【目的】大腸憩室出血に対する内視鏡止血法の治療成績を明らかにする．

【方法】大腸憩室出血のなかで大腸内視鏡（CS）で出血憩室を特定し内視鏡的止血法を行った122例を対象とした．対象の背景因子や内視鏡止血法の治療成績について検討した．

【結果】1）平均年齢は66.3±12.0歳，性別は男性90例，女性32例．基礎疾患は91例（75％）で認め，59例（48％）が抗血栓薬やNSAIDsを内服していた．2）出血憩室と特定したCS所見は，活動性出血が106例（87％），露出血管11例（9％）などであった．出血当日から翌日にCS施行の89例中81例（91％）で活動性出血を確認でき，それ以降にCS施行の33例中25例（76%）より高頻度であった（p＜0.027）．3）内視鏡止血法は，クリップ法が119例（98％）で多くを占めた．活動性出血を認めた106例での内視鏡的一次止血率は97%（103例）であった．内視鏡的止血法施行後の早期再出血は21例（18％）で認め，18例は内視鏡的止血に成功したが3例は緊急手術を要した．

【結論】大腸憩室出血は，出血後早期にCSを行うことが活動性出血の確認に必要である．クリップ法による内視鏡的止血法は一次止血には有効であるが，再出血が多いことが問題である．

【目的】大腸憩室出血に対するEndoscopic Band Ligation（EBL）は，従来，食道静脈瘤結紮術用の食道EVLデバイス（MD48710 U：Sumitomo Bakelite Co. Ltd）が用いられてきた．2018年8月に同社よりEBLデバイス（MD-48910B，白；MD-48912B，緑；MD-48913B，青；憩室出血に対し薬事承認済）が発売された．今回，新規EBLデバイスを用いた大腸憩室出血の治療成績を報告する．【方法】2018年12月～2019年8月に当院で大腸憩室出血に対して新規デバイスを用いてEBL施行した22症例を後方視的に検討した．主要評価項目として30日以内の早期再出血率，副次評価項目としてEBL手技時間，EBL直後の完全内反率，穿孔等の偶発症を評価した．【結果】早期再出血は4症例（18.2％）で認めた．22症例中EBLバンド装着成功例は20症例（90.9%）であった．EBL手技時間は中央値15.5分，EBL後の完全内反例はEBL装着成功例20症例中15症例（75%）であった．穿孔等の偶発症はみられなかった．【考察】新規EBLデバイスを用いた大腸憩室出血治療は旧EBLよりデバイス早期再出血率が高く，完全内反率が低い傾向にあった．しかし良好な視野が確保でき，スコープへのデバイス装着時の工夫を行うことで，再出血率の改善も期待される．

【目的】直腸粘膜脱症候群（mucosal prolapse syndrome；MPS）は直腸粘膜の一部が逸脱を繰り返し粘膜表面に隆起性変化や潰瘍形成を来す良性疾患であるが，腫瘍性病変と診断されることがある．当院にてMPSと診断された症例をもとに腫瘍性病変との鑑別点について検討する．【方法】2016年1月から2018年12月までに当院にて大腸内視鏡検査が実施されMPSと診断された31症例を対象とした．対象症例の中で前医にて直腸腫瘍と診断され当院に紹介された症例を抽出し検討した．【結果】当院でMPSと診断された症例の局在は前壁21例，後壁1例，左壁3例，右壁6例であった．肉眼型は隆起型21例，平坦型5例，潰瘍型5例であった．生検は19例で実施され全て非腫瘍性病変の診断であった．前医にて直腸腫瘍と診断され当院紹介となった症例は7例であった．前医診断時の肉眼型は隆起型3例，潰瘍型4例であった．全例が直腸腫瘍を疑われ生検が実施されていた．病理組織学的診断はGroup 5が2例，Group 4が1例，Group 3が1例，Group 2が1例，Group 1が2例であった．【考察】MPSの臨床病理学的特徴を熟知し直腸腫瘍の診断においてはMPSを鑑別疾患として想起する必要がある．MPSを疑った場合には生検を行い臨床症状や内視鏡所見を病理医と共有し診断を進めていくことが重要であると考えられた．

内視鏡技師と内視鏡専門医での助手の違いによるERCP関連手技における治療成績を比較検討した．対象は当院にて総胆管結石，悪性胆道狭窄の診断にてERCP関連手技を施行した188例．内視鏡技師が助手を施行した（N群）96例，内視鏡専門医が助手を施行した（D群）92例につき，総胆管結石，悪性胆道狭窄症例ごとに患者背景，治療成績，偶発症につき後ろ向きに検討した．専門医群の方がERCP困難症例が多くWire-guided cannulation法以外の胆管挿管法が多い傾向があり処置時間が長くなる傾向があったが，助手の違いによる治療成績や偶発症の発生率に有意差は認めなかった．胆管挿管不成功に助手の違いは寄与せず　ERCP関連手技において適切に症例が選択されている状況では，内視鏡技師が助手に入ることは許容されることが示唆された．

日本の大腸がん検診にはFOBT (免疫学的便潜血検査) が行われているが, 受診率の低さ, さらにFOBT陽性者の全大腸内視鏡検査 (TCS) 受診率の低さが問題である. S状結腸内視鏡及び内視鏡的ポリープ切除による大腸がん死亡率減少効果が報告されているも, 大腸内視鏡挿入技術は容易に習得できない. 通常のコロンモデルを用いたトレーニングでは, 大腸の撓みの状態を確認しながら挿入することは可能である. しかしスコープの状態を確認することが不可能であった. 一方UPDを併用すると大腸の撓みとスコープ屈曲の関連性を同時に把握することが可能である. 今後の大腸内視鏡医の教育において有用性が高いと思われた.

