Acute pancreatitis with colon cutoff sign.

Key Clinical Message: Acute pancreatitis can present with a colon cutoff sign. The colon cutoff sign can also occur in gastric cancer, splenic artery bleeding, and ruptured abdominal aortic aneurysm. A CT scout image can also be an important laboratory finding for diagnosing a disease. Abstract: A 22-year-old woman visited our hospital with a complaint of epigastric pain. An abdominal contrast-enhanced computed tomography (CT) scan revealed that intestinal gas was interrupted at the splenic flexure on the CT scout image (colon cutoff sign). Scan images showed a poorly contrasted area in the pancreatic tail. Based on these results, the patient was diagnosed with acute pancreatitis. The colon cutoff sign is an image showing the spread of inflammation to the colon. A CT scout image can also be an important laboratory finding for diagnosing a disease.

An unusual ileocecal tumor.

We report the case of diffuse large B-cell lymphoma (DLBCL) with a fistula from the ileum to the cecum. A 57-year-old male came to the hospital complaining of abdominal pain. He underwent an abdominal computed tomography with contrast, which showed full-thickness wall thickening at the ileocecal region. He underwent a lower gastrointestinal endoscopy. No tumor was found at the ileocecal valve, and macroscopic findings were normal. The scope was advanced to the cecum, an additional outpouching was found. The outpouching appeared to be an ileocecal fistula. The diagnosis was DLBCL.

Mediastinal Primary Synovial Sarcoma With Postoperative Pericardial Recurrence in a Previously Treated Angiofibroma.

Synovial sarcoma is a malignant soft tissue tumor that often occurs near the limb joints. Here, we report a case of a patient with a synovial sarcoma that occurred in the mediastinum. The initial pathological diagnosis was suspected angiofibroma after surgical resection. After surgery, the tumor recurred in the pericardium and caused cardiac tamponade. Pericardial fenestration was performed and the patient was diagnosed with synovial sarcoma. The final diagnosis was the postoperative pericardial recurrence of the mediastinal synovial sarcoma. It is important to consider follow-up on the basis of the malignant tumor, especially if the disease is rare.

A Case of Advanced Gastric Cancer With Multiple Liver Metastases in Which Hypoglycemic Symptoms Triggered the Diagnosis.

We experienced a case of gastric cancer with multiple liver metastases characterized by frequent hypoglycemic attacks. Hypoglycemia was observed on admission. We suspected that the cause of this hypoglycemia was non-islet cell tumor hypoglycemia (NICTH). Staining of the tissue with an insulin-like growth factor (IGF)-II antibody revealed that IGF-II was present in the tumor cells. This finding suggested that the tumor was producing IGF-II, which leads to NICTH. After starting parenteral nutrition, the patient emerged from the hypoglycemic coma. He remained out of the coma until he died of liver failure.

Risk for Colorectal Cancer in Patients with Serially Positive Fecal Immunochemistry Test in an Annual Screening Program.

OBJECTIVES: There are patients who do not undergo colonoscopy even if the fecal immunochemistry test (FIT) results are positive and even with repeated positive test results the following year. We aimed to investigate colorectal cancer (CRC) risk in examinees with positive FIT results in our annual screening program. METHODS: We analyzed patients who underwent initial colonoscopy from April 2010 to March 2017 because of positive FIT results using an endoscopy database in our hospital. We investigated the difference in the risk of advanced colorectal neoplasia as a surrogate marker of CRC between those who had an initial positive test and those who had repeated positive tests. RESULTS: A total of 748 patients were included in this analysis. The advanced neoplasia detection rates were 7.6% (50/656) and 18.5% (17/92) for the initial and repeated positive test groups, respectively. Subgroup analysis of those with repeated positive tests revealed that the detection rates in examinees with positive tests 1-2 and >2 years ago were 16.7% (6/36) and 19.6% (11/56), respectively. The odds ratios for advanced neoplasia detection in patients with positive tests 1-2 and >2 years ago compared with those in the initial positive test group were 2.72 (95% confidence interval [CI], 1.04-7.10) and 3.09 (95% CI, 1.47-6.48), respectively. CONCLUSIONS: The risk of CRC appears more than doubled in patients with a repeated positive FIT result. Prompt colonoscopy is recommended for FIT-positive cases.

