Dexmedetomidine (DEX) , which has been available since 2013, is a new option for sedation during endoscopic submucosal dissection (ESD) . However, its utility in esophageal ESD has not been fully studied in Japan.
To examine the usefulness and safety of DEX, we compared the specimen size, treatment time, total dose of midazolam (MDZ) and pentazocine, body movement, blood pressure, heart rate, oxygen administration, and additional medications during esophageal ESD treatment between patients who received MDZ (Group M, 34 lesions in 32 patients) and those who received DEX (Group D, 21 lesions in 21 patients) for sedation. Group D received small amounts of MDZ for the induction and maintenance of sedation. No significant difference in specimen size or treatment time was seen. However, the total dose of MDZ and pentazocine was significantly less in Group D than in Group M. Group M more frequently required additional sedatives due to body movement. Group D showed a smaller decrease in SpO2. On the other hand, Group D more frequently showed bradycardia and a decrease in blood pressure. Low-dose DEX is a useful sedative, but the circulatory dynamics of patients who receive DEX have to be carefully monitored and managed.

Objective : We aimed to examine gastrointestinal symptoms, the eradication rate (ER) after first-line therapy, and the degree of atrophy in patients with Helicobacter pylori–associated gastritis.
Methods and Subjects : Between March 2013 and March 2018, of 70 patients diagnosed with atrophic gastritis, according to the Kimura–Takemoto classification, after upper endoscopy and later with H. pylori-associated gastritis after a urea breath test, 69 underwent successful first- or second-line eradication therapy covered by Japan’s National Health Insurance. The global overall symptom scale was administered before H. pylori eradication, and the severity of symptoms was compared between those with successful first-line and those with failed first-line eradication. The first-line H. pylori eradication regimen consisted of 7-day therapy ［esomeprazole 20 mg b.i.d., amoxicillin 750 mg b.i.d., and clarithromycin 400 mg b.i.d.］.
Results : The ER of first-line therapy was 74.3% (52/70) . Comparisons of CI (ER : 94.4%, 17/18) , CII (ER : 62.5%, 15/24) , and OI (ER : 46.2%, 6/13) showed that the ER was high in cases where the degree of atrophy was low. Stomach-ache, heartburn, stomach oppression, and nausea were significantly milder in patients with successful first-line eradication than in those with failed first-line eradication (p＜0.05) , but there were no differences in the severity of acid reflux, feeling of gastric distension, belching, and loss of appetite.
Conclusion : For cases where patients were diagnosed as having a mild atrophic gastritis, the ER was high. Before H. pylori eradication, stomach ache, heartburn, stomach oppression, and nausea were milder in patients with successful first-line eradication.

Endoscopic submucosal dissection (ESD) in patient with gastric superficial neoplasms is wide spread. Accordingly, many devices have developed. The Stag-Beetle knife GX (SB-GX) was on sale in 2016 and was introduced to our institution. In this study, we sought to investigate its efficacy. We included 112 lesions from 168 patients with gastric neoplasms who underwent ESD between 2014 and 2017. Lesions were divided into the GX group, which used SB-GX, and Dual group, which used Dual knife. No significant difference was observed in treatment results between either group. Propensity score matching demonstrated that procedure time tended to be shorter in the GX group than in the Dual group, without an increase in adverse events. Unfortunately, the usefulness of SB-GX in patients with gastric ESD was not verified in this study. Further studies that include more cases are warranted.

We investigated the safety of digestive endoscopic examinations based on 59 incident reports between January 2015 and January 2017 in our hospital. Drugs were the most common cause, in particular sedatives and antithrombotic drugs. In addition, there were adverse events and the management of specimens.
As for antithrombotic drugs, performing the examination without first confirming their use or not represents an incident itself. We now perform 3 checks for these drugs in order to avoid such incidents.
Adverse events happen with a certain probability, and they often require vigorous treatment. It is necessary to sufficiently explain to the patients about the possibility of the occurrence of adverse events and regularly confirm the safety of the laboratory and equipment.
Regarding the incident of specimen management, the elimination of local rules and compliance with hospital rules proved to be effective.
Pretreatment drug selection for colonoscopy is based on renal and cardiac function. Multiple checkpoints are required for this.
It is vital that the physicians, nurses and medical staffs cooperate for the prevention of incidents related to endoscopic examinations.

Although balloon enteroscopy-assisted ERCP has provided marked improvement in the success of ERCP procedures in patients with surgically altered anatomy, countermeasures against adverse events are also important. We retrospectively analyzed 493 balloon enteroscopy-assisted ERCP procedures performed in our department from April 2011 to August 2017. In our department, CO2 gas supply was used in all cases. The insertion success rate was 94.1%, the procedure success rate was 88.0%, and the mean total procedure time was 57.1 minutes. There were 25 cases (5.07%, 25/493) of adverse events. Adverse events included retroperitoneal perforation (1.2%, 6/493) , mucosal laceration (1.6%, 8/493) , pancreatitis (1.8%, 9/493) , bile duct injury (0.2%, 1/493) , and gas embolism (0.2%, 1/493) . The perforation cases were conservatively repaired by clip squeezing, and in the gas embolism case, sudden oxygen desaturation and cardiopulmonary arrest occurred during the ERCP procedure, but it was possible to rescue the patient by emergency treatment. Balloon enteroscopy-assisted ERCP is useful, but serious complications may occur. Therefore, sufficient knowledge of measures including systemic management is necessary.

