Ulcer Floor Research Articles

Simple extraction method using a nontraumatic tube for impacted stool in a diverticulum near the ulcer floor after endoscopic submucosal dissection.

With the development of specific knives and traction devices, endoscopic submucosal dissection (ESD) of colorectal tumors such as those that extend into diverticula, which are technically difficult, is becoming possible [1] [2] [3] [4]. A colonic diverticulum is a false diverticulum without a muscular layer, and therefore only the serosa remains after submucosal dissection. To prevent delayed perforation, complete closure of the diverticulum is necessary; however, colonic diverticula often exist in multiples close to each other, and closure of a diverticulum containing impacted stool carries a risk of causing diverticulitis.

Endoscopic hemostasis of an active hypopharyngeal hemorrhage via gel immersion endoscopy.

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Bleeding Risk Factors after Endoscopic Submucosal Dissection in Early Gastric Cancer and the Necessity of "Second-Look" Endoscopic Examination on the following Day.

Background and Aim: Hemorrhage is often encountered after endoscopic submucosal dissection (ESD). In addition to active bleeding after resection, exposed blood vessels and blood clots without active bleeding on the post-dissection ulcer floor have been recognized within our department. We consider exposed and/or observable vessel findings and clots on the ulcer floor after re-section as important risk factors for hemorrhage. Here, we compared and examined the active bleeding frequency and “post-resection ulcer at risk of bleeding” on the day following ESD, in relation to their risk factors. Method: We retrospectively examined 447 patients who underwent second-look endoscopy in our department between August 2008 and March 2018. Logistic regression analyses were performed to determine the hazard ratio and 95% confidence interval. We compared the association of each factor mentioned above with active bleeding on the day after ESD and the presence of ulcers at risk of bleeding after resection. Results: Our retrospective analysis revealed that the risk factors were larger ulcer sizes and the administration of antithrombotic drugs. Additionally, the risk was low for upper body lesions but high for antral lesions. Conclusion: Our results may help determine whether second-look endoscopy should be performed to minimize active bleeding after ESD, reduce postoperative complications, and improve medical safety.

A narrative review of postoperative bleeding in patients with gastric cancer treated with endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is now considered a standard treatment for selected patients with early gastric cancer. Compared with endoscopic mucosal resection (EMR), ESD provides a higher complete resection rate (R0), and therefore, a lower local recurrence rate. However, ESD is a more time-consuming procedure, creating a wider and deeper ulcer floor which may cause complications. Post-ESD bleeding is one of them. Although most post-ESD bleedings can be controlled by endoscopic hemostasis at the time of operation, some bleeding after ESD may result in serious conditions such as hemorrhagic shock. Even with preventive methods such as ulcer closure, the application of fibrin glue and polyglycolic acid shielding, acid secretion inhibitors and hemostasis on second-look endoscopy, our experiences told us that post-ESD bleeding cannot be entirely avoidable, especially for patients with big size ulcer bed, anticoagulants/antithrombosis and chronic kidney diseases. The present review first defined post-ESD bleeding, then the incidence, the risk factors, such as the location of operative lesion, the size and depth, chronic kidney diseases, the impacts of anticoagulant and antithrombotic agents. We finally reviewed the managements of post-ESD bleeding, including approaches of coagulating potential bleeding spots during the procedure, lesion closure, lesion shielding and the application of gastric acid secretion inhibitors.

A technique for safe ulcer floor closure using an over-the-scope clip after endoscopic submucosal dissection of lesions adjacent to the ampulla of Vater

A technique for safe ulcer floor closure using an over-the-scope clip after endoscopic submucosal dissection of lesions adjacent to the ampulla of Vater

Role of nano-collagen particles dressing in the management of chronic ulcer: a prospective non-randomized trial on 100 cases

Background: Collagen has unique property of adhere to the ulcer floor thus reduces plasma oozing, bacterial colonization, pain and ulcer size which boost the process of granulation and epithelialization thus healing.Methods: In this prospective, non-randomized study 100 patients of different age and sex having chronic ulcer situated on various parts of the body were taken. Nano collagen particles preparation “collofibre” of TNC health care was used.Results: Most of the patients fall in their most productive life (3rd and 4th decade), restricted mobility due to pain. Thus anaemia, diabetes, old age, debility, bed ridden situations, other associated injuries and certain medical conditions contribute to delay in ulcer healing and hospital stay. Bacterial contamination, presence of necrotic tissue and slough delay the healing process. 73% of patients complain of itching and burning sensation after application otherwise no major side effect detected.Conclusions: Use of nano collagen particles dressing accelerate the healing process in chronic ulcers.

