Takuji Yamao

Successful management of bleeding duodenal varices by endoscopic variceal ligation and balloon-occluded retrograde transvenous obliteration

Upper-GI variceal bleeding is an important complication of portal hypertension. Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are widely accepted as primary therapies for esophageal and gastric varices. Balloonoccluded retrograde transvenous obliteration (B-RTO) has been introduced recently as a new interventional modality to prevent fatal bleeding from gastric fundic varices. Compared with esophageal and gastric varices, duodenal varices are less common in portal hypertension. And, although bleeding is often severe and fatal, a definitive treatment for bleeding duodenal varices has not been established. A case of bleeding duodenal varices successfully controlled by EVL and B-RTO is presented, and the usefulness of these procedures in the management of this condition is discussed.

Efficacy of long-term 4.0 g/day mesalazine (Pentasa) for maintenance therapy in ulcerative colitis.

Background High-dose (4.0 g/day) mesalazine is typically used for induction therapy, but its efficacy as maintenance therapy remains to be determined. We conducted a multicenter retrospective study to investigate the efficacy of continuous treatment with 4.0 g/day of mesalazine. Material/Methods Japanese ulcerative colitis (UC) patients receiving acute induction therapy with 4.0 g/day mesalazine were enrolled and followed. Those who clinically improved or who achieved clinical remission were categorized into 2 sub-groups according to the median duration of treatment with 4.0 g/day of mesalazine. The clinical relapse frequency and the time to relapse were analyzed. Results We enrolled 180 patients with active UC, and then 115 patients who clinically improved or who achieved clinical remission after treatment with 4.0 g/day mesalazine were categorized into 2 sub-groups according to the median of treatment duration: a short-term treatment group (≤105 days, n=58) and a long-term treatment group (>105 days, n=57). Overall, 45 (39.1%) patients relapsed: 28 (48.3%) in the short-term treatment group and 17 (29.8%) in the long-term treatment group. This difference was statistically significant (p<0.05). The relapse-free rate in the long-term treatment group was significantly higher than that in the short-term treatment group (p<0.05). The mean time to relapse in the long-term treatment group was significantly longer than that in the short-term treatment group (425.6±243.8 days vs. 277.4±224.5 days; p<0.05). Conclusions Long-term continuous treatment with high-dose mesalazine (4.0 g/day) may be more effective than short-term treatment for maintenance of remission in UC patients.

Cyst formation of duodenal heterotopic pancreas accompanied by pancreas divisum.

Heterotopic pancreas and pancreatic divisum are wellknown anatomic anomalies of the pancreas (1). Although heterotopic pancreas is usually asymptomatic, it may become clinically evident with any symptoms related to complications, including ulceration, bleeding, hyperinsulinism, obstructive jaundice, and gastric outlet obstruction (2). In addition, cystic degeneration is an uncommon and serious complication of heterotopic pancreas (3–5). In this article, we report an unusual case of cyst formation in duodenal heterotopic pancreas accompanied by pancreas divisum.

Endoscopic papillectomy for a Duodenal Duplication Cyst

A 39-year-old woman presented with a history of recurrent abdominal pain. She had been hospitalized for mild pancreatitis 3 years ago. Her vital signs were stable, and other tests were normal. Radiography showed a well-defined spherical duodenal mass measuring 3.2 cm × 5.0 cm (Figure 1 [A], white arrows). On endoscopy, the lesion appeared as a submucosal mass immediately anterior to the duodenal papilla (Figure 1 [B]). Endoscopic ultrasonography (US) revealed a double-layered wall, and an inner echogenic and outer hypoechoic layer (Figure 1 [C]). A characteristic finding was the double-wall sign1 for duodenal duplication cyst (DDC) (Figure 1 [C]). This article is protected by copyright. All rights reserved.

Education and Imaging. Gastrointestinal: gastric mucosa-associated lymphoid tissue (MALT) lymphoma observed by magnifying endoscopy with narrow band imaging.

Mucosa-associated lymphoid tissue (MALT) lymphoma derived from the B-lymphocytes, rarely occurs in the gastrointestinal (GI) tract. The commonest site of occurrence is the stomach. Narrow band imaging (NBI) with magnifying endoscopy can identify MALT lymphoma and there have been several reports and case series on this. We presently report a 79-year-old man who underwent GI endoscopy as part of a health checkup. Conventional endoscopy showed a depressed reddish lesion in the posterior wall of the mid-gastric body (Figure 1A). Chromoendoscopy with indigo carmine identified this to be a depressed lesion. (Figure 1B) Magnifying endoscopy with NBI showed a cleare demarcation line of this depressed lesion (Figure 1C, arrows), and revealed an loss of the normal epithelium and abnormal micro-vessels that did not have the typical tree-branching calibre changes around white round lesions (Figure 1D). Endoscopic biopsy specimens taken from the lesion showed a diffuse proliferation of abnormal lymphoid cells within the mucosa (low-power histology—not shown). High-power histology showed a diffuse proliferation of small centrocyte-like cells and lymphoepithelial lesions. Immunohistochemical analysis was positive for CD20 but negative for CD3. He was diagnosed as having gastric MALT lymphoma. The positron-emission tomography/computed tomography showed only gastric uptake and no other extra-nodal disease. Based on the histopathological findings, a diagnosis of gastric MALT lymphoma (high-grade) was made, and combination-chemotherapy with pirarubicin hydrochloride, cyclophosphamide, vincristine sulfate and rituximab was started.

