[in Japanese]

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Recently, the diagnosis and the treatment of small intestinal inflammatory disorders have been advanced by the progress of the diagnostic instruments including capsule endoscopy (CE), balloon endoscopy (BE), CT-enterography and MRI.
CE is useful when deciding on the treatment strategy of the small intestinal inflammatory disorders by evaluating disease severity (ex. the Lewis score), reactivity to treatment and appropriateness of the treatment. The diagnostic utility of CE for small intestinal Crohn's disease has been reported as well as an evaluation of the NSAID induced small intestinal mucosal injuries in Europe and the USA. In other words, it has been reported that CE produced a higher detection rate of ulcerative lesions in small intestinal Crohn's disease than the enteroclysis and other examination.
BE is mainly applied for confirmational diagnosis and therapeutic procedures (including hemostasis, balloon dilatation) of small bowel disorders. In addition, BE is useful for diagnosis of OGIB cases with evident active bleeding and mucosal healing of small intestinal Crohn's disease. Furthermore, the endoscopic balloon dilatation for the small intestinal stenosis of Crohn's disease has consistently helped to avoid surgery.
However, the utility of CE and BE for the diagnosis of stenoses and fistula formation is low, and it seems that enteroclysis is superior. It is thought that CT-enterography and MRI supplement this and contribute to the evaluation of inflammation of intestinal wall, but more improvement of these techniques is necessary.
This report introduces the present conditions and topics based mainly on a literature review about the utility and limitations of these examinations. In addition, we show the images of these examinations in some cases with small intestinal inflammatory disorders.

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Background : The sensitivity of bile cytology is recognized as being low. Repeating cytological sampling is likely to improve the sensitivity. We studied the usefulness of bile cytology obtained via an endoscopic nasobiliary drainage (ENBD) tube. Moreover, the frequency of the cytological examinations to obtain a positive rate of 95% or more was examined.
Methods : One hundred and thirty-three patients were enrolled in the study who had attended Hiroshima Red Cross and Atomic-bomb Survivors Hospital with malignant biliary stricture, with an indwellng ENBD tube, from May 2004 to February 2009. Diagnoses included pancreatic carcinoma (n = 49), bile duct carcinoma (n = 39), gallbladder carcinoma (n = 20), cholangiocellular carcinoma (n = 12), carcinoma of the major papilla (n = 7), and other malignancies (n = 6).
Results : The mean number of cytological examinations was 3 (range, 2-9). In 42 of 133 patients, cytology was positive at the first examination (sensitivity 31.6%). Cytology was cumulatively positive in 73 of 133 patients (sensitivity 54.9%). The sensitivity of bile duct carcinoma was 66.7% and that of pancreatic carcinoma was 42.9%. A significant difference of p=0.03 was recognized between the two groups. In 70 of 73 (97.2%) patients with positive cytology, positive results were obtained by the sixth or less examination. In both bile duct carcinoma and pancreatic carcinoma, the positive rate became 95% or more by the sixth examination (Bile duct carcinoma : 96.2%, pancreatic carcinoma : 95.2%).
Conclusion : Bile can be obtained repeatedly via an ENBD tube and that contributes to improve the diagnostic accuracy. The optimal number of repeated cytological samplings to obtain a positive rate of 95% or more was concluded to be 6.

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A 74-year-old man developed hematemesis immediately after ingestion of a diet for a colonoscopy examination. Endoscopic examination on admission revealed deep ulceration with blood oozing immediately above the esophago-gastric junction and we stopped the bleeding with endoscopic clips and Argon Plasma Coagulation. We suspected spontaneous rupture of the esophagus based on endoscopic findings. A chest computed tomography (CT) scan showed evidence of extensive mediastinal emphysema. Consequently, we diagnosed spontaneous rupture of the esophagus. Although we stopped the bleeding eight hours after first endoscopic examination because the patient developed hematemesis again, we performed conservative treatment with intravenous hyperalimentation and antibiotics. On the 9th day of admission, a chest CT scan showed little emphysema. On the 17th day of admission, scar on the esophagus was observed endoscopically, and no leakage of radiopaque contrast agent from esophagus was observed on an esophagogram. The patient was discharged from our hospital on the 27th day of admission.

