A case of hemorrhagic Meckel's diverticulum diagnosed by transabdominal ultrasound.

A 23-year-old man with a history of anemia of unknown cause was referred to our hospital. He had experienced melena three times: at 6 months, 10 years, and 20 years of age. He underwent upper and lower gastrointestinal endoscopy at 10 and 20 years of age, and small intestinal capsule endoscopy twice at 20 years of age, but the site of bleeding could not be identified. At first, a transabdominal ultrasound was performed for suspected Meckel's diverticulum. A cystic diverticulum was found in the ileum, with an apertural diameter of 5 mm and a total size of 4 cm. The cyst showed an area of loss of wall stratification, which appeared to be an ulcer scar. Based on these observations, we diagnosed anemia resulting from a hemorrhagic Meckel's diverticulum and performed laparoscopic resection. Postoperative histopathology revealed ectopic gastric mucosa and ulcer formation within the Meckel's diverticulum, which was thought to be the cause of the bleeding. Meckel's diverticulum should be considered in cases of hemorrhage in young patients. A transabdominal ultrasound as a screening test detected a diverticulum with an ulcer scar in the ileum, which led to the identification of the underlying disease.

Contrast-enhanced ultrasonography combined with superb microvascular imaging for preoperative diagnosis of sporadic intra-abdominal desmoid-type fibromatosis: A case report.

We herein report a case of sporadic intra-abdominal desmoid-type fibromatosis in which contrast-enhanced ultrasonography (US) combined with superb microvascular imaging (SMI) was useful for preoperative diagnosis. 18-Fluorodeoxyglucose positron emission tomography performed for systematic screening for lung cancer revealed an abnormal accumulation in the abdominal cavity. Transabdominal US showed a tumor with a mixture of hypoechoic and hyperechoic areas. Contrast-enhanced US combined with SMI revealed dendritic blood flow signals and no abnormal vascular network within the tumor. Macroscopic examination of the resected specimen revealed a white tumor with relatively clear boundaries. Microscopic examination revealed spindle cells with poor atypia proliferating in bundles with collagenous stromal cells. Immunohistochemistry showed nuclear localization of beta-catenin within the tumor cells. From these findings, we finally diagnosed intra-abdominal desmoid-type fibromatosis. Contrast-enhanced US combined with SMI is useful for diagnosing intra-abdominal desmoid-type fibromatosis.

A Study of the Risk Factors for 402 Patients with Esophageal Squamous Cell Carcinoma - A Retrospective Comparison with Health Checkup Participants.

Objective Esophageal cancer is a gastrointestinal cancer with a poor prognosis. However, it is curable and can be treated endoscopically if it is detected at an early stage. The objective of this study was to identify the factors that contribute to early detection. Methods From April 2011 to December 2019, we retrospectively investigated consecutive patients diagnosed with esophageal squamous cell carcinoma (ESCC) through upper gastrointestinal endoscopy at two hospitals of Kawasaki Medical University based on medical records. The factors contributing to the early detection of ESCC were investigated by comparing patients with ESCC with those undergoing health checkups in whom no organic lesions were found in the upper gastrointestinal tract on endoscopy (controls). Patients Factors contributing to early detection were examined in 402 ESCC cases and 391 sex- and age-matched controls, and early and advanced cancers were compared along with the risk factors for ESCC. Results A multivariate analysis showed that alcohol consumption and smoking, concomitant cancer of other organs, and a low body mass index (BMI) were factors associated with ESCC (odds ratio [OR], 4.65; 95% confidence interval [CI], 2.880-7.520, OR,3.63; 95% CI, 2.380-5.540, OR, 2.09; 95% CI, 1.330-3.270, OR, 6.38; 95% CI, 3.780-10.800), whereas dyslipidemia was significantly less common in patients with ESCC (OR, 0.545; 95% CI, 0.348-0.853). Comparing early and advanced cancers, a history of endoscopic screening was the only factor involved in early detection (OR, 7.93; 95% CI, 4.480-14.00). Conclusion The factors associated with ESCC include alcohol consumption, smoking, concomitant cancer of other organs, and a low BMI. Endoscopy in subjects with these factors may therefore be recommended for the early detection of ESCC.

