Clinical Journal of Gastroenterology最新文献

Introduction: In the treatment of metastatic liver tumors, identifying the primary cancer is crucial for determining the appropriate treatment strategy. The management of colorectal liver metastases often centers around surgical resection, whereas breast cancer liver metastases are predominantly treated with chemotherapy. To our knowledge, this case represents a rare example of dual primary liver metastasis.

Case presentation: A 55-year-old female underwent systemic therapy with tamoxifen plus T-DM1 after right breast cancer resection 3 years ago. Two years ago, the patient developed simultaneous sigmoid colon cancer with liver metastasis. Due to liver damage from T-DM1, she initially underwent sigmoid colon resection, followed 2 months later by partial S5/8 resection and caudate lobectomy. S5/8 lesion was histologically diagnosed as colon cancer liver metastasis, while the caudate lobe lesion was breast cancer liver metastasis. 6 months after surgery, five liver metastases recurred, and the patient was diagnosed with liver metastatic recurrence of colorectal cancer. Six cycles of chemotherapy FOLFOX + Cetuximab were administered before surgery. The largest lesion of S5/8 shrunk, and the other four lesions were slightly enlarged. The histological examination confirmed the shrunken lesion as colorectal liver metastasis and the other lesions as breast cancer liver metastases.

Conclusion: Although radiological differentiation of metastatic liver lesions is challenging, chemotherapy response and tumor localization can aid in diagnosis. Multi-disciplinary cooperation is essential in determining treatment strategies for dual primary liver metastases.

Cryopyrin-associated periodic syndrome (CAPS) is a rare, autosomal dominant inflammatory disorder linked to interleukin (IL)-1β dysregulation. Muckle-Wells syndrome (MWS) is a clinical subtype of CAPS that is often managed with canakinumab, an anti-IL-1β monoclonal antibody. Canakinumab has been approved for all phenotypes of CAPS, with no age restrictions, since 2011. Despite its efficacy in controlling systemic inflammation, its gastrointestinal side effects remain unclear. This report presents the case of a 28 year-old man who developed abdominal pain and diarrhea during treatment with canakinumab for MWS. Colonoscopy revealed findings suggestive of inflammatory bowel disease, and a diagnosis of IBD-unclassified (IBD-U) was made after exclusion of other conditions. Treatment with oral budesonide and vedolizumab led to marked clinical and endoscopic improvements, maintaining remission after budesonide discontinuation. Although the usefulness of systemic prednisolone and anti-TNFα antibody preparations for treating IBD-U in patients with MWS has been previously reported, to the best of our knowledge, this is the first report to highlight the therapeutic effects of budesonide and vedolizumab. Therefore, IBD-U should be considered in the differential diagnosis of patients with CAPS who develop gastrointestinal symptoms. Considering their favorable side-effect profiles, budesonide and vedolizumab may serve as promising treatment alternatives in the future.

A 70-year-old woman presented with a mass in the tail of the pancreas, which was incidentally detected during screening with plain computed tomography (CT). Dynamic CT revealed a 14-mm mass in the pancreatic tail, characterized by low density in the early arterial phase and delayed contrast enhancement from the portal to the equilibrium phase. Magnetic resonance imaging revealed that the tumor had slightly high signal intensity dorsally and slightly low signal intensity ventrally on T1-weighted fat suppressed images, and low signal intensity on T2-weighted images. Endoscopic ultrasonography revealed a well-demarcated hypoechoic mass. However, biopsy showed no definitive tumor cells. Due to the difficulty in ruling out acinar cell carcinoma, laparoscopic distal pancreatectomy was performed. Histologically, the lesion revealed an enlarged pancreatic duct and adenohypophysis with fibrosis, lacking concentric elastic fibers in the duct walls, peripheral nerves, and islets of Langerhans. The final pathological diagnosis was pancreatic hamartoma-a rare tumor with only 52 cases reported previously in the literature. Preoperative histological diagnosis is extremely challenging. Here, we report a case of pancreatic hamartoma that was difficult to distinguish from malignant tumor preoperatively.

