Background and Purpose: Endoscopic submucosal dissection (ESD) has been identified as the standard treatment for superficial gastric neoplasms. However, pyrexia is sometimes observed during postoperative course, the clinical significance yet to be identified. Therefore, we investigated these concerns focusing on the electrocoagulation syndrome. Methods: We retrospectively assessed a total of 422 patients who undergone gastric ESD in a single institution between January 2014 and December 2020. They were divided into two groups, Pyrexia (38.0°C or higher) group (n=79) and No-pyrexia group (n=343) and compared with background characteristics and treatment outcomes using propensity-score matching analysis. Results: Propensity-score matching analysis yielded 79 pairs. This comparison demonstrated a significant difference for the following outcomes: the number of penetrating blood vessels (P=0.017), WBC count (P<0.0001), and CRP value (P=0.0002). Others were similar values for outcomes. Histopathological examination revealed the possibility of thermal degeneration of the muscle layer around penetrating blood vessels. Conclusion: This study indicated that excessive preventative hemostasis for penetrating blood vessels might cause the electrocoagulation syndrome leading to pyrexia after ESD.

The use of a self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) in obstructive colorectal cancer (OCC) enables restoration of patients' condition and preoperative evaluation of the entire colon. We investigated the safety and efficacy of total colonoscopy after stenting as a BTS at our hospital. Of the 129 patients who underwent SEMS placement as a BTS for OCC from July 2012 to February 2021, total colonoscopy was performed in 94 patients (73%). Synchronous colorectal cancer was detected in 47 lesions in 30 patients (32%); 26 of these lesions were resected concurrently during surgery of the main lesion and 20 lesions were resected endoscopically. No adverse events associated with SEMS placement and endoscopic examination were observed. In OCC patients, it was considered safe and beneficial to perform total colonoscopy after stenting, keeping in mind the possibility of synchronous multiple colorectal cancers.

Aims: To evaluate the efficacy of endoscopic submucosal dissection (ESD) using S-O clip for appendiceal lesions.

Methods: This retrospective study was conducted on 40 appendiceal lesions that underwent ESD at our hospital. Lesions were classified as follows: Type 0: near the opening but does not extend, Type 1: extends to the opening but does not reach the lumen, Type 2: reaches the lumen but the lesion margin can be identified, Type 3: the opening is covered and extends deep into the lumen.

Results: Types 0/1/2/3 had 16/9/9/6 cases, respectively. S-O clips were used in all cases. The average procedure time and the en bloc resection rate were 46.8 minutes and 97.5%, respectively. Types 2/3 had significantly longer operation times for diameter than Types 0/1. Perforation was observed in 3 Types 2/3 cases, but were treated conservatively.

Conclusions: Although ESD becomes more difficult as the lesion progresses to the lumen of the appendix, it can be performed relatively safely using the S-O clip.

The ongoing coronavirus disease (COVID19) pandemic has resulted in substantial delay in patients receiving timely medical examinations, Further, a rise in the number of cancer-related deaths in the long run and deterioration of the healthcare system are growing concerns. To perform routine endoscopy, the Japanese Society of Gastrointestinal Endoscopy recommends to consider testing for infection as a preventive measure. However, reports on COVID19 screening tests before the endoscopy are limited. Therefore, in this report, we attempted to screen for COVID19 using loop-mediated isothermal amplification (LAMP) among patients scheduled to undergo upper gastrointestinal endoscopy at Chiba Nishi General Hospital. We investigated whether publicizing this information on the website would have the effect of discourage people from undergoing medical checkups and whether this screening method was cost-effective. We found that the number of endoscopies in 2020 did not decrease significantly under the third wave when compared with that in 2019 (P>0.01). Further, this method helped identify two asymptomatic infected individuals. Therefore, screening using LAMP is cost-effective.

We present the advantages and limitations of the over-the-scope clip (OTSC) for gastrointestinal bleeding. Two cases of acute hemorrhagic rectal ulcers (AHRU) and two cases of duodenal ulcer (DU) bleeding were included. The OTSC was chosen to manage these cases due to difficulty in achieving hemostasis using conventional methods. The OTSC is advantageous because it may be used for additional cauterization without fear of perforation due to the use of full-layer sutures; furthermore, it could be used to stop the bleeding in cases where it is difficult to treat guttural vessels or the bleeding point is not identified because of the use of suction. We should be aware of the possibility of rebleeding due to gaps in tissue return and the need for additional hemostasis after OTSC when full-layer sutures are not possible.

