Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage.

Aim: This study was aimed to clarify the effectiveness of conservative treatment without performing early colonoscopy and the indications for early colonoscopy in patients with colonic diverticular hemorrhage. Methods: This retrospective study included 142 participants who were urgently hospitalized due to bloody stools and were diagnosed with colonic diverticular hemorrhage between April 2012 and December 2016. At the time of hospital visit, only when both shock based on vital signs and intestinal extravasation on abdominal contrast-enhanced computed tomography were observed, early colonoscopy was performed within 24 hours after hospitalization. However, in other cases, patients were conservatively treated without undergoing early colonoscopy. In cases of initial treatment failure in patients with shock, interventional radiology (IVR) was performed without undergoing early colonoscopy. Results: Conservative treatment was performed in 137 (96.5%) patients, and spontaneous hemostasis was achieved in all patients. By contrast, urgent hemostasis was performed in five (3.5%) patients; three and two attained successful hemostasis via early colonoscopy and IVR, respectively. There were no significant differences between two groups in terms of early rebleeding (7.3% vs. 0%,P=0.690) and recurrent bleeding (22.7% vs. 20.0%, P=0.685). The factors associated with the cumulative recurrent bleeding rates were a previous history of colonic diverticular hemorrhage (hazard ratio 5.63, 95% confidence interval 2.68-12.0, P < 0.0001) and oral administration of thienopyridine derivative (hazard ratio 3.05, 95% confidence interval 1.23-7.53, P=0.016). Conclusions: In this series, conservative treatment without early colonoscopy was successful in patients with colonic diverticular hemorrhage.

[A case of autoimmune pancreatitis associated with ulcerative colitis].

A 31-year-old man was admitted to our hospital because of upper abdominal pain. He had been diagnosed with ulcerative colitis (UC) at age 28, but the disease has been in remission since then. On admission, he had slight fever, abdominal pain, and bloody stools six times a day, and the serum levels of pancreatic enzyme and IgG4 were elevated. Diffuse enlargement of the pancreas was detected by abdominal computed tomography; furthermore, narrowing of the main pancreatic duct was revealed using endoscopic retrograde cholangiopancreatography. Based on these findings, he was given a diagnosis of autoimmune pancreatitis (AIP) associated with UC. Both diseases improved without using steroids. After discharge, he has not had any recurrence of AIP or UC despite not being on steroid treatment, although the serum IgG4 level has shown a slight tendency to elevate.

[The usefulness and limitations of the new Japanese criteria for severity assessment in acute pancreatitis].

New Japanese criteria for severity assessment in acute pancreatitis were introduced in October 2008. The new criteria are simpler than the previous ones, and are also expected to be more useful for the severity assessment. We retrospectively analyzed the clinical factors in our patients to predict prognosis, and evaluated the usefulness and limitations of the new criteria. There were few missing data in the new criteria compared with the previous criteria. The areas under the receiver operating characteristic (ROC) curves for mortality prediction were 0.870 for the new criteria and 0.884 for the previous criteria. However, there were more patients whose disease severity on admission were underestimated using the new criteria and who finally progressed to worse stages including death. This evidence strongly suggests the lower sensitivity of the new criteria in mortality prediction. Repeated assessment of severity after admission will be indispensable in the proper treatment of patients with acute pancreatitis.

[A case of HIV coinfected with hepatitis B virus treated by entecavir].

A 45-year-old male active homosexual was given a diagnosis of HIV-1 and acute hepatitis B in August 2007. Since his liver function became rapidly impaired, anti-HBV therapy with oral administration of entecavir (ETV) was started, and resulted in a favorable outcome. However, serum concentration of HIV-RNA decreased by log 1.26 within 60 days, which strongly suggested the inhibition of HIV proliferation by ETV. To prevent the appearance of mutated HIV, novel therapeutic strategies should be established in HIV/HBV-coinfected patients.

Real-time in vivo virtual histology of colorectal lesions when using the endocytoscopy system.

BACKGROUND: The histological findings of GI lesions are based on light-microscopic examination of H&E-stained thin-slice specimens. Recently, a concept of optical biopsy has been advocated. A study of the observation of colorectal lesions using endocytoscopy to obtain real-time histological images in vivo during endoscopy was performed. DESIGN: Prospective study. AIM: To evaluate the usefulness of optical biopsy of colorectal lesions with the endocytoscopy (E-C) system. PATIENTS: The subjects were 113 consecutive patients who underwent a complete colonic examination, from April 2003 to March 2004, performed by a single colonoscopist. SETTING: Digestive Disease Center of Showa University Northern Yokohama Hospital. RESULTS: With E-C, it was possible to observe lesions at the cellular level and evaluate cellular atypia in addition to structural atypia in vivo. The correlation was statistically significant between the endocytoscopic diagnosis and the histological diagnosis. LIMITATIONS: The endocytoscope had to be touched to the target colonic glands. CONCLUSIONS: It was possible to distinguish neoplastic from non-neoplastic lesions, and also possible to distinguish invasive cancer from adenoma. "Ultra-high" magnifying endoscopy, the E-C system, provides real-time histological images in vivo, which correspond well with those of H&E-stained microscopic images.

The clinical meaning of a nonstructural pattern in early gastric cancer on magnifying endoscopy.

BACKGROUND: In the field of colorectal cancer, the presence of a nonstructural pattern in magnifying colonoscopy means that cancer involves the submucosal layer. Since en bloc EMR was developed, differentiation between mucosal and submucosal cancer is a critical issue in the management of gastric cancer. In this study, we evaluated the clinical meaning of a nonstructural pattern in magnifying gastroscopy. METHODS: Between April 2002 and July 2003, 59 patients with 50 cancers and 11 adenomas were enrolled in this study. A cancerous lesion was subclassified into a differentiated-type group or a undifferentiated-type group according to histologic type. Before treatment, magnifying endoscopic observation was performed. After EMR or surgical intervention, resected specimens were observed by using stereomicroscopy. In both in vivo magnifying endoscopic and in vitro stereomicroscopic observations, the presence of a nonstructural pattern on the lesion was investigated. Compared with histologic findings, the clinical meaning of the presence of a nonstructural pattern on the gastric neoplastic lesion was evaluated. RESULTS: A nonstructural pattern could not be confirmed in any adenomas and in 29 of 31 mucosal differentiated cancers. However, in 9 of 11 submucosal cancers, a nonstructural pattern could be identified. CONCLUSIONS: The presence of a nonstructural pattern appeared to be a useful marker to not proceed with EMR of gastric cancer.

In vivo observation of living cancer cells in the esophagus, stomach, and colon using catheter-type contact endoscope, "Endo-Cytoscopy system".

A catheter-type endomicroscope has been developed with a maximum magnifying power of 1100 times. Living cancer cells in the esophagus, stomach, and colon were successfully observed in high-resolution images. The "Endo-Cytoscopy system" (prototype,Olympus Optical, Co., Tokyo, Japan) is a catheter-based probe capable of passage through the accessory channel of the endoscope(GIF-1T, Olympus). Methylene blue solution was used for vital staining of the in vivo gastrointestinal mucosa. Living cells in both normal mucosa and malignant tissue were clearly demonstrated in luminal organs. In particular, the nucleus, cell body, and nucleolus were clearly demonstrated with high-quality images similar to those of conventional cytology. This novel technology has the potential to provide an in vivo histologic diagnosis via "optical biopsy" and virtual histology.