Abdominal actinomycosis is difficult to diagnose by endoscopy. A man in his thirties was presented to our hospital for evaluation of pain in the right lower abdominal quadrant and an abnormal C-reactive protein level on routine health checkup. Computed tomography revealed thickened walls of the rectum and sigmoid colon. On subsequent colonoscopy, the visibility of blood vessels was decreased and aphthous erosion was seen in the rectum and sigmoid colon. We considered the presence of infectious colitis and prescribed levofloxacin. However, his abdominal pain worsened, and he was admitted to our hospital two months later. A second colonoscopy showed that the sigmoid colon had narrowed due to edematous swelling. A mucosal tissue specimen was sent to the laboratory for culture, and Actinomyces israelii was detected. Abdominal actinomycosis was suspected, and the patient was treated with ampicillin. Abdominal actinomycosis may be suspected by mucous membrane culture of an endoscopic biopsy specimen and can be cured with antibiotics if administered in the early phase of the disease. Abdominal actinomycosis should always be included in the differential diagnoses of patients who present with nonspecific colitis, and a mucous membrane culture should be performed in such cases.

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A 53-year-old man was referred to our hospital for evaluation and treatment of an ileal neuroendocrine tumor (NET). Colonoscopy revealed a xanthochromic submucosal tumor of 3 mm in diameter in the terminal ileum. It was diagnosed as NET by histological analysis of a biopsy specimen. Preoperative examinations including contrast-enhanced CT, FDG-PET and small-bowel endoscopy did not reveal synchronous or distant metastatic lesions. As a result, the patient was diagnosed as having clinical stage I (cT1, N0, M0) NET. The patient underwent segmental resection of the ileum with D3 lymph node dissection. Despite the small diameter of the tumor, the final pathological diagnosis was grade 2 ileal NET accompanied by metastasis to the ileocolic lymph nodes (#203). Surgical resection and appropriate lymph node dissection should thus be considered for the treatment of ileal NET, regardless of tumor size.

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A 50-year-old male with right lower abdominal pain consulted a nearby general practitioner, and was referred to the emergency room of our hospital with the suspicion of appendicitis. Abdominal CT revealed an intussusception, along with a large cecal lipoma that was thought to be the cause of the intussusception. Emergency colonoscopy then uncovered a submucosal tumor (SMT) that appeared to be the lead point of the intussusception, which was reduced endoscopically. Further, to prevent recurrence of intussusception, endoscopic unroofing (EU) was performed. This case suggests that, under the appropriate conditions, one-step EU can be an effective choice for reduction of an intussusception arising from a lipoma. We report its details along with a review of related literature.

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A 68-year-old male was referred to our hospital because of fever and diarrhea. Blood examination revealed an elevated C-reactive protein (CRP) level and normal white blood cell (WBC) count. Abdominal computed tomography (CT) revealed rectal wall thickening and densification of the surrounding fatty tissue. On admission, we treated the patient under the provisional diagnosis of common infectious colitis caused by food poisoning, but his symptoms did not respond. On colonoscopy, a circular ulcer in the upper rectum with granular mucosa was observed. This lesion assumed an appearance similar to spawn (mass of fish eggs). Pathological diagnosis of colonic mucosal biopsy samples with the cytomegalovirus antigenemia assay demonstrated cytomegalovirus (CMV) infection. The patient was then treated with valganciclovir and his symptoms quickly improved. The result from our patient suggests that we should perform colonoscopy and cytomegalovirus antigenemia assay in patients with refractory colitis. In addition, there is no reported case of cytomegalovirus colitis with ‘spawn-like’ ulcer until now.

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A 40-year-old man had symptoms of diarrhea and mucinous and bloody stools for one week. He developed severe abdominal pain and presented to our hospital. He had been diagnosed with ulcerative colitis four years ago, although he had not received appropriate treatment at that time. Computed tomography demonstrated intussusception in the ascending colon. Although surgical treatment has been chosen for many previous cases of intussusception in adults, we were able to reduce it endoscopically and evaluate the disease activity of ulcerative colitis. We could not find a tumorous lesion that might have caused intussusception on endoscopy. In adults with ulcerative colitis, intussusception that is not associated with a tumorous lesion is rare. We present this case with a review of the literature.

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[Background and aim] Cold snare polypectomy (CSP) is a colorectal polypectomy procedure that does not use high-frequency current, while endoscopic mucosal resection (EMR) is the conventional colorectal polypectomy procedure. We reviewed the safety and availability of CSP.
[Methods] A comparative review was performed between the CSP group consisting of 204 consecutive lesions (110 patients : male 78/female 32, mean age : 54.4±6.4 yr) for which CSP was conducted over seven months from August 2014 to March 2015, and the EMR group consisting of 282 lesions (213 patients : male 132/female 81, mean age : 61.4±3.24 yr) for which EMR was conducted over seven months from January to July 2014.
[Results] No significant differences in en-bloc resection rate, complicated procedural accident rate and histopathological diagnosis were found between the two groups. Evaluable stump lesion was found in 86 (42.2%) of the 204 lesions in the CSP group and 232 (82.3%) of the 282 lesions in the EMR group, showing a significantly lower rate in the CSP group, whereas treatment time was significantly shorter in the CSP group (36 seconds vs. 87 seconds, CSP group vs. EMR group).
[Conclusions] Among colorectal polypectomy methods, CSP which required a shorter treatment time than EMR, is expected to reduce labor and costs. It has also been suggested that CSP is a possible important therapy to achieve a clean colon. There are many problems to be reviewed including evaluation of stump lesions. Further accumulation of cases is needed in the future.

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Autoimmune pancreatitis (AIP) must be differentiated from pancreatic carcinoma, and immunoglobulin (Ig) G4-related sclerosing cholangitis (SC) from cholangiocarcinoma and primary sclerosing cholangitis (PSC). Pancreatographic findings such as a long narrowing of the main pancreatic duct, lack of upstream dilatation, skipped narrowed lesions, and side branches arising from the narrowed portion suggest AIP rather than pancreatic carcinoma. Cholangiographic findings for PSC, including band-like stricture, beaded or pruned-tree appearance, or diverticulum-like outpouching are rarely observed in IgG4-SC patients, whereas dilatation after a long stricture of the bile duct is common in IgG4-SC. Transpapillary biopsy for bile duct stricture is useful to rule out cholangiocarcinoma and to support the diagnosis of IgG4-SC with IgG4-immunostaining. IgG4-immunostaining of biopsy specimens from the major papilla advances a diagnosis of AIP. Contrastenhanced endoscopic ultrasonography (EUS) and EUS elastography have the potential to predict the histological nature of the lesions. Intraductal ultrasonographic finding of wall thickening in the non-stenotic bile duct on cholangiography is useful for distinguishing IgG4-SC from cholangiocarcinoma. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely used to exclude pancreatic carcinoma. To obtain adequate tissue samples for the histological diagnosis of AIP, EUS-Tru-cut biopsy or EUS-FNA using a 19-gauge needle is recommended, but EUS-FNA with a 22-gauge needle can also provide sufficient histological samples with careful sample processing after collection and rapid motion of the FNA needles within the pancreas. Validation of endoscopic imaging criteria and new techniques or devices to increase the diagnostic yield of endoscopic tissue sampling should be developed.

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