Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is a recently described alternative to percutaneous transhepatic biliary drainage (PTBD) for patients in whom endoscopic retrograde cholangiopancreatography (ERCP) has failed. Both EUS-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are relatively well established as alternatives to PTBD. EUS-BD is a useful procedure, but severe or fatal complications have been reported. When learning EUS-BD, we recommend a mentor’s supervision for a beginner. It is important to instruct beginners about the proper techniques in performing EUS-BD.

A 40-year-old man visited our emergency room because of left flank pain. His laboratory data showed elevated inflammatory reaction. Ultrasound, CT and MRI examinations showed a mildly enhanced mass in the pancreas body with retention cysts in the pancreas tail. Endoscopic retrograde cholangiopancreatography showed irregular filling defect in the main pancreatic duct in the head and body, disruption of the main pancreatic duct in the body, and a hemorrhagic mass that protruded from the duodenal papilla. Based on biopsy examination of the mass and cytology of the pancreatic juice, we strongly suspected that this mass was a pancreatic neuroendocrine tumor.

Although there was metastasis in the left hepatic lobe, we performed total pancreatectomy and partial hepatectomy for the purpose of radical excision and pain control. The final diagnosis was pancreatic neuroendocrine tumor (WHO classification grade 2). The patient is alive for 17 months after the operation. We report this rare case of pancreatic neuroendocrine tumor with intraductal extension accompanied by tumor exposure to the duodenal papilla.

Most cases of ulcerative colitis (UC)-complicated cytomegalovirus (CMV) infection occur in patients who have been treated with steroids and/or immunosuppressants. However, we experienced two UC patients who developed CMV infection in the absence of a history of steroid and immunosuppressant therapy. Both patients were over the age of 65 years. Colonoscopy showed only redness, edema, and erosion. These findings did not suggest CMV enterocolitis, but that CMV had been reactivated. Even though we did not observe the typical endoscopic image of CMV enteritis, we suspected CMV reactivation in primary and recurrence of the elderly UC patients. Furthermore, when we diagnose elderly UC patients with CMV reactivation, treatment that does not include steroids should be considered.

A 52-year-old woman was admitted to our hospital because of repeated episodes of abdominal pain and nausea. Colonoscopy revealed dark blue mucosa extending from the cecum to the descending colon, and abdominal computed tomography showed wall thickening and linear calcification along the wall from the cecum to the descending colon. Abdominal angiography showed vein insufficiency of the mesenteric vein. Based on these findings, the patient was given the diagnosis of idiopathic mesenteric phlebosclerosis. She had been a long-term user of a Chinese herbal product for menopausal disorder. We considered the etiology of the manifestation as vein insufficiency of the mesenteric vein ; therefore, we treated her with the combination therapy of warfarin and aspirin for a period of six years. Colonoscopy and abdominal computed tomography have shown prominent improvement. We feel that the combination therapy of warfarin and aspirin is effective for the treatment of idiopathic mesenteric phlebosclerosis.

A 74-year-old man with chronic myelogenous leukemia receiving dasatinib presented with hematochezia. Colonoscopy showed multiple, small, aphthoid, hemorrhagic lesions covered with pale yellow exudate from the transverse colon to the rectum. Pathological examination of biopsy specimens of the lesions showed inflammatory cell infiltration into the mucosal surface with adhesion of exudate. Since an antibiotic medication for suspected intestinal infection was ineffective, we then suspected hemorrhagic colitis caused by dasatinib. Cessation of dasatinib eliminated hematochezia and improved the endoscopic findings. Although there are several reports of gastrointestinal hemorrhage as an adverse effect of dasatinib, which is a 2nd-generation tyrosine kinase inhibitor, this case is considered valuable in that endoscopic findings before and after the cessation of dasatinib were observed.

In the present report, we describe a rare case of Staphylococcus aureus colitis, wherein hepatic portal venous gas (HPVG) and pneumatosis cystoides intestinalis (PCI) were observed at onset.

A 40-year-old man presenting with hematochezia, abdominal pain and fever was admitted to our hospital. He had been diagnosed with ulcerative colitis (UC) when he was 31 years old. The activity of UC had been maintained in remission since he was prescribed mesalazine. On the current admission, abdominal CT indicated the presence of HPVG and PCI, along with contrast medium-enhanced mucosa and edema of the wall of the rectum and sigmoid colon. On colonoscopic examination, multiple longitudinal ulcers were observed at the rectum and sigmoid colon. Biopsy specimen revealed inflammation involving the infiltration of neutrophils. It was speculated that these longitudinal ulcers caused HPVG and PCI. Administration of antibiotics was started. The differential diagnoses of the current status were exacerbation of UC or the onset of another disease such as infectious colitis. Making the correct diagnosis was initially difficult. However, Staphylococcus aureus was cultured in the stool culture. Based on the stool culture, clinical course and biopsy result of colonoscopy, the patient was diagnosed with Staphylococcus aureus colitis. Antibiotic administration led to improvement of the symptoms, and the patient was discharged on day 7. The multiple longitudinal ulcers at the rectum and sigmoid colon were healed completely and only scars were observed on colonoscopy performed three months later.

