Autoimmune pancreatitis is currently diagnosed in accordance with the Japan Pancreas Society diagnostic criteria for the condition. The diagnostic criteria require confirmation of irregular narrowing of the main pancreatic duct and enlargement of the pancreas. Assessment of pancreatic duct narrowing is therefore the most important part of diagnosing the condition. Pancreatic duct narrowing is usually diagnosed from images of the pancreatic duct on endoscopic retrograde cholangiopancreatography. It is generally agreed that the pancreatic duct is narrowed if "the diameter of the main pancreatic duct is smaller (narrower) than the normal portion of the duct, the walls are irregular, and such abnormalities are seen along a certain length of the duct (at least one-third of the extreme length of the pancreas according to the current diagnostic criteria). It is important to differentiate between pancreatic duct narrowing and pancreatic duct stenosis. Specifying that there must be narrowing of at least one-third of the length of the pancreatic duct prevents confusion with pancreatic cancer. There are still problems with the diagnosis of autoimmune pancreatitis with regard to the relationship with mass-forming pancreatitis and dealing with patients who test negative for autoantibodies and patients in whom only the pancreatic duct findings do not meet the diagnostic criteria. It should be recognized that the current diagnostic criteria deal with autoimmune pancreatitis with pancreatic duct narrowing (duct-narrowing autoimmune pancreatitis) rather than autoimmune pancreatitis in the broader sense of the term.

View full abstract

<Background> We experienced 14 cases of flat type mucosal prolapse syndrome (MPS) in the period from May, 1994 to May, 2002. <Methods> We investigated endoscopic, clinical and pathological findings of 14 cases. <Results> There were two types of endoscopic findings. (1) A lesion annular in shape centering the anterior wall of the lower Huston valve (4 cases), and (2) A lesion with reddness in the rectum just above the anus (10 cases). <Conclusions> The former was frequent in patients with irritable bowel disease. Most of the latter cases were asymptomatic and had hemorrhoids. The endoscopic retroversion maneuver in the rectum was useful for detecting the latter.

View full abstract

A 51-year-old male was admitted because of chest pain. He liked spiced food and had no history of bleeding tendency. He had taken a large amount of pepper sauce two days before the onset, and had been complaining of discomfort in the upper chest since then. On the day before admission, shortly after dinner, during which he had a heated quarrel, he felt a sharp pain in the upper chest and vomited twice. The last vomit contained a small amount of blood. After vomiting the pain extended to the epigastrium and became severer. Endoscopy on admission the next morning revealed a small ulcer in the upper esophagus. And from the distal edge of the ulcer, a submucosal hematoma extended continuously to just above the esophagogastric junction, being gigantic in the distal part. The symptom resolved with only supportive treatment. Although a long belt-like shallow ulcer lesion was formed after breaking down of the hematoma, it was healed by the 21st hospital day without any stricture. A possible mechanism leading to the submucosal hematoma is as follows : pepper sauce could cause damage to the mucosa in the upper esophagus. With additional factors such as the stimuli of eating and drinking, ulceration might be induced, followed by vomiting. Hemorrhage could develop in the submucosal layer, forming a long gigantic hematoma.

View full abstract

A 47-year-old man was admitted to our hospital with the chief complaint of frequent nasal bleeding. Several telangiectatic lesions were observed both on his skin and on his oral mucosa. His father had not only similarly experienced frequent nasal bleeding but also had similar skin lesions as those demonstrated by the patient. We, therefore, made a diagnosis of Hereditary Hemorrhagic Telangiectasia (Rendu-Osler-Weber disease : ROW disease). Upper gastrointesti-nal endoscopy revealed a number of hemorrhagic telangiectasia lesions throughout the stomach which are considered to cause chronic anemia. Argon plasma coagulation was used to treat the hemorrhagic telangiectasia, with which resulted in an improvement of his anemia. He also demonstrated a couple of pulmonary arteriovenus malformations (p-AVM) and multiple hepatic hemangiomatous lesions associated with ROW disease. Since he also suffered from exartional dyspnea with hypoxia due to p-AVM, embolization with platinum coils was performed to treat the p-AVM. The argon plasma coagulation method is considered to be an effective treatment for gastric lesions in ROW disease.

