Decreased anti-parietal cell antibody titer in the advanced phase of autoimmune gastritis.

BACKGROUND: Autoimmune gastritis (AIG) is histologically classified into three phases according to the severity of oxyntic mucosal atrophy: early, florid, and end phases. This study aimed to clarify the relationship between the AIG phase and the anti-parietal cell antibody titer. METHODS: Patients who underwent upper gastrointestinal endoscopy were retrospectively reviewed in this study. We enrolled patients who were histologically diagnosed with AIG and serologically tested for anti-parietal cell antibody (APCA). AIG patients were classified into three groups: early, florid, and end phase groups. Clinical characteristics, including APCA titers, were compared among these three groups. RESULTS: A total of 44 AIG patients were enrolled. There were two patients in the early phase, 11 in the florid phase, and 31 in the end phase. APCA-positive rates were 100% in the early phase, 90.9% in the florid phase, and 90.3% in the end phase. The mean APCA titer was 480 U in the early phase, 220 U in the florid phase, and 150 U in the end phase. There was a stepwise decrease in the APCA titer from the early phase to the end phase. The mean APCA titer for the end phase was significantly lower than that of the early phase or florid phase. Additionally, there was a stepwise decrease in serum gastrin levels from the early phase to the end phase. CONCLUSION: AIG progresses from the early phase to the end phase, and the APCA titer shows a decrease. The negativity of APCA could occur, especially in the end phase.

Simple feedback of colonoscopy performance improved the number of adenomas per colonoscopy and serrated polyp detection rate.

Background and study aims High-quality endoscopy requires improvement of not only the adenoma detection rate (ADR) but also the serrated polyp (SP) detection rate and the mean number of adenomas per positive procedure (MAP +). We evaluated whether a simple feedback of colonoscopy performance improves those quality indicators using propensity-score matching. Patients and methods Eleven endoscopists were evaluated regarding colonoscopy performance including ADRs, SP detection rates, mean numbers of adenomas per procedure (MAPs), and MAPs + with their ranking in the clinic. Endoscopic performance was compared before and after the feedback. Results Colonoscopies were performed for 874 patients before the feedback and 1,272 patients after the feedback. Using propensity-score matching, 803 patients before the feedback and 803 patients after the feedback were matched. ADR after the feedback was significantly higher than that before the feedback (50.8 % and 40.8 %, respectively). MAP after feedback was significantly larger than that before the feedback (0.92 and 0.69, respectively), as well as MAP + (1.96 and 1.69, respectively). Clinically significant SP detection rate was also improved from 10.0 % to 14.9 %. Conclusions Feedback including ADR, MAP, MAP +, and clinically significant SR detection rate could improve on those quality indicators. Further studies are needed to effectively prevent colorectal cancer in colonoscopy practice.

Clue of Diagnosis for Autoimmune Gastritis.

BACKGROUND: The diagnostic clues for autoimmune gastritis (AIG) can be classified into 2 categories: endoscopic findings and pathological diagnosis. We believe that research on the AIG detection rate by endoscopists could provide a better understanding of the diagnosis of AIG. This study aimed to clarify the ratio of the endoscopic and the pathological diagnoses of AIG. METHODS: We retrospectively reviewed consecutive patients who underwent esophagogastroduodenoscopy (EGD). During their first EGD, the gastric mucosa with C2 atrophy or more was biopsied for pathological evaluation based on the updated Sydney system. A gastric biopsy was also performed after Helicobacter pylori eradication, obtaining specimens from at least 2 sites, the greater curvature of the corpus and the antrum. We enrolled patients who were positive for the anti-parietal cell antibody and were diagnosed with AIG, histologically and/or endoscopically. The detection rates of AIG were compared between endoscopic diagnosis and pathological diagnosis. RESULTS: A total of 10,822 patients underwent EGD during the study period. Finally, 41 patients with AIG were enrolled, leading to an AIG prevalence of 0.38% in this study. As for the clue leading to AIG detection, 31.7% (13/41) were diagnosed through endoscopy (proximal-predominant atrophy), and 68.3% (28/41) were diagnosed pathologically. The AIG detection rate by endoscopists in the posteradication group was significantly lower than in the H. pylori-negative group (p < 0.05). CONCLUSION: Endoscopists frequently overlooked AIG, especially in posteradication cases. Pathological assessment using the updated Sydney system after H. pylori eradication might be a promising strategy to detect AIG better.

