Familial adenomatous polyposis (FAP) manifests occasionally as a gastric epithelial tumor. It is important to diagnose the tumor at an early stage for less invasive treatment. In this study, we examined the usefulness of magnifying endoscopy with narrow-band imaging (ME-NBI) for examining gastric epithelial tumors in patients with FAP. Four FAP patients with gastric epithelial tumors underwent ME-NBI and subsequently, endoscopic resection of the lesions. There were 8 lesions (3 adenoma, 5 cancer) in the four patients. We enrolled these patients into the present retrospective study.
We analyzed the ME-NBI findings using the 'VS classification system’ and compared them with the pathological findings after endoscopic resection.
A demarcation line was observed clearly in all the lesions, and an irregular vascular pattern was recognized in all the cancer lesions. Two of the 3 adenoma lesions had regular microvascular and microsurface patterns. There was only 1 lesion in which the ME-NBI findings did not match the pathological findings. Thus, the concordance rate between the ME-NBI findings using the VS classification and the pathological findings was 87.5%. Although there are some limitations of this study, we think that ME-NBI for FAP patients with gastric epithelial tumors is useful for establishing a qualitative diagnosis.

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Background : The Japanese Gastrointestinal Stromal Tumor (GIST) therapeutic guidelines recommend histopathological diagnosis of gastric submucosal tumors measuring 20-50 mm in size or with malignant findings. However, histopathological diagnosis of gastric submucosal tumors is difficult. In the present study, we investigated the usefulness of mucosal cutting biopsy for the diagnosis of these tumors.
Patients and methods : Mucosal cutting biopsy was carried out for 3 gastric submucosal tumors, and the histopathological diagnosis and complications were examined. In cases that were treated by surgical resection, we compared the pre- and postoperative histopathological diagnoses.
Results : Histological diagnosis of submucosal tumor was obtained in all the cases. In all 3 patients, the histological diagnosis was GIST. In all three who underwent surgical resection, the histopathological findings of the mucosal cutting biopsy specimens were consistent with those of the surgically resected specimens.
No complications were seen after this procedure.
Conclusions : The mucosal cutting biopsy technique is a useful diagnostic modality for histological diagnosis of submucosal tumors of the stomach.

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Mucosal healing (MH) is thought to be the endpoint of therapy in patients with ulcerative colitis (UC) . Endoscopic mucosal healing is currently considered as an optimal indicator of mucosal healing, however, it is still not clear whether endoscopic mucosal healing concurs with histological mucosal healing. We investigated the correlation between endoscopic healing and histological healing using Mayo endoscopic subscores and Sandborn’s histological scores, and also comparatively investigated the incidence of relapse of UC in patients with endoscopic MH and histological MH. Fifty patients with UC underwent complete colonoscopy by the same endoscopist, and each of seven colonic segments were evaluated prospectively using the Mayo endoscopic subscores (grade 0-3) . Biopsies were also performed in the same colonic segments and evaluated by the Sandborn’s histology scores (grade 0-4) . Endoscopic MH was defined as Mayo score 0 or 1, and histological MH was defined as Sandborn’s score 0 or 1. Relapse was defined as recurrence of overt hematochezia. Endoscopic MH was found in 93.4%, and histologic MH in 82.2% of the total of 350 colonic segments. Among all the segments showing endoscopic MH, 85.6% also showed histological MH, while the remaining 14.4% showed histological active inflammation. Of 37 patients with endoscopic MH, the incidence of relapse was higher in the histological non-MH patients (30.8%) than in the histological MH patients (12.5%) . No cases of relapse were found among the patients with a histological score of 0 in all the colonic segments, whereas 18% of those with a histological score of 1 in any of the colonic segments developed relapse. There was a dissociation between endoscopic and histological mucosal healing, and histological mucosal healing may represent true healing rather than endoscopic mucosal healing, and may need to be considered as the ultimate goal of treatment in patients with UC.

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Background : Colonoscopy is useful and important for early detection of colorectal cancer. There are some elements that can reduce the burden of patients undergoing colonoscopy, including appropriate scope selection, use of appropriate insertion techniques, use of sedation, etc. In 2013, we began to use the next generation-type of bowel cleaning agent, MoviPrep (hypertonic polyethylene glycol : hPEG) .
Aims : The aim of this study was to clarify the significance of using the newly developed hPEG in comparison to the conventional preparation agents.
Methods : We used hPEG for bowel preparation prior to colonoscopy in 120 patients from August to December 2013. Conventionally, we use Niflec (isotonic PEG : iPEG) at our hospital. For this study, we selected 120 iPEG cases, matched for age and sex with cases in which hPEG was used. Patients scheduled to undergo colonoscopy were instructed to take sennoside the night before the procedure, and conventional iPEG or hPEG on the morning of the day of the examination.
We defined preparation time as the duration from the beginning of drinking of the PEG to the time when the nurses confirmed a clear state of the stools. We also defined the duration of drinking and the volume of PEG consumed. Finally, we investigated these parameters in the hPEG group and the iPEG group.
Results : The average age was 63.7 ± 14.0 years in the hPEG group and 64.5 ± 12.8 years in the iPEG group. The preparation time was 144 ± 61 min in the hPEG group and 184 ± 55 minutes in the iPEG group (p< 0.05) . The drinking time was 129 ± 57 min in the hPEG group and 142 ± 37 min in the iPEG group (p< 0.05) . The volume of PEG consumed was 1543 ± 304 ml (hPEG 1033 ml + water 510 ml) in the hPEG group and 1,990 ± 140 ml in the iPEG group (p< 0.05) . There were no complications in either group. The preparation time and volume of PEG consumed were significantly lesser in the hPEG group.
Conclusion : The next-generation MoviPrep is expected as a promising agent to facilitate bowel preparation for colonoscopy, allowing a shorter preparation time, a lower volume of PEG to be consumed, and better drinking quality.

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Endoscopic papillary large balloon dilation (EPLBD) is becoming increasingly popular for the removal of large common bile duct stones. There have been only few studies on the early and late complications of this procedure. We retrospectively reviewed the complications in 18 patients with choledocholith treated by EPLBD at our hospital. The indications for EPLBD were patient age 75 years or older and bile duct and stone diameters greater than 11 mm. After small or medium endoscopic sphincterotomy, we dilated the papilla using a balloon catheter appropriate in diameter for the stones and lower bile duct, and removed the stones using a lithotripter, while watching out for their impaction. Complete removal was achieved in 17 of the 18 patients (94.4%) . Lithotripsy was necessary in two patients (11.1%) , but in most patients even large stones were removed intact. Three (16.7%) patients developed asymptomatic hyperamylasemia, there were no severe complications such as bleeding, perforation or acute pancreatitis. During the follow-up period (mean, 11.0 months ; range, 0.5-17 months) , only one patient developed recurrent stones (5.6%) . The results of this study indicate EPLBD as a useful treatment technique, because of the lower frequency of early complications ; the long-term prognosis is still unclear, and the inclusion criteria for the use of this treatment technique are stringent, e.g., with regard to age.

