Current status of portal vein thrombosis in Japan: Results of a questionnaire survey by the Japan Society for Portal Hypertension.

AIM: To investigate the current status of portal vein thrombosis (PVT) in Japan, the Clinical Research Committee of the Japan Society of Portal Hypertension undertook a questionnaire survey. METHODS: A questionnaire survey of 539 cases of PVT over the previous 10 years was carried out at institutions affiliated with the Board of Trustees of the Japan Society of Portal Hypertension. RESULTS: The most frequent underlying etiology of PVT was liver cirrhosis in 75.3% of patients. Other causes included inflammatory diseases of the hepatobiliary system and the pancreas, malignant tumors, and hematologic diseases. The most frequent site was the main trunk of the portal vein (MPV) in 70.5%, and complete obstruction of the MPV was present in 11.5%. Among the medications for PVT, danaparoid was given to 45.8%, warfarin to 26.2%, heparin to 17.3%, and anti-thrombin III to 16.9%. Observation of the course was practiced in 22.4%. Factors contributing to therapeutic efficacy were implementation of various medications, thrombi localized to either the right or left portal vein only, non-complete obstruction of the MPV and Child-Pugh class A liver function. A survival analysis showed that the prognosis was favorable with PVT disappearance regardless of treatment. CONCLUSION: The questionnaire survey showed the current status of PVT in Japan. Any appropriate medication should be given to a patient with PVT when PVT is recognized. It is necessary to compile a large amount of information and reach a consensus on safe and highly effective management of PVT.

Balloon-occluded retrograde transvenous obliteration using a new microballoon for gastric varices.

We here present a case involving a complicated type of gastric fundal varices treated by balloon-occluded retrograde transvenous obliteration. A newly developed 1.8-Fr tip coaxial microballoon catheter was successfully advanced into narrow and tortuous varices, and a sclerosant could be infused in a reasonable manner, avoiding reflux into collaterals. Divided injections of sclerosant were performed over two days, via a microballoon catheter that remained inserted overnight with balloon inflation, and the sclerosant could be infused sufficiently in the entirety of the varices. The varices were completely thrombosed and prominently reduced.

Balloon-occluded arterial stump pressure before balloon-occluded transarterial chemoembolization.

OBJECTIVE: To evaluate balloon-occluded arterial stump pressure (BOASP), which is responsible for effective balloon-occluded transarterial chemoembolization (B-TACE), at each hepatic arterial level before B-TACE using a 1.8-French tip microballoon catheter for unresectable hepatocellular carcinoma (HCC). MATERIAL AND METHODS: The BOASP at various embolization portions was retrospectively investigated. "Selective" and "non-targeted" BOASP was defined as the BOASP at the subsegmental or segmental artery and the lobar artery, respectively. RESULTS: The measurement of the BOASP was carried out in 87 arteries in 47 patients. BOASP > 64 mmHg was revealed in the caudate lobe artery (A1) and the left medial segmental (A4), right anterior superior segmental (A8), anterior segmental, right and left hepatic arteries. Significant difference was noted in the incidence of BOASP above 64 mmHg between "non-targeted" and "selective" BOASP (p = 0.01). "Non-targeted" BOASP was significantly greater than "selective" BOASP (p = 0.0147). In addition, the BOASP in A1, 4, 8 and the anterior segmental arteries were significantly greater than in the other subsegmental and segmental arteries (p = 0.0007). CONCLUSION: "Non-targeted" B-TACE should be avoided to perform effective B-TACE and "selective" B-TACE at A1, 4, 8 and the anterior segmental arteries may become less effective than at the other segmental or subsegmental arteries.

Balloon-occluded transarterial chemoembolization using a 1.8-French tip coaxial microballoon catheter for hepatocellular carcinoma: technical and safety considerations.

