Collagenous colitis (CC) is a distinct clinicopathological entity characterized by chronic watery diarrhea and a thickened subepithelial collagen band, and mainly affects middle-aged and elderly women. The etiology of CC is largely unknown ; however, a variety of factors have been implicated including genetic factors, autoimmune diseases, intestinal infections, bile salts and drugs such as proton pump inhibitors, non-steroidal anti-inflammatory analgesics, aspirin, and ticlopidine. Although endoscopy usually reveals only normal or non-specific minimal abnormalities of the colonic mucosa, such as increased capillary growth and multiple longitudinal ulcers called mucosal tears, are occasionally observed. The diagnosis of CC is made based on clinical symptoms and histopathologic features of colonic mucosal biopsies. Improvement may be achieved by cessation of possible causative drugs alone. Antidiarrheal drugs such as loperamide and cholestyramine are recommended as first line treatments, followed by subsequent administration of mesalazine, oral corticosteroids and immunosuppressive drugs in non-respondent cases.

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Background : In emergency departments of hospitals, patients with foreign bodies lodged in the upper gastrointestinal tract are often encountered. Flexible endoscopy is useful for the removal of foreign bodies and, here, we review the clinical characteristics of these cases and clarify the risk of complications. Methods : We retrospectively examined 104 cases between July 1996 and December 2008 at Saiseikai Kumamoto Hospital in which a foreign body was endoscopically removed from the upper gastrointestinal tract of an adult patient. We analyzed the age and sex of patients, symptoms, complications, previous history, type and location of foreign body, the endoscopic device used, and clinical course. Results : Most foreign bodies were sharp objects : press-through packaging (PTP) in 30 cases, dental prosthesis in 24, bone (fish or other animal bone) in 22, and toothpick in 4. Foreign bodies were lodged in the esophagus in 59 cases (57%) and in the stomach in 33 (33%). In 7 patients who had complications caused by the foreign body, the foreign body was a sharp object. Of the 75 patients who knew the time of accidental ingestion, complications occurred in 4 of 67 cases (6%) treated less than 24 hours after ingestion and in 3 of 8 (38%) patients treated more than 24 hours after ingestion. Conclusion : Most foreign bodies lodged in the upper gastrointestinal tract were sharp objects. Attention must be paid to complications in patients treated ≥24 hours after accidental foreign body ingestion.

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A 74-year-old man who was diagnosed with esophageal Candidiasis in the lower esophagus at the age of 66, was reexamined due to dysphasia. He had been repeatedly treated with antifungal agents without infection resolution. Endoscopy revealed esophageal Candidiasis from the pharynx to the lower esophagus, and stenosis of the lower esophagus. Post-admission treatment with combined argon plasma coagulation (APC) and antifungal agents successfully resolved the fungal lesions. These findings suggest the utility of APC in the treatment of refractory esophageal Candidiasis.

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A 55-year-old man with a history of having undergone gastroduodenostomy (Billroth I method) for perforated duodenal ulcer was admitted to our hospital due to hematemesis that occurred 4 days after eating uncooked mackerel. Emergency gastroduodenoscopy revealed an A1 stage hemorrhagic ulcer with bleeding at the greater curvature of the mid-gastric body in the remnant stomach. An Anisakis simplex was found at the base of the ulcer, which was successfully removed by biopsy forceps. An endoscopic hemostasis procedure was performed on the visible vessels at the base of the ulcer to stop the bleeding. Thereafter, the patient was treated with proton pump inhibitors (PPI), and the ulcer had improved to H2 stage at 14 days after the hospital admission. We report a rare case of hemorrhagic gastric ulcer associated with anisakiasis.

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We report herein three cases of collagenous colitis with longitudinal ulcers. Longitudinal ulcers were first observed in the sigmoid and descending colon on colonoscopy performed due to chronic diarrhea and loose stool. Biopsy from the ulcer revealed diffuse proliferation of the subepithelial collagen band, and the diagnosis of collagenous colitis was made. All patients had taken lansoprazole for 5 to 16 months prior to examination, and this was believed to be a possible cause of the pathology. In one patient, discontinuation of lansoprazole resulted in immediate improvement in diarrhea. In the two patients who continued taking lansoprazole, symptoms persisted for 2 to 8 months then improved without discontinuation of the drug.