Objective : This study aimed to analyze the clinical outcomes of therapeutic endoscopic transpapillary gallbladder drainage (ETGBD) and to clarify its characteristics.
Methods : This was a retrospective study where we examined data from 25 patients who had undergone therapeutic ETGBD.
Results : The indications included acute cholecystitis (22 cases ; 88%) , gallbladder bleeding (2 cases ; 8%) , and gallbladder perforation (1 case ; 4%) . The technical success rate was 76% (19 cases) ; we performed endoscopic gallbladder stenting in 13 cases and endoscopic nasogallbladder drainage in 6 cases. The functional success rate in 19 technically successful cases was 84% (16/19 cases) . Adverse events occurred in 2 cases (8%) , one case each of cystic duct perforation and gallbladder perforation.
Conclusion : ETGBD may not be suitable as a therapy for patients with gallbladder bleeding. The indications of ETGBD should be carefully decided.

A 38-year-old man who was a heavy drinker was referred to our hospital due to abdominal pain. CT showed a pseudocyst in the head of the pancreas. ERCP performed via the ventral pancreatic ducts (PD) revealed the cystic cavity, and cyst drainage was performed. On injection of contrast material into the minor papilla, the dilated PD in the body and tail of the pancreas were visualized, and no communication with the ventral PD was evident. Pancreatic divisum was diagnosed on the basis of the pancreatography. A stent was placed in the cyst cavity via the major papilla, and a pancreatic stent was placed in the dilated main PD via the minor papilla. CT performed after 3 months revealed that the cyst had disappeared. Transpapillary drainage was considered a useful procedure for the management of PPC associated with alcoholic chronic pancreatitis accompanied by pancreatic divisum.

Polyethylene glycol-based solutions are some of the most common bowel preparation regimens used prior to colonoscopy worldwide. However, poor tolerability may prevent complete ingestion of the preparation and may hinder a patient’s willingness to undergo repeat procedures. Sodium picosulfate/magnesium citrate (PICOPREP^®) has been used in Japan since August 2016. PICOPREP® is a low-volume bowel cleanser that is naturally orange-flavored and is expected to improve patient tolerability. Results from a questionnaire survey showed that 67.3% of patients feel that PICOPREP® is easy to take. However, 53.1% of nurses recognize PICOPREP^® requires longer times for cleansing, and 77.6% of doctors report impaired evaluation due to residual stool in the colon, which was actually only in limited amounts and could be suctioned. PICOPREP^® appears to be slightly inferior in terms of cleansing power ; however, the improvement in patient tolerability deserves recognition.

Background : Some studies have reported that endoscopic hemostasis using hemostatic forceps with soft coagulation is useful for gastric ulcer bleeding than using the clipping. However, there have been no reports of endoscopic hemostasis using hemostatic forceps for duodenal bleeding.
Methods : We retrospectively studied the treatment results of 10 patients with duodenal bleeding who were undertaken hemostasis using hemostatic forceps between January 2017 and October 2017.
Results : In treatment results, 9 patients succeeded in endoscopic hemostasis using hemostatic forceps. Two patients occurred re-bleeding. There were no severe complications in all patients.
Conclusion : Endoscopic hemostasis using hemostatic forceps seems to be safe and efficacy for duodenal bleeding.

An 83-year-old man who was suffering from dysphagia, underwent upper endoscopy which revealed a type 3 tumor at the middle of the esophagus. The biopsy specimen revealed high-grade neuroendocrine cell carcinoma. Tumor cells were positive for synaptophysin, CD56, chromogranin A, and TTF-1 on immunohistochemical staining. There was no lung tumor on computed tomographic scan. Therefore, we diagnosed primary neuroendocrine cell carcinoma of the esophagus. Carboplatin (CBDCA) ＋ etoposide (VP-16) combination chemotherapy and radiation therapy (total 50.4Gy) were administered. After this therapy, upper endoscopy and computed tomographic scan showed disappearance of the tumor.
Neuroendocrine cell carcinoma of the esophagus is rare and there is no standard therapy. It is a cancer with high-grade malignancy and the prognosis is extremely poor. We report the good outcome that was achieved after treatment with combination chemotherapy and radiation therapy.

The third edition of the guidelines for esophageal cancer clinical practice stated that there is no limitation in the circumferential range for endoscopic submucosal dissection (ESD) adaptation. However, the technical difficulty of broad esophageal ESD and the risk of stenosis after surgery are possible challenges encountered.
We have experienced a case of superficial spreading type of esophageal cancer in which complete resection was achieved by circumferential esophageal ESD with the tunnel method. Local steroid injection and oral administration combination therapy was useful for controlling stenosis after ESD.

