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Human diplogonoporiasis caused by the tapeworm Diplogonoporus balaenopterae has been rarely reported in Japan in the last decade. A 38-year-old man complained of a fever, diarrhea, intermittent abdominal pain, and worm excretion. He had a history of consuming raw juvenile Japanese anchovy one month earlier. On admission, the patient had acute enteritis and received intravenous fluids. During hospitalization, he excreted a white worm in his stool. On a macroscopic examination, the worm was found to be a tapeworm with scolexes. His health improved spontaneously without taking anthelmintic agents. Based on the genetic analysis, the tapeworm was identified as Diplogonoporus balaenopterae.

Post-ERCP pancreatitis (PEP) after self-expandable metallic stent (SEMS) insertion across the papilla of Vater is an important adverse event that affects the patient's quality of life (QOL). We examined the predictive factors of PEP after SEMS insertion to treat obstructive jaundice due to malignancy.Ninety patients who underwent biliary SEMS insertion for biliary obstruction due to malignancy at Iwata City Hospital between 2010 and 2018 were reviewed. We evaluated the relationship between the incidence of PEP after biliary SEMS insertion and clinical factors. We measured the thickness of the pancreatic parenchyma and diameter of the main pancreatic duct (MPD) at the left side of the corpus vertebrae.Mild and severe PEP were diagnosed in 10 (11.1%) and 1 (1.1%) patients, respectively. Only the thickness of the pancreatic parenchyma and diameter of MPD significantly differed between the PEP and non-PEP groups. The incidence of PEP among patients whose thickness of the pancreatic parenchyma at the left side of the corpus vertebrae was less than 9.5 mm (0%) on computed tomography was lower than that in patients whose thickness was 9.5 mm or greater (34.4%). Similarly, a wider (5 mm or more) diameter of MPD (4.3%) reduced the incidence of PEP compared with a narrower diameter (40.0%). Logistic regression analysis revealed that the probability of PEP decreases 3.91 times for every 1-mm increase in MPD diameter (95% CI 1.23-12.4,Based on our study, a dilated MPD is a negative predictive factor of pancreatitis related to biliary SEMS insertion.

A 37-year-old woman exhibited abnormal liver enzyme levels without any symptoms at a medical check-up. She was born and raised in Hubei, China, and had immigrated to Japan in her mid-thirties. Ultrasonography revealed an enlarged caudate lobe of the liver and a wide moniliform portal vein, whereas computed tomography revealed lined calcification on the surface of the liver and on the collateral vein of the portal vein. Although imaging studies provided no critical findings, the crucial information that led to diagnosis was gained through the interview with the patient. Schistosomiasis japonica was known to be prevalent in her hometown, and she reported that her father's past infection was due to Schistosoma japonicum. Serological analysis demonstrated high levels of anti-S. japonicum antibodies, which were reduced using praziquantel administration.

OBJECTIVE Slow responders to pegylated interferon (Peg-IFN) and ribavirin (RBV) among patients infected with hepatitis C virus (HCV) genotype 1 may benefit from an extended treatment course. The aim of this study was to determine the efficacy of persistent negative serum HCV RNA over 96 weeks during long-term Peg-IFN monotherapy following 72 weeks of combination therapy. METHODS A total of 46 HCV genotype 1-infected slow responders were treated for 72 weeks with Peg-IFN and RBV combination therapy alone (n=25) or additional long-term biweekly treatment with 90 μg of Peg-IFN-α2a (n=21). The criterion for the completion of long-term Peg-IFN monotherapy was defined as the attainment of constantly negative HCV RNA in the serum over 96 weeks during IFN treatment. RESULTS The patients with sustained negative serum HCV RNA during 96 weeks of IFN treatment had a higher rate of sustained virological response (SVR) than those without (81 vs. 40%, p=0.012). A multivariate analysis identified sustained negativity of serum HCV RNA over 96 weeks of IFN treatment to be a predictive factor for SVR. CONCLUSION In the present study, sustained negative serum HCV RNA over 96 weeks during long-term Peg-IFN monotherapy following 72 weeks of combination therapy of Peg-IFN and RBV resulted in beneficial virological outcomes among HCV genotype 1-infected slow responders.

