Efficacy and safety of temporary biliary stent for prevention of post-ERCP cholangitis after endoscopic common bile duct stone removal: a retrospective study

　Although post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) is not as severe as post-ERCP pancreatitis, this complication should not be disregarded. The aim of the present study was to evaluate the efficacy of a temporary biliary stent for prevention of PEC. Between April 2011 and May 2017, 190 patients underwent complete stone removal in a first session of ERCP at our hospital. Using propensity score matching, 72 pairs were enrolled in this study. After common bile duct (CBD) stone removal, the endoscopists decided to insert a temporary biliary stent if necessary. The incident rate of PEC was significantly lower in the stent group than the no-stent group (1% vs. 11%, p = 0.03). The length of hospital stay was also significantly shorter in the stent group than the no-stent group (5 days vs. 7 days, p < 0.01). In the stent group, one case had stent migration into the bile duct and two cases had a mooring stent at the papilla after 1 month. Multivariate analysis identified the pancreatic guide wire technique as a risk factor for PEC. We demonstrated that a temporary biliary stent reduced the incidence of PEC significantly and the outcome of its placement contributed to shortening the hospital stay. Furthermore, the placement of a temporary biliary stent caused fewer adverse effects than expected. Mooring stents were noted in three cases, which were confirmed by plain abdominal X-ray, but the patients had no symptoms. In two cases, the stent remained in the orifice of the papilla, and in one case it migrated into the CBD. All three stents were retrieved by elective endoscopic procedures. In conclusion, a temporary biliary stent can reduce the incidence of PEC and shorten the length of hospital stay without severe adverse outcomes

Fatal case of subdural empyema caused by Campylobacter rectus and Slackia exigua

We report a fatal subdural empyema caused by Campylobacter rectus in a 66-year-old female who developed acute onset of confusion, dysarthria, and paresis in her left extremities. A CT scan showed hypodensity in a crescentic formation with a mild mid-line shift. She had a bruise on her forehead caused by a fall several days before admission, which initially raised subdural hematoma (SDH) diagnosis, and a burr hole procedure was planned. However, her condition deteriorated on the admission night, and she died before dawn. An autopsy revealed that she had subdural empyema (SDE) caused by Campylobacter rectus and Slackia exigua. Both microorganisms are oral microorganisms that rarely cause extra-oral infection. In our case, head trauma caused a skull bone fracture, and sinus infection might have expanded to the subdural space causing SDE. CT/MRI findings were not typical for either SDH or SDE. Early recognition of subdural empyema and prompt initiation of treatment with antibiotics and surgical drainage is essential for cases of SDE. We present our case and a review of four reported cases

Four cases of gastric cancer in patients with autoimmune gastritis

　Here, we report on four cases of gastric cancer in patients with autoimmune gastritis (AIG). AIG is characterized by the corpus-predominant atrophic gastritis with preserved antrum caused by autoimmune mechanisms. Although AIG is a high risk factor for gastric cancer and neuroendocrine tumors (NET), there are few reports describing the characteristics of gastric cancer in patients with AIG. In this case report, all four cases were diagnosed as having AIG by endoscopic findings and the presence of extra-gastric autoimmune diseases before the treatment for gastric cancer

Combination of shear-wave elastography and liver fibrosis markers predicts severe fibrosis in patients with non-alcoholic steatohepatitis

