[Two cases of chronic upside down stomach with "reverse incarceration" in the abdominal cavity].

Upside down stomach (UDS) is a rare type of hiatal hernia. It is categorized by herniation of either the entire stomach or most of the gastric portion of the stomach into the posterior mediastinum. Acute UDS usually presents with abdominal and thoracic symptoms immediately after the stomach rotates, while chronic UDS often has either mild or no symptoms with the entire stomach rotated in the mediastinum. The first case was a 70-year-old female who was admitted with complaints of sudden vomiting and epigastric pain after eating. Computed tomography (CT) revealed UDS. Almost the entire stomach was twisted in the mediastinum, but the fornix was located in the abdominal cavity. After endoscopic reduction, the entire stomach was located in the mediastinum. Her symptoms disappeared and she was able to eat. The second case was another 70-year-old female with multiple hospitalizations due to frequent vomiting after eating. A review of previous CT scans showed a typical chronic UDS with the entire stomach located in the mediastinum. During her most current hospitalization, she was admitted with complaints of frequent vomiting and chest pain after overeating, and a CT showed UDS with only the fornix located in the abdominal cavity. Following hospitalization, the persistent vomiting disappeared and a CT scan at that point revealed that the fornix had returned to the mediastinum and she now had a normal UDS. These results indicate that chronic UDS caused acute symptoms due to "reverse incarceration" in the abdominal cavity through the diaphragmatic hiatus following eating. Chronic UDS is often either asymptomatic or only mildly symptomatic. However, these cases suggest that there is a mechanism whereby chronic UDS may cause acute UDS-like symptoms when the fornix becomes "reversely incarcerated" in the abdominal cavity following eating.

[A case of early syphilitic hepatitis with jaundice cured by high-dose amoxicillin and probenecid].

A 44-year-old man was admitted because of general malaise, jaundice, and epigastric pain. The patient had no significant medical history. However, the patient visited a brothel 3 months ago and noticed initial induration on his penis 2 months ago. Physical examination revealed swelling surface lymph nodes in the inguinals. Laboratory examination showed moderate hepatic disorder and jaundice. Hepatitis virus markers and various types of autoantibodies were negative, but serological test for syphilis was positive. The symptoms and abnormal data improved immediately after the patient was treated with amoxicillin (3000mg/day) and probenecid (750mg/day). Thus, a diagnosis of early syphilitic hepatitis was established. In addition, syphilis is not just a genital disease. This disease should be thought of in a patient with liver dysfunction, especially among people of high sexual activity.

[Responsiveness of well-differentiated PanNET G3 to platinum-based chemotherapy: a case report].

According to the 2017 WHO classification (4th version), PanNEC G3 was subdivided into two groups:well-differentiated PanNET G3 and poorly differentiated PanNEC. Considering the insufficient number of case reports, appropriate chemotherapy for the new category PanNET G3 remains unknown. Here, we report a case of PanNET G3 that responded to platinum-based chemotherapy.

[Gastric myxoid epithelioid gastrointestinal stromal tumor harboring PDGFRA gene mutation:a case report].

A 67-year-old man visited our hospital with an enlarging abdominal mass several months after he had first noticed his symptoms. An elastic firm tumor was palpated on the left side of the abdomen upon physical examination. The blood test results were normal. Contrast-enhanced computed tomography of the abdomen revealed a 10-cm-diameter homogeneous low-density cystic tumor located at the dorsal portion of the gastric corpus. Enhancement of a few net-like structures was noted, but most of the lesion was not enhanced. Gastroendoscopy revealed the lesion to be a submucosal tumor with a smooth mucosal surface and no ulceration. Endoscopic ultrasonography showed the tumor arising from the fourth layer of the gastric wall. The tumor was completely resected by laparotomy and partial gastrectomy. It was capsulated and contained serous fluid with little solid tissue. Histologically, there were sparse tumor cells within the myxoid interstitium. Immunostaining results were weakly positive for KIT and CD34-positive accompanied by mast cell infiltration. A platelet-derived growth factor receptor alpha (PDGFRA) exon 18 (D842V) mutation was identified, and the lesion was ultimately diagnosed as myxoid epithelioid gastrointestinal stromal tumor (GIST) of intermediate- and low-risk according to Fletcher's classification and Miettinen's classifications, respectively. GISTs with PDGFRA D842V mutations are reportedly resistant to imatinib, and GISTs originating from the stomach are reportedly less malignant than others. The patient was observed without adjuvant therapy after surgery because of the relatively low risk of metastasis or recurrence and the potential risk of imatinib resistance. No recurrence was observed for ≥5 years after the surgery. We herein report this rare case and describe its clinical characteristics.

