Antimicrobial therapy outcomes in acute cholangitis: Hilar multiple obstructions versus single hilar and common bile duct obstructions.

Background and Aim: The appropriate duration of antimicrobial therapy for acute cholangitis (AC) arising from multiple hilar biliary obstructions as opposed to simple obstruction in the extrahepatic bile duct has not been established. This study assessed the efficacy of the duration of antimicrobial treatments in the Tokyo Guidelines 2018 for AC based on the cause and site of obstruction. Methods: This single-center retrospective study involved patients with AC who underwent successful biliary drainage and completed a 7-day or shorter antimicrobial treatment. Patients were categorized into three groups: Group 1, bile duct stone or benign obstruction; Group 2, simple biliary obstruction due to malignancy; and Group 3, multiple hilar biliary obstruction due to malignancy. The primary outcome was clinical cure rate, and the secondary outcomes were 3-month recurrence rate and length of hospital stay. Results: A total of 373 patients were selected. Patients in Group 3 were younger or had Charlson Comorbidity Index ≥4, and had fewer positive blood cultures. In Group 3, the clinical cure rate (87.1%) and 3-month recurrence rate (32.3%) were less favorable than those in the other groups. In Group 1, the clinical cure rate was significantly higher (98.1%, P = 0.02) with a much lower 3-month recurrence rate of only 3.4% (P < 0.001) than that in the other groups. The median hospital stay for all groups was 7 days. Conclusion: This study suggests that the outcomes in Group 3 may be worse than those in Groups 1 or 2, regardless of the duration of the antibiotic treatment.

Phlegmonous Colitis after Cold Snare Polypectomy in an Immunosuppressed Patient: A Case Report.

Introduction: Cold snare polypectomy (CSP) is a procedure with a low risk of complications. Here, we present our experience of a rare case of submucosal abscess following CSP in an immunosuppressed patient. Case Presentation: Seventy-eight-year-old man underwent CSP, developing a fever, chills, and right lower abdominal pain 8 days later. Ultrasound and computed tomography revealed wall thickening of the ascending colon, presenting as whitening and thickening of the same region, and excretion of pus was observed after biopsy. The diagnosis was made as phlegmonous colitis, for which antibiotic therapy was commenced. The patient was diagnosed with chronic myelomonocytic leukemia (CMML) during admission. We considered the following reasons as possible causes of infectious complications after CSP: (1) the patient had a highly immunosuppressed state with comorbidities such as CMML as well as diabetes mellitus and (2) disruption of the mucosal barrier occurred during endoscopic resection. Conclusion: Although CSP is generally considered safe, our case highlights the potential for serious complications in immunosuppressed patients. Therefore, the decision to perform CSP in such patients should be made with caution to avoid unnecessary interventions. In instances where treatment is essential, thorough bowel preparation and prophylactic antibiotic use may be necessary to mitigate the risks.

Association of short-course antimicrobial therapy and bacterial resistance in acute cholangitis: Retrospective cohort study.

Background and study aims Although the number of resistant bacteria tends to increase with prolonged antimicrobial therapy, no studies have examined the relationship between the duration of antimicrobial therapy and increase in the number of resistant bacteria in acute cholangitis. We hypothesized that the short-term administration of antimicrobial agents in acute cholangitis would suppress bacterial resistance. Patients and methods This was a single-center, retrospective, observational study of patients with acute cholangitis admitted between January 2018 and June 2020 who met the following criteria: successful biliary drainage, positive blood or bile cultures, bacteria identified from cultures sensitive to antimicrobials, and subsequent cholangitis recurrence by January 2022. The patients were divided into two groups: those whose causative organisms at the time of recurrence became resistant to the antimicrobial agents used at the time of initial admission (resistant group) and those who remained susceptible (susceptible group). Multivariate analysis was used to examine risk factors associated with the development of resistant pathogens. Multivariate analysis investigated antibiotics used with the length of 3 days or shorter after endoscopic retrograde cholangiopancreatography (ERCP) and previously reported risk factors for the development of bacterial resistance. Results In total, 89 eligible patients were included in this study. There were no significant differences in patient background or ERCP findings between the groups. The use of antibiotics, completed within 3 days after ERCP, was associated with a lower risk of developing bacterial resistance (odds ratio, 0.17; 95% confidence interval, 0.04-0.65; P =0.01). Conclusions In acute cholangitis, the administration of antimicrobials within 3 days of ERCP may suppress the development of resistant bacteria.

Difficulty in the diagnosis of pancreatic cancer based on the initial CT report: A retrospective study.