39. HPV-related multiphenotypic sinonasal carcinoma, an emerging entity in an unusual location: A case report

Background: Human papillomavirus (HPV)–related multiphenotypic sinonasal carcinoma (HMSC), originally known as HPV-related carcinoma with adenoid cystic carcinoma-like features, is a distinct tumour recently described in the sinonasal tract. This peculiar tumour exhibits morphologic features of a salivary gland tumour including admixed ductal and myoepithelial elements, as well as displays an unusual pattern of surface involvement with atypical squamous cells. It is associated with high-risk HPV. Most cases usually present as a large and destructive sinonasal mass with high-grade histologic features. Aim: We present a case report of HMSC arising in the floor of mouth of a 57-year-old Chinese man. Methods (clinical history): The patient was an ex-smoker who presented with a floor of mouth ulcer. The lesion was biopsy and was called a submucosal adenoid cystic carcinoma. Subsequently, the patient underwent wide resection of floor of mouth tumour, marginal mandibulectomy and neck dissection. Results (pathological findings): Macroscopic examination revealed an ulcerative tumour measuring 2.5 cm, extending to the margins. Microscopically, the tumour was composed of basaloid cells showing variable growth patterns including a cribriforming pattern that closely resembles adenoid cystic carcinoma. It was continuous with the mucosa that showed dysplastic squamous epithelium. On immunohistochemistry, the myoepithelial cells were positive for the myoepithelial markers. p16 was positive in both squamous and epithelial components. Metastatic carcinoma was present in two of the harvested lymph nodes. The patient developed pulmonary and liver metastases after two years of follow-up, which were confirmed histologically. Conclusions: This is the first case of HMSC reported in the floor of mouth, which behaves more aggressively as opposed to those arise from the sinonasal tract. It is important to recognise HMSC as they have a different clinical behaviour. The clue to the diagnosis is recognising the atypical squamous cells on the surface, corroborated by p16 positivity in tumour cells.

Endoscopic tissue shielding to prevent bleeding after endoscopic submucosal dissection: a prospective multicenter randomized controlled trial.

Bleeding after endoscopic submucosal dissection (ESD) is a severe adverse event. Recent reports have described the efficacy of the endoscopic shielding method with polyglycolic acid (PGA) sheets and fibrin glue for the prevention of adverse events after ESD. The aim of the present study was to investigate whether the PGA shielding method provides additional benefit in preventing post-ESD bleeding compared with standard care. This was a prospective, multicenter, randomized controlled trial. Patients at high risk of post-ESD bleeding were enrolled in the study. Before ESD, patients were randomized to either the PGA group or the control group. After completing ESD in the PGA group, PGA sheets were placed onto the ulcer floor and adhered with fibrin glue. The primary end point was the post-ESD bleeding rate. 140 eligible patients were enrolled from September 2014 to September 2016, and 137 were included in the intention-to-treat analysis (67 in the PGA group and 70 in the control group). Post-ESD bleeding occurred in three patients (4.5 %) in the PGA group and in four patients (5.7 %) in the control group; there was no significant difference between the two groups (P > 0.99). Post-ESD bleeding tended to occur later in the control group than in the PGA group (median 12.5 days [range 8 - 14] vs. 2 days [range 0 - 7], respectively). The PGA shielding method did not demonstrate a significant effect on the prevention of post-ESD bleeding.

