Background : Several reports showed that endoscopic balloon dilatation is efficacious for intestinal stenosis in Crohn’s disease (CD) . Recurrent stenosis, however, is not infrequent. Aim : Factors to affect the outcome after endoscopic of balloon dilatation for intestinal stenosis in patients with CD patients are assessed. Data Source : Comparative cohort studies about endoscopic dilatation for stenosis due to CD are collected through searching PubMed and Igaku-Chuo-Zasshi, a Japanese database, until August 2016. Study Selection : Studies to investigate the efficacy of endoscopic balloon dilatation as a primary outcome were selected. Data Extraction : All data evaluations and inclusion decisions were performed by investigators. Data Synthesis : Extracted data were collected into a structured database, and hazard ratio (HR) was examined using surgery rate as an outcome in case control studies. If HR was not shown, Tierney’s method was applied. Results : Eight studies met the inclusion criteria, and HR for surgery free survival after balloon dilatation was synthesized with meta-analysis. Three studies (n＝240) for anastomotic stenosis did not show clinical benefit as compared to stenosis of de novo as evidenced in HR (0.77 ; 95% CI 0.44-1.37) . Two small trials (n＝56) comparing a group with thiopurine therapy after balloon dilatation with no thiopurine group showed no benefit of thiopurine therapy (HR 0.61 ; 95% CI 0.16-2.36) . Also no difference was found concerning steroid injection into the stenotic lesion (HR 6.1 ; 95% CI 0.70-53.0) . One trial comparing smokers to non-smokers after balloon dilatation showed difference (HR 2.5 ; 95% CI 1.14-5.50) . Limitation : The eligible studies involved relatively small number of subjects and suffer from relatively high risk of bias. Conclusion : Prognosis was not affected by the nature of stenosis (de novo or anastomotic) or use of thiopurine. Surgery may be avoided by smoking cessation.

This study aims to provide further comparative data on the safety and feasibility of ESD provision in super-elderly patients above 85 years of age. Patients had ESD performed for colonic lesions from June 2013 till September 2015 were included and divided into 3 groups - ＜64 years old (group A) , 65〜84 years old (group B) , or ＞85 years old (group C) . Data on baseline characteristics, ESD procedure date, complications and specimen histology were analysed and compared. A total of 106 patients were included in this study of which 10 were group A, 76 were group B and 20 were group C. There was no significant difference among 3 groups in procedure time, en bloc resection rate and curative resection rate. Overall, no major adverse events were reported. ESD is a safe procedure for resection of colonic lesions even in super-elderly patients.

A 53-year-old man who suffered from continuous cough was referred to our hospital for the treatment of pulmonary nontuberculous mycobacterial infection (NTM) . After beginning administration therapeutic agents for including which were rifampicin, ethambutol and clarithromycin, the patient was hospitalized because of severe diarrhea and abdominal pain. The patient did not improve by stopped the drugs. Then the patient underwent fasting and treatment with IV fluids for over 1 month. Abdominal CT scan and colonoscopy suspected Pan-ulcerative colitis. General symptom and diarrhea improved after the administration of 5-aminosalicylic acid (5-ASA) . The final pathological diagnosis was ulcerative colitis (UC) .
The characteristic of drug-induced enterocolitis is that discontinuation of the drug leads to rapid improvement of symptoms. The criteria for diagnosing UC may require exclusion of drug-induced enterocolitis. The reasons why this case was diagnosed with UC were that diarrhea did not improve for over 1 month after discontinuation of the drugs, and UC was strongly suspected by colonoscopy, CT scan and pathological diagnosis. Herein, we reported the rare case of UC that was difficult to differentiate from drug-induced enterocolitis.

Amyloidosis is a relatively rare disorder, characterized by amyloid deposition in various organs, disrupting tissue structure and function. We report a case of AA amyloidosis with polymyalgia rheumatica (PMR) . The patient was an 80-year-old woman with a history of chronic lower abdominal pain, nausea, and constipation. She was referred to our hospital for raised inflammatory markers (CRP 20 mg/dL and WBC 24520/µL) . Abdominal CT revealed iliopsoas abscess resulting from sigmoid colon perforation. She was treated with CT-guided drainage, antibiotics, and total parenteral nutrition (TPN) instead of emergency surgery because of her poor general condition on admission. She suffered from catheter infection, candidemia, candida endophthalmitis, cholecystitis, and pseudomembranous colitis during the treatment and experienced nausea, vomiting, and abdominal pain after starting oral nutrition. The diagnosis of AA amyloidosis was confirmed by endoscopic biopsies. She underwent colostomy on day 271. She still suffered from severe infection after the surgery, and immunosuppressive treatment was not indicated. She had progressive malabsorption due to gastrointestinal amyloidosis and died on day 425.
The prognosis of gastrointestinal perforation with amyloidosis is poor because of the severity of underlying illnesses, infections, and postoperative leakage. Serum AA levels must be reduced to prevent gastrointestinal amyloidosis caused by AA amyloidosis. Tocilizumab, a humanized anti-interleukin-6 receptor antibody, is a potential treatment option for AA amyloidosis.

