Rare cause of severe anemia due to pyogenic granuloma in the jejunum.

BACKGROUND: Pyogenic granuloma (PG) is a polypoid lobular capillary hemangioma rarely observed in the gastrointestinal tract. Only a few cases in the small bowel have been described in the literature. CASE PRESENTATION: A 58-year-old man had been suffering from general fatigue and severe anemia. Esophagogastroduodenoscopy and colonoscopy did not reveal any significant bleeding. Abdominal computer tomography revealed a hypervascular tumor in the small intestine. Oral double-balloon endoscopy (DBE) detected a polypoid lesion (2 cm in diameter) in the jejunum. We performed laparoscopic-assisted partial resection of the jejunum. The histological features of the tumor were consistent with PG. The patient's anemia gradually improved without the need for oral iron after surgery. CONCLUSION: In this case report, we present a case of pyogenic granuloma in in the jejunum that was detected by DBE.

[A case of giant testicular tumor in a schizophrenic patient].

A 55-year-old man with schizophrenia presented with right scrotal enlargement. Clinical examination revealed a right adult -head-sized testicular tumor, multiple lymph node metastasis with marked elevation of serum lactic dehydrogenase (LDH) and ß -human chorionic gonadotropin (ß -HCG). Right high orchiectomy followed by chemotherapy with bleomysin, etoposide and cisplatin (BEP) for 4 cycles was performed. The tumor weighed 5,270 g, and was pathologically diagnosed as seminoma. After the treatment, the tumor markers were normalized, but he refused to undergo retroperitoneal lymph node dissection.

[Case of Behcet's disease diagnosed by bilateral epididymitis].

A 24-year-old man visited our emergency room with testicular pain and left shoulder pain, and was admitted to our hospital for diagnosis of bilateral epididymitis. Antibiotics and anti-inflammatory medication were started, but the symptoms did not improve. During hospitalization, ulcerous lesions, erythema nodosum, folliculitis-like exanthema and multiple oral aphtha appeared. Then, we consulted the department of dermatology. As he had a combination of arthritis and epididymitis, he was diagnosed with the abortive form of Behcet's disease. After diagnosis, we began administering colchicine. Then, all symptoms improved in a few days, and he has remained free of the disease after the discontinuation of colchicine.

[Castleman's disease of the kidney: a case report].

Castleman's disease is a rare disorder characterized by benign proliferation of lymphoid tissue. A 61-year-old man was referred to our department for a renal mass incidentally detected by magnetic resonance imaging. Computed tomography showed a 18 × 20 × 14 mm mass in the upper pole of the right kidney, which enhanced at the early phase and washed out at the late phase. On the diagnosis of renal cell carcinoma, laparoscopic partial nephrectomy was performed. Pathological examinations revealed a hyaline-vascular type of Castleman's disease confined to the kidney.

Comparison of carbon dioxide and air insufflation use by non-expert endoscopists during endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is subject to several complications that include a lengthy procedure time, technical difficulty, and active bowel movement induced by air insufflation. In ERCP carried out by non-expert endoscopists who are prone to excessive luminal insufflation, insufflation with carbon dioxide (CO2 ) may provide better and safer outcomes. We aimed to assess the efficacy and safety of CO2 insufflation during ERCP by non-expert endoscopists. METHODS: This study included 208 consecutive patients who received ERCP, excluding those in poor general health or with obstructive lung disease. The first operator for each patient was a non-expert endoscopist having done 50 or fewer ERCP procedures. Primary outcomes were the changes in cardiopulmonary state during ERCP. Secondary outcomes were ERCP complications. We designed a single-center, randomized, prospective, double-blind, controlled trial with CO2 and air insufflation during ERCP. RESULTS: CO2 insufflation did not affect overall procedure progression or results. A positive correlation was observed between procedure time and change in maximal systolic blood pressure from baseline among patients in the air insufflation group, but not in the CO2 insufflation group (correlation coefficient 0.408 vs 0.114, change in the maximal systolic blood pressure from baseline +4.2 vs+1.2 mmHg/10 min). This was consistent with our findings in patients treated by the first operator alone. The occurrence rate of post-ERCP pancreatitis tended to be lower in the CO2 group than the air group (4/102 [3.9%]vs 0/106 [0%], P = 0.056). CONCLUSIONS: CO2 insufflation during ERCP by non-expert endoscopists is recommended from the standpoints of efficacy and safety.