We report the case of a 44-year-old man with pT3bN1aM0, stage IIIb primary malignant melanoma of the left shoulder. He was treated with tumor resection, lymph node dissection, and postoperative adjuvant chemotherapy. Three years later, abnormal accumulation on PET-CT was identified in the intrathoracic esophagus. We conducted upper endoscopy ; the pharynx and intrathoracic esophagus showed a black, diffuse, flat lesion. Pathological studies showed atypical cells with melanin pigment, and immunostaining for S-100 and HMB-45 were performed. The lesion was diagnosed as metastatic malignant melanoma of the esophagus. The patient was treated with molecular therapy consisting of BRAF and MEK inhibitors. The intrathoracic esophageal lesion was extremely responsive to this treatment.

A 43-year-old man presented to our hospital with the chief complaint of melena. An ulcerating lesion suggestive of inflammatory bowel disease was detected in the rectum by colonoscopy. Subsequently, epigastric pain occurred and upper gastrointestinal endoscopy was performed, revealing multiple irregular ulcers throughout the stomach. Immunohistochemical examination of a gastric mucosa biopsy specimen detected Treponema pallidum. In addition, a serological test for syphilis antibody was positive and Treponema pallidum was also found in the rectal lesion. Therefore, the patient was diagnosed as having secondary syphilis with syphilitic gastric and rectal lesions. In this patient, the endoscopic features of the gastric lesions were relatively typical of syphilis. However, the rectal lesion resembled an ulcer caused by inflammatory bowel disease and differential diagnosis was difficult. There have been reports that the number of patients with syphilis has been increasing recently. It will be important for physicians to learn to recognize the endoscopic appearance of gastrointestinal tract lesions caused by syphilis.

A 78-year-old man with acute appendicitis underwent computed tomography, which incidentally revealed a 70 mm-sized nodular lesion adherent to the stomach and the pancreas. Endoscopic ultrasonography ( EUS ) showed a solid mass with a heterogeneous hypoechoic texture, but could not reveal whether the lesion arose from the stomach or pancreas. Laparotomy was performed. A pedunculated mass was found arising from the lesser curvature of the stomach without involvement of the pancreas. The mass was excised and diagnosed as a GIST histopathologically. According to the literature, the mean ratio of the diameter of the stem / the tumor in pedunculated extragastric GISTs is 0.17. In our case, video review of EUS showed that the ratio was 0.05. This ratio and video review are helpful when diagnosing pedunculated extragastric GIST using EUS.

A 40-year-old female was referred to our hospital for further examination of gastric ulcers. Upper gastrointestinal endoscopy revealed ulcer scars and a pyloric hematoma that developed due to stimulation by the endoscope. Lower gastrointestinal endoscopy revealed multiple submucosal hematomas in the sigmoid colon. Biopsy specimens were obtained from the stomach, duodenum and colon. Histological examination revealed amyloid protein deposition, and Bence-Jones protein was detected in the urine. The patient was diagnosed with AL amyloidosis caused by multiple myeloma and received chemotherapy. It is important to be able to recognize the typical endoscopic findings of AL amyloidosis such as submucosal hematomas and identify amyloid protein deposition in endoscopic biopsy specimens to diagnose amyloidosis of the gastrointestinal tract. Therefore, the physician should report the probability of gastrointestinal amyloidosis to the pathology department so that they can perform a detailed examination.

A 78-year-old man was referred to the hospital because of abdominal pain and vomiting. Plain chest x-ray showed an elevated left hemidiaphragm with a large gastric air bubble beneath it. The CT scan showed a dilated fluid-filled stomach, and the gastric antrum was moving behind the body and the pyloric region was located in the superior and anterior side of the cardia. A diagnosis of mesenteroaxial gastric volvulus was made, then endoscopic reduction was attempted. As an ordinary gastroscope could not pass through the antrum, an endosope for lower digestive tract was utilized. The longer scope could reach the second portion of the duodenum, and successful reduction of the volvulus was performed.
The CT scan is valid to diagnose gastric volvulus because of capability of building three-dimensional images. Endoscopic reduction utilizing a longer endoscope is a good choice for the adult-onset volvulus.

A woman in her 60’s was admitted to our hospital due to sudden onset hematemesis. She underwent maintenance haemodialysis and took anticoagulant therapy for atrial fibrillation. Endoscopic examination revealed a large submucosal hematoma in the antrum of the stomach. We attempted to treat conservatively at first. But anemia progressed and the computer tomography on admission had showed extravasation, therefore angiography was done for hematoma. Extravasation was noted at the branch of gastroepiploic artery, and transcatheter arterial embolization (TAE) was performed to it. After TAE, anemia improved gradually. Endoscopic examination on the eleventh hospital day revealed a giant ulcer with remarkable mound. On the eighteenth hospital day, endoscopic examination showed an open ulcer with flat flour. Further, six months later, endoscopic examination showed smooth ulcer scar without deformation of the stomach. In the present case, anticoagulant therapy, maintenance hemodialysis and decreased platelets count may be background factors related to gastric submucosal hematoma. We presented this case because gastric submucosal hematoma treated with TAE is rare and we could endoscopically observe the healing process ; giant submucosal hematoma, giant open ulcer induced by disintegration of hematoma and smooth ulcer scar without deformity.

