Search

No prediction scores for the mortality of both inpatients and outpatients who developed nonvariceal upper gastrointestinal bleeding (UGIB) without endoscopic findings have been established. We aimed to derive and validate a novel prediction score for in-hospital mortality. We conducted a three-stage, multicenter retrospective study. In the derivation stage, patients with nonvariceal UGIB at six institutions were enrolled to derive the prediction score by logistic regression analysis. External validation of the score was performed to analyze discrimination by patients at six other institutions. Then the performance of this score was compared with that of four existing scores. We enrolled 1380 and 825 patients in the derivation and validation cohorts, respectively. A prediction score (CHAMPS-R Score) comprising seven variables (Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin

BACKGROUND Although post-bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs). METHODS Data on duodenal ulcers with evidence of endoscopically-active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in-hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses. RESULTS Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically-confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in-hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P

When a lesion does not meet the curative criteria of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), referred to as non-curative resection or curability C-2 in the guidelines, an additional surgery is the standard therapy because of the risk of lymph node metastasis (LNM). This study aimed to identify high-risk patients for recurrence after additional surgery for curability C-2 ESD of EGC. This multicenter retrospective cohort study enrolled 1064 patients who underwent additional surgery after curability C-2 ESD for EGC. We evaluated the recurrence rate and the risk factors for recurrence after additional surgery in these patients. The 5-year recurrence rate after additional surgery was 1.3%. Multivariate Cox analysis revealed that the independent risk factors for recurrence after additional surgery were LNM (hazard ratio [HR] 32.47; p

The incidence of peptic ulcers unrelated to H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs), termed idiopathic peptic ulcers (IPUs), has increased worldwide. We recently reported that IPUs were refractory to proton pump inhibitor (PPI) treatment. Vonoprazan, which was recently developed in Japan, has shown a more potent acid-inhibitory effect than ordinary PPIs. In the present study, we compared the healing rates among peptic ulcers of different etiologies following treatment with vonoprazan. A multicenter observational study was performed at six participating hospitals in Akita Prefecture, Japan. Consecutive patients who had endoscopically confirmed gastro-duodenal ulcers were enrolled between August 2016 and March 2018. For each patient, the Helicobacter pylori infection status and NSAID use, including aspirin, were checked, and 20 mg vonoprazan was administered for 6 weeks for duodenal ulcers and 8 weeks for gastric ulcers. The healing status was checked by endoscopy at the end of vonoprazan treatment. Patients were divided into four subgroups according to the H. pylori status and NSAID usage. The proportion of IPUs was 18.2%. A total of 162 patients completed the study protocol. The healing rate of IPUs was marginally lower than that of simple H. pylori-associated ulcers (81.2% vs. 93.5%, P = 0.05). Similarly, the healing rate of NSAID-related ulcers, irrespective of concomitant H. pylori infection, was significantly lower than that of simple H. pylori-associated ulcers. Six- or 8-week vonoprazan treatment still seems to be insufficient for healing IPUs. Longer-term vonoprazan or another treatment option may be required to heal potentially refractory peptic ulcers.

INTRODUCTION: About one-third of patients with severe ulcerative colitis (UC) do not respond to corticosteroid therapy and receive rescue therapy with infliximab or cyclosporine. Up to 20% of such patients fail to respond to rescue therapy and undergo colectomy. OBJECTIVE: We investigated the outcomes of infliximab and a plant-based diet (PBD) as first-line therapy for severe UC. METHODS: Patients with severe UC defined by the Truelove and Witts criteria were admitted and given standard induction therapy with infliximab (5.0 mg/kg-7.5 mg/kg) at 0, 2, and 6 weeks. Additionally, they received a PBD. The primary endpoint was remission or colectomy in the induction phase and 1 year after discharge. Secondary endpoints were changes in inflammatory markers in the induction phase and the PBD score at baseline and follow-up. A higher PBD score indicates greater adherence to a PBD. RESULTS: Infliximab and PBD as first-line therapy was administered in 17 cases. The remission rate was 76% (13/17), and the colectomy rate was 6% (1/17) in the induction phase. C-reactive protein values and the erythrocyte sedimentation rate significantly decreased at week 6 from 9.42 mg/dL to 0.33 mg/dL and from 59 to 17 mm/h, respectively (p < 0.0001). At 1-year follow-up, the cumulative relapse rate was 25%, and there were no additional colectomy cases. Mean PBD scores of 27.7 at 1 year and 23.8 at 4 years were significantly higher than baseline scores of 8.3 and 9.9, respectively (p < 0.0001 and p = 0.0391). CONCLUSION: This new first-line therapy for severe UC demonstrated a higher remission rate and lower colectomy rate than with the current modality.

