ENDOSONOGRAPHY‐GUIDED GALLBLADDER DRAINAGE FOR ACUTE CHOLECYSTITIS FOLLOWING COVERED METAL STENT DEPLOYMENT

Endosonography‐guided biliary drainage (ESBD) is gaining acceptance as an effective treatment for obstructive jaundice. Only a few reports on the application of this technique to the gallbladder (endosonography‐guided gallbladder drainage [ESGBD]) have been published in the literature. In order to relieve acute cholecystitis which developed in a patient with unresectable malignant biliary obstruction after deployment of a covered metal stent (CMS), we applied this technique. ESGBD was carried out by using an electronic curved linear array echoendoscope. After visualization of the gallbladder and determination of the puncture route, a needle knife papillotome was advanced with electrocautery to pierce the gastric and gallbladder walls. Under the guidance of a guidewire inserted through the needle sheath into the gallbladder, a 7.2 Fr, 30 cm‐long, single pigtail plastic tube was placed to bridge the gallbladder and the stomach. No complications relevant to the procedure were encountered. ESGBD was quite effective in ameliorating the patient's acute cholecystitis and the drainage tube was removed after 10 days without sequelae. Acute cholecystitis following CMS deployment is considered to be a good indication for ESGBD.     

IMPACT OF ENDOSCOPIC TRANSPAPILLARY NASO‐GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

Aim: To evaluate prospectively the efficacy of endoscopic transpapillary naso‐gallbladder drainage (ETGBD) after endoscopic sphincterotomy (ES) in patients with acute cholecystitis with choledocholithiasis. Patients: Twenty‐six patients with acute cholecystitis and choledocholithiasis, but without pericholecystic liver abscess, were evaluated. After ES and extraction of stones, ETGBD was performed immediately. Results: In 24 of the 26 patients with ES, complete bile duct clearance was achieved. In the other two cases treated with ES, stones could be completely removed in an additional session after ETGBD. ETGBD was successfully performed in 23 patients (88%). In three patients with unsuccessful ETGBD, a percutaneous cholecystostomy (PC) was performed. Of the 23 patients that underwent ETGBD, a positive clinical response at 72 h was seen in 22 (96%) patients. In one patient who did not show a clinical response at 72 h, catheter drainage was continued and a positive clinical response was seen 5 days after the procedure. In three patients treated with PC, a clinical response at 72 h was seen in all cases (100%). No major procedure‐related complications occurred. Conclusions: ETGBD after ES proved useful in the management of acute cholecystitis and choledocholithiasis.     

DIAGNOSIS OF BARRETT’S ESOPHAGUS AND ESOPHAGEAL NEOPLASIA: EAST MEETS WEST

Barrett’s esophagus has traditionally been considered to be a predominantly ‘Western world’ neoplastic condition. However, over the years, Asian countries are beginning to diagnose increasing numbers of patients with gastroesophageal reflux disease, columnar metaplasia at the gastroesophageal junction, Barrett’s esophagus, and esophageal adenocarcinoma. Hence, the controversies regarding screening for and surveillance of Barrett’s esophagus and esophageal adenocarcinoma have become more widely relevant to gastroenterologists around the world. Emerging concepts related to esophageal cancer prevention and early detection include the screening for Barrett’s esophagus using wireless videocapsule endoscopy, and chromoendoscopy, enhanced high resolution endoscopy. There is also interest in improving surveillance for esophageal neoplasia using novel imaging techniques, such as high resolution and high magnification endoscopy, narrow‐band imaging, autofluorescence imaging, and endocytoscopy/endomicroscopy. The enhanced detection of Barrett’s esophagus and esophageal neoplasia become even more clinically relevant because of accumulating data on the safety and effectiveness of mucosal ablative techniques (such as photodynamic therapy, argon plasma coagulation, low pressure cryotherapy) and endoscopic mucosal resection. This article summarizes the latest developments related to Barrett’s esophagus that are of interest to endoscopists from the East or West.     

CURRENT STATUS AND FUTURE EXPECTATIONS FOR ENDOSCOPIC BILIARY DRAINAGE IN 16 HOSPITALS

The authors examined the performance of endoscopic biliary drainage (EBD) in 16 hospitals. The examination was in the form of a questionnaire given between 1 June and 20 July 2005 to clarify the status of 369 patients who had undergone EBD. A total of 124 patients underwent endoscopic nasobiliary drainage (ENBD), 224 patients underwent endoscopic biliary drainage (EBS), and one patient underwent simultaneous ENBD and EBS. With regard to the underlying diseases, 227 patients had malignant disease and 142 had benign disease. A total of 244 patients underwent EBS. Plastic stent (PS) was used in 200 cases, and metal stent (MS) in 44 cases. One stent was used in 89% of cases, two stents in 10%, three or more stents in 1%. Metal stent was used in 44 patients (23 were covered and 21 uncovered) with unresectable biliary stenosis. One stent was used in 33 patients, two stents in 10 patients, and three stents in one patient. For treating middle and inferior common bile duct stenosis, PS having a caliber of 10 Fr is too soft; newer tubes should be developed utilizing materials that provide longer stent patency. Longer patency can be achieved now by applying EBS using a covered MS. Improving the materials will also improve stent flexibility and the smoothness of the coating film. When treating superior common bile duct and porta hepatic bile duct stenosis, the stent is placed in both lobes of the liver.     

