We report a 75-year-old woman with advanced hepatocellular carcinoma (HCC) with portal vein main trunk tumor thrombosis treated successfully by repeated hepatic arterial infusion chemotherapy (HAIC). She had been diagnosed with hepatitis B virus cirrhosis since 1998 and followed up by a local practitioner. As hepatocellular carcinoma occurrence was suspected on abdominal computed tomography in March 2007, she was referred to our hospital. Although transcatheter arterial chemoembolization (TACE) with emulsion of epirubicin and lipiodol was performed twice, the therapeutic response was poor and temporary. Serum alpha-fetoprotein (AFP) level was elevated, and portal vein tumor thrombosis (PVTT) involving main trunk of portal vein (Vp4) appeared. In January 2008, the treatment was changed to hepatic arterial infusion chemotherapy (HAIC) with a fine-powder formulation of cisplatin (IA-call®). Immediately after HAIC, there was a significant decrease in AFP levels, and we estimated that IA-call® was effective. An arterial infusion reservoir was placed in the right hepatic artery in March 2008, and repeated HAIC of IA-call® was performed 7 times until December 2008. During this period, HCC with PVTT disappeared, and AFP level decreased to normal range. We judged complete remission was obtained, and it persisted for 7 years and 8 months after terminating HAIC. In July 2016, although recurrence was observed, it was controlled by repeated TACE, and she is alive as of December 2020. We encountered a case of advanced HCC with Vp4 who survived for over 13 years owing to the remarkable effect of repeated HAIC of IA-call®.

[Case 1] A 30-year-old male presented to our hospital with fever. Blood lab results were as follows: T.Bil, 4.8 mg/dL; AST, 3,130 IU/L; ALT, 4,787 IU/L; IgM HAV antibody, positive; and IgA HEV antibody, positive. Superinfection was suspected; however, he was negative for HEV RNA. [Case 2] A 37-year-old female presented to our hospital with fever. Blood lab results were as follows: T.Bil, 10.9 mg/dL; AST, 168 IU/L; ALT, 315 IU/L; EB VCA-IgM, 20; EB VCA-IgG, 160; EBNA, ＜ 10; and IgA HEV antibody, positive. The paired serum test results were as follows: EB VCA-IgM, 80; EB VCA-IgG, 320; and EBNA, ＜ 10. Superinfection was suspected; however, she was negative for HEV RNA. Even for patients who are positive for the IgA HEV antibody, the HEV RNA test should be performed, con-sidering the possibility of a false-positive result arising from other factors for liver dysfunction.

Objectives: Self-expandable metallic stent (SEMS) therapy for malignant colorectal strictures has been covered by the national insurance in Japan since 2012. There has been a gradual increase in the use of bridge to surgery (BTS), in which a stent is inserted for obstructive colorectal cancer to avoid emergency surgery, following which elective surgery is performed. SEMS reportedly reduces the rate of postoperative complications compared to emergency surgery. Malnutrition is also known to be a risk factor for postoperative complications, however, few reports have assessed nutritional status with respect to obstructive colorectal cancer. Therefore, we retrospectively investigated changes in nutritional status and colorectal cancer treatment outcomes in BTS patients following SEMS placement for obstructive colorectal cancer.Methods: Subjects included 33 BTS patients who underwent nutritional assessment before and after SEMS placement for obstructive colorectal cancer at Kawasaki Municipal Tama Hospital between January 2012 and December 2018. The indicators of nutritional status were prealbumin (PA) and the prognostic nutritional index (PNI). In addition to nutritional status, patient background, SEMS outcome, and postoperative results of BTS were examined. Regarding the postoperative results of BTS, nutritional status was compared with and without postoperative complications.Results: In the group with postoperative complications, before SEMS placement and after SEMS placement PA didn’t differ significantly (P=0.603); and after SEMS placement PNI was significantly lower than before SEMS placement PNI (P=0.014). On the contrary, in the group without postoperative complications, PA after SEMS placement was significantly higher than that before SEMS placement (P=0.008); and PNI didn’t increased after SEMS placement (P=0.205).Conclusions: In BTS patients with SEMS for obstructive colorectal cancer, PA may be a useful indicator of postoperative complications. PA and PNI demonstrated different manifestations related to SEMS as a BTS use for obstructive colorectal cancer, and improvement of PA may be useful as a predictor of postoperative course.

