Opportunities for diagnosis of familial adenomatous polyposis (FAP) have increased with widespread use of colonoscopy, at the occasions of screening for colorectal cancer including fecal occult blood test or complete medical checkup using colonoscopy. In this paper, we describe the important points in the diagnosis of FAP that endoscopists should keep in mind, and introduce the latest studies on treatment of FAP.

FAP is an autosomal dominant inherited disorder whose main characteristic is multiple polyposis that develops in the large intestine. We describe particularly important points for the diagnosis of gastric adenoma, gastric cancer, fundic gland polyp, duodenal adenoma, colorectal adenoma, colorectal cancer, and adenoma that develops from the ileal pouch, all of which are observed among FAP patients at high frequency.

Previously, total colectomy and pancreaticoduodenectomy were the only treatment options for FAP. However, recently, endoscopic polypectomy is frequently performed for the treatment of FAP, and studies on chemoprevention therapy to suppress colorectal polyps are being conducted. We present the current status of our studies.

For additional information on the treatment of FAP, the “JSCCR 2016 Guidelines for the Treatment of Hereditary Colorectal Cancer” published by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) can also be consulted.

The increasing frequency of colonic diverticular bleeding along with the increasing frequency of diverticulosis in the background of the rapidly-aging population and more comorbidities has become clinically significant. We often encounter difficulties in identifying the bleeding site in patients with colonic diverticular bleeding due to its feature of intermittent bleeding. Spontaneous cessation of hemorrhage is often experienced; however, rebleeding occurs at a high rate unless proper intervention is provided. Endoscopic clipping and ligation are useful because of their high hemostatic success rates. It is essential to identify SRH （stigmata of recent hemorrhage） during endoscopic examination. There is a high probability of identifying the responsible diverticulum if colonoscopy/contrast-enhanced computed tomography (CT) is performed at the onset of bleeding and a new technique, the “step clipping” method, is used.

We report a case of gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS). The patient was a 69-year-old female who had numerous fundic gland polyps (FGPs) and a whitish flat elevated area sized 5cm in the upper gastric body. She had no colon polyps endoscopically. Endoscopic findings showed an irregular reddish area in the whitish lesion, and the lesion was resected. Histological examination revealed that the area within the reddish part and the whitish lesion were gastric-type adenocarcinoma and adenoma, respectively. She eventually underwent total gastrectomy. We finally diagnosed this case as GAPPS after detection of a causal point mutation (c.-191T＞C) in the APC promoter 1B. It was found that her two sons also had similar FGPs and the same mutation in the gene. GAPPS is a unique gastric polyposis syndrome and patients with GAPPS are at high risk for gastric adenocarcinoma. When patients are diagnosed as having GAPPS, close follow-up is required.

A 66-year-old woman was admitted to our hospital because of right flank pain of about two months’ duration. Her past medical history revealed that there were multiple episodes of ascending colon diverticulitis since the patient was in her 40s, but each episode of diverticulitis was relieved with conservative treatment. Abdominal computed tomography revealed intestinal obstruction due to thickened wall of the terminal ileum. Colonoscopy showed right-sided diverticular disease, and the terminal ileum was narrowed and it was impossible to insert a scope, but no malignant findings were observed in the mucosa of the ascending colon and ileocecal region. Significant stenotic findings were noted in the above-mentioned examinations. Since malignancy could not be completely ruled out, ileocecal resection was performed. Examination of the resected specimen revealed diverticular disease of the ascending colon and stenosis of 3cm in length near the ileocecal valve due to thickening of the terminal ileum. On pathological examination, fibrosis around the diverticula and muscle layer thickening were noted in the ascending colon. The stenosis of the terminal ileum was caused by fibrosis of the submucosal and the subserosal layers. Fibrosis was observed continuously from the ascending colon to the terminal ileum. No malignancy was seen.

Among cases of diverticulosis with stenotic symptoms, there are many case reports of stenosis accompanying diverticular disease of the sigmoid colon. However, right-sided diverticular disease with ileocecal obstruction has rarely been reported. We report this case together with a literature review.

We report a rare case of ileocecal ulcers associated with familial Mediterranean fever. A 38-year-old woman presented with soft stool and melena at our hospital. The patient had been diagnosed with familial Mediterranean fever five years previously and has been treated with colchicine. Colonoscopy revealed rounded, punched-out ulcers in the ileocecum. A diagnosis of intestinal Behçet’s disease or simple ulcer was made on the basis of endoscopic examination and clinical findings. Steroid treatment was effective for the abdominal symptoms. Endoscopy performed after initiation of steroid revealed that the ulcers had improved remarkably.

There are many reports of endoscopic ultrasound (EUS)-guided transrectal drainage of a pelvic abscess from Europe and the United States, but few cases from Japan. Here, we report two cases of pelvic abscess treated using this procedure. Case 1 involved a 42-year-old female. A pelvic abscess was found after surgery for gangrenous appendicitis. The abscess in Douglasʼs fossa was punctured through the vagina, but the patientʼs condition did not improve. We visualized the abscess from the rectum via EUS, punctured it with a 19-gauge EUS-fine needle aspiration needle, and placed external drainage catheters inside the abscess. The abscess nearly disappeared. Case 2 involved an 84-year-old female. A pelvic abscess was found after surgery for idiopathic rectal perforation. We treated the abscess using the same method as used for Case 1. In both cases, we removed the external drainage catheters after about one week, and complications and recurrence of abscess were not observed. These two cases show that EUS-guided transrectal drainage is effective for treating pelvic abscess.

Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation and fistula has traditionally required surgical interventions due to limited performance of conventional endoscopic instruments and technique. A newly developed suturing device, the Over-The-Scope Clip (OTSC) system, can play an important role in rescue therapy. Thus, this innovative device is a final option in endoscopic treatment.

The device has several advantages including a powerful sewing force for GI defect closure with a simple mechanism, and an accessory forceps that can be used to suture a large defect and fistula. Consequently, the OTSC system can provide outstanding clinical effects for rescue therapy. As the procedure of endoscopic closure for perforation and fistula has been newly covered by health insurance in Japan since April 2018, an environment in which the OTSC system can be applied more efficiently has been prepared. Therefore, we here explain useful tips on using the OTSC system in clinical practice.

Background and Aim: Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for diagnosis of localized gallbladder lesions.

Methods: One hundred and twenty-five patients with localized gallbladder lesions were evaluated by CH-EUS between March 2007 and February 2014. This was a single-center retrospective study. Utilities of fundamental B-mode EUS (FB-EUS) and CH-EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images.

Results: In the differentiation between gallbladder lesions and sludge plug, FB-EUS had a sensitivity, specificity, and accuracy of 82％, 100％, and 95％, respectively, whereas CH-EUS had a sensitivity, specificity, and accuracy of 100％, 99％, and 99％, respectively. FB-EUS-based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61-87％, 71-88％, and 74-86％, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH-EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90％, 98％, and 96％, respectively. There was a significant difference between FB-EUS and CH-EUS in terms of carcinoma diagnosis.

Conclusion: CH-EUS was useful for the evaluation of localized gallbladder lesions.