眞嶋 浩聡

A 54-year-old man was admitted with obstructive jaundice. Computed tomography showed common bile duct stricture and a tumor around the celiac artery. Repeated endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) as well as a laparotomic biopsy around the celiac artery were diagnostically unsuccessful. Since the bile duct stricture progressed, EUS-FNA and ERCP were performed a third time, finally leading to the diagnosis of diffuse large B-cell lymphoma. The treatment plan and prognosis of obstructive jaundice differ greatly depending on the disease. It is important to conduct careful follow-up and repeated histological examinations with appropriate modifications until a diagnosis is made.

A 66-year-old man underwent a single endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) session and distal pancreatectomy for the pancreatic body adenocarcinoma measuring 12 mm in diameter. At 3 years after surgery, we diagnosed needle tract seeding (NTS) and performed total gastrectomy. NTS can occur with small tumors or after a single session of EUS-FNA.

BACKGROUND AND AIMS: Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system. METHODS: We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. RESULTS: The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay. CONCLUSION: We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.

Immunoreconstitution inflammatory syndrome (IRIS) was reported to occur in 7-13% of AIDS patients on anti-retroviral therapy (ART). IRIS due to Mycobacterium infection is one of the most difficult IRIS types to manage. A male patient in his early 70s was diagnosed with AIDS and treated with an ART. One year after starting ART, abdominal ultrasound was performed for screening and a 4 cm hypoechoic mass was found from the outside of the stomach to the surface of the hepatic lateral segment. Based on various imaging tests, including contrast CT, a malignant tumor, such as malignant lymphoma, was suspected. Then, a percutaneous tumor biopsy was performed. Pathologically, the tumor was recognized as mycobacterial granulomas. Disseminated mycobacterium avium complex can produce granulomas anywhere in the body. The patient was diagnosed with a mycobacterial infection associated with IRIS. When an intra-abdominal mass is found in a patient with HIV, both malignancy and mass formation due to opportunistic infections should be considered differential diseases.

OBJECTIVE: The standard treatment for ampullary tumors is pancreaticoduodenectomy. However, minimally invasive procedures such as endoscopic papillectomy (EP) and transduodenal ampullectomy (TDA) have recently gained popularity. Therefore, we aimed to evaluate the effectiveness of these minimally invasive procedures for ampullary tumors. METHODS: We conducted a retrospective study of 42 patients who underwent either EP or TDA for ampullary tumors between June 2011 and November 2020. RESULTS: We found that in patients with significantly larger tumors, TDA was often selected. Patients who underwent EP had significantly shorter hospital stays. No significant differences were observed regarding procedural accidents, tumor size, and recurrence. CONCLUSION: No differences were observed regarding the treatment outcomes of EP and TDA except hospital stay. EP is less invasive and can be the initial choice of procedure. TDA is performed when EP is not technically feasible. No significant relationship was noted between tumor size and recurrence, and careful observation of the patient's postoperative course is required.

OBJECTIVE: The concept of early chronic pancreatitis (ECP) and its diagnostic criteria were first proposed by Japan, using endoscopic ultrasonography (EUS) findings for diagnosis. However, these findings have not been supported by pathological findings. We aimed to examine the association between the EUS and pathological findings of the same area of the pancreas. METHODS: In 12 patients who underwent pancreaticoduodenectomy for distal bile duct cancer without accompanying pancreatitis, a comparative analysis between preoperative EUS and pathological findings was performed. The part of the pancreas adjoining the portal vein was evaluated. RESULTS: In 7 cases, abnormal EUS findings included in the diagnostic criteria for ECP were seen; the correlation of the accuracy of lobularity seen on EUS compared with the pathological findings of the pancreatic parenchyma (inflammatory cell infiltration, atrophy of acinar cells, and fibrosis) was high (83.3%-91.7%). Pancreatic duct findings revealed that the accuracy of the hyperechoic margin of the pancreatic duct on EUS compared with pathological findings (wall thickness of pancreatic duct) was high (83.3%). CONCLUSIONS: Endoscopic ultrasonography findings for ECP, according to Japan's 2019 revised criteria, lobularity, and the hyperechoic margin of the pancreatic duct may highly correspond to the pathological findings of chronic inflammation.