Primary gastric follicular lymphoma manifesting as a submucosal tumor-like lesion

Follicular lymphoma occurs rarely in the gastrointestinal (GI) tract. Although previous studies have reported cases of follicular lymphoma in the GI tract by using advanced endoscopic imaging, gastric follicular lymphoma presenting as a submucosal tumor (SMT)-like lesion is rarely described.We report a case of primary follicular lymphoma which was resected by endoscopic submucosal dissection (ESD). A 69-year-old woman underwent gastrointestinal health check-up. Upper GI endoscopy revealed a SMT-like lesion with bridging folds in the greater curvature of the stomach (Fig. 1). Magnified endoscopy with narrow band imaging (ME-NBI) showed a nominal change of microsurface structures and microvessels. Endoscopic ultrasonography (EUS) showed the hypoechoic lesion with a lattice-work structure in the mucosal and submucosal layer (Fig. 2a). Histopathology of endoscopic biopsy specimens taken from the lesions showed atypical lymphoid cells, but no neoplastic changes. Abdominal computed tomography (CT) and colonoscopy showed no abnormalities. As EUS indicated that the tumor was localized within the submucosal layer and histopathology from the lesions showed atypical lymphoid cells, ESD was carried out for accurate histopathlogical diagnosis and en bloc resection. En bloc resection was completed without complications. Endoscopic horizontal margin was negative. The resected specimen revealed a dome-shaped tumor measuring 18 mm ¥ 14 mm ¥ 10 mm (Fig. 2b). Microscopic examination showed the follicular structures consisting of medium-sized abnormal lymphoid cells with dense nuclei. Neoplastic cells infiltrated into the submucosal layer, but the vertical margin was negative. Immunohistochemical analysis revealed that the neoplastic cells were positive for CD20 and Bcl-2, but negative for CD3, and hence, she was diagnosed as having gastric follicular lymphoma. We report a rare case of gastric follicular lymphoma manifesting as a SMT. In this case, the accurate diagnosis was difficult by various endoscopic modalities such as EUS and ME-NBI; therefore, ESD was carried out for diagnostic and therapeutic purpose. The exact diagnosis was due to acquisition of sufficient tissue by ESD procedure. We believe that ESD should be considered as one of the minimally invasive diagnostic methods in gastric malignant lymphoma.

Gastrointestinal: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma observed by magnifying endoscopy with narrow band imaging

Mucosa-associated lymphoid tissue (MALT) lymphoma derived from the B-lymphocytes, rarely occurs in the gastrointestinal (GI) tract. The commonest site of occurrence is the stomach. Narrow band imaging (NBI) with magnifying endoscopy can identify MALT lymphoma and there have been several reports and case series on this. We presently report a 79-year-old man who underwent GI endoscopy as part of a health checkup. Conventional endoscopy showed a depressed reddish lesion in the posterior wall of the mid-gastric body (Figure 1A). Chromoendoscopy with indigo carmine identified this to be a depressed lesion. (Figure 1B) Magnifying endoscopy with NBI showed a cleare demarcation line of this depressed lesion (Figure 1C, arrows), and revealed an loss of the normal epithelium and abnormal micro-vessels that did not have the typical tree-branching calibre changes around white round lesions (Figure 1D). Endoscopic biopsy specimens taken from the lesion showed a diffuse proliferation of abnormal lymphoid cells within the mucosa (low-power histology—not shown). High-power histology showed a diffuse proliferation of small centrocyte-like cells and lymphoepithelial lesions. Immunohistochemical analysis was positive for CD20 but negative for CD3. He was diagnosed as having gastric MALT lymphoma. The positron-emission tomography/computed tomography showed only gastric uptake and no other extra-nodal disease. Based on the histopathological findings, a diagnosis of gastric MALT lymphoma (high-grade) was made, and combination-chemotherapy with pirarubicin hydrochloride, cyclophosphamide, vincristine sulfate and rituximab was started.

Gastrointestinal: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma observed by magnifying endoscopy with narrow band imaging: Education and Imaging

Mucosa-associated lymphoid tissue (MALT) lymphoma derived from the B-lymphocytes, rarely occurs in the gastrointestinal (GI) tract. The commonest site of occurrence is the stomach. Narrow band imaging (NBI) with magnifying endoscopy can identify MALT lymphoma and there have been several reports and case series on this. We presently report a 79-year-old man who underwent GI endoscopy as part of a health checkup. Conventional endoscopy showed a depressed reddish lesion in the posterior wall of the mid-gastric body (Figure 1A). Chromoendoscopy with indigo carmine identified this to be a depressed lesion. (Figure 1B) Magnifying endoscopy with NBI showed a cleare demarcation line of this depressed lesion (Figure 1C, arrows), and revealed an loss of the normal epithelium and abnormal micro-vessels that did not have the typical tree-branching calibre changes around white round lesions (Figure 1D). Endoscopic biopsy specimens taken from the lesion showed a diffuse proliferation of abnormal lymphoid cells within the mucosa (low-power histology—not shown). High-power histology showed a diffuse proliferation of small centrocyte-like cells and lymphoepithelial lesions. Immunohistochemical analysis was positive for CD20 but negative for CD3. He was diagnosed as having gastric MALT lymphoma. The positron-emission tomography/computed tomography showed only gastric uptake and no other extra-nodal disease. Based on the histopathological findings, a diagnosis of gastric MALT lymphoma (high-grade) was made, and combination-chemotherapy with pirarubicin hydrochloride, cyclophosphamide, vincristine sulfate and rituximab was started.