Keiichiro Kume

Variable stiffness colonoscopes are associated with less pain during colonoscopy in unsedated patients

OBJECTIVES:Application of a new variable stiffness colonoscope (VSC) is expected to control loop formation and to lessen patient discomfort. The aim of this prospective study was to compare the efficacy of VSC with a conventional colonoscope (CC) in unsedated colonoscopy, based on the experience of examiners.METHODS:Four-hundred sixty-seven patients were randomly assigned to undergo colonoscopy with either VSC or CC by an endoscopist, including experienced and less-experienced examiners. The percentages of completed procedure and time to cecal intubation were recorded. Patients were asked to rate pain on a 5-point pain score.RESULTS:The percentages of completed procedure with VSC and CC were 98% and 95%, respectively, by less-experienced hands, and 99% and 98%, respectively, by experienced hands. Time for cecal intubation with VSC and CC was 15.7 and 18.5 min, respectively, by less-experienced hands, and 9.8 and 10.6 min, respectively, by experienced hands. A significantly lower mean pain score was noted in VSC patients compared with CC patients, irrespective of experience of the examiner. The percent of patients rating the procedure as moderately or severely painful was significantly lower with VSC than with CC, both in less-experienced (19% vs 40%; p < 0.01) and experienced hands (15% vs 26%; p < 0.05).CONCLUSIONS:Our results indicated that VSC allows favorable examination compared with CC regarding completeness, time to cecal intubation, and comfort of patients undergoing unsedated colonoscopy, irrespective of the examiners experience. These features suggest VSC as the preferred colonoscope for patients undergoing unsedated colonoscopy.

Asymptomatic amebic colitis in a homosexual man

ABSTRACTWe describe case of a 75-yr-old Japanese homosexual man who was diagnosed as having amebic colitis. The present case is unique in that invasive amebiasis has occurred in a homosexual man, because Entamoeba histolytica in homosexual patients is considered to be a nonpathogenic and commensal organism in western countries, and that the patient has not complained of any gastrointestinal symptoms associated with minute colonic lesion of an isolated cecal ulcer. This report indicates that the absence of gastrointestinal symptoms does not rule out invasive amebiasis. Therefore, once the ameba is identified in stool specimens, even in homosexual men, it is important to differentiate pathogenic from nonpathogenic species irrespective of whether the patient is symptomatic, and to treat the patient infected with pathogenic species. By means of this strategy, we can prevent pathogenic ameba from spreading in the community.

EMR of upper GI lesions when using a novel soft, irrigation, prelooped hood

BACKGROUND EMR with a cap-fitted endoscope, including a soft, prelooped hood, is a useful, effective, and safe technique. One problem with this method, however, is that the lesion cannot always be kept in the center of the cap because the procedure is performed blindly after aspiration. A soft, prelooped hood with attached irrigation tube was developed. The usefulness of this device for EMR of upper-GI intramucosal cancers was evaluated. METHODS The end-hood piece was fabricated by drilling a side hole in the cap portion of a conventional soft, prelooped hood and then attaching an irrigation tube with glue to the exterior surface of the hole. The fabricated transparent hood was placed at the tip of an endoscope, and aspiration mucosectomy under irrigation was performed in 15 patients with upper-GI intramucosal cancer. When the field of view at the aspiration site was obscured by oozing blood, the site was irrigated. RESULTS A satisfactory view was obtained of all lesions. The mean diameter of specimens was 24.5 mm (interquartile range: 15-35). The proportion of en bloc resected lesions was 86.7% (13/15). Bleeding was the only complication (4/15; 26.7%) and was controlled by using endoscopic hemostatic techniques under irrigation. CONCLUSIONS EMR when using the soft, prelooped hood with irrigation tube is effective and safe for intramucosal cancers 20 mm or less in diameter.

