Effect of electron beam irradiation in gas atmosphere during ETEM.

Transmission electron microscopy (TEM) is used to observe the atomic structures of materials. Environmental TEM (ETEM) is a method wherein a gas can be evaluated and it has been used to observe the dynamic reaction between materials and gases at the atomic level. An electron beam (EB), which has a sufficiently high energy (exceeding a few tens of kilovolts), can be used to ionize gas molecules. Subsequently, the ionized molecules might react with the materials during ETEM. Therefore, the current generated by the ions and electrons were measured to verify the presence of ions generated due to the ionization of the N2 gas atmosphere during EB irradiation in ETEM. The electron energy loss spectra (EELS) were acquired from the N2 gas atmosphere to estimate the types of ions generated. The results demonstrated that ions and electrons were generated in the N2 atmosphere during ETEM and EB irradiation. Moreover, the EELS analysis indicated that the generated ion was N2+. The material observation conducted using gas ETEM can detect the reaction between gases, ions, and materials.

Emergency Endoscopic Retrograde Cholangiopancreatography Did Not Increase the Incidence of Postprocedural Pancreatitis Compared With Elective Cases: A Prospective Multicenter Observational Study.

OBJECTIVE: The aim of this study was to identify the incidence of and risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after emergency endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We performed a prospective multicenter observational study of 3914 patients who underwent ERCP. We compared the incidence of PEP after emergency and elective ERCP. RESULTS: A total of 3410 patients were enrolled in this study. Post-ERCP pancreatitis occurred in 44 of 800 patients (5.5%) and in 190 of 2418 patients (7.9%) in the emergency and elective groups, respectively. No significant difference was noted between the groups (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.52-1.03; P = 0.07). Multivariate analysis showed that the following factors increased the risk for PEP after emergency ERCP: contrast medium injection into the pancreatic duct (OR, 2.56; 95% CI, 1.30-5.03; P = 0.005), >4 cannulation attempts (OR, 5.72; 95% CI, 2.61-12.50; P < 0.001), and endoscopic papillary balloon dilatation (OR, 9.24; 95% CI, 2.13-40.10; P < 0.001). CONCLUSIONS: No significant difference was noted in the incidence of PEP in patients after emergency and elective ERCP. We may prevent PEP even after emergency ERCP by avoiding contrast injection into the pancreatic duct, multiple cannulation attempts, and endoscopic papillary balloon dilatation.

Post-endoscopic retrograde cholangiopancreatography pancreatitis assessed using criteria for acute pancreatitis.

BACKGROUND AND AIM: International consensus on the definition and classification of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been reached. However, the diagnosis and severity of PEP are often assessed according to the diagnostic criteria and classification for acute pancreatitis (AP). This study determined the incidence, severity, and risk factors of PEP diagnosed according to the diagnostic criteria and classification for AP in a large cohort. METHODS: This prospective, multicenter, observational cohort study conducted at five high-volume centers included 1932 patients who underwent ERCP-related procedures. The incidence, severity, and risk factors for PEP were evaluated. RESULTS: PEP occurred in 142 patients (7.3%); it was mild in 117 patients (6.0%) and severe in 25 patients (1.3%). According to the Cotton criteria, PEP occurred in 87 patients (4.5%); it was mild in 54 patients (2.8%), moderate in 20 patients (1.0%), and severe in 13 patients (0.7%). In the multivariate analysis, female sex (odds ratio [OR] 2.239; 95% confidence interval [CI] 1.546-3.243), naïve papilla (OR 3.047; 95% CI 1.803-5.150), surgically-altered gastrointestinal anatomy (OR 2.538; 95% CI 1.342-4.802), procedure time after reaching the papilla (OR 1.009; 95% CI 1.001-1.017), pancreatic duct injection (OR 2.396; 95% CI 1.565-3.669), and intraductal ultrasonography (OR 1.641; 95% CI 1.024-2.629) were independent risk factors. CONCLUSION: According to the diagnostic criteria and classification for AP, the incidence of PEP was higher than that according to the Cotton criteria and the severity of PEP tended to be severe.

Fatal case of pancreatic panniculitis caused by occult neuroendocrine tumor in the corresponding organ: A case report and review of the published work.

