Diagnostic Ability of Ultrasonography Compared with Computed Tomography for Assessing Rectal Feces.

Objectives: Chronic constipation is a common gastrointestinal disorder, and management is crucial. Computed tomography (CT) is useful for evaluating rectal fecal mass but limited owing to radiation exposure, cost, and inaccessibility at certain facilities. Ultrasonography (US) avoids these pitfalls, but it is unknown whether it accurately assesses rectal feces. In this study, we evaluated the diagnostic performance of US compared with CT as the gold standard for assessing rectal feces. Methods: We prospectively evaluated rectal fecal mass retention using US performed within 1 h of CT to assess the degree of agreement between methodologies. Rectal stool findings were evaluated on three levels: no stool (R1), presence of stool (R2), and hard stool filling (R3). Results: The sample included 100 patients (55 men, 45 women), of whom 47 were constipated. The kappa coefficients for rectal content detection were excellent between US and CT (p <0.001). Eighty-two cases (R1: 46 cases; R2: 28 cases; R3: 8 cases) were matched with CT and US findings, and 18 were not. Cases that did not match had low urine or high gas volumes. CT and US findings showed high agreement in constipation (kappa coefficient 0.674, p <0.001) and non-constipation groups (kappa coefficient 0.677, p <0.001). All cases with R3 on CT were found in the constipation group, while more than half of the cases with R1 on CT were in the non-constipation group. Conclusions: CT and US showed high agreement in evaluating rectal fecal mass retention, indicating that US can substitute CT.

Diagnostic performance of linked color imaging for gastric cancer by Helicobacter pylori infection status: A subanalysis of the large-scale, multicenter randomized controlled trial LCI-FIND.

BACKGROUND: Linked color imaging (LCI) is a new image enhancement technology that facilitates the recognition of subtle differences in mucosal color. In the large-scale, multicenter randomized controlled trial LCI-FIND, LCI demonstrated good diagnostic performance for the detection of tumor lesions in the upper gastrointestinal tract. The aim of the present study was to exploratively evaluate the diagnostic performance of LCI according to H. pylori infection status as a subanalysis of LCI-FIND trial. METHODS: The patients were randomly allocated to receive white light imaging (WLI) first, followed by LCI (WLI group), or vice versa (LCI group), and the two groups were compared for the detection of tumors. Data from this trial were analyzed by the presence/absence of H. pylori infection and further analyzed by successful or unsuccessful eradication in the H. pylori infection group. RESULTS: The 752 patients in the WLI group and 750 patients in the LCI group who had participated in the LCI-FIND trial were included. In the successful eradication group, more gastric lesions were detected by primary mode in the LCI group than in the WLI group, indicating that more lesions were missed by WLI. Fisher's exact probability test for the comparison of the WLI and LCI groups yielded a p-value of 0.0068, with missed gastric lesions being detected 0.136 times (95% confidence interval: 0.020-0.923), significantly less with LCI than with WLI. CONCLUSION: The current study suggests that LCI should be used for gastric cancer screening, particularly in patients with successful H. pylori eradication.

Impact of mixed-infection rate of clarithromycin-susceptible and clarithromycin-resistant Helicobacter pylori strains on the success rate of clarithromycin-based eradication treatment.

BACKGROUND: Clarithromycin (CAM) resistance is a major contributor to the failure to eradicate Helicobacter pylori (H. pylori). The mixed-infection ratio of CAM-susceptible and CAM-resistant H. pylori strains differs among individuals. Pyrosequencing analysis can be used to quantify gene mutations at position each 2142 and 2143 of the H. pylori 23S rRNA gene in intragastric fluid samples. Herein, we aimed to clarify the impact of the rate of mixed infection with CAM-susceptible and CAM-resistant H. pylori strains on the success rate of CAM-containing eradication therapy. MATERIALS AND METHODS: Sixty-four H. pylori-positive participants who received CAM-based eradication therapy, also comprising vonoprazan and amoxicillin, were enrolled in this prospective cohort study. Biopsy and intragastric fluid samples were collected during esophagogastroduodenoscopy. H. pylori culture and CAM-susceptibility tests were performed on the biopsy samples, and real-time PCR and pyrosequencing analyses were performed on the intragastric fluid samples. The mutation rates and eradication success rates were compared. RESULTS: The overall CAM-based eradication success rate was 84% (54/64): 62% (13/21) for CAM-resistant strains, and 95% (39/41) for CAM-sensitive strains. When the mutation rate of the 23S rRNA gene was 20% or lower for both positions (2142 and 2143), the eradication success rate was 90% or more. However, when the mutation rate was 20% or higher, the eradication success rate was lower (60%). CONCLUSIONS: The mutation rate of the CAM-resistance gene was related to the success of eradication therapy, as determined via pyrosequencing analysis.

