Yoshiki Kimura

Long-Term Outcome after Double-Balloon Endoscopy in Patients with Obscure Gastrointestinal Bleeding

Background and Aims: There are limited data concerning the clinical outcome of patients with obscure gastrointestinal bleeding (OGIB) after double-balloon endoscopy (DBE). The aim of the present study was to evaluate the long-term outcome of patients with OGIB after DBE. Patients and Methods: Eighty-seven consecutive patients with OGIB (47 men and 40 women; mean age 65.3 years) underwent DBE between July 2006 and December 2009. The criteria for assessment included documented iron deficiency anemia/occult or obscure small intestinal bleeding, and overt small intestinal bleeding. They were followed for a mean period of 41.4 months after DBE, and were divided into two groups according to their outcome, that is a good clinical course group (GC group) and a poor clinical course group (PC group). The clinical characteristics associated with rebleeding after DBE were analyzed by comparison of these two groups. Results: The source of bleeding was identified in 40 patients (46.0%) and endoscopic treatment was required in 21 of them (52.5%). The most frequent source of bleeding was ulcers/erosions (18.4%). During the follow-up period, 39 patients (44.8%) experienced bleeding and/or persistent iron deficiency anemia after DBE, while 48 patients did not. There were no significant differences of clinical characteristics between the two groups. However, there were more patients with diverticular bleeding in the GC group than the PC group, and there were significantly more patients with treatable small intestinal tumors/polyps in the GC group. There were also more patients with normal DBE findings in the GC group. Conclusion: This study demonstrated that the rebleeding rate after DBE varies depending on the source of bleeding.

Analysis of small-bowel capsule endoscopy reading by using Quickview mode: training assistants for reading may produce a high diagnostic yield and save time for physicians.

Goal: The aim was to investigate the clinical utility of RAPID Access 6.5 Quickview software and to evaluate whether preview of the capsule endoscopy video by a trained nurse could detect significant lesions accurately compared with endoscopists. Background: As reading capsule endoscopy is time consuming, one possible cost-effective strategy could be the use of trained nonphysicians or newly available software to preread and identify potentially important capsule images. Study: The 100 capsule images of a variety of significant lesions from 87 patients were investigated. The minimum percentages for settings of sensitivity that could pick up the selected images and the detection rate for significant lesions by a well-trained nurse, two endoscopists with limited experience in reading, and one well-trained physician were examined. Results: The frequency of the selected lesions picked up by Quickview mode using percentages for sensitivity settings of 5%, 15%, 25%, and 35% were 61%, 74%, 93%, and 98%, respectively. The percentages for sensitivity significantly correlated (r=0.78, P<0.001) with the reading time. The detection rate by the nurse or the well-trained physician was significantly higher than that by the physician with limited capsule experience (87% and 84.1% vs. 62.7%; P<0.01). The clinical use of Quickview at 25% did not significantly improve the detection rate. Conclusions: Quickview mode can reduce reading time but has an unacceptably miss rate for potentially important lesions. Use of a trained nonphysician assistant can reduce physician’s time and improve diagnostic yield.

Accuracy of CT Colonography for Detection of Polypoid and Nonpolypoid Neoplasia by Gastroenterologists and Radiologists: A Nationwide Multicenter Study in Japan.

