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Rib fractures can cause injury to some organs. We herein report a case of hemorrhagic shock due to intercostal artery injury that occurred during initial trauma care (ITC) treated by resuscitative thoracotomy (RT) and transcatheter arterial embolization (TAE) with multiple displaced rib fractures (RFs) and traumatic head injury (THI). A man in his 50s who was injured in a traffic accident was transferred to our institution by helicopter for emergency medical treatment. He underwent left thoracic drainage on site. On admission, he was diagnosed with multiple RF, THI, pelvic fracture and right humerus fracture. His D-dimer and fibrin degradation products (FDP) level were extremely elevated. However, contrast enhance CT (CECT) revealed no extravasation. At 2 h after arrival, massive hemorrhaging from his thoracic tube suddenly occurred and his blood pressure decreased to approximately 40s mmHg. CECT performed after volume resuscitation and massive transfusion revealed extravasation from the intercostal artery. Because his blood pressure could not be maintained by massive transfusion, we performed RT and TAE followed by RT. He then received intensive care and several surgical procedures were performed, including craniotomy for removal of hematoma, rib fixation and humerus fixation. He was transferred to another hospital for rehabilitation on day 63, with a GCS of 15. Hemorrhagic shock due to intercostal artery injury may occur at any time from arrival in cases with displaced RF, especially when complicated by THI., Competing Interests: The authors declare that they have no conflict of interests., (© 2022 The Authors.)

Objectives: We evaluated the preventive effect of low-dose diclofenac (25-50 mg) on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) by propensity score matching analysis., Methods: We retrospectively analyzed the data of 515 patients who underwent ERCP for the first time with or without the rectal administration of low-dose diclofenac before the procedure. For the purpose of minimization of the intrinsic selection bias, we compared the incidence rate of PEP between the diclofenac and control group after propensity score matching., Results: Post-ERCP pancreatitis developed in 15 patients (2.9%). There was no significant difference in the incidence of PEP between the diclofenac (2.4%) and control group (3.3%) (P = 0.608). One hundred ninety matched pairs were generated by propensity score matching and analyzed; however, the incidence rate of PEP was the same in both groups (2.1%, P = 1.000). In the subgroup analysis using data of patients with high-risk factors for developing PEP, the incidence rate of PEP was comparable between the diclofenac (3.8%) and control groups (4.0%) (P = 0.917)., Conclusions: In our propensity score analysis, rectal administration of low-dose diclofenac was not shown to be useful in preventing PEP., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Self-expandable metallic stents (SEMSs) are widely used for malignant biliary stricture (MBS). Acute pancreatitis is an early complication following SEMS placement. In the present case, the patient developed severe acute pancreatitis after SEMS placement for MBS because of metastatic lymph nodes. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and an endoscopic nasobiliary drainage tube placement were performed. After seven days, an uncovered SEMS was placed; however, severe acute pancreatitis occurred, and the SEMS was drawn out emergently. In SEMS placement for patients with MBS caused by non-pancreatic cancer, SEMS should be selected carefully while considering each patient's case.

Background and Objectives: Differential diagnosis to estimate the malignant potential of gastric submucosal tumor (g-SMT) is important for decision-making. This study evaluated the use of a 20G needle with a core trap for EUS-guided fine-needle biopsy (EUS-FNB) for g-SMT., Methods: This multicentric prospective trial was registered in the University Hospital Medical Information Network (UMIN000021410). Consecutive patients with g-SMT who presented at one of the nine Japanese Referral Centers between June 2017 and November 2018 were enrolled. All patients underwent EUS-FNB using a 20G needle with a core trap. Samples obtained with the first-needle pass were used for central pathological review. EUS-FNB was evaluated in terms of (i) technical success rate, (ii) adequacy for histological evaluation, (iii) rate of complications, (iv) accuracy for histological diagnosis of gastrointestinal stromal tumor (GIST), and (v) concordance between GIST mitotic index determined by EUS-FNB and after tumor resection., Results: The study included 52 patients. The technical success rate of EUS-FNB was 100%. The adequacy rate for histological evaluation was 90.4% (P < 0.001). There were no complications related to EUS-FNB. Of the 38/52 patients who underwent surgical resection, 36 were finally diagnosed with GIST. The sensitivity, specificity, and accuracy of EUS-FNB for the histological diagnosis of g-SMT were 80.6%, 100%, and 81.6%, respectively. The concordance rate between the mitotic index on EUS-FNB and that after analysis of the resected tumor was 89.7%., Conclusions: EUS-FNB using a 20G needle with a core trap is feasible, providing histological samples of sufficient quality for diagnosing g-SMT., Competing Interests: None

