Shinsaku Hamanaka

Endoscopy-Guided Evaluation of Duodenal Mucosal Permeability in Functional Dyspepsia

OBJECTIVES: The pathophysiology of functional dyspepsia (FD) is not fully understood. Impaired duodenal mucosal integrity characterized by increased mucosal permeability and/or low‐grade inflammation was reported as potentially important etiologies. We aimed to determine the utility of a recently developed simple catheterization method to measure mucosal admittance (MA), the inverse of mucosal impedance, for evaluation of duodenal mucosal permeability in patients with FD. METHODS: We conducted two prospective studies. In the first study, duodenal MA of 23 subjects was determined by catheterization during upper endoscopy, and transepithelial electrical resistance (TEER) of duodenal biopsy samples in Ussing chambers was measured to assess the correlation between MA and TEER. In the second study, duodenal MA of 21 patients with FD fulfilling the Rome III criteria was compared with that of 23 healthy subjects. RESULTS: The mean MA and TEER values were 367.5±134.7 and 24.5±3.7 Ω cm2, respectively. There was a significant negative correlation between MA and TEER (r=−0.67, P=0.0004, Pearsons correlation coefficient). The mean MA in patients with FD was significantly higher than that in healthy subjects (455.7±137.3 vs. 352.1±66.9, P=0.002, unpaired t‐test). No procedure‐related complications were present. CONCLUSIONS: We demonstrated the presence of increased duodenal mucosal permeability in patients with FD by MA measurement using a simple catheterization method during upper endoscopy.

The Effect of Ineffective Esophageal Motility on Gastroesophageal Reflux Disease

Background/Aims: Ineffective esophageal motility (IEM) is the most common gastrointestinal motility disorder. Studies have reported that IEM is related to gastroesophageal reflux disease (GERD). However, the relationship between IEM and GERD remains uncertain. This study aims to clarify this relationship retrospectively. Methods: We analyzed 195 subjects who underwent high-resolution manometry between January 2011 and September 2016. Of these subjects, 72 had normal esophageal motility (NEM) and 26 had IEM. We investigated differences in the clinical characteristics, severity and duration of GERD symptoms, and comorbid extra-esophageal symptoms of the subjects. Comorbid extra-esophageal symptoms were assessed with the Gastrointestinal Symptom Rating Scale questionnaire. Investigation-defined GERD was diagnosed when erosive esophagitis or abnormal multichannel intraluminal impedance was present. Results: We found no significant difference in the prevalence of IEM between patients with and without GERD (37.5 and 21.1%, respectively; p = 0.174). There were no differences in age, gender, body mass index, presence of hiatal hernia, or duration of GERD between the groups. Compared to patients with NEM, those with IEM were significantly less likely to have comorbid extra-esophageal symptoms (p < 0.05). Conclusion: There is no association between IEM and GERD.

Evaluation of Esophageal Mucosal Integrity in Patients with Gastroesophageal Reflux Disease

Background: Impaired esophageal mucosal integrity plays a role in causing symptoms of gastroesophageal reflux disease (GERD). Recently, the assessment of esophageal baseline impedance (BI) using the multichannel intraluminal impedance-pH (MII-pH) test was suggested as a surrogate technique for the study of esophageal mucosal integrity and was reported to be useful in distinguishing GERD from non-GERD. However, measuring BI requires a 24-h testing period, is complicated, and causes considerable patient discomfort. Summary: Recently, endoscopy-guided catheters that can measure mucosal impedance (MI) and mucosal admittance (MA), which is the inverse of impedance, were developed, and their usefulness in measuring MI and MA for the diagnosis of GERD has been reported. In these studies, esophageal MI values were significantly lower in patients with GERD than in those without GERD. In contrast, esophageal MA was significantly higher in patients with GERD than in those without. Furthermore, we reported that MA is inversely correlated with BI and correlated with acid exposure time. Key Messages: Endoscopy-guided real-time measurement of MI and MA may allow the estimation of mucosal integrity and may be a useful diagnostic tool for patients with GERD in a manner similar to 24-h MII-pH monitoring.

Comparison of a novel predictor of venous thromboembolic complications in inflammatory bowel disease with current predictors: Novel predictor of DVT in IBD patients

Venous thromboembolism (VTE) is a common complication of inflammatory bowel disease (IBD). The aim of the present study was to identify predictors of VTE in hospitalized patients with IBD.

Investigation of novel biomarkers for predicting the clinical course in patients with ulcerative colitis: Novel UC biomarkers in clinical course

The clinical course of ulcerative colitis (UC) is characterized by repeated episodes of relapse and remission. We hypothesized that biomarkers that help distinguish refractory UC patients who are in remission using strong anti‐immunotherapy could contribute in preventing the overuse of corticosteroids for treatment. Here, we clarified novel autoantibodies for UC patients in remission as clinical indicators to distinguish between refractory and non‐refractory UC.

