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Risk factors for adverse in-hospital outcomes in acute colonic diverticular hemorrhage

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World Journal of Gastroenterology 2015年第37期21卷 10697-10703页

作者： Naoyoshi Nagata Ryota Niikura Tomonori Aoki Shiori Moriyasu Toshiyuki Sakurai Takuro Shimbo Katsunori Sekine Hidetaka Okubo Kazuhiro Watanabe Chizu Yokoi Junichi Akiyama Mikio Yanase Masashi Mizokami Kazuma Fujimoto Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and Medicine department of Clinical Research and Informatics National Center for Global Health and Medicine department of Gastroenterology and Hepatology National Center for Global Health and Medicine Kohnodai Hospital Kohnodai department of internal medicine and Gastrointestinal Endoscopy Saga Medical School

AIM: To investigate the factors associated with transfusion, further bleeding, and prolonged length of ***: In total, 153 patients emergently hospitalized for diverticular bleeding who were examined by colonoscopy were prospectively enrolled. Patients in whom the bleeding source was identified received endoscopic treatment such as clipping or endoscopic ligation. After spontaneous cessation of bleeding withconservative treatment or hemostasis with endoscopic treatment, all patients were started on a liquid food diet and gradually progressed to a solid diet over 3d, and were discharged. At enrollment, we assessed smoking, alcohol, medications [non-steroidal antiinflammatory drugs(NSAIDs)], low-dose aspirin, and other antiplatelets, warfarin, acetaminophen, and oral corticosteroids), and co-morbidities [hypertension,diabetes mellitus, dyslipidemia, cerebro-cardiovascular disease, chronic liver disease, and chronic kidney disease(CKD)]. The in-hospital outcomes were need for transfusion, further bleeding after spontaneous cessation of hemorrhage, and length of hospital *** odds ratio(OR) for transfusion need, further bleeding, and prolonged length of stay were estimated by logistic regression ***: No patients required angiographic embolization or surgery. Stigmata of bleeding occurred in 18% of patients(27/153) and was treated by endoscopic procedures. During hospitalization, 40patients(26%) received a median of 6 units of packed red blood cells. Multivariate analysis revealed that female sex(OR = 2.5, P = 0.02), warfarin use(OR= 9.3, P hospitalization, 6 patients(3.9%) experienced further bleeding, and NSAID use(OR = 5.9, P = 0.04)and stigmata of bleeding(OR = 11, P hospital stay was 8 d. Multivariate analysis revealed that age > 70years(OR = 2.1, P = 0.04) and NSAID use(OR = 2.7,P = 0.03) were

关键词： In-hospital adverse clinical outcomes Antithrombot

Predictive findings forHelicobacter pylori-uninfected, -infected and -eradicated gastric mucosa: Validation study

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World Journal of Gastroenterology 2013年第27期19卷 4374-4379页

作者： Kazuhiro Watanabe Naoyoshi Nagata Ryo Nakashima Etsuko Furuhata Takuro Shimbo Masao Kobayakawa Toshiyuki Sakurai Koh Imbe Ryota Niikura Chizu Yokoi Junichi Akiyama Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and Medicine department of Clinical Research and Informatics National Center for Global Health and Medicine department of Gastroenterology and Hepatology National Center for Global Health and MedicineKohnodai Hospital

