Recently, international consensus guidelines for management of IPMN/MCN of the pancreas have been issued and argued the recommended management strategy for diagnosis and treatment of IPMNs. IPMNs can be categorized to main duct IPMNs (MD-IPMNs) or branch duct IPMNs (BD-IPMNs) depending on the localization of the lesion.
The guidelines recommended surgical resection for all MD-IPMNs. In addition, surgery was recommended for patients with BD-IPMNs who have symptoms, presence of mural nodules (MNs), a dilated main pancreatic duct (MPD), positive cytology, or cyst size > 3cm.
However, they include some controversial issues and still have been developing.
Endoscopic examination plays some precise roles for diagnosis of IPMNs, including the differential diagnosis, evaluation of the lesion extension and indication for surgery. Especially, EUS is the most sensitive examinations for identification of MNs.
In Japan, ERCP is recommended for histological and/or cytological diagnosis of IPMNs instead of EUS-FNA because of the risk of the dissemination after EUS-FNA. On the other hand, in Western countries EUS-FNA is preferable for histological and/or cytological diagnosis. IDUS and POPS are also effective for evaluation of MPD extension.
The guidelines would be expected to revise more practically, based on the further consideration of detailed endoscopic examinations and studies.

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Background : Definitive chemoradiotherapy is widely used for the treatment of esophageal cancer. However, detailed influence of chemoradiotherapy to radiated organs in not known. The current article aimed to determine the esophageal mucosal change after chemoradiotherapy of esophageal cancer.
Methods : Between January 2009 and September 2009, 58 patients after chemoradiotherapy for esophageal cancer (CRT group), 70 patients after endoscopic resection for esophageal cancer (ER group) and 105 patients without esophageal cancer (Non-esophageal cancer group) received endoscopic examination of a single endoscopist. Endoscopic appearances of esophageal mucosa in CRT group were compared with other two groups.
Results : Scattered greenish dots, a cluster of tortuous vessels, disappearance of intraepithelial papillary capillary loop (IPCL), destroyed arborescent and oblique running vessels were more frequently seen in CRT group compared to ER group and Non-esophageal cancer group (P<0.001). Association between abnormal mucosal findings and following findings are assessed ; radiation dose, interval between chemoradiotherapy and endoscopic examination, tumor category of esophageal cancer, esophagitis during chemoradiotherapy. Among these factors, only radiation dose of 60Gy was significantly associated with abnormal mucosal findings.
Conclusion : Typical endoscopic findings after chemoradiotherapy of esophageal cancer were scattered greenish dots, a cluster of tortuous vessels, disappearance of IPCL, destroyed arborescent and oblique running vessels. Endoscopic diagnosis should be made considering that these findings are common after chemoradiotherapy.

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A 69-year old male who suffered from melena and underwent lower digestivee tract endoscopy in a neighboring hospital was diagnosed with lymphoma, and was referred to our hospital. Upper gastrointestinal endoscopy demonstrated that the body of his stomach had thickening folds and many erosions ; erosions in the shape of a map were also observed on the entire circumference of the rectum. The lymphoma was diagnosed as a mantle cell lymphoma as a result of immunohistological examination.
Rituximab combination chemotherapy was initiated, and efficacy was confirmed by endoscopy. The patient is alive with no recurrence 20 months after treatment cessation.

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A 72-year-old man had massive hematochezia 8 days after admission with acute enteritis. Upper GI endoscopy and total colonoscopy did not reveal any abnormality immediately after the GI bleeding. A small amount of hematochezia continued repeatedly for 6 days. Colonoscopy was performed again 6 days after the initial bleeding. It showed a press through package (PTP) located in the rectum, and was removed endoscopically. Capsule endoscopy on the day showed a small, linear ulcerated lesion with oozing bleeding in the ileum. The patient was treated with fasting conservatively. This is the report of small intestinal bleeding by PTP, which was diagnosed with capsule endoscopy.

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We report a 82-year-old female with liver chirrhosis who presented melena and anemia. Initial upper GI endoscopy, colonoscopy and computed tomography failed to find the bleeder. Double balloon endoscopy revealed sub mucosal nodule about 60mm in diameter located at proximal jejunum. Surgical resection was carried out.
Pathologic examination indicated that the tumor was adenomyomatous hamartoma.
The patient was symptom-free after the operation.

