Koichi Kurahara

Clinical and endoscopic features of nonsteroidal anti-inflammatory drug-induced colonic ulcerations

OBJECTIVE:Clinical and endoscopic features of nonsteroidal anti-inflammatory drug (NSAID)-induced colonic ulcerations have not been fully investigated.METHODS:During a 3-yr period from April 1996 to March 1999, 6076 subjects underwent total colonoscopy at our institutions. Among them, the diagnosis of NSAID-induced colonic ulceration was made by their clinical and colonoscopic findings. All patients diagnosed as having this disease underwent upper endoscopy and follow-up colonoscopy. Clinical features, serial changes in colonoscopic findings, and upper GI lesions were analyzed.RESULTS:Among the subjects, 14 patients were diagnosed as having NSAID-induced ulcerations. Seven patients were complicated by renal failure. Three patients had gastric ulcers concurrently. Eleven patients had colonic lesions in the ileocecal region. In 13 of 14 patients, initial colonoscopy demonstrated sharply demarcated, semilunar or circumferential ulcers without stricture formation. After discontinuance of NSAIDs, improvement of the ulcers without stricture or inflammatory polyps could be confirmed 3–10 wk later. In one patient with diaphragm-like stricture, follow-up colonoscopy performed 2 yr later demonstrated resolution of circumferential ulcer.CONCLUSIONS:NSAID-induced colonic ulceration may occur more frequently than previously recognized. Frank ulcerations, rather than stricture formation, seem to be the typical colonoscopic signs of NSAID-induced colonic ulceration.

Comparison of EUS and magnifying colonoscopy for assessment of small colorectal cancers

BACKGROUND Prediction of invasion depth and lymph node metastasis is mandatory when local treatment is considered for small colorectal cancer. The aim of this study was to compare the accuracy of EUS with a catheter probe (probe-EUS) and magnifying colonoscopy for prediction of invasion depth and lymph node metastasis for small colorectal cancer. METHODS Small colorectal cancers were imaged by both probe-EUS and magnifying colonoscopy. Invasion depth by probe-EUS was determined by the presence or absence of distortion of the third sonographic layer. Findings by magnifying colonoscopy were divided into regular, distorted, and amorphous patterns. Histopathologically, depth of invasion was classified as intramucosa/slight or deep invasion. Findings by probe-EUS and magnifying colonoscopy were compared with respect to deep invasion and lymph node metastasis. RESULTS There were 22 small colorectal cancers with intramucosa/slight invasion and 28 with deep invasion. Four of 30 cancers had associated lymph node metastasis. Accuracy for depth of invasion was 91.8% for probe-EUS and 63.3% in magnifying colonoscopy, the difference being statistically significant (p = 0.0013). Negative predictive value of probe-EUS for deep invasion was higher than that for magnifying colonoscopy (respectively, 90.9% vs. 54.1%) in the population studied (prevalence deep invasion 56%). The accuracy for lymph node metastasis was 24.1% for probe-EUS and 72.4% for magnifying colonoscopy, the difference being statistically significant (p < 0.001). Positive predictive value for lymph node metastasis was higher when the amorphous pattern was noted by magnifying colonoscopy compared with the positive predictive value for deep invasion by probe-EUS (respectively, 33.3% vs. 8.7%) in the population studied (prevalence lymph node metastasis 13.3%). CONCLUSIONS Probe-EUS is superior to magnifying colonoscopy for determination of invasion depth in small colorectal cancer. Magnifying colonoscopy may be predictive of lymph node metastasis, thereby suggesting that the procedures provide complementary information with respect to the decision for local versus surgical therapy.

Treatment of herpes simplex esophagitis in an immunocompetent patient with intravenous acyclovir: a case report and review of the literature.

A 35-yr-old, immunocompetent male was admitted complaining of severe odynophagia. He was diagnosed as having herpes simplex esophagitis and was started on intravenous acyclovir 5 mg/kg every 8 h on the day of admission. His response was dramatic. Within 24 h he was virtually asymptomatic. Acyclovir therapy in immunocompetent adults with esophagitis has been described in only a handful of cases in the literature, although the therapy is well established in immunocompromised patients. We review the English literature and discuss the efficacy of the therapy. Acyclovir therapy may be beneficial in immunocompetent patients with particularly severe odynophagia.

Management and clinical outcomes of type I gastric carcinoid patients: retrospective, multicenter study in Japan.

