Kazunari Tominaga

Efficacy of a concomitant elemental diet to reduce the loss of response to adalimumab in patients with intractable Crohn's disease

Secondary loss of response to adalimumab (ADA‐LOR) commonly occurs in patients with Crohns disease (CD) treated with adalimumab (ADA). We evaluated the efficacy of concomitant elemental diet (ED) therapy to reduce ADA‐LOR in adult CD patients.

Association between Functional Dyspepsia and Gastric Depressive Erosions in Japanese Subjects

Objective The association between functional dyspepsia (FD) and endoscopic findings has not been fully elucidated. Helicobacter pylori infection is considered a key factor in the pathophysiology of FD. The Kyoto Classification of Gastritis (KCG) was proposed in 2014 to evaluate endoscopic findings based on the H. pylori status. We investigated the endoscopic findings associated with FD according to the KCG. Methods This cross-sectional study included subjects who underwent esophagogastroduodenoscopy during a medical health check-up. We compared the endoscopic findings between subjects with FD and healthy controls (HCs) according to the KCG. Results A total of 456 subjects were analyzed. Among them, the detection rate of FD was 5.5% (25/456 persons). In a univariate analysis of the endoscopic findings, a significantly lower proportion of subjects with FD had gastric red streak in comparison to HCs (0% vs. 18.6%, respectively; p=0.0124). Subjects with FD were more likely to have gastric depressive erosion (20.0% vs. 7.9%; p=0.0522). A higher proportion of the erosion-positive subjects had FD in comparison to erosion-negative subjects (12.8% vs. 4.8%). There were no significant differences in the other endoscopic findings, including gastric atrophy, intestinal metaplasia, enlarged fold, nodularity, and diffuse redness. A multivariate analysis revealed that gastric depressive erosion was significantly and independently associated with FD (odds ratio, 2.92; 95% confidence interval, 1.03-8.26; p=0.0436). In contrast, gastric red streak was not associated with FD (p=0.989). Conclusion Gastric depressive erosions may be associated with dyspepsia.

Neuro-gastroenterology: Central and Autonomic Nervous System

The pathophysiology of functional dyspepsia (FD) is multifactorial. The Japanese clinical practice guideline for FD published in 2014 proposes two steps of pharmacological treatment strategy: initial treatment including acid suppressants or prokinetics (strong recommendation), and second-line treatment including anxiolytics, antidepressants, and Japanese traditional medicine (weak recommendation). However, the definitive treatment flow has not been established.

Neuro-gastroenterology: Enteric Nervous System

Functional dyspepsia (FD) is a nonorganic functional disorder. The pathogenesis of FD is involved in visceral hypersensitivity and gastroduodenal dysmotility based on both genetic and environmental factors. The brain-gut interaction may be of particular importance in the regulation of digestive functions such as visceral perception, motility, and secretion. Enteric nervous system (ENS) consists of neurons and glial cells similar to the central nervous system, and can also control digestive function independently. Accordingly, ENS is so-called as a “second brain.” Interestingly, enteric glial cells (EGCs) affect both neurons and non-neuronal cells including epithelial cells, immune cells, and enteroendocrine cells to regulate neuroprotection, neurotransmission, and mucosal barrier. Moreover, EGCs change the morphology or functions in response to environmental stressors.

Pancreatic Exocrine Function

Disorders of digestive tract functions, secretion, digestion, propagation, absorption, and metabolism, can easily lead to abdominal symptoms of meal-related diseases such as functional dyspepsia (FD). Pancreatic exocrine function also exerts an important role in digestion and absorption after meal. Therefore, pancreatic exocrine must be a significant function associated with the pathogenesis of FD as well as acid secretion and gastroduodenal motility. However, it is unclear which dysfunction or organ is an origin of abdominal symptoms of FD, because symptoms felt at the epigastrium are complicatedly caused by dysfunction of both the gastroduodenum and the adjacent organ (e.g., pancreas). In addition, it is known that a mismatch in the perception site and expression between the general epigastric symptoms and FD-specific symptoms often appears in most FD patients. This issue may cause poor understandings of the accurate pathogenesis of FD.