A case of strangulated bowel obstruction in which transabdominal ultrasound was useful for preoperative diagnosis.

A 74-year-old man presented to the emergency department with the chief complaint of abdominal pain. A computed tomography scan showed paralytic ileus. An ileostomy tube was placed, but the symptoms of bowel obstruction did not improve. Two days after admission, the patient's renal function deteriorated. Transabdominal ultrasound (TUS) showed linear high-intensity echoes consistent with a fibrotic band and microbubbles suggestive of circulatory disturbance in the dilated intestinal tract. Subsequent contrast-enhanced ultrasound revealed circulatory disturbance of the small bowel wall. Emergency surgery was performed under the diagnosis of strangulated ileus. Intraoperative examination revealed that the terminal ileum was strangulated by a fibrotic band from the retroperitoneum, which was confirmed by TUS. The fibrotic band was resected, the strangulation was released, and ileocecal resection was performed. Postoperatively, intestinal peristalsis was rapidly restored. TUS was able to depict the fibrotic band, which could not be detected by a computed tomography scan, allowing the patient to undergo immediate surgical treatment. We herein report this case of strangulated bowel obstruction in which TUS and contrast-enhanced ultrasound were useful in preoperative assessment of the patient's condition.

Appendiceal mucocele pathologically classified as appendiceal epithelial hyperplasia and preoperatively diagnosed by contrast-enhanced ultrasonography: A case report.

We report a patient with a mucocele with diffuse wall thickening diagnosed by transabdominal ultrasonography and contrast-enhanced ultrasonography. Transabdominal ultrasonography showed diffuse thickening of the entire appendix wall and an anechoic area that appeared to be fluid collected throughout the appendix lumen. However, the "onion skin sign" was not detected. Contrast-enhanced ultrasonography combined with superb microvascular imaging revealed abundant mucosal blood flow and no abnormal vascular network within the mucosa of the appendix wall. We preoperatively diagnosed a mucocele complicated by acute and chronic appendicitis, and ileocecal resection was performed. Macroscopic and microscopic findings of the resected specimens demonstrated that the appendiceal wall was diffusely thickened, with fibrosis and inflammatory cell infiltration, and that the appendiceal root rumen was narrowed with epithelial hyperplasia. No neoplastic changes were observed. The cause of the appendiceal mucocele was likely fibrosis and stenosis at the root of the appendix due to initial acute appendicitis.

A multi-institutional study designed by members of Tokyo Guidelines (TG) Core Meeting to elucidate the clinical characteristics and pathogenesis of acute cholangitis after bilioenteric anastomosis and biliary stent insertion with a focus on biliary obstruction: Role of transient hepatic attenuation difference (THAD) and pneumobilia in improving TG diagnostic performance.

BACKGROUND/PURPOSE: The aim of this study was to clarify the clinical characteristics of acute cholangitis (AC) after bilioenteric anastomosis and stent-related AC in a multi-institutional retrospective study, and validate the TG18 diagnostic performance for various type of cholangitis. METHODS: We retrospectively reviewed 1079 AC patients during 2020, at 16 Tokyo Guidelines 18 (TG 18) Core Meeting institutions. Of these, the post-biliary reconstruction associated AC (PBR-AC), stent-associated AC (S-AC) and common AC (C-AC) were 228, 307, and 544, respectively. The characteristics of each AC were compared, and the TG18 diagnostic performance of each was evaluated. RESULTS: The PBR-AC group showed significantly milder biliary stasis compared to the C-AC group. Using TG18 criteria, definitive diagnosis rate in the PBR-AC group was significantly lower than that in the C-AC group (59.6% vs. 79.6%, p < .001) because of significantly lower prevalence of TG 18 imaging findings and milder bile stasis. In the S-AC group, the bile stasis was also milder, but definitive-diagnostic rate was significantly higher (95.1%) compared to the C-AC group. The incidence of transient hepatic attenuation difference (THAD) and pneumobilia were more frequent in PBR-AC than that in C-AC. The definitive-diagnostic rate of PBR-AC (59.6%-78.1%) and total cohort (79.6%-85.3%) were significantly improved when newly adding these items to TG18 diagnostic imaging findings. CONCLUSIONS: The diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

Serial Changes in Intestinal Stenotic Stiffness in Patients with Crohn's Disease Treated with Biologics: A Pilot Study Using Ultrasound Shear Wave Elastography.