Endoscopic mucosal resection for early gastric cancer : comparison of two modifications of the cap method

BACKGROUND AND STUDY AIM Endoscopic mucosal resection using a cap (EMR-C) is an established method for curative resection of early neoplastic lesions; prelooping of the snare may however be difficult and lead to imprecise resection. We therefore compared two modifications of the conventional technique using outer snare placement with an accessory channel in a prospective, nonrandomized study. PATIENTS AND METHODS Between October 2004 and March 2007, 54 patients (men 37, women 17; mean age 71 years) underwent EMR. One method involved an internally retained snare (IRS) cap, with a fixed prelooped snare inside the cap; the other method used an externally guided snare (EGS) cap with the snare guided over an oblique cap. The main outcome parameters were specimen size, en bloc resection, and complications. RESULTS There was no difference between use of the IRS and EGS cap methods in relation to specimen size (27.6 vs. 27.1 mm), or rates of en bloc resection (88.9 % vs. 83.3 %); only one perforation occurred, and this was in the EGS group. CONCLUSION Both techniques appeared to provide similar efficacy, the inner rim of the IRS cap stabilizes aspiration of the lesion compared with the EGS cap that does not have it.

Ischemic Colitis Associated With Paclitaxel and Carboplatin Chemotherapy

TO THE EDITOR: Combination chemotherapy regimens including paclitaxel have been widely used for standard treatment of many solid tumors. Reported adverse effects on the gastrointestinal tract in paclitaxel-containing chemotherapy regimens are pseudomembranous colitis (1) and gastrointestinal necrosis (2). We describe a case of ischemic colitis (IC) after chemotherapy with paclitaxel and carboplatin. Endoscopic findings of IC are documented. The patient was a 68-yr-old Japanese woman who had been operated on for left upper lobectomy for squamous cell lung cancer. Thirty-seven days after the operation (on day 1), the patient was treated for lymph node metastasis with 135 mg/body of paclitaxel and 240 mg/body of carboplatin at the surgery department of our university hospital. On day 3, she had bloody watery diarrhea five times, with upper abdominal pain, although she had no constipation, fever, nausea, or vomiting. She also had no mucositis or abdominal tenderness. The white blood cell count was increased (15,600/mm), but the C-reactive protein level was normal. On day 5, the patient was consulted at the internal medicine department. Although she had no diarrhea, both white blood cell count and C-reactive protein levels were increased (12,600/mm and 5.3 mg/100 ml, respectively). Colonoscopy showed acute colitis on the right side of the transverse colon. Annular colonic mucosa was hemorrhagic with superficial ulceration (Fig. 1A). It also showed longitudinal ulcerations on the anal side of the hemorrhage with ulceration (Fig. 1B). A pseudomembrane was not detected. A pathological examination of the biopsy specimens showed a mild acute inflammatory infiltration and mild edema with regenerative epithelium, together with a necrotic slough in the colonic mucosa. Stool cultures were normal flora. From these findings, we diagnosed the patient with IC caused by chemotherapy. The patient received total parental nutrition from day 5 to day 14. On day 9, both white blood cell count and C-reactive protein levels returned to normal. On day 14, a barium study showed mild stenosis with ulceration on the right side of the transverse colon indicating healing stage of IC. On day 37, colonoscopy showed a scar on the right side of the transverse colon. Chemotherapy reagents have been implicated in three patterns of necrotizing colitis—pseudomembranous colitis, neutropenic enterocolitis, and IC (3). Pseudomembranous colitis is the common disease after chemotherapy including paclitaxel (1). Several cases of neutropenic enterocolitis after taxane (paclitaxel and docetaxel)-containing chemotherapy have been reported (4–6). Although IC typically develops in people who are otherwise healthy (7), it can also develop after anticancer chemotherapy (3). Ibrahim et al. (4) reported a case of IC as pancolitis after chemotherapy with docetaxel and cyclophosphamide for liver metastasis from breast cancer. Seewaldt et al. (2) also observed and reviewed paclitaxel-associated gastrointestinal necrosis. They postulated that gastrointestinal necrosis is the result of a direct taxane-based effect on the gastrointestinal epithelium (2), although a synergistic interaction between compromised bowel and taxan-induced mitotic arrest is also suggested. Only a single brief report about paclitaxel-associated IC is available. Daniele et al. (8) reported a case of transient mild IC after chemotherapy with paclitaxel and carboplatin for liver metastasis from a neuroendocrine tumor of unknown origin. Colonoscopy is the preferred diagnostic examination for many kinds of colitis because it is more sensitive in diagnosing mucosal abnormalities, and tissue biopsy can be obtained (7). Diarrhea is a common complication of cancer chemotherapy, whereas bloody diarrhea is rare. Therefore, colonoscopy is also important for diagnosis and prompt therapy after chemotherapy with bloody diarrhea (9). Be-