Endoscopic submucosal dissection (ESD) is a useful procedure for digestive tract cancer, and becoming common procedure. As the adaptation spreads, we experience many difficult cases of large lesions, ulcerative scars, and difficult to control bleeding.
For performing ESD smoothly, it is most important to keep clear view. Good counter-traction makes ESD easier. Thread-traction-method was reported in esophageal ESD. For example, thread-traction-method is very usefulness, but it has problems in durability and complication.
So, we reported an adjustable counter-traction method using suction tube, snare and clips for gastric ESD. After we insert a suction tube intranasally and attached clips to edge of lesion, we insert snare through the tube and catch the clip using snare. This method has strong durability. It is easy to repeatedly use, and makes it possible to push and pull. This point is useful for gastric ESD.
Adjustable counter-traction is one useful method to make ESD easier.

ESD was performed for 118 cases of superficial esophageal carcinoma (144 lesions) . Of the cases, 110 lesions (76.4%) were treated using the double channel (DC) ESD with the Clutch Cutter and an EEMR-tube. En bloc resection was possible in 100% of the cases, which prevented bleeding. However, perforation occurred in 2 cases (1.3%) , which were treated conservatively. The DC method with the EEMR-tube did not cause any perforations. Complete resection was performed in 95.8% of cases without local recurrence or metastasis. The DC method with the EEMR-tube allows for countertraction by grasping the cut end with fine V-shaped forceps through the side channel. This method allows endoscopists to 1) create a better operative field, 2) maintain a good stable view, 3) change the retraction direction by rotating the EEMR-tube, 4) alter the retraction point during the procedure, 5) avoid interrupting the procedure by alternating between the forceps and the devices, 6) easily detect vascular structure and stop bleeding. The procedure should be performed under general anesthesia in an operating room to avoid respiratory complications and limit the stress on endoscopists.

Background : Henoch-Schönlein purpura (HSP) preferentially affects children, but may rarely occur in adult, therefore, there are few reports about their endoscopic findings. Thus, we investigate endoscopic features in HSP patients.
Methods : Descriptive study was carried out in the department of Gastroenterology, Toranomon Hospital during the period from January 2001 to January 2016. Seven patients who were subjected to endoscopy were included in the study.
Results : A total of 7 patients ; 2 females, and 5 males. Mean age is 51.4 years old (27-73 years old.) Clinical features : purpura (100%) , stomach pain (86%) , nephropathy (71%) , arthralgia (57%) , and hematochezia (43%) . Location of lesions in the gastrointestinal (GI) tract : small intestine including duodenum (100%) , large colon (57%) , stomach (17%) , esophagus (0%) . Endoscopic findings : mucosal edema (100%) , erosion/ulcer (87%) , hemorrhage (43%) , submucosal hemorrhage (87%) . Pathological findings : granulocyte recruitment (100%) , leukocytoclastic vasculitis (0%) , IgA deposition (0%) .
Conclusion : All GI tracts can be affected in the patients with HSP, therefore, we need detailed survey of endoscopic examinations, which, in turn, would contribute to early diagnosis of it.

Formerly our colorectal ESD training required preceding mastery of gastric ESD, but we have changed the system so that it can be started irrespective of gastric ESD experiences since 2014. Here, we present the course of a trainee who was trained in the new training system. The trainee had an experience of 40 gastric and 5 colorectal ESD at another institution. At the first step of the new training system, the teaching expert taught the following points to the trainee ; how to operate endoscope at will to meet the pre-determined objective criteria, and how to perform colorectal ESD in a pig colon model. After that, the trainee was allowed to perform colorectal ESD practice, starting with rectal lesions, under full back-up by the expert. 20 colorectal lesions were treated by the trainee within six months. The en bloc and self-completion resection rates were both 100%. The mean procedure time was 106 minutes with a mean tumor size of 36.6 mm. Thus, the trainee who had a limited experience of ESD at another hospital could perform colorectal ESD safety under our training system. We believe intensive coaching before ESD practice and full-back up by an expert in the initial step of ESD practice are necessary.

Background : A risk factor during endoscopic retrograde cholangiopancreatography (ERCP) is peristalsis of the duodenum. Common antispasmodic drugs such as scopolamine butylbromide and glucagon are associated with a risk of complications in patients with heart, prostate, diabetes mellitus, and thyroid disease. l-menthol has an antispasmodic effect on the smooth muscles of the stomach, bowel, and colon.
Methods : We prospectively evaluated ERCP without gastrectomy at Teikyo University Mizonokuchi Hospital, between July 2014 and March 2016.
Results : The total number of eligible patients was 359. The complete procedure rate with l-menthol alone was 90.5%. The median total procedure time was 23 seconds. In almost 80% of cases, appropriate peristalsis of duodenum for ERCP l-menthol alone was observed.
Conclusion : We propose that l-menthol can be useful as an antispasmodic drug during ERCP.

