A hemodialytic male in his 60s presented with intermittent chest pain and coffee-ground emesis. Esophagogastroduodenoscopy showed a well-circumscribed area with indistinct vascular pattern in the ...middle esophagus, followed by blackish ulcerative mucosa at the distal esophagus, ending abruptly at the squamocolumnar junction, which findings were compatible with AEML. With fasting and proton-pump inhibitors, his symptoms rapidly resolved. He did not appear at the follow-up appointment one month after hospital discharge. Five months after hospital discharge, he suffered cardiac arrest and died. AEML is an acute erosive esophagitis whose endoscopic appearance resembles that of severe reflux esophagitis (sRE). Our case-control study showed higher mortality from AEML than from sRE. The endoscopic finding of "well-circumscribed esophageal mucosa with indistinct vascular pattern" could be an endoscopic feature of AEML, and may be useful for distinguishing AEML from sRE.
A 75-year-old man was referred to our hospital with suspected gastric cancer. Endoscopy revealed a 10 mm-sized, reddish, depressed lesion in the middle gastric body. Biopsy tissue suggested a poorly ...differentiated adenocarcinoma. Since submucosal invasion could not be ruled out, the patient underwent laparoscopic distal gastrectomy. Resected specimen showed a poorly differentiated adenocarcinoma with significant lymphocytic infiltrate, and 390 μm of submucosal invasion. There was no lymph node metastasis or lymphovascular invasion. Epstein-Barr virus-encoded RNA in situ hybridization was positive, and the diagnosis of Epstein-Barr virus-associated gastric carcinoma with lymphoid stroma (GCLS) was made. GCLS has a low incidence of lymph node metastasis and a relatively good prognosis. In this case, if we had diagnosed GCLS preoperatively, endoscopic submucosal dissection may have been an option for treatment.
Occult pancreatobiliary reflux refers to a condition in which pancreatic juice flows back into the biliary tract with a normal pancreaticobiliary junction.A 45-year-old woman was found to have ...gallbladder wall thickening on abdominal ultrasonography screening. Endoscopic ultrasonography showed thickening of the inner hypoechoic layer and scattered areas of punctate hyperechoic foci inside the layer. Endoscopic retrograde cholangiopancreatography showed no abnormalities in the pancreaticobiliary junction, and the biliary amylase level in the bile in the bile duct was 1962 IU/l. Therefore, we diagnosed occult pancreatobiliary reflux. The patient was considered to be at high risk for gallbladder cancer and underwent prophylactic cholecystectomy. Pathological examination revealed hyperplastic changes and cholesterolosis of the gallbladder, which corresponded to the findings of endoscopic ultrasonography. Our experience suggests that if endoscopic ultrasonography shows gallbladder wall thickening and multiple punctate hyperechoic foci on the luminal side of the gallbladder wall, endoscopic retrograde cholangiopancreatography should be performed suspecting pancreatobiliary reflux. Direct cholangiopancreatography and intraductal amylase measurement are useful.
An 80-year-old woman presented with an asymptomatic, painless lump in the right breast. Positron emission tomography incidentally revealed a 45 mm × 25 mm-sized, dumbbell-shaped mass in the ...epigastric region. Abdominal computed tomography showed that the mass was adjacent to both the stomach and the small intestine. Endoscopic ultrasonography (EUS) showed that the hypoechoic mass had a 1.6 mm-diameter stalk attached to the 4th layer of the gastric wall. Laparoscopic partial gastrectomy was performed. The gastric mass with a narrow stalk was resected and was confirmed as GIST of the stomach histopathologically. The stalk of this tumor was composed of smooth muscle tissue without tumor cells. The diameter of the stalk was 1.6 mm on EUS, and 2.2 mm on histopathological examination. We believe that in vivo in some extra-luminal pedunculated gastric GISTs the stalk may become longer and thinner as the GIST grows.
Background:
Recently, granulocyte and monocyte adsorption apheresis (GCAP) has been shown to be safe and effective for active ulcerative colitis (UC). We analyzed the safety and efficacy of GCAP (G‐1 ...Adacolumn) in patients with steroid‐refractory and ‐dependent UC. G‐1 Adacolumn is filled with cellulose acetate carriers that selectively adsorb granulocytes and monocytes/macrophages.
Methods:
Forty‐four patients with UC were treated with GCAP. These patients received 5 apheresis sessions over 4 weeks. Twenty patients had steroid‐refractory UC (group 1) and 10 had steroid‐dependent UC (group 2). Fourteen patients who did not want re‐administration of steroids were treated with GCAP at the time of relapse, just after discontinuation of steroid therapy (group 3).
Results:
Of 44 patients treated with GCAP, 24 (55%) obtained remission (CAI ≤ 4), 9 (20%) showed a clinical response, and 11 (25%) remained unchanged. Only 2 of 10 patients (20%) with severe steroid‐refractory UC (CAI ≥ 12) achieved remission, whereas 7 of 10 patients (70%) with moderate steroid‐refractory UC achieved remission (p < 0.05). The dose of corticosteroids was tapered in 9 of 10 (90%) patients with steroid‐dependent UC after GCAP therapy. Twelve (86%) of 14 patients in group 3 showed an improvement in symptoms and could avoid re‐administration of steroids after GCAP. No severe adverse effects occurred.
Conclusions:
The findings of this study suggest that GCAP may be a useful alternative therapy for patients with moderate steroid‐refractory or ‐dependent UC, although cyclosporin A or colectomy is necessary in patients with severe UC. GCAP may also be useful for avoiding re‐administration of steroids at the time of relapse. Randomized, controlled clinical trials are needed to confirm these findings.
A 50-year-old man with a hypervascular submucosal tumor in the second part of the duodenum presented melena during chemotherapy with Irinotecan, S-1, and Bevacizumab for peritoneal metastasis of ...rectal cancer. Esophagogastroduodenoscopy showed a bleeding ulcer on the submucosal tumor. The ulcer healed after discontinuation of Bevacizumab. Laparoscopic surgery was performed to excise the submucosal tumor. The mass measuring 20 × 16 mm in size was diagnosed as a very-low-risk gastrointestinal stromal tumor (GIST) histopathologically. An ulcer on GISTs is associated with high-grade malignancy. Although the GIST was very low risk in our case, an ulcer formed. The cause of the ulcer was related to administration of Bevacizumab, an angiogenesis inhibitor, for the hypervascular tumor. Caution must be exercised when Bevacizumab is given to patients with GISTs.
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