The frequency of lower digestive tract hemorrhage is about one-tenth that of upper gastrointestinal bleeding. There are almost no cases of large intestinal hemorrhage. The primary diseases associated with lower digestive tract hemorrhage are more varied than for upper gastrointestinal bleeding. We encountered 480 cases of lower digestive tract hemorrhage over a 24-year period (1982∼2005). We encountered many cases of lower digestive tract hemorrhage associated with hemorrhagic colitis (63 cases), ischemic colitis (62 cases), hemorrhoids (61 cases), acute hemorrhagic rectal ulcers (61 cases) and diverticular bleeding (58 cases). Additional diseases we encountered included colonic cancer, colonic polyps, iatrogenic hemorrhage, small intestinal hemorrhage, and so on. Endoscopic diagnosis of lower digestive tract hemorrhage is more difficult than in the case of upper gastrointestinal bleeding. Endoscopic treatments for lower digestive tract hemorrhage which we have used include the heater probe method for acute hemorrhagic rectal ulcers, polypectomy for large intestinal polyps and clipping for other diseases. The indications for small intestinal endoscopy have recently increased, and further popularization is expected in the future.

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Diseases with lower gastrointestinal bleeding that require endoscopic hemostasis, interventional radiology or a surgical procedure have mainly been diverticular bleeding of the colon, acute hemorrhagic rectal ulcers, non-steroidal anti-inflammatory drug-induced enteropathy or arteriovenous malformations. We must thus choose precise methods for cleansing of the colon on a patient-by patient basis depending on their suspected disease, and perform emergency colonoscopy. Colonoscopy using a transparent hood was very effective for diagnosis and hemostasis of diverticular bleeding of the colon and acute hemorrhagic rectal ulcers. Endoscopic hemostasis with hemoclipping and hypertonic saline-epinephrine solution injection therapy has proved a very safe and useful therapeutic intervention. If endoscopic hemostasis fails, interventional radiology with arterial embolization using microcoils is effective.

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Non-operative hemostatic therapeutic strategies for lower gastrointestinal bleeding have been less-reported than in the case of upper gastrointestinal bleeding and have not yet been established. To evaluate non-operative hemostatic therapeutic strategies for lower gastrointestinal bleeding, 11 patients without iatrogenic bleeding from a total of 37 patients with lower gastrointestinal bleeding were reviewed for medication and results. Bleeding points were the ileum in 1 the ascending colon in 3, the transverse colon in 1, the descending colon in 2, and the rectum in 4 patients. Five patients had colonic diverticula, 2 had a rectal ulcer, and 1 each had ulcerative colitis, angiodysplasia, bleeding at the anastomosis, and metastasis from lung cancer. Interventional radiology (IVR) with arterial embolization using microcoils was performed for 2 patients. IVR for 1 patient with ileal metastasis from lung cancer succeeded, but IVR for i patient with colonic diverticula started bleeding again and colonoscopy with clipping was performed to stop the bleeding. Endoscopic hemostasis was achieved with clipping in 7 patients using, and argon plasma coagulation and radiofrequency coagulation in 1 patient each. Among non-operative hemostatic therapeutic strategies for lower gastrointestinal bleeding, the first choice for small intestinal hemorrhage was IVR, and the first choice for colonic hemorrhage was endoscopy.

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Video capsule endoscopy (VCE) is a major advance in visualization of the small intestine and has been widely used for small intestinal involvement. We have developed a new capsule endoscope in collaboration with Olympus Medical Systems Corporation. Its features include upgraded resolution, depth of field and brightness of the image by improving the optical system. They also have a new function which adjusts the level of lighting to automatically coordinate with the brightness of the field, and are fitted with an original handy real-time viewer display. Together with double-balloon endoscopy (DBE) or single-balloon enteroscopy (SBE), VCE is a new device which contributes to the diagnosis and the treatment of obscure gastrointestinal bleeding (OGIB). The algorithm for OGIB using VCE has been reported in the consensus meeting of International conference on capsule endoscopy in 2005, however, it does not include DBE/SBE methods. In the near future, establishment of the approach to the diagnosis of OGIB using VCE, DBE/SBE and conventional methods including angiography, small bowel series and scintigraphy will be expected.

