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Shunsuke Watanabe, Masao Toki, Komei Kambayashi, Shuichi Kitada, Takes ...
2019 Volume 95 Issue 1 Pages
22-25
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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The inside stent, which is stent placement above the Vater papilla, has been invented to retain the function of the sphincter of Oddi. It is expected to extend the patency period compared with the normal biliary plastic stent. To remove the stent, the attached nylon thread must be pulled and exposed to the duodenal lumen, which may cause an accidental event if it is not removed properly. We examined the causes that had difficulty in removing the inside stent. In case 1, we grasped the nylon thread with a biopsy forceps but slipped, therefore, we inserted a biopsy forceps into the bile duct and grasped the inside stent directly. Because the removal procedure did not along the biliary axis, the inside stent was bent and got caught on Vater papilla. After EST, the bent stent was removed from papilla. In case 2, the nylon thread was slipped as in case 1. We changed the biopsy forceps and removed the inside stent. We suggested that the inside stent must be removed carefully along the biliary axis.
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Kazunori Tokizawa, Nobuhiko Okamoto
2019 Volume 95 Issue 1 Pages
26-28
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 62-year-old man complained of fever and chest pain after undergoing transesophageal echocardiography (TEE). Computed tomography (CT) showed marked mediastinal emphysema and a defect of the right anterior wall of the lower thoracic esophagus. The patient was referred to our Department of Surgery to assess whether surgery was required. Non-surgical management was selected because the leakage of contrast was contained within the lower mediastinum on the esophagogram and there were no signs of sepsis. The fever and chest pain ameliorated promptly, while an esophagomediastinal fistula seemed to have formed and remained on repeated CT scans even 62 days after TEE. However, 65 days after TEE, esophagoscopy revealed that esophageal epithelium covered the entire fistula and a pseudodiverticulum had formed. Solid diet was started and the patient was discharged 69 days after TEE without any other complications. This case demonstrates that pseudodiverticulum formation is one of the clinical conditions that may occur after esophageal perforation.
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Yuka Higashi, Yuichi Morohoshi, Yuji Koike, Seitaro Tsujino, Satoshi I ...
2019 Volume 95 Issue 1 Pages
29-31
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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An 89-year-old man with early esophageal squamous cell carcinoma, measuring 20 mm in diameter in the lower thoracic esophagus was admitted to our hospital. Endoscopic Submucosal dissection was performed under sedation. After dissection, a pinhole was found in an esophageal ulcer by endoscopy. Vomiting by the patient caused esophageal rapture from this pinhole, resulting in tearing of one-third of the circumference of the esophagus. To avoid surgery, two nasogastric tubes were inserted for local drainage. One tube was placed below the perforation to irrigate saline, and the other was placed in the stomach for suctioning. Continuous flushing with saline was performed. Computed Tomography showed free air over a wide area of the mediastinum and pneumothorax. There was no abscess, and healing of the wound was confirmed endoscopically on post-ESD Day 40. This drainage method is assumed to be effective when conventional methods would be ineffective.
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Shinya Kodashima, Taku Honda, Daisuke Manabe, Atsushi Miki, Hitoshi Ao ...
2019 Volume 95 Issue 1 Pages
32-34
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 79-year-old man was referred to our hospital due to superficial spreading type of esophageal squamous cell carcinoma. Esophagogastoroduodenoscopy showed this lesion needed complete circular ESD which has high risk of esophageal stricture after ESD. To prevent esophageal stricture after ESD, we performed ESD forming minimum mucosal defect, placed polyglycolic acid sheet over the surgical wound after resection, and administered oral prednisolone after ESD. This combination of methods for prevention of stricture after ESD were effective, and this patient had not required endoscopic balloon dilation yet.
A case of superficial spreading type of esophageal cancer resected endoscopically with combination of methods for prevention of stricture.
A 79-year-old man was referred to our hospital due to superficial spreading type of esophageal squamous cell carcinoma. Esophagogastoroduodenoscopy showed this lesion needed complete circular ESD which has high risk of esophageal stricture after ESD. To prevent esophageal stricture after ESD, we performed ESD forming minimum mucosal defect, placed polyglycolic acid sheet over the surgical wound after resection, and administered oral prednisolone after ESD. This combination of methods for prevention of stricture after ESD were effective, and this patient had not required endoscopic balloon dilation yet.
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Nana Momose, Soichiro Yamamoto, Hiroyasu Makuuchi, Rin Abe, Yasuhiko U ...
2019 Volume 95 Issue 1 Pages
35-37
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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The patient was a woman in her 60s. A lesion was pointed out by esophagography at a health checkup. Endoscopy showed a white granular elevated lesion at 34 to 40 cm from the incisor teeth. Since she was initially diagnosed with candida esophagitis, antifungal drug was administered but no change was observed. Six years later, endoscopic examination showed morphological changes in the lesion, and it was diagnosed as 0-IIc-type early esophageal cancer. Endoscopic mucosal resection was performed, and it was pathologically diagnosed as pT1a-MM, ly0, v0. The tumor may have originally existed under the keratinized epithelium. Or cancer may have been caused by prolonged chronic inflammation such as reflux esophagitis.
