Impact of linked color imaging and blue laser imaging on the diagnosis of esophageal squamous cell carcinoma in iodine unstained areas.

The pink color sign in iodine unstained areas is useful to differentiate esophageal squamous cell carcinoma (ESCC) from other lesions. However, some ESCCs have obscure color findings which affect the ability of endoscopists to differentiate these lesions and determine the resection line. Using white light imaging (WLI), linked color imaging (LCI) and blue laser imaging (BLI), 40 early ESCCs were retrospectively evaluated using images before and after iodine staining. Visibility scores for ESCC by expert and non-expert endoscopists were compared using these three modalities and color differences measured for malignant lesions and surrounding mucosa. BLI had the highest score and color difference without iodine staining. Each determination with iodine was much higher than without iodine regardless of the modality. With iodine, ESCC mainly appeared pink, purple and green using WLI, LCI and BLI, respectively and visibility scores determined by non-experts and experts were significantly higher for LCI (both p < 0.001) and BLI (p = 0.018 and p < 0.001) than for WLI. The score with LCI was significantly higher than with BLI among non-experts (p = 0.035). With iodine, the color difference using LCI was twice that with WLI and one with BLI was significantly larger than with WLI (p < 0.001). These greater tendencies were found regardless of location, depth of cancer or intensity of pink color using WLI. In conclusion, areas of ESCC unstained by iodine were easily recognized using LCI and BLI. Visibility of these lesions is excellent even by non-expert endoscopists, suggesting that this method is useful to diagnose ESCC and determine the resection line.

A case of gastric cancer that developed thrombocytopenia during treatment with nivolumab.

A 72-year-old man was treated by two-regimen chemotherapies for unresectable advanced gastric cancer with metastatic lymph nodes near the pancreatic head, followed by the third-line chemotherapy using nivolumab (Nivo). Ten days after the two-course Nivo chemotherapy, grade 4 thrombocytopenia (TCP) occurred according to the Common Terminology Criteria for Adverse Events. He was treated by steroid and Helicobacter pylori (HP) eradication therapies. Consequently, the platelet count improved rapidly without any complications. Before resuming the Nivo therapy, the platelet count was already improved. Fourth-line chemotherapy was then started using irinotecan. After three courses, his general condition worsened. Unfortunately, the patient died 18 months after gastric cancer diagnosis. Although rare, severe TCP is potentially a fatal complication of chemotherapy using immune checkpoint inhibitors. In addition to standard treatment with steroids, HP eradication therapy may be effective for Nivo-associated TCP.

Mucosal healing of Crohn's disease in a patient with concurrent systemic lupus erythematosus using infliximab.

We describe a patient with Crohn's disease (CD) concurrent with systemic lupus erythematosus (SLE). Continuous prednisolone and cyclosporine treatment resulted in no recurrent symptoms. However, diarrhea, vomiting, and fever occurred for approximately 3 months. A colonoscopy was then performed, which showed a discontinuous cobblestone appearance and longitudinal ulcers extending from the sigmoid colon to the descending colon and distal ileum. A biopsy revealed a noncaseating granulomatous lesion in the colonic mucosa. These findings led to a diagnosis of CD concurrent with SLE. We first attempted treatment with a full elemental diet, mesalazine, and azathioprine, in that order. However, as there was no improvement in inflammation, we started infliximab, a tumor necrosis factor-alpha inhibitor. Transanal double-balloon enteroscopy performed 4 months after starting infliximab showed mucosal healing, suggesting that infliximab was effective. There are few reports of treating patients with CD concurrent with SLE using a tumor necrosis factor-alpha inhibitor. We report our experience with a patient who had mucosal healing with infliximab and review the literature.

Crohn's disease presenting as a ceco-urachal fistula.

We report the case of a patient with Crohn's disease who initially presented with a ceco-urachal fistula. The patient was a 31-year-old female who underwent an appendectomy 6 years before presenting to our institution. She had a one-year history of diarrhea, and had recently developed polyuria and a sensation of residual urine. She was admitted with fever and lower abdominal pain. Endoscopy and computed tomography revealed a ceco-urachal fistula, which was consistent with Crohn's disease. An urachal resection was performed, which included partial cystectomy and ileocecal resection. A ceco-urachal fistula is a rare initial symptom of Crohn's disease. During the surgical management of such cases, it is necessary to resect the urachus, the affected portion of the bladder, the fistula, and the affected part of the digestive tract in order to avoid recurrence.

[Small-Bowel Cancer].

Diagnosis of small-bowel cancer has become easier thanks to the development of both balloon-assisted endoscopy and capsule endoscopy. Balloon-assisted endoscopy allows not only for observation of the deep intestine but also for biopsies and for establishing a histological diagnosis. Although endoscopic diagnosis is reported to improve the prognosis of small-bowel cancer by early detection, it is still difficult and the prognosis in general is poor. Surgery and chemotherapy protocols for this disease are similar to those for colon cancer. At present, the response rate to chemotherapy for small-bowel cancer is low. There is an urgent need in this patient population to establish a new diagnostic and therapeutic algorithm using balloon-assisted endoscopy and capsule endoscopy.