Clinical Journal of Gastroenterology最新文献

A woman in her 70s was referred for evaluation of a small (8 mm) hepatic nodule detected on magnetic resonance imaging (MRI). The lesion demonstrated high signal intensity on diffusion-weighted imaging (DWI) with low apparent diffusion coefficient (ADC) values, which is atypical for small hepatocellular carcinoma (HCC). Contrast-enhanced ultrasonography (CEUS) revealed washout within 60 s, which is also atypically early for HCC. Histopathological examination confirmed hepatic mucosa-associated lymphoid tissue (MALT) lymphoma. The combination of high signal intensity on DWI, a low ADC value, and early washout on CEUS is particularly useful in identifying small atypical hepatic tumors, such as MALT lymphoma, that mimic HCC.

Gastric fundic gland polyps (FGPs) are common benign lesions, typically found in Helicobacter pylori (HP)-uninfected stomachs. While syndromic FGPs resulting from genetic diseases may exhibit dysplasia, sporadic FGPs rarely develop into adenocarcinomas. Here, we present the first case of invasive gastric adenocarcinoma that occurred in a sporadic FGP in an HP-uninfected patient. A 77-year-old man on proton pump inhibitor (PPI) therapy for 6 years developed an enlarged reddish FGP. The absence of atrophic changes in the entire gastric mucosa was confirmed endoscopically and multiple HP tests were negative. After PPI discontinuation, the lesion initially reduced in size from 25 to 15 mm in 1 month; however, malignancy was suspected because of rapid enlargement and persistent discoloration. En bloc resection was performed by endoscopic mucosal resection. Histological examination confirmed FGP and submucosal adenocarcinoma with a depth of approximately 700 μm, negative for lymphovascular invasion, and negative resection margins. A subsequent distal gastrectomy confirmed the absence of residual disease or lymph node metastases. The unusual endoscopic findings of rapid enlargement and reddish tone pushed us to perform endoscopic treatment, which resulted in a correct diagnosis and appropriate treatment.

Werner syndrome is a rare progeroid condition caused by a mutation in the WRN gene. It is characterized primarily by premature aging, diabetes mellitus, atherosclerosis, and an increased risk of malignancy. In this case, we present a man in his 40s with liver cirrhosis who was subsequently diagnosed with Werner syndrome. Shortly afterwards, he developed refractory ascites and a non-healing ulcer on his left big toe and ultimately died of liver failure. Despite having only mild fatty liver disease and being of normal weight, his liver became cirrhotic within a little over 4 years. Although a liver biopsy was not performed, the presumed etiology of his liver cirrhosis was non-alcoholic fatty liver disease (NAFLD) due to fatty liver disease. This case report highlights the importance of considering Werner syndrome in the differential diagnosis of fatty liver, particularly in the absence of obesity, as it can lead to the rapid progression of NAFLD-related liver cirrhosis.

Hepatocellular carcinoma (HCC) has a high recurrence rate, typically within 2 years after surgical radical resection. Pancreatic metastasis from HCC is extremely rare. We present the first case of pancreatic metastasis from HCC recurring 17 years after radical hepatic lobectomy.

We report the case of a patient with anaplastic carcinoma of the pancreas derived from an intraductal papillary mucinous neoplasm. A 51-year-old man was reported to have an enlarged cystic lesion in the pancreatic head. Contrast-enhanced computed tomography revealed a multifocal cystic lesion with an internal contrasted nodule. The patient was diagnosed with IPMN with high-risk stigmata and underwent pylorus-preserving pancreaticoduodenectomy. The pathological diagnosis was anaplastic carcinoma of the pancreas, classified as pleomorphic type, derived from intraductal papillary mucinous neoplasm. Based on the morphological features and immunohistochemical reactivity for MUC1, MUC2, MUC5AC, and MUC6, the intraductal papillary mucinous carcinoma was classified as pancreatobiliary type. Immunostaining for tumor-suppressor genes CDKN2A(p16), TP53, SMAD4, and STK11 was performed; aberrant expression of p53, Smad4, and STK11 was observed in intraductal papillary mucinous carcinoma and anaplastic carcinoma. The patient's postoperative course was uneventful; however, para-aortic lymph node metastasis was observed 10 months postoperatively. Immunohistochemical analysis of intraductal papillary mucinous neoplasm subtypes and tumor-suppressor genes may contribute to predicting prognoses in such cases.

The postoperative recurrence rate of esophageal cancer ranges from 28 to 47%, with recurrences often affecting distant organs such as the lungs, liver, bones, and brain. However, colonic metastasis is rare. This report presents a case of transverse colon metastasis after radical resection of esophageal cancer in a 70-year-old man. The patient underwent neoadjuvant chemotherapy followed by esophagectomy for advanced esophageal cancer 15 months ago. He reported loss of appetite during a routine outpatient visit, and computed tomography revealed bowel obstruction and intussusception with a tumorous lesion in the transverse colon. Positron emission tomography did not reveal any abnormal accumulation in other areas. Based on these findings, a transverse colectomy was performed. Pathological examination of the resected specimen revealed squamous cell carcinoma components in the normal colonic mucosa, which were diagnosed as colonic metastases from the esophageal cancer. Postoperatively, the patient recovered uneventfully and commenced adjuvant therapy with capecitabine monotherapy, which was later discontinued at the patient's request. Four months post-surgery, liver metastasis developed, and the patient underwent immunochemotherapy. Colorectal metastasis from esophageal cancer is relatively rare, making preoperative diagnosis challenging. Nonetheless, a multidisciplinary approach combining surgery and perioperative systemic therapy has the potential to improve patient outcomes.

