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BACKGROUND This study aimed to identify the risk factors for walled-off necrosis (WON) associated with severe acute pancreatitis (SAP). METHODS This retrospective study was conducted in eight institutions in Japan between 2014 and 2017. We analyzed WON incidence, patient characteristics, and risk factors for WON in patients with SAP who were observed for >28 days. RESULTS Of 134 patients with SAP, WON occurred in 40 (29.9%). Male sex (P = .045), body mass index (BMI) ≥25 (P

Background To provide updates on clinical practice of acute pancreatitis (AP) in Japan, we conducted a nationwide epidemiological survey. Methods This study consisted of a two-staged survey; the number of AP patients was estimated by the first-stage survey and their clinical features were examined by the second-stage survey. We surveyed AP patients who had visited hospitals in 2016. Results The estimated number of AP patients in 2016 was 78,450, with an overall incidence of 61.8 per 100,000 persons. We obtained detailed clinical information of 2994 AP patients, including 706 (23.6%) severe cases classified according to the Japanese severity criteria. The male-to-female sex ratio was 2.0, and the mean age at onset was 59.9 years in males and 66.5 years in females. Alcohol was the most common etiology (42.8%) in males and gallstones in females (37.7%). The AP-associated mortality was 6.1% in severe AP cases, which was decreased by 40% compared to the 2011 survey. Antibiotics were administered to most cases, with carbapenem being frequently used. Enteral nutrition was given in 31.8% of severe cases, but majority cases received after 48 h. Among the 107 patients who received intervention for walled-off necrosis, five patients received surgery-first approach, 66 received endoscopic ultrasound-guided transluminal drainage, and 19 underwent step-up approach. Conclusions We clarified the current status of AP in Japan including the significant reduction of mortality in severe cases, shift to endoscopic approaches for walled-off necrosis, and poor compliance of the recommendations in the guidelines including management of enteral nutrition and antibiotic administration.

Peliosis hepatis (PH) is a rare disease characterized by the presence of sinusoidal dilation and blood-filled cysts throughout the hepatic parenchyma. We report a case of PH in a 49-year-old woman with chronic renal failure (CRF) on hemodialysis and with renal cell carcinoma (RCC). Dynamic contrast-enhanced computed tomography (CT) showed a 35-mm-diameter, hypervascular tumor in the liver and RCC in the right renal cyst. Ultrasound and superparamagnetic iron oxide-enhanced magnetic resonance imaging were also performed; however, the liver tumor could not be distinguished from the metastasis of RCC. Therefore, echo-guided biopsy of the liver tumor using an 18-G Majima needle was performed. Histological evaluation of the specimen showed irregular sinusoidal dilatation and blood-filled cavities without malignant cells. She was ultimately diagnosed with PH. Subsequently, she underwent total right nephrectomy for RCC and was diagnosed with RCC stage 1 (pT1N0M0). A follow-up CT performed 4 months after nephrectomy showed no growth of PH. Although the development of PH in patients with CRF or RCC who do not undergo renal transplantation is extremely rare, it should be considered in the differential diagnosis to distinguish PH from the metastasis of RCC.

Pancreatic pseudocysts (PPs) can be accompanied by infection, pseudoaneurysm ruptures, and fistulae to other organs, which can be fatal without appropriate treatment. Herein, we present the case of an 82-year-old man with PPs accompanied by infection, pseudoaneurysm rupture, and pseudocystocolonic fistula that were managed via multidisciplinary treatment. Computed tomography (CT) revealed two inflamed PPs, one each in the pancreatic head and tail. He was, therefore, diagnosed with infectious PPs. The pancreatic head PP shrunk on endoscopic nasopancreatic drainage (ENPD), but the pancreatic tail PP did not. Endoscopic ultrasound (EUS)-guided transluminal drainage was performed to treat the pancreatic tail PP; his symptoms improved. However, he vomited blood at 14 day post-drainage. Angiography revealed pseudoaneurysm rupture in a left gastric artery branch. After successful angioembolization, he developed hematochezia 2 days later. We suspected re-bleeding of the pseudoaneurysm. The bleeding stopped spontaneously, but CT and radiography revealed the presence of a pseudocystocolonic fistula. Careful follow-up was performed, and he has not had any symptoms at 9 month post-discharge. We managed PP-related complications via ENPD, EUS-guided transluminal drainage, angioembolization, and careful follow-up. Infection, pseudoaneurysm rupture, and pseudocystocolonic fistula are rare, but can occur simultaneously. Therefore, clinicians should consider these complications when treating patients with PPs.

Sedation using dexmedetomidine hydrochloride (DEX) was administered to patients with hepatocellular carcinoma (HCC) prior to local therapy. Case 1 was a 58-year-old man undergoing radiofrequency ablation in combination with transcatheter arterial chemoembolization for HCC in S3. In accordance with the package insert, the initial loading dose was set at 6 μg/kg/hour. Although a favorable sedative effect was achieved, his blood pressure and pulse rate decreased. Case 2 was a 79-year-old woman undergoing percutaneous ethanol injection therapy for HCC in S6. Half the initial loading dose indicated in the package insert (3 μg/kg/hour) was administered, but the sedative effect was appreciable. No marked blood pressure or pulse rate decreases were observed. We believe that the use of DEX as a sedative agent in local therapy for HCC can be expected to increase. However, the optimal dose setting for DEX requires further examination.

Background We assessed the usefulness of acetic acid–enhanced magnifying endoscopy in the diagnosis of gastric neoplasia. Methods Forty-five patients (27 men, 18 women; median age 61.6 years) with gastric carcinoma or adenoma were enrolled in a prospective trial of enhanced magnifying endoscopy after instillation of 1.5% acetic acid. Acetic acid–enhanced magnified views of carcinoma or adenoma and the surrounding non-neoplastic mucosa were observed, and the duration of whitening time of each lesion was recorded. Observations Magnified views of carcinoma showed a minute, grain-like pattern that differed from the surrounding noncancerous mucosa. The histopathologic diagnostic criteria were based on the Vienna classification of GI epithelial neoplasia. The mean duration of whitening differed with each histologic type: low-grade adenoma, 94 seconds; high-grade adenoma, 24.3 seconds; noninvasive carcinoma, 20.1 seconds; invasive intramucosal carcinoma, 3.5 seconds; and submucosal carcinoma or beyond, 2.5 seconds. The duration in the non-neoplastic surrounding mucosa was 90 seconds. After the disappearance of whitening in the carcinoma, the irregular pattern of the carcinoma reappeared, and the contrast between carcinomatous microvessels and the whitened non-neoplastic tissue became very clear on magnifying endoscopy. In accordance with the duration of whitening, more than 1 minute was termed "continuous whitening," from 31 to 60 seconds was "delayed disappearance of whitening," from 30 to 6 seconds was "early disappearance of whitening," and 0 to 5 seconds was "no response." Conclusions Acetic acid–enhanced magnifying endoscopy was useful for the diagnosis of gastric adenocarcinoma. The duration of whitening differed among grades of neoplasia, and it was possible to observe changes in the whitening with time. Acetic acid–enhanced magnifying endoscopy, therefore, can be termed "dynamic chemical magnifying endoscopy."