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An 84-year-old nursing home resident who had been on percutaneous endoscopic gastrostomy (PEG) feeding for five years was brought to our emergency room after repetitive vomiting and tachypnea for two days. She was diagnosed as having aspiration pneumonia based on the radiographic findings of opacities in both the lung bases. The chest X-ray also showed two pieces of PEG bumpers in the right upper quadrant of the abdomen. Upper gastrointestinal endoscopy revealed one of the bumpers within the stomach impacted in the pylorus, which was evidently the cause of the repetitive vomiting. It was a 25×25 mm X-shaped bumper, consisting of a central tube (17 mm in length and 6 mm in diameter) with four expandable wings. Attempts to remove the bumper endoscopically with a grasper or a net retriever were unsuccessful due to the resistance at the lower esophageal sphincter. Then, using a dual-channel endoscope, we first grasped and pulled two adjacent wings of the bumper. This action transformed the X-shaped bumper into a Y-shape, allowing it to be easily retrieved into the overtube, 17 mm in size, without causing esophageal injury. Through this case, we recognized the risk and complications of a retained internal bumper, and devised a new method to retrieve it endoscopically.

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Recently, duodenal tumors have been detected more often due to technical progress and the development of endoscopic instruments. However, no standard endoscopic diagnostic criteria or therapeutic strategies for duodenal epithelial tumors have been established. Radical resection techniques such as pancreaticoduodenectomy should be avoided, if possible, for treating non-invasive duodenal cancer or adenoma, because they cause more serious postoperative dysfunction in the duodenum than in other parts of the gastrointestinal tract. Endoscopic submucosal dissection (ESD) yields higher rates of en bloc resection and curative resection than endoscopic mucosal resection, and these advantages explain the lower rates of residual and recurrent tumors seen after ESD. However, it is more difficult to perform ESD for duodenal tumors than for gastric tumors, as the muscle layer of the duodenum is thinner than that in other parts of the gastric tract, which results in relatively higher frequencies of perforation and bleeding. Here, we report our experience with duodenal ESD. Closure of post-ESD duodenal artificial ulcers is very effective for avoiding delayed bleeding and perforation. We consider that post-ESD ulcer closure using a loop snare and clipping is one of the most effective ways of preventing delayed perforation. Duodenal ESD requires a high level of skill due to its technical difficulty and the increased risk of perforation associated with the procedure ; however, we consider that it is very effective. In addition, ESD is less invasive than open surgery.

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The placement of self-expanding metallic stents (SEMS) in malignant colorectal obstruction is a minimally invasive medical alternative to surgery and may be used as a definitive palliative procedure or as a “bridge to surgery” to allow stabilization of the patient’s condition before surgery. There are, however, few reports about the efficacy and safety of SEMS in very elderly patients with malignant colorectal obstruction. We report the cases of two elderly patients aged 85 years or older with malignant colonic obstructions, in whom we carried out endoscopic palliative stenting. Placement of SEMS is safe even in very elderly patients with colorectal malignant obstruction, and furthermore, it could improve their quality of life.

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We reviewed the data of 35 cases of colorectal carcinoid tumors seen over a period of 11 years (2004-2014) . The tumor was located in the rectum in all cases. Of the 35, 32 were operated by endoscopic resection (3 EMRs, 29 ESDs) , and 2 cases required additional surgical treatment due to lymph vessel permeation. In regard to the 29 cases treated by ESD, 9 showed a positive vertical margin, and 8 showed an uncertain vertical margin due to heat-damage. The size of the carcinoid tumors in the cases with a positive or uncertain vertical margin varied from 3 to 12mm, indicating the size had no influence on the risk of a positive margins, and that there might be a technical limitation to the ESD method itself. After endoscopic resection of the carcinoid tumors, the patients were followed by periodic follow-up examinations in the same way as carcinoma cases. Twenty-three (83.6%) of 32 cases with endoscopic resection were operated by periodic endoscopy. The recurrence-free time recorded in this study was 6 to 56 months (median 23 months) : none of the patients developed recurrence during the observation period. We conclude that there is a need to encourage patients to undergo frequent follow-up examinations.

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A 71-year-old woman was admitted to our hospital with nausea and vomiting. Esophagogastroduodenoscopy revealed hiatus hernia, Barrett’s esophagus and multiple esophageal ulcers. She was treated with a proton pump inhibitor (PPI) . The Barrett’s ulcer improved and the patient was discharged from the hospital. After three days, she was admitted to our hospital with hematemesis. Esophagogastroduodenoscopy revealed recurrence of the Barrett’s ulcer.
To our question about her compliance with her medication, she and her brother said that she was certainly compliant with the prescribed PPI. The Barrett’s ulcer improved again and the patient was discharged from the hospital. However, after eight days again, the Barrett’s ulcer recurred and the patient was again admitted to our hospital. Again, both the patient and her brother confirmed her compliance with the prescribed medication.
However, when the brother was asked to bring all her medicines, we found that she had not taken the proton pump inhibitor at all. Thereafter, after we ensured that she remained compliant with the prescribed PPI, the Barrett’s ulcer improved and did not recur. Thus, adherence to treatment is important.

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A 51-year-old man was admitted to our hospital with a history of chest pain and vomiting of blood after drinking alcohol. Emergency endoscopy was performed, which showed a hemorrhagic ulcer in the lower esophagus. Successful hemostasis was performed by endoscopic clipping and argon plasma coagulation. Plain CT obtained at admission did not show pneumomediastinum or pleural effusion, and a diagnosis of hemorrhagic esophageal ulcer caused by vomiting was made. A proton pump inhibitor (PPI) was prescribed, and oral intake was resumed on Day 5. Endoscopy revealed improvement of the esophageal ulcer on Day 9, and the patient was discharged on Day 10. Although hemorrhagic esophageal ulcer caused by vomiting is a relatively rare occurrence, it must be considered in the differential diagnosis of upper gastrointestinal bleeding.