Our endoscopy center has 12 examination rooms, and 35 doctors and 17 nurses are working. Approximately 19,000 upper gastrointestinal endoscopies and 8,500 colonoscopyies are performed in a year. To improve the quality of the examinations and patients’ safety, our hospital got JCI (Joint Commission International) certificate in 2011 and it was updated in 2014. We perform all endoscopic activities with special attention to the followings. First, with regard to safety management, we assure the safety of not only patients, but also medical staffs. Second, regarding the efficiency of the examinations, arrangement of the nurses and the doctors are decided for each examination room in advance. In addition, doctors in charge of emergency examinations are decided beforehand. And third, regarding the quality assurance of endoscopic procedures, we provide regular study sessions for all medical staffs of our hospital. It is important for all endoscopic staffs to consider these three points. In this way, we can perform maximal endoscopic procedures efficiently and safely with a limited number of staffs.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been widely utilized for diagnosis of upper gastrointestinal pathologies. However, there is only a few reports for usage of such technique for biopsy of mediastinal lesions. In this article, we report the feasibility and safety of EUS-FNA for mediastinal lesions. From 2013 to 2016, a total of 198 EUS-FNA cases were performed in our institution. Among them, a total of 10 mediastinal lesions were performed. Outcome data was evaluated retrospectively. In these cases, the final diagnoses were, a case of lung cancer, breast cancer, cancer from unknown origin, malignant lymphoma, suspected lymphoma, sarcoidosis and schwannoma each. Three cases were of inflammatory adenopathies. There was no complication noted in all cases. In conclusion, EUS-FNA has a high accuracy, safe, and is minimally invasive for diagnosis of mediastinal lesions.

We report the first case of biperiden (Tasmolin^®) -induced Stevens-Johnson syndrome (SJS) with late complications of gastric ulcer perforation and esophageal stricture. A 53-year-old male with schizophrenia had a fever and skin erythema after biperiden had been administered for 8 weeks. He was admitted, and diagnosed as biperiden-induced SJS. The skin erythema was disappeared after steroid pulse and immunoglobulin combined therapy. On the 22th day, he had melena and anemia. Endoscopic findings revealed the hemorrhagic gastric ulcers and the peelings of esophageal mucosal membrane. He was treated with endoscopic hemostasis and proton pump inhibitor. On the 44th day, gastric ulcer was perforated and treated surgically. On the 126th day, he had dysphagia because of the esophageal stricture. The mucosal inflammation was disappeared and stricture was 1 cm in length. Dysphagia was improved after endoscopic balloon dilation therapy.

The patient was a 78-year-old female who had ingested an acidic detergent (Sunpole^™) with suicidal intent. She underwent partial gastrectomy and enterostomy to treat perforations in the gastric remnant (from previous cancer surgery) . She was successfully treated in an intensive care unit, but later she developed esophageal stricture due to corrosive esophagitis and was transferred to our hospital. Mucosal damage was discovered in the esophagus beginning at the cervical region. Her medical history included, along with stomach cancer, a total laryngectomy. These observations suggested that esophageal reconstruction would require invasive and complicated surgery that would involve intestinal tissues. We also considered her advanced age and illiteracy, and decided to use conservative esophageal dilation. During six dilation sessions within half a year, her oral food intake increased gradually. Here, we detail this successful dilation procedure for corrosive esophageal stricture.

We encountered a patient with type I diabetes who developed acute necrotizing esophagitis during hospitalization for the treatment of left humeral neck fracture. Hyperglycemia and dehydration associated with type I diabetes were thought to have affected the development of acute necrotizing esophagitis in this patient. Conservative treatment improved the mucosal damage. However, thereafter, the patient developed esophageal stenosis that required esophageal balloon dilatation. Since some patients with acute necrotizing esophagitis develop advanced esophageal stenosis during its healing process, careful follow-up is necessary.

The patient was a 64-year-old man in whom esophagogastroduodenoscopy showed a 30-mm-diameter, reddish, depressed, partly nodular lesion at the lower esophagus as the depth of invasion was SM1/2. Magnifying endoscopy with NBI revealed type B1 vessels in the depressed area and Type B2 vessels in the nodular area as the depth of invasion was MM1/SM1. Since there was a deviation between the white-light and NBI findings, we performed EUS, and confirmed that the third layer was intact. Based on these findings, the lesion was classified as type 0-IIc＋Is with an invasion depth of MM/SM1. Based on the final pre-operative diagnosis, ESD underwent for achieving a block resection. Histopathologically, the depth of invasion of the lesion was classified as up to MM. 0-Is area contained more abundant inflammatory cells, and was observed as a tall lesion, with the result that the depth of invasion was diagnosed as deeper with white-light. The present case suggests that the depth of invasion should be comprehensively and accurately diagnosed using not only white-light but also NBI-magnifying endoscopy and EUS.

A 65-year-old man had been receiving yearly esophagogastroduodenoscopy (EGD) at another hospital. A type 0-IIc lesion was found at the midthoracic esophagus, and he visited our hospital. We performed EGD and white light imaging revealed a shallow depressed lesion of about 10-mm diameter. The lesion was seen as a brownish area on NBI, and a unstained area by iodine staining. Magnifying endoscopy showed few intraepithelial papillary capillary loop area. We could not determine whether the tumor was malignant. Although histological examination of biopsy specimens showed evidence of inflammation, endoscopic findings suggested carcinoma. Thus, we performed endoscopic submucosal dissection (ESD) for diagnosis and treatment. Histopathological findings were squamous cell carcinoma, and depth was SM2. The surface differentiation was maintained and it might be reflected in the endoscopic findings. In this particular case, ESD was useful for diagnosis.

