Olmesartan-associated sprue-like enteropathy diagnosed by capsule endoscopy and double balloon endoscopy.

Sprue-like enteropathy associated with olmesartan is characterized by villous atrophy in the duodenum. We report the case of an 81-year-old woman diagnosed with olmesartan-associated sprue-like enteropathy with no villous atrophy in the duodenum. The patient had been taking olmesartan for 10 years and complained of diarrhea and weight loss. Despite undergoing general treatment for 2 months, her symptoms showed no improvement. Gastrointestinal endoscopy and pathological findings showed no villous atrophy in the duodenum. However, villous atrophy was observed in the small intestine by capsule endoscopy. Pathological biopsy with double balloon endoscopy provided a definitive diagnosis. Diarrhea improved with the discontinuation of olmesartan and weight increased within a week of withdrawal. After the improvement of clinical symptoms, both endoscopic and pathological findings of villous atrophy in small intestine showed improvement.

Inhibitory effects of a selective prostaglandin E2 receptor antagonist RQ-15986 on inflammation-related colon tumorigenesis in APC-mutant rats.

Prostaglandin E2 receptor EP4 is involved in inflammation and related tumorigenesis in the colorectum. This study aimed to investigate the chemopreventive ability of RQ-15986, a selective EP4 antagonist, in colitis-related colorectal tumorigenesis. Male Kyoto APC delta rats, which have APC mutations, were treated with azoxymethane and dextran sulfate sodium and subsequently administered RQ-15986 for eight weeks. At the end of the experiment, the development of colorectal tumor was significantly inhibited in the RQ-15986-treated group. The cell proliferation of the crypts and tumors in the colorectum was decreased following RQ-15986 treatment. RQ-15986 also suppressed the expression of pro-inflammatory cytokines, including tumor necrosis factor-α, interleukin-6, interleukin-18, and monocyte chemotactic protein-1, in the colon mucosa. In addition, the expression levels of indoleamine 2,3-dioxygenase, which is involved in immune tolerance, were decreased in the colorectal epithelium and tumors of the RQ-15986-treated group. These findings indicate that RQ-15986 inhibits colitis-associated colorectal tumorigenesis by attenuating inflammation, suppressing cell proliferation, and modulating the expression of indoleamine 2,3-dioxygenase. Targeting prostaglandin E2/EP4 signaling might be a useful strategy for chemoprevention of inflammation-related colorectal cancer.

Skeletal Muscle Depletion: A Risk Factor for Pneumonia following Gastric Endoscopic Submucosal Dissection in Elderly Patients.

INTRODUCTION: Endoscopic submucosal dissection (ESD) is an effective treatment for gastric neoplasms in elderly patients; however, it involves several adverse events, including pneumonia. This study aimed to investigate whether skeletal muscle depletion (SMD) was associated with the development of pneumonia in elderly patients who underwent gastric ESD. METHODS: This retrospective observational cohort study included 157 patients (≥80 years) who had undergone gastric ESD. The skeletal muscle cross-sectional area was measured by CT, and the value of the third lumbar vertebra skeletal muscle index (L3 SMI) was evaluated. The SMD was defined as an L3 SMI value ≤38.0 cm2/m2 for women and ≤42.0 cm2/m2 for men. Pneumonia was also diagnosed using CT to identify all included patients. RESULTS: Among 157 patients, 66 (42.0%) showed SMD. In the SMD group, the incidence of pneumonia was 21.2%, whereas it was 7.7% in the non-SMD group (p = 0.018). The longest hospitalization duration was 19 days. Antibiotics were administered in 61.9% of the patients. Procedure time was not significantly different between the groups (72 ± 54 min vs. 62 ± 44 min, p = 0.201). On multivariate analysis, SMD was an independent risk factor for the development of pneumonia (odds ratio = 3.16, 95% confidence interval, 1.18-8.50, p = 0.023). CONCLUSIONS: SMD was not a rare entity in patients aged ≥80 years with gastric neoplasms. SMD was a significant risk factor for pneumonia related to gastric ESD in elderly patients.

Advanced appendiceal goblet cell carcinoids with intestinal obstruction: two case reports.

A goblet cell carcinoid is quite rare and has features, wherein, a carcinoid-like image and an adenocarcinoma-like image coexist. We encountered two cases of rare goblet cell carcinoid originating in the appendix. Case 1 is that of a 48-year-old man with a chief complaint of abdominal distension and case 2 is that of a 64-year-old woman with a chief complaint of constipation. At the time of diagnosis, both cases had already metastasized to the peritoneum and other organs, and no radical surgical treatment could be administered in either case. Chemotherapies were performed according to the regimen for colon cancer, and they were effective to a certain extent. During the course of treatment, however, both cases developed intestinal obstruction, presumably due to peritoneal dissemination, which led to worse condition and death several months afterwards. Chemotherapy for goblet cell carcinoids has not yet reached a consensus, and further studies and establishment of therapeutic strategy are desired in the future.