富士フイルムメディカル社から2019年11月に発売されたインフィニティ細胞診ブラシミニの細胞採取能力を評価した．本製品の特徴は，通常のブラシよりも硬めのブラシをブラシの両端に備えていることである．2019年5月から11月に胆管狭窄の質的診断として胆管擦過細胞診を施行した9例を対象とし，診断能とカテーテルの挿入性能を後方視的に評価した．カテーテルの挿入性は高く，全例で目的部位を擦過できた．悪性狭窄を疑った6例は擦過細胞診で良好な検体が採取されており，正診率は100%であった．一方で，胆汁細胞診の正診率は33.3%，胆管生検は66.7%であった．我々の検討は，この製品の有用性を示した．

症例は76歳女性．前日からの上腹部痛と嘔吐を主訴に当院消化器内科を受診．既往歴に特記事項はない．血液検査でWBC 8800，CRP 5.58と炎症値の上昇を認め，腹部造影CTで小腸内の異物および腸管の拡張を認めた．Free airは認めなかった．生活歴より魚骨による小腸穿通と診断し，上部消化管内視鏡検査および小腸内視鏡検査を即日施行した．内視鏡検査においては食物残渣が多く，穿通部位に到達することができず，翌日緊急で外科的手術の方針となった．手術は全身麻酔下，仰臥位で施行．回腸末端から口側に腸管を辿ると非拡張腸管から拡張腸管に移行する部位で明らかな腸管の炎症所見を認めたが魚骨は同定できなかった．穿通部位として考えられるのはその他の腸管には認められなかったため，魚骨は移動したものと判断し炎症部位を含めた範囲で小腸部分切除術を施行した．術後第5病日で再度術前同様の腹部症状を認めたため，腹部CT施行したところS状結腸に異物を確認した．これを下部消化管内視鏡検査により除去した．術後経過良好で第12病日で退院となった．穿通をきたした小腸異物に対し内視鏡的アプローチと外科的アプローチを施行した希少な症例を経験したので若干の文献的考察を含め報告する．

Eosinophilic gastrointestinal diseases (EGIDs) are distinct immunologic diseases that show a variety of clinical manifestations and endoscopic findings with unknown cause or association of immunologic diseases. The incidence of eosinophilic esophagitis (EoE) seems to be increasing, although it is still unclear whether this is general phenomenon or attributable to an increased awareness of the disease. Our aim was to examine clinical features, endoscopic findings, and associated diseases of 4 cases of EGIDs. These cases included 1 eosinophilic gastroenteritis and 4 EoE, 3 men and 1 woman, and the mean age was 46±7 year-old. The most common endoscopic findings were mucosal edema, linear furrows, and rings in esophagus, and white specks in colon. An increased number of eosinophils was infiltrated in esophageal or colonic epithelium. Two cases were complicated with celiac disease (CD), and scleroderma, respectively and all cases were associated with gastroesophageal reflux disease. While one case complicated with CD showed a marked serum eosinophilia, others were in normal serum eosinophils. Three cases were treated with a proton-pump inhibitor and the symptoms improved in 2 cases.

A 78-year-old man visited our department following classification B in gastric cancer screening by ABC method. Upper gastrointestinal endoscopy revealed multiple black mucous membranes in his stomach. Subsequent hematoxylin and eosin staining of sections revealed small clusters of eosinophilic non-structural substances that also tested positive for amyloids through Congo red staining. Additional testing indicated a diagnosis of AL-type amyloidosis, revealing systemic amyloidosis in the lower gastrointestinal tract, kidneys, and bone marrow. Typically, amyloid deposits are found in the gastrointestinal tract in 90% of systemic amyloidosis cases, with endoscopic findings providing variable results. AL-type deposits are found deeper in the mucosal muscularis and may also present with a submucosal mass-like ridge. Thus, we encountered a rare case of frequent black mucosa where submucosal hemorrhage was presumably formed by amyloid deposition in the mucosal muscularis area causing peripheral circulatory disturbance.

A 32-year-old female with epigastric pain visited our clinic. Esophagogastroduodenoscopy revealed multiple antral erosions and notch-like depressions in the second portion of the duodenum that were typical of Crohn's disease. Colonoscopy revealed no lesions in the small intestine, colon, and anus. Sulpiride was prescribed and her symptom resolved, indicating functional dyspepsia. We diagnosed Crohn's disease localized only in the upper gastrointestinal tract. No granuloma was detected on biopsy examination. We prescribed an elemental diet, mesalazine, and milled mesalazine. Esophagogastroduodenoscopy and colonoscopy were performed annually for six years. The erosions and depressions did not change, and no new lesions appeared in other parts of the gastrointestinal tract. There has been no domestic report of long-term, quiescent Crohn's disease. Although this case does not fulfill the diagnostic criteria, we report this rare case of Crohn's disease.

Eight cases diagnosed with human intestinal spirochetosis (HIS) from January 2019 to July 2019 in our hospital were compared. The patients were 7 males and 1 female; their ages ranged from 17 to 72 (mean 52.8) years. Five out of the 8 patients had symptoms. Colonoscopic findings included redness (n=4), edema (n=2), and polyps (n=4). These eight patients comprised 2.1% of all patients who underwent colonoscopy and histological examination during the same period. Metronidazole was administered to two patients, one of whom showed improved symptoms. Currently, the diagnosis of HIS largely depends on pathological examination. HIS should be considered as a cause of gastrointestinal symptoms of unknown etiology, and we believe that eradication may be an option for treatment.

