Helicobacter pylori infection and the use of drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin (LDA), are the major risk factors for the development of peptic ulcers. However, in Japan, the prevalence of peptic ulcer is rapidly decreasing due to a reduction in the H. pylori infection rate to 30-40％ and increased use of potent acid secretion inhibitors, such as proton pump inhibitors and potassium-competitive acid blockers. In addition to peptic ulcer, prevalent use of NSAIDs and LDA increases the aging of society and the rate of drug-induced gastric mucosal injury/ulcer in clinical practice. Accumulating data led to the updation of the evidence-based clinical practice guidelines for peptic ulcer disease in 2020, which incorporated recommendations for using new acid secretion inhibitors, selecting H. pylori eradication regimens, and treating NSAIDs/aspirin users and patients with idiopathic ulcers. Here, we discuss the usefulness of the updated guidelines for peptic ulcer management and the role of gastrointestinal endoscopy in the treatment of peptic ulcers caused by H. pylori infection and NSAID use.
Endobiliary radiofrequency ablation (RFA), a novel adjunctive procedure, is a promising therapeutic option for malignant biliary obstruction. RFA can achieve local tumor control, with consequent improvement in biliary stent patency and a potential survival benefit in patients with malignant biliary obstruction. However, the efficacy of endobiliary RFA remains controversial. Previous studies have reported conflicting results, which could be attributed to an important limitation of the conventional RFA catheter. In addition to further well-designed randomized controlled trials, development of innovative devices is warranted to investigate and conclusively establish the usefulness of endobiliary RFA. In this review, we summarize the latest evidence with regard to endobiliary RFA for malignant biliary obstruction and discuss the issues that should be addressed in future studies.
The patient was a 32-year-old woman who presented diarrhea, bloody stool, and 38-degree fever during treatment for SAPHO syndrome using salazosulfapyridine enteric coated tablets (1,000mg). We performed colonoscopy. Although the case was atypical, we suspected ulcerative colitis due to the presence of continuous lesions from the descending colon to the cecum, and changed to time-dependent release mesalazine (2,000mg) and mesalazine enema (1g). She then presented shivering, a 39-degree fever, headache, and arthralgia. The drug was discontinued in consideration of the side effects of mesalazine. The patient’s fever improved 24 hours later. The drug was subsequently discontinued because the patient’s side effects recurred with re-administration, and the patient was diagnosed with 5-ASA intolerance. Since mucosal healing was confirmed by colonoscopy approximately 1 month later, we diagnosed the patient with drug-induced enteritis due to salazosulfapyridine and considered that the causative component was 5-ASA.
A 74-year-old woman who underwent colonoscopy was diagnosed with four laterally spreading tumors (LSTs) in the cecum and ascending and sigmoid colon, as well as type 1 and 2 cancers in the transverse colon. We performed endoscopic submucosal dissection (ESD) for all four LSTs and subsequent laparoscopic transverse colectomy for the transverse colon cancers. Colonoscopy performed one year later revealed newly developed type 2 cancer in the cecum and sigmoid colon at the site of the previous ESD. The patient denied a family history of colorectal cancer; therefore, recurrent colorectal cancer was attributed to tumor implantation and not hereditary colorectal cancer such as Lynch syndrome. We speculate that tumor implantation at the post-ESD ulcer site from any of the primary transverse colon cancers or LSTs could have led to cancer recurrence. To our knowledge, only a few cases of recurrent colon cancer secondary to post-ESD tumor implantation have been reported in the literature. Endoscopists who perform ESD for gastrointestinal cancers should consider the possibility of tumor cell implantation in patients with the aforementioned or similar clinical presentation.
A 42-year-old man presented to a clinic with a chief complaint of anal pain. Rectal examination and transanal echography revealed the presence of a tumorous lesion. At our hospital, while CT and MRI showed a 65×55mm tumor that had evacuated the lower rectum, colonoscopy revealed that a part of the tumor was exposed at the mucosal surface of the rectum. Even though we performed a forceps biopsy, most of specimen was necrotic and insufficient for pathological diagnosis.
Therefore, colonoscopy was performed followed by EUS-FNA, and the samples obtained for EUS-FNA were adequate for pathological analysis as they contained lesser necrotic tissue. H&E staining revealed a high N/C ratio and proliferation of atypical cells with unclear nucleoli. However, morphological images did not show differentiation to a cancer cell. Immunostaining was positive for NSE and CD99 and partially positive for c-kit, CD4, CD56, and chromogranin. Genetic analysis revealed the presence of the fusion gene EWS/FLI-1, confirming the diagnosis of Ewingʼs sarcoma.