Pruritus is known to be a common complication in hepatitis patients, but the exact frequency and degree are not fully elucidated. Thus, we evaluated pruritus of 450 patients with chronic liver disease at our hospital. Pruritus was observed in 240 (53%) of the patients. Pruritus was significantly associated with males (OR = 1.51, P = 0.038) and patients with alkaline phosphatase (ALP) ≥ 200 U/L (OR = 1.56, P = 0.0495) and was significantly less in HBsAg-positive patients (OR = 0.449, P = 0.004). Seasonally, there was no difference in the frequency of pruritus between summer and winter. Of the 24 refractory pruritus patients treated with nalfurafine, 17 (71%) indicated improvement of itch, which is defined as a decrease in the visual analog scale score ≥ 30 mm. Pruritus was improved by nalfurafine both during daytime and nighttime in the Kawashima's scores evaluation. All patients who received nalfurafine exhibited improved Kawashima's scores ≥ 1 point during the daytime or nighttime. In conclusion, pruritus occurred in > 50% of patients with chronic liver disease, and predictors of pruritus were males and ALP ≥ 200 U/L. Nalfurafine may be useful for pruritus, regardless of whether daytime or nighttime.

70歳男性。発熱、悪寒および右季肋部痛を主訴とした。64歳時に胃癌(pStage IB)で胃全摘術(Roux-en Y再建術)を受けていた。血液検査でCRP値の軽度高値を認め、造影CTで肝S1に内部に隔壁を伴う被膜の厚い40mm大の嚢胞性病変を認めた。また、輸入脚から肝S1にかけて線状の高吸収域がみられた。以上より、輸入脚盲端異物の穿通による肝膿瘍と診断した。輸入脚盲端と肝臓は密着しており、ダブルバルーン内視鏡を用いて異物を摘出した。摘出した異物は長さ40mm、直径3mmの竹串であった。問診で3ヵ月前に泥酔状態で焼き鳥を串ごと摂取したことが判明した。術後はTAZ/PIPC投与を開始した。CRP値は低下したが、第8病日に40度台の発熱が出現し、経皮的ドレナージを施行した。その後、発熱なくCRP値が低下し、第14病日にドレーンを抜去した。第19病日に退院となり、退院後半年のCTで肝膿瘍の消失を認めた。

Antiangiogenic agents, such as ramucirumab, should be cautiously administered along with radiotherapy because of the enhanced risk of adverse events.

33歳男性。食欲不振、関節痛を主訴に前医を受診し、A型肝炎と診断された。診断後は保存的加療にて肝酵素の改善傾向を認めたが、ビリルビン上昇が遷延し、ステロイド内服なども改善に乏しいため、黄疸遷延の加療目的に当院へ転院となった。受診時、血液検査ではビリルビンは高値を示しており、ステロイドの増量やビリルビン吸着などを検討したが、自然経過中に、ビリルビンは低下傾向となり、ステロイドの内服を継続することで、その後もビリルビン値は低下し、患者は第19病日に軽快退院後、外来での経過観察となった。

An 83-year-old man with a history of carbon ion radiotherapy for hepatocellular carcinoma nine years ago presented to a primary care hospital with a fever and abdominal pain. He underwent computed tomography, which revealed the rupture of a hepatic pseudoaneurysm close to the fiducial marker for carbon ion radiotherapy and bleeding into the bile duct. He was successfully treated with transcatheter arterial embolization. Thereafter, re-rupture occurred from a site proximal to the first rupture, and this was treated similarly. It is necessary to be alert for not only tumor recurrence but also pseudoaneurysm occurrence after carbon ion radiotherapy.

急性膵炎の発症にはトリプシンの異所性活性化やNF-κBの活性化、オートファジー不全、小胞体ストレス、酸化ストレス、細胞内カルシウムシグナル異常などが関与している。オートファジーは老廃物の分解や再利用を通じて細胞の恒常性の維持に寄与するが、膵炎発症時には機能不全が生じ、トリプシンの活性化を生じる。急性膵炎が発症すると外分泌が障害されるが、エキソサイトーシスと表裏一体の関係にあるエンドサイトーシスはオートファジーと類似の機能であり、急性膵炎の発症にも関与している。細胞内の小胞輸送はさまざまなRabタンパク質によって制御されているが、オートファゴソームとエンドソームの膜上に存在するRab7を欠失させた膵臓では、オートファジー不全とエンドソームの成熟過程に障害が生じて、膵炎反応が増悪する。(著者抄録)