Misinterpretation or Underestimation of the Appearance, Location, or Size of Non-bleeding Visible Vessels (Forrest Class IIa) as a Cause of Hemostasis Failure

(1) Background: Endoscopy has become the primary diagnostic and treatment technique for non-variceal upper gastrointestinal bleeding. Despite advancements in therapeutic methods and instrumentation, endoscopic hemostatic failure occurs in 10% of patients. This study aimed to analyze endoscopic findings in patients with failed hemostasis and to elucidate strategies for endoscopists and gastroenterologists to facilitate improved treatment outcomes. (2) Methods: A total of 128 patients received hemostatic treatment for non-variceal upper gastrointestinal bleeding. Endoscopic findings in three patients in whom hemostasis could not be achieved after the initial and secondary endoscopies were analyzed. (3) Results: Hemostasis failure occurred in three cases (2.3%). All three cases involved patients with gastric ulcer and belonged to the Forrest class IIa category presenting with a non-bleeding visible vessel in endoscopic findings. Misinterpretation or underestimation of the appearance, location, or size of the vessel resulted in hemostasis failure. (4) Conclusions: Our findings demonstrate that identification of a non-bleeding visible vessel and assessment of the risk of re-bleeding in such vessels is often difficult. Detailed observation of the ulcer floor with awareness of the possibility of a non-bleeding visible vessel will lead to improved hemostatic treatment. The decision regarding hemostatic treatment of a visible vessel with a diameter larger than 2 mm should be made cautiously, and treatment should be followed by an appropriate fasting period under confirmatory endoscopy.

A comparative study of collagenase ointment versus povidone-iodine dressing in non-healing ulcers

Background: The aim of the study was to evaluate effect of collagenase ointment and povidone-iodine on non-healing ulcer in the form of duration of ulcer covered with red granulation tissue and total hospital stay.Methods: The Study was conducted on 80 patients admitted in Surgery Department, SSG Hospital and Medical College Baroda, Gujarat, India during November 2006 to October 2008. All ulcers due to trauma, chronic ulcer or infected ulcer following debridement and incision and drainage were included in this study. In group A were wounds dressed in collagenase ointment and in group B were wounds dressed in povidone-iodine ointment till second surgery or complete healing. All data from both groups were collected and analyzed by chi-square test.Results: In this study, there was no difference in age distribution (p=0.62, p>0.05) with similar male to female ratio in both groups and also no significant difference in distribution of wounds size in both groups (p=0.92, p>0.05). Average size of wound in group A was 43 sq. cm and group B was 44 sq. cm. The significant difference was seen on floor of ulcer by healthy granulation which came on an average of within 11days in group A and within 18 days in group B (p=0.005, p<0.05). There was also a significant difference in average hospital stay, which was 25 days in group A and 35 days in group B (p=0.01, p<0.05).Conclusions:Collagenase ointment is clinically more efficient as a topical dressing and lowers the morbidity by reducing the hospital stay and the duration of dressing by promoting healing in non-healing wounds than povidine-iodine ointment.

A novel and effective delivery method for polyglycolic acid sheets to post-endoscopic submucosal dissection ulcers.

Background and aims Shielding methods for post-endoscopic submucosal dissection (ESD) ulcers have delivery-related problems. We developed an enveloped device for this purpose and evaluated its usefulness. Materials and methods Polyglycolic acid (PGA) sheets were delivered to six 3.0-cm ulcers in two resected porcine stomachs and six 5.0-cm ulcers in another three stomachs. In the regular method group, small PGA sheets were delivered via forceps. In the novel method group, a large PGA sheet was delivered via the new device. The methods were compared in terms of time, and macroscopic and histological findings of the ulcer floor. Results The median time required to cover a 3.0-cm ulcer was 0.39 min/cm2 in the novel method group and 1.03 min/cm2 in the regular method group (P = 0.03), and to cover a 5.0-cm ulcer was 0.38 min/cm2 and 0.85 min/cm2, respectively (P = 0.03). In the novel method group, the PGA sheets were in close contact, fully covering the ulcer floor. In the regular method group, the sheets were partly elevated from the ulcer floor. Conclusions This novel technique seems promising in this preliminary study.