Filiform polyposis with sigmoid colon adenocarcinoma: a case report.

BACKGROUND: Filiform polyposis is a rare form of inflammatory polyposis, which is occasionally formed in the colon of patients with history of inflammatory bowel disease (IBD). It is characterized by presence of several to hundreds of slender, worm-like polyps in the colon lined by histologically normal colonic mucosa and often coalesce, resulting in a tumor-like mass. Filiform polyposis is most frequently associated with a post-inflammatory reparative process in patients with IBD history, and only cases of filiform polyposis occurring in patients without IBD history have been reported. Filiform polyposis has been considered as a benign inflammatory polyposis without any risk of dysplasia, while the possibility of carcinogenesis of inflammatory polyps is not fully excluded. To date, only three cases of filiform polyposis coexisting with dysplasia have been reported. CASE PRESENTATION: A 59-year-old male patient with no past medical history of IBD underwent laparoscopic sigmoidectomy for obstructive filiform polyposis, which was associated with sigmoid colon adenocarcinoma. Based on the histological findings of the resected specimen, invasive sigmoid colon adenocarcinoma was surrounded by filiform polyposis, and adenocarcinoma also scattered uniformly on the surface of filiform polyposis. In immunohistochemistry, abnormal p53 expression was observed in adenocarcinoma, while it was not shown in mucosa on filiform polyposis. CONCLUSIONS: This is the fourth case of filiform polyposis that is closely associated with colon dysplasia or adenocarcinoma based on histological findings. However, immunohistochemical findings did not support the theory that inflammation initiates adenocarcinoma in filiform polyposis like IBD. Hence, further immunohistochemical and genetic analyses are needed to clarify the association between filiform polyposis and carcinogenesis.

Family history is an independent risk factor for the progression of gastric atrophy among patients with Helicobacter pylori infection.

BACKGROUND AND AIM: Risk factors for progression of gastric atrophy have not been fully elucidated. The aim of this study was to evaluate the risk factors for the development of atrophic gastritis in patients with Helicobacter pylori (H. pylori ) infection. METHODS: We reviewed 206 H. pylori-infected patients retrospectively. Endoscopic gastric atrophy was classified into closed- and open-type. We conducted univariate and multivariate logistic regression analyses on the contribution of age, sex, body mass index, past history of cancer, the first-degree family history of gastric cancer, habitual smoking and alcohol drinking, and endoscopic findings of gastric ulcer or duodenal ulcer for open-type gastric atrophy. RESULTS: On multivariate analysis, age (odds ratio = 1.079, 95% confidence interval = 1.048-1.11, p < 0.001), family history of gastric cancer (odds ratio = 3.967, 95% confidence interval = 1.414-10.6, p = 0.006) and duodenal ulcer (odds ratio = 0.834, 95% confidence interval = 0.711-0.977, p = 0.024) were the factors independently associated with open-type gastric atrophy. CONCLUSIONS: A first-degree family history of gastric cancer, absence of duodenal ulcer, and old age were independent risk factors for the progression of gastric atrophy among H. pylori-infected patients. Careful examination with upper gastrointestinal endoscopy is necessary in patients with such risk factors.

Endoscopic gastric atrophy is strongly associated with gastric cancer development after Helicobacter pylori eradication.

