Background and Aims : Various societies have published guidelines on managing antithrombotic agents during the periendoscopic period. Management of anticoagulants in high-risk procedures is similar among these guidelines : however, management of antiplatelet agents in low-risk procedures such as biopsy differs between Western and Japanese guidelines. Therefore, we conducted a clinical study to assess the bleeding risk attributable to upper gastrointestinal biopsy in patients taking antiplatelet agents and the validity of performing endoscopic biopsy with small cup biopsy forceps.
Methods : We changed the management of antithrombotic agents during the periendoscopic period in our hospital as follows : esophagogastroduodenoscopy was performed without cessation of antithrombotic agents and biopsy with small cup biopsy forceps was permitted in patients taking antiplatelet agents. Then, a prospective cohort study in a clinical setting was performed from March 2011 to February 2012 for 5,374 scheduled esophagogastroduodenoscopies. 1,128 patients, including 65 who were taking antiplatelet agents, underwent gastric biopsy, and 2,025 biopsy specimens were obtained from each part of the stomach. Clinical bleeding was investigated during and after endoscopy. Two pathologists assessed the presence of muscularis mucosae in biopsy specimens in addition to the suitability of specimens for histological diagnosis.
Results : Ratio of appropriate specimens obtained with small cup biopsy forceps was 99.3% (2,010/2,025) and muscularis mucosae was detected in 27.8% (538/1,394) of specimens. After endoscopy, 1 of 1,049 patients who took no antithrombotic agents experienced major bleeding (0.095%). In addition, no bleeding was experienced by the 65 patients who received antiplatelet treatment.
Conclusions : Endoscopic forceps with a small cup is useful and the absolute risk attributable to gastric biopsy in patients taking antiplatelet agents seems to be low.

View full abstract

A 63-year-old man presented at our hospital with the complaint of continuous dysphagia. He was a chronic smoker and also consumed excessive amounts of alcohol. A barium esophagogram showed multiple outpouchings in the entire esophagus. Gastrointestinal endoscopy revealed multiple ostia and a stenotic lesion at the lower thoracic esophagus. Candida infection was detected in white patches around the ostia. We made the diagnosis of esophageal intramural pseudodiverticulosis, prohibited the consumption of alcohol and performed endoscopic dilatation. Thereafter his symptoms showed a tendency to improve.
A case report of esophageal intramural pseudodiverticulosis with typical endoscopic and radiographic images and candidiasis is presented accompanied by a review of the literature.

View full abstract

Case 1 : A 17-month-old girl with cerebral palsy was diagnosed as having a duodenal ulcer by esophagogastroduodenoscopy (EGD). When EGD was repeated, a false aneurysm was found. We decided that endoscopic treatment was impossible and performed coil embolization. Case 2 : A 1-year-old girl was diagnosed with duodenal ulcer by EGD and duodenal ulcer perforation was revealed by computed tomography scan. We performed omental plombage and abdominal cavity drainage. Case 3 : A 17-month-old boy was diagnosed by EGD as having a duodenal ulcer with protruding vessels. Endoscopic local injection and clipping were applied. Upon re-examination, we found a false aneurysm. We performed duodenal plication, gastroduodenal artery ligation and omental coating. Postoperative courses were good in all three cases. As peptic ulcers in infants sometimes become severe, we should remember that intensive care is needed.

View full abstract

A 62-year-old woman was admitted to our hospital because of lower intestinal bleeding. The diagnosis of Meckel's diverticulum was made by small bowel imaging and transanal double-balloon enteroscopic examination. Partial resection of the ileum was performed. Pathological examination of the resected specimen showed proliferation of spindle-shaped cells in the wall of the diverticulum. The tumor was diagnosed as a gastrointestinal stromal tumor (GIST) by reason of immunohistochemical staining that was positive for c-kit and CD34 and negative for desmin and S-100. The coexistence of Meckel's diverticulum and GIST is considered to be rare. However, when Meckel's diverticulum is diagnosed, the possibility of the coexistence of neoplastic diseases should be kept in mind.

View full abstract

A 73-year-old man was admitted to our hospital due to ileus. Since he underwent laparotomy 40 years previously, he has had repeated ileus. About 6 months ago, results of a screening blood test indicated liver dysfunction. Although abdominal CT demonstrated no remarkable abnormality, he has been followed and was taking UDCA. On admission, abdominal CT and small bowel contrast radiography demonstrated a movable mass (about 40 mm) with a smooth surface in the ileum. For diagnosis and endoscopic treatment, we performed double balloon endoscopy (DBE). DBE demonstrated annular stenosis with erosion and an enterolith at about 150 cm proximal from the Bauhin valve. We performed endoscopic lithotomy using a snare and successfully removed the enterolith. The stone consisted of bile acid and was compatible with a true enterolith. As most cases of enterolith have undergone surgery, there have been few reports of a small bowel enterolith successfully removed by DBE. We consider that endoscopic therapy with DBE may be a non-surgical alternative to surgery for an enterolith.

View full abstract

An 82-year-old woman was admitted to our hospital because of epigastralgia with prominent peripheral eosinophilia. Since findings by previous upper gastrointestinal endoscopy and colonoscopy were negative, we performed capsule endoscopy, which revealed multiple reddish and erosive lesions at the upper jejunum. Finally, a diagnosis of eosinophilic enteritis was made from examination of a pathological specimen obtained by single balloon small intestinal endoscopy. Oral predonisolone (25 mg/day) dramatically improved her symptoms and peripheral eosinophilia. This is, to our knowledge, the second case of eosinophilic enteritis successfully observed by capsule endoscopy before and after treatment.

