Background : Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation because it is an invasive procedure. Dexmedetomidine (DEX), a highly selective α2-adrenoceptor agonist with sedative activity and minimal effects on respiration, has recently been widely used for patients in the intensive care unit. However, its utility for endoscopic procedures remains unclear. In this study, we retrospectively investigated the safety and efficacy of dexmedetomidine sedation during ERCP.
Methods : Among the patients who underwent ERCP from January 2013, eighty-six patients were sedated with dexmedetomidine (i.v. infusion of 3.0μg/kg/hr over 10 min followed by continuous infusion at 0.4μg/kg/hr) with the addition of midazolam and pentazocine. As a control group, we collected patients who underwent ERCP before January 2013 and who were sedated with midazolam and pentazocine without DEX. Additionally, pentazocine, midazolam and propofol were administered as needed to maintain Ramsay sedation scale 4. Elderly patients (above 81 years old) and patients with reduced cardiac function were excluded from this study. Outcome measures were the amounts of midazolam and pentazocine administered, adverse events associated with sedation, and hemodynamics.
Results : The incidence rate of decreased SpO₂ was significantly lower (3.5% vs. 11.6%, p=0.04) and the median dose of additional midazolam and pentazocine was significantly lower in the DEX group than in the control group (5.2mg vs. 12.5mg; p<0.001, 7.5mg vs. 11.4mg ; p<0.001). There was no case in which propofol was needed or the procedure was discontinued because of respiratory depression in the DEX group. Blood pressure and pulse rate were significantly lower in the DEX group than in the control group. However, no case required a vasopressor.
Conclusions : Dexmedetomidine reduced the incidence of respiratory complications and total dose of other sedative agents. Dexmedetomidine can be used as an alternative to conventional methods for adequate sedation during ERCP.

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A 29-year-old man who had received a diagnosis of Crohn's disease (CD) in 2001 was referred to our department because of relapse of CD. Upper gastrointestinal endoscopy revealed white stipple-like exudates and red linear furrows in the esophagus, and pathological examination of biopsied specimens showed infiltration of eosinophils which was confirmed by the presence of more than 20 eosinophils in every high-power field. Eosinophilic esophagitis (EoE) was suspected ; however, only treatment for CD was started, because the patient was asymptomatic for EoE with no dysphagia, food impaction nor heartburn. After induction of remission of CD, the patient developed food impaction and heartburn without a change in endoscopic and pathological findings. Therefore, the diagnosis of EoE was confirmed. Swallowed fluticasone therapy was provided for 8 weeks. The patient's symptoms improved immediately, and the endoscopic and histologic findings improved as well. EoE in patients with CD is very rare.

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Upper gastrointestinal lesions were investigated in three cases of Crohn's disease of aphthous type (Type A Crohn's disease). All three cases had a bamboo joint-like appearance of the stomach and aphthous ulcerations, which are characteristic gastric and/or duodenal lesions in Crohn's disease. In addition, noncaseating epithelioid cell granulomas were present in two of the three cases with bamboo joint-like lesions. Focally enhanced gastritis was recognized in 46% of biopsy specimens from the upper gastrointestinal tract of the cases. Characteristic gastric and/or duodenal lesions were observed in Type A Crohn's disease, as in typical Crohn's disease, and the identification of these lesions, as well as their histological features, was useful for diagnosis.

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Percutaneous endoscopic gastrostomy (PEG) is the first choice for administration of enteral nutrition in patients who find oral intake difficult. However, in patients with a history of upper gastrointestinal tract surgery such as gastrectomy or esophagectomy, PEG is sometimes difficult because the anatomical location of the stomach is different from the original position. Herein we describe two cases of successful percutaneous endoscopic duodenostomy (PED). In both cases, the duodenum was selected for feeding tube insertion, because it was technically impossible to insert the feeding tube into the stomach.
The first case is an 85-year-old woman with a history of Billroth I reconstruction after distal gastrectomy. As the transverse colon was located close to the duodenum in the CT image, a water-soluble contrast agent was injected through the nasogastric tube 3 hours before PED. Using this procedure, the colon was visualized at the time of duodenal tube insertion. By using the fluoroscopic image, it was possible to puncture the duodenum while avoiding puncturing the overlapping colon (colonic radiography-assisted PED).
The second case is a 71-year-old man with a history of subtotal esophagectomy with gastric tube reconstruction through the posterior mediastinal route. As some part of the duodenum appeared to be overlapped by the colon in the CT image, a colonoscope was inserted, and the transverse colon was moved toward the direction of the pelvis by manipulating the scope shaft. Simultaneously, an upper endoscope was inserted and PED was performed (colonoscopy-assisted PED). To avoid gastroesophageal reflux, a jejunal feeding tube was inserted through the duodenal fistula using an ultrathin endoscope.
In both cases, there were no serious complications after injecting the nutrients through the duodenal fistula. PED can therefore be a useful choice if PEG is difficult, such as in cases with previous upper gastrointestinal tract surgery.

