Extrahepatic Collateral Artery Extravasation in Patients with Ruptured Hepatocellular Carcinoma.

This report describes 3 patients with previously untreated hepatic tumors who underwent embolization for the treatment of extravasation from extrahepatic arteries. Although development of extrahepatic collateral blood supply is well known, its importance in the presentation of rupture of liver tumors may be underrecognized. Findings that suggest bleeding from extrahepatic arteries include a discrepancy in the pattern of extravasation on computed tomography vs hepatic angiography and a lack of stabilization of vital signs after embolization of hepatic arteries. To achieve successful hemostasis in embolization, the potential involvement of such extrahepatic arteries should be accurately recognized, suggestive imaging findings considered, and the occult vessels selected and embolized.

Biosynthesis of volatile terpenes that accumulate in the secretory cavities of young leaves of Japanese pepper (Zanthoxylum piperitum): Isolation and functional characterization of monoterpene and sesquiterpene synthase genes.

Volatile terpenes are ones of the characteristic aromas of Japanese pepper (Zanthoxylum piperitum). It has been hypothesized that the specialized epithelial cells surrounding the secretory cavities of Japanese pepper fruits and leaves are responsible for the synthesis of monoterpenes and sesquiterpenes, which are generally produced by terpene synthases (TPSs); however, direct evidence for the formation of terpenes in Japanese pepper remains elusive. Here we report that monoterpenes and sesquiterpenes accumulate inside the secretory cavities of Japanese pepper leaves, but not in other parts of leaf tissues that do not include secretory cavities. We have obtained cDNAs for ZpTPS1 and ZpTPS2, which are responsible for biosynthesis of the sesquiterpenes ß-caryophyllene and germacrene D, respectively, in Japanese pepper. In addition, we also identified a cDNA for the monoterpene synthase ZpTPS3. Expression of ZpTPS3 in Escherichia coli in addition to Agrobacterium-mediated transient ZpTPS3 expression in Nicotiana benthamiana demonstrated the catalytic activity of ZpTPS3 to form ß-phellandrene as the major product. In situ hybridization in Japanese pepper leaf tissue revealed that ZpTPS3 transcript specifically accumulated in the epithelial cells surrounding secretory cavities. Expression of ZpTPS3 in epithelial cells was only detectable during early stages of cavity development, whereas the formation of volatile terpenes occurred at a constant rate throughout the expansion of secretory cavities. Our studies have improved the understanding of the currently uncharacterized processes controlling volatile terpene biosynthesis in Japanese pepper leaves.

Aromatic amino acid decarboxylase is involved in volatile phenylacetaldehyde production in loquat (Eriobotrya japonica) flowers.

Post anthesis, loquat flowers emit volatile benzenoids, including phenylacetaldehyde, phenylethyl alcohol, and 2-phenethyl benzoate. Previous studies have shown that pyridoxal phosphate-dependent aromatic L-amino acid decarboxylase (AADC) produces phenylacetaldehyde from L-phenylalanine. Here, two AADC genes (EjAADC1 and EjAADC2) were isolated from loquat (Eriobotrya japonica) flowers. The EjAADC1 and EjAADC2 proteins showed approximately 72% and 55% identity, respectively, to a rose AADC homolog that has phenylacetaldehyde synthase activity. Transcript analyses indicated that EjAADC1 was specifically expressed in petals, with the highest level of expression in fully opened flowers; the petals showed high levels of volatile benzenoids, including phenylacetaldehyde. In contrast, EjAADC2 was expressed at a lower level than EjAADC1 in all tested tissues, including leaves and developing flowers. Functional characterization of a recombinant EjAADC1 protein expressed in Escherichia coli showed that it catalyzes the formation of phenylacetaldehyde from L-phenylalanine in a pyridoxal phosphate-dependent manner. Our results suggest that EjAADC1 is mainly responsible for the biosynthesis of volatile benzenoids in loquat flowers.

Familial Occurrence of Enteric Muco-Submucosal Elongated Polyp.