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Nozomu Miyajima, Atsushi Okawara, Toshiro Kamoshida, Shinji Hirai, Aki ...
2019 Volume 95 Issue 1 Pages
38-40
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Case 1: A 70-year-old man underwent endoscopic examination for epigastric pain. Esophagogastroduodenoscopy revealed an 8-mm whitish elevated lesion at the fornix, suggesting the absence of Helicobacter pylori. Gastric adenocarcinoma of the fundic gland (GA-FG) was suspected based on the endoscopic findings and endoscopic mucosal dissection (ESD) was performed. Pathological examination demonstrated GA-FG. Case 2: A 40-year-old woman underwent endoscopic examination for epigastric distress. Esophagogastroduodenoscopy revealed a 6-mm reddish elevated lesion at the fornix. Gastric atrophy was unclear because of previous eradication therapy for Helicobacter pylori. GA-FG was suspected and ESD was performed. Pathological examination demonstrated gastric adenocarcinoma of the fundic gland mucosa (GA-FGM). Magnified narrow-band imaging is useful for preoperative diagnosis. As GA-FG and GA-FGM in particular often invade submucosal areas, ESD is preferable for curative treatment, as in our cases.
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Keisuke Shiina, Tomohiro Iida, Masashi Namikawa
2019 Volume 95 Issue 1 Pages
41-42
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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An 81-year-old male with diarrhea and increased carcinoembryonic antigen (CEA) was referred to our hospital. Past medical history included diabetes, pulmonary emphysema, and hypertension. Esophagogastroduodenoscopy (EGD) revealed ulcerous lesions with thick exudates on the anterior wall of the fornix. Pathological examination of biopsy specimens revealed exudative necrotic material and Candida. Upon confirming ulcer healing after oral administration of esomeprazole (20 mg/day) for 2 months, he was found to be positive for serum anti-Helicobacter pylori antibody and first-line therapy for H. pylori eradication started. The urea breath test showed that he became negative; however, EGD revealed recurrent ulcer six months later. Candida-associated gastric ulcer was suspected, and fluconazole was administered. Consequently, his ulcer improved, Candida disappeared in biopsy specimens and his CEA level decreased. So far, no finding suggesting recurrence has been observed.
In elderly patients with compromised immunity, Candida-associated gastric ulcer should be considered in the differential diagnoses of gastric ulcer.
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Hiroyuki Eto, Koichi Kawabe, Toyotaka Kasai, Taro Ogino, Seiji Muramat ...
2019 Volume 95 Issue 1 Pages
43-46
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A male in his 70s noticed appetite loss and experienced transient loss of consciousness while standing up from a sitting position. On the evening of the same day, he developed black stools and came to our hospital.
Upper gastrointestinal endoscopy revealed multiple ulcers in the stomach. Pathological examination of biopsy specimens of an ulcer revealed infiltration of atypical lymphocytes and lymphoepithelial lesions. In addition, he was diagnosed with mucosa-associated lymphoid tissue (MALT) lymphoma by immunostaining. The patient was negative for Helicobacter pylori antibodies in sera and H. pylori antigens in stool specimens. Moreover, combined positron emission tomography and computed tomography (PET-CT) imaging showed no nodular lesions. Clinical remission has been maintained by radiotherapy (32 Gy in 20 fractions).
Although rare, MALT lymphoma may cause hematemesis and/or melena.
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Kazumasa Sanada, Yuri Hanaoka, Akira Fujimura, Akiko Wakutsu, Akitoshi ...
2019 Volume 95 Issue 1 Pages
47-50
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 70-year-old man with anemia was found in esophagogastroduodenoscopy to have a Type1 lesion in the gastric body. Biopsy specimens showed poorly differentiated adenocarcinoma. We performed total gastrectomy. Histopathological findings confirmed two types of the feature one was solid nest pattern that was suspected neuroendocrine carcinoma, and another was trabecular pattern that was suspected tubular adenocarcinoma. Immunohistochemically, all of the tumor cells were positive for AFP and synaptophysin, and some of the tumor cells were positive for chromogranin A. We concluded our case was a AFP-producing gastric cancer with neuroendocrine carcinoma.
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Hiroyuki Oka, Hayato Yoshimura, Mamoru Watanabe, Ayaka Ishida, Akihiro ...
2019 Volume 95 Issue 1 Pages
51-53
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 64-year old man was visited to our hospital with melena. Esophagogastroduodenoscopy revealed gastric ulcer and submucosal tumor of 20 mm in diameter with central depression located at the posterior wall of middle gastric body. Endoscopic ultrasonography revealed anechoic lesion of 14 mm in diameter at the third layer and we diagnosed as lymphangioma. 8 years later, esophagogastroduodenoscopy revealed submucosal tumor with hyperplastic-like elevated lesion of 20 mm in diameter. One and a half years later, esophagogastroduodenoscopy revealed submucosal tumor of 35 mm in diameter with hyperplastic-like flat elevated lesion and central depression. One year later, endoscopic ultrasonography revealed multiple anechoic lesions at the second and third layer and we diagnosed as hamartomatous inverted polyp. Endoscopic submucosal dissection was performed and pathological examination of resected specimen revealed inverted growth of mucosa and muscularis mucosa into submucosal layer and cystic-like proliferation of gastric glands.
