Eosinophilic esophagitis is a rare type of esophageal disease that features dense intra-epithelial infiltration by eosinophils, which is caused by an allergic reaction to food or aeroallergens. Chronic eosinophil-related inflammation causes edema and fibrosis in the esophageal submucosal layer, while abnormal esophageal motor activity and fibrosis-related esophageal stenosis result in unpleasant symptoms including dysphagia and food impaction. In an endoscopic study of affected patients, longitudinal furrows, whitish stipple-like exudates, and multiple focal strictures were often found. For establishment of the diagnosis, dense infiltration of eosinophils (15-30 eosinophils/HPF) should be identified in an esophageal mucosal biopsy specimen. Local administration of glucocorticoids has recently been reported as useful first-line therapy for eosinophilic esophagitis.

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Several studies have reported that argon plasma coagulation (APC) is effective for hemorrhagic radiation proctitis resistant to medical treatment. We analyzed 24 patients with hemorrhagic radiation proctitis resistant to medical treatment to assess the effectiveness of APC. Colonoscopic findings of the hemorrhagic lesions were categorized as type-A, type-B, and type-C conforming to Chino's classification. In all patients, rectal bleeding stopped or was reduced and colonoscopic examination revealed eradication of the dilated veins after APC. We conclude that APC is a useful, effective and safe treatment for hemorrhagic radiation proctitis.

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An esophageal submucosal tumor (SMT) was discovered in 50 years-old male and was diagnosed as leiomyoma by strip biopsy. The tumor gradually expanded, and squamous cell carcinoma (SCC) emerged just above the leiomyoma. We performed ESD, for both the SMT and esophageal carcinoma. The SMT was positive for SMA, and negative for s100, vimentin, CD34 and c-kit. Pathological examination revealed low-high grade dysplasia and carcinoma in situ (ml) on the leiomyoma. Although chronic inflammation might cause esophageal dysplasia, the findings in our case suggested that mechanical stress caused by the SMT induced chronic inflammation, leading to the development of carcinoma.

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The patient was a 61-year-old man, who sought medical care for epigastralgia provoked by swallowing. Upper endoscopy revealed a Mt IIc lesion 3 cm in the major axis halfway around the esophagus and a biopsy established a diagnosis of squamous cell cancer (Mt 0-IIc T1a [lpm] [halfway around the circumference] Stage 0. ESD was performed under general anesthesia. On histopathological examination, the lesion was a poorly differentiated squamous cell cancer 22 mm in diameter (sm1, ly1, v1, HM0, VM0). Additional therapy of 5 courses of FP (5FU+CDDP) was conducted at the patient's request. Follow-up CT disclosed an approximately 3 cm mass in the region of the thoracic descending aorta at 14 months of ESD. The mass was diagnosed as lymph node metastasis and a right thoracotomy was performed for subtotal excision of the esophagus as well as lymphadenectomy.
Clinically there were lymph node metastases around the thoracic aorta, while histologically the lesion was endocrine cell carcinoma. The excised esophagus was free of cancer remnants. Lung and bone metastases were detected at 3 months of reoperation for the recurrence that occurred in spite of 60 Gy radiotherapy as well as FP chemotherapy. The patient died of the primary disease at 25 months after the initial therapy, 10 months from the esophageal resection. We report herein on a patient with a highly malignant esophageal cancer with a neuroendocrine component that was hard to recognize from ESD specimens and who died after recurrent lymph node metastases.

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The patient was an 80 year-old female with hematemesis. Upper gastrointestinal endoscopy revealed a Dieulafoy's ulcer in the gastric fornix with pulsatile bleeding. Following unsuccessful attempts of several endoscopic hemostasis techniques, endoscopic submucosal dissection (ESD) involving local injection, incision, and cautery was performed to stop bleeding. On the following day, visible exposed vessels were found at a different site, and hemostasis was achieved with endoscopic clipping. The ESD method may be an option of the treatment for gastric Dieulafory's bleeding. In addition, this may be a rare case where another potential but doubtful gastric Dieulafoy's ulcer developed after successful treatment of a previous Dieulafoy's ulcer.

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A 83-year-old man was diagnosed as having a duodenal SMT-like tumor with an opening pit via an esophagogastroduodenoscopy (EGD), and the size of the tumor increased over two months. He was referred to our hospital for further examination. The tumor was located on the superior duodenal angle (SDA) of the duodenal bulb, and had a depression on its anal side. Biopsy specimens showed well differentiated adenocarcinoma. The tumor was diagnosed as advanced carcinoma with duodenography and endoscopic ultrasonography therefore we selected a partial distal gastrectomy and partial duodenectomy as the surgical approach. Histological findings of the resected specimen revealed well differentiated tubular adenocarcinoma, which had invaded the subserosa and lymphatic vessels. Immunohistochemical staining indicated that gastric mucin such as MUC5AC and MUC6 were both positive, and that intestinal mucin such as MUC2 and CD10 were both negative, so this duodenal tumor was the completely gastric type of carcinoma.

