Results of the interim analysis of a prospective, multicenter, observational study of small subepithelial lesions in the stomach

OBJECTIVES

Long-term outcomes of gastric subepithelial lesions have not been elucidated. To reveal the natural history, we initiated a prospective, 10-year follow-up of patients with small (≤20 mm) gastric subepithelial lesions in September 2014. Here, we report the results of an interim analysis of a prospective observational study.

METHODS

In total, 567 patients with 610 lesions were prospectively registered between September 2014 and August 2016. The location, size, morphology, and number of subepithelial lesions were recorded on a web-based case report form. This study has been conducted as an Academic Committee Working Group of the Japan Gastroenterological Endoscopy Society.

RESULTS

The endoscopic follow-up period was 4.60 ± 1.73 years (mean ± standard deviation), and survival data were investigated for 5.28 ± 1.68 years. This interim analysis revealed that the estimated cumulative incidence of a size increase ≥5 mm, after accounting for patients' death and resection of the tumor as competing risk events, was 4.5% at 5 years. In addition, the estimated cumulative incidence of lesion size increase ≥5 mm or resection of lesions was 7.9% at 5 years, and that of size increase ≥10 mm or resection of lesions was 4.5% at 5 years.

CONCLUSION

These results indicate that approximately one in 13 patients with small (≤20 mm) gastric subepithelial lesions may require resection or further investigation for increased tumor size (≥5 mm) within 5 years.

Endoscopic evaluation by the Kyoto classification of gastritis combined with serum anti-Helicobacter pylori antibody testing reliably risk-stratifies subjects in a population-based gastric cancer screening program

BACKGROUND

We previously demonstrated that the Kyoto classification of gastritis was useful for judging the status of Helicobacter pylori infection in a population-based screening program, and that adding H. pylori antibody test improved its accuracy (UMIN000028629). Here, we tested whether our endoscopic diagnosis of H. pylori infection status reliably estimated gastric cancer risk in the program.

METHODS

Data were collected from1345 subjects who underwent endoscopic follow-up 4 years after the end of the registration. We analyzed the association of three diagnostic methods of H. pylori infection with gastric cancer detection: (1) endoscopic diagnosis based on the Kyoto classification of gastritis; (2) serum diagnosis according to the ABC method (H. pylori antibody and pepsinogen I and II); and (3) endoscopic diagnosis together with H. pylori antibody test.

RESULTS

During the follow-up, 19 cases of gastric cancer were detected. By Kaplan-Meier analysis, the detection rates of cancer were significantly higher in the past or current H. pylori infection groups than in the never-infected group with all 3 methods. By the Cox proportional hazards model, the hazard ratio for cancer detection was highest in evaluation with the combined endoscopic diagnosis and the antibody test (method 3; hazard ratio 22.6, 95% confidence interval 2.99-171) among the three methods (the endoscopic diagnosis (method 1); 11.3, 2.58-49.8, and the ABC method (method 2); 7.52, 2.49-22.7).

CONCLUSIONS

Endoscopic evaluation of H. pylori status with the Kyoto classification of gastritis, especially combined with serum anti-Helicobacter pylori antibody testing, reliably risk-stratified subjects in a population-based gastric cancer screening program.

Real-world efficacy of antibiotic prophylaxis for upper gastrointestinal bleeding in cirrhotic patients in Japan

BACKGROUND AND AIMS

Antibiotic prophylaxis is recommended for cirrhotic patients with upper gastrointestinal bleeding (UGIB). However, the frequency of bacterial infection in such patients has remarkably decreased over the decades, which has reduced the necessity for prophylaxis. Therefore, here we investigated the real-world adherence and effectiveness of antibiotic prophylaxis in cirrhotic patients with UGIB in Japan.

METHODS

This population-based study was conducted with a Japanese real-world database of the Health, Clinic, and Education Information Evaluation Institute. We enrolled cirrhotic patients who were hospitalized for UGIB between April 2010 and March 2020. After those who died within 24 h and who had aspiration pneumonia at admission were excluded, 1232 patients were analyzed. Rates of 6-week mortality, in-hospital bacterial infection, 30-day readmission, and length of hospital stay were evaluated.

RESULTS

Prophylactic antibiotics were prescribed in 142 (11.5%) patients. Multivariate analysis revealed that antibiotic prophylaxis was not significantly associated with either 6-week mortality or bacterial infection. After propensity score matching, the rates of 6-week mortality (7.2% vs. 8.4%, P = 0.810), bacterial infection (9.6% vs. 4.2%, P = 0.082), and 30-day unexpected readmission (7.2% vs. 7.8%, P = 1.000) were similar in patients with and without prophylaxis, whereas the median length of hospital stay was significantly longer in patients with prophylaxis (17 days vs. 13 days, P = 0.013).

CONCLUSIONS

Under current real-world circumstances in Japan, prophylactic antibiotics were prescribed in only 11.5% of cirrhotic patients with UGIB and were not associated with better clinical outcomes.

Long-term outcomes of patients with primary intestinal follicular lymphoma managed with watch-and-wait strategy

Patients with primary intestinal follicular lymphoma are often followed-up without a specific treatment, and this approach is called the "watch-and-wait approach." However, the long-term outcomes of this patient group have not been sufficiently investigated. We enrolled patients with primary intestinal follicular lymphoma who were diagnosed before 2016 and managed with the watch-and-wait approach in 20 institutions. We retrospectively investigated the overall, disease-specific, and event-free survival rates as well as the rate of spontaneous regression. Among the 248 patients with follicular lymphoma with gastrointestinal involvement, 124 had localized disease (stage I or II₁). We analyzed the data of 73 patients who were managed using the watch-and-wait approach. During the mean follow-up period of 8.3 years, the follicular lymphoma had spontaneously resolved in 16.4% of the patients. The 5-year and 10-year overall survival rates were 92.9% and 87.1%, respectively. With disease progression (n = 7), initiation of therapy (n = 7), and histologic transformation to aggressive lymphoma (n = 0) defined as events, the 5-year and 10-year event-free survival rates were 91.1% and 86.9%, respectively. No patient died of progressive lymphoma. Thus, both 5-year and 10-year disease-specific survival rates were 100%. In conclusion, an indolent long-term clinical course was confirmed in the patients with primary intestinal follicular lymphoma. The watch-and-wait strategy is a reasonable approach for the initial management of these patients.

Erratum: Prospective multicenter study of the efficacy and safety of cold forceps polypectomy for ≤ 6-mm non-ampullary duodenal low-grade adenomas

[This corrects the article DOI: 10.1055/a-1793-9439.].

Endoscopic features of oxyntic gland adenoma and gastric adenocarcinoma of the fundic gland type differ between patients with and without Helicobacter pylori infection: a retrospective observational study

BACKGROUND

The endoscopic features of oxyntic gland adenoma and gastric adenocarcinoma of the fundic gland type have not been fully investigated in relation to Helicobacter pylori infection status. We compared the morphology, color, and location of these lesions between patients with and without H. pylori infection.

METHODS

We retrospectively enrolled 165 patients (180 lesions) from 10 institutions. We divided the patients into the (i) Hp group (patients with current H. pylori infection [active gastritis, n = 13] and those with past infection [inactive gastritis, n = 76]) and (ii) uninfected group (H. pylori-uninfected patients, n = 52). We compared the clinical and endoscopic features of the two groups. We also performed an analysis between (i) lesions with atrophy of the surrounding gastric mucosa (atrophy group) and (ii) lesions without atrophy of the surrounding gastric mucosa (non-atrophy group).

RESULTS

The average age was older in the Hp group than in the uninfected group (68.1 ± 8.1 vs. 63.4 ± 8.7 years, p < 0.01). Although the difference was not statistically significant (p = 0.09), multiple lesions were observed in 9 of 89 patients (10.1%) in the Hp group and in only 1 of 52 patients (1.9%) in the uninfected group. Meanwhile, significant differences were observed in the prevalence of lesions located in the gastric fornix or cardia (uninfected group: 67.3% vs. Hp group: 38.0%, p < 0.01), with an elevated morphology (80.0% vs. 56.0%, p < 0.01), with a subepithelial-like appearance (78.2% vs. 42.0%, p < 0.01), and with a color similar to that of the peripheral mucosa (43.6% vs. 25.0%, p = 0.02). The male-to-female ratio, lesion size, and presence or absence of vascular dilatation or black pigmentation on the surface were not different between the two groups. In the analysis comparing lesions with and without mucosal atrophy, the prevalence of multiple lesions was significantly higher (p = 0.02) in the atrophy group (5/25 patients, 20.0%) than in the non-atrophy group (7/141 patients, 5.0%).

