機能性ディスペプシア（Functional dyspepsia：FD）は基礎疾患に依らない慢性的な心窩部症状を呈する疾患である．成人領域ではピロリ菌感染に付随するディスペプシアはH. pylori関連ディスペプシア（H. pylori-associated dyspepsia：HpD）と呼ばれているが，小児期の消化器症状とピロリ菌感染との関連性については否定的なエビデンスが多い．実際に，小児におけるピロリ菌感染症の多くは無症状で，消化器症状の発生リスクを増大させない．一方，ピロリ菌感染を伴うFD小児に対する除菌治療の症状軽減効果については十分に検証されていない．当院の小児FD症例の中にもHpDに相当するサブグループが存在する．十分なエビデンスを構築し，このサブグループにおける適正な診断・治療の手順，内視鏡検査の適応，心理的なサポート方法などを確立することが必要である．

【目的】小腸カプセル内視鏡における小腸疾患（潰瘍，angioectasia，腫瘍）に対する人工知能（AI）の画像診断の感度と偽陽性のメタ解析を行うこと．

【方法】Pubmedを用いて2014-22年間の文献検索を行った．累積感度，累積偽陽性率をランダム効果モデルにて算出した．累積感度，累積偽陽性に対する診断病変，診断ラベル，AIモデル，学習に用いたデータ量別の関連を検討した．

【結果】12研究33406863枚のデータを解析した．小腸病変における累計感度は0.967，累計偽陽性は0.009であった．病変別の累積感度，累積偽陽性は同等であった．AIモデル別の解析において，Segmentationモデル，Multiラベルの累積感度が高値であった．学習に用いたデータ量がLow volume（＜10000枚）とLarge volume（＞20000枚）の累積感度は同等であった．一方，累積偽陽性は，Large volume（0.002）がLow volume群（0.010），Moderate volume群（0.029）より低値であった．

【結論】小腸カプセル内視鏡画像診断におけるAIの累積感度は高く，累積偽陽性は低いことを明らかにした．AIの累積感度は病変間で同等であったが，Segmentationモデルの感度が最も高く，50000枚の画像データを学習に用いたAIモデルは累積偽陽性が低かった．

背景：消化器内視鏡は，大量の飛沫やエアロゾルが発生することにより，COVID-19感染リスクが非常に高い手技として認識されている．特にCOVID-19患者に対する内視鏡は，感染リスクが高い行為であり，その適応や診療体制に関しては十分な検討が必要である．

対象：2020年4月から2021年10月までに当院で経験したCOVID-19患者に対する内視鏡施行例を対象とする．

結果：COVID-19患者に対しては，術者および介助者ともに，full PPEを着用し，陰圧個室内で検査を施行した．適応はバイタルサインの変動を伴う顕性出血例を適応とした．検討期間内に，6症例22件の内視鏡が施行されており，その内訳は上部消化管スクリーニング検査1症例1件，上部消化管出血3症例3件，下部消化管出血2症例18件であった．内視鏡検査に伴う院内感染の発生は認めなかった．

考察：COVID-19患者への内視鏡検査は，感染リスクの高い行為であるが，適切な感染対策を行えば，内視鏡による院内感染の発生は認められなかった．しかし，その適応に関しては，血管内治療などの他の選択肢も考慮に入れて，慎重に検討する必要がある．

Although the detection rate and treatment opportunities regarding superficial duodenal epithelial tumors (SDET) are improving, an algorithm for a diagnosis based on a magnified endoscopic examination with image-enhanced endoscopy (IEE-ME) has not yet been established. We focused on the possibility that the surface structure of SDET differs depending on the mucin phenotypes. Hence, based on the surface structure, we developed an algorithm to differentiate between SDET and non-neoplastic lesions, which is important in determining the indication for treatment. We examined the usefulness of the algorithm retrospectively. The results were very good; the accuracy was 93.4%, tumor sensitivity was 97.7%, and the negative predictive value was 88.6%. It was suggested that this algorithm may be useful as an optical biopsy technique.

