Taira Kuroda

Utility of Contrast-Enhanced Transabdominal Ultrasonography to Diagnose Early Chronic Pancreatitis.

Purpose. The purpose of this study was to establish the relationship between the grade of chronic pancreatitis (CP) and pancreatic blood flow as measured by contrast-enhanced transabdominal ultrasonography (CEUS) and to diagnose early CP easily. Methods. This pilot study was conducted in 8 patients with CP, 7 patients with early CP, and 6 control participants. After injecting 0.015 mL/kg of perflubutane by manual bolus, values in one region of interest (ROI) in pancreatic parenchyma and one ROI including the superior mesenteric artery (SMA) were measured. Results. The ratio of blood flow in the SMA and pancreatic parenchyma increased with grade of CP and was significantly higher in patients with CP (5.41; 2.10–11.02) than in patients with early CP (2.46; 1.41–5.05) and control participants (2.32; 1.25–3.04) (P = 0.0279, P = 0.0142, resp.). The ratio of blood flow in the SMA and pancreatic parenchyma correlated with grade of CP (rs = 0.5904, P = 0.0048). Conclusion. The ratio of blood flow correlates with grade of CP on CEUS. This safe and convenient method may be useful to diagnose early CP.

Multicenter prospective evaluation study of endoscopic ultrasound‐guided hepaticogastrostomy combined with antegrade stenting (with video)

Endoscopic ultrasonography‐guided hepaticogastrostomy (EUS‐HGS) is often indicated for advanced stage patients. Therefore it is important to prevent adverse events associated with EUS‐HGS procedures and obtain long stent patency. EUS‐guided antegrade stenting (AS) has been developed as an advanced technique. Thus, to prevent adverse events and achieve long stent patency, EUS‐AS combined with EUS‐HGS (EUS‐HGAS) has been reported. The aim of the present study was to evaluate the technical feasibility and efficacy of EUS‐HGAS in a multicenter, prospective study.

An unusual case of subclinical diffuse glucagonoma coexisting with two nodules in the pancreas: characteristic features on computed tomography.

A lesion was discovered in the tail of the pancreas by ultrasonography performed during a health checkup for a 59-year-old Japanese man. Abdominal contrast-enhanced computed tomography (CE-CT) revealed strong enhancement in a 4-cm tumor in the pancreatic tail and in a 1-cm tumor in the pancreatic body. Serum glucagon levels were elevated to 54,405 pg/mL and a preoperative diagnosis of glucagonoma was made. The pancreatic tail and spleen were resected en bloc, along with a protruding tumor in the pancreatic body. However, histopathological evaluation revealed diffuse glucagonoma throughout the pancreas. When we retrospectively reviewed abdominal CE-CT after the operation, the entire pancreas was seen to be enlarged and diffusely enhanced by strong spots. Immunohistochemical examination using anti-CD31 demonstrated rich microvessels in two solid glucagonomas as well as microglucagonoma throughout the entire pancreas, indicating hypervascularity. Enlarged pancreas and diffuse enhancement of the pancreas by strong spots may be characteristic features of diffuse glucagonoma on abdominal CE-CT.

Usefulness of laparoscopy and intraductal ultrasonography in a patient with isolated immunoglobulin G4-related sclerosing cholangitis

Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is often associated with type 1 autoimmune pancreatitis, and the frequency of isolated IgG4-SC seems to be quite low, making the diagnosis of isolated IgG4-SC challenging. A 63-year-old male was admitted to our hospital for frequent fever. Abdominal magnetic resonance cholangiopancreatography showed diffuse narrowing of the common bile duct and post-stenotic dilatation of the right posterior bile duct. Laboratory tests showed abnormalities in the levels of hepatobiliary enzymes and serum IgG4 levels. Endoscopic retrograde cholangiopancreatography showed diffuse narrowing of intrahepatic bile ducts and post-stenotic dilatation of the right posterior bile duct but no abnormalities in the pancreas. Intraductal ultrasonography showed symmetric circumferentially thickened walls of both narrowed and non-narrowed common bile ducts. Histologic examination of the common bile duct mucosa showed infiltration of IgG4-positive plasma cells. Laparoscopic observations showed discoloration with red lobular markings and multiple small depressed lesions. Liver histology showed mild cholangitis with infiltration of IgG4-positive plasma cells around the bile ducts. From these findings, the patient was diagnosed with isolated IgG4-SC. After treatment with a steroid, bile duct dilatations improved. Laparoscopy and intraductal ultrasonography were useful to diagnose isolated IgG4-SC.

Diagnostic Challenge in Pancreatic Sarcoidosis using Endoscopic Ultrasonography.

We herein report a 55-year-old woman who presented with erythema and bilateral hilar lymphadenopathy 4 months prior to the detection of pancreatic lesions on an ultrasound. A skin biopsy showed evidence of sarcoidosis. The largest lesion in the tail of the pancreas was hypoechoic on endoscopic ultrasonography (EUS). The lesion was initially iso-enhanced on contrast enhanced-EUS (CE-EUS) but subsequently became hypoenhanced. The lesion revealed heterogeneous components of both soft and hard tissue on EUS elastography. She was ultimately diagnosed with pancreatic sarcoidosis based on the presence of noncaseating granulomas seen on pancreatic tissue retrieved through an EUS-guided fine needle aspiration biopsy.