CONCLUSIONS

The endoscopic features of oxyntic gland adenoma and gastric adenocarcinoma of the fundic gland type differ between patients with and without H. pylori infection.

Prospective multicenter study of the efficacy and safety of cold forceps polypectomy for ≤ 6-mm non-ampullary duodenal low-grade adenomas

Background and study aims  Because the endoscopic treatment for non-ampullary duodenal adenoma (NADA) has a non-negligible risk of adverse events (AEs), a safe and easy treatment for NADA is desirable. This was a multicenter prospective trial evaluating the efficacy and safety of cold forceps polypectomy (CFP) for diminutive NADAs. Patients and methods  This study was prospectively conducted at six general hospitals and one university hospital. The inclusion criteria were histologic and endoscopic diagnosis of low-grade NADA measuring ≤ 6 mm. A second endoscopy was scheduled for 1 month after CFP. After confirmation of the success of CFP, 6-month and 12-month surveillance endoscopies were scheduled. The primary endpoint was the endoscopic and histologic disease disappearance rates at the 12-month endoscopy. Results  Thirty-nine lesions from 38 patients were prospectively included. Median tumor size at enrollment was 5 mm (range 3-6 mm). There were four cases of remnant lesions at the second endoscopy, and the lesion disappearance rate of single CFP was 89.7 % (35 /39; 95 % confidence interval (CI), 76.9 %-97.9 %). In three cases, complete removal of the lesion was achieved with a single re-CFP, but one case required four repeat CFPs. The lesion disappearance rate at 12-month endoscopy was 97.4 % (38 /39; 95 %CI, 86.8 %-99.5 %). During the follow-up period, no AEs related to CFP were observed. Conclusions  CFP for NADA ≤ 6 mm was safe and effective in this study. This common endoscopic method to remove lesions may be an option for treatment of diminutive NADAs.

Nonrecurrence Rate of Underwater EMR for ≤20-mm Nonampullary Duodenal Adenomas: A Multicenter Prospective Study (D-UEMR Study)

BACKGROUND AND AIMS

Endoscopic resection of nonampullary duodenal adenoma is often challenging, and its technique has not yet been standardized. To overcome the practical difficulty of conventional endoscopic mucosal resection, underwater endoscopic mucosal resection (UEMR) was recently developed; therefore, we investigated the effectiveness and safety of UEMR for nonampullary duodenal adenoma.

METHODS

A multicenter, prospective cohort study was conducted at 21 institutions in Japan. We enrolled patients with no more than 2 nonampullary duodenal adenomas ≤20 mm in size, who were planned to undergo UEMR. After UEMR, follow-up endoscopies were scheduled at 2 and 12 months after the procedure, and biopsy specimens were taken from the post-UEMR scars. The primary endpoint was the proportion of patients with histologically proven nonrecurrence at follow-up endoscopy and biopsy.

RESULTS

A total of 155 patients with 166 lesions underwent UEMR. One patient with a non-neoplastic lesion in the resected specimen and 10 patients with 10 lesions who were lost to follow-up were excluded. Finally, 144 patients with 155 lesions who received all follow-up endoscopies were analyzed for the primary endpoint. The proportion of patients with proven nonrecurrence was 97.2% (n = 140 of 144; 95% confidence interval, 92.8%-99.1%) which exceeded the predefined threshold value (92%). Two cases of delayed bleeding (1.2%) occurred and they were successfully managed by clips. All recurrences were successfully treated by additional endoscopic treatment.

CONCLUSIONS

This multicenter, prospective cohort study demonstrated effectiveness and safety of UEMR for nonampullary duodenal adenomas ≤20 mm in size. (University Hospital Medical Network Clinical Trials Registry, Number: UMIN000030414).

Epidemiological Review of Gastroesophageal Junction Adenocarcinoma in Asian Countries

BACKGROUND

Similar trends in the prevalence of gastroesophageal reflux disease (GERD), obesity, and Helicobacter pylori infection have been observed in Asian and Western countries despite their time differences. However, it is unclear whether the prevalence of gastroesophageal junction adenocarcinomas in Asian countries is increasing. In this review, we discuss the epidemiological trends of gastroesophageal junction adenocarcinoma in Asian countries.

SUMMARY

The prevalence of GERD is increasing in Asian countries, but most cases are considered mild. Obesity is a serious problem worldwide, but it is considered less serious in Asia than in Western countries. In Asian countries where gastric cancer is common, both cardiac and noncardiac cancers are associated with high rates of H. pylori infection, which is considered a carcinogenic risk factor for both sites of cancer. The widespread use of H. pylori eradication therapy for chronic gastritis in several Asian countries has not directly led to an increased prevalence of esophageal adenocarcinoma. One of the originating sites of junctional adenocarcinoma in most Asian countries is Barrett's esophagus, with short-segment Barrett's esophagus having much lower carcinogenicity than long-segment Barrett's esophagus. Key Messages: Considering the future trends of several risk factors for gastroesophageal junction adenocarcinoma in Asian countries, it is likely that the incidence of gastroesophageal junction adenocarcinoma will gradually increase, but not at a rate that exceeds that of squamous cell carcinoma, as in Western countries.

Clinical characteristics and course of sporadic non-ampullary duodenal adenomas: A multicenter retrospective study

Sporadic non-ampullary duodenal adenoma (SNADA) is a rare disease, and therefore, its clinical characteristics have not been comprehensively investigated. Furthermore, owing to the high complication rates and severity of endoscopic resection, treatment strategies vary among facilities. In the present study, we aimed to clarify the clinical characteristics and course of SNADA.We extracted clinical and histological records of SNADA cases diagnosed in 11 hospitals between September 1999 and August 2014. The patients were divided into "no-resection" and "resection" groups based on the initial treatment approach. We investigated the long-term outcome of the "no-resection" group and treatment results of the "resection" group, with particular interest in endoscopic resection.Overall, 299 patients were diagnosed with SNADA. The median age at diagnosis was 67 years (range, 31-88 years), with approximately twice as many men as women. The median tumor size was 8.0 mm (2-60 mm). In total, 161 patients were initially selected for no-resection and 138 underwent resection. Age >70 years and the presence of either severe illness or poor performance status were significantly related to opting for no-resection. In the no-resection group, 101 patients underwent endoscopic follow-up for at least 1 year. During the observational period (2.5 ± 2.2 years), 27 lesions (27%) disappeared following cold forceps biopsy, and 13 lesions (14%) presented lateral growth. Four lesions (4%) changed to mucosal carcinoma, 3 were treated endoscopically, and 1 was surgically resected. Nineteen patients died; however, no one died of duodenal carcinoma. In the endoscopic resection group, en bloc resection was achieved in 78% of patients. However, the complication rate for perforation was 7%, and endoscopic submucosal dissection was associated with a 36% perforation rate.With the low incidence of cancer development and no disease specific death, the strategy of initially not performing resection could be considered especially for the older adults, poor-prognosis patients, or small lesions.

Two Types of Polyp Shape Observed in the Stomach of Patients with Peutz-Jeghers Syndrome

The characteristics of gastric polyps in patients with Peutz-Jeghers (PJ) syndrome (PJS) have not been fully investigated. The objective of this study was to reveal the endoscopic and pathologic findings of gastric polyps in patients with PJS. We reviewed 11 patients with PJS treated at 6 institutions, and summarized the endo-scopic and pathologic features of their gastric polyps. The polyps were mainly classified into 2 types: (i) soli-tary or sporadic polyps > 5 mm, reddish in color with a sessile or semi-pedunculated morphology (n = 9); and (ii) multiple sessile polyps ≤ 5 mm with the same color tone as the peripheral mucosa (n = 9). Patients who underwent endoscopic mucosal resection for polyps > 5 mm were diagnosed with PJ polyps (n = 2), whereas those who underwent biopsy were diagnosed with hyperplastic polyps. Polyps ≤ 5 mm were pathologically diagnosed as fundic gland polyps or hyperplastic polyps. This study revealed that patients with PJS present with 2 types of polyps in the stomach. Endoscopic mucosal resection of polyps > 5 mm seems necessary for the pathologic diagnosis of PJ polyps.

