In this study, we examined the effectiveness of ionized alkaline water as washing solution for endoscopic lens. We performed 109 cases of esophagogas- troduodenoscopy (56 cases in alkaline ionized water group, and 53 cases in distilled water group) from August to November 2010. Ionized alkaline water and distilled water were prepared as solutions for lens cleaning, and we measured the level of adenosine triphosphate (ATP) on the lens before and after endoscopic examination.
In ionized alkaline water group, ATP levels of the lens after endoscopic examination were significantly lower than those in distilled water group (P<0.05) . Ionized alkaline water is useful as a washing solution for lens cleaning in esophagogastroduodenoscopy.

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We had the opportunity to use prototype colonoscope PCF-Y0003-I (abbreviated proto PCF as follows) produced by Olympus company which could be inserted to the cecum safely with lesser pain than conventional colonoscope. Proto PCF is the tentative model equipped with the advantage of PCF-PQ260I already on sale having passive bending section added newly behind the first bending section of the conventional scope.
Proto PCF was additionally equipped with variable stiffness function to avoid loop reformation at SD junction which is frequently experienced in PCF-PQ260I.
Forty-one colonoscopic examinations with proto PCF were compared with 53 cases with PCF-PQ260I on the point of passing pattern of SD junction, time to reach the cecum and presence of patient′s pain during examinations.
Between proto PCF and PCF-PQ260I, there was no significant difference in the passing pattern of SD junction, time required passing SD and time to reach the cecum.
Number of patients with abdominal pain during colonoscopy was significantly few in examinations with proto PCF than with PCF-PQ260I.
Variable stiffness function was useful for the colonoscope with passive bending section as well as the conventional PCF-PQ260I to prevent frequent loop reformation in SD junction and other portions of the colon.

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As a new technique of ESD for the colorectal neoplasm, we contrive and enforce the “Three-channeled scope method”. In this study, we compared it with the conventional ESD method from the view of the usability and the problem. This technique is one kind of “counter-traction method”. Two-channeled colonoscope, added the third channel outside the scope for the grasping forceps, is used for this purpose. Through these channels, we can use some type of devices to enforce the operations, to say, local injection, lifting up and dissection of the tumor.
Out of 260 cases of colorectal ESD which we have performed, 46 cases of Three-channeled scope method and 79 cases of conventional method are compared in the view of removal major diameter, removing time, dissecting time and complications. At the removal major diameter, there is not a significant difference in both methods. Meanwhile, the average removing time is 31.0 minutes in 51.7 minutes, the Three-channeled method in the conventional one. Identically, in the average dissecting time, the former is better than the latter, by 19.4 minutes vs. 34.6 minutes. No perforation is seen in the cases of Three-channeled method, nor hemorrhage with a blood transfusion.
In future, the development of new cutting devices, maneuverable scopes, 3-D displays and the robot operation and so on are thought of.
It judged that this technique is very useful in performing the colorectal ESD more safely and rapidly.

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Objectives : Although an invasive treatment, gastrojejunostomy is a commonly used palliative treatment for malignant gastric outlet obstruction (mGOO) . Recently, an endoscopically placed duodenal stent has been introduced as an alternative treatment. We report our experience with the stent.
Methods : Between April and December 2010, twelve inoperable patients with mGOO received an endoscopically placed duodenal stent. The mGOOs were caused by the following carcinomas : pancreatic head cancer (7/12) or pancreatic body and/or tail cancer (5/12) . Oral intake was measured by the Gastric Outlet Obstruction Scoring System (GOOSS) before and after stenting.
Results : Technical success was achieved in 100% (12/12) of cases. The average of stent deployment time was 27min (range, 15-43min) . Eleven patients (91.7%) benefited from a GOOSS increase of 1 or more within 1 day. Median time with a GOOSS of 2 or more was 57 days. Median survival was 83 days after stent placement. A major complication occurred in one case in which cholangeitis was seen.
Conclusion : An endoscopic duodenal stenting improved oral intake rapidly in a majority of patients with mGOO, and resulted in quality of life improvement.

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It has been proposed by Riddell that sessile serrated adenoma/polyp (SSA/P) with a high degree of cell proliferation exist in the conventional hyperplastic polyp of the colon and rectum. In this article, the purpose of this study was to determine whether cell proliferation of SSA/P is different from that of HP by the use of immunohistochemistory of Ki-67. Fiftysix subjects of HP and classified SSA/P according to three histological feature of the Higuchi’s criteria were assessed by measuring the proliferative compartment with Ki-67 positve cells. The proliferative zone and Labelling index of Ki-67 positeve cells differed siginificantly (p<0.01) between SSA/P and HP. We concluded that this criteria was reasonable to separate from conventional HP to SSA/P in view of cell proliferation.

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The disease that becomes an operation adjustment such as gastrointestinal stromal tumor (GIST) is included in the submucosal tumor of the stomach. If there is no malignant opinion for small submucosal tumor, we often do the passage observation because the diagnosis is difficult. We diagnose the submucosal tumor of stomach by histologic examination using techniques of endoscopic submucosal dissection. We performed a biopsy using techniques of endoscopic submucosal dissection for gastric SMT less than 5cm in size in our hospital. For three cases being diagnosed with GIST and resected surgically we compared the biopsy specimen and the resected specimen for histological and examined the diagnostic performance and histological grade. As a result histological diagnosis of the biopsy specimen was the same in the resected specimen and histological grade with Ki-67 index was same result. In a few cases in the study histologic examination using techniques of endoscopic submucosal dissection is useful in the diagnosis of GIST and possible to predict histological grade before surgery.

