Ayako Saito

Role of para‐esophageal collateral veins in patients with portal hypertension based on the results of endoscopic ultrasonography and liver scintigraphy analysis

Background and Aims: Para‐esophageal collateral veins (para‐ECV) are observed by endoscopic ultrasonography (EUS) in patients with portal hypertension. However, the role of para‐ECV in the portal venous system is not clear. To verify the role of para‐ECV in the portal venous system, we investigated the relationship between the development of para‐ECV as determined by EUS, and the portal blood flow ratio (PBFR) as determined by liver scintigraphy using 99mTc‐phytate.

Collateral vessels around the esophageal wall in patients with portal hypertension: comparison of EUS imaging and microscopic findings at autopsy.

BACKGROUND In patients with portal hypertension, EUS reveals the presence of collateral vessels within and outside the esophageal wall such as esophageal varices, periesophageal collateral veins (peri-ECVs), paraesophageal collateral veins (para-ECVs), and perforating veins. This study retrospectively compared radial EUS images of these collateral vessels with histopathologic findings. METHODS Four patients with esophageal varices treated by endoscopic injection sclerotherapy were studied. EUS was performed to evaluate the effects of endoscopic injection sclerotherapy. After endoscopic injection sclerotherapy, the segment of the esophagus from the esophagogastric junction to a point 5 cm proximal to junction was imaged with a 20-MHz radial scanning catheter US probe. Esophageal collateral veins outside the esophageal wall were identified as peri-ECVs (veins lateral to muscularis propria or within adventitia) and para-ECVs (veins lateral and separate from muscularis propria) along with perforating veins (veins connecting extramural collateral veins to submucosal varices). At autopsy, the esophagus with surrounding tissue was removed and cross-sectioned at 1-cm intervals from the esophagogastric junction to a point 5 cm proximal to the junction. Radial EUS images were correlated with histopathologic findings. RESULTS Radial EUS after endoscopic injection sclerotherapy demonstrated peri-ECVs and perforating veins in all cases and para-ECVs in 3 cases. Based on histopathologic findings, veins associated with the esophageal wall were divided into 3 groups: those adjacent to the muscularis propria, veins separated from the wall without contact with the muscularis propria, and veins perforating the muscularis propria. All 3 groups of veins were observed in all cases. These 3 types of veins identified by histopathologic examination corresponded, respectively, to the peri-ECVs, para-ECVs, and perforating veins observed by EUS. CONCLUSION Collateral esophageal veins demonstrated by radial EUS in patients with portal hypertension correspond to collateral veins identified histopathologically. In patients with portal hypertension, EUS is useful for assessment of vascular anatomy around the esophageal wall.

Analysis of prognostic factors in patients with gastric varices after endoscopic treatment.

Background:  The prognostic factors, including gastric variceal bleeding itself, in patients with gastric varices (GV) after endoscopic treatment remain unclear. The aim of this study was to analyze prognostic factors in patients with GV after endoscopic treatment as well as to evaluate safety and efficacy of our endoscopic treatment.

The influence of the Great East Japan earthquake on microscopic polyangiitis: A retrospective observational study

Background Antineutrophil cytoplasmic antibody-associated vasculitis is triggered by environmental factors, including silica dust exposure. Repeated tsunami waves brought a large volume of silica-containing sludge inland after the Great East Japan earthquake in 2011. We aimed to determine if the serious disaster influenced the clinical features of the microscopic polyangiitis. Methods This is an observational retrospective study conducted in a single institute. A total of 43 patients were included based on the CHCC2012 criteria for microscopic polyangiitis from 2007 to 2015. We used the Poisson regression model to determine the incidence of microscopic polyangiitis within the annual population of the medical district. The participants were selected during a 3-year period from before (N = 13) to after the disaster (N = 20). The differences of parameters and the overall survival between the groups were analyzed. Results The incidence of microscopic polyangiitis increased after the disaster (λ = 17.4/million/year [95%CI: 7.66–39.6] before the disaster and λ = 33.1/million/year [17.7–61.7] after the disaster, P = 0.044). A high Birmingham Activity Score was associated with a high incidence of microscopic polyangiitis after the disaster. The overall survival of the patients with microscopic polyangiitis declined significantly after the disaster. Conclusions The Great East Japan earthquake influenced the development of the microscopic polyangiitis in our restricted area. The patients who developed after the disaster had severe symptoms and a high mortality rate.

