Eosinophilic esophagitis (EoE) is mainly a non-IgE-mediated (Th2-cell-mediated) immunological chronic condition that is characterized by clinical symptoms related to esophageal dysfunction and histologically intense eosinophilic inflammation in the esophagus, leading to long-term esophageal narrowing or strictures. EoE has increasingly been implicated as a major cause of dysphagia and food impaction in middle-aged men in Western countries during the previous two decades. This disease is independently distinct from eosinophilic gastroenteritis that can affect the entire gastrointestinal tract including the esophagus. Recognizing characteristic endoscopic findings, such as linear furrows, rings, and white exudates, enables definitive histological diagnosis of this clinicopathological disease. The treatment of EoE involves diet therapy or pharmacological therapy; however, relapse is common if treatment is discontinued. A proton-pump inhibitor (PPI) is now used as a first-line pharmacological agent, and topical steroid is strongly recommended for non-PPI-responsive esophageal eosinophilia owing to fewer adverse effects. Successful diet therapy is challenging in the general clinical setting because it warrants very strict management by many specialists. Clinicians need to understand this emerging esophageal inflammatory disease that induces chronic dysphagia and food impaction.

Adenocarcinoma of the esophagogastric junction (EGJ) includes both esophageal cancer and gastric cancer whose center is located in the EGJ. The incidence of EGJ adenocarcinoma has increased sharply in the past 30 years in the United States and European countries, and has shown a gradual increase in Japan. Because the infectious rate of Helicobacter pylori in Japan has decreased and our eating habit has become westernized, the incidence of gastroesophageal reflux disease has increased in Japan. Thus, it is estimated that the incidence of EGJ adenocarcinoma in Japan will also increase in the near future.

When we differentiate T1 EGJ adenocarcinoma into two types according to the presence of endoscopic mucosal atrophy, lesions were located above and in the upper-right of the EGJ in cases without mucosal atrophy, whereas lesions were located below the EGJ in cases with mucosal atrophy. For the cases that were treated with endoscopic submucosal dissection, although en-bloc resection rates were 100% in both Barrettʼs esophageal cancer and gastric fundic cancer, the curative resection rate in Barrettʼs esophageal cancer cases was significantly lower than that in gastric fundic cancer cases, indicating the difficulty in diagnosing the depth of invasion of Barrettʼs esophageal cancer.

To detect Barrettʼs esophageal cancer, it is recommended that endoscopists ask patients to take a deep breath to extend the wall of the EGJ and observe the upper and right wall, where EGJ adenocarcinoma is frequently detected. Acetic acid which emphasizes the microstructure and magnifying endoscopy with narrow band imaging (NBI) were reported to increase the accuracy of diagnosing dysplasia.

Acute hemorrhagic rectal ulcer (AHRU) is a critical disease, and AHRU needs to be managed as soon as possible. Here we investigate the clinical features of AHRU and the efficacy of endoscopic hemostasis with hemostatic forceps for the treatment of AHRU.

Forty-five patients with AHRU were enrolled, and their clinical features were investigated. Twenty-eight patients with AHRU were managed by endoscopic hemostasis with hemostatic forceps, and we report its efficacy and safety. AHRU was often seen in elderly patients with comorbidities such as cerebrovascular disease. The hemostatic success rate was 100%(28/28), and the recurrent bleeding rate was 14.3%(4/28). No patient died from AHRU. In conclusion, hemostatic forceps is an effective and safe instrument for the hemostasis of AHRU.

A 50-year-old man underwent esophagogastroduodenoscopy for the purpose of screening. A 20 mm, large, type 0-Ⅱc early esophageal cancer was found in the upper thoracic esophagus, and endoscopic submucosal dissection (ESD) was performed. On histopathological examination, the tumor was squamous cell carcinoma invading the pT1a - LPM (lamina propria mucosae), and vascular and vertical invasion were negative, but the horizontal margin was difficult to judge. However, 3 years and 8 months after ESD, he presented with cervical lymphadenopathy as a chief complaint. He was re-examined and was diagnosed with esophageal cancer. Recurrence of multiple metastasis after endoscopic resection of LPM esophageal cancer is relatively rare.

A 44-year-old man on oral steroid therapy for eosinophilic gastrointestinal disorder (EGID) was admitted to our hospital with persistence of severe abdominal pain, watery diarrhea, lumbago, and noncardiac chest pain after taking nonsteroidal anti-inflammatory drugs (NSAIDs). He had suffered from almost the same symptoms while taking NSAIDs twice within the previous 18 months before admission. Over the previous 10 months before admission, he had been treated with oral prednisolone for EGID at a nearby clinic because of the presence of eosinophilia. At admission, his serum levels of amylase and lipase were found to be elevated. Computed tomography and ultrasonography showed a thickened small intestinal wall. Esophagogastroduodenoscopy revealed severe edematous change with whitish turbidity in the entire esophagus. Biopsy examination showed infiltration of numerous eosinophils in the esophageal epithelium. He received 30mg of prednisolone intravenously, and his symptoms dramatically disappeared. Although he seemed to be in the active phase of his EGID at first glance, his clinical episodes had been consistent with aspirin intolerance. In conclusion, we describe a rare case of aspirin intolerance presenting with eosinophilic esophagitis, gastroenteritis and pancreatitis.