In recent years, the usefulness of enteroscopy-assisted ERCP in the patients with surgically altered gastrointestinal anatomy has been reported. Now, we examined in detail the cases of enteroscopy-assisted ERCP performed in our hospital.

In our hospital from January 2018 to December 2020, eight patients with surgically altered gastrointestinal anatomy, twelve times who underwent single-balloon endoscopic ERCP were included. We retrospectively examined the outcomes. The success rate of the deep cannulation of the biliary duct was 91.7%. The treatment completion rate was 100%. Of eight, we underwent tatooing for 6 patients. In 2 cases with tatooing we could shorten time.

It suggested that the usefulness of single-balloon enteroscopy-assisted ERCP for the patients with surgically altered gastrointestinal anatomy. The marking by tatooing can be useful as to saving time.

Photodynamic therapy (PDT) is used for salvage treatment of esophageal cancer after failed response to chemoradiotherapy (CRT) or radiotherapy (RT). However, post-procedural strictures occur often after PDT, which require extensive fiberization and frequent expansions. Therefore, we performed PDT using tip food for painting a black oil-based ink paint marking that could conduct a stable laser radiation locally and induce light blocking and hardness to prevent esophageal strictures. We retrospectively analyzed 7 patients with esophageal cancer (T1b in 5 patients and T2 in 2 patients) who were treated by this modified PDT technique in our hospital from January 2020 to August 2021. After PDT, a localized complete remission rate of 85.7% was achieved (5 patients with T1b (100%) and 1 of 2 patients with T2 (50%) esophageal cancer). No signs of esophageal stenosis were observed. By using a black oil-based ink paint marking, esophageal stenosis following PDT can be prevented.

This single-center retrospective pilot study sought to evaluate the computer-aided detection (CADe) function of CAD EYE™ (FUJIFILM Co., Ltd.) in colonoscopy screening. We assessed the clinical efficiency of CADe in detecting colorectal neoplastic lesions. The subjects were 100 patients who underwent total colonoscopy. They were divided into two groups: the 'AI group' who were examined with CADe and the 'Control group' who were examined without CADe. The background factors and lesion features did not differ between the two groups. The main outcome of this research was the adenoma detection rate (ADR). The ADR of the AI group was 8.0% higher than that of the Control group (P = 0.548). This suggests that ADR would be improved if CADe were combined with colonoscopy screening. However, the difference between the two groups in this main outcome was not statistically significant. Evaluating the effectiveness of AI devices in clinical settings is a key factor in their development. The authors propose to continue this research.

In clinical practice, we often encounter foreign bodies in the upper gastrointestinal tract and perform emergency endoscopic treatment. We analyzed 31 patients (12 males and 19 females, mean age: 58.2 years) who underwent endoscopic removal of foreign bodies at our hospital from May 2016 to May 2020. The foreign bodies were anisakis in 12, a press-through-package in 9, a fishbone in 3, a denture in 2, a coin battery in 2, a food bolus in 2, and a toothbrush in 1. The locations of the foreign bodies were as follows: the esophagus in 14, the stomach in 16, and the duodenum in 1. All objects were removed by grasping forceps and a retrieval net, and measures were taken to prevent further mucosal damage. The endoscopic treatment strategy differs depending on the type and location of the foreign body. It is important to evaluate conditions by imaging before endoscopic treatment is performed.

In 2020, the coronavirus disease (COVID-19) epidemic led to limited medical practices, including endoscopic procedures, to prevent infection. This study aimed to clarify the effect of the epidemic on the diagnosis of advanced colorectal cancer. We enrolled 113 patients diagnosed with advanced colorectal cancer by colonoscopy at our institution from April 2018 to January 2021. Patients were classified into the non-COVID-19 period group (April 2019 to March 2020; n = 84) and the COVID-19 period group (April 2020 to January 2021; n = 29). The detection rate of advanced colorectal cancer in each group was 3.2% and 3.6% (not significant). Regarding the opportunity to perform endoscopy and the level of stenosis, no significant difference was found in all the items examined. In addition, no obvious adverse effects were observed due to restriction of endoscopic practice.

