Constipation is a condition frequently encountered in general medical practice. In recent years, it has been demonstrated that chronic constipation has an impact on survival prognosis, and attention has been drawn to its diagnosis and treatment. Regarding the relationship between chronic constipation and colorectal cancer, it has been reported that chronic constipation does not necessarily increase the risk of developing colorectal cancer. Melanosis coli is associated with an increase in the adenoma detection rate during colonoscopy. Chronic constipation appears not to be associated with colonic diverticulosis. Colonoscopic examination of patients with chronic constipation is useful for diagnosing the underlying organic disease such as colorectal cancer and constipation-related colorectal disease such as melanosis coli, solitary rectal ulcer syndrome/mucosal prolapse syndrome, and stercoral ulcer. Furthermore, colonoscopy is performed in the endoscopic treatment of chronic constipation such as endoscopic balloon dilatation, colonic stent placement, and percutaneous endoscopic cecostomy.
When diagnosing inflammatory bowel disease (IBD), it is important to distinguish it from other intestinal infections as clinical treatments may differ completely. In addition, when there are signs of IBD relapse, it is important to accurately distinguish among IBD relapse, onset of infectious disease, or a combination of both. Intestinal infections can be an aggravating factor for IBD, and intestinal infections should always be considered when treating IBD. In this paper, we explain the etiology of this condition and show endoscopic findings of major intestinal infections that need to be differentiated from IBD when treating IBD.
A 40-year-old man presented to the emergency room of our hospital with precordial pain after eating chicken for dinner. Computed tomography showed a high-density linear shadow of 40 mm in length in the lower esophagus. Mediastinal emphysema was noted around the mediastinal tip of the foreign body. The patient was diagnosed with bilateral perforation of the lower esophagus by chicken bone, and was referred to our department. After making preparations for on-site surgical backup, endoscopic removal of the foreign body was attempted. Upper endoscopy showed bilateral perforation of the side walls of the lower esophagus. We attempted to remove the foreign body, which was adjacent to the descending aorta, with a grasping forceps from the left side. The foreign body was pulled into the attachment and extracted without aortic injury. Esophageal perforation was managed conservatively and curatively. The patient was discharged 20 days after endoscopic extraction without surgery. Esophageal perforation may cause severe or fatal complications. A foreign body in the esophagus is often removed surgically. Furthermore, in the case of esophageal perforation by a sharp foreign object, severe bleeding may occur during endoscopic extraction. Therefore, it is necessary to devise a technique for endoscopic extraction.
An 88-year-old man was referred to our hospital with a complaint of abdominal pain. Abdominal computed tomography (CT) revealed retroperitoneal free air, and a diagnosis of duodenal perforation was established. On upper gastrointestinal endoscopic examination, a press-through package (PTP) was found in the third portion of the duodenum. The PTP was removed endoscopically, and the perforated portion of the duodenum was 15mm in size. The perforated portion was closed completely with an over-the-scope clip.
There have been few reports on duodenal perforation due to PTP, and no report that was treated conservatively and able to avoid surgery. The OTSC may be useful for treatment of duodenal perforation.
A 68-year-old man presented to our hospital with complaints of bleeding during defecation. Colonoscopy revealed a coarse nodular elevated lesion with white mucus on the rectum above the peritoneal reflection. The lesion was accompanied by dark brown pigmentation. A biopsy specimen of the lesion was obtained, and histopathological examination showed atypical round cells with melanin pigment that had proliferated to become a solid lesion. Immunohistochemical examination showed that the neoplasm was positive for S-100, HMB-45, and Melan A, which indicated that the lesion was a malignant melanoma. There was no pigmentation in the skin. Positron emission tomography showed abnormal uptake in the rectum and gallbladder. He underwent low anterior resection and cholecystectomy. He was diagnosed with primary rectal malignant melanoma with gallbladder metastasis.
A 78-year-old female who had taken prednisolone 5mg/day for neuromyelitis optica had fever and right hypochondriac pain. Laboratory evaluation showed elevated hepatobiliary enzyme level, C-reactive protein level, and proportion of eosinophils. Abdominal enhanced computed tomography showed thickening and enhancement of the bile duct wall. Endoscopic retrograde cholangiography (ERC) showed irregularity of the extrahepatic bile duct wall. Cholangioscopy showed edema and unevenness of the bile duct wall, but there was no malignant finding. Biopsy specimens of the bile duct and liver showed infiltration of eosinophils into the bile duct wall. Considering the above findings, we made the diagnosis of eosinophilic cholangitis and increased her prednisolone dose to 25mg/day. Repeat ERC and bile duct biopsy showed normal bile duct on cholangiogram and disappearance of eosinophilic infiltration into the bile duct wall. Cholangioscopy may contribute to differentiation of eosinophilic cholangitis from primary sclerosing cholangitis or bile duct cancer.
Background & Aims: Endoscopic submucosal dissection (ESD) is associated with technical difficulty. The usefulness of magnetic anchor-guided (MAG) systems using neodymium magnets in difficult cases of ESD has been reported. However, problems of this procedure include the inability to deliver the magnetic anchor through the scope and sticking of the internal magnet on the endoscope. The aim of this study was to evaluate the feasibility of MAG systems using a stainless-steel anchor (SSA) for treatment of gastrointestinal tumors.
Methods: We examined 16 patients with a lesion in the stomach and 17 patients with a lesion in the colon who underwent MAG-ESD using SSA. The anchor consisted of a stainless steel bar attached to a hemoclip with 3-0 silk. After circumferential mucosal incision, the SSA was attached to the proximal mucosal edge of the lesion without retrieving and reinserting the endoscope. The external magnet was a handheld neodymium magnet, and was maneuvered around the abdominal surface to obtain adequate traction. The feasibility of MAG-ESD using SSA, en bloc resection rate, procedure time, rate of retrieval of SSA, and adverse events were evaluated.
