Background:Benzodiazepines are often used for sedation during endoscopic retrograde cholangiopancreatography （ERCP), but may occasionally induce paradoxical reactions such as excessive movement. We evaluated the tolerability and effectiveness of droperidol, fentanyl and ketamine (DFK) cocktail regimen for sedation during ERCP.

Methods:A total of fifty-nine cases underwent ERCP from August 2012 until September 2013. Seventeen cases were sedated with the DKF method and forty-two cases were treated with midazolam and pentazocine (conventional method). Outcome measures were adverse events associated with sedation and the effectiveness of sedation.

Results:There was no significant difference in the incidence rate of decreased SpO₂ less than 90% between the DFK method (6%) and conventional method (10%). The occurrence rate of paradoxical reaction (insufficient sedation) in the DFK group was lower than that in the conventional group (0% vs. 19% ; p=0.09). Daily alcohol drinking of over 20g per day was identified as a risk factor for paradoxical reaction. The incidence rate of paradoxical reaction among the daily drinkers was significantly lower in the DFK group than in the conventional group (0% vs. 50% ; p=0.02).

Conclusions:The tolerability of DKF cocktail sedation during ERCP was similar to that of the conventional method. The DFK method would be effective for patients in whom it is difficult to maintain sufficient sedation by the conventional method.

An 84-year-old woman who used minodronate for two years visited our institute with chest discomfort and dysphagia. Esophagogastroduodenoscopy revealed ulcerations in the anal end of an esophageal diverticulum and distal esophageal mucosa. She was suspected of having esophageal ulcers induced by minodronate. Administration of minodronate was stopped and treatment with lansoprazole and sodium alginate was started. The ulcers rapidly improved and no recurrence was observed. Although there have been a few cases of esophageal ulcers induced by bisphosphonates, no case was induced by minodronate in the presence of an esophageal diverticulum.

A 73-year-old male with dermatomyositis and secondary Sjögren’s syndrome who had hypoproteinemia, was diagnosed with protein-losing gastroenteropathy on the basis of α1-antitrypsin clearance and 99mTc-labeled human serum albumin scintigraphy. Small-bowel endoscopic examination revealed erosions located in ringed fashion around circular Kerckring’s folds in the upper jejunum. Biopsy specimens obtained from the jejunum revealed submucosal edema and infiltration of mononuclear cells. Immunohistochemical study showed deposits of immunoglobulin and C3 on the capillary walls in the lamina propria. The patient was treated with steroid therapy. The hypoproteinemia improved and the erosions in the jejunum healed. We report small-bowel endoscopic findings considered to be associated with autoimmune diseases.

A 40-year-old man was referred to our hospital due to several episodes of vomiting after meals. Endoscopy revealed circular stenosis in the entire second portion of the duodenum (the length of the stenotic section was about 5cm), and biopsy specimens showed no malignant cells. Three months after gastrojejunal bypass operation, the gross appearance on endoscopy had changed little. However, examination of biopsy specimens revealed signet ring cell carcinoma in the lamina propria mucosae. He underwent surgical resection, and pathological findings revealed poorly differentiated adenocarcinoma with signet ring cells that showed a diffuse invasive pattern.

A 61-year-old woman (Case 1) was admitted to our hospital with the complaint of right lower abdominal pain. Colonoscopy CS detected focal edematous mucosa and segmental poor expansion in spite of air loading, at the ascending colon. Based on histological examination of biopsy samples, she was diagnosed as having MALT lymphoma and underwent R-CHOP chemotherapy. She has had a complete response to R-CHOP.

A 66-year-old woman was admitted to our hospital with the complaints of abdominal pain and diarrhea. CS detected similar endoscopic and pathological findings as those in Case 1, at the ascending colon and the sigmoid colon. She had a partial response to R-CHOP.

Endoscopic findings of diffuse-type large intestinal MALT lymphoma are ①segmental poor expansion, and ②edematous mucosa with erosion. To detect these findings, sufficient air supply and adequate usage of antispastic drugs are important.