[Successful treatment of spontaneous rupture of pheochromocytoma with laparoscopic adrenalectomy: a case report].

A 46-year-old man had sudden onset of severe left hypochondrial pain and went into shock following hospitalization. Computed tomography, echocardiography, and endocrinological tests revealed spontaneous rupture of a pheochromocytoma associated with catecholamine cardiomyopathy. After he underwent conservative management with fluid replacement, his blood pressure stabilized and cardiac function improved. Twenty-two days later, he was referred to our hospital. After admission, as his circulatory dynamics was stable, we performed elective laparoscopic left adrenalectomy. He was discharged on the tenth postoperative day. Spontaneous rupture of a pheochromocytoma is very rare : laparoscopic surgery for this condition has been reported only on 2 previous occasions worldwide.

[Poor outcome due to spontaneous rupture of renal cell carcinoma : a case report].

A 54-year-old man experienced sudden onset of severe pain in his left lower back. Because the pain persisted for two days, he visited our hospital. Abdominal computed tomography revealed a hematoma around his left kidney, which was diagnosed as spontaneous rupture of a renal tumor. He was immediately admitted and was scheduled to undergo elective surgery. However, because his hemoglobin level decreased suddenly on Day 9 and rebleeding from the renal tumor was suspected, we chose to perform left radical nephrectomy following emergency transcatheter arterial embolization of his left renal artery. The resected specimen was a solid brownish-red mass surrounded by hematoma, and the histopathological findings revealed that it was a renal clear cell carcinoma (G3＞G2, INFα, pT1b, and pV0). On Day 51, he was found to have a local recurrence of carcinoma, and died five months after surgery. Spontaneous rupture of renal cell carcinoma is relatively rare : this is the 104th report on surgery for this carcinoma in Japan.

[A case of bladder cancer with metastasis to the bone of the hand].

Metastasis to the bone of the hand is rare. In addition, metastasis to the bone of the hand from bladder cancer is extremely rare. We herein report a case of distal phalanx metastasis from bladder cancer. A 64- year-old man who was diagnosed with bladder cancer (cT2bN0M0) received total cystectomy (pT3bN2). Two months after the surgery, a roentgenogram revealed lung metastasis. Then we administered 2 cycles of chemotherapy using gemcitabine and cisplatin. Computed tomography revealed a partial response. However, several months after chemotherapy, we noted that his left ring finger was swollen and showed erythema. We made a diagnosis of metastasis to the distal phalanx of the left ring finger and amputated the finger. Pathological findings showed no conflict with metastasis from bladder cancer. Postoperative course was good, but he died about three months after the diagnosis of metastasis.

[Primary adenocarcinoma of the seminal vesicle difficult to differentiate from rectal carcinoma : a case report].

A 78-year-old man with urinary retention visited our hospital in June 2011. He presented with intestinal bleeding one month later and was admitted immediately. Contrast enhancement computed tomography revealed a lobulated intrapelvic tumor and liver metastasis. The prostate specific antigen level was normal, but his carcinoembryonic antigen level was elevated. Based on these results, his tumor was diagnosed as rectal carcinoma. On day 26, total pelvic exenteration and pelvic lymph node dissection to arrest bleeding were performed. We created an ileal conduit for urinary diversion and performed a sigmoid colostomy. The final histopathological assessment confirmed that he had primary adenocarcinoma of the seminal vesicle. The patient received the best supportive care because he rejected postoperative adjuvant chemotherapy and hormonal therapy. He died three months postoperatively. Primary adenocarcinoma of the seminal vesicle is very rare. The prognosis for this carcinoma is poor.

[IgG4-related idiopathic segmental ureteritis which was difficult to distinguish from ureteral cancer: a case report].

