Penetration of a swallowed fish bone into pulmonary vein: diagnosis and management.

We present a case of a 71-year-old woman who accidently swallowed a large fish bone that penetrated into the pulmonary vein. She visited the hospital the next day with a complaint of mild chest discomfort with slight pain and fever of 37.4 °C. Contrast-enhanced chest computed tomography (CT) scan revealed a large fish bone with a length of 35 mm impacted in the middle esophagus. The bone had penetrated into the pulmonary vein, causing mediastinitis. Blood tests revealed elevation in the white blood cell count and C-reactive protein level. Because intractable bleeding from pulmonary vein after endoscopic removal can be lethal, endoscopic removal of the fish bone in an operating room under general anesthesia with cardiovascular surgical standby for possible emergency surgery was selected. After endoscopic removal, mediastinal hematoma was absent with a follow-up chest CT scan, and the mediastinitis was treated with intravenous antibiotics. The patient shortly became afebrile with normalized blood test findings. After confirming the normal findings on the follow-up chest CT scan and endoscopic inspection in the next week, she was discharged from the hospital 10 days after hospitalization without any complications. When the swallowed bone penetrates into the major pericardial vessels, unprepared endoscopic removal may result in fatal sequelae such as intractable mediastinal hemorrhage. Urgent consultation with cardiovascular or thoracic surgeons for a possible emergent surgery is needed before endoscopic removal is attempted.

A case of intracystic papillary neoplasm of the gallbladder that exhibited findings similar to gallbladder adenomyomatosis with the formation of intramural cysts because of Rokitansky-Aschoff sinus infiltration.

A 74-year-old man underwent regular follow-up observations after being diagnosed with gallbladder adenomyomatosis based on findings, such as the thickening of the wall of the gallbladder fundus and the presence of intramural cysts. Over the course of 3 years, a papillary tumor located on the thickened wall of the gallbladder had increased in size and extended into the lumen. Consequently, the patient was diagnosed with gallbladder cancer and underwent extended cholecystectomy. The histological diagnosis was intracystic papillary neoplasm (ICPN) of the gallbladder. Although several Rokitansky-Aschoff sinuses that had increased in size because of tumor progression were observed, no adenomyomatosis of the gallbladder was detected. ICPN, a recently identified disease, is not widely known to present with imaging findings similar to adenomyomatosis. The primary treatment of ICPN is radical resection, whereas adenomyomatosis is generally conservatively managed with regular follow-up observations. As the treatment strategies for these two diseases greatly differ, differential diagnosis must be carefully performed.

Efficacy of acetic acid-spraying method in diagnosing extension of Barrett's cancer under the squamous epithelium.

AIM: Endoscopic diagnosis of the lateral extension of Barrett's cancer under the squamous epithelium (BCUS) is sometimes difficult because the cancer is unobservable in the esophageal lumen. The aim of the present study was to clarify the endoscopic features of the extension of BCUS and verify the usefulness of the acetic acid-spraying method (AAS) for diagnosis. METHODS: A total of 25 patients with Barrett's cancer who had undergone endoscopic resection were included in this study. Histological examination of patients' resected specimens was performed to identify the presence of BCUS. Then, the endoscopic images of the BCUS cases were reviewed to summarize the findings and to evaluate the feasibility of diagnosing the extent of BCUS with each imaging technique. RESULTS: Of the 25 patients, 10 (40%) had BCUS. With white-light imaging, subtle reddish change was observed in the area of BCUS in 80% of the patients, and a flat elevated lesion was recognized in 30%. With narrow band imaging, slight brownish change was observed in the area of BCUS in 86% of the patients. Slight white changes were visualized in all cases with AAS. The extension of BCUS was correctly diagnosed by white-light imaging, narrow band imaging and AAS in 50%, 43% and 100% of the cases, respectively. Histology verified the opening of cancerous glands, which extended under the squamous epithelium, into the esophagus in the area showing slight white changes by AAS. CONCLUSION: AAS can be useful for diagnosing the extension of BCUS.