The frequency of extra skeletal pelvic Ewingʼs sarcoma, as seen in our patient, is rather low. Cytogenetic analysis and immunostaining are strongly recommended for the diagnosis of Ewingʼs sarcoma. In such cases, tissue biopsies are mainly performed with CT-guided, open laparotomy and laparoscopic methods. This report is the first to describe the diagnosis of Ewingʼs sarcoma using EUS-FNA. In cases of hypervascular tumors requiring immunohistological and genetic examinations for diagnosis, it is necessary to obtain sufficient sample with lower risk of bleeding. Additionally, EUS-FNA is a potentially safer and more useful method than forceps biopsy.
A 58-year-old woman presented to our hospital due to bleeding during bowel movements for approximately 5 years. Lower gastrointestinal endoscopy revealed a 40-mm, slightly uneven, yellowish, ridge-like lesion that rose steeply from the lower Huston valve. The raised surface was covered with a nontumor mucosa that showed an ulcerated surface. Biopsies from the ulcer margin resulted in the diagnosis of a neuroendocrine tumor (NET). Abdominal computed tomography revealed lateral lymphadenopathy and a calcified liver tumor. We diagnosed the lymphadenopathy and liver tumor to be metastatic from the rectal NET and resected the rectal and liver tumors along with the enlarged lymph nodes during a two-stage surgery. All the resected tissues were pathologically diagnosed as G1 NET. We describe this rare case of G1 NET progressing to a large tumor, with lymphadenopathy and liver metastasis.
Endoscopic submucosal dissection (ESD) is widely used as minimally invasive treatment for superficial early esophageal cancer. Various traction methods have been developed to overcome the technical difficulties encountered during submucosal dissection. Esophageal ESD is associated with a high risk of perforation, and traction methods are particularly important to improve submucosal visualization and ensure a safe and effective procedure. The clip-with-line traction method is the simplest and easiest among the various traction methods available in clinical practice. After creation of an incision involving the entire circumference, the clip, which is tied using dental floss, is attached to the oral aspect of the resected mucosal specimen. The dental floss is pulled from the patient’s mouth, which improves tension and visualization of the submucosa and facilitates a rapid procedure. The clip-with-line traction method is also effective in challenging cases, such as fibrotic lesions or lesions covering the entire circumference of the esophagus. In our view, the clip-with-line traction method is essential to assist esophageal ESD.
With the increase of endoscopic treatments, the need to consider how to approach complications has also increased. Shielding uses polyglycolic acid sheets and fibrin glue and has been used in surgery for many years-recently it has also been applied in the field of endoscopy. In this paper, I describe the preparation of polyglycolic acid sheets and fibrin glue utilized for the shielding method and how to perform this shielding method for each organ (esophagus, stomach, duodenum, and large intestine) as well as its purpose (prevention of stenosis, delayed perforation, and delayed bleeding). Because of the great success of polyglycolic acid shielding in surgery, I expect this method will be more widely applied in the future.
Background: Small bowel endoscopy, including small bowel capsule endoscopy (SBCE) and balloon-assisted endoscopy (BAE), is useful for small bowel bleeding (SBB) assessment. However, the specific management strategy for overt SBB is not well established. This meta-analysis aimed to evaluate the pooled diagnostic yields (DYs) and therapeutic yields (TYs) of small bowel endoscopy in overt SBB and to determine the optimal endoscopy timing.
Methods: A comprehensive literature search was performed of studies examining the DY and/or TY of small bowel endoscopy in overt SBB. Data on the DY, TY, and timing of small bowel endoscopy were extracted, pooled, and analyzed. The pooled DY and TY of small bowel endoscopy for patients with overt SBB were calculated. Meta-regression and subgroup analysis were performed.
Results: Twenty-two studies were included. The pooled DY was 65.2% and 74.0% for SBCE and BAE, respectively. The pooled TY of SBCE and BAE was 55.9% and 35.8%, respectively. A meta-regression model showed that the timing of endoscopy was significantly associated with the DY of BAE and the TY of SBCE and BAE.
Conclusions: Small bowel capsule endoscopy and BAE would be useful diagnostic and therapeutic modalities in overt SBB. According to the subgroup analysis, in which the TY seemed to be higher within 2 days after bleeding for SBCE and BAE, the optimal timing of endoscopy would be within 2 days.