Aim: This study aimed to analyze the clinical outcomes of upper gastrointestinal endoscopic foreign body removal.

Methods: This was a single-center retrospective study examining data from 48 patients who had undergone upper gastrointestinal endoscopic foreign body removal from April 2013 to September 2018.

Results: In 40 patients (83%), we succeeded in completely removing the foreign body endoscopically, while 2 (4.2%) required surgery to remove the object. Among the cases requiring surgery, one was the case of the synthetic resin present in the stomach and the other was the case of the sponge present in the duodenum.

Conclusion: In cases where removal of foreign body is expected to be difficult, an endoscopic procedure should be started after ensuring surgery can be undertaken if the endoscopic approach fails.

The association between antithrombotic drugs and hemorrhagic complications was investigated in 201 patients who underwent percutaneous endoscopic gastrostomy (PEG) using the introducer technique between 2014 and 2017. Antithrombotic drugs were administered with preoperative withdrawal according to guidelines in 67 patients (antithrombotic group), but not in 134 patients (non-antithrombotic group). Antithrombotic drugs used (single-agent or multiagent therapy) were direct oral anticoagulants (24 patients), warfarin (12) and antiplatelets (34). Early complications occurred by postoperative day (POD) 14 in 33 patients. Hemorrhagic complications occurred in 7 patients in the antithrombotic group (10.5%) and 6 patients in the non-antithrombotic group (4.5%). Of 13 cases of hemorrhagic complications, 1 required endoscopic hemostasis the day after surgery, despite intraoperative clipping of a mucosal laceration; 11 cases had external bleeding from the insertion site, which was treated by site closure or pulling the tube with gauze. No patient required blood transfusion. Thromboembolism did not occur during antiplatelet withdrawal. PEG can be performed relatively safely with antithrombotic withdrawal with caution because of the moderate risk of hemorrhagic complications.

Cold snare polypectomy (CSP) is proposed as a safe and effective technique, however which haven't been fully evaluated in the patients under antithrombotic therapy. Therefore we conducted present study to investigate the efficacy and safety of CSP under such conditions. Between Mar 2016 and Jun 2018, 1404 patients with 2653 colorectal polyps were enrolled. Of 2653 lesions, a total of 499 lesions (19.4%) in 273 patients were resected under antithrombotic therapy. The mean tumor size was 5.2±3.1mm and the predominant morphology was protruded type (72.2%). En-bloc resection was achieved in all cases, meanwhile R0 resection rate was quite low (11.3%). As for adverse events, the overall rate of delayed bleeding was 0.2% (3/1404), and which wasn't different between with or without antithrombotic therapy (0.6% vs 0.4%, respectively, P=0.42). In conclusion, CSP is easy, safe and useful technique even for the patients under antithrombotic therapy.

The third edition of the guidelines for esophageal cancer clinical practice started 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 stricture formation are possible challenges encountered.

We reported on methods using steroid administration to prevent stricture, especially for local injected steroid for cases with semi-circumferential mucosal defect after ESD in our hospital.

There is no established method to prevent stricture formation. Further study will be needed to show that stricture can be prevented.

The patient was a 73-year-old man with amyotrophic lateral sclerosis (ALS) and dysphagia. A percutaneous endoscopic gastrostomy (PEG) tube was placed according to the introducer modification technique without difficulty. Six months later, as the PEG tube was being exchanged, a colocutaneous fistula was discovered by radioscopy and abdominal CT. The gastrostomy tube was able to be exchanged with using a guide wire and a Pean forcep through the fistula and fixing the gastric wall to the abdominal wall. The patient experienced no complications and was discharged after two days. In cases of colocutaneous fistula without emergency laparotomy, PEG tube exchange can still be performed safely if an appropriate protocol is in place.

The case is of a 34-year-old female, who developed pan-ulcerative colitis at the age of 27 years. At the age of 29 years, because the patient was resistant to medical therapy, a total colectomy and ileal pouch-anal canal anastomosis were performed.

At the age of 34 years, five years post-surgery, the patient was admitted to the hospital for upper abdominal pain and nausea. On performing upper and lower gastrointestinal endoscopy, upper gastrointestinal tract lesions of UC and pouchitis were detected. Upon administration of crushed 5ASA and metronidazole, the symptoms improved and the patient was discharged.

The reported case is a highly suggestive case indicating that upon post-UC surgery upper abdominal symptoms, the possibility of upper gastrointestinal lesions should be considered.

Multi-bending 2 channel scope (GIF-2TQ260M, Olympus Optical, Japan) is the operative endoscope which has multi-bending system and two channels of 3.2mm in diameter. This scope can approach to everywhere in stomach by multi-bending system and we can use both channels depending on the situation. In addition, it is possible to use two channels at the same moment.

The primary hemostasis rate using this scope was 100% among 5 months in our institute. Comparing to GIF-Q260J, suction ability of GIF-2TQ260M is almost the same. However, when we insert treatment devices such as hemostatic forceps through the channel, suction ability of GIF-2TQ260M is sometimes better than GIF-Q260J. This is because the right channel of GIF-2TQ260M doesn't connect to suction channel. So when we insert treatment devices through the left channel, suction capability gets worse. In contrast, when we insert treatment devices through the right channel, suction ability remains normal. GIF-2TQ260M is useful for not only treatment such as ESD but also hemostatic treatment.