大腸内視鏡的処置時に鉗子口からの処置具の急な突出を防ぐための装置を開発したので報告した。方法は生検鉗子やポリペクトミー用スネア外筒など処置具に熱収縮性ビニルテープを内視鏡処置管路長より5cm短く設置し、その凹凸と色の変化を利用する処置具カラーマーキング法とした。実際に処置具カラーマーキング法を使用すると、画面に視野を集中する際も処置具のマーカーが視野の片隅に入り、また処置具挿入中の手元でも5cm手前のマーカーを触知することができた。そこから処置具を慎重に挿入することにより急な突出を防止することが可能であった。

OBJECTIVE: Suspected sphincter of Oddi dysfunction (SOD) is a well-known risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The indication of ERCP for suspected SOD patients was very low in Japan compared to other countries. Therefore, the risk of PEP may be different in Japanese SOD patients. The objective of this study was to evaluate the risk of PEP in suspected biliary type SOD in Japan. METHODS: From December 1996 to January 2017, 72 patients were suspected as having biliary type SOD, by questionnaire, liver function tests, hepatobiliary scintigraphy, abdominal ultrasonography, upper gastrointestinal endoscopy, endoscopic ultrasonography and magnetic resonance cholangiopancreatography. Finally, 60 patients who underwent ERCP were included in this study, and the factors associated with PEP were evaluated. RESULTS: The overall PEP rate was 23.3% (n = 14). Diagnostic ERCP alone for SOD did not increase the risk of PEP. The correlation of PEP incidence with pancreatic duct guidewire (PGW) technique and endoscopic sphincterotomy (EST) was indicated in univariate and multivariate analysis. Pancreatic stent placement was a risk in univariate analysis but not in multivariate analysis. CONCLUSIONS: PGW technique and EST for biliary type SOD were important risk factors for PEP. Pancreatic stenting was ineffective for prevention of PEP.

Background and aims: At Saitama Medical Center, for remission induction in active ulcerative colitis (UC) patients with endoscopic evidence of severe disease, we tend to preferentially use tacrolimus (TAC) over anti-tumor necrosis factor (TNF)-a agents. We conducted this study to evaluate the validity of our therapeutic strategies. Patients and methods: This retrospective study was conducted in 52 steroid-refractory active UC patients with a Clinical Activity Index (CAI) score of ≥7 who were receiving remission induction therapy with TAC or anti-TNF-α agents. The patients were divided into a TAC treatment group (TAC group, n = 29) and an anti-TNF-α agent treatment group (anti-TNF group, n = 23). The CAI, Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and incidence of events (relapse, hospitalization and surgery) were retrospectively analyzed. Results: At treatment initiation, the CAI score was 12.6 in the TAC group and 11.5 in the anti-TNF group (P = 0.09), while the corresponding values of the UCEIS were 6.5 and 5.1, respectively (P = 0.0035). The clinical remission rate at 12 weeks was 55% (65% when only the subgroup that received rapid induction therapy was included in the analysis) in the TAC group and 57% in the anti-TNF group, with no significant difference. The cumulative event-free rates at 1, 6 and 12 months were 65.5%, 39.4%, and 39.4%, respectively, in the TAC group and 95.7%, 77.2% and 71.7%, respectively, in the anti-TNF group (P = 0.0037). Conclusion: Rapid induction therapy with TAC tended to be selected for active UC patients with endoscopic evidence of severe disease, and the present study supported the validity of this therapeutic approach. However, transition to the remission-maintenance phase was more favorable in the anti-TNF group.

Although endoscopic submucosal dissection (ESD) is becoming the mainstay of the treatment strategies, rather than surgical treatment, for colorectal tumors extending to the dentate line, ESD is technically more difficult. This study was aimed at assessing the usefulness of ESD for the treatment of colorectal tumors extending to the dentate line. This study included 531 patients with colorectal tumors who underwent colorectal ESD between 2008 and 2015. They were divided into three groups: rectal tumors extending to the dentate line (anorectal group), those not extending to the dentate line (proximal rectal group), and colonic tumors (colonic group), and a retrospective comparative analysis was carried out. Of the total patients, 18 (3.4%) had lesions extending to the dentate line area. The procedure times were 103.4 +/- 84.0, 80.4 +/- 64.3, and 71.8 +/- 52.3 min, respectively (P = 0.0318). All the patients in the anorectal group were operated by operators who had performed at least 20 colorectal ESDs (P &lt; 0.0001). No significant difference among the three groups was found in the en bloc resection rate, complete resection rate, or curative resection rate. Although no significant difference in the incidence of perforation was observed among the three groups, intraoperative bleeding was observed in 61% of the patients in the anorectal group (P &lt; 0.0001). ESD is an effective treatment strategy for colorectal tumors extending to the dentate line. However, it seems that anorectal ESD, which is technically more difficult than colorectal ESD, should be performed by operators with ample experience in performing ESD.

