Behçet's disease is a refractory systemic inflammatory disorder characterized by the following four cardinal symptoms : recurrent oral aphthous ulcers, cutaneous symptoms, ocular symptoms, and pubic ulceration. The disorder is also associated with the following five accessory symptoms : arthritis, epididymitis, vasculitis, gastrointestinal symptoms, and central nervous system symptoms. Gastrointestinal Behçet's disease is defined as a variant in which the gastrointestinal symptoms appear primarily. Gastrointestinal lesions in this variant can occur in all parts of the gastrointestinal tract. They present as refractory, deep, punched-out ulcers that are often observed in the ileocecal region. For accurate diagnosis, it is important to rule out other disorders that cause similar mucosal lesions. The similarities and differences in clinical course and mucosal findings are taken into account to exclude other causes. Treatment for gastrointestinal Behçet's disease has not been established yet. 5-Aminosalicylates, corticosteroids, immunosuppressants, and parenteral nutrition have been widely used for treatment. Recently, anti-TNF-α antibodies have been proposed as an efficacious therapeutic option.

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BACKGROUND : Acute hemorrhagic rectal ulcer (AHRU) is an important etiology of lower gastrointestinal bleeding. The clinical and endoscopic features of AHRU have been increasingly reported, especially in Japan. To our knowledge, the clinical characteristics of AHRU based on endoscopic ulcerative patterns have not yet been reported. The aim of this study was to elucidate the clinicoendoscopic features of AHRU and clarify the clinical characteristics based on the ulcerative form classified by endoscopic findings. METHODS : We enrolled 23 patients diagnosed with AHRU on the basis of colonoscopic findings in our hospital. The following were reviewed retrospectively : (1) The background of primary disease and ADL ; (2) usage history of three drugs (NSAIDs, antiplatelet drugs, and steroids) ; (3) endoscopic features of AHRU ; (4) details of the hemostasis and clinical course after endoscopy ; (5) and clinical characteristics based on the ulcerative form classified by endoscopic findings. Fifteen (65.2%) patients underwent blood transfusion (average amount, 7.1 units). Eleven patients (47.8%) were in hypovolemic shock at the time of admission. Hypoalbuminemia was present, with an average albumin level of 2.4 g/dl. In all cases, the chief complaint was fresh hematochezia, moreover painless in nineteen all patients with communication. RESULTS : Most patients were bedridden. A significant proportion of patients suffered from diabetes mellitus (30.4%) as well as other comorbidities such as cerebrovascular disease, orthopedic disease, and cardiovascular disease. Usage of antiplatelet drugs, NSAIDs, and steroids was common, with 9 (39.1%), 5 (21.7%), and 10 patients (43.5%), respectively, using them. NSAIDs were administered as oral formulations in 4 patients and as suppositories in 1. Endoscopic hemostasis was performed in 12 patients (52.2%). Both hypertonic saline-epinephrine administration and clipping were the most frequently performed procedures to achieve hemostasis. Eight patients showed rebleeding after endoscopy, but repeat endoscopic intervention stopped the bleeding in all cases. The ulcerative forms were endoscopically classified into 4 types : Dieulafoy-like type (n = 5, 21.7%), irregular type (n = 12, 52.2%), nearly round type (n = 4, 17.4%), and circumferential type (n = 2, 8.7%). In this study, patients with Dieulafoy-like type had the worst clinical course ; these patients needed the most blood transfusions (80%) and experienced the most frequent rebleeding (80%) after endoscopy. CONCLUSIONS : Successful hemostasis was ultimately possible in all patients ; therefore, AHRU is considered to be a serious disease but has a relatively good prognosis with appropriate therapy. Because Dieulafoy-like type ulcers have the highest risk of major bleeding and highest rate of rebleeding after hemostasis, additional attention and care may be needed to achieve hemostasis in patients with this type.

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An 80-year-old female was referred to our hospital with anorexia and epigastric discomfort. Endoscopic examination revealed a type IIa tumor in the posterior wall of the gastric antrum. A well-differentiated adenocarcinoma was diagnosed by pathological analysis of the biopsied specimen. En bloc resection of the tumor was achieved by endoscopic submucosal dissection. Histopathological analysis of the resected tissue showed that adenocarcinoma was limited to the mucosal layer. However, intramucosal lymphatic vessel invasion was detected. We describe a case of intramucosal gastric cancer with lymphatic invasion and review the relevant literature.

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A woman in her 60s who had squamous cell carcinoma (SCC) at the esophagogastric junction detected by esophagogastroduodenoscopy was referred to our hospital for further examination. We used narrow-band imaging with magnifying observation to show that the SCC also involved the gastric cardia. En bloc resection was successfully achieved by endoscopic submucosal dissection. Histological examination identified a type 0-IIc superficial SCC located in the esophagogastric junction, with spread to the gastric cardia epithelium. We present this case along with a review of the previously reported cases of SCC at the esophagogastric junction showing spread to the stomach.

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A 62-year-old woman was referred to our hospital with an enlarging gastric submucosal tumor (SMT). Her gastric SMT was considered to be a lipoma on the basis of findings in plain radiography, esophagogastroduodenoscopy, and endoscopic ultrasonography. However, we could not exclude the possibility of a malignant neoplasm because the lesion was increasing in size. Therefore, we performed endoscopic submucosal dissection (ESD) because the SMT was located in the submucosal layer. Local complete resection of the SMT was achieved, and we diagnosed the SMT as a benign lipoma. Our case suggests the clinical benefit of ESD for therapeutic diagnosis of gastric SMTs.

