Malignant transformation of a gastric hyperplastic polyp in a context of Helicobacter pylori-negative autoimmune gastritis: a case report.

BACKGROUND: Gastric foveolar hyperplastic polyps (GFHPs) are common findings in clinical practice. GFHPs commonly arise in a background of chronic atrophic gastritis, including autoimmune gastritis (type A gastritis), and have a potential risk of malignant transformation. CASE PRESENTATION: In 2005, a 55-year-old Japanese woman underwent upper endoscopy at another hospital and was found to have a pedunculated polyp (10 mm in diameter) on the greater curvature of the lower gastric body. On biopsy, the polyp was diagnosed as a GFHP. Nine years later, the polyp had grown to 20 mm in diameter, and the biopsy specimen taken at this time showed tubular adenocarcinoma. On admission to our hospital, the serum Helicobacter Pylori (H. pylori) immunoglobulin G antibody and stool H. pylori antigen were both negative. Anti-gastric parietal cell antibody was positive, as was the anti-intrinsic factor antibody, and the fasting serum gastrin level was markedly increased. In 2014, en bloc resection of the pedunculated polyp was performed by endoscopic submucosal dissection. The final histological diagnosis was adenocarcinoma of the stomach with submucosal and lymphatic invasion. Subsequently, additional radical distal gastrectomy was performed. At the latest follow-up (12 months postoperatively), no recurrence was noted. CONCLUSIONS: We here reported a rare case of malignant transformation of GFHP arising in a context of type A gastritis. To our knowledge, there are no previous reports on malignant transformation of GFHP with submucosal and lymphatic invasion arising in a background of type A gastritis in the English literature. Further, there is currently no effective treatment other than endoscopic or surgical treatment for such cases. Given the potential risk of malignant transformation due to hypergastrinemia, we consider that endoscopic treatment should be considered as a first-line therapy when a malignant growth is suspected.

Late-onset Wilson Disease in a Patient Followed-up for Nonalcoholic Fatty Liver Disease.

A 73-year-old woman was referred to our hospital for persistent liver dysfunction. When the patient was 45 years old, her youngest sister had been diagnosed with Wilson disease (WD). The patient therefore underwent several family screening tests, all of which were unremarkable. She had an annual medical checkup and was diagnosed with liver dysfunction and fatty liver at 68 years old. A liver biopsy and genetic testing were performed, and she was diagnosed with WD; chelation therapy was then initiated. In patients with hepatic disorders and a family history of WD, multiple medical examinations should be conducted, as the development of WD is possible regardless of age.

Primary Bile Duct Diffuse Large B-cell Lymphoma Diagnosed by Repeated Endoscopic Ultrasound-guided Fine-needle Aspiration and Endoscopic Retrograde Cholangiopancreatography.

A 54-year-old man was admitted with obstructive jaundice. Computed tomography showed common bile duct stricture and a tumor around the celiac artery. Repeated endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) as well as a laparotomic biopsy around the celiac artery were diagnostically unsuccessful. Since the bile duct stricture progressed, EUS-FNA and ERCP were performed a third time, finally leading to the diagnosis of diffuse large B-cell lymphoma. The treatment plan and prognosis of obstructive jaundice differ greatly depending on the disease. It is important to conduct careful follow-up and repeated histological examinations with appropriate modifications until a diagnosis is made.

Ulcerative colitis: comparison between elderly and young adult patients and between elderly patients with late-onset and long-standing disease.