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We report a case of so-called carcinosarcoma of the esophagus in which we could examine the correlations between the endoscopic examination and pathological examination findings. A 70-year-old male was referred to us for the investigation of anemia that had been detected during a periodic medical check-up. Barium swallow revealed a protruding tumor on the right side of the esophageal wall in the middle to lower thoracic portion of the esophagus. Upper gastrointestinal endoscopy showed a Type 0-Ip tumor at 29-36 cm from the incisors. Taking these results into consideration, we suspected the tumor as a carcinosarcoma of the esophagus. We performed subtotal esophagectomy with lymph node dissection. Histopathological examination showed that the greater part of the protruding tumor was composed of spindle cells with a sarcoma-like appearance. However, the base was composed of squamous cell carcinoma. Pathologically, there was a transitional zone between the two elements. On immunochemistry, the sarcoma-like spindle cells showed positive staining for vimentin with a few parts of the cells showing slightly positive staining for AE1/AE3 ; on the other hand, the SCC component showed negative staining results for vimentin, S-100, and desmin. Therefore, we diagnosed the tumor as a carcinosarcoma pT2, ly0, v0, n0, Stage II according to the Guideline for Clinical and Pathological Studies on Carcinoma of the esophagus.

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An 81-year-old man was diagnosed as having cStage IVa esophageal cancer and treated by chemoradiation therapy. His treatment response to the CRT was classified as CR. Then, 34 months after the CRT, he was detected to have a small elevated lesion with abnormal blood vessels coursing over it in the rt pyriform sinus, with the lesion showing rapid increase in size to a clearly elevated lesion over the next 6 months. The surface of the lesion was covered by normal mucosa and blood vessels (Type B2) could be seen coursing over it by magnifying endoscopy with NBI. We diagnosed the lesion as a superficial hypopharyngeal cancer (Type 0-I+IIa) and performed endoscopic laryngo-pharyngeal surgery. The pathological diagnosis was poorly differentiated squamous cell carcinoma with ly1, v1, and prominent subepithelial invasion. Pharyngeal cancer is often found synchronously or metachronously in patients with esophageal cancer, presumably as a result of the shared risk factors between the two cancers, such as alcohol drinking, smoking and deficient ALDH2 activity. Endoscopic examination to detect any pharyngeal cancer must be performed in esophageal cancer patients with the aforementioned risk factors. Diagnosis of a pharyngeal elevated lesion is often difficult due to the presence of the tonsils and lymphoid follicles. Therefore, careful magnifying endoscopy with NBI should always be performed to confirm the presence/absence of blood vessels coursing over small and slightly elevated lesions.

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A 59-year-old man presented with long-lasting mild epigastric discomfort. He was admitted to our hospital because of epigastralgia and nausea. Computed tomography demonstrated a 65×45 mm mass in the stomach, and endoscopy revealed a phytobezoar. Coca-Cola ingestion softened the stone. Subsequently, we successfully crushed the stone via endoscopy. Component analysis of the stone revealed that the principal element (＞98%) was tannin. In addition, gastroduodenography revealed midgut malrotation. In previous reports, delayed emptying of the stomach and chronic abdominal symptoms have been reported in cases with midgut malrotation. This patient had a history of intake of a large amount of dried persimmon fruit. Therefore, we assumed that the midgut malrotation might have induced delayed gastric emptying and the large intake of persimmon contributed to the formation of the phytobezoar.

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An 87-year-old woman who had been receiving enteral feeding through a gastrostomy tube was brought to our hospital with the complaints of vomiting and hematemesis. Abdominal computed tomography revealed dislocation of the inflated balloon of the gastrostomy tube into the duodenum. A subsequent upper gastrointestinal endoscopy revealed that the inflated gastrostomy tube balloon had translocated to the duodenal bulb, obstructing the pylorus like a ball valve. In addition, a hemorrhagic gastric ulcer, possibly caused by the mechanical stress of the tube, was also observed. Prompt deflation of the balloon and replacement of the gastrostomy tube relieved the patient’s symptoms dramatically. In this case, dislocation of the tubing balloon not only resulted in obstruction of the gastric outlet, but also induced gastric ulceration due to mechanical friction caused by the tube. It is concluded that ball-valve syndrome caused by a displaced inflated balloon is a rare, but important, complication in patients receiving enteral feeding though a gastrostomy tube.

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A 32-year-old man visited our hospital for further evaluation of a gastric tumor. Esophagogastroduodenoscopy (EGD) performed by a physician at a previous hospital revealed a submucosal tumor with bleeding at the gastric fornix. Emergency EGD was performed at our hospital, and an ulcer with Anisakis worm was identified in place of the submucosal tumor. After removing Anisakis worm with forceps, we started drug therapy for the gastric ulcer, and the patient’s condition improved. We diagnosed a gastric ulcer after a tumor diagnosis (with anisakiasis) , referred to as a “gastric vanishing tumor.” Such vanishing tumors have been reported to be caused by Anisakis worms, alcohol, acute gastritis, etc. When a submucosal tumor with bleeding is detected endoscopically, gastric vanishing tumor should be considered in the differential diagnosis.

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A 50-year-old man was referred for further examination of a gastric submucosal tumor. Upper gastrointestinal endoscopy revealed an erythematous submucosal tumor measuring 5 mm in diameter in the anterior wall of the middle third of the gastric body, but no atrophy of the gastric mucosa. Biopsy of the tumor showed a well-differentiated neuroendocrine tumor ; the serum gastrin level was within normal limits and the test for anti-gastric parietal cell antibody was negative. Based on the findings, the tumor was diagnosed as a sporadic Type III gastric carcinoid. The tumor was resected en bloc by endoscopic mucosal resection using a cap-fitted panendoscope. Histology showed invasion of the submucosal layer by carcinoid cells, but no lymphatic/venous invasion, and a sufficient horizontal and vertical margin of the resected specimen. The mitosis rate was low (＜2/10HPF) and the Ki-67 labeling index was less than 2%, consistent with the histological results of the biopsy specimen. Until now, 24 months since the surgery, no local remnant lesion or metastasis has been found. As sporadic Type III gastric carcinoids behave more aggressively than Type I and II tumors, the guidelines recommend radical gastrectomy plus regional lymphadenectomy. However, surgical resection might possibly be overtreatment for some cases, and further examination is necessary to determine the precise indications of endoscopic resection for sporadic Type III gastric carcinoids.

