[A case of autopsy-confirmed duodenal perforation due to calcium polystyrene sulfonate].

A 77-year-old male patient was referred to our hospital because of jaundice. He was diagnosed with alcoholic liver cirrhosis and was admitted to our hospital because of liver failure. After admission, we observed conservative liver disease, but the liver damage did not improve and gradually worsened. Renal function deteriorated during liver failure. Hyperkalemia presented due to renal dysfunction. Hence, calcium polystyrene sulfonate (CPS) was initiated. He died because of liver failure although hyperkalemia improved. An autopsy revealed ulcer perforation with CPS crystals in the duodenum. A basic substance considered a crystal of CPS was found by hematoxylin and eosin staining from the ulcer adjacent to the perforation and the exudate attached to the peritoneum. Furthermore, a large amount of CPS crystals were found in the ascites. A final diagnosis of gastrointestinal perforation peritonitis due to CPS was made. Gastrointestinal perforation due to CPS is presumed as a direct mucosal injury due to the drug, most of which is the sigmoid colon of elderly patients. Upper gastrointestinal tract perforation is extremely rare. We experienced a case of autopsy in which duodenal perforation due to CPS was pathologically confirmed. CPS is a widely used drug for renal disorders, but it has a risk of gastrointestinal injury. Therefore, a potential gastrointestinal mucosal injury should be considered when using CPS.

A fat containing combined neuroendocrine carcinoma and hepatocellular carcinoma in the liver: A case report.

A 79-year-old man was admitted to our hospital because of increased hepatobiliary enzyme levels. Dynamic computed tomography and magnetic resonance imaging showed a liver tumor measuring 60mm containing fat foci at the cranial aspect of the tumor. We diagnosed the patient with hypovascular hepatocellular carcinoma (HCC) and fat deposition, and performed a caudate lobe resection. Pathology examination revealed two intermingled components: moderately differentiated HCC with fat deposition and neuroendocrine carcinoma (NEC). Primary combined NEC and HCC is extremely rare. To our knowledge, this is the first report of combined NEC and HCC including a fat component. HCC is the most common primary hepatic malignancy with fat. HCC might include fat, even if HCC coexists with another type of cancer. The imaging characteristics of and HCC with another type of cancer vary depending on the amount of each component. We should not simply diagnose such tumors as HCC, but think about the possibilities of HCC with another type of cancer, because there is a fat component.

Comparison of a 22-gauge Franseen-tip needle with a 20-gauge forward-bevel needle for the diagnosis of type 1 autoimmune pancreatitis: a prospective, randomized, controlled, multicenter study (COMPAS study).

BACKGROUND AND AIMS: Histologic diagnosis of autoimmune pancreatitis (AIP) using EUS-guided FNA (EUS-FNA) is difficult. To address this issue, new fine-needle biopsy (FNB) needles were recently developed. Here, we prospectively evaluated 2 newly designed EUS-FNB needles for histologic evaluation in patients with type 1 AIP. METHODS: This was a prospective, randomized, multicenter trial comparing biopsy specimens obtained with a 22-gauge Franseen needle or a 20-gauge forward-bevel needle in patients with suspected type 1 AIP. AIP was diagnosed according to international consensus diagnostic criteria. The primary endpoint was the sensitivity of EUS-FNB needles, and secondary endpoints were the amount of specimen obtained, histology of the pancreas based on evaluation of lymphoplasmacytic sclerosing pancreatitis (LPSP), and contribution of histologic findings to the diagnosis of AIP. RESULTS: One hundred ten patients were randomly assigned to the Franseen group (22-gauge Franseen needle) or the forward-bevel group (20-gauge forward-bevel needle). EUS-FNB sampling was successful in all patients. Nine patients were excluded because of diagnoses other than AIP. Compared with the forward-bevel needle, the Franseen needle obtained a significantly greater number of high-power fields. Of 101 patients, 39 patients (78%) in the Franseen group and 23 patients (45%) in the Forward-bevel group were diagnosed with level 1 or 2 LPSP (P = .001). Thirty-six patients could not be diagnosed with type 1 AIP without EUS-FNB specimen results. CONCLUSIONS: The 22-gauge Franseen needle should be routinely used for histologic diagnosis of type 1 AIP. (Clinical trial registration number: UMIN 000027668.).