BACKGROUND: Risk factors for gastric cancer during continuous infection with Helicobacter pylori have been well documented; however, little has been reported on the risk factors for primary gastric cancer after H. pylori eradication. We conducted a retrospective, endoscopy-based, long-term, large-cohort study to clarify the risk factors for gastric cancer following H. pylori eradication. METHODS: Patients who achieved successful H. pylori eradication and periodically underwent esophagogastroduodenoscopy surveillance thereafter at Toyoshima Endoscopy Clinic were enrolled. The primary endpoint was the development of gastric cancer. Statistical analysis was performed using the Kaplan-Meier method and Cox's proportional hazards models. RESULTS: Gastric cancer developed in 15 of 1232 patients. The cumulative incidence rates were 1.0 % at 2 years, 2.6 % at 5 years, and 6.8 % at 10 years. Histology showed that all gastric cancers (17 lesions) in the 15 patients were of the intestinal type, within the mucosal layer, and <20 mm in diameter. Based on univariate analysis, older age and higher endoscopic grade of gastric atrophy were significantly associated with gastric cancer development after eradication of H. pylori, and gastric ulcers were marginally associated. Multivariate analysis identified higher grade of gastric atrophy (hazard ratio 1.77; 95 % confidence interval 1.12-2.78; P = 0.01) as the only independently associated parameter. CONCLUSIONS: Endoscopic gastric atrophy is a major risk factor for gastric cancer development after H. pylori eradication. Further long-term studies are required to determine whether H. pylori eradication leads to regression of H. pylori-related gastritis and reduces the risk of gastric cancer.

Mesalazine-induced Pleuropericarditis in a Patient with Crohn's Disease.

A 16-year-old boy was diagnosed with Crohn's disease. Treatment with oral mesalazine was started at 3 g per day; however, he complained of high fever, a nonproductive cough, and left shoulder pain after 2 weeks. His chest radiography and chest computed tomography showed cardiomegaly and left pleural effusion, while an echocardiogram revealed pericardial effusion. Because no infection was detected by thoracentesis and the drug lymphocyte stimulation tests for mesalazine were positive, the patient was diagnosed with mesalazine-induced pleuropericarditis. After the cessation of mesalazine, the clinical symptoms and laboratory findings quickly improved.

Alpha-fetoprotein-producing early rectal carcinoma: a rare case report and review.

BACKGROUND: Alpha-fetoprotein (AFP)-producing rectal cancer is very rare, and this type of cancer frequently metastasizes to the liver with a poor prognosis. To date, only 11 cases of AFP-producing colorectal cancer have been reported. CASE PRESENTATION: A 41-year-old woman was first presented to the hospital for anal bleeding. An elevated tumor with a central shallow depression in the lower rectum was detected by colonoscopy. Transanal excision was performed, and the histology revealed adenocarcinoma. Further immunohistopathological examination revealed that the tumor was an AFP-producing adenocarcinoma of the rectum. Although local resection was performed 2 months before the diagnosis of AFP tumor, the serum AFP level was normal. The depth of the submucosal invasion was 5,000 µm, and there was venous invasion. Also, no lymphatic invasion was detected. Therefore, additional surgical resection with lymph node dissection was conducted, and the patient underwent laparoscopic intersphincteric resection. No residual cancer was identified in the surgical specimens, and there was no evidence of lymph node metastasis. The patient was discharged 18 days postoperatively, and 12 months after the operation, there are no signs of recurrence. CONCLUSION: To the best of our knowledge, this is the first case of an AFP-producing rectal cancer that was diagnosed at an early stage.

Giant solitary fibrous tumor of the pelvis successfully treated with preoperative embolization and surgical resection: a case report.

Solitary fibrous tumors (SFTs) rarely develop in the pelvis. When they do arise, they are usually treated using surgery, although SFTs are often very large by the time of diagnosis, which makes surgical excision difficult. We report a case of a 63-year-old man who was referred to our hospital for the treatment of a giant tumor of the pelvis. Computed tomography (CT) revealed a 30 × 25 × 19 cm sized hypervascular tumor that almost completely filled the pelvic cavity. The diagnosis of SFT was made by CT-assisted needle biopsy. The feeding arteries of the tumor were embolized twice. The first embolization aimed to reduce the tumor volume, while the second one was planned a day prior to the surgery to obtain hematostasis during the operation. Tumor resection was then performed. The blood loss during the operation was 440 ml, and there was no uncontrollable bleeding. The postoperative course was uneventful. No recurrence of SFT was observed during a 2-year follow-up.