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A 41-year-old man was admitted to our hospital with abdominal pain. He had purpura He had purpura on his lower extremities and computer tomography demonstrated intussusception in the ileocecum. We endoscopically detected a submucosal hematoma in the cecum and suspected IgA vasculitis (HENOCH-SCHöNLEIN : HSP) with intussusception. We decided to administer conservative therapy because there was no ischemic lesion in the intestinal tract there was no ischemic lesion in the intestinal tract. Fortunately, the abdominal pain, hematoma and intussusception alleviated the abdominal pain, hematoma and intussusception alleviated with disappearance of purpura on his lower extremities under conservative therapy. After discharge, he was diagnosed with HSP by hematoxylin and eosin staining and IgA immunohistochemistry on skin biopsy. Endoscopy can be useful in the diagnosis of HSP, judgment of whether to perform surgery or conservative therapy, and disease progression.

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A 77-year-old man complained of weight loss and tarry stools. Gastroscopy revealed a duodenal ulcer and multiple duodenal erosions. Contrast-enhanced abdominal computed tomography revealed severe circumferential wall thickening of the descending colon, sigmoid colon, and rectum. 18F-fluorodeoxyglucose positron emission tomography showed diffuse uptake in the colorectal wall. Colonoscopic examination revealed focal hyperemia and edema of the mucosa, and a biopsy of colonic mucosal tissue showed the characteristic histological features of T-cell lymphoma. An inguinal lymph node biopsy revealed the characteristic histological features of angioimmunoblastic T-cell lymphoma (AITL). The lower digestive tract is an unusual site for extranodal AITL.

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A 52-year-old man who presented with progressive abdominal pain was diagnosed with colonic ileus due to rectal stricture by CT and colonoscopy. Colonoscopy demonstrated pinhole stenosis of the rectum. He underwent three courses of endoscopic balloon dilatation (EBD) without resolution of the rectal stricture. Recently, the endoscopic radial incision and cutting (RIC) method was reported to be effective for treating refractory esophageal stricture. MRI revealed that the severe stricture was caused by thickening of the rectal muscle layer. We used the RIC method to treat the rectal stricture with an IT knife 2 for the endoscopic submucosal dissection (ESD) device. There were no complications such as bleeding or perforation. After treatment, the degree of stenosis decreased and re-stenosis did not occur. This case suggests that the RIC method is a potentially promising treatment option for severe rectal stricture.

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The patient was a 43-year-old Pakistani man who had lived in Japan for 16 years. He presented at our hospital with abdominal pain and fever. His temperature was 39.4°C and blood biochemistry tests showed increased WBC and CRP levels as well as elevated levels of liver and biliary system enzymes. CT showed multiple abscesses in the liver. Although treatment was started with antibiotics, no improvement was observed. Thus, the abscesses were punctured on day 3. The culture results were negative and no ameba was detected. After drainage, the fever subsided and his hematological parameters returned to normal. Colonoscopy showed multiple small ulcers in the right side of the colon. As Giardia lamblia was then detected in the washing solution, oral administration of metronidazole was started. After the patient was discharged, CT showed that the abscesses had decreased in size, colonoscopy showed disappearance of the ulcerous lesion in the appendix, and Giardia lamblia was undetectable.

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Enteral stenting is widely performed in advanced cancer patients with malignant enteral obstruction. Four gastroduodenal stents and two colonic stents are now commercially available in Japan. The mechanical properties (axial force and radial force) of these metallic stents differ based on the structure of each stent. The thickness and stitch of the wire affect the mechanical properties. Axial force is one of the major mechanical properties of metallic stents. Axial force is defined as the force with which the stent tends to become straight when it bends. We need to pay attention to the axial force of the metallic stent when the enteral stent is deployed at the bending site of the gastrointestinal tract. The structure of the metallic stent also influences the fashion of stent deployment. The stent shortening rate is quite different among metallic stents. Moreover, the visibility under fluoroscopic guidance also differs among the various metallic stents. These factors strongly influence the difficulty of enteral stenting. Therefore, we need to understand the features of each enteral stent and choose the appropriate stent based on the situation of malignant enteral obstruction to perform the procedure more safely.

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Background and Aim : The aim of this study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases.
Methods : Thirty-four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were performed for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients.
Results : All 34 patients had iron-deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, cirrhosis associated with hepatocellular carcinoma in 6, and idiopathic portal hypertension 2. The liver function was classified by Child-Pugh classification : class A (n=6), class B (n=21), and class C (n=7). Antral motility was frequent and intense in all 34 GAVE patients. APC was performed in 22 patients, and endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate : 68.2%). Seven patients died during the follow-up period, including 2 cases with bleeding-related deaths. EBL was performed in 12 patients, and during endoscopies revealed the recurrence of GAVE in 1 patient requiring further treatment by EBL (recurrence rate : 8.3%). Two patients died during the follow-up period, neither were bleeding-related deaths.
Conclusions : The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.

Disclosure
All authors disclosed no financial relationships relevant to this publication.

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