OBJECTS Although anti-thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti-thrombotic agents on in-hospital mortality following UGIB. METHODS Information on clinical parameters, including usage of anti-thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high-volume centers in Japan between 2011 and 2018. The all-cause in-hospital mortality rate was evaluated according to the usage of anti-thrombotic agents. RESULTS Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty-five (29.3%) patients used anti-thrombotic agents. The all-cause in-hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end-stage malignancy, 96 deaths (bleeding-related, n = 22 ; non-bleeding-related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti-thrombotic users was significantly higher than that in non-users (6.0% vs. 3.7%, P

We describe a scarcely reported case in which ulcerative colitis (UC) occurred in the postpartum period. The aims of this case report are to reinforce the recent assertion that a diet is a ubiquitous environmental factor in inflammatory bowel disease (IBD) and that a plant-based diet (PBD) is recommended for IBD. A 29-year-old woman normally delivered her first child. She first noticed bloody diarrhea 4.5 months after delivery. She was diagnosed with UC (left-sided colitis, moderate severity). Sulfasalazine induced remission. She then experienced and learned about PBD during an educational hospitalization. She resumed breast-feeding and stopped medication. An interview and questionnaire revealed a change in her diet 3 months after delivery, from a sound diet (plant-based diet score: 25) to an unhealthy diet (score: 9). It happened along with a change in residence, from her parent’s home where her mother prepared traditional Japanese meals to her home where she prepared meals by herself. A feeling of release from childbirth prompted her to eat sweets and cheese despite being aware that the quality of the meals deteriorated. We described a scarcely reported case in which UC occurred in the postpartum period. It happened along with a change in her diet, from a sound diet to an unhealthy diet due to a feeling of release from childbirth. She replaced an omnivorous diet by PBD and stopped medication. The critical role of diet is largely ignored by healthcare professionals. We believe that greater appreciation of diet will change and improve management of IBD.

Background/Aims: The role of an undifferentiated component in submucosal invasion and submucosal invasion depth (SID) for lymph node metastasis (LNM) of early gastric cancer (EGC) with deep submucosal invasion (SID ≥500 μm from the muscularis mucosa) after endoscopic submucosal dissection (ESD) has not been fully understood. This study aimed to clarify the risk factors (RFs), including these factors, for LNM in such patients. Methods: We enrolled 513 patients who underwent radical surgery after ESD for EGC with deep submucosal invasion. We evaluated RFs for LNM, including an undifferentiated component in submucosal invasion and the SID, which was subdivided into 500–999, 1,000–1,499, 1,500–1,999, and ≥2,000 µm. Results: LNM was detected in 7.6% of patients. Multivariate analysis revealed that an undifferentiated component in submucosal invasion (OR 2.22), in addition to tumor size >30 mm (OR 2.51) and lymphatic invasion (OR 3.07), were the independent RFs for LNM. However, the SID was not significantly associated with LNM. Conclusion: An undifferentiated component in submucosal invasion was one of the RFs for LNM, in contrast to SID, in patients who underwent ESD for EGC with deep submucosal invasion. This insight would be helpful in managing such patients.

Previous studies comparing survival outcomes between patients who did and did not undergo additional surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) were limited in that the baseline characteristics differed significantly between the groups. We aimed to address this limitation and compared survival outcomes between these two groups using propensity score matching analysis. The study enrolled 1969 consecutive patients who underwent non-curative ESD for EGC between 2000 and 2011 at any of 19 institutions across Japan. Using propensity score matching analysis, patients who underwent additional surgery (n = 1064) were compared with patients who did not (n = 905). Overall survival (OS) and disease-specific survival (DSS) after ESD were compared between both groups. Propensity score matching analysis yielded 553 matched pairs and well-balanced baseline characteristics between the two groups. The 5-year OS rates were 91.0% in the additional surgery group and 75.5% in the no additional surgery group, and the 5-year DSS rates were 99.0 and 96.8%, respectively. OS and DSS in the additional surgery group were significantly higher than in the no additional surgery group (OS, p

Sufficient information is not available on the extent to which lymph node metastasis (LNM) and prognosis are affected by submucosal manipulation during endoscopic submucosal dissection (ESD) for submucosal invasive gastric cancer (SMGC). We aimed to identify the effects of submucosal manipulation during ESD on LNM and prognosis in patients with SMGC. From 19 institutions in Japan, 2526 patients who failed to meet the current curative criteria for ESD between 2000 and 2011 were recruited. After exclusion, 1969 patients were remained. Based on the treatment strategy after ESD, 1064 patients underwent additional radical surgery. A total of 890 of 1064 patients with SMGC, LNM and cancer recurrence, and prognosis were retrospectively reviewed. The median follow-up duration was 67 months. A total of 214 patients had SM1 (depth of tumor invasion from the muscularis mucosae