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A 31-year-old woman was referred to our department because of dysphagia and food impaction for more than 6 years. Upper gastrointestinal endoscopy revealed a marked stricture at the esophagogastric junction without tumor. Endosonography revealed mucosal thickening of the esophagus and pathological examination of biopsied specimens showed marked infiltration of eosinophils (≥100/high-power field, HPF) and microabscess in the esophageal epithelium. Blood chemistry revealed an increase in the number of peripheral eosinophils and total immunoglobulin E (IgE) levels, and patch tests were positive for foods, including eggs and fish. The diagnosis of eosinophilic esophagitis was confirmed on the basis of the clinical symptoms and endoscopic and pathological findings. The patient was started on fluticasone swallowing therapy. Improvement in the symptoms, stricture, and histology was noted 2 months after the topical steroid therapy.

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Metastasis of tumors to the stomach is quite uncommon. In particular, gastric wall metastasis from a renal cell carcinoma is extremely rare. This report presents a case of gastric wall metastasis from a renal cell carcinoma, treated with endoscopic mucosal resection. A 65-year-old male who had undergone left radical nephrectomy for renal cell carcinoma in October 2007, was referred for further evaluation of a gastric tumor in July 2009. Upper gastrointestinal endoscopy revealed a solitary polypoid lesion about 10 mm in diameter in the posterior wall of the middle gastric body. Endoscopic mucosal resection was performed as diagnostic therapy. Histopathological examination of the resected specimen confirmed a diagnosis of clear cell carcinoma, thus suggesting the presence of renal cell carcinoma metastasis.

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A 72-year-old woman was admitted to our hospital for the treatment of gallstones and common bile duct stones. We removed the common bile duct stones with endoscopic sphincterotomy and placed an endoscopic nasobiliary drainage (ENBD) tube in the common bile duct. When the tube was pulled out spontaneously it got stuck at the juxtapapillary duodenal diverticula, and this led to the perforation of the duodenum. The patient was treated by stopping oral intake and administering antibiotics intravenously. The perforation improved without an operation. Although ENBD is an effective method for the release of obstructive jaundice and for use in cases where stones have been crushed, few reports have described the complications associated with ENBD. We present this case report considering the possible rarity of the observed complication.

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Percutaneous gastrojejunal feeding is a method to provide nutrition by inserting a tube via a gastrostomy site into the jejunum. A 70-year-old man, incapacitated by a stroke, was admitted to our hospital with repetitive aspiration and vomiting. Passage disturbance of the horizontal portion of the duodenum was recognized on abdominal CT and an upper gastrointestinal series, and the diagnosis was superior mesenteric artery (SMA) syndrome. Jejunal tubing through a percutaneous endoscopic gastrostomy catheter (Jett PEG) was performed on day 11 of his disease for a period of time, and the outcome was successful. As the patient's nutrition condition and SMA syndrome had improved by postoperative day 75, we changed the percutaneous gastrojejunal feeding tube for a gastric feeding tube, the outcome of which was successful. This approach is considered to be a useful option for patients with a swallowing disorder and SMA syndrome.

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A 67-year-old female was admitted to our hospital because of right lower abdominal pain. Colonoscopy showed an edematous, dark blue mucosa with ulcers and erosions in the ascending to the transverse colon. An abdominal CT scan showed linear venous calcifications around the ascending colon. Histologic examination of the biopsy specimens showed enlarged microvessels and the proliferation of collagenous fibers in the submucosal layer. Based on these findings we diagnosed idiopathic mesenteric phlebosclerosis (IMP). Induction therapy was performed by fasting and total parenteral nutrition, and then the patient began to receive mesalazine as maintenance. Induction therapy was effective and she has maintained clinical remission. Follow-up colonoscopy after one year revealed that ulcers and erosions had dramatically decreased and there was improvement in the edematous change. There has not been any definite therapeutic strategy for the disease. Oral mesalazine might contribute to the maintainance of remission for patients with IMP.