BACKGROUND/AIMS: Intestinal strictures represent an important serious complication of Crohn's disease. Shear wave elastography is a promising noninvasive ultrasound technique for assessing tissue stiffness. This study aimed to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease using shear wave elastography and the changes in stiffness after biologics. MATERIALS AND METHODS: We enrolled 21 Crohn's disease patients having intestinal stricture. The patients consisted of 3 groups, which were the infliximab naïve (n = 6) group, the ustekinumab naïve (n = 8), and the bio-switch from infliximab to ustekinumab (n = 7) group. Bowell wall thickness was examined by ultrasound sonography, and the stiffness of Crohn's disease stricture lesions was evaluated using Shear wave speed before and 1 year after anti-tumor necrosis factor-alpha antibody infliximab, anti-interleukin 12/23 antibody ustekinumab, and bio-switch from infliximab to ustekinumab. RESULTS: Bowell wall thickness was significantly improved after infliximab, ustekinumab, and the bio-switch. However, shear wave speed indices only in the ustekinumab group significantly decreased after treatment (P = .028), but not in the other group. CONCLUSIONS: Shear wave elastography might be a useful method to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease treated with biologics. However, a prospective randomized study evaluating the development of obstruction after biological treatment is needed to validate the study findings.

LONG-HOSP Score: A Novel Predictive Score for Length of Hospital Stay in Acute Lower Gastrointestinal Bleeding - A Multicenter Nationwide Study.

INTRODUCTION: Length of stay (LOS) in hospital affects cost, patient quality of life, and hospital management; however, existing gastrointestinal bleeding models applicable at hospital admission have not focused on LOS. We aimed to construct a predictive model for LOS in acute lower gastrointestinal bleeding (ALGIB). METHODS: We retrospectively analyzed the records of 8,547 patients emergently hospitalized for ALGIB at 49 hospitals (the CODE BLUE-J Study). A predictive model for prolonged hospital stay was developed using the baseline characteristics of 7,107 patients and externally validated in 1,440 patients. Furthermore, a multivariate analysis assessed the impact of additional variables during hospitalization on LOS. RESULTS: Focusing on baseline characteristics, a predictive model for prolonged hospital stay was developed, the LONG-HOSP score, which consisted of low body mass index, laboratory data, old age, nondrinker status, nonsteroidal anti-inflammatory drug use, facility with ≥800 beds, heart rate, oral antithrombotic agent use, symptoms, systolic blood pressure, performance status, and past medical history. The score showed relatively high performance in predicting prolonged hospital stay and high hospitalization costs (area under the curve: 0.70 and 0.73 for derivation, respectively, and 0.66 and 0.71 for external validation, respectively). Next, we focused on in-hospital management. Diagnosis of colitis or colorectal cancer, rebleeding, and the need for blood transfusion, interventional radiology, and surgery prolonged LOS, regardless of the LONG-HOSP score. By contrast, early colonoscopy and endoscopic treatment shortened LOS. CONCLUSIONS: At hospital admission for ALGIB, our novel predictive model stratified patients by their risk of prolonged hospital stay. During hospitalization, early colonoscopy and endoscopic treatment shortened LOS.

Differences between patients with inpatient-onset and outpatient-onset acute lower gastrointestinal bleeding: An observational study.