Tracheobronchitis with dyspnea in a patient with ulcerative colitis.

We herein report the case of a 42-year-old man with a one-year history of ulcerative colitis who presented with exacerbated bloody diarrhea, a productive cough and increasing breathing difficulties. Colonoscopy revealed typical deep ulcers in the rectosigmoid colon and atypical multiple sucker-like ulcers in the transverse colon, and computed tomography of the chest demonstrated wall thickening of the trachea and bronchi. In addition, bronchoscopy showed ulcers in the trachea, and histopathology disclosed findings of necrosis and inflammation of the subepithelial tissue of the trachea. Based on these findings, the patient's respiratory symptoms were strongly suspected to be due to ulcerative colitis-related tracheobronchitis. Treatment with systemic corticosteroids subsequently resulted in a rapid clinical improvement.

Synchronous colorectal malignancy and abdominal aortic aneurysm treated with endovascular aneurysm repair followed by laparoscopic colectomy.

Although the incidence of synchronous abdominal aortic aneurysm (AAA) and malignancies is increasing, there has been no clear consensus in the surgical treatment of such patients. The focus on surgical treatments with minimal invasiveness, such as endovascular aneurysm repair (EVAR) for AAA and laparoscopic colectomy for colorectal cancer, has increased; however, the clinical applicability of combination treatment with EVAR and laparoscopic colectomy has not been established. A 61-year-old man was diagnosed with AAA, advanced sigmoid colon cancer, and coronary artery stenosis. Because the patient also had chronic renal failure with nephrotic syndrome, among several other comorbidities, surgery was considered to be associated with high risks in this patent. Sequential treatments with percutaneous coronary intervention, EVAR, and laparoscopic colectomy were successfully performed. Staged treatment of EVAR followed by laparoscopic colectomy may be a promising strategy for high-risk patients with AAA associated with malignancy.

Clinical Characteristics and Postoperative Complications of Patients Undergoing Emergency Surgery for Ulcerative Colitis.

BACKGROUND/AIMS: Despite recent advances in medical therapy, the role of surgery for severe ulcerative colitis remains important and determining the timing and indications for colectomy are difficult for both gastroenterologists and surgeons. We compared the clinical characteristics and postoperative complications of emergency surgeries for ulcerative colitis to those of elective surgeries. METHODOLOGY: We retrospectively examined 77 patients with ulcerative colitis who underwent colectomy without cancer or dysplasia in our institute in 1989-2012. Clinicopathological features, cytomegalovirus involvement, and postoperative complications were evaluated. RESULTS: Twenty-seven patients underwent emergency surgeries and the other 50 underwent elective surgeries. Emergency surgeries were performed significantly earlier in the disease course than elective surgeries. Postoperative complications were more frequent in emergency surgeries than in elective surgeries. Those who underwent emergency surgeries with relative indications tended to develop postoperative complications more frequently when intensive long-term steroid therapy was introduced. CONCLUSIONS: Emergency surgeries were associated with frequent postoperative complications. For refractory severe ulcerative colitis, cytomegalovirus involvement should be determined and prolonged steroid therapy is associated with postoperative complications; therefore, early treatment decisions are important.

Prognostic significance of the lymph node ratio in stage IV colorectal cancer patients who have undergone curative resection.

