White light imaging has limitations in the surveillance of neoplasms using conventional endoscopy. However, autofluorescence imaging (AFI) is expected to improve the detection rate of lesions. Detection of early gastric cancer using AFI is not easy, because AFI has low specificity due to inflammatory changes and regenerative changes in the gastric mucosa. Trimodal imaging with magnifying endoscopy using narrow band imaging improved the high false positive rate and low sensitivity. AFI is useful for detection of colonic neoplasms ; however, it has not been established whether AFI is useful for differentiation between adenomas and hyperplastic polyps. AFI is useful for surveillance of ulcerative colitis ; however, it is not easy to detect dysplasia if inflammation of the mucosa occurs similar to inflammation of the gastric mucosa. AFI is useful for detection of dysplasia in patients with Barrett's esophagus ; however, AFI is not superior to random biopsy. In the near future, development of real-time computer-assisted analysis of AFI images are expected to reduce the false-positive rate and improve the accuracy rate of detection of the lesions.

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A 69-year-old man visited our hospital with massive melena and hemorrhagic shock. Emergency colonoscopy was performed, but could not detect the source of bleeding. Abdominal dynamic computed tomography (CT) revealed extravasation of blood in a lumen protruding from the ileal end, suggesting bleeding from an ileal diverticulum. Repeat colonoscopy was performed and identified active bleeding from an ileal diverticulum that was located approximately 10cm from the ileocecal junction. We successfully performed endoscopic hemostasis with hemoclips.
Dynamic CT was highly specific for diagnosing the bleeding site and was useful for planning the treatment procedure.

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We report two cases of diverticular colitis (DC) that subsequently progressed to ulcerative colitis (UC) after sigmoidectomy. The two patients underwent surgery because of either repeated diverticulitis or intractable bleeding. In case 1 (55-year-old male), colonoscopy revealed scattered reddish mucosa on crescentic folds, polypoid lesions and stenosis preoperatively. In case 2 (69-year-old female), preoperative colonoscopy and barium enema study depicted multiple diverticula and diffuse reddish granular mucosa resembling UC in the sigmoid colon, whereas no obvious inflammatory change was found in the rectum. Diarrhea and hematochezia occurred in both patients 28 and 13 months after the surgery, respectively, resulting in confirmation of typical UC. Careful follow-up is necessary in patients with DC considering that DC has a potential to develop into typical UC.

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A 75-year-old man was admitted to our hospital for close examination of transverse colon cancer. Colonoscopy revealed a submucosal tumor-like, elevated lesion, 10mm in diameter, with an irregular depression at the top of the tumor. Magnifying colonoscopy detected a type I-like round pit and a type III_L-like pit in the depressed area. Biopsied specimens showed signet ring cell carcinoma with mucinous carcinoma in the mucosal layer, and laparoscopic transverse colectomy was performed. Histopathological findings showed well differentiated tubular adenocarcinoma in the depressed area, and signet ring cell carcinoma had invaded the mucosal layer and the submucosal layer. The histopathological diagnosis was adenocarcinoma (muc>sig>tub1), pT1 (SM), ly2, v1, pN0. The patient is alive in good health 13 months after the operation. There have only been a few reports on primary mucinous carcinoma of the colon with signet ring cell carcinoma.

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Objective
To elucidate the actual radiation exposure to medical staffs during endoscopic retrograde cholangiopancreatography (ERCP) and therapeutic procedures, and to investigate whether a workshop, including results of verification experiments, could affect the recognition of the need for radiation protection and reduce radiation exposure to staff.
Methods
First, we asked medical staff in our gastroenterological center to carry personal radiophotoluminescence glass dosimeters, and measured their radiation exposure. Next, we conducted verification experiments, using a phantom in the X-ray fluoroscopic room. Then, we examined which physical positions of staff members and position of protection devices during ERCP could reduce their radiation exposure. Finally, we conducted a workshop for medical staffs to reduce their radiation exposure. We investigated the changes in recognition of the importance of radiation protection by staff and personal radiophotoluminescence glass dosimeters during ERCP and their therapeutic procedures.
Results
Before this study, the staff did not sufficiently recognize the risk of radiation exposure and the importance of radiation protection. Through the study, we found that radiation doses were influenced by the positions of staff members and height of the measurement site from the floor. Specifically, the protection devices could protect staff from scattered radiation effectively. The workshop of radiation exposure and protection improved recognition of the importance of radiation protection by staff and reduced the radiation dose to nurses especially.
Conclusion
The investigation of radiation doses in the X-ray fluoroscopic room, workshop for radiation exposure, and effective practical use of protection devices contributed to improvement of recognition of the importance of radiation protection by medical staff and actual protection to medical staff.

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Helicobacter pylori-uninfected gastric cancer is rare. We experienced Helicobacter pylori (HP)-uninfected undifferentiated-type early gastric cancers. Almost all cases were signet ring cell carcinoma. The lesions were pale and were IIb lesions on white light endoscopy. Chromoendoscopy with indigocarmine could not detect the lesions. On narrow band imaging (NBI), the lesions were easy to detect by their discoloration. These findings were correlated with the histological proliferation pattern in the mucosa observed on magnified endoscopy. Vascular patterns were recognized in cases in which there was a growth pattern in the mid mucosa to upper mucosa. However, a structure pattern was recognized in cases in which there was a growth pattern only in the mid mucosa. All of the intramucosal lesions were treated by endoscopic submucosal dissection (ESD). It is easy to detect HP-uninfected, early, undifferentiated-type gastric cancer if one recognizes their characteristic features.

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Background and Aim : Double-balloon endoscopy (DBE) has enabled direct, detailed examination of the entire small bowel with interventional capabilities. Although its usefulness is recognized, efficacy and safety have not been extensively evaluated by prospective multicenter studies. To evaluate the efficacy and safety of DBE carried out by expert and non-expert endoscopists, a prospective, multicenter study was conducted in five university hospitals and a general hospital in Japan.
Methods : A total of 120 patients who underwent 179 procedures were enrolled in the study. Experts carried out 129 procedures and non-experts carried out 50 procedures. Primary and secondary end points were evaluation of safety, the rate of achievement of procedural objectives, namely, identification of a new lesion, detailed examination to establish a therapeutic strategy, or exclusion of significant lesions by total enteroscopy, and rate of successful examination of the entire small bowel and evaluation of safety.
Results : Overall rate of achievement of procedural objectives was 82.5% (99/120). Overall success rate for examination of the entire small bowel was 70.8% (34/48). Incidence of adverse events was 1.1% (a mucosal injury and an episode of pyrexia in two of 179 examinations). No severe adverse events were encountered. There were no significant differences in any of the outcome measures comparing expert and non-expert operators.
Conclusions : DBE is effective and safe for patients with suspected small bowel diseases, and can be safely carried out even by a non-expert under the supervision of an expert, following a simple training program.

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