Fuyuhiko Yamamura

Diagnosis of colorectal lesions with the magnifying narrow-band imaging system

BACKGROUND Narrow-band imaging (NBI) emphasizes the surface microvasculature of the GI tract and may help in detecting small neoplasms. OBJECTIVE The aim of this study was to clarify the value of the NBI system in tissue characterization and differential diagnosis. DESIGN A prospective study. SETTING Digestive Disease Center of Showa University Northern Yokohama Hospital. PATIENTS The subjects were 495 patients who, from January 2006 to June 2007, underwent a complete colonoscopic examination. A total of 617 lesions were evaluated in the 495 patients (33 hyperplastic polyps, 532 adenomas, 52 submucosally invasive [T1] cancers). RESULTS Most hyperplastic polyps showed a faint pattern. The vascular patterns of adenomas were mainly the network pattern or the dense pattern. The major vascular patterns of cancers were the irregular pattern and the sparse pattern. The irregular pattern was characteristic for protruded or flat-elevated cancers, whereas the sparse pattern was unique for depressed cancers. When we assumed that the faint pattern was diagnostic for hyperplastic polyps, we could differentiate between neoplastic and non-neoplastic lesions with a sensitivity of 90.9% and a specificity of 97.1%. Likewise, irregular and sparse patterns were assumed to be indices of massively invasive submucosal cancer, the sensitivity was 100%, the specificity was 95.8%, and the accuracy rate was 96.1%. LIMITATIONS This study was performed at a single center. CONCLUSIONS The NBI system was valuable for distinguishing between neoplastic and non-neoplastic lesions, as well as between cancers and adenomas. Vascular pattern analysis can also be a promising tool for determining treatment selection, either endoscopy or surgery.

A case of autoimmune pancreatitis responding to steroid therapy

We report a case of autoimmune pancreatitis without obvious evidence of autoimmunological participation, which responded well to steroid treatment and provided histologic and radiographic evidence for this improvement. A 68-year-old woman presented abdominal fullness, diffuse pancreatic swelling on abdominal computed tomography and ultrasonography, and diffuse narrowing of the main pancreatic duct on endoscopic retrograde pancreatography. Transgastric aspiration needle biopsy of the body of the pancreas performed under endoscopic ultrasonography showed severe atrophy of acinar cells, infiltration of T lymphocytes. She was diagnosed as having autoimmune pancreatitis without obvious evidence of autoimmunological participation. Administration of 30 mg/day of predonisolone was started. Computed tomography showed marked improvement of the diffuse swelling of the pancreas, and endoscopic retrograde pancreatograpy showed amelioration of the narrowing of the main pancreatic duct after the start of treatment. Pancreatic tissue obtained by needle biopsy after the start of treatment with predonisolone revealed marked histologic improvement, including amelioration of the fibrosis, and infiltration of inflammatory lymphocytes, and a substantial increase in the number of pancreatic acinar cells. The present report is the first to demonstrate histologic recovery of autoimmune pancreatitis after steroid therapy.

A case of autoimmune pancreatitis complicated with immune thrombocytopenia during maintenance therapy with prednisolone.

A unique form of chronic pancreatitis, primary inflammatory sclerosis of the pancreas, which may result from an autoimmune mechanism, was first reported by Sarles et al (1). Since then, several authors have reported similar cases, and Yoshida et al (2) first proposed the concept of autoimmune pancreatitis. One of the characteristics of so-called autoimmune pancreatitis is an occasional association with other autoimmune diseases such as Sj ̈ ogren’s syndrome (3), primary biliary cirrhosis (4), and primary sclerosing cholangitis (4, 5). However, autoimmune pancreatitis rarely associates with immune thrombocytopenia, and only one case has been previously reported in the Japanese literature (6). According to this report, autoimmune pancreatitis and immune thrombocytopenia occurred concomitantly. We report a case complicated with immune thrombocytopenia during maintenance therapy with prednisolone for autoimmune pancreatitis. In our case, elevation of serum level of total immunoglobulin (Ig) G was thought to be suggestive of the development of other autoimmune disease, and the determination of IgG subclass would provide a useful tool to differentiate exacerbation of autoimmune pancreatitis from the development of other autoimmune disease.