Infliximab treatment in a patient with Crohn’s disease on haemodialysis

A 33-year-old man with a 15-year history of CD, first diagnosed in 1991, underwent an ileal resection the same year. In 1997 he developed marked proteinuria (2 g ⁄ day) that gradually worsened so that haemodialysis was required by 2002. Secondary amyloidosis was diagnosed in 1997. The patient underwent a second small bowel resection in June 2003. Between 2000 and 2003, the Crohn’s disease activity index (CDAI) was always more than 300, despite treatment with steroids and immunosuppressants. The use of infliximab was discussed with the patient and, as a result, this drug was given from August 2003, at a dose of 5 mg ⁄ kg, at 0, 2 and 6 weeks, and then every 8 weeks thereafter. Following initiation of infliximab, a dramatic improvement the patient’s disease was observed, as evidenced by both clinical and laboratory parameters, without impairment in renal function. The CDAI fell below 150. After approximately 5 years of infliximab treatment, the patient has remained in clinical remission with no adverse effects.

Disappearance of both MALT lymphoma and hyperplastic polyps in the stomach after eradication of Helicobacter pylori

Disappearance of both MALT lymphoma and hyperplastic polyps in the stomach after eradication of Helicobacter pylori

Focal therapeutic efficacy of transcatheter arterial infusion of styrene maleic acid neocarzinostatin for hepatocellular carcinoma

Abstract: We evaluated the focal therapeutic effect of oily carcinostatic agents administered by transcatheter arterial infusion (TAI) as the initial therapy in patients with hepatocellular carcinoma in a randomized controlled clinical trial. Group A (19 patients) received 4 mg of styrene maleic acid neocarzinostatin in 4 ml of Lipiodol, and group B (18 patients) received 100 mg of epirubicin in 4 ml of Lipiodol via the tumor feeding arteries as peripherally as possible. The grade of Lipiodol accumulation and the tumor regression rate were determined 2 weeks after TAI by computerized tomography. Adverse effects within 2 weeks after TAI were evaluated by subjective signs and symptoms such as fever (maximum body temperature) and the frequency of shaking chills and abdominal pain, and by biochemical parameters such as albumin, prothrombin time, and aspartate and alanine aminotransferases. Lipiodol accumulation in the tumor was significantly greater in group A (12/19; 63.2% showing grade IV Lipiodol accumulation) than in group B (3/18; 16.7% showing grade IV) (P < 0.05). The tumor regression rate was also significantly greater in group A (8/17; 47.1% showing more than 25% tumor regression) than in group B (1/13; 7.7% showing more than 25% tumor regression) (P < 0.05). Although clinically significant elevations of aminotransferases and reductions of cholinesterase, and shaking chills were observed more often in group A than in group B (P < 0.0001), these factors had little influence on the clinical outcome. Our results suggest that styrene maleic acid neocarzinostatin in Lipiodol exerts a more favorable focal therapeutic effect than does epirubicin in Lipiodol in the initial treatment of hepatocellular carcinoma.

