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ABSTRACT: We report a case of main pancreatic duct (MPD)-type intraductal papillary mucinous neoplasms of the pancreas (IPMNs), in whom
diagnostic imaging modalities showed abnormal findings after 4 episodes of acute pancreatitis. The patient was 51years old
at his first admission for acute pancreatitis. He experienced two more episodes of acute pancreatitis, though repeated computed
tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) showed no abnormality to explain the cause of the
pancreatitis. After 3½ years from his first episode of pancreatitis, CT and endoscopic ultrasonography revealed pancreatic
duct dilation of the pancreas head. Seven years after the first admission, a second ERCP and intraductal ultrasonography revealed
a partially dilated MPD with papillary tumors. He underwent pancreaticoduodenectomy, and the pathological diagnosis was intraductal
papillary mucinous adenoma with moderate atypia. This case suggests that acute pancreatitis can precede visualized IPMNs.
Therefore, acute recurrent pancreatitis with unknown etiology should be followed up for the possibility of IPMNs, in order
to detect neoplastic changes in the early stage to provide a better prognosis for the patient.
KeywordsIntraductal papillary mucinous neoplasms of the pancreas–Acute pancreatitis–Endoscopic retrograde cholangiopancreatography–Endoscopic ultrasonography
Clinical Journal of Gastroenterology 05/2012; 4(5):307-312.
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Digestive Endoscopy 05/2012; 24(3):195-6. · 1.19 Impact Factor
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Naoyuki Nishimura,
Kiichi Tamada, Shinichi Wada,
Akira Ohashi,
Hisashi Hatanaka,
Katsuyuki Nakazawa,
Norikatsu Numao,
Aya Kitamura,
Kiichi Satoh,
Hironori Yamamoto,
Kentaro Sugano
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ABSTRACT: A 51-year-old woman was admitted to our department because of upper abdominal pain. The serum IgG4 concentration was elevated,
and abdominal computed tomography revealed diffuse enlargement of the pancreas associated with a large cyst, measuring 8cm
in diameter. Endoscopic retrograde cholangiopancreatography revealed narrowing of the main pancreatic duct (from the body
to the tail), narrowing of the intrapancreatic bile duct, and dilatation of the bile ducts. The patient was given a diagnosis
of autoimmune pancreatitis (AIP) associated with a pancreatic pseudocyst and intrapancreatic bile duct stenosis. Oral steroid
therapy resulted in reduced pancreatic swelling, complete disappearance of the pancreatic cyst, and an improvement in biliary
stenosis. AIP is rarely associated with pancreatic cyst, and only 13 cases, including ours, have been reported to date. In
our patient, intense inflammation apparently led to cyst formation in association with AIP, which responded remarkably to
corticosteroid therapy. Correct diagnosis of AIP associated with a pancreatic pseudocyst might save patients from undergoing
unnecessary endoscopic and surgical procedures.
Clinical Journal of Gastroenterology 04/2012; 2(3):199-203.
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Gastrointestinal endoscopy 05/2009; 70(3):592-5. · 6.71 Impact Factor
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ABSTRACT: Little is known about the long-term results of endoscopic papillary balloon dilation (EPBD) for bile duct stones.
Between 1995 and 2000, 204 patients with bile duct stones successfully underwent EPBD and stone removal. Complete stone clearance was confirmed using balloon cholangiography and intraductal ultrasonography (IDUS). Long-term outcomes of EPBD were investigated retrospectively in the year 2007, and risk factors for stone recurrence were multivariately analyzed.
Long-term information was available in 182 cases (89.2%), with a mean overall follow-up duration of 9.3 years. Late biliary complications occurred in 22 patients (12.1%), stone recurrence in 13 (7.1%), cholangitis in 10 (5.5%), cholecystitis in four, and gallstone pancreatitis in one. In 11 of 13 patients (84.6%), stone recurrence developed within 3 years after EPBD. All recurrent stones were bilirubinate. Multivariate analysis identified three risk factors for stone recurrence: dilated bile duct (>15 mm), previous cholecystectomy, and no confirmation of clean duct using IDUS.
Approximately 7% of patients develop stone recurrence after EPBD; however, retreatment with endoscopic retrograde cholangiopancreatography is effective. Careful follow up is necessary in patients with dilated bile duct or previous cholecystectomy. IDUS is useful for reducing stone recurrence after EPBD.