Although radical surgery is recommended for patients not meeting the curative criteria for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) because of the potential risk of lymph node metastasis (LNM), this recommendation may be overestimated and excessive. We aimed to establish a simple scoring system for decision making after ESD.This multicenter retrospective study consisted of two stages. First, the risk-scoring system for LNM was developed using multivariate logistic regression analysis in 1,101 patients who underwent radical surgery after having failed to meet the curative criteria for ESD of EGC. Next, the system was internally validated by survival analysis in another 905 patients who also did not meet the criteria and did not receive additional treatment after ESD.In the development stage, based on accordant regression coefficients, five risk factors for LNM were weighted with point values: three points for lymphatic invasion and 1 point each for tumor size30 mm, positive vertical margin, venous invasion, and submucosal invasion ≥500 μm. Then, the patients were categorized into three LNM risk groups: low (0-1 point: 2.5% risk), intermediate (2-4 points: 6.7%), and high (5-7 points: 22.7%). In the validation stage, cancer-specific survival differed significantly among these groups (99.6, 96.0, and 90.1%, respectively, at 5 years; P0.001). The C statistic of the system for cancer-specific mortality was 0.78.This scoring system predicted cancer-specific survival in patients who did not meet the curative criteria after ESD for EGC. ESD without additional treatment may be an acceptable option for patients at low risk.

CONTEXT: No known previous study has focused on plant-based diet (PBD) to prevent relapse of ulcerative colitis (UC) except our previous educational hospitalization study. OBJECTIVE: To describe the relapse rate in a large case series of UC after incorporation of PBD into induction therapy. DESIGN: All patients with UC between 2003 and 2017 were admitted for induction therapy. Patients receiving educational hospitalization or treated with infliximab were excluded. A lacto-ovo-semivegetarian diet (PBD) together with medication prescribed according to UC guidelines was provided during hospitalization. MAIN OUTCOME MEASURES: The primary endpoint was relapse during follow-up. The secondary endpoint was change over time in the plant-based diet score (PBDS), which evaluated adherence to the PBD. RESULTS: Ninety-two cases were studied, of which 51 were initial episodes and 41 were relapses. Cases varied in severity (31 mild, 48 moderate, 13 severe) and extent (15 proctitis, 22 left-sided colitis, 55 extensive colitis). More severe cases existed among the relapse cases than among the initial episode cases. Cumulative relapse rates at 1- and 5-year follow-up (Kaplan-Meier analysis) were 14% and 27%, respectively, for the initial episode cases, and 36% and 53%, respectively, for relapse cases. At long-term follow-up (6 years 4 months), PBDS was significantly higher than baseline PBDS (p < 0.0001). CONCLUSION: Relapse rates in UC after induction therapy with PBD were far lower than those previously reported with conventional therapy. Adherence to PBD was significantly higher than baseline even at 6-year follow-up. We conclude PBD is effective for preventing UC relapse. (Study identification no.: UMIN000019061: Registration: www.umin.ac.jp)

Background: Additional surgery is recommended after noncurative endoscopic submucosal dissection (ESD) for early gastric cancer due to the risk of lymph node metastasis. However, age may affect the clinical management of these patients. Objectives: The aim of our retrospective multicenter study was to clarify whether age affects decision-making after noncurative ESD and if the decision affects long-term outcomes. Methods: Age was classified as follows: non-elderly, n = 811); elderly, 70–79 years (n= 760); and super-elderly, ≥80 years (n = 398). Age associations with the selection for additional surgery were evaluated using logistic regression analysis. Long-term outcomes were also evaluated in each age group. Results: Age was inversely related to the rate of additional surgery, which ranged from 70.0% in the non-elderly group to 20.1% in the super-elderly group (p < 0.001). On multivariate analysis, age p< 0.001), whereas the difference was not significant in the super-elderly group (p = 0.23). Conclusions: Despite the fact that almost 80% of super-elderly patients did not undergo additional surgery, the difference of OS between patients with and without additional surgery was not significant only in patients ≥80 years. Therefore, establishment of criteria for selecting treatment methods after noncurative ESD in elderly patients is required.

Although radical surgery is routinely performed for patients who do not meet the curative criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) due to the risk of lymph node metastasis (LNM), this standard therapeutic option may be excessive given the lower number of patients with LNM. Therefore, we aimed to investigate long-term outcomes and validate risk factors predicting recurrence after ESD. Of 15,785 patients who underwent ESD for EGC at 19 institutions between 2000 and 2011, 1969 patients not meeting the curative criteria were included in this multi-center study. Based on the treatment strategy after ESD, patients were divided into radical surgery (n = 1064) and follow-up (no additional treatment, n = 905) groups. Overall survival (OS) and disease-specific survival (DSS) were significantly higher in the radical surgery group than in the follow-up group (p

