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Spontaneous retroperitoneal hematoma is rare and can cause duodenal obstruction. We report four cases of spontaneous retroperitoneal hematoma with duodenal obstruction, wherein endoscopic ultrasound was useful for diagnosis. The patients complained of vomiting with stable vital signs. Computed tomography, esophagogastroduodenoscopy, and endoscopic ultrasound findings were similar in all cases. Contrast-enhanced computed tomography revealed a low-density mass around the 2nd to 3rd part of the duodenum. Esophagogastroduodenoscopy showed an edematous, reddish, but non-neoplastic duodenal mucosa with stenosis of the lumen. Endoscopic ultrasound revealed a low-echoic mass around the duodenum and high-echoic floating matter suggesting debris and anechoic areas that indicated a liquid component. These findings suggested hematomas or abscesses. Although pseudoaneurysm of the pancreaticoduodenal artery was suspected in Case 3, we chose conservative treatment because the aneurysm was small. In Case 4, median arcuate ligament syndrome was suspected on angiography. No aneurysms or arteriovenous malformations were found; thus, endovascular embolization was not performed. The patients were treated conservatively and discharged within 3–5 weeks. English literature queries on spontaneous retroperitoneal hematoma with duodenal obstruction in MEDLINE revealed 21 cases in 18 studies. The clinical features of these patients and the present four cases have been discussed.

Background The role of computed tomography (CT) in the initial diagnosis of pancreatic cancer (PC) is well-known. CT reports made by radiologists are important as not all patients with PC are examined by specialists; however, some cases are not identified based on CT reports. Diagnosis via imaging of PC is sometimes difficult, and the diagnostic rate of PC and other pancreatic diseases can vary across radiologists. This study examined the diagnostic rate of PC in initial CT reports and the details of cases with diagnostic difficulties. Methods Clinical data of 198 patients with histologically diagnosed PC were retrospectively collected between January 2018 and April 2022. Out of these contrast-enhanced CT was performed in 192 cases (124 men and 68 women) and these cases were examined. Results In the reports, PC was not reported as the main diagnosis in 18 patients (9.4%; 11 men and 7 women; mean age, 69.7 years). Among these 18 cases, intrapancreatic mass lesions were detected in 3 (1.6%), indirect findings such as bile duct/pancreatic duct stenosis or dilation were detected in 5 (2.6%), and no PC-related findings were found in 10 (5.2%). The specialists suspected PC in 15 of these 18 cases based on initial CT reports. Seventeen cases were confirmed by endoscopic ultrasound-fine needle aspiration (EUS-FNA) and one by biopsy after upper gastrointestinal endoscopy. Conclusions To improve accuracy of the diagnosis of the PC, it is important that specialists provide feedback to diagnostic radiologists regarding the findings they did not report. Additionally, non-specialists should be aware of the importance to seek the advice of specialists when such indirect findings or any kind of pancreatic mass are present. EUS-FNA should be performed by specialists when there is clinical information which indicates pancreatic disease of any kind.

Cartilage in the head of sturgeon or salmon has been gaining attention as a rich source of functional chondroitin sulfate (CS) or proteoglycans. Although the cartilage was found in the heads of other bony fishes, the structure of CS and its core protein, especially aggrecan, was not fully investigated. In this study, comprehensive analysis of CS and aggrecan in the head cartilage of 10 bony fishes including sturgeon and salmon was performed. The 4-O-sulfation to 6-O-sulfation ratio (4S/6S ratio; S: sulfate residue) of CS in Perciformes was ≧1.0, while the 4S/6S ratios of CS from sturgeons and salmon were less than 0.5. Dot blotting and proteomic analysis revealed that aggrecan was a major core protein in head cartilage of all bony fishes. These results suggest that the head cartilage of bony fishes is a promising source for the preparation of CS or proteoglycans as a health food ingredient.

Campylobacter jejuni is common cause of enteritis, but biliary infection rarely reported. An 82-year-old woman with pancreatic head cancer underwent endoscopic biliary drainage for malignant biliary obstruction. She was subsequently admitted for management of diarrhea. C. jejuni was identified in stool culture. Her symptoms resolved temporarily without antibiotics but flared up with a fever a few days later. She was diagnosed with acute cholangitis and bacteremia with C. jejuni. Endoscopic biliary drainage and antimicrobial administration improved her symptoms. As complications of C. jejuni diarrhea are rare, antibiotics are not necessarily indicated but sometimes are needed to prevent complications.

