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Background and aim: Ulcerative colitis (UC) is characterized by repeated relapse and remission. Because no fundamental therapeutic strategy has been established, the treatment goal is generally to maintain the remission phase for a long period after rapid remission induction. Granulocyte and monocyte adsorption (GMA) for UC is reportedly quite safe because it does not affect immunosuppression. Moreover, it is useful in combination with other remission induction therapy. The aim of this study was to evaluate the difference in efficacy by the timing of the addition of GMA with corticosteroids, calcineurin inhibitors, and anti‐cytokine therapy for active UC. Methods: The study included 59 patients. Patients who started GMA of 5–11 days were in the early GMA combination group. Patients who started GMA 12 days or more were in the late GMA combination group. The primary endpoint was difference in the effect of additional GMA according to the timing of the intervention. The secondary endpoint was difference in the time to remission induction between the two groups. Results: Of the 32 early GMA group patients, 24 achieved remission induction. Of the 27 late group patients, 18 achieved remission induction. No significant difference in induction rates was found (P = 0.481). The early group had shorter mean time to remission induction (P < 0.001). Conclusions: In conclusion, results suggest that early addition of GMA might lead to earlier remission in patients who have had an inadequate response to remission induction therapy with corticosteroids, calcineurin inhibitors, and anti‐cytokine therapy. [ABSTRACT FROM AUTHOR]

Summary: Background: Endoscopic healing (EH) is a therapeutic target in ulcerative colitis (UC). However, even patients who have achieved EH relapse frequently. Aims: To investigate the association between recent steroid use and relapse risk in UC patients with EH. Methods: This multi‐centre cohort study included 1212 UC patients with confirmed EH (Mayo endoscopic subscore ≤1). We excluded patients with current systemic steroid use or history of advanced therapy. We divided patients into a recent steroid group (last systemic steroid use within 1 year; n = 59) and a non‐recent or steroid‐naïve group (n = 1153). We followed the patients for 2 years to evaluate relapse, defined as induction of systemic steroids or advanced therapy. We used logistic regression to estimate the odds ratio (OR) of relapse. Results: Relapse occurred in 28.8% of the recent steroid group and 5.6% of the non‐recent/steroid‐naïve group (multi‐variable‐adjusted OR 5.53 [95% CI 2.85–10.7]). The risk of relapse decreased with time since the last steroid use: 28.8% for less than 1 year after steroid therapy, 22.9% for 1 year, 16.0% for 2 years and 7.9% beyond 3 years, approaching 4.0% in steroid‐naïve patients. (ptrend <0.001). Conclusions: Even for patients with UC who achieved EH, the risk of relapse remains high following recent steroid therapy. Physicians need to consider the duration since last steroid use to stratify the relapse risk in UC patients with EH. [ABSTRACT FROM AUTHOR]

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS‐elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self‐expanding metal stents for stent placement for pancreatic duct stenosis and EUS‐guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS‐guided drainage using a double‐pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen‐apposing metal stents have led to advances in the treatment of walled‐off necrosis after acute pancreatitis. EUS‐guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self‐expanding metal stents in difficult‐to‐treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS‐guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case. [ABSTRACT FROM AUTHOR]

Background/purpose: The aim of this study is to clarify the relation between the incision size for endoscopic sphincterotomy (EST) and common bile duct stone (CBDS) recurrence. Methods: Patients who underwent elective endoscopic treatment for CBDS between January 2013 and December 2017 were enrolled, excluding those who met the exclusion criteria. The clinical characteristics were investigated using propensity score matching analysis. Results: A total of 243 patients were investigated. Propensity scores were calculated using multinomial logistic regression with five relevant variables (age, gender, follow‐up time, maximum stone size, and bile duct diameter), which led to extraction of 188 cases to compose cohorts of the small and medium EST incision groups. The CBDS recurrence rate was 17.0% in the small incision group and 6.4% in the medium incision group. Multivariate analysis identified the medium incision as an independent predictor of CBDS recurrence (hazard ratio 0.350, 95% confidence interval 0.133‐0.922, P =.034). The CBDS non‐recurrence rate of the medium incision group was significantly higher than that of the small incision group (log‐rank test P =.019). Conclusions: Our findings suggest that the CBDS recurrence rate was lower in EST with medium incision size than with small incision size. [ABSTRACT FROM AUTHOR]

