Progress of Digestive Endoscopy
Online ISSN : 2187-4999
Print ISSN : 1348-9844
ISSN-L : 1348-9844
84 巻, 1 号
選択された号の論文の78件中1~50を表示しています
掲載論文カラー写真集
内視鏡の器械と技術
  • 田中 匡実, 島田 祐輔, 原田 舞子, 林 昌武, 佐々木 善浩, 上市 英雄, 川村 紀夫, 平田 啓一
    2014 年 84 巻 1 号 p. 40-42
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    【症例】65歳,女性。【現病歴】2012年12月に自宅にて吐血し,近医に救急搬送。噴門部胃癌からの出血を認め,止血困難なため当院救急搬送となった。当院で行った緊急上部消化管内視鏡検査では,動脈性の拍動性出血を認め,内視鏡的止血術では治療困難と判断し,外科にて緊急胃切開切除術に加え,胃全摘+脾摘+膵尾部切除術を施行された。術後は経過順調により退院し,外来で経過観察をしていた。2013年3月上旬に腹痛のため外来受診し,精査の結果,胃癌の腹膜播種による横行結腸浸潤に伴う大腸イレウスの診断で,緊急再入院となった。【経過】著明な体力低下に加えて本人の希望もあり,人工肛門造設術は施行せず大腸ステントの挿入予定となった。下部消化管内視鏡検査を実施したところ,脾彎曲部に狭窄を認めWallFlex colonic stentを挿入した。翌日より排ガスを認めたものの,イレウス管造影でステントの口側に別の狭窄を認めたため,5日後に再度ステント挿入術を施行した。翌日から排便を認め,食事摂取も可能となり退院となった。【考察】大腸ステントは本邦では2012年に保険適用となった。それまでは悪性腫瘍による大腸イレウスに対して,経肛門的ステントや人工肛門造設術しか選択肢がなかった。大腸ステントが保険適用となったことで,患者にとってはよりQOLの高い選択肢が増えたと考えられる。
臨床研究
  • 谷田 恵美子, 和泉 元喜, 土谷 一泉, 大熊 幹二, 林 依里, 日高 章寿, 野口 正朗, 内田 苗利, 阿部 孝広, 伊藤 善翔, ...
    2014 年 84 巻 1 号 p. 43-47
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
     経皮内視鏡的胃瘻造設術(PEG)中の誤嚥を防ぐため,当院では口腔咽頭内分泌物を下咽頭で持続吸引する留置持続吸引法を行っている。同方法の有効性を検討するため,胸部CTを用いて評価した。2010年11月〜2013年3月にPEGを施行し,事前に研究への同意を得られた60症例を対象とした。術直前に胸部単純CTを撮影した後,術中に留置持続吸引法を行う群(持続吸引群)と,術中に口腔内に分泌物が貯留した時など必要に応じて用手的に吸引を行う群(従来法群)に無作為に振り分けた。翌日にも胸部単純CTを撮影し,変化を評価した。術当日から翌日の朝にかけての体温・血中酸素飽和度・血中白血球数・C reactive protein(CRP)値の変化,術中の分泌物吸引量,PEGが原因となった術後肺炎の発症数を調査し,それぞれについて2群間での比較をした。その結果,持続吸引群では胸部CTの変化を認めなかったが,従来法群で有意に多くの変化を認めた(0% vs 33%,P<0.001)。術中吸引量は持続吸引群で有意に多かった(2ml vs 0ml,P=0.02)。術後肺炎の発症数に差は認めなかった。留置持続吸引法は,効率的な分泌物除去により,誤嚥による呼吸器の不顕性変化を抑制したものと考えられ,誤嚥予防に有効であった。
  • 綱島 弘道, 梶山 祐介, 小林 猛, 松本 光太郎, 山田 はな恵, 井上 泰介, 青柳 賀子, 中村 圭介, 内藤 善久, 谷口 桂三, ...
    2014 年 84 巻 1 号 p. 48-51
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
     大腸癌イレウスおよび大腸癌による悪性狭窄に対する大腸ステント治療を8例経験した。bridge to surgeryの6例,緩和療法の2例とも偶発症を認めず,手術までの期間が平均48.4日と既報告より長かったが,大腸閉塞スコアを落とすことはなかった。緩和療法例でも生存期間中にステントの閉塞を認めず,患者QOLの向上に有用であると考えた。
  • 麻生 健一朗, 木田 光広, 奥脇 興介, 山内 浩史, 宮澤 志朗, 岩井 知久, 竹澤 三代子, 菊池 秀彦, 渡辺 摩也, 今泉 弘, ...
    2014 年 84 巻 1 号 p. 52-55
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
     今回,我々は当院で経験した膵粘液性囊胞性腫瘍(mucinous cystic neoplasm : MCN)16例の臨床病理学的所見に関してretrospectiveな検討を行った。
     年齢中央値は62歳,男性 : 女性=1 : 15。6例が有症状,10例が無症状で発見された。平均腫瘍径は54.8mm,局在は頭部 : 体部 : 尾部=1 : 7 : 8例であった。EUSでは全例が境界明瞭な類円形の形態を呈し,単房性12例,多房性4例であった。内部の隔壁構造を6例,囊胞内囊胞を6例,点状エコーを2例,壁在結節を7例,石灰化を3例に認めた。ERPでは4例が正常膵管像,11例が腫瘍による主膵管圧排像であった。切除標本の病理検討では4例が悪性であった。悪性例は年齢中央値が高く,平均腫瘍径が大きく,壁在結節高が高かった。
  • 升谷 寬以, 木田 光広, 奥脇 興介, 徳永 周子, 山内 浩史, 宮澤 志朗, 岩井 知久, 竹澤 三代子, 今泉 弘, 小泉 和三郎
    2014 年 84 巻 1 号 p. 56-59
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
     膵漿液性囊胞腫瘍(serous cystic neoplasm : SCN)には亜分類があり,非典型例とされるMacrocystic typeやSolid typeは,他のmalignant potentialを有する膵腫瘍との鑑別にしばしば難渋する。我々は当院で経験したSCN(26例28病変)の臨床的特徴に関してretrospectiveな検討を行った。検討項目は,発症年齢,性別,症状の有無,腫瘍の局在,腫瘍径,ERCP所見,EUS所見(SCNの亜分類),経過とした。平均年齢は60.0歳で,女性に多かった。有症状は7例に認められた。腫瘍の局在は,膵鉤部/頭部/体部/尾部/体尾部=1/5/12/7/3病変,平均腫瘍径34.4mmであった。EUSによる亜分類は,Microcystic type/Macrocystic type/Solid type=14/13/1病変で,これまでに14例に対し切除が施行された。malignant potentialを有する他の膵腫瘍との鑑別が必要となるMacrocystic typeは,microcystic typeと比べ有意に切除例が多かった(p<0.05)。
症例
  • 南雲 大暢, 小川 史洋, 安達 哲史, 江川 優子, 市原 広太郎, 齋藤 訓永, 多田 正弘, 風間 博正
    2014 年 84 巻 1 号 p. 60-63
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
     症例は生来健康な58歳,男性。2012年11月に水様下痢・嘔吐で受診。整腸剤のみで下痢は改善した。念のため施行した大腸内視鏡検査にて直腸に径8mm黄白色調の隆起性病変を認め,生検でカルチノイドと診断した。腹部CTで転移を疑う所見はなく,超音波内視鏡で病変は粘膜下層に留まると考えられ,2013年2月に内視鏡的切除(結紮リング法 : EMR─L)を行った。その際に上行結腸の一部に血管透見消失像を認め,生検にて潰瘍性大腸炎(ulcerative colitis : UC)に矛盾しない所見を得た。病変は軽度であり症状もなく経過観察としていたが,2013年5月に行った大腸内視鏡検査では,盲腸から上行結腸の粘膜は細顆粒状で黄白色の点状粘液付着を認め,典型的なUC像に変化していた。長期罹患例で全大腸炎型のUCに癌やdysplagiaの発生が多いことは知られているが,カルチノイドの報告は少ない。またUCに合併したカルチノイドは,主に長期罹患例や直腸に炎症が存在する症例であり,自験例のように初発の右側型UCでカルチノイドを合併した報告はこれまでにない。またカルチノイドの内視鏡治療後に増悪しており両者の関連性について示唆に富む症例と考えられ文献的考察を加え報告する。
臨床研究
  • 三箇 克幸, 杉森 一哉, 戸塚 雄一郎, 桑島 拓史, 清水 悠郎, 亀田 英里, 三輪 治生, 金子 卓, 粉川 敦史, 沼田 和司, ...