Downregulation of ANP32B exerts anti-apoptotic effects in hepatocellular carcinoma

The acidic (leucine-rich) nuclear phosphoprotein 32 family member B (ANP32B), a highly conserved member of the acidic nuclear phosphoprotein 32 (ANP32) family, is critical for the development of normal tissue. However, its role in the development of hepatocellular carcinoma (HCC) is controversial. In this study, we elucidated the role of ANP32B in HCC cell lines and tissues. ANP32B expression in HCC cell lines was modulated using siRNA and ANP32B expression plasmids and lentiviruses. The levels of apoptosis-related proteins were analyzed by real-time RT-PCR and Western blotting. The expression of ANP32B in tissues from patients with HCC was investigated using real-time RT-PCR and immunohistochemistry. ANP32B knockdown by siRNA altered the expression of apoptosis-related proteins in HCC cell lines and reduced the expression of cleaved forms of caspase 3 and caspase 9, but not that of caspase 8, in HCC cells cultured with the pro-apoptotic agent staurosporine. Phosphorylated Bad was upregulated, whereas Bak was downregulated. Moreover, ABT-737, which binds to and inhibits anti-apoptotic proteins of the Bcl-2 family, rendered HCC cells resistant to apoptosis induced by ANP32B silencing. Conversely, ANP32B overexpression decreased Bad phosphorylation and upregulated Bak, but did not induce apoptosis because Bax expression was downregulated. In tissues from patients with HCC, a low tumor/non-tumor ratio of ANP32B mRNA expression was related to advanced UICC stage (p = 0.032). TUNEL-positive cells were observed in parallel with ANP32B expression in HCC tissues. ANP32B modulates Bad phosphorylation as well as Bak and Bax expression, resulting in regulation of apoptosis in HCC. These findings indicate the potential value of ANP32B as a therapeutic target for HCC.

Difficulty in management of intraductal papillary mucinous neoplasm-associated pancreatobiliary fistulas and the role of “pig-nose” appearance and intraductal ultrasonography in diagnosis

Pancreatobiliary fistulas associated with intraductal papillary mucinous neoplasms (IPMN) often develop obstructive jaundice and cholangitis; thus, early diagnosis is important. However, computed tomography and cholangiography, the current methods for detecting pancreatobiliary fistulas, are not always effective. We previously reported a case of IPMN-associated pancreatobiliary fistula and proposed a potential new diagnostic marker: the “pig-nose” appearance of the duodenal papilla, which results from dilated pancreatic and bile ducts and can be visualized via endoscopy. In this study, we report another three cases of IPMN-associated pancreatobiliary fistulas detected by a different technology, intraductal ultrasonography (IDUS). As with our previously reported case, we confirmed the utility of the “pig-nose” appearance and IDUS in the diagnosis of IPMN-associated pancreatobiliary fistulas. In addition, we found it difficult to manage biliary obstruction that resulted from the flow of mucinous material through pancreatobiliary fistulas. The obstruction was treated with endoscopic nasal biliary drainage (ENBD), but this was not always successful. In two of our cases, additional treatment with a large diameter fully covered metal stent failed to improve jaundice. Therefore, we conclude that standard endoscopic stenting may not be effective, and that alternative endoscopic methods or surgery may be necessary.

Mo1422 Changes in the Characteristics and Prognosis of Pancreatic Cancer Within the Gemcitabine Era and the Issues Facing Elderly Patients

Background Identifying pancreatic adenocarcinoma (PAC) at a resectable stage, or conversely those with unresectable disease, might be used in an attempt to identify patients at an early, potentially curable stage of the disease and those at an unresectable stage be sparred surgery that would add to patients morbidity as well as costs to the health care system at no additional benefit. Although imaging technology has advanced the management of patients with PAC there still are limitations, the pooled sensitivity for vascular invasion for computerized tomography (CT) scans is 71% and for magnetic resonance imaging is 67%. Objective. This study aimed to identify clinical as well as laboratory factors that could predict PAC at a resectable stage. Methods. A retrospective study was conducted of individuals who underwent CT scans at King Khalid University Hospital, a major tertiary care, university hospital in Riyadh, Saudi Arabia, between April 1996 and April 2012 and a pancreatic mass was reported. We also reviewed the endoscopic reporting database of the endoscopy unit for all endoscopic procedures where the indication included PAC. Any patient with a histologicaly confirmed diagnosis of PAC was included in the analysis. We collected demographic information (age, sex), height, weight, body mass index (BMI), historical data (smoking, co-morbidities), symptoms (abdominal pain and its duration, anorexia and its duration, weight loss, its amount and over what duration, vomiting, abdominal distention, itching and its duration, change in bowel movements, change in urine color), jaundice and its duration, laboratory values, location of the mass, the investigation undertaken, staging of the tumors, as well as the management undertaken for these patients. Results. A total of 61 patients with histologically proven adenocarcinoma were included in the analysis. The mean age was 61.2 +/1.51 years, 41%were females. The only variables that beard statistically significant differences between resectable and unresectable PAC respectively were the duration of vomiting (2.5 months vs. 7.3 months) (p-value = 0.01), the level of hemoglobin (10.6 g/dL vs. 11.9 g/dL) (p-value = 0.05), and the CA 19-9 level (107 ng/ml vs. 5448 ng/ ml) (p-value = 0.01). Conclusion. Patients with resectable pancreatic cancer had a shorter duration of vomiting a lower level of hemoglobin and a lower level of CA 19-9; none of the other variables evaluated could predict resectabilty, this might be due to being underpowered. Further research is required to evaluate factors that could be used as markers to unresectable pancreatic cancer for the better management of patients with adenocarcinoma of the pancreas. Baseline demographic, symptoms and laboratory variables of patients diagnosed with pancreatic adenocarcinoma S-662 AGA Abstracts BMI; Body mass index, CI; Confidence interval, COPD; Chronic obstructive pulmonary disease, DM; Diabetes mellitus, HTN; hypertension, IHD; Ischemic heart disease, NA; Not applicable. * In months # In kilograms Differences between patients found to have resectable pancreatic adenocarcinoma and those not resectable