Acute cytomegalovirus infection in an immunocompetent patient with ulcerative colitis: A case report.

Cytomegalovirus (CMV) is a ubiquitous member of the Herpesviridae family that can present with a variety of clinical manifestations, including encephalitis, retinitis, interstitial pneumonia and colitis. These serious symptoms are generally observed as opportunistic infections in immunocompromised hosts, including patients with acquired immunodeficiency syndrome and those receiving steroids and/or immunosuppressants. Symptomatic CMV infections in patients with ulcerative colitis are found in patients treated with steroids and/or immunosuppressants but rarely affect those who are not taking these agents. The present study reported the case of a young patient without concurrent use of immunosuppressive agents for the treatment of ulcerative colitis. The patient presented with acute mononucleosis and colitis caused by primary CMV infection. This was characterized by the presence of atypical lymphocytes and hepatosplenomegaly, elevation of transaminase levels, serology-positive anti-CMV IgM, and CMV antigenemia. Additionally, CMV-positive cells were histologically detected in colonic biopsy specimens. The patient's symptoms and clinical parameters improved following initiation of intravenous ganciclovir. It was concluded that even if patients with ulcerative colitis are not treated with steroids and/or immunosuppressants, significant attention should be paid to acute CMV infections in the context of severe or persistent colonic inflammation.

Idiopathic Ileocolonic Varices Coexisting with a Colon Polyp Treated Successfully by Endoscopy: A Case Report and Literature Review.

Colonic varices are usually associated with portal hypertension. Idiopathic colonic varices are extremely rare. A 68-year-old man with a positive fecal occult blood test result underwent colonoscopy. We detected idiopathic ileocolonic varices and a coexisting ascending colon polyp. While reviewing the literature, we found cases of biopsies and polypectomies resulting in significant bleeding. We herein report a case of idiopathic ileocolonic varices coexisting with a colon polyp treated successfully by endoscopy. The coexistence of colonic varices and a colorectal lesion that requires endoscopic treatment may lead to significant bleeding. During management, the development of a treatment strategy and obtaining informed consent are necessary.

Safety of Carbon Dioxide Insufflation during Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma.

BACKGROUND: Pulmonary dysfunction often accompanies esophageal squamous cell carcinoma (SCC). AIMS: This study examined the use of carbon dioxide (CO2) insufflation and its safety during esophageal endoscopic submucosal dissection (ESD) while under conscious sedation. METHODS: ESD using CO2 insufflation (1.4 L/min) was performed in 102 consecutive esophageal SCC patients. Patients with a forced expiratory volume of 1.0 s/forced vital capacity (FEV1.0%) < 70% or a vital capacity < 80% were defined as having pulmonary dysfunction. Transcutaneous partial pressure of CO2 (PtcCO2) was recorded before, during, and after ESD. RESULTS: A history of smoking was found in 90 patients (88%), while 43 patients (42%) had pulmonary dysfunction. No significant differences were found between the pulmonary dysfunction and normal groups for the baseline PtcCO2 before ESD, peak PtcCO2 during ESD, and median PtcCO2 after ESD. There was a significant correlation between the PtcCO2 elevation from baseline and the ESD procedure time (r = 0.32, p < 0.01), with the correlation for the pulmonary dysfunction group much stronger (r = 0.39, p < 0.05) than that for the normal group (r = 0.30, p < 0.01). Neither of the groups exhibited any differences for either the complication incidence or the hospital stay. CONCLUSIONS: Although the use of CO2 insufflation during esophageal ESD under conscious sedation is safe with regard to the risk of complications, longer procedure times can potentially induce CO2 retention in patients with obstructive lung disease. Thus, it is necessary to both shorten the procedure times and perform CO2 monitoring.

Carbon dioxide insufflation reduces residual gas in the gastrointestinal tract following colorectal endoscopic submucosal dissection.

Quantitative examinations evaluating the effects of CO2 insufflation on residual gas in the gastrointestinal tract following colorectal endoscopic submucosal dissection (ESD) are lacking. The present study aimed to assess whether CO2 insufflation could decrease the amount of residual gas in the gastrointestinal tract following ESD in patients with colorectal neoplasms. Computed tomography (CT) was used to objectively examine whether CO2 insufflation during colorectal ESD reduced residual gas levels in the gastrointestinal tract following ESD. A total of 83 patients who underwent colorectal ESD between January and December 2009 at Gifu University Hospital (Gifu, Japan) were enrolled. Following exclusion of 17 patients with chronic pulmonary dysfunction, 66 patients were randomized into a CO2 insufflation group (n=34) and an air insufflation group (n=32). The level of residual gas and the presence of transmural and free-air leaks following ESD were evaluated in both groups using CT. Transcutaneous CO2 tension (PtcCO2) and ESD-related complications were also compared between the groups. CT measurements of the major and minor axes of the cecal lumen, and of the terminal ileum diameter, indicated the level of residual gas following ESD to be significantly reduced in the CO2 insufflation group compared with the air insufflation group (P<0.001). Neither the incidences of ESD-related complications, including post-procedure hemorrhage and air leak, nor the abnormalities in vital signs differed between the groups. No significant between-group differences were identified in the baseline and peak PtcCO2 levels during ESD or in the median PtcCO2 following ESD. In conclusion, CO2 insufflation during colorectal ESD was effective in reducing residual gas in the gastrointestinal tract following ESD.

