A case of pancreatic mucinous cystic neoplasm that enlarged during pregnancy and was resected after childbirth.

A 28-year-old pregnant woman presented with an abdominal mass at 12 weeks' gestation. Magnetic resonance imaging revealed a 7 cm cystic lesion arising extrinsically from the pancreatic head, which was diagnosed as a mucinous cystic neoplasm. Although we recommended surgical excision during the second trimester, the patient refused the procedure and chose to continue her pregnancy. We monitored the lesion and noted that it gradually grew to 13 cm over the course of the pregnancy. Subsequently, we enucleated it after childbirth. Histopathological examination was compatible with high-grade dysplasia and confirmed the diagnosis of mucinous cystadenoma of the pancreas.

[Two cases of dabigatran-induced esophageal ulcer indicating the usefulness of drug administration guidance].

Here we report two cases of dabigatran-induced esophageal ulcer. Case 1 was a 67-year-old man who presented with heartburn that developed a month after dabigatran administration. Case 2 was an 81-year-old woman who presented with epigastralgia that developed within a few days of dabigatran administration. Endoscopic findings were similar in both cases, including shallow esophageal ulcers covered with a thin whitish membrane. The patients were advised to consume the drug with plenty of water during meals and to remain in a sitting position for 30 min after consumption. This method successfully decreased their symptoms and ulcers, indicating that drug administration guidance is extremely effective in managing dabigatran-induced esophageal injury.

[Present status of gastrointestinal damage due to non-steroidal anti-inflammatory drugs (NSAIDs)].

Non-steroidal anti-inflammatory drugs (NSAIDs) are roughly divided into a low-dose aspirin group used for primary and secondary prevention of cardiovascular events and non-aspirin NSAIDs used for treatment of bone and joint diseases. Both cause gastrointestinal damage directly or indirectly. In the present study, we reviewed gastrointestinal damage due to non-aspirin NSAIDs with respect to the esophagus, stomach/duodenum, small intestine and colon. Damage due to NSAIDs occurs in all digestive tracts and since the analgesic effect of NSIADs hides subjective symptoms, the symptoms are often not treated until they are advanced to a serious state. Further, patients receiving NSAIDs are mostly elderly and have complications so that the onset of the conditions is serious and prevention is important. It is necessary to investigate a method that is effective for preventing damage for all digestive tracts and the mechanisms of damage must be understood for this reason.

Exposed blood vessels of more than 2 mm in diameter are a risk factor for rebleeding after endoscopic clipping hemostasis for hemorrhagic gastroduodenal ulcer.

BACKGROUND AND AIM: There are few clinical studies on the risk factors for rebleeding based on the endoscopic hemostatic procedure carried out, including ulcer characteristics such as exposed blood vessels. The present study aims to clarify the risk factors for rebleeding after endoscopic clipping hemostasis for hemorrhagic gastroduodenal ulcers. METHODS: A retrospective study was carried out with data collected during the 10-year period from January 2000 to December 2009 for 312 consecutive patients with hemorrhagic gastroduodenal ulcer. Two hundred and ninety-three patients (216 men and 77 women; mean age, 67.0 ± 15.0 years) who underwent endoscopic clipping as the initial hemostatic treatment were analyzed. The risk factors for rebleeding were determined by comparing 271 patients who did not rebleed after initial treatment with 22 patients who developed rebleeding. RESULTS: The success rate of initial clipping hemostasis was 100%; however, rebleeding occurred in 7.5% (22/293) and a multivariate analysis identified exposed blood vessels of more than 2 mm in diameter as independent risk factors for rebleeding (P = 0.0124, odds ratio 6.25 [95% CI: 1.53-13.62]). CONCLUSIONS: Endoscopic clipping monotherapy is effective for hemorrhagic gastroduodenal ulcers; however, exposed blood vessels of more than 2 mm in diameter in the initial endoscopic procedure are a risk factor for rebleeding.

Endoscopic features of sessile serrated adenoma and other serrated colorectal polyps.

BACKGROUND/AIMS: Sessile serrated adenoma is a subtype of serrated colorectal polyps that can potentially give rise to colorectal carcinoma. We aimed to characterize the endoscopic features of sessile serrated adenoma as compared to those of other subtypes of serrated colorectal polyps. METHODOLOGY: A total of 202 serrated colorectal polyps were retrospectively collected and pathologically subclassified as sessile serrated adenoma, hyperplastic polyp, or traditional serrated adenoma. The patients' demographics and endoscopic findings were reviewed, and comparisons were made between groups. RESULTS: We found 57 sessile serrated adenomas, 104 hyperplastic polyps, and 41 traditional serrated adenomas. Sessile serrated adenomas were larger in size, and they had more granular or nodular surface and more irregular or vague margin than hyperplastic polyps; however, these two subgroups were similar in terms of their sessile configuration and white coloring. Sessile serrated adenomas could be distinguished from traditional serrated adenomas based on the pedunculated configuration and red coloring unique to the traditional serrated adenomas. Nine sessile serrated adenomas were of note due to coverage with abundant mucus, which was rarely seen in other subgroups. CONCLUSIONS: We characterize the endoscopic features of sessile serrated adenoma as compared to those of hyperplastic polyp and traditional serrated adenoma.

[A case of hemolytic uremic syndrome after adjuvant chemotherapy with gemcitabine in a patient with pancreatic cancer].