Background : Identification of the margin is important for the diagnosis and treatment of early gastrointestinal (GI) cancer. However, it is sometimes difficult in Barrett esophageal cancer. We report a case which was able to accurate demarcation of the area.
Case : A 59 years old man received an upper GI endoscopy for follow-up of reflux esophagitis. Reddish granular change was found in posterior wall of esophagogastric junction, and biopsy of this lesion revealed adenocarcinoma. Based on the clinical diagnosis of type 0-IIc＋IIa intra-mucosal cancer arising from short-segment Barrett’s esophagus, ESD was performed. Although the proximal margin was unclear with influence of inflammation, recognizing mucosal thickness and microvascular network pattern is useful to diagnose demarcation line. At distal margin, demarcation line was difficult to recognize because of unnatural depressed line under SCJ considered to be caused by exfoliation of covering squamous epithelium above the cardiac gland. Pathological finding was identical with pre-operative endoscopic diagnosis of the cancer margin.
Conclusion : Approach from certificate endoscopic findings is important, especially in case of superficial Barrett esophageal cancer which is difficult to identify cancer margin.

A 59-year-old woman visited the previous clinic because of abdominal fullness. Esophago-gastro-duodenoscopy (EGD) showed a depressed lesion measuring 6mm in diameter at the greater curvature of the angle.
She was diagnosed as gastric mucosa-associated lymphoid tissue (MALT) lymphoma on biopsy and was referred to our hospital for intensive examination and treatment. Both Helicobacter pylori antibody in serum and urea breath test were negative.
The lesion was considered a minute H. pylori-negative MALT lymphoma and was resected by endoscopic submucosal dissection (ESD) . Pathologically, the lesion was curatively resected with ESD.
For H. pylori-negative gastric MALT lymphoma, the response rate to H. pylori eradication is generally low, so and radiation therapy or chemotherapy may be selected.
This case report suggests that ESD may be an alternative treatment for a minute H. pylori-negative gastric MALT lymphoma.

A 77-year-old woman was admitted with complaint of anorexia and anemia. We performed diagnostic upper gastrointestinal endoscopy. Features indicative of reflux esophagitis and severe atrophic gastritis were recognized, but hemorrhagic lesions were not observed. During the examination, there were multiple lacerations in the lesser curvature of stomach, immediately halted by the removal of gastric air. Free air was confirmed on abdominal CT image, and a diagnosis of gastric perforation. We decided conservative management because neither fever nor abdominal symptoms and mild inflammatory response. Inflammatory response improved with continued suction via nasogastric intubation, and antimicrobial administration. Abdominal CT taken after 2 weeks showed no free air and confirmed the closure of the perforation in the stomach X-ray contrast examination.
This was a case of gastric perforation resulting from air insuffitation during upper gastrointestinal endoscopy.

A 66-year-old woman was admitted to our hospital for persistent vomiting after replacement of percutaneous endoscopic gastrostomy (PEG) catheters at another hospital. Abdominal computed tomography revealed a PEG catheter bumper retained in the stomach, which appeared to be the cause of vomiting. Although we attempted to retrieve the bumper with a retrieval net and grasping forceps employing upper gastrointestinal endoscopy, high resistance at the gastroesophageal junction hampered our efforts. While the bumper was endoscopically grasped, two bumper legs were cut with a laparoscopic surgical scalpel inserted from the fistula. The bumper was then safely retrieved, employing grasping forceps, without resistance.
Endoscopic retrieval is recommended for retained PEG internal bumper, but can be difficult in certain cases. We herein report a case in which a PEG internal bumper was safely retrieved in combination with a trans-fistula approach.

A 72-year-old woman visited our hospital for further investigation of a gastric polyp diagnosed via upper gastrointestinal series. Upper gastrointestinal (GI) endoscopy revealed a submucosal tumor in the stomach. The patient was advised regular follow-up with upper GI endoscopy or further investigation with endoscopic ultrasonography (EUS) ; EUS showed a 15-mm low-echo lesion. Specimens obtained using EUS-guided fine needle aspiration showed spindle-shaped cells. The cells were positive for CD34 and CD117, and the tumor was diagnosed as a gastrointestinal stromal tumor. The patient was advised to either undergo surgical treatment or continue regular follow-up, and preferred regular follow-up. No tumor growth has been observed.

Inflammatory fibroid polyp (IFP) is a rare disease characterized by spindle-shaped tumor cells with eosinophilic infiltration. A 70-year-old woman was hospitalized with hematemesis in March 2015. Upper gastrointestinal endoscopy revealed blood coagulum in the stomach and a submucosal tumor-like lesion (2cm in diameter) at the posterior wall of the antrum. Because the blood clot-containing ulcer was observed on the tumor surface, we performed hemostasis under endoscopy. Distal gastrectomy was performed under laparoscopy with laparoscopic reconstruction in April 2015. Because microscopic examination revealed spindle-shaped tumor cells with eosinophilic infiltration in the sample and immunohistological staining showed the tumor cells to be negative for KIT, IFP was diagnosed. We performed minimally invasive surgery under laparoscopy with laparoscopic reconstruction for gastric IFP.

A flat reddish lesion was detected in a 69-year-old man on the posterior wall of the upper gastric body by EGD. Although biopsy specimens revealed a Group4 lesion, the lesion’s margin was unclear. After four years, the same lesion showed enhanced redness with the possibility of gastric carcinoma, and the patient was referred to our hospital for further examination. Although there was no finding by NBI and biopsy specimens showed no malignancy, we performed ESD because the lesion was detected by spraying with acetic acid and indigo carmine. Microscopic examination revealed Type0-IIc, 9×5 mm, tub1＞tub2, pT1a (M) , UL (＋) , ly (−) , v (−) . We report here our clinical experience, the curative resection of the gastric cancer and the difficult diagnosis after long-term follow-up.