BACKGROUND: The lymph node ratio (LNR) was proposed as a prognostic indicator in Stage III colorectal cancer (CRC) patients in recent studies. The purpose of this study was to evaluate the prognostic impact of the LNR in Stage IV CRC patients who have undergone curative resection. METHODS: A retrospective review of 119 Stage IV CRC patients who underwent curative resection in our institute from 1997 to 2009 was performed. Patients were divided into two groups (low LNR and high LNR) by means of their median LNR. A disease-free survival (DFS) and an overall survival (OS) were analyzed using the Kaplan-Meier curve; multivariate analysis was performed using the Cox proportional hazard model. RESULTS: The cutoff value for the LNR was 0.111. For the entire study group, the 5-year DFS was 22 % and the 5-year OS was 65 %. DFS was not significantly different between patients in the low LNR group and the high LNR group (25 and 19 %, respectively; P = 0.317), but OS was significantly higher in the low LNR group patients compared with the high LNR group patients (77 and 54 %, respectively; P < 0.001). Using multivariate analysis, we identified the LNR as an independent prognostic factor for OS, with a hazard ratio of 3.08 (95 % CI 1.38-8.19; P = 0.005). CONCLUSIONS: LNR is a potent prognostic indicator for stratification in Stage IV CRC patients who have undergone curative resection.

Successful treatment of rectovaginal fistula complicating ulcerative colitis with infliximab: a case report and review of the literature.

Rectovaginal fistula is a rare complication of ulcerative colitis (UC) regardless of surgical history of rectum. Various surgical treatment modalities for the closure of rectovaginal fistula have been developed, but a radically curative therapy remains to be developed. Recently, infliximab, the chimeric anti-human tumor necrosis factor alpha (TNF-α) antibody, has been largely applied for the treatment of inflammatory bowel disease (IBD), and a few reports have shown its partial effectiveness in the management of rectovaginal fistulas associated with UC. In the present report, we describe the successful management of a rectovaginal fistula, following the stapled ileo-anal canal anastomosis in a UC patient, by administration of infliximab. The patient was a 40-year-old female, initially diagnosed as UC (total colitis type) at the age of 15. She received a restorative proctocolectomy at the age of 22, and developed a rectovaginal fistula at the eighth postoperative day. The surgical treatment of the fistula was repeated four times during the 10-year period, but it recurred in intervals ranging between 2 months and 5 years after the operation. The last recurrence occurred at the age of 32, but the surgical repair was considered difficult and a conservative management was indicated. At the age of 40, infusions of infliximab were started. Four weeks after the first infusion, drainage from the fistula was evidently reduced, and 2 weeks later, the fistula was completely closed. Thereafter, no recurrence of the fistula is observed, as confirmed by the abdominal magnetic resonance imaging (MRI) and the barium-enema study. From the present case, we concluded that infliximab may be an effective strategy for the management of fistulas associated with UC.

Patient factors predisposing to complications following laparoscopic surgery for colorectal cancers.

The aim of this study was to clarify patient factors contributing to complications after laparoscopic surgery for colorectal cancers. A total of 333 colorectal cancer patients who underwent laparoscopic colorectal resection between January 2007 and December 2012 were enrolled. The association between patient factors and the incidence of complications were analyzed. Postoperative complications were divided into 2 categories: infectious complications and noninfectious complications. The overall complication rate was 13% and mortality rate 0%. Multivariate analysis showed that body mass index >25 kg/m [odds ratio (OR)=3.02, P=0.0254] and tumor location (right colon cancer/rectal cancer: OR=0.11, P=0.0083) were risk factors for infectious complications; in addition, male sex (OR=3.91, P=0.0102) and cancer stage (stage 2/stage 4: OR=0.17, P=0.0247) were risk factors for noninfectious complications. This study shows that different patient factors are associated with the risk of different types of complications.

Passage of a sigmoid colon cast in a patient with ischemic colitis.

Colon cast passage, which is the spontaneous passage of a full-thickness, infarcted colonic segment per rectum, is a rare occurrence. The main cause is acute ischemic colitis resulting from a circulation compromise. Most of the colon cast cases reported were secondary to abdominal aortic aneurysm repairs or colorectal surgery. We report a case of an 80-year-old woman with ischemic colitis who excreted a 20-cm colon cast. In most cases that involve a colon cast containing a muscle layer component, invasive therapy is required owing to colonic obstruction or stenosis. However, in the present case, the colon cast consisted only of a mucosa layer and was not associated with severe stenosis or obstruction; therefore, it was successfully treated by conservative therapy. Histologic examination of the colon segment may be crucial in determining the appropriate treatment.

