Japanese Journal of Gastroenterology最新文献

Methotrexate (MTX), the first-line drug for rheumatoid arthritis, rarely causes malignant lymphomas, which have been reported as MTX-associated lymphoproliferative disorders (MTX-LPD). Herein, report a case of MTX-LPD in the ileum with fistula formation in the small bowel and rectum. At the end of January 2023, an 81-year-old man who had been taking MTX for rheumatoid arthritis since the age of 73 years complained of abdominal pain and was diagnosed with intestinal obstruction at a previous hospital. In the early February 2023, the patient was referred to our hospital for further examination and treatment. A computed tomography scan revealed a thickened terminal ileum wall and enlarged mesenteric lymph nodes. A retrograde double-balloon endoscopy (DBE) detected circumferential ulcerative lesions at the terminal ileum with deep depressions in parts of the ulcer base. In addition, submucosal tumor-like lesions with central depressions were observed in the rectum. Retrograde contrast imaging under DBE confirmed the presence of fistulae between the ileum and rectum. A biopsy of the ulcerative lesion revealed hyperplasia of germinal center cell-like cells, and immunohistochemistry demonstrated CD20 and CD79a positivity, but CD5, CD10, and cyclin D1 negativity. Ki-67 positivity was 90%, indicating B-cell lymphoma. Based on histopathological findings and patient's history, the patient was suspected to have MTX-LPD, resulting in ileal and high anterior rectal resection. Histopathological examination of the resected specimen revealed large atypical lymphocyte proliferation. Immunohistochemistry confirmed CD20 and CD79a positivity;CD5, CD10, and cyclin D1 negativity;a Ki-67 positivity rate of 70%;and Epstein-Barr virus-encoded small RNA in situ hybridization negativity, confirmming the MTX-LPD diagnosis, presenting as diffuse large B-cell lymphoma. Postoperatively, the patient was monitored with MTX discontinuation, and no recurrence occurred. The clinical course remained consistent with MTX-LPD.

A 47-year-old male patient with anal pain underwent a colonoscopy 12 years after Crohn's disease diagnosis. A biopsy from the protuberance of the anal canal revealed a well-differentiated adenocarcinoma. A reexamination of the histopathological specimen at our hospital revealed anal high grade dysplasia (HGD), thereby changing the initial diagnosis. A distal colon resection and rectal amputation were performed, and the final diagnosis of the resected specimen was anal canal HGD. While HGD associated with Crohn's disease is rare in Japan, this case suggests the importance of endoscopic examination, which might help in early detection of HGD.

Purpose: Gastrointestinal cancer surgery is often complicated by adhesive small bowel obstruction (ASBO) and paralytic ileus (PI), managed with a long intestinal tube (LIT), surgery, or hyperbaric oxygen therapy (HBOT). LIT insertion is challenging for both patients and medical staff, whereas HBOT requires only bed rest. However, HBOT has not been reported in clinical practice. Therefore, this study aimed to investigate its use for postoperative ASBO in patients with gastrointestinal cancer.

Methods: This single-center, retrospective study included gastrointestinal cancer patients with postoperative ASBO between January 2012 and March 2023. A total of 126 patients (mean age 77.3 years) diagnosed with ASBO or PI at our hospital were assigned to either HBOT (96 patients) or LIT (30 patients). The primary outcome was the fasting period. Responders were defined as cases that resolved with a single treatment.

Results: The fasting periods did not differ significantly between the HBOT group (median [IQR], 5 [4-7] days) and the LIT group (5 [4-7.8] days;p=0.574). Among responders, the fasting period was also not significantly longer in the HBOT group (5 [3-7] days) than in the LIT group 5 [4-7.3] days;p=0.181). HBOT non-responders were significantly more emetic (94% vs 63%, p=0.018) and older (mean 82.0 vs 75.1 years;p=0.023) than HBOT responders.

Conclusion: HBOT appears no less effective than LIT for patients with ASBO or PI and offers greater comfort. It may be preferable for patients with mild vomiting, improvement after nasogastric tube placement, age <77 years, lower CRP, moderate intestinal dilatation, and within 24 hours of onset.

