放射線胃炎についての報告は少なく，ときに内視鏡治療抵抗性の難治例が散見されるが，その臨床的特徴についての十分な検討はなされていない．今回われわれは，肝細胞癌放射線治療後症例を対象に，肝硬変症例における放射線胃炎の臨床的特徴に関する遡及的検討を行った．放射線胃炎は肝硬変症例12例中6例に認め，腹部リンパ節照射後に有意に高率であった．発症時期は放射線照射終了後3〜3.5カ月であり，内視鏡所見は前庭部のびまん性毛細血管拡張像が主体であった．出血性放射線胃炎4例にアルゴンプラズマ凝固法（APC）が施行されたが，腹部リンパ節照射後の3例でAPC抵抗性であった．腹部リンパ節照射後の肝硬変症例では，放射線胃炎を高頻度に認め，APC治療抵抗性の出血性放射性胃炎が多く認められる傾向のあることが示唆された.

2004〜2013年に咽頭・食道同時性重複癌と診断し治療を行った50例を対象とした．咽頭癌は表在癌31例，進行癌19例であり，食道癌は粘膜癌25例，SM1癌3例，SM2癌3例，進行癌19例であった．今回，食道癌は粘膜癌と内視鏡治療の相対的適応SM1癌を含めER群として扱った．表在癌の70〜90％は検診あるいは他癌精査時の内視鏡検査で発見されており，進行癌の70〜80％は有症状で発見されていた．治療は，病変の進行度，存在部位，大きさや個数，喉頭機能の温存，年齢・全身状態の5項目について検討し，進行度と生命予後を規定する因子を中心に治療内容や治療の順番を決定した．1）咽頭表在癌＋食道癌ER群19例では，咽頭癌の74％，食道癌の84％に内視鏡治療を行い，ともに内視鏡治療例は13例（68％）であった．咽頭癌では多発，食道癌は壁深達度，全周性，多発を理由に，放射線療法あるいは外科手術を施行した．原病死は1例（5％）であった．2）一方が進行癌の症例では，進行癌を対象に化学療法＋外科手術，CRT，化学療法などを行ったが予後は不良で，食道進行癌＋咽頭表在癌11例のうち，生存は2例のみであり，7例（64％）が原病死した．咽頭進行癌＋食道癌ER群9例 or 食道SM2癌2例の計11例でも生存は4例のみであり，6例（55％）が原病死した．進行癌＋表在癌では，表在癌に対する積極的な治療例は20％程度であった．3）咽頭癌＋食道癌ともに進行癌の8例では，CRT，化学療法＋RT，外科切除などを行ったが，生存は手術例1例のみであり，6例（75％）が原病死した．

【目的】2013年2月より上部消化管内視鏡検査（EGD）を施行しH. pylori感染胃炎が疑われた場合にはH. pylori感染診断検査，除菌治療が保険収載された．H. pylori感染胃炎で除菌前後の消化器症状の変化について検討する．【方法・対象】2013年3月から2017年3月までにEGDで木村・竹本分類による萎縮性胃炎と診断され尿素呼気試験でH. pylori感染と診断された61症例中，保険適用である一次，二次除菌に成功した60症例を対象とした．除菌前後の問診はGOS質問票を使用する．H. pylori除菌レジメンは下記のとおりである．一次除菌はEPZ40mg 分2＋AMPC1,500mg 分2＋CAM800mg 分2／日を7日間．二次除菌はEPZ40mg 分2＋AMPC1,500mg 分2＋MNZ500mg 分2／日を7日間．【結果】除菌成功率は一次除菌67.2％，二次除菌94.4％であった．除菌前に比べて除菌後，胃痛，胃もたれ，胸やけ，膨満感，食欲不振，げっぷ，胃酸逆流，吐き気の平均値の順番で有意に低下した（p＜0.05）．【結語】H. pylori除菌により，胃痛，胃もたれ，胸やけ，膨満感，食欲不振，げっぷ，胃酸逆流，吐き気の順番で軽減するためQuality of Life（QOL）改善が期待できると考えられた．

2006年1月から2016年12月までの間，腹腔鏡内視鏡合同手術（LECS）を施行した胃粘膜下腫瘍36例と早期胃癌3例の合計39例について治療成績を検討した．胃粘膜下腫瘍36例における手術成績は，手術時間の中央値が189分（112-373分），出血量の中央値が5ml（5-455ml），開腹移行例はなく，術後在院日数の中央値が9日（5-16日）であった．Clavien-Dindo分類（C-D）GradeⅡ以上の術後合併症を36例中3例（8.3％）で認め，36例中1例（2.8％）に再手術を要したが，全例で再発を認めなかった．また，ICG蛍光色素法によるセンチネルリンパ節を指標としたセンチネルリンパ節流域郭清を併用したInverted LECSを早期胃癌3例に施行し，手術時間の中央値は280分（213-331分），出血量の中央値は70ml（10-150ml），郭清リンパ節個数の中央値は6個（4-7個），開腹移行はなく，術後在院日数の中央値は9日（9-11日）であった．また，C-D分類GradeⅡ以上の術後合併症，あるいは再発は認めなかった．胃粘膜下腫瘍に対し安全かつ低侵襲な治療法であるLECSは，今後十二指腸や大腸病変，あるいは早期胃癌に対し臨床応用が期待されるが，その適応や手技等に問題点も指摘されており，さらなる診断・技術の向上が必要であると思われた．

