng/ml) (p<0.0001). Association between GP88 serum concentrations and overall survival (OS) was examined in patients with diffuse large B cell lymphoma (DLBCL) who had been stratified based on their serum GP88 concentrations. Kaplan Meier survival analysis showed that patients with serum GP88 concentrations of ≤116 and >116ng/ml, had 5-y OS rates of 70% and 50%, respectively (p=0.02). The immunohistochemical analyses of GP88 tumor expression revealed that DLBCL patients had lymphoma cells that were positive for GP88. CONCLUSIONS: High serum GP88 concentrations are associated with poor prognosis in patients with DLBCL.

A refractory duodenal ulcer with a biliary-duodenal fistula following the administration of bevacizumab.

A 65-year-old woman with recurrent breast cancer was repeatedly treated with bevacizumab, an anti-VEGF antibody. In addition, she was also frequently prescribed a nonsteroidal anti-inflammatory drug for abdominal pain. Melena was revealed 2 months after the final treatment with bevacizumab, and an endoscopic study revealed a duodenal ulcer (DU) that was resistant to anti-ulcer therapy. A cholangiography identified a biliary-duodenal fistula with bile juice leaking from the ulcer base. Therefore, a biliary stent was placed into the common bile duct for 3 months until the DU healed. This is the first case of a refractory DU with a biliary-duodenal fistula in a patient treated with bevacizumab.

Development of a Novel Scoring System for Predicting the Risk of Colorectal Neoplasia: A Retrospective Study.

OBJECTIVE: The purpose of this study was to develop a novel scoring system to screen subjects who have a high risk for colorectal neoplasia. STUDY DESIGN AND SETTING: We retrospectively analyzed 1061 subjects undergoing total colonoscopy (TCS) for the first time at Gihoku Kosei Hospital. The characteristics and habits of the subjects were analyzed using a multivariate logistic regression analysis. The risk score was established according to each odds ratio of the individual risk factors, and the correlations between the sum of the risk scores and the prevalence of colorectal neoplasia for each individual were evaluated. RESULTS: Age 45-59 (risk score: 2 points) and ≥60 (3 points), male gender (1 point), and habitual alcohol consumption ≥21g daily (1 point) were extracted as the significant risk factors for colorectal neoplasia. When the risk groups were determined by summing up these risk scores, the prevalence rates of colorectal neoplasia were 8.8% for the low risk group (0-2 points), 30.5% for the low-moderate risk group (3 points), 39.1% for the high-moderate risk group (4 points), and 57.6% for the high risk group (5 points). In comparison with the low risk group, the odds ratio of the low-moderate risk, the high-moderate risk, and the high risk groups were 4.6, 6.7, and 14.1 folds, respectively. CONCLUSION: Our scoring system, which linearly correlates with the prevalence rate of colorectal neoplasia, may be an effective tool for screening the subjects who have a high risk for colorectal neoplasia. These subjects, therefore, should be recommended to undergo TCS.

[Bile duct injury and severe bleeding after endoscopic papillary large balloon dilation without sphincterotomy: a case report].

We report the case of an 80-year-old woman with multiple choledocholithiasis who suffered severe bleeding after endoscopic papillary large balloon dilation (EPLBD). Astriction by balloon tamponade and a covered, self-expandable, metallic stent failed. However, embolization using a transcatheter arterial coil stopped the bleeding. After hemostasis was achieved, a bile duct injury was observed. We presume that a bile duct stone, which had remained in the lower common bile duct, entered the balloon and the bile duct and caused the bile duct injury. This case emphasizes the need for careful attention during EPLBD.

Cytokeratin-positive fibroblastic reticular cell tumor with follicular dendritic cell features: a case report and review of the literature.

Fibroblastic reticular cell (FRC) neoplasms, which are one of the histiocyte tumor types, are very rare. Here we report a cytokeratin (CK)-positive FRC neoplasm having features of follicular dendritic cells in a 54-year-old woman with right axillary lymph node swelling. The resected lymph node showed multiple nodular aggregations simulating and replacing normal follicles. The tumor cells had a uniform, large and oval to polygonal shape, abundant cytoplasm, and various sizes of nuclei with central eosinophilic nucleoli and coarse nuclear chromatin. They were positive for CK AE1/AE3+CAM5.2, CK7, tenascin C, l-caldesomone, and CD21, weakly positive for S100, and negative for CD1a. Ultrastructurally, the tumor cells had long interdigitating microvillus-like cell processes and oval to elongated vesicular nuclei. In addition, the intercellular spaces contained accumulations of collagen, and some tumor cells had desmosomal-like junctions. These findings suggest that the present case is a CK-positive FRC tumor with follicular dendritic cell features.

