Colonic diverticular bleeding is a leading cause of lower gastrointestinal bleeding, accounting for the increasing hospitalization rate in Japan. Although over-the-scope clips (OTSCs) have demonstrated favorable outcomes as an initial hemostatic method, their effectiveness as a rescue therapy after rebleeding from primary endoscopic hemostasis remains unclear. This study describes four patients with colonic diverticular bleeding who underwent an OTSC procedure after rebleeding from primary endoscopic hemostasis using standard methods. Immediate hemostasis was achieved in all cases; however, three patients experienced rebleeding during hospitalization, requiring interventional radiology or surgical intervention. Although immediate hemostasis can be achieved using OTSCs in cases of rebleeding after primary endoscopic hemostasis, their effectiveness in reducing short-term rebleeding might be limited. Further large-scale studies are warranted to evaluate OTSC efficacy in managing colonic diverticular bleeding after rebleeding from primary endoscopic hemostasis.

ABSTRACT Objectives Gastrointestinal stromal tumors (GISTs) are vascular tumors that can cause significant gastrointestinal hemorrhage. While endoscopic treatment is common for other hemorrhagic disorders, its role in GIST‐related hemorrhage remains unclear. This study presents a case series of five patients who underwent successful endoscopic hemostasis for upper gastrointestinal GISTs and explores potential risk factors for hemorrhage. Methods This single‐center retrospective study included patients diagnosed with upper gastrointestinal GISTs between January 2013 and December 2022. Of the 61 eligible patients, the clinical courses of five patients who underwent endoscopic hemostasis were reviewed. In addition, an exploratory analysis was conducted to identify risk factors associated with GIST‐related hemorrhage by comparing hemorrhagic and non‐hemorrhagic groups using univariate analyses. Results Five patients underwent successful endoscopic hemostasis using hypertonic saline‐epinephrine injection and/or clipping for hemorrhage from exposed vessels at the ulcer. Consequently, emergency surgery within 24 h was avoided in all cases, and elective surgery was conducted between 7 and 51 days. Additionally, ulcer formation (odds ratio [OR] 37.20; 95% confidence interval [CI] 2.40–582.00; p < 0.01), elevated white blood cell count (OR 1.05; 95% CI 1.01–1.09; p = 0.03), and elevated body mass index (OR 1.22, 95% CI 1.02–1.47, p = 0.03) were identified as risk factors for hemorrhage in the exploratory analysis. Conclusions Endoscopic hemostasis may help avoid emergency surgery in GIST‐related hemorrhage when hemorrhage points are clearly visualized. Ulceration may serve as a predictive factor for hemorrhage; therefore, early surgical intervention should be considered in GISTs with ulceration.

Secondary aortoduodenal fistula (sADF) is a rare but life-threatening complication after aortic graft surgery. Diagnosis is often challenging, particularly when contrast-enhanced computed tomography (CT) and endoscopy results are inconclusive. We report a case in which diagnosis was challenging due to contrast media allergy and non-diagnostic endoscopic findings, highlighting the importance of clinical suspicion in such scenarios. A 76-year-old man with a history of graft replacement for a ruptured abdominal aortic aneurysm presented with five episodes of gastrointestinal bleeding over 3 months. Despite multiple examinations, no bleeding source was identified. Eventually, after the patient developed hypovolemic shock, contrast-enhanced CT was performed with informed consent, which revealed contrast extravasation from the aorta into the horizontal portion of the duodenum. Endoscopy subsequently identified an exposed vessel in the same location, confirming the diagnosis of sADF. Endovascular aortic repair was successfully performed. This case underscores the need to consider sADF in patients with aortic grafts who present with recurrent, unexplained gastrointestinal bleeding.

ABSTRACT Cronkhite–Canada syndrome (CCS) is a rare nonhereditary disorder characterized by multiple gastrointestinal polyps and ectodermal changes. The mortality rate can reach up to 50% in patients with delayed diagnosis or inadequate treatment. A 78‐year‐old Japanese woman presented with diarrhea as the primary complaint. Her clinical presentation included diarrhea, dysgeusia, anorexia, and weight loss. Physical examination revealed alopecia, nail atrophy, and hyperpigmentation. Abdominal computed tomography (CT) revealed multiple enlarged mesenteric lymph nodes, whereas endoscopic examination showed numerous hyperplastic polyps extending from the stomach to the colon. Following the diagnosis of CCS, the patient was treated with prednisolone (30 mg/day). Abdominal CT imaging one month later showed a reduction in the mesenteric lymph node size. Although it is uncommon, mesenteric lymphadenopathy can appear in CCS and may regress with corticosteroid therapy.

