Effect of ice water injection toward the duodenal papilla for preventing post-ERCP pancreatitis: study protocol for a multicenter, single-blinded, randomized controlled trial (EUTOPIA study).

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the diagnosis and treatment of biliopancreatic diseases. The most common adverse event of ERCP is post-ERCP pancreatitis (PEP), which can sometimes be severe. Our previous study suggested that injecting ice water at the end of ERCP suppressed PEP, and we decided to investigate this effect in a multicenter randomized controlled trial. METHODS: This study is being conducted at eight hospitals in Japan starting in April 2022. Patients undergoing ERCP will be randomized to ice water group and control group. In the ice water group, 250 ml of ice water is injected toward the papilla at the end of ERCP. The next morning, a physical examination and blood tests are performed to evaluate for the development of pancreatitis. The goal is to have 440 cases in each group. DISCUSSION: The main cause of PEP is thought to be papilla edema. Cooling the papilla, as everyone naturally does at the time of a burn, is expected to prevent its inflammation and edema. Various methods to suppress PEP have been reported, but so far none of them are reliable. The method we have devised is very simple, easy, and safe. We hope that our study will change the world's ERCP common practice. TRIAL REGISTRATION: UMIN000047528. Registered 20 April 2022, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053209.

Cooling the papilla with ice water in preventing post-ERCP pancreatitis (ice water challenge study).

BACKGROUND: The most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). The aim of this study was to investigate the efficacy of cooling the papilla with iced water to reduce PEP. PATIENTS AND METHODS: Between December 2018 and July 2019, 100 consecutive patients with native papilla undergoing ERCP were prospectively enrolled in this study. In all patients, iced water was injected endoscopically toward the papilla via the working channel at the end of ERCP. The results were compared with 100 previous cases with native papilla that underwent ERCP under the same conditions without papilla cooling. RESULTS: Although the difference was not significant, the incidence of PEP tended to be lower in the study group (4%) than in the control group (11%) (p = 0.060). In addition, the incidence of PEP was significantly reduced in patients who underwent biliary sphincterotomy (p = 0.033). All cases of PEP were mild. CONCLUSIONS: Cooling the papilla with iced water injection, which is safe, easy, and cheap might reduce PEP.

Risk factor analysis for early rebleeding after endoscopic treatment for colonic diverticular bleeding with stigmata of recent hemorrhage.

BACKGROUND AND AIM: Colonic diverticular bleeding is a common cause of acute lower gastrointestinal bleeding. Endoscopic hemostasis is generally selected as the first-line treatment; however, a considerable number of patients experience early rebleeding after endoscopic treatment. We investigated the risk factors for early rebleeding after endoscopic treatment. METHODS: We retrospectively evaluated the data of 142 consecutive patients who underwent endoscopic treatment (endoscopic clipping or endoscopic band ligation) for colonic diverticular bleeding with stigmata of recent hemorrhage between April 2012 and April 2020. Multivariate logistic regression analysis was conducted to evaluate the statistical relationship between patient characteristics and the incidence of early rebleeding occurring within 30 days after endoscopic treatment. RESULTS: Of 142 patients, early rebleeding was detected in 34 (23.9%) patients. According to univariate analysis, platelet count of <10 × 104/µL, bleeding from the left-sided colon, and endoscopic clipping usage were associated with early rebleeding (P < 0.05). The subsequent multivariate logistic regression analysis identified bleeding from the left-sided colon (odds ratio [OR], 4.16; 95% confidence interval [CI], 1.73-10.0; P = 0.001) and endoscopic clipping usage (OR, 2.92; 95% CI, 1.21-7.00; P = 0.017) as the independent risk factors for early rebleeding. CONCLUSIONS: Bleeding from the left-sided colon and endoscopic clipping usage were the risk factors for early rebleeding after endoscopic treatment. Using endoscopic band ligation was associated with a decreased risk for early rebleeding compared with the use of endoscopic clipping, indicating that endoscopic band ligation was a preferable endoscopic modality to prevent early recurrent bleeding.

An unusual tumor of the bile duct.

Highlight Sawada and colleagues report a case of mucinous cholangiocarcinoma not originating from intraductal papillary neoplasm of the bile duct. While recognizing the imaging features of the bile ducts is difficult due to their narrow area, the detailed characteristic features may enable preoperative diagnosis of this rare type of cholangiocarcinoma.