In May 2016, a 70-year-old male underwent total gastrectomy with R-Y reconstruction using a stapled anastomosis for gastric cancer. Although no recurrence occurred postoperatively, the patient visited the outpatient department in March 2017 with the chief complaint of abdominal distension. An abdominal CT revealed a significant dilation of the afferent loop, leading to the diagnosis of afferent loop syndrome due to R-Y anastomotic site occlusion. Upon hospitalization, we performed single-balloon small-bowel endoscopy and identified the estimated site of an anastomosis using the Y-loop anastomotic site stapler position as a marker under fluoroscopy. Endoscopic findings suggested a white-colored region surrounded by the stapler with no intestinal mucosa, leading to our diagnosis of scar tissue due to anastomotic stricture. An endoscopic retrograde cholangiopancreatography catheter used to investigate the site could pass through the Y loop, and balloon dilation was performed.

A 74-year-old man was aware of a mass in the right axilla for three years. The patient presented to internal medicine clinic with pain in the right axilla. He had a markedly elevated serum soluble interleukin-2 receptor level, and 18F-fluorodeoxyglucose positron emission tomography showed diffuse uptake in lymph nodes. He began to complain of epigastric pain after meals. Esophagogastroduodenoscopy in our hospital revealed ulcerative lesions disseminated in the gastric body. Biopsy examination of gastric mucosal tissues showed the characteristic histological features of T-cell lymphoma, and biopsy examination of the right axilla showed the characteristic histological features of angioimmunoblastic T-cell lymphoma (AITL) . We encountered a rare case of AITL with diffuse gastric involvement.

Introduction : We report a case of patient with advanced gastric cancer that might develop in the region where omental implantation was previously performed.
Case : A 73-year-old man had undergone laparotomy for a gastric ulcer when he was in his 20s. Based on detailed examinations for anemia, a type 2 lesion was observed close to the anterior wall of the greater curvature in the gastric body. We performed a distal gastrectomy, D2 lymph node dissection, and Billroth I. There was no ulcer scar in the resected specimen except the main lesion ; the greater omentum was sucked down into the main lesion. Pathological specimens showed that the greater omentum directly adhered to cancer in the center of cancer without a serous membrane between the greater omentum and cancer.
Discussion : We concluded that the previous laparotomy would be omental implantation for gastric perforation. In this case, the main lesion of gastric cancer was considered to be advanced gastric cancer that arose from the remained gastric mucosa in the region of the perforated ulcer where the greater omentum had been implanted. Based on the morphological analysis, our case was notable because advanced gastric cancer developed in the region where omental implantation was previously performed.

Three whitish lesions on the body of the stomach were detected in the Helicobacter pylori uninfected mucosa of a 71-year-old man who underwent a screening endoscopy. It was difficult to confirm the diagnosis of malignancy by endoscopic biopsy. In a 1-year follow-up biopsy, lesion A was classified as group 5 and lesion B was classified as group 4. Because gastric adenocarcinoma of fundic gland type (GAFG) was suspected based on the biopsy, the patient was referred to our hospital, and he underwent Endoscopic submucosal dissection. Histologically, HE staining determined that these lesions comprised cells resembling chief cells, and the tumor cells were shown to have invaded the submucosa. We diagnosed these lesions as GAFG.
Even though reports of GAFG have increased in recent years, little literature is present on multiple lesions. Herein we report an exceptionally rare case of multiple GAFG.

A 56-year-old man was admitted because of an upper abdominal pain. He had taken successfully the eradication of Helicobacter pylori in duodenal ulcer 10 years ago. He had smoked 20 cigarettes a day for about 30 years. He didn’t take NSAIDs. On February 2017 he had suddenly severe epigastric pain and he visited our hospital by an ambulance. With rebound tenderness, Abdominal Computed Tomography revealed opacity of the adipose tissue around the duodenum as well as free air at around gallbladder bed. He was diagnosed duodenal ulcer perforation and had emergency operation. 5 mm perforation was found at an anterior of duodenal bulb in laparotomy findings. The perforated site was filled and covered with omentum, and the abdominal cavity was drainage after irrigation. He had a favorable postoperative course treated with omeprazole and discharged on postoperatively day 15. After having taken omeprazole for 12 weeks, he has taken medication of Lafutidine as maintenance therapy. He didn’t have Helicobacter pylori infection by urea breath test. He has been under follow-up as an outpatient and well with no abdominal complaints.

Case 1 was a 54-year-old woman who underwent endoscopic mucosal resection for duodenal neoplasm near the papilla. Specimens of the endoscopic surgery scar and papilla were obtained by an esophagogastroduodenoscopy (EGD) . The same afternoon, the patient came back to our department for the chief complaints of epigastralgia and vomiting and was diagnosed with severe acute pancreatitis. Case 2 was a 58-year-old man who underwent an endoscopic papillectomy. An EGD was taken approximately 18 months later to obtain specimens of the endoscopic surgery scar at 2 sites. The same afternoon, the patient came back to our department with the chief complaint of epigastralgia, and the patient was diagnosed with severe acute pancreatitis. It is important to recognize that papillary biopsies always carry a risk of pancreatitis and to inform patients of this possible complication prior to performing the biopsy.

