Rintaro Hashimoto

Small bowel anisakiasis detected by capsule endoscopy.

A 36-year-old man sought medical attention at his local hospital with complaints of consistent epigastric and right lower abdominal pain that had begun three days before. Vital signs were normal. Computed tomography (CT) showed diffuse wall thickening of the distal ileum (Fig. 1). He was referred to our hospital for further evaluation. This article is protected by copyright. All rights reserved.

Spontaneous resolution of intramural gastric abscess without treatment

© 2016 Hellenic Society of Gastroenterology www.annalsgastro.gr A gastric wall abscess is a type of phlegmonous gastritis characterized by inflammation confined to the stomach wall and abscess formation. It is caused by biopsy, polypectomy, cancer and accidental ingestion of foreign objects [1]. Endoscopic drainage has been considered useful [2]. No case of spontaneous alleviation of gastric wall abscess has been reported previously. A 57-year-old man with no previous medical history swallowed a fish bone (flounder). The next day, he complained of epigastric discomfort and fever. He came to our hospital 10 days after the onset of the symptoms, and upper gastrointestinal endoscopy was performed. A submucosal tumor (SMT)-like protrusion was observed in the anterior wall just below the stomach cardia, as well as pus discharge from the top of the lump (Fig. 1A). Contrast-enhanced computed tomography revealed fluid collection in the gastric wall (Fig. 2), and these findings were consistent with that of gastric abscess. On the next day, endoscopy revealed that the protrusion suspected as a gastric wall abscess had clearly shrunk, but pus discharge was observed (Fig. 1B). Endoscopic ultrasound (EUS) showed inhomogeneous lesion of mixed echogenicity located mainly in the submucosal layer with mucosal involvement (Fig. 1C), consistent with the reported features of EUS of gastric wall abscess [3]. Streptococcus spp. was detected on pus culture. Three days after, the subjective symptoms had completely alleviated; the SMT-like protrusion had further shrunk, as observed via endoscopy. The SMT-like protrusion was not observed via upper endoscopy performed 1 month after discharge (Fig. 1D).

A string-like structure in the center of colonic polypoid lesion

Q2 98 99 100 101 102 103 104 105 106 107 108 Amedical or surgical history underwent a screening colonoscopy that showed a 10-mm elevated lesion in the ascending colon with a string-like structure at its center (Figure A). Chromoendoscopy using 0.2% indigo carmine (Figure B) and 0.05% crystal violet (Figure C) suggested that the lesion was not a tumor. After extracting the string-like structure using forceps, we performed a biopsy of the surrounding raised mucosa. The origin of the string-like structure remained obscure given the patient’s negative surgical history (Figure D). The

Kappa light-chain amyloidosis of gastrointestinal tract

A 65-year-old man with no previous medical history presented to our hospital with hematochezia. The patient’s vital signs were normal. Physical examination revealed nothing remarkable except left lower quadrant tenderness. Laboratory data indicated mild anemia. Upper endoscopy revealed small erosion in the esophagus (Fig. 1A), mild linear erythema in the lesser curvatures of the gastric body (Fig. 1B), and normal appearance of the mucosa in the duodenum. Colonoscopy revealed multiple submucosal hematomas (Fig. 1C) and ulcerations (Fig. 1D). Biopsies were taken from the stomach and the colonic lesions. Histopathological examination with Congo red staining revealed amorphous eosinophilic infiltrates, while immunostaining revealed found the cells to be positive for kappa light chain (Fig. 2) and negative for lambda chain and amyloid A. The patient was diagnosed with systemic kappa amyloid light-chain (AL) amyloidosis given the involvement of heart and kidney. The patient was transferred to the hematology department and received chemotherapy. Amyloidosis is characterized by the extracellular deposition of abnormal fibrillary protein. The endoscopic findings have been reported to be very diverse but characteristic [1]. The treatment for AL amyloidosis with evidence of organ involvement is chemotherapy and autologous stem cell transplantation [2]. In our case, although the clinical course at the first episode was compatible with ischemic colitis, retrospective evaluation of biopsy specimens from the first episode revealed they were positive for Congo red staining. Amyloidosis should be considered in patients with non-specific ulcerative findings and Congo red staining should be performed as part of the histopathological evaluation.