Objectives: Preoperative grading of pancreatic neuroendocrine tumors (PanNET) is challenging. The aim of this study was to prospectively evaluate the use of a 25-gauge needle with a core trap for diagnosis and grading of PanNET., Methods: This multicenter prospective trial was registered with the University Hospital Medical Information Network (UMIN000021409). Consecutive patients with suspected PanNET between June 2016 and November 2017 were enrolled. All patients underwent endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a 25-gauge needle with a core trap. Samples obtained after the first needle pass were used for central pathological review. EUS-FNB was evaluated in terms of (i) technical success rate, (ii) adequacy for histological evaluation, (iii) complication rate during the procedure, and (iv) concordance between PanNET grading on EUS-FNB and that after analysis of the resected tumor., Results: Fifty-two patients were enrolled. Of the 36/52 patients who underwent surgical resection, 31 were finally diagnosed with PanNET and were eligible for analysis. The technical success rate of EUS-FNB was 100%. The rate of adequacy for histological evaluation was 90.3%. There were no complications related to EUS-FNB. The concordance rate between PanNET grading on EUS-FNB and that after analysis of the resected tumor was 82.6% (95% confidence interval = 61.22-95.05, P = 0.579)., Conclusions: EUS-FNB using a 25-gauge needle with a core trap is feasible, providing histological samples are of sufficient quality for diagnosis and grading of PanNET., Competing Interests: Declaration of competing interest The authors declare no potential competing interests., (Copyright © 2020 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background and Aim: A self-expandable metallic stent (SEMS) is commonly used for biliary stricture caused by pancreatic cancer. Covered SEMS may obstruct the cystic duct, causing acute cholecystitis. This study aimed to determine the outcomes of using a half-covered SEMS with an offset covered portion for preventing cystic duct obstruction., Methods: Among 80 patients with half-covered SEMS placement for the treatment of pancreatic cancer-induced distal biliary stricture, 74 were followed up. The half-covered SEMS has a total length of 6 or 7 cm, and the offset covered part was 0.5-4.5 or 0.5-5.5 cm, respectively. Intraductal ultrasonography (IDUS) and endoscopic nasobiliary drainage (ENBD) were performed during the initial endoscopic retrograde cholangiopancreatography (ERCP). IDUS findings and ENBD tube cholangiogram confirmed the cystic duct confluence. SEMS placement was performed on the second ERCP or several weeks after the initial tube stent placement., Results: Half-covered SEMS placement was successful in all patients. However, four (5.4%) patients exhibited early complications, including acute cholecystitis in one patient and stent displacement in another. Over 30 days, cholangitis, tumor growth, and stent displacement occurred in nine (11.3%), five (6.3%), and two (2.5%) patients, respectively. The median stent patency was 71.1 weeks, and the median overall survival in patients with and without chemotherapy was 31.8 and 12.2 weeks, respectively., Conclusions: With confirmation of the cystic duct confluence, half-covered SEMS placement may become a treatment option for distal biliary stricture caused by pancreatic cancer to prevent acute cholecystitis. Half-covered SEMS patency was comparable with that of covered SEMS., (© 2020 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Objectives: It is important for diagnosing early chronic pancreatitis (CP), which may be improved by therapeutic intervention. We aimed to examine the pancreatic ductal changes on magnetic resonance cholangiopancreatography (MRCP) in patients with early CP defined by the Japanese Diagnostic Criteria., Methods: This retrospective study included patients suspected early CP and performed both endoscopic ultrasonography (EUS) and MRCP from January 2010 to August 2018. We assessed the diameter of the main pancreatic duct (MPD) and the number of irregularly dilated duct branches using MRCP imaging in early CP., Results: We enrolled 165 patients and 25 patients (15%) fulfilled the diagnostic criteria for early CP. Irregular dilatation of ≥ 3 duct branches on MRCP was more often observed in early CP compared to non-early CP (P = 0.004), although MPD diameter was comparable (2.06 mm in early CP vs. 1.96 in non-early CP, P = 0.698). The sensitivity and specificity were 45% and 74%, respectively. The prevalence of positive MRCP findings in patients with ≥ 2 positive EUS findings was higher than that in patients with 1 positive EUS finding (P = 0.08) and in patients without an EUS finding (P < 0.001). There was no difference in