門脈血栓合併肝硬変での食道胃静脈瘤の臨床像を検討した．門脈血栓症患者は24例中20例（83％）が肝硬変で，アルコール性，C型肝炎，NASH疑いが多かった．門脈血栓の初期治療としてダナパロイドナトリウムとAT-III製剤の併用が最多で，次いでAT-III製剤単剤，ワーファリン，ヘパリンが多く，経過観察は6例（30％）であった．維持療法は直接経口抗凝固薬（Direct oral anticoagulant：DOAC），ワーファリン，アスピリンが用いられた．門脈血栓治療後の経過として6例（30%）で血栓の改善や消失を認めた．食道・胃静脈瘤所見・治療の検討では，食道静脈瘤はF1が11例（55％），F2が6例（30％）であり，胃静脈瘤はF1が3例（15％）のみで合併していた．門脈血栓合併静脈瘤の内視鏡治療は5例（25％）に内視鏡的静脈瘤結紮術（Endoscopic variceal ligation：EVL）治療が行われたが，5例中3例（60％）が静脈瘤出血に対して緊急EVL，残り2例（40％）が待機的治療であった．門脈血栓症薬物治療とEVLによる内視鏡治療併用で食道胃静脈瘤治療は可能であったが，門脈血栓症や胸腹水の治療に難渋する症例があり今後の課題である．

悪性胆道閉塞に対しては，通常，内視鏡的逆行性胆管膵管造影（ERCP：endoscopic retrograde cholangiopancreatography）で経乳頭的な胆道ドレナージを施行する．しかしながら，術後再建腸管症例や十二指腸狭窄を合併した症例などに対しては，ERCPは施行困難であり，従来経皮経肝胆道ドレナージが行われてきたが，Quality of Lifeの低下が問題であった．近年，これらの症例に対して超音波内視鏡下胆管ドレナージ（EUS-BD：endoscopic ultrasound-guided biliary drainage）の有効性・安全性が報告されている．通常，両葉ドレナージが推奨される肝門部悪性胆道閉塞に対しても，EUS-BDによる左肝ドレナージに加え，肝門部の橋渡し（bridging method）を施行することで右葉のドレナージも可能となる．今回，胃全摘・Roux-en-Y再建後に肝門部悪性胆道閉塞をきたした胃癌・腹膜播種症例に対し，超音波内視鏡下肝空腸吻合術およびbridging stent留置に成功した症例を経験したので，報告する．

近年，術後膵液漏に対する超音波内視鏡下ドレナージの報告が散見されるが，最適なドレナージ法や治療時期についてコンセンサスは形成されていない．当院で2013年～2021年の期間に術後膵周囲液体貯留に対して超音波内視鏡下ドレナージを施行した9例を対象とし，後ろ向きに解析した．術後膵周囲液体貯留の分類は急性膵周囲液体貯留（APFC）が7例・仮性嚢胞（PPC）が2例であり，手術から内視鏡治療までの期間の中央値はAPFCが19日（10日～31日），PPCが234日（198日～270日）であった．内外瘻の選択は様々であったが，PPCの2例では内外瘻が選択されていた．外瘻のみとした1例で自己抜去があり再留置が必要となったが，全例で液体貯留の消失がみられ合併症は認めなかった．APFCでは隔壁形成は十分ではないと考えられるが，本邦からの報告でもAPFCに対するドレナージ報告が多数見られ，炎症・感染がある状況ではAPFCであっても比較的早期のドレナージを考慮してもよいと考えられた．

We analyzed minute and small gastric cancers in our hospital and considered the conventional endoscopic observation for efficient detection of minute and small gastric cancers. The results of our study showed that 98% of minute and small gastric cancers were detected by normal white light endoscopy with neither NBI nor staining, 80% of the lesions were located in M, L region of the stomach, 90% of 0-IIa lesions were fading color, 90% of 0-IIc lesions were reddish color. In order to detect minute and small gastric cancer, we considered it important to observe the fading elevated lesions and the reddish depressed lesions by focusing on the M, L region with normal white light endoscopy.

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is useful in the diagnosis for pancreatic tumors or gastric subepithelial lesions (GSEL).

Rapid on-site cytologic evaluation (ROSE), which was considered to be useful in improving the results of EUS-TA could not be available in our hospital owing to the lack of cytopathologists. Several reports demonstrated previously the efficacy of EUS-TA under the sample isolation processing by Stereomicroscopy (SIPS) and the stereomicroscopic on-site evaluation (SOSE) as an alternative to ROSE.