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Insufflation, which is requisite for colonoscopy, generally uses air today. However, air insufflation during colonoscopy often causes abdominal bloat. Therefore, we used carbon dioxide (CO₂) instead of air insufflation during colonoscopy for screening of a total of 101 patients. We examined their previous history, their degree of discomfort, and running costs. They underwent CO₂ insufflation during colonoscopy at the Inui Clinic of Internal Medicine during Sep.10-Dec. 1, 2009. Their answers to a seven -item questionnaire were analyzed from the viewpoint of their feelings of discomfort. Moreover, running costs were calculated considering the amount of CO₂. The results can be summarized as follows. First, almost all the patients answered that CO₂ insufflation eased abdominal bloat both during and after colonoscopy. Secondly, their answers did not change according to their prior history of colonoscopy, abdominal surgery, or endoscopist. Thirdly, running costs for CO₂ insufflation were only 277 yen/examination. A colonoscopy using CO₂ insufflation can be performed safely without discomfort, irrespective of prior abdominal surgery. In conclusion, it is suggested that CO₂ insufflation should be introduced as a promising and an economical method for colonoscopy.

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We here report a case study of acute hemorrhagic rectal ulcer (AHRU) . From April 1 2007 to July 31 2010, 20 patients presenting with sudden-onset of hematochezia were diagnosed as AHRU. AHRU was diagnosed based on endoscopic findings. Data regarding demographics and colonoscopy were retrospectively retrieved. The patients consisted of seven males and thirteen females with a mean age of 78.3 year ranging from 58 to 96. The co-morbid diseases included hypertension, diabetes mellitus, chronic renal failure, cerebrovascular disease and terminal stage of cancer. Most of patients were bedridden because of disabilities due to the co-morbid diseases. Four patients were exposed to anti-coagulation agents. Colonoscopy which was performed within 24 hours of hematochezia revealed single ulcer in 6 patients and multiple rectal ulcers in 14 patients. In 13 cases, the ulcers were irregular in shape while Dieulafoy type ulcer was observed in 5 cases. Exposed blood vessels were detected in 11 patients (55%) to whom endoscopic hemostasis was challenged. In all but two cases, treatment was successful (82%) irrespective of procedures. The procedure employed were clipping in 5, argon plasma coagulation (APC) in 2, local injection of hypertonic saline-epinephrine solution together with APC in 1 and endoscopic band ligation in 1. Two patients failed endoscopic hemostasis and subsequently received surgery. One of the two patients died of multiple organ failure after surgery. The demographic features of AHRU in the current study were mostly consistent with those previously reported ; immobilized elderly patients with co-morbid diseases. In contrast to other reports, female were predominant. Endoscopic hemostasis was effective for active bleeding and may be a first-line therapy for AHRU.

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We investigated usefulness of magnifying endoscopy using NBI system in the diagnosis of analcanal lesions. Subjects of this study were three endscopic lesions, dysplasia, condyloma, and early squamous cell carcinoma (early SCC) , diagnosed by colono scopy at Tokyo Metropolitan Cancer Detection Center. All of these lesions were a IIa type or IIb type and slightly whitish. Especially it was difficult to find dysplagia because of its flat and smooth surface and its unclear margin. But magnifying endoscopy using NBI system was useful in the diagnosis of existence, because it revealed capillaries similar to irregular IPCL (intra-epithelial papillary capillary loop) of esophagus and pharynx. Condyroma revealed luster, whitish, minute glanules. Magnifying endoscopy using NBI system confirmed brownish capillaries in each glanules like papillary growth. Early SCC was difficult to distinguish from adenoma and adenocarcinoma. Because it existed nearby the dentalline, and its surface was minute. Magnifying endoscopy using NBI system visualized irregular capillaries and caliber varieation. We could, therefore, diagnosed a small lesion as squamous cell carcinoma. We concluded that magnifying endoscopy using NBI system was useful in the diagnosis of analcanal lesion.

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We report a case of gastric carcinoid tumor associated with atrophic gastritis which was treated by endoscopic submucosal dissection followed by eradication of H. pylori infection. A 71-year-old male visited our hospital for further examination and treatment of eight elevated lesions which size were smaller than 1cm in diameter existing through gastric corpus to vestibular part which were detected by gastoroscopy in health examination. His blood gastrin level was high (243pg/ml) . The submucosal tumor with central umbilication in the posterior wall of the middle gastric corpus was the largest with 10 mm in size. Pathological examination of biopsied specimen revealed carcinoid cells and immunohistologically, Chromogranin A was positive. In the other polypoid lesions, carcinoid compositions were not recognized and diagnosed as atrophic gastritis. Consequently, a diagnosis of sporadic gastric carcinoid was made, and the endoscopic submucosal dissection was performed. Pathologically, invasion of carcinoid cells to muscularis mucosae with mild cellular atypism and few cell division images was seen. Therefore, we did not perform additional resection. H. pylori eradication therapy resulted in diminishing polypoid lesions and normal blood gastrin level. After two-year follow-up, recurrence of carcinoid has not been seen. We propose that it is possible that H. pylori eradication which follows endoscopic resection for patients with gastric carcinoid with H. pylori infection and high gastrinemia is effective for prevention of tumor recurrence.