Surveillance esophagogastroduodenoscopy using linked color imaging and narrow-band imaging: A multicenter randomized controlled trial.

BACKGROUND AND AIM: There has been no report on a direct comparison between linked color imaging (LCI) and second-generation narrow-band imaging (2G-NBI) for surveillance of epithelial neoplasms in the upper gastrointestinal tract (UGIT). The aim of this study was to verify the superiority of LCI to 2G-NBI for surveillance esophagogastroduodenoscopy and to clarify how each endoscopic system should be used. METHODS: This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial at six institutions. Patients aged 20-85 years with a treatment history of epithelial neoplasms in the UGIT were recruited. Patients were assigned to a 2G-NBI group and an LCI group, and esophagogastroduodenoscopy was performed with primary image-enhanced endoscopy followed by white light imaging (WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the primary image-enhanced endoscopy. A WLI-detected epithelial neoplasm was defined as a lesion that was detected in only WLI. RESULTS: A total of 372 patients in the 2G-NBI group and 378 patients in the LCI group were analyzed. Epithelial neoplasms in the UGIT were detected by 2G-NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). WLI-detected epithelial neoplasms were in 11 patients in the 2G-NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). CONCLUSIONS: Linked color imaging did not show superiority to 2G-NBI for the detection of epithelial neoplasms. Also, the percentage of WLI-detected epithelial neoplasms in primary NBI was significantly higher than that in primary LCI.

Invasive lobular carcinoma of the breast with colonic metastasis: a case series of three patients.

BACKGROUND: Although metastatic spread of breast cancer to the gastrointestinal tract is very rare, it is more likely to occur in invasive lobular carcinoma (ILC) than in ductal carcinoma. Colonic metastasis is particularly rare, and the treatment strategies for these cases are not clearly defined. Herein, we report three cases of ILC with various abdominal symptoms associated with colonic metastasis. CASE PRESENTATION: Case 1 A 70-year-old female patient with vomiting and melena was referred to our hospital. Endoscopic examination revealed a Dieulafoy ulcer in the rectum and an elevated lesion in the descending colon. She also had two breast nodules, and was diagnosed as ILC with colonic metastasis. Considering her general condition, the best supportive care (BSC) was offered. The patient died 4 months after confirmation of the diagnosis. Case 2 An 80-year-old female patient presented with diarrhea and vomiting. She was diagnosed with ILC with colonic metastasis, and a coloscopy revealed stenosis of the transverse colon with a metastatic lesion. Ileosigmoid bypass surgery was performed for intestinal obstruction, and systemic treatment for breast cancer was initiated. The patient developed peritoneal carcinomatosis and died 1 year and 2 months after surgery. Case 3 A 56-year-old female patient underwent left total mastectomy for ILC, and laparoscopic transverse colectomy was conducted for a colonic lesion 9 years and 2 months after. The diagnosis as colonic metastasis was not confirmed at that time. Two years and 2 months later, torose lesions were detected in the hepatic flexural and descending colon, and histopathological findings indicated that all colon tumors, including the previously resected tumor, were metastatic spread of ILC. Systemic treatment was continued, but the transverse colonic lesion penetrated the abdominal wall, and an abscess formed 2 years and 11 months after the resection. The fistula improved by continuous suction drainage following ileostomy but recurred, and the patient died 3 years and 8 months after colectomy. CONCLUSIONS: Colonic metastases from breast cancer can trigger various abdominal symptoms, and the prognosis in these cases is generally poor. In selected cases, surgical treatment for abdominal symptoms and subsequent systemic therapy can contribute to a prolonged prognosis.