OBJECTIVE: To evaluate the technical feasibility and safety considerations of balloon-occluded transarterial chemoembolization (B-TACE) using a newly developed 1.8-French (Fr) tip microballoon catheter for hepatocellular carcinoma (HCC). MATERIAL AND METHODS: Between February 2013 and May 2013, 31 patients (20 males, 11 females; age range 56-85 years) underwent B-TACE using a 1.8-Fr tip microballoon catheter for unresectable HCC. The technical success rate, procedural complications, and adverse events of B-TACE were retrospectively investigated. RESULTS: A total of 31 patients were subjected to 70 sessions of B-TACE using a 1.8-Fr tip microballoon catheter. The level of B-TACE was sub-subsegmental in 11, subsegmental in 35, segmental in 14, lobar in five, and right inferior phrenic artery in five sessions. The overall technical success rate was 99% (69 out of 70 sessions). As procedural complications, rupturing of the microballoon (n = 3) and aneurysmal dilatation at the site of balloon occlusion (n = 2) were encountered. There were no significant differences in any parameters between blood biochemical examination before and between two to four weeks after the procedure. CONCLUSION: A 1.8-Fr tip microballoon catheter enables selective catheterization in patients with HCC and B-TACE using the 1.8-Fr tip microballoon catheter is a safe procedure.

The Influence of Drinking Based on Data from Health Check-up.

A survey of 21,493 patients who visited our Health Check-up Center during the 6-year period from 2005 to 2010 was conducted for the endpoints of drinking situation and various lifestyle-related diseases. Males accounted for 57.2% (mean age: 53.2 ± 11.4) and females accounted for 42.8% (mean age: 52.5 ± 11.4) of patients surveyed. Patients with no drinking habit accounted for 24.8% and 62.9% of males and females, respectively, and a large gender difference was seen in drinking frequency. When examined by age group, drinking frequency was found to increase with age in males, but gradually decreased with age in females. An examination of alcohol consumption in males revealed that 23.5% had an ethanol conversion rate of 10 g/day, 19.1% had a rate of < 20 g/day, and 18.2% had a rate of < 40 g/day. Meanwhile, in females, 22.7% had a rate of ≤ 10 g/day, 7.6% had a rate of ≤ 20 g/day and 4.6% had a rate of ≤ 40 g/day. The association between lifestyle-related disease endpoints and alcohol consumption was next examined by multivariate logistic analysis. The association between drinking and body mass index (BMI) revealed an odds ratio of around 0.8 in patients who consumed ≤ 40 g/day and a significantly reduced frequency of obesity. The odds ratio of hypertension increased in a dose-dependent manner from 1.3 to 1.6 in patients who consumed ≥ 40 g/day. The frequency of high low-density lipoprotein cholesterol (LDL-C) was reduced in light drinkers and the odds ratio decreased from 0.77 to about 0.6 as alcohol consumption increased: The frequency of low high-density lipoprotein cholesterol (HDL-C) was similarly reduced in light drinkers, and the odds ratio decreased remarkably in a dose-dependent manner from 0.73 to 0.22 as alcohol consumption increased. The risk of triglycerides was reduced in light drinkers and was conversely significantly enhanced in heavy drinkers. In patients who consumed ≥ 20 g/day, the risk of impaired glucose tolerance increased significantly in a dose-dependent manner. Increased risk of hyperuricemia was seen even in light drinkers. and the odds ratio increased from 1.2 to 1.8 as alcohol consumption increased. The results of this cross-sectional study suggested that light drinking has a positive effect on BMI, LDL-C, HDL-C and triglycerides. On the other hand, heavy drinking was found to have a positive effect on LDL-C and HDL-C, but a negative effect on systolic blood pressure, triglycerides, fasting blood glucose and uric acid.

[The outcome of patients with alcoholic liver cirrhosis].

We investigated the outcome of the patients with alcoholic liver cirrhosis who had visited our hospital from 2007 to 2013. We compared them with the patients with type C liver cirrhosis, matched in gender and in age. The patients with alcoholic liver cirrhosis who dropped out accounted for 19.3% (17 cases) of the whole. In 401 days of mean treatment period, the median value of the dropout patients was 43 days, indicating that a number of the patients dropped out in an early stage. The percentage of abstinence from alcoholic drinking was 35.3% in the dropout groups, whereas it was 67.6% in the non-dropout groups. It was conceivable that the abstinence was difficult for the dropout groups to perform. The percentage of the dropout in patients receiving livelihood protection was 35.7%, which was higher than that in general patients. There were no differences of the rate of dropout in general patients between alcoholic and type C liver cirrhosis. Since none of the patients with type C liver cirrhosis receiving livelihood protection dropped out, it was speculated that the cause of liver cirrhosis may be related to the rate of dropout. In summary, a number of patients with alcoholic liver cirrhosis have a difficulty in abstinence from alcoholic drinking. We also have to be careful to the high rate of dropout in patients with alcoholic liver cirrhosis receiving livelihood protection. In addition, it was thought that early incentive and education were important for these patients.

