Mice Treated with an Antibiotic Cocktail Containing Metronidazole Show Attenuated Allergy Responses through the Induction of Regulatory T Cells in the Intestinal Mucosa

This study sought to determine whether antibiotic treatments affect the pathogenesis of allergic diseases. We demonstrated that mice treated with a mixture of four antibiotic agents （ampicillin, neomycine, metronidazole, and vancomycin） showed significantly decreased antigen-specific IgE production compared to control mice, whereas mice treated with the same cocktail without metronidazole showed no change in IgE production compared to controls. Regulatory T cell suppression induced by particular antibody combinations is a possible mechanism of this effect, with an increased frequency of regulatory T cells also observed in the mesenteric lymph nodes （MLN） of mice treated with the mixture of four antibiotics, but not in the second cocktail without metronidazole. Our antibiotic treatments also dramatically decreased the diversity of mouse intestinal microbiota compared to control mice, based on 16SrRNA analysis of the cecum fecal composition. In conclusion, mice treated with antibiotic mixtures containing metronidazole, but not those treated without metronidazole, showed attenuated allergy responses and increased induction of regulatory T cells in the mucosa

A Case of Pneumatosis Cystoides Intestinalis Mimicking Intestinal Perforation

An 85-year-old man was referred to the Department of Gastroenterological and General Surgery after complaining of abdominal pain and distention. Abdominal computed tomography (CT) revealed intra-abdominal free air, mimicking perforated peritonitis, with air collection within the jejunum bowel wall. On the basis of these findings, we made a diagnosis of pneumatosis cystoides intestinalis (PCI) with intra-abdominal free air. The PCI signs had disappeared completely by Day 7 of hospitalization. The patient was discharged from hospital after 15 days. At the time of writing, the patient’s PCI has not reappeared. This case highlights the clinical importance of PCI, and that the lung window settings of abdominal CT are useful tools to enable an accurate diagnosis of PCI

Diagnostic Ability of Diffusion-weighted Magnetic Resonance Imaging to Discriminate Ampullary eoplasms: A Preliminary Study of 15 Cases

We assessed the diagnostic capability of diffusion-weighted magnetic resonance imaging (DWI) to predict the histological diagnosis of ampullary lesions to resolve the diagnostic uncertainty of endoscopic biopsy for ampullary neoplasms. From January 2009 to August 2011, we performed DWI using b values of 0 and 1000s/mm2 for 15 patients with a histological diagnosis of ampullary lesion (adenocarcinoma, n = 8; adenoma, n = 4; hyperplasia, n = 3). We compared the signal intensities (determined by comparing signal intensities of ampullary lesions and rating them as markedly hyperintense, hyperintense, or hypo-to-isointense relative to the duodenal wall) and the apparent diffusion coefficient (ADC, × 10-3 mm2/s) values of the ampullary lesions on DWI among the three groups based on the histological diagnosis. Values are expressed as median (range). The cancer-group lesions showed a significantly higher signal intensity than either adenoma or hyperplasia (markedly hyperintense/hyperintense/hypo-to-isointense; adenocarcinoma, 7/1/0; adenoma, 0/4/0; hyperplasia, 0/0/3; P < 0.005). The ADC values were significantly lower in adenocarcinoma at 1.46 (0.83-1.63) than in either adenoma at 2.14 (1.92-2.37) or hyperplasia at 2.06 (1.88-2.53) (P < 0.005). In addition, the ADC values in the malignant group (adenocarcinoma) were significantly lower than those in the benign groups (adenoma and hyperplasia) (P < 0.001). The findings suggested that DWI could contribute significantly to accurate preprocedural diagnosis of ampullary lesions

Involvement of Adrenomedullin Expression in Tumor Cells and Stroma in the Development of Diabetes in Pancreatic Cancer Patients