View full abstract

A 61-year-old man with systemic lupus erythematosus (SLE) had been treated at our hospital since 2000. He had been administered 15-mg/day prednisolone therapy for more than 7 years until the dosage was reduced to 12.5 mg/day beginning in August 2010. Approximately one month later, he presented with lower abdominal pain, fever, and bloody stool. Colonoscopy revealed multiple rectal ulcers. The symptoms decreased with conservative medical treatment, and the prednisolone dose was subsequently reduced to 10 mg/day in May 2011. Lower abdominal pain, fever, and bloody stool recurred in July 2011. Colonoscopy showed multiple punched-out rectal ulcers and examination of a biopsy specimen revealed vasculitis in the ulcer beds. A diagnosis of colonic ulcers complicated with SLE was made, and the prednisolone dose was increased to 20 mg/day. Colonoscopy performed 3 months later revealed improvement in the rectal ulcers.

View full abstract

A 73-year-old man diagnosed with acute pancreatitis underwent total colonoscopy for colorectal screening. A IIa+IIc lesion was detected in the cecum. Type III L pit with serration and type II open pit patterns were observed on the protruded part, which was diagnosed as a mixed serrated polyp (SSA/P and TSA). The pit pattern of the depressed floor was an invasive pattern (invasion to deep submucosa : SM). The patient strongly wished endoscopic submucosal dissection despite our suggestion of colectomy. Pathological diagnosis was well and focal moderately differentiated adenocarcinoma with a mixed serrated polyp. Depth of invasion was SM (1,900μm). Lymphatic vessel invasion was identified by D2-40. Thus, colectomy was performed later. We assumed cancer pathogenesis of this lesion with mucin core protein and gene expression profiles.

View full abstract

A 61-year-old woman was admitted to our hospital because of passage of tarry stools. She had undergone pancreaticoduodenectomy (PD) for traumatic pancreatic injury 6 months previously. Gastrointestinal endoscopy and colonoscopy were performed, but the source of bleeding could not be identified. Since the symptom disappeared with conservative treatment, she was discharged. However, 2 weeks later, she again passed tarry stools. Conventional endoscopy indicated bleeding from the afferent loop. Pancreaticojejunal varices were detected by double balloon endoscopy (DBE). We performed endoscopic clipping for the varices. Symptomatic remission was attained, and no recurrence of gastrointestinal hemorrhage has occurred over a period of 4 years and 6 months. DBE was a successful method for observation, diagnosis, and treatment of pancreaticojejunal varices after PD.

View full abstract

We previously reported a spiral cone-type endoscopic nasobiliary drainage catheter (Spiral-K ENBD catheter, Gadelius Medical, Tokyo, Japan) with a tip having a three-dimensional shape to prevent a stone from sliding upstream past the tip in patients of choledocholithiasis. We have used this catheter and also used a newly designed plastic stent (Spiral-K stent, Gadelius Medical).” Also, the second time a company is mentioned we do not have to give the location.) This stent is 7 Fr in diameter with a distal spiral cone-shaped tip and a proximal pigtail-shaped end and is 5 cm long at the straight part. We used it in 31 choledocholithiasis patients.
The Spiral-K stent was successfully placed in all 31 patients and provided good biliary drainage. In addition, upstream passage of the stones was prevented. No distal migrations and complications were observed during insertion, indwelling and removal. In conclusion, the Spiral-K stent appears suitable for choledocholithiasis patients.

View full abstract

Endoscopic submucosal dissection (ESD) for colorectal tumors has been conducted by the government-approved advance medical treatment system since August 2009. Then, in April 2012, the governmental public insurance system began to cover colorectal ESD. The present article described preparations, techniques and accident prevention for beginners in colorectal ESD. From the technical aspect, we gave detailed instructions on how to use the IT knife nano and dual knife. Important points in using the IT knife nano for colorectal ESD are maintaining a good visual field and avoiding blind operations. There is not a great difference between the IT knife nano and the tip-type knives. We have successfully performed colorectal ESD with a shortened procedure time while preserving quality and safety since the introduction of the IT knife nano. Beginners should decide which knife that they will mainly use and make an effort to master the techniques required for colorectal ESD.

View full abstract

Aims : To assess the prevalence and clinical significance of mediastinal emphysema (ME) after esophageal endoscopic submucosal dissection (ESD).
Methods : A total of 105 patients in whom assessment of ME was prospectively carried out with multi-detector row computed tomography (MDCT) after esophageal ESD were included in this study. ME was graded as follows: Grade-0, no ME ; Grade-I, bubbles around the esophagus; Grade-II, ME around the thoracic aorta ; Grade-III, ME extending around the heart or beyond the mediastinum into the neck ; and Grade-IV, ME with pneumothorax or subcutaneous emphysema. MDCT grading was compared with the finding of conventional chest X-ray images (CXR) and clinical symptoms.
Results : CXR revealed the presence of ME in 6.6% of the subjects. On MDCT, ME was recognized in 62.9% (Grade-0, 37.1% ; I, 46.7% ; II, 10.5% ; III, 5.7% ; and IV, 0%), most (83.8%) being Grade-I or 0. CXR was able to visualize ME of Grade-II or greater. Exposure of the muscularis propria layer and location of the lesion were significant risk factors for development of ME of Grade-II or greater (P = 0.008 and P = 0.03, respectively). The duration of a fever of 37°C or higher was longer and the serum C-reactive protein level was higher in patients with a higher grade of ME.
Conclusions : MDCT revealed the occurrence of ME in 62.9% of the patients who had undergone esophageal ESD, most of which, however, was clinically silent. Exposure of the muscular layer during ESD and location of the lesion were independent risk factors for the development of ME.

View full abstract