Colorectal biopsy is helpful in the diagnosis of patients with colitis, in whom the most important but often controversial differential diagnosis is between idiopathic inflammatory bowel disease (IBD) and various other forms of colitis (non-IBD), and further between Crohn's disease involving the colon (CD) and ulcerative colitis (UC). Several biopsy criteria have been constructed by multivariate analysis, and the most recent ones have high sensitivity and specificity exceeding 96% in the first set (IBD versus non-IBD) and 92% in the second set (CD versus UC). The combined use of the criteria and diagnostic algorithm introduced in this paper will enable general pathologists to differentiate among CD, UC, and non-IBD under active or acute phase. For patients with UC, there are additional criteria reliably predicting failure in response to glucocorticoid therapy. When all of the pathological distinguishing features have been exhausted, however, a firm diagnosis of either CD or UC is difficult in about 3 to 10% of surgical specimens ; indeterminate colitis (IC) is the term applied to such unclassified cases. Although the frequencies of IC subsequently reclassified as CD or UC are variously reported due to difference in diagnostic method and timing, it is generally accepted that at least about 20% of patients preoperatively classified as IC are finally diagnosed as having CD.

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A 40 year-old female was found to have three minute submucosal tumors on atrophic gastric mucosa endoscopically. Histological examination of the specimen obtained by endos-copic mucosal resection showed the tumors to be classic carcinoid tumors with low malignant potential. An anti-parietal cell antibody was positive, and blood gastrin value was high. We diagnosed them as gastric carcinoid tumors with type A gastritis by the histological examina-tion of the background gastric mucosa. The gastric carcinoid tumors have passed without recurrence after endoscopic mucosal resection. Endoscopic mucosal resection was useful for gastric carcinoid tumors as the method of diagnostic treatment.

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A 73-year-old man was referred to our hospital for further examination and treatment for hematemesis. Upper gastrointestinal endoscopy revealed a submucosal elevated lesion covered with normal mucosa on the posterior wall of the prepyloric region with pyloric ring stenosis. The pyloric ring was barely visible in the frontal view, but an endoscope could not pass through the pyloric ring. We were unable to detect erosions and ulcers . Histological examination of the specimen obtained from the pyloric region by forceps biopsy could not confirm malignancy . The tumor was detected by computed tomography (CT) as a low density area with ring-like enhancement on the gastric wall, and it was accompanied with multiple liver metastases. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for the definite diagnosis. Histological examination of the biopsied specimen revealed adenocarcinoma. Subtotal gastrectomy was performed because the patient was unable to take by mouth. Histological examination of the resected specimen revealed moderately differentiated adenocarcinoma infiltrating into the serosa and forming a tumor with marked stromal fibrosis. The cancer cells were located mainly under the mucosa, and a small part of the tumor was exposed. Therefore, histological examination of the specimen obtained by forceps biopsy could not confirm malignancy. Histological diagnosis is critically important for determining the therapeutic strategy and for the patient to provide an informed consent . Our experience suggests that EUS-FNA was useful for the histological diagnosis of advanced gastric cancer resembling a submucosal tumor.

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We report five cases of primary follicular lymphoma of the duodenum, and discuss with focusing on the diagnosis and treatment of them. On diagnosis, it is important to notice the patchy whitish nodular lesion at the duodenum around the ampulla of Vater on the endoscopic examination. Phenotypic analysis with immunohistochemical procedure should be done for the proper diagnosis. The treatment of primary follicular lymphomas of the duodenum is very heterogeneous in the literature. This includes the 'watch and wait' policy, irradiation, surgical excision, and rituximab in combination with chemotherapy. Since the follicular lymphoma of the duodenum is infrequent, no standard therapy is yet established.

