Efficacy, safety and cost analyses in ulcerative colitis patients undergoing granulocyte and monocyte adsorption or receiving prednisolone.

BACKGROUND: Patients with ulcerative colitis (UC) are treated with prednisolone (PSL), which causes adverse side effects. Extracorporeal granulocyte/monocyte adsorption (GMA) with an Adacolumn depletes elevated/activated myeloid lineage leucocytes as sources of inflammatory cytokines. We were interested to evaluate the efficacy, safety and the treatment cost for PSL and GMA. METHODS: Forty-one patients with active UC had achieved remission with GMA, at 1 or 2 sessions/week, up to 10 sessions (n=24) or with orally administered PSL (1mg/kg bodyweight, n=17). Clinical activity index (CAI) ≤4 was considered clinical remission. Following remission, patients received 5-aminosalicylic acid (2250-3000mg/day) or sulphasalazine (4000-6000mg/day) as maintenance therapy and were followed for 600 days. The total treatment cost was assessed based on 1€=150JPY. RESULTS: PSL was tapered after two weeks, and discontinued when a patient achieved remission. The average time to the disappearance of at least one major UC symptom (haematochezia, diarrhoea, or abdominal discomfort) was 15.3 days in the GMA group and 12.7 days in the PSL group, while time to remission was 27.9 days in the GMA group and 27.6 days in the PSL group, CAI 0.8 and 2.0, respectively. The Kaplan-Meier plots showed similar remission maintenance rates over the 600 days follow-up period. The average medical cost was 12739.4€/patient in the GMA group and 8751.3€ in the PSL group (P<0.05). In the GMA group, 5 transient adverse events were observed vs 10 steroid related adverse events in the PSL group (P<0.001). CONCLUSIONS: In appropriately selected patients, GMA has significant efficacy with no safety concern. The higher cost of GMA vs PSL should be compromised by good safety profile of this non-pharmacological treatment intervention.

[¹8F-fluorodeoxyglucose PET/CT and small bowel endoscopy in a patient with small bowel leiomyoma].

A 49-year-old man was admitted to our hospital because of recurrent gastrointestinal bleeding of unknown origin, after repeated negative endoscopic and radiographic evaluation, including colonoscopy, esophago-gastro-duodenoscopy, CT and angiography. His condition had not been diagnosed for the past 18 years. ¹8F-fluorodeoxyglucose (FDG) on positron emission tomography (PET/CT) showed mild FDG uptake by a tumor of the small bowel (SUVmax 2.83), and capsule endoscopy (CE) and double balloon endoscopy (DBE) revealed a well-defined smooth submucosal tumor in the jejunum. The patient underwent a laparotomy and small bowel resection. The pathologic diagnosis was a small intestinal leiomyoma. Our report suggests the significance of combination of CE, DBE and PET/CT in the diagnosis of small bowel leiomyoma.

AJM300 (carotegrast methyl), an oral antagonist of α4-integrin, as induction therapy for patients with moderately active ulcerative colitis: a multicentre, randomised, double-blind, placebo-controlled, phase 3 study.

