Hepatic hemangioma in a simple liver cyst mimicking biliary cystic neoplasm.

BACKGROUND: Follow-up is recommended for an asymptomatic unilocular hepatic cystic lesion without wall-thickness and nodular components. A few liver cystic lesions represent biliary cystic neoplasms, which are difficult to differentiate from simple cysts with benign mural nodules on imaging alone. CASE PRESENTATION: An 84-year-old woman with a history of simple liver cyst diagnosed one year prior was admitted for evaluation of a developed mural nodule in the cystic lesion. She had no specific symptoms and no abnormalities in blood tests except for carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (43.5 U/mL) levels. Contrast-enhanced computed tomography revealed a well-defined, low-attenuation lesion without a septum that had enlarged from 41 to 47 mm. No dilation of the bile duct was observed. A gradually enhancing mural nodule, 14 mm in diameter, was confirmed. MRI revealed a uniform water-intense cystic lesion with a mural nodule. This was followed by T2-enhanced imaging showing peripheral hypointensity and central hyperintensity. Enhanced ultrasonography revealed an enhanced nodule with a distinct artery within it. A needle biopsy of the wall nodule or aspiration of intracystic fluid was not performed to avoid tumor cell spillage. The possibility of a neoplastic cystic tumor could not be ruled out, so a partial hepatectomy was performed with adequate margins. Pathologically, the cystic lesion contained a black 5 mm nodule consisting of a thin, whitish fibrous wall and dilated vessels lined by CD31 and CD34 positive endothelial cells. The final diagnosis was a rare cavernous hemangioma within a simple liver cyst. CONCLUSIONS: Cavernous hemangiomas mimicking well-enhanced mural nodules can arise from simple liver cysts. In less malignant cases, laparoscopic biopsy or percutaneous targeted biopsy of the mural nodules, together with needle ablation, may be recommended to avoid unnecessary surgery.

Efficacy of Upper Gastrointestinal Endoscopic Examination to Identify Patients with Obstructive Sleep Apnea Syndrome: A Retrospective Cross-Sectional Study.

BACKGROUND/AIMS: Despite the high prevalence of obstructive sleep apnea syndrome (OSAS), most individuals are unaware of its diagnosis. We assessed whether an upper gastrointestinal (GI) endoscopy can accurately predict the incidence of OSAS. METHODS: After endoscopic evaluation of laryngo-pharyngeal collapse, a total of 154 subjects with laryngo-pharyngeal collapse and 52 control subjects underwent polysomnography. Based on the modified Fujita Classification, upper airway obstruction was classified into 3 different types: oropharyngeal, supraglottic and combined type, and associations between upper airway obstruction and OSAS were evaluated. RESULTS: Of 154 subjects with laryngo-pharyngeal collapse, 108 (70.1%) were diagnosed as OSAS, while only 4 (7.7%) control subjects were diagnosed as OSAS (p < 0.001). The sensitivity and specificity of endoscopic diagnosis were 96.4 and 51.1%, respectively. Oropharyngeal involvement was frequently found in 90.2% of the subjects (139/154). The severity of upper airway obstruction was significantly correlated with the apnea-hypopnea index score (r = 0.55, p < 0.001). A multivariate logistic regression analysis revealed that a male sex (OR 5.20; 95% CI 2.65-10.2, p < 0.001), body mass index ≥25 kg/m2 (OR 4.98; 95% CI 2.23-11.2, p = 0.02) and severe obstruction (OR 7.79; 95% CI 3.34-18.2, p < 0.001) were significant independent predictors of severe OSAS. CONCLUSION: A conventional upper GI endoscopic examination might be useful as a diagnostic modality for OSAS.

Balloon overtube-guided colorectal endoscopic submucosal dissection.

AIM: To evaluate the usefulness of a balloon overtube to assist colorectal endoscopic submucosal dissection (ESD) using a gastroscope. METHODS: The results of 45 consecutive patients who underwent colorectal ESD were analyzed in a single tertiary endoscopy center. In preoperative evaluation of access to the lesion, difficulties were experienced in the positioning and stabilization of a gastroscope in 15 patients who were thus assigned to the balloon-guided ESD group. A balloon overtube was placed with a gastroscope to provide an endoscopic channel to the lesion in cases with preoperatively identified difficulties related to accessibility. Colorectal ESD was performed following standard procedures. A submucosal fluid bleb was created with hyaluronic acid solution. A circumferential mucosal incision was made to marginate the lesion. The isolated lesion was finally excised from the deeper layers with repetitive electrosurgical dissections with needle knives. The success of colorectal ESD, procedural feasibility, and procedure-related complications were the main outcomes and measurements. RESULTS: The overall en bloc excision rate of colorectal ESD during this study at our institution was 95.6%. En bloc excision of the lesion was successfully achieved in 13 of the 15 patients (86.7%) in the balloon overtube-guided colorectal ESD group, which was comparable to the results of the standard ESD group with better accessibility to the lesion (30/30, 100%, not statistically significant). CONCLUSION: Use of a balloon overtube can improve access to the lesion and facilitate scope manipulation for colorectal ESD.

Prevalence of changes in undiagnosed glucose intolerance according to age and gender in Japanese middle-aged working people.