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Takeshi Yano, Kazuhide Kumagai
2019 Volume 95 Issue 1 Pages
54-55
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Introduction: Percutaneous transesophageal gastro-tubing (PTEG) is associated with nosebleed.
Patient: The patient was an 88-year-old man with dysphagia. Since it would be difficult for him to undergo gastrostomy because of his previous history of dysphagia associated with subarachnoid hemorrhage, thoracoabdominal aortic aneurysm and esophageal hiatal hernia, we chose PTEG as the feeding method.
Initially, we inserted a rupture-free balloon catheter (RFB) nasally according to the original PTEG method, but it caused massive nosebleed requiring consultation of an otorhinolaryngologist. On a subsequent day, a Jagwire™ was inserted through a scope channel of the endoscope into the esophagus and then an RFB was perorally inserted along the Jagwire™, thereby preventing the occurrence of nosebleed.
Results and discussion: The lack of requirement of an endoscope is an advantage of the original PTEG method. In this patient, however, aggressive use of the endoscope enabled us to perform PTEG while preventing nosebleed.
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Haruka Yagishita, Naoto Kurihara, Yasuhiro Sasaki, Hideshi Matsuda, Yu ...
2019 Volume 95 Issue 1 Pages
56-58
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 73-year-old man with a history of sigmoid colon cancer was diagnosed as having advanced gastric cancer at the esophagocardiac junction with multiple liver metastasis. The biopsy revealed poorly differentiated adenocarcinoma which was HER-2 negative. Six cycles of chemotherapy with CDDP/S-1 were administered. Three months after the initial treatment, dendritic cell vaccines pulsed with Wilms tumor 1 peptide antigen were administered in one course which comprised 7 bi-weekly sessions. After four months of treatment the multiple liver metastasis had disappeared on computed tomography imaging. After nine months, gastrointestinal endoscopy revealed that the primary gastric cancer lesion on the esophagocardiac junction had also resolved. Based on the results of these examinations, the response was judged as complete. He remains well with no recurrence of the gastric cancer or and metastatic lesions for more than four years after starting treatment. This combination therapy might play an important role in the treatment of a certain type of patient with gastric cancer and liver metastases.
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Koji Takahashi, Takeshi Nihei, Naoaki Konno, Akari Munakata, Hiroshi K ...
2019 Volume 95 Issue 1 Pages
59-61
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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An 84-year-old female was admitted to a hospital with a lumbar compression fracture; however, she had recurrent vomiting at the time of admission. Her serum hepatic transferase levels were elevated and bile duct dilation was observed by MRCP. She was transferred to our hospital with the diagnosis of obstructive jaundice. The attempted ERCP for biliary drainage failed because of duodenal stenosis, the endoscope did not pass through the stenosis. Her ECOG performance status score was 3, and surgery was not appropriate; thus, percutaneous transhepatic biliary drainage and endoscopic duodenal stenting were performed. Forceps biopsy of the duodenal mucosa was repeated from the mesh gap of the duodenal stent, but there were no signs suggesting malignancy. Upper gastrointestinal endoscopy was performed on post-stenting day 166, and forceps biopsy of the duodenal mucosa from the mesh gap of the duodenal stent led to the diagnosis of signet-ring cell carcinoma. Chemotherapy was not performed, and she died 193 days after the duodenal stenting.
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Masaki Tominaga, Hiroshi Kashimura, Akari Munakata, Naoaki Konno, Koji ...
2019 Volume 95 Issue 1 Pages
62-64
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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We encountered a case of duodenojejunal lesion of ulcerative colitis (UC), a 63-year-old woman. 16 years ago, she developed ulcerative pancolitis and underwent total colectomy and ileostomy 3 months ago. Upper abdominal pain appeared 2 months after the surgery and the administration of proton-pump-inhibitors were ineffective. CT showed diffuse edema of the duodenum and jejunum, and enlargement of the mesenteric lymph nodes. Upper gastrointestinal endoscopy showed diffuse granular mucosa from the duodenal bulb to the anal side. We diagnosed her illness as duodenojejunal lesion of UC.
Although administrating crushed Mesalazine, her symptoms worsened and she was hospitalized. After receiving corticosteroid therapy, her symptoms improved and she was discharged.
In this case, her UC was refractory to Mesalazine but steroid therapy was remarkably effective. Although not frequent, ulcerative duodenal lesion should be considered a possible complication of UC.
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Ryota Hanada, Kentaro Inoue, Shohei Matsubara, Yuta Hisatake, Ken Arii ...