Digestive Endoscopy 04/2009; 21(2):73-7. · 1.19 Impact Factor
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ABSTRACT: When performing endoscopic retrograde cholangiopancreatography (ERCP), the smooth introduction of the duodenoscope into the papilla of Vater, an appropriate view of the papilla of Vater, and deep cannulation of the bile duct are essential. The operator must know the difference between the side-viewing endoscope and the forward-viewing endoscope. The rotation of the body and the left arm of the operator, switching with the left wrist, and dialing of the endoscope are essential for appropriately viewing the papilla of Vater. When training operators to do ERCP, a model is useful for helping them understand basic handling. The approach to deep cannulation of the bile duct should be selected based on the type of papilla (slit type, onion type, tongue protrusion type, flat type, and tumor type). Cannulation is more difficult in patients with the tongue protrusion-type of papilla than with a slit type, onion type, or tumor type. According to previous reports, therapeutic ERCP requires the ability to cannulate the common bile duct deeply 80% of the time; 180 to 200 supervised ERCP are necessary to achieve this success rate.
Digestive Endoscopy 09/2007; 19(4):195 - 200. · 1.19 Impact Factor
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Hiroyoshi Aoki,
Hirohide Ohnishi,
Kouji Hama,
Takako Ishijima,
Yukihiro Satoh,
Kazunobu Hanatsuka,
Akira Ohashi, Shinichi Wada,
Tomohiko Miyata,
Hiroto Kita,
Hironori Yamamoto,
Hiroyuki Osawa,
Kiichi Sato,
Kiichi Tamada,
Hiroshi Yasuda,
Hirosato Mashima,
Kentaro Sugano
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ABSTRACT: Pancreatic stellate cells (PSCs) are activated during pancreatitis and promote pancreatic fibrosis by producing and secreting ECMs such as collagen and fibronectin. IL-1beta has been assumed to participate in pancreatic fibrosis by activating PSCs. Activated PSCs secrete various cytokines that regulate PSC function. In this study, we have examined IL-1beta secretion from culture-activated PSCs as well as its regulatory mechanism. RT-PCR and ELISA have demonstrated that PSCs express IL-1beta mRNA and secrete IL-1beta peptide. Inhibition of TGF-beta(1) activity secreted from PSCs by TGF-beta(1)-neutralizing antibody attenuated IL-1beta secretion from PSCs. Exogenous TGF-beta(1) increased IL-1beta expression and secretion by PSCs in a dose-dependent manner. Adenovirus-mediated expression of dominant-negative (dn)Smad2/3 expression reduced both basal and TGF-beta(1)-stimulated IL-1beta expression and secretion by PSCs. Coexpression of Smad3 with dnSmad2/3 restored IL-1beta expression and secretion by PSCs, which were attenuated by dnSmad2/3 expression. In contrast, coexpression of Smad2 with dnSmad2/3 did not alter them. Furthermore, inhibition of IL-1beta activity secreted from PSCs by IL-1beta-neutralizing antibody attenuated TGF-beta(1) secretion from PSCs. Exogenous IL-1beta enhanced TGF-beta(1) expression and secretion by PSCs. IL-1beta activated ERK, and PD-98059, a MEK1 inhibitor, blocked IL-1beta enhancement of TGF-beta(1) expression and secretion by PSCs. We propose that an autocrine loop exists between TGF-beta(1) and IL-1beta in activated PSCs through Smad3- and ERK-dependent pathways.
AJP Cell Physiology 05/2006; 290(4):C1100-8. · 3.54 Impact Factor
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ABSTRACT: We usually use yolks to assess gallbladder motility by ultrasonography. In this study, we evaluated liquid type CalorieMate as a simple oral stimulus instead of yolks. The volunteers (n = 27) underwent ultrasonography before, 30 min after, and 60 min after taking liquid type CalorieMate. Gallbladder volume and the ejection fraction were measured by ellipsoid method. The mean fasting gallbladder volume, 30-min ejection fraction, and 60-min one were 13.5 ml, 53%, and 62%, respectively. These results were similar to the previous reports by yolks. If the fasting volume is lower than 4ml, they should take re-examination after longer fast to reduce the influence of the dinner the day before the exam. In conclusion, liquid type CalorieMate is useful stimulus to assess gallbladder motility.
Nippon Shokakibyo Gakkai zasshi The Japanese journal of gastro-enterology 12/2005; 102(11):1412-6.
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ABSTRACT: Intraductal ultrasonography is useful in the staging of extrahepatic bile duct cancer including tumor depth infiltration, pancreatic parenchymal invasion, portal vein invasion, and right hepatic artery invasion. However, it has limitations in assessing lymph node metastases. The assessment of longitudinal cancer extension along the bile duct is a promising aspect of this area. However, a thickening of the bile duct wall may represent either inflammatory changes that may result from mechanical irritation by a biliary drainage catheter or other factors, or the longitudinal extension of the cancer.
Digestive Endoscopy 07/2005; 17(s1):S75 - S77. · 1.19 Impact Factor
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Nippon rinsho. Japanese journal of clinical medicine 12/2004; 62 Suppl 11:402-4.
