Endoscopic Submucosal Dissection in the Era of Proton Pump Inhibitors

Endoscopic submucosal dissection (ESD) has the advantage over endoscopic mucosa resection, permitting removal of gastrointestinal neoplasms en bloc, but is associated with relatively high risk of complications. Indications for early gastric cancer (EGC) are expanded: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ≤3 cm in diameter; and minute submucosal invasive cancer ≤3 cm in size. The indications for early esophageal cancer (EEC) are the tumors confined to the two-third layer of the lamina propria. The EEC lesions spreading more than three-quarter of circumference of the esophagus are at frequent risk of stenosis. The procedures include marking, submucosal injection, circumferential mucosal incision and exforiation of the lesion along the submucosal layer. Complete ESD can achieve a large one-piece resection, allowing precise histological assessment to prevent recurrence. Clinical outcomes of gastric and esophageal ESD have been promising, and the prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted. Notification of perforation risk is essential in particular for esophageal ESD. Bleeding during ESD can be managed with coagulation forceps, and postoperative bleeding may be reduced with routine use of the stronger acid suppressant, proton pump inhibitors

Successful Resolution of Fecal Impaction During Endoscopy Using a Looped Guidewire

Fecal impaction is the impaired excretion of a large fecal mass, and mild cases are treated by enema and osmotic laxatives. However, treatment-resistant cases need more invasive alternatives. A woman in her 60s presented with abdominal discomfort. Her abdomen was soft and without tenderness. Computed tomography revealed a large mass of feces in her sigmoid colon and no intestinal dilatation proximal to the mass. Endoscopy confirmed a fecal mass occupying the lumen. A glycerin enema, oral administration of polyethylene glycol, and enteral administration of amidotrizoic acid during colonoscopy were ineffective. We maneuvered a guidewire to form a loop at the tip of an endoscope, with which we subdivided the mass for successful removal. The patient’s abdominal discomfort disappeared immediately. Endoscopic disimpaction is far less invasive than surgery and should be considered when treating fecal impaction cases, without severe obstructive colitis, which are nonresponsive to conservative treatment

Infective Endocarditis-Associated Glomerulonephritis: A Comprehensive Review of the Clinical Presentation, Histopathology, and Management

A significant proportion of patients with infective endocarditis presents with acute renal failure related to infective endocarditis-associated glomerulonephritis (IEAGN). However, the clinical presentation of IEAGN differs from that of other infection-related glomerulonephritis (IRGN) with anti-neutrophil cytoplasmic antibody (ANCA) positivity occurring in almost onethird of cases; therefore, it may be difficult to establish a definitive diagnosis and provide appropriate treatment. This review article provides a comprehensive understanding of the clinical presentation, investigations, histopathology, and treatment/management of IEAGN so that clinicians can keep this differential in mind for patients with fever of unknown origin accompanied by signs and symptoms of acute renal failure

Photodynamic diagnosis with special reference to gastric cancer with a laser-equipped video image endoscope

This review focuses on the studies to investigate the feasibility of 5-aminolevulinic acid （5-ALA）-mediated photodynamic diagnosis（PDD） in particular, for detecting gastric cancer and upper GI tumors in the earlier stage. Using a prototype endoscope equipped with a blue laser light excitation for protoporphyrin IX, a photosensitizer, 5-ALA-mediated PDD was conducted in 30 cases of gastric cancer and upper GI tumors. 5-ALA solution was given orally 3 hours before PDD. Red fluorescence signal and intensity was assessed as for clinicopathological features of the cases. The laser-based endoscopy could detect upper GI tumors as red fluorescent navigation （PDD-positive） in 77%（23/30）．There were nominal adverse events. Thus, 5-ALA-PDD using the blue laser-equipped endoscope offers a promising diagnostic tool for the other digestive tumors such as colonic and pancreatic tumors. Further studies on the basic mechanisms of the difference in fluorescence intensity are warrant to be executive

