Treatment options for esophageal varices (EV) include conservative medical management (pharmacological therapy, balloon tamponade), endoscopic treatment [endoscopic injection sclerotherapy (EIS), endoscopic variceal ligation (EVL)] and surgical therapy. In Japan, the first-line therapy for bleeding EV is EVL, while both EIS and EVL are popular for elective and prophylactic treatment of EV.
In order to treat EV in a safe and effective manner, it is essential to master comprehensive knowledge such as general rules for recording endoscopic findings of EV and gastric varices, indications and contraindications of EV treatment, mechanism of action of each sclerosant, how to select optimal treatment strategies according to each patient's clinical condition, and portal hemodynamics (obtained by EUS and 3D-CT), and also to learn various treatment techniques, how to find possible complications and preventive measures against them, and how to monitor patients periodically after treatment.
This review article discusses the optimal treatment strategies for EV in Japanese patients as well as those adopted in Western countries based on evidence-based medicine.

View full abstract

A 63-year-old man was admitted to our hospital for vomitus niger. Chest X-ray showed elevation of the left diaphragm, and computerized tomography revealed that the stomach was extended and rotated on the short axis. Therefore, the diagnosis was gastric volvulus.
Because of the extension of the stomach, the upper gastrointestinal endoscopy, which we routinely use, was not able to reach the duodenum. By using balloon endoscopy we were able to reach the third portion of the duodenum, and to fix the volvulus with the balloon. We had success with the noninvasive treatment, and were able to avoid surgical treatment. Balloon endoscopy should be considered as one of the options to treat gastric volvulus.

View full abstract

Advanced gastric cancer was detected in the angular part of the lesser curvature of the stomach during upper endoscopy of a 75-year-old male patient. An abdominal computed tomography scan showed several swollen lymph nodes at the lesser curvature of the stomach, but no distant metastases were observed. Since cystic lesions were observed nearby the pancreatic tails, further imaging evaluations including endoscopic ultrasound and magnetic resonance imaging were performed. With preoperative diagnoses of cT3N2M0, stage IIIA, and cystic lesions of the pancreas, a distal gastrectomy and a D2 lymphadenectomy were performed. Postsurgical pathological diagnosis showed that the cystic lesions were lymph node metastases of gastric cancer.

View full abstract

We report a 66-year-old woman who was diagnosed with paroxysmal atrial fibrillation one year ago and had been on dabigatran treatment. She was admitted to our hospital with hematochezia, and colonoscopy revealed a submucosal hematoma in the sigmoid colon. We assumed that it was the source of bleeding, so dabigatran treatment was stopped, and she was treated conservatively with bowel rest and intravenous fluid hydration. Following initiation of the therapy, she had no symptoms of hematochezia ; she recovered with conservative therapy. Then, she started taking pilsicainide because of atrial fibrillation, and the hematoma healed without rebleeding. To our knowledge, colorectal submucosal hematoma in anticoagulant dabigatran therapy is unusual, and we are the first to report a case like this in Japan.

View full abstract

A 66-year-old man presented with diarrhea, borborygmus, and abdominal distension. Enhanced computed tomography revealed the thickening of the colonic wall. F-18 fluorodeoxyglucose positron emission tomography showed uptake in the thickened colonic wall. Colonoscopy revealed granular and edematous appearance of the hepatic colon, circumferential ulcer with dirty necrotic materials of the sigmoid colon, and a polyp of the rectum with smooth surface. Capsule endoscopy showed edematous villi and cracked mucosa of the small intestine. Pathology examination of the resected polyp revealed proliferation of small- to medium-sized atypical lymphocytes into the colonic mucosa. In immunohistochemistry, tumor cells were positive for CD3 and CD8, partially positive for CD56, and negative for CD4, CD5, and CD20. Consequently, he was diagnosed with type II enteropathy-associated T-cell lymphoma. He received chemotherapy at the Department of Hematology in our hospital and has been under treatment for eight months since the diagnosis.