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Journal of Gastroenterology and Hepatology 11/2003; 18(10):1215-8. · 2.87 Impact Factor
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Gastrointestinal Endoscopy 10/2003; 58(3):464-6. · 4.88 Impact Factor
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ABSTRACT: When we remove bile duct stones in endoscopic retrograde cholangiopancreatography, we sometimes encounter the complication of basket impaction. In most cases, bile duct stones can be crushed with a mechanical lithotriptor. An endotriptor also is commonly used to resolve the problem of basket impaction. An endotriptor is more powerful than a mechanical lithotriptor in crushing stones. We report a case of basket impaction that was not resolved by means of an endotriptor. When abdominal radiography shows apparent calcified bile duct stone, it should be cautioned that the stone is sometimes too hard to be crushed, even with use of the endotriptor as well as a mechanical lithotriptor.
Surgical laparoscopy, endoscopy & percutaneous techniques 07/2002; 12(3):184-6. · 1.23 Impact Factor
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ABSTRACT: The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage.
Endoscopic bile duct biopsy was attempted in 61 patients with bile duct strictures. After the introduction of a guidewire into the bile duct, biopsy forceps were inserted via the papilla. Both devices were inserted through the working channel (3.2 mm in diameter) of a conventional duodenoscope. After the procedure, an endoscopic naso-biliary drainage catheter was advanced along the guidewire. The success rate of inserting the biopsy forceps, the sensitivity of the biopsy, and the success rate of endoscopic biliary drainage after the biopsy were analyzed prospectively.
The final diagnosis was malignant strictures in 50 patients and benign strictures in 11. The success rate of inserting biopsy forceps without performing endoscopic papillary balloon dilation was 85%. The sensitivity of the biopsy for primary bile duct cancer (83%) was significantly higher (P < 0.05) than that of pancreatic cancer (47%). All patients had successful endoscopic biliary drainage after the procedure.
A previously placed guidewire facilitates insertion of biopsy forceps and endoscopic biliary drainage. The histological diagnosis of cancer is more likely with bile duct cancer than with pancreatic cancer.
Journal of Gastroenterology and Hepatology 03/2002; 17(3):332-6. · 2.87 Impact Factor
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ABSTRACT: Background: The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage.Methods: Endoscopic bile duct biopsy was attempted in 61 patients with bile duct strictures. After the introduction of a guidewire into the bile duct, biopsy forceps were inserted via the papilla. Both devices were inserted through the working channel (3.2 mm in diameter) of a conventional duodenoscope. After the procedure, an endoscopic naso-biliary drainage catheter was advanced along the guidewire. The success rate of inserting the biopsy forceps, the sensitivity of the biopsy, and the success rate of endoscopic biliary drainage after the biopsy were analyzed prospectively.Results: The final diagnosis was malignant strictures in 50 patients and benign strictures in 11. The success rate of inserting biopsy forceps without performing endoscopic papillary balloon dilation was 85%. The sensitivity of the biopsy for primary bile duct cancer (83%) was significantly higher (P < 0.05) than that of pancreatic cancer (47%). All patients had successful endoscopic biliary drainage after the procedure.Conclusion: A previously placed guidewire facilitates insertion of biopsy forceps and endoscopic biliary drainage. The histological diagnosis of cancer is more likely with bile duct cancer than with pancreatic cancer.© 2002 Blackwell Science Asia Pty Ltd
Journal of Gastroenterology and Hepatology 02/2002; 17(3):332 - 336. · 2.87 Impact Factor
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ABSTRACT: To clarify the cholangiographic findings of early-stage (T1, tumor confined to the mucosal or fibromuscular layer) extrahepatic
bile duct carcinoma. Methods. Cholangiographic images were retrospectively analyzed without other information in 55 patients with extrahepatic bile duct
carcinoma who underwent surgical treatment. Tumor stages were T1 (n = 10), T2 (n = 17), and T3 (n = 28). Cholangiographic findings were classified as "diffuse sclerosis," "stenosis," "papillary polypoid filling defect,"
or "nodular polypoid filling defect". "Papillary polypoid filling defect" was the term used when the width of the base was
smaller than the width of the polypoid filling defect. Results. T1 patients showed papillary polypoid filling defects (n = 8) or nodular polypoid filling defects (n = 2) on cholangiography. When cholangiography showed papillary polypoid filling defects, 8 of the 14 resected patients showed
T1 stage tumor histologically. Conclusions. In this study, 57% (8/14) of resected patients with papillary polypoid filling defects showed T1 stage tumor. No T1 stage
tumor showed stenosis or diffuse sclerosis.
