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A 70-year-old man was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia. Twenty-six days after admission, he experienced hematemesis despite improvement in his respiratory symptoms. Contrast-enhanced computed tomography revealed edematous stomach wall thickening with neither ischemic findings in the gastric wall nor obstruction of the gastric artery. Emergent esophagogastroduodenoscopy showed diffuse dark-red mucosa accompanied by multiple easy-bleeding, irregularly shaped ulcers throughout almost the whole stomach without active bleeding or visible vessels. The clinical course, including the endoscopic findings, progressed favorably with conservative treatment. COVID-19 pneumonia can present with acute gastric mucosal lesion, which may be induced by microvascular thrombosis due to COVID-19-related coagulopathy.

Background The clinical characteristics of IgG4-related sclerosing cholangitis (IgG4-SC) especially without autoimmune pancreatitis (AIP) have not been investigated in a large cohort. Aims To clarify the clinical characteristics of IgG4-SC and IgG4-SC without AIP. Methods We retrospectively reviewed imaging, serology, other organ involvement (OOI) and histology of 872 patients with IgG4-SC who participated in a Japanese nationwide survey in 2019, and compared these items between IgG4-SC with and without AIP. Results AIP was present in 83.7% (730/872) of IgG4-SC. In IgG4-SC, bile duct wall thickening was observed on ultrasound (528/650; 81.2%), computed tomography (375/525; 71.4%) and magnetic resonance imaging or cholangiopancreatography (290/440; 65.9%). An elevated serum IgG4 level (≥ 135 mg/dL) was found in 88.0% (322/366). IgG4-related OOI other than AIP was observed in 25.2% (211/836). The proportion of females was significantly higher in IgG4-SC without AIP (28.9% vs. 20.1%; p = 0.025). Hilar stricture was the most common cholangiographic type in IgG4-SC without AIP (39/107; 36.4%).There were no significant differences between IgG4-SC with and without AIP in the rates of bile duct wall thickening, elevated serum IgG4 level, or IgG4-related OOI. Conclusions The clinical characteristics of IgG4-SC was similar between IgG4-SC with and without AIP in a large cohort.

We experienced a case of gastric cancer with multiple liver metastases characterized by frequent hypoglycemic attacks. Hypoglycemia was observed on admission. We suspected that the cause of this hypoglycemia was non-islet cell tumor hypoglycemia (NICTH). Staining of the tissue with an insulin-like growth factor (IGF)-II antibody revealed that IGF-II was present in the tumor cells. This finding suggested that the tumor was producing IGF-II, which leads to NICTH. After starting parenteral nutrition, the patient emerged from the hypoglycemic coma. He remained out of the coma until he died of liver failure.

An 81-year-old man was diagnosed with Goodpasture syndrome (GS) because he met the criteria of positive anti-GBM antibodies, rapid progressive glomerulonephritis and pulmonary hemorrhage. After starting plasmapheresis and steroid pulse therapy, he experienced tarry stool and contrast-enhanced CT revealed an aneurysmal finding in the jejunum. Paroral enteroscopy showed a jejunal Dieulafoy's lesion (DL) with gush-out hemorrhage. Hemostasis was successfully achieved by hemoclipping, and he then experienced no re-bleeding events. GS can present as a jejunal DL, and contrast-enhanced CT is useful for investigating the etiology and site of small intestinal bleeding, which can lead to smooth, effective endoscopic hemostasis.

Magnetic compression anastomosis (MCA) was developed as a low-invasive treatment for gastro-enteric or entero-enteric obstruction. A 72-year-old man underwent subtotal gastrectomy with Billroth II reconstruction for early gastric cancer. After the operation, he suffered from repeated aspiration pneumonia due to anastomotic obstruction caused by jejunal kinking at the efferent loop of anastomosis. We therefore performed jejunojejunostomy via the MCA technique, as his situation was not improved despite conservative therapy and he had a high reoperative risk. We prepared two flat plate-shaped neodymium magnets (15 × 3 mm) each with a small hole, and a nylon thread was passed through each hole. Each magnet was then delivered endoscopically to the anal side of the jejunal kinking, subsequently to the anastomosis, using biopsy forceps. The two magnets immediately became attracted towards each other transmurally. Oozing hemorrhage with clot at the mated magnets was observed 10 days after starting the compression. After retrieving the magnets, we confirmed the completion of jejunojejunostomy and then successfully achieved hemostasis of the anastomotic hemorrhage using argon plasma coagulation. The widely patent anastomosis was confirmed endoscopically 1 month after canalization; and he has been asymptomatic and able to eat a normal diet ever since. Endoscopic MCA is an effective, low-invasive treatment for anastomotic obstruction after subtotal gastrectomy. A standardized, safer procedure should be established for general use in the clinical setting.