An asymptomatic pancreatic tumor was discovered in a 77-year-old man during a medical check-up. An abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed a cystic mass containing a septum-like solid portion in the head of the pancreas, measuring 3.5cm in diameter. Additionally, abdominal contrast-enhanced ultrasonography (US) revealed increased flow in the solid portion and a tumor capsule in its early phase. We preoperatively diagnosed the lesion as a cystic-degenerated pancreatic neuroendocrine tumor or solid-pseudopapillary tumor and performed a pancreatoduodenectomy. Histopathological examination revealed a cystic pancreatic mass consisting of spindle-shaped cells, with S-100-positive and SMA-negative immunohistochemical stainings. This lesion was diagnosed as a pancreatic schwannoma from these findings.

A 46-year-old female patient was referred to our hospital for endoscopic treatment of stenotic pancreatogastrostomy. She had undergone pylorus-preserving pancreatoduodenectomy due to duodenal carcinoma of the papilla of Vater 5 years before referral. Two years after the operation, she had to be hospitalized several times during a 1-year period because of acute recurrent pancreatitis caused by stenosis of the anastomosis of the pancreatoduodenostomy. An endoscopic ultrasound (EUS)-guided rendezvous technique was selected to puncture the main pancreatic duct via a transgastric approach. We identified the dilated main pancreatic duct with a convex array echoendoscope from the lower gastric body near the anastomosis and successfully punctured the dilated main pancreatic duct. The guidewire passed through the stenosis to the gastric cavity and we could place a stent through the stenotic anastomosis. After the procedure, the patient has not experienced acute recurrent pancreatitis for 9 months. Pancreatogastrostomy has been the preferred method used to carry out post-pancreatoduodenectomy reconstruction. However, stenosis of the anastomosis has been reported as one of the late complications of pancreatogastrostomy. The main symptom of this complication is recurrent epigastralgia due to obstructive pancreatitis. As a result, patients are compelled to stay in the hospital for an extended duration with no oral intake allowed. Surgical resection of the stenosis is often the treatment of choice but can be troublesome due to post-operative adhesions. Here, we report a case of pancreatogastrostomy complicated by stenosis, which was treated using the EUS-guided rendezvous technique.

症例は66歳男性. 上腹部痛および背部痛を主訴に当院を受診し, 肝胆道系酵素および膵酵素の上昇がみられ, 同日入院した. 腹部超音波検査では主膵管拡張と膵頭部に内部に点状高エコーが散在し, 後方エコーの増強を伴う低エコーの腫瘤が認められた. ERCPでは拡張した主膵管内に粘液がみられたが, 経口膵管鏡検査ではイクラ状隆起などは認められなかった. 腹部造影CT検査では膵頭部の腫瘤内の一部が淡く造影され, 腹部MRI検査のT2強調画像で強い高信号とやや高信号を呈した. 以上より, 分枝型の膵管内乳頭粘液性腫瘍由来で粘液癌の形態を呈した浸潤癌と診断し, 膵頭十二指腸切除術を施行した. 腫瘤の主体は粘液癌の形態であり, 隔壁様の間質には血管が認められ, 膵管内乳頭粘液性腫瘍由来の浸潤癌であった.

We describe a case of varicella pneumonia in a 24-year-old healthy man presenting with severe respiratory failure. A chest radiograph showed diffuse, bilateral airspace consolidation; additional complications included liver dysfunction and thrombocytopenia. However, treatment with intravenous acyclovir and gamma-globulin improved his clinical symptoms and signs. A greater than four-fold change in paired titers of the varicella-zoster virus antibody was observed. Bronchoalveolar lavage performed during the recovery phase revealed increased total cell and lymphocyte counts and a decreased CD4:CD8 ratio of T lymphocytes. Transbronchial lung biopsy findings were compatible with a diagnosis of interstitial pneumonia.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients after Billroth II or Roux-en-Y reconstruction is challenging because of difficulties in insertion of the endoscope into the afferent loop, which is a great distance away from the papilla of Vater, and cannulation into the desired duct from a reverse position. To facilitate ERCP, various endoscopes have been selected according to operator preference. Previously, we reported that an oblique-viewing endoscope (XK-200; Olympus, Tokyo, Japan) can contribute to successful performance of ERCP and associated procedures in Billroth II gastrectomy patients. We report here our experience with two post-gastrectomy patients with chronic pancreatitis who were treated with an oblique-viewing endoscope from the minor papilla.