[A case of non-alcoholic fatty liver disease (NAFLD) aggravated after treatment with raloxifene].

A 70-year-old woman presented with abnormal liver function test 3 months after the introduction of daily intake of raloxifene, a selective estrogen receptor modulator, for osteoporosis. She had a history of NAFLD, diabetes mellitus and depression. The ratio of the computed-tomographic value of the liver against that of the spleen decreased remarkably. Pathological examination of the liver biopsy revealed severe steatosis. We thought her NAFLD was aggravated by raloxifene and discontinued the drug. The liver function test results improved and the computed tomographic liver-spleen ratio rose. This is the second case report of NAFLD becoming aggravated after treatment with raloxifene. It still remains unclear how raloxifene affects liver. Monitoring liver function is recommended when treating with raloxifene.

A comparison of outcomes of endoscopic submucosal dissection (ESD) For early gastric neoplasms between high-volume and low-volume centers: multi-center retrospective questionnaire study conducted by the Nagano ESD Study Group.

OBJECTIVE: Outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasms at low-volume centers have been unknown, because all previous reports have studied in advanced single centers. The aim of this study was to compare ESD outcomes between high- and low-volume centers. METHODS: A retrospective questionnaire survey was conducted and 30 centers (96.8%) responded. The complete en-bloc resection rate (CERR) and the incidence of complications were analyzed. Early gastric cancer (EGC) was divided into three categories on the basis of pathological diagnosis-standard indication (SI), expanded indication (EI) and out-of-indication (OI). RESULTS: A total of 703 early gastric neoplasms (586 EGCs, 117 gastric adenomas) were treated with ESD from January to December 2005. The institutions that treated more than 30 cases a year were classified as high-volume centers, and those with less than 30 cases, low-volume centers. In SI, the CERRs at high- and low-volume centers were 92.1% and 91.1%, in EI, CERRs were 86.2% and 82.6% and in OI, CERRs were 80.3% and 88.0%. The perforation rates at high- and low-volume centers were 3.6% and 4.7%. The intra-operative bleeding rates at high- and low-volume centers were 0.26% and 0%, while the delayed bleeding rates were 0% and 0.63%. CONCLUSION: There were no significant difference in the outcomes of ESD for early gastric neoplasms between high- and low volume centers.

[A case of gastrointestinal AL amyloisosis requiring emergency surgery].

A 69-year-old man tarry stools received emergency endoscopy. Which revealed a solitary submucosal tumor about 15mm in diameter with a central ulcer, exhibiting woozing bleeding in the duodenal second portion. Endoscopic hemostasis was unsuccessful so emergency surgery was performed. Histological examination revealed amyloid with A-lambda immunoreactivity. Usually, this type of amyloidosis appears multiple submucosal masses. However this case presented as a single nodule at initial examination. We should keep in mind the potential of encountering this atypical form of amyloidosis.

[Solid-pseudopapillary tumor with an elderly woman, showing an increase in size over a four-year follow-up period: report of a case].

Solid-pseudopapillary tumor (SPT) is considered to be a tumor showing an essentially benign biological behavior based on the results of histological examination of resected specimens and postsurgical follow-up. Little is known regarding the growing speed and pattern, and the process of cystic structure formation of this tumor due to a lack of reports describing its natural history. We herein report a case of SPT showing an increase in size in a four-year follow-up period, which underwent resection thereafter.

Autoimmune pancreatitis and multiple bile duct strictures treated effectively with steroid.

We herein report a patient with strictures of the hepatic hilar and intrapancreatic bile duct associated with autoimmune pancreatitis, who responded well to corticosteroid therapy. Although this bile duct lesion resembled primary sclerosing cholangitis (PSC) morphologically,its dramatic response to corticosteroid therapy seems to indicate that it is a different entity. A review of the literature revealed 13 patients with multiple biliary strictures and chronic pancreatitis successfully treated with corticosteroid therapy. From the clinical point of view, knowledge of the existence of a patient group with autoimmune pancreatitis with morphology similar to that of PSC and which responds well to corticosteroid therapy is important.