“Helicobacter pylori-uninfected gastric cancer” that develops from H. pylori-uninfected gastric mucosa is rare. “H. pylori-uninfected gastric cancer” seems to represent gastric adenocarcinoma of fundic gland type which Yao et al. proposed for intestinal-type gastric cancer, and early signet ring cell adenocarcinoma for the diffuse type.
Gastric adenocarcinoma of fundic gland type develops primarily in the body of the stomach and is a tumor with low grade of atypism that is mainly composed of gastric-type cancer immunohistologically ; however, this tumor tends to invade the submucosa at an early stage. Therefore, a small submucosal lesion that is observed endoscopically in the gastric mucosa of the body of the stomach without atrophic changes should be tested further for potential cancer. On the other hand, it seemed that signet ring cell adenocarcinoma which was relatively frequently detected in uninfected gastric mucosa was representative of diffuse gastric cancer, and a small discolored region in the body of the stomach that is observed endoscopically should be tested further. In the near future, many cases of “H. pylori-uninfected gastric cancer” will accumulate, and they should be analyzed clinically and genetically.

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In order to evaluate the usefulness and acceptability of prescribing isotonic magnesium citrate solution (MGP) in increments as a method of colonic preparation for total colonoscopy (TCS), we compared the following two methods:prescribing isotonic MGP in increments and prescribing isotonic MGP in one dose. Seventy-eight patients were randomly allocated to either preparation method. Colonic preparation was graded as excellent, good, suboptimal, or poor. The proportion of patients with colonic preparation graded as “excellent” or “good” for TCS was 82.5% (33/40) in the MGP increment group and 52.6% (20/38) in the MGP one-dose group. Results in the MGP increment group were superior to those in the MGP one-dose group with regard to the cleaning status of the colon and the acceptability of the preparation method by the patients. We conclude that prescribing MGP in increments is effective and safe. Thus it is recommended as a preparation for colonoscopy.

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An 80-year-old man ingested polyethylene glycol solution orally as a preparatory treatment for lower gastrointestinal tract endoscopy. Vomiting and hematemesis occurred immediately after the oral administration was started. Emergency upper gastrointestinal endoscopy revealed a vertical laceration of approximately 3 cm in the left wall of the lower esophagus. Initially, the patient was diagnosed as having Mallory-Weiss syndrome. He was placed on fasting without water, and maintenance drip infusion was started. Then, epigastric pain occurred. A CT scan revealed mediastinal emphysema and inflammation spreading to the left thorax, and spontaneous rupture of the esophagus was diagnosed. The patient was emergently transferred to a regional critical care center, where he received conservative therapy and his symptoms improved. Spontaneous rupture of the esophagus during preparation for lower gastrointestinal tract endoscopy is rare but may be intractable if the diagnosis is delayed. Our results suggest that when chest pain or epigastric pain occurs associated with preparatory treatment-induced vomiting, spontaneous rupture of the esophagus should be suspected as a possible diagnosis.

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A 57-year-old woman was admitted to our hospital with severe shock following massive hematemesis. One day prior to her admission, an upper endoscopic screening exam and gastric mucosal biopsy were performed. On admission, emergency upper gastrointestinal endoscopy revealed blood spurting from the upper body of the stomach. Endoscopic hemostasis using hemoclip was performed successfully. Follow-up endoscopy and contrast-enhanced CT revealed a gastric submucosal cirsoid aneurysm at the greater curvature of the upper body. She had been diagnosed with pseudoxanthoma elasticum (PXE) at the age of 45 years by characteristic retinal angioid streaks and skin biopsy. During her admission, a gene analysis study was performed, which revealed two ABCC6 mutations as being responsible for PXE. As gastrointestinal hemorrhage is a rare complication of PXE and can be a life-threatening event, extreme care is required when performing gastrointestinal endoscopy. This is the first case report in Japan of a patient with PXE with ABCC6 mutations with gastrointestinal hemorrhage.

