Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occ...Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management.展开更多
Esophageal diverticula are rare conditions that cause esophageal symptoms,such as dysphagia,regurgitation,and chest pain.They are classified according to their location and characteristic pathophysiology into three ty...Esophageal diverticula are rare conditions that cause esophageal symptoms,such as dysphagia,regurgitation,and chest pain.They are classified according to their location and characteristic pathophysiology into three types:epiphrenic diverticulum,Zenker's diverticulum,and Rokitansky diverticulum.The former two disorders take the form of protrusions,and symptomatic cases require interventional treatment.However,the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum,particularly when it is located closer to the oral orifice.Since the condition itself is not malignant,minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms.Several types of endoscopic devices and techniques are currently employed,including peroral endoscopic myotomy(POEM).However,the use of minimally invasive endoscopic approaches,like POEM,has allowed the development of new disorder called iatrogenic esophageal diverticula.In this paper,we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.展开更多
AIM To define clinical criteria to differentiate eosinophilic gastrointestinal disorder(Eo GD) in the esophagus. METHODS Our criteria were defined based on the analyses of the clinical presentation of eosinophilic eso...AIM To define clinical criteria to differentiate eosinophilic gastrointestinal disorder(Eo GD) in the esophagus. METHODS Our criteria were defined based on the analyses of the clinical presentation of eosinophilic esophagitis(Eo E), subepithelial eosinophilic esophagitis(s Eo E) and eosinophilic esophageal myositis(Eo EM), identified by endoscopy, manometry and serum immunoglobulin E levels(s-Ig E), in combination with histological and polymerase chain reaction analyses on esophageal tissue samples.RESULTS In five patients with Eo E, endoscopy revealed longitudinal furrows and white plaques in all, and fixed rings in two. In one patient with s Eo E and four with Eo EM, endoscopy showed luminal compression only. Using manometry, failed peristalsis was observed in patients with Eo E and s Eo E with some variation, while Eo EM was associated with hypercontractile or hypertensive peristalsis, with elevated s-Ig E. Histology revealed the following eosinophils per high-power field values. Eo E = 41.4 ± 7.9 in the epithelium and 2.3 ± 1.5 in the subepithelium; s Eo E = 3 in the epithelium and 35 in the subepithelium(conventional biopsy); Eo EM = none in the epithelium, 10.7 ± 11.7 in the subepithelium(conventional biopsy or endoscopic mucosal resection) and 46.8 ± 16.5 in the muscularis propria(peroral esophageal muscle biopsy). Presence of dilated epithelial intercellular space and downward papillae elongation were specific to Eo E. Eotaxin-3, IL-5 and IL-13 were overexpressed in Eo E.CONCLUSION Based on clinical and histological data, we identified criteria, which differentiated between Eo E, s Eo E and Eo EM, and reflected a different pathogenesis between these esophageal Eo GDs.展开更多
Duodenal gastrointestinal stromal tumors(GISTs) are extremely rare disease entities, and the extraluminal type is difficult to diagnose. These tumors have been misdiagnosed as pancreatic tumors; hence, pancreaticoduod...Duodenal gastrointestinal stromal tumors(GISTs) are extremely rare disease entities, and the extraluminal type is difficult to diagnose. These tumors have been misdiagnosed as pancreatic tumors; hence, pancreaticoduodenectomy has been performed, although partial duodenectomy can be performed if accurately diagnosed. Developing a diagnostic methodology including endoscopic ultrasonography(EUS) and fine-needle aspiration(FNA) has allowed us to diagnose the tumor directly through the duodenum. Here, we present a case of a 50-year-old woman with a 27-mm diameter tumor in the pancreatic uncus on computed tomography scan. EUS showed a well-defined hypoechoic mass in the pancreatic uncus that connected to the duodenal proper muscular layer and was followed by endoscopic ultrasoundguided fine-needle aspiration(EUS-FNA). Histological examination showed spindle-shaped tumor cells positively stained for c-kit. Based on these findings, the tumor was finally diagnosed as a duodenal GIST of the extraluminal type, and the patient underwent successful mass resection with partial resection of the duodenum. This case suggests that EUS and EUS-FNA are effective for diagnosing the extraluminal type of duodenal GISTs, which is difficult to differentiate from pancreatic head tumor, and for performing the correct surgical procedure.展开更多