Twelve cases of GSEL performed EUS-TA under the SIPS or SOSE at our institution from January 2019 to July 2021 were retrospectively reviewed.

The final diagnosis was GIST in 8, leiomyoma in 2, and ectopic pancreas in 2 cases. The accuracy rate of EUS-TA under the SIPS or SOSE was 91.7% in GSEL.

The SIPS or SOSE may contribute to improving diagnostic yield of EUS-TA in hospitals where ROSE could not be available.

The diagnostic yield of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) remains suboptimal for subepithelial lesions (SEL) of the gastrointestinal tract. A novel FNB needle has been developed to increase diagnostic yield by procuring tissue suitable for histological processing. This study was conducted to assess the diagnostic ability of a novel fork-tip needle. Data from consecutive patients with SEL in the upper gastrointestinal tract who underwent EUS-FNB using the 22-gauge needles were retrieved. A total of 27 patients (mean age: 61years, 48% male) underwent EUS-FNB at our institution between August 2020 and January 2022. The location of the lesions was as follows: esophagus 7, stomach 19, and duodenum 1. The median size of the lesions was 20 (8-82) mm, and the median number of passes was 3 (2-6). Histopathological diagnosis with immunohistochemical staining was achieved in 81.5%, and no adverse events were encountered. When the lesions smaller than 20 mm were excluded, the diagnostic yield was 92.9% (13/14). EUS-FNB using the novel fork-tip needle showed a favorable procurement yield and diagnostic ability.

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) is an established endoscopic treatment for common bile duct stones and acute cholangitis. However, there is only a limited number of reports of the validation of Japan Gastrointestinal Endoscopy Society (JGES) guidelines concerning the management of anticoagulants during EST. An analysis of a total of 683 patients of EST including 57 patients taking anticoagulants revealed that there were no significant differences in the bleeding rate although the blood transfusion rate was significantly higher in the DOAC group (5.6%) and antiplatelet drug combination cases (7.7%) compared to other cases (0.5%). Multivariate analysis revealed that the DOAC and hemodialysis were significant risk factors of severe bleeding requiring blood transfusion. Thus, the management based upon JGES guidelines might not increase the bleeding rate but the severe bleeding rate requiring blood transfusion.

Endoscopic submucosal dissection (ESD) has become a common treatment for superficial pharyngeal cancer in recent years. We herein investigated the efficacy and safety of nasal intubation for lesions occurring in the areas from the lingual surface of the epiglottis to the tongue root.

Data were collected from six patients who underwent ESD under nasal intubation at our hospital between September 2020 and June 2021.

No vascular invasion was observed, and the margins were negative in all the cases. No fever, hemorrhage, perforation, pneumonia or epistaxis occurred in any of the patients. The median time to oral food intake was 2.5 days.

In conclusion, nasal intubation was a safe and effective treatment for peri-epiglottic lesions and depending on the lesion site, may be superior to oral intubation in terms of enhancing the safety and effectiveness of ESD.

The patient was a 78-year-old man who had attended our hospital with alcoholic liver cirrhosis as Child-Pugh classification A.

Endoscopy showed a red-colored depressed lesion on varices (LmF1CbRc0Lg (-)) of the posterior wall of the middle esophagus.

Narrow Band Imaging (NBI) with magnified endoscopy showed loop-like irregular vessels (Type B1) in the lesion.

Pathlogical examination was squamous cell carcinoma (SCC) as a result of the biopsy.

Endoscopic variceal ligation (EVL) was done for all varices, and the oral side of EVL was carried out about 1.5 cm away from the anal side of the lesion.

One week after EVL, endoscopic submucosal dissection (ESD) was performed without severe complications.

Histopathologically, tumor was diagnosed as SCC, Type 0-IIc, 16×18 mm, pT1a-EP, ly0, v0, pHM0, pVM0.

EVL that precedes ESD could be useful and safety for endoscopic therapy of early esophageal cancer on esophageal varices.