[A case of concomitant pancreatic neuroendocrine neoplasm and intraductal papillary mucinous neoplasm in which preoperative diagnosis was difficult].

A 75-year-old male patient has been followed-up for mixed-type intraductal papillary mucinous neoplasm (IPMN) in the tail of the pancreas for about 20 years. Upon close examination, he was diagnosed of high-risk stigmata due to a nodule having a contrast effect of 5mm or more in the tumor. Based on this, a distal pancreatectomy was performed. Histopathological analysis revealed concomitant IPMN (low-grade) and pancreatic neuroendocrine neoplasm (PNEN) (G1). This prompted us to report a very rare case of coexisting PNEN and IPMN with an interesting pathological finding that might suggest its pathogenic mechanism.

[Prediction of pancreatitis following endoscopic retrograde cholangiopancreatography].

OBJECTIVE: The aim of this study was to determine if the difference in serum amylase levels prior to, and two hours following, an endoscopic retrograde cholangiopancreatography (ERCP), or the ratio of the two-hour post-ERCP amylase level to the pre-ERCP amylase level was a better predictor of post-ERCP pancreatitis (PEP). METHODS: This was a retrospective, single-center study of consecutive patients, who underwent ERCP between April 2015 and August 2018. Serum amylase was measured before and two hours following ERCP. We compared the difference and the ratio of the two levels in predicting PEP using a receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 1029 patients underwent ERCP, with PEP occurring in 118 (11.5%). Multivariate analysis revealed that an elevated two-hour post-ERCP serum amylase level was a significant predictor of PEP. ROC analysis of the difference and the ratio of the two levels found good performance for both parameters, with an area under the curve (AUC) of 0.861 (95% confidence interval [CI], 0.823-0.900) and 0.847 (95% CI, 0.809-0.886), respectively. The difference between the values was a significantly more effective predictor of PEP, based on the AUC analysis (P = 0.011). CONCLUSION: The difference between pre and two-hour post-ERCP amylase levels is a better predictor of PEP than the ratio of the two.

[Successful biliary drainage by percutaneous transhepatic puncture common bile duct and rendezvous technique for a case of recurrent biliary pancreatitis with a Roux-en-Y reconstruction and without extension of the bile duct].

A 92-year-old woman was hospitalized with upper abdominal pain. She had a history of acute biliary pancreatitis and chronic heart failure and had undergone gastrectomy with Roux-en-Y reconstruction. She was admitted with recurrent pancreatitis and an exacerbation of heart failure. Biliary drainage could not successfully be achieved endoscopically or with percutaneous transhepatic biliary drainage and EUS-guided biliary drainage because of the Roux-en-Y reconstruction and non-dilation of bile duct. We successfully accomplished biliary drainage in one session with percutaneous transhepatic puncture of the common bile duct with ultrasound guidance and the rendezvous technique. We report this case because it is rare.

[A case of relapsed hemosuccus pancreaticus successfully treated with interventional radiology].

A 67-year-old male with chronic pancreatitis presented with upper abdominal pain and melena. Abdominal dynamic computed tomography revealed a splenic artery aneurysm in the main pancreatic duct. Esophagogastroduodenoscopy showed active bleeding from Vater's papilla. The patient was diagnosed with hemosuccus pancreaticus (HP) due to rupture of the aneurysm and treated with interventional radiology (IVR). The patient's poor lung function did not allow for a radical operation and a follow-up examination was recommended. The HP relapsed 7 months later and was successfully retreated with IVR. Although IVR is associated with a high recurrence rate, it is less invasive and therefore effective for treating relapsing HP in patients with a poor general condition.

Neoadjuvant therapy with intensity-modulated radiotherapy combined with S-1 for borderline-resectable pancreatic cancer.