大腸ESDは現在広く普及しており，関連機器やデバイス，切除方法など，技術的困難性を克服するための様々な工夫がなされている．Pocket Creation Method （以下PCM）は全周切開を行わない新しいESD法であり，病変下にポケット形成を行うことで，さまざまな病変における有用性が示唆されている．今回われわれはPCMによる大腸ESDについて当院での経験を報告する．【対象と方法】2013年6月から2017年3月までの間に当院で施行された大腸ESD 184例のうち，PCMによりESDを施行した13例について検討した．【結果】患者背景は平均年齢76.4歳，男女比は5対8．術前生検が2例で行われていたが，それに伴う明らかな線維化は認めなかった．線維化病変を1例で認めたが，全例でポケット形成は可能であった．平均腫瘍径は34.1mm，平均切除時間は47.8分であった．一括切除率，治癒切除率ともに100％であった．病理組織診断は腺腫4例，腺癌8例，SSA/P1例であった．偶発症は後出血を1例で認め，内視鏡的止血術を施行した．【考察】今回の検討で，PCMの特徴として線維化病変や盲腸病変における有用性，偶発症の軽減，Dual Knife Jとの親和性などが挙げられた．PCMによるESDは安全に確実な一括切除が可能であり，有用性が高いと思われた．

組織学的診断が必要な肝腫瘍に対して超音波ガイド下の経皮的生検が広く行われている．しかし，ときに経皮的生検が困難な症例も経験する．2013〜2016年の期間に経皮的生検が困難でEUS-FNAを用いて肝腫瘍生検を施行した16例を後ろ向きに検討した．平均年齢67.5歳（43〜82歳），男性 : 女性＝9 : 7．経皮的肝生検が困難な理由は，腹水貯留12例，Chilaiditi症候群2例，尾状葉の腫瘍2例，小さな腫瘍（＜15mm）2例であった（重複あり）．対象病変の平均径は30.3mmで，左葉 : 右葉 : 尾状葉＝12 : 2 : 2と左葉に多い傾向があった．全例で組織学的診断が可能で，13例（81.3％）で免疫染色を併用していた．合併症（出血・感染・穿孔）は認めなかった．肝腫瘍に対するEUS-FNAは安全で有用な方法である．経皮的生検が困難な場合，EUS-FNAが有効な代替手段となる可能性があり，常に念頭に置くべきである．

悪性胆道狭窄に対する病理組織診断は，検体採取が容易でないこともあり，診断に苦慮することも少なくない．当院では経乳頭的胆汁細胞診，擦過細胞診，胆管生検を組み合わせて正診率の向上に努めている．今回，当院における病理診断の現状を把握する目的で後ろ向きに検討した．対象は悪性胆道狭窄41例で，細胞診class Ⅳ，組織診group Ⅳ以上を悪性と診断した．検体は経乳頭的胆汁吸引細胞診，擦過細胞診，胆管生検，擦過直後の胆汁細胞診，経鼻胆道ドレナージチューブからの後日胆汁細胞診とし，正診率を比較した．胆管生検の正診率が85.7％と最も高く，後日胆汁細胞診が25.0％と最も低かった．胆汁細胞診は26.8％，擦過後細胞診は28.6％，擦過細胞診は39.5％であった．悪性胆道狭窄では胆管生検が診断に最も有用であったものの，検体採取に苦慮した症例ではEUS-FNABやPOCS下生検も考慮する必要があると考えられた．

胆膵内視鏡は処置時間が長いことから，安定した処置を実現するために，鎮静を深く設定する必要がある．さらに，高齢者や全身状態の悪い患者を対象とすることが多いため，リスクマネージメントが必要である．今回我々は，まずAmerican Society of Anesthesiologists physical status （ASA-PS）と胆膵内視鏡中の呼吸循環器系合併症の関与について検討した．介入を要する低血圧，徐脈，低酸素血症を来した症例はASA-PSが有意に不良であった．全身状態，背景疾患およびASA-PSによる術前の患者評価を行い，鎮静薬の投与量を調整する必要性が示唆された．また，当院で導入した急変時シミュレーションは，多職種が関わることで複数の有効な安全対策を同時に検討・導入することが可能となり，より安全な胆膵内視鏡診療を構築する機会を得ることができた．十分に計画された急変時シミュレーションの導入は，安全・確実な内視鏡診療を進めるうえで有用であり，今後，多くの施設での導入が期待される．

【背景】近年，pancreatic/peripancreatic fluid collection（PFC）に対してEUSを用いた経消化管的ドレナージ（EUS-CD）や，それに引き続きEndoscopic necrosectomy（EN）が行われるようになり，良好な成績を得られている．以前は外科的処置が必要な症例であっても内視鏡治療のみで治療が行え低侵襲に処置が行うことが可能となった．【目的】Pancreatic fluid collectionに対する内視鏡治療の有用性と安全性を検討する．【結果】2000年1月から2016年12月までの期間，当院で施行されたEUS-CDは67例であった．そのうち臨床的に改善を認めない症例22例に対しENを行っている．また経皮ドレナージを追加した症例が4例ある．EN施行後全例臨床的に改善を認めている．短期での偶発症は，EUS-CDでは7例（1.9％）で認められた．内訳は出血4例，leakage1例，ステント迷入1例，GW断裂迷入1例であった．ENでは出血を3例に認めた．またENで空気塞栓，誤嚥性肺炎の合併は認めなかった．【結論】PFCに対するEUS-CDやENは多くの施設で繁用されその有用性についてはコンセンサスが得られつつある．低侵襲であるが偶発症は，ときとして致命的となりうる．安全な処置を行うために今後さらなる症例の蓄積が必要である．

