Obstructive colorectal cancer is an oncological emergency commonly observed in our daily clinical practice. Conventional treatments such as the Hartmann procedure or stoma creation have been performed to treat obstructive colorectal cancer. Due to the recent introduction of the trans-anal drainage tube and colonic stent placement, emergency surgery can now be avoided. Colonic stent placement is performed as a safe bridge to surgery or palliative treatment for non-curative colorectal cancer, but complications such as perforation or migration may occur. Therefore, scrupulous attention is necessary when a colonic stent is retained. We have experience with six cases of colonic stent treatment: three cases for palliative treatment of non-curative colorectal cancer and three cases for bridge to surgery. Colonic stent placements were successful in all cases, but one patient died with sepsis on the seventh day after placement of a colonic stent. Five patients avoided uncomfortable pain due to ileus tube placement and stoma creation without risking occurrences such as perforation or migration. Colonic stent placement played a satisfactory role in improvement of patient QOL.

View full abstract

INTRODUCTION : Walled-off necrosis (WON) is a potentially life-threatening complication in acute necrotising pancreatitis (ANP) . In recent times, minimally invasive therapy has been recommended for patients with symptomatic WON. Here we report the efficacy and complications seen in cases of ANP with symptomatic WON managed using percutaneous drainage, with or without endoscopic necrosectomy.
AIMS & METHODS : We retrospectively searchedadmission records at our hospital of patients with ANP and symptomatic WON.
Treatment firstly involved puncturing of the WON using US-guidance, and then placement of a 7Fr drainage catheter into the cavity of the lesion. Lavage of the cavity was performed daily using 500-1000 ml saline. If the patientʼs symptoms were not stable, the percutaneous tract was dilated up to 10 mm in diameter and a larger sized catheter placed. Endoscopic necrosectomy was then performed once or twice weekly via the tract. The procedure was ceased when necrotic tissues had almost been eradicated. After necrosectomy, a pancreatic stent was placed endoscopically into the WON cavity.
RESULTS : Seven patients with WON were treated at our hospital using the percutaneous approach during the period from May 2009 to May 2013 : six patients were treated via the transperitoneal approach and one via the transperitoneal-transgastric approach. Four were treated using drainage only and three by endoscopic necrosectomy.
Timing of intervention after the onset of pancreatitis ranged from 24 to 131 days. The mean number of necrosectomy sessions was 3.6 (2-7) . After drainage was successfully completed, a pancreatic stent was placed via the duodenal papilla (five cases) or transgastrically (two cases) . Symptoms resolved in six patients ; one patient died of sepsis.
CONCLUSION : Percutaneous drainage with or without endoscopic necrosectomy is one option for minimally invasive treatment of ANP with symptomatic WON. Compared with the EUS-guided approach, the percutaneous approach has several merits. Firstly, a larger sized catheter can be placed, so lavage of WON can be more effectively performed. Secondly, in a hospital where EUS-guided drainage is not available, the percutaneous approach can be the treatment of choice.

View full abstract

Sedative agents─such as benzodiazepines─and analgesics are generally used during endoscopic procedures. However, despite expectations, in some cases benzodiazepines are ineffective. In those cases, haloperidol (HLP) and propofol are used, but it has not yet been clearly established in which cases benzodiazepines will be ineffective. In order to identify predictors for this scenario, we analyzed cases of patients who underwent endoscopic submucosal dissection (ESD) for treatment of early gastric or esophageal cancer using sedative agents. ESD was performed in 169 patients with solitary lesions at our institute between November 2011 and June 2012. The patients were divided into a standard group (using midazolam (MZ) and pethidine hydrochloride (PH) ; 152 patients (90%) ) and an HLP group (using MZ, PH and additional HLP ; 17 patients (10%) ) . We retrospectively analyzed factors in cases that required additional use of HLP.
In the HLP group, patients were younger, consisted of more men, with a larger body surface area, had a greater history of drinking and smoking within the previous year, and were more likely to have large and/or esophageal lesions compared to the standard group. Furthermore, the HLP group needed significantly higher doses of MZ and PH during the preoperative endoscopic examination, and a higher PH dose and longer procedure time during endoscopic resection compared to the standard group. Significant factors determined by univariate analysis were examined using multivariate analysis. Three significant factors were thus identified : “age < 60 years”, “diameter of the lesion ≧ 30 mm” and “MZ dose (during preoperative endoscopic examination) ≧ 0.06 mg/kg”. These factors are useful to predict the requirement for additional HLP during ESD procedures.

View full abstract

Background : Recently, aspirin has been used to prevent cerebro-cardiovascular disease because of its antiplatelet effect in elderly patients, and NSAIDs are widely used for their anti-inflammatory effects. However, use of these drugs incurs the risk of severe gastroduodenal bleeding ulcers. Endoscopic hemostasis has been introduced as a safe and effective approach to treat bleeding ulcers. The aim of this retrospective cohort study was to investigate the efficacy of hemostasis as an initial treatment in patients with aspirin, NSAIDs and peptic types of ulcers.
Patients and methods : At Showa University Hospital, 188 patients received emergency endoscopic hemostasis of bleeding gastroduodenal ulcers. Criteria for assessment of completeness of hemostasis was defined as the absence of either coagulated or fresh blood.
Results : Patients were classified into three groups as follows: aspirin ulcers (43 patients) , NSAIDs (without use of aspirin) ulcers (31 patients) , and conventional peptic (without use of NSAIDs) ulcers (114 patients) . Re-bleeding rate was 14.0% (6 of 43patients) , 6.5% (2 of 31) and 11.4% (13 of 114) , re-spectively. There were no statistically significant differences between the three groups.
Conclusions : In this study, there was no difference for re-bleeding rates between patients with aspirin, NSAIDs or peptic ulcers. Aspirin and NSAIDs should therefore not necessarily be considered risk factors for re-bleeding gastroduodenal ulcers after endoscopic hemostasis.