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Diagnosis and treatment of any disease causing small bowel bleeding is difficult because of the length and arrangement of the small bowel and lack of diagnostic tools that can directly visualize small bowel in its entirety. Capsule endoscopy permits examination of the entire small bowel, but this method lacks tissue sampling and endoscopic hemostasis. Double balloon enteroscopy (DBE) permits direct examination of the small intestine and allows biopsy and therapeutic interventions to be performed. The enteroscope used for DBE has a 2.8 mm working channel, which permits the introduction of therapeutic accessories. Between July 2004 and July 2007, 100 patients (70 male, 30 female ; mean age 63.1 years ; range 19-89 years) with a variety of indications were included in the DBE study. All patients with obscure gastrointestinal hemorrhage had undergone more than one EGD and colonoscopy with negative finding prior to DBE. The cases consisted of 30 patients with vascular lesion, 28 patients with ulcerative lesion, and 12 patients with neoplastic lesions. We endoscopically treated 16 angiodysplasias, 2 Dieulafoy's ulcer, 2 erosions, and 1 each of jejunal varices, diverticulitis, and chronic hemorrhagic ulcer of the small intestine without any complications. Endoscopic hemostasis is effective for enteral ulcers, diverticulitis, angiodysplasia, inflammatory bowel disease and varices. DBE has a high diagnostic and therapeutic success rate in patients with obscure gastrointestinal bleeding.

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PURPOSE : Bleeding ectopic varices can be difficult to manage. We report our experience of 13 cases with bleeding ectopic varices of the small intestine. METHODS : From 1982 to 2006, 13 portal hypertensive patients had bleeding ectopic small intestinal varices. The location of the varices was an esophageal jejunal anastomosis (n = 3) and jejuno-jejunal anastomosis (n = 1) after total gastrectomy, gastric jejunal anastomosis after partial gastrectomy (n = 1), hepatico-jejunal anastomosis (n = 1), and small intestine (n = 7). RESULTS : Endoscopic injection sclerotherapy (EIS) was performed in 3 patients, and percutaneous transhepatic obliteration (PTO) was performed in 2 patients. In 1 patient surgical resection of the small intestine was performed, and in the remaining 6 patients balloon-occluded retrograde transvenous obliteration (B-RTO) was performed. A beta-blocker was administered in 1 patient. The bleeding was controlled in all patients. Preoperative MD-CT clearly showed ectopic varices in 9 patients who underwent EIS or B-RTO, and then postoperative MD-CT confirmed the disappearance of the variceal blood flow. Rebleeding occurred in 2 patients who underwent PTO. CONCLUSION : The present study demonstrates that bleeding from ectopic varices could be managed relatively safely by embolization of ectopic small intestinal varices with EIS or B-RTO with a low incidence of rebleeding.

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An 89-year-old man felt epigastralgia in January 2006. Two days later, he was brought to the hospital by ambulance for sudden onset of severe abdominal pain. He had muscular defence in the upper abdomen. An abdominal CT revealed free air and an upper gastrointestinal endoscopic examination showed a perforated ulcer in the gastric angle. An emergency laparoscopic drainage was therefore carried out. On the 17^th postoperative day, we performed an endoscopic examination again. The biopsied specimen taken from the tissue around the ulcer was diagnosed as well differentiated tubular adenocarcinoma. We next performed a distal gastrectomy followed by Billroth I reconstruction on the 35^th postoperative day. The resected specimen showed type IIc + III gastric cancer in the ulcerative lesion. The depth of the cancer was pathologically diagnosed as sm2. The final diagnosis was T1, N0, H0, P0, CYX, M0, stage IA. The patient's postoperative course was uneventful and he was discharged on the 12^th day following the second operation. No signs of recurrence have been detected for 11 months after the operation. Perforation of early gastric cancer is relatively rare, and elderly patients over 80 years old, like our case, are is very rare.

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A 74-year-old man was admitted our hospital with nausea and abdominal fullness. Abdominal X-ray and computed tomography both showed expanded small intestine and sigmoid colon. The patient was diagnosed as having ileus based on sigmoid colon cancer and underwent emergency colonoscopy to insert the transanal decompression tube. The efficacy of decompression tube was not sufficient and an emergency operation was performed. We found tumor of the rectum by digital examination and intraoperative colonoscopy revealed that the tumor was present in the rectum. A low anterior resection was performed and both tumors were resected. Minor leakage occurred at the anastomosis but the patient was discharged on the 70th day after the operation. It is important to confirm the anal side of a colorectal cancer stenosis as well as the oral side of the colon.