A 68-year-old man showed a 10-mm, red-tinted, flat, depressed lesion in the descending limb of the duodenum on esophagogastroduodenoscopy (EGD) for periodic follow-up after H.pylori eradication. Biopsy revealed an adenocarcinoma with low-grade atypia ; therefore, we adopted a wait-and-watch policy. EGD after 5 years revealed that the ulcer diameter had increased to 20 mm ; biopsy revealed an adenocarcinoma with partial high-grade atypia. We performed endoscopic treatment. Given the tumor diameter, gross appearance, and lesion biopsy findings, we performed endoscopic submucosal dissection. On pathological examination, the lesion was 19×19 mm and was accompanied by a highly differentiated intramucosal carcinoma within the adenocarcinoma ; the resection margins were negative. In Japan, there is no standard treatment for duodenal epithelial tumors, and a wait-and-watch policy is often adopted for adenocarcinomas with low-grade atypia and diameters of ≦10 mm, owing to the complication rates of endoscopic treatment. However, as in this case, where the lesion exhibits marked growth and high-grade atypia on pathology, endoscopic resection is necessary.

A 67-year-old woman with infected walled-off necrosis (WON) after post endoscopic retrograde cholangiopancreatography pancreatitis was transferred to our hospital. Computed tomography (CT) guided percutaneous drainage and endoscopic trans-duodenal drainage to the infected WON were performed. The WON improved after drainage, and all drainage tubes were removed on discharge. However, 1 month later, she was admitted to our hospital due to vomiting. Abdominal CT scan showed a remarkable duodenal stenosis. Esophagogastroduodenoscopy and upper gastrointestinal series showed that duodenal fistula remained and beaky stenosis developed in the 2nd to 3rd portion of the duodenum. A nasal duodenal drainage tube was placed immediately above the stenosis. The stenosis was improved dramatically after 2 weeks. Thus, the drainage tube was effective in treating duodenal stenosis with remaining fistula, and surgery was avoided.

A 76-year-old man was referred to our hospital in 2014 with a duodenal tumor. Esophagogastroduodenoscopic (EGD) examination showed a pedunculated polypoid lesion in the 3rd portion of the duodenum, measuring 30 mm in size, with a nodular-appearing overlying mucosa. The lesion was white in color with a few areas of focal erythema. Based on its size and the mucosal appearance, the lesion was presumed to be cancerous or a tubulovillous adenoma with severe atypia. Endoscopic mucosal resection (EMR) was performed and unexpectedly resulted in a piecemeal mucosal resection. The resected specimen was observed to be a tubulovillous adenoma with severe atypia. Following EMR, he underwent an EGD every 6 months without any recurrence observed over 3 years. The complete resection rate is low with EMR of the duodenum, and regular EGD is necessary to assess the risk of local recurrence.

A 62-year-old man who had been diagnosed with adult T-cell leukemia (ATL) and received chemotherapy and peripheral blood stem cell transplantation, had a loss of appetite and vomiting on the 89th day after transplantation. Upper and lower endoscopic examinations were performed. Reflecting the dense lymphocyte infiltration along the villous structure, it was observed as multiple white granular elevations on upper endoscopic examination. It was suggested that gastrointestinal lesions including those in the duodenum are a single disease as a systemic lesion, which may indicate a reduction in immunological ability and the disease state. If gastrointestinal symptoms appear during ATL therapy, the gastrointestinal tract should be searched to exclude cytomegalovirus infection and graft-versus-host disease, and the presence of multiple duodenal elevations may indicate ATL infiltration.

A 53-year-old man was admitted to our hospital with a chief complaint of massive bloody stools and underwent upper and lower gastrointestinal endoscopy. However, the source of bleeding wasn’t revealed. Thus, he underwent abdominal computed tomography, which showed the thicking of small bowel walls and enlargement of lymphnodes. Double-balloon endoscopy (DBE) was performed for the purpose of further examination. The submucosal tumor detected through peranal DBE was located about 45 cm from the ileocecal valve. Histologic examination of the biopsy sample obtained by endoscopy confirmed the diagnosis of a carcinoid tumor. By using DBE, we were able to locate the multiple ileal tumors and to perform surgery successfully without intraoperative endoscopy.

A 45 year-old female was admitted with small bowel obstruction. A CT scan revealed caliber change in the small bowel along with multiple diverticula in the sigmoid colon. Subsequent colonoscopy revealed colonic edema and erythema localized at the sigmoid colon. Another interesting finding was the presence of pus and oil droplets at the mesenteric margin of the bowel lumen. Our hypothesis is that a diverticulitis of the sigmoid colon was complicated by perforation into the mesenteric area adjacent to the small bowel thus leading to obstruction as well as oil droplet leakage of mesenteric fat origin. As soon as contrast was injected into the fistula extraintestinal leakage became evident in the absence of any signs indicative of intraperitoneal spread. No fistulization into the small bowel was identified. Considering that the drainage had been achieved, we opted to treat the patient conservatively.

