Malabsorption syndrome is a complex of diseases arising from an abnormality in absorption of nutrients caused by various gastrointestinal disorders. The absorptive function test is one major method of diagnosis, whereas small bowel endoscopy was used as a subsidiary examination because of its complexity before. However, recently two newly developed endoscopy modalities, double balloon endoscopy and capsule endoscopy, have facilitated the observation of the entire small intestinal tract and have contributed greatly to the increased ability to diagnose malabsorption syndrome. Here we present several representative intestinal disorders that cause malabsorption syndrome, especially featuring their characteristic endoscopic findings.

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[Purpose]A percutaneous endoscopic gastrostomy (PEG) is a safe and effective way to provide food, liquids and medications directly into the stomach. The procedure is performed in patients with difficulty swallowing. Indications for selecting individuals for PEG remain a matter of debate. In this study, we retrospectively investigated the relation between the clinical parameters before PEG and improvement in oral intake function after PEG. [Methods]Eighty-five patients were enrolled in this study and their swallowing function was assessed based on Fujishima's swallowing function grades. The preoperative clinical parameters were analyzed by Student's t test and χ2-test, and then the parameters which showed higher p value (>0.2) were evaluated by logistic regression analysis. [Results]Multivariate analysis showed that the swallowing function before PEG (Fujishima grade >=3) was a significant independent determinant of improvement in oral intake function after PEG. These results provide support that an objective numerical evaluation of swallowing function is useful for selecting patients optimally suited for PEG feeding. [Conclusion] Nutritional improvement by PEG feeding and rehabilitation of swallowing ability could contribute to functional improvement in oral intake in patients with modest retention of the ability to swallow before PEG.

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A 73-year-old man swallowed a fish bone when he was eating Arajiru. After that, he continued to have a feeling that something was stuck. He was admitted to our hospital after three days because this symptom did not improve. Chest CT scan revealed a high-density area in the thoracic esophagus, and it was regarded as a fish bone. On the CT scan, there was no finding that suggested esophageal perforation. Upper esophagogastrointestinal endoscopy revealed a flat fish bone whose edges were stuck in the esophageal wall. It was able to be removed endoscopically, because we could recognize its shape on the CT scan in advance. Areas of the esophageal wall which had been pierced by edges of the fish bone became ulcers, but we determined that the wall was not perforated. He was treated conservatively and attained remission. For a patient with a fish bone sticking in the esophageal wall, CT scan should be performed before treatment, and its shape should be confirmed. If possible, endoscopic removal is recommended.

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We report a rare case of a 58-year-old male patient with a gastrocolic fistula (GCF) caused by a benign peptic ulcer who had been referred because of epigastric pain and weight loss. Emergent gastrointestinal endoscopy revealed a gastric ulcer at the posterior wall of the stomach. Conservative treatment with a proton pump inhibitor (PPI) was immediately initiated ; however, a second endoscopic examination showed a portion of exposed colonic wall located in the center of an active gastric ulcer on day 4 after the administration of PPI. Endoscopic findings of the penetration site implied that the colonic wall invaginated into the stomach might have functioned as a check valve that prevented the flow of gastric contents into the colon. Supportive parenteral nutrition was preoperatively provided. Resection due to adhesion between the transverse colon and posterior wall of the stomach was performed without gastrectomy and partial colectomy under laparoscopy.

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A 61-year-old female was admitted to our hospital due to leg purpura and renal dysfunction. After admission, she complained of abdominal pain and melena. A double-balloon enteroscopic study revealed multiple ulcers in the distal ileum. We suspected arteritis syndrome, and started to treat the patient with a corticosteroid. However, we could not control the intestinal bleeding, even when abdominal arteriography was performed. Fluoroscopy revealed widespread inflammation of the small intestine. Therefore, we performed ileocecal resection. The pathological diagnosis was polyarteritis nodosa. In cases of uncontrolled hemorrhagic enteritis, arteritis including polyarteritis nodosa can be diagnosed early with endoscopy. On the other hand, fluoroscopy is useful for detecting widespread inflammation of the small intestine.

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A 61-year-old man developed abdominal pain during dialysis and consulted our hospital. Colonoscopy showed longitudinal ulcers and a cobblestone appearance along the periphery of ulcers discontinuously in the entire colon. A course of antibiotics, 5-ASA, and nutrition therapy had a limited effect. Barium enema radiography and colonoscopy revealed narrowing of the bowel canal in the terminal ileum and sigmoid colon, and surgery was performed. We made the diagnosis of non-occlusive mesenteric ischemia caused by hypotension during dialysis on the basis of histological findings in the resected specimen.