Cancer of Unknown Primary With Presumptive Pancreatic Cancer Treated With FOLFIRINOX.

A 52-year-old man was found to have an increase in carbohydrate antigen (CA)19-9. He underwent endoscopic ultrasound/fine needle aspiration (EUS-FNA) of the soft tissue shadow near the pancreas and was diagnosed with adenocarcinoma. The cancer was judged to be of unknown primary. Cancers of unknown primary make up 3-5% of malignant tumors, and it is difficult to determine the treatment policy. FOLFIRINOX's efficacy in cancer of unknown primary is unclear. In this case, he received chemotherapy with FOLFIRINOX. After five cycles of treatment, the best effect was stable disease (SD). However, he died about 6 months after the onset of symptoms. Pathological anatomy after death revealed that the primary lesion was in the pancreas. FOLFIRINOX may be effective for cancers of unknown primary. Pathological anatomy is important to confirm the validity of treatment. It is important to consider giving chemotherapy if there is a presumed primary tumor even if the cancer is of unknown primary.

Malignant Peritoneal Mesothelioma with Latent Tuberculosis Infection.

Malignant peritoneal mesothelioma (MPM) is a rare malignant tumor with peritoneal thickening. Tuberculous peritonitis also shows peritoneal thickening, so differentiating between the two is important but difficult if latent tuberculosis infection (LTBI) is present. We herein report a patient with MPM and LTBI. A 79-year-old man was diagnosed with peritoneal thickening on computed tomography. Interferon gamma release assay (IGRA) results were positive, suggesting tuberculous peritonitis. He underwent a laparoscopic omental biopsy and was diagnosed with MPM, which can occur together with LTBI. If peritoneal thickening is observed, an IGRA should be performed early, and the possibility of LTBI should be considered.

[Endoscopic closure of an esophago-pleural fistula resulting from a perforated esophageal ulcer due to systemic sclerosis:filling and shielding using polyglycolic acid sheets and fibrin glue].

A woman in her 70s with systemic sclerosis experienced dyspnea, and consequently, she was diagnosed with an esophago-pleural fistula, which was caused by a perforated esophageal ulcer. We administered conservative treatments including continuous pleural drainage and total parenteral nutrition. The fistula was closed but recurred, at which point we attempted to close the fistula by filling and shielding using polyglycolic acid (PGA) sheets and fibrin glue (FG). We were able to safely and smoothly fill and shield the fistula using the PGA sheets with a guidewire. We show that endoscopic closure of an esophago-pleural fistula using this technique is an effective, low-invasive treatment for gastrointestinal perforation and refractory fistulas.

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire.

BACKGROUND: This retrospective study aimed to investigate the suitable indications, methodology and long-term effect of the closure of gastrointestinal (GI) fistulas using polyglycolic acid (PGA) sheets and fibrin glue (FG) and to evaluate the usefulness of a delivery technique using a guidewire. METHODS: It involved 10 applications in six patients (median age 73 (range 53 - 78) years old, three men) with GI fistulas. A guidewire was introduced endoscopically or percutaneously into the fistula beyond the opposite orifice of the fistula with radiologic control. A tapered catheter was inserted over the guidewire, and the fistula was cleaned with an adequate quantity of saline. Subsequently, a small piece of PGA sheet was skewered onto the guidewire at the center and then pushed using the tapered catheter over the guidewire and delivered into the fistula. In cases of endoscopic procedure, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG. RESULTS: Technical success of fistula closure was achieved in all applications, and no complications were observed after the procedure. The long-term occlusion of the fistula was ultimately achieved in four of six patients at 202 - 654 days (median duration, 244 days) after the last procedure with one or two applications. CONCLUSIONS: The closure of GI fistulas using PGA sheets and FG demonstrated long-term efficacy for upper GI fistula of a certain length, and the filling technique using a guidewire ensured a safe smooth procedure.

