Bleeding gastroduodenal ulcers are a serious medical issue and, together with their treatment, have a long history. However, the discovery of Helicobacter pylori, the main cause of ulcers, and H₂-receptor antagonists as well as the advances in endoscopy have greatly improved the treatment of ulcer. We have made great progress and gastroduodenal ulcers have gone from being a life-threatening condition to a controllable disease. However, the population in Japan is aging and the background of ulcer development has changed dramatically. Even with the increased focus on the detection and treatment of cancer, gastroduodenal ulcers remain an important disease today because of the aging population. Herein, we review the history of gastroduodenal ulcer treatment over the last quarter of a century.

Confocal laser endomicroscopy (CLE) is used as a magnifying endoscopy for gastrointestinal diseases, and recently its application has expanded into pancreatobiliary diseases, such as indeterminate biliary stricture and pancreatic cystic neoplasms. CLE in pancreatobiliary diseases is performed via insertion of miniature CLE probes through a catheter or needle under ERCP or EUS guidance. Characteristic findings are reported for indeterminate biliary stricture and pancreatic cystic neoplasm diagnosis. A recent study demonstrated the diagnostic yield of CLE for determining the grade of dysplasia in intraductal papillary mucinous neoplasm. The role of peroral cholangioscopy (POCS) and EUS-guided through-the-needle biopsy (EUS-TTNB) is being reported increasingly in this field; thus, the comparison and/or combination with these other modalities should be further evaluated. Despite its cost and the limited approval of CLE by the Japanese insurance system, the role of CLE needs to be established via large-scale clinical trials.

A 34-year-old man underwent endoscopic evaluation, which revealed an elevated lesion (10 mm) with an erosion-like depression at the antrum; however, qualitative diagnosis could not be established. Re-evaluation was performed after administration of an antacid. Magnifying endoscopy with narrow-band imaging confirmed an irregular microvascular and microsurface pattern within a clear tumor demarcation line. A partial light blue crest and an irregular white opaque substance were visualized, and the lesion was diagnosed as differentiated early gastric cancer with an intestinal phenotype. We performed endoscopic submucosal dissection for tumor resection. Endoscopic and histopathological evaluation revealed no atrophy or intestinal metaplasia of the background mucosa. Serum Helicobacter pylori antibody and fecal antigen tests showed negative results. The final histopathological diagnosis was a well-differentiated adenocarcinoma with an intestinal phenotype that originated in H. pylori-uninfected mucosa.

A 66-year-old man underwent laparoscopic total proctocolectomy with ileal pouch surgery, 9 months after he was diagnosed with ulcerative colitis (UC). He observed blood in the stool on postoperative day 2, and endoscopic examination revealed diffuse erosion and ulceration with mucosal bleeding in both the duodenum and ileum. Despite treatment with intravenous steroids, ganciclovir, and cyclosporin in addition to a blood transfusion, the patient died of hypovolemic shock secondary to massive hemorrhage. Pathological evaluation revealed severe duodenitis and jejunoileitis. Histopathological examination showed findings consistent with UC-induced enteritis as opposed to those associated with infection, Crohnʼs disease, or ischemic enteritis. Early evaluation and prompt treatment are warranted in patients with persistent gastrointestinal bleeding after colectomy for UC because these lesions can cause massive bleeding.

A 70-year-old woman was admitted to our hospital with acute abdominal pain and vomiting, 2 days after she ate raw bonito. Contrast-enhanced abdominal computed tomography revealed the nearly pathognomonic target sign of intussusception in the ascending colon, with a thickened wall of the terminal ileum, an elevation in fat density, and fluid collection around the ileocolic region. We diagnosed the patient with ileocolic intussusception secondary to suspected ileal anisakiasis. Using a colonoscope, we performed successful endoscopic reduction of the intussusception and removed an Anisakis larva using endoscopic forceps. Her symptoms rapidly improved after endoscopic repositioning of the intussusception, and invasive surgery could be avoided.

Intussusception secondary to small intestinal anisakiasis is rare. To our knowledge, this is the first case report that describes successful conservative treatment of ileal anisakiasis-induced intussusception, following endoscopic intussusception reduction and removal of the Anisakis larva.