BACKGROUND AND AIM: We examined the pathologies, treatment characteristics, and clinical course of elderly ulcerative colitis (UC) patients. METHODS: Among 222 UC patients (127 men, 95 women; average age, 34 ± 16 years), we selected 109 with UC diagnosed between 20 and 39 years of age (young adult group) and 23 diagnosed at ≥ 60 years of age (elderly group). Moreover, 12 patients diagnosed between 60 and 64 years of age (late-onset group) and 6 patients aged ≥ 60 years diagnosed under 50 years old (long-standing group) were also extracted for sub-analysis. The clinical characteristics and course were compared among the groups. RESULTS: The average age at onset was 29 ± 6 years in the young adult group and 66 ± 5 years in the elderly group. The frequency of immunomodulator or steroid use did not differ between the two groups. The comorbidity rate was 14.7 % in the young adult group and 69.6 % in the elderly group (P < .0001). Seven patients (58.3 %) in the late-onset UC group and none of the patients in the long-standing UC group were on steroid treatment. None of the patients in the long-standing UC group required hospitalization/surgery for UC exacerbation, while 3 (25.0 %) and 2 patients (16.7 %) in the late-onset group required hospitalization and surgery, respectively. CONCLUSIONS: The comorbidity rate was significantly higher in the elderly group. Treatments did not differ significantly between the young adult and elderly groups. Therefore, it appears that the inflammation tends to subside with age in elderly patients with long-standing UC.

Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: A pilot study.

BACKGROUND AND AIMS: Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system. METHODS: We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. RESULTS: The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay. CONCLUSION: We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.

Adult-onset Still's Disease Diagnosed during Puerperium with Liver Dysfunction in Pregnancy and Liver Failure of the Infant.

Most cases of liver dysfunction in pregnancy are pregnancy-related, but the onset of systemic autoimmune diseases is also differentiated. A 24-year-old woman presented with liver dysfunction at 28 weeks' gestation with suspected autoimmune hepatitis and started taking ursodeoxycholic acid. She gave birth prematurely at 35 weeks' gestation, and the infant presented with pancytopenia and liver failure but survived because of liver transplantation. Since the patient had major symptoms during the puerperium, she was diagnosed with adult-onset Still's disease. When encountering a patient with liver dysfunction during pregnancy, we should also consider the onset of autoimmune diseases.

[Successful endoscopic transpapillary pancreaticobiliary drainage for omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula].

A 78-year-old man with hepatocellular carcinoma treated by chemoembolization and percutaneous ethanol injection was admitted to our hospital because of acute abdomen. The CT scan showed biliary fistula caused by hepatocellular carcinoma protruding from S3. Endoscopic retrograde cholangiopancreatography showed disruption of an intrahepatic duct and the main pancreatic duct, and contrast agent leaked into the peritoneal cavity from each duct. Omental panniculitis with biliary fistula and pancreatic fistula was diagnosed. The symptoms improved by endoscopic nasobiliary drainage and endoscopic pancreatic stenting. On the 13th day after admission, we added endoscopic nasopancreatic drainage because his abdominal pain had been exacerbated by pancreatic juice leakage. Omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula is extremely rare. Endoscopic transpapillary pancreaticobiliary drainage was effective for omental panniculitis in this case.

Utility of endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) for diagnosing small subepithelial lesions (< 20 mm).

AIM: Subepithelial lesions (SELs) are defined as being located under the mucosa. Presently, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is commonly performed to diagnose SELs. With the development of new puncture needles, endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB), which allows for the acquisition of large tissue samples, has been proposed. However, studies on EUS-FNB of SELs measuring < 20 mm have not yielded satisfactory results. Therefore, we aimed to assess the performance and usefulness of EUS-FNB of SELs measuring less than < 20 mm. METHODS: The present study included 62 patients who underwent EUS-FNA or EUS-FNB for SELs at our hospital between January 2015 and March 2019. EUS-FNA was performed using fine-needle aspiration needles, and EUS-FNB was performed using fine-needle biopsy needles. These needles, which come in different shapes and diameters, were compared in terms of their usefulness in performing procedures for SELs measuring ≥ 20 mm and those measuring < 20 mm. RESULTS: For SELs measuring ≥ 20 mm, the use of needles with a large diameter, such as 19 or 20 G, resulted in significantly improved diagnostic rates. For SELs measuring < 20 mm, the use of FNB needles showed significantly improved diagnostic rates, regardless of the size of the puncture needles. CONCLUSION: Even when SELs are less than 20 mm, they might have malignant potential, and histological diagnosis may be desirable in some cases. EUS-FNB has an advantage over EUS-FNA in the diagnosis of SELs measuring < 20 mm.