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A 52-year-old woman was referred to the hospital with the chief complaint of dysphagia. Upper gastrointestinal (GI) endoscopy showed reflux esophagitis ; fundic gland polyps and a shallow discolored depressed lesion measuring approximately 10 mm in diameter were observed in the anterior wall of the gastric lower body, with no evidence of atrophic changes. Histopathological examination of biopsy specimens showed evidence of signet ring cell carcinoma in the depressed lesion and a negative result for Helicobactor pylori (HP) on Giemsa staining. The patient had no history of HP eradication therapy. Serology for HP IgG antibody was negative and the result of testing by the pepsinogen method was negative. The carcinoma risk was classified as group A according to the ABC classification. Laparoscopic gastrectomy was performed under the tentative diagnosis of early gastric cancer without metastasis, the latter determined by CT imaging. Histopathological examination of the resected specimen revealed signet ring cell carcinoma in the mucosal layer, with invasion of mainly por2 cancer from the submucosal layer to the proper muscular layer, and abundant connective tissue of the scirrhous type. The background mucosa showed no neutrophil infiltration, or any evidence of atrophy. Based on the findings, we diagnosed the patient as a case of non-HP-infected gastric cancer. In the future, a higher incidence of HP-negative gastric cancer may be found among patients classified into Group A of the ABC risk classification. Upper GI endoscopy should be performed bearing in mind the possibility of HP-negative gastric cancer in cases with GI symptoms, regardless of the results of the ABC classification for gastric cancer screening.

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A 58-year-old man with gastric carcinoma was referred to our hospital for further examination and treatment. Esophagogastroduodenoscopy showed a depressed lesion measuring approximately 25 mm in diameter below the esophagogastric junction (EGJ) , which was slightly elevated proximally. Pathological examination of biopsy specimens revealed well-differentiated adenocarcinoma. No evidence of atrophy was detected in the background gastric mucosa, and serological examination showed negative results for Helicobacter pylori infection. Although we assumed submucosal invasion in the proximal part, the patient opted for endoscopic treatment. No metastases were detected by computed tomography ; therefore, endoscopic submucosal dissection was performed. Histopathological examination of the resected specimen revealed well- to moderately differentiated adenocarcinoma (Type 0-IIc, 20×27 mm, pT1b1, ly0, v0, pHM0, pVM0) . The proximal part was found to be due to an esophageal retention cyst, and there was no evidence of submucosal invasion. Histopathology ruled out Barrett’s esophagus, and we diagnosed EGJ carcinoma. With a decrease in the incidence of H. pylori infection, the detection rate of lesions such as EGJ cancer may be expected to increase. However, such lesions are likely to be overlooked; thus, careful examination is required even in H. pylori-negative patients.

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A 70-year-old woman diagnosed as having cancer of the esophago-gastric junction (EGJ) . She had intermittently received treatment with a proton pump inhibitor (PPI) for over 10 years for gastro-esophageal reflux disease (GERD) . As her symptoms were extremely severe 3 years ago, we decided to repeat a course of her PPI treatment. Endoscopic examination carried out 7 months prior to the surgery revealed a type 0-Is lesion at the EGJ, which was confirmed as Group 2. Thereafter, a repeat endoscopy performed 2 months prior to the surgery revealed that the tumor had progressed to Group 4. The palisade vessels characteristic of Barrett’s esophagus were not recognized in the distal portion of the esophagus. Due to suspected sm invasion by the tumor, a laparoscopic proximal gastrectomy was performed. The resected specimen showed a tumor that was Type 0-Is, 2.0 × 1.5 cm, tub1, sm, v0, (Stage IA) . Although Barrett’s esophageal cancer was strongly suspected based on the clinical data, histopathology failed to reveal Barrett’s epithelium in the vicinity of the carcinoma lesion. This could be due to the short length of the resected specimen. EGJ cancer should be carefully resected and examined, bearing in mind the diagnosis of Barrett’s esophageal cancer.

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A 76-year-old man was referred to our hospital for the treatment of gastric tumors. He had a past medical history of angina pectoris and hyperlipidemia. Endoscopic examination revealed three tumors in the gastric antrum, a sessile polyp, an elevated cancer with a central depression extending into the submucosa, and a pedunculated multinodular polyp prolapsing into the duodenum. Biopsy specimens taken from the three tumors revealed that they comprised an adenoma and two adenocarcinomas. The pedunculated polyp could not be returned into the stomach. Therefore, under the diagnosis of coexistent gastric adenoma and two adenocarcinomas, laparoscopy-assisted distal gastrectomy was performed. Histopathological examination of the resected specimen revealed the sessile polyp as a gastric adenoma, a well- to moderately differentiated tubular adenocarcinoma invading the submucosa (Type 0-IIa＋IIc gastric cancer) , and the pedunculated polyp as an intramucosal well- differentiated tubular adenocarcinoma.
It is important to carefully observe the surface and form of a pedunculated gastric tumor prolapsing into the duodenum, and consideration of endoscopic treatment might be warranted after it is repositioned in the stomach.

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A 55-year-old man was diagnosed as having advanced gastric cancer in 2011 and subsequently underwent total gastrectomy with Roux-en Y reconstruction. Pathology revealed poorly differentiated adenocarcinoma (pT4N0M0, pStage IIB) , and no cancer cells were found at the surgical margin. The patient visited our hospital in February 2014 with anorexia and vomiting. Computed tomography showed wall thickening and luminal stenosis at the esophagojejunostomy site. Upper gastrointestinal endoscopy indicated that the stenotic region was covered by normal mucosa. Histological examination of mucosal biopsy specimens showed no evidence of neoplastic cells. However, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) indicated the presence of poorly differentiated adenocarcinoma. This finding was consistent with the anastomotic recurrence of gastric cancer, and chemotherapy was subsequently administered. Based on our experience, we suggest that EUS-FNA can be useful for the histological diagnosis of anastomotic recurrences covered with normal mucosa after surgery for gastric cancer.

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Autoimmune gastritis (type A gastritis) is characterized by the presence of hypergastrinemia, a positive test result for anti-parietal cell antibody and macrocytic anemia, and is associated with a high incidence of gastric carcinoid tumor. However, there are only a few reports of gastric cancer associated with autoimmune gastritis. In this case report, we describe a patient with autoimmune gastritis, who presented with psychological symptoms, in whom we performed endoscopic submucosal dissection (ESD) for associated early gastric cancer.
Case : An 88-year-old female was admitted to our hospital because of some psychological symptoms. The laboratory data at admission revealed macrocytic anemia, a low serum level of vitamin B₁₂, and a negative serological test result for anti-parietal cell antibody. Endoscopically, findings of pangastritis were observed, strongly suggestive of autoimmune gastritis. Histopathologically, a biopsy specimen from the stomach confirmed autoimmune gastritis, based on the positive staining result for Chromogranin A. At the same time, the patient was also diagnosed as having early gastric cancer ; therefore, ESD was performed successfully using a dual knife and sodium hyaluronate. Histopathological examination of the resected specimen confirmed well-differentiated adenocarcinoma. There are only a few reports of gastric ESD for gastric cancer associated with autoimmune gastritis.