the average diameter of MPD., Conclusion: Patients with early CP often exhibit alteration in duct branches and not in MPD in addition to parenchymal alteration. Both pancreatic parenchyma and duct branches might need to be evaluated by EUS and MRCP., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2020 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background/aim: We evaluated urinary levels of porphyrin metabolites, such as uroporphyrin (UP) and coproporphyrin (CP), after 5-Aminolevulinic acid (ALA) administration in patients with or without pancreatic cancer (PaC)., Patients and Methods: Sixty-seven subjects with PaC, 11 with pancreatitis, and 9 with normal pancreas (NP) were enrolled. Urine samples from all subjects were collected prior to ALA administration and at more than 4 hours after ALA administration. We measured the urinary levels of UP and CP by high-performance liquid chromatography analysis., Results: The PaC group showed significantly higher UP levels compared to NP groups (104.9 nmol/g Cre vs. 53.4 nmol/g Cre, p=0.014). Moreover, PaC patients with long-term survival had significantly lower urinary levels of UP at diagnosis (98.8 nmol/gCre) than the short-term survival group (125.2 nmol/gCre) (p=0.042)., Conclusion: The urinary levels of UP after ALA administration might serve as a promising biomarker for diagnosis and prognosis prediction of PaC., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The molecular basis of type 1 autoimmune pancreatitis (AIP) remains unclear. Recent attention on the role of extracellular vesicles microRNA (EV miRNA) in immune homeostasis has prompted us to perform an extensive miRNA screening of serum-derived EV in AIP., Methods: EV miRNA expression was analyzed using microarrays in AIP, chronic pancreatitis (CP), and healthy adult (HC) samples (n = 10 from each group). Differences in signals, > 3 or <1/3 times, represented significant differences in expression. Another cohort of AIP (n = 14), CP (n = 10), and HC (n = 10) samples of EV miRNA was analyzed using reverse-transcription polymerase chain reaction (RT-PCR). miRNA expression in pancreatic tissues was evaluated using in situ hybridization (ISH) in three additional subjects from each group., Results: Signals of eight miRNAs (miR-659-3p, -27a-3p, -99a-5p, -21-5p, -205-5p, -100-5p, -29c-3p, and -125b-1-3p) were significantly higher, while those of two miRNAs (miR-4252 and -5004-5p) were significantly lower in AIP than in HC. EV miR-21-5p was significantly up-regulated in AIP than in HC (P = 0.035) and CP (P = 0.048). The number of miR-21-5p positive inflammatory cells was significantly elevated in AIP than in CP (P = 0.014)., Conclusions: Circulating EVs exhibited altered miRNA expression patterns with elevated miR-21-5p in AIP when compared with those in HC and CP. miR-21-5p was highly expressed in pancreatic inflammatory cells in AIP. Our data suggests that miR-21-5p may be involved in the regulation of effector pathways in the pathophysiology of AIP, thus differentiating AIP from CP., Competing Interests: Declaration of competing interest None., (Copyright © 2020 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Neuroendocrine carcinoma (NEC) in the extrahepatic bile duct is extremely rare and clinically aggressive. Cytological examination of bile and/or bile duct brushing specimens plays an important role in the diagnosis of carcinoma of the extrahepatic bile duct, but only a few articles have described the cytological features of NEC in this area. Thus, we retrospectively analyzed the cytological features of NEC in bile and/or bile duct brushing specimens. Patients with a histopathological diagnosis of NEC who underwent bile and/or bile duct brush cytological examination were enrolled in this study. The cytological features, including the background, arrangement, and shape of the neoplastic cells, and nuclear and cytoplasmic features were reviewed. Six patients with small cell NEC were enrolled, and two of them had pancreatic tumors directly invading the bile duct wall. The cytological specimens showed small and/or large neoplastic cell clusters with occasional single cells in all cases. The neoplastic cells had a high nuclear/cytoplasmic ratio and round-to-oval nuclei with powdery chromatin, inconspicuous nucleoli, and scant cytoplasm. Nuclear molding was a characteristic finding in all cases. One case had an adenocarcinoma component, which was also present in the cytological specimen. Cytological examination of bile and/or bile duct brushing specimens can be useful for the diagnosis of small cell NEC. This is an extremely rare but aggressive carcinoma, and its diagnosis by identifying characteristic cytological features may facilitate early detection and treatment., (© 2019 Wiley Periodicals, Inc.)