    2014 年 84 巻 1 号 p. 64-65
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Endoscopic retrograde cholangiopancreatography (ERCP) is now considered as the first-line modality for biliary drainage. However, it is limited by failure rate to achieve bile duct access of 3%-5%. In such cases with failure of access to the bile duct, percutaneous transhepatic biliary drainage (PTBD) is needed. Unfortunately, PTBD is associated with a high rate of complications. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been introduced as an effective alternative to PTBD in patients with failure of ERCP. Little is known, however, about the long-term outcomes of EUS-BD performed with a fully covered self-expandable metallic stent (FCSEMS) . We examined the long-term outcomes of EUS-BD performed with an FCSEMS. From August 2010 to October 2013, EUS-BD was performed in 8 patients with distal malignant biliary obstructions. The technical success rate was 100%. The stent patency was maintained in 5 (62.5%) patients until their death, while distal migration of the stent occurred during the follow-up period in the remaining 3 (37.5%) patients. In 2 of these patients, the FCSEMS could be easily reinserted, because the opening of the fistula tract was large enough to be easily found, even after the stent migration. In conclusion, EUS-BD is a safe and effective method in patients with distal malignant biliary obstruction and the stent patency is maintained for a long duration in a high percentage of the patients. However, the distal stent migration rate was significantly high, suggesting the need for a newly designed metallic stent for performing EUS-BD.
症例
  • 太田 一樹, 三好 由里子, 横須賀 路子, 平井 三鈴, 橋本 周太郎, 小島 拓人, 宮本 彰俊, 林 康博, 小林 修, 黒田 博之, ...
    2014 年 84 巻 1 号 p. 66-67
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 37-year-old male visited a nearby medical clinic with a history of recurrent vomiting after taking a commercial calcium supplement (calcium tablets) and drinking water. Since fiberoptic laryngoscopy revealed no abnormalities, the patient was referred to our hospital for further examination. Emergency endoscopy revealed a supplement-like white substance incarcerated in the upper esophagus. We crushed it with forceps, followed by washing. A proton pump inhibitor (PPI) and alginic acid were prescribed. At the second endoscopy performed on June, 2013, transnasal endoscopy was needed and insertion of the endoscope was found to be difficult due to ulceration and stenosis of the upper esophagus. When we performed the third endoscopy on June, there was no improvement in the stenosis and the ulceration was cicatrized, and minor bleeding was caused by the transnasal endoscope insertion. The patient was prescribed oral PPI therapy for the following month. The subjective symptoms disappeared and food intake became possible. Recently, a large number of subjects have begun to take a variety of supplements available in the market, and various types of complications related to the use of these supplements have been reported. We report this rare case of esophageal ulceration/cicatricial stenosis caused by oral administration of a commercial calcium supplement, with a discussion of the relevant literature.
  • 楠 隆昌, 武井 ゆりあ, 大川 修, 中谷 行宏, 吉野 耕平, 唐鎌 優子, 並木 伸, 竹縄 寛, 芝 祐信
    2014 年 84 巻 1 号 p. 68-69
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Esophageal anisakiasis is a rare disease, accounting for about 0.2% of all cases of anisakiasis.
    A 26-year-old woman visited our hospital because of severe epigastric pain and heart burn several hours after eating pickled mackerel, which progressively worsened, and subsequently presented with fever. Contrast CT showed marked hypertrophy of the gastric wall and a significant edematous change in the lower esophagus, in addition to inflammation of the mediastinum. Upper gastrointestinal endoscopy revealed an Anisakis worm in the gastric corpus and lower esophagus. After removing it by endoscopy, her condition immediately improved.
    The present patient was complicated with mediastinitis. It was suggested that anisakiasis can become severe in an esophagus with a thin wall, as can be the case with the small intestine, where the worm may burrow in some cases. As in this case, we can achieve the marked amelioration of anisakiasis through the removal of worms. Thus we should perform endoscopy in the early stage. In addition, since some patients may ingest several worms of Anisakis, we should carefully check whether or not worms burrow in sites other than the stomach, where worms have already been identified.
  • 岡村 明彦, 大森 泰, 石井 賢二郎, 中村 理恵子, 高橋 常浩, 和田 則仁, 川久保 博文, 才川 義朗, 竹内 裕也, 山上 淳, ...
    2014 年 84 巻 1 号 p. 70-71
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Pemphigoid is an autoimmune bullous disease characterized by subepithelial blistering of the skin and mucosa. The lesions are caused by autoantibodies against components of the hemidesmosomes, the junctional adhesion complex. Various subtypes of pemphigoid are recognized, such as bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa acquisita. Mucosal lesions are usually located in the oral and pharyngeal mucosa. Although the esophagus is also covered by squamous epithelium, there are only a few case reports of esophageal lesions of pemphigoid. From Jul/2011 to Jul/2013, we performed gastrointestinal endoscopy in 23 pemphigoid patients and found esophageal lesions in four (17%) ; in all four cases, blisters, erosions, ulceration and stenosis were found in the esophagus. While oropharyngeal lesions coexist in many cases, we should pay attention to cases without skin lesions, depending on the subtypes. Therefore, the gastrointestinal endoscopist has an important role in the diagnosis of pemphigoid.
  • 亀崎 秀宏, 畦元 亮作, 今井 雄史, 大和 睦実, 稲垣 千晶, 矢挽 眞士, 妹尾 純一, 藤本 竜也, 山田 博之, 大部 誠道, ...
    2014 年 84 巻 1 号 p. 72-73
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 61-year-old man was diagnosed as having an esophagobronchial fistula while undergoing chemotherapy and radiotherapy for esophageal cancer. We placed a tracheobronchial stent (Ultraflex) on day 1, but it did not improve the upper and lower respiratory tract symptoms. Esophagography revealed that the fistula was patent. Therefore, we also placed an esophageal stent (Hanaro Stent) on day 26, which permitted the patient to eat and drink. He was discharged from the hospital, but subsequently died of cancerous pleurisy on day 106. We consider that the stenting for the esophagobronchial fistula due to the esophageal cancer contributed to improvement of the quality and prolongation of this patient’s life.
  • 小林 真介, 岡村 幸重, 伊倉 顕彦, 水野 達人, 山本 悠太, 上岡 直史, 吉野 雄大, 片山 正, 白石 貴久, 上原 淳, 佐伯 ...
    2014 年 84 巻 1 号 p. 74-75
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 61-year-old woman presented to the hospital complaining of vomiting. She was diagnosed by upper gastrointestinal endoscopy as having a benign esophageal stricture associated with reflux esophagitis. Although her symptoms improved temporarily with balloon dilatation performed three times, the stricture recurred immediately after each dilatation. Because she refused to undergo frequent endoscopic treatments, an esophageal stent was temporarily inserted, with informed consent from both the patient and her family. Three months later, endoscopy no longer revealed evidence of esophageal stricture, and the stent was endoscopically removed. Until now, approximately 6 months after the endoscopic stent removal, the patient has developed no recurrence of the symptoms of stricture.
  • 西 知彦, 鳥海 史樹, 岩崎 栄典, 遠藤 高志, 山本 立真, 五十嵐 一晴, 相澤 栄俊, 下山 豊
    2014 年 84 巻 1 号 p. 76-77
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    The patient was a 60-year-old man with alcoholic liver cirrhosis. Esophagogastroduodenoscopy performed for upper gastrointestinal bleeding revealed a superficial depressed lesion close to esophageal varices, about 35-37 cm from the incisors. Biopsy of the lesion revealed squamous cell carcinoma. Magnifying endoscopy with NBI (narrow band imaging) showed many inhomogeneous loop-like vessels varying in caliber within the lesion, and the tumor was found to invade the lamina propria mucosa.