The efficacy of anti-tumor necrosis factor (TNF) -α antibody therapy in the treatment of intestinal Behçet's disease (BD) is under active clinical investigation. Here, we analyzed the endoscopic findings in patients with intestinal BD and investigated the therapeutic effects of anti-TNF-α antibody therapy in them.

In this study, at 52 weeks there were five patients in the remission group and three in the non-remission group. Therefore, the remission rate at 52 weeks was 62.5%. The clinical remission rates at 14 weeks were as follows: 80% in the remission group and 100% in the non-remission group. Endoscopic findings in the remission group were characterized by the presence of diffuse shallow ulcers of <20-mm diameter. Aphthous-type ulcers were recognized in 80% of the patients in the remission group. Endoscopic findings in the non-remission group were characterized by the presence of deep ulcers of >20-mm diameter. Volcano-type ulcers were recognized in 66.7% of the patients in the non-remission group.

Endoscopic findings may be predictive of the response to anti-TNF-α antibody therapy. In particular, in the cases of intestinal BD with deep volcano-type ulcers of diameter ≥ 20 mm, relapses occur often even after clinical remission and require careful follow-up including colonoscopy.

A 40s-year-old man was admitted to our hospital owing to severe general fatigue with blood pressure lowering. He was diagnosed with diabetic ketoacidosis as the laboratory examinations revealed hyperglycemia and metabolic acidosis. An esophago-gastro-duodenoscopy (EGD) was performed on the third day of the illness due to suspected upper gastrointestinal bleeding. Since the EGD showed circumferential blackening and white moss-like adhesions in the lower esophageal mucosa, he was diagnosed with acute necrotizing esophagitis. He was kept fasting, and was administered proton pump inhibitors and high-calorie infusions. The clinical course was good; he resumed eating on day 20 and was discharged on day 37.

We herein report a rare case of esophageal carcinoma with giant intramural metastasis to the stomach. Endoscopy revealed a 71-year-old man with deglutition disorder to have a lesion in the middle esophagus and a giant submucosal tumor about 60 mm in diameter in the gastric cardia with erosion on its top. Histopathologically, the tumor was shown to be moderately differentiated squamous cell carcinoma, so we diagnosed him with esophageal carcinoma with intramural metastasis to the stomach. Chemoradiation therapy was administered given to prevent regional recurrence, A complete response was achieved, and this patient remains alive without recidivation at 10 months.

In the past, there have been a few cases in which gastric lesions were diagnosed as intragastric metastasis before surgery, and as a result regarding the diagnosis of gastric submucosal tumor, many cases were diagnosed as intragastric metastasis only by surgery. This is a rare case of esophageal carcinoma with giant intramural metastasis to the stomach that has been successfully treated with chemoradiation therapy; thus, we report this case along with a discussion.

A 91-year-old woman was admitted for rehabilitation after undergoing right total knee arthroplasty. Her oral intake was poor after hospitalization, and she experienced vomiting on the 13^th day of the disease. Abdominal computed tomography showed mesenteroaxial gastric volvulus with a giant esophageal hiatal hernia, and she underwent endoscopic repair under X-ray fluoroscopic guidance. However, her oral intake did not improve following treatment secondary to gastric volvulus recurrence. She refused surgical intervention owing to her advanced age, and we performed percutaneous endoscopic gastropexy using a Funada-style loop gastropexy device. Her postoperative course was uneventful, and oral intake was gradually resumed without recurrence of gastric volvulus. Percutaneous endoscopic gastropexy may be a useful, less invasive treatment option in patients with gastric volvulus who are at high risk for surgery.

A 70s man admitted to our hospital with a gastric abnormality. Esophagogastroduodenoscopy showed submucosal tumor-like lesion, approximately 25 mm in diameter, on lesser curvature of middle corpus of the stomach and depressed lesion on the top of the elevation. Biopsy specimens indicated well-differentiated tubular adenocarcinoma. Endoscopic ultrasonography (EUS) revealed multiple heterotopic gastric glands mainly in the gastric submucosa, which were diagnosed diffuse cystic malformation (DCM). We performed endoscopic submucosal dissection (ESD) for early gastric cancer based on DCM. DCM frequently causes gastric cancer, but DCM makes it difficult to diagnose the invasion depth by conventional endoscopy. Consequently EUS is important in deciding the treatment strategy for gastric cancer with DCM. Careful follow-up observation is necessary in consideration of the occurrence of metachronous gastric cancer because cancer often occurs frequently.

A 64-year-old woman visited a nearby hospital complained of stomachache. EGD showed atrophic gastritis due to Helicobacter pylori infection and a submucosal tumor in the greater curvature of the antrum. Her symptoms was not improved due to eradication for H. pylori infection, therefore, she was introduced to our hospital. EGD revealed the submucosal tumor with erosion and oozing 2 cm in diameter. Hemostasis was conducted. Endoscopic ultrasonography (EUS) showed hypoechoic tumor with aechoic area in the submucosal layer. Histopathological findings of biopsy specimens showed regenerated epithelium.

Because of rebleeding, she underwent laparoscopic gastric local resection. Histopathological findings revealed a large number of fibroblasts with eosinophilic infiltration, and she was diagnosed with gastric inflammatory fibroid polyp (IFP).

