Ileal polypoid lymphangiectasia bleeding diagnosed and treated by double balloon enteroscopy

Intestinal lymphangiectasia is a rare disease characterized by focal or diffuse dilated enteric lymphatics with impaired lymph drainage.It causes protein-losing enteropathy and may lead to gastrointestinal bleeding.Commonly,lymphangiectasia presents as whitish spots or specks.To our knowledge,small bowel bleeding resulting from polypoid intestinal lymphangiectasia has not been reported.Here,we report a rare case of active bleeding from the small bowel caused by polypoid lymphangiectasia with a review of the relevant literature.An 80-year-old woman was hospitalized for melena.Esophagogastroduodenoscopy could not identify the source of bleeding.Subsequent colonoscopy showed fresh bloody material gushing from the small bowel.An abdominal-pelvic contrast-enhanced computed tomography scan did not reveal any abnormal findings.Video capsule endoscopy showed evidence of active and recent bleeding in the ileum.To localize the bleeding site,we performed double balloon enteroscopy by the anal approach.A small,bleeding,polypoid lesion was found in the distal ileum and was successfully removed using endoscopic snare electrocautery.

Upper gastrointestinal bleeding from duodenal vascular ectasia in a patient with cirrhosis

We report a cirrhotic patient with duodenal vascular ectasia and spontaneous bleeding. The bleeding was successfully controlled with argon plasma coagulation. Duodenal vascular ectasia may be a cause of upper gastrointestinal bleeding in patients with cirrhosis, and argon plasma coagulation may be effective and safe to achieve hemostasis of this lesion.

Hepatolithiasis and intrahepatic cholangiocarcinoma: A review

Although the incidence of hepatolithiasis is decreasing as the pattern of gallstone disease changes in Asia, the prevalence of hepatolithiasis is persistently high, especially in Far Eastern countries. Hepatolithiasis is an established risk factor for cholangiocarcinoma(CCA), and chronic proliferative inflammation may be involved in biliary carcinogenesis and in inducing the upregulation of cell-proliferating factors. With the use of advanced imaging modalities, there has been much improvement in the management of hepatolithiasis and the diagnosis of hepatolithiasis-associated CCA(HLCCA). However, there are many problems in managing the strictures in hepatolithiasis and differentiating them from infiltrating types of CCA. Surgical resection is recommended in cases of single lobe hepatolithiasis with atrophy, uncontrolled stricture, symptom duration of more than 10 years, and long history of biliaryenteric anastomosis. Even after resection, patients should be followed with caution for development of HL-CCA, because HL-CCA is an independent prognostic factor for survival. It is not yet clear whether hepatic resection can reduce the occurrence of subsequent HL-CCA. Furthermore, there are no consistent findings regarding prediction of subsequent HL-CCA in patients with hepatolithiasis. In the management of hepatolithiasis, important factors are the reduction of recurrence of cholangitis and suspicion of unrecognized HL-CCA.

How good is cola for dissolution of gastric phytobezoars?

AIM:To evaluate the efficacy of cola treatment for gastric phytobezoars,including diospyrobezoars.METHODS:A total of 17 patients(range:48 to 78 years) with symptomatic gastric phytobezoars treated with cola and adjuvant endoscopic therapy were reviewed.Three liters of cola lavage(10 cases) or drink(7 cases) were initially used,and then endoscopic fragmentation was done for the remnant bezoars by using a lithotripsy basket or a polypectomy snare.The overall success of dissolving a gastric phytobezoars with using three liters of cola and the clinical and endoscopic findings were compared retrospectively between four cases of complete dissolution by using only cola and 13 cases of partial dissolution with cola.RESULTS:After 3 L of cola lavage or drinking,a complete dissolution of bezoars was achieved in four patients(23.5%),while 13 cases(76.5%) were only partially dissolved.Phytobezoars(4 of 6 cases) were observed more frequently than diospyrobezoars(0 of 11) in the group that underwent complete dissolution(P = 0.006).Gender,symptom duration,size of bezoar and method of cola administration were not significantly different between the two groups.Twelve of 13 patients with residual bezoars were completely treated with a combination of cola and endoscopic fragmentation.CONCLUSION:The rate of complete dissolution with three liters of cola was 23.5%,but no case of diospyrobezoar was completely dissolved using this method.However,pretreatment with cola may be helpful and facilitate endoscopic fragmentation of gastric phytobezoars.