BACKGROUND AND AIM: The clinical severity and course of acute lower gastrointestinal bleeding (ALGIB) are believed to differ between inpatient-onset and outpatient-onset cases, but no reports have investigated these issues in detail. We aimed to evaluate the clinical differences between inpatient-onset and outpatient-onset ALGIB. METHODS: Medical records of patients who had undergone emergency colonoscopy for ALGIB were retrospectively reviewed. The severity was evaluated using the NOBLADS score. Patients with obvious ALGIB relapse and/or persistent iron-deficiency anemia after emergency colonoscopy were considered to exhibit a poor clinical course. RESULTS: We reviewed 723 patients with ALGIB and divided them into the inpatient-onset cohort (172 patients) and outpatient-onset cohort (551 patients). Compared with the outpatient-onset cohort, the inpatient-onset cohort had a significantly higher proportion of patients with a poor clinical course (51.2% vs 21.6%; P < 0.001) and a significantly higher mean NOBLADS score (3.6 ± 1.1 vs 2.5 ± 1.0; P < 0.001). The most common bleeding source was acute hemorrhagic rectal ulcer (52.3%) in the inpatient-onset cohort and colonic diverticular bleeding (29.4%) in the outpatient-onset cohort. Multivariate analysis showed that a platelet count < 15 × 104 /µL and albumin concentration < 3 g/dL were significantly associated with a poor clinical course in the inpatient-onset cohort. CONCLUSIONS: The clinical course was significantly worse in the inpatient-onset cohort than in the outpatient-onset cohort. The bleeding source, clinical characteristics, and clinical course differed between the inpatient-onset and outpatient-onset cohorts. The clinical course in the inpatient-onset cohort may depend on the patient's condition at ALGIB onset.

Basic practices for gastrointestinal ultrasound.

The standard diagnostic modalities for gastrointestinal (GI) diseases have long been endoscopy and barium enema. Recently, trans-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, have become increasingly utilized in daily practice. In transabdominal ultrasonography (US), the bowel sometimes interferes with the observation of abdominal organs. Additionally, the thin intestinal walls and internal gas can make structures difficult to identify. However, under optimal US equipment settings, with identification of the sonoanatomy and knowledge of the US findings of GI diseases, US can be used effectively to diagnose GI disorders. Thus, the efficacy of GIUS has been gradually recognized, and GIUS guidelines have been published by the World Federation for Ultrasound in Medicine and Biology and the European Federation of Societies for Ultrasound in Medicine and Biology. Following a systematic scanning method according to the sonoanatomy and precisely estimating the layered wall structures by employing color Doppler make diagnosing disease and evaluating the degree of inflammation possible. This review describes current GIUS practices from an equipment perspective, a procedure for systematic scanning, typical findings of the normal GI tract, and 10 diagnostic items in an attempt to help medical practitioners effectively perform GIUS and promote the use of GIUS globally.

Subjective factors affecting prognosis of 469 patients with esophageal squamous cell carcinoma: a retrospective cohort study of endoscopic screening.

BACKGROUND: To date, no in-depth studies have focused on the impact of various clinical characteristics of esophageal squamous cell carcinoma (ESCC), including its association with subjective symptoms, on patient prognosis. We aimed to investigate the clinical factors that affect the prognosis of patients with ESCC and to clarify how subjective symptoms are related to prognosis. METHODS: We retrospectively evaluated the clinical records of 503 consecutive patients with ESCC from April 2011 to December 2019. Six established prognostic factors for ESCC (body mass index, alcohol drinking, cigarette smoking, sex, clinical stage, and age) and subjective symptoms were used to subgroup patients and analyze survival differences. Next, the patients were divided into two groups: a symptomatic group and an asymptomatic group. In the symptomatic group, differences in the incidence of subjective symptoms according to tumor size, tumor location, macroscopic tumor type, and clinical stage were examined. Finally, subjective symptoms were divided into swallowing-related symptoms and other symptoms, and their prognosis was compared. RESULTS: Multivariate Cox regression analysis identified sex [hazard ratio (HR) 1.778; 95% CI 1.004-3.149; p = 0.049], TNM classification (HR 6.591; 95% CI 3.438-12.63; p < 0.001), and subjective symptoms (HR 1.986; 95% CI 1.037-3.803; p = 0.0386) as independent risk factors for overall survival. In the symptomatic group, the mean time from symptom onset to diagnosis was 2.4 ± 4.3 months. The incidence of subjective symptoms differed by clinical stage, and the prognosis of patients with swallowing-related symptoms was significantly worse than that of patients with other symptoms. CONCLUSION: The results of this study suggest that screening by upper gastrointestinal endoscopy, independent of subjective symptoms (especially swallowing-related symptoms), may play an important role in the early detection and improvement of prognosis of ESCC, although further validation in a large prospective study is needed.

