論文

胆膵内視鏡関連処置は,消化器内視鏡検査の中で偶発症のリスクが高い処置の一つであり,特に十二指腸乳頭部周囲に生じた穿孔は,胆汁や膵液の直接的な曝露も重なり,管理に難渋することも少なくない.症例は47歳男性.肝胆道系酵素の上昇を伴う総胆管結石に対して,ERCPを行なった.EST施行後,結石除去を試みたが,結石の把持と破砕が困難であり,一期的な処置を断念した.処置から5時間後,腹痛を契機に穿孔の診断に至ったため,緊急でERCPを行い,胆管と膵管へ経鼻ドレナージを挿入した.以降,次第に炎症所見は改善し,処置20日後に退院した.当院では,ESTに伴う穿孔を2例,内視鏡的乳頭部切除術に伴う穿孔を2例経験し,ドレナージを行わなかった1例で最終的に外科的手術を要した.乳頭部の穿孔症例に対する内視鏡的胆管・膵管ドレナージ術の有効性が示唆される症例であった.(著者抄録)

急性膵炎重症患者の院内死亡率について、生理食塩液(NS)で治療した患者とリンゲル液(RS)で治療した患者で差があるかについて検討した。日本のDiagnosis Procedure Combination(DPC)データベースを用いて、後ろ向きコホート研究を行った。2010年7月～2021年3月を対象期間とし、急性膵炎によりICUまたは高度治療室(HDU)に入室し、3日間以上生存し、入室後3日以内に十分な輸液蘇生を受けた成人患者を調べた。輸液の80%超が生理食塩液だった患者をNS群、80%超がリンゲル液だった患者をRS群とし、傾向スコアマッチングを行って2群間の院内死亡率を比較した。患者8710例[NS群:657例(7.5%、中央値66.0歳、男性67.7%)、RS群:8053群(92.5%、中央値63.0歳、男性64.5%)]が組み入れ基準を満たした。傾向スコアマッチング後の各群578例を解析した。NS群はRS群より院内死亡率が有意に高く、重度急性膵炎や遷延性腎不全の転帰も不良であった。以上より、急性膵炎でICUまたはHDUに入室して輸液蘇生を受ける患者では、生理食塩液よりリンゲル液が望ましい輸液治療である可能性が示唆された。

This study aimed to investigate a suggestive case of IgA vasculitis that developed following acute tonsillitis in a patient with Crohn’s disease treated with adalimumab. IgA vasculitis and Crohn’s disease can both cause abdominal pain, joint pain, and erythema, making an early diagnosis difficult. When they occur together, it can be challenging to determine which is the primary condition. Due to similar symptoms, a careful assessment and thorough understanding of each disease’s characteristics are essential for an accurate diagnosis and proper management. In this case, the overlapping of immunological events due to anti-tumor necrosis factor-ɑ (TNF-ɑ) agents and infection, in addition to pre-existing immune abnormalities, may be contributing factors to the development of IgA vasculitis. Based on this experience, we suggest that patients with inflammatory bowel disease receiving anti-TNF-ɑ agents should be monitored not only for the relapse of their underlying disease but also for the development of IgA vasculitis following tonsillitis.

Objectives: Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP), their optimal dosage is unknown. Given possible interindividual variability in the pharmacodynamics of NSAIDs, we hypothesized that the dose required to achieve adequate PEP prophylaxis varies with body weight. Materials and Methods: We conducted an analysis using single-center, prospective, observational cohort study data. The primary outcome was PEP incidence by NSAID dosage per body weight (mg/kg). Patients meeting the inclusion criteria were classified into 3 groups. Results: We included 891 patients, with 400, 454, and 37 patients in the control group with no NSAID therapy, the NSAID <1.0 mg/kg group, and the NSAID ≥1.0 mg/kg group, respectively. In the adjusted cohort, the odds ratio of PEP was 0.18 (95% confidence interval: 0.041–0.79; P = 0.023) for NSAID ≥1.0 mg/kg and 1.3 (95% confidence interval: 0.76–2.3; P = 0.31) for NSAID <1.0 mg/kg compared to the control group without NSAID. Conclusions: PEP was not prevented by NSAID dosages below 1.0 mg/ kg body weight whereas a dosage above 1.0 mg/kg body weight had a significant prophylactic effect. An NSAID dosage adjusted to body weight may be necessary to achieve an adequate prophylactic effect against PEP.