Real-time Endoscopy-Guided Measurement of Rectal Mucosal Admittance Is a Novel and Safe Method for Predicting Ulcerative Colitis Relapse

Background There are known associations between inflammatory bowel disease (IBD) and changes in mucosal paracellular permeability. We recently developed a novel catheter that can measure mucosal admittance (MA). Methods Patients with ulcerative colitis (UC) in clinical remission underwent real-time MA measurement during colonoscopy between June 2014 and July 2015 and were prospectively followed. MA measures were taken from normal-appearing mucosa using the Tissue Conductance Meter (TCM). We examined relationships between mucosal admittance, clinical parameters at the time of MA measurement, and disease relapse during the follow-up period using the Cox proportional hazards model. Results We measured baseline MA in 54 patients with UC during remission, with no complications. Of these, 23 patients relapsed during the subsequent follow-up period, at a median of 25.8 ± 7.6 months. Rectal MA was the only predictor of disease relapse in multivariate analysis (P = 0.027). The optimal rectal MA cutoff value for relapse was 781.0 (area under the receiver operating characteristic curve, 0.712), and in patients who showed lower than normal cutoff values, there was a significantly higher likelihood of relapse compared with other patients (log-rank test, P < 0.001). Conclusions High rectal MA measured by TCM is associated with long-term sustained remission. Real-time rectal MA measurement using a novel endoscopy-guided catheter could be a safe and useful means of predicting prognosis for patients with UC in remission.

Long-Term Outcome of Endoscopic Balloon Dilatation for Strictures in Patients with Crohn’s Disease

Background/Aims: Endoscopic balloon dilatation (EBD) is an alternative to surgery for strictures in patients with Crohn’s disease (CD). The aim of the present study was to clarify the efficacy and safety of EBD for strictures in patients with CD. Methods: Twenty-six patients with CD who underwent EBD for strictures from August 2008 to November 2015 were followed up after dilatation. Short-term success was defined as the disappearance of obstructive symptoms after technically adequate dilatation was achieved. The short-term success rate of EBD, safety profile of EBD, and cumulative surgery-free and redilatation-free rates were analyzed. Results: Sixty-five EBDs were performed for CD patients in the follow-up period. The short-term success rate was 100% (26/26), and no complications were encountered during this study. Two (7.7%) patients underwent surgery during the observation period. The cumulative surgery-free rate after the initial EBD was 90.3% at both 2 and 3 years. The cumulative redilatation-free rate after the initial EBD was 52.1% at 2 years and 39.1% at 3 years. Conclusion: EBD for strictures secondary to CD provides not only short-term success but also long-term efficacy. Although a high redilatation rate is one of the clinical problems of this procedure, EBD is an effective therapy for avoiding intestinal recession in CD stricture.

A case of endoscopic hemostasis using double-balloon endoscopy for an intestinal hemorrhage in a giant incisional hernia

A 62-year-old man was referred to Chiba University Hospital with melena. He had previously suffered from severe peritonitis due to appendicitis and consequently had a giant abdominal incisional hernia. Although his appearance was pale due to a hemoglobin concentration of 6.9 g/dL, his vital signs were stable. His abdomen was distended in the right side because of, not only the hernia, but also his severe obesity; he had a body mass index of 42.3 kg/m2 (▶Fig. 1). An abdominal computed tomography scan clearly demonstrated the giant incisional hernia, which included the jejunum, ileum, and ascending colon (▶Fig. 2). No suspected bleeding point was found during esophagogastroduodenoscopy and small-bowel capsule endoscopy; however, transoral and transanal double-balloon endoscopy (DBE) were performed when the patient presented with melena (▶Fig. 3). We found a small Dieulafoy’s lesion with pulsatile bleeding in the lower section of the ileum, and performed hemostatic clipping for the lesion (▶Video1). Rebleeding was not seen after clipping, and the patient was discharged. There are no reports on endoscopic hemostasis using DBE for an intestinal hemorrhage in a giant incisional hernia. The presence of an abdominal hernia is not a contraindication to colonoscopy [1]. Careful assessment by physical examination and radiological images before endoscopy is important because this can alert an endoscopist to potential risks, such as perforation and incarceration, especially in the case of an incisional hernia [2, 3]. Furthermore, although DBE has not been found to be superior to other deep enteroscopy techniques, such as single-balloon endoscopy and spiral endoscopy, for increasing diagnostic or therapeutic yields, the rate of complete enteroscopy with DBE has been shown to be higher than the rate with other techniques [4, 5]. To conclude, endoscopic hemostasis by DBE should be considered in cases with a giant incisional hernia. Endoscopy_UCTN_Code_CCL_1AC_2AB