Chronic nonspecific multiple ulcers of the small intestine is a rare disease characterized by multiple small intestinal ulcers of nonspecific histology. Recent research revealed that the disease is caused by recessive mutations of the SLCO2A1 gene encoding a prostaglandin transporter, and a new nomenclature “chronic enteropathy associated with SLCO2A1 gene (CEAS)” was proposed. CEAS occurs predominantly in females and most patients have iron deficiency anemia without gross hematochezia. This condition shows a relatively low inflammation status. The disease causes the development of multiple intestinal lesions predominantly in the ileum except the terminal ileum, and those lesions are characterized by shallow circular or oblique ulcers with asymmetrical deformity. Genetic analysis of the SLCO2A1 gene should be considered only when CEAS is suspected based on the clinical course and endoscopic and radiographic findings of the intestinal lesions. The presence of upper gastrointestinal lesions and extraintestinal manifestations such as digital clubbing, pachydermia, and periostosis can be helpful for differential diagnosis.

A female in her 60s underwent screening colonoscopic examination. Colonoscopy showed an elevated reddish lesion and a small reddish area at the anal canal. Magnifying endoscopy with narrow band imaging (ME-NBI) of the elevated lesion and the small reddish area revealed microvessels similar to the irregular intra-epithelial papillary capillary loops (IPCL) that are observed in superficial esophageal squamous cell carcinoma. These vessels are generally equivalent to type B1 vessel in the Magnifying Endoscopy Classification of the Japan Esophageal Society. We diagnosed the lesions as multiple intramucosal cancer, and endoscopic submucosal dissection (ESD) was performed for en bloc resection. The pathological diagnosis of both lesions was squamous cell carcinoma, pTis, INFa, Ly0, V0, HM0, VM0, ER0.

In this case, we demonstrated that ME-NBI was useful for diagnosis of multiple intramucosal squamous cell carcinoma at the anal canal. In addition, en bloc resection of the lesions by ESD was useful for pathological evaluation.

A 62-year-old female patient with a 5-year history of ulcerative colitis that affected the entire colon had been treated with 5-ASA and oral steroids in a hospital. She was treated with herbal medicine including indigo naturalis by her primary care doctor due to deterioration of the disease condition. She developed vomiting, diarrhea with bloody stool, and abdominal pain more than 3 weeks after starting indigo naturalis. She developed an intestinal obstruction of the small intestine, and was transferred to our hospital. Double-balloon endoscopy showed stenosis 50cm distal from the Treitz ligament. The length of the stenosis was 10cm with a shallow and sharply demarcated ulcer arranged in a circular manner. Partial resection of the small intestine was performed. In the surgical specimen, there were ulcers with a wide range of depths with stricture of the small intestine. The diagnosis of ischemic enteritis was confirmed. After surgery, she has been healthy without recurrence.

Indigo naturalis has been shown to be a promising therapeutic agent for ulcerative colitis, but various side effects including liver dysfunction, pulmonary arterial hypertension, and intussusception, have been reported. This is the first report of ischemic enteritis induced by indigo naturalis. Further studies are needed to elucidate the mechanism by which indigo naturalis causes small intestinal ischemia.

Gastrointestinal perforation /penetration by an accidentally ingested fish bone has often been reported in Japan. Surgical intervention, such as traditional open surgical procedures including removal of the fish bone and colectomy, is widely accepted to prevent peritonitis, even though the inflammatory impact of the perforation /penetration is localized in the abdominal cavity. A 49-year-old man, presenting with complaints of acute abdominal pain, was referred to the surgical department. On admission, his vital signs were stable and his physical examination was unremarkable except for epigastric tenderness to palpation with a slight peritoneal sign. Abdominal computed tomography (CT) examination revealed a linear, high-density signal measuring 3 cm, protruding from the lumen through the wall of the transverse colon with a very small amount of free air, suggesting a fish bone penetrating the transverse colon. Based on the findings of these examinations, the patient was diagnosed as having transverse colon perforation caused by a fish bone. After conservative treatment with fasting and antibiotic administration for several days, the fish bone penetrating the colon was retrieved by an endoscope using grasping forceps. His subsequent course was favorable, and he was discharged without any problems on the third day after endoscopy. This clinical case allows us to discuss the alternative endoscopic treatment method, instead of an emergency surgical approach, for colonic perforation/penetration caused by a fish bone. We here report a case of transverse colon perforation by a fish bone that was removed endoscopically, along with a brief review of the literature.

