[in Japanese]

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Confirmation of the characteristic irregular narrowing of the main pancreatic duct (MPD) plays a pivotal role in the endoscopic diagnosis of autoimmune pancreatitis (AIP). Irregular narrowing of the MPD may be diffuse or localized, and it is sometimes recognized as multiple skip lesions. The finding may sometimes be unconfirmed when the pancreatic lesion is localized in the tail, and the MPD seems to be disrupted in such a case. Besides irregular narrowing, clear depiction of side branches arising from the narrowed portions and no significant upstream dilation of the MPD are useful for the differential diagnosis between AIP and pancreatic cancer. Sclerogenic biliary changes and swelling of the duodenal papilla should also be noted at the time of endoscopic retrograde cholangiopancreatography (ERCP) because these symptoms are often observed in AIP. Although the diagnostic ability of AIP with EUS-guided fine-needle aspiration biopsy is comparatively low, it is very useful for ruling out pancreatic cancer.

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A total of 307 patients (213 men, 94 women, mean age : 68.2 years) who received emergency endoscopy for acute upper GI bleeding were examined. They were divided into 2 groups : 154 in the elder (aged 70 years or older) and 153 in the younger (<70 years) groups. We compared the rate of concomitant disease, drug administration, Helicobacter pylori (H. pylori) infection, endoscopic diagnosis, endoscopic hemostasis, blood transfusion requirement and mortality between the 2 groups. Patients with variceal bleeding, and hematemesis or melena after endoscopic mucosal resection were excluded from this study. The ratio of females to males was significantly higher in the elderly group than that in the younger group. Gastric ulcer and duodenal ulcer were the most common diseases in both groups. The incidence of concomitant disease, drug administration (anticoagulation drugs, antiplatelets, and NSAIDs), and blood transfusion requirement were significantly higher in the elderly group than in the younger group. On the other hand, the prevalence of H. pylori infection was significantly lower in the elderly group compared with the younger group. There was no significant difference in the endoscopic hemostasis rate between the 2 groups. The mortality rate in the elderly group was significantly higher than in the younger group. In the elderly, mortality in males was significantly higher than in females. Accompanying adverse comorbid conditions are one of the major causes of death in acute upper GI bleeding.

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We present herein on a rare case of differentiated-type intramucosal gastric cancer with intramucosal lymphatic vessel involvement. A 75-year-old woman came to our hospital with unintentional weight loss. She underwent esophagogastroduodenoscopy (EGD) and a protruding lesion measuring approximately 15 mm was observed in the lower body of the stomach. A biopsy was performed and the pathological diagnosis was tubular adenocarcinoma, tub1-2, Group 5. Upon closer inspection, we diagnosed the lesion as a differentiated-type intramucosal gastric cancer. We performed endoscopic submucosal dissection, and the pathological diagnosis was well-differentiated intramucosal tubular adenocarcinoma with intramucosal lymphatic vessel involvement. We performed laparoscopy-assisted distal gastrectomy and lymph node resection as a radical cure, but residual carcinoma was not seen. The final full diagnosis was M, Post, Type0-I, 18 × 17 mm, tub1, pT1a(M), ly1, v0, pN0(0/23), pPM0 (60 mm), pDM0 (80 mm), Stage IA.

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A 74-year bedridden female patient was admitted as an emergency patient with repeated vomiting. Following a CT scan of the abdomen, revealing a significantly dilated stomach, the patient was diagnosed as having gastric volvulus. As endoscopic reduction of the volvulus was not possible, laparoscopic surgery was performed, and intraoperatively the greater omentum, incarcerated in a Morgagni hernia, and the stomach twisting along its short axis were observed. Based on a diagnosis of Morgagni hernia-associated gastric volvulus, laparoscopic repositioning was performed. This paper reports on a rare case of Morgagni hernia-associated gastric volvulus occurring in an adult.

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During a medical check-up, a granular nodule in the duodenal bulb was found in a 73-year-old male. The nodule was suspected as being a mucosa-associated lymphoid tissue (MALT) lymphoma at the initial endoscopic biopsy. The urease test was positive and Helicobacter Pylori eradication had been done. The third endoscopic biopsy diagnosis confirmed the lesion as a MALT lymphoma. The urease test became negative and the size of lesion temporarily decreased. However, the lesion subsequently began to enlarge again. The patient was treated with radiotherapy and the outcome was complete remission. Radiotherapy proved effective for a MALT lymphoma of the duodenum. Further studies are required to confirm this positive finding in one patient.