OBJECTIVES:The objective of this study was to assess prospectively the diagnostic accuracy of computer-assisted computed tomographic colonography (CTC) in the detection of polypoid (pedunculated or sessile) and nonpolypoid neoplasms and compare the accuracy between gastroenterologists and radiologists.METHODS:This nationwide multicenter prospective controlled trial recruited 1,257 participants with average or high risk of colorectal cancer at 14 Japanese institutions. Participants had CTC and colonoscopy on the same day. CTC images were interpreted independently by trained gastroenterologists and radiologists. The main outcome was the accuracy of CTC in the detection of neoplasms ≥6 mm in diameter, with colonoscopy results as the reference standard. Detection sensitivities of polypoid vs. nonpolypoid lesions were also evaluated.RESULTS:Of the 1,257 participants, 1,177 were included in the final analysis: 42 (3.6%) were at average risk of colorectal cancer, 456 (38.7%) were at elevated risk, and 679 (57.7%) had recent positive immunochemical fecal occult blood tests. The overall per-participant sensitivity, specificity, and positive and negative predictive values for neoplasms ≥6 mm in diameter were 0.90, 0.93, 0.83, and 0.96, respectively, among gastroenterologists and 0.86, 0.90, 0.76, and 0.95 among radiologists (P<0.05 for gastroenterologists vs. radiologists). The sensitivity and specificity for neoplasms ≥10 mm in diameter were 0.93 and 0.99 among gastroenterologists and 0.91 and 0.98 among radiologists (not significant for gastroenterologists vs. radiologists). The CTC interpretation time by radiologists was shorter than that by gastroenterologists (9.97 vs. 15.8 min, P<0.05). Sensitivities for pedunculated and sessile lesions exceeded those for flat elevated lesions ≥10 mm in diameter in both groups (gastroenterologists 0.95, 0.92, and 0.68; radiologists: 0.94, 0.87, and 0.61; P<0.05 for polypoid vs. nonpolypoid), although not significant (P>0.05) for gastroenterologists vs. radiologists.CONCLUSIONS:CTC interpretation by gastroenterologists and radiologists was accurate for detection of polypoid neoplasms, but less so for nonpolypoid neoplasms. Gastroenterologists had a higher accuracy in the detection of neoplasms ≥6 mm than did radiologists, although their interpretation time was longer than that of radiologists.

Severe Colitis Associated with both Epstein-Barr Virus and Cytomegalovirus Reactivation in a Patient with Severe Aplastic Anemia

Epstein-Barr virus (EBV) and cytomegalovirus (CMV) are members of the herpesvirus family and common causes of viral infection in humans. CMV infection of the gastrointestinal tract occurs mainly in immunocompromised individuals, on the other hand EBV infection and reactivation involving the gastrointestinal tract is very rare. A 56-year-old man was diagnosed with severe aplastic anemia and treated with antithymocyte globulin (ATG) and cyclosporine (CSP). After 2 years of ATG/CSP therapy, he suddenly started passing bloody diarrhea and developed a high fever despite CSP treatment. Endoscopic features included severe edema and multiple superficial ulcers; the patient was initially diagnosed with severe colitis resembling inflammatory bowel disease (IBD). However, his symptoms did not resolve with steroid treatment. Immunohistochemical analysis of samples obtained from a second colonoscopy showed cells positive for CMV, and in situ hybridization revealed EBV-encoded small RNA-1-positive cells. Additionally, the patients serum was positive for C7-HRP, and both blood and colon tissues were positive for EBV DNA, which was detected using PCR analysis. We finally diagnosed the patient with colitis associated with reactivation of both CMV and EBV. The patient remains diarrhea-free after 1.5 years with scheduled globulin treatment and after cessation of immunosuppressive drug therapy. To our knowledge, this is the first reported case of an immunodeficient patient with severe hemorrhagic colitis that was associated with reactivation of both EBV and CMV, and whose endoscopic findings mimicked IBD.

Su1951 Over Expression of Cd55 and Loss of Dsc2 From Barrett's Columnar-Lined Esophagus Are Associated With Esophageal Adenocarcinoma Risk

activity of the lymph nodes described on the PET scan. Results: A total of 498 patients (median age 64, 84.13%males) with newly diagnosed esophageal cancer underwent complete EUS for initial staging at our center during 1999 to 2009. Adenocarcinoma was present in 440 patients and squamous cell cancer in 53 patients. The T stage distribution among 498 patients was T1 (including T1a, T1b and undifferentiated T1) was 91(18%), T2 was 59(12%), T3 was 317(64%), T4 was 14(3%) and T0 was 17(3%). There were 31 patients who underwent PET scan at another hospital and their report was not available. There were 170 lymph nodes that underwent FNA of which 96 lymph nodes (in 83 patients) were found to be positive for malignant cells. Among these, 72 lymph nodes (in 60 patients) were noted on the PET scan, 18 lymph nodes (in 18 patients) were not noted on the PET scan and 8 lymph nodes belonged to patients with no record of a PET scan either at our facility or outside. Among the 72 malignant lymph nodes noted on the PET scan, 12 lymph nodes were not FDG-avid. Table 1 shows the distribution of FNA positive lymph nodes and their detection on PET scan. FNA positive lymph nodes not noted on the PET scan were more commonly found below the diaphragm. Conclusion: EUS and PET scan are complimentary for esophageal cancer staging. The findings of PET scan should not limit an endosonographer in performing a complete lymph node survey.