Feasibility of endoscopic evaluation of Helicobacter pylori infection status by using the Kyoto classification of gastritis in the population-based gastric cancer screening program: A prospective cohort study

BACKGROUND AND AIMS

We have started a new population-based endoscopic gastric cancer screening program in Kurashiki city with consideration of Helicobacter pylori infection status based on endoscopic features. We aimed to verify the feasibility of this attempt in a prospective case-registration study (UMIN000028629).

METHODS

Data were collected from 1784 subjects without past eradication of H. pylori and who underwent endoscopic gastric cancer screening in Kurashiki Central Hospital Preventive Healthcare Plaza from September 2017 to June 2018. Endoscopic judgment of H. pylori infection status was made according to the Kyoto classification of gastritis. For comparison, a combination serum test of anti-H. pylori antibody and pepsinogen I and II, the ABC method, was used.

RESULTS

The endoscopic diagnoses were nongastritis, 1215 (68.1%); active or inactive gastritis, 469 (26.3%); and undefined, 23 (1.3%). With the ABC method as a reference standard, the false-negative rate of the endoscopic judgment for H. pylori infection was 16.3% (95% confidence interval: 13.1%-20.0%). Most false-negative cases were of Group B in the ABC method, which is considered gastritis with mild mucosal atrophy. Antibody titers in this population were mostly in the weak-positive range but clinically significant elevation of the antibody suggesting current infection was observed in some cases.

CONCLUSIONS

Endoscopic diagnosis of H. pylori infection status in a population-based gastric cancer screening program is mostly reliable, but false-negative results may occur, especially in patients with mild gastric atrophy. To avoid this limitation, we recommend adding H. pylori antibody test to the program.

Clinical and phenotypical characteristics of submucosal invasive carcinoma in non-ampullary duodenal cancer

Objective

The rare incidence of submucosal invasive non-ampullary duodenal carcinoma has led to scant information in literature; therefore, we compared the clinicopathological features between submucosal invasive carcinoma (SM-Ca), mucosal carcinoma (M-Ca), and advanced carcinoma (Ad-Ca).

Materials

We retrospectively analyzed 165 patients with sporadic non-ampullary duodenal carcinomas (SNADCs) from four institutions between January 2003 and December 2018. The SNADCs were divided to three groups according to histological diagnosis: SM-Ca, M-Ca, and Ad-Ca. The clinicopathological characteristics and mucin phenotypes were compared between groups.

Results

Among the 165 SNADCs, 11 (7%) were classified as SM-Ca, 70 (42%) as M-Ca, and 84 (51%) as Ad-Ca. We found that all SM-Ca (P = 0.013) and most Ad-Ca (P = 0.020) lesions were located on the oral-Vater; however, an almost equal distribution of M-Ca lesions was found between the oral- and anal-Vater. No significant difference was observed between the tumor diameter of M-Ca and SM-Ca; however, 45% (5/11) of SM-Ca were ≤10 mm. A total of 73% (8/11) of SM-Ca were classified as gastric phenotype and no lesions were classified as intestinal phenotype; whereas most M-Ca were classified as intestinal phenotype (67%, 8/12).

Conclusions

SM-Ca lesions were all located on the oral-Vater and were highly associated with the gastric mucin phenotype, which were different from the features of most M-Ca.

Efficacy and safety of cold forceps biopsy for diminutive pharyngeal neoplasms: Single-center, prospective pilot study

BACKGROUND

Management of diminutive pharyngeal neoplasms is controversial. Thus, we conducted a single-center, prospective pilot study to investigate the efficacy and safety of endoscopic excision with cold forceps biopsy (CFB) of these lesions.

PATIENTS AND METHODS

Thirty-nine lesions endoscopically diagnosed with narrow-band imaging as pharyngeal neoplasms of 3 mm or smaller were excised with CFB using jumbo biopsy forceps (cap diameter 2.8 mm, jaw volume 12.4 mm³ ). The primary outcome was endoscopically determined local remnant/recurrence rate 3 months after CFB. The secondary outcomes were histopathologically determined local remnant/recurrence rate; risk factors associated with the endoscopic remnant/recurrence; and incidence of intraoperative or delayed bleeding and other adverse events.

RESULTS

Histological diagnosis of the 39 CFB-excised lesions were: 11 high-grade dysplasia (28.2%), 22 low-grade dysplasia (56.4%), two basal cell hyperplasia (5.1%) and four atypical squamous epithelium (10.3%).Twenty-seven patients (30 lesions) underwent follow-up endoscopy 3 months after CFB; the endoscopic and pathological local remnant/recurrence rate was 20% (6/30; 95% confidence interval (CI), 7.7-36.6%) and 16.7% (5/30; 95% CI, 5.6-34.7%), respectively. Location of the lesion in the hypopharynx was a significant risk factor associated with the endoscopic local remnant/recurrence (P = 0.049). No significant adverse events occurred.

CONCLUSIONS

Cold forceps biopsy with jumbo biopsy forceps appears to be a safe and effective technique for excising diminutive pharyngeal neoplasms. Although small, the excised lesions may have a remarkably high frequency of high-grade dysplasia. (Clinical trial registration number: UMIN000037980).

Endoscopic resection is a suitable initial treatment strategy for oxyntic gland adenoma or gastric adenocarcinoma of the fundic gland type

The aim of this study was to reveal the histological features of oxyntic gland adenomas and gastric adenocarcinoma of the fundic-gland type (GA-FG). We retrospectively examined the histological features of 126 lesions of oxyntic gland adenoma and/or GA-FG in 116 patients. The prevalence of oxyntic gland adenomas and GA-FG was approximately equal. The majority of the lesions were resected by endoscopic mucosal resection using a diathermic snare (EMR, n = 42) or endoscopic submucosal dissection (ESD, n = 72). Histologically, there were no lesions with invasion at the level of the muscularis propria or deeper, and lymphovascular invasion was present in 1.6%. Of the ESD and EMR specimens, there were no lesions that were positive for vertical margins. Among the eight GA-FG patients with deep (≥ 500 μm) submucosal invasion, six were treated with endoscopic resection alone, and no recurrence was documented. No patients died of the disease during the median follow-up period of 14.5 months. In conclusion, all lesions were confined to the mucosa or submucosa and were negative for vertical margins. Lymphovascular invasion was present in only 1.6% of the patients. Thus, we believe that endoscopic resection is a suitable initial treatment method for oxyntic gland adenoma and GA-FG.

Multicenter survey on mesalamine intolerance in patients with ulcerative colitis

BACKGROUND AND AIM

Although oral mesalamine is the first-choice drug for treating mild-to-moderate ulcerative colitis (UC), some patients show symptoms of intolerance, including exacerbation of diarrhea and abdominal pain. The present study clarified the current state and clinical courses of patients with mesalamine intolerance.

METHODS

Patients who were diagnosed with UC and administered oral mesalamine at eight hospitals in Japan with a follow-up period exceeding 1 year were analyzed.

RESULTS

Sixty-seven (11%) of 633 patients showed intolerance to at least one formulation of oral mesalamine. The frequency of mesalamine intolerance has increased in recent years, rising from 5.3% in 2007-2010 to 9.1% in 2011-2013 and 16.2% in 2014-2016. The most common complications were the exacerbation of diarrhea (n = 29), a fever (n = 25), and abdominal pain (n = 22). Readministration of mesalamine/sulfasalazine was attempted in 43 patients, mostly with other types of formulation of mesalamine, and more than half of these patients proved to be tolerant. The risk factors for mesalamine intolerance were female gender (odds ratio [OR] = 1.83; 95% confidence interval [CI], 1.08-3.12), age < 60 years old (OR = 2.82; CI, 1.19-8.33), and pancolitis (OR = 2.09; 95% CI, 1.23-3.60). There were no significant differences in the use of anti-tumor necrosis factor-α agents, colectomy, or steroid-free remission at the last visit between patients with and without mesalamine intolerance.

