Long-standing Helicobacter pylori infection causes chronic inflammation in the gastric mucosa, induces biomolecular alteration and transforms gastric mucosa into epithelium having the intestinal phenotype. This phenomenon is called intestinal metaplasia. Because both intestinal metaplasia and gastric cancer develop through chronic Helicobacter pylori infection, and intestinal metaplasia and a portion of differentiated-type gastric cancers have a common development pathway, intestinal metaplasia is important as a para- and pre-neoplastic condition of gastric carcinoma. Intestinal metaplasia, together with atrophy, initially develops as multiple foci in the lesser curvature near the incisura angularis and at the border of the antrum and the body in the anterior and posterior walls. Then, new independent foci appear along the lesser curvature of the body and, later, in the anterior and posterior walls. The multiple foci coalesce, resulting in extensive areas of atrophy with intestinal metaplasia, which finally may involve most of the gastric mucosa. The microsurface structure of normal gastric mucosa appears as the foveola type in the body and the groove type in the antrum, whereas the microsurface structure of intestinal metaplasia shows the groove type or villiform structures that mimic the normal antral or intestinal mucosa. Intestinal metaplasia looks whitish on white light endoscopy, and narrow band imaging contrasts color difference because of 1) the white opaque substance that obscures subepithelial capillaries, 2) light blue crest that reflects short wavelength light on the surface of the epithelium, 3) marginal turbid band that makes the epithelium cloudy, and 4) decreased vascular density due to different mucosal structure. Endoscopy enables us to observe the actual prevalence and distribution of intestinal metaplasia, to perform targeted biopsy and to bridge macroscopic findings, histological findings and biomolecular findings of lesions in the stomach. Consequently, understanding the endoscopic finding of gastric intestinal metaplasia increases the yield of endoscopy when investigating the pathogenesis of chronic gastritis and gastric carcinogenesis.

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Precise identification of the marginal line of gastric mucosal neoplasms is necessary for endoscopic curative resection by ESD. The use of an acetic acid-indigocarmine mixture (AIM) has been reported as safe and convenient for detecting gastric mucosal cancers and adenomas. It needs no special light instruments and magnifying endoscopic observation. We retrospectively investigated the usefulness of AIM-spraying for appropriate marking by detecting the marginal line of gastric mucosal neoplasms just before ESD. From June 2008 to February 2011, ESD was performed in 165 cases of gastric mucosal neoplasm in our hospital. Retrospectively, 8 endoscopists evaluated the marginal line of these cases by endoscopic images that were stored in the digital filing system. In 71 of the 165 cases in which the marginal line could not be decided by white light it was verified whether AIM-spraying made the marginal line clear and whether appropriate marking was performed according both endoscopic and pathological findings. A clear margin line was identified in 62 cases (87%) by AIM-spraying, and endoscopic findings agreed with pathological mapping. AIM-spraying can be a useful method for identifying gastric mucosal neoplasms and can be used to detect these horizontal margin lines just before ESD. In the other 9 cases, the lesions were not washed out by AIM-spraying. These cases were small depressed lesions or/and mucus stained lesions.

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A 79-year-old woman with senile dementia had repeated vomiting after percutaneous endoscopic gastrostomy (PEG). Simple abdominal CT findings showed diffuse emphysema in the gastric wall, portal venous gas and gastric hypomotility. Gastrointestinal endoscopic examination revealed sporadic spotty erythema on the gastric mucosa. After discontinuance of enteral nutrition, the above findings improved after two days. We diagnosed a rare case of gastric emphysema caused by PEG.

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An 81-year-old female was under medical treatment following diagnosis of ulcerative colitis (pan-ulcerative colitis type) in 1998. Total colonoscopy in 2006 showed a IIa lesion of 3mm in diameter at the rectosigmoid colon with a distinct border. The lesion was biopsied and diagnosed as moderate atypical adenoma. Total colonoscopy performed four years later revealed an elevated lesion (20 mm in diameter) that had an irregular surface and showed redness and that was surrounded by a flat elevated lesion. Biopsy of this lesion revealed a well-differentiated adenocarcinoma. Upon diagnosis of ulcerative colitis-associated cancer, she underwent total colectomy, rectectomy, and ileostomy. Postoperative pathological examination revealed that the lesion was 0-Isp+IIa+IIb+IIc, tub1 (+pap), pM, ly0, v0, pPM0, pRM0, pN0, and Stage p0. In addition, postoperative pathological examination revealed a IIa+IIc-like lesion near the site of the cancer ; however, this lesion could not be endoscopically detected before the total colectomy. Four years earlier, this lesion was IIa and stained positive for p53. We propose that a low-grade dysplasia (flat-elevated type) had progressed to ulcerative colitis-associated cancer in this patient within approximately four years.