The characteristic finding of sausage-shaped pancreas or capsule-like rim facilitates the diagnosis of autoimmune pancreatitis. We herein report a case of a 67-year-old man showing a sausage-shaped, enlarged pancreas with a capsule-like rim on computed tomography. Furthermore, endoscopic retrograde cholangiopancreatography demonstrated diffuse narrowing of the main pancreatic duct, in addition to stenosis of the lower bile duct. Finally, we were able to diagnose pancreatic cancer in this patient by an endoscopic ultrasound-guided fine-needle aspiration biopsy following peroral cholangioscopy and bile cytology. This report emphasizes the significance of pathological confirmation before starting treatment, even in cases with diffuse pancreatic enlargement.

Background: In Asian population, there is limited information on the relevance between obesity and poor outcomes in acute pancreatitis (AP). The objective of this study was to examine the clinical impact of obesity based on body mass index (BMI) on prognosis of AP in Japanese patients., Methods: A total of 116 patients with AP were enrolled in this study. Univariate and multivariate logistic regression analyses were performed to examine relations between BMI and patients' outcomes. Additionally, to investigate whether including obesity as a prognostic factor improved the predictive accuracy of a Japanese prognostic factor score (PF score), a receiver-operating characteristic (ROC) curve analysis of mortality was conducted., Results: Multiple logistic regression analyses revealed that BMI =25 kg/m 2 was associated with a significant higher mortality [odds ratio (OR)=15.8; 95% confidence interval (CI): 1.1-227; P=0.043]. The area under the ROC curve (AUC) for the combination of PF score and BMI =25 kg/m 2 (AUC=0.881; 95% CI: 0.809-0.952) was higher than that for the PF score alone (AUC=0.820; 95% CI: 0.713-0.927) (P=0.034)., Conclusions: The negative impact of a high BMI on the prognosis of AP was confirmed in a Japanese population. Including BMI =25 kg/m 2 as an additional parameter to PF score enhanced the predictive value of the PF score for AP-related mortality., (Copyright © 2017 The Editorial Board of Hepatobiliary & Pancreatic Diseases International. Published by Elsevier B.V. All rights reserved.)

Objectives: The abdominal pain associated with chronic pancreatitis (CP) may be related to the increased number and size of intrapancreatic nerves. On the other hand, patients with type 1 autoimmune pancreatitis (AIP) rarely suffer from the pain syndrome, and there are no previous studies concerning the histopathological findings of intrapancreatic nerves in patients with type 1 AIP. The current study is aimed at investigating the differences in the histopathological and immunohistochemical findings of intrapancreatic nerves in patients with CP and type 1 AIP., Methods: Neuroanatomical differences between CP and type 1 AIP were assessed by immunostaining with a pan-neuronal marker, protein gene product 9.5 (PGP9.5). The number (neural density) and area (neural hypertrophy) of PGP9.5-immunopositive nerves were quantitatively analyzed. Furthermore, the expression of nerve growth factor (NGF), and a high affinity receptor for NGF, tyrosine kinase receptor A (TrkA), was assessed by immunohistochemistry., Results: Both neural density and hypertrophy were significantly greater in pancreatic tissue samples from patients with CP than those with normal pancreas or type 1 AIP. NGF expression was stronger in type 1 AIP than in CP, whereas TrkA expression in type 1 AIP was poorer than in CP., Conclusions: Although CP and type 1 AIP are both characterized by the presence of sustained pancreatic inflammation, they are different in terms of the density and hypertrophy of intrapancreatic nerve fibers. It is possible that this may be related to the difference in the activity of the NGF/TrkA-pathway between the two types of pancreatitis., (Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