This study aimed to elucidate the clinical features of patients with acute rectal hemorrhagic ulcer (AHRU) and risk factors for rebleeding. We retrospectively evaluated 79 patients, which were endoscopically diagnosed with AHRU at our hospital from January 2009 to April 2020. The mean age of patients was 79.8 years. The performance status 3 and 4 were 74 (93.7%). The patients with hypertension and cardiovascular disease accounted for about half. Rebleeding was observed in 17 (21.5%), and we compared rebleeding group (n=17) and non-rebleeding group (n=62) using univariate analysis. There was no significant difference inpatient clinical features, but ulcers with active bleeding was observed more frequency in case of hemostasis perfomoed with hemostatic forceps in univariate analysis (p=0.011). Therefore, the hemostasis method may require reconsideration.

The rate of local recurrence of esophageal cancer after chemoradiotherapy (CRT) remains high despite its demonstrated utility in treatment. Local recurrent lesions after CRT are treated with surgical and endoscopic interventions, however, surgical approaches are associated with high postoperative mortality rates. Recent studies reported the utility of endoscopic submucosal dissection (ESD) for locally recurrent lesions after CRT. We herein report two cases (both 71-year-old men) of clinical Stage I squamous cell carcinoma that were treated with CRT and then ESD for local recurrences. Although the patients achieved a complete response following CRT, local recurrences were observed 4 months and 5 years later. ESD was used to achieve complete resections in both patients without any adverse events. An endoscopic ultrasound with a miniature probe was useful for performing salvage ESDs. There were no lesion recurrences at 15 months and 18 months after the post-ESD.

A man in his 50s complaining of heartburn underwent upper gastrointestinal endoscopy. A submucosal tumor (SMT) of 10 mm in size was found on the right posterior wall of the thoracic esophagus, and a lesion with a reddish border was found on the apex.

Endoscopic ultrasonography showed the SMT as a hypoechoic mass. Then, we diagnose this lesion as intramucosal cancer on the SMT. The intramucosal cancer along with the SMT was curatively resected by endoscopic submucosal dissection (ESD).

ESD for esophageal cancer on a SMT is rare. We report this case with a literature review.

A 64-year-old man with decompensated liver cirrhosis secondary to nonalcoholic steatohepatitis presented to the emergency room with chief complaints of hematemesis. The patient had a medical history of hemodialysis due to diabetic nephropathy. Computed tomography revealed diffuse gastric wall thickness, and upper endoscopy showed fibrinopurulent exudates lining the stomach and superficial ulcerations. From imaging studies, we suspected phlegmonous gastritis and immediately administered vancomycin and piperacillin/tazobactam. Staphylococcus epidermidis was grown in a culture of gastric juice and tissue specimen. Based on these studies, phlegmonous gastritis was diagnosed.

Follow-up endoscopy revealed a remarkable recovery of the gastric mucosa. After 2 weeks of antibiotics treatment, the patient's condition improved.

Phlegmonous gastritis is a rare bacterial infection that poses diagnostic and therapeutic challenges. Early diagnosis and treatment will lead to improved outcomes, without the need for a surgical intervention.

A 68-year-old man was referred to our hospital for anemia. Abdominal computed tomography showed wall thickening with calcification in the lesser curvature of the gastric pylorus. Upper endoscopy revealed a submucosal tumor-like lesion with multiple superficial irregular ulcers from the gastric angle to the lesser curvature of the antrum. However, biopsy from the ulcer margin detected group 2. After gastric antacid administration, the edematous changes at the ulcer margin improved, the tumor surface became apparent, and por1 was detected on biopsy. Distal gastrectomy with D2 lymph node dissection and Roux-en-Y reconstruction was performed, and the final diagnosis was muc >>por1, tub1, pStage IIB T3N1M0, gastric mucinous carcinoma. Submucosal tumor-like gastric cancer is mostly covered by non-cancerous mucosa, and the positive biopsy rate of gastric mucinous carcinoma is low (19-24%). Targeting the tumor surface at the edge of an ulcer by using antacids and image enhancement endoscopy during biopsy may increase the positive diagnosis rate.