【目的】分枝型膵管内乳頭粘液性腫瘍（IPMN）疑い病変の治療方針決定における超音波内視鏡検査（EUS）の有用性を明らかにする．【方法】2012年1月から2017年3月までの期間に，当科でEUSを施行した分枝型IPMN疑い186例のうち，囊胞内に所見を認めた44例を対象とし，そのEUS所見，臨床経過，手術例においては病理所見を後方視的に調査した．【結果】囊胞内有所見の内訳は，粘液塊疑い9例，囊胞壁の顆粒状変化11例，壁在結節24例．平均観察期間は26.2カ月，観察期間中に囊胞・主膵管径・結節の増大を認めたのは5例（壁顆粒状群2例，壁在結節群3例）．手術例20例のうち当院で行った18例は良性12例（粘液塊群1例，壁顆粒状群4例，壁在結節群7例），悪性6例（壁在結節群6例）であった．良・悪性群の比較で囊胞径・主膵管径に差はみられなかったが，結節高は悪性群で有意に高く，7mmをcut-offとすると，正診率96.9％であった．【結論】粘液塊群と壁顆粒状群は経過観察が妥当であった．小さい壁在結節も経過観察可能であるが，結節高7mm以上は手術が勧められる．

内視鏡診断・治療の進歩によって，消化管腫瘍における内視鏡診療はますます重要となっている．当院では，精査内視鏡検査を専属の内視鏡医が実施し，内科，外科と放射線科の総意で治療方針を決定する体制を構築している．さらに，laparoscopic and endoscopic cooperative surgery（LECS）の導入以降，手術の場でも内科と外科の連携が必要となった．当院で臨床研究として実施しているcT1N0胃癌を対象としたsentinel node navigation surgery（SNNS）はその典型例である．SNNSは，色素法と放射性同位体トレーサーを用いてsentinel node（SN）を同定し，術中迅速病理診断でSNの転移が陰性であれば縮小手術を行う術式である．当院では，SNNSに非開放式LECSであるnon-exposed endoscopic wall-inversion surgeryを組み合わせた縮小手術を行っているが，その術前診断と実際の治療において，内科と外科の協調は必須である．また，内視鏡用持針器と針付き縫合糸を用いて，胃内で手縫い縫合を行う内視鏡的手縫い縫合法は，お互いのノウハウの融合によって開発された．このように，内科と外科の協調はあらゆる面で重要であり，今後のさらなる可能性を秘めているといえる．

症例は 75歳の男性．2016年7月貧血と黒色便を主訴に当科を受診．2年前に施行した上部消化管内視鏡検査では異常を認めなかったが，再検したところ胃体上部後壁に約10cm大の隆起性腫瘍を認めた．同部位からの生検では，多角，類円，紡錘形などの多彩な異型細胞が密に増生しており，未分化肉腫または癌肉腫が疑われた．当初は積極的な治療希望がなかったが，高度貧血が遷延したため出血管理目的で胃全摘術を施行した． 病理組織学的には腫瘍のほとんどを多彩な異型細胞が占めていたが，特定の間葉系組織への分化は認められなかった．免疫組織学的には肉腫様組織は間葉系マーカーが陰性だったのに対し，上皮性マーカーが一部の細胞で陽性を示したことから，sarcomatoid carcinomaと診断した．本疾患の発育進展過程を内視鏡的に経過観察することができた症例であり，胃癌肉腫の発生過程を考えるうえで貴重な症例と考えられた．

幽門狭窄を呈する高齢者進行胃癌に対し，十二指腸ステント留置術を施行した4例について検討したので報告する．特に96歳女性の幽門前庭部の2型進行胃癌の症例は，現在も経口摂取可能で生存中であった．外来通院中でステント留置927日目である．患者の平均年齢は85.8歳，ステント挿入時間は平均19分であった．また，経口摂取は術後平均2日より開始可能であった．ステント挿入後から退院までの平均日数は50日（9－92日），ステント挿入後の生存期間は（2017年10月6日現在）平均372日（98－927日）であった．当院ではバイパス手術後の経口摂取開始期間は3－10日であり，ステント留置術では2日と短縮できた．高齢者の幽門狭窄に対しての十二指腸ステント挿入は手技時間も短く安全で，挿入後早期に経口摂取が可能となりQOL改善に有用な処置である．

症例は69才，男性．40才時，肺サルコイドーシスと診断され無治療で経過観察．健康診断の上部消化管造影で萎縮性胃炎を指摘され他院受診．上部消化管内視鏡の生検で悪性リンパ腫を疑われ当院受診．血液検査でアンギオテンシン変換酵素，リゾチームは正常域であった．上部消化管内視鏡は体下部大彎前壁寄りと体中部大彎後壁寄りに中心部に発赤瘢痕を認め周囲はやや隆起していた．病理組織学的所見で非乾酪性類上皮肉芽腫を認め胃サルコイドーシスと診断した．抗潰瘍剤で3カ月間治療するも病変は増大していた．無症状でH. pylori陽性のため除菌治療を行ったが，除菌後の内視鏡形態に変化は認められなかった．サルコイドーシスは両側肺門リンパ節，肺，眼，皮膚に好発するが消化器病変は比較的稀である．内視鏡所見は多彩で多発潰瘍やびらん，粘膜肥厚や壁硬化，結節性隆起等が挙げられる．長期経過中に胃病変が出現した例は稀なため報告した．

症例は68歳，女性．胃前庭部のⅡc様病変からの生検にてアミロイド沈着がみられ，λ陽性の形質細胞浸潤が目立ち，病変が胃に限定されていることから，胃原発性ALアミロイドーシスと診断された．診断後，6カ月の内視鏡検査にてⅡc様病変は浅く，広い潰瘍性病変に変化しており，この所見は数年間にわたり変化がみられなかった．NBI観察では通常光観察に比較して潰瘍境界部がより明瞭に観察され，潰瘍部が白色調を呈した．これらの所見はアミロイド沈着による粘膜・粘膜下層の循環障害が寄与しており，NBIがアミロイド沈着・非沈着部の評価に有用であることが示唆された．

症例は78歳，女性．突然の血便を主訴に救急外来を受診された．腹部造影CTを施行したところ，小腸にextravasationを認めた．緊急でダブルバルーン内視鏡を行ったところ，小腸にわずかな粘膜欠損を伴う露出血管を認め，拍動性出血を来していた．小腸Dieulafoy潰瘍と診断し，クリップ法にて止血した．その後，再発なく経過している．