A SSA/P in the right colon, which transformed to an invasive submucosal adenocarcinoma finally, was endoscopically observed in a 67-year-old woman. 16 years prior to the surgery, a sessile elevated lesion (approximately 15 mm in diameter) was detected in the cecum. 20 months before surgery, a lusterless reddish part emerged in the polyp, in which a few atypical glands as adenoma were detected by biopsy. On colonoscopy 18 months later, the reddish part changed into a roughly elevated tumor. We diagnosed it as a submucosal cancer with a serrated lesion and performed ileocecal resection. Histological examination revealed moderate to poorly differentiated adenocarcinoma with a serrated lesion. This case suggests that the right-side SSA/Ps should be removed immediately, considering the potential for rapid progression to deep and extensive cancer.

In Japan, perforations/penetrations by fish bones are frequently reported; however, colorectal perforation/penetration by chicken bones is rare. An 88-year-old female with a history of 3 surgeries for rectal cancer, liver metastasis, and renal cancer presented with a 10-day history of abdominal pain and diarrhea after consuming chicken fries. Computed tomography showed a linear high-density structure penetrating the sigmoid colon. We performed an emergent endoscopic extraction and diagnosed her with colonic penetration caused by an accidentally ingested chicken bone. Colonoscopy revealed a chicken bone with the ends piercing the wall of the sigmoid colon. The chicken bone was removed with grasping forceps. Her subsequent course was favorable, and she was discharged on hospital day 11.

A 20-year-old man presented to our department with hematemesis and odynophagia. The patient had been in his usual state of health before this presentation. Esophagogastroduodenoscopy (EGD) revealed multiple ulcer scars in the esophagus. EGD findings suggested Herpes esophagitis (HE). Endoscopic biopsy specimens were obtained from esophagus, stomach and duodenum. Histological examination showed only nonspecific neutrophilic infiltration of the esophageal mucosa, but we could not reveal the evidence of any virus infection. There was not the rise of the antibody titer of HSV. 3 weeks later, his symptoms improved without antiviral therapy. And the ulcer of esophagus disappeared endoscopically.

HE is commonly seen in immunocompromised hosts, such as those with malignancy, HIV infection. However it has rarely been reported in immunocompetent hosts, and they are typically diagnosed at younger average age than immunocompromised hosts.

We concluded HE in young immunocompromised host from EGD findings.

Here, we describe three cases wherein gastric black dots appeared after the eradication of Helicobacter pylori as observed by magnifying endoscopy. In case 1, a 65-year-old woman was diagnosed with H. pylori -related gastritis and underwent H. pylori eradication. After 1 year, gastric black dots were observed by esophagogastroduodenal endoscopy (EGD) and dilation of the gastric crypts was noted on magnifying endoscopy. In case 2, a 63-year-old woman was diagnosed with H. pylori -related gastritis and underwent H. pylori eradication. After 1 year, gastric black dots were observed by EGD and magnifying endoscopy revealed dilated gastric crypts. In case 3, a 63-year-old woman was diagnosed with H. pylori -related gastritis and underwent H. pylori eradication by her previous doctor. After 2 years, gastric black dots were noticed on EGD and magnifying endoscopy showed dilated gastric crypts.

Case 1 is an 85-year-old man. Radiotherapy was performed in the diagnosis of liver cancer. Esophagogastroduodenoscopy (EDG) was performed 1 month after radiotherapy due to general fatigue and eating disorder. Friable and edematous mucosa was observed in the antrum. We diagnosed gastric mucosal disorder after radiotherapy and started oral administration of proton pump inhibitor (PPI). 7 months after radiotherapy, edematous mucosa disappeared and vascular ectasia was observed. Case 2 is a 77-year-old man. Chemoradiotherapy was performed in the diagnosis of gallbladder cancer. EGD was performed 2 months after radiotherapy due to anemia. Ulcer and friable, edematous mucosa were observed in the antrum. We diagnosed gastric mucosal disorder after radiotherapy and started oral administration of PPI. Due to progression of anemia, EGD was performed 3 months after radiotherapy. Oozing from vascular ectasia was observed and argon plasma coagulation was performed.

A 60-year-old man with HCV liver cirrhosis was pointed out an early gastric cancer. EGD showed a 20 mm reddish slightly depressed lesion (Paris type 0-IIa) in the anterior wall of lower gastric body. Biopsy revealed well differentiated adenocarcinoma. The lesion was resected in a single piece by ESD. We closed the mucosal defect with clip with string technique and filling the dead space with fibrin glue to prevent complications. Second look endoscopy revealed wound remained closed POD 2. The mucosal defect completely healed 3 months after. We report successful closure of mucosal defect with endoloop/clips technique and filling fibrin glue for a high-risk patient.

An 11-year-old girl vomited blood during school and was taken to our hospital. A duodenal ulcer was detected by upper gastrointestinal endoscopy and treated with ethanol injection therapy. She was negative for Helicobacter pylori infection by three tests: rapid urease test, circulating antibody, and antigen in stool specimens.

