Although pain is a common complication of endoscopic submucosal dissection (ESD), management strategies are inadequate. The aim of this study was to evaluate the efficacy of topical bupivacaine and triamcinolone acetonide for abdominal pain relief and as a potential method of pain control after ESD for gastric neoplasia. In this randomized, double-blind, placebo-controlled trial, 111 eligible patients with early gastric neoplasm were randomized into one of three groups: bupivacaine (BV) only, bupivacaine with triamcinolone (BV-TA), or placebo. The present pain intensity (PPI) score and the Short-Form McGill Pain Questionnaire (SF-MPQ) were used to evaluate pain at 0, 6, 12, and 24 h after ESD. The mean values for the 6-hour PPI in the BV-TA and BV groups were lower than those of the placebo group (1.57 ± 1.09 and 1.97 ± 1.09 vs. 2.63 ± 0.98, p < 0.001). The 12-hour PPI of the BV-TA group (1.20 ± 0.83) was the lowest among the three groups (p = 0.001). The total 6-hour SF-MPQ score, especially in the sensory domain, was higher in the placebo group than in BV and BV-TA groups. The 12-hour SF-MPQ score was the lowest in the BV-TA group. Multivariate analysis demonstrated that BV-TA injection protocol, fibrosis, and size of residual ulcer were independently associated with the PPI score at 6 h. Bupivacaine after ESD was effective for pain relief at 6 h postoperatively. Particularly, topical infiltration of bupivacaine mixed with triamcinolone acetonide was helpful for producing a more long-lasting benefit of pain relief after gastric ESD.

The efficacy of topical bupivacaine and triamcinolone acetonide injection in the relief of pain after endoscopic submucosal dissection for gastric neoplasia: a randomized double-blind, placebo-controlled trial.

Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English andSpanish literature is carried out, from 1980 to the present time.The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/or fibrogastroscopy. There are many existing risk factors described.The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications.

/pdf/phlegmonous-gastritis-a-rare-entity-as-a-differential-4qlnjxxxgg.pdf

Phlegmonous gastritis: A rare entity as a differential diagnostic of an acute abdomen. Description of a case and a bibliographic review.

Gastric biopsies are often submitted with as clinical question Helicobacter pylori (HP) infection. Regularly, the morphology suggests a HP infection but the organism is not detected in special stains. This review presents a practical approach to deal with such biopsies. The first step is to exclude a false negative result of the search for HP, by ensuring that both antral and oxyntic mucosa are present, by the use of sensitive stains, identification of marked reactive changes, such as intestinal, pseudo-pyloric, pancreatic metaplasia that may suggest a diagnosis of (HP associated or autoimmune) atrophic gastritis, and finally identification of signs of the use of proton pump inhibitors (PPI) as in such biopsies, HP may sometimes be found only within parietal cells. The differential diagnosis should include lymphocytic gastritis, other diseases affecting the stomach, such as inflammatory bowel disease (IBD), vasculitis, granulomatous disease, viral infection, such as cytomegalovirus (CMV) or more rarely Epstein-Barr virus (EBV) infection, or other bacterial infections, such as Enterococcus and Treponema pallidum. Clinical input may be required to ensure the patient is not taking medication that may cause gastritis, such as antibiotics used for HP eradication or common medications that cause a form of gastropathy. When these have been excluded, a known cause has not been found and in such a case, the term idiopathic focal/diffuse gastritis can be used.

The differential diagnosis of Helicobacter pylori negative gastritis

Signet ring cell carcinoma of early gastric cancer, is endoscopic treatment really risky?

Phlegmonous gastritis (PG) is a rare, often fatal, condition characterized by suppurative bacterial infection of the stomach. Mucosal damage of the stomach, alcoholism and an immunocompromised state are predisposing factors. Phlegmonous gastritis rarely develops after therapeutic endoscopy and only a few instances have been reported. We describe a patient with PG that arose as a complication after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). A 70-year-old woman with a diagnosis of pancreatic tumor attended our hospital. A 50-mm, low echoic lesion at the pancreatic body was identified by EUS and EUS-FNA proceeded through the stomach using a 19-gauge needle (Echo Tip®Ultra;Wilson-Cook,Winston Salem, NC, USA). She was discharged on the following day. She returned to our hospital 1 week later due to persistent upper abdominal pain and low-grade fever. Her vital signs were: blood pressure, 105/ 66 mmHg; regular pulse, 96 b.p.m. and temperature of 38°C. The patient’s abdomen was soft, flat, and slightly distended with mild tenderness in the upper area. The laboratory findings were as follows: obvious inflammation with white blood cells (WBC) 13 500/mL and C-reactive protein (CRP) 28 mg/ dL. Multi-detector row computed tomography (MDCT) revealed diffuse thickening of the gastric wall and air trapped within it (Fig. 1). Upper gastrointestinal endoscopy revealed diffuse erythema, edema and erosions (Fig. 2). EUS also showed diffuse gastric wall thickening, predominantly in the submucosa (Fig. 3). The culture of several biopsy specimens from the mucosal surface revealed a-Streptococcus and PG caused by EUS-FNA was clinically diagnosed. The patient recovered after antibiotic therapy with peperacillin/ tazobactam and she was discharged on hospital day 15. EUS-FNA is a safe procedure with a complication rate of approximately 1% that does not normally require antibiotic prophylaxis. However, the risk of PG must be considered for immunocompromised patients with advanced cancer and preventative antibiotics may be necessary.