近年の高齢化社会の影響で100歳を超える超高齢者の消化器疾患も増加している．内視鏡治療を施行した100歳の超高齢者症例を2例経験したので報告する．症例1は100歳の男性で，総胆管結石性胆管炎の診断にて他院より当科転院．腹部造影CTにて肝門部胆管に結石を示唆する所見を認め，血液検査所見にて胆管結石による閉塞性黄疸・胆管炎の所見を認めたため，同日緊急ERCPを施行した．Plastic stentを留置し1週間後砕石し第25病日軽快退院した．症例2は100歳の女性であり，施設入所中に上腹部痛と嘔吐を認め，当院に救急搬送された．腹部単純CTにて結腸肝彎曲部に不整な壁肥厚認め，口側の腸管が拡張し液面形成しており，大腸癌による腸閉塞が考えられた．肝彎曲部に全周性の2型腫瘍を認め，Niti-S大腸用ステント（18mm径/8cm長）を留置した．留置後6日目より食事開始し，第15病日軽快退院した．以上の2症例について若干の文献的考察を加え報告する．

Since Helicobacter pylori (H. pylori) eradication therapy in gastritis patients was covered by health insurance in February 2013, endoscopic findings of black spots in the gastric mucosa have increased. This study was conducted to clarify the relationship between H. pylori eradication and black spots. Subjects were 587 consecutive cases who underwent esophagogastroduodenoscopy. 82.5% (226/274) of those with black spots were cases of successful eradication, and 71.5% (226/316) of successful H. pylori eradication patients showed black spots ; the differences were significant. Therefore, black spots were likely to be observed in patients with successful H. pylori eradication. Among the 587 cases who underwent esophagogastroduodenoscopy, only four H. pylori-infected patients before eradication therapy showed black spots. The other cases with black spots were H. pylori-eradicated or H. pylori-uninfected. The mechanism of the generation of black spots is unclear. Although black spots are not mentioned in the Kyoto Classification of Gastritis as a finding in patients after successful eradication, black spots are suggested to be a useful indicator of successful H. pylori eradication.

We here report two patients with esophageal intramural pseudodiverticulosis (EIPD) that showed typical findings by esophagography and endoscopy. Case 1 was a 70-year-old man, and Case 2 was an 83-year-old man. The initial symptom of both patients was dysphagia. Esophagography revealed pseudodiverticula which were observed as multiple small flask-shaped outpouchings. The opening of the pseudodiverticulum was observed as small, pinhole-like depressions by endoscopic examination. Histologically, a pseudodiverticulum does not extend beyond the proper muscle layer, and is different from the usual esophageal diverticulum. EIPD is important as one of the diseases causing esophageal stenosis, but it is not well known in Japan.

A 69-year-old man was admitted to our hospital due to worsening dysphagia. He had esophageal achalasia 12 years prior and underwent endoscopic balloon dilatation (EBD) twice. Non-steroidal anti-inflammatory drugs (NSAIDs) were also administered because of lower foot fracture 10 days before hospitalization. On the second day, he had hematemesis, and emergency endoscopy revealed an actively oozing Dieulafoy’s ulcer on the left wall of the lower thoracic esophagus. Although the bleeding temporarily stopped by clipping, four hemostatic procedures were required four days thereafter. Because endoscopic hemostasis was considered difficult, transcatheter arterial embolization (TAE) was performed on the esophageal artery branch and left bronchial artery from the left gastric artery. Subsequently, rebleeding did not occur, and EBD was applied to the achalasia. Dysphagia improved, and he was discharged. Dieulafoy’s ulcers associated with esophageal achalasia are rare, and chronic food residue and stagnation of NSAIDs associated with transit disorder may have possibly contributed to ulceration in this case. TAE was effective for this case, wherein the feeder was considered to be a relatively dilated artery and endoscopically difficult to stop the bleeding.

A 66-year-old man experienced epigastric pain after massive vomiting. He was diagnosed with spontaneous perforation of the esophagus. Laparoscopic transhiatal repair was immediately performed. After surgery, esophageal-mediastinal fistula resulting from the anastomotic insufficiency remained and didn’t improve with conservative treatment. We attempted to close the fistula with a polyglycolic acid sheet and fibrin glue via endoscopy. First, a polyglycolic acid sheet was packed in the fistula. Then, we sprayed fibrin glue on the sheet. Finally, we used endoscopic clips to prevent from falling off the sheet. As a result, leakage stopped completely and the endoscopy confirmed closure of the fistula. We report endoscopic closure of the remaining esophageal fistula after surgical repair with literature reviews.

The patient was a 63-year-old man. He vomited black-colored hematemesis the day after his heavy alcohol consumption. Due to falling into shock afterward, he was refered to Dokkyo Medical University Hospital. After administration of intravenous fluid to manage dehydration, his condition was improved. Since upper gastrointestinal bleeding was suspected, endoscopy was performed, which revealed extensive black necrosis in the mucosa of the lower esophagus. He was thus diagnosed as acute esophageal necrosis. He was kept in NPO and treated with intravenous administration of proton pump inhibitor. Examination by upper gastrointestinal endoscopy performed 12- and 22 days after the treatment demonstrated normal esophageal mucosa with regeneration. He began to intake foods without problems and discharged 23 days after admission. We herein report a rare case of acute necrotizing esophagitis presenting as a black esophagus on endoscopy.