Partial splenic embolisation using n-butyl cyanoacrylate: intraprocedural evaluation by magnetic resonance imaging.

OBJECTIVES: To evaluate the use of diffusion-weighted imaging (DWI) for estimating infarcted splenic volume during partial splenic embolisation (PSE) using n-butyl cyanoacrylate (NBCA). METHODS: Twenty consecutive patients (57.2 ± 11.7 years) with hypersplenism underwent PSE. Intrasplenic branches were embolised using NBCA via a 2.1-French microcatheter aiming at infarction of 50 to 80 % of total splenic volume. Immediately after PSE, signal intensities (SI) of embolised and non-embolised splenic parenchyma were measured on DWI. Semi-automated volumetry (SAV) on DWI was compared with conventional manual volumetry (MV) on contrast-enhanced CT 1 week after PSE. Platelet counts were recorded before and after PSE. RESULTS: The SI on DWI in the embolised parenchyma decreased significantly (P < 0.01) to 24.7 ± 8.1 % as compared to non-embolised parenchyma. SAV and MV showed a strong correlation (r = 0.913 before PSE, r = 0.935 after PSE, P < 0.01) and significant (P < 0.01) reduction of normal splenic volume was demonstrated on both SAV (71.9 ± 12.4 %) and MV (73.6 ± 9.3 %) after PSE. Based on the initial SAV, three patients (15 %) underwent additional branch embolisation to reach sufficient infarction volume. Platelet counts elevated significantly (522.8 ± 209.1 %, P < 0.01) by 2 weeks after PSE. No serious complication was observed. CONCLUSION: Immediate SI changes on DWI after PSE allowed semi-automated splenic volumetry on site. KEY POINTS: • Partial splenic embolisation (PSE) is an important interventional technique for hypersplenism • Diffusion-weighted MR reveals an immediate decrease in signal in the embolised parenchyma • Such signal reduction permits semi-automated splenic volumetry on site. • This allows precise quantification of the amount of parenchyma infarcted, avoiding additional PSE.

Senescent case of cholesterol ester storage disease that progressed to liver cirrhosis with a novel mutation (N250H) of lysosomal acid lipase gene.

The patient, a 69-year-old man, had a chief complaint of hepatomegaly. The liver was palpated four fingerbreadths below the costal margin, and the spleen was three fingerbreadths below the costal margin. There were no other abnormal findings. Laparoscopy showed that the liver resembled an orange-yellow crayon in appearance and was nodular. The pathological findings of the liver biopsy tissue were consistent with liver cirrhosis. Inside the fibrous septum was an apparent aggregation of enlarged macrophages that phagocytosed lipid components, as well as enlarged Kupffer cells that phagocytosed lipid droplets. Electron microscopy showed the lipid droplets to have a moth-eaten appearance. Using monocytes extracted from the peripheral blood, acid lipase activity was measured by fluorescence spectrometry using 4-methylumbelliferone palmitate as a substrate. This patient's human lysosomal acid lipase activity was 0.020 nM/min per 10(6) cells, corresponding to 5.9% of that in healthy subjects (0.332 ± 0.066 nM/min per 10(6) cells). Cholesterol ester storage disease was therefore diagnosed. The acid lipase A base sequence obtained from leukocytes by direct sequencing was compared with a library. This patient had a point mutation of N250H/N250H in exon 7, a novel gene abnormality that has not previously been reported.

Meloxicam as an adjuvant to peginterferon-α-2a and ribavirin treatment for genotype 1 chronic hepatitis C: A randomized trial.

AIM: In this multicenter, randomized trial, we evaluated the effectiveness of meloxicam - a non-steroidal anti-inflammatory drug - as an adjuvant for enhancing antiviral efficacy and preventing neutropenia during the treatment of patients with genotype 1 chronic hepatitis C using peginterferon and ribavirin. METHODS: A total of 60 patients were randomly assigned, in a 1:1 ratio, to either the meloxicam or the control group after stratification by neutrophil count. Both groups received weekly peginterferon-α-2a (180 µg) and a weight-based dose of ribavirin for 48 weeks. The meloxicam group received meloxicam (10 mg/day) for the first 8 weeks after initiation of treatment. RESULTS: Through intent-to-treat analysis, we found that the sustained virological response rate in the meloxicam group (19/30, 63.3%) was significantly higher than in the control group (11/30, 36.7%, P < 0.05). The relapse rate was more than twice as high (45%) in the control group than in the meloxicam group (19.0%); however, this difference was not statistically significant. The rate of neutrophil decrease, calculated by dividing the lowest value observed during the first 8 weeks by pretreatment count, was significantly smaller in the meloxicam group (55.1 ± 14.3%) than in the control group (62.3 ± 9.6%, P < 0.05). CONCLUSION: Meloxicam enhanced antiviral efficacy and reduced the decline in neutrophil counts for the peginterferon and ribavirin treatment of genotype 1 chronic hepatitis C. This drug could be a reasonable adjuvant for the treatment of patients with chronic hepatitis C. The present study including a small number of patients warrants larger clinical trials.