    ESD (endoscopic submucosal dissection) was performed after EVL (endoscopic variceal ligation) of the esophageal varices. EVL carried out 2 cm away from the lesion did not cause fibrosis of the submucosa under the tumor. En-bloc resection was achieved without any complications. Histopathologically, the tumor was diagnosed as squamous cell carcinoma, pT1a-LPM, ly0, v0, pHM0, pVM0.
    ESD following EVL could be a useful therapeutic strategy for superficial esophageal carcinomas associated with esophageal varices.
  • 岡村 亮, 小柳 和夫, 相浦 浩一, 市東 昌也, 壁島 康郎, 星本 相淳, 萬谷 京子, 和多田 晋, 田中 求, 杉浦 仁, 掛札 ...
    2014 年 84 巻 1 号 p. 78-79
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 70-year-old man was diagnosed by upper gastrointestinal endoscopy to have superficial esophageal cancer at 34-37 cm from the incisors and had undergone ESD two years ago. After the first ESD, periodic examination had been performed every six months. At the one-year follow-up, endoscopic examination showed a small superficial protruded lesion on the posterior esophageal wall at 30 cm from the incisors. The lesion increased in size rapidly and appeared like a submucosal tumor. The tumor, however, was less than 5 mm in diameter. Magnifying endoscopy with NBI revealed B2 or B3 intraepithelial papillary capillary loops at the top of the lesion. The lesion was suspected to be malignant. A repeat ESD was performed 20 months from the first ESD. Pathological examination of the resected specimens revealed moderately differentiated squamous cell carcinoma invading the submucosal layer (SM2) , with no vascular involvement. The surgical margin was negative for cancer (pHM0 VM0) . However, in deference to the patient’s wishes, we carried out esophagectomy. Pathological examination of the resected specimens revealed no residual cancer cells or any lymph node metastasis. Herein, we have reported a rare case of micro-carcinoma of the esophagus that showed apparent protrusion.
  • 森山 友章, 長主 直子, 出張 玲子, 池田 隆明
    2014 年 84 巻 1 号 p. 80-81
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 67-year-old Japanese man was admitted to the hospital because of dysphagia. He had a past medical history of hypertension, atrial fibrillation, diabetes mellitus, and ureterolithiasis. Nine months earlier, endoscopy had revealed a protruding lesion in the lower esophagus. A barium study showed a giant elevated lesion with a deep ulcer associated with marked stenosis in the lower esophagus. Endoscopy revealed a multi-nodular protruding tumor covered with smooth and reddish mucosa. CT revealed a low-density mass. Biopsy specimens taken from the lesion showed proliferation of spindle cells, and immunohistochemical analysis of the tumor showed positive staining for c-kit and CD34. A diagnosis of gastrointestinal stromal tumor (GIST) was made and esophagectomy was performed. The resected specimen measured 9.3×8.1×5.1 cm in size and the risk of GIST was estimated to be high by histopathological examination. The diagnosis of submucosal tumor (SMT) should be carefully considered in cases where endoscopy reveals a smooth protruding lesion in the esophagus or compression of the esophagus. Rapidly growing esophageal GISTs should be borne in mind in such cases, and endoscopic follow-up of SMTs measuring more than 2 cm in diameter at least twice a year is thought to be necessary.
  • 河村 貴広, 浅川 剛人, 金城 美幸, 高浦 健太, 西尾 匡史, 勝倉 暢洋, 小橋 健一郎, 橋口 真子, 先田 信哉, 有村 明彦, ...
    2014 年 84 巻 1 号 p. 82-83
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Esophageal GISTs are rare tumors, accounting for 2%-5% of all GISTs. Imatinib mesylate has been reported to have an excellent effect in patients with unresectable and recurrent esophageal GISTs, however, there are few reports on the adverse effects. We present the first case report of a patient with esophageal GIST who developed pleuritis during treatment with imatinib mesylate. A 67-year-old woman was referred to us with fever, cough and dysphagia. CT showed a large mass in the thoracic cavity. By endoscopic and histopathological examinations, the tumor was diagnosed as an esophageal GIST. Because the tumor was adherent to the thoracic aorta, heart and left lung, it was judged as being unresectable. Oral administration of imatinib mesylate at 400 mg/day was started, however, the patient developed pleuritis after 3 weeks of treatment. It appeared that because the tumor rapidly liquefied and reduced in size during the imatinib treatment, necrotic substances from the tumor were leaking into the thoracic cavity. The patient was treated for the pleuritis while being continued on imatinib mesylate. The pleuritis resolved by two months with drainage and antibiotic treatment. The clinical course after treatment of the pleuritis has been excellent, the patient is symptom-free and the effect of imatinib mesylate has remained sustained for over twelve months.
  • 武居 友子, 大森 泰, 中村 理恵子, 高橋 常浩, 和田 則仁, 川久保 博文, 竹内 裕也, 才川 義朗, 細江 直樹, 緒方 晴彦, ...
    2014 年 84 巻 1 号 p. 84-85
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    There is no definite consensus on the most suitable endoscopic treatment for esophageal varices in children. Especially, endoscopic treatment of infants under 1 year of age is very rare. We performed endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) for two 10-month-old infants with liver cirrhosis associated with congenital biliary atresia.
    Case 1 was a 10-month-old female infant who was 72 cm in height and weighed 10.0 kg. Endoscopic examination under general anesthesia was performed for melena, The source of the bleeding was identified as esophageal varices 〔Li, F2, Cb, RC (+) 〕. An endoscope with an EVL device could be passed through the narrow opening of the esophagus, and the bleeding varix was ligated by EVL. Case 2 was a 10-month-old female infant who was 65.2 cm in height and weighed 6.6 kg. Endoscopic examination was performed as a screening procedure prior to living donor liver transplantation. Esophageal varices 〔Ls, F3, Cb, RC (+) 〕 were found. An endoscope with an EVL device could not be negotiated through the opening of the esophagus, therefore, EIS was performed.
    Because of the scarcity of cases receiving endoscopic treatments among children, it is difficult to evaluate the differential therapeutic outcomes between EIS and EVL in this patient population. Based on previous reports, it would appear that the risk of complications is higher in cases treated by EIS than that in cases treated by EVL. Therefore, we think that EVL might be preferable to EIS in children. In case 1, we succeeded in performing EVL effectively and safely in a 10-month-old infant. Therefore, the endoscopic procedure of first choice for esophageal varices in infants below 1 year of age is EVL, if the EVL device can be negotiated past the opening of the esophagus.
  • 福田 知広, 今村 諭, 大野 恵子, 角田 裕也, 伊藤 剛, 田村 寿英, 長久保 秀一, 諸星 雄一, 小池 祐司, 藤田 由里子, ...
    2014 年 84 巻 1 号 p. 86-87
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 60-year-old woman was referred to our hospital with nausea, vomiting, taste disorder, alopecia, onichodystrophy and epigastric pain. Laboratory examination showed under-nutritionand abdominal computed tomography showed a thickened stomach wall. Endoscopic examination of the entire digestive tract showed multiple salmon roe-like polyp in the stomach, duodenum, ileum, and colon. Pathologically, biopsy specimens from the polyp-like lesions and mucosa revealed edematous change of the intestitium and cystic dilatation of the glands. We diagnosed the patient as having Cronkhite-Canada syndrome because of the polyposis associated with abnormalities of the ectoderm.
    Prednisolone therapy was initiated at 40 mg per day, with tapering of the dose subsequently. The clinical symptoms, laboratory data and polyposis improved with the prednisolone therapy. The prognosis of patients with Cronkhite-Canada syndrome treated with prednisolone is favorable, however, it has been reported recently that Cronkhite-Canada syndrome is associated with a risk of carcinogenesis. Therefore, it is necessary to conduct periodic screening of the entire digestive tract even after mucosal improvement.
  • 三宅 麗, 筋野 智久, 小林 拓, 加藤 裕佳子, 中野 雅, 芹澤 宏, 渡辺 憲明, 土本 寛二, 末森 友浩, 森永 正二郎, 日比 ...
