Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is associated with a high risk of bleeding. Patients who are taking an antithrombotic agent tend to carry a higher hemorrhagic risk, but inappropriate cessation of antithrombotic agents would lead to serious thrombotic events. Therefore, appropriate management of antithrombotic agents is necessary. In this review, we summarize clinical tips for EUS-FNA in patients who are taking antithrombotic agents (antiplatelet and/or anticoagulant therapy).

Patients with hereditary gastric cancer syndromes account for 1-3% of patients with gastric cancer. Among hereditary gastric cancer syndromes, there are various genotype-phenotype features such as hereditary diffuse gastric cancer (HDGC), familial intestinal gastric cancer, gastric cancers associated with gastrointestinal polyposis syndromes, gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS), gastric cancer in gastrointestinal polyposis syndromes and others. Although endoscopy may be a useful tool to understand gastrointestinal phenotypes, the sensitivity of surveillance endoscopy is uncertain and thought to be poor for the detection of early disease in Western countries. However, some groups in Japan recently reported patients with HDGC in which the presence of HDGC had been suspected by endoscopic findings of multiple tiny pale areas. This may lead to standardization of endoscopic screening/surveillance system in the future. We herein review hereditary cancer syndromes associated with gastric cancer and will introduce several topics that were discussed at the 2019 IGCLC Hereditary Diffuse Gastric Cancer Consensus Clinical Guidelines Meeting held in New Zealand.

Objective: Our objective was to evaluate the effectiveness of polyethylene glycol containing ascorbic acid (Asc-PEG) and glycerin enema (GE) as preparation for colon capsule endoscopy (CCE). Methods: We conducted a prospective multi-center study of patients who were scheduled to undergo CCE using Asc-PEG and GE as preparation. We evaluated visualization of the colon, excretion rate and associated factors, colonic polyp detection rate, and adverse events. Results: Eighty-two patients were analyzed. Adequate visualization of the entire colon was achieved in 82% (67/82). Capsules were excreted in 83% (68/82), and the mean small bowel transit time was significantly shorter in the group with successful excretion than in the group with unsuccessful excretion (p=0.025). GE was used in 27 cases (33%) and induced anus excretion in 78% (21/27) of cases. The colonic polyp detection rate was 49% (40/82). No adverse events were observed. Conclusion: Our regimen using Asc-PEG and GE seems to be a useful and safe preparation method for CCE.

A 49-year-old man who was being treated with methotrexate (MTX) for rheumatoid arthritis, was referred to our hospital because his annual screening esophagogastroduodenoscopy showed a small submucosal tumor (SMT)-like lesion in the greater curvature of the lower gastric body. The lesion had grown larger 4 weeks later, and an ulcer had appeared on the lesion by 7 weeks. Based on histology, immunostaining, flow cytometry and his clinical course, we diagnosed MTX-associated diffuse large B-cell lymphoma (DLBCL). As discontinuing use of MTX did not shrink the lesion, we introduced the CHOP regimen. Complete remission (CR) was achieved after 4 courses of CHOP; this CR has continued for 3 years to date. To our knowledge, this is the first report to show endoscopic findings of gastric DLBCL from the initial to moderately advanced stages. This experience suggests that gastric SMT-like lesions in the subepithelial mucosal layer might be early-stage DLBCL. Therefore, such lesions should be carefully diagnosed and followed up, especially in patients treated with MTX.

Mixed adenoneuroendocrine carcinoma (MANEC) is a complex form of neuroendocrine carcinoma (NEC) and adenocarcinoma, and early-stage MANEC is rarely found by endoscopy. An 80-year-old man with a past history of gastric ulcer on the posterior wall of the gastric corpus underwent follow-up esophagogastroduodenoscopy (EGD). EGD revealed a depressed region in the greater curvature of the gastric angle. Biopsy led to the diagnosis of moderately-differentiated tubular adenocarcinoma. We established the diagnosis of intra-mucosal gastric cancer and performed endoscopic submucosal dissection (ESD). During ESD, a discolored region contiguous with the depressed region was noted. Narrow-band imaging with magnification indicated that a surface pattern was absent and an irregular microvascular pattern with high density was present in the depressed region. The discolored region had an irregular and papillary surface pattern with sparse microvasculature. Histopathological examination of the ESD-resected specimen revealed large-cell NEC in the depressed region and well-differentiated adenocarcinoma in the discolored region. The patient was diagnosed with MANEC. In this case, we correlated the endoscopic and pathological findings and diagnosed NEC given the absence of a surface pattern within the depression and the presence of a well-differentiated tubular adenocarcinoma in the continuous papillary structure. Thus, our case illustrates the diagnostic procedure of MANEC on endoscopic observation.