AIM:To validate the usefulness of screening endoscopy findings for predictingHelicobacter pylori (H. pylori) infection status. METHODS:H. pylori infection status was determined by histology, serology, and the urea breast test in 77 consecutive patients who underwent upper endoscopy. Based on the findings, patients were categorized as H. pylori -uninfected, -infected, or -eradicated cases. Using six photos of certain sites in the stomach per case, we determined the presence or absence of the following endoscopic findings:regular arrangement of collecting venules (RAC), linear erythema, hemorrhage, fundic gland polyp (FGP), atrophic change, rugal hyperplasia, edema, spotty erythema, exudate, xanthoma, and mottled patchy erythema (MPE). The diagnostic odds ratio (DOR) and inter-observer agreement (Kappa value) for these 11 endoscopic findings used in the determination of H. pylori infection status were calculated. RESULTS:Of the 77 patients [32 men and 45 women; mean age (SD), 39.7 (13.4) years] assessed, 28 were H. pylori uninfected, 28 were infected, and 21 were eradicated. DOR values were significantly high (< 0.05) for the following H. pylori cases:uninfected cases with RAC (11.5), linear erythema (24.5), hemorrhage (4.1), and FGP (34.5); for infected cases with atrophic change (8.67), rugal hyperplasia (15.8), edema (14.2), spotty erythema (11.5), and exudate (3.52); and for eradicated cases with atrophic change (32.4) and MPE (103.0). Kappa values were excellent for FGP (0.93), good for RAC (0.63), hemorrhage (0.79), atrophic change (0.74), and MPE (0.75), moderate for linear erythema (0.51), rugal hyperplasia (0.49), edema (0.58), spotty erythema (0.47), and exudate (0.46), and poor for xanthoma (0.19). CONCLUSION:The endoscopic findings of RAC, hemorrhage, FGP, atrophic change, and MPE will be useful for predicting H. pylori infection status.

关键词： Diagnostic odds ratio Endoscopic finding Eradication therapy Helicobacter pylori Inter-observer agreement

Diagnostic value of antigenemia assay for cytomegalovirus gastrointestinal disease in immunocompromised patients

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World Journal of Gastroenterology 2011年第9期17卷 1185-1191页

作者： Naoyoshi Nagata Masao Kobayakawa Takuro Shimbo Kazufusa Hoshimoto Tomoyuki Yada Takuji Gotoda Junichi Akiyama Shinichi Oka Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and Medicine department of Clinical Research and Informatics International Clinical Research center Research Institute National Center for Global Health and Medicine department of Clinical Laboratory Pathological Division National Center for Global Health and Medicine department of Gastroenterology and Hepatology National Center for Global Health and MedicineKohnodai Hospital Division of Aids Clinical center National Center for Global Health and Medicine

AIM:To investigate the utility of the cytomegalovirus(CMV)antigenemia assay for the diagnosis of CMV gastrointestinal disease(GID). METHODS:One hundred and thirty immunocompromised patients were enrolled in this *** with a history of anti-CMV treatment and who had not undergone examination using the antigenemia assay were ***-GID was defined as the detection of large cells with intranuclear inclusions alone or associated with granular cytoplasmic inclusions by *** sections were stained with hematoxylin and eosin and immunohistochemically stained with *** evaluated the association between CMV-GID and patient characteristics(symptoms,underlying disease,medication,leukocyte counts,and antigenemia assay).All patients were checked with an human immunodeficiency virus(HIV)antibody test before endoscopic *** blood cell(WBC)counts were obtained from medical records within 1 wk of *** was defined as a total WBC count<5000 cells/mm 3 . For HIV patients,we also checked CD4+counts from medical records. RESULTS:A total of 99 patients were retrospectively selected for *** the immunocompromised patients,19 had malignant disease,18 had autoimmune disease,19 had disorders of biochemical homeostasis, three had undergone transplantation,and 45 had HIV infection.A total of 50 patients had received immunosuppressive *** patients had inflammatory bowel ***-five patients were diagnosed as having *** analysis indicated an association between HIV infection,leukopenia,and positive antigenemia and CMV-GID(P<0.05).Multivariate analysis using logistic regression revealed that HIV infection and positive antigenemia were the only independent factors related to CMV-GID(P<0.01).The sensitivity,specificity,positive predictive value,and negative predictive value of antigenemia for CMV-GID were 65.4%,93.6%, 91.9%,and 71.0%,*** a subgroup analy-sis,patients with leukopenia displayed

关键词： Cytomegalovirus Gastrointestinal disease Antigenemia assay Real-time polymerase chain reaction Human immunodeficiency virus infection

Impact of discontinuing non-steroidal antiinflammatory drugs on long-term recurrence in colonic diverticular bleeding

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World Journal of Gastroenterology 2015年第4期21卷 1292-1298页

作者： Naoyoshi Nagata Ryota Niikura Tomonori Aoki Takuro Shimbo Katsunori Sekine Hidetaka Okubo Kazuhiro Watanabe Toshiyuki Sakurai Chizu Yokoi Junichi Akiyama Mikio Yanase Masashi Mizokami Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and MedicineTokyo 162-8655Japan department of Clinical Research and Informatics National Center for Global Health and MedicineTokyo 162-8655Japan department of Gastroenterology and Hepatology National Center for Global Health and MedicineKohnodai HospitalChiba 272-8516Japan