[A case of primary splenic angiosarcoma with intraperitoneal hemorrhage treated by transcatheter arterial embolization].

Splenic tumors are very rare. In Japan only 42 cases of splenic angiosarcoma have been reported. We encountered a case of spontaneous rupture of a splenic angiosarcoma and liver metastasis. A 60-year-old woman who suddenly went into hemorrhagic shock presented at our hospital. Then acute spontaneously ruptured spleen and hepatic tumors were diagnosed by abdominal CT. After emergency TAE, the patient was hemodynamically stable, but died of liver failure 13 days after admission. The pathological diagnosis was primary splenic angiosarcoma with multiple organ metastasis on autopsy. Splenic angiosarcoma should be kept in mind in the differential diagnosis of splenomegaly or splenic tumor. TAE can be effective in primary hemostasis for angiosarcoma with intraperitoneal hemorrhage from multiple tumors.

Pruritus is common in patients with chronic liver disease and is improved by nalfurafine hydrochloride.

Pruritus is known to be a common complication in hepatitis patients, but the exact frequency and degree are not fully elucidated. Thus, we evaluated pruritus of 450 patients with chronic liver disease at our hospital. Pruritus was observed in 240 (53%) of the patients. Pruritus was significantly associated with males (OR = 1.51, P = 0.038) and patients with alkaline phosphatase (ALP) ≥ 200 U/L (OR = 1.56, P = 0.0495) and was significantly less in HBsAg-positive patients (OR = 0.449, P = 0.004). Seasonally, there was no difference in the frequency of pruritus between summer and winter. Of the 24 refractory pruritus patients treated with nalfurafine, 17 (71%) indicated improvement of itch, which is defined as a decrease in the visual analog scale score ≥ 30 mm. Pruritus was improved by nalfurafine both during daytime and nighttime in the Kawashima's scores evaluation. All patients who received nalfurafine exhibited improved Kawashima's scores ≥ 1 point during the daytime or nighttime. In conclusion, pruritus occurred in > 50% of patients with chronic liver disease, and predictors of pruritus were males and ALP ≥ 200 U/L. Nalfurafine may be useful for pruritus, regardless of whether daytime or nighttime.

[Endoscopic ultrasound-guided transmural cyst drainage (EUS-CD) was effective in a case of pancreatic pseudocyst with obstructive jaundice and duodenal stenosis].

A 40-year-old man was admitted to our hospital because of epigastralgia and vomiting. His condition was diagnosed as acute pancreatitis with a pancreatic pseudocyst, obstructive jaundice, and duodenal stenosis. Because he had fever, abdominal pain, and elevated levels of C-reactive protein (CRP), endoscopic ultrasound-guided transmural cyst drainage (EUS-CD) was performed with a nasocystic tube on the 6th day. After the cyst was reduced and the patient recovered from the obstructive jaundice and duodenal stenosis, the nasal drainage tube was replaced with a plastic stent. Because a short extent of stenosis in the main pancreatic duct in the pancreatic head was found by endoscopic retrograde cholangiopancreatography (ERCP), a 5Fr pancreatic stent was placed to prevent pancreatitis. No recurrence of pancreatitis and the cyst occurred after removal of both stents 5 days later.

Slow growing flat-type primary malignant melanoma of the esophagus treated with cap-assisted EMR.

We report a rare case of flat-type primary malignant melanoma of the esophagus treated with endoscopic mucosal resection (EMR). A 64-year-old woman was referred for examination of a small pigmented lesion located in the mid esophagus. On endoscopy, the lesion exhibited almost no change in size over the year. Cap-assisted EMR was performed en bloc. The histopathological findings showed atypical melanocyte proliferation in the basal layer, spindle cells, and epithelioid cell proliferation with nuclear enlargement and a few mitotic figures. Histopathological examination confirmed the diagnosis of primary malignant melanoma. Immunostaining for S-100 protein and HMB-45 antibody were positive, and the Ki-67 index was low. The patient was discharged without additional surgical resection and/or chemotherapy. The patient had no symptoms and no signs of recurrence 20 months after EMR. There has been no report on a slow growing esophageal melanoma. It is difficult to estimate the malignant behavior of this case.