The serrated neoplastic pathway has been reported to be involved in the development of colorectal cancer, and serrated lesions are recognized to have malignant potential. Recently, serrated lesions of the duodenum have been increasingly reported. Serrated polyposis syndrome (SPS) is characterized by multiple serrated lesions in the colon; however, it is unknown whether serrated lesions in the duodenum occur in patients with SPS. A 58-year-old man with SPS underwent a routine colonoscopy. When he underwent esophagogastroduodenoscopy for screening, two 4-mm white flat-elevated lesions in the second portion of the duodenum were found. The biopsy results were suggestive of sessile serrated lesions (SSLs); therefore, we performed endoscopic mucosal resection with a cap-fitted pan-endoscope for therapeutic purposes. Pathology results showed an SSL in the duodenum. One SSL lesion was positive for the BRAF mutation; multiple duodenal SSLs in patients with SPS are rare, and there are no previous reports of BRAF mutation-positive SSLs. The grade and molecular abnormalities of duodenal SSLs are currently unknown, as is the relationship between SPS and duodenal SSL. Further case accumulation is expected.

Chronic esophageal achalasia can lead to significant morphological changes in the esophagus, posing challenges during endoscopic examinations. Here, we report a case of iatrogenic esophageal perforation in an elderly patient with achalasia. An 80-year-old woman presented with severe dysphagia and marked weight loss, indicating chronic malnutrition. She had a 50-year history of achalasia, previously treated with a Heller-Dor operation. Endoscopic evaluation was performed to assess the esophageal condition; however, during the procedure, an iatrogenic perforation occurred. The patient underwent urgent management under general anesthesia. Two drainage tubes were placed at the base of the right thoracic cavity. Saline infusion via the perforation site enabled endoscopic lavage of the thoracic cavity. The perforation was initially closed with the thread-and-clip technique. After 30 days, the perforation site had developed into a fistula approximately 1 cm in size. Attempts to close it using argon plasma coagulation ablation and over-the-scope clip were unsuccessful. It was presumed that the significant accumulation of fluid in the esophagus due to achalasia was hindering fistula closure. Consequently, peroral endoscopic myotomy was performed, ultimately leading to the closure of the fistula. Despite requiring prolonged hospitalization for recovery and nutritional rehabilitation, the patient was eventually discharged in stable condition, able to consume meals without difficulty. This case underscores the high risk of esophageal perforation during endoscopy in elderly patients with advanced achalasia and subsequent malnutrition. Furthermore, it highlights the potential for successful management of severe complications like esophageal perforation through advanced endoscopic techniques, thereby avoiding the need for surgical intervention.

Pancreatic cancer is an aggressive malignancy with a poor prognosis. Although distant metastases are common at the time of diagnosis, metastatic spread to the rectum is rare. Furthermore, there have been no reports of acute rectal obstruction caused by a metastatic rectal tumor from pancreatic cancer. A 75-year-old man presented with lower gastrointestinal bleeding, abdominal pain, and distention. Colonoscopy and abdominal computed tomography confirmed acute rectal obstruction. Additionally, computed tomography identified a tumor in the pancreatic tail. An emergency loop colostomy on the transverse colon was performed. During preoperative assessment, the patient was initially considered to have synchronous primary cancers of the rectum and pancreas. However, microscopic examination confirmed that the rectal tumor was a metastasis from pancreatic cancer. Chemotherapy for pancreatic cancer was initiated immediately, and as of this writing, the patient has survived for more than 1 year. In summary, we herein report a rare case of pancreatic cancer metastasizing to the rectum. The prognosis of pancreatic cancer with distant metastases may be improved by enabling early initiation of chemotherapy. Minimally invasive surgery could be an effective approach for managing rectal obstruction due to metastasis.

Endoscopic step-up approach, which involves endoscopic ultrasound-guided drainage followed by necrosectomy, has been suggested as a potentially advantageous alternative to the surgical step-up approach for walled-off necrosis (WON) following acute pancreatitis. Recent studies indicate that although there is no significant difference in major complications or mortality between the two approaches, the endoscopic step-up approach is often preferred due to shorter hospital stays and lower re-intervention rates. However, a multidisciplinary approach should be considered for complex cases. Transgastric or transduodenal approaches can be challenging in cases of extensive intra-abdominal WON, whereas percutaneous endoscopic necrosectomy (PEN) has been reported as a safe and effective minimally invasive technique. We report the cases of two critically ill patients with extensive WON and uncontrolled sepsis who were successfully treated with simultaneous dual-endoscopic PEN. This approach may offer a promising strategy for enhancing treatment efficacy in extensive WON when performed appropriately.