Clinical Journal of Gastroenterology最新文献

We herein report a case of pancreatic ductal adenocarcinoma (PDAC) that developed within the pancreatic duct and was initially diagnosed as an intraductal tubulopapillary neoplasm (ITPN). A 76-year-old man presented with weight loss and main pancreatic duct dilation. The imaging studies revealed a 30-mm hypovascular tumor within the main duct of the pancreatic head. An endoscopic examination with a biopsy revealed high-grade atypical epithelial cells with immunostaining patterns suggestive of ITPN. Following robot-assisted pancreaticoduodenectomy, postoperative pathology revealed conflicting features: nodular/cribriform infiltrations typical of ITPN and non-lobular replacement with scattered infiltrations characteristic of PDAC. A comprehensive genomic profiling test detected KRAS and TP53 mutations, leading to the final diagnosis of PDAC (fT3N1aM0, stage IIB). The patient received adjuvant S-1 chemotherapy and remained recurrence-free for 15 months post-surgery. This case highlights the diagnostic challenges of differentiating intraductal pancreatic tumors and demonstrates the utility of integrating genetic testing with conventional diagnostic modalities for an accurate diagnosis and appropriate treatment selection.

An 80-year-old woman with a history of endoscopic balloon dilation for esophageal stricture caused by accidental ingestion of caustic soda during infancy presented with dysphagia. Upper gastrointestinal endoscopy revealed a 10-cm-long, highly white, elevated lesion with a feathered appearance. This lesion was determined to be the cause of dysphagia and was completely resected via endoscopic submucosal dissection. Histopathological examination revealed a thick keratin layer on the surface of the stratified squamous epithelium, with a prominent granular layer underneath and some areas showing nuclear atypia. The lesion was diagnosed as a well-differentiated squamous cell carcinoma, pT1a-LPM, derived from epidermoid metaplasia. Cancer genome analysis revealed mutations in TP53 as well as amplification of MYC, FGFR1, chromosome 7, and chromosome 20q. This case suggests that epidermoid metaplasia caused by chronic irritation from an esophageal stricture may have been exacerbated by the dilation procedure.

Chemotherapy has been developed for many years for malignancies, including advanced pancreatic cancer, downsizing the primary site, thereby enabling complete cure with the combination of conversion surgery. Pathological complete remission from operation samples was usually identified as a promising indication for a good prognosis for many carcinomas. Several case reports consisting of pathological complete remission after chemotherapy application have been reported but no case of pathological complete remission that resulted from successful extensive resection by surgery after S-1, irinotecan, and oxaliplatin (SIROX) chemotherapy. A 48-year-old male patient was hospitalized due to abdominal pain which turned out to be a 25 mm-sized advanced uncinate process of pancreatic cancer with possible duodenum invasion and hepatic metastasis. The tumor had decreased after administering 23 sessions of modified SIROX chemotherapy, and he underwent pylorus-preserving pancreaticoduodenectomy with portal vein resection. He was successfully managed with conservative treatment and discharged 12 days postoperatively despite his postoperative weakness. He had been taking S-1 pills for 6 months and until now, 3 years postoperatively, with no relapse. The final pathology reported complete tumor regression. Therefore, we emphasize the oncologic significance of chemotherapy in the uncinate process of pancreatic cancer and the potential role of conversion surgery.

An 82-year-old man presented with intermittent abdominal pain and elevated liver enzymes. Blood tests showed normal levels of tumor markers (CEA, CA19-9, NSE). Contrast-enhanced computed tomography (CE-CT) revealed a 20 mm hypovascular mass in the pancreatic head. Magnetic resonance imaging indicated low intensity on both T1- and T2-weighted images and high intensity on diffusion-weighted images. Endoscopic ultrasonography visualized an irregular hypoechoic mass. Initially, it was diagnosed as pancreatic ductal adenocarcinoma (PDAC) based on imaging. Subsequent histopathological analysis via endoscopic ultrasound-guided fine-needle aspiration revealed a neuroendocrine tumor (NET). The preoperative diagnosis was changed to a pancreatic NET grade1. Consequently, a pancreaticoduodenectomy was performed. Histopathological examination of the resected specimen unveiled a mixed tumor-NET-Grade1/Grade3 and invasive PDAC. No clear transition between the NETs and PDAC was observed. The high grade of NET with significant fibrosis contributed to decreased enhancement of CE-CT. Finally, we diagnosed this case as a pancreatic collision tumor involving both NET and PDAC components, with lymph node metastases attributed to the NET components. In this case, achieving an accurate preoperative diagnosis was challenging despite utilizing both imaging and biopsy diagnostics. This unique case underscores the difficulties encountered in the preoperative assessment of mixed tumors.

Arsenic toxicity is rare in developed countries. It may be difficult to diagnose due to its heterogenous symptom presentation. We present a case of severe hepatic steatosis and cholestatic hepatitis associated with arsenic toxicity in an adult.