Gastric IFP is a benign submucosal tumor and bleeding is rare. We reported the rare gastric bleeding IFP with bibliographical consideration.

A 69-year-old woman visited our hospital for gastric abnormality in the upper gastrointestinal series. She had no subjective symptoms. Blood examination including tumor marker revealed normal levels. A gastrointestinal endoscopic study revealed a stage 0-IIc-like lesion of the stomach body. Histological findings of the biopsy specimen revealed gastric carcinoma with lymphoid stroma on hematoxylin and eosin staining, and the tumor cells were positive for the in situ hybridization of Epstein-Barr virus (EBV) -encoded small RNAs. Enhanced computed tomography images revealed no metastasis to lymph nodes and other organs in the chest and abdomen. Therefore, the diagnosis was gastric carcinoma with lymphoid stroma-associated EBV (clinical stage IA), and surgery was performed. The frequency of EBV-associated carcinoma is not small and it has poor subjective symptoms; hence, its discrimination by characteristic clinical pathology findings is necessary.

A 34-year-old man visited my clinic for the symptoms of GERD. He has allergies including food and had a dog as a pet.

Upper gastrointestinal endoscopy revealed nodular mucosa in the gastric antrum and the presence of linear furrows and bamboo-joint like appearance throughout the esophagus. In blood biochemistry, IgE RAST of crustacea was positive; H. pylori IgG antibody and Urea Breath Test were negative.

Histopathological findings showed eosinophil infiltration of more than 40 / HPF in the esophageal mucosa and chronic active gastritis with lymphoid follicles with large helical bacilli with Gimenes staining. He was diagnosed with H. heilmannii-like Organism (HHLO) nodular gastritis accompanied by eosinophilic esophagitis (EE). He was prescribed oral proton pump inhibitor and fluticasone inhalation which resulted in improvement of endoscopic and histologic findings.

Reports of HHLO nodular gastritis accompanied by EE are rare. Therefore, this case is considered to have some clinical significance in H. pylori negative era.

A 76-year-old male was scheduled for gastric endoscopic submucosal dissection (ESD) of early-stage gastric cancer. During the ESD procedure, hypoxemia caused by laryngeal edema occurred and ESD was discontinued. Emergency tracheal intubation was attempted but it was difficult due to the presence of a large epiglottic cyst. Using a McGRATH laryngoscope, tracheal intubation was managed successfully. He was treated with steroids for laryngeal edema, and was discharged to home without any sequelae. An epiglottic cyst is a risk factor for difficult intubation. In patients who are scheduled for upper endoscopic treatment that requires sedation, a large epiglottic cyst should be removed before treatment.

A 47-year-old man complained about chronic epigastric pain. He underwent upper gastrointestinal endoscopy, revealing a 20-mm smooth, cushion sign-negative SMT in the greater curvature of the stomach. Endoscopic ultrasonography (EUS) revealed a low echogenic mass from the 4th layer, which was heterogeneous in the inside. EUS and abdominal computed tomography after 1.5 year showed a tendency to increase to 25 mm. Neuroendocrine tumor (NET) G1 was diagnosed by EUS-FNA, laparoscopic gastrectomy was performed, and glomus tumor was diagnosed by pathological analysis. Primary gastric glomus tumors are rare and need further study with a literature review.

A woman in her seventies presented with multiple polyps in her stomach, and a polyp in the lower gastric body was diagnosed pathologically as Group 4, borderline malignancy. Helicobacter pylori was eradicated as an alternative to gastrectomy, and the lesion disappeared morphologically and histologically 10 months after eradication. However, after 28 months, advanced gastric cancer suddenly appeared at a site different from that of the borderline malignancy lesion. Gastrectomy was performed, and the gastric cancer was diagnosed as a poorly differentiated adenocarcinoma. Most of the polyps were diagnosed as foveolar hyperplastic gastric polyps, but a few polyps were diagnosed as Peutz-Jeghers-type hamartomatous gastric polyps, which were histologically characterized by distinctive arborization of smooth muscle within the lamina propria. The patient was diagnosed with a solitary gastric Peutz-Jeghers-type polyp because she had Peutz-Jeghers-type hamartomatous polyps without family history, mucocutaneus pigmentation, and intestinal polyposis and did not meet the diagnostic criteria of Peutz-Jeghers syndrome. A solitary gastric Peutz-Jeghers-type polyp is very rare, and a high frequency of cancer complications has been reported; thus, careful observation for cancer screening is required.

The patient was a 66-year-old man with a history of hepatitis B, hepatocellular carcinoma, and early-stage esophageal cancer. Although gastric submucosal tumor in the greater curvature of the upper stomach was suspected at upper gastrointestinal endoscopy over 10 years ago, biopsy was not performed because of unchanged tumor size and morphology. Endoscopy performed 1 year before visiting our hospital revealed the morphology of a submucosal tumor, which transformed to a type 3 lesion the following year. Moderately-to-poorly differentiated adenocarcinoma (stage I, T2N0M0) was diagnosed with biopsy, and open total gastrectomy with D2 lymph node dissection was performed.

The histopathology revealed moderately differentiated tubular adenocarcinoma and non-solid-type poorly differentiated adenocarcinoma with regional lymph node metastasis. The final diagnosis was stage IIIA (T4aN2M0), and outpatient chemotherapy is currently being administered.

Endoscopic ultrasound-guided fine-needle aspiration should be actively performed even for gastric submucosal tumors with no morphological changes.