A 79-year-old woman was admitted with a chief complaint of gross hematuria, pollakisuria, lower abdominal pain. Urine cytology, intravenous pyelography, and cystoscopy were performed but showed no abnormal findings. About 6 months later, abdominal computed tomography (CT) revealed a 5cm long segment of ureteral narrowing with wall thickening, hydronephrosis, para-aortic lymph node swelling. Retrogradepyelography (RP) was done. Pelvic urine cytology was class IV. Under the clinical diagnosis of ureteral carcinoma and lymph node metastasis, a left nephroureterectomy with lymph node dissection was performed. The pathological diagnosis was IgG4-related idiopathic segmental ureteritis.

[A case of metabolic acidosis and tetany after ileal neobladder replacement].

A 64-year-old man visited our hospital with the complaint of macrohematuria and bilateral hydronephrosis. He had undergone total cystectomy and ileal neobladder replacement under the diagnosis of muscle invasive bladder cancer (cT2bN0M0). Tetany due to hyperventilation syndrome appeared on postoperative day 42. Blood gas analysis showed metabolic acidosis (pH 7.260, pO2 148.1 mmHg, pCO2 20.7 mmHg, HCO3 9.1 mmHg, BE -16.0 mmol/l). His condition was immediately improved after a urethral catheter was placed and sodium bicarbonate was administered. After re-removal of the urethral catheter, however, hyperventilation syndrome recurred. He was discharged from the hospital with the urethral catheter placed.

[Panhypopituitarism caused by an intrasellar cystic mass in late-onset hypogonadism clinic].

A 74-year-old man who was referred to our late onset hypogonadism clinic presented with sweating and loss of appetite. His aging males' symptoms (AMS) and international index of erectile function (IIEF-5) scores were 59 and 2, respectively. His hormonal examination revealed extremely low free testosterone values. The patient was started on androgen replacement therapy, but his symptoms did not improve. Additional hormonal examinations revealed low values for other anterior pituitary hormones. Magnetic resonance imaging revealed an intrasellar cystic mass with suprasellar extension. We considered this mass caused hypothalamic hypopituitarism. A load test for anterior pituitary hormones revealed panhypogonadism. His symptoms improved after administration of adrenal and thyroid hormones and androgen. Five months after start of drug administration, his AMS score improved to 29, but IIEF-5 score showed little change. As a matter of course, not only androgen but all pituitary-related hormones are needed for hypopituitarism patients.

[Three cases of penile self-mutilation].

Penile self-mutilation is rare. We report our experience with 3 cases of penile self-amputation. One case was in a 48-year-old man who had no background history of mental disorders. He amputated his penis using a utility knife. He was referred to our hospital and underwent suture of the wound, but he took his own life one week after the surgery. Another case was in a 42-year-old man who had intelligence impairment. He amputated his penis using a kitchen knife. The other case was in a 41-year-old man who had schizophrenia. He amputated his penis using a piece of broken glass.

[A case of solitary epididymis rupture after blunt scrotal trauma].

Blunt trauma of the scrotum is sometimes associated with severe injuries such as testis rupture. However, there are few reports of traumatic rupture of the epididymis with blunt scrotal trauma. In addition, severe epididymis injuries after scrotal trauma are always associated with severe testis trauma. We experienced a case of solitary rupture of the left epididymis that occurred in a traffic accident. We report herein such a case and review the literature. To our knowledge, this case is the 4th case of solitary epididymis rupture by blunt scrotal trauma.

[Retroperitoneal tumor diagnosed as metastatic lymph node from gastric adenocarcinoma following laparoscopic resection].

A 55-year-old woman who presented with a retroperitoneal tumor was referred to our department. At the age of 51, she underwent a total gastrectomy for gastric cancer. Postoperatively, TS-1 administration was given for Virchow lymph node metastasis, which disappeared within 2 years and TS-1 was stopped. However, computed tomography revealed a retroperitoneal tumor adjacent to the inferior vena cava, which gradually increased and began to compress the inferior vena cava. Under a diagnosis of retroperitoneal tumor, laparoscopic resection was performed. Pathological findings led to a diagnosis of lymph node metastasis from an adenocarcinoma of the stomach.

[A case of chemical burn of the penis].