2019 Volume 95 Issue 1 Pages
65-67
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 50-year-old man with a hypervascular submucosal tumor in the second part of the duodenum presented melena during chemotherapy with Irinotecan, S-1, and Bevacizumab for peritoneal metastasis of rectal cancer. Esophagogastroduodenoscopy showed a bleeding ulcer on the submucosal tumor. The ulcer healed after discontinuation of Bevacizumab. Laparoscopic surgery was performed to excise the submucosal tumor. The mass measuring 20 × 16 mm in size was diagnosed as a very-low-risk gastrointestinal stromal tumor (GIST) histopathologically. An ulcer on GISTs is associated with high-grade malignancy. Although the GIST was very low risk in our case, an ulcer formed. The cause of the ulcer was related to administration of Bevacizumab, an angiogenesis inhibitor, for the hypervascular tumor. Caution must be exercised when Bevacizumab is given to patients with GISTs.
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Shun Ito, Kiyotaka Umeki, Shosuke Hosaka, Shinichiiro Sato, Satoshi On ...
2019 Volume 95 Issue 1 Pages
68-71
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 97-year-old woman presented with chief complaints of epigastric pain and vomiting. Computed tomography revealed signs of acute pancreatitis accompanied by two large juxtapapillary diverticula that had compressed on the intrapancreatic portion of the common bile duct (CBD) and the main pancreatic duct along with dilatation of the suprapancreatic portion of the CBD.
Contrast-enhanced computed tomography, abdominal ultrasonography revealed no evidence of choledocholithiasis or tumor. Since the patient's condition did not improve with observational treatments, esophagogastroduodenoscopy was performed on the 4th hospital day. We found that the juxtapapillary diverticula were filled with food residues comprising Shirataki. Most of the food residues were removed, leading to immediate resolution of the symptoms. Furthermore, there was no recurrence of the symptoms during the 18 month follow-up.
This study demonstrated that endoscopic removal of intradiverticular food residues should be considered prior to endoscopic retrograde cholangiopancreatography and surgery.
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Yusuke Sakurai, Hirotsugu Sakamoto, Tomonori Yano, Keijiro Sunada, Hir ...
2019 Volume 95 Issue 1 Pages
72-74
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 21 year-old male with repeat episodes of right lower quadrant pain for 4 months, was admitted. Retrograde double-balloon endoscopy (DBE) revealed the ileocecal valve was deformed with 10 cm tight stricture and a nearby internal fistula. The stricture and fistula were accompanied by ulcers, which led to a diagnosis of Crohn's disease. We attempted treatment with an elemental diet, mesalazine, and adalimumab. Retrograde DBE performed 3 months after starting treatment showed reduction in the stricture length and ulcers. Endoscopic balloon dilation (EBD) was then performed for the stricture. The dilation diameter at the first procedure was 8 mm. We repeated EBD at intervals of several months and gradually increased the dilation diameter to 15 mm. Retrograde DBE performed 7 months after starting treatment showed mucosal healing. Strictures with internal fistulas in patients with Crohn's disease has typically been managed by surgical resection. The present patient suggests that repeated EBD can avoid surgical resection if mucosal healing is promoted by medical treatment with a strict elemental diet.
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Keisuke Ojiro, Kyoko Arahata, Sakiko Takarabe, Shogo Kaida, Hiroshi Ki ...
2019 Volume 95 Issue 1 Pages
75-77
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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An 83-year-old man with multiple myeloma presented with anemia and increased immunoglobulin A (IgA) level after chemotherapy. Computed tomography revealed wall thickening in the small intestine, and contrast radiography showed a 3/4-rounded ulcerative lesion in the jejunum. Endoscopic biopsy revealed monoclonal infiltration of IgAκ plasma cells, which resembled the initial pathological finding of bone marrow biopsy, leading to a diagnosis of extramedullary plasmacytoma secondary to multiple myeloma. Although systemic chemotherapy was administered, frequent transfusion of red blood cells was needed because of increased bloody stool until the patient underwent small intestine resection. He died from disease progression of multiple myeloma 7 months after the diagnosis of plasmacytoma in the jejunum.
The incidence of secondary extramedullary plasmacytoma in the small intestine is extremely rare. Although this disease confers poor prognosis, the treatment strategy remains uncertain because of a small number of patients.
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Koji Takahashi, Takeshi Nihei, Naoaki Konno, Akari Munakata, Hiroshi K ...
2019 Volume 95 Issue 1 Pages
78-80
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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An 88-year-old female was referred to our hospital because she was anemic and was experiencing general fatigue. Eleven years ago, CT-guided lymph node biopsy revealed diffuse large B-cell lymphoma for which she underwent R-CHOP therapy. Ten years ago, she was judged to be in complete remission using PET-CT. At the time of her current visit to our hospital, her serum hemoglobin was 6.2 g/dL, and abdominal CT scan showed an ileal tumor and multiple swollen lymph nodes in the peritoneal space. Colonoscopy revealed a tumor of the terminal ileum, and forceps biopsy was performed. Pathologically, the tumor was diagnosed as diffuse large B-cell lymphoma. As she was elderly, chemotherapy was not performed, and she died 54 days after her visit to our hospital.
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Takahiro Hobo, Akiko Ueno, Mayo Tanabe, Genki Tsukuda, Kai Matsuo, Shu ...