A 73-year-old female patient underwent esophago-gastro-duodenoscopy (EGD) because of a sore throat. The EGD detected a prominent granulomatous lesion in the middle of the esophagus, a finding that had not appeared in an EGD performed one year earlier. The patient was referred to our hospital for detailed examination. We observed a soft, lobular, pedunculated lesion with a reddened color and white deposits. Narrow Band Imaging showed dilated blood vessels at the base of the lesion, and no malignant findings of intrapapillary capillary loop. We performed an en-bloc resection by endoscopic mucosal resection following snaring for 1 minutes to prevent bleeding. The histopathological diagnosis was an esophageal pyogenic granuloma with a covering of hyperplastic squamous epithelium, proliferation of capillaries showing a lobular structure, and infiltration of inflammatory cells. Though mostly found along the gastrointestinal tract, esophageal pyogenic granuloma is rarely reported in the literature, unlike lesions of the skin and oral cavity. In summary, we reported the case of a 73-year-old female patient with an esophageal pyogenic granuloma that grew rapidly in a short period.

The case was a 77-year-old female who was undergoing chemotherapy because of recurrence of lymph nodes after open ileocecal resection for cecal cancer two years ago. She was admitted to our hospital with vomiting and poor oral intake from several days ago. CT showed exacerbation of esophageal hiatal hernia. After admission, vomiting did not improve and aspiration pneumonia developed even after fasting and fluid replacement management, so a nasogastric tube was inserted. Upper GI endoscopy showed reflux esophagitis and gastric volvulus. After conservative therapy, endoscopic repair was performed under X-ray fluoroscopy. The symptoms did not improve, so upper GI endoscopy was performed again and recurrence of gastric volvulus was observed. Percutaneous endoscopic gastrostomy was performed by pull method with using a Funada-style loop gastropexy device. Postoperatively, her oral intake was resumed without recurrence of gastric volvulus. Percutaneous endoscopic gastrostomy is minimally invasive technique for the high-risk patients who have gastric volvulus with esophageal hiatal hernia.

Barium meal study revealed gastric erosion in a 62-year-old woman.

Esophagogastroduodenoscopy showed friable mucosa from the middle body to the lesser curvature of the stomach. Biopsy examination revealed AL-type amyloidosis. Systemic examinations were performed, but no other lesions were found and she was diagnosed with localized gastric amyloidosis. Localized amyloidosis usually has a good prognosis. However, since there have been reports of cases leading to surgery due to the progression of anemia, cases with malignant tumors, and cases of transition to systemic amyloidosis, it is important to perform periodic systemic searches for amyloid deposits when amyloidosis is proven by stomach biopsy.

A 78-year-old woman with a decreased renal function was referred to our hospital after a simple computed tomography (CT) revealed a gastric mass. There were no abnormal findings on physical examination and blood tests. Upper gastrointestinal endoscopy showed a 50-mm submucosal tumor with a central depression in the gastric body, and enhanced CT showed a heterogeneous contrast effect on the mass. Malignant gastrointestinal stromal tumor was suspected, and partial gastrectomy was performed. The tumor was yellowish-white with smooth margins and clear borders. Immunostaining was positive for S-100 and negative for CD34, c-kit, desmin, and alpha-smooth muscle actin, and the tumor was diagnosed as schwannoma. Gastric schwannomas arise from the Auerbach's plexus in the muscularis propria of the gastric wall and are often difficult to diagnose preoperatively. In Japan, the frequency of malignancy in schwannoma is 10-25%, and the treatment method should be carefully considered.

White globe appearance (WGA) has been recently reported as a novel endoscopic marker that can help differentiate between gastric cancer and low-grade adenoma. Here, we describe two cases of WGAs after vonoprazan administration. Case 1 was of a woman in her seventies who had been diagnosed with gastroesophageal reflux disease (GERD) and treated with vonoprazan for 11 months. Esophagogastroduodenoscopy revealed WGAs in the fornix and body of the stomach. The WGA was located underneath the epithelium with overlying microvessels. Histopathology revealed eosinophilic material with necrotic fragments in the dilated glands. Case 2 was of a woman in her eighties who had been diagnosed with GERD and treated with vonoprazan for 1.3 year. Esophagogastroduodenoscopy revealed WGAs in the fornix and body of the stomach. The WGA located underneath the epithelium with overlying microvessels. Histopathology revealed eosinophilic material with necrotic fragments in the dilated glands and parietal cell protrusion.

