There have been an increased number of patients with cerebrovascular and cardiovascular diseases in the aging population. Antiplatelet therapy is very important for cerebrovascular and cardiovascular diseases, and antiplatelet drugs are often prescribed for secondary prevention of vascular events. In particular, low-dose aspirin may impair the mucosa of the entire gastrointestinal tract, including the esophagus, stomach, duodenum, small intestine, and large intestine. This mucosal injury may be fatal due to complications of bleeding and perforation, and it is a task of pressing urgency to take appropriate preventive measures.
Discontinuation of antiplatelet drugs because of gastrointestinal bleeding sometimes results in the complication of severe thrombosis. Therefore, rapid and appropriate endoscopic hemostasis as well as early resumption of antiplatelet drugs is desirable. Taken together, not only gastroenterologists, but also physicians who prescribe antiplatelet drugs should share information on antiplatelet drugs and gastrointestinal mucosal injuries. Experts in different fields should cooperatively prescribe antiplatelet drugs appropriately in each case, prevent the occurrence of gastrointestinal injuries, and provide treatment in emergencies.

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Purpose : The aim of this study was to clarify if small colorectal cancers with substantial invasion can be diagnosed by colonoscopy.
Methods : Nine lesions of T1 stage colorectal cancers measuring 10mm or smaller with submucosal invasion of 1,000μm or deeper were studied. Two authors reviewed colonoscopic findings, i.e. apparent depression, fold convergence, irregular surface, ulcer/erosion, spontaneous bleeding on non-magnified image and pit pattern (Kudo's classification) on magnified image.
Results : Apparent depression, fold convergence, irregular surface, ulcer/erosion and spontaneous bleeding on non-magnified image were present in 56%(5/9), 44%(4/9), 56%(5/9), 22%(2/9) and 33%(3/9), respectively. On magnified image, V_N type pit was present in 57%(4/7). Eight of 9 lesions revealed positive in either 6 findings evaluated.
Conclusions : Majority of small T1 colorectal cancers with substantial invasion could be diagnosed based upon ordinary and magnified colonoscopic findings.

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A 50-year-old man with appetite loss and high fever was admitted to our hospital. Endoscopic examination revealed anodular lesion covered with thick white coat. Biopsy findings confirmed diffuse large B-cell lymphoma. The patient was treated with combined immunochemotherapy consisting of rituximab plus cyclophosphamide, vincristine, adriablastin, and prednisone (CHOP-R). A complete response was achieved. The patient was disease-free at 10 months after treatement.

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We report a case of carcinoid tumor occurred in the mucosal layer of lower thoracic esophagus (Lt), which was resected by endoscopic submucosal dissection (ESD).
A 55-year-old female with SMT like lesion in Lt was diagnosed as carcinoid by the Esophago-gastro-duodenoscopy and pathological examination of another hospital. She was referred to our development to treat. A red-spot lesion in the same part was detected, and was completely resected by ESD. The tumor was histopathologically diagnosed as carcinoid located in the mucosal layer. In the tumor, much blood capillary were seen so that we suggest tumor surface was endoscopically red. We supposed this red phenomenon as the characteristic one in early stage of esophageal carcinoid.
Carcinoid tumor of the esophagus located in the mucosal layer is very rare. We could investigate the mucosa of surrounding esophageal carcinoid from the present case.

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We report a rare case of intramural hematoma of the papilla vater. The case is 64-year-old man. He had a history of diabetes and the deep-vein thrombosis. The steroid and Warfarin are administerd. He admitted to our hospital, due to epigastralgia with leucocytosis and liver dysfunction. Abdominal computed tomography revealed dilated intrahepatic bile duct and common bile duct. On ERCP, the duodenal papilla presented markedly swollen and colored shade red. Endoscopic sphincterotomy and endoscopic biliary drainage were performed because of insufficient decrease of serum total bilirubin and amylase level. Diagnosis of internal hematoma of the papilla was also made by intraductal ultrasonography. On the 31st day, he discharged without any symptoms. Duodenal intramural hematoma without any extrinsic causes is quite rare. The mechanism of this lesion was not clear, however, the diagnosis and treatment may be suggestive for same cases.