A 63-year-old man with Stage IVa pancreas tail cancer was admitted for a distal pancreatectomy and splenectomy; adjuvant chemotherapy with gemcitabine was also administered. The chemotherapy was terminated after 16 courses due to hemolytic anemia, thrombocytopenia and renal dysfunction. Plasma exchange was performed; however the patient's renal function was diminished, requiring chronic hemodialysis. Physicians should be cautious of hemolytic uremic syndrome as a possible adverse reaction to gemcitabine and be aware that tests are needed for its early detection.

[ case of autoimmune pancreatitis with various extrapancreatic fibrosclerosis followed by malignant diseases].

We experienced a rare case of autoimmune pancreatitis with sclerosing cholangitis, retroperitoneal fibrosis and interstitial pneumonia. The patient was a 68-year old man and had abnormal liver function with jaundice. We performed endoscopic retrograde cholangiopancreatography (ERCP) and needle biopsy of the liver and pancreas. We obtained histological findings such as dense infiltration of plasma cells and lymphocytes and remarkable fibrosis and diagnosed AIP. The patient received treatment by prednisolone and thereafter developed bladder cancer and gastric cancer. He has been followed up for 4.5 years with no recurrence.

[Marked effect of combination chemotherapy with tegafur-gimeracil-oteracil potassium and gemcitabine on a suspected case of pancreas cancer or gallbladder cancer metastasis to bone: further diagnosis of disseminated carcinomatosa of bone marrow recurrence after the 23 years of gastric cancer operation by autopsy findings].

A 70-year-old woman who underwent proximal gastrectomy for gastric cancer (poorly-differentiated adenocarcinoma) of Stage IIIB at age 46 visited our hospital April 2004 because of exacerbated pain by movement in the buttocks since November 2003. She showed multiple bone metastasis by CT (computerized tomography). Pancreas cancer or gallbladder cancer was suspected by CT, and a high tumor marker score (CA19-9 18,625 U/mL, DUPAN-II 15,000 U/ mL elevations were acknowledged). Although her symptoms were severe with performance status (PS) 4, she was administered combination chemotherapy with gemcitabine and cisplatin. After 2 cycle therapy, her PS was improved to 2, but the tumor markers had elevated. So we changed the chemotherapy menu to S-1 and gemcitabine. Her tumor markers lowered and PS was improved to 1. There was a remarkable response to this chemotherapy, and the result of CT and bone scintigraphy suggested that her bone metastasis was improved. Because of hematologic relapse due to DIC at 1 year after the first treatment, she was readmitted to our hospital and later died. The autopsical result revealed recurrence of gastric cancer 23 years post-operatively.

Randomized open trial for comparison of proton pump inhibitors in triple therapy for Helicobacter pylori infection in relation to CYP2C19 genotype.

BACKGROUND AND AIMS: Genetic polymorphism of cytochrome P450 (CYP) 2C19 influences the efficacy of Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI) and amoxicillin. However, in triple therapy (PPI plus amoxicillin and clarithromycin), little is known about the impact of CYP2C19 polymorphism, or the use of rabeprazole, which is not well metabolized by CYP2C19. The efficacy of three PPI (omeprazole, lansoprazole, and rabeprazole) in a 1-week triple regimen were compared in relation to CYP2C19 polymorphism. METHOD: One hundred and eighty-three patients were randomized to receive one of the following regimens: amoxicillin 500 mg t.i.d., clarithromycin 200 mg t.i.d., and PPI (omeprazole 20 mg, lansoprazole 30 mg, or rabeprazole 10 mg) b.i.d. CYP2C19 polymorphism was analyzed by PCR restriction fragment length polymorphism. RESULTS: Intention-to-treat-based overall cure rates for omeprazole, lansoprazole or rabeprazole regimens were 83.1% (95% confidence interval (CI): 69-89%), 86.7% (CI: 75-93%), and 76.6% (CI: 64-85%), respectively, without significant difference. The cure rate of the rabeprazole regimen (but not the lansoprazole or omeprazole regimens) tended to be correlated with CYP2C19 genotypes (P = 0.076). In patients with a homozygous extensive metabolizer genotype, the per protocol-based cure rate with rabeprazole (62.5%) was significantly lower than that with lansoprazole (90.0%; P = 0.038). CONCLUSION: The overall cure rate of 1-week triple therapy for H. pylori eradication was not significantly different between regimens with omeprazole, lansoprazole or rabeprazole, but the impact of CYP2C19 genetic polymorphism on the cure rate appeared to differ between these PPI.

Reinfection rate following effective therapy against Helicobacter pylori infection in Japan.

BACKGROUND AND AIM: In developed countries, reinfection of Helicobacter pylori (H. pylori) after eradication of the bacterium is unusual, while the reinfection rate in developing countries is variable. In this study, we determined the reinfection rate after successful H. pylori eradication in Japan, a country with a high prevalence of H. pylori infection. METHODS: After successful eradication, 377 patients were followed up by endoscopy and urea breath test annually. In reinfected patients, H. pylori strains isolated initially and after reinfection were compared by using random amplification of polymorphic DNA fingerprinting. RESULTS: H. pylori became positive in four of 337 patients (1.2) 1 year after eradication and in two of 133 patients (1.5) 2 years after eradication. One patient experienced an ulcer relapse 2 years after eradication therapy. Random amplification of polymorphic DNA fingerprinting of the isolated strains from four of the six patients showed two had identical strains (at 1 year) while the other two had different strains (one at 1 year and one at 2 years). When infection in the two patients reinfected with identical strains is considered a recrudescence, the true reinfection rate is < 0.8 per patient year. CONCLUSIONS: The reinfection rate after eradication of H. pylori is low in Japan despite the country's high prevalence of H. pylori infection.