Akiko Kuno

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.

BACKGROUND & AIMS A specialized system for a new method for enteroscopy, the double-balloon method, was developed. The aim of this study was to evaluate the usefulness of this endoscopic system for small-intestinal disorders. METHODS The double-balloon endoscopy system was used to perform 178 enteroscopies (89 by the anterograde approach and 89 by the retrograde approach) in 123 patients. The system was assessed on the basis of the rates of success in jejunal and ileal insertion and the entire examination of the small intestine, diagnostic yields, ability to perform treatment, and complications. RESULTS Insertion of the endoscope beyond the ligament of Treitz or ileocecal valve was possible in all 178 procedures. It was possible to observe approximately one half to two thirds of the entire small intestine by each approach, and observation of the entire small intestine was possible in 24 (86%) of 28 trials. The source of bleeding was identified in 50 (76%) of 66 patients with GI bleeding, scrutiny of strictures was possible in 23 patients, and a tumor was examined endoscopically in 17 patients. Two complications (1.1%) occurred. Endoscopic therapies in the small intestine including hemostasis (12 cases), polypectomy (1 case), endoscopic mucosal resection (1 case), balloon dilation (6 cases), and stent placement (2 cases) were performed successfully. CONCLUSIONS Double-balloon endoscopy permits the exploration of the small intestine with a high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.

Sporadic acute hepatitis E of a 47-year-old man whose pet cat was positive for antibody to hepatitis E virus

We encountered a patient with sporadic acute hepatitis E who had not traveled to areas endemic for hepatitis E virus (HEV) infection and may have been infected in Japan. The patient was a 47-year-old male who had no history of blood transfusion or contact with travelers to hepatitis E-endemic regions or unspecified individuals. The disease presented with general malaise, fever, and brown urine as chief complaints in April 2002. Various hepatitis virus markers were negative, but IgM class antibodies to hepatitis E virus (anti-HEV) and HEV RNA were positive, and the patient was diagnosed with acute hepatitis E. The entire nucleotide sequence (7240 bases) of HEV (HE-JK4) isolated from this patient was determined and compared with known HEV strains. HE-JK4 belonged to genotype IV and exhibited higher similarities to genotype IV HEV strains previously isolated in Japan than to those isolated in China, Taiwan, and Vietnam. The patients family members living with him were negative for anti-HEV IgG and IgM, but their pet cat was anti-HEV IgG-positive. This finding suggests a potential route of infection of sporadic cases of hepatitis E in Japan. Since the presence of HEV indigenous to Japan is predicted, HEV infection should be considered in the diagnosis of acute hepatitis of unknown cause, even for patients who have not traveled abroad.

Gastrointestinal stromal tumor in the jejunum: diagnosis and control of bleeding with electrocoagulation by using double-balloon enteroscopy.

A 43-year-old man presented with gastrointestinal bleeding. A tumor with central ulceration was observed in the jejunum, with the use of a new enteroscopy system called “double-balloon enteroscopy”. Bleeding after biopsy sampling of the tumor was controlled endoscopically by using electrocoagulation. Histological findings of the biopsy specimens were consistent with gastrointestinal stromal tumor, and this was surgically resected. Double-balloon enteroscopy was useful for the diagnosis as well as the control of bleeding in this patient.

Successful treatment with balloon dilatation using a double‐balloon enteroscope for a stricture in the small bowel of a patient with Crohn's disease

The requirement for endoscopic access to a stricture is a major limitation of the endoscopic dilatation for the treatment of strictures in the gastrointestinal tract. We have developed the double‐balloon enteroscopy method that enables visualization of the entire small bowel. In addition, double‐balloon enteroscopy has a potential for the interventional therapy including dilatation of strictures. We present here a case of jejunal strictures in a 47‐year‐old woman with Crohns disease successfully treated with a balloon catheter in combination with double‐balloon enteroscopy. Balloon dilation with double‐balloon enteroscopy is a promising method for the treatment of small bowel strictures in Crohns disease.

Endoscopic submucosal dissection using sodium hyaluronate for large superficial tumors in the colon

Endoscopic submucosal dissection is becoming popular for large superficial gastric cancer in Japan. However, it is considered difficult in the colon because the colonic wall is much thinner than the gastric wall. We use several devices to overcome this difficulty and have made it feasible in the colon as well. Submucosal injection of sodium hyaluronate is used to maintain sufficient thickening of the submucosal tissue and a small‐caliber‐tip or regular cylindrical transparent hood is used to open up the incised mucosa as a substitute for countertraction. In this method, not only the lateral margin, but the vertical margin of the resection can also be determined precisely because submucosal incision is carried out under direct visualization of the submucosal tissue.

Direct Observation with Double-Balloon Enteroscopy of an Intestinal Intramural Hematoma Resulting in Anticoagulant Ileus

Ileus induced by an intramural hematoma due to exces-sive anticoagulant therapy, namely, anticoagulant ileus, was first described by Hafner et al. (1) in 1962. Warfarin is responsible for 98% of the reports of anticoagulant ileus (2), but there is no relationship between the duration of an-ticoagulation and this disease (2, 3). Most anticoagulant ileus occurs in the jejunum (2, 4). Features of anticoag-ulant ileus in the small bowel have been described using gastrointestinal radiograph series (2, 5-10), computed to-mography (CT) (9, 10), ultrasound (8, 11), and angiog-raphy (8). However, enteroscopic findings of intramural hematoma in the small bowel have not previously been reported because of the difficulty in accessing the small in-testine. We have developed a new double-balloon method of enteroscopy (12, 13). This new enteroscopy facilitates deep insertion of an enteroscope into the small bowel. Using this new method, we were able to identify a hematoma in the small intestine of a patient with anticoagulant ileus.

Technical modification of the double-balloon endoscopy to access to the proximal side of the stenosis in the distal colon.

BACKGROUND The inability to pass endoscopes beyond strictures is a considerable problem in patients with a colonic stricture. METHODS In patients with bowel obstruction, we have modified the insertion method for double-balloon endoscopy with a long, transnasal decompression tube. OBSERVATIONS We have succeeded in reaching the proximal side of the stricture from the oral approach across the entire small bowel in a patient. CONCLUSIONS This modified double-balloon enteroscopy is useful for patients with bowel obstruction in whom a long decompression tube is already placed.

A case report of chronic enterocolic phlebosclerosis; a possible consequence of chronic manifestation of enterocolic phlebitis.

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