We report 2 cases of enteric muco-submucosal elongated polyps (EMSEPs) that presented with gastrointestinal bleeding. The 2 patients are siblings. They both had a history of percutaneous coronary intervention for coronary artery disease and were on dual antiplatelet therapy. They underwent endoscopic resection of the polyps, which displayed identical endoscopic and histological features compatible with EMSEP. This is the first report of familial occurrence of EMSEP, suggesting possible genetic involvement. It is also important to note that the use of antiplatelet agents appears to be a predisposing factor for gastrointestinal bleeding from EMSEP.

High-Flow Vascular Malformation in the Sigmoid Mesentery Successfully Treated with a Combination of Transarterial and Transvenous Embolization.

Mesenteric high-flow vascular malformation can cause various clinical symptoms and demand specific therapeutic interventions owing to its peculiar hemodynamics. We report a case of high-flow vascular malformation in the sigmoid mesentery which presented with ischemic colitis. The main trunk of the inferior mesenteric vein was occluded. After partially effective transarterial embolization, transvenous embolization was performed using a microballoon catheter advanced to the venous component of the lesion via the marginal vein. Complete occlusion of the lesion was achieved. Combination of transarterial and transvenous embolization may allow us to apply endovascular treatment to a wider variety of high-flow lesions in the area and possibly avoid the bowel resection.

Provocative Endoscopy to Identify Bleeding Site in Upper Gastrointestinal Bleeding: A Novel Approach in Transarterial Embolization.

This report describes a novel approach to endoscopically induce bleeding by removing a clot from the bleeding site during angiography for upper gastrointestinal (UGI) hemorrhage. This procedure enabled accurate identification of the bleeding site, allowing for successful targeted embolization despite a negative initial angiogram. Provocative endoscopy may be a feasible and useful option for angiography of obscure bleeding sites in patients with UGI arterial hemorrhage.

Endoscopic Submucosal Dissection for the Complete Resection of the Rectal Remnant Mucosa in a Patient With Familial Adenomatous Polyposis.

A 47-year-old woman underwent prophylactic subtotal colectomy with ileorectal anastomosis (IRA) for familial adenomatous polyposis (FAP) 18 years ago. She underwent 5 transanal endoscopic microsurgeries for rectal remnant polyps, and was referred for the treatment of rectal remnant polyp recurrence. Endoscopic submucosal dissection (ESD) was performed to remove multiple polypoid lesions that circumferentially extended throughout the rectal remnant with lesions spreading onto the anastomotic site. The rectal remnant mucosa was resected in 2 pieces without complication. Specimens showed high-grade adenoma but no malignancy. Follow-up colonoscopy showed no recurrence.

Multiple Acute Infection by Anisakis: A Case Series.

The ingestion of raw seafood infected with nematode larvae of the Anisakidae family can lead to gastric anisakiasis. The majority of the infections involve a single larva, however, there have been instances of multiple infection. The incidence rate and the characteristics of multiple infection by Anisakis remain poorly understood. We herein present a case of parasitization by multiple Anisakis larvae and describe 14 cases of multiple parasitization representing the largest reported case series to date. Endoscopists should therefore be aware of the potential for multiple infection by Anisakis and the need for a thorough inspection of all parts of the stomach when encountering such cases.

Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization.

BACKGROUND AND AIMS: Endoscopic band ligation (EBL) has been used to achieve hemostasis in patients with colonic diverticular bleeding. The safety and effectiveness of EBL when performed by non-expert endoscopists have not been sufficiently verified. This study aimed to elucidate the feasibility of the EBL technique when performed by non-expert endoscopists and of considering EBL as a standard treatment for colonic diverticular bleeding. PATIENTS AND METHODS: A retrospective cohort study was conducted in a tertiary referral center in Tokyo, Japan, between June 2009 and October 2014. A total of 95 patients treated with EBL were included in the study and were divided into two groups according to whether they had been treated by expert or non-expert endoscopists. Comorbidities, medications, shock index, hemoglobin level on admission, location of the bleeding diverticula, rate of bowel preparation, procedure time, and EBL-associated adverse events were evaluated in each group. Multivariate linear regression analyses were used to investigate factors related to EBL procedure time, which is the time elapsed between marking the site of bleeding with hemoclips and completion of the band release. RESULTS: A total of 47 (49.5 %) procedures were performed by expert endoscopists. In a bivariate analysis, the median EBL procedure times in the expert and non-expert groups were 15 minutes (range 4 - 45) and 11 minutes (range 4 - 36), respectively (P = 0.03). When a multivariate linear regression model was used, EBL for right-sided diverticula was the factor most significantly affecting EBL procedure time. No adverse events were encountered. CONCLUSION: EBL can be safely and effectively performed by non-expert endoscopists. A right-sided location of diverticula was the factor most significantly affecting EBL procedure time.