BACKGROUND: AJM300 is an oral, small-molecule α4-integrin antagonist. We assessed the efficacy and safety of AJM300 in patients with moderately active ulcerative colitis. METHODS: This multicentre, randomised, double-blind, placebo-controlled, phase 3 study consisted of two phases: a treatment phase and an open-label re-treatment phase. The study was done at 82 hospitals and clinics in Japan. Patients with a Mayo Clinic score of 6-10, endoscopic subscore of 2 or more, rectal bleeding subscore of 1 or more, and an inadequate response or intolerance to mesalazine were enrolled. Patients were randomly allocated (1:1) via a website to either AJM300 (960 mg) or placebo by the minimisation method, which was adjusted centrally by dynamic assignment against the Mayo Clinic score (≥6 to ≤7, ≥8 to ≤10 points), any use of corticosteroid, anti-TNFα antibody, or immunosuppressants during the disease-active period (yes vs no), duration of induction therapy until randomisation (<4 weeks vs ≥4 weeks) as the minimisation factors. Patients, investigators, site staff, assessors, and the sponsor were masked to treatment assignments. The study drug was administered orally, three times daily, for 8 weeks, and continued for up to 24 weeks if endoscopic remission was not achieved or rectal bleeding did not stop. The primary endpoint was the proportion of patients with a clinical response at week 8, and was analysed in the full analysis set. Clinical response was defined as a reduction in Mayo Clinic score of 30% or more and 3 or more, a reduction in rectal bleeding score of 1 or more or rectal bleeding subscore of 1 or less, and an endoscopic subscore of 1 or less at week 8. The study is registered with ClinicalTrials.gov, NCT03531892, and is closed to recruitment. FINDINGS: Between June 6, 2018, and July 22, 2020, 203 patients were randomly assigned to AJM300 (n=102) or placebo (n=101). At week 8, 46 (45%) patients in the AJM300 group and 21 (21%) patients in the placebo group had a clinical response (odds ratio 3·30, 95% CI 1·73-6·29; p=0·00028). During the 8-week treatment and 16-week extension treatment periods, adverse events occurred in 39 (39%) of 101 patients in the placebo group and 39 (38%) of 102 patients in the AJM300 group. We found no difference in the incidence of adverse events between groups or after repeated administration of AJM300. The most common adverse event was nasopharyngitis (11 [11%] of 101 patients in the placebo group and ten [10%] of 102 patients in the AJM300 group). The most common treatment-related adverse event was also nasopharyngitis (four [4%] of 101 patients in the placebo group and three [3%] of 102 patients in the AJM300 group). Most adverse events were mild-to-moderate in severity. No deaths were reported. A serious adverse event was reported in the AJM300 group (one patient with anal abscess), but this was judged to be unrelated to study drug. INTERPRETATION: AJM300 was well tolerated and induced a clinical response in patients with moderately active ulcerative colitis who had an inadequate response or intolerance to mesalazine. AJM300 could be a novel induction therapy for the treatment of patients with moderately active ulcerative colitis. FUNDING: EA Pharma and Kissei Pharmaceutical. TRANSLATION: For the Japanese translation of the abstract see Supplementary Materials section.

[Strategy to manage low dose aspirin-induced gastrointestinal injury].

Low dose aspirin, as an anti-platelet medication, has been increasingly prescribed to elderly patients for primary and secondary prevention of cardio- and cerebro-vascular events. Nonetheless, aspirin's effectiveness in such disease prevention is limited by the risk of upper and lower gastrointestinal (GI) complications such as ulceration, hemorrhage and perforation. Aspirin administration is associated with 2-fold increase in the GI risk in middle-aged users without prior history of peptic ulcer and without concomitant medications. However, such GI risk increases dramatically in patients with a prior history of peptic ulcer disease, advanced age, and concomitant use of NSAIDs, corticosteroids, clopidogrel, or anticoagulants. Mechanisms of aspirin-induced GI injury are believed to be through local effects within the GI mucosa that cause topical injury and through systemic inhibition of cyclo-oxygenase (COX) resulting in depletion of mucosal protective prostaglandins. Herein, we focus on the strategy to manage aspirin-induced peptic ulcerations and their complications, based on the scientific evidence.

Management of obscure gastrointestinal bleeding based on the classification of capsule endoscopic bleeding findings.