A new method of polyglycolic acid sheet placement in the stomach after endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer. Further efforts are needed to decrease the complications associated with ESD, such as bleeding and perforation. A polyglycolic acid (PGA) sheet (NEOVEIL; Gunze Co., Kyoto, Japan) has the potential to prevent post-ESD bleeding because it covers post-ESD ulcers [1]. The PGA sheet is a soft, non-woven, bioabsorbable fabric that is already used clinically in respiratory and pharyngolaryngeal surgery [2]. However, difficulties are associated with the delivery of PGA sheets to the ulcer floor by endoscopy because the sheet easily sticks to itself under wet conditions. As a result, several strips of the PGA sheet need to be sequentially arranged [3]. We report a new method for PGA sheet placement in the stomach using monofilament sutures (polydioxanone: PDS II; Ethicon US LLC, Cincinnati, Ohio, USA). We have named it “the framing method.” ● Video1 shows the procedure described here. After ESD has been performed, we measure the diameter of the ulcer (● Fig.1), cut the sheet into an oval shape of the desired size (● Fig.2a), and sew the circumference of the sheet with PDS II (● Fig.2b). The suture thread functions as a “frame” and keeps the sheet flat (● Fig.2c). After soaking the sheet in fibrinogen solution, artery forceps are inserted through the instrument channel of an endoscope, the sheet is grasped by the forceps, and the endoscope is inserted into the stomach. An overtube (Sumitomo Bakelite Co., Tokyo, Japan) assists the endoscope to pass smoothly through the pharynx. The sheet is dropped into the stomach and positioned on the ulcer floor (● Fig.3a). An injection of fibrinogen solution and thrombin solution (Beriplast P combi-set; CSL Behring K.K., Tokyo, Japan) promotes the adherence of the sheet to the ulcer floor (● Fig.3). We successfully covered ulcers with one piece of the sheet in two patients (● Fig.4). This method is easy, quick, and covers post-ESD ulcers.

Adipose mesenchymal stromal cells minimize and repair radiation-induced oral mucositis

Background aimsMesenchymal stromal cells (MSCs) have been used to minimize and repair radiation-induced normal tissue injury in the intestine, salivary gland, liver, skin, lungs and cardiac muscle. This study investigated the ability of adipose tissue–derived MSCs (aMSCs) to minimize and/or repair single dose radiation-induced oral mucositis (RIOM). MethodsSyngenic phenotypically and functionally characterized BALB/c mouse aMSCs were implanted intraperitoneally in a RIOM mouse model with different dosing protocols. Response was quantified macroscopically, microscopically and by using different histological and clinically relevant parameters. ResultsIrradiation at 18 Gy generated a self-resolved single-dose RIOM BALB/c mouse model with 5.6 ± 0.3 days mean duration (95% confidence interval (CI) 4.233–7.1 days) and 100% survival rate. Intraperitoneal implantation of 5 doses of 2.5 million freshly cultured syngenic aMSCs significantly and reproducibly reduced RIOM ulcer duration to 1.6 ± 0.3 days (95% CI 0.0233–3.1 days, a 72% reduction in RIOM ulcer duration), ulcer size and ulcer floor epithelial height. The therapeutic benefits were significantly dependent on dose size and frequency, number of doses, and therapy onset time. aMSCs therapy significantly minimized the RIOM-related weight loss, accelerated the weight gain and improved irradiated animals' hydration and nutritional status. aMSCs therapy did not potentiate head and neck cancer in vitro. ConclusionsSyngenic freshly cultured aMSCs significantly minimized and repaired radiation-induced oral mucositis with a 72% reduction in ulcer duration. aMSCs dose size and frequency, number of doses and therapy onset time are the main keys for optimized therapeutic outcome. aMSCs therapy did not stimulate Head and Neck cancer cell growth in-vitro.

Single-Dose Radiation-Induced Oral Mucositis Mouse Model.

The generation of a self-resolved radiation-induced oral mucositis (RIOM) mouse model using the highest possibly tolerable single ionizing radiation (RT) dose was needed in order to study RIOM management solutions. We used 10-week-old male BALB/c mice with average weight of 23 g for model production. Mice were treated with an orthovoltage X-ray irradiator to induce the RIOM ulceration at the intermolar eminence of the animal tongue. General anesthesia was injected intraperitoneally for proper animal immobilization during the procedure. Ten days after irradiation, a single RT dose of 10, 15, 18, 20, and 25 Gy generated a RIOM ulcer at the intermolar eminence (posterior upper tongue surface) with mean ulcer floor (posterior epithelium) heights of 190, 150, 25, 10, and 10 μm, respectively, compared to 200 μm in non-irradiated animals. The mean RIOM ulcer size % of the total epithelialized upper surface of the animal tongue was RT dose dependent. At day 10, the ulcer size % was 2, 5, 27, and 31% for 15, 18, 20, and 25 Gy RT, respectively. The mean relative surface area of the total epithelialized upper surface of the tongue was RT dose dependent, since it was significantly decreased to 97, 95, 88, and 38% with 15, 18, 20, and 25 Gy doses, respectively, at day 10 after RT. Subcutaneous injection of 1 mL of 0.9% saline/6 h for 24 h yielded a 100% survival only with 18 Gy self-resolved RIOM, which had 5.6 ± 0.3 days ulcer duration. In conclusion, we have generated a 100% survival self-resolved single-dose RIOM male mouse model with long enough duration for application in RIOM management research. Oral mucositis ulceration was radiation dose dependent. Sufficient hydration of animals after radiation exposure significantly improved their survival.