View full abstract

Background and aim : Strategies for diagnosis and treatment of small bowel diseases improved drastically between 2000 and 2001, when capsule endoscopy (CE) and double-balloon endoscopy (DBE) were commercially introduced. However, the current situation of the spread and clinical practice of these new modalities have not been well elucidated in Gunma prefecture. Our study aim was to clarify the current status of endoscopic diagnosis and treatment of small bowel diseases in our department and its affiliated hospitals.
Methods : We evaluated the current status of institutions that own DBE, CE or single-balloon endoscopy (SBE) in all hospitals in Gunma prefecture, as well as treatment data of DBE and CE in our department and its affiliated hospitals as of April 2012. We also evaluated the current situation of the CE network (CEN) established in 2009 in our department and its affiliated hospitals.
Results : Although institutions that own CE, DBE or SBE were unevenly distributed in Gunma prefecture, the numbers of such institutions have been increasing. Furthermore, the rental of these modalities has also been increasing. Evaluation for obscure gastrointestinal bleeding (OGIB) made up two-thirds of the use of DBE. An unusual event was onecase (0.5%) of pancreatitis. In contrast, evaluation of OGIB made up three quarters of CE utility. Capsule retention occurred in three patients and subsequently, two patients required DBE and one required surgery to retrieve the capsules. In general, the results of diagnosis and treatment of these modalities were comparable to those in previous reports. In the CEN system, the original workflow is active and currently Gunma University also functions as the institution advising affiliated hospitals about medical care of small bowel diseases, accepting patients referred from these hospitals, or educating endoscopists in these hospitals about interpretation of CE.
Conclusions : New modalities for diagnosis and treatment of small bowel diseases have been widespread in Gunma prefecture and medical standards in this field have been improving in our department and its affiliated hospitals.

View full abstract

Our hospital started performing laparoscopic appendectomy to treat acute appendicitis in January 2011. The current study compared the postoperative course of patients undergoing a conventional open appendectomy (OA) or laparoscopic appendectomy (LA) , along with the complications of each procedure. Data on the two procedures were gathered during the period from April 2009 to December 2012─the transition period for the switch from OA to LA. Differences in the pre-operative inflammatory laboratory data of patients undergoing OA or LA were not noted. The procedure time was 49.0±22.1 minutes for OA and 71.0±26.6 minutes for LA-thus the LA procedure tended to take longer. Post-procedural complications primarily involved wound infection. If even slight infections are included, then the incidence of complications after surgery was 45.4% for OA patients and 18.5% for LA patients. Laparoscopic appendectomy has merit in facilitating a reduction in postoperative complications.

View full abstract

We evaluated the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for the treatment of difficult common bile duct (CBD) stones in patients with altered gastrointestinal anatomy. The study group comprised 16 patients (15 male, 1 female) who underwent EPLBD for CBD stones with surgically altered gastrointestinal anatomy between February 2011 and May 2013. Reconstruction was performed by Billroth II gastrectomy in five patients and Roux-en-Y gastrectomy in 11 patients. The median diameter of the maximum stone removed was 12.0 mm (range 8-26 mm) and the mean diameter of the CBD was 14.8±3.3 mm. Twelve patients had an intact papilla, but in four patients EST or EPBD had previously been performed. The median diameter of balloon used was 12.8 mm (range 10-16.5 mm) . In all the patients, EPCP was performed with single-balloon enteroscopy and EPLBD was performed without EST. CBD stones were successfully removed in all patients. Repeated sessions of ERCP were required in only three patients (19%) to completely remove the CBD stones. The average total therapeutic time was 44.2±20.7 min. Mechanical lithotripsy was required in only one case (6%) . Acute complications from EPLBD included mild bleeding in one patient (6%) . Pancreatitis and other complications were not observed. Stone recurrence was not detected in the eight patients available for follow up. In cases of altered gastrointestinal anatomy, EPLBD without EST is a safe and highly effective technique for the removal of CBD stones.

View full abstract

We conducted a feasibility study to evaluate bowel preparation method before colonoscopy using a pre-packaged low-residue diet and 1l of polyethylene glycol solution plus sodium picosulfate. All patients completed this preparation method. Of 29 enrolled patients, 26 patients (89.7%) were adequately cleansed for colonoscopy. This method had high patient acceptance and preference. A randomized-controlled trial using a larger sample size is required to confirm effectiveness of this method. This preparation method has a potential application for bowel cleansing.

View full abstract

These cases included one patient with bile duct cancer, two with pancreatic cancer and one with gallbladder cancer. Duodenal SEMS were deployed prior to biliary SEMS in three patients, and the remaining patient was treated in the reverse order. Duodenal SEMS were placed at the oral side of the papilla via the through-the-scope method because the strictures were proximal to the papilla in all patients. Combined endoscopic stenting was successful and no procedure-related complications occurred in any of the patients. One patient developed recurrent GOO due to tumor ingrowth as a late complication, and was treated by re-insertion of another SEMS using the stent-in-stent method 161days after the first SEMS. The QOL of all patients was well-maintained until the time of death. Combined endoscopic biliary and duodenal stenting is a feasible and effective technique for the palliation of malignant GOO and biliary obstruction.

View full abstract

The patient was a 69-year-old man diagnosed with type 0-IIa＋IIc superficial carcinoma in the right epiglottis and base of the tongue, and type 0-Is＋IIb superficial carcinoma in the right pyriform sinus. Lymph node and organ metastases were not detected. Endoscopic laryngo-pharyngeal surgery (ELPS) was performed on these lesions. Pathological findings revealed that the type 0-IIa＋IIc lesion was a well differentiated squamous cell carcinoma (SEP, ly0, v0, HM0, VM0) and the type 0-Is＋IIc lesion was a moderately differentiated squamous cell carcinoma (SEP, ly1, v1, HM0, VM0) .
ELPS is video-assisted surgery which is performed under general anesthesia. The concept and technique of ELPS are based on the principles of laparoscopic surgery and endoscopic submucosal resection (ESD) . Using ELPS it is possible to perform large en bloc resection in the oral, supraglottic and pharyngeal areas. We perform ELPS with two doctors of the operator and the endoscopic operator. The endoscopic operator inserts a digestive endoscope through the mouth. The surgeon inserts surgical instruments via the mouth, and removes the lesion while watching the image on a monitor. Our experience indicates that it is possible to safely remove a carcinoma from the base of the tongue using ELPS, and also that the procedure is useful and effective for treatment of superficial carcinoma.

