In this study on endoscopic hemostasis in patients aged 70 years or older with gastrointestinal ulcer bleeding, presence of shock, volume of transfusion over 6 units, and ulcer size over 3cm and solitary ulcer were significant risk factors for rebleeding. For 30-day mortality, concomitant disease and inpatient status were significant risk factors. Based on these results, we consider elderly patients with the above risk factors as high-risk patients for rebleeding or fatal outcome. The purpose of this study was to evaluate the efficacy of prevention of rebleeding such as by combined hemostatic methods and scheduled second-look endoscopy, and also to evaluate the offers of multidisciplinary approach such as interventional radiology for decreasing of mortality. Our conclusion is that we were able to reduce rebleeding rate and mortality after endoscopic hemostasis in high-risk patients and implement strategy to provide more careful endoscopic management with a multidisciplinary approach.
Between 1989 and 2009, 10 patients with small bowel adenocarcinoma were treated in our hospital. These tumors appeared in the jejunum in 6 patients and in the ileum in the remaining 4 patients. All patients had some symptoms. The median size of the tumors was 50mm(30-110mm). All tumors were advanced type 2 lesion with severe stricture. Histologically there were 8 well, 1 moderately and 1 poorly differentiated adenocarcinomas. There were 8 tumors invading the serosa and 2 tumors invaded other organs. Positive lymph nodes were identified in 6 cases. Liver metastasis and peritoneal dissemination were identified in 3 and 4 cases, respectively. Eight cases were diagnosed as small bowel adenocarcinoma preoperatively by double balloon endoscopy. The 4 patients with stage II tumor and 2 patients with stage III tumor underwent curative-intent surgery. The 4 patients with stage II tumor are all surviving without evidence of disease now.
A 77-year-old man was admitted to our hospital on a diagnosis of acute mediastinits, 17 days after he had high fever. Computed tomography of the chest revealed an abscess cavity in the left upper mediastinum. Endoscopic examination showed multiple pin-hole perforations in the upper esophagus from 23 to 24cm distal from the incisors and drainage through the perforation. We diagnosed acute mediastinitis caused by multiple esophageal perforations of unknown etiology. We initiated conservative therapy. Oral intake was restarted on the 17th day because radiological examination showed the esophageal perforation had closed. The patient was discharged on the 36th day from admission. Although mediastinitis caused by esophageal perforation often demands surgical treatment, conservative nonoperative therapy was successful in this patient.
We encountered a very rare case of eosinophilic gastroenteritis accompanied with fasciitis of the extremities. The patient was a 28-year-old woman with epigastralgia, eosinophilia plus leukocytosis, massive pleural effusion and ascites, and thickening of the walls of the intestine. Increase of the eosinophilic fraction in her ascites led to a diagnosis of eosinophilic gastroenteritis. She soon developed resting pain in all limbs and MRI revealed fasciitis. Prednisolone was effective in treating both gastroenteritis and fasciitis.
A 40-year-old woman with ulcerative colitis (UC) was admitted to our hospital because of diminution of consciousness and left palsy. UC had been diagnosed 6 years before, but had not been treated. MRI revealed complete obstruction of the superior sagittal sinus. Cerebral sinus thrombosis, as a complication of UC, was diagnosed. We started anticoagulant therapy, but she passed away 5 days later. UC has been reported to show hypercoagulation status, leading to deep vein thrombosis within the body which sometimes causes pulmonary infarction, but occurrence of cerebral sinus thrombosis is rare.
A case of pedunculated colonic adenoma with pseudocarcinomatous invasion and squamous metaplasia occurring in the sigmoid colon is reported. The patient was a 65-year-old man who visited our hospital for further evaluation of a positive fecal occult blood test. Colonoscopy revealed a pedunculated polyp with a thick swollen stalk in the sigmoid colon. EUS revealed a hyperechoic lesion in the stalk. However, endosonographically, the third and fourth layers of the colonic wall were shown to be normal. It was suspected to be a colonic adenoma with pseudocarcinomatous invasion from these endoscopic findings. Endoscopic polypectomy was performed. Histological examination of the specimen revealed tubular adenoma with moderate epithelial atypia and submucosal displacement of adenomatous glands with variable cystic changes. Squamous metaplasia and hemosiderin deposition were also seen in the mucosal and submucosal layer, respectively. This polyp was diagnosed as a colonic adenoma with pseudocarcinomatous invasion with squamous metaplasia.
A 59-year-old man was admitted to our hospital because of watery diarrhea and bloody stool lasting for a month. The patient had been a habitual smoker, smoking 25 cigarettes/day for 35 years. However, he had recently stopped smoking since a giant bulla in the left lung had been found. One month after discontinuing smoking, the patient's symptoms appeared. Colonoscopic examination demonstrated granulated mucosa, edema, and diminished vascular pattern were over the entire colon. Endoscopic and histological findings were compatible with the diagnosis of ulcerative colitis. We reported a case of ulcerative colitis that developed after smoking cessation and discussed the relationship between smoking and ulcerative colitis. Smoking may be associated with ulcerative colitis developed in middle aged person.
A 72-year-old man was admitted to our hospital for further investigation of pancreatic mass. Ultrasonography revealed hypoechoic mass with hyperechoic and aechoic area. Contrast enhanced ultrasonography (CE-US) revealed a vascular image in the lesion. CT showed some enhanced parts of low density mass in the pancreatic body, which was recognized as low-, high- and relatively high-intensity mass on T1-, T2-WI MRI and MRCP, respectively. The final pathological diagnosis showed mucinous carcinoma. CE-US may be useful for diagnosis of mucinous carcinoma.