View full abstract

The case subject was an 83-year-old woman. During lower gastrointestinal endoscopy for blood stool examination, a brownish-red semi-pedunculated polyp was found in the lower rectum. The possibility of malignant melanoma was taken into consideration, and endoscopic mucosal resection (EMR) was performed for diagnosis by total biopsy. The polyp was diagnosed as a malignant melanoma by histopathological tests including immunohistochemical stain. Two weeks after the EMR, abdominoperineal resection was performed after confirming that there were no metastatic lesions. No residual tumor or lymph node metastasis was found in the resected specimen. At present, two years and six months after surgery, the patient is alive and relapse free. The incidence of anorectal malignant melanoma is low ; therefore, a standardized treatment strategy has not been established yet. Thus, further cases need to be studied in addition to this case.

View full abstract

A 76-year-old male with atrial fibrillation was diagnosed with asymptomatic choledocholithiasis at an outpatient clinic. The patient was admitted and endoscopic lithotripsy was attempted using endoscopic retrograde cholangiopancreatography (ERCP). The major duodenal papilla with a periampullary diverticulum (PAD) was located on the ridge to the left inside of the diverticulum, turned toward the back side. Therefore, it was difficult to insert the injection catheter into the bile duct. Submucosal injection of hyaluronate sodium was performed at the top right of the oral protrusion. The injection enabled shifting the direction of the papilla to a favorable position and ERCP was performed. This is the first case report on bile duct cannulation using submucosal injection of hyaluronate sodium. Although this procedure may not prove beneficial in all PAD cases, submucosal injection of hyaluronate sodium can be a beneficial adjunct to the ERCP procedure in cases with major duodenal papilla with PAD.

View full abstract

Second-generation ultrasonographic contrast has been developed and it has made possible contrast-enhanced harmonic EUS (CE-EUS) based on low mechanical index. CE-EUS enables visualization of vascular structures and hemodynamics in the lesion in real time. A meta-analysis showed that CE-EUS could detect pancreatic carcinoma with high sensitivity, specificity and accuracy. Pancreatic carcinoma is typically hypoenhancing with heterogeneous. distribution of contrast on CE-EUS. It was reported that CE-EUS was useful in the differential diagnosis of malignant gallbladder lesions including polyps and wall thickness. Malignant gallbladder wall typically showed a heterogeneous distribution pattern of contrast. Moreover, software to quantify the findings of CE-EUS is now available. Thus, CE-EUS might be an indispensable diagnostic modality for pancreaticobiliary pathologies.

View full abstract

Background and Aim : Gastric atrophy is one of the important pathological states that cause gastric cancer. As atrophic gastritis is related to the risk of gastric cancer, it is important to diagnose atrophic gastritis. In the present study, we tried to establish endoscopic criteria for atrophic gastritis.
Methods : A multicenter study of prospectively collected patients was conducted in 24 participating facilities. Two hundred and seventy-five patients received endoscopic examination and 15 endoscopic features, including diffuse redness, swelling of areae gastrica, and mucosal swelling, were evaluated. Biopsy specimens were taken from five points recommended by the Updated Sydney System, and evaluated by a single pathologist for atrophy. Sensitivity, specificity, positive predictive value, negative predictive value, area under the receiver operating characteristic curve (AUC/ROC) of each endoscopic finding to histological atrophy were calculated. Pepsinogen I/II ratios of these patients were measured and compared to the endoscopic features.
Results : There was no single endoscopic feature that is highly specific for histological atrophy. In the corpus, the combination of visibility of vascular pattern and swelling of areae gastrica by indigocarmine chromoendoscopy showed the highest AUC/ROC (0.83). In the antrum, the combination of visibility of vascular pattern and mucosal swelling showed the highest AUC/ROC (0.70). These endoscopic findings correlated very well to the pepsinogen I/II ratio.
Conclusions : Combination of endoscopic findings can improve diagnostic accuracy, and endoscopic diagnosis of atrophy is improved especially with new endoscopic criteria, such as swelling of areae gastrica or mucosal swelling.

View full abstract