BACKGROUND: Double-balloon endoscopy (DBE) and capsule endoscopy (CE) have been useful in managing obscure gastrointestinal bleeding (OGIB). However, DBE is invasive, complex and time-consuming, therefore indications should probably be selective. The aim of this study was to evaluate the usefulness of the classification of the CE bleeding findings for determining the indications and timing of DBE in patients with OGIB. METHODS: From February 2003 to January 2009, 123 patients with OGIB who underwent CE were included in this study. These CE findings were classified based on the bleeding source. Type CE-I, II, III, IV and 0 indicate active bleeding, previous bleeding, lesions without active bleeding, a lesion outside of the small bowel, and no findings, respectively. We compared diagnostic yield and outcome between the classification and the findings of DBE or enteroclysis. RESULTS: Comparisons of the positive findings rate with DBE or enteroclysis, the treatment rate and the rebleeding rate with the classification showed: CE-Ia, 100% (6/6), 50% (3/6), 33.3% (2/6); Ib, 66.7% (4/6), 0% (0/6), 16.7% (1/6); IIa, 33.3% (1/3), 33.3% (1/3), 33.3% (1/3); IIb, 53.8% (7/13),15.4% (2/13), 30.8% (4/13); III, 100% (84/84), 9.5% (8/84), 8.3% (7/84); IV, 100% (2/2), 50% (1/2), 0% (0/2); and 0, 0% (0/9), 0% (0/9), 0% (0/9), respectively. CONCLUSIONS: The proportion of patients requiring treatment, the positive findings rate with DBE or enteroclysis and the rebleeding rates tended to be higher in the higher ranked classification types (CE-I>II>III>IV>0). These findings suggest that the classification can provide useful information on determining the indications and timing of DBE.

IPMN penetration of the stomach.

An 83-year old Japanese man was transferred to our hospital due to a 1-week history of melena and signs of disordered awareness. Esophagogastroduodenoscopy showed a villous tumor associated with massive white mucous discharge in the posterior wall of the gastric corpus, where pathologically identified mucin-producing epithelium with nuclear atypia had developed into a papillary form. An abdominal enhanced computed tomography scan demonstrated communication between the dilated main pancreatic duct and the gastric lumen. Based on these findings, we reached a diagnosis of gastric penetration by an intraductal papillary mucinous neoplasm (IPMN) of the main pancreatic duct. IPMN is partly characterized by expansive mucinous growth that may result in penetration into adjacent organs.

An open-label prospective randomized multicenter study shows very rapid remission of ulcerative colitis by intensive granulocyte and monocyte adsorptive apheresis as compared with routine weekly treatment.

OBJECTIVES: Granulocyte and monocyte adsorptive apheresis (GMA) has shown efficacy in patients with active ulcerative colitis (UC). However, with routine weekly treatment, it may take several weeks to achieve remission, and to date, the efficacy of a more frequent treatment schedule remains unknown. The aim of this study was to assess the clinical efficacy and safety of intensive GMA treatment in patients with active UC. METHODS: This was an open-label, prospective, randomized multicenter study to compare an intensive, two GMA sessions per week, with the routine, one GMA session per week. A total of 163 patients with mild-to-moderately active UC were randomly assigned to routine weekly treatment or intensive treatment. The maximum number of sessions of GMA permitted was 10. However, when patients achieved remission, GMA was discontinued. Remission rate at the end of the study, time to remission, and adverse events were assessed in both groups. RESULTS: Of the 163 patients, 149 were available for efficacy analysis as per protocol, 76 were in weekly GMA, and 73 were in intensive GMA. At the end of the study period, clinical remission was achieved in 41 of 76 patients (54.0%) in weekly GMA and in 52 of 73 patients (71.2%) in intensive GMA (P=0.029). The mean time to remission was 28.1+/-16.9 days in the weekly GMA treatment group and 14.9+/-9.5 days in the intensive GMA group (P<0.0001). Intensive GMA was well tolerated without GMA-related serious adverse side effects. CONCLUSIONS: Intensive GMA in patients with active UC seems to be more efficacious than weekly treatment, and significantly reduced the patients' morbidity time without increasing the incidence of side effects.

Endoscopic submucosal dissection in 100 lesions with early gastric carcinoma.