BACKGROUND Immunosuppression is effective in treating a number of diseases,but adverse effects such as bone marrow suppression,infection,and oncogenesis are of concern.Methotrexate is a key immunosuppressant used to t...BACKGROUND Immunosuppression is effective in treating a number of diseases,but adverse effects such as bone marrow suppression,infection,and oncogenesis are of concern.Methotrexate is a key immunosuppressant used to treat rheumatoid arthritis.Although it is effective for many patients,various side effects have been reported,one of the most serious being methotrexate-related lymphoproliferative disorder.While this may occur in various organs,liver involvement is rare.Information on these liver lesions,including clinical characteristics,course,and imaging studies,has not been summarized to date.CASE SUMMARY We present a case of 70-year-old woman presented with a 2-wk history of fever and abdominal pain.She had had rheumatoid arthritis for 5 years and was being treated with medication including methotrexate.Contrast-enhanced computed tomography revealed multiple low density tumors in the liver and the histological analyses showed significant proliferation of lymphocytes in masses that were positive on immunohistochemical staining for CD3,CD4,CD8,and CD79a but negative for CD20 and CD56.Staining for Epstein-Barr virus-encoded RNA was negative.And based on these findings,the liver tumors were diagnosed as Methotrexate-related lymphoproliferative disorders.A timedependent disappearance of the liver tumors after stopping methotrexate supported the diagnoses.CONCLUSION The information obtained from our case and a review of 9 additional cases reported thus far assist physicians who may face the challenge of diagnosing and managing this disorder.展开更多
BACKGROUND A type 2b immunoglobulin G4(IgG4)-related sclerosing cholangitis(SC)without autoimmune pancreatitis is a rare condition with IgG4-SC.While the variety of the imaging modalities have tested its usefulness in...BACKGROUND A type 2b immunoglobulin G4(IgG4)-related sclerosing cholangitis(SC)without autoimmune pancreatitis is a rare condition with IgG4-SC.While the variety of the imaging modalities have tested its usefulness in diagnosing the IgG4-SC,however,the usage of ultrasonography for the assessment of the response to steroidal therapy on the changes of bile duct wall thickness have not been reported in the condition.Therefore,the information of our recent case and reported cases have been summarized.CASE SUMMARY We report the case of an 82-year-old Japanese man diagnosed with isolated IgG4-related SC based on the increase of serum IgG4,narrowing of the bile duct,its wall thickness,no complication of autoimmune pancreatitis,and IgG4 positive inflammatory cell infiltration to the wall with the fibrotic changes.The cholangiogram revealed type 2b according to the classification.Corticosteroid treatment showed a favorable effect,with the smooth decrease in serum IgG4 and the improvement of the bile duct wall thickness.CONCLUSION As isolated type 2b,IgG4-SC is rare,the images,histological findings,and clinical course of our case will be helpful for physicians to diagnose and treat the new cases appropriately.展开更多
Pyoderma gangrenosum(PG)is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous.As it is frequently associated with inflammatory bowel diseases,including ulc...Pyoderma gangrenosum(PG)is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous.As it is frequently associated with inflammatory bowel diseases,including ulcerative colitis,gastroenterologists should be familiar with the disease including therapeutic options.Therefore,we have conducted a review focusing on the cytapheresis for PG in cases of inflammatory bowel diseases.A literature search was conducted to extract studies published in the last 20 years,with information on demographics,clinical symptoms,treatment,and the clinical course from a total of 22 cases reported and our recent case.In most patients,cytapheresis was associated with improvement or resolution of PG after failure of conventional therapeutic options such as corticosteroids,antibiotics,immunosuppressive agents and immunoglobulin.Based on the information summarized,cytapheresis is helpful in the majority of patients with PG refractory to medical treatment associated with inflammatory bowel diseases and could be further studied in a multicenter,randomized trial.展开更多