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A 47-year-old man underwent esophagogastroduodenoscopy and it showed a slightly white depressed lesion at the greater curvature of the mid-gastric body. On magnifying endoscopy with narrow band imaging, the tumor surface presented a relatively uniform papillary and granular structure although the microstructures differed in size, and the microvessels in the part between the fossa presented a relatively uniform loop pattern. The background gastric mucosa did not have atrophy. The ratio of serum pepsinogen I and II also suggested a nonatrophic gastric mucosa and he was not infected with Helicobacter pylori. We made the diagnosis of well differentiated adenocarcinoma infiltrating the submucosal layer on the basis of a biopsy specimen from the lesion, and performed distal gastrectomy. The pathological examination showed well differentiated adenocarcinoma with minimal cytologic atypia. Mucin histochemistry showed a gastric phenotype and positivity for pepsinogen - I. Therefore, we diagnosed him as having gastric adenocarcinoma of the fundic gland type.

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A 55-year-old man presented with flatulence and vomiturition. Abdominal computed tomography, upper gastrointestinal endoscopy and biopsy findings suggested pyloric stenosis due to gastric cancer, and therefore, surgery was scheduled. Preoperative gastric lavage using a 16-Fr polyvinylchloride nasogastric tube or a rubber oral gastric tube with an external diameter of 15 mm was not effective, because these tubes became clogged with food residue. However, gastric lavage with the sliding tube used in single-balloon enteroscopy could be performed.

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A 63-year-old man underwent esophagogastroduodenoscopy, which revealed a type 0-Is lesion (indefinite for neoplasia), 5mm in size, in the superior duodenal angle. Four years later, the lesion increased in size to 7mm, and it was diagnosed as suspected adenocarcinoma at endoscopic biopsy. It was considered to be a mucosal lesion in the endoscopic ultrasound performed one month later. Therefore, we decided to resect it by endoscopic treatment. Two months later, at the time of treatment, the lesion had changed to 0-IIa+IIc-type. En bloc resection was performed using the endoscopic mucosal resection technique. Histopathological examination of the resected specimen verified well-differentiated tubular adenocarcinoma, SM. We report a very rare case of early duodenal cancer showing morphological change in a short period of two months.

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Upside-down stomach is a rare condition characterized by the occurrence of a gastric volvulus in a supradiaphragmatic hernia sac. In the present report, we describe a case of upside-down stomach with mesenteroaxial volvulus wherein both the stomach and transverse colon had prolapsed into the esophageal hiatal hernia sac ; the gastric volvulus and transverse colon herniation were successfully resolved by colonoscopy-assisted percutaneous endoscopic gastrostomy (PEG).
A 91-year-old woman presented with a three-month history of intermittent vomiting after ingestion of meals. Esophagogastroduodenoscopy indicated the presence of severe deformity of the stomach. Abdominal plain radiography indicated deviation of digestive tract gas that appeared to overlap the cardiac silhouette. Abdominal computed tomography indicated migration of the antrum and body of the stomach, as well as a part of the transverse colon, into the mediastinum. Upper gastrointestinal series indicated subtotal herniation of the stomach into the mediastinum in an inverted position ; only the gastric fornix was found to remain in the infradiaphragmatic position. Based on the above-mentioned findings, we diagnosed the patient with upside-down stomach with mesenteroaxial torsion. Although surgical repair is recommended in such cases, the present patient was considered unsuitable for surgery.
PEG has been reported as an alternative to standard surgical therapy in symptomatic patients with upside-down stomach. In the present case, as the transverse colon had prolapsed into the thoracic cavity, the transverse mesocolon may interfere with the puncture route. Therefore, to prevent complications, a colonoscope was inserted under X-ray fluoroscopy, and the transverse colon was pulled from the mediastinum into the abdominal cavity. The displaced stomach was endoscopically repositioned and anchored to the abdominal wall by PEG. Following the procedure, the symptoms of the patient resolved. At follow-up 1 year and 8 months later, we have confirmed her well-being and that she was symptom-free.

