Kazuhiro Matsueda

Measurement of Spleen Stiffness by Acoustic Radiation Force Impulse Imaging Identifies Cirrhotic Patients With Esophageal Varices

BACKGROUND & AIMSnWe 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.nnnMETHODSnIn 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.nnnRESULTSnPatients 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%).nnnCONCLUSIONSnMeasurements 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.

Hepatoid carcinoma of the pancreas producing protein induced by vitamin K absence or antagonist II (PIVKA-II) and α-fetoprotein (AFP)

We describe a rare case of hepatoid carcinoma of the pancreas with production of protein induced by vitamin K absence or antagonist II (PIVKA-II) and α-fetoprotein (AFP). The patient was a 49-year-old woman admitted because of high serum levels of PIVKA-II (1.63u2009AU/ml) and AFP (623u2009ng/ml) and abnormal ultrasonographic findings of the pancreas, found incidentally at medical checkup. Both ultrasonography and computed tomography showed swelling of the pancreas with small areas of low density, but no hepatic lesions. The serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were not increased. A PIVKA-II and AFP-producing pancreatic cancer was strongly suspected, and total pancreatectomy was performed. Pathological examination showed that the tumor cells were arranged in trabecular and solid patterns with bile production, and were immunohistochemically positive for PIVKA-II and AFP, resembling hepatocellular carcinoma cells. The tumor was diagnosed as hepatoid carcinoma of the pancreas, and the patient has survived 48 months after initial diagnosis. It is important that hepatoid carcinoma be considered as a possible malignant tumor of the pancreas, and simultaneous measurement of the serum levels of AFP and PIVKA-II will enable earlier diagnosis. This is the first report describing hepatoid carcinoma of the pancreas producing PIVKA-II.

An autopsy case of granulocytic sarcoma of the porta hepatis causing obstructive jaundice.

Abstract: We describe an extremely rare case of granulocytic sarcoma of the porta hepatis causing obstructive jaundice. The patient was an 84-year-old man admitted because of obstructive jaundice. Ultrasonography (US) and computed tomography (CT) scanning of the abdomen disclosed a mass about 2.5 cm in diameter near the neck of the gallbladder, and thickening of the gallbladder wall. Based on these findings, gallbladder carcinoma was suspected. After endoscopic retrograde biliary drainage (ERBD) was performed, the jaundice resolved. However, blast cells were detected in the peripheral blood 51 days after admission, and laboratory studies disclosed acute myelocytic leukemia (AML: French-American-British [FAB] type M0). We treated him conservatively, with antibiotics and ERBD but he died of disseminated intravascular coagulation. Autopsy showed that the suspected gallbladder carcinoma was actually a granulocytic sarcoma arising in association with AML and causing obstructive jaundice. The largest tumor involved the porta hepatis. It should be kept in mind that granuloctyic sarcoma is a possible cause of obstructive jaundice, even in patients with no evidence of AML.

Effectiveness of endoscopic biliary drainage for unresectable hepatocellular carcinoma associated with obstructive jaundice.

Abstract: Endoscopic biliary drainage (EBD) for unresectable hepatocellular carcinoma (HCC) associated with obstructive jaundice remains controversial because of the short survival of these patients. To evaluate the effectiveness of this procedure, we retrospectively studied 18 patients who had unresectable HCC with obstructive jaundice and underwent EBD with poly-ethylene stents, over a 10-year period. Nine patients with tumor thrombus involving the first branches of the portal vein or portal trunk (Vp3) formed group A and the other 9 (Vp0–Vp2) formed group B. The serum albumin level and serum total bililubin level differed significantly between the two groups (P < 0.05 and P < 0.005, Students t-test), but prothrombin time did not. The obstructive jaundice was mainly caused by direct tumor invasion in 6 patients from group A and 3 from group B, by blood clots and/or tumor fragments in 2 patients from group A and 3 from group B, by the tumor protruding into the common hepatic duct in 2 patients from group B, and by tumor compression of the common bile duct in 1 patient from each group. Drainage was successful in 4 patients (44%) from group A and in all 9 patients (100%) from group B. Among the 5 patients with unsuccessful drainage in group A, 4 had obstruction of both the left and right hepatic ducts and 3 had multiple tumors in both lobes. The mean survival time (mean ± SD) after EBD was 47 ± 44 days in group A and 181 ± 70 days in group B. In group A, the average survival time was only 85 days in the 4 patients with successful drainage. However, an improvement in the quality of life after EBD was observed in one-third of the Vp3 patients and in all of the Vp0–Vp2 patients. In summary, satisfactory palliation is possible with successful EBD, but this is difficult in most patients with Vp3 portal thrombus, direct tumor invasion involving both hepatic ducts, and multiple tumors in both lobes. It is important to determine the site, extent, and nature of the obstruction, as well as liver function and the presence of portal thrombus, before performing EBD.