While H. pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) have been major causes of peptic ulcer, the percentage of idiopathic ulcers (e.g., non-H. pylori, non-NSAIDs ulcers) has increased. The recurrence rate of idiopathic ulcer is high, requiring preventive measures against its recurrence.

Although specific precautions are required, therapeutic endoscopy for pediatric patients is feasible in the endoscopy unit, provided that sufficient adjustments of settings can be undertaken in collaboration with relevant physicians including pediatric surgeons.

A solitary Peutz-Jeghers-type polyp in the duodenum is rare. Here, we report about a 65-year-old man with diabetes mellitus and hypertension. Screening with upper gastrointestinal endoscopy revealed a pedunculated polyp in the duodenal second portion. Endoscopic biopsies revealed a hyperplastic polyp. The polyp had an irregular nodular and lobular surface and was increasing in size over time. Therefore, endoscopic resection was performed. Histopathological examination of the polyp revealed smooth muscle bundles from the muscularis mucosae extending to the polyp, forming a typical branch-like structure. The present case was diagnosed as a Peutz-Jeghers-type polyp of the duodenum. Its histopathological features were identical to those of Peutz-Jeghers polyp; however, the clinical features of Peutz-Jeghers syndrome, such as mucocutaneous pigmentation and family history of the disease, were absent.

This is a case of a 61-year-old woman with rheumatoid arthritis who was treated with methotrexate and prednisolone. She visited our outpatient department due to diarrhea and vomiting that lasted for one month and was admitted with a diagnosis of gastroenteritis. Upper gastrointestinal endoscopic examination revealed erythema, erosions, and granular mucosa in the duodenum. Duodenal biopsy revealed amyloid deposition, leading to a diagnosis of secondary gastrointestinal amyloidosis associated with rheumatoid arthritis. Subsequently, her condition was not improved even after changing to total parenteral nutrition; however, after introduction of an anti-IL-6 receptor antibody, marked improvement was achieved both in clinical symptoms and endoscopic findings. Gastrointestinal amyloidosis should be considered as a differential diagnosis when a patient with chronic inflammatory disease presents with diarrhea and vomiting, and if the patient does not respond to conventional therapies, anti-IL-6 receptor antibody should be introduced at an early stage.

A 70-year-old man who had been diagnosed as having anaphylactoid purpura during a first episode was admitted to our hospital. Anemia and hemorrhagic diarrhea were also observed at the same time as the purpura appeared, and gastrointestinal examination was requested. Upper gastrointestinal endoscopy revealed ulcer accompanied by bleeding and erosive lesions, mainly in the lower duodenum. Endoscopic examination of the lower gastrointestinal tract revealed ulcers accompanying bleeding and erosive lesions throughout the entire colon. On the other hand, no lesion was evident when capsule endoscopy was performed to examine the small intestine. We initiated steroid therapy and improvement of the abdominal symptoms was observed. Upper and lower endoscopy was performed again after treatment, and showed that the gastrointestinal lesions had improved. In this case, gastrointestinal bleeding was combined with the incipient anaphylactoid purpura. This case is valuable in that gastrointestinal endoscopy was able to confirm the lesions and improvement after treatment. We will report on this in consideration of the relevant literature.

A 58-year-old woman was referred to our hospital because abdominal ultrasonography during a medical check-up revealed dilation of the main pancreatic duct. Contrast-enhanced abdominal computed tomography showed a contrast-enhanced mass in the duodenal papilla associated with a dilated common bile duct and pancreatic duct. Endoscopy showed a submucosal protuberance in the duodenal papilla. Endoscopic ultrasonography (EUS) revealed a hypoechoic mass 12 mm in diameter in the second and third layers at the same site. A diagnosis was not reached on mucosal biopsy. Endoscopic papillectomy was performed to achieve complete biopsy and diagnostic treatment. The tumor was diagnosed with a grade 1 neuroendocrine tumor. Pancreaticoduodenectomy was performed because the tumor measured 17 mm in diameter and had a positive vertical margin. Complications of endoscopic papillectomy were acceptable in our hospital. Endoscopic papillectomy can thus be used as a diagnostic technique.

A 65-year-old male visited a local physician due to shortness of breath on exertion. He was found to have iron-deficiency anemia, but esophagogastroduodenoscopy and colonoscopy identified no bleeding source. The patient was referred to our hospital with suspected small intestinal hemorrhage. Small intestinal capsule endoscopy found no hemorrhagic lesion in the small intestine but identified angiectasia and fresh blood in the cecum, and he was diagnosed as having gastrointestinal bleeding caused by cecal angiectasia. Endoscopic clipping of the angiectasia was performed. After this procedure, his anemia improved. Angiectasia requires endoscopic treatment if it causes hemorrhage. The incidence of overt bleeding due to angiectasia identified during colonoscopy ranges from as low as 1.2 to 1.9%. Small intestinal capsule endoscopy was useful for excluding small intestinal hemorrhage and identifying overt bleeding caused by angiectasia in this patient.