AIM: To determine the effect of discontinuing nonsteroidal antiinflammatory drugs(NSAIDs) on recurrence in long-term follow-up patients with colonic diverticular bleeding(CDB).METHODS: A cohort of 132 patients hospitalized for CDB examined by colonoscopy was prospectively enrolled. Comorbidities, lifestyle, and medications(NSAIDs, low-dose aspirin, antiplatelet agents, anticoagulants, acetaminophen, and corticosteroids) were assessed. After discharge, patients were requested to visit the hospital on scheduled days during the followup period. The Kaplan-Meier method was used to estimate ***: Median follow-up was 15 mo. The probability of recurrence at 1, 6, 12, and 24 mo was 3.1%, 19%, 27%, and 38%, respectively. Of the 41 NSAID users on admission, 26(63%) discontinued NSAID use at discharge. Many of the patients who could discontinue NSAIDs were intermittent users, and could be switched to alternative therapies, such as acetaminophen or an antiinflammatory analgesic plaster. The probability of recurrence at 12 mo was 9.4% in discontinuing NSAID users compared with 77% in continuing users(P 70 years, right-sided diverticula, history of hypertension, and hemodialysis. No patients developed cerebrocardiovascular events during ***: There is a substantial recurrence rate after discharge among patients hospitalized for diverticular bleeding. Discontinuation of NSAIDs is an effective preventive measure against recurrence. This study provides new information on risk reduction strategies for diverticular bleeding.

关键词： Non-steroidal anti-inflammatories Drug withdrawal

Post-polypectomy bleeding and thromboembolism risks associated with warfarin vs direct oral anticoagulants

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World Journal of Gastroenterology 2018年第14期24卷 1540-1549页

作者： Naohiro Yanagisawa Naoyoshi Nagata Kazuhiro Watanabe Tatsuhiro Iida Mariko Hamada Sakurako Kobayashi Takuro Shimbo Junichi Akiyama Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and MedicineTokyo 162-8655Japan Ohta Nishinouchi hospital Fukushima 963-8022Japan department of Gastroenterology and Hepatology National Center for Global Health and MedicineKohnodai HospitalChiba 272-8516Japan

AIM To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants(DOAC).METHODS We collected data from 218 patients receiving oral anticoagulants(73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics(age-and sexmatched controls) who underwent polypectomy.(1) We evaluated post-polypectomy bleeding(PPB) risk in patients receiving warfarin or DOAC compared with controls;(2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge(HPB)(endoscopy guideline recommendation), continuing AC, and discontinuing AC without *** PPB rate was significantly higher in warfarin users and DOAC users compared with controls(13.7% and 13.7% vs 0.9%, P < 0.001), but was not significantly different between rivaroxaban(13.2%), dabigatran(11.1%), and apixaban(13.3%) users. Two thromboembolic events occurred in warfarin users, but none in DOAC users. Compared with the continuing anticoagulant group, the discontinuing anticoagulant with HPB group(guideline recommendation) had a higher PPB rate(10.8% vs 19.6%, P = 0.087). These findings were significantly evident in warfarin but not DOAC users. One thrombotic event occurred in the discontinuing anticoagulant with HPB group and the discontinuing anticoagulant without HPB group; none occurred in the continuing anticoagulant *** PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.

关键词： High-risk endoscopic procedures Novel oral anticoagulants Endoscopic guideline validation Postprocedure gastrointestinal bleeding

Colonoscopy can miss diverticula of the left colon identified by barium enema

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World Journal of Gastroenterology 2013年第15期19卷 2362-2367页

作者： Ryota Niikura Naoyoshi Nagata Takuro Shimbo Junichi Akiyama Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and MedicineShinjukuTokyo 162-8655Japan department of Clinical Research and Informatics National Center for Global Health and MedicineShinjukuTokyo 162-8655Japan department of Gastroenterology and Hepatology Kohnodai HospitalNational Center for Global Health and MedicineIchikawaChiba 272-8516Japan