A 68-year-old male who was referred by respiratory medicine for an endoscopic gastrostomy. Upper gastrointestinal endoscopy revealed a flat, reddish lesion (10 × 10 mm) in the gastric antrum area. The biopsy specimen was diagnosed as well differentiated adenocarcinoma. We treated the patient with endoscopic submucosal resection (ESD) . Histopathologic examination revealed gastric-type extremely well-differentiated adenocarcinoma (EWDA) with infiltration of the submucosa.
EWDA is a rare type of gastric adenocarcinoma characterized by its mimicking of normal epithelium. The most important clinicopathologic feature is cancer invasion of the submucosal layer, which is in contrast to its benign microscopic appearance and small diameter.
We have reported a case of gastric adenocarcinoma including extremely well-differentiated adenocarcinoma that was completely resected and diagnosed by ESD.

A 73-year-old man was referred to our department because of recurrent epigastralgia and nausea. Esophagogastroduodeno- scopy revealed a pedunculated tumor in the greater curvature of the middle body and drawn folds from the gastric body into the pyloric side. After pushing the scope, the protruding tumor was shifted aside and a good view was obtained. Another pedunculated tumor was evident in the greater curvature of the gastric angle. Computed tomography and gastrography with a barium meal revealed a tumor prolapsing in the duodenum. A diagnosis of multiple early gastric cancer with ball valve syndrome was made. Endoscopic submucosal dissection was performed. Histopathological examination revealed a poorly differentiated adenocarcinoma with an invasion depth of submucosa and lymph vessel permeation was positive. Therefore, the patient underwent a total gastrectomy. He is being followed up regularly.

A 77-year-old woman underwent adnexectomy for right ovarian cancer six years ago. As the recurrence of the cancer in the left supraclavicular and right paraaortic lymph nodes was detected by computed tomography, she received intensity modulated radiation therapy for both lymph nodes. After three months of radiotherapy she complained of tarry stools and shortness of breath, and she was referred to our hospital. Frequent erythrocyte transfusions had been received due to the continuous tarry stools and severe anemia. Upper gastrointestinal endoscopy showed friable mucosa with telangiectasias in the descending and horizontal part of the duodenum. A diagnosis of radiation-induced hemorrhagic duodenitis was made, then argon plasma coagulation (APC) was performed consecutively. The tarry stools ceased after the second APC treatment. Her hemoglobin level was sustained more than 9 g/dL after the sixth APC treatment without further blood transfusions.
APC is effective in the management of radiation-induced hemorrhagic duodenitis. On the occasion of the APC treatment a skill seems required because the duodenal lumen is not wide and spasms occur strongly during ablation.

Proton beam radiation is an effective treatment method for hepatocellular carcinoma. Radiation-induced duodenitis with severe hemorrhage is rare side effect by proton beam therapy. We report a case of hemorrhagic duodenitis caused by proton beam therapy for hepatocellular carcinoma, which was treated successfully with APC. A 65-year-old man, who had liver cirrhosis due to hepatitis C virus, was diagnosed hepatocellular carcinoma of right anterior segment. He received proton beam radiation. Three months later, he suffered anemia and hematochezia. Hemorrhagic duodenitis caused by proton beam radiation was found. We performed APC two times for hemorrhage from duodenitis. After the treatments, the patient had no relapse of hemorrhagic duodenitis for ten months until his death of hepatocellular carcinoma.

A female was admitted presenting with melaena. She had previously been diagnosed with deep vein thrombosis which was being treated with Warfarin. Esophagogastroduodenoscopy revealed a symptomatic submucosal pedunculated tumor located in the second portion of the duodenum. The tumor showed a thick stalk, yellow in color, and measuring 20 mm at its base. Definitive diagnosis of a duodenal lipoma located in the submucosal layer was supported by histological examination. During endoscopic examination blood was discovered issuing from a mucosal break in the stalk. Hemostasis was achieved via hemostatic clips that were administered endoscopically. Eighteen days after undergoing endoscopic hemostasis the patient had melaena again. After the melaena, removal of the duodenal lipoma via endoscopic polypectomy using a detachable snare was determined the choice treatment. After seventeen days the patient showed no postoperative complications and was subsequently discharged. In this case, the use of a detachable snare was determined an effective technique in performing endoscopic polypectomy in the removal of the symptomatic duodenal lipoma.

A case is sixty three years-old male. Chief compliant was vertigo and dizziness. He visited the emergency room at our hospital because his symptom had become progressively more severe. When we interviewed and examined him, there was no hematemesis and tarry stool. We decided to perform urgent endoscopy due to anemia (Hb 7.1 g/dl) . The duodenal ulcer (A1 stage) with spurting bleeding was observed in the horizontal portion of duodenum. Complete haemostasis was attained with HSE injection and clipping.

A 72-year-old man who had undergone endoscopic papillectomy for adenoma of the papilla of Vater 6 years earlier presented with general malaise and epigastric pain. Hematologic investigations revealed increased inflammatory markers and elevated hepatic enzymes, and abdominal computed tomography showed biliary dilatation. We diagnosed acute cholangitis. The patient was started on antibiotics on admission, but in the following 24 h developed fever, thrombocytopenia, systemic fibrinolysis, asthenia, sepsis, and disseminated intravascular coagulation syndrome. We performed endoscopic retrograde cholangiopancreatography, and confirmed stenosis of the inferior bile duct by cholangiography. The cholangitis improved after endoscopic biliary stenting. We subsequently performed endoscopic sphincterotomy for the bile duct and confirmed appropriate biliary outflow. Endoscopic treatment was effective for stenosis of the bile duct after endoscopic papillectomy.