View full abstract

Recently, endoscopic submucosal dissection (ESD) has been widely used as a therapeutic procedure for mucosal cancer of the digestive tract, including esophageal disease. However, ESD may result in bleeding, perforation and post-treatment stenosis of the esophagus. In high-risk patients with underlying disease, ESD should be avoided for treatment of superficial esophageal carcinoma. Argon plasma coagulation (APC) has been reported to be a safe and useful procedure for the management of gastric mucosal cancer. We report here two cases of superficial esophageal carcinoma and high-grade dysplasia of the esophagus which were treated using APC.
Case 1 : An 84-year-old man─with malignant lymphoma─was diagnosed with superficial squamous cell carcinoma of the esophagus. Since he had been receiving steroid therapy and had renal dysfunction, he underwent APC in preference to endoscopic resection to treat the esophageal carcinoma. After ablation of the lesion by APC, the ablated epithelial layer was removed by endoscopic distal attachment (soft hood) and additional APC was performed on the lesion. The esophageal carcinoma disappeared.
Case 2 : A 55-year-old man─who had lower pharyngeal cancer─was diagnosed with early esophageal cancer. Since he had multiple tiny lesions unstained by iodine, he underwent chemoradiotherapy for the esophageal cancer. High-grade dysplasia of the esophagus developed 20 months after CRT. After repeated APC therapy, the esophageal dysplasia disappeared.
No complications were observed in either case. This suggests that APC is a safe and effective treatment for superficial esophageal carcinoma that cannot be resected endoscopically because of underlying severe disease, as well as treatment of local recurrence after chemoradiotherapy.

View full abstract

A 64-year-old man was admitted to our hospital with tarry stool. Esophageal carcinoma was diagnosed based on gastrointestinal endoscopy showing a type 2 advanced cancer of the middle thoracic esophagus. After three courses of chemotherapy and radiation therapy (56 Gy) , he developed a fever and began strong coughing. On chest CT, a passage between the mediastinum and esophagus was identified. The fistula was completely sealed by a covered esophageal stent. Oral intake became possible on day seven after the procedure. Nevertheless, the patient again developed pneumonia one month later. His general condition slowly worsened, and he died on day 96 after stenting.
Pathological autopsy demonstrated the fistula between esophagus and right bronchi, still sealed by the stent. Esophageal stenting was thus deemed an effective method to improve the patient’s quality of life.

View full abstract

A male in his 60’s had undergone hepatectomy twice to treat hepatocellular carcinoma and intrahepatic bile duct cancer, as well as proximal gastrectomy for gastric cancer. The patient had been diagnosed with esophageal varices (EV) caused by alcohol-related cirrhosis (Child Pugh A) and was treated by EVL/EIS in 2010. EV recurred (Lm, F₂, Cb, RC＋) and were treated by EVL again in February 2012. Additional EVL was conducted seven days after the first EVL. Three days after the second treatment, the patient suddenly vomited blood. Emergency endoscopy was performed, and confirmed spurting hemorrhage from the F₀ varix close to the esophago-gastric anastomosis, with EV in the scar site. It was not possible to ligate the bleeding point using EVL due to the presence of scars. EIS was not effective as the mucosa was too hard to penetrate using the injection needle. Finally, the bleeding was successfully controlled using an endoscopic clipping device. Fortunately, it was facile as the bleeding point was clearly visible. In general, EVL or EIS are chosen to stop bleeding of EV and endoscopic clipping is rarely used as a hemostatic device. However, when the bleeding cannot be controlled using standard devices─such as in this case─we should consider endoscopic clipping as an option.

View full abstract

A 60-year-old woman with hepatitis C virus-related liver cirrhosis was admitted to our institute for treatment of recurrent esophageal varices. After endoscopic injection sclerotherapy (EIS) using 1% polidocanol, the patient complained of chest pain, aphagia and dyspnea. At POD 3, upper gastrointestinal endoscopy and computed tomography showed a large submucosal hematoma of the esophagus. The lumen of the esophagus was occluded by the hematoma, which extended proximally to the larynx. Laryngeal endoscopy revealed that the hematoma also resulted in marked swelling of the epiglottis. Tracheotomy was performed as emergency airway management. At POD 6, the hematoma extended to the pharynx and a subcutaneous hematoma was observed in the cervical region. From POD 9 onward, the hematoma reduced in size, and the patient recovered gradually with no aftereffects. Submucosal hematoma of the esophagus should be considered as a potential major complication of EIS.

View full abstract

A 47-year-old male was referred to our clinic because GERD was suspected based on the frequency scale for the symptoms of GERD (FFSG) . Upper gastrointestinal endoscopy showed rough whitish mucosa, loss of vascularity, and the presence of linear furrows and mucosal rings throughout the esophagus. Histological examination of biopsy specimens revealed marked infiltration of more than 50 eosinophils per high power field (HPF) in the esophageal mucosa and slight infiltration of about 2 eosinophils/HPF in the gastric mucosa. The patient was diagnosed with eosinophilic esophagitis (EE) based on diagnostic guidelines for the disease. He was prescribed an oral proton pump inhibitor (PPI) and although the patient’s symptoms improved, endoscopic and histologic findings did not change remarkably. Therefore, an oral administration of fluticasone inhalation was initiated, which resulted in improvement of endoscopic and histologic findings. Reports of EE are rare in Japan. Therefore, this case is considered to have some clinical significance in establishing this disease concept.

View full abstract

An 83-year-old woman presented complaining of malaise, poor appetite and vomiting. After upper gastrointestinal endoscopy revealed severe stenosis in the lower esophagus, she was admitted for further investigation and treatment. Whole-body examination detected no malignant findings. A diagnosis of benign esophageal stenosis due to repeated reflux esophagitis was made. A total of 14 regularly scheduled endoscopic balloon dilations were performed at the stenotic site, but no improvement of the stenosis was seen. Therefore ablation was performed on three areas of the stenotic lesion, using microwave coagulation. This resulted in improvement of the stenosis and accompanying symptoms.

