Colonoscopy plays an integral role in the diagnosis, management, and surveillance of ulcerative colitis (UC). In established UC, colonoscopy obtaining mucosal tissue for histologic evaluation helps to define the extent and severity of involvement. In clinical practice, the endoscopic and histologic severity of disease using a standard score system is usually sufficient to make evaluations and decisions regarding medical treatment. Since Matts presented firstly the colonoscopic and histologic grading score system for the assessment of disease severity in UC in 1961, many scoring systems using activity indices by endoscopy and histology have been proposed. However, these activity indices were similar to Matts' scores. In using the activity index, it is reported that the endoscopic assessment alone tends to underestimate the extent when compared to histological scores, and does not often coincide with histologic findings using sigmoidoscopy. Recently, we clarified the correlation among the total colonoscopic features, histological findings and clinical disease activity in UC, and further, investigated the correlation between the histological inflammation and colonoscopic findings at the sites from periappendicular region to rectum in UC. We performed total colonoscopy examinations in 56 cases with UC. The large intestine was divided into seven parts for endoscopic scoring degree of activity, and histological activity was graded in biopsy specimens from each part by observers with blind fashion. Disease activity was also evaluated using a clinical-activity index which was composed of symptomatic components just before colonoscopic examination. In the study, we used the Matts' grading score for colonoscopic and histologic findings at the 7 parts of the colon, and adopted the total endoscopic and histologic grading scores all inclusive 7 sites as an activity score of the UC. The colonoscopic scores correlated significantly with histological scores and clinical disease activity. Comparing to endoscopic grading scores, histological grading scores correlated with clinical-activity scores more accurately. This new colonoscopic and histologic activity assessment method by accumulation of seven points scores is thought to reflect to the total colon disease activity in UC. Therefore, we propose here the new activity assessment method to use for the efficacy regarding medical treatment.

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[Aim]To evaluate the clinical characteristics of high incidences of bleeding after endoscopic treatment of colonic tumors, we performed a case-control study in which morphology, tumor size, location and endoscopic treatment were examined. [Method] Cases with bleeding after endoscopic treatment (n=34) were selected from our database of 14, 381 polyps which had been removed by Hot biopsy, Polypectomy or EMR from June 1995 to September 2002 at Juntendo University Hospital. In addition, we randomly selected no-bleeding cases (n=136) from our database and matched them to bleeding cases of age and gender. We studied morphology, tumor size, location, and resection technique associated with high incidences of post-bleeding and determined which is most associated with high incidences of post-bleeding among these factors. [Results] The proportion of pedunculated polyps in the bleeding group was significantly higher than that in the non-bleeding group (p < 0.01). The size of lesions in the bleeding group was significantly larger than that in the non-bleeding group (p < 0.01). The proportion of lesions which were located in the ascending colon in the bleeding group was significantly higher than that in the non-bleeding group (p < 0.05). The proportion of lesions which were removed by Endoscopic Mucosal Resection (EMR) in the bleeding group was significantly higher than that in the non-bleeding group (p < 0.01). Size was found to be most associated with high incidences of post-bleeding. [Conclusions] The size of the lesion was the biggest factor in determining the likelihood of bleeding. Therefore it was suggested that clips or forceps on the cut surface or vessels after endoscopic resection should be used.

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A case of gastorointestinal stromal tumor (GIST) of the small intestine diagnosed before operation was reported. A 57-year-old man was admitted to our hospital with a complaint of anemia. The cause of anemia was unclear by upper and lower gastrointestinal endoscopic examinations. Then the results of radiographic examination were suggestive of a small intestinal tumor. For a preoperative diagnosis, double-balloon enteroscopy was performed, which could make a diagnosis of GIST by detailed endoscopic observation of the tumor with the histological findings derived from endoscopic biopsy. From this case, it was suggested that GIST can cause anemia due to gastrointestinal bleeding. Especially, double-balloon enteroscopy was very useful in making the diagnosis of the disease of the small intestine.

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Solitary juvenile polyp may relate to inflammation of colonic mucosa. We reported a rare case of a solitary juvenile polyp in a patient with ulcerative colitis. A 30-year-old man was diagnosed as having ulcerative colitis when he was 6-year-old. His total colitis relapsed several times and was treated with salazosulfapyridine and steroid, but kept in remission for the last 12 years. In 2004, at the age of 30, he suddenly had diarrhea with abdominal pain. Colonoscopy revealed mild inflammation in his left colon and a pedunculated polyp in the transverse colon. The polyp was transected, of which head was about 50mm with lobulated surface and superficial erosion. Microscopic examination showed a dilated cystic glands and inflammatory cell infiltration to stroma, and was diagnosed as juvenile polyp. Although rare, previous reports showed solitary juvenile polyp may develop adenocarcinoma. Polypectomy should be done for juvenile polyps and surveillance colonoscopy is inevitable for the patients with longstanding ulcerative colitis.