A 60-year-old male with esophageal cancer underwent endoscopic mucosal resection and thereafter developed esophageal stricture. He was treated with oral steroids and underwent endoscopic balloon dilatation (EBD) several times. The esophageal stricture did not improve after two EBD treatments. Esophageal perforation occurred during the third EBD treatment, and the esophageal muscular layer was rupturv ed. The perforation became larger and a mediastinal abscess that reached the abdomen was observed by a naso-esophageal extraluminal drainage catheter. Therefore, esophageal and mediastinal drainage was performed. The patient was treated with antibiotics and drainage. The perforation closed, but the patient again developed esophageal stricture. A covered removable esophageal stent was placed considering the risk of EBD-induced perforation. The stent was retrieved two weeks after placement without complications. Fifteen months have passed since stent retrieval, and the patient has had no recurrence of esophageal stricture.

A 73year-old man underwent chemoradiotherapy for cervical esophageal cancer 10 years ago. The effect of treatment was clinical complete response, and he was followed up by endoscopy and CT for 9 years. However, he came to hospital 9years after CRT because of dysphagia. We found local recurrence in cervical esophagus. At first, we could not detect cancer cell in specimen with pathologic findings, finally we diagnosed it suspicion of squamous cell carcinoma. We carried out laryngopharyngoesophagectomy. Pathologic findings revealed pT3, INFb, pIM0, ly0, v0, pPM0, pDM0, pRM0, pN0, pStage II. We report here our clinical experience, local recurrences 10 years after chemoradiotherapy for cervical esophageal cancer, together with some literature review.

A 68-year-old man had undergone radical resection for thoracic esophageal squamous cell carcinoma (fT1bN0M0, fStage I) , and received chemoradiation therapy (CRT) for cervical spine metastasis on 32 months after operation. Gastrointestinal endoscopy 22 months after CRT revealed an ulcerative and localized type tumor in the gastric conduit. A biopsy yielded a diagnosis of squamous cell carcinoma, consistent with metastasis from the esophageal carcinoma. We conducted photodynamic therapy (PDT) for the recurrent tumor as salvage treatment. PDT was fairly efficacious, prolonging survival concomitant with tumor stasis. During 6 times PDT, the patient developed no adverse effect for this treatment with favorable activities of daily life. Salvage PDT, minimally invasive tool as multimodality therapy, may improve prognosis of the patients with a difficult-to-treat recurrent esophageal cancer after CRT

　内視鏡治療の穿孔報告例は散見されるが，非処置部における穿孔の報告例は稀である．今回，我々は十二指腸腺腫に対するESD後に生じた食道穿孔の1例を経験したので報告する．患者は56歳女性．心窩部痛を主訴に受診．上部消化管内視鏡検査にて，40mm大の十二指腸腺腫を認めた．全身麻酔下でのESDにより一括切除施行した．術後第12病日に37.5℃の発熱，頸部痛を認め，CTで頸部食道背側の上部縦隔に膿瘍を認めた．上部消化管内視鏡検査で，食道内に黄色調の膿汁を認め，食道入口部の6時方向に5mm程度の裂創を認め同部からの排膿を確認した．透視下に裂創から0.035インチのガイドワイヤーを挿入し，8FrEDチューブを留置した．膿瘍は消失し，経口摂取再開でき第38病日に軽快退院となった．
　自験例の穿孔の原因として，頸椎が前屈していること，また，C6/7骨棘の存在を考えた．この骨棘と食道後壁との距離は6.8mmと短く，全身麻酔の挿管チューブ留置下において内視鏡と骨棘に挟まれた食道後壁が挫滅し穿孔に至ったと考えた．
　自験例のような穿孔の予防策として，ESD術前のCTにおいて食道と椎体の距離を計測すること，頸椎の変形を確認することの重要性を考えた．しかし，明確な穿孔リスクの基準は不明であり，術後の慎重な頸部痛の聴取を心がけるべきである．

Esophagogastroduodenoscopy on a 44-year-old man revealed numerous white flattened polypoid lesions in the esophagus. Those elevations stained by lugol was classified as glycogenic acanthosis based from histopathological findings. Cowden’s disease was strongly suspected from the typical endoscopic findings. Since Cowden’s disease is one of multiple hamartoma syndrome, which manifest high incidence of benign/malignant tumors in skin mucosal abnormalities, breast, thyroid, endometrium, in addition to tumors in the gastrointestinal tract, thus other signs of tumor for other body parts of the patient was investigated. As a result, goiter, skin lesion, macrocephaly, mental development retardation and family history were confirmed from the investigation. Thus confirming the diagnostic criteria of a Cowden’s disease, and it is currently undergoing a follow-up observation. Since an example of Cowden’s disease, which is a relatively rare disease was experienced, thus a report including some literature considerations will be presented in this paper.

A 50-year-old male was referred to our hospital for further examination of non-cancerous, irregular-shaped gastric ulcers. Endoscopic examination showed friable and confluent ulcers covered with dirty white mucous in the gastric body and antrum, and pyloric stenosis was observed with normal pliability. Several verrucous lesions resembling syphilitic eruptions were observed in the middle body. Although was not identified in gastric biopsy specimens, the patient was diagnosed with secondary syphilis based on positive serologic tests for syphilis, presence of generalized eruptions in the past month and typical endoscopic findings of gastric syphilis. After administration of ampicillin (1500 mg/day for one week) , gastric edema, erythema, ulceration and pyloric stenosis significantly improved upon examination four months later. Recently, the incidence of syphilis has been gradually increasing, and it is important to be able to recognize the typical endoscopic findings of gastric syphilis.

A 52-year-old woman was diagnosed with esophageal perforation, sepsis and infective endocarditis (IE) , and she was hospitalized for more than half a year. As oral ingestion proved difficult, intestinal nutrition via naso-gastric tube was initiated. Two days later, she developed hematemesis. Esophagogastroendoscopy revealed mucosal congestion, edema and multiple erosive lesions in the posterior gastric wall. Gas in the gastric wall and wall thickening, accompanied by hepatic portal venous gas, were demonstrated by enhanced CT scan. Based on these findings, the patient was diagnosed with emphysematous gastritis with hepatic portal venous gas. E.coli, gas-producing bacteria, developed in the patient’s gastric juice. It was thought that mucosal damage was caused by the tube. Her clinical symptoms improved with the administration of antibiotics.
Gastric tube placement is one of the risks of emphysematous gastritis, and early diagnosis and treatment appear to be crucial when this disease is suspected.