    2014 年 84 巻 1 号 p. 88-89
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 56-year-old-woman diagnosed as having primary gastric amyloidosis at age 52 was followed up by annual gastroscopy. Although small granular lesions in the antrum of the stomach were seen at age 52, a variety of lesions, such as small ulcers, submucosal tumor-like lesions and elevated granular lesions in the antrum and cardia of the stomach were found at age 56. With narrow-band imaging (NBI) enhancement, the mucosa surrounding the ulcers appeared to be intact. The histological examination findings were consistent with gastric amyloidosis. She was continued on treatment with a proton pomp inhibitor.
    Primary gastric amyloidosis is rare and only 17 case reports with a description of the endoscopic findings have been published in Japan. Primary gastric amyloidosis manifests with a variety of endoscopic findings. We divided these findings into the following four types, submucosal tumor-like, early cancer-like (IIc-like) , advanced cancer-like (Borrmann typeII-like) and elevated granular lesions. In our case, we observed two types of endoscopic findings over the course of 5 years. Surgical interventions have been reported in some cases because of uncontrolled hemorrhage or stenosis. We would perform endoscopy annually in our case.
  • 荻野 悠, 三村 亨彦, 土方 一範, 馬越 智子, 乾山 光子, 岸本 有為, 伊藤 謙, 岡野 直樹, 中野 茂, 五十嵐 良典
    2014 年 84 巻 1 号 p. 90-91
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    We report the case of a 70-year-old man who was admitted to another hospital with a chief complaint of hematochezia. He had undergone total gastrectomy 15 years ago. Abdominal computed tomography (CT) showed complete obstruction of the splenic vein by a tumor in the head of the pancreas. He was then referred to our hospital for further management of anemia and the pancreatic tumor. Upper gastrointestinal endoscopy revealed isolated varices lacking the red color sign in the region of the gastric anastomosis. We made the diagnoses of pancreatic head cancer based on the findings on the cytological specimens obtained by endoscopic retrograde cholangiopancreatography, and left-sided portal hypertension due to splenic vein invasion of the tumor based on the CT findings. Because we could not conclude that the bleeding was caused by the varices, we started the patient on chemotherapy and kept her under observation. During the hospitalization, however, the hematochezia recurred repeatedly, and two blood transfusions were required. Upper gastrointestinal endoscopy performed a second time revealed enlarged and oozing varices, and we performed partial splenic artery embolization (PSE) to reduce the blood ooze from the site of bleeding. Well-developed collateral circulation was seen at the splenic hilum and we performed 80% embolization using Gelfoam and metallic coils. The PSE reduced the varices in the anastomosis, and nine months later, the varices had almost disappeared entirely. Left-sided portal hypertension complicated by pancreatic cancer is comparatively rare. In the present case, PSE was effective for stemming the bleeding from the gastric varices.
  • 矢吹 拓, 千嶋 巌, 千嶋 さやか, 北岡 吉民, 上原 慶太, 中山 成一
    2014 年 84 巻 1 号 p. 92-93
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    〔Case 1〕A 71-year-old woman was admitted to our hospital because of acute heart failure. She had a history of diabetes, rheumatoid arthritis and atrial fibrillation. She was bedridden after suffering from cardiogenic cerebral embolism while being hospitalized. On day 127 after admission, she developed high fever and hypotension of sudden onset. Investigations revealed leukocytosis. She was suspected as having septic shock, and while seeking the septic focus, we performed computed tomography (CT) . CT showed air in the wall of the stomach and wall thickening with portal venous gas. Based on these findings, emphysematous gastritis was diagnosed. Broad-spectrum antibiotics were administered immediately after obtaining a blood sample for bacterial culture. On day 140 after admission, endoscopic examination was performed, which revealed a giant ulcer with a yellow-white membrane in the posterior wall of the stomach.
    〔Case 2〕A 65-year-old woman was admitted to our hospital with myalgia. She had a history of amyotrophic lateral sclerosis (ALS) and diabetes mellitus. She was using a ventilation device and had a percutaneous gastrostomy feeding tube. She was diagnosed as having polymyalgia rheumatica and started on treatment with low-dose prednisolone. On day 25 after admission, she developed epigastric pain and nausea of sudden onset, and a bloody drainage from the gastrostomy tube. We suspected gastrointestinal hemorrhage and performed emergency endoscopy. Endoscopic examination revealed a giant ulcer and erosions in the posterior wall of the stomach. Abdominal CT showed gas within a thickened gastric wall and also in the peripheral portal venous radicals. Based on the imaging findings, the patient was diagnosed as having emphysematous gastritis. The patient was commenced on broad-spectrum antibiotics. Klebsiella pneumoniae was cultured from the gastric mucosa.
    〔Conclusion〕We encountered two rare cases of emphysematous gastritis with portal venous gas.
  • 青松 直撥, 中村 雅憲, 長谷川 毅, 青松 敬補
    2014 年 84 巻 1 号 p. 94-95
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    We report a case of hyperplastic polyp prolapsing into the duodenum, which caused the ball valve syndrome. A 65-year-old woman was admitted because of epigastric pain and vomiting after eating. CT of the upper abdomen showed a tumor within the duodenal bulb. Endoscopic examination revealed transpyloric prolapse caused by the typeIV gastric polyp. The polyp was pushed back into the stomach. Polypectomy was performed. The tumor was 25×20 mm in size. Histological findings were consistent with a hyperplastic gastric foveolar polyp. After treatment, the patient’s symptoms resolved. She has not shown any recurrence of the symptoms until now.
  • 石井 優, 野津 史彦, 小西 一男, 北村 勝哉, 佐藤 悦基, 三田村 圭太郎, 山崎 公靖, 青木 武士, 村上 雅彦, 斉藤 光次, ...
    2014 年 84 巻 1 号 p. 96-97
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 60-year-old woman was referred to our hospital for further evaluation of a gastric submucosal tumor (SMT) on the lesser curvature in the supra-angular region of the stomach. Blood tests revealed elevation of the serum gastrin level and positive test results for intrinsic factor antibody and antiparietal cell antibody. Gastric endoscopy revealed evidence of mucosal atrophy from the fornix to the lower body of the stomach, but not in the antrum. The diagnosis of gastric SMT with type A gastritis was made. EUS revealed an internally heterogeneous hypoechoic tumor localized mainly in the fourth layer of the stomach. Since EUS-guided fine needle aspiration could not be performed successfully on account of the tumor location, we proposed three management options to the patient : observation with annual endoscopy, tumor biopsy using an ESD device, and surgical resection. She decided on surgical resection, and distal laparoscopic gastrectomy was performed. Histology of the resected specimen revealed an aberrant pancreas, Type 1 of Heirich’s classification and the serum gastrin level recovered to almost within the normal range.
  • 竹中 一央, 吉竹 直人, 岩崎 茉莉, 星野 敦, 櫻井 紘子, 山本 義光, 笹井 貴子, 冨田 茂樹, 新井 ほのか, 平石 秀幸
    2014 年 84 巻 1 号 p. 98-99
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 65-year-old woman with liver cirrhosis (type C) underwent esophagogastroduodenoscopy (EGD) for examination of esophago-gastric varices. EGD revealed a submucosal tumor (SMT) -like appearance in the anterior wall of the gastric body. Endoscopic ultrasonogaraphy indicated that the lesion was a low-echoic mass localized within the muscularis mucosa. Histopathology of a biopsy specimen from the lesion showed enlarged follicles composed of atypical small lymphoid cells, however, the atypical cells did not infiltrate or destroy the glandular epithelium, i.e., there were no lympho-epithelial lesions. On immunohistochemical analysis, the atypical cells was positive for CD10, CD20, CD79a and BCL-2, and negative for Cyclin D1. We diagnosed the SMT-like lesion as a follicular lymphoma. There was no obvious accumulation on FDG-PET. However, a bone marrow aspirate and biopsy revealed CD10-and BCL-2-positive cells. Based on these findings, the patient was diagnosed as having Stage IV primary gastric lymphoma, and was adiministered chemotherapy with rituximab. EGD after three courses showed that the SMT-like lesion had disappeared. We report a rare case of gastric follicular lymphoma presenting with a SMT-like appearance.
