Asymptomatic mesenchymal tumors are often found out by routine exams especially by endoscopy as submucosal tumors in our country. A great part of them is speculated to be GIST, however the diagnosis is clinically difficult for their non-specific radiological or clinical features. It is advisable to say all GISTs are potentially malignant, although they rarely behave in a malignant fasion on the long clinical course. The gold standard for the diagnosis of GIST depends on immunohistochemistry, however the mucosal coverage over the tumor hinders getting biopsy specimen by routine biopsy. Therefore EUS-FNAB is recommended to obtain a biopsy specimen and to have histological diagnosis, if possible. A tyrosine kinase inhibitor, Imatinib mesylate, is a key drug and the effect on GIST is closely related to the genotype. Evaluation of malignant potential for pathologically diagnosed GIST is clinically of great importance.

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Background : In Japan in recent years colonic diverticular disease has increased, as has bleeding Secondary to diverticular disease. Methods : From July 1996 to November 2005, 332 patients with hematochezia had a colonoscopy, and 32 cases (9.6%) had colonic diverticular bleeding. The patients were evaluated in detail. Results : Of the 32 cases : 29 (90.6%) were more than 65 years old ; 25 (78.1%) had diverticular bleeding located on the left side of the colon ; 7 (21.9%) had bleeding on the right side of the colon; 26 (81.3%) had a blood clot that filled a diverticulum ; 5 (15.6%) had bleeding that oozed ; and 1 (3.1%) had bleeding that spurted. There were 30 cases (93.8%) with multiple diverticula of the colon and 2 cases (6.2%) with a single diverticulum of the colon. Furthermore, of the 32 cases : 26 (81.3%) were mild and did not need a blood transfusion ; and 26 (81.3%) required no endoscopic treatment. The recent use of anticoagulant drugs was higher in patients with diverticular bleeding of the colon (50%) than in patients with other causes of hematochezia (10%). Conclusions : Most of the patients with diverticular bleeding were more than 65 years of age, and half of them were taking anticoagulant drugs. Thus, anticoagulant drugs may be one of the causes of colonic diverticular bleeding.

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A 34-year-old woman was referred to our hospital for a medical check-up for gastric cancer. Endoscopic examination showed a depressed type of gastric cancer on the greater curvature of the lower body and nodular gastritis on the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma. A subtotal gastrectomy was performed. Histological examination of the resected specimen showed the tumor invaded the proper muscle. We experienced a case of advanced gastric cancer with nodular gastritis in a young adult.

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A 74-year-old woman was admitted to our hospital because of repeated gastrointestinal bleeding. In spite of several examinations including upper gastrointestinal endoscopy, colonoscopy, small bowel series, angiography, and red blood cell scintigraphy, the origin of the bleeding has not been detected. The finding of first capsule endoscopy (CE) showed the vascular spider on the ileum, which was suggestive of the origin of bleeding. Double balloon endoscopy (DBE) was performed via anterograde route and India ink was injected into the submucosal layer (endoscopic tattooing) at the terminal point of the examination. Next, it was performed via retrograde route to the tattooing site. However, origin of the bleeding could not be detected. Her bleeding was stopped spontaneously and she was discharged. Two months later, gastrointestinal bleeding was recurred. Second CE was performed and the active bleeding was recorded at the anal side from the tattooing site. Based on this finding, the second DBE was performed via retrograde route. Pulsating bleeding was observed on the distal ileum about 40cm from the terminal ileum, suggesting the hemorrhagic vascular ectasia. Hemostasis was successfully done with the combination of local hyper-saline-epinephrine injection and coagula-tion therapy with hot-biopsy forceps. She has never experienced re-bleeding for two years since then. In conclusion, the combination of CE and DBE was very useful for detecting the origin of repeated obscure intestinal bleeding. Moreover, endoscopic tattooing during the first DBE is easily detected by CE and also the decisive marker to judge which route of insertion is optimal for therapeutic approach of small intestinal bleeding in this case such as we encountered.

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Criteria for endoscopic resection of early colon cancer have been established in Japan. However, some cases can not undergo additional surgical resection after endoscopic resection because of poor general condition. Sometimes there is rapid recurrence of the tumor. A man who had been hospitalized for liver failure, was diagnosed as having early sigmoid colon cancer and endoscopic mucosal resection was performed. Additional resection was recommended because pathology showed tumor invasion near the cut margin, but the poor condition of this patient prevented further surgery. Although there was no recurrence 3 months after the resection, advanced cancer was detected at the stump of the excisional site by endoscopy 15 months after resection. More frequent endoscopic surveillance after the resection should be needed for lesion with tumor invasion near the cut margin.

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A 71-year-old woman with a history of asthma was admitted to our hospital with edema, numbness and muscle weakness of the ambilateral crura. Hematological tests revealed eosinophilia. Colonoscopic examination demonstrated multiple shallow irregular-shaped ulcers in the entire colon. A biopsy specimen of the ulcer showed granulomatous vasculitis with infiltration of eosinophils in the mucosal layer. A diagnosis of allergic granulomatous angiitis was made. After the administration of prednisolone, the eosinophil counts decreased and colonoscopic findings improved. Colonoscopic biopsy may be helpful in the diagnosis of allergic granulomatous angiitis.

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A 55-years-old married man was referred to our hospital for further examination with positive fecal occult blood test. He had no symptom. Colonoscopy showed the cyctic submucosal tumor at the ascending colon. Numberous trophozoites of Giardia lamblia were detected in aspirated liquid of the cystic submucosal tumor. Biopsied specimen of mucosa at the cystic submucosal tumor showed no trophozoites. He complained of abdominal pain and diarrhea after this examination. And trophozoites of Giardia lamblia were betected in diarrheal stool, too. A treatment by metronidazole was not effected at once. It has been no report about Giardia lamblia such existence style like this case.

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We herein report a case of ampullary cancer in 74-year-old man who underwent pancreaticodoudenectomy. Endoscopic Retrograde Cholangio-pancreatography (ERCP) revealed the ampullary cancer which was grew into the bile duct. However, The tumor did not invade to the pancreushead and the duodenum. It was diagnosed pathologically as the special type of well-differentiated tubular adenocarcinoma which was presented as unique progress in the bile duct. We discuss this case with references.

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We reviewed the NBI colonoscopy focusing on the magnifying observation of the microvascular architecture of colorectal lesions and discuss the utility of the detailed observation of the microvascular architecture for differential diagnosis during NBI colonoscopy. Angiogenesis is critical to the transition of premalignant lesions in a hyperproliferative state to the malignant phenotype. Therefore, diagnosis based on angiogenic or vascular morphologic changes might be ideal for early detection or diagnosis of neoplasms. In this review, we propose the term "meshed -like capillary" for the distinction between non-neoplastic and neoplastic lesions and the microvascular classification "capillary pattern : CP" for the differential diagnosis of colorectal lesions. We believe that the combined use of NBI optical chromoendoscopy and real chromoendoscopy decreases the time and cost of screening colonoscopy. To assess the feasibility and efficacy of using the NBI system, further studies are required for colorectal lesions and other lesions of the gastrointestinal tract.

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