Double staining with crystal violet and methylene blue is appropriate for colonic endocytoscopy: An in vivo prospective pilot study

Endocytoscopy (EC) at ultra‐high magnification enables in vivo visualization of cellular atypia of gastrointestinal mucosae. Clear images are essential for precise diagnosis by EC. The aim of the present study was to evaluate the optimal staining method for EC in the colon.

Relationship between Helicobacter pylori infection and histologic features of gastritis in biopsy specimens in gastroduodenal diseases, including evaluation of diagnosis by polymerase chain reaction assay.

Abstract: We investigated the relationship between Helicobacter pylori infection and the histologic features of gastritis in gastroduodenal disease, and evaluated the diagnostic usefulness of the polymerase chain reaction (PCR) assay for the detection of H. pylori before and after eradication therapy. Endoscopic biopsy specimens from 81 patients with gastroduodenal disease were examined for the presence of H. pylori by culture and histologic examination. Histologic features of gastritis were classified according to the updated Sydney System, and results of the PCR assay were compared with those of histologic examination, using histologic scores. The density of H. pylori was significantly correlated with polymorphonuclear neutrophil activity and chronic inflammation. These findings suggest that the grades of infiltration of polymorphonuclear neutrophil cells and chronic inflammatory cells correspond to the density of H. pylori infection assessed by the updated Sydney System. Patients with positive results on PCR assay and negative results on histologic examination may have a low density of H. pylori because of severe atrophy in the gastric mucosa. Differences in results for the PCR assay and histologic examination were found in 2 of 12 patients in the detection of H. pylori after eradication therapy. According to the results of the PCR assay and histologic features before and after eradication, the gastric tissue-based PCR assay for H. pylori after eradication may be too sensitive to judge successful eradication of H. pylori.

Endocytoscopic narrow-band imaging efficiency for evaluation of inflammatory activity in ulcerative colitis.

AIM To assess the efficacy of endocytoscopic narrow-band imaging (EC-NBI) for evaluating the severity of inflammation in ulcerative colitis (UC). METHODS This retrospective study was conducted at a single tertiary care referral center. We included UC patients who underwent colonoscopy with endocytoscopy from July 2010 to December 2013. EC-NBI was performed, and the images were evaluated by assessing visibility, increased vascularization, and the increased calibers of capillaries and were classified as Obscure, Visible or Dilated. Obscure was indicative of inactive disease, while Visible and Dilated were indicative of acute inflammation. This study received Institutional Review Board approval. The primary outcome measures included the diagnostic ability of EC-NBI to distinguish between active and inactive UC on the basis of histological activity. The conventional endoscopic images were classified according to the Mayo endoscopic score. A score of 0 or 1 indicated inactive disease, whereas a score of 2 indicated active disease. RESULTS Fifty-two patients were enrolled. There was a strong correlation between the EC-NBI findings and the histological assessment (r=0.871, P<0.01). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EC-NBI for diagnosing acute inflammation were 84.0%, 100%, 87.1%, 100%, and 92.3%, respectively, while those for the Mayo endoscopic score were 100%, 40.7%, 100%, 61.0%, and 69.2%, respectively. Compared with conventional endoscopy, EC-NBI was superior in diagnostic specificity, negative predictive value, and accuracy (P<0.001, P=0.001 and P=0.047, respectively). CONCLUSION The EC-NBI finding of capillaries in the rectal mucosa was strongly correlated with histological inflammation and aided in the differential diagnosis between active and inactive UC.

Case of liver localized nodular hyperplasia reduced by natural course.

患者は, 58歳, 女性. 検診の腹部超音波検査で肝のS2およびS6領域に腫瘤性病変が認められた. さらにCD-US, CT, MRI, scintigraphy, angiography, 肝生検等の検査を施行した. S2領域の腫瘤は不変であったが, CD-USとangiographyにてS6領域の腫瘤内に車軸様血管を認め, 肝生検組織検査にて悪性所見を認めないことよりFocal nodular hyperplasia (FNH) と診断された. 腫瘤は, 約3年で16mmから30mmに増大し, 約2年後に17mmまで縮小した. 肝動脈の形成異常に起因する動脈床の増大による肝細胞の過形成変化として形成されたFNHは, 自然経過, あるいは生検による腫瘤内血流の変化により, 動脈血栓を生じて縮小したと推定された.