BACKGROUND/AIMS: ESD is a new diagnostic and treatment technique for early gastric cancer. This study aimed to evaluate the therapeutic effects observed at our department. METHODOLOGY: The subject group included 95 patients with 100 early-stage gastric cancers. According to the Gastric Cancer Treatment Guidelines published by the Japanease Gastric Cancer Association (JGCA) in 2001. Sixty-seven lesions presented a tumor measuring less than 20 mm and were concave (if not flat) without ulceration (specified indication of the guidelines of the Japanese Gastric Cancer Association), and 33 lesions were expanded indications. We then compared one-piece resection rates, en-bloc resection rates (one-piece resection that is lateral- and vertical-stump negative), curative en-bloc resection rates (en-bloc resection that fulfills the following three criteria: 1. differentiated adenocarcinoma; 2. no lymphtic or venous invasion, 3a. intramucosal cancer regardless of tumor size without ulceration, 3b. intramucosal cancer 30 mm in size with ulceration, 3c. minute submucosal cancer 30 mm in size). RESULTS: Among the specified indications and expanded indications, one-piece resection rates accounted for 97.0% and 75.8%, en-bloc resection rates for 83.6% and 60.6%, and curative en-bloc resection rates for 83.6% and 57.6%. The numbers of accident cases were three (postoperative hemorrhage; n = 1 perforation; n = 2) and four (postoperative hemorrhage; n = 1, perforation; n = 3), respectively. CONCLUSIONS: These studies indicated higher one-piece resection rates, en-bloc resection rates and curative en-bloc resection rates for lesions based on the guidelines than those based on the expanded guidelines.

Evaluation of the excluded stomach by double-balloon endoscopy after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Morbid obesity has become a serious health problem. We have been performing laparoscopic Roux-en-Y gastric bypass (LRYGBP) for morbid obesity since February 2002. Although LRYGBP ameliorates complications of morbid obesity, postoperative investigation of the excluded stomach is difficult. In patients with a family history of gastric cancer, resection of the bypassed stomach is sometimes added, but this requires longer operating time. There are two problems associated with LRYGBP: the high rate of gastric cancer in Japan, and how to investigate the excluded stomach. METHODS: To resolve these problems, we introduced double-balloon intestinal endoscopy. We report double-balloon endoscopy (DBE) in 4 patients. RESULTS: No problems with advancing the endoscope were encountered during observation. We used an overtube to insert the scope further in order to avoid forming redundant loops in the small intestine, and two balloons to grip the intestinal wall. Although performing DBE involves a learning curve, there were no major obstacles to passage of the scope into the esophagus, small gastric pouch, lifted jejunum, the jejunojejunal anastomosis, Y-loop, duodenum and excluded stomach. CONCLUSION: Use of the double-balloon technique makes it possible to observe the GI tract after laparoscopic LRYGBP irrespective of the length between the gastrojejunostomy and the jejunojejunostomy.

Comparison between endoscopic papillary balloon dilatation and endoscopic sphincterotomy for the treatment of common bile duct stones.

BACKGROUND: This study was designed to evaluate the therapeutic outcome and early postoperative complications, especially pancreatitis, of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in patients with common bile duct stones in our department. METHODS: One hundred eighty patients with common bile duct stones were randomized to undergo EPBD or EST. An 8-mm dilatation balloon was used for EPBD. Modified Cotton's criteria, in which relatively mild pancreatitis is also included as a complication, were used to determine the incidence of postoperative complications. RESULTS: The rate of complete removal of stones was significantly higher in the EST group (95.6%) than in the EPBD group (86.6%); for stones less than 10 mm in diameter, however, the rate with EPBD (93.8%) was almost equivalent to that with EST (98.1%). According to modified Cotton's criteria, the incidence of postoperative pancreatitis was significantly higher in the EPBD group (16.7%) than in the EST group (6.7%). Bleeding was encountered in one patient (1.1%) in the EST group, but in none in the EPBD group. No fatal complication occurred in either the EPBD or the EST group. CONCLUSIONS: Although EPBD appears to be comparable to EST for removal of small common bile duct stones, mild postoperative pancreatitis is more likely to occur with EPBD than with EST.

