Serrated adenoma (SA) of the colorectum shows the identifiable features of serrated architecture. The SA includes a wide spectrum of lesions, from examples very similar to traditional hyperplastic polyp (HP) to those involving conventional adenoma (AD). Recently, SA would be subdivided into the more traditional pedunculated variant (traditional SA, TSA) and sessile SA (SSA). SA range in size mostly from 0.5cm to 1.0cm and 2-15% of the lesion contained areas of carcinoma. The frequency of co-existing carcinoma is equal or lower in SA than in AD. Carcinomatous component was more prevalent in flat type SA or the lesion larger than 1 cm in size. TSA, distributed mainly in the rectosigmoid colon, has a somewhat villiform configuration and consists of eosinophilic cells with pseudostratified nuclei. SSA that is predominantly located in the right-sided colon characterizes dilated and serrated crypts at the crypt base with mild nuclear atypia. In SA, the proliferative zone remains in the lower crypt compartment with extending beyond the limit of normal (‘ bottom-up’ model). Ki67+ proliferative rate in the upper and middle crypt zones in SA was significantly higher than in HP but lower than in AD. SA shows mixed gastrointestinal differentiation, expressing both gastric (MUC5AC or HGM) and intestinal (MUC2) mucins. Both DNA microsatellite instability (MSI) and the epigenetic silencing of DNA mismatch repair (MMR) gene through the methylation within the promoter region have been demonstrated in SA. This evidence points to a serrated adenoma-carcinoma sequence (serrated neoplasia pathway). Loss of expression of hMLH1 and O-6-methylguanine DNA methyltransferase MMR protein has been found immunohistochmically in some of SSA. Diagnostic difficulties occur in the distinction of SSA from TSA because histologic overlap among the features of both lesions and existence of mixed SSA-TSA. The term SSA also has been criticized because of the use of macroscopic term "sessile" in histologic diagnosis, which potentially might cause confusion. It is almost impossible to distinguish between SSA and HP, in which most diagnostic histologic features are present at the base of the crypts, with tangentially sectioned or superficially fragmented biopsy material. Management of SA begins with accurate histologic diagnosis. According to the ordinary management of AD, SA, especially flat or large (>1cm) lesion, would be entirely removed endoscopically if possible. It would be recommended endoscopic resection and regular surveillance (particularly MSI+ right-sided colon carcinoma ; at 1 year interval) for right-sided SSA with risk factors as follows : (1) multiplicity (>20 polyps), (2) large lesion (>1cm in size), (3) family history of intestinal polyposis syndrome or colorectal cancer.

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A 62-year-old-woman was admitted our hospital for treatment of idiopathic pulmonary fibrosis and treated with methylprednisolon on the 9th day of admission hematemesis and melena were noted. On gastrointestinal fiberscopy examination, gastric vascular ectsia with a bleeding spot was found at greater curvature of stomach near posterior wall of the upper gastric body. After a single procedure of endoscopic band ligation (EBL), vascular ectasia successfully disappeared without any complications. EBL could be one of the effective treatments for hemorrhagicgastric vascular ectasia.

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The patient is detected in a 53-year-old male. Endoscopic examination revealed two superficial cancers ; a type of flat elevation with central depression (the main lesion) and type IIa in the duodenal bulb. Duodenal X ray examination revealed one more lesion of type ha. Endoscopic ultrasonogram suggested that the main lesion invaded the muscularis propria (MP) and two ha lesions were localized in the mucosal layer (M). Pancreaticoduodenectomy was performed. Three lesions were found discontinuously. Histological examination of the resected specimen showed the main lesion to be papillary adenocarcinoma (mp, ly0, v0) and two ha lesions to be both well differentiated adenocarcinomas (m, ly0, v0). Immunohistochemical examination of human gastric mucins (HGM, MUC6, and MUC2) were performed. The main lesion was HGM (+), MUC6 (+), MUC2 (+). Two ha lesions were (+, +, -), (+, -, +), respectively. We herein reported a very rare case of primary duodenal tripple adenocar-cinomas which occurred simultaneously.