Identification of a Novel Deactivating Small-Molecule Compound for Fibrogenic Hepatic Stellate Cells

Background: Liver fibrosis progresses to decompensated liver cirrhosis, for which medical needs remain unmet. We recently developed IC-2, a small-molecule compound that suppresses Wnt/β-catenin signaling, and found that IC-2 also suppresses liver fibrosis. In this study, we performed three-step screening of newly synthesized IC-2 derivatives to identify other small-molecule compounds that suppress liver fibrosis. Methods: The screening system consisted of three steps: a cell viability assay, a transcription factor 4 (TCF4) reporter assay, and induction of α-smooth muscle actin (α-SMA) and collagen 1α1 (Col1A1) expression in response to each compound. Screening using human LX-2 hepatic stellate cells (HSCs) was performed to target HSCs, which are the driver cells of liver fibrosis. Results: In the first step, since 9b and 9b-CONH2 at 100 μM did not have any effects on cell viability, they were omitted in the next screening. Additionally, the conditions that led to > 40% inhibition of the controls were also excluded in subsequent screening. The second step was performed under 31 conditions for 19 small-molecule compounds. Sixteen small-molecule compounds caused significant reduction of TCF4 activity relative to that of 0.1% DMSO. Of the 16 compounds, the 10 showing the greatest suppression of TCF4 activity were selected for the third step. Expressions of mRNA for α-SMA and Col1A1 were significantly reduced by seven and three small-molecule compounds, respectively. The greatest reductions in the α-SMA and Col1A1 mRNA expressions were observed in the cells treated with IC-2-F. Protein expressions of α-SMA and Col1A1 caused by IC-2-F were also comparable to those caused by IC-2. Conclusion: IC-2-F was identified as a novel deactivating small-molecule compound for HSCs in vitro. These data suggest that IC-2-F is a promising medicine for liver fibrosis

A case of liver abscess caused by Fusobacterium nucleatum in a patient with periodontitis

We report a case of liver abscess due to Fusobacterium nucleatum in a 68-year-old man with periodontitis. He was admitted to our hospital complaining of high fever. Abdominal ultrasound sonography and computed tomography scan revealed a single liver abscess. Fusobacterium nucleatum was isolated from liver aspirates. He had no dental symptoms but periodontitis was diagnosed. After extraction of a tooth, he had high fever again suffered from sepsis. Fusobacterium nucleatum is anaerobic gram-negative bacilli found in normal flora of oral cavity and gastrointestinal tract, but it has rarely proven as a causative pathogen of liver abscess or systemic infection associated with periodontal disease. It should be noted that poor dental hygiene could lead to serious systemic infection

Characteristics of Advanced Colorectal Cancer Detected by Fecal Immunochemical Test Screening in Participants with a Negative Result the Previous Year

Background: There is sufficient evidence to show the mortality reduction effect of colorectal cancer (CRC) screening programs using the fecal occult blood test (FOBT). However, we see cases that are found to be advanced CRC despite yearly FOBT screening. Methods: The aim of this study was to investigate the characteristics of advanced CRC detected by a fecal immunochemical test (FIT) screening program in participants with a negative screening result the previous year, which we call “Negative advanced CRC”. A total of 109,639 participants (10.0% required colonoscopy, of whom 76.9% received one) underwent a CRC screening program using a FIT from fiscal 2009 to 2017. Negative advanced CRC was compared with advanced CRC (First advanced CRC) found at the first visit in a person who had not had a FIT screening history for more than 3 years. In addition, we compared the characteristics of Negative advanced CRC with those of interval cancer: cancer cases detected after a negative screening result and before the date of the next recommended screening. Results: A total of 339 cases of CRC (175 male: 164 female, 173 early stage: 166 advanced stage) were detected in the nine-year CRC screening period. The rate of right-sided CRCs was significantly higher in female (P < 0.01), advanced stage (P < 0.01), negative result previous year (P < 0.01), and symptom-negative (P < 0.01) participants than in each counterpart, respectively. The ratio of female (22/35; 62.9%) patients in Negative advanced CRCs tended to be high compared with that (40/83; 48.2%) in First advanced CRCs (P = 0.145). Overall, 22 (62.9%) of 35 Negative advanced CRCs and 28 (33.7%) of 83 First advanced CRCs were located in the right-sided colon, and the rate was significantly higher in Negative advanced CRCs (P < 0.01). In addition, the frequency of female patients was significantly higher in right-sided Negative advanced CRCs than in right-sided First advanced CRCs (P = 0.03). Conclusion: The characteristics of Negative advanced CRC cases (female and right-sided colon) were similar to those of interval cancer reported so far. In the future, it will be necessary to introduce a screening program that is highly sensitive to right-sided CRC