CONCLUSIONS

Mesalamine intolerance is not rare, and its frequency has been increasing recently. The prognosis of patients with mesalamine intolerance did not differ significantly from that of those without intolerance.

Effect of Vonoprazan on Delayed Bleeding after Endoscopic Submucosal Dissection for Gastric Neoplasia among Antithrombotic Drug Users: A Single-Center, Single-Arm Prospective Observational Case Control Study

Antithrombotic therapy is a major risk factor for delayed bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasia. A potassium-competitive acid blocker, vonoprazan, is expected to prevent delayed bleeding better than conventional proton pomp inhibitors (PPIs), but the evidence is controversial. We sought to clarify the efficacy of vonoprazan for prevention of delayed bleeding after gastric ESD in patients under antithrombotic therapy. We prospectively registered 50 patients who underwent gastric ESD while receiving antithrombotic therapy and vonoprazan in our institution between October 2017 and September 2018. The incidence of delayed bleeding was compared with that in a historical control group of 116 patients treated with conventional PPI. We also evaluated risk factors associated with delayed bleeding. Delayed bleeding was observed in 8 of 50 patients (16.0%), which was not dissimilar from the incidence in the historical control group (12.1%) (p=0.49). In the univariate analysis, age (> 70 years) (p=0.034), multiple antithrombotic drug use (p<0.01), procedure time (> 200 min) (p=0.038) and tumor size (> 40 mm) (p<0.01) were associated with delayed bleeding after gastric ESD, but vonoprazan was not (p=0.49). Vonoprazan may not be more effective than conventional PPIs in preventing delayed bleeding after gastric ESD in patients receiving antithrombotic therapy.

Changes in Liver and Spleen Stiffness by Virtual Touch Quantification Technique after Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices and Exacerbation of Esophageal Varices: A Preliminary Study

PURPOSE

 To assess liver stiffness (LS) and spleen stiffness (SS) values measured by virtual touch quantification (VTQ) technique in the monitoring of portal pressure and their usefulness for the prediction of the exacerbation of esophageal varices (EV) in patients with gastric varices undergoing balloon-occluded retrograde transvenous obliteration (B-RTO).

MATERIALS AND METHODS

 The LS, SS, and hepatic venous pressure gradient (HVPG) were measured in 20 patients both before and after B-RTO. The change in each parameter between the two groups (EV exacerbation and non-exacerbation groups) was compared by analysis of variance. The efficacy of the parameters for the prediction of the exacerbation of EV was analyzed using a receiver operating characteristic (ROC) curve analysis.

RESULTS

 9 patients (40.9 %) exhibited an exacerbation of EV within 24 months after B-RTO. Significant changes were observed in the HVPG and SS after B-RTO between the two groups (EV exacerbation group vs. non-exacerbation group: HVPG before 12.7 ± 4.4 mmHg vs. 11.0 ± 4.4 mmHg; HVPG after 19.6 ± 6.0 mmHg vs. 13.6 ± 3.1 mmHg P = 0.003; SS before 3.40 ± 0.50 m/s vs. 3.20 ± 0.51 m/s; SS after 3.74 ± 0.53 m/s vs. 3.34 ± 0.43 m/s P = 0.016). However, no significant changes in LS were observed between the two groups. The area under the ROC curves of elevation in HVPG and SS for the prediction of the exacerbation of EV after B-RTO were 0.833 and 0.818, respectively.

CONCLUSION

 Elevation of the HVPG and SS measured by VTQ after B-RTO was useful for the prediction of the exacerbation of EV.

[Peutz-Jeghers syndrome and cancer:a retrospective study in 14 Japanese patients with Peutz-Jeghers syndrome]

We retrospectively investigated 14 Japanese patients with Peutz-Jeghers (PJ) syndrome who were treated in six hospitals to determine the prevalence of cancer in Japanese patients with PJ syndrome. The study included seven males and seven females. The mean age at the time of diagnosis of PJ syndrome was 28.1 years (range 2-60 years). Hamartomatous polyps were observed in 13 (92.9%) patients, mucocutaneous pigmentation in 11 (78.6%), and positive family history in six patients (42.9%). The mean observation period after the diagnosis of PJ syndrome was 10.1 years (range 0-34 years). Although one patient died of cancer of unknown primary origin, the remaining 13 patients included in the study completed their last follow-up at each hospital. Cancers were detected in six patients (42.9%), including cancer of the uterine cervix (N=3), breast cancer (N=1), duodenal cancer (N=1), transverse colon cancer (N=1), and cancer of unknown primary origin (N=1). One patient presented with both cervical cancer and breast cancer. No patient presented with pancreatic cancer. This study highlights that patients with PJ syndrome are at high risk for intestinal and extra-intestinal cancers, such as uterine and breast cancer. Routine surveillance for intestinal and extra-intestinal malignancies is warranted in patients with PJ syndrome.

Post-polypectomy bleeding in hot-snare polypectomy of colonic polyps under continued warfarin or short interruption of direct oral anticoagulants

BACKGROUND

Newly published guidelines of the Japanese Gastroenterological Endoscopy Society (JGES) suggest to consider endoscopic procedures with high risk of bleeding without stopping warfarin and with stopping direct oral anticoagulants (DOACs) only on the day of the procedure. In this study, we aimed to test the validity of these recommendations.

PATIENTS AND METHODS

We retrospectively reviewed medical records of 344 patients with anticoagulant therapy who underwent hot-snare polypectomy between January 2012 and October 2018. Patients (n = 132) with interruption of anticoagulants (3-7 days for warfarin and 2-3 days for DOACs before the procedure) and without heparin-bridging were excluded. Among the remaining 212 patients, the incidence of post-polypectomy bleeding was compared between the following 2 patient groups: patients who had interruption of anticoagulants with heparin-bridging (HB group, n = 139) and patients treated according to the new JGES guideline (FG group, n = 73).

RESULTS

The rate of post-polypectomy bleeding (PPB) in FG group (9.6%) was not significantly different from that in HB group (12.9%, p = 0.5). In subgroup analysis, the incidence of bleeding in patients with warfarin (12.2%) and with DOAC (6.3%) in FG group was not significantly different from corresponding figures in HB group (14.2%, 0%). In multivariate analysis, number of resected polyps was associated with PPB, but the administration of anticoagulants according to the new guidelines was not a significant risk factor for PPB (p = .98).

CONCLUSIONS

Our study affirms the recommendations of JGES for the management of anticoagulants in patients who undergo colonic polypectomy regarding post-polypectomy bleeding.

Concerns and Side Effects of Azathioprine During Adalimumab Induction and Maintenance Therapy for Japanese Patients With Crohn's Disease: A Subanalysis of a Prospective Randomised Clinical Trial [DIAMOND Study]

BACKGROUND

Combining a thiopurine with the human anti-tumour necrosis factor-α monoclonal antibody adalimumab for Crohn's disease [CD] treatment is controversial with regard to efficacy and safety. By conducting a subanalysis of a multicentre, randomised, prospective, open-label trial [the DIAMOND study, UMIN registration number 000005146], we studied the risk of discontinuation of thiopurine in combination with adalimumab.

METHODS

In the preceding DIAMOND study, we analysed the: [i] timing and reasons for dropout in the monotherapy group and combination group; [ii] risk factors for dropout in the combination group.

RESULTS

There was no significant difference in the dropout rate up to Week 52 between the monotherapy group and combination group [p = 0.325]. The main reason for study dropout was active CD in the monotherapy group, whereas it was adverse effects in the combination group [Fisher's exact test, p <0.001]. Kaplan-Meier analyses revealed significantly earlier dropout in the combination group [log-rank test, p = 0.001]. Multivariable analysis revealed low body weight to be a risk for dropout due to adverse effects in the combination group.

CONCLUSIONS

Combination of azathioprine with adalimumab resulted in dropout in the early stage of the study due to side effects of azathioprine, in comparison with late dropout due to active CD in the adalimumab monotherapy group.

