Gastric intestinal metaplasia is associated with the risk of differentiated gastric cancer. Due to the remarkable development of image-enhanced endoscopy (IEE) represented by narrow-band imaging (NBI), various findings have been reported about the diagnosis of gastric intestinal metaplasia. Points in the diagnosis of gastric intestinal metaplasia by magnifying endoscopy with NBI (M-NBI) are firstly to evaluate the presence or absence of indicators specific to metaplasia [light blue crest (LBC), white opaque substance (WOS), marginal turbid band (MTB)], and secondly to determine the presence or absence of villous-like change of the marginal crypt epithelium (MCE) regarding the micro-surface pattern. By performing these observations in real time during endoscopy, it may be possible to accurately diagnose the localization of intestinal metaplastic mucosa spreading multifocally and multicentrically without obtaining biopsy specimens, and to perform appropriate risk stratification of gastric cancers.
Familial Mediterranean fever (FMF) is a hereditary auto-inflammatory disease in which patients suffer repeated episodes of peritonitis and fever. Generally, the main symptom of FMF is peritonitis, and gastrointestinal mucosal involvement is considered to be rare in FMF patients. Recent reports demonstrated that FMF patients had intestinal lesions mimicking inflammatory bowel disease. However, the information on the intestinal lesions related to FMF has been limited. This review focuses on the possible mechanism of onset of FMF and intestinal lesions in FMF patients, and discusses their endoscopic features. Several reports indicated that the main characteristics of intestinal lesions in FMF patients were ulcerative colitis-like lesions surrounded by reddish mucosa, ulcers and edema with no involvement of the rectum; however, some FMF patients had longitudinal ulcerative lesions and stenosis mimicking Crohnʼs disease. The prevalence of FMF-related enterocolitis among FMF patients remains unclear. Therefore, further accumulation of cases of intestinal lesions in FMF patients will be required for elucidation of their clinical characteristics.
A 76-year-old woman complaining of epigastric pain and melena was admitted to our hospital. She had been treated with methotrexate (MTX) due to rheumatoid arthritis (RA) since she was 41 years old. Endoscopic examination revealed an ulcerated lesion in the descending portion of the duodenum. Pathological and immunohistochemical examination of biopsy specimens from the duodenal ulcerated lesion showed diffuse large B-cell lymphoma (DLBCL). Computed tomographic scan showed swelling of lymph nodes in her entire body. We diagnosed methotrexate-associated lymphoproliferative disorder (MTX-LPD), and discontinued administration of MTX. After cessation of MTX, the duodenal ulcerated lesion gradually improved but each lymph node showed reduction or enlargement. Cessation of MTX did not lead to remission, and we started rituximab administration nine months later. Her lymph nodes decreased in size, her soluble interleukin-2 receptor (sIL-2R) level decreased, and the duodenal ulcerated lesion underwent cicatrization. A case report of a duodenal lesion in a patient with MTX-LPD is very rare. When a gastrointestinal lesion is detected in RA patients who are taking MTX, the possibility of MTX-LPD should be kept in mind.
A 35-year-old male presented to our hospital due to abdominal pain and diarrhea. Colonoscopy revealed multiple irregular shallow ulcers in the terminal ileum, edematous ileocecal valve, and aphthous lesions in the entire colon. Yersinia enterocolitica was isolated from the culture of a biopsy specimen and a stool, and he was diagnosed with Y. enterocolitica enterocolitis. Since the patient’s symptoms were improving, he was not treated with antibiotics. Three months later, he presented to our hospital again due to mucous and bloody stool. Colonoscopy revealed multiple edematous, reddish and shallow ulcers. He was diagnosed with ulcerative colitis from the results of endoscopic findings and biopsy examination. We report a rare case of ulcerative colitis after Yersinia enterocolitis, showing multiple endoscopic findings over several months.
A 52-year-old woman with a positive fecal occult blood test was referred to our hospital. Colonoscopy revealed a 3-mm, whitish, elevated lesion in the ascending colon by white light imaging, which was highlighted as a smoothly demarcated, elevated lesion with a smooth surface by narrow-band imaging (NBI) with magnification. Biopsy was carried out on the suspected special type of submucosal tumor. Histologically, in contrast to the mucosal layer which was found to be intact, the polypoid lesion was found to be a colorless, whorl-like aggregate in the submucosa, which tested positive on elastic tissue-Masson trichrome stain and was thus identified as accumulated degenerative elastic fibers. The lesion was finally diagnosed as a colonic elastofibromatous polyp.