Pancreatic panniculitis (PP) is a rare clinical variant of subcutaneous fat necrosis, developing in patients with a variety of pancreatic diseases such as acute or chronic pancreatitis, tumors and cysts. The tumor-associated PP represents a noteworthy skin manifestation of underlying internal malignancies, also known as dermadrome. Among causative pancreatic tumors, acinar cell carcinoma is the most frequent malignancy; however, little is known about how the origin of tumor cells and progression stage of pancreatic tumors potentially contribute to the establishment of panniculitis. Here, we present a 69-year-old Japanese male case of clinically aggressive PP on the bilateral legs, whose skin lesions developed prior to the diagnosis of occult pancreatic tumor and liver metastasis. Moreover, the immunopathology of the pancreatic lesion revealed neuroendocrine tumor (NET), a rare pathological variant. Skin lesions immediately spread to the upper limbs with extensive ulcerations and necrosis, accompanied by high levels of serum lipase and elastase, but not with other pancreatic enzymes. He died 2 months after the initial development of the skin lesion due to rapid deterioration of general condition. We reviewed 14 cases, including ours, of PP with NET in the pancreas thus far reported, to identify the clinicopathological characteristics regarding to what extent this rare complication could reflect the clinical course of pancreatic tumors and overall prognosis. Our published work review found that the disease has a significant male predominance (male : female, 13:1) and cases with occult pancreatic tumors died within 4 months after the development of their skin lesions. Our case was the poorest prognostic outcome. This report emphasizes that dermatologists should recognize PP with NET, reflecting a fatal prognosis, and to make a prompt diagnosis.

Diagnostic Value of Serum Amylase Levels Indicating Computed Tomography-Defined Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Multicenter Observational Study.

OBJECTIVE: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis involves persistent serum amylase levels of 3 times or more the standard upper limit. However, these criteria were mostly based on retrospective studies and not necessarily supported by diagnostic imaging. Our prospective study aimed to investigate cutoff serum amylase levels suggesting post-ERCP pancreatitis using computed tomography as the criterion standard. METHODS: We prospectively followed 2078 cases. Computed tomography was performed in patients whose serum amylase levels exceeded the institutional upper limit 12 to 24 hours after ERCP. Two expert radiologists blindly assessed the images and judged the presence or absence of pancreatitis. Correlations between serum amylase levels with pancreatitis were investigated using receiver operating characteristic analysis. RESULTS: Amylase levels increased in 416 (23.2%) of 1789 cases included, and 350 cases were analyzed using computed tomography. Post-endoscopic retrograde cholangiopancreatography pancreatitis was diagnosed in 12.0% (214/1789). The cutoff amylase levels for judging pancreatitis after 12 to 24 hours was 2.75 times higher than the institutional upper limit, with an area under the curve of 0.77. CONCLUSIONS: The appropriate cutoff serum amylase level for judging post-ERCP pancreatitis at 12 to 24 hours after ERCP was 2.75 times higher than the institutional upper limit. These results may clarify the definition of post-ERCP pancreatitis.

A Bile Duct Stone Formation around a Fish Bone as a Nidus after Pancreatoduodenectomy.

We report a rare case of bile duct stone formation around an ingested fish bone as a nidus after pancreatoduodenectomy. A 78-year-old woman was admitted to our department for fever and epigastric pain. Abdominal computed tomography revealed an elongated bile duct stone containing a linearly shaped foreign body of bone density. Enteroscopic lithotomy was performed using single balloon enteroscopy to safely remove the stone and foreign body from the bile duct. The foreign body was determined to be a fish bone by pathological examination and component analysis.

Helicobacter pylori Eradication Therapy Ameliorates Latent Digestive Symptoms in Chronic Atrophic Gastritis.

BACKGROUND/AIMS: This study investigated the effect of Helicobacter pylori eradication therapy on latent digestive symptoms in chronic atrophic gastritis. METHODS: We enrolled 650 health checkup patients who underwent eradication therapy for chronic gastritis and completed a self-report questionnaire before and after the treatment between January 2014 and December 2016 at the Japanese Red Cross Society Kyoto Daiichi Hospital. RESULTS: H. pylori eradication therapy for chronic atrophic gastritis improved latent digestive symptoms, including both the acid reflux and dyspepsia components in the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) scores. The effect was sustained until 1 year after the treatment. Higher FSSG scores (≥8 points) before H. pylori eradication therapy and age <70 years were significantly associated with the improvement of digestive symptoms after H. pylori eradication therapy. CONCLUSION: H. pylori eradication therapy may improve patients' quality of life through the resolution of latent abdominal symptoms.

Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion.

Here, we report our experience with a case of severe biliary bleeding due to a hepatic arterial pseudoaneurysm that had developed 1 year after endoscopic biliary plastic stent insertion. The patient, a 78-year-old woman, presented with hematemesis and obstructive jaundice. Ruptured hepatic arterial pseudoaneurysm was diagnosed, which was suspected to have been caused by long-term placement of an endoscopic retrograde biliary drainage (ERBD) stent. This episode of biliary bleeding was successfully treated by transarterial embolization (TAE). Pseudoaneurysm leading to hemobilia is a rare but potentially fatal complication in patients with long-term placement of ERBD. TAE is a minimally invasive procedure that offers effective treatment for biliary bleeding.

Usefulness of vonoprazan, a potassium ion-competitive acid blocker, for primary eradication of Helicobacter pylori.

AIM: To investigate usefulness of triple therapy with vonoprazan, a potassium ion-competitive acid blocker and antibiotics, for Helicobacter pylori (H. pylori) eradication. METHODS: The H. pylori eradication rate was examined in 2507 patients (2055 undergoing primary eradication and 452 undergoing secondary eradication, excluding patients with subtotal gastrectomy) at the Japanese Red Cross Kyoto Daiichi Hospital from March 2013 to September 2015. For patients treated from March 2013 to February 2015, a proton pump inhibitor (PPI) was used to reduce acid secretion, while vonoprazan was used after March 2015. The success rates of the 2 regimens (PPI + amoxicillin + clarithromycin/metronidazole, or vonoprazan + amoxicillin + clarithromycin/metronidazole) were compared. RESULTS: The success rate of primary H. pylori eradication was significantly higher in the vonoprazan group. When stratified by the underlying disease, a significant increase of the H. pylori eradication rate was observed in patients with chronic gastritis. A significantly lower H. pylori eradication rate was observed in younger patients compared to older patients in the PPI group, but there was no difference according to age in the vonoprazan group. On the other hand, the success rate of secondary eradication was similar at approximately 90% in both groups. CONCLUSION: Vonoprazan is very useful for primary eradication of H. pylori, and may become a first-line acid secretion inhibitor instead of PPIs.

[A case of recurrent lymph node metastases of advanced colon cancer with penetration of the gastric wall, treated effectively by cetuximab monotherapy as third-line treatment].

A 45-year-old man was first treated for lymph node metastases of colon cancer with FOLFIRI. After 13 courses, the lymph node metastases worsened, and he was treated with mFOLFOX6 plus bevacizumab as the second-line chemotherapy. After 8 courses, his anorexia and anemia became increasingly troublesome. We diagnosed this as the direct invasion of lymph node metastases to the gastric wall. As the third-line chemotherapy, cetuximab monotherapy was applied. The gastric ulcer lesion then began healing as a scar. In our progressive case, cetuximab monotherapy was effective as a third-line treatment.

A case of ischemic duodenitis associated with superior mesenteric artery syndrome caused by an abdominal aortic aneurysm.

A 74-year-old woman was admitted to our hospital with upper abdominal pain and bloody vomiting. An abdominal aneurysm compressed the third portion of the duodenum and the second portion of duodenum was distended with thickened walls as in superior mesenteric artery syndrome. Endoscopic examination showed an edematous mucosa with hemorrhagic erosions, shallow longitudinal ulcers, and star-shaped ulcers in the duodenum. We diagnosed this case as ischemic duodenitis associated with superior mesenteric artery syndrome caused by compression by an abdominal aortic aneurysm. The symptoms improved on treatment with bowel rest, total parenteral nutrition and administration of a proton pump inhibitor. We present here a rare case of ischemic duodenitis and summarize the previous medical literature on the disease.

[A case of rectal GIST treated with imatinib mesylate neoadjuvant therapy to preserve the anus].

A 64-year-old man was admitted to our hospital with anal pain on evacuation. MRI revealed a large rectal submucosal tumor, more than 6 cm in diameter. Fine needle histological diagnosis indicated GIST with moderate risk. The patient was treated with imatinib mesylate in order to preserve the anus. The anal pain and tumor size decreased. Trans-anal local excision was performed. This case suggests that imatinib mesylate can make it possible to treat large rectal GIST cases by preserving anus, if neoadjuvant chemotherapy can be effective.