Delayed stenosis of the small intestine after cardiopulmonary arrest.

A man in his 70s experienced cardiopulmonary arrest (CPA) due to acute myocardial infarction. He was resuscitated and treated with a multimodal approach, and he fortunately survived CPA without neurological damage. However, abdominal pain and vomiting occurred 45 days after the CPA. Small intestinal endoscopy showed pinhole-like stenosis of the ileum. Although balloon dilation was performed through the scope, his symptoms did not improve. Partial small bowel resection was eventually performed 139 days after the CPA. Pathological findings revealed ischemic changes in the mucosa at two spots. We speculate that an ischemic event occurred in the small bowel during CPA.

[A case of advanced gastric cancer with liver abscesses].

A man visited to our hospital because of high grade fever. Computed tomography revealed multilocular space occupying lesion which were suspected liver abscess. Upper gastrointestinal endoscopy showed an advanced gastric cancer with an ulcer on antrum. Antibiotics decreased the level of CRP, concurrently with the reduction of liver space occupying lesion. While he underwent distal gastrectomy, pathological examination demonstrated the existence of bacterial foci and microabscesses on the surface of the gastric cancer. We speculate in this case that liver abscesses were formed by the infection of resident bacteria through portal vein.

Inhibitory effects of carbon dioxide insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy.

AIM: To evaluate the inhibitory effects of carbon dioxide (CO(2)) insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy (PEG). METHODS: A total of 73 consecutive patients who were undergoing PEG were enrolled in our study. After eliminating 13 patients who fitted our exclusion criteria, 60 patients were randomly assigned to either CO(2) (30 patients) or air insufflation (30 patients) groups. PEG was performed by pull-through technique after three-point fixation of the gastric wall to the abdominal wall using a gastropexy device. Arterial blood gas analysis was performed immediately before and after the procedure. Abdominal X-ray was performed at 10 min and at 24 h after PEG to assess the extent of bowel distension. Abdominal computed tomography was performed at 24 h after the procedure to detect the presence of pneumoperitoneum. The outcomes of PEG for 7 d post-procedure were also investigated. RESULTS: Among 30 patients each for the air and the CO(2) groups, PEG could not be conducted in 2 patients of the CO(2) group, thus they were excluded. Analyses of the remaining 58 patients showed that the patients' backgrounds were not significantly different between the two groups. The elevation values of arterial partial pressure of CO(2) in the air group and the CO(2) group were 2.67 mmHg and 3.32 mmHg, respectively (P = 0.408). The evaluation of bowel distension on abdominal X ray revealed a significant decrease of small bowel distension in the CO(2) group compared to the air group (P < 0.001) at 10 min and 24 h after PEG, whereas there was no significant difference in large bowel distension between the two groups. Pneumoperitoneum was observed only in the air group but not in the CO(2) group (P = 0.003). There were no obvious differences in the laboratory data and clinical outcomes after PEG between the two groups. CONCLUSION: There was no adverse event associated with CO(2) insufflation. CO(2) insufflation is considered to be safer and more comfortable for PEG patients because of the lower incidence of pneumoperitoneum and less distension of the small bowel.

Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices.

BACKGROUND: Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement. OBJECTIVE: To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices. DESIGN: A retrospective study. SETTING: Single center: Nishimino Kosei Hospital. PATIENTS: This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010. INTERVENTION: A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage. MAIN OUTCOME MEASUREMENTS: Complications and their outcomes. RESULTS: Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair. LIMITATIONS: A single center, retrospective analysis. CONCLUSION: Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding.

Predominant copper deficiency during prolonged enteral nutrition through a jejunostomy tube compared to that through a gastrostomy tube.

BACKGROUND & AIMS: Trace element deficiencies are known to occur during long-term enteral nutrition feeding. We compared the serum concentrations of trace elements between patients treated with gastrostomy and those treated with jejunostomy. METHODS: Our subjects were 36 patients who underwent percutaneous endoscopic gastrostomy (PEG group) and 23 patients who underwent percutaneous endoscopic jejunostomy (PEJ group) and were maintained with enteral tube feeding for more than one year. The serum concentrations of copper, zinc, selenium, and iron were measured in the two groups. Clinical manifestations and the effectiveness of supplementation therapy against copper deficiency were also investigated. RESULTS: From 6 months after the onset of enteral feeding, the copper concentration of the PEJ group was significantly decreased compared with that of the PEG group (p<0.001). There were no significant differences in the concentrations of zinc, selenium, or iron between the two groups. Severe copper deficiency was observed in 6 patients of the PEJ group and was accompanied with neutropenia and anemia. The copper deficiency was successfully treated in all of these patients by supplementation with 10-40 g of cocoa powder a day which was equivalent to a total daily dose of 1.36-2.56 mg of copper. CONCLUSIONS: Prolonged PEJ tube nutrition tends to result in copper deficiency, and cocoa supplementation is effective for treating such copper deficiency.