Linked color imaging provides enhanced visibility with a high color difference in upper gastrointestinal neoplasms.

BACKGROUND AND AIM: The aim of this post-hoc analysis in a randomized, controlled, multicenter trial was to evaluate the visibility of upper gastrointestinal (UGI) neoplasms detected using linked color imaging (LCI) compared with those detected using white light imaging (WLI). METHODS: The visibility of the detected UGI neoplasm images obtained using both WLI and LCI was subjectively reviewed, and the median color difference (ΔE) between each lesion and the surrounding mucosa according to the CIE L*a*b* color space was evaluated objectively. Multivariate logistic regression analysis was performed to identify factors associated with neoplasms that were missed under WLI and detected under LCI. RESULTS: A total of 120 neoplasms, including 10, 32, and 78 neoplasms in the pharynx, esophagus, and stomach, respectively, were analyzed in this study. LCI enhanced the visibility 80.9% and 93.6% of neoplasms in pharynx/esophagus and stomach compared with WLI, respectively. LCI also achieved a higher ΔE of enhanced neoplasms compared with WLI in the pharynx/esophagus and stomach. The median WLI ΔE values for gastric neoplasms missed under WLI and later detected under LCI were significantly lower than those for gastric neoplasms detected under WLI (8.2 vs 9.6, respectively). Furthermore, low levels of WLI ΔE (odds ratio [OR], 7.215) and high levels of LCI ΔE (OR, 22.202) were significantly associated with gastric neoplasms missed under WLI and later detected under LCI. CONCLUSION: Color differences were independently associated with missing gastric neoplasms under WLI, suggesting that LCI has an obvious advantage over WLI in enhancing neoplastic visibility.

Clinical evaluation of a novel molecular diagnosis kit for detecting Helicobacter pylori and clarithromycin-resistant using intragastric fluid.

BACKGROUND: Although there are many Helicobacter pylori (H. pylori) diagnostic methods, the culture and antibiotic susceptibility test is an important method for selecting the most effective H. pylori eradication regimen. However, this diagnostic method is complicated and takes several days; therefore, the development of a rapid and simple diagnostic method is required. Eradication failure due to clarithromycin (CAM) resistance should also be considered. In this study, we report the clinical evaluation of point-of-care testing (POCT) kit using intragastric fluid, a novel kit for detecting H. pylori and CAM resistance. MATERIALS AND METHODS: The study participants were 143 patients suspected of H. pylori infection and had an endoscopic examination. The novel diagnostic kit diagnosed H. pylori infection and CAM resistance-associated mutation using intragastric fluid. To diagnose H. pylori infection, the relationship between the diagnostic kit and conventional diagnostic methods (urea breath test, stool antigen test, culture test, and real-time polymerase chain reaction [PCR]) was evaluated. For CAM resistance-associated mutation detection, the concordance between the diagnostic kit and antibiotic susceptibility test was evaluated. RESULTS: The diagnosis of H. pylori infection with the novel molecular diagnostic kit using intragastric fluid showed significant relationship with conventional diagnostic methods. Especially when the culture was control, the sensitivity was 100% (67/67), the specificity was 95.9% (71/74), and the overall concordance was 97.9% (138/141). The detection of CAM resistance-associated mutations had a concordance rate of 97.0% (65/67) when compared with the antibiotic susceptibility test. CONCLUSIONS: The H. pylori molecular POCT kit uses intragastric fluid as a sample and can diagnose H. pylori infection and detect CAM resistance-associated mutations within an hour. This novel kit is expected to prove useful in selecting the most effective eradication regimen for H. pylori.

Fitz-Hugh-Curtis Syndrome Presenting as Perihepatic and Subcapsular Enhancement on MRI.