In 1995, Yoshida and colleagues proposed the concept of 'autoimmune pancreatitis' (AIP). Recently, it is accepted that the existence of two subtypes of AIP-type 1, which involves immunoglobulin G4 (IgG4) as the pancreatic manifestation of IgG4-related disease (IgG4-RD), and type 2, which is characterized by granulocytic epithelial lesions. Type 2 AIP is thought to be rare in Japan. In 2011, the International Consensus Diagnostic Criteria (ICDC) for autoimmune pancreatitis was proposed. In Japan, the clinical diagnostic criteria of AIP 2011 was proposed by the Japan Pancreas Society (JPS) and the Research Committee of Intractable Diseases of the Pancreas. The JPS 2011 is based on ICDC and a simplified checklist of items to diagnose type 1 AIP. Although recent progress in type 1 AIP has resolved clinical features, diagnosis, treatment, and pathogenesis, many clinical and basic issues still remain unclear. Here, we provide an overview of the recent clinical and basic issues associated with type 1 AIP.

Background: EUS-guided FNA (EUS-FNA) has been increasingly performed to obtain specimens for the pathological evaluation of patients with GI and pancreaticobiliary masses as well as lymphadenopathies of unknown origin. Photodynamic diagnosis by using 5-aminolebulinic acid (ALA) has been reported to be useful for enabling the visual differentiation between malignant and normal tissue in various cancers., Objective: To evaluate the diagnostic accuracy of fluorescence cytology with ALA in EUS-FNA., Design: A prospective study., Setting: A single center., Patients: A total of 28 consecutive patients who underwent EUS-FNA for the pathological diagnosis of a pancreaticobiliary mass lesion or intra-abdominal lymphadenopathy of unknown origin., Interventions: Patients were orally administered ALA 3 to 6 hours before EUS-FNA. The sample was obtained via EUS-FNA for fluorescence cytology and conventional cytology. A single gastroenterologist performed the fluorescence cytology by using fluorescence microscopy after the procedure, independently of the conventional cytology by pathologists., Main Outcome Measurements: The accuracy of fluorescence cytology with ALA in the differentiation between benign and malignant lesions by comparing the results of fluorescence cytology with the final diagnosis., Results: Of the 28 patients included in the study, 22 were considered as having malignant lesions and 6 patients as having benign lesions. Fluorescence cytology could correctly discriminate between benign and malignant lesions in all patients. Therefore, both the sensitivity and specificity of fluorescence cytology were 100% in our study., Limitations: Fluorescence cytology was performed by only 1 gastroenterologist with a small number of patients., Conclusion: Fluorescence cytology with ALA in EUS-FNA may be an effective and simple method for differentiating between benign and malignant lesions., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objectives: Ordinary chronic pancreatitis (CP), such as alcoholic CP, is well established to have the increased risk for pancreatic cancer (PaC), nevertheless an association between autoimmune pancreatitis (AIP) and PaC is still unknown. The aims of this study are to examine the frequency of patients who developed PaC during follow-up after being diagnosed with type 1 AIP and to compare the incidence rate of PaC between patients with type 1 AIP and CP., Methods: Sixty-three patients with type 1 AIP and 41 patients with CP were enrolled. We examined development of PaC during follow-up from their clinical records., Results: The mean follow-up period was 62.4 months in AIP group and 49.2 months in CP group. The occurrence of PaC was observed in 3 patients with AIP during the mean follow-up period of 94.7 months (range, 31-186), whereas a single CP patient developed PaC 38 months after CP diagnosis. The incident rate of PaC during follow-up was comparable between the 2 groups [4.8% (3/63) in type 1 AIP group vs. 2.4% (1/41) in CP group]. In all of 3 AIP patients who developed accompanying PaC, the clinical remission of AIP was achieved with maintenance steroid therapy, when tumors were discovered. In the histological examination of one surgical patient with PaC, lymphoplasmacytic infiltration in storiform fibrosis with abundant IgG4-positive cell infiltration was observed around the PaC area., Conclusions: Similar to patients with ordinary CP, surveillance for development of PaC is needed at regular interval during follow-up in AIP patients., (Copyright © 2014 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: Patients with type 1 autoimmune pancreatitis (AIP) have several immunologic and histologic abnormalities. It is known that depletion of B cells by rituximab is effective for treatment of IgG4-related disease (IgG4-RD) such as type 1 AIP, suggesting that B cells may be a key player in IgG4-RD. However, the role of regulatory B cells (Bregs) in type 1 AIP is unclear, and the objective of this paper is to clarify the role of Bregs in the pathophysiology of type 1 AIP by analyzing circulating Bregs., Method: We recruited 21 patients with type 1 AIP as determined by the International Consensus Diagnostic Criteria for AIP (ICDC). No patients received corticosteroid treatments. For comparison, we recruited 14 patients with chronic pancreatitis (CP), 20 patients with pancreatic cancer, and 25 healthy subjects as controls. We analyzed Bregs as CD19+ CD24high CD38high and CD19+ CD24high CD27+ from peripheral blood by flow cytometry., Results: In peripheral blood, CD19+ CD24high CD38high Bregs were significantly increased in type 1 AIP patients compared with CP, pancreatic cancer, and healthy controls. Although not significant different, CD19+ CD24high CD27+ Bregs of type 1 AIP were decreased compared to those of other groups. IL-10(+) B cells were not significantly different from type 1 AIP patients and healthy controls. In untreated type 1 AIP patients, the number of CD19+ CD24high CD38high Bregs and IgG4 were not correlated., Conclusions: Our data suggested that CD19+ CD24high CD38high Bregs seemed to increase reactively to suppress the disease activity, and are consistent with the hypothesis that CD19+ CD24high CD27+ Bregs might be involved in the development of type 1 AIP, although it still remains unclear whether the decrease of CD19+ CD24high CD27+ cells is cause or effect of AIP., (Copyright © 2014 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)-related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP-related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB-ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB-ERCP and provide several tips for insuring a successful procedure., (© 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy and to cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction., (© 2013 The Authors. Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society.)