View full abstract

A 54-year-old man suffered tonsillar pain, extending through the chest, resulting in an inability to eat or drink. Initial endoscopic examination showed a diffuse edematous swelling of the esophagus, with no abnormality in the mucosal surface. Inflammation or tumor of the esophagus was suspected, and conservative therapy was commenced. On the fourth day of hospitalization, the patient spat up some coagulated blood, after which his symptoms greatly improved. Esophageal endoscopy on the eighth day of hospitalization showed submucosal dissection in the upper part of the esophagus, with edema and bleeding in the false part of the esophagus. After endoscopic study, an upper GI series and CT were performed. These showed the false diverticulum in the esophagus, with no evidence of extravasation. Submucosal dissection of the esophagus was diagnosed, and conservative therapy continued. Endoscopic examination on the 16^th day of hospitalization showed reduction of the edema and bleeding, with mucosal regeneration. Through such a clinical course, organic disease of the esophagus may occur before submucosal dissection.

View full abstract

A woman in her seventies underwent surgery for the removal of varicose veins from a lower extremity under general anesthesia. After extubation, the patient developed vomiting and severe precordial chest pain. On the following day, tarry stool was noted. However, as no blood clots were observed in a gastric lavage and tarry stool was seen only once, esophagogastroduodenoscopy (EGD) was not performed. As the postoperative clinical course was uneventful and obvious recovery was observed, the patient was discharged. Subsequently, the woman was referred to our hospital for management of persistent precordial chest pain. An EGD performed as a preoperative procedure about two weeks prior to the surgery had not revealed any abnormality of the esophagus. However, a repeat EGD performed about one month post-surgery showed submucosal dissection and mucosal bridge from the middle to lower esophagus. Judging by the clinical course, the cause of the symptoms was considered to be spontaneous intramural hematoma of the esophagus associated with the vomiting reflex after extubation. EGD was performed again about six months later, which revealed no change in the state of the submucosal dissection. Lugol solution spraying revealed deep staining of the dissection plane, and regeneration of the mucosal surface layer was confirmed by biopsy. We report here this rare case of esophageal submucosal dissection caused by spontaneous intramural hematoma of the esophagus along with a literature review.

View full abstract

An 88-year-old man was referred to our hospital for treatment of gastric cancer. Endoscopy showed a flat elevation with central protrusion (lesion 1) and a shallow depression (lesion 2) in the antrum. Biopsy specimens revealed a moderately differentiated adenocarcinoma and a moderately to poorly differentiated adenocarcinoma, respectively. Although there was a slight possibility of SM invasion in lesion 1, endoscopic submucosal dissection (ESD) of both lesions was performed as a diagnostic procedure. En-bloc resections with negative margins were achieved, but pathological findings revealed the resections to be non-curative due to the following : well to moderately differentiated and papillary adenocarcinoma invaded SM2 layer with lymphovascular invasion (lesion 1) , and moderately to poorly differentiated adenocarcinoma limited to mucosa with lymphatic invasion (lesion 2) . However, additional gastrectomy was not performed at this time due to the patient’s older age. Endoscopy one year later showed local recurrence. After further evaluation of the patient, he was regarded as a suitable candidate for surgery and gastrectomy was performed. The resected specimen revealed mucinous and poorly to moderately differentiated adenocarcinoma with subserosal invasion and regional lymph node metastasis. After seven months, the patient was in good condition with no evidence of recurrence. Based on the outcome of this case, it is advisable to monitor for local recurrences after diagnosis of non-curative ESD with lymphovascular invasion even when en-bloc resections show negative margins.

View full abstract

A 62-year-old man presented with aggravation of limb edema. Abdominal enhanced computed tomography revealed an increase in the wall thickness of the gastric corpus with a gastrocolic fistula. Endoscopic examination showed a type 3 tumor on the greater curvature of the middle body of the stomach, shown by tumor biopsy to be poorly differentiated adenocarcinoma. Gastrografin enema demonstrated complete obstruction of the transverse colon and gastrocolic fistula. Total gastrectomy, partial resection of transverse colon and splenectomy were performed. The tumor penetrated the transverse colon at two sites. Final pathological examination revealed poorly differentiated adenocarcinoma. Beyond the serosa, tumor had invaded the mucosa of the transverse colon. The patient died nine months postoperatively of peritonitis carcinomatosa. Gastric cancer with gastrocolic fistula is particularly rare. When a tumor is detected on the greater curvature of the stomach, it is advisable to perform barium enema in order to establish an early prognosis.

View full abstract

A 50-year-old man underwent esophagogastroduodenoscopy as part of a routine health screen. Endoscopic examination showed a small depressed lesion approximately 10 mm in size on the lesser curvature of the lower gastric body. Pathological examination of biopsy specimens revealed signet-ring cell carcinoma. Atrophic findings were not recognized in the background gastric mucosa, and rapid urease and serological tests were negative for Helicobacter pylori infection. Endoscopic submucosal dissection was performed. Pathological examination of the resected specimen revealed signet-ring cell carcinoma, 10×9 mm in diameter. The cancer extended to the level of the glandular neck within the lamina propia and was covered with normal crypt epithelium. It has been reported that most gastric cancers develop in patients with chronic active gastritis or chronic atrophic gastritis caused by H. pylori infection. H. pylori-negative gastric cancer is a rare disease in Japan, hence detection of H. pylori-associated gastritis has been determined a significant indicator for early detection of gastric cancer. However, H. pylori-negative gastric cancer has become more common recently because of a decrease in the incidence of H. pylori infection. Studies on the characteristic endoscopic findings for H. pylori-negative gastric cancer are required to assist diagnosis in the future.

View full abstract

A 64-year-old female was diagnosed with advanced type 3 gastric cancer with para-aortic lymph node metastases. Since a curative operation was deemed impossible, S-1/DOC combination therapy was administered. After five courses of chemotherapy, both the primary tumor and metastatic lesions reduced in size but a CT scan showed metastasis of Virchow’s lymph nodes. The patient therefore received 2nd line chemotherapy with CPT-11/CDDP. Repeated CT showed that Virchow’s lymph nodes further diminished in size. After 18 courses of treatment, however, the treatment had an adverse effect (renal dysfunction) . As 3rd line chemotherapy, CPT-11 alone was administered. After 13 courses of treatment, the primary lesion was remarkably improved and para-aortic lymph node metastases had disappeared. We discontinued chemotherapy after an additional 26 courses of treatment, followed by observation. The patient has now been in good health without a recurrence.