The case is A 63-year-old man. He visited our emergency outpatient clinic for headache and dizziness in 201X. CT examination was performed, and a diagnosis of left renal cell carcinoma, brain metastasis, multiple lung metastasis, and mediastinal lymph node metastasis was confirmed.He was treated in the urology department.He was referred to our department because of Progression of anemia during treatment for 201X+5 years.

Esophagogastroduodenoscopy (EGD) revealed a submucosal tumor, mainly immediately below the gastric cardia, and a biopsy was performed. Renal cell carcinoma was confirmed by histology, and the patient was diagnosed with gastric metastasis of renal cell carcinoma. Transcatheter arterial embolization (TAE) was performed to prevent rebleeding, and the follow-up EGD showed apparently tumor shrinkage. We report a case in which TAE was performed for gastric metastasis of renal cell carcinoma.

The incidence of gastric cancer after eradication of Helicobacter pylori (HP) is expected to increase in the future. Although reports of early gastric cancer after the eradication account for the majority of cases, scirrhous gastric cancer is rare. Herein, we report three cases of scirrhous gastric cancer after eradication of HP. Case 1: A 50-year-old woman had been treated with eradication of HP and was followed up by esophagogastroduodenoscopy (EGD) on a regular basis. Two years after the eradication, EGD revealed advanced type 4 gastric cancer. Case 2: A 50-year-old woman had been treated with eradication and was followed up by EGD on a regular basis. Twenty-four years after the eradication, EGD revealed advanced type 4 gastric cancer. Case 3: A 50-year-old man had been treated with eradication and was followed up every year by EGD. Five years after the eradication, EGD revealed advanced type 4 gastric cancer. Despite performing regular EGD, cases of scirrhous gastric cancer can be found after eradication. We report our encountered cases, along with relevant literature.

【Case1】An 83-year-old man was diagnosed with signet ring cell carcinoma and underwent ESD. Helicobacter pylori eradication therapy was performed after ESD. A whitish flat lesion with dilated vessels was found five years later. Biopsy examination revealed irregular fundic glands, and we performed ESD. Pathological examination demonstrated GAFG, Type 0-IIb.

【Case2】A 59-year-old man was diagnosed with signet ring cell carcinoma and underwent ESD. Both gastric mucosal atrophy and Helicobacter pylori antibody in serum were negative. A whitish flat lesion with a black pigment point was found one year later. Biopsy examination revealed irregular fundic glands, and we performed ESD. Pathological examination demonstrated GAFG, Type 0-IIc.

An 80-year-old woman presented with an asymptomatic, painless lump in the right breast. Positron emission tomography incidentally revealed a 45 mm × 25 mm-sized, dumbbell-shaped mass in the epigastric region. Abdominal computed tomography showed that the mass was adjacent to both the stomach and the small intestine. Endoscopic ultrasonography (EUS) showed that the hypoechoic mass had a 1.6 mm-diameter stalk attached to the 4th layer of the gastric wall. Laparoscopic partial gastrectomy was performed. The gastric mass with a narrow stalk was resected and was confirmed as GIST of the stomach histopathologically. The stalk of this tumor was composed of smooth muscle tissue without tumor cells. The diameter of the stalk was 1.6 mm on EUS, and 2.2 mm on histopathological examination. We believe that in vivo in some extra-luminal pedunculated gastric GISTs the stalk may become longer and thinner as the GIST grows.

A 50-year-old woman underwent an esophagogastroduodenoscopy, which revealed a 7 mm submucosal tumor on the greater curvature of the upper gastric body. A biopsy was performed and the tumor was diagnosed as a granular cell tumor (GCT). The patient was then referred to our hospital. Endoscopic ultrasonography revealed a homogeneous low echoic tumor in the 2nd-3rd layer. An endoscopic submucosal dissection (ESD) was performed and the tumor was resected en bloc. Histopathological diagnosis was a benign GCT. The treatment of GCT of the stomach is still controversial, because of its rarity. Malignant GCT of the stomach has been reported, so we must consider the removal of tumors. ESD could become a treatment option after preoperative detailed examination.

A 84-year-old male patient complained of epigastric pain and fever. A computed tomographic (CT) scan revealed thickening of the stomach wall, and an increased peripheral fat tissue concentration, which was suspected to be caused by gastric cancer. The next day, an upper gastrointestinal endoscopy A type 2 lesion was found in the stomach. The abdominal pain worsened, and CT was repeated. Fluid retention was observed in contact with the tumor, and gastric perforation was suspected. Surgical findings showed a large number of abscesses in the wall. The pathological diagnosis was gastric endocrine cell carcinoma. Endocrine cell carcinoma of the stomach is a rare disease, and the prognosis is poor. In this report, we describe a rare intramural abscess associated with gastric endocrine cell carcinoma and review the related literature.

Woman in her fifties. She had been received regularly an upper gastrointestinal endoscopy noted for gastric polyp for several years. Biopsy sample from the polyp was suspected malignancy, so she was referred to come our hospital for examination. Blood examination revealed anti-parietal cell antibody positive, hypergastrinemia and anti-Helicobacter pylori antibody negative. She had severe atrophic gastritis in the body and fundus, but no atrophic gastritis in the antrum. Based on the above, we diagnosed autoimmune gastritis (AIG). We also detected hyperplastic type polyp in anterior wall in the middle body. Magnify endoscopy revealed hyperplastic change and abnormal vessel in the polyp. Afterward we conducted endoscopic mucosal resection (EMR) for the polyp, which was pathologically diagnosed as well-differentiated adenocarcinoma was diagnosed pathologically from EMR sample. It was reported that the risk of cancer in hyperplastic type polyp in AIG was high. We will have to check H. pylori infection but also AIG about gastric hyperplastic type polyp with atrophic gastritis.