Endoscopic retrograde cholangiopancreatography (ERCP) using a double-balloon enteroscope (DBE) in patients with bowel reconstruction due to a previous abdominal surgery is now widely accepted. In particular, a short DBE, which has a 2.8-mm working channel and 152-cm working length, is useful for ERCP because of its good rotational and straightening ability and the availability of various conventional ERCP accessories through the working channel. Herein we report a case of intrahepatic cholangiocarcinoma via ERCP with a short DBE. This is the first report in which the pre-cutting and the brush cytological examination were performed successfully under a DBE to diagnose intrahepatic cholangiocarcinoma pathologically. The short DBE allowed us to perform all diagnostic and therapeutic procedures accepted in conventional ERCP in patients with surgically altered anatomies.

Background: Among many diagnostic criteria for autoimmune pancreatitis (AIP), the International Consensus Diagnostic Criteria (ICDC) first enabled us to diagnose and compare type 1 and type 2 AIP, which permitted tailoring individual diagnostic algorithms depending on local expertise. We compared them and validated ICDC with special reference to levels 1 and 2, and proposed a diagnostic algorithm for AIP in Japan., Methods: The diagnostic sensitivity of 5 major criteria (ICDC, Korean, Japanese-2011, Asian, and HISORt criteria) was compared, using 61 patients with AIP. Fifty six patients with pancreatic cancer served as a control. Pancreas imaging on computed tomography (CT) and endoscopic retrograde pancreatography (ERP) were independently evaluated by 3 pancreatologists (5, 10, and 20 years of career experience) and each diagnostic criterion of ICDC was validated with special reference to levels 1 and 2., Results: The sensitivities of 5 major criteria were 95.1% (ICDC), 90.2% (Korean), 86.9% (Japanese), 83.6% (Asian), and 83.6% (HISORt) with 100% of specificity in each. In the evaluation of pancreas imaging, diagnostic sensitivities of combination with CT and ERP in segmental/focal type AIP were significantly higher than single imaging (26% in CT (P < 0.01) or 35% in ERP (P < 0.05) vs 63% in CT + ERP), but not significantly different in the diffuse type., Conclusions: Of the 5 criteria, ICDC is the most sensitive and useful for diagnosing AIP. We have proposed a diagnostic algorithm with CT for the diffuse type of AIP, and combination with CT + ERP followed by EUS-FNA for the segmental/focal type., (Copyright © 2013 IAP and EPC. All rights reserved.)