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A 57-year-old woman developed persistent lower right abdominal bulging continuously after colonoscopy. Blumberg's sign and free air in the abdominal cavity were observed 17 days post colonoscopy. Emergency surgery was performed for suspected digestive tract perforation. Perioperatively, a large hematoma was observed in the retroperitoneal space of the hepatic flexure. The oral side at the hematoma of the ascending colon had been expanded and perforated. Therefore, a right hemicolectomy and ileostomy were performed. We report this case of delayed perforation of the ascending colon caused by retroperitoneal hematoma after colonoscopy and review the relevant literature.

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Purpose : Percutaneous endoscopic gastrostomy (PEG) is widely used. However, there are concerns with the adverse effects caused by improper PEG tube replacement. In order to confirm whether the PEG tube has been properly placed in the stomach, the presence of gastric juice was determined using a disposable colormetric CO₂ detector (CO₂nfirm Now^TM, Tyco Healthcare, Japan) and 7% sodium bicrbonate solution (Mylon^TM). The usefulness of this procedure was evaluated.
Method : 10 patients (males 6, females 4 ; 22 to 99 years old, mean 69.9 years old). All were outpatients. The PEG sizes used included 18 to 24Fr (Bumper type) in 9 patients, and a 16Fr (Tube type) in 1 patient. The PEG tube was replaced using a routine procedure. After replacement, Mylon^TM (3ml) was injected through the replacement tube. When the PEG tube was properly placed in the stomach, carbon dioxide (CO₂) was generated. The CO₂nfirm Now^TM test was used to identify color changes consistent with the presence of CO₂ in the stomach cavity.
Result : All patients, including three patients treated with a proton pump inhibitor or H2-blocker, had immediate and unambiguous color changes consistent with the presence of CO₂. There were no complications caused by the injection of Mylon^TM.
Conclusion : Our new method of confirming gastric juice using the CO₂nfirm Now^TM test and Mylon^TM may be useful in patients requiring PEG tube replacement. It can be easily and safely performed even at the bedside.

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Background : Endoscopic submucosal dissection (ESD) for colorectal tumors enables us to achieve en-bloc resection of large tumors which is not able to be by EMR (endoscopic mucosal resection). In ESD, it is important to shorten the operation time to minimize the patient's abdominal fullness. Furthermore, it is a problem to need many medical staffs for ESD in undermanned medical institution. In the current study, we developed the new one-man method of ESD to solve these problems. Methods : We studied 152 colorectal tumors that were treated by ESD at Kyoto Prefectural University of Medicine or Nara City Hospital between 2007 and 2009. In these, 64 cases were treated by new one-man method and 88 cases were by previous method. The 88 cases of previous method were divided into 2 groups based on the date of procedure ; the preceding group (44 cases) and the last group (44 cases). Tumor size, operation time, rate of en-bloc resection, and complications were analyzed in these 3 groups. The one-man method of ESD was performed using Flush knife with automatic injection device. Original device, which was made of paper clip and clothespin, was used to connect knife and endoscope. Results : ESD with the new method was accomplished in all 64 cases. The method enabled us to reduce medical staff who held knife during ESD. The average tumor size, rate of en-bloc resection, and rate of perforation and postoperative hemorrhage as a complication was not different significantly among the 3 groups. The average operation time was slightly shorter in the new method group, i. e. preceding group, 110 min ; last group, 112 min ; new method group, 97 min. Conclusions : The new one-man method of ESD has the possibility for shortening operation time and reduction of medical staffs during ESD.

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Transnasal endoscopy is considered suitable for screening examination. It is safer and easier to accept than conventional endoscopy. However, transnasal endoscopy involves many problems yet to be solved, including image resolution. At first we pay attention to a performance difference according to the generation of transnasal endoscopy. It is necessary to use the method of the preparation properly by thinking about the balance with the diameter of the transnasal endoscope used. It seems that transnasal endoscope is enough precious examination for screening endoscopy. However, the detection rate of gastric cancer from the non-atrophic gastritis in transnasal endoscopy is significantly less than conventional endoscopy. Targetting biopsy of transnasal endoscope is almost equal to the conventional endoscope according to the appearance of a new device.

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