: Objectives: Ultrasound speed (USS) correction improves image quality by estimating the optimal USS correcting the deviation from a predetermined USS. This study assessed USS differences between chronic pancreatitis (CP), early CP (ECP), and normal pancreas when using endoscopic ultrasound (EUS). The usefulness of measuring optimal USS was evaluated for patients with CP, including early stage patients. Methods: This study enrolled 116 consecutive patients for whom USS was measured using an EUS system. The USS correction principle is generation of a B‐mode image by changing the USS in all ranges while correcting the delay in the received data. Final diagnoses were made according to the Japanese diagnostic criteria for CP in 2019. They were classified as CP, ECP, or normal. We compared USS applied for these three groups. Results: The medians and ranges of USS values for patients in the normal, ECP, and CP groups were 1506.0 (1407–1600) m/s, 1580.0 (1520–1630) m/s, and 1574.0 (1537–1610) m/s, respectively. The USS values of the ECP and CP groups were significantly higher than those of the normal group (P < 0.001). Analyses of the receiver operating characteristic curve in the normal pancreas, ECP, and CP revealed the area as 0.957, with specificity and sensitivity of 95.9% and 87.5%, respectively, using the USS of 1535 m/s as a cut‐off. Conclusion: Measurement of USS might be particularly useful for distinguishing between normal and ECP imaging. [ABSTRACT FROM AUTHOR]

Summary: Background: The increasing incidence of older‐onset ulcerative colitis (UC), which has a higher risk of surgery, is a global health issue. However, data regarding intravenous steroid treatment, one of the important treatment options to avoid surgery, for older‐onset UC is lacking. Aims: To evaluate the association between onset age and effectiveness of intravenous steroids in UC. Methods: This retrospective multicentre (27 facilities) cohort study included moderate‐to‐severe hospitalised UC patients who underwent their first intravenous steroids between April 2014 and July 2019. The primary outcome was clinical remission at day 30, using two‐item patient‐reported outcome scoring. The key secondary outcomes were risks of surgery and adverse events (death, infection and venous thrombosis) within 90 days. A modified Poisson regression model was used for analysis. Results: Overall, 467 UC patients (384 younger‐onset and 83 older‐onset) were enrolled. Clinical remission at day 30 was observed in 252 (65.6%) among younger‐onset patients and 43 (51.8%) among older‐onset patients (adjusted risk difference, −21.7% [95% CI, −36.1% to −7.2%]; adjusted risk ratio [ARR], 0.74 [95% CI, 0.59 to 0.93]). The risks of surgery and adverse events were higher in older‐onset UC (20.5% vs. 3.1%; ARR, 8.92 [95% CI, 4.13 to 19.27], 25.3% vs. 9.1%; ARR, 2.19 [95% CI, 1.22 to 3.92], respectively). Four deaths occurred, all involving older‐onset UC. The risks of infection and venous thrombosis were also higher in older‐onset UC (18.1% vs. 8.6%, 7.2% vs. 0.5%, respectively). Conclusions: Older‐onset was associated with a lower effectiveness of intravenous steroids with higher risks of surgery and adverse events in UC. [ABSTRACT FROM AUTHOR]

