Restorative proctocolectomy (RPC), when performed with a stapled ileal pouch-anal anastomosis (IPAA), allows the retention of the rectal mucosa above the dentate line and can result in disease persistence or recurrence, as well as neoplastic lesions in patients with ulcerative colitis (UC). We report the case of a patient with chronic UC who underwent staple mucosectomy, which is an alternative technique that evolved from stapled hemorrhoidopexy, rather than more traditional procedures. The patient had undergone laparoscopic RPC with a stapled IPAA 2 cm above the dentate line and a temporary loop ileostomy. Because the histopathology showed low-grade dysplasia in the proximal rectum, stapled mucosectomy with a 33-mm circular stapler kit at the time of ileostomy closure was scheduled. Following the application of a purse-string suture 1 cm above the dentate line, the stapler was inserted with its anvil beyond the purse-string and was fired. The excised rectal tissue was checked to ensure that it was a complete cylindrical doughnut. Histopathology of the excised tissue showed chronic inflammation. There were no complications during a follow-up period of 5 months. Because it preserves the normal rectal mucosal architecture and avoids a complex mucosectomy surgery, stapled mucosectomy seems to be a technically feasible and clinically acceptable alternative to the removal of rectal mucosa retained after RPC.
Colitis, Ulcerative ; Dietary Sucrose ; Fires ; Follow-Up Studies ; Humans ; Ileostomy ; Inflammation ; Mucous Membrane ; Proctocolectomy, Restorative ; Rectum ; Recurrence ; Retention (Psychology) ; Sutures

Pancreatic tuberculosis (TB) is extremely rare and mimics pancreatic carcinoma both clinically and radiologically. This paper discusses the occurrence of 2 heterogeneous masses located in the head and tail of the pancreas in an adult male. In this patient, laparotomy was performed because of the high suspicion of pancreatic carcinoma. Intraoperative fine needle aspiration biopsy revealed the coexistence of pancreatic carcinoma with pancreatic TB, and a combined resection of the distal pancreas and spleen was successfully performed. Following surgery, the patient received standard chemotherapy for TB. At 7-month follow-up, computed tomography showed resolution of the mass in the pancreatic head. Clinicians must maintain a high index of suspicion for pancreatic TB in patients with pancreatic masses. The coexistence of malignancy and TB should be considered when patients present with multiple pancreatic masses.
Adult ; Biopsy ; Biopsy, Fine-Needle ; Follow-Up Studies ; Head ; Humans ; Laparotomy ; Male ; Pancreas ; Pancreatic Neoplasms ; Spleen ; Tuberculosis

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.
Adenoma ; Humans ; Pancreatic Ducts ; Pancreatitis ; SNARE Proteins ; Stents

Mantle cell lymphoma (MCL) is a relatively rare subgroup of non-Hodgkin's lymphoma that is characterized by an aggressive and severe disease course with frequent involvement of regional lymph nodes and/or early metastasis. Because most cases of MCL are diagnosed in the advanced stages, clinical data on extranodal or early stage MCL is lacking, and MCL that is both extranodal and diagnosed during the early stages is even more rare. There have been several case reports on primary gastric MCL, which comprise a type of extranodal MCLs. However, to our knowledge, there have been no reports on solitary primary gastric MCL without regional lymph node involvement or distant metastasis. Recently, the authors experienced an uncommon case of MCL with the aforementioned characteristics that was managed with chemotherapy followed by allogenic stem cell transplantation.
Lymph Nodes ; Lymphoma, Mantle-Cell ; Lymphoma, Non-Hodgkin ; Neoplasm Metastasis ; Stem Cell Transplantation ; Stomach

BACKGROUND/AIMS: The Rosemont classification system was designed to standardize the endosonographic assessment of chronic pancreatitis. To determine whether the Rosemont classification system can predict the response to pancreatic enzyme supplementation in patients undergoing endoscopic ultrasound (EUS) evaluation of suspected chronic pancreatitis. METHODS: Sixty-five patients were included with abdominal pain undergoing endosonography for suspected chronic pancreatitis were included. Patients completed a questionnaire for evaluation of their abdominal pain. Group 1 (n=13) had EUS findings consistent with or suggestive of chronic pancreatitis. Group 2 (n=45) had EUS findings that were normal or indeterminate in the Rosemont classification system. Patients were given pancreatic enzyme supplementation and then given a follow-up pain questionnaire for a mean of 37 days subsequent to EUS regarding the change in pain. RESULTS: Group 1 patients were more likely to have a response to pancreatic enzymes (62% vs 24%, p=0.012) and a decrease in their pain scale ratings (2.62 vs 0.29, p=0.01). Computed tomography findings of chronic pancreatitis and narcotic use did not predict the response to pancreatic enzyme supplementation. The individual Rosemont criteria of hyperechoic foci with shadowing (p=0.03), lobularity (p=0.02), and stranding (p=0.001) were associated with improvement of pain after treatment. CONCLUSIONS: The Rosemont classification system can identify patients who are more likely to have improvement in abdominal pain after treatment with pancreatic enzyme supplementation.
Abdominal Pain ; Endosonography ; Follow-Up Studies ; Humans ; Pancreatitis, Chronic ; Shadowing (Histology) ; Surveys and Questionnaires