A 75-year-old man was admitted to our hospital because of abdominal pain and fullness that he had developed during preparation for colonoscopy. He had a medical history of constipation and ulcerative colitis. Sigmoid volvulus was diagnosed by plain abdominal X-ray and computed tomography. We successfully reduced the volvulus by colonoscopy. It is rare that ulcerative colitis is involved with volvulus of the sigmoid colon and that volvulus of the sigmoid colon is induced by preparation for colonoscopy. Due to the progressive aging of the general population, the number of elderly patients with ulcerative colitis is increasing. Because of their older age, many of these ulcerative colitis patients also have constipation. Therefore, the possibility of developing sigmoid colon volvulus during the treatment of elderly ulcerative colitis patients with constipation should be kept in mind.

Currently, endoscopic treatment is widely performed as a first-line procedure in the management of benign biliary strictures. Endoscopic placement of plastic stents with or without balloon dilation has been the standard technique for the treatment. However, recently, many studies have shown the efficacy of temporary placement of covered self-expandable metallic stents (CSEMSs) for refractory cases. We here illustrate the indication and techniques of CSEMS placement for benign biliary strictures. In addition, we introduce recent study results on CSEMS placement for benign biliary strictures.

Adaptations of endoscopic treatment of the minor papilla are performed in patients with main pancreatic duct stricture in the head of the pancreas in those with chronic pancreatitis, chronic pancreatitis patients who are difficult to treat because of extensive flexure in the head of the pancreas, patients with a pancreatic stone in the accessory pancreatic duct region, and patients with pancreatic divisum. In such patients, we perform endoscopic minor papilla sphincterotomy (EMPST) to cut the minor papilla up to the superior border in the direction of 12 to 1 oʼclock. Bleeding, acute pancreatitis, and perforation are reported as complications of EMPST. In endoscopic pancreatic stone removal via the minor papilla, we insert a basket catheter along with a guidewire, and open the basket catheter while being careful not to injure the pancreatic duct wall, and remove stones that had been fragmented to a size of 5~6mm by extracorporeal shockwave lithotripsy. Acute pancreatitis, basket impaction, and pancreatic juice outflow disorders with minor papilla edema are reported as complications of endoscopic pancreatic stone removal via the minor papilla. We perform endoscopic stent placement via the minor papilla to insert a stent of 5 Fr along with a guidewire in patients who do not undergo EMPST, or a stent of 5～7 Fr along with a guidewire in patients in whom we perform EMPST. Stent obstruction, migration, and transformation of the pancreatic duct are reported as complications of endoscopic stent placement via the minor papilla. We review the procedures of these endoscopic treatments by describing cases that we have treated.

Background and Aim : White globe appearance (WGA) is a small white lesion with a globular shape that can be identified by magnifying endoscopy with narrow-band imaging (M-NBI). WGA was recently reported as a novel endoscopic marker that can differentiate between gastric cancer (GC) and low-grade adenoma. However, the usefulness of WGA for differentiating GC from noncancerous lesions (NC), including those of gastritis, is unknown.

Methods : To compare the prevalence of WGA in GC and NC, we carried out a prospective study of 994 patients undergoing gastroscopy. All patients were examined for target lesions that were suspected to be GC. When a target lesion was detected, the presence or absence of WGA in the lesion was evaluated using M-NBI, and all target lesions were biopsied or resected for histopathological diagnosis. Primary endpoint was a comparison of WGA prevalence in GC and NC. Secondary endpoints included WGA diagnostic performance for diagnosing GC.

Results : A total of 188 target lesions from 156 patients were analyzed for WGA, and histopathological diagnoses included 70 cases of GC and 118 cases of NC. WGA prevalence in GC and NC was 21.4% (15/70) and 2.5% (3/118), respectively (P ＜ 0.001). WGA diagnostic accuracy, sensitivity, and specificity for detecting GC were 69.1%, 21.4%, and 97.5%, respectively.

Conclusions : WGA prevalence in GC is significantly higher than that in NC. Because WGA is highly specific for GC, the presence of WGA is useful to diagnose GC.