Background Epstein–Barr virus-positive mucocutaneous ulcer (EBV-MCU) is a new category of mature B-cell neoplasms. Ulcers occur in the oropharyngeal mucosa, skin, and gastrointestinal tract. The onset of EBV-MCU is suggested to be related to the decreased immunity of the patient, the causes of which include the use of immunosuppressive agents and aging. EBV-MCU may regress spontaneously and it often has a benign course after the dose reduction or discontinuation of immunosuppressive agents or during follow-up. Here, we report the case of a patient who required surgical resection for the intestinal obstruction arising from EBV-MCU. Case presentation A Japanese elderly male visited our hospital with chief complaints of a palpable mass and dull pain in the left upper quadrant, loss of appetite, and weight loss. Although abdominal computed tomography and total colonoscopy (TCS) revealed a tumor with circumferential ulcer in the transverse colon, histopathological analysis of a biopsy specimen of this lesion showed only nonspecific inflammation. Because the tumor spontaneously regressed during the time he underwent tests to obtain a second opinion from another hospital, TCS was reperformed on the patient. TCS revealed that the tumor decreased in size and the inflammatory changes in the surrounding mucosa tended to improve; however, tightening of the surrounding mucosa due to scarring was observed. Another histopathological analysis of a biopsy specimen showed widespread erosion of the mucosa and the formation of granulation tissue with marked infiltration of various inflammatory cells into the mucosal tissue of the large intestine. Moreover, some of the B-lymphocyte antigen CD20-positive B cells were also positive for EBV-encoded small RNA-1, suggesting the possibility of EBV-MCU. Later, the tumor developed into an intestinal obstruction; thus, the transverse colon was resected. Histopathological analysis of the resected specimen demonstrated scattered Hodgkin and Reed–Sternberg-like multinucleated large B cells in addition to EBER-1-positive cells. The patient was finally diagnosed as having EBV-MCU. Conclusions This is the first report of a case of EBV-MCU that developed into an intestinal obstruction requiring surgical resection. It is necessary to consider the possibility of EBV-MCU when examining an ulcerative or tumorous lesion in the gastrointestinal tract.

With the development of direct-acting antiviral (DAA) treatment for chronic hepatitis C including liver cirrhosis (type C chronic liver disease; type C CLD), almost 100% virus elimination can be achieved. DAA treatment is also being expanded for elderly patients and/or patients with advanced fibrosis. Therefore, there is a concern that the risk of hepatocellular carcinoma (HCC) after DAA treatment may increase. We examined the current status of HCC occurrence in 241 patients who achieved a sustained virologic response (SVR) upon DAA treatment for type C CLD with no history of liver cancer. HCC was developed in 12 patients (5.0%), and the cumulative incidence rate was 1.3% for 1 year, 3.1% for 2 years, 3.6% for 3 years, 4.7% for 4 years, and 6.4% for 5 years, respectively. Moreover, the rate of HCC incidence was significantly higher in elderly patients (≧70 years old; P=0.0488). Nine cases were diagnosed as HCC stages I and II, and the prognosis was favorable with proper treatment. The remaining three cases were suspected to rapidly progress toward advanced HCC, diagnosed as stage III and IV at the time of diagnosis; all the patients died within a year. Consequently, post-SVR HCC occurrence after DAA treatment should be carefully followed on a case-by-case basis, especially in the elderly and in patients with advanced fibrosis.

A 20-year-old man presented to the outpatient clinic of our hospital with gradually worsening chest pain exacerbated by motion. His symptoms had begun the evening prior to presentation following ingestion of grilled frozen mackerel. His condition worsened after swallowing cornflakes at breakfast on the day of presentation. Computed tomography revealed right-sided pneumomediastinum and pneumothorax (Picture 1, 2). Emergency esophageal endoscopy revealed a fish bone stuck head-side-up at the thoracic esophagus (Picture 3), which was retrieved using a foreign body removal

抄 録 背景: 近年の内視鏡技術の向上や機器の開発により,早期胃癌 (Early gastric cancer: ECG) に 対する内視鏡的粘膜下層剥離術 (Endoscopic Submucosal Dissection: ESD) は一般的な治療法と して確立している。現在では高齢者の ECG に対して ESD が広く行われているが,併存疾患が 多く,偶発症の発生による全身状態の深刻な悪化が懸念される一方で,安全性や有用性に対す る一定の見解は得られていない。 目的: 当施設の胃 ESD の治療成績から,高齢者に対する ESD の安全性と有用性を検討する。 対象と方法: 2006 年 1 月から 2016 年 12 月までの間,当院にて胃 ESD を施行した 235 症例 261 病変を対象とした。79 歳以下を非高齢者群 (Non-elderly: NE 群),80 歳以上を高齢者群 (Elderly: E 群) とし,retrospective に両群間の治療成績を比較検討した。 結果: 全体での偶発症発生率は両群間に有意差は認めなかったが,内容別に検討すると E 群に て肺炎が多く認められた (P=0.03)。一括切除率,完全一括切除率に有意差は認めなかったが, E 群において有意に治癒切除率は低く (P=0.03),処置時間は長かった (P=0.03)。両群間の入院 期間に差は認められなかった。 結論: 高齢者早期胃癌に対する ESD は肺炎に留意する必要はあるものの,偶発症全体の発症 率に差異はなく,安全な治療遂行が可能である。