AIM: We evaluated the efficacy of neoadjuvant chemotherapy with intensity-modulated radiotherapy (NAC-IMRT) in patients with borderline-resectable pancreatic cancer (BRPC). METHODS: BRPC patients were treated with IMRT (45 Gy/15fr) combined with two courses of S-1 (40 mg/m2 bid) before surgery. Outcomes after NAC-IMRT, surgery, and survival were then evaluated. This single-center retrospective study assessed 26 consecutive patients. RESULTS: Twenty-six patients (BR-PV: 7, BR-A: 19) with a median age of 73 years were enrolled from 2016 to 2021. Ten (38%) patients were 75-years-old and above. Twenty-three patients completed NAC-IMRT treatment. The median reductions in tumor size and cancer antigen 19-9 level were 13.6% and 69%, respectively. All 26 patients underwent resection within a median time of 71 days after NAC-IMRT initiation. R0 resection was achieved in 24 patients (92%). The median overall survival (OS) was 28.0 months, and the 1- and 3-year OS rates were 100% and 34%, respectively. The median progression-free survival (PFS) was 12.5 months, and the 1- and 3-year PFS rates were 50% and 32%, respectively. No significant differences were observed in OS between the patients under and over the age of 75 (29 vs. 20 months, p = 0.86). The 12 patients who completed NAC-IMRT, resection, and subsequent adjuvant chemotherapy (AC) exhibited a 3-year survival rate of 73%, which was significantly better than that of the patients who did not receive or complete AC (median OS, not reached vs. 19 months, p < 0.001). CONCLUSION: NAC-IMRT showed outstanding clinical efficacy with acceptable tolerability in patients with BRPC, including geriatric patients.

Emergency Endoscopic Retrograde Cholangiopancreatography Did Not Increase the Incidence of Postprocedural Pancreatitis Compared With Elective Cases: A Prospective Multicenter Observational Study.

OBJECTIVE: The aim of this study was to identify the incidence of and risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after emergency endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We performed a prospective multicenter observational study of 3914 patients who underwent ERCP. We compared the incidence of PEP after emergency and elective ERCP. RESULTS: A total of 3410 patients were enrolled in this study. Post-ERCP pancreatitis occurred in 44 of 800 patients (5.5%) and in 190 of 2418 patients (7.9%) in the emergency and elective groups, respectively. No significant difference was noted between the groups (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.52-1.03; P = 0.07). Multivariate analysis showed that the following factors increased the risk for PEP after emergency ERCP: contrast medium injection into the pancreatic duct (OR, 2.56; 95% CI, 1.30-5.03; P = 0.005), >4 cannulation attempts (OR, 5.72; 95% CI, 2.61-12.50; P < 0.001), and endoscopic papillary balloon dilatation (OR, 9.24; 95% CI, 2.13-40.10; P < 0.001). CONCLUSIONS: No significant difference was noted in the incidence of PEP in patients after emergency and elective ERCP. We may prevent PEP even after emergency ERCP by avoiding contrast injection into the pancreatic duct, multiple cannulation attempts, and endoscopic papillary balloon dilatation.

Post-endoscopic retrograde cholangiopancreatography pancreatitis assessed using criteria for acute pancreatitis.

BACKGROUND AND AIM: International consensus on the definition and classification of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been reached. However, the diagnosis and severity of PEP are often assessed according to the diagnostic criteria and classification for acute pancreatitis (AP). This study determined the incidence, severity, and risk factors of PEP diagnosed according to the diagnostic criteria and classification for AP in a large cohort. METHODS: This prospective, multicenter, observational cohort study conducted at five high-volume centers included 1932 patients who underwent ERCP-related procedures. The incidence, severity, and risk factors for PEP were evaluated. RESULTS: PEP occurred in 142 patients (7.3%); it was mild in 117 patients (6.0%) and severe in 25 patients (1.3%). According to the Cotton criteria, PEP occurred in 87 patients (4.5%); it was mild in 54 patients (2.8%), moderate in 20 patients (1.0%), and severe in 13 patients (0.7%). In the multivariate analysis, female sex (odds ratio [OR] 2.239; 95% confidence interval [CI] 1.546-3.243), naïve papilla (OR 3.047; 95% CI 1.803-5.150), surgically-altered gastrointestinal anatomy (OR 2.538; 95% CI 1.342-4.802), procedure time after reaching the papilla (OR 1.009; 95% CI 1.001-1.017), pancreatic duct injection (OR 2.396; 95% CI 1.565-3.669), and intraductal ultrasonography (OR 1.641; 95% CI 1.024-2.629) were independent risk factors. CONCLUSION: According to the diagnostic criteria and classification for AP, the incidence of PEP was higher than that according to the Cotton criteria and the severity of PEP tended to be severe.