Reports from Japan suggest that Helicobacter pylori infection could be a risk factor for gastric cancer in patients with Lynch syndrome (LS), similar to its role in sporadic gastric cancer. Therefore, eradication of H. pylori infection is recommended. However, the evidence regarding the risk of gastric cancer in H. pylori-uninfected patients with LS remains insufficient. Between 2014 and 2023, we encountered five cases of suspected LS-specific gastric cancer in H. pylori-uninfected patients during esophagogastroduodenoscopy (EGD) surveillance in individuals either genetically diagnosed with or suspected of having LS. This report describes the novel clinicopathological characteristics observed in these patients. A common endoscopic finding in all five cases was the presence of a characteristic elevated lesion with a reddish hue in the cardia or fornix. Histopathological examination confirmed LS-specific gastric cancer, including undifferentiated carcinoma. In cases initially presenting as subepithelial lesions, cancer diagnosis through biopsy was difficult. In tumors ≤ 15 mm, submucosal invasion is a key characteristic of H. pylori-uninfected gastric cancer with LS. This suggests the need for intensive endoscopic surveillance to detect rapid tumor growth.

Immune checkpoint inhibitors, such as ipilimumab and nivolumab, target cytotoxic T-lymphocyte-associated antigen 4 and programmed cell death protein 1, respectively, and are increasingly used in cancer treatment. These therapies can induce immune-related adverse events, including colitis and ileitis. However, the reports on enteritis caused by these immune-related adverse events are limited, particularly in Japan, with only a few case reports available. The incidence, typical location, and timing of onset of such inflammation remain undefined. We present the case of a 56-year-old male patient who developed severe colitis and enteritis after receiving immune checkpoint inhibitor treatment for metastatic lung tumor recurrence following surgery for renal cell carcinoma. Despite treatment with high-dose prednisolone and infliximab, the patient developed colonic perforation, requiring subtotal proctocolectomy and colostomy. Six months postoperatively, he presented with enteritis with luminal narrowing. Oral budesonide was initiated, and endoscopic balloon dilation of the stenotic site improved the obstruction. Consequently, 3.5 years after initiating immune checkpoint inhibitor therapy, the metastatic lung tumor has not recurred. Moreover, the patient is alive, with no difficulty in oral intake. This report has highlighted the need for careful consideration of immune checkpoint inhibitor administration, even when transitioning to single-agent therapy.

Red Dichromatic Imaging (RDI) is an advanced endoscopic technology designed to enhance the visualization of gastrointestinal bleeding. While RDI with Mode 2 has demonstrated significant efficacy in the detection and management of esophageal varices, its role in treating anastomotic varices remains underexplored. We report a challenging case of anastomotic variceal rupture, highlighting the advantages of RDI in precise localization and treatment. A woman in her 70 s with a history of pancreaticoduodenectomy for pancreatic head cancer and liver metastasis, presented with melena, fever, and suspected cholangitis during chemotherapy. Laboratory findings revealed anemia, leukocytosis, and elevated biliary enzymes. Blood transfusion and antibiotic therapy were initiated. CT revealed portal vein stenosis and contrast extravasation into the jejunum. Endoscopy showed a white plug at the gastrojejunal anastomosis, but no visible varices on white light imaging. RDI with Mode 2 identified subtle color changes, enabling successful N-butyl-2-cyanoacrylate injection. Accumulation of lipiodol confirmed variceal obliteration. No further bleeding occurred, and the patient was discharged in stable condition on hospital day 19. This case suggests that RDI may improve the detection and therapeutic precision of ectopic varices and serve as a valuable adjunct in their management.