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A 10-month-old boy was referred to our hospital with bloody stool. Abdominal ultrasonography demonstrated intussusception of the descending colon with a target sign, and abdominal computed tomography revealed a slightly enhanced mass in the same region. Barium enema study showed a pedunculated polyp, approximately 15 mm in size, forming the leading edge of the intussusception. Endoscopic resection of the polyp was performed during colonoscopy under general anesthesia and the resected specimen was histopathologically diagnosed as juvenile polyp. No recurrence of intussusception has been observed to date.
A relatively frequent cause of pediatric intestinal obstruction, intussusception is usually ileocolic with no underlying organic disease. Colocolic intussusception is very rare, and most cases are associated with underlying bowel lesions such as juvenile and Peutz-Jeghers polyps. When a pediatric patient presents with bloody stool or abdominal pain suggestive of colocolic intussusception, colonoscopy is recommended. This should be performed under appropriate sedation with the endoscope selected in consideration of the patient's age and physical attributes. Endoscopic polypectomy is believed to be more useful than surgical treatment when organic lesions such as juvenile polyps are present, as in the present case.

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A 49-year-old man was hospitalized for acute pancreatitis and pancreatic pseudocysts. Symptoms and blood test results improved with fasting and antibiotic administration and oral feeding was initiated. However, fever reemerged and his inflammatory response was exacerbated. On abdominal computed tomography (CT), gas was observed within the pancreatic cyst and intracyst infection was suspected. Endoscopic ultrasound (EUS)-guided transgastric cyst drainage, i.e., placement of an internal and external drainage tube, was performed. At postoperative one week, his inflammatory response had normalized. However, when contrast imaging was performed via the external drainage tube with the aim of removing the tube, the descending colon was visualized and colonic fistula was still clearly visible. It was expected that the fistula would close on its own with conservative therapy ; therefore, he was kept under observation under NPO and antibiotic treatment. On CT performed about 20 days later, the abscess was no longer visible. After oral feeding was reinitiated, his course was favorable and was discharged. Colonic fistula rarely occurs in conjunction with an abscess after acute pancreatitis and treatment has not yet been established. This is an important case demonstrating that EUS-guided cyst drainage facilitates closure of such a fistula.

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A 60-year-old man with iron-deficiency anemia underwent upper and lower gastrointestinal endoscopies to determine the cause of the anemia, but no responsible lesions considered responsible for the anemia was found. Thus, small intestinal bleeding was suspected, and single-balloon enteroscopy was performed. Three hours after the end of the examination procedure, the patient complained of abdominal pain. Laboratory tests revealed hyperamylasemia, and abdominal computed tomography showed enlargement of the body-tail region of the pancreas with inflammation spreading to surrounding areas. He was thus diagnosed as having acute pancreatitis, a complication of single-balloon enteroscopy. Conservative treatment resulted in improvement of symptoms and hyperamylasemia.

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The tips of traditional endoscopic nasobiliary drainage (ENBD) catheters, such as the straight type and the pigtail type, have shapes that are not three-dimensional. However, in patients with choledocholithiasis, the stones may slide upstream past the tip, and this may cause stone re-impaction. Therefore, to prevent this phenomenon, a spiral-cone type ENBD catheter having a tip with a three-dimensional shape was developed and used for 16 choledocholithiasis patients. This catheter was successfully placed in all patients, and it provided good biliary drainage. In addition, upstream passage of the stones was prevented until just before the tip came out of the bile duct at the time of catheter removal. No complications were observed. This catheter appears suitable for choledocholithiasis patients.

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The key to successful endoscopic submucosal dissection (ESD) is hemostasis. This involves prior recognition and coagulation of the large blood vessels within the submucosal layer and performing careful dissection to avoid hemorrhage. Maximal reduction of hemorrhage risk with appropriate perioperative management and treatment strategies based on individual patients and lesions is essential for safe and reliable ESD. When using recently-developed equipment such as flex or dual knives, dissection can be performed with direct visualization of the blood vessels, and the chances of hemorrhage can be minimized through pre-coagulation.

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