Portal vein thrombosis due to essential thrombocythemia with limited cutaneous systemic sclerosis.

Portal vein thrombosis is caused by various diseases, including liver cirrhosis, cancer, abdominal infection, and myeloproliferative disorders. Essential thrombocythemia is one of the myeloproliferative disorders in which the bone marrow produces excessive amount of platelets and can be accompanied by various thrombotic diseases; however, essential thrombocythemia with limited cutaneous systemic sclerosis has not been reported yet. We herein report a case of extensive portal vein thrombosis due to essential thrombocythemia with limited cutaneous systemic sclerosis. A 49-year-old woman was referred to our hospital due to liver dysfunction. Extended portal vein thrombosis, splenomegaly, and thrombocytosis were founded. The examination of Janus kinase 2 V617F mutation in the bone marrow was positive. These findings resulted in the diagnosis of portal vein thrombosis due to essential thrombocythemia. Furthermore, Raynaud's phenomenon, finger's sclerosis, and positive anti-centromere antibody led to limited cutaneous systemic sclerosis. To further analyze the causal relationship between essential thrombocythemia and limited cutaneous systemic sclerosis, platelet-derived growth factor was examined. High level of serum platelet-derived growth factor, possibly caused by high platelet count due to essential thrombocythemia, was observed. As platelet-derived growth factor has been reportedly associated with the occurrence of systemic sclerosis, the present case indicates the possible causal link between essential thrombocythemia and limited cutaneous systemic sclerosis through high platelet-derived growth factor.

Hepatitis-associated Aplastic Anemia with Rapid Progression of Liver Fibrosis Due to Repeated Hepatitis.

Hepatitis-associated aplastic anemia (HAAA) is a variant of acquired aplastic anemia and characterized by bone marrow failure that follows the development of acute hepatitis. We herein report a rare case of HAAA with rapid progression of liver fibrosis due to repeated hepatitis. A pathological examination of liver specimens revealed liver fibrosis progression over a short period. Immunosuppressive therapy with cyclosporine effectively cured both the pancytopenia and hepatitis. Our case suggests that the pathological examination of the liver tissue is useful for determining a treatment plan and that immunosuppressive therapy is a promising treatment for both aplastic anemia and persistent hepatitis.

Accelerated Progression of Hepatocellular Carcinoma during Immunosuppressive Therapy with Abatacept for Rheumatoid Arthritis.

Abatacept, a cytotoxic T lymphocyte antigen-4 immunoglobulin recombinant fusion protein, is an immunosuppressive agent indicated for rheumatoid arthritis. Although no significant increase in malignancy has been reported in abatacept-treated patients, whether or not abatacept accelerates tumor progression in specific cancer types remains unclear. We herein report a 66-year-old woman who showed unusually rapid progression of hepatocellular carcinoma following abatacept therapy for rheumatoid arthritis. Abatacept was speculated to have accelerated her hepatocellular carcinoma progression in the setting of her preexisting risk factors: autoimmune hepatitis and long-term methotrexate use. We propose close tumor surveillance be performed during abatacept therapy, especially for high-risk patients.

Choledochoduodenal Fistula during Chemotherapy with Brentuximab Vedotin for Methotrexate-associated Lymphoproliferative Disorder.

We herein report a patient with a history of rheumatoid arthritis treated with methotrexate, which caused methotrexate-associated lymphoproliferative disorder and obstructive jaundice due to an enlarged lymph node. The obstructive jaundice was treated with endoscopic biliary stenting. A histopathological examination revealed features of Hodgkin's lymphoma, and chemotherapy with brentuximab vedotin was administered. Cholangiography and duodenoscopy after four rounds of chemotherapy revealed a choledochoduodenal fistula that developed in response to chemotherapy. It should be noted that, in cases of lymphoma infiltrating the gastrointestinal wall, fistulae can occur because of rapid regression due to regimens comprising monoclonal antibodies, such as rituximab and brentuximab vedotin.

Inhibitory effect of 1α-hydroxyvitamin D3 on N-nitrosobis(2-oxopropyl)amine-induced cholangiocarcinogenesis in Syrian hamsters.