Efficacy and safety of Helicobacter pylori eradication therapy immediately after endoscopic submucosal dissection: Ulcer healing of submucosal dissection

In the treatment of patients after endoscopic submucosal dissection (ESD), there is no consensus on the optimum time to start Helicobacter pylori eradication therapy or on whether eradication therapy improves ulcer healing rate after ESD. The aim of this study was to examine the effect of immediate eradication of H. pylori on ulcer healing after ESD in patients with early gastric neoplasms.

Cytomegalovirus infection in ulcerative colitis assessed by quantitative polymerase chain reaction: risk factors and effects of immunosuppressants

We investigated the risk factors of and appropriate treatment for cytomegalovirus colitis in patients with ulcerative colitis, using quantitative polymerase chain reaction analysis to detect cytomegalovirus in the colonic mucosa. Between February 2013 and January 2017, patients with exacerbated ulcerative colitis who were admitted to our hospital were consecutively enrolled in this retrospective, single-center study. Patients were evaluated for cytomegalovirus using serology (antigenemia) and quantitative polymerase chain reaction analyses of the colonic mucosa, which were sampled during colonoscopy. Of 86 patients, 26 (30.2%) had positive quantitative polymerase chain reaction results for cytomegalovirus; only 4 were also positive for antigenemia. The ages of the cytomegalovirus DNA-positive patients were significantly higher than those of negative patients (p = 0.002). The mean endoscopic score of cytomegalovirus DNA-positive patients was significantly higher than that of cytomegalovirus DNA-negative patients. Treatment with combined immunosuppressants was associated with an increased risk of cytomegalovirus. Fourteen of 15 (93.3%) cytomegalovirus DNA-positive patients who were negative for antigenemia showed a clinical response to treatment with additional oral tacrolimus, without ganciclovir. cytomegalovirus reactivation in active ulcerative colitis is associated with age and combined immunosuppressant therapy. Because additional treatment with tacrolimus was effective, patients who are negative for antigenemia and cytomegalovirus DNA-positive colonic mucosa may recover without antiviral therapy.

Dual antiplatelet therapy does not affect the incidence of low-dose aspirin-induced small intestinal mucosal injury in patients after percutaneous coronary intervention for coronary stenosis: a multicenter cross-sectional study

Although low-dose aspirin (LDA) is known to induce small intestinal mucosal injury, the effect of dual antiplatelet therapy (DAPT; LDA + clopidogrel) on small intestinal mucosa in patients after percutaneous coronary intervention (PCI) for coronary stenosis is unknown. Fifty-one patients with a history of PCI and LDA use were enrolled, and 45 eligible patients were analyzed. Patients were grouped based on DAPT (DAPT: n = 10 and non-DAPT: n = 35) and proton pump inhibitor (PPI) use (PPI user: n = 22 and PPI-free patients: n = 23) to compare small intestinal endoscopic findings. The relationship between LDA-use period and small intestinal endoscopic findings was also examined. Multivariate analysis was performed to identify risk factors for LDA-induced mucosal injury using age, sex, DAPT, PPI, gastric mucoprotective drug, and LDA-use period. The rate of small intestinal mucosal injury incidence did not significantly differ between DAPT and non-DAPT patients (50% vs 51.1%, respectively; p = 0.94), or PPI users and PPI-free patients (50% vs 52.2%, respectively; p = 0.88). Additionally, LDA-use period of ≤24 months (n = 15) yielded a significantly higher rate of small intestinal mucosal injury incidence than LDA-use period >24 months (n = 30) (80% vs 36.7%, respectively; p = 0.006). Multivariate analysis revealed that a LDA-use period of ≤24 months was a significant risk factor for small intestinal mucosal injury (odds ratio: 19.5, 95% confidence interval: 2.48–154.00, p = 0.005). Following PCI for coronary stenosis, neither DAPT nor PPI affected LDA-induced small intestinal mucosal injury. Moreover, patients who used LDA within the last 24 months were at a greater risk of small intestinal mucosal injury.