Concomitant pancreatic ductal adenocarcinoma (PDA) is observed in a subset of patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas, and early detection of those progressing lesions is difficult. We present a case with a de novo carcinoma in situ (CIS) discovered incidentally around the resection margin of IPMNs. A man in his 70s with a history of acute pancreatitis at the age of 50 years and no family history of PDA had a pancreatoduodenectomy for three isolated branch duct IPMNs that caused recurrent pancreatitis. During the 2-year follow-up period, the index lesion in the pancreatic head grew significantly, whereas the other cysts remained small and without mural nodules. The majority of the cysts are histologically composed of low-grade dysplasia and are classified as gastric-type IPMN. CIS with nuclear overexpression of p53 was located in the main pancreatic duct and adjacent brunch duct, which involved the pancreatic resection margin. The precise pathological analysis combined with multiregion sequencing revealed the CIS harbored KRAS G12V and TP53 R248W. Conversely, IPMNs contained GNAS mutant cells as well as components containing additional KRAS mutations. These findings suggested that the CIS formed independently of the multiple IPMNs and appeared to be an early manifestation of concomitant PDA with coexisting IPMNs. Despite widespread agreement on the resection of the radiographically significant IPMN lesion (s), the latent invasive cancer was not eradicated. A detailed pathological and molecular assessment of the resected materials may aid in a better management strategy for concurrent lesions.

Pancreatobiliary tumors frequently contain multiple malignant and precancerous lesions; however, the origin of the driver mutations and the mechanisms that underlie the generation of distinct clones within an organ field remain unclear. Herein, we describe a 76-year-old male suffering from moderately differentiated adenocarcinomas of the pancreas that primarily involved the distal bile duct and multiple "dispersing" invasive lesions in the pancreatic head. The patient underwent pylorus-preserving pancreaticoduodenectomy with superior mesenteric vein resection, and targeted sequencing of 18 genes associated with pancreatic tumorigenesis and immunohistochemical analysis of RNF43 and ARID1A were performed on each tumor compartment, including the invasive and non-invasive areas. Multi-region sequencing revealed shared KRAS and TGFBR1 mutations in all invasive foci, including those involving the distal bile duct. Distinct KRAS variants were found to be present in other non-continuous and non-invasive lesions in the pancreas. Intraductal lesions with KRAS G12D and RNF43 V50R mutations were evident in the main pancreatic duct. This appeared to be a founder clone, given that the mutation profile was common to the invasive foci as well as the additional high-grade dysplasia harboring ARID1A mutations, thereby suggesting a clonal branch-off during tumor evolution. In addition, we also observed independent intraductal papillary mucinous neoplasms with KRAS G12V and GNAS R201H mutations. Our theory, learned from this patient, was that lesions skipped dissemination and wide-spread movement potentially through the pancreatic ductal system as a process of pancreatic cancer development.

Objectives: Isolated superior mesenteric arterial dissection (ISMAD) is an uncommon type of arterial dissection and treated with surgery, stenting, or conservative management. This study aimed to evaluate the criteria for conservative therapy for ISMAD patients based on imaging findings. Methods: Eighteen consecutive ISMAD patients without peritoneal irritation at onset were retrospectively studied. The decision to perform stenting was based on the emergence of peritoneal irritation, aneurysm, or mesenteric ischemia. Clinical manifestations, follow-up contrast-enhanced computed tomography (CECT) findings, and patient outcome were evaluated. Results: Most patients (16, 89%) were successfully treated conservatively; two patients (11%) required endovascular stenting because of an aneurysm or ulcer-like projection (ULP) sign. The median duration of fasting and hospital stays was 3 (range, 1-8) and 9 (range, 4-34) days, respectively. On CECT, the median distance from the superior mesenteric artery (SMA) origin to the entry site was 12 mm (range, 5-35 mm), and the median length of dissection was 87.5 mm (range, 20-150 ram). Among 16 patients treated conservatively, serial imaging was obtained in 11 patients (69%), and disappearance of the dissection within 4 months occurred in five patients. Two patients treated with endovascular scent underwent follow-up CECT 1 year after onset, and there were no complications. Conclusions: ISMAD patients without peritoneal irritation can be treated conservatively if there are no signs of an aneurysm, ULP, or mesenteric ischemia. When an aneurysm or ULP sign exists, endovascular stenting was able to preserve SMA blood flow with the improvement of the dissection.

A 56-year-old man presenting with abdominal pain had an elevated serum immunoglobulin 4 (IgG4) concentration. Computed tomography angiography revealed a celiacomesenteric trunk aneurysm with wall. After admission, the celiacomesenteric trunk aneurysm grew rapidly along with wall thinning. Emergency transcatheter arterial embolization was completed using detachable coils. After transcatheter arterial embolization, the patient’s abdominal pain disappeared completely. Steroid administration, which continues to the present day, was started 1 month after the transcatheter arterial embolization. No clinical symptoms associated with recurrent arteritis or other IgG4-related disease have been confirmed.