Endoscopic papillary balloon dilation (EPBD)—a low-risk procedure for bleeding—has been suggested as an alternative to endoscopic sphincterotomy (EST) for papillary dilatation in patients undergoing choledocholithotomy and at a high risk of bleeding. Several guidelines recommend dual antiplatelet therapy (DAPT) be reduced to single antiplatelet therapy (SAPT) when EST is performed. However, there is no evidence that EPBD increases the risk of bleeding in patients receiving DAPT. Thus, we aimed to address this problem. We included 31 patients who underwent EPBD for CBD stones and received DAPT or SAPT prior to EPBD (9 in the DAPT group and 22 in the SAPT group) treated at our hospital from May 2014 to August 2022. The DAPT group included patients who underwent EPBD without antiplatelet therapy withdrawal or with a shorter withdrawal period than those recommended by the guidelines. In the DAPT group, one of the two antiplatelet agents used was thienopyridine. No bleeding was observed after EPBD in this study. We did not find any significant between-group differences in the change in hemoglobin levels and post-ERCP pancreatitis. Thus, we propose that EPBD does not increase the bleedingrisk in patients with DAPT.

To prevent the increase of resistant bacteria, it is important to minimize the use of antimicrobial agents. Studies have found that administration for ≤3 days after successful endoscopic retrograde cholangiopancreatography (ERCP) is appropriate. Therefore, the present study aimed to verify if administration of antimicrobial agents can be further shortened to ≤2 days after ERCP. We divided 390 patients with mild and moderate cholangitis who underwent technically successful ERCP from January 2018 to June 2020 and had positive blood or bile cultures into two groups: antibiotic therapy within two days of ERCP (short-course therapy, SCT; n = 59, 15.1%), and for >3 days (long-course therapy, LCT; n = 331, 84.9%). The increased severity after admission and other outcomes were compared between the two groups, and the risk factors for increased severity were verified. There were no between-group differences in patient characteristics. Total length of hospital stay was shorter in SCT than in LCT, and other outcomes in SCT were not significantly different from those in LCT. Being 80 or older was a risk factor for increased severity; however, SCT was not associated with increased severity. Antimicrobial therapy for ≤2 days after successful ERCP is adequate in patients with mild and moderate acute cholangitis.

Background: Acute esophageal mucosal lesions (AEMLs) cause circumferential mucosal damage in the lower esophagus in patients with deteriorating general health. However, its etiology remains unclear. AEML is often diagnosed and treated as severe reflux esophagitis (sRE), particularly that of Los Angeles classification grade D (sRE-D). This study aimed to determine whether it is appropriate to classify these two diseases according to the characteristics of the proximal mucosa of erosion as previously reported, and to clarify the clinical features of AEML in comparison with sRE-D.Methods: Patients were classified into AEML and sRE-D groups, based on previous reports. Patient background, presence of shock, medical history, medications, comorbidities, death during hospitalization, blood sampling data, endoscopic findings, and presence of stenosis after treatment were evaluated.Results: There were significantly more cases with comorbidities in the AEML group than in the sRE-D group, particularly comorbidities involving infectious diseases. In addition, abnormalities in blood test results were significantly more frequent in the AEML group than in the sRE-D group. This suggests that the onset of AEML may be due to peripheral circulatory disturbance caused by worsening general condition.Conclusions: AEML and sRE-D showed distinctly different features and it was considered reasonable to distinguish them. AEML, unlike sRE-D, may be caused by microcirculatory disturbances related to comorbidities rather than gastric acid reflux. However, it is under-recognized and should be considered in the setting of upper gastrointestinal bleeding in patients with deteriorating general condition.

Campylobacter jejuni is common cause of enteritis, but biliary infection rarely reported. An 82-year-old woman with pancreatic head cancer underwent endoscopic biliary drainage for malignant biliary obstruction. She was subsequently admitted for management of diarrhea. C. jejuni was identified in stool culture. Her symptoms resolved temporarily without antibiotics but flared up with a fever a few days later. She was diagnosed with acute cholangitis and bacteremia with C. jejuni. Endoscopic biliary drainage and antimicrobial administration improved her symptoms. As complications of C. jejuni diarrhea are rare, antibiotics are not necessarily indicated but sometimes are needed to prevent complications.

The musculocutaneous nerve innervates the brachial flexors; i.e., the coracobrachialis, biceps brachii, and brachialis. The musculocutaneous and median nerve sometimes share a communicating branch and also muscular branches to brachial flexors are sometimes transposed to median nerve. Because these variations constitute a potentially important clinical and surgical issue, we evaluated 130 upper limbs of 65 cadavers and 184 cases of musculocutaneous and median nerve variations in the literature and devised a novel system of classification that covers each pattern of variation. Our proposed classification was applicable in all of our cases and those previously reported. In addition, transposed innervation of the brachial flexors from the musculocutaneous nerve to the communicating branches was observed in one limb in our case series. In this case and all previously reported cases of transposed innervation of the brachial flexors, communicating branches between the musculocutaneous and median nerve were found and no brachial flexor branch arose from the musculocutaneous nerve distal to the communicating branches. Consequently, we established that, as per our novel classification, all patterns of communicating branches could be classified into five types and the patterns of transposed innervation of the brachial flexors into three types.