A 73-year-old man underwent upper gastrointestinal endoscopy for abdominal pain, which revealed an ampullary adenoma with no obvious extension into the bile or pancreatic ducts. Endoscopic papillectomy (EP) was performed and a 5-Fr 5-cm stent was placed in the pancreatic duct. The patient developed acute pancreatitis on postoperative day (POD) 1 and contrast-enhanced computed tomography performed on POD 2 revealed that the proximal end of the stent had migrated into the retroperitoneum, forming a pancreatic fistula. Stent removal and endoscopic nasopancreatic drainage were performed and the pancreatitis rapidly improved. The tumor was completely resected and after approximately three years of follow-up, no tumor recurrence or acute pancreatitis was observed.Retrospectively, the inferior branch of the pancreatic duct was prominent on pancreatography at the time of EP and the proximal end of the stent had dislocated into the inferior branch. The stent subsequently moved proximally, which could have caused pancreatitis and pancreatic fistula. The morphology of the pancreatic duct should be carefully monitored during stenting. Selecting a stent that matches each patient's specific pancreatic duct morphology may help physicians minimize the risk of adverse outcomes.

Cabozantinib is a multi-kinase inhibitor targeting multiple tyrosine kinases. It improves overall survival and progression-free survival in patients previously treated with sorafenib for advanced hepatocellular carcinoma (HCC) compared to the placebo in the phase 3 CELESTIAL trial. A 71-year-old man presented to our hospital for treatment of HCC with chronic hepatitis C. He was refractory to sorafenib, lenvatinib, regorafenib, and ramucirumab and started atezolizumab and bevacizumab therapy in November 2020. After administering the second cycle on December 10, 2020, the patient was diagnosed with progressive disease in January 2021. Therefore, cabozantinib (60 mg/day) was initiated on January 14, 2021. As the grade 3 aspartate aminotransferase and alanine aminotransferase levels increased, grade 3 anorexia and a decline in performance status were observed in the first week, and cabozantinib was terminated. His performance status and anorexia gradually improved, and contrast-enhanced computed tomography (CT) in June 2021 showed complete remission (CR) according to the modified Response Evaluation Criteria in Solid Tumors. The patient did not show disease progression for 11 months without receiving any treatment for HCC. To the best of our knowledge, this is the first report of CR with cabozantinib in advanced HCC.

Epiphrenic esophageal diverticulum is rare and often associated with abnormalities of esophageal motility. Here, we report a case of a patient diagnosed with high-resolution manometry as having epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction, which were successfully treated with laparoscopic transhiatal surgery. A 59-year-old woman presented to our hospital for treatment of a symptomatic epiphrenic esophageal diverticulum. An esophagogram revealed a left epiphrenic diverticulum measuring 50 mm. High-resolution manometry showed a high integrated relaxation pressure of 35.6 mmHg (> 26 mmHg) and preserved esophageal peristalsis. A chest computed tomography scan showed no external compression of the distal esophagus. Therefore, we diagnosed an epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction according to the Chicago Classification v3.0. Laparoscopic transhiatal diverticulectomy, planned and selective myotomy, and Dor fundoplication were performed. We performed myotomy just on the esophageal side and did not perform gastric myotomy. The postoperative course was uneventful, and the postoperative esophagogram showed smooth passage of contrast without leakage or stenosis. High-resolution manometry showed a normal integrated relaxation pressure (11.6 mmHg) at three months after surgery. Because an epiphrenic esophageal diverticulum is frequently associated with esophageal motility disorder, not only morphologic but also functional and appropriate treatment must be considered.

Tuberculosis is a global epidemic infection that typically presents with symptoms affecting the respiratory system. Abdominal tuberculosis is an uncommon manifestation, occurring in only 5% of tuberculosis cases globally and can present with a broad range of vague symptoms that mimic other biliary and pancreatic pathologies. We report a case of a 36-year-old woman presenting with jaundice and biliary obstruction secondary to abdominal tuberculosis. Computed tomography and magnetic resonance cholangiopancreatography revealed a loculated retroperitoneal mass abutting the pancreatic head and duodenum with associated common bile duct dilatation. Endoscopic ultrasound demonstrated an ulcerated mass in the duodenum which was biopsied. Necrotising granulomas were identified on histology and the biopsied tissue was positive on tuberculosis polymerase chain reaction testing. Thus, extrapulmonary abdominal tuberculosis was diagnosed. The patient was commenced on a 6-month course of rifampicin, isoniazid, pyrazinamide and ethambutol treatment and demonstrated complete response to medical therapy. Abdominal tuberculosis can be difficult to diagnose but should remain an important differential to be considered for patients with previous travel or residence in endemic areas presenting with gastrointestinal symptoms. Prompt diagnosis and treatment can prevent unnecessary procedures, complications and death in patients with biliary obstruction caused by abdominal tuberculosis.

We herein present four cases of Eosinophilic colitis (EoC) in adult patients who were successfully treated with a Janus kinase (JAK) inhibitor. Case 1 is a 23-year-old female who was treated with baricitinib (BAR, 4 mg, once a day) for atopic dermatitis (AD). Colonoscopy (CS) initially did not reveal any significant abnormalities. However, she underwent another CS when she underwent a food challenge test involving wheat without baricitinib medication. During this procedure, the CS subsequently leading to her diagnosis of EoC based on eosinophil infiltration. Case 2 is a 26-year-old man whereas Case 3 is a 40-year-old man. Both patients were started on upadacitinib (UPA, 15 mg, once daily) for the treatment of AD. Their abdominal symptoms improved, and colonic histology revealed the disappearance of eosinophils. Case 4, on the other hand, is a 29-year-old woman who was also started on UPA (15 mg, once daily). Her skin lesions and abdominal symptoms also improved within 2 weeks. To the best of our knowledge, this is the first novel clinical observational case report on the efficacy of JAK inhibitors in treating adult patients with both EoC and AD.