　非アルコール性脂肪性肝疾患（Non-alcoholic fatty liver disease：NAFLD）の中から予後の悪い線維化が進展した非アルコール性脂肪肝炎（Non-alcoholic steatohepatitis：NASH）を非侵襲的診断法にて拾い上げることが重要である．今回，バイオマーカーやshear wave elastography（以下 SWE）を組み合わせた非侵襲的診断における肝線維化進展症例の診断能の向上について検討を行った．肝生検および SWE を施行し，肝線維化マーカーを測定した NAFLD 患者140名を対象とし，SWE 値と肝線維化マーカーの測定を行い線維化進展例（stage3以上）の診断の拾い上げについて検討した．各種線維化マーカーは stage3-4の線維化進展例で有意に上昇を認め，SWE においてはstage2の段階から上昇し，他の線維化マーカーより早い段階から NASH の線維化の診断ができた．SWE，Ⅳ型コラーゲン7S，WFA+M2BP，P-Ⅲ-P，ヒアルロン酸，FIB4 index における stage3以上の AUC はそれぞれ0.86，0.83，0.79，0.75，0.75，0.77であった．さらに SWE と線維化マーカーを組み合わせたところ，AUC はそれぞれ0.92，0.88，0.86，0.88，0.88で診断能の上昇を認めた．特に SWE とⅣ型コラーゲン7S の診断能が最も優れていた．NASH における SWE は簡便に線維化進展の診断が可能であり，バイオマーカーを組み合わせることで肝線維化診断能が上昇した．以上より線維化の軽度な NASH 症例や非アルコール性脂肪肝（Non-alcoholic fatty liver：NAFL）を識別し，肝生検を減少させる可能性があり，NAFLD の予後の改善に繋がると思われた．　In the recent years, the incidence of nonalcoholic fatty liver disease (NAFLD) is increasing rapidly worldwide. It is important to detect nonalcoholic steatohepatitis (NASH) with a poor prognosis in patients with NAFLD using noninvasive diagnostic methods. Conventional ultrasound (US) is the most common, low-cost technique for NASH diagnosis and improving patient prognosis. We studied the usefulness of US elastography (shear-wave elastography [SWE]) in diagnosing liver fibrosis (LF) with NAFLD and examined the possibility of improving the diagnosis of patients with advanced LF by combining SWE and LF-marker testing. The subjects were 140 patients with NAFLD who underwent liver biopsies, SWE, and LF-marker tests, such as type IV collagen 7S, Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA[+]-M2BP), P-Ⅲ-P, hyaluronic acid, and fibrosis-4 (FIB4) index, at the General Medical Center, Kawasaki Medical School. We evaluated the efficacy of combined SWE and LF-marker tests to diagnose advanced LF (stage ≥3). SWE was performed using 3.75-MHz probes (Canon Aplio 500, JAPAN). There were minimal differences in LF-marker levels for NASH stages 0–2, whereas significantly increased LF-marker levels were observed in patients with advanced LF (stages 3 and 4). SWE showed significantly elevated LF-marker levels at stage 2 compared with stages 0–1, and NASH was detected earlier than other LF markers. The areas under the receiver-operating characteristic curves (AUCs) for SWE, type IV collagen 7S, WFA(+)-M2BP, P-Ⅲ-P, hyaluronic acid, and FIB4 index for stage ≥3 were 0.86, 0.83, 0.79, 0.75, 0.75, and 0.77, respectively. With combined SWE and LF markers, the AUCs increased to 0.92, 0.88, 0.86, 0.88, and 0.88, respectively, showing increased diagnostic ability compared to that of single markers. The diagnostic ability of combined SWE and type IV collagen 7S was superior to that of other combinations. In addition, we detected that most cases were in stage ≥3 on combining SWE and LF markers. SWE for NASH can simply diagnose LF progression; the diagnostic capacity of SWE for LF improves in combination with LF-marker tests. It may be possible to detect the need for liver biopsy and treatment or follow-up, as well as reduce the number of liver biopsies by identifying NAFLD with low LF levels

当院で経験したA 型胃炎の４例

A 型胃炎は稀な疾患で，悪性貧血や胃癌，胃NET の発生母地として知られている．抗胃壁細胞抗体陽性，高ガストリン血症，さらに胃体部を中心とした萎縮性胃炎が診断基準とされている．今回，過去１年に４例のA 型胃炎を診断した．全例で自覚症状は見られなかったが，内視鏡検査での逆萎縮所見からA 型胃炎を疑い，胃生検の病理所見と血液検査で確診した．A 型胃炎が他の自己免疫性疾患に合併することが多いとされているが，本症例にも高齢発症のBasedow 病が１例あり，A 型胃炎は日本でも決してまれな疾患ではないと考えられた．診断には内視鏡所見からA 型胃炎を疑うことが重要で，胃生検や血清ガストリンと抗胃壁細胞抗体の測定を行うことにより確診できる．Type A gastritis is a rare disease and is known as a cause of various conditions including pernicious anaemia, gastric cancer and gastric NETs (Neuroendocrine tumour). The diagnostic criteria of type A gastritis include positive parietal cell antibody, hypergastrinaemia and the presence of atrophic gastritis mainly corpus predominantly atrophic gastritis. We diagnosed four cases of type A gastritis in the past year in our hospital. Although they were all asymptomatic, type A gastritis was suspected by the endoscopic findings (the reverse atrophy) and all confirmed by pathological examination of biopsy specimens and blood test subsequently. It is well known that the patients with autoimmune disease are frequently associated with type A gastritis and there is a case of late onset of Basedow’s disease in our case report. Our study suggests that type A gastritis is not as rare as initially thought in Japan. In order to diagnose type A gastritis, it is important to have a high index of suspicion with endoscopic findings, and to confirm it with gastric biopsy, serum gastrin level and parietal cell antibody