Fitz-Hugh-Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease and its MRI findings remain poorly described. A 34-year-old woman was raced to our hospital with slight fever and severe right upper quadrant pain. Gadoxetic acid-enhanced magnetic resonance imaging revealed high-intensity regions in the surface and subcapsule of the right liver on T2-weighted imaging and on diffusion-weighted imaging. A definitive diagnosis of FHCS was confirmed based on high titers of serum IgA and IgG antibodies to Chlamydia trachomatis. She was treated with oral azithromycin and discharged 6 days after admission with improvement of her symptoms. To our knowledge, this report represents a valuable addition to the FHCS literature describing MRI findings in the early stage of FHCS onset.

Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography.

Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient's colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.

Diagnostic ability of linked color imaging in ultraslim endoscopy to identify neoplastic lesions in the upper gastrointestinal tract.

Background and study aims Linked color imaging (LCI) is a new image-enhancing technique that facilitates the differentiation of slight differences in mucosal color tone. We performed an exploratory analysis to evaluate the diagnostic capability of LCI in ultraslim endoscopy, using data from patients examined in the LCI-Further Improving Neoplasm Detection in upper gastrointestinal (LCI-FIND) trial, a large-scale, multicenter, randomized controlled trial that demonstrated the capability of LCI for detecting neoplastic lesions in the upper gastrointestinal tract. Patients and methods Data from the LCI-FIND prospective trial were used. In the LCI-FIND trial, 1502 patients with a history of gastrointestinal cancer were randomly assigned to two groups based on examination methods: white light imaging (WLI) followed by LCI (WLI group) and LCI followed by WLI (LCI group). The present exploratory analysis investigated the outcomes of patients who underwent ultraslim and standard endoscopies. Results Ultraslim endoscopes were used in 223 patients and standard endoscopes in 1279 patients. The primary endpoint of the LCI-FIND trial was the percentage of patients diagnosed with a neoplastic lesion using WLI or LCI. The corresponding percentage tended to be higher with LCI than with WLI among patients who underwent ultraslim endoscopy and among those who underwent standard endoscopy; the crude risk ratio was 2.21 [95 % confidence interval (CI): 1.06-4.67], and the adjusted odds ratio was 2.46 (95 % CI: 1.07-5.63). Conclusions Our exploratory analysis of data from the LCI-FIND trial showed that LCI is useful in identifying neoplastic lesions, when used in ultraslim endoscopy.

Eradication of Helicobacter pylori may improve dyspepsia in the elderly for the long term.

BACKGROUND: Therapy for eradication of Helicobacter pylori (H. pylori) improves symptoms of H. pylori-associated dyspepsia (HPD), but the effects of eradication in elderly patients are unclear. The aim of our study was to investigate dyspepsia symptoms and long-term effects of eradication in elderly patients. METHODS: This retrospective study included 496 patients who received H. pylori eradication therapy. The patients were divided into a group of elderly patients (group E: ≧ 65 years old) and a group of non-elderly patients (group N: < 65 years old). Abdominal symptoms were evaluated using a questionnaire about abdominal symptoms before eradication and after eradication (1-2 months and more than one year). Dyspepsia was defined as a score of 4 points or more for at least one of 4 items (postprandial fullness, early satiety, epigastric pain, and hunger pain). Improvement of symptoms was defined on the basis of changes in Global Overall Systems scores. RESULTS: There were no differences in abdominal symptoms before eradication between the two groups. Successful eradication improved symptoms in patients with dyspepsia within 2 months (in 75.6% (56/74) of the patients in group N and in 64.5% (20/31) of the patients in group E). The questionnaire showed that 80% (32/40) of the patients in group N and 60% (12/20) of the patients in group E had long-term relief of dyspepsia. The scores for abdominal symptoms in group E continued to improve for a mean period of 54.8 months after eradication. CONCLUSIONS: Eradication of H. pylori age-independently improved dyspepsia symptoms for the long term.