ENDOSCOPIC NASOBILIARY GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

A 77‐year‐old man was admitted for the treatment of obstructive jaundice and right hypochondralgia with high fever. An abdominal computed tomography revealed common bile duct stones and acute cholecystitis with gallstones. Magnetic resonance cholangiopancreatography revealed stones in the common bile duct. Endoscopic retrograde cholangiopancreatography also revealed stones in the common bile duct, and immediately endoscopic sphincterotomy was performed. After lithotripsy of the bile duct, continuous endoscopic nasogallbladder drainage was performed successfully. There was severe pus in the gallbladder. Next day, the patient was doing well; there was no pain and fever was down.     

Dieulafoy’s disease treated by endoscopic haemostatic clipping

Dieulafoy’s disease is an uncommon cause of upper gastrointestinal haemorrhage. We report three patients with Dieulafoy’s disease treated with the endoscopic haemostatic clip application. There was no recurrent bleeding from the upper gastrointestinal tract after application of the clips in all three patients. Two patients survived while the third succumbed to renal failure after hypovolaemic shock. We conclude that endoscopic haemostatic clip may have a role in the treatment of Dieulafoy’s disease.     

WEGENER’S GRANULOMATOSIS COMPLICATED WITH APHTHOID COLITIS

A 58‐year‐old man was admitted with upper abdominal pain and high fever. There was no abnormality on chest X‐ray, abdominal ultrasonography, abdominal CT and upper gastrointestinal endoscopy. Antineutrophil cytoplasmic antibodies (C‐ANCA) titers were high and a chest CT scan depicted multiple nodules in the bilateral lungs. A diagnosis of Wegener’s granulomatosis was therefore made. Three weeks after admission, diarrhea and bloody stool developed. Colonoscopy revealed many aphthoid lesions surrounded by redness in the entire colon. Although the biopsy from aphtha did not show vasculitis or granuloma, the aphthoid lesions were suspected as a complication of Wegener’s granulomatosis. As a result of predonisolone medication (60 mg/day), the plasma C‐reactive protein (CRP) and high fever improved promptly. In conclusion, although colonic involvement in a patient with Wegener’s granulomatosis is extremely rare, it is important to keep in mind that colonic lesions might be due to vasculitis in ANCA‐positive disease, such as Wegener’s granulomatosis.     

Breast adenocarcinoma complicating Kallmann’s syndrome

Carcinoma of the breast is relatively rare among men, accounting for less than 1% of all malignancies. An increased risk has been associated with benign breast diseases, such as gynecomastia, Klinefelter’s syndrome, testicular disorders, exogenous estrogen use, radiation, or a family history of male or female breast cancer. To date, hypogonadotrophic hypogonadism has never been associated with male breast cancer. We report here the first case of breast cancer coexisting with Kallmann’s syndrome in a 66-year-old man.     

ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE

Endoscopic biliary drainage (e.g. endoscopic biliary stenting [EBS]) is the treatment of choice in the management of obstructive jaundice due not only because of its lesser invasiveness and greater safety as compared with surgical drainage or percutaneous transhepatic biliary drainage (PTBD), but also due to its ability to maintain the physiological flow of bile. EBS, however, is not always possible, and surgical drainage or PTBD have been performed in such cases with difficult cannulation of the bile duct or difficult intubation of the duodenum with a duodenoscope during endoscopic retrograde cholangiopancreatography (ERCP). Recently, the role of endoscopic ultrasonography (EUS), or endosonography (ES), has expanded from simply obtaining cross‐sectional images of the gut wall or surrounding organs and tissue samples by fine‐needle aspiration cytology/biopsy to therapeutic applications. Endosonography‐guided biliary drainage (ESBD) is one of such therapeutic applications of ES and reports on this procedure are increasing. In the present article, technical aspects and the current status of ESBD are discussed. As in EBS, ESBD makes it possible to recover physiological bile flow without pain following the procedure. Therefore, ESBD is expected to soon be widely accepted as a new option for difficult cases of not only EBS but also PTBD with obstructive jaundice, and may become the treatment of choice in selected cases. Development of relevant devices will expand its indications and accelerate its spread.     

