Advances in Digestive Medicine最新文献

Inflammatory bowel disease (IBD) is a chronic gastrointestinal disorder characterized by relapsing inflammation and severe mucosal damage in the intestine. Young IBD women are often worried about their fertility, the disease activity during pregnancy, the heritability of the disease to their unborn child, and also the effect of their disease on the pregnancy itself. The pregnancy outcome and drug usage during pregnancy are rarely discussed in an area of low IBD prevalence. To evaluate (a) decision-making around drug therapy during pregnancy and (b) the prognosis for pregnant IBD patients in an area of low IBD prevalence. We conducted a retrospective analysis across seven medical centers in Taiwan from February 2009 to February 2019. Maternal and fetal/neonatal outcomes were analyzed. A total of 17 patients (21 pregnancies) were enrolled. The mean age of patients was 35.9 ± 4.6 years. Six patients (35.3%) had fertility worries and two (11.8%) had infertility. Five patients had Crohn's disease (CD), of whom 60% had undergone prior abdominal surgery. The remaining 12 patients had ulcerative colitis (UC), of whom 8.3% had undergone prior abdominal surgery (significantly lower than CD patients [P = .02]). There were no significant differences between the CD and UC groups in terms of age, age of primigravida, height, weight, fertility worries, or infertility. Abortion, miscarriage, or stillbirth was seen in 23.8% of patients, and 14.3% of patients needed treatment to prevent miscarriage. Low birth weight (<2500 g) was seen in 14.3% of births, and 14.3% had associated complications. There was no significant difference between CD and UC patients in terms of pregnancy outcome. During pregnancy, 33.3% of patients changed their drug regimens, stopping the use of 5-ASA (9.5%), immunosuppressants (4.8%), corticosteroids (4.8%), or biologics (9.5%). However, if IBD progressed during pregnancy, corticosteroids were considered (19.4%) for disease control. These are real-world experiences of IBD during pregnancy in Taiwan. High rates of abortion, miscarriage, or stillbirth and treatment to prevent miscarriage were noted. Among all subjects, 33.3% of patients changed their drug regimen during pregnancy. Corticosteroids were also considered if IBD progressed during pregnancy in this study.

A 69-year-old man with alcohol use disorder presented with tarry stools for 1 week. Upon presenting at the hospital, his hemoglobin level was 4.3 g/dL (normal range: 13–18 g/dL). Esophagogastroduodenoscopy revealed a firm, dark-brown, irregularly island-like mass (around 3 cm) on a clean-based ulcer, with no active bleeding, on the anterior wall of the duodenal bulb (Figure 1A). Abdominal computed tomography of the duodenal lesion showed a 6.5 cm mass in the hepatic hilum with a satellite mass infiltrating the proximal duodenum (Figure 2). Histopathology of the lesion showed tumor elements that were weakly positive on α-fetoprotein immunostaining; thus, indicating a moderate differentiation of hepatocellular carcinoma (HCC). A few days later, the patient presented with recurrent gastrointestinal bleeding and underwent endoscopic argon plasma coagulation (ERBE Elektromedizin GmbH, Germany, VIO 200D; forced mode, gas flow 1.8 L/min, power setting 30 W) with an axial probe (2.3 mm in diameter, 220 cm in length) (Figure 1B), with a subsequent transcatheter arterial embolization. Temporary hemostasis was achieved; unfortunately, he died of tumor progression and persistent duodenal bleeding 2 months later.

Extrahepatic metastases of HCC have been reported mainly in the lung and in regional lymph nodes, while direct invasion into the gastrointestinal tract is rare (0.5%–2% of the cases)¹ and is generally associated with advanced disease (with a large tumor >5 cm).² In these cases, the stomach and duodenum are the most frequent sites of direct invasion and commonly present with bleeding and gastric outlet obstruction. The first line of treatment for such cases would be a surgical resection with a pancreas-sparing duodenectomy.³ Other treatment approaches include external beam radiation therapy, transcatheter arterial embolization, and a local injection with an ethanol injection. However, attempts to control tumor bleeding often fail, and the prognosis of HCC with duodenal invasion is poor. Liang et al. reported that 50% of patients with duodenal invasion died within 3 months.⁴ If endoscopic findings reveal an infiltrating mass into the duodenal bulb, it should raise suspicions of direct invasion by a liver tumor (Table S1).

All authors declare no conflicts of interest.

Informed consent was obtained from all participating adult subjects, together with the manner in which informed consent was obtained (ie, oral or written).