Carbon dioxide (CO2) vs iodinated contrast digital subtraction angiography during balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerosant for gastric varices.

PURPOSE: To compare the visualization of the target gastric varices (GV) on balloon-occluded retrograde transvenous venography (BRTV) using iodinated contrast material vs carbon dioxide (CO(2)) in preparation for subsequent balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerotherapy. MATERIALS AND METHODS: In 16 consecutive patients with nonruptured GV, BRTV was performed first using iodinated contrast material and then with CO(2). BRTV was repeated whenever there were changes in the catheter or patient position or when coil embolization of collaterals was needed. Each visualization grade of GV (grade 1 = GV only; grade 2 = GV > collaterals; 3 = GV < collaterals; grades 4-5 = collaterals only) was determined by two observers in consensus. During foam BRTO, the GV visualization grade was recorded again and confirmed by C-arm computed tomography (CT). RESULTS: In 38 pairs of BRTV, GV grades were significantly (P < .0001) lower (ie, favoring BRTO) on CO(2) BRTV (mean ± standard deviation, 1.8 ± 0.8) than on iodine BRTV (3.4 ± 0.8). GV grades on foam BRTO (1.4 ± 0.7) were similar to the grades obtained on the most recent CO(2) BRTV (1.3 ± 0.5) but were significantly smaller (P < .0001) than on iodinated BRTV (3.1 ± 0.9). GV were opacified by foam on initial C-arm CT in 14 patients (87.5%), and complete thrombosis of GV was obtained without any complication in all 16 patients (100%). CO(2) reached the GV even when iodinated contrast material could not (grade 4) in seven of our 16 patients (43.8%), leading to successful BRTO. CONCLUSIONS: CO(2) BRTV visualized GV better than did iodine BRTV and changed the management of more than 40% of patients by enabling successful foam BRTO in patients in which conventional liquid BRTO could not be performed.

Incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures.

PURPOSE: To investigate the incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures and to determine the risk factors for this combination. METHODS: We retrospectively analyzed 161 consecutive patients with 170 distal radius fractures who were treated between 2007 and 2011. Posteroanterior, lateral, and oblique radiographs of the wrist were examined, as were computed tomography scans when available. We evaluated the incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures and the patient factors of gender, age, AO/ASIF classification, and energy of the injury. RESULTS: Of the 170 distal radius fractures, 11 (7%) also had 1 or 2 carpal fractures. Of the 15 carpal fractures, 8 were scaphoid, 2 triquetrum, 2 pisiform, 1 capitate, 1 trapezium, and 1 hamate. Eleven of the 15 carpal fractures were diagnosed by computed tomography alone. Male gender, patients of lower mean age, AO/ASIF type B, and high-energy trauma significantly raised the risk of simultaneous fractures of the distal radius and carpals. CONCLUSIONS: The incidence of carpal fractures occurring concurrently with distal radius fractures was not negligible, and almost all carpal fractures had no or minimal displacement. Suspicion of carpal fractures occurring concurrently with distal radius fracture should be high, and computed tomography should be considered, in males, young patients, and those with AO/ASIF type B fractures and high energy trauma.

Analysis of Comorbidity for Patients with Pancreatic Cysts in Medical Checkup Screening.

OBJECTIVES: We investigated whether there is a difference in the frequency of comorbidity between patients with pancreatic cysts and those without pancreatic cysts by abdominal ultrasonography in patients undergoing medical checkup screening. METHODS: The subjects were 6,627 patients who underwent abdominal ultrasonography at Tokai University Hachioji Hospital's Health Screening Center between April 2019 and March 2020. RESULTS: Of the total 6,627 patients, 158 (2.4%) were pointed out to have pancreatic cysts. Multivariate analysis revealed that the related factors were female sex, age 60 years or older, diabetes, lung cancer, and uterine/ovarian cancer. CONCLUSION: Unlike pancreatic cancer, pancreatic cysts are more common in women. In addition, it is known that pancreatic cysts have a high complication rate of cancers of other organs; lung cancer and uterine/ovarian cancer were identified as high-risk factors in this study.