Tu1639 Japanese Kampo (Herbal) Medicine, Hangeshashinto Improves Dextran Sulfate Sodium-Induced Colitis

Polyunsaturated fatty acid (PUFA)metabolism provides eicosanoid and docosanoidmediators that contribute to inflammation and to its resolution. In inflammatory bowel diseases, the homeostasis between these two types of metabolites is dysregulated. The aim of our study was to investigate the effect of two anti-inflammatory drugs (5-ASA and dexamethasone) on PUFA metabolites pattern in mice colitis. Methods: 5 groups of mice were treated with DSS 3% in drinking water to induce colitis and with 5-ASA (100 mg/kg), dexamethasone (DEX, 0.6 mg/kg) or their vehicle. After 7 days, colons were removed and inflammation evaluated by micro and macroscopic damages scores and myeloperoxidase activity (MPO). Eicosanoids and docosanoids from mouse colon were quantified by liquid chromatography tandem mass spectrometry. N-6 eicosanoids quantified were product of arachidonic acid metabolism by lipoxygenase (15-hydroxyeicosatetraenoic acid (15-HETE), 12-HETE, 8HETE, 5-HETE, lipoxin A4 and B4, leukotriene B4 (LtB4) and 5-oxoeicosatetraenoic acid (5-oxo-ETE)), by cyclooxygenase (6-keto-prostaglandin F1α (6-k-PGF1α), thromboxane B2 (TxB2), 8-iso-PGA2 and PGE2), by cytochrome epoxygenase (5,6-, 8,9-, 11,12and 14,15epoxyeicosatrienoic acid). N-3 eicosanoids and docosanoids quantified were metabolites of eicosapentaenoic acid (PGE3 and LtB5) and docosahexaenoic acid (resolvin D1, maresin-1, protectin (Pdx), 17-hydroxy-docosahexaenoic (17-HDoHE) and 14-HDoHE). Results: In vehicle treated mice, DSS augmented intestinal macro and microscopic damage score, MPO activity and weight lost compared to control animals. PUFA metabolite analysis in these samples revealed increased levels of pro-inflammatory (TxB2, PGE2, 5-, 8-HETE, 5-oxo-ETE and LtB4) and pro-resolving mediators (17-HDoHE, 14-HDoHE and Pdx). 5-ASA treatment decreased slightly damage score but has no effect on weight lost and MPO activity. This treatment only decreased the quantity of 5-HETE. Interestingly, concentration of two polymorphonuclear chemoattractant (5-oxo-ETE and LtB4) correlated to MPO. DEX treatment decreased MPO activity and the concentration of pro-inflammatory and pro-resolving PUFA metabolites but increased the other inflammatory parameters. Moreover, in DSS/dexamethasone treated group, the concentration of PDx and 17-HDoHE correlated with microscopic damage score, and 5-oxo-ETE and LtB4 with MPO. Conclusions: In DSS colitis, 5-ASA did not decrease pro-inflammatory PUFA metabolites and only slightly diminished inflammation. In contrast, dexamethasone decreased both pro-inflammatory and pro-resolving metabolites, as well as MPO activity but failed to prevent all the others signs of colitis. These results suggest that the concentration of some PUFA metabolites correlates with specific parameters of inflammation and might explain the effects or lack of effects of drugs treatments.

Mo1180 Identification of Serum Mirnas As Novel Non-Invasive Biomarkers for Detection of High Risk for Early Gastric Cancer

Background: Many micro-RNAs (miRNAs) are differentially expressed in Helicobacter pylori-infected gastric mucosa and in gastric cancer tissue and previous reports have suggested the possibility of serum miRNAs as complementary tumour markers. The aim of the study was to investigate serum miRNAs and pepsinogen levels in individuals at high risk for gastric cancer both before and after H. pylori eradication. Methods: Patients with recent history of endoscopic resection for early gastric cancer and the sex- and age-matched controls were enrolled. Serum was collected from subjects before or after eradication and total RNA was extracted to analyse serum levels of 24 miRNAs. Serum pepsinogen (PG) I and II levels were measured using enzyme-linked immunosorbent assay kits.