Risk factors for early rebleeding after endoscopic band ligation for colonic diverticular hemorrhage.

BACKGROUND AND STUDY AIMS: Endoscopic band ligation (EBL) has been used for hemostasis of colonic diverticular hemorrhage. However, early rebleeding (< 30 days after EBL) has been reported in some cases. The aim of this study was to elucidate risk factors for early rebleeding after EBL in treatment of colonic diverticular hemorrhage. PATIENTS AND METHODS: A total of 101 patients with definite diverticular hemorrhage treated using EBL from June 2009 to October 2014 were included in the retrospective cohort study and divided into rebleeding and non-rebleeding groups, depending on the presence or absence of early rebleeding. Patients' ages, comorbid diseases, stigmata of recent hemorrhage (SRH) [active bleeding (AB), non-bleeding visible vessel (NBVV), or adherent clot (AC)], locations of bleeding diverticula, and eversions of the diverticula after EBL were retrospectively evaluated in each group. RESULTS: Early rebleeding occurred in 15 cases. The median time (range) of early rebleeding occurrence was 5 days (range, 2 h to 26 days). Early rebleeding could be managed conservatively and/or endoscopically, except in one case in which surgery was done. Multivariate analysis revealed that age under 50 (adjusted OR, 8.7; 95 % CI 1.6 - 52.5; P = 0.014) and AB (adjusted OR, 4.21; 95 % CI 1.15 - 18.1; P = 0.03) were shown to be significant risk factors. The right side of the colon carried less risk than did the left side (adjusted OR, 0.21; 95 % CI 0.04 - 0.84; P = 0.028). CONCLUSIONS: Younger age, AB of SRH, and leftsided lesions were identified as the risk factors for early rebleeding after EBL in the treatment of colonic diverticular hemorrhage.

Comparison of long-term outcomes between endoscopic band ligation and endoscopic clipping for colonic diverticular hemorrhage.

BACKGROUND AND STUDY AIMS: Long-term outcomes of endoscopic band ligation (EBL) for colonic diverticular hemorrhage have not been reported to date. The aim of this study was to determine the long-term outcomes of EBL and to retrospectively compare them with those of endoscopic clipping (EC) in the treatment of colonic diverticular hemorrhage. PATIENTS AND METHODS: The study included patients with colonic diverticular hemorrhage who were treated with EBL or EC from January 2004 to November 2014 and followed up more than 1 year (61 patients in the EBL group and 39 patients in the EC group). Time-to-event analysis of rebleeding was performed with the Kaplan-Meier method. A follow-up colonoscopy was performed to confirm the disappearance of the banded diverticula in the EBL group. RESULTS: Rebleeding occurred in 21 patients in the EBL group and in 26 patients in the EC group. The cumulative incidence of rebleeding at 1, 12, 24, and 36 months after first treatments was 14 %, 23 %, 26 %, and 41 % in the EBL group and 38 %, 49 %, 59 %, and 68 % in the EC group, respectively. Time-to-event analysis revealed statistically significant data (Log-rank test, P = 0.0036). Scar formation with fold convergence at the previously banded site was observed in 11 of 24 patients who underwent follow-up colonoscopy (46 %). However, late rebleeding (rebleeding more than 30 days after EBL) occurred in five of these 11 cases. CONCLUSIONS: EBL was superior to EC in the treatment of colonic diverticular hemorrhage. However, the risk of rebleeding was not avoided even after the diverticula had been resolved using EBL.

Association of Primary Biliary Cirrhosis-autoimmune Hepatitis Overlap Syndrome with Immune Thrombocytopenia and Graves' Disease.