An 83-year-old female who presented with vomiting was diagnosed with stenosis from the duodenal bulb to the gastric antrum caused by unresectable pancreatic ductal adenocarcinoma. A self-expandable metal stent (SEMS) was placed under endoscopy at the obstructed region. Following discharge, she underwent 7 courses of gemcitabine+nab-paclitaxel chemotherapy as an outpatient. She developed abdominal pain 205 days after SEMS placement, and abdominal computed tomography revealed intraperitoneal free gas. Emergency laparotomy was performed for a diagnosis of upper gastrointestinal perforation. The patient regained capacity to take food after surgery, and was released on postoperative day 46. The present case is an example of perforation occurring after placement of a metallic stent, a rare complication. We report our experience in a case with late onset of perforation, while also reviewing the literature.

A 59-year-old woman underwent esophagogastroduodenoscopy as a health check-up, which revealed a submucosal tumor-like lesion with a central recess, measuring 20 mm in diameter, on the opposite side of the major duodenal papilla. A biopsy specimen revealed an atypical gland. Although endoscopic ultrasound showed that the tumor may be submucosal invasive cancer, we performed endoscopic submucosal dissection (ESD) due to her lung cancer. Histopathological examination of the tumor showed intramucosal adenocarcinoma (pap>tub1) without vascular and lymphatic invasion. Immunostaining of the tumor revealed positivity for MUC5AC and MUC6, and negativity for CD10 and MUC2, indicating the gastric phenotype. No recurrent cancer has been observed one year after ESD. Endoscopic therapy for early duodenal cancer of the gastric phenotype might lead to the improved prognosis of the patient.

A 60-year-old woman visited our department with the chief complaint of repeated nausea and abdominal pain. Abdominal contrast-enhanced computed tomography revealed circumferential jejunal wall thickening and dilatation of the oral end of the intestinal tract. Therefore, under the diagnosis of small intestinal ileus, she was hospitalized. Small intestinal endoscopy revealed a circumferential ulcerative lesion in the upper jejunum 14 cm from the ligament of Treitz. Biopsy revealed an adenocarcinoma, which led to the diagnosis of small intestinal cancer. No apparent metastasis was observed. Partial resection of the small intestine was performed. The pathological diagnosis was adenocarcinoma tub 2, 50×29 mm, T3 (SS) N0 M0 stage IIA. Postoperative adjuvant chemotherapy was not performed, and the patient has had no recurrence.

Intestinal arteriovenous malformations (AVMs) are an important cause of gastrointestinal bleeding. However, diagnosis is difficult depending on the timing of the examination. [Case] An 86-year-old man complained of bloody stool. Small intestinal capsule endoscopy (CE) revealed a submucosal tumor (SMT) -like elevation in the jejunum. Single-balloon enteroscopy (SBE) did not identify any lesions. Transfusion improved anemia, but gastrointestinal bleeding was observed again. Ninty-four days after the initial CE, small intestinal CE was performed again and revealed an SMT-like bulge with active bleeding in the jejunum. SBE revealed an SMT-like bump with redness in the jejunum, which was considered to be the source of hemorrhage. Small intestinal AVM was diagnosed. Partial resection of the small intestine was performed at a later date.

A 78-year-old female with a bleeding elevated lesion in the sigmoid colon was referred to our hospital. Therefore, endoscopic mucosal resection (EMR) was performed. The pathological diagnosis was pyogenic granuloma. Despite the positive margin, further treatment was withheld because of the absence of hematochezia. After 3 months, she complained of hematochezia. Colonoscopy revealed an elevated lesion on the scar. We performed EMR using a ligation device. The pathological diagnosis was recurrence of pyogenic granuloma and positive margin. After 3 months, colonoscopy revealed a red area on the scar. Biopsy led to the pathological diagnosis of pyogenic granuloma. We performed follow up because the size was small and there was no bleeding. It is important to differentiate pyogenic granuloma from hematochezia, and an appropriate method is required for complete resection.

An 81-year-old woman presented to the Emergency Department complaining of abdominal pain and anorexia ongoing for 3 days. Abdominal contrast CT scan showed intussusception of the small intestine into the transverse colon, with adipose tissue at the lead point. After first performing emergency reduction by colonoscopy, we used single-balloon small-bowel endoscopy to snare and remove the lipoma. Adult-onset intussusception is relatively rare, accounting for only 5% of all cases. While malignant tumors are often the cause of colon intussusception, small intestine cases are more frequently caused by benign tumors. There have been many reports of small intestinal intussusceptions caused by lipomas like in this case, but no cases in which polyp resection was conducted in addition to endoscopic reduction have been reported yet. The choice to treat intussusception by endoscopy is made when surgery is difficult or unnecessary.

We report a case of small intestinal ulcer with active bleeding stopped by colonoscopy.

The 87-year-old man with a history of angina, taking aspirin and clopidogrel was referred for bloody stool. He was suspected of having small intestinal bleeding because of extravasation in the oral side of the terminal ileum on computed tomography, and emergency colonoscopy was performed. Small intestinal Dieulafoy's ulcer with active bleeding was detected, which was stopped by the clip method. Post-endoscopic hemostasis was uneventful. He have passed without recurrence to date.