ENDOSCOPIC STENT DRAINAGE FOR MALIGNANT BILIARY OBSTRUCTION: THE KOREAN EXPERIENCE

Endoscopic biliary drainage (EBD) is the treatment of choice for biliary obstruction caused by unresectable pancreaticobiliary malignancies. Clogging is an unsolved problem of the plastic stent. A self‐expanding metal stent (SEMS) was developed to overcome this limitation. Total resource utilization was reported to be lower with SEMS compared with plastic stents in the West. However, in Korea, the average total cost is estimated to be higher in the metal stent group. The use of SEMS should be indicated if the survival is expected to be more than 3 months. Covered SEMS was introduced to overcome the problem of tumor ingrowth into the uncovered stent. Patency rates for covered SEMS tended to be greater than uncovered SEMS, but the complication rate in covered SEMS was higher than uncovered SEMS due to migration, occlusion of the cystic duct, of a contralateral hepatic duct, or of pancreatic duct. Stents without clogging or migration, with antitumor or biodegradable properties are being investigated. For unresectable hilar cholangiocarcinoma (HC) of Bismuth type III or IV, unilateral percutaneous transhepatic biliary drainage (PTBD) and subsequent internal stent causes less cholangitis and longer patency than EBD or PTBD alone. However, the result with EBD is good if the Bismuth type of biliary obstruction is I or II. Photodynamic therapy may improve survival of patients with unresectable cholangiocarcinoma. Preoperative biliary drainage is not usually necessary except for HC. Procedure‐related complication and inflammation of the operative field resulting from endoscopic nasobiliary drainage or endoscopic retrograde biliary drainage are expected to cause surgical difficulties and to affect postoperative complications.     

Endoscopic ultrasound‐guided gallbladder drainage: Current status and future prospects

Early surgical treatment using the laparoscopic approach is generally accepted as the treatment of choice for acute cholecystitis (AC) according to Tokyo Guidelines 2018 (TG2018). If the patient is a poor candidate for surgery because of the presence of advanced malignancy or severe organ failure, this treatment may be too invasive. In such cases, gallbladder drainage is considered an alternative treatment method to surgery. Several drainage methods have been established, such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic transpapillary gallbladder drainage (ETGBD) under endoscopic retrograde cholangiopancreatography (ERCP), including endoscopic naso‐gallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS). PTGBD is a well‐established procedure that is relatively easily carried out by general clinicians. And ETGBD has been developed as an alternative drainage method. The procedure also calls for guidewire passage across the cystic duct. Therefore, in AC cases who are contraindicated for surgery, PTGBD should be considered before ETGBD, and ETGBD may be considered only in high‐volume institutes where expert hands are available, as described in the TG2018. However, there are several limitations to these procedures. Recently, endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) is increasingly being done as an alternative method to PTGBD and ETGBD. In this review, the current status and problems of EUS‐GBD are reviewed, including technical review and clinical data of previous papers, current indication, long‐term outcome, and comparison data with PTGBD or ETGBD, and their future prospects are discussed.     

Fludarabine-induced tumour lysis in low-grade non-Hodgkin’s lymphoma

We report two cases of acute tumour lysis following treatment with fludarabine in low-grade non-Hodgkin’s lymphoma.     

Breast lymphoma in Sjögren’s syndrome complicated by acute monocular blindness

A 69‐year‐old hypertensive woman presented with eye and mouth dryness, bilateral parotid gland enlargement, associated with anasarca and proteinuria. Family history was notable for malignancies including breast, nasopharyngeal and colon cancers. Physical exam disclosed hypertension, bilaterally enlarged, firm, non‐tender parotid glands, fine bibasilar crackles and bipedal edema. Anti Ro/Sjögren’s syndrome antigen A antibody was positive, with negative tests for anti La/Sjögren’s syndrome antigen B and anti‐nuclear antibody (ANA). Chest radiographs showed basal infiltrates. Sjögren’s syndrome associated with glomerulonephritis and interstitial lung disease was diagnosed, and she received pulse methylprednisololone followed by oral prednisone with dramatic improvement. Two months later, while on prednisone 5 mg/day, she returned to the clinic with an enlarging fixed non‐tender right breast mass. She underwent modified radical mastectomy of the right breast, and pathologic report revealed diffuse, small cell, non‐Hodgkin’s lymphoma of the breast; axillary lymph nodes were negative for tumor. She opted for alternative therapy and did not return to the clinic until 7 months later when she developed sudden monocular blindness in the right eye with no other systemic manifestations. Magnetic resonance imaging (MRI) revealed swelling and enhancement of intracanalicular and pre‐chiasmatic segments of the right optic nerve and right side of the optic chiasm. Considerations were Devic’s disease versus metastases. She received pulse methylprednisolone therapy (1 g/day for 3 days) with partial recovery of vision. She is scheduled for lymphoma chemotherapy to include rituximab.     