A 34-year-old woman was admitted because of severe liver dysfunction due to excessive alcohol intake. Liver biopsy performed on the fifth day showed liver tissue with marked granulocyte infiltration and pericellular fibrosis. As there were no improvements in white blood cell count and serum total bilirubin levels despite the use of corticosteroids and plasma exchange, hemodiafiltration, we performed granulocytapheresis (GCAP). Peripheral white blood cells decreased from just after GCAP. Her condition remained stable and she was discharged on the 54th day. We suggest that GCAP can be recommended as an effective therapy for severe alcoholic hepatitis.

Background: We report that an oblique-viewing endoscope facilitates endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II reconstruction. With this endoscope, we carried out ERCP in Roux-en-Y reconstruction. Methods: Fifteen patients with Roux-en-Y reconstruction were enrolled. Eleven of these patients had undergone gastrectomy, while Whipple's operation or choledochectomy had each been carried out in two patients. Among the 11 post-gastrectomy patients, eight had bile duct stones, and there was one case each of pancreatic abscess with chronic pancreatitis, bile duct obstruction due to gallbladder, or pancreatic cancer. The remaining four patients suffered from stenotic anastomosis of choledochojejunostomy. All procedures were carried out with an oblique-viewing endoscope. Results: The papilla of Vater or anastomosis was reached in 10 patients. In these 10 patients, all planned procedures were completed. Endoscopic papillary balloon dilatation (EPBD) was carried out in three patients with bile duct stones. The remaining three patients with bile duct stones underwent sphincterotomy with tube stent placement, EPBD after sphincterotomy with biliary tube stent placement, and biliary tube stent placement, respectively. Pancreatic stent placement via the minor papilla was carried out in one patient with pancreatic abscess, and a biliary tube stent was introduced in the patient with gallbladder cancer. Two patients underwent cutting of a stenotic anastomosis with a needle knife, followed by balloon dilatation. None of the patients experienced any complications. Conclusion: The results appear to support the feasibility of using an oblique-viewing endoscope for ERCP in Roux-en-Y reconstruction. Further studies including a large population of patients should be planned to confirm these results.

Background Marked duodenal stenosis makes endoscopic biliary stenting (EBS) impossible, although it is the most common method for treating obstructive jaundice in patients with benign or malignant biliary strictures. Large-balloon dilation can be used to enable endoscope passage in the GI tract. Objective We describe 4 cases of successful EBS combined with the use of a large balloon for the treatment of difficult duodenal strictures in patients with benign and malignant biliary strictures. Design A retrospective case series. Setting Two tertiary referral centers. Patients Four patients: 1 with hilar carcinoma, 1 with gallbladder carcinoma, and 2 with chronic pancreatitis. Interventions After duodenal dilation, the slightly deflated balloon was pushed with the endoscope into the major papilla through the duodenal stricture (pushing method used in 2 patients). In the cases in which the major papilla was not accessible with the pushing method, a large dilation balloon was deflated completely after dilation, advanced beyond the stricture into the third portion of the duodenum, and reinflated to the maximum size. Pulling the dilation balloon catheter into the working channel while hooking the inflated balloon as the anchor at the anal side of the duodenal stricture, the endoscope was straightened to advance to the major papilla (hooking method used in 2 patients). Main Outcome Measurement Successful EBS. Results Reaching the major papilla and EBS was accomplished in all 4 patients. Limitation Small number of cases. Conclusions Use of large-balloon dilation can contribute to successful ERCP in patients with difficult duodenal strictures.

We report here a case of an unusual extrahepatic portosystemic venous shunt in a 37-year-old woman without liver cirrhosis or portal hypertension, who developed portal systemic encephalopathy. Angiography demonstrated an inferior mesenteric-caval shunt characterized by the presence of direct communication of the inferior mesenteric vein with the left internal iliac vein. After the treatment with percutaneous transcatheter embolization of the shunt via a femoral vein approach using coils, she had no episode of portal systemic encephalopathy.