The patient was an 86-year-old man admitted to the neurology department with inclusion body myositis. Owing to dysphagia, a gastric tube was placed on 2nd hospital day 2, and steroid pulse therapy was initiated on day 7. On day 14, contrast-enhanced computed tomography (CT) performed for elevated D-dimer level revealed intra-mural gastric gas and intra-abdominal free air. He was referred to our department, where conservative treatment was initiated, as abdominal symptoms and ischemic findings were absent. Follow-up contrast-enhanced CT on day 8 after the onset showed resolution of both intra-mural gas and intra-abdominal free air. An esophagogastroduodenoscopy on day 9 revealed erosive gastritis in the gastric body, without necrosis or ulceration. The patient had an uneventful course. We report a case of gastric emphysema with intra-abdominal free air successfully managed conservatively, along with a literature review.

We report a case of vascular Ehlers-Danlos syndrome in a 30-year-old male patient. He presented to his local doctor with sudden onset of epicardial pain at around 5:00 p.m. on July 3, XXXX. On the same day, he was transferred to our hospital for extensive intra-abdominal hemorrhage suspected on abdominal computed tomography (CT). During emergency transport, his abdomen was flat, soft, and tender in the pericardial area, and blood biochemistry tests revealed a decreased hemoglobin of 10.2g/dL. He was admitted to our hospital, and conservative treatment was initiated. Five years ago, he underwent Hartmann procedure at another hospital for idiopathic perforation of the sigmoid colon. A month after discharge from the hospital, he had to undergo emergency surgery again at our hospital for colon resection and colostomy reconstruction due to colon perforation at the mouth side of the colostomy. He reported a history of colorectal perforation on the mouth side of the colostomy. After 6 months, a colostomy was performed and he was diagnosed with a terminal illness. Based on a family history of idiopathic colorectal perforation on his mother's side and the ruptured aneurysm, vascular-type Ehlers-Danlos syndrome was suspected. After admission, his symptoms of pericardial pain improved, but a CT scan on the 16th day revealed enlarged hepatic and splenic aneurysms. On July 24, he was transferred to a local hospital for splenic artery aneurysm treatment and underwent coiling the next day. His postoperative course was good, and he was transferred back to our hospital on July 26. He continued to show good progress and was discharged from the hospital on August 1. After discharge, he visited the outpatient genetic clinic for further examination. However, on October 9 of the same year, he developed aortic dissection and passed away.

An 86-year-old woman was under follow-up at the Breast Surgery Department of our hospital for postoperative treatment for right breast cancer. During this period, a 22-mm cystic mass was identified in the pancreatic head. Its size gradually increased, and she was eventually referred to our department. Abdominal computed tomography revealed a cystic mass with a faintly enhanced septum in the pancreatic head as well as stenosis and dilation of the hepatic bile duct. Imaging suggested a serous cystic neoplasm (SCN);however, considering that the mass was growing and the patient had periodic liver dysfunction and abdominal pain, which were indicative of cholangitis, further assessment was required. The patient declined surgery, and endoscopic ultrasonography-guided tissue acquisition was performed for a definitive diagnosis of SCN. Cholangitis episodes were infrequent and resolved spontaneously, and the patient was monitored through follow-up. After 2 years, cholangitis occurred more frequently, and the SCN showed further growth. Moreover, the patient developed obstructive jaundice. The patient refused surgery again despite our recommendation. As a result, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and a covered metallic stent was placed in the common bile duct to resolve bile duct stricture. Three years after diagnosis, the patient was hospitalized for recurrent orbital pain. ERCP revealed a filling defect in the stent and upper bile duct with proximal bile duct dilation. Balloon curettage resulted in the drainage of bile sludge and thrombus. The patient presented with cholangitis complicated by biliary hemorrhage, and an endoscopic nasobiliary drainage (ENBD) tube was placed to relieve obstruction caused by the thrombus. However, frequent bleeding from the ENBD tube suggested recurrent biliary hemorrhage, probably due to SCN, thereby requiring surgical intervention. At the request of the patient and her family, a pylorus-preserving pancreaticoduodenectomy was performed. The resected specimen was a large, 50-mm nodular lesion in the pancreatic head, extending from the pancreatic parenchyma to the bile duct, with stent compression and scarring from previous drainage. The lesion had a lobulated surface with cysts ranging from <1mm to 15mm, some of which exhibited hemorrhage. Surgical resection is the preferred treatment for symptomatic SCN. Although this patient eventually required surgery due to repeated biliary bleeding, the possibility that stent placement contributed to the hemorrhage suggests that surgical resection should remain the first-line treatment for SCN with obstructive jaundice.