MECKEL’S DIVERTICULUM WITH ULCERATION DIAGNOSED BY DOUBLE BALLOON ENTEROSCOPY

A 31‐year‐old man was referred to our hospital for an evaluation of recurrent episodes of melena. Esophagogastroduodenoscopy, total colonoscopy, computed tomography and Tc‐99 m scintigraphy were performed at a previous hospital, but the bleeding source remained unidentified. Double balloon enteroscopy (DBE) was performed with the use of an anal approach at our hospital. DBE was inserted into the ileum approximately 100 cm from the ileocecal valve, and then Meckel’s diverticulum was discovered. There was a circular ulceration in the middle part of the diverticulum without adherent blood clots, visible vessels nor heterotopic gastric mucosa. Meckel’s diverticulum was identified as the bleeding source, but an immediate risk of rebleeding was considered relatively low. The patient chose conservative therapy without surgery. Two years later, he is well, without further bleeding episodes. DBE made it possible not only to diagnose the existence of the Meckel’s diverticulum but also to assess the risk of rebleeding.     

SNARE‐OVER‐THE‐WIRE TECHNIQUE FOR SAFE EXCHANGE OF A STENT FOLLOWING ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE

Endosonography‐guided biliary drainage (ESBD) is a new option that allows establishment of biliary drainage. Due to the diameter of the working channel of an echoendoscope, it is necessary to replace a small caliber stent with a larger one to lessen the risk of stent occlusion. However, insertion of a guidewire into the bile duct via the hole of the sinus tract following direct removal of a previously placed stent is not always possible, resulting in guidewire passage outside the fistula and bile leakage. Cannulation of the previously deployed stent, guidewire insertion into the bile duct via the cannula and the stent, and removal of the stent with the snare over the guidewire leaving the guidewire in place (the snare‐over‐the‐wire technique [SOW]) for stent exchange following ESBD was attempted. Four patients who required stent exchange following ESBD were included in the present study to evaluate the feasibility and usefulness of SOW. SOW was successful in all the cases. A new stent was also successfully deployed over the guidewire in all the cases. No complications were encountered. The snare‐over‐the‐wire technique is feasible and useful in stent exchange following ESBD for the reduction of the risk of guidewire migration.     

Pulmonary amyloidosis in Sjögren’s syndrome: a rare diagnosis for nodular lung lesions

Lung involvement in Sjögren’s syndrome (SS) can affect trachea, bronchus, small airways, pleura and may cause interstitial lung injury. It may also be associated with malignancies, particularly non‐Hodgkin’s lymphoma, which is a well‐recognized complication of this disease. Here we describe the occurrence of localized amyloidosis presenting as pulmonary nodules in a patient with newly diagnosed SS. We highlight this rare occurrence as a diagnostic possibility that should be considered in the evaluation of pulmonary involvement in this disease.     

Response of cutaneous Crohn’s disease to infliximab and methotrexate

Cutaneous or metastatic Crohn's disease is a rare complication of Crohn's disease and is frequently refractory to medical treatment. A case of metastatic Crohn's disease affecting first the abdominal wall and subsequently both submammary folds is reported. These extraintestinal manifestations occurred many years after proctocolectomy. The activity of cutaneous disease was associated with a chronic active fistulizing disease. Skin manifestations were resistant to treatment with steroids, antibiotics and azathioprine. Repetitive treatment with infliximab led to significant improvement of both cutaneous and fistulous disease. However, disease relapsed and even progressed after a period of 6 weeks following each infliximab treatment. Only the introduction of methotrexate, together with repetitive administration of infliximab, allowed maintenance of the patient in remission.     

Study of intestinal metaplasia in Barrett’s esophagus

OBJECTIVE : The aim of the present study was to investigate the factors predisposing patients with Barrett’s esophagus (BE) to intestinal metaplasia (IM). METHODS : Forty‐seven BE patients were studied. By using endoscopic and histological methods, esophageal IM was diagnosed in 36 patients, who were compared with 11 patients without IM in regard to their age, the endoscopic appearance of the esophagus and esophageal motility. RESULTS : The patients’ age and endoscopic features of the esophagus, but not esophageal motor function and grade of macroscopic esophagitis, were risk factors for the development of IM. CONCLUSIONS : Patient age and endoscopic features of the BE mucosa are associated with IM and may be prognostic factors for BE.