Gastroesophageal reflux disease (GERD) is classified into “reflux esophagitis,” characterized by esophageal mucosal break, and “non-erosive reflux disease (NERD),” characterized by the presence of only GERD symptoms without mucosal injury. The revised Los Angeles classification, which adds minimal change, is widely used in Japan for the endoscopic diagnosis of reflux esophagitis. The main treatment for GERD is pharmacotherapy, and proton pump inhibitors are the first-line drugs. Vonoprazan, a potassium-competitive acid blocker, is highly effective in the treatment of severe reflux esophagitis. Endoscopic treatment of GERD is not widely used in Japan. However, from April 2022, endoscopic treatment reported as anti-reflux mucosectomy (ARMS) and endoscopic submucosal dissection for GERD (ESD-G) have been covered by health insurance as endoscopic anti-reflux mucosectomy. Therefore, it is expected that endoscopic treatment for GERD will become more widespread in Japan. Moreover, it is necessary to clarify the indications and long-term prognosis of this treatment in the future.

Immune checkpoint inhibitors are widely used in clinical practice, and immune-related adverse events (irAE) have been reported. An irAE liver injury, cholangitis, has been reported to occur frequently in patients who respond to treatment with immune checkpoint inhibitors. Sclerosing cholangitis is rare, occurring in only 4.5% of patients with liver injury who respond to immune checkpoint inhibitor therapy, and often difficult to diagnose. Ultrasonography shows thickness of the bile duct wall, cholangiography shows no obvious obstruction or stenosis, and cholangioscopy shows erosions and ulcerative changes on the surface of the bile duct. In patients who use immune checkpoint-inhibitors, damage of the biliary system should always be considered as irAE sclerosing cholangitis, and a definitive diagnosis should be made using various imaging studies. Although irAE sclerosing cholangitis is treated using steroids, it is often refractory to treatment and intractable.

The case subject was an 83-year-old woman. On upper gastrointestinal endoscopy examination performed for close examination of heartburn symptoms and feeling of chest tightness, early-stage gastric cancer presenting a 0-Ⅱa lesion of 10 mm in size in the angular incisure of the lesser curvature was observed. Endoscopic treatment was indicated; however, manipulation of the scope was difficult due to the presence of a type Ⅳ esophageal hiatal hernia with upside down stomach. Due to the subjectʼs advanced age, and to minimize the degree of invasiveness, upon deliberation with the department of surgery, surgical repair of the esophageal hiatal hernia was performed, after which the early-stage gastric cancer could be treated by performing ESD. We report a possible treatment method for early-stage gastric cancer concurrent with type Ⅳ esophageal hiatal hernia presenting with an upside down stomach in an elderly individual with a review of the literature.

A 46-year-old woman underwent an upper gastrointestinal endoscopy for physical examination in 2013 and received a diagnosis of Helicobacter pylori gastritis; a 0-Ⅱc lesion was found on the lesser curvature of the stomach. Histopathological diagnosis indicated a signet ring cell carcinoma. ESD was performed for the diagnosis of early-stage gastric cancer, and the final pathological stage was pStage Ⅰ [10×9 mm, sig＞tub2, pT1a, ly (-), v (-), HM0, VM0]. We performed regular follow-up CT scans and upper gastrointestinal endoscopy for 5 years after ESD, but no recurrence was observed. However, 7 years after ESD, a mass in the left inguinal region was diagnosed as an inguinal lymph node and multiple bone metastases of gastric cancer, which were treated with chemotherapy; nevertheless, the patient could not be saved.

A 68-year-old man tested positive for fecal immunochemical test during colorectal cancer screening and underwent lower gastrointestinal endoscopy at our hospital. Endoscopic examination revealed a 6-mm-diameter elevation in the ascending colon and a 3-mm-diameter, flat, well-defined lesion in the transverse colon. Endoscopic resection of the two lesions was performed for diagnostic and therapeutic purposes. Pathological examination revealed that both lesions showed spindle-shaped cell proliferation with infiltration of eosinophils and lymphocytes in the intrinsic layer of the colonic mucosa. Immunohistochemical staining showed spindle-shaped cells that were CD34-positive and negative for c-kit, EMA, GLUT-1, S-100, andα-SMA. Therefore, we diagnosed these lesions as inflammatory fibrinoid polyp (IFP). We report a rare case of endoscopically resectable IFP that was microscopic and found in multiple lesions.

A 71-year-old woman was admitted to our hospital with epigastric pain. Computed tomography revealed a 55mm-sized tumor in the body of the pancreas resulting in distal biliary obstruction. She was diagnosed with unresectable pancreatic cancer. Although we inserted a covered self-expandable metal stent (SEMS), she developed multiple liver abscesses due to non-occlusion cholangitis the following day. We performed percutaneous transhepatic liver abscess drainage, endoscopic naso-biliary drainage, and removal of the SEMS; however, her condition did not improve. Therefore, we inserted a SEMS with a duckbill-shaped anti-reflux valve (D-ARMS). First, the D-ARMS migrated above the papilla after a period of three months, which resulted in exacerbation of the liver abscesses. After replacing the D-ARMS and increasing the length from the papilla to the lower end of the D-ARMS to prevent migration, the liver abscesses resolved without recurrence. D-ARMS may be an effective treatment for resolving uncontrollable non-occlusion cholangitis.

In ERCP, the proper identification and view of the duodenal papilla is related to the success of the procedure.

However, there are a certain number of difficult cases, and the typical one is a case with intradiverticular papilla (IDP). The presence of IDP increases the difficulty of cannulation during ERCP. For such cases, several techniques have been reported for easy cannulation.

We encountered three cases of IDP who underwent an ERCP-related procedure by traction and fixed the papilla using a traction device for ESD (multi loop traction device, MLTD^Ⓡ).

In all the cases, the papillary orifice could not be identified initially; however, after traction and fixing, the papilla was secured in a good field of view and this allowed for cannulation.

In addition, no complications were observed after the procedure.

Therefore, we feel that this method can be effective and safe in cases of IDP with invisible orifice.

ESD has been developed as a minimally invasive treatment. However, major adverse events, including delayed perforation and bleeding are yet to be overcome. Therefore, a stronger and more secure closure method is desirable. Here, we describe the closure of a mucosal defect after ESD using a novel endoscopic suturing device.

The use of interventional EUS, referred to as IV-EUS procedures is increasing in high-volume centers in the failed/difficult cases for performing ERCP related procedures. As EUS-guided drainage/anastomosis (EUS-D/A) is not only for drainage, but also aids in the creation of anastomosis, endoscopic treatments through EUS-guided anastomosis are available. EUS-guided antegrade procedures (EUS-AG) and transluminal procedures through the EUS-anastomosis are mainly performed for cases with surgically altered anatomy, biliary/pancreatic stones, and stenosis. Endoscopic necrosectomy for walled-off necrosis after severe pancreatitis is classified in this procedure as well. These procedures are less invasive than percutaneous procedures, and the patient quality of life is better; however, the procedure has not been established because there are still a few dedicated devices. In our institution, the management of biliary/pancreatic stones and stricture with per-oral cholangioscopy and pancreatoscopy through the EUS-anastomosis are mainly performed. In this article, the tips and considerations for the techniques through EUS-anastomosis of the biliary and pancreatic duct are explained.

Objectives: Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis.

Methods: We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients.

Results: Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%.

Conclusions: Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.