In June 2008, a 74-year-old male was diagnosed with IgG4-related disease including histologically proven IgG4-related prostatitis, and then followed as an outpatient. In July 2011, cervical, chest, and abdominal computed tomography (CT) revealed right parotid gland swelling and lymph node enlargement of the supraclavicular, mediastinal, left hilar, porta hepatis, and para-aorta. A biopsy of the right parotid gland was performed, and we diagnosed diffuse large B-cell lymphoma (DLBCL). As malignancies are possible complications for patients with IgG4-related disease, we must be careful in the follow-up of IgG4-related disease patients.

Recent studies suggested the existence of two subtypes of autoimmune pancreatitis (AIP): type 1 related with IgG4 (lymphoplasmacytic sclerosing pancreatitis; LPSP) and type 2 related with a granulocytic epithelial lesion (idiopathic duct-centric chronic pancreatitis; IDCP). Apart from type 2 AIP, the pathological features of type 1 AIP with increased serum IgG4/IgE levels, abundant infiltration of IgG4+ plasmacytes and lymphocytes, fibrosis, and steroid responsiveness are suggestive of abnormal immunity such as allergy or autoimmunity. Moreover, the patients with type 1 AIP often have extrapancreatic lesions such as sclerosing cholangitis, sclerosing sialadenitis, or retroperitoneal fibrosis showing similar pathological features. Based on these findings, many synonyms have been proposed for these conditions, such as "multifocal idiopathic fibrosclerosis", "IgG4-related autoimmune disease", "IgG4-related sclerosing disease", "IgG4-related plasmacytic disease", and "IgG4-related multiorgan lymphoproliferative syndrome", all of which may refer to the same conditions. Therefore, the Japanese Research Committee for "Systemic IgG4-related Sclerosing Disease" proposed a disease concept and clinical diagnostic criteria based on the concept of multifocal fibrosclerosis in 2009, in which the term "IgG4-related disease" was appointed as a minimal consensus on these conditions. Although the significance of IgG4 in the development of "IgG4-related disease" remains unclear, we have proposed a hypothesis for the development of type 1 AIP, one of the IgG4-related disease. The concept and diagnostic criteria of "IgG4-related disease" will be changed in accordance with future studies.

ALTHOUGH THE PATHOGENESIS OF AUTOIMMUNE PANCREATITIS REMAINS UNCLEAR, THIS REPORT PRESENTS RECENT EVIDENCE OF THE CLINICAL ASPECTS OF THIS DISEASE: mild abdominal symptoms, usually without acute attacks of pancreatitis; occasional presence of obstructive jaundice; elevated levels of serum gammaglobulin, immunoglobulin (Ig)G, or IgG4; presence of autoantibodies; diffuse enlargement of the pancreas; irregular narrowing of the pancreatic duct (sclerosing pancreatitis), often with intrapancreatic biliary stenosis or coexisting biliary lesions (sclerosing cholangitis similar to primary sclerosing cholangitis) seen on endoscopic retrograde cholangiopancreatography; fibrotic changes with lymphocyte and IgG4-positive plasmacyte infiltration and obliterative phlebitis; occasional association with other systemic lesions (such as sialadenitis), retroperitoneal fibrosis, and interstitial renal tubular disorders; and response to steroid therapy. Based upon these findings, several sets of diagnostic criteria have been proposed. Further studies and international consensus for diagnostic criteria and pathogenetic mechanisms are needed.