View full abstract

A 59-year-old woman visited to our hospital because of right lower abdominal pain. The computed tomography (CT) findings ; localized thickening of the colonic wall and increased density in the pericolic fat around the hepatic flexure were compatible with pericolic abscess. Colonoscopy revealed a smooth hemispherical protrusion covered with normal mucosa on the anal side of the hepatic flexure and then drainage of pus into the colonic lumen was observed from the top of the lesion at biopsy. Her symptoms were almost disappeared day after colonoscopy and the CT findings one month later were ameliorated without admission. Colonoscopic intraluminal drainage would be useful for the treatment of pericolic abscess.

View full abstract

A 62-year-old man was referred to our hospital for positive fecal occult blood. Colonoscopy showed a tumor consisting of a ha +IIc and ha parts in the ascending colon. This tumor did not have the character of collision tumor histopathologically. The part of superficial depressed type (ha +IIc) was diagnosed as moderately-differentiated adenocarcinoma with submucosal invasion (sm2). However, the part of superficial elevated type (ha) was diagnosed as well-differentiated adenocarcinoma with intramucosal lesion (m). Intramucosal lesion consisting of well-differentiated adenocarcinoma remained in the margin of type ha + IIc tumor. Considering these findings in the developmental pattern of this carcinoma, the part of superficial elevated type (ha) may be transformed from well-differentiated to moderately-differentiated adenocarcinoma at the mucosal stage which possessed malignant potencial, invaded submucosally and elevated the surrounding normal mucosa, leading to type IIa+IIc in shape. Therefore, we speculate that this tumor developed from superficial elevated carcinoma despite of the superficial depressed carcinoma on macroscopic appearance.

View full abstract

We report a case of metachronous and multiple mucosa-associated lymphoid tissue (MALT) lymphomas of the cecum and rectum. A 67-year-old male was first admitted to another hospital. Colonoscopy revealed a flat elevated lesion in the cecum and rectum. Endoscopic mucosal resection was performed for the diagnostic purpose. The histopathology of the resected specimens demonstrated a MALT lymphoma with the depth of invasion being at the deep submucosal layer and the cut-end was free of lymphoma. Then he was referred to our hospital and followed up closely by endoscopy, but no relapse of these lesions occured. However, 14 months after previous lesions, a new lesion appeared in the rectum and the depth of invasion was diagnosed as the muscular propria (MP) by endoscopic ultrasonography (EUS). We performed operation in October 2002. According to the General Rule for Clinical and Pathological Studies on Cancer of the colon, rectum and anus, we diagnosed the lesion as SM, N₁(+), M(-) stage I. If EMR is the first choice of therapy, a close follow-up should be performed. The long term follow-up is necessary to assesse the prognosis.

View full abstract

An 88-year-old man, visited our hospital due to jaundice. Duodenal endoscopic findings revealed the orifice of Vater's papilla to be full of mucin. Endoscopic retrograde cholangiogra-phy (ERC) revealed a filling defect in the common bile duct and dilatation extending from the intrahepatic bile ducts to the common bile duct. Obstructive jaundice resulting from mucin-like material retention in the biliary duct was suggested. Percutaneous transhepatic cholangioscopy (PTCS) revealed tumorous lesions in the bilateral intrahepatic biliary ducts and upper common bilialy duct. The histological diagnosis of PTCS biopsy specimens was atypical epithelium which was suspicious of adenocarcinoma. The patient received microwave coagulation therapy to reduce mucus that was produced by biliary carcinoma. Obstructive jaundice had not occurred for 3 months after microwave therapy. Microwave coagulation therapy is considered to be useful for high-risk patients with mucus-producing biliary carcinoma.

View full abstract