  • 藤本 愛, 堀井 城一朗, 後藤 修, 落合 康利, 高橋 幸志, 佐々木 基, 高林 馨, 佐々木 文, 下田 将之, 亀山 香織, 浦岡 ...
    2014 年 84 巻 1 号 p. 100-101
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    This subject was a 50-year-old male who underwent routine health check-up at another clinic. Upper gastrointestinal endoscopy performed during the check-up revealed a flat, slightly reddish lesion measuring about 5 mm in diameter, that appeared malignant. Hiatal hernia, reflux esophagitis, and several fundic gland polyps measuring less than 5 mm in diameter each were also observed, however, there was no evidence of atrophic gastritis. Biopsy of the reddish lesion revealed a moderately differentiated adenocarcinoma. The cancerous lesion was resected by endoscopic submucosal resection (ESD) . Histopathologic examination revealed gastric adenocarcinoma of the fundic gland type.
    Gastric adenocarcinoma of the fundic gland type is a neoplastic lesion mainly composed of highly differentiated columnar cells mimicking the fundic gland cells, mainly chief cells, with nuclear atypia. The most important clinicopathologic feature is cancer invasion of the submucosal layer, however, most recurrent lesions tend to be less than 10 mm in diameter, as they were in our case. Immunohistochemical examination was useful for the diagnosis. The cancer cells were diffusely positive for MUC6 (a marker of fundic gland cells) and pepsinogen I (a marker of chief cells) .
    We have reported the clinicopathologic findings of a case of gastric adenocarcinoma of the fundic gland type that was completely resected by ESD.
  • 山里 哲郎, 入口 陽介, 小田 丈二, 水谷 勝, 山村 彰彦
    2014 年 84 巻 1 号 p. 102-103
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A-70-year-old man presented to our center with dysphagia. Upper gastrointestinal endoscopy revealed a type 3 lesion in the area between the lesser curvature and the posterior wall of the cardia. A shallow depressed area with a strong reddish color was found at the anal side of the ulceration and a marked elevation of the submucosal part with erosions was found at the posterior and greater curvature side of the lesion. Biopsy of the type 3 lesion revealed well-differentiated adenocarcinoma. The second lesion, a IIa lesion, was found in the lesser curvature of the lower gastric body. The two lesions were not contiguous with each other. A barium examination was performed, which revealed only the type 3 lesion mentioned above. Complete gastric resection was performed. Histopathological examination of the resected specimen revealed a well-differentiated adenocarcinoma involving the mucosa and submucosal layer. Endocrine cells of different sizes and shapes were found in the area of the ulceration. Immunohistochemical staining showed a strongly positive reaction for chromogranin A and synaptophysin. The final pathological diagnosis was endocrine carcinoma. The case is reported with a review of the literature.
  • 原田 篤, 荒川 廣志, 小山 誠太, 安達 世, 伊藤 善翔, 斉藤 恵介, 松本 喜弘, 高倉 一樹, 月永 真太郎, 小田原 俊一, ...
    2014 年 84 巻 1 号 p. 104-105
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Recently, synchronous multiple early gastric cancers are being increasingly reported due to the aging of society and development of high-performance endoscopy techniques. We present two cases of synchronous multiple early gastric cancers in which the diagnosis was made before the treatment. In Case 1, three pedunculated lesions measuring approximately 10 mm in diameter and one depressed lesion measuring 20 mm in diameter were detected endoscopically in the gastric antrum, and examination of biopsy specimens revealed the diagnosis of cancer for all the lesions. Laparoscopic subtotal gastrectomy was performed, and histology of the resected tissue revealed intramucosal well-differentiated tubular adenocarcinoma in the three pedunculated lesions and intramucosal poorly differentiated adenocarcinoma in the depressed lesion. In Case 2, two depressed lesions measuring approximately 10 mm in diameter and one pedunculated lesion measuring 3 mm in diameter detected in the gastric body were treated by endoscopic submucosal resection. All the resected lesions were diagnosed histopathologically as intramucosal well-differentiated tubular adenocarcinomas. Histopathological examination revealed evidence of atrophic gastritis with intestinal metaplasia due to H. pylori infection in the background gastric mucosa in both the cases, and the mucin expression phenotype of the gastric cancer was the gastric phenotype in the three pedunculated lesions of Case 1 and the intestinal phenotype in all the three lesions in Case 2. We suggest that the possible presence of synchronous multiple cancerous lesions, e.g., well-differentiated adenocarcinoma located in the atropic gastric mucosa, should be investigated endoscopically in patients diagnosed as having early gastric cancer.
  • 宮下 春菜, 矢野 貴史, 長谷川 力也, 山根 敬子, 三島 孝仁, 中目 哲平, 石黒 康浩, 村田 東, 荒木 正雄, 風間 暁男
    2014 年 84 巻 1 号 p. 106-107
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 65-year-old man presented with liver dysfunction. Abdominal contrast-enhanced computed tomography (CT) revealed findings suggestive of advanced gastric cancer and a lower bile-duct tumor with hilar lymph node and abdominal para-aortic lymph node metastasis. Esophagogastroduodenoscopy (EGD) showed ulcer-like lesions extending from the cardia to the lower gastric body. Endoscopic retrograde cholangiopancreatography (ERCP) showed severe stenosis of the lower bile duct. Histopathological examination of biopsy specimens obtained from the stomach and duodenal papilla showed moderately to poorly differentiated adenocarcinoma. The findings were suggestive of a bile duct metastasis from the gastric cancer, or a double cancer of the stomach and lower bile duct cancer. Because of the presence of distant metastases, the patient was administered chemotherapy directed against the gastric cancer. At the time of writing, the gastric cancer has shrunk slightly, and the lymph node metastasis has disappeared. On the other hand, the stenotic portion of the lower bile duct has expanded, and the tumor at the duodenal papilla has grown. On the basis of these findings, we diagnosed double cancer. We describe our experience with an extremely rare case of concurrent gastric cancer and lower bile duct cancer and discuss the case with a review of the literature.
  • 大隅 寛木, 石山 晃世志, 平澤 俊明, 由雄 敏之, 山本 頼正, 土田 知宏, 藤崎 順子, 五十嵐 正広, 山本 智理子
    2014 年 84 巻 1 号 p. 108-109
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Familial adenomatous polyposis (FAP) is a rare hereditary syndrome characterized by multiple colorectal polyps and early development of colorectal cancer. Although FAP uniformly involves the large bowel, it may also produce lesions in the stomach and upper intestinal tract. Management of the risk of development of upper gastrointestinal cancer is one of the greatest challenges faced by clinicians involved in the care of polyposis families.
    We present the case of a 45-year-old woman with FAP who developed gastric cancer early post proctocolectomy. A gastric adenoma with moderate atypia was detected during the upper gastrointestinal endoscopic screening performed prior to the colorectomy. However, 14 months later, the gastric adenoma had progressed to early gastric cancer. In FAP patients living in East Asia, gastric adenoma is a high risk factor for gastric cancer and shows rapid progression. Therefore, it is important in FAP patients detected to have gastric adenomas, to perform upper gastrointestinal endoscopy in the short term and to resect any gastric adenomas, regardless of their tissue grade.
  • 倉本 崇光, 加藤 順子, 染谷 秀忍, 谷口 源太郎, 伊藤 智康, 村上 敬, 東原 良恵, 内山 明, 長田 太郎, 永原 章仁, 荻 ...
    2014 年 84 巻 1 号 p. 110-111
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    We report the case of a patient with submucosal tumor (SMT) -like gastric cancer who had been followed up for 5 years. A 67-year-old man who had a SMT-like elevation of about 1 cm in diameter with a mild depression on the lesser curvature of the upper body of the stomach was followed up from 2008. At the examination in 2010, the tumor had enlarged slightly, however, no changes in the morphological characteristics were noted. During the follow-up period, periodic biopsy of the lesion revealed no evidence of carcinoma. Endoscopy carried out in 2013 revealed that the lesion had increased in size to 15 mm and was accompanied by a deep depression in the center. Pathological examination of biopsy specimens obtained from the lesion revealed adenocarcinoma. The urea breath test result for H. pylori infection was positive. Proximal partial gastrectomy was performed. Histological examination of the resected specimen revealed moderately differentiated adenocarcinoma proliferating mainly in the submucosal layer. In cases with small lesions, such as in this patient, it is difficult to make an early diagnosis of SMT-like gastric carcinoma. It is important to perform periodic endoscopic examinations and to be alert to any morphological changes in order to make the diagnosis at an early stage.