The clinicopathological differences of sporadic non-ampullary duodenal epithelial neoplasm depending on tumor location

BACKGROUND AND AIM

Although sporadic non-ampullary duodenal adenoma is speculated to be precancerous lesion, the relationship between adenoma and carcinoma remains unclear due to their rarity. Previous studies on sporadic non-ampullary duodenal epithelial neoplasm (SNADEN) have mainly targeted superficial tumors, like adenoma and early carcinoma. The clinicopathological features, including those of advanced carcinoma, remain poorly investigated. We assessed the clinicopathological features of SNADEN, including advanced carcinoma, focusing on tumor location.

METHODS

We retrospectively collected the data of 410 patients who had been clinically and pathologically diagnosed with SNADEN at 11 institutions in Japan between June 2002 and March 2014.

RESULTS

The SNADEN was mucosal neoplasia and invasive carcinoma in 321 (78.3%) and 89 (21.7%) patients, respectively. The proportion of invasive carcinomas in SNADEN was significantly higher on the oral side of the papilla of Vater (oral-Vater) than on the anal side (anal-Vater) (27.9% vs 14.4%, P < 0.001). Undifferentiated-type carcinoma was significantly more frequent with oral-Vater than anal-Vater (38.7% vs 14.8%, P = 0.026). The recurrence rate of surgically R0 resected locally advanced carcinomas was significantly higher with oral-Vater than anal-Vater (46.4% vs 8.3%, P = 0.021). Furthermore, the relapse-free survival with oral-Vater was significantly shorter than with anal-Vater (hazard ratio: 2.35; 95% confidence interval: 1.09-5.50; P = 0.028).

CONCLUSIONS

The clinicopathological features of SNADEN on oral-Vater were different from those on anal-Vater. SNADEN on oral-Vater was more likely to be invasive carcinomas and might behave more aggressively due to biologically higher malignancy than that on anal-Vater.

[Sclerosing mesenteritis diagnosed using computed tomography- and ultrasound-guided needle biopsy -utility of the coaxial technique]

Here, we report the case of an 82-year-old woman with sclerosing mesenteritis diagnosed using needle biopsy under the guidance of computed tomography (CT) and ultrasound (US). The patient manifested appetite loss, weight loss, and epigastric pain. CT of the abdomen and pelvis revealed increased density of the mesentery adjacent to the small bowel along with enlarged lymph nodes. Hence, we suspected sclerosing mesenteritis but also considered malignancies, such as lymphoma. We then performed CT- and US-guided needle biopsy with coaxial technique. We inserted an introducer needle by verifying its location using CT and extracted multiple specimens using a finer needle that passed through the introducer without incident. The collected specimens were adequate and histological diagnosis revealed sclerosing mesenteritis. We treated the patient with corticosteroids, and her symptoms and radiographic findings improved. Thus, the coaxial technique was a useful and minimally invasive tool for the diagnosis of sclerosing mesenteritis.

A giant apocrine hidrocystoma associated with elevated serum carcinoembryonic antigen levels: a case report

Background

Serum carcinoembryonic antigen levels are often elevated in patients with malignant diseases. However, the etiology of elevated serum carcinoembryonic antigen levels may be extremely difficult to determine considering that this finding may occasionally occur in patients with benign diseases. Apocrine hidrocystomas, which are typically small and found on the face, are benign cystic lesions of apocrine sweat glands.

Case presentation

A 58-year-old Japanese man was referred to us because of high serum carcinoembryonic antigen levels (15.9 ng/mL) found incidentally during a routine medical checkup. A physical examination revealed a hemispherical mass approximately 5 cm in diameter on his left thigh. Magnetic resonance imaging of the region showed a multilocular cystic mass with clear margins and a smooth surface, suggesting a cystic tumor. He underwent local mass resection. Pathological examination of the resected mass revealed an apocrine hidrocystoma with luminal cells, which tested immunohistochemically positive for carcinoembryonic antigen. Postoperatively, serum carcinoembryonic antigen levels returned to normal. This report is the first to describe an apocrine hidrocystoma associated with high serum carcinoembryonic antigen levels.

Conclusions

An apocrine hidrocystoma can cause elevation of serum carcinoembryonic antigen levels. Despite its rarity, apocrine hidrocystoma should be considered in the differential diagnosis of conditions causing high serum carcinoembryonic antigen levels. In addition, skin diseases deserve more careful attention for patients with high serum carcinoembryonic antigen levels.

Early gastric cancer with ball valve syndrome treated by endoscopic submucosal dissection

An 84-year-old woman with pneumonia, congestive heart failure and chronic renal failure presented for iron-deficiency anemia and appetite loss. Esophagogastroduodenoscopy revealed a 60-mm sub-pedunculated tumor arising from the antrum of the stomach. The tumor was friable, with bleeding, and prolapsed into the duodenal bulb, the ball valve syndrome. The tumor was considered the cause of the anemia and appetite loss. Attempted endoscopic reduction of the prolapsing tumor was unsuccessful, but the base of its stalk could be identified through the transparent hood; thus, we removed the tumor with endoscopic submucosal dissection. The tumor was retrieved successfully, and pathohistological examination revealed the tumor to be a well-differentiated adenocarcinoma. This case suggests that endoscopic submucosal dissection is useful as an alternative to surgery for removal of gastric tumors that have prolapsed into the duodenal bulb when polypectomy was difficult, but provided the tumor's attachment site can be identified endoscopically.

Endoscopic Submucosal Dissection for Gastric-phenotype Adenoma on the Surface of Gastric Gastrointestinal Stromal Tumor

We herein report a rare case of a gastric adenoma overlying a gastrointestinal stromal tumor (GIST) that was removed by endoscopic submucosal dissection (ESD). A 78-year-old woman was referred to our hospital. Esophagogastroduodenoscopy revealed an elevated lesion of 15 mm in diameter overlying a submucosal mass in the gastric cardia. ESD was performed for the epithelial neoplasm, and biopsy specimens were obtained directly from the exposed surface of the submucosal tumor. The epithelial tumor was a tubular adenoma with focal severe atypia and a gastric phenotype. Biopsy specimens revealed a GIST, which was resected by laparoscopic intragastric surgery afterward.

Risk factors for recurrent bleeding from acute hemorrhagic rectal ulcer

OBJECTIVES

Acute hemorrhagic rectal ulcer (AHRU) occurs suddenly with painless massive bleeding from rectal ulcers, usually in patients who have severe underlying disorders. The rate of recurrent bleeding from AHRU is high, but there have been few studies on the risk factors for recurrent bleeding. The aim of this study was to identify risk factors for recurrent bleeding from AHRU.

METHODS

Among 27,151 patients who underwent colonoscopy from 2006 November to 2017 March in our hospital, 120 patients with AHRU were retrospectively reviewed to identify risk factors for recurrent bleeding. Factors analyzed were: age, sex, Charlson Comorbidity Index (CCI), comorbidities (congestive heart failure, liver cirrhosis, renal failure, respiratory failure, diabetes mellitus and malignancy), medications (antiplatelet drugs, anticoagulants and steroids); endoscopic therapy and endoscopic features of AHRU.

RESULTS

Recurrent bleeding from AHRU occurred in 30% of patients (36/120). In multi-variate analysis, individual comorbidities, medications, endoscopic features and endoscopic hemostasis were not significant or independent risk factors for recurrent bleeding. However, a high CCI score (4 or more) was a risk factor (odds ratio, 7.0; 95% confidence interval, 1.8-27.1). Endoscopic hemostasis was performed in 61% (73/120) of AHRU patients, and successful hemostasis was achieved in 99% of the treated patients (72/73).

CONCLUSIONS

High CCI score was a predictor of recurrent bleeding from AHRU, but individual comorbidities, medications, endoscopic features or endoscopic hemostasis were not. Endoscopic hemostasis for bleeding from AHRU was achieved in most patients, but the recurrent bleeding rate was high.