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An 85-year-old female presented with watery diarrhea after taking the medication lansoprazole. Colonoscopic findings showed cat scratch colon (sharp longitudinal erosions) on the rectal colon. A colonic mucosal biopsy showed marked thickening of the subepithelial collagen bands, which were more than 10 μm thick. She was diagnosed as having collagenous colitis. After discontinuing the lansoprazole, the patient’s symptom improved. A case of collagenous colitis associated with cat scratch colon has rarely been reported in Japan and findings of cat scratch colon could be a useful endoscopic marker for collagenous colitis.

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A woman in her mid 70s ingested self-made salted squid guts. Two days later she asymptomatically and incidentally underwent screening colonoscopy which revealed an Anisakis parasite protruding from an elevated lesion of the ascending colon. The worm was removed endoscopically. Adenocarcinoma was found in a biopsy specimen from the bulging mucosa. The lesion was an uncertain indication for endoscopic mucosal resection and a laparoscopic ileocecal resection was performed. We report herein on a rare case of colonic cancer with Anisakis. We should take the possibility of malignancy into consideration and make a careful diagnosis when we come across protruding lesions with Anisakis worms.

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A 67-year-old female with recurrent hepatocellular carcinoma (HCC) in the caudate lobe was successfully treated with endoscopic ultrasound (EUS)-guided ethanol injection. Her past medical history included HCC in the S5/6 at the age of 61 and underlying liver cirrhosis associated with hepatitis C since the age of 56. She was readmitted for recurrent HCC in the caudate lobe for which transcatheter arterial chemoembolization (TACE) was performed. Her HCC, however, remained viable in follow-up CT after the TACE. As for the management of this recurrent HCC, EUS-guided ethanol injection was chosen since it is impossible to inject ethanol through a percutaneous route. The total amount of injected ethanol was 22 mL. Follow-up CT scan showed complete necrosis of the HCC. Based on this experience, EUS-guided ethanol injection may be a new innovative treatment option for HCC in the caudate lobe.

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We experienced two patients with an intraductal papillary mucinous neoplasm (IPMN) suffering from suppurative pancreatic ductitis (SPD), which presented with abdominal pain and fever with elevated inflammatory reactions. One of the two patients with a main duct type suffered from SPD two days after transpapillary pancreatic duct biopsy, which was relieved mainly with transpapillary mucin extraction. The patient underwent distal pancreatectomy but died from an iliopsoas muscle abscess on the 35th post-operative day. In another patient with a branch duct type at the head, SPD occurred 9 days after pancreatic juice cytology and was treated with antibiotics administration.

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Spiral Endoscopy (SE) has recently been developed. Currently, SE has been performed in more than 10,000 patients all over the world. SE has two components, an endoscope and a rotating overtube with spiral protrusion at the tip of the overtube. The rotating overtube pleats the small intestine onto the proximal side of the overtube and makes it possible to access deeper into the small intestine. Akerman et al. reported that the overall severe complication rate was 0.3%. SE is technically feasible and safe even in elderly patients with numerous comorbidities. Some studies have compared SE with double balloon endoscopy (DBE) and showed that SE enabled insertion to similar depths in a significantly shorter time as compared with DBE. SE can be performed by a single endoscopist with an assistant who manipulates the overtube. The procedure is performed under conscious sedation with carbon dioxide instead of the air for insufflation. In order to achieve the deep insertion, “engagement”, which indicates that the spiral part of the rotating overtube properly grips the small intestine, is necessary. After the engagement, the engaging unit is advanced with clockwise rotation. When the scope is withdrawn, a counter clockwise rotation is required. So far, we have performed 31 SEs in 2 hospitals. Among them, we were able to diagnose 16 patients with small intestinal lesions using SE, including 6 malignant lymphomas, 3 erosions, 3 polyps, 2 angioectasias, 1 adenocarcinoma, and 1 submucosal tumor. Moreover, 4 patients underwent endoscopic interventions ; 2 hemostases and 2 polypectomies. The average insertion time was 26 minutes. Relatively high dose sedation was required during the procedure. Mallory Weiss syndrome occurred in 1 patient. Thirteen patients had mucosal injury during the procedure. No perforation occurred in any patient. SE can be introduced safely, but is relatively invasive and technically demanding. More experience is need to conduct SE easily and safely.

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