Although aberrations of intracellular vesicle transport systems towards lysosomes including autophagy and endocytosis are involved in the onset and progression of acute pancreatitis, the molecular mechanisms underlying such aberrations remain unclear. The pathways of autophagy and endocytosis are closely related, and Rab7 plays crucial roles in both. In this study, we analyzed the function of Rab7 in acute pancreatitis using pancreas-specific Rab7 knockout (Rab7(Delta pan)) mice. In Rab7(Delta pan) pancreatic acinar cells, the maturation steps of both endosomes and autophagosomes were deteriorated, and the lysosomal functions were affected. In experimental models of acute pancreatitis, the histopathological severity, serum amylase concentration and intra-pancreatic trypsin activity were significantly higher in Rab7(Delta pan) mice than in wild-type mice. Furthermore, the autophagy process was blocked in Rab7(Delta pan) pancreas compared with wild-type mice. In addition, larger autophagic vacuoles that colocalize with early endosome antigen 1 (EEA1) but not with lysosomal-associated membrane protein (LAMP)-1 were much more frequently formed in Rab7(Delta pan) pancreatic acinar cells. Accordingly, Rab7 deficiency exacerbates the severity of acute pancreatitis by impairing the autophagic and endocytic pathways toward lysosomes.

Objective: Unusual setting of medical care Background: Tacrolimus is reportedly effective for the treatment of refractory ulcerative colitis (UC). At our hospital, there has been an increase in the number of patients, including elderly patients, with refractory UC treated with tacrolimus. Here, we review the data from 5 patients with elderly-onset UC treated with tacrolimus as remission induction therapy. Case Report: The subjects were 5 patients ≥65 years of age with refractory UC who had received oral tacrolimus as remission induction therapy between 2009 and 2014 (3 men and 2 women median age at onset, 75 years). At the start of the tacrolimus treatment, the median duration of disease was 3 months, and the type of UC was total colitis in 4 cases, and left-sided colitis in 1 case. The drugs used concomitantly at the start of tacrolimus treatment were mesalazine (5 cases) and an immunomodulator drug (1 case). Standard induction therapy (0.05 mg/kg/day) was used in 2 patients and rapid induction therapy (0.1 mg/kg/day) was used in the remaining 3 patients. One week after the start of treatment, the blood trough concentrations of tacrolimus were over the target level of 15 mg/mL in 4 patients. The clinical activity index values on day 0 and day 14 were 10.6±2.1 and 7.6±3.4, respectively. The ulcerative colitis endoscopic index of severity in the remaining 3 patients, after excluding the 2 patients who required colectomy within 14 days after the start of tacrolimus therapy, was 7.3±1.0 before the start of the tacrolimus treatment, improving to 4.5±0.5 on day 14. Subsequently, 1 of these 3 patients was also judged to need surgery due to symptom exacerbation, while complete remission was maintained in the other 2 patients. Conclusions: In elderly-onset refractory UC patients, tacrolimus appears to be effective as remission induction therapy. However, since tacrolimus concentrations in the blood can rise easily in elderly patients, frequent monitoring of the drug concentrations and dosage adjustments are necessary.

Objective: Unusual setting of medical care Background: Serrated polyposis syndrome (SPS) is characterized by numerous hyperplastic polyps and sessile serrated ad-enoma/polyp (SSA/P) in the large intestine. SSA/P is known to transform into malignant lesions through the serrated pathway instead of the adenoma-carcinoma sequence. Early diagnosis with lower gastrointestinal endoscopy and early treatment are now considered to be essential. Case Report: We had an experience with a case of SPS to which endoscopic treatment was applied in multiple sessions. Endoscopic treatment was performed for 16 lesions in total, and the pathological findings were SSA/P for 15 and adenoma for the other lesion. We intend to continue performing endoscopic surveillance for any newly developing lesions. Conclusions: SPS has a potential for malignant transformation, and issues, such as long-term prognosis and optimal therapeutic strategies, await resolution. However, multiple endoscopic treatments are useful for cases with lesions that are controllable employing this modality.