Although gastric polyps are common, they are a rare cause of anemia. We report a case of a woman in her eighties who developed anemia with shortness of breath on exertion. She had been diagnosed with gastroesophageal reflux disease and treated with lansoprazol for three years. Colonoscopic examination revealed polyps and diverticula. Esophagogastroduodenoscopy revealed multiple red polyps with erosion and white edematous polyps in the lower body and middle body of the stomach, respectively. The polyps were friable and easily bleed. The histopathological findings were foveolar hyperplasia with proliferation of capillary vessels and inflammatory cells in the stroma. Therefore, we discontinued lansoprazole administration and prescribed an H2-blocker. After six months, esophagogastroduodenoscopy revealed that the red polyps with erosion and white edematous polyps had diminished. The patient is being followed up and anemia has not progressed.

A 69-year-old man with renal cell carcinoma developed melena and hematemesis and was seen by our department. Esophagogastroduodenoscopy revealed a protruding lesion on the anterior wall of the upper gastric body. Flowing hemorrhage was observed and was stopped by argon plasma coagulation. Later, we performed a biopsy, which was found to be gastric metastasis of renal cell carcinoma. We performed endoscopic mucosal resection to control hemorrhage, and the gastrointestinal hemorrhage improved.

Metastatic gastric tumors are extremely rare, and the major primary tumors are malignant melanoma, breast cancer, esophageal cancer, and lung cancer. Metastatic gastric tumors are often submucosal tumor-like, while gastric metastases of renal cell carcinoma are often polyp-like. If complete resection is possible, metastatic resection is expected to improve survival. Endoscopic resection should be considered for gastric metastasis of renal cell carcinoma.

For GIST treatment, total resction of tumor is very important to cure. Using ESD skills, we resected GIST only by endoscopy in five cases. Toese resections were done at operation room under general anesthesia. These patients were 4 females and a man. Duration were May, 2018 to December, 2019. Endoscopic treatment time was 25 to 92 minutes. Average time was 53 minutes. There were no complication involving gastric perforation or bleeding. None of them, any metastasis or recruuence appears follow-up CT and endoscopy surveillance.

We used mainly SB knife GX type, a kind of scissors foeceps. High frequency setting was ENDO CUT Q effect 1, duration 1 at ERBE VIO 300. Using scissors foeceps, it is possible to grip, rsect and tow.

Laparoscopy and Endoscopy Cooperative Surgery (LECS) is widely performed in Japan, however, only endoscopic resction would contribute to save time, cost and invasion.

A male in his eighties was endoscopically diagnosed with a gastric adenoma 11 years ago. His yearly follow-up consultations were unremarkable. Four years ago, he underwent H. pylori eradication. One year later, the lesions reportedly shrank. Two years later, the lesion enlarged and exhibited morphological changes. A malignancy was suspected, and endoscopic treatment was recommended. However, the patient refused. One year later, the lesion was further enlarged and deformed. Submucosal invasion was suspected. Surgery was performed, and the final diagnosis was an adenocarcinoma, pT1b (SM2).

This case highlighted the malignant transformation of gastric adenoma over time.

A 20-year-old woman was admitted to our hospital for consolidation therapy for acute leukemia. Seventeen days after her treatment, she developed abdominal pain, vomiting, and hematemesis. Laboratory data showed a decrease in neutrophils and a high inflammatory response. Contrast-enhanced computed tomography (CT) showed diffuse edematous thickening of the gastric wall and a small amount of ascites. Esophagogastroduodenoscopy showed hemorrhagic inflammatory findings with prominent white moss adherence from the gastric body to the fornix. No mucosal changes in the gastric antrum were noted. We suspected that an opportunistic infection developed in this immunosuppressed patient. Under fasting control, meropenem, micafungin, proton pump inhibitors, and vancomycin, were administered. Her abdominal symptoms improved on the sixth day after treatment, and the thickening of the gastric wall was noted on the CT scan. Bacteriological examination of the gastric mucosa showed Bacillus cereus, and the diagnosis of infectious gastritis due to myelosuppression was made.

The patient was a male in his 70s. Endoscopic submucosal dissection (ESD) was performed for early-stage gastric cancer in the anterior wall of the antral zone and gastric adenoma in the anterior wall of the lower gastric body. Subsequently, an elevated lesion appeared in the area of the ESD scar on the anterior wall of the antral zone. It grew to become a giant polyp of 40×30×23 mm in size 2.5 years after ESD of gastric cancer. Biopsy results showed hyperplastic polyps. However, ESD was performed because malignancy could not be ruled out due to its size, and progressive anemia. We describe a case in which a large gastric hyperplastic polyp was found in the ESD scar and was resected.