An 89-year-old woman came to our hospital because of anemia. She was found to have a major duodenal papilla tumor by screening upper gastrointestinal endoscopy. The preoperative diagnosis by biopsy was adenoma. We performed endoscopic resection and the tumor was deeply resected. However, the final pathological diagnosis of the resected specimen was well-differentiated adenocarcinoma with positive margins. About 6 months later, local recurrence and lower bile duct invasion was confirmed on endoscopic retrograde cholangiopancreatography (ERCP) , but the patient and her family decided against re-resection. We performed repeated endoscopic plastic stenting for decompression of bile duct obstruction due to biliary invasion every 6 months, a total of 11 times, and eventually placed a fully covered metal stent. Subsequently, the patient was hospitalized because of pneumonia and sepsis and died on the 7 th day. Recently, reports of endoscopic resection for duodenal papilla carcinoma have increased and recurrence after resection has become a problem. However, studies describing the postoperative course are rare. Here, we have report the natural course of a case of recurrent adenocarcinoma of the major duodenal papilla after endoscopic resection with long-term survival of 6 years.

A 76-year-old man presented to our hospital because he had noticed a long, white, string-like discharge in his feces. He had a history of eating raw fish. Tapeworm infection was suspected. We performed capsule endoscopy to investigate whether there were parasitic tapeworms. Capsule endoscopy revealed a scolex in the jejunum at 2 hours and 4 minutes, and another scolex at 2 hours and 37 minutes. He was treated with praziquantel (1200 mg) followed by a cathartic (magnesium citrate) . The two tapeworms were successfully expelled. Their lengths were 404 centimeters and 135 centimeters, respectively. After analysis of the expelled tapeworms, we diagnosed the patient with Diphyllobothrium nihonkaiense infection.
In our case, capsule endoscopy was useful for evaluation of the number of parasitic tapeworms.

A 60-year-old woman visited our hospital complaining of epigastric discomfort, nausea and vomiting for 10 days. Although CT findings suggested superior mesenteric artery (SMA) syndrome, some of her physical characteristics mismatched the diagnosis. Further examinations including esophagogastroduodenoscopy and enhanced CT with foaming agent revealed entire circumference of the tumor with ulcer in the fourth portion of duodenum, pathological diagnosis was adenocarcinoma by biopsy. Laparotomy showed the tumor was located in jejunum, partial resection of jejunum was done. To avoid misdiagnosis of the SMA syndrome, we should carefully check any courses of duodenal dilatation with chronic upper abdominal symptoms. In this case, we could diagnose of the jejunal cancer correctly by detailed inspection.

Fish bones are the leading type of gastrointestinal foreign body in Japan, and most require surgical removal. We describe the endoscopic removal of fish bones from the gastrointestinal tracts of two patients.
Case 1 : A 70-year-old man presented with pain in the left lower abdomen. A 3-cm linear, high-density foreign body was identified by CT in the sigmoid colon. A fish bone was removed by colonoscopy.
Case 2 : A 49-year-old woman was referred to our institution with upper abdominal pain. A linear, high-density structure was identified by CT in the proximal jejunum, and a fish bone was removed using single balloon endoscopy. This is the first report of removal of fish bones from the small intestine by balloon assisted endoscopy. We emphasize that clinicians should be aware of the characteristic imaging features of fish bones : they are usually linear and have high density on CT images. Endoscopic removal and laparotomy should be considered as the first and second approaches, respectively, for removing fish bones from the gastrointestinal tract.

A 73-year-old woman with intermittent fever and abdominal pain was referred to our hospital. Her hepatobiliary system enzymes and inflammatory reaction were elevated, and an enterolith of a juxtapapillary duodenal diverticulum, cholangiectasis were showed on CT scan. On suspicion of Lemmel syndrome, performs emergency ERCP, was placed the ENBD. Cholangitis is gradually improving, and replacing the ENBD to plastic stent on the 19th hospital day. On the 34th hospital day, she developed vomiting and abdominal pain. Although the enterolith of a juxtapapillary duodenal diverticulum was not recognized, the enterolith in the small intestine and small bowel ileus were revealed. Did not improve in the conservative therapy by ileus tube inserted, an enterotomy was performed to remove the enterolith. The enterolith was spherical, 25mm in diameter. On CT scan and in operative findings, there was no traffic in the juxtapapillary duodenal diverticulum to gallbladder and common bile duct. Therefore, the enterolith was thought to have been formed in the juxtapapillary duodenal diverticulum.

An around 20 years old woman was admitted to our hospital because of lower right abdominal pain and fever. She had occasionally suffered from lower right abdominal pain only. Abdominal tenderness was found in the lower right abdomen. Abdominal CT scan findings showed wall thickness of the ileum end. Colonoscopy findings showed a sore and small upheaval lesion of the mucous membrane at the same area. So we took the biopsy specimen from the lesion. The pathological finding of biopsy suspected MALT lymphoma. She hoped to receive the surgical ileocecal resection. After surgical operation, she recovered quickly without symptoms. We reported a case with primary MALT lymphoma of the small intestine.