In endoscopic submucosal dissection (ESD), it is important to obtain a good field of view of the detached surface for safe dissection. In our department we have devised a Nylon-loop Traction method (NT method) as an inexpensive method that can be used irrespective of the characteristics of the equipment. In the NT method, after performing a peri-mucosal incision, the endoscopist hooks a nylon thread that had been tied in an annular shape of about 2 cm in diameter, around an endoscopic clip on the mucosal wall opposite of the lesion. The annular nylon thread is then hooked around a second clip that is attached to the mucosa of the lesion. Even this alone has a traction effect, and some mucosal dissection becomes easy to perform, but the essence of this method is different. If the mobility of the lesion increases due to detachment, tension is loosened only with the initial traction, and often there is no longer effective countertraction. However, because the nylon thread is in a loop shape, the endoscopist can attach more clips to the mucosal surface and hook the thread around the clips, thereby maintaining and adjusting the traction force. There is no other way to maintain the traction force on the whole than by using a string in an annular shape and using a clip like a pulley.

An 86-year-old man with gastrostomy who has difficulty with oral intake due to cerebral infarction, was admitted to our hospital for acute cholangitis caused by common bile duct stones. We considered and discussed carefully with his family about the potential complications of various procedures. On the 13th hospital day, we performed transgastrostomal endoscopic retrograde cholangiopancreatography (TG-ERCP) using an Olympus GIF-XQ240 gastroscope after dilatation of the gastrostomy opening. It was difficult to find the major papilla. Using a papillotome, we succeeded in performing selective cholangiography, performing endoscopic sphincterotomy and removing the bile stones using a balloon catheter. He recovered and was discharged with no complications. Therefore, this method was considered to be useful.

In Barrettʼs esophageal adenocarcinoma (EAC), particularly those arising from long-segment Barrettʼs esophagus (LSBE), there are many cases of Ⅱb spreading and it is difficult to diagnose lateral extension. Therefore, in cases of EAC derived from LSBE with an unclear margin, it is necessary to confirm the lateral extension by taking biopsy samples from areas outside of the lesion. In EAC that abuts the squamocolumnar junction (SCJ), EAC often extends under the squamous epithelium. Endoscopic findings of sub-epithelial invasion include changes in color of the mucosa, and the appearance of abnormal blood vessels and small holes. However, some cases do not develop these features. The mean distance of sub-epithelial invasion of short-segment Barrettʼs esophagus (SSBE) and LSBE is 4 (1-12, range) and 5 (1-20) mm, respectively. Therefore, an enough safety margin should be kept for LSBE.

Endoscopic submucosal dissection (ESD) of EAC is more difficult than that of squamous cell carcinoma (SCC) because of submucosal fibrosis caused by reflux esophagitis or ulcer scar in EAC.

In Western countries, radiofrequency ablation (RFA) for residual Barrettʼs mucosa is recommended after endoscopic treatment of a visible lesion because the rate of metachronous cancer of EAC is high (10.3～21.5%). However, RFA ablates only the surface layer and Barrettʼs epithelium sometimes remains in the deep mucosa after RFA. It is necessary to be aware that RFA cannot always eradicate Barrettʼs epithelium. Japanese guidelines recommend careful follow-up observation. However, in order to prevent metachronous EAC, we have been performing circumferential ESD or stepwise radical ESD for the treatment of EAC.

Colorectal endoscopic submucosal dissection (ESD) with a scissor-type knife does not require complex endoscopic movements and techniques, and thus, it can be performed relatively safely and easily. Since the usage of scissor-type knives is fundamentally different from conventional ESD knives, it is important to become familiar with the features of both types of knives. With a scissor-type knife, circumferential mucosal incision is performed “like cutting paper” without applying too much tension to the tissue being resected, and submucosal dissection with imaging proceeds while “connecting optimal depths of resection point by point”. In this article, we focus on the procedure of colorectal ESD with a scissor-type knife and describe fundamentals and tips for using the scissor-type knife in detail to reduce the operative time. Since the scissor-type knife is highly useful as a secondary device in difficult situations, we highly recommend mastering the use of the scissor-type knife.

Background and Aim: Endoscopic sphincterotomy (ES) is a standard procedure for the treatment of common bile duct stones (CBDS). Endoscopic papillary large balloon dilation (EPLBD) is emerging as an effective method to treat difficult CBDS, providing several advantages over ES without increasing early adverse events (AE). However, the late AE of EPLBD have not yet been well studied. The aim of the present study was to compare late AE after EPLBD versus ES for the treatment of CBDS using a propensity score-based cohort analysis.

Methods: Propensity score matching was introduced to reduce the possible bias in baseline characteristics between two treatment groups and formed the matched cohort including 240 patients. Primary endpoint was cumulative as well as estimated 1-year and 3-year late AE rates. Secondary outcome was the incidence of early AE.

Results: Cumulative late AE rates were 12.5% and 16.7% in the ELPBD and ES groups (P=0.936) with a median follow-up period of 915.5 and 1,544.5 days, respectively. Estimated 1-year and 3-year late AE rates were 8.4% and 13.1% in the EPLBD group and 5.0% and 15.0% in the ES group, respectively. In multivariate analysis, ≥two procedures were identified as independent risk factors for late AE. Overall early AE rate did not differ between the groups.

Conclusion: In the present study, late AE rate after EPLBD showed no significant difference compared with that after ES, which had a relatively long follow-up period. Therefore, EPLBD could be used for the treatment of CBDS, if CBDS are considered difficult to treat. Clinical Trial Registry: UMIN000027798.