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Backgrounds and Aims : Cholangiopancreatoscopy is used to visualize directly the biliary and pancreatic duct, snd make precise diagnosis of pancreato-biliary diseases. However, conventional scopes had a limitation due to poor usability and fragility. Recently, the newly developed cholangiopancreatoscope : Spyglass? has been introduced to Japan. The aim of this study was to evaluate diagnostic value of Spyglass in the diagnosis of IPMNs and biliary strictures.
Methods : Subjects were 5 patients with IPMN and 5 with biliary stricture. Using Spygrass, examination was conducted by mother-baby method.
Results : Insertion of the scope via duodenal papilla and direct visualization of the main lesion was succeeded in all cases. The scope was inserted to the proximal pancreatic duct from the lesion in 2 of IPMN and to the 1st branch of the common bile duct in 4. Assessment of the tumor extension was successful in 1/1 of cholangiocarcinoma and 3 (60%) of IPMN. Adequate specimen for clinic-pathological examination taken under direct vision were collected in 8 out of 9 attempted cases. Final diagnosis could be made in 9 (90.0%) by Spyglass examination.
Conclusion : Spyglass was shown to be effective for the diagnosis of IPMN and biliary stricture, however further evaluation is needed for obtaining its actual value.

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We observed a case in which we were able to extract press-through-package (PTP) safely using a silicone rubber-hooded skirt mounted to the tip of an endoscope.
This is a case of a woman in her nineties who was admitted to the hospital because of accidental ingestion of PTP. During upper gastrointestinal endoscopy, PTP was identified directly below the entrance to the esophagus. As it had passed into the stomach by air supply, we advanced the endoscope into the stomach and grasped PTP using forceps. It was then recovered by removing the endoscope with PTP housed inside the skirt. The size of the recovered PTP was 19×18×5 mm. Adverse consequences such as ruptured membranes, perforation, and bleeding were not observed, and the patient was discharged on the same day. We believe that this device can effectively recover comparatively large and sharp foreign substances such as PTP.

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An 88 years old woman had suffered from vomiting and appetite loss from June 17, 2010. She was admitted to the hospital diagnosed with pneumonia by chest X-ray and blood test on 18. Endoscopy was performed after admission, because of black fluid drainaged from the Gastric tube. Endoscopic evaluation revealed multiple shallow ulcers in Stomach and Stomach deformity due to Hiatal Hernia which prevented from endoscopy insertion into duodenum. A computed tomography scan showed a severely incarcerated hiatal hernia involving dilated stomach due to obstruction. Reset trial by endoscopy was failed and surgical approach was chosen. The surgical findings showed massive incarceration of the stomach through the hiatal hernia orifice to the mediastinum. It was not easy to reduce the stomach from it, because of adhesion. As the reported mortality of perforated gastric ulcer associated with a hiatal hernia is high, early elective surgery should be performed in patients with incarcerated hiatal hernia especially with gastric ulcers that is resistant to acid-reducing regimen.

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A 61-year-old man suffered from upper abdominal discomfort and appetite loss. He had underwent surgery of pharyngeal cancer the year before at the other hospital. Endoscopic examinations of upper gastrointestinal tract and colon revealed no abnormal findings. The patient also felt lower abdominal pain and had appendectomy next year. However, discomfort and pain on upper and lower abdomen unchanged and his fecal occult blood test was positive, he visited our hospital to survey metastasis of pharynx cancer by capsule endoscopy. The patient was nutritionally depleted, but immunologically unaffected. Capsule endoscopy showed multiple erosions and ulcers on small intestine. This time, upper abdominal endoscopy demonstrated geographical ulcers and erosions on esophageal mucosa. The biopsy specimens of the esophagus showed “ground glass” nuclei and positively immunostained with anti-herpes simplex virus antibody. According to nutritional improvement, the ulcers of esophagus disappeared endoscopically, together with a relief of upper abdominal discomfort. Simultaneously, the lower abdominal pain resolved and it was speculated that small intestinal lesions were also herpes simplex virus-associated. Because herpes simplex virus could affect all gastrointestinal tract, and the ulcers on capsule endoscopy resembled those on upper gastrointestinal endoscopy, aggressive endoscopic examinations are recommended, especially with longstanding symptom in the abdomen.

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A 62-year-old woman who recognized dysphagia for more than ten years was referred from a local doctor to our hospital for consultation. Upper gastrointestinal endoscopy was performed and revealed an esophageal stenosis that the scope insertion was impossible. She was diagnosed as having Plummer-Vinson syndrome by glossitis, perleche, iron deficiency anemia and esophageal stenosis. At first, an esophageal passage of food was improved by endoscopic balloon dilation. Multiple gastric scars and ulcers were also detected by endoscopy. Because H. pylori was positive, eradication therapy was performed. H. pylori was successfully eradicated and all symptoms disappeared. Since then, the condition of the patient became good. In this case, it was speculated that Plummer-Vinson syndrome including iron deficiency anemia was closely related with H. pylori infection.

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63 years old man visited our hospital with a chief complaint of tarry stool. We recognized gastric bezoar and gastric ulcer by upper endoscopy. The gastric ulcer was cured by conservative treatment without endoscopic treatment. With a detailed dietary history, it has been revealed that he took in a pack of agar (40g) , and so the bezoar is believed to be “agar bezoar”. As the bezoar on this case was relatively soft, it was possible to crush and remove it by endoscopic measure. Since temperature to be dissolved (melting point) for agar is higher than body temperature once it got set, the bezoar may have been formed by that reason. As agar bezoar reports are few, we report our successful endoscopic treatment experienced in a precious case with review of the relevant literature.