Context No known published study has focused on a plant-based diet (PBD) in the treatment of ulcerative colitis (UC). Objective To investigate relapse prevention in UC after consumption of a PBD during educational hospitalization in Japan. Design Prospective study of patients with mild UC or UC in remission who did not need immediate treatment. A PBD and dietary guidance were provided during a two-week hospitalization. Main outcome measures The primary end point was relapse (a flare-up that required more aggressive treatment) during the follow-up period. Kaplan-Meier analysis was used to calculate the cumulative relapse rate. Secondary end points were immediate improvement in symptoms or laboratory data during hospitalization and a chronologic change in the PBD score, which evaluated adherence to the PBD. Results Sixty cases were studied: 29 initial episode cases and 31 relapse cases. Of these, 31 involved proctitis; 7, left-sided colitis; and 22, extensive colitis. Thirty-seven patients were receiving medication; 23 were not. The median age was 34 years; median follow-up was 3 years 6 months. Eight cases relapsed during follow-up. The cumulative relapse rates at 1, 2, 3, 4, and 5 years of follow-up were 2%, 4%, 7%, 19%, and 19%, respectively. Most patients (77%) experienced some improvement such as disappearance or decrease of bloody stool during hospitalization. The short- and long-term PBD scores after the hospitalization were higher than baseline PBD scores. Conclusion Relapse rates after educational hospitalization providing a PBD were far lower than those reported with medication. Educational hospitalization is effective at inducing habitual dietary changes.

There is a lack of data regarding the long-term outcomes of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) without curative resection, and the relationship of these outcomes with hospital volumes remains unclear. This study evaluated long-term outcomes of patients who underwent ESD for EGC without curative resection according to hospital volumes in Japan. This multicenter retrospective study evaluated 1,969 patients who did not meet the criteria of the Japanese Gastric Cancer Association for curative resection between January 2000 and August 2011. Hospitals were classified according to the annual number of ESD procedures: low- and medium-volume group (LMVG), high-volume group (HVG), and very high-volume group (VHVG). Clinicopathological features, overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were compared across groups after a generalized propensity score matching analysis. In 495 pairs of generalized propensity score-matched patients, the 5-year OS, DSS, and RFS rates were 81.5%, 97.9%, and 97.6% for LMVG; 86.9%, 98.2%, and 97.0% for HVG; and 85.4%, 98.5%, and 97.6% for VHVG, respectively. The 5-year DSS and RFS rates did not significantly differ among the three groups. However, 5-year OS was significantly worse in the LMVG than in the HVG and VHVG (P

BACKGROUND Approximately 30% of patients with Crohn disease (CD) are unresponsive to biologics. No previous study has focused on a plant-based diet in an induction phase of CD treatment. OBJECTIVE To investigate the remission rate of infliximab combined with a plant-based diet as first-line (IPF) therapy for CD. METHODS This was a prospective single-group trial conducted at tertiary hospitals. Subjects included consecutive adults with a new diagnosis (n = 26), children with a new diagnosis (n = 11), and relapsing adults (n = 9) with CD who were naive to treatment with biologics. Patients were admitted and administered a standard induction therapy with infliximab (5 mg/kg; 3 infusions at 0, 2, and 6 weeks). Additionally, they received a lacto-ovo-semivegetarian diet. The primary end point was remission, defined as the disappearance of active CD symptoms at week 6. Secondary end points were Crohn Disease Activity Index (CDAI) score, C-reactive protein (CRP) concentration, and mucosal healing. RESULTS Two adults with a new diagnosis were withdrawn from the treatment protocol because of intestinal obstruction. The remission rates by the intention-to-treat and per-protocol analyses were 96% (44/46) and 100% (44/44), respectively. Mean CDAI score (314) on admission decreased to 63 at week 6 (p < 0.0001). Mean CRP level on admission (5.3 mg/dL) decreased to 0.2 (p < 0.0001). Mucosal healing was achieved in 46% (19/41) of cases. CONCLUSION IPF therapy can induce remission in most patients with CD who are naive to biologics regardless of age or whether they have a new diagnosis or relapse.

We have established a risk-scoring system, termed the “eCura system,” for the risk stratification of lymph node metastasis in patients who have received noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to clarify whether this system contributes to the selection of patients requiring radical surgery after ESD. Between 2000 and 2011, 1,969 patients with noncurative ESD for EGC were included in this multicenter study. Depending on the treatment strategy after ESD, we had patients with no additional treatment (n = 905) and those with radical surgery after ESD (n = 1,064). After the application of the eCura system to these patients, cancer recurrence and cancer-specific mortality in each risk category of the system were compared between the two patient groups. Multivariate Cox analysis revealed that in the high-risk category, cancer recurrence was significantly higher (hazard ratio = 3.13, p = 0.024) and cancer-specific mortality tended to be higher (hazard ratio = 2.66, p = 0.063) in patients with no additional treatment than in those with radical surgery after ESD, whereas no significant differences were observed in the intermediate-risk and low-risk categories. In addition, cancer-specific survival in the low-risk category was high in both patient groups (99.6 and 99.7%). A limitation of this study is that it included a small number of cases with undifferentiated-type EGC (292 cases). The eCura system is a useful aid for selecting the appropriate treatment strategy after noncurative ESD for EGC. However, caution is needed when applying this system to patients with undifferentiated-type EGC.