Double pylorus (DP) means rare morphological abnormalities that form a secondary route other than the pylorus by congenital or acquired factors. We report three cases of DP after gastroduodenal ulcer. Case 1: A 75-year-old man presented with lightheadedness and tarry stool. Emergency endoscopy revealed a gastroduodenal fistula at the antrum other than the pylorus. Case 2: A 56-year-old man presented with epigastralgia. Emergency endoscopy was performed, and a gastroduodenal fistula was found in the pylorus at 0 o'clock. The biopsy results revealed duodenal adenocarcinoma, and surgery was performed. Case 3: An 86-year-old woman presented with nausea. Endoscopy was performed and incidentally DP was detected. DPs (case 1, 3) are based on benign ulcers, and DP (Case 2) is accompanied with malignancy. Since some cases of DP are associated with malignancy, careful endoscopic observation and follow-up are essential.

A 50-year-old man underwent an upper gastrointestinal endoscopy. A 10-mm flat elevated lesion was found on the descending part of the duodenum. It was recognized as a lesion with clear borders by indigocarmine staining, and was diagnosed as a high grade duodenal adenoma with NBI magnified findings. EMR was conducted after injection of glycerol.

Pathological findings showed the formation of many large lymphatic follicles in the mucosal lamina propria, with atypical small to medium-sized lymphocytes comprising the follicles. The lesion was diagnosed as follicular lymphoma with immunostaining positive for CD3(-), CD10(+), CD20(+), and Bcl-2(+). To the best of our knowledge, this is the first report of follicular lymphoma with a macroscopic type of solitary solid tumor.

A male in his 80s with small cell lung cancer (T4N1M1b, cStage IVb) was admitted to our hospital for chemotherapy. However, since the blood test at admission revealed anemia and melena was observed, upper gastrointestinal endoscopy was performed, which revealed a mass in the duodenal bulb. Biopsy examination led to the diagnosis of duodenal metastasis of lung cancer. Chemotherapy was discontinued due to the deterioration of activities of daily living as the patient's general condition worsened, and he died on hospital day 41. When anemia and fecal occult blood are detected in lung cancer patients, gastrointestinal metastasis should be suspected and endoscopy should be performed. Since there are few cases of small intestinal metastasis of lung cancer, our case is valuable.

A 55-year-old man with atrial fibrillation and cerebral infarction presented with one-month history of abdominal pain, watery diarrhea, and hematochezia. Abdominal computed tomography showed wall thickening of a limited area of the jejunum. Although his symptoms improved as a result of fasting and fluid therapy, abdominal pain recurred after the resumption of oral intake. Single-balloon endoscopy revealed multiple round ulcers in the jejunum, and the endoscope could not pass through the area due to stenosis. Microscopic examination of a biopsy of the stricture lesion showed nonspecific inflammatory findings, without malignant or granulomatous findings. Judging from these clinical findings, we diagnosed an ischemic stricture of the small intestine and performed a partial resection with laparoscopy.

An 88-year-old woman had a history of chronic gallstone cholecystitis. In January 20XX, she had a cholecysto-gastric fistula, and was treated conservatively due to her advanced age. In March, she was admitted to the previous hospital complaining of vomiting and was diagnosed with small bowel obstruction. Although she was treated with ileus tube, her condition didn't improve, and she was referred to our hospital for further treatment. She was suspected to have gallstone ileus due by cholecysto-gastric fistula. On day 7, a single-balloon enteroscopy was inserted transanally, and the 40 mm stone was found at approximately 10 cm proximal to the ileocecal valve which was crushed with an endoscopic device. After crushing to a size of 25 mm, the stone was grasped using a snare and carried to the cecum. After confirming the passage, the stone was retrieved. After the treatment, the patient's hospital course was good. On day 22, she was discharged without any complication.

A 73-year-old man came to our hospital stating chief complaints of constipation and anal pain. Colonoscopy revealed a 20-mm elevated depressed lesion in the ascending colon. The pit pattern in the depressed area could not be detected by endoscopy due to mucus accumulation. The lesion was diagnosed as an inverted SSL; ESD was performed due to dysplasia, while cancer could not be ruled out.