The prevalence of periampullary diverticulum (PAD) is relatively high in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP). It is currently unclear if the presence of PAD impacts the success, difficulty, and complication rates of ERCP. The aim of the study is to investigate and compare the success rate, procedure difficulty, and complication rate between patients with or without PAD. Patients with PAD were further analyzed according to location and size. A total of 548 ERCP procedures were performed at our endoscopy center from 2015 to 2016. Those patients with previous ERCP, inability to locate the ampulla or abandoned procedure were excluded. 357 procedures were analyzed. A t test (normally distributed) or Mann-Whitney U test (skewed) for continuous data and chi-square or fisher's exact test for categorical data. A total of 116 were found to have PAD. The ampulla was located within the diverticulum in 8.9%, on the edge in 38.9%, and near in 52.2%. 64.3% of the PAD was large and 35.7% small. Patients with PAD were significantly older (P < .001) and more likely to undergo ERCP for common bile duct stone (P = .007). There was no difference in ERCP grade, cannulation difficulty, cannulation success, procedure time, and complication rate between the two groups. Location and size of PAD also did not impact ERCP. The presence of PAD did not affect ERCP cannulation rates, increase the difficulty of cannulation or caused more complications.

Sung, K-Y, Lu, C-L, Wang, Y-P. An unusual cause of obscure gastrointestinal bleeding. Adv Dig Med. 2022; 9:203-204.

Additional funding information details should be added on both Funding Information and Acknowledgment sections respectively. These should have read:

1. Funding information.

Taipei Veterans General Hospital, Grant/Award Number: V109-B-041, V111C-207; Taiwan Ministry of Science and Technology, Grant/Award Number: MOST 111-2628-B-075-011.

2. Acknowledgments.

The case report was supported by grants from the Taipei Veterans General Hospital (V109-B-041, V111C-207) and Taiwan Ministry of Science and Technology (MOST 111-2628-B-075-011).

We apologize for these errors.

Here, we present the case of an 87-year-old woman with heart failure, hypertension, and iron deficiency anemia with a treatment history of amlodipine, olmesartan, carvedilol, and hydralazine for 4 years, and ferrous sodium citrate for 2 years. The patient was referred to the Department of Gastroenterology for occult blood in stool, and endoscopic examination was arranged. Colonoscopy showed sigmoid colon adenocarcinoma, and esophagogastroduodenoscopy revealed speckled black pigmentation distributed from the duodenal bulb to the duodenal second portion (Figure 1). Histopathology revealed macrophages in the lamina propria containing pigmented granules negative for Prussian blue stain (Figure 2). The final diagnosis was pseudomelanosis duodeni.

Pseudomelanosis duodeni, characterized by brown to black spotty pigmentation in the duodenal bulb and the second portion on esophagogastroduodenoscopy,^1-3 was first described in 1976 by Bisordi and Kleinman.⁴ It occurs more commonly in older women.³ The pathogenesis is distinct from melanosis coli and remains poorly understood.¹ Previous studies have shown association with diabetes mellitus, hypertension, renal disease, folate deficiency, gastrointestinal bleeding, and ingestion of food or oral agents containing iron and sulfur.^1-3 Thus, one hypothesis implicates the accumulation of iron and sulfur in the duodenal mucosa caused by drugs (eg, hydralazine, furosemide, and hydrochlorothiazide) and food absorption, microhemorrhages, or reduced sulfur clearance due to decreased renal function.¹ Usually, this is an incidental finding without obvious clinical symptoms. Microscopically, the pigmented granules are found in the macrophages located in the lamina propria.^{1, 3} Although all pseudomelanosis duodeni contains an iron component, Prussian blue stain can still sometimes be negative, possibly because the iron pigments are in a sulfide form, and do not react with Prussian blue staining reagents.⁵ Pseudomelanosis duodeni should be distinguished from metastatic malignant melanoma as it is a benign condition with no evidence of malignant transformation in the future.^1-3 Further investigation or management are not required.

All authors contribute to all stages of article composition: data acquisition and editing, manuscript drafting, and manuscript revision.

The authors declare no conflict of interest.

The patient authorized the publication of the data and the patient's anonymity is preserved in the article.

Endoscopic submucosal dissection (ESD) achieves higher en bloc resection rates than endoscopic mucosal resection in early colorectal neoplasms. However, perforation occurs more frequently during ESD. We aimed to identify the risk factors for perforation during colorectal ESD. A total of 161 patients treated with colorectal ESD at a tertiary center between January 2014 and December 2019 were enrolled in this retrospective study. Perforation was defined as a deep defect of the muscularis propria, with or without direct contact with connective tissue outside the colon. Clinical risk factors for perforation during ESD, including age, sex, tumor morphology, tumor size, tumor location, procedure time, en bloc resection rate, histology, and submucosal fibrosis, were analyzed. The mean size of the ESD specimens was 38.2 ± 24.6 mm. The overall en bloc resection rate was 98.1%. Perforations occurred during ESD in 31 out of 161 patients (19.3%). All perforations were successfully treated with endoscopic closure using the hemoclips and nonsurgical management. Emergency surgery was not required in our patients. On multivariate analysis, severe submucosal fibrosis (odds ratio [OR] 3.06; 95% confidence interval [CI] 1.23-7.59; P = .016) and location in the right colon (OR 4.54; 95% CI 1.31-15.79; P = .017) were independent risk factors. Perforation during colorectal ESD occurred in 31 patients (19.3%), but all patients had a good outcome without surgery. Submucosal fibrosis and its location are risk factors for perforation during ESD.