Type I gastric carcinoids (TIGC) are associated with chronic atrophic gastritis (CAG) with hypergastrinemia and hyperplasia of enterochromaffin‐like cells. Several treatment options are currently available for these tumors including total gastrectomy, partial resection, antrectomy, endoscopic resection and endoscopic surveillance. The present study evaluated different treatment approaches and clinical outcomes of patients with TIGC in Japan.

Double-contrast barium enteroclysis as a patency tool for nonsteroidal anti-inflammatory drug-induced enteropathy.

BackgroundEvaluating small bowel patency is recommended for capsule endoscopy in patients suspected of nonsteroidal anti-inflammatory drug-induced (NSAID) enteropathy.AimsThe aim of this investigation was to examine whether radiography is a candidate of patency tool in NSAID enteropathy.MethodsWe reviewed double-contrast barium enteroclysis in 21 patients with NSAID enteropathy diagnosed either by capsule endoscopy or balloon-assisted endoscopy. The endoscopic findings were classified into circular ulcers, linear ulcers and small mucosal defects. The radiographic signs of the corresponding endoscopic findings were retrieved and the depiction rate was calculated.ResultsOf the 21 patients, endoscopy detected circular ulcers, linear ulcers, and small ulcers in 12, 3 and 12 patients, respectively. Small bowel radiography depicted circular narrowing as pseudo-folds in 10 patients (83%) and linear ulcers as eccentric rigidity in 2 patients (67%). However, radiography was able to depict small mucosal defects in only 3 patients (17%). Two of 5 patients with pseudo-folds experienced retention of the capsule.Conclusion“Pseudo-folds” is a sign corresponding to circular ulcer in NSAID enteropathy, which may be predictive of capsule retention.

Time Trends of the Impact of Helicobacter pylori Infection and Nonsteroidal Anti-Inflammatory Drugs on Peptic Ulcer Bleeding in Japanese Patients

Background/Aims:Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the main causes of peptic ulcers. The purpose of the present study was to elucidate the time trends of the impact of H. pylori infection and use of NSAIDs and/or antithrombotic agents on peptic ulcer bleeding (PUB) in Japanese patients. Methods: We retrospectively reviewed 719 patients who had received endoscopic hemostasis for PUB between 2002 and 2013. Subjects were divided into either the first-half group (2002-2007, n = 363) or the second-half group (2008-2013, n = 356). The clinical characteristics of the patients, including the prevalence of H. pylori infection and use of NSAIDs and antithrombotic agents, were compared between the two groups. Results: Compared to the first-half group, patients in the second-half group were characterized by older age (proportion of the patients above 60 years old, 63.9 vs. 76.7%, p = 0.0002), less frequent H. pylori infection (71.6 vs. 57.9%, p < 0.001) and more frequent NSAID intake (39.9 vs. 48.6%, p = 0.02). No significant difference was observed regarding the use of antithrombotic agents between the two groups (18.6 vs. 23.3%, p = 0.13). The prevalence of H. pylori infection and proportion of patients above 60 years old were significantly different between the two groups in a multivariate analysis. Conclusion: The main cause of PUB has clearly shifted from H. pylori infection to the use of NSAIDs over the last decade.

Significance of a white opaque substance under magnifying narrow-band imaging colonoscopy for the diagnosis of colorectal epithelial neoplasms.

BACKGROUND AND AIMS The aim of this study was to examine the significance of a white opaque substance (WOS) found on magnifying narrow-band imaging (M-NBI) for the diagnosis of colorectal neoplastic lesions. METHODS We retrospectively reviewed colonoscopy records from 2006 to 2012 at our institution and identified cases of endoscopically or surgically resected colorectal epithelial neoplasms observed by M-NBI colonoscopy. The colonoscopic and histologic characteristics of the lesions were compared between WOS-positive and WOS-negative lesions. We further classified the WOS as regular or irregular and compared the histologic characteristics between the two types of lesions. RESULTS There were 105 WOS-positive lesions and 451 WOS-negative lesions. The former were subdivided into lesions with regular and irregular WOS. The incidence of high-grade dysplasia or carcinoma was significantly higher in WOS-positive lesions (61.9%) than in WOS-negative lesions (28.6%) (P < .05). Among the WOS-positive lesions, massive submucosal invasion was more frequent in lesions with irregular WOS (82.4%) than in those with regular WOS (1.4%) (P < .05). Among cancers with massive submucosal invasion, lymph node metastasis was more frequent in cancers with irregular WOS (17.4%) than in those with regular WOS or without the WOS (0%) (P < .05). CONCLUSIONS A WOS in colorectal neoplasms may be an optical marker for high-grade dysplasia and cancer. An irregular WOS may be indicative of massive submucosal invasion and lymph node metastasis.