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A 59-year-old female was admitted to our hospital with the suspected diagnosis of Crohn's disease. Colonoscopy revealed multiple longitudinal ulcers and a cobblestone-like appearance in the constricted transverse colon. Histological examination of biopsy specimens showed non-caseous epithelioid granulomas. However, a barium enema x-ray disclosed a straight line to the ileocecum and the shortening of the ascending colon, including a circular narrowing transverse colon. The contrast enema findings cast strong doubt on intestinal tuberculosis. However, mycobacterium tuberculosis complex was detected with the smear technique and PCR method from the biopsy specimens at the time of the reexamination. We report herein on a case of intestinal tuberculosis which was thought to be important for a differential diagnosis for Crohn's disease.

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Percutaneous Endoscopic Gastrostomy (PEG) was carried out in a patient with Child-Pugh C hepatic cirrhosis complicated by esophageal varices. Measures against bleeding from the esophageal varices and leakage of ascitic fluid were required. PEG could be safely carried out using the direct method and fixing the gastric wall closer to the abdominal wall by the four-point fixation method. No postoperative bleeding or ascitic fluid leakage was found. Although the presence of ascites and portal hypertension are relative contraindications for PEG, PEG could be safely carried out by taking appropriate measures, even in the presence of such contraindications.

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A 55-year-old man was referred to our hospital with elevation of the biliary duct enzymes in February 2006. Computed tomography images showed a tumor in the bile duct. The patient had a history of removal of the left little finger of his left hand due to a malignant melanoma in December 2004. Endoscopic retrograde cholangiography showed a movable defect in the bile duct. Biliary brushing cytology and a biopsy were performed. The histological findings revealed melanoma cells that were positive for HMB45 and Melan A. According to these findings, we made a diagnosis of recurrence of metastatic malignant melanoma in the common bile duct. We placed a plastic tube stent in his common bile duct, and he then underwent a pancreaticoduodenectomy. Multiple recurrences were noted one year after surgery, and the patient has undergone palliative care.

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This case involves a 56-year-old male patient. He had undergone a pylorus-preserving pancreaticoduodenectomy for the treatment of bile duct cancer. While he was being followed up for a pancreatic pseudocyst that had developed after the surgery, he attended the emergency room with fever and abdominal pain. A blockage of the afferent jejunal loop, which was caused by an increase in the size of the pancreatic pseudocyst, was found on CT scan imaging. As the afferent jejunal loop had penetrated into the abdominal skin, it was treated with echo-guided percutaneous drainage. Endoscopic ultrasound-guided drainage using an echo-guided percutaneous drainage route was considered for the treatment of the pancreatic pseudocyst. First, the external skin of the fistula was dilated enough for the insertion of the ultrasonic endoscope itself. Thereafter, the ultrasonic endoscope was inserted percutaneously into the afferent jejunal loop in preparation for puncturing the pancreatic pseudocyst. At a later date, it became possible to insert the endoscope into the pancreatic pseudocyst through the jejunum, and later debridement was also performed. Consequently, the pancreatic pseudocyst was successfully treated.

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The development of the second generation ultrasound contrast Sonazoid which produces a second harmonic component with low acoustic power has enabled vascular assessment in the field of EUS. With the use of the echoendoscope provided by OLYMPUS-ALOKA, contrast-enhanced EUS is performed in the eFLOW mode which depicts fine vessels without Doppler-related artifacts or in the ExPHD mode which enables perfusion imaging by selective depiction of signals from microbubbles. The echoendoscope should be manipulated in order to position it as close to the target lesion as possible. Contrast-enhanced harmonic EUS depicts fine vessels in the lesions 10-20 seconds after the infusion, and subsequently parenchymal perfusion with strong contrast with the pancreatic duct, biliary system and surrounding tissue. In the pancreato-biliary region, contrast-enhanced harmonic EUS is useful for detection and characterization of small lesions, particularly discrimination between benign and malignant lesions. In GISTs, specific tumor vessels can be observed with contrast-enhanced harmonic EUS. It is also useful for differentiation between benign and malignant lymphadenopathy. Visualization of the microcirculation and perfusion imaging in EUS which has high spatial resolution may further improve imaging of the digestive organs.

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Sporadic nonampullary duodenal adenomas are extremely uncommon. Furthermore, the incidence of duodenal tumors for which endoscopic resection (ER) is indicated is low, and moreover there are no guidelines for the indication, treatment methods, and how to manage the post-ER course. When considering EMR or ESD for duodenal tumors, it is more difficult to carry out endoscopic resection in the duodenum than in the stomach, because of the thin wall and narrow lumen of the duodenum. We describe herein how to manage duodenal tumors via endoscopic treatment methods.

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