A 83-year-old man was transferred to our department for investigation of bloody stool, fever and dizziness. He had a history of bronchial asthma. He was diagnosed with diverticulitis at the ileum by abdominal computed tomography and was suspected of having diverticular bleeding. The bleeding did not stop by conservative treatment. We performed colonoscopy and identified the site of bleeding and diverticulitis. We diagnosed the patient with diverticular bleeding and diverticulitis in the terminal ileum. Hemostasis by clipping was attempted and no recurrence of bleeding after the treatment. Seven days after admission, diverticulitis improved and he resumed eating. We here present a case of diverticular bleeding at terminal ileum treated by endoscopy.

A male in his 60s was hospitalized for a thorough examination of anemia. Upper and lower gastrointestinal endoscopic examinations showed no bleeding sources, and contrast-enhanced computed tomography showed no contrast media leakage into the gastrointestinal tract. Meckel's diverticulum was suspected by small bowel capsule endoscopy. Transanal small bowel single-balloon endoscopy showed that there were two exposed vessels with diverticula and hemorrhage in the ileum about 65 cm from the ileocecal valve, with eruptive hemorrhage from one of the exposed vessels and exudative hemorrhage from the other. Endoscopic hemostasis was difficult, and laparoscopic-assisted wedge resection of Meckel's diverticulum was performed. The resected specimen showed ulceration and no ectopic gastric mucosa nor ectopic pancreatic tissue. This was a rare case of multiple exposed vessels within a Meckel's diverticulum.

A 38-year-old woman with a history of endometriosis visited our hospital with (complaints of) abdominal pain and vomiting. She was then admitted with a diagnosis of intestinal obstruction in the ileocecal region based on abdominal contrast-enhanced computed tomography findings, she was subsequently treated with an ileus tube. Colonoscopy showed edema and erythema, with severe stenosis such that the colonoscope couldn't pass through the terminal ileum, as well as erythematous mucosa in the sigmoid colon. Biopsies of the same area revealed nonspecific colitis. Ileus angiography showed disruption of the contrast-enhanced image beyond the terminal ileum. Suspecting intestinal endometriosis, and after consulting both the Department of Surgery and the Department of Obstetrics and Gynecology, we performed laparoscopic ileocecal resection, left adnexectomy, and right salpingectomy. The pathological findings of the surgical specimens suggested endometriosis. We herein report a case of ileal endometriosis, an infrequent cause of intestinal obstruction.

A 68-year-old man underwent low anterior resection for rectal cancer in October 2018. In December 2019, follow-up colonoscopy revealed findings suspicious of local recurrence in the vicinity of the anastomosis. Therefore, EMR with the OTSC system (EMRO) was performed in the area. Pathological examination showed adenocarcinoma, and the resection margin was negative.

The OTSC system is an endoscopic clipping system for the treatment of gastrointestinal perforation, postoperative suture failure, etc. EMRO was devised to reduce the risk of perforation by using an OTSC before resection. In this case, a high degree of fibrosis and residual staples were expected due to its proximity to the postoperative anastomosis, and we judged that conventional EMR/endoscopic submucosal dissection would be dangerous and chose EMRO.

A 18-year-old man complaing of lower abdominal pain was diagnosed ulcerative colitis complicated hip arthritis. Here, we report a rare case of ulcerative colitis with hip arthritis.

An 82-year-old woman was referred to our clinic for diarrhea and positive occult blood test findings. Colonoscopy showed a slightly depressed and friable submucosal tumor (SMT) of about 15 mm in diameter in the lower rectum. Campylobacter jejuni was detected in a stool culture. A biopsy of the SMT was performed and the tumor was diagnosed as a lymphangioma. After the biopsy, she complained of hematochezia, and emergency colonoscopy revealed gushing bleeding from a visible vessel. Although endoscopic hemoclipping was conducted, her symptoms were not improved. Therefore, we performed endoscopic mucosal resection (EMR) to control the bleeding. A histopathological examination of the tumor showed hemolymphangioma (mixed hemangioma and lymphangioma) based on distended lymphatic and blood vessels. She is currently undergoing careful follow-up after EMR. We encountered an extremely rare case of rectal hemolymphangioma with Campylobacter enteritis treated using EMR.