A-86-year male patient was transferred to our department for investigation of two episodes of bloody stool in August and October, X. Hemostasis was performed on a suspicion of colonic diverticulosis or capillary telangiectasia in the small intestine. The patient admitted to the hospital because of a recurrent bloody stool in December, X. Abdominal CT showed an extravasation of contrast from the terminal ileum. Lower GI endoscopy was performed but failed to detect the bleeding point. However, at the 4th episode of bloody stool after admission, endoscopy revealed active bleeding from one of multiple diverticula at 10-cm proximal to Bauhin’s valve in the terminal ileum. An exposed blood vessel was recognized after irrigation and hemostasis by clipping was attempted. The patient was discharged without any further bleeding episode. We here present a case of bleeding small intestinal diverticulosis in which the bleeding point was detected by abdominal CT and hemostasis was achieved by clipping during lower GI endoscopy. Our present case suggests that abdominal CT is useful in case with bleeding small intestinal diverticulosis.

A 75-year-old woman was admitted to our hospital with melena. She had a history of chronic kidney disease. Abdominal computed tomography without contrast agent showed diverticula in the ascending colon. Diverticular bleeding in the colon was suspected. She was treated by fasting and blood transfusion. However the bleeding did not stop. We performed colonoscopy to identify the site of bleeding. Colonoscopy revealed oozing of blood from an ileal diverticulum. We diagnosed the patient with diverticular bleeding in the terminal ileum. Five endoscopic clips were applied near the site of bleeding. She had no recurrence of bleeding after the treatment.
It is difficult to detect of bleeding from an ileal diverticulum because of blood pooling, as had been observed in our patient. In patients with lower gastrointestinal bleeding, the terminal ileum should be observed carefully.

A 50-year-old man was admitted to our hospital with complain of diarrhea and hematochezia. Colonoscopy showed multiple shallow ulcers with a white exudate on cecum and rectum, and no tumor was detected on the same site. A biopsy specimen of the ulcer on cecum revealed the inflammation with trophozoites of Entamoeba histolytica. The patient was diagnosed as amoebic colitis and was administered metronidazole (750 mg/day) for 5 days. The second colonoscopy, 8 months later, showed a completely healed rectal and cecal mucosa, but a 25 mm LST (granular homogenous type) was detected on the same site of cecum. The patient underwent ESD and the resected specimen showed well-differentiated adenocarcinoma in adenoma component, the depth of Tis, 25×18 mm in size. We have reported a rare clinical course of cecal LST which was detected after treating amoebic colitis.

A 76-year-old man complained of frequent diarrhea and appetite loss. He had undergone colorectal surgery for descending colon cancer and received a follow-up without recurrence for approximately a year. Computed tomography revealed colon wall thickening from the descending colon to the rectum and enlarged para-aortic lymph nodes, leading us to suspect descending colon cancer recurrence. However, endoscopic findings suggested ischemic colitis from the anal side of the anastomotic site to the rectum. There were circumferential redness, edematous change, and ulcer with distensibility. As pathological findings indicated no malignancy, we diagnosed ischemic colitis. Symptoms did not improve despite conservative treatment ; thus, low anterior resection was performed. Patient recovered after surgery and pathological findings confirmed ischemic colitis. He was discharged and progressed without symptoms. Therefore, it is important to differentiate ischemic colitis when cancer recurrence is suspected after surgery.

A 67-year old man, who had been diagnosed with cavernous hemangioma of the rectum 2 years before, was admitted to our department presenting with continuous bloody stool. The conservative management approach that had been administered was unsuccessful resulting in repeated hematochezia. During routine colonoscopy it was decided that endoscopic hemostasis was not advisable due to the discolored circumferential mucosal elevation diffusing from sigmoid to rectum. Hemostasis was achieved by abdominaoperineal resection. The resected specimen showed thickening of the intestinal wall, vascular proliferation, and mucosal congestion in the rectum. Histological examination of the tissue revealed diffuse vascular proliferation and aggregation from the submucosa to muscularis propria as well as intravascular calcification. Here we report the diagnosis and treatment of colonic cavernous hemangioma with precise histopathological findings post-surgical treatment.

A 42 years old female was admitted into our hospital on July 2016 complaining of pain in the lower abdomen and watery bloody stool. Colonoscopy showed ischemic change in the descending and sigmoid colon and multiple erosions in the ascending colon. Patient treated as ischemic colitis, and she discharged after conservative therapy for 7 days. After 4 months, colonoscopy showed linear ulcer scar in the descending and sigmoid colon and annular ulcer in the ascending colon. A diagnosis of tuberculosis was made from a biopsy sample taken at the annular ulcer that revealed positive mycobacterium culture results as well as a positive polymerase chain reaction (PCR) assay. Quantiferon (QFT) was also positive. She was placed on four-drug therapy for 6 months.
Following treatment colonoscopy showed no evidence of erosions or ulcers. Findings of erosions in the ileum or ileocecal region suggest tuberculosis, and a high index of suspicion should be maintained when performing diagnostics. Workup should include QFT, which has high sensitivity and specificity and close follow up with colonoscopy should also be done.