AIM: To identify the diagnostic value of colonoscopy for diverticulosis as determined by barium enema. METHODS: A total of 65 patients with hematochezia who underwent colonoscopy and barium enema were analyzed, and the diagnostic value of colonoscopy for diverticula was assessed. The receiver operating characteristic area under the curve was compared in relation to age (< 70 or ≥ 70 years), sex, and colon location. The number of diverticula was counted, and the detection ratio was calculated. RESULTS: Colonic diverticula were observed in 46 patients with barium enema. Colonoscopy had a sensitivity of 91% and specificity of 90%. No significant differences were found in the receiver operating characteristic area under the curve (ROC-AUC) for age group or sex. The ROC-AUC of the left colon was significantly lower than that of the right colon (0.81 vs 0.96, P=0.02). Colonoscopy identified 486 colonic diverticula, while barium enema identified 1186. The detection ratio for the entire colon was therefore 0.41 (486/1186). The detection ratio in the left colon (0.32, 189/588) was significantly lower than that of the right colon (0.50, 297/598) (P < 0.01). CONCLUSION: Compared with barium enema, only half the number of colonic diverticula can be detected by colonoscopy in the entire colon and even less in the left colon.

关键词： Colonoscopic diagnosis Colonic diverticulosis Colonic diverticular bleeding Barium enema Receiver operating characteristic area under the curve

Diagnostic value of endothelial markers and HHV-8 staining in gastrointestinal Kaposi sarcoma and its difference in endoscopic tumor staging

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World Journal of Gastroenterology 2013年第23期19卷 3608-3614页

作者： Naoyoshi Nagata Toru Igari Takuro Shimbo Katsunori Sekine Junichi Akiyama Yohei Hamada Hirohisa Yazaki Norio Ohmagari Katsuji Teruya Shinichi Oka Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and MedicineTokyo 162-8655 Japan department of Clinical pathology National Center for Global Health and MedicineTokyo 162-8655 Japan department of Clinical Research and Informatics National Center for Global Health and MedicineTokyo 162-8655 Japan Division of AIDS Clinical center (ACC) National Center for Global Health and MedicineTokyo 162-8655 Japan department of Infectious disease National Center for Global Health and MedicineTokyo 162-8655 Japan department of Gastroenterology and Hepatology National Center for Global Health and Medicine Kohnodai HospitalChiba 272-8516 Japan

AIM: To clarify the diagnostic values of hematoxylin and eosin (HE), D2-40, CD31, CD34, and HHV-8 immunohistochemical (IHC) staining in gastrointestinal Kaposi's sarcoma (GI-KS) in relation to endoscopic tumor staging. METHODS: Biopsy samples (n = 133) from 41 human immunodeficiency virus-infected patients were reviewed. GI-KS was defined as histologically negative for other GI diseases and as a positive clinical response to KS therapy. The receiver operating characteristic area under the curve (ROC-AUC) was compared in relation to lesion size, GI location, and macroscopic appearances on endoscopy. RESULTS: GI-KS was confirmed in 84 lesions (81.6%). Other endoscopic findings were polyps (n = 9), inflammation (n = 4), malignant lymphoma (n = 4), and condyloma (n = 2), which mimicked GI-KS on endoscopy. ROC-AUC of HE, D2-40, blood vessel markers, and HHV-8 showed results of 0.83, 0.89, 0.80, and 0.82, respectively. For IHC staining, the ROC-AUC of D2-40 was significantly higher (P < 0.05) than that of HE staining only. In the analysis of endoscopic appearance, the ROC-AUC of HE and IHC showed a tendency toward an increase in tumor staging (e.g. , small to large, patches, and polypoid to SMT appearance). D2-40 was significantly (P < 0.05) advantageous in the upper GI tract and for polypoid appearance compared with HE staining. CONCLUSION: The diagnostic value of endothelial markers and HHV-8 staining was found to be high, and its accuracy tended to increase with endoscopic tumor staging. D2-40 will be useful for complementing HE staining in the diagnosis of GI-KS, especially in the upper GI tract and for polypoid appearance.