Pathology revealed a lesion combining features of TSA and SSL, with an inverted growth pattern invading the muscularis mucosae. Dysplasia was observed in the depressed area that could not be detected.

It is essential to consider that inverted SSLs may be complicated by dysplasia or cancer and grow into the muscularis mucosae.

We report a case that an ileo-ileal fistula in the pelvis due to Crohn's disease adhered to the rectum, formed an abscess, and resulted in multiple nodular protrusion in the rectum resembling phlegmonous colitis. In Crohn's disease, inflammation of the ileum may spread to the pelvis and form cystic or rectal fistulas. It was considered a rare endoscopic finding that could be seen in Crohn's disease.

A man in his 70s underwent colonoscopy due to annual follow-up after rectal cancer surgery. Colonoscopy revealed multiple elevated lesions of various sizes and forms in the descending colon and rectum. Magnifying endoscopy with narrow band imaging showed abnormal microvessels with a variable caliber on the surface of the polyps, and white opaque spots under the microvessels. Crystal violet staining demonstrated round pits showing type I pit pattern. Based on the pathological examination involving immunohistochemical staining, the colorectal tumor was diagnosed as follicular lymphoma (FL). No lymphoma invasion was found in other organs. We diagnosed the primary colorectal FL as clinical stage I according to the Lugano classification, and followed-up by watch and wait therapy.

There are few reports of colorectal FL and its diagnosis and treatment policy have not been clarified yet. In addition, there are few reports on the endoscopic findings. We here present a case of primary colorectal FL in which detailed endoscopic examination was possible.

We report about a man in his seventies who developed anemia. He had been diagnosed with diabetes, dyslipidemia, hyperuricemia, and gastroesophageal reflux disease. Colonoscopic examination revealed an irregular surface submucosal tumor - like lesion, with the top being depressed in the sigmoid colon. We attemped to lift the lesion, to inject saline into the submucosal layer when the saline spouted from the top of the depressed lesion. Next, we snared and partially resected the lesion. After clipping to the cutting section, a yellow-whitish mass appeared from oral side of the lesion. Histopathological finding of the cut section revealed hyperplastic mucosa with lymphocyte infiltration and serrated structure glands in the submucosal layer. The yellow-whitish mass contained bacteria, feces, and inflammatory cell infiltration with hyaline and calcification. The patient is being followed up, his anemia has not progressed.

A 70-year-old man was referred to our hospital because of elevated hepatobiliary enzymes. He was admitted for endoscopic retrograde cholangiopancreatography (ERCP) because abdominal echography showed dilatation of the intrahepatic bile duct and common bile duct, and abdominal contrast-enhanced CT showed thickening of the wall of the lower bile duct. The large papilla was located near the inferior border of the diverticulum and could be imaged from the front. However, the supporting tissue of the papilla was weak and the papilla was retracted into the diverticulum, making insertion of the bile duct difficult. After changing to an anterior-viewing endoscope with a cap and fixing the papilla with the cap, insertion of the bile duct became possible, and the patient was diagnosed with cholangiocarcinoma. This method may be effective in cases of periampullary diverticulum with weak supporting tissue.

A man in his 90s presented to the emergency department with cardiac pain. He had hypertension, atrial fibrillation, angina pectoris, and benign prostatic hyperplasia. On physical examination, there was tenderness in the cardiac region, and blood tests showed elevated hepatobiliary enzymes. The patient was diagnosed as mild acute cholecystitis and treated with antibiotics. After improvement, ERCP was performed. The papillae were elevated in a cystic fashion, and the diagnosis of choledochocele was made. Adenocarcinoma of the distal bile duct was suspected based on the cytological diagnosis, and a subtotal gastric-sparing pancreaticoduodenectomy was performed. Choledochocele, characterized by cystic dilatation of the terminal portion of the common bile duct within the duodenal wall, is a rare disease that has been reported to be associated with carcinogenesis. After diagnosis, appropriate imaging evaluation is important prior to considering the treatment plan.

Diagnostic and therapeutic procedures under ultrasound endoscopy (EUS), which began with EUS-FNA, have expanded its realms. Recently, endoscopic ultrasound-guided cyst drainage (EUS-AD) are increasing its applications to various infected cavities that originated from causes other than pancreatitis. We experienced three cases of EUS-AD to abscesses that were not caused by pancreatitis. In all of these cases, improvement was seen with EUS-AD, and open surgery was avoided.

