Modified BEST-J Score Model Predicts Bleeding after Endoscopic Submucosal Dissection with Fewer Factors.

This study constructed a simplified post-endoscopic submucosal dissection (ESD) prediction model with a prognostic nutritional index (PNI). A total of 449 patients who underwent gastric ESD was included, divided with a ratio of 2:1, and assigned to the model or validation cohort. A prediction model of post-ESD (modified BEST-J score) was constructed using the model cohort. The modified BEST-J score was evaluated by comparing its accuracy to the BEST-J score in the validation cohort. Within 4 weeks of ESD, melena, hematemesis, or a 2 g/dL or greater decrease in hemoglobin level that required esophagogastroduodenoscopy was defined as post-ESD bleeding. In the model cohort, 299 patients were enrolled and 25 (8.4%) had post-ESD bleeding. Independent risk factors for post-ESD bleeding were use of P2Y12RA, tumor size > 30 mm, location of lesion at lower one-third of the stomach, and PNI ≤ 47.9. Constructing the modified BEST-J score based on these variables, the sensitivity, specificity, and positive likelihood ratio were 73.9%, 78.1%, and 3.37. When comparing the modified BEST-J score to the BEST-J score in the validation cohort, no significant difference was observed by ROC-AUC (0.77 vs. 0.75, p = 0.81). Modified BEST-J score can predict post-ESD bleeding more simply, with the same accuracy as the BEST-J score.

Obstructive cholangitis by mucus from an intraductal papillary mucinous neoplasm with pancreatobiliary fistula treated by endoscopic septotomy and direct peroral cholangioscopy: a case report.

Intraductal papillary mucinous neoplasms (IPMNs) occasionally form a fistula to adjacent organs, resulting in obstructive jaundice and cholangitis due to mucus obstruction. Although some procedures such as endoscopic nasobiliary drainage are attempted, they often do not work adequately because of high mucus viscosity. Herein, we report the case of an 87-year-old man with obstructive cholangitis treated by endoscopic septotomy and mucus suction with direct peroral cholangioscopy using conventional endoscopy. The patient incidentally showed a branched-type IPMN in the pancreatic head on computed tomography (CT) approximately 10-years ago. Although the patient's tumor had grown slowly and he occasionally developed cholangitis, he did not want surgery. He was admitted to our hospital because of cholangitis by mucus obstruction with a PB fistula. Endoscopic retrograde cholangiopancreatography (ERCP) and septotomy were performed. Septotomy made the duodenal papilla a large orifice, thereby facilitating spontaneous drainage of mucus. In addition, conventional endoscopy with a large working channel enabled direct access into the orifice and smooth mucus suction, thereby alleviating his cholangitis. In conclusion, septotomy and direct peroral cholangioscopy using conventional endoscopy could be useful to control biliary tract infection and obstructive jaundice due to mucus obstruction from an IPMNs with PB fistula.

[Case report:multiple gastrointestinal stromal tumors of the small intestine associated with von Recklinghausen disease].

Abdominal ultrasonography revealed a low echoic mass in the upper abdomen of a 65-year-old man. He was referred to our department, where abdominal CT revealed a tumor with a 30-mm contrast effect on the distal side of the inferior part of the duodenum. Endoscopy revealed a submucosal tumor in the same region, and ultrasonic endoscopy showed a low echoic mass with a clear boundary derived from the muscle layer. The duodenum was partially resected based on a diagnosis of suspected gastrointestinal stromal tumors (GIST), and the skin tumor was simultaneously resected. An elastic, soft, 30-mm tumor mass was found in the upper duodenum during surgery, and small nodules of 3-5mm were identified throughout the 110-cm length of the jejunum at intervals of 20-30cm. The histopathological diagnosis was GIST and immunostaining showed the mass to be c-kit and CD34 positive. We diagnosed the skin tumor as a neurofibroma (von Recklinghausen disease). Mutational analysis of c-kit in the resected specimen showed no mutation, therefore suggesting that imatinib would not be effective. Since the nodules remaining in the small intestine might also be GIST, we established a policy of regular imaging assessments.

Case of pseudo-Meigs' syndrome caused by gastric cancer-related metastatic ovarian tumor with prolonged survival.

A 48-year-old woman presented with bilateral enlarged ovaries, ascites, bilateral pleural effusion, and advanced gastric cancer. Pleural fluid cytology did not reveal malignant cells. Oophorectomy, performed as a palliative procedure, was followed by rapid resolution of the pleural effusion and ascites. The patient was diagnosed with pseudo-Meigs' syndrome, and underwent chemotherapy followed by partial gastrectomy. At the last follow-up, 84 mo following oophorectomy, she was alive, and free of disease recurrence, despite not receiving any further treatment. Pseudo-Meigs' syndrome should be considered in patients with bilateral ovarian tumors, ascites and pleural effusion, and treatment such as oophorectomy may result in symptomatic improvement and better prognosis in similar patients.

Three cases of mediastinal pancreatic pseudocysts.

