RYUZO DEGUCHI

A 55-year-old woman presented to her primary care physician with facial and lower leg edema. After being referred to our hospital because of hypothyroidism and hypokalemia on blood tests, she also had elevated adrenocorticotropic hormone (ACTH) and cortisol levels, but a dexamethasone suppression test showed no cortisol suppression. Ectopic ACTH syndrome due to pancreatic neuroendocrine carcinoma (PNEC) was suspected. endoscopic ultrasound-guided fine-needle aspiration was performed, and a histopathological examination of the obtained specimen revealed multiple liver metastases of the PNEC. Imaging after etoposide and cisplatin therapy showed cystic changes in the primary lesions and shrinkage of the liver metastases, and the ACTH levels were within the normal range.

INTRODUCTION: Autonomic imbalance has been reported to correlate with clinical remission in patients with ulcerative colitis (UC). This study evaluated heart rate variability (HRV), a potential digital biomarker, in patients with active UC using a smartwatch that is easy to handle. METHODS: Patients with active UC were recruited for this prospective study. The patients' HRV was measured via the Fitbit Inspire2™ linked via Bluetooth to their smartphone. HRV during nighttime sleep was obtained from continuous data. Patients were required to input the Simple Clinical Colitis Activity Index (SCCAI) score once daily by the application on their smartphones for 3 months. RESULTS: Nine patients with UC were included. In clinically active disease, SCCAI scores showed a weak inverse relationship with parasympathetic activity, differences of successive R-R pulse intervals (RMSSD) (r = -0.44, p < 0.0001), high frequency (HF) (r = -0.42, p < 0.0001), and total autonomic nervous activity, low frequency (LF) (r = -0.43, p < 0.0001). Receiver operating characteristic analysis indicated that the RMSSD, HF, and LF were significantly higher in patients with active UC. Meanwhile, LF showed the most correlation with severity for bowel urgency scores. CONCLUSION: Longitudinal nighttime HRV recorded using a smartwatch is associated with disease activity in patients with active UC. In particular, RMSSD and HF, which are indices of the parasympathetic nervous system, have been suggested as potential digital biomarkers for UC.

Amoebic dysentery is designated a Category 5 disease under the Infectious Disease Control Law in Japan, with approximately 1,000 cases reported annually. About 10% of these are cases of invasive amoebic dysentery, 90% of which have an asymptomatic course and are often discovered incidentally, and there is concern that the number of undiagnosed cases is increasing since the reagent for that blood antibody test was discontinued in 2017. Invasive amoebic dysentery often causes ulcerative lesions that affect the cecum and rectum predominantly, but eradication of amoebic dysentery is possible with proper diagnosis and treatment. However, there have been cases in which delayed diagnosis and treatment have resulted in fulminant forms of colorectal ulceration, including perforated peritonitis and amoebic liver abscesses. In this report, the importance of the diagnosis and treatment of this disease is reiterated, and a case that was difficult to diagnose is presented.

A man in his 70s came to our department with jaundice. He was diagnosed with Merkel cell carcinoma in the left eyebrow area 3 years ago and was followed up after tumor resection. Endoscopic retrograde cholangiopancreatography was performed because the computed tomography and abdominal ultrasonography revealed bile duct dilatation. However, the duodenum was too narrow and deformed to reach the ventral papilla. Percutaneous transhepatic cholangiodrainage was performed, and bile cytology revealed no malignant findings; however, it did not sufficiently reduce the jaundice. Subsequently, endoscopic ultrasound-fine needle biopsy was performed on his right adrenal mass, which led to a diagnosis of the rare Merkel cell carcinoma. In summary, we report here of a case in which endoscopic ultrasound-fine needle biopsy led to the diagnosis of Merkel cell carcinoma recurrence.

An 87-year-old man experiencing lower abdominal discomfort resulting from the ingestion of a fish bone underwent conservative management involving endoscopic extraction of the fish bone lodged in the sigmoid colon. Most patients with lower gastrointestinal tract perforations typically develop peritonitis or abscesses, necessitating surgical intervention. Notably, endoscopic management of lower gastrointestinal tract perforations is infrequently employed. Patients presenting with localized abdominal symptoms along with a stable overall health condition may benefit from conservative therapeutic approaches that utilize endoscopic methods. Notably, the transition from endoscopic procedures for foreign body removal to surgical intervention requires close collaboration with a surgeon and must be executed judiciously.

Two cases of colorectal mucosa-associated lymphoid tissue lymphoma (cMALT) are presented and discussed with the reports from 1997 to the present. Helicobacter pylori (HP)-negative cases showed tumor resolution 2 months after eradication therapy. HP-positive cases were successfully eradicated and tumor resolution was confirmed 16 months later. Analysis of the data reported to date shows that cMALT resolution rates were 68.4% (13/19) in the HP-negative group and 33.3% (7/21) in the HP-positive group. HP eradication should be considered the primary treatment for cMALT regardless of HP infection, especially in untreated patients under follow-up.

A 71-year-old woman was found to have submucosal tumor-like lesion on colonoscopy (CS) before gastric surgery, and computed tomography (CT) showed a 12-mm structure at the base of the appendix. The lesion could not be clearly detected on CT nine months later, but it had enlarged again on CT one year later; therefore, CS and endoscopic ultrasound (EUS) were performed. The lesion was determined to be cystic with viscous contents, and laparoscopic appendicectomy was performed. This is the first report of low-grade appendiceal mucinous neoplasm (LAMN) diagnosed by a histopathologic examination of a resected specimen showing shrinkage and re-expansion of the appendix.