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A 58 year-old man who had no history of disease underwent emergency admittance to our hospital for severe abdominal pain and distension. Because enhanced abdominal CT revealed a small bowel obstruction and liver tumor, we suspected either inflammatory bowel disease or a metastatic tumor from an enteral malignant tumor. We were, however, unable to confirm it with a colonoscopy and a percutaneous liver biopsy. Since the same symptom appeared again one month later, we made use of the laparoscopic approach for diagnosis which revealed that the liver tumor was a hardening-related angioma and that the histological findings of the resected small intestine tumor were Crohn's disease. From the viewpoints of the postoperative quality of life and of cosmetic results, the laparoscopic approach has achieved wide recognition as an useful technique for the management of benign and chronic bowel disease. On the other hand, it was formerly believed to be unsuitable for emergency diagnosis and treatment because of the time limitation. Using laparoscopy, we could observe extensive internal lesions in the patients with acute small bowel obstruction with only a small incision. Therefore, we suggest laparoscopy is not only an excellent speedy diagnostic tool but also a swift therapeutic surgical approach.

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A 66-year-old man was hospitalized because of vomiting. Upper gastrointestinal tract radiography revealed a leakage of gastrographin out of the 2^nd portion of the duodenum and computed tomography showed air and fluid collection in the retroperitoneal space. A retroperitoneal abscess due to a perforated duodenal ulcer was diagnosed. Conservative treatment with a proton pump inhibitor and antibiotics was chosen because the general condition of the patient was good and the symptoms were not severe. The patient started eating on the 6^th day and was discharged on the 17^th postoperative day. Though retroperitoneal abscess formation due to a perforation of a duodenal ulcer is relatively rare and often results in a serious condition, conservative treatments can be adapted in some cases.

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A 68-year-old man was admitted to our hospital for epigastralgia and abdominal fullness. He had been undergoing hemodialysis for chronic renal failure for 28 years. A physical examination revealed marked abdominal distension and tenderness. Abdominal CT images revealed neither gastric dilatation nor emphysema. An increase in serum amylase level to 6780 IU/l was noted, so a concurrence of pancreatitis was suspected. Aspiration of gastric juice resulted in conservative remission. On the 4th hospital day, CT findings revealed no gastric dilatation and emphysema, and EGD showed erosive gastritis. Feeding was permitted on the 8th hospital day, and on the 20th he was discharged.

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A 64-year-old woman with continuous abdominal pain was admitted to our hospital under a provisional diagnosis of intestinal obstruction. Abdominal X-ray examination showed a dilated small intestinal loop. Abdominal CT scanning indicated intussusception of the small intestine. An X-ray examination through a long intestinal decompressing tube indicated a tumor of the ileum but no sign of obstruction. We performed an elective operation. A tumor was observed at a point 140 cm oral from Bauhin's valve, and a partial resection of the ileum with the tumor was performed. The tumor was 2.8 cm in diameter, round, with a short stalk, and lacked mucosa on its superior surface. Histological findings showed proliferation of stromal tissues and inflammatory cells containing eosinophils. The tumor was diagnosed as an inflammatory fibroid polyp (IFP). The postoperative course was uneventful and the patient was discharged on postoperative day 9. IFP is a benign submucosal lesion of the gastrointestinal tract that rarely arises in the small intestine. Over 80% of patients with IFP affecting the small intestine develop intussusception and are diagnosed by pathological examination of the resected specimen, as in the case presented here.

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We report on the diagnosis and treatment of six cases of obturator hernia in our hospital from August 2003 to December 2006. All patients were thin elderly women with a mean age of 84.3 years (range : 77-97) who were complaining of small intestinal obstruction symptoms such as abdominal pain and vomiting. Only two patients (33%) had the Howship-Romberg sign. All patients were diagnosed based on pelvic CT imaging with scanning below the pubic symphysis preoperatively. Surgery was performed under general anesthesia in the supine position with light flexion, abduction and external rotation of the ipsilateral hip joint. The incarcerated intestine was reduced without injury to the intestine by light traction of the intestine and percutaneously pushing the obturator canal from the medial side of the thigh. The hernia hilus was closed with insertion of a mesh-plug via the preperitoneal approach from the midline incision. All patients improved and were discharged without complication. No recurrence has been noted after surgery.