Sixty-three male 5-week-old Syrian hamsters received the carcinogen N-nitrosobis(2-oxopropyl)amine (BOP) s.c. in 5 weekly injections (the first, 70 mg/kg body, and the remaining, 20mg/kg each). The hamsters that received BOP were given intragastric administration of 0.2 ml of medium chain triglyceride (MCT) with or without 0.04 µg of 1α-hydroxyvitamin D3 [1α(OH)D3] through a feeding tube for 12 weeks. Thus, 3 groups were assigned:Group 1;BOP alone (n＝20), Group 2;BOP＋MCT (n＝18) and Group 3;BOP＋1α(OH)D3 (n＝25). The mean body weight of Group 3 was lower than those of Groups 1 and 2 at the end of the experiment (p＜0.001,Tukey-Kramer HSD test). At the end of week 12, all surviving hamsters were put to sleep. The incidences of liver tumors were 80%, 72% and 32% in Groups 1, 2 and 3, respectively. The incidence of tumors in Group 3 was significantly lower than in Group 1 and Group 2 (p＜0.05, χ2-test). All tumors were cholangiocarcinoma. These results indicated that BOP-induced cholangiocarcinogenesis was suppressed by the supplemental administration of 1α(OH)D3.

[Efficacy of vitreous surgery for uveal effusion syndrome].

PURPOSE: To evaluate the efficacy of pars plana vitrectomy for uveal effusion syndrome retrospectively. SUBJECTS AND METHODS: Six patients (six eyes) with uveal effusion syndrome(UE) underwent vitrectomy followed by internal drainage of subretinal fluid, fluid-gas exchange, and pan-retinal photocoagulation. Three of these cases with nanophthalmos underwent silicone oil injection. RESULTS: The retina became reattached in all cases. The silicone oil was not removed in two of the three cases with nanophthalmic eyes. Two cases of the three cases with nanophthalmic eyes needed to perform full thickness sclerostomy additionally, and in one case subchoroidal hemorrhage occurred. The visual acuity finally improved in five out of the six eyes. CONCLUSIONS: In cases of uveal effusion without nanophthalmic, vitrectomy hastens quick reattachment of the retina and may result in better visual outcome. But in cases of nanophthalmic eyes, it would be better to perform sclerostomy first.

[Evaluation of the efficacy of intravitreal gas injection for submacular hemorrhages].

PURPOSE: To evaluate the efficacy of intravitreal gas injection for submacular hemorrhages(SMH). PATIENTS AND METHODS: The records of 29 patients with SMH, who were treated by pneumatic displacement with expansile gas, were reviewed retrospectively. RESULT: In observable cases, SMH had started moving within five days after the procedure. After 6 months visual acuity had been improved 2 or more lines in 23 eyes(79%). The causes of SMH were age-related macular degeneration (17 eyes) and microaneurysm (12 eyes). The larger the size of SMH, had the greater the risk of developing vitreous hemorrhage. Twelve eyes of the 29 eyes required vitrectomy owing to vitreous hemorrhage, insufficient removal of SMH, etc. but this pneumatic procedure often eliminated the need for vitrectomy. The visual acuity of the patients with additional vitrectomy was improved with only pneumatic displacement. None of the patients had serious complications with this pneumatic procedure and the vitrectomy. CONCLUSION: The first choice for SMH is intravitreal gas injection which saves foveal function, and improves the prognosis for better vision.

[Influence of vitrectomy for diabetic retinopathy on health-related quality of life].

PURPOSE: To evaluate the vision-related quality of life (QOL) in patients undergoing vitrectomy for diabetic retinopathy with the Japanese version of the 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25). SUBJECTS AND METHODS: Subjects were 87 patients undergoing vitrectomy for diabetic retinopathy of vitreous hemorrhage, macular edema, or fibrovascular membrane, only for the subject eye, or for subjects undergoing vitrectomy for the fellow eye within 6 months or later. The VFQ-25 date was recorded one month before and 6 months after the vitrectomy. The VFQ-25 data were compared before and after the vitrectomy. The subjects were classified by the pathological condition: 41 eyes with vitreous hemorrhage, 28 eyes with macular edema, and 18 eyes with fibrovascular membrane. RESULTS: The average VFQ-25 scores of all the patients increased in almost all of the 12 subscales. Vitrectomy for vitreous hemorrhage was most effective in improving the VFQ-25 score, in improving 10 of the 12 subscales in the VFQ-25, and in increasing VFQ-25 scores to almost the same level as in phacoemulsification and foldable intraocular lens implantation for cataract patients in both eyes. CONCLUSION: NEI VFQ-25 quantitatively clarified that vitrectomy for diabetic retinopathy is effective in increasing the QOL of diabetic retinopathy patients.