A 76-year-old male with past history of distal gastrectomy/Billroth2 construction was developed hepatic disorder and jaundice. He was undergoing palliative therapy for refractory pancreatic cancer. Abdominal contrast-enhanced computed tomography revealed obstructive jaundice derived from afferent loop syndrome caused by direct invasion of the pancreatic cancer. The endoscopic drainage tube was inserted urgently and his clinical condition improved immediately. Four days later, we implanted metallic stent (Wallflex duodenal stent) into the stricture in exchange for the tube. After the procedure, afferent loop syndrome never relapsed for 2 months until he died from pancreatic cancer. Although the endoscopic therapy for malignant afferent loop syndrome with obstructive jaundice was rarely reported, the present case indicated endoscopic stenting would effectively improve the patients' quality of life.

Hamartomatous polyps in the digestive tract are common in Peutz-Jeghers syndrome, but a solitary hamartomatous polyp in the jejunum is rare. Moreover, endoscopic resection of such a polyp has been rarely reported.

A 26-year-old man underwent esophagogastroduodenoscopic and colonoscopic examination because of palpitation and melena; however, the source of the melena could not be identified. We performed a single-balloon enteroscopy via the mouth, and found a pedunculated polyp of φ30 mm on the anal side, approximately 30 cm from the Treitz ligament. Pathologically, it was a Peutz-Jeghers type hamartomatous polyp. No other polyp was detected in the jejunum or the ileum. We resected the Peutz-Jeghers polyp in the jejunum with single-balloon enteroscopy. The postoperative course of the patient was good.

A 69-year-old man was diagnosed as having diffuse large B-cell lymphoma (DLBCL) of the thyroid. Complete remission with chemotherapy was observed for 5 years without relapse. Ten years after the initial diagnosis, he visited our hospital with a complaint of abdominal pain, and abdominal computed tomography revealed a mass measuring 48 mm in diameter in the mesentery around the terminal ileum. After admission, the mass enlarged rapidly, and the patient developed bloody stool. Colonoscopy revealed a submucosal tumor-like lesion and an ulcer in the terminal ileum. Hemostasis was difficult both endoscopically and angiographically; therefore, we performed ileocecal resection, and DLBCL was diagnosed from the resected tissue specimen. In this patient, DLBCL was identified because of gastrointestinal bleeding. Rapid progression is possible with malignant lymphoma of the gastrointestinal tract, as in our patient; therefore, these tumors should be followed carefully.

Ischemic colitis usually occurs in the elderly, in association with cardiovascular and arteriosclerotic diseases such as hypertension, hyperlipidemia, and diabetes mellitus. We report the case of young woman, with no underlying diseases or bowel movement abnormality. A 15-year-old woman presented with sudden onset severe, cramping lower abdominal pain while sleeping, followed by hematochezia. Colonoscopic examination revealed erythematous mucosa with longitudinal ulcers in the descending and the sigmoid colon. Histopathological findings were compatible with ischemic colitis. Her symptoms were alleviated in a few days with conservative therapy. Ischemic colitis has rarely been reported in patients younger than 20 years of age. It should however be considered in the differential diagnosis of sudden-onset abdominal pain with hematochezia.

A case was a 77-year-old male dialysis patient. He had a history of arteriosclerosis-related diseases such as angina, peripheral arterial disease and diabetic nephropathy.

He developed a peripheral arterial disease and had catheter treatment. 16 days after the treatment, he presented with lower right abdominal pain on the day of dialysis. On the day after consultation, CT imaging showed edematous swelling wall in the cecum. Colonoscopy showed the presence of ulcers localized in the opposite side of the ileocecal valve. Examination of a biopsy sample revealed granulation tissue with inflammatory cells and capillaries hyperplasia, which is consistent with ischemic colitis. The bacterial culture indicated negative. These findings led to a diagnosis of ischemic colitis and we started conservative treatment. After the treatment, clinical symptoms were improved and the follow up colonoscopy showed the ulcer scars covered with regenerated epithelium. A case of ischemic colitis of the cecum is very rare. We reported a case of transient ischemic colitis located in the cecum induced by catheter treatment and low blood flow after dialysis.

Case l: A 56-year-old male with an entro-enterostomy for small bowel perforation during chemotherapy for malignant lymphoma presented with fever. Computed tomography (CT) showed a 7-cm pelvic abscess adjacent to the rectum, which was drained via rectal puncture using a 19-gauge needle with endoscopic ultrasound (EUS) guidance and a 6Fr drainage tube. The patient became afebrile rapidly, and the abscess decreased significantly on follow-up CT. The tube was removed a week later after his symptoms resolved. Case 2: A 66-year-old male with a laparoscopic appendectomy presented with fever. EUS revealed perirectal fluid collection. CT revealed a 4-cm pelvic abscess, which was drained via rectal puncture using a 19-gauge EUS-FNA needle. The cavity was flushed with saline until the return was clear and the cavity size decreased. The needle was removed with recovery.