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A case of Churg-Strauss syndrome (CSS) complicated with a jejunal perforation is reported. A 40-year-old man who was diagnosed as having CSS six months previously had been treated with steroid-pulse therapy. Although the steroid-pulse therapy had normalized his symptoms and laboratory data, the patient presented with acute abdominal pain. Abdominal physical findings and computed tomography indicated a gastrointestinal perforation and the patient underwent an emergency laparotomy. The intraoperative findings revealed milky ascites and a jejunal perforation which was located 20 cm distally from the Treitz ligament. The diameter of the jejunal perforation was 3 mm. A jejunal wedge resection was performed with an automatic suture device because no other ulcers or tumors were found. The postoperative course of the patient was uneventful and he was discharged 25 days after the surgery.

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Two cases of esophageal rupture treated successfully with a simple suture and omental covering are reported. Case 1 : A 41-year-old man noticed chest pain after repetitive vomiting. He was referred to our hospital 4 hours later under the suspected diagnosis of a spontaneous esophageal rupture. Intraoperatively, the ruptured site was found to be edematous and fragile. Case 2 : A 49-year-old man complained of vomiting followed by upper abdominal pain. An initial chest X-ray revealed mediastinal emphysema, which led to the possible diagnosis of spontaneous esophageal rupture. He underwent an emergency operation 5 hours after the onset. Severe mediastinitis was also noted. In both cases, the ruptured esophagus was repaired by simple suturing after sufficient lavage. The thoracotomy was then extended to a left oblique abdominal incision and the omentum was easily mobilized and used to cover the suture site. The patients were discharged within 3 weeks without any leakage. Direct suturing associated with omental covering on the ruptured site of the esophagus is highly recommended particularly for cases with a rupture site that appear edematous and/or fragile, and which carries high risk of leakage.

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A 71-year-old man was admitted to our hospital because of a sudden onset of medial lower abdominal pain. He had not previously undergone open laparotomy. Tenderness and muscular defense were noted in the medial lower abdomen, together with the pain. Elevated levels of both white blood cells and C-reactive protein were noted. Based on computed tomography (CT) imaging, a strangulated ileus was suspected and emergency surgery was performed. A laparotomy revealed dirty ascites in the peritoneal cavity and perforation of Meckel's diverticulum by a fish bone 30 cm orally from the end of the ileum. We performed a resection of the diverticulum with an autosuture system. When we asked the patient about what he had eaten, he responded that he had eaten a sea bream (porgy) the day before, although he was not aware of having swallowed a bone. The 2.2 cm long fish bone was recognized as a sharp bone from a sea bream. There was no abnormal mucosa around the perforated portion of the small intestine. Fifteen cases of perforation of Meckel's diverticulum by a fish bone have been reported in the Japanese literature. We experienced this further rare case, and report on it with a review of the literature.

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The patient was an 83-year-old woman who presented with sudden-onset abdominal pain. She came to our hospital with progressive symptoms and exhibited severe muscle guarding, bloody stool, and ascites on an imaging study. Progressive bowel infarction accompanied with panperitonitis was suspected and the patient underwent an emergency operation. Following entry of the abdominal cavity, since the thickened intestinal wall was palpated primarily at the left side colon, a colostomy was placed at the anal side and mucosal side necrosis was recognized. The extent of resection was determined based on the macroscopic findings and the palpation. However, mucosal side necrosis was evident in the specimen, and the oral stump remained necrotic. Accordingly, the extent of resection was considered using intraoperative colonoscopy, and appropriate resection of the remnant necrotic intestine was achieved. The patient was finally diagnosed as having nonocclusive mesenteric ischemia. The consideration of resection of the intestine without penetrating necrosis occurs occasionally in some cases of emergency operation for ischemic intestinal disease. Therefore, intra-operative colonoscopy could be useful in determining the appropriate extent of intestinal resection.

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We report on a patient with a fall trauma-related liver/kidney injury and complete rupture of the bilateral hepatic ducts. The patient was a 20-year-old male who had fallen from some scaffolding (height : approximately 8 m). To treat the liver injury, transcatheter arterial embolization was performed. After hemostasis was confirmed, ascites puncture drainage was performed. Bile excretion was observed. Endoscopic retrograde cholangiography suggested hepatic duct injury. The laparotomy findings included complete rupture of the bilateral hepatic ducts involving the confluence area. Bilateral hepatocholangiojejunostomy was performed. As a stent, a retrograde transhepatic biliary drain was inserted, which was removed after 5 months. The subsequent course has been good without stenosis of the anastomotic sites.

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