There has been increased detection of duodenal adenoma and early cancer. However, there are many equivocal aspects of their differential diagnosis in part due to their low frequencies. In addition, adenoma and early cancer are not easy to diagnose by biopsy, and endoscopic or pathological diagnosis is more challenging for lesions in the duodenum than in other parts of the digestive tract. There are also problems related to the indications for endoscopic therapy, technical difficulties, and high rates of complications. It is also important to understand non-neoplastic elevated lesions in differential diagnosis. Although Brunner's gland hyperplasia and ectopic gastric mucosa occur at high frequencies, differentiation is possible based on detailed observations, including findings under magnification. In addition, whitened villi are a characteristic of intestinal-type adenoma and intramucosal carcinoma and are an important finding. Further clinicopathological examination is necessary regarding the relationship between whitening and the mucin phenotype.

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Acute esophageal mucosal lesion (AEML) is a comprehensive disease that includes necrotizing and acute erosive esophagitis, and occasionally results in upper gastrointestinal bleeding. We classified 88 patients with AEML into two categories, i.e., 18 patients with black esophagitis and 70 patients with non-black esophagitis, and subsequently examined their clinicopathological features. Elderly men, sliding hernia and gastroduodenal ulcers were frequent in both groups, with no significant differences noted between the subtypes. Mortality was 28% and 13%, respectively, showing no significant difference, and was associated with exacerbation of the underlying diseases. The area of inflammation was more broadly extended and delay of mucosal healing was observed more frequently in the black esophagitis group relative to the non-black esophagitis group. In addition, delayed esophageal stenosis was more frequently observed in the former group. Furthermore, the black esophagitis group required longer periods of intravenous feeding (8.7 days vs. 3.8 days ; p=0.004) and hospitalization (33.1 days vs. 12.8 days ; p<0.001) compared to the non-black esophagitis group. In summary, black and non-black esophagitis are considered to belong to the same disease entity. However, black esophagitis may represent a more severe clinical subtype.

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A 77-year-old man underwent total pharyngo-laryngo-esophagectomy, radical neck lymph node dissection, reconstruction using the gastric tube through the posterior mediastinal route and anterior mediastinal tracheostomy with bipedicled upper thoracic apron flap (Grillo) for advanced cervical esophageal cancer. Seventeen years later, the patient complained of dysphagia. Upper gastrointestinal endoscopy revealed an elevated lesion in the reconstructed gastric tube and the biopsy specimen showed adenocarcinoma. A small-bore endoscope could not pass through the tumor because of generalized narrowing of the reconstructed gastric tube. Even a 0.038 inch guide wire could not pass through the tumor. Endoscopic argon plasma coagulation was repeated twice, and the endoscope could be inserted to the duodenum by necrotic deciduation of the tumor. A covered-type self-expandable metallic esophageal stent was placed under fluoroscopic guidance, which has enabled the patient to take food orally.

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Refractory esophagogastric anastomotic stenosis after esophageal cancer resection is a complication that often requires frequent dilatation treatment and severely impairs the patient's quality of life (QOL). We experienced three patients with refractory anastomotic stenosis after esophagectomy who obtained good patency by temporary placement of a removable self-expandable metallic stent (SEMS, Flexella-J Esophageal Stent). Careful attention should be paid to the choice and maintenance of SEMS in terms of the complications of SEMS placement such as stent slippage and pharyngeal bleeding. More effective and longer-term patency and improvement of patient's QOL could be obtained by placement of a removable SEMS against refractory anastomotic stenosis compared with conventional dilatation procedures.

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A 60-year-old man suffered from fever and epigastric pain. Computed tomography (CT) showed a 10 cm multiseptated cystic mass with a bubble in the left lobe of the liver and a hepatogastric fistula. Upper gastrointestinal endoscopy showed an oval-shaped ulcer with pus at the antrum of the lesser curvature of the stomach. Endoscopic liver abscess drainage was performed. Subsequently, a nasal catheter and gastric catheter were inserted into the liver abscess for continued drainage. The procedure was completed without any complications. After 22 days, the patient was discharged with only the gastric catheter still in place. After 45 days, CT showed disappearance of the liver abscess, and the gastric catheter was removed.

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A 17-year-old male visited our hospital for right lower abdominal pain. Abdominal X-ray and CT scan revealed multiple air-filled cysts along the intestinal wall and an intussusception with a multiple concentric ring sign. Colonoscopy improved the intussusception and showed multiple elevated lesions in the ascending colon. These lesions had a smooth surface, and resembled a cluster of grapes. From these findings, we diagnosed intussusception associated with pneumatosis cystoides intestinalis (PCI). In spite of hyperbaric oxygen therapy, the PCI did not improve. Therefore, we conducted right colectomy to excise the area containing PCI. The postoperative course was good and he was discharged from the hospital six days after the operation.