The patient was a 66-year-old woman. Approximately 2 years after she was started on oral administration of vonoprazan fumarate (potassium-competitive acid blocker [P-CAB]) for treatment of intractable reflux esophagitis, she complained of diarrheal symptoms. Symptomatic treatment was administered for the diarrhea. However, because no symptom relief was obtained, colonoscopy (CS) was performed. In the segment from the sigmoid colon to the rectum, mucosal erythema and cat scratch signs were partially observed, while histological examination revealed an approximately 30-μm collagen band directly under the mucosal epithelium. Thus, collagenous colitis (CC) was diagnosed. Oral administration of P-CAB was discontinued, and the symptoms had disappeared one month later. When CS was repeated after another 3 months, no endoscopic abnormalities were observed. Based on histological examination, the collagen band had become thinner but persisted. Most superficial epithelium had exfoliated.

Though a few reports have described endoscopic monitoring of CC, ours is the first reported case of CC caused by P-CAB.

A 70-year-old woman presented to our hospital with a liver tumor, which was suspected as a liver metastasis on enhanced CT. Colonoscopy revealed an elevated lesion, 6 mm in diameter, at the transverse colon. We endoscopically diagnosed the lesion as invasive cancer. However, since the lesion was small, we performed EMR for diagnostic therapeutic purposes. Pathological examination revealed a well-differentiated adenocarcinoma invading the submucosa and lymphatic invasion. Therefore, additional surgical resection with lymph node dissection and partial hepatectomy was performed. Histological examination of the liver tumor revealed a well-to-moderately differentiated adenocarcinoma, similar to the primary colonic carcinoma. The hepatic lesion was also immunohistochemically consistent with the primary colonic carcinoma. We finally diagnosed this case as colonic cancer with liver metastasis. We consider this case valuable because of its rarity.

Metal clips have been commonly used after endoscopic mucosal resection to prevent the risk of bleeding or perforation. In some cases, it is necessary to remove the indwelled clip before the operation. However, it is difficult to remove indwelled clips without mucosal damage. There were few reports describing the method of removing metal clips. We successfully removed the indwelled clip with combined use of colonoscopy and nasal endoscopy. This method seemed to be useful for removing the clip in the rectum.

A 77-year-old female admitted to our hospital after a positive test for fecal occult blood. The colonoscopy showed a reddish granular mucosa area in the cecum, and the biopsy revealed the possibility of lymphoma. Colonoscopy was re-examined, and magnifying endoscopy with NBI showed a type I pit pattern with capillary vessels that were partially expanded. Since we needed a specimen without crushig, CSP was performed for a wide range sampling. Pathological examination revealed mucosa-associated lymphoid tissue (MALT) lymphoma. Lymphatic tissue develops in the submucosal layer in the large intestine, therefore it is sometimes dificult to diagnose colonic MALT lymphoma by biopsy. We have reported a case of cecal MALT lymphoma, diagnosed by CSP.

An 81-year-old woman visited our hospital in September 20XX+2, having muddy stools 4-5 times per day since 20XX. Lower gastrointestinal endoscopic examination revealed enlargement of the Bauhin valve and multiple shallow ulcers with an annulus tendency from the ascending colon to the descending colon, with a shallow irregular ulcer observed in the sigmoid colon. Because diagnosis was not reached from pathological findings or culture of the intestinal juice, we decided to follow-up with symptomatic treatment. At the six month reexamination, Mycobacterium kansasii (M.kansasii) was detected in an acid-fast bacterial culture of intestinal juice. We diagnosed Non-tuberculous mycobacterial colitis caused by M.kansasii and started treatment with anti-tuberculosis drugs. After the treatments started, the symptoms were improved, and ulcers almost disappeared on endoscopic findings. Most cases of M.kansasii were reported in lung infection cases, and cases of colitis were not reported in Japan Medical Abstracts Society.

A 65 year-old man with history of Chronic Kidney Disease due to diabetes was admitted to our hospital with fever of unknown origin. We started antibiotic therapy. On hospital day 2, he was transferred to ICU with low blood pressure and disturbance of consciousness. On the next day, bloody stools admitted. Colonoscopy revealed edematous mucosa throughout the colon and multiple ulcers in sigmoid colon. From the result of blood culture, we diagnosed septic shock due to Salmonella enteritidis. Generally, Salmonella enteritidis will become mild. However, we should consider that Salmonella enteritis in a compromised host in this case might be severe condition.

A 22-year-old woman with a history of diarrhea and bloody stools presented at our hospital because of diarrhea, bloody stools, and loss of appetite. Colonoscopy revealed pan-ulcerative colitis. We started treatment with continuous intravenous infusion of prednisolone 40 mg (1 mg/kg), granulocyte apheresis, and oral mesalazine granules (4000 mg). After starting treatment, symptoms promptly improved. The dose of oral prednisolone was decreased to 15 mg/day. Watery stools occurred 5 times per day. The patient wanted to receive Chinese medicine. We requested Hiroshima Sky Clinic to treat the patient with us. Treatment with prednisolone and mesalazine was discontinued, and Hiroshima Chinese medicine was begun. Clinical remission was achieved. The calprotectin level decreased to 37 μg/g. Colonoscopy showed complete mucosal healing. Chinese medicine including natural indigo has side effects. The relevance of use of natural indigo is controversial because of the potential adverse effect. However, Chinese medicine may be useful, and some patients desire such treatment. In the assessment of symptoms on basis of the results of endoscopic and pathological examinations and calprotectin testing, Chinese medicine was effective in our patient.