Prognostic impact of tumor location in stage IV colon cancer: a propensity score analysis in a multicenter study.

BACKGROUND: Right-sided colon cancer is considered to be biologically different from left-sided colon cancer; however, conflicting results have been reported regarding differences in prognosis. We aimed to clarify the prognostic impact of tumor location in stage IV colon cancer. METHODS: Stage IV colon cancer treated from January 1997 to December 2007 (n = 2208) were retrospectively studied. Clinical and pathological features were compared between right-sided colon cancer (cecum, ascending, and transverse colon) and left-sided colon cancer (descending, sigmoid, and rectosigmoid colon). The impact of tumor location on cancer-specific survival (CSS) was analyzed in a multivariate analysis and propensity score analysis to mitigate the differences in background features. RESULTS: Right-sided colon cancer was associated with older age, female sex, larger tumor size, poorly differentiated adenocarcinoma, mucinous adenocarcinoma, and signet-ring cell carcinoma, a more advanced state within stage IV disease, and a worse CSS. In the cohort matched by propensity scores for background clinicopathological features, tumor location in the right-sided colon was associated with a significantly worse CSS (hazard ratio 1.2, 95% confidence interval 1.1-1.4, p = 0.008) in patients treated with palliative primary tumor resection, but not in those treated with R0 resection or no resection. CONCLUSION: Right-sided colon cancer were diagnosed at a more advanced state within stage IV disease and showed a significantly worse prognosis than left-sided colon cancer, suggesting that stage IV right-sided colon cancer is oncologically more aggressive than left-sided colon cancer.

Laparoscopic resection of a gastrointestinal stromal tumor of the lower rectum in a patient with coronary artery disease following long-term neoadjuvant imatinib treatment and anticoagulation therapy.

Surgery is the mainstay of treatment for gastrointestinal stromal tumors (GISTs). However, complete resection of rectal GISTs is sometimes difficult because of bulkiness and/or anatomical reasons. Neoadjuvant imatinib therapy has gained attention as an alternative treatment to increase the chance of en bloc resection of rectal GISTs, although it usually takes several months. In this case report, we first demonstrated that neoadjuvant imatinib therapy can be performed safely not only to downsize tumors, but also to allow adequate time for the effective treatment of major comorbid illnesses. A 74-year-old man was diagnosed with a 45 mm GIST of the lower rectum. He also had severe stenosis in the proximal segment of the left anterior descending coronary artery. Following the implantation of a drug-eluting stent, the patient received imatinib together with dual anti-platelet therapy for 12 months without obvious side effects. Follow-up image studies revealed tumor shrinkage as well as stent patency. En bloc resection of the GIST was performed laparoscopically, which preserved the anus. The patient is currently alive without any evidence of relapse for 12 months after surgery.

A case of extraperitoneal stoma-associated internal hernia after abdominoperineal resection.

Published reports concerning internal hernias after extraperitoneal stoma construction are scarce. In our present report, we describe the case of a 56-year-old man who was referred to our hospital for the treatment of rectal cancer. He underwent abdominoperineal resection of the rectum with sigmoidostomy using an extraperitoneal route. On the ninth postoperative day, the patient experienced sudden and intense abdominal pain and was diagnosed with strangulation of the small intestine due to a stoma-associated internal hernia. Therefore, an emergency laparotomy was performed. The surgical findings showed that the small intestine protruded through the space between the sigmoid colon loop and the abdominal wall in a cranial-to-caudal direction. The strangulated portion of the small intestine was recovered, and the orifice of herniation was closed. No recurrence of internal herniation was observed during the follow-up period.