Transabdominal Ultrasonography for Assessing the Depth of Tumor Invasion in Gastric Cancer

[Background] Although endoscopy and endoscopic ultrasonography are generally used to diagnose the depth of gastric tumor invasion, endoscopy is invasive and frequently results in patient discomfort. Transabdominal ultrasonography (TUS) is noninvasive and may be useful in determining this depth. We investigated the usefulness of TUS in determining the depth of tumor invasion in patients with gastric cancer. [Methods] This retrospective study included 190 patients with gastric cancer and 200 lesions who underwent curative resection at the Department of Gastrointestinal Surgery of Tottori University Hospital from July 2007 to July 2015. The results of conventional diagnostic imaging and TUS were compared with those of pathological analysis obtained after surgery. Furthermore, the ruptured form of the third layer on TUS imaging was reviewed and investigated to differentiate between the SM2 and MP lesions. [Results] The accuracy of TUS was similar to that of conventional diagnostic imaging for all depths of tumor invasion. Eight lesions could not be assessed by TUS, including four that could not be identified and four in which TUS was unable to diagnose the depth. In cases where the ruptured form of the third layer could be determined in MP lesions, the forms were observed toward the inside of the gastric lumen. [Conclusion] The results of this study suggested that the accuracy of TUS was equivalent to that of conventional diagnostic imaging in determining the depth of tumor invasion. TUS assessment criteria may be useful to classify this depth. Furthermore, the ruptured form of the third layer is believed to be important in distinguishing between early and advanced gastric cancer

Salvage Photodynamic Therapy Using Talaporfin Sodium for Local Failure of Esophageal Squamous Cell Carcinoma

[Background] Talaporfin sodium photodynamic therapy (TS-PDT) for local failure after chemoradiotherapy (CRT) in patients with esophageal squamous cell carcinoma has recently been reported to be highly effective and less invasive, compared to other treatment modalities. TS-PDT was recently introduced at the Tottori University Hospital, Japan. The aim of this study is to clarify the efficacy and safety of PDT in our hospital. [Methods] This was a single-center observational study. We examined eight cases of TS-PDT performed between January 2016 and December 2019. The main endpoints were local complete remission (L-CR) rate and the adverse events. In addition, age, gender, histology, tumor location, TNM stage, tumor depth, irradiation dose, and overall survival (OS) were examined. [Results] The patients included 7 men and a woman, with an average age of 72.1 years (range 63–82 years). The baseline clinical stages before CRT or radiotherapy were stage I in 1, stage II in 3, stage III in 3, and stage IVA in 1 patient. The T stage on endoscopic assessment before TS-PDT was T1 in 6 patients and T2 in 2 patients. Treatment outcomes and adverse events were evaluated. There were no treatment-related deaths, and no significant adverse events occurred intraoperatively or postoperatively. The L-CR rate was 7/8 (87.5%); T1 cases had 100% (6/6) L-CR, while T2 cases had 50% (1/2). The 2-year OS rates were 87%. [Conclusion] TS-PDT was observed to be safe and effective in the first eight cases of its application following its introduction in our hospital