Idiopathic mesenteric phlebosclerosis is a relatively rare disease, however, it has now been established as a single disease entity. Clinically it is characterized by the average age in the 6^th decade, a slightly higher prevalence in women, affecting only Asian patients (especially Japanese), and right-sided colon predominance. Calcification along the intestinal wall in plain abdominal X-ray images, and calcification along the mesenteric veins in CT scans are characteristic features. Histologically, perivascular collagen deposition, marked submucosal fibrosis and calcification in the veins are characteristic features, accompanied by minimal inflammation except for areas of erosion. Clinically, conservative management is common for asymptomatic patients and, surgical resection is generally accepted for the patients with stenosis, ulcers of the colon or other such symptoms. The cause of idiopathic mesenteric phlebosclerosis still remains unknown, however Chinese medicine, including some toxic agents, has been attracting attention as a factor in the development of idiopathic mesenteric phlebosclerosis. In the future, it is expected that preventive measure will be established by elucidating its cause.

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Objective : Multiple neoplastic lesions are frequently present in patients with gastric tumors, thus raising the concern that lesions may be missed during endoscopic examination. We examined the findings of false-negative lesions of multifocal gastric tumors that were detected by high-resolution fiberoscopy over 3 years. Subjects : The subjects were 501 patients with gastric tumors who underwent endoscopic submucosal dissection (ESD) at our hospital. Results : Of the 501 cases, 94 with multiple lesions had more severe atrophy of the background mucosa (grade 0-2 or higher) and were older than the remaining 407 cases with a solitary lesion. Of the 94 cases with multiple lesions, 68 (72.3%) were referred from other hospitals, of which 30.7% were false-negative cases. Of these false-negative cases, 14.7% were found to be false negative by re-examination at our hospital. Of the 26 patients in whom multifocal gastric tumors were detected at our hospital, 29.8% were false-negative cases. False-negative findings were more common in lesions that were as small as 10 mm or lower in diameter or those that were characterized by unnoticeable color or visual shape. Conclusions : Multifocal gastric tumors occurred in older patients with severe atrophy of the gastric mucosa. Smaller lesions were more likely to yield false-negative results. Thus, gastric endoscopic examination should be carefully performed in cases of multifocal gastric tumors, and preoperative re-examination is likely to reduce the incidence of false-negative lesions.

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A 68-year-old man was admitted to our hospital complaining of anterior chest pain. He had undergone subtotal esophagectomy and retrosternal esophagogastrostomy for esophageal cancer 10 years before admission. He was diagnosed as having pneumopericardium caused by a perforating ulcer from the gastric tube into the pericardium. Surgical drainage of the pericardial space and antibiotic administration were performed, but residual pericardial abscess around gastric tube was observed. We performed endoscopic ultrasound-guided intraluminal drainage with a gastric tube wall incision using an endoscopic submucosal dissection (ESD) device. After the endoscopic therapy, the abscess resolved. To our knowledge, endoscopic drainage for a pericardial abscess has never been reported.

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Diffuse submucosal heterotopic gastric glands are a rare disorder which appears in a few percent of resected stomachs. This entity is recognized as a paracancerous lesion which frequently accompanies gastric cancer, especially multiple gastric cancers on the mucosal surface. We report herein on a case of early gastric cancer associated with diffuse submucosal heterotopic gastric glands treated with endoscopic submucosal dissection. In the case of gastric cancer which exists above multiple submucosal cysts resulting from cystic dilatation of the heterotopic gastric glands, endoscopic diagnosis of the cancer form and depth of invasion is influenced by the submucosal cysts. Endoscopic ultrasonography is effective to evaluate the lesion in such a case. Careful observation is needed after endoscopic resection of gastric cancer associated with diffuse submucosal heterotopic gastric glands because of the possibility of multiple gastric cancers.

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A 35-year-old female gave birth to a girl weighing 4,324 g with natural delivery. The abdominal wall was compressed during delivery employing Kristeller's expression. Megacolon developed in the cecum over the ascending colon on the day following delivery, and the mucosa of the dilated intestine was circumferentially injured. An intestinal tube was endoscopically placed per anus. Decompression was effective and mucosal injury had mostly resolved on endoscopy on the 12th day. It was assumed that the cecum was displaced toward the center of the abdominal cavity, termed a mobile cecum, and compressed by Kristeller's expression while being caught between the abdominal wall and the uterine floor, leading to megacolon. A mobile cecum and excessive external pressure due to Kristeller's expression may be risks for maternal intestinal damage.

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A 60-year-old woman with constipation and a sensation of inadequate defecation visited a local doctor. Because barium enema showed the presence of a 75-mm fecal mass in the rectum, she was referred to our hospital. She had undergone a operation for an anal fistula about 35 years previously. Plain abdominal radiography revealed an enormous high-density mass in the rectum. Endoscopy of the large intestine also revealed a huge fecal mass within the rectum. A hard calculus was detected in the center of the fecal mass. With holmium: yttrium-aluminum-garnet (Ho:YAG) laser endoscopy, the calculus was bored and partially disintegrated. Finally, the calculus was completely crushed using chalazion forceps and removed through the anus. The intestinal calculus was composed of ammonium magnesium phosphate. Herein, we report on this rare case of an ammonium magnesium phosphate enterolith.

