Ulcerated Stenosis of the Small Intestine Associated With Hepatic Portal Venous Gas After Treatment for Cytomegalovirus Enteritis: A Case Report.

Due to its rarity, cytomegalovirus (CMV) enteritis remains poorly described with regard to its endoscopic and radiological findings. A 75-year-old woman was admitted to our hospital with abdominal pain and was treated with an antiviral agent for CMV enteritis. She was readmitted to our hospital 10 days after discharge due to a recurrence of abdominal pain. Emergency computed tomography revealed hepatic portal venous gas (HPVG) and ileal dilatation involving focal stenosis of the ileum. The patient underwent laparoscopic partial resection of the small intestine and was finally diagnosed with ulcered stenosis of the small intestine after treatment for CMV enteritis. This report represents a valuable addition to the literature describing a rare case of ulcerated stenosis of the small intestine associated with HPVG after treatment for CMV enteritis.

A Case of Duodenal Adenocarcinoma Effectively Highlighted by Linked Color Imaging and Confirmed by Histopathology.

While the differential diagnosis of duodenal adenocarcinoma versus adenoma remains the key to determining treatment strategies in patients with suspected duodenal adenocarcinoma, the role of linked color imaging (LCI) in their differential diagnosis remains insufficiently documented. In this case, esophagogastroduodenoscopy (EGD) was performed on a 67-year-old man for anemia, which revealed a 20-mm-sized, whitish, partially reddish, pedunculated lesion located in the duodenal bulb on white light imaging. Using LCI, the lesion was highlighted as a whitish, pedunculated lesion with its central and inferior areas depicted as orangish and reddish, respectively. Endoscopic mucosal resection was performed on the suspicion of an adenocarcinoma for biopsy and endoscopic diagnosis. Histological examination revealed the lesion to be an adenocarcinoma contained in an adenoma: papillary, type 0-Ip, measuring 20x20 mm, pTis (M), involving no lymphovascular invasion. This case appears to underpin the usefulness of LCI in the differential diagnosis of duodenal adenocarcinoma.

Endoscopic Hemostatic Treatment with a Novel Self-Assembling Peptide Gel for Precut Fistulotomy-Related Bleeding.

Introduction: Precut fistulotomy is of interest as one of the salvage techniques for selective bile duct cannulation using endoscopic retrograde cholangiopancreatography. Of the various endoscopic treatments reported to date for bleeding associated with papillotomy incision, endoscopic hemostasis treatment with a novel self-assembling peptide (SAP) matrix-forming gel (TDM-621) (3-D Matrix Ltd., Tokyo, Japan) remains only insufficiently reported in the literature. Case Presentation: We herein report 6 cases of precut fistulotomy-related bleeding successfully treated with endoscopic hemostasis treatment with TDM-621, i.e., 5 and 1 cases during and after precut fistulotomy, respectively, in 2 males and 4 females aged 68-96 years (mean age, 85 years), 3 of whom had been on antithrombotic drugs. Types of bleeding treated included oozing bleeding (n = 5) and oozing bleeding from a visible vessel (n = 1). In all cases, complete hemostasis was achieved with TDM-621 without causing rebleeding. Conclusion: Endoscopic hemostasis with TDM-621 may prove effective for precut fistulotomy-related bleeding and represent a potential modality of first choice in hemostasis. In addition, endoscopic hemostasis with combined modality therapy using TDM-621 and endoscopic hemoclips may prove effective for bleeding from visible vessels.

Impact of mixed-infection rate of clarithromycin-susceptible and clarithromycin-resistant Helicobacter pylori strains on the success rate of clarithromycin-based eradication treatment.