Objective: We attempted to develop a scoring system for facilitating decision making regarding the performance of emergency endoscopy in patients with colonic diverticular hemorrhage. Methods : This study involved analysis of the data of 178 patients who presented with hematochezia and were diagnosed as having colonic diverticular hemorrhage by colonoscopy. The patients were divided into 2 groups depending on whether the bleeding source was identified or not at the initial endoscopy (source-identified and source-not-identified groups), and on the basis of the results obtained, we established a scoring system for predicting successful identification of the bleeding source. Res ults : The percentages of patients on oral anticoagulant therapy or with a Charlson comorbidity index of ≥6, serum C-reactive protein level of ≥1 mg/dL, or extravasation of contrast medium visualized on contrast-enhanced computed tomographic (CT) images were all significantly higher in the identified than in the nonidentified group. Multivariate analysis identified extravasation of contrast medium on contrastenhanced CT images (odds ratio [OR]: 10.6 95% confidence interval [CI]: 2.7-42.2) and use of anticoagulants (OR: 4.5 95% CI: 1.5-13.5) as independent predictors of successful identification of the bleeding source at the initial endoscopy in patients with colonic diverticular hemorrhage. On the basis of these results, we established a scoring system, which showed a sensitivity of 80% and specificity of 81% for successful identification of the bleeding source at the initial endoscopy. Conclusions: Herein, we propose a scoring system as a useful tool for determining whether emergency endoscopy is indicated in individual patients with suspected colonic diverticular hemorrhage.

Although biologics are important inflammatory bowel disease therapies, loss of response (LOR) remains problematic. We evaluated LOR to biologics in our Crohn disease (CD) patients receiving biologics. Of 137 biologic-treated CD patients, 68 continuously receiving the same biologic type for at least 1 year were divided into 2 groups: infliximab (IFX) (n= 39) and adalimumab (ADA) (n= 29). Clinical courses were compared at biologic introduction and at 1 year. Both groups were retrospectively analyzed for LOR at and beyond 1 year after biologic introduction (study endpoint). Patients were then divided into LOR and non-LOR groups to identify factors predicting LOR. At 1 year after biologic introduction, decreases in CD activity index were 94 +/- 105 in the IFX and 102 +/- 89 in the ADA group, not significantly different. Blood test data did not differ between these groups. LOR occurred in 14 IFX and 5 ADA group patients. Event-free rates at 5 years after biologic introduction were 62% in the IFX and 61% in the ADA group. Patients achieving clinical remission 1 year after biologic introduction accounted for 69% of the IFX and 90% of the ADA group, while respective rates of secondary LOR at 5 years were 32% and 26%. C-reactive protein (CRP) at biologic introduction (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.04-2.06; P=. 02) and age at CD onset (OR, 1.1; 95% CI, 1.01-1.20; P=. 03) predicted LOR. As to IFX and ADA efficacies after 1 year of administration, there were no significant differences in event-free rates for the 5 years after biologic introduction or the secondary LOR rate. CRP at biologic introduction and age at CD onset predicted LOR.

2種の大腸内視鏡前処置薬polyethilene glycol(PEG)高張液(新P)と等張クエン酸マグネシウム液(M)の大腸内視鏡挿入時間を比較し、腸管洗浄度および患者受容性について比較検討した。対象は、新P法使用23例(男女比0.48、平均年齢54.7歳)、M法使用22例(男女比0.38、平均年齢57.6歳)である。その結果、新P法はM法と比較して大腸内視鏡平均挿入時間が長い傾向で、洗浄度、受容度ともに劣ることが示唆された。また、M法の方が医療費が安く経済性が高いことが分かった。