Objective. There is no consensus regarding administration of propofol for performing endoscopic submucosal dissection (ESD) in patients with comorbidities. The aim of this study was to evaluate the safety and efficacy of propofol-induced sedation administered by nonanesthesiologists during ESD of gastric cancer in patients with comorbidities classified according to the American Society of Anesthesiologists (ASA) physical status. Methods. Five hundred and twenty-two patients who underwent ESD for gastric epithelial tumors under sedation by nonanesthesiologist-administrated propofol between April 2011 and October 2017 at Dokkyo Medical University Hospital were enrolled in this study. The patients were divided into 3 groups according to the ASA physical status classification. Hypotension, desaturation, and bradycardia were evaluated as the adverse events associated with propofol. The safety of sedation by nonanesthesiologist-administrated propofol was measured as the primary outcome. Results. The patients were classified according to the ASA physical status classification: 182 with no comorbidity (ASA 1), 273 with mild comorbidity (ASA 2), and 67 with severe comorbidity (ASA 3). The median age of the patients with ASA physical status of 2/3 was higher than the median age of those with ASA physical status of 1. There was no significant difference in tumor characteristics, total amount of propofol used, or ESD procedure time, among the 3 groups. Adverse events related to propofol in the 522 patients were as follows: hypotension (systolic blood pressure<90 mmHg) in 113 patients (21.6%), respiratory depression (SpO2<90%) in 265 patients (50.8%), and bradycardia (pulse rate<50 bpm) in 39 patients (7.47%). There was no significant difference in the incidences of adverse events among the 3 groups during induction, maintenance, or recovery. No severe adverse event was reported. ASA 3 patients had a significantly longer mean length of hospital stay (8 days for ASA 1, 9 days for ASA 2, and 9 days for ASA 3, P=0.003). However, the difference did not appear to be clinically significant. Conclusions. Sedation by nonanesthesiologist-administrated propofol during ESD is safe and effective, even for at-risk patients according to the ASA physical status classification. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal hemorrhage occurs frequently. We reviewed the tendency of occurrence of bleeding gastric and duodenal ulcers and their association with antithrombotic therapy before and after the widespread use of Evidence‐Based Clinical Practice Guidelines for Peptic Ulcer 2009 (1st edition), which was published to improve treatment outcomes and prevent peptic ulcers. Methods: The study enrolled 1105 patients with bleeding gastric and duodenal ulcers treated at our hospital between January 2000 and March 2016. They were divided into the preguideline group (807 patients treated between January 2000 and December 2010) and the postguideline group (298 patients treated between January 2011 and March 2016). The use of medications, severity, the incidence of Helicobacter pylori infection, the presence of any underlying disease, and other factors were compared between the pre‐ and postguideline groups. Results: The number of patients receiving antithrombotic therapy was slightly higher in the postguideline group without a significant difference (P = 0.50). The incidence of H. pylori infection was significantly lower in the postguideline group (P < 0.001). The rate of premedication with a proton pump inhibitor (PPI) and the rate of severe ulcers were significantly higher in the postguideline group (P = 0.001 and P < 0.001, respectively). The rebleeding rate showed no significant difference, whereas the recurrence rate was significantly higher in the postguideline group (P = 0.041). Conclusions: The major cause of hemorrhagic gastroduodenal ulcers seems to be shifting from H. pylori infection to the administration of drugs with gastrointestinal risk. Antithrombotic therapy tends to be associated with severe ulcers but without statistical significance. As the overall rebleeding or recurrence rates were low, antithrombotic therapy needs to be resumed as soon as possible after adequate hemostasis is achieved. [ABSTRACT FROM AUTHOR]

Coronal short tau inversion recovery magnetic resonance imaging shows high signal intensity in the left hip. gl Oral lesions are often observed in patients with inflammatory bowel disease (IBD), particularly paediatric patients with Crohn's disease.[1] This combination often presents as aphthae with longitudinal presentation or skip lesions separated by normal-appearing mucosa buccally or labially. Though her oral symptoms and perianal lesions improved, perianal lesions recurred after gingivitis, and numerous aphthae were observed. GLO:81V/01dec22:jpc16260-fig-0001.jpg PHOTO (COLOR): 1 (a, b) The patient presented with oral aphthae with longitudinal ulcers in the soft palate and gingivitis in both molar regions. [Extracted from the article]