A 54-year-old woman suffering from pruritus for five years was diagnosed to have Graves' disease and immune thrombocytopenia (ITP) associated with primary biliary cirrhosis (PBC)-autoimmune hepatitis (AIH) overlap syndrome, which was confirmed histologically after a prompt recovery in the platelet count number following steroid therapy. The association between PBC-AIH overlap syndrome and ITP has been rarely reported and the additional association with Graves' disease has not yet been reported. An underlying global derangement of autoimmunity or shared genetic susceptibility was suspected.

Colonic Diverticulitis After Endoscopic Band Ligation Performed for Colonic Diverticular Hemorrhage.

A 72-year-old woman presented with massive hematochezia. Colonoscopy revealed active bleeding from a diverticulum in the ascending colon, diagnosed as colonic diverticular hemorrhage. Endoscopic band ligation (EBL) was performed for the hemostasis. The patient developed abdominal pain in the right lower quadrant 1 day after EBL. Computed tomography (CT) demonstrated dirty fat around the ascending colon and thickened peritoneum without perforation or abscess formation, consistent with uncomplicated diverticulitis. The patient was discharged with intravenous antibiotic therapy 5 days after EBL. Attention should be given to the occurrence of colonic diverticulitis after EBL for colonic diverticular hemorrhage.

Endoscopic Band Ligation For Treatment of a Colonic Polyp Extending Into the Colonic Diverticulum.

A 66-year-old male was referred for the treatment of a polyp extending into a diverticulum. Endoscopic band ligation (EBL) was used to resolve the diverticulum. The banded diverticulum resolved and scar formation was observed 2 months after EBL. Residual small polypoid lesions were resected using endoscopic mucosal resection (EMR), and no complications occurred after treatment.

Safety and Efficacy of Endoscopic Submucosal Dissection for Non-Ampullary Duodenal Neoplasms: A Case Series.

Sixteen non-ampullary duodenal neoplasms in 16 patients were treated with endoscopic submucosal dissection (ESD) performed by an endoscopist and an instrument assistant between February 2011 and November 2014. En bloc resection was performed in 15 cases (94%); lateral and vertical margins were pathologically free in 13 cases. Perforation occurred during submucosal dissection using a flex knife, but no perforations occurred in 15 cases using the hook knife only. No postoperative bleeding nor recurrence has been reported in any patient during the median 17-month follow-up period. Use of the hook knife as the main instrument and targeted training of the endoscopist and instrument assistant contributed to safe and effective duodenal ESD for non-ampullary duodenal neoplasms.

Endoscopic findings and lesion distribution in amebic colitis.

A retrospective cohort study was conducted in 55 symptomatic patients with amebic colitis that visited at St. Luke's International Hospital and Mie University Hospital from 1994 through 2013. To diagnose amebic colitis, 40 patients underwent total colonoscopy within 1 week after hospital visiting and before receiving any treatment. The percentage of characteristic endoscopic findings of amebic colitis including discrete ulcers or erosions with white or yellow exudates were 0% in terminal ileum, 93% in cecum, 28% in ascending, 25% in transverse, 15% in descending, 20% in sigmoid colon and 45% in rectum. The rectal lesions in 55% of patients with amebic colitis were nonspecific. The trophozoite identification rate by direct smear of intestinal tract washings performed during colonoscopy was 88%. The protozoan identification rate was 70% in biopsy specimens taken from the periphery of the characteristic discrete ulcers. Total colonoscopy should be considered for the diagnosis of amebic colitis.

Perforation of the neovagina in a male-to-female transsexual: a case report.

INTRODUCTION: There are several techniques for creation of a neovagina in male-to-female reassignment surgery. Although vaginoplasty with the sigmoid colon is not a common procedure, it is becoming more common. Perforation of the recto-sigmoid neovagina after sex reassignment surgery is very rare. We hereby report a case of perforation of the neovagina that presented as acute peritonitis, with a massive abscess in the intra-abdominal cavity. CASE PRESENTATION: This case report describes a 33-year-old Asian woman presenting with mild persistent abdominal pain, nausea, and vomiting who had undergone male-to-female sex reassignment surgery four years prior. Physical examination revealed mild abdominal pain without rebound tenderness. An abdominal computed tomography scan showed a massive abscess that occupied a significant portion of the intra-abdominal cavity. Perforation of the neovagina was confirmed by exploratory laparotomy and surgical drainage with primary closure was performed without any complications. CONCLUSION: This is a rare case involving perforation of the neovagina that was successfully treated with surgical intervention. This case emphasizes the importance of taking a detailed medical history and to make physicians and patients aware that bowel vaginoplasty can result in a weak vagina.