BACKGROUND: Undiagnosed diabetes mellitus (DM) and impaired glucose tolerance (IGT) have important health consequences. METHODS AND RESULTS: To examine the prevalence of undiagnosed glucose intolerance, oral glucose tolerance tests were administered to 1,142 consecutively enrolled middle-aged subjects (age range 40-55 years; 914 men, mean 50.7 years; 228 women, mean 49.4 years) who worked in a company and underwent a health check in 2006. No subject had a history of glucose intolerance. Fasting glucose levels increased with age in both men and women, with the levels being higher in men than women at every age. Glucose intolerance was more common in men compared with women (fasting glucose 100.1 +/-19.7 vs 92.9 +/-9.6, P<0.01; 1-h 170.7 +/-52.1 vs 139.7 +/-11.6, P<0.01; 2-h 136.0 +/-50.1 vs 119.8 +/-31.5 mg/dl, P<0.01). The prevalence of IGT and DM was also higher in men than in women (IGT: 24.1 vs 16.7, P<0.01; diabetes 10.7 vs 1.4%, P<0.01). CONCLUSIONS: Fasting glucose levels increased with age in both men and women, with levels being higher in men than in women at every age. The prevalences of undiagnosed IGT and type 2 DM were also higher in men than in women.

Staging of early colorectal cancers: magnifying colonoscopy versus endoscopic ultrasonography for estimation of depth of invasion.

BACKGROUND AND AIMS: Preoperative estimation of depth of invasion in early colorectal cancers (CRCs) is essential for patient management. This study was conducted to compare the diagnostic accuracies of magnifying colonoscopy and endoscopic ultrasonography (EUS) for estimating the depth of invasion of early CRCs. SUBJECTS AND METHODS: A total of 438 early CRCs were removed endoscopically or surgically from July 1993 through March 1999 at our hospital. Before removal, 102 lesions were evaluated with both magnifying colonoscopy and EUS and were included in this analysis. The diagnostic accuracy of each method, referring to the histology of the resected specimens, was evaluated. RESULTS: The overall diagnostic accuracies were 87% (89/102) for magnifying colonoscopy and 75% (76/102) for EUS (P = 0.0985). Subgroup analysis was also done for polypoid and non-polypoid lesions. For polypoid lesions, the overall diagnostic accuracies of magnifying colonoscopy and EUS were 88% (60/68) and 72% (49/68), (P = 0.0785), and for non-polypoid lesions, they were 85% (29/34) and 79% (27/34), (P = 0.7169). CONCLUSION: Although, there is a substantial difference in the overall diagnostic accuracies, it is not statistically significant. Therefore, we conclude that magnifying colonoscopy is at least as accurate as EUS for preoperative staging of early CRCs.

Magnifying colonoscopy as a non-biopsy technique for differential diagnosis of non-neoplastic and neoplastic lesions.

AIM: To clarify whether mucosal crypt patterns observed with magnifying colonoscopy are feasible to distinguish non-neoplastic polyps from neoplastic polyps. METHODS: From June 1999 through March 2000, 180 consecutive patients with 210 lesions diagnosed with a magnifying colonoscope (CF-200Z, Olympus Optical Co., Ltd., Tokyo, Japan) were enrolled. Magnification and chromoendoscopy with 0.2% indigo-carmine dye was applied to each lesion for mucosal crypt observation. Lesions showing types I and II crypt patterns were considered non-neoplastic and examined histologically by biopsy,whereas lesions showing types III to V crypt patterns were removed endoscopically or surgically. The correlation of endoscopic diagnosis and histologic diagnosis was then investigated. RESULTS: At endoscopy, 24 lesions showed a type I or II pit pattern, and 186 lesions showed type III to V pit patterns. With histologic examination, 26 lesions were diagnosed as non-neoplastic polyps, and 184 lesions were diagnosed as neoplastic polyps. The overall diagnostic accuracy was 99.1% (208/210). The sensitivity and specificity were 92.3% (24/26) and 99.8% (184/186), respectively. CONCLUSION: Magnifying colonoscopy could be used as a non-biopsy technique for differentiating neoplastic and non-neoplastic polyps.

Incidence and localization of lymphoid follicles in early colorectal neoplasms.

AIM: To investigate the incidence and localizations of lymphoid follicles (LFs) in early colorectal neoplasms in human beings. METHODS: From July 1992 to September 1999, a total of 1,324 early colorectal neoplasms were removed endoscopically or surgically at our hospital; 1,031 (77.9%) were available for analysis in this study. Localization of LFs was defined histologically: as submucosal LFs, if located under the muscularis mucosa; and as intramucosal LFs, if located across or over the muscularis mucosa. RESULTS: Histologically, the materials included 903 intramucosal neoplasms and 128 submucosal cancers. Overall incidence of LFs was 27.2% (280/1 031). The incidence of LFs was significantly higher in females (33.6% vs 24.9%, P=0.0064), the right-sided colon (32.2% vs 25.6%, P=0.0403) and in flat or depressed type lesions (34.6% vs 25.2%, P<0.0001) as compared to males, left-sided colon and protruding type lesions, respectively. The incidences of intramucosal neoplasms and submucosal cancers were 24.3% and 43.8%, respectively (P<0.0001). Localizations of LFs (intramucosal LF/submucosal LF) in depressed, flat, and protruding types were 1/24, 14/36, and 131/74, respectively. CONCLUSION: The incidence of LFs in early human colorectal neoplasms significantly differs by gender, location, macroscopic type, and histology. Moreover, localization significantly differs by macroscopic type.