Introduction: Cold snare polypectomy (CSP) is a procedure with a low risk of complications. Here, we present our experience of a rare case of submucosal abscess following CSP in an immunosuppressed patient. Case Presentation: Seventy-eight-year-old man underwent CSP, developing a fever, chills, and right lower abdominal pain 8 days later. Ultrasound and computed tomography revealed wall thickening of the ascending colon, presenting as whitening and thickening of the same region, and excretion of pus was observed after biopsy. The diagnosis was made as phlegmonous colitis, for which antibiotic therapy was commenced. The patient was diagnosed with chronic myelomonocytic leukemia (CMML) during admission. We considered the following reasons as possible causes of infectious complications after CSP: (1) the patient had a highly immunosuppressed state with comorbidities such as CMML as well as diabetes mellitus and (2) disruption of the mucosal barrier occurred during endoscopic resection. Conclusion: Although CSP is generally considered safe, our case highlights the potential for serious complications in immunosuppressed patients. Therefore, the decision to perform CSP in such patients should be made with caution to avoid unnecessary interventions. In instances where treatment is essential, thorough bowel preparation and prophylactic antibiotic use may be necessary to mitigate the risks.

BACKGROUND Duodenal Brunner's gland hyperplasia (BGH) is a therapeutic target when complications such as bleeding or gastrointestinal obstruction occur or when malignancy cannot be ruled out. Herein, we present a case of large BGH treated with endoscopic mucosal resection (EMR). CASE SUMMARY An 83-year-old woman presented at our hospital with dizziness. Blood tests revealed severe anemia, esophagogastroduodenoscopy showed a 6.5 cm lesion protruding from the anterior wall of the duodenal bulb, and biopsy revealed the presence of glandular epithelium. Endoscopic ultrasonography (EUS) demonstrated relatively high echogenicity with a cystic component. The muscularis propria was slightly elevated at the base of the lesion. EMR was performed without complications. The formalin-fixed lesion size was 6 cm × 3.5 cm × 3 cm, showing nodular proliferation of non-dysplastic Brunner's glands compartmentalized by fibrous septa, confirming the diagnosis of BGH. Reports of EMR or hot snare polypectomy are rare for duodenal BGH > 6 cm. In this case, the choice of EMR was made by obtaining information on the base of the lesion as well as on the internal characteristics through EUS. CONCLUSION Large duodenal lesions with good endoscopic maneuverability and no evident muscular layer involvement on EUS may be resectable via EMR.

Helicobacter pylori (H pylori) eradication is expected to effectively prevent gastric cancer (GC). However, GC cases may occur even longer than 10 years after H pylori eradication (L10AE). Moreover, the associated factors and characteristics are unknown. In this retrospective, single-center study conducted between 2017 and 2022, patients with GC diagnosed after H pylori eradication were enrolled and categorized into groups according to whether they were shorter than 10 years after H pylori eradication (S10AE) or L10AE. Patients were also categorized according to the depth of cancer invasion. Clinical data, pathological data, and risk factors were analyzed using logistic regression. Clinicopathological characteristics of GC diagnosed at L10AE and those invading the submucosal tissue or deeper (SMD) were investigated. In total, 202 cases of GC occurring after H pylori eradication were identified. Comparison of 158 S10AE and 44 L10AE GC cases revealed a significantly longer surveillance interval (SI) in L10AE cases (median: 2.0 vs 1.0 years, P = .01). Comparison of 150 intramucosal and 52 SMD GC cases revealed that L10AE GC cases were significantly more frequent amongst the SMD cases (18.0% vs 32.7%, P = .03). Pathologically, undifferentiated and mixed types were significantly more frequent in GC cases with SMD invasion (P < .001). Multivariate analysis revealed that L10AE was significantly related to GC cases with SMD invasion (odds ratio, 2.45; 95% confidence interval, 1.15-5.11; P = .019). SI was significantly longer in GC that developed at L10AE than at S10AE. In addition, GC with SMD invasion was more frequently detected in L10AE than in S10AE. Our data indicated that SI should not be groundlessly extended in patients at L10AE.