Vonoprazan-Associated Gastric Mucosal Redness in Non-Helicobacter pylori-Infected and Helicobacter pylori-Eradicated Stomach.

Vonoprazan-associated gastric mucosal redness is rare, and its endoscopic and pathological features remain poorly described. We report 4 cases of vonoprazan-associated gastric mucosal redness, that is, 2 cases each in non-Helicobacter pylori-infected and -eradicated stomach. In all cases, esophagogastroduodenoscopy demonstrated spotty and linear redness newly appearing in the greater curvature of the gastric body after initiation of vonoprazan but disappearing after its discontinuation. A tissue biopsy taken from the gastric mucosa with redness revealed various pathological findings and included inflammatory cell infiltration, parietal cell protrusions, oxyntic gland dilatations, congestion, focal hemorrhage with congestion beneath the basement membrane, and vacuolar degeneration of parietal cells. To our knowledge, this is the second report describing the endoscopic and pathological features of vonoprazan-associated gastric mucosal redness.

Proton Pump Inhibitor-Associated Large Hyperplastic Polyp in Non-Helicobacter pylori-Infected Stomach.

A proton pump inhibitor (PPI)-associated hyperplastic polyp (HP) in the non-Helicobacter pylori-infected stomach is rare, and its endoscopic features remain poorly described. A 42-year-old man with tarry stool was referred to our hospital for examination and treatment. He had taken PPI for 14 years and was confirmed to be H. pylori-negative. Transnasal endoscopy revealed bleeding from a 20-mm, reddish pedunculated polyp with a nodular surface, located in the greater curvature of the upper gastric body. Endoscopic mucosal resection was performed, and the lesion was diagnosed as an HP. To our knowledge, this report represents a valuable addition to the HP literature describing a rare case of PPI-associated large HP in the non-H. pylori-infected stomach.

Oxaliplatin-Associated Amaurosis Fugax.

Oxaliplatin-associated amaurosis fugax has not been reported, and its clinical course and treatment remain largely unclear. A 70-year-old man with advanced gastric cancer was treated with the SOX regimen. After cycle 1 of oxaliplatin infusion, the patient realized that his right eye had visual field impairment, which he described as darkening of the right half of his visual field and loss of vision lasting about 1 min and occurring about 7 times a day. The daily frequency of this occurrence gradually decreased, and his visual field impairment improved in 1 week. However, as the same symptoms recurred from cycle 2 to cycle 5 of treatment, oxaliplatin was discontinued from cycle 6 and switched to S-1 monotherapy. Subsequently, the patient's amaurosis fugax improved. To our knowledge, this is the first report describing clinical course and treatment of oxaliplatin-associated amaurosis fugax.

Collision Tumor of the Stomach.

Collison tumor of the stomach is rare, and its endoscopic and pathological features remain poorly described. A 70-year-old woman was referred to our hospital for examination and treatment of undifferentiated gastric cancer. Esophagogastroduodenoscopy revealed a whitish, superficial elevated lesion in contact with a reddish, superficial depressed lesion from the anterior wall of the gastric angle and antrum to the lesser curvature. Laparoscopic distal gastrectomy was performed for preoperative diagnosis of suspected early gastric cancer presenting as a differentiated and undifferentiated collision tumor, which led to the lesion being diagnosed as collision tumor, tub1-tub2+por1-sig, pT1a (M), ly0, v0, N0, stage IA. To our knowledge, this report represents a valuable addition to the collision tumor literature describing a rare case of preoperatively diagnosed collision tumor of the stomach.

Linked Color Imaging Focused on Neoplasm Detection in the Upper Gastrointestinal Tract : A Randomized Trial.