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A 72 year-old man was admitted due to appetite loss to our hospital. A routine gas-troduodenoscopy revealed a tumor with an irregular ulcer of the fourth portion of the duode-num. Re-examination of the duodenal tumor, using a pediatric colonoscopy (PCF240I, OLYMPUS, Tokyo), led to a diagnosis of moderately-differentiated adenocarcinoma by biopsy. We segmentally resected the duodenum, and dissected the lymph nodes and vessels. The postoperative diagnosis was a primary adenocarcinoma of the fourth portion of the duodenum, T3N1M0 Stage III. Most primary adenocarcinomas of the fourth portion of the duodenum cannot be detected by routine gastroduodenoscopy due to their location. We report here a duodenal cancer of the fourth portion detected by routine gastroduodenoscopy.

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A 43-year-old woman who had suffered from mucous diarrhea over a week visited Taigenkai hospital in April 2005. Colonoscopy showed an edematous mucosal appearance with indistinct vascular transparency. Histologically, biopsy specimens of the colon and rectum showed prominent subepithelial collagen-layer thickening (10 25μm) without lymphocyte infiltration into the colonic epithelium. She had complained the similar symptom about 7 years before. A case of Collagenous colitis observed such a long time has been rarely reported in Japan.

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A88-year old woman was admitted to nearby hospital due to thighbone fracture of left cervix developed sudden massive rectal bleeding and went into shock. She was referred to our hospital and colonoscopic examination was performed. Multiple Dieulafoy's ulcers were found out and one of them showed active bleeding. Endoscopic clipping were performed and successfully hemostated. Endoscopic clipping is preferable to hemostate bleeding from rectal Dieulafoy's ulcer.

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Cholecystocolic fistula is a comparatively rare among internal biliary fistula. We report a case of cholecystocolic fistula enclosed by colonoscopic clipping. A 82-year-old man was admitted because of acute cholecystitis. PTGBD (Percutaneous transhepatic gallbladder drainage) was enforced. Afterwards, cholecystocolic fistula was turned out. But it was judged that the operation for the fistula was difficult because of cardiopulmonary defective function. Therefore, we tried colonoscopic enclosure by clip. As a result, the fistula had been improved. In general, the treatment of cholecystocolic fistula is surgical methods. It seems that treatment by colonoscopic enclosure with clip was effective, when operation is difficult.

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The indications of endoscopic ultrasonography (EUS) for diseases of the lower digestive tract include cancers, submucosal tumors, extramural lesions, inflammatory diseases, etc. Ultrasonic endoscopes and miniature probes are available ; the use of miniature ultrasonic probes is generally adequate except for lesions of the lowermost part of the rectum, tumors with considerable thickness, and extramural lesions. Especially, miniature ultrasonic probes are useful for evaluating the depth of early colorectal cancers, which consists of the majority of practice with EUS. Mainly, deaerated water instillation method is employed for observation ; adequate positioning of a patient for immersing a lesion with water and short time examination are important. If the advantages and disdvantages of EUS in various disorders are satisfactorily recognized, the use of EUS will contribute to improving the diagnostic capability.

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Background and aim: Pouchitis is one of the late complications of restorative proctocolectomy in ulcerative colitis (UC) and is associated with increased bowel frequency. The present study aimed to clarify the endoscopic findings that are associated with bowel frequency. Patients and methods : The macroscopic and microscopic features in the ileum proximal to the pouch, the pouch, and the remnant short rectum in 100 endoscopies on 63 patients were studied retrospectively. Results : Four of 28 (14%) patients had inflammatory changes in the proximal ileum. Sixty-seven percent of patients showed an abnormal appearance of the pouch. Granularity, friability, presence of mucus, erythema, and erosions were significantly related to bowel frequency. 'Endoscopic pouch activity index' (EPAI), which is the number of positive findings of diffuse erythema, mucus, friability, ulcer, erosion, and granularity, was strongly associated with bowel frequency (P< 0.0001). Patients without macroscopic inflammation in the rectum had significantly lower bowel frequency than those with mild or moderately active inflammation (P0.0294 and 0.0183, respectively). Multivariate analysis revealed that 'endoscopic pouch activity index' and histological grade of pouch inflammation were significant factors (P=0.0004 and P0.0429, respectively) influencing bowel frequency. Time-course study demonstrated that changes in EPAI and macroscopic grade of the rectum were significantly related to alteration in bowel frequency (P=0.0120 and 0.0244, respectively). Conclusion : Erythema, mucus discharge and granularity were significantly related to bowel frequency. EPAI may be useful to evaluate endoscopic pouch inflammation.

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