A patient (56 years old) who developed ulcerative colitis (UC) in 11 achieved remission with oral mesalazine. In January 20XX, the patient (63 years old) visited our hospital for diarrhea and bloody stools. Colonoscopy (CS) findings resulted in a diagnosis of total UC and remission was achieved with high-dose steroid therapy (prednisolone). In November 20XX+8 (64 years old), worsening diarrhea and bloody stools prompted CS, which led to a diagnosis of relapsed UC. Oral prednisolone (PSL) 30 mg was administered but the disease was refractory to treatment. We considered immunosuppressive therapy but given the advanced age of the patient (64 years old) and COVID-19 pandemic, VED therapy was chosen as the safer option. In the tenth week of VED therapy, a medical examination revealed clinical remission. After approx. 1 year of VED therapy, CS revealed a healed mucosa after the patient experienced no infections, including COVID-19, and no adverse events. VED is considered a very safe therapeutic that acts selectively on gut immunity and does not cause systemic immune suppression. Given an increasing number of elderly patients with UC and the ongoing COVID-19 pandemic, there is a growing need for VED.

Mucosal prolapse syndrome (MPS) is thought to occur because of chronic mechanical stimulation and ischemic condition. It has a variety of endoscopic findings and is often difficult to differentiated from rectal neoplastic lesions. We report the case of the flat type of the rectal mucosal prolapse syndrome that was not definitely diagnosed on the first biopsy. Considering one of the reason why it was difficult to differentiated from the neoplastic lesions, this case had mild fibromuscular obliteration (FMO) which is characteristic of MPS. Therefore, when additional staining with desmin was performed, the findings of FMO could be clearly confirmed. It may be useful to make a histopathological diagnosis while adding desmin staining as necessary for the differentiation from the neoplastic lesions. We need to diagnosis MPS comprehensively by comparing clinical, endoscopic, and histopathological findings.

An 83-year-old man with vomiting visited our hospital. Computed tomography revealed wall thickening of the descending colon and dilated proximal colon. Colonoscopy revealed obstructive descending colon cancer (CROSS 0, cT3N0M0 cStage IIa). We inserted a partially covered self-expandable metallic stent (SEMS). Two months after SEMS placement, he was admitted to our hospital because of difficulty in passing stool. While we were attempting to resolve the obstruction, the SEMS migrated to the oral side of the tumor. We successfully removed the SEMS using the sliding tube of a single balloon endoscope.

In cases of SEMS migration to the oral side of the tumor, the SEMS is seldom excreted spontaneously outside the body. Therefore, it is important to know the strategy of endoscopic removal.

We report the applicability of a self-expandable metallic stent (SEMS) for the treatment of colostomy stricture caused by stoma retraction. A 59-year-old woman with interstitial pneumonia and long-term use of steroids underwent Hartmann's operation for sigmoid colon perforation. After the surgery, she required long-term ventilator management due to septic shock and respiratory disorder. In addition, stoma necrosis due to the septic shock resulted in stoma retraction. Four months after the surgery, she complained of constipation due to colostomy stricture caused by stoma retraction. Considering the risk of the surgical procedure, we inserted SEMS through colostomy. At a 6-month follow-up, no adverse event was noted. Therefore, SEMS therapy could be a useful option for the treatment of colostomy stricture.

Hepatic epithelioid hemangioendothelioma (EHE) is a rare non-epithelial tumor originating from vascular endothelial cells. EHE is difficult to diagnose based on needle biopsy specimens. Recently it was reported that immunohistochemical staining for CAMTA1 could be helpful for diagnosing EHE. We report the first case of using endoscopic ultrasonography (EUS) -guided fine-needle aspiration (EUS-FNA) for pathological diagnosis of EHE.

A 76-year-old woman had multiple hepatic and bone tumors on positron emission tomography/computed tomography. Abdominal ultrasonography (US) showed that many liver tumors were located near the liver surface and microvessels were present around the tumors. It was difficult to perform US-guided percutaneous biopsy. EUS visualized the tumors and microvessels. Avoiding microvessels, EUS-FNA of liver tumors was performed without any adverse events. She was diagnosed with EHE based on immunohistochemical positivity for CAMTA1.