Background/aims: Our previous studies demonstrated enhanced neutrophil chemotaxis in bile duct-ligated, obstructive jaundice rats. In the present study, we produced a reversible obstructive jaundice model in rats. The efficacy of the present model in producing sufficient bile flow blockade and subsequent internal biliary drainage was assessed. Furthermore, the effect of internal biliary drainage on neutrophil chemotaxis was evaluated., Methodology: Bile duct was obstructed with a polyester tape attached with a stainless steel coil. Internal biliary drainage was performed by removing the tape. Rats were subjected to either 10 days' bile duct obstruction or 4 days' bile duct obstruction followed by 6 days' internal biliary drainage. Some animals underwent conventional bile duct ligation and dissection for 4 or 10 days. Neutrophil chemotaxis was evaluated with a modified Boyden method using interleukin-8 (recombinant rat Gro-beta) as chemoattractant., Results: The present technique produced sufficient obstructive jaundice as evidenced by increases in serum alanine aminotransferase and total bilirubin throughout the observation period, the values of which were insignificant with those induced by the conventional method. Internal biliary drainage effectively normalized these values. Similarly, neutrophil chemotaxis was enhanced with both procedures, and increased neutrophil chemotaxis was significantly decreased after drainage., Conclusions: The present reversible obstructive jaundice method is as efficacious as the conventional method for producing obstructive jaundice, and internal biliary drainage could be readily available. With the present model, neutrophil overactivity in obstructive jaundice was effectively alleviated by internal biliary drainage. The result may support the role of preoperative biliary drainage in the prevention of postoperative septic complications.

Background: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography., Methods: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge., Results: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully., Conclusions: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.

Background/aims: Raised biliary pressure may affect antibiotic biliary excretion. We evaluated whether biliary decompression for patients with biliary obstruction could improve antibiotic biliary excretion., Methodology: Eight patients with common bile duct obstruction undergoing endoscopic nasobiliary drainage were evaluated. During endoscopic cannulation, biliary pressure above the obstruction and antibiotic concentrations in the bile and peripheral blood were determined 60 min after the intravenous antibiotic (panipenem) administration., Results: Biliary pressure was initially elevated above normal in all the patients, but normalized after biliary drainage for 5 to 7 days. At the initial endoscopic retrograde cholangiopancreatography, the aspirated bile contained low or undetectable levels of the antibiotic, but the mean bile panipenem concentration and the mean bile/plasma ratio of panipenem concentrations significantly improved after biliary decompression., Conclusions: The results suggest an important role of biliary pressure in determining antibiotic transfer into the bile.

So-called "ampulla" cardiomyopathy is characterized by transient abnormal left ventricular wall motion showing hypokinesia around the apical area and hyperkinesia at the basal area, without any detectable coronary lesion. We recently treated a patient with "ampulla" cardiomyopathy (Case 1) and a patient with acute myocardial infarction showing similar abnormal left ventricular wall motion (Case 2). A 75-year-old female (Case 1) presented with "ampulla" cardiomyopathy without coronary lesion. Vasospasm was induced at segment 8 on the left anterior descending (LAD) coronary artery by intracoronary administration of acetylcholine. A 58-year-old male (Case 2) presented with acute myocardial infarction due to occlusion at segment 8 and underwent successful coronary reperfusion therapy by direct percutaneous transluminal coronary angioplasty. Both Case 1 and Case 2 revelaed similar abnormal left ventricular wall motion, with hypokinesia around the apical area and hyperkinesia at the basal area by echocardiography, in the acute phase. Furthermore, these two patients showed elevated ST segment at both anterior and inferior leads by electrocardiography, and markedly reduced uptake of beta-methyl-p-iodophenyl-pentadecanoic acid around the apical area in the acute phase by scintigraphy. Interestingly, the LAD perfused a relatively wide area including the anterior, apical and part of the inferior area of the left ventricle in both patients by coronary angiography. The abnormal wall motion of Case 1 disappeared 4 weeks after onset, but that of Case 2 did not disappear. Although the diagnoses of Case 1 and Case 2 were different, abnormal wall motion of these cases might be due to myocardial ischemia due to distal LAD lesion. "Ampulla" cardiomyopathy might develop from transient myocardial ischemia induced by coronary vasospasm at the distal LAD which perfuses a relatively wide area.