A submucosal hematoma in the colon is rare. Here we report a case of submucosal hematoma in the colon during anticoagulation therapy.
An 80-year-old man was admitted to a previous hospital due to hematochezia. He had taken a direct oral anticoagulant, Edoxaban, for chronic atrial fibrillation. Because the bleeding continued in spite of stopping the anticoagulant, he was transferred to our hospital on the third day of hospitalization. On emergency colonoscopy, several protruded submucosal hematomas with mucosal exfoliations were observed from the sigmoid colon to the descending colon. It was impossible to insert the endoscope to the proximal side because of obstruction by hematomas. Conservative therapy including discontinuation of Edoxaban was administered. The hematochezia stopped and anemia did not progress. On the second day, the patient had a high fever with septic shock and two sets of blood culture tests both showed positivity for Clostridium perfringens. In addition to intravenous antibiotic therapy, intensive cares were provided. After his general condition recovered, follow-up colonoscopy was conducted on the 9th day. The submucosal hematomas had completely disappeared and changed to a wide longitudinal ulcer. The patient was discharged without any sequela such as stricture.
Anticoagulants may be a risk factor for submucosal hematoma in the colon, and it is necessary to keep in mind the characteristic endoscopic findings.
A homosexual man in his twenties visited a local doctor with complaints of tenesmus and bloody stools. He was referred to our hospital for detailed examination of rectal protruding lesions. Colonoscopy revealed three vertical ulcerative lesions in the anterior wall of the rectum. Two oral-side lesions accompanied the elevated lesions with ulcer. The endoscopic findings were similar to those of amebic colitis. Laboratory evaluation revealed positivity for the Treponema pallidum antibody and human immunodeficiency virus (HIV) and negativity for entamoeba histolytica antibody. Histological examination of rectal mucosa did not reveal amoeba. Immunostaining of rectal biopsy specimens with anti Treponema pallidum antibodies identified spirochetes. We diagnosed the patient with syphilitic proctitis complicated with HIV infection. The patient developed a skin eruption. Oral administration of amoxicillin was initiated. His digestive symptom and skin eruption resolved, and the rapid plasma reagin titers decreased.
Although it has become possible to carry out colorectal endoscopic submucosal dissection (ESD) for large lesions and its safety and efficacy have been clarified, its technical difficulty is still high. This is because in addition to the technical elements required for normal colorectal ESD, it is necessary to devise a strategy unique to large lesions. During ESD for large lesions, the treatment must be assembled while constantly looking at the whole picture. In addition, in order to make effective use of gravity, the endoscopist should not hesitate to change the orientation of the patientʼs body and change the treatment tool to another tool as needed. It is most important to not be overconfident of oneʼs own ability so that the decision to discontinue the endoscopic procedure or shift to surgery is not delayed. We recommend that the endoscopist perform safe colonic ESD for large colorectal lesions after acquiring sufficient technical skill.
The technique of balloon endoscopy such as double balloon endoscopy and single balloon endoscopy makes it possible to examine the small intestine and has been widely used in daily clinical practice. By applying balloon endoscopy and ultra-thin endoscopy (balloon endoscopy and ultra-thin endoscopy method: BUT method), we can observe and treat stenosis. The BUT method is useful not only for endoscopic observation but also for endoscopic treatments such as hemostasis and insertion of an ileus tube. This method is quite simple; however, there are some technical points. In this chapter, the indication and technical knacks of the BUT method will be described.
Stricture formation after esophageal endoscopic resection has a negative impact on patients’ quality of life because it causes dysphagia and requires multiple endoscopic dilations. Various methods by which to prevent stricture have recently been developed and reported. Among these methods, local steroid injection is the most commonly used and is currently considered the standard method for noncircumferential resection. However, local steroid injection has a limited effect on circumferential resection. Thus, oral steroid administration is used for such cases because it may have a stronger effect than local injection. Steroid treatment, both by local injection and oral administration, is effective and low-cost; however, it may cause fragility of the esophageal wall, resulting in adverse events such as perforation during balloon dilatation. Many innovative approaches have been developed, such as tissue-shielding methods with polyglycolic acid, tissue engineering approaches with autologous oral mucosal epithelial cell sheet transplantation, and stent insertion. These methods may be promising, but they are limited by a scarcity of data. Further investigations are needed to confirm the efficacy of these methods.