  • 尾野 大気, 大森 泰, 中村 理恵子, 高橋 常浩, 和田 則仁, 川久保 博文, 竹内 裕也, 才川 義朗, 亀山 香織, 北川 雄光
    2014 年 84 巻 1 号 p. 112-113
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    With an increase in the incidence of superficial oro/hypo-pharyngeal cancer, it has become clear that metachronous cancer may also develop often in these cases, as in the case of superficial esophageal cancer. Patients with risk factors such as ALDH2 deficiency or a heavy drinking and/or smoking history require long-term follow-up for the detection of metachronous cancer. If the metachronous cancer is also of the superficial type, endoscopic treatment may be indicated. It is estimated that cases requiring multiple treatments will increase in the future. However, the oro/hypo-pharyngeal lumen is narrow and uneven. Endoscopic resection may become difficult due to scar formation from the previous treatment. In this situation, a safe and reliable resection method is required. We were able to safely perform complete en-bloc resection of the superficial cancer that developed in the scar from the previous operation, by endoscopic laryngo-pharyngeal surgery (ELPS) . ELPS is a safe and secure procedure for patients with postoperative scars.
  • 菊地 秀昌, 山田 哲弘, 竹内 健, 新井 典岳, 岩佐 亮太, 古川 竜一, 曽野 浩治, 長村 愛作, 中村 健太郎, 青木 博, 吉 ...
    2014 年 84 巻 1 号 p. 114-115
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 63-year-old man with the chief complaints of hematemesis and melena was admitted to our hospital. Neither gastroscopy nor colonoscopy revealed the source of the bleeding, however, CTE (CT enterography) revealed three giant diverticula arranged in a row in the third portion of the duodenum. Capsule endoscopy (CE) could not be carried out successfully, because the agile patency capsule swallowed prior to the capsule endoscopy was trapped in a duodenal diverticulum. Single balloon enteroscopy revealed an ulcer in one of the duodenal diverticula. Endoscopic clipping of the ulcer was performed prophylactically, which successfully controlled the bleeding.
    However, the patient desired to undergo a definitive operation for the diverticular hemorrhage. Histopathologic examination of the resected specimen showed granulation tissue causing narrowing of the blood vessels in the diverticulum with the ulcer treated by clipping.
    The findings in this case suggest that CTE may be a useful diagnostic tool in the screening for obscure gastrointestinal bleeding, especially in cases where CE is not available.
  • 長尾 さやか, 長尾 二郎, 斉田 芳久, 渡邉 学, 榎本 俊行, 松清 大, 高林 一浩, 渡邉 良平, 大辻 絢子, 永岡 康志, 石 ...
    2014 年 84 巻 1 号 p. 116-117
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    In recent years, laparoscopy-endoscopy cooperative surgery (LECS) has been empoloyed as one of the minimally invasive therapies for the treatment of gastric submucosal tumors. In this study, we report a case of LECS applied for the treatment of a duodenal submucosal tumor ; LECS was performed in a 75-year-old man detected to have a submucosal tumor measuring 20 mm in size in the portion of the duodenum contralateral to the ampulla of Vater. Utilizing 5 trocars, we first confirmed the location of the tumor by exposing the second portion of the duodenum. Then the duodenum was mobilized by the Kocher maneuver. A suture anchor was placed on the tumor, followed by duodenal full-thickness incision as in endoscopic submucosal dissection (ESD) . For preventing exposure of the tumor mucosa outside the intestinal lumen, a careful incision was made around the tumor under laparoscopic guidance. After the resection, the duodenum was closed by utilizing the suture technique of gathering the cutting edges vertically to gain a wider lumen. The blood loss was 10 ml, the operative time was 296 minutes, and no intraoperative complications were observed. No postoperative complications, including anastomotic leakage and/or stricture were observed. Histopathology revealed a low-risk gastrointestinal stromal tumor (GIST) and the resection margin was negative. LECS is feasible for the treatment of gastric submucosal tumors, since it preserves gastric function by avoidance of excessive resection and deformation. As long as the indications are carefully selected, especially in respect of the size and location of the tumor, this procedure is also considered to be feasible for the treatment of duodenal submucosal tumors.
  • 遠藤 佑香, 藤原 崇, 林 星舟, 小泉 理美, 千葉 和朗, 岩崎 将, 來間 佐和子, 桑田 剛, 江頭 秀人, 小泉 浩一, 神澤 ...
    2014 年 84 巻 1 号 p. 118-119
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    The patient was a 67-year-old woman in whom endoscopic retrograde cholangiopancreatography (ERCP) performed to treat choledocholithiasis revealed a 1.5-cm pedunculated polyp in the duodenum in October 2010. Pathological examination of a biopsy specimen showed no evidence of malignancy. In July 2012, the polyp had grown to 3.5 cm in diameter. The head of the polyp was lobular and red, and revealed no irregularity of the surface or vascular pattern on magnifying endoscopy with narrow-band imaging (NBI) . The stalk of the polyp showed no marked differences from the normal duodenal epithelium. Another biopsy specimen revealed arborecent hyperplasia of the muscularis mucosa, and a hamartomatous polyp was suspected. The patient was admitted to the hospital for endoscopic treatment in view of the possibility of malignancy. She underwent polypectomy; her subsequent clinical course was uneventful, and she was discharged from the hospital 8 days after treatment. The resected specimen showed a lobular polyp measuring 34×18×14 mm, and pathological examination confirmed the diagnosis of a hamartomatous polyp. She did not have any family history of Peutz-Jeghers (P-J) syndrome and showed no pigmented spots; therefore, P-J-type polyp was diagnosed. No recurrence or evidence of other polyps was seen on gastrointestinal endoscopy or colonoscopy performed 1 year after the treatment. P-J-type polyps are hamartomatous polyps with the same pathological findings as the polyps associated with P-J syndrome without the family history or pigmented spots. P-J-type polyps can cause bleeding and obstruction, and show potential for malignant transformation; therefore, treatment such as surgery or endoscopic removal is warranted. In addition, other areas of the gastrointestinal tract, including the small intestine, need to be examined to rule out multiple lesions.
  • 平井 太, 石井 貴, 原田 貴之, 鈴木 広和, 田中 耕太郎, 阿部 径和
    2014 年 84 巻 1 号 p. 120-121
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 64-year-old man was referred to our hospital for further management of anemia and duodenal tumor. Esophagogastroduodenoscopy (EGD) in our division showed a semipedunculated tumor, 7 mm in diameter, above the major papilla of the duodenum. The positional relationship between the tumor and the minor papilla of the duodenum was unclear. A biopsy led to the diagnosis of pyogenic granuloma. Contrast-enhanced computed tomography (CT) showed clear enhancement of the tumor. Endoscopic retrograde cholangiopancreatograpy (ERCP) showed no pancreas divisum. We performed endoscopic mucosal resection (EMR) of the tumor. Pathological examination of the resected tumor showed proliferation of blood capillaries within a stroma containing lymphocytic inflammatory cells and fibrosis. The surface of the tumor was covered with slough. These findings were most consistent with the diagnosis of pyogenic granuloma. Follow-up EGD after 3 months showed no signs of tumor recurrence, and the normal minor papilla of the duodenum was detected above the EMR scar. At the follow-up after 6 months, the patient remained in good general condition.
  • 馬越 智子, 原 精一, 松清 靖, 宅間 健介, 岸本 有為, 三村 享彦, 伊藤 謙, 岡野 直樹, 五十嵐 良典, 高地 良介, 土屋 ...
    2014 年 84 巻 1 号 p. 122-123
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 64 year-old man was admitted to our hospital with acute pancreatitis. Abdominal CT showed a well-enhanced tumor (size 3-5 cm) .