Background: Gastric foveolar hyperplastic polyps (GFHPs) are common findings in clinical practice. GFHPs commonly arise in a background of chronic atrophic gastritis, including autoimmune gastritis (type A gastritis), and have a potential risk of malignant transformation. Case presentation: In 2005, a 55-year-old Japanese woman underwent upper endoscopy at another hospital and was found to have a pedunculated polyp (10 mm in diameter) on the greater curvature of the lower gastric body. On biopsy, the polyp was diagnosed as a GFHP. Nine years later, the polyp had grown to 20 mm in diameter, and the biopsy specimen taken at this time showed tubular adenocarcinoma. On admission to our hospital, the serum Helicobacter Pylori (H. pylori) immunoglobulin G antibody and stool H. pylori antigen were both negative. Anti-gastric parietal cell antibody was positive, as was the anti-intrinsic factor antibody, and the fasting serum gastrin level was markedly increased. In 2014, en bloc resection of the pedunculated polyp was performed by endoscopic submucosal dissection. The final histological diagnosis was adenocarcinoma of the stomach with submucosal and lymphatic invasion. Subsequently, additional radical distal gastrectomy was performed. At the latest follow-up (12 months postoperatively), no recurrence was noted. Conclusions: We here reported a rare case of malignant transformation of GFHP arising in a context of type A gastritis. To our knowledge, there are no previous reports on malignant transformation of GFHP with submucosal and lymphatic invasion arising in a background of type A gastritis in the English literature. Further, there is currently no effective treatment other than endoscopic or surgical treatment for such cases. Given the potential risk of malignant transformation due to hypergastrinemia, we consider that endoscopic treatment should be considered as a first-line therapy when a malignant growth is suspected.

症例は58歳男性で、1週間ほど前に空腹時心窩部痛、嘔気、嘔吐が出現し、近医で胃炎と診断された。H2ブロッカーと胃粘膜保護薬を処方されたが、深夜に症状が増悪し、救急搬送された。血液検査所見で好中球優位の白血球高増加、直接型優位のビリルビン値上昇、肝胆道系酵素上昇を認めた。腹部CT所見では両側の肝内胆管、総胆管が拡張しており、十二指腸乳頭部近傍の下部胆管内に10mm大の高吸収域を認めた。胆石性胆管炎の診断で緊急内視鏡的逆行性胆管膵管造影を施行し、生検で十二指腸乳頭部腺腫と診断した。内視鏡的乳頭切除術(EP)を施行したところ、切除病理組織所見は高度異型を伴う管状絨毛腺腫で断端陰性であった。EP施行後第12病日に残存する総胆管結石に対して内視鏡的切石術を行い、胆管開口部をEPBDバルーンで拡張し採石バルーンで排石した。その後の経過は良好で、半年後の内視鏡MR胆管膵管撮影で乳頭部腺腫や胆管結石の再発を認めていない。

急性膵炎はトリプシンの異所性活性化が中心的な役割を果たすと考えられてきたが、NF-κBの活性化、オートファジー不全、酸化ストレス、小胞体ストレス、細胞内カルシウムの異常などの多くの異常が同時に進行することが明らかとなってきた。これらにも進行の序列はあるはずだが、未だ明らかにされておらず、急性膵炎の発症のメカニズムの詳細は不明のままである。膵酵素の調節性外分泌は細胞内カルシウムによって制御されている。アセチルコリンやコレシストキニンの分泌刺激が基底膜側の受容体から入ると頂端側にカルシウムスパイクが生じて開口放出が起こる。過剰な分泌刺激などを加えて膵炎を発症させると細胞内全体に異常なカルシウム濃度の上昇がみられて遷延する。その異常な上昇をカルシウム結合蛋白やキレート剤、カルシウムチャンネルの阻害剤などを用いて制御すると膵炎発症が抑制されることが明らかになってきた。本項ではカルシウムシグナルに焦点をあてて膵炎との関係を概説する。(著者抄録)

Diversion colitis is a benign inflammatory process that occurs in any part of the large bowel excluded from the fecal stream by a diverting colostomy. While most of the patients with diversion colitis usually are asymptomatic, a minority has abdominal pain and rectal discharge of blood or mucus. A 65-year-old Japanese man was diagnosed as having diversion colitis with ulcerative colitis at 4 months after subtotal colectomy. Corticosteroid and mesalazine enemas were started nonsynchronously. A proctoscopy after 2 months showed no response. Prednisolone injections were started at 1.0 mg/kg daily, but the mucosal inflammation still failed to improve. A combined mesalazine 1 g plus prednisolone sodium phosphate 20 mg enema was started once daily. The rectal bleeding and endoscopic findings improved. Finally proctectomy and ileal pouch-anal anastomosis were successfully performed. A combined mesalazine plus corticosteroid enema may be effective in patients with diversion colitis associated with ulcerative colitis.