[Three cases of lung cancer detected after smoking cessation].

COPD is an independent risk factor for lung cancer. There is emerging evidence that chronic inflammation may play a significant role in the pathogenesis of lung cancer as a tumor promoter. Cigarette smoke exponentially up-regulates the production of cytokines. After stopping smoking, the risk of lung cancer remains increased in patients with COPD. We report 3 patients with COPD in whom lung cancer was detected within 16 months after smoking cessation. All were outpatients of our hospital, and participated in a program for smoking cessation according to their doctor's advice. Two successfully stopped smoking, and the other was in the program for smoking cessation. It was difficult to detect lung cancers on chest X-ray films 8-11 months previously. Periodic medical examination chest X-ray films revealed lung cancers 2-16 months after smoking cessation. Heavy smokers, especially COPD patients, have a high risk of developing lung cancer at the start of smoking cessation, and therefore have a high risk of contracting lung cancer even after halting smoking. Generally, most patients do not visit hospitals for the purpose of only smoking cessation after successfully halting smoking. Nevertheless, it is necessary for previously heavy smokers, especially COPD patients, to undergo repeated careful medical examination to detect lung cancer.

[A bleeding ileal ulcer associated with Sweet's syndrome].

A 76-year-old woman was admitted to our institution because of high fever and erythema in the upper body with right back pain, and was given a diagnosis of Sweet's syndrome. She also had abdominal pain and developed hematochezia from the fourth hospitalization day. Double balloon enteroscopy detected multiple ulcers with a punched-out appearance at the terminal ileum. Endoscopic hemostasis of the ulcers was achieved using a hemoclip for treatment of a focal pulsating hemorrhage. After oral administration of prednisolone (PSL), both the ileal ulcer and erythema disappeared. The daily dosage of PSL was tapered. Since termination of PSL administration, there has been no recurrence of either Sweet's syndrome or ileal ulcer. We report a rare case of Sweet's syndrome complicated by bleeding ileal ulcers.

[A case of cardiac sarcoidosis occurring during combination therapy by IFN alpha and ribavirin for chronic hepatitis C].

A 72-year-old woman received combination therapy with peginterferon alpha and ribavirin for treatment of chronic hepatitis C. Approximately 40 weeks after starting treatment, she developed an eruption in the left inner canthus and sarcoidosis was diagnosed after biopsy of the eruption. Combination therapy was discontinued, and further detailed examinations revealed bilateral hilar lymphadenopathy, uveitis, and complete atrioventricular block. A permanent cardiac pacemaker was implanted, and her sarcoidosis improved upon administration of corticosteroids.

Clinical investigation of upper gastrointestinal hemorrhage after percutaneous endoscopic gastrostomy.

BACKGROUND: Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG. PATIENTS AND METHODS: We retrospectively investigated the causes of upper GI hemorrhage among a total of 416 patients out of 426 consecutive patients who underwent PEG in our institution, excluding 10 patients who showed upper GI tumors on PEG placement. RESULTS: Among 17 patients who developed upper GI hemorrhage after PEG, three and four patients showed PEG tube placement and replacement-related hemorrhage, respectively; these lesions were vascular or mucosal tears around the gastrostomy site. Ten patients experienced 12 episodes of upper GI hemorrhage during PEG tube feeding. The lesions showing bleeding were caused by reflux esophagitis (five patients), gastric ulcer (two patients), gastric erosion due to mucosal inclusion in the side hole of the internal bolster (two patients), and duodenal diverticular hemorrhage (one patient). Anticoagulants were administered in six patients, including four patients with replacement-related hemorrhage and one patient each with reflux esophagitis and gastric ulcer. CONCLUSIONS: Reflux esophagitis was the most frequent reason for upper GI hemorrhage after PEG. The interruption of anticoagulants should be considered for the prevention of hemorrhage on the placement as well as replacement of a gastrostomy tube.