    Upper gastrointestinal endoscopy revealed a pedunculated submucosal tumor in the second part of the duodenum. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy, and a gangliocytic paraganglioma was diagnosed as the cause of the acute pancreatitis. A pylorus-preserving pancreaticoduoenectomy was performed. The surgical specimen contained a pedunculated solid nodular tumor located near the major duodenal papilla, measuring about 4 cm in diameter. The pathological diagnosis was identical to the preoperative diagnosis, that is, gangliocytic paraganglioma.
  • 大村 卓也, 西村 誠, 新井 冨生, 金澤 伸郎, 三井 秀雄, 弥勒寺 紀栄, 田村 優子, 中嶋 研一朗, 佐々木 美奈, 上垣 佐登 ...
    2014 年 84 巻 1 号 p. 124-125
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    An 80-year-old male presenting with abdominal distension was referred to our institution after being detected to have a positive test for fecal occult blood. Computed tomography revealed a retroperitoneal tumor. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed an invasive mass inside the inferior duodenal angle, and cytological examination confirmed the diagnosis of squamous cell carcinoma (SCC) . Despite careful examination, the origin of the tumor remained unclear. Analysis of specimens obtained during right hemicolectomy, partial hepatectomy, and mesenteric tumor resection confirmed the diagnosis of SCC.
    Typically, retroperitoneal carcinoma is a metastatic cancer, and primary retroperitoneal carcinoma is extremely rare. This paper describes a case of retroperitoneal SCC diagnosed by EUS-FNA and considered as a case of carcinoma of unknown primary (CUP) . According to a widely accepted hypothesis about the onset of primary cancer in the retroperitoneum, these cancers arise from serous or mucinous metaplasia of pre-existing retroperitoneal coelomic mesothelium. In our case, the tumor specimens revealed no serous or mucinous metaplasia; therefore, the diagnosis of retroperitoneal SCC with CUP was considered more reasonable.
    If a carcinomatous lesion does not contain an epithelial component, it is unlikely to be a primary tumor. In this case, EUS-FNA strongly suggested the diagnosis of SCC before surgery; therefore, the treatment course was changed. Thus, EUS-FNA was useful both for diagnosis and selection of the therapeutic strategy.
  • 桂田 純二郎, 松本 力雄, 山田 博文, 黒田 徹
    2014 年 84 巻 1 号 p. 126-127
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 70-year-old man was admitted to our hospital with jaundice. Abdominal ultrasonography (US) and computed tomography (CT) showed a multilobular cystic lesion in the head of the pancreas. Abdominal contrast-enhanced CT suggested a tumor in the papilla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) showed redness and swelling of the papilla of Vater, a dilated common bile duct and a multilobular cystic lesion in the head of the pancreas. ERCP and endoscopic biliary drainage (EBD) were performed. Because the fever remained persistent even after the drainage, we performed a CT, which showed a liver abscess. Percutaneous transhepatic abscess drainage (PTAD) was therefore performed, and histopathological examination of a biopsy specimen from the papilla of Vater revealed adenocarcinoma. On the basis of these findings, pancreaticoduodenectomy (PD) was performed. Histopathological examination of the resected specimen revealed a 10×23 mm tumor of the papilla of Vater and an intraductal papillary mucinous neoplasm (IPMN) . The patient was discharged without complications.
  • 平井 三鈴, 小林 修, 横須賀 路子, 三好 由里子, 橋本 周太郎, 小島 拓人, 宮本 彰俊, 林 康博, 太田 一樹, 黒田 博之, ...
    2014 年 84 巻 1 号 p. 128-129
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 40-year-old man presented to our hospital with the complaint of long white string-like discharges from the anal. No significant abnormality was noted on physical examination. He had history of diabetes mellitus, thus, the laboratory tests revealed a markedly increased HbA1c level (13.3%) . The serum IgE level was slightly increased (645 IU/ml) . Other laboratory values were within normal range. He gave a history of eating raw Oncorhynchus masou 2 months earlier, and had been diagnosed as having Diphyllobothrium nihonkaiense by evaluation of the expelled proglottids. Therefore, vermifuge treatment with gastrografin was started, however, we could not identify the tape worm and no proglottids were excreted. Therefore, the patient was kept under observation, and 16 months later, he presented again with the same complaint. We performed capsule endoscopy to confirm whether the scolices could be found in the bowel ; this examination revealed scolices of Diphyllobothrium nihonkaiense attached to the jejunal wall, as well as numerous freely floating proglottids in the small intestine. Praziquantel (20 mg/kg) was administered, followed by administration of a cathartic 2 hours later, and the worm was expelled successfully. It was considered that capsule endoscopy was very useful for the diagnosis of the parasites in this case.
  • 遠藤 大輔, 小池 祐司, 藤田 由里子, 大野 恵子, 福田 知広, 角田 裕也, 伊藤 剛, 今村 諭, 田村 寿英, 長久保 秀一, ...
    2014 年 84 巻 1 号 p. 130-131
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 74-year-old man visited our hospital with complaints of abdominal discomfort and diarrhea. Upper gastrointestinal endoscopy and colonoscopy showed no evidence of disease that could explain his symptoms. He had a medical history of inguinal hernia repair by laparoscopic surgery five years ago and blood transfusion treatments for obscure gastrointestinal bleeding (OGIB) two years ago. Since some unknown small intestinal disease was suspected, capsule endoscopy was performed with a patency capsule used prior to the capsule endoscopy. At 54 hours after the capsule ingestion, he developed ileus. Computed tomography showed obstruction of the small intestine around the right inguinal region, and the patency capsule remained in the proximal extended small intestine. Ileo─jejunal resection with re-anastomosis was performed at 75 hours after the capsule ingestion. The stenosis was hard and measured 1 cm. The patency capsule was not incarcerated and had not dissolved. Histopathological (hematoxylin-eosin staining) examination showed infiltration of lymphocytes in the transmural layers within the limits of the stenosis, and to our surprise, multiple granulomas infiltrating the serosa, although the result of acid-fast bacterial staining was negative. There were no abnormal findings of the vessel walls. There are several case reports of paravesical granulomas whose formation is triggered by foreign bodies several years after inguinal hernia repair. In this case, the intestinal stenosis was adjacent to the narrow space between the adhesive cord and the abdominal wall. We thought that temporary and repeated incarcerations of the small intestine into that narrow space may have been responsible for the severe stenosis with granulomas in the serosa and the chronic ischemic inflammation of the intestine.
  • 亀井 佑太郎, 湯原 宏樹, 中江 浩彦, 中村 淳, 仁品 玲子, 築根 陽子, 内田 哲史, 小池 潤, 五十嵐 宗喜, 鈴木 孝良, ...
    2014 年 84 巻 1 号 p. 132-133
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 76-year-old woman was admitted to our hospital complaining of abdominal pain and vomiting. Abdominal computed tomography revealed small bowel obstruction and tumors in the sigmoid colon. Colonoscopy revealed a circumferential tumor in the sigmoid colon.
    The findings were suggestive of ischemic enteritis with stricture and sigmoid colon cancer. The patient was thus treated by partial resection of the ileum and sigmoid colon.
    Pathological findings in the resected specimens were compatible with the diagnosis of ischemic enteritis associated and sigmoid colon cancer.
  • 眞鍋 恵理子, 萩原 信敏, 松谷 毅, 野村 務, 若林 秀幸, 高田 英志, 三井 啓吾, 藤森 俊二, 丸木 雄太, 藤田 逸郎, 金 ...
    2014 年 84 巻 1 号 p. 134-135
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 76-year-old man was admitted to our hospital with dyspnea on exertion, diarrhea, and anemia. Abdominal ultrasonography and computed tomography showed a tumor in the abdominal cavity. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) revealed an elevated mass with an ulcer in the ileum. Histopathological examination showed a spindle-cell tumor, and the spindle cells were immunopositive for c-kit and CD34. Thus, a definitive diagnosis of gastrointestinal stromal tumor (GIST) was made before surgery. After the diagnosis was confirmed by both CE and DBE, single-incision laparoscopic surgery with partial resection of the segment of the small intestine with tumor was performed via a single 2.5-cm umbilical incision. The postoperative course was uneventful. CE and DBE may be useful diagnostic tools in patients with diseases of the small intestine.