BACKGROUND: Clarithromycin (CAM) resistance is a major contributor to the failure to eradicate Helicobacter pylori (H. pylori). The mixed-infection ratio of CAM-susceptible and CAM-resistant H. pylori strains differs among individuals. Pyrosequencing analysis can be used to quantify gene mutations at position each 2142 and 2143 of the H. pylori 23S rRNA gene in intragastric fluid samples. Herein, we aimed to clarify the impact of the rate of mixed infection with CAM-susceptible and CAM-resistant H. pylori strains on the success rate of CAM-containing eradication therapy. MATERIALS AND METHODS: Sixty-four H. pylori-positive participants who received CAM-based eradication therapy, also comprising vonoprazan and amoxicillin, were enrolled in this prospective cohort study. Biopsy and intragastric fluid samples were collected during esophagogastroduodenoscopy. H. pylori culture and CAM-susceptibility tests were performed on the biopsy samples, and real-time PCR and pyrosequencing analyses were performed on the intragastric fluid samples. The mutation rates and eradication success rates were compared. RESULTS: The overall CAM-based eradication success rate was 84% (54/64): 62% (13/21) for CAM-resistant strains, and 95% (39/41) for CAM-sensitive strains. When the mutation rate of the 23S rRNA gene was 20% or lower for both positions (2142 and 2143), the eradication success rate was 90% or more. However, when the mutation rate was 20% or higher, the eradication success rate was lower (60%). CONCLUSIONS: The mutation rate of the CAM-resistance gene was related to the success of eradication therapy, as determined via pyrosequencing analysis.

Emergency Endoscopic Hemostasis Using the Endoscopic Mucosal Resection Technique for Severe Bleeding From Early Gastric Cancer: A Case Report.

Bleeding from gastric cancer may lead to severe anemia and hypovolemic shock, and can be a life-threatening condition in affected patients; thus, achieving hemostasis is essential to improving their clinical course. While endoscopic hemostasis is recommended as the hemostatic modality of first choice, endoscopic hemostasis involving the endoscopic mucosal resection (EMR) technique is also being used, though under-reported. An 85-year-old man diagnosed with bleeding from gastric cancer was raced to our hospital for hemostasis. Emergency esophagogastroduodenoscopy (EGD) revealed a 45 mm-sized elevated lesion involving the coagula due to dripping bleeding from the surface of the posterior wall of the gastric lower body. EMR was performed without any technical difficulty, and hemostasis was achieved immediately. The patient was discharged without rebleeding. This case appears to support the usefulness of EMR as an emergency endoscopic hemostatic modality for severe bleeding from early gastric cancer.

Potassium-competitive acid blocker-associated gastric mucosal lesions.

Since the introduction of vonoprazan, a potassium-competitive acid blocker (P-CAB), it has been demonstrated to reversibly inhibit gastric acid secretion by engaging in potassium-competitive ionic binding to H+/K+-ATPase. In contrast, proton pump inhibitors (PPIs) achieve H+/K+-ATPase inhibition through covalent binding to cysteine residues of the proton pump. Reported cases have indicated an emerging trend of P-CAB-related gastropathies, similar to those associated with PPIs, as well as unique gastropathies specific to P-CAB use, such as the identification of web-like mucus. Pathologically, parietal cell profusions, which show a positively correlated with hypergastrinemia, have a higher incidence in P-CAB users compared to PPI users. Thus, this review aims to summarize the endoscopic and pathological findings reported to date concerning P-CAB-related gastric mucosal lesions. Additionally, it seeks to discuss the differences between the PPIs and P-CABs in terms of the formation and frequency of associated gastropathies. This review highlights the evident differences in the mechanism of action and potency of acid inhibition between P-CABs and PPIs, notably contributing to differences in the formation and frequency of associated gastropathies. It emphasizes the necessity to distinguish between P-CAB-related and PPI-related gastropathies in the clinical setting.

Diagnostic Accuracy of a Novel Stool Antigen Test for Helicobacter pylori Infection in a Medical Checkup Setting: A Prospective Cohort Study.

Objective Of the highly accurate tests for current Helicobacter pylori infection, the urea breath test (UBT) and stool antigen test (SAT) are noninvasive and do not require endoscopy. We conducted a prospective study to evaluate the accuracy of the newly developed SAT in a medical checkup setting. Methods The accuracy of the proposed SAT was examined by determining H. pylori infection status based on a history of eradication therapy, endoscopic H. pylori infection diagnosis, and blood tests (serum H. pylori antibody, serum PG II) in individuals undergoing esophagogastroduodenoscopy (EGD) during a health checkup. Results The new SAT showed 97.3% (108/111) sensitivity for those "currently infected," as well as 99.3% (530/534), 98.0% (402/410), and 98.7% (932/944) specificity for those "never infected," those "previously infected," and those "never/previously infected", respectively. Conclusion The newly developed H. pylori SAT may be useful for diagnosing H. pylori infection. Patients should be suspected of being infected even after H. pylori eradication if they have a high cutoff index in this test.