Amniotic membrane can be a valid source for wound healing.

Amniotic membrane (AM) can promote proper epithelialization with suppression of excessive fibrosis by creating a supportive milieu for regeneration of chronic ulcer bed.ObjectiveThe objective of this study is to investigate whether AM scaffold can modulate the healing of a wound by promoting tissue reconstruction rather than promoting scar tissue formation.Subjects and methodsAM was obtained and prepared and then applied to patients with chronic leg ulcers who were randomly divided into two different groups. Group I (control group) included eleven patients in whom ulcers were treated with conventional wound dressings that were changed daily for 8 weeks. Group II (study group) included 14 patients in whom the AM was placed in contact with the ulcer and held in place with a secondary dressing, which was changed daily. Follow-up was done to detect healing rate and detection of ulcer size, assessment of pain, and to take ulcer images (days 0, 7, 14, 21, 30, 45, and 60).ResultsIn group I, all ulcers showed no reduction in their size, and ulcer floor remained the same. Healthy granulations were present in two ulcers (18.2%) and absent in nine ulcers (81.8%). There was no improvement of pain level in the eleven ulcers. In group II, complete healing of 14 ulcers occurred in 14–60 days with a mean of 33.3±14.7; healing rate range was 0.064–2.22 and the mean 0.896±0.646 cm2/day. Healthy granulations were present in 13 ulcers (92.9%) and absent in one ulcer (7.1%). Three ulcers (21.4%) were of mild severity (grade 1 ulcers) while eleven ulcers (78.6%) were of moderate severity (grade 2 ulcers). The healing rate was faster in ulcers of mild severity (1.7±0.438 cm2/day) in comparison to ulcers of moderate severity (0.673±0.498 cm2/day). Eleven cases (78.6%) showed improvement in their pain level on a scale from 0 to 10.ConclusionAM graft can be of value in wound healing. Further studies are needed to confirm these findings.

Second-look endoscopy and factors associated with delayed bleeding after endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy (SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.

<i>Entamoeba histolytica </i>による大腸炎から人工肛門周囲に皮膚潰瘍を併発した1 例

A 66-year-old Japanese male with a history of a rectal ulcer and rectovesical fistula following brachytherapy and radiotherapy for prostate cancer, who had undergone colostomy and vesicotomy presented with a painful peristomal ulcer of approximately 5 x 2.5cm adjacent to the direction of 6 o'clock of the stoma in his left lower abdomen. Although he was admitted to be treated with intravenous antibiotics and topical debridement, the ulcer was rapidly increasing. In the laboratory findings, WBC was 12,400/μL, CRP was 16.9 mg/dL, ESR was 105mm in the first hour. Contrast enhanced CT images showed a wide high density area of skin and subcutaneous tissue around the stoma and dillitation of the transverse and descending colon. Colonoscopy showed furred profound ulcers in the rectum. A biopsy from the ulcer floor submitted to histopathology showed necrotic tissue with a mixed inflammatory infiltrates mainly composed of neutrophils and lymphocytes in the dermis. We suspected pyoderma gangrenosum with an inflammatory bowel disease in the beginning. Although he was started on oral prednisolone 60 mg daily, the ulcer did not respond to treatment. Additional methylprednisolone pulse therapy, intravenous cyclosporine and granulocytapheresis were also ineffective. A biopsy specimen from the skin ulcer margin showed erythrophagocytosis by trophozoites of amebae which were identified on PAS stained slides. The PCR method and stool examination showed positive for Entamoeba histolytica (E. histolytica), but serum antibodies were negative. Within two weeks of treatment with oral metronidazole 2,250 mg/day and topical metronidazole ointment, resolution of the ulcer was observed, then the prednisolone dosage was tapered. A split-thickness skin graft was used to cover the ulcer with a successful result. Even though we originally misdiagnosed this case, we finally reached a diagnosis of amebiasis. It is important to take account of amebiasis in the differential diagnosis of intractable ulcers which can be contaminated by feces.