PSEUDOMALIGNANT EROSION IN HYPERPLASTIC POLYP AT ESOPHAGO‐GASTRIC JUNCTION

To the Editor, Generally, the hyperplastic polyp of the stomach must be considered to be a benign lesion. We have observed atypical changes, like malignancy, in the stroma of one hyperplastic polyp located at the esophago-gastric junction (EGJ). A 70-year-old man, with no history of non-steroidal anti-inflammatory drug use and prior hematemesis, visited our hospital because of melena and concomitant severe anemia. He had been subjected to a subtotal gastrectomy 25 years ago. Upper gastrointestinal endoscopy revealed a polyp, shell-shaped, at the EGJ and no other lesions in the remnant stomach. The head of the polyp was formed out of white-coated ulcer and erosion (Fig. 1a). Microscopic findings of the biopsy specimen taken from the gastric polyp demonstrated fragments of elongated hyperplastic foveolar epithelium and inflamed granulation tissue with large cells having basophilic cytoplasm and large hyperchromatic nuclei containing prominent nucleoli, associated with necrotic slough peripherally. Nuclear pleomorphism and mitotic figures were seen (Fig. 1b). Immunohistochemically, the large cells were negative for anticytomegalovirus, antiherpes simplex virus antibodies and cytokeratins (CAM5.2, AE1/AE3), while they were positively reactive to vimentin. Based on these findings, the patient was suspected to have stromal atypia in the remnants of polypoid lesion at the EGJ and so an endoscopic mucosal resection (EMR) of the whole polyp was performed. Histologically, the resected polypoid lesion proved to be hyperplasia of foveolar epithelia with moderate chronic inflammation and edema of the stroma. In the regional polypoid lesion, there was inflamed granulation tissue with large cells having basophilic cytoplasm and large hyperchromatic nuclei containing prominent nucleoli, associated with erosion and necrotic debris. There was no evidence of malignancy. The resected polypoid lesion was hyperplastic polyp, so this case was diagnosed as hyperplastic polyp with pseudomalignant erosion. Follow-up of this patient, ranging in duration of 2 years, disclosed no evidence of recurrence. We have described a polypoid lesion with a distinctive histological appearance associated with ulceration and erosion, which locates at the EGJ. Endoscopic features, white coated and reddish mucosa of the top of the polyp, suggested a malignant lesion. Histologically, some stromal cells have striking atypical form, like occasional mitotic figures. It is difficult to make the differential diagnosis (DD) of this polyp with its endoscopic and histological appearance of a malignancy. The DD includes viral infection, lymphoma, poorly differentiated carcinoma, spindle cell carcinoma, and sarcoma. Although the large atypical cells have a superficial resemblance to cells infected with cytomegarovirus, typically cytomegalovirus-infected cells have a large intranuclear halo and, not infrequently, intracytoplasmic inclusions. There is absence of characteristic features of their malignancy and cytomegalovirus infection in this case.

Gastrointestinal : Inflammatory myoglandular polyp of the colon

An inflammatory myoglandular polyp of the large bowel is a rare but distinct clinical entity that was first described by Dr S Nakamura and others in 1992. It is characterized histologically by inflammatory granulation tissue in the lamina propria, proliferation of smooth muscle and hyperplastic glands which sometimes show cystic dilatation. The typical endoscopic appearance is that of a pedunculated spherical polyp with a smooth surface and patchy redness that resembles a ripe strawberry. There may also be a patchy mucous exudate. Thus far, only a small number of cases have been reported and the pathogenesis and natural history remain unclear. We describe the endoscopic and histological findings of an inflammatory myoglandular polyp in the distal transverse colon. A 42-year-old Japanese man was investigated because of a positive fecal occult blood test. Barium enema radiographs revealed two colonic polyps: one in the distal transverse colon and one in the sigmoid colon. At colonoscopy, the polyp in the transverse colon was approximately 10 mm in diameter with a spherical shape, pedunculated base and a smooth surface as shown in Figure 1. Red areas were noted on the surface of the polyp. Histological evaluation revealed hyperplastic glands and an inflamed and widened fibromuscular stroma with lymphoid follicles (Fig. 2; HE ×25). The appearance was consistent with an inflammatory myoglandular polyp. The polyp in the sigmoid colon was a small tubular adenoma. Inflammatory myoglandular polyps need to be distinguished from Peutz-Jegher-type polyps, juvenile polyps, inflammatory polyps, inflammatory cap polyps, and polyps associated with mucosal prolapse, sometimes involving colostomy sites.