Antiviral Therapy for Patients Chronically Infected with Hepatis C Virus at Tokai University Hospital.

OBJECTIVE: Hepatitis C virus (HCV) was identified in 1989. In 2020, three decades after HCV identification, three researchers won the Nobel Prize in Physiology or Medicine for the discovery of this virus. In 1992, three years after the discovery, interferon (IFN) was launched as the first anti-HCV therapy in Japan; however, the efficacy of IFN therapy was far from acceptable due to severe adverse effects. The advent of IFN-free direct-acting antivirals (DAAs) in 2014 dramatically improved the outcomes of antiviral treatment without serious adverse effects. In this study, we aimed to summarize anti-HCV therapy at the Tokai University Hospital. METHODS: We identified patients who underwent anti-HCV therapy by searching medical records from January 1992 to December 2020, analyzed their background, and compared safety and efficacy among treatments. RESULTS: A total of 1777 treatments were given to 1299 patients. The sustained virologic response rate has dramatically increased over the past 30 years, with only 7% for IFN monotherapy and 95% or higher for recent IFN-free DAA therapies. CONCLUSIONS: We documented the results of anti-HCV therapy at the Tokai University Hospital. In the 30 years since the discovery of HCV, surprisingly successful progress has been accomplished in the anti-HCV treatment.

Primary Sclerosing Cholangitis Complicated with Aphthoid Colitis Difficult to Diagnose from IgG4-Related Sclerosing Cholangitis.

A 19-year-old man visited our hospital because of diarrhea and blood and liver dysfunction. Magnetic and endoscopic retrograde cholangiography revealed diffuse narrowing of the common biliary tract and intrahepatic biliary tract. A biopsy specimen from the narrowed area of the common biliary tract revealed IgG4-related sclerosing cholangitis (IgG4-SC). Colonoscopy showed multiple aphthoid colitis. He was treated with corticosteroids, and the levels of hepatobiliary enzymes, IgG, and IgG4 gradually decreased. This is an extremely rare case of colitis in which the patient had a phenotype of sclerosing cholangitis similar to IgG4-SC, which was finally diagnosed as primary sclerosing cholangitis.

A Case of Lupus Enteritis in Which Multiple Colorectal Ulcers Were the Only Signs of Relapse.

The patient was a 62-year-old woman. She had been treated for systemic lupus erythematosus (SLE) for 15 years and had a stable clinical course with cyclosporine, prednisolone, and ticlopidine. She experienced anal pain, diarrhea, and bloody stools for four months. Colonoscopy showed scattered large and small punchedout ulcers in the colon and deep longitudinal ulcers in the sigmoid colon. Blood test results indicated low SLE activity. Culture of mucosal biopsy did not reveal any findings. Computed tomography showed intestinal membrane arteriovenous dilatation (comb sign), therefore lupus enteritis was suspected. After initiating endoxan pulse therapy, symptoms improved rapidly. Disappearance of ulcers was confirmed by endoscopic images.

Posterior reversible encephalopathy syndrome (PRES) caused by chemotherapy containing S-1 against diffuse type gastric cancer.

A 23-year-old woman who complained of abdominal distension and anorexia was referred to our hospital. Computed tomography showed ascites, a huge hepatic tumor and ovarian tumor. Gastroscopy revealed type 4 gastric cancer and biopsy examination showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. We diagnosed her with stage IV advanced gastric adenocarcinoma. She received the chemotherapy with S-1 and CDDP regimen. After two courses, this regimen was changed to the SOX (S-1 + OHP) regimen because of acute kidney injury. After one course of the SOX regimen, she developed general muscle cramp. Magnetic resonance imaging showed a 15 mm, round, high-intensity signal at the parietal lobe on T2-weighted images. She was hospitalized for with the suspicion of brain metastasis. Anticonvulsants improved her muscle cramp, but she had consciousness disturbance on the 9th hospital day. T2WI showed high-intensity signals within the cerebral white matter at both sides of the occipital lobe. We suspected leukoencephalopathy caused by S-1 and discontinued the SOX regimen. We also treated her hypertension and hyponatremia. Her consciousness disturbance improved in several days, and the T2WI finding was markedly improved on the 20th hospital day. We diagnosed her with posterior reversible encephalopathy syndrome caused by chemotherapy containing S-1.