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Patient : A 68-year-old woman.
Major complaint : Epigastric pain.
History of current disease : The patient occasionally had epigastric pain and underwent upper gastrointestinal endoscopy each year. Atrophic gastritis and Helicobacter pylori infection were diagnosed, however, the patient refused eradication therapy. Examination this year showed a white protruding lesion, about 15 mm in diameter, along the lesser curvature in the middle of the gastric body. The histopathological diagnosis was tubular adenoma.
Clinical course : Endoscopic mucosal resection was considered, however, the patient did not provide consent for the procedure. Eradication therapy was administered to prevent the development of new lesions, and first-line eraHelicobacter pyloridication was successful. Follow-up endoscopy was performed 1 month after the complication of eradication therapy, to exclude gastric cancer. An ulcer had developed at the site previously occupied by the white protruding lesion. Histopathological examination of biopsy specimens obtained from around the ulcer showed a cancer nest with signet-ring cells or non-tubular structure. Proximal gastrectomy was performed. Histopathological examination revealed a double cancer consisting of a non-solid type (por2) and a well-differentiated type (tub1) of gastric cancer. Subsequent review of the endoscopic results showed pale mucosa surrounding the white protrusion, suggesting the presence of gastric cancer around the protrusion.
Conclusion : We describe an interesting case of early-stage gastric cancer, consisting of undifferentiated carcinoma and differentiated carcinoma, that followed ulcer formation in the cancer after eradication of H. pylori.

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A 73-year-old man with a history of gastric ulcer scar underwent chemoradiation therapy for prostate cancer associated with multiple bone and lymph node metastases at the Department of Urology of our hospital. He visited our department because of diarrhea. Laboratory examination revealed a hemoglobin level of 9.6 g/dl, serum alkaline phosphatase level of 4,292 IU/l and serum PSA level of 654.1 ng/ml. The diarrhea improved with the discontinuation of lansoprazole. Upper gastrointestinal endoscopy was performed because of the history of gastric ulcer and history of eradication therapy against Helicobacter pylori infection. Endoscopic examination revealed a reddish protruding lesion measuring about 7 cm in diameter in the greater curvature of the gastric body, with a depression at its top, which was considered likely to be a submucosal tumor. Another similar, but smaller, lesion was also seen near the main lesion. Histological examination of biopsy specimens showed poorly differentiated adenocarcinoma, similar in histology to that of the prostate cancer, which was immunohistologically positive for PSA. Therefore, this case was diagnosed as a case of gastric metastasis from prostate cancer. Thereafter, the patient was admitted with dyspnea associated with bilateral pleural effusion and died four months later. We have reported the rare case of metastasis from prostate cancer to the stomach which was diagnosed by endoscopy.

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A 79-year-old woman was transferred to our hospital for scurtiny anemia. Upper gastrointestinal endoscopy revealed no hemorrhagic previous hospital. Bone marrow puncture, computed tomography and colonoscopy were performed in our hospital. But, the cause of anemia was not identified. We performed small bowel capsule endoscopy and diagnosed gastric antral vascular ectasia (GAVE) . It was overlooked in previous hospital. We treated GAVE by argon plasma coagulation. It is important that appropriate timing and sufficient accuracy of endoscopy when treating obscure gastrointestinal bleeding. Furthermore, We must recognize that one of the causes diseases of the digestive tract bleeding.

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A 71-year-old man was referred to our hospital with gastrointestinal (GI) bleeding. At the previous hospital, where he had presented with hematemesis and melena, even repeated esophagogastroduodenoscopy (EGD) and colonoscopy could not identify the source of bleeding.
Initially, we performed EGD, because his present history suggested upper GI bleeding. However, we could not identify the bleeding point. Immediately thereafter, we performed trans-oral double-balloon endoscopy (DBE) , based on the suspicion of jejunal bleeding.
This examination revealed an exposed vessel with pulsatile bleeding in a jejunal diverticulum located about 95 cm from the incisors, and we successfully performed endoscopic hemostasis with hemoclips.
This experience suggested the importance of emergency DBE for patients with upper GI bleeding in whom the source of bleeding cannot be detected by EGD.

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A 79-year-old woman was admitted to our hospital with bloody stools and shock. Capsule endoscopy showed a diverticulum with an ulcer in the ileum. We suspected hemorrhage from the Meckel’s diverticulum. As the bloody stool persisted, surgery was performed. A diverticulum measuring about 3 cm in length was found in the ileum, approximately 70 cm from the ileocecal valve. The resected specimen showed the ulcer with an exposed blood vessel in the diverticulum. Histopathology confirmed a true diverticulum, although no heterotopic pyloric glands were observed in the circumference of the ulcer. Capsule endoscopy is a useful technique to diagnose hemorrhage from a Meckel’s diverticulum. Meckel’s diverticulum should be considered as a possible bleeding lesion, even in elderly patients with OGIB.

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A 72-year-old man visited our hospital with weight loss. CT examination showed right pleural effusion, ascites and mural thickening of the distal ileum. Examination of the ascitic fluid revealed increase in the level of adenosine deaminase associated with an increase in the number of lymphocytes ; there were no malignant cells. PCR assay of the ascitic fluid, and smear examination of the
sputum and feces for acid-fast bacilli were all negative, however, the T-spot test was positive. Capsule enteroscopy revealed ulcers and stenosis of the ileum. Single-balloon enteroscopy showed annular ulcers and stricture of the ileum at 50 cm from the ileocecal valve. Histological examination of biopsy specimens showed infiltration of lymphocytes and eosinophils and noncaseating granulomas. Based on these results, we diagnosed the patient as having intestinal tuberculosis. Anti-tuberculous therapy was started with isoniazid, rifampicin, pyrazinamide and ethambutol and the ascites disappeared in 2 months.
Intestinal tuberculosis is often difficult to diagnose, because there are no specific symptoms and the positivity rate for tubercle bacilli in fluids such as ascites and feces is not so high. In our case, single-balloon enteroscopy was useful for the diagnosis.

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A 42-year-old-woman who had being undergoing periodic colonoscopy since 2008 as follow-up for a colonic polyp, underwent colonoscopy at our hospital in June 2013. Although she had no abdominal symptoms, the endoscopic examination revealed Anisakis larva penetrating the mucosa of the ascending colon, which was removed with biopsy forceps. She had consumed raw mackerel in sushi 2 days prior to the colonoscopy.
Colonic anisakiasis (similar to gastric anisakiasis) is treated by early colonoscopic removal of Anisakis larvae. In patients presenting with acute abdominal pain, tumor-like lesions on imaging or localized peritonitis, colonic anisakiasis must be included in the differential diagnosis, and it is important to obtain a thorough medical history, including information concerning the ingestion of raw fish. Early colonoscopic diagnosis is useful in such cases to prevent unnecessary tests and surgery.