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A 31-year-old female was admitted to our hospital with right abdominal pain. She had been taking oral herbal medicine since five years previously, and had complained of abdominal pain with an unknown cause for 3 years. Since abdominal X-ray revealed linear calcifications in the right lower abdomen, and abdominal CT also revealed calcifications in the blood vessels near the ascending colon, idiopathic mesenteric phlebosclerosis was suspected. Although colonoscopic mucosal findings were not remarkable, biopsy specimens from the cecum to the ascending colon revealed fibrous thickening of the vein wall and deposition of collagen fibers in the stromal lamina propria. Based on these findings, this case was diagnosed as idiopathic mesenteric phlebosclerosis. In most cases, idiopathic mesenteric phlebosclerosis has been reported in middle-aged and older people, but may also occur at a young age as our case. Endoscopists must consider idiopathic mesenteric phlebosclerosis at any age as one of the diseases when patients present with abdominal pain of unknown origin.

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A 88-year-old man was referred to our hospital with jaundice. Obstructive jaundice was diagnosed following the biochemical examination on admission. Endoscopic retrograde cholangiopancreatography (ERCP) showed obstruction in the common bile duct and endoscopic sphincterotomy (EST), intraductal ultrasonography (IDUS), and endoscopic nasobiliary drainage (ENBD) was performed following ERCP. When ERCP was performed for stone removal after one week, bleeding was seen from the incision in the duodenal papilla. As an endoscopic hemostatic procedure was not effective, transcatherter arterial embolisation (TAE) was carried out. On the first attempt we used metallic coils for the embolic material and it was unsuccessful. The second TAE was perfomed with N-butyl-2-cyanoacrylate and achieved complete hemostasis. TAE is one of effective therapeutic maneuvers for post EST hemorrhage when endoscopic treatment has not been effective. Additionally, N-butyl-2-cyanoacrylate is considered one of the active embolic materials.

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A 27-year-old woman consulted our hospital with epigastric pain. Since obstructive jaundice caused by limy bile in the common bile duct was diagnosed based on blood tests and imaging studies, emergency endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic balloon dilatation (EBD) were performed to remove limy bile and stones in the common bile duct. The drainage was assumed effective, because a massive volume of limy bile flowed from the common bile duct ; however, jaundice was exacerbated due to EBD stent obstruction on the following day, Endoscopic papillary balloon dilatation (EPBD) and lithotripsy were carried out. Endoscopic nasobiliary drainage (ENBD) was performed after removal of the common bile duct stones. The limy bile was subsequently removed completely from the common bile duct. After improvement of the jaundice, laparoscopic cholecystectomy was performed for the gallstones. EPBD and lithotripsy were effective for obstructive jaundice due to limy bile in a young patient.

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Biliary cannulation is indispensable for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary diseases. As difficulties in selective biliary cannulation during ERCP are sometimes encountered due to anatomical constraints or papillary spasm, numerous techniques have been developed to overcome such difficulties. Wire-guided cannulation may improve the success rate of biliary cannulation and reduce the frequency of post-ERCP pancreatitis. Pancreatic guidewire placement or the double guidewire technique have been reported to be useful for achieving biliary cannulation in cases of difficult biliary cannulation. If selective biliary cannulation is unsuccessful even with these techniques, precut followed by placement of a pancreatic duct stent by an experienced endoscopist is recommended.

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Aim : Self-expandable metallic stents are widely used for palliation of malignant gastric outlet obstruction (GOO), but clinical outcomes of different stents have not been compared. Here, we compared outcomes in patients with GOO receiving either an Ultraflex (UF) or Niti-S (NS) stent.
Methods : Prospective outcomes in 53 patients receiving palliative placement of an NS stent for symptomatic GOO over a 3-year period were compared with those obtained retrospectively in 31 patients receiving a UF stent in a previous 5-year period. Main outcome measurement was between-group comparison of clinical outcome, complications, and reintervention.
Results : Baseline characteristics between the groups were comparable. No difference in technical or clinical success rate was observed. Median procedure time for NS placement was shorter than for UF (15 vs. 40 min ; P<0.0001). Complications were more frequent with NS than UF placement, albeit without statistical significance (16% vs. 25%). Although two severe complications occurred in each group, neither was stent-related in the NS group. Reintervention was more frequent in the NS group (3% vs. 21% ; P=0.0485). Median survival time was 53 versus 88 days.
Conclusion : Although no significant difference was seen with regard to feasibility, reintervention was less frequent with UF stents than NS stents,. However, UF stents requires much more procedure time, and complicated and difficult placement procedure. These observations suggest that although NS stents placed using a through-the-scope technique may be more patient-friendly than UF stents, further optimization of TTS stents is still required. Further prospective comparison of NS stents and UF stents in GOO treatment is warranted.

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