Autoimmune pancreatitis (AIP) is characterized by enlargement of the pancreas and irregular narrowing of the main pancreatic duct. AIP is often complicated by IgG4-related sclerosing cholangitis (IgG4-SC), in which the bile duct becomes narrowed. Endoscopic retrograde cholangiopancreatography (ERCP) reveals irregular narrowing of the pancreatic duct and long stenosis of the bile duct as typical findings of AIP and IgG4-SC ; however, it is difficult to differentiate localized AIP from pancreatic cancer and IgG4-SC from cholangiocarcinoma based on only ERCP images. The findings of intraductal ultrasonography are useful in differentiating IgG4-SC from bile duct cancer. Endoscopic ultrasound (EUS) can reveal hypoechoic enlargement of the pancreas and bile duct wall thickening. Elastography and contrast-enhanced EUS have the potential of improving the diagnosis of AIP. The ability of histological diagnosis of AIP using EUS-guided fine-needle aspiration (EUS-FNA) has improved due to improvements in technique and the new EUS-FNA needle. Steroid administration has been used to induce remission of AIP and maintenance of AIP treatment. Many problems regarding the indications of bile duct drainage and the use of immunomodulating drugs remain to be solved.

The risk of pancreatic cancer is increased among individuals with a family history of pancreatic cancer and among patients with several genetic cancer syndromes. In Western countries, since 2000, clinical surveillance in these high-risk groups was initiated for the early detection of pancreatic cancer. In addition to magnetic resonance imaging (MRI) and computed tomography (CT), endoscopic ultrasonography (EUS) has been used because of its high resolution of both the pancreatic duct and pancreatic parenchyma. When a lesion is suspected of being cancer or its precursor, endoscopic retrograde pancreatography (ERP) and EUS-guided fine needle aspiration (EUS-FNA) have been performed for further evaluation and acquisition of pathological samples. Characteristic EUS findings of the pancreas of high-risk individuals with a family history of pancreatic cancer include high echoic foci, high echoic strand, presence of a cyst, high echoic margin of the main pancreatic duct and lobularity, which are also suggestive of early chronic pancreatitis. In 2011, the International Cancer of the Pancreas Screening (CAPS) Consortium was held, and the goal of surveillance was set as diagnosis and treatment of high-grade epithelial lesions (PanIN3)〜 stage 1 pancreatic cancer. However, to date, the status of surveillance is far from the goal set at the Consortium. In 2014, the Japanese Familial Pancreatic Cancer Registry was established and clinical surveillance is about to start in Japan.

A 99-year-old woman was admitted to our hospital with complaints of purpura at her lower extremities and upper abdominal pain. She was also suffering from diabetes, hypertension and nephropathy. Abdominal computed tomography showed prominent duodenal wall thickness. Endoscopic examination revealed hemorrhagic blebs in the esophagus, multiple spots of redness in the stomach, and reddish erosions at the duodenum. Leukocytoclastic vasculitis was observed in skin biopsy specimens. Therefore, she was diagnosed as having IgA vasculitis with gastrointestinal lesions. IgA vasculitis is more common in children than in adults, with decreasing frequency with increasing age. However, the case we experienced showed that the disease can also occur in extremely elderly patients.

Primary mesenteric neuroendocrine tumors (NETs) are extremely rare. Here we report a case of NET originating from the mesentery, which was diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). A 61-year-old man who was being treated for hypertension, gout, and diabetes in our hospital’s department of metabolic internal medicine, was referred to our department for evaluation of pancreatic cystic lesions. The patient did not present gastrointestinal symptoms. Contrast-enhanced CT incidentally revealed a solid mass of 45 mm in diameter in the lower abdominal mesenterium and lymphadenopathy occurring beside the abdominal aorta. FDG-PET/CT scan revealed significant uptake into the abdominal mass, lymph nodes, left femoral bone, and third lumbar vertebra. Gastrointestinal endoscopy and colonoscopy revealed no abnormal findings. The patient underwent EUS-FNA of the solid mass for histological diagnosis and was diagnosed with NET. Somatostatin receptor scintigraphy showed the absence of primary lesions in other organs. The small intestine was examined by capsule endoscopy, and no tumor was observed. Therefore, the patient was diagnosed with primary mesenteric NET. Given the absence of intestinal obstructions and the presence of metastases in distant lymph nodes and bone, the patient did not undergo surgery and has been on octreotide therapy.

