Background/AimsTo evaluate the usefulness and safety of treating disseminated intravascular coagulation (DIC) complicating cholangitis primarily with antithrombin (AT) and thrombomodulin (rTM).MethodsA DIC treatment algorithm was determined on the basis of plasma AT III levels at the time of DIC diagnosis and DIC score changes on treatment day 3. Laboratory data and DIC scores were assessed prospectively at 2-day intervals.ResultsDIC reversal rates >75% were attained on day 7. In the DIC reversal group, statistically significant differences from baseline were observed in interleukin-6 and C-reactive protein levels within 5 days. Patients with no DIC score improvements after treatment with AT alone experienced slow improvement on a subsequent combination therapy with rTM. Although a subgroup with biliary drainage showed greater improvement in DIC scores than did the nondrainage subgroup, the mean DIC score showed improvement even in the nondrainage subgroup alone. Gastric cancer bleeding that was treated conservatively occurred in one patient. As for day 28 outcomes, three patients died from concurrent malignancies.ConclusionsAlthough this algorithm was found to be useful and safe for DIC patients with cholangitis, it may be better to administer rTM and AT simultaneously from day 1 if the plasma AT III level is less than 70%.

A 74-year-old man visited a nearby clinic because he had been experiencing abdominal fullness for 2 weeks. Abdominal computed tomography (CT) performed at the clinic revealed a large volume of ascites; he was referred to our department. Given that general malaise and anorexia were also observed at the time of referral, the patient was hospitalized for additional examination. He had not experienced any fever or night sweats at home. His past medical history was unremarkable.Physical examination indicated a distended abdomen, and a fluid wave was present. There was no abdominal tenderness. The patient's superficial lymph nodes were not palpable. The biochemical results were: WBC count, 7,840/L; hemoglobin level, 14.0 g/dL; AST, 114 IU/L; ALT, 19 IU/L; total bilirubin level, 0.8 mg/dL; lactate dehydrogenase (LDH), 1,713 IU/L (reference range, 110-210 IU/L); and soluble interleukin-2 receptor (sIL-2R) level, 2,240 U/mL (reference range, 145-519 U/mL). The levels of carcinoembryonic antigen and CA19-9 were within normal limits.Chest radiographs did not show any abnormality; however, the abdominal CT scan indicated an irregular solid lesion of approximately 6 cm in diameter accompanied by a gradual increase of contrast in the body of the pancreas (Fig 1A, arrows). The CT scan also revealed a solid tumor at the tail of the pancreas with marginal enhancement of the contrast medium, suggesting an advanced pancreatic adenocarcinoma (Fig 1B, arrows). No retroperitoneal and para-aortic lymph nodes were detected. The splenic vein was also not visible, suggesting infiltration. A large quantity of D I A G N O S I S I N O N C O L O G Y

Malignant epithelial tumor of the broad ligament is rare and to our knowledge only 17 cases have been reported. We report a 54-year-old Japanese woman in whom transvaginal sonography (TVS) and magnetic resonance imaging (MRI) showed a left adnexal tumor. Serum CA125 was elevated to 10,000 U/ml. Preoperatively, we diagnosed this tumor was a left ovarian malignant tumor though, it was confirmed a the 47x57 mm tumor in the left broad ligament at laparotomy. Histologically most of the tumor showed serous papillary adenocarcinoma with changes similar to poorly differentiated carcinoma and as seen in transitional cell carcinoma on hematoxylin-eosin staining. After three courses of platinum based adjuvant chemotherapy, the patient is alive with no recurrence at 18 months postoperatively.

Colonoscopy-assisted percutaneous endoscopic gastrostomy to avoid a gastrocolocutaneous fistula of the transverse colonAn 80-year-old woman with a nasogastric tube in situ for cerebral infarction sequelae was referred for percutaneous endoscopic gastrostomy (PEG). The abdominal computed tomography scan on admission showed that the transverse colon was interposed between the anterior abdominal wall and the stomach (• " Fig. 1). The usual PEG placement posed a high risk of piercing the transverse colon. A fluoroscopy-assisted colonoscopy was performed, which showed that the transverse colon was present in the upper abdomen (• " Fig. 2 a). While maintaining the tip of the colonoscope at the hepatic flexure, the transverse colon was moved toward the pelvis under fluoroscopic guidance by using a twisting maneuver of the scope shaft. While the colonoscope was in situ, the esophagogastroduodenoscope was inserted (• " Fig. 2 b). The stomach was expanded as usual to perform the PEG. PEG feeding was initiated as usual without problems. When the PEG button was replaced with a new one 6 months later, no specific abnormalities were observed. A gastrocolocutaneous fistula is a rare complication of PEG [1,2]. It results from the interposition of the colon between the anterior abdominal and gastric walls, so the PEG tube inadvertently passes through the colon into the stomach, resulting in the development of an iatrogenic fistula. The risk of this complication increases in cases of megacolon, subphrenic transposition of the colon, a history of abdominal surgery, or overinflation of the stomach [1, 2].Colonoscopy-assisted PEG insertion is slightly different from conventional endoscopic methods in terms of its approach. To the best of our knowledge, only one study used both a colonoscope and an esophagogastroduodenoscope for PEG placement [3]. In that report, Tominaga et al. used fluoroscopy to detect sigmoid interposition between the abdominal wall and the stomach; subsequent evacuation of gas from the sigmoid using colonoscopy resulted in successful PEG placement. In the present case, colonoscopy was used to move the transverse colon toward the pelvis under fluoroscopic guidance. Serious complications can be prevented using this method. Endoscopy_UCTN_Code_TTT_1AO_2AKCompeting interests: None Fig. 1 Abdominal computed tomography showed that the transverse colon was interposed between the anterior abdominal wall and the stomach. Fig. 2 Fluoroscopy-assisted colonoscopy to aid percutaneous endoscopic gastrostomy. a A fluoroscopy-assisted colonoscopy showed that the transverse colon was present in the upper abdomen. Water-soluble contrast medium introduced from the distal end of the scope was seen. b The transverse colon was moved toward the pelvis under fluoroscopic guidance by using a twisting maneuver of the scope shaft. While the colonoscope was in situ, the upper gastrointestinal endoscope was inserted.

IPSP is a practicable method allowing reliable post-EP pancreatic stenting and can contribute to pancreatitis prevention. However, larger studies need to be performed before its use can be recommended.