The Malignant Obstruction Caused by Pancreatic Cancer Within the Uncinate Process in the Third Portion of the Duodenum.

Pancreatic cancer has a poor prognosis, and it often causes duodenal obstruction and obstructive jaundice associated with tumor invasion. Self-expandable metal stent (SEMS) placement is useful for duodenal obstruction. Pancreatic cancer can occur in the uncinate process, which may lead to malignant obstruction in the third portion of the duodenum. However, the upper gastrointestinal endoscope often cannot reach the third portion of the duodenum, and SEMS placement is sometimes difficult. We report a case of successful SEMS placement with a colonoscope for the obstruction of the third portion of the duodenum due to uncinate process cancer. A 67-year-old Japanese male was referred to our hospital for palliative treatment of unresectable pancreatic cancer. He complained of anorexia and vomiting and was admitted to our hospital. Computed tomography (CT) scans showed the tumor with delayed enhancement in the pancreatic uncinate process. Esophagogastroduodenoscopy (EGD) and gastrografin enema revealed the stenosis caused by tumor invasion in the third portion of the duodenum. The stenosis was thought to cause his symptom. PCFQ260AZ endoscope (Olympus, Tokyo, Japan) was able to reach the stenosis, and a 22 mm × 80 mm uncovered SEMS (Niti-S, Taewoong Medical, Seoul, South Korea) was placed beyond the stenosis. After SEMS placement, his symptoms disappeared. Uncinate process cancer is located close to the third portion of the duodenum and caused the obstruction there. We should be cautious about this, and a colonoscope is useful for SEMS placement for malignant obstruction in the third portion of the duodenum.

Colonic Diverticulitis Complicated by Stenosis Causing Bowel Obstruction.

Colonic diverticulitis is one of the most common gastrointestinal diseases. There are several complications in colonic diverticulitis, such as stenosis, perforation, and abscess. Stenosis is a rare complication and can cause bowel obstruction. We report a case of colonic diverticulitis complicated by stenosis causing bowel obstruction. A 66-year-old Japanese man was referred to our hospital for abdominal pain. Computed tomography (CT) scans showed the presence of diverticula, concentric wall thickening, and pericolic fat stranding in the descending colon. He was diagnosed with descending colon diverticulitis. His abdominal pain improved with fasting and intravenous antibiotics. However, after three months, diverticulitis complicated by stenosis occurred in the descending colon. The stenosis was severe and was treated with left hemicolectomy. Histologic examination revealed diverticula, chronic inflammation, and fibrosis in the stenosis, with no malignancy. Stenosis caused by colonic diverticulitis can cause bowel obstruction. Conservative treatment may lead to recurrence, and surgical treatment is preferable.

Successful argon plasma coagulation treatment for self-expandable metal stent obstruction in colorectal cancer.

Self-expandable metal stents (SEMS) have often been used to treat malignant colorectal obstruction. But SEMS obstruction occurs due to the ingrowth of colorectal cancer. We report a case in which treatment with argon plasma coagulation (APC) was effective for SEMS obstruction. An 89-year-old man was admitted to our hospital for obstructive colorectal cancer. A SEMS was inserted and it improved malignant colorectal obstruction. Computed tomography scans demonstrated liver and lung metastases. His clinical cancer staging was IVb and he wished to receive palliative care. Two months later, SEMS obstruction occurred due to ingrowth of colorectal cancer. Treatment other than stent-in-stent SEMS insertion was considered because SEMS obstruction occurred in a short period of time. APC treatment was chosen and it improved the obstruction. The duration of stent patency was 62 days. APC is an option but it needs further studies to assess the safety of APC.

Successful Palliative Radiotherapy for Malignant Cardiac Obstruction Caused by Gastric Cancer.