Context Plant-based diets (PBDs) are a healthy alternative to westernized diets. A semivegetarian diet, a PBD, has been shown to prevent a relapse in Crohn disease. However, there is no way to measure adherence to PBDs. Objective To develop a simple way of evaluating adherence to a PBD for Japanese patients with inflammatory bowel disease (IBD). Design PBD scores were assigned according to the frequency of consumption provided on a food-frequency questionnaire, obtained on hospitalization for 159 patients with ulcerative colitis and 70 patients with Crohn disease. Eight items considered to be preventive factors for IBD were scored positively, and 8 items considered to be IBD risk factors were scored negatively. The PBD score was calculated from the sum of plus and minus scores. Higher PBD scores indicated greater adherence to a PBD. The PBD scores were evaluated on hospitalization and 2 years after discharge for 22 patients with Crohn disease whose dietary pattern and prognosis were established. Main outcome measure Plant-Based Diet score. Results The PBD scores differed significantly, in descending order, by dietary type: pro-Japanese diet, mixed type, and pro-westernized diet (Wilcoxon/Kruskal-Wallis test). The PBD scores in the ulcerative colitis and Crohn disease groups were 10.9 ± 9.5 and 8.2 ± 8.2, respectively. For patients with Crohn disease, those with long-term remission and normal C-reactive protein concentration were significantly more likely to have PBD scores of 25 or greater than below 25 (χ2). Conclusion The PBD score is a valid assessment of PBD dietary adherence.

In Japan, Helicobacter pylori eradication has been approved since 2013 for treatment of H pylori-induced chronic gastritis, in an attempt to reduce the prevalence of gastric cancer, a leading cancer in Japan. H pylori infection affects more than 50% of the world's population. H pylori eradication therapy is generally safe. To our knowledge, no case of newly diagnosed ulcerative colitis occurring immediately after H pylori eradication therapy has previously been reported.A 63-year-old man received a diagnosis of chronic gastritis and H pylori infection. In early March 2014, primary H pylori eradication therapy was initiated; lansoprazole, amoxicillin, and clarithromycin were administered for 1 week. Beginning on the fourth day, he had watery diarrhea twice a day. From the 11th day, bloody stools and watery diarrhea increased to 6 times a day. Colonoscopy, performed on the 40th day after termination of drug therapy, revealed diffuse inflammation in the distal aspect of the colon, with histologic findings consistent with ulcerative colitis. He was admitted to the hospital and was provided with a semivegetarian diet and metronidazole. He noticed a gradual decrease in the amount of blood in his feces then a disappearance of the blood. A fecal occult blood test on the 11th hospital day recorded 337 ng/mL. Fecal occult blood test is not indicated during macroscopic bloody stool but is indicated after disappearance of bloody stool. Therefore, he achieved clinical remission by the 11th hospital day. He was in remission on discharge.New onset of ulcerative colitis should be added to a list of adverse events of H pylori eradication therapy.

Appendiceal orifice inflammation (AOI) is observed as skip lesion in distal ulcerative colitis (UC). The endoscopic frequency of AOI is reported to be 7.9% to 76% of distal colitis. UC is a relapsing and remitting disease and a morphological change of the large bowel occurs over time. Patient and physician can easily understand the shape of the whole large bowel not through endoscopic photograph but by roentgenogram of the bowel. Therefore, the authors undertake barium enema study when a diagnosis of UC is made. We have experienced a patient with proctitis in which an appendiceal submucosal tumor (SMT) was suspected on the roentgenogram but it was turned out to be a protruding lesion of AOI. A 16-year-old boy visited us with complaining of blood in his stool for the past 10 days. Sigmoidoscopy revealed mild diffuse inflammation. Crypt abscess was found in biopsy specimen. A diagnosis of UC, proctitis type, was made. A double contrast barium enema study revealed a defect shadow with a smooth surface, length 37 mm, height 12 mm, over the appendix. An appendiceal SMT was suspected. Abdominal ultrasonography and computed tomography were non-contributory. Colonoscopy revealed a spiral inflamed mucosa at the site of an appendiceal orifice. There was an inflammation in the cecum surrounding the orifice. Biopsy specimen of the appendiceal orifice showed inflammatory cells infiltration, goblet cell depletion, and cryptitis. The suspected SMT lesion was concluded to be AOI.