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A 67-year-old woman who had suffered from IgG4-related lacrimalitis and sialoadenitis and had been treated with steroid for five years, was referred to our hospital with the complaint of abdominal pain.
The level of tumor marker CA19-9 was 1134U/ml and serum IgG4 was 920mg/dl. Abdominal enhanced CT showed a 25mm hypovascular tumor in the pancreatic head. ERCP showed narrowing of the main pancreatic duct in the pancreatic head with slight caudal dilation and stricture of the lower common bile duct. There were no characteristic findings of autoimmune pancreatitis (AIP). We diagnosed her as having pancreatic cancer by EUS-FNA and she underwent pancreaticoduodenectomy. Pathological examination of the resected tissue revealed well-differentiated adenocarcinoma surrounded by type 1 AIP characterized as lymphoplasmacytic sclerosing pancreatitis. The relationship between AIP and pancreatic cancer is not yet clear, but we should treat AIP patients while keeping in mind that AIP may predispose to pancreatic cancer.

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Objective:This study compared the acceptance by patients of unsedated transnasal versus sedated peroral upper gastrointestinal endoscopy using pethidine hydrochloride.
Methods:A total of 274 patients who underwent both sedated peroral and unsedated transnasal endoscopy for screening purposes, were analyzed retrospectively. Acceptance by patients was assessed using a questionnaire completed by patients after each procedure and the number of occurrences of gagging reflex.
Results:Compared with the previous sedated peroral endoscopy, 77.4% (212/274) of patients stated that they tolerated unsedated transnasal endoscopy well. Among all patients, 72.3% (198/274) of patients stated that they were willing to undergo unsedated transnasal endoscopy in the future. The number of gagging episodes was significantly lower in unsedated transnasal endoscopy (p<0.05).
Conclusion:Transnasal upper gastrointestinal endoscopy is well tolerated and considerably reduces patient discomfort compared with sedated peroral endoscopy with pethidine hydrochloride.

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The Los Angeles Classification System (LA system) is widely used as endoscopic criteria for identifying reflux esophagitis and focuses on describing the extent of visible mucosal breaks. In Japan, the LA system has been modified (modified LA system) to include grade N, defined as no endoscopic findings, and grade M, defined as minimal changes in the mucosa such as erythema and/or whitish turbidity. To establish accurate diagnosis of esophagitis by endoscopy, some key points and techniques must be noted. First, the endoscopist should require patients to take a deep breath dilating the lower esophagus so the endoscopist can easily detect the squamo-columnar junction (SCJ) circumferentially. Second, we need to observe the mucosa of the SCJ both carefully and precisely to detect the presence of mucosal breaks or minimal changes. Close-up observation and/or image-enhanced endoscopy can distinguish erosion from erythema and white plaque from squamous epithelium in terms of partial mucosal injury. In particular, it is important to establish endoscopic diagnostic criteria and a training program for endoscopic diagnosis of minimal changes.

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Background:Endoscopic features corresponding to pathological findings in the Sydney System have not been identified, and endoscopic diagnosis of chronic gastritis has not yet been established. To establish the diagnosis of Helicobacter pylori (H. pylori) infection in gastric mucosa by endoscopic features, a prospective multicenter study was carried out.
Patients and Methods:Two hundred and ninety-seven registered patients from 24 facilities between March 2008 and February 2009 were enrolled. Association between endoscopic findings (conventional findings and indigocarmine contrast (IC) method findings) and diagnosis of H. pylori infection made by microscopic observation of biopsy specimenswas investigated in the corpus and antrum and their diagnostic accuracies were investigated.
Results:Two hundred and seventy-five patients were analyzed. The area under the receiver operating characteristic (ROC) curve for H. pylori infection of conventional endoscopy was 0.811 in the corpus and 0.707 in the antrum (P = 0.006). Evaluation of diffuse redness, spotty redness and mucosal swelling by conventional endoscopy and swelling of areae gastricae by the indigocarmine contrast (IC) method were useful for diagnosing H. pylori infection. Regular arrangement of collecting venules (RAC) in the angle, fundic gland polyposis, hemorrhagic erosion and bleeding spot in the corpus and red streaks, and erosions (flat, raised, hemorrhagic and bleeding spot) in the antrum may be used as diagnostic features suggesting negative H. pylori infection.
Conclusion:It is suggested that endoscopic diagnosis of H. pylori infection in gastric mucosa by conventional endoscopy and the IC method is mostly possible.

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