Endoscopic band ligation for bleeding lesions in the small bowel.

AIM: To investigate the safety and efficacy of endoscopic band ligation (EBL) for bleeding lesions in the small bowel. METHODS: This is a retrospective study evaluating EBL in six consecutive patients (three males, three females, 46-86 years of age) treated between May 2009 and February 2014: duodenal vascular ectasia; 1, jejunal bleeding diverticulum; 1, ileal Dieulafoy's lesion; 1 and ileal bleeding diverticula; 3. The success of the initial hemostasis was evaluated, and patients were observed for early rebleeding (within 30 d after EBL), and complications such as perforation and abscess formation. Follow-up endoscopies were performed in four patients. RESULTS: Initial hemostasis was successfully achieved with EBL in all six patients. Eversion was not sufficient in four diverticular lesions. Early rebleeding occurred three days after EBL in one ileal diverticulum, and a repeat endoscopy revealed dislodgement of the O-band and ulcer formation at the banded site. This rebleeding was managed conservatively. Late rebleeding occurred in this case (13 and 21 mo after initial EBL), and re-EBL was performed. Follow-up endoscopies revealed scar formation and the disappearance of vascular lesions at the banded site in the case with a duodenal bleeding lesion, and unresolved ileal diverticula in three cases. Surgery or transarterial embolization was not required without any complications during the median follow-up period of 45 (range, 2-83) mo. CONCLUSION: EBL is a safe and effective endoscopic treatment for hemostasis of bleeding lesions in the small bowel.

Determination of the discriminant score of intestinal microbiota as a biomarker of disease activity in patients with ulcerative colitis.

BACKGROUND: In recent years, the gut microbiota has been found to provide an important link to the development of inflammatory bowel diseases (IBD) like ulcerative colitis (UC). Accordingly, inter-individual variation in the gut microbial community may be linked to inter-individual variation in the risk of IBD or other diseases. Further, the Terminal Restriction Fragment Length Polymorphism (T-RFLP) is a molecular biology technique for profiling bacterial species in faecal samples. This study was to evaluate a biomarker based on intestinal microbiota. METHODS: The study subjects were 69 patients with UC together with 80 relatives as controls. Twenty-three patients had active UC (group I) and 46 had quiescent UC (group II). The later included 17 patients with mild inflammation in the large intestine (group IIa), 29 without inflammation (group IIb). The patients' relatives were consanguineous (group III, n = 47), and non-consanguineous (group IV, n = 33). Faecal samples were obtained from all subjects for the investigation of intestinal microbiota by applying the T-RFLP method. The Discriminant analysis of operational-taxonomic-unit (OTU) on T-RFLP fingerprints was performed. The Canonical Discriminant Function Coefficient (Df) for each OTU was calculated. The individual OTUs were multiplied by the Df value, and the sum was termed the Discriminant Score (Ds). RESULTS: The Ds decreased thus: group I > group IIa > group IIb > group III > group IV. Significant difference was calculated for group I vs group IV (P < 0.01), group I vs group IIb (P < 0.05), group I vs group III (P < 0.01), group IIa vs IV (P < 0.01), group IIb vs group IV (P < 0.01), group III vs group IV (P < 0.01), indicating a strong association between gut microbial species and the development of UC. CONCLUSIONS: In this study, the Ds related to UC, or otherwise absence of UC in the five groups. Potentially, Ds may become a clinically relevant biomarker of disease activity in UC. To our knowledge, this is the first application of the Ds to the study of microbiota in UC patients, consanguineous and non-consanguineous relatives. TRIAL REGISTRATION: Clinical trial No: UMIN 000004123.