Olmesartan has recently been reported as a cause of drug-induced enteropathy characterized by chronic diarrhoea and duodenal mucosal atrophy demonstrating sprue-like enteropathy. 82-year-old, male presented to our hospital because of chronic severe watery diarrhea without abdominal pain or fever. Blood examination showed mild anemia (Hb 11.2 mg/dl). Abdominal contrast-enhanced computed tomography showed mucosal edema in the large intestine. Esophagogastroduodenoscopy showed no villous atrophy in the duodenum with the possibility of pyloric gastrectomy, however, colonoscopy showed villous flattering in the terminal ileum and edematous changes in sigmoid colon. Histopathologic examination in biopsy samples from the terminal ileum and sigmoid colon showed interstitial lymphocytic infiltration. He was treated with olmesartan for hypertension at least two years before the onset of symptoms. In addition, watery diarrhea improved soon after discontinuation of olmesartan. Therefore, he was diagnosed as olmesartan-induced enteropathy. Its pathogenesis remains unclear; however, olmesartan-induced enteropathy must be included in the differential diagnosis for patients with chronic diarrhea after the intake of olmesartan.

There are various causes of hematochezia, among which diverticulum hemorrhage is a pathological condition that is often encountered in the clinic and often occurs repeatedly. Therefore, if a patient who has a history of diverticulum hemorrhage presents with hematochezia, conservative treatment is usually administered based on the assumption that the patient has diverticulum hemorrhage and in many cases endoscopy is not performed. We experienced an 85-year-old patient who developed melena three times and whose cause of melena the first time was diverticulum hemorrhage but whose causes of melena the second and third times were different. Just because it is the same symptom in the same person, the cause is not necessarily the same. It is thought that performing endoscopy immediately after melena, taking into consideration various possibilities, is always useful for finding the cause of hematochezia and hemostasis.

A 50-year-old female was referred to our hospital for examination and treatment of a rectal tumor. A colonoscopic examination revealed a 20-mm-diameter, laterally spreading, granular-type tumor in the lower rectum. A conventional image showed a villous tumor in the middle area and narrow-band imaging (NBI) showed a Japan NBI Expert Team type-2A tumor. The biopsy specimen was interpreted as well-differentiated tubular adenocarcinoma. No endoscopic findings suspicious of advanced rectal cancer were obtained; therefore. we planned to perform endoscopic submucosal dissection. However, computed tomography (CT) and magnetic resonance imaging showed multiple enlarged mesorectal lymph nodes. Therefore, a laparoscopic low-anterior resection with lateral pelvic lymph-node dissection was performed. A histological examination showed rectal cancer of por>tub, pT3 N3 M0, and pStage IIIc. The patient rejected adjuvant chemotherapy, and multiple liver and lymph-node metastases were detected at 3 months postoperatively. Although systemic chemotherapy was started, the patient died of cancer 9 months postoperatively.

A 76-year-old woman admitted to our hospital with a positive test for fecal occult blood. Colonoscopy revealed a reddish 20 mm-sized polyp with a nodule in the transverse colon. The nodule partially contained a vessel pattern of JNET type 2B. Therefore, we conducted endoscopic mucosal resection (EMR) for diagnosis and treatment. The specimen led to a diagnosis of inflammatory fibroid polyp (IFP) based on predominantly of eosinophils and onion skin pattern. IFP is an inflammatory lesion arising from the submucosal layer. It is commonly found in the stomach or small intestine, but rarely in the colon.

A 54-year-old woman was referred to our hospital for continuous abdominal pain and melena lasting for 2 weeks. Blood examination results were normal. We performed a colonoscopy and observed a tumor of 30-mm diameter with ulcers and bleeding on the surface. Computed tomography showed low absorption densities of lesions larger than 30 mm. Magnetic resonance imaging of the tumor showed high signal intensity on T1-weighted images, iso-signal intensity on T2-weighted images, and low signal intensity on fat-suppressed T2-weighted images. We performed laparoscopic sigmoidectomy, and the tumor was histopathologically diagnosed as a lipoma. A colonic lipoma is a benign nonepithelial tumor, which is relatively rare in clinical practice.

Although intestinal intussusception is relatively common in children, it remains a rare clinical entity in adults. We report a case of an 84-year-old woman who had mild diarrhea for 6 months. Further examination was performed. Ultrasonographic examination revealed the multiple concentric ring sign in her right flank. Colonoscopic examination revealed a pedunculated tumor with small nodular surface in the ascending colon from the cecum. The histopathological findings were consistent with the diagnosis of a carcinoma in adenoma. Computed tomography revealed the target sign in the transverse view, and invaginated mesenteric fat and associated vessels in the coronary view. She underwent laparoscopic ileocecal resection. The resected specimen revealed a round, pedunculated tumor with a small nodular surface, measuring 55×45 mm in size, in the cecum. The histopathological findings showed well differentiated tubular adenocarcinoma invading the mucosa. She is currently undergoing regular follow-up.

A 51-year-old man presented to our hospital with complaints of blood in his stool and abdominal pain. Contrast-enhanced computed tomography scanning revealed thickening of the rectal wall and dilatation of the oral colon. The patient was diagnosed with obstructive rectal cancer. Retrograde bowel drainage was performed. Subsequently, he relapsed colonic obstruction and ileostomy was performed. Following lower anterior resection and adjuvant chemotherapy, stoma closure was scheduled. However, colonoscopy revealed colon stenosis caused by obstructive colitis from the transverse colon to the descending colon. Balloon dilatation was performed twice; however, adequate improvement was not noted in the colon stenosis. Local injection of a steroid was performed immediately following balloon dilatation. The colon stenosis improved after four balloon dilatations and two local steroid injections. Eventually, stoma closure was performed and his postoperative course was favorable.