A 60-year-old-woman presented to our hospital with right lower quadrant pain. A contrast-enhanced CT scan revealed approximately 7cm low density area with air-fluid level, close to the ascending colon. Patient was diagnosed with intra-abdominal abscess and was started on intravenous antibiotics. CT guided percutaneous drainage was performed. However, there was continuous extravasation of contrast medium into the colon upon follow-up contrast examination. Five days later, abscess was noted to be smaller than before, however, extravasation of contrast medium was still observed. Fistula formation from the abscess cavity leading to the ascending colon was noted. Colonoscopy examination revealed erythema and swelling of the diverticulum in the ascending colon. When we injected indigo carmine from the drain tube, liquid flowed the diverticulum. We closed the diverticulum using 8 short clips. Patient had an uneventful course after hospital discharge without recurrence for more than 1 year, and the diverticulum resolved.

85-year-old woman was admitted to our hospital because of anemia and fecal occult blood. Blood test showed iron deficiency anemia (Hb 7.5 g/dl) and negative for T-SPOT. Acid-fast bacillus in the gastric juice was negative. Barium enema showed shortening from the cecum to the descending colon, pseudodiverticulum and atrophic scars in the ascending colon, stenosis in the ileocecal valve, the sigmoid colon, the terminal ileum, and the transverse colon. Colonoscopic findings showed irregular circular ulcers in the terminal ileum, stenosis in the ileocecal valve, and multiple ulcer scars in the ascending colon, and irregular ulcer and flat elevated lesions around the ulcer in the transverse colon. The pathological findings of biopsy specimens showed tubular adenocarcinoma in the transverse colon and chronic inflammation without granuloma in the terminal ileum and ascending colon. Acid-fast bacillus for biopsy specimens was negative. Laparoscopic right hemicolectomy was performed. The depth of the colonic cancer was the subserosa without lymph node metastasis. The flat elevated lesion surrounding the cancer was not dysplasia but hyperplastic change. Based on these data, intestinal tuberculosis was suspected. We reported a rare case of colonic cancer associated with intestinal tuberculosis.

A male aged in his 60s was admitted to our hospital with abdominal pain, fever and vomiting. He revealed a history of bilateral nephrectomy for renal cell carcinoma (RCC) and was undergoing dialysis. Computed tomography (CT) showed no recurrence of RCC and distant metastasis; however, multiple colonic diverticula were observed in the left-sided colon. Colonoscopy (CS) revealed a longitudinal nodular mucosal elevated lesion (not a diverticulum) in the descending colon, and following a confirmatory biopsy, the lesion was diagnosed as inflammatory regenerative and granulation tissue. Follow-up CT and CS were performed 5 months later and showed severe colonic stenosis secondary to a submucosal tumor-like lesion. Biopsy examination of the stenotic lesion revealed spindle-shaped atypical cells, which on immunohistochemical examination stained positive for CD10, CA9, and PAX8 stains leading to a diagnosis of colonic metastasis of RCC. Left hemicolectomy was performed, and histopathological examination of the resected specimen showed sarcomatoid RCC, similar to the findings at the time of the left nephrectomy performed 2 years earlier.

An 80-year-old man was admitted to our hospital due to general fatigue. Laboratory examinations revealed liver dysfunction and inflammation. Ultrasonography revealed choledocholithiasis and dilated bile duct. Acute cholangitis was diagnosed and treated with antibacterial agents. Dynamic CT revealed a lesion with contrast effect in the cystic duct wall. We suspected cystic duct carcinoma. Endoscopic removal of bile duct stone was performed, and bile cytology revealed no atypical cells. Follow-up CTs were performed to rule out inflammatory changes. After five months, CT scan revealed worsening of the cystic duct thickness. However, malignant cells were not identified on newly performed bile cytology. However, the clinical course strongly suggested cystic duct carcinoma. Therefore, an extrahepatic bile duct resection was performed. The nodular lesion of the cystic duct was a well-differentiated adenocarcinoma that expanded to the common bile duct epithelium. In this study, cystic duct carcinoma was suspected before surgery due to its tendency to grow larger.

A 75-year-old woman was referred to our department to be investigated for liver damage. Abdominal computed tomography findings revealed choledocholithiasis with an 11-mm stone. We attempted endoscopic lithotomy using a duodenoscope. However, it was impossible to pass the duodenoscope beyond a gastric deformity with duodenal ulcer scar. The intrahepatic biliary duct was not dilatated, so we performed percutaneous transhepatic gallbladder drainage (PTGBD). Although we attempted percutaneous removal of the stone via the PTGBD route, this was difficult due to the steep angle of the cystic duct junction. We finally succeeded in removing the stone by the rendezvous method via the PTGBD route, as a forward-viewing scope could reach the papilla of Vater. The rendezvous method via the PTGBD route was an effective option for a patient with choledocholithiasis.