BACKGROUND/AIMS: Heat shock proteins (HSPs) protect rats from cerulein-induced acute pancreatitis (AP) by preventing the subcellular redistribution of cathepsin B and the activation of trypsinogen. Autophagy plays a critical role in the secretion of digestive enzymes and triggering of cerulein-induced AP via the colocalization of trypsinogen and lysosomes. Therefore, using a rat cerulein-induced AP model, we investigated whether HSPs prevent AP by regulating autophagy. METHODS: Twelve hours after fed standard laboratory chow and water, the experimental groups (cerulein, water-immersion [WI]-cerulein and heat-shock [HS]-cerulein) and the control groups (control, WI, and HS) received one intraperitoneal injection of cerulein (50 microg/kg) or saline, respectively. All of the rats were sacrificed at 6 hours after injection. The severity of the AP was assessed based on the serum amylase level and the histological and electron microscopy findings. Western blotting was also performed for HSP60/70 and LC3B-II. RESULTS: WI and HS induced HSP60 and HSP70, respectively. The induced HSP60/70 effectively prevented the development of cerulein-induced AP. Autophagy developed in the rats with cerulein-induced AP and was documented by the expression of LC3-II and electron microscopy findings. The WI-stressed rats and HS-treated rats did not develop cerulein-induced autophagy. CONCLUSIONS: HSPs exert protective effects against cerulein-induced AP in rats by inhibiting autophagy.
Amylases ; Animals ; Autophagy ; Blotting, Western ; Caerulein ; Cathepsin B ; Heat-Shock Proteins ; Hot Temperature ; Injections, Intraperitoneal ; Lysosomes ; Microscopy, Electron ; Pancreatitis ; Rats ; Trypsinogen ; Water

BACKGROUND/AIMS: Interferon-gamma-inducible protein 10 (IP-10) plays important roles in the pathogenesis of hepatitis C virus (HCV) infection. We investigated the association between serum IP-10 levels and liver pathology in patients with chronic HCV infection. METHODS: The serum IP-10 concentration was assessed in 85 patients with chronic HCV infection using a solid phase sandwich enzyme-linked immunosorbent assay, and a liver biopsy specimen was obtained. The pathology was scored using the Knodell histologic activity index (HAI). RESULTS: Of the 85 patients, 58 had genotype 1 HCV infection, 21 had genotype non-1, and 6 were undetermined. The serum IP-10 levels did not differ between patients infected with genotype 1 and genotype non-1 (p=0.472). In patients with genotype 1 infection, the total HAI score and the stage of fibrosis were highly correlated with the serum IP-10 level (r=0.555, r=0.578, p<0.001). Furthermore, the serum IP-10 concentrations of patients with severe fibrosis (stages 3, 4) were higher than those of patients with mild fibrosis (stages 0 to 2; 214.4 vs. 72.3 pg/mL, p=0.002) among patients with genotype 1 infection. However, in patients without genotype 1 infection, the histopathology was not associated with the serum IP-10 level. A multivariate analysis showed that serum IP-10 was an independent predictor of fibrosis (stages 3, 4) in patients with genotype 1 infection (odds ratio, 1.034; 95% confidence interval, 1.006 to 1.064; p=0.018). CONCLUSIONS: Serum IP-10 concentration was significantly correlated with the severity of liver histology in genotype 1 HCV infection.
Biopsy ; Enzyme-Linked Immunosorbent Assay ; Fibrosis ; Genotype ; Hepacivirus ; Hepatitis C, Chronic ; Humans ; Liver ; Multivariate Analysis