An 84-year-old man was admitted to our hospital with vomiting. Computed tomography revealed an ASBO. Nasogastric tube (NGT) deployment for two days was ineffective ; hence, we switched to TIT. Two days after the TIT conservative treatment, the patient did not show clinical improvement. Therefore, we administered 70 ml of GG into the small intestine through TIT. Three hours later, an abdominal X-ray showed that GG had reached the large bowel, and 24 h later, GG was completely washed out. This suggested that the obstruction had subsided. TIT significantly reduced the amount of output from the intestine. After the treatment with GG, the patient passed stool on day 5 and started ingesting food on day 7, without recurrence. GG therapy through TIT is an effective method to treat ASBO if there is no clinical improvement after conservative treatment.

A-54-year-old male presented epigastric pain, loss of appetite and body weight loss 3 months prior to admission. An abdominal CT showed the dilatation of small intestine. We diagnosed as Enteropathy Associated T-cell Lymphoma (EATL) / Monomorphic epitheliotropic intestinal TCL (MEITL) by biopsy specimens under double-balloon-endoscopy. He was evaluated as stage IVB according to Ann Arbor staging classification. He was treated with CHOP therapy for 2 cycles. EATL is one of the rare diseases in Japan and known of poor prognosis. Here we show the usefulness of double-balloon-endoscopy for the diagnosis of EATL with brief review of literature.

A 76-year-old man presented with a two-month history of slight fever and lower abdominal pain. Colonoscopy showed slightly reddish mucosa with many white spots at the rectum. Biopsy specimens from the rectum showed no malignancy. Colonoscopy was performed again two months later, and revealed a circumferential ulcer and fistula tract at the rectum. The fistula communicated with the small bowel. Biopsy specimens from the fistula showed diffuse large B-cell lymphoma. Ileorectal resection and Hartmann’s operation were performed. Histopathological examination demonstrated diffuse large B-cell lymphoma of the ileum invading the rectum.
We confirmed the presence of slightly reddish mucosa with many white spots at the rectum prior to the formation of an ileorectal fistula.

A 61 - year - old man was referred to our hospital with abdominal pain. Abdominal computed tomography was perfoemed and indicated thickening of the ileal wall. He often ate raw fish and he had eaten raw fish one day prior to the onset of his symptom. Based on his clinical history and these images, enteric anisakiasis was suspected. Colonoscopic examination showed an anisakis larva penetrating the mucosa with redness and enlargement of the terminal ileum. The anisakis larva was removed by colonoscopy with a forceps, and his symptohm disappeared. Some patients with ileal anisakiasis develop ileus and intestinal perforation which may require surgical treatment. It is desirable to perform extraction by colonoscopy if possible when ileal anisakiasis is suspected.

The patient was a 45-year-old man who had positive results of a fecal occult blood test on a medical examination. A colonoscopic examination revealed a submucosal tumor measuring 7 mm in diameter in the cecum. Colorectal endoscopic submucosal dissection (ESD) was thus performed for diagnosis and therapy. A schwannoma was diagnosed on the basis of Immunostaining of the resected specimen. To our knowledge, treatment of a cecal schwannoma by ESD has not been reported previously in Japan. We therefore believe that this is the first report to document the treatment of a cecal schwannoma by ESD in Japan and consider this case report very valuable.

A 58-year-old woman with a history of chronic myelogenous leukemia, for which she was taking dasatinib, was admitted to our hospital with diarrhea and bloody stool. Colonoscopic examination showed multiple protruding polyps with white exudates at the top in the ascending and transverse colon. Biopsy specimens showed erosions with exudates on the surface of the mucosa and intranuclear inclusions. Immunostaining with cytomegalovirus (CMV) antigen was positive. Endoscopic and pathological features suggested cap polyposis (CP) with CMV colitis. The patient was treated with ganciclovir and her symptoms quickly improved. CP is a rare colorectal disease characterized by multiple inflammatory polyps covered with a cap of fibrinopurulent exudates. The etiology of this disease remains unknown and there is no specific treatment. We report this rare case with a review of the literature.

A 69-year-old woman presented with constipation after being administered a sodium picosulfate and polyethylene glycol preparation prior to performing a follow-up colonoscopic examination. Abdominal radiography revealed dilated colon with laxative and niveau. Following administration of a glycerin enema, she returned home for defecation. At home, she passed a large amount of stool accompanied by hematochezia and abdominal pain the next morning. Colonoscopic examination revealed an edematous and erythematous mucosa, with longitudinal ulcers observed at the splenic flexure, as well as the descending and the sigmoid colon. Histopathological findings revealed purulent exudate, necrotic debris, and granulation tissue, compatible with ischemic colitis with an open ulcer. Her symptoms improved with conservative therapy. It is rarely reported a case of ischemic colitis occurring secondary to bowel preparation for colonoscopic examination.