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We report a case of follicular lymphoma of the jejunum. A 64-year-old man who presented with hematochezia was admitted to our hospital. Abdominal CT showed jejunal wall thickening and swelling of lymph nodes around the lesion. Double balloon endoscopy revealed an ulcerative lesion and spurting bleeding from the ulcer base in the jejunum. Partial resection of the small intestine was performed. Pathological examination confirmed follicular lymphoma of the jejunum. Follicular lymphoma of the small intestine with spurting bleeding is very rare. Double balloon endoscopy was a useful modality to diagnose tumors of the small intestine.

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A 62-year-old man with chronic hepatitis B was admitted to our hospital with abdominal pain. Computed tomography (CT) demonstrated superior mesenteric thrombosis and jejunum with severely thickened wall. Thrombolysis via the superior mesenteric artery using urokinase and systemic anticoagulant therapy using heparin were started immediately and improved the symptom and thrombosis. However, ileus occurred on day 75 after the onset of superior mesenteric vein thrombosis (SMVT). CT demonstrated a jejunal stricture of 2cm. We chose balloon dilatation using a single-balloon endoscope and treatment was successful. He has remained asymptomatic during the one-year follow-up period. We describe for the first time a case of effective treatment with endoscopic balloon dilatation for a jejunal stricture after anticoagulant and thrombolytic therapy for SMVT.

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A 61-year-old female underwent a left hepatic lobectomy. One year and 10 months after the lobectomy, a focal pelvic mass was found and treated surgically. The pelvic mass and three mesenteric nodules around the mass were removed by laparotomy and were histologically diagnosed as hepatocellular carcinoma. Three years and 5 months later, CT scan showed tumorous lesions in the pericecal region and in the pelvis. A cecal mass was found during colonoscopy, and biopsy revealed features of hepatocellular carcinoma. Ileocecal resection for the cecal metastasis and surgical resection of a disseminated lesion were planned. During the laparotomy, an ileocecal mass, a serosal mass in the ascending colon, and a mass in the parietal peritoneum were palpated and a pelvic tumor was found in the preperitoneal space. The surgery was completed as planned. The patient has been recurrence-free for approximately 7 years since the first surgery.
Extrahepatic metastatic hepatocellular carcinoma is often found in the lungs, bones, and abdominal organs. The present resection was performed in a patient who had experienced localized peritoneal metastasis after hepatectomy for hepatocellular carcinoma. However, cecal metastasis was found in a subsequent colonoscopy. Here, we report a rare case of hepatocellular carcinoma.

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A 76-year-old woman was diagnosed with pancreatic cancer by endoscopic ultrasonographic fine-needle aspiration (EUS-FNA) biopsy. She had undergone thoracoscopic left lower lobe resection for lung cancer 14 months before presenting to our department. Thyroid transcription factor-1 (TTF-1) was positive in the adenocarcinoma of the resected lung cancer. Since serum CYFRA and CEA levels, which were negative after the surgery, increased again, recurrence of the lung cancer was suspected. FDG-PET examination showed intense uptake in the pancreatic head, and therefore pancreatic metastasis of lung cancer was suspected. CT and MRI revealed no dilatation of the main pancreatic duct and a deeply stained, ring-like tumor ; therefore, these results also supported the diagnosis of pancreatic metastasis of lung cancer. EUS-FNA biopsy was performed, and TTF-1-negative adenocarcinoma was detected. The patient subsequently underwent pylorus-preserving pancreaticoduodenectomy.

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As the dietary habits of Japanese have been westernizing, the number of colon cancer patients is increasing. With the advance of the instruments and techniques of colonoscopy, the success rate of cecal intubation has increased. However, total colonoscopy cannot be achieved using a standard colonoscope in some patients for various reasons. Balloon-assisted endoscopy (BAE) is very useful for those patients. There are two methods in BAE : double-balloon endoscopy (DBE) and single-balloon endoscopy (SBE). BAE was originally developed for examination of deep small intestine. However, BAE is as useful as colonoscopy. At our hospital, we select DBE for most of the patients who require BAE. For colonoscopy using BAE, good bowel preparation is desired.
Three kinds of endoscopes are available for DBE, and we use the EI-530B endoscope for most of the colonic cases. As long as DBE is performed with a good understanding of its principle, it is very useful in cases where colonoscopy would be difficult, for example, in patients with adhesion of the sigmoid colon. By using DBE, the inserting force applied to the endoscope shaft is effectively transmitted to the endoscope tip while stretching of the colon is prevented with a balloon-attached overtube. Furthermore, the double balloon endoscope can be inserted reliably with minimal pain. It is also very useful for endoscopic treatment such as endoscopic submucosal dissection (ESD) in difficult positions because stable endoscopic operation can be performed by using DBE.