Aortoenteric fistula (AEF) is a life-threatening condition that can present with gastrointestinal (GI) bleeding. AEFs have been classified into primary and secondary types. Primary AEF (PAEF) is a direct communication between the aorta and the GI tract. Secondary AEF (SAEF) is the result of a previous abdominal aortic aneurysm repair involving placement of a synthetic aortic graft. Diagnosis of AEF, especially PAEF, is difficult largely because AEF is so rarely encountered in practice. Computed tomography (CT) and endoscopic gastroduodenoscopy (EGD) are most frequently used to diagnose AEF, with abdominal contrast-enhanced CT being the preferred initial diagnostic test of choice. Although EGD can exclude other common causes of GI hemorrhage, it cannot be used to rule out AEF when another source of bleeding is identified, as the two conditions can coexist. We discuss here two patients with GI bleeding who were diagnosed as PAEF and SAEF. We tried to diagnose and treat with EGD, but failed. That bleeding was due to an AEF became evident when abdominal CT scans revealed direct extravasation of contrast media from the abdominal aorta into the GI tract. The lack of awareness of AEF, coupled with the inaccessibility to the distal duodenum via EGD, were probably responsible for initial misdiagnosis and delay of appropriate management. We suggest that the diagnosis of AEF remains dependent on the clinician's heightened suspicion.

We present a case of resected mucinous cystic neoplasm of the liver in a 71-year-old woman admitted to our hospital with epigastric discomfort. Abdominal ultrasonography and computed tomography revealed a multi-locular cystic tumor measuring 35 mm in diameter in segment IV of the liver. Left hepatic lobectomy was performed based on the diagnosis of mucinous cystic neoplasm of the liver; subsequent histology revealed that the tumor was multi-locular, cystic, and lined with a single layer of columnar epithelium with low-grade atypia and was associated with a typical ovarian-like stroma. There was no evidence (imaging or histological) to support communication of the cyst with the intrahepatic bile duct, despite modest bile deposition being observed in the cystic wall. The definitive diagnosis was mucinous cystic neoplasm with low-grade intrahepatic epithelial neoplasia.

【目的】当院で経験した成人腸重積21例の臨床病理学的特徴と診断から治療にいたる時間経過から緊急性の検討を行った．【結果】主訴は腹痛を52％，血便を28％に認めたがイレウスや腫瘤触知は10％と少なく，病悩期間は半数以上が亜急性から慢性の経過であった．発生部位は大腸型57％，回盲部型38％であった．原因疾患は53％が大腸癌であった．治療は12例で外科手術，9例に保存的治療が行われ，超高齢でBSCを行った2例以外で全例腸重積は改善した．手術した12例において緊急手術を行った3例を含め全例に腸管壊死例はなく緊急性は低かった．手術した大腸癌9例では0-I型もしくは1型の隆起癌が6例，stage0-IIに留まるものが7例と多かった．【結論】成人腸重積21例の検討では大腸型および回盲部型が多く，半数が大腸癌であった．また本検討では緊急性を要する症例はなく待期的治療で良いものが多いと考えられた.

BACKGROUND:Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable, because it is almost impossible to approach the bleeding point by endoscopy. We herein describe the first case of bleeding from the appendix, which was successively controlled by a therapeutic barium enema administered into the appendix.CASE PRESENTATION:A 71-year-old male visited our hospital because of melena. He has been receiving an anti-coagulation drug, ticlopidine hydrochloride, for 10 years. By an emergency colonoscopy, a hemorrhage was detected in the appendix, and the lesion responsible for the bleeding was regarded to exist in the appendix. Two hundred milliliters of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube. The bleeding could thus be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix. The barium accumulation disappeared by the next day, and no obvious anal bleeding was observed. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent any further refractory hemorrhaging. The patient has had no complaints of any abdominal symptoms or anal bleeding for 10 months.CONCLUSIONS:A therapeutic barium enema is a useful procedure to control bleeding from the appendix and to avoid emergency surgery, such as partial cecectomy and hemicolectomy.