A 97-year-old woman was admitted with a chief complaint of abdominal pain and fullness. She was diagnosed with transverse colon cancer and a colon cancer ileus by abdominal computed tomography. Although surgery was considered high risk, the patient underwent colon stenting on the same day by emergency endoscopy. Her symptoms improved and she resumed her normal dietary intake without any obvious complications. Colon stents have been widely used since 1991 and their safety has remained unchanged in the elderly and young alike. With regard to the oldest old, colon stents can also be considered safe and effective.

We report the case of an 84-year-old man with an inferior mesenteric artery aneurysm three years after rectal cancer surgery. An enhanced computed tomography showed the aneurysm in the inferior mesenteric artery area. We performed a transcatheter arterial embolization through the inferior mesenteric artery. Although an ischemic colitis occurred around the embolization area about two weeks later, the patient recovered without any stenosis. An inferior mesenteric artery aneurysm is a rare disease among visceral aneurysms, and here we report a successful transcatheter arterial embolization therapy.

An asymptomatic 40-years old woman had Colonoscopy because of high serum level of CEA. Colonoscopy revealed rectal polypoid lesion 10 mm in size, which endoscopic diagnosis was high grade adenoma or intramucosal carcinoma. The lesion was located lower rectum to anal canal, ESD was performed. Resected specimen showed Tubular adenoma with severe atypia in elevated lesion, and anal intraepitherial neoplasia was adjacent to adenoma. She had a history of HPV infection. We should take care AIN during examining anal canal endoscopically, especially a patient have a history of HPV infection.

A 45-year-old woman at 14th week of pregnancy was admitted our hospital for pain with defecation. Proctoscopy revealed white polyp 20 mm in diameter at the dentate line. The lesion grew to 60 mm and she underwent transanal polyp excision at 26 th week pregnancy. Postoperative diagnosis was fibroepithelial polyp (FP) or fibroepithelial stromal polyp (FSP) , which show similar histological features. FPs are typically located in anus and caused by physical stimuli during defecation. FSPs are commonly found in female external genitalia, considered to be hormone sensitive and sometimes grow rapidly during pregnancy. However FSPs are rarely located in anus, we concluded this case is more appropriate to considered to be FSP.

A 60-year-old man was transported to our hospital with hematemesis. Upon admission, emergency esophagogastroduodenoscopy revealed an elevated, submucosal lesion just below the gastroesophageal junction. The top of the lesion was ulcerated and this seemed to be the source of the bleeding. Laboratory data showed liver dysfunction and enhanced computed tomography revealed a massive tumor ranging from the cardia to the left hepatic lobe. Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of the tumor through the gastric wall revealed pathological hepatocellular carcinoma (HCC) and direct extrahepatic HCC invasion of the gastric wall was diagnosed. Extrahepatic HCC is rare among the types of primary liver cancer. EUS-FNA helped to achieve an accurate diagnosis. We believe that EUS-FNA is useful, not only for pancreatic cancer and submucosal tumors of the digestive tract, but also for extrahepatic hepatocellular carcinoma.

A 46-year-old man had undergone Roux-en-Y choledochojejunostomy for pancreatobiliary maljunction at 35 years of age. The patient was given a diagnosis of cholangitis with hepatolithiasis and was admitted to the hospital. A long-type single-balloon enteroscope was difficult to insert to the choledochojejunostomy anastomosis (CJA) . A percutaneous approach was attempted, but precluded by the intestine in the puncture route. Transgastrohepatic puncture of the bile duct (B2) was done under endoscopic ultrasound (EUS) guidance. Cholangiography was performed and revealed several filling defects, suggesting stones up to 20 mm in diameter. The CJA was dilated with a balloon, and the stones were then removed in an antegrade fashion with the use of a balloon catheter for stone removal. The stones were completely removed after 2 sessions of treatment, with no procedural complications. This procedure is useful in patients in whom transanastomotic and percutaneous procedures are difficult to perform.

A 72-year-old man with a fever was admitted to our hospital. He was initially diagnosed with cholangitis in the common bile duct. We attempted to remove the stone by using conventional endoscopic retrograde cholangiography (ERC) , but the stone could not be moved by any type of catheter. ERC revealed that the stone was incarcerated in the part of communication of three ducts. We found it difficult to remove the stone through conventional way. Therefore, we decided to use the Spyglass DS and electrohydraulic lithotripsy (EHL) . Using these methods, we were able to clearly visualize the stone and break it into pieces. The patient developed mild cholangitis after the treatment, but recovered with antibiotics. Spyglass DS is useful for cases involving difficult bile duct stones.

A 91-year-old female was admitted due to acute cholecystitis with choledocholithiasis.
Abdominal computer tomography (CT) revealed stones, 25 mm in diameter in the common bile (CBD) and 15 mm in diameter in the neck of the gallbladder. We attempted percutaneous transhepatic gallbladder drainage, but it was difficult to ensure a safe percutaneous puncture route.
Therefore, we performed endoscopic drainage. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stone in the CBD ; however, the cystic duct was not detected. Following this procedure, it was possible to approach the gallbladder via advancement of a guidewire ; ERCP revealed another stone in the cystic duct. Following endoscopic papillotomy, a biliary plastic stent was placed in the gallbladder and the CBD. No complications were observed following treatment, and the clinical course during recovery was good.Endoscopic transpapillary gallbladder stenting is an effective treatment for patients with acute cholecystitis who have contraindications to percutaneous drainage.