Here, recent morphological findings and diagnosis of the depth of superficial esophageal squamous cell carcinoma by endoscopic examination was reviewed. The risks of lymph node metastasis of esophageal carcinoma depends, so its diagnosis is very important. Esophageal carcinoma bears a poor prognosis in general, and its standard radical surgery is extremely invasive and affects quality of life. However, if the cancer is detected in its early stage, endoscopic mucosal resection or endoscopic submucosal dissection is possible, thus leading to a less invasive treatment preserving the esophagus. The depth of invasion is determined using the conventional endoscopic view. Its accuracy rate has improved with image enhancement endoscopy applying narrow band imaging, fine observation according to the subclassification of abnormal vessels on magnified endoscopic classification of the Japan Esophageal Society, and endoscopic ultrasonography and esophagography of the upper gastrointestinal series.

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[Background] Japan Gastroenterological Endoscopy Society (JGES) guidelines for antithrombotic agents and endoscopy, which were revised in 2012, recommend the continuation of aspirin (ASA) or cilostazol (CLZ) during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with a high risk of thromboembolism. In this study to evaluate the effectiveness of the new guidelines, we investigated hemorrhagic complications of EUS-FNA of pancreatic lesions in patients taking ASA or CLZ. [Patients and Methods] We retrospectively analyzed 154 consecutive patients who underwent EUS-FNA of pancreatic lesions in our hospital between October 2010 and February 2014. Of these patients, 118 (76.6%) did not take any anticoagulant or antiplatelet agents, 16 (10.4%) had taken some anticoagulant and/or antiplatelet agents but stopped taking the drugs before EUS-FNA, and 20 (13.0%) patients had taken antiplatelet agents and continued taking ASA or CLZ. [Results] A little hemorrhaging occurred into the gastro-intestinal lumen or pancreatic duct, or around the pancreas in 3 (2.5%), 0 (0%), and 1 (5.0%) of each group, respectively, during the course of EUS-FNA. There was no significant difference in the rate of hemorrhage between the three groups. Serious hemorrhaging after EUS-FNA was not observed in any patient. [Conclusion] These findings indicate that, as stated in the revised guidelines, the continuous use of ASA or CLZ does not increase hemorrhagic risk during and after EUS-FNA of pancreatic lesions.

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A follow-up esophagogastroduodenoscopy was performed in an 85-year-old man after endoscopic mucosal resection of early gastric cancer. Irregular red depressed lesions were observed in the esophagus and were confirmed to be adenocarcinoma in the biopsy., and Afterwards, an Endoscopic Submucosal Dissection was performed. The pathology result was Lt, 0-IIc, adenocarcinoma, pT1a-MM, ly0, v0, pHM0, pVM0, stage 0. Since this lesion is not the commonly observed Barrett's esophageal adenocarcinoma, this is a rare case.

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A 57-year-old man visited our hospital for treatment of an early gastric cancer, which had been detected by screening endoscopy. Endoscopic examination revealed that the lesion was depressed, about 20 mm in diameter, and located at the posterior lesser curvature of the middle body of the stomach. A biopsy specimen revealed a poorly differentiated adenocarcinoma with profusely infiltrating lymphoid cells. Magnifying endoscopic examination of the lesion revealed a microvascular pattern similar to that of an undifferentiated adenocarcinoma. The lesion was resected en bloc by endoscopic submucosal dissection (ESD). Histological examination revealed a gastric carcinoma with lymphoid stroma (GCLS) limited to the mucosa. In situ hybridization for Epstein-Barr virus-encoded small RNA was positive. We report on this rare case of GCLS resected by ESD and discuss the relevant literature.

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An 80-year-old woman was admitted to our hospital because of high fever and general fatigue. On the basis of abdominal computed tomography findings, a duodenal diverticular perforation was diagnosed. Upper gastrointestinal endoscopy revealed an incarcerated enterolith in the periampullary diverticulum. We achieved conservative management by inserting an endoscopic nasal biliary drainage tube into the duodenal diverticulum to remove the incarcerated enterolith and aid drainage. The patient was discharged from hospital without serious complications 26 days after admission. We report a case of duodenal diverticular perforation with an incarcerated enterolith treated conservatively using endoscopic therapy.