2019 Volume 95 Issue 1 Pages
81-83
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 50-year-old male was admitted to our hospital due to small bowel obstruction. Contrast enhanced abdominal CT scan showed ileo-colic intussusception. The patient underwent colonoscopy which revealed an incarcerated ileal mass protruding through the ileocecal valve into the ascending colon. Attempted endoscopic reduction of the intussusception was unsuccessful, therefore, we inserted a transnasal ileus tube for decompression. The histopathological result of the biopsy sample was benign ulcerative lesion, Group1, however, laboratory investigation showed elevated serum IL-2 receptor level of 1634 U/ml and normal CEA, CA19-9 levels. Under the preoperative diagnosis of intussusception secondary to intestinal malignant lymphoma, ileocecal resection was performed. The histopathology of the resected specimen proved to be diffuse large B-cell lymphoma of the ileum. Since the malignant lymphoma of this case was staged as StageI disease, the patient was followed up without adjuvant chemotherapy. Up to now, the patient remains free of recurrence or metastasis under surveillance with serum IL-2 receptor level and contrast enhanced abdominal CT scans.
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Toyotaka Kasai, Koichi Kawabe, Hiroyuki Eto, Taro Ogino, Seiji Muramat ...
2019 Volume 95 Issue 1 Pages
84-86
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 31-year-old male had been receiving outpatient treatment for Crohn's disease of the small and large intestines for seven months. The patient presented to our hospital with body weight loss, slight fever and bleary eyes. Laboratory testing showed that the patient had fungal endophthalmitis and infective endocarditis by Candida parapsilosis. The patient was admitted to our hospital. Since cardiac ultrasonography showed verrucas on the aortic valve, aortic valve replacement was performed. An antimycotic was administered for fungal endophthalmitis. Treating this patient was extremely difficult since he concomitantly presented with fungal endophthalmitis and infective endocarditis caused by Candida parapsilosis.
In the medical treatment of Crohn's disease, it should be noted that patients may be at risk for complicated infections due to central venous catheter placement as well as administration of steroids, immunomodulatory agents, and biologics. If the patient's clinical condition deteriorates, infection should be suspected.
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Masayo Ogiri, Hiroki Ochiai, Yoshiyuki Ishii, Ryusuke Amemiya, Hiroyuk ...
2019 Volume 95 Issue 1 Pages
87-89
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 34-year-old woman with a history of infectious enteritis one year ago. Colonoscopy showed intestinal constriction and inflammation. She was referred to our hospital for further treatment. We suspected that she had small intestinal endometriosis and performed laparoscopic ileocecal resection. Surgical findings showed bending and adhesion of the terminal ileum. A pathological examination of the resected ileum showed infiltration by endometrial tissue through almost the entire wall from serosa to muscularis of the ileum. The postoperative course was uneventful. Endometriosis should be considered as a differential diagnosis with a high index of suspicion in premenopausal women.
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Junko Yagi, Takami Suzuki, Yoko Nakajima, Satoshi Kusayanagi, Fumihiko ...
2019 Volume 95 Issue 1 Pages
90-91
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 54-year-old woman presented to our hospital with watery diarrhea and abdominal pain for 1 month since she started escitalopram for depression. Physical and laboratory examinations were normal. On colonoscopy, only slight redness in the rectum was observed. The majority of biopsy specimens showed collagen bands in the subepithelial layer. She was diagnosed with collagenous colitis (CC). After discontinuation of escitalopram, her symptoms disappeared. Recently, some endoscopic findings of CC have been proposed, but over 80% of cases have no significant findings in many reports. Therefore, we propose that, in cases of chronic watery diarrhea, enough biopsies should be taken even if no abnormal endoscopic findings are observed.
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Koichi Kawabe, Toyotaka Kasai, Hiroyuki Eto, Seiji Muramatsu, Yosuke M ...
2019 Volume 95 Issue 1 Pages
92-94
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 56-year-old male patient was referred to our outpatient clinic with a chief complaint of lower right abdominal pain in 2010. He had a history of surgery for ileocecal ulcer. Colonoscopy was performed and he was diagnosed as having postoperative recurrent simple ulcer. Although mesalazine was administered, it was not sufficiently effective. Thus, salazosulfapyridine was added in 2011. Colonoscopy performed two years later showed that the ulcer had shrunk. The patient has continued to take mesalazine and salazosulfapyridine up through the present time. Five years after presentation, the ulcer at the anastomotic site was completely replaced by a scar. This combination therapy had few adverse effects and was inexpensive; therefore, it is worth attempting this therapy.
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Masao Kusano, Masaki Tosa, Yasushi Takahashi, Tomoyuki Ikeda, Seiichi ...
2019 Volume 95 Issue 1 Pages
95-97
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Pneumatosis cystoides intestinalis (PCI) is a rare intestinal condition that is characterized by the presence of gaseous cysts within the intestinal wall. We herein report a case of PCI after treatment with mitiglinide/voglibose. A 74-year-old man had diabetes mellitus for 7 years, and was being treated with mitiglinide/voglibose since 5 years and 5 months. Recently, after he complained about constipation, further examination was performed. Colonoscopic examination revealed multiple elevated lesions with smooth surface-like submucosal tumor in the sigmoid colon. Histopathological findings demonstrated fissure-like cavities and granuloma with multinuclear foreign body giant cell. Computed tomography showed multiple cystic lesions in the colonic wall of the sigmoid colon. We diagnosed PCI, and discontinued treatment with mitiglinide/voglibose. Two months later, he was retreated with only mitiglinide. Four months later, colonoscopic examination revealed elimination of elevated lesions.