Background and Aims Endoscopic papillectomy (EP) is a minimally invasive treatment for ampullary epithelial tumors. However, clinical outcomes and predictors of recurrence remain unclear. Methods We conducted a multicenter, retrospective cohort study at 22 tertiary centers in Japan, including patients who underwent EP between January 2009 and December 2020. The primary outcome was cumulative recurrence in patients with histologically confirmed adenoma or adenocarcinoma. Recurrence predictors were evaluated using Cox proportional hazards model. Results Of 875 patients, 798 had confirmed ampullary epithelial tumor, and 776 were included in the long-term outcome analysis. The 3-year cumulative recurrence rate was 20%. Indeterminate (Rx) and positive (R1) resection margins were independently associated with higher recurrence compared with negative margins (R0), with hazard ratios of 2.30 (95% CI, 1.44-3.68) and 2.95 (95% CI, 1.85-4.71), respectively. R0 resection was achieved in 52.1% (416/798) of patients, with a 3-year cumulative recurrence rate of 11% (95% CI, 7.6%-15%). Conclusions Recurrence after EP for ampullary epithelial tumors is common, even after R0 resection. These findings highlight the need for long-term surveillance following EP.

Primary sclerosing cholangitis (PSC) is frequently accompanied by colitis with clinicopathologic features that differ from conventional inflammatory bowel disease (IBD). Accumulating evidence indicates that PSC-associated IBD (PSC-IBD) often presents as extensive colitis with a right-sided predominant distribution and characteristic endoscopic features, such as rectal sparing and backwash ileitis. Beyond endoscopic appearance, PSC-IBD also appears to have distinct biological underpinnings, including shared genetic susceptibility, dysregulated bile acid signaling, altered gut microbial communities, and immune crosstalk along the gut–liver axis. These mechanisms may contribute not only to intestinal inflammation but also to PSC-related clinical outcomes. From a long-term perspective, patients with PSC and colitis are consistently classified as a high-risk group for colorectal neoplasia, warranting early and intensive colonoscopic surveillance. In parallel, surveillance for hepatobiliary malignancies remains central in PSC care, although risk stratification continues to evolve. Therapeutic management generally follows established IBD algorithms, yet the extent to which colitis-directed therapies modify PSC outcomes remains uncertain, with heterogeneous findings across cohorts and endpoints. In this review, we summarize current knowledge on the clinical phenotype, mechanistic framework, and outcome-driven management of PSC-IBD, and highlight future directions toward precision surveillance and mechanism-based interventions targeting bile acid–microbiota–immune interactions.

The incidence of duodenal tumors (DTs) is increasing. However, the mechanisms underlying its development remain unclear. Environmental factors, including the microbiome and bile acids (BAs), are believed to influence tumor development. Therefore, we conducted a single-center, prospective, observational study to investigate the potential differences between patients with DTs and healthy controls (HCs) based on these factors. In addition, the BAs in the duodenal fluid were measured using liquid chromatography-tandem mass spectrometry. We recruited 41 patients and performed 16S rRNA-seq. There was no difference in the observed ASVs or PCoA plot of Bray–Curtis dissimilarity between the DTs and HCs. The lithocholic acid concentration was significantly lower in the DT group than in the control group. The ratio of CDCA to LCA was significantly higher in patients with DTs. No significant differences in microbiota were observed between DTs and HCs. In patients with DTs, the lithocholic acid concentration in duodenal was significantly lower than in HCs.

Background and Aims: We compared ERCP using a balloon-assisted endoscope (BE-ERCP) with EUS-guided antegrade treatment (EUS-AG) for removal of common bile duct (CBD) stones in patients with Roux-en-Y (R-Y) gastrectomy. Methods: Consecutive patients who had previous R-Y gastrectomy undergoing BE-ERCP or EUS-AG for CBD stones in 16 centers were retrospectively analyzed. Results: BE-ERCP and EUS-AG were performed in 588 and 59 patients, respectively. Baseline characteristics were similar, except for CBD diameter and angle. The technical success rate was 83.7% versus 83.1% (P = .956), complete stone removal rate was 78.1% versus 67.8% (P = .102), and early adverse event rate was 10.2% versus 18.6% (P = .076) in BE-ERCP and EUS-AG, respectively. The mean number of endoscopic sessions was smaller in BE-ERCP (1.5 ± .8 vs 1.9 ± 1.0 sessions, P = .01), whereas the median total treatment time was longer (90 vs 61.5 minutes, P = .001). Among patients with biliary access, the complete stone removal rate was significantly higher in BE-ERCP (93.3% vs 81.6%, P = .009). Negative predictive factors were CBD diameter ≥15 mm (odds ratio [OR], .41) and an angle of CBD <90 degrees (OR, .39) in BE-ERCP and a stone size ≥10 mm (OR, .07) and an angle of CBD <90 degrees (OR, .07) in EUS-AG. The 1-year recurrence rate was 8.3% in both groups. Conclusions: Effectiveness and safety of BE-ERCP and EUS-AG were comparable in CBD stone removal for patients after R-Y gastrectomy, but complete stone removal after technical success was superior in BE-ERCP.