BACKGROUND Colorectal mucinous adenocarcinoma is a rare subtype of colorectal cancer and is characterized by an abundance of mucin in the tumor.In addition,the colorectal mucinous adenocarcinoma often demonstrates poo...BACKGROUND Colorectal mucinous adenocarcinoma is a rare subtype of colorectal cancer and is characterized by an abundance of mucin in the tumor.In addition,the colorectal mucinous adenocarcinoma often demonstrates poor differentiation in the histology of tumor cells and poor prognosis compared with those with adenocarcinoma.Here,we present the case of a young woman with colonic mucinous adenocarcinoma showing significantly rapid progression within four months of immunosuppressant therapy for Henoch-Schonlein purpura.CASE SUMMARY Here we report a rare case of ascending colon mucinous adenocarcinoma with lymph node and liver metastases which developed and progressed rapidly within four months during the treatment of Henoch-Schonlein purpura using corticosteroids.The systemic screening examinations showed no tumors before the immunosuppressant therapy.Fortunately,the patient was successfully treated with chemotherapy.CONCLUSION While no direct evidence that the immunosuppressants accelerated the tumor development,the case presen-ta tion and review of the literature demonstrated that surveillance for malig-nancies before and during treatment with immunosuppressive agents is essential.展开更多
Although infliximab (IFX) is effective for inducing and maintaining remission in patients with Crohn’s disease (CD), it is much more expensive than other treatments. The aim of this study is to evaluate the cost-effe...Although infliximab (IFX) is effective for inducing and maintaining remission in patients with Crohn’s disease (CD), it is much more expensive than other treatments. The aim of this study is to evaluate the cost-effectiveness of several therapies, including IFX, for moderately to severely active CD. A Markov cohort model was constructed to simulate treatment effectiveness and costs. Transition probabilities, utilities, direct medical costs, and productivity costs were estimated using the results of published research. The primary effectiveness measurement was quality-adjusted life years (QALYs), as estimated by the 15D instrument. Expected effectiveness and total costs were calculated for a 10-year period using a yearly discount rate of 3% for QALYs and costs. Multiple one-way sensitivity analyses were performed by varying parameters that were likely to change QALYs and costs. As compared with nonbiologic therapy, therapy with IFX alone resulted in more QALYs and lower costs for the 10-year period. Combination therapy with IFX and elemental diet yielded an additional 0.252 QALYs at an additional cost of $18,522 as compared with nonbiologic therapy over 10 years. The resulting incremental cost-effectiveness ratio (ICER) of combination therapy vs nonbiologic therapy was $73,500/QALY. Patient body weight was the most important factor for cost-effectiveness. In conclusion it was revealed that combination therapy with IFX plus elemental diet appears not to be a cost-effective treatment for moderately to severely active CD.展开更多
文摘Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management.
文摘Esophageal diverticula are rare conditions that cause esophageal symptoms,such as dysphagia,regurgitation,and chest pain.They are classified according to their location and characteristic pathophysiology into three types:epiphrenic diverticulum,Zenker's diverticulum,and Rokitansky diverticulum.The former two disorders take the form of protrusions,and symptomatic cases require interventional treatment.However,the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum,particularly when it is located closer to the oral orifice.Since the condition itself is not malignant,minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms.Several types of endoscopic devices and techniques are currently employed,including peroral endoscopic myotomy(POEM).However,the use of minimally invasive endoscopic approaches,like POEM,has allowed the development of new disorder called iatrogenic esophageal diverticula.In this paper,we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.