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The patient was a 74-year-old man with rectal cancer. A colonic stent was placed at the site of a stricture of the rectum to alleviate the symptoms of ileus. FOLFIRI (70%) was given as preoperative chemotherapy. However, the patient developed anal pain and anorexia after 2 courses of treatment, and the chemotherapy was discontinued. He strongly desired surgical therapy and was admitted for preoperative evaluation. Abdominal radiography revealed that the colonic stent was lodged in the anus.
Endoscopic examination confirmed that the stent was lodged in the mucosa of the anal canal. Because there was a high risk of perforation, surgery was performed. With the patient under general anesthesia, the stent was manually removed transanally. A Hartmann’s procedure was concurrently performed. The patient recovered uneventfully after the surgery and was discharged. FOLFOX was given as postoperative chemotherapy. The patient is currently receiving treatment on an outpatient basis, with no adverse events.
We described our experience with a patient in whom chemotherapy-induced tumor shrinkage apparently led to migration of a colonic stent. Because of the increasing number of patients undergoing colonic stent implantation, the safety of concurrent chemotherapy and methods to remove migrated stents should be reconsidered.

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A 89-year-old woman was admitted to our hospital with vomiting and appetite loss. Abdominal CT revealed thickening of the sigmoid colon with an abscess cavity and ileus. A colonoscopy was performed, which revealed subtotal malignant obstruction of the sigmoid colon. A diagnosis of abdominal abscess resulting from penetration of sigmoid colon cancer was made. The patient was administered conservative therapy alone, as she was an unsuitable candidate for surgery. The size of the abscess cavity decreased and symptomatic remission was achieved. A colonic stent insertion was carried out to relieve the intestinal obstruction. Three days after insertion of the stent, a passage between the abscess cavity and sigmoid colon was identified on abdominal CT. This fistula was completely sealed by an esophageal covered stent. These procedures enabled the patient to take food orally. However, the patient died suddenly on day 34 after the stenting. In the present case, an esophageal covered stent was effective to seal the fistula resulting from a colonic stent insertion.

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A 70-year-old woman, in whom a previously performed colonoscopy by another physician had revealed a submucosal tumor in the lower rectum. She was therefore referred to our hospital for further examination. No ulcer formation was observed in a subsequent colonoscopy, however, endoscopic ultrasonography (EUS) depicted the lesion as a 30-mm mass with a well-defined border that appeared to have originated from the fourth layer, and the internal echo was relatively uniformly hypoechoic. The lesion was visualized similarly as a submucosal tumor on abdominal CT and MRI and no apparent distant metastases were observed. EUS-FNA was performed to obtain a definitive diagnosis. A 19G needle was used for the FNA. Cytological examination of the aspirated tissue revealed fusiform tumor cells. Positive immunostaining results were obtained for c-kit, CD34 and DOG-1. Ki-67 positivity rate was 9%. The mitotic figure count was over 14 per 50 high-power fields. On the basis of the above findings, the lesion was diagnosed as a high-risk GIST, and a laparoscopy-assisted low anterior resection was performed. The patient is currently under follow-up at our hospital on an outpatient basis. The risk categories for GIST are based on the tumor diameter and mitotic figure count. In this case, we were able to identify the lesion as high risk on the basis of the mitotic figure count in EUS-FNA. This method was useful for determining the course of treatment. We describe this case along with a brief review of the literature.

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A 90-years-old woman was admitted to our hospital with a prolapsing tumor through the anus. The tumor caused intussusception of the colon and drew the rectum and sigmoid colon out of the anus. A trans-anal resection of the tumor was performed, however, the intussusception of the sigmoid colon could not be reversed completely. We attempted colonoscopic repositioning of the intussusception by applying pressure with air and water through the colonoscope and by pushing the colonoscope directly into the region of the intussusception, however, these procedures were not effective because the force for the repositioning was lost through the lumen of the intussuscepted intestine. Therfore, we joined a balloon catheter to the head of the colonoscope in order to catch the intussuscepted lumen and pushed the colonoscope to achieve repositioning of the intussusception.
After repositioning of the intussusception, ALTA was injected via the colonoscope below the region of the intussusception. The tumor was diagnosed pathologically as a villous adenoma with moderate atypia. The intussusception and prolapse have not recurred until date after the operation. Therefore, for intussusception with prolapse of the lower colon due to a tumor in older patients, such as in our case, the combination of trans-anal operation and the colonoscopic repositioning procedure may be suitable because of the low invasiveness.

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An 82-year-old woman who had been administered an α-glucosidase inhibitor for diabetes consulted our hospital complaining of nausea and vomiting. Her abdomen was soft, and there was no abdominal tenderness. A plain chest X-ray and contrast-enhanced abdominal CT revealed pneumatosis cystoides intestinalis (PCI) with free air. The patient was treated conservatively with “nil by mouth”, hydration, and oxygen supplementation, which led to improvement of the symptoms. Although PCI with pneumoperitoneum caused by the administration of an α-glucosidase inhibitor is extremely rare, gastrointestinal perforation should be excluded in such patients and careful observation is required.

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A 21-year-old man was admitted to our hospital because of abdominal pain. Abdominal ultrasonography showed the target sign in the right lower abdomen and abdominal enhanced computed tomography showed a fatty layer in the ascending colon. A diagnosis of intussusception was made, which was reduced by a gastrografin enema. The patient recovered and was discharged. Colonoscopy showed elevated lesions like submucosal tumors in the cecum and ascending colon. Then, the patient was referred to us again with intussusception, and we performed ileocecal resection. The resected specimen showed soft polypoid lesions in the cecum and ascending colon, the surface of which showed multiple gas-filled cysts. Histopathological examination revealed pneumatosis of the submucosal layer. A diagnosis of pneumatosis cystoides intestinalis (PCI) was made. The postoperative course was good and the patient was discharged 9 days after the operation. PCI is a relatively rare disease. We report a case of PCI with recurrent intussusception over the short term and a review of the relevant literature.

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A 50-year-old woman with constipation, high blood pressure, and a history of open abdominal surgery for myoma of the uterus was referred to our hospital for colonoscopy because of a positive fecal occult blood test during a medical checkup. The patient was administered 10 ml of picosulfate at 9 PM. Approximately 8 hours later, she developed vomiting, melena, and severe lower abdominal pain. Colonoscopy revealed reddening, edema, longitudinal erosions and easy bleeding in the sigmoid colon. The patient was diagnosed as having ischemic colitis and hospitalized. With conservative treatment, she recovered within 5 days and was discharged. Six weeks later, she underwent a colonoscopy without prior administration of picosulfate, and the findings revealed complete recovery.
Risk factors for ischemic colitis include high intracolonic pressure, rapid peristalsis, constipation, adhesions, postoperative state, and high blood pressure, some of which were present in this patient. Prior administration of a mild laxative instead of picosulfate should be considered for patients with such risk factors.