Phlegmonous gastritis caused by endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA)

thelioma-like gastric carcinoma that presented as a flat depressed lesion and was treated by complete en-bloc resection using endoscopic submucosal dissection (ESD). A 73-year-old manwas referred to the department of internal medicine because of an incidental finding suspicious of early gastric cancer. The patient’s medical history and laboratory test results were unremarkable. Gastroscopy revealed an erythematous, flat depressed lesion in the posterior wall of the upper part of the gastric body (●" Fig. 1). No abnormalities were detected on abdominal computed tomography. The tumor was removed completely by ESD, using an insulation-tipped knife (KD610L; Olympus, Tokyo, Japan) (●" Fig. 2). Histopathological findings of the resected specimen were compatible with the diagnosis of lymphoepithelioma-like gastric carcinoma (●" Fig. 3). Lymphoepithelioma-like gastric carcinoma is a rare type of gastric carcinoma, constituting about 4% of all gastric carcinomas [1]. It is characterized by the presence of a lymphoid stroma and small nests of cancer cells that are uniformly distributed throughout the lymphoid stroma. There is clear demarcation between the tumor nests and the nondesmoplastic lymphocyte-rich stroma, as is the case with lymphoid tissue. Lymphoepithelioma-like gastric carcinoma has a good prognosis and is closely associated with the presence of the Epstein-Barr virus and microsatellite instability [2]. The recently introduced technique of ESD can be useful in the diagnosis and treatment of early gastric cancer. In particular, this method enables en-bloc resection of the tumor, regardless of tumor size and location. In our case, endoscopic examination of the flat depressed lesion revealed an appearance typical of early gastric adenocarcinoma. However, the histological examination revealed that the tumor was a lymphoepithelioma-like gastric carcinoma.

/pdf/lymphoepithelioma-like-gastric-carcinoma-resected-by-1iwicwywct.pdf

Lymphoepithelioma-like gastric carcinoma resected by endoscopic submucosal dissection (ESD).

single filiform polyp discovered during routine screening in an individual without symptoms or a history of colonic disease. A 47−year−old man was transferred to our outpatient department for treatment of a single colon polyp which had been inci− dentally found on medical examination. Other results including upper endoscopy and laboratory test except colonoscopy were normal. The patient was asympto− matic and in good health. He had no sig− nificant history of intestinal complaint or gastrointestinal bleeding. We carried out a routine colonoscopic examination. Co− lonoscopy demonstrated a long, thin and finger−like polyp in the transverse colon (l\" Fig. 1a, b). We carried out an endo− scopic polypectomy by snare. Histologi− cally, the polyp was filiform and covered by normal mucosa (l\" Fig. 2a, b). Obser− vation has continued to date, but no gas− trointestinal symptoms or signs have been observed. Filiform polyposis is a rare condition of postinflammatory polyposis as a benign, nonspecific sequela characterized by multiple, slender, arborizing, vermiform projections of submucosa covered by mu− cosa on all sides. Filiform polyps are often long and thin (2±5 cm in length and 0.5 cm in diameter), and almost always multiple. Filiform polyposis has been rarely reported in patients without pre− vious colonic disease. A review of the lit− erature revealed only six cases of filiform polyposis without evidence and history of inflammatory bowel disease [1, 2]. All of the patients experienced diarrhea or gas− trointestinal bleeding. A single filiform polyp was shown in only two patients with severe hemorrhage [1,2]. To our knowledge, this is the first report of filiform polyposis, which was fortu− nately found in an asymptomatic adult without evidence of inflammatory bowel disease on health screening. Our case is the first that shows no symptoms and a single filiform polyp. It is difficult to ex− plain why a filiform polyp is born in an asymptomatic adult. Single filiform polyp in asymptomatic healthy Korean without history of inflammatory bowel disease

/pdf/single-filiform-polyp-in-asymptomatic-healthy-korean-without-2baczqm8ts.pdf

Single filiform polyp in asymptomatic healthy Korean without history of inflammatory bowel disease.