Clinical course of biliary-type sphincter of Oddi dysfunction: endoscopic sphincterotomy and functional dyspepsia as affecting factors.

BACKGROUND AND STUDY AIMS: The objective of this study was to clarify the effectiveness of treatment selection for biliary-type sphincter of Oddi dysfunction by severe pain frequency and the risk factors for recurrence including the history of functional gastrointestinal disorder. PATIENTS AND METHODS: Thirty-six sphincter of Oddi dysfunction patients who were confirmed endoscopic retrograde cholangiopancreatography enrolled in this study. Endoscopic sphincterotomy was performed for type I and manometry-confirmed type II sphincter of Oddi dysfunction patients with severe pain (⩾2 times/year; endoscopic sphincterotomy group). Others were treated medically (non-endoscopic sphincterotomy group). RESULTS: The short-term effectiveness rate of endoscopic sphincterotomy was 91%. The final remission rates of the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups were 86% and 100%, respectively. Symptoms relapsed after endoscopic sphincterotomy in 32% of patients. Patients in the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups had or developed functional dyspepsia in 41% and 14%, irritable bowel syndrome in 5% and 14%, and gastroesophageal reflux disorder in 14% and 0%, respectively. History or new onset of functional dyspepsia was related to recurrence on multivariate analysis. The frequency of occurrence of post-endoscopic retrograde cholangiopancreatography pancreatitis and post-endoscopic retrograde cholangiopancreatography cholangitis was high in both groups. Two new occurrences of bile duct stone cases were observed in each group. CONCLUSION: According to the treatment criteria, endoscopic and medical treatment for biliary-type sphincter of Oddi dysfunction has high effectiveness, but recurrences are common. Recurrences may be related to new onset or a history of functional dyspepsia.

Crohn's Disease with Mesalazine Allergy that Was Difficult to Differentiate from Comorbid Ulcerative Colitis.

An 18-year-old man diagnosed with ileocolonic Crohn's disease with circumferential strictures of the ascending colon started treatment with mesalazine and subsequently underwent right hemicolectomy. After surgery, the patient was started on adalimumab, and the clinical course was favorable. Nine months postoperatively, colonoscopy revealed granular mucosa with circumferential and continuous involvement from the transverse colon down to the rectum, findings which resembled ulcerative colitis. Mesalazine allergy was suspected, and the inflammatory findings resolved after discontinuing mesalazine. In patients of inflammatory bowel disease receiving mesalazine with an atypical clinical course, the possibility of mesalazine allergy must be borne in mind.

A case of gossypiboma diagnosed with transanal double-balloon enteroscopy.

Gossypiboma is an iatrogenic granuloma caused by retained surgical gauze. A 48-year-old woman with a history of cesarean section was incidentally found to have a pelvic mass on preoperative computed tomography examination for pectus excavatum. Abdominal enhanced computed tomography showed a 40-mm mass containing air in the pelvis. The mass was suspected to be continuous with the ileum. Transanal double-balloon enteroscopy showed a small fistula that was likely caused by penetration of the ileum dozens of centimeters from the ileocecal valve. A yellow-brown, movable, and fibrous body was found in the fistula. A part of the fibrous body was extracted with forceps. Pathological examination revealed that it was gauze. This is the first reported case of an asymptomatic gossypiboma penetrating the ileum that was diagnosed with double-balloon enteroscopy. Our results suggest that double-balloon enteroscopy is useful for early diagnosis of pelvic mass penetrating intestine, including gossypiboma.

Appropriate Timing of Discontinuation of Tacrolimus Therapy for Refractory Ulcerative Colitis.