  • 今井 仁, 市川 仁志, 白井 孝之, 伊藤 裕幸, 永田 順子, 小嶋 清一郎, 高清水 眞二, 宇田 周司, 山本 壮一郎, 向井 正哉 ...
    2014 年 84 巻 1 号 p. 136-137
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 62-year-old man presented with black stool. Laboratory data showed anemia. Contrast-enhanced computed tomography revealed a hypervascular tumor in the pelvic cavity measuring 50×60 mm in size, with air pooling in the central portion of the tumor. A small bowel series demonstrated gastrografin accumulation through the fistula on the opposite side of the mesenterium, 30 cm from the ligament of Treitz. Single-balloon endoscopy showed a low-growing elevated mucosa-like submucosal tumor, which showed a pinhole formation in the center.
    Partial jejunectomy was performed for resection of the tumor. The solid tumor appeared to arise from the jejunum on the opposite side of the mesentrium. The pathological diagnosis was GIST, because immunohistochemical analysis showed positive staining for c-kit. Interestingly, the surface of the fistula was covered with ordinary jejunal mucosa. Based on this finding, it is considered that the GIST probably arose from a jejunal diverticulum.
  • 新井 万里, 細江 直樹, 長沼 誠, 柏木 和弘, 緒方 晴彦, 林 雄一郎, 下田 将之, 金井 隆典
    2014 年 84 巻 1 号 p. 138-139
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    We report the case of a 74-year-old man with mantle cell lymphoma, who was referred to our hospital for further investigation of multiple gastric submucosal tumors. Esophagogastroduodenoscopy (EGD) showed tonsillar enlargement, submucosal tumors measuring under a few mm in diameter in the esophagus, and submucosal tumors measuring less than 20 mm in diameter in the stomach. Trans-anal single-balloon endoscopy revealed multiple lymphomatous polyposis in the lower ileum, colon and rectum. Immunohistological staining of the gastric biopsy specimen showed positive staining for CD5 and CyclinD1, which was compatible with the diagnosis of mantle cell lymphoma (MCL) . Thus, we encountered a case of MCL with GI involvement, which could be successfully evaluated by EGD and single-balloon enteroscopy.
  • 瀬戸口 智彦, 砂山 健一, 清水 進一, 小里 俊幸
    2014 年 84 巻 1 号 p. 140-141
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 70-year-old woman with von Recklinghausen’s disease was admitted for abdominal distention. Abdominal CT showed a huge solid tumor in the right abdomen and laparotomy was performed. Because the tumor originated from the ileum and invaded the ascending colon, we performed tumorectomy with right hemicolectomy. Pathological examination showed a high-risk GIST, with a tumor size of 110×100 mm, a mitotic rate of 50/50, and positive staining for KIT. The postoperative course was uneventful and the patient was discharged 15 days after the operation. Two weeks after the discharge, the patient was rehospitalized for anorexia. Abdominal CT revealed multiple liver, lung and peritoneal metastases. The patient was treated with imatinib mesylate, however, the tumors continued to grow rapidly. The patient died 51 days after the surgery. Herein, we have reported a case of von Recklinghausen’s disease with a rapidly growing GIST.
  • 伊藤 慎吾, 市川 亮介, 本庄 薫平, 河合 雅也, 田代 良彦, 丹羽 浩一郎, 石山 隼, 杉本 起一, 神山 博彦, 高橋 玄, 柳 ...
    2014 年 84 巻 1 号 p. 142-143
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 68-year-old woman was admitted to the hospital with lower abdominal pain. Abdominal CT revealed a long linear high-density foreign object measuring about 3 cm long, which had penetrated the wall of the sigmoid colon. Emergency endoscopy was performed, because the patient was diagnosed as having possible penetration of the sigmoid colon by a fish bone. The emergency endoscopic examination revealed a fish bone penetrating the sigmoid colon, which was removed with grasping forceps. The removed bone measured 3 cm in length and was believed to belong to a sea bream. The patient was treated conservatively without any complications. For intestinal perforation and penetration caused by a fish bone, such as in our case, endoscopic treatment may be considered as the treatment procedure of first choice.
  • 榎本 俊行, 斉田 芳久, 高林 一浩, 大辻 絢子, 中村 陽一, 長尾 さやか, 渡邊 良平, 永岡 康志, 石井 智貴, 高橋 亜紗子 ...
    2014 年 84 巻 1 号 p. 144-145
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 67-year-old woman was admitted to our hospital with constipation. Colonoscopy revealed a rectal tumor measuring 10 mm in diameter. Endoscopic mucosal resection of the lesion was performed. Histological examination revealed the diagnosis of rectal cancer invading the submucosa. Therefore, laparoscopic low anterior resection was performed. After the anastomosis, intraoperative endoscopy revealed leaking air bubbles from the site of the anastomosis, and we therefore clipped the anastomotic site with a metallic clip. After the surgery, the patient was discharged without any complications.
  • 堀井 城一朗, 藤本 愛, 落合 康利, 後藤 修, 下田 将之, 矢作 直久
    2014 年 84 巻 1 号 p. 146-147
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    Case 1 : A 70-year-old man was referred for endoscopic resection, as a screening colonoscopy had revealed a flat neoplasm in the sigmoid colon measuring 40 mm in diameter without a granular pattern on the surface (laterally spreading tumor, non-granular type [LST-NG]) . Magnifying endoscopy with narrow-band imaging (NBI) revealed capillary pattern (CP) type II, whereas magnifying chromoendoscopy revealed a Kudo type IIIs pit pattern.
    Case 2 : A 70-year-old woman was referred for endoscopic resection of a 40-mm LST-NG located in the rectum. Magnifying endoscopy with NBI revealed CP type IIIB, and even magnifying chromoendoscopy failed to reveal the pit pattern clearly, although the endoscopic examination revealed no hardness of the tumor.
    Thus, the neoplasms were diagnosed as intramucosal carcinoma or cancer with superficial submucosal invasion, and we decided to attempt endoscopic submucosal dissection (ESD) to remove them. In Case 1, the histopathologic assessment showed a cancer with deep submucosal invasion, which was fully covered by the cancer with low-grade atypia in the mucosal layer. In Case 2, the histopathologic assessment showed tubular adenoma with a large quantity of mucus on the surface of the tumor. Thus, the histopathologic assessment also revealed the depth of the tumor invasion and the reason for the difficulty in the preoperative diagnosis. This case report highlights the importance of ESD, which enabled a precise histopathologic diagnosis of the LSTs in which estimation of the depth of submucosal invasion was difficult even with the use of magnifying NBI and chromoendoscopy.
  • 天田 塩, 藤田 晃司, 内 雄介, 一坂 俊介, 森 克昭, 石川 啓一, 堂脇 昌一, 菊永 裕行, 熊井 浩一郎, 片桐 真理, 三浦 ...
    2014 年 84 巻 1 号 p. 148-149
    発行日: 2014/06/14
    公開日: 2014/06/21
    ジャーナル フリー
    A 76-year-old man was admitted to our hospital with the complaint of stool discharge from a right subcostal incisional scar following open cholecystectomy performed 23 days earlier. He had undergone distal gastrectomy 20 years ago and partial small-intestinal resection 17 years ago. Hematological examination showed elevation of the inflammatory reaction markers (WBC 11,700/μl, serum CRP 10.1 mg/dl) . CT showed an enteroctaneous fistula between the transverse colon and subcostal scar. Preoperative colonoscopy showed a small perforation with overhanging mucosa and severe ischemic change at the transverse colon near the hepatic flexure. Absorbable suturing materials of the abdominal wall were also recognized. Fistulography was performed and the fistula and scar were visualized. Laparotomy was performed 28 days after the open cholecystectomy. The transverse colon around the fistula showed segmental necrosis. Right hemicolectomy and ileo-colostomy were performed. The patient was discharged from the hospital 24 days after the surgery. Preoperative colonoscopy was useful to determine the operative procedure with colectomy.
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