Peroxisome proliferator-activated receptor-delta agonist ameliorated inflammasome activation in nonalcoholic fatty liver disease

AIM: To evaluate the inflammasome activation and the effect of peroxisome proliferator-activated receptors(PPAR)-δ agonist treatment in nonalcoholic fatty liver disease(NAFLD) models.METHODS: Male C57BL/6J mice were classified according to control or high fat diet(HFD) with or without PPAR-δ agonist(GW) over period of 12 wk [control, HFD, HFD + lipopolysaccharide(LPS), HFD + LPS + GW group]. Hep G2 cells were exposed to palmitic acid(PA) and/or LPS in the absence or presence of GW.RESULTS: HFD caused glucose intolerance and hepatic steatosis. In mice fed an HFD with LPS, caspase-1 and interleukin(IL)-1β in the liver were significantly increased. Treatment with GW ameliorated the steatosis and inhibited overexpression of pro-inflammatory cytokines. In Hep G2 cells, PA and LPS treatment markedly increased m RNA of several nucleotide-binding andoligomerization domain-like receptor family members(NLRP3, NLRP6, and NLRP10), caspase-1 and IL-1β. PA and LPS also exaggerated reactive oxygen species production. All of the above effects of PA and LPS were reduced by GW. GW also enhanced the phosphorylation of AMPK-α.CONCLUSION: PPAR-δ agonist reduces fatty acidinduced inflammation and steatosis by suppressing inflammasome activation. Targeting the inflammasome by the PPAR-δ agonist may have therapeutic implication for NAFLD.

Usefulness of CA 19–9 for pancreatic cancer screening in patients with new-onset diabetes

Background： Generally, carbohydrate antigen 19–9 （CA 19–9） is not useful for screening pancreatic cancerin the asymptomatic general population. This study aimed to evaluate the utility of CA 19–9 level as a screening indicator of pancreatic cancer in asymptomatic patients with new-onset diabetes.

Butein effects in colitis and interleukin-6/signal transducer and activator of transcription 3 expression

AIM: To evaluate the effects of butein on inflammatory cytokines, matrix metalloproteinase-9(MMP-9), andcolitis in interleukin(IL)-10-/- mice.METHODS: To synchronize colitis, 8- to 10-wk-old IL-10-/- mice were fed pellet-chow containing piroxicam for 2 wk. Subsequently, phosphate-buffered saline or butein(1 mg/kg per day, ip) was injected for 4 wk. Histologic scores, inflammatory cytokines, MMP-9 and phosphorylated signal transducer and activator of transcription 3(p STAT3) expressions were analyzed in IL-10-/- mice and in Colo 205 cells.RESULTS: Butein reduced the colonic inflammatory score by > 50%. Expression levels of IL-6, IL-1β, interferon(IFN)-γ and MMP-9 were decreased in the colons of mice exposed to butein, whereas other inflammatory cytokines(IL-17 A, IL-21 and IL-22) were unchanged. Immunohistochemical staining for p STAT3 and MMP-9 was significantly decreased in the buteintreated groups compared with the controls. Butein inhibited IL-6-induced activation of STAT3 in Colo 205 cells.CONCLUSION: Butein ameliorated colitis in IL-10-/-mice by regulating IL-6/STAT3 and MMP-9 activation.

Inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum

Benign neoplasia of the duodenum are very rare. Moreover, duodenal tubulovillous adenomas are more uncommon lesions. The microscopic structure of tubulovillous adenoma has frond-like projection of mucosa with branching papillary structure and generally upward growth into the lumen. We describe a 72-year-old man who showed aduodenal tubulovillous adenoma with unusual inverted cystic growth pattern. Interestingly, this tubulovillous adenomatous lesion was interrupted by gastric metaplasia in the deep portion of the cyst and was closely surrounded by Brunner’s glands. Although histogenesis of gastric metaplasia of duodenum is not fully understood, Brunner’s glands has been suggested as a precursor for gastric metaplasia. Therefore, these findings argued that this adenoma arises from Brunner’s glands through gastric metaplasia. This is the first case of inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum with gastric metaplasia.

Application of the Prague C and M criteria for endoscopic description of columnar-lined esophagus in South Korea

AIM:To ascertain whether the Prague circumferential(C) length and maximal(M) length criteria for grading the extent of Barrett's esophagus can be applied prior to its widespread application in South Korea.METHODS:Two hundred and thirteen consecutive cases with endoscopic columnar-lined esophagus(CLE) were included and classified according to the Prague C and M criteria.RESULTS:Of 213 cases with CLE, the distribution of maximum CLE lengths was: 0.5-0.9 cm in 99 cases(46.5%); 1.0-1.4 cm in 63 cases(29.6%); 1.5-1.9 cm in 15 cases(7.0%); 2.0-2.4 cm in 14 cases(6.6%); 2.5-2.9 cm in 1 case(0.5%); and 7.0 cm in 1 case(0.5%). Twenty cases(9.4%) had columnar islands alone. Two hundred and eight cases(97.7%) lacked the circumferential CLE component(C0Mx). Columnar islands were found in 70 cases(32.9%), of which 20 cases(9.4%) had columnar islands alone.CONCLUSION:In regions where most CLE patients display short or ultrashort tongue-like appearance, more detailed descriptions of CLE's in < 1.0 cm lengths and columnar islands, as well as avoidance of repeating the prefix "C0" need to be considered in parallel with the widespread application of the Prague system in South Korea.