BACKGROUND:Nodular gastritis (NG) is characterized by marked antral lymphoid follicle formation, and is a strong risk factor for diffuse-type gastric cancer in adults. However, it is unknown whether aberrant DNA methylation, which is induced by atrophic gastritis (AG) and is a risk for gastric cancer, is induced by NG. Here, we analyzed methylation induction by NG.METHODS:Gastric mucosal samples were obtained from non-cancerous antral tissues of 16 NG and 20 AG patients with gastric cancer and 5 NG and 6 AG patients without, all age- and gender-matched. Genome-wide methylation analysis and expression analysis were conducted by a BeadChip array and RNA-sequencing, respectively.RESULTS:Clustering analysis of non-cancerous antral tissues of NG and AG patients with gastric cancer was conducted using methylation levels of 585 promoter CpG islands (CGIs) of methylation-resistant genes, and a large fraction of NG samples formed a cluster with strong methylation induction. Promoter CGIs of CDH1 and DAPK1 tumor-suppressor genes were more methylated in NG than in AG. Notably, methylation levels of these genes were also higher in the antrum of NG patients without cancer. Genes related to lymphoid follicle formation, such as CXCL13/CXCR5 and CXCL12/CXCR4, had higher expression in NG, and genes involved in DNA demethylation TET2 and IDH1, had only half the expression in NG.CONCLUSIONS:Severe aberrant methylation, involving multiple tumor-suppressor genes, was induced in the gastric antrum and body of patients with NG, in accordance with their high gastric cancer risk.

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

An 87-year-old man with dysphagia presented to our hospital. He was diagnosed with autoimmune gastritis (AIG) with severe atrophy and hypergastrinemia. The patient was positive for parietal cell antibody (PCA) and anti-intrinsic factor antibody (IFA), without evidence of H. pylori infection. A flat elevated tumor was detected in the middle corpus, and therapeutic endoscopic submucosal dissection was performed. Histopathological examination revealed atypical cells mimicking the fundic glands, which were positive for pepsinogen-I and partially positive for MUC6 and H + /K + -ATPase, proliferating to the deep layer. The final diagnosis was gastric adenocarcinoma of the fundic gland type (GAFG). AIG is expected to be difficult to develop GAFG because the basal gastric glands are highly atrophic due to the production of PCA. However, some chief cells may remain and could have the potential to develop into malignancy during AIG progression. Therefore, careful observation is required in patients with AIG when considering the occurrence of GAFG.

A 71-year-old female visited our hospital owing to fainting and black stools. Subsequent laboratory testing revealed a low hemoglobin level of 9.6 g/dL. A sac structure sized 60 mm on the posterior cardia and fluid retention in the stomach was observed with contrast-enhanced abdominal computed tomography as a high-density area (Figure A). Emergency upper gastrointestinal endoscopy revealed a gastric diverticulum with an oval entrance 6.7 cm in diameter on the posterior cardia and a small ulcer bleeding at the bottom of the diverticulum (Figure B and Figure C). Clip hemostasis was performed on a visible bleeding vessel on the ulcer surface (Figure D). Second-look endoscopy confirmed successful hemostasis. The patient did not experience further bleeding and was discharged. She had been prescribed methotrexate for rheumatoid arthritis, which may have caused the gastric diverticulum. Gastric diverticulum is a rare disorder that generally affects the posterior wall of the fundus owing to the anatomically thin muscle layer and the penetration of large blood vessels. However, surgical hemostasis is sometimes required because of the difficulty in detecting the bleeding site and the risk of perforation due to endoscopic procedures. In our case, endoscopic hemostasis was successfully achieved with reliable visibility of the bleeding site.

Splenic diseases may be caused by infections and can be either malignant, such as lymphoma and lung cancer, or benign, such as hemangioma. In some cases, diagnostic uncertainty of imaging persists, and image-guided splenic needle biopsy is a useful diagnostic tool to avoid the disadvantages of incorrect diagnosis, including performing unnecessary splenectomy or not giving the necessary treatment. Splenic biopsies can be divided into ultrasound-guided, computed tomography (CT)-guided fine-needle aspiration, or core needle biopsy (CNB). However, few studies have focused exclusively on complications associated with CT-guided CNB of the spleen. Therefore, we assessed bleeding, the most common complication of CT-guided CNB of the spleen, and evaluated factors associated with the bleeding. Using the biopsy database maintained at the institution, all patients who underwent CT-guided CNB of the spleen between May 2012 and September 2022 were identified retrospectively. The 18 identified patients were divided into post-biopsy bleeding and non-bleeding groups for analysis. In total, 17 patients (94.4%) could be diagnosed accurately with CT-guided CNB. Bleeding complications occurred in 7 cases of CT-guided CNB; of these, 2 patients with Common Terminology Criteria for Adverse Events grade 4 disease required transcatheter arterial embolization. The bleeding group was characterized by diffuse spleen tumors in all cases, with significantly more diffuse spleen tumors than the non-bleeding group. CT-guided CNB is a useful option for neoplastic lesions of the spleen that are difficult to diagnose using imaging alone. However, consideration should be given to post-biopsy bleeding in patients with diffuse splenic tumors.