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We experienced 4 cases of iatrogenic colorectal perforation which were successfully treated by conservative therapy with endoscopic repair using a clipping device. In 2 cases (case 1, 2), perforations occurred during endoscopic mucosal resection for sessile polyps in the sigmoid colon, and the rectum, respectively. In another case (case 3), perforation was recognized during endoscopic submucosal dissection for a large sessile polyp in the transverse colon. In the remaining case (case 4), perforation happened in the sigmoid colon during diagnostic colonoscopy. The perforation sites were immediately closed in all cases using hemostatic clips. Abdominal puncture was required to reduce the pressure of the abdominal cavity in 2 of 4 cases. Plain abdominal X--rays showed free air in the intraperitoneal space in 3 cases, and in the retroperitoneal space in the remaining case (case 2). Conservative treatment including no oral intake and intravenous administration of broad spectrum antibiotics was performed in each case. Two to three days after colonic perforation, slight fever, localized peritoneal sign, leukocytosis, and C-reactive protein were recognized in all cases. However, symptoms and physical signs were resolved within a few days of the onset, and oral intake was resumed 5-9 days after perforation and continued in 3 cases without complications. On the other hand, delayed bleeding was recognized 2 days after EMR in the remaining case (case 2), and required an endoscopic hemostatic procedure and a long-term treatment. Endoscopic repair using a clipping device is a useful therapeutic procedure in the conservative treatment for iatrogenic colorectal perforation.

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A 65-year-old woman was admitted to the other hospital because of diarrhea and abdominal pain. Colonoscopy showed ulcers spreading widely and annularly in the descending colon. There was no improvement under conservative therapy. Therefore she was given steroid under the diagnosis of Crohn's disease. Since her symptoms got worse when she started to inject meal orally, she was transferred to our hospital. Because biopsy specimen from the ulcer in the descending colon showed inclusion bodies in the cell nuclei, we administered ganciclovir to her under the diagnosis of CMV infection. Although laboratory data improved, X-ray showed bowel stenosis, hence left hemi-colectomy was performed.

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A 75-years-old man received external radiation with a cumulative dose of 6OGy for prostatic cancer. Severe hematochezia occurred approximately 16 months after irradiation. A extensive and circumf erential telangiectatic lesion in the lower segment of the rectum was detected, then he was diagnosed as having radiation proctitis. Pharmacotherapy was employed at first, but the bleeding was uncontrollable. Colostomy was performed, but the bleeding could not be controlled. Argon plasma coagulation therapy (APC) was applied, and the bleeding ceased after first session of APC. But the severe rectal stricture appeared three months after APC. APC is effective treatment for refractory radiation proctitis, but the rectal stenosis was occurred three months after APC.

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A case of mesenteric panniculitis after colonoscopic polypectomy is reported. The patient was a 39-year-old female, complaining of abdominal pain after polypectomy for sigmoid colon polyp on a long stalk. Abdominal CT showed increased density of the pericolonic fat tissue closed to the clip, which was used after colonoscopic polypectomy. Endoscopic examination revealed edematous mucosa in sigmoid colon. She was diagnosed as having mesenteric panniculitis from these findings, which was considered to be induced by colonic polypectomy or clipping. Physicians would pay care for hemorrhage, but not for the other complications, e.g. perforation and mesenteric panniculitis, when polypectomy for polyp on a long stalk is performed, because major of complications associated with polypectomy for such a polyp is bleeding. Such a case, mesenteric panniculitis after colonic polypectomy for polyp on a long stalk, is rare and has not been reported from Japan. Since unexpected complications could occur, careful follow-up would be wise after endoscopic polypectomy.

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Endoscopic biopsy is the method to proof the diagnosis of the endoscopist logically, and every biopsy mast to have a meening in spite of the number of biopsy. If we have a prospect of the pathology firmly when we perform the biopsy, we never leave the result of the biopsy if there exists a contradiction between the pathology and our diagnosis. The endoscopic biopsy is the basic procedure such as the endosocpic treatment, so we have to become proficient in the manipulation of the endoscopy and the biopsy forceps until we can take the precise lesion where we want to take. We never depend upon the result of the biopsy about the diagnosis and shoud make the endoscopic diagnosis due to the naked eye. Especially if there is the tiny lesion which is suspected of the malignant lesion, we are thinking that it shoud be added to the choice to perform the endoscopic mucosal resection (EMR) of it for the diagnostic treatment instead of the biopsy.

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