Invasive lobular carcinoma of the breast with colonic metastasis: a case series of three patients.

BACKGROUND: Although metastatic spread of breast cancer to the gastrointestinal tract is very rare, it is more likely to occur in invasive lobular carcinoma (ILC) than in ductal carcinoma. Colonic metastasis is particularly rare, and the treatment strategies for these cases are not clearly defined. Herein, we report three cases of ILC with various abdominal symptoms associated with colonic metastasis. CASE PRESENTATION: Case 1 A 70-year-old female patient with vomiting and melena was referred to our hospital. Endoscopic examination revealed a Dieulafoy ulcer in the rectum and an elevated lesion in the descending colon. She also had two breast nodules, and was diagnosed as ILC with colonic metastasis. Considering her general condition, the best supportive care (BSC) was offered. The patient died 4 months after confirmation of the diagnosis. Case 2 An 80-year-old female patient presented with diarrhea and vomiting. She was diagnosed with ILC with colonic metastasis, and a coloscopy revealed stenosis of the transverse colon with a metastatic lesion. Ileosigmoid bypass surgery was performed for intestinal obstruction, and systemic treatment for breast cancer was initiated. The patient developed peritoneal carcinomatosis and died 1 year and 2 months after surgery. Case 3 A 56-year-old female patient underwent left total mastectomy for ILC, and laparoscopic transverse colectomy was conducted for a colonic lesion 9 years and 2 months after. The diagnosis as colonic metastasis was not confirmed at that time. Two years and 2 months later, torose lesions were detected in the hepatic flexural and descending colon, and histopathological findings indicated that all colon tumors, including the previously resected tumor, were metastatic spread of ILC. Systemic treatment was continued, but the transverse colonic lesion penetrated the abdominal wall, and an abscess formed 2 years and 11 months after the resection. The fistula improved by continuous suction drainage following ileostomy but recurred, and the patient died 3 years and 8 months after colectomy. CONCLUSIONS: Colonic metastases from breast cancer can trigger various abdominal symptoms, and the prognosis in these cases is generally poor. In selected cases, surgical treatment for abdominal symptoms and subsequent systemic therapy can contribute to a prolonged prognosis.

Endoscopic Hemostatic Treatment for Acute Gastrointestinal Bleeding by Combined Modality Therapy with PuraStat and Endoscopic Hemoclips.

Acute gastrointestinal bleeding (AGIB) is a common condition leading to hospitalization and is associated with significant morbidity and mortality. Various endoscopic treatments have been reported for AGIB, while its endoscopic hemostasis treatment by combined modality with PuraStat and endoscopic hemoclips remains less well documented. We report 6 cases of AGIB, i.e., 5 cases of ulcer bleeding and 1 case of ruptured gastric varices in 3 males and 3 females aged 49-97 years (mean age, 77 years), 2 and 1 of whom had been on antithrombotic drugs and nonsteroidal anti-inflammatory drugs, respectively, with 2 of these found to be in critical condition with hemorrhagic shock. Types of bleeding treated included oozing bleeding from visible vessels (n = 3), spurting bleeding from visible vessels (n = 2) and from gastric varices (n = 1). In all cases, complete hemostasis was achieved with no rebleeding. To our knowledge, this report represents a valuable addition to the AGIB literature describing endoscopic hemostasis by combined modality therapy with PuraStat and endoscopic hemoclips.

Clinical evaluation of a novel molecular diagnosis kit for detecting Helicobacter pylori and clarithromycin-resistant using intragastric fluid.