Selection of anticoagulants for leukocytapheresis therapy in cases of active ulcerative colitis.

BACKGROUND AND AIM: Leukocytapheresis (LCAP) is an extracorporeal leukocyte removal therapy that removes immunocompetent leukocytes from the peripheral blood. Nafamostat mesilate (NM) is the most commonly used anticoagulant for LCAP due to various benefits associated with its use, such as a reduced likelihood of bleeding and minimization of adverse reactions caused by contact between blood and the LCAP device. However, adverse reactions have also been reported with NM administration. We reviewed the safety of anticoagulants other than NM, from the perspective of bradykinin production and the consequent drop in blood pressure during treatment. METHODS: For each of 10 patients with ulcerative colitis, we used four types of anticoagulants sequentially [NM (30-50 mg), heparin, low-molecular-weight heparin (LMWH) and NM (1 mg), and LMWH] for LCAP. We then examined the changes in the blood bradykinin concentrations from the perspective of adverse reactions during LCAP. RESULTS: The bradykinin production levels from Cellsorba EX varied, depending on the type of anticoagulant used. NM alone (30-50 mg) or LMWH + NM (1 mg) inhibited bradykinin production, whereas heparin alone or LMWH alone significantly accelerated it. However, an excessive fall of blood pressure was not noted in any of the cases. Use of LMWH alone was frequently associated with pressure elevations in the column. CONCLUSIONS: Given the significant benefits of minimized adverse reactions of LCAP and of continuation of LCAP, we suggest that an appropriate selection of the anticoagulant(s) may allow safer execution of LCAP.

Therapeutic efficacy of an elemental diet for patients with crohn's disease and its association with amino acid metabolism.

BACKGROUND/AIM: We investigated the association between blood amino acid concentration changes caused by elemental diet (ED) and their relationship to its therapeutic effect. PATIENTS AND METHODS: Patients with active Crohn's disease (CD) followed ED for 12 weeks. Patients not previously treated with ED were defined as new ED, and those with previous ED therapy (≥900 kcal/day) were defined as previous ED. Disease activity markers [Crohn's disease activity index (CDAI) and C-reactive protein (CRP) level], blood biochemistry test results, and plasma amino acid concentrations were measured before and after the treatment. RESULTS: Histidine (His), tryptophan (Trp), valine (Val), and methionine (Met) increased after the treatment in the 17 patients with clinical remission, however, no increase occurred in plasma amino acid concentrations in the 8 patients without remission. The multivariate index using AminoIndex™technology (MIAI) was correlated with the CDAI (r = 0.475,P < 0.001), and it decreased as patients' conditions improved during the treatment. All patients in the new ED group (n = 11) exhibited increases in the nutritional indices, albumin level, and body mass index after treatment, as well as increased levels of His, Trp, Val, and phenylalanine. None of these changes were observed in the previous ED group (n = 14). CONCLUSIONS: Plasma amino acid concentrations and MIAI may provide useful noninvasive markers for evaluating disease activity and response to treatment. ED was effective in improving disease activity, nutritional status, and plasma amino acid levels, and thus it may be particularly effective for poorly nourished patients with CD who have not previously undergone this treatment.

Prediction of colorectal neoplasia by quantitative methylation analysis of estrogen receptor gene in nonneoplastic epithelium from patients with ulcerative colitis.