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A 60-year-old man underwent endogastroduodenoscopy because of a close examination of the prostate cancer. Endoscopic examination of the esophagus revealed a spherical elevation that was 3×5 mm in size, colored evenly，and rose up gently. The tumor did not show cushion sign. He was admitted to our hospital for further evaluation and treatment. Physical examination on admission was unremarkable. Laboratory tests on admission revealed normocytic normochromic anemia. Endoscopic ultrasonography (EUS) was performed. Ultrasonic imaging showed a hyperechoic mass in the third layer. The differential diagnoses included leiomyoma, GIST, and lipoma in EUS. The patient desired endoscopic treatment, and endoscopic mucosal resection was performed. Histopathologic examination showed composed of closely packed polygonal cells containing delicate acidophilic granules in the submucosal layer. S-100 was positive，and α-SMA was negative. The tumor was diagnosed as granular cell tumor.
In our case，the esophageal lesion revealed hyperecoic tumor，although usual GCTs exhibit hypoechoic mass by EUS. We could not figure out the cause of the high echogenecity in spite of close analysis with histopathological evaluation. GCT of higecho is rare. We report a case with esophageal GCT as demonstrated as a hyperechoic mass by EUS, which is rare phenomenon, in addition to a discussion of the relevant literature.

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A 78-years-old woman was admitted to our hospital because of massive hematoemesis and clouding of consciousness.The emergency endoscopic examination revealed a huge coagulated mass in the stomach, but the orogin of bleeding was not detected. So over-tube was inserted and hood was attached on the tip of the endoscope for the purpose of removing the coagulated mass. Then a small red spot was detected on the greater curvature of the fornix and was found to be Dieulafoy-ulcer. Clipping and epinephrine injection was performed for hematostasis. Endoscopic Examinations 3 and 10 days later revealed no breeding and no vessel. We confirm that seemingly obscure origins of massive hemorrhage of the upper part of the gastrointestinal tract should increase the suspicion of Dieulafoy-ulcer, prompting careful examination of gastric fundic area and greater curvature.

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A patient was a 72-year old man complains of vomiting and anorexia. Upper gastrointestinal endoscopy revealed a type 3 gastric cancer in the gastric antrum with pyloric stenosis. Patient presented with vomiting, anorexia, leading to a markedly impaired quality of life. Recent reports have described stent placements are a desirable alternative to the palliative surgical procedures by bypass anastomosis in patient with gastric outlet obstruction (GOO). Stent placements can enhance patient′s quality of life, as it provides immediate clinical benefit. He had thoracic aortic aneurysm of refused operation, so we selected to treatment for GOO by endoscopic metalic stent placement. Endoscopic metalic stent placement promptly improves oral intake in a majority of inoperable patient with malignant gastric outlet obstruction. We report endoscopic metalic stent placement was successfully treated.

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The patient was a 69-year-old man who diagnosed as having diabetes mellitus. He was referred to our hospital complaining of bloody stool. The result of laboratory studies and blood gas analysis showed states of diabetic ketosis. Gastrointestinal endoscopy showed a Trench ulcer at the lesser curvature of the gastric upper body. Three days after the endoscopy, he was admitted with bloody stool again.
As the emergency gastrointestinal endoscopy demonstrated that the breeding and parforated ulcer at the lesser curvature of the gastric body, an emergency surgical operation was performed.
In some cases, the trench ulcer present with severe ulcer. Although gastrointestinal endoscopic diagnosis proved useful in this case, a careful manipulation of endoscopy in case of the risk for perforation was required.

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A 62-year old homeless man with poor nutrition was admitted to the Department of Dermatology of our University Hospital with leg edema and abdominal bloating. He had a past history of chronic diarrhea and leg tenderness for 9 months and once saw a doctor, but didn′t take regular medication or clinical check. After the leg edema got better, he was referred to the Division of Gastroenterology because of persisting abdominal bloating. CT scan showed a thickened part of the wall of transverse colon and ascites. The ascites was examined by aspiration and the cytology was class II. Finally with colonoscopy the thickened part was diagnosed as the fistula between stomach and transverse colon. The biopsy of this part revealed to be benign. In order to do the operation, he was moved to the Department of Surgery in January 2010 and soon the fistula was repaired.
Reports of gastrocolic fistula due to benign ulcer are quite rare. We diagnosed the fistula by using the dye while doing a colonoscopy. This is the first report of the use of this technique. This disease often presents with the trias of diarrhea, loss of weight, and stool-smelling vomit, and in this case we found 2 of them. We conclude that when seeing a patient with continuing diarrhea and weight loss in spite of good appetite, this condition should be investigated.

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A 42-years-old woman was referred to our hospital for the treatment of submucosal tumor of the stomach which detected by medical examination. Upper gastrointestinal endoscopy showed a submucosal tumor measuring about 2cm at the upper posterior wall of the stomach. The ulcer was accompanied with the center of tumor. Computed tomography (CT) examination was performed and early phase showed that central portion of the mass was enhanced. Positron emission tomography (PET) showed no abnormal accumulation. On endoscopic ultrasonography, submucosal tumor was found in the forth layer and its size was 15×18mm. The color doppler showed blood flow in the tumor. Endoscopic ultrasonography-fine-needle aspiration biopsy was taken. And the histopathological examination showed proliferation of the cells which had oval nuclei and pale eosinophilic cytoplasm. Immunocytochemical staining was positive in the SMA, negative in the c-kit, CD34, S-100. Preoperative diagnosis was the gastric glomus tumor. We performed laparoscopy assisted partial resection of the stomach. The histopathologic findings of the resected specimen were characteristic of glomus tumor. Gastric glomus tumors are basically benign tumor. But preoperative diagnosis of gastric glomus tumor is difficult. In our case, we could diagnose the glomus tumor preoperatively, and less invasive therapy, such as laparoscopic surgery, could be selected.