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Masao Kusano, Masaki Tosa, Yasushi Takahashi, Tomoyuki Ikeda, Seiichi ...
2019 Volume 95 Issue 1 Pages
98-100
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Edwardsiella tarda, a member of the family Enterobacteriaceae found in aquatic environments, is an unusual cause of human disease. We herein report a case of acute colitis caused by E. tarda. A 73-year-old man who had a poorly controlled diabetes mellitus underwent, further examination of his digestive system by our hospital from his home doctor. He had right flank discomfort and soft stool on the previous day. Abdominal ultrasonography revealed focal wall thickening of the ascending colon. Colonoscopic examination revealed mucosal redness, swelling, and submucosal tumor-like elevated lesions. The histopathological finding revealed erosive colitis. In the stool culture, E. tarda was identified, and no other pathogenic bacteria were detected. Abdominal computed tomography revealed focal wall thickening from the cecum to the ascending colon. His symptoms improved with conservative therapy.
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Sodai Arai, Hiroshi Kuwabara, Yoshiaki Tomi, Taku Sato, Tatsuya Yoshid ...
2019 Volume 95 Issue 1 Pages
101-103
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 69-year-old woman was referred to our hospital with symptom of tumor prolapsed through anus. A yellowish and elastic soft mass protruding through the anal verge was seen in physical examination, however it was manually reducible. Colonoscopy revealed a large tumor with a diameter of 100 mm located in the sigmoid colon. According to CT and MRI, the tumor was diagnosed as a pedunculated lipoma of the sigmoid colon. Because the tumor was too large to be strangled by snare and the feeding vessel was firm, we selected endoscopic submucosal dissection (ESD) instead of polypectomy. Final histopathological diagnosis showed the tumor as submucosal lipoma. Cases of endoscopic removal for symptomatic colonic lipoma has been increasing. However, there are no cases reported that lipoma, prolapsed from anus, was treated with ESD in Japan.
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Kazuya Miyaguchi, Yumi Arai, Keigo Ashitani, Hideki Ohgo, Yoshikazu Ts ...
2019 Volume 95 Issue 1 Pages
104-106
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Recently, the usefulness of greatly enlarged observation using Endocytoscopy (ECS) has been reported.
A 38-years old, male was admitted to another hospital with fever, diarrhea and mucous blood a year and a half ago. Colonoscopy revealed multiple erosions in the rectum. His symptoms were alleviated by antimicrobial agents. He visited a nearby hospital with right lower abdominal pain two weeks ago, and his symptoms improved with re-administration of the antimicrobial agent. However, he was referred to our hospital because of positive fecal occult blood.
Colonoscopy revealed diffuse sputum-like erosions and redness with irregular white plaques from the sigmoid colon to the rectum and the cecum. Endocytoscopy showed multiple amebic trophozoites by super-magnifying observation.
As amebic colitis is one of the increasing parasitic diseases in Japan, it' s important to distinguish it from IBD and other enterocolitis. Detection of trophozoite of dysentery amoeba by in vivo real-time observation using ECS is considered to be useful for rapid diagnosis and treatment of amebic colitis.
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Maiho Ogawa, Akiko Ueno, Mayo Tanabe, Mary Raina Angeli Abad, Genki Ts ...
2019 Volume 95 Issue 1 Pages
107-108
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 51-year-old Korean woman came to our hospital for annual medical examination, including gastroscopy and colonoscopy. One year prior to consult, she traveled to Hainan Island, located in the South China Sea, and stayed there for 3 months.
During colonoscopy, we found a foreign body at the sigmoid colon. It was glossy, cylindrical, milky-white, and wriggling continuously. From the morphological characteristics, we diagnosed it as Ascariasis. We captured it using a net and removed it transanally. We then checked the upper GI deeply using a short intestinal scope and no other worms were detected. Although only one worm was found, we prescribed an anti-helminthic to prevent the potential risk of superinfection. In Japan, with modernization, the incidence of Ascariasis has decreased. However, it may increase with internationalization, hence the importance of being able to diagnose this disease.
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Satoshi Suda, Keiichiro Saigusa, Shinsuke Funakoshi, Hidenori Kita, Ta ...
2019 Volume 95 Issue 1 Pages
109-111
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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The patient was 74 years old man who had intermittent lower right abdominal pain from June 20xx. In October, he received endoscopic examination of the lower gastrointestinal tract and an elevated lesion with redness was revealed in the ascending colon, which was suggested intussusception. Lower gastrointestinal endoscopy and enema was fail to reduce intussusception. Surgical resection was performed and pathological diagnosis showed no malignancy and was diagnosed as idiopathic intussusception.