BACKGROUND AND AIMS:Endoscopic papillary balloon dilation (EPBD), a low-risk procedure for bleeding, has been suggested as an alternative to endoscopic sphincterotomy for papillary dilatation in patients undergoing endoscopic stone removal who are at a higher risk of bleeding. Several guidelines recommend that combination of two antiplatelet agents should be reduced to single antiplatelet therapy when endoscopic sphincterotomy is performed. However, there is no evidence that EPBD affects the risk of bleeding in patients receiving a combination of two antiplatelet agents; thus, we aimed to explore this problem.METHODS:We included 31 patients who underwent EPBD for common bile duct stones at our hospital from May 2014 to August 2022 and received either a combination of two antiplatelet agents or single antiplatelet therapy prior to the procedure. The group receiving a combination of two antiplatelet agents included patients who underwent EPBT without antiplatelet therapy withdrawal or with a shorter withdrawal period than those recommended by the guidelines.RESULTS:In the group that received a combination of two antiplatelet agents, one of the two antiplatelet agents used was thienopyridine. No bleeding was observed after EPBD in this study. We did not find any significant between-group differences in hemoglobin levels and rate of post-endoscopic retrograde cholangiopancreatography pancreatitis.CONCLUSIONS:In patients treated with a combination of two antiplatelet agents, EPBD could be safely performed without bleeding. Therefore, future prospective studies are warranted.

Amyloid light-chain (AL) amyloidosis rarely causes colorectal submucosal hematoma. A 76-year-old man presented with a complaint of bloody stool. An initial colonoscopy revealed ulcerative lesions in the descending colon, leading to a diagnosis of ischemic colitis. One month later, he presented with cardiac failure, suspected cardiac amyloidosis, and underwent a second colonoscopy. Although it revealed multiple ulcerative lesions from the ascending to transverse colon, biopsy samples did not confirm amyloid deposition. He underwent a third colonoscopy 3 weeks later due to recurrent bloody stool. It showed multiple submucosal hematomas from the ascending to descending colon concomitant with ulcerative lesions in the descending colon and multiple elevated lesions in the sigmoid colon. Biopsy samples confirmed amyloid deposition. Using a systemic search, multiple myeloma with AL amyloidosis was diagnosed. Colorectal submucosal or intramural hematomas are conditions usually encountered in trauma, antithrombotic use, or coagulation disorders. Based on our review of the literatures, we identified several differences between colorectal intramural hematoma caused by amyloidosis and those caused by other etiologies. We believe that amyloidosis should be considered when relatively small and multiple colorectal hematomas, not restricted to the sigmoid colon, and with concomitant findings of erosions and ulcers, are observed.

Chronic ischemic gastritis (CIG) requires early diagnosis and treatment as complications of thromboembolism can be fatal. Although computed tomography (CT) is useful in the diagnosis of CIG, it is difficult to diagnose from a patient's history, endoscopic findings, and tissue biopsy. Identification of the key findings that motivate computed tomography is an important issue. We report a case of CIG diagnosed by endoscopic findings of white patches of mucosa over time. A 63-year-old man presented with epigastric pain. He had a history of repeated gastric ulcers of an undetermined cause. We performed upper endoscopy and observed the appearance of multiple white patches on the gastric mucosa. Central vessel stenosis was considered, and aortic computed tomography revealed complete occlusion of the superior mesenteric artery and stenosis of the celiac artery. We carried out a surgical bypass and found no postoperative endoscopic mucosal changes or abdominal pain. White patch changes in the gastric mucosa over time during endoscopy may indicate CIG. This finding may help in the future diagnosis of CIG.

Embolization with IMPEDE embolization plug cannot be confirmed on site. Therefore, we propose that the diameter of the device selected be up to 50% larger than the vein diameter to prevent embolization failure and recanalization.

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.