PURPOSE: The incidence of colorectal neoplasia has increased among patients with longstanding and extensive ulcerative colitis (UC). Therefore, surveillance colonoscopy has been widely recommended. However, there is controversy about the impact of cancer surveillance, and ways to improve its effectiveness are being sought. The estrogen receptor (ER) gene shows age-related methylation in the colorectal epithelium and is frequently methylated in colorectal neoplasia, suggesting that ER methylation occurs early in the process of colorectal tumorigenesis. EXPERIMENTAL DESIGN: To clarify whether methylation analysis of the ER gene in nonneoplastic epithelium can help predict an increased risk for UC-associated neoplasia, a total of 105 nonneoplastic colorectal epithelia from 18 patients with longstanding and extensive UC, including 8 patients with neoplasia and 10 patients without neoplasia, were analyzed. In all patients, multiple samples were taken from six regions of the colorectum. The combined bisulfite restriction analysis method was used to determine the methylation status of the ER gene. RESULTS: The mean methylation level of the ER gene was 25.4% in the nonneoplastic epithelia from UC patients with neoplasia, whereas it was only 4.0% in those without neoplasia (P<0.001). The methylation level of the ER gene in UC patients with neoplasia was significantly higher than in UC patients without neoplasia throughout the colorectum except for the cecum. In UC patients with neoplasia, the mean ER methylation level in the distal colon (36.1%) was significantly higher than in the proximal colon (14.6%; P<0.001). CONCLUSIONS: These results suggest that the analysis of ER gene methylation in nonneoplastic colorectal epithelium could have the potential to be a useful adjunct for identifying individuals with longstanding and extensive UC who are at increased risk of neoplasia and contribute to more effective cancer surveillance.

Adsorptive granulocyte and monocyte apheresis for refractory Crohn's disease: an open multicenter prospective study.

BACKGROUND: Active Crohn's disease (CD) is often associated with elevated levels of platelets, granulocytes, and monocytes that are activated and resistant to apoptosis. The level of neutrophils in the intestinal mucosa has been quantitatively related to the severity of intestinal inflammation in CD. We postulated that patients with CD that is refractory to conventional medications might respond to a reduction of granulocytes and monocytes by adsorptive apheresis. METHODS: Twenty-one patients with a CD activity index (CDAI) of 200-399 and unresponsive to standard medication, which included nutritional intervention, received granulocyte and monocyte adsorptive apheresis (GCAP) as an adjunct to their ongoing medication. GCAP was performed with an Adacolumn, which adsorbs granulocytes, monocytes, and a small fraction of lymphocytes (FcgammaR and complement receptor-bearing leucocytes). Patients received one GCAP session/week for 5 consecutive weeks. CDAI, International Organization for the Study of Inflammatory Bowel Disease (IOIBD), and IBD questionnaire (IBDQ) scores were evaluated. RESULTS: During the initial conventional/nutritional therapy, no significant improvement was seen in any patient. However, at week 7 of GCAP therapy, significant improvements in CDAI, IOIBD, and IBDQ scores were observed. The CDAI, IOIBD, and IBDQ scores before GCAP were 275.6+/-54.2, 3.4+/-1.4, and 152+/-22, respectively. The corresponding values after GCAP were 214.8+/-89.2 (P=0.0005), 2.54+/-1.5 (P=0.0224), and 165+/-29 (P=0.0327), respectively. CONCLUSIONS: GCAP could be effective for inducing remission and improving quality of life in patients with active CD that is refractory to conventional therapy.

Endoscopic papillary balloon dilation for treatment of common bile duct stones.