The Role of Double-balloon Enteroscopy in the Diagnosis and Surgical Treatment of Metastatic Small Bowel Tumors

Objective The aim of the present study is to investigate the role of double-balloon enteroscopy in the diagnosis and surgical treatment of metastatic small bowel tumors. Patients We retrospectively reviewed the records of 13 patients with metastatic small bowel tumors among 376 patients who underwent double-balloon enteroscopy from June 2005 to March 2017 in our hospital. Results The primary lesion sites were the lung (n=9), kidney (n=2), stomach (n=1) and duodenum (n=1). The clinical presentations were anemia requiring blood transfusion (n=10), obstructive symptoms (n=2), and no symptoms (n=1). The locations of the metastatic small bowel tumors were the jejunum (n=7), ileum (n=1), and both sites (n=5). The histological diagnosis of the metastatic tumor was made from biopsy specimens taken with double-balloon enteroscopy from all 11 patients whose condition permitted a biopsy. In seven patients, the findings on double-balloon endoscopy were determinants of the kind and extent of surgical treatment performed. Four patients had multiple metastatic small bowel tumors, and all were able to be removed surgically with guidance from preoperative tattooing at double-balloon endoscopy. After operation, blood transfusions were no longer needed in four of six patients who had required preoperative transfusions for the treatment of anemia, and one patient with intestinal obstructive symptoms was able to resume oral intake. Conclusion Double-balloon endoscopy was useful for making a histological diagnosis and directing surgical treatment in patients with metastatic small bowel tumors. Surgical treatment afforded palliation of symptoms in five patients.

Factors Associated with possibly Inappropriate Histological Evaluation of Excised Specimens in Cold-snare Polypectomy for Small Colorectal Polyps

Background & Aims: Small colorectal polyps may be removed with cold snare polypectomy (CSP). Some of these polyps may contain unexpectedly advanced neoplasia. Thus, it is important to establish criteria for excision that will ensure that the CSP specimens are adequate for accurate histological assessment. We retrospectively investigated depth of excised small polyps and their vertical margins in patients who underwent CSP.Method: CSP-excised specimens of 376 small colorectal polyps were examined. We histologically evaluated negative tumor vertical margins and complete resection through the muscularis mucosae, which was defined as muscularis mucosae present under the tumor along more than 80% of its horizontal axis. We also evaluated the fragmentation of the retrieved specimens.Results: The mean size of the 376 polyps was 4.9 ±1.4 mm, and 25 polyps (6.6%) had unexpectedly advanced histology. Thirty-two lesions (8.5%) were fragmented. In 275 (79.9%) of the remaining 344 unfragmented polyps, muscularis mucosae resection was judged complete. Vertical margins were confirmed negative in 99.6% (274/275) of polyps that had complete muscularis mucosae resection, but in only 33.3% (23/69) of polyps with incomplete resection. In 79 polyps (21%) (32 fragmented specimens and 47 unfragmented specimens), including 5 polyps with advanced histology, negative vertical margins could not be confirmed. Sessile morphology and location in the cecum were independent risk factors for incomplete muscularis mucosae resection and fragmentation.Conclusion: Incomplete muscularis mucosae resection and fragmentation at retrieval are risk factors for inadequate histological evaluation of CSP-excised small colorectal polyps, especially for sessile polyps and polyps in the cecum.

Sclerosing mesenteritis diagnosed with computed tomography and ultrasound-guided needle biopsy: the utility of the coaxial technique

Here we report a case of sclerosing mesenteritis that we diagnosed with needle biopsy under the guidance of computed tomography (CT) and ultrasound (US) observation. An 82-year-old woman presented with appetite loss, weight loss and epigastric pain. CT of the abdomen and pelvis revealed increased density of the mesentery adjacent to the small bowel and enlarged lymph nodes. Sclerosing mesenteritis was suspected, but malignancies, such as lymphoma, were also considered. We performed CT and US-guided needle biopsy with the coaxial technique. An introducer needle was inserted, its correct location was documented with CT, and multiple specimens were taken with a finer needle passed through the introducer without incident. Adequate specimens were obtained, and the histological diagnosis of sclerosing mesenteritis was made. We treated the patient with corticosteroids and her symptoms and the radiographic findings improved. The coaxial technique was a useful and minimally invasive tool for making the diagnosis of sclerosing mesenteritis.

The characteristics and outcomes of small bowel adenocarcinoma: a multicentre retrospective observational study

Background:

Small bowel adenocarcinoma (SBA) is a rare malignancy that accounts for 1–2% of gastrointestinal tumours. We investigated the clinical characteristics, outcomes, and prognostic factors of primary SBA.

Methods:

We retrospectively analysed the characteristics and clinical courses of 205 SBA patients from 11 institutions in Japan between June 2002 and August 2013.

Results:

The primary tumour was in the duodenum and jejunum/ileum in 149 (72.7%) and 56 (27.3%) patients, respectively. Sixty-four patients (43.0%) with duodenal adenocarcinoma were asymptomatic and most cases were detected by oesophagogastroduodenoscopy (EGD), which was not specifically performed for the detection or surveillance of duodenal tumours. In contrast, 47 patients (83.9%) with jejunoileal carcinoma were symptomatic. The 3-year survival rate for stage 0/I, II, III, and IV cancers was 93.4%, 73.1%, 50.9%, and 15.1%, respectively. Multivariate analysis revealed performance status 3–4, high carcinoembryonic antigen, high lactate dehydrogenase (LDH), low albumin, symptomatic at diagnosis, and stage III/IV disease were independent factors for overall survival (OS). Ten patients (18.5%) with stage IV disease were treated with a combination of resection of primary tumour, local treatment of metastasis, and chemotherapy; this group had a median OS of 36.9 months.

Conclusions:

Although most SBA patients were diagnosed with symptomatic, advanced stage disease, some patients with duodenal carcinoma were detected in early stage by EGD. High LDH and symptomatic at diagnosis were identified as novel independent prognostic factors for OS. The prognosis of advanced SBA was poor, but combined modality therapy with local treatment of metastasis might prolong patient survival.

Safety of cold polypectomy for small colorectal neoplastic lesions: a prospective cohort study in Japan

BACKGROUND

Cold polypectomy has been widely accepted for removal of small colorectal polyps. However, no large-scale prospective study exists as for its safety in Japan. We investigated this issue in this single-center, prospective cohort study in a total of 1198 colorectal polyps resected with cold polypectomy.

PATIENTS AND METHODS

Four hundred and seventy-four patients who underwent cold polypectomy for colorectal neoplastic lesions less than 10-mm diameter between September 2014 and October 2016 were enrolled. Primary outcome was the incidence of delayed bleeding within 2 weeks after the procedure. Secondary outcomes were the rate of immediate bleeding, perforation, endoscopic en bloc resection, and advanced histology.

RESULTS

Cold polypectomy was performed on 1198 polyps in the 474 patients. No delayed bleeding or colonic perforation was observed. Immediate bleeding during the procedure, requiring endoscopic hemostasis, occurred in 97 lesions (8.1%), and all of them were successfully managed endoscopically. The endoscopic en bloc resection rate was 97.2%. Twenty-eight lesions (2.3%) were histologically diagnosed as advanced neoplasia; among them, three lesions were well-differentiated adenocarcinomas, and in two of them, a negative margin was not histologically confirmed.

CONCLUSIONS

Cold polypectomy for small colorectal polyps is a safe technique without significant complication, but careful endoscopic diagnosis at cold polypectomy is necessary to identify advanced neoplasia. The reliability of cold polypectomy in excision of polyps with high-grade neoplasia should be established before the procedure becomes standard in the excision of small colorectal polyps.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000014812.

Gastric superficial neoplasia: high miss rate but slow progression

BACKGROUND AND AIMS

 Gastric superficial neoplasia (GSN) is often overlooked at endoscopy because of difficulty in identifying it. The miss rate of GSN at endoscopy and the impact on clinical outcome of the missed GSN have not been fully elucidated. In this study, we investigated these issues.

METHODS

 Among 1462 endoscopically and pathologically diagnosed gastric cancers in our hospital from January 2011 to December 2014, previous records of esophagogastroduodenoscopy (EGD) were available for 198 lesions (index lesions) and were reviewed retrospectively. Among those, 157 lesions, which were diagnosed as GSN on the basis of their EGD findings at initial endoscopy, were analyzed. Progression was defined as advanced cancer in the index lesion.

RESULTS

 Among the 157 GSNs, 118 (75.2 %) had not been recorded in the previous EGD report but were evident upon review of endoscopic photographs for this study. Progression to advanced cancer was observed in only 13 (8.3 %) of the 157 GSNs during a mean interval of 41 months and as long as 96 months, and the rate of progression was similar in missed and not-missed lesions (8.5 % and 7.7 %, respectively). Cumulative incidence rates of progression of missed GSNs to advanced cancer were 0.8 %, 1.7 %, 4.2 %, and 7.6 % at 36, 48, 60, and 72 months after the initial EGD, respectively.