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The present case was a 68-year-old female. She had been diagnosed to have a hyperplastic polyp in the posterior wall of the gastric antrum by a routine check-up with transnasal esohagogastroduodenoscopy (EGD) and biopsy. At the 1-year follow-up with EGD, a small elevated lesion with a depressed area supposed to early gastric adenocarcinoma was revealed at same position where the hyperplastic polyp had been detected. The diagnosis based on biopsy specimens was group IV, adenocarcinoma suspected. It was difficult to diagnose the existence and range of the lesion by conventional endoscopy with white-light and/or chromoendoscopy with indigocarmine. However, the modified acetic acid-indigocarmine mixture (AIM) method clearly revealed a small IIc cancerous lesion at the top of the elevated lesion. Magnifying endoscopy with narrow-band imaging showed an irregular mucosal structure, and dilatated irregular vessels demonstrating an unequal caliber. Because early gastric cancer was suspected based on the endoscopic findings, an endoscopic mucosal dissection (ESD) was selected for both diagnostic and treatment purposes. The lesion was completely resected, and there were no complications due to the ESD procedures. A histopathological examination revealed well differentiated intra-mucosal adenocarcinoma without vascular invasion. This case showed us the importance of performing image enhanced endoscopy and magnifying endoscopy to accurately rule out the presence of carcinoma even after biopsy specimens have previously indicated the presence of hyperplastic polyps.

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A patient is 59 years old woman who complained of right lower eyelid swelling, and admitted to our hospital. The tumor is circular small atypical cell in histological findings, and we suspected a metastasis from lobular carcinoma because of ER (+), E cadherin (-), HER2 (1+) by immunohistochemical stains. Upper GI endoscopy was performed and it found the hypertrophy of fold like gastric cancer of type 4. We performed biopsy from the stomach and a mammary grand. Histological findings showed the tumor cell was stained of ER (+), E cadherin (-) and HER2 (1+). We diagnosed that the breast cancer was primary and it metastasized to stomach and orbit. It is very important to perform upper GI endoscopy in case of the breast cancer.

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Recently, laparoscopy-assisted endoscopic full-thickness resection for submucosal tumor of stomach has been reported. The procedure is performed firstly endoscopic submucosal dissection to determine the exact resection line of stomach intraluminally, then laparoscopy is used to assist the full-thickness resection. In this study, we report a case of laparoscopy-assisted endoscopic full-thickness resection for submucosal tumor and gallbladder stone with oral extraction of the specimen.

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A 61-year-old man with liver cirrhosis admitted our hospital because of hematemesis. Gastroduodenal endoscopy revealed duodenal ulcer with exposed vessel covered with clot but showed no active bleeding. Since his general condition was poor because of severe liver cirrhosis and hepatic encephalopathy, we did not perform clipping. At the fourth day after admission his consciousness and general condition was improved, thus we reperformed gastroduodenal endoscopy and we found exposed vessel covered with fresh clot at the ulcer. Because it was considered to be a sign of impending bleeding, clipping was performed ; however, severe hemorrhage occurred. Despite of added clips and injection of HSE, bleeding continued. Then sudden cardiopulmonary arrest occurred. The CT for autopsy revealed the gas in the systemic blood vessels. The autopsy revealed duodenoportal fistula and air embolism in the whole body ; however, no intracardiac shunt was found.
Air embolism during endoscopy is very rare and unpredictable, but once occurred, it is very critical. If the patient status deteriorate during endoscopy, we should be aware of this complication.

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A 58-year-old man with hepatitis-C-virus-related and alcoholic cirrhosis was admitted to our hospital with fever and abdominal distension. The laboratory data showed his liver functions had been gotten worse than before. Abdominal CT scan showed his duodenum was swelling and ascites was appeared. Upper gastrointestinal endoscopy revealed multiple erosions in the second portion of the duodenum. And also, similar erosions were in his transverse colon and rectum by colonoscopy. Serological tests was positive IgM antibody to cytomegalovirus (CMV) and CMV antigenemia was positive. Biopsy specimen from the duodenum and colon showed the presence of intranuclear inclusion bodies and CMV was demonstrated in biopsy specimen by immunocytochemistry using monoclonal antibody against CMV antigen. He was recovered with antiviral agents for 14days and upper gastrointestinal endoscopy performed 1 month after showed normal duodenal mucosa. CMV associated lesions in the duodenum are rare, especially in a patient with cirrhosis, but some literature said cirrhosis was considered at risk of CMV infection.

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The standard treatment for duodenal carcinoid has been surgical resection. This report describes the possibility of endoscopic treatment as an alternative treatment for duodenal carcinoid. The patient was 78 year-old man with partial paralysis. Submucosal tumor in the bulb of duodenum was found during follow-up endoscopic examination after endoscopic mucosal resection of gastric hyperplastic polyp. Biopsy specimens revealed a carcinoid tumor. He had no symptom. Biochemical value and endocrine functions were normal. Computed Tomography did not detect any evident lymph node metastasis and endoscopic ultrasound showed a homogeneously low echoic mass located at the submucosal layer. We suggested surgical resection but he refused. Endoscopic mucosal resection was difficult because carcinoid was close to pylorus. So we performed endoscopic submucosal dissection in our hospital. Histological examination of the resected specimen revealed that horizontal margin were negative and there was no vascular infiltration. Although vertical margin were positive, there has not been the evidence of tumor recurrence after two years. Small carcinoid often has lymph node metastasis so surgical resections are ideal but some cases are inoperable. Our experience in this case shows the possibility of endoscopic submucosal dissection as an alternative treatment.