Perfusion CT is superior to angiography in predicting pancreatic necrosis in patients with severe acute pancreatitis

BackgroundWe performed perfusion computed tomography (P-CT) and angiography of the pancreas in patients with severe acute pancreatitis (SAP) and compared the usefulness of these two methods in predicting the development of pancreatic necrosis.MethodsWe compared P-CT and angiography results taken within 3xa0days after symptom onset in 21 SAP patients. We divided the pancreas into three areas, the head, body, and tail, and examined each area for perfusion defects (via P-CT) and arterial vasospasms (by angiography). Three weeks later, all patients underwent contrast-enhanced CT to determine whether pancreatic necrosis had developed.ResultsOf the 21 SAP patients, 16 exhibited perfusion defects, while 17 proved positive for vasospasms in at least one area. Fourteen patients developed pancreatic necrosis. Of the 63 pancreatic areas from the 21 SAP patients, perfusion defects appeared in 25 areas (39.7%), 24 of which showed vasospasms (96.0%). Angiography showed 33 areas with vasospasms (52.4%), of which 24 showed perfusion defects (72.7%). Of the 25 areas with perfusion defects, 21 developed pancreatic necrosis (84.0%). Of the 33 areas with vasospasms, 21 developed necrosis (63.6%). Pancreatic necrosis developed only in the areas positive both for perfusion defects and for vasospasms. No areas without perfusion defect or vasospasms developed pancreatic necrosis. P-CT predicted the development of pancreatic necrosis with significantly higher accuracy than angiography.ConclusionWhile both P-CT and angiography are useful in predicting the development of pancreatic necrosis in patients with SAP, P-CT appears to be more accurate for this purpose.

Usefulness of perfusion computed tomography for early detection of pancreatic ischemia in severe acute pancreatitis

Epinephrine undergoes a significant first pass effect in the liver. Lack of systemic side-effects after a submucosal epinephrine injection in the stomach and duodenum has been attributed to its rapid clearance by the hepatic enzymes, catechol-O-methyl transferase and monoamine oxidase. As for the patient reported here, the injections probably produced an unusually high plasma epinephrine level, resulting in the observed hypertension and its related complications as amaurosis fugax. Thus, it would be reasonable to perform a careful follow-up of patients who are hypertensive, elderly and have atherosclerotic heart disease during and after an endoscopic submucosal epinephrine injection.

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 ageu2009±u2009standard 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.

Hepatic arterial perfusion increases in the early stage of severe acute pancreatitis patients: evaluation by perfusion computed tomography.

PURPOSEnAlthough hepatic perfusion abnormalities have been reported in patients with acute pancreatitis, hepatic perfusion with severe acute pancreatitis (SAP) has not been quantitatively evaluated in humans. Therefore, we investigated hepatic perfusion in patients with SAP using perfusion CT.nnnMATERIALS AND METHODSnHepatic perfusion CT was performed in 67 patients with SAP within 3 days after symptom onset. The patients were diagnosed as having SAP according to the Atlanta criteria. Fifteen cases were established as a control group. Perfusion CT was obtained for 54s beginning with a bolus injection of 40 ml of contrast agent (600-630 mgI/kg) at a flow rate of 4 ml/s. Perfusion data were analyzed by the dual-input maximum slope method to obtain hepatic arterial perfusion (HAP) and hepatic portal perfusion (HPP). Finally, we compared HAP and HPP in SAP patients with those in the control group, respectively.nnnRESULTSnAverage HAP was significantly higher in SAP patients than in the control group (75.1 ± 38.0 vs. 38.2 ± 9.0 ml/min/100ml; p<0.001). There was no significant difference in average HPP between SAP patients and the control group (206.7 ± 54.9 vs. 204.4 ± 38.5 ml/min/100ml; p=0.92).nnnCONCLUSIONnUsing quantitative analysis on perfusion CT, we first demonstrated an increase of HAP in the right hepatic lobe in SAP patients.

Mo1998 Adenocarcinoma of the Esophagogastric Junction Is Still Low in Japan -Multicenter Epidemiological Study in Kurashiki, Japan

Background & Aims: In Asia, gastroesophageal reflux disease (GERD) related diseases such as Barretts esophagus (BE) and adenocarcinoma of the esophagogastric junction (AEGJ), have traditionally been considered less common than in Western countries. Although the number of reported cases of these conditions in Japan has been gradually increasing in recent years, little is known about the epidemiology of AEGJ. The aim of this study was to investigate the clinicoepidemiological characteristics of AEGJ in Japan. Methods: From January 2008 to June 2010, 88,199 consecutive cases (48,548 males and 39,651 females; mean age, 62 years) of upper gastrointestinal (GI) endoscopies performed at 12 hospitals in Kurashiki, Japan were recruited. They were prospectively followed up for a mean period of 4.0 years. For a 6.5-year period ranging from January 2008 to June 2014, we reviewed all endoscopic reports and associated medical records. AEGJ was defined as an adenocarcinoma of the distal esophagus (Siewert Type I) and a true carcinoma of the cardia (Siewert Type II). Furthermore, risk factors associated with AEGJ were identified by comparing data from AEGJ patients with age and gender matched controls using a multiple logistic regression method. Results: During the study period, 83 patients with AEGJ were identified (72 males and 11 females; mean age, 68 years); six patients of Siewert Type I and 77 patients of Siewert Type II. The incidence rate of AEGJ was in the range of 0.9 1.5 per 100,000 person-years and did not increase by year. Results of univariate analysis were shown in Table 1. Multivariate analysis showed that risk factors for AEGJ included obesity [body mass index (BMI) > 25 kg/m2] (Odds ratio (OR) = 3.33; 95% confidence interval (CI), 1.57 7.08; P = 0.002), hiatal hernia (OR= 2.08; 95% CI, 1.04 4.18; P = 0.039), and smoking (OR= 1.92; 95% CI, 1.01 3.65; P = 0.047). Conclusions: The incidence of AEGJ is still lower in Japan than in Western countries, although similar risk factors of AEGJ as western patients are detected such as obesity, hiatal hernia, smoking, and male gender. Table 1. Results of univariate analysis for AEGJ

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.