The findings of the present case suggest that the appearance of HPVG and PCI does not necessarily indicate the presence of intestinal necrosis. Furthermore, in patients with a history of UC who develop infectious colitis, HPVG and PCI may appear because of vulnerability of the colonic mucosa.

[OBJECTIVE] Our objective was to study the usefulness and safety of cold snare polypectomy (CSP) for colorectal polyps.

[METHODS] CSP was performed on colonic polyps of 10mm or less. CSP was performed on 645 lesions except the depressed type between April 2015 and December 2015. The presence or absence of late-onset bleeding, use of a clip, margins-negative rate, bulk resection rate, and recovery rate were compared between lesions that had been treated by CSP and 546 lesions that had been treated by polypectomy by coagulation (HSP).

[RESULTS] There was no case of delayed bleeding in the CSP group. Use of the clip was significantly less in the CSP group than in the HSP group. The rate of negative resection margins was 66.7%, rate of polyp bulk resection 97.5%, and recovery rate 99.5% in the CSP group, and there were no significant differences in these parameters between the CSP and HSP groups. In addition, within the CSP group, the margins-negative rate was 56.3% between April and August and 80.3% between September and December, showing a significant improvement. This suggests that a specific learning curve exists.

[CONCLUSION] CSP is highly safe and effective. Identifying adaptation lesions and lesions for bulk resection is important. Endoscopic evaluation is sufficient after resection, and CSP can be a very effective treatment.

Stent (SEMS : self-expandable metallic stent) treatment for the colon and rectum was finally covered by the public health insurance system in Japan starting in 2012. This review describes the present conditions and key points in the technique of colonic stent placement. The current indication for colonic stent placement in Japan is malignant colorectal stenosis including palliation and bridge to surgery (BTS).

In palliation, patients with colorectal obstruction can avoid colostomy when a colonic stent can be introduced.

In patients who undergo BTS, short duration of hospitalization, reduced postoperative complications, reduced colostomy rate and reduced mortality rate are expected in comparison with those who undergo emergency surgery. Although it has been reported that the complication rate is low, adequate preparation and obtaining informed consent are important because complications can still occur during colonic stent placement. There are some tips and points to be taken into consideration in order to perform a safe procedure. The occurrence of complications can be minimized by following these guidelines. The Colonic Stent Safe Procedure Research Group, one of the subordinate organizations of the Japanese Society for Gastrointestinal Endoscopy, has put together a set of mini-guidelines for colonic stent placement and the mini-guidelines have been published on the Society’s website.

Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy using conventional endoscopes had been considered impractical due to the difficulty in performing deep insertions to a blind end which precluded other related interventions. Consequently, more invasive procedures such as percutaneous interventions and open surgery were selected as primary treatments for biliary disease in these patients. However, the development of balloon-assisted endoscopy has enabled endoscopic interventions in post-operative patients. This paper describes techniques of insertion to a blind end and ERCP-related interventions using short-type double-balloon endoscopy.

Background and Aim : Gastric acidic abnormalities are related to various types of diseases in Helicobacter pylori (H. pylori) infection status. However, no studies have shown correlations between many tiny endoscopic findings and the acid secretion level simultaneously. In the present study, we investigated predictive tiny endoscopic findings of hyperchlorhydria and hypochlorhydria.

Methods : A total of 223 subjects without organic diseases who underwent esophagogastroduodenoscopy and endoscopic gastrin test (EGT) for estimating gastrin-stimulated gastric acid secretory response between 1999 and 2012 at our institution were retrospectively analyzed. Two blinded expert endoscopists reviewed the images independently and recorded the endoscopic findings.

Results : According to the EGT values, the enrolled subjects were categorized into hyperchlorhydria, normal acid secretion, and hypochlorhydria groups. In all subjects, hematin (odds ratio [95% confidence interval] = 3.32 [1.40-7.84]) and antral erosion (2.88 [1.24-6.70]) were the predictive endoscopic findings for hyperchlorhydria, and swelling of areae gastricae (14.4 [5.74-36.1]) and open-type atrophy (15.1 [7.35-31.1]) were those for hypochlorhydria. In addition, the predictive endoscopic findings for hyperchlorhydria differed according to the H. pylori infection status, hematin in H. pylori-positive subjects and antral erosion in H. pylori-negative subjects, in contrast to those for hypochlorhydria, which were the same irrespective of the H. pylori infection status.

Conclusions : We could predict the acid secretion status based on the endoscopic findings regardless of H. pylori infection status, which would be of some help for evaluating the risk for acid-related diseases.