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The patient is a 60 years old woman, She had an epigastric discomfort in late March, 2010. She was admitted to our hospital in 2 April, 2010. The upper gastrointestinal endoscopy was performed in 16 April. It showed hemorrhgic polypoid lesions with a white granulated duodenal papilla. The specimen showed tubulovillous adenoma.Then abdominal CT scan, endoscopic retrograde cholangiopancreatography, intraductal ultrasonography were performed, which not showed the infiltration of the pancreas.Endoscopic snare papillectomy for tumors of the duodenal papilla was performed 20 May, 2010. There were no postoperative complications including pancreatitis, bleeding, perforation. The histopathologic diagnosis was tubulovillous adenoma.
In recent years, technology in endoscopy has advanced, IDUS and EUS for ampullary lesions has become possible for more diagnostics.Endoscopic therapy appears to be a reasonable alternative to surgery for management of papillary tumors.

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A 61-year-old man admitted for melena who was receaving anti coagulant and anti platlet therapy for prosthetic heart valves. Endoscopic examination revealed a large pedunculated poly with erosion on its surface, which arose from the anterior wall of the duodenal bulb. Oozing bleeding was observerd on the erosive region of the polyp. Wafarin and low dose aspirin was interrupted with heparin administration, and proton pump inhibitor and fasting were prescribed. Melena disappeared. To prevent bleeding, we performed endoscopic polypectomy without complication. The resection specimen was 40mm in maximal length.
Histopathologically, remarkable Brunner's glands hyperplasia was observed in submucosal layer. The polyp was diagnosed as Brunner's gland hyperplasia polyp. Brunner's gland hyperplasia polyp was common benign tumor in the duodenum, but large region or causing gastorointestinal bleeding was rare. We review cases reported in the literature.

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The development of new technique against the gastrointestinal tract has revealed that various hemorrhagic lesions exist in the small intestine. Single- or double balloon endoscopy (balloon assisted endoscopy) is essential for the treatment of the lesions as well as making a diagnosis. Here we report on a case of hemorrhagic vascular ectasia successfully treated by single-balloon endoscopy.
A 85-year-old female with history of chronic heart failure was admitted to our hospital due to severe anemia. Although the upper and lower gastrointestinal endoscopy did not show any lesion causing bleeding, the sintigraphy implicated hemorrhage from the small intestine. Consequently, we performed single-balloon endoscopy which demonstrate hemorrhagic vascular ectasia. Hemostasis was immediately achieved using argon-plasma coagulation, and anemia had not been found after the treatment.

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A 68-year-old female received upper and lower gastrointestinal endoscopies due to severe anemia, but both studies revealed no lesions that may provoke bleeding. Then, video capsule endoscopy (VCE) was performed followed by double balloon intestinal endoscopy (DBE), and hemorrhage was found in the jejunum by the former examination, while jejunum mucosa showing redness on the surface was seen by the latter examination. DBE was done again 1month later, since progression of anemia was not discontinued, and angiodysplasia with hemorrhage was detected in the jejunum. Although clipping devise was done for the angiodysplasia under DBE, severe anemia complicated with tarry stool was not attenuated. Then, Argon Plasma Coaglation (APC) therapy through DBE was performed for hemorrhage angiodysplasia twice for 1month. However, progression of anemia with tarry stool continued despite of APC therapy and clipping devises repeatedly performed through DBE. Both APC therapy and clipping devise may be effective transiently for the arrest of bleeding from angiodysplasia on intestinal mucosa, but the therapies other than those under DBE, such as medical therapies, should be done in cases showing recurrent hemorrhage.

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A 65-year-old woman presented at our hospital with the symptom of bloody stool. Esophagogastroduodenoscopy and colonoscopy showed no bleeding lesion. Abdominal CT scan and MRI showed a mass in the pelvic cavity which close to the ileum. Capsule endoscopy revealed hemorrhagic enteritis of the ileum. We considered that the mass is the cause of enteritis of the ileum. The operation was performed to diagnose and treat. The mass was abscess, adhering to the ileum and the right ovary. We peeled adherence to the ileum and extract the abscess and the right ovary. After the operation, anemia and bloody stool were disappeared and capsule endoscopy showed no bleeding lesion in the ileum.

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An 83 years old man was admitted with melena. As Oesophagogastroduodenoscopy and colonoscopy provided inconclusive in determining a source of bleeding, capsule endscopy endscopy (CE) was perfomed. The submucosal tumor with ulcer scar was identified in jejunum. Two weeks later double ballon endscopy (DBE) was carried out for tattooing before surgery. The SMT showed marked morphological change accompanied active open ulcer with spontenous bleeding.

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We often use capsule endoscopy for examination of OGIB. Vascular lesion, neoplastic lesion, ulcerative lesion are cause of OGIB. Capsule endoscopy is less invasive than double balloon endoscopy. But its′weak point is diagnostic performance about neoplastic lesions, especially submucosal tumor. GIST is the most common cause of submucosal tumor in small intestine. And GIST often occurs in proximal jejunum.
We experienced a cese of jejunal GIST, which diagnose by double balloon endoscopy but missed by capsule endoscopy. In this paper, we show our facility and reporting policies of the literature on diagnostic strategies for patients with negative capsule endoscopy for OGIB.

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We report acute appendicitis with abscess treated by laparoscopic interval appendectomy (lapIA) after a few months′conservative management. From January 2007 to April 2010, we performed a total of 71 1aparoscopic appendectomies in our department. Five cases of them were associated with abscess and treated by lapIA. No postoperative complication was observed. Therefore, 1apIA for appendicitis with abscess is considered to be a feasible therapeutic procedure.