Current chronic diseases are a reflection of the westernized diet that features a decreased consumption of dietary fiber. Indigestible dietary fiber is metabolized by gut bacteria, including Faecalibacterium prausnitzii, to butyrate, which has a critical role in colonic homeostasis owing to a variety of functions. Dietary fiber intake has been significantly inversely associated with the risk of chronic diseases. Crohn disease (CD) is not an exception. However, even authors who reported the inverse association between dietary fiber and a risk of CD made no recommendation of dietary fiber intake to CD patients. Some correspondence was against advocating high fiber intake in CD. We initiated a semivegetarian diet (SVD), namely a lacto-ovo-vegetarian diet, for patients with inflammatory bowel disease. Our SVD contains 32.4 g of dietary fiber in 2000 kcal. There was no untoward effect of the SVD. The remission rate with combined infliximab and SVD for newly diagnosed CD patients was 100%. Maintenance of remission on SVD without scheduled maintenance therapy with biologic drugs was 92% at 2 years. These excellent short- and long-term results can be explained partly by SVD. The fecal bacterial count of F prausnitzii in patients with CD is significantly lower than in healthy controls. Diet reviews recommend plant-based diets to treat and to prevent a variety of chronic diseases. SVD belongs to plant-based diets that inevitably contain considerable amounts of dietary fiber. Our clinical experience and available data provide a rationale to recommend a high fiber intake to treat CD.

There is limited information in the use of antitumor necrosis factor α, infliximab, in patients on hemodialysis. In Crohn’s disease (CD), only 3 cases are reported. A 76-year-old man on hemodialysis for renal failure caused by immunoglobulin A nephropathy developed diarrhea and abdominal pains. A marked edema was observed in the pretibia and ankle. An increase of C-reactive protein (CRP) and erythrocyte sedimentation rate, hypoalbuminemia, hypocholesterolemia, and moderate anemia was found. Ultrasonography and computed tomography (CT) found wall thickness in the left colon. Sigmoidoscopy revealed multiple ulcers in the sigmoid colon and noncaseating epithelioid granuloma was found in the biopsy specimen. Barium enema study exhibited collar button signs and longitudinal ulcers in the left colon. A severe form of CD was diagnosed. Metronidazole seemed to decrease CRP but was ineffective in ameliorating diarrhea. Infliximab rather than steroid hormone was chosen for the treatment. Standard induction therapy with infliximab was initiated. Symptoms rapidly improved then disappeared. CD activity index decreased from 747 to a remission level of 134 after 2 infusions of infliximab. Scheduled maintenance infliximab therapy was administered after the induction therapy. Ultrasonography and CT showed a disappearance of the wall thickness of the colon. Adverse reactions were not observed. Infliximab was effective and safe in a patient with CD on hemodialysis. Our case has added additional literature in accordance with previous reports supporting infliximab as effective and safe in patients on hemodialysis.

A 46-year-old woman with systemic lupus erythematosus (SLE) was admitted owing to a sudden severe back pain. She had been receiving corticosteroids throughout the course of long-standing nephritis, and had a family history of dissecting aortic aneurysm. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations of the chest with intravenous contrast revealed a dissecting aortic aneurysm. Surgical replacement of the aortic arch was performed. The histological findings in the thoracic aorta were compatible with cystic medial necrosis. We report this rare case, and review the literature relating to this complication.

Background To examine the effects of percutaneous endoscopic gastrostomy (PEG) on quality of life (QOL) in patients with dementia. Methods We retrospectively included 53 Japanese community and tertiary hospitals to investigate the relationship between the newly developed PEG and consecutive dementia patients with swallowing difficulty between Jan 1st 2006 and Dec 31st 2008. We set improvements in 1) the level of independent living, 2) pneumonia, 3) peroral intake as outcome measures of QOL and explored the factors associated with these improvements. Results Till October 31st 2010, 1,353 patients with Alzheimer’s dementia (33.1%), vascular dementia (61.7%), dementia with Lewy body disease (2.0%), Pick disease (0.6%) and others were followed-up for a median of 847 days (mean 805 ± 542 days). A total of 509 deaths were observed (mortality 59%) in full-followed patients. After multivariate adjustments, improvement in the level of independent living was observed in milder dementia, or those who can live independently with someone, compared with advanced dementia, characterized by those who need care by someone: Odds Ratio (OR), 3.90, 95% confidence interval (95%CI), 1.59 - 9.39, P = 0.003. Similarly, improvement of peroral intake was noticed in milder dementia: OR, 2.69, 95%CI, 1.17 - 6.17, P = 0.02. Such significant associations were not observed in improvement of pneumonia. Conclusions These results suggest that improvement of QOL after PEG insertion may be expected more in milder dementia than in advanced dementia.