CONCLUSIONS

 Our findings illustrate that GSNs are often missed at endoscopy but progress slowly in most cases. Even though the rate of progression to cancer is relatively low, rigorous attempts should be made to reduce the miss rate of GSNs at EGD.

Optimal dose of ramosetron in female patients with irritable bowel syndrome with diarrhea: A randomized, placebo-controlled phase II study

BACKGROUND

Previous studies showed that 5 μg of ramosetron, a serotonin (5-hydroxytryptamine: 5-HT)-3 receptor antagonist, is only effective in male patients with irritable bowel syndrome (IBS) with diarrhea (IBS-D). We hypothesized that either dose 1.25, 2.5, or 5 μg of ramosetron would be effective in female patients with IBS-D.

METHODS

This randomized, double-blind, placebo-controlled, phase II dose-finding exploratory trial included 409 female outpatients with IBS-D treated in Japan. They were administered oral placebo (n=102), or 1.25 μg (n=104), 2.5 μg (n=104), or 5 μg (n=99) of ramosetron once daily for 12 weeks after a 1-week baseline period. The primary endpoint was monthly responder rates of global improvement of IBS symptoms in the first month. Secondary endpoints included global improvement in the other months, abdominal pain/discomfort, weekly mean changes in the Bristol Stool Form Scale (BSFS), and IBS-QOL.

KEY RESULTS

Middle dose (2.5 μg) of ramosetron significantly improved abdominal pain/discomfort at second month (62.5%, P=.002), third month (60.6%, P=.005), and the last evaluation point (63.5%, P=.002) and weekly BSFS (P<.05) except at Week 8, 11, and 12 than placebo. IBS-QOL did not change. Ramosetron induced more constipation than placebo.

CONCLUSIONS & INFERENCES

The trial suggested that 2.5 μg of ramosetron is the most effective and least harmful option for treating female patients with IBS-D (Clinicaltrials.gov ID: NCT01274000).

Clinical characteristics and associated factors of Japanese patients with adenocarcinoma of the esophagogastric junction: a multicenter clinicoepidemiological study

Gastroesophageal reflux disease-related diseases, such as Barrett's esophagus and adenocarcinoma of the esophagogastric junction (AEGJ), are believed to occur less frequently in Asia than in Western countries. However, the number of reported cases is increasing, yet little is known regarding the epidemiology of AEGJ in Japan. The primary study aim is to investigate the clinicoepidemiological characteristics of AEGJ. The secondary aim is to identify factors associated with it. In the 6.5 years between January 2008 and June 2014, we reviewed 88,199 esophagogastroduodenoscopy (EGD) reports and associated medical records (Study 1). We conducted a case-control study to identify factors associated with AEGJ (Study 2). Control subjects were randomly selected and age and sex matched from among subjects who underwent EGD during medical evaluations. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using an unconditional logistic regression method. During the study period, 83 patients with AEGJ (72 men and 11 women; mean age 68 years) were diagnosed. Six cases were Siewert type I and 77 were type II. The incidence rate of AEGJ was 0.6-1.7/100,000 person-years. Compared with the 101 control subjects, obesity (body mass index ≧ 25 kg/m2; [OR = 2.82; 95% CI: 1.13-7.01]) was associated with AEGJ. The incidence rate of AEGJ is lower in Japan than in Western countries, but associated factors similar to those in Western patients were detected, including obesity, a hiatal hernia, smoking, and the male sex.

Two cases of acute gastric dilation after radiofrequency catheter ablation for supraventricular arrhythmia

We describe our experience with two cases of acute gastric dilation after radiofrequency catheter ablation (RFCA) for supraventricular arrhythmia. After the RFCA procedure, patients experienced epigastric pain, abdominal distension, and vomiting. Computed tomography showed marked dilation of their stomachs, but without apparent obstruction of the gastric antrum or the duodenum. Esophagogastroduodenoscopy and upper gastrointestinal series revealed significant gastroparesis. We considered that gastric hypomotility had been induced by vagus nerve injury after RFCA. Peristaltic stimulants effectively improved the patients' symptoms by improving gastric motility. There have been few reports of acute gastric dilation after RFCA in Japan to date, but the possibility of encountering this condition is expected to increase in parallel with the recent increased use of RFCA. Therefore, gastroenterologists should be alert to this rare complication.

Risk factors for active bleeding from colonic angiodysplasia confirmed by colonoscopic observation

PURPOSE

Colonic angiodysplasia is an important cause of lower gastrointestinal bleeding in the elderly. Here, we investigated the risk factors for bleeding from colonic angiodysplasia seen at endoscopy.

METHODS

We conducted a retrospective case-control study by reviewing records of 435 patients with angiodysplasia at colonoscopy from November 2006 to November 2015 in our hospital. To identify risk factors for active bleeding, the following were analyzed: age, sex, comorbidities, use of antithrombotic drugs and non-steroidal anti-inflammatory drugs, and the size and location of the lesions.

RESULTS

Among the 435 patients, active bleeding from angiodysplasia was observed at endoscopy in 29 patients (6.7 %). Using multivariate analysis, we identified advanced age (odds ratio 5.15, 95 % confidence interval, 1.61-16.5), comorbidity of heart disease (6.88, 1.04-45.5), use of anticoagulant drug (4.22, 1.21-14.7), multiple lesions (6.67, 1.77-25.2), and small lesions (≤5 mm) (17.7, 4.90-64.0) as independent and significant risk factors for active bleeding. Actively bleeding colonic angiodysplasia lesions were very small in most cases (1-2 mm, 24/29, 83 %) and predominantly located in the right-side colon (26/29, 90 %). All of the 29 patients with active bleeding were successfully and safely treated endoscopically, but re-bleeding occurred in nine patients (31 %, 9/29) during the follow-up period of 2-84 months.

CONCLUSIONS

Multiple and small colonic angiodysplasia lesions in patients of advanced age, with heart disease, or receiving anticoagulants have increased risk for bleeding. We should be aware that small colonic angiodysplasia lesions in the right-side colon at colonoscopy in these patients may be a source of bleeding.

Portal Hypertension in Patients with Liver Cirrhosis: Diagnostic Accuracy of Spleen Stiffness

PURPOSE

To evaluate the accuracy of spleen stiffness (SS) and liver stiffness (LS) measured by using acoustic radiation force impulse imaging in the diagnosis of portal hypertension in patients with liver cirrhosis, with the hepatic venous pressure gradient (HVPG) as a reference standard.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained for this prospective single-center study. From February 2012 to August 2013, 60 patients with liver cirrhosis (mean age, 70.8 years; age range, 34-88 years; 34 men, 26 women) with HVPG, LS, and SS measurements and gastrointestinal endoscopy and laboratory data were included if they met the following criteria: no recent episodes of gastrointestinal bleeding, no history of splenectomy, no history of partial splenic embolization, no history of β-blocker therapy, and absence of portal thrombosis. The efficacy of the parameters for the evaluation of portal hypertension was analyzed by using the Spearman rank-order correlation coefficient and receiver operating characteristic (ROC) curve analysis.

RESULTS

The correlation coefficient between SS and HVPG (r = 0.876) was significantly better than that between LS and HVPG (r = 0.609, P < .0001). The areas under the ROC curve of SS for the identification of clinically important portal hypertension (HVPG ≥ 10 mm Hg), severe portal hypertension (HVPG ≥ 12 mm Hg), esophageal varices (EVs), and high-risk EVs were significantly higher (0.943, 0.963, 0.937, and 0.955, respectively) than those of LS, spleen diameter, platelet count, and platelet count to spleen diameter ratio (P < .05 for all). SS could be used to accurately rule out the presence of clinically important portal hypertension, severe portal hypertension, EVs, and high-risk EVs (negative likelihood ratios, 0.051, 0.056, 0.054, and 0.074, respectively).

CONCLUSION

SS is reliable and has better diagnostic performance than LS for identifying portal hypertension in liver cirrhosis.

