The pathogenesis of eosinophilic gastroenteritis has not been clarified. A possible mechanism is allergy-related, caused by activation of eosinophils and mast cells through increased production of Th2 type cytokines, such as IL-5, -13, -15, and eotaxins. Eosinophilic gastroenteritis most frequently occurs in middle-aged males and females with a history of other allergic diseases including bronchial asthma, while their most frequent complaints are abdominal pain and diarrhea. More than 80% of these cases show peripheral blood leukocytosis and eosinophilia. Endoscopic examinations show various types of mucosal abnormalities, such as erosions, redness, and edema on the mucosa invaded by eosinophils. Multiple endoscopic biopsies are necessary for diagnosis, since the endoscopic abnormalities revealed are not specific for eosinophilic gastroenteritis. In patients with subserosal lesions, ascites with a large number of eosinophils is frequently found. Glucocorticoid hormone administration is the most widely used treatment for this pathological condition. Co-administration of various kinds of anti-allergic drugs is given to decrease the doses of glucocorticoids, as the latter is frequently accompanied by disease recurrence or exacerbation.

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The need for gastrointestinal (GI) endoscopy for patients under antithrombotic therapy has recently been increasing. The Guidelines for antithrombotic therapy in GI endoscopy is different between Japan and Western countries. We investigated the clinical practice of the management of antithrombotic therapy and the frequency of bleeding and thrombo-embolism in GI endoscopy. About 80% of the endoscopists had performed an invasive procedure for the patients under antithrombotic therapy. In a half of them the problems were caused by operator error. After an invasive procedure, half of the endoscopists prescribed antiulcerative medication, and 20% of the endoscopists had performed endoscopic preventive hemostasis. No GI bleeding occurred in this investigation. However, 10 thrombo-embolic events occurred during cessation of the antithrombotic therapy. Antithrombotic therapy should be stopped with exact assessment and informed consent. Furthermore, evidence in Japanese patients established by the Japan Gastroenterological Endoscopy Society is required.

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Esophageal strictures induced by chemoradiotherapy (CRT) for lung cancer are rare entities. We came across two patients in our institute treated with CRT for non-small cell lung cancer who developed high grade esophageal strictures. We tried endoscopic dilation using a balloon dilator for the stricture. Case 1 was a 37-year-old woman. She was treated with CRT for Stage IIIa lung cancer. After CRT, she had oral discomfort because of an esophageal stricture induced by the CRT and we tried endoscopic dilation for the stricture over a 4-month period. The esophageal stricture and oral intake improved gradually. Case 2 was a 68-year-old man. He was treated with CRT for Stage IIIa lung cancer. After 1 year, he was treated with 2nd-line chemotherapy because of local relapse of the lung cancer. He complained of oral discomfort because of an esophageal stricture induced by the CRT and endoscopic dilation was started. Oral intake was improved greatly but the endoscope could not pass through the stricture. Endoscopic dilatation has been continued for esophageal stricture up to the present. We believe that endoscopic balloon dilation was effective for esophageal strictures induced by CRT in patients with non-small cell lung cancer.

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A 46-year-old woman with a gastric submucosal tumor (SMT) had been followed up with endoscopy for 30 months in our hospital. The SMT showed gradual enlargement during the follow-up period. EUS revealed the submucosal layer was maintained beneath the SMT which was located between the mucosa and submucosa. Because malignancy could not be ruled out, endoscopic submucosal dissection (ESD) was performed for the purpose of a “total biopsy” and the lesion was resected en bloc. Immunohistochemical findings revealed that the tumor was negative for SMA, KIT, CD34, and positive for S-100. It was also positive for PAS stain. The MIB-1 index was around 5%. Thus, the tumor was pathologically diagnosed as a benign granular cell tumor of the stomach. We conclude that the combination of EUS and ESD is useful for the diagnosis and treatment of SMTs above the submucosal layer such as granular cell tumors.

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An 83-year-old woman was diagnosed as having a submucosal gastric tumor in November 2006, and had been followed up regularly. She presented to the emergency department of our hospital with acute abdominal pain in September 2007. Laboratory studies showed anemia, and a contrast-enhanced CT scan was consistent with intratumoral hemorrhage and tumor rupture. The patient underwent partial resection of the stomach, and histological examination of the gastric tumor revealed a KIT-positive gastrointestinal stromal tumor (GIST). A case report of a ruptured gastric GIST during endoscopic follow-up is presented, accompanied by a review of the literature.

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A 60 year-old woman was admitted with severe bilateral leg edema. She had no obvious abdominal discomfort and had a good appetite. On further workup, a diagnosis of mucinous colon cancer with a giant fistula to the duodenum secondary to the tumor invasion was made and a right hemicolectomy associated with pancreaticoduodenectomy was performed. Although patients with advanced colon cancer usually present with abdominal symptoms, the chief complaints of this particular case was only leg edema. This was probably due to the malnutrition secondary to direct excretion of the undigested food into the colon through the fistula.