Clinicopathologic Features of Inverted Serrated Lesions of the Large Bowel.

Background/Aims: Serrated lesions (SLs) of the large bowel occasionally manifest as inverted growths with endophytic expansion within the muscularis mucosa. The aims of this investigation were to investigate the incidence of inverted SLs (ISLs) among SLs and to describe the clinicopathologic features. Methods: We reviewed the colonoscopy records from 2006 to 2014 at our institution and identified cases of endoscopically or surgically resected SLs, including hyperplastic polyps (HPs), sessile serrated adenomas/polyps (SSA/Ps) and traditional serrated adenomas (TSAs). The incidence of ISLs among the SLs and their colonoscopic findings were investigated retrospectively. Results: There were 35 HPs in 30 patients, 80 SSA/Ps in 65 patients and 70 TSAs in 65 patients. The incidence of ISLs was significantly higher among SSA/Ps (8.8%) and HPs (5.7%) than among TSAs (0%; p = 0.04). A predominant right-sided location, a flat-elevated configuration with a central depression and round-open pit pattern or expanded crypt openings were characteristic of ISLs of the SSA/P type. Conclusions: Right-sided flat lesions with a central depression and round or expanded crypts are indicative of ISLs of the SSA/P type.

ENDOSCOPIC MANAGEMENT OF A DIEULAFOY-LIKE LESION IN A DUODENAL DIVERTICULUM

We present a 70‐year‐old man who had two episodes of melena during the preceding 8‐year period. He had a Dieulafoy‐like lesion in a diverticulum in the third portion of the duodenum. While emergency endoscopy revealed neither apparent blood nor clots around the diverticular orifice, there was a non‐bleeding vessel in the fundus of the diverticulum. The vessel ceased bleeding after argon plasma coagulation and, since then, the patient has not experienced bleeding. In cases of gastrointestinal bleeding of obscure origin, duodenal diverticulum should be considered as a possible source of bleeding, even when endoscopy discloses no apparent bleeding.

Endoscopic diagnosis of malignant enterocolic fistula caused by ileal lymphoma

A 67-year-old Japanese man was referred because of pain in his right lower abdomen and weight loss. Physical examination revealed a mass in the right lower quadrant without lymphadenopathy, hepatosplenomegaly, or cutaneous lesions. Laboratory data included an erythrocyte count of 344 × 104 (450-550), hemoglobin 9.8 gm/dL (14.018.0), and leukocyte count was 9800/μL (3500-9000). His serum total protein and immunoglobulin levels were within normal limits. Severe melena was noted and confirmed. Small bowel radiography revealed an ulcerating mass in the terminal ileum (Fig. 1). The tumor measured 12 cm in length. In addition, a fistulous tract originating from the lesion to the sigmoid colon was also identified (Fig. 1). Ileonoscopy revealed an ulcerating mass in the terminal ileum (Fig. 2A). In addition, colonoscopy disclosed the orifice of the fistula in the sigmoid colon, seen as a polypoid lesion with a central depression (Fig. 2B). Biopsies from the tumor in the terminal ileum and from the polypoid lesion in the sigmoid colon showed an aggregation of atypical lymphoid cells suggestive of lymphoma. Ileocecal resection and partial resection of the sigmoid colon with mesenteric lymph node resection were subsequently performed. Macroscopic examination of the resected specimen demonstrated an ulcerating mass of the ileum with a fistulous tract originating from the lesion to the sigmoid colon. Histologically, the ulcerating mass in the ileum and the polypoid lesion of the sigmoid colon were composed of a diffuse proliferation of large atypical lymphoid cells (Fig. 3). The tumors were characterized by massive involvement of adjacent tissues, extensive coagulative necrosis, and absence of a desmoplastic reaction. These lymphoma cells were characterized as diffuse large B-cell lymphoma. Based on these histologic findings, a diagnosis of primary ileal lymphoma invading the sigmoid colon was made. The lymphoma also involved the mesenteric lymph node. According to Musshoff ’s modification of the Ann Arbor staging system,4 the clinical stage of the lymphoma in the current case was II2E. Two weeks later, bilateral pleural effusion developed. The patient died of respiratory failure 4 weeks after the surgery.