Double-balloon assisted trans-anal ERCP in a patient with Roux-en-Y choledochojejunostomy

A 66-year-old man was referred to our hospital with fever and elevated liver enzymes. His medical history was significant for Roux-en-Y choledochojejunostomy performed because of iatrogenic bile duct injury during cholecystectomy a few years earlier. CT showed biliary tract dilatation and some small liver abscesses. Endoscopic sonography revealed mild dilatation of the common bile duct (CBD). Drip infusion cholecystocholangiography/ computed tomography revealed the stenosis at the anastomosis. These results led to a diagnosis of acute cholangitis due to a postoperative CBD stricture. We attempted transoral ERCP with a long-type double-balloon enteroscope (DBE) (EN-450T5, Fujifilm, Tokyo, Japan), but we

Intestinal ascariasis detected by double-balloon enteroscopy

A 69-year-old woman with no significant medical history presented with abdominal pain and frequent vomiting. Laboratory investigation revealed microcytic anemia (hemoglobin 10.1 mg/dL, mean corpuscular volume 79 fL). Contrast-enhanced computed tomography showed small bowel obstruction. Her symptoms were relieved after transnasal ileus tube insertion. The tube was removed four days later. She remained asymptomatic after she resumed eating. Esophagogastroduodenoscopy and colonoscopy showed no abnormal findings. This article is protected by copyright. All rights reserved.

The Safety of Diagnostic and Therapeutic Colonoscopies in the Very Elderly (≥85 Years of Age)

The Safety of Diagnostic and Therapeutic Colonoscopies in the Very Elderly (≥85 Years of Age)

Usefulness of dilated blood vessels in the tumor periphery for assessing the invasion depth of small-sized depressed colorectal cancer

AbstractThe relationship between dilated blood vessels in the tumor periphery and the tumor invasion depth is unclear. Therefore, the present study aimed to clarify the relationship between dilated blood vessels and the invasion depth of small-sized (<30 mm) colorectal cancer (CRC), and its implications on endoscopic treatment.We performed a single-arm observational study of the diagnostic accuracy of the existence of dilated vessels in the tumor periphery of CRC lesions as an indicator of submucosal deep (SM-d, ≥1000 &mgr;m) carcinomas. Lesions were classified into two groups based on the existence of dilated vessels by two experienced endoscopists. The clinicopathological features, invasion depth, and lymphovascular invasion/poorly differentiated clusters were analyzed in all resected specimens.Four hundred and two consecutive small-sized CRC lesions were included. The dilated vessels were observed in 96/402 (24%) lesions, and most of them (93/96) were found in depressed lesions. In depressed lesions, the histopathological diagnosis of the dilated vessels group showed SM-d or deeper invasion in 84/93 (90%) cases, whereas 3/20 (15%) had SM-d invasion in the nondilated vessels group (P < 0.001). When the dilated vessels were used as an indicator of SM-d or deeper invasion in depressed lesions, the sensitivity was 95.6%, specificity was 66.7%, and accuracy was 90.2%. No correlation was observed between the existence of dilated vessels and the lesion site, lesion diameter, and lymphovascular invasion/poorly differentiated cluster.The existence of dilated blood vessels in the tumor periphery suggests SM-d or deeper invasion in depressed lesions.

Fulminant Hepatosplenic B-Cell Lymphoma Without Hepatitis C Infection.

priate antibiotics.2–4 Finally, the results of this study1 confirm our standpoint. Herewith we also want to include our observations regarding the statement of some authors that “digestive enzymes found in the abdominal fluid in acute pancreatitis were once thought to be active, but are now known to remain largely inactive and likely contribute minimally to injury.”11 It is clear that the level of pancreatic enzymes in peritoneal ascitic fluid is low due to the consequent dilution of pancreatic juice into the abdominal cavity. However, according to our experience, content obtained from pancreatic collections through the catheters placed next to the pancreas always showed as enzyme-rich pancreatic juice collections with extremely high values of pancreatic enzymes, especially at the onset of the disease. Therefore, we think that the relationship between the levels of pancreatic enzymes released from the pancreas to the abdominal cavity during SAP and clinical course of SAP is still not fully clarified. Once again, we think that this is an excellent article and our observations are given with the intention to contribute to the clarification of this important and complex subject. We agree with the authors that further studies are needed to document prospectively both the safety and the value of APD, as well as to determine the patients who might benefit from this intervention.

An Elderly Woman With Facial Erythema and Hematemesis

Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 Question: A 72-year-old woman with a history of schizophrenia presented to our hospital with dysphagia and hematemesis. She had complaints of fever and painful erythema around the mouth for the past 3 days. Her vital signs were normal except body temperature, which was 38.3 C. Physical examination revealed erythema and tenderness around her mouth (Figure A) and mild epigastric tenderness. Laboratory studies showed a white cell count of 25,000 cells/mL and C-reactive protein of 22.68 mg/dL. Contrast-enhanced computed tomography scan showed diffuse wall thickening from the pharynx (Figure B) to the stomach (Figure C), indicating edematous change. Emergent upper endoscopy showed markedly edematous mucosa of the pharyngolarynx (Figure D), diffuse redness from the esophagus to the duodenal bulb (Figure E) and a large gastric erosion with coagulation at the fundus (Figure F). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 108 109 110 111 112 113 114 Conflicts of interest The authors disclose no conflicts.