基金Supported by JSPS Grants-in-Aid for Scientific Research,No.16K19332Takeda medical research grants
文摘AIM To define clinical criteria to differentiate eosinophilic gastrointestinal disorder(Eo GD) in the esophagus. METHODS Our criteria were defined based on the analyses of the clinical presentation of eosinophilic esophagitis(Eo E), subepithelial eosinophilic esophagitis(s Eo E) and eosinophilic esophageal myositis(Eo EM), identified by endoscopy, manometry and serum immunoglobulin E levels(s-Ig E), in combination with histological and polymerase chain reaction analyses on esophageal tissue samples.RESULTS In five patients with Eo E, endoscopy revealed longitudinal furrows and white plaques in all, and fixed rings in two. In one patient with s Eo E and four with Eo EM, endoscopy showed luminal compression only. Using manometry, failed peristalsis was observed in patients with Eo E and s Eo E with some variation, while Eo EM was associated with hypercontractile or hypertensive peristalsis, with elevated s-Ig E. Histology revealed the following eosinophils per high-power field values. Eo E = 41.4 ± 7.9 in the epithelium and 2.3 ± 1.5 in the subepithelium; s Eo E = 3 in the epithelium and 35 in the subepithelium(conventional biopsy); Eo EM = none in the epithelium, 10.7 ± 11.7 in the subepithelium(conventional biopsy or endoscopic mucosal resection) and 46.8 ± 16.5 in the muscularis propria(peroral esophageal muscle biopsy). Presence of dilated epithelial intercellular space and downward papillae elongation were specific to Eo E. Eotaxin-3, IL-5 and IL-13 were overexpressed in Eo E.CONCLUSION Based on clinical and histological data, we identified criteria, which differentiated between Eo E, s Eo E and Eo EM, and reflected a different pathogenesis between these esophageal Eo GDs.
文摘Duodenal gastrointestinal stromal tumors(GISTs) are extremely rare disease entities, and the extraluminal type is difficult to diagnose. These tumors have been misdiagnosed as pancreatic tumors; hence, pancreaticoduodenectomy has been performed, although partial duodenectomy can be performed if accurately diagnosed. Developing a diagnostic methodology including endoscopic ultrasonography(EUS) and fine-needle aspiration(FNA) has allowed us to diagnose the tumor directly through the duodenum. Here, we present a case of a 50-year-old woman with a 27-mm diameter tumor in the pancreatic uncus on computed tomography scan. EUS showed a well-defined hypoechoic mass in the pancreatic uncus that connected to the duodenal proper muscular layer and was followed by endoscopic ultrasoundguided fine-needle aspiration(EUS-FNA). Histological examination showed spindle-shaped tumor cells positively stained for c-kit. Based on these findings, the tumor was finally diagnosed as a duodenal GIST of the extraluminal type, and the patient underwent successful mass resection with partial resection of the duodenum. This case suggests that EUS and EUS-FNA are effective for diagnosing the extraluminal type of duodenal GISTs, which is difficult to differentiate from pancreatic head tumor, and for performing the correct surgical procedure.
文摘BACKGROUND Immunosuppression is effective in treating a number of diseases,but adverse effects such as bone marrow suppression,infection,and oncogenesis are of concern.Methotrexate is a key immunosuppressant used to treat rheumatoid arthritis.Although it is effective for many patients,various side effects have been reported,one of the most serious being methotrexate-related lymphoproliferative disorder.While this may occur in various organs,liver involvement is rare.Information on these liver lesions,including clinical characteristics,course,and imaging studies,has not been summarized to date.CASE SUMMARY We present a case of 70-year-old woman presented with a 2-wk history of fever and abdominal pain.She had had rheumatoid arthritis for 5 years and was being treated with medication including methotrexate.Contrast-enhanced computed tomography revealed multiple low density tumors in the liver and the histological analyses showed significant proliferation of lymphocytes in masses that were positive on immunohistochemical staining for CD3,CD4,CD8,and CD79a but negative for CD20 and CD56.Staining for Epstein-Barr virus-encoded RNA was negative.And based on these findings,the liver tumors were diagnosed as Methotrexate-related lymphoproliferative disorders.A timedependent disappearance of the liver tumors after stopping methotrexate supported the diagnoses.CONCLUSION The information obtained from our case and a review of 9 additional cases reported thus far assist physicians who may face the challenge of diagnosing and managing this disorder.