The role of computed tomography (CT) in the initial diagnosis of pancreatic cancer (PC) is well-known. CT reports made by radiologists are important as not all patients with PC are examined by specialists; however, some cases are not identified based on CT reports. Diagnosis via imaging of PC is sometimes difficult, and the diagnostic rate of PC and other pancreatic diseases can vary across radiologists. This study aimed to examine the diagnostic rate of PC in initial CT reports and the details of cases with diagnostic difficulties. This single-centered, retrospective study collected clinical data of 198 patients with histologically diagnosed PC between January 2018 and April 2022. Out of these contrast-enhanced CT was performed in 192 cases. PC was not reported as the main diagnosis in 18 patients (9.4%; 11 men and 7 women). Among these 18 cases, intrapancreatic mass lesions were detected in 3 (1.6%), indirect findings such as bile/pancreatic duct stenosis or dilation were detected in 5 (2.6%), and no PC-related findings were found in 10 (5.2%). The specialists suspected PC in 15 of these 18 cases based on initial CT reports. 17 cases were confirmed by endoscopic ultrasound-fine needle aspiration and one by biopsy after upper gastrointestinal endoscopy. To improve accuracy of its diagnosis, it is important that specialists provide feedback to diagnostic radiologists regarding the findings they did not report. Endoscopic ultrasound-fine needle aspiration should be performed by specialists when there is clinical information which indicates pancreatic disease of any kind.

Exploration of predictors associated with bleeding in computed tomography-guided core needle splenic biopsy: A retrospective study.

Splenic diseases may be caused by infections and can be either malignant, such as lymphoma and lung cancer, or benign, such as hemangioma. In some cases, diagnostic uncertainty of imaging persists, and image-guided splenic needle biopsy is a useful diagnostic tool to avoid the disadvantages of incorrect diagnosis, including performing unnecessary splenectomy or not giving the necessary treatment. Splenic biopsies can be divided into ultrasound-guided, computed tomography (CT)-guided fine-needle aspiration, or core needle biopsy (CNB). However, few studies have focused exclusively on complications associated with CT-guided CNB of the spleen. Therefore, we assessed bleeding, the most common complication of CT-guided CNB of the spleen, and evaluated factors associated with the bleeding. Using the biopsy database maintained at the institution, all patients who underwent CT-guided CNB of the spleen between May 2012 and September 2022 were identified retrospectively. The 18 identified patients were divided into post-biopsy bleeding and non-bleeding groups for analysis. In total, 17 patients (94.4%) could be diagnosed accurately with CT-guided CNB. Bleeding complications occurred in 7 cases of CT-guided CNB; of these, 2 patients with Common Terminology Criteria for Adverse Events grade 4 disease required transcatheter arterial embolization. The bleeding group was characterized by diffuse spleen tumors in all cases, with significantly more diffuse spleen tumors than the non-bleeding group. CT-guided CNB is a useful option for neoplastic lesions of the spleen that are difficult to diagnose using imaging alone. However, consideration should be given to post-biopsy bleeding in patients with diffuse splenic tumors.

Endoscopic Papillary Balloon Dilation Can Be Safely Performed in Patients on Dual Antiplatelet Therapy: A Pilot Study.

BACKGROUND AND AIMS: Endoscopic papillary balloon dilation (EPBD), a low-risk procedure for bleeding, has been suggested as an alternative to endoscopic sphincterotomy for papillary dilatation in patients undergoing endoscopic stone removal who are at a higher risk of bleeding. Several guidelines recommend that combination of two antiplatelet agents should be reduced to single antiplatelet therapy when endoscopic sphincterotomy is performed. However, there is no evidence that EPBD affects the risk of bleeding in patients receiving a combination of two antiplatelet agents; thus, we aimed to explore this problem. METHODS: We included 31 patients who underwent EPBD for common bile duct stones at our hospital from May 2014 to August 2022 and received either a combination of two antiplatelet agents or single antiplatelet therapy prior to the procedure. The group receiving a combination of two antiplatelet agents included patients who underwent EPBT without antiplatelet therapy withdrawal or with a shorter withdrawal period than those recommended by the guidelines. RESULTS: In the group that received a combination of two antiplatelet agents, one of the two antiplatelet agents used was thienopyridine. No bleeding was observed after EPBD in this study. We did not find any significant between-group differences in hemoglobin levels and rate of post-endoscopic retrograde cholangiopancreatography pancreatitis. CONCLUSIONS: In patients treated with a combination of two antiplatelet agents, EPBD could be safely performed without bleeding. Therefore, future prospective studies are warranted.

Comprehensive review on small common bile duct stones.

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

A case of unsuccessful obliteration of percutaneous transhepatic gastric varices using the IMPEDE embolization plug.