Diagnostic Value of Serum Amylase Levels Indicating Computed Tomography-Defined Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Multicenter Observational Study.

OBJECTIVE: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis involves persistent serum amylase levels of 3 times or more the standard upper limit. However, these criteria were mostly based on retrospective studies and not necessarily supported by diagnostic imaging. Our prospective study aimed to investigate cutoff serum amylase levels suggesting post-ERCP pancreatitis using computed tomography as the criterion standard. METHODS: We prospectively followed 2078 cases. Computed tomography was performed in patients whose serum amylase levels exceeded the institutional upper limit 12 to 24 hours after ERCP. Two expert radiologists blindly assessed the images and judged the presence or absence of pancreatitis. Correlations between serum amylase levels with pancreatitis were investigated using receiver operating characteristic analysis. RESULTS: Amylase levels increased in 416 (23.2%) of 1789 cases included, and 350 cases were analyzed using computed tomography. Post-endoscopic retrograde cholangiopancreatography pancreatitis was diagnosed in 12.0% (214/1789). The cutoff amylase levels for judging pancreatitis after 12 to 24 hours was 2.75 times higher than the institutional upper limit, with an area under the curve of 0.77. CONCLUSIONS: The appropriate cutoff serum amylase level for judging post-ERCP pancreatitis at 12 to 24 hours after ERCP was 2.75 times higher than the institutional upper limit. These results may clarify the definition of post-ERCP pancreatitis.

Magnifying narrow-band imaging with acetic acid to diagnose early colorectal cancer.

AIM: To evaluate the diagnostic characteristics of magnifying endoscopy with acetic acid spray and narrow-band imaging (MA-NBI) for early colorectal cancer. METHODS: We conducted a prospective study to evaluate the diagnostic characteristics of MA-NBI in differentiating early colorectal adenocarcinomas from adenomas. To compare the results, we used magnifying endoscopy with NBI (M-NBI) and magnifying endoscopy with crystal violet staining (M-CV). The study was performed in 2 phases. In phase 1, 10 colonoscopists at our institution were shown still photographs of 35 colorectal polyps (24 adenocarcinomas and 11 adenomas) in M-NBI, MA-NBI, and M-CV. They made diagnostic predictions using a five-grade scoring evaluation. We plotted receiver operating characteristic curves and compared the areas under the curves (AUCs). In phase 2, colorectal polyps measuring ≥ 8 mm were prospectively enrolled. During real-time colonoscopy, one of the 7 colonoscopists scored the lesion as an adenocarcinoma or an adenoma and assigned a level of confidence to the prediction (high or low). We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each method and compared the proportions of high-confidence predictions. RESULTS: In phase 1, the mean ± SD AUCs were 0.64 ± 0.031 in M-NBI, 0.71 ± 0.066 in MA-NBI, and 0.76 ± 0.059 in M-CV (P < 0.05 for M-NBI vs MA-NBI, P < 0.001 for M-NBI vs M-CV, and not significant for MA-NBI vs M-CV). In phase 2, 84 patients with 91 lesions (46 adenocarcinomas and 45 adenomas) were enrolled. The diagnostic characteristics were as follows: 73% accuracy, 85% sensitivity, 60% specificity, 68% PPV, and 79% NPV in M-NBI; 73% accuracy, 80% sensitivity, 64% specificity, 70% PPV, and 76% NPV in MA-NBI; and 73% accuracy, 83% sensitivity, 62% specificity, 69% PPV, and 78% NPV in M-CV. The proportions of high-confidence predictions were 57% in M-NBI, 75% in MA-NBI, and 76% in M-CV (P < 0.005 for M-NBI vs MA-NBI, P < 0.0005 for M-NBI vs M-CV, and P = 1.0 for MA-NBI vs M-CV). CONCLUSION: MA-NBI is useful for differentiating early colorectal adenocarcinomas from adenomas.