Some studies have reported that adrenomedullin （AM） is involved in diabetes mellitus （DM） associated with pancreatic cancer. Therefore, in this study we investigated the relationship between diabetes and AM expression in patients with pancreatic cancer. We examined 48 biopsies and 26 surgical resections from 74 patients with histologically diagnosed pancreatic cancer. Patients were classified into either DM or non-DM groups. The immunohistochemical expression of AM and various clinicopathological factors were compared between the two groups. Among the biopsy cases, 21 were classified as DM and 27 as non-DM. AM expression in pancreatic cancer cells was significantly lower in the DM group （p＝0.03）. No significant differences were noted in age, body mass index, tumor diameter or location, serum CA19-9, amylase, or C-reactive protein levels, pancreatic ductal dilatation, portal vein invasion, clinical stage, or histological differentiation between the DM and non-DM groups. The proportion of men was significantly lower in the DM group （p＝0.04）, as was the frequency of liver metastasis at diagnosis （p＝0.03）. Among the resection cases, 13 were classified as DM and 13 as non-DM. There were no significant differences in AM expression in pancreatic cancer cells between the two groups. However, marked AM expression was observed in the inflammatory cells and fibroblasts of the tumor stroma in all cases. In addition, the inflammatory response in the tumor stroma tended to be stronger in the DM group. Although the present study failed to find a positive correlation between diabetes and AM expression in pancreatic cancer cells, the results indicate that AM expression in stromal cells may be more closely related to the development of DM in pancreatic cancer patients

A Case of Laparoscopic Ileocecal Resection for Intussusception Secondary to Cecal Cancer

An 83-year-old woman presented with a right lower abdominal mass, lower abdominal pain, and distension. She had no medical or surgical history. Clinical examination revealed a right lower abdominal mass, abdominal distension, and decreased bowel sounds in the lower abdomen. Abdominal computed tomography showed an intussusception involving the ileocecal junction. A Gastrografin enema showed a tumor shadow with an irregular defect caused by the intussusception in the transverse colon. The protruding tumor was also pushed back into the cecum by the enema pressure. Colonoscopy revealed a protruding mass at the leading edge of the intussusception in the ascending colon, and biopsy results of the cecal mass indicated an adenocarcinoma. The patient underwent laparoscopic ileocecal resection of the intussuscepted cecal cancer using reduced port surgery. The resected specimen contained a type 1 tumor measuring 40mm that was histopathologically diagnosed as cecal cancer. The patient remains asymptomatic 8 months after surgery

Image Analysis of Magnifying Endoscopy for Differentiation between Early Gastric Cancers and Gastric Erosions

The primary goal of upper gastrointestinal endoscopy is the detection of early gastric cancers, although diagnosing small gastric cancers remains difficult. Narrow-band imaging with magnifying endoscopy （NBI-ME） is a recently developed advanced endoscopic imaging technology recommended for the accurate diagnosis of gastric cancer; however, reports of NBI-ME image analysis are still scarce. This study aimed to accurately diagnose early gastric cancers based on NBI-ME findings. We compared NBI-ME image differences between small early gastric cancers and gastric erosions using computerized image analysis. We retrospectively examined 94 lesions of early gastric cancers that were treated by endoscopic submucosal dissection （ESD） from January 2011 to March 2014 in our institution and 65 lesions of erosion diagnosed by biopsy as controls. We used “ProStudyⓇ＜Olympus＞” as the image analysis software and compared the differences. The microvascular pattern of early gastric cancers was characterized by a larger vascular area, a more complicated depiction region, more vascular endpoints and points of intersection, and greater length and size, compared to gastric erosions. We found no differences in vascular structure between the cancers and erosions by normal endoscopy. This finding confirms the superiority of image analysis in the diagnosis of early gastric cancer. NBI-ME image analysis is a promising approach for accurate and simple diagnosis of early gastric cancers

