International consensus guidelines for the management of pancreatic intraductal papillary mucinous neoplasm (IPMN) were revised in 2012. The most important difference between the first and revised editions is an algorithmic change about the treatment policy for branch duct (BD)-IPMN. The first edition recommended the algorithm in which cyst size was of great importance. However, in the revised edition, both high-risk stigmata and worrisome features are recognized as findings indicating the suspicion of malignancy more than cyst size. On the other hand, it was recommended that the term carcinoma in situ be abandoned according to the recent WHO classification, and that the term high-grade dysplasia be used. The usefulness of the revised edition should be validated in the future. It will be necessary to revise the guidelines further based on new evidence.

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Background and Purpose : Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is an endoscopic-related complication. Improvement of the prognosis of patients with PEP is a compelling problem for the attending physician. Based on the data of post-pancreatitis patients in our hospital, we have investigated risk factors for the development of PEP and risk factors for aggravation of PEP. Subjects and Methods : We studied patients who developed PEP among the 2089 patients who underwent ERCP-related procedures. Results : The probability of PEP with duration of examination time of less than 21 minutes, was 3%. In a study of risk factors for onset and aggravation of PEP, different factors were related to the onset and aggravation of PEP. The severity score of acute pancreatitis that had been developed by the Ministry of Health, Labour and Welfare was statistically correlated with gender, body weight, BMI and post-endoscopic sphincterotomy (EST). Conclusion : We should pay attention to the duration of the examination time at ERCP. Different factors are related to the onset and aggravation of PEP. Factors associated with the aggravation of PEP were male gender, obesity and post-EST.

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An 83-year-old female was referred to Aso Iizuka Hospital because of massive ascites. She was negative for hepatitis viruses and had normal liver function. There were no abdominal masses. On admission, CT scan revealed portal vein thrombosis and massive ascites. Esophagogastroduodenoscopy (EGD) revealed esophageal varices with red color sign. Low-molecular heparinoid and warfarin were administered for the portal vein thrombosis, but no treatment such as sclerotherapy was performed for the varices. The portal vein thrombosis was diminished on CT one month later. The esophageal varices also diminished upon observation by EGD one month after beginning treatment for portal vein thrombosis, and disappeared completely 1 year later.
This case may be helpful to elucidate the mechanism of the development of portal hypertension. Also, treatment for esophagogastric varices following portal vein thrombosis is very problematic as the thrombosis may recur and there is a risk of bleeding of the esophageal varices.

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It has been reported that dissolution with Coca-Cola or carbonated drinks may be useful for treating gastric phytobezoars. However, its mechanism has not been clarified yet. We hypothesize that the effectiveness of dissolution therapy is mediated through the air bubbles of carbon dioxide. Here we report two successfully treated cases of gastric phytobezoars using dissolution therapy with carbonated water administration and endoscopic fragmentation. The patients were a 91-year-old woman and a 79-year-old woman, having a 5 cm phytobezoar and a 4 cm phytobezoar with gastric ulcer, respectively, both revealed by upper gastrointestinal endoscopy. After they received 2000 ml per day of carbonated water through a nasogastric tube for 3 days, the bezoars that had been resistant to endoscopic therapy were softened and easily destroyed by endoscopic treatment.

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Intestinal spirochetosis (IS) is a zoonotic infection caused by gram-negative, spiral-shaped bacilli belonging to the genus Brachyspira and an entity characterized histologically by spirochetes attached to the surface of colorectal epithelium resulting in a basophilic fringe. Although, as in animals, Brachyspira spp. can infect the colon in humans, their pathogenicity in humans remains controversial. Brachyspira infection is weak and subtle in most cases, and clinicians usually pay little attention to this bacillus ; however, it is severe enough in some cases to be mistaken for inflammatory bowel disease. We report herein our experience with a 16-year-old female who suffered from diarrhea for 2 months. Her colonoscopy findings showed edema and reddening at the ascending and transverse colon. The biopsy specimen showed gram-negative, spiral-shaped bacilli, confirming the diagnosis of IS. The pathological and clinical features of IS are discussed along with a review of the literature.

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A 68-year-old man with primary lung adenocarcinoma was admitted to our hospital because of double tumors in the pancreatic head and body. Diagnosis was not possible, but we performed ERCP and EUS. Although these tumors were identified as adenocarcinoma on endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), it was difficult to histopathologically confirm whether they were primary tumors or metastases. In addition, TTF-1 immunohistochemical staining demonstrated that the staining pattern of the pancreatic double tumors was different from that of the lung cancer. The lung cancer was TTF-1-positive, but the pancreatic cancers were TTF-1-negative. Therefore, our diagnosis was primary lung cancer and synchronous double invasive ductal carcinomas of the pancreas. The patient underwent total pancreatectomy and right upper video-assisted thoracoscopic lobectomy. The diagnosis based on the post-operative pathological findings was the same. Herein, we report an important case in which we diagnosed triple cancers in the lung and pancreas pre-operatively, and we note that multiple pancreatic cancers are rare.

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The patient was an approximately 30-year-old man with Crohn's disease. He was in clinical remission after receiving Infliximab. To evaluate the mucosal lesion, trans-anal double-balloon endoscopy was performed. The ileum was stenotic, and the endoscope could not pass through. Because mucosal healing was achieved, we attempted to perform endoscopic retrograde ileography. During the ileography, contrast media leaked to the abdominal space and the appearance of hepatic portal venous gas was observed. For the intestinal perforation, partial ileal resection was performed by emergency operation. The hepatic portal venous gas disappeared in the natural course without any special treatment. We report a case of Crohn's disease in which intestinal perforation occurred and hepatic portal venous gas appeared during double-balloon endoscopy and retrograde ileography.

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An 80-year-old woman visited our hospital with a complaint of constipation. Colonoscopy revealed a submucosal tumor-like elevated lesion in the appendix orifice which had a depression in the center. A biopsy material taken from the epithelia of the appendix orifice revealed signet ring cell carcinoma, and ileocecal resection was carried out. Microscopically, most of the lesion was occupied by signet ring cells, but tub2 and muc coexisted in the same lesion. It is suggested that signet ring cell carcinoma had originated from tubular adenocarcinoma.

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Eosinophilic esophagitis (EoE) is a chronic inflammatory condition that is characterized by dense eosinophilic infiltration in the esophageal mucosa, which leads to esophageal dysfunction and stricture. It has been proposed that an abnormal immunological reaction, localized in the esophagus, against any food and/or inhaled antigen participates pivotally in this condition, but the pathological mechanism is largely unknown. The incidence of EoE has recently been increasing in Western countries and EoE is noted as a major cause of dysphagia and food impaction. The basis for the diagnosis is clinical symptoms related to esophageal dysfunction and histopathological findings, and in addition secondary causes of esophageal eosinophilia need to be excluded. In particular, to discriminate from GERD, unresponsiveness to PPI therapy is essential for the diagnosis of EoE in the updated clinical diagnostic guidelines of Western countries. Patients with EoE have several characteristic endoscopic findings, and the recognition of these findings is an important clue in the diagnosis of this disease. In this chapter, in addition to presenting the updated clinical guidelines in Western countries and Japan, we describe the points and pitfalls in the diagnosis of EoE, especially with regard to endoscopic findings and histopathological findings.

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