Peutz–Jeghers syndrome is an autosomal dominant disorder characterized by hamartomatous polyposis, pigmentation, and malignant tumors. We report a case of ileocecal carcinoma that was incidentally ...detected during follow-up for Peutz–Jeghers syndrome. A 39-year-old man with solitary Peutz–Jeghers syndrome had undergone three abdominal surgeries. He had been followed up via upper and lower gastrointestinal endoscopy and small intestinal endoscopy. In the endoscopic examination of the lower gastrointestinal tract, a 35 mm large, bumpy, elevated lesion was observed in the cecum. This lesion was not observed 9 months earlier during lower endoscopy. Biopsy of the specimen confirmed tubulovillous adenoma and carcinoma. This lesion was judged to be an indication for operation, and we performed ileocecectomy + D3 lymph node dissection. From the excised specimen, poorly differentiated carcinoma and adenoma components in contact with Peutz–Jeghers-type polyps in the appendix were recognized. A review of the computed tomography image obtained 2 years ago confirmed appendiceal swelling. We suspect that the ileocecal carcinoma in the appendix may have rapidly developed within the 9 months, and was incidentally detected on lower endoscopic examination during follow-up. For the prevention of appendicular tumorigenesis, prophylactic appendectomy may be considered in certain cases during follow-up for Peutz–Jeghers syndrome.
Helicobacter pylori (H. pylori) eradication is usually assessed using the 13C-urea breath test (UBT), anti-H. pylori antibody and the H. pylori stool antigen test. However, a few reports have used ...pepsinogen (PG), in particular, the percentage change in the PG I/II ratio. Here, we evaluated the usefulness of the percentage changes in serum PG I/II ratios for determining the success of eradication therapy for H. pylori.
In total, 650 patients received eradication therapy from October 2008 to March 2013 in our Cancer Institute Hospital. We evaluated the relationship between H. pylori eradication and percentage changes in serum PG I/II ratios before and 3 months after treatment with CLEIA® (FUJIREBIO Inc, Tokyo, Japan). The gold standard of H. pylori eradication was defined as negative by the UBT performed 3 months after completion of eradication treatment. Cut-off values for percentage changes in serum PG I/II ratios were set as +40, +25 and +10% when the serum PG I/II ratio before treatment was below 3.0, above 3.0 but below 5.0 and 5.0 or above, respectively.
Serum PG I and PG II levels were measured in 562 patients with H. pylori infection before and after eradication therapy. Eradication of H. pylori was achieved in 433 patients studied (77.0%). The ratios of first, second, third-line and penicillin allergy eradication treatment were 73.8% (317/429), 88.3% (99/112), 75% (12/16) and 100% (5/5), respectively. An increasing percentage in the serum levels of the PG I/II ratios after treatment compared with the values before treatment clearly distinguished success from failure of eradication (108.2±57.2 vs. 6.8±30.7, p<0.05). Using the above cut-off values, the sensitivity, specificity and validity for determination of H. pylori were 93.1, 93.8 and 93.2%, respectively.
In conclusion, the percentage changes in serum PG I/II ratios are useful as evaluation criteria for assessing the success of eradication therapy for H. pylori.
AIM:To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection(ESD)treatment for colorectal neoplasms.METHODS:We retrospectively reviewed the medical records of ...317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June2013.Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion.We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses:age,gender,presence of comorbidities,use of antithrombotic drugs,use of intravenous heparin,resected specimen size,lesion size,lesion location,lesion morphology,lesion histology,the device used,procedure time,and the presence of significant bleeding during ESD.RESULTS:Delayed post-ESD bleeding was found in14 lesions from 14 patients(4.3%of all specimens,4.4%patients).Patients with episodes of delayed postESD bleeding had a mean hemoglobin decrease of2.35 g/dL.All episodes were treated successfully using endoscopic hemostatic clips.Emergency surgery was not required in any of the cases.Blood transfusion was needed in 1 patient(0.3%).Univariate analysis revealed that lesions located in the cecum(P=0.012)and the presence of significant bleeding during ESD(P=0.024)were significantly associated with delayed post-ESD bleeding.The risk of delayed bleeding was higher for larger lesion sizes,but this trend was not statistically significant.Multivariate analysis revealed that lesions located in the cecum(OR=7.26,95%CI:1.99-26.55,P=0.003)and the presence of significant bleeding during ESD(OR=16.41,95%CI:2.60-103.68,P=0.003)were independent risk factors for delayed post-ESD bleeding.CONCLUSION:Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding.Therefore,careful and additional management is recommended for these patients.