BACKGROUND/AIMS: Use of endoscopic papillary balloon dilation (EPBD) for the treatment of common bile duct stones has increased in recent years, owing to its simplicity and its advantage of preserving sphincter function. It has been reported that EPBD is associated with a lower risk of bleeding, but a higher risk of pancreatitis than endoscopic sphincterotomy. However, there have been few reports on studies of post-EPBD pancreatitis. This report concerns the use of EPBD at our department for the treatment of common bile duct stones and early postoperative complications, with a focus on pancreatitis. METHODOLOGY: The study was conducted in 63 patients with choledocholithiasis, including 4 patients with cirrhosis and 21 patients with periampullary diverticula. The stones were extracted after EPBD conducted with an 8-mm dilatation balloon. RESULTS: Complete removal of stones was achieved in 53 out of 63 patients (84.1%). Pancreatitis meeting the criteria of Cotton et al. occurred in 7 of the 63 patients (11.1%), while 12 patients (19.5%) were affected when milder cases of pancreatitis were included. Severe pancreatitis occurred in 1 patient only. Cholangitis occurred in 3 patients (4.8%) and basket impaction occurred in 1 patient (1.6%), but no serious complications such as bleeding or perforation were encountered. CONCLUSIONS: These results suggest that EPBD is an effective procedure for the treatment of common bile duct stones, with a low risk of serious complications.

Endoscopic ultrasonography can diagnose distal biliary strictures without a mass on computed tomography.

AIM: To assess the diagnostic ability of endoscopic ultrasonography (EUS) for evaluating causes of distal biliary strictures shown on endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), even without identifiable mass on computed tomography (CT). METHODS: The diagnostic ability of EUS was retrospectively analyzed and compared with that of routine cytology (RC) and tumor markers in 34 patients with distal biliary strictures detected by ERCP or MRCP at Dokkyo Medical School Hospital from December 2005 to December 2008, without any adjacent mass or eccentric thickening of the bile duct on CT that could cause biliary strictures. Findings considered as benign strictures on EUS included preservation of the normal sonographic layers of the bile duct wall, irrespective of the presence of a mass lesion. Other strictures were considered malignant. Final diagnosis of underlying diseases was made by pathological examination in 18 cases after surgical removal of the samples, and by clinical follow-up for > 10 mo in 16 cases. RESULTS: Seventeen patients (50%) were finally diagnosed with benign conditions, including 6 "normal" subjects, while 17 patients (50%) were diagnosed with malignant disease. In terms of diagnostic ability, EUS showed 94.1% sensitivity, 82.3% specificity, 84.2% positive predictive value, 93.3% negative predictive value (NPV) and 88.2% accuracy for identifying malignant and benign strictures. EUS was more sensitive than RC (94.1% vs 62.5%, P = 0.039). NPV was also better for EUS than for RC (93.3% vs 57.5%, P = 0.035). In addition, EUS provided significantly higher sensitivity than tumor markers using 100 U/mL as the cutoff level of carbohydrate antigen 19-9 (94.1% vs 53%, P = 0.017). On EUS, biliary stricture that was finally diagnosed as malignant showed as a hypoechoic, irregular mass, with obstruction of the biliary duct and invasion to surrounding tissues. CONCLUSION: EUS can diagnose biliary strictures caused by malignant tumors that are undetectable on CT. Earlier detection by EUS would provide more therapeutic options for patients with early-stage pancreaticobiliary cancer.

Successful endoscopic procedures for intraductal papillary neoplasm of the bile duct: a case report.

Attention has recently been focused on biliary papillary tumors as the novel disease entity intraductal papillary neoplasm of the bile duct (IPNB), which consists of papillary proliferation of dysplastic biliary epithelium. As even benign papillary tumors are considered as premalignant, some investigators recommend aggressive surgical therapy for IPNB, although no guidelines are available to manage this disease. Few reports have described long-term follow-up of patients with benign IPNB without radical resection. If patients with IPNB who are treated only with endoscopic procedures are noted, clinical profiles and alternative therapies other than resection may be recommended. We report the case of a patient who experienced repetitive cholangitis for 10 years and was finally diagnosed with IPNB. Radical resection could not be recommended because of the age of the patient, therefore, endoscopic sphincterotomy was performed. Although an endoscopic retrograde biliary drainage catheter was placed several times for repetitive cholangitis, the patient has done well during follow-up. Our case may offer insights into the natural course and management decisions for the novel disease entity of IPNB.