An 88-year-old woman who visited the hospital with a complaint of right hypochondrial pain received a diagnosis of cholecystitis based on imaging findings. After hospitalization, endoscopic retrograde cholangiopancreatography and endoscopic trans-papillary gallbladder drainage (ETGBD) were performed. Although the cystic duct was not visualized even though imaging was performed after the choledocholithiasis was treated, intraductal ultrasonography (IDUS) was performed, and an air image mixed during the imaging was found on the cystic duct side. Contrast-enhanced imaging was not performed due to the opening above gravity, that is, on the dorsal side. When the position was changed from the prone position to the supine position, the cystic duct was easily visualized, the orifice of the cystic duct was grasped, and complete ETGBD was performed. It was suggested that ETGBD may have been successful due to repositioning the patient based on IDUS.

A 70-year-old male patient with inoperable cholangiocarcinoma was diagnosed with abdominal abscess. The oral antibiotics therapy did not have much effect on the abscess. Ultrasound findings also showed that percutaneous transhepatic abscess drainage was difficult. We then evaluated the feasibility of performing the endoscopic ultrasound (EUS) guided abscess drainage from the cardia of the stomach. Thus, we decided to perform EUS guided abscess drainage. When we inserted a 19-gauge needle into the EUS scope, the maximum bending angle of the EUS scope got too shallow to puncture the abscess. By filling the stomach with water, we were able to perform underwater EUS abscess drainage.

Occult pancreatobiliary reflux refers to a condition in which pancreatic juice flows back into the biliary tract with a normal pancreaticobiliary junction.

A 45-year-old woman was found to have gallbladder wall thickening on abdominal ultrasonography screening. Endoscopic ultrasonography showed thickening of the inner hypoechoic layer and scattered areas of punctate hyperechoic foci inside the layer. Endoscopic retrograde cholangiopancreatography showed no abnormalities in the pancreaticobiliary junction, and the biliary amylase level in the bile in the bile duct was 1962 IU/l. Therefore, we diagnosed occult pancreatobiliary reflux. The patient was considered to be at high risk for gallbladder cancer and underwent prophylactic cholecystectomy. Pathological examination revealed hyperplastic changes and cholesterolosis of the gallbladder, which corresponded to the findings of endoscopic ultrasonography. Our experience suggests that if endoscopic ultrasonography shows gallbladder wall thickening and multiple punctate hyperechoic foci on the luminal side of the gallbladder wall, endoscopic retrograde cholangiopancreatography should be performed suspecting pancreatobiliary reflux. Direct cholangiopancreatography and intraductal amylase measurement are useful.

A 41-year-old man with an 8 mm-sized nodule in the pancreatic head revealed by abdominal ultrasonography was referred to our hospital for further examination. To make a pathological diagnosis, we firstly performed an EUS-FNA. However, we couldn't obtain sufficient specimens to diagnose pathologically. Seven months later, we performed an EUS-FNB for the nodule and the histopathological findings showed spindle-shaped tumor cells proliferating in bundles. With immunostaining, the specimen was negative for c-kit, CD34, and desmin but positive for S-100 protein. Based on these findings above, the lesion was diagnosed as a pancreatic schwannoma. Therefore, we decided to follow up the patient with careful observation rather than surgical resection of the lesion. Pancreatic schwannoma is difficult to diagnose preoperatively because of the lack of imaging characteristics. However, adequate pathological diagnosis using biopsy specimen provide crucial information for clinical decision. Therefore, EUS-FNB is considered to be useful modality for the diagnosis of pancreatic tumor.

A male patient in his 30s was referred to our institution for a detailed checkup of the dilation of the tail of the main pancreatic duct. Through endoscopic ultrasonography, stenosis of the main pancreatic duct in the body of pancreas was shown. ERP with brush cytology was also carried out from the stenosis and pancreatic juice cytology which showed atypical cells (Papanicolaou Class IIIa). Due to the possibility of the tumor being developed into pancreatic cancer, with the patient's consent, surgical treatment was performed. Through Laparoscopic middle pancreatectomy, the final pathological diagnosis was the low-grade pancreatic intraepithelial neoplasia (PanIN) with localized pancreatitis. We experienced a case of localized pancreatitis caused by stenosis and obstruction of the origin of the bifurcated pancreatic duct owing to PanIN, which resulted in narrowing of the main pancreatic duct owing to fibrosis associated with pancreatitis.