A 14-year-old boy presented with diarrhea and anemia. The patient had 5 episodes of diarrhea 3 months previously. However, more than 10 episodes of diarrhea accompanied by mucous and bloody stools and abdominal pain occurred 2 weeks previously, and the patient presented at the Department of Pediatrics. The face was pale, and a blood test showed severe anemia. The patient was suspected to have inflammatory bowel disease and was referred to the Department of Gastroenterology. Colonoscopy revealed a pancolitis type of ulcerative colitis (UC) , and treatment was begun. Because the patient was in the growth phase, steroids, associated with potential adverse effects on growth, were not used. Intensive granulocyte apheresis (GCAP) procedures were performed twice weekly, and oral mesalazine granules (4000 mg) were administered. After about 2 weeks, diarrhea resolved, the patient defecated solid stools 2 times, and the hemoglobin level normalized. The use of steroids, associated with various adverse effects, should be carefully considered in children. Our findings suggest that treatment with intensive GCAP twice weekly and mesalazine granules (4000 mg) can suppress even severe UC in steroid-naive children.

We report two patients with diagnoses of rectal colon cancer. Endoscopic treatments for colon cancer using newly colon stent were performed. Newly colon stents can be considered safe and effective.

A 68-year-old woman visited our hospital because of a positive fecal occult blood test. Colonoscopy revealed a type 2 tumor in the ascending colon, and a whitish flat lesion that had a white node in the center of the transverse colon. Magnifying endoscopy showed Vi pit pattern at the white node, and an open II type surrounding the flat lesion. Therefore, we diagnosed this patient as having cancer of both the ascending and transverse colon. We performed Endoscopic Submucosal Dissection (ESD) for the transverse colon cancer, and a right hemicolectomy for the ascending colon cancer. On histology, the ascending colon tumor and the transverse colon tumor were diagnosed as papillary well-differentiated adenocarcinoma, and well-differentiated adenocarcinoma in serrated adenoma, respectively.
The ascending colon cancer had no microsatellite instability (MSI) and BRAF mutation, but the transverse colon cancer had MSI-high and BRAF mutation. These findings suggest that each cancer had different pathways of colon carcinogenesis.

The patient was 60-year old woman underwent total colonoscopy following with sigmoid colon polyp at the referring hospital. Two flat elevated lesions looked like SMT, 10 mm and 3 mm in size, was detected in the lower rectum by colonoscopic examination. Biopsy results from referring hospital showed a lymphoid hyperplasia and the patient was referred to our hospital for diagnosis and treatment. We performed diagnostic endoscopic submucosal resection with ligation device (ESMR-L) .The resected specimen showed benign lymphoid polyp (BLP) , and the vertical and lateral margin were negative. ESMR-L followed by pathological examination makes the safety resection of rectum BLP possible.

A 97-year-old woman was admitted to our hospital complaining of malaise and frequent mucous diarrhea of two months’ duration. On physical examination, the patient showed signs of volume depletion. Laboratory tests showed renal failure and hypokalemia. A colonoscopy revealed a circumferential polypoid mass covered with clear mucous fluid in the rectum. Electrolyte depletion syndrome caused by a rectal villous adenoma was diagnosed. Surgical or endoscopic resection of the tumor was avoided considering the patient’s age and the size of the polyp. External beam radiation therapy was performed in an attempt to ameliorate the symptoms. After the therapy, the patient’s diarrhea and hypokalemia improved, and the tumor decreased in size. The present case suggests that radiotherapy is a possible therapeutic option for inoperable patients with electrolyte depletion syndrome.

We report the case of a 51-year-old male with rectal cancer and multiple liver metastases. Upon admission, abdominal computed tomography revealed dilation of the intrahepatic bile duct and bowel obstruction associated with rectal cancer. First, rectal obstruction was successfully palliated with a 22-mm self-expandable metallic stent (SEMS) . Then, we attempted endoscopic biliary stenting but failed due to unsuccessful guidewire negotiation into the left hepatic duct. Finally, we successfully placed two 8-mm biliary SEMSs for both sides (side-by-side) using the PTBD-assisted rendezvous technique. These endoscopic procedures were very effective palliation despite slightly complicated maneuvers.

A 95-year-old female was transferred to our hospital for the purpose of the treatment of cholangitis due to common bile duct stones. One day after removal of bile duct stones with endoscopic retrograde cholangiopancreatography (ERCP) , she suddenly suffered cardiopulmonary arrest. Prompt cardiopulmonary resuscitation was performed, and the spontaneous circulation and breathing resumed. Contrast-enhanced computed tomography revealed pulmonary embolisms (PE) in the bilateral pulmonary arteries. PE is known as a common but sometimes fatal complication after surgery, and prophylactic approaches including early ambulation, wearing compression stockings, intermittent pneumatic compression, and anticoagulants have been proposed based on the risk of developing PE. However, only a few reports have focused on the development of PE as a complication after invasive endoscopic procedures. In this article, we discuss the risk factors and the prophylaxis policy against PE after ERCP.

A 64-year-old man with jaundice was diagnosed with pancreatic head cancer (T3N1M0 stage III) , and gastroduodenectomy of pancreaticoduodenoductomy (SSPPD-II-A) was performed.
Enhanced computed tomography revealed local recurrence and metastasis in the liver and portal stenosis 6 months after SSPPD-II-A.
The patient had melena after 10 months, and he was admitted because of gastrointestinal bleeding, with hemoglobin of 4.5 g/dl. Esophagogastroduodenoscopy and colonoscopy did not reveal other sources of bleeding. Bleeding scintigraphy was performed, which revealed a bleeding source in the afferent loop. He underwent small intestine endoscopy, which showed vasodilation at the choledocho-jejuno anastomosis. We conclude that vasodilation of the choledocho-jejuno anastomosis occurred because of portal hypertension due to portal stenosis caused by tumor local recurrence. We conducted argon plasma coagulation for vasodilation thrice, and melena did not recur until his death.