Background The usefulness of prophylactic biliary stenting for patients with common bile duct stones (CBDS) and gallstones (GS) to prevent recurrent biliary events after endoscopic sphincterotomy (EST) and CBDS extraction before elective cholecystectomy remains controversial. The aim of this study was to evaluate the risk of recurrent CBDS around the perioperative period and clarify its risk factors. Methods The clinical data of all patients who received prophylactic biliary stenting after EST for CBDS and later underwent cholecystectomy for GS followed by stent extraction in our institution were retrospectively reviewed. The numbers of residual CBDS at the end first and second endoscopic retrograde cholangiography (ERC) studies were compared. Univariate and multivariate analyses were performed using a logistic regression model to determine risk factors for recurrent CBDS in the perioperative period. Results Forty-two consecutive patients received prophylactic biliary stenting and subsequent cholecystectomy for GS. Three of these patients were excluded from this study because the number of residual stones was not confirmed. The median maximum CBDS diameter at second ERC was 0 mm (range, 0 - 10 mm); six patients had multiple CBDS (≥ 5). The number of CBDS at second ERC was increased in comparison to that at the first ERC in 15 patients (38.4%), and was unchanged or decreased in 24 patients. The median minimum cystic duct diameter was 4 mm (range, 1 - 8 mm). The median interval between first ERC and operation was 26 days (range, 2 - 131 days). The median interval between operation and second ERC was 41 days (range, 26 - 96 days). Laparoscopic cholecystectomy (LC) was performed in 38 patients, one of whom was converted from LC to open cholecystectomy. Postoperative complications (transient bacteremia) occurred in one patient. The cystic duct diameter was an independent risk factor for an increased number of CBDS at second ERC in the multivariate analysis (odds ratio 0.611 (95% confidence interval (0.398 - 0.939)), P = 0.03). Conclusion Recurrent CBDS around the perioperative period of cholecystectomy is not a rare complication after EST and the removal of CBDS with concomitant GS. Prophylactic biliary stenting is considered useful for preventing CBDS-associated complications, especially for patients in whom the cystic duct diameter is larger (≥ 5 mm).

We experienced two cases in which manual compression hemostasis under endoscopic observation was used in patients with acute hemorrhagic rectal ulcer (AHRU). The patients experienced an episode of massive fresh hematochezia, requiring the blood transfusion. Emergent sigmoidoscopy revealed multiple ulcers with a large protuberant visible vessel or with gush-out hemorrhage on the lower rectum. Endoscopic hemostasis by hemoclips and hypertonic saline-epinephrine injection was attempted; however, mechanical mucosal injury induced by hemoclips and needles caused another gush-out hemorrhage. Thus, the site of bleeding was manually compressed by a forefinger under endoscopic observation. After 5 min, compression hemostasis was achieved, and the postoperative course was uneventful. Manual compression hemostasis under endoscopic observation is useful and worth attempting for AHRU.

A woman in her 70s with systemic sclerosis experienced dyspnea, and consequently, she was diagnosed with an esophago-pleural fistula, which was caused by a perforated esophageal ulcer. We administered conservative treatments including continuous pleural drainage and total parenteral nutrition. The fistula was closed but recurred, at which point we attempted to close the fistula by filling and shielding using polyglycolic acid (PGA) sheets and fibrin glue (FG). We were able to safely and smoothly fill and shield the fistula using the PGA sheets with a guidewire. We show that endoscopic closure of an esophago-pleural fistula using this technique is an effective, low-invasive treatment for gastrointestinal perforation and refractory fistulas.

A 69-year-old man was referred to our department with acute hepatitis. He had been newly treated with benidipine hydrochloride for two months. His blood test results were as follows: aspartate aminotransferase, 1,614 IU/L; alanine aminotransferase, 1,091 IU/L and anti-smooth muscle antibody, ×80. Needle liver biopsy specimen showed interface hepatitis with mainly lymphocytic infiltration and bridging fibrosis in the periportal area. Immunohistochemistry revealed lymphocytic infiltration positive for IgG4. We diagnosed him with IgG4-related AIH with an etiology that was suspected of being drug-induced. Oral prednisolone was started and then tapered after achieving biochemical remission. Hepatitis recurred after the cessation of steroids; however, remission was achieved with ursodeoxycholic acid.

A 78-year-old man underwent endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) (type 0-IIa) in the anterior wall of the antrum. En bloc resection was achieved. The histopathological examination revealed very well-differentiated tubular adenocarcinoma (tub1) of 30 × 22 mm in size, confined to the mucosa. No lymphovascular invasion or ulceration was observed, and there was no undifferentiated-type component and the margins were tumor-free. Therefore, this lesion fulfilled the eCuraA criteria. Two years after ESD, esophagogastroduodenoscopy revealed an irregular, slightly-depressed lesion within the post-ESD scar. Tubular adenocarcinoma was suspected based on histopathological examination of a biopsy specimen. The tumor was resected by ESD. A histopathological examination revealed well-differentiated tubular adenocarcinoma (tub1) of 6 × 4 mm in size, confined to the mucosa. No lymphovascular invasion was detected and the margins were tumor-free. These findings indicated a curative resection. Recurrence following a curative ESD of an intramucosal differentiated-type EGC which fulfilled the eCuraA criteria is rare. Careful endoscopic observation using magnifying narrow band imaging (NBI) is needed after ESD, even when curative resection is achieved.