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A 70-year-old man was admitted to our hospital for further evaluation of a protruded stone in the duodenal bulb that was detected by endoscopic examination . Abdominal CT showed a stone in the duodenal bulb with a diameter of 2 cm, that was adjacent to a gallbladder in which air image as well as another stone was observed, leading to the diagnosis of gallstone impacted in the cholecystoduodenal fistula. Reexamination by abdominal CT for assessing the abdominal pain with repeated vomiting that suddenly occurred during planning therapeutic strategy revealed the air-fluid formation in the small intestine where the migration of the duodenal stone was confirmed. The diagnosis of gallstone ileus was followed by an oral insertion of a long intestinal tube into the small intestine. Then, the symptom due to ileus soon ameliorated with excretion of the gallstone. The subsequent ERC confirmed the cholesystoduodenal fistula, where no more stone but deep ulceration was endoscopically observed from a duodenal side of view. To our knowledge, this is a rare case that endoscopilally demonstrates the course of natural excretion of gallstone impacted in the cholecystoduodenal fistula.

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A 56-year-old man presented with abdominal pain at a local hospital. Barium enema revealed a stenosis of the transeverse colon, and he was referred to our hospital. Colonoscopy revealed an anisakis worm. We removed the worm endoscopically using biopsy forceps, upon which the symptoms improved. History taking clarified that the patient had eaten cuttlefish before the onset of the disease. Endoscopic examination is useful for both the diagnosis and treatment of anisakiasis.

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The subject was a male, aged 62, with a chief complaint of abdominal distention. He was a hard drinker and had been diagnosed with chronic pancreatitis. Hematological results showed increased pancreatic enzymes and increased CRP, and image photographs indicated marked ascites, pleural effusion, and pancreatic cysts. Furthermore, he had an expanded main pancreatic duct and a pancreatic stone. The ascites and pleural effusion were high-protein and high-amylase. The diagnosis of pancreatic ascites and pleural effusion followed alcoholic chronic pancreatitis. It was difficult to drain the ascites and pleural effusion via the major papilla. A pancreatic duct stent was then placed via the minor papilla, and the ascites and pleural effusion were eliminated.

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Direct percutaneous endoscopic jejunostomy (DPEJ) was first described by Shike et al in 1987. Indications for DPEJ include a risk of aspiration, severe gastroesophageal reflex, mechanical or functional gastric outlet obstraction etc. Technical success rate is about 70%. Failed procedures are due to inadequate transillumination, finger indentation and due to unable pass scope to jejunum. Selection of a length of the scope and technical improvements may rise a success rate. Using a fluoroscopy with contrast material is useful to identify the target jejunum. The complication rate according to the report of large number cases is 22.5% of all cases and 4.2% of severe adverse events. Especially, three severe advers events were associated with traction removal of the PEJ tube. This rate is higher than that of PEG. Mortality from DPEJ is 0.3% (1/307).

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Background and Study Aims : Contact endoscopy is a technique allowing detailed magnified imaging of living epithelium, used extensively to assess tissues of gynecological and laryngeal oragan. We used this technique during cholecystectomy to investigate its potential value for staging laparoscopy in gallbladder cancer. Patients and Methods : Eight patients with gallbladder cancer, four with mucosal hyperplasia, two with benign polyps and nine with gallstones were evaluated. During surgery, the lens of the contact endoscope (Karl Storz, Germany, 8715AA, 5.5 mm in diameter with a 0° angle) was placed in contact with the serosa of the gallbladder and observations were performed at magnifications of 60xand 150x. Results : Enlarged color images of the subserosal layer of the gallbladder were obtained. In normal mucosa, a fine vascular network with flowing erythrocytes was observed in the subserosal layer. Subserosal fat appeared as tortoiseshell-like markings, shown histologically to be clumps of fat cells surrounded by fine fibrous tissue. A gap between the deep vessels and the superficial vessels in the subserosal fat was also observed. The same findings were detected in gallbladder cancer patients where invasion was limited to the muscular layer. However, in patients with advanced gallbladder cancer, with invasion beyond the muscular layer, both the vessel gap and the fat tissue markings were absent. There was also encasement of the vessels and decreased intravascular flow of erythrocytes. Conclusions : The contact endoscope can be useful in differentiating between early and advanced gallbladder cancer and has some potential for use in staging laparoscopy for gallbladder cancer.

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