膵頭十二指腸切除術9年後に生じた肝炎症性偽腫瘍の1例

今回われわれは,悪性腫瘍術後で転移性肝腫瘍が疑われたが,経皮的針肝生検により肝炎症性偽腫瘍と診断し得た症例を経験した.症例は67歳の男性.十二指腸乳頭部癌に対する膵頭十二指腸切除術の既往がある.糖尿病のために当院の内科に入院し,腹部超音波検査で肝腫瘍が指摘された.発熱はないが,炎症所見と胆道系酵素の上昇を認めた.腫瘍マーカーは正常値であった.種々の画像検査で転移性肝腫瘍が疑われたが確定診断は得られなかった.そこで経皮的針肝生検を行い,組織学的に炎症性肉芽組織と判断され,肝炎症性偽腫瘍と診断した.肝炎症性偽腫瘍は炎症性細胞の浸潤と線雄性組織の増生による腫瘤が肝に形成される疾患である.その発生要因は不明であるが感染が有力視され,慢性肝膿瘍と同一疾患と考えられている.自験例は,組織学的所見より膵頭十二指腸切除術後の晩期合併症としての胆管炎から肝膿瘍が形成され,それが瘢痕化したものと推察した.The patient was a 67 year-old man who had undergone pancreaticoduodenectomy for duodenal papillary cancer. He was admitted to the Department of Medicine for the treatment of diabetes mellitus and a liver tumor was found by abdominal ultrasonography. Although the patient did not have fever, elevated inflammatory markers and biliary enzymes were observed, while tumor markers were normal. Various imaging studies suggested a metastatic liver tumor, but a definitive diagnosis was not possible. Therefore, percutaneous needle liver biopsywas performed and a diagnosis of inflammatory pseudotumor of the liver was made. Inflammatory pseudotumorof the liver is a hepatic mass formed by the infiltration of inflammatory cells and the proliferation of fibrous tissue. From the histological findings, this patient was concluded to have a resolving liver abscess that had formed due to cholangitis as a late complication of pancreaticoduodenectomy

Ultrathin versus pediatric instruments for colonoscopy in older female patients: a randomized trial

Background and Aim: Small-caliber endoscopes such as gastroscopes or pediatric colonoscopes are occasionally required to negotiate fixed or angulated colons. However, the use of a new ultrathin instrument (diameter 7.0 mm) narrower than other conventional colonoscopes has not been evaluated. The aim of the present study was to compare the use compare the use of an ultrathin colonoscope (UTC) with a pediatric colonoscope (PDC) for colonoscopy in older female patients. Methods: A prospective, randomized, controlled trial was conducted in a single academic endoscopy unit. A total of 77 female patients aged ≥70 years undergoing unsedated colonoscopy were randomized to colonoscopy with a UTC (n = 39) or PDC (n = 38). Primary outcome measurement was the degree of pain using a numerical rating scale, and secondary outcomes were cecal intubation rate, ileal intubation rate, time to cecum and adenoma detection rate. Results: There was a significant difference in reported pain using the numerical rating scale (median, UTC 1 vs PDC 4, P < 0.0001). Cecal intubation rates were 97.4% in UTC and 92.1% in PDC (P = 0.36), and ileal intubation rates were 82.0% and 89.4% (P = 0.76), respectively. However, median times to cecum were significantly longer using UTC compared with PDC (15.2 min vs 11.1 min, P = 0.022). Adenoma detection rates were 30.7% in UTC and 26.3% in PDC (P = 0.80). Conclusions: Colonoscopy using UTC was almost equivalent to that of PDC in older female patients, with significantly less pain compared with PDC. UTC may be an alternative to PDC for the difficult colon

Double-balloon colonoscopy carried out by a trainee after incomplete conventional colonoscopy

Background and Aim It has been reported that double-balloon colonoscopy (DBC) is useful for patients after failed colonoscopy. In most cases previously reported, expert colonoscopists have carried out DBC. However, DBC may not require significant expertise. The objective of the present study is to assess DBC carried out by an inexperienced colonoscopist in patients referred after previously incomplete colonoscopy. Methods In a single center between June 2011 and September 2012, we enrolled 28 consecutive patients referred following incomplete conventional colonoscopy. The reported reasons for previous failed colonoscopy were severe pain during the procedure in 15, long redundant colon in 13 and sigmoid fixation in eight. Under instruction by an experienced colonoscopist, all procedures were carried out by a gastroenterology trainee with little colonoscopy experience. A double-balloon instrument with carbon dioxide insufflation was used under fluoroscopicguidance, with i.v. sedation. Cecal intubation rate, time to cecum and patient-reported pain using a visual analog scale (0 to 10) were evaluated. Results The trainee achieved a cecal intubation in all patients (100%) without primary involvement by the experienced colonoscopist. Time to cecum ranged from 6min to 66min (median time to cecum 15min 55s). No patients required additional sedation. Visual analogue pain scores ranged from 0/10 to 10/10 (median score 2.5/10). There were no complications. Conclusion DBC may enable inexperienced colonoscopists to achieve total colonoscopy after previously incomplete conventional colonoscopy

Morphometric study of the blood supply of pedunculated colon polyps: What is the optimal position on the stalk for snare resection?

Background and study aims: Bleeding after colonoscopic resection of pedunculated polyps cannot be easily predicted. The aims of this study were to evaluate the blood supply in pedunculated polyps and to clarify the optimal position on the polyp stalk for snare placement to prevent post-polypectomy hemorrhage

Blue laser imaging endoscopy system for the early detection and characterization of colorectal lesions: a guide for the endoscopist

Blue laser imaging is a new system for image-enhanced endoscopy using laser light. Blue laser imaging utilizes two monochromatic lasers (410 and 450 nm) instead of xenon light. A 410 nm laser visualizes vascular microarchitecture, similar to narrow band imaging, and a 450 nm laser provides white light by excitation. According to three recently published reports, the diagnostic ability of polyp characterization using blue laser imaging compares favorably with narrow band imaging. No published data are available to date regarding polyp detection with blue laser imaging. However, blue laser imaging has the possibility to increase the detection of colorectal polyps by depicting brighter and clearer endoscopic images, even at a distant view, compared with first-generation image-enhanced endoscopy. A clinical trial to compare the detection between blue laser imaging and xenon light is warranted