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A 22-year-old man who had been suffering from ulcerative colitis (UC) was admitted to our hospital because of complains of fever and chest pain on swallowing in November in 2006. Because he was refractory to 5-aminosalycylates and corticosteroids, immunosuppressive therapy with 6-mericaptopurine (6-MP) was introduced 2 months prior to the presentation. At the time of presentation, he was malaise and had dysphagia. Laboratory tests showed mild anemia and inflammatory responses. Serological assays for viruses including herpes simplex, cytomegalo, varicella, and Epstein-Bar did not demonstrate primary infection. Esophagogastroduodenoscopy revealed multiple ulcers and vesicles with normal-appearing intervening mucosa. Histologic findings were infiltration of inflammatory cells in the epithelia and no specific information for diagnosis was noted. Although clinical evidence of viral infection was not confirmed, he was immunocompromised by 6-MP and endoscopy findings were similar to those of herpes esophagitis. Thus, we administered acyclovir for 7 days. Though oropharyngeal aphtha temporarily appeared, symptomatic and endoscopic resolutions were obtained thereafter. Because symptoms related to UC including bowel frequency, hematochezia and rectal urgency never changed throughout the above period, we concluded that the esophageal lesion was not a part of UC but superimposition of viral infection. Because esophageal involvement in UC is very rare and Crohn's disease affects upper gastrointestinal tract more preferably than UC, we have been following up him carefully.

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Divercular bleeding is one of the common origins in cases of hemorrhage from the lower bowel. Colonoscopy is performed to detect a bleeding source and to treat it with a clip. Sometime it is difficult to find out the source, because of natural hemostasis or poor preparation. Long time examination suffers both patients and doctors. Enhanced abdominal CT is useful to find out the point of bleeding. Technetium scintigraphy is also useful. These two typical cases demonstrate the validity of radiological diagnosis before colonoscopy, reducing patient's pain and doctor's burden.

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[in Japanese]

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A 71-year-old woman with polymyalgia rheumatica developed diarrhea 6 months after starting lansoprazole (LPZ) and predonisolone. Colonoscopy was performed and showed numerous crowded blood vessels in the transverse and descending colon (Color 1) and a linear ulcer scar in the sigmoid colon (Color 2) . The pathologic examination of the biopsy specimen revealed thickening of the epithelial collagen layer, and intraepithelial infiltration with inflammatory cells. Ten days after she stopped LPZ, the diarrhea ceased. Therefore her disease was diagnosed as a LPZ-associated collagenous colitis.
A 67-year-old man with reflux esophagitis developed diarrhea 7 months after starting lansoprazole (LPZ) . Colonoscopy was performed and showd numerous crowded blood vessels in the ascending and transverse colon. The pathologic examination of the biopsy specimen revealed thickening of the epithelial collagen layer, and intraepitherial infiltration with inflammatory cells. His disease was daiagnosed as a collagenous colitis.
In addition, we analyzed the colonoscopic findings of our experienced 12 cases of collagenous colitis including the two cases in 2009 and 2010. The results were summarized in Table 1.

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A 60-year-old female underwent total colonoscopy in February 2010 for a positive fecal occult blood test. A long pedunculated polyp 20 mm in size was observed in the descending colon. It lacked apparent rising in the neck and the head was reddish and swollen like a club. Normal mucosa extended beyond the neck and magnified views after crystal violet staining revealed the mass Pit (so-calledIIIs pit pattern) in some parts of the top of the mass. Endoscopic ultrasonography demonstrated a low-echoic cystic mass with inner high-echoic spots from the head to the neck. Pedunculated mucosal polyp was suspected by endoscopy and was resected endoscopically from the base because pseudoinvasion of adenoma or cancer invasion to the mucosal lake was differentially diagnosed by magnified endoscopy and ultrasonography. Pathohistology revealed tubular adenoma that comprised epithelial cells with homogeneously dark-stained oval nucleus and developed branched tubular structure. At the top of the polyp, in particular, inverted growth of adenoma (so-called pseudoinvasion) was observed with marked mucus retention in some parts. At the neck, on the other hand, relatively large blood vessels accompanying wall thickening and hyalinization were present.
We here report a case of adenoma with pseudoinvasion which was difficult to differentiate from a pedunculated mucosal polyp.

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A 19-year-old woman visited to common doctor complainting of low grade fever of the first half of between 37 to 38℃ and bloody stool. As continuing bloody stool ten times per day after taking antibiotics and medicine for intestinal disorders, she was referred to our hospital. Colonoscopy revealed ulcerative colitis on all colon type, and a subpedunclated polyp about 6mm of ascending colon, histopathological findings showed hyperplastic polyp. The symptoms has improved her by administering mesalazine 3000mg per day, attending our hospital regularly for a while. After one year, colonoscopy revealed a pedunclated polyp enlarged about 15mm of ascending colon, so EMR was done. The polyp was 15×14mm in diameter, subpedunclated type with superficial redness and erosion. Magnifyied endoscopy with crystal-violet staining showed I and II pit patterns with wide interstitial tissue, not showed neoplastic pit patterns on IV and Vpit patterns. Histopathological findings showed the polyp with superficial redness and erosions, was made for severe inflammatory cells infiltration and expanded cystic glands. So we diagnosisd juvenile polyp, and ulcerative colitis was in remission.

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A 45-year-old woman was admitted to our hospital due to bilateral hydronephrosis with vomiting and back pain. On admission, hematological study showed normal CEA (2.9ng/ml) but, PET-CT revealed FDG uptake in the sigmoid colon. Barium enema and colonoscopy demonstrated segmental irregular narrowing of sigmoid loop with diffuse mural thickening showing cobblestone appearance. We attempted to do chemotherapy with FOLFOX4 for down staging. Nevertheless, we could not continue for 2 courses because of her death. Gross finding of the sigmoid colon showed typical cobblestone appearance with mural narrowing caused by submucosal as well as severe subserosal fibrosis due to lymphangitic carcinomatosa. The endoscopic images such as cobblestone appearance completely correlated with autopsy findings such as scirrhous infiltration of cancer cells and massive fibrosis.