Endoscopic mucosal resection using a cap-fitted panendoscope (EMRC) and an endoscopic submucosal dissection (ESD) are increasingly performed to treat superficial esophageal carcinoma (SEC). As an endoscopic procedure appropriate for en bloc complete resection, ESD requires a much higher level of skill and experience than EMRC. This retrospective study reviewed 127 SECs in 112 patients treated by EMRC or ESD from January 1997 to September 2009. For lesions 10 mm in diameter or smaller, EMRC and ESD had equivalent en bloc resection rates with tumor-free margins (en bloc + R0 resection rates). For lesions 11 mm in diameter or larger, however, the rate was significantly higher in the ESD group than in the EMRC group (p

Vascular endothelial growth factor (VEGF) expression and microvessel parameters have not yet been quantified in the colonic mucosa of ulcerative colitis (UC). The aim of this study was to correlate the parameters with clinical responsiveness to steroid therapy.Colorectal biopsy specimens from 39 UC patients with high sensitivity to steroid (H-UC), 9 UC patients with low sensitivity to steroid (L-UC) and 6 normal controls (NC) were examined.Tissue sections were immunostained with anti-VEGF antibody for number of inflammatory cells (/mm(2)), VEGF-positive cell (/mm(2)) and VEGF-positive ratio (%), and with CD34 for microvessel counts (/mm(2)) and the mean microvessel diameter (microm).The H-UC group had a significantly larger total cell count (10,048+/-2751, p0.0001) or VEGF-positive cells (2363+/-707, p0.0001) than the NC group (7235+/-2088 or 1537+/-297, respectively) with no difference in VEGF-positive ratio (24.3+/-6.9 for H-UC versus 22.7+/-6.9 for NC). The L-UC group had a significantly lower VEGF-positive cell count (1420+/-701, p0.0005) or VEGF-positive ratio (11.6+/-5.5, p0.0005) than the H-UC group, whereas microvessel counts were almost constant regardless of the subject groups (345+/-7 0 for NC versus 346+/-99 for H-UC versus 349+/-114 for L-UC). Significant increases in microvessel diameter were seen when comparing NC (6.68+/-0.60) with H-UC (7.83+/-1.09, p0.0001) and H-UC with L-UC (9.05+/-1.70, p0.03). Out of the five parameters, VEGF-positive ratio and microvessel diameter had a predictive value for L-UC with an 88.9% sensitivity and 88.9% specificity.L-UC was characterized either as VEGF underexpression or enlarged microvessel. The disruption of the healing process or disturbance of microcirculation may be involved in low sensitivity to steroid therapy in UC.

We quantified microvessel morphology and vascular endothelial growth factor (VEGF) expression in human colonic carcinoma with or without metastasis. The cancerous growth and the noncancerous section of surgical specimens from 36 patients with colorectal carcinoma (14 without metastasis and 22 with metastasis) were studied. Tissue slices immunostained with CD34 were processed for microvessel counts (per mm(2)), the mean diameter of microvessels (microm), and the mean spatial direction of microvessels (degree), defined by the angle between the longitudinal axis of microvessels and the direction perpendicular to the surface of the mucosa. Tissue slices immunostained with anti-VEGF antibody were processed for total epithelial cell counts (per mm(2)), VEGF-positive cell counts (per mm(2)), and VEGF-positive ratio (%). Carcinoma without metastasis had significantly larger microvessel counts (213 +/- 77, p0.01), larger microvessel diameter (7.99 +/- 1.77, p0.05), and larger spatial direction (47.2 +/- 8.3, p0.01) than normal tissue (144 +/- 49 for microvessel counts; 7.03 +/- 0.90 for microvessel diameter; 39.5 +/- 6.6 for spatial direction). Compared with carcinoma without metastasis, carcinoma with metastasis had a significantly larger microvessel diameter (9.75 +/- 2.65, p0.03) and lower microvessel counts (180 +/- 92, p = 0.51). Carcinoma without metastasis had a significantly larger VEGF-positive cell count (1276 +/- 805, p0.05) and larger VEGF-positive ratio (53.6 +/- 39.3, p0.05) than normal tissue (571 +/- 553 for VEGF-positive cell counts; 24.6 +/- 23.2 for VEGF-positive ratio). Carcinoma with metastasis had a significantly lower total cell count (1443 +/- 237, p0.001) and lower VEGF-positive cell count (716 +/- 463, p0.05) than carcinoma without metastasis. With tumor progression, microvessel diameter significantly increased and microvessel counts decreased, which can be in part explained by VEGF expression. The microvessel diameter seems to be the dominant parameter responsible for cancer cell intravasation as the first step of metastasis.