Intrahepatic cholangiocarcinoma producing granulocyte colony-stimulating factor and parathyroid hormone-related protein.

A 78-year-old man was referred to our hospital with suspected liver abscess. Fever and inflammatory reaction resolved after percutaneous drainage and administration of antibiotics. However, leukocyte count was remarkably increased, and hypercalcemia was noted. The liver mass was also enlarged, as observed in the follow-up abdominal CT scans. Therefore, a percutaneous needle biopsy was performed, and the histopathological findings indicated the presence of adenocarcinoma. Additional blood examination revealed high serum levels of granulocyte colony-stimulating factor (G-CSF) and parathyroid hormone-related protein (PTHrP). Lastly, the patient was diagnosed with cholangiocarcinoma producing G-CSF and PTHrP. Chemoradiotherapy with S-1 was initiated, which was partially effective. However, the patient died 134 days after initiating the therapy. Only two cases of cholangiocarcinoma producing G-CSF and PTHrP have been reported to date. Here we reported an additional case of cholangiocarcinoma producing G-CSF and PTHrP.

Prospective randomized study of endoscopic biliary stone extraction using either a basket or a balloon catheter: the BasketBall study.

BACKGROUND: In Japan and Europe, a retrieval basket is generally used for endoscopic extraction of bile duct stones, while in the US, a retrieval balloon is mainly used. However, the efficacies of these two devices have not been previously compared. Therefore, the present multicenter, prospective, randomized study was performed to compare the efficacies of these two devices for endoscopic biliary stone extraction. METHODS: This study was designed as a non-inferiority study in comparing a basket removal with a balloon removal. Six Japanese institutions participated in this study, which included 184 patients with bile duct stones <11 mm in diameter with no limitation in the number of stones. The stones were identified and measured during ERCP, after which the patients were randomly assigned to undergo endoscopic stone extraction using either a basket catheter or a balloon catheter. The primary end point was the rate of complete removals of stones within 10 min, and the secondary end point was the rate of procedure-related complications. RESULTS: There were 91 patients in the basket group and 93 in the balloon group. The rate of successful stone extraction within 10 min was 81.3 % (74/91) in the basket group and 83.9 % (78/93) in the balloon group (p = 0.7000). The complication rate was 6.6 % in the basket group and 11.8 % in the balloon group (p = 0.3092). Complications included bleeding, pancreatitis, and cholangitis. CONCLUSIONS: Basket and balloon catheters showed similar efficacies for endoscopic biliary stone extraction when stone size is 11 mm or smaller.

Risk factors for pyrexia after endoscopic submucosal dissection of gastric lesions.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is widely used in the resection of gastric tumors en bloc, however, complications such as pyrexia frequently occur following the procedure. The study aim was to elucidate the incidence, clinical characteristics, and risk factors of post-ESD pyrexia. PATIENTS AND METHODS: We conducted a retrospective cohort study of 471 consecutive patients with 485 gastric lesions resected by ESD between December 2005 and 2010. Pyrexia was defined as body temperature above 37.5 °C, regardless of its duration. Blood tests and chest radiography were performed three times before and after ESD. Chest and abdominal computed tomography (CT) was taken on postoperative day 1. RESULTS: Post-ESD pyrexia developed in 117 patients (24.8 %), including 40 patients with pneumonia as shown by computed tomography. The pyrexia was resolved in all the patients after 1 day (median; range, 1 - 36 days). A multivariate analysis identified age (P = 0.0029) and resection diameter (P = 0.0009) as risk factors for pyrexia in patients without pneumonia, and operation time (P = 0.0025) as a risk factor for pyrexia in patients with pneumonia. CONCLUSION: The patient would be at risk for post-ESD pyrexia if a large ESD is performed in the elderly. The longer operation time would raise the risk for pneumonia-associated fever.

[A case of mucinous adenocarcinoma of the sigmoid colon with disseminated carcinomatosis of the bone marrow successfully treated with FOLFOX4/bevacizumab].

A 68-year-old man complaining of back pain was given the diagnosis of mucinous adenocarcinoma of the sigmoid colon with disseminated carcinomatosis of bone marrow and disseminated intravascular coagulation(DIC). We started chemotherapy using FOLFOX4. After we confirmed that DIC had improved following 2 courses of FOLFOX4, bevacizumab was added to FOLFOX4. Laboratory studies revealed a serum CEA level of 11, 432 ng/mL, which improved to 245 ng/mL after a total of 9 courses of chemotherapy. Chemotherapy is continuing as scheduled at 6 months from the onset of this disease.