Key Clinical Message: Embolization with IMPEDE embolization plug cannot be confirmed on site. Therefore, we propose that the diameter of the device selected be up to 50% larger than the vein diameter to prevent embolization failure and recanalization. Abstract: Balloon-occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration (PTO) are performed for treating sporadic gastric varices. IMPEDE embolization plug has been recently developed for these procedures; however, no studies have reported its use. This is the first report on its use in PTO of gastric varices.

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor.

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.

White gastric mucosa during endoscopy as a new endoscopic feature of chronic ischemic gastritis: A case report.

Chronic ischemic gastritis (CIG) requires early diagnosis and treatment as complications of thromboembolism can be fatal. Although computed tomography (CT) is useful in the diagnosis of CIG, it is difficult to diagnose from a patient's history, endoscopic findings, and tissue biopsy. Identification of the key findings that motivate computed tomography is an important issue. We report a case of CIG diagnosed by endoscopic findings of white patches of mucosa over time. A 63-year-old man presented with epigastric pain. He had a history of repeated gastric ulcers of an undetermined cause. We performed upper endoscopy and observed the appearance of multiple white patches on the gastric mucosa. Central vessel stenosis was considered, and aortic computed tomography revealed complete occlusion of the superior mesenteric artery and stenosis of the celiac artery. We carried out a surgical bypass and found no postoperative endoscopic mucosal changes or abdominal pain. White patch changes in the gastric mucosa over time during endoscopy may indicate CIG. This finding may help in the future diagnosis of CIG.

A novel use of CT attenuation value: increased bone marrow density in patients with acute myeloid leukemia.

BACKGROUND: Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults. Bone marrow computed tomography (CT) attenuation may increase in patients with myeloproliferative disorders; however, the actual threshold CT attenuation value predictive of myeloproliferative has not been reported. PURPOSE: To determine whether the unenhanced CT attenuation value of the bone marrow may be useful for predicting AML. MATERIAL AND METHODS: We retrospectively analyzed patients with AML (n = 56) who underwent unenhanced CT before treatment, and age- and sex-matched controls without any hematologic disease. For each patient, the CT attenuation value (HU) of the iliac bone was measured and compared between the two groups. Receiver operating characteristic (ROC) curve analysis was used to define the cutoff value for predicting AML on all patients, and only on late elderly patients (aged ≥75 years). RESULTS: Patients with AML showed higher bone marrow CT attenuation value (131.4 ± 58.3 vs. 53.9 ± 67.2 HU; P < 0.001), compared to the controls. The sensitivity and specificity for the diagnosis of AML in all patients were 78.6% and 80.4%, respectively, at a threshold value of 90 HU, whereas they were 83.3% and 91.7%, respectively, at 40 HU in late elderly patients. CONCLUSION: The iliac bone CT attenuation value was elevated in patients with AML and may be useful for predicting AML.

Severe Generalized Epidemic Myalgia in an Adult due to Human Parechovirus Type 3: A Case Report.

Parechovirus A type 3 (PeVA3) is most commonly transmitted to adults from children. Although PeVA3 infection is rarely diagnosed, as the symptoms are generally mild and self-limiting, this infection has been associated with epidemic myalgia in Japan. The patient, a 37-year-old man, presented with severe generalized myalgia, inability to open his mouth, and orchitis, which resolved over a period of 10 days. All members of his family were thought to have been infected with PeVA3 during a visit to an amusement park. Although the source of infection and inability to open his mouth are atypical, the acute generalized muscle symptoms made us suspect epidemic myalgia and enabled us to make a diagnosis of PeVA3 infection.

Clinical features and progress of ischemic gastritis with high fatalities: Seven case reports.

BACKGROUND: Ischemic gastritis is a clinically rare and highly fatal disease that occurs when the hemodynamics of a patient with vascular risk is disrupted. Early diagnosis and treatment are possible only with upper endoscopy after symptom appearance. We report seven cases of ischemic gastritis and its clinical features, prognosis, and indicators that may help in early detection. CASE SUMMARY: Of the seven patients, six had vascular risk and five died within 2 wk of diagnosis. Their symptoms included hematemesis and hypotension. Although surgery is a choice for radical treatment, not all patients were tolerant. For such patients, conservative treatment was selected, but all of them died. In contrast, patients who underwent repeat endoscopy showed improved mucosal findings, suggesting that this improvement may not affect prognosis. Some ischemic changes such as wall thickening, mural emphysema, and fluid retention in the stomach were observed before diagnosis through endoscopy and computed tomography (CT). The CT scan can be effective for early detection, and improvement in circulatory failure and aggressive treatment may save the lives of patients with this disease. CONCLUSION: The characteristic CT findings enable early detection of ischemic gastritis. Early diagnosis increases the chance of survival if early therapeutic intervention and improvement of circulatory dynamics can be achieved in this highly fatal disease.