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A 58-year old female who had been diagnosed as protein-losing enteropathy in 2005 was admitted to our hospital in September 2008 with severe anorexia and general fatigue. Laboratory data showed severe low proteinemia. Capsule endoscopy was performed to investigate the mucosa of the small intestine. Capsule endoscopy showed white villi widely in the proximal jejunum. Jejunal biopsy performed by oral single balloon enteroscopy showed dilated lymphatics in the lamina propria. We propose that capsule endoscopy is a promising technique to diagnose intestinal lymphangiectasia.

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We describe a rare case of mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) concomitant with tubular adenoma of the rectum. The patient was a woman in her early 70s with complaint of hematochezia. Colonoscopic examination revealed lateral spreading tumor (LST), homogeneous granular type and multiple submucosal tumours (SMT) together with vascular ectasia in the rectum. Some of the SMT were seen in the LST as well. Endoscopic mucosal resection was carried out in accord with the diagnosis. Histological examinations of the biopsy specimens revealed that SMTs were MALT lymphoma and the LST was a tubular adenoma. Based on a report that rectal MALT lymphoma regressed in association with H. pylori eradication therapy, an eradication therapy was done. Colonoscopic examinations revealed a dramatic regression of the MALT lymphoma three months after the eradication and disappeared ten months after H. pylori eradication.

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After beginning lansoprazol for a month, a 71-year-old woman was admitted to our hospital due to acute abdomen appearing colonic longitudinal ulcers. She recovered rapidly, but one month later she started suffering from continuous diarrhea. A colonoscopy re-examination was done. The spiecimen disclosed the collagen band below the colonic mucosa. Then we finally diagnosed this case as collangenous colitis because of clininal course and specific colonoscopy findings. We think she appeared acute abdomen because of collagenous colitis complicated with colonic longitudinal ulcers.

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A 62-year-old woman came to our hospital with a chief complaint of epigastric pain. She had shown a limited calcification in the gallbladder on computed tomography six months earlier, but the calcification had now reached the common bile duct. Blood examination revealed elevation of hepatobiliary system enzymes and jaundice.
Therefore endoscopic sphincterotomy was performed, causing massive sludge to drain.
After reduction of the jaundice, laparoscopic cholecystectomy was performed. The patient had a paste-like mass in the gallbladder and an impacted stone in the cystic duct. The mass contained 95% or more calcium carbonate and thus was diagnosed as limy bile. The limy bile, extending from the gallbladder to the common bile duct, was treated with endoscopic sphincterotomy and laparoscopic cholecystectomy.

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The patient was a 71-year-old man who was admitted to our referral hospital for treatment of severe acute pancreatitis. He was transferred to our hospital because of ruture of a pseudoaneurysm on the 18th disease day. He underwent transcatheter embolization of the pseudoaneurysm. From the 40th disease day serum CRP levels were elevated and the hematoma was suspected to be infected. He underwent EUS-guided drainage through the gastric wall. A nasocystic catheter enabled us to provide continuous irrigation with saline solution. He had complete resolution of the abscess with dilation of the puncture site twice.
He had bleeding after balloon dilation, which was controlled by insertion of cEMS.

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Aphthoid ulceration has been regarded as an early macroscopic feature of Crohn's disease (CD) and ulcerative colitis (UC). The important endoscopic findings in this condition are (1) redness and/or white coated change of the ulceration, (2) elevation of the area around the aphthae, and (3) the distributions of the aphthae. Indigo carmine dye spraying is useful for the careful observation of such ulcers. The characteristic findings in the case of early lesions in CD are mild elevation with central depression of the affected surface or ulceration and longitudinal distribution of ulcers, but these findings are not unique to inflammatory bowel disease. Histological findings such as non-caseating epithelioid granulomas provide colonoscopists useful information for the diagnosis of CD. When only aphthous lesions are detected, it is necessary to confirm the diagnosis of IBD, especially CD, on the basis of findings in the upper gastrointestinal tract and small intestine and extraintestinal manifestations.

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There are many kinds of the therapy for gastric vavices, and the strategy is different by each hospital. Endoscopiologists should decide a standard algorism in advance by themselves in time of emergent bleeding from gastric varices. When a patient with gastric variceal bleeding is admitted to your hospital, you had better start conservative treatment such as a transfusion and obtain informed consent as soon as possible, followed by endoscopic therapy The first choice of endoscopic treatment is sclerotherapy with cyanoacrylate (CA). CA 70% mixture with Lipiodol is injected directly near bleeding site and filled large lumen of gastric varices immediately. Additional injection sclerotharapy plus balloon-occluded retrograde transvenous obliteration (B-RTO) is the second choice of the therapy. Hassab's operation is an excellent method in young patient. The survey on portal circulation is necessary and diagnosis of liver disease is essential. Co-existence of hepatic malignancy should be investigated.

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