AIM: To examine the long term survival of geriatric patients treated with percutaneous endoscopic gastrostomy (PEG) in Japan. METHODS: We retrospectively included 46 Japanese community and tertiary hospitals to investigate 931 consecutive geriatric patients (≥ 65 years old) with swallowing difficulty and newly performed PEG between Jan 1st 2005 and Dec 31st 2008. We set death as an outcome and explored the associations among patient’s characteristics at PEG using log-rank tests and Cox proportional hazard models. RESULTS: Nine hundred and thirty one patients were followed up for a median of 468 d. A total of 502 deaths were observed (mortality 53%). However, 99%, 95%, 88%, 75% and 66% of 931 patients survived more than 7, 30, 60 d, a half year and one year, respectively. In addition, 50% and 25% of the patients survived 753 and 1647 d, respectively. Eight deaths were considered as PEG-related, and were associated with lower serum albumin levels (P = 0.002). On the other hand, among 28 surviving patients (6.5%), PEG was removed. In a multivariate hazard model, older age [hazard ratio (HR), 1.02; 95% confidence interval (CI), 1.00-1.03; P = 0.009], higher C-reactive protein (HR, 1.04; 95% CI: 1.01-1.07; P = 0.005), and higher blood urea nitrogen (HR, 1.01; 95% CI: 1.00-1.02; P = 0.003) were significant poor prognostic factors, whereas higher albumin (HR, 0.67; 95% CI: 0.52-0.85; P = 0.001), female gender (HR, 0.60; 95% CI: 0.48-0.75; P < 0.001) and no previous history of ischemic heart disease (HR, 0.69; 95% CI: 0.54-0.88, P = 0.003) were markedly better prognostic factors. CONCLUSION: These results suggest that more than half of geriatric patients with PEG may survive longer than 2 years. The analysis elucidated prognostic factors.

Background: Colonic surface color on endoscopy is largely determined by hemoglobin content in the colonic tissue, which has been calculated from spectral reflectance of the colonic surface as an index of hemoglobin (IHB). Histological colonic layers, influencing the surface reflectance has, however, still remained undetermined. Aims: The aim of this study was to determine the colonic layers, which influence the surface reflectance and the relative IHB against the total IHB in each colonic layer. Methods: Colonic tissue specimen with a gradation of thickness was constructed by using normal parts of resected colon from 5 patients with colorectal cancer. By using a spectrophotometer, spectral reflectance (410 to 690 nm) was measured at sampling points along a line of interest on the specimen at every 1mm intervals for IHB, which is give by 32Log (r650/r569). r650 and r569 designate reflectance at a wavelength of 650 and 569 nm, respectively. After photometry, the specimen was fixed in 10% formalin and sliced along the line of interest for a thickness of histological layers (micro-meter) in each sampling site. Results: IHB linearly increased to reach plateau as a thickness of the submucosa increased (Table). When a thickness of the submucosa exceeded 400 micro-meter, IHB remained constant, regardless of the presence or absence of deeper layers (propria muscle, subserosa and serosa). A thickness of the mucosa was found to have only least influence on IHB. The relative IHB against the total IHB was less than 45% for the mucosa and the remaining more than 55% for the submucosa. Conclusions: On colonoscopy, surface color was determined exclusively by the mucosa (45%) and submucosa (55%). In spectroscopy, it should be cautious to interpret IHB exclusively as mucosal hemoglobin especially in normal colon.

Background: We have previously demonstrated that the degree of endoscopic surface redness was significantly larger in colonic carcinoma than in normal mucosa. Aim: The aim of this study was to correlate endoscopic redness with histological variables, concerning microvasculature in the tissue of colonic carcinoma and normal mucosa. Methods: Five patients with colorectal carcinoma were studied. They underwent colonoscopy for pictures of the growth and normal appearing parts more than 5 cm apart from the growth. Endoscopic pictures were processed for an index of hemoglobin (IHB) as the degree of surface redness in each region of interest by an image processor. The surgical specimens, sliced were stained with CD34 for vascular counts (/mm 2 ) and the total cross sectional area of vasculature per the unit area of region of interest (%VA). In this study, the spatial direction of longitudinal axis of each vascular canal (θ) was reconstructed from a shape of vascular cross section. When the direction is vertical to the mucosal surface (θ=0 degree), the vessel is recognized as a point on endoscopy. While, when it is parallel to the mucosal surface (θ=90 degree), the vessel is recognized as a line. Results: IHB was significantly larger in colonic carcinoma (37.0± 8.1) than in normal mucosa (29.7±5.8, p=0.049). Vascular counts was large in colonic carcinoma (274±183) compared with that in normal mucosa (203±58), but it did not reach the significant level (p =0.176). %VA also was larger in carcinoma (3.8±2.0) than in normal mucosa (3.1±1.5), although it was not statistically significant (p=0.253). While, θ was significantly larger in carcinoma (52.1±6.7) than in normal mucosa (44.0±5.8, p=0.021). Conclusions: Colonic carcinoma was significantly more red than normal mucosa. A novel histological variable, the spatial arrangement of microvasculature can reasonably account for this difference along with vascular counts and vascular bed area.