Adult-onset intussusception is considered to be rare, and most of those are reported to be associated with organic lesions. Since this case was considered an extremely rare, we report with some literature consideration.
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Shoko Takahashi, Yusuke Maeda, Masahiro Ueda, Hidenori Kita, Natsuko K ...
2019 Volume 95 Issue 1 Pages
112-113
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 90-year-old man was referred to our hospital complaining of bilateral lower extremity edema and chronic diarrhea. Laboratory data revealed hypokalemia (K 1.7 mEq/L). He developed diarrhea 6 months after starting lansoprazole. We suspected drug-induced collagenous colitis (CC) from lansoprazole therapy. Colonoscopy revealed no obvious abnormal findings, but biopsies were taken from the sigmoid colon for differentiation of CC. Based on biopsy findings of a subepithelial collagen band, he was diagnosed with CC. In addition, his diarrhea improved 3 days after discontinuing lansoprazole and changing to esomeprazole magnesium hydrate. In the differential diagnosis of chronic diarrhea it is important to review the patient's medical history in detail and to perform a colonoscopy and mucosal biopsy while considering CC as a possible diagnosis.
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Kei Sugimoto, Keigo Ashitani, Yoshikazu Tsuzuki, Kazuya Miyaguchi, Yos ...
2019 Volume 95 Issue 1 Pages
114-117
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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The complication of diverticulitis in the patients with ulcerative colitis (UC) is rare, because UC is common in young people and diverticulosis in elderly people. Here we presented a rare case of UC with sigmoid colon stenosis due to the abscess derived from diverticulitis.
70-year-old male with 2-year history of ulcerative colitis (UC) treated with 5-aminosalycilic acid (5-ASA) admitted to our hospital due to the recurrence after one-year remission. Blood examination demonstrated elevated white blood cell (WBC) and CRP. Contrast-enhanced computed tomography (CT) demonstrated abscess formation around sigmoid colon with multiple diverticulosis, and thickening of colonic wall from sigmoid colon to rectum. Colonoscopy demonstrated recurrence of UC and sigmoid colon stenosis. Prednisolone improved mucosal inflammation, however, did not improve stenosis and abscess formation. Therefore, sigmiodectomy was performed and resected specimen presented sigmoid colon stenosis with diverticulitis with the infiltration of neutrophils. Differential diagnosis may include superimpose of diverticular colitis in the setting of UC.
Diverticulitis should be considered as differential diagnosis when segmental stenosis was complicated in elderly patients with UC.
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Rina Odakura, Yugo Suzuki, Akira Matsui, Yorinari Ochiai, Junnosuke Ha ...
2019 Volume 95 Issue 1 Pages
118-120
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A patient with a xanthochromic submucosal tumor-like tumefactive lesion, identified in the lower rectum during periodic colonoscopy, was referred to our hospital for further examination and treatment. Through magnified endoscopic observation using NBI, dilated, tortuous microvessels were visible, primarily in the apex of the lesion. The lesion appeared as a hypoechoic, submucosal mass in EUS. The third layer was compressed and displaced by the tumor. ESD, performed as a diagnostic therapy, led to the final pathological diagnosis of an inflammatory fibroid polyp (IFP). IFP occurring in the rectum is extremely rare and we report here a valuable case that we experienced recently, along with a review of the literature.
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Rintaro Nibuya, Naoto Kurihara, Yusuke Asada, Hirofumi Shimoda, Toru Y ...
2019 Volume 95 Issue 1 Pages
121-123
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A woman in her 50s was admitted to our hospital with a history of melena and abdominal pain. Physical examination revealed no rebound tenderness in the abdomen, but abdominal computed tomography revealed a target-like appearance including the presence of a fat-density lesion in the descending colon. Colonoscopy revealed invagination of the descending colon by a lipoma. Based on these findings, the patient was diagnosed as having an intussusception. A standby emergency operation was performed. At laparoscopy, an intussusception was found on the descending colon. Partial resection of the left side of the colon was performed. The histological diagnosis confirmed a benign lipoma. After operation the patient remains well. An intussusception caused by a lipoma might be treated with laparoscopic surgery in the case of stable patients requiring surgical intervention.
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Shotaro Oki, Hirofumi Fukushima, Naoto Sakamoto, Taro Kurosawa, Takash ...
2019 Volume 95 Issue 1 Pages
124-125
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Colonoscopy in a 33-year-old man showed a submucosal tumor with a depression, 13 mm in size, in the lower rectum. Biopsy examination revealed NET. Endoscopic ultrasound showed that the muscularis propria was preserved and the lesion was localized to the submucosal layer. We selected ESD method for complete resection. Immunohistochemistry revealed synaptophysin (+), chromogranin A (+), CD56 (+), and Ki-67index 2%, and he was diagnosed with NETG1. The lesion remained in the submucosal region, and the margin was negative. Lympho-vascular invasion was not recognized. The cell proliferation ability was low. From these findings, we considered that the risk of metastasis was low and did not perform additional resection. Five years have passed without recurrence. This case was able to avoid surgical excision by appropriate treatment and detailed histopathological diagnosis.