We report three cases of colonoscope incarceration in a left inguinal hernia. In the first case, colonoscopy could be successfully performed with manual compression. The colonoscope could not be inserted in the other two cases. It is important to obtain a careful history and physical examination before colonoscopy. The scope must be carefully removed in patients with an inguinal hernia.

A 73-year-old woman presented to the emergency room of our hospital complaining of right upper quadrant abdominal pain as well as back pain. Computed tomography revealed linear calcification in the common bile duct (CBD) and she was admitted to our hospital for further examination. Endoscopic sphincterotomy (EST) was conducted with the suspected diagnosis of choledocolithiasis, and led to the successful removal of two needle-shaped objects from the CBD. Component analysis revealed that the removed objects mainly consisted of calcium phosphate. In addition, pathologic assessment of the specimens showed a bone-like structure, leading to the final diagnosis of choledocolithiasis caused by fish bones that served as cores around which gallstones developed. Interestingly, our case has no history of having received treatment on the major duodenal papilla.

Colon capsule endoscopy (CCE) has received widespread attention as an emerging minimally invasive endoscopic technique that is likely to have an impact on colorectal examination. The sensitivity of CCE has been reported to be 84-94％ and 88-92％ for the detection of polyps ＞＝6mm and ＞＝10mm, respectively.

Prerequisites for successful CCE examination are adequate cleansing of the bowel and excretion of the capsule within its battery life. Our CCE procedure is as follows. Magnesium citrate is administered in the evening before the CCE procedure. Then, polyethylene glycol solution with ascorbic acid is administered in the morning of the CCE procedure day. If the quality of bowel preparation before ingestion of the capsule is unsatisfactory as assessed by experienced medical staff, an additional laxative is administered and this appears to be crucial for adequate cleansing of the bowel. All patients with satisfactory bowel preparation proceed to capsule ingestion and are administered remaining polyethylene glycol solution with ascorbic acid as a booster after ingesting the capsule. In our approach, dimethicone was shown to be useful in achieving a high cleansing level by dissolving intraluminal air bubbles as bowel preparation and as a booster solution. Recently, adding castor oil in the booster solution was reported to effectively accelerate passage and excretion of the capsule, resulting in an excretion rate within its battery life of close to 100％. We describe our original approach to CCE examination in this paper.

Our institution has treated colonic diverticular hemorrhage using endoscopic band ligation (EBL). Based on our experience, we have divided the EBL method into three steps : detection of the responsible diverticula (step A), the EBL procedure (step B), and post-EBL management (step C). In step A, it is important to detect stigmata of recent hemorrhage (SRH) before colonic spasm starts. SRH include not only active bleeding, but also non-bleeding visible vessels and adherent clots. In step B, the key to the EBL procedure is to place two marking clips on both sides of the diverticulum. Endoclips and/or epinephrine injection may be needed if EBL is not successful. In step C, we explain how to manage early re-bleeding after EBL. There are several case reports of delayed perforation after EBL from other institutions, although we have not experienced this complication.

Background and Aim : Anticoagulants are used to prevent thromboembolic events. Direct oral anticoagulants (DOAC) are our new choice ; however, their effect on bleeding risk for endoscopic treatment has not been reported. We aimed to assess the clinical effect of DOAC compared to warfarin for gastric endoscopic submucosal dissection (ESD).

Methods : We retrospectively studied 97 patients on anticoagulants and treated 108 gastric neoplasms with ESD in three referral institutes. Twenty-four patients were taking DOAC, including dabigatran (12), rivaroxaban (11), and apixaban (one) and 73 were taking warfarin.

Results : In the DOAC group, delayed bleeding rate was significantly higher in patients on rivaroxaban than in patients on dabigatran (45％ vs 0％, P＜0.05) without relation to heparin bridge therapy (HBT). In the warfarin group, 78％ of patients underwent HBT, and delayed bleeding rate was significantly higher in patients with HBT than in those without (36％ vs 0％, P＜0.05). Delayed bleeding rate increased as intake of antithrombotic agents increased (P＜0.05). HBT period was shorter (P＜0.05) in DOAC because DOAC achieve the maximum effect quicker, and hospitalization period was shorter (P＜0.05), compared with warfarin. Multivariate analysis showed that HBT (OR, 10.7), rivaroxaban (OR, 6.00) and multiple antithrombotic agents (OR, 4.35) were independent delayed bleeding risk factors.

Conclusions : The DOAC effect differs in each agent. Dabigatran is a feasible alternative to warfarin for shortening the hospitalization period and decreasing delayed bleeding rate, although rivaroxaban has a significantly higher delayed bleeding risk.