Magnetic compression anastomosis (MCA) has been developed as a non-surgical alternative treatment for biliary obstruction without serious complications. A 70-year-old woman who had undergone pancreaticoduodenectomy with modified Child reconstruction for pancreatic head cancer suffered from obstructed choledochojejunostomy with no recurrent findings 4 months after the operation. Cholangiography using the percutaneous transhepatic cholangiographic drainage (PTCD) and fluoroscopy revealed complete obstruction of the upper common bile duct, and the length of the obstruction was 7 mm. Intraductal ultrasonography (IDUS) showed fibrous heterogenous hyperechoic appearance without fluid collection, vessels or foreign bodies at the site of the obstruction. We performed choledochojejunostomy using the MCA technique. One magnet was inserted into the obstruction of the hepatic side through the PTCD fistula. Another was delivered endoscopically to the obstruction of the jejunal side. The two magnets were immediately attracted towards each other transmurally, and reanastomosis was confirmed 7 days after starting the compression. The magnets were easily retrieved endoscopically. A 16-Fr indwelling drainage tube was placed in the jejunum through the PTCD. The internal tube is still in place 6 months after reanastomosis, and no MCA-related complications have been observed. In conclusion, MCA is a safe, effective, low-invasive treatment for biliary obstruction, and IDUS is useful for the pretreatment assessment of feasibility and safety.

A 58-year-old male receiving two types of antithrombotic medication developed acute obstructive suppressive cholangitis due to choledocholithiasis. During the first endoscopic retrograde cholangiopancreatography (ERCP) procedure, we performed biliary plastic stenting. Seven days after this procedure and with continued antithrombotic treatment, we performed ERCP with endoscopic sphincterotomy and stone extraction. Twelve hours after this procedure, the patient suffered transient unconsciousness and progression of anemia. Sixty hours after the procedure, he experienced right hypochondralgia and hiccups. Ultrasonography and computed tomography revealed a subcapsular hepatic hematoma. Bleeding was successfully arrested with selective arterial embolization. We suspected that the cause of these problems was vessel injury from the rigid portion of the guidewire during the ERCP procedure.

We investigated the usefulness of screening for colorectal cancer (CRC) using immunological fecal occult blood test (FOBT) in 472 scheduled inpatients (median age, 68.6 years) who underwent screening for CRC via FOBT (single stool sample) at our hospital. The recall rate for further examination was 26.6% (126/472), and the rate of patients who underwent further examination was only 34.9% (44/126). The overall colorectal neoplasm detection rate, overall CRC detection rate, and positive predictive value for CRC in inpatients were 5.5% (26/472), 1.4% (7/472), and 5.5% (7/126), respectively, which were higher than those of population-based screening for CRC. Screening for CRC using FOBT in inpatients is a non-invasive and efficient method to detect latent CRC.

患者は68歳女性で, 右季肋下で5横指, 心窩部で4横指にわたる肝腫大を認めた. 血液検査成績では, 血清アルブミンの著しい低下と胆道系酵素の上昇を認めた. 腹部造影CT検査にて肝右葉と左葉の一部に造影効果の乏しい部分を認め, dynamic MRIでも同様の部位に著しい造影効果の低下を示した. また, 99mTc-PYP (ピロ燐酸) シンチグラムにて肝に取込みを認め, 肝アミロイドーシスを疑った. 超音波下肝生検像では, アミロイドの沈着および肝細胞の圧迫と萎縮を認めた. 免疫組織学的検討では, 沈着物質はκ型AL蛋白であり, 原発性アミロイドーシスと診断し, 腎生検でも同様の所見が得られた. アミロイドーシスの確定診断は組織学的手段によるが, 近年の画像診断の進歩はめざましく, 各種の画像診断法を駆使することで肝生検に迫る診断が可能であると考える.

We have used endoscopic ultrasonography (EUS) for all the colorectal diseases. For cancer, we determined the treatment method by evaluating the depth of cancer invasion. Moreover, we have applied EUS for submucosal cancer to decide whether the depth of submucosal invasion was superficial and thus to estimate the indication of endoscopic resection. Lymph node metastasis has been examined for staging in cases with invasive cancer. We have performed EUS for active ulcerative colitis in observing the depth of inflammation and determined treatment strategy by diagnosing clinical severity. Submucosal tumorous lesions and extramural lesions have been examined to clarify the site and inner condition. EUS is an essential method that leads to accurate diagnosis of any colorectal disease by delineating pathological conditions precisely. With improvement of the instrumentation, EUS can be used as a routine diagnostic tool as is colonoscopy.