Review of the diagnosis and management of gastrointestinal bezoars

The formation of a bezoar is a relatively infrequent disorder that affects the gastrointestinal system. Bezoars are mainly classified into four types depending on the material constituting the indigestible mass of the bezoar: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars. Gastric bezoars often cause ulcerative lesions in the stomach and subsequent bleeding, whereas small intestinal bezoars present with small bowel obstruction and ileus. A number of articles have emphasized the usefulness of Coca-Cola^® administration for the dissolution of phytobezoars. However, persimmon phytobezoars may be resistant to such dissolution treatment because of their harder consistency compared to other types of phytobezoars. Better understanding of the etiology and epidemiology of each type of bezoar will facilitate prompt diagnosis and management. Here we provide an overview of the prevalence, classification, predisposing factors, and manifestations of bezoars. Diagnosis and management strategies are also discussed, reviewing mainly our own case series. Recent progress in basic research regarding persimmon phytobezoars is also briefly reviewed.

Clinical features and endoscopic findings in patients with actively bleeding colonic angiodysplasia

Colonic angiodysplasia (AGD) is an important cause of lower gastrointestinal bleeding. However, most episodes of bleeding from colonic AGD stop spontaneously. To date, few data are available regarding the endoscopic findings of bleeding colonic AGD. In order to clarify the clinical features and endoscopic findings of actively bleeding colonic AGD, we conducted a retrospective study of patients treated with colonoscopy at our hospital. From November 2006 to March 2013 inclusive, 32,586 colonoscopies were performed at this hospital, among which 13 patients with bleeding colonic AGD were enrolled in the current study. The mean age was 84 years (range: 69-90 years). All patients had chronic heart disease and were currently using anticoagulant and/or antiplatelet drugs. Sites of bleeding AGD were localized in the left colon in two patients (15 %) and in the right colon in the remaining patients (85 %). A total of 77 % of the lesions (10/13) were 1-2 mm in size and two lesions were 4 mm in size; only one lesion was larger than 5 mm. Endoscopic treatment resulted in a therapeutic success rate of 100 %, and no recurrence of bleeding was observed in 85 % of the patients (11/13) after treatment. During the study period, two patients presented with bleeding from residual AGD and underwent endoscopic treatment. In the present study, most sites of bleeding colonic AGD were very small, termed "micro-angiodysplasia", and targeted endoscopic treatment for actively bleeding AGD was found to be effective and safe. It is essential that physicians consider the potential for actively bleeding colonic AGD, especially "micro-angiodysplasia", when performing colonoscopy in elderly patients with a history of cardiovascular disease and/or treatment with anticoagulant or antiplatelet therapy.

Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation

BACKGROUND

Splenic vein ligation may result in sinistral (left-sided) portal hypertension and gastrointestinal haemorrhage. The aim of this study was to analyse the pathogenesis of sinistral portal hypertension following splenic vein ligation in pancreaticoduodenectomy.

METHODS

Patients who underwent pancreaticoduodenectomy for pancreatic cancer between January 2005 and December 2012 were included in this retrospective study. The venous flow pattern from the spleen and splenic hypertrophy were examined after surgery.

RESULTS

Of 103 patients who underwent pancreaticoduodenectomy with portal vein resection, 43 had splenic vein ligation. There were two predominant venous flow patterns from the spleen. In the varicose route (27 patients), flow from the spleen passed to colonic varices and/or other varicose veins. In the non-varicose route, flow from the spleen passed through a splenocolonic collateral (14 patients) or a spontaneous splenorenal shunt (2 patients). The varicose route was associated with significantly greater splenic hypertrophy than the non-varicose route (median splenic hypertrophy ratio 1·52 versus 0·94; P < 0·001). All patients with the varicose route had colonic varices, and none had a right colic marginal vein at the hepatic flexure.

CONCLUSION

Pancreaticoduodenectomy with splenic vein ligation may lead to sinistral portal hypertension. To avoid the development of varices, it is important to preserve the right colic marginal vein. Reconstruction of the splenic vein should be considered if the right colic marginal vein is divided.

[A case report of endosonography used for the diagnosis of early gastric cancer and gastrointestinal stromal tumor]

A 79-year-old man was referred to our hospital complaining of weight loss. Esophagogastroduodenoscopy revealed a flat, elevated lesion of 30-mm diameter located on the posterior wall of the upper gastric body. The lesion was histologically diagnosed as a well-differentiated adenocarcinoma. Endosonography showed a submucosal tumor under the carcinoma, which was highly suspicious of a gastrointestinal tumor derived from the muscle layer. Adenocarcinoma was diagnosed as an intramucosal lesion, but laparoscopic fundectomy was performed because of the submucosal tumor. Pathological diagnosis was U, less, pType 0-IIa, 18×30 mm, pT1b (SM1), tub2, int, INFa, ly0, v0, pN0, H0, P0, CYX, M0, pStage IA, gastrointestinal stromal tumors, prognostic group 1.

Measurement of spleen stiffness by acoustic radiation force impulse imaging identifies cirrhotic patients with esophageal varices

BACKGROUND & AIMS

We evaluated whether spleen stiffness (SS), measured by acoustic radiation force impulse imaging, can identify patients who have esophageal varices (EVs); those without EVs would not require endoscopic examination.

METHODS

In a prospective study, we measured SS and liver stiffness (LS) in 340 patients with cirrhosis undergoing endoscopic screening for EVs and 16 healthy volunteers (controls) at the Kurashiki Central Hospital in Okayama, Japan. The diagnostic accuracy of SS for the presence of EVs was compared with that of other noninvasive parameters (LS, spleen diameter, and platelet count). Optimal cutoff values of SS were chosen to confidently rule out the presence of varices.

RESULTS

Patients with cirrhosis had significantly higher SS and LS values than controls (P < .0001 and P < .0001, respectively). Levels of SS were higher among patients with EVs (n = 132) than controls, and values were highest among patients with high-risk EVs (n = 87). SS had the greatest diagnostic accuracy for the identification of patients with EVs or high-risk EVs compared with other noninvasive parameters, independent of the etiology of cirrhosis. An SS cutoff value of 3.18 m/s identified patients with EVs with a 98.4% negative predictive value, 98.5% sensitivity, 75.0% accuracy, and 0.025 negative likelihood ratio. An SS cutoff value of 3.30 m/s identified patients with high-risk EVs with a 99.4% negative predictive value, 98.9% sensitivity, 72.1% accuracy, and 0.018 negative likelihood ratio. SS values less than 3.3 m/s ruled out the presence of high-risk varices in patients with compensated or decompensated cirrhosis. SS could not be measured in 16 patients (4.5%).

CONCLUSIONS

Measurements of SS can be used to identify patients with cirrhosis with EVs or high-risk EVs. A cutoff SS was identified that could rule out the presence of varices and could be used as an initial noninvasive screening test; UMIN Clinical Trials Registry number, UMIN000004363.

Endoscopic Submucosal Dissection for Treatment of Patients Aged 75 Years and over with Esophageal Cancer

Background. Although many reports concerning the use of endoscopic submucosal dissection (ESD) for esophageal cancer have been published, the feasibility of ESD in elderly patients has not been reported. Therefore, we evaluated the efficacy and safety of ESD for treating early esophageal cancer in elderly patients. Methods. A total of 62 cases (52 men, 10 women; mean age ± standard deviation, 66.5 ± 10.5 years) for which the first resection (first treatment) of esophageal cancer was performed by ESD were identified from 77 consecutive esophageal epithelial cancers in 67 patients treated at our institution from January 2005 to March 2011. Patient characteristics, clinical findings, and outcomes were retrospectively assessed for patients separated into older (aged 75 years and older) and younger (aged under 75 years) groups. Results. No significant differences in specimen size, procedure time, median length of the hospital stay (8 versus 9 days; P = 0.252) or procedure-associated complications (8% versus 27%; P = 0.264) were observed between the older (n = 13) and younger (n = 49) groups. Lesions were completely resected in 12 patients and 44 patients, in the younger and older groups, respectively, and the curative resection rate was 77% and 59%, respectively. There were no deaths attributable to procedure-associated complications. Conclusions. ESD is an effective treatment for early esophageal cancer and is well tolerated by elderly patients.