A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP), which is caused by tracking of pancreatic fluids through anatomical openings of the diaphragm into the mediastinum. Herein, we report the imaging characteristics of three cases of this condition. Our results revealed three features in common: (i) the connection between the mediastinum and the pancreatic cystic lesion; (ii) the presence of pleural effusions; and (iii) imaging findings consistent with chronic pancreatitis, such as pancreatic atrophy and calcifications and dilatation and/or stricture of main pancreatic duct (MPD). Serial diameter changes of the MPD and of the adjacent pseudocysts were necessary for the determination of the therapeutic strategy used in each case.

[Case of villous tumor of the rectum presenting with severe diarrhea and electrolyte depletion syndrome].

A 83-year-old man with a 2-year history of diarrhea was admitted hospital because of increased diarrhea and general fatigue. He had severe dehydration, hyponatremia, hypokalemia and hypochloremia. Abdominal CT showed tumor and fluid in the rectum. Colonoscopy revealed large tumor with a villous structure in the rectum. Low anterior resection was performed. The histopathological diagnosis was adenocarcinoma with villous adenoma. The immunostaining of the tumor revealed positive COX-2 expression. The diarrhea and electrolyte disturbance disappeared after the resection of tumor.

Extracellular matrix metabolism-related gene expression in bile duct-ligated rats.

Bile duct-ligated rats have been widely used as a model of cholestatic liver fibrosis. The aim of this study was to analyze the sequential expression of extracellular matrix (ECM) metabolism-related genes in these rats. We analyzed the intrahepatic messenger RNA (mRNA) expression of several ECM metabolism-related genes: transforming growth factor ß1 (TGF-ß1), connective tissue growth factor (CTGF), procollagen-α1 (collagen-I), matrix metalloproteinase (MMP)-2, MMP-13 and tissue inhibitor of metalloproteinases (TIMP)-1 on days 10, 21 and 42 after bile duct ligation (BDL). A DNA microarray was used to evaluate the expression of genes related to early fibrogenesis on day 10 following BDL; the grade of hepatic fibrosis was found to gradually progress from day 10 to 42. Collagen-I mRNA expression significantly increased from day 10 to day 42, as did TGF-ß1 and CTGF mRNA. On the other hand, MMP-13 and -2 mRNA expression increased maximally from day 10 to 21, but tended to decrease by day 42. TIMP-1 mRNA expression was significant on day 21 and was sustained until day 42. The DNA microarray revealed genes significantly increased on day 10, including calgranulin B, solute carrier family 34, thymosin and tubulin, but not fibrogenesis-related cytokines or MMPs/TIMPs. In conclusion, the enhanced gene expression of collagen-I, TGF-ß1, CTGF and TIMP-1 and the decreased gene expression of MMP-13 and -2 was noted on day 42 in BDL-induced liver fibrosis.

Preventative and therapeutic effects of perindopril on hepatic fibrosis induced by bile duct ligation in rats.

The aim of this study was to examine the preventative and therapeutic effects of an angiotensin-converting enzyme inhibitor, perindopril, on cholestasis-induced liver fibrosis. Perindopril was administered orally for 21 days immediately after bile duct ligation at a dose of 2 mg/kg in order to evaluate the preventative effects, and for 21 days starting 3 weeks after bile duct ligation at doses of 2 and 8 mg/kg in order to evaluate the therapeutic effects. With regard to the preventative effects, perindopril reduced the hepatic hydroxyproline content by 33%, collagen-I mRNA by 38%, α-smooth muscle actin (α-SMA)-positive cells by 46%, α-SMA mRNA by 40%, transforming growth factor-ß1 (TGF-ß1) mRNA by 21% and connective tissue growth factor (CTGF) mRNA by 27%. With regard to the therapeutic effects, at 2 mg/kg perindopril had no inhibitory effects on the progression of liver fibrosis, but at 8 mg/kg, it reduced hepatic hydroxyproline contents by 63%, collagen-I mRNA by 94%, TGF-ß1 mRNA by 79%, CTGF mRNA by 97% and tissue inhibitor of metalloproteinase-1 mRNA by 87%. Significant decreases in the oxidative stress markers hepatic 4-hydroxy-2-nonenal and 8-hydroxy-2-deoxyguanosine were noted for perindopril administration at 8 mg/kg, but not at 2 mg/kg. In conclusion, perindopril had preventative and therapeutic effects on cholestasis-induced liver fibrosis through the inhibition of oxidative stress and/or the activation of hepatic stellate cells, thus suggesting the possible application of perindopril as an antifibrotic drug.

Preventive effects of ME3738 on hepatic fibrosis induced by bile duct ligation in rats.

