Background: Amino acid imbalance, characterised by decreased branched‐chain amino acids (BCAAs) and increased tyrosine levels, is a common metabolic disturbance associated with various complications in patients with cirrhosis. However, the independent prognostic value of these changes remains unclear. Aims: This study aimed to elucidate the prognostic impact of amino acid imbalance by analysing BCAA and tyrosine levels in patients with cirrhosis. Methods: This multicenter retrospective study reviewed patients hospitalised for cirrhosis in Gifu, Japan. Amino acid imbalance was evaluated using serum BCAA and tyrosine levels and the BCAA‐to‐tyrosine ratio (BTR). Prognosis was assessed using a Cox proportional hazards regression model. Multivariable analyses were conducted using a model that included BTR, which was then replaced with both BCAA and tyrosine levels. Results: Amongst 541 patients (median age, 66 years; 50.3% female), 129 (23.8%) died during a median follow‐up of 3.5 years. The median BTR, serum BCAA and tyrosine levels were 4.36, 378 and 90 μmol/L, respectively. Multivariable analysis identified BTR (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.72–0.94; p = 0.004) as a significant prognostic factor after adjustment for established factors. In the subsequent model, both BCAA (HR, 1.00; 95% CI, 1.00–1.00; p = 0.019) and tyrosine levels (HR, 1.01; 95% CI, 1.00–1.01; p = 0.002) independently predicted mortality. Conclusions: Amino acid imbalance is an independent factor for poor prognosis in patients with cirrhosis. Notably, decreased BCAA and increased tyrosine levels were identified as independent prognostic factors.

Endoscopic submucosal dissection (ESD), the standard treatment for early gastric cancer, typically results in homogeneous flat scars. However, in some cases, polypoid nodule scars (PNS) may develop, complicating the cancer recurrence assessment. This case report describes a 60‐year‐old man with a history of Helicobacter pylori infection who underwent two ESD procedures: first for early antral gastric cancer and then for gastric body adenoma. Subsequently, an erythematous protruding lesion developed at the antral ESD scar site. Lesion biopsy revealed regenerative and hyperplastic tissue growth, consistent with PNS. Despite H. pylori eradication therapy and discontinuation of potassium‐competitive acid blockers and H₂‐receptor antagonists, the lesion continued to enlarge. PNS growth may be caused by excessive mucosal regeneration and enhanced antral peristalsis, suggesting that hypergastrinemia, which may enhance these effects, may be an underlying cause. Further, elevated serum gastrin levels, decreased pepsinogen levels, the presence of antiparietal cell antibodies, and consistent pathological findings confirmed autoimmune gastritis (AIG).This case highlights the diagnostic challenges of AIG, especially in cases of active or previous H. pylori infection because typical endoscopic features may be obscured. Persistent PNS after ESD warrants the consideration of excessive mucosal regeneration and enhanced peristalsis, with AIG as a potential cause because of its association with hypergastrinemia. To our knowledge, this is the first case report describing a potential link between AIG and PNS.

Objectives: Few attempts have been made to determine the risk factors for the recurrence of esophageal varices (EV) and the optimal surveillance interval. This study analyzed whether endoscopic ultrasonography can be used to predict EV recurrence and determine the optimal timing for surveillance endoscopy post‐treatment. Methods: We retrospectively evaluated patients with EVs who underwent endoscopic variceal ligation (EVL) combined with argon plasma coagulation (APC), followed by endoscopic ultrasonography (EUS) using a miniature ultrasonic probe 1 month after APC. Factors associated with EV recurrence were assessed using the Fine‐Gray competing risk regression model, with death considered as the competing risk. The cumulative incidence of EV recurrence was estimated using the cumulative incidence function, and groups were compared using Gray's test. Results: Of 163 eligible patients, 37 (23%) experienced EV recurrence during a median follow‐up period of 36 months (interquartile range: 15–76 months). Multivariable analysis revealed that the presence of perforating veins (PVs) was a significant factor for EV recurrence (sub‐distribution hazard ratio, 4.30; 95% confidence interval, 2.13–8.71; p < 0.001). The cumulative incidence of EV recurrence was significantly higher in patients with PV than in those without (6‐month and 1‐year recurrence rates: 27.3% and 41.6% vs. 3.9% and 5.5%, respectively; p < 0.001). Conclusions: PVs detected using EUS independently predict EV recurrence risk after EVL combined with APC. Given that patients with PVs experience a high recurrence rate within 6 months, comprehensive surveillance endoscopy at 6‐month intervals is recommended in the first year post‐treatment.

Delayed perforation after esophageal endoscopic submucosal dissection is a rare complication that may result in severe outcomes. Here, we report a case of delayed perforation that was successfully managed with conservative treatment. A 72‐year‐old male with hypertensive renal failure and on maintenance hemodialysis underwent endoscopic submucosal dissection for a 2/3 circumferential superficial esophageal cancer in the middle thoracic esophagus, involving resection of 4/5 of the esophageal circumference. Locoregional steroid injections were administered after resection to prevent stenosis. No perforation occurred during the procedure; however, delayed perforation was identified on postoperative day 3. Endoscopy revealed necrosis and brittleness in a large area of the post‐endoscopic submucosal dissection ulcer. The patient developed fever and mediastinal emphysema, and endoscopic attempts to close the perforation were unsuccessful. Conservative management—including fasting, antibiotics, and subsequent drainage—was initiated. The patient's condition improved with drainage tube placement, enteral nutrition, and antibiotic administration. A follow‐up computed tomography scan on postoperative day 56 confirmed the resolution of mediastinal emphysema, and endoscopy revealed that the perforation healed with scarring. This case highlights that surgery may be avoided if appropriate treatment is initiated as early as possible, including drainage to prevent exposure to gastric and intestinal fluids, early initiation of enteral nutrition, rehabilitation to maintain strength, and blood transfusions as supportive care.