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A 60-year-old man was found to have a tumor in the accessory papilla of the duodenum by upper gastrointestinal endoscopy. The tumor was 10mm in size and pathological examination revealed that it was a neuroendocrine tumor. Endoscopic retrograde cholangiopancreatography (ERCP) showed complete pancreas divisum. Computed tomography revealed that there was no distant metastasis. Therefore, pancreaticoduodenectomy was performed. The resected specimen showed that the neuroendocrine tumor was 5mm in size and invaded the submucosal layer, but there was no lymph node metastasis.
Neuroendocrine tumor in the accessory papilla is rare, but it is frequently associated with pancreas divisum.

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Objective : The purpose of this study was to investigate the incidence of organic diseases, especially microscopic colitis, in biopsy-obtained tissue in patients with chronic diarrhea whose colonoscopy results were normal or showed faint or nonspecific findings.
Methods : We analyzed biopsy samples of the ascending colon, transverse colon and rectum taken from patients suffering from chronic diarrhea without bloody stools and/or without specific colonoscopic findings between November 2007 and February 2012.
Results : Of the 95 patients, 58 were male, and the average age was 47 years old. The results showed collagenous colitis in 6 patients (6.3%), human intestinal spirochetosis in 2 (2.1%) , non-specific colitis in 48 (50.5%) and normal in 39 patients (41.1%).
Conclusion : We identified collagenous colitis or human intestinal spirochetosis in 8.4% of patients having chronic diarrhea with almost normal colonoscopic findings. Therefore, histologic examination of colonic mucosal biopsies is necessary to establish a diagnosis of chronic diarrhea.

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Endoscopic therapy is the primary treatment for esophageal varices. Endoscopic injection sclerotherapy (EIS) with 5% ethanolamine oleate with iopamidol (EOI) is one of the most commonly used techniques. A 25-gauge needle is used for injection. The balloon attached to the endoscope is inflated to over 30 cc and EOI should be injected into the varices near the gastroesophageal junction to prevent the EOI from flowing out of the varices hepatofugally. The injection is halted when the EOI just fills the esophagogastric varices and the supply veins, i.e. the left gastric and short gastric veins, as shown under fluoroscopic observation. At the initial treatment, most varices observed endoscopically can be treated. The amount of EOI injected varies according to the amount required to fill the varices and supply veins, but the maximum dose is 20 ml. Most of the complications occur in association with extravariceal injection of EOI. A severe complication such as perforation can occur if a large amount of EOI leaks into the muscular layer. Therefore, careful infusion of EOI under fluoroscopic observation is needed to avoid unwanted systemic distribution. Additional EIS should be performed if the varices enlarge or display the red color sign, indicating possible hemorrhage.
Endoscopic variceal ligation (EVL) has been considered to be a safe and noninvasive therapy. It is an appropriate procedure for acute variceal bleeding and for patients whose condition is severe. But if it is used alone, recurrence or worsening of varices over a short duration can occur. In combination with EIS it can produce good control for variceal bleeding.
Surgery may become necessary in patients with splenomegaly in whom esophageal variceal bleeding occurs after repeating EIS and EVL.

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Aim:The main aim of this study was to determine whether questionnaire evaluations of clinical symptoms in gastroesophageal reflux discase were useful to assess proton pump inhibitor therapy.
Methods:A total of 185 Japanese patients (men, 88;women, 97;age:55.7±16.1 years) with gastroesophageal reflux disease were enrolled. The patients were divided based on the frequency scale for symptoms of gastroesophageal reflux disease:severe symptoms with scores ≥8 and mild symptoms with scores ≤7. Quality of life was evaluated with the Medical Outcomes Study 8-Item Short-Form Health Survey. All patients were treated with a proton pump inhibitor, rabeprazole (10mg/day), for 8 weeks.
Results:Patients were classified into four groups:reflux esophagitis with severe symptoms (n=92, 49.7%);reflux esophagitis with mild symptoms (n=17, 9.2%);non-erosive reflux disease with severe symptoms (n=66, 35.7%);and non-erosive reflux disease with mild symptoms (n=10, 5.4%). The dysmotility score was high in non-erosive reflux disease with severe symptoms compared with reflux esophagitis with severe symptoms (9.1±0.5 vs 6.8±0.5, P<0.05). The symptom score and quality of life in the severe symptoms groups for both reflux esophagitis and non-erosive reflux disease were significantly improved by rabeprazole treatment. Only the reflux score was improved by rabeprazole in the reflux esophagitis with mild symptoms group;no therapeutic effect was observed for the non-erosive reflux disease with mild symptoms group.
Conclusions:Low scores on the frequency scale for the symptoms of gastroesophageal reflux disease indicate poor responsiveness to proton pump inhibitor treatment, and high scores indicate good responsiveness.

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[in Japanese]

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