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A 40-year-old woman, who attended our hospital in 2007, was diagnosed with idiopathic mesenteric phlebosclerosis (IMP) after stool abnormalities and a positive fecal occult blood test. Since 2000, she had been taking several Chinese herbal medicines, mainly orengedokuto and ryutansyakakuto, for the treatment of atopic dermatitis. After the initial diagnosis, we performed yearly examinations, including a colonoscopy, on the patient. Calcifications along the mesenteric vein on the right side of the colon, as detected by computed tomography (CT), progressed rapidly until 2009, when the patient was hospitalized due to an ileus associated with IMP. Since 2009, when the patient discontinued taking Chinese herbal medicine, her IMP steadily and markedly improved according to subsequent clinical examinations, and endoscopic and histologic findings; however, according to CT, calcifications along the mesenteric vein remained unchanged. This is a case report of improved IMP after the discontinuance of Chinese herbal medicine, with a long-term observation period of seven years after onset. This report is important in highlighting the association between the pathogenesis of IMP and Chinese herbal medicine.

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We experienced two cases of small varices of the ascending colon, presenting with recurrent massive hematochezia, requiring frequent blood transfusions. Case 1 was a 49-year-old man who had the superior mesenteric vein obstruction due to pancreatic head cancer. Case 2 was a 68-year-old woman who had hepatitis C virus-related liver cirrhosis with the superior mesenteric vein and portal vein thrombosis. In both cases, abdominal, contrast-enhanced, computed tomography (CT) showed collateral veins around the ascending colon and colonoscopy revealed faint varices with a tiny red dot on their surfaces (“red dot sign”). Endoscopic variceal ligation (EVL) was effective in achieving successful hemostasis in both patients. Contrast-enhanced CT should be performed to evaluate collateral veins if mesenteric vein occlusion is suspected. EVL is useful and reasonable for colonic varices, especially when focusing on the “red dot sign”.

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We have developed a novel technique, which involves inserting an ultrathin endoscope (UTE), assisted only by a Super Stiff guidewire, into the proximal jejunum. By inserting the guidewire into the biopsy channel until it was 20 cm from the distal end of the UTE, we were able to make the UTE stiff enough to avoid it bending in the stomach. Using this technique, we were successful in inserting a UTE into the proximal jejunum of 16 (94%) out of 17 patients when performed under fluoroscopic guidance. The median examination time (until the UTE advanced beyond the duodenojejunal junction) was 290 seconds. Patients did not experience any complications such as heavy nasal bleeding or serious nasal pain. Using a guidewire to keep an inserted UTE rigid may be useful in cases of obscure gastrointestinal lesions prior to performing a double-balloon enteroscopy or capsule endoscopy.

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Diagnosing diverticular hemorrhage of the colon using a standard colonoscopy under insufficient purging is highly difficult. Purging the colon with polyethylene glycol and using a transparent hood on the endoscope are essential for making an accurate diagnosis. Based on clinical observations including history of illness, history of medication, and sign of digital examination, we recommend contrast-enhanced computed tomography (CT) if diverticular hemorrhage is suspected. Based on CT imaging, we proceed to purge the colon and examine the colon using a colonoscopy with a transparent hood. The hood is gently pressed onto the perimeter of the diverticulum and mild suction is applied. This inverts the diverticular lumen and enables clear observation of the inside of the diverticulum. Furthermore, while applying continuous light pressure onto the diverticular perimeter using the hood, it is possible to introduce water into the channel of the endoscopy. Nonbleeding diverticula are readily cleansed by this purging technique, whereas bleeding diverticula are not easily cleansed. Thereby, purging serves to clearly differentiate offending from the nonoffending divericula. Eroded visible blood vessels are a sign of bleeding diverticula. For such offending diverticula, we suggest to directly apply clips onto the suction-inverted hemorrhagic diverticulum. We attempt to clip only the visible blood vessel. For cases with poor circulation or for cases with an unsuccessful endoscopic hemostasis, we suggest that interventional radiology as the next most effective treatment, though it has to be performed with care to reduce risk of complications.

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