Gastric cancer is a common malignancy and some patients are diagnosed with an unresectable stage of advanced gastric cancer. Although palliative radiotherapy (RT) is effective for several symptoms in gastric cancer, the duration of efficacy is limited. We report a case where palliative RT significantly improved malignant cardiac obstruction caused by gastric cancer over a long period of time. A 78-year-old woman was referred to our hospital for anorexia and severe anemia. Esophagogastroduodenoscopy showed the giant gastric tumor in cardia and it was thought to be the cause of anemia. Biopsy revealed poorly differentiated adenocarcinoma; she was diagnosed with gastric cancer. Her clinical cancer staging was IV and she wished to receive palliative care. The malignant cardiac obstruction became severe, and to improve the obstruction, palliative RT was performed. The gastric tumor with a diameter of 4 cm was significantly reduced and the obstruction disappeared. For three years after RT, she had no obstruction symptom. The sensitivity of cells to radiation is proportional to the degree of differentiation. Palliative RT is effective for several symptoms in gastric cancer, and in our case, the duration of RT efficacy was long. Hence, RT may be useful when the histological type is poorly differentiated in gastric cancer.

A Case of Cecal Diverticulitis Complicated by Pseudoaneurysm in the Ileocolic Artery.

Acute colonic diverticulitis is a common gastrointestinal illness. It has several complications, such as perforation, abscess, and fistula formation. In addition, pseudoaneurysm caused by diverticulitis has been reported. We report a case of cecal diverticulitis complicated by pseudoaneurysm in the ileocolic artery. A 58-year-old Japanese man was referred to our hospital for abdominal pain. Abdominal examination revealed right lower quadrant pain. Computed tomography (CT) scans showed the presence of diverticula and pericolic fat stranding in the cecum. Following this, he was diagnosed with cecal diverticulitis. Despite antibiotic treatment, his abdominal pain and blood test results worsened. On the third hospital day, a CT scan was performed again, revealing a pseudoaneurysm with hematoma in the ileocolic artery. Interventional radiology (IVR) was conducted to treat the pseudoaneurysm. It was embolized with n-butyl-2-cyanoacrylate (NBCA) and lipiodol. After embolization, he had stable hemoglobin. His abdominal pain and blood test results improved. Pseudoaneurysms have been reported as a rare complication for diverticulitis. When a rupture occurs, it has a high risk of mortality. Early diagnosis and treatment of pseudoaneurysms are essential, and we should consider pseudoaneurysms as a complication of acute colonic diverticulitis.

[A patient with autoimmune pancreatitis complicated by pancreatic pseudocyst that caused colonic perforation-induced gastrointestinal bleeding].

A 62-year-old male patient was referred to our hospital for jaundice and bloody feces. He had hyper-IgG4-emia. Computed tomography (CT) showed diffuse pancreatic enlargement, pancreatic pseudocyst, and hematoma of the splenic flexure of the colon. Magnetic resonance imaging (MRI) showed a fistula in the pancreatic pseudocyst and splenic flexure of the colon. Moreover, lower gastrointestinal endoscopy showed a fistula in the same region. Endoscopic retrograde cholangiopancreatography (ERCP) showed narrowing of the main pancreatic duct and stenosis of the lower bile duct. Following this, the patient was diagnosed with autoimmune pancreatitis-induced pancreatic pseudocyst and colonic perforation-induced gastrointestinal bleeding. The pancreatic pseudocyst and fistula were resolved through steroid treatment.

Elevation of tau protein levels in the cerebrospinal fluid of children with West syndrome.

PURPOSE: West syndrome is an epileptic encephalopathy with a poor developmental outcome. Tau protein levels in the cerebrospinal fluid (CSF) are reported to be markers of axonal damage and neurodegeneration. This study aimed to investigate axonal damage and the effects of adrenocorticotropic hormone (ACTH) therapy on axons in West syndrome, as measured by tau protein levels in CSF. METHODS: Tau protein levels in CSF before and after ACTH therapy were determined by an enzyme-linked immunosorbent assay in 26 children with West syndrome. Of these 26 children, 18 were symptomatic, and 8 had a cryptogenic form of West syndrome. A group of 41 unaffected children was included in the study as a control group. RESULTS: The levels of tau protein in CSF were significantly higher in children with West syndrome than in the control group, and these levels remained high after ACTH therapy. ACTH therapy was effective for 20 of the 26 children with West syndrome, and their CSF tau protein levels were significantly higher after ACTH therapy than before therapy. CONCLUSION: Our results suggest that axonal damage occurs in West syndrome, as judged by tau protein levels in CSF.