Point-of-care ultrasound for acute abdomen: 5W1H (Translated version).

In this paper, point-of-care ultrasound (POCUS) for the initial diagnosis and the management of acute abdomen is discussed. POCUS is supposed to be executed mainly by doctors other than ultrasound specialists anytime and anywhere such as in the emergency room or the intensive care unit. Although it seems rather difficult to cover the wide spectrum of organs as well as diseases causing acute abdominal pain, the author advocates a "six approach" for the diagnosis and triage of acute abdomen, which consists of scanning at eight points in less than 5 min. With this method, the attending doctor can diagnose most of the diseases frequently encountered in patients with acute abdomen, which can help patients avoid unnecessary examinations or admissions. However, users of POCUS should be aware of its limitations, especially when they are using pocket-sized ultrasound equipment. Therefore, users should be careful when ruling out a disease even when they cannot find any pathological findings, and consider the need for further examinations such as US done by specialists with high-end equipment or CT. Since there has been no standard curriculum in Japan for POCUS training that should deal with basic physics and techniques for US, normal abdominal anatomy, typical pathological US findings, and interventional US, the establishment of a learning program for doctors and training of experts as instructors of POCUS are needed.

A sonographic software program, Fluctuational Imaging, for diagnosis of hepatic hemangioma.

Hepatic hemangioma is the most common benign solid lesion of the liver. Contrast-enhanced computed tomography or magnetic resonance imaging is recommended for definitive diagnosis of hepatic hemangioma. However, these modalities have drawbacks in terms of radiation exposure, invasiveness, and high cost for examination. "Fluttering sign" is one of the candidate findings considered specific for hepatic hemangioma that can be useful for diagnosis of hepatic hemangioma using grayscale US alone. However, the assessment is subjective and the findings are weak and likely to be overlooked in some cases. We developed a software program, Fluctuational Imaging, for objective detection and depiction of "fluttering sign". Here, we evaluated the ability of Fluctuational Imaging software to depict "fluttering sign" in hepatic hemangioma. Presence or absence of "fluttering sign" was evaluated in the grayscale US videos and Fluctuational Imaging software analysis results of patients with hepatic hemangioma. The Cohen's kappa test showed very good agreement (0.95). Fluctuational Imaging software can detect and depict the phenomenon of "fluttering sign" well and may be a useful tool for diagnosis of hepatic hemangioma.

The Use of Transabdominal Ultrasound in Inflammatory Bowel Disease.

Transabdominal ultrasound (TAUS) is useful in all aspects of lesion screening, monitoring activity, or treating/diagnosing any related complications of inflammatory bowel disease. Its ability to screen or diagnose complications is almost the same as that of other methods, such as CT or MRI. Moreover, its noninvasiveness makes it a first-line examination method. A TAUS image depicting ulcerative colitis will show large intestinal wall thickening that is continuous from the rectum, which is mainly due to mucosal layer thickening, while for Crohn's disease, a TAUS image is characterized by a diversity in the areas affected, distribution, and layer structure. Indicators of activity monitoring include wall thickness, wall structure, and vascular tests that use Doppler ultrasound or contrast agents. While all of these have been reported to be useful, at this time, no single parameter has been established as superior to others; therefore, a comprehensive evaluation of these parameters is justified. In addition, evaluating the elasticity of lesions using elastography is particularly useful for distinguishing between fibrous and inflammatory stenoses. However, the lack of objectivity is the biggest drawback of using ultrasound. Standardizing and popularizing the ultrasound process will be necessary, including scanning methods, equipment settings, and image analysis.

Modified Socratic Method (planned and executed by Takada) for medical education: Grade II Acute Cholecystitis of Tokyo Guidelines 2018 as an example case.