View full abstract

An 80-year-old man was diagnosed with adenoma of the main papilla in 1999 and underwent endoscopic papillectomy in January 2003 due to disease progression. Histological findings showed a tubulovillous adenoma. At follow-up examinations, the patient underwent routine upper gastrointestinal endoscopy (GE) , MRCP and CT, with no recurrence noted. However in July 2011, GE revealed a 5 mm 0-IIc and a 12 mm 0-IIc tumor in the posterior wall of the middle and upper stomach, respectively, with histological findings of well-differentiated adenocarcinoma. Endoscopic submucosal dissection was performed for en bloc resection in October 2011. Histological findings were type 0-IIc, pT1a (M) , ly (−) , v (−) , UL (−) , pHM0, pVM0, StageI. This is a rare case of adenoma of the main papilla complicated by gastric cancer.

View full abstract

A 51-year-old woman was admitted to our hospital because of tarry stools and dizziness. She had undergone investigation of anemia at another hospital previously, and endoscopy and biopsy had been performed a few days earlier. Endoscopy showed an elevated lesion 6 mm in size at the greater curvature of the middle body of the stomach. The surface of the lesion was covered with normal gastric mucosa and blood was leaking from the lesion center. Forty days later, the lesion had enlarged to 12 mm in size, now had redness at the surface and formed a polypoid lesion with a depression at the center. Magnifying endoscopy findings showed an unclear surface structure of the depression. To reduce the risk of re-bleeding and establish a diagnosis by total biopsy, endoscopic submucosal resection was subsequently performed. Histological examination revealed lobular growth of capillary vessels with hyperplasia of endothelial cells, and a diagnosis of pyogenic granuloma was made. Pyogenic granuloma is rare in the gastrointestinal tract and only seven cases have been reported in the gastric mucosa. Here, we report a case of pyogenic granuloma of the stomach with rapid change of form over a short period of observation.

View full abstract

This case report describes a 67-year-old female who underwent upper gastrointestinal endoscopy in 2005, demonstrating a 10-mm sized tumor at the greater curvature of the antrum. In 2010, a second endoscopy showed that the tumor had increased slightly in size. In October 2012, the tumor size had increased to 20 mm and its shape had changed. At this point, the tumor was further investigated. EUS showed a homogeneous low-echoic mass located in the second and third layers (mucosa and submucosa) . In February 2013, endoscopic submucosal dissection (ESD) was performed in order to resect the tumor. The pathological diagnosis was inflammatory fibroid polyp (IFP) . Recently, the standard method of diagnosis of IFP has been endoscopic mucosal resection (EMR) . However, ESD is useful to diagnose IFP effectively in cases where it is difficult to perform en-bloc resection using conventional EMR. We report a case in which ESD was used to diagnose IFP of the stomach.

View full abstract

The patient was a 74-year-old man who was admitted with a drop in blood pressure and anemia during dialysis. He was referred to our hospital because upper gastrointestinal bleeding was suspected. Upper gastrointestinal endoscopy did not detect any active bleeding, but showed multiple hyperplastic polyps in the stomach. All polyps were less than 20 mm in size, but had increased since an examination performed two years prior. Other endoscopic findings suggestive of cancerous polyps included adhesion of white mucus and increased mucosal irregularity. The patient was also undergoing hemodialysis and oral anti-platelet drugs may promote bleeding. Additionally, the patient wished to receive treatment to reduce the risk of future bleeding. For diagnostic and therapeutic purposes, endoscopic mucosal resection was performed, and diagnosed foveolar hyperplastic polyps containing a focus of intramucosal carcinoma.

View full abstract

A 65-year-old man with liver cirrhosis due to HCV infection and receiving hemodialysis for chronic renal failure was admitted to our hospital due to sudden onset hematemesis. Endoscopic examination revealed a large submucosal hematoma on the antrum of the stomach. A repeat examination performed 24 hours later showed formation of an ulcerative lesion due to spontaneous rupture of the hematoma. Two months later, the patient showed melena and anemia associated with hemorrhage from the gastric ulcer due to rupture of the hematoma; similar events repeatedly occurred six times during the subsequent two years. Total gastrectomy was performed, and histological examination revealed amyloid protein deposition─identified by immunostaining as being derived from β2-microgloblin─in the muscularis mucosae and muscularis propria of the stomach. Gastric amyloidosis should be considered a candidate of cause of gastric ulcer in patients without H. pylori infection or NSAIDs intake.

View full abstract

A 70-year-old man was admitted to our hospital with weight loss, appetite loss and anemia (Hb 6.7 g/dl) . He had been prescribed diclofenac sodium and methylprednisolone by another clinic to treat rheumatoid arthritis for the previous eight years. Esophagogastroduodenoscopy (EGD) revealed multiple gastric ulcers in the midbody and antrum. Colonoscopy revealed an ulcer in the transverse colon. Both gastric and colonic ulcers were suspected to be induced by the nonsteroidal anti-inflammatory drug (NSAID) . Capsule endoscopy revealed there were several red areas in the small intestine. Diclofenac sodium administration was ceased; the dose of methylprednisolone reduced and a proton pump inhibitor administered. EGD repeated one month later demonstrated healing of the gastric ulcers. The anemia and appetite improved and the patient was discharged. Four months later, a second colonoscopy showed scarring of the colonic ulcer. We report here a case showing simultaneous gastric and colonic ulcers induced by NSAID. Only one previous case with concurrent gastric and colonic ulcers induced by NSAIDs has been reported in Japan. In anemic patients receiving NSAIDs, both upper and lower gastrointestinal tracts should be examined.

View full abstract

A 69-year-old woman presented to our hospital with sudden nausea and epigastric pain. Her abdomen was tympanic, and upper abdominal tenderness without muscular defense was detected. Non-contrast CT scan revealed upside-down stomach, diagnosed as mesentero-axial gastric volvulus. A nasogastric tube was inserted after admission. On the following day, emergency laparoscopic gastropexy was performed because endoscopic repositioning was unsuccessful. The patient’s postoperative course was uneventful and she was discharged from hospital. Although acute gastric volvulus is relatively rare in adults, early diagnosis is critical because this condition has a risk of gastric perforation. In our case, abdominal CT was helpful to diagnose gastric volvulus.