A chemical burn is not so common in the urological field. In addition, a chemical burn of the penis is quite rare. We experienced a case of chemical burn of the penis caused by resin for making fiber-glass reinforced plastics (FRP). He was a 41-year-old man and was referred to our hospital complaining of genital pain. He had sustained an injury to his penis induced by FRP at his workplace and had developed phimosis by the severe edematous foreskin. He underwent dorsal incision immediately and his postoperative course was favorable.

[Successful testicular sperm extraction in a non-obstructive azoospermic man with severe testicular microlithiasis : a case report].

A 45-year-old man was referred to our hospital for treatment of azoospermia. On physical examination, right testicular volume was 2 ml, left testicular volume was 3 ml, and pubic Tanner stage was 5. Scrotal ultrasonography revealed a high echoic lesion with acoustic shadowing at surfaces of bilateral testes. Semen analysis showed azoospermia and serum follicle stimulating hormone value was high (28.42 mIU/ml). He was diagnosed with non-obstructive azoospermia, and underwent microdissection testicular sperm extraction. Both testes were filled with shiny granular materials. In excised tissue of the testes, seminiferous tubules containing spermatozoa were found and motile spermatozoa were successfully retrieved. The histological examination revealed many small calcifications which had laminated structure. Spermatogenesis was slightly impaired, and Johnsen's score count was 9. Testicular microlithiasis has been reported to be an infrequent condition associated with conditions such as testicular tumors and testicular dysgenesis syndrome. Such a severe testicular microlithiasis has not been reported previously.

[Plexiform neurofibroma of the bladder associated with neurofibromatosis type 1: a case report].

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease with multiple neurofibroma and café-au-lait spots. We report a case of plexiform neurofibroma of the bladder associated with NF1. A 34-year-old female was referred to our hospital for thickness of the bladder wall. Multiple café-au-lait spots and neurofibroma was found on her skin,and she was diagnosed with neurofibromatosis type 1. Ultrasound examination demonstrated bladder wall thickening,and cystoscopy revealed an irregular and erythematous mucosa. Transurethral biopsy of the bladder wall was performed. Histopathological diagnosis was plexiform neurofibroma of the bladder.

Association of serum cytokine levels with treatment response to pegylated interferon and ribavirin therapy in genotype 1 chronic hepatitis C patients.

BACKGROUND: We sought to clarify the associations among serum cytokines, amino acid substitutions in the interferon sensitivity-determining region (ISDR) and core region, and treatment outcome of pegylated interferon and ribavirin therapy in genotype 1 hepatitis C virus (HCV)-infected patients. METHODS: We quantified a total of 8 serum cytokines before, during, and after treatment in 79 genotype 1 chronic HCV patients. Viral ISDR and core region variants were determined by direct sequencing. RESULTS: High levels of interleukin (IL)-12 and IL-18 and more than 2 mutations in the ISDR were associated with a sustained virological response (SVR). Conversely, high baseline IL-10 levels and glutamine at amino acid 70 of the HCV core protein (Gln70) were significantly associated with a nonresponse to treatment, and patients with Gln70 had significantly higher IL-10 levels. In multivariate analysis, low IL-10, high IL-12, and high IL-18 levels were independently associated with an SVR. These 3 cytokine levels were decreased from baseline levels 4 weeks into treatment and remained low in patients with an SVR. CONCLUSION: Serum IL-10, IL-12, and IL-18 levels are predictive of the response to HCV treatment with pegylated interferon and ribavirin and are associated with amino acid substitutions in the ISDR and core region.

[Dieulafoy lesion of the ileal conduit: a case report].

Late side effects of ileal conduit are uncommon. Here we report a case of ileal conduit hemorrhage in a 78-year-old woman 8 years after radical cystectomy and ileal conduit diversion. The patient presented with gross hematuria and abdominal dynamic computed tomography showed extravasation of contrasts in ileal conduit and the patient was diagnosed with ileal conduit hemorrhage. Clipping hemostasis was performed under gastrointestinal endoscope and revealed that Dieulafoy's ulcer was the cause of ileal conduit hemorrhage. This is the first case of Dieulafoy's ulcer occurred in ileal conduit. Hemorrhage from ileal conduit is an important late side effect.