The major modes of spread for colon cancer are local invasion and lymphatic and hematogenous metastasis, with the liver being the most common site of metastasis, followed by the peritoneum, omentum, lung, and mesentery. Parotid gland involvement by adenocarcinoma of the colon is extremely rare. We report here a patient who developed a mass in the right neck due to a metastasis from a double primary adenocarcinoma of the colon. A 78-year-old woman attended our hospital after an episode of hematochezia that had occurred 3 days previously. At her visit, she also complained of a lump in her neck that she had noticed amonth before. A colonoscopy performed to evaluate the hematochezia showed a coin-shaped, elevated lesion in the area adjacent to the ileocecal valve (●\" Fig.1a) and an ulcerated, fungating mass surrounding the lumen of the sigmoid colon (●\" Fig.1b). Biopsies of each lesion were taken for histology, and both revealed a diagnosis of moderately differentiated colon adenocarcinoma. Combined positron emission tomography and computed tomography (PET/CT) was performed for the staging and evaluation of the colon cancer. This showed a hypermetabolic lesion accompanied by diffuse wall thickening in the sigmoid colon and a hypermetabolic mass in the right parotid gland (●\" Fig.2). Subsequent magnetic resonance imaging (MRI) showed a 5.6-cm mass with low intensity T1weighted signal and heterogeneous high intensity T2-weighted signal in the right parotid gland (●\" Fig.3). To further evaluate the right neck mass, a fine needle aspiration (FNA) was performed, whichwas consistent with a diagnosis of metastatic carcinoma. A decision was made to perform a right hemicolectomy and anterior resection followed by a parotidectomy (●\" Fig.4a). Histopathology of the resected parotid gland revealed tumor cell infiltration and accompanying necrosis of the capsule. Columnar cells, which are not observed in normal parotid tissue, were present (●\" Fig.4b), and staining for carcinoembryonic antigen (CEA), performed to verify the colonic origin of the metastasis, showed focal positivity (●\" Fig.4c). Based on the above results, the patient was diagnosed as having double primary cancer of the colon Fig.1 Views from a colonoscopy performed in a 78-year-old woman with hematochezia showing: a a coin-shaped, elevated lesion in the area of the ileocecal valve; b an ulcerated, fungating mass surrounding the lumen of the sigmoid colon.

/pdf/a-rare-case-of-double-primary-cancer-of-the-colon-with-4xqb5p4be7.pdf

A rare case of double primary cancer of the colon with parotid gland metastasis.

cancer associated with overt bone mar− row metastasis in the form of osteoblastic lesions. A 71−year−old man was referred to the Department of Internal Medicine because of an incidental finding of anemia and in− creased alkaline phosphatase. The patient had no specific medical history and his la− boratory results showed his hemoglobin level to be 9.2 g/dL and his alkaline phos− phatase to be 2366 IU/L. It was concluded that his anemia was due to chronic ill− ness. Gastroscopy was performed and four flat erosions were found at the great− er curvature and anterior wall of the an− trum (l\" Fig. 1), which were biopsied. No abnormalities were found in the stomach or in any other organs on abdominal com− puted tomography (l\" Fig. 2). Bone scinti− graphy showed increased uptake, espe− cially in the diaphyses of the long bones (l\" Fig. 3). The endoscopic biopsy was re− ported as showing signet ring cell carci− noma (l\" Fig. 4), and signet ring cells were also found in a bone marrow biopsy. The patient was eventually diagnosed with early gastric cancer with bone mar− row metastasis (l\" Fig. 5).

/pdf/overt-bone-marrow-metastasis-from-early-gastric-cancer-3po9y4z7fw.pdf

Overt bone marrow metastasis from early gastric cancer.

Phlegmonous gastritis, or acute suppurative gastritis, is a rare, life-threatening condition which is characterized by purulent necrosis and thickening of the gastric wall. A combination of gastrectomy and antibiotic therapy is an effective treatment. We report a rare case of phlegmonous gastritis occurring after endoscopic mucosal resection. The patient was treated initially with antibiotic therapy but eventually required surgery.

Phlegmonous gastritis after endoscopic mucosal resection.

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