A 69-year-old male was diagnosed as having gastric disease at a nearby hospital and presented to our hospital for further evaluation of this disease. Esophagogastroduodenoscopy (EGD) showed multiple submucosal tumor-like polypoid lesions on the greater curvature of the gastric body. The biopsy specimens from the lesions revealed noncaseating granulomas in lamina propria mucosae. Interestingly, cells that were positive on immunostaining with the antibody against Propionibacterium acnes (PAB antibody), a possible pathogen of sarcoidosis, were detected in the granulomas. The patient was diagnosed with gastric sarcoidosis. EGD performed seven months later revealed a reddish depressed lesion of 13 mm in diameter with elevated margins near a granuloma on the greater curvature of the lower gastric body. We diagnosed Type 0-Ⅱc early gastric cancer and performed endoscopic submucosal dissection. The pathological examination revealed a p Type 0-Ⅱc, 15×8 mm, tub1＞tub2, pT1b (350μm), ly0, v0, UL＋, p HMX, p VMX. There are few reports of the coexistence of gastric sarcoidosis and gastric cancer, and this case showed interesting histological findings such as PAB antibody-stained cells in the granulomas. We report this case with reference to the literature.

A 78-year-old man was admitted to our hospital complaining of abdominal pain. He had purpura, and endoscopy revealed mucosal edema and erosions in the duodenum, suggesting IgA vasculitis (IAV). Deep duodenal biopsy specimens containing submucosal vessels enabled us to make a pathological diagnosis of IAV with necrotizing vasculitis. On the sixth hospital day, he developed abdominal bloating and lack of bowel sounds. Computed tomography (CT) showed dilatation of the small intestine. We diagnosed functional ileus since there was no evidence of organic lesions causing intestinal obstruction on CT, including perforation or intussusception. An ileus tube was inserted for decompression of the small intestine.

In addition, intravenous prednisolone (50 mg/day) was administered. On the third day of this treatment, his abdominal symptoms were improved with resolution of ileus, allowing us to remove the ileus tube on the following day. In conclusion, endoscopic findings are helpful for suggesting the possibility of IAV, while deep mucosal biopsy is key for pathological diagnosis.

Although many studies have attempted to correlate pathological images to endoscopic images, few cases have been examined by a systematic process for correspondence between endoscopic findings and histology. We previously reported a systematic process of achieving detailed adjustments of endoscopic findings to fit histopathological findings of the stomach, named the Kyoto One-To-One Correspondence Method (KOTO Method). Here we describe details of the correspondence method.

The method is composed of three steps: 1) photographing the whole ESD-resected specimen and magnified images of the resected specimen with a color digital camera and a stereomicroscope with a digital camera system for microscopy, respectively; 2) adjusting the histologic images to the whole and magnified surface images; and 3) adjusting the endoscopic image and histologic images.

One-to-one correspondence between endoscopic images and histologic images will improve endoscopic diagnosis.

Large lesions can be resected by endoscopic submucosal dissection (ESD) and diagnosed by pathological examination. However, when the resected specimens are handled improperly, it is impossible to make a correct diagnosis even if the specimen was obtained by en bloc resection. Endoscopists need to know how to handle the endoscopically resected specimens appropriately. The task of the endoscopist is not only ESD but also verification between endoscopic findings and pathological findings. This verification is needed to improve endoscopic diagnosis.

Background and Aim: Extensive use of laxatives and incomplete excretion rates are problematic for colon capsule endoscopy (CCE). The aim of the present study was to determine the effectiveness of castor oil as a booster.

Methods: At four Japanese hospitals, 319 examinees undergoing CCE were enrolled retrospectively. Before and after the introduction of castor oil, other preparation reagents were unchanged.

Results: Of 319 examinees who underwent CCE, 152 and 167 examinees took regimens with castor oil (between November 2013 and June 2016) and without castor oil (between October 2015 and September 2017), respectively. Capsule excretion rates within its battery life in the groups with and without castor oil were 97% and 81%, respectively (P＜0.0001). Multivariate analysis showed that ages younger than 65 years (adjusted odds ratio [OR], 3.00; P=0.0048), male gender (adjusted OR, 3.20; P=0.0051), and use of castor oil (adjusted OR, 6.29; P=0.0003) were predictors of capsule excretion within its battery life. Small bowel transit time was shorter and total volume of lavage and fluid intake was lower with castor oil than without (P = 0.0154 and 0.0013, respectively). Overall adequate cleansing level ratios with and without castor oil were 74% and 83%, respectively (P = 0.0713). Per-examinee sensitivity for polyps ≥6 mm with and without castor oil was 83% and 85%, respectively, with specificities of 80% and 78%, respectively.

Conclusion: Bowel preparation with castor oil was effective for improving capsule excretion rate and reducing liquid loading.