A 71-year-old man was admitted to our hospital because of dehydration, rhabdomyolysis, decubitus ulcers, and severe dementia. The patient, who suddenly passed black tarry stools and had a drop in the hemoglobin level on the third day of hospitalization, underwent emergency upper endoscopy that revealed an ulcer without an exposed vessel at the gastric angle. The patient received blood transfusions and proton pump inhibitors (PPI) . The upper endoscopy after 2 weeks showed a pseudoaneurysm measuring approximately 10 mm at the ulcer floor. CT angiography indicated left gastric artery pseudoaneurysm. In consideration of the fact that the patients had dementia and poor performance status, conservative treatment continued. After 1 month, an endoscopy revealed that the aneurysm was tending toward a decrease in size, and after 2 months, it revealed the disappearance of the aneurysm. Here, we report a rare case of pseudoaneurysm.

A 56-year-old female and a 62-year-old male were referred to our hospital with gastric elevated lesions. White light imaging revealed a submucosal tumor-like lesion located at the upper gastric body, and endoscopic ultrasound sonography revealed multiple anechoic areas in the second and third layers in both patients. The masses in the female and male patients were resected by ESD and LECS, respectively. Microscopic findings of resected specimens showed cystic proliferation of glands and formation of ectopic duct-like structures, which was diagnosed as a gastric hamartomatous inverted polyp (GHIP) .
GHIPs are rare and difficult to diagnose based on forceps biopsy. We describe GHIPs with characteristic endoscopic findings in two patients.

A sixties woman was found to have a about 25mm gastric submucosal tumor (SMT) on the anterior wall of the antrum on esophagogastroduodenoscopy (EGD) , which had not been observed on EGD one year previously. Endoscopic ultrasonography (EUS) showed that the SMT was a heterogenous and echogenic lesion with an anechoic area and it was mainly located in the third layer. Endoscopic submucosal dissection (ESD) was performed in order to diagnose the tumor.
Pathological examination revealed heterotopic gastric glands (HGG) with hyperplastic mucosa. HGG are sometimes accompanied by gastric cancer. Our case was not complicated with gastric cancer.
We experienced a case of HGG whose size increased rapidly within one year, in which ESD was performed in order to obtain a diagnosis.

A 50-year-old woman was found to have a tumor shadow on the posterior wall of the gastric cardia on X-ray examination. Gastroendoscopy revealed a submucosal tumor-like, elevated lesion with a depression. Magnifying endoscopy showed an abnormal microvascular pattern in the depression. Biopsy examination of the lesion revealed signet ring cell carcinoma. Endoscopic ultrasonography revealed a low-echogenic, solid mass mainly in the third layer. Interpretation of images of the 4th layer and deeper tissues was difficult due to the location. Its invasion depth was diagnosed as T2. Proximal gastrectomy was performed. Pathological examination revealed infiltration of signet ring cell carcinoma in the mucosal layer, and poorly differentiated solid adenocarcinoma with lymphoid stroma in the submucosal layer. The final diagnosis was T3 cancer, 23×20 mm in size, without lymph node metastasis. The lesion was positive for Helicobacter pylori but negative for Epstein-Barr virus.

Patient is an 82 years old male with a chief complaint of chest disturbance and vomiting. Gastroendoscopy was performed and erupting nodule was detected on gastric antral wall, suspicious of submucosal tumor. Biopsy showed Group 1 study. CA19-9 and CEA was both positive, and thickening of antral wall was shown on abdominal CT with contrast. Repeat biopsy showed no malignancy. EUS-FNA was performed, and biopsy specimen showed Group 5 to confirm malignancy.Therefore, EUS-FNA may be considered to be the next tool for diagnosis.

A 53-year-old woman with Hashimoto’s disease visited our clinic because of abnormality in the gastric barium examination. In blood biochemistry, IgE RAST of wheat was positive ; H. pylori IgG antibody and pepsinogen were classified into group D of the ABC screening method. Upper gastrointestinal endoscopy revealed chronic gastritis with reverse atrophy. Histopathological findings showed eosinophil infiltration of more than 20 / HPF in the gastric and duodenal mucosa, endocrine cell micronest with chromogranin A staining. Additionally, hyper gastrinemia and anti-parietal cell antibody, anti-intrinsic factor antibody were detected. Therefore, this case was diagnosed as type A gastritis accompanied by eosinophil infiltration in the gastric and duodenal mucosa Eosinophilic gastroenteritis and type A gastritis are still rare, but it is reported that type A gastritis is present in 25 % of group D of the ABC screening method, so type A gastritis is expected to increase by spread of the ABC screening method.

A 70-year-old man with past medical history of left renal cell carcinoma status post nephrectomy in 1988 presented to our department, complaining of melena and anemia. He underwent partial gastrectomy for gastric metastasis in 2007, followed by pancreatectomy for pancreatic metastasis, by radiofrequency ablation for right renal metastasis (2009) , and by molecular target therapy for multiple liver metastasis and retroperitoneal metastasis (2012) . He also had an evidence of right adrenal metastasis in 2013. On gastrointestinal endoscopy, a protruding lesion covered with white moss was found on greater curvature of the upper part of gastric body (color 1, 2, 3) . The lesion showed bleeding diathesis during the procedure. The pathological findings of the lesion were consistent with the gastric metastasis of renal cell carcinoma. Although the patient’s initial symptoms, melena and anemia, were disappeared spontaneously after the biopsy, the patient decided to take palliative care including the deep sedation. Here, we report a case of gastric metastasis of renal cell carcinoma, which presented with gastrointestinal hemorrhage.