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We report our initial experience of single-incision laparoscopy-assisted (SILS) colectomy in patients who underwent segmental colectomy for colon tumor as an additional procedure after colonoscopic treatment. The key points of our SILS colectomy are (1) placing a 3/4-circumferential peruimbilical skin incision with multiple radial splits if necessary, and (2) using a multiport channel system with a surgical glove. There were 3 men and 2 women, with a median age of 68 (range : 59-72) years. The median patients′body mass index was 21.9 (range : 19.1-22.8) kg/m². The reasons for additional colectomy included non-lifting sign in two patients, endoscopically unresectable lesion in one patient, positive resective margin in one patient, and massive invasion to the submucosa in two patients with positive vertical margin in one patient. The location of tumor was transverse colon in three patients and sigmoid colon in two patients. Segmental colectomy with D2-lymph node dissection was successfully performed in all patients. The median operative time was 155 (range : 135-230) minutes and median blood loss was 60 (range : 20-90) mL. Pathological examination revealed adenoma with severe atypia in one patient, pTNM stageI adenocarcinoma in the remaining 4 patients. Wound infection occurred in one patient. At the median follow-up period of 13.3 (range : 6.1-15.2) months, there have been no recurrence or late wound complications. Therese results suggest that our SILS colectomy seems feasible, safe, and could be a minimally invasive alternative in selective patients with colon tumor.

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Angiectasia is one of the diseases that should be considered in lower gastrointestinal haemorrhaging in elderly people. This article details our experience with a case of rectal angiectasia with myelodysplastic syndrome (hereafter referred to as MDS) as the underlying disease, where the identification of the source of haemorrhaging and diagnosis were difficult. The patient was an 81 year-old male diagnosed with MDS. The patient was diagnosed with sigmoid colon diverticulitis on the basis of left lower abdominal pain and the appearance of melena. As the melena continued even after signs of swelling improved, a colonoscopy was conducted. Oozing from the angiectasia was detected immediately above the dentate line and stopped with APC. Although it is believed that colonic angiectasia usually occurs on the right side of the abdomen, we concluded that it is important to thoroughly examine the recto-anal area as well.

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A 77-year-old man was referred to our hospital for workup of multiple liver metastases. The endoscopic view showed the submucosal tumor (SMT) of 9mm in a diameter, which was located in the rectum. There was no depression of surface on the SMT. EUS imaging showed a hypoechoic mass in the third layer. Biopsy specimen revealed carcinoid. An abdominal ultrasonograpy and CT demonstrated multiple masses of the liver. As there was no metastasis in other organs with further examinations, we suspected the liver tumors were metastases from the carcionid. Rectal carcinoid tumor less than 10mm in diameter with liver metastasis is rare. When SMT has a depression of central part in the tumor, the rate of metastasis become higher compared to that without the sign. Eighteen cases of rectal carcinoid tumors less than 10 mm that caused liver metastasis have been reported in the Japanese literature.
We should be aware that even the rectal carcinoid less than 10 mm in diameter without depression in central part has the possibility of the distant metastasis.

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It is difficult to evaluate the infiltration of early protruding colorectal cancer in the anal canal in many cases due to the regional specificity. In particular, rectal lesions may be overestimated employing standard-light observation with retroflex observation.
Furthermore, it is very difficult to assess the degree of infiltration by using endosonography. In this study, we report a patient with early rectal cancer in whom the degree of infiltration was regarded as mucosa, although colonoscopy, including magnified narrow band imaging, digital rectal examination, and endosonography findings, as well as an extremely high serum CEA level, suggested massive infiltration in the submucosal layer.

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We experienced a case of ESD-resected retum-origin MALT-lymphoma. A 74-years old female visited our hospital for intestinal examination. The total colonoscopy revealed a rectal polyp with tubular adenoma diagnosis. 3-months later, the patient admitted to our hospital for polyp resection. The rectal polyp feature had changed, resembling carcinoid appearance. The polyp was resected by ESD method for definite diagnosis, and was diagnosed as MALT-lymphoma. We have planned PET-examination, and Helicobacter pylori eradication in future.

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EUS-guided fine needle aspiration (EUS-FNA) has widely accepted as a reliable diagnostic procedure in many countries. In this article, we report a case of B-cell type malignant lymphoma with huge abdominal mass and diffuse venous thrombus, diagnosed by EUS-FNA. 48 year old male complained epigastralgia, and noted a huge abdominal mass and diffuse venous thrombus by CT scan. The patient was referred to our department for evaluation. EUS revealed heterogenisity-echoic abdominal mass, and EUS-FNA was performed with 22 gauge needle. Cytology results showed B-cell type malignant lymphoma, and Flow Cytometry showed the feature of CD10+, CD19+, CD20+, κ-ch+, λ-ch-. Gene analysis showed evidence of gene point mutation at 3 genes. Pathological results strongly suggested diffuse large B cell type lymphoma (DLBCL) . Therefore, the patient had underwent Cyclo-BEAP-R regimens, and the patient had compete response (CR) and the venous thrombosis was also good controlled with anticoagrant therapy.
EUS-FNA allows abdominal or retroperitoneal evaluation pathologically without surgery. Since we started EUS-FNA in 2009, because of the high accuracy of the pathological results, the number of surgery for pathological evaluation is decreasing. Especially, EUS-FNA allows not only cytology but also Flow Cytometry, gene transmutation nor pathological results by immune stain, which is indispensable for correct diagnosis and further treatment for malignant lymphoma.

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