View full abstract

Rendu-Osler-Weber disease is a rare condition─found only in one or two people in every 100,000─which causes anemia by systemic telangiectasis and repeated hemorrhage. This disease currently has no curative treatment, but it is said that the prognosis is quite good with symptomatic treatment. However, in many cases a blood transfusion is necessary to resolve anemia caused by hemorrhage. We report here a case of Rendu-Osler-Weber disease in a 78-year-old Asian female who underwent effective treatment of bleeding gastric angioectasia with argon plasma coagulation.

View full abstract

A 59-year-old man was referred in 2007 to our hospital with duodenal adenoma. Esophagogastroduodenoscopy (EGD) showed a slightly elevated whitish lesion at the 2nd portion of the duodenum. The lesion was 15 mm in size and appeared to be accompanied by a scar. Biopsy showed low grade adenoma and hence the lesion was monitored. On endoscopic examination, it gradually changed to a reddish color and became more depressed. In 2012, the lesion was examined using a magnifying endoscope with narrow band imaging (ME-NBI) . This revealed an irregular microvascular pattern of the lesion. At this stage the lesion was diagnosed as a cancer, and endoscopic biopsy of this identified well differentiated adenocarcinoma (tub1) . ESD was performed and the resected specimen showed D, 15 × 10 mm, Type 0-IIa, tub1, pT1a, ly (−) , v (−) , pHM0, pVM0. In this case, ME-NBI was useful to diagnose the cancer. The endoscopy was performed every one year. Repeated biopsy procedures result in fibrosis of the submucosal layer of the duodenum and may make subsequent ESD difficult. Consequently, we recommend the use of ME-NBI as optical biopsy for duodenal adenoma.

View full abstract

An asymptomatic 57-year-old woman was admitted to our hospital for further investigation of a duodenal tumor detected by screening abdominal CT. Duodenoscopy revealed an ulcerative tumor at the major duodenal papilla fistula on the longitudinal fold. A biopsy specimen from the ampullary tumor showed tubular adenocarcinoma. Endoscopic retrograde cholangiopancreatography through the fistula revealed a communication with the common bile duct. After diagnosis of ampullary carcinoma, pylorus-preserving pancreatoduodenectomy was performed. Microscopically, infiltration of cancer cells was detected beneath the normal duodenal mucosa around the fistula. According to histopathological data, the mechanism of the fistula formation was speculated to have been created by cancer invasion, explaining why this patient was not jaundiced. To our knowledge, choledochoduodenal fistulae formed by cancer invasion are rare.

View full abstract

A 59-year-old man with chronic glomerulonephritis─who had undergone kidney transplantation─was incidentally found on routine upper gastrointestinal (GI) endoscopy to have- a 5-mm 0-IIa tumor in the descending portion of the duodenum. Histological findings of a biopsy specimen showed atypical cells. Upper GI endoscopy was therefore repeated, and adenoma was suspected based on these latest biopsy findings. One month later, the structure of the tumor was noted on endoscopy to have changed and elevating the tumor by physiological saline injection was not possible. The decision was made to perform endoscopic mucosal resection (EMR) as the tumor was small. However, perforation occurred immediately upon starting the procedure. The defect was closed by endoscopic clipping, and it healed with conservative treatment. Histological assessment of the EMR specimen showed Brunner’s glands in the submucosal layer beneath the tumor. The second biopsy specimen was reviewed and similarly found to contain Brunner’s glands in the submucosal layer. Perforation likely occurred due to failure of the physiological saline injection for two reasons-firstly because there were Brunner’s glands beneath the tumor, and secondly because the submucosal layer had become thin due to removal of Brunner’s glands by biopsy. Physicians should recognize the presence of Brunner’s glands during EMR for duodenal neoplasms.

View full abstract

An asymptomatic 80-year-old man─who had been taking low-dose aspirin for more than ten years─was recruited for surveillance endoscopy of small intestinal lesions caused by aspirin. Capsule endoscopy was performed, identifying a duodenal adenoma. Laboratory data at this point revealed no abnormal findings. The patient then initially underwent upper gastrointestinal endoscopy and colonoscopy but the lesion could not be observed.
Single-balloon endoscopy revealed an elevated flattened lesion─10 mm in size with a central ulcer─in the 4^th portion of the duodenum. Endoscopic mucosal resection (EMR) was performed. Histopathological diagnosis was tubular adenoma with moderate dysplasia.
This case suggests that capsule endoscopy may be a useful diagnostic tool in the screening of small intestinal lesions.

View full abstract

A 53-year-old man with alcoholic liver disease was admitted to our hospital with symptoms of gastrointestinal hemorrhage. Emergency upper GI endoscopy was performed, detecting bleeding varices in the second part of the duodenum. Endoscopic obliteration using N-butyl-2-cyanoacrylate (Histoacryl, 0.5 ml) and lipiodol (0.3 ml) was performed. The varices were successfully obliterated, and no recurrent bleeding or complications were encountered. Treatment of bleeding duodenal varices has not been firmly established. Endoscopic procedures such as sclerotherapy or ligation, interventional radiology (IVR) , and surgical procedures have been reported. Endoscopic obliteration using Histoacryl was effective, and could become the first standard technique for bleeding duodenal varices.

View full abstract

A 76-year-old man developed progressive anemia during treatment for diabetes and was hospitalized for further investigation. No melena was observed, and upper gastrointestinal endoscopy and colonoscopy revealed no findings to indicate the cause of anemia. Abdominal contrast-enhanced computed tomography (CT) identified intussusception in the small bowel, but intestinal obstruction was not observed. A small bowel series─performed on suspicion of intussusception due to a small bowel tumor─revealed a protruded lesion in the jejunum. Enteroscopy confirmed the presence of the protruded lesion and biopsy results found it to be a papillary adenocarcinoma. Laparoscopic resection of a portion of the small bowel was subsequently performed to treat for small bowel cancer. The tumor was in a state of intussusception at the time of surgery and was resected after removing th-e invagination. Pathologically, the tumor was a papillary adenocarcinoma with a postoperative diagnosis of T3N1M0 in accordance with the general classification of stomach cancer. Adult intussusception is a rare pathology that is commonly caused by malignant diseases. The present case was diagnosed with the aid of CT, which identified the intussusception. Since small bowel cancer presents with few symptoms, investigation of anemia of unknown cause may lead to suspicion of small bowel diseases-demonstrating the importance of performing detailed examinations.