BACKGROUND: Socratic method, which is an educational method to promote critical thinking through a dialogue, has never been practiced in a large number of people at the academic societies. METHODS: Modified Socratic method was performed for the first time as an educational seminar using an example case of moderate acute cholecystitis based on the evidence described in Tokyo Guidelines 2018. We adopted a method that Takada had been modifying for many years: the instructor first knows the degree of recognition of the audience, then the instructor gives a lecture in an easy-to-understand manner and receives questions from the audience, followed by repeated questions and answers toward a common recognition. RESULTS: Using slides, video, and an answer pad, 281 participants including the audience, instructors and moderators came together to repeatedly ask and answer questions in the five sessions related to the case scenario. The recognition rate of the topic of Critical View of Safety increased significantly before vs after this method (53.0% vs 90.3%). The seminar had been successfully performed by receiving a lot of praise from the participants. CONCLUSION: This educational method is considered to be adopted by many academic societies in the future as an effective educational method.

Contrast-enhanced ultrasonographic findings of non-occlusive mesenteric ischemia: a case series.

PURPOSE: Diagnosis of non-occlusive mesenteric ischemia (NOMI) is difficult, with diagnostic imaging being mainly performed using angiography or contrast-enhanced computed tomography. Contrast-enhanced ultrasonography (CEUS) offers an alternative diagnostic method, although diagnosis of NOMI using CEUS is not common. In this report, we review CEUS findings in a series of patients with NOMI. METHODS: The records of patients diagnosed with NOMI who underwent a surgical procedure in our institution between January 2015 and February 2020 were retrospectively assessed. Grayscale ultrasonography and CEUS findings were evaluated. RESULTS: Ten patients (mean age 65 ± 25 years, 7 men) were studied. Grayscale ultrasonography revealed bowel dilatation, the presence of intestinal pneumatosis, portal venous gas, bowel wall thickening, and no or decreased peristalsis. A CEUS finding of note was a partial lack of enhancement of the bowel wall. CONCLUSION: In a small case series of 10 patients with surgically/histopathology confirmed NOMI, partial lack of ultrasound contrast-enhancement of the bowel wall was observed.

Usefulness of radiographic targeting on the evaluation of the location of a patency capsule using abdominal ultrasonography.

BACKGROUND AND AIM: The usefulness of a radio-tag-free PillCam patency capsule (PatCap) has been reported to evaluate the patency of the small intestine. If the PatCap is not excreted within 33 h, the location of the failed PatCap must be confirmed. Although several methods for locating the failed PatCap have been reported, a universal method has not been established. In this study, we aimed to confirm the clinical feasibility of abdominal ultrasonography combined with abdominal X-ray in the determination of the location of a failed PatCap. PATIENTS AND METHODS: Consecutive patients who were scheduled to undergo the capsule endoscopy and had received PatCap examination between July 2012 and September 2019 were retrospectively analyzed. Failed PatCap was assessed using ultrasonography combined with abdominal X-ray. RESULTS: Among the eligible 250 patients, 129 retrieved the PatCap in their stool within 33 h after ingestion. Among the remaining 121 patients, abdominal X-ray was performed and the PatCaps were suspected to be in the small bowel in 57 patients. Among these 57 patients, abdominal ultrasonography identified 17 PatCaps in the small bowel. Among the selected 250 patients, 233 patients (93.2%) were eligible for capsule endoscopy examination, while 17 patients (6.8%) were not eligible. Capsule endoscopy passed through the small intestine without any incident. CONCLUSION: We confirmed that the abdominal ultrasonography with a radiographic targeting of the PatCap location is a reliable indicator to avoid the risk of capsule endoscopy retention or impaction and can be performed in most hospitals and clinics.

Diagnosis and treatments for oropharyngeal dysphagia: effects of capsaicin evaluated by newly developed ultrasonographic method.

Oropharyngeal dysphagia (OD) is a common symptom in the older people, and may cause fatal complications such as aspiration pneumonia. However, there is no established treatment for OD. The relationship between the transient receptor potential vanilloid 1 (TRPV1) and substance P released by activated TRPV1 was recently demonstrated. Further, there are several reports showing that capsaicin, a specific agonist of TRPV1, can improve OD. Currently, the evaluation of swallowing is mainly performed by videofluoroscopic examination. However, there are no reports on the clinical application of ultrasonography using tissue Doppler imaging. In this review, we describe the pathophysiology and treatments for OD, introduce our novel US method to evaluate cervical esophageal motility, and then outline our clinical study examining the effects of capsaicin, a specific TRPV1 agonist, in older patients with OD.