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Aim : This retrospective study estimated the efficacy and safety of the WallFlex duodenal stent for malignant gastric outlet obstruction (GOO) in Japan.
Methods : Forty-two consecutive patients with symptomatic malignant GOO were treated using WallFlex duodenal stents between January 2010 and October 2010.
Results : The technical and clinical success rates were 100% and 83.3%, respectively. The median gastric outlet obstruction scoring system increased significantly, from 0 to 2, after stent placement (P<0.01). The median survival time was 3.3 months (95% confidence interval (CI), 1.8-6.0 months), and the median eating period was 3.0 months (95% CI, 1.1-4.3 months). Re-intervention was required in 11 patients (26.2%). The complication rate was 26.2%. The major complication was stent occlusion (23.8%) by tumor ingrowth, which occurred in nine (21.4%) patients, and tumor overgrowth, which occurred in one (2.4%) patient. Stent migration, perforation, and food impaction without stent occlusion were not observed. The median survival time of the patients with stent occlusion was 11.7 months (95% CI, 2.2 months - not reached), and the median stent patency of these patients was 4.0 months (95% CI, 0.8-4.7 months). These patients were successfully treated with additional stent insertion using a stent-in-stent procedure.
Conclusion : Duodenal stent placement using a WallFlex duodenal stent was safe and effective for managing malignant GOO. This stent is an uncovered metallic stent, and the major problem was stent occlusion due to tumor ingrowth. However, the occluded stent could be corrected by inserting an additional duodenal stent.

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Background and aim : Little is known about the clinical significance of treatment for endoscopically determined peptic ulcers (EPU), incidentally detected as surrogate endpoints for non-steroidal anti-inflammatory drugs (NSAIDs)-associated ulcers complication, such as overt bleeding and perforation. Even uncomplicated-EPU without overt bleeding signs when antithrombotic agents (AT) were cotherapied may be of potential bleeding sites. The aim of the present study was to evaluate whether microcytic anemia, implying potential bleeding, is associated with NSAIDs-associated EPU or cotherapies with AT.
Methods : Two hundred and thirty-eight outpatients with rheumatoid arthritis under long-term NSAIDs therapies underwent upper endoscopy and were divided into the following four groups according to the pattern (presence : + or absence : -) of AT cotherapy/EPU, respectively : A, -/- (n = 165); B, -/+ (n = 44) ; C, +/- (n = 25) ; and D, +/+ (n = 4).
Results : EPU were found in 48 of the 238 studied patients (20.2%). After significant interactions among four groups hadstatistically been identified, hemoglobin (Hb) and mean corpuscular volume (MCV) as biomarkers for potential bleeding were compared between the groups. Hb and MCV were significantly lower in the D group than in the A, B, or C groups (Hb : P < 0.01, respectively; P < 0.05, MCV; P < 0.01 or P < 0.05, respectively).
Conclusions : Patients with NSAIDs-associated EPU and AT cotherapy indicated significantly more severe microcytic anemia pattern than those without EPU or AT cotherapy, despite no evidence of overt bleeding. Even uncomplicated-EPU without overt bleeding when ATs were cotherapied may be of potential bleeding sites.

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Background:We have been studying the potential use of sodium alginate solution in endoscopic submucosal dissection (ESD). Previous sodium alginate solutions were too viscous to handle. This time, we conducted a basic experiment to optimize the physical property of sodium alginate solution and conducted a clinical study to evaluate the safety of the optimized solution.
Methods:Sodium alginate solutions of concentrations varying from 0.3% to 0.8% were prepared and evaluated in terms of ease to inject through a catheter and to raise the mucosa, using a 0.4% sodium hyaluronate solution as control. A prospective clinical study was then conducted using a 0.6% sodium alginate solution for ESD in 10 patients with gastric neoplasm.
Results:Compared with the 0.4% sodium hyaluronate solution, the 0.6% sodium alginate solution showed no significant difference in ease to inject through a catheter, but it was significantly superior regarding raising of the mucosa. No adverse events occurred in any subjects in the clinical study.
Conclusions:The 0.6% sodium alginate solution proved to be safe as a submucosal injectant, suggesting that a larger clinical study to confirm its usefulness is warranted.

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