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We report herein on a case of idiopathic mesenteric phlebosclerosis with 8 years of free of symptoms. This case was of a 79-year-old man who had complained of right hypochondolargia about 8 years before. At that time, abdominal CT demonstrated calcification of the veins around the right side of the colon which was revealed subsequently with colonoscopy, showing an abnormal mucosal color on the right side of the colon. The histological findings of biopsy specimens showed that fibrous overgrowth was present in the mucosal layer. We made a diagnosis of phlebosclerotic colitis. The patient underwent colonoscopy after about 8 years of being free of symptom.

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Background : The pH measurement of fasting gastric juice is often used to investigate acid-related disorders. Grape juice contains anthocyanin pigments that change color according to the pH. The aim of this study was to evaluate the pH of fasting gastric juice with grape juice. Methods : Before the upper endoscopy, pharyngeal anesthesia was achieved with a frozen mixture of viscous lidocaine and grape juice, which the patient licked to ingest. During the upper endoscopy the colors of the gastric juice on the LCD monitor were evaluated. The gastric juice was serially collected and the pH of the gastric juice was evaluated. Results : The colors of the gastric juice were classified into four groups of red, blackish-blue, clear-white and yellow. Red and clear-white groups showed a low pH. The blackish-blue group showed weak acid to neutral pH. The yellow group showed no specific pH. The pH values of each pair of groups except for yellow and clear-white showed significant differences. Conclusions : The pH values of gastric juice are useful to realize the pathophysiology of acid-related disorders. Using this method, in most of cases we can easily determine the approximate intragastric acidity.

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Endoscopic procedures in patients on anticoagulation therapy or antiplatelet therapy pose an increased risk of hemorrhage. Discontinuation of anticoagulation or antiplatelet therapy, however, has the risk of life-threating complications in some patients. In such patients, anticoagulation therapy should be replaced with heparin therapy while the minimum antiplatelet therapy is continued. Although endoscopic biopsies and therapeutic approaches (i.e. ESD, EMR and EPBD) on aspirin therapy add increased risk of hemorrhage, these procedures are feasible when performed with care. Confirmation of complete hemostasis at the end of each procedure is the most crucial in avoiding undue post-procedural bleeding. For the endoscopic biopsies, it is important to use endoscopic forceps with a small cup and to collect as small a specimen as possible from the surface tissue of the lesion. If the hemostasis after biopsy is incomplete, add compression hemostasis with endoscopic forceps and/or spray hemostatic agents (e.g. thrombin, epinephrine and sodium alginate). In endoscopic therapeutic approaches, the ulcer floor should be thoroughly coagulated after ESD or EMR, and ulcers should be closed with endoclips wherever possible. For endoscopic cholangiolithotomy, EPBD is preferred, and a pancreatic stent should be placed before EPBD or EST to prevent post-ERCP pancreatitis.

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Background : The aim of this prospective study is to compare the usefulness of magnifying narrow band imaging (NBI) and magnifying chromoendoscopy in the diagnosis of colorectal lesions.
Methods : The subjects were 1185 patients who underwent a complete colonoscopic examination and endoscopic or surgical treatment, from January 2006 to February 2008. A total of 1473 lesions were evaluated (53 hyperplastic polyps, 1317 adenomas, 103 submucosally invasive cancers). The digital images with NBI or chromoendoscopy were recorded and diagnosed independently from each other by two endoscopists who were blinded to the final pathological diagnosis.
Results : We could differentiate between neoplastic and non-neoplastic lesions with sensitivity of 88.9%, specificity of 98.5% and accuracy of 98.2% according to the vascular pattern. By recognizing an irregular of sparse pattern with NBI, massively invasive submucosal cancer could be diagnosed with the sensitivity and specificity of 94.9% and 76.0%. Using chromoendoscopy, we could differentiate between neoplastic and non-neoplastic lesions with sensitivity of 86.8% and specificity of 99.2%. We were able to differentiate between massively invasive cancers and slightly invasive cancers using the pit patterns with sensitivity of 89.7% and specificity of 88.0%. The specificity was superior to that of NBI colonoscopy.
Conclusion : Both NBI and chromoendoscopy can be useful for distinguishing between neoplastic and non-neoplastic lesions. In the diagnosis of submucosal cancer, pit pattern diagnosis was slightly superior to vascular pattern diagnosis. It is desirable to perform chromoendoscopy in addition to NBI for distinguishing between slightly and massively invasive submucosal cancer lesions and determining the treatment.

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