症例は44歳，同性愛者の男性．発熱および粘血便を主訴に受診．下部消化管内視鏡所見および血清抗体価よりアメーバ性大腸炎と診断した．同時点では肝胆道系酵素異常はなく，HBs抗原は陰性であった．アメーバ性大腸炎に対する加療後の経過観察期間中に全身倦怠感に伴うHBs抗原の陽転化ならびに肝胆道系酵素異常が出現した．IgM-HBc抗体が高力価陽性でありB型急性肝炎と診断した．HBV genotypeはAであった．以後ALT 1565 U/L，T.Bil 17.2 mg/dlを最大値に肝炎は沈静化し，HBs抗原から抗体へのセロコンバージョンを認めた．アメーバ性大腸炎治療後の経過観察中に続発したため，発症を捉えることが可能であったB型急性肝炎の1例を経験した．性感染症においては，重複感染を考慮し，潜伏期間を念頭に置いた慎重な経過観察および全身検索が必要である．

Reports in Japan indicate that the type II-open pit pattern is a useful endoscopic finding for SSA/Ps. Thus, although this criterion can be used to diagnose most typical SSA/Ps, consensus has not yet been reached on the treatment of the diagnosed lesions. The absolute indication for resection currently includes carcinoma in SSA/Ps and SSA/Ps with cytological dysplasia (advanced SSA/Ps); this clinicopathological characteristic is a very important index for establishing future SSA/P treatment.

Hepatitis B surface antigen (HBsAg) levels in sixteen patients who underwent switching of previous nucleos(t)ide analogues (NAs) to Tenofovir (TDF) were evaluated. Patients were classified into Adefovir (ADF)-pretreated group and Entecavir (ETV)-pretreated group. HBsAg levels were significantly decreased throughout the course, especially after administration of TDF in all patients. In ADF-pretreated group, no significant difference of HBsAg levels was observed before and after administration of TDF. On the other hand, HBsAg levels after administration of TDF were significant decreased, while no significant difference was observed before administration of TDF in ETV-pretreated group. As conclusion, it is suspected that administration of TDF may have some effect on control of HBsAg levels.

Diverticulum of the horizontal portion of the duodenum is a rare cause of upper gastrointestinal (GI) bleeding. Since it is difficult to access the horizontal portion of the duodenum by standard upper GI endoscopy, only a very few cases of endoscopic hemostasis have been reported. Herein, we report a case of diverticular bleeding from the horizontal portion of the duodenum for which hemostasis was achieved using a small-caliber colonoscope, which has an insertion part designed with a passive-bending function/high-force transmission and a transparent tip hood.

Antiplatelet therapy is the standard of care for the secondary prevention of acute coronary syndrome and ischemic stroke, especially after coronary intervention. However, this therapy is associated with bleeding complications such as gastrointestinal bleeding, which is one of the most common life-threatening complications. Early endoscopy is recommended for most patients with acute upper gastrointestinal bleeding. After successful endoscopic hemostasis, immediate resumption of antiplatelet therapy with proton-pump inhibitors (PPIs) is recommended to prevent further ischemic events. PPI prophylaxis during antiplatelet therapy reduces the risk of upper gastrointestinal bleeding. The potential negative metabolic interaction between PPIs and clopidogrel is still unclear.

