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

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

ナマ シラス ノ セイ ショク ニヨル カンセン ガ ウタガワレタ クジラ フクショクモンジョウチュウ ショウ ノ 1レイ

埼玉県在住の男性・64 歳.2012 年11 月初旬,近医で日本海裂頭条虫症の診断を受け,駆虫目的で本院消化器内科を紹介受診.外来で駆虫治療したところ,全長約250 cm の白色紐状で,全体的に肉厚感のある虫体を排出した.虫体は形態学的特徴より日本海裂頭条虫ではなく,クジラ複殖門条虫が強く疑われたため,遺伝子解析を行った.PCR によって増幅されたcytochrome c oxidase subunit 1 遺伝子(cox1)の全長塩基配列を解析したところ,既知のクジラ複殖門条虫の塩基配列と99%の相同性を示したことから,本症例はクジラ複殖門条虫症と確定した.該当患者は,便に白色紐状物が混入する2&#12316;3 か月前に,生シラスを生食しており,これが感染源となった可能性が高いと考えられた.We have reported a case of infection with whale tapeworm,Diplogonoporus balaenopterae, in Dokkyo MedicalUniversity Hospital. The patient, a 64-year-old Japanesemale, living in Saitama Prefecture was admitted to our hospitalon Nov. 1st 2012, owing to pieces of tapeworm beingdischarged. He was treated with Biltricide&reg; (20 mg/kg)and Magcorol P&reg;( 100 g) in the hospital and he expelled atapeworm about 250 cm, in length along with the scolex afterabout 2 hours of treatment. Based on the morphologicalfeatures of the strobila and the scolex we strongly suspectedthat the tapeworm belongs to the genus Diplogonoporus.To identify the species of the discharged tapeworm, thecomplete cox1 gene was amplified by PCR and the nucleotidesequence was analyzed. The sequence showed 99 %homology against those from D. balaenopterae. From theseresults the patient was diagnosed as a diplogonoporiasiscaused by D. balaenopterae, whale tapeworm. We could notfind any proglottides of tapeworm nor eggs in stools whenwe performed follow up medical examinations three monthsafter treatment. Therefore it can be concluded that the patientwas cured of this disease. In most cases the infectionsource of the whale tapeworm to humans is reported ascoming from marine fish such as sardines and bonitos. Thepatient had frequently consumed various kinds of raw marinefish, and we suspect that the infection source can beattributed to eating raw whitebait

ケイカチュウ ニ オウショク シュヨウ ケイタイ オ テイシタ ソウキ イガン ノ イチレイ

症例は63歳の男性,既往歴に30歳時胃潰瘍にて胃切除(Billroth II法), 60歳時肺癌で右肺下葉切除(低分化扁平上皮癌)がある.現病歴は右肺癌手術後の経過観察中にCEAの上昇を認め消化管精査を目的に当科紹介となった. 2001年5月の上部消化管内視鏡検査では胃噴門部後壁に白苔を有する隆起を認め,生検ではGroup IIIであった.以後経過観察となったが, 2003年5月には黄白色調の扁平隆起を呈し黄色腫類似の形態を呈し,生検ではGroup IVであった. 7月Group Vであり, 10月内視鏡的粘膜切除術が施行され病変は完全切除された.病理診断では管状腺癌であった.本症例は経過中に病巣表面が黄色腫類似の所見を呈した稀な症例であった.A 63-year-old man, who received gastrectomy for a peptic ulcer at 30 year-old and received pneumoresection for his undifferentiated squamous cell carcinoma of the lung at 60 years-old, was inspected by postoperative follow-up study. In May 2001, serum carcinoembryonic antigen level exceeded 5ng/ml, and he was referred to our department for endoscopic examinations. Endoscopic examination revealed a flat elevated lesion whose surface was covered with dense exudate on the posterior wall of the cardiac region, and the histopathological diagnosis was tubular adenoma. In May 2003, the flat elevated lesion was accompanied by yellow-whitish spots and endoscopically diagnosed as xanthoma, while the biopsy specimen from the elevated lesion demonstrated tubular ade noma with severe atypia. In October 2003, endoscopic mucosal resection was successfully completed for the lesion, and it was diagnosed as well differentiated adenocarcinoma. We consider that a gastric elevated lesion should be carefully followed when tubular adenoma is detected, even if endoscopically looks like benign xanthoma

ホゾンテキ ニ チリョウ シエタ モンミャク ケッセン オ ガッペイ スル ジョウチョウカン マク ジョウミャク ケッセンショウ ノ 1レイ

症例は47歳の男性. 40℃の発熱と頭痛が出現し近医を受診.一時症状は軽快したが,再び発熱が出現し前医入院となった.入院後の腹部CT検査及び腹部超音波検査により上腸間膜静脈血栓症と診断され,精査加療を目的に当院に転院となった.厳重な経過観察の下に抗菌薬投与と抗血栓および抗凝固療法による保存的治療を行い,これにより第4病日には症状の改善が得られた.本症例は後にプロテインC欠乏症と診断され,感染と脱水が影響して門脈血栓に及ぶ上腸間膜静脈血栓症が引き起こされたものと考えられた.今回我々は保存的に治療しえた門脈血栓を合併する上腸間膜静脈血栓症の一例を経験したので報告した.The patient was a 47-year-old male who had presented with a fever of 40℃ and headaches. He was treated by antibiotics at a local hospital under the diagnosis of the common cold. But progress of symptoms was temporary, so he was admitted to the hospital. Based on the findings of an abdominal CT and US after the admission, he was diagnosed as superior mesenteric vein thrombosis (SMVT) and transferred to our hospital on the 25th day of his illness. Antibiotics, together with antithrombotics and anticoagulant agents, were carefully administered as the treatment. As a result, symptoms were improved on the fourth day of admission to our hospital. This case was detected later to be associated with protein C deficiency. We speculated that portal vein thrombosis complicated with SMVT had occurred following infection and dehydration. We reported a case of SMVT with portal vein thrombosis, which was effectually treated with conservative therapy