BACKGROUND AND OBJECTIVES: Tacrolimus is very effective at inducing remission in patients with refractory ulcerative colitis. However, the optimal time-point for the discontinuation of tacrolimus is controversial because administration of tacrolimus for > 3 months is currently not approved for insurance reimbursement in Japan. We conducted this study to determine the optimal time of discontinuation of tacrolimus in patients with ulcerative colitis. METHODS: Of 38 patients who received tacrolimus as remission induction therapy for refractory active ulcerative colitis between 2009 and 2018, this study included 21 patients who received tacrolimus for ≥ 3 months before being switched to thiopurines. These patients were divided into two groups for analysis: the confirmed switch (CS) group (n = 13), in which tacrolimus was switched to azathioprine after endoscopic confirmation of mucosal improvement, and the mandatory switch (MS) group (n = 8), in which tacrolimus was switched to a thiopurine agent without endoscopic confirmation of improvement. RESULTS: The relapse rates after the switch to azathioprine were 23% and 88% in the CS and MS groups, respectively (p = 0.0075). No patient of the CS group underwent surgery, while 50% of patients of the MS group underwent surgery (p = 0.0117). The cumulative event-free rates at 6 months, 1 year, and 2 years were 92%, 92%, and 65%, respectively, in the CS group and 15%, 15%, and 0%, respectively, in the MS group (p < 0.0001). The incidence rate of adverse reactions was 31% in the CS group and 13% in the MS group, but there were no serious adverse reactions. CONCLUSIONS: It seems preferable to discontinue tacrolimus after endoscopic confirmation of mucosal healing. However, attention should be paid to the potential occurrence of adverse reactions associated with long-term tacrolimus therapy.

Rupture of Hepatic Pseudoaneurysm Formed Nine Years after Carbon Ion Radiotherapy for Hepatocellular Carcinoma.

An 83-year-old man with a history of carbon ion radiotherapy for hepatocellular carcinoma nine years ago presented to a primary care hospital with a fever and abdominal pain. He underwent computed tomography, which revealed the rupture of a hepatic pseudoaneurysm close to the fiducial marker for carbon ion radiotherapy and bleeding into the bile duct. He was successfully treated with transcatheter arterial embolization. Thereafter, re-rupture occurred from a site proximal to the first rupture, and this was treated similarly. It is necessary to be alert for not only tumor recurrence but also pseudoaneurysm occurrence after carbon ion radiotherapy.

A Diagnostically Challenging Case of Autoimmune Pancreatitis Due to Contamination of the Pathological Specimen with Early Gastric Cancer.

A 73-year-old man with worsened diabetes underwent abdominal computed tomography and was diagnosed with localized enlargement of the pancreatic tail. Based on the suspicion of autoimmune pancreatitis, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. A cytologic examination showed findings suggestive of adenocarcinoma. Due to discrepancies between the imaging and pathological findings, esophagogastroduodenoscopy was performed. An extensive early gastric cancer lesion was detected in the posterior wall of the gastric corpus. It was therefore likely that puncturing through the tumor resulted in the contamination with cancer tissue. The possibility of a concomitant malignancy should be considered in EUS-FNA, and thorough examinations should be conducted.

Post-ERCP biliary complications in patients with biliary type sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) has a high risk of post-ERCP pancreatitis. Cholangitis, colicky pain, and jaundice from cholestasis also occur after ERCP. However, these post-ERCP biliary complications have not been sufficiently evaluated in SOD. Thus, the risk factors and post-ERCP biliary complications in biliary-type SOD were evaluated. From December 1996 to January 2017, 72 patients with suspected biliary-type SOD were selected, and 60 patients who underwent ERCP were included in this study. The incidence of biliary complications compared to control group and factors associated with post-ERCP cholangitis were investigated. More frequent biliary complications, including biliary pain and abnormal liver function, occurred in SOD group than in control group, especially in type I SOD patients. Post-ERCP cholangitis occurred significantly more often with bile duct diameter ≥12 mm (26%, 5/19) than with bile duct diameter <11 mm (2.4%, 1/41; p = 0.016). Age ≥75 years was also a risk factor for post-ERCP cholangitis (p = 0.013). Multivariate analysis confirmed that bile duct diameter ≥12 mm was a significant risk factor for post-ERCP cholangitis. Post-ERCP biliary complications occurred frequently in biliary-type SOD, especially type I. Biliary diameter ≥12 mm was an important risk factor for post-ERCP cholangitis.