A 71-year-old man with a history of distal gastrectomy (Billroth-I reconstruction) presented to our hospital with frequent vomiting and was hospitalized. On the third day after admission, an upper endoscopy showed gastric bezoars in the descending portion of the duodenum, hence we performed endoscopic lithotripsy, but it failed to achieve complete crushing, and cola dissolution therapy was initiated via the gastric tube. Similarly, on the eighth day after admission, we performed an additional endoscopic lithotripsy but failed to achieve complete crushing. An ileus tube was then placed and cola dissolution therapy was continued. On the eleventh day after admission, the patient complained of abdominal pain, and abdominal CT scan revealed that ascites appeared around the liver and the bezoars had migrated to the distal jejunum. Further conservative treatment was considered difficult, so the bezoars were removed by performing an emergency surgery. There are reports suggesting that surgery for intestinal obstruction caused by bezoars could be avoided by dissolution therapy with cola via an ileus tube, while other reports indicate that intestinal necrosis may occur during dissolution therapy. Therefore, it is important to carefully judge the indications for dissolution therapy and not miss the timing of surgery.

A 64-year-old male patient presented with severe anemia and hematochezia following sunitinib administration for the treatment of pulmonary metastasis of renal cell carcinoma. Sunitinib administration was discontinued because of digestive hemorrhage and pancytopenia. Since a bleeding site could not be detected by esophagogastroduodenoscopy and colonoscopy, small bowel capsule endoscopy (CE) was performed. Angioectasia and blackish intestinal contents around the angioectasia in the middle intestine were found with the CE. We performed transanal double-balloon endoscopy (DBE) , but it could not reach the site of angioectasia. Argon plasma coagulation was then performed during the DBE at distal sites of ileum which were not detected by the CE. After discontinuation of sunitinib and DBE, bleeding stopped and anemia was improved.

A 71-year-old woman who had been diagnosed as chronic nonspecific multiple ulcers of the small intestine (CNSU) at the age of 25, and ileocecal resection was performed for the ileal stenosis in total three times. The patient had abdominal pain, vomiting from March X year. Colonoscopy was performed to investigate these symptoms. The shallow ulcer with stenosis was observed in the 3 to 4 cm oral side from the ileocecal anastomosis. The stenosis was successfully treated by endoscopic balloon dilatation, and this case was avoided surgical resection. This case was positive for SLCO2A1 gene mutation which was considered as a causative gene mutation of CNSU.

An upper gastrointestinal endoscopy showed a submucosal tumor of the papilla of Vater for a 38 year-old woman. Endoscopic ultrasonography (EUS) showed a mixed echoic mass (12mm) in the submucosal layer of papilla of Vater and showed no remarkable findings in the common bile duct and the main pancreatic duct. Endoscopic biopsy was performed, but pathologic findings showed normal duodenal mucosa. Abdominal computed tomography showed a well-enhanced tumor in the papilla of Vater. These findings led us to suspect a neuroendocrine tumor or gangliocytic paraganglioma. EUS-FNA was not performed because of high level of catecholamine and a transduodenal extirpation of the tumor was performed. The yellowish tumor was located in the duodenal submucosal layer. We identified three components in the tumor : epithelioid cells, ganglion-like cells, and spindle cells. The tumor was finally diagnosed as a gangliocytic paraganglioma of the duodenum according to the histological findings. Gangliocytic paraganglioma is a rare disease in the duodenum. Therefore, we report a case of gangliocytic paraganglioma with a review of the literature.

A 49-year-old man visited our hospital for investigation of duodenal SMT. Compared with endoscopic findings 2 years earlier, the lesion showed enlargement. LECS was performed. Pathological diagnosis was Brunner’s gland adenoma. A 72-year-old woman visited our hospital for investigation of anemia.
An EGDS revealed SMT with erosion on the duodenum. We diagnosed the lesion was the cause of anemia. EMR was performed. Pathological diagnosis was Brunner’s gland adenoma. A 67-year-old-man visited our hospital for investigation of hematemesis. An EGDS revealed the ulcer on the known duodenal SMT. Because of the patient’s complications, we chose oral PPI administration was begun. The patient has been clear of recurrence since. Brunner’s gland adenoma and hyperplasia are basically benign lesions. When we decide their treatment policy, we must take into consideration the risk of malignancy and the patient’s ability to tolerate an operation.

A 17-year-old female was admitted to our hospital with abdominal pain, vomiting and abdominal swelling. On the same day, we performed computed tomography (CT) and diagnosed it as small intestine ileus, so an ileus tube was inserted. As both small bowel X-Ray examination through the ileus tube and single balloon enteroscopy showed a stenosis of the upper jejunum, we took a biopsy specimen. Histological findings showed that the stenosis was an adenocarcinoma. We diagnosed it as primary small intestinal cancer and performed a surgical operation one month later. We will report on this rare case of juvenile small intestinal cancer, including some review of literature.

A 86-year-old woman was admitted to our hospital with hematochezia. Colonoscopy was performed, and showed multiple telangiectasia and congestive bleeding on sigmoid colon. She has a medical history of uteri cancer and treated with radiation therapy. Thus, she was diagnosed radiation sigmoiditis. Argon plasma coagulation (APC) was performed, but because of its wide range of lesion, sufficient therapeutic effect could not obtained. The steroid suppository and enema are commonly used to treat proctitis and sigmoiditis, and which is considered to be effective to improve edema and inflammation of intestinal tract. Because of it, we started the steroid enema. After 10 days of treatment, colonoscopy was performed, and it shows the mucosal healing of sigmoid colon. This case suggests that combination of APC and the steroid enema are useful to the treatment of chronic hemorrhagic radiation sigmoiditis.