AIM: The aim of this study was to examine the preventive effects of ME3738 on hepatic fibrosis induced by bile duct ligation (BDL) in rats. METHODS: ME3738 (20 mg/day) was administered orally for 21 days immediately after BDL. Fibrosis was assessed by measuring hepatic hydroxyproline (Hyp) content. Activated hepatic stellate cells (HSCs) were assessed by alpha-smooth muscle actin (alpha-SMA) immunostaining. Hepatic thiobarbituric acid-reactive substance (TBARS), 4-hydroxy-2-nonenal (4-HNE) and 8-hydroxy-2-deoxyguanosine (8-OHdG) immunostaining were used to analyze oxidative stress. The gene expressions of collagen-I, transforming growth factor-beta1 (TGF-beta1), tissue inhibitor of metalloproteinases-1 (TIMP-1), interleukin-6 (IL-6) and heme oxygenase-1 (HO-1) in the liver were examined by real-time reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: Hepatic Hyp content and the area of hepatic fibrosis in BDL rats treated with ME3738 were reduced by 24% and 39% compared with non-treated BDL rats (hepatic Hyp, 9.40 +/- 2.85 vs. 12.39 +/- 3.91 mg/liver; P = 0.036; area of hepatic fibrosis, 13.1 +/- 3.8 vs. 21.5 +/- 10.9; P = 0.045). Furthermore, alpha-SMA-positive cells were significantly reduced by 40% (22.3 +/- 14.8 vs. 37.6 +/- 14.2; P = 0.011), collagen-I mRNA by 83% (6.5 +/- 2.2 vs. 38.3 +/- 9.1; P = 0.002), HO-1 mRNA by 58% (4.13 +/- 1.22 vs. 9.73 +/- 1.80; P = 0.018) and hepatic HO-1 content by 26% (2.13 +/- 0.80 vs. 2.87 +/- 0.19; P = 0.01) following ME3738 treatment. The hepatic expression of TBARS, 4-HNE, 8-OHdG and mRNA levels of TGF-beta1, TIMP-1 and IL-6 in the liver were unchanged by ME3738 treatment. CONCLUSION: Oral ME3738 administration may prevent the progression of hepatic fibrosis in BDL rats through suppression of the activation and collagen synthesis of HSC and, in part, oxidative stress. ME3738 has potential as a therapeutic drug for cholestatic liver fibrosis.

Serum immunoglobulins in patients with chronic hepatitis C: a surrogate marker of disease severity and treatment outcome.

BACKGROUND/AIMS: Moderate polyclonal hypergammaglobulinemia is a common finding in chronic viral liver disease; however, its clinical significance has not been completely elucidated. We attempted to determine whether serum immunoglobulin levels were correlated with the disease severity and the treatment outcome in patients with chronic hepatitis C. METHODOLOGY: In a total of 102 patients with chronic hepatitis C, we performed serum tests on immunoglobulins and determined the histology activity index (HAI) score by liver biopsy. In 97 patients, immunoglobulin levels were followed prior to and 6 months after interferon (IFN) therapy. RESULTS: Serum gamma (y)-globulin and immunoglobulin (IgG) were well correlated with HAI score (both; p < 0.0001), grading score (both; p < 0.01), and staging score (both; p < 0.0001). Among the 97 patients who received 6 months of IFN monotherapy, 31, 29, and 37 patients were complete, transient and non-responders, respectively. In the three subgroups, a significant difference was found in histological HAI, grading, and staging scores (p < 0.01, p < 0.05 and p < 0.0001, respectively), and in serum levels of gamma-globulin and IgG (both; p < 0.0001). Following IFN treatment, serum gamma-globulin and IgG were significantly decreased in the complete responders (both; p < 0.0001). Furthermore, serum levels of gamma-globulin and IgG of 1.5 g/dL were useful for predicting the treatment outcome of IFN monotherapy. CONCLUSIONS: The measurement of serum gamma-globulin and IgG is a valuable non-invasive tool for assessing the disease severity and treatment outcome in patients with chronic hepatitis C.

[Two cases of primary T cell lymphoma of the small intestine diagnosed by perforated peritonitis].

We encountered 2 cases (a 28-year-old man and a 63-year-old woman) of primary T cell lymphoma of the small intestine diagnosed by perforated peritonitis. T cell lymphoma perforates the small intestine more easily than B cell lymphoma, because T cell lymphoma infiltrates the intestinal tract wall, and forms an ulcerative tumor.

Development of hypoxemia in alcoholic liver disease.

The aim of this study was to investigate the arterial hypoxemia in Japanese patients with alcoholic liver disease (ALD) with regard to alcohol consumption and/or disease severity. Hypoxemia was observed in 78% patients with ALD and in all 46 patients with alcoholic liver cirrhosis (ALC) and 33 (56%) of 59 patients with noncirrhotic alcoholic liver disease (NCALD) (P < 0.0001). The partial pressure of oxygen (PaO2) was 71.1 +/- 5.2 mm Hg in ALC and 78.7 +/- 6.3 mm Hg in NCALD (P < 0.0001). The oxygen consumption in ALD was significantly higher than that in control subjects (P < 0.0001), and a high oxygen consumption was seen in 88% of the patients with ALD, in all 46 ALC patients, and in 46 (78%) of 59 NCALD patients (P < 0.01). Following abstinence from alcohol, the PaO2 and oxygen consumption significantly recovered after day 2 (P < 0.0001), whereas the prothrombin index did not change in either NCALD or ALC patients. Multivariate analysis showed that alcohol consumption and oxygen consumption were significant independent predictors of PaO2. In conclusion, the present findings suggest that increased oxygen consumption due to alcohol ingestion is principally responsible for the hypoxemia in ALD patients.