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Introduction : We analyzed the efficacy of a reduced volume of Moviprep^® (Ajinomoto, Tokyo, Japan) as a highly concentrated polyethylene glycol (PEG) solution.
Methods : This study was a prospective single-arm clinical study. We analyzed patients who were scheduled for colonoscopic examination at the Kyoto Prefectural University of Medicine from July 2013 to December 2013. All patients took a commercial special diet for the examination and sodium picosulfate the day before the examination. The patients took one liter of Moviprep^® and 0.5 liter of water on the day of the examination. We compared the preparation time and grade of endoscopic cleansing, and results of blood examination before and after taking Moviprep^®, with those in 122 patients receiving the standard PEG solution.
Results : One hundred eleven patients were enrolled in the Moviprep^® group and analyzed. The cleansing time of the Moviprep group was significantly shorter than that of the standard PEG group (165±53 mins vs. 192±72 mins) (p<0.05). In the Moviprep^® group, good endoscopic cleansing was achieved in the right-sided colon in 85.8% and in the left-sided colon in 91.5%. With respect to blood examination, the chloride level was lower after taking Moviprep^® compared to that before taking Moviprep^® in patients without disorder of renal function. There were no significant differences in results of blood examination in patients with disorder of renal function between before and after taking Moviprep^®.
Conclusions : Our study showed that bowel cleansing was efficient with a reduced volume of Moviprep^® using a special diet and sodium picosulfate.

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The diagnosis and prediction of tumor infiltration depth are crucial for selecting the optimal treatment strategy for superficial esophageal cancers. The surface structure and vascular architecture of the tumor change during the development of esophageal squamous neoplasia. These features can thus be used to differentiate cancer from a benign lesion and predict the degree of cancer infiltration. A new endoscopic classification, the Japan Esophageal Society classification, was developed for the diagnosis of esophageal squamous neoplasia.
High-magnification endoscopic diagnosis using this classification is mainly based on the appearance of superficial vascular architecture, especially changes in intrapapillary capillary loops. Cancer was diagnosed when well-demarcated change of the epithelium and vessels demonstrating dilatation, tortuosity, caliber change, and various shapes (four signs) (Type B1 vessels) were identified. An undetermined status was assigned when vessels with one to three of these signs (Type A vessels) were identified. Cancer limited to the epithelium or invading into the lamina propria usually appears as loop vessels demonstrating dilatation, tortuosity, caliber change, various shapes and elongation (Type B1 vessels) or a small avascular area measuring ≤0.5 mm surrounded by vessels (AVA-small). Cancer invading into the muscularis mucosa or the submucosa ≤200 μm usually appears as non-loop vessels demonstrating destruction of loop-like structure of vessels and appearance of thin branch-shaped vessels (Type B2 vessels) or a medium-sized avascular area measuring 0.6-3.0 mm surrounded by non-loop vessels (AVA-middle). Cancer invading into the submucosa >200 μm usually appears as non-loop thick vessels demonstrating destruction of loop-like structure of vessels and appearance of thick non-loop vessels (Type B3 vessels) or a large avascular area >3 mm surrounded by non-loop vessels (AVA-large). Detailed observation of the surface structure and vascular architecture of esophageal neoplasias is thus very important because it can provide valuable information for the diagnosis and prediction of infiltration depth of such tumors. Further development of this classification is warranted based on detailed investigation by members of this society.

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Aim : Gastritis is an important pathological state that causes gastric atrophy and cancer. The Sydney System is a well-used classification for histological evaluation for gastritis. However, there is no concordance with endoscopic findings. In the present study, we tried to establish endoscopic criteria and diagnosis for the inflammation activity of gastric mucosa.
Methods : A prospective multicenter study was conducted and 24 facilities participated. Two hundred and seventy patients received endoscopic examinations and 15 endoscopic features were evaluated. Biopsy specimens were taken from five points, and evaluated by a single pathologist for mononuclear cell infiltration and polymorphonuclear cell infiltration. Sensitivity, specificity, positive predictive value, negative predictive value, area under curve of receiver operating characteristics (AUC/ROC) of each endoscopic finding to histological gastritis were calculated.
Results : There was no single endoscopic finding that was highly specific for mononuclear cell infiltration and polymorphonuclear cell infiltration. In the corpus, the combination of swelling of areae gastrica by the indigo carmine contrast method (IC method) and lack of a regular arrangement of collecting venules (RAC) in angle for mononuclear cell infiltration (0.887), and the combination of swelling of areae gastrica by the IC method and diffuse redness for polymorphonuclear cell infiltration (0.851) showed the highest AUC/ROC. In the antrum, the combination of diffuse redness and visibility of a vascular pattern for mononuclear cell infiltration (0.780), and the combination of visibility of vascular pattern and swelling of areae gastrica by the IC method for polymorphonuclear cell infiltration (0.795) showed the highest AUC/ROC.
Conclusion : Combination of endoscopic findings can improve diagnostic accuracy, and sensitivity of examination for inflammation.

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