Obscure gastrointestinal bleeding (OGIB) accounts for approximately ５％ of cases of gastrointestinal bleeding and is frequently caused by a lesion in the small bowel. Due to advances in small bowel imaging with capsule endoscopy, balloon-assisted endoscopy and radiographic imaging, the cause of bleeding in the small bowel can be identified. Various causes of small bowel bleeding such as vascular lesions, ulcers and tumors have been found among patients with suspected small bowel bleeding. Endoscopic hemostatic intervention can be performed. Especially, vascular lesions such as angioectasia can be treated by endoscopic therapy using argon plasma coagulation or clipping. However, the rebleeding rate after hemostatic treatment of small bowel bleeding remains high. To improve important clinical outcomes such as the prevention of rebleeding, improvement of hemostatic treatment and intervention to reduce the risk factors for rebleeding may be required.

[Background and purpose]

The aim of this study was to investigate factors affecting the proliferative activity of early undifferentiated gastric cancer.

[Method]

We investigated endoscopic and pathological features of early undifferentiated gastric cancer (74 lesions in 73patients). We used Ki-67 staining to evaluate the proliferative activity and identified factors affecting the proliferative activity.

[Results]

H.pylori infection was significantly associated with high Ki-67 index.

[Conclusion]

H. pylori infection may increase the proliferative activity of early undifferentiated gastric cancer.

An 80-year-old, male patient was hospitalized for melena. He had been diagnosed with type 0-Ⅱc＋Ⅲ gastric cancer and cholangiocarcinoma two years previously. Esophagogastroduodenoscopy (EGD) performed one year later showed that the known gastric cancer had changed morphologically from type 0-Ⅱc＋Ⅲ to type 0-Ⅰ. The cancer presented with spurting bleeding and showed a change in morphology from type 0-Ⅰ to type 0-Ⅱc＋Ⅲ. We report this case because it is rare in the development of gastric cancer observed with EGD.

Malakoplakia is a rare form of chronic inflammatory disease. It is pathologically characterized by the accumulation of macrophages containing intracytoplasmic structures with iron and calcium deposits (Michaelis-Gutmann bodies). Malakoplakia most commonly occurs in the urinary tract system such as the bladder. Only a few cases of malakoplakia have been reported in the gastrointestinal tract.

A 72-year-old woman was receiving steroid therapy for interstitial pneumonia. Her blood test showed enhancement of inflammatory reaction. Therefore, we performed positron emission tomography (PET) /computed tomography (CT), which showed accumulations in the ascending colon and left kidney. Colonoscopy showed a collection of squamous elevated lesions with a yellowish-white tone of 5-7 mm in diameter from the cecum to the ascending colon, as well as a 10mm Isp-like polypoid lesion in the ascending colon. Histopathology of biopsy specimens of the lesions in both the kidney and large intestine revealed Periodic Acid Schiff-positive histiocytes and Michaelis-Gutmann bodies. Thus, we made the diagnosis of renal and colonic malakoplakia. The patient was treated with ascorbic acid and ciprofloxacin, and the lesions decreased in size.

During a secondary screening visit by an 81-year-old man at our hospital, we detected a 5-mm flat elevated lesion in the rectum while performing total colonoscopy. The lesion consisted of a white, flat, elevated portion and a reddened protruding portion. On magnified endoscopy, the white, flat, elevated portion showed a type Ⅱ pit pattern and the reddened protruding portion showed a type Ⅲ_L pit pattern. To assess the possibilities of a partial change in the serrated lesion or the development of a collision tumor in the serrated lesion along with adenoma, endoscopic mucosal resection was performed. Pathological examination determined that the flat elevated portion was a hyperplastic polyp and that the protruding portion was tubular adenoma. Molecular biological analysis indicated a K-ras mutation only in the white flat elevated portion, and neither a K-ras mutation nor a BRAF mutation was observed in the reddened protruding portion. The findings on endoscopy, pathology, and molecular biology analysis indicated that the growth was a collision tumor of a hyperplastic polyp and tubular adenoma.

It was examined whether observing the visibility of collecting vessels (CV) and the glandular structure (GS) by close observation of the gastric fundic mucosa using the EG-L580NW laser transnasal endoscope, can be used to diagnose the Helicobacter pylori (Hp) status. CV and GS visibility were each classified into three groups of disappearance, or unclear or clear visibility, respectively. ① In the case of present Hp infection, the CV had disappeared but the GS was clearly visible ; ② in the case of post-Hp eradication, the CV were clearly or unclearly visible, and the GS had disappeared ; ③ in the case of non-infection, the CV were clearly visible. It is suggested that these findings improve the specificity of the diagnosis of Hp status. Disappearance of GS was observed less than 2 years after Hp eradication. For diagnosis of Hp status, it is important to closely and carefully observe the gastric mucosa while avoiding lesions of intestinal metaplasia which are suggested by lavender coloration using the LCI (Linked Color Imaging) mode.

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma is gradually becoming the standard treatment since being covered by the Japanese national health insurance in 2008. However, post-procedural stricture is common after ESD for extensive tumors, especially among patients who underwent complete or semi-complete circular dissection. These cases are challenging as multiple endoscopic balloon dilation (EBD) procedures are required. We previously reported that systemic steroid hormone (SH) administration and cell sheet transplantation therapy reduced the frequency of EBD. In this article, we investigate the usefulness and limitations of steroid administration for prevention of post-ESD stenosis. Furthermore, we clarify the usefulness of SH oral + local injection combination therapy for cases that are resistant to these stenosis prevention treatments.

Background and Aim : In patients with unresectable malignant distal biliary obstruction, covered self-expandable metallic stents (CSEMS) may remain patent longer than uncovered self-expandable metallic stents as a result of tumor ingrowth prevention. One main cause of recurrent biliary obstruction (RBO) in CSEMS is sludge formation, which can be prevented using a large-bore stent. Therefore, we developed a novel, 12-mm diameter fully covered SEMS (FCSEMS) and investigated its clinical safety, efficacy, and rate of adverse events.

Methods : This prospective, multicenter pilot study, which ran between June 2011 and November 2012, included 38 consecutive patients with unresectable malignant distal biliary obstruction. All patients underwent endoscopic insertion of our novel stent. Primary endpoint was non-RBO rate 6 months after placement.

Results : Technical and functional success rates of the procedures were 100％. Six-month non-RBO rate was 50％, and median time to RBO was 184 days. Median survival time was 241 days. Twelve patients died within 6 months after stent placement without RBO. RBO was observed in 10 patients (26％), with seven experiencing stent occlusion and three experiencing stent migration. Adverse events other than RBO (at ＜30 days) developed in six patients (16％ ; cholecystitis, one ; pancreatitis, one ; hyperamylasemia, one ; pancreatic ductitis, one ; abdominal pain, two). Stent removal for reintervention was successfully completed in eight patients.

Conclusion : Our novel FCSEMS may be safe and effective for managing malignant distal obstruction with an acceptable incidence of adverse events.