Case Study of a Refractory Idiopathic Peptic Ulcer in Which 24-h Intragastric pH Monitoring Contributed to Its Pathophysiological Analysis.

Introduction: In recent years, the frequency of idiopathic peptic ulcers (IPUs) has increased. However, the clinicopathological characteristics of IPU have not been fully elucidated and treatment methods for recurrent and refractory cases have not yet been established. Case Presentation: A man in his forties complained of epigastric discomfort. Esophagogastroduodenoscopy revealed a gastric ulcer in the lesser curvature of the gastric angle. After Helicobacter pylori was eradicated, the gastric ulcer recurred despite the administration of a potassium competitive acid blocker (PCAB), and a diagnosis of IPU was made. Twenty-four-hour intragastric pH monitoring revealed insufficient gastric acid suppression. Misoprostol was added to the patient's treatment. Subsequently, the ulcer healed and recurrence was not observed. Conclusion: For refractory IPU, the evaluation of pathophysiological function through 24-h gastric pH monitoring may lead to the selection of an appropriate treatment. If a proton pump inhibitor and PCAB do not improve the IPU, combination treatment with misoprostol may be considered as an option.

Characteristics of Helicobacter pylori Eradication Therapy in Patients 80 Years or Older Living in a Metropolitan Area: A Multicenter Retrospective Study.

BACKGROUND: The situation of Helicobacter pylori eradication therapy has been changing over time, owing to increases in antimicrobial-resistant strains, lifestyle improvements, and changes in indications for eradication. In Japan, eradication therapy is now available to all H. pylori-positive patients under the medical insurance system, and the potassium-competitive acid blocker vonoprazan has been used for eradication from 2015. Recently, with the aging of society, opportunities to provide eradication to elderly patients are increasing, but the current status and effectiveness of eradication in elderly patients remains unclear. Therefore, we aimed to investigate the trends of H. pylori eradication in a metropolitan area to determine the factors associated with successful H. pylori eradication in elderly patients older than 80 years. METHODS: Trends in the eradication rates of patients who received first- or second-line eradication at 20 hospitals in the Tokyo metropolitan area from 2013 to 2023 were investigated. RESULTS: The eradication rates in the per-protocol analysis were 82.3% (95% confidence interval [CI]: 81.2%-83.2%) for the first-line treatment (n = 6481), and 87.9% (86.9%-88.9%) for the second-line treatment (n = 4899). Multivariate analysis showed that independent factors for successful eradication in the first-line treatment were an age of older than 80 years (OR: 0.606; 95% CI: 0.448-0.822), peptic ulcers (vs. atrophic gastritis: 3.817; 3.286-4.433), and vonoprazan (vs. proton pump inhibiters (PPIs), 3.817; 3.286-4.433), and an age of older than 80 years (0.503; 0.362-0.699) and vonoprazan (1.386; 1.153-1.667) in the second-line treatment. CONCLUSION: After 2015, the eradication rate of both first- and second-line therapies were maintained at a higher level than before 2015, owing to the use of vonoprazan. As the H. pylori eradication rate in patients older than 80 years was low, an effective strategy for these patients needs to be developed in the future.

Residual Recurrence of a Small Intestinal Capillary Hemangioma with Obscure Gastrointestinal Bleeding Treated by Double-Balloon Endoscopy: A Case Report and Literature Review.

An 86-year-old man presented with anemia. He underwent abdominal contrast-enhanced computed tomography, gastroscopy, and colonoscopy without any bleeding detected. Small bowel capsule endoscopy (SBCE) revealed a reddish polypoid lesion with blood oozing into the jejunum. Antegrade double-balloon endoscopy (DBE) revealed a 5 mm sized protrusion into the jejunum. Endoscopic mucosal resection (EMR) was difficult; the lesion was snared and resected before energization. Clips prevented further bleeding and the lesion's position was marked with a tattoo. Histopathological examination of the lesion led to a diagnosis of capillary hemangioma. After 11 months, the patient was again anemic. A reddish polypoid lesion oozing blood near the tattoo was found by SBCE. Another antegrade DBE showed a 7 mm sized protrusion near the tattoo. The lesion was successfully treated by EMR. Histopathological examination revealed the residual recurrence of a small intestinal capillary hemangioma. The patient recovered from anemia after the EMR. Two months later, SBCE showed no findings around the tattoo. Hemangiomas account for 7-10% of benign small intestinal tumors; most are cavernous hemangiomas, and capillary hemangiomas are rare. We report a rare case of a recurring small intestinal capillary hemangioma detected by SBCE and treated using DBE. We also review the literature.

Development of an Artificial Intelligence Diagnostic System Using Linked Color Imaging for Barrett's Esophagus.

Background: Barrett's esophagus and esophageal adenocarcinoma cases are increasing as gastroesophageal reflux disease increases. Using artificial intelligence (AI) and linked color imaging (LCI), our aim was to establish a method of diagnosis for short-segment Barrett's esophagus (SSBE). Methods: We retrospectively selected 624 consecutive patients in total at our hospital, treated between May 2017 and March 2020, who experienced an esophagogastroduodenoscopy with white light imaging (WLI) and LCI. Images were randomly chosen as data for learning from WLI: 542 (SSBE+/- 348/194) of 696 (SSBE+/- 444/252); and LCI: 643 (SSBE+/- 446/197) of 805 (SSBE+/- 543/262). Using a Vision Transformer (Vit-B/16-384) to diagnose SSBE, we established two AI systems for WLI and LCI. Finally, 126 WLI (SSBE+/- 77/49) and 137 LCI (SSBE+/- 81/56) images were used for verification purposes. The accuracy of six endoscopists in making diagnoses was compared to that of AI. Results: Study participants were 68.2 ± 12.3 years, M/F 330/294, SSBE+/- 409/215. The accuracy/sensitivity/specificity (%) of AI were 84.1/89.6/75.5 for WLI and 90.5/90.1/91.1/for LCI, and those of experts and trainees were 88.6/88.7/88.4, 85.7/87.0/83.7 for WLI and 93.4/92.6/94.6, 84.7/88.1/79.8 for LCI, respectively. Conclusions: Using AI to diagnose SSBE was similar in accuracy to using a specialist. Our finding may aid the diagnosis of SSBE in the clinic.

Risk Factors for Mucosal Redness in the Duodenal Bulb as Detected via Linked Color Imaging.

Linked color imaging (LCI) for image-enhanced endoscopy (IEE) highlights mucosal color differences. We investigated risk factors associated with mucosal redness of the duodenal bulb using LCI. Consecutive patients were retrospectively selected after their duodenal bulbs were observed via LCI. A symptom questionnaire (Izumo scale) was completed. The LCI of the duodenal bulb was subjectively evaluated on whether redness was present and objectively evaluated based on L* a* b* color values. The clinical characteristics of the 302 study participants were: male/female, 120/182; mean age, 70.9 years. Twenty-one cases (7.0%) were in the redness (+) group. After multiple regression analysis, independent predictors for the red component (a*) of the duodenal bulb using LCI were: age (ß = -0.154, p < 0.01), female (ß = -0.129, p < 0.05), body mass index (BMI; ß = -0.136, p < 0.05), Helicobacter pylori eradication (ß = 0.137, p < 0.05), endoscopic gastric mucosal atrophy score (EGAS; ß = -0.149, p < 0.05), and constipation-related quality of life (QOL) (ß = -0.122, p < 0.05) scores. Lower age, lower BMI, lower EGAS, a constipation-related QOL score, post-H. pylori eradication, and being male were associated with mucosal redness in the duodenal bulb with IEE using LCI.