A 55-year-old woman who had undergone extrahepatic bile duct resection and choledochojejunostomy for pancreatobiliary maljunction was admitted to our hospital with acute cholangitis caused by large intrahepatic bile duct stones. We performed direct peroral cholangioscopy using a double-balloon endoscope. After fragmenting the stones with a snare under direct visualization, we attempted to remove them using a retrieval net, which led net impaction. To address this, we inserted the electrohydraulic lithotripsy probe-known for its lack of rigidity-into the working channel via an endoscopic retrograde cholangiopancreatography catheter, enabling electrohydraulic lithotripsy under direct visualization, without scope removal, and complete stone removal. This case demonstrated successful stone dislodgement with electrohydraulic lithotripsy, highlighting an innovative probe insertion method. Owing to the complexity of balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography, more careful instrument selection is crucial than in conventional endoscopic retrograde cholangiopancreatography. Electrohydraulic lithotripsy proved to be effective in managing stone impaction during balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography.

A 74-year-old woman underwent endoscopic retrograde cholangiopancreatography because of obstructive jaundice, caused by pancreatic cancer. The patient received a plastic biliary stent (half-pigtail type) placement into the left hepatic bile duct for biliary drainage. After 28 days, the patient presented to our hospital with fever and jaundice. Emergent endoscopic retrograde cholangiopancreatography revealed bleeding from the papilla and blood clots filling the entire bile duct. To treat the hemobilia, endoscopic nasobiliary drainage was performed after placement of a self-expandable metallic stent in the common bile duct. Frequent irrigation of the bile duct failed to remove the clots. Although endoscopic retrograde cholangiopancreatography was repeated to remove the clots, fresh blood flowed from the bile duct. Enhanced computed tomography revealed a left hepatic artery pseudoaneurysm that had likely ruptured into the bile duct. Following successful transcatheter arterial embolization, there was no recurrent bleeding. Since the tip of the stent was located at the site of the pseudoaneurysm, it was suspected that stent insertion caused the complication. This report describes a rare case of hemobilia of a hepatic artery pseudoaneurysm caused by insertion of a half-pigtail type biliary stent into the left hepatic duct. The case was successfully treated with embolization.

Malignant triton tumor (MTT) is a rare subset (5%) of malignant peripheral nerve sheath tumors (MPNSTs), classified as soft-tissue sarcomas. MTT is an orphan disease characterized by rhabdomyoblastic differentiation, therapeutic resistance, and a sinister prognosis. The neoplasms classically arise at the trunk, head and neck region, and extremities. In 50% of the cases, MTT is associated with neurofibromatosis type 1 (NF1), a relatively common autosomal dominant cancer-prone disorder of the central nervous system. Few cases of MTT in the gastrointestinal tract have been published, including esophagus, duodenum, and rectum. In this article, we present what we believe to be the first report of MTT in the common bile duct. A multidisciplinary approach was the key in establishing this particular diagnosis, and workup included endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, pathological staining, and genetic testing. Literature focusing on MTT remains scarce, and patients with MTT are often included with other subtypes in broader studies of MPNST. Therefore, our literature review covers MPNST and focusses on MTT where appropriate. It provides the current understanding of tumor epidemiology, genetics, and diagnostic workup, and discusses therapeutic challenges and future perspectives. Our case report underlines the value of cholangioscopy-guided biopsies, and honoring patient's autonomy in end-of-life setting.

This case report describes a 77-year-old man with chronic hepatitis C-related hepatocellular carcinoma who developed severe portal vein thrombosis after combination therapy with atezolizumab (ATZ) plus bevacizumab (BEV). Following treatment, he experienced abdominal distension and subsequent deterioration, leading to hospitalization. Despite intensive care, including anticoagulation therapy, the patient succumbed to multi-organ failure. An autopsy revealed intestinal necrosis, along with severe thrombosis of the portal vein and superior mesenteric vein. This case highlights a rare but serious risk of portal vein thrombosis associated with ATZ plus BEV therapy, underscoring the need for vigilant monitoring in patients receiving this treatment.