Quantification of bleeding volume using computed tomography and clinical complications after percutaneous renal biopsy

Background: The aim of this study was to investigate specific bleeding volume after percutaneous renal biopsy (PRB) and the correlation between bleeding volume and clinical parameters. Methods: A retrospective study of 252 consecutive patients (153 male patients and 99 female patients) who underwent PRB at the Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, between July 2013 and January 2016 was conducted. PRB was performed under ultrasound guidance using an automated spring-loaded biopsy device and a 16-cm, 16-gauge needle. Patients underwent computed tomography (CT) the day after PRB. Bleeding volume after PRB was evaluated using reconstructed CT data. Results: The median bleeding volume after PRB was 38 mL (25th–75th percentile, 18–85 mL), with ≥4 punctures identified as a risk factor for massive bleeding. The incidence rates of macrohematuria, transient hypotension and bladder obstruction were 14.3, 8.7 and 4.7%, respectively. Post-PRB blood transfusion and intervention were required in 4.7 and 0.8% of patients, respectively. Conclusion: Although it is difficult to assess the risk for massive bleeding prior to PRB, we do provide evidence of a specific increased risk with ≥4 puncture attempts, and recommend careful follow-up of these patients.

Perirenal fat stranding is not a powerful diagnostic tool for acute pyelonephritis

Purpose Pyelonephritis, an upper urinary tract infection, is a serious infection that often requires hospitalization. However, the accurate diagnosis of acute pyelonephritis can be difficult, especially among older individuals who can present with unusual symptoms. Imaging with computed tomography (CT) is not unusual in the diagnosis of pyelonephritis, with some clinicians regarding perirenal fat stranding (PFS) as a characteristic finding. However, the sensitivity and specificity of PFS in diagnosing pyelonephritis are currently unknown. We therefore sought to clarify the relevance of PFS in diagnosing acute pyelonephritis. Patients and methods We conducted a case-controlled retrospective analysis of medical records. The pyelonephritis group included 89 patients who had been diagnosed with acute pyelonephritis, while the control group included 319 patients who had undergone percutaneous renal biopsy. CT findings were available for both groups. The frequency of PFS and its sensitivity and specificity for the diagnosis of acute pyelonephritis were investigated. Results The mean ages of the pyelonephritis and control groups were 74±15 years and 63±16 years, respectively. A total of 28% of men were in the pyelonephritis group vs 61% of men in the control group. The frequency of PFS was 72% in the pyelonephritis group vs 39% in the control group. Age and renal dysfunction were associated with an increased frequency of PFS. After adjusting for age, sex, and renal function using a propensity score analysis, the sensitivity, specificity, and positive likelihood ratio of PFS for diagnosing acute pyelonephritis were 72%, 58%, and 1.7, respectively. Conclusion The presence of PFS was not useful in diagnosing acute pyelonephritis.

Pre‐Dialysis Neutrophil‐Lymphocyte Ratio, a Novel and Strong Short‐Term Predictor of All‐Cause Mortality in Patients With Diabetic Nephropathy: Results From a Single‐Center Study

Neutrophil‐lymphocyte ratio (NLR) is an inflammatory marker affecting the prognosis of end‐stage renal disease (ESRD) patients. This study aimed to evaluate NLR levels predicting all‐cause mortality in ESRD patients with diabetic nephropathy (DN), which have not been evaluated. We recruited 151 isolated DN patients who started hemodialysis between January 2009 and December 2014 at the Japanese Red Cross Ishinomaki Hospital. The primary outcomes were 1‐ and 3‐year survival rates. The association between NLR and survival rate was evaluated using the Kaplan–Meier method and Cox proportional hazard regression analysis. Patients with an NLR ≥ 3.5 had a significantly higher mortality rate than did those with an NLR < 3.5 (log rank P = 0.02). The area under the curve (AUC) of 1‐year survival for NLR was significantly larger than that for other commonly used nutritional and inflammatory variables. NLR was a more accurate predictor than other well‐known markers.