Results: Sixteen patients (10 men, 6 women) had gastric lesions. Their median age was 70 years (range, 50-80 years), median tumor size was 22.5 mm (range, 12-55 mm), and median procedure time was 90 min (range, 27-205 min). Adequate counter traction was obtained in all cases. Seventeen patients (10 men, 7 women) had colonic lesions. Their median age was 73 years (range, 52-86 years). Adequate counter traction with good visualization was successfully obtained in 15 cases (88%). The median tumor size was 26.5 mm (range, 20-65 mm), and median procedure time was 90 min (range, 18-259 min). En bloc resection or complete en bloc resection was achieved in all cases, and the SSA was retrieved in all cases without adverse events.
Conclusions: MAG-ESD using SSA is feasible and safe, and may facilitate the treatment of all difficult lesions.
The presence of a pancreatic stone in the main pancreatic duct (MPD) may cause pain due to pancreatic stasis or increased MPD pressure. Pancreatic stone lithotomy is a suitable treatment for pain relief and prevents acute exacerbation of pancreatitis. Indications for endoscopic pancreatic stone lithotomy are the presence of a pancreatic duct stone in the Santorini duct or Wirsung duct with abdominal symptoms. Younger patients in whom pancreatic function is expected to be preserved by removing pancreatic stones are also candidates for endoscopic pancreatic lithotomy. Basket extraction and balloon removal are the first choices of treatment in cases of small stones (≦5mm). For stones with a size greater than 5mm, extracorporeal shock wave lithotripsy (ESWL) was preferentially performed before endoscopic lithotomy. Pancreatic stone often coexists with MPD stricture, which requires MPD dilation procedures and pancreatic stent placements. The endoscopic pancreatic stone lithotomy procedure requires proficient knowledge and trouble-shooting techniques to avoid serious complications such as basket impaction, hemorrhage, and perforation. It is also necessary to know the appropriate timing of the endoscopic treatment, and not to miss the timing so that surgical treatment can be avoided.
There are two important modalities in the endoscopic diagnosis of autoimmune pancreatitis (AIP). One is endoscopic retrograde cholangiopancreatography (ERCP), which is useful in confirmation of the presence of characteristic irregular narrowing of the main pancreatic duct (MPD), and the other is endoscopic ultrasound fine needle aspiration and biopsy (EUS-FNAB), which enables histological diagnosis. Irregular narrowing of the MPD may be diffuse or localized, and it is sometimes recognized as multiple skip lesions. The presence of irregular narrowing of the MPD sometimes cannot be confirmed by ERCP when the pancreatic lesion is localized in the tail, and the MPD seems to be disrupted in such cases. The ability of EUS-FNAB in diagnosing AIP is still not sufficient, but it has shown dramatic improvement in the past several years due to the improvements in biopsy needles.
Background and aim: A state of emergency was declared throughout Japan from 16 April to 14 May, 2020 due to the coronavirus disease 2019 (COVID-19) outbreak. All gastrointestinal endoscopic procedures are considered to be a high risk factor for COVID-19 infection, and infection prevention and control have been required in endoscopy units. The aim of this study was to clarify the actual condition of endoscopy units during the state of emergency.
Methods: We distributed a questionnaire survey to endoscopists in Japan.
Results: 534 endoscopists provided valid answers. Almost all doctors knew the recommendations by the Japan Gastroenterological Endoscopy Society, and thought that 90% or more of the recommendations were appropriate. The numbers of endoscopic procedures performed before and during the state of emergency were the same in approximately 10% of the facilities, while a reduced number of endoscopic procedures was performed during the state of emergency at 77.5% of the facilities. Endoscopic procedures were completely stopped during the state of emergency at 10.3% of the facilities. The stock of personal protective equipment was not sufficient, and the same personal protective equipment was often used continuously.
Conclusions: Endoscopy units during the state of emergency were significantly affected by COVID-19. It is necessary to continue infection prevention and control.
Background and aims: Needle tract seeding after preoperative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic body and tail cancer has been reported. This study aimed to investigate the long-term outcomes, including the needle tract seeding ratio, of patients undergoing distal pancreatectomy for pancreatic body and tail cancer diagnosed preoperatively by EUS-FNA.
Methods: This retrospective, observational cohort study assessed patients from three university hospitals and 11 tertiary referral centers. All patients who underwent distal pancreatectomy for invasive cancer of the pancreatic body and tail between January 2006 and December 2015 were identified and reviewed. Needle tract seeding rate, recurrence-free survival (RFS), and overall survival (OS) were evaluated.
Results: Of the 301 total patients analyzed, 176 underwent preoperative EUS-FNA (EUS-FNA group) and 125 did not (non- EUS-FNA group). The median follow-up periods of the EUS-FNA group and non-EUS-FNA group were 32.8 and 30.1 months. Six patients (3.4%) in the EUS-FNA group were diagnosed as having needle tract seeding. The 5-year cumulative needle tract seeding rate estimated using Fine and Gray’s method was 3.8% (95% CI 1.6-7.8%). The median RFS or OS was not significantly different between the EUS-FNA group and the non-EUS-FNA group (23.7 vs 16.9 months: P=0.205; 48.0 vs 43.9 months: P=0.392).
Conclusion: Although preoperative EUS-FNA for pancreatic body and tail cancer has no negative effect on RFS or OS, needle tract seeding after EUS-FNA was observed to have a non-negligible rate. (UMIN000030719)