Mesenteric inflammatory veno-occlusive disease (MIVOD) is an ischemic disorder caused by inflammation of the mesenteric veins without involvement of the arterial vessels. Lacking specific diagnostic ...findings, MIVOD is difficult to confirm until surgical resection and histological analysis. We herein describe the clinical outcome of an 82-year-old woman admitted to our hospital for abdominal pain, abdominal distention, and other symptoms unresponsive to conservative medical treatment. No specific laboratory findings were noted apart from slightly elevated C-reactive protein. Abdominal contrast-enhanced computed tomography (CT) revealed wall thickness in the small intestine without abnormalities of the major trunk mesenteric vessels or free air in the abdominal cavity. Conservative therapy with levofloxacin and streptomycin was given considering the possibility of intestinal infection. The drugs were discontinued once her symptoms improved, but abdominal pain recurred along with exacerbation of small intestinal niveau at 21 days of admission. A stenotic lesion on the anal side of the small intestine detected in a gastrointestinal series was surgically resected. The excised tissue showed histopathological evidence of ulceration and inflammation along with thrombus formation and luminal stenosis and recanalization in the mesenteric vein, but not in arterial vessels, which confirmed the diagnosis of MIVOD. She was later discharged with a favorable postoperative clinical course. Clinicians should bear in mind MIVOD when encountering patients with unexplained abdominal pain or stenosis of the small intestine who are refractory to conservative treatment.
Backgrounds
The present study sought to establish a standard third-line eradication regimen for
Helicobacter pylori
in Japan.
Methods
Subjects were 204 patients with
H. pylori
infection in whom the ...standard Japanese first- and second-line eradication therapies had proven unsuccessful. Patients were randomly assigned to one of the following third-line eradication therapy groups: (1) LA group: lansoprazole (LPZ) 30 mg 4 times a day (qid) + amoxicillin (AMPC) 500 mg qid for two weeks; (2) LAL group: LPZ 30 mg twice a day (bid) + AMPC 750 mg bid + levofloxacin (LVFX) 300 mg bid for one week; (3) LAS group: LPZ 30 mg bid + AMPC 750 mg bid + sitafloxacin (STFX) 100 mg bid for one week. Patients for whom these therapies failed underwent a crossover fourth-line eradication regimen. Drug sensitivity was also tested for AMPC, clarithromycin (CAM), MNZ, LVFX, and STFX.
Results
Drug resistance rates prior to third-line eradication therapy were 86.4 % for CAM, 71.3 % for MNZ, 57.0 % for LVFX, 8.2 % for AMPC, and 7.7 % for STFX. Intention-to-treat analysis of third-line eradication therapy eradication rates showed a significantly higher rate in the LAS group (70.0 %) compared with the LA group (54.3 %;
p
< 0.05) and the LAL group (43.1 %;
p
< 0.001). The significantly lower rate in the LAL group than the LAS group was caused by bacterial resistance to LVFX.
Conclusions
The findings suggest that triple therapy with PPI, AMPC, and STFX for one week would be an effective standard third-line eradication regimen for
H. pylor
i in Japan.
Background
Early esophagogastric junction (EGJ) cancer is currently being treated in the same way as early gastric cancer, by endoscopic submucosal dissection (ESD), but long-term outcomes are still ...unknown. Our aim was to retrospectively evaluate the safety and efficacy of ESD in treating early EGJ cancer and compare risk factors in curative and non-curative resection cases.
Methods
Forty-four cases of early EGJ cancer, defined as a Siewert’s type II tumor, in 44 patients with a mean age of 70.0 years and a male/female ratio of 90.9:9.1 % were treated by ESD between January 2004 and June 2010. There were 30 standard indication cases; the remaining 14 cases were expanded indication cases.
Results
Mean resected specimen and tumor sizes were 35 and 17 mm, respectively, and median procedure time was 121 min, with no bleeding or perforation complications. All cases were resected en bloc with an 84.1 % curative resection rate (37/44). The curative resection rates in the standard and expanded indication cases were 90.0 % (27/30) and 71.4 % (10/14), respectively. There were no significant differences in tumor location, tumor morphology, tumor size, histology of biopsy specimens, or standard versus expanded indication cases with regard to risk factors for curative and non-curative resections. However, submucosal invasion, positive tumor margins, lymphovascular invasion, and some components of poorly differentiated adenocarcinomas in just the submucosal layer were significantly more common in the non-curative resection cases.
Conclusions
ESD was a safe, effective, and minimally invasive treatment for early EGJ cancer. For tumors without any submucosal invasion findings, therefore, ESD is an acceptable treatment option, in addition to also being suitable for diagnostic purposes in evaluating the need for surgery.