Journal of Gastroenterology 11/2001; 36(12):837-841. · 4.16 Impact Factor
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ABSTRACT: Because biopsy forceps tend to turn towards the right hepatic duct during endoscopic retrograde cholangiopancreatography
(ERCP), selective access to the left hepatic duct is difficult. Methods. In this study, we managed to insert biopsy forceps selectively into the left hepatic duct, by using a looping technique,
in three patients. Biopsy forceps were inserted into the right hepatic duct by the conventional method. The elevator of the
endoscope was kept down, and the shaft of the biopsy forceps was then advanced to the duodenal cavity until it formed a loop
between the endoscope and the papilla. During the procedure, the tip of the forceps was kept at the hepatic hilus. Results. In this condition, we were able to slowly rotate the tip of the forceps and direct the forceps towards the left. Sufficient
material from the left hepatic duct was obtained in all patients. Conclusions. The looping technique was useful for selective access to the left hepatic duct.
Journal of Gastroenterology 06/2001; 36(7):492-494. · 4.16 Impact Factor
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ABSTRACT: Background and Aim: Tumor thrombi in the bile duct caused by hepatocellular carcinoma (HCC), and cholangiocarcinoma show polypoid lesions on cholangiographic findings. This study prospectively compared the images of intraductal ultrasonography between HCC and polypoid cholangiocarcinoma.Methods: In five patients with tumor thrombi in the bile duct caused by HCC, a 2.0 mm diameter ultrasonic probe with a frequency of 20 MHz was inserted into the bile duct via the transpapillary route (n = 4) or the transhepatic route (n = 1). The images were compared to that of 65 patients with cholangiocarcinoma.Results: In all patients with HCC, intraductal ultrasonography showed a ‘polypoid tumor with a narrow base’. In 16 of 65 patients with cholangiocarcinoma, it showed a ‘polypoid tumor with a narrow base’. When intraductal ultrasonography showed a ‘polypoid tumor with a narrow base’, the findings of a positive ‘nodule within a nodule’ (40 vs 0%; P < 0.05), and the absence of a ‘papillary-surface pattern’ (80 vs 13%; P < 0.05) were more highly associated with tumor thrombi caused by HCC than to polypoid-type cholangiocarcinoma.Conclusions: Intraductal ultrasonography was useful to distinguish between tumor thrombi caused by HCC and polypoid-type cholangiocarcinoma.
Journal of Gastroenterology and Hepatology 06/2001; 16(7):801 - 805. · 2.87 Impact Factor
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ABSTRACT: Background: An imaging modality that can be used to identity small stones after a biliary lithotripsy is required. Intraductal ultrasonography was evaluated by using percutaneous transhepatic cholangioscopy as the gold standard.Methods: Lithotripsy, under percutaneous transhepatic cholangioscopy guidance, was performed in 20 patients. A thin-caliber ultrasonic probe (2.0 mm in diameter and 20 MHz frequency) was inserted into the bile duct through the percutaneous tract after lithotripsy, and residual stones were identified. This was followed by percutaneous transhepatic cholangioscopy.Results: In the extrahepatic bile ducts, intraductal ultrasonography provided images of all the stones demonstrated on cholangioscopy (n = 11). The sensitivity was superior to that of cholangiography (P < 0.005). However, in the intrahepatic bile ducts, intraductal ultrasonography only visualized the stones located in the cannulated lobe. Extrahepatic stones smaller than 5.0 mm in diameter or in a common hepatic duct larger than 15.0 mm in diameter were missed by cholangiography, but were visualized by the use of intraductal ultrasonography (P < 0.05).Conclusions: Intraductal ultrasonography is equivalent to cholangioscopy in the extrahepatic bile ducts. Cholangiography and intraductal ultrasonography should be used in combination to image intrahepatic and extrahepatic stones.
Journal of Gastroenterology and Hepatology 12/2000; 16(1):100 - 103. · 2.87 Impact Factor
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ABSTRACT: Percutaneous recanalization of the bile duct is essential for placing biliary stents and carrying out other interventions.
This prospective study was performed to establish safe approaches for percutaneous recanalization of the bile duct when it
had previously resulted in failure. Between July 1995 and July 1999, percutaneous recanalization of the bile duct was attempted
in 58 patients with a malignant biliary stenosis. When recanalization failed, an endoscopic naso-biliary drainage (ENBD) catheter
was placed across the stenosis. The procedure was again attempted along the ENBD catheter. In the period of the study, four
patients underwent successful recanalization after ENBD, although attempts prior to ENBD had been unsuccessful. As a result,
the success rate of recanalization in the period was 100% (58/58). When recanalization fails, the use of an ENBD catheter
may provide access to the biliary tree, and the biliary stenosis can be recanalized safely.
Journal of Gastroenterology 07/2000; 35(8):622-626. · 4.16 Impact Factor