Vedolizumab has a good safety profile for the treatment of inflammatory bowel disease. Agranulocytosis is a rare but fatal condition. Although many drugs are considered to have a high risk of agranulocytosis, no previous study has mentioned vedolizumab. A 71-year-old female with Sjogren's syndrome received vedolizumab treatment for moderate to severe ulcerative colitis. Her symptoms improved; however, leukopenia was noted after the first dose. Four days after the second dose, she complained of oral and chest pain. Agranulocytosis, oral candidiasis, and Epstein-Barr virus esophagitis with ulceration were noted. After granulocyte-colony stimulating factor treatment, the white blood cell count returned to normal and the esophageal ulcers healed. Vedolizumab is a very safe gut-selective biologic agent, but it also carries the risk of agranulocytosis.

The outcome of laparoscopic sleeve gastrectomy (LSG), one of the most common bariatric surgery (BS) procedure, may differ depending on the patient's age, gender, and postoperative follow-ups. In this study, we aimed to evaluate the efficacy of LSG technique on weight loss, obesity-associated co-morbidities and complications in patients undergoing LSG over 3 months and 1 year, regarding their age, gender, and postoperative follow-ups. The LSG associated complications in participants regarding their preoperative BMI (<39.9 and >39.9), age (30-40 and 40-50), and gender were assessed after 3 and 12 months. Besides, the remission and improvement rates of comorbid conditions in patients were examined after 12 months of LSG. Our results showed that LSG led to a significant weight loss in the resolution of obesity-associated co-morbidities and different complications after 1 year. No significant difference was found in the improvement and the resolution of obesity-associated co-morbidities according to gender. Also, the class 3 patients had significantly higher rates of hearing loss after 12 months and had higher levels of depression and brittle nails 3 months after the surgery. The younger patients also showed a significantly higher percentage of dry skin, intolerance to bread, and menstrual disorder compared to the older group. In conclusion, this study emphasized the importance and necessity of further research into the factors influencing the outcome of LSG such as age, gender, and postoperative follow-ups.

Chang et al reported the prognostic factors in single large (>5 cm) hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE).¹ Their radiological responses of complete response (CR, 8.7%), partial response (PR, 24.8%), stable disease (32.9%), and progressive disease (36%) correlated to median overall survival (OS) 71.4, 44.8, 17.7, and 14.3 months respectively. Large tumor size revealed poor prognosis factors for radiological response, while worse ALBI score and unsatisfied radiological response were two additional factors for OS.

The current article shows that low tumor burden and better liver function are the key prognostic factors, with this finding being compatible to commonly used staging systems such as BCLC,² et al. HCC screening in high-risk groups³ and anti-viral treatment for patients with hepatitis B⁴ and C⁵ are essential care modalities for liver diseases; additionally, the current study also pointed out that radiological response, an on-treatment factor, was also a significant factor of OS.

In most outcome research studies, authors have focused only on initial treatment modality and included mostly non-modifiable factors. In most guidelines,^{2, 6} treatment algorithm is the same for initial or repeat treatments. Sequential treatment and on-treatment prognostic factors are sometimes mentioned. Downstaging for curative treatments such as transplantation has been reported without consistent results,^{7, 8} while TACE-failure has been discussed in this era of targeted therapy.⁹ The concept of sequential treatment was firstly documented in treatment algorithms in the latest EASL guidelines¹⁰ where recommendations for sequential treatments for BCLC stage B and C were included. The concept of sequential treatment after TACE is gaining momentum.⁹

Although TACE is recognized as non-curative treatment in most guidelines, radiologists tend to eradicate tumors. For curative modalities, treatment response should be most adequately described as CR or non-CR after two or three sessions of TACE. In the current article, OS was related to treatment response. Up to 8.8% of patients achieved CR and gained nearly 6 years of OS, especially in patients with smaller tumor size. TACE appears to play some role in the treatment of single large HCC, and whereas surgical resection is the first priority for patients with such tumors, TACE might be an alternative modality.¹¹ The current article reported that patients with smaller tumor size should have better treatment response (<10 cm) and better OS (<7 cm).

The remaining 91.2% of non-CR patients, even PR, should undergo further intervention. This means that sequential management is an iss

Type III choledochal cyst (choledochocele) is a rare disease. Therefore, some endoscopists are not familiar with the clinical feature of choledochocele. We present a choledochocele case that was difficult to diagnosed until endoscopic retrograde cholangiopancreatography was performed. A 46-year-old Taiwanese gentleman had unexplained biliary colic pain with negative findings of physical examination and normal laboratory tests. Magnetic resonance cholangiopancreatography and endoscopic ultrasonography showed dilation of common bile duct (CBD) about 1.8 cm without choledocholithiasis and a cystic lesion at distal CBD about 0.9 cm. The endoscopy showed a cystic-like bulging structure above the ampullary orifice. Cholangiography showed cystic enlargement of the intramural bile duct superior to the ampullary orifice after contrast injection. Choledochocele was proved. We performed papillotomy and biopsy of the papilla. Awareness of the endoscopic feature and management strategy of choledochoele is important, which is illustrated in this case report.