Self-expandable metallic stents (SEMS) are used as a bridge to surgery or palliative treatment in patients with colorectal cancer accompanied by bowel obstruction. Perforation and stent migration are known SEMS-induced complications; reportedly, the rate of stent migration is approximately 3％-10％. A 78-year-old man was referred to our hospital with a complaint of abdominal distention and pain. He was diagnosed with bowel obstruction secondary to sigmoid colon cancer. He refused radical surgery and wished to undergo palliative SEMS placement. The SEMS that was initially placed migrated to the oral aspect of the tumor; therefore, we immediately inserted another SEMS, which was correctly positioned. After expansion of the second SEMS, we attempted endoscopic removal of the initially placed stent that had migrated to the oral aspect of the tumor. Following careful endoscopic balloon dilation of the second SEMS, the endoscope with the sliding overtube was passed through the second SEMS, and using a snare, the migrated SEMS was captured and restored into the sliding overtube and was safely removed.

Endoscopic removal using a sliding overtube is a useful option in cases of SEMS migration.

Given the development of advanced endoscopic treatment techniques and the increased number of people taking antithrombotic drugs, measures for managing several complications involving perforation and postbleeding are required. Endoscopic wound closure is indicated for iatrogenic perforation and prevention of complications after resection. At present, various measures, which include endoscopic closure using hemoclips and the sheet covering method, are used. Endoscopic closure for the artificial wound is ideal because “wound closure” is the basis of the surgical field. However, there are several issues regarding reliable endoscopic closure, including the technical limitation of one arm versus single forceps and cost-effective device. In particular, the thick stomach wall makes wound closure more difficult, and the possible formation of a submucosal pocket after mucosal closure can result in insufficient closure. Herein, we introduce a novel endoscopic closure method using the O-ring and ring thread.

Initially, EUS was a mechanical radial scanning method, but it has now become an electronic scanning method, and technologies used in transabdominal ultrasound, such as color / power Doppler imaging, have been applied to EUS. Evaluation of blood flow information by EUS has become possible. Furthermore, the introduction of the second-generation ultrasonic contrast agent Sonazoid^Ⓡ (Daiichi Sankyo Co., Ltd.), which was released in January 2007, is based on the property of generating second harmonic signals at low acoustic power. It enables long-term observation using the contrast harmonic imaging method and enables evaluation of minute blood flow information. In addition to fundamental B-mode observation, contrast-enhanced imaging with Sonazoid^Ⓡ under EUS can improve diagnostic ability for biliary and pancreatic diseases.

This paper describes the actual method of contrast-enhanced EUS and its findings for major biliary and pancreatic diseases. Since the use of Sonazoid^Ⓡ for biliary and pancreatic diseases is not covered by insurance, it is necessary to obtain sufficient informed consent and implement it with the approval of the Institutional Review Board of the facility. In the future, if Sonazoid^Ⓡ insurance coverage is approved for biliary and pancreatic diseases, contrast-enhanced EUS is expected to further develop as a precise diagnostic method for the biliary and pancreatic region.

Study aims: The PillCam patency capsule (PPC) is an Agile tag-less patency capsule used to evaluate gastrointestinal (GI) patency. We determined the appropriate use of PPC to preclude subsequent small bowel capsule endoscopy (SBCE) retention.

Methods: This prospective multicenter study consecutively enrolled patients indicated for SBCE with suspected or established small bowel stenosis. Excretion of an intact PPC or its radiologic visualization in the large bowel was considered GI patency. Primary and secondary study endpoints were SBCE retention rates in patients with confirmed patency and identification of factors associated with patency and SBCE retention, respectively.

Results: Of 1096 patients enrolled in the study, patency was confirmed in 976 (89.1％). PPC excretion occurred in 579 patients. Of the remaining 517 patients, patency was confirmed using imaging modalities in 401 (77.5％). SBCE retention occurred in five (0.51％) of 963 patients who underwent SBCE: 1.0％ in established Crohnʼs disease (CD) patients, 0％ in suspected CD, 0％ in tumors, and 1.6％ in patients with obscure GI bleeding, for which PPC localization had been radiographically misinterpreted. The non-confirmation of patency was associated with established CD, stenosis identified using imaging modalities, abdominal fullness, serum albumin levels <4.0g/dL, and previous small bowel obstruction (adjusted odds ratios: 4.21, 2.60, 2.47, 2.12, and 2.00; 95％ confidence intervals: 2.62-6.78, 1.62-4.17, 1.43-4.27, 1.32-3.40, and 1.15-3.47, respectively).

Conclusions: The PillCam^TM patency capsule helped preclude SBCE retention in most patients, but its accurate localization was essential for cases without excretion (Study registered the University Hospital Medical Information Network, #UMIN000010513).