Acute esophageal mucosal lesion (AEML) is a comprehensive disease that includes necrotizing esophagitis and acute erosive esophagitis, which result in upper gastrointestinal bleeding. However, little is known about AEML. We examined the clinicopathological features of 57 AEML cases. AEML presented as acute diffuse esophagitis showing an endoscopically erosive mucosa. The disease did not include corrosive injury, radiation-induced damage, infectious esophagitis, or acute exacerbation of chronic gastroesophageal reflux disease. AEML predominantly affected elderly men, and upper gastrointestinal bleeding was the frequent presenting symptom. Severe underlying diseases such as cranial nerve disease or pneumonia were observed in 98% of the patients. Esophageal sliding hernia and gastroduodenal ulcers were endoscopically observed in 67% and 63% of the patients, respectively. Deaths due to exacerbation of the underlying diseases accounted for 16%. Most cases rapidly improved with conservative management using a proton pump inhibitor or an H2 blocker. Therefore, AEML should be considered a disease having characteristics different from those of common gastroesophageal reflux disease.

Digestive EndoscopyVolume 24, Issue 3 p. 193-193 PSEUDO-DIVERTICULAR FORMATION DUE TO A CYTOMEGALOVIRUS INFECTION IN THE COLORECTUM MOMOTARO MUTO, MOMOTARO MUTO Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorRYU SATO, RYU SATO Internal Medicine, Kotoni Royal Hospital, SapporoSearch for more papers by this authorMIKIHIRO FUJIYA, MIKIHIRO FUJIYA Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorKAZUYUKI TANAKA, KAZUYUKI TANAKA Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorSHINYA SERIKAWA, SHINYA SERIKAWA Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorAKIHIRO HAYASHI, AKIHIRO HAYASHI Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorYOHKO KONNO, YOHKO KONNO Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorJUN SAKAMOTO, JUN SAKAMOTO Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorTOMOYA NISHIKAWA, TOMOYA NISHIKAWA Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorKENSUKE OIKAWA, KENSUKE OIKAWA Pathology, Asahikawa Kosei Hospital, AsahikawaSearch for more papers by this authorNOBUHIRO UENO, NOBUHIRO UENO Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorKATSUYA IKUTA, KATSUYA IKUTA Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorYUSUKE MIZUKAMI, YUSUKE MIZUKAMI Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorSATOSHI TANNO, SATOSHI TANNO Internal Medicine, Kotoni Royal Hospital, SapporoSearch for more papers by this authorJIRO WATARI, JIRO WATARI Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, JapanSearch for more papers by this authorYUTAKA KOHGO, YUTAKA KOHGO Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this author MOMOTARO MUTO, MOMOTARO MUTO Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorRYU SATO, RYU SATO Internal Medicine, Kotoni Royal Hospital, SapporoSearch for more papers by this authorMIKIHIRO FUJIYA, MIKIHIRO FUJIYA Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorKAZUYUKI TANAKA, KAZUYUKI TANAKA Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorSHINYA SERIKAWA, SHINYA SERIKAWA Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorAKIHIRO HAYASHI, AKIHIRO HAYASHI Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorYOHKO KONNO, YOHKO KONNO Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorJUN SAKAMOTO, JUN SAKAMOTO Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorTOMOYA NISHIKAWA, TOMOYA NISHIKAWA Internal Medicine, Engaru-Kosei General Hospital, EngaruSearch for more papers by this authorKENSUKE OIKAWA, KENSUKE OIKAWA Pathology, Asahikawa Kosei Hospital, AsahikawaSearch for more papers by this authorNOBUHIRO UENO, NOBUHIRO UENO Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorKATSUYA IKUTA, KATSUYA IKUTA Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorYUSUKE MIZUKAMI, YUSUKE MIZUKAMI Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this authorSATOSHI TANNO, SATOSHI TANNO Internal Medicine, Kotoni Royal Hospital, SapporoSearch for more papers by this authorJIRO WATARI, JIRO WATARI Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, JapanSearch for more papers by this authorYUTAKA KOHGO, YUTAKA KOHGO Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical CollegeSearch for more papers by this author First published: 17 April 2012 https://doi.org/10.1111/j.1443-1661.2011.01188.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and 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BACKGROUND:We developed a novel method of methylation-specific PCR (MSP) using immunoprecipitation with anti-histone antibody (IP-MSP) to efficiently detect serum methylated DNA tightly bound to de-acetylated histones. MATERIALS AND METHODS:The detection limit of IP-MSP for p16 methylation was determined with a standard made by cell line (SKCO-1) lysate. p16 methylation of tumor and/or serum of 51 colorectal cancers and 10 adenoma patients, and 10 healthy volunteers was detected with conventional MSP or IP-MSP. RESULTS:IP-MSP detected p16 methylation from 0.5pg/mul of the cell lysate. The sensitivity of IP-MSP for detecting serum p16 methylation in 27 patients with tumors characterized by p16 methylation was significantly higher than that with conventional method (81% versus 59%), particularly in Stage II patients (91% versus 45%). IP-MSP detected no p16 hypermethylation in sera of adenoma patients and volunteers. CONCLUSIONS:IP-MSP is thus considered to be a promising procedure to detect serum methylated DNA in colorectal cancer patients.