A Case of Acute Superior Mesenteric Artery Embolism with Severe Ischemic Liver Injury Successfully Treated by Endovascular Treatment

We describe an interesting clinical course of a patient who developed severe ischemic liver injury due to acute embolism of the superior mesenteric artery (SMA) and celiac artery. A 70-year-old man was hospitalized for abdominal pain and diarrhea. Abdominal computed tomography demonstrated a variant common hepatic artery arising from the SMA and multiple thromboembolic occlusions of visceral arteries, including the SMA and celiac artery. Laboratory data showed markedly elevated hepatic enzymes, which increased after admission despite the initiation of systemic anticoagulant and thrombolytic therapy. The patient was successfully treated by endovascular recanalization of the SMA occlusion via transcatheter embolus aspiration, thrombolysis, balloon angioplasty, and stent placement. Severe ischemic liver injury may occur in the setting of synchronous embolism of the SMA and celiac artery, and these phenomena may have a critical impact on the choice of treatment strategies and prognosis. Endovascular treatment appears to an effective treatment option

The role of Kyoto classification in the diagnosis of Helicobacter pylori infection and histologic gastritis among young subjects in Japan

　BACKGROUND AND AIM: Helicobacter pylori (H. pylori) infection induces inflammation of the gastric mucosa and leads to erosions, gastro-duodenal mucosa atrophy, and intestinal metaplasia. The Kyoto classification diagnoses H. pylori infection via endoscopic findings. We aimed to clarify the role of the Kyoto classification in diagnosing H. pylori infection and histologic gastritis in young Japanese individuals.　METHODS: From1031 consecutive subjects aged ≤29 years who underwent esophagogastroduodenal endoscopy at our two hospitals from 2010 to 2017, 220 were selected for participation in the present study. Endoscopic biopsy specimens from the antrum and corpus were used to investigate H. pylori infection and histology. Endoscopic and histological interpretations were based on the Kyoto classification and updated Sydney System. H. pylori infection was confirmed by histology and Giemsa or Gimenez staining.　RESULTS: Endoscopic findings were normal in 103 cases. Atrophy was found in 56 cases; diffuse redness, in 45 cases; nodularity, in 38 cases; and mucosal swelling, in 34 cases. The infection rate was 30.9% (68/220). In total, 67 subjects with H. pylori -positive endoscopic findings and confirmed as H. pylori -positive had histologic gastritis of the antrum and corpus. In contrast, of 153 subjects with H. pylori -negative endoscopic findings only 1 was subsequently confirmed to be H. pylori positive. Among the 67 subjects with H. pylori -positive endoscopic findings, 23 (34.3%) presented with histological atrophic gastritis of the corpus and 6 (9.0%) with intestinal metaplasia.　CONCLUSIONS: Our findings show that H. pylori infection is strongly associated with endoscopic and histologic gastritis in young subjects and both H. pylori infection and histologic gastritis can be evaluated endoscopically based on the Kyoto classification. Furthermore, prompt H. pylori eradication may prevent gastric cancer development given the high prevalence of atrophic gastritis and intestinal metaplasia in young Japanese individuals

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

A case of synchronous triple cancer of the esophagus, stomach, and colon detected by using gastrointestinal screening endoscopy

　In recent years, the detected number of multiple primary malignant tumors (MPMTs) in the gastrointestinal tract has been increasing with the advancement of gastrointestinal endoscopic equipment and the spread of endoscopic screening.　Here, we report a case of synchronous MPMTs of the esophagus, stomach, and colon detected by means of gastrointestinal screening endoscopy. The patient was a 67-year-old man who regularly visited the medical clinic for hypertension. He had a history of alcohol consumption (sake index: 250, with alcohol flushing syndrome) and smoking (Brinkman index: 800), and a family history of cancer (his father had gastric cancer).　At the medical clinic, he underwent gastrointestinal endoscopy for screening purposes. Prior observation with linked-color imaging (LCI), a type of image-enhanced endoscopy (IEE), revealed an irregular depressed lesion in the mid-esophagus. Simultaneously, an irregular, highly deformed depressed lesion and a small depressed lesion were detected on the incisura of the lesser curvature and the lesser curvature of the antrum, respectively. The esophageal lesion was identified as squamous cell carcinoma and both gastric lesions were identified as well-differentiated adenocarcinoma.　The patient was referred to our hospital for further examination and treatment for esophageal and gastric cancer. Subsequent colonoscopy revealed a well-defined, ulcerative tumor in the transverse colon. First, endoscopic submucosal dissection was performed for the esophageal lesion, followed by laparoscopy-assisted distal gastrectomy with D1+ lymph-node dissection and transverse colectomy with D2 lymph-node dissection for the gastric and colorectal lesions, respectively. Histopathologically, the main gastric and colonic tumors were in advanced stages; fortunately, the esophageal cancer was an early-stage lesion (7 × 5 mm, 0-IIc, pT1a-LPM, INFa, ly0, v0, pCurA), which has a much better prognosis than advanced esophageal cancer.　In patients with multiple cancer risk factors (alcohol consumption, smoking, and family history), it is important to consider the possibility of MPMTs. Furthermore, upper gastrointestinal observation combined with IEE, such as LCI, may be useful in the early detection of lesions

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