文摘BACKGROUND A type 2b immunoglobulin G4(IgG4)-related sclerosing cholangitis(SC)without autoimmune pancreatitis is a rare condition with IgG4-SC.While the variety of the imaging modalities have tested its usefulness in diagnosing the IgG4-SC,however,the usage of ultrasonography for the assessment of the response to steroidal therapy on the changes of bile duct wall thickness have not been reported in the condition.Therefore,the information of our recent case and reported cases have been summarized.CASE SUMMARY We report the case of an 82-year-old Japanese man diagnosed with isolated IgG4-related SC based on the increase of serum IgG4,narrowing of the bile duct,its wall thickness,no complication of autoimmune pancreatitis,and IgG4 positive inflammatory cell infiltration to the wall with the fibrotic changes.The cholangiogram revealed type 2b according to the classification.Corticosteroid treatment showed a favorable effect,with the smooth decrease in serum IgG4 and the improvement of the bile duct wall thickness.CONCLUSION As isolated type 2b,IgG4-SC is rare,the images,histological findings,and clinical course of our case will be helpful for physicians to diagnose and treat the new cases appropriately.
文摘Pyoderma gangrenosum(PG)is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous.As it is frequently associated with inflammatory bowel diseases,including ulcerative colitis,gastroenterologists should be familiar with the disease including therapeutic options.Therefore,we have conducted a review focusing on the cytapheresis for PG in cases of inflammatory bowel diseases.A literature search was conducted to extract studies published in the last 20 years,with information on demographics,clinical symptoms,treatment,and the clinical course from a total of 22 cases reported and our recent case.In most patients,cytapheresis was associated with improvement or resolution of PG after failure of conventional therapeutic options such as corticosteroids,antibiotics,immunosuppressive agents and immunoglobulin.Based on the information summarized,cytapheresis is helpful in the majority of patients with PG refractory to medical treatment associated with inflammatory bowel diseases and could be further studied in a multicenter,randomized trial.
文摘BACKGROUND Colorectal mucinous adenocarcinoma is a rare subtype of colorectal cancer and is characterized by an abundance of mucin in the tumor.In addition,the colorectal mucinous adenocarcinoma often demonstrates poor differentiation in the histology of tumor cells and poor prognosis compared with those with adenocarcinoma.Here,we present the case of a young woman with colonic mucinous adenocarcinoma showing significantly rapid progression within four months of immunosuppressant therapy for Henoch-Schonlein purpura.CASE SUMMARY Here we report a rare case of ascending colon mucinous adenocarcinoma with lymph node and liver metastases which developed and progressed rapidly within four months during the treatment of Henoch-Schonlein purpura using corticosteroids.The systemic screening examinations showed no tumors before the immunosuppressant therapy.Fortunately,the patient was successfully treated with chemotherapy.CONCLUSION While no direct evidence that the immunosuppressants accelerated the tumor development,the case presen-ta tion and review of the literature demonstrated that surveillance for malig-nancies before and during treatment with immunosuppressive agents is essential.
文摘Although infliximab (IFX) is effective for inducing and maintaining remission in patients with Crohn’s disease (CD), it is much more expensive than other treatments. The aim of this study is to evaluate the cost-effectiveness of several therapies, including IFX, for moderately to severely active CD. A Markov cohort model was constructed to simulate treatment effectiveness and costs. Transition probabilities, utilities, direct medical costs, and productivity costs were estimated using the results of published research. The primary effectiveness measurement was quality-adjusted life years (QALYs), as estimated by the 15D instrument. Expected effectiveness and total costs were calculated for a 10-year period using a yearly discount rate of 3% for QALYs and costs. Multiple one-way sensitivity analyses were performed by varying parameters that were likely to change QALYs and costs. As compared with nonbiologic therapy, therapy with IFX alone resulted in more QALYs and lower costs for the 10-year period. Combination therapy with IFX and elemental diet yielded an additional 0.252 QALYs at an additional cost of $18,522 as compared with nonbiologic therapy over 10 years. The resulting incremental cost-effectiveness ratio (ICER) of combination therapy vs nonbiologic therapy was $73,500/QALY. Patient body weight was the most important factor for cost-effectiveness. In conclusion it was revealed that combination therapy with IFX plus elemental diet appears not to be a cost-effective treatment for moderately to severely active CD.