View full abstract

Two cases of small intestinal metastasis from pulmonary cancer are reported.
Case 1 : A 64-year-old man was diagnosed with non-small-cell lung cancer in November 2011. First-line chemotherapy was ineffective, and in July 2012 the patient was admitted to the hospital with abdominal pain, hematemesis, hematochezia and anemia. Abdominal CT and capsule endoscopy were suggestive of an ulcerative tumor with bleeding in the jejunum. Partial jejunectomy was performed. Pathological diagnosis was small intestinal metastasis from the pulmonary cancer. The patient could eat and his anemia was controlled until he died seven months post-surgery.
Case 2 : A 46-year-old man received surgery for treatment of a large cell carcinoma of the right lung in February 2012. He was admitted to the hospital in July 2012 with anorexia, abdominal pain and dyschezia. Abdominal CT showed an enhanced tumor in the ileum. Single-balloon assisted endoscopy revealed an ulcerative tumor. Pathological findings based on the biopsy specimen were compatible with small intestinal metastasis from the pulmonary cancer. After palliative ilectomy, the patient’s symptoms were controlled. He received second-line and third-line chemotherapies, until peritoneal metastasis progressed and he died four months after ilectomy.

View full abstract

A 79-year-old woman was admitted to our hospital with melena. On abdominal computed tomography (CT) , an enhanced mass was shown in the small bowel. Capsule endoscopy (CE) was performed. A submucosal tumor found in the jejunum was suspected to be the source of bleeding. After hospitalization, melena persisted and surgical resection of the tumor was performed to achieve hemostasis. Histopathological findings confirmed the diagnosis as gastrointestinal stromal tumor (GIST) .

View full abstract

An 84-year-old woman was admitted to our hospital complaining of tarry stool and anemia. She also had tarry stool three years previously. Gastrointestinal endoscopy and colonoscopy were performed, but the source of the hemorrhage was not detected. Videocapsule endoscopy was performed and located an actively bleeding lesion. The small intestine was examined using double-balloon endoscopy, and a submucosal tumor with ulceration was found. Laparoscopy-assisted partial resection of small intestine was performed. Immunopathological study of the tumor was positive for c-kit, CD34 and α-SMA but negative for S-100 protein, indicating gastrointestinal stromal tumor. Findings with this case suggest that patients with obscure gastrointestinal bleeding should be examined both by videocapsule endoscopy and double-balloon endoscopy.

View full abstract

A 50-year-old man was admitted to our hospital for investigation of anemia and a positive fecal occult blood test. No obvious pathology was seen on esophago-gastro-duodenoscopy and colonoscopy, and the patient was diagnosed with obscure gastrointestinal bleeding (OGIB) .
Capsule endoscopy showed an ulcerative lesion in the upper jejunum. Biopsies from the ulcer were taken by single-balloon assisted enteroscopy. Pathological findings were compatible with small intestinal gastrointestinal stromal tumor (GIST) , and partial jejunectomy was performed laparoscopically. Macroscopic examination of the resected specimen showed a tumor measuring 60 mm in diameter. Histopathologically, the tumor cells were spindle-shaped (HE staining) and KIT positive, and the final pathological diagnosis was high risk GIST.
Although the percentage of small intestinal tumors as the cause of OGIB is only 14%, the ratio of GIST is high in small intestinal tumors. It has previously been reported that 63% of small intestinal GIST diagnosed with balloon assisted enteroscopy are detected from OGIB. Examination of the small intestine should be performed in patients with OGIB while considering the potential presence of small intestinal tumors including GIST.

View full abstract

We report two cases of aspirin-induced multiple small bowel ulceration treated with antiplatelet agent change. An 83-year-old man and a 75-year-old man were referred to our hospital for evaluation of chronic anemia. Both patients had been diagnosed with acute myocardial infarction and treated with percutaneous coronary intervention a few years previously, and were prescribed aspirin (100 mg/day) . Multiple small bowel ulcers were diagnosed using small bowel capsule endoscopy. After treatment involving a change of aspirin to clopidogrel (75 mg/day) , the multiple small bowel ulcers and chronic anemia improved. Changing aspirin to clopidogrel is thought to be an effective treatment for aspirin-induced multiple small bowel ulceration.

View full abstract

A man in his sixties presented at our hospital with a chief complaint of diarrhea accompanied by nail deformation, skin pigmentation, dysgeusia, anorexia, weight loss and edema of the lower leg. Laboratory data showed malnutrition, and Technetium-99m-labeled human serum albumin scan showed positive accumulation in the intestine. On endoscopy, many more polypoid lesions were found in the stomach and colon than in the esophagus, duodenum, and terminal ileum. Background mucosa between polypoid lesions was reddish and edematous. This case was diagnosed as Cronkhite-Canada syndrome, and treatment initiated with intravenous hyperalimentation, prednisolone, sulfasalazopyridine and tranexamic acid. Gastrointestinal endoscopy performed after three months of treatment showed a decrease in the number of polypoid lesions and reduction in mucosal redness and edema. Gastrointestinal endoscopy after nine months’ treatment showed a disappearance of almost all the polypoid lesions.

View full abstract

A 66-year-old woman presented at our hospital after a positive result in her annual fecal occult blood test. The patient showed no abdominal symptoms. Colonoscopy revealed a sessile submucosal tumor─with a pellucid and smooth surface─on the ileocecal valve and type 1 advanced cancer in the ascending colon. Biopsy results showed lymphangioma and well differentiated adenocarcinoma (tub1) .
A fluoroscopic image identified a submucosal tumor-like smooth surface on the ileocecal valve and an elevated lesion in the ascending colon. Right colectomy was performed.
Macroscopic findings of the resected specimen were submucosal tumor on the ileocecal valve (15×10 mm) and type 1 tumor (35×35 mm) in the ascending colon. Pathological examination revealed lymphatic spaces separated by a thin septum, lined with flattened endothelium on the ileocecal valve of submucosal tumor, and a mainly well differentiated adenocarcinoma with partially mucinous adenocarcinoma in the ascending colon cancer.
We report here a relatively rare case of colonic lymphangioma associated with ascending colon cancer.