Perforation of the Papilla of Vater in Wire-Guided Cannulation

Background. WGC in ERCP is considered a safe technique, although rare complications can occur. One unique complication of WGC is the perforation of the papilla of Vater by the guidewire. Subjects and Methods. Of 2032 patients who underwent ERCP at our department between January 2010 and December 2014, we selected 208 patients who underwent WGC for naïve papilla as subjects. A detailed examination of patients in whom a perforation occurred was conducted, and risk factors for perforations were investigated. Results. The perforation was observed in 7 of 208 patients (3.4%). All patients recovered with conservative treatment without the need for surgery. The perforation rate was significantly higher in the patients with juxtapapillary duodenal diverticula than those without diverticula (12.5% versus 0.6%, p<0.001). Cannulation of the bile duct was ultimately achieved in 5 of 7 patients; PSP was performed for 4 of these patients. Conclusion. Caution must be exercised when dealing with patients who have a juxtapapillary duodenal diverticula because they are at higher risk of perforations. Because these are small perforations made by a wire, most of them heal with conservative treatment. However, perforations can make cannulation difficult, and PSP may be useful for deep cannulation

A Case of Krukenberg Tumor Metastasized from Colon Cancer Subsequent to Synchronous Multiple Liver Metastasis

A 34-year-old woman with synchronous, multiple liver metastases of stage IV, T4N2M0H2P0 descending colon cancer was referred to our hospital. The lesion was considered unresectable because of insufficient estimated future remnant liver volume resulting from invasion of three hepatic veins and the hepatic hilum, and she underwent laparoscopic left hemicolectomy. The patient underwent 14 courses of mFOLFOX6 (5-flurouracil, leucovorin and oxaliplatin) and 21 cetuximab administrations as first-line chemotherapy, which allowed her to maintain a complete response for 6 months despite adverse reactions such as mild neutropenia and thrombocytopenia. However, abdominal computed tomography (CT) revealed a large ovarian mass 6 months after chemotherapy cessation. A bilateral adnexectomy at another hospital revealed involvement of both ovaries, and immunohistochemistry revealed that the tumor was CK7− and CK20+, compatible with a colon cancer origin. The ovarian lesions were histologically diagnosed as Krukenberg tumor metastasized from the colon cancer. This case highlights the possibility of metastatic tumor development from colon cancer

A Case of Ileocecal IgG4-Related Sclerosing Mesenteritis Diagnosed by Endoscopic Ultrasound-Guided Fine Needle Aspiration using Forward-Viewing Linear Echoendoscope

A 25-year-old woman had undergone removal of a cryptogenic tumor in the left maxillary sinus 1 year prior to presentation. The patient experienced abdominal pain for 4 days with repeated vomiting episodes; therefore, she was transferred to our hospital by an ambulance. Contrast-enhanced computed tomography revealed a 3-cm tumor in the ileocecal region, which caused small bowel obstruction. Contrast imaging of the ileus tube showed extrinsic compression of the ileocecal region. Forward-viewing linear echoendoscope revealed an irregular hypoechoic tumor measuring 3 cm outside the gastrointestinal tract. Using a 25G needle, endoscopic ultrasound-guided fine needle aspiration (EUS–FNA) was performed. Pathological finding was an inflammatory fibrous tissue with diffuse lymphoplasmacytic infiltration, with more than 10 IgG4-positive cells detected in a high-power field. Re-examination of a pathology specimen of the maxillary sinus tumor provided by the previous attending physician revealed that the inflammatory tissue had diffuse lymphoplasmacytic infiltration, which were accompanied by storiform fibrosis and obliterative phlebitis. Immunostaining revealed more than 50 IgG4-positive cells in a high-power field, a finding suggestive of IgG4-related disease. The serum IgG4 level was 21 mg/dl, which was within the normal range. Treatment was initiated with prednisolone at a dose of 50 mg/day, and the dose was later tapered off. CT and MRI performed 2 months later showed complete disappearance of the ileocecal tumor. The final diagnosis was asynchronously occurring IgG4-related maxillary sinusitis and sclerosing mesenteritis