BACKGROUND/AIMS: The notion that acute hepatitis A superimposed on chronic hepatitis B infection leads to a worse outcome than acute hepatitis A alone remains controversial. The aim of this study was to determine the influence of the presence of hepatitis B surface antigen (HBsAg) on the severity of acute hepatitis A. METHODS: We retrospectively analyzed 449 patients hospitalized for acute hepatitis A from January 2000 to February 2010 and compared clinical outcomes based on the presence of HBsAg. RESULTS: Of the 449 patients, 30 patients were in the HBsAg-positive group and 419 in the HBsAg-negative group. The HBsAg-positive group was older than the HBsAg-negative group (36.1+/-8.3 vs 31.8+/-8.5 years, p=0.004); however, other baseline characteristics were similar between the 2 groups. Mean peak values of prothrombin time, serum total bilirubin, and serum creatinine at admission were significantly higher in the HBsAg-positive group. When comparing clinical outcomes between the 2 groups, gastrointestinal bleeding, acute renal failure, and acute liver failure were more frequently observed in the HBsAg-positive group. In particular, the incidence of acute liver failure was approximately 9-fold higher in the HBsAg-positive group than in the HBsAg-negative group (23.3% vs 3.3%; odds ratio [OR], 8.80; p<0.001). Multivariate analysis showed that HBsAg (OR, 7.43; 95% confidence interval [CI], 2.56 to 21.57) and age (OR, 1.07; 95% CI, 1.02 to 1.13) were independent risk factors for the occurrence of acute liver failure. CONCLUSIONS: In patients with chronic hepatitis B infection, acute hepatitis A is associated with more severe clinical outcomes, including acute liver failure, compared with patients with acute hepatitis A alone.
Acute Kidney Injury ; Bilirubin ; Creatinine ; Hemorrhage ; Hepatitis ; Hepatitis A ; Hepatitis B Surface Antigens ; Hepatitis B, Chronic ; Humans ; Incidence ; Liver ; Liver Failure, Acute ; Multivariate Analysis ; Odds Ratio ; Prothrombin Time ; Retrospective Studies ; Risk Factors

BACKGROUND/AIMS: Complementary medicines, including herbal preparations and nutritional supplements, are widely used without prescriptions. As a result, there has been growing interest in the risk of hepatotoxicity with these agents. It is difficult to determine causal relationships between these herbal preparations and hepatotoxicity. We report on 25 patients diagnosed with toxic hepatitis following ingestion of Polygonum multiflorum Thunb. METHODS: Twenty-five patients (median age, 48 years [24 to 65 years]; M:F=18:7) with suspected P. multiflorum Thunb-induced liver injury were admitted to our hospital between 2007 and 2009. We analyzed clinical and histological data, including the types and the duration of P. multiflorum Thunb intake and the duration of hospital care. We also determined the type of liver injury using the R ratio (serum activity of ALT/serum activity of ALP). RESULTS: The types of complementary medicine used included tea (n=16), liquor (n=5), tea and liquor (n=2), powder (n=1), and honeyed pudding (n=1). The most common presenting sign was jaundice (76%), and 18 patients (72%) had evidence of hepatocellular liver injury. Histological findings were consistent with acute hepatitis in all cases (n=10) for which liver biopsy was performed. Twenty-three patients (91.6%) recovered with conservative management, 1 patient (4%) had a liver transplant, and 1 patient (4%) died of hepatic failure. CONCLUSIONS: In our cases, we found that P. multiflorum Thunb could be hepatotoxic and could lead to severe drug-induced liver injury, and even death.
Biopsy ; Complementary Therapies ; Drug-Induced Liver Injury ; Eating ; Hepatitis ; Humans ; Jaundice ; Liver ; Plant Preparations ; Polygonum ; Prescriptions ; Tea ; Transplants

BACKGROUND/AIMS: The role of uncoupling protein-2 (UCP2) in the liver is currently unclear. Emerging evidence suggests a relationship between UCP2 and oxidative stress. In the present study, we tested the hypothesis that UCP2 expression in the liver might change during warm ischemia-reperfusion (I/R) according to oxidative stress. METHODS: Wistar rats were subjected to 40 (short ischemia) or 90 (long ischemia) minutes of partial lobar ischemia followed by 4 hours of reperfusion. UCP2 expression in the ischemic and nonischemic lobes was assessed using reverse transcription-polymerase chain reaction and immunohistochemistry. Malondialdehyde concentrations in the liver tissue were also compared. RESULTS: Malondialdehyde concentrations in the ischemic lobes were significantly higher in the long ischemia group. In the ischemic lobes of the short ischemia group, UCP2 protein expression was induced in hepatocytes, which did not express the protein prior to treatment, and the expression levels were higher than in the long ischemia group. The intralobular distribution of UCP2 seemed to correlate inversely with that of the necrotic area. UCP2 expression was observed, even in nonischemic lobes with similar intralobular heterogeneity. CONCLUSIONS: UCP2 was induced in hepatocytes after warm I/R. Although the primitive role of UCP2 expression may be cytoprotective in nature, its actual protective effect in hepatic I/R may be minimal
Animals ; Hepatocytes ; Immunohistochemistry ; Ion Channels ; Ischemia ; Liver ; Malondialdehyde ; Mitochondrial Proteins ; Oxidative Stress ; Rats ; Rats, Wistar ; Reperfusion