OBJECTIVE We evaluated the diagnostic performance of computed tomography (CT) as an initial radiologic test for assessing the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding (LGIB) and investigated the effectiveness of contrast-enhanced (CE) CT for detecting colonic diverticular bleeding. METHODS This was a retrospective study of 1,604 consecutive patients who visited or were referred to St. Marianna University Hospital due to acute LGIB and underwent colonoscopy within three months after presentation between September 2004 and December 2012. The clinicopathological data of the subjects were obtained from their medical records. RESULTS Among the 1,604 patients presenting with LGIB, 879 (55%) underwent a CT scan. Elective colonoscopy was considered in cases in which typical colonic wall thickening was observed on CT, suggesting colonic inflammation or malignancy (239 patients; 27%). The diagnoses in the elective cases included ischemic colitis (38%), infectious colitis (8%), inflammatory bowel disease (8%) and malignancy (5%). Urgent colonoscopy was performed after the CT examination in 640 cases (73%). The most common presumptive CT diagnosis was diverticulum (402/640; 63%). Of the 638 patients who underwent CE-CT, diverticula were observed in 346 cases, including 104 cases of extravasation indicating ongoing diverticular bleeding. Among these 104 patients, the site of bleeding was identified in 71 subjects (68%) during colonoscopy. The rate of detection of the bleeding source on colonoscopy was significantly higher in the patients with extravasation on CE-CT than in those without extravasation on CE-CT (68% vs. 20%, respectively; p<0.001). CONCLUSION Urgent CT is useful for determining the optimal timing of colonoscopy in cases of acute LGIB. CE-CT may be used to depict the presence and location of active hemorrhage and provides useful information for subsequent colonoscopy, especially in patients with diverticular bleeding.

Gastric cancer(GC)is one of the most common malignancies and remains the second leading cause of cancer-related death worldwide.There is an increasing understanding of the roles that genetic and epigenetic alterations play in GCs.Recent studies using nextgeneration sequencing(NGS)have revealed a number of potential cancer-driving genes in GC.Whole-exome sequencing of GC has identified recurrent somatic mutations in the chromatin remodeling gene ARID1A and alterations in the cell adhesion gene FAT4,a member of the cadherin gene family.Mutations in chromatin remodeling genes(ARID1A,MLL3 and MLL)have been found in 47%of GCs.Whole-genome sequencing and whole-transcriptome sequencing analyses have also discovered novel alterations in GC.Recent studies of cancer epigenetics have revealed widespread alterations in genes involved in the epigenetic machinery,such as DNA methylation,histone modifications,nucleosome positioning,noncoding RNAs and microRNAs.Recent advances in molecular research on GC have resulted in the introduction of new diagnostic and therapeutic strategies into clinical settings.The antihuman epidermal growth receptor 2(HER2)antibody trastuzumab has led to an era of personalized therapy in GC.In addition,ramucirumab,a monoclonal antibody targeting vascular endothelial growth factor receptor(VEGFR)-2,is the first biological treatment that showed survival benefits as a single-agent therapy in patients with advanced GC who progressed after firstline chemotherapy.Using NGS to systematically identify gene alterations in GC is a promising approach with remarkable potential for investigating the pathogenesis of GC and identifying novel therapeutic targets,as well as useful biomarkers.In this review,we will summarize the recent advances in the understanding of the molecular pathogenesis of GC,focusing on the potential use of these genetic and epigenetic alterations as diagnostic biomarkers and novel therapeutic targets.

症例は27歳，男性。心窩部痛を主訴に近医受診。上部消化管内視鏡にて食道胃接合部に粘膜不整を認め，生検にてGroup 4であり悪性疾患が疑われ当院へ紹介受診となった。当院での上部消化管内視鏡では，NBI拡大観察にて血管蛇行や癒合を伴う異型血管を認め，short segment Barrett’s esophagus（SSBE）より発生したBarrett腺癌が疑われ，診断的治療目的に内視鏡的粘膜下層剥離術を施行した。病理組織学的診断にてBarrett腺癌と診断され，粘膜下層浸潤，脈管侵襲を認めたため追加外科的切除となった。本邦では全食道癌の90％以上が扁平上皮癌であり腺癌は比較的稀である。しかしH. pylori感染率低下，食生活欧米化によるGERD増加に伴い，近年Barrett腺癌の増加が懸念されている。一方，若年者におけるBarrett腺癌の報告は本邦，欧米含め散見されるのみである。今回我々は若年者に発生したBarrett腺癌を経験したので文献的考察を含め報告する。

Giardia lamblia is one cause of prolonged diarrhea in overseas travelers. Demonstration of trophozoites in stool is the traditional method of diagnosis. Here we present a case of giardiasis diagnosed by lavage fluid collected during colonoscopy (CS) .A 60-year-old woman presented at our hospital with prolonged watery diarrhea since travel in Southeast Asia. She had been treated empirically due to negative results from EGD, CS and stool culture. A second CS was performed one year and nine months after the first CS, because the diarrhea persisted. Trophozoites of Giardia lamblia were detected microscopically in lavage fluid sediment collected during this CS. Oral administration of metronidazole (750 mg/day) for one week dramatically improved the patient’s symptoms. This case suggests that CS lavage fluid assessment is a useful method to detect Giardia lamblia in patients with chronic diarrhea.