A 74-year-old man admitted to our hospital with diarrhea and alopecia. Gastroendoscopy and colonoscopy revealed diffuse reddish, inflammatory polyps and adjacent edematous mucosa in the stomach and colon. Histopathology of biopsy specimens showed cystic dilatation of mucosal glands and invasion by inflammatory cells, compatible with Cronkhite-Canada syndrome. Narrow band imaging identified eleven polyps in the colon showing NBI International Colorectal Endoscopic (NICE) Classification type 2, and histopathology of biopsy specimens from the polyps showed several adenoma cells. He was treated intravenously with prednisolone (PSL) at 50 mg/day, and his symptoms improved. PSL was gradually tapered and was continued orally at 10 mg/day. Six months after initiating steroid therapy, repeat colonoscopy revealed resolution of inflammatory polyposis and could not detect NICE Classification type 2 polyps.

A 56-year-old woman presented with abdominal pain after undergoing a barium study for gastric cancer screening 2 days prior. On day 3 after the examination, she visited an emergency room and a glycerin enema was performed as the abdominal radiography revealed stagnation of barium in the pelvic region. On day 7 after the examination, she was referred to our department because of lower abdominal pain and a sensation of retained feces. Abdominal radiography revealed a small amount of barium pooled in the pelvic region and splenic flexure without free air. Colonoscopy revealed a deep ulcer with barium stagnation. The barium was removed with forceps. After 1 month, the ulcer lesion was covered elevated mucosa with dilated and tortuous surface vessels. Histopathology revealed inflammatory granulation. Five months after the initial colonoscopy, the elevated lesion was improved slightly and was incidentally biopsied. Histopathological findings remained unchanged. Eleven months after the initial colonoscopy, the elevated lesion was replaced by an ulcer scar.

A 40-year-old woman was referred to our department because of constipation and hematochezia about 3 days before menstruation. Colonoscopy revealed a slightly elevated lesion in the sigmoid colon. Histopathological examination revealed non-specific colitis. Three months later, a second colonoscopy during menstruation revealed an elevated lesion with an irregular surface and erythematous mucosa. Histopathological examination revealed ectopic glands in the muscle layer.
Estrogen and progesterone-receptors, and CD10 stained positively on immunostaining. Therefore, we made a diagnosis of endometriosis of the sigmoid colon. Gonadotropin-releasing hormone agonist treatment was performed once a month for 6 months. Endoscopy revealed reduction of the elevated lesion with irregular surface and erythematous mucosa. Histopathological examination showed no evidence of endometriosis. The patient is still being followed-up regularly.

An 82-year-old woman with disturbance of consciousness was admitted to our hospital. Blood examination results showed renal failure, hyponatremia, and hypokalemia. Endocrine function was normal. Abdominal computed tomography images revealed a 53-mm tumor and intussusception in the recto-sigmoid. Contrast enema results revealed a concave pressure defect. Endoscopic examination revealed a continuous circumferential villous tumor located at 5 cm from the lower rectum, which could have intussuscepted due to peristalsis. We diagnosed EDS due to villous tumor of rectum and performed a Hartmann procedure ; the resected specimen showed a 140 × 110 mm circumferential villous tumor, and pathological investigation revealed adenocarcinoma with an adenoma component. EDS is a rare disorder characterized by a villous tumor leading to chronic secretory diarrhea which in turn leads hypokalemia, hyponatremia, and renal failure. Intussusception in adults is rare in comparison with children.

A 58-year-old woman visited our hospital with the complaint of bleeding on defecation. Colorectal endoscopy showed a 10-mm submucosal tumor with a slight central depression. Histopathological examination of biopsy specimens led to the diagnosis of rectal neuroendocrine tumor (NET) . Thoracoabdominal computed tomography did not reveal lymph node or distant metastasis. We performed endoscopic submucosal dissection. Immunohistopathological examination of the resected tumor led to the diagnosis of synaptophysin-positive, chromogranin-negative, CD56-positive grade 2 NET with a positive resection margin. Therefore, we additionally performed laparoscopic-assisted low anterior resection and lymphadenectomy. No remaining tumor was found in the resected ESD scar. Metastasis was identified in one (No. 251) of the 35 dissected lymph nodes. Her postoperative course was good, and she was discharged on the 12th hospital day. We report a case of a small rectal carcinoid tumor with lymph node metastasis with a literature review.

Colonic neuroendocrine cell carcinoma (NEC) is a rare colon cancer. Most NEC patients are diagnosed at an advanced stage and subsequently have a poor prognosis. We report our experience with early-stage NEC.
A lower gastrointestinal endoscopy was performed on a 77-year-old man with a positive fecal occult blood test. A laterally spreading tumor (25 mm diameter) with nodules was observed in the lower rectum. A biopsy of the nodular region led to a NEC diagnosis after positive MNF-116, CD56, and CG-A immunostains ; the Ki-67 labeling index was approximately 70% by immunohistochemistry. Regional lymph node metastases or distant metastases were not found. The patient underwent a low anterior resection following computed tomographic cystography. The final pathological diagnosis was : rectal NEC, T1b (SM) , ly1, v1, pN0, pM0, and pathological stage I. We describe a rare case of early-stage NEC.

An 84-year-old man was monitored after resection of descending colon cancer. During follow-up, colonoscopy showed a flat elevated lesion, 8 mm in size, in the lower rectum. The lesion was slightly reddish and had dilated vessels with branch architecture on the surface. Follow-up colonoscopy performed 10 months later showed that the lesion had progressed to the lateral side and increased to 15 mm. Dilated vessels with branch architecture were further emphasized by magnifying endoscopy with NBI. Biopsy specimens showed MALT lymphoma. Image findings and bone marrow biopsy were negative. We performed an ESD. Immunohistochemically, the lesion was confirmed to be MALT lymphoma. We reported a case of MALT lymphoma that could be observed at an early developmental stage by endoscopy.