View full abstract

A 68-year-old woman was admitted to our hospital with severe back pain. Laboratory data revealed high serum levels of LDH, CRP, and NSE (101 ng/ml) . The diagnosis of PDNEC was confirmed with a biopsy specimen from the lesion. Conventional cisplatin plus irinotecan chemotherapy was administered. Furthermore, radiation therapy was performed at the primary site and bone metastases, and radiofrequency ablation (RFA) was administered to hepatic metastases for down staging. Nevertheless, chemotherapy could only be continued for two courses because of the patient’s depression, and overall survival was ten months. This is a report describing a case of advanced PDNEC in which multidisciplinary treatment was performed.

View full abstract

This report describes three cases where colonic submucosal tumors (SMT) were definitively diagnosed using endoscopic submucosal dissection (ESD) as excisional biopsy. ［Case 1］ An approximately 8 mm hemispherical SMT with a smooth surface was present in the rectosigmoid colon of a 44-year-old woman. Endoscopic ultrasonography (EUS) showed hypoechogenicity in the third layer from the epithelial lining. ESD was performed, and histopathological examination revealed a leiomyoma. ［Case 2］ A ＜10 mm yellowish hemispherical SMT was present in the ascending colon of a 43-year-old man. An SMT with hyperechogenicity was suspected in a region of calcification, with the main locus assumed to be in the tertiary layer based on EUS findings. A granular cell tumor was diagnosed, and ESD was performed. The histopathological diagnosis was leiomyoma with calcification. ［Case 3］ A 7 mm yellowish SMT with a mildly irregular surface was present in the transverse colon of a 63-year-old man. EUS revealed a hypoechoic spherical mass, assumed to be located in the tertiary layer. The resected specimen showed necrotic nodules in the submucosa. Colonic SMTs are difficult to diagnose in many cases and are simply followed up ; however, ESD as excisional biopsy may aid in diagnosis in such cases.

View full abstract

Rectal mucosal prolapse syndrome is often difficult to differentiate from neoplastic lesions─such as advanced rectal carcinoma or rectal malignant lymphoma─using conventional colonoscopy. We report here two cases of rectal mucosal prolapse syndrome diagnosed using endoscopic ultrasonography.
Case 1 : A 35-year-old man. Colonoscopy showed a flat elevated lesion about 5 cm diameter in the rectum. Multiple erosions were present on the surface of the lesion.
Case 2 : A 51-year-old woman. Colonoscopy showed an elevated lesion about 4 cm diameter in the rectum. Erosion and scarring were seen at the center of the lesion.
Endoscopic ultrasonography of both lesions showed smooth, diffuse thickening of the second and third layers of the rectal wall. Neither a solid hypoechoic mass nor a transmural infiltrating lesion was visible, and the five-layer structure of the rectal wall was preserved except for the scarred region. Histological examination of several biopsy specimens obtained from each lesion revealed fibromuscular obliteration. Based on these findings, the lesions were diagnosed as rectal mucosal prolapse syndrome. These findings suggest endoscopic ultrasonography is useful in diagnosis of rectal mucosal prolapse syndrome.

View full abstract

A 78-year-old man underwent total colonoscopy to investigate a positive fecal occult blood test, and was diagnosed with three submucosal tumors (SMTs) of the rectum. He was admitted to our department and endoscopic submucosal dissection (ESD) was performed on the largest lesion. Histological findings confirmed the diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma. Since MALT lymphoma is generally a low grade lymphoma, additional chemotherapy or surgery was not performed. Subsequently the other two lesions were treated by endoscopic mucosal resection (EMR) . Since the patient was also infected with H. pylori, eradication therapy was administered (and confirmed to be successful) . There has been no evidence of recurrence during the four years following treatment. Colorectal MALT lymphoma is a rare disease. Although H. pylori eradication is the treatment of choice for gastric MALT lymphoma, no standard therapy has been established for colorectal MALT lymphoma. Previously, surgical resection was most common performed, but recent reports even show efficacy of H. pylori eradication against colorectal MALT lymphoma. In this case, H. pylori eradication after ESD was effective and there have been no signs of recurrence in four years after treatment.

View full abstract

A 75-year-old man underwent total colonoscopy (TCS) after a positive fecal occult blood test, and was diagnosed with submucosal tumor (SMT) in the Bauhin valve. In 2009, the patient had a hot reddish face and easily became angry. In 2010, TCS re-examination showed the enlarged SMT lesion to be approximately 12 mm in size. Laboratory data showed normal serum gastrin and elevated serum serotonin (299 ng/ml) . Abdominal CT scan identified a 12 mm sized enhanced mass on the Bauhin valve. Subsequently, endoscopic submucosal dissection (ESD) of the SMT was performed. Pathological examination was positive for synaptophysin, CD56 and chromogranin, and the results confirmed the diagnosis of neuroendocrine tumor (NET-G1, i.e. carcinoid) . Following ESD, serum serotonin decreased to 133 ng/ml, and the patient’s symptoms of carcinoid syndrome─such as readiness to anger─were gone. In this case we performed ESD to treat colonic carcinoid with carcinoid syndrome. Follow-up shows there have been no signs of recurrence for three years.

View full abstract

Colonoscopy in an 81-year-old man undergoing dialysis treatment identified a 20 mm laterally spreading tumor (LST) in the transverse colon, and endoscopic submucosal dissection (ESD) was performed. The tumor was pathologically diagnosed as a tubular adenoma. Parasite eggs were present in the submucosal layer and the case was diagnosed as schistosomiasis japonica. Several theories exist regarding the association between schistosomiasis japonica and colorectal cancer, but no consensus has been reached. Schistosoma japonica ova were present beneath the colon adenoma. This case report is presented with a literature review, with regard to future follow-up and the possibility of carcinogenesis.

View full abstract