BACKGROUND: Linked color imaging (LCI) is a new image-enhanced endoscopy technique that allows users to recognize slight differences in mucosal color. OBJECTIVE: To compare the performance of LCI with white light imaging (WLI) in detecting neoplastic lesions in the upper gastrointestinal tract. DESIGN: A controlled, multicenter trial with randomization using minimization. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000023863). SETTING: 16 university hospitals and 3 tertiary care hospitals in Japan. PATIENTS: 1502 patients with known previous or current cancer of the gastrointestinal tract and undergoing surveillance for gastrointestinal cancer. INTERVENTION: WLI followed by LCI examination (WLI group) or LCI followed by WLI examination (LCI group). MEASUREMENTS: Diagnosis of 1 or more neoplastic lesions in the pharynx, esophagus, or stomach in the first examination (primary outcome) and 1 or more neoplastic lesions overlooked in the first examination (secondary outcome). RESULTS: 752 patients were assigned to the WLI group and 750 to the LCI group. The percentage of patients with 1 or more neoplastic lesions diagnosed in the first examination was higher with LCI than with WLI (60 of 750 patients or 8.0% [95% CI, 6.2% to 10.2%] vs. 36 of 752 patients or 4.8% [CI, 3.4% to 6.6%]; risk ratio, 1.67 [CI, 1.12 to 2.50; P = 0.011]). The proportion with overlooked neoplasms was lower in the LCI group than in the WLI group (5 of 750 patients or 0.67% [CI, 0.2% to 1.6%] vs. 26 of 752 patients or 3.5% [CI, 2.3% to 5.0%]; risk ratio, 0.19 [CI, 0.07 to 0.50]). LIMITATION: Endoscopists were not blinded. CONCLUSION: LCI is more effective than WLI for detecting neoplastic lesions in the pharynx, esophagus, and stomach. PRIMARY FUNDING SOURCE: Fujifilm Corporation.

Mesenteric Phlebosclerosis Associated with Herbal Medicine.

Mesenteric phlebosclerosis (MP) associated with herbal medicine is rarely reported and its endoscopic and radiological features remain poorly described. An 81-year-old woman was admitted to our hospital for right lower abdominal pain and high-grade fever. Computed tomography (CT) revealed wall thickening, pericolic fat stranding, and linear calcifications extending from the cecum to the hepatic flexure of the colon. Ultrasonography (US) revealed wall thickening of the cecum and ascending colon. Colonoscopy (CS) revealed dark-purple edematous mucosa with erosion and ulcers from the cecum to the hepatic flexure of the colon. The patient was histopathologically diagnosed with MP, discontinued orengedokuto, and was treated with intravenous antibiotics for 1 week. Six months after treatment, US and CT revealed no significant changes, but CS showed improvement in dark-purple edematous mucosa with erosion and ulcers. To our knowledge, this report represents a valuable addition to the MP literature describing a rare case of MP associated with herbal medicine.

Blind Pouch Syndrome-Associated Enterolithiasis Successfully Treated with Colonoscopy.

Enterolithiasis associated with blind pouch syndrome secondary to functional end-to-end anastomosis is rare, and its endoscopic and radiological features remain poorly described. A 72-year-old woman was admitted to our hospital for abdominal pain and difficulty defecating. Colonoscopy (CS) with Gastrografin revealed a 10 × 8 cm calculus, an anastomotic ulcer, a blind pouch, and an end-to-end anastomosis in the transverse colon. The calculus was successfully crushed and removed with snares and alligator forceps through CS during the ensuing 4-day period. To our knowledge, this is the first report describing the endoscopic and radiological features of blind pouch syndrome-associated enterolithiasis successfully treated with CS.

Perforated Goblet Cell Carcinoid of the Appendix.

Goblet cell carcinoid (GCC) of the perforated appendix is rare, and its pathological features and prognosis remain poorly described. A 71-year-old woman was admitted to our hospital for right lower abdominal pain, vomiting, and high-grade fever. She was diagnosed with acute appendicitis and underwent emergency laparoscopic appendectomy. Intraoperative examination revealed an enlarged and perforated appendix. Histopathological examination revealed GCC of the appendix with subserosal invasion. She underwent laparoscopic ileocecal resection with lymph node dissection (D3) following appendectomy. Histopathological findings showed no residual tumor or lymph node metastases. To the best of our knowledge, this report is a valuable addition to the GCC literature, describing a case of GCC of the appendix presenting as perforated appendix.