A man in his 60s visited the emergency department after developing left lower-quadrant pain that day (Day X) . A biliary stent had been placed 4 years earlier for stacked common bile duct stones, and he had been followed-up as an outpatient. Ileus was diagnosed, and he was admitted the same day. CT on Day X revealed dilation of the presence of stacked common bile duct stones and a migrated biliary stent at the tip of the jejunum. The biliary stent was retrieved on Day X＋20 by single-balloon enteroscopy via an oral approach. Following stent retrieval, a large stone was found on the side of the anus. The patient developed abdominal distension on Day X＋21, and CT on Day X＋24 revealed ileus caused by the stones. Laparotomy was performed to resolve the ileus and remove the common bile duct stones.

An 81-year-old man with a poor performance status presented with high fever to our hospital. He had been diagnosed with gallstone pancreatitis 9 months prior to admission, and had been treated with biliary stent placement. An abdominal computed tomography (CT) scan revealed that the plastic stent was penetrating the ascending colon. Therefore, we performed an emergency laparoscopic ileal resection. After his recovery, we performed endoscopic retrograde cholangiopancreatography (ERCP) and removed endoscopic common bile duct stones. On post-operative day 35, he underwent laparoscopic cholecystectomy.
Although the placement of a long-term biliary stent to treat acute cholangitis in elderly patients is becoming common, the migration of biliary stents has often been reported, and colon perforations are a severe complication in those cases. As ERCP-related procedures have a high incidence rate of accidental diseases, it is imperative to choose appropriate treatments on the basis of the patients’ background such as age and the underlying disease.

A 70-year-old male was admitted to our hospital due to high level of serum CA19-9 and the presence of major papilla swelling by CT examination. We could not confirm the presence of malignant cells at initial EGD and ERCP. Although serum CA19-9 level was further increased, PET-CT showed no FDG accumulation. Thereafter, serum CA19-9 level was further increased up to 5612.9U/ml, and second CT examination showed minor worsening of gallbladder wall thickness suspected of gallbladder cancer. Then, we could confirm the presence of gallbladder cancer cell by gallbladder bile juice cytology following ENGBD. And, EUS-FNA specimens from swelling lymph node around pancreas head (#13b) showed adenocarcinoma. Finally the patient was diagnosed with unresectable gallbladder cancer.
Therefore, EUS-FNA was considered to be useful to avoid unnecessary surgery in this case.

We are reporting on two cases of IPMN with pancreatobiliary fistula.
Case1 : A 70s-year-old male was admitted，with jaundice. CT finding showed cystic masses in the pancreatic head, and hepatic mass．ERCP finding revealed pancreatobiliary fistula. Due to the cholangitis caused by a mucus plug, we performed repeatedly ERCP. Finally, we performed a total pancreatectomy and a partial hepatectomy. The pathological diagnosis was main-duct IPMC and intrahepatic cholangiocarcinoma.
Case2 : An 80s-year-old male was admitted，with jaundice．CT and ERCP findings showed IPMN with pancreatobiliary fistula.．A covered self-expandable metal stent (CSEMS) was inserted in the bile duct．However, CSEMS dislocation and cholangitis occurred 7 days later．We performed ENBD. Before the operation，however, his condition deteriorated resulting in death. Pathological diagnosis was the main-duct IPMC.

An 89-year-old woman had biliary obstruction due to a periphilar cholangiocarcinoma, which obstructed the ducts of the right anterior segment and right posterior segment and the left hepatic duct. We initially performed endoscopic biliary stenting using plastic stents. After successful biliary drainage, we deployed multiple self-expandable metallic stents (SEMS) using a novel combination of the side-by-side (SBS) and stent-in-stent (SIS) methods. First, the two SEMS were deployed in the right posterior segment and left hepatic ducts using the SBS method. Next, another SEMS was deployed in the right anterior segment duct using the SIS method. During the 8-month follow-up period, we performed re-intervention five times. All treatments were successful, suggesting that this new method may facilitate insertion techniques and re-intervention.

We report the case of a man in his 70s, who was diagnosed with IPMN in the head of the pancreas. The patient was followed-up annually using EUS and magnetic resonance cholangiopancreatography for 12 years. A 9-mm mass in the body of the pancreas was detected via contrast-enhanced computed tomography and EUS. He underwent EUS-FNA, and examination of the biopsy specimen revealed intraductal papillary mucinous carcinoma (IPMC) . He also underwent distal pancreatectomy with splenectomy, and a 5-mm IPMC was confirmed in the surgical specimen.The diagnostic accuracy of EUS-FNA correlates with the tumor size. Although it is useful for the diagnosis of pancreatic cystic tumors, some cases have reported peritoneal dissemination after EUS-FNA. Thus, the usefulness of EUS-FNA for pancreatic cystic tumors remains controversial.