We report a case involving a 69-year-old woman who presented to our hospital with jaundice 2 months after cholecystectomy for a gallbladder stone. Computed tomography revealed choledocholithiasis measuring 2 cm in diameter in the distal bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and we tried to remove the bile duct stone. However, the stone could not be entrapped using a mechanical lithotriptor. We suspected that the stone was impacted at the confluence of the residual cystic duct. Therefore, we decided to crush the stone with electrohydraulic lithotripsy (EHL) using cholangioscopy. When standard endoscopic techniques for removal of impacted confluence stones fails, EHL using cholangioscopy should be considered.

A 72-year-old female who was admitted to our hospital for jaundice received the diagnosis of cholangitis based on blood test and abdominal CT findings. We performed biliary drainage by placing a stent via endoscopic retrograde cholangiography (ERC). After the cholangitis improved, we attempted to remove the stone using a catheter but were unsuccessful. Cholangiography showed the stone in the cystic duct, and Mirizzi syndrome was diagnosed. We planned an electronic hydraulic lithotripsy (EHL) but replaced the stent several times due to occlusion or displacement. On Day 43 from the first visit, we used EHL to crush and remove the stone in the cystic duct. The post-operative course was uneventful, and the cholangitis has not recurred.

An 84-year-old woman underwent endoscopic papillary large balloon dilatation (EPLBD), electronic hydraulic lithotripsy (EHL) and temporary insertion of one plastic stent (PS) for large and heaped common bile duct stones at her previous hospital, but it was difficult to remove these stones. Although she underwent extracorporeal shock wave lithotripsy (ESWL) in our hospital, these stones didn't be fractured. After insertion of two PSs and exchange of them every six months, the amount and size of stones decreased gradually. As a result, we succeeded in removing stone after one and a half years. It was suggested that an increase of the friction effect between the stones and the PSs due to insertion of two PSs resulted in decrease of the amount and size of stones.

Postoperative biliary leakage is a complication that can lead to serious clinical problems. We report our use of the fully covered metallic stent for the management of postoperative biliary leakage. A 72-year-old man, who had undergone resection of the lower middle region of the liver and a biliary tract stone due to advanced gallbladder cancer and common bile duct stone-, presented with biliary leakage. Endoscopic retrograde cholangiography (ERC) was performed and a plastic stent was inserted; however, bile leakage persisted. Thus, we performed repeat ERC and inserted a fully covered metallic stent at the site of bile fistula. Subsequently, recurrent leakage was not noted. We propose that, using a covered metallic stent improves postoperative biliary leakage without impairing the patient's quality of life based on our experience reported here.

A 63-year-old woman was admitted to our hospital with umbilical pain and vomiting. After a detailed examination, she was diagnosed with acute pancreatitis. Enhanced abdominal computed tomography showed a low-density lesion measuring 13 mm in size at the papilla of Vater and dilatation of the common bile duct. Endoscopic retrograde cholangiopancreatography was performed to rule out the occurrence of choledocholiths. Endoscopic imaging revealed a markedly edematous papilla of Vater protruding into the duodenum. A contrast study revealed a cystic lesion in the wall of the duodenum followed by the bile duct and the pancreatic duct; however, no stone was identified. Her biliary amylase level was markedly elevated at 63350 U/L. Thus, she was diagnosed with choledochocele with the formation of a common duct. Endoscopic sphincterotomy was performed considering that pancreatitis may have been caused by the mixing of bile and pancreatic juice secondary to choledochocele. Her biliary amylase level decreased to within normal limits, and no recurrent pancreatitis has occurred over 15 months.

A 42 year-old man had a chief complaint of abdominal pain lasting for a few days. His medical record comprised lacrimal gland enlargement, surgery, and PSL. He also had lacrimal gland enlargement on admission. Blood test revealed elevated IgG and IgG4 levels of 2,119 and 1,060 mg/dl, respectively. Other parameters were normal. Abdominal computed tomography revealed a 20-mm tumor within the pancreatic body, and endoscopic retrograde cholangiopancreatography revealed irregular narrowing of the main pancreatic duct. Our diagnosis was autoimmune pancreatitis (AIP) based on Clinical Diagnostic Criteria for Autoimmune Pancreatitis 2011. Corticosteroid, the standard AIP therapy, was administered to the patient, resulting in IgG4 elevation and gland enlargement improved. AIP is characterized by enlarged pancreas and irregular narrowing of the main pancreatic duct. The condition is often complicated by IgG4-related sclerosing cholangitis, dacryoadenitis, and other diseases. Many issues related to the indications of bile duct drainage and use of immunomodulating drugs remain unaddressed for better AIP diagnoses. Whole-body evaluation is vital when an IgG4-related disease is suspected.