A 76-year-old man was diagnosed with gallbladder cancer, direct liver invasion, and para-aortic lymph node metastasis. During chemotherapy with S-1, he developed a fever, and blood tests revealed an increase in hepatic biliary enzymes. Computed tomography revealed growth of gallbladder tumors, common bile duct dilation, and low-density structure in the common bile duct; thus, obstructive cholangitis due to biliary sludge was suspected. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a 10 mm tumor defect in the common bile duct, and it was extracted with a balloon catheter. The pathological diagnosis was adenocarcinoma. Despite some reports of cholangitis and acute pancreatitis due to a gallbladder tumor fragment, tumors extracted using ERCP are rarely reported. When patients with gallbladder cancer develop cholangitis, not only biliary hemorrhage but also bile duct obstruction due to tumor fragments should be suspected.

The case is a man in his 70s.

Pancreaticoduodenectomy was performed for intraductal papillary mucinous tumor. On the 3rd day after the operation, total bilirubin level was high as 16.5 mg/dl in the the choledochojejunostomy drain, and the patient was diagnosed with bile leakage. A single-balloon endoscopy was inserted to the anastomotic site of choledochojejunostomy. A catheter was inserted into the choledochojejunostomy and a contrast medium was injected. The intrahepatic bile duct was imaged with the leakage of contrast medium into the abdominal cavity. The left intrahepatic bile duct was selected with a guide wire, and a 5 Fr Endoscopic nasobiliary drainage (ENBD) was placed. No complications were seen. After the ENBD placement, the bile leakage was improved. Endoscopic biliary drainage for biliary leakage is an effective treatment option, even early after surgery.

A 51-year-old man was referred to our hospital for an examination of a pancreatic mass with cysts noted during a physical examination two years ago. Computed tomography showed a 12 mm large hyper vascularized tumor with cysts in the pancreas, and diffusion MRI showed low signal in the same area. As EUS showed a multifocal mass with cysts, we considered a diagnosis of pNEN and performed a subtotal gastric preservation pancreaticoduodenectomy. Pathological examination showed small round atypical cell clusters. Immunostaining was positive for Chromogranin A, Synaptophysin, CD56, and glucagon, and mitotic count was less than 2/10 HPF. This led to the diagnosis of NEN G1. In pNEN, cystic changes are more likely to occur in cases with positive glucagon production and immunostaining. In cases with cysts, it is important to differentiate between pNEN and MCN, and evaluation including immunostaining may be useful.

A 76-year-old man with a pancreatic tumor consulted our hospital for further examination. Imaging studies, including contrast-enhanced computed tomography, magnetic resonance imaging, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography, revealed a cystic tumor encircled with rich enhanced 13.88-mm parenchymal component on the tail of the pancreas. He was pre-operatively diagnosed to have a pancreatic neuroendocrine neoplasm (PNEN) with cystic degeneration, and underwent laparoscopic splenic-preserving pancreatic tail resection. The tumor was histologically diagnosed as a grade 1 PNEN, positive in glucagon immunostaining, and containing a cystic portion. Although most PNENs appear as rich enhanced solid tumors, 17% of the PNENs are reported to have cystic components. Though the exact mechanism of cystic degeneration remains unknown, it is reported that glucagon-producing PNENs are likely to have a cystic portion.

The case was an 80-year-old man with Billroth II reconstruction after distal gastrectomy for gastric cancer. His abdomen had been beaten and he was hospitalized for pancreatic trauma. CT showed extravasation from the anterior superior pancreaticoduodenal artery, and coil embolization was performed. In addition, rupture of the main pancreatic duct with peripancreatic fluid collection was observed, and endoscopic ultrasound-guided transluminal drainage was performed. As transgastric puncture was difficult, EUS-guided transjejunal drainage was performed from the afferent leg instead. It was possible to perform puncture by adhesion to the stomach wall due to inflammation. In addition, we were able to carry out safe and reliable treatment through various measures such as paying close attention to the position of blood vessels with color Doppler and eliminating the overlap of folds of the afferent leg by carefully operating the puncture needle.