Aim: Endoscopic submucosal dissection (ESD) has been positively applied to and gradually standardized for early gastric cancer; however, it is not widely used in the colorectum because of its technical difficulty. Methods: To increase the safety and ease of carrying out colon ESD, we developed a new scissors-type device that we call the stag beetle knife (SBK). Here we report on our efforts to assess the efficacy and safety of colon ESD using the SBK. Results: ESD was carried out using SBK in 25 patients with colorectal neoplasia. All lesions were treated safety and easily, without any unexpected incisions. No delayed hemorrhage and perforation occurred. An en-bloc resection and a negative resection margin were obtained in all cases. Conclusion: ESD using the SBK can be carried out with greater ease and safety for colorectal neoplasia. [ABSTRACT FROM AUTHOR]

Background and Aim: Recent advances in colonoscopic techniques have led to the increased detection of, and interest in, superficial type colorectal tumors, and a new category, the ‘laterally spreading tumor (LST)’, has been proposed. However, the characteristics of the genetic alterations in these LSTs have not yet been fully determined. We therefore classified LSTs as LST-granular (LST-G) or LST-non-granular (LST-NG), according to their macroscopic appearance, and examined the genetic alterations in these two tumor groups compared with those in protruded type tumors. Methods: We obtained a total of 62 colorectal tumors, including 26 protruded type, 17 LST-G and 19 LST-NG, from specimens resected surgically or endoscopically. We examined K-ras codon 12 mutations by using the polymerase chain reaction-restriction fragment length polymorphism method and by fluorescence direct sequencing. We also performed immunohistochemistry to analyze cyclooxygenase (COX)-2 and gastrin abnormalities. Results: The incidence of K-ras mutation was 50.0% in protruded type tumors, 76.5% in LST-G, and 26.3% in LST-NG. The frequencies of COX-2 overexpression were 73.1, 88.2, and 31.6%, respectively, and those of gastrin overexpression were 61.5, 82.4, and 26.3%, respectively. Therefore, LST-G is similar to protruded type tumors in that the incidence of K-ras mutation and the frequencies of COX-2 and gastrin overexpression are high. LST-NG differs from both of these tumor types in that the values of these three indicators are all low. Conclusions: These results show that LST-G and LST-NG have different genetic alterations. © 2005 Blackwell Publishing Asia Pty Ltd [ABSTRACT FROM AUTHOR]

Extension of inflammation into the scrotum is rare in acute pancreatitis. If inflammation spreads in the scrotum, it may become severe. Clinicians should be aware of this condition as a possible complication. Proactive imaging testing is recommended when complaining of cyst swelling or testicular pain. [ABSTRACT FROM AUTHOR]

With the recent development of interventional endoscopic ultrasound (EUS), EUS‐guided vascular interventions have seen increased clinical and research focus. This modality can be used to diagnose portal hypertension and treat portal hypertension‐related gastrointestinal varices and refractory gastrointestinal hemorrhage, including pseudoaneurysm. The vascular embolic materials used for treatment include tissue adhesives (cyanoacrylates), sclerosants, thrombin, and vascular embolic coils, all of which are associated with favorable results. The feasibility of EUS‐guided procedures, including portal vein stenting and portosystemic shunt formation conventionally performed percutaneously and transvenously, has also been demonstrated, albeit in animal studies. As EUS‐guided vascular intervention is a technique that may receive significant attention in the future, we provide a thorough review of the current evidence for its use. [ABSTRACT FROM AUTHOR]

An 83-year old Japanese man was transferred to our hospital due to a 1-week history of melena and signs of disordered awareness. Esophagogastroduodenoscopy showed a villous tumor associated with massive white mucous discharge in the posterior wall of the gastric corpus, where pathologically identified mucin-producing epithelium with nuclear atypia had developed into a papillary form. An abdominal enhanced computed tomography scan demonstrated communication between the dilated main pancreatic duct and the gastric lumen. Based on these findings, we reached a diagnosis of gastric penetration by an intraductal papillary mucinous neoplasm (IPMN) of the main pancreatic duct. IPMN is partly characterized by expansive mucinous growth that may result in penetration into adjacent organs. [ABSTRACT FROM AUTHOR]