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A 55-year-old man presented to a clinic with a one-month history of constipation and mucous and bloody stools. He was diagnosed as having rectal cancer at the clinic and referred to our hospital for treatment. We performed colonoscopy to reevaluate the cancer. In addition to the cancer, an irregular ulcerated lesion covered with a white exudate was observed at the anal aspect of the cancer in the rectum. A biopsy specimen was taken from the ulcerated lesion, and microscopic examination revealed trophozoites of Entamoeba histolytica. We diagnosed the patient as a case of rectal cancer associated with amoebic colitis.
Routine clinical tests such as complete blood count, serologic tests for syphilis, HIV, HBV, HCV, liver function tests, and renal function tests revealed no abnormalities. The serum titer for antibody against E. histolytica was 100-fold and the serum CEA level was 5.3 ng/ml. The patient was treated for amoebic colitis preoperatively with paromomycin (1,500 mg/day) for 10 days. Colonoscopy revealed complete healing of the mucosal lesion distal to the tumor after the antibiotic therapy, and a laparoscopic low anterior resection was performed for the rectal cancer.
The patient’s postoperative course was uneventful, and he was discharged on postoperative day 8. We report this rare case and the benefits of preoperative antibiotic therapy for such cases.

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We report a relatively rare case of malignant lymphoma in a patient with ulcerative colitis. A 31-year-old woman visited our hospital for right cervical lymphadenopathy associated with common cold-like symptoms. She had been diagnosed as having ulcerative colitis at the age of 19 years and received treatment with salazosulfapyridine and prednisolone intermittently. CT examination revealed enlarged lymph nodes in the cervical, supraclavicular, and mediastinal lymph node regions. Histopathological examination yielded a diagnosis of non-Hodgkin lymphoma (peripheral T-cell lymphoma) , Stage IIB. She was treated with six cycles of combination chemotherapy with the CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisolone) , followed subsequently by autologous peripheral blood stem cell transplantation. No evidence of relapse of ulcerative colitis was observed during the period of chemotherapy and autologous peripheral blood stem cell transplantation.

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A 60-year old woman was examined by a local physician for the chief complaint of bloody stool, and underwent colonoscopy. A laterally spreading tumor 〔IIa (LST-G) 〕 measuring approximately 10 cm along the major axis and occupying approximately 5/6th of the circumference of the rectum was identified, and the patient was referred to our department. Although submucosal invasion was suspected, endoscopic submucosal dissection (ESD) was performed as per the desire of the patient ; en-bloc resection of the tumor was performed, with dissection of almost the entire circumference of the rectal mucosa. After the ESD, steroid suppositories were administered for 26 days to prevent stenosis. However, one month after the ESD, colonoscopy revealed cicatricial stenosis at the resection site, with inability to pass the scope through the stenotic site. Histopathological examination indicated pT1b (4,000 µm) adenocarcinoma in adenoma. Therefore, laparoscopic low anterior resection was performed 2 months after the ESD. Histopathological examination did not indicate residual cancer or lymph node metastasis, however, the fibrosis had extended to the muscularis propria at the scar site, which was considered to be the cause of the stenosis.
Post ESD stenosis of the rectum is considered to be rare. We carried out histopathological investigation to identify the cause of the stenosis in a patient who presented with bowel stenosis after ESD for a large rectal tumor.

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A 72-year-old man presented to the hospital with tonsillar swelling. Histopathological examination of a biopsy specimen from the tonsil showed diffuse proliferation of abnormal lymphocytes. Immunohistochemical analysis revealed positive staining for CD20, CD5 and Cyclin D1. These findings were compatible with the diagnosis of mantle cell lymphoma (MCL) . PET-CT revealed abnormal accumulation in the
stomach and duodenum, in addition to that in the tonsils and lymph nodes. As we suspected invasion of the gastric tract by the MCL, esophagogastroduodenoscopy (EGD) was performed, which showed submucosal tumors in the esophagus and duodenum, and giant folds in the stomach. Colonoscopy showed lymphomatous polyposis in the terminal ileum, cecum and rectum.
The patient was treated with first-line chemotherapy. EGD after 2 courses of chemotherapy revealed a decrease in the size of all the lesions; the lesions reduced even further in size after 4 courses of chemotherapy, as compared to the sizes before the start of therapy. With this medical history, the patient was admitted to the hospital with an 8-month history of bloody stool. Colonoscopy revealed lymphoid follicles in the terminal ileum, cecum and rectum. Since histopathological examination of HE-stained sections of biopsy specimens showed normal lymphoid follicles, we did not perform immunohistochemical examination.
When multiple lymphoid follicles are found on endoscopy, it is important to consider the possibility of malignant lymphoma invading the gastrointestinal tract.

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A 49-year-old woman was found to have a tumor of the pancreatic head at a medical checkup. Abdominal ultrasonography revealed a mass measuring 4 cm in diameter in the pancreatic head. Abdominal CT also demonstrated a cystic tumor with a solid tumor component at the pancreatic head. EUS revealed a low-echoic tumor without clear continuity with the muscularis propria. Blood flow was abundant in the margin of the tumor. ERCP revealed compression of the pancreatic head and distal bile duct by the tumor.
Under the tentative diagnosis of P-NET, pancreatoduodenectomy was performed. Histologically, the tumor showed spindle cells arranged in whorls in a storiform pattern, and immunohistochemically, the tumor was positive for c-kit, which clinched the diagnosis of gastrointestinal stromal tumor (GIST) of the duodenum. Obtaining tissue samples from GISTs is difficult, particularly from tumors located in the distal duodenum. However, it seems essential to obtain samples for a definitive diagnosis of submucosal tumors, such as by EUS-FNA.

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A 66-year-old woman was admitted to the hospital complaining of melena. An urgent esophagogastroduodenoscopy (EGD) was performed, which revealed an abnormal opening in the horizontal segment of the duodenum with bleeding. Abdominal enhanced computed tomography (CT) showed a tumor measuring about 90 mm in diameter arising from the horizontal segment of the duodenum. There was no lymph node swelling or evidence of metastasis. On immunohistochemical analysis of the biopsy specimen, the tumor was found to show positive staining for c-kit and CD34. Based on the findings, a definitive diagnosis of duodenal gastrointestinal stromal tumor (GIST) was made, and partial resection of the horizontal segment of the duodenum was performed for complete resection of the tumor. The postoperative course was uneventful. The patient was initiated on treatment with oral imatinib mesylate (400mg/day) .