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Kai Tsugaru, Kaoru Takabayashi, Kousaku Nanki, Marin Noda, Yukie Hayas ...
2019 Volume 95 Issue 1 Pages
126-128
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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Amoebic colitis is well known as the disease with the characteristical endoscopic image of multiple erosions or raised ulcer with dirty belag, which frequently appears on cecum or rectum. Herein, we experienced the patient of unusual type of severe amoebic pan-colitis.
A patient was 63-year-old male with chief complaints of intermittent diarrhea lasting for 2 years. The result of colonoscopy showed widely spreading ulcerative lesion on entire part of large intestine, and Entamoeba histolytica was detected by both fecal samples and biopsy samples. He recovered by anti-amoebic drugs, but partial colon stenosis was remained. Amoebic colitis could become critical if diagnosis was delayed. But sometimes typical endoscopic images are undetectable if severe inflammation circumferentially spreads around entire part of large intestine. We should consider amoebic colitis as a possible differential diagnosis when experienced uncertain cause of chronic pancolitis.
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Takayoshi Akase, Ryuichi Yamamoto, Toshiyuki Abe, Shosuke Hosaka
2019 Volume 95 Issue 1 Pages
129-131
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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We report a case of a 59-year-old man with an incarcerated confluence stone who was admitted in our hospital. At first, we diagonosed that he had cholangitis with a common bile duct (CBD) stone by CT scan and MRI. Then, we performed endoscopic retrograde cholangiography (ERC) to remove the CBD stone. But, we couldn't remove the CBD stone because it was an incarcerated in the part of communication of three ducts. We failed two times to remove the incarcerated confluence stone by using standard basket or balloon extraction, endoscopic mechanical lithotripsy (EML). So, we decide to use the Spyglass DS-guided EHL. Fainally, we were able to visualize the confluence stone and break it into pieces. Spyglass DS System can be considered useful and effective for removal of confluence stones.
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Junya Tsunoda, Chikako Hirose, Masashi Takahashi, Hiroki Hoshino, Kuni ...
2019 Volume 95 Issue 1 Pages
132-134
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 79-year-old man presented to our hospital with complaints of itchiness and jaundice. Contrast-enhanced computed tomography scan revealed an approximately 20-mm poorly enhanced area in the head of the pancreas and a dilated common bile duct. The patient was diagnosed with obstructive jaundice associated with pancreatic head cancer. Preoperative biliary drainage was performed using a plastic stent. Subsequently, he developed biliary infection; we performed stent exchange and initiated antibiotic therapy. However, these approaches did not completely resolve the biliary infection, and we performed percutaneous transhepatic gallbladder drainage and bile culture. Eventually, pancreaticoduodenectomy was performed on day 30 of hospitalization. Bile culture test results showed that Enterococcus faecium caused biliary infection on the postoperative day 1. We switched the antibiotics to vancomycin, which is effective against E. faecium. His postoperative course was favorable, and he was discharged on postoperative day 45.
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Miku Kato, Takeshi Sato, Yoshimasa Suzuki, Yuichiro Tozuka, Satoshi Ko ...
2019 Volume 95 Issue 1 Pages
135-137
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 75-year-man diagnosed with locally advanced pancreatic cancer underwent biliary stent exchange every 3 months. The latest cholangiography showed hilar stenosis. Bilateral biliary drainage was attempted; however, a plastic biliary stent (PS) could not be advanced to the left hepatic duct. We placed PS in the right and an endoscopic nasobiliary drainage tube in the left intrahepatic duct. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed a week later to switch from external to internal drainage. We placed 7 Fr PS in the left intrahepatic duct via the transgastric approach. Abdominal radiography performed 2 days after EUS-HGS revealed PS kinking. Therefore, we performed endoscopic transgastric re-intervention and exchanged PS with a self-expandable metallic stent, 9 days after the EUS-HGS. The patient showed good biliary drainage with a favorable clinical course after replacement of the transgastric PS.
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Tsugumi Habu, Koichi Kawabe, Toyotaka Kasai, Hiroyuki Eto, Seiji Muram ...
2019 Volume 95 Issue 1 Pages
138-141
Published: December 20, 2019
Released on J-STAGE: December 26, 2019
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A 69-year-old man complaining of epigastric pain was transported by ambulance to our hospital. Computed tomography showed severe acute pancreatitis and he was admitted. Endoscopic retrograde cholangiopancreatography was performed because he had fever and jaundice, and it revealed that the papilla was enlarged. Biopsy specimens of the papilla were obtained and histopathological examination revealed adenocarcinoma. We inserted a biliary and pancreatic stent; however, jaundice reappeared. Endoscopic retrograde cholangiopancreatography was performed again and revealed a pancreaticoduodenal fistula with drainage. We continued conservative treatment. Subtotal stomach-preserving pancreaticoduodenectomy was performed after inflammation improved.
Spontaneous drainage from the pancreaticoduodenal fistula led to a good course of treatment for pancreatitis. Also, duodenal papillary carcinoma rarely causes pancreatitis. Searching for neoplastic lesions is important when we encounter patients with pancreatitis whose cause cannot be determined.
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