Simple and reliable treatment for post-EMR artificial ulcer floor with snare cauterization for 10- to 20-mm colorectal polyps: a randomized prospective study (with video).

BackgroundComparative studies on wound surface treatments after endoscopic mucosal resection (EMR) of 10- to 20-mm colorectal polyps have not been reported. We conducted a prospective trial of postoperative hemorrhage prevention measures after EMR of such polyps.MethodsOf 138 patients (397 polyps) who had undergone EMR, 62 patients (148 polyps) with 10- to 20-mm colorectal polyps were enrolled. Using the sealed envelope method, the subjects were randomly assigned to either a snare cauterization (75 polyps) or clip closure group (73 polyps). The primary assessment item was the wound surface treatment time (from immediately after polyp resection to wound surface treatment completion). The secondary assessment items were the incidence of delayed bleeding, perforation incidence 1–7 days after EMR, and difference in medical costs between the groups (University Hospital Medical Information Network: No. 000013473).ResultsThe time required for wound surface treatment completion was 3.26 ± 1.57 min in the snare cauterization group and 12.7 ± 2.92 min in the clip closure group, thus demonstrating a significant difference (P = 0.0001). Delayed bleeding was observed in two patients in the clip group, but was not observed in the snare cauterization group (P = 0.098). The clip group required the use of 720 clips that cost \\523,410, US $5,163.50, or €3,665.5. ConclusionsAfter EMR of with 10- to 20-mm colorectal polyps, snare cauterization was superior to clip closure in terms of procedure time, and medical costs, and not inferior to clip closure in terms of the preventing effect of delayed bleeding.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-014-3983-y) contains supplementary material, which is available to authorized users.

Small intestinal perforation caused by cytomegalovirus reactivation after subtotal colectomy for ulcerative colitis: report of a case.

A 79-year-old woman with bloody diarrhea was diagnosed with ulcerative colitis. She developed intestinal perforation after high-dose steroid therapy. An emergency laparotomy revealed a perforation in the ascending colon, and a subtotal colectomy was performed with an ileostomy and a mucous fistula in the sigmoid colon. Histological findings of the resected colon showed the presence of cytomegalovirus in the endothelial cells of vessels around the ulcer floor. Twelve days after the laparotomy, she developed an ileal perforation with a bloody discharge from the ileostomy and underwent an emergency laparotomy. Multiple intestinal perforations were found in the ileum, and the perforated ileum was resected. Cytomegalovirus infection was controlled with ganciclovir postoperatively. Histological findings of the resected ileum showed the presence of cytomegalovirus in the endothelial cells of vessels around the ulcer floor. This is the first report of ileal perforation due to cytomegalovirus infection confirmed pathologically in a patient with ulcerative colitis.

Cytomegalovirus-associated gastric ulcer: A side effect of steroid injections for pyloric stenosis

The local injection of triamcinolone acetonide (TA) is effective in preventing pyloric stenosis and deformity following large endoscopic submucosal dissection (ESD). However, because of its long-acting nature, TA can induce long-term local immunosuppression and subsequent adverse events. We report a case of a cytomegalovirus (CMV) ulcer that formed only at the TA local injection site. A 68-year-old man underwent ESD to treat early gastric cancer that formed over the pylorus. The lesion extended to the duodenum, and an artificial ulcer covered more than two-thirds of the circumference of the pylorus. To prevent pyloric stenosis, TA was locally injected into the ulcer floor. On day 12, a deeper ulcer 10 mm in diameter was discovered in the center of the post-ESD ulcer. Biopsies revealed large cells with intranuclear inclusion bodies, which stained positive for the anti-CMV antibody. Local TA injections are useful, however, CMV ulcer might occur as adverse events.