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An 87-year-old female patient was referred to our hospital with a history of fever and abdominal pain. Abdominal CT revealed a gallbladder stone, findings suggestive of cholecystitis, and a choledocholith. We performed percutaneous transhepatic gallbladder aspiration (PTGBA) . Eight days later, CT showed a thinned gallbladder wall, a pericholecystic abscess and a diverticulum-like prominence. We diagnosed acute gangrenous cholecystitis and performed percutaneous transhepatic gallbladder drainage (PTGBD) . After the cholecystitis improved, we performed endoscopic retrograde cholangiopancreatography (ERCP) to remove the stone. The papilla was located in a duodenal diverticulum. Therefore, we could not cannulate the common bile duct (CBD) , and performed endoscopic choledocholithotomy by the rendezvous method via the PTGBD route. A guidewire was introduced into the duodenum via the papilla and the bile duct intubation was successful.
The choledocholith was removed with a mechanical lithotripter after endoscopic sphincterotomy.
The rendezvous method via the PTGBD route is useful when selective cannulation of the CBD is difficult due to the presence of a duodenal diverticulum.

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There are few reports of bile duct cancer detected during long-term follow-up after treatment of choledocholithiasis, which is a rare occurrence. We report one such rare case. A 67-year-old man with a history of Billroth II gastrectomy who had undergone endoscopic sphincterotomy for choledocholithotomy 9 years ago was referred to our hospital for recurrent cholangitis caused by choledocholithiasis. Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography showed a stenosis in the common hepatic duct. Biliary cytology revealed that the stenosis was caused by an adenocarcinoma. There was no evidence of metastasis other than hilar lymph node metastasis, and left hepatic lobectomy was performed. Histopathological examination of the surgically resected specimen revealed a moderately differentiated tubular adenocarcinoma, pT1N1M0, pStage IIIB.●改行● Although cases of bile duct cancer caused by choledocholithiasis are rare, malignancy should be suspected in patients presenting with recurrent cholangitis after treatment for choledocholithiasis.

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A 71-year-old woman was admitted to our hospital with abdominal pain and jaundice. Abdominal CT revealed an enhancing mass measuring 20 mm in diameter in the middle portion of the common bile duct. MRCP showed stenosis of the middle portion of the bile duct, with a maximal diameter of the distal bile duct of 7 mm. ERCP showed pancreaticobiliary maljunction (PBM) with a long common channel (14 mm) , obstruction in the middle portion of the bile duct and mild stenosis in the right hepatic duct. Peroral transpapillary cholangioscopy revealed a papillary mass in the middle bile duct and reddish and irregular mucosa in the hilar bile duct. Histological examination of biopsies from the two lesions led to the suspicion of adenocarcinoma.
Reflux of pancreatic juice into the biliary tract in PBM is probably the reason for the higher incidence of biliary tract cancer in these patients. Although both gallbladder and bile duct cancers occur in cases of congenital biliary dilatation, most biliary cancers associated with PBM without bile duct dilatation are gallbladder cancers. This is a rare case of PBM without bile duct dilatation associated with two bile duct cancers.

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A 46-year-old man was admitted to our hospital with abdominal pain. Abdominal ultrasonography and computed tomography (CT) showed a large pancreatic cyst in the pancreatic body. Magnetic resonance cholangiopancreatography suggested a large pancreatic pseudocyst. Endoscopic retrograde cholangiopancreatography revealed communication between the cyst lumen and the main pancreatic duct. Endoscopic nasopancreatic drainage was performed. Post-drainage CT revealed reduction in the size of the pancreatic cyst. Therefore, endoscopic pancreatic stenting was performed. The patient is being followed up and remains in good general condition. Two methods are available for endoscopic drainage of a pancreatic pseudocyst : transpapillary drainage and drainage guided by endosonography through the stomach or the duodenum. Drainage guided by endosonography is impossible without a specific modality and devices, as it carries a high risk of hemorrhage and perforation. The indication for transpapillary drainage is a cyst in communication with the pancreatic duct. It is a less invasive and safer procedure.

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Xanthogranulomatous cholecystitis (XGC) is difficult to differentiate from malignant tumors, such as gallbladder and bile duct carcinoma. We report a case of XGC which was diagnosed preoperatively by recognizing the continuity of the mucosal layer in the gallbladder wall on multi-detector computed tomography (MDCT) . A 63-year-old man was admitted to the hospital because of jaundice. Abdominal ultrasound showed intrahepatic bile duct dilatation and stones in the gallbladder. MDCT showed diffuse thickening of the gallbladder wall and stenosis of the upper biliary tract. ERC showed bile duct stricture extending from the common bile duct to both hepatic ducts. Positron emission tomography (PET) showed abnormal accumulation in the bile duct stricture, with a standardized uptake value (SUV) of 5.0. The serum levels of the tumor markers CA19-9, DUPAN2 and SUPAN1 were also elevated. Based on these findings, the diagnosis of gallbladder carcinoma infiltrating the bile duct was suspected.
On the other hand, ERCP brush cytology and EUSFNA did not reveal any evidence of malignancy. Furthermore, we recognized continuity of the mucosal layer in the gallbladder wall on MDCT. Although XGC was strongly suspected based on the imaging findings, we performed resection of the gallbladder bed. Intraoperative pathological examination confirmed the diagnosis of XGC and ruled out malignancy. The findings on MDCT allowed us to avoid unnecessary extended operation.

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A 31-year-old Japanese man, who worked in Hong Kong, presented with a 1-month history of jaundice and was admitted to our hospital. Blood tests revealed evidence of obstructive jaundice. Abdominal ultrasonography, computed tomography (CT) , and magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the intrahepatic bile ducts and thickening of the upper portion of the bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a dominant stricture of the bile duct at the porta hepatis. Bile juice and brush cytology performed during the ERCP revealed no evidence of malignancy. A biopsy of the stricture lesion showed inflammatory cell infiltration and mild fibrosis.
There was no evidence of malignancy or infection. Additional blood tests showed no evidence of infection or IgG4-related sclerosing cholangitis. Surgical treatment was selected because of the difficulty in ruling out the possibility of malignancy. Histopathological analysis of the resected specimen of the bile duct stricture showed inflammatory changes, but no malignancy. Although sclerosing cholangitis was considered as the most likely diagnosis, all secondary causes of this condition were excluded on the basis of the patient’s history and examinations. Therefore, establishing the diagnosis was difficult in spite of the detailed examination in this case.

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