We experienced a case of colonoscopic release of adult intussusception that was due to cecal cancer which was subsequently treated using elective laparoscopic surgery. An 81-year-old woman being treated for upper abdominal pain at our hospital was found to have a target sign in the ascending colon on computed tomography (CT). Enhanced CT showed multiple concentric ring signs and local colon-wall thickening, which were diagnosed as tumor-induced intussusception. Colonoscopy showed an elevated lesion in the cecum, and histological findings of a biopsy specimen from the lesion showed mucinous adenocarcinoma. Intussusception was easily reduced using air injection. Three days after intussusception repositioning, laparoscopic ileocecal resection with lymph node dissection was conducted using five trocars. Examination of the resected specimen revealed a type 1 tumor in the cecum measuring 22×27mm. Pathologically, the tumor was a mucinous adenocarcinoma type1 pMP in depth, ly1, v1, and pN0. The patient had an uncomplicated postoperative course and was discharged 11 days after surgery. Adult intussusception is rare. Most cases of adult intussusception caused by a tumorous lesion tend to be treated by emergency surgery without a definitive diagnosis. Preoperative reduction, if possible, may be important for preoperative diagnosis and appropriate surgical treatment. We reviewed 16 such cases in the Japanese literature, including our own, that were treated using laparoscopic surgery.

Balloon-assisted enteroscopy (BAE) has recently become an invaluable diagnostic and therapeutic modality for small intestinal diseases. The method of insertion of the endoscope in BAE differs from that in regular large intestinal endoscopy although many similarities exist.

Insertion of the endoscope in BAE is sometimes difficult if the patient has a history of multiple abdominal operations, a history of radiation therapy or visceral obesity, and requires some ingenuity such as appropriate scope selection, postural change, and abdominal manipulation. Caution must be taken as the complication of pancreatitis can occur with BAE.

BAE involves special insertion using an overtube, which makes it more complicated than regular upper/lower gastrointestinal endoscopy. Because of this, there are variations in intestinal tract shortening methods with a relative scope-overtube combination.

In BAE, perceiving the scope status during the examination, considering the underlying reason if the scope fails to progress, and correcting insertion methods are the most practical tips for insertion of the scope.

Objective: To evaluate the usefulness of a training program on endoscopic head and neck surveillance for beginner endoscopists.

Methods: This prospective multicenter study included 13 beginner endoscopists from 10 institutions who received training in systematic observation techniques and diagnostic criteria, and the training involved hands-on learning. Between May 2016 and February 2017, enrolled patients with current or previously diagnosed esophageal squamous cell carcinomas underwent head and neck surveillance using narrow band imaging (NBI) endoscopy, and histologically confirmed head and neck squamous cell carcinoma (HNSCC) detection rates, endoscopic image quality, and examination times were compared before (group A) and after (group B) the training program. Maximum possible score for the endoscopic images was 30 points.

Results: A total of 330 patients, comprising 181 in group A and 149 in group B, were enrolled. Three patients with HNSCC were detected in group A (1.7%) and in group B (2.0%; P=1.000). Mean±standard deviation (SD) examination times were 157±71 s and 174±109 s in groups A and B, respectively, (P=0.073). Mean±SD scores of the endoscopic images were 25.04±5.47 points and 27.01±4.35 points in groups A and B, respectively, (P＜0.001).

Conclusion: The HNSCC detection rate based on the use of NBI on patients with ESCC did not improve after the training program for beginner endoscopists; however, endoscopic image quality improved significantly after the training program.