A potential pathogenic association between periodontal disease and Crohn's disease.

Oral conditions are relatively common in patients with inflammatory bowel disease (IBD). However, the contribution of oral maladies to gut inflammation remains unexplored. Here, we investigated the effect of periodontitis on disease phenotypes of patients with IBD. In all, 60 patients with IBD (42 with ulcerative colitis [UC] and 18 with Crohn's disease [CD]) and 45 healthy controls (HCs) without IBD were recruited for this clinical investigation. The effects of incipient periodontitis on the oral and gut microbiome as well as IBD characteristics were examined. In addition, patients were prospectively monitored for up to 12 months after enrollment. We found that, in both patients with UC and those with CD, the gut microbiome was significantly more similar to the oral microbiome than in HCs, suggesting that ectopic gut colonization by oral bacteria is increased in patients with IBD. Incipient periodontitis did not further enhance gut colonization by oral bacteria. The presence of incipient periodontitis did not significantly affect the clinical outcomes of patients with UC and CD. However, the short CD activity index increased in patients with CD with incipient periodontitis but declined or was unchanged during the study period in patients without periodontitis. Thus, early periodontitis may associate with worse clinically symptoms in some patients with CD.

C-arm CT-guided foam sclerotherapy for the treatment of gastric varices.

The authors describe here the use of foam sclerotherapy under C-arm computed tomography (CT) guidance for the treatment of gastric varices via balloon-occluded retrograde transvenous obliteration in seven patients and percutaneous transhepatic obliteration in one patient. All gastric varices were occluded successfully after replacement of blood by foam, which was trapped in the gastric varices as shown by C-arm CT. It also helped reduce the amount of sclerosant, an issue that is associated with severe complications, such as hemolysis, allergy, acute respiratory distress syndrome, and others. Foam sclerotherapy under C-arm CT guidance is a promising tool in the therapeutic armamentarium against gastric varices.

Altered expression of a putative progenitor cell marker DCAMKL1 in the rat gastric mucosa in regeneration, metaplasia and dysplasia.

BACKGROUND: Doublecortin and calcium/calmodulin-dependent protein kinase-like-1 (DCAMKL1) is a candidate marker for progenitor cells in the gastrointestinal mucosa. Lineage cells in the gastric mucosa are derived from progenitor cells, but this process can be altered after injury. Therefore, we explored DCAMKL1 expression under pathological conditions. METHODS: An immunohistochemical analysis was performed in rat stomach with acute superficial injury, chronic ulcer, intestinal metaplasia and dysplasia. RESULTS: DCAMKL1 was exclusively expressed in immature quiescent cells in the isthmus of normal fundic glands, where putative progenitor cells are thought to reside. DCAMKL1-positive cells and proliferating cells shed into the lumen after superficial injury and re-appeared during the regenerative process, mainly in the superficial mucosa. In the marginal mucosa around the active ulcer, parietal and chief cells diminished, foveolar hyperplasia was evident, and trefoil factor family 2 (TFF2)/spasmolytic polypeptide-expressing metaplasia (SPEM) emerged at the gland base. DCAMKL1 cells re-emerged in the deep mucosa juxtaposed with SPEM and proliferating cells. In the healing ulcer, the TFF2 cell population expanded and seemed to redifferentiate to chief cells, while proliferating cells and DCAMKL1 cells appeared above and below the TFF2 cells to promote healing. SPEM appeared and PCNA cells increased in the intestinalized mucosa, and DCAMKL1 was expressed in the proximity of the PCNA cells in the deep mucosa. DCAMKL1, PCNA and TFF2 were expressed in different dysplastic cells lining dilated glands near SPEM. CONCLUSION: The ultrastructural appearance of DCAMKL1-positive cells and the expression patterns of DCAMKL1 in normal and pathological states indicate that the cells belong to a progenitor cell population. DCAMKL1 expression is closely associated with TFF2/SPEM cells after injury. DCAMKL1 cells repopulate close to proliferating, hyperplastic, metaplastic and dysplastic cells, and the progenitor zone shifts according to the pathological circumstances.