Pranlukast treatment and the use of respiratory support in infants with respiratory syncytial virus infection.

BACKGROUND: In infants, respiratory syncytial virus (RSV) infection occasionally causes severe symptoms requiring respiratory support; however, supportive care is the primary treatment. This study compared the use of respiratory support among infants with RSV infection treated with or without pranlukast. METHODS: This retrospective cohort study included infants aged <10 months with RSV infection who were admitted to three secondary level hospitals in Japan between 2012 and 2019. The infants were divided into two groups depending on whether they were treated with pranlukast. The primary outcome was the receiving respiratory support (high-flow nasal cannula, nasal continuous positive airway pressure, or ventilator). The secondary outcomes were the length of hospital stay, and the Global Respiratory Severity Score (GRSS) on starting respiratory support or at the time of the worst signs during hospitalization. We performed a propensity score-matched analysis. RESULTS: A total of 492 infants, including 147 propensity score-matched pairs, were included in the analysis. The use of respiratory support was significantly lower in infants treated with pranlukast (3.4% [5/147]) than those treated without pranlukast (11.6% [17/147]; P = 0.01). In the propensity score-matched analysis, pranlukast use was associated with a significantly lower chance of needing respiratory support (odds ratio: 0.27, 95% confidence interval: 0.08-0.79; P = 0.01); however, the length of hospital stay (median: 4 days) and the GRSS (median: 2.804 and 2.869 for infants treated with and without pranlukast, respectively) did not differ significantly between propensity score-matched pairs. CONCLUSIONS: Pranlukast use was associated with a reduced likelihood of requiring respiratory support in infants aged <10 months with RSV infection.

Antibiotic Administration within Two Days after Successful Endoscopic Retrograde Cholangiopancreatography Is Sufficient for Mild and Moderate Acute Cholangitis.

To prevent the increase of resistant bacteria, it is important to minimize the use of antimicrobial agents. Studies have found that administration for ≤3 days after successful endoscopic retrograde cholangiopancreatography (ERCP) is appropriate. Therefore, the present study aimed to verify if administration of antimicrobial agents can be further shortened to ≤2 days after ERCP. We divided 390 patients with mild and moderate cholangitis who underwent technically successful ERCP from January 2018 to June 2020 and had positive blood or bile cultures into two groups: antibiotic therapy within two days of ERCP (short-course therapy, SCT; n = 59, 15.1%), and for >3 days (long-course therapy, LCT; n = 331, 84.9%). The increased severity after admission and other outcomes were compared between the two groups, and the risk factors for increased severity were verified. There were no between-group differences in patient characteristics. Total length of hospital stay was shorter in SCT than in LCT, and other outcomes in SCT were not significantly different from those in LCT. Being 80 or older was a risk factor for increased severity; however, SCT was not associated with increased severity. Antimicrobial therapy for ≤2 days after successful ERCP is adequate in patients with mild and moderate acute cholangitis.

Liver cyst with biliary communication treated with endoscopic ultrasound-guided drainage: A case report.

RATIONALE: Simple liver cysts are common, and usually benign and asymptomatic, requiring little to no treatment. Liver cysts with biliary communication, however, are rare and require effective treatment to avoid recurrence. PATIENT CONCERNS: A 70-year-old woman with breast cancer visited our hospital for treatment. Physical examination revealed abdominal distension and bilateral lower leg edema. DIAGNOSIS: Abdominal contrast-enhanced computed tomography revealed a giant liver cyst, inducing inferior vena cava compression that was causing her edema. INTERVENTIONS: Percutaneous transhepatic cyst drainage was performed. Since the bilirubin level in the drained fluid was high, the patient was diagnosed with a liver cyst with biliary communication. After the procedure, her symptoms improved and the cyst decreased in size. However, the drainage volume did not decrease after approximately 2 weeks. Sclerotherapy with minocycline was ineffective. Thus, endoscopic retrograde cholangiopancreatography was performed, and an endoscopic nasobiliary drainage tube was inserted. The percutaneous drainage tube was clamped, and the cyst showed increase in size. Therefore, endoscopic ultrasound-guided cyst drainage, which is less invasive than surgery, was performed. OUTCOMES: The cyst tended to decrease in size even after the percutaneous drainage tube had been removed. At 3years follow-up, the cyst has almost disappeared. LESSONS: Endoscopic ultrasound-guided drainage can treat liver cyst with biliary communication.