Diagnostic yield of transabdominal ultrasonography of pancreatic solid pseudopapillary neoplasm: a case report

　症例は10歳代，女性．主訴は左上腹部痛．部活中に腹部を強打し，左上腹部痛が出現した．食物残渣様嘔吐も認め，当院に救急搬送された．当院搬送時，左上腹部に疼痛及び圧痛を認めたが，反跳痛はなかった．当院搬送時の血液検査は白血球8,950 /μl，アミラーゼ204 U/l と高値を示していた．体外式腹部超音波検査では膵体部に76.1×68.1 mm 大の境界明瞭な被膜を伴う類円形腫瘤を認めた．周囲臓器への浸潤所見は認めず，腫瘍内部は不整で一部無エコー領域を伴い，ペルフルブタン（ソナゾイド ®）による造影超音波検査では腫瘍内部の血流は乏しい所見であった．超音波内視鏡検査所見も体外式腹部超音波検査と同様であった．以上より，腫瘍内出血を伴った solidpseudopapillary neoplasm（SPN）が最も考えられた．第10病日に膵体尾部切除術を施行し，術後経過は良好である．腹部打撲を契機に偶然発見され，体外式腹部超音波検査が質的診断に有用であった膵 SPN を経験したので文献的考察を加えて報告する．　We report a teenage girl with a solid pseudopapillary neoplasm (SPN) of the pancreas. The patient was transported to our hospital by ambulance and presented with left-sided abdominal pain after sustaining abdominal trauma during sports activities. Her white blood cell count (8950 cells/μl) and serum amylase level were increased (204 U/l) on admission. Transabdominal ultrasonography showed a well-encapsulated, complex pancreatic body mass measuring 76.1 × 68.1 mm with solid and cystic components. Contrastenhanced ultrasonography using Perflubutane (Sonazoid®) revealed poor contrast inside the tumor. Abdominal computed tomography and magnetic resonance imaging revealed similar findings. Partial pancreatectomy was performed 10 days after admission. The gross appearance of the resected specimen revealed mixed cystic and solid components with thick walls, and microscopy revealed the characteristic pseudopapillary pattern of SPN. The patient’s postoperative course proceeded well without recurrence as of this report. The imaging features of transabdominal ultrasonography and contrast-enhanced ultrasonography are useful to diagnose SPN. We discussed this patient’s detailed information and reviewed the related literature in this report

Fine-mapping analysis including over 254,000 East Asian and European descendants identifies 136 putative colorectal cancer susceptibility genes

Genome-wide association studies (GWAS) have identified more than 200 common genetic variants independently associated with colorectal cancer (CRC) risk, but the causal variants and target genes are mostly unknown. We sought to fine-map all known CRC risk loci using GWAS data from 100,204 cases and 154,587 controls of East Asian and European ancestry. Our stepwise conditional analyses revealed 238 independent association signals of CRC risk, each with a set of credible causal variants (CCVs), of which 28 signals had a single CCV. Our cis-eQTL/mQTL and colocalization analyses using colorectal tissue-specific transcriptome and methylome data separately from 1299 and 321 individuals, along with functional genomic investigation, uncovered 136 putative CRC susceptibility genes, including 56 genes not previously reported. Analyses of single-cell RNA-seq data from colorectal tissues revealed 17 putative CRC susceptibility genes with distinct expression patterns in specific cell types. Analyses of whole exome sequencing data provided additional support for several target genes identified in this study as CRC susceptibility genes. Enrichment analyses of the 136 genes uncover pathways not previously linked to CRC risk. Our study substantially expanded association signals for CRC and provided additional insight into the biological mechanisms underlying CRC development

A Case of Idiopathic Peptic Ulcer Disease Treated Effectively with Trimebutine Maleat

A 30-year-old man with idiopathic peptic ulcer disease (IPUD) experienced repeated recurrence of ulcerative bleeding despite treatment with lansoprazole and then vonoprazan. Further evaluation suggested that the cause of the ulcer was strong contractile movements of the antrum. This prompted the co-administration of trimebutine maleate (TM) and vonoprazan to relieve the stomach contractions. TM was effective in preventing the recurrence of ulcerative bleeding, and the patient has remained in remission for 4 years. This case highlights the potential efficacy of TM in treating IPUD and the importance of considering hypercontractility as the underlying cause in cases of IPUD