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A woman in her 50s was diagnosed via colonoscopy as having a circumferential villous tumor from the rectosigmoid to the sigmoid colon. We considered the difficulty of treating the lesion with endoscopic submucosal dissection. We decided on surgery.About one and a half months later, preoperative colonoscopy performed to mark the lesion. The lesion had developed with the formation of nodular tissue resulted in narrowing of the colon lumen. Laparoscopic assisted sigmoidectomy and lymph node dissection were perfomed. The histological findings of the resected specimen revealed well differentiated adenocarcinoma in a villous adenoma invaded the submucosa with lymph node metastasis (size 70×65mm, IIa+Is, SM, ly0, v0, OW(-), AW(-), EW(-), lymph node metastasis : n1 ; 241(1/7), n2 ; 242(0/1), 251b(0/8), final stage IIIa). It was treated with UFT/UZEL (UFT 450mg/day, UZEL 75mg/day) orally for 6 months as postoperative chemotherapy. About one year after the operation, no evidence of recurrence has been noted. Recently, advances have been noted in the application of endoscopic diagnosis. In villous tumors such as in the present case, however, signs of malignant findings are not always revealed by endoscopy. The characteristic findings of villous tumor should be noted with reference to these cases.

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Regarding capsule endoscopy (CE), it is generally considered to be not so difficult technically to perform, but presents many problems in the interpretation of the results. In May 2011, two CE systems, the ‘PillCam SB’ by Given Imaging Co. and ‘Endo Capsule’ by Olympus Medical Co., were introduced into real clinical practice, and both are not so different regarding the method of examination.
The interpretation time, which was initially 60 to 90 minutes, has been shortened to 30 minutes due to the improvement of optional modalities. The software image interpretation programs of these CE devices have some different functions including options. We believe that the better interpretation can be managed by utilizing the original function and basing the image interpretation on our own style.
For the PillCam software, the optimum interpretation can be obtained based on three steps, preview, review and report. We believe that, for the preview step, the options of 10 times the speed and four visions are the best approach. In this way, each landmark should be checked, for example, the first gastric image or cecal image. For the review stage, we think 15 times the speed for two visions or 20-25 times the speed and four visions give the best results. We usually interpret in the manual mode, but change into the automatic mode when the capsule is stationary at the same part. Finally, we check all the thumbnails and complete the patient's report. As for the EndoCapsule, we suggest that the reader learns the method to utilize the functions of the overview, selected and skipped modes. In the near future, improved software will be introduced for the whole automatic diagnosis. Since CE is performed under physiological conditions without air supply, the CE findings are often different from those obtained by standard endoscopy for the same lesion. Diagnosis is requested whenever only a part of the lesion is shown in the images. Thus, to achieve an exact final diagnosis, it is important to practice the various cases, thus advancing the reading skills. CE interpretation requires training and getting new information. It is estimated that the experience of 10 cases and assessment by an expert are needed for standard CE interpretation.

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The “endocytoscopy system” (ECS), adapted for clinical use in 2003, is an ultra-high-power magnifying endoscope that allows observations at the cell level. ECS is based on the technology of light-contact microscopy. The most evident use of ECS is for real-time, high-resolution diagnosis of nuclear abnormalities, mainly in patients with esophageal cancer. Up to now, three different types of ECS have been available. This diagnostic tool makes it possible to omit histologic examination of biopsy samples in about 84% of esophageal squamous cell carcinoma, as evidence for both an increase of cell density and nuclear abnormalities is considered to be convincing proof that a lesion is malignant. Here we describe the features of ECS and the background that led to its development, and review the published literature pertaining to the observation of esophageal neoplasms using ECS.

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