关键词： Gastrointestinal Kaposi’s sarcoma Hematoxylin and eosin CD31 CD34 D2-40 Human herpesvirus-8

Endoscopic appearance of AIDS-related gastrointestinal lymphoma with c-MYC rearrangements: Case report and literature review

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World Journal of Gastroenterology 2013年第29期19卷 4827-4831页

作者： Shohei Tanaka Naoyoshi Nagata Sohtaro Mine Toru Igari Taiichiro Kobayashi Jun Sugihara Haruhito Honda Katsuji Teruya Yoshimi Kikuchi Shinichi Oka Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and Medicine Tokyo 162-8655 Japan Clinical Laboratory and Pathology National Center for Global Health and Medicine Tokyo 162-8655 Japan Division of AIDS Clinical center National Center for Global Health and Medicine Tokyo 162-8655 Japan department of Gastroenterology and Hepatology National Center for Global Health and Medicine Kohnodai Hospital Chiba 272-0827 Japan

Acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL) remains the main cause of AIDS-related deaths in the highly active anti-retroviral therapy (HAART) era. Recently, rearrangement of MYC is associated with poor prognosis in patients with diffuse large B-cell lymphoma. Here, we report a rare case of gastrointestinal (GI)-ARL with MYC rearrangements and coinfected with Epstein-Barr virus (EBV) infection presenting with various endoscopic findings. A 38-yearold homosexual man who presented with anemia and was diagnosed with an human immunodeficiency virus infection for the first time. GI endoscopy revealed multiple dish-like lesions, ulcerations, bloody spots, nodular masses with active bleeding in the stomach, erythematous flat lesions in the duodenum, and multiple nodular masses in the colon and rectum. Magnified endoscopy with narrow band imaging showed a honeycomb-like pattern without irregular microvessels in the dish-like lesions of the stomach. Biopsy specimens from the stomach, duodenum, colon, and rectum revealed diffuse large B-cell lymphoma concomitant with EBV infection that was detected by high tissue EBV-polymerase chain reaction levels and Epstein-Barr virus small RNAs in situ hybridization. Fluorescence in situ hybridization analysis revealed a fusion between the immunoglobulin heavy chain (IgH) and c-MYC genes, but not between the IgH and BCL2 loci. After 1-mo of treatment with HAART and R-CHOP, endoscopic appearance improved remarkably, and the histological features of the biopsy specimens revealed no evidence of lymphoma. However, he died from multiple organ failure on the 139 th day after diagnosis. The cause of his poor outcome may be related to MYC rearrangement. The GI tract involvement in ARL is rarely reported, and its endoscopic findings are various and may be different from those in non-AIDS GI lymphoma; thus, we also conducted a literature review of GI-ARL cases.

关键词： Acquired immune deficiency syndromerelated lymphoma Non-Hodgkin-lymphoma EpsteinBarr virus infection c-MYC rearrangement Endoscopic appearance

Fulminant gastrointestinal graft-versus-host disease concomitant with cytomegalovirus infection:Case report and literature review

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World Journal of Gastroenterology 2013年第4期19卷 597-603页

作者： Hidetaka Okubo Naoyoshi Nagata Naomi Uemura department of Gastroenterology and Hepatology National Center for Global Health and MedicineTokyo 162-8655Japan department of Gastroenterology and Hepatology Kohnodai HospitalIchikawa 272-0827ChibaJapan

Here,we report a case of fulminant gastrointestinal graft-versus-host disease(GI-GVHD) with cytomegalovirus(CMV) infection in 44-year-old *** the difficulties associated with the treatment of GIGVHD and GI-CMV disease,the mucosal findings and the clinical course showed marked improvements during long-term clinical *** endoscopic findings were remarkable,with diffuse sloughing mucosa in the stomach and highly active inflammation and deep discrete ulcers throughout the *** in the CMV quantitative polymerase chain reaction results were correlated with the endoscopic mucosal findings and were useful for assessing the efficacy of the *** a definite diagnosis of GI-GVHD is generally made by endoscopy with biopsy,the gross appearance of this disease can vary depending on the *** this paper,we also conduct a literature review of patients with GI-GVHD.

关键词： Acute gastrointestinal graft-versus-host disease Allogenic stem-cell transplantation Cytomegalovirus gastrointestinal disease Cytomegaloviruspolymerase chain reaction Endoscopy