An 83-year-old woman with left lower abdominal pain was referred to our hospital. Ultrasonographic examination showed a cystic lesion in the pancreatic body. Magnetic resonance cholangiopancreatography and computed tomography revealed dilatation of the main pancreatic duct in the pancreatic body and tail. However, there was no evidence of distinct tumorous lesions. Endoscopic ultrasonography of the pancreatic duct revealed a hypoechoic mass (major axis, 5 mm). Pancreatic cancer was suspected. Endoscopic retrograde cholangiopancreatography was performed, and an endoscopic nasopancreatic drain was placed. Cytologic examinations of pancreatic juice showed atypical cells. The possibility of pancreatic cancer could not be ruled out, and distal pancreatectomy, splenectomy, and D2 lymph-node dissection were performed. Postoperative pathological examination showed low-grade pancreatic intraepithelial neoplasia in the main pancreatic duct and high-grade pancreatic intraepithelial neoplasia in the lesion. Pancreatic intraepithelial cancer (carcinoma in situ) was diagnosed.

A 75-year-old man with lung and bilateral adrenal tumors was referred to our hospital. Although the patient was suspected of having adrenal metastasis from lung cancer, the pathologic diagnosis was not confirmed by transbronchial lung biopsy (TBLB). He then underwent endoscopic ultrasound-guided aspiration (EUS-FNA) of the left adrenal tumor. From the stomach, a swollen left adrenal lesion could be visualized, and EUS-FNA was successfully performed. Histopathology results showed squamous cell carcinoma, consistent with metastasis from lung cancer. We concluded that EUS-FNA for adrenal lesions was a useful alternative approach for cases in which obtaining the histologic diagnosis from the primary tumor was not feasible. Before the procedure, it is necessary to exclude cases of pheochromocytoma and paraganglioma, because these tumors may cause hypertensive crisis.

The patient was a 62-year-old man who presented with the chief complaints of diminished visual acuity in his right eye. Cranial magnetic resonance imaging revealed multiple osteoclastic tumors. Moreover, contrast-enhanced computed tomography revealed lesions in the pancreas and left thoracic wall. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) of the pancreatic lesion was performed using a 22-gauge needle, and multiple immunostaining assays were conducted. These findings led to the diagnosis of multiple myeloma with metastasis to the pancreas. Although, EUS-FNB is widely used as an effective endoscopic procedure to support pathological diagnoses of rare cancers, it is important to select the puncture needle for each case while carefully considering safety. We report a rare case in which extramedullary lesions associated with multiple myeloma were diagnosed based on pathological findings.

Renal cell carcinoma (RCC) often metastasizes to the pancreas long after surgery. A 79-year-old male, who had undergone left nephrectomy for RCC 30 years ago, visited us because a growing tumor had been found in the tail of his pancreas on computed tomography. The tumor exhibited stronger enhancement in the arterial phase than in the delayed phase. An endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy was performed, and the pathological diagnosis was clear cell carcinoma. Sunitinib was administered, and the tumor shrank. It is important to be aware that pancreatic metastasis from RCC can occur more than 30 years after surgery, and EUS-FNA is diagnostically useful in such cases.

The subject was a 45-year-old male who was examined for acute pancreatitis. Endoscopic ultrasound (EUS) revealed a low echoic tumor with a poorly defined border and a poorly vascularized interior at the pancreatic tail. Contrast-enhanced EUS showed that the tumor was hypovascular, and its interior exhibited non-uniform contrast staining. A clinical diagnosis of pancreatic ductal carcinoma (PDAC) was made. Distal pancreatectomy was performed, but pancreatic neuroendocrine neoplasm (PNEN), NET G2, with a total of six tumors up to 3 mm in size, was pathologically diagnosed. The aggregation of PNEN that were a few millimeters in size in a small area with fibrosis around tumors occured tumor-associated pancreatitis and appeared similar to PDAC during imaging, which probably caused the difficulties in the preoperative diagnosis.

An 87-year-old woman was found to have dilation of the main pancreatic duct on endoscopic therapy for choledocholithiasic cholangitis and a small protrusion in the main pancreatic duct on peroral pancreatoscopy. We made a diagnosis of benign main-duct intraductal papillary mucinous neoplasm (IPMN) and decided to follow up using abdominal ultrasonography. After 4 years, the patient returned and was found to have obstructive jaundice and increased diameter of the main pancreatic duct. Abdominal computed tomography revealed ring enhancement around the major duodenal papilla and endoscopic retrograde cholangiopancreatography showed enlargement of the major duodenal papilla; thus, cancer of the major duodenal papilla was diagnosed. Endoscopic biliary stenting using 10-Fr DLS was performed. She was discharged under the policy of best supportive care due to old age. IPMN in the main pancreatic duct is associated with other organ cancer in 20-30% of cases; routine follow-up examination is crucial.

A 73-year-old man was referred for gastrointestinal surgery to our hospital due to rectal cancer. The CT before the operation showed a tumor, 20 mm in size, in the pancreatic head. Somatostatin receptor scintigraphy showed mild accumulation. Prior to the surgery for rectal cancer, the CT showed that the tumor's size had increased in the 5 months since the first visit. We considered a pancreatic neuroendocrine tumor (P-NET) based on the image, and the patient wished to undergo a pancreaticoduodenectomy without a preoperative pathological diagnosis. The lesion was diagnosed as a pathologically solid variant of serous cystic neoplasm (SCN). We experienced a case of a solid variant of SCN which was difficult to distinguish from an NET.