IgG4-Related Disease Manifesting as Interstitial Nephritis Accompanied by Hypophysitis

Patient: Male, 85 Final Diagnosis: IgG4-related disease Symptoms: Renal failure Medication: — Clinical Procedure: — Specialty: Nephrology Objective: Rare disease Background: IgG4-related disease is a systemic disease with marked infiltration of IgG4-positive plasma cells into affected organs and elevated serum IgG4. On clinical examination, swelling, nodules, and hypertrophic lesions might appear simultaneously or metachronously in different organs. Case Report: An 85-year-old man with sudden-onset polydipsia and polyuria insipidus was transported to our hospital because of hypothermia and general malaise. Laboratory tests revealed renal failure and central diabetes insipidus. According to his serum IgG4 level, the patient was diagnosed with possible IgG4-related kidney disease accompanied by IgG4-related hypophysitis. Abdominal contrast-enhanced computed tomography, hypophysis magnetic resonance imaging, and histological examination of the kidney were performed. Glucocorticoid therapy was administered and his renal function improved gradually. However, his central diabetes insipidus did not improve. Conclusions: Glucocorticoid therapy showed different therapeutic effects on the kidney and posterior lobe of the hypophysis. It is possible that glucocorticoid therapy needs to be supported by other immunomodulatory therapies to have an effect on all affected organs.

Endoscopic Feature of Gastric Varices Caused by Left-Sided Portal Hypertension due to Pancreatic Disease

Endoscopic Feature of Gastric Varices Caused by Left-Sided Portal Hypertension due to Pancreatic Disease Tadayuki J. Takagi, Atsushi Irisawa, Katsutoshi Obara, Ayako Saito, Goro Shibukawa, Go Yamamoto, Takuto Hikichi, Takeru Wakatsuki, Hidemichi Imamura, Yukio Sato Background: Left-sided portal hypertension was occurred by the stricture of splenic vein due to the infiltration of the pancreatic inflammation or carcinoma, and then gastric varices often developed. The aim of this study is to reveal the endoscopic feature of gastric varices caused by left-sided portal hypertension due to pancreatic disease. Patients and Methods: One hundred six patients with pancreatic disease (chronic pancreatitis;45, carcinoma;60, metastasis;2) who were undergone endoscopic examination in our hospital were enrolled. The pancreatic diseases were diagnosed by computed tomography, ultrasonography, ERCP, and EUS-FNA. The hemodynamics of gastric varices was evaluated utilizing 3dimentiomal computed tomography and/or angiography. Results: In 7 patients (chronic pancreatitis; 1, pancreatic carcinoma; 5,metastatic pancreatic carcinoma; 1), the gastric varices were visualized by endoscopy. The frequency of existence of the gastric varices was 2.3% in chronic pancreatitis and 8.3% in pancreatic carcinoma. The endoscopic features of those gastric varices were identified as the widespread tortuous gastric-varices locating from the cardia to lower gastric body. These findings were seen in all cases. Angiographic analysis of variceal hemodynamics revealed that these gastric varices were formed by two routes; 1: the collaterals from the short gastric vein to the portal vein via coronary veins, 2; the collaterals from short gastric vein to the portal vein via gastro-epiproic vein. Conclusion: The endoscopic feature of gastric varices in patient with left-sided portal hypertension due to the pancreatic disease was the widespread tortuous gastric-varices locating from the cardia to lower gastric body, reflecting the portovariceal hemodynamics.

⁎4536 Do collaterals around esophageal wall and perforating veins influence variceal recurrence? - analysis of thirty-three patients by endoscopic ultrasonography-.

Background: The development of the esophageal varices has been demonstrated to be related to the severity of the esophageal collateral veins (ECVs) adjacent to the muscularis externa (peri-ECVs) and external to the esophageal wall but with out contact with the muscularis externa (para- ECVs) as well as the veins perforating the esophageal wall (Gastrointestinal Endosc 1999;50). In the present study, we investigated whether the recurrence of esophageal varices after initial endoscopic injection sclerotherapy (EIS) is correlated with the severity of peri- and para- ECVs and the perforating veins. Patients and Methods: Thirty-three patients who had been treated once with EIS were enrolled in this study. During a follow-up of more than 2 years after the initial EIS, 10 patients were found to have recurrent esophageal varices and 23 patients showed no signs of recurrence. The collateral and perforating veins were analyzed with a 20-MHz ultrasound catheter probe. Recurrence of esophageal varices was determined on the basis of the appearance of the esophageal varices, with a grade of F0 or higher together with red color sign positive, or varices with F1 or higher forms. Results: In the recurrence group, a higher incidence of severe-type peri-ECVs (8/10, 80% vs. 2/23, 8.7%; p