We report a rare case of extensive esophageal squamous papillomas (ESPs) involving the entire esophagus and florid cardiac gland hyperplasia involving only the lower esophagus in a 39-year-old woman ...with heartburn and epigastric distress for the past 2 years. Previous esophagogastroduodenoscopy showed multiple ESPs involving the entire esophagus extending 38 cm from the esophageal orifice to the esophagogastric junction (EGJ). Additionally, prominent cardiac gland hyperplasia over the esophageal posterior wall was exhibited extending 12 cm from the mid-esophagus to the EGJ. A biopsy obtained from the ESP area showed typical squamous papillomas and cardiac gland hyperplasia with no evidence of koilocytosis or malignancy. Polymerase chain reaction was negative for a variety of human papilloma virus DNAs. Subsequently, Siewert type II gastric cancer with submucosal elevation of the stomach was detected at the EGJ. Endoscopy showed a 20-mm-thick lesion appearing to extend to the muscularis propria; subsequent biopsy showed invasive adenocarcinoma. Total gastrectomy with D2 lymph node dissection, splenectomy, and Roux-en-Y reconstruction were performed for the EGJ cancer. The patient died from widespread multiorgan metastasis within 2 years following surgery.
Hemorrhagic radiation cystitis is an example of a typical radiotherapy-induced adverse event. However, the optimal treatment for hemorrhagic radiation cystitis is not known. There are limited data ...regarding the use of argon plasma coagulation for hemorrhagic radiation cystitis. Here, we present the use of argon plasma coagulation using a gastrointestinal endoscope to treat hemorrhagic radiation cystitis. The patient was a 75-year-old male patient with hemorrhagic radiation cystitis due to external beam irradiation for prostate adenocarcinoma. Six years after radiotherapy, the patient presented with macroscopic hematuria over the preceding 4 months, and laboratory investigations revealed a low hemoglobin level. The hematuria was not controlled with 2 days of bladder irrigation using normal saline. Thus, argon plasma coagulation using an upper gastrointestinal endoscope was considered for treatment of the hemorrhagic radiation cystitis. The cystoscopic examination revealed diffuse radiation cystitis with oozing telangiectasia and coagula. All of the bleeding sites and telangiectasia were coagulated using argon plasma coagulation. Following treatment, the patient's clinical symptoms improved and did not recur. The hemoglobin level also recovered. No complications associated with the treatment were observed during the 6-month follow-up period. Thus, argon plasma coagulation using a gastrointestinal endoscope is a safe and effective treatment for hemorrhagic radiation cystitis.
A 67-year-old man, presenting with anemia and suspected gastric cancer, was referred to our hospital, where he underwent esophagogastroduodenoscopy (EGD). Biopsy revealed densely populated ...semi-circular cells with abundant cytoplasm that were positive for S-100 protein, melanoma antigen, and HMB-45, resulting in a diagnosis of malignant melanoma. A gastrointestinal barium study for further exploration demonstrated a filling defect 6 cm in size at the ligament of Treitz. Follow-up EGD of this finding revealed an ulcerated, half-circumferential lesion with a distinct ulcer mound extending from the ascending part of the duodenum to the jejunum, and additional biopsy also indicated malignant melanoma. Computed tomography scans showed wall thickening from the ascending part of duodenum to the proximal jejunum, whereas positron emission tomography revealed accumulation at the upper gastric body, the duodenum to the jejunum, and the left adrenal gland. Systemic exploration of the patient, including the skin, anus, and eyeballs, revealed no other lesions, and primary small intestinal malignant melanoma with metastasis to the stomach and adrenal gland was diagnosed. Partial duodenojejunectomy, partial gastrectomy, and left adrenalectomy were performed, and adjuvant chemotherapy with dacarbazine, nimustine hydrochloride, and vincristine sulfate was administered. No postoperative recurrence has been observed in the past 3 years.
Currently, transnasal esophagogastroduodenoscopy using an ultrathin endoscope is being widely carried out as a screening test for early gastric cancer. We compared the diagnostic utility of ultrathin ...esophagogastroduodenoscopy with that of conventional esophagogastroduodenoscopy in detecting 42 lesions of early gastric cancer that had a diameter of ≤20 mm. Only 27 lesions (64%) could be accurately diagnosed using ultrathin esophagogastroduodenoscopy. In nine lesions (22%), we failed to discern whether they were malignant. Six lesions (14%) could not even be detected. We found that the diagnostic utility of ultrathin esophagogastroduodenoscopy was inadequate, especially in the case of lesions that were located in the upper third region of the stomach and variegated lesions. In conclusion, the diagnostic utility of ultrathin esophagogastroduodenoscopy might be lower than that of conventional esophagogastroduodenoscopy in terms of screening for early gastric cancer. The disadvantages of ultrathin esophagogastroduodenoscopy should be taken carefully into consideration while examining lesions.
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