A 74-year-old man presented to our hospital complaining of a sensation of retained feces. Colonoscopy revealed a rectal cancer. After preoperative chemoradiotherapy, laparoscopic Miles' operation was performed. On postoperative day 6, the patient complained of abdominal pain around the stoma. Contrast-enhanced computed tomography scanning revealed a low-density area with an air-fluid level near the descending colon. Intraperitoneal abscess resulting from the perforation of the descending colon diverticulum was diagnosed, and percutaneous abscess drainage was performed. However, the fistula persisted. Indigo carmine was injected into the drainage catheter and the perforated diverticulm was identified. The fistula was closed using three short clips. After the clipping, there was no liquid discharge from the drainage catheter. The patient was discharged on postoperative day 56.

The case is a 52-year-old man. He was admitted to our hospital with colonoscopy (CS) showing appendiceal swelling and increasing lesions over time. Contrast-enhanced computed tomography (CT) showed a 10 mm-sized mass lesion which was originated from cecal wall. CS showed a elevated lesion on the appendix with a smooth surface of 10 mm in size and covered by normal mucosa. Endoscopic ultrasonography (EUS) revealed the lesion as a 13 mm-sized cystic lesion, and the inside was dense with fine spotty echoes. No nodules or papillae were found inside. Based on the above, appendiceal mucous cystadenoma was suspected, and laparoscopic partial cecal resection was performed. The final pathological diagnosis was a WHO-classified low-grade appendiceal mucinous neoplasm.

We report a case of appendiceal mucous cyst diagnosed using EUS and undergoing laparoscopic resection.

The patient was a 66-year-old woman who had not been to the hospital or taking any medication. She visited our hospital with chief complaints of fever, headache, and general malaise. Blood tests showed an abnormally high inflammatory response. Chest, abdominal, and pelvic plain CT did not reveal any obvious abnormalities that could cause inflammation.

Streptococcus bovis was detected in blood cultures. Because of the high incidence of colorectal lesions related with the bacterium, a lower gastrointestinal endoscopy showed an advanced colonic cancer in the ascending colon. A laparoscopically assisted right hemicolectomy was performed.

It is a rare case of advanced colorectal cancer discovered by bacteremia caused by S. bovis.

A 66-year-old male with positive fecal occult blood test underwent conventional colonoscopy, which revealed a 10 mm 0-Is lesion with a slightly depressed area in the sigmoid colon. Three days later, the second endoscopic examination revealed that the depressed area had developed well-demarcated and deeper, and microsurface structure could not be evaluated due to erosion on the depressed surface. However, the conventional images and morphological changes of the lesion strongly suggested T1b colorectal cancer with rapid growth. Fourteen days after detection, just before the laparoscopic surgery, the third examination revealed that the depressed area had become much deeper with increased thickness of the elevated margin, and a V_I high-grade pit pattern was observed on the depressed surface with exposure of the submucosal cancer mass. Histological examination revealed submucosal massive invasion (2800 μm) of moderately differentiated tubular adenocarcinoma and lymph node metastasis (N1). Some T1b cancers develop rapid morphological changes in a short period of time. In those cases, we should perform surgery even for T1b cancers as soon as possible.

A 27 year-old male was admitted to our hospital because of having bloody stool and diarrhea. Serum hemoglobin level was 7.9 g/dl. Because of bloody stool as anemia progressed, so he underwent colonoscopy. Endoscopy showed of ulcer in the ileocecal valve, it had bleeding point. Endoscopic hemostasis was performed for the vessel using Argon Plasma Coagulation (APC). After endoscopic procedure, he had no bloody stool and anemia was improved. Hemoglobin level recovered to 10 g/dl. Campylobacter jejuni was detected by the cultivation for the stool. So we used for the patient the antibiotic to Fosfomycin Calcium Hydrate for a couple of the days. On the basis of literature, endoscopic procedure is not necessary for campylobacter colitis. However, when bloody stools continues and values of hemoglobin decrease, colonoscope may be recommended as therapeutic option for enterocolitis.

A 66-year-old man visited our hospital complaining of anorexia and hair loss. Upper gastrointestinal endoscopy revealed polyposis with redness throughout the gastric mucosa. Colon scopy also showed polyposis over the entire colon and was complicated by sigmoid colon cancer. On pathological examination, mucous lamina propria was accompanied by cystic dilation of the gland, mucosal edema, inflammatory cell infiltration, and it was a diagnosis of hamartomatous polyps. Based on the above, the patient was diagnosed with Cronkhite-Canada syndrome complicated with colon cancer. Steroid treatmet was started after surgical treatment for colon cancer. After the start of steroid treatment, gastrointestinal tract lesons, alopecia and anorexia was improved. Since steroid treatment was gradually reduced and remission was made, steroid treatment was terminated. However gastrointestinal tract lesions and alopecia worsened, steroid treatment was resumed, and treatment is continued now. Discontinuation and low-dose maintenance of steroid in treatment of CCS have not been clarified in previous studies.

This case report may indicate that the maintenance treatment with low-dose steroid is nessesary for remission of CCS.