IgG4-related Autoimmune Hepatitis with a Suspected Drug-induced Etiology.

A 69-year-old man was referred to our department with acute hepatitis. He had been newly treated with benidipine hydrochloride for two months. His blood test results were as follows: aspartate aminotransferase, 1,614 IU/L; alanine aminotransferase, 1,091 IU/L and anti-smooth muscle antibody, ×80. Needle liver biopsy specimen showed interface hepatitis with mainly lymphocytic infiltration and bridging fibrosis in the periportal area. Immunohistochemistry revealed lymphocytic infiltration positive for IgG4. We diagnosed him with IgG4-related AIH with an etiology that was suspected of being drug-induced. Oral prednisolone was started and then tapered after achieving biochemical remission. Hepatitis recurred after the cessation of steroids; however, remission was achieved with ursodeoxycholic acid.

A rare case of Goodpasture syndrome concomitant with bleeding jejunal Dieulafoy's lesion.

An 81-year-old man was diagnosed with Goodpasture syndrome (GS) because he met the criteria of positive anti-GBM antibodies, rapid progressive glomerulonephritis and pulmonary hemorrhage. After starting plasmapheresis and steroid pulse therapy, he experienced tarry stool and contrast-enhanced CT revealed an aneurysmal finding in the jejunum. Paroral enteroscopy showed a jejunal Dieulafoy's lesion (DL) with gush-out hemorrhage. Hemostasis was successfully achieved by hemoclipping, and he then experienced no re-bleeding events. GS can present as a jejunal DL, and contrast-enhanced CT is useful for investigating the etiology and site of small intestinal bleeding, which can lead to smooth, effective endoscopic hemostasis.

Endoscopic Gastrojejunostomy for Superior Mesenteric Artery Syndrome Using Magnetic Compression Anastomosis.

An 89-year-old woman who was bedridden suffered repeated vomiting due to superior mesenteric artery syndrome (SMAS). We performed gastrojejunostomy via the magnetic compression anastomosis (MCA) technique because her situation was not improved by conservative therapy and because the operative risk was high. We prepared two neodymium magnets: a flat plate-shaped magnet (15 × 3 mm) and a ring-shaped magnet of the same size. The ring-shaped magnet which passed through a guidewire was pushed to the duodenum by an endoscope over the guidewire. The duodenal stricture was balloon-dilated in front of the magnet, and the magnet was pushed all together beyond the stricture and placed at the duodenojejunal junction. Subsequently, the flat plate-shaped magnet was delivered endoscopically to the stomach using a biopsy forceps. The magnets were attracted towards each other transmurally after one more flat plate-shaped magnet was added to the gastric-side magnet. Completion of gastrojejunostomy was confirmed while retrieving the magnets 10 days after starting compression. She has been asymptomatic for 1 month since anastomosis. Endoscopic gastrojejunostomy using MCA was an effective, low-invasive treatment for SMAS.

Experience of Endoscopic Jejunojejunostomy for Anastomotic Obstruction After Subtotal Gastrectomy Using Magnetic Compression Anastomosis.