BACKGROUND: Although there are many Helicobacter pylori (H. pylori) diagnostic methods, the culture and antibiotic susceptibility test is an important method for selecting the most effective H. pylori eradication regimen. However, this diagnostic method is complicated and takes several days; therefore, the development of a rapid and simple diagnostic method is required. Eradication failure due to clarithromycin (CAM) resistance should also be considered. In this study, we report the clinical evaluation of point-of-care testing (POCT) kit using intragastric fluid, a novel kit for detecting H. pylori and CAM resistance. MATERIALS AND METHODS: The study participants were 143 patients suspected of H. pylori infection and had an endoscopic examination. The novel diagnostic kit diagnosed H. pylori infection and CAM resistance-associated mutation using intragastric fluid. To diagnose H. pylori infection, the relationship between the diagnostic kit and conventional diagnostic methods (urea breath test, stool antigen test, culture test, and real-time polymerase chain reaction [PCR]) was evaluated. For CAM resistance-associated mutation detection, the concordance between the diagnostic kit and antibiotic susceptibility test was evaluated. RESULTS: The diagnosis of H. pylori infection with the novel molecular diagnostic kit using intragastric fluid showed significant relationship with conventional diagnostic methods. Especially when the culture was control, the sensitivity was 100% (67/67), the specificity was 95.9% (71/74), and the overall concordance was 97.9% (138/141). The detection of CAM resistance-associated mutations had a concordance rate of 97.0% (65/67) when compared with the antibiotic susceptibility test. CONCLUSIONS: The H. pylori molecular POCT kit uses intragastric fluid as a sample and can diagnose H. pylori infection and detect CAM resistance-associated mutations within an hour. This novel kit is expected to prove useful in selecting the most effective eradication regimen for H. pylori.

Primary Duodenal Adenocarcinoma Expressing Carbonic Anhydrase IX.

Primary duodenal adenocarcinoma is a rare malignancy whose carbonic anhydrase IX (CA9) expression remains poorly understood. A 73-year-old man visited our hospital for a medical checkup. Transnasal endoscopy revealed a submucosal, tumor-like lesion with a central depression located in the descending part of the duodenum on white light imaging. On texture and color enhancement imaging mode 1, the lesion was highlighted as a reddish, elevated lesion with an irregular mucosa in its central depressed area. Pancreaticoduodenectomy was performed on the suspicion of duodenal adenocarcinoma for biopsy and endoscopic diagnosis, which led to the lesion being diagnosed as tubular adenocarcinoma, pT1b (SM). Immunohistological staining revealed an adenocarcinomatous component positive for CA9, as well as a normal duodenal mucosa. To our knowledge, this report is among the first to describe CA9-expressing primary duodenal adenocarcinoma.

Colonic Intramural Hematoma.

Colonic intramural hematoma is a rare condition and its endoscopic and radiological findings remain poorly described. An 82-year-old woman was hospitalized with a diagnosis of acute cerebral infarction. She immediately received anticoagulant therapy with argatroban for 1 week. With the appearance 4 days later of hematochezia, she was found to have severe anemia. Following insertion of the colonoscope, a large submucosal hematoma was shown to be present in the descending colon, with the mucosa shown to be necrotic and the residual mucosa around the hematoma shown to be yellowish. Computed tomography revealed a hyperdense mass in the descending colon. Laparoscopic colectomy was performed for the lesion diagnosed as intramural hematoma. Pathologically, it was a hematoma located in the subserosal layer involving full-thickness hemorrhage. To our knowledge, this report represents a valuable addition to the literature describing a case of colonic intramural hematoma whose diagnosis was effectively established by the combined use of CS and CT.

Fitz-Hugh-Curtis Syndrome Presenting as Perihepatic and Subcapsular Enhancement on MRI.

Fitz-Hugh-Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease and its MRI findings remain poorly described. A 34-year-old woman was raced to our hospital with slight fever and severe right upper quadrant pain. Gadoxetic acid-enhanced magnetic resonance imaging revealed high-intensity regions in the surface and subcapsule of the right liver on T2-weighted imaging and on diffusion-weighted imaging. A definitive diagnosis of FHCS was confirmed based on high titers of serum IgA and IgG antibodies to Chlamydia trachomatis. She was treated with oral azithromycin and discharged 6 days after admission with improvement of her symptoms. To our knowledge, this report represents a valuable addition to the FHCS literature describing MRI findings in the early stage of FHCS onset.

Vonoprazan-associated long QT syndrome.

To our knowledge, this is the first report describing a case of vonoprazan-associated QT prolongation newly occurring after initiation of the drug and improving after its discontinuation in a patient concurrently receiving polypharmacy including a drug metabolized by CYP3A4.