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A man in his 60's was admitted to our hospital after being diagnosed with duodenal cancer. Upper gastrointestinal endoscopy showed an elevated lesion of 15 mm diameter in the horizontal portion of the duodenum, which was accompanied by several elevated reddish lesions in the duodenal bulb and descending portion. The elevated lesion in the horizontal portion and some of the other lesions had depressed areas on their surfaces. A biopsy of the elevated lesion in the horizontal portion identified a well-differentiated adenocarcinoma and that of one of the elevated lesions in the duodenal bulb identified heterotopic gastric mucosa with inflammation. We resected the lesion in the horizontal portion by endoscopic mucosal resection (EMR). Histopathological analysis revealed an adenocarcinoma confined to the mucosal layer that was adjacent to the heterotopic gastric mucosa. The gastrointestinal endoscopy and histopathology suggested that the duodenal cancer arose from the heterotopic gastric mucosa. Duodenal cancer with heterotopic gastric mucosa in the horizontal portion is considered to be rare. We report the case and review the relevant literature.

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A 50-year-old male was hospitalized for further investigations after clinical features suggestive of hepatic dysfunction were detected. Ultrasonography, magnetic resonance cholangiopancreatography, and multidetector computed tomography revealed biliary dilation and enhancement of a tumor in the distal common bile duct. Duodenoscopy revealed pale mucosa with granules and nodules over the entire circumference of the descending 2nd portion. The ampulla of Vater was located in the center of the lesions, and adenocarcinoma was detected on biopsy. Percutaneous transhepatic cholangioscopy was performed following percutaneous transhepatic cholangiodrainage, and polyp-like elevated lesions were observed extruding from the papillary portion into the biliary lumen. Papillary carcinoma was diagnosed and pancreatoduodenectomy was performed. Histopathological findings revealed a well-differentiated adenocarcinoma with partial invasion of the tissue surrounding the sphincter of Oddi in the ampulla of Vater alone and superficial spread across the lower bile duct, pancreatic duct, and duodenum. We report a case of carcinoma of the ampulla of Vater without deep invasion that showed superficial spread over the entire circumference of the descending portion of the duodenum and distal bile duct.

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An 82-year-old woman who was under observation for multiple myeloma was admitted to our hospital with hematochezia. Colonoscopy showed no hemorrhagic lesion in her colon and rectum but blood was detected in the terminal ileum. Capsule endoscopy revealed multiple erosions and ulcers in the ileum. Double-balloon endoscopy was performed using an anal approach, and multiple submucosal hematomas were observed in the ileum. Histological analysis revealed amyloidosis. We diagnosed this case as amyloid light-chain amyloidosis associated with multiple myeloma and initiated chemotherapy. We concluded that the submucosal hematoma in the ileum was caused by stimulation of the endoscope and overtube in addition to ischemic change and fragility of the tissue caused by amyloid deposition.

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An 80-year-old woman was admitted to our hospital for the work-up of bloody stool. Colonoscopy showed a protruding brownish lesion of 15-mm diameter in her rectum. Furthermore, narrow-band imaging (NBI) showed regular and partial-pitting structures with abnormal corkscrew vessels on the surface of the lesion. We suspected a malignant melanoma on the basis of the above endoscopic findings. The lesion was treated by endoscopic mucosal resection ; it was pathologically diagnosed as a malignant melanoma. Nine years earlier, she had been treated by local excision for an anorectal malignant melanoma. However, the resection was incomplete because the vertical margin of the biopsy was positive for tumor cells. Additional surgery had not been performed as follow-up at the request of the patient and her family. Therefore, we considered this lesion to be a recurrence. The 5-year survival rate of anorectal malignant melanoma was reported to be 5.2%. This is the first reported case in which NBI was used to observe an anorectal malignant melanoma in a patient who experienced long-term survival.

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Infectious colitis is often misdiagnosed as inflammatory bowel disease or one of the other forms of inflammatory colonic diseases because of the similarity of associated gastrointestinal symptoms (e.g., diarrhea, hematochezia, and abdominal pain). Endoscopy is useful not only for obtaining an image but also for biopsy and aspiration of intestinal fluid. Definitive diagnosis of infectious colitis is based on the detection of a specific pathogen. Therefore, various methods, including histological assessment of collected specimens using immunohistochemical staining, culture, microscopy, and polymerase chain reaction are recommended to identify suspected pathogens. Clinical information should be included when the specimens are sent for analysis to increase the chance of diagnosis. We believe that this diagnostic strategy could facilitate early diagnosis and treatment of infectious colitis.

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Endoscopic management of lesions in the esophagogastric junction (EGJ) has become increasingly important clinically because the incidence of target diseases has been increasing. However, management is confusing because of discrepancies in the endoscopic diagnostic procedures in Japan and Western countries. The lower end of the esophageal palisade vessels is frequently used in Japan as an endoscopic landmark for determining the EGJ line, whereas the upper end of gastric folds is usually used for the same purpose in Western countries. Recently, endoscopic diagnosis of Barrett's esophagus and subsequent Barrett's cancer has become very important for clinical management of the EG junctional lesions in Japan as well as in Western countries. Although clinically available classification criteria for EG junctional lesions have not been fully established, image-enhanced endoscopy is becoming an important technique for their accurate endoscopic diagnosis. Improvements in the classification using endoscopic diagnostic criteria of EG junctional lesions and development of adequate endoscopic surveillance procedures for EG junctional cancers, including Barrett's cancer, are expected in the near future.

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Background : The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction.
Patients and Methods : Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y-configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty-seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y-configured placement were endoscopically deployed in a partial stent-in-stent manner in one session. Technical success, early complications, and stent patency were evaluated.
Results : The technical success rate in the YMS group was 100%. Mild post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P=0.65). During a median follow-up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P=0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P=0.0061). Risk factors for stent occlusion were bile duct cancer (P=0.035) and the PS group (P=0.07) by multivariate analysis.
Conclusion : Single-session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.

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