Magnetic compression anastomosis (MCA) was developed as a low-invasive treatment for gastro-enteric or entero-enteric obstruction. A 72-year-old man underwent subtotal gastrectomy with Billroth II reconstruction for early gastric cancer. After the operation, he suffered from repeated aspiration pneumonia due to anastomotic obstruction caused by jejunal kinking at the efferent loop of anastomosis. We therefore performed jejunojejunostomy via the MCA technique, as his situation was not improved despite conservative therapy and he had a high reoperative risk. We prepared two flat plate-shaped neodymium magnets (15 × 3 mm) each with a small hole, and a nylon thread was passed through each hole. Each magnet was then delivered endoscopically to the anal side of the jejunal kinking, subsequently to the anastomosis, using biopsy forceps. The two magnets immediately became attracted towards each other transmurally. Oozing hemorrhage with clot at the mated magnets was observed 10 days after starting the compression. After retrieving the magnets, we confirmed the completion of jejunojejunostomy and then successfully achieved hemostasis of the anastomotic hemorrhage using argon plasma coagulation. The widely patent anastomosis was confirmed endoscopically 1 month after canalization; and he has been asymptomatic and able to eat a normal diet ever since. Endoscopic MCA is an effective, low-invasive treatment for anastomotic obstruction after subtotal gastrectomy. A standardized, safer procedure should be established for general use in the clinical setting.

Prophylactic Biliary Stenting Before Cholecystectomy in Patients With Gallstones and Common Bile Duct Stones.

BACKGROUND: The usefulness of prophylactic biliary stenting for patients with common bile duct stones (CBDS) and gallstones (GS) to prevent recurrent biliary events after endoscopic sphincterotomy (EST) and CBDS extraction before elective cholecystectomy remains controversial. The aim of this study was to evaluate the risk of recurrent CBDS around the perioperative period and clarify its risk factors. METHODS: The clinical data of all patients who received prophylactic biliary stenting after EST for CBDS and later underwent cholecystectomy for GS followed by stent extraction in our institution were retrospectively reviewed. The numbers of residual CBDS at the end first and second endoscopic retrograde cholangiography (ERC) studies were compared. Univariate and multivariate analyses were performed using a logistic regression model to determine risk factors for recurrent CBDS in the perioperative period. RESULTS: Forty-two consecutive patients received prophylactic biliary stenting and subsequent cholecystectomy for GS. Three of these patients were excluded from this study because the number of residual stones was not confirmed. The median maximum CBDS diameter at second ERC was 0 mm (range, 0 - 10 mm); six patients had multiple CBDS (≥ 5). The number of CBDS at second ERC was increased in comparison to that at the first ERC in 15 patients (38.4%), and was unchanged or decreased in 24 patients. The median minimum cystic duct diameter was 4 mm (range, 1 - 8 mm). The median interval between first ERC and operation was 26 days (range, 2 - 131 days). The median interval between operation and second ERC was 41 days (range, 26 - 96 days). Laparoscopic cholecystectomy (LC) was performed in 38 patients, one of whom was converted from LC to open cholecystectomy. Postoperative complications (transient bacteremia) occurred in one patient. The cystic duct diameter was an independent risk factor for an increased number of CBDS at second ERC in the multivariate analysis (odds ratio 0.611 (95% confidence interval (0.398 - 0.939)), P = 0.03). CONCLUSION: Recurrent CBDS around the perioperative period of cholecystectomy is not a rare complication after EST and the removal of CBDS with concomitant GS. Prophylactic biliary stenting is considered useful for preventing CBDS-associated complications, especially for patients in whom the cystic duct diameter is larger (≥ 5 mm).

Risk of colorectal cancer for fecal immunochemistry test-positive, average-risk patients after a colonoscopy.

BACKGROUND AND AIM: Because the risk of colorectal cancer has not been well examined in fecal immunochemistry test (FIT)-positive patients who previously underwent colonoscopy, this study aimed to investigate this topic. METHODS: This was a single-center, observational study of prospectively collected data in Japan. FIT-positive, average-risk patients who underwent colonoscopy were divided into groups as follows: those who never underwent colonoscopy in the past (no colonoscopy group), those with a history of colonoscopy between 6 months and 5 years (0.5- to 5-year colonoscopy group), and those with a history of colonoscopy more than 5 years ago (> 5-year colonoscopy group). We investigated the prevalence of advanced neoplasia and invasive cancer among these groups using multiple logistic regression analysis. RESULTS: Detection rates of advanced neoplasia in the no colonoscopy group, 0.5- to 5-year colonoscopy group, and > 5-year colonoscopy group were 14.8% (240/1626), 3.9% (13/330), and 6.9% (17/248), respectively. Detection rates of invasive cancer in each aforementioned group were 5.7% (92/1,626), 0.3% (1/330), and 1.2% (3/248), respectively. Odds ratios of advanced neoplasia in the 0.5- to 5-year colonoscopy group and > 5-year colonoscopy were 0.23 (95% confidence interval [CI]: 0.13-0.42) and 0.40 (95% CI: 0.24-0.68), respectively, in multivariate analysis. The odds ratios of invasive cancer in each aforementioned group were 0.05 (95% CI: 0.01-0.37) and 0.19 (95% CI: 0.06-0.61), respectively. CONCLUSION: Re-screening with the FIT should not be recommended for at least 5 years for average-risk patients after colonoscopy without high-risk neoplasms, because the risks of colorectal cancer are low in such patients.

[Subcapsular hepatic hematoma due to vessel injury from the rigid portion of a guidewire during endoscopic retrograde cholangiopancreatography].

A 58-year-old male receiving two types of antithrombotic medication developed acute obstructive suppressive cholangitis due to choledocholithiasis. During the first endoscopic retrograde cholangiopancreatography (ERCP) procedure, we performed biliary plastic stenting. Seven days after this procedure and with continued antithrombotic treatment, we performed ERCP with endoscopic sphincterotomy and stone extraction. Twelve hours after this procedure, the patient suffered transient unconsciousness and progression of anemia. Sixty hours after the procedure, he experienced right hypochondralgia and hiccups. Ultrasonography and computed tomography revealed a subcapsular hepatic hematoma. Bleeding was successfully arrested with selective arterial embolization. We suspected that the cause of these problems was vessel injury from the rigid portion of the guidewire during the ERCP procedure.

Endoscopic closure of an anastomo-cutaneous fistula: Filling and shielding using polyglycolic acid sheets and fibrin glue with easily deliverable technique.

Background and study aims Recently, endoscopic closure of gastrointestinal fistulas using polyglycolic acid (PGA) sheets with fibrin glue (FG) has been attempted. A 70-year-old woman who had undergone pancreaticoduodenectomy for pancreatic cancer suffered from a refractory anastomo-cutaneous fistula at the site of gastro-jejunostomy. We attempted endoscopic closure with filling and shielding using PGA sheets and FG. After introducing a guidewire into the fistula, a small piece of PGA sheet was skewered onto the guidewire and then pushed using a tapered catheter over the guidewire and delivered into the fistula. A total of 10 sheets were delivered via the same procedure. Next, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG. After this procedure, the leakage disappeared and the fistula was undetectable on contrast radiograms. Endoscopic closure of anastomo-cutaneous fistula with filling and shielding using PGA sheets and FG is an effective, safe, low-invasive treatment, and the filling technique using a guidewire ensures a safe, smooth procedure.

[Screening for colorectal cancer using immunological fecal occult blood test in inpatients].

We investigated the usefulness of screening for colorectal cancer (CRC) using immunological fecal occult blood test (FOBT) in 472 scheduled inpatients (median age, 68.6 years) who underwent screening for CRC via FOBT (single stool sample) at our hospital. The recall rate for further examination was 26.6% (126/472), and the rate of patients who underwent further examination was only 34.9% (44/126). The overall colorectal neoplasm detection rate, overall CRC detection rate, and positive predictive value for